Transcript Obesity workshop

Obesity: why a big issue?
Overview of the public health
problem
Pamela Mason
Prevalence of obesity in adults
England
70
60
50
Mean BMI
% OW
% obese
% OW/OB
40
30
20
10
0
1980
1990
2000
2004
Rates of obesity in children in
England
30
25
20
Girls
Boys
15
10
5
0
1970
1980
1990
2000
2010
2020
What could happen?
 If current trends continue, 1/3 of adults, 1/5
of boys and 1/3 of girls will be obese by
2020
 24 million adults in the UK
 Life expectancy - 9 years less
Costs of obesity
 Total cost of obesity - £3.7billion/year
 Total cost of obesity plus overweight - £7.4
billion a year
Relative risks of disease in obese vs. nonobese individuals (NAO, 2001)
Women
Men
Type 2 diabetes 12.7
5.2
Hypertension
4.2
2.6
Heart attack
3.2
1.5
Colon cancer
2.7
3.0
Angina
1.8
1.8
Stroke
1.3
1.3
Benefits of weight loss
(10-15% of initial weight)
Mortality
 20% fall in total mortality
 30% fall in diabetes related death
Diabetes
Improves insulin sensitivity and
glycaemic control
Blood pressure
Fall of 10 mmHg systolic
Fall of 20mmHg diastolic
Blood lipids
Fall of 10% total cholesterol
Fall of 15% LDL
Fall of 30% TG
Increase of 8% HDL
Improves fibrinolytic activity
Reduces red cell aggregability
Blood clotting
Physical complications
Improved back and joint pain
Improved lung function
Improves sleep apnoea
Obesity can only occur when energy intake
remains higher than energy expenditure
Energy expenditure
Energy intake
Adipose tissue
Causes of Obesity
 Obesity is a complex and multi-factorial
disease :
– Metabolic
– Genetic
– Medications
 Environmental & Behavioural
– Changes in PA & Diet
The Availability of Energy-dense
Foods
 A move away from the traditional diet
 An increase in the use of convenience foods
 A decrease in cooking, menu planning and
shopping skills
 An increase in the consumption of snacks and soft
drinks (biscuits, cakes, chocolate, crisps and fizzy
drinks).
 Significant growth in the UK market for fast food
and take-away outlets
 Food portion sizes
Influences on obesity
 Work and leisure time
– Sedentary jobs
– Labour saving devices
– Car use
– Less walking/cycling
– Screen-based entertainment
– Eating out and snacking more common
– Alcohol intake increased
Energy output: examples of changes over 50 years
Energy output kcals (1950s)
Energy output kcals (2000)
Grocery shopping (foot) 2,400
Grocery shopping (car) 276
Washing clothes (hand) 1,500
Washing clothes (machine) 270
Heating (making a coal fire) 1,300
Heating (no effort) 0
Making a bed (blankets) 575
Making a bed (duvet) 300
DIET
PHYSICAL
ACTIVITY
BEHAVIOUR
CHANGE
Treatment Strategies
 Lifestyle Changes
– Diet
– Physical Activity
 Medication
 Surgery
 Weight Maintenance
Evidence: weight loss? (HDA, 2003)
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Low calorie diets (1000-1500 kcal/day)
VLCD (400-500 kcal/day)
Low fat diets with energy restriction
Low fat diets (<30% energy from fat) with no target on energy
restriction)
Increased physical activity
Diet and increased physical activity
Behavioural therapy plus other weight loss practices
Worksite health promotion programmes
Reminders to GPs to prescribe diets delivered by health psychologists
Brief educational intervention for GPs
Shared care between GP and hospital
In-patient obesity treatment services
Training for both HPs and leaders of self-help weight loss clinics
Weight Loss Diets
A diet with a goal of weight loss needs to
have a 500 – 1000 kcal/day deficit to
achieve a 1 – 2 pound weight loss per
week.
Controlling calories is the bottom line to
a weight loss diet.
Jackson el al 2001
Producing a calorie deficit
 Advice can be based on altering the
– Frequency
– Amount
– Type
Of food or a combination of these
Key Points
 Needs to be tailored to the individual
 Needs to be applied taking into account:
 Patient preferences
 Current lifestyle
 Clinician needs to use own judgement
and clinical experience
 Needs to be incorporated with a
behavioural approach
Estimated Energy
Requirements
An individualised approach to weight
reduction, based on calculation of actual
energy requirements has been shown to
be more effective than the
indiscriminate application of low calorie
diets.
(Frost 1989, Lean & James 1986)
Other dietary options
 Meal replacements
 Very Low Calorie Diets
 Popular Diets
– High protein/low CHO
– Glycaemic index
 Fad Diets
– Detox, etc,etc
Physical Activity
 Key message
’30 minutes of moderate intensity activity
on 5 days of the week’
or
‘half an hour a day’
 Needs to be more for weight loss
For Weight Management
 Prevention of overweight/obesity:
45 – 60 minutes
 Prevention of weight regain:
60 – 90 minutes
Treatment strategies – what works?
Successful Slimmers
– Incorporate activity into their lifestyle
– Have breakfast
– Check weight regularly
– Have regular meals
– Learn to plan ahead
– Develop problem-solving skills
– Make small changes
National Weight Control Registry (USA)
Why a Behavioural Approach?
Interventions combining a low-calorie
diet, physical activity, and behaviour
therapy are most effective for weight
loss and maintenance
(SIGN 1996, NHLBI 1998, HDA 2003)
What is a behavioural approach?
The main principles of this approach
include the modification of current
behaviour patterns, new adaptive
learning, problem solving and a
collaborative relationship between client
and therapist
(HDA 2003)
Motivation
 Motivation is not something you can do to
people
 It has to come from within
 It is not an ‘all or nothing’ state
 It is influenced by the helping style of the
health practitioner
Assessment
 Medical history
 Medical exam - BMI, waist,
 Investigations – BP, blood glucose,
lipids, thyroid function etc
 Risk Factors/co-morbidities
 Weight history
Assessing Readiness to Change
Motivation/Importance/ Confidence
‘Is the patient ready, willing & able?’
‘Is now the right time?’
‘Are there other options that should be explored?’
Assessing Current Lifestyle
‘Patients tend to under-report food intake
& over-report activity’ Why?
 Physical Activity
Different methods could include:
– Typical day/week
– Keep a diary/chart
– Pedometer
Assessment of current diet
 Traditional 24hr recall
 Food Diary
How useful is a detailed dietary intake?
 Typical Day
– Gives information about patient’s lifestyle
– Gives information about eating behaviour
Behaviour Modification
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Don’t shop when hungry
Pre-plan meals and snacks
Use a smaller plate
Take one bite at a time
Chew slowly
Use stairs instead of lift
Get off the bus one stop earlier
Etc,etc…
Limitations of advice giving
Review of evidence clearly shows
that giving knowledge alone does
not necessarily lead to a change in
behaviour
Glanz 1985, Contento 1995, Roe 1997, Thorogood 2001
Self-monitoring
 Keeping a diary is important for several
reasons:
– Raises awareness
– Indicates problem areas or trends
– Leads to problem solving
 But, it is a difficult skill that needs
practice!
Outcomes
It is important that outcomes, other than
weight loss are monitored:
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Changes in clinical outcomes i.e.BP, blood
glucose, cholesterol, waist circumference
Changes in diet and physical activity levels
Feelings of well-being
Increase in self-esteem
Patient’s own goals i.e.fitting into clothes.
Weight maintenance
 No simple solution has been highlighted
 Extended support appears to be emerging
as being significant
 Continued changes to diet & physical
activity seem to be important
(Perri 2002)
Guidance
 SIGN (1996). Obesity in Scotland.
www.sign.ac.uk
 WHO (2000) Obesity: preventing and
managing the global epidemic. www.who.int
 HDA (2003). The management of obesity
and overweight www.hda.nhs.uk
 DH (2004) Choosing heath: making
healthier choices easier
 HDA/NICE(2006). Guidance on obesity
What can pharmacists do?
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Provision of information
Raising awareness
Participation in local campaigns
Measurement of height, weight, BMI, waist
circumference
 Client motivation
 Readiness to change
 Motivational interviewing
Barriers
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Psychological complexities of cases
High rate of relapse
Perceived lack of effective interventions
Lack of training
Lack of time
Lack of resources
Lack of onward referral options
Dearth of properly structured, well resourced
weight management services throughout the UK
What is needed?
 Agreed clinical pathway with clear guidelines on
intervention and referral
 Clear prescribing guidelines
 Good support materials
 Expanded community dietetic service
 Expanded exercise referral service
 Well resourced training programmes
 Collaborative working
 Subsidised referrals to commercial slimming clubs
 Funding
 Research to identify most effective approaches
Developments
 Dedicated weight management clinics in
primary care
 Referral to commercial slimming
organisation (with free vouchers)
 Triple tier pathways
Triple tier pathway for weight
management (Maryon-Davies, 2004)
3. Hospital based treatment
Dietary/activity management
Surgery
2. Community-based lifestyle programme
Referral to community dietitian and/or physical activity facilitator
Commercial slimming group
Pharmacological treatment through GP or PGD
1. Brief intervention in primary care
Risk factor screening and case selection
Primary motivational counselling with written/video support material
Support from lay/community lifestyle advisor
Summary
 Weight management is a complex area
 Requires knowledge, skills
 A thorough assessment is key
 Treatment strategies must be tailored to
individual