Obesity: why a big issue? Overview of the public health problem

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Obesity why a big issue? Overview of the public
health problem

• Pamela Mason

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Prevalence of obesity in adults England
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Rates of obesity in children in England
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What could happen?

• If current trends continue, 1/3 of adults, 1/5 of
  boys and 1/3 of girls will be obese by 2020
• 24 million adults in the UK
• Life expectancy - 9 years less

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Costs of obesity

• Total cost of obesity - 3.7billion/year
• Total cost of obesity plus overweight - 7.4
  billion a year

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Relative risks of disease in obese vs. non-obese
individuals (NAO, 2001)
Women Men
Type 2 diabetes 12.7 5.2
Hypertension 4.2 2.6
Heart attack 3.2 1.5
Colon cancer 2.7 3.0
Angina 1.8 1.8
Stroke 1.3 1.3
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Benefits of weight loss(10-15 of initial weight)
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• Obesity can only occur when energy intake remains
  higher than energy expenditure

Energy expenditure
Energy intake
Adipose tissue
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Causes of Obesity

• Obesity is a complex and multi-factorial disease
  
• Metabolic
• Genetic
• Medications
• Environmental Behavioural
• Changes in PA Diet

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The Availability of Energy-dense Foods

• A move away from the traditional diet
• An increase in the use of convenience foods
• A decrease in cooking, menu planning and shopping
  skills
• An increase in the consumption of snacks and soft
  drinks (biscuits, cakes, chocolate, crisps and
  fizzy drinks).
• Significant growth in the UK market for fast food
  and take-away outlets
• Food portion sizes

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Influences on obesity

• Work and leisure time
• Sedentary jobs
• Labour saving devices
• Car use
• Less walking/cycling
• Screen-based entertainment
• Eating out and snacking more common
• Alcohol intake increased

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Energy output examples of changes over 50 years
Energy output kcals (1950s) Energy output kcals (2000)
Grocery shopping (foot) 2,400 Grocery shopping (car) 276
Washing clothes (hand) 1,500 Washing clothes (machine) 270
Heating (making a coal fire) 1,300 Heating (no effort) 0
Making a bed (blankets) 575 Making a bed (duvet) 300
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DIET
PHYSICAL ACTIVITY
BEHAVIOUR CHANGE
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Treatment Strategies

• Lifestyle Changes
• Diet
• Physical Activity
• Medication
• Surgery
• Weight Maintenance

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Evidence weight loss? (HDA, 2003)

• Low calorie diets (1000-1500 kcal/day)
• VLCD (400-500 kcal/day)
• Low fat diets with energy restriction
• Low fat diets (lt30 energy from fat) with no
  target on energy restriction)
• Increased physical activity
• Diet and increased physical activity
• Behavioural therapy plus other weight loss
  practices
• Worksite health promotion programmes
• Reminders to GPs to prescribe diets delivered by
  health psychologists
• Brief educational intervention for GPs
• Shared care between GP and hospital
• In-patient obesity treatment services
• Training for both HPs and leaders of self-help
  weight loss clinics

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Weight Loss Diets
A diet with a goal of weight loss needs to have
a 500 1000 kcal/day deficit to achieve a 1 2
pound weight loss per week. Controlling
calories is the bottom line to a weight loss
diet. Jackson el al 2001
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Producing a calorie deficit

• Advice can be based on altering the
• Frequency
• Amount
• Type
• Of food or a combination of these

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Key Points

• Needs to be tailored to the individual
• Needs to be applied taking into account
• Patient preferences
• Current lifestyle
• Clinician needs to use own judgement and clinical
  experience
• Needs to be incorporated with a behavioural
  approach

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Estimated Energy Requirements
An individualised approach to weight reduction,
based on calculation of actual energy
requirements has been shown to be more effective
than the indiscriminate application of low
calorie diets. (Frost 1989, Lean James 1986)
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Other dietary options

• Meal replacements
• Very Low Calorie Diets
• Popular Diets
• High protein/low CHO
• Glycaemic index
• Fad Diets
• Detox, etc,etc

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Physical Activity

• Key message
• 30 minutes of moderate intensity activity on 5
  days of the week
• or
• half an hour a day
• Needs to be more for weight loss

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For Weight Management

• Prevention of overweight/obesity
• 45 60 minutes
• Prevention of weight regain
• 60 90 minutes

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Treatment strategies what works?

• Successful Slimmers
• Incorporate activity into their lifestyle
• Have breakfast
• Check weight regularly
• Have regular meals
• Learn to plan ahead
• Develop problem-solving skills
• Make small changes
• National Weight Control Registry (USA)

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Why a Behavioural Approach?
Interventions combining a low-calorie diet,
physical activity, and behaviour therapy are most
effective for weight loss and maintenance (SIGN
1996, NHLBI 1998, HDA 2003)
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What is a behavioural approach?
The main principles of this approach include
the modification of current behaviour patterns,
new adaptive learning, problem solving and a
collaborative relationship between client and
therapist (HDA 2003)
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Motivation

• Motivation is not something you can do to people
• It has to come from within
• It is not an all or nothing state
• It is influenced by the helping style of the
  health practitioner

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Assessment

• Medical history
• Medical exam - BMI, waist,
• Investigations BP, blood glucose, lipids,
  thyroid function etc
• Risk Factors/co-morbidities
• Weight history

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Assessing Readiness to Change

• Motivation/Importance/ Confidence
• Is the patient ready, willing able?
• Is now the right time?
• Are there other options that should be explored?

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Assessing Current Lifestyle

• Patients tend to under-report food intake
  over-report activity Why?
• Physical Activity
• Different methods could include
• Typical day/week
• Keep a diary/chart
• Pedometer

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Assessment of current diet

• Traditional 24hr recall
• Food Diary
• How useful is a detailed dietary intake?
• Typical Day
• Gives information about patients lifestyle
• Gives information about eating behaviour

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Behaviour Modification

• Dont shop when hungry
• Pre-plan meals and snacks
• Use a smaller plate
• Take one bite at a time
• Chew slowly
• Use stairs instead of lift
• Get off the bus one stop earlier
• Etc,etc

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Limitations of advice giving

Review of evidence clearly shows that
giving knowledge alone does not necessarily
lead to a change in behaviour Glanz 1985,
Contento 1995, Roe 1997, Thorogood 2001
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Self-monitoring

• Keeping a diary is important for several reasons
• Raises awareness
• Indicates problem areas or trends
• Leads to problem solving
• But, it is a difficult skill that needs practice!

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Outcomes

• It is important that outcomes, other than weight
  loss are monitored
• Changes in clinical outcomes i.e.BP, blood
  glucose, cholesterol, waist circumference
• Changes in diet and physical activity levels
• Feelings of well-being
• Increase in self-esteem
• Patients own goals i.e.fitting into clothes.

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Weight maintenance

• No simple solution has been highlighted
• Extended support appears to be emerging as being
  significant
• Continued changes to diet physical activity
  seem to be important
• (Perri 2002)

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Guidance

• SIGN (1996). Obesity in Scotland. www.sign.ac.uk
• WHO (2000) Obesity preventing and managing the
  global epidemic. www.who.int
• HDA (2003). The management of obesity and
  overweight www.hda.nhs.uk
• DH (2004) Choosing heath making healthier
  choices easier
• HDA/NICE(2006). Guidance on obesity

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What can pharmacists do?

• Provision of information
• Raising awareness
• Participation in local campaigns
• Measurement of height, weight, BMI, waist
  circumference
• Client motivation
• Readiness to change
• Motivational interviewing

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Barriers

• Psychological complexities of cases
• High rate of relapse
• Perceived lack of effective interventions
• Lack of training
• Lack of time
• Lack of resources
• Lack of onward referral options
• Dearth of properly structured, well resourced
  weight management services throughout the UK

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What is needed?

• Agreed clinical pathway with clear guidelines on
  intervention and referral
• Clear prescribing guidelines
• Good support materials
• Expanded community dietetic service
• Expanded exercise referral service
• Well resourced training programmes
• Collaborative working
• Subsidised referrals to commercial slimming clubs
• Funding
• Research to identify most effective approaches

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Developments

• Dedicated weight management clinics in primary
  care
• Referral to commercial slimming organisation
  (with free vouchers)
• Triple tier pathways

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Triple tier pathway for weight management
(Maryon-Davies, 2004)
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Summary

• Weight management is a complex area
• Requires knowledge, skills
• A thorough assessment is key
• Treatment strategies must be tailored to
  individual