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The Obesity Challenge

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Defined by World Health Organisation using body mass index (BMI) ... include sibutramine, orlistat, phentermine, diethylpropion, fluoxetine and ... – PowerPoint PPT presentation

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Title: The Obesity Challenge


1
The Obesity Challenge
  • Donal OShea
  • St Vincents University Hospital
  • St Columcilles Hospital

2
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)

3
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

4
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)
5
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

6
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).

7
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)
13
     International Pediatric Association
                                           FISPGHA
N    
14
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

15
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


16
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
17
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

18
Where does responsibility lie?
19
Obesity Taskforce Reported May 2005
  • Report emphasises prevention, prevention,
    prevention
  • Treatment is difficult
  • Never allowed refer to obesity as a disease

20
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

21
Active Management of Obesity
  • Does Treatment work
  • Reductil (Sibutramine) Xenical (Orlistat)
  • Meta-analysis Pharmacologic Treatment
  • Annals of Internal Medicine April 5th 2005

22
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

23
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

24
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)

25
Active Management of Obesity
  • Meta-Analysis of Surgical Treatment of Obesity
  • Maggard et al, Annals of Internal Medicine 2005

26
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

29
Weight Changes among Subjects in the SOS Study
over a 10-Year Period
30
  • 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

31
  • 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

32
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

33
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
38
What should we do in practice?
39
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

40
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

41
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