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

Personal Details
Organisation Name: 
Covidien Pty Ltd
Additional Information
In regard to your comments, do you have a Conflict of Interest to disclose?: 
Please specify any real or perceived conflicts in regard to your comments: 
Covidien manufactures devices used in bariatric surgery.
Specific questions
Question 2: What would help you implement these recommendations into practice?: 

These guidelines have the potential to be extremely useful for GPs responsible for the primary, secondary and tertiary prevention of overweight and obesity in Australia. These prevention levels may be summarised as being:

  1. Primary - practiced prior to the biologic origin of disease;
  2. Secondary - practiced after the disease can be recognized, but before it has caused suffering and disability; and
  3. Tertiary - practiced after suffering or disability has been experienced, in order to prevent further deterioration.

It is standard healthcare practice in the primary, secondary and tertiary prevention of chronic progressive diseases, such as skin cancer, for the management practices to be segmented and tailored to the circumstances and needs of patients in each level of disease. Patients with melanoma may rightly expect their GP’s advice to extend beyond the ‘slip, slop, slap’ message of primary prevention. It is interesting that despite class II and III obesity being identified as important risk factors for some cancers, the guidelines recommend the gradual intensification of treatments via trial and failure for all but the few patients in the BMI>50 category.

The review article by Ashrafian et al (Metabolic Surgery and Cancer Protective Effects of Bariatric Procedures Cancer 2011;117:1788–99) gives some supporting evidence that substantial weight loss reduces rates of cancer. For this reason, class II and III obese patients are likely to appreciate their GPs initiating timely discussions informing them of the option of potentially lifesaving treatments before a possible malignancy develops. Similarly, the same patients progressing towards type 2 diabetes also have the need for timely treatment advice, including bariatric surgery, before irreversible end organ damage occurs or pancreatic function is irretrievably lost.

There are many reasons why sufferers of class II and III obesity fail to be adequately treated. Most of these stem from the fact that lifestyle interventions fail for most patients within five years (Table 6.10, page 25). In the face of these repeated failures; GPs may be forgiven for losing faith in their advice and their patients also forgiven for losing faith in themselves. The result is a gradual disengagement from the healthcare system by patients, many of whom are in the most vulnerable and disadvantaged sections of our community. Perhaps engagement between GPs and patients would improve and outcomes be subsequently enhanced if the stepwise escalation approach used in the draft was modified so that the recommendations were patient centred and hence differed according to the level of disease that each patient was in?

The societal notion of obesity treatment is simply that people should ‘eat less and exercise more’. This is personally reinforced each time we use our will power to change our lifestyles and see the strategy’s short term success. The ‘strong recommendation’ for the use of lifestyle in the draft guidelines gives explicit reinforcement to the idea that lifestyle changes should and will work. It is logical then that when these lifestyle changes fail, with minor exception, to achieve sustainable significant weight loss (Table 6.10, page 25), this failure will be attributed to an absence of will power and a failure of character. Further disillusionment amongst the afflicted and a corresponding reinforcement of prejudicial attitudes by the remainder are the eventual and obvious consequences.

In order to help drive through these obstacles and for interventions to have a real (i.e. significant and sustained) impact sooner, the guideline recommendations must be far more than a reflection of the contemporary literature. Perhaps an evidence-based algorithm, segmented by weight category and co-morbid disease would be less prone to misinterpretation or equivocation. This would lead to selected patients accessing more intensive but sustainably effective secondary and tertiary treatment strategies sooner.

Specific comments

Summary - page vii

  • There is mention of a ‘tailored approach’. Perhaps this could be better facilitated if the recommendations were organised into an algorithm segmented by various patient characteristics (e.g. co-morbid disease, previous attempts, social factors etc.)?
  • There is mention that ‘most people regain the weight they have lost’. Table 6.10 on page 25 shows that bariatric surgery is a clear and unique exception to this statement.
Summary of recommendations

Summary of recommendations – page viii

The staged approach begins with ‘Ask about and assess weight’. There is a body of literature showing that helath care professionals are sometimes reluctant to initiate a conversation with an obese patient. Their reasons include; lack of belief in the advice (particularly if they are obese themselves) they have to offer and fear that the patient will be offended and possibly not return. If the guidelines are to be used by GPs to optimum effect, perhaps they could include advice as to the best manner in which such discussions may be conducted?

Recommendations 4-8, page ix

  • Could this section benefit by including i) the increased health risks and shortened life expectancy associated with severe obesity, ii) the significant health benefits that are not sustained by modest (<5kg) weight loss and iii) expectations of the sustainability and extent of weight losses that can be achieved via the different interventions (Table 6.10, page 25). This will help the majority of readers, who may not progress beyond the preface pages, from giving advice to patients out of its proven context.

Recommendation 9-11, page ix

  • Perhaps include brief description of expected weight loss outcomes at 5 years, following the sustained implementation of each recommendation.

 Recommendation 12-13, page ix

  • It is a convention in the construction of recommendations that where the evidence is strong (Grade A) that the language used is relatively assertive. Given the Grade A evidence underlying these recommendations and the various barriers currently limiting the efficacy of existing treatment approaches outlined above, perhaps a more prescriptive algorithm for treatment escalation may be useful. In the context of the strength of the evidence, use of the word ‘consider’ is inappropriately weak and allows for some prevarication and possible inaction. To enhance the effectiveness of the guidelines, GPs could be instructed, in an evidence based way, how to consider the tailoring of a patient’s management to include additional intensive interventions.

Part A, Section 1, pages 1-3

  • The disproportionate representation by disadvantaged sections of society amongst those suffering from class II and class III obesity is well documented. Is it possible for the guidelines to include some kind of affirmative action in their recommendations to help address discrimination against these groups?
4.2 Waist circumference

Part B, Section 4.2.1, page 12

Table 4.5 provides good information regarding different disease risks associated with different patient characteristics. As risk escalates, preventative strategies should move from primary through secondary and into tertiary prevention approaches. These differing approaches could be included in a treatment algorithm to assist GPs and their patients in accessing the most sustainably effective treatment for their individual disease state, sooner.

4.3 Other factors in assessment of health risk in adults

Part B, Section 4.3.4, page 15

  • There is D grade evidence for other interventions that are not part of the guidelines, perhaps some explanation is needed to help GPs understand why this particular recommendation has been included.
6.1 Lifestyle interventions

Part B, Section 6.1.2, page 22

  • Table 6.6 outlines the use of differing durations of physical activity to prevent weight gain or to promote weight loss. Given weight loss and weight regain prevention from physical activity is dose dependant, it is critical that the intensity component of the dose is also included – as it is in the cited ACSM (2009) reference. This will help achieve informed consent and ensure that patient outcomes are in line with evidence based expectations.
6.2 Intensive interventions

Part B, Section 6.2, page 25

  • The document states that ‘Bariatric surgery is not generally an immediate consideration unless other interventions have not been successful; other interventions are contraindicated; or a person’s BMI is >50 kg/m2.’
  • This would seem to be based on the NHS’s NICE Guideline 43 from 2006, p11. The complete NHS recommendation is:
    • ‘Bariatric surgery is recommended as a treatment option for adults with obesity if all of the following criteria are fulfilled:
      • they have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight
      • all appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months
      • the person has been receiving or will receive intensive management in a specialist obesity service
      • the person is generally fit for anaesthesia and surgery
      • the person commits to the need for long-term follow-up.
    • Bariatric surgery is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate.’
  • Perhaps this section of the NHS’s position could be included in its entirety? Alternatively what was the evidence used to substantiate the modified version (i.e. removal of the 6 month failure period) in the draft guidelines?

Part B, Section 6.2.3, page 31-32

  • Several landmark prospective randomised studies demonstrating the superiority of different bariatric procedures over medical management in certain patient populations have been published in 2012. In order to support the evidence based use of bariatric surgery, perhaps reference to the results should be included in the guidelines?
    • Schauer et al (NEJM, 2012)
    • Mingrone et al (NEJM, 2012)
    • Leonetti et al (Arch Surg, 2012)
    • Sjostrom et al (JAMA, 2012)


  • A recent report of bariatric safety and efficacy from a national database of over 23,000 patients with Metabolic Syndrome is also contained in a publication by Inabnet et al (J Am Coll Surg, 2012).
7.2 Long-term weight management

Part B, Section 7.2, page 43

  • The draft states that a loss of 5kg is a reasonable goal. Whilst achieving such a goal may ameliorate some of the comorbidities associated with weight in some people, it may be entirely inadequate for others. Perhaps a fuller and more instructive discussion around what constitutes a ‘reasonable goal’ for different patient groups could be of benefit?
General comments

Many people afflicted with the problems of class II and class III obesity are vulnerable to being exploited and enrol in treatments that have limited evidence of sustained efficacy. It is hoped that these guidelines will begin the process of helping sufferers gain access to those treatments with a sound evidence base, in a timely fashion.

Many people in society hold discriminatory and prejudiced views towards people afflicted with class II and class III obesity. It is widely believed these sufferers only have themselves to blame for their disease. In fact, many believe this is not a disease, simply a choice. Further evidence based publication from authoritative sources such as the NH&MRC is needed to help correct these views.

There is a significant knowledge deficit regarding the interaction between the obesogenic environment and a person’s genetic makeup which substantially sets their lifelong weight trajectory. A greater appreciation that class II and class III obesity are largely outside a person’s sustained control will lead to this disease being no more the subject of discrimination in the future than breast cancer is today.

Various lifestyle interventions are generally promoted as first line treatments as they are relatively safe and cheap. Society is however largely ignorant regarding the sustained weight reduction that is proven to be achieved by various doses of lifestyle intervention. Those promoting various interventions directly to the general public should be required to disclose the evidence of long term efficacy and safety of their treatment dosage prior to it being undertaken.

Changes to community attitudes are required before any significant impact can be made to improve the obesogenic environment. Political support for these changes is currently nascent but will only develop if driven by the constituency. The costs of overweight and obesity are borne by all of society – not just those afflicted. Even if humanitarian or scientific arguments fail to break down long held beliefs or prejudices, the public cost consequences flowing from a failure to adequately address this disease, should motivate society to take collective action.

Whilst weight loss is easy to achieve, maintenance of that weight loss for a significant length of time is very difficult. Strategies specifically targeted at each phase are much needed. Whilst effective change faces substantial obstacles and will be slow to happen, these new guidelines are a very significant and long overdue contribution to the process.

Page reviewed: 6 September, 2012