Obesity Flashcards
The terms ‘overweight’ and ‘obesity’ are used to describe excess body fat.
Different weight classes are defined according to a person’s body mass index (BMI) as follows:
Healthy weight — BMI of 18.5–24.9 kg/m2
Overweight — BMI of 25–29.9 kg/m2
Obesity l — BMI of 30–34.9 kg/m2
Obesity ll — BMI of 35–39.9 kg/m2
Obesity lll — BMI of 40 kg/m2 or more
Obesity is one of the leading causes of death and disability worldwide.
An increased risk of developing (or exacerbation of) a number of chronic diseases and conditions, including:
Type 2 diabetes.
Coronary heart disease.
Hypertension and stroke.
Asthma.
Depression.
Metabolic syndrome.
Dyslipidaemia.
Cancer.
Gastro-oesophageal reflux
disease (GORD).
Gallbladder disease.
Reproductive problems.
Osteoarthritis and back pain.
Obstructive sleep apnoea.
Breathlessness.
Psychological distress.
=> Life expectancy is reduced by about 2–4 years in people with a body mass index (BMI) of 30–35 kg/m2, and by about 8–10 years in people with a BMI of 40–50 kg/m2
What are the causes of obesity?
- Lifestyle factors:
=> Diet - high sugar/fat; eating out; portion sizes
=> Excessive alcohol (>2 drinks/day)
=> Physical inactivity - Genetics
3. Medical conditions => Polycystic ovary syndrome. => Growth hormone deficiency. => Cushing's syndrome. => Hypothyroidism => Genetic syndromes associated with hypogonadism (for example Prader-Willi syndrome and Laurence-Moon-Biedl syndrome) => Hypothalamic damage
- Medications:
=> Pizotifen.
=> Beta-blockers.
=> Corticosteroids.
=> Lithium.
=> Antipsychotics, especially atypical antipsychotics.
=> Anticonvulsants — sodium valproate, gabapentin, vigabatrin.
=> Antidepressants — tricyclics, mirtazapine, monoamine oxidase inhibitors (MAOIs).
=> Insulin — when used in the treatment of type 2 diabetes.
=> Oral hypoglycaemic drugs — sulphonylureas, thiazolidinediones (glitazones)
5. Other risk factors: => Age => Peri- and menopause => Prior pregnancy => Sleep deprivation => Less formal education => Low socioeconomic status
What is the management for overweight and obesity?
- BMI 25-29 and
i) Low waist circumference => general advice on healthy weight and lifestyle
ii) Large waist circumference => offer structured advice regarding physical activity and diet
=> consider using behavioural interventions to achieve this
- BMI 27 with assoc. risk factors i.e. type 2 diabetes, hypertension or dyslipidaemia => consider drug treatment
* drug treatment only considered after dietary and physical activity interventions evaluated + form part of integrated approach to weight management including advice, support, counselling on diet and activity and behavioural strategies - BMI 30-34 (Obesity I)
i) Structured advice re physical activity and diet. Use behavioural interventions
ii) Drug treatment if risk factors present
=> consider bariatric surgery if recent onset T2DM (10-year time frame) as long as the person is receiving specialist assessment
iii) Need for referral for weight management services or specialist obesity services
- BMI >35 (Obesity II and Obesity III)
i) Offer structured advice regarding physical activity and diet. Consider the use of behavioural interventions to achieve this aim.
ii) Consider starting drug treatment.
iii) Consider the need for bariatric surgery
=> Bariatric surgery first line if BMI >50
*referral for surgery made by specialist obesity services
Aim for an overall 5–10% reduction in body weight (or higher [for example more than 20%] in people with BMI of more than 35 kg/m2). Weekly weight loss should be no more than 1 kg.
ADVICE: DIETARY
Flexible and sustainable approaches to dietary changes that takes into account person’s food preferences.
*Restrictive and nutritionally unbalanced diets, because they are ineffective in the long term and can be harmful.
Advise a nutritionally balanced diet:
=> 5 portions of a variety of fruit and vegetables each day.
=> Meals based on starchy foods e.g. bread, pasta, rice, and potatoes) — these should include high fibre varieties if possible.
=> Moderate amounts of low fat milk and dairy products
=> Moderate amounts of protein-rich foods (for example meat, fish, eggs, beans, and lentils).
=> Reduce the consumption of foods high in fat (especially saturated fat), sugar, and salt.
=> Not exceed recommended levels of alcohol, as alcohol is high in calories. Practical ways to limit alcohol consumption may include replacing alcoholic drinks with non-alcoholic, sugar-free drinks and increasing the number of alcohol-free days
ADVICE: PHYSICAL ACTIVITY
When advising on exercise and physical activity, consider the person’s:
=> Motivations and goals.
=> Current physical fitness and ability.
=> Preferences.
=> Barriers to being physically active health status e.g. a medical condition or a disability
If appropriate, encourage the person to:
=> Reduce the amount of time they spend being inactive (for example watching television or using a computer).
=> Do at least 30 minutes of at least moderate intensity exercise on 5 days a week or more (this can be done in one session or split into a number of sessions each lasting at least 10 minutes); they should build up to these recommended levels.
=> Recommended types of physical activity include:
Activities that can be incorporated into everyday life, such as gardening, brisk walking, or cycling.
=> Supervised exercise programmes - referral.
=> Set goals and adjust these as their physical fitness improves.
Advise the person that:
=> They should take more exercise even if it does not lead to weight loss, because exercise has other health benefits, such as reducing the risk of coronary heart disease, stroke, cancer, and type 2 diabetes. It can also help to keep the musculoskeletal system healthy, promote mental wellbeing, and improve life expectancy.
=> To prevent obesity, most people may need to do 45–60 minutes of moderate-intensity activity a day, especially if they do not reduce their energy intake. People who have been obese and have lost weight may need to do 60–90 minutes of activity a day to avoid regaining weight.
=> A pedometer may be useful for motivation and to help monitor their activity levels. If appropriate, they can gradually work towards a goal of 10,000 steps a day.
OBESITY: DRUG TREATMENT
Drug treatment should:
=> Only be considered once dietary and physical activity interventions have been evaluated.
=> Form part of an integrated approach to weight management, which should include advice, support, counselling on diet and physical activity, and behavioural strategies.
The decision to start drug treatment should be made after discussing the potential benefits and limitations with the person, including the mode of action, adverse effects, monitoring requirements, and the potential impact on the person’s motivation.
Provide information on patient support programmes.
Monitor the effect of drug treatment, and reinforce lifestyle advice and adherence through regular review.
- Orlistat
=> alongside mild hypocaloric diet
=> adults aged 18-75 years who meet the one of the criteria:
i) obese BMI >30
ii) overweight BMI >28 with assoc. risk factors
=> Taken before, during or an hour after each meal
=> Stop treatment after 12 weeks if person has not lost at least 5% of their body weight
=> Do not take dose if a meal is missed or contains little to no fat
=> Stop taking orlistat and get help if jaundice, itching, dark coloured urine, stomach pain develops
*prescribed by GP - regular monitoring of weight
- Liraglutide (Saxenda)
=> alongside reduced calorie diet and increased activity
=> used in adults with
i) BMI >30
ii) BMI >27 with risk factors i.e. dysglycaemia (prediabetes or T2DM), hypertension, dyslipidaemia or obstructive sleep apnoea
=> Stop if after 12 weeks, person hasn’t lost at least 5% of initial body weight
BARIATRIC SURGERY:
Bariatric surgery is recommended as a treatment option if all of the following criteria are fulfilled:
=> BMI > 40, or between 35 and 40 with other significant disease that could be improved if they lost weight e.g. type 2 diabetes, hypertension, or severe mobility problems.
=> All appropriate non-surgical measures have been tried but has not worked
=> Been receiving or will receive intensive management in a tier 3 service.
=> TFit for anaesthesia and surgery.
=> Commits to the need for long-term follow up
=> BMI of >50 when other interventions have not been effective.
*Drug treatment (with orlistat) may be used to maintain or reduce weight before surgery for people who have been recommended surgery as a first-line option, if it is considered that the waiting time for surgery is excessive.
For type 2 diabetes (diagnosed within 10 years):
=> offer assessment for surgery BMI >35
=> consider assessment for surgery BMI 30-35
=> asian descent - consider surgery at lower BMI
ADVICE & SUPPORT
- Offer a level of support appropriate to the person’s needs.
- Take into account the person’s age and stage of life, gender, cultural needs and sensitivities, ethnicity, social and economic circumstances, and specific communication needs (for example because of due to learning disabilities, physical disabilities, or cognitive impairments due to neurological conditions).
- Offer encouragement and praise for successes, however small.
- Give information on voluntary organisations and support groups and how to contact them e.g.
i) British Obesity Society (BOS),
ii) HOOP UK,
iii) Weight Concern.
- Advise the person on the aims and benefits of treatment.
=> the aim of management is for an overall 5–10% reduction in body weight (or higher e.g more than 20% with BMI >35); weekly weight loss should be no more than 1 kg. - Explain the benefits of modest weight loss
=> Explain why excess weight can be problematic in terms of comorbidities and the chance of developing complications - heart problems, diabetes, stroke. - Need long-term behavioural changes, including adherence to advice on diet and physical activity.
=> Explain the distinction between losing weight and maintaining weight loss, and the importance of developing skills for both.
=> Advise that the change from losing weight to maintenance typically happens after 6–9 months of treatment. - Advise that weight cycling, defined by repeated loss and regain of body weight, may be linked to increased risk for hypertension, dyslipidaemia, gallbladder disease, psychological distress, and depression.
- Explain that physical activity alone without dietary changes are not effective for weight loss.
How do you assess a person who is overweight or obese?
- Assess the person’s willingness and motivation to lose weight.
=> Stress that obesity is a clinical term with specific health implications, rather than a question of how people look
=> certain ethnic and socioeconomic backgrounds may be at greater risk of obesity
Questions which may help to clarify a person’s readiness to lose weight include:
=> Are you concerned about your weight?
=> How important is it for you to lose weight at the moment?
=> Do you believe that you could lose weight?
=> What would have to change in your life for you to be able to tackle your weight?
=> Is your weight affecting your life in any way at the moment?
- If help decide, explain advice and support available in the future.
- Assess the person’s feelings about being overweight (previous attempts to lose weight) and their confidence in making changes.
Barriers to lifestyle change include:
=> Lack of knowledge about food and how diet and exercise affect health.
=> Cost and availability of healthy foods and opportunity for exercise.
=> Safety concerns.
=> Lack of time.
=> Personal tastes.
=> Views of family and community members.
=> Low levels of fitness, or disability.
=> Low self-esteem and lack of assertiveness.
- Assess for underlying causes and comorbidities; family hx; drug hx; social hx i.e. lifestyle, diet, exercise, alcohol, smoking, work, leisure activity
- Check BP, blood glucose, lipid profile
- Assess person’s risk of developing complications of obesity
=> BMI and waist circumference
=> Family hx of diabetes or CHD
Examples of some behavioural interventions
Self-monitoring of behaviour and progress.
Stimulus control.
Goal setting.
Slowing rate of eating.
Ensuring social support.
Problem-solving.
Assertiveness.
Cognitive restructuring (modifying thoughts).
Reinforcement of changes.
Relapse prevention.
Strategies for dealing with weight regain.
