OBESITY

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OBESITY

• Paul Bolton

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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

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What is obesity?

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

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Who is obese?

• Overweight Men 45
• Women 34
• Obese Men and Women 24¹
• 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)
• Tackling Obesity in England. National Audit
  Office. London The Stationary Office 2001.
• Health Survey for England 2000.

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Who is obese?

• Prevalence BMI gt25 in adults has trebled in 20
  years.
• In Children?
• Eds presentation!

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Why does it happen?

• Consuming more calories than are expended for
  daily energy needs
• Sedentary lifestyle
• Calorie rich, fatty food
• Availability of food
• Marketing?

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Why does it happen?

• Majority polygenic trait plus environment
• Very rarely single gene defects e.g.
  Prader-Willi, leptin deficiency, endocrine disease

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Why is it a problem?

• CHD doubled if BMIgt25
• Quadrupled if BMI 29 etc.¹
• Diabetes
• BMIgt35 are at 40 x non obese risk¹
• Colon cancer and Endometrial cancer
• Increased 2 5 times¹
• Osteoarthritis
• Sleep apnoea
• Jung R T. Obesity as a disease. Br Med Bull
  199753307-21.

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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
• Tackling Obesity in England. National Audit
  Office. London The Stationary Office 2001.
• House of Commons Health Committee Obesity.

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CONVINCED?!
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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 gt50
• Obesity related Cancer ? 50
• ? syst and diast BP 10mmHg
• Lipid profile improves
• 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.

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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 gt30 or 27 (28) with co-morbidities, NICE
  recommends drug Rx.

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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)
• BMIgt30 or 27 with co-morbidity.
• 10mg OD, 15mg if lt2kg loss in 4 weeks
• Stop if lt5 loss in 3 months
• Max 1 year treatment

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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 gt10mmHg/bpm rise.
• CI in CHD, CCF, CVA, uncontrolled HTN,
  arrhythmia, psychiatric illness

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What can you do about it?

• Orlistat (Xenical)
• Inhibits lipases 30 passed unabsorbed
• 2-5Kg per year loss c.f. placebo
• BMI gt30 or 28 with co morbidity
• No need for initial 2.5Kg loss first (EDRA)
• 120mg TDS
• Discontinue if lt5 lost at 3/12 or 10 at 6/12

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What can you do about it?

• CIs few malabsorption, pregnancy, cholestasis
  good for IHD
• ADEK Vits may need supplements
• Terrible SEs
• Oily anal discharge
• Flatus with discharge
• Fatty stool
• Faecal urgency
• Less fat less SEs

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What can you do about it?

• Which drug?
• Sibutramine if BMI 27 with co-morbidity
• Sibutramine for snackers
• Orlistat if IHD
• At present, cant combine
• Treatment licensed for 1 year
• Prob. need follow up in practice clinic

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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!

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The Future

• Neuropeptide Y
• hypothalamic neurotransmitter
• Most powerful appetite stimulant known
• Monoclonal antagonist being studied
• Leptin
• Hormone high in obese, lower in normal but genes
  for leptin normal
• Not fully understood

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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..

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Summary

• Most UK adults BMIgt25
• Rate increasing
• Childhood timebomb
• Significant morbidity / mortality
• GPs should be proactive
• Role for drugs
• Developing area

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THE END