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Recommendations: auditCentralised equipment poolsSharing between LHNs and services to follow patioent
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National Weight Control Registry (Success or maintenance defined as keeping off all initial weight lost or at least 9-11kg of initial weight loss)
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The Obesity Epidemic - Do we only treat or do we demand change
The Obesity Epidemic-do we only treat or do we demandchangeHal Robertson>Manual Tasks Services>Workforce Health
Obesity is now the Number 1 World Health Problem• Approx 25% of Australian and 26.5% NZ adults have a BMI>30.¹• NZ and Australia are ranked 6th and 7th in the world for obesity. ² 07-08 National Health Survey. ² Australian Bureau of Statistics (2009). www.oecd.org/health/fitnotfat
Obesity Epidemic 2005-2010Obesity as a percentage of total population.Country 2005 2010 ChangeUnited States 30.6% 33.8% 10.5%New Zealand 20.9% 26.5% 26.8%Australia 21.7% 24.8% 14.3%United Kingdom 23.0% 24.5% 6.5%Luxembourg 18.4% 20.0% 8.7%http://www.abcdiamond.com/overweight-and-obesity
Bariatric definition Person fits two or more of the following criteria: > Weighs 120+Kg > BMI 40+ > Seated hip width >20” (51cm) Body mass Index (BMI)=weight in KG/height in metres ² SA Health
Bariatric statisticsRoyal Adelaide Hospital and Flinders Medical Centre> 2% of inpatient admissions are bariatric. Ie approx 80 inpatients per month at RAH> 5% of maintenance stay patients waiting for nursing home placement (RAH) are bariatric> The average acute LOS for a patient over 120kg is 1.6 times longer than a normal weight patient and 1.8 times longer if the patient is over 150kg compared for other patients with same Diagnostic Related Group matched for age and sex. SA Health
The Risks> Adverse patient outcomes and inequitable standards of care> Increased injury risk for workers SA Health
Increase risk of worker injuryBariatric patients…> Are involved in between 14%-21% of body stressing incidents assoc with patient care in acute hospitals in Adelaide> Caused 30% body stressing Workcover claims FMC 2009-10- the relative risk of workers sustaining Musculoskeletal injury is 19:1SALHN 2010: Nursing and Allied Health Survey on Care of Bariatric Patients> 20% did not feel safe caring for a B patient> 70% reported appropriate equipment is rarely available SA Health
Increased risk due to poor design• Patient 250kg• Room 15²m• 7 workers• Bed removed for Chair access SA Health
Impact on Heath Care systems> Acute hospitals-increased risks to workers and the patient with dependent patients>200kg> Aged Care Facilities- struggle to care for dependant residents in 120-150kg range> Community support programs- limited equipment options, environment and home design restrictions, and often only 1-2 worker(s) available SA Health
Methods of management> BMI 20-25 food choice, exercise, behaviour change> BMI 25-30 dieting-low calorie diets> BMI 30-35 very low calorie diets, drug therapy> BMI 35-40 very low calorie diets, drug therapy, surgery> BMI 40-50 surgery> BMI 50-100 surgeryNational Clinical guidelines for weight control and Obesity management in Adults, NHMRC 2003
Dieting –it is not easy!Combined approach•Calorie controlled diet•Regular exercise•Self monitoring•Motivation or strong reason tochange•Good relapse strategy•Long term support www.drsharma.ca
Maintaining weight loss > Weight loss tends to plateau at 3- 6 months (Less body fat, reduces resting metabolic rate and hence reduces energy requirements) > Studies show 20% retain 10% of initial weight loss for 1 year Wing RR, Phelan S. Long term weight loss maintenance. Am J Clin Nutr. 2005:82 (1): 2225-2255.
Achieving long term weight loss> National Weight Control Registry Australia • Little similarity in weight loss methods> Common behaviours in weight loss maintenance • Low calorie diet • Low to moderate fat intake • Limited fast food • Eat breakfast most days • Regular self monitoring • Engaging in high levels of physical activity (min 1 hour a day)
Drug therapy for weight loss> Weight loss drugs developed in past have had harmful side effects> Phentermine is effective but there is no safety data for long term use> Be aware of other pharmaceuticals that have side effect of weight gain
Obesity and Mental health > People with a severe mental illness are 1.5-2x more likely to be obese > Reduced physical activity > Poor nutrition habits > Medication side effects- weight gain > Poor motivation Mental health -40% Glenside Hospital clients have BMI>30kg/m² (Survey August 2011)
Bariatric Surgery> Aim-reduce mortality from obesity related co-morbidities> Dietary, psychological and medical assessments> Commitment to change. Pre surgery weight loss requirement
Sleeve Gastrectomy> Vertical stapling of stomach> Excise greater curve> ‘restrictive’> Mal absorption-need long term dietary supplements> 1-2 day post OP stay> 50% excessive weight loss
Laparoscopic Adjustable GastricBanding> Silicone band placed around upper stomach> Subcutaneous access port> Inflate or deflate band> ‘restrictive’> No real mal absorption> Day surgery or overnight stay> 50% excessive weight loss> Safest option
Why are we gaining weight?> Energy input ≠ energy expenditure> There is only a very slight daily discrepancy of 50-80Kcal required to gain 3kg a year
High fat, high energy diet > 1/3rd of food is 1970 Now Food item consumed outside of 350 600 Cheese burger cal cal the home Size Bagels > Portions are bigger X3 since 1970s (‘portion 375ml 600ml Soft drink can can distortion’) 200 625 Serve of > Reduced physical cal cal French fries activityPlates
Sugared drinksPrimary obesity and diabetes strategy (Centre of Disease Control USA)> ‘reduce intake of sugar sweetened beverages’> Since late 1970s USA soft drink consumption has↑ 2x for females and 3x for males> On average 8% of USA children’s calories come from sugared drinks> Advertising companies spend billions pa and aim advertising at children and teenagers –www.cnn.com/2011/08/31/health/soda-drinking- habits/index.html
Projected increase in diabetes 2000-2030 • USA 36.5% • China 75.5% • India 134% Centre of Disease Control USA
Link with advertising and obesity Food promotion is having an effect particularly on childrens’ preferences, purchases behaviours and consumption. Hastings et al 2003 77% of obese children will become obese adults. Pre schoolers in the USA will see on average 5000 fast food ads by the time they reach 5. www.yaleruddcenter.org
Focus on PREVENTING obesity•Healthy lifestyleprogrammes- are theyworking?•Programmes for theyounger generation areshowing somesuccess–but it will bedecades until we see theresultshttp://www.drsharma.ca/oecd-dont-place-all-your-bets-on-obesity-prevention.html
How do we control obesity?Need for public health policies? Factual nutrition disclosures on food packaging • Denmark-Taxes on foods with sugars and saturated fats • France-Govt health warnings on adverts for processed, sweetened or salted food. Fines if companies to not comply. • NY. Menu label laws. Menu displays calorie count of meal • Proposed sugar tax in some USA states- unsuccessful to date Pomeranz JL, Teret SP, Sugarman SD, Rutkow L, Brownell KD. Innovative legal approaches to address obesity. Milbank Quarterly. 2009 Mar;87(1):185-213.
> 62 yo patient weighing 276kg UTI and chest infection> Ambulance retrieval-2 teams> HIGH STAFF DEMAND: • 6 staff to roll her when she was acutely ill, and 3 staff to assist with placing her on a bed pan when she was ‘well’. • 5 physiotherapy staff to stand her from lying in bed, + 2 nurses to move equipment during this procedure.> STAFF INJURY • 2 physiotherapists were injured attempting to lift her legs back onto the bed. (legs weighed 80kg each)> Specialist equipment needed> POOR PATIENT OUTCOME • Patient quickly became deconditioned due to limited resources to mobilise her • She died in hospital 4 months after admission SA Health