Obesity workshop: Obesity workshop March 2005


Why talk about obesity ? (some NICE facts): Why talk about obesity ? (some NICE facts) It’s a hot topic! Obesity has a major impact on physical social and emotional well being. It substantially increases morbidity and mortality particularly when linked with disease, notably diabetes, dyslipidaemia and hypertension. It also plays a role in cancer, reproductive health and mental health. The prevalence is rising, in 1998 21% of males and 17% of females were classed as being obese. About 50% of the adult population is obese or overweight.


Government Facts: Government Facts KEY FACTS n Obesity and overweight increase the risk of the biggest killer diseases, such as heart disease, cancer and diabetes. n The prevalence of obesity has trebled since the 1980s, and well over half of all adults are either overweight or obese – almost 24 million adults. n If the number of obese children continues to rise, children will have a shorter life expectancy than their parents. n If current trends continue, at least one-third of adults, one-fifth of boys and one-third of girls will be obese by 2020. n The cost of obesity is estimated at up to £3.7 billion per year, including £49 million for treating obesity, £1.1 billion for treating the consequences of obesity, and indirect costs of £1.1 billion for premature death and £1.45 billion for sickness absence. The cost of obesity plus overweight is estimated at up to £7.4 billion per year. n Burning off the calories in a fast food chain’s cheeseburger, fries and a shake equates to a nine-mile walk.


What is the definition of obesity?: What is the definition of obesity?


The definition in children is different: The definition in children is different Definition and diagnosis Body Mass Index (BMI) is the most practical measure of obesity/overweight, provided values are related to reference standards for age. Currently available British Childhood BMI charts show 91st, 98th and 99.6th centile lines. The 2002 charts also show the recommended International Obesity Task Force cut-offs for obesity and overweight in children. These correspond to the adult definitions of overweight (BMI ³25)and obesity (BMI ³30) at age 18. Rapid changes in BMI can occur during normal growth. There is great potential for reducing overweight in childhood and adolescence.


Second Wanless Report: Second Wanless Report The Second Wanless Report (2004) Securing the Good Health of the Whole Population Commissioned by the treasury Criticises previous government failures to produce public health improvements Calls for strong leadership Raised the need to think radically about ways to discourage unhealthy food intake


Choosing Health: Choosing Health NICE guidelines by 2007. Produce a weight loss guide to help people maintain a more health weight. New funding Comprehensive Pathway of care.


White Paper (“Choosing Health”): White Paper ('Choosing Health') Voluntary restrictions on advertising of high-fat and high-sugar foods to children Possible legislation by 2007 Voluntary food coding system plan Traffic light system related to fat and salt Simple practical way to help choose a healthy diet School meals to conform to nutrition guidelines Fruit and veg vouchers for low income families Personal lifestyle guru NHS health trainer


How are we going to talk about it?: How are we going to talk about it? Consider an agenda based on what we know and don’t know and what we think we should know. Review some of the resource material we have available. Consider some questions that might arise about the management of obesity.


Cause and Effect: Cause and Effect Up until recently doctors have been treating the consequences of obesity rather than the condition it self. Increasingly we will treat the condition itself. The Government, food manufactures and advertisers also have essential parts to play.


Orlistat: Orlistat 120mg tds before/with meals Inhibits pancreatic lipase, hence reduces fat absorption (up to 30%) Licensed for use in adults with BMIandgt;30, or andgt;28 if other risk factors present Must lose 2.5kg in 4 weeks prior to prescription Prescribing should cease if there is andlt;5% weight loss after 12 weeks NICE guidelines published on its use


Orlistat: Orlistat GI side effects occur in up to 27% including flatulence and 'oily leakage' May reduce incidence of new diabetes in obese patients by a third or more May inhibit absorption of fat-soluble vitamins and possibly the COCP Helps weight loss combined with diet NNT to get 5% reduction at one year was 3.9; to get 10% reduction NNT=5.6 (O’Meara et al 2001)


Orlistat: Orlistat Lancet 1998 Clinical trial up to 2 years duration Average weight loss of about 10%, compared with 6% on placebo Reduces BP, LDL and total cholesterol, improves insulin resistance and blood glucose control in diabetic patients 43% diabetic patients reduced their sulphonylurea dose and 12% stopped their oral diabetic medication


Orlistat-the NICE guidance: Orlistat-the NICE guidance


Sibutramine: Sibutramine 10-15mg daily Centrally acting drug suppressing appetite via serotonin NICE guidance in Oct 2001 similar to Orlistat license. BP must be checked regularly It may cause a rise in BP and heart rate Some changes in cardiovascular risk factors, including levels of lipids, insulin and urate, although significance is uncertain


Sibutramine: Sibutramine STORM study (Sibutramine Trial of Obesity Reduction and Maintenance) Lancet 2000 When combined with diet and support, it induces significant weight loss compared with placebo or diet alone 43% of patients maintained at least 80% of their weight loss compared with 16% of placebos Additional treatment for 18 months maintains the weight loss At 6 months NNT was 2.7 for at least 5% reduction (O’Meara et al 2001)


Sibutramine-The NICE guidance: Sibutramine-The NICE guidance Should only be prescribed as part of an over all strategy in patients with a BMI of greater than 27 if co-morbidities exist or more than 30 if they don’t. Adequate monitoring of progress should be in place. Prescribing beyond 4 weeks should only continue if it is supported by weight loss of 2kgs, and beyond 3 months if body weight falls by 5%. Monitor blood pressure and pulse. Prescribing should not extend beyond 12 months.


What if…?: What if…? Obesity became an important part of the new contract. If GP income was based on their ability to target and manage their over-weigh population. How would you manage that?


Slide19:


Obesity in your practice: Obesity in your practice How do we target groups? What management plans and protocols? What personel and resources?


Approach to treatment in Primary care (NOF. www.nationalobesityforum.org.uk): Approach to treatment in Primary care (NOF. www.nationalobesityforum.org.uk)


Management: Management Team approach, nurses, dieticians etc Involve the whole family. Aim for 10% weight reduction over the first 3 months


Management: Management


Management: Management


Surgery: Surgery For the morbidly obese only, BMI greater than 40. All other methods have been tried and failed. After a full multidisciplinary team assessment. In July 2002 (when NICE guidance was published) only 200 operation were done annually. Bypass surgery and banding. Long term outcomes are good. There is sustained weight loss and reduction in the development of hypertension and diabetes


Interventions in schools: Interventions in schools Intervention in Primary Schools Active Programmes Promoting Lifestyle Education in Schools (APPLES) BMJ 2001 Intervention of a multidisciplinary, multi-agency programme producing changes at school level Effects to be monitored into adulthood RCT of primary school-based intervention to reduce risk factors for obesity (BMJ 2001) Intervention of teacher training, modification of school meals, PE etc Little effect on children’s behaviour other than increase in vegetable consumption


Other evidence: Other evidence Implications of childhood obesity for adult health: findings from thousand families cohort study (Dec 2001) No excess health risk from childhood overweight Only children obese at 13 showed significant risk of adult obesity The thinnest children who became the fattest adults had the highest adult risk BMJ 2001 Eating more frequently is significantly associated with reduced total cholesterol and LDL