Obesity

Obesity is excessive body fat storage that can impair health. In 2008, 1.5 billion adults,
20years and older, were overweight [1]. The declaration of obesity as a chronic degenerative
disease signalled a new approach towards obesity. Obesity is no more just a major risk factor
to many chronic degenerative diseases but it is one just like hypertension or diabetes.
Nevertheless, obesity is preventable and reversible. Although there are different theories on
the causes of obesity, experts have not still agreed on one major cause. Prevention of obesity
is possible weather it was caused by nature (biological) or nurture (behaviour). It can be said
that obesity is nurture allowing nature to express itself, like an accident waiting to happen.
This article explores the development, different causes and the role of the pharmacist in the
prevention and reversal of obesity.

Objectives

1. To discuss the development and major causes of obesity.

2. To increase awareness on the health implications of obesity.

3. To explore the role of the pharmacist in the prevention and reversal of obesity.

A person is considered to be obese if he/she is so heavy that weight endangers his/her health.
[1]
Obesity is a growing problem in most developed countries. There are several facets to the
problem of obesity:

The prevention of obesity

The correction of obesity

The population-based approach

The individual approach.

Prevention is better than cure and easier. The population-based approach is very important
but the pharmacist will have to cope with the individual and so this will be the thrust of this
article.

What is obesity?

WHO recommends the use of both the Body Mass Index (BMI) and waist circumference to
assess overweight and obese individuals, as different health risks have been defined for
different combinations of these two measures.[2]

The Body Mass Index

In adults, the diagnosis of obesity is most commonly made using BMI levels. BMI is
calculated as weight in kilograms (kg) divided by height in metres squared (m2). As a general
rule, an ideal BMI is 20 to 25. Above this:[1]

A BMI of 25-29.9 kg/m2 is overweight.

1
 A BMI of 30-34.9 kg/m2 is obese (I).

A BMI of 35-39.9 kg/m2 is obese (II).

A BMI of 40 kg/m2 is obese (III) or morbidly obese meaning that weight is a real
and imminent threat to health.

There are a few exceptions that are worthy of note:

A person who is very muscular will have a great weight in muscles and bone to
support the muscles and so may have a high BMI without an excess of fat.
In the elderly, the lowest morbidity is in the group with a BMI of 25 to 30[3] rather
than 20 to 25.

Waist-hip ratio

An alternative measure of obesity is the waist-to-hip ratio (WHR). It indicates abdominal fat
and is a more accurate predictor for cardiovascular risk than BMI in different ethnic
populations, as well as being more valuable in those over 75 years old.[4] The upper limit for
acceptable is 0.90 in men and 0.85 in women.

Epidemiology

According to 2007 figures, about 24% of adults are obese and 61.6% are overweight
or obese.[5] This number rises with age, particularly between 35 and 64.
Obesity is also said to cause 18 million days lost from work due to illness each year.[7]

Several factors have now been shown to predict the development of obesity in
individuals, such as a family history of obesity, lifestyle, diet and socio-economic
factors.[8]

Genetic factors

The medical profession is traditionally sceptical about claims that obesity 'runs in the family'.
However, the recent mapping of the human genome, combined with evidence from single-
gene mutation cases and animal cross-breeding experiments, have identified a significant link
between genetic factors and obesity. Over 600 genes, markers and chromosomal regions have
now been identified.[9] It is emerging that obesity is the result of a complex
pathophysiological pathway involving many factors that control adipose tissue metabolism.
Cytokines, free fatty acids and insulin all play a part and genetic defects are likely to have a
significant effect on the fine balance of this process.[10]

Presentation

A patient may present directly asking for help.

Confrontation of the problem may arise opportunistically when the patient presents
for something else.
It may be a related problem for the patient with diabetes, coronary heart disease or
hypertension.

2
The following groups are particularly in need of help and advice:

Obesity treatment or advice should be offered to:

Patients with a BMI >30.

Patients with a BMI >28 and co-morbidities such as chronic obstructive pulmonary
disease (COPD) ischemic heart disease and diabetes.
Patients who are overweight and have diabetes, other severe risk factors or serious
disease.
Patients who appropriately self-refer.

Parents of families with more than one obese member. This group may need special
consideration and more intensive support.

Prevention advice should be offered to high-risk individuals, eg those with a family

history of obesity, smokers, people with learning disabilities, low income groups.

Assessment

History

Physical or psychological problems associated with obesity.

Ask: "Why do you want to lose weight?" The response may give an indication of
motivation.
Past medical history including history of dieting.

Social history including diet, exercise, occupation, smoking.

Family history including history of obesity, diabetes, heart disease.

Drugs that aggravate weight gain

Oral hypoglycaemic agents, especially sulphonylureas and thiazolidinediones

('glitazones')
Antidepressants including tricyclics, mirtazapine, monoamine oxidase inhibitors.

Anticonvulsants, particularly sodium valproate, gabapentin, vigabatrin.

Antipsychotics, especially the atypical antipsychotics amisulpride, aripiprazole,

clozapine, olanzapine, quetiapine, risperidone, and zotepine.
Corticosteroids

Oral contraceptives, hormone replacement therapy.

Beta-blockers.

Pizotifen.

Conditions that may affect weight [1]

3
 Hypothyroidism.
Cushing's syndrome.

Growth hormone deficiency.

Polycystic ovary syndrome.

Hypothalamic damage.

Genetic syndromes associated with hypogonadism.

Examination

Weight, height and BMI.

Blood pressure measurement - using appropriately sized cuff.

Waist circumference should be no more than 88 cm in women and 102 cm in men.

Bioelectrical impedance analysis gives a more accurate assessment of body fat and
lean tissue mass. This is usually unnecessary and the other measures can all be made
with simple equipment found in any surgery.

Investigations

Consider:[12]

Urinalysis - for glucose and protein.

Microalbuminuria screen - the value of this test is not limited to diabetics.[13]

U&E and LFTs.

Fasting blood glucose unless already known to be diabetic.

Fasting lipid profile.

In addition, a few other investigations may be required as indicated by history and

examination.

Hormone profile including sex hormones and cortisol. Hormonal causes of obesity are
rare and cortisol may be slightly elevated simply by obesity.
Thyroid Stimulating Hormone - hypothyroidism is a rare cause of obesity and does
not cause gross obesity.

Motivation for losing weight

Risks of obesity

The National Audit Office (NAO) report included a calculation of relative risks of other
diseases resulting from obesity. The risks are just averages and risks increase with increasing
obesity.

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 Relative increased risk of diseases in obesity
Disease Relative risk for women Relative risk for men
Type 2 diabetes 12.7 5.2
Hypertension 4.2 2.6
Myocardial infarction 3.2 1.5
Cancer of colon 2.7 3.0
Angina pectoris 1.8 1.8
Gall bladder disease 1.8 1.8
Ovarian cancer 1.7 N/A
Osteoarthritis 1.4 1.9
Stroke 1.3 1.3

Obesity is an important risk factor in the development of chronic respiratory disorders such as
COPD, asthma, obstructive sleep apnoea and obesity hypoventilation syndrome.[14]

Obesity increases the risk of breast cancer[15] and carcinoma of the endometrium. Polycystic
ovary disease is usually a disease of the obese. Obesity impairs fertility, especially in the
female. Obesity may account for as much as 65% of type 2 diabetes.[16]

By the end of the assessment, you should have an idea of:[5]

The degree of the problem
Any underlying physical contributing factors (medical problems, medication)

Co-morbidities

Risk of developing complications

Lifestyle in terms of exercise and diet

Person's feelings about being overweight

Person's willingness and motivation to try to lose weight

Management

There is no quick fix. The World Health Organisation sees obesity as a chronic disease.
Management is not simply helping to shed some unwanted weight but a long-term approach
to change attitude, habits and values for the rest of that person's life.

General points

The majority of obese patients can be managed successfully by the Primary Health
Care team with only a very few requiring referral for specialist help.[1]
The following should be included in a plan of action:[12]

o Identify the causes that have made the person obese. There are probably
several contributory factors.

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 o Reiterate why the patient wants to lose weight to emphasise potential benefits
and incentives and perhaps to ascertain the degree of motivation.
o Examine what can be done to facilitate weight loss (eg exercise programme).

o Set realistic targets for rate of loss of weight and desired end point. For a
person who has a BMI above 35, the aim of a BMI of less than 25 is probably
unrealistic.

Overview of management of different categories of obesity[1]

Overweight
o Low waist circumference (<80 cm in women, <90 cm in men) - general advice
on weight and lifestyle.
o High waist circumference - structured advice regarding diet and exercise.

o Co-morbidities - structured advice on diet and activity; consider drug

treatment after evaluating effect of lifestyle changes.
Obese (I)

o No co-morbidities - structured advice regarding diet and exercise.

o Co-morbidities - structured advice on diet and activity; consider drug

treatment after evaluating effect of lifestyle changes.
Obese (II)

o No co-morbidities - structured advice on diet and activity; consider drug

treatment after evaluating effect of lifestyle changes.
o Co-morbidities - structured advice on diet and activity; consider drug
treatment after evaluating effect of lifestyle changes. Consider referring for
surgery (follow local protocol).
Obese (III)

o Structured advice on diet and activity. If available, may need to be via a

specialised weight management programme.
o Consider starting drug treatment after evaluation of lifestyle changes.

o Consider referring for surgery (follow local protocol).

Diet and exercise

Aim for both dietary modification and the initiation of exercise. Losing weight without
exercise is very difficult. This is one reason for early intervention, before exercise is severely
limited by morbid obesity, coronary heart disease, severe COPD, severe osteoarthritis or
other such diseases that prevent physical exertion. The initial aim should be towards a daily
500 Kcal deficit of energy requirements through change in dietary habits and exercise.[8]

6
Diet

Diet and cognition - the first problem may be to convince the patient that he is eating too
much. It is important to explain to the patient that the equation about calories in and calories
out has no exception. It may be helpful to ask the patient to keep a food diary, including all
snacks and drinks taken.

Dietary advice - there are many different approaches to dieting; be flexible to find the one
that suits the individual.[17] There may be occasions where there is benefit in referral to a
dietician or the pharmacy may have diet sheets to hand out.

Exercise

Value of exercise - this is more than just the calories expended in the session. It tends to
increase basal metabolic rate and, after vigorous exercise, metabolism is stimulated for the
next 36 hours. It also helps people to feel good about themselves.

Realistic expectations - people who are obese may have done no exercise for many years. It
is important to discuss the options to find something appropriate and sustainable. It must also
be something that the individual will enjoy or he will not persevere. An overambitious
programme is doomed to failure. An inadequate programme will confer no benefit.

Expert advice - this is that patients should be encouraged to take 30 to 40 minutes of

sustained exercise at least 5 times per week[18] and introduce more exercise into their daily
routine.

Drug management

General points

Drugs have a limited role in the management of obesity. Their use is governed by
strict criteria which should be met before medication is prescribed.[1]
Anti-obesity drugs should only be considered after diet, behavioural changes and
exercise have been tried and evaluated. If the patient's weight has reached a plateau
despite these measures, drug treatment may be considered.
The choice of drug should be made after discussing with the patient the risks and
benefits, mode of action, monitoring requirements, and possible impact on the
patient's motivation. Information and support on dietary, exercise and behavioural
changes should be maintained.
Drug treatment may be used to maintain weight loss, rather than continue to lose
weight.
Vitamin and mineral supplements should be considered, particularly for vulnerable
groups like the elderly and growing adolescents.
Type 2 diabetics may lose weight at a slower rate and appropriate allowance should be
made.
Regular review of adverse effects and to reinforce lifestyle advice is important.
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 People being withdrawn from drugs should be offered support because it is at this
time that their self-confidence and belief in their ability to make changes may be low.

Orlistat[19]

Action - orlistat is a lipase inhibitor which acts by reducing the absorption of dietary
fat. About 30% of the fat that would otherwise be absorbed passes straight through to
the large bowel.[12]
Effectiveness[12][20] - this drug has a good pharmaco-economic profile.[21] Clinical trials
suggest a moderate weight loss compared to placebo - about 2-5 kg over a year. There
is also a small but significant reduction in total cholesterol, the ratio of total
cholesterol to high-density lipids, and systolic and diastolic blood pressure. Most
patients gain weight after stopping treatment but trials suggest it takes three years to
gain weight lost in one year on the drug.
Indications - individuals aged between 18 and 75[1] with a BMI of 28 kg/m2 or more
in the presence of significant co-morbidities (eg type 2 diabetes, high blood pressure,
hyperlipidaemia) OR a BMI of 30 kg/m2 or more with no associated co-morbidities.
These individuals should be on a mildly hypocaloric, low-fat diet.

Sibutramine (withdrawn)

Action - this is a centrally-acting serotonin and noradrenaline reuptake inhibitor

which has the effect of promoting satiety and increasing energy expenditure.[26] Its use
has been suspended in the UK amid fears it increases the risk of heart attacks and
strokes.[27]

Rimonabant[28][29][30]

Rimonabant was a selective cannabinoid 1 (CB1) receptor antagonist which has now had its
marketing suspended. The European Medicines Agency completed a review of rimonabant
(Acomplia, a treatment for obesity) after concerns about its psychiatric safety - the benefits
of rimonabant do not outweigh the risks of psychiatric reactions in clinical use.

Surgery

Bariatric Surgery

Bariatric surgery (weight-loss surgery) includes a variety of procedures performed on

people who are obese. Weight loss is achieved by reducing the size of the stomach with a
gastric band or through removal of a portion of the stomach (sleeve gastrectomy or
biliopancreatic diversion with duodenal switch) or by resecting and re-routing the small
intestines to a small stomach pouch (gastric bypass surgery).

Herbal or complementary therapies

A number of such therapies has been put forward as remedies to the problem and may be very
attractive to prospective customers. However, the evidence base for these treatments is really
not there.[31]

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Psychological aspects

Consider cognitive and behavioural therapy to assist in behaviour modification, ie help the
patient to identify the wrong attitudes and actions in their lives, understand why they are
wrong and need to be rectified, identify correct responses and to implement them. There may
be "comfort eating" or even clinical depression that needs treatment.[1]

Follow-up

As with any chronic disease, follow-up must be arranged. This implies interest in the patient's
progress. A fortnight to a month would be appropriate at first, with intervals getting longer
with time but treat it as a chronic disease. The practice may have a nurse-run weight control
clinic. The achievement of a target weight is not the end of the process. Obesity is a chronic
disease and needs to be managed throughout the person's life as relapse is common. "Yo-yo
dieting" with weight going up and down is undesirable and unhealthy.

Referral[1]

Consider secondary care referral if:

There are underlying causes which need investigating

There are complex co-morbidities

If conventional treatment has failed in primary care

If specialist interventions may be needed (eg very low calorie diet)

The Future [5]

The problem of obesity needs to be addressed through a broad range of measures covering
different aspects contributing to it.
We have focused on the management of obese individuals but the future lies in the
management of an obese society and, more particularly, in curbing and perhaps reversing the
growing trend.

In Summary

The pharmacists' medication knowledge adds a unique perspective to obesity management.

When counselling individuals interested in weight loss, the pharmacist should perform a
review of current medications. The pharmacist may identify medication-related causes for
weight gain. Also, pharmacists can play a supportive role in helping consumers choose safe
and appropriate weight-loss supplements. The final ruling on dietary supplements requires
that companies adhere to strict guidelines for manufacturing, packaging, labelling, and
storing of products, as well as identification of all ingredients, plus purity, strength, and
composition. In addition, the pharmacist may refer patients to their physicians for diagnosis
of an underlying medical disorder responsible for weight gain. As members of the health care
team, pharmacists should embrace, participate in, and support lifestyle measures such as a
healthy diet, portion control, and exercise for personal maintenance of a healthy weight.

References
9
1. Obesity, Clinical Knowledge Summaries (2008)
2. NHS - The Information Centre; Health Survey for England 2007.
3. Kamel HK & Morley JE in Oxford Textbook of Geriatric Medicine, eds Grimley
Evans et al. 2nd ed OUP 2000. page 163
4. Price GM, Uauy R, Breeze E, et al; Weight, shape, and mortality risk in older persons:
elevated waist-hip ratio, not high body mass index, is associated with a greater risk of
death. Am J Clin Nutr. 2006 Aug;84(2):449-60. [abstract]
5. Department of Health; Obesity (updated June 2009); many links to relevant articles
and sites.
6. Haslam D, Sattar N, Lean M; ABC of obesity. Obesity--time to wake up. BMJ. 2006
Sep 23;333(7569):640-2.
7. National Obesity Forum; Portal for information on obesity.
8. SIGN Guideline 8.Obesity in Scotland. Integrating prevention with weight
management (November 1996).
9. Perusse L, Rankinen T, Zuberi A, et al; The human obesity gene map: the 2004
update.; Obes Res. 2005 Mar;13(3):381-490. [abstract]
10. Roth J, Qiang X, Marban SL, et al; The obesity pandemic: where have we been and
where are we going?; Obes Res. 2004 Nov;12 Suppl 2:88S-101S. [abstract]
11. National Obesity Forum; Portal for information on obesity.
12. Obesity, NICE Clinical Guideline (2006); Obesity: the prevention, identification,
assessment and management of overweight and obesity in adults and children
13. Lambers Heerspink HJ, Brinkman JW, Bakker SJ, et al; Update on microalbuminuria
as a biomarker in renal and cardiovascular disease. Curr Opin Nephrol Hypertens.
2006 Nov;15(6):631-6. [abstract]
14. Poulain M, Doucet M, Major GC, et al; The effect of obesity on chronic respiratory
diseases: pathophysiology and therapeutic strategies. CMAJ. 2006 Apr
25;174(9):1293-9. [abstract]
15. Chun J, El-Tamer M, Joseph KA, et al; Predictors of breast cancer development in a
high-risk population. Am J Surg. 2006 Oct;192(4):474-7. [abstract]
16. Bray GA; Medical consequences of obesity. J Clin Endocrinol Metab. 2004
Jun;89(6):2583-9. [abstract]
17. NNUH Nutrition & Dietics; "Dietary Tips to Help You with Your Weight Loss"
18. At least five a week: Evidence on the impact of physical activity and its relationship
to health, Dept of Health, 2004
19. Summary of Product Characteristics (SPC) - Xenical 120 mg hard capsules
(orlistat), Roche Products Limited, electronic Medicines Compendium. Last updated
July 2008

10
20. O'Meara S, Riemsma R, Shirran L, et al; A systematic review of the clinical
effectiveness of orlistat used for the management of obesity.; Obes Rev. 2004
Feb;5(1):51-68. [abstract]
21. Iannazzo S, Zaniolo O, Pradelli L; Economic evaluation of treatment with orlistat in
Italian obese patients. Curr Med Res Opin. 2008 Jan;24(1):63-74. [abstract]
22. Practice Guidance: OTC Orlistat, Royal Pharmaceutical Society of Great Britain
(2009)
23. Filippatos TD, Derdemezis CS, Gazi IF, et al; Orlistat-associated adverse effects and
drug interactions: a critical review. Drug Saf. 2008;31(1):53-65. [abstract]
24. Zhi J, Moore R, Kanitra L, et al; Effects of orlistat, a lipase inhibitor, on the
pharmacokinetics of three highly lipophilic drugs (amiodarone, fluoxetine, and
simvastatin) in healthy volunteers. J Clin Pharmacol. 2003 Apr;43(4):428-35.
[abstract]
25. Kim DH, Lee EH, Hwang JC, et al; A case of acute cholestatic hepatitis associated
with Orlistat. Taehan Kan Hakhoe Chi. 2002 Sep;8(3):317-20. [abstract]
26. O'Meara S, Riemsma R, Shirran L, et al; The clinical effectiveness and cost-
effectiveness of sibutramine in the management of obesity: a technology assessment.
Health Technol Assess. 2002;6(6):1-97.
27. Sibutramine: Suspension of marketing authorisation as risks outweigh benefits,
Medicines and Healthcare products Regulatory Agency (MHRA), Jan 2010
28. Rimonabant for the treatment of overweight and obese patients; NICE Final appraisal
determination March 2008
29. Obesity - rimonabant, NICE Technology Appraisal Guidance (June 2008);
Rimonabant for the treatment of overweight and obese patients
30. Europe wide suspension of Marketing Authorisation for Acomplia (rimonabant),
Medicines and Healthcare products Regulatory Agency (MHRA), Oct 2008
31. Cho SH, Lee JS, Thabane L, et al; Acupuncture for obesity: a systematic review and
meta-analysis. Int J Obes (Lond). 2009 Feb;33(2):183-96. Epub 2009 Jan 13.
[abstract]

11
Multiple Choice Questions

1. Body Mass Index (BMI)

a. Is used to diagnose obesity in adults and children.

b. Is calculated as weight in kilograms (kg) divided by height in metres squared (m2).
c. Is most ideal between 25-29.9 kg/m2 in an individual.
d. BMI of 30 kg/m2 is obese (III) or morbidly obese meaning that weight is a real
and imminent threat to health.
2. Which of the following statements is FALSE?
a. Drugs have a limited role in the management of obesity.
b. Oral contraceptives, hormone replacement therapy aggravate weight gain.
c. Obesity runs in the family.
d. Management of obesity is simply helping to shed some unwanted weight and is not
necessarily a long-term approach to change attitude, habits and values for the rest
of that patient's life.
3. The following drugs can aggravate weight gain except:
a. Propranolol
b. Prednisolone
c. Metformin
d. Amitriptyline
4. 4. Consideration of secondary care referral for obesity is necessary if:
a. There are underlying causes which need investigating
b. There are complex co-morbidities
c. Conventional treatment has failed in primary care
d. All of the above
5. 5. Concerning drug management in obesity, which of the following is INCORRECT?
a. Anti-obesity drugs should only be considered after diet; behavioural changes and
exercise have been tried and evaluated.
b. Drug treatment may be used to maintain weight loss, rather than continue to lose
weight.
12
 c. Vitamin and mineral supplements are not necessary for vulnerable groups like the
elderly and growing adolescents.
d. Type 2 diabetics may lose weight at a slower rate and appropriate allowance should
be made.
6. Waist-Hip Ratio (WHR)
a. Indicates abdominal fat only in an individual.
b. WHR is a less accurate predictor for cardiovascular risk than BMI in different
ethnic populations.
c. Has an acceptable upper limit of 0.85 in men and 0.90 in women.
d. Is recommended together with BMI, by the WHO to assess overweight and obese
individuals.
7. Primary care obesity management includes all the following except:
a. Bariatric surgery
b. Diet and exercise
c. Drug therapy
d. Patient counselling
8. Concerning diet and exercise:
a. Losing weight without exercise is the only method of weight loss for morbidly
obese patients.
b. Exercise tends to increase basal metabolic rate and, after vigorous exercise,
metabolism is stimulated for the next 36 hours.
c. Patients should be encouraged to take 30 to 40 minutes of sustained exercise at
least 5 times per day.
d. The first step is to convince the patient that he/she is eating too much.
9. The following should NOT be included in a plan of action for management of an
obese patient:
a. Identify the causes that have made the person obese. There are probably several
contributory factors.
b. Reiterate why the patient wants to lose weight to emphasise potential benefits and
incentives and perhaps to ascertain the degree of motivation.
c. Examine what can be done to facilitate weight loss (eg exercise programme).
d. Set very high targets for rate of loss of weight and desired end point. For a person
who has a BMI above 35, the aim of a BMI of less than 25 is optimum.
10. Which of the following statements is INCORRECT?
13
a. Herbal or complementary therapies for obesity are heresy
b. Bariatric surgery for weight loss should be the last resort in the management of
morbid obesity.
c. Sibutramine use has been suspended due to its increase in probability of heart
attacks and stroke.
d. Obesity is an important risk factor in the development of chronic respiratory
disorders such as COPD, asthma, obstructive sleep apnoea and obesity
hypoventilation syndrome.

14