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

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Australian Medical Association
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AMA Submission

Clinical Guidelines for Management of Overweight and Obesity in Adults, Adolescents and Children for Primary Care Health Professionals

 

Introduction

An increasing number of Australians are at high risk of serious diseases and premature death because of excess body weight or obesity.  More than two thirds of Australian adults are either overweight or obese and 23 per cent of children aged 2 – 16 years are either overweight or obese.

 

Obesity substantially contributes to preventable, non-communicable diseases, shortened life-expectancy and impaired quality of life. Obesity is a major risk factor for chronic conditions such as type 2 diabetes, heart disease, hypertension, stroke, musculoskeletal disorders and impaired psychosocial functioning. Obesity is now challenging smoking as the major cause of potentially preventable death in Australia.

 

General Practitioners (GPs) are a trusted and highly trained source of health information and advice.  Approximately 83 per cent of Australians visit their GP at least once per year. [i]  GPs therefore have a significant role in identifying patients who are overweight and obese.  GPs also support patients who wish to lose weight. [ii]  Waiting room surveys of patients found that 78 percent of patients felt GPs had a role in weight management and over 80 per cent were likely to follow weight loss recommendations). [iii]  However the identification and management of overweight and obesity is just one component of a GPs workload that includes providing care for patients with chronic or complex health conditions.  The revised Clinical Guidelines must provide practical support for GPs who are engaging with patients who wish to lose weight.

 

Prevention of overweight and obesity

In tackling obesity, it is important to consider the potential for preventative intervention at multiple stages, including reducing the chances that excess weight gain will occur, to interrupt or minimise the progress of unhealthy weight gain at an early stage and to attempt to halt or reduce existing health problems associated with unhealthy weight gain. [iv]  It is important to focus on children and young people for obesity prevention because of the evidence that excess body weight in childhood or adolescence is a strong predictor of obesity or health problems in adulthood. [v]

 

At an individual level, prevention of overweight and obesity involves identifying patients at risk and encouraging them to eat less and exercise more.  However, the aetiology of obesity is complex, as there may be a range of contributing factors that are often outside of an individual’s control.  These factors include access to and affordability of healthy foods, exposure to unhealthy food advertising and environmental factors such as urban design and access to safe space to exercise.  While the Clinical Guidelines focus on the interactions at an individual level it is important to recognise that interventions that target the broader contributing factors may have more impact on obesity for the population as a whole. [vi]  Such interventions are likely to require support from a range of stakeholders including governments, non government organisations, the health and food industries, the media, employers, schools and community organisations.

 

Supporting medical professionals in combating overweight and obesity

Given the extent of the problem, it is essential that the updated Clinical Guidelines provide practical and realistic advice to GPs who are supporting patients who are engaged in weight reduction.  The Clinical Guidelines must also be readily accessible in a format that recognises the dynamic nature of General Practice.

 

Evidence about the effectiveness of any single weight loss intervention is limited.  Patients value the advice provided by their doctor and many patients will seek information and support relating to weight reduction.  Advice and support that is tailored to suit the needs of the patient is likely to have the greatest chance of success.  Unfortunately the provision of tailored advice and support does not guarantee that patients will be able to sustain the necessary behaviour change.  This raises some questions about how ‘success’ is measured.  It also highlights the need for medical practitioners to be provided with up to date evidence summaries on the various approaches to weight loss.

 

It is also important to ensure that opportunities are extended to GPs so that they can spend sufficient time with patients who are at risk, or who are already overweight or obese.  Patients have expressed positive views about the lifestyle advice received from their GPs but only 46 per cent felt that GPs had enough time to provide effective weight loss advice. [vii]  While not the focus of this review, it may be timely to consider the classification of obesity as a chronic disease, in turn facilitating access to GP Management Plans and Team Care Arrangements. This would make Medicare rebates available to support visits to allied health professionals including dieticians and exercise physiologists.

 

As noted earlier, many (if not most) attempts at weight reduction will be unsuccessful.  It is difficult for patients to commit to long term behaviour change, but there are also physiological responses that encourage weight regain.  These difficulties highlight the need to support GPs and their patients who are engaged in a program of weight reduction, especially in circumstances where previous weight loss efforts have failed.

 

For some patients the expectation that they will return to their healthy weight range may not be realistic.  Patients who have unrealistic expectations about weight loss may be easily disheartened.  As recognised in the revised Clinical Guidelines, small amounts of weight loss (5 per cent) or weight maintenance may be a more realistic and achievable goal for some people.  Resources that recognise this should be developed.

 

Parents may have difficulties recognising that their child is overweight or obese and parents are unlikely to raise concerns about their child’s weight with their GP. [viii]  For GPs, this can make discussions with parents particularly difficult.  For overweight and obese children there will be less focus on weight reduction.  GPs play an important role in supporting parents to adopt family based strategies that improve eating habits and increase physical activity.  This is another area where practical resources (for both patients and GPs) are essential. 

 

An often overlooked group of patients who may require additional support with weight loss or weight maintenance are patients who are experiencing mental illness.  A number of medications prescribed for mental illness may encourage weight gain.  Doctors are an extremely important source of tailored information and support for patients who are affected by these medications.  Again, practical resources for doctors and patients are important.

 

In an Australian survey concerned with weight loss medication, half of participants stating that they would be unlikely to take medication to lose weight. [ix]  However, for some patients, lifestyle approaches to weight loss may need to be supplemented by weight reduction medication.  The draft Clinical Guidelines note that two medications are currently registered for use in the treatment of overweight and obesity.  It is likely that the number of weight loss medications will grow.  It is important that all new medications are thoroughly assessed and only made available once their safety and efficacy is established.  Medications that have been associated with serious adverse effects should be made available to patients only by medical prescription so medical practitioners can discuss the potential risks and benefits to enable patients to be informed participants in the treatment plan and ensure patients are closely monitored for adverse events.

 

While these Guidelines tend to focus on the role of the GP, it is important to note that other medical practitioners will have opportunities to engage patients in discussions around excess body weight.  Patients may be particularly receptive to the advice and referral provided by these doctors, particularly if excess body weight has contributed to an acute health problem. Online resources, tailored to suit the needs of medical specialists who are engaging with patients about weight loss will also be valuable.

 

Referral and resources

Some groups of patients may face additional barriers to weight loss.  Practical resources that recognise these difficulties and provide strategies that minimise barriers to weight loss must be developed.  Resources must also be accessible to culturally and linguistically diverse populations. These resources should include but are not limited to:

 

  • Two or three day eating plans for doctors to provide to patients who are at risk of common diet related health problems such as prediabetes and high blood pressure. These plans would provide patients with initial guidance about appropriate food choices and can be followed up with more specific advice from an accredited dietician;

 

  • Evidence summaries about the latest approaches to weight loss, including medications, popular eating plans such as VLCD & commercial weight loss programs.  This information will support discussions around approaches to weight loss between patients and GPs.

 

  • Multi media videos and fact sheets that summarise the Australian Dietary Guidelines for GPs and other medical professionals.  Similar videos and facts sheets that support patient discussions around weight loss would also be helpful and should be developed in consultation with the relevant medical colleges and professional associations;

 

In order to ensure that the resources are suitable, specific engagement with GPs during their development must be undertaken.  In the longer term, ongoing evaluation will help identify any shortfalls in information.  Existing resources such as Life Scripts would also benefit from regular review that considers their uptake and use.  The AMA recognises that GPs are not the only source of weight related information, advice and support.  If weight loss support is provided through a multi disciplinary team it is essential that the treating GP is kept informed of progress.

 

As noted in the draft Clinical Guidelines, GPs would benefit from having up to date information about programs and services that operate in their local area such as community dieticians, healthy cooking classes, group weight loss programs and sporting groups.  However, the AMA does not support the proposal that this information be compiled and maintained by each medical professional (or someone who is employed by them).  The AMA believes that this duplication of efforts could be avoided by developing lists for each local area.  The lists should be easily accessible and regularly updated (including information about cost, intake requirements and time frame).  Once established, Medicare Locals may be an appropriate organisation to undertake this activity.

 

In some cases, referral will mean a formal referral to a medical practitioner who specialises in bariatric surgery.  While the AMA believes referral should only be made when other approaches to weight loss have failed, the AMA recognises that for some adult patients this approach will be appropriate.  The bariatric surgery may be appropriate for adolescents who have significant co morbidities and where other measures have failed but it is unlikely to be appropriate for children.  Once a referral is made, it is important that prompt and appropriate access to a specialised service is available.

 

While not the focus of the Clinical Guidelines it is important to highlight that the practical resources aimed at GPs and other medical practitioners should be complemented with suitable education and training opportunities for medical students and junior doctors (focusing on prevalence, aetiology, treatment strategies).  Similar opportunities should also be made available to other medical practitioners, and ideally should be tailored to their clinical needs.

 

Summary

Clinical guidelines for the management of overweight and obesity are critical but the Guidelines must be supported by a range of other measures if Australia is to reduce the current prevalence of overweight and obesity.  Broadly focused initiatives that will compliment the Guidelines include access to and affordability of healthy foods, reduced exposure to unhealthy food advertising, easy to understand food labelling and environmental factors such as urban design and access to safe space to exercise.

 

A key challenge for the revised Clinical Guidelines is to ensure that they are not only evidence based but also practical and easy for GPs and other medical practitioners to adopt in their clinical practice.  Ongoing dialogue and assessment of the Guidelines with GPs and other medical professionals should be undertaken on a regular basis.  This will ensure that medical practitioners are being suitably supported in the provision of advice and support to patients who are overweight or obese.

 




[i] Britt H, Miller GC, Charles J, Henderson J, Bayram C, Pan Y, Valenti L, Harrison C, O’Halloran J & Fahridin S 2010. General practice activity in Australia 2009–10. General practice series no. 27.  Canberra: AIHW

[ii] Preventive Health Taskforce. (2009).  Australia: The healthiest country by 2020. Technical Report 1. Obesity in Australia: A need for urgent action including addendum for October 2008 to June 2009. Available from: http://www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/Content/E233F8695823F16CCA2574DD00818E64/$File/obesity-jul09.pdf

[iii] Tan, D., Zwar, N.A., Dennis, S.M., Vagholkar, S. (2006) Weight management in general practice: what do patients want?, MJA, 185: 73-75

[iv] Preventive Health Taskforce. (2009).  Australia: The healthiest country by 2020. Technical Report 1. Obesity in Australia: A need for urgent action including addendum for October 2008 to June 2009. Available from: http://www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/Content/E233F8695823F16CCA2574DD00818E64/$File/obesity-jul09.pdf

[v] Waters, E., de Silva-Sanigorski, A., Brown, T., Campbell, K. J., Gao, Y., Armstrong, R., Prosser, L., & Summerbell, C. D. (2011). Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews, Issue 11.

[vi] Gortmaker, S., Swinburnm B.A., Levy, D., Carter, R., Mabry, P.L., Finegood, D.T., Huang, T., Marsh, T., & Moodie, M. (2011). Changing the future of obesity: science, policy and action. The Lancet, 389: 838-847

[vii] Tan, D., Zwar, N.A., Dennis, S.M., Vagholkar, S. (2006) Weight management in general practice: what do patients want?, MJA, 185: 73-75

[viii] King, L., Loss, J., Wilkenfirld, R., Pagnini, D., Booth, M., & Booth, S. (2007). The Weight of opinion: General Practitioners perceptions about child and adolescent overweight and obesity.  NSW Centre for Overweight and Obesity.

[ix] Tan, D., Zwar, N.A., Dennis, S.M., Vagholkar, S. (2006) Weight management in general practice: what do patients want?, MJA, 185: 73-75

Page reviewed: 6 September, 2012