OBESITY Paul Bolton. Aims of Presentation What is obesity? Who is obese? Why does it happen? Why is it a problem? What can you do about it? The future…

OBESITYPaul Bolton

Aims of Presentation

• What is obesity?• Who is obese?• Why does it

happen?• Why is it a

problem?• What can you do

about it?• The future…

What is obesity?

• BMI = Kg / M²• BMI > 25 but ≤ 30 is overweight• BMI > 30 is obese• (BMI > 40 morbid obesity)

Who is obese?• Overweight = Men 45% Women 34%• Obese = Men and Women 24%¹ • Morbidly Obese = Men 0.8% Women 1.8% (1999)² This is 650 000 people in UK• So most people are overweight or obese! = 24 million adults in UK (2002)1. Tackling Obesity in England. National Audit Office. London: The Stationary Office 2001.2. Health Survey for England 2000.

Who is obese?

• Prevalence BMI >25 in adults has trebled in 20 years.

• In Children? Ed’s presentation!

Why does it happen?

• Consuming more calories than are expended for daily energy needs

• Sedentary lifestyle• Calorie rich, fatty food• Availability of food• Marketing?

Why does it happen?

• Majority polygenic trait plus environment

• Very rarely single gene defects e.g. Prader-Willi, leptin deficiency, endocrine disease

Why is it a problem?

• CHD doubled if BMI>25Quadrupled if BMI 29 etc.¹

• Diabetes:BMI>35 are at 40 x non obese risk¹

• Colon cancer and Endometrial cancer Increased 2 – 5 times¹

• Osteoarthritis• Sleep apnoea

1. Jung R T. Obesity as a disease. Br Med Bull 1997;53:307-21.

Why is it a problem?

• Low self esteem• Surgical risk / Obstetric risk• PCOS• Gallstones• Stress incontinence• Shortens life by average 9 years¹• Indirect costs estimated 7.4 billion

pounds per year²

1. Tackling Obesity in England. National Audit Office. London: The Stationary Office 2001.2. House of Commons Health Committee – Obesity.

CONVINCED?!

What can you do about it?

• Evidence shows 10% weight loss has benefit (100Kg to 90Kg)¹:

Fall in mortality 20%Reduction risk of T2DM >50%Obesity related Cancer ↓ 50%↓ syst and diast BP 10mmHgLipid profile improves

1. Royal College of Physicians Report. Clinical management of overweight and obese patients with particular reference to the use of drugs. Royal College of Physicians, 1998.

What can you do about it?

• Think of it!• Explain risks• Advice from health professionals• Eat less and exercise more• Weight Watchers / Slimmers World.• Offer 3 months diet and exercise then

review• If BMI >30 or ≥27 (28) with co-

morbidities, NICE recommends drug Rx.

What can you do about it?

• Sibutramine (Reductil)• Noradrenalin and Serotonin uptake inhibitor –

promotes satiety/smaller meals• Effective in 77% patients (4-5kg at 1 yr)• BMI>30 or 27 with co-morbidity.• 10mg OD, 15mg if <2kg loss in 4 weeks• Stop if <5% loss in 3 months• Max 1 year treatment

What can you do about it?

• SEs constipation, dry mouth, insomnia• May cause 3mmHg rise in BP and 7bpm

rise in HR• Regular check of BP/Pulse

SPC guidelines intensive! Discontinue >10mmHg/bpm rise.

• CI in CHD, CCF, CVA, uncontrolled HTN, arrhythmia, psychiatric illness

What can you do about it?

• Orlistat (Xenical)• Inhibits lipases – 30% passed

unabsorbed• 2-5Kg per year loss c.f. placebo• BMI >30 or 28 with co morbidity• No need for initial 2.5Kg loss first

(EDRA)• 120mg TDS• Discontinue if <5% lost at 3/12 or 10%

at 6/12

What can you do about it?

• CI’s few: malabsorption, pregnancy, cholestasis – good for IHD

• ADEK Vits: may need supplements• Terrible SEs:

Oily anal dischargeFlatus with dischargeFatty stoolFaecal urgency

• Less fat = less SE’s

What can you do about it?

• Which drug?Sibutramine if BMI = 27 with co-morbiditySibutramine for snackersOrlistat if IHD

• At present, can’t combine• Treatment licensed for 1 year• Prob. need follow up in practice clinic

If all else fails…

• Obesity clinic Dr Whitelaw• Mr. May (upper GI surgeon)• Private stomach surgery• Stomach Stapling = Vertical

banded gastroplasty• Lap-band procedure – can adjust

and reverse, lower morbidity.• Watch this space!

The Future

• Neuropeptide Yhypothalamic neurotransmitterMost powerful appetite stimulant knownMonoclonal antagonist being studied

• LeptinHormone high in obese, lower in normal but genes for leptin normalNot fully understood

The Future

• NICE developing guidance• Due to publish in 2006• Public Health white paper due soon• Only 3 points in nGMS for

measuring BMI in diabetics.• Obesity points in revised GMS

contract in 2006 hinted at..

Summary

• Most UK adults BMI>25• Rate increasing• Childhood timebomb• Significant morbidity / mortality• GPs should be proactive• Role for drugs• Developing area…

THE END