National Guide

Chapter 15 | Overweight and obesity







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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    16. Chapter 15 | Overweight and obesity

Overweight and obesity

Mr Ray Kelly   

Key messages

  • Healthy eating, regular physical activity, avoiding prolonged sedentary activities and adequate sleep support a healthy weight.1
  • A healthy diet primarily consists of fresh unprocessed foods, with traditional foods strongly encouraged.1,2
  • Obesity is a chronic health condition and requires ongoing monitoring and support.
  • Obesity is an independent risk factor for many cardiovascular, metabolic and other conditions.3,4
  • Many chronic conditions begin at a lower body mass index (BMI) for Aboriginal and Torres Strait Islander peoples.5,6
  • Waist circumference is a more sensitive measure of risk than BMI alone.5
  • Weight loss strategies may include the use of traditional foods, a Mediterranean-type diet, carbohydrate reduction, calorie reduction through the use of low energy or very low energy formats, increased physical activity and/or pharmacotherapy.4
  • Bariatric surgery might be considered for some people where other strategies have not been successful. 4
  • Weight stigma is a psychosocial contributor to obesity and can be a barrier to people accessing weight management and other healthcare.4
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people aged 2–18 years Assess BMI using age and sex specific centile charts Opportunistically Good practice point International guideline7
Literature review8		 The earlier the identification of increasing weight, the less risk of developing overweight, obesity or a weight-related chronic condition
All people aged 5–18 years Assess waist circumference Opportunistically Good practice point Consensus statement9  
All people aged 18 years and older Assess BMI and waist circumference (see Table 1 ) Annually Strong National guideline4
Consensus statement9		 Weight gain can occur due to many life factors and at any age

It is important to provide screening across the life course
 
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people aged 18 years and older Provide advice to promote healthy eating and physical activity as per Australian guidelines (refer to Box 1 and Chapter 2: Healthy living and health risks, Physical activity and sedentary behaviour) At least every two years Strong Australian guidelines10,11 The focus in prevention should be on a healthy diet and physical activity

Improving the quality of food intake will help with healthy weight and overall health, and will improve outcomes with other illnesses and chronic disease

The Australian dietary guidelines provide general advice on healthy eating
All people Encourage the intake of traditional foods or modern formats that replicate the more traditinal reduction in carbohydrates and daily energy intake Opportunistically Good practice point Cohort studies12–14 Traditional diets were well balanced and healthy
Adults with overweight/obesity Advise that weight loss, even as modest as 5%, has multiple health benefits, particularly in decreasing risks of cardiovascular, diabetes and kidney disease, during pregnancy, for brain health and for general fitness. These benefits compound more favourably when greater increments of weight loss are achieved Opportunistically Strong National guideline4 A patient does not require large amounts of weight loss to experience health benefits

Determine whether the patient is in a position to make the lifestyle changes required
Adults with overweight/obesity Develop an individualised weight management plan that includes:
  • targeted information as per Australian dietary guidelines (see Box 1) and The Australian Obesity Management Algorithm
  • goal setting
  • at least one follow-up consultation
  • an assessment of individual contextual and social factors that influence weight loss and maintenance (see Box 2)
  • individualised strategies to support weight loss or weight maintenance, including context-specific social and cultural supports (if necessary)
 As clinically indicated Conditional National guideline4
International guideline15		 Consensus-based advice combined with input from the patient can result in an effective plan for achieving health goals

Ongoing support is critical to the achievement of health outcomes
Adults with overweight/ obesity Consider referral to allied health providers, such as an accredited practising dietician, exercise physiologist, lifestyle coach or an established commercial weight loss program to support the development of a weight management plan As clinically indicated and when appropriate services are available Good practice point National guideline4 The cultural safety of services and appropriateness of advice are key to engagement, safety and effectiveness
Adults with overweight/obesity Encourage regular self-weighing in most adults As clinically indicated as part of a weight management plan Good practice point Systematic review16 Regular monitoring of weight is effective at reducing the risk of weight re-gain for most people

Self-weighing may not be appropriate for people with some eating disorders
Adults with overweight/obesity Encourage a net energy deficit of 2000–4000 kJ (480–960 kcal/day) if based on whole foods, or more if a supervised low-energy diet or very low-energy diet is being used As clinically indicated as part of a weight management plan Strong National guidelines4,17
International guidelines15,17,18		 Reducing daily calorie intake is an effective method for reducing body weight
Regular physical activity can help achieve weight loss goals. It can also improve other areas of health
All people with overweight/obesity Encourage regular physical activity Opportunistically Strong National guideline11 Regular physical activity supports healthy weight and has many other health benefits
Adults with overweight/obesity Consider individual or group-based psychological interventionsA in combination with dietary and physical activity advice As clinically indicated as part of a weight management plan Good practice point National guideline19 Psychological support can help overcome barriers to following a healthy lifestyle
Children with overweight/obesity Involve parents/carers and families in all behavioural change As clinically indicated Good practice point National guideline19 This is an important principle in supporting behavioural change for children and young people
Children with overweight/obesity Develop a targeted weight management plan. This plan must involve at least one parent/carer and aim to change the whole family’s lifestyle (see Useful resources) As clinically indicated Good practice point National guideline19  
Children with overweight/obesity Except in severe obesity, weight maintenance rather than weight loss is recommended for healthy growth and development As clinically indicated as part of a weight management plan Conditional National guideline20 Weight maintenance can support greater lean body mass growth and may help with favourable body composition associated with healthier ageing in young, middle and old adulthood
Children with overweight/obesity Consider referral for specialist review for children with severe obesity (BMI >40 kg/m2) As clinically indicated Conditional National guideline4 Specialist obesity services can support weight management when culturally appropriate and available
Type of preventive activity - Medications
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People aged 18 years and over with one or more weight-related comorbidities (severe mobility restriction, arthritis, type 2 diabetes) and a BMI equal to or greater than 28 kg/m2 Assess, or make appropriate referral, for medication to support weight loss as part of a comprehensive obesity management plan (see Clinical guidelines) As clinically indicated Conditional National guideline4
Narrative review21		 Medications can help achieve weight loss goals, especially when used in combination with healthy lifestyle behaviours
People aged 18 years and over with one or more weight-related comorbidities (as above) and a BMI equal to or greater than 35 kg/m2 Assess the risk/benefit of bariatric surgery on an individual basis in conjunction with behavioural changes and as part of a comprehensive specialist management program As clinically indicated Conditional National guideline22 Patients should undergo full physical and psychological assessment to determine suitability
Primary care clinicians and practices Advocate for multifactorial and coordinated community-based interventions to increase access to healthy and nutritious food (eg subsidised healthy food in stores) Opportunistically Good practice point Systematic review and community-based studies2,14,23–26 Access to programs and equipment is a barrier for many Aboriginal and Torres Strait Islander people, particularly in remote and very remote areas
Type of preventive activity - Surgical
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People aged 18 years and over with one or more weight-related comorbidities (as above) and a BMI equal to or greater than 35 kg/m2 Assess the risk/benefit of bariatric surgery on an individual basis in conjunction with behavioural changes and as part of a comprehensive specialist management program As clinically indicated Conditional National guideline22 Patients should undergo full physical and psychological assessment to determine suitability
Type of preventive activity - Environmental
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Primary care clinicians and practices Advocate for multifactorial and coordinated community-based interventions to increase access to healthy and nutritious food (eg subsidised healthy food in stores) Opportunistically Good practice point Systematic review and community-based studies2,14,23–26 Access to programs and equipment is a barrier for many Aboriginal and Torres Strait Islander people, particularly in remote and very remote areas
Primary care clinicians and practices Be familiar with services in your area that offer weight loss programs, such as allied health professionals, fitness centres and community groups Opportunistically Good practice point Expert opinion Weight loss programs provided by other qualified health professionals can provide a localised approach to weight loss and added support
 
ACognitive focused behavioural support includes:
  • situational control and stimulus control, avoiding cues to overeating
  • cognitive reframing and reinforcement techniques
  • self-recording and monitoring of calorie intake and eating behaviours
  • goal setting and relapse-prevention strategies
  • social and emotional wellbeing holistic care.  
 
Table 1. Combined measures to assess obesity and disease riskA in adults27
Classification 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
ARisk of type 2 diabetes, elevated blood pressure and cardiovascular disease.
BMI, body mass index
 

Box 1. Australian dietary guidelines for Australian adults10

Guideline 1: To achieve and maintain a healthy weght, 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 foodsA
  • Enjoy traditional bush foods whenever possibleA
  • 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 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

AAdditional recommendations specific to some Aboriginal and Torres Strait Islander communities.

 

Box 2. 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 person-centred 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 the following factors into consideration and, where possible, implement local support services to address these factors:
    • social isolation
    • reduced health literacy
    • unemployment and financial constraints
    • access to recreational facilities
    • transport support
    • 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, the establishment of men’s and women’s groups).
  • Initiating discussion: Discuss general health, such as nutrition and physical activity, when appropriate in appointments. A discussion about nutrition could be initiated by asking the patient whether they feel they are eating enough nutritious food, then highlighting the impact of healthy food choices on chronic diseases. Physical activity can be discussed by asking whether the patient participates in any structured exercise sessions each week, then highlighting the importance of daily physical activity. There can be many barriers to physical activity, so inform the patient that any movement is beneficial and that something as simple as a light walk can provide health benefits.
  • Stigma/attitudes: Stigma is a psychosocial contributor to obesity4,28 and can affect the uptake of exercise and other lifestyle and eating pattern changes. Your attitude towards the person with extra weight will determine how open they will be to help and support. Historically, people have had to endure the stigma that they are to blame for being overweight or obese,4 are lazy or simply eat too much. However, there are many reasons a person may be carrying extra weight. It could be due to a health condition, or the medications provided for an illness. Many people also experience injuries as they age, and this can limit their ability to move and could restrict most physical activity.29 In addition to the injury, a person could be experiencing chronic pain and mental duress. This, in turn, can affect sleep, energy and the quality and amount of food or alcohol intake. The stigma around weight may also be compounded by racism experienced by Aboriginal and Torres Strait Islander people.
  • To improve health outcomes it is important to have a culture in your healthcare setting that takes a non-judgemental, people-first approach.4
  • Physical environment and equipment: Make sure the clinical environment has appropriate equipment, including bariatric seating, and suitable weighing scales and blood pressure cuffs.
  • Reducing weight: There are various formats to follow for weight loss; however, a critical component of success is ongoing support. Patients may not have support at home and, without it, long-term success with health goals is less likely.2 Prior to referring to external programs, ensure a culturally safe environment and appropriate advice will be provided for the patient.
  • Be familiar with services in your area that offer weight loss programs.
  • Physical activity and exercise: It is important to have some form of physical activity each day, ideally at least 20–30 minutes per day to begin with, and steadily increasing the duration. Patients should be encouraged to participate in an activity they enjoy; however, walking is a great option because it does not require any special equipment and there is no added cost. Increasing activities of daily living, including household jobs like sweeping and vacuuming, can also increase daily calorie expenditure. In addition, encourage a reduction in sedentary behaviours, such as screen time and prolonged lying and sitting.
  • Mobility issues: Mobility issues are most often due to foot, knee, hip or back injury. Once the issue is diagnosed and the patient is cleared for weight-bearing physical activity, walking is a great activity to start with. Ask the patient how long (in minutes) they could walk for before they feel they need to rest. Once a length of time is provided, ask them whether they could complete a specific time under that. For example, if they state they could walk for 15 minutes, ask whether they would be happy to start walking for 10 minutes at a time. Once a time period is agreed upon, ask the patient to complete that walk each day and try to increase it a little each week.
  • Aboriginal and Torres Strait Islander health workers and health practitioners: Aboriginal and Torres Strait Islander health workers provide an integral service by improving health outcomes by breaking down communication and cultural barriers between Aboriginal and non-Indigenous health staff, and making the patient feel more comfortable within the healthcare setting.30,31 They also have a range of skills that can help in the provision of healthcare, particularly in assisting with annual health checks.31
  • Allied health: To help achieve health goals, referral to an allied health professional is a viable option, including an exercise physiologist or physiotherapist for physical activity, a dietician for eating plans and a podiatrist or physiotherapist for pain and mobility issues. Programs and services provided by other health professionals may be considered based on their engagement with the Aboriginal and Torres Strait Islander community and history of success in providing improved health outcomes. Always try to find allied health professionals who have a strong history of achieving good health outcomes with Aboriginal and Torres Strait Islander people.
  • Technology: Personal movement monitors can provide motivation for patients to increase their physical activity levels. The most common brands are Fitbit, Garmin and Apple, but most smartphones have an activity tracker in their Health app.32 Just be mindful that accuracy and reliability can vary and that these devices are best used as motivational tools rather than objective measurement devices.33
  • Staff training: Training can include healthy living principles (diet, physical activity, sleep) and the prevention and management of obesity, including effective behaviour change and how to minimise stigma. Often behaviour change is centred on the patient; however, the health professional must work with the patient to find strategies they feel they can implement and ensure that the patient understands what needs to be done. Staff must also have a good understanding of the local Aboriginal and Torres Strait Islander culture. Each community will be different and, if trust with the patient is to be achieved, understanding and respecting their culture is essential.
  • Recalls and reminders: Many in the Aboriginal and Torres Strait Islander community have additional responsibilities to family and community and may need reminding of check-ups and appointments. A simple way of doing this is with automated emails, text messages and the use of messaging services through social media.34
  • Health promotion: Providing health promotion activities outside of the medical centre can provide a culturally safe way of engaging with the community, especially those not currently engaged with the health staff. This could be at school or at sporting or cultural events.
  • Service/practice level: Providing annual health checks, reviews and usual cycles of care can provide opportunities to identify heath issues early before additional comorbidities occur.

Clinical guidelines

Other resources for health professionals

Health promotion

General

Patient resources

 
 

Background

Overweight and obesity are defined as ‘abnormal or excessive fat accumulation that presents a risk to health’.35 Aboriginal and Torres Strait Islander people experience health disparities influenced by ongoing colonisation36 and systemic racism directly affecting health status, including overweight and obesity. This may be made worse by the design of health services and programs, which are often based on dominant (coloniser/settler) group values, principles and beliefs.2,37,38

Definitions

BMI is an approximate measure of total body fat calculated by dividing weight (kg) by height squared (m2). In adults, BMI is used to classify overweight (BMI >25 kg/m2) and obesity (BMI >30 kg/m2); in children aged 5–19 years, definitions are derived from WHO child growth standards, with overweight and obesity defined as BMI-for-age greater than one and two standard deviations, respectively, above the WHO growth reference median.35,39 However, it is important to note that these thresholds for overweight and obesity are derived from White populations and may not be applicable to some Aboriginal and Torres Strait Islanders peoples. Although there are presently no adjusted thresholds validated for Aboriginal and Torres Strait Islander people, a healthy BMI ranging from 17 to 22 kg/m2 for adults has been proposed as a more accurate indicator of health risk given the observed onset of chronic disease at a lower BMI.5 However, in view of the heterogeneity of Aboriginal and Torres Strait Islander peoples, it may not be helpful to apply different thresholds to define excess body fat in this population. In addition, BMI, which provides a measure of overall adiposity, was designed as a population measure and should only ever be used as a general guide because the amount of extra weight carried is not as important as where it is stored.40 Excess weight stored around the abdominal region is particularly associated with a higher risk of type 2 diabetes and cardiovascular disease.41 Waist circumference has been shown to be a more reliable predictor of health risk for Aboriginal and Torres Strait Islander people.5 Waist circumference is measured by recording the circumference of the waist at the midpoint between the lowest ribs and the iliac crest.5,41 A combination of BMI and waist circumference can be used to assess obesity and associated health risks.9 A systematic review found that measures of central fatness were associated with higher all-cause mortality than BMI alone.42 This was consistent with a prospective study in an Aboriginal population examining the associations of BMI and waist circumference with all-cause mortality that followed nearly 1000 adults over 18 years and found that waist circumference had a stronger association with mortality than BMI.5

Prevalence

The Australian Aboriginal and Torres Strait Islander Health Survey 2018–19 is the most recent comprehensive survey of diet, physical activity and overweight and obesity.43 This survey found that 67% of the total Australian adult population was overweight or obese. For Aboriginal and Torres Strait Islander adults (age ≥15 years), the incidence of overweight or obesity was 71%,43 reflecting increasing rates of obesity from 40% of adults in 2012–13 and 45% in 2018–19.44 The 2018 Australian Burden of Disease Study found that excess weight contributed to around 9.7% of the total disease burden experienced by Aboriginal and Torres Strait Islander people, and an additional 6.2% of disease burden was attributed to dietary factors.3

Risk factors

The risk factors for obesity are similar for Aboriginal and Torres Strait Islander and non-Indigenous Australians, as are the associations between sociodemographic factors and obesity.29 However, the prevalence of those risk factors is higher in Aboriginal and Torres Strait Islander populations. These include individual- and area-level disadvantage, physical inactivity, poor dietary patterns (availability and/or choices) and poor physical and mental health.29 Obesity is less likely if a person is employed, and has decreasing prevalence with increasing education, physical activity, income and area-level advantage.29

Being overweight/obese is an independent risk factor for numerous comorbidities associated with:

  • metabolic complications, including insulin resistance, diabetes and polycystic ovarian syndrome
  • cardiovascular conditions, including heart attack, stroke, high blood pressure and lipid (blood fat) disorders such as elevated triglycerides and reduced high-density lipoprotein cholesterol levels45
  • complications in pregnancy
  • some site-specific cancers46
  • mental health disorders
  • cognitive impairment and dementia
  • musculoskeletal complications of the excess adiposity itself.6

Obesity rates are rising for Aboriginal and Torres Strait Islander children,47 with rates higher in urban areas than in remote communities.48,49 As with adults, waist circumference is a more accurate predictor of health risk for children,50 and carrying excess weight has a higher association with adverse cardiometabolic profiles among Indigenous youth.49 There have been limited studies addressing weight concerns for Aboriginal children, and those that have been published have not been successful in reducing body weight.47 When seeking improvement in health risks for children, it is important to include the parents in the design of any interventions because they provide the food for the child and need to be involved in opportunities to decrease sedentary behaviour and increase physical activity.51 It is important that screen time (ie television, iPad, smart phone) is discussed because most children in Australia exceed the recommended time using screens and this is associated with poorer health outcomes11,51 (see Chapter 2: Healthy living and health risks, Physical activity and sedentary behaviour).

Management

When designing health programs at both the individual and community level, it is essential that the individual and community members are consulted because they will understand the issues facing them best and will be able to provide practical contributions towards the design of solutions. Outcomes will be further improved if the advice provided takes a strength-based approach that aligns with Aboriginal and Torres Strait Islander ways of knowing, being and doing regarding health and adopting an optimistic frame of reference to address problems linked with excessive body weight.2,51–53 This includes all clinicians and services provided. Confidence about cultural safety and appropriateness needs to be a key consideration when making referrals (eg to allied health providers), particularly given recognition that learning about working with Aboriginal and Torres Strait Islander peoples has historically often not been included in allied health professional curricula.54 It is important to recognise that for some Aboriginal and Torres Strait Islander people, fulfilling family and cultural obligations is more important that ensuring their own health is a priority.55

Dietary interventions might include calorie reduction using whole foods, reduced carbohydrate diets, traditional foods, low-energy diets or very low-energy diets.4,12–14,56 Consideration should also be given to pharmacotherapy and bariatric surgery if suitable for the patient.4

The consensus-based Australian Obesity Management Algorithm developed in 2022 provides detailed guidance for the management of adults with obesity in primary care.4 Guidance on managing overweight and obesity in children and adolescents is also available.57 Neither of these is specific to Aboriginal and Torres Strait Islander peoples. The current National Health and Medical Research Council Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia have been rescinded, and new guidelines are expected to be published in 2024.19,58

Healthy diet

Consuming fresh, unprocessed foods such as fruits, vegetables and lean meats in most meals will help maintain a healthy body weight because these foods are nutritious, more filling and contain fewer calories than ultra-processed foods. Ultra-processed foods, such as sweetened breakfast cereals, soft drinks, ice cream, packaged soups, chicken nuggets, chips, chocolate, candy, hotdogs, some protein and muesli bars and balls and many preprepared meals, make up a large proportion of stock in supermarkets and are highly accessible.59 These foods are also often less expensive than fresh foods, and are therefore more affordable. However, the overconsumption of ultra-processed foods can lead to excessive daily calorie intake and weight gain.

The cost and accessibility of fresh foods can be a barrier for some families, so guidance may be required. Frozen vegetables are a healthy alternative to fresh vegetables. Fresh produce that is in season will often be cheaper and more readily available. Food banks, farmers markets and wholesale stores can provide quality foods at a reduced price.

Encourage traditional foods

Traditional foods, which have food matrix mostly consisting of protein, fibre and micronutrients, have been shown to provide health benefits for Aboriginal and Torres Strait Islander people.2,12,14 It is widely accepted that prior to colonisation, and whenever traditional foods formed most of the diet since colonisation, Aboriginal and Torres Strait Islander people maintained a healthy body weight and were free of many of the chronic diseases found in most communities today.60

Design strategies with the patient

To improve engagement and the likelihood of long-term success, it is important to include the patient in the design of healthy lifestyle strategies.4,52 When designing strategies to improve the quality of food intake, ask the patient which specific meals they and their family enjoy eating at home. If these meals are not based on fresh, unprocessed foods, ask the patient how they might be able to adapt the recipes to provide a more nutritious meal. A referral to an accredited practising dietician who has experience and trust within the local Aboriginal/Torres Strait Islander community could help with this.

Physical activity

Physical activity can include, but should not be limited to, structured, planned exercise sessions (eg those performed in a fitness centre) and can include a range of novel and traditional activities, such as gardening, dog walking, cleaning, swimming, walking on Country, hunting, dancing and other cultural activities enjoyed by the patient. When designing a personalised structured physical activity session, a referral to an accredited exercise physiologist who is experienced and trusted by the local community can result in better engagement and health outcomes.

Physical limitations

A higher percentage of Aboriginal people are affected by chronic injury, illness and disability that may restrict their ability to perform some physical activities,29 so this should be considered when providing advice. Patients should be encouraged to work within pain and mobility tolerances, but not repeatedly push through them. Movements such as walking are a good starting point, because this will also improve independence and other activities of daily living. If a patient reports that they can only walk for five minutes before pain increases, then a duration of three minutes could be a good starting point. This should be increased each week, with an emphasis on progression. When shorter durations are required, multiple sessions could be completed across the day to meet or approximate physical activity guidelines.

Join with others

Improving food intake and increasing physical activity can be more engaging if family and friends are included.61 Encourage patients to consider including others in their health improvement journey.

Be inclusive of family

It can be difficult for an individual to achieve long-term success following a healthy lifestyle if it does not work for the whole family.13,55 Consider asking the patient about the type of healthy foods their children will eat and base meal plans around that. With physical activity, consider options that can be completed either while their children are participating in sport or training, or can include them.

Medications in weight loss

The patient should be assessed for the appropriateness of weight management medications and clinicians should be guided by clinical guidelines such as The Australia Obesity Management Algorithm.4,21

Bariatric surgery

Patients with severe obesity, and with careful assessment of suitability, may benefit from bariatric surgery.4,22 Patients undergoing bariatric surgery should do so in conjunction with a lifestyle program for education and ongoing support in losing weight and maintaining weight loss.4,22

Environmental/built environments

Advocate for healthy built environments that include adequate footpaths and cycle ways, access and connection to public transport and sustainable healthy food sources. Enhance food security and access to healthy foods (fresh and frozen) by ensuring supermarkets stock healthy foods and reduce the supply of unhealthy foods.62,63

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