OBESITY Liz Brown September 2005


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OBESITY Liz Brown September 2005

  1. 1. OBESITY Liz Brown September 2005
  2. 3. Examples of the prevalence of obesity in adults throughout the world                                                                                                                                                                                                      
  3. 4. Defining Overweight & Obesity <ul><li>Body Mass Index (BMI) </li></ul><ul><ul><li>(Weight (Kg)/(Height (m) 2 ) </li></ul></ul><ul><li>Distribution of Body Fat </li></ul><ul><ul><li>Measurement of waist circumference </li></ul></ul>
  4. 5. WHO standard classification of obesity (WHO 1997) BMI Risk of co-morbidities Normal BMI 18.5-24.9 average Overweight: Pre-obese 25.0-29.9 increased Obesity class I 30.0-34.9 moderate Obesity class II 35.0-39.9 severe Obesity class III  40 very severe
  5. 6. Sex-specific waist circumferences for ‘increased risk’ and ‘substantially increased risk’ of metabolic complications associated with obesity in Caucasians Risk of obesity-associated metabolic complications Increased Substantially increased Men  94 cm  102 cm Women  80 cm  88 cm
  6. 8. Why is Obesity On the Increase <ul><li>Last 20 years calorie intake has not significantly changed </li></ul><ul><ul><li>Decreased carbohydrate intake </li></ul></ul><ul><ul><li>Increased fat increase </li></ul></ul><ul><ul><li>Less home cooking more convenient food </li></ul></ul><ul><ul><li>More sedentary lifestyle </li></ul></ul>
  7. 10. Relationship between BMI and cardiovascular risk factors                                                                                                                                                                     
  8. 12.                                                                                                                                                                                                                                                                                      
  9. 13. Cost <ul><li>1998 NHS spent £50million/yr for treating obesity </li></ul><ul><li>Indirect cost of treating co-morbidities £1.7 - £1.9 B </li></ul><ul><li>3.5-4% of all NHS expenditure </li></ul>
  10. 14. Weight Loss Treatments <ul><li>Combination of: </li></ul><ul><li>controlled energy diet </li></ul><ul><li>increased physical activity </li></ul><ul><li>behaviour therapy </li></ul><ul><li>provide the most successful treatment for weight loss and maintenance of weight loss </li></ul>
  11. 15. Counselling & Support <ul><li>Educate patients regarding hazards of obesity and benefits of modest weight loss (5-10% of body weight) </li></ul><ul><li>Help set realistic goals </li></ul><ul><li>Encourage to give up short term ‘diet’ mentality and stress need for long term lifestyle change </li></ul><ul><li>Recommend increased physical activity and incorporating exercise into daily routine </li></ul><ul><li>Acknowledge the difficulties of loosing weight </li></ul>
  12. 16. Medical Treatments <ul><li> </li></ul>
  13. 17. Drug Treatments <ul><li>Adjuvant management of obesity </li></ul><ul><li>BMI>30 with no associated co-morbidity </li></ul><ul><li>BMI of 27 in presence of co-morbidity (e.g. NIDDM) </li></ul><ul><li>NICE / SIGN & British Heart Foundation provided guidance of use of drug treatments </li></ul><ul><li>All pt on drug treatment require regular review and at 3/12 treatment stopped if 5% of wt loss not achieved </li></ul><ul><li>RCT suggest that approx 60% of treated patients achieve & maintain a 5% wt loss after 12 months of treatment </li></ul>
  14. 19. ORLISTAT <ul><li>Inhibits pancreatic & gastric lipase </li></ul><ul><li>Reduces approx. 30% of fat absorption </li></ul><ul><li>Very low quantities absorbed but SE on GI tract </li></ul><ul><li>Side effects </li></ul><ul><ul><li>Steatorrhoea </li></ul></ul><ul><ul><li>Increased urgency & frequency of defecation </li></ul></ul><ul><ul><li>Anal leakage </li></ul></ul><ul><ul><li>Oily spotting </li></ul></ul><ul><ul><li>Consider vitamin supplementation (esp. Vit D) if concerned about deficiency of fat sol vitamins </li></ul></ul>
  15. 20. ORLISTAT <ul><li>Criteria </li></ul><ul><ul><li>Age 18-75 yrs </li></ul></ul><ul><ul><li>Contra-indicated in pregnancy & breast feeding </li></ul></ul><ul><ul><li>Must have attempted long-term control of wt using lifestyle measures without success </li></ul></ul><ul><ul><li>Need to loose 2.5Kg in 1 month prior to treatment </li></ul></ul><ul><ul><li>Review after 3/12- need to loose 5% of starting wt. to continue treatment </li></ul></ul><ul><ul><li>Review after 6/12 need to loose 10% of starting wt. continue treatment </li></ul></ul><ul><ul><li>Licensed for 2 years </li></ul></ul>
  16. 21. ORLISTAT <ul><li>Cost </li></ul><ul><ul><li>49 pence/capsule </li></ul></ul><ul><ul><li>Dosing 3 capsules a day costs £537/yr </li></ul></ul><ul><ul><li>2000 England & Wales spent £6 million on prescriptions </li></ul></ul><ul><ul><li>Effectiveness </li></ul></ul><ul><ul><li>14 trials have shown clinically effective in reducing wt loss over 1 yr BUT only small reduction in wt decline compared to placebo. </li></ul></ul><ul><ul><li>Significant but small reduction in total cholesterol and diastolic & systolic BP </li></ul></ul><ul><ul><li>Wt loss on cessation of treatment regained over time, average 3 years </li></ul></ul><ul><ul><li>Short term wt loss may not have as much effect on co-morbidities in longer term as been assumed </li></ul></ul>
  17. 23. SIBUTRAMINE <ul><li>Re-uptake inhibitor or nor adrenaline and serotonin </li></ul><ul><li>Promotes a sense of satiety </li></ul><ul><li>Licensed for 1 year in 18-65 yr olds </li></ul><ul><li>Costs between £456-£510/year </li></ul><ul><li>Contra-indicated in breast feeding, pregnancy & BP>145/90 </li></ul>
  18. 24. SIBUTRAMINE <ul><li>Dosage </li></ul><ul><ul><li>Starting dose 10mg/day </li></ul></ul><ul><ul><li>Review at 4/52. If 2Kg wt loss can continue Rx and increase dose to 15mg/day </li></ul></ul><ul><ul><li>Review at 3/12, require 5% wt loss from initial wt to continue treatment </li></ul></ul><ul><li>Monitoring </li></ul><ul><ul><li>Careful monitoring of BP </li></ul></ul><ul><ul><li>STOP if BP>145/90 </li></ul></ul><ul><ul><li>STOP if BP rises more than 10mmHg (diastolic & systolic) </li></ul></ul><ul><ul><li>STOP if resting HR increases by 10bpm </li></ul></ul>
  19. 25. SIBUTRAMINE <ul><li>Effectiveness </li></ul><ul><ul><li>16 trials </li></ul></ul><ul><ul><li>RCT indicate dose related wt loss with an optimal dose of 10-15mg/day. </li></ul></ul><ul><ul><li>Mean wt loss greater than placebo </li></ul></ul><ul><ul><li>More likely to maintain wt loss than pt randomised to diet & exercise </li></ul></ul><ul><ul><li>No statistical difference between men & women or ethnic groups </li></ul></ul><ul><ul><li>Risk factors, improvement seen but only some were statistically significant </li></ul></ul>
  20. 27. Future Research <ul><li>Need to assess if: </li></ul><ul><ul><li>Pts who have had a successful treatment but regain weight after cessation can have treatment recommenced </li></ul></ul><ul><ul><li>RCT to compare orlistat/sibutramine and behaviour treatment alone </li></ul></ul><ul><ul><li>Effects and toxicity on longer treatments </li></ul></ul><ul><ul><li>Use in younger children now obesity in children is increasing </li></ul></ul><ul><ul><li>Assess the benefits of short term wt loss by decreasing co morbidities compared to permanent wt loss </li></ul></ul>
  21. 28. FUTURE <ul><li>Regard obesity as chronic disease requiring long term support and follow up </li></ul><ul><li>GP magazine this week, article regarding obesity as a disease requiring quality indicators </li></ul><ul><li>GMS contract offer 3 points directly to obesity- measuring BMI in diabetics </li></ul><ul><li>Chronic condition affecting 25% of population but only gets 0.3% of quality points </li></ul><ul><li>Management of independent markers of metabolic syndrome comprises approx 30% of all available points </li></ul>
  23. 30. SURGICAL TREATMENTS <ul><li>BMI > 40 </li></ul><ul><li>BMI >35 with significant disease </li></ul><ul><li>3 operations: </li></ul><ul><li>gastric restriction: 40-60% XS wt loss </li></ul><ul><li>gastric bypass: approx 50% wt loss </li></ul><ul><li>1% operative mortality </li></ul><ul><li>biliopancreatic diversion:78% wt loss </li></ul><ul><li>1% operative mortality, </li></ul><ul><li>nutritional deficiencies </li></ul><ul><li>Most can be performed laparoscopically </li></ul>
  24. 32.