The Medical Management of Obesity
Nerys Williams
Consultant Occupational Physician and former Honorary
Consultant in Obesity and Weight Management
Firefit, Durham
6 July 2009
(the views expressed are personal and not those of any
employer)
Outline
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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
Women
25
20
15
10
5
year
99
19
97
19
95
19
93
0
19
% BMI > 30
Now
>50% adults now
overweight (BMI >25)
>22% of men and >23%
of women are now
obese (BMI>30)
Men
Projected trend for BMI>30 in EU over 25 years
45
40
35
%
30
%
25
20
15
10
5
0
2005
2010
2015
2020
2025
2030
Year
IOTF projection 2005
Causes of Obesity
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Heredity
Familial
Demographic factors
 age
 gender
 ethnicity
 social class
 marital status
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Physical inactivity
Dietary intake
Smoking cessation
Drugs ( steroids,
lithium,
sulphonylureas)
rarely endocrine
disorders
Why the Increase ?
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Increased energy in
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greater choice
high fat/calorie
dense food
processed/prepared
food
eating out + fast
food
snacking
super sizing
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Reduced energy
expenditure
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less sport
computer games/TV
increase in cars
change in work
practices
How obesity occurs
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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
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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
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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
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Umbilicus ?
Narrowest part ?
Midway rib and pelvis ?
Other ?
Amended WHO Definitions of Obesity
(Taking Into Account Waist Circumference)
BMI
Men <102cm
Women <88 cm
Men > 102cm
Women 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
Extremely high
* Disease risks
Definitions
For Indo Asian patients
WHO (modified) classification
Overweight
Obese
Morbid obesity
BMI 23-25 (25-29.9)
BMI 25-30 (>30)
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)
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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
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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.
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sleep apnoea
sweating
hirsutism
infertility (esp.PCOS)
menorrhagia
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varicose veins
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Recently identified increased
inflammatory markers and
risk of atrial fibrillation
Health Risks
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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
Age adjusted models of type 2 diabetes risk
according to BMI
20
15
Age adjusted
10
relative risk
5
BMI (kg/m2)
0
<21 <23 <25 <27 <31 >35
BMI (kg/m2)
Implications for Occupational Health
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Short term absences
Obesity in women
Overweight and obesity in men
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Long term absences
Overweight 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
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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
Prejudice
employers
healthcare
service providers
Discrimination
Perceptions
lack self control
lazy
less intelligent
less likely to have
friends
Prejudice and presumptions
UK
Personnel Today
Survey November 2005
PCT
BMI >30 not allowed hip
replacements on the
basis of “clinical risk of
failure”
Is this
 Ethical ?
 Moral ?
 Judgemental ?
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Impact on obesity and
work ?
Worthwhile Treating ?
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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
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Prevent normal weight
people becoming
overweight
Prevent overweight
people becoming obese
Individual vs. Environment
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Individual
screening, support, weight loss clinics
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Environment
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Increase activity in tasks
Increase opportunities for activity
Reduce opportunities to consume calories
Philosophy of Weight Management
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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
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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 Activity
in Weight Management
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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
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Work design
Local walking groups
Step distances from
premises and
around local area
Tax breaks on cycles
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Pedometers
Gym/health club
subsidy
Reward “weight loss
clubs” capitalise on
New Year
resolutions
Food Intake
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Vending machines
Carousel catering
Conferences
Reception
Distraction eating
Canteen:
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labelling
options
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Farmers
markets/local
producers
Subsidise healthy
options
Info sessions
Provide one piece of
fruit per day
Weight Expectations:
What to Communicate to Patients
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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
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NICE approved bariatric surgery
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according to guidelines
Developments
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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
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Health trainers
Training of primary care staff
Directory of courses/training
Patient activity questionnaires
Change4life
NOF NOW 2009
Workplace Obesity Strategy
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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
Summary
Your Choices
Manage the condition
or
Manage the complications