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Dr Ian W Campbell Weight Management What really works

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Dr Ian W Campbell Weight Management What really works

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    1. Dr Ian W Campbell Weight Management What really works?

    2. Benefits of 10% Weight Loss

    3. How to keep weight off successfully National Weight Control Registry McGuire, Wing, Klem, Lang, Hill (1999) Physical activity extra 500kcal/week = extra 2000 steps 5 days a week ? >10,000 steps per day Avoid high-fat foods 24% vs 26% Energy from fat even after adjustment for energy density (Wyatt et al 2004) Replace with low-fat options (Weststrate et al, 1995) Satisfy appetites

    4. Where the evidence is for effectiveness and efficiency Loss Maintenance/ Prevention Diet ++ + Physical activity - ++ Combined ++ +++

    5. Where the evidence is for effectiveness and efficiency Loss Maintenance/ Prevention NHS/Research +++ ++ Commercial clubs (+) - Books, leaflets - - Web-based - - Low fat products + ++ Low Carb ++ + Reduced sugar + + Exercise referral - - Physical Activity - ++

    7. Dietary changes Three regular meals daily Low fat, low sugar choices Min. 5 portions fruit and veg Avoidance “empty calories” Reduce snacking between meals Minimise alcohol intake Dedicated place to eat, not in the car, 20 min. between courses, smaller portions Eating should still be pleasurable

    9. Activity changes 30 minutes each day Brisk walking, swimming, gym? Leave the car at home Walk children to school Avoid lifts, use the stairs Get off the bus a stop early Formalised exercise schemes Make activity a normal part of life Best form of exercise?

    14. Working with commercial weight loss groups: Weight Watchers meetings compared with self-help/brief counselling programme

    15. Maintenance of weight loss? Life-time members 5 years after reaching goal weight: - 30% remained within 5 lbs of goal weight - 50% had maintained a weight loss of 5% or more - 70% were still below their starting weight Lowe et al 2001, International Journal of Obesity Related Metabolic Disorders, 25:325-331

    19. Medical management of obesity Medical Management of Obesity: Implications for Care Obesity is a legitimate, chronic disease2 – It has serious health consequences – It is a major risk factor for common causes of death (eg, cardiovascular disease14) Obesity has multiple causes1: – Genetic, hormonal, behavioural, environmental, socio-economic, cultural – Blaming the patient is inappropriate and does not produce positive outcomes Treatment options3 – Lifestyle modifications must be lifelong and encompass: Nutrition/diet Physical activity Behaviour modification – Pharmacotherapy – Surgery Medical Management of Obesity: Implications for Care Obesity is a legitimate, chronic disease2 – It has serious health consequences – It is a major risk factor for common causes of death (eg, cardiovascular disease14) Obesity has multiple causes1: – Genetic, hormonal, behavioural, environmental, socio-economic, cultural – Blaming the patient is inappropriate and does not produce positive outcomes Treatment options3 – Lifestyle modifications must be lifelong and encompass: Nutrition/diet Physical activity Behaviour modification – Pharmacotherapy – Surgery

    20. Counterweight Obesity Management Intervention (COMIN) A national primary care weight management programme 80 practices in 7 regions of the UK Audit to assess burden of obesity on disease prevalence, prescribing and GP attendance Dietitian trained, nurse-led, intervention programme Programme methodology and preliminary results published educational grant from Roche Products Ltd

    21. Counterweight Obesity Management Intervention (COMIN) Programme Nurse-led intervention, Facilitated by dietitians Structured treatment pathway for obesity Patients with BMI = 28 with co-morbidities, or BMI 30+ Only weight management programme to show clinical effectiveness in weight loss/ maintenance in primary care 78% of compliant patients lose weight at 12 months 40% of compliant patients lose >5% weight at 12 months The model consists of 4 phases…. Audit – to identify prevalence of obesity and burden in each practice. Practice training – to improve knowledge, skills and attitudes and includes component of clinical support. Intervention programme – use of structured pathway based on national agreed guidelines. Evaluation – results are feedback to practices on a 6 monthly basis to promote changes in clinical practice. Designed to maximise changes in clinical practice. The model consists of 4 phases…. Audit – to identify prevalence of obesity and burden in each practice. Practice training – to improve knowledge, skills and attitudes and includes component of clinical support. Intervention programme – use of structured pathway based on national agreed guidelines. Evaluation – results are feedback to practices on a 6 monthly basis to promote changes in clinical practice. Designed to maximise changes in clinical practice.

    22. Weight management in secondary care University Hospital Nottingham

    23. Weight Management Clinic 120 patients, 6/12 treatment 75 women (62.5%), age 44.6 yrs (19 – 69) BMI 49.8 (29.7 – 73.8) 15 lost to follow-up Orlistat 31, Sibutramine 20 Response > 5% weight loss 39 responders

    25. Orlistat in primary care Slide 15: Weight loss in the primary care setting The management of obesity now increasingly lies within the remit of the primary care physician. However, due to a lack of awareness of the co-morbidities and cardiovascular risk factors associated with obesity, treatment is often not optimal. A randomised, double-blind, placebo-controlled study was undertaken in 796 obese patients in the primary care setting to determine the long-term efficacy of Xenical (US Primary Care Study) in which patients were given little dietary or behavioural counselling. Weight loss was identical in Xenical and placebo groups during the 4-week run-in period, in which patients received a mildly hypocaloric diet. Weight reduction stabilised after 8 weeks in the placebo group, but there was a continuing decrease in weight throughout 12 months of Xenical therapy. After 1 year, weight loss was 7.9% in the Xenical group compared with 4.2% for placebo. During the second year (in which patients received a eucaloric, weight maintenance diet) the tendency for weight regain was much more marked in the placebo group and at the end of the study, the weight lost in the Xenical group was significantly greater compared with placebo (p<0.001). Slide 15: Weight loss in the primary care setting The management of obesity now increasingly lies within the remit of the primary care physician. However, due to a lack of awareness of the co-morbidities and cardiovascular risk factors associated with obesity, treatment is often not optimal. A randomised, double-blind, placebo-controlled study was undertaken in 796 obese patients in the primary care setting to determine the long-term efficacy of Xenical (US Primary Care Study) in which patients were given little dietary or behavioural counselling. Weight loss was identical in Xenical and placebo groups during the 4-week run-in period, in which patients received a mildly hypocaloric diet. Weight reduction stabilised after 8 weeks in the placebo group, but there was a continuing decrease in weight throughout 12 months of Xenical therapy. After 1 year, weight loss was 7.9% in the Xenical group compared with 4.2% for placebo. During the second year (in which patients received a eucaloric, weight maintenance diet) the tendency for weight regain was much more marked in the placebo group and at the end of the study, the weight lost in the Xenical group was significantly greater compared with placebo (p<0.001).

    26. STORM – Mean bodyweight changes during weight loss and weight maintenance phases over 2 years

    27. XENDOS (XENical in the prevention of Diabetes in Obese Subjects) 3304 obese patients in placebo controlled trial 4 years duration, multicentre, prospective 79% patients normal glucose control, 21% IGT Orlistat treated group had a 37% relative risk reduction in developing diabetes compared to placebo at 4 years Orlistat assisted weight loss improved significantly other metabolic parameters (BP, lipids and BMI)

    28. Bariatric Surgery NICE 2002 Gastro-intestinal reconstruction Laparoscopic banding Gastric pacing Children?

    31. What does “work” mean? Weight loss – 5-10% Waist loss – 5-10cm Improved nutritional and physical activity levels Improved co-morbid disease control Improved met. synd. risk markers BP, dyslipidaemia, glucose Reduced co-morbid medication Improved well being, self esteem Less breathlessness, more energy, less pain, more mobility, improved quality of life

    32.

    34. Obesity cannot be prevented or managed solely by government (or health professionals). The food industry, international agencies, the media, communities and individuals need to work together so that the environment is less conducive to weight gain

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