Transcript No Slide Title

Cumulative incidence of Diabetes after 50 years
based on average BMI aged 20-50 years
Johns Hopkins precursors study - n=916 males
Cumulative incidence (%)
15
>25
24-24.9
22-23.9
<22
12
9
6
3
0
50
55
60
65
70
75
age (years)
Arch Intern Med 1999;159:957-63
TV watching and activity as risk factors for DM
in 37519 health professionals
Arch Intern Med 2001;161:1542-8
What can we do about obesity ?
Julian H Barth
Obesity Clinic, Leeds, UK.
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
Obese
Overweight
Normal
Years of management or intermittent monitoring
How do we treat obese patients?
• identify ideal weight
• prescribe 800-1000 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
Sedentary
lifestyle
Drug therapy
for other diseases
Dysfunctional
eating
Social/emotional
turmoil
Chronic failure of
life-long dieting
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 (800-1500kCal/day) (3.4-6.3MJ)
High fibre diets
calorie counting
energy prescribed
low CBH diets
• VLCD (<800kCal/day) (<3.4MJ)
• Milk diet
• Alternative diets
XENDOS
What treatment gave these results?
0
weight loss (%)
-2
-4.1 kg
-4
-6
-8
-6.9 kg
-10
-12
0
13 26 39 52 65 78 91 104 117 130 143 156 169 184 197 204
time (weeks)
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 longterm 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
• Sibutramine
• Rimonabant
‘Xenical’
‘Reductil’
‘Accomplia’
Aims of obesity therapy
• Weight loss
• Weight maintenance
Orlistat: mean weight changes
0
–2
Change –4
in
body
weight –6
(%)
Placebo (n=249)
–6.1%
*p<0.001
–8
Orlistat 120 mg (n=271)
–10
–10.2%
–12
-4 0
10
20
30
40
52
Time (weeks)
Sjostrom L et al. Lancet 1998;352:167
XENDOS
• 4 years therapy with orlistat
• Weight loss
– Active Rx
– Placebo
6.9 kg loss
4.1 kg loss
• Cumulative incidence of type 2 Diabetes
– Active Rx
– Placebo
6.2%
9.0%
Weight maintenance: sibutramine
Weight loss Weight maintenance
Bodyweight (kg)
104
102
100
Control
98
96
94
Sibutramine
92
90
88
0
2
4
6
8
10 12 14 16 18 20 22 24
Month
STORM Study. Lancet 2000;356:2119-25
Combination of lifestyle modification & sibutramine on
weight loss
Sibutramine alone
Sibutramine + Lifestyle
Combined Treatment
20
18
16
14
12
10
8
6
4
2
0
2
4
6
Time (months)
12
Arch Intern Med 2001;161:218-227
Rimonabant
Van Gaal LF et al. Lancet 2005;365:1389-1397.
Counterweight
• 7 UK centres
• Weight management advisors at
each centre
• Obesity audit of disease burden
• Prospective obesity
management programme
through practise education
Weight loss
0
start
3 months
6 months
12 months
-1
-2
kg -3
*
-4
*
*
-5
-6
* p<0.001(n=446)
Completers
Non-completers
Int J Obes 2004;28 (suppl 1):S29
Slimming on Referral
• Collaborative project
between Derby HA &
Slimming World
• Pilot study
• 107 subjects
70
60
50
40
12w
24w
30
• 58% competed 12w
20
• 27% completed 24w
10
0
<5% 5-10% >10%
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;351:2683-93
What do we need ?
Slimming clubs
Support
groups
Occupational
health
Primary care team
GP, nurse, dietitian,
psychologist
Secondary care team
Dietitian, physician,
surgeon
Obesity
research unit
Sports &
leisure facilities
Disinterested
Primary care team
HEALTHY ENVIRONMENT