1. OBESITY Paul Bolton

2. Aims of Presentation What is obesity? Who is obese? Why does it happen? Why is it a problem? What can you do about it? The future…

3. What is obesity? BMI = Kg / M² BMI > 25 but 30 is overweight BMI > 30 is obese (BMI > 40 morbid obesity)

4. Who is obese? Overweight = Men 45% Women 34% Obese = Men and Women 24%¹ Morbidly Obese = Men 0.8% Women 1.8% (1999)² This is 650 000 people in UK So most people are overweight or obese! = 24 million adults in UK (2002) 1.Tackling Obesity in England. National Audit Office. London: The Stationary Office 2001. 2.Health Survey for England 2000.

5. Who is obese? Prevalence BMI >25 in adults has trebled in 20 years. In Children? Eds presentation!

6. Why does it happen? Consuming more calories than are expended for daily energy needs Sedentary lifestyle Calorie rich, fatty food Availability of food Marketing?

7. Why does it happen? Majority polygenic trait plus environment Very rarely single gene defects e.g. Prader-Willi, leptin deficiency, endocrine disease

8. Why is it a problem? CHD doubled if BMI>25 Quadrupled if BMI 29 etc.¹ Diabetes: BMI>35 are at 40 x non obese risk¹ Colon cancer and Endometrial cancer Increased 2 – 5 times¹ Osteoarthritis Sleep apnoea 1.Jung R T. Obesity as a disease. Br Med Bull 1997;53:307-21.

9. Why is it a problem? Low self esteem Surgical risk / Obstetric risk PCOS Gallstones Stress incontinence Shortens life by average 9 years¹ Indirect costs estimated 7.4 billion pounds per year² 1.Tackling Obesity in England. National Audit Office. London: The Stationary Office 2001. 2.House of Commons Health Committee – Obesity.

11. CONVINCED?!

12. What can you do about it? Evidence shows 10% weight loss has benefit (100Kg to 90Kg)¹: Fall in mortality 20% Reduction risk of T2DM >50% Obesity related Cancer 50% syst and diast BP 10mmHg Lipid profile improves 1.Royal College of Physicians Report. Clinical management of overweight and obese patients with particular reference to the use of drugs. Royal College of Physicians, 1998.

13. What can you do about it? Think of it! Explain risks Advice from health professionals Eat less and exercise more Weight Watchers / Slimmers World. Offer 3 months diet and exercise then review If BMI >30 or 27 (28) with co- morbidities, NICE recommends drug Rx.

14. What can you do about it? Sibutramine (Reductil) Noradrenalin and Serotonin uptake inhibitor – promotes satiety/smaller meals Effective in 77% patients (4-5kg at 1 yr) BMI>30 or 27 with co-morbidity. 10mg OD, 15mg if <2kg loss in 4 weeks Stop if <5% loss in 3 months Max 1 year treatment

15. What can you do about it? SEs constipation, dry mouth, insomnia May cause 3mmHg rise in BP and 7bpm rise in HR Regular check of BP/Pulse SPC guidelines intensive! Discontinue >10mmHg/bpm rise. CI in CHD, CCF, CVA, uncontrolled HTN, arrhythmia, psychiatric illness

16. What can you do about it? Orlistat (Xenical) Inhibits lipases – 30% passed unabsorbed 2-5Kg per year loss c.f. placebo BMI >30 or 28 with co morbidity No need for initial 2.5Kg loss first (EDRA) 120mg TDS Discontinue if <5% lost at 3/12 or 10% at 6/12

17. What can you do about it? CIs few: malabsorption, pregnancy, cholestasis – good for IHD ADEK Vits: may need supplements Terrible SEs: Oily anal discharge Flatus with discharge Fatty stool Faecal urgency Less fat = less SEs

18. What can you do about it? Which drug? Sibutramine if BMI = 27 with co- morbidity Sibutramine for snackers Orlistat if IHD At present, cant combine Treatment licensed for 1 year Prob. need follow up in practice clinic

19. If all else fails… Obesity clinic Dr Whitelaw Mr. May (upper GI surgeon) Private stomach surgery Stomach Stapling = Vertical banded gastroplasty Lap-band procedure – can adjust and reverse, lower morbidity. Watch this space!

20. The Future Neuropeptide Y hypothalamic neurotransmitter Most powerful appetite stimulant known Monoclonal antagonist being studied Leptin Hormone high in obese, lower in normal but genes for leptin normal Not fully understood

21. The Future NICE developing guidance Due to publish in 2006 Public Health white paper due soon Only 3 points in nGMS for measuring BMI in diabetics. Obesity points in revised GMS contract in 2006 hinted at..

22. Summary Most UK adults BMI>25 Rate increasing Childhood timebomb Significant morbidity / mortality GPs should be proactive Role for drugs Developing area…

23. THE END