Obesity in adults & bariatric surgery Flashcards
Obesity intro media & stigma
- represented in media by body only- rolls & burgers
- lack of control, lazy- stigmatized more then other EDs.
Epidemiology of obesity in adults
-Health Survey for England 2015-
-overtime obesity stabilising from around 2002, was increasing until then.
Epidemiology - Age & Gender
-H S E- 2015
- broadly same across genders
- Men more overweight than Females
- both M & F have weight jump from 35-44 to 45-54 years old -not biological factor it is social factor.
- still many M not get to over 85+ y/o
- F tend lose weight 85+- this typically occurs in the oldest ppl.
Epidemiology- Regional Variation
-H S E- 2015
- North East only region where M outweigh F in obesity- manual labour?
- urban, rural & suburban- diff types of work, food, financial pressures, food insecurity, family structures, cooking skills.
Epidemiology- Economic Variation
-H S E- 2015
- lowest income jobs for M tend be manual labour- whilst not for F.
- M across all incomes weigh roughly same.
- M in lower income tend have less to spend on compared to F- (child care- F prioritise children’s food).
- F as get lower income more overweight & obese you are.
- F give birth- tend gain weight while pregnant- lower income have reduced weight loss after.
Epidemiology- Occupational class
- F in lowest skills lvl- highest obesity v richer F.
- M less diff in obesity due to job.
Consequences of obesity
-Calle et al 1999
- looked at death rates & BMI
- once have fat cells have them forever- can gain weight easier, more predisposed to higher weight.
- M much higher risk of extremes of weight v F.
- M’s BMI pref is higher than normal (24-25) however tend focus on Muscularity - not a reality.
- Healthy ideals vary but can can be healthy at slightly low weight or slightly high.
- risks at both extremes of BMI- however this research -could be done to pre-existing illnesses?- if low BMI & get ill have less of buffer to protect- could also be linked to age- as u get old tend lose weight.
Consequences of obesity
-Carey et al 2014
- looked at % of M & F with depression by BMI category.
- underweight M at most risk- farthest from muscular ideal or common with other disorders- drug use, other psych disorders.
- normal & overweight low risk group.
- obese roughly x2 likely- could be due to psychology of society against obesity.
Consequences of obesity
-National Obesity Observatory 2011
(diagram- look at notes)
- found both moderators & mediators.
- Moderators- like volume knobs, some more pronounced. (gender, lvl of obesity…)
- Mediators- help explain relationship. Provide mechanism. (social factors, behavioural, bio, psychological)
- -bi-directional.
- exercise & eating well= decrease risk of depress.
- Bio, obesity certain lvl= inflammation response- link to depress & other psych disorders.
Epidemiology- Long standing illness & obesity.
- H S E- 2015
- Bhaskaran et al 2014
- not much diff b/w normal & overweight BMIs & illness.
- obesity see, linked more illness in F v M.
- type 2 diabetes with poor control overtime leads to blindness, amputation etc…
- Bhaskaran et al 2014- cancer risk by BMI
- -gall bladder, uterine have strong links, others have mild to no link (thyroid, cervix…).
- -organs surrounded/covered in fat may be due to BMI & is linked to cancers.
Contributing factors: The Foresight Report 2007
see notes for diagram
- prevention not cure- if find what greatest risk factors for becoming obese.
- The Foresight Report 2007-
- -huge map, sought map broad range of factors that influence obesity & their interrelations.
- -e.g. cheap ingredients- fructose, less fibre, convenience, alcohol, value on physical activity, parenting, stress.
-Simplified- (see image)- e.g. activity enviro- extremes- druggy park v village green= diff lvls of physical activity.
Contributing factors: Familial Transmission
- programmes (tv)
- H S E 2011
- strong evidence that overweight & obesity runs in families- genetic & enviro factors.
- a combo of genes & shared enviro factors & interactions b/w both account for this pattern.
- –programmes- show stereotypical images- try make look stupid, not happy fam photos- done make us judge.
Health Survey for England 2011-
- 24% boys aged 2-15 y/o living in overweight/obese households were obese v 11% in non-overweight households.
- -21% girls v 10% non-obese.
- -impact starts early.
-have be careful what we talk to kids about as it can make it worse.
Contributing factors: Birth Weight
- Yu et al 2013
- Yu et al 2011
- Qiao et al 2015
Yu et al 2013- maternal pre-preg BMI is pos associated with higher birth-weight for gestational age & also higher BMI in childhood.
–higher birthweight is ass with later obesity.
Yu et al 2011- BUT mixed indication that low birth weight is also associated with later obesity:
–mixed evidence!
Qiao et al 2015- low birth weight may predispose obesity in boys but not girls.
- does nutrition in utero set metabolic patterns for life outside the womb i.e. the “foetal origins” hypothesis?
- alterations in foetal nutrition may cause developmental adaptations that permanently change structures, physiology & metabolism, thereby predisposing individuals to overweight/obesity in adulthood.
- if not avg birth weight- it can effect metabolic rates etc…
- however you can’t test on foetuses.
Contributing factors: Maternal Smoking in Pregnancy
- systematic review
- Oken et al 2008
- Systematic review- direct exposure to prenatal tobacco via maternal smoking increases odds of obesity in children aged 2 & above.
- smoking during the entire pregnancy had greater effect than smoking during pregnancy only.
- Oken et al 2008- effects persist after rigorously controlling for confounds.
- -confounds looked at- health, education, stress..
- Smoking is a UNIQUE factor.
Contributing factors: -Genetics
- Congenital Leptin- leptin receptor deficiency.
- -leptin produced by adipocytes & secreted in proportion to body fat mass- inhibits appetite.
- —genetic mutations in leptin production OR reception result in massive overeating & obesity.
- –but is very low proportion.
Contributing factors: Epigenetic Influences
-Campion et al 2009; Symonds et al 2013
- some syndromes diagnosed in early childhood- all rare.
- genetic factors in population overweight/obese are extremely complex: 250+ alleles.
- Epigenetics are beyond simple individual genetic predispositions.
- -“heritable changes in gene expression that not involve changes underlying DNA sequence”.
- change how genetics are expressed by what you eat, how you exercise & pollution exposure etc…
-Campion et al 2009; Symonds et al 2013- epigenetic changes can result from diet, in particular, but also other environmental changes.
Contributing factors: Childhood Obesity.
-Simmons et al 2015
- Simmons et al 2015- meta-analysis of 15 cohort studies.
- -overall x5 likely be obese as adult if obese as a child.
- -even weakest impact studies show x3 more likely.
- -therefore need stop obesity in childhood.
- -psychological welding as children.
- -roughly 80% of obese adolescence still obese in adulthood.
- -70% obese after 30 years- normal as a child.
- -obesity persists less strongly from childhood to adolescence- around 50% obese children still obese in adolescence.
- -however 70% obese adults were not obese as children or adolescence
- -& 80% if obese ppl aged over 30 were not obese in adolescence.
- -so childhood BMI has POOR SENSITIVITY to predict adult obesity.
-tracking childhood to adult overweight gave similar results: obesity is primarily an adult-onset condition.
Contributing factors: Sedentary Behaviour
-Thorp et al 2011
Thorp et al 2011- reviewed 48 longitudinal studies looking links across time b/w sedentary behaviour & weight change.
- -most studies used self-reported measures including combination of sitting time, TV viewing, non-TV screen time & other sedentary behaviours.
- -was association with mortality & with weight gain from childhood to adult years.
- -however mixed findings for links to diseases incidence, weight gain during adulthood & cardio-metabolic risk.
- we are not designed as humans to sit down for long periods of time.
Contributing factors: Sleep Duration
-Cappuccio et al 2008
- short sleep defined as less than or 5 hours per night.
- Cappuccio et al 2008- short sleep, seem gain weight= issue for shift workers.
Contributing factors: Smoking Cessation
- Filozof et al 2005
- Swan et al 1995
associated with weight gain.
-most ppl gain less than 4.5kg but 13% quitters gain at least 11kg.
- Filozof et al 2005- ppl of African heritage, ppl <55 & heavy smokers are at higher risk of weight gain, as those of lower socio-economic status.
- -genetic component to weight gain after cessation?
- Swan et al 1995- pairwise concordance for weight change in 146 MZ & 111 DZ twin pairs in which both twins quit smoking was sig greater in MZ.
- -nicotine appetite suppressor, hand to mouth need, smoking takes up time. Heavier smokers= more weight gain.
Contributing factors: Increased Energy Intake Through Portion Size
- Hollands et al 2015
- Marteau et al 2015
-Hollands et al 2015- ppl consume more food/non-alcoholic drinks if offered larger sized portions or package or when using larger items of tableware.
- Marteau et al 2015- the size of this effect suggests that eliminating larger items of tableware.
- -reduce avg daily energy consumed by 12-16% among UK adults & 22-29% US adults.
Portions getting huge:
- America 7oz to 42oz drinks.
- messy portions- pack of crisps- 5 is a portion etc.
Contributing factors: BED & Emotions
- Marcus et al 1990
- Ricca et al 2009
- Spoor et al 2007
- Polivy & Herman 1993
- Van Strien 2012
- binge-eating linked to obesity.
- Marcus et al 1990- BED more common in M v other EDs- link to obesity.
- Ricca et al 2009- BED in obese individuals highly ass with emotional eating.
- Spoor et al 2007- pathology associated with excessive external & emotional eating is essentially different to other types of obesity.
- Polivy & Herman 1993- research evidence to supp Affect Regulation Model- F BED- difficulty regulating neg emotions & try cope by binging.
- Van Strien 2012- at least 40% community sample of obese-ppl- high lvls emotional eating.
Where does that leave us?
- population lvl
- individual lvl
- Population lvl- there are multiple points at which interventions to prevent or reverse obesity can be attempted.
- Individual lvl- treatment for obesity include: health behaviour change, weight loss medication, bariatric surgery, occasionally psychotherapy (CBT or CBT-E) for binge-eating.
- Smoking dropped in UK- due to making it expensive (most impact), stopped showing packets, no colours & pics, lack advertisement, socially unacceptable, smoking areas & shelters.
- Sugar Tax- need to eat but eating in moderation is good- can’t vilify like you can with cigs.
- -modelling from parents.
Obesity care pathway
-Department of Health 2013.
(see notes)
- Department of Health 2013:
- Tier 4- surgery (bariatric).
- Tier 3- specialist services (multidisciplinary intervention).
- Tier 2- lifestyle intervention (multicomponent weight management).
- Tier 1- universal prevention (environmental health promotion).
- surgery only offered at high risk- medical risk.
- not much investing in tier 1 or 2- which should be done to prevent need for upper tiers.
Health behaviour change
- Dombrowski, Sniehotta & Avenell 2011-
- Dombrowski et al 2014-
- Dombrowski, Sniehotta & Avenell 2011- just dieting in 6 months= most weight loss.
- -keep weight off better if diet & activity in long-term 9 months+.
- -initially exercise increases appetite so weight loss less at start- however keeps metabolism up so better in long run= more sustainable.
- Dombrowski et al 2014- 45 trials, N= 7788- weight loss maintenance.
- -1.56kg diff lifestyle interventions v controls.
- -1.80kg diff lifestyle + drug used v control= best combo.
- face-to-face interventions- remotely delivered.
- hard to stay focused, have to learn how to eat properly.
Weight loss meds
- UK
- Khera et al 2016
- Butryn, Webb & Wadden 2011
- Butryn et al 2001
-UK only Orlistat licenced- blocks digestions of trio-glycerides- leaves via poo- not very pleasant- risk of anal leakage- this also reduces desire to eat fatty food.
- Khera et al 2016- systematic review of orlistat, lorcaserin, naxtrexone-bupropian, phentermine-topiramate & liraglutide v placebo- all associated with achieving >5% loss after a year.
- USA- use other drugs- some amphetamines, some reduce insulin, some opiates= addiction.
- Butryn, Webb & Wadden 2011- 8-10% weight loss in 6 months- with diet & exercise + basic behavioural therapy= better.
- Butryn et al 2001- however 1st year 1/3 gained weight back, 5th year returned or weighed more.
Bariatric surgery
- what it does
- NICE 2014; SIGN 2010
-induces weight loss by REDUCING size of stomach, REMOVING portion of stomach or RESECTING & RE-ROUTING the small intestine to a small stomach pouch.
(sleeve gastrectomy, gastric banding, gastric bypass).
- reduces amount you can eat & surface area can absorb from.
- but easy to get malnourished, lack vitamins, minerals.
- offered if BMI 40+ or 35-40 & tried other methods or with co-morbidities (diabetes) that are expected to improve with weight loss (NICE 2014; SIGN 2010).
- all appropriate non-surgical measured tried without success- the patient has/will receive intensive weight loss management.
- often need lose 10kg first= hard, so proves you want to lose weight.
Bariatric surgery: Effectiveness
-Robinson 2009; Buchwald et al 2004
-long-term studies show:
Robinson 2009; Buchwald et al 2004; remission from diabetes, improvement cardiovascular risk factors, reduction in mortality of 23% from 40%, (possible) improvements in psychological issues.
- more effective than conservative treatment (drug/lifestyle intervention).
- cost effective- cost a lot upfront but cost alone diabetic meds recouped within 3 years.
- not quick fix & is risky- can’t eat normally again.
Bariatric surgery: Weight Regain After
- if weight regain occurs is the surgery still cost effective?
- should we focus on post-operative issues in the pre-operative phase, teaching skills to MAINTAIN weight loss?
- are effective strategies for weight maintenance the same as those for weight loss?
-typical trend to gain some weight after 24 months, slow increase.
Bariatric surgery: Surgery risks
4
Surgical complications- morality (low 0.25% within 90 days), bleeding, infection, dmg to other structures, hospital readmission, extended stay.
Patient non-adherence- to postoperative requirements, important dietary instructions, maintaining sufficient lvls of physical activity, sabotages success of surgery.
Patient satisfaction- body image issues are common- left with lots of loose skin- body image issues.
Long-term weight outcomes- weight regain common.
Factors associated with “success”
-Sarwer et al 2008-
- Sarwer et al 2008- weight loss success depends on patient adherence to pre & post-surgical procedure.
- some factors ass with success or failure: demographic variables, pre-op weight, motivation & expectations, presence (or not) of ED, psychological functioning, personality, psychiatric disorders.
Postoperative issues
-Lynch 2016
- non-adherence to dietary & lifestyle requirements.
- Lynch 2016- disordered eating patterns are common & patients can find it challenging to match mind to body- loose skin.
- not always a robust follow-up process after surgery e.g. follow-up with psychologist.
- -rare because cus surgery is rare itself.
Alternative treatments
- Linehan 1993
- Hayes et al 1999
- Lillis et al 2009
- Tapper et al 2009
-Linehan 1993- Dialectical Behaviour Therapy (DBT)- modified for BED= effective in 82% of F after full treatment (6 months) abstain from BED.
- Hayes et al 1999- Acceptance & Commitment Therapy (ACT)- third generation intervention. -slow become adopted for weight loss.
- about acceptance, mindfulness & value processes to produce psychological flexibility
- –e.g. if don’t exercise look at why? fear of being judged at gym? v Skills Based Therapy (SBT)- behavioural changes0 try go to gym early or late.
- Lillis et al 2009- 1 day ACT workshop (5 hours) to increase psych flexibility & reduce avoidance.
- -3 month follow-up additional 1.6% weight loss v 0.3% gain of control.
- Tapper et al 2009- 1 time 2 hour ACT. 6 months after engaging in sig more physical activity.
- decrease on avg 2.3 kg.
