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

Chapter 1. Lifestyle
Overweight and obesity
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☰ Table of contents

Recommendations: Overweight and obesity

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Screening

 All people aged <18 years Assess body mass index (BMI) using age-specific and sex-specific centile charts
(refer to Chapter 3: Child health, and ‘Resources’)		 Opportunistic and as part of an annual health assessment GPP 35
All people aged ≥18 years Assess BMI and waist circumference (Box 1) Opportunistic and as part of an annual health assessment IB 20,  22,  36, 37
Specific groups associated with improved outcomes from BMI/ waist conference monitoring include:
  • individuals seeking advice on weight management
  • those with conditions associated with overweight and obesity (cardiovascular disease [CVD], diabetes, stroke, gout, liver or gallbladder disease)
      

Behavioural

 All people aged ≥18 years Provide advice to promote healthy eating and physical activity as per Australian guidelines
(Box 2; and refer to Chapter 1: Lifestyle, ‘Physical activity’)		 Opportunistic IA 20
Adults with overweight or obesity




 		 Advise that modest weight loss of 5% or more has multiple health benefits, particularly lowered cardiovascular, diabetes and kidney disease risks Opportunistic and as part of an annual health check IA 20
Develop a weight management plan that must include:
  • targeted information as  per Australian dietary guidelines (Box 2)
  • goal setting
  • at least one follow-up consultation
  • an assessment of individual contextual and social factors that influence weight loss and maintenance (Box 3)
  • individualised strategies to support weight loss or weight maintenance, including context-specific social supports (if necessary)
 Opportunistic and as part of an annual health check IA 22
Encourage regular self-weighing   IC 23
Encourage a net energy deficit of 2500 kilojoules per day through combined dietary and physical activity interventions as per Australian dietary and physical activity guidelines   IA 20, 22, 36, 37
Consider referral to specialist services, dietician and/or exercise physiologist or telephone coaching services (refer to ‘Resources’) if available   GPP  
Individual or group-based psychological interventions* are recommended in combination with dietary and physical activity advice   IA 22, 28
Children with overweight or 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 (refer to ‘Resources’) Opportunistic and as part of an annual health check IB 22, 37
  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   IVD 22

Chemo- prophylaxis

 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 and only prescribe it as part of a comprehensive obesity management plan

Continue orlistat therapy beyond three months only if the person has lost at least 5% of their initial body weight since starting drug treatment. Monitor for malabsorption of fat-soluble vitamins if prolonged use is being considered		 Opportunistic and as part of an annual health check IA 20 , 22,  36, 37

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 and as part of a comprehensive specialist management program Opportunistic IA 20, 22, 36, 37

Environmental

 Community Advocate for multifactorial and coordinated community-based interventions to increase access to healthy and nutritious food (eg subsidised healthy food in stores)

 

 GPP

15, 17, 32, 34


*Cognitive-focused behavioural interventions include:

  • situational control and stimulus control, avoiding cues to over-eating
  • cognitive reframing and reinforcement techniques
  • self-recording of calorie intake and eating behaviours
  • goal setting and relapse prevention strategies.

Box 1. Combining measures to assess obesity and disease risk* in adults9

Classification

Body mass index (BMI) (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 (CVD).

Box 2. Australian dietary guidelines for Australian adults19  

                                                               
Guideline 1: To achieve and maintain a healthy weight, be physically active and choose amounts of nutritious food and drinks to meet your energy needs

  • Children and adolescents should eat sufficient nutritious foods to grow and develop normally. They should be physically active every day and their growth should be checked regularly.
  • Older people should eat nutritious foods and keep physically active to help maintain muscle strength and a  healthy weight.

Guideline 2: Enjoy a wide variety of nutritious foods from these five food groups every day

  • Plenty of vegetables of different types and colours, and legumes/beans
  • Fruit
  • Grain (cereal) foods, mostly wholegrain and/or high-cereal varieties, such as breads, cereals, rice, pasta, noodles, polenta, couscous, oats, quinoa and barley
  • Lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans
  • Milk, yoghurt, cheese and/or their alternatives, mostly reduced fat
  • Choose store foods that are most like traditional bush foods*
  • Enjoy traditional bush foods whenever possible* And, drink plenty of water.

Guideline 3: Limit intake of foods containing saturated fat, added salt, added sugars and alcohol

  • Limit intake of foods high in saturated fat such as many types of biscuits, cakes, pastries, pies, processed meats, commercial burgers, pizza, fried foods, potato chips, crisps and other savoury snacks.
    • Replace high-fat foods that contain predominately saturated fats such as butter, cream, cooking margarine, coconut and palm oil with foods that contain predominately polyunsaturated and monounsaturated fats such as oils, spreads, nut butters/pastes and avocado.
    • Low-fat diets are not suitable for children under the age of two years.
  • Limit intake of foods and drinks containing added salt.
    • Read labels to choose lower sodium options among similar foods.
    • Do not add salt to foods in cooking or at the table.
  • Limit intake of foods and drinks containing added sugars such as confectionary, sugar-sweetened soft drinks and cordials, fruit drinks, vitamin waters, energy and sports drinks.
  • If you choose to drink alcohol, limit intake. For women who are pregnant, planning a pregnancy or breastfeeding, not drinking alcohol is the safest option.

Guideline 4: Encourage, support and promote breastfeeding Guideline 5: Care for your food; prepare and store it safely

Box 3. Social and contextual factors that influence disease prevention strategies

Disease prevention strategies for obesity and other lifestyle-related conditions need to be individualised, and a personcentred approach should be adopted.

  • Recognise that each person’s context will be different and this will shape their readiness and capacity to make lifestyle changes. The capacity to make changes will be reduced if multiple comorbid conditions are present.
  • Care plans incorporating weight loss recommendations should take consideration of the following factors; where possible, implement local support services to address these factors: – social isolation
    • reduced health literacy
    • unemployment and financial constraints
    • limited availability of recreational facilities
    • difficulties accessing transport support
    • limited physical and economic access to healthy food (food security).
  • Consider intersectoral approaches to influence the social determinants of overweight and obesity (eg partnerships with providers of recreational facilities, establishment of men’s and women’s groups).



Background

Obesity is a surplus of body weight due to an excess accumulation of body fat. Being overweight is an independent risk factor for numerous comorbidities associated with metabolic complications and/or the excess weight itself.1 It is associated with other cardiovascular risk factors including insulin resistance, blood pressure elevation, elevated triglycerides and reduced high-density lipoprotein (HDL) cholesterol levels.2

Body mass index (BMI) is an approximate measure of total body fat represented by weight (kg)/height (m2).
It 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).3 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 peoples. While there are presently no adjusted thresholds validated for Aboriginal and Torres Strait Islander peoples, a BMI of 22 kg/m2 for overweight adults has been proposed as a more accurate representation of risk, particularly in remote populations.4–6 However, in view of the heterogeneity of Australians who are of Aboriginal or Torres Strait Islander origin, it may not be helpful to apply different thresholds to define excess body fat in this population.

Waist circumference, as an indicator of abdominal adiposity, may be a better predictor of obesity-associated complications for Aboriginal and Torres Strait Islander populations, and should be used in combination with BMI to refine assessment of risk.4,5,7,8 (Refer to ‘Resources’ for tips on waist circumference measurement.) The National Heart Lung and Blood Institute guidelines provide thresholds that combine BMI and waist circumference to assess chronic disease risk (Box 1).9

The 2011 Australian Burden of Disease Study found that excess weight contributed to around 8% of the total disease burden experience by Aboriginal and Torres Strait Islander peoples, and almost 10% of disease burden was attributed to dietary factors and is second only to tobacco use as the largest contributing risk factor to total disease burden for men and women aged over 35 years.10 The 2012–13 Australian Aboriginal and Torres Strait Islander Health Survey is the most recent comprehensive survey of dietary activity and overweight or obesity.11 It found that two-thirds of Aboriginal and Torres Strait Islander males and females over the age of 15 years had overweight or obesity, based on BMI.11 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.11

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.12 In both urban and remote areas food access is affected by low income and inadequate transport, and overcrowding, poor housing and inadequate cooking and food storage facilities are additional environmental factors.13 Community store and takeaway food is often nutritionally poor and apart from traditional food sources is the principal source of food in many areas.14 Even if nutritious, less energy-dense food is available, it is disproportionately more expensive than energy-dense food and therefore is less accessible to people on low incomes.15–17 A recent study examined the increasing gap in affordability and accessibility of nutritional food occurring between remote and urban areas. It found that individuals living in remote areas pay the highest prices in Australia for healthy food and drinks.17

 

Interventions

There are myriad dietary interventions that have been trialled and very little evidence to suggest that any particular dietary intervention is superior. Generally, a low-energy diet, achieved particularly through reduction in total fat intake, is the most effective intervention for weight loss.18 The Australian dietary guidelines for adults are highlighted in Box 2.19 Two recommendations that may be more relevant to some Aboriginal and Torres Strait Islander communities are also included.

An evidence-based approach to weight management has been outlined in the National Health and Medical Research Council (NHMRC) 2013 guidelines using the 5As framework (refer to Chapter 1: Lifestyle, ‘Introduction’).20
Ask and assess:

  • Assess adults for overweight or obesity to identify people who may benefit from advice about weight management and/or intervention.
  • Conduct routine assessment of BMI and waist circumference.
  • Assess for risk or presence of comorbidities that may be influenced by overweight and obesity to enable overall risk to be estimated and for conditions to be managed together.
  • Ask about other contributors to weight gain (eg medications such as psychotropic drugs, steroids, insulin, quitting smoking) and weight history (including previous weight loss attempts) as part of the assessment of people who are overweight or obese.
  • Discuss a person’s readiness for behavioural change by talking about the person’s interest and confidence in making changes, as well as the benefits and difficulties of weight management.

Advise: Adults who are overweight or obese should be advised that modest weight loss reduces cardiovascular disease (CVD) risk factors. People with diabetes, pre-diabetes, kidney disease and sleep apnoea should be advised that a 5% weight loss is associated with improvements in these conditions.20 Although the evidence base is not as strong, weight loss of any amount is also associated with improvements in quality of life, self-esteem and depression symptoms.20

Assist: In terms of assistance, counselling to promote healthy behaviours, reduced energy intake and increased physical activity in people with overweight or obesity 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.21 Designing tailored dietary interventions that aim to produce a 2500 kg energy deficit per day is recommended in most cases.20 A combination of advice on diet and exercise is more effective than either diet or exercise alone.21 Cognitive-focused behavioural interventions include situational control and stimulus avoidance, 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.20,22 Weight and waist circumference are easy to self-measure and there is some evidence that self-weighing and monitoring are effective in achieving weight loss.23

Intensive interventions are recommended when standard measures have not been successful. These include very low energy diets, weight loss medication and surgery. Very low-energy diets involve replacing one or more meals each day with foods or formulas providing a specified number of kilojoules. There is some evidence that these diets are associated with significant weight loss, usually when implemented in conjunction with medically superposed programs.20

Orlistat is the most effective agent in the treatment of obesity. If it is used, it 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.22,24 Orlistat in combination with behavioural interventions can lead to greater weight loss than behavioural interventions alone.22,24 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. Orlistat increases the risks of liver damage and kidney stones and there are regulatory agency warnings to alert health professionals and patients to these risks. Prolonged use for 12 months or longer is associated with malabsorption of fat-soluble vitamins and may require additional supplementation, particularly for people with diets that may be deficient in these vitamins. The risks and benefits should therefore be thoroughly discussed before considering adding orlistat to behavioural interventions.

Systematic reviews have found that bariatric surgery, mainly in people with a BMI ≥35kg/m2, is an effective weight loss intervention.25–27 Bariatric surgery encompasses a range of procedures that are either restrictive (eg adjustable gastric banding, sleeve gastrectomy), a gastric bypass (eg bilio-pancreatic diversion) or a combination of the two. All of these procedures have been shown to reduce all-cause mortality and offer a number of other clinically significant health outcomes (eg improved cardiovascular risk, glycaemic control and renal function).27 The degree of weight loss is influenced by the type of surgery performed, with gastric bypass procedures tending to produce the greatest weight loss but at a higher complication rate.25 Adjustable gastric banding has lower mortality and complication rates than gastric bypass procedure, but the reoperation rate is higher and weight loss is less substantial.25 Sleeve gastrectomy appears to be more effective in weight loss than adjustable gastric banding and is comparable to gastric bypass.25 One large cohort study found that surgery is associated with some harms (wound complications, bleeding, thromboembolism, pulmonary complications, so the decision to recommend surgery should be balanced against these harms.22 There are few studies examining long-term outcomes (beyond two years) from bariatric surgery. One systematic review found that gastric bypass had better outcomes than gastric band procedures for long-term weight loss, type 2 diabetes control and remission, hypertension, and hyperlipidaemia.28 Insufficient evidence exists regarding long-term outcomes for gastric sleeve resections.28

 

Arrange: Although current evidence is lacking, most clinical guidelines recommend a period of review and monitoring following the initial assessment and advice. If there is no weight loss (less than 1% body weight or no change in waist circumference) after three months of active management, lifestyle behaviours and causes of weight gain should be reviewed. The review at three months should include calculating BMI and measuring waist circumference, and comparing these to baseline measurements and anticipated weight loss and targets; tracking progress towards goals (eg whether health behaviours have changed); monitoring changes in risk factors and comorbidities; reviewing the plan for care; and providing support and encouragement.
Intensive weight-loss interventions may also be considered, depending on degree of overweight or obesity and whether comorbidities are present.
In terms of maintenance of weight loss, it should be recognised that weight regain is common after weight loss and that this is a combination of both physiological and psychological factors. However, it should be stressed that the benefits of weight loss may still be maintained even if some weight is regained. There is evidence to support adoption of ongoing specific strategies, tailored to individual situations for people who achieve an initial weight loss.20 Such strategies have been shown to minimise the risk of weight regain. Longer term monitoring by healthcare providers also tends to achieve better outcomes.20

 

Social determinants

The above disease prevention strategies must be individualised, and a person-centred approach should be adopted (Box 3). Each person’s context will be different, shaping their readiness and capacity to make lifestyle changes. The capacity to make changes will also be reduced if patients have comorbidity. One reason for the limited success of prevention programs is the failure to incorporate an intersectoral approach to influence the social determinants of overweight and obesity. Care plans incorporating weight-loss recommendations should ensure that factors such as social isolation, reduced health literacy, unemployment, financial constraints, access to recreational facilities, lack of transport, physical and economic access to healthy food (food security), and other contextual barriers to a healthy diet and weight loss are considered, with local support provided to address the problems identified.

 

Local supports can be identified through a range of non-government organisations, Aboriginal Community Controlled Health Services, integrated care models such as ‘health pathways’ (developed by several primary health networks), social worker referral, or other health navigation initiatives such as RedLink in Redfern, New South Wales. Chronic disease care coordinators (care coordination and supplementary services program) at the primary health network level may also assist (refer to ‘Resources’).

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 reduce social isolation.29 Interventions that employ a peer- to-peer education model are likely to be more effective in enhancing food security. 

 
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:30

  1. Food supply in remote and rural communities
  2. Food security and socioeconomic status
  3. Family-focused nutrition promotion
  4. Nutrition issues in urban areas
  5. The environment and household infrastructure
  6. Aboriginal and Torres Strait Islander nutrition workforce
  7. National food and nutrition information systems

The 2009 National Preventative Health Strategy similarly stressed that multi-component, community-based programs are critical to reducing the obesity-related disease burden experienced by Aboriginal and Torres Strait Islander peoples.31 A number of 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.16,32–34

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 that 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, and that they support each individual patient.
 

 

Resources

Weight, BMI and waist assessment

Department of Health fact sheets

Resources for assisting with addressing social needs

Other fact sheets and resource kits

 

Free Get Healthy telephone coaching services for residents in New South Wales, Queensland and South Australia

 

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

 





 
 
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