the obese woman
DESCRIPTION
This is a look at the physiology of obesity and the effects on the woman in terms of illness.TRANSCRIPT
An exploration of problems for the obese woman in Obstetrics and Gynaecology for Primary Care Specialists
bull Epidemiologybull Science of obesity bull General diseasebull Gynae cancersbull Subfertilitybull Pregnancybull Contraception
Dr Jane WilcockBSc FRCGP MA H EdYear 3 academic curriculum lead University of LiverpoolCommunity clinical tutor General Practitioner Silverdale Medical Practice ( formerly Lowry Medical Practice) Salford
How much has obesity risen in the UK over the past eight years 1993 16 of women were obese2011 26 of women
bull Definitionsbull BMI 25-30 overweightbull BMI 30+ obesebull BMI40+ severely obesebull BMIgt50 extreme obesity
bull Concerns relate to abdominal obesity and so waist sizeWomen 88cm 34ins increases the risk of T2DM x 3
Science of obesity
Relationships between fat GIT ovaries and the brain
are complex uncertain and interesting
Fat increases with age It is related to ethnicity Visceral obesity increases after the menopause
135 genes identified as related to obesity so far
Epigenetics (foetal programming)
Subcutaneous fat doesnrsquot really matter but white fat around the abdomen proliferates sets up inflammation cell death and causes disease
Is obesity a low grade inflammatory process
Interleukins and TNF-alfa are released in obesity
Where does the brain control obesity
Paraventricular nucleus and arcuate nucleus at the hypothalamus control hunger satiety
Ghrelin acts on the hypothalamus to increase appetite increases gastric acid and GIT motilityHigh levels occur before eatingHigh levels in Prader-Willi syndromeLower levels after bariatric surgery BUT not reduced in obesity Ghrelin produced from GITsecreted by an empty stomach
Vagus nerve Reduces appetite
Leptin is secreted by fat cellswhen lipid levels arehigh and regulates fat storesReduces appetiteIncreased levels in obesity BUT patients are Leptin resistant
Fat cells are endocrine organs
SecreteOestrogen
Secrete Leptinto cause satietyBut obesity has high leptin levels but leptinresistance
Secrete Adiponectinwhich regulates fatty acidand glucose metabolismIncreases insulin sensitivityIncreased by pioglitazoneLow levels in obesityRelated to insulin resistance
Thiazolidines (glitazones pioglitazone) modulates the transcription of the insulin-sensitive genes involved in the control of glucose and lipid metabolism in muscle fat and
liver
Metabolic syndrome
Lack of confidenceDepressionCVA
CHD
HypertensionDyslipidaemia
Type 2 DMGallstonesCKD in type 2 DMNAFLDNASHcirrhosis
SnoringSleep apnoea
DVTLeg oedema
Life expectancy reduced by 3-10 years inobese people Obesitycontributes to 1 in 13 deaths in Europe
Cancers any age but cancer is age related163 endometrial cancer131 gallbladder cancerKidneyLiverColonCervixThyroid109 Ovary105Postmenopausal breastcancerPancreasRectumLeukaemiaAssociation with increased BMI and adenocarcinomaof the oesophagusin non-smokers pancreas and gastric in non-smokers
Increased BMI reduces risk of premenopausal breast cancer
bull 2 of thyroid cancer and
30 endometrial cancers in the UK
due to overweight and obese BMIs
bull Risk of endometrial cancer is increased by x 2-3 and
if very obese increased by x 6
bull Physical activity can reduce endometrial cancer risk by 20-30
bull PCOS women have an increased x 4 risk of endometrial cancer pre-menopause related to obesity
50 of obese people do not think that losing weight reduces their risk of cancer
Maternal deathDVTDMPETSevere haemorrhageLabour inductionShoulder dystociaDelivery by caesarean section General anaesthesia and anaesthetic complications
Early onset obesity is related tooligomenorrhoeamenstrual irregularityanovulation and subfertility
Increased rate of miscarriage
Reduced IVF if BMIgt30women are less likely to come for help with fertility and if BMIgt40 less likely to be accepted for treatment
Ovulatory obese women have an increased rate of subfertility but may have less sex
Male obesity associated with low testosteroneLow LH and FSHReduced spermatogenesisIncreased EDReduced libido
Conception and Pregnancy
poor perinatal outcomesmacrosomiaincluding stillbirth and neonatal death
Bottom LinesHigher maternal complications and mortalityHigher perinatal complications and mortalityMore difficult to conceive
Measure BMI and waist at bookingRefer for nutritional advice and exercise programmesAsk women to keep BMI 20-25 in pregnancy (Asian women 23)Take folic acid 5mg a dayThink T2DM and BPMay end up on heparin (DVT) and aspirin ( if one other risk
factor for PET and obese)Bariatric surgery Nutritional deficiency and problems donrsquot
conceive for 12 monthsMultidisciplinary teams required
Contraception
CHC
FRSH consider risks of DVT and hypertension in
Assessing CHC and possibly CHC is less effective
BMIgt35 risk 3 (donrsquot use)
BMI 30-34 probably okay risk2
POP okay
Nexplanon Current Faculty guidance states that women
with a BMI gt 30 can use a progestogen-only implant without restriction and without a reduction in contraceptive efficacy for the duration of the licensed use
Depo-provera increased weight gain than non-obese women but recommended
IUS and Cu-IUCD may be difficult to insert but recommended
Emergency contraceptions
Copper bearing intrauterine device Cu- IUCD
Ulipristal acetate (UPA) Ella One
Levonorgestrel (LNG)
Nov 2013 ldquoIn clinical trials contraceptive efficacy was reduced in women weighing 75 kg or more and levonorgestrel was not effective in women who weighed more than 80 kgldquo
This has been reversed by FRSH June 2014
ldquoEmergency contraceptives can continue to be used to prevent
unintended pregnancy in women of any weight or body mass index
(BMI) The available data are limited and not robust enough to support
with certainty the conclusion of decreased contraceptive effect with
increased bodyweightBMIrdquo
Obesity is not a contraindication to any of these methods
Summary
bull The obese woman attending the GP or Nurse should be thought of holistically not just BP and CHD risk
bull Risks re conception pregnancy outcomes and cancer are not widely known and discussed
bull There is a whole skill set to develop in discussing these issues
Thankyou
bull Articles used in this slide set
ndash httpwwwnhsuknews201302FebruaryPagesLatest-obesity-stats-for-England-are-alarming-readingaspx NHS Choices
ndash Annals of the New York Academy of Sciences 2012 Obesity and cancer risk evidence mechanisms and recommendations by Vucenik et al
ndash wwwnhsuknew20307JulyDoes genetic fat mutation cause obesityndash wwwcancerresearchukobesityndash Obesity and infertility by Pasquali R Patton L Gamineri A Curr Opin Endcrinol
Diabetes Obes 2007 Dec 14(6) 482-7 wwwncbinimnihgovpubmedndash Obesity and male infertility Ahmad O Hammond et al Obesity and Male Infertility
Semin Reprod Med 2012 30(6) 468-495ndash Nature July 2014 Neuroscience Dissecting appetite Bijal P Trivedi Nature 508 S64ndashS65
(17 April 2014) Published online 16 April 2014 Obes Rev 2007 Jan8(1)21-34 The role of leptin and ghrelin in the regulation of food intake and body weight in humans a review Klok MD1 Jakobsdottir S Drent ML
ndash Obes Rev 2005 Feb6(1)13-21 Adiponectin action regulation and association to insulin sensitivity Lihn AS1 Pedersen SB Richelsen B
ndash Obesity and Reproductive Health- study group statement RCOG clinical guideance on line accessed 0814 at wwwrcoguk
ndash First Nordic Conference on Obesity 9n Gynaecology and Obstetrics Jorgensen JS et al May 2013 Acta Obstetrica et Gynaecologica Scandinavia 93 pp 982-987
ndash Slide illustration templates Grace at magicsheepiehotmailcouk
How much has obesity risen in the UK over the past eight years 1993 16 of women were obese2011 26 of women
bull Definitionsbull BMI 25-30 overweightbull BMI 30+ obesebull BMI40+ severely obesebull BMIgt50 extreme obesity
bull Concerns relate to abdominal obesity and so waist sizeWomen 88cm 34ins increases the risk of T2DM x 3
Science of obesity
Relationships between fat GIT ovaries and the brain
are complex uncertain and interesting
Fat increases with age It is related to ethnicity Visceral obesity increases after the menopause
135 genes identified as related to obesity so far
Epigenetics (foetal programming)
Subcutaneous fat doesnrsquot really matter but white fat around the abdomen proliferates sets up inflammation cell death and causes disease
Is obesity a low grade inflammatory process
Interleukins and TNF-alfa are released in obesity
Where does the brain control obesity
Paraventricular nucleus and arcuate nucleus at the hypothalamus control hunger satiety
Ghrelin acts on the hypothalamus to increase appetite increases gastric acid and GIT motilityHigh levels occur before eatingHigh levels in Prader-Willi syndromeLower levels after bariatric surgery BUT not reduced in obesity Ghrelin produced from GITsecreted by an empty stomach
Vagus nerve Reduces appetite
Leptin is secreted by fat cellswhen lipid levels arehigh and regulates fat storesReduces appetiteIncreased levels in obesity BUT patients are Leptin resistant
Fat cells are endocrine organs
SecreteOestrogen
Secrete Leptinto cause satietyBut obesity has high leptin levels but leptinresistance
Secrete Adiponectinwhich regulates fatty acidand glucose metabolismIncreases insulin sensitivityIncreased by pioglitazoneLow levels in obesityRelated to insulin resistance
Thiazolidines (glitazones pioglitazone) modulates the transcription of the insulin-sensitive genes involved in the control of glucose and lipid metabolism in muscle fat and
liver
Metabolic syndrome
Lack of confidenceDepressionCVA
CHD
HypertensionDyslipidaemia
Type 2 DMGallstonesCKD in type 2 DMNAFLDNASHcirrhosis
SnoringSleep apnoea
DVTLeg oedema
Life expectancy reduced by 3-10 years inobese people Obesitycontributes to 1 in 13 deaths in Europe
Cancers any age but cancer is age related163 endometrial cancer131 gallbladder cancerKidneyLiverColonCervixThyroid109 Ovary105Postmenopausal breastcancerPancreasRectumLeukaemiaAssociation with increased BMI and adenocarcinomaof the oesophagusin non-smokers pancreas and gastric in non-smokers
Increased BMI reduces risk of premenopausal breast cancer
bull 2 of thyroid cancer and
30 endometrial cancers in the UK
due to overweight and obese BMIs
bull Risk of endometrial cancer is increased by x 2-3 and
if very obese increased by x 6
bull Physical activity can reduce endometrial cancer risk by 20-30
bull PCOS women have an increased x 4 risk of endometrial cancer pre-menopause related to obesity
50 of obese people do not think that losing weight reduces their risk of cancer
Maternal deathDVTDMPETSevere haemorrhageLabour inductionShoulder dystociaDelivery by caesarean section General anaesthesia and anaesthetic complications
Early onset obesity is related tooligomenorrhoeamenstrual irregularityanovulation and subfertility
Increased rate of miscarriage
Reduced IVF if BMIgt30women are less likely to come for help with fertility and if BMIgt40 less likely to be accepted for treatment
Ovulatory obese women have an increased rate of subfertility but may have less sex
Male obesity associated with low testosteroneLow LH and FSHReduced spermatogenesisIncreased EDReduced libido
Conception and Pregnancy
poor perinatal outcomesmacrosomiaincluding stillbirth and neonatal death
Bottom LinesHigher maternal complications and mortalityHigher perinatal complications and mortalityMore difficult to conceive
Measure BMI and waist at bookingRefer for nutritional advice and exercise programmesAsk women to keep BMI 20-25 in pregnancy (Asian women 23)Take folic acid 5mg a dayThink T2DM and BPMay end up on heparin (DVT) and aspirin ( if one other risk
factor for PET and obese)Bariatric surgery Nutritional deficiency and problems donrsquot
conceive for 12 monthsMultidisciplinary teams required
Contraception
CHC
FRSH consider risks of DVT and hypertension in
Assessing CHC and possibly CHC is less effective
BMIgt35 risk 3 (donrsquot use)
BMI 30-34 probably okay risk2
POP okay
Nexplanon Current Faculty guidance states that women
with a BMI gt 30 can use a progestogen-only implant without restriction and without a reduction in contraceptive efficacy for the duration of the licensed use
Depo-provera increased weight gain than non-obese women but recommended
IUS and Cu-IUCD may be difficult to insert but recommended
Emergency contraceptions
Copper bearing intrauterine device Cu- IUCD
Ulipristal acetate (UPA) Ella One
Levonorgestrel (LNG)
Nov 2013 ldquoIn clinical trials contraceptive efficacy was reduced in women weighing 75 kg or more and levonorgestrel was not effective in women who weighed more than 80 kgldquo
This has been reversed by FRSH June 2014
ldquoEmergency contraceptives can continue to be used to prevent
unintended pregnancy in women of any weight or body mass index
(BMI) The available data are limited and not robust enough to support
with certainty the conclusion of decreased contraceptive effect with
increased bodyweightBMIrdquo
Obesity is not a contraindication to any of these methods
Summary
bull The obese woman attending the GP or Nurse should be thought of holistically not just BP and CHD risk
bull Risks re conception pregnancy outcomes and cancer are not widely known and discussed
bull There is a whole skill set to develop in discussing these issues
Thankyou
bull Articles used in this slide set
ndash httpwwwnhsuknews201302FebruaryPagesLatest-obesity-stats-for-England-are-alarming-readingaspx NHS Choices
ndash Annals of the New York Academy of Sciences 2012 Obesity and cancer risk evidence mechanisms and recommendations by Vucenik et al
ndash wwwnhsuknew20307JulyDoes genetic fat mutation cause obesityndash wwwcancerresearchukobesityndash Obesity and infertility by Pasquali R Patton L Gamineri A Curr Opin Endcrinol
Diabetes Obes 2007 Dec 14(6) 482-7 wwwncbinimnihgovpubmedndash Obesity and male infertility Ahmad O Hammond et al Obesity and Male Infertility
Semin Reprod Med 2012 30(6) 468-495ndash Nature July 2014 Neuroscience Dissecting appetite Bijal P Trivedi Nature 508 S64ndashS65
(17 April 2014) Published online 16 April 2014 Obes Rev 2007 Jan8(1)21-34 The role of leptin and ghrelin in the regulation of food intake and body weight in humans a review Klok MD1 Jakobsdottir S Drent ML
ndash Obes Rev 2005 Feb6(1)13-21 Adiponectin action regulation and association to insulin sensitivity Lihn AS1 Pedersen SB Richelsen B
ndash Obesity and Reproductive Health- study group statement RCOG clinical guideance on line accessed 0814 at wwwrcoguk
ndash First Nordic Conference on Obesity 9n Gynaecology and Obstetrics Jorgensen JS et al May 2013 Acta Obstetrica et Gynaecologica Scandinavia 93 pp 982-987
ndash Slide illustration templates Grace at magicsheepiehotmailcouk
Science of obesity
Relationships between fat GIT ovaries and the brain
are complex uncertain and interesting
Fat increases with age It is related to ethnicity Visceral obesity increases after the menopause
135 genes identified as related to obesity so far
Epigenetics (foetal programming)
Subcutaneous fat doesnrsquot really matter but white fat around the abdomen proliferates sets up inflammation cell death and causes disease
Is obesity a low grade inflammatory process
Interleukins and TNF-alfa are released in obesity
Where does the brain control obesity
Paraventricular nucleus and arcuate nucleus at the hypothalamus control hunger satiety
Ghrelin acts on the hypothalamus to increase appetite increases gastric acid and GIT motilityHigh levels occur before eatingHigh levels in Prader-Willi syndromeLower levels after bariatric surgery BUT not reduced in obesity Ghrelin produced from GITsecreted by an empty stomach
Vagus nerve Reduces appetite
Leptin is secreted by fat cellswhen lipid levels arehigh and regulates fat storesReduces appetiteIncreased levels in obesity BUT patients are Leptin resistant
Fat cells are endocrine organs
SecreteOestrogen
Secrete Leptinto cause satietyBut obesity has high leptin levels but leptinresistance
Secrete Adiponectinwhich regulates fatty acidand glucose metabolismIncreases insulin sensitivityIncreased by pioglitazoneLow levels in obesityRelated to insulin resistance
Thiazolidines (glitazones pioglitazone) modulates the transcription of the insulin-sensitive genes involved in the control of glucose and lipid metabolism in muscle fat and
liver
Metabolic syndrome
Lack of confidenceDepressionCVA
CHD
HypertensionDyslipidaemia
Type 2 DMGallstonesCKD in type 2 DMNAFLDNASHcirrhosis
SnoringSleep apnoea
DVTLeg oedema
Life expectancy reduced by 3-10 years inobese people Obesitycontributes to 1 in 13 deaths in Europe
Cancers any age but cancer is age related163 endometrial cancer131 gallbladder cancerKidneyLiverColonCervixThyroid109 Ovary105Postmenopausal breastcancerPancreasRectumLeukaemiaAssociation with increased BMI and adenocarcinomaof the oesophagusin non-smokers pancreas and gastric in non-smokers
Increased BMI reduces risk of premenopausal breast cancer
bull 2 of thyroid cancer and
30 endometrial cancers in the UK
due to overweight and obese BMIs
bull Risk of endometrial cancer is increased by x 2-3 and
if very obese increased by x 6
bull Physical activity can reduce endometrial cancer risk by 20-30
bull PCOS women have an increased x 4 risk of endometrial cancer pre-menopause related to obesity
50 of obese people do not think that losing weight reduces their risk of cancer
Maternal deathDVTDMPETSevere haemorrhageLabour inductionShoulder dystociaDelivery by caesarean section General anaesthesia and anaesthetic complications
Early onset obesity is related tooligomenorrhoeamenstrual irregularityanovulation and subfertility
Increased rate of miscarriage
Reduced IVF if BMIgt30women are less likely to come for help with fertility and if BMIgt40 less likely to be accepted for treatment
Ovulatory obese women have an increased rate of subfertility but may have less sex
Male obesity associated with low testosteroneLow LH and FSHReduced spermatogenesisIncreased EDReduced libido
Conception and Pregnancy
poor perinatal outcomesmacrosomiaincluding stillbirth and neonatal death
Bottom LinesHigher maternal complications and mortalityHigher perinatal complications and mortalityMore difficult to conceive
Measure BMI and waist at bookingRefer for nutritional advice and exercise programmesAsk women to keep BMI 20-25 in pregnancy (Asian women 23)Take folic acid 5mg a dayThink T2DM and BPMay end up on heparin (DVT) and aspirin ( if one other risk
factor for PET and obese)Bariatric surgery Nutritional deficiency and problems donrsquot
conceive for 12 monthsMultidisciplinary teams required
Contraception
CHC
FRSH consider risks of DVT and hypertension in
Assessing CHC and possibly CHC is less effective
BMIgt35 risk 3 (donrsquot use)
BMI 30-34 probably okay risk2
POP okay
Nexplanon Current Faculty guidance states that women
with a BMI gt 30 can use a progestogen-only implant without restriction and without a reduction in contraceptive efficacy for the duration of the licensed use
Depo-provera increased weight gain than non-obese women but recommended
IUS and Cu-IUCD may be difficult to insert but recommended
Emergency contraceptions
Copper bearing intrauterine device Cu- IUCD
Ulipristal acetate (UPA) Ella One
Levonorgestrel (LNG)
Nov 2013 ldquoIn clinical trials contraceptive efficacy was reduced in women weighing 75 kg or more and levonorgestrel was not effective in women who weighed more than 80 kgldquo
This has been reversed by FRSH June 2014
ldquoEmergency contraceptives can continue to be used to prevent
unintended pregnancy in women of any weight or body mass index
(BMI) The available data are limited and not robust enough to support
with certainty the conclusion of decreased contraceptive effect with
increased bodyweightBMIrdquo
Obesity is not a contraindication to any of these methods
Summary
bull The obese woman attending the GP or Nurse should be thought of holistically not just BP and CHD risk
bull Risks re conception pregnancy outcomes and cancer are not widely known and discussed
bull There is a whole skill set to develop in discussing these issues
Thankyou
bull Articles used in this slide set
ndash httpwwwnhsuknews201302FebruaryPagesLatest-obesity-stats-for-England-are-alarming-readingaspx NHS Choices
ndash Annals of the New York Academy of Sciences 2012 Obesity and cancer risk evidence mechanisms and recommendations by Vucenik et al
ndash wwwnhsuknew20307JulyDoes genetic fat mutation cause obesityndash wwwcancerresearchukobesityndash Obesity and infertility by Pasquali R Patton L Gamineri A Curr Opin Endcrinol
Diabetes Obes 2007 Dec 14(6) 482-7 wwwncbinimnihgovpubmedndash Obesity and male infertility Ahmad O Hammond et al Obesity and Male Infertility
Semin Reprod Med 2012 30(6) 468-495ndash Nature July 2014 Neuroscience Dissecting appetite Bijal P Trivedi Nature 508 S64ndashS65
(17 April 2014) Published online 16 April 2014 Obes Rev 2007 Jan8(1)21-34 The role of leptin and ghrelin in the regulation of food intake and body weight in humans a review Klok MD1 Jakobsdottir S Drent ML
ndash Obes Rev 2005 Feb6(1)13-21 Adiponectin action regulation and association to insulin sensitivity Lihn AS1 Pedersen SB Richelsen B
ndash Obesity and Reproductive Health- study group statement RCOG clinical guideance on line accessed 0814 at wwwrcoguk
ndash First Nordic Conference on Obesity 9n Gynaecology and Obstetrics Jorgensen JS et al May 2013 Acta Obstetrica et Gynaecologica Scandinavia 93 pp 982-987
ndash Slide illustration templates Grace at magicsheepiehotmailcouk
Where does the brain control obesity
Paraventricular nucleus and arcuate nucleus at the hypothalamus control hunger satiety
Ghrelin acts on the hypothalamus to increase appetite increases gastric acid and GIT motilityHigh levels occur before eatingHigh levels in Prader-Willi syndromeLower levels after bariatric surgery BUT not reduced in obesity Ghrelin produced from GITsecreted by an empty stomach
Vagus nerve Reduces appetite
Leptin is secreted by fat cellswhen lipid levels arehigh and regulates fat storesReduces appetiteIncreased levels in obesity BUT patients are Leptin resistant
Fat cells are endocrine organs
SecreteOestrogen
Secrete Leptinto cause satietyBut obesity has high leptin levels but leptinresistance
Secrete Adiponectinwhich regulates fatty acidand glucose metabolismIncreases insulin sensitivityIncreased by pioglitazoneLow levels in obesityRelated to insulin resistance
Thiazolidines (glitazones pioglitazone) modulates the transcription of the insulin-sensitive genes involved in the control of glucose and lipid metabolism in muscle fat and
liver
Metabolic syndrome
Lack of confidenceDepressionCVA
CHD
HypertensionDyslipidaemia
Type 2 DMGallstonesCKD in type 2 DMNAFLDNASHcirrhosis
SnoringSleep apnoea
DVTLeg oedema
Life expectancy reduced by 3-10 years inobese people Obesitycontributes to 1 in 13 deaths in Europe
Cancers any age but cancer is age related163 endometrial cancer131 gallbladder cancerKidneyLiverColonCervixThyroid109 Ovary105Postmenopausal breastcancerPancreasRectumLeukaemiaAssociation with increased BMI and adenocarcinomaof the oesophagusin non-smokers pancreas and gastric in non-smokers
Increased BMI reduces risk of premenopausal breast cancer
bull 2 of thyroid cancer and
30 endometrial cancers in the UK
due to overweight and obese BMIs
bull Risk of endometrial cancer is increased by x 2-3 and
if very obese increased by x 6
bull Physical activity can reduce endometrial cancer risk by 20-30
bull PCOS women have an increased x 4 risk of endometrial cancer pre-menopause related to obesity
50 of obese people do not think that losing weight reduces their risk of cancer
Maternal deathDVTDMPETSevere haemorrhageLabour inductionShoulder dystociaDelivery by caesarean section General anaesthesia and anaesthetic complications
Early onset obesity is related tooligomenorrhoeamenstrual irregularityanovulation and subfertility
Increased rate of miscarriage
Reduced IVF if BMIgt30women are less likely to come for help with fertility and if BMIgt40 less likely to be accepted for treatment
Ovulatory obese women have an increased rate of subfertility but may have less sex
Male obesity associated with low testosteroneLow LH and FSHReduced spermatogenesisIncreased EDReduced libido
Conception and Pregnancy
poor perinatal outcomesmacrosomiaincluding stillbirth and neonatal death
Bottom LinesHigher maternal complications and mortalityHigher perinatal complications and mortalityMore difficult to conceive
Measure BMI and waist at bookingRefer for nutritional advice and exercise programmesAsk women to keep BMI 20-25 in pregnancy (Asian women 23)Take folic acid 5mg a dayThink T2DM and BPMay end up on heparin (DVT) and aspirin ( if one other risk
factor for PET and obese)Bariatric surgery Nutritional deficiency and problems donrsquot
conceive for 12 monthsMultidisciplinary teams required
Contraception
CHC
FRSH consider risks of DVT and hypertension in
Assessing CHC and possibly CHC is less effective
BMIgt35 risk 3 (donrsquot use)
BMI 30-34 probably okay risk2
POP okay
Nexplanon Current Faculty guidance states that women
with a BMI gt 30 can use a progestogen-only implant without restriction and without a reduction in contraceptive efficacy for the duration of the licensed use
Depo-provera increased weight gain than non-obese women but recommended
IUS and Cu-IUCD may be difficult to insert but recommended
Emergency contraceptions
Copper bearing intrauterine device Cu- IUCD
Ulipristal acetate (UPA) Ella One
Levonorgestrel (LNG)
Nov 2013 ldquoIn clinical trials contraceptive efficacy was reduced in women weighing 75 kg or more and levonorgestrel was not effective in women who weighed more than 80 kgldquo
This has been reversed by FRSH June 2014
ldquoEmergency contraceptives can continue to be used to prevent
unintended pregnancy in women of any weight or body mass index
(BMI) The available data are limited and not robust enough to support
with certainty the conclusion of decreased contraceptive effect with
increased bodyweightBMIrdquo
Obesity is not a contraindication to any of these methods
Summary
bull The obese woman attending the GP or Nurse should be thought of holistically not just BP and CHD risk
bull Risks re conception pregnancy outcomes and cancer are not widely known and discussed
bull There is a whole skill set to develop in discussing these issues
Thankyou
bull Articles used in this slide set
ndash httpwwwnhsuknews201302FebruaryPagesLatest-obesity-stats-for-England-are-alarming-readingaspx NHS Choices
ndash Annals of the New York Academy of Sciences 2012 Obesity and cancer risk evidence mechanisms and recommendations by Vucenik et al
ndash wwwnhsuknew20307JulyDoes genetic fat mutation cause obesityndash wwwcancerresearchukobesityndash Obesity and infertility by Pasquali R Patton L Gamineri A Curr Opin Endcrinol
Diabetes Obes 2007 Dec 14(6) 482-7 wwwncbinimnihgovpubmedndash Obesity and male infertility Ahmad O Hammond et al Obesity and Male Infertility
Semin Reprod Med 2012 30(6) 468-495ndash Nature July 2014 Neuroscience Dissecting appetite Bijal P Trivedi Nature 508 S64ndashS65
(17 April 2014) Published online 16 April 2014 Obes Rev 2007 Jan8(1)21-34 The role of leptin and ghrelin in the regulation of food intake and body weight in humans a review Klok MD1 Jakobsdottir S Drent ML
ndash Obes Rev 2005 Feb6(1)13-21 Adiponectin action regulation and association to insulin sensitivity Lihn AS1 Pedersen SB Richelsen B
ndash Obesity and Reproductive Health- study group statement RCOG clinical guideance on line accessed 0814 at wwwrcoguk
ndash First Nordic Conference on Obesity 9n Gynaecology and Obstetrics Jorgensen JS et al May 2013 Acta Obstetrica et Gynaecologica Scandinavia 93 pp 982-987
ndash Slide illustration templates Grace at magicsheepiehotmailcouk
Fat cells are endocrine organs
SecreteOestrogen
Secrete Leptinto cause satietyBut obesity has high leptin levels but leptinresistance
Secrete Adiponectinwhich regulates fatty acidand glucose metabolismIncreases insulin sensitivityIncreased by pioglitazoneLow levels in obesityRelated to insulin resistance
Thiazolidines (glitazones pioglitazone) modulates the transcription of the insulin-sensitive genes involved in the control of glucose and lipid metabolism in muscle fat and
liver
Metabolic syndrome
Lack of confidenceDepressionCVA
CHD
HypertensionDyslipidaemia
Type 2 DMGallstonesCKD in type 2 DMNAFLDNASHcirrhosis
SnoringSleep apnoea
DVTLeg oedema
Life expectancy reduced by 3-10 years inobese people Obesitycontributes to 1 in 13 deaths in Europe
Cancers any age but cancer is age related163 endometrial cancer131 gallbladder cancerKidneyLiverColonCervixThyroid109 Ovary105Postmenopausal breastcancerPancreasRectumLeukaemiaAssociation with increased BMI and adenocarcinomaof the oesophagusin non-smokers pancreas and gastric in non-smokers
Increased BMI reduces risk of premenopausal breast cancer
bull 2 of thyroid cancer and
30 endometrial cancers in the UK
due to overweight and obese BMIs
bull Risk of endometrial cancer is increased by x 2-3 and
if very obese increased by x 6
bull Physical activity can reduce endometrial cancer risk by 20-30
bull PCOS women have an increased x 4 risk of endometrial cancer pre-menopause related to obesity
50 of obese people do not think that losing weight reduces their risk of cancer
Maternal deathDVTDMPETSevere haemorrhageLabour inductionShoulder dystociaDelivery by caesarean section General anaesthesia and anaesthetic complications
Early onset obesity is related tooligomenorrhoeamenstrual irregularityanovulation and subfertility
Increased rate of miscarriage
Reduced IVF if BMIgt30women are less likely to come for help with fertility and if BMIgt40 less likely to be accepted for treatment
Ovulatory obese women have an increased rate of subfertility but may have less sex
Male obesity associated with low testosteroneLow LH and FSHReduced spermatogenesisIncreased EDReduced libido
Conception and Pregnancy
poor perinatal outcomesmacrosomiaincluding stillbirth and neonatal death
Bottom LinesHigher maternal complications and mortalityHigher perinatal complications and mortalityMore difficult to conceive
Measure BMI and waist at bookingRefer for nutritional advice and exercise programmesAsk women to keep BMI 20-25 in pregnancy (Asian women 23)Take folic acid 5mg a dayThink T2DM and BPMay end up on heparin (DVT) and aspirin ( if one other risk
factor for PET and obese)Bariatric surgery Nutritional deficiency and problems donrsquot
conceive for 12 monthsMultidisciplinary teams required
Contraception
CHC
FRSH consider risks of DVT and hypertension in
Assessing CHC and possibly CHC is less effective
BMIgt35 risk 3 (donrsquot use)
BMI 30-34 probably okay risk2
POP okay
Nexplanon Current Faculty guidance states that women
with a BMI gt 30 can use a progestogen-only implant without restriction and without a reduction in contraceptive efficacy for the duration of the licensed use
Depo-provera increased weight gain than non-obese women but recommended
IUS and Cu-IUCD may be difficult to insert but recommended
Emergency contraceptions
Copper bearing intrauterine device Cu- IUCD
Ulipristal acetate (UPA) Ella One
Levonorgestrel (LNG)
Nov 2013 ldquoIn clinical trials contraceptive efficacy was reduced in women weighing 75 kg or more and levonorgestrel was not effective in women who weighed more than 80 kgldquo
This has been reversed by FRSH June 2014
ldquoEmergency contraceptives can continue to be used to prevent
unintended pregnancy in women of any weight or body mass index
(BMI) The available data are limited and not robust enough to support
with certainty the conclusion of decreased contraceptive effect with
increased bodyweightBMIrdquo
Obesity is not a contraindication to any of these methods
Summary
bull The obese woman attending the GP or Nurse should be thought of holistically not just BP and CHD risk
bull Risks re conception pregnancy outcomes and cancer are not widely known and discussed
bull There is a whole skill set to develop in discussing these issues
Thankyou
bull Articles used in this slide set
ndash httpwwwnhsuknews201302FebruaryPagesLatest-obesity-stats-for-England-are-alarming-readingaspx NHS Choices
ndash Annals of the New York Academy of Sciences 2012 Obesity and cancer risk evidence mechanisms and recommendations by Vucenik et al
ndash wwwnhsuknew20307JulyDoes genetic fat mutation cause obesityndash wwwcancerresearchukobesityndash Obesity and infertility by Pasquali R Patton L Gamineri A Curr Opin Endcrinol
Diabetes Obes 2007 Dec 14(6) 482-7 wwwncbinimnihgovpubmedndash Obesity and male infertility Ahmad O Hammond et al Obesity and Male Infertility
Semin Reprod Med 2012 30(6) 468-495ndash Nature July 2014 Neuroscience Dissecting appetite Bijal P Trivedi Nature 508 S64ndashS65
(17 April 2014) Published online 16 April 2014 Obes Rev 2007 Jan8(1)21-34 The role of leptin and ghrelin in the regulation of food intake and body weight in humans a review Klok MD1 Jakobsdottir S Drent ML
ndash Obes Rev 2005 Feb6(1)13-21 Adiponectin action regulation and association to insulin sensitivity Lihn AS1 Pedersen SB Richelsen B
ndash Obesity and Reproductive Health- study group statement RCOG clinical guideance on line accessed 0814 at wwwrcoguk
ndash First Nordic Conference on Obesity 9n Gynaecology and Obstetrics Jorgensen JS et al May 2013 Acta Obstetrica et Gynaecologica Scandinavia 93 pp 982-987
ndash Slide illustration templates Grace at magicsheepiehotmailcouk
Metabolic syndrome
Lack of confidenceDepressionCVA
CHD
HypertensionDyslipidaemia
Type 2 DMGallstonesCKD in type 2 DMNAFLDNASHcirrhosis
SnoringSleep apnoea
DVTLeg oedema
Life expectancy reduced by 3-10 years inobese people Obesitycontributes to 1 in 13 deaths in Europe
Cancers any age but cancer is age related163 endometrial cancer131 gallbladder cancerKidneyLiverColonCervixThyroid109 Ovary105Postmenopausal breastcancerPancreasRectumLeukaemiaAssociation with increased BMI and adenocarcinomaof the oesophagusin non-smokers pancreas and gastric in non-smokers
Increased BMI reduces risk of premenopausal breast cancer
bull 2 of thyroid cancer and
30 endometrial cancers in the UK
due to overweight and obese BMIs
bull Risk of endometrial cancer is increased by x 2-3 and
if very obese increased by x 6
bull Physical activity can reduce endometrial cancer risk by 20-30
bull PCOS women have an increased x 4 risk of endometrial cancer pre-menopause related to obesity
50 of obese people do not think that losing weight reduces their risk of cancer
Maternal deathDVTDMPETSevere haemorrhageLabour inductionShoulder dystociaDelivery by caesarean section General anaesthesia and anaesthetic complications
Early onset obesity is related tooligomenorrhoeamenstrual irregularityanovulation and subfertility
Increased rate of miscarriage
Reduced IVF if BMIgt30women are less likely to come for help with fertility and if BMIgt40 less likely to be accepted for treatment
Ovulatory obese women have an increased rate of subfertility but may have less sex
Male obesity associated with low testosteroneLow LH and FSHReduced spermatogenesisIncreased EDReduced libido
Conception and Pregnancy
poor perinatal outcomesmacrosomiaincluding stillbirth and neonatal death
Bottom LinesHigher maternal complications and mortalityHigher perinatal complications and mortalityMore difficult to conceive
Measure BMI and waist at bookingRefer for nutritional advice and exercise programmesAsk women to keep BMI 20-25 in pregnancy (Asian women 23)Take folic acid 5mg a dayThink T2DM and BPMay end up on heparin (DVT) and aspirin ( if one other risk
factor for PET and obese)Bariatric surgery Nutritional deficiency and problems donrsquot
conceive for 12 monthsMultidisciplinary teams required
Contraception
CHC
FRSH consider risks of DVT and hypertension in
Assessing CHC and possibly CHC is less effective
BMIgt35 risk 3 (donrsquot use)
BMI 30-34 probably okay risk2
POP okay
Nexplanon Current Faculty guidance states that women
with a BMI gt 30 can use a progestogen-only implant without restriction and without a reduction in contraceptive efficacy for the duration of the licensed use
Depo-provera increased weight gain than non-obese women but recommended
IUS and Cu-IUCD may be difficult to insert but recommended
Emergency contraceptions
Copper bearing intrauterine device Cu- IUCD
Ulipristal acetate (UPA) Ella One
Levonorgestrel (LNG)
Nov 2013 ldquoIn clinical trials contraceptive efficacy was reduced in women weighing 75 kg or more and levonorgestrel was not effective in women who weighed more than 80 kgldquo
This has been reversed by FRSH June 2014
ldquoEmergency contraceptives can continue to be used to prevent
unintended pregnancy in women of any weight or body mass index
(BMI) The available data are limited and not robust enough to support
with certainty the conclusion of decreased contraceptive effect with
increased bodyweightBMIrdquo
Obesity is not a contraindication to any of these methods
Summary
bull The obese woman attending the GP or Nurse should be thought of holistically not just BP and CHD risk
bull Risks re conception pregnancy outcomes and cancer are not widely known and discussed
bull There is a whole skill set to develop in discussing these issues
Thankyou
bull Articles used in this slide set
ndash httpwwwnhsuknews201302FebruaryPagesLatest-obesity-stats-for-England-are-alarming-readingaspx NHS Choices
ndash Annals of the New York Academy of Sciences 2012 Obesity and cancer risk evidence mechanisms and recommendations by Vucenik et al
ndash wwwnhsuknew20307JulyDoes genetic fat mutation cause obesityndash wwwcancerresearchukobesityndash Obesity and infertility by Pasquali R Patton L Gamineri A Curr Opin Endcrinol
Diabetes Obes 2007 Dec 14(6) 482-7 wwwncbinimnihgovpubmedndash Obesity and male infertility Ahmad O Hammond et al Obesity and Male Infertility
Semin Reprod Med 2012 30(6) 468-495ndash Nature July 2014 Neuroscience Dissecting appetite Bijal P Trivedi Nature 508 S64ndashS65
(17 April 2014) Published online 16 April 2014 Obes Rev 2007 Jan8(1)21-34 The role of leptin and ghrelin in the regulation of food intake and body weight in humans a review Klok MD1 Jakobsdottir S Drent ML
ndash Obes Rev 2005 Feb6(1)13-21 Adiponectin action regulation and association to insulin sensitivity Lihn AS1 Pedersen SB Richelsen B
ndash Obesity and Reproductive Health- study group statement RCOG clinical guideance on line accessed 0814 at wwwrcoguk
ndash First Nordic Conference on Obesity 9n Gynaecology and Obstetrics Jorgensen JS et al May 2013 Acta Obstetrica et Gynaecologica Scandinavia 93 pp 982-987
ndash Slide illustration templates Grace at magicsheepiehotmailcouk
Cancers any age but cancer is age related163 endometrial cancer131 gallbladder cancerKidneyLiverColonCervixThyroid109 Ovary105Postmenopausal breastcancerPancreasRectumLeukaemiaAssociation with increased BMI and adenocarcinomaof the oesophagusin non-smokers pancreas and gastric in non-smokers
Increased BMI reduces risk of premenopausal breast cancer
bull 2 of thyroid cancer and
30 endometrial cancers in the UK
due to overweight and obese BMIs
bull Risk of endometrial cancer is increased by x 2-3 and
if very obese increased by x 6
bull Physical activity can reduce endometrial cancer risk by 20-30
bull PCOS women have an increased x 4 risk of endometrial cancer pre-menopause related to obesity
50 of obese people do not think that losing weight reduces their risk of cancer
Maternal deathDVTDMPETSevere haemorrhageLabour inductionShoulder dystociaDelivery by caesarean section General anaesthesia and anaesthetic complications
Early onset obesity is related tooligomenorrhoeamenstrual irregularityanovulation and subfertility
Increased rate of miscarriage
Reduced IVF if BMIgt30women are less likely to come for help with fertility and if BMIgt40 less likely to be accepted for treatment
Ovulatory obese women have an increased rate of subfertility but may have less sex
Male obesity associated with low testosteroneLow LH and FSHReduced spermatogenesisIncreased EDReduced libido
Conception and Pregnancy
poor perinatal outcomesmacrosomiaincluding stillbirth and neonatal death
Bottom LinesHigher maternal complications and mortalityHigher perinatal complications and mortalityMore difficult to conceive
Measure BMI and waist at bookingRefer for nutritional advice and exercise programmesAsk women to keep BMI 20-25 in pregnancy (Asian women 23)Take folic acid 5mg a dayThink T2DM and BPMay end up on heparin (DVT) and aspirin ( if one other risk
factor for PET and obese)Bariatric surgery Nutritional deficiency and problems donrsquot
conceive for 12 monthsMultidisciplinary teams required
Contraception
CHC
FRSH consider risks of DVT and hypertension in
Assessing CHC and possibly CHC is less effective
BMIgt35 risk 3 (donrsquot use)
BMI 30-34 probably okay risk2
POP okay
Nexplanon Current Faculty guidance states that women
with a BMI gt 30 can use a progestogen-only implant without restriction and without a reduction in contraceptive efficacy for the duration of the licensed use
Depo-provera increased weight gain than non-obese women but recommended
IUS and Cu-IUCD may be difficult to insert but recommended
Emergency contraceptions
Copper bearing intrauterine device Cu- IUCD
Ulipristal acetate (UPA) Ella One
Levonorgestrel (LNG)
Nov 2013 ldquoIn clinical trials contraceptive efficacy was reduced in women weighing 75 kg or more and levonorgestrel was not effective in women who weighed more than 80 kgldquo
This has been reversed by FRSH June 2014
ldquoEmergency contraceptives can continue to be used to prevent
unintended pregnancy in women of any weight or body mass index
(BMI) The available data are limited and not robust enough to support
with certainty the conclusion of decreased contraceptive effect with
increased bodyweightBMIrdquo
Obesity is not a contraindication to any of these methods
Summary
bull The obese woman attending the GP or Nurse should be thought of holistically not just BP and CHD risk
bull Risks re conception pregnancy outcomes and cancer are not widely known and discussed
bull There is a whole skill set to develop in discussing these issues
Thankyou
bull Articles used in this slide set
ndash httpwwwnhsuknews201302FebruaryPagesLatest-obesity-stats-for-England-are-alarming-readingaspx NHS Choices
ndash Annals of the New York Academy of Sciences 2012 Obesity and cancer risk evidence mechanisms and recommendations by Vucenik et al
ndash wwwnhsuknew20307JulyDoes genetic fat mutation cause obesityndash wwwcancerresearchukobesityndash Obesity and infertility by Pasquali R Patton L Gamineri A Curr Opin Endcrinol
Diabetes Obes 2007 Dec 14(6) 482-7 wwwncbinimnihgovpubmedndash Obesity and male infertility Ahmad O Hammond et al Obesity and Male Infertility
Semin Reprod Med 2012 30(6) 468-495ndash Nature July 2014 Neuroscience Dissecting appetite Bijal P Trivedi Nature 508 S64ndashS65
(17 April 2014) Published online 16 April 2014 Obes Rev 2007 Jan8(1)21-34 The role of leptin and ghrelin in the regulation of food intake and body weight in humans a review Klok MD1 Jakobsdottir S Drent ML
ndash Obes Rev 2005 Feb6(1)13-21 Adiponectin action regulation and association to insulin sensitivity Lihn AS1 Pedersen SB Richelsen B
ndash Obesity and Reproductive Health- study group statement RCOG clinical guideance on line accessed 0814 at wwwrcoguk
ndash First Nordic Conference on Obesity 9n Gynaecology and Obstetrics Jorgensen JS et al May 2013 Acta Obstetrica et Gynaecologica Scandinavia 93 pp 982-987
ndash Slide illustration templates Grace at magicsheepiehotmailcouk
bull 2 of thyroid cancer and
30 endometrial cancers in the UK
due to overweight and obese BMIs
bull Risk of endometrial cancer is increased by x 2-3 and
if very obese increased by x 6
bull Physical activity can reduce endometrial cancer risk by 20-30
bull PCOS women have an increased x 4 risk of endometrial cancer pre-menopause related to obesity
50 of obese people do not think that losing weight reduces their risk of cancer
Maternal deathDVTDMPETSevere haemorrhageLabour inductionShoulder dystociaDelivery by caesarean section General anaesthesia and anaesthetic complications
Early onset obesity is related tooligomenorrhoeamenstrual irregularityanovulation and subfertility
Increased rate of miscarriage
Reduced IVF if BMIgt30women are less likely to come for help with fertility and if BMIgt40 less likely to be accepted for treatment
Ovulatory obese women have an increased rate of subfertility but may have less sex
Male obesity associated with low testosteroneLow LH and FSHReduced spermatogenesisIncreased EDReduced libido
Conception and Pregnancy
poor perinatal outcomesmacrosomiaincluding stillbirth and neonatal death
Bottom LinesHigher maternal complications and mortalityHigher perinatal complications and mortalityMore difficult to conceive
Measure BMI and waist at bookingRefer for nutritional advice and exercise programmesAsk women to keep BMI 20-25 in pregnancy (Asian women 23)Take folic acid 5mg a dayThink T2DM and BPMay end up on heparin (DVT) and aspirin ( if one other risk
factor for PET and obese)Bariatric surgery Nutritional deficiency and problems donrsquot
conceive for 12 monthsMultidisciplinary teams required
Contraception
CHC
FRSH consider risks of DVT and hypertension in
Assessing CHC and possibly CHC is less effective
BMIgt35 risk 3 (donrsquot use)
BMI 30-34 probably okay risk2
POP okay
Nexplanon Current Faculty guidance states that women
with a BMI gt 30 can use a progestogen-only implant without restriction and without a reduction in contraceptive efficacy for the duration of the licensed use
Depo-provera increased weight gain than non-obese women but recommended
IUS and Cu-IUCD may be difficult to insert but recommended
Emergency contraceptions
Copper bearing intrauterine device Cu- IUCD
Ulipristal acetate (UPA) Ella One
Levonorgestrel (LNG)
Nov 2013 ldquoIn clinical trials contraceptive efficacy was reduced in women weighing 75 kg or more and levonorgestrel was not effective in women who weighed more than 80 kgldquo
This has been reversed by FRSH June 2014
ldquoEmergency contraceptives can continue to be used to prevent
unintended pregnancy in women of any weight or body mass index
(BMI) The available data are limited and not robust enough to support
with certainty the conclusion of decreased contraceptive effect with
increased bodyweightBMIrdquo
Obesity is not a contraindication to any of these methods
Summary
bull The obese woman attending the GP or Nurse should be thought of holistically not just BP and CHD risk
bull Risks re conception pregnancy outcomes and cancer are not widely known and discussed
bull There is a whole skill set to develop in discussing these issues
Thankyou
bull Articles used in this slide set
ndash httpwwwnhsuknews201302FebruaryPagesLatest-obesity-stats-for-England-are-alarming-readingaspx NHS Choices
ndash Annals of the New York Academy of Sciences 2012 Obesity and cancer risk evidence mechanisms and recommendations by Vucenik et al
ndash wwwnhsuknew20307JulyDoes genetic fat mutation cause obesityndash wwwcancerresearchukobesityndash Obesity and infertility by Pasquali R Patton L Gamineri A Curr Opin Endcrinol
Diabetes Obes 2007 Dec 14(6) 482-7 wwwncbinimnihgovpubmedndash Obesity and male infertility Ahmad O Hammond et al Obesity and Male Infertility
Semin Reprod Med 2012 30(6) 468-495ndash Nature July 2014 Neuroscience Dissecting appetite Bijal P Trivedi Nature 508 S64ndashS65
(17 April 2014) Published online 16 April 2014 Obes Rev 2007 Jan8(1)21-34 The role of leptin and ghrelin in the regulation of food intake and body weight in humans a review Klok MD1 Jakobsdottir S Drent ML
ndash Obes Rev 2005 Feb6(1)13-21 Adiponectin action regulation and association to insulin sensitivity Lihn AS1 Pedersen SB Richelsen B
ndash Obesity and Reproductive Health- study group statement RCOG clinical guideance on line accessed 0814 at wwwrcoguk
ndash First Nordic Conference on Obesity 9n Gynaecology and Obstetrics Jorgensen JS et al May 2013 Acta Obstetrica et Gynaecologica Scandinavia 93 pp 982-987
ndash Slide illustration templates Grace at magicsheepiehotmailcouk
Maternal deathDVTDMPETSevere haemorrhageLabour inductionShoulder dystociaDelivery by caesarean section General anaesthesia and anaesthetic complications
Early onset obesity is related tooligomenorrhoeamenstrual irregularityanovulation and subfertility
Increased rate of miscarriage
Reduced IVF if BMIgt30women are less likely to come for help with fertility and if BMIgt40 less likely to be accepted for treatment
Ovulatory obese women have an increased rate of subfertility but may have less sex
Male obesity associated with low testosteroneLow LH and FSHReduced spermatogenesisIncreased EDReduced libido
Conception and Pregnancy
poor perinatal outcomesmacrosomiaincluding stillbirth and neonatal death
Bottom LinesHigher maternal complications and mortalityHigher perinatal complications and mortalityMore difficult to conceive
Measure BMI and waist at bookingRefer for nutritional advice and exercise programmesAsk women to keep BMI 20-25 in pregnancy (Asian women 23)Take folic acid 5mg a dayThink T2DM and BPMay end up on heparin (DVT) and aspirin ( if one other risk
factor for PET and obese)Bariatric surgery Nutritional deficiency and problems donrsquot
conceive for 12 monthsMultidisciplinary teams required
Contraception
CHC
FRSH consider risks of DVT and hypertension in
Assessing CHC and possibly CHC is less effective
BMIgt35 risk 3 (donrsquot use)
BMI 30-34 probably okay risk2
POP okay
Nexplanon Current Faculty guidance states that women
with a BMI gt 30 can use a progestogen-only implant without restriction and without a reduction in contraceptive efficacy for the duration of the licensed use
Depo-provera increased weight gain than non-obese women but recommended
IUS and Cu-IUCD may be difficult to insert but recommended
Emergency contraceptions
Copper bearing intrauterine device Cu- IUCD
Ulipristal acetate (UPA) Ella One
Levonorgestrel (LNG)
Nov 2013 ldquoIn clinical trials contraceptive efficacy was reduced in women weighing 75 kg or more and levonorgestrel was not effective in women who weighed more than 80 kgldquo
This has been reversed by FRSH June 2014
ldquoEmergency contraceptives can continue to be used to prevent
unintended pregnancy in women of any weight or body mass index
(BMI) The available data are limited and not robust enough to support
with certainty the conclusion of decreased contraceptive effect with
increased bodyweightBMIrdquo
Obesity is not a contraindication to any of these methods
Summary
bull The obese woman attending the GP or Nurse should be thought of holistically not just BP and CHD risk
bull Risks re conception pregnancy outcomes and cancer are not widely known and discussed
bull There is a whole skill set to develop in discussing these issues
Thankyou
bull Articles used in this slide set
ndash httpwwwnhsuknews201302FebruaryPagesLatest-obesity-stats-for-England-are-alarming-readingaspx NHS Choices
ndash Annals of the New York Academy of Sciences 2012 Obesity and cancer risk evidence mechanisms and recommendations by Vucenik et al
ndash wwwnhsuknew20307JulyDoes genetic fat mutation cause obesityndash wwwcancerresearchukobesityndash Obesity and infertility by Pasquali R Patton L Gamineri A Curr Opin Endcrinol
Diabetes Obes 2007 Dec 14(6) 482-7 wwwncbinimnihgovpubmedndash Obesity and male infertility Ahmad O Hammond et al Obesity and Male Infertility
Semin Reprod Med 2012 30(6) 468-495ndash Nature July 2014 Neuroscience Dissecting appetite Bijal P Trivedi Nature 508 S64ndashS65
(17 April 2014) Published online 16 April 2014 Obes Rev 2007 Jan8(1)21-34 The role of leptin and ghrelin in the regulation of food intake and body weight in humans a review Klok MD1 Jakobsdottir S Drent ML
ndash Obes Rev 2005 Feb6(1)13-21 Adiponectin action regulation and association to insulin sensitivity Lihn AS1 Pedersen SB Richelsen B
ndash Obesity and Reproductive Health- study group statement RCOG clinical guideance on line accessed 0814 at wwwrcoguk
ndash First Nordic Conference on Obesity 9n Gynaecology and Obstetrics Jorgensen JS et al May 2013 Acta Obstetrica et Gynaecologica Scandinavia 93 pp 982-987
ndash Slide illustration templates Grace at magicsheepiehotmailcouk
poor perinatal outcomesmacrosomiaincluding stillbirth and neonatal death
Bottom LinesHigher maternal complications and mortalityHigher perinatal complications and mortalityMore difficult to conceive
Measure BMI and waist at bookingRefer for nutritional advice and exercise programmesAsk women to keep BMI 20-25 in pregnancy (Asian women 23)Take folic acid 5mg a dayThink T2DM and BPMay end up on heparin (DVT) and aspirin ( if one other risk
factor for PET and obese)Bariatric surgery Nutritional deficiency and problems donrsquot
conceive for 12 monthsMultidisciplinary teams required
Contraception
CHC
FRSH consider risks of DVT and hypertension in
Assessing CHC and possibly CHC is less effective
BMIgt35 risk 3 (donrsquot use)
BMI 30-34 probably okay risk2
POP okay
Nexplanon Current Faculty guidance states that women
with a BMI gt 30 can use a progestogen-only implant without restriction and without a reduction in contraceptive efficacy for the duration of the licensed use
Depo-provera increased weight gain than non-obese women but recommended
IUS and Cu-IUCD may be difficult to insert but recommended
Emergency contraceptions
Copper bearing intrauterine device Cu- IUCD
Ulipristal acetate (UPA) Ella One
Levonorgestrel (LNG)
Nov 2013 ldquoIn clinical trials contraceptive efficacy was reduced in women weighing 75 kg or more and levonorgestrel was not effective in women who weighed more than 80 kgldquo
This has been reversed by FRSH June 2014
ldquoEmergency contraceptives can continue to be used to prevent
unintended pregnancy in women of any weight or body mass index
(BMI) The available data are limited and not robust enough to support
with certainty the conclusion of decreased contraceptive effect with
increased bodyweightBMIrdquo
Obesity is not a contraindication to any of these methods
Summary
bull The obese woman attending the GP or Nurse should be thought of holistically not just BP and CHD risk
bull Risks re conception pregnancy outcomes and cancer are not widely known and discussed
bull There is a whole skill set to develop in discussing these issues
Thankyou
bull Articles used in this slide set
ndash httpwwwnhsuknews201302FebruaryPagesLatest-obesity-stats-for-England-are-alarming-readingaspx NHS Choices
ndash Annals of the New York Academy of Sciences 2012 Obesity and cancer risk evidence mechanisms and recommendations by Vucenik et al
ndash wwwnhsuknew20307JulyDoes genetic fat mutation cause obesityndash wwwcancerresearchukobesityndash Obesity and infertility by Pasquali R Patton L Gamineri A Curr Opin Endcrinol
Diabetes Obes 2007 Dec 14(6) 482-7 wwwncbinimnihgovpubmedndash Obesity and male infertility Ahmad O Hammond et al Obesity and Male Infertility
Semin Reprod Med 2012 30(6) 468-495ndash Nature July 2014 Neuroscience Dissecting appetite Bijal P Trivedi Nature 508 S64ndashS65
(17 April 2014) Published online 16 April 2014 Obes Rev 2007 Jan8(1)21-34 The role of leptin and ghrelin in the regulation of food intake and body weight in humans a review Klok MD1 Jakobsdottir S Drent ML
ndash Obes Rev 2005 Feb6(1)13-21 Adiponectin action regulation and association to insulin sensitivity Lihn AS1 Pedersen SB Richelsen B
ndash Obesity and Reproductive Health- study group statement RCOG clinical guideance on line accessed 0814 at wwwrcoguk
ndash First Nordic Conference on Obesity 9n Gynaecology and Obstetrics Jorgensen JS et al May 2013 Acta Obstetrica et Gynaecologica Scandinavia 93 pp 982-987
ndash Slide illustration templates Grace at magicsheepiehotmailcouk
Contraception
CHC
FRSH consider risks of DVT and hypertension in
Assessing CHC and possibly CHC is less effective
BMIgt35 risk 3 (donrsquot use)
BMI 30-34 probably okay risk2
POP okay
Nexplanon Current Faculty guidance states that women
with a BMI gt 30 can use a progestogen-only implant without restriction and without a reduction in contraceptive efficacy for the duration of the licensed use
Depo-provera increased weight gain than non-obese women but recommended
IUS and Cu-IUCD may be difficult to insert but recommended
Emergency contraceptions
Copper bearing intrauterine device Cu- IUCD
Ulipristal acetate (UPA) Ella One
Levonorgestrel (LNG)
Nov 2013 ldquoIn clinical trials contraceptive efficacy was reduced in women weighing 75 kg or more and levonorgestrel was not effective in women who weighed more than 80 kgldquo
This has been reversed by FRSH June 2014
ldquoEmergency contraceptives can continue to be used to prevent
unintended pregnancy in women of any weight or body mass index
(BMI) The available data are limited and not robust enough to support
with certainty the conclusion of decreased contraceptive effect with
increased bodyweightBMIrdquo
Obesity is not a contraindication to any of these methods
Summary
bull The obese woman attending the GP or Nurse should be thought of holistically not just BP and CHD risk
bull Risks re conception pregnancy outcomes and cancer are not widely known and discussed
bull There is a whole skill set to develop in discussing these issues
Thankyou
bull Articles used in this slide set
ndash httpwwwnhsuknews201302FebruaryPagesLatest-obesity-stats-for-England-are-alarming-readingaspx NHS Choices
ndash Annals of the New York Academy of Sciences 2012 Obesity and cancer risk evidence mechanisms and recommendations by Vucenik et al
ndash wwwnhsuknew20307JulyDoes genetic fat mutation cause obesityndash wwwcancerresearchukobesityndash Obesity and infertility by Pasquali R Patton L Gamineri A Curr Opin Endcrinol
Diabetes Obes 2007 Dec 14(6) 482-7 wwwncbinimnihgovpubmedndash Obesity and male infertility Ahmad O Hammond et al Obesity and Male Infertility
Semin Reprod Med 2012 30(6) 468-495ndash Nature July 2014 Neuroscience Dissecting appetite Bijal P Trivedi Nature 508 S64ndashS65
(17 April 2014) Published online 16 April 2014 Obes Rev 2007 Jan8(1)21-34 The role of leptin and ghrelin in the regulation of food intake and body weight in humans a review Klok MD1 Jakobsdottir S Drent ML
ndash Obes Rev 2005 Feb6(1)13-21 Adiponectin action regulation and association to insulin sensitivity Lihn AS1 Pedersen SB Richelsen B
ndash Obesity and Reproductive Health- study group statement RCOG clinical guideance on line accessed 0814 at wwwrcoguk
ndash First Nordic Conference on Obesity 9n Gynaecology and Obstetrics Jorgensen JS et al May 2013 Acta Obstetrica et Gynaecologica Scandinavia 93 pp 982-987
ndash Slide illustration templates Grace at magicsheepiehotmailcouk
Emergency contraceptions
Copper bearing intrauterine device Cu- IUCD
Ulipristal acetate (UPA) Ella One
Levonorgestrel (LNG)
Nov 2013 ldquoIn clinical trials contraceptive efficacy was reduced in women weighing 75 kg or more and levonorgestrel was not effective in women who weighed more than 80 kgldquo
This has been reversed by FRSH June 2014
ldquoEmergency contraceptives can continue to be used to prevent
unintended pregnancy in women of any weight or body mass index
(BMI) The available data are limited and not robust enough to support
with certainty the conclusion of decreased contraceptive effect with
increased bodyweightBMIrdquo
Obesity is not a contraindication to any of these methods
Summary
bull The obese woman attending the GP or Nurse should be thought of holistically not just BP and CHD risk
bull Risks re conception pregnancy outcomes and cancer are not widely known and discussed
bull There is a whole skill set to develop in discussing these issues
Thankyou
bull Articles used in this slide set
ndash httpwwwnhsuknews201302FebruaryPagesLatest-obesity-stats-for-England-are-alarming-readingaspx NHS Choices
ndash Annals of the New York Academy of Sciences 2012 Obesity and cancer risk evidence mechanisms and recommendations by Vucenik et al
ndash wwwnhsuknew20307JulyDoes genetic fat mutation cause obesityndash wwwcancerresearchukobesityndash Obesity and infertility by Pasquali R Patton L Gamineri A Curr Opin Endcrinol
Diabetes Obes 2007 Dec 14(6) 482-7 wwwncbinimnihgovpubmedndash Obesity and male infertility Ahmad O Hammond et al Obesity and Male Infertility
Semin Reprod Med 2012 30(6) 468-495ndash Nature July 2014 Neuroscience Dissecting appetite Bijal P Trivedi Nature 508 S64ndashS65
(17 April 2014) Published online 16 April 2014 Obes Rev 2007 Jan8(1)21-34 The role of leptin and ghrelin in the regulation of food intake and body weight in humans a review Klok MD1 Jakobsdottir S Drent ML
ndash Obes Rev 2005 Feb6(1)13-21 Adiponectin action regulation and association to insulin sensitivity Lihn AS1 Pedersen SB Richelsen B
ndash Obesity and Reproductive Health- study group statement RCOG clinical guideance on line accessed 0814 at wwwrcoguk
ndash First Nordic Conference on Obesity 9n Gynaecology and Obstetrics Jorgensen JS et al May 2013 Acta Obstetrica et Gynaecologica Scandinavia 93 pp 982-987
ndash Slide illustration templates Grace at magicsheepiehotmailcouk
Summary
bull The obese woman attending the GP or Nurse should be thought of holistically not just BP and CHD risk
bull Risks re conception pregnancy outcomes and cancer are not widely known and discussed
bull There is a whole skill set to develop in discussing these issues
Thankyou
bull Articles used in this slide set
ndash httpwwwnhsuknews201302FebruaryPagesLatest-obesity-stats-for-England-are-alarming-readingaspx NHS Choices
ndash Annals of the New York Academy of Sciences 2012 Obesity and cancer risk evidence mechanisms and recommendations by Vucenik et al
ndash wwwnhsuknew20307JulyDoes genetic fat mutation cause obesityndash wwwcancerresearchukobesityndash Obesity and infertility by Pasquali R Patton L Gamineri A Curr Opin Endcrinol
Diabetes Obes 2007 Dec 14(6) 482-7 wwwncbinimnihgovpubmedndash Obesity and male infertility Ahmad O Hammond et al Obesity and Male Infertility
Semin Reprod Med 2012 30(6) 468-495ndash Nature July 2014 Neuroscience Dissecting appetite Bijal P Trivedi Nature 508 S64ndashS65
(17 April 2014) Published online 16 April 2014 Obes Rev 2007 Jan8(1)21-34 The role of leptin and ghrelin in the regulation of food intake and body weight in humans a review Klok MD1 Jakobsdottir S Drent ML
ndash Obes Rev 2005 Feb6(1)13-21 Adiponectin action regulation and association to insulin sensitivity Lihn AS1 Pedersen SB Richelsen B
ndash Obesity and Reproductive Health- study group statement RCOG clinical guideance on line accessed 0814 at wwwrcoguk
ndash First Nordic Conference on Obesity 9n Gynaecology and Obstetrics Jorgensen JS et al May 2013 Acta Obstetrica et Gynaecologica Scandinavia 93 pp 982-987
ndash Slide illustration templates Grace at magicsheepiehotmailcouk
bull Articles used in this slide set
ndash httpwwwnhsuknews201302FebruaryPagesLatest-obesity-stats-for-England-are-alarming-readingaspx NHS Choices
ndash Annals of the New York Academy of Sciences 2012 Obesity and cancer risk evidence mechanisms and recommendations by Vucenik et al
ndash wwwnhsuknew20307JulyDoes genetic fat mutation cause obesityndash wwwcancerresearchukobesityndash Obesity and infertility by Pasquali R Patton L Gamineri A Curr Opin Endcrinol
Diabetes Obes 2007 Dec 14(6) 482-7 wwwncbinimnihgovpubmedndash Obesity and male infertility Ahmad O Hammond et al Obesity and Male Infertility
Semin Reprod Med 2012 30(6) 468-495ndash Nature July 2014 Neuroscience Dissecting appetite Bijal P Trivedi Nature 508 S64ndashS65
(17 April 2014) Published online 16 April 2014 Obes Rev 2007 Jan8(1)21-34 The role of leptin and ghrelin in the regulation of food intake and body weight in humans a review Klok MD1 Jakobsdottir S Drent ML
ndash Obes Rev 2005 Feb6(1)13-21 Adiponectin action regulation and association to insulin sensitivity Lihn AS1 Pedersen SB Richelsen B
ndash Obesity and Reproductive Health- study group statement RCOG clinical guideance on line accessed 0814 at wwwrcoguk
ndash First Nordic Conference on Obesity 9n Gynaecology and Obstetrics Jorgensen JS et al May 2013 Acta Obstetrica et Gynaecologica Scandinavia 93 pp 982-987
ndash Slide illustration templates Grace at magicsheepiehotmailcouk