The Obesity Epidemic-do we only treat or do we demand change

Hal Robertson>Manual Tasks Services>Workforce Health

Obesity is now the Number 1 World Health Problem

• Approx 25% of Australian and 26.5% NZ adults have a BMI>30.¹

• NZ and Australia are ranked 6th and 7th in the world for obesity. ²

'07-08 National Health Survey. ² Australian Bureau of Statistics (2009).

www.oecd.org/health/fitnotfat

Country 2005 2010 Change

United States 30.6% 33.8% 10.5%

New Zealand 20.9% 26.5% 26.8%

Australia 21.7% 24.8% 14.3%

United Kingdom 23.0% 24.5% 6.5%

Luxembourg 18.4% 20.0% 8.7%

http://www.abcdiamond.com/overweight-and-obesity

Obesity as a percentage of total population.

Obesity Epidemic 2005-2010

SA Health

Bariatric definition

Person fits two or more of the following criteria:

> Weighs 120+Kg> BMI 40+> Seated hip width >20” (51cm)

Body mass Index (BMI)=weight in KG/height in metres ²

SA Health

Bariatric statistics Royal Adelaide Hospital and Flinders Medical Centre

> 2% of inpatient admissions are bariatric. Ie approx 80 inpatients per month at RAH

> 5% of maintenance stay patients waiting for nursing home placement (RAH) are bariatric

> The average acute LOS for a patient over 120kg is 1.6 times longer than a normal weight patient and 1.8 times longer if the patient is over 150kg compared for other patients

with same Diagnostic Related Group matched for age and sex.

SA Health

The Risks

> Adverse patient outcomes and inequitable standards of care

> Increased injury risk for workers

SA Health

Increase risk of worker injury

Bariatric patients…> Are involved in between 14%-21% of body

stressing incidents assoc with patient care in acute hospitals in Adelaide

> Caused 30% body stressing Workcover claims FMC 2009-10- the relative risk of workers sustaining Musculoskeletal injury is 19:1

SALHN 2010: Nursing and Allied Health Survey on Care of Bariatric Patients

> 20% did not feel safe caring for a B patient> 70% reported appropriate equipment is rarely

available

SA Health

• Patient 250kg• Room 15²m• 7 workers • Bed removed

for Chair access

Increased risk due to poor design

SA Health

Impact on Heath Care systems

> Acute hospitals-increased risks to workers and the patient with dependent patients>200kg

> Aged Care Facilities- struggle to care for dependant residents in 120-150kg range

> Community support programs- limited equipment options, environment and home design restrictions, and often only 1-2 worker(s) available

SA Health

Managing Obesity

SA Health

Methods of management

> BMI 20-25 food choice, exercise, behaviour change

> BMI 25-30 dieting-low calorie diets

> BMI 30-35 very low calorie diets, drug therapy

> BMI 35-40 very low calorie diets, drug therapy,

surgery> BMI 40-50 surgery

> BMI 50-100 surgery

National Clinical guidelines for weight control and Obesity management in Adults, NHMRC 2003

Dieting –it is not easy!

www.drsharma.ca

Combined approach• Calorie controlled diet

• Regular exercise

• Self monitoring

• Motivation or strong reason to change

• Good relapse strategy

• Long term support

Maintaining weight loss

> Weight loss tends to plateau at 3- 6 months (Less body fat, reduces resting metabolic rate and hence reduces energy requirements)

> Studies show 20% retain 10% of initial weight loss for 1 year

Wing RR, Phelan S. Long term weight loss maintenance. Am J Clin Nutr. 2005:82 (1): 2225-2255.

Yoyo dieters

Achieving long term weight loss

> National Weight Control Registry Australia• Little similarity in weight loss methods

> Common behaviours in weight loss maintenance• Low calorie diet• Low to moderate fat intake• Limited fast food• Eat breakfast most days• Regular self monitoring• Engaging in high levels of physical activity

(min 1 hour a day)

Drug therapy for weight loss

> Weight loss drugs developed in past have had harmful side effects

> Phentermine is effective but there is no safety data for long term use

> Be aware of other pharmaceuticals that have side effect of weight gain

Obesity and Mental health

> People with a severe mental illness are 1.5-2x more likely to be obese

> Reduced physical activity> Poor nutrition habits> Medication side effects-

weight gain> Poor motivation

Mental health -40% Glenside Hospital clients have BMI>30kg/m² (Survey August 2011)

Bariatric Surgery

> Aim-reduce mortality from obesity related co-morbidities

> Dietary, psychological and medical assessments

> Commitment to change. Pre surgery weight loss requirement

Sleeve Gastrectomy

> Vertical stapling of stomach

> Excise greater curve> ‘restrictive’> Mal absorption-need

long term dietary supplements

> 1-2 day post OP stay> 50% excessive weight

loss

Laparoscopic Adjustable Gastric Banding

> Silicone band placed around upper stomach

> Subcutaneous access port> Inflate or deflate band> ‘restrictive’> No real mal absorption> Day surgery or overnight stay> 50% excessive weight loss> Safest option

Why are we gaining weight?

> Energy input ≠ energy expenditure

> There is only a very slight daily discrepancy of 50-80Kcal required to gain 3kg a year

High fat, high energy diet

> 1/3rd of food is consumed outside of the home

> Portions are bigger since 1970s (‘portion distortion’)

> Reduced physical activity

1970 Now Food item 350cal

600cal

Cheese burger

Size X3

Bagels

375mlcan

600mlcan

Soft drink

200cal

625cal

Serve of French fries

Plates

Sugared drinks

Primary obesity and diabetes strategy (Centre of Disease Control USA)

> ‘reduce intake of sugar sweetened beverages’> Since late 1970s USA soft drink consumption

has↑ 2x for females and 3x for males> On average 8% of USA children’s calories come

from sugared drinks> Advertising companies spend billions pa and aim

advertising at children and teenagers

– www.cnn.com/2011/08/31/health/soda-drinking-habits/index.html

Projected increase in diabetes 2000-2030

• USA 36.5%

• China 75.5%

• India 134%

Centre of Disease Control USA

Link with advertising and obesity

Food promotion is having an effect particularly on children's’ preferences, purchases behaviours and consumption.

Hastings et al 2003

www.yaleruddcenter.org

77% of obese children will become obese adults.

Pre schoolers in the USA will see on average 5000 fast food ads by the time they reach 5.

Focus on PREVENTING obesity

• Healthy lifestyle programmes- are they working?

• Programmes for the younger generation are showing some success–but it will be decades until we see the results

http://www.drsharma.ca/oecd-dont-place-all-your-bets-on-obesity-prevention.html

How do we control obesity?

Need for public health policies? Factual nutrition disclosures on food packaging• Denmark-Taxes on foods with sugars and saturated

fats • France-Govt health warnings on adverts for

processed, sweetened or salted food. Fines if companies to not comply.

• NY. Menu label laws. Menu displays calorie count of meal

• Proposed sugar tax in some USA states-unsuccessful to date

Pomeranz JL, Teret SP, Sugarman SD, Rutkow L, Brownell KD.

Innovative legal approaches to address obesity. Milbank Quarterly. 2009 Mar;87(1):185-213.

SA Health

> 62 yo patient weighing 276kg UTI and chest infection> Ambulance retrieval-2 teams> HIGH STAFF DEMAND:

• 6 staff to roll her when she was acutely ill, and 3 staff to assist with placing her on a bed pan when she was ‘well’.

• 5 physiotherapy staff to stand her from lying in bed, + 2 nurses to move equipment during this procedure.

> STAFF INJURY• 2 physiotherapists were injured attempting to lift her

legs back onto the bed. (legs weighed 80kg each)

> Specialist equipment needed > POOR PATIENT OUTCOME

• Patient quickly became deconditioned due to limited resources to mobilise her

• She died in hospital 4 months after admission