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

ID: 
39
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Organisation Name: 
Queensland University of Technology
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In regard to your comments, do you have a Conflict of Interest to disclose?: 
No
Specific comments
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Summary

p xii, Intended Audience

The intended audience is described as general practitioners, general practice nurses, Aboriginal and Torres Strait Islander health workers and allied health professionals.  These groups are referred to throughout the document.  As allied health professionals are a diverse group it would be useful to have some more specific reference to differing roles, scope of practice and those for whom these guidelines would be especially relevant.

1.3 High risk groups

The guidelines appropriately include Aboriginal and Torres Strait Islander peoples, and people from different regions of birth and cultural background, socioeconomic disadvantage and geographical location as high risk groups.  It is suggested that people with mental illness, especially those requiring medications linked with weight gain, could also be considered as a high risk group.

2.2 Drivers of weight gain

2.2.2 Environment

Multiple important environmental factors are included within drivers of weight gain.  Other potential factors that could be considered here include: changes in leisure based activities; emotional eating; cultural and social aspects of eating including alcohol and consumption of foods high in fat and sugar as part of workplace, family and other cultural activities.  The pleasurable aspects of food and eating could also be acknowledged.

Income should be acknowledged as an important determinant of poor dietary choices and consequent increase in risk of overweight and obesity. Multiple studies have suggested that household income is strongly associated with food insecurity, and consequent deviations from dietary recommendations as a result of insufficient financial resources to procure food. Furthermore, the cyclic nature of food insecurity may results in cycles of fasting and bingeing for individuals, which may impact on metabolic processes and further increase the risk of the development of overweight and obesity.

2.2.3  Biology

The overview of the role of biology in the aetiology of obesity provides a clear and succinct explanation of a complex topic.  This section could perhaps also consider evidence relating to transgenerational effects and the role of paternal nutrition (Glickman et al, 2007, Non-genomic transgenerational inheritance of disease risk BioEssays 29:145–154) although we acknowledge that further research is required in this area.

3.2 Health professionals involved in weight management

3.2.2 Multidisciplinary care teams

The description of the activities multi-disciplinary team members are involved in could also include identification of factors or behaviours contributing to the development or maintenance of overweight and obesity in individuals such as emotional eating, misconceptions, physical disability, lack of food skills or food insecurity.  Consideration of the importance of addressing these as part of interventions and the particular health care professional most appropriate to do so should also be included. 

4.1 Body mass index in adults

4.1.2 Interpreting the BMI

Table 4.3 considers factors which influence interpretation of BMI including increases in body mass with age and ethnic background.  We recognize that classifications are consistent with the conclusions of the WHO 2004 consultation (WHO expert consultation (2004) Appropriate body-mass-index for Asian populations and its implications for policy and intervention strategies.  Lancet 13; 363(9403):157-63).  However more specific reference should  be made to the proposed different thresholds and the possibility of their revision following further review.  In the event that cut-offs are modified the need for further education should also be considered.

We also query whether the suitability of the range cut-offs used for older adults has been considered, particularly with respect to risk of malnutrition and whether higher BMI thresholds should be used for this group.

4.3 Other factors in assessment of health risk in adults

Overall

In addition to the factors already included, this section could include the importance of assessment of psycho-social factors which may influence the suitability and feasibility of interventions.  These could include socio-economic status, education, work patterns and ethnic background. 

4.3.1  Risk or presence of comorbidities

This section identifies key co-morbidities associated with excess weight.  It is suggested that Polycystic Ovarian Syndrome could also be considered in assessment of pre-menopausal women.

4.3.3  Weight history

A useful list of questions that could be relevant in taking a weight history is provided here.  Other questions that could be considered are:

Has the person used over the counter meal replacements?

Has the person used complementary and alternative medications recommended for weight loss?

Has the person used other sources to obtain information on weight loss (e.g. internet, magazines, books or friends)?

5.2 Explaining the benefits of lifestyle change and weight loss

Table 5.2 could also consider evidence relating to the benefits of weight loss with respect to insulin resistance

6.1 Lifestyle interventions

6.1.1  Reducing energy intake

Within the cost and resource implications box guidelines state "...development of a tailored program to create an energy deficit may be more cost effective if delivered by a dietitian or nutrition expert."  According to the Dietitians Association of Australia (DAA) "Accredited Practising Dietitians (APDs) have the qualifications and skills to provide expert nutrition and dietary advice to both groups and individuals" (http://daa.asn.au/for-the-public/find-an-apd/what-is-an-accredited-practising-dietitian/, accessed 30-04-2012).  The DAA also state that the "Accredited Nutritionist" credential specifically excludes individual dietary counselling.  The inclusion of the term "nutrition expert" alongside "dietitian" in this sentence therefore seems unnecessary and broad and also could condone the involvement of persons who consider themselves "nutrition experts" that do not have rigorous qualifications or use an evidence based approach.

With respect to the section overall this is a simplistic approach to weight loss, as it fails to acknowledge the importance of socio-demographic factors in the development of overweight and obesity. Earlier in the document itself it is acknowledged that individuals from lower socioeconomic groups are at high risk of experiencing overweight and obesity, in many cases this is predominantly due to low household incomes, which results in insufficient financial resources with which to acquire sufficient amounts of healthy food. Guidance on the selection of healthy foods to fit in to a budget should be included in the practical information outlined in Table 6.2.

On page 20 the document states that "Several dietary interventions can produce weight loss, including low carbohydrate diets (in which <40% of total energy is obtained from carbohydrates)..."  We agree that there is at least short term evidence that these diets can produce weight loss.  However the limited time duration of most of these studies could be stated here.  In addition consumption of 40% of energy as carbohydrate is inconsistent with NHMRC Nutrient Reference Values for Australia and New Zealand Acceptable Macronutrient Distribution Ranges for lowering chronic disease risk of 45 to 65% of energy from carbohydrate (NHMRC, 2006, p 271).  Therefore some acknowledgement of the limitations and inconsistency of this statement with other recommendations would be useful. 

Practical considerations influencing compliance with the dietary guidelines could also be considered.  These include factors such as cost, accessibility and availability, taste preferences, convenience, cooking skills and storage and preparation facilities.

This section also does not consider options for approaches in delivery for nutrition based interventions.  In particular the limitations and benefits of individual vs. group based interventions as the use of group based interventions is a common method of delivery within health services.  These factors also have important cost and resource delivery implications which could be considered within recommendation 10. 

CALD groups have been identified as being at high risk of experiencing overweight or obesity, in part; this may be due to food insecurity resulting from inability to access culturally-appropriate and familiar foods. The ability to suggest appropriate alternatives or assist in locating sources of familiar food should be included in the practical information in Table 6.2.

6.1.2 Increasing physical activity

The final two evidence statements relating to physical activity duration per week and specified weight losses of 2-3kg and 5-7.5kg are confusing as written as they do not specify the period of time over which this weight loss has occurred and could be interpreted as expected weight loss per week.

6.2 Intensive interventions

6.2.1 Very low energy diets

In the section ‘Discussing very low-energy diets’, points to be included are the encouragement of two litres of fluid per day, and the possible inclusion of a fibre supplement. Both of these strategies are regularly implemented in practice to aid in the prevention of constipation, which is an acknowledged side effect of meal replacement therapy.

6.2.2 Weight loss medications

The medication rimonabant is included within the list of those shown to increase weight loss.  While it is not mentioned elsewhere in the document we do query the need to include reference to a drug that has been suspended and was never approved for use in Australia.

6.2.3 Bariatric surgery

In bariatric surgery degree of weight loss is reported as percentage excess weight loss (EWL) rather than % of total body weight.  Approximately 50% EWL has been reported over 10 years in LAGB, GB and RYGB.  LSG being a newer procedure has yet to have data of greater than 10 years follow up.

Stomach ulceration is a contraindication for a LSG and should be included in medical comorbidities.  Also iron and folate should be included in simple blood tests to be monitored within nutrient status.

6.4 Tailoring weight management programs to specific population groups

6.4 General

Despite the acknowledgement that lower-socioeconomic groups are at higher risk of experiencing overweight or obesity, this group has been omitted from the section ‘Tailoring weight management programs to specific population subgroups’. Based on the results of multiple national surveys, it is known that those from lower socioeconomic groups (specifically those with lower household incomes and lower levels of education) are at higher risk of experiencing overweight and obesity. Given these findings, and the severity and importance of obesity as a public health issue, information about the tailoring of weight management programs to suit lower-socioeconomic groups should be included in this section.

6.4.4  Aboriginal and Torres Strait Islander peoples

The section on Aboriginal and Torres Strait Islander peoples could specify the importance and potential benefits of traditional foods and food acquisition skills as part of culturally appropriate messages and skills. 

6.4.5  People from culturally and linguistically diverse backgrounds

This section should be more explicit about the importance of creating a diet/ healthy eating plan that incorporates culturally-appropriate and familiar foods or appropriate alternatives, and the importance of assisting clients to identify sources of these foods.

7.1 Review and monitoring

7.1.2  Review in the first three months

We agree with the value of fortnightly review for the first three months however do question the feasibility of compliance and resource implications, especially for groups most at risk.

7.2 Long-term weight management

7.2.1  Discussing long-term weight management

There appears to be an inconsistency within this section with the recommendation that it may be helpful to set a weight regain limit (e.g. 3-4 kg) whereas the evidence given states that "recovery from weight regains of more than 2.6 kg is difficult" (Phelan et al 2003).

We agree the strategy "reduce emotional eating" is relevant to weight maintenance.  However we question the usefulness of this simplistic statement with limited reference to further guidance or suggestions as to how this complex and difficult behaviour could be addressed.  The behaviour change section earlier does consider the role of psychological interventions however does not make specific reference to emotional eating.  

General comments
Comments: 

This document should highlight the potential for referral to an Accredited Practising Dietitian (APD) through the provision of an enhanced primary care (EPC) scheme. This scheme would provide the client with a number of bulk-billed/ subsidised visits to an Accredited Practising Dietitian, allowing for initial personalised dietary consult and consequent follow-up and further tailoring of the diet plan. It is the responsibility of the GP to initiate an EPC, and the consequent referral to an APD or other allied health practitioner. Those who are considered by their GP to have a chronic condition are eligible for this scheme.

The document should also specify that where relevant any interventions used should comply with the Therapeutic Goods Administration Advertising Code 2007

Page reviewed: 6 September, 2012