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Revised draft Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Children and Adolescents

ID: 
5
Personal Details
Organisation Name: 
the Children's Hospital at Westmead
Additional Information
In regard to your comments, do you have a Conflict of Interest to disclose?: 
No
Specific questions
Question 2: What would help you implement these recommendations into practice?: 

Resources to disseminate guidelines

  • The 2003 NHMRC CPGs for the Management of Overweight & Obesity were very detailed. However, uptake of the guidelines was poor, in part due to the lack of resources made available for dissemination.
  • It would be important for DoHA to make appropriate resourcing available in order to disseminate the guidelines to a range of health professionals

Process for regular updating of the guidelines

  • The current NHMRC process for guideline development appears quite slow. By the time this CPG is officially published, parts of it may be already out of date
  • Has consideration been given to other strategies for more rapid guideline development and updating?
Specific comments
Comments: 
9.1 Identifying overweight and obesity

Recommendation of the CDC BMI for age charts is currently reasonable and in keeping with previous recommendations. However, while Australia has been using the US CDC growth charts, many countries, including New Zealand, have recently moved to using the new WHO growth charts. These include:

  • BMI for age charts from 0-19 years
  • WHO Child Growth Standards – 0-5 years (although there is a disjunction at age 5)
  • WHO Growth Reference 2007 for 5-19 years

We believe there should be further consideration about moving to the WHO reference charts.

Waist circumference. The following publication is a primary source of information about the usefulness of a waist:height ratio >0.5 being indicative of increased cardio-metabolic risk.:

-          Garnett SP, Baur LA, Cowell CT. Waist to height ratio: a simple option for determining excess central adiposity in young people. Int J Obes 2008; 32, 1028-1030.

We suggest inclusion of measurement of waist, and not just BMI, as a specific recommendation.

9.2 Other factors in assessment

History:

-          Family history – Consider including obstructive apnoea, bariatric surgery

-          Consider including a history of constipation and enuresis

Sleeping history – consider specifically including sleep duration

  • Pg. 53 There are a number of factors in the diet that need to be assessed in more detail then stipulated in the guidelines; A trained paediatric dietitian would take a thorough assessment of all aspects of dietary behaviour/quality and quantity specifically related to children and adolescents. This is a very different diet history to adults with obesity.
  • The guidelines reference and encourage the Australian Guide to Healthy Eating, which are still in draft form. There were a number of issues with the draft guidelines, and in practice, adhering to the core food group quantities would not work in our population. For example, there is a tendency towards excessive carbohydrate loads and juice as a substitute serve for fruit.
  • The AGHE also assumes a level of activity far above the sedentary lifestyle patterns we see on a practical level in our obesity clinics.

 

 

DIETARY Habits / Behaviours.

 

  • Are meals eaten regularly including snacks?
  • Are there regular family based meals?
  • How many days per week does the child / adolescent eat breakfast? 
  • Does the adolescent have structure / routine to their day with set meal times?
  • What time are children and adolescents getting to sleep?
  • Is lunch packed for school or bought from the canteen?
  • Is there food swapping happening at school?
  • Are the children hungry after school?
  • What types of snacks are bought for the family?
  • Are the children having defined meal and snack times or are they grazing all day?
  • What is for afternoon tea?
  • What types of fluids does your child drink?
  • Do the children like fruit and vegetables?
  • How often does the family have dinner together at the table?
  • Are the kids allowed to snack in front of the TV?
  • Is the TV on whilst the family eats dinner?
  • How often do you eat takeaway or eat at fast-food restaurants?
  • Do you usually eat together as a family?
  • In particular for adolescents , are they spending time with their peers eating foods away from home?
  • Are children hungry after dinner and do they continue snacking late into the evening?

 

 

Dietary Quantity

 

  • How much does your child eat at the evening meal compared with the rest of the family? Are similar quantities served as the rest of the family?
  • Are the children allowed unlimited amounts of second helpings?
  • How much soft drink, cordial and fruit juice does your child drink each day?
  • How many serves of fruit and vegetables are the children eating every day?
  • We know from Kids Eat, Kids Play Survey, 2007, children and adolescents are not eating enough vegetables.
  • How many snack foods are packed for school?
  • How much food does your child want for afternoon tea?
  • Which is the largest meal of the day for your child?

 

Dietary Quality

 

 

  • Are non-starchy vegetables being displaced from the diet with high carbohydrate, high fat, energy dense foods.
  • Are vegetables being eaten at lunch and dinner as opposed to just one meal per day?
  • Is there enough satiating protein at meal and snack times?
  • We need to assess for what isn’t in the diet as much as what is – are there enough calcium and iron rich foods?
  • What is the fibre content of the diet?
  • What is the nature of the carbohydrate being eaten? Is it primarily whole grains?

 Section 9.2, measuring waist circumference. Page 53

Would a pictorial representation of measurement of waist be helpful here?

Section 9.2.1, History. Page 53

Consider adding:

  • Past medical history – including perinatal history
  • Sleeping history – bedtime routine and sleep duration, snoring, morning headache, daytime somnolence

Usual levels of PA….. including family activities and number of screens in household

 

Another bullet point should be

 

Screen time hours per day spent in some kind of screen recreation. and

Parents' views of the problems caused by their child or adolescent's weight.

 

11.2 Weight management goals

Weight Management Goals – pg 58.

 

“Provide advice that weight maintenance is an acceptable goal for the majority of children who are overweight or obese.”

 

We would argue that a distinction needs to be made between overweight and obese. If a child is obese, and if their weight exceeds the 95th centile there is no evidence to suggest there is harm in children losing fat mass. A dietitian can ensure adequate dietary intake so that growth potential is still reached. If an adolescent is 125kg weight maintenance would not be the goal. We are seeing an increasing proportion of the more severe cases in our clinics.

Section 11.2 Weight management goals. Page 58

Again I think it must be reiterated that weight maintenance is recommended in those who do not have any obesity related complications

Recommendation 20 

There is evidence that for children/adolescents who need to lose weight, there are no problems with monitoring their own weight.  Regular monitoring of weight (supervised by parents) can be recommended to children and adolescents who need to lose weight.

Useful Reference is Boutelle, K et al. (2009) Weight control strategies of overweight adolescents who successfully lost weight.  Journal of the American Dietetic Association.

11.3 Weight management interventions

Table 11.4: Practical information for parents to support healthy eating in children pg. 60.

Needs more specific guidelines for the morbidly obese.

 Section 11.3 weight management interventions. Page 58

Consider addition of  “family centred” to first sentence.

Section 11.3.2 Specialist interventions to support weight loss

Again the overall impression is that is it only obese post – pubertal adolescents that need to lose weight. I think this should be altered to appropriately reflect that there are severely obese pre-pubertal children who also need to lose weight

 

  1. Prescriptive meal plans for portion control and optimal macronutrient and micronutrient composition.
  2. Individualised practical suggestions of what to eat i.e. brands and snack ideas as well as recipes etc for meal times in line with family budgetary constraints.
  3. Educate on the serve allowances for core food groups, particularly focusing on increasing non-starchy vegetables.
  4. Have clear boundaries at home around food and meal times. Help children achieve success with a healthy environment.
  5. Children spend the majority of their time at school. Families need to have clear guidelines as to what is in their lunch box.

We suggest to include;

              I.        Wholegrain sandwich or wrap with a lean protein + salad filling

            II.        A protein rich food that promotes calcium intake e.g. low fat yoghurt or flavoured milk, or crackers and low fat cheese.

           III.        1 piece of whole fruit.

          IV.        One “extra” snack food that can be packaged but portion controlled – around 400kJ and ideally a source of protein.

            V.        Water to drink.

          VI.        One extra salad vegetable such as cucumber, celery or carrot

 

  1. Healthy choices for after school when children are often hungry and there is an increased risk of consuming excessive ‘extra’ and meals rather than snacks
  2. A regular breakfast containing a small portion of whole grain breads and cereals, low fat dairy and a protein rich source
  3. Have set meals and snack times and protected dinner times

 Table 11.2

Screen time or Reducing Sedentary Behaviour needs to be added to this table

Page 59  Add to bullet points at the end of the page

Goal setting should be specific and include plans for when barriers to goals come up.

(This is because everyone finds the goal "eat healthier" to be easy to set but it is not helpful and quite meaningless.  There is a literature -base to this suggestion.  Lit search on Peter Gollwitzer would be useful.)

Table 11.5  add

 have family rules around "screen time".

 

11.1 Therapeutic engagement

The following publication, which is a systematic review of international clinical practice guidelines for the management of paediatric obesity, also highlights the importance of involvement of parents in the treatment of paediatric obesity

Shrewsbury VA, Steinbeck KS, Torvaldsen S, Baur LA. The role of parents in pre-adolescent and adolescent weight management: a systematic review of clinical recommendations.  Obesity Reviews 2011; 12:759–769.

The recommendation is set at Level C, but, given the range of studies supporting this, it should probably be set at Level B

Section 11, Assist, key messages. Page 57

Middle bullet point  - again I think clarification is needed that weight maintenance is fine as long as the child/adolescent does not have any obesity related complications

Section 11, Assist, Recommendation 19. Page 57

What is the definition of “frequent”? Weekly/fortnightly/monthly?

Under 11.1, somewhere it needs to be emphasised that the whole family adopting a healthier lifestyle is a key part of the process.  Perhaps add a point that says:

The obese parents of obese children and adolescents should also be encouraged to lose weight as part of a family wide approach.

 

 

13.2 Supporting weight management

Case Studies

Case study 13 and 14

Under Assist

Provide appropriate energy controlled dietary guidelines with macronutrient composition favouring a more moderate carbohydrate intake and low GI to assist with weight control (Thomas DE, Elliott EJ, Baur L. Low glycaemic index or low glycaemic load diets for overweight and obesity. Cochrane Database o fSystematic Reviews 2007, Issue 3. Art. No.: CD005105. DOI: 10.1002/14651858.CD005105.pub2.

 

Adolescent cases:

1)    Assess motivation to change

2)    Nutrient and lifestyle assessment

3)    Identify dietary factors impacting on weight status

4)    Integrate diet and physical activity intervention

5)    Regular follow up and self monitoring

6)    Specialist referral for medical issue impacting on weight

7)    Psychologist referral for management of pyscho/social issues

 

When the document says, “Provide information about healthy eating…” this is far too general for a patient with type 2 diabetes or insulin resistance. They require specific and tailored dietary advice that is practical and includes examples of portions sizes and brands.

 Table 13.2, Case study 12

What is the evidence for a 3 weekly follow up? This may not be frequent enough. There should be some discussion about what an appropriate frequency of follow up should be. For example, at The Children’s Hospital at Westmead, we aim for an initial 2 weekly follow-up in most of our new patients. This timing is largely pragmatic, but may not be frequent enough for some patients and their families.

 

3.2 Health professionals involved in weight management

Multidisciplinary care teams:  Include mention of Accredited Exercise Physiologists (AEP) as part of allied health services. This group of allied health professional is specifically trained in implementing exercise programs for obesity including appropriate consideration of associated comorbidities.

11.3 Weight management interventions

Pg 60. Table 11.5: Practical information for parents to support physical activity and reduced sedentary behaviour in children.

-          Encourage and facilitate active transport (as a general guide for adolescents, distances  <2km can be walked)

-          Where possible engage in organised sport to reduce pressure on parents, and encourage intensities not usually achieved alone.

-          Be aware that excessive physical activity (eg gym work, cardio training etc) is thought to be detrimental to normal growth and puberty

  • Wording of this statement is somewhat misleading and could potentially discourage patients from activity and cause anxiety to parents.
  • Perhaps rephrase to ‘Be aware that unsupervised high intensity resistance training and excessive volumes of aerobic training have the potential to be detrimental to normal growth. ‘
  • Consider including a further statement that suggests any child or adolescent wishing to engage in gym-based exercises or frequent high intensity activity must be supervised by a qualified kids trainer or appropriately trained exercise professional who can facilitate a safe and fun environment.  

 

1.2 Children and adolescents

Section 1.2 (Trends in overweight & obesity – Children & adolescents), pages 2 & 3

The following recently published article looks at changes in BMI, weight, waist and waist:height ratio in Australian school-aged children and adolescents from 1985 to 2007. The publication particularly highlights the disproportionate increase in central adiposity compared with BMI:

Garnett SP, Baur LA, Cowell CT. The prevalence of increased central adiposity in Australian school children 1985 to 2007. Obesity Reviews 2011; 12:887-896.

 

An additional issue to consider is that the prevalence of overweight & obesity in children presenting to Australian general practice, for whatever reason, is higher than in the general population (Cretikos et al, 2008). This is also the case for tertiary paediatric hospital presentations (O’Connor et al, 2004). Thus, health services will see overweight and obese children and adolescents more commonly than if they were just randomly sampled from the broader population. This has implications for general practice and other parts of the health sector.

Cretikos MA, Valento L, Britt HC, Baur LA. General practice management of overweight and obesity in children and adolescents in Australia. Medical Care 2008; 46:1163-1169.

O’Connor J, Youde LS, Allen JR, Baur LA.  Obesity and under-nutrition in a tertiary paediatric hospital.  J Paediatr Ch Health 2004; 40:299-304

10 Advise

Section 10, Table 10.1, page 55

Suggest dyslipidaemia, rather than hyperlipidaemia

Consider addition of behaviour disorders  in the list of mental health

If need a reference: Pruder JJ, Munsch S. Psychological correlates of childhood obesity. Int J Obesity 2010;34:s37-s43.

Section 10.1, page 56

Reference for statement in last paragraph about quality of life in adolescents?

11.3 Weight management interventions

Table 11.4, page 60

Consider including role modelling by parents

Table 11.5, page 60

The comment that gym work and cardio training “is thought to be detrimental to normal growth and puberty” seems unsupported. Perhaps this is an issue especially for pre-adolescent children? Adolescents may benefit from youth-appropriate structured gym programs.

Table 11.7, page 61

Metformin: The following systematic review shows the effect of metformin in obese, insulin resistance adolescents:

Quinn SM, Baur LA, Garnett SP, Cowell CT. Treatment of clinical insulin resistance in children: a systematic review. Obesity Reviews 2010; 11:722-730

PART D - AREAS FOR FUTURE RESEARCH

Part D, Health system recommendations for research, Page 72

Research into appropriate models of care for different levels of severity of obesity is needed

 

Under Children and adolescents research into "predictors of success and failure in weight managment service" should also be added.

Summary

Summary: page vii

Children and adolescents section

Consider rewording of the first sentence from “Most children and adolescents who are overweight or obese are identified through primary or community care” to something along the lines of “The primary or community care setting is well placed for the identification of overweight or obese children and adolescents” as most children with overweight/obesity issues are not identified at all in any setting!

I feel the overall tone of the second paragraph suggests that it is only post pubertal adolescents with severe obesity who  need to be referred and to lose weight. I think the message needs to be that any child or adolescent with severe obesity and in particular with obesity related co-morbidities need to be considered for referral and weight loss. The whole paragraph should be reworded to reflect this.

Table of recommendations page x: Assist 20

Again I think this recommendation should make specific  reference to those without obesity related co-morbidities

 

On Page X

In the Assist Recommendations

21: "Recommend Lifestyle change" needs to be clarified because, for example the reader may not know that "sedentary behaviour" often means reducing screen time and "measures to support lifestyle change" is really a treatment that should be applied to the whole family.  It is succinct but more information is needed here.

 

 

1 Trends in overweight and obesity

Section 1, trends in overweight and obesity: key messages. Page 1

Consider including changing “and many people born overseas” to “and certain ethnic backgrounds”

3 Approaches to weight management in primary care

Section 3, approaches to weight Mx in primary care: key messages. Page 7

Last point in relation to co-ordination, consider changing “can” to “should”

13.3 Review and continuing care

Case study 15, page 70

Does not mention whether the girl has been assessed for comorbidities

Case study 16. Page 71

Is the BMI < or > 97th percentile?

2.2 Drivers of weight gain

There is enough evidence to support that sedentary behaviour - namely the rise in screen time is also a driver of child and adolescent obesity.  Also reducing screen time prevents weight gain in children and adolescents.  Readers of these guidelines need to know this because they will be met with clinical examples of obese children and adolescents with very high amounts of screen time.

Useful references include:

Hancox and Poulton.  (2006).  watching television is associated with childhood obesity: but is it clinically important?  International Journal of Obesity 30, 171-175.

Robinson, T.N.  (1999).  Reducing Children's Television Viewing to Prevent Obesity:  AN RCT.  JAMA.  282 (16)

 

3.3 Organisational approaches

Add to Table 3.2

That it should be a routine part of primary health care to measure and discuss weight and being in the healthy weight range.

 

12.1 Monitoring and review

12.1.3

Add a bullet point saying:

how well are the family working together.

12.2 Referral

I would add a bullet point:

 

When the components of a healthy lifestyle cannot be implemented due to complex family problems.

13.1 Assessment

Case study 10 page 68

 

to Arrange add

Family intervention to raise awareness......and the impact of screen time on weight.

13.2 Supporting weight management

Case Study 13 page 69

 

this case study need to clarify if the goal is weight loss for the 14 year old.  It probably is.  There fore a point should also be added "  For the adolescent to monitor his own weight in the family environment".

General comments
Comments: 

Two professional bodies within the Children's Hospital at Westmead (Medical and psychology departments) are concerned about  patients with intellectual disability or development disability

  • No specific mention appears to have been made of this group of people in the document
  • There are Australian and international data showing the higher prevalence of obesity in people with ID (Maiano et al 2011)
  • There is little research looking at the way in which treatment may need to be modified to better suit the needs of people with ID, and their families and carers
  • This is an area of research need

Page reviewed: 6 September, 2012