CLINICAL FOCUS
Individualisation of care and the obesity paradox David Haslam
David Haslam is GP, Watton Place Clinic and Bariatric Physician, Luton University Hospital
Obesity management in the community setting Obesity management programmes begin the moment an obese person is encountered in a clinic or at home, whether they present with an obesity-related problem, a symptom irrelevant to their weight, or even if they are merely the accompanying parent, spouse or companion. The majority of the population presents to primary care clinicians for reasons as wide-ranging as minor injuries, flu jabs and anti-malarials—and the concept ‘make every contact count’ guides GPs and nurses toward seizing any opportunity in clinical situations to identify, engage and act to help the obese individual. The number of superobese people in the population is unknown since many
ABSTRACT
The obesity ‘paradox’ has recently been discussed based upon the observation that although obesity may be a major causative factor in certain conditions, its presence appears to be protective once that condition occurs. There is a growing body of persuasive evidence to support the obesity paradox in diseases including renal failure and heart failure. Recent evidence is reliable, adjusting more effectively for confounders such as smoking and intercurrent illness, which make lower weight an unhealthy state. The existence of the paradox highlights the fact that approaches to weight management are not as simple as inducing the loss of a few kilograms in overweight and obese individuals, and emphasises the importance of individualisation of care in obesity management taking into account age, ethnicity and comorbid illness. This article explores the individualisation of care in obesity, drawing attention to the obesity paradox in particular.
KEY WORDS
w Obesity paradox w Sarcopenia w Weight loss
110
are housebound and a community nurse might be the only point of contact.
Clinical experiences of obesity management The first minute of the obesity management programme is arguably the most difficult. Identification of the obese individual is done by first principles on clinical examination; anyone who looks as though they have a weight problem has a weight problem, regardless of the limitations of body mass index (BMI) in defining body morphology. Raising the topic of obesity and engaging the individual is a different matter. In order to raise the topic with a patient presenting with a sore throat, or on behalf of an accompanying adult, the question ‘am I looking after you properly?’ may act as a stimulus for measuring weight and initiating basic screening, while simultaneously deflecting ‘blame’ away from the individual, and onto the healthcare professional for neglecting to have instigated action earlier. An individual can be successfully engaged or, conversely, alienated depending on the success of these initial moments: very little can actually be achieved clinically in the last 2 minutes of an unrelated appointment, but as long as blood pressure and weight/BMI are measured, fasting blood tests are organised and follow-up is ensured, most patients will engage. BMI, although useful for public health or in research studies, is limited in usefulness when assessing an individual, as body morphology is more important— measures which demonstrate if a person possesses excess adipose tissue and, if so, where, are superior in defining a true risk. An athlete may be technically obese without an ounce of excess fat, whereas a ‘lean’ individual may have sarcopenia, and a pot belly and thus be at high risk. It is usually obvious when a patient is suffering from abdominal obesity from their appearance, and once visual identification has occurred, BMI is an acceptable way of monitoring progress, but measures such as waist circumference, waistto-hip ratio, and emerging measures such as body volume index and weight-to-height ratio are better. Bio-impedance analysis—available relatively cheaply on a specialised scale—goes one step further, directly assessing the amount of fat versus lean tissue a person is carrying. However, even this cannot assess whether abdominal obesity is benign subcutaneous fat or malign visceral adipose tissue. Magnetic resonance imaging (MRI) or more complex
© 2014 MA Healthcare Ltd
I
n every aspect of medicine (and especially with multimorbidity), individualisation of care and the concept of patient-centredness are crucial parts of management (Luijks et al, 2012). This management depends upon information gained from history-taking, examination, motivation, understanding, psychosocial circumstance and, indeed, patients’ preferences (Bowling and Ebrahim, 2001). In managing obesity, individualisation of care is as important as in any other field of medicine.
Email: [email protected]
British Journal of Community Nursing March 2014 Vol 19, No 3
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 2, 2015. For personal use only. No other uses without permission. . All rights res
CLINICAL FOCUS
measures are required for precision, but are inappropriate for routine practice. In identifying and engaging patients in this manner, otherwise anonymous, uninformed obese individuals may become motivated, not just regarding their weight, but about the possible comorbidities, such as diabetes, hypertension, mental health problems, fatty liver, or sleep apnoea. Someone identified as being obese, and found to have high blood pressure, sugar or abnormal lipids can be a success within a weight-management programme without losing any weight, since, if each of their disparate individual factors is treated, and behaviour improves, global risk will be reduced. Studies such as the Diabetes Prevention Program (Knowler et al, 2002), Diabetes Prevention Study (Lindström et al, 2003), and Counterweight (Counterweight Project Team, 2008) show that inducing significant weight reduction in the long term is difficult to induce, but the effects of seemingly minor weight loss are clinically impressive—a 58% reduction in the cumulative incidence of diabetes. The Look AHEAD study (Look AHEAD Research Group, 2013) recently demonstrated excellent weight loss—6% maintained at nearly 10 years—alongside significant reductions in cardiometabolic risk markers, but, because not enough people died in either control or intervention group to meet primary outcomes, the trial was stopped on the basis of ‘futility’.
Risks of obesity
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Abdominal fat deposited intracellularly can be considered as the body’s most prolific endocrine organ and its secretory products (cytokines such as interleukins 1 and 6 and tumour necrosis factor-α) induce insulin resistance. It also has a paracrine suppressive effect on the secretion of adiponectin (Kojima et al, 2005), a powerful insulin sensitiser (Arita et al, 1999) secreted in dwindling quantities as the adiposity increases (Haslam and James, 2005). Thus, the expanded adipocyte mass underpins inflammatory conditions such as type 2 diabetes and cardiovascular disease. Ectopic fat infiltrating pancreatic islet cells amplifies age-related decline in their capacity to maintain increased insulin output demanded by insulin resistance, so glucose intolerance and premature type 2 diabetes ensue. Subepicardial fat in the heart is linked to abdominal adiposity and associated with cardiovascular risk (Chaowalit et al, 2006). The risks of obesity are not limited to cardiometabolic sequelae and include hypercoagulability of the blood, obstructive sleep apnoea, joint and skin conditions and mental health disorders.
what causes obesity, and the answer is the obesigenic environment (Hill et al, 2007), particularly sugar and refined carbohydrates. This theory goes some way to explaining why diet and lifestyle changes are disappointing; weight is usually regained, in order to re-achieve the pre-ordained set point. In some cases, long-standing sustainable changes in macronutrient intake can induce long-term weight loss, but such individuals are the exception, not the rule. Many patients fare well on low-carbohydrate diets, which benefit from nutritious carbohydrates (fruit and vegetables) but not sugar, or refined ‘empty’ carbohydrates (bread, rice, pasta, potatoes and flour). Increasingly, the evidence for sustained weight loss and improvement in cardiometabolic risk supports the Mediterranean (Nordmann et al, 2011) and low-carbohydrate (Gardner et al, 2007) approaches above low-fat diets, although individuals may respond differently. A food diary is often revealing in these instances, while also unearthing individuals who graze, snack, comfort eat or indulge in emotional eating, as well as those suffering from eating disorders, now formally recognised by the latest update to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013) such as binge-eating disorder and night-eating syndrome. Weight reduction will prove impossible in many of these patients unless some form of psychological intervention is employed in order to discover the root cause of the eating behaviour and address it accordingly by stimulus control and alternative coping strategies. One of the author’s patients presented with hyperphagia; her history revealed that, as a child, she became bored with her hamsters. A friend, on being asked what she should do with them replied ‘you could eat them’, which she did! Simply ‘putting a patient on a diet’ is not sufficient in these circumstances. Some patients will be immediately motivated to change their lifestyle or behaviour, or accept drug or surgical treatment, others will respond differently, and the clinician’s approach should reflect that degree of motivation.
Risk factors Ethnicity Different ethnic groups will display varying levels of risk, and require different parameters for risk assessment. South Asians (Misra and Khurana, 2011), particularly immigrants to countries such as the UK, are more prone to abdominal obesity, and more susceptible to conditions such as type 2 diabetes at lower levels of obesity, so should be monitored more closely for diabetes and the metabolic syndrome.
Management of obesity
Age
A carefully taken clinical history may unearth the aetiology of a person’s weight problem. Modern theory is challenging the assumption that obesity is caused by excess food intake and insufficient physical activity (the energy-balance equation), instead suggesting that obesity occurs first, and that overeating and sedentariness are required to maintain the obese set point. There is therefore a question regarding
Elderly individuals tend to have a higher percentage of body fat at any given BMI than their younger counterparts, because of fat within muscles, or sarcopenia (Zamboni et al, 2008), often owing to reduction of physical activity due to joint pains, or retirement from sport or active work. In these circumstances, weight loss is often not an appropriate goal, but any form of physical activity should be enhanced.
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CLINICAL FOCUS Patient history Those individuals with a family history of diabetes, or who have had gestational diabetes, should be carefully monitored. Individuals who have undergone bariatric surgery represent a group who should be monitored extremely closely. A person with a BMI of 35 who formerly had a BMI of 55 prior to bariatric surgery is at much higher risk of cardiovascular disease and mortality than someone who has gradually achieved weight gain to a similar BMI. The ‘post-obese’ patient—who will benefit from permanent weight loss following bariatric surgery and will spend the rest of their lives under the care of the primary care team— must always be considered to be a high-risk individual, and remain on their appropriate disease registers (e.g. hypertension), even if their blood pressure returns to normal. They should remain on drugs such as metformin, or other drugs which do not induce hypoglycaemia, to reflect their higher risk.
Systems for individualising care Edmonton Obesity Staging System The Edmonton Obesity Staging System (EOSS) (Figure 1) is a means of individualising patient care on the basis of a person’s medical, social and psychological needs, rather than just their weight or BMI. An individual with any degree of obesity as measured by BMI, will be at stage 0 if they have no medical or psychosocial comorbidities, so treatment should arguably be prioritised to stage 4 patients who might only have a BMI of 30, but have severe associated problems such as type 2 diabetes with severe insulin resistance and microvascular complications such as retinopathy at an early age. In this model, there is also a suggestion that some patients require palliative care only, without any attempt at weight loss, as long as issues such as pain control and psychosocial needs are addressed.
These models are particularly relevant in an assessment for eligibility for bariatric surgery. A 34-year-old with a BMI of 34, type 2 diabetes on 500 units of insulin, and retinopathy might be considered an ideal patient for bariatric surgery, but a 64-year-old woman with a BMI of 70 and sleep apnoea who chain smokes in front of the TV all day may be prioritised to access surgery first. Both may be considered deserving cases; the former has more to gain as a matter of urgency but falls outside National Institute for Health and Care Excellence (NICE) guidelines whereas the latter case might benefit from smoking cessation and optimised psychosocial care while falling within the guidelines.
Drugs Drug management of weight is becoming increasingly problematic: more agents are being withdrawn than authorised, leaving clinicians without options where options are needed. Orlistat, either on prescription as Xenical, or over the counter as Alli, is the one remaining agent, allowing 30% of ingested fat to be passed unabsorbed through the gut (Guerciolini, 1997). It is moderately successful but often fraught with side effects of flatulence and faecal leakage. Sibutramine and Rimonabant were popular and powerful weight-loss agents whose withdrawal could have been avoided. After its withdrawal, Sibutramine was shown to have the effect of reducing mortality in those who lost weight (Caterson et al, 2012). The US Food and Drug Administration has approved two new drugs recently: Lorcaserin (a moderately potent serotonin agonist) and Qsymia (a powerful combination of the epilepsy drug, topiramate, and phentermine) (Shyh and Cheng-Lai, 2014) European agencies turned them down in case they were used for reasons for which they were not intended.
A similar model exists at King’s College London whereby a series of parameters are assessed, including quality of life, employment, mental health and so on, with the success of obesity management being judged not merely by weight lost, but by how well each parameter improves because of the wider weight-management programme. This approach also ensures that no individual aspect is forgotten. In the same way that the management of type 2 diabetes is becoming less glucose-centric and increasingly targeting lifestyle measures, blood pressure and lipid profile weight management should consider holistic care of patients and individualisation of care. In the King’s Staging System, which is presented in alphabetical order as an aide memoire, obesity can be tracked by improvements in BMI, but equally important is the transition down the stages of, for example, ‘F’ for ‘function’, if a person had previously been housebound but, posttreatment, can be helped by a third party to get around outside, or to become self-sufficient. Diabetes may improve from being uncontrolled to controlled, or may even revert to impaired glucose tolerance.
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A further problem with drug management of obesity surrounds the metabolic syndrome—the clustering together of obesity with other cardiometabolic risk factors such as dysglycaemia, dyslipidaemia and hypertension. As all the disparate aspects of the syndrome fall under the same umbrella, treatment should target more than one facet, i.e. the management of one aspect should address or at least acknowledge the others. Unfortunately, the opposite is often true, which is a particular concern with traditional glucose-lowering agents, particularly sulphonylureas. Their widespread use as an add-on to metformin is because of their cost, but are a false economy, as their effect is shortlived, and they cause hypoglycaemia, which is increasingly recognised as being highly dangerous (UK Hypoglycemia Study Group, 2007) as well as damaging and demoralising weight gain. Insulin too, has hypoglycaemia and considerable weight gain associated with its use, and pioglitazone (Phung et al, 2010) causes weight gain alongside worsening of heart failure and fractures. Once again, individualisation of care is essential, and anyone with type 2 diabetes who has excess weight should, instead, be considered for a modern agent such
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Metabolic syndrome King’s Obesity Staging System
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CLINICAL FOCUS
With permission of A. Sharma
2
Figure 1. The Edmonton Obesity Staging System.
as a gliptin, a sodium-glucose co-transporter 2 (SGLT-2) inhibitor or an injectable glucagon-like peptide 1 (GLP-1) agonist, all of which should be initiated in primary care and are weight-neutral (gliptins) or induce considerable weight loss (SGLT-2s and GLP-1s). Unfortunately, drugs to manage other aspects of the metabolic syndrome tend to adversely affect the rest. Statins and niacin increase HbA1c, B-blockers and thiazides adversely affect glycaemic control, weight loss agents have had a tendency to increase pulse and blood pressure. Although general guidelines can be useful, drug combinations should be bespoke for each patient. Telmisartan (Pershadsingh and Kurtz, 2004), for instance, has a unique effect on improving insulin sensitivity and should arguably be considered as an antihypertensive of choice in insulin-resistant individuals. Bariatric surgery (operations intended to induce weight loss such as the Roux-en-Y gastric bypass) are highly effective and costeffective procedures, readily available on the NHS.
© 2014 MA Healthcare Ltd
Individualisation of care: the obesity paradox Evidence is emerging that although obesity may be a determinant for conditions such as heart failure, other cardiovascular diseases and renal failure, once the disease has occurred, excess weight may become a protective factor against mortality. The discomfort surrounding this concept has been well described by Katsnelson and Rundek (2011) as follows:
occurrence of a vascular clinical event is both surreal and troubling’. Obesity is a risk factor for heart failure. It is known that increased BMI is a determinant for heart failure: a Framingham 14-year follow-up study of 5881 participants found a graded increased risk of heart failure with increasing BMI. For every 1 unit increase in BMI, the risk of heart failure increased by 5% in men and 7% in women (Kenchaiah et al, 2002). It is known that weight loss reduces cardiometabolic risk factors: weight loss is associated with beneficial changes in cardiovascular structure and function. There is a decrease in left ventricular mass, improvement in diastolic and systolic function, and a decrease in vascular hypertrophy in patients who attain modest weight loss. In one study, authors observed that, even though maximal weight loss occurred at 6 months, maximal cardiovascular benefits
LEARNING POINTS w Obesity management in an individual depends upon their own unique characteristics and syptoms; individualisation of care is crucial
w Arguably the most important part of the obesity management programme is the initial identification, engagement and screening of patients
w The obesity paradox suggests that although obesity may be a risk factor for conditions such as heart failure, once the condition exists, it may be a protective factor
‘The idea that a known risk factor somehow transforms into a “protective” agent after an
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occurred much later and usually lagged maximal weight loss by 3–12 months. Any weight regain after the weight loss led to reversal of improvements in cardiovascular markers (Wing et al, 2011). In an observational analysis of the Look Action For Health in Diabetes (Look AHEAD) trial, it was observed that even a modest weight loss of 5–10% can produce clinically relevant improvements in cardiovascular risk factors, glycaemic control, blood pressure, high-density lipoprotein and triglycerides (de las Fuentes et al, 2009). Yet a meta-analysis of 28 209 heart-failure recruits demonstrated that obese patients had reduction in cardiovascular mortality of 40% and all-cause mortality of 33% (Oreopoulos et al, 2008). Furthermore, with regard to renal disease, obesity is a risk factor for end-stage renal failure, but may improve outcomes, with some reports suggesting a paradoxical association with obesity and improved survival (Kalantar-Zadeh et al, 2005). In a study of 12 000 veterans by McAuley et al (2010), underweight men with low fitness suffered the highest mortality, and highly fit overweight men the lowest of any subgroup. Overweight and obese men with moderate fitness had mortality rates similar to those of a highly fit normal-weight reference group. Possible explanations are as follows: w It may be that fat does actually exert a protective influence in certain conditions through an unknown mechanism possibly through improved metabolic reserve w Obesity might lead individuals becoming identified earlier as high-risk individuals, allowing the protective influence of statins and antihypertensive agents to have been present for longer prediagnosis w Obese individuals who had heart failure ‘thrust upon them’ through weight gain are naturally less susceptible to the disease, and therefore equally naturally less prone to poor prognosis, and might not have developed the condition had they stayed lean w Lower weight might be smoking-related, or due to intercurrent illness w BMI is used inappropriately as a measure of body morphology, although the latter two have been adjusted for in recent studies.
Conclusion Obesity management means more than a mere reduction in kilograms. Individualisation of care is crucial for deciding whether weight loss is appropriate, for whom it is a desired outcome, and what method should be used for each individual. Identification, engagement, screening and treatment are dependent on many different features and phenotypes which affect success or failure in any given patient. BJCN American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th edn. American Psychiatric, Arlington, VA Arita Y, Kihara S, Ouchi N (1999) Paradoxical decrease of an adipose-specific protein, adiponectin, in obesity. Biochem Biophys Res Commun 257(1): 79–83 Bowling A, Ebrahim S (2001) Measuring patients’ preferences for treatment and perceptions of risk. Qual Health Care 10(Suppl. 1): 12–18
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Caterson ID, Finer N, Coutinho W et al; SCOUT Investigators (2012) Maintained intentional weight loss reduces cardiovascular outcomes: results from the Sibutramine Cardiovascular OUTcomes (SCOUT) trial. Diabetes Obes Metab 14(6): 523–30. doi:10.1111/j.1463-1326.2011.01554.x Chaowalit N, Somers VK, Pellikka PA, Rihal CS, Lopez-Jimenez F (2006) Subepicardial adipose tissue and the presence and severity of coronary artery disease. Atherosclerosis 186(2): 354–9 Counterweight Project Team (2008) Evaluation of the Counterweight Programme for obesity management in primary care: a starting point for continuous improvement. Br J Gen Pract 58(553): 548–54 de las Fuentes L, Waggoner AD, Mohammed BS et al (2009) Effect of moderate diet-induced weight loss and weight regain on cardiovascular structure and function. J Am Coll Cardiol 54: 2376–81 Gardner CD, Kiazand A, Alhassan S et al (2007) Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study—a randomized trial. JAMA 297(9): 969–77 Guerciolini R (1997) Mode of action of orlistat. Int J Obes 21(Suppl. 3): S12–23 Haslam DW, James PT (2005) Obesity. Lancet 366(9492): 1197–209 Hill JO, Peters JC, Wyatt HR (2007) The role of public policy in treating the epidemic of global obesity. Clin Pharmacol Ther 81(5): 772–5 Kalantar-Zadeh K, Abbott KC, Salahudeen AK, Kilpatrick RD, Horwich TB (2005) Survival advantages of obesity in dialysis patients. Am J Clin Nutr 81: 543–54 Katsnelson M, Rundek T (2011) Obesity paradox and stroke: noticing the (fat) man behind the curtain. Stroke 42: 3331–2 Kenchaiah S, Evans JC, Levy D et al (2002) Obesity and the risk of heart failure. N Engl J Med 347(5): 305–13 Knowler WC, Barrett-Connor E, Fowler SE et al; Diabetes Prevention Program Research Group (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346(6): 393–403 Kojima S, Funahashi T, Maruyoshi H et al (2005) Levels of the adipocyte derive plasma protein, adiponectin, have a close relationship with atheroma. Thromb Res 115(6): 483–90 Lindström J, Louheranta A, Mannelin M et al; Finnish Diabetes Prevention Study Group (2003) The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 26: 3230–6 Look AHEAD Research Group (2013) Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 369(2):145–54 Luijks HD, Loeffen MJ, Lagro-Janssen AL, van Weel C, Lucassen PL, Schermer TR (2012) GPs’ considerations in multimorbidity management: a qualitative study. Br J Gen Pract 62(600): e503–10. doi:10.3399/bjgp12X652373 McAuley PA, Kokkinos PF, Oliveira RB, Emerson BT, Myers JN (2010) Obesity paradox and cardiorespiratory fitness in 12,417 male veterans aged 40 to 70 years. Mayo Clin Proc 85(2): 115–121 Misra A, Khurana L (2011) Obesity-related non-communicable diseases: South Asians vs White Caucasians. Int J Obes 35: 167–87. doi:10.1038/ijo.2010.135 Nordmann AJ, Suter-Zimmermann K, Bucher HC et al (2011) Meta-analysis comparing Mediterranean to low-fat diets for modification of cardiovascular risk factors. Am J Med 124(9): 841–51. doi: 10.1016/j.amjmed.2011.04.024 Oreopoulos A, Padwal R, Kalantar-Zadeh K, Fonarow GC, Norris CM, McAlister FA (2008) Body mass index and mortality in heart failure: a metaanalysis. Am Heart J 156(1): 13-22 Pershadsingh HA, Kurtz TW (2004) Insulin-sensitizing effects of telmisartan: implications for treating insulin-resistant hypertension and cardiovascular disease. Diabetes Care 27(4): 27(4): 1015 Phung OJ, Scholle JM, Talwar M, Coleman CI (2010) Effect of noninsulin antidiabetic drugs added to metformin therapy on glycemic control, weight gain, and hypoglycemia in type 2 diabetes. 303(14): 1410–18. doi: 10.1001/ jama.2010.405 Shyh G, Cheng-Lai A (2014) New antiobesity agents: lorcaserin (Belviq) and phentermine/topiramate ER (Qsymia). Cardiol Rev 22(1): 43–50. doi: 10.1097/CRD.0000000000000001 UK Hypoglycemia Study Group (2007) Risk of hypoglycemia in types 1 and 2 diabetes: effects of treatment modalities and their duration. Diabetologia 50:1140–7 Wing RR, Lang W, Wadden TA et al (2011) Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes Care 34: 1481–6 Zamboni M, Mazzali G, Fantin F, Rossi A, Di Francesco V (2008) Sarcopenic obesity: a new category of obesity in the elderly. Nutr Metab Cardiovasc Dis 18(5): 388–95. doi: 10.1016/j.numecd.2007.10.002
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CLINICAL FOCUS
British Journal of Community Nursing March 2014 Vol 19, No 3
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Individualisation of care and the obesity paradox David Haslam
David Haslam is GP, Watton Place Clinic and Bariatric Physician, Luton University Hospital
Obesity management in the community setting Obesity management programmes begin the moment an obese person is encountered in a clinic or at home, whether they present with an obesity-related problem, a symptom irrelevant to their weight, or even if they are merely the accompanying parent, spouse or companion. The majority of the population presents to primary care clinicians for reasons as wide-ranging as minor injuries, flu jabs and anti-malarials—and the concept ‘make every contact count’ guides GPs and nurses toward seizing any opportunity in clinical situations to identify, engage and act to help the obese individual. The number of superobese people in the population is unknown since many
ABSTRACT
The obesity ‘paradox’ has recently been discussed based upon the observation that although obesity may be a major causative factor in certain conditions, its presence appears to be protective once that condition occurs. There is a growing body of persuasive evidence to support the obesity paradox in diseases including renal failure and heart failure. Recent evidence is reliable, adjusting more effectively for confounders such as smoking and intercurrent illness, which make lower weight an unhealthy state. The existence of the paradox highlights the fact that approaches to weight management are not as simple as inducing the loss of a few kilograms in overweight and obese individuals, and emphasises the importance of individualisation of care in obesity management taking into account age, ethnicity and comorbid illness. This article explores the individualisation of care in obesity, drawing attention to the obesity paradox in particular.
KEY WORDS
w Obesity paradox w Sarcopenia w Weight loss
110
are housebound and a community nurse might be the only point of contact.
Clinical experiences of obesity management The first minute of the obesity management programme is arguably the most difficult. Identification of the obese individual is done by first principles on clinical examination; anyone who looks as though they have a weight problem has a weight problem, regardless of the limitations of body mass index (BMI) in defining body morphology. Raising the topic of obesity and engaging the individual is a different matter. In order to raise the topic with a patient presenting with a sore throat, or on behalf of an accompanying adult, the question ‘am I looking after you properly?’ may act as a stimulus for measuring weight and initiating basic screening, while simultaneously deflecting ‘blame’ away from the individual, and onto the healthcare professional for neglecting to have instigated action earlier. An individual can be successfully engaged or, conversely, alienated depending on the success of these initial moments: very little can actually be achieved clinically in the last 2 minutes of an unrelated appointment, but as long as blood pressure and weight/BMI are measured, fasting blood tests are organised and follow-up is ensured, most patients will engage. BMI, although useful for public health or in research studies, is limited in usefulness when assessing an individual, as body morphology is more important— measures which demonstrate if a person possesses excess adipose tissue and, if so, where, are superior in defining a true risk. An athlete may be technically obese without an ounce of excess fat, whereas a ‘lean’ individual may have sarcopenia, and a pot belly and thus be at high risk. It is usually obvious when a patient is suffering from abdominal obesity from their appearance, and once visual identification has occurred, BMI is an acceptable way of monitoring progress, but measures such as waist circumference, waistto-hip ratio, and emerging measures such as body volume index and weight-to-height ratio are better. Bio-impedance analysis—available relatively cheaply on a specialised scale—goes one step further, directly assessing the amount of fat versus lean tissue a person is carrying. However, even this cannot assess whether abdominal obesity is benign subcutaneous fat or malign visceral adipose tissue. Magnetic resonance imaging (MRI) or more complex
© 2014 MA Healthcare Ltd
I
n every aspect of medicine (and especially with multimorbidity), individualisation of care and the concept of patient-centredness are crucial parts of management (Luijks et al, 2012). This management depends upon information gained from history-taking, examination, motivation, understanding, psychosocial circumstance and, indeed, patients’ preferences (Bowling and Ebrahim, 2001). In managing obesity, individualisation of care is as important as in any other field of medicine.
Email: [email protected]
British Journal of Community Nursing March 2014 Vol 19, No 3
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 2, 2015. For personal use only. No other uses without permission. . All rights res
CLINICAL FOCUS
measures are required for precision, but are inappropriate for routine practice. In identifying and engaging patients in this manner, otherwise anonymous, uninformed obese individuals may become motivated, not just regarding their weight, but about the possible comorbidities, such as diabetes, hypertension, mental health problems, fatty liver, or sleep apnoea. Someone identified as being obese, and found to have high blood pressure, sugar or abnormal lipids can be a success within a weight-management programme without losing any weight, since, if each of their disparate individual factors is treated, and behaviour improves, global risk will be reduced. Studies such as the Diabetes Prevention Program (Knowler et al, 2002), Diabetes Prevention Study (Lindström et al, 2003), and Counterweight (Counterweight Project Team, 2008) show that inducing significant weight reduction in the long term is difficult to induce, but the effects of seemingly minor weight loss are clinically impressive—a 58% reduction in the cumulative incidence of diabetes. The Look AHEAD study (Look AHEAD Research Group, 2013) recently demonstrated excellent weight loss—6% maintained at nearly 10 years—alongside significant reductions in cardiometabolic risk markers, but, because not enough people died in either control or intervention group to meet primary outcomes, the trial was stopped on the basis of ‘futility’.
Risks of obesity
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Abdominal fat deposited intracellularly can be considered as the body’s most prolific endocrine organ and its secretory products (cytokines such as interleukins 1 and 6 and tumour necrosis factor-α) induce insulin resistance. It also has a paracrine suppressive effect on the secretion of adiponectin (Kojima et al, 2005), a powerful insulin sensitiser (Arita et al, 1999) secreted in dwindling quantities as the adiposity increases (Haslam and James, 2005). Thus, the expanded adipocyte mass underpins inflammatory conditions such as type 2 diabetes and cardiovascular disease. Ectopic fat infiltrating pancreatic islet cells amplifies age-related decline in their capacity to maintain increased insulin output demanded by insulin resistance, so glucose intolerance and premature type 2 diabetes ensue. Subepicardial fat in the heart is linked to abdominal adiposity and associated with cardiovascular risk (Chaowalit et al, 2006). The risks of obesity are not limited to cardiometabolic sequelae and include hypercoagulability of the blood, obstructive sleep apnoea, joint and skin conditions and mental health disorders.
what causes obesity, and the answer is the obesigenic environment (Hill et al, 2007), particularly sugar and refined carbohydrates. This theory goes some way to explaining why diet and lifestyle changes are disappointing; weight is usually regained, in order to re-achieve the pre-ordained set point. In some cases, long-standing sustainable changes in macronutrient intake can induce long-term weight loss, but such individuals are the exception, not the rule. Many patients fare well on low-carbohydrate diets, which benefit from nutritious carbohydrates (fruit and vegetables) but not sugar, or refined ‘empty’ carbohydrates (bread, rice, pasta, potatoes and flour). Increasingly, the evidence for sustained weight loss and improvement in cardiometabolic risk supports the Mediterranean (Nordmann et al, 2011) and low-carbohydrate (Gardner et al, 2007) approaches above low-fat diets, although individuals may respond differently. A food diary is often revealing in these instances, while also unearthing individuals who graze, snack, comfort eat or indulge in emotional eating, as well as those suffering from eating disorders, now formally recognised by the latest update to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013) such as binge-eating disorder and night-eating syndrome. Weight reduction will prove impossible in many of these patients unless some form of psychological intervention is employed in order to discover the root cause of the eating behaviour and address it accordingly by stimulus control and alternative coping strategies. One of the author’s patients presented with hyperphagia; her history revealed that, as a child, she became bored with her hamsters. A friend, on being asked what she should do with them replied ‘you could eat them’, which she did! Simply ‘putting a patient on a diet’ is not sufficient in these circumstances. Some patients will be immediately motivated to change their lifestyle or behaviour, or accept drug or surgical treatment, others will respond differently, and the clinician’s approach should reflect that degree of motivation.
Risk factors Ethnicity Different ethnic groups will display varying levels of risk, and require different parameters for risk assessment. South Asians (Misra and Khurana, 2011), particularly immigrants to countries such as the UK, are more prone to abdominal obesity, and more susceptible to conditions such as type 2 diabetes at lower levels of obesity, so should be monitored more closely for diabetes and the metabolic syndrome.
Management of obesity
Age
A carefully taken clinical history may unearth the aetiology of a person’s weight problem. Modern theory is challenging the assumption that obesity is caused by excess food intake and insufficient physical activity (the energy-balance equation), instead suggesting that obesity occurs first, and that overeating and sedentariness are required to maintain the obese set point. There is therefore a question regarding
Elderly individuals tend to have a higher percentage of body fat at any given BMI than their younger counterparts, because of fat within muscles, or sarcopenia (Zamboni et al, 2008), often owing to reduction of physical activity due to joint pains, or retirement from sport or active work. In these circumstances, weight loss is often not an appropriate goal, but any form of physical activity should be enhanced.
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CLINICAL FOCUS Patient history Those individuals with a family history of diabetes, or who have had gestational diabetes, should be carefully monitored. Individuals who have undergone bariatric surgery represent a group who should be monitored extremely closely. A person with a BMI of 35 who formerly had a BMI of 55 prior to bariatric surgery is at much higher risk of cardiovascular disease and mortality than someone who has gradually achieved weight gain to a similar BMI. The ‘post-obese’ patient—who will benefit from permanent weight loss following bariatric surgery and will spend the rest of their lives under the care of the primary care team— must always be considered to be a high-risk individual, and remain on their appropriate disease registers (e.g. hypertension), even if their blood pressure returns to normal. They should remain on drugs such as metformin, or other drugs which do not induce hypoglycaemia, to reflect their higher risk.
Systems for individualising care Edmonton Obesity Staging System The Edmonton Obesity Staging System (EOSS) (Figure 1) is a means of individualising patient care on the basis of a person’s medical, social and psychological needs, rather than just their weight or BMI. An individual with any degree of obesity as measured by BMI, will be at stage 0 if they have no medical or psychosocial comorbidities, so treatment should arguably be prioritised to stage 4 patients who might only have a BMI of 30, but have severe associated problems such as type 2 diabetes with severe insulin resistance and microvascular complications such as retinopathy at an early age. In this model, there is also a suggestion that some patients require palliative care only, without any attempt at weight loss, as long as issues such as pain control and psychosocial needs are addressed.
These models are particularly relevant in an assessment for eligibility for bariatric surgery. A 34-year-old with a BMI of 34, type 2 diabetes on 500 units of insulin, and retinopathy might be considered an ideal patient for bariatric surgery, but a 64-year-old woman with a BMI of 70 and sleep apnoea who chain smokes in front of the TV all day may be prioritised to access surgery first. Both may be considered deserving cases; the former has more to gain as a matter of urgency but falls outside National Institute for Health and Care Excellence (NICE) guidelines whereas the latter case might benefit from smoking cessation and optimised psychosocial care while falling within the guidelines.
Drugs Drug management of weight is becoming increasingly problematic: more agents are being withdrawn than authorised, leaving clinicians without options where options are needed. Orlistat, either on prescription as Xenical, or over the counter as Alli, is the one remaining agent, allowing 30% of ingested fat to be passed unabsorbed through the gut (Guerciolini, 1997). It is moderately successful but often fraught with side effects of flatulence and faecal leakage. Sibutramine and Rimonabant were popular and powerful weight-loss agents whose withdrawal could have been avoided. After its withdrawal, Sibutramine was shown to have the effect of reducing mortality in those who lost weight (Caterson et al, 2012). The US Food and Drug Administration has approved two new drugs recently: Lorcaserin (a moderately potent serotonin agonist) and Qsymia (a powerful combination of the epilepsy drug, topiramate, and phentermine) (Shyh and Cheng-Lai, 2014) European agencies turned them down in case they were used for reasons for which they were not intended.
A similar model exists at King’s College London whereby a series of parameters are assessed, including quality of life, employment, mental health and so on, with the success of obesity management being judged not merely by weight lost, but by how well each parameter improves because of the wider weight-management programme. This approach also ensures that no individual aspect is forgotten. In the same way that the management of type 2 diabetes is becoming less glucose-centric and increasingly targeting lifestyle measures, blood pressure and lipid profile weight management should consider holistic care of patients and individualisation of care. In the King’s Staging System, which is presented in alphabetical order as an aide memoire, obesity can be tracked by improvements in BMI, but equally important is the transition down the stages of, for example, ‘F’ for ‘function’, if a person had previously been housebound but, posttreatment, can be helped by a third party to get around outside, or to become self-sufficient. Diabetes may improve from being uncontrolled to controlled, or may even revert to impaired glucose tolerance.
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A further problem with drug management of obesity surrounds the metabolic syndrome—the clustering together of obesity with other cardiometabolic risk factors such as dysglycaemia, dyslipidaemia and hypertension. As all the disparate aspects of the syndrome fall under the same umbrella, treatment should target more than one facet, i.e. the management of one aspect should address or at least acknowledge the others. Unfortunately, the opposite is often true, which is a particular concern with traditional glucose-lowering agents, particularly sulphonylureas. Their widespread use as an add-on to metformin is because of their cost, but are a false economy, as their effect is shortlived, and they cause hypoglycaemia, which is increasingly recognised as being highly dangerous (UK Hypoglycemia Study Group, 2007) as well as damaging and demoralising weight gain. Insulin too, has hypoglycaemia and considerable weight gain associated with its use, and pioglitazone (Phung et al, 2010) causes weight gain alongside worsening of heart failure and fractures. Once again, individualisation of care is essential, and anyone with type 2 diabetes who has excess weight should, instead, be considered for a modern agent such
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Metabolic syndrome King’s Obesity Staging System
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CLINICAL FOCUS
With permission of A. Sharma
2
Figure 1. The Edmonton Obesity Staging System.
as a gliptin, a sodium-glucose co-transporter 2 (SGLT-2) inhibitor or an injectable glucagon-like peptide 1 (GLP-1) agonist, all of which should be initiated in primary care and are weight-neutral (gliptins) or induce considerable weight loss (SGLT-2s and GLP-1s). Unfortunately, drugs to manage other aspects of the metabolic syndrome tend to adversely affect the rest. Statins and niacin increase HbA1c, B-blockers and thiazides adversely affect glycaemic control, weight loss agents have had a tendency to increase pulse and blood pressure. Although general guidelines can be useful, drug combinations should be bespoke for each patient. Telmisartan (Pershadsingh and Kurtz, 2004), for instance, has a unique effect on improving insulin sensitivity and should arguably be considered as an antihypertensive of choice in insulin-resistant individuals. Bariatric surgery (operations intended to induce weight loss such as the Roux-en-Y gastric bypass) are highly effective and costeffective procedures, readily available on the NHS.
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Individualisation of care: the obesity paradox Evidence is emerging that although obesity may be a determinant for conditions such as heart failure, other cardiovascular diseases and renal failure, once the disease has occurred, excess weight may become a protective factor against mortality. The discomfort surrounding this concept has been well described by Katsnelson and Rundek (2011) as follows:
occurrence of a vascular clinical event is both surreal and troubling’. Obesity is a risk factor for heart failure. It is known that increased BMI is a determinant for heart failure: a Framingham 14-year follow-up study of 5881 participants found a graded increased risk of heart failure with increasing BMI. For every 1 unit increase in BMI, the risk of heart failure increased by 5% in men and 7% in women (Kenchaiah et al, 2002). It is known that weight loss reduces cardiometabolic risk factors: weight loss is associated with beneficial changes in cardiovascular structure and function. There is a decrease in left ventricular mass, improvement in diastolic and systolic function, and a decrease in vascular hypertrophy in patients who attain modest weight loss. In one study, authors observed that, even though maximal weight loss occurred at 6 months, maximal cardiovascular benefits
LEARNING POINTS w Obesity management in an individual depends upon their own unique characteristics and syptoms; individualisation of care is crucial
w Arguably the most important part of the obesity management programme is the initial identification, engagement and screening of patients
w The obesity paradox suggests that although obesity may be a risk factor for conditions such as heart failure, once the condition exists, it may be a protective factor
‘The idea that a known risk factor somehow transforms into a “protective” agent after an
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occurred much later and usually lagged maximal weight loss by 3–12 months. Any weight regain after the weight loss led to reversal of improvements in cardiovascular markers (Wing et al, 2011). In an observational analysis of the Look Action For Health in Diabetes (Look AHEAD) trial, it was observed that even a modest weight loss of 5–10% can produce clinically relevant improvements in cardiovascular risk factors, glycaemic control, blood pressure, high-density lipoprotein and triglycerides (de las Fuentes et al, 2009). Yet a meta-analysis of 28 209 heart-failure recruits demonstrated that obese patients had reduction in cardiovascular mortality of 40% and all-cause mortality of 33% (Oreopoulos et al, 2008). Furthermore, with regard to renal disease, obesity is a risk factor for end-stage renal failure, but may improve outcomes, with some reports suggesting a paradoxical association with obesity and improved survival (Kalantar-Zadeh et al, 2005). In a study of 12 000 veterans by McAuley et al (2010), underweight men with low fitness suffered the highest mortality, and highly fit overweight men the lowest of any subgroup. Overweight and obese men with moderate fitness had mortality rates similar to those of a highly fit normal-weight reference group. Possible explanations are as follows: w It may be that fat does actually exert a protective influence in certain conditions through an unknown mechanism possibly through improved metabolic reserve w Obesity might lead individuals becoming identified earlier as high-risk individuals, allowing the protective influence of statins and antihypertensive agents to have been present for longer prediagnosis w Obese individuals who had heart failure ‘thrust upon them’ through weight gain are naturally less susceptible to the disease, and therefore equally naturally less prone to poor prognosis, and might not have developed the condition had they stayed lean w Lower weight might be smoking-related, or due to intercurrent illness w BMI is used inappropriately as a measure of body morphology, although the latter two have been adjusted for in recent studies.
Conclusion Obesity management means more than a mere reduction in kilograms. Individualisation of care is crucial for deciding whether weight loss is appropriate, for whom it is a desired outcome, and what method should be used for each individual. Identification, engagement, screening and treatment are dependent on many different features and phenotypes which affect success or failure in any given patient. BJCN American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th edn. American Psychiatric, Arlington, VA Arita Y, Kihara S, Ouchi N (1999) Paradoxical decrease of an adipose-specific protein, adiponectin, in obesity. Biochem Biophys Res Commun 257(1): 79–83 Bowling A, Ebrahim S (2001) Measuring patients’ preferences for treatment and perceptions of risk. Qual Health Care 10(Suppl. 1): 12–18
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Caterson ID, Finer N, Coutinho W et al; SCOUT Investigators (2012) Maintained intentional weight loss reduces cardiovascular outcomes: results from the Sibutramine Cardiovascular OUTcomes (SCOUT) trial. Diabetes Obes Metab 14(6): 523–30. doi:10.1111/j.1463-1326.2011.01554.x Chaowalit N, Somers VK, Pellikka PA, Rihal CS, Lopez-Jimenez F (2006) Subepicardial adipose tissue and the presence and severity of coronary artery disease. Atherosclerosis 186(2): 354–9 Counterweight Project Team (2008) Evaluation of the Counterweight Programme for obesity management in primary care: a starting point for continuous improvement. Br J Gen Pract 58(553): 548–54 de las Fuentes L, Waggoner AD, Mohammed BS et al (2009) Effect of moderate diet-induced weight loss and weight regain on cardiovascular structure and function. J Am Coll Cardiol 54: 2376–81 Gardner CD, Kiazand A, Alhassan S et al (2007) Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study—a randomized trial. JAMA 297(9): 969–77 Guerciolini R (1997) Mode of action of orlistat. Int J Obes 21(Suppl. 3): S12–23 Haslam DW, James PT (2005) Obesity. Lancet 366(9492): 1197–209 Hill JO, Peters JC, Wyatt HR (2007) The role of public policy in treating the epidemic of global obesity. Clin Pharmacol Ther 81(5): 772–5 Kalantar-Zadeh K, Abbott KC, Salahudeen AK, Kilpatrick RD, Horwich TB (2005) Survival advantages of obesity in dialysis patients. Am J Clin Nutr 81: 543–54 Katsnelson M, Rundek T (2011) Obesity paradox and stroke: noticing the (fat) man behind the curtain. Stroke 42: 3331–2 Kenchaiah S, Evans JC, Levy D et al (2002) Obesity and the risk of heart failure. N Engl J Med 347(5): 305–13 Knowler WC, Barrett-Connor E, Fowler SE et al; Diabetes Prevention Program Research Group (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346(6): 393–403 Kojima S, Funahashi T, Maruyoshi H et al (2005) Levels of the adipocyte derive plasma protein, adiponectin, have a close relationship with atheroma. Thromb Res 115(6): 483–90 Lindström J, Louheranta A, Mannelin M et al; Finnish Diabetes Prevention Study Group (2003) The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 26: 3230–6 Look AHEAD Research Group (2013) Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 369(2):145–54 Luijks HD, Loeffen MJ, Lagro-Janssen AL, van Weel C, Lucassen PL, Schermer TR (2012) GPs’ considerations in multimorbidity management: a qualitative study. Br J Gen Pract 62(600): e503–10. doi:10.3399/bjgp12X652373 McAuley PA, Kokkinos PF, Oliveira RB, Emerson BT, Myers JN (2010) Obesity paradox and cardiorespiratory fitness in 12,417 male veterans aged 40 to 70 years. Mayo Clin Proc 85(2): 115–121 Misra A, Khurana L (2011) Obesity-related non-communicable diseases: South Asians vs White Caucasians. Int J Obes 35: 167–87. doi:10.1038/ijo.2010.135 Nordmann AJ, Suter-Zimmermann K, Bucher HC et al (2011) Meta-analysis comparing Mediterranean to low-fat diets for modification of cardiovascular risk factors. Am J Med 124(9): 841–51. doi: 10.1016/j.amjmed.2011.04.024 Oreopoulos A, Padwal R, Kalantar-Zadeh K, Fonarow GC, Norris CM, McAlister FA (2008) Body mass index and mortality in heart failure: a metaanalysis. Am Heart J 156(1): 13-22 Pershadsingh HA, Kurtz TW (2004) Insulin-sensitizing effects of telmisartan: implications for treating insulin-resistant hypertension and cardiovascular disease. Diabetes Care 27(4): 27(4): 1015 Phung OJ, Scholle JM, Talwar M, Coleman CI (2010) Effect of noninsulin antidiabetic drugs added to metformin therapy on glycemic control, weight gain, and hypoglycemia in type 2 diabetes. 303(14): 1410–18. doi: 10.1001/ jama.2010.405 Shyh G, Cheng-Lai A (2014) New antiobesity agents: lorcaserin (Belviq) and phentermine/topiramate ER (Qsymia). Cardiol Rev 22(1): 43–50. doi: 10.1097/CRD.0000000000000001 UK Hypoglycemia Study Group (2007) Risk of hypoglycemia in types 1 and 2 diabetes: effects of treatment modalities and their duration. Diabetologia 50:1140–7 Wing RR, Lang W, Wadden TA et al (2011) Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes Care 34: 1481–6 Zamboni M, Mazzali G, Fantin F, Rossi A, Di Francesco V (2008) Sarcopenic obesity: a new category of obesity in the elderly. Nutr Metab Cardiovasc Dis 18(5): 388–95. doi: 10.1016/j.numecd.2007.10.002
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CLINICAL FOCUS
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