Obesity prevention and management


Position

The Royal Australian College of General Practitioners (RACGP) recognises that obesity is one of the most important health issues facing Australia and affects the health, wellbeing and productivity of many Australians.1–3 Obesity is linked directly and indirectly to many chronic conditions and also causes significant morbidity.

General practice has a central role to play in the prevention and management of obesity. This role needs to be supported through improved funding of effective and evidence-based services and therapies. Funding for research into obesity prevention and management is also much needed.

Background

Obesity affects individuals, their families and/or carers and the wider community. The causes of obesity are multiple and complex, and the condition requires lifelong management.4,5

People living with obesity commonly experience stigmatisation and social inequity in daily life6 – a situation compounded because systemic inequity and stigmatisation currently limit access to effective treatments.7,8

The worldwide prevalence of obesity has increased over recent decades, reflecting the significant contribution of changes in lived environments and lifestyle factors.4,9

To work effectively and equitably towards reducing obesity in our communities, we need a balanced combination of individual and public health measures.10,11

Obesity has been an Australian National Health Priority Area since 2008;3 currently, approximately two-thirds of Australian adults have a body weight in the overweight or obese categories.1 Obesity causes metabolic and hormonal changes in the individual.5 It is also associated with an increased risk for other chronic diseases such as diabetes, heart disease, osteoarthritis and some cancers.12

The causes of obesity are multiple and complex, and include epigenetics13,14 (a change in the way genes are expressed) and alteration in the gut microbiome15 (bacteria and cells that live in the gut), among others. While the heritability of obesity has been shown in twin studies16 and clinical practice, only a small percentage of patients have a purely genetic cause (eg leptin deficiency)17,18 or a purely medical cause (eg hypothalamic tumour) for their obesity. For the majority of patients at genetic risk of developing obesity, environmental factors (physical, social and economic)19 facilitate weight gain.

Despite 25% of Australian adults living with obesity, it is estimated that <1% of general practice consultations20 centre around obesity. Of those Australian adults who qualify for bariatric metabolic surgery based on body mass index (BMI) alone, uptake of surgery is unacceptably low. This reflects barriers to access and inequities as evidenced by <12% of these surgeries being performed in the public healthcare system.21

The prevalence of obesity in Aboriginal and Torres Strait Islander communities is alarming.22 Obesity is thought to contribute to 16% of the health gap between Aboriginal and Torres Strait Islander peoples and the total Australian population.22 The inequity in health service access and provision for Australians with obesity is further accentuated in those from Aboriginal and/or Torres Strait Islander backgrounds.

Mental health issues place people at increased risk of obesity and deserve special consideration.12,23,24

Weight gain may be a consequence of symptoms such as impaired motivation or self-care, insomnia, inactivity or unhealthy relationships with food.25–27

In addition, many psychotropic medications are prone to cause weight gain and other metabolic side effects, which are a significant cause of morbidity and demand the careful attention of the treating clinician.28–31

General practice, as a fundamental component of primary care, has always been the foundation of management of chronic diseases in the Australian community.32 It is recognised that general practitioners (GPs) need to be better supported to play their role in assisting patients with obesity.33,34

Currently we have an ‘obesogenic’ environment that does not support people to make healthy decisions about their nutrition and physical activity levels.9,19 Obesity prevention requires a whole-of-systems approach that includes not only the healthcare sector, but also public health safeguards, town planning, transport, nutrition and education.9,35–37

Weight bias and stigmatisation are serious issues affecting the health and wellbeing of people living with obesity.7 People with obesity may avoid healthcare if they feel shamed about their weight. Public obesity messages that focus only on weight and individual factors contribute to stigma and bias.8 The emphasis should shift from loss of weight to gain in heath.5

Policy response

Recognise the importance of obesity

Obesity is both a cause and consequence of many other chronic conditions and diseases. It is expected to have periods of relapse and remission and, given its progressive nature, lifelong management will be required.38 Obesity represents a disturbance in normal physiology,39 is detrimental to health, and is associated with many comorbidities.12 The RACGP recommends increased government support for effective services, therapies and surgical procedures.

Public policy

The RACGP recognises the need for a change in public policy to support healthy environments, where healthy options are readily available and affordable. To prioritise their health, individuals increasingly must work against the environments in which they live.10,11,40 The RACGP advocates that the focus of the health message be on ‘gaining health’ rather than simply ‘losing weight’, recognising that obesity is about more than body weight.41

Recognise the key role of GPs in managing obesity

The RACGP recognises that a skilled and enabled primary care workforce is essential for obesity prevention and management.33,34 GPs are in a unique position to bridge issues that cross primary care and public health; GPs deal with individuals day to day, but also have a deep understanding of the communities in which they work. The Department of Health has made available Medicare Benefits Schedule (MBS) provisions for GPs in this role, via the use of Chronic Disease Management Plans for the care of individuals with complex obesity.

Education and support for GPs in managing obesity

The RACGP recognises the need for more education of registrars and GPs in prevention, detection and management of obesity, and importantly the need for awareness of stigmatisation and inequity.

Many GPs have the skills required to provide professional advice to individuals at risk of developing obesity, but they need to be supported to provide effective, evidence-based management to patients with obesity.33,34

GPs are part of a multi-dimensional approach

The RACGP recognises the need for a multipronged approach, including population-wide public health measures, and targeted approaches for particular ‘at risk’ groups.

‘Systems thinking’ is producing encouraging results in the crucial paediatric age group, and may be applicable to other high-risk groups.36,37,42

In the context of holistic health promotion, GPs are key to promoting obesity prevention by identifying patients at higher risk.

Stigmatisation

The stigmatisation of obesity in our communities is a major problem, and well-intentioned but insensitive comments or policies may do more harm than good.6–8 As a step to reduce the stigmatisation of obesity, the RACGP commits to using person-first language and to ending the use of stigmatising images and messages.

Health inequity

Health inequity is a consequence of, and a contributing factor to, obesity.11,22 All obesity initiatives should clearly state how they are working towards reducing health inequity in underserved populations, particularly Aboriginal and Torres Strait Islander communities. The RACGP recognises that to effectively and equitably prevent obesity, a balanced combination of individual and upstream measures is required.10

Advocacy

The RACGP calls for all levels of government, and other sectors including manufacturing and retail and public health authorities, to join GPs in addressing Australia’s obesogenic environment. Obesity is a serious health issue for individuals with obesity, and for their families and carers. The RACGP is committed to the primary prevention of this life-threatening condition to ensure better health outcomes and quality of life for all Australians.

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  2. Australian Institute of Health and Welfare. Australia’s health 2014. Cat. no: AUS 178. Canberra: AIHW, 2014.
  3. Australian Institute of Health and Welfare. Improving Australia’s burden of disease (including references to National Health Priority Areas). Canberra: AIHW, 2018. [Accessed 23 January 2019].
  4. World Health Organization. Global Health Observatory (GHO) data: Obesity. Geneva: WHO, 2019. [Accessed 15 January 2018].
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  7. Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity reviews: An official journal of the International Association for the Study of Obesity 2015;16(4):319–26.
  8. Ramos Salas X. The ineffectiveness and unintended consequences of the public health war on obesity. Can J Public Health 2015;106(2):e79–81.
  9. Swinburn B, Egger G. Preventive strategies against weight gain and obesity. Obes Rev 2002;3(4):289–301.
  10. Rutter H, Bes-Rastrollo M, de Henauw S, et al. Balancing upstream and downstream measures to tackle the obesity epidemic: A position statement from the European Association for the Study of Obesity. Obes Facts 2017;10(1):61–63.
  11. Willcox S. Chronic diseases in Australia: Blueprint for preventive action. Melbourne: Australian Health Policy Collaboration, 2015.
  12. National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Melbourne: NHMRC, 2013.
  13. Barker DJ, Eriksson JG, Forsén T, Osmond C. Fetal origins of adult disease: Strength of effects and biological basis. Int J Epidemiol 2002;31(6):1235–39.
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  16. Stunkard AJ, Harris JR, Pedersen NL, McClearn GE. The body-mass index of twins who have been reared apart. N Engl J Med 1990;322(21):1483–87.
  17. Farooqi IS, O›Rahilly S. Genetic factors in human obesity. Obes Rev 2007;8 Suppl 1:37–40.
  18. Loos RJ. Genetic determinants of common obesity and their value in prediction. Best Pract Res Clin Endocrinol Metab 2012;26(2):211–26.
  19. Moodie R, Stuckler D, Monteiro C, et al. Profits and pandemics: Prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet 2013;381(9867):670–79.
  20. Britt H, Miller G, Henderson J, et al. General practice activity in Australia 2015–16. General practice series 40. Sydney: Sydney University Press, 2016.
  21. Australian Institute of Health and Welfare. Weight loss surgery in Australia 2014–15: Australian hospital statistics. Cat. no: HSE 186. Canberra: AIHW, 2017.
  22. Australian Health Ministers’ Advisory Council. Aboriginal and Torres Strait Islander Health Performance Framework 2017 report. Canberra: AHMAC, 2017.
  23. Dickerson FB, Brown CH, Kreyenbuhl JA, et al. Obesity among individuals with serious mental illness. Acta Psychiatr Scand 2006;113(4):306–13.
  24. Galletly CA, Foley DL, Waterreus A, et al. Cardiometabolic risk factors in people with psychotic disorders: The second Australian national survey of psychosis. Aust N Z J Psychiatry 2012;46(8):753–61.
  25. Allison DB, Newcomer JW, Dunn AL, et al. Obesity among those with mental disorders: A National Institute of Mental Health meeting report. Am J Prev Med 2009;36(4):341–50.
  26. Foley DL, Mackinnon A, Watts GF, et al. Cardiometabolic risk indicators that distinguish adults with psychosis from the general population, by age and gender. PLoS One 2013;8(12):e82606.
  27. Lambert TJ. The medical care of people with psychosis. Med J Aust 2009;190(4):171–72.
  28. Allison DB, Mentore JL, Heo M, et al. Antipsychoticinduced weight gain: A comprehensive research synthesis. Am J Psychiatry 1999;156(11):1686–96.
  29. De Hert M, Detraux J, van Winkel R, Yu W, Correll CU. Metabolic and cardiovascular adverse effects associated with antipsychotic drugs. Nat Rev Endocrinol 2011;8(2):114–26.
  30. Lett TA, Wallace TJ, Chowdhury NI, Tiwari AK, Kennedy JL, Muller DJ. Pharmacogenetics of antipsychotic-induced weight gain: Review and clinical implications. Mol Psychiatry 2012;17(3):242–66.
  31. Serretti A, Mandelli L. Antidepressants and body weight: A comprehensive review and meta-analysis. J Clin Psychiatry 2010;71(10):1259–72.
  32. Harris MF, Zwar NA. Care of patients with chronic disease: The challenge for general practice. Med J Aust 2007;187(2):104–07.
  33. Jansen S, Desbrow B, Ball L. Obesity management by general practitioners: The unavoidable necessity. Aust J Prim Health 2015;21(4):366–68.
  34. Sturgiss EA, van Weel C, Ball L, Jansen S, Douglas K. Obesity management in Australian primary care: Where has the general practitioner gone? Aust J Prim Health 2016;22(6):473–76.
  35. King L, Gill T, Allender S, Swinburn B. Best practice principles for community-based obesity prevention: Development, content and application. Obes Rev 2011;12(5):329–38.
  36. Allender S, Owen B, Kuhlberg J, et al. A community based systems diagram of obesity causes. PLoS One 2015;10(7):e0129683.
  37. Malakellis M, Hoare E, Sanigorski A, et al. School-based systems change for obesity prevention in adolescents: Outcomes of the Australian Capital Territory ‘It’s Your Move!’. Aust N Z J Public Health 2017;41(5):490–96.
  38. Bray G, Kim KK, Wilding J. Obesity: A chronic relapsing progressive disease process. A position statement of the World Obesity Federation. Obes Rev 2017;18(7):715–23.
  39. Sumithran P, Prendergast LA, Delbridge E, et al. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med 2011;365(17):1597–604.
  40. Moodie R, Stuckler D, Monteiro C, et al. Profits and pandemics: Prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet 2013;381(9867):670–79.
  41. Sturgiss E, Jay M, Campbell-Scherer D, van Weel C. Challenging assumptions in obesity research. BMJ 2017;359:j5303.
  42. Wolfenden L, Wyse R, Nichols M, Allender S, Millar L, McElduff P. A systematic review and meta-analysis of whole of community interventions to prevent excessive population weight gain. Prev Med 2014;62:193–200.

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