Obese Patients in Acute Medicine. Hutt Acute medical Conference July 2012

Transcription

1 Obese Patients in Acute Medicine Hutt Acute medical Conference July 2012

2 What Causes Obesity? The difference between a fat person and a thin person is their genes or other biological factors beyond their control The change in the number of people who are fat now compared to 30 years ago is due to the change in the environment The geno-environmental interaction has resulted in genetically susceptible individuals consuming more calories and becoming obese

3 Genes and the Environment BMI * * * Genetically thin Genetically fat

4 Effect of obesity on intensive care morbidity and mortality: A meta-analysis * Akinnusi, Morohunfolu E. MD; Pineda, Lilibeth A. MD; El Solh, Ali A. MD, MPH Conclusion: Obesity in critically ill patients is not associated with excess mortality but is significantly related to prolonged duration of mechanical ventilation and intensive care unit length of stay. Future studies should target this population for intervention studies to reduce their greater resource utilization. Critical Care Medicine: January Volume 36 - Issue 1 - pp

5 Morbid Obesity in the Medical ICU * CHEST. 2001;120(6): doi: /chest Comparison of the causes of respiratory failure bysubtypes between the morbidly obese and the nonobese group. Type 1,acute hypoxic respiratory failure; type 2, hypercapnic respiratoryfailure; type 3, metabolic respiratory failure; type 4, airwayprotection-related respiratory failure. Date of download: 7/23/2012 Copyright American College of Chest Physicians. All rights reserved.

6 Risks associated with obesity Increased morbidity as a direct result of obesity Type 2 Diabetes Mellitus Cardiovascular disease Obstructive sleep apnoea Type 2 respiratory failure Cancers of breast, bowel and prostate NASH Cholecystitis Osteo-arthritis

7 Each 5 kg/m2 above 25 is associated with an increase in mortality of.. 40% for vascular mortality % for diabetic, renal and hepatic mortality 10% for neoplastic mortality 20% for respiratory and all other casues (but glaucoma improves with weight gain!)

8 Proportion of Cancers Caused by poor diet and obesity Endometrial 70% Oesophageal 69% Mouth, pharynx, larynx 63% Stomach 47% Colorectal 45% Pancreas 39% Breast 38% Lung 36% Prostate 11% World cancer Research Fund 2009

9 Body-mass index and cause-specific mortality in adults: collaborative analyses of 57 prospective studies Prospective Studies Collaboration The Lancet, Volume 373, Issue 9669, Pages , 28 March 2009

10 Yearly deaths per 1000 (95% CI) All Cause Mortality versus BMI (Lancet 2009;373: ) Male Female Baseline BMI

11 Are There Risks Associated with Weight Loss? Should we be telling our patients to lose weight?

12 Obesity: a disease or a biological adaptation? An update Obesity Reviews J.-P. Chaput1,*, É. Doucet2, A. Tremblay3 Article first published online: 14 MAR 2012 DOI: /j X x

13 Changes Associated with Weight Loss Obesity Reviews Volume 13, Issue 8, pages , 14 MAR 2012 DOI: /j X x

14 Other consequences of weight loss Disruption of glucose homeostasis with propensity to reactive hypoglycaemia Increased plasma levels of lipid soluble persistent organic pollutants (POPs) Dieting has been shown to produce chronic stress and elevations in cortisol levels

15 Does dieting make you fat? A twin study K H Pietiläinen1,2,3, S E Saarni2,4, J Kaprio2,3,4 and A Rissanen1 International Journal of Obesity (2012) 36, ; doi: /ijo ; published online 9 August 2011

16 Subjects included 4129 individual twins from the population-based FinnTwin16 study (90% of twins born in Finland ). Weight and height were obtained from longitudinal surveys at 16, 17, 18 and 25 years, and number of lifetime intentional weight loss (IWL) episodes of more than 5kg at 25 years. In MZ pairs discordant for IWL, co-twins with at least one IWL were 0.4kgm 2 (P=0.041) heavier at 25 years than their non-dieting co-twins (no differences in baseline BMIs). The effect was greater for dizygotic twins

17 Does Dieting Work?

18 Even effective dietary and exercise treatments for adult obesity produced modest weight loss (about 3-5 kg) compared with no treatment or usual care.... Although the weight loss of 3-5 kg was statistically significant and had some health benefits, its clinical significance was not shown that is, it may not have been enough to improve the health or quality of life of patients. In most studies with long term follow-up, the weight lost initially gradually came back. Anjali Jain; BMJ 2005;331;

19 Diet, Behaviour Modification, and Exercise: A Review of Obesity Treatments from a Long-Term Perspective average % weight regain years of follow-up Southern medical Journal; 84; ,1991

20 The Stigma of Obesity

21 Social and Psychological Effects of Obesity Rejection by peers weight prejudice observed in children aged 3-5 years Educational discrimination higher rates of wrongful dismissals from College, lower acceptance rates to College despite equivalent grades Economic hardship overweight children receive less financial support from parents than slimmer siblings Social isolation Depression Chronic stress

22 Getting Worse: The Stigmatization of Obese Children Janet D Latner and Albert J Stunkard Obesity Research Vol. 11 No. 3 March 2003

23 Physicians attitudes to obese patients (anonymous questionnaire) Out of dozens of categories, 400 physicians surveyed reacted negatively to obese people, ranking them 4 th behind drug addiction, alcoholism and mental illness Obesity was associated with poor hygeine, noncompliance, hostility and dishonesty Another study of family physicians revealed that 2/3 thought their obese patients lacked self-control and 39% thought they were lazy. Of health care professionals working in nutrition, 87% believed that obese people were self-indulgent, 74% thought they had family problems and 32% thought they lacked will-power

24 Obesity and DNA rates. One study found a significant relation between body mass index (BMI) and appointment cancellation. 32% of women with BMI over 27 and 55% of women with BMI over 35 delayed or cancelled visits because they knew they would be weighed. The most common reason for delaying appointments was embarrassment about weight.

25 Increased Morbidity Due to Late Presentation A study of nearly 7000 women,14 included in the National Health Interview Survey for 1992, found that increased BMI was associated with both increased physician visits and decreased preventive health care services. Obese women were significantly more likely than nonobese women to delay breast and gynecologic exams and Pap tests, despite more frequent visits.

26 Reducing Anti-Fat Prejudice in Pre-service Health Students: A Randomized Trial Kerry S. O Brien1, Rebecca M. Puhl2, Janet D. Latner3, Azeem S. Mir4 and John A. Hunter5 Obesity (2010) doi: /oby Measures of anti-fat prejudice increased in the group of psychology students following a tutorial on diet and exercise as a means of managing obesity Measures of anti-fat prejudice decreased in the group who received a tutorial on the geno-environmental causes of obesity.

27 Correlations (and 95% CIs) between monozygotic (MZ) and dizygotic (DZ) twin pairs for Baby Eating Behavior Questionnaire (BEBQ) subscale scores by zygosity. Llewellyn C H et al. Am J Clin Nutr 2010;91: by American Society for Nutrition

28 The role of physicians in the care of obese individuals is to Acknowledge and understand the stigmatization of obese individuals in the health system Be aware and make allowances for the fact that they will be reluctant to access routine medical care Optimise all metabolic risk factors Screen for obesity related disease Encourage exercise in whatever shape or form Review diet with the aim of increasing healthy foods

29 With Whom Should Bariatric Surgery be Discussed? BMI > 40 Obesity > 5 years Age years Non-smoker Type II Diabetes Mellitus An obesity related condition that results in recurrent hospitalisation Failed non-surgical attempts at weight loss for more than 2 years Understanding of and motivated for surgery Accepts long term to follow-up Weight < 200kg or BMI < 55

30 What should physicians be advocating for in regard to obesity prevention? taxing unhealthy products; regulating foods high in saturated fats, salt and sugar; cracking down on junk food advertising; overhauling misguided agricultural subsidies that make certain ingredients cheaper than others; and supporting local food production so that consumers have access to healthy, fresh and nutritious foods. Olivier De Schutter, the United Nations Special Rapporteur

31 Portrayal of obesity as an issue of personal responsibility, as opposed to the result of geno-environmental interaction causes great harm. It places an unfair burden on those already suffering the effects of obesity and distracts us from addressing the real causes of the problem

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