Obesity: why a big issue? Obesity: why a big issue? Overview of the public health Overview of the public health

problem problem

Pamela MasonPamela Mason

Prevalence of obesity in adults Prevalence of obesity in adults EnglandEngland

0

10

20

30

40

50

60

70

1980 1990 2000 2004

Mean BMI% OW% obese% OW/OB

Rates of obesity in children in Rates of obesity in children in EnglandEngland

0

5

10

15

20

25

30

1970 1980 1990 2000 2010 2020

Girls

Boys

What could happen?What could happen?

If current trends continue, 1/3 of adults, 1/5 If current trends continue, 1/3 of adults, 1/5 of boys and 1/3 of girls will be obese by of boys and 1/3 of girls will be obese by 20202020

24 million adults in the UK24 million adults in the UK Life expectancy - 9 years lessLife expectancy - 9 years less

Costs of obesityCosts of obesity

Total cost of obesity - £3.7billion/yearTotal cost of obesity - £3.7billion/year Total cost of obesity plus overweight - £7.4 Total cost of obesity plus overweight - £7.4

billion a yearbillion a year

Relative risks of disease in obese vs. non-Relative risks of disease in obese vs. non-obese individuals (NAO, 2001)obese individuals (NAO, 2001)

WomenWomen MenMen

Type 2 diabetesType 2 diabetes 12.712.7 5.25.2

HypertensionHypertension 4.24.2 2.62.6

Heart attackHeart attack 3.23.2 1.51.5

Colon cancerColon cancer 2.72.7 3.03.0

AnginaAngina 1.81.8 1.81.8

StrokeStroke 1.31.3 1.31.3

Benefits of weight lossBenefits of weight loss(10-15% of initial weight)(10-15% of initial weight)

Mortality 20% fall in total mortality 30% fall in diabetes related death

Diabetes Improves insulin sensitivity andglycaemic control

Blood pressure Fall of 10 mmHg systolicFall of 20mmHg diastolic

Blood lipids Fall of 10% total cholesterolFall of 15% LDLFall of 30% TGIncrease of 8% HDL

Blood clotting Improves fibrinolytic activityReduces red cell aggregability

Physical complications Improved back and joint painImproved lung functionImproves sleep apnoea

Obesity can only occur when energy intake remains higher than energy expenditure

Energy expenditureEnergy intake

Adipose tissue

Causes of ObesityCauses of Obesity

Obesity is a complex and multi-factorial Obesity is a complex and multi-factorial diseasedisease : :– MetabolicMetabolic– GeneticGenetic– MedicationsMedications

Environmental & BehaviouralEnvironmental & Behavioural– Changes in PA & DietChanges in PA & Diet

The Availability of Energy-dense The Availability of Energy-dense FoodsFoods

A move away from the traditional diet A move away from the traditional diet An increase in the use of convenience foods An increase in the use of convenience foods A decrease in cooking, menu planning and A decrease in cooking, menu planning and

shopping skills shopping skills An increase in the consumption of snacks and soft An increase in the consumption of snacks and soft

drinks (biscuits, cakes, chocolate, crisps and fizzy drinks (biscuits, cakes, chocolate, crisps and fizzy drinks). drinks).

Significant growth in the UK market for fast food Significant growth in the UK market for fast food and take-away outlets and take-away outlets

Food portion sizesFood portion sizes

Influences on obesityInfluences on obesity

Work and leisure timeWork and leisure time– Sedentary jobsSedentary jobs– Labour saving devicesLabour saving devices– Car useCar use– Less walking/cyclingLess walking/cycling– Screen-based entertainmentScreen-based entertainment– Eating out and snacking more commonEating out and snacking more common– Alcohol intake increasedAlcohol intake increased

Energy output: examples of changes over 50 yearsEnergy output: examples of changes over 50 years

Energy output kcals (1950s)Energy output kcals (1950s) Energy output kcals (2000)Energy output kcals (2000)

Grocery shopping (foot) 2,400Grocery shopping (foot) 2,400 Grocery shopping (car) 276Grocery shopping (car) 276

Washing clothes (hand) 1,500Washing clothes (hand) 1,500 Washing clothes (machine) 270Washing clothes (machine) 270

Heating (making a coal fire) 1,300Heating (making a coal fire) 1,300 Heating (no effort) 0Heating (no effort) 0

Making a bed (blankets) 575Making a bed (blankets) 575 Making a bed (duvet) 300Making a bed (duvet) 300

DIET PHYSICALACTIVITY

BEHAVIOURCHANGE

Treatment StrategiesTreatment Strategies

Lifestyle ChangesLifestyle Changes– DietDiet– Physical ActivityPhysical Activity

MedicationMedication SurgerySurgery Weight MaintenanceWeight Maintenance

Evidence: weight loss? (HDA, 2003)Evidence: weight loss? (HDA, 2003)

Low calorie diets (1000-1500 kcal/day)Low calorie diets (1000-1500 kcal/day) VLCD (400-500 kcal/day)VLCD (400-500 kcal/day) Low fat diets with energy restrictionLow fat diets with energy restriction Low fat diets (<30% energy from fat) with no target on energy Low fat diets (<30% energy from fat) with no target on energy

restriction)restriction) Increased physical activityIncreased physical activity Diet and increased physical activityDiet and increased physical activity Behavioural therapy plus other weight loss practicesBehavioural therapy plus other weight loss practices Worksite health promotion programmesWorksite health promotion programmes Reminders to GPs to prescribe diets delivered by health psychologistsReminders to GPs to prescribe diets delivered by health psychologists Brief educational intervention for GPsBrief educational intervention for GPs Shared care between GP and hospitalShared care between GP and hospital In-patient obesity treatment servicesIn-patient obesity treatment services Training for both HPs and leaders of self-help weight loss clinicsTraining for both HPs and leaders of self-help weight loss clinics

Weight Loss DietsWeight Loss Diets

A diet with a goal of weight loss needs to A diet with a goal of weight loss needs to have a 500 – 1000 kcal/day deficit to have a 500 – 1000 kcal/day deficit to achieve a 1 – 2 pound weight loss per achieve a 1 – 2 pound weight loss per week.week.

Controlling calories is the bottom line to a Controlling calories is the bottom line to a weight loss diet.weight loss diet.

Jackson el al 2001Jackson el al 2001

Producing a calorie deficitProducing a calorie deficit

Advice can be based on altering theAdvice can be based on altering the– FrequencyFrequency– AmountAmount– TypeType

Of food or a combination of theseOf food or a combination of these

Key PointsKey Points

Needs to be tailored to the individualNeeds to be tailored to the individual Needs to be applied taking into account:Needs to be applied taking into account:

Patient preferencesPatient preferences Current lifestyleCurrent lifestyle

Clinician needs to use own judgement Clinician needs to use own judgement and clinical experience and clinical experience

Needs to be incorporated with a Needs to be incorporated with a behavioural approachbehavioural approach

Estimated Energy Estimated Energy RequirementsRequirements

An individualised approach to weight An individualised approach to weight reduction, based on calculation of actual reduction, based on calculation of actual energy requirements has been shown to energy requirements has been shown to be more effective than the indiscriminate be more effective than the indiscriminate application of low calorie diets.application of low calorie diets.

(Frost 1989, Lean & James 1986)(Frost 1989, Lean & James 1986)

Other dietary optionsOther dietary options

Meal replacementsMeal replacements Very Low Calorie DietsVery Low Calorie Diets Popular DietsPopular Diets

– High protein/low CHOHigh protein/low CHO– Glycaemic indexGlycaemic index

Fad DietsFad Diets– Detox, etc,etcDetox, etc,etc

Physical ActivityPhysical Activity

Key messageKey message

’’30 minutes of moderate intensity activity on 5 30 minutes of moderate intensity activity on 5 days of the week’days of the week’

oror

‘‘half an hour a day’half an hour a day’ Needs to be more for weight lossNeeds to be more for weight loss

For Weight ManagementFor Weight Management

Prevention of overweight/obesity:Prevention of overweight/obesity:

45 – 60 minutes45 – 60 minutes

Prevention of weight regain:Prevention of weight regain:

60 – 90 minutes60 – 90 minutes

Treatment strategies – what works?Treatment strategies – what works?

Successful SlimmersSuccessful Slimmers– Incorporate activity into their lifestyleIncorporate activity into their lifestyle– Have breakfastHave breakfast– Check weight regularly Check weight regularly – Have regular mealsHave regular meals– Learn to plan aheadLearn to plan ahead– Develop problem-solving skillsDevelop problem-solving skills– Make small changesMake small changes

National Weight Control Registry (USA)National Weight Control Registry (USA)

Why a Behavioural Approach?Why a Behavioural Approach?

Interventions combining a low-calorie Interventions combining a low-calorie diet, physical activity, and behaviour diet, physical activity, and behaviour therapy are most effective for weight therapy are most effective for weight loss and maintenanceloss and maintenance

(SIGN 1996, NHLBI 1998, HDA 2003)(SIGN 1996, NHLBI 1998, HDA 2003)

What What isis a behavioural approach? a behavioural approach?

The main principles of this approach The main principles of this approach include the modification of current include the modification of current behaviour patterns, new adaptive learning, behaviour patterns, new adaptive learning, problem solving and a collaborative problem solving and a collaborative relationship between client and therapistrelationship between client and therapist

(HDA 2003)(HDA 2003)

MotivationMotivation

Motivation is Motivation is notnot something you can do to something you can do to peoplepeople

It has to come from withinIt has to come from within It is not an ‘all or nothing’ stateIt is not an ‘all or nothing’ state It is influenced by the helping style of the It is influenced by the helping style of the

health practitionerhealth practitioner

AssessmentAssessment

Medical historyMedical history Medical exam - BMI, waist,Medical exam - BMI, waist, Investigations – BP, blood glucose, Investigations – BP, blood glucose,

lipids, thyroid function etclipids, thyroid function etc Risk Factors/co-morbiditiesRisk Factors/co-morbidities Weight historyWeight history

Assessing Readiness to ChangeAssessing Readiness to Change

Motivation/Importance/ ConfidenceMotivation/Importance/ Confidence

‘‘Is the patient ready, willing & able?’Is the patient ready, willing & able?’

‘‘Is now the right time?’Is now the right time?’

‘‘Are there other options that should be explored?’Are there other options that should be explored?’

Assessing Current LifestyleAssessing Current Lifestyle

‘‘Patients tend to under-report food intake & Patients tend to under-report food intake & over-report activity’ Why?over-report activity’ Why?

Physical ActivityPhysical ActivityDifferent methods could include:Different methods could include:

– Typical day/weekTypical day/week– Keep a diary/chartKeep a diary/chart– PedometerPedometer

Assessment of current dietAssessment of current diet

Traditional 24hr recall Traditional 24hr recall Food DiaryFood Diary

How useful is a detailed dietary intake?How useful is a detailed dietary intake?

Typical DayTypical Day– Gives information about patient’s lifestyleGives information about patient’s lifestyle– Gives information about eating behaviourGives information about eating behaviour

Behaviour ModificationBehaviour Modification

Don’t shop when hungryDon’t shop when hungry Pre-plan meals and snacksPre-plan meals and snacks Use a smaller plateUse a smaller plate Take one bite at a timeTake one bite at a time Chew slowlyChew slowly Use stairs instead of liftUse stairs instead of lift Get off the bus one stop earlierGet off the bus one stop earlier Etc,etc…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-monitoringSelf-monitoring

Keeping a diary is important for several Keeping a diary is important for several reasons:reasons:– Raises awarenessRaises awareness– Indicates problem areas or trendsIndicates problem areas or trends– Leads to problem solvingLeads to problem solving

But, it is a difficult skill that needs But, it is a difficult skill that needs practice!practice!

Outcomes

It is important that outcomes, other than weight loss are monitored: 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 maintenanceWeight maintenance

No simple solution has been highlightedNo simple solution has been highlighted Extended support appears to be emerging Extended support appears to be emerging

as being significantas being significant Continued changes to diet & physical Continued changes to diet & physical

activity seem to be importantactivity seem to be important(Perri 2002)(Perri 2002)

GuidanceGuidance

SIGN (1996). Obesity in Scotland. SIGN (1996). Obesity in Scotland. www.sign.ac.ukwww.sign.ac.uk

WHO (2000) Obesity: preventing and WHO (2000) Obesity: preventing and managing the global epidemic. managing the global epidemic. www.who.intwww.who.int

HDA (2003). The management of obesity HDA (2003). The management of obesity and overweight and overweight www.hda.nhs.ukwww.hda.nhs.uk

DH (2004) Choosing heath: making DH (2004) Choosing heath: making healthier choices easierhealthier choices easier

HDA/NICE(2006). Guidance on obesityHDA/NICE(2006). Guidance on obesity

What can pharmacists do?What can pharmacists do?

Provision of informationProvision of information Raising awarenessRaising awareness Participation in local campaignsParticipation in local campaigns Measurement of height, weight, BMI, waist Measurement of height, weight, BMI, waist

circumferencecircumference Client motivationClient motivation

Readiness to changeReadiness to change Motivational interviewingMotivational interviewing

BarriersBarriers

Psychological complexities of casesPsychological complexities of cases High rate of relapseHigh rate of relapse Perceived lack of effective interventionsPerceived lack of effective interventions Lack of trainingLack of training Lack of timeLack of time Lack of resourcesLack of resources Lack of onward referral optionsLack of onward referral options Dearth of properly structured, well resourced Dearth of properly structured, well resourced

weight management services throughout the UKweight management services throughout the UK

What is needed?What is needed?

Agreed clinical pathway with clear guidelines on Agreed clinical pathway with clear guidelines on intervention and referralintervention and referral

Clear prescribing guidelinesClear prescribing guidelines Good support materialsGood support materials Expanded community dietetic serviceExpanded community dietetic service Expanded exercise referral serviceExpanded exercise referral service Well resourced training programmesWell resourced training programmes Collaborative workingCollaborative working Subsidised referrals to commercial slimming clubsSubsidised referrals to commercial slimming clubs FundingFunding Research to identify most effective approachesResearch to identify most effective approaches

DevelopmentsDevelopments

Dedicated weight management clinics in Dedicated weight management clinics in primary careprimary care

Referral to commercial slimming Referral to commercial slimming organisation (with free vouchers)organisation (with free vouchers)

Triple tier pathwaysTriple tier pathways

Triple tier pathway for weight Triple tier pathway for weight management (Maryon-Davies, 2004)management (Maryon-Davies, 2004)

3. Hospital based treatmentDietary/activity management

Surgery

2. Community-based lifestyle programmeReferral to community dietitian and/or physical activity facilitator

Commercial slimming groupPharmacological treatment through GP or PGD

1. Brief intervention in primary careRisk factor screening and case selection

Primary motivational counselling with written/video support materialSupport from lay/community lifestyle advisor

SummarySummary

Weight management is a complex areaWeight management is a complex area

Requires knowledge, skills Requires knowledge, skills

A thorough assessment is keyA thorough assessment is key

Treatment strategies must be tailored to Treatment strategies must be tailored to individualindividual