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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

7.2 Overweight

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 >80

Body mass index (BMI) and waist circumference should be measured every two years and recorded in the medical record (A). On its own, BMI may be misleading, especially in older people and muscular individuals, and classifications may need to be adjusted for some ethnic groups9. Waist circumference is a stronger predictor of CVD and diabetes than weight alone76,77.

Patients who are overweight or obese should be offered individual lifestyle education and skills training (A)9 . Restrictive dieting is not recommended for children and most adolescents who have not completed their growth spurt9. A modest loss of 5–10% of starting body weight in adults who are overweight is sufficient to achieve some health benefits.9,78

Table 7.2.1. Obesity-related complications: Identifying risks
Who is at risk?What should be done?How often?
Average risk
Adults Assess body mass index (BMI) and waist circumference in all adults >18 years of age (I, A) Offer education on nutrition and physical activity (I, A)78 Every two years (IV, D)
Adolescents Assess weight and height using age-specific BMI charts (either Centers for Disease Control and Prevention [CDC] or World Health Organization [WHO]; Practice Point) 9

Involve parents, carers and families in lifestyle change (Practice Point)
Every two years
Children Aged >2 years: Assess weight and height using age specific BMI charts (either CDC or WHO; Practice Point)9

Aged <2 years: Monitor growth using WHO growth charts (Practice Point)

Involve parents, carers and families in lifestyle change
At times of child health surveillance or immunisation
Increased risk49
Aboriginal and Torres Strait Islander peoples and people from the Pacific Islands Assess BMI and waist circumference in all adults aged >18 years (I, B)

Offer individual or group-based education on nutrition and physical activity (II, A)
Every 12 months (IV, D)
Patients with existing diabetes or cardiovascular disease, stroke, gout or liver disease Assess BMI and waist circumference in all adults aged >18 years (I, B)

Offer individual or group-based education on nutrition and physical activity (II, A)
Every 12 months (IV, D)
Identified risk
Adults who are overweight or obese Assess weight and waist circumference (I, B)9,79

Develop weight management plan* (II, B)

Offer behaviour-oriented interventions to assist with weight loss (I, B)

Consider referral for:
  • self-management support
  • coaching in an individual or group-based diet
  • physical activity program
  • allied health provider (eg dietitian, exercise physiologist, psychologist)
Every six months† (III, C)
Children and adolescents who are overweight or obese 80 Recommend lifestyle change including reducing energy intake and sedentary behaviour, and increased physical activity and measures to support behaviour change (II, B)
*Refer to the National Health and Medical Research Council’s (NHMRC) Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia.9 The plan should include frequent contact (not necessarily in general practice), realistic targets and monitoring for at least 12 months

†Review impact on changes in behaviour in two weeks

BMI, body mass index; CDC, Centers for Disease Control and Prevention; NHMRC, National Health and Medical Research Council; WHO, World Health Organization
Table 7.2.2. Overweight and obesity: Assessment and preventive interventions
AssessmentTechnique
Body mass index (BMI) BMI = body weight in kilograms divided by the square of height in metres. BMI of ≥25 kg/m2 conveys increased risk
Waist circumference An adult’s waist circumference is measured halfway between the inferior margin of the last rib and the crest of the ilium in the mid-axillary plane over bare skin. The measurement is taken at the end of normal expiration.

≥94 cm in males and ≥80 cm in females conveys increased risk

≥102 cm in males and ≥88 cm in females conveys high risk
Weight reduction in adults (5As approach) Ask: Patients what concerns they have about their weight and if they tried to lose weight in the past 9,81

Assess: BMI, waist circumference, diet, physical activity, motivation to change and health literacy

Advise: That weight loss can have health benefits, including reduced blood pressure and prevention of diabetes in high-risk patients. Advise the risks of being overweight and a lifestyle program that includes reduced caloric intake (aiming for 600 kcal or 2500 kJ energy deficit) and increased physical activity (increasing to 60 minutes at moderate intensity five days per week), supported by behavioural counselling

Assist/Agree: Discuss goals, including a realistic initial target of 5% weight loss and specific measurable changes to diet and physical activity. Make contact (eg visit, phone) two weeks after commencing weight loss to determine adherence and if goals are being met. If no response (<1 kg weight or <1 cm waist reduction) after three months, consider alternative approaches, including referral to lifestyle programs or coaching. These programs may be face to face or delivered by phone

Arrange: After achieving initial weight loss, advise that patients may regain weight without a maintenance program that includes support, monitoring and relapse prevention

Consider very low energy diets if there is no response to lifestyle programs. Bariatric surgery may be considered in patients who fail lifestyle interventions and who have a BMI >35 kg/m2 with comorbidities, such as poorly controlled diabetes, who are expected to improve with weight reduction
BMI, body mass index
Table 7.2.3. Nutrition: Healthy weight: Body mass index (kg/m2)82
ClassificationBody mass index (BMI; kg/m2)Risk of morbidities
Underweight <18.5 Increased
Normal weight 18.5–24.9 Low
Overweight 25.0–29.9 Increased
Obese I 30.0–34.9 Moderate
Obese II 35–39.9 Severe
Obese III ≥40.0 Very severe
BMI, body mass index

Implementation

Consider and offer adult patients a range of treatment options. Individual education and simple behavioural interventions are appropriate for some patients, while behavioural approaches may be more appropriate for those with disordered eating patterns. Behaviour change techniques include goal setting, self-monitoring of behaviour and progress, stimulus control (eg recognising and avoiding triggers that prompt unplanned eating), cognitive restructuring (modifying unhelpful thoughts or thinking patterns) or problem-solving, and relapse prevention and management.9

Telephone coaching has been demonstrated to be comparable with face-to-face techniques and is available in most states.83,84

For adolescents and children, lifestyle programs should focus on parents, carers and families. Advise that weight maintenance is an acceptable approach in most situations for children who are overweight or obese. Recommend lifestyle changes, including reducing energy intake and sedentary behaviour, and increasing physical activity based on current Australian dietary and physical activity guidelines.9

For more information, refer to The Royal Australian College of General Practitioners’ (RACGP) Smoking, Nutrition, Alcohol and Physical activity (SNAP): A population health guide to behavioural risk82 and National Health and Medical Reserach Council’s (NHMRC) Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia9

References

  1. National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Canberra: NHMRC, 2013.
  2. National Aboriginal Community Controlled Health Organisation and The Royal Australian College of General Practitioners. National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. 2nd edn. East Melbourne, Vic: The Royal Australian College of General Practitioners, 2012.
  3. National Vascular Disease Prevention Alliance. Guidelines for the assessment of absolute cardiovascular disease risk. Melbourne: National Heart Foundation of Australia: 2009
  4. Schulze MB, Heidemann C, Schienkiewitz A, Bergmann MM, Hoffmann K, Boeing H. Comparison of anthropometric characteristics in predicting the incidence of type 2 diabetes in the EPIC-Potsdam Study. Diabetes Care 2006;29(8):1921–23.
  5. US Preventive Services Task Force. Final recommendation statement: Obesity in adults: Screening and management. Washington, DC USPSTF, 2014. Available at www.uspreventiveservicestaskforce.org/ Page/Document/RecommendationStatementFinal/ obesity-in-adults-screening-and-management [Accessed 23 March 2016].
  6. 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 Int Med 2011;155(7):434–47.
  7. Sargen G, Pilotto L, Baur L. Components of primary care interventions to treat childhood overweight and obesity: A systematic review of effect. Obes Rev 2011;12:e219–e35.
  8. US Preventive Services Task Force. Screening for and management of obesity in adults. Ann Intern Med 2012;157(5):373–78.
  9. The Royal Australian College of General Practitioners. Smoking, nutrition, alcohol, physical activity (SNAP): A population health guide to behavioural risk factors in general practice. 2nd edn. East Melbourne, Vic: RACGP, 2015.
  10. Dennis SM, Harris M, Lloyd J, Powell Davies G, Faruqi N, Zwar N. Do people with existing chronic conditions benefit from telephone coaching? A rapid review. Aust Health Rev 2013;37(3):381–88.
  11. O’Hara BJ, Phongsavan P, Venugopal K, et al. Effectiveness of Australia’s Get healthy information and coaching service(R): Translational research with population wide impact. Prev Med 2012 Oct;55(4):292–98.
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