Abstract
As a general practitioner, I am very aware of the obesity epidemic that has engulfed the UK over the past 10 years. We are seeing a huge increase in younger adults with diabetes, sleep apnoea, arthritis, gout, heart disease and despair. The number of knee replacements in women in their 50s has increased, as shown in the Million Women study, 1 and is directly correlated with a body mass index (BMI) > 30. The breast and endometrial cancer risks of increased obesity in postmenopausal women are well known to doctors and unknown to women. This is important as there is an increased prevalence of obesity in older women; 39% aged 65–74 years in the US. 2 In two year's time, it is estimated that 12 million adults and one million children in the UK will be obese. 3 In this edition of Menopause International are two interesting papers that look into this problem.
Magliano summarizes the implications for joints. 4 The data are stark: for every 5-unit increase in BMI, the risk of radiographic changes consistent with knee OA were doubled. 5 The pain and disability arthritis of the knees and back cause is enormous, and of course it is a vicious circle: the more immobile the pain makes you, the fatter and more miserable you get. For obese men the relative risk of gout was almost three times as high as for men with BMI of 21–22.9. Weight gain from the age of 21 years increased the risk of gout, while weight loss >10 lb reduced it by almost 40%. 6 What is less clear is the effect in rheumatoid arthritis, as fat people do better, but this may reflect more severe disease and higher circulating levels of pro-inflammatory cytokines in people who are losing weight. Magliano concludes that ‘weight loss and exercise should therefore be recommended at least to patients with symptomatic knee OA’, but how do we achieve it?
Miller and Kral from Chicago review surgical options for the older women. 7 In the UK, we still have the view that our patients should achieve weight reduction from motivation, but we know it does not work. Also anaesthetists and surgeons do not like the increased risks of morbidly obese patients. Yet, current 30-day mortality rates for bariatric surgery in large series are 0.1–2.0% depending upon the type of operation, experience of the hospital and surgeons, 8 and characteristics of the population being studied. The newer, minimally invasive gastroscopic approaches have not got comparative data yet. Even factoring in perioperative deaths there is a three-fold lower mortality in operated patients compared with age- and sex-matched patients over a period of five years. Miller and Kral conclude that not only is antiobesity surgery safe and effective in older obese adults, it normalizes survival in a group that would otherwise have increased mortality from co-morbidities. Where America leads, Europe follows and I am sure we will be referring many more people for bariatric surgery in the future.
Competing interests
None declared.