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Educational

Obesity

Session organised by Duncan Chambler and Helen Peet, and hosted at Queen Alexandra Hospital, Portsmouth.

  • Facilitators: Duncan Chambler & Helen Peet
  • Venue: Queen Alexandra Hospital, Portsmouth
  • Date: 17th December 2015
  • Summary blog by: Duncan Chambler

Introduction

Is obesity a disease or is it just a lack of will power in lazy individuals!? If it is a disease, then it has a prevalence of 1.9 billion globally. Of this,42 million are children. It has an associated mortality incidence of 2.8 million per year, which is nearly double the mortality from HIV/AIDS and is over 200x the mortality from the most recent Ebola outbreak. This disease affects men and women alike. Here in the UK, five in 10 men suffer from the milder form (overweight) along with four in 10 women. In the USA, prevalence has increased from 10% to 50% in the last 50 years. Although it predominantly affects developed nations, it crosses all borders and communities.

Disease or not, obesity is becoming the greatest threat to humanity’s health. If it is a simple as calories in balanced against calories burnt, then why are we failing to correct our path toward physical, psychological, and economic doom?

What’s relevant to us?

Many aspects of obesity are obvious. So many of our ITU patients are overweight or obese it almost feels normal. So what do we need to learn?

We could have talked about drug dosing, but that’s easily summarised: dose most drugs on “ideal weight + 40% of excess weight” and you won’t go far wrong.

Or, we could have talked about airway management, but usually this isn’t to hard if there is adequate preparation: ramp until their ear, sternum and abdomen are about parallel to the floor!

So instead we had two expert speakers who look at the bigger problems: why do people get fat, and what can we do for them (as members of society, the profession of medicine and the specialty of critical care)?

The history of nutritional advice

As an interlude between the speakers, I presented a brief history of nutritional advice and diets (I confessed my own biases first – I believe sugar is bad and fats may not be so bad).

In 1864, William Banting produced a pamphlet for the public called “A Letter On Corpulence”. Banting had an idea that worked for him, so he wanted to tell the world (these days he would have used Twitter). His high fat and low carbohydrate diet helped him drop weight so effectively it became the popular diet of the time.

In the 1950s and 60s, cardiologists wanted to blame something for coronary disease. Cholesterol and saturated fats became that something after Dr Ancel Keys produced the Seven Countries Study, which strongly associated cholesterol to coronary disease. This evidence, along with a committee in a rush, led to the USDA’s advice and subsequent Food Pyramid, which advises a high carbohydrate and low fat diet. This is still mainstream advice today 50 years later. Take a look at this short YouTube video about the unbelievable McGovern Report

Only now are we beginning to understand that coronary disease is more complicated than just dietary intake, and eggs are back on the menu!

If you fancy a different way of eating, backed up by science, take a look at The Real Meal Revolution by Prof Tim Noakes.

Why people get fat

Lorraine Albon – Diabetologist at Portsmouth Hospitals NHS Trust with an interest in Obesity Medicine.

Key Points

Obesity is a problem for healthcare and health professionals: difficult to examine, investigate, nurse and treat; prone to ulcers, VTE and infection.

Studies have shown negativity, stereotyping and bias against obese individuals by healthcare professionals.

Is it a disease? A hands-up polls suggests 50% in the room agree whilst 50% think it is simple calorie maths and will power.

Problems from obesity can be considered as two disorders:

  • a metabolic syndrome associated with multi system disease related to the endocrine and metabolic consequences of excess adipose tissue (e.g. type 2 diabetes, heart disease);
  • a physical syndrome of problems related to the excess body mass (e.g. sleep apnoea, lower back pain)

Individuals can be fit and fat: mortality hazard ratios for aerobically fit but fat individuals are better than unfit thin individuals.

Edmonton Obesity Staging System is better at discriminating those at risk than classical BMI calculation

The gut is an extensive neuro-hormonal organ and appetite regulation depends upon many hormones, with particular interest currently in Ghrelin and Leptin

Monogenic and polygenic polymorphisms have been associated with hormone irregularities and consequential obesity – as many as 5% of severe obesity cases may be due to genetic mutations

At risk groups for obesity include: those who are vulnerable, have limited opportunities and those with large parents; also ex-athletes (who previous ate well and burnt the calories but now continue to eat well without the exercise!), drivers and night workers

Energy regulation is tightly controlled – within ±1% margin of error

  • One bar of chocolate extra per day = +100 Kcals
  • Equates to 35,000 Kcals extra per year
  • Which would cause 5 kg weight gain per year if not balanced

Strong evidence exists demonstrating diets don’t work

Conversely, strong evidence exists supporting metabolic surgery (new term for obesity surgery – the aim is to correct the metabolic syndrome, as opposed to bariatric surgery that is just cosmetic)

Obesity surgery is commissioned by NHS England as a specialist service, and NICE quality standards will reward trusts through CQUINS for addressing the issue of obesity through a 4-tier management pathway: essentially common advice, specialist nutritional advice, medical advice / drugs and then finally surgery

Issues relating to ITU

  • Record overweight / obesity as diagnostic text
  • Consider malnutrition and treat deficiencies
  • Consider further assessment: sleep studies, tier 3 referral
  • Warn people about weight loss post ITU

Fat and Malnourished

Denise Thomas is a Dietitian with a doctorate in the study of obesity. She is head of Nutrition and Dietetics at Portsmouth Hospitals NHS Trust.

Key points

  • Despite rising obesity rates, food poverty is also increasing
  • Recommended eating includes ‘5 portions of fruit & veg per day’, but only 25% of adults achieve this regularly
  • High fat and high sugar foods, from take-aways or pre-made meals, are consumed frequently
  • A paradox now exists: high energy intake but low nutritional quality
  • This is encouraged by agricultural techniques and the low cost of these foods
  • Obesity often associated with deficiency of: Vitamins A, E, C and D, selenium, folate, zinc and thiamine

The best advice is to match the Eatwell Plate! With subtle differences to the USDA’s Food Pyramid in the UK this is the current advice we should give our patients

If there was one thing society (and government) could do to halt the obesity epidemic, it is to limit and reduce fast-food and take-away outlets

Final Thoughts

We all felt a little disheartened at the size of the problem, the complexity of the science and the uncertainty of the advice. What should we do for our patients when we meet them for just a short period of time? Nudge them with a suggestion perhaps!

  • “Have you thought about how your weight might affect your health?”
  • “Do you realise that being overweight might make this problem worse?”

From there, if they’re receptive, they can initiate a referral through the 4-tier pathway via their GP!

Christmas Quiz

We concluded the afternoon with a possibly the most academic Christmas Quiz ever, followed by a pint of beer and fish & chips! I guess we ignored all the learning points.