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Obesity- the Health Time Bomb

Speaker name, affiliation,etc

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Definition

• Obesity is an excess of body fat frequently resulting in a significant impairment of health and longevity.

• BMI offers a reasonable measure with which to assess fat and the standards used to identify overweight and obesity should agree with the standards used to identify grade 1 and grade 2 overweight (BMI of 25 and 30, respectively) in adults.

• BMI calculated by dividing individuals weight by height in meters squared.(kg/m2)

• Waist Circumference: Risk for Women >32” and Men >37”

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BMIClassification BMI

(kg/m2)Risk of Co-morbidities

Underweight <18.5 Low (Risks are increased in other areas)

Desirable 18.5-24.9

Average

Overweight 25.0-29.9

Mildly Increased

Obese >30.0

Class 1 Obesity 30.0-34.9

Moderate

Class 11 Obesity 35.0-39.9

Severe

Class 111 (morbid obesity)

>40.0 Very severe

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National Audit Office

Obesity• Increases with age• More prevalent among lower socio-economic

and lower income groups, with particular strong social gradient towards women.

• More prevalent among certain ethnic groups, particularly among Afro-Caribbean and Pakistani women

• Is a problem across all regions in England but shows some regional variations.

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Why is reducing obesity important?

• In 2006 it was anticipated that obesity will soon surpass smoking as the greatest cause of premature life loss in England.

• Obesity will bring levels of sickness that will put enormous strain on health services

• By 2010 the costs of obesity to the NHS will increase to £3.7 billion a year.

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Why is reducing obesity important?

• WHO predicts 1/3rd increase in loss of healthy life because of being obese/overweight.

• Proportion of population of England who obese has grown by 400% in the last 25 years.• In England, 24% of the adult population are

now obese.

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Why is reducing obesity important?

Obesity is a known risk factor for • Type 2 Diabetes• Coronary Heart Disease• Metabolic Syndrome• Cancer: especially Breast and Colon• Psychological ill health • Osteoarthritis• Hypertension

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Greatly increased (relative risk much greater than 3)

Moderately increased

( relative risk 2-3)

Slightly increased (relative risk 1-2)

Type 2 diabetes Coronary Heart Disease

Cancer (Breast cancer in postmenopausal women, endometrial cancer, colon cancer)

Gallbladder disease Hypertension Reproductive hormone abnormalities

Dyslipidaemia Osteoarthritis (Knees) Polycystic ovary syndrome

Insulin resistance Hyperuricaemia and gout

Impaired fertility

Breathlessness Low back pain

Sleep apnoea Anaesthetic risk

Foetal defect associated with maternal obesity

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Epidemiology – population impact

• Prevalence of Obesity in Great Britain is three times greater than 20 years ago.

• 30,000 deaths were attributable to obesity during 1998 in England.

• Equivalent to 9 years lost life for each individual

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Prevalence of Obesity in Men in England 1980-2002

(Source: Health Survey for England 2002)

0

10

20

30

40

50

1980 1993 2000 2002

Year

Per

cen

tag

e Healthy Weight

Overweight

Obese

Mobidly Obese

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Prevelence of Obesity in Women in England 1980-2002

(Source: Health Survey for England 2002)

0

10

20

30

40

50

1980 1993 2000 2002

Year

Perc

en

tag

e Healthy Weight

Overweight

Obese

Mobidly Obese

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Causes of Obesity

• Increase too rapid to indicate that genetic factors are primary cause

• Reflects change in eating patterns and levels of physical activity

• Over consumption of energy relative to need

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Groups at Risk

• Children

• Racial and Ethnic Groups

• Lower Socio Economic groups

• Women

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Children

• Population target: To halt the rise in obesity of 11 year olds by 2011.

• Worldwide 22 million children under the age of 5yrs are obese and 122 million overweight.

• Nearly 30% of children aged 2 to 15 were classed as overweight or obese in 2006.

• Conservative estimates indicate that without any intervention one fifth of boys and one third of girls will be obese by 2020.

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Racial & Ethnic Influences

• Pakistani, Indian and Bangladeshi men in England have relatively low levels of obesity measured by BMI.

• However, 41% of Indian men are classed as centrally obese compared to 28% of men in the general population.

• In 2004, Black Caribbean and Irish men had the highest prevalence of obesity (25% each). For women, obesity prevalence was higher for Black African (38%), Black Caribbean (32%) and Pakistani ethnic groups (28%) and lower for Chinese women (8%), than for women in the general population.

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Racial & Ethnic Influences

• In South Asia, approximately, 20% of the population is diabetic and 25% glucose intolerant.

• In England, children who are Asian are four times more likely to be obese than those who are white.

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Inequalities

• Large social class differences, particularly for women.

• In 2003, prevalence of obesity among women was lower in managerial and professional households (18.7%) and in intermediate households (19.6%) than in routine and manual households (29.0%)

• Difference in dietary consumption not clear, although there appears to be some differences.

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Women

At risk times;

• Puberty / Menstruation

• Childbirth

• Menopause

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Public Health Interventions

Prevention and treatment of obesity:

1. Prevention of developing obesity

2. Correction of existing obesity

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Interventions

Obesity is a complex condition that has contributingfactors at four different levels.• Individual: Food Consumption, Levels of Exercise• Inter-personal: Parental and Personal Beliefs and

Behaviours• Organisational: School Dinners, Healthy Workplace

Policies• Governmental: Guidance/ Policy, Funding, Food

labelling, Advertising

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Prevention of developing obesity

• Some evidence to suggest that school based programmes that promote physical activity, modification of dietary intake and the targeting of sedentary behaviours may help to reduce obesity in children, particularly girls.

• A systematic review concludes that compulsory rather than voluntary aerobic exercise is causally related to the reduction in adiposity in children.

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Prevention of developing obesity

• Applying this to the family situation with parental support, maybe beneficial.

• Some evidence to suggest that parents as change agents for their children is successful.

• Evidence to suggest that parents underestimate the weight of their children and therefore do not recognise the risk.

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Health benefit of modest (10%) weight loss

Mortality 20-25% fall in overall mortality

30-40% fall in diabetes related deaths

40-50% fall in obesity-related cancer deaths

Diabetes Up to 50% fall in fasting blood glucose

Reduces risk of developing diabetes by over 50%

Lipids Fall of 10% total cholesterol, 15% LDL and 30% TG

Increase of 8% HDL

Blood

Pressure

10 mmHg fall in diastolic and systolic pressures

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Individual approaches to health promotion: Aims

Medical To identify those at risk

Behaviour

Change

To encourage individuals to take

responsibility for their own health

and choose healthier lifestyles

Educational To increase knowledge and

skills about healthier lifestyles

Empowerment To work with clients to meet their perceived needs

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Individual approaches to health promotion: Methods

Medical Primary health care consultant.

e.g. Weight, BMI, waist circumference measurement. Identify co-morbidities.

Behaviour

change

Persuasion through one to one advice and information. Discuss the risks and benefits of a modest weight loss.

Educational Provide information, backed up by support. Identify how ready the patient is to change. Exploration of attitudes and lifestyle.

Empowerment Refer to another member of the team for support or specialist. Provide regular monitoring, set goals, use self help material.

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Individual approaches to health promotion:

Professional / Client relationshipMedical Expert led. Passive, conforming client. Evidence

would suggest patients are more motivated to lose weight if they are advised to do so by health professional

Behaviour

change

Expert led. Dependant client.

Beware of “victim blaming”.

Educational May be expert led, involves client in negotiation of issue for discussion. Voluntarism

Empowerment Health promoter is facilitator, client becomes empowered.

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Professional practice

Take care with ethics - ask yourself • Is my communication style, method and

content appropriate?• Am I acting in the best interests of the

client and/or their family?• What harm could I cause- eg reduce

self esteem, blame, arouse fear, anxiety or guilt feelings

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Beattie’s Model

Health Persuasion

Legislative Action

Personal Counselling

Community Development

Mode of intervention Authoritative

Mode of thought Objective knowledge

Mode of intervention

Mode of intervention Negotiated

Mode of thoughtParticipatory, subjective knowledge

Individual Collective

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Stages of Change Model

Pre-contemplation:Not interested in changing

‘risky’ lifestyle

Exit:Maintaining ‘safer’

lifestyle

Action: Making

changes

Maintenance: Maintaining

changeCommitment: Ready to Change

Contemplation: Thinking about

change

Relapse: Relapsing

Back

Attitude Development

Behaviour Development

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First steps in tackling obesity

For the Client:

• Personal acknowledgement of excess weight and an understanding of its health consequences are essential.

• Willing to explore of current lifestyle and attitudes.

For the Health Professional:• Explore what is modifiable given the context

/circumstances. • Respond appropriately with informed evidenced based

interventions

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First steps in tackling obesity

• Encourage healthy eating

• Increase physical activity

• Provide brief behavioural advice.

E.g. keep a food diary

• Aim for 5-10% weight loss

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Evidence-Based Treatment Goals

Individual Aims:

• To reduce BMI to less than or equal to 25

• To reduce waist circumference to below:– 37” for men – 33” for women

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Healthy Eating

• Eat five or more portions of fruit a day• Base meals on starchy foods, such as

wholemeal bread, pasta, rice, cereal or potato• Reduce intake of foods high in fat and food

high in sugars• Use cooking methods which reduce fat, such

as grilling• Reduce alcohol intake (high in calories)• Consume less high fat/sugar snacks

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Changes required by Individuals

Action Target per day Current Average

Increase avg. intake of fruit and veg

5 portions 2.8 portions

Increase avg. intake of dietary fibre

18gms 13.8gms

Reduce the avg. intake of salt

6gms 9.5gms

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Changes required by Individuals

Action Target Per day Current Average

Reduce the avg. intake of saturated fat

11% of food energy

35.3% of food intake

Maintain total intake of fat

35% 35.3%

Reduce the avg. intake of sugar to food energy

12.7%

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Physical exercise

• Children and Young People should achieve a total of at least 60 minutes of at least moderate-intensity physical activity each day.

• Twice a week this activity should include activities which improve bone health.

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Physical exercise

• For general health adults should achieve a total of at least 30 minutes a day of at least moderate-intensity physical activity on five or more days a week.

• Can be broken down into 10 minute chunks.• A stepwise increase in activity is

recommended, such as walk to work, use the stairs, etc.

• 60-90 minutes per day is recommended for weight loss and maintenance.

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Physical exercise

• Advice should be combined with decreasing sedentary behaviour.

• Older adults should keep moving and retain their mobility through daily activity.

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Brief Behavioural Advice

• Plan for action (start date, what action will be taken)

• Regularly monitor diet and activity levels• Set goals (specific and manageable)• Use stimulus control (avoid tempting

situations)• Reward achievements• Seek support from friends and family• Use self-help materials on cognitive

behavioural treatment

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Management of Overweight and Obesity

First approach should be nonpharmacological• Dietary advice, physical activity,

psychological therapies.

If at increased risk and other attemptshave not been successful, consider• Pharmacology • Surgery

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Pharmacological Intervention

• Pharmacotherapy may be helpful for eligible high-risk patients. Medication should be used only in the context of a treatment program that includes the elements described previously—diet, physical activity changes, and behavior therapy.

• NICE Guidance on obesity in adults and children

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Pharmacological Interventions

• Orlistat: inhibits the action of pancreatic lipase enzymes in the gastrointestinal system and needs to be used in conjunction with low fat eating plan.

• Sibutramine: is a satiety enhancer which works on the central nervous system by altering the chemical messages that control how a person feels and thinks about food. Needs to be used in conjunction with a healthy eating plan.

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Maintenance

• Individuals who have successfully lost weight are prone to relapse.

• Continued support should be available.

• Limited evidence on the positive effects of self help peer groups with therapist led booster sessions.

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Further resources

• Department of Health • NICE guidance on Obesity• National obesity observatory for England• Foresight Report 2007 • Tackling Obesities: Future Choices - Key Messages• Nuffield Council on Bioethics Report 2007• Obesity White Paper DH 2008• National Child Measurement Programme 2006/07 Results• FPH Obesity Toolkit - Lightening the load, tackling overweight and obesity • The information Centre for Health & Social Care• Statistics on Obesity, Physical Activity and Diet, England 2008 • The NHS Information Centre

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