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

ID: 
16
Personal Details
Organisation Name: 
National Eating Disorders Collaboration
Additional Information
In regard to your comments, do you have a Conflict of Interest to disclose?: 
Yes
Please specify any real or perceived conflicts in regard to your comments: 
A member of the Steering Committee of the NEDC has participated in the development of the draft guidelines acting in her private professional capacity and not as a representative of the NEDC. This member has not contributed to the development of this submission. The review of the draft guidelines has been conducted by the National Standards expert advisory group of the NEDC.
Specific comments
Comments: 
Summary of recommendations

Where the text refers to the comorbid conditions strongly associated with overweight and obesity (page vii), we suggest that eating disorders be included in the named health conditions e.g. “Overweight and obesity are strongly associated with several chronic diseases including type 2 diabetes, cardiovascular disease and some cancers and certain types of eating disorder.

We recommend that screening for eating disorder risk factors, using a recognised screening tool such as SCOFF, be added to the first steps “ask about and assess weight” in the recommendations for weight management in adults and in the recommendations for weight management in children and adolescents (page ix and page x).

4.3 Other factors in assessment of health risk in adults

In the discussion of risk and comorbidities (page 13/14) it would be appropriate to note that people with mental health problems/psychosis experience an increased risk of weight related problems and cardiovascular disease independent of any risks associated with psychotropic medication. An increased incidence of Type II diabetes was found in a 1926 study of patients with schizophrenia prior to the introduction of modern psychotropic medication.

 We congratulate the NHMRC on the inclusion of a history of eating disorders, symptoms of eating disorders and problems of weight cycling (page 14/15) in the assessment of health risks.

5.1 Explaining the health risks associated with overweight and obesity

We recommend that eating disorders such as binge eating disorder should be listed in Table 5.1 (page 17) as a mental health risk for adults in the same way that they are listed in Table 10.1 for children and adolescents.

6.2 Intensive interventions

Very low energy diets (discussed on page 26 and elsewhere in the guidelines) are not associated with long term weight loss.  We strongly recommend that there should be a specific recommendation against the use of very low energy diets promoting rapid weight loss because of their lack of long term benefit and the associated risk of weight cycling through extreme under-nutrition (in eating disorders) and obesity.

The risk of mood disorder and binge eating disorder should be added to the list of adverse effects of very low energy diets.

In the discussion of bariatric surgery it is imperative that assessment of binge eating and other mental health problems are included in the assessment of suitability for surgery (page 33). Untreated binge eating will impact adversely on outcomes.

8.1 Assessment

In the practice guidelines, inclusion of input from psychiatry would be helpful. For example with reference to case study 2 on page 47, olanzapine is now not first choice for ongoing use in someone with bipolar and risk metabolic disorder and it would be reasonable to alert the mental health team to considering changing the mood stabiliser especially if the weight gain continues.

9.1 Identifying overweight and obesity

We note that the WHO growth charts for 0-2 years are included, although to the best of our knowledge these have not yet been formally adopted across Australia.

11.1 Therapeutic engagement

In the tips for fostering engagement (page 57) the recommendation currently reads “Speak to the adolescent directly, as well as to parents or carers”.  We believe that this should read “speak to the adolescent separately, as well as to the parents and carers with the adolescent”.

11.2 Weight management goals

We confirm that weight maintenance rather than weight loss is appropriate for most children and young adolescents but note that this is not always appropriate in later adolescence.

3.2 Health professionals involved in weight management

We congratulate the NHMRC on the adoption of a multidisciplinary care team approach to the complexities of overweight and obesity. Multidisciplinary team approaches are also core to the effective treatment of eating disorders. Further work is needed to identify how this approach may be consistently implemented in primary care.

4.1 Body mass index in adults

We note that the guidelines have adopted the WHO chart of BMI. While there are different views on the ideal target weight for people with eating disorders, a BMI of 20 is widely recognised as the acceptable minimum. A person who has an eating disorder whose weight drops to BMI of 20 or less may require hospitalisation.

We strongly recommend the adoption of a target goal weight or optimal healthy weight range between BMI 20.0 and 24.9.

The following thresholds are recommended as they take into consideration the implications of lower BMIs for people with eating disorders:

  • BMI 17.5 or below: significantly underweight (marked adverse effects likely)
  • BMI 17.6 - 18.9: underweight (some adverse effects likely)
  • BMI 19.0 - 19.9: low weight (although low, not unhealthy)
  • BMI 20.0 - 24.9: healthy weight (ideal for optimum health)
  • BMI 25.0 - 29.9: overweight (some increased health risks)
  • BMI 30.0 +: obesity (markedly increased health risks)

(Fairburn, CBT and Eating Disorders, 2008)

General comments
Comments: 

The NHMRC is to be congratulated for developing the first rigorous and thorough guidelines that focus upon primary care interventions for individuals with overweight and obesity. The examples and scenarios (e.g. pp 46-51) are a very good addition which will enhance the practical application of the guidelines.

We particularly congratulate the NHMRC on the underlying principle of the guidelines “care centred on the needs of the affected individual” which is consistent with the first principle of care for people with eating disorders (National Eating Disorders Framework, 2012). The focus of care on behaviour change and improved health rather than on weight loss alone is also consistent with safe approaches to weight related messages for people at risk of developing eating disorders (National Eating Disorders Communication Strategy Report, 2012).

It would be helpful to see the inclusion of information and guidelines about the emotional reasons for overeating and struggling to maintain a healthy body size. Many people who are overweight or obese experience disordered eating, social pressures and psychological difficulties.  These issues need to be addressed in addition to the physical issues of body weight in order to achieve sustainable weight loss.

We note the relationship of overweight and obesity to socioeconomic disadvantage, and emphasise that the problem of overweight and obesity is more than a medical or psychosocial problem, and will thus require a more extensive socio-economic response.

We also note the similarities between the complex causes of overweight and obesity, including social influences, and many of the risk factors for eating disorders (Becker, 2011).

Research indicates that the prevalence of eating disorder behaviour in Australia is increasing in parallel with the increase in obesity. It is probable that there is a relationship between the increase in concerns about obesity and an increase in extreme weight loss behaviours and body dissatisfaction.

Obesity and eating disorders may be viewed as occurring at the same end of a spectrum with healthy beliefs, attitudes, and behaviours at one end, and problematic beliefs, attitudes, and behaviours (and ultimately syndromes) at the other end (Academy of Eating Disorders, 2011).

Screening for Eating Disorders

There is evidence that obesity is a serious and common outcome for people with bulimic eating disorders and binge eating disorder (Fairburn, Cooper, Doll, Norman, & O'Connor, 2000). 

People with bulimic eating disorders and binge eating disorder most frequently present to primary health care for help with weight loss (Hay, Marley & Lemar, 1998) and generalised psychological distress (Mond, Myers, Crosby, Hay & Mitchell, 2010). 

We congratulate the NHMRC on the inclusion of eating disorders and binge eating as important issues in the patient’s history, assessment and referral.

We strongly recommend the inclusion of screening for eating disorders in the assessment of weight related issues for every patient using a recognised screening tool such as SCOFF.

People with or at high risk of developing an eating disorder may require referral to mental health professionals with expertise in eating disorders and this should be noted in the guidelines with all references to screening or assessment for eating disorders.

Treatment for eating disorders and obesity is not an ‘either/or’ issue’.  Behavioural weight loss programs and drugs (e.g. Orlistat) are effective in reducing binge eating in the short term for both obesity and binge eating disorders (Golay A, Laurent-Jaccard A, Habicht F, Gachoud JP, et al.2005; Grilo CM, Masheb RM, Salant SL, 2005). However, for people with eating disorders benefits are less likely to be maintained over time without appropriate psychotherapy.

For patients who are already participating in psychotherapy or who are referred for psychotherapy, it is important that weight loss advice and treatment does not undo the work achieved in psychotherapy (Paxton & Hay, 2009).

Very low energy diets

There is a substantial body of evidence from the eating disorder literature demonstrating a connection between an emphasis on appearance and weight control and the development of eating disordered behaviours (AED).

While moderate changes in diet and exercise are safe, extreme dieting practices are associated with significant mental and physical consequences. Dieting and disordered eating are proximal risk factors for the development of eating disorders. The act of starting any diet increases the risk of eating disorders. Research conducted in Australia has shown that adolescent females who diet at a severe level are 18 times more likely to develop an eating disorder within six months than someone who has not done so (Daee et al., 2002; Yeo & Hughes, 2011).

Unhealthy weight loss dieting is also associated with other health concerns including depression, anxiety, nutritional and metabolic problems, and, contrary to expectation, with an increase in weight (Paxton et al., 2002). Among girls who dieted, the risk of obesity is greater than for non-dieters (Daee et al., 2002; O’Dea, 2005).

We strongly recommend that there should be a specific recommendation against the use of very low energy diets promoting rapid weight loss because of their lack of long term benefit and the associated risk of weight cycling through extreme under-nutrition (in eating disorders) and obesity.

 Future research

People do not set out to become obese or overweight. Strategies to address weight loss are unlikely to address the reasons behind the development of obesity. We support the identification of obesity as a complex health issue. There is an urgent need to research the barriers to weight loss maintenance and interventions that promote weight loss maintenance taking into consideration the social and psychological contributors to weight management.

Many of the techniques listed in the guidelines, such as motivational interviewing, while the best available at this time, have not been shown to be very successful for weight loss for people with eating disorders.  There is a need for new paradigms and approaches to the prevention and management of both obesity and eating disorders.

 

Page reviewed: 6 September, 2012