Cumulative incidence of Diabetes after 50 years based on average BMI aged years Arch Intern Med 1999;159:957-63

TV watching and activity as risk factors for DM in health professionals Arch Intern Med 2001;161:1542-8

Julian H Barth Obesity Clinic, Leeds, UK. What can we do about obesity ?

What is obesity ? The disease process of obesity is weight gain not the absolute value of overweight The average man gains 1 gm per day

A toxic or obesogenic environment Obesity as a normal response to an abnormal environment side-effect of technological advances reflects natural human preferences (eg easy, convenient, fast, low effort, value for money) key vectors –energy-saving machines, passive recreation –energy-dense foods & drinks, large portion sizes

Natural history of obesity Years of management or intermittent monitoring Obese Overweight Normal

How do we treat obese patients? identify ideal weight prescribe kCal diet castigate the patient as a failure await the development of co-morbidities

Treatments for obesity Diet / eating patterns Physical activity Psychological / behaviour modification therapy Pharmacotherapy Surgery Prevention

Evaluation of the obese patient Examine the patient for co-morbidities Examine the patient for a “medical” cause of obesity Ask why the patient wants to lose weight Ask how much weight loss is desired

What are the causes of obesity? Nutritional ignorance Drug therapy for other diseases Sedentary lifestyle Chronic failure of life-long dieting Social/emotional turmoil Dysfunctional eating

Successful obesity management patient accepts the benefit of weight loss patient accepts modality of therapy competent, sympathetic health-carer available to review progress regularly realistic claims for weight loss indefinite after-weight-loss service BNF 1999

Eating & obesity Eating patterns Nutritional knowledge Missed meals Social eating Binge eating Emotional eating Alcohol ex-sports-(wo)men

Dietary therapy Low calorie diets –LCD ( kCal/day) ( MJ) –High fibre diets –calorie counting –energy prescribed –low CBH diets VLCD (<800kCal/day) (<3.4MJ) Milk diet Alternative diets

XENDOS -4.1 kg -6.9 kg What treatment gave these results?

Physical activity and obesity 4th risk factor for IHD – as important as cholesterol and  bp PA improves cardiovascular fitness, plasma lipids & blood pressure physically active subjects live longer exercise results in more weight loss than diet Doctors do NOT advise their patients to be active

Before starting drug therapy… Previous therapies –dietary approaches –Physical activity –Behavioural modification Motivation Effective Safe lifestyle changes have the potential for long- term weight loss

Drugs that promote weight gain steroids beta-blockers anti-diabetic agents anti-histamines anti-psychotic agents anti-depressants anti-convulsants anti-migraine agents breast cancer therapies

Medical therapy for diabetes Sulphonylurea + Insulin Insulin Diet alone UKPDS 57 Diabetes Care 2002;25:330-6

Indications for drug therapy Obesity of severity to shorten life span Obesity related disorders that might be improved by weight loss –eg hypertension, NIDDM, hyperlipidaemia & sleep apnoea Need to reduce weight for other medical therapy eg surgery

Timing of drug therapy Good motivation –weight loss already achieved with diet &/or physical activity –newly diagnosed obese subject with diabetes or bp Poor motivation Weight loss usually occurs within the first 4-6 months of programme Realistic expectations of therapy

Pharmacotherapy for obesity (2001) Phentermine Mazindol Diethylproprion Fenfluramine Dexfenfluramine all have been withdrawn Orlistat‘Xenical’ Sibutramine‘Reductil’ Rimonabant‘Accomplia’

Aims of obesity therapy Weight loss Weight maintenance

Orlistat: mean weight changes Time (weeks) Change in body weight (%) Placebo (n=249) Orlistat 120 mg (n=271) –6.1% –10.2% –10 –12 *p< –2 –4 –6 – Sjostrom L et al. Lancet 1998;352:167

XENDOS 4 years therapy with orlistat Weight loss –Active Rx6.9 kg loss –Placebo4.1 kg loss Cumulative incidence of type 2 Diabetes –Active Rx6.2% –Placebo9.0%

Weight maintenance: sibutramine Month Bodyweight (kg) Control Sibutramine Weight loss Weight maintenance STORM Study. Lancet 2000;356:

Combination of lifestyle modification & sibutramine on weight loss Time (months) Reduction in initial weight (%) Arch Intern Med 2001;161:

Rimonabant Van Gaal LF et al. Lancet 2005;365:

Counterweight 7 UK centres Weight management advisors at each centre Obesity audit of disease burden Prospective obesity management programme through practise education

Weight loss Int J Obes 2004;28 (suppl 1):S29 * p<0.001(n=446) * * *

Slimming on Referral Collaborative project between Derby HA & Slimming World Pilot study 107 subjects 58% competed 12w 27% completed 24w

Obesity surgery 1-2% morbidly obese ~ 8-16,000 people in Leeds Considerable weight loss maintained over 8-10 years Considerable reduction in comorbidities –Diabetes –Musculoskeletal disorders –Sleep apnoea –Improved quality of life Only about 200 operations p.a. in England & Wales …so what are the indications for surgery?

NEJM 2004;351:

H E A L T H Y E N V I R O N M E N T Primary care team GP, nurse, dietitian, psychologist Slimming clubs Disinterested Primary care team Secondary care team Dietitian, physician, surgeon Sports & leisure facilities Support groups Obesity research unit Occupational health What do we need ?