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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Overweight/obesity

Author Dr David Peiris
Expert reviewer Dr Elizabeth Denney-Wilson

Background

Obesity is a surplus of body weight due to an excess accumulation of body fat.52 Being overweight is an independent risk factor for numerous comorbidities associated with metabolic complications and/or the excess weight itself.53 It is associated with other cardiovascular risk factors including insulin resistance, blood pressure elevation, elevated triglycerides and reduced high density lipoprotein (HDL) cholesterol levels.54 

Body mass index (BMI) is an approximate measure of total body fat represented by weight/(height in metres) squared. BMI is the recommended measure for classifying overweight (BMI >25 kg/m2 for adults and >85th centile for children aged 2–18 years) and obesity (BMI >30 kg/m2 for adults and >90th centile for children aged 2–18 years).55 It is important to note, however, that these thresholds for overweight and obesity are derived from Caucasian populations and they may not be applicable to some Aboriginal and Torres Strait Islander people. While there are presently no adjusted thresholds validated for Aboriginal and Torres Strait Islander people, a BMI of 22 kg/m2  for overweight adults has been proposed as a more accurate representation of risk, particularly in remote populations.56

Waist circumference, as an indicator of abdominal adiposity, may be a better predictor of obesity associated complications for Aboriginal and Torres Strait Islander populations,56,57 and should be used in combination with BMI to refine assessment of risk.58 Waist circumference may be easier to measure by the patients themselves and thus an appropriate alternative measure for self assessment and monitoring (see Resources).59 World Health Organization guidelines provide thresholds that combine BMI and waist circumference to assess disease risk of type 2 diabetes, elevated blood pressure and cardiovascular disease. These are shown in Table 1.2.

Table 1.2. Combining measures to assess obesity and disease risk* in adults
ClassificationBody mass index
(kg/m2)
Disease risk (relative to normal measures)
Waist circumference
Men 94–102 cm
Women 80–88 cm
Waist circumference
Men >102 cm
Women >88 cm
Underweight <18.5 - -
Healthy weight 18.5–24.9 - Increased
Overweight 25.0–29.9 Increased High
Obesity 30.0–39.9 High to very high Very high
Severe obesity >40 Extremely high Extremely high
* Risk of type 2 diabetes, elevated blood pressure and cardiovascular disease
Source: NHMRC 2003a2

The 2004–05 National Aboriginal and Torres Strait Islander Health Survey is the most recent comprehensive survey of dietary activity and overweight/obesity. It found Aboriginal and Torres Strait Islander males and females were 1.5 and 2 times more likely respectively to be obese than non-Indigenous males and females.60 Further, the survey found that Aboriginal and Torres Strait Islander people were twice as likely to report no usual daily fruit intake and seven times more likely to report no daily vegetable intake when compared with non-Indigenous Australians.60 

Poor food supply is a major barrier to addressing healthy nutrition for Aboriginal and Torres Strait Islander people. A 2008 survey in the Northern Territory found that 55% of surveyed communities did not have access to any fresh food for extended periods.61 In both urban and remote areas food access is affected by low income and inadequate transport;62 overcrowding, poor housing and inadequate cooking and food storage facilities are additional environmental factors.63 Community store and takeaway food is often nutritionally poor and apart from traditional food sources is the principal source of food in many areas. Even if nutritious, less energy dense food is available it is disproportionately more expensive than energy dense food and therefore less accessible to people on low incomes.64

Counselling to promote healthy eating is widely recommended in clinical guidelines. Encouraging people to adopt healthier diets as part of a specific weight management plan (which includes at a minimum targeted information, goal setting and follow up consultations) has been shown to change dietary intake and lead to improved health outcomes.65,66 A combination of advice on diet and exercise is more effective than advice on either diet or exercise alone.65 A low energy diet is the most effective intervention for weight loss.58 

The Australian Dietary Guidelines for adults are highlighted in Table 1.3. Two recommendations that may be more relevant to some Aboriginal and Torres Strait Islander communities are also included.

Table 1.3. Dietary guidelines for Australian adults*
  • Enjoy a wide variety of nutritious foods
  • Eat plenty of vegetables, legumes and fruits
  • Eat plenty of cereals (including breads, rice, pasta and noodles), preferably wholegrain
  • Include lean meat, fish, poultry and/or alternatives
  • Include milks, yoghurts, cheeses and/or alternatives. Reduced-fat varieties should be chosen, where possible
  • Drink plenty of water
  • Choose store foods that are most like traditional bush foods*
  • Enjoy traditional bush foods whenever possible*
  • And take care to:
    • limit saturated fat and moderate total fat intake
    • choose foods low in salt
    • limit your alcohol intake if you choose to drink
    • consume only moderate amounts of sugars and foods containing added sugars
Source: NHMRC 2003b28
* Recommendations specific to some Aboriginal and Torres Strait Islander communities

Cognitive focused behavioural interventions include situational control and stimulus control avoiding cues, cognitive reframing, reinforcement techniques, self recording of calorie intake and eating behaviours, goal setting and relapse prevention strategies. The combination of diet plus exercise plus behavioural interventions produces more beneficial outcomes than each component in isolation.58

Orlistat is the most effective agent in the treatment of obesity and should be prescribed in combination with a weight reducing diet and other lifestyle changes to maximise its effectiveness. It also causes small decreases in total cholesterol, glycosylated haemoglobin and progression to diabetes.58,66 Orlistat in combination with behavioural interventions can lead to greater weight loss than behavioural interventions alone.66 The most common side effects of orlistat medication are gastrointestinal and these are more likely if the diet is high in fat. Typically treatment should only be continued beyond 12 weeks if there has been at least a 5% weight loss. The risks and benefits should therefore be thoroughly discussed before considering adding Orlistat to behavioural interventions.

There has been one systematic review which has found that bariatric surgery, mainly in people with a BMI ≥35 kg/m2, is an effective weight loss intervention.58,67 Bariatric surgery encompasses a range of procedures that are either restrictive (eg. laparoscopic banding, sleeve gastrectomy), malabsorptive (eg. bilio-pancreatic diversion) or a combination of the two. It has also been shown to reduce all-cause mortality and have a number of other clinically significant health outcomes (eg. improved cardiovascular risk, glycaemic control and renal function). The degree of weight loss is influenced by the type of surgery that is performed, with malabsorptive procedures tending to produce the greatest weight loss. One large cohort study found that surgery is associated with some harms (wound complications, bleeding, thromboembolism, pulmonary complications)68 and so the decision to recommend surgery should be balanced against these harms.

There are few robust evaluations of health promotion strategies to prevent overweight/obesity in Aboriginal and Torres Strait Islander communities. Interventions to improve food security include school based nutrition education programs, structured workshops, cooking classes, demonstrations and community kitchens. There is both local and international evidence to suggest that these programs can improve participants’ food security through developing cooking, shopping and budgeting skills as well as reducing social isolation. Interventions that employ a peer-to-peer education model are likely to more effective in enhancing food security.

One reason for the limited success of prevention programs is the failure to incorporate an intersectoral approach. The National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan identified the following seven priority areas to build on efforts to improve access to nutritious and affordable food across urban, rural and remote communities:

  • Food supply in remote and rural communities
  • Food security and socioeconomic status
  • Family focused nutrition promotion
  • Nutrition issues in urban areas
  • The environment and household infrastructure
  • Aboriginal and Torres Strait Islander nutrition workforce
  • National food and nutrition information systems.

More recently the National Preventative Health Strategy has stressed that multicomponent, community based programs are critical to reducing the obesity related disease burden experienced by Aboriginal and Torres Strait Islander people.68 A number of environmental strategies have been introduced to improve remote store food supply, including food production, freight subsidies, store food and nutrition policies, improved management of stores through training and education, store charters outlining consumers’ and store operators’ rights and obligations, takeaway outlet interventions, food aid and food subsidy programs, interventions to improve storage and kitchen facilities and health education.69,70 

The complexity of interventions highlights the importance of coordinated action between health and non-health sectors to improve the range, quality, variety and cost of food supplies to remote and rural communities. It is important primary care practitioners are aware of the breadth and complexity of these interventions as they may be able to play a key role in their implementation at the local level.

Recommendations: Overweight/obesity
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Screening All people aged <18 years Assess BMI using age and sex specific centile charts (see Chapter 2: Child health and Resources) Opportunistic and as part of an annual health assessment GPP58
All people aged ≥18 years Assess BMI and waist circumference (see Table 1.2) Opportunistic and as part of an annual health assessment GPP58
Groups associated with improved outcomes from BMI/waist circumference monitoring include:
  • individuals seeking advice on weight management
  • those with conditions associated with overweight/ obesity (CVD, diabetes, stroke, gout, liver or gallbladder disease)
1B58
Behavioural All people aged ≥18 years Provide brief advice to promote healthy eating and physical activity as per Australian guidelines (see Table 1.1 and Chapter 1: Physical activity) Opportunistic GPP
Adults with overweight/ obesity Develop a weight management plan that must include:
  • targeted information as per Australian dietary guidelines (see Table 1.3)
  • goal setting
  • at least one follow up consultation
Opportunistic and as part of an annual health assessment  IB58,65
Encourage regular self weighing IC71
Encourage a net energy deficit through combined dietary and physical activity interventions as per Australian dietary and physical activity guidelines IB58,72
Consider referral to specialist services, dietitian and/or exercise physiologist if available GPP
Individual or group based psychological interventions* are recommended in combination with dietary and physical activity advice IA58,66
Children with overweight/ obesity Develop a targeted weight management plan as for adults. This plan must involve at least one parent/carer and aim to change the whole family’s lifestyle Opportunistic and as part of an annual health assessment IB58
Except in severe obesity, weight maintenance rather than weight loss is recommended for healthy growth and development
Recommend referral for specialist review for children with severe obesity
IVD58
Chemoprophylaxis People aged ≥18 years with one or more weight related comorbidities present (severe mobility restriction, arthritis, type 2 diabetes) and a BMI ≥28 kg/m2 Assess risk/benefit of orlistat on an individual basis in conjunction with lifestyle interventions Opportunistic and as part of an annual health assessment IA58,66
Surgical People aged ≥18 years with one or more weight related comorbidities present (as above) and a BMI ≥35 kg/m2 Assess risk/benefit of bariatric surgery on an individual basis in conjunction with lifestyle interventions Opportunistic IIC58,67
Environmental Communities Advocate for multifactorial and coordinated community based interventions to increase access to healthy and nutritious food (eg. subsidised healthy food in stores) N/A GPP69,70
* Cognitive focused behavioural interventions include: situational control and stimulus control, avoiding cues to overeating, cognitive reframing and reinforcement techniques, self recording of calorie intake and eating behaviours, goal setting and relapse prevention strategies

Resources

Growth charts (Centers for Disease Control and Prevention)
www.cdc.gov/growthcharts/cdc_charts.htm

BMI charts (WHO)
children 5–19 years
www.who.int/growthref/ who2007_bmi_for_age/en/index.html
children under 5 years
www.who.int/childgrowth/ standards/bmi_for_age/en/index.html

Helpful tips for measuring waist circumference (Australian Government)
www.health.gov.au/internet/ abhi/publishing.nsf/Content/How+do+I+measure+myself-lp.

References

  1. World Health Organization. Obesity: preventing and managing the global epidemic. World Health Organization Technical Report Series No. 894. Geneva: WHO, 2000.
  2. National Health and Medical Research Council. Overweight and obesity in adults: a guide for GPs. Canberra: NHMRC,2003a.
  3. Wilson PWF, D’Agostino RB, Sullivan L, Parise H, Kannel WB. Overweight and obesity as determinants of cardiovascular risk: the Framingham experience. Arch Intern Med 2002;162(16):1867–72.
  4. US Centers for Disease Control. Growth charts. US Centers for Disease Control, 2000 October 25. Available at www.cdc.gov/growthcharts/cdc_charts.htm.
  5. Wang Z, Hoy WE. Waist circumference, body mass index, hip circumference and waist-to-hip ratio as predictors of cardiovascular disease in Aboriginal people. Eur J Clin Nutr 2004;58(6):888–93.
  6. Kondalsamy Chennakesavan S, Hoy WE, Wang Z, Briganti E, Polkinghorne K, Chadban S, et al. Anthropometric measurements of Australian Aboriginal adults living in remote areas: comparison with nationally representative findings. Am J Hum Biol 2008;20(3):317–24.
  7. Scottish Intercollegiate Guidelines Network. Management of obesity. Guideline no. 115. Edinburgh: SIGN, 2010. Cited October 2011. Available at www.sign.ac.uk/pdf/sign115.pdf.
  8. Booth ML, Hunter C, Gore CJ, Bauman A, Owen N. The relationship between body mass index and waist circumference: implications for estimates of the population prevalence of overweight. Int J Obes Relat Metab Disord 2000;24(8):1051–61.
  9. Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander people, an overview 2011. Cat. no. IHW 42. Canberra: AIHW, 2011.
  10. Hudson S. Healthy stores, healthy communities: the impact of outback stores on remote Indigenous Australians: Centre for Independent Studies, 2010.
  11. Couzos S, Murray R. Aboriginal primary healthcare: an evidence-based approach, 3rd edn. Melbourne: Oxford University Press, 2008.
  12. Burns J, Thomson N. Review of nutrition and growth among Indigenous peoples, 2008. Updated November 2010. Cited October 2011. Available at www.healthinfonet.ecu.edu.au/ health-risks/nutrition/reviews/ our-review.
  13. Brimblecombe J, O’Dea K. The role of energy cost in food choices for an Aboriginal population in northern Australia. Med J Aust 2009;190(10):549–51.
  14. World Health Organization. Interventions on diet and physical activity: what works: summary report. Geneva: WHO, 2009.
  15. LeBlanc ES, O’Connor E, Whitlock EP, Patnode CD, Kapka T. Effectiveness of primary care-relevant treatments for obesity in adults: a systematic evidence review for the US Preventive Services Task Force. Ann Intern Med 2011;155(7):434–47.
  16. Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity. Cochrane Database Syst Rev 2009;Apr 15;(2):CD003641.
  17. National Preventative Health Taskforce. Australia: the healthiest country by 2020 – National Preventative Health Strategy – overview. Canberra: Commonwealth of Australia, 2009.
  18. Black A. Evidence of effective interventions to improve the social and environmental factors impacting on health: informing the development of Indigenous community agreements. Canberra: Office for Aboriginal and Torres Strait Islander Health, 2007.
  19. Browne J, Laurence S, Thorpe S. Acting on food insecurity in urban Aboriginal and Torres Strait Islander communities: policy and practice interventions to improve local access and supply of nutritious food 2009. Cited October 2011. Available at www.healthinfonet.ecu.edu.au/ health-risks/nutrition/ other-reviews.
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