Powerpoint presentation

a Clinical problem and a National problem

• Define obesity • Revise normal energy balance and its • Revise energy in food and basal metabolic rate Doctor of Medicine

• Discuss the aetiology of obesity for individuals (nature vs nuture) including the social determinants of health • Discuss the aetiology and evolution of the obesity epidemic in Australia over the last • Discuss the future projections of obesity and outline the health service demands and cost Doctor of Medicine • List the common complications of obesity • Describe the social implications of obesity • Describe treatment options available for patients with obesity (including individual and family approaches) • Discuss the ways of managing the obesity epidemic at community, national and international levels Doctor of Medicine

• Mrs Grosso comes to your surgery with her 8 year old son who has a sore throat and feels hot. • You examine the child and diagnose a viral URTI. • You notice however that both mum and child are • Knowing the consequences of obesity and the fact that weight loss has many benefits, you explore the issue further. Doctor of Medicine

First let's revise the regulation of Consider the energy in food and the influence of basal metabolic rate Doctor of Medicine

What is obesity? Why does it occur and how common is this Doctor of Medicine What questions would you like to ask Mrs Grosso? What important complications should you consider with Doctor of Medicine • You learn that all of the family are obese. Mr Grosso in particular is a very heavy man. In addition, the eldest child (aged 15) is obese. Finally there is a 9 month old baby who is still being breast fed. • After discussing the issue with Mrs Grosso, with her agreement, you refer the family to a newly established Family Obesity Clinic at the Austin hospital staffed by both adult and paediatric obesity experts. Doctor of Medicine In the clinic the following histories are obtained for each of the Grosso Family Doctor of Medicine • Age 42 years • Overweight all of his life but gained even more • Has never attempted weight loss • Gives a past history of – Hypertension diagnosed 3 years ago – Obstructive sleep apnoea diagnosed 1 year ago now treated with CPAP – No diabetes but has been found to have an elevated fasting blood glucose Doctor of Medicine On Examination: Wt: 144 kg Ht: 175 cm BMI: 47.0 kg/m2 Waist: 135 cm BP: 154/86 Lipids: T Chol 4.5 mmol/L, Tg 3.6 mmol/L, HDL-C 0.7 mmol/L Rest of examination normal Doctor of Medicine Does Mr Grosso have the Metabolic Syndrome? Doctor of Medicine Definitions of the MetSyn…. • Al agree on the core components of the metabolic syndrome: – Obesity – Insulin resistance/glucose intolerance – Hypertension – Dyslipidaemia • However key criteria differ between groups Doctor of Medicine • Mandatory component:
– High insulin levels, an elevated fasting blood glucose or an elevated post meal glucose • With at least 2 of the following criteria: – Abdominal obesity as defined by: • a waist to hip ratio of greater than 0.9 • BMI of at least 30 kg/m2 • waist measurement over 94 cm – Triglyceride level of at least 1.7 mmol/L – HDL cholesterol lower than 0.9 mmol/L – Blood pressure of 140/90 or above (or on treatment for high blood pressure). Doctor of Medicine NCEP - ATP III criteria National cholesterol education program Doctor of Medicine • Mandatory component: – Central obesity - waist circ. ethnicity specific • Europid >=94cm men, >=80cm women • Asian (not Japanese) >=90cm men,>=80cm women • Japanese >=85cm men, >=90cm women • Plus two or more of other criteria: – Triglycerides >1.7mmol/L or on specific treatment – HDL cholesterol <1.03mmol/L in men, <1.29 in women or on specific treatment – Blood Pressure >/= 130/85 or on treatment – FBG >/=5.6mmol/L or previously diagnosed T2DM Doctor of Medicine Mrs Grosso is a 38 year woman who has always struggled with her weight. She has had many attempts at weight loss always with some initial success but she has ineviatably General Health is good Doctor of Medicine Weight 130 kg Height 168 cm BMI 46.1 kg/m2 All other examination normal Doctor of Medicine Why does the equal y obese Mrs Grosso not have the same co-morbidities as her husband? Doctor of Medicine Miss Angela Grosso Miss Grosso has just turned 15. She is in year 10 at her local high school. She has been overweight from early childhood. Lately she has not enjoyed going to school as she has become self-conscious about her body shape and has been the target of teasing from other Doctor of Medicine Miss Angela Grosso Weight 95kg Height 170 cm BMI 32.9kg/m2 Lipids: Chol 4.5 mmol/l; Tg 1.2 mmol/l; HDL 1.6 LFT's: Abnormal, ALT 60 Rest of examination normal Doctor of Medicine What is the most pressing problem for Miss Grosso? Doctor of Medicine Rebecca Puhl and Kel y D. Brownel Bias, Discrimination, and Obesity Obesity Research (2001) 9, 788–805

This article reviews information on discriminatory attitudes and behaviors against obese
individuals, integrates this to show whether systematic discrimination occurs and why, and discusses needed work in the field. Clear and consistent stigmatization, and in some cases discrimination, can be documented in three important areas of living: employment, education, and health care. Among the findings are that: 1.28% of teachers in one study said that becoming obese is the worst thing that can happen to a person; 2.24% of nurses said that they are "repulsed" by obese persons; and, 3.control ing for income and grades, parents provide less col ege support for their overweight than for their thin children. 4.There are also suggestions but not yet documentation of discrimination occurring in adoption proceedings, jury selection, housing, and other areas. Given the vast numbers of people potentially affected, it is important to consider the research-related, educational, and social policy implications of these findings. Doctor of Medicine What treatment options do we have for Mr and Mrs Grosso and possibly Miss Grosso? What are the pros and cons of each Could we precipitate an eating disorder in Doctor of Medicine Is there an optimal way Doctor of Medicine Long term effects of weight loss – diet therapy
Weight loss
Weight loss
1-2 years
> 2 years
Ad lib low fat
Low energy
Very low energy -11.8 kg
replacement
‘Popular' diets
NH&MRC Evidence-based guidelines 18 September 2003 Doctor of Medicine Long term effects of weight loss – Physical activity
Weight loss
Weight loss
1-2 years
> 2 years
Physical
activity
Diet plus
activity
NH&MRC Evidence-based guidelines 18 September 2003 Doctor of Medicine Long term effects of weight loss – Behavior therapy
Weight loss
Weight loss
1-2 years
> 2 years
NH&MRC Evidence-based guidelines 18 September 2003 Doctor of Medicine Weight Loss Agents : • SSRI's – Fluoxetine • Phentermine (Duromine) • [Topiramate (Topamax)] • (Duromine + Topamax (Qsymia)) • (Lorcaserin (Belviq)) • (Bupropion + Naltraxone (Contrave)) • (Leptin + Amylin) • Orlistat [ ] = Off Label use ( ) = under investigation () = available USA Doctor of Medicine Weight Loss Agents (Cont) • [Exenatide (Byetta)] • [Liraglutide (Victoza)] • Amylin (long acting) • Leptin (long acting) [ ] = Off Label use ( ) = under investigation () = available USA Doctor of Medicine Bariatric Surgery • Adjustable gastric Banding • Sleeve Gastrectomy • Roux-en-Y bypass Sleeve gastrectomy Roux-en-Y bypass Master Anthony Grosso Anthony will be 8 in a few weeks. He loves his food and is "solid" On Examination: Weight: 45kg Height: 140 cm BMI: 23kg/m2 Otherwise healthy Doctor of Medicine Do we need to do anything to treat Anthony? With a BMI of 23 kg/m2 is Anthony obese? Should we do blood tests on Anthony to exclude metabolic illness? Doctor of Medicine Overweight is being 85-94 percentile for weight with a BMI of 18 kg/m2 Obesity is being > 95 percentile for weight with a Doctor of Medicine Master Joseph Grosso Joseph is 9 months old and has been largely breast fed although lately mum has been supplementing with formula and started to introduce solids. On Examination he is a healthy baby Doctor of Medicine What should we advise Mrs and Mr Grosso to do to prevent Joseph becoming obese? Doctor of Medicine Why is it that Mrs and Mr Grosso and their children are not rare cases? What are the changes? Doctor of Medicine Is it better to treat the adults in an adult clinic or should we treat the whole family at once? Doctor of Medicine Why have the obesity rates in Australian adults risen from 10% in 1980, to 28% in 2011 in just 30 Why has the prevalence of overweight and obesity in Australian children 7-15yrs gone from 11% in 1995 to 25% in 2007? (see Swinburn et al The Global Obesity epidemic: shaped by Global drivers and local environments Lancet 2100;378:804-14; Gortmaker et al Changing the future of obesity: science, policy and action Lancet 2011;378:838-47; Swinburne, Sacks Commonwealth Ministers Reference Book 2012) What are the predictions for overweight and obesity in Australia? Doctor of Medicine Between 2000 and 2025, the adult prevalence of obesity is estimated to increase from 20.5 to 33.9%, while the prevalence of normal [sic] weight is estimated to decrease from 40.6 to 28.1%. [See Wal s et al Projected progression of the prevalence of Obesity in Australia Obesity 11 SEP 2012, Doctor of Medicine Why has this occurred? What are the drivers? Doctor of Medicine It has started in most high income countries in Although the behavioural patterns and their environmental determinant are complex and vary from country to country the following important causes • Major change in global food systems – processing (energy densification) of food • Ensuring food is more appealing – market and laboratory research by food and drink companies to "addict" consumers through added fats, sugar and flavour enhancers Doctor of Medicine • Food becoming much cheaper with quicker, more convenient supply – the rise of the fast food • Movement from individual to mass preparation of • Greater availability and ubiquity of food (e.g. vending machines) • Massive ongoing advertising, promotion to children and adults; sponsorship of sport – normalising of their products in the culture of Doctor of Medicine This occurred at the same time as: • Decreased incidental (the exercise we get in carrying out in our daily activities) physical exercise – rise in car ownership and use, (more so in Australia and USA compared to European countries • Children not walking but being driven to school, decreased emphasis on physical education in • Rapid rise in sedentary entertainments e.g. TV, videos, video games, internet, social media • Mechanisation of the workplace and in the home – decreased manual labour Doctor of Medicine • These are all modified in different countries and sub populations by: • National wealth • Government policy • Cultural norms • The built environment • Genetic and epigenetic mechanisms • Biological bases for food preferences and regulate motivation for physical activity Doctor of Medicine What impact will this have on your clinical What impact will this have on health services demands and costs? Doctor of Medicine How are we to stop the obesity epidemic? What can be done by governments, by industry and in local communities? Doctor of Medicine Norm and the "Life- be in it" campaign
(run on television in the 1980"s)
From The Science Show ABC Radio (www.abc.net.au) Doctor of Medicine "Insanity is doing more of the same thing and expecting a dif erent Doctor of Medicine The Pessimistic view To overcome the powerful biological mechanisms causing and maintaining obesity we would need to recreate an environment where food is limited and physical activity is obligatory. Such a society is unthinkable in a free democratic country. Doctor of Medicine The optimistic view We wil limit the obesity epidemic by identifying and avoiding the environmental (dietary) triggers to Doctor of Medicine Copyright The University of Melbourne 2016 Last updated: January 2013

Source: https://mdconnect.medicine.unimelb.edu.au/portal/mdresources/general/other/year2/notes/2015/CC201_Obesity_i8fdh4wert7yg.pdf