Obesity in adults & bariatric surgery

Question 1

Obesity intro media & stigma

Answer 1

• represented in media by body only- rolls & burgers

- lack of control, lazy- stigmatized more then other EDs.

Question 2

Epidemiology of obesity in adults

-Health Survey for England 2015-

Answer 2

-overtime obesity stabilising from around 2002, was increasing until then.

Question 3

Epidemiology - Age & Gender

-H S E- 2015

Answer 3

• 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.

Question 4

Epidemiology- Regional Variation

-H S E- 2015

Answer 4

• 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.

Question 5

Epidemiology- Economic Variation

-H S E- 2015

Answer 5

• 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.

Question 6

Epidemiology- Occupational class

Answer 6

• F in lowest skills lvl- highest obesity v richer F.

- M less diff in obesity due to job.

Question 7

Consequences of obesity

-Calle et al 1999

Answer 7

• 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.

Question 8

Consequences of obesity

-Carey et al 2014

Answer 8

• 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.

Question 9

Consequences of obesity
-National Obesity Observatory 2011
(diagram- look at notes)

Answer 9

• 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.

Question 10

Epidemiology- Long standing illness & obesity.

• H S E- 2015
• Bhaskaran et al 2014

Answer 10

• 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.

Question 11

Contributing factors: The Foresight Report 2007

see notes for diagram

Answer 11

• 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.

Question 12

Contributing factors: Familial Transmission

• programmes (tv)
• H S E 2011

Answer 12

• 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.

Question 13

Contributing factors: Birth Weight

• Yu et al 2013
• Yu et al 2011
• Qiao et al 2015

Answer 13

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.

Question 14

Contributing factors: Maternal Smoking in Pregnancy

• systematic review
• Oken et al 2008

Answer 14

• 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.

Question 15

Contributing factors: -Genetics

Answer 15

• 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.

Question 16

Contributing factors: Epigenetic Influences

-Campion et al 2009; Symonds et al 2013

Answer 16

• 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.

Question 17

Contributing factors: Childhood Obesity.

-Simmons et al 2015

Answer 17

• 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.

Question 18

Contributing factors: Sedentary Behaviour

-Thorp et al 2011

Answer 18

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.

Question 19

Contributing factors: Sleep Duration

-Cappuccio et al 2008

Answer 19

• short sleep defined as less than or 5 hours per night.

- Cappuccio et al 2008- short sleep, seem gain weight= issue for shift workers.

Question 20

Contributing factors: Smoking Cessation

• Filozof et al 2005
• Swan et al 1995

Answer 20

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.

Question 21

Contributing factors: Increased Energy Intake Through Portion Size

• Hollands et al 2015
• Marteau et al 2015

Answer 21

-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.

Question 22

Contributing factors: BED & Emotions

• Marcus et al 1990
• Ricca et al 2009
• Spoor et al 2007
• Polivy & Herman 1993
• Van Strien 2012

Answer 22

• 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.

Question 23

Where does that leave us?

• population lvl
• individual lvl

Answer 23

• 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.

Question 24

Obesity care pathway
-Department of Health 2013.
(see notes)

Answer 24

• 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.

Question 25

Health behaviour change

• Dombrowski, Sniehotta & Avenell 2011-
• Dombrowski et al 2014-

Answer 25

• 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.

Question 26

Weight loss meds

• UK
• Khera et al 2016
• Butryn, Webb & Wadden 2011
• Butryn et al 2001

Answer 26

-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.

Question 27

Bariatric surgery

• what it does
• NICE 2014; SIGN 2010

Answer 27

-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.

Question 28

Bariatric surgery: Effectiveness

-Robinson 2009; Buchwald et al 2004

Answer 28

-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.

Question 29

Bariatric surgery: Weight Regain After

Answer 29

• 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.

Question 30

Bariatric surgery: Surgery risks

4

Answer 30

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.

Question 31

Factors associated with “success”

-Sarwer et al 2008-

Answer 31

• 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.

Question 32

Postoperative issues

-Lynch 2016

Answer 32

• 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.

Question 33

Alternative treatments

• Linehan 1993
• Hayes et al 1999
• Lillis et al 2009
• Tapper et al 2009

Answer 33

-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.