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)

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

Size of Problem - US

Mokhdad 1991

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

%

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

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

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

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.

Interaction

Genes load the gun and environment pulls the trigger

George Bray 1996

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

Caution With BMI

Case study JM 27 years Height 6 ft 4 ins Weight 325 lbs BMI 39.6

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 ?

Waist Measurement

Umbilicus ? Narrowest part ? Midway rib and

pelvis ? Other ?

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

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)

Defining abdominal obesity

Waist circumference (Caucasians)

Men >94 - 102 cm

Women >80 - 88 cm

WHO 894 Obesity Report

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

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

Health Risks

risks increase as obesity increases

risks increase as visceral fat increases

risks best defined in type 2 DM and in hypertension

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)

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

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

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 ?

Prejudice and presumptions

Prejudiceemployers

healthcare service

providers

Discrimination

Perceptionslack self controllazyless intelligentless likely to have

friends

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 ?

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)

Prevention of Obesity

Key Objective Prevent normal

weight people becoming overweight

Prevent overweight people becoming obese

Individual vs. Environment

Individual

screening, support, weight loss clinics Environment

Increase activity in tasks Increase opportunities for activity Reduce opportunities to consume calories

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”

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

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

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

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

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

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

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

Public Health Initiatives

Health trainers Training of primary care staff Directory of courses/training Patient activity questionnaires Change4life NOF NOW 2009

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

SummaryYour Choices

Manage the condition or

Manage the complications