Obesity Symposium

Question 1

Define obesity

Answer 1

Obesity is a disorder in which excess body fat has accumulated to an extent that health may be adversely affected.

Question 2

How is an assessment of obesity made?

Answer 2

Most widely used measure is Body Mass Index

BMI=person’s weight in kilograms divided by the square of their height in metres

Question 3

Which BMI is obese?

Answer 3

At or over 30 kg/m2

Question 4

How is obesity assessed in children?

Answer 4

Population reference charts using BMI centiles

Children with a BMI at or above the 91st centile will require clinical intervention

Question 5

State some exceptions to the BMI measurement

Answer 5

Children - use age & gender specific standards
Athletes - particularly those with high muscle mass
People at the extremes of the height distribution
Non-Caucasian populations
(BMI >27.5 in Asian person is associated with comparable morbidities to those in Caucasian with BMI >30)

Question 6

State some patterns of obesity

Answer 6

General obesity

Central abdominal obesity

Question 7

Describe general obesity

Answer 7

Fat is distributed over the whole body

Question 8

Describe central abdominal obesity

Answer 8

Fat is distributed mainly in the chest and abdomen.

Question 9

What is central abdominal obesity more associated with?

Answer 9

Central abdominal obesity is associated with higher risks of diabetes, raised blood lipids, and greater cardiovascular morbidity and mortality compared to general obesity.

Question 10

Define metabolic syndrome

Answer 10

A cluster of conditions (body fat, blood lipids, BP, blood sugar associated with increased risk of stroke, heart disease and diabetes).

Increased waist circ. and at least 2 of the following:

Raised blood triglyceride:
Reduced HDL (good) cholesterol:
Raised BP:
Raised fasting glucose:

Question 11

What is the most common way to define central obesity?

Answer 11

Measurement of the waist circumference

Question 12

List some individual social factors associated with weight

Answer 12

Gender, age, ethnicity, employment, income, education, marriage status, parenthood, household size, residential density

Question 13

Is obesity at epidemic levels?

Answer 13

Worldwide increase in prevalence
Dramatic accelerated in last decade
Dire predictions:
Obesity to overtake smoking as cause of preventable death
Parents to outlive obese children

Question 14

Why are health and obesity linked?

Answer 14

Increased mass of fat causes changes at cellular and metabolic levels

Increased weight causes increased wear and tear in joints

Increased fat around the airway – asthma and sleep apnoea (breathing pauses while asleep)

Increased fat in blood alters the insulin response

Associated inactivity has independent effects

Question 15

Describe the health impact of obesity in children

Answer 15

Type 2 Diabetes Mellitus – former adult disease, increasing in children – 95% of children with Type 2 DM are overweight and 83% obese

Asthma – overweight / obesity increases asthma risk by 40-50%

Sleep apnoea – Obstructive sleep apnoea prevalence estimated at 60% in obese children

Cardiovascular risk – damage in childhood increases risk of hypertension in adults (26% risk vs 6% risk in normal wt.)

Musculoskeletal – Tibia vara (bow legs), slipped femoral epiphysis, knee pain, ankle foot pain / problems

Mental health – Low self esteem, emotional and behavioural problems

Question 16

Describe the health impact of obesity in adults

Answer 16

Circulatory system– Increased risk of hypertension – co-factor for stroke and coronary heart disease, deep venous thrombosis, pulmonary embolism

Musculoskeletal – weight on the joints – especially the knees with cartilage degeneration. Low back pain.

Metabolic and endocrine systems – Type 2 DM, dyslipidaemias (high cholesterol and triglycerides) with atherosclerosis (fat in lining of arteries), gout

Cancer– Increased risk of breast, colon and endometrial cancers

Reproductive and urological problems – Stress incontinence in women, menstrual abnormalities, polycystic ovarian syndrome, infertility, childbirth risks, erectile dysfunction

Respiratory system – Sleep apnoea and asthma

Liver disease – fatty liver = non-alcoholic fatty liver disease (NAFLD) (steatosis = fat infiltration of liver cells). NAFLD prevalence rising, may require liver transplant at later stages

Gastrointestinal– gastro-oesophageal reflux, gall stones, pancreatitis

Psychological and social – Low self esteem, stress, social disadvantage, depression, reduced libido

Question 17

List some interventions to address obesogenic behaviour. Give some examples of each

Answer 17

Policy- Legislation, voluntary agreements with industry
Education/communication- media campaigns
Technological changes- Food processing
Treatments of individuals- Motivational interviewing, diets, exercise, drugs, surgery

Question 18

What are obesogenic environments?

Answer 18

Environments that encourage eating unhealthily and not doing enough exercise

For example: High streets, public spaces dominated by takeaways, coffee shops - calorie dense foods

Question 19

Describe some brief interventions for behaviour change

Answer 19

Short
Evidence-based
Structured
Non-confrontational
Seeks to motivate to think about behaviour change
Can use motivational interviewing techniques.
Making Every Contact Count (MECC)

Question 20

What is brief intervention?

Answer 20

A conversation with a patient in a non-confrontational way to motivate and support the individual to think about and/or plan a change in their lifestyle

Brief interventions could be around 30 seconds . They should identify the patients at risk (ASK), explain how best to change behaviour (ADVISE) and refer to obtain help (ASSIST) (PHE 2017. Let’s talk about weight)

Question 21

Describe the assessment of obesity in primary care

Answer 21

Assess eating behaviour, lifestyle, risk factors environment, willingness to change, psychological problems, medical problems and medication
Advise on management: diet (avoid very low calorie [<800]), exercise, behaviours,
Consider drugs
Referral for surgery

Question 22

List some different treatments for obesity

Answer 22

Diet/exercise
drugs
surgery

Question 23

Describe how to give diet based treatment

Answer 23

Set realistic target 5-10% weight / weekly loss 0.5-1.0 kg
Focus on long-term lifestyle change rather than short term quick fix
Balanced healthy eating diet
Multi-component – diet and variety of activities
Regular physical activities that are part of daily life (walking, gardening)
Identify high risk situations, encourage in face of lapses
Ongoing support

Question 24

Describe the use of drugs in treatment of obesity

Answer 24

Sibutramine - promotes satiety by inhibiting Noradrenaline and Serotonin re-uptake
Orlistat – a lipase inhibitor, can cause steatorrhoea (fatty stools) – consider need for Vitamin D supplements
Avoid use of bulking agents (methyl cellulose), diuretics, dexamphetamine and thyroxine.
Metformin and Acarbose (Type 2 DM drugs) have no proven efficacy and are not licensed for obesity along

Question 25

List the potential outcomes of bariatric surgery

Answer 25

Type 2 Diabetes Mellitus – 65% will achieve remission in 2 years post-surgery however 1/3 of these will re-develop diabetes within 5 years
Hypertension – Effect from weight loss is variable and can be unpredictable; some patients can stop antihypertensives
Dyslipidaemia – Surgery reduces total cholesterol, LDL and triglycerides while increasing HDL. Consider continuation of statins
Over 10 year period – around 25% of patients will regain any lost weight

Question 26

How does weight loss work?

Answer 26

Eat less calories than you expend

Question 27

Why is weight loss so difficult?

Answer 27

Obesogenic environment.
Genetics, family history, pharmacology, physical and mental health.
Microbiome.
= difficulty maintaining lower calorie diet
Body “protects” from weight loss through
Metabolic adaptations to weight loss
Hunger in response to weight loss

Question 28

How much weight loss is enough to improve health outcomes? Is it worth it?

Answer 28

Almost any amount of weight loss is beneficial: weight reductions as small as 2-5% can improve metabolic control

Question 29

What are our options for dietary interventions

Answer 29

Calorie deficit- 500Kcal les than requirements
Very low calorie diet- Meal replacements as in DIRECT
Intermittent fasting- The 5:2 diet
Time Restricted eating – Eating within a certain period in 24 hrs.
Health at every size approach- Focusing on health not weight