Rotherham Institute for Obesity (RIO)Multidisciplinary approach to the management and prevention of obesity - a working model

Dale CarterObesity Specialist Nurse (OSN) Rotherham Institute for Obesity

To discuss:

1) Why do we care about obesity?

2) Waist circumference and central/visceral fat

3) Weighing and measuring

4) The NHSR obesity strategy and RIO

5) Common myths and mistakes

6) Questions?

The cover of "The Economist", Dec. 13-19, 2003.

How things have changed:

The changing look of women

The changing look of men

It’s getting worse

Kids today!How we could end up

by 2050

Impact of obese population

Obesity – Public health concerns

2011 Health Survey for England (2009 data):22% of men and 24% of women are obese (BMI >30)

Increasing numbers are morbidly obese (BMI >40) and ‘super obese’ (BMI >50)

66% men and 57% women obese or overweight

Foresight report (Oct07): estimates on current trends >50% of the UK will be obese by 2050

Currently 2/3 adults and 1/3 children overweight or obese Without action 9/10 and 2/3 by 2050

By 2050 total direct and indirect costs of obesity may increase to £49.9bn

Obesity – it’s a social problem, isn’t it? Yes...but, we treat social problems all the time

eg, sporting injuries, smoking problems, common infections etc

Plus...we treat the consequences of obesity anyway, eg, dyslipidaemia, T2DM, hypertension

So why not treat the cause?

Cost effective – prescribing savings Even a few kilos makes a difference to individuals Any weight loss reduces morbidity and mortality Weight regain is inevitable (whatever intervention)

Obesity is a chronic relapsing condition

Weight Change

-6

-5

-4

-3

-2

-1

0

1

2

3

Start 3 Months 6 Months 12 Months 24 Months

kg

-2.4

-4.3

-3.5

-3.0

0

All (completers) n = 684, 12m

-3.3

-4.3

-5.0

-3.8

High Attenders n = 422

-1.1

-2.0-2.2

-0.8

Low Attenders n = 262

Haitman BL & GarbyL (1999) Int J Obes Relat Metab Disord

2.0

1.0

0.50.2

Expected change

Pulmonary diseasePulmonary diseaseobstructive sleep apneaobstructive sleep apneaAsthma/COPDAsthma/COPD

Nonalcoholic fatty Nonalcoholic fatty liver diseaseliver diseasesteatohepatitissteatohepatitiscirrhosiscirrhosis

Coronary heart diseaseCoronary heart disease

DyslipidemiaDyslipidemia

HypertensionHypertension

DiabetesDiabetes

Gynaecologic Gynaecologic abnormalitiesabnormalitiesabnormal mensesabnormal mensesinfertilityinfertilitypolycystic ovarian syndromepolycystic ovarian syndrome

OsteoarthritisOsteoarthritis

Gall bladder diseaseGall bladder disease

CancerCancerbreast, uterus, cervixbreast, uterus, cervixcolon, esophagus, pancreascolon, esophagus, pancreaskidney, prostatekidney, prostate

PhlebitisPhlebitisvenous stasisvenous stasis

Leg ulcersLeg ulcerspressure sorespressure sores

Hyperuricaemia Hyperuricaemia and Goutand Gout

StrokeStroke

Diseases related to obesity

Stress incontinence

Relative risk of health problems associated with obesity

National Audit Office Report. Tackling Obesity in England. London, 2001.

Disease Women Men

T2D

Hypertension

Myocardial infarction

Colon cancer

Angina

Gall bladder disease

Ovarian Cancer

Osteoarthritis

Stroke

12.7

4.2

3.2

2.7

1.8

1.8

1.7

1.4

1.3

5.2

2.6

1.5

3.0

1.8

1.8

-

1.9

1.3

1.13 1 0.961.33

1.9

4.63

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

<18.5 18.5-24.9

25-29.9 30-34.9 35-39.9 >40

Onyike, et al. Amer J Epidemiology 2003;158:1139-1147.

Risk of Major Depression with Risk of Major Depression with Extreme ObesityExtreme Obesity

Odds ratio

BMI

Weight Loss Reduces Mortality

Betteridge DJ and Morrell JM Clinicians' Guide to Lipids and Coronary Heart Disease Second edition Arnold, London 2003 p173 (based on Jung R. Obesity as a disease.  Br Med Bull 1997; 53 (2): 307-321

Weight loss of 10 kg produces a marked improvement in mortality

Mortality > 20-25% fall in mortality > 30-40% fall in diabetes-related

deaths > 40-50% fall in obesity-related

cancer deaths

Blood pressure

Fall of approximately 10 mmHg SBP and DBP

Diabetes Fall of 50% in fasting glucose

Lipids Fall of 10% in total cholesterol Fall of 15% in LDL-C Fall of 30% in triglycerides Rise of 8% in HDL-C

BMI classification of obesityBMI = weight(kg)/height(m)2WHO ClassificationWHO Classification BMIBMI Risk of ComorbidityRisk of Comorbidity

UnderweightUnderweight Below 18.5Below 18.5 Low Low (but risk of other (but risk of other clinical problems increased)clinical problems increased)

Healthy weightHealthy weight 18.5-24.918.5-24.9 AverageAverage

OverweightOverweight 25.0-29.925.0-29.9 Mild increaseMild increase

ObeseObese >30.0>30.0

Grade 1 obesityGrade 1 obesity 30.0-34.930.0-34.9 Moderate increaseModerate increase

Grade 2 obesityGrade 2 obesity 35.0-39.935.0-39.9 Severe increaseSevere increase

Grade 3 obesity Grade 3 obesity

(morbid obesity)(morbid obesity)

>40.0>40.0 Very severeVery severe

Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004

Android (apple) vs. gynoid (pear) obesity

A tribute to a pioneer: Jean Vague (1947)RIM06/413

Visceral Fat

©1994 Mayo Foundation for Medical Education and Research. By permission of Mayo Foundation.

Women

>88 cm (80cm) = Increased risk

Men

>102 cm (94cm) = Increased risk

Lean MEJ et al. Lancet; 1998; 351:853-6

Body fat distributionApple shaped obesity

cm

Excess visceral fat:a root cause of CVD and Type 2 diabetes

Treating the cause Treating the complications

So, what works?

NICE Recommends (for adults): Diet Exercise Behavioural therapy Drug treatment Surgery (if BMI >40, or >35 with co-morbidities)

NICE Clinical Guideline 43; Treating people who are overweight or obese. Dec 1996

Explaining calories

P9791818/June 2007

The role of Exercise Isolated exercise is an inefficient way of burning calories and losing weight 1 mile (15 mins) burns up 100kcals Regular exercise has a huge effect on burning calories and losing weight

Energy expenditure = BMR x PAL (modified Harris Benedict equation)

BMR (kcal/day):Age (yrs) Men Women

10-18 17.5 x Kg + 651 12.2 x Kg + 746 eg, 18-30 15.3 x Kg + 679 14.7 x Kg + 496 24yr old man

80kg 31-60 11.6 x Kg + 879 8.7 x Kg + 829 BMR = 1903 >60 13.5 x Kg + 487 10.5 x Kg + 696 PAL = 1.3

energy = 2474 PAL (Patient Activity Level)

Activity level Men Women PAL = 1.55 Inactive 1.3 1.3 energy = 2950 Light 1.55 1.56 Moderate 1.78 1.64 Heavy 2.1 1.82

Behaviour change:

Talking Therapies:Life coachingCognitive Behavioural Therapy (CBT)Neurolinguistic Programming (NLP)Emotional Freedom Techniques (EFT)HypotherapyHypnobandingetc

Pharmaceutical Strategies

Old Medications:Am-Bar (amphetamine + Barbiturate),

Phentermine,

Rimonabant,

Sibutramine

etc

Current licensed medications: Pancreatic lipase inhibitors

Orlistat - XenicalAlli – otc

Some medications cause weight gain – action often unknown

Common mistakesAll sugars are the same (4kcal/g) i.e., sucrose = fructose etc Coco pop straws 34g/100g = 2 finger kitkat Fruit juice approx 9g/100mls

All fats (satd/polyunsatd/monounsatd) are the same (9kcal/g) Jordan’s Country Crisp Cereal: 28.5g/100g = McDonalds McBacon Roll Thick pork sausages: 20.3g/100g

Alcohol (think of each drink as a chocolate bar!)

High fat foods vs Low fat foods

Premium vs Economy ranges vs Home cooked food:Premium - likely to have high fat and high sugar (high calories)

Economy - likely to have high salt

Home cooked - likely to have high fat (depends on how it is cooked) ?better

Rotherham Town & Demographics

252,000 population5.2% of the population from BME communitiesLife expectancy (women & men) - below the national average2008 – 68th most deprived out of 354 English Districts

MA

TER

NA

L OB

ES

ITY

Facilities offered by RIO:Job Description RoleHealth Trainer Motivational interviewing

Healthcare assistant Weighing & measuring. Follow up care

Obesity Specialist Nurse Initial triage. Basic nutrition & advice

Dietician Specialist intervention. Pre/post surgery

“Cook & Eat” Cooking skills and nutrition

Exercise Therapist Personal exercise programme (on-site gym)

Talking Therapists CBT, NLP, EFT, life-coaching, hypnotherapy

GPwSI Pharmacotherapy

Pre-camp assessments (children)

Pre-surgery assessments (adults)

Admin supervisor Liaise with referrers & service providers

Clinical Manager Managing service

Education room/library Resource room, group work

Other consultants Eg, pre-conception care

RIO Venue:DoncasterGate

Clifton Medical CentreDoncaster GateDoncaster RoadRotherham, S65 1DA08444773622

Weighing and Measuring

Multi-use rooms: One-to-one dietetics

“Cook & Eat”

RIO Education room Resource room MDT meetings Exergaming Group sessions

Fully equipped on-site gym

Talking therapies

Reducing local waist!

Results so far: Tender began April 2009 Launch of service Sep 2009 Official RIO launch Nov 2009

In July 2011 a RIO internal audit showed at that time: Referrals to date >2890 adults + 307 children 1111 adults + 94 children already completed the RIO programme

During the 2010/11 year: 96% adults lost weight and 71% met or did better than targets 72% children met target of weight maintenance/loss Cumulative weight loss = 5.3 tons! Average (adult) weight loss of 8.3kg (18.3lb) 50% reduction in anticipated numbers for bariatric surgery referral

Impact of referral patterns for bariatric surgery (tier 4): Referral patterns prior to April 2009:

approx 100 referred via GP and 50 operations

considered suitable and proceeded to surgery

Surgery rates after April 2009:Anticipated (in 2008): 56 (09/10), 67 (10/11), 78 (11/12)

Actual: less than 50 referred and performed each year

(just 33 in 2010/11)

Conclusions:Tier 3 primary care based MDT specialist service

triage:

reduces inappropriate referrals

reduces numbers of procedures performed

Long term development

Research & training centre √ Extended hours √ Role in pre- & post- operative surgery √ OSA screening √ Outreach clinics + target children Primary care bariatric surgery Advertising service Offer service to neighbouring PCTs

The Health Village

Doncaster Gate Hospital

Doncaster Road

Rotherham

S65 1DA

0844 477 3622

www.rotherhaminstituteforobesity.co.uk

www.rioweightmanagement.co.uk

www.nationalobesityforum.co.uk

www.nof.uk.com