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

ID: 
20
Personal Details
Organisation Name: 
Queensland Paediatric Obesity Working Group
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?: 

Some key tip sheets for GPs and Paediatricians to implement the recommendations. Incorporation for instance of Body Mass Index charts into exisiting GP Medical software to allow GPs to follow children with overweight and obesity and then have a pathway for management built into these computer practice systems.

 

An adequately funded practical public campaign through GP Australia and state GP organisations  should be put in place to promote the use of these guidelines in clinical practice around the country. The 2003 guidelines were underutilised becasue no effort or funding was provided to educcate GPs about their use.

Specific comments
Comments: 
1 Trends in overweight and obesity

At the beginning of the section (around Trends), it doesn't specify if these trends include paediatrics or are exclusive to adults.  For example, lower SES link with obesity - is that the same for paediatrics?

PART C - CHILDREN AND ADOLESCENTS

25th April 2012

 

Comments from Queensland Paediatric Obesity Working Group (POWG) from the QLD Health Child Health Networks on the Draft Clinical Practice Guideline for the Management of Overweight and Obesity in Adults, Children and Adolescents (The Guideline).

 

The group has focused on making specific comments on the relevant paediatric section of the guidelines only.

 

Part C – “Children and Adolescents” of the new NHMRC Draft guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children – Clinical Practice Guidelines for Primary Care Health Professionals. 

 

 

General Comments

 

Overall, we found the recommendations limited in detail and would like to have had actual numbers or details included in the recommendations.  There is a lot of use of words such as "more frequent" and "reduce" without actually describing it further.

 

  • At the beginning of the section (around Trends), it doesn't specify if these trends include paediatrics or are exclusive to adults.  For example, lower SES link with obesity - is that the same for paediatrics?

 

  • Compared to the NHMRC 2003 guideline – there is limited information and detail around management of obesity in children and adolescents and how best to treat them.
  • The new draft does highlight the need for family members monitoring their eating habits (increasing self efficacy), multi-component approach and including the family/parents/care givers in the intervention. 
  • Very little information specifying primary/secondary and tertiary components - this would be very useful when planning a service.

 

Section 9.1 Page 53

 

Recommendation – Use US_CDC BMI percentiles 

 

While identification of obese childhood subjects will occur using the 95% percentile, we would suggest incorporating a comment about either using 97% percentile or 99th centile (i.e. 120% of 95th centile) to help GPs identify those children with severe obesity who may require more urgent referral to specialist care.

 

Section 9.2 Page 54

 

Recommendation – Consider using Waist circumference measurement at the umbilicus level to reduce the need for palpation of bony landmarks (ribs and iliac crest) in obese and severely obese children.  The reliability and accuracy of the waist circumference measurement is questionable when using bony landmarks in severely obese children and may in fact increase the child’s self consciousness during the measurement process if prolonged palpation is required to assist with ensuring accuracy of position for measurement.

 

Section 9.2.2 Clinical Assessment Page 55

 

Add comment to emphasise the balance and co-ordination difficulties obese children have.

 

“ abnormal gait, balance and co-ordination difficulties, flat feet or problems with hips and knees:

 

9.2.2 History page 54

 

History should also include a child’s birth weight, birth length if it was a FT or PT pregnancy etc, did the mother have GDM.  

 

There also needs to be a clear area in the history of information on developmental isses such as ADHD, aspergers, behavioural issues usch as outburst of aggression, tantrums, abuse both physical and verbal towards parents or carers.      

 

Also mention that it should be asked for all other multidisciplinary treatment being done now or in the past (speech, physio, endo, child psycho)’

 

 

9.2.3 Need for referral before intervention Page 55

 

Add comment about 99th centile.

 

When BMI is well above 95 th centile (especially >99th centile), comorbidities are present etc

 

More emphasis should be put on this area.  Any child with a BMI of 95th percentile or overweight and obese presenting with comorbidites or other should be referred onto other specialist.  Children with BMI’s well above the 95th percentile (>99th centile) should receive urgent referrals even if they do not present with co-morbidites.  

 

Section 10. 1 Page 56

 

Explaining the benefits of weight management

 

Based on the saying that “A picture says a thousand words” the use of a diagram outlining for  Health professionals and their patients the potential complications would be very useful.  As an example refer to figure in review article of Batch JA and Baur LA. Med J Aust 2005 182 (3):130-135. Management and prevention of obesity and its complications in children and adolescents.

 

11.1 tips for fostering engagement with adolescents

This should include a title “tips for fostering engagement with parents, carers adolescents and children”  not just adolescents as it is very important to capture the parents and carers as they are the ones that will ultimately be bringing the children and be in the majority position to enable changes.  

No matter how old the adolescent or child or their maturity if the parent or carer is in charge of purchasing the food, cooking etc then they must be involved in the sessions for the children or adolescents.  Separate consults or education to encourage the children or adolescents is an added benefit to get everyone on the same level at home.

Section 11.2  and 11.3 page 59

Heading and content of paragraph should focus less on Weight management goals in children and adolescents and more on  Lifestyle and Behaviour Changes.

Thus we suggest a change to this section heading to:

Heading 11.2 “ Lifestyle and Weight management goals”

Consider changing the focus of this paragraph to be more about setting goals related to increasing physical activity and decreasing sedentary behaviours in addition to healthy dietary behaviours rather than setting goals about weight loss.  The outcome measures may still include weight but the focus of the goal may be more appropriately directed at behaviour changes (activity and diet).

Consider extending this section to include appropriate forms of goal setting – i.e. SMART / Goal Attainment Scales with possible links to motivational interviewing prior to goal setting.  (This may also link into section 11.1 – Therapeutic engagement).

Recommendation 20

Suggest change in wording to “Provide advice on either weight maintenance or weight loss as the appropriate goal or aim for each individual child or adolescents” 

Weight maintenance is dependent upon age of child, the older the child more consideration should be given to weight loss as they will not be able to grow into their weight as a younger child would.  Adolescents should be encouraged to lose some weight. 

The statement that weight maintenance is an acceptable goal for the majority of children who are overweight or obese needs to be changed as this is no longer the case as the escalation rates and severity of the disease increases with time.  

11.3 Lifestyle, behavioural and weight management interventions.

Active involvement of the family for overall success is important when it comes to lifestyle interventions.  There is no reference to this in this section.  

  •  11.3.1 (page 59) Interventions recommend multi-component based however it is 

unclear as to what setting? What duration? Individual? Groups? Again, not sure what details is required.

  • In table 11.4 –  Avoid classifying foods as good or bad – suggest using “sometimes foods”

 

Including information for parents to be role models etc – parents to be a good role model and do as they ask the children would be a good thing to mention 

 

Table 11.5 page 61

Practical information for parents to support physical activity and reduced sedentary behaviour in children

 

No mention is made in this table of incorporating increasing physical activity by enhancing daily living activities such as walking and riding to and from school.  

Encouragement of creative, reasonable priced or cost free activities is paramount in this section, your suggestion are above are very good, could also include things such as general household task to help out parents, mow grass, peg clothes, vaccum floor.

Section 12.1.3 Assessing child and family eating, activity and weight control Page 63

  • The interventions recommend more regular contact with health professionals to ensure better outcomes, however it is unclear as to how often - what is the frequency of review recommended?  Page 63 highlights that BMI needs to be reviewed every 3 months or even more frequently.  More details around this recommendation is required as is of critical importance.

 

No mention is made of the importance of mindful slow eating in this section. The evidence is clear that slow mindful eating reduces portion size and improves satiety.

  • In 12.1.3 – you could add “night time eating?” or ask about actual "fluid intake" including juice/soft drink rather than just amount of water intake daily.

 

  • Page 64 – unclear what “family time spent in active pastimes” and “family time spent in sedentary pastimes” means…..?

 

Section 12.2 Referral

Referral to specialist care could include non-medical allied health or psychological specialists. (for example, the Physiotherapy profession now have “Specialist Physiotherapists”

We suggest slight change to wording by saying:

“Referral to paediatric medical specialist care may be a consideration when”

 

Figure 13.2 page 67 and 68 and BMI centile charts for boys and girls

Consideration should be made to incorporate 97th centile BMI which are available from CDC and the 99th centile as defined as 120% of 95th centile for severe obesity (as per Prof Tim Cole suggestion).

 

 

 

 

 

 

General comments
Comments: 

Overall, we found the recommendations limited in detail and would like to have had actual numbers or details included in the recommendations.  There is a lot of use of words such as "more frequent" and "reduce" without actually describing it further.

 

At the beginning of the section (around Trends), it doesn't specify if these trends include paediatrics or are exclusive to adults.  For example, lower SES link with obesity - is that the same for paediatrics?

 

Compared to the NHMRC 2003 guideline – there is limited information and detail around management of obesity in children and adolescents and how best to treat them.

The new draft does highlight the need for family members monitoring their eating habits (increasing self efficacy), multi-component approach and including the family/parents/care givers in the intervention. 

Very little information specifying primary/secondary and tertiary components - this would be very useful when planning a service.

Page reviewed: 6 September, 2012