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The Medical Management of Obesity
Nerys WilliamsConsultant Occupational Physician and former
Honorary Consultant in Obesity and Weight Management
Firefit, Durham6 July 2009
(the views expressed are personal and not those of any employer)
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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
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Size of Problem - US
Mokhdad 1991
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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)
0
5
10
15
20
25
1993
1995
1997
1999
year%
BM
I >
30
Men Women
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%
Projected trend for BMI>30 in EU over 25 years
0
5
10
15
20
25
30
35
40
45
2005 2010 2015 2020 2025 2030
Year
%
IOTF projection 2005
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Causes of Obesity
Heredity Familial Demographic factors
age gender ethnicity social class marital status
Physical inactivity Dietary intake Smoking
cessation Drugs ( steroids,
lithium, sulphonylureas)
rarely endocrine disorders
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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
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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.
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Interaction
Genes load the gun and environment pulls the trigger
George Bray 1996
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Definitions
Weight is only a limited surrogate for obesity Body mass index = kg/m2
WHO classification Underweight < 18.5 Normal 18.5-24.9 Overweight 25-29.9 Obese 30-34.9 class I Obese 35-39.9 class II Extreme obesity 40 + class III
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Caution With BMI
Case study JM 27 years Height 6 ft 4 ins Weight 325 lbs BMI 39.6
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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 ?
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Waist Measurement
Umbilicus ? Narrowest part ? Midway rib and
pelvis ? Other ?
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Amended WHO Definitions of Obesity(Taking Into Account Waist Circumference)
BMI Men <102cmWomen <88 cm
Men > 102cmWomen 88cm
Underweight <18.5
Normal 19-24.9 Average Average
Overweight 25-29.9 Increased High
Obese 30-34.9 Class I High Very High
Obese 35-39.9 Class II Very High Very High
Extreme obesity 40 + Class III Extremely high
* Disease risks
Extremely high
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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)
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Defining abdominal obesity
Waist circumference (Caucasians)
Men >94 - 102 cm
Women >80 - 88 cm
WHO 894 Obesity Report
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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
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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
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Health Risks
risks increase as obesity increases
risks increase as visceral fat increases
risks best defined in type 2 DM and in hypertension
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Risk of Diabetes with rising BMI
0
5
10
15
20
Age adjusted relative risk
<21 <23 <25 <27 <31 >35
BMI (kg/m2)
Age adjusted models of type 2 diabetes risk according to BMI
BMI (kg/m2)
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Implications for Occupational Health
Short term absencesObesity in women Overweight and obesity in men
Long term absencesOverweight 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 www.eupha.org/html/2005
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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
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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 ?
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Prejudice and presumptions
Prejudiceemployers
healthcare service
providers
Discrimination
Perceptionslack self controllazyless intelligentless likely to have
friends
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Prejudice and presumptions
UK Personnel Today Survey November 2005
PCTBMI >30 not allowed hip replacements on the basis of “clinical risk of failure”
Is this Ethical ? Moral ? Judgemental ?
Impact on obesity and work ?
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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)
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Prevention of Obesity
Key Objective Prevent normal
weight people becoming overweight
Prevent overweight people becoming obese
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Individual vs. Environment
Individual
screening, support, weight loss clinics Environment
Increase activity in tasks Increase opportunities for activity Reduce opportunities to consume calories
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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”
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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
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Rationale for Physical Activityin 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
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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
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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
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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
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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
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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
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Public Health Initiatives
Health trainers Training of primary care staff Directory of courses/training Patient activity questionnaires Change4life NOF NOW 2009
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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
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SummaryYour Choices
Manage the condition or
Manage the complications