Successfully reported this slideshow.
How to stage patients with obesity
Carel le Roux
Diabetes Complications
Research Centre
University College
Dublin,
Univers...
Morbid
obesity
vs
Obese
morbidity
Sharma et al
CMAJ 2011
Do you want to Medicalise this man?
Physically active
Happy
Employed
120/78 mmHg
Normal glucose
and lipids
Indication for Obesity intervention
55 years
Pipe smoker
3rd
party assistance for ADL
No exercise
148/88mmHg
Fasting gluco...
Recidivism after volitional weight loss
BMI
Time
40
30
20
Volitional /
pharmacological
weight loss
Homeostatic
response pr...
Weight Management vs Obese Morbidity
Clinic Treatment
kg
Weight
management
Stop
coming
Multi-
modal
Strategy
Morbid Obesit...
Morbidity and weight loss sensitivity or resistance
Metabolic
Ventilatory
Reproductive
CV risk
Perceived health status
ADL...
Edmonton Obesity Staging System (EOSS)
Stage 0
Sharma AM & Kushner RF, Int J Obes 2009
Stage 1
Stage 2
Stage 3
Stage 4
Med...
Edmonton Obesity Staging System (EOSS)
Stage 0 Normal
blood glucose
Sharma AM & Kushner RF, Int J Obes 2009
Stage 1
IFT/
I...
EOSS Predicts Mortality in NHANES III
Padwal R, Sharma AM et al. CMAJ 2011www.drsharma.ca
EOSS Predicts Mortality at Every Level of BMI
NHANES III
Padwal R, Sharma AM et al. CMAJ 2011
Overweight
www.drsharma.ca
EOSS Distribution Across BMI Categories
NHANES III (1988-1994)
Overweight
Class
III
Padwal R, Sharma AM et al. CMAJ 2011
5...
EOSS Case 1
24 year-old physically active female,
BMI of 32 Kg/m2
no demonstrable risk factors, no functional
limitations,...
EOSS Case 2
32 year-old male
BMI of 36 Kg/m2
hypertension, sleep apnea, depression
Class 2, Stage 2 Obesity
- Clear benefi...
EOSS Case 3
63 year-old male
BMI of 74 Kg/m2
disabling osteoarthritis (wheel chair)
severe hypoventilation, fibromyalgia, ...
www.drsharma.ca
Key Points: EOSS provides
framework for clinical prioritization
predictor of obesity risk
Basis for management strategies
...
Obesity Staging Score: Aylwin et al Front Horm Res 2008
Stage 0 Stage 1 Stage 2 Stage 3
Airway Normal Apnoea CPAP Cor pulm...
Airway
Basdevant et al. Obes Surg. 2007
0
20
40
60
80
100
%improvement
Banding Bypass
Control +1.6%Control +1.6%
Banding -13.2%Banding -13.2%
VBG -16.5%VBG -16.5%
Bypass -25%Bypass -25%
Weight loss at 10 yrs:...
Cardiovascular disease
Diet/Drug induced weight loss NO mortality benefit (yet)
Sjostrom NEJM
2007
Diabetes
Hawkins S, Welbourn R et al Obes Surg May 2007
Economic
0
10
20
30
40
50
60
70
80
% in paid work Mean hours worked
Before ...
Functional
0
20
40
60
80
100
%improvement
Banding Bypass
Basdevant et al. Obes Surg. 2007
12 patients: 100% resolution of menstrual abnormalities
Normalisation of sex hormones and SHBG
Significant improvements in...
Heath status perceived (Quality of Life)
Karlsson et al. Int J Obes. 2007
50
30
10
-10
Health
perception
Social
interactio...
Image
Returns to same levels as rest of population
Conclusions
Health care professionals – morbidity & mortality
Companies - productivity
Governments – healthcare costs
Pati...
Acknowledgements
Wellcome Trust
NIHR
University College Dublin
Prof Donal O’Shea
Prof Catherine Godson
Imperial College Lo...
10
15
20
25
30
35
40
45
50
0
5
1 2 3 4 5 6 7
2nd centile
50th centile
98th centile
Age (years)
Child B
Response to leptin ...
SCOPE School Dublin - Carel Le Roux
SCOPE School Dublin - Carel Le Roux
Upcoming SlideShare
Loading in …5
×

SCOPE School Dublin - Carel Le Roux

1,664 views

Published on

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

SCOPE School Dublin - Carel Le Roux

  1. 1. How to stage patients with obesity Carel le Roux Diabetes Complications Research Centre University College Dublin, University of Gothenburg
  2. 2. Morbid obesity vs Obese morbidity Sharma et al CMAJ 2011
  3. 3. Do you want to Medicalise this man? Physically active Happy Employed 120/78 mmHg Normal glucose and lipids
  4. 4. Indication for Obesity intervention 55 years Pipe smoker 3rd party assistance for ADL No exercise 148/88mmHg Fasting glucose 7.5mmol/L Low HDL, high Tg +/- Sleep apnoea Good candidate for intervention ?
  5. 5. Recidivism after volitional weight loss BMI Time 40 30 20 Volitional / pharmacological weight loss Homeostatic response promotes weight regain Settling point Reduced- obese state
  6. 6. Weight Management vs Obese Morbidity Clinic Treatment kg Weight management Stop coming Multi- modal Strategy Morbid Obesity Obese Morbidity 10 domain assessment P1 P2 P3 Weight sensitive? Weight resistant? Non-weight related? Therapy specific?
  7. 7. Morbidity and weight loss sensitivity or resistance Metabolic Ventilatory Reproductive CV risk Perceived health status ADL / QoL Eating behaviour Depression Body Image dysphoria Economic cost -5 -10 -15 -20 -25 -30 % weight loss to improve morbidity Aylwin 2005
  8. 8. Edmonton Obesity Staging System (EOSS) Stage 0 Sharma AM & Kushner RF, Int J Obes 2009 Stage 1 Stage 2 Stage 3 Stage 4 Medical MentalFunctional absent absent absent pre-clinical risk factors m ild m ild co-morbidity moderate moderate end-organ dam age severe severe end-stage end-stage end-stage Obesity www.drsharma.ca
  9. 9. Edmonton Obesity Staging System (EOSS) Stage 0 Normal blood glucose Sharma AM & Kushner RF, Int J Obes 2009 Stage 1 IFT/ IGT Stage 2 Type 2 Diabetes Stage 3Micro-/macro- vascular disease Stage 4Blindness ESRD Type 2 Diabetes www.drsharma.ca
  10. 10. EOSS Predicts Mortality in NHANES III Padwal R, Sharma AM et al. CMAJ 2011www.drsharma.ca
  11. 11. EOSS Predicts Mortality at Every Level of BMI NHANES III Padwal R, Sharma AM et al. CMAJ 2011 Overweight www.drsharma.ca
  12. 12. EOSS Distribution Across BMI Categories NHANES III (1988-1994) Overweight Class III Padwal R, Sharma AM et al. CMAJ 2011 50 million 23 million 10 million 6 million www.drsharma.ca
  13. 13. EOSS Case 1 24 year-old physically active female, BMI of 32 Kg/m2 no demonstrable risk factors, no functional limitations, or mental health issues Class I, Stage 0 Obesity - Focus on prevention of further weight gain - Health benefits of more aggressive obesity treatment likely marginal Sharma AM & Kushner RF, Int J Obes 2009www.drsharma.ca
  14. 14. EOSS Case 2 32 year-old male BMI of 36 Kg/m2 hypertension, sleep apnea, depression Class 2, Stage 2 Obesity - Clear benefits of obesity treatment Sharma AM & Kushner RF, Int J Obes 2009www.drsharma.ca
  15. 15. EOSS Case 3 63 year-old male BMI of 74 Kg/m2 disabling osteoarthritis (wheel chair) severe hypoventilation, fibromyalgia, generalized anxiety disorder Class 3, Stage 4 Obesity - Aggressive obesity treatment unless deemed palliative Sharma AM & Kushner RF, Int J Obes 2009www.drsharma.ca
  16. 16. www.drsharma.ca
  17. 17. Key Points: EOSS provides framework for clinical prioritization predictor of obesity risk Basis for management strategies www.drsharma.ca
  18. 18. Obesity Staging Score: Aylwin et al Front Horm Res 2008 Stage 0 Stage 1 Stage 2 Stage 3 Airway Normal Apnoea CPAP Cor pulmonale BMI <35 35-50 50-60 >60 CVD <10% >20% IHD CCF Diabetes Normal IFG/IGT Controlled Uncontrolled Economic No impact disadvantage unemployed Function Normal limited 3rd party House-bound Gonadal Normal PCOS Subfertile Breakdown Health status Normal Low mood Depression Disorder Image Normal impaired dysphoria Disorder
  19. 19. Airway Basdevant et al. Obes Surg. 2007 0 20 40 60 80 100 %improvement Banding Bypass
  20. 20. Control +1.6%Control +1.6% Banding -13.2%Banding -13.2% VBG -16.5%VBG -16.5% Bypass -25%Bypass -25% Weight loss at 10 yrs:Weight loss at 10 yrs:5 0 -5 -10 -15 -20 -25 -30 -35 -40 -45 0 0.5 1 2 3 4 6 8 10 Years of follow-up Weightchange(%)Weightchange(%) Body mass index Sjöström L. et al N Engl J Med 2004
  21. 21. Cardiovascular disease Diet/Drug induced weight loss NO mortality benefit (yet) Sjostrom NEJM 2007
  22. 22. Diabetes
  23. 23. Hawkins S, Welbourn R et al Obes Surg May 2007 Economic 0 10 20 30 40 50 60 70 80 % in paid work Mean hours worked Before surgery After surgery Population average **** ****** 59 patients SW England Jan 04 – Aug 06 14 months FU (3-32)
  24. 24. Functional 0 20 40 60 80 100 %improvement Banding Bypass Basdevant et al. Obes Surg. 2007
  25. 25. 12 patients: 100% resolution of menstrual abnormalities Normalisation of sex hormones and SHBG Significant improvements in hirsutism Moreale et al, JCEM 2005 Gonadal
  26. 26. Heath status perceived (Quality of Life) Karlsson et al. Int J Obes. 2007 50 30 10 -10 Health perception Social interaction Obesity related problems Depression %improvement
  27. 27. Image Returns to same levels as rest of population
  28. 28. Conclusions Health care professionals – morbidity & mortality Companies - productivity Governments – healthcare costs Patients - discrimination
  29. 29. Acknowledgements Wellcome Trust NIHR University College Dublin Prof Donal O’Shea Prof Catherine Godson Imperial College London Prof Steve Bloom Prof Mohammad Ghatei University of Gothenburg Dr Malin Werling Dr Torsten Olbers King’s College London Dr Simon Aylwin Prof Stephanie Amiel Mr Ameet Patel Musgrove Hospital, Taunton Mr Richard Welbourn Mr Dimitri Pournaras University of Zurich Dr Marco Bueter Prof Thomas Lutz University of Florida Prof Alan Spector
  30. 30. 10 15 20 25 30 35 40 45 50 0 5 1 2 3 4 5 6 7 2nd centile 50th centile 98th centile Age (years) Child B Response to leptin therapy in a child with congenital leptin deficiency Males Weight (kg) Courtesy Prof Steve O’Rahilly

×