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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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Organisation Name: 
Nutrition Department, Royal Children's Hospital Melbourne
Additional Information
In regard to your comments, do you have a Conflict of Interest to disclose?: 
Specific questions
Question 2: What would help you implement these recommendations into practice?: 

We have concern about the ‘Advise’ section within all groups, but particularly for children and adolescents. An assumption that discussions of risk associated with overweight prompts translation into change of practice by the individual is unfounded. Whilst 90% of parents in a large study indicated a belief that parents has the greatest responsibility for reducing childhood overweight this does not always translate into positive outcomes.  Personal responses to the news of overweight vary and are often in parallel with the determinants of overweight- responses relate to gender, parental education, to socio-economic status and with cultural background.  Other factors affecting response are family lifestyle, maternal overweight, the hours parents (especially fathers) spend with their child and the families’ estimation of the problem.  More than 30% parents underestimate the weight of their children and this is more marked when children are overweight and parents are more likely to underestimate weight in boys than in girls. 

Recommend: Reduce or minimise the content of ‘Advise’ sections, and increase the emphasis on ‘Assist’ sections.


Greater attention to sensitivity of approach, specific wording used in conversation, particularly with children and adolescents, is required.  Raising the issue of a child’s weight is a difficult issue and requires sensitivity of approach by skilled and confident health workers.  International and Australian studies indicate the reluctance of health care professionals to raise the issue of overweight children with parents.  A number of studies, including the Victorian LEAP study, showed practitioners felt more comfortable after training.  Family’s perceptions, and wording used are important  for example: ‘fatness’ and ‘obesity’ are perceived as negative terms but the terms ‘weight’, ‘overweight’ and ‘higher BMI’ are less likely to offend.  At The RCH we use the term ‘above his/her healthiest weight’ and aiming for ‘the healthiest weight’ for your child.  Even more important than the language are the attitude and degree of comfort which accompanies the conversation. There are lessons to be learned from others areas of communicating health  and ‘bad news’, where considerably more research has been done than in obesity.


Recommend:  Greater attention to the issue of ‘how’ to raise the issue of weight with parents, children and adolescents. Discussion with families indicates improved communication comes from: 

  • Concern, rather than professional detachment.
  • Confident, caring and concerned attitude.
  • Plenty of time for questions.
  • Written information to support the discussion (or details of where to find it).
  • Valuing the child and respecting the parents.


Specific comments

PART A  Overweight and obesity in Australia

Section 1: Trends in overweight and obesity

1.1   Definition, or cross-reference to other sections, is required for definitions of ‘overweight’ and ‘obesity’, i.e. BMI reference range, waist circumference, waist:hip ratios, etc.

Use of the comparison between energy intake as ‘equivalents to x slice of bread’ is good but also needs quantification. i.e. an extra 400kJ over the past x years.



PART B Weight management in Adults

Section 4: Ask and Assess

4.2.1 Identifying risk level associated with waist circumference. Use of racial background to discern difference in level of risk associated with waist circumference provides interesting background but questionable about translation of this point into practice.

4.3 Other factors in assessment in health risk in adults. There are no mention of lifestyle factors (eg diet, physical activity) predisposing to overweight, which appears a major oversight in this section.

4.3.4 Readiness to change – good and essential component


Section 5: Advise

Recommend minimise the emphasis on this section. The evidence base that this approach motivates individuals to change behaviour is lacking. Recommend less emphasis on ‘advise’ and greater emphasis on ‘assist’.

5.1 Explaining the health risks associated with overweight and obesity. Risk explanation is generally not the best motivator for people to change; will depend on their self-efficacy and broader determinants.  

5.2 Explaining the benefits of lifestyle change and weight loss. This is a preferred approach than explanation about health risks. Recommend place this section (benefits) prior to section 5.1 (risks)


Section 6: Assist

6.1 Lifestyle interventions

Good recognition of the essential key components (nutrition, physical activity and behavioural modifications) used concurrently in weight management approaches. 

We question the benefit of emphasis on food label reading as an intervention. Recommend more practical examples such as physical activity and practical dietary changes examples.

Recommend include a small discussion about the role of carbohydrates in weight management as a possible controversial area.  

Table 6.6 Physical activity interventions for promoting weight loss. This requires additional detail about time period required. For example xx kg weight loss over xx months.

6.1.3 Good overview of supporting behavioural change approach. Recommend greater detail and examples of possible strategies.

6.1.4   Complementary therapies. Good inclusion of this topic

6.2 Intensive interventions includes bariatric surgery, very low energy diets, medications,/statins. This section needs a cautionary note about contradictions e.g.; children.  

6.4. Tailoring for specific populations. Sections 6.4.3 Rural and remote, 6.4.4 Aboriginal and Torres Strait Islander peoples, 6.4.5 CALD appear non-specific and tokenistic.


PART C Children and Adolescents

Section 9: Ask and Assess

In the section ‘chronic diseases’ recommend inclusion of impaired psychosocial function, isolation, bullying, low self esteem. Concerns around stigmatisation and the psycho-social effects of overweight are more likely to be of concern to parents than physical problems. 

Use of CDC BMI centile should be qualified with a statement about clinical judgement. For example a mesomorph may appear to be ‘overweight’, but have a very low percentage body fat.  Although BMI was initially developed for use in populations and epidemiological studies, it is now clearly useful as part of a total assessment for individuals –as are body type, genetic predisposition etc.

Revise Recommendation 17: According to current best practice paediatric practice, BMI centile charts are used for all children and adolescents up to 18 years of age, not just pre-pubertal adolescents.  Assessment of pre and post-pubertal status would prove difficult in many primary health care settings and therefore not a practical approach.

Also include mention of how schools and other agencies can assist with setting and policy, but should be discouraged from weighing, calculating BMIs and providing feedback about weight status.

9.2.1 History

Include menstrual history as many overweight females are amenorraeic

9.2.2 Clinical assessment

Blood tests may be relevant in some instances 

Section 10: Advise

As mentioned in overall comments, we question the applicability of this approach ‘Advise’.

‘Key messages’ set the scene for the content of the section which is a bit ambiguous at first (see comment above).

‘The older and more overweight a child or adolescent, the more likely the same level of overweight will persist into adulthood’ could be rephrased to ‘Older and more significantly overweight children and adolescents are more likely to remain overweight to the same degree as an adult’.

Section 11:   Assist

Recommend that some of these recommendations could be expanded to be more specific and therefore more easily adhered to by the child / family.  

Recommendation 19:  Plan weight management programs for children and adolescents that involve frequent contact with health professionals: Recommend time period for ‘frequent’ review eg; weekly/monthly etc

Table 11.4: Practical information for parents to support healthy eating in children

Noted some non-specific recommendations i.e. “ensure children have regular meals” –this needs further explanation.

Some conflicting messages i.e. “avoid classifying foods as good or bad” however next line down recommends having “healthy foods readily available” and subsequently “avoid regularly using unhealthy foods as treats or rewards” i.e should we be using different terminology such as “energy-dense” to move away from “bad” and “good”?

Table 11.5:  Practical information for parents to support physical activity and reduce sedentary behaviour in children - “Be a good role-model by being physically active yourself” should include more specific examples and cross-reference with adult physical activity recommendations e.g. Put together at least 30 minutes of moderate-intensity physical activity on most, preferably all, days etc. 

Section 12:   Arrange
This section provides a comprehensive overview and guidelines taking into account psychosocial and body image factors, in addition to dietary and exercise behaviours and with appropriate indicators for specialist referral. In particular, we agree that

  • Weight management services should offer minimum 3 monthly review.
  • Regular monitoring is co-morbidities is essential
  • Raises the important issue of transition from paediatric to adult services.

Section 13:  Practice guide – weight management in children and adolescents

Include length-for-age charts for girls and boys birth to 2 years as well. BMI charts for boys and girls 2 to 20 years should be labeled as sourced from CDC.

Also recommend include CDC weight-for-age and height-for-age charts for boys and girls over 2 years.

Need explanation about why WHO charts for under 2 years and CDC charts for over 2 years.


PART D. Areas for future research

Recommend re-ordering of areas for future research focusing on the bigger picture issues through to specific sub-groups. We also recommend additional research topics specifically for children and adolescents:

  • 3. Weight loss related to health benefits
    • Adequate research into children and adolescent mental health
    • NAFLD children with continuing issues in adulthood
  • 1. Health system recommendations for research
    • health system benefits (days at work, compensation, medicare)
    • First point summary of ‘effectiveness’ section.
    • Last point ?include in specific populations section
  • 4. Effectiveness of weight loss and weight maintenance interventions
    • Good section, should help us work out why we are not being successful
  • 2. Health workforce training
    • Good
  • 7. Children and adolescents
    • Looks good, but include health benefits as above also
  • 5. Bariatric surgery
    • Comprehensive and obvious focus following media attention
  • 6. Specific populations
    • Newly arrived immigrants
    • Needs to ensure accurately reflects current Australian population
    • Appropriate translations and catering to literacy levels
General comments

It is noted that an implementation and dissemination strategy is planned for the guidelines. We agree this is an essential component of the guidelines development.

Recommend: End-user consultation to determine and develop relevant resource / practice guidelines for practitioners.

Page reviewed: 6 September, 2012