The Obesity Challenge

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The Obesity Challenge

• Donal OShea
• St Vincents University Hospital
• St Columcilles Hospital

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What is Obesity?

• Defined by World Health Organisation using body
  mass index (BMI) (Weight in Kg divided by height
  in meters squared)
• 54 Normal 65kgs (10 stone 3 lbs) Obese 78kgs
  (12 stone 2 lbs)
• 510 Normal 78kgs (12 stone 2 lbs) Obese 94kgs
  (14 stone 10 lbs)

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Grades of BMI Kg/M2

• BMI 19-25 -Normal
• BMI 25-30 -Overweight
• BMI 30-35 -Grade 1 Obesity
• BMI 35-40 -Grade 2 Obesity
• BMI 40 -Grade 3(Morbid) Obesity
• USA 5 have BMI 40 Ireland 2 have BMI 40

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Relationship of BMI to Excess Mortality
300
Age at Issue
20-29
250
30-39
200
150
Mortality Ratio
100
High
Moderate
Low
Risk
Risk
Risk
50
0
15
20
25
30
40
35
Body Mass Index (kg/m2)
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Obesity and Life expectancy

• January 2003 Life Table analysis of Framingham
  Data
• Obese at 40 live 6 to 7 years less than normal
• Overweight at 40 live 3 years less than
  normalObese smoker live 14 years less than
  normal

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Obesity Accounts for

• 5 of heart attacks and strokes
• 10 cases of osteoarthritis
• 20 cases of hypertenstion
• 30 of cancers
• 80 cases of Type 2 diabetes.
• There is limited data on the cost of obesity but
  evidence suggests that the direct cost accounts
  for 5 to 7 of total health care expenditure
  (WHO,1998).

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Excess weight is a risk factor for diabetes - US
adults, 2001 (n195, 005)
Prevalence of diabetes ()
30
25.6
20
14.9
10
7.3
4.1
0
Normal
OverweightBMI 25-29.9
ObeseBMI 30-39.9
ObeseBMI ?40
Mokdad et al. JAMA 2003 289 76-9
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Burning a lot less energy (per half hour)
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     International Pediatric Association
                                           FISPGHA
N    
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Childhood Obesity in Ireland

• 30 overweight and 14.7 obese overall
• 12 obese 7 year olds
• 20 obese aged 9-10 years
• 2001/2 National Dental Survey, Perry et al

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Current and Future morbidity

• fatty streaks, raised lesions and calcifications
• aorta coronary arteries increases with age
• Berensen, NEJM, 19983381650-6
• Cardiovascular risk factors for later life
  
• 65 obese 5-10 yo min 1 cardiovascular risk
  factor
• 25 obese 5-10 yo / 2 risk factors
• Freedman et al, The Bogalusa Heart
  Study, Paediatrics, 1999
• Impaired glucose tolerance type 2 diabetes
  rising
• 8-45 of child diabetes population
• Metabolic syndrome
• US up to 50 Weiss et al NEJM 2004
  350232362-74
• UK 30 Viner et al, Arch Dis Child 2004

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Childhood obesity worse prognosis in adulthood
Hazard Ratio all cause mortality
1.5, Ischaemic Heart
Disease 2 for 75 percentile v
Boyd-Orr cohort, Gunnell et al, Am J Clin Nutr,
1998
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Do obese children become obese adults?

• 30 of adult obesity begins in childhood so many
  adults were not obese children and not all obese
  children will stay obese
• 1/3 obese preschoolers obese adults (26-41)
• All ages risk twice as high for obese as
  non-obese (range 2-6.5 fold risk)
  Serdula,Preventative Medicine 199322167-177
• Parental obesity doubles the risk of adult
  obesity in both obese and non-obese children years Whittaker NEJM 1997337(13)869-73

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Where does responsibility lie?
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Obesity Taskforce Reported May 2005

• Report emphasises prevention, prevention,
  prevention
• Treatment is difficult
• Never allowed refer to obesity as a disease

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93 Recommendations in total

• Joined up Thinking
• Intersectoral/Cross Departmental
• Certain Initiatives Happening Ready, Steady,
  Play Cardiovascular Strategy - 60 million to
  date
• Government Lead
• Acknowledged need for treatment

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Active Management of Obesity

• Does Treatment work
• Reductil (Sibutramine) Xenical (Orlistat)
• Meta-analysis Pharmacologic Treatment
• Annals of Internal Medicine April 5th 2005

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Sibutramine (Reductil)

• More effective than placebo
• BMI 25 aged 34 to 54
• Average weight loss 4.5 kg compared to placebo at
  1 year
• Diet intervention in nearly all studies
• Exercise and behaviour in 25

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Orlistat (Xenical)

• Meta-analysis of 29 studies
• Average age 48 years, Average BMI 36.7Kg /M2
• Average weight loss 2.6 kg a 6 months and 2.9kg
  at 1 year compared to placebo
• Diet intervention in all / exercise in 18

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Duration of Use

• Randomised Control Trials have looked to 12
  months (except for Xendos)
• Predicted adverse events up to 1.5 per 1000
• No correlation to reduced morbidity or
  mortality(Scout, Xendos on the way)

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Active Management of Obesity

• Meta-Analysis of Surgical Treatment of Obesity
• Maggard et al, Annals of Internal Medicine 2005

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Gastric Reduction Surgery Procedures in US

• 1992 16,200 bariatric surgeries carried out
• 2004 144,000 bariatric surgeries expected

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Swedish Obese Subjects Study

• Bariatric surgery versus medically matched
  controls
• Average age 47 years
• 2/3 were women
• Average baseline BMI 41 kg/m2

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Weight Changes among Subjects in the SOS Study
over a 10-Year Period
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• Christou et al 2004 Annals of Internal Medicine
• 1035 patients undergoing bariatric surgery (BMI
  50 kg/m2) versus 5746 controls
• At 2 years
• 6.17 of controls had died versus 0.68 of the
  surgical patients
• 0.4 perioperative death rate

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• Review of all case series
• Surgery caused an improvement or resolution of
• Diabetes (64 to 100)
• Hypertension (25 to 100)
• Dyslipidaemia (60 to 100)
• Sleep apnoea (80)
• Others

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Obesity Service in St Columcilles

• 640 patients attending high intensity
  programmefor 6 months
• Overall 56 loose weight, mean loss 5.2 kgs
• Over 60 years old weight loss 0.1kg Can greatly
  improve cardiovascular fitness though

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Obesity Service in St Columcilles

• 64 patients through surgery to date
• Initial 10 open, laparoscopic since
• Psychologist input essential for screening out
  binge eaters
• New Addictions emerged in 6 post op

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Results in Surgical Patientsn60
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What should we do in practice?
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ACP Recommendations (1-3)

• Counsel all patients BMI30 on diet/lifestyle
  agreeing individual goals.
• Fail to achieve goals offer pharmacotherapy
  highlighting side effects and lack of longterm
  data
• Agents to choose from include sibutramine,
  orlistat, phentermine, diethylpropion, fluoxetine
  and bupropion according to side effects

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ACP Recommendations (45)

• Surgery should be considered with BMI 40 who
  have failed an adequate trial of diet and
  lifestyle. Counselling re risks vital.
• Patients for surgery should be referred to high
  volume centers

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