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

ID: 
29
Personal Details
First Name: 
Anita
Last Name: 
Star
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?: 

Increased allied health sessions allowed with Medicare funding rebates for those with obesity and co-morbid conditions. Also as discussed in our letter more practical advice on assessment of co-morbidities (i.e. eating disorders) that are likely to impact on weight loss outcomes. 

Specific comments
Comments: 
Summary

Pg vii summary, paragraph 1 :

Bulimic Eating Disorders and Depression need to be listed under the co-morbidities of which are strongly associated with overweight and obesity.

 Pg vii adult summary,  paragraph 4:

 Following discussion of physiological barriers to maintained weight loss. An additional sentence regarding psychological barriers to maintain weight loss should also be added e.g. dichotomous attitude toward diet/ particular foods/ and acceptable weight loss (leading persons to give up if for example they break their diet or although have lost weight, give up as have not achieve desired weight), depression, maladaptive coping responses to life events/ life stress e.g. emotional eating, overly restrictive diets (either restrictive cognitively with lots of strict food rules or overly restrictive in terms of energy deficit) which can lead to binge eating and/ or a start/ stop approach to diet, multiple diets and weight cycling. 

 

Summary of recommendations

Pg ix:

This is an excellent summary table which no doubt will be referred to frequently. It would be helpful therefore to include a section entitled ‘Ask about and assess diet, activity, physical and mental co-morbidities’.  Gaining an understanding of where the client is coming from what diets they have tried in the past and what their current food beliefs/ intake is like, what physical activity they do/ have done in the past, what co-morbidities they have or have had in the past e.g. diabetes, cardiovascular diseases, disordered eating, poor body image, depression and other mental illness is important. These discussions help the clinician gain rapport with the client rather than straight away launching into why they need to lose weight, which without knowing any background may come across as judgemental and stigmatising (a problem reported frequently by obese suffers even when seeking health care), more importantly these discussions should guide the approach to the following advice/ discussion and the choice of appropriate interventions.

Pg X:

Suggest add 23 under assist: Assist children and adolescents get help for disordered eating, poor body image, depression and anxiety and weight related bullying where this is present. 

1.1 Adults

paragraph 1

We feel it is important to have the percentages of overweight and obese adults reported separately rather than grouped together as this gives clinicians a more accurate/ truthful picture of the situation. 

2.2 Drivers of weight gain

Page 4, section 2.2.1

Under diet and activity section it would be useful to say more about the psychological influences on behaviour. For example the impact of depression and poor body image on physical activity, ability and willingness to exercise regularly. Also need to discuss possibility of disordered eating patterns e.g. may follow an overly restrictive diet and be exercising regularly but then have large binges on energy dense foods, or may follow a reasonably well balanced diet most of the time but several times a week binge eat in response to anxiety or stress. It is important to acknowledge these types of patterns because it is not always as simple as eating too much/ exercising too little.    

4.2 Waist circumference

Following the measure up campaign which encouraged people to measure waist we have had a number of discussions with women concerned about their waist measure (between 80 and 88 cm) but who have a BMI in the healthy weight range. We are also aware of individuals who had a BMI of above 25 but whose waist was less than 80cm. Our advice to those in this situation would be to try not to get overly concerned about cut off points, but to focus on risk factors they can change such by eating well, exercising regularly, and getting help to change other risk factors i.e. quit smoking. However to clarify this issue and standardise health professional responses to this, we think it would be helpful to add to table 4.5, a row with the classification of healthy weight and a column for waist measure less than the at risk cut offs points, with corresponding interpretation of disease risk across the new combinations. 

4.3 Other factors in assessment of health risk in adults

Page 13 section 4.3.1    

The comorbidities section focuses on cardiovascular disease and diabetes mellitus. Given the research indicating obese persons are at high risk of eating disorder behaviours/ body image distress and given the bidirectional relationship between obesity and depression (obese persons with body image distress likely to become depressed overtime; depressed persons likely to become obese overtime) and that research has indicated General Practitioners, Dietitians and Counsellors often feel a lack of confidence and skills in the assessment and management of bulimic eating disorders, we think it is very important that eating disorders are discussed in this section, along with a table (similar to that provided for cardiovascular disease and type 2 diabetes), outlining how and when to best assess. We would be happy to provide further input on such a table should this be required.

 

A simple tool that can be used to screen for eating disorders is the SCOFF questionnaire. See below

The following questions may assist in assessing if a patient has or is at high risk of an ED.

 

1.    Do you think you have an eating disorder?

2.    Do you worry about your shape and weight?

 

The SCOFF screening tool questions

      S-  Do you make yourself Sick because you feel uncomfortably full?

      C- Do you worry you have lost Control over how much you have eaten

      O- Have you recently lost more than 6.35 KilO grams (One Stone) in a 3 month period?

      F- Do you believe yourself to be Fat when others say you are too thin?

      F- Would you say Food dominates your life?

One point for every yes; a score of > 2 indicates further questioning is warranted. (Morgan et al 1999).

 

A further two questions have been found to have a high sensitivity and specificity to BN (but are not diagnostic).

1.       Are you satisfied with your eating patterns? (‘no’)

2.       Do you ever eat in secret? (‘yes’)

A ‘no’ for question 1 and a ‘yes’ for question 2 indicates high suspicion for bulimia nervosa and further questioning is warranted.

 

Morgan JF, Ried F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ, 319; 1467-1468.

 

If screening yields a positive result, a table on further assessment could have additional items which could be adapted from the Eating Disorder Examination and Eating Disorder Examination questionnaire to assist clinicians gather details regarding binge eating, other disordered behaviours and body image concerns. 

Mond J, Myers T, Crosby R, Hay P, Rodgers B, Morgan J, Lacey H, Mitchell J. Screen for eating disorders in prmary care: EDE-Q versus SCOFF. Behaviour Research and Therapy 2008; 46: 612-622

Fairburn CG, Cooper Z. (1993) The Eating Disorder Examination (Twelfth Edition). In Binge eating: Nature, Assessment and Treatment, Eds: CG Fairburn and GT Wilson. New York: Guildford Press.pp317-360.

 

Page 14 section 4.3.3

We note the assessment of weight history does include a statement on assessing history of eating disorders, however as mentioned above, we feel given lack of health professional confidence and skills in this area more detailed advice on assessment of this rather complex problem should be provided.

 

Page 15 section 4.3.3

Add to discussion on the problems of weight cycling the association with eating disorders and overall increase in weight over time.  

5.1 Explaining the health risks associated with overweight and obesity

Page 17 table 5.1

Add eating disorders (especially binge eating disorder) to list under mental health

6.1 Lifestyle interventions

Page 21 section 6.1.1

There is a list of considerations when choosing a particular diet approach. We feel this should include a point regarding history of or current eating disorder (e.g. there is no evidence to support very low calorie meal replacement diets in this group, and there is evidence linking very low calorie diets to binge eating).  Furthermore under the point on finding a sustainable approach, we feel another example should be that it is not necessary to follow a very strict diet and cut out all favourite foods as there is evidence that persons who include small portions of their often energy dense favourite foods as part of a balanced reduced energy diet are more likely to maintain lost weight compared to those with strict rules about what can and cannot be consumed.

 

Table 6.2

This table discusses practical information to support healthy eating. The first point suggests recommending websites listing kilojoule content of food, we suggest that this may be harmful to those with history of or current eating disorder or obese persons susceptible to this (namely young to middle aged women). We believe focus should be instead on understanding which foods are energy dense and offer little other nutritional value (e.g. soft drink, confectionary, cakes, deep fried chips) and thus should be consumed only occasionally in reduced portion sizes; which foods can be energy dense but also offer important nutrients and thus knowledge of appropriate portions/ suggested frequency range would be helpful (e.g. meats, oils and spreads, breads and cereals, dairy products); and foods which are low in energy and rich in other nutrients (e.g. vegetables).

The list of practical information could be also added to e.g.

  • Reasons for eating outside regular meals and for hunger (e.g. boredom, tiredness, stress, anxiety, excitement, because it’s there) and more adaptive coping mechanisms/ responses to these cues.
  • Explanation of why it may be better to avoid dichotomous thinking toward diets or particular foods.
  • Cooking methods
  • Healthier takeaway and eating out food choices

 

 

Page 23, section 6.1.2. Increasing physical activity

Considerations in discussing physical activity could/ should also include

-          Current or previous exercise and why or why not these were sustained and advice to overcome these barriers

-          Attitude toward exercise, why overemphasis on weight loss may sabotage ability to maintain efforts 

-          Sustainability of exercise plan, need to not go too hard/ too fast to begin with to prevent injury/ exhaustion and make it pleasant experience that one will want to do again.  

-          Exercise as a mechanism for managing depression and anxiety symptoms 

 

Page 24

When discussing psychological and behavioural therapies it may be useful to note that there is reasonable evidence for the efficacy of guided self-help cognitive behavioural therapy to assist with bulimic eating disorders, which maybe an alternate to improve eating patterns and body image dissatisfaction in those with binge eating disorder, bulimia nervosa and those with disordered eating patterns which would not meet threshold for clinical diagnosis of an eating disorder. This can also be helpful for those living in locations where access to psychological services is poor.

 

It may also be helpful to note that carefully structured behavioural weight loss therapies are not contraindicated for those with eating disorders and can assist them reduce disordered eating behaviours and improve body image. Group behavioural weight loss therapies (or individual therapies were disordered eating is identified as a co-morbidity), should include strategies for managing disordered eating patterns and improve body image, in addition to diet and exercise advice/ behavioural therapies.           

 

Page 25 table 6.1

Weight loss via lifestyle change alone not likely to be maintained, is true on average, but it may be helpful (and make sure clinicians do not feel that it is all a waste of time) to note in this table that some people are more successful and can maintain weight loss (this is discussed later in the guideline on pages 43-44).

6.2 Intensive interventions

Page 26, section 6.2.1

Until further research is available contraindications for very low calorie diets should include those with co-morbid eating disorders, as it has been shown to result in cases of binge eating even in those without any eating disorders at the commencement of treatment. Earlier research on very restrictive diets (but not meal replacement formulas) have also shown onset on depression and binge eating in previously mentally well individuals. 

 

Page 27, section 6.2.1

Adverse effects of very low calorie diets

Potential adverse effects should include binge eating and mood disorders.

 

Page 30 section 6.2.3

Whilst we agree that disordered eating is not necessarily a contraindication for bariatric surgery, it is imperative binge eating and other mental health problems are assessed and treatment commenced prior to surgery  - as untreated binge eating will impact adversely on outcomes. 

6.4 Tailoring weight management programs to specific population groups

Page 40, suggest that a new section i.e. 6.4.6 to be created

We believe an important population group which has  specific needs and consideration would be those with mental illnesses, such as major depression, bipolar disorder, schizophrenia, any form of psychosis etc. There are many challenges and specific needs of this group.  A section should be created for this group.

Page 40, suggest that another new section i.e. section 6.4.7 be created

Outside those suffering from other mental illness (see above), those persons suffering from co-morbid eating disorders have separate important considerations that should impact on the assessment and advice provided. It may be useful create a section which summarises these considerations for this group of sufferers. 

7.1 Review and monitoring

Page  42, table 7.1

Knowing when and who to refer for multidisciplinary and specialist support should include those with co-morbid eating disorders and those with depression. 

7.2 Long-term weight management

Page 44, section 7.2 

Other research has shown that ED behaviours (including binge eating, and complete restriction of favourite foods), body dissatisfaction, and poor psychological health are associated with less success in weight loss treatments and greater likelihood of weight regain. 

8.1 Assessment

Page 46 table 8.1

The check list should include prompts to assess for co-morbidities both physical (e.g. cardiovascular disease) and mental (e.g. eating disorders) which occur in high frequency in obese adults. 

8 Practice guide

Page 46-51 case studies

It would be helpful to include an additional case where long standing disordered eating, weight fluctuations, and body image distress were a part of the assessment and how this would impact on care provided.

 

Page 47 Case 2

It would be useful to note that olanzapine is now not usually first choice for ongoing use in someone with bipolar and risk of metabolic disorder, a reasonable action would be to alert the mental health team and request consideration into changing the mood stabiliser especially if the weight gain continues. 

9.1 Identifying overweight and obesity

Page 52-53, section 9.1  Identifying overweight and obesity

Could provide practical advice about how to best talk (in a sensitive manner given high likelihood of obese children suffering from weight related teasing and obese children and adolescents more likely to take up disordered eating behaviours)  to children and adolescents and/ or their parents about their body weight. 

9.2 Other factors in assessment

Page 53, section 9.2.1

Also get a history of dieting frequency and types of diets (repeated diets especially fad diets- not professional behavioural therapies) likely to lead to disordered eating including binge eating and increased weight gain over time, compared to children who have never dieted.  

13 Practice guide — weight management in children and adolescents

Page 70, section 13.2, case study 14

We disagree with the assistance and arrangements suggested for this 15 year old with infrequent meals and binge eating. The example regarding advice on healthy eating places emphasis on diet restriction by avoiding junk and processed food. Over emphasis on restriction is likely to escalate binge eating. They key to normalise her eating would be to have regular healthy meals and snacks (with education on healthy choices) and allowing/ normalising some energy dense treat foods in small portions. 

Arrangements could include discussion and referral to specialist care with expertise in bulimic eating disorders and co-morbid obesity.

PART D - AREAS FOR FUTURE RESEARCH

Urgently need research as to the barriers to weight loss maintenance and interventions that promote weight loss maintenance. Given that diet and lifestyle get A ratings they will continue to be used but they usually fail over time and can have adverse long term effects i.e.  repeated dieting leading to a higher weight over time

Many of the techniques listed e.g. motivation interviewing have not been very successful (e.g. Cooper study) - there is a need for new paradigms and novel ideas in obesity treatment

General comments
Comments: 

Townsville Campus

Townsville QLD 4811AUSTRALIA

Web: www.jcu.edu.au

 

 

Amy Goodwin & Committee Members

Obesity Guidelines Project
National Health and Medical Research Council

Melbourne Australia

 

19th April 2012

 

Re: Public Consultation of the Primary Care Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Children and Adolescents. 

 

Dear Amy Goodwin (Project Officer) and Distinguished Colleagues on the NHMRC Clinical Practice Obesity Guideline Organising and Guideline Development Committee,

We congratulate you on all the hard work putting together these comprehensive clinical practise guidelines. We particularly like the way in which research evidence and summaries on particular clinical practice areas, are integrated with the graded recommendations, and most importantly practical information and case studies to aid clinicians.    

As researchers and clinicians specialising in eating disorders, weight management and mental health we were encouraged by specific recommendations to take into account the sufferers mental health status and to assess history of any eating disorder behaviours. However we feel that the information and practical advice to primary care clinicians on these areas needs further enhancement and further integration into the guideline.  We feel this is of upmost importance as:

  • One in five obese adults in the Australian community suffers from eating disorder behaviours, and the portion of obese persons suffering from this co-morbidity is increasing over time1-2. Research in clinical samples of persons seeking help for obesity has shown the prevalence rate has shown to be even higher around 30% 3-5.
  • Obese children adolescents and adults are at greater risk of suffering ED behaviours and cognitions compared to non-obese persons 1-2, 6-13.
  • Children, adolescents and adults suffering from eating disorder behaviours and cognitions are at high risk further weight gain and obesity onset 14- 18;  have difficulties maintaining lost weight following weight loss 19- 22.  
  • There is also a bidirectional association between depression and obesity, with obese persons more likely to become depressed longitudinally; and depressed persons more likely to become obese 23.  
  • Unless working in specialist eating disorder services it has been found that General Practitioners, Dietitians, and Counsellors often have poor recognition, knowledge and confidence in the assessment and treatments of bulimic eating disorders 24-25.
  • Help seeking among eating disorder sufferers is poor, with individuals more likely to seek help for a real or perceived weight problem26-29.

Thus in recognition of the above factors, to improve both physical and mental health outcomes in those suffering from co-morbid obesity and eating disorders and/ or depression, and to help prevent the further escalation of co-morbid obesity and eating disorder behaviours, we think the guidelines need to recognise co-morbid mental issues more thoroughly and provide clinicians practical advice to improve their ability to assess and manage these issues.

We feel it is important to note the treatment of eating disorders and obesity is not an either/ or issue with treatments such as carefully designed behavioural weight loss programs e.g. 30, and drug treatments (Orlistat)31-32 been shown to be effective in reducing both weight and binge eating in the short term.  

Our feedback includes comments and recommendations on specific sections of the guideline of how better recognition and treatment of these interconnected disorders could be achieved. We would be happy to be consulted further on these matters should this be required.   

 

Yours Sincerely

Ms Anita Star: PhD Candidate, School of Medicine and Dentistry, James Cook University & Accredited Practising Dietitian.

Prof Phillipa Hay: Foundation Chair of Mental Health, School of Medicine, University of Western Sydney.

A/Prof Jonathan Mond: College of Arts and Social Science, Australian National University  

A/ Prof Frances Quirk: Dscipline of Psychiatry and Department of Psychology, School of Medicine and Denistry and School of Arts and Social Sciences, James Cook University

 

References 

1. Darby AM, Hay PJ, Mond JM, Quirk F, Buttner P, Kennedy L. The rising prevalence of comorbid obesity and eating disorder behaviours from 1995 to 2005. International Journal of Eating Disorders 2009;42:104-08.

2. Darby AM, Hay PJ, Mond JM, Rodgers B, Owen C. Disordered eating behvaiours and cognitions in young women with obesity: relationship with psychological status. International Journal of Obesity 2007;31:876-82.

3. de Zwaan. Binge eating disorder and obesity. International journal of obesity 2001;25 Supplement 1:S51-S55.

4. Stunkard A, Allison K. Two forms of disordered eating in obesity: binge eating and night eating. International journal of obesity 2003;27:1-12.

5. Hsu L, Mulliken B, McDonagh B, Krupa Das S, Rand W, Fairburn CG, et al. Binge eating disorder in extreme obesity. International Journal of Obesity 2002;26:1398-403.

6.  Lamerz A, Kuepper-Nybelen J, Bruning N, Wehle C, Trost-Brinkhues G, Brenner H, et al. Prevalence of obesity, binge eating and night eating in a cross sectional filed survey of 6-year-old children and their parents in a German urban population. Journal of Child Psychology and Psychiatry 2005;46(4):385-93.

7. Braet C, Van Strien T. Assessemnt of emotional, externally induced and restrained eating behaviour in nine to twelve-year-old obese and non-obese childern. Behaviour Reserach Therepy 1997;35(9):863-73.

8. Vander Wal JS, Thelen MH. Eating and body image concerns among obese and average weight children. Addictive behaviours 2000;25(5):775-78.

9. Neumark-Sztainer D, Story M, Hannan PJ, Perry CL, Irving LM. Weight-related concerns and behaviors among overweight and nonoverweight adolescents: Implications for preventing weight related disorders. Archives of Pediatric and Adolescent Medicine 2002;156:171-78.

10. Boutelle K, Neumark-Sztainer D, Story M, Resnick M. Weight control behaviors among obese, overweight and nonoverweight adolescents. Journal of Pediatric Psychology 2002;27(6):531-40.

11. Stice E, Presnell K, Spangler D. Risk factors for binge eating onset in adolescent girls: A 2-year prospective investiagation. Health Psychology 2002;21(2):131-38.

12. French S, Jeffery R, Sherwood N, Neumark-Sztainer D. Prevalence and correlates of binge eating in a nonclinical sample of women enrolled in a weight gain prevention program. International Journal of Eating Disorders 1999;23:576-85.

13. Grucza RA, Przybeck TR, Cloninger RC. Prevalence and correlates of binge eating disorder in a community sample. Comprehensive Psychiatry 2007;48(2):124-31.

14. Serdar K, Mazzeo SE, Mitchell KS, Aggen SH, Kendler KS, Bulik CM. Correlates of weight instability across the lifespan in a population-based sample. International Journal of Eating Disorders 2010;early online view.

15. Tanofsky-Kraff M, Yanovski SZ, Schvey NA, Gustafson J, Yanovski JA. A prospective study of loss of control eating for body weight gain in children at high risk of adult obesity. International Journal of Eating Disorders 2009;42:26-30.

16. Stice E, Presnell K, Shaw H, Rohde P. Psychological and behavioural risk factors for obesity onset in adolescent girls: A prospective study. Journal of consulting and clinical psychology 2005;73(2):195-202.

17. Neumark-Sztainer D, Wall M, Guo J, Story M, Haines J, Eisenberg M. Obesity, disordered eating, and eating disorders in a longitudinal study of adolescents: How do dieters fare 5 year later? Journal of the American Dietetic Association 2006;106(4):559-68

18. Fairburn CG, Cooper Z, Doll H, Norman P, O'Connor M. The natural course of Bulimia Nervosa and Binge Eating Disorder in Young Women. Archives of General Psychiatry 2000;57(7):659-65.

19. Byrne S, Cooper Z, Fairburn C. Weight maintenance and relapse in obesity: a qualitative study. International Journal of Obesity 2003;27:955-62.

20. Kayman S, Bruvold W, Stern JS. Maintenance and relapse after weight loss in women: behavioral aspects. American Journal of Clinical Nutrition 1990;52:800-7.

21. Foster G, Wadden T, Swain R, Stunkard A, Platte P, Vogt R. The eating inventory in obese women: clinical correlates and relationship to weight loss. International Journal of Obesity 1998;22:778-85.

22. Hainer V, Kunesova M, Bellisle F, Hill M, Braunerova R, M W, et al. Psycholobehavioral and nutritional predictors of weight loss in obese women treated with sibutramine. International Journal of Obesity 2005;29:208-16.

23. Luppino FS, de Wit LM, Bouvy PF, Stijnen T, Cuijpers P, Penninx BW, et al. Overweight, obesity and Depression: A systamatic review and meta-analsis of longitudinal studies. Archives of General Psychiatry 2010;67(3):220-29.

24. Hay PJ, de Angelis C, Millar H, Mond JM. Bulimia nervosa and health literacy of general practitioners. Primary Care and Community Psychiatry 2006;10:103-08.

25. Hay PJ, Darby AM, Mond JM. Knowledge and beliefs about bulimia nervosa and its treatment: a comparative study of three disciplines. Journal of Clinical Psychology in Medical settings 2007;14:59-68.

26. Mond JM, Hay PJ, Rodgers B, Owen C. Health service utilization for eating disorders: findings from a community based study. International Journal of Eating Disorders 2007;40(5):399-408.

27. Striegel-Moore R, DeBar L, Wilson G, Dickerson J, Rosselli F, Perrin N, et al. Health services use in eating disorders. Psychological Medicine 2008;38:1465-74.

28.  Hart LM, Granillo TM, Jorm AF, Paxton SJ. Unmet need for treatment in the eating disorders: A systematic review of eating disorder specific treatment seeking among community cases. Clnical Psychology Review 2011;31:727-35.

29. Mond J, Myers T,, Crosby R, Hay P, Mitchell J. Bulimic eating disorders in primary care: Hidden Morbidity Still? J Clin Psychol Med Settings 2010; 17:56-63

30. Grilo CM, Masheb R, Wilson GT, Gueorguieva R, White MA. Cognitive-behavioural therapy, behavioral weight loss, and sequential treatment for obese patients with binge eating disorder: A randomised control trial. Journal of consulting and clinical psychology 2011;79(5):675-85.

31. Golay A, Laurent-Jaccard A, Habicht F, Gachoud JP et al. Effect of Orlistat in obese patients with binge eating disorder. Obesity Research 2005; 3: 1701-1708.

32. Grilo CM, Masheb RM, Salant SL. Cognitive behavioural therapy guided self help and Orlistat for the treatment of binge eating dusorder: A randomised, double blind, placebo controlled trial. Biological Psychiatry 2005; 57: 301-309.  

 

 

Page reviewed: 6 September, 2012