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

ID: 
36
Personal Details
Organisation Name: 
Australian and New Zealand Obesity Society
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?: 

 

Implementation by health professionals will require the production of a smaller document based around a clear algorithm for weight management that contains more practical examples of appropriate actions.  An effective distribution system will be required including the integration of the core weight management algorithm into existing GP software (with prompts) as well as existing practice guidance documents of other health professionals.

Key health professional organisations will need to be co-opted into integrating these guidelines into their existing training and update courses as well as placing them onto the program of continuing professional development sessions and conferences

 

Specific comments
Comments: 
9.2 Other factors in assessment

P 53 Last table

Should include menstrual history if girls.

This is to highlight early identification of PCOS features from childhood.

10.1 Explaining the benefits of weight management

Page 55 table 1

Should include other cardiovascular abnormalities - early markers well studied now in childhood- only few references included

Increased carotid intima media thickness:  Huang K et al. Arch Pediatr Adolesc Med. 2010 Sep;164(9):846-51.Meyer AA et al Pediatrics. 2006 May;117(5):1560-7.

Vascular endothelial dysfunction:   Meyer AA et al Pediatrics. 2006 May;117(5):1560-7. Pena A et al. J Clin Endocrinol Metab. 2006 Nov;91(11):4467-71. Epub 2006 Aug 8.

10.1 Explaining the benefits of weight management

Page 55 table 1 Endocrine

Should include a very common cause of referral for obese children

Premature adrenarche Sopher AB et al. Obesity (Silver Spring). 2011 Jun;19(6):1259-64. Epub 2011 Feb 10.

13.1 Assessment

page 68 table 13. 1

Comment to case 10, 11, 12,15 and 16

Should add in Arrange section for cases mentioned to "Ensure regular review"

This is as per recommendation 19 Page 57 …. Involve frequent contact with health professionals.

6.2 Intensive interventions

Section 6.2.1 Very Low Energy Diets

This section has confused partial and full meal replacement therapy with VLED.  When only 1 or 2 meals are replaced it is no longer a VLED but a low energy diet.  The paragraph should be changed accordingly or the heading should read Full or Partial Meal replacement therapy.  Partial meal replacement therapy has been shown to be an effective intervention technique with good long term outcomes in many studies and deserves to be mentioned in its own right.

6.2 Intensive interventions

section 6.2.1

Discussing very low energy diets should have an extra dot point that states “should always be followed by a weight maintenance programme to aid in weight loss retention.

 

8 Practice guide

It is important to be mindful of patients reason for attending GP in first place.  A big xomplaint from patients is that they are seeing their GP for an important concern and all the GP talks about is weight loss without addressing the issue they have come in for.  IT should be advised to doctors to first talk about the reason they have come in and then link this to weight concerns.

Eg in case study 1 The advise should include discuss the impact of weight on sleep problems not just the benefits of a healthy lifestyle.

 

Case study 3

Advise suggest: congratulate the man on attempting to quit and acknowledge that it often takes many attempts before success. It would also be wise to discuss the impact of giving up smoking has on weight so that he can be prepared and not go back to smoking because weight gain occurs.

 

Case study 4

The advise should start by saying that there are a a few public clinics that address bariatric surgery and that the doctor will investigate where these are but in the mean time why don’t they try the more intensive intervention and that weight loss now will not preclude them from getting surgery later.

 

Case study 5

Advise IT is too late to be saying to the mother that she should have been smaller why not take a different approach and discuss the importance of good nutrition during pregnancy and the need to not over-consume (ie eat for two) during this period.  And that although weight loss is not recommended keeping weight gain down will help both her during pregnancy and the baby. Then perhaps go on and talk about the impact of too much weight during the birthing process.  However, this is not the time to get the mother completely stressed out by her pregnancy.

 

Case study 6

Advise the first thing you would discuss is why has he not be taking his mineral and vitamin supplement as he should have been taking this from the time of surgery if he has been regularly followed up then asking if he has been taking his mineral and vitamin supplement should have been asked several times and assuming it is now several visits down the track it has become obvious that he has not been taking his supplementation.

 

Case study 7

Advise

Explain that some weight regain is normal after the reintroduction of food as carbohydrate intake has normally increased and therefore lead to increased storage of glycogen and water.  The key is to make sure that no further weight gain occurs.

 

Case study 8

Advise

Investigate whether she is eating for emotional reasons rather than due to hunger

 

4.3 Other factors in assessment of health risk in adults

table 4.7

Steriods are not included as a class of drugs cntributing to weight gain

2 Factors contributing to overweight and obesity

It may be useful to include a list of medical conditions listed early in the document that cause weight gain - hypothyroidism, Cushing's syndrome etc.

3.1 Approach to prevention and management in individuals

Notes that mental health should be taken into account in assessing risk factors and developing treatment plans – more specific advice required re how to do this.

4.3 Other factors in assessment of health risk in adults

Expertise required to assess mental health problems should be acknowledged. Other mental health issues (e.g., disordered eating), in addition to depression, should to be explicitly discussed.

5.1 Explaining the health risks associated with overweight and obesity

Disordered eating is not included in mental health – disordered eating is one of the most prevalence mental illnesses in obese adults and it has very important implications in treatment – this needs to be explicitly noted in this section

6.1 Lifestyle interventions

6.1.3 Supporting behavioural changes

Most health professionals report that they have not received adequate training in the use of behaviour change strategies therefore delivery in primary care is likely to be impaired.

Notes that more intensive psychological intervention may be required in those with mental health issues. However, more intensive behavioural weight loss interventions are likely to be helpful in anyone having difficulty achieving behaviour change (not just those with a mental illness).

6.1 Lifestyle interventions

Table 6.10 Summary of weight management interventions

Table does not mention psychological interventions? The Cochrane systematic review of psychological interventions demonstrates the benefits of psychological interventions however this is not listed in the table.

 

6.3 Developing an appropriate weight loss program

6.3.1 Therapeutic engagement

Note role of motivational interviewing and associated strategies effective in improving engagement (compared to standard care).

7 Arrange

Table 7.1 Knowing when to refer

“When specific health indicators demonstrate increased health risks (e.g., increased blood pressure, lipid profiles and blood glucose) and the individual would benefit from interventions related to weight loss.” – mental health issues not included

7.2 Long-term weight management

7.2 Long term weight management

Should be more specific about the type of group programs that are helpful e.g., behavioural weight loss interventions, self-management interventions

9.2 Other factors in assessment

9.2 Other factors in assessment

Family functioning, capacity to make changes to the family environment required to support behavioural change and additional support needs should be included assessment.

 

10.1 Explaining the benefits of weight management

Social impacts (e.g., discrimination, teasing, exclusion) are not mentioned in the review of the adverse consequences of overweight and obesity in children & explaining the benefits of weight management yet these social factors are most immediate, what parents are most concerned about and the most common triggers for treatment.

11.3 Weight management interventions

11.3.1 Lifestyle interventions

Behavioural family interventions/parenting interventions need to be explicitly mentioned in the table – this is not the same as behaviour modification

11.3 Weight management interventions

Table 11.4 Practical information....

Target whole of family change – do not single out overweight/obese children.

Focus on the health benefits rather than weight benefits of health behaviour changes

 

Table 11.6 Effect of measure to augment lifestyle intervention

Behavioural family interventions/parenting interventions need to be explicitly mentioned in the table – this is not the same as patient education

12.1 Monitoring and review

12.1.3 Assessing child and family eating, activity and weight control

Parental/family modelling/message regarding body image (not just child body image) need to be included.

Non-hungry eating is different from disordered eating (e.g., binge eating).

13.1 Assessment

Case study 11

Eating behaviours could be due to disordered eating (e.g., binge eating disorder, night eating syndrome)

Case study 14

Assessment and treatment of disordered eating (i.e., binge eating) is not addressed.

General comments
Comments: 

The Australian and New Zealand Obesity Society (ANZOS) is a professional society that represents  a wide range of researchers, clinical practitioners  (physicians, GPs nurses, dietitians, psychologists etc.), public health practitioners and educators workingto improve the understanding, management or prevention of obesity.   The broad membership of ANZOS means that there may be significant variations in opinion on some issues around the management of obesity in adults and children and thus this response to the NHMRC guidelines is focussed more on the broader themes and principles but also addresses issues within specific recommendations as raised by our individual members.

 

ANZOS is very supportive of the need for, and value of clinical guidelines on the management of Overweight and Obesity in Adults, Adolescents and Children.   We broadly support the structure, content and tone of the guidelines and complement the committee and consultants on the current draft.  In particular ANZOS would like to support the revised guidelines approach to some key issues:

 

  • The comprehensive and logical review of the evidence that was driven by specific questions of practice.
  • The translation of the evidence into a clear and graded set of recommendations
  • The willingness to build upon existing, international obesity guidelines and integrate with other Australian clinical guidelines
  • The production of one unified set of guidelines which address adults, adolescents and children
  • Ensuring the relevance of recommendations to a wide range of health professionals with the potential to lead or partner weight management programs.
  • The recognition of the broad environmental and physiological factors that influence an individual’s ability to control their own weight or make changes to reduce weight.
  • The statement that care to an individual should be delivered in a non-judgemental or directive way and should allow the individual to participate in their own care.  
  • The use of an accepted clinical decision-making process – 5As
  • The inclusion of broader principles of behaviour change(including readiness to change)
  • The reference to cost and resource implications of specific recommendations

  

General issues which ANZOS feels  are  missing from or not so well addressed within the draft guidelines include:

 

  • There remain some uncertainties around the use and application of the “NHMRC levels of Evidence and Grades for Recommendations”.  It is not clear from the guideline reviews how the grades were generated and the relative influence of the amount of evidence, the quality of the evidence and the size of the observed effect
  • Although it is recommended that weight history be recorded for both adults and children,  the identification of high risk individuals is based solely on current BMI and/or waist circumference measurements. Weight change is an independent health risk factor and a high and increasing weight or an acceptable and increasing weight may pose more risk than a high but stable weight status.  This is particularly so in children where a single BMI measurement has greater potential to misrepresent the true weight status of a child.
  • More attention should be paid to behaviour chnage approaches and the role of psychologists in facilitating such interventions

 

Page reviewed: 6 September, 2012