2. Obesity and Life expectancy
January 2003 Life Table analysis of Framingham Data
Obese at 40 live 6 to 7 years less than normal
Overweight at 40 live 3 years less than normal Obese smoker live 14 years less than normal

3. Obesity Accounts for 5% of heart attacks and strokes
10% cases of osteoarthritis
20% cases of hypertenstion
40% of cancers
80% cases of Type 2 diabetes.
There is limited data on the cost of obesity but evidence suggests that the direct cost accounts for 5 to 7% of total health care expenditure (WHO,1998).

4. What is Obesity?
Defined by World Health Organisation using body mass index (BMI) (Weight in Kg divided by height in meters squared)
5’4” Normal 65kgs (10 stone 3 lbs) Obese 78kgs (12 stone 2 lbs)
5’10” Normal 78kgs (12 stone 2 lbs) Obese 94kgs (14 stone 10 lbs)

5. Relationship of BMI to Excess Mortality
300
Age at Issue
20-29
250
30-39
200
Mortality Ratio
150
100
Low
Moderate
High
A paper by George Bray examined the relationship of BMI to excess mortality.
Data was pooled from 5 prospective studies (3 industrial and 2 community) and included a total sample of 8,422 white males with a mean length of followup of 8.6 years.
This slide points out the relationship of BMI to excess mortality. There is a curvilinear increase in excess mortality with rising BMI. The risk is low with a BMI of 25 to30 and increases as BMI increases. The greatest risk is seen with BMIs above 40. 50
Risk
Risk
Risk 15 20 25 30 35 40
Body Mass Index (kg/[m2])
Bray GA. Overweight is risking fate. Definition, classification,
prevalence and risks. Ann NY Acad Sci 1987;499:14-28.

7. Current Prevalence data in Ireland
Female: 33% Overweight % Obese (13% self report)
Male: 45% Overweight 24% Obese (16% self report)
Children: 20% Overweight or obese (5-12 yo) Slan 2007 Independently Measured

8. Grades of BMI Kg/M2 BMI 19-25 -Normal BMI 25-30 -Overweight Obesity
BMI Grade 1
BMI Grade 2 BMI >40 -Grade 3(Morbid) Overweight or obese USA 71%, UK 65%
USA 5% have BMI > 40 Ireland 2% have BMI > 40

9. Grades of BMI Kg/M2 BMI 19-25 -Normal BMI 25-30 -Overweight Obesity
BMI Grade 1
BMI Grade 2 BMI >40 -Grade 3(Morbid) Overweight or obese USA 71%, UK 65%
USA 5% have BMI > 40 Ireland 2% have BMI > 40

10. BMI and weight

11. Normal weight finishes at
BMI Male 12st 2lbs Kgs
Female 10st 3lbs kgs

12. BMI ranges
BMI 1
BMI 2

13. BMI range <20 to 25
BMI 19
BMI 25

14. BMI range <20 to 25
BMI 19
Guess 20
BMI 25
Guess 23

15. BMI 4
BMI 3

16. BMI range 40 to 45
BMI 44
BMI 40

17. BMI range 40 to 45
BMI 44
Guess 35
BMI 40
Guess 32

18. BMI 5
BMI 6

19. BMI range 50 to 55
BMI 51
BMI 52

20. BMI range 50 to 55
BMI 51
Guess 43
BMI 52
Guess 42

21. BMI 7
BMI 8

22. BMI range 70 to >75
BMI 72
BMI 76

23. BMI range 70 to >75
BMI 72
Guess 50
BMI 76

24. Severe (Grade 3) Obesity
BMI Male 20st kgs Female 16st 10lbs kgs

25. Current Prevalence data (Adult)
Female: 33% Overweight % Obese (13% self report)
Male: 45% Overweight 24% Obese (16% self report) Slan 2007 Independently Measured

26. Obesity is associated with
Diabetes
Cancer
Sleep Apnoea
Osteoarthritis
Fatty liver disease
Psoriasis
Dementia
Cardiovascular Disease
Death from H1N1 (Swine Flu)

27. Prevalence of diabetes (%)
Excess weight is a MAJOR risk factor for diabetes in US adults, 2001 (n=195, 005)
Prevalence of diabetes (%) 30
25.6 20
14.9 10
7.3
A total of 4483 subjects aged years participating in a large family study of T2D in Finland and Sweden (the Botnia study) were included in the analysis of CV risk associated with metabolic syndrome. CV mortality was assessed in 3606 subjects with a median follow-up of 6.9 years.
4.1
Normal
Overweight BMI
Obese BMI
Obese BMI 40
Mokdad et al. JAMA 2003; 289: 76-9

28. Figure 3: Summary risk estimates by cancer sites in men
I squared is a method of quantifying heterogeneity between studies
Figure 3: Summary risk estimates by cancer sites in men

29. Figure 4: Summary risk estimates by cancer sites in women

30. Relative Risk of Developing Cancer in Males
Cancer Type
Relative Risk if Overweight
Relative Risk if
Obese
Oesophegeal
1.5
2.3
Thyroid
1.3
1.7
Colon
1.2
Renal

31. Obesity also reduces survival in certain cancers
Colon
Breast
Endometrium
Prostate
Ovary

32. Increased risk of dementia
BMI and increased risk of dementia – analysis of prospective cohort study (Whitmer et al. 2005)
Increased risk of dimentia in later years for those overweight / obese in mid-life
Increased risk for
Males
Females

33. Relative Risk of Developing Dementia
Normal Weight population
Overweight Population
Obese Population
Female 1
(Incidence 69/million)
1.55
2.07
Male
(Incidence 43/million)
1.16
1.3

34. Obese patient with Acute abdomen
30% chance of atelecasis/pneumonia
2.8 times more likely than non obese

35. Overweight and obesity following Road Accidents
Study of 1,615 Crashes Crash factor adjusted odds for dying for overweight for obese
Injury severity adjusted odds for dying for overweight for obese
Ryb J.Trauma 2008(64) CIREN study

36. Role of weight and seatbelts
Seatbelts decrease risk of death and intraabdominal injury in obese and non obese Lack of seatbelt increases risk of death 9.7 fold in obese 5.2 fold in non obese
Zarzaur & Marshall J Trauma 2008(64)

37. Crash Dummy Research

38. Equipment Needs

39. A lot of equipment
Has upper weight limit of ~ 150kgs Trolleys Beds Theatre Tables Radiology – equipment and quality

40. Radiology Equipment in Ireland
Audit of 40 hospitals
CT, MRI, Fluoroscopy
Weight Limit
Aperture Diameter

43. Toxic environment we live in…

44. Unsuspected calories abound

45. Unsuspected Calories

46. Unsuspected Calories

47. Bagel Cheeseburger Chips 140 calories 350 calories 333 calories
20 Years Ago
20 Years Ago
Cheeseburger
Today
Today
140 calories
350 calories
333 calories
590 calories
Chips
20 Years Ago
Today
210 calories
610 calories

49. Burning a lot less energy (per half hour)
Calories Burned 2004
Calories Burned 1984
Lift (2 mins)
Take Stairs
Order take away
Cook Meal
Load Dishwasher 23
Wash Up
Watch TV
Play Cards
Go to car wash
Wash Car
Play Video Game 53
Play Basketball 280
Ride Lawn Mower 88
Mow Lawn

50. What about children?

52.     
International Pediatric
Association
                                           FISPGHAN
   

53. Childhood Obesity in Ireland
30% overweight and 14.7% obese overall
12% obese 7 year olds
20% obese aged 9-10 years
Slan Survey 2007

54. Do obese children become obese adults?
30% of adult obesity begins in childhood so many adults were not obese children and not all obese children will stay obese
1/3 obese preschoolers = obese adults (26-41%)
All ages risk twice as high for obese as non-obese (range fold risk) Serdula,Preventative Medicine 1993:22;
Parental obesity > doubles the risk of adult obesity in both obese and non-obese children < 10 years Whittaker NEJM 1997;337(13):869-73
The Key Question is Do obese children become obese adults?
Detecting and predicting relevant obesity is important 30% of adult obesity begins in childhood so many adults were not obese children
And Not all obese children will stay obese.
Tracking of childhood obesity varies between studies (major methodological differences) but Approx 1/3 obese preschoolers = obese adults (26-41%), Approx half (42-63%) obese school age = obese adults. The Predictive value increases with age.All ages risk twice as high for obese as non-obese (range fold risk][ Serdula et al, Do obese children become obese adults, a review of the Literature – 17 international studies from 15 study populations]
Parental Obesity - Whittaker NEJM 1997;337(13): – Obese < age of 3 years & no obese parents low risk for obesity in adulthood . Obese Toddler with no obese parents less likely obese than child if both parents obese. Parental obesity OR 1 obese 2.2 at to 3.2 at 1-2 years more likely if both obese Parental obesity > doubles the risk of adult obesity in both obese and non-obese children < 10 years.

55. Just say no……

56. Treatment Options for Obesity
Diet & Lifestyle changes
Pharmacotherapy
Surgery

57. Nothing works without diet/lifestyle change
Diet – kcalorie deficit/day healthy eating priciples
Activity - No consensus 1 hour daily every day
No treatment works without this

58. Who would you rather be?
Man on Left = Driver
Man on Right = Conductor

59. Physical Activity at Work
Prof. Jerry Morris,
Physical Activity Epidemiology
Lancet 1953
31,000 London Transport Workers
Drivers and Conductors
London Double Decker Bus
Drivers had higher rates of Coronary Occlusion (heart attacks) and higher early mortality than conductors

60. Does type of exercise matter?

61. Does type of exercise matter?

62. Results
Morris JN et al., Lancet 1953

63. Cardiorespiratory Fitness and Incident Metabolic Syndrome, 9007 men and 1491 women ACLS, 1979 - 2003
All p <0.001
Age adjusted rate/ 1000 person years
Cardio Resp Fitness is inversely associated with Metabolic Syndrome
Cardiorespiratory fitness tertile
LaMonte, M. et al, 2005 Circulation

64. Need environment conducive to exercise
Ireland has improved cycle lanes recently, but only as a secondary or tertiary consideration!!

65. Obesity Pandemic in Adults and Children
Tracks to adulthood strongly from kids
Is preventable
Is treatable

66. Malnutrition in Hospital

67. Malnutrition in Hospitals
“Food is your medicine - hence let your medicine be your food”
Hippocrates, circa 400 BC

68. Malnutrition in Hospitals
Malnutrition risk has been identified in 20% - 60% of hospital admissions to medical, surgical, elderly and orthopaedic wards.
Further, hospitalization with surgery or other medical treatments often result in additional weight loss.
It has been reported as undiagnosed in up to 70% of cases.
BDA UK

69. Malnutrition in Hospitals
Under-nutrition is associated with
Impairment of body systems including muscle weakness, immune system and gut function
Delayed wound healing
Apathy and depression
Reduction of appetite and ability to eat
Increased mortality rates

70. Which patients are at risk?
Elderly
Cancer
Trauma/ sepsis
Chronic disease states
Pre and post operative
Obese as well as normal weight
Alcohol dependent

71. Malnutrition in Hospitals
There are many cost benefits in treating and preventing under-nutrition including
Reduced length of stay as inpatient
Reduced costs per stay
Reduced mortality
Benefits are seen the earlier under-nutrition is recognised and treated

72. MUST ‘Malnutrition Universal Screening Tool’
Allows health care professionals to easily identify those at risk of malnutrition in a rapid and consistent manner.
This best targets appropriate nutrition therapy.

73. MUST
A screening tool should be used within the hospital to identify patients at risk of malnutrition
Within 48 hours of admission
Once weekly thereafter
Need to act on results of the screening tool
Should be included in nursing handover

74. MUST Quick and easy to complete Universal- suitable for all patients
Facilitates continuity of care
Evidence- based
Precedes nutritional assessment
Ensures appropriate referrals

75. MUST
Take a look at the format of the MUST screening tool………..

76. The 5 steps of ‘MUST’
Steps 1-3: Take 3 measurements and score them against the scale provided
BMI
Weight loss
Acute disease effect
Step 4: Add scores together to identify overall risk of malnutrition
Step 5: Form appropriate care plan in line with local policy

77. What do you need to measure?
Weight:
Only 25% of patients are weighed on admission. (McWhirter & Pennington, 1994)
Very difficult to assess nutritional status without weight
Height:
Measure with stadometer (height measure)
Self reported or Ulna Length
BMI: Weight / Height2
Normal range = kg/m2
Below 20 kg/m2 possible malnutrition
Below 18.5 kg/m2 likely malnutrition
NB. A word of warning  Obese patients can still be at risk of malnutrition if they lose weight rapidly i.e. lose lean body mass

78. Step 1
Weigh the patient

79. Step 1
Measure the patients height using the stadometer – height measure

80. Step 1 – if you can’t measure height….
Estimated height from ulna length

81. Estimating height from ulna length

82. BMI

83. STEP 1 Body Mass Index (BMI)
BMI (kg/m2)
Weight Category
BMI Score
<18.5
Very underweight 2
Underweight 1
20-25
Desirable weight
25-30
Overweight
>30
Obese

84. Step 2 - ‘MUST’ and weight loss
Unintentional weight loss over a period of 3-6 months is an indicator of acute or recent-onset malnutrition
If previous weight is unavailable, subjective criteria include:
Clothes and/or jewellery having become loose
History of reduced food intake, reduced appetite, and swallowing problems
Over 3–6+ months, underlying disease of psychosocial or physical disability  weight loss

85. Step 2 - MUST and weight loss
Score
Unplanned weight loss in past 3-6 months (% body weight)
Significance 2
>10%
Clinically significant weight loss 1
5-10%
Exceeds normal variation - early indicator of increased risk of under-nutrition
<5%
A ‘normal’ level variation for individuals

86. STEP 3 Acute disease effect
Most likely to apply to patients in hospital
Applies to patients who have had or are likely to have no nutritional intake for more than five days
‘MUST’ Score: Add 2 if acute disease effect applies

87. STEP 4 - Overall risk of malnutrition
Total of scores from steps 1, 2 and 3
Document score

88. STEP 5 Nutrition Care Plan
Low risk of malnutrition
Repeat screening weekly
Medium and high risk of malnutrition
Nutritional intervention – refer to dietitian

89. Need to Screen in all healthcare institutions
Get the surgeons on board
Manage obesity in hopsital – huge missed opportunity

90. 10 Key Characteristics of good nutritional care in hospitals
All patients are screened on admission to identify the patients who are malnourished or at of becoming malnourished. All patients are re-screened weekly.
All patients have a care plan which identifies their nutritional care needs and how they are to be met.

91. 10 Key Characteristics of good nutritional care in hospitals
The hospital includes specific guidance on food services and nutritional care in its Clinical Paths
Patients are involved in the planning and monitoring arrangements for food service provision.
The ward implements Protected Mealtimes to provide an environment conducive to patients enjoying and being able to eat their food.

92. 10 Key Characteristics of good nutritional care in hospitals
All staff have the appropriate skills and competencies needed to ensure that patient’s nutritional needs are met.
All staff receive regular training on nutritional care and management.
Hospital facilities are designed to be flexible and patient centred with the aim of providing and delivering an excellent experience of food service and nutritional care 24 hours a day, every day.

93. 10 Key Characteristics of good nutritional care in hospitals
The hospital has a policy for food service and nutritional care which is patient centred and performance managed in line with home country governance frameworks.
Food service and nutritional care is delivered to the patient safely.
The hospital supports a multi-disciplinary approach to nutritional care and values the contribution of all staff groups working in partnership with patients and users.

94. Thank you.