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The Medical Management of Obesity Nerys Williams Consultant Occupational Physician and former Honorary Consultant in Obesity and Weight Management Firefit,

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Presentation on theme: "The Medical Management of Obesity Nerys Williams Consultant Occupational Physician and former Honorary Consultant in Obesity and Weight Management Firefit,"— Presentation transcript:

1 The Medical Management of Obesity Nerys Williams Consultant Occupational Physician and former Honorary Consultant in Obesity and Weight Management Firefit, Durham 6 July 2009 (the views expressed are personal and not those of any employer)

2 Outline  The epidemic  Measurements and their limitations  The co-morbidities  why obesity is important for occupational health (fitness for work, sickness absence and early retirement, safety implications)  Prejudice and discrimination  Current management

3 Size of Problem - US Mokhdad 1991

4 Size of the Problem - UK Health Survey of E&W Showing 2000 data Now >50% adults now overweight (BMI >25) >22% of men and >23% of women are now obese (BMI>30)

5 % Projected trend for BMI>30 in EU over 25 years IOTF projection 2005

6 Causes of Obesity Heredity Familial Demographic factors è age è gender è ethnicity è social class è marital status Physical inactivity Dietary intake Smoking cessation Drugs ( steroids, lithium, sulphonylureas) rarely endocrine disorders

7 Why the Increase ? Increased energy in greater choice high fat/calorie dense food processed/prepared food eating out + fast food snacking super sizing Reduced energy expenditure less sport computer games/TV increase in cars change in work practices

8 How obesity occurs Daily excess calorie intake over energy usage. Only needs daily excess of 130 calories to lead to gain of 1 stone (6.5kgs) per year Background of weight gain every decade, peak increase in weight 30-50 years = peak decades of inactivity.

9 Interaction Genes load the gun and environment pulls the trigger George Bray 1996


11 Definitions Weight is only a limited surrogate for obesity Body mass index = kg/m 2 WHO classification Underweight < 18.5 Normal 18.5-24.9 Overweight 25-29.9 Obese 30-34.9class I Obese 35-39.9class II Extreme obesity 40 +class III

12 Caution With BMI Case study JM 27 years Height 6 ft 4 ins Weight 325 lbs BMI 39.6

13 Definitions Waist circumference is a surrogate for body fat More accurate in determining intra abdominal fat and health risks than BMI Important to measure waist accurately WHO has amended obesity classification to take account of the abdominal distribution of fat and its effect on risk of disease So were is the waist ?

14 Waist Measurement Umbilicus ? Narrowest part ? Midway rib and pelvis ? Other ?

15 Amended WHO Definitions of Obesity (Taking Into Account Waist Circumference)

16 Definitions For Indo Asian patients WHO (modified) classification Overweight BMI 23-25 (25-29.9) Obese BMI 25-30 (>30) Morbid obesity BMI>30(>40)

17 Defining abdominal obesity Waist circumference (Caucasians) Men >94 - 102 cm Women >80 - 88 cm WHO 894 Obesity Report

18 Waist Circumference and Health Risks in South Asians Risk of CVD and diabetes increases if : > 80 cm (approx 32”) in females > 94 cm (approx 37”) in males (Europids)  90 cm (approx 36”) in males (South Asian) “researchers and clinicians should use the new criteria for the identification of high risk individuals and for research studies” Alberti G, Zimmett P, Shaw J. IDF guidelines Lancet Sept 24 2005

19 Complications and Health Impact of Obesity Type 2 diabetes x10 Cancer of uterus x4.6 Gout x3. Hypertension x2.9 Gallstones x2.7 CHD x2.5 Osteoarthritis x2 *relative risks for BMI >27-30. Finer N. Clinical Medicine 2003;3:23-7. sleep apnoea sweating hirsutism infertility (esp.PCOS) menorrhagia varicose veins Recently identified increased inflammatory markers and risk of atrial fibrillation

20 Health Risks risks increase as obesity increases risks increase as visceral fat increases risks best defined in type 2 DM and in hypertension

21 Risk of Diabetes with rising BMI

22 Implications for Occupational Health Short term absences Obesity in women Overweight and obesity in men Long term absences Overweight and obesity in women Obesity in men “the current obesity epidemic in industrialised countries is likely to result in significant increases in sickness absence” Reference: Ferrie JE et al

23 The Union Pacific Experience “the most significant predictors of injury besides age and tenure are health status, tobacco use, stress,weight. Weight is particularly significant for the 45+ age group” IHPM Phoenix, Arizona 2004

24 Implications for Occupational Health Huge burden of chronic disease, frequent medical appointments, increased sick absence and early retirement due to complications of diabetes/CVD Sleep apnoea increased risk of occupational and RTA More ergonomic difficulties, fit of p.p.e /uniforms, weight bearing of chairs, desk and office size, double plane seats Reduced mobility and effects on performance Stigma of obesity and co existence of other pathology e.g. depression Issues around medical standards Does the DDA apply ?

25 Prejudice and presumptions Prejudice employers healthcare service providers Discrimination Perceptions lack self control lazy less intelligent less likely to have friends

26 Prejudice and presumptions UK Personnel Today Survey November 2005 PCT BMI >30 not allowed hip replacements on the basis of “clinical risk of failure” Is this Ethical ? Moral ? Judgemental ? Impact on obesity and work ?

27 Worthwhile Treating ? Weight loss of 5 kg reduces risk of T2DM by 50% (Manson et al 1995) Loss of 9 kgs reduces diabetes related mortality by 30-40% (Williamson et al 1995) 5% weight loss reduces fasting blood glucose by 15% (Dattilo and Krita-Etherton 1992) Weight loss of 10-20% can stabilise blood sugar and improve life expectancy (Jung 1997) Evidence of evidence of the effectiveness of workplace health promotion programmes (HDA review 2003)

28 Prevention of Obesity Key Objective Prevent normal weight people becoming overweight Prevent overweight people becoming obese

29 Individual vs. Environment Individual screening, support, weight loss clinics Environment Increase activity in tasks Increase opportunities for activity Reduce opportunities to consume calories

30 Philosophy of Weight Management No longer strive to “ideal weight” but aim for realistic weight loss of 5-10% and maintain it Manage patient expectations Small changes bring about big results – biggest health benefits in first 5-10% weight loss Little calorie reductions help Myth busting : unlikely to be able to “walk it off”

31 Approach Measure Assess co morbids and readiness for change (Advantages and disadvantages of change and staying the same, what motivates, what goals) Manage expectations and dispel myths Diet and physical activity Medication Onward referral

32 Rationale for Physical Activity in Weight Management Increases energy expenditure Protects/builds lean body mass Improves psychological factors Reduces risk of morbidity and mortality May suppress appetite Reference: Grilo CM et al. In: Stunkard AJ and Wadden TA (eds). Obesity: Theory and Therapy. New York: Raven Press Ltd.;1993:253-273

33 Physical Activity Work design Local walking groups Step distances from premises and around local area Tax breaks on cycles Pedometers Gym/health club subsidy Reward “weight loss clubs” capitalise on New Year resolutions

34 Food Intake Vending machines Carousel catering Conferences Reception Distraction eating Canteen: labelling options Farmers markets/local producers Subsidise healthy options Info sessions Provide one piece of fruit per day

35 Weight Expectations: What to Communicate to Patients Weight regulated by complex set of biological and environmental factors Benefits of sustained moderate weight loss Work to alter fundamental thoughts and assumptions vs. patient expectation Emphasise importance of slow, steady loss followed by maintenance Focus on long-term outcome/sustained changes Reference: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH Publication No. 98-4083, September 1998

36 Further Help NICE approved drugs  Xenical (orlistat) reduces fat absorbed by 30%  Reductil (sibutramine) enhances satiety Both on prescription according to guidelines and orlistat available OTC as “Alli” Acomplia (rimonabant) – no longer an option NICE approved bariatric surgery  according to guidelines

37 Developments Rimonabant – Acomplia - blocks the urge to smoke and eat (? also cravings for alcohol) (endocabannoid) Over eating, marajuana use and smoking all stimulate the centre, Rimonabant blocks it. Study in JAMA showed effective weight loss and waist reduction in treated compared to placebo groups Caution re; neurological conditions Marketing suspended by EMEA October 08

38 Public Health Initiatives Health trainers Training of primary care staff Directory of courses/training Patient activity questionnaires Change4life NOF NOW 2009

39 Workplace Obesity Strategy Nutrition Physical activity H&S principles ? Design out at source Joined up with other initiatives - “holistic” Top down or bottom up ? empowerment or central direction and control ? How to make an impact on obesity respecting diversity, other policies, personal sensitivities and ensuring sustainability

40 Summary Your Choices Manage the condition or Manage the complications

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