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Obesity More to Inactivity Than to Food Intake

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Obesity More to Inactivity Than to Food Intake CME Endocrinology Obesity more to inactivity than to food intake. 4 the 1980s showed a strong correlation Worldwide, the adoption of industri- between the weight class (thin, median alised western society lifestyles (urbani- weight, overweight or obese) and the Nicholas Finer MBBS BSc FRCP , Clinical sation, western foods, increased BMI of the biological parents (for Director, Wellcome Trust Clinical Research sedentariness and car ownership) is mothers p<0.0001, for fathers p<0.02), Facility and Honorary Consultant in Obesity associated with increasing obesity. but no correlation with the BMI of Medicine, Addenbrooke’s Hospital, In countries adopting these lifestyles their adoptive parents. 5 In a study in Cambridge; Visiting Professor, Institute for there appears to be a particularly rapid South-West American Indians, energy Health Services Research, Luton University increase in childhood obesity; for expenditure correlated with the rate of example, in Chile, Peru and Mexico 25% change in body weight over a two-year Clin Med 2003;3:23–7 of children are overweight and obese. follow-up period. Also, in 94 siblings from 36 families, 24-hour energy expenditure aggregated in families. 6 Genetics Genetic factors are estimated to Prevalence At the same time, there is increasing explain 30–50% of the heritability of obesity. The human obesity gene map 7 is In its recent world health report, 1 the evidence for a genetic predisposition to now complex. Currently identified are: World Health Organization stated that: obesity. Studies in adopted children in We are facing a worldwide epidemic of obesity, a key risk factor in type2 diabetes, cardiovascular diseases, high blood pressure 25 Men >30 >40 and stroke, as well as various types of cancer. 21 More than one billion adults worldwide are 20 18.7 17.3 overweight, and at least 300 million of these 16.4 17 15.3 are clinically obese. 15 13.8 I 13.2 M Obesity prevalence is 14–20% in B industrialised countries, but the fastest 10 increases, particularly in childhood obesity, are seen in developing countries 5 such as Chile and China. 2 Worldwide, 22 million children under the age of five 0.2 0.4 0.3 0.4 0.8 0.6 0.8 0.6 0 are overweight; 10% of US preschool 1993 1994 1995 1996 1997 1998 1999 2000 children are obese, half of whom are likely to have impaired glucose toler- ance.3 In Europe, England and Wales have seen one of the most rapid increases 25 Women >30 >40 in prevalence of overweight and obesity. 21.2 21.1 21.4 19.7 There has been an increase from 6% and 20 18.4 17.3 17.5 8%, respectively, for men and women in 16.4 1980 to 8% and 12% in 1990, and to over 15 I 21% for both in 2000 (Fig1). More than M 50% of adults are overweight (body mass B index (BMI) 25). 10 5 Aetiology 2.3 2.3 1.4 1.6 1.4 1.4 1.9 1.9 Lifestyle 0 1993 1994 1995 1996 1997 1998 1999 2000 There are complex causes for this increasing prevalence, involving secular Year changes in lifestyles affecting both energy and energy expenditure (Table 1). Fig1. Prevalence of different degrees of obesity in England and Wales (data from Analysis of food intake data and proxy Health Survey of England and Wales, 1993–2000) (BMI = body mass index). These graphs allow the prescription of an individually tailored weight-reducing diet providing a measures of exercise and activity suggest 600 kcal (2.5 MJ)/day deficit to men and women of varying degrees of body weight, that the recent rise in overweight and according to sex (assuming mild to moderate activity level) with a minimum energy obesity in England can be attributed prescription of 122 kcal (5 MJ)/day. Clinical Medicine Vol 3No 1January/February 2003 23 CME Endocrinology Table 1. Examples of changes in energy intake (diet) and energy expenditure (clinically assessed by the waist circum- (physical activity and exercise) over the past 50 years. ference). This relationship has been particularly well defined for type2 Energy intake Energy expenditure diabetes mellitus (Fig 3) 8 and highlights Cheaper food Increased ownership of cars the need to assess both BMI and waist cir- cumference in the clinical evaluation of Greater availability of food: Change in work practices: Supermarkets Construction machines the obese patient (Table2). Different Freezers Production lines criteria are proposed for non-European Fast food outlets Computers ethnic groups (egadult Asians: over- 9 Change in diet composition: Labour-saving devices: weight BMI >23, obesity >25). In Increased fat Washing machines addition, obesity impairs quality of life, Increased refined sugars Dishwashers increases morbidity and leads to prema- Less complex carbohydrates Remote controls ture mortality. More alcohol Cordless phones Change in eating patterns: Sedentary relaxation: More snacks Television Treatment Fewer ‘family’ meals Computer games Increased portion sizes Lifts Lifestyle interventions Escalators Treatment aims to produce clinically Children: Children: valuable weight loss (5–10%) Targeted by food industry Push chairs (Table 3)10,11 that is maintained Greater autonomy Fewer walk to school Greater spending power Decreased sport at school long-term. Lifestyle modification remains a cornerstone of obesity treatment, combining dietary modifica- six single gene mutations which the prevalence of obesity has tion, increased activity and exercise, 25 Mendelian disorders with map increased, thus pointing to the impor- behavioural and cognitive therapy. location tance of gene–environment interactions. Therapy is often delivered to groups of 48 candidate genes patients who need to be ‘ready to change’, and able and willing to spend 33 human quantitative trait loci, Health risks time working on learning and practising and The health risks of overweight are well new skills. 48 other human linkages. defined (Fig2). They increase with Current dietary management com- Clearly, the human gene pool has not greater degrees of obesity as well as with monly advises on healthy eating princi- changed over the past 50 years during central or visceral fat accumulation ples and a fixed caloric deficit of 600 kcal Fig 2. Schematic representation of some of the major Hirsutism ~2 Stroke ~1.6 Sweating Low mood complications of Low self-esteem overweight and obesity and their approximate relative risks for body Hypoventilation Hypertension ~2.9 mass index greater than Sleep apnoea CHD ~2.5 27–30 (CHD = coronary Breathlessness ~3.5 Thromboembolism~1.5 heart disease). Heart failure ~1.5 Infertility Breast cancer ~1.3 Pregnancy problems~2 Cancer of uterus ~4.6 Menorrhagia ~1.8 Gallstones ~2.7 Cancer of colon~1.5 Osteoarthritis ~2 Cancer of pancreas ~1.6 Gout ~3 Kidney disease Varicose veins Diabetes mellitus 10 Dyslipaemia 1.5 Hyperinsulinaemia 24 Clinical Medicine Vol 3No 1January/February 2003 CME Endocrinology (2.5MJ) from the calculated energy monoamine uptake inhibitor that Table 3. Benefits of a 10kg weight loss expenditure (Fig 4). If complied with, enhances satiety and possibly (based on data from Scottish Intercollegiate Guidelines Network). 10 such diets reliably predict a loss of attenuates the fall in metabolic rate 0.5 kg/week. The short-term use of that occurs with weight loss. Mortality liquid, very low calorie diets (ca800 kcal Both drugs have been approved by the Reduction: (3.4MJ)) can be an effective strategy to National Institute for Clinical Excellence >20% total mortality produce initial weight loss, but requires (NICE).12,13 They have slightly differing >30% diabetes-related deaths adjunctive treatment for longer-term prescribing guidance, precautions and >40% obesity-related cancer deaths weight maintenance. adverse events (Table4). Both drugs Blood pressure achieve an approximate 10% weight loss Reduction: Pharmacological interventions that reaches a maximum after sixmonths 10 mmHg systolic which is almost totally maintained for 20 mmHg diastolic Two drugs are currently licensed for use twoyears. Patients losing weight success- in the UK: fully with either drug will show improve- Diabetes orlistat, a pancreatic and gastric ment in metabolic factors such as fasting Reduction: 50% fasting glucose lipase inhibitor that produces about glucose, lipids and urate. There is no 30% fat malabsorption evidence that combining the drugs is Lipids sibutramine, a centrally acting worthwhile. Reduction: 10% total cholesterol 15% LDL Fig 3. Age-adjusted incidence rates of type2 diabetes cross-classified according to 30% triglycerides quintile of body mass index (BMI) and waist circumference. Increase: 8% HDL Respiratory Reduced sleep apnoea Decreased breathlessness 600 Gynaecological Improved ovarian function Log age- adjusted and fertility in POS incidence/ >27.4 100,000 HDL = high-density lipoprotein; <27.4 LDL = low-density lipoprotein; person- POS = polycystic ovary syndrome. years <24.4 <22.7 BMI <21.1 0 >86.4 <86.4 <78.7 <73.7 <70 Key Points Waist (cm) Obesity is reaching pandemic proportions due to environmental changes affecting both sides of the Table 2. World Health Organization definitions of obesity, amended to take account energy balance of fat distribution assessed by waist circumference. Modest weight reduction of 10% Disease risk* achieves medically important outcomes Classification of BMIObesity Men <102cm Men 102 cm obesity class Women <88cm Women 88cm Pharmacotherapy can be a useful adjunct to lifestyle modification to Underweight <18.5 achieve medically worthwhile Normal 18.5–24.9 Average Average weight loss Overweight 25.0–29.9 Increased High Bariatric surgery should be considered Obesity 30.0–34.9 I High Very high in those with a body mass index Obesity 35.0–39.9 II Very high Very high above 35 and comorbidities Extreme obesity >40 III Extremely high Extremely high KEY WORDS: diet, energy balance, * relative to normal weight and waist circumference. exercise, leptin, lifestyle modification, BMI = body mass index.
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