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					Cumulative incidence of Diabetes after 50 years
  based on average BMI aged 20-50 years
                                     Johns Hopkins precursors study - n=916 males
                           15
                                       >25
Cumulative incidence (%)




                           12          24-24.9
                                       22-23.9
                           9           <22


                           6


                           3


                           0
                                50        55         60         65        70        75
                                                     age (years)

                                                                       Arch Intern Med 1999;159:957-63
TV watching and activity as risk factors for DM
       in 37519 health professionals




                                 Arch Intern Med 2001;161:1542-8
What can we do about obesity ?
             Julian H Barth
        Obesity Clinic, Leeds, UK.
              What is obesity ?

The disease process of obesity is weight gain
not the absolute value of overweight



The average man gains 1 gm per day
A toxic or obesogenic environment

Obesity as a normal response to an abnormal
 environment
• side-effect of technological advances
• reflects natural human preferences (eg easy,
  convenient, fast, low effort, value for money)
• key vectors
  – energy-saving machines, passive recreation
  – energy-dense foods & drinks, large portion sizes
            Natural history of obesity



   Obese

Overweight


   Normal




       Years of management or intermittent monitoring
   How do we treat obese patients?


• identify ideal weight

• prescribe 800-1000 kCal diet

• castigate the patient as a failure

• await the development of co-morbidities
         Treatments for obesity

• Diet / eating patterns
• Physical activity
• Psychological / behaviour modification
  therapy

• Pharmacotherapy
• Surgery

• Prevention
    Evaluation of the obese patient

• Examine the patient for co-morbidities
• Examine the patient for a “medical” cause of
  obesity



• Ask why the patient wants to lose weight
• Ask how much weight loss is desired
   What are the causes of obesity?

                           Dysfunctional
   Nutritional                eating
   ignorance

                              Social/emotional
                                  turmoil
Sedentary
 lifestyle

                             Chronic failure of
         Drug therapy         life-long dieting
      for other diseases
   Successful obesity management

• patient accepts the benefit of weight loss

• patient accepts modality of therapy

• competent, sympathetic health-carer available to
  review progress regularly

• realistic claims for weight loss

• indefinite after-weight-loss service




                                                     BNF 1999
               Eating & obesity

•   Eating patterns
•   Nutritional knowledge
•   Missed meals
•   Social eating
•   Binge eating
•   Emotional eating
•   Alcohol
•   ex-sports-(wo)men
                   Dietary therapy
• Low calorie diets
   –   LCD (800-1500kCal/day) (3.4-6.3MJ)
   –   High fibre diets
   –   calorie counting
   –   energy prescribed
   –   low CBH diets

• VLCD (<800kCal/day) (<3.4MJ)
• Milk diet
• Alternative diets
                                         XENDOS
                                      What treatment gave these results?
                   0

                   -2
                                                                          -4.1 kg
weight loss (%)




                   -4

                   -6

                   -8
                                                                           -6.9 kg
                  -10

                  -12
                        0   13 26 39 52 65 78 91 104 117 130 143 156 169 184 197 204

                                               time (weeks)
       Physical activity and obesity

• 4th risk factor for IHD
   – as important as cholesterol and  bp

• PA improves cardiovascular fitness, plasma lipids &
  blood pressure

• physically active subjects live longer

• exercise results in more weight loss than diet

• Doctors do NOT advise their patients to be active
    Before starting drug therapy…
• Previous therapies
   – dietary approaches
   – Physical activity
   – Behavioural modification
• Motivation

• Effective
• Safe
• lifestyle changes have the potential for long-
  term weight loss
    Drugs that promote weight gain
• steroids
• beta-blockers
• anti-diabetic agents
• anti-histamines
• anti-psychotic agents
• anti-depressants
• anti-convulsants
• anti-migraine agents
• breast cancer therapies
Medical therapy for diabetes

                                    Sulphonylurea
                                     + Insulin
                                      Insulin

                                      Diet alone




               UKPDS 57 Diabetes Care 2002;25:330-6
       Indications for drug therapy

• Obesity of severity to shorten life span

• Obesity related disorders that might be improved by
  weight loss
   – eg hypertension, NIDDM, hyperlipidaemia &
     sleep apnoea

• Need to reduce weight for other medical therapy eg
  surgery
          Timing of drug therapy

• Good motivation
   – weight loss already achieved with diet &/or physical
     activity
   – newly diagnosed obese subject with diabetes or bp

• Poor motivation

• Weight loss usually occurs within the first 4-6
  months of programme

• Realistic expectations of therapy
    Pharmacotherapy for obesity (2001)

•   Phentermine
•   Mazindol
                       all have
•   Diethylproprion
•   Fenfluramine       been
•   Dexfenfluramine    withdrawn


• Orlistat            „Xenical‟
• Sibutramine         „Reductil‟
• Rimonabant          „Accomplia‟
        Aims of obesity therapy


• Weight loss


• Weight maintenance
            Orlistat: mean weight changes
        0


       –2

Change –4
   in
 body                                                  Placebo (n=249)
weight –6
                                                                –6.1%
  (%)
       –8                                                        *p<0.001
                                               Orlistat 120 mg (n=271)
      –10
                                                                    –10.2%

      –12
               -4 0   10       20         30   40           52
                           Time (weeks)
                                               Sjostrom L et al. Lancet 1998;352:167
                  XENDOS

• 4 years therapy with orlistat
• Weight loss
   – Active Rx    6.9 kg loss
   – Placebo      4.1 kg loss
• Cumulative incidence of type 2 Diabetes
   – Active Rx    6.2%
   – Placebo      9.0%
                            Weight maintenance: sibutramine
                            Weight loss Weight maintenance
                  104
                  102
Bodyweight (kg)




                  100                                                           Control
                  98
                  96
                  94
                  92                                                           Sibutramine
                  90
                  88
                        0     2   4   6   8   10 12 14 16 18 20 22 24
                                              Month



                                                      STORM Study. Lancet 2000;356:2119-25
Combination of lifestyle modification & sibutramine on
                      weight loss
                                            Sibutramine alone
      20
                                            Sibutramine + Lifestyle
      18                                    Combined Treatment
      16
      14
      12
      10
       8
       6
       4
       2
       0
             2        4        6          12
                   Time (months)
                                   Arch Intern Med 2001;161:218-227
Rimonabant




        Van Gaal LF et al. Lancet 2005;365:1389-1397.
                      Counterweight

• 7 UK centres
• Weight management advisors at
  each centre
• Obesity audit of disease burden
• Prospective obesity
  management programme
  through practise education
                Weight loss
   0
        start    3 months      6 months           12 months
   -1

   -2

kg -3
                     *
   -4                                                 *
                                   *
   -5

   -6
                                        * p<0.001(n=446)
                 Completers   Non-completers


                                       Int J Obes 2004;28 (suppl 1):S29
                 Slimming on Referral
• Collaborative project     70
  between Derby HA &        60
  Slimming World
                            50
• Pilot study
                            40                    12w
• 107 subjects                                    24w
                            30
• 58% competed 12w          20
• 27% completed 24w         10
                            0
                                 <5% 5-10% >10%
                  Obesity surgery
• 1-2% morbidly obese ~ 8-16,000 people in Leeds
• Considerable weight loss maintained over 8-10
  years
• Considerable reduction in comorbidities
  –   Diabetes
  –   Musculoskeletal disorders
  –   Sleep apnoea
  –   Improved quality of life
• Only about 200 operations p.a. in England &
  Wales …so what are the indications for surgery?
NEJM 2004;351:2683-93
                     What do we need ?
                          Occupational
  Slimming clubs             health



 Support               Primary care team       Secondary care team
  groups               GP, nurse, dietitian,    Dietitian, physician,
                          psychologist                 surgeon


    Sports &                                           Obesity
leisure facilities                                  research unit
                           Disinterested
                        Primary care team


      HEALTHY ENVIRONMENT

				
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