YOR/800/038494.

A Clinical Case Study: Obesity

National Proect !ar"in# Sc$edule %or &ritten Sub'ission (le'ent o%
Su''ati)e Assess'ent. *eneral Practice +ocational ,rainin#.
A Clinical Case
Study: Obesity
*P Re#istrar. YOR/800/038494
Introduction.
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YOR/800/038494. A Clinical Case Study: Obesity
The case study I have chosen to work on for my project is quite
unique. This young girl sufers from obesity, an increasing burden to
the Nations health and budget. I was in the unusual position of
being the !ouse "#cer when she was admitted for specialist
obesity surgery. $hen I started in my %eneral &ractice 'egistrar job,
I found out she was a patient at our practice. !aving been involved
in her care in hospital, I can now e(plore her care in the community
and how a knowledge of obesity and its treatment is important for
%&s.
Case Study.
Background
SM is a 28 year old patient at the practice where I undertook my
frst GPR attachment. She has sufered from oesity prolems since
childhood. !er oesity is thou"ht to e secondary to
pituitary#hypothalamic dysfunction.
She was frst shunted for hydrocephalus in infancy. She has also had
craniotomy and draina"e of arachnoid cyst in $%%&. She has
sufered se'eral episodes of headache( for which she was
thorou"hly in'esti"ated. !owe'er( no shunt dysfunction was pro'en.
)his comple* prolem was mana"ed y neurosur"eon and
endocrinolo"ists at one of the )eachin" !ospitals in the re"ion. +s a
result of her endocrine dysfunction she was( for a time treated with
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YOR/800/038494. A Clinical Case Study: Obesity
hormone replacement therapy and "rowth hormone. She also had
eha'ioral prolems in the past( interestin"ly ha'in" kleptomania.
The Surgery
,ith respect to her oesity( the most recent treatment has een
sur"ery from a specialist oesity sur"eon at the re"ional )eachin"
!ospital. )his in'ol'ed a Rou*-en-. loop "astroplasty. )his is a
comination of a restricti'e procedure and intestinal ypass( in
efect creatin" decreased asorption of calories. )he sur"eon
'olunteers that this particular form of sur"ery has a /pro'en track-
record0 with /predictale and durale wei"ht loss with restriction of
symptomatic co-moridity and hypertensi'e disease to"ether with a
rapid reduction in cardio'ascular risk factors0.
21
She was admitted in 2uly 2332 and spent $1 days reco'erin"( with
some time on Sur"ical !i"h 4ependency. Prior to this she was
admitted to a day unit for a thorou"h metaolic and endocrine
profle and cardiopulmonary testin". )hese showed no correctale
disturance and that she was ft for sur"ery. She reco'ered well
post-operati'ely. She has had a minor wound infection( ut
continues to do well.
Where It All Began
5ookin" throu"h her notes( the frst contact aout her oesity was
with the endocrinolo"ists in her youth. Many strate"ies ha'e een
tried( usually with poor results or reound wei"ht "ain.
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YOR/800/038494. A Clinical Case Study: Obesity
In the early $%%36s she was placed on calorie-restricted diets( ut
still "ained wei"ht. She kept wei"ht charts( ut still "ained. )his
cycle continued throu"hout the early %36s. 7'en with controlled
dietin" intake and ad'ice she failed to lose wei"ht and still "ained.
)hrou"hout her "ain( she continued to ha'e prolems wither her
hydrocephalus( re8uirin" fre8uent contact with the neurosur"eons.
!er wei"ht was re"ularly recorded on our computer system. 9arious
methods were discussed with her for e*ample e*ercise pro"rammes
and health eatin".
In 2333 she tried orlistat and e"an to respond( steadily losin"
wei"ht. !owe'er( she was intolerant of the ad'erse efects and
discontinued treatment. She was referred to an endocrinolo"ist at
the local hospital. !ere :uo*etine was used to reduce appetite( ut
she still seemed to "ain. She was placed on the waitin" list in 233$(
still "ainin" wei"ht. ,e had fre8uent contact in this year( many with
wei"ht-related co-moridities. She was started on siutramine and
has a promisin" initial response. ;nfortunately she had to stop
usin" it in 2332 ecause she was consistently hypertensi'e.
It was at this point in her life( when admitted under the care of the
sur"eons( I "ot to know her.
Where Are We Now?
I ha'e had infre8uent contact since ut did see her in <o'emer for
some follow-up. She has now reduced her wei"ht to $=st %l >?MI
1$@ from 22st &l >?MI AA@( a 8uite astonishin" wei"ht loss. She
fre8uently swims and is less self-conscious aout her ody ima"e.
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YOR/800/038494. A Clinical Case Study: Obesity
She fnds re"ular attendance at the support "roup 'ital. She feels
she has more ener"y and her life ack. She thinks the operation
was 'ery painful( ut defnitely worth it. She has much hope for the
future and hopes to lose until reachin" appro*imately $2 stones.
She has noticed there are certain foods she can6t eat. She stru""led
with 'omitin" after the operation( due to consumin" too much
'olume. She feels less interested in food now. She isn6t tempted to
in"e eat and feels she now has will-power to a'oid this. If she eats
too much su"ar( she sufers from "astrointestinal dumpin". )akin"
all of this into account( she still thinks this is the est thin" she has
e'er done and is lookin" forward to the future.
Ais O! The "ro#ect.
)uestions I hope to answer are*
$hat treatments are there for obesity+
!ow has this patient been managed+
,oes this case-study teach me any lessons for future
management of obese patients in my career as a %&+
$ethodology I %sed.
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YOR/800/038494. A Clinical Case Study: Obesity
I searched the ./0 for any references to obesity. I found several
good sources of information and conducted a &ub/ed search for
1obesity1 and 1management1. I used internet learning resources
cited in a recent ./0 article
2
. These were the National 3udit "#ce
website, 45 preventative 5ervices Task 6orce, 7ochrane ,atabase,
$!" global database on "besity and ./I. I also used 8&rodigy*
9vidence .ased 7linical %uidance:. I conducted a review of the case
notes from our computer database and summarised them. I also
contacted the "besity 5urgery department I used to work for to sit
in at a clinic.
6inally I used the evidence to formulate a management plan for
obese patients.
What Is Already &nown About Obesity And Its
Treatent?
"besity is an e(cess of body fat. It is de;ned by the $orld !ealth
"rganisation in terms of body mass inde( or ./I. This is given by*
Weight 'kg( ) *eight '(
+
The $!" de;nes a ./I of <=.>-<?.? as being overweight and
obesity as a ./I of more than @>.
<
It is important to note that ./I is
an indirect measure of body fat, it doesnAt take into account body
frame.
@
$aist circumference is an alternative measurement with
strong correlations to cardiovascular risk factors and could be used.
2
!owever it is the standard measurement used by healthcare
professionals in this country.
0
YOR/800/038494. A Clinical Case Study: Obesity
3 recent report by the National 3udit o#ce revealed startling
epidemiology on obesity. The 3uditor general reports that 2 in =
adults are obese, with nearly two thirds of men and over half of
women overweight or obese. 5omewhat worryingly this number has
trebled over the last twenty years. 'elevant to &rimary care, the
N3" suggest that the estimated human cost is around 2Bmillion sick
days per year, @>>>> deaths per year, and deaths linked to obesity
shorten lives by about nine years. The estimated ;nancial cost to
the nation is C2D< billion a year in treatment costs to the N!5 with a
possible C< billion a year impact on the economy.
E
"besity has a negative impact on the health and wellbeing of people
it afects. .eing overweight puts patients at risk form numerous
chronic conditions. There is increased incidence of ischaemic heart
disease, hypertension, type < diabetes, gallbladder disease,
cancers of the endometrium, breast, prostate and colon,
osteoarthritis, sleep apnoea in overweight and obese people.
=
"besity has also been shown to lead to disability and early
retirement.
E
The risk of I!, is doubled when ./I is greater than <=
and nearly quadrupled if over @>. The risk of developing diabetes is
E> times greater if ./I is over @=.
F
"besity can also lead to
psychological complications such as low self-esteem, isolationist
behaviour and depression. /ortality rates increase above a ./I of
<E. The 6ramingham !eart 5tudy showed that the risk of dying
within a <F-year period increased by 2G for each e(tra pound gain
in weight between the ages of @>-E<, and <G between =>-F<.
H
The
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YOR/800/038494. A Clinical Case Study: Obesity
successful management of obesity can lead to health bene;ts.
9vidence shows that reducing obestity can help to prevent these
chronic illnesses.
B,?
Indeed, one group suggest that a 2>kg loss in
weight can have signi;cant bene;ts, for e(ample a <>-<=G overall
fall in mortality.
2>
/anagement of obese people needs to be multifactoral.
4nfortunately, there is no 8magic cure:. 5trategies for weight loss
need to revolve around a central principle* calori;c restriction and
increased energy e(penditure.
22
3chieving efective weight
management requires a long-term approach, providing an
appropriate physical environment for the overweight or obese
patient, proper evaluation of the impact of a patients weight on
health, evaluating their readiness to change, setting appropriate
weight-loss goals, and providing information and help about how to
do it.
2<,2@
3 diet high in comple( carbohydrates I to suppress hungerJ,
restricted in total fat and moderate in protein should be used
I 3lthough most $estern diets seem to be low in carbohydrates,
high in protein and fat, and indeed 8low fat: meals often contain
large quantities of simple carbohydratesJ. 'eductions of =>>-
2>>>kcal per day produce weight loss of >.E=->.?kg per week.
2
'ealistic goals should chosen for steady sustained weight loss. The
patient should integrate this new diet into their lifestyle. &hysical
activity can lead to weight loss. 3lso activity has other bene;ts such
as increased cardiovascular ;tness. Kow intensity aerobic e(ercise
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YOR/800/038494. A Clinical Case Study: Obesity
promotes greater use of fat stores.
2E
5upervised e(ercise sessions
provide social interaction, support and can have encouraging
outcomes.
2=
/anagement should include advice, setting behavioural goals,
positive thinking and promoting better self-image.
2F
These
behavioural treatments seem only to be efective when combined
with e(ercise and dietary change as part of lifestyle changes.
2=
There is a place for pharmacological management of obesity. 5trict
criteria are involved in the use of these agents.
2H
5everal agents
have been used for the treatment of obesity. These have been
associated with serious adverse efects.
,e(fenLuramine, fenLuramine, fenLuramine plus phentermine have
been associated with valvular heart

disease and primary pulmonary
hypertension and have since been withdrawn.
2B
There are currently
two agents used in the 4M. These are orlistat and sibutramine.
"rlistat, a pancreatic lipase inhibitor, inhibits absorption of dietary
fat by appro(imately @>G. 5ibutramine is a centrally-acting agent
which enhances satiety and thermogenesis by inhibiting serotonin
and noradrenaline re-uptake.
2?
.oth of these agents have been
shown to promote weight loss in conjunction with a hypocalori;c
diet and other measures. "rlistat is efective in reducing weight over
a period of a year. !owever, in absolute terms, mean weight loss
from trials shows a relatively small reduction, of some two to ;ve
kilograms per year over the weight decline with placebo.
<>
'andomised controlled trials found that sibutramine produced a
9
YOR/800/038494. A Clinical Case Study: Obesity
dose-related weight loss when given in the range =-@> mgDday, with
an optimal dose of 2>-2= mgDday. /ean weight loss was greater with
sibutramine than with placebo, on average by about @ kg at B
weeks, by between E and ? kg at <E weeks, and by between E and =
kg at 2 year. There is no bene;t from combining the two.
<2
.oth
medications are frequently stopped because of intolerance of side-
efects. The main adverse efects of orlistat are %I dysfunction such
as steatorrhoea, diarrhoea and sometimes faecal incontinence.
5ibutramineAs main problem is it can cause hypertension, tremor,
insomnia and LushingDsweating.
2H
The ;nal step, according to NI79, should be limited to the most
severe cases. 5urgery to aid weight reduction Ibariatric surgeryJ
may be considered when all other measures have failed. .ariatric
surgery is not commonly undertaken in 9ngland and $ales There
are two main types of surgical intervention N malabsorptive and
restrictive. /alabsorptive surgery involves gastrointestinal tract
bypass, limiting food absorption. 'estrictive surgery limits stomach
siOe inducing 5urgery provides signi;cant, maintained weight loss.
5urgery is also associated with improved quality of life and reduced
co-morbidities. These bene;ts outweigh the risk.
<<
'esults of long term eforts to lose weight are disappointing. 7linical
trials of conventional weight loss techniques report that most weight
is regained, and that long-term reduction is very di#cult to achieve.
2
There needs to be a partnership with e(tended support between the
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YOR/800/038494. A Clinical Case Study: Obesity
patient and healthcare professional, and obesity needs to be
treated as a chronic disease.
2@,2E,<@
There is always new research on obesity and it remains to be seen if
an efective treatment can be found, 3n e(citing new development
is the discovery of a potent stimulator of appetite produced by the
stomach called %hrelin. It is a peptide of <B amino acids which
regulates food intake by acting on the hypothalamic arcuate
nucleus. %hrelin is an endogenous regulator of feeding behaviour
and may be able to be used in future management of eating
disorder.
<E
6urther research is needed.
,iscussion.
/y aims were to e(plore treatments for obesity, see how this patient
has been managed and to learn more about management of obesity
for my future practice. I believe my comprehensive method allowed
me to ful;ll these aims. I have been able to assess evidence
regarding the problem and management of obesity. It is clear that it
is an increasing problem afecting a high proportion of patients. It is
important to treat obesity because of its detrimental efect on
peopleAs morbidity and mortality, not to mention quality of life.
"besity is also a huge drain on national resources.
The evidence shows that it is directly involved in many chronic
diseases, many of these needing frequent consultations and causing
premature death. It also shows that successful management of this
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YOR/800/038494. A Clinical Case Study: Obesity
problem can lead to signi;cant health bene;ts and reduction of
mortality. There are many strategies for management of obesity. The
mainstay of treatment has to be diet and e(ercise. 9vidence
suggests that it is incredibly di#cult to treat obesity. /ost
strategies, e(cept certain types of .ariatric surgery, seem to result
in rebound weight gain and feel there is only a limited place for
pharmacological management.
There must be long-term lifestyle changes and constant
support. &atients need re-education with respect to eating and
e(ercise habits. There is no magic cure, but with help it may be
possible to help prevent an 8epidemic: of obesity.
If simple treatment strategies of calorie controlling, e(ercise
and lifestyle change are not working Ias is often the caseJ, then it is
necessary to use a 8stepwise: management plan. In other words,
poor results with lifestyle change should lead to consideration of the
use of orlistat of sibutramine. In the most e(treme cases, where
health is signi;cantly at risk Ias per NI79 guidelinesJ I believe there
is a place for surgical management. "ne of the more successful
operations is the 'ou(-en P gastric bypass
<<
, which this patient had.
!aving researched the topic and seen a patientAs management both
conservatively and surgically, I have been able to formulate my own
evidence-based management guidelines which I will be able to use
in my future career.
This patient seems to be a typical e(ample of the overweight
persons constant battle for control of weight. It seems my patient
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YOR/800/038494. A Clinical Case Study: Obesity
conforms to the picture described by my review of current literature.
The only way she has been able to lose weight is with surgery, the
most drastic of options. Kooking at her history, it becomes apparent
that a stepwise system of management has been employed. 6irst
lifestyle, diet and e(ercise changes were attempted, unfortunately
with little success. Then pharmacological methods were used, only
to be discontinued due to intolerance of the adverse efects. 6inally,
after years of struggling, she was surgically managed. 3lthough it is
impossible to see the long-term outcome of her surgery, in the
short-term results are promising.
3ttending the clinic of the surgeon who performed the
operation was very interesting. The service is well run, with precise
dietary changes and lifestyle changes used. The surgeon stresses it
only works if patients modify lifestyle too, in other words eat less
and take more e(ercise. !e has noticed over the years that people
have less co-morbidity as time goes on. !e added that this is only a
last step, and there are always conservative treatments available.
The unit also sticks to guidelines based on the NI79 guidelines.
"f course, one case study doesnAt provide enough information
to base management of similar patients. 5everal individual cases
would need to be investigated to see what outcomes arise from
management of obesity. 3lso, the con;nes of this project only allow
for an abridged e(amination of the evidence. There are many
studies and articles that would need to be seen in order to formulate
speci;c guidelines. !owever, I think that there is su#cient
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YOR/800/038494. A Clinical Case Study: Obesity
information for me to base my clinical practice, which as for any
topic, should be continually updated by keeping abreast of changes
in the ;eld.
Conclusion.
This project has shown that obesity is a common problem,
responsible for a large proportion of morbidity in the 4M. It has also
shown that there are great bene;ts to be had by attempting to
lower ./I to acceptable ranges. 3lthough management is di#cult
and success is often limited, one of the main messages is
perseverance with lifestyle changes and a partnership between
healthcare professional and patient. It is important, however, that
further research into the science behind obesity continues in the
hope of less drastic treatments than surgery providing similar
results. I think it also could raise the suggestion that prevention is
better than cure. &erhaps a large study of interventions beginning in
childhood, promoting healthy lifestyles could be compared with the
general population+
!ere is a simpli;ed suggested management plan for overweight
adults. 6urther work could be undertaken to produce National
strategies based on the work of the National 3udit o#ce. I had the
opportunity to present my ;ndings at a practice meeting and the
practice is considering using my guidelines.
$ord 7ount -<?=B
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YOR/800/038494. A Clinical Case Study: Obesity
A--endi.
/y management protocol, based upon the evidence I have found.
BMI 25-29.9
Decide on long-term, achievable weight loss plans of around
.5!g per wee! until desirable weight is reached
Introduce calorie controlled diet, developed with specific
nutritional content to encourage weight loss "e.g. low calorie,
high comple# carboh$drate, low fat diet% and re-educate
patients to eat this t$pe of diet naturall$
Introduce e#ercise plan with realistic e#ercise goals
&ontinued support and regular monitoring
'ncourage continuation of health$ diet and regular e#ercise
to avoid rebound weight-gain and maintain health$ bod$
weights.
BMI (- (9.9
'mplo$ all above strategies
&onsider treatment with orlistat or sibutramine, following
)I&' guidelines.
&onsider referral for specialist medical help
BMI *+ "or (5 with significant co-morbidit$%
,ttempt all of the above
&onsider referral for surgical management ")I&' guidelines
22
%
o -atients ./+ with morbid obesit$
o ,lread$ had intensive management in speciali0ed
obesit$ clinics
o 1ailed to lose weight with appropriate non-surgical
measures
o )o clinical or ps$chological contraindications to
anaesthesia
o &ommitted to long-term follow-up
-/
YOR/800/038494. A Clinical Case Study: Obesity
/e!erences.
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<=. &rofessional correspondence from operating surgeon.
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