Obesity and Life expectancy
• January 2003 Life Table analysis of Framingham Data
• Obese at 40 live 6 to 7 years less than normal
• Overweight at 40 live 3 years less than normalObese smoker live 14 years less than normal
Obesity Accounts for
– 5% of heart attacks and strokes– 10% cases of osteoarthritis– 20% cases of hypertenstion– 40% of cancers– 80% cases of Type 2 diabetes.
• There is limited data on the cost of obesity but evidence suggests that the direct cost accounts for 5 to 7% of total health care expenditure (WHO,1998).
What is Obesity?
• Defined by World Health Organisation using body mass index (BMI) (Weight in Kg divided by height in meters squared)
• 5’4” Normal 65kgs (10 stone 3 lbs)Obese 78kgs (12 stone 2 lbs)
• 5’10” Normal 78kgs (12 stone 2 lbs)Obese 94kgs (14 stone 10 lbs)
Relationship of BMI to Excess Mortality
300Age at Issue
Bray GA. Overweight is risking fate. Definition, classification, prevalence and risks. Ann NY Acad Sci 1987;499:14-28.
20-29250
Mo
rtal
ity
Rat
io
Body Mass Index (kg/[m2])
200
150
100
50
150
30-39
20 25 30
Low
Risk
4035
High
Risk
Moderate
Risk
Current Prevalence data in Ireland
• Female: 33% Overweight 26% Obese (13% self report)
• Male: 45% Overweight24% Obese (16% self report)
• Children: 20% Overweight or obese(5-12 yo)
Slan 2007 Independently Measured
Grades of BMI Kg/M2• BMI 19-25 -Normal• BMI 25-30 -Overweight
Obesity• BMI 30-35 -Grade 1• BMI 35-40 -Grade 2
BMI >40 -Grade 3(Morbid)
Overweight or obese USA 71%, UK 65%
USA 5% have BMI > 40Ireland 2% have BMI > 40
Grades of BMI Kg/M2• BMI 19-25 -Normal• BMI 25-30 -Overweight
Obesity• BMI 30-35 -Grade 1• BMI 35-40 -Grade 2
BMI >40 -Grade 3(Morbid)
Overweight or obese USA 71%, UK 65%
USA 5% have BMI > 40Ireland 2% have BMI > 40
BMI and weight
Normal weight finishes at
• BMI 25
Male 12st 2lbs
78Kgs
Female 10st 3lbs
65 kgs
BMI ranges
BMI 1 BMI 2
BMI range <20 to 25
BMI 19 BMI 25
BMI range <20 to 25
BMI 19Guess 20
BMI 25Guess 23
BMI 3 BMI 4
BMI range 40 to 45
BMI 40 BMI 44
BMI range 40 to 45
BMI 40Guess 32
BMI 44Guess 35
BMI 5 BMI 6
BMI range 50 to 55
BMI 51 BMI 52
BMI range 50 to 55
BMI 51Guess 43
BMI 52Guess 42
BMI 7 BMI 8
BMI range 70 to >75
BMI 72 BMI 76
BMI range 70 to >75
BMI 72Guess 50
BMI 76
Severe (Grade 3) Obesity
• BMI 40 ---
Male 20st
128kgs
Female 16st 10lbs
108kgs
Current Prevalence data (Adult)
• Female: 33% Overweight 26% Obese (13% self report)
• Male: 45% Overweight24% Obese (16% self report)
Slan 2007 Independently
Measured
Obesity is associated with
• Diabetes • Cancer• Sleep Apnoea• Osteoarthritis• Fatty liver disease• Psoriasis• Dementia• Cardiovascular Disease• Death from H1N1 (Swine Flu)
Excess weight is a MAJOR risk factor for diabetes in US adults, 2001 (n=195, 005)
4.17.3
14.9
0
10
20
30
Normal OverweightBMI 25-29.9
ObeseBMI 30-39.9
Prevalence of diabetes (%)
ObeseBMI 40
25.6
Mokdad et al. JAMA 2003; 289: 76-9
Figure 3: Summary risk estimates by cancer sites in men
Figure 4: Summary risk estimates by cancer sites in women
Relative Risk of Developing Cancer in Males
Cancer Type Relative Risk if Overweight
Relative Risk if
Obese
Oesophegeal 1.5 2.3
Thyroid 1.3 1.7
Colon 1.2 1.5
Renal 1.2 1.5
Obesity also reduces survival in certain cancers
• Colon
• Breast
• Endometrium
• Prostate
• Ovary
Increased risk of dementia
• BMI and increased risk of dementia – analysis of prospective cohort study (Whitmer et al. 2005)– Increased risk of dimentia in later years for
those overweight / obese in mid-life– Increased risk for
• Males• Females
Relative Risk of Developing Dementia
Normal Weight population
Overweight Population
Obese Population
Female 1 (Incidence 69/million)
1.55 2.07
Male 1(Incidence 43/million)
1.16 1.3
Obese patient with Acute abdomen
• 30% chance of atelecasis/pneumonia
• 2.8 times more likely than non obese
Overweight and obesity following Road Accidents
• Study of 1,615 CrashesCrash factor adjusted odds for dying
2.08 for overweight3.17 for obese
Injury severity adjusted odds for dying1.87 for overweight3.89 for obese
Ryb J.Trauma 2008(64)406-411
CIREN study
Role of weight and seatbelts
• Seatbelts decrease risk of death and intraabdominal injury in obese and non obese
Lack of seatbelt increases risk of death9.7 fold in obese5.2 fold in non obese
Zarzaur & Marshall J Trauma 2008(64)412-417
Crash Dummy Research
Equipment Needs
A lot of equipment
• Has upper weight limit of ~ 150kgs
TrolleysBedsTheatre TablesRadiology – equipment and quality
Radiology Equipment in Ireland
• Audit of 40 hospitals
• CT, MRI, Fluoroscopy
• Weight Limit
• Aperture Diameter
Food Intake vs. Physical Activity
Food Activity
Toxic environment we live in…
Unsuspected calories abound
Unsuspected Calories
Unsuspected Calories
140 calories
Bagel20 Years Ago Today
350 calories 333 calories 590 calories
Today20 Years Ago
Cheeseburger
Chips20 Years Ago Today
210 calories 610 calories
Burning a lot less energy (per half hour)
Calories Burned 2004 Calories Burned 1984
Lift (2 mins) 3 Take Stairs 19
Order take away 1 Cook Meal 70
Load Dishwasher 23 Wash Up 80
Watch TV 35 Play Cards 52
Go to car wash 35 Wash Car 104
Play Video Game 53 Play Basketball 280
Ride Lawn Mower 88 Mow Lawn 193
What about children?
Childhood Obesity in Ireland
• 30% overweight and 14.7% obese overall
• 12% obese 7 year olds• 20% obese aged 9-10 years
Slan Survey 2007
Do obese children become obese adults?
• 30% of adult obesity begins in childhood so many adults were not obese children and not all obese children will stay obese
• 1/3 obese preschoolers = obese adults (26-41%)
• All ages risk twice as high for obese as non-obese (range 2-6.5 fold risk) Serdula,Preventative Medicine 1993:22;167-177
• Parental obesity > doubles the risk of adult obesity in both obese and non-obese children < 10 years Whittaker NEJM
1997;337(13):869-73
Just say no……
•
Treatment Options for Obesity
• Diet & Lifestyle changes
• Pharmacotherapy
• Surgery
Nothing works without diet/lifestyle change
• Diet – 500 kcalorie deficit/dayhealthy eating priciples
• Activity - No consensus1 hour daily every day
• No treatment works without this
Who would you rather be?
• Man on Left = Driver• Man on Right = Conductor
Physical Activity at Work
• Prof. Jerry Morris, – Physical Activity Epidemiology– Lancet 1953
• 31,000 London Transport Workers– Drivers and Conductors– London Double Decker Bus
• Drivers had higher rates of Coronary Occlusion (heart attacks) and higher early mortality than conductors
Does type of exercise matter?
Does type of exercise matter?
ResultsCoronary Artery Disease of 31,000
London Transport Workers
00.20.40.60.8
11.21.41.6
Coronary Occulsion(MI)
Early Mortality (within 3 days of MI)
Rate p
er 1000
Drivers
Conductors
Morris JN et al., Lancet 1953
Cardiorespiratory Fitness and Incident Metabolic Syndrome, 9007 men and 1491 women
ACLS, 1979 - 2003
0
5
10
15
20
25
30
35
40
45
Men Women
Low
Middle
High
Ag
e ad
just
ed r
ate
/ 10
00 p
erso
n y
ears
LaMonte, M. et al, 2005 Circulation
Cardiorespiratory fitness tertile
All p <0.001
Need environment conducive to exercise
Obesity
• Pandemic in Adults and Children
• Tracks to adulthood strongly from kids
• Is preventable
• Is treatable
Malnutrition in Hospital
Malnutrition in Hospitals
“Food is your medicine - hence let your medicine be your
food”Hippocrates, circa 400 BC
Malnutrition in Hospitals
• Malnutrition risk has been identified in 20% - 60% of hospital admissions to medical, surgical, elderly and orthopaedic wards.
• Further, hospitalization with surgery or other medical treatments often result in additional weight loss.
• It has been reported as undiagnosed in up to 70% of cases.
Malnutrition in Hospitals
• Under-nutrition is associated with– Impairment of body systems including muscle
weakness, immune system and gut function– Delayed wound healing– Apathy and depression– Reduction of appetite and ability to eat– Increased mortality rates
Which patients are at risk?
• Elderly
• Cancer
• Trauma/ sepsis
• Chronic disease states
• Pre and post operative
• Obese as well as normal weight
• Alcohol dependent
Malnutrition in Hospitals
• There are many cost benefits in treating and preventing under-nutrition including– Reduced length of stay as inpatient– Reduced costs per stay– Reduced mortality
• Benefits are seen the earlier under-nutrition is recognised and treated
MUST
• ‘Malnutrition Universal Screening Tool’
• Allows health care professionals to easily identify those at risk of malnutrition in a rapid and consistent manner.
• This best targets appropriate nutrition therapy.
MUST
• A screening tool should be used within the hospital to identify patients at risk of malnutrition
• Within 48 hours of admission
• Once weekly thereafter
• Need to act on results of the screening tool
• Should be included in nursing handover
MUST
• Quick and easy to complete
• Universal- suitable for all patients
• Facilitates continuity of care
• Evidence- based
• Precedes nutritional assessment
• Ensures appropriate referrals
MUST
Take a look at the format of the MUST screening tool………..
The 5 steps of ‘MUST’
• Steps 1-3: Take 3 measurements and score them against the scale provided
• BMI• Weight loss• Acute disease effect
• Step 4: Add scores together to identify overall risk of malnutrition
• Step 5: Form appropriate care plan in line with local policy
What do you need to measure?• Weight:
– Only 25% of patients are weighed on admission. (McWhirter & Pennington, 1994)
– Very difficult to assess nutritional status without weight
• Height: – Measure with stadometer (height measure)– Self reported or Ulna Length
• BMI: Weight / Height2
– Normal range = 20-25 kg/m2
– Below 20 kg/m2 possible malnutrition– Below 18.5 kg/m2 likely malnutrition
NB. A word of warning Obese patients can still be at risk of malnutrition if they lose weight rapidly i.e. lose lean body mass
Step 1
• Weigh the patient
Step 1
• Measure the patients height using the stadometer – height measure
Step 1 – if you can’t measure height….
Estimated height from ulna length
Estimating height from ulna length
BMI
STEP 1 Body Mass Index (BMI)
BMI (kg/m2)
Weight Category BMI Score
<18.5 Very underweight 2
18.5-20 Underweight 1
20-25 Desirable weight 0
25-30 Overweight 0
>30 Obese 0
Step 2 - ‘MUST’ and weight loss
• Unintentional weight loss over a period of 3-6 months is an indicator of acute or recent-onset malnutrition
• If previous weight is unavailable, subjective criteria include:
• Clothes and/or jewellery having become loose• History of reduced food intake, reduced appetite,
and swallowing problems• Over 3–6+ months, underlying disease of
psychosocial or physical disability weight loss
Step 2 - MUST and weight loss
Score Unplanned weight loss
in past 3-6 months (% body weight)
Significance
2 >10% Clinically significant weight loss
1 5-10% Exceeds normal variation - early indicator of increased risk of under-nutrition
0 <5% A ‘normal’ level variation for individuals
STEP 3 Acute disease effect
• Most likely to apply to patients in hospital
• Applies to patients who have had or are likely to have no nutritional intake for more than five days
• ‘MUST’ Score: Add 2 if acute disease effect applies
STEP 4 - Overall risk of malnutrition
• Total of scores from steps 1, 2 and 3
• Document score
Score 0 1 2
BMI + Weight loss + Acute Disease effect
Low risk
Medium risk
High risk
STEP 5 Nutrition Care Plan
• Low risk of malnutrition
– Repeat screening weekly
• Medium and high risk of malnutrition
– Nutritional intervention – refer to dietitian
– Repeat screening weekly
Need to
• Screen in all healthcare institutions
• Get the surgeons on board
• Manage obesity in hopsital – huge missed opportunity
10 Key Characteristics of goodnutritional care in hospitals
• All patients are screened on admission to identify the patients who are malnourished or at of becoming malnourished. All patients are re-screened weekly.
• All patients have a care plan which identifies their nutritional care needs and how they are to be met.
10 Key Characteristics of goodnutritional care in hospitals
• The hospital includes specific guidance on food services and nutritional care in its Clinical Paths
• Patients are involved in the planning and monitoring arrangements for food service provision.
• The ward implements Protected Mealtimes to provide an environment conducive to patients enjoying and being able to eat their food.
10 Key Characteristics of goodnutritional care in hospitals
• All staff have the appropriate skills and competencies needed to ensure that patient’s nutritional needs are met.
• All staff receive regular training on nutritional care and management.
• Hospital facilities are designed to be flexible and patient centred with the aim of providing and delivering an excellent experience of food service and nutritional care 24 hours a day, every day.
10 Key Characteristics of goodnutritional care in hospitals
• The hospital has a policy for food service and nutritional care which is patient centred and performance managed in line with home country governance frameworks.
• Food service and nutritional care is delivered to the patient safely.
• The hospital supports a multi-disciplinary approach to nutritional care and values the contribution of all staff groups working in partnership with patients and users.
Thank you.