Czech Approach

THE CZECH APPROACH IN COMPREHENSIVE OBESITY MANAGEMENT

Vojtich Hainer, Marie Kunesova, Jana Parizkova, Vladimir Stich, Martin Fried, Iva Malkova

Czech Society for the Study of Obesity (CSSO)
Obesity Management Centre
General Faculty Hospital
Charles University
Lannova 2
110 00 Prague 1
Czech Republic

STOB Weight Reduction Club, Prague - Czech Republic

As reported in the International Obesity Task Force Newsletter, the prevalence of obesity is rising to epidemic proportions in both developed and developing countries around the world, and the central European region is characterized by the highest prevalence of obesity in Europe. At the end of the eighties the prevalence of obesity (BMI>30) in the Czech Republic reached 16.3% in men and 20.2% in women (Table 1).

According to the recent Monica study (1996) the prevalence of obesity rose extremely in the rural population of the Czech Republic, to 29.4% in men and to 40.6% in women aged 33-73 years (Table 2). Overweight, defined as BMI>25, affects more than 50% of the Czech population (Table 1). The high prevalence of obesity is observed in spite of a decrease in both daily energy consumption (by more than 500 kJ) and fat intake (by 12.4 g) in the period of socioeconomic transition (Table 3). Thus a sedentary lifestyle might be responsible for the increasing manifestation of the "thrifty" gene in our population.

In response to the increasing prevalence of obesity, the Czech Society for the Study of Obesity has introduced a comprehensive weight management program which includes not only obesity treatment but also postgraduate training for physicians as well as training of counsellors of weight reduction clubs. The three week postgraduate course for internists involved in the care of obese patients in obesity out-patient clinics includes one week of theoretical lectures, two weeks of clinical practice in the obesity unit and a final interview. We consider obesity clinics lead by an obesity specialist a necessary step in providing sophisticated care of severely obese patients. Moreover, obesity specialists should spread knowledge about obesity among primary care physicians and try to eliminate underestimation of obesity by health professionals, local health policy makers and the lay public.

The system of obesity management should include national and regional centres (obesity units) for obesity management attached to five major teaching hospitals, obesity out-patient clinics (lead by an obesity specialist), primary care physicians and weight reduction clubs (Table 4). The obesity specialist should stimulate a link between the obesity unit and both the primary care physician and weight reduction clubs. In spite of the support of the obesity management program by many representatives of Czech internists, cardiologists, endocrinologists and diabetologists, a lack of awareness of obesity as a serious disease among specialists has survived as a result of insufficient undergraduate and postgraduate education in nutrition. behavioural medicine and exercise physiology.

Methods currently employed in the treatment of obese patients include diet, exercise, behavioural modification, drug treatment and bariatric surgery (Table 5). Obesity management should be individually tailored according to the age of the patient, degree and phase of obesity, body fat distribution and the presence of comorbidities. Individuals with BMI < 34.9 and without comorbidities are dealt with through weight reduction clubs, whereas those obese with comorbidities or with BMI>35 are treated in obesity out-patient clinics.

It is planned that in each district of the Czech Republic one obesity specialist will take care of about 2,500-3,000 severely obese patients with BMI>35 (Table 6). A holistic and time demanding therapeutic strategy employed in obesity out-patient clinics including both management of obesity and treatment of co-morbidities should be taken into consideration by health policy makers and health insurance institutes. A dietary regimen including very low calorie diets as well as a long-term treatment of obesity by a new generation of antiobesity drugs should be pursued under the supervision of an obesity specialist. Unfortunately, many severely obese patients cannot afford to pay for these modern drugs as their price represents about 7% of the average monthly income in the Czech Republic.

Complicated cases of obesity as well as obese patients in whom a rapid weight loss is required are referred to obesity units attached to major teaching hospitals. Bariatric surgery is conducted in specialized clinical settings after indication by an obesity specialist. Gastric banding is covered by health insurance except adjustable one which is to be paid (in sum of approximately 1,000 USD) by the patient and therefore has only been rarely conducted.

Regular clinical conferences are run by the Czech Society for the Study of Obesity once a month in order to discuss interesting case reports and present patients referred for bariatric surgery. It is necessary to set realistic goals in obesity management (Table 5). These goals have to take into account that even modest weight reduction corresponding to 5-10% of initial weight substantially ameliorates health risks associated with obesity (Table 7). The main task of the program is to find optimal approaches in obesity management leading to a long-term beneficial outcome and ameliorating the variety of disorders associated with obesity. Continual evaluation of the therapeutic outcome of obesity treatment strategies carried out throughout the obesity management system will constitute the biggest task for obesity management centres.

Table 1. Prevalence of overweight and obesity in the Czech Republic

Adult (20 - 65 years of age) prevalence of overweight and obesity (BMI >25)

Men 66.2%

Women 54.3%

Adult (20.65 years of age) prevalence of obesity (BMI >30)

Men 16.3%

Women 20.2%

Table 2. Prevalence of obesity - MONICA Study (R. Cifkova et al., 1996)

MEAN AGE:	53.5 +11.3 years
MEAN BMI:	males 28.33 +- 4.04	females 29.20 -+ 5.72
BODY MASS INDEX	<25.00	25.01-27.00	27.01-30.00	>30.00
Males	19.1	22.1	29.4	29.4
Females	25.6	13.1	20.6	40.6
All	22.6	17.2	24.7	35.5

Table 3. Consumption of essential nutrients in the Czech Republic (1989-1993, expressed as a consumption per inhabitant, per day)

	1989	1990	1991	1992	1993
ENERGY (kJ)	11658	11880	12024	11817	11491
PROTEIN - total(g)	92.2	92.1	91.1	88.6	87.0
- animal(g)	56.8	56.6	52.3	49.6	47.7
- plant (g)	35.4	35.5	38.8	39.0	39.3
FAT (g)	124.6	125.9	121.2	117.1	113.5
CARBOHYDRATE (g)	338.6	349.2	368.7	369.8	358.2

Table 4. System of obesity management introduced by the Czech Society for the Study of Obesity

National Obesity Management Centre

¦¦

Obesity Unit (Regional Obesity Management Centre)

¦¦

Obesity Outpatient Clinic ---------------- Other Specialists

¦¦

Weight Reduction Club ---------------Primary Care Physician

Table 5 Treatment of obesity according to degree of overweight

RANGE OF BMI DEGREE OF OBESITY	MODE OF TREATMENT	WHERE TO TREAT?	GOALS OF OBESITY MANAGEMENT
25.0-29.9 OVERWEIGHT	LOW ENERGY DIET (fat intake < 30%) PHYSICAL EXERCISE (of aerobic character is preferred) BEHAVIOURAL MODIFICATION	IN WEIGHT REDUCTION CLUBS (i.e. ,,STOB.')	WITHOUT HEALTH RISKS: To avoid weight gain, to prevent health complications WITH HEALTH COMPLICATIONS OR IN OVERWEIGHT WITH ANDROID BODY FAT DISTRIBUTION: To lose 5-10 kg during 6 months, to reduce health risks
30.0-34.9 OBESITY GRADE I WITHOUT SERIOUS HEALTH RISKS	See above or ENERGY INTAKE REDUCTION BY 2 MJ/DAY or LOW ENERGY DIET WITH ENERGY INTAKE < 6000 ki/day	IN WEIGHT REDUCTION CLUBS IN PRIMARY HEALTH CARE	To lose 5-10 kg during 6 months To reduce health risks To sustain weight loss achieved
30.0-34.9 OBESITY GRADE I WITH SERIOUS HEALTH RISKS	See above + VLCD (energy intake 1500-3500 ki/day) + ANTIOBESITY DRUGS + HOLISTIC MANAGEMENT OF OBESITY IS REQUIRED INCLUDING THE TREATMENT OF COMORBIDITIES	IN OBESITY OUTPATIENT CLINICS IN OBESITY UNITS attached to major university hospitals (in complicated cases and before surgery when rapid w-loss is required)	To lose about 10% of initial weight To reduce health risks To sustain weight loss achieved
35.0-39.9 OBESITY GRADE II	See above BARIATRIC SURGERY (laparoscopic gastric banding is preferred)	IN OBESITY OUTPATIENT CLINICS IN OBESITY UNlTS attached to major university hospitals (in complicated cases and before surgery when rapid w-loss is required) in patients referred to SPECIALIZED SURGICAL DEPARTMENTS from obesity units or obesity clinics	CONSERVATIVE TREATMENT: To lose about 10% of Initial weight To reduce health risks TO sustain weight loss achieved TREATMENT BY BARIATRIC SURGERY: To reduce initial weight by 25% TO achieve substantial reduction of health risks TO sustain weight loss achieved
>40 OBESITY GRADE III	See above BARIATRIC SURGERY PLAYS PRIMARY ROLE IN THE TREATMENT	See above	See above

* One obesity unit is planned per 2 million inhabitants

** Approximately one outpatient clinic per 100.000 inhabitants, thus taking care of about 2000-3000 of severely obese subjects or obese with serious health complications (in collaboration with approx. 50 GPs)

Table 6. Estimating the medical burden of obesity in relation to health care services in the Czech Republic

NUMBER OF OBESE ADULTS (BMI > 30) (aged 20-65 years)

Men ................... 490,000

Women Total . 1,105,000

NUMBER OF PRIMARY CARE PHYSICIANS 5,057

NUMBER OF PATIENTS FOR MANAGEMENT/GP 220

NUMBER OF SEVERELY OBESE ADULTS (BMI >35) (aged 20-65 years)

Men . . . 73,000

Women . 153,000

Total 226,000

PLANNED NUMBER OF OBESITY SPECIALISTS . 80

NUMBER OF OBESE (BMI>35) FOR MANAGEMENT

PER OBESITY SPECIALIST 2,825

Table 7. Set realistic goals in obesity management

- Even modest weight loss (5-10%) is associated with amelioration of obesity related health risks in our study of 456 obese females (mean BMI: 38.9 + 1.2) a weight loss of 9.8 + 0.4 kg resulted:

A) In a significant reduction (p < 0.01) of:

* Systolic blood pressure by 9.80~

* Diastolic blood pressure by 8.4%

* Total cholesterol level by 14.9%

_ Triglyceride level by 25.6%

Apo B by 14.2%

* Fibrinogen by 13.5%

* Fasting blood glucose by 12.5%

_ Fasting serum insulin level by 29.0%

* Fasting serum cortisol level by 25.3%

* Waist circumference by 10.5%

* Sagittal diameter at 14/5 level by 13.6%

* Intraabdominal fat thickness determined by US by 29.5%

* visceral fat determined by CT (n=52) at 14/5 level by 27.4%

* Subscapular skinfold by 28.9%

* Beck score of depression by 31.5%

B) in a significant Increase of

* Sex hormone binding globulin level (n=48, p <0.01) by 70.0%

* Mean diumal concentration of growth hormone

(n=40, p < 0.05) by 60.0%

Supported by grants provided by the Czech Ministry of Health and by the Institute Danone.

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