Obesity Eppie Habashi

Classification Obesity is excess body fat and is due to an imbalance between energy intake and expenditure – can be caused by lifestyle, genetics, drugs, medical problems BMI 25-29.9 – Overweight 30-34.9 – Obesity I 35-39.9 – Obesity II 40+ - Obesity III

HUGE Problem 26% of adults in the UK are obese 68% of men and 58% of women are overweight Associated with many chronic diseases, many of the complications reduced with weightloss Associated with cancers Psychological problems

Table 1 . Classification of cardiovascular and metabolic disease risk by waist circumference in people who are overweight or in obesity class I. Cardiovascular and metabolic disease risk relative to normal weight and waist circumference BMI Low§ High§ Very high§ Overweight (BMI 25–29.9) No increased risk Increased risk High risk Obesity I (BMI 30–34.9) Very high risk § For men, waist circumference < 94 cm (37 inches) is low, 94–102 cm (37–40 inches) is high, and > 102 cm (approx 40 inches) is very high.§ For women, waist circumference < 80 cm (31.5 inches) is low, 80–88 cm (31.5–34.5 inches) is high, and > 88 cm (approx 34.5 inches) is very high. Data from: [NICE, 2006b; SIGN, 2010]

Lifestyle Factors Food intake Physical Inactivity Social and psychological factors Economic factors

Genetics Genes thought to contribute 25-40% of the difference in adiposity between people Possibly related to the hypothalamus being insensitive to leptin

Medical Conditions Hypothyroid Cushings PCOS Growth hormone deficiency Hypothalamic damage Genetic conditions eg Prader-Willi

Medications Insulin Oral hypoglycaemics Antidepressants Anticonvulsants Antipsychotics Lithium Steroids Beta blockers Pizotifen

Management Broach the subject with sensitivity Explain risks of being overweight Benefits of moderate weightloss Enquire into medical problems that contribute to or are complications of weight FH DH SH

Investigations Check glucose and lipids Consider other tests – TFT, LFT etc

Assess readiness to lose weight Concerned about weight? Believe they can lose it? How important? Is it affecting your life? What would you have to change? Barriers to lifestyle change? Knowledge, cost, time, taste, disability, self-esteem If not keen, explore why, discuss benefits of even 10% weightloss

Table 1 . The benefits of a 10 kg weight loss in a person with obesity.  Aspect Benefit Mortality 20–25% reduction in total mortality30–40% reduction in deaths related to diabetes40–50% reduction in obesity-related cancer deaths Blood pressure (in people who are hypertensive) 10 mmHg reduction in both systolic and diastolic values Diabetes (in people who are newly diagnosed) 30–50% reduction in fasting glucose15% reduction in HbA1c Lipids 10% reduction in total cholesterol15% reduction of low density lipoprotein cholesterol (LDL-C)30% reduction in triglycerides8% increase in high density lipoprotein cholesterol (HDL-C) Other benefits Improved lung function, insulin sensitivity, and ovarian functionReduced back pain, joint pain, breathlessness, and sleep apnoea

Dietary Advice DH website – “your weight your health” Sustainable and balanced diet 5 portions of fruit and veg/day High fibre Moderate amount of dairy, low fat Moderate amount of protein Low fat, low sugar Reduce alcohol Lean ways of cooking

Exercise Advice According to individual fitness At least 5 x 30minutes per week Build up the intensity May find group program beneficial Health benefits, not just weight loss

Orlistat Age 18-75 with BMI at least 30 or 28 with co-morbidities Contraindicated if cholestasis or malabsorption Adverse effects : GI, ADEK, rare hepatitis, drug interactions Only continue beyond 3 months if 5% weight loss, no restriction on length of treatment 120mg with meals upto tds Caution in pregnancy, contraindicated in breast feeding

Surgery 1st line if BMI>50 If BMI > 40 and unable to achieve and maintain clinically significant weight loss for at least 6 months Or If BMI > 35 and has other disease that could be improved by weight loss (and meets above criteria)

Summary Multiple factors Huge effects Lifestyle Orlistat Surgery