COMPaRE-PHC is funded by the Australian Primary Health Care Research Institute, which is supported by a grant from the Commonwealth of Australia as represented by the Department of Health and Ageing

Implementation of NHMRC Obesity guideline recommendations for adults

Mark Harris, Ian Caterson, Nigel Stocks, Elizabeth Denney-Wilson, Gary Wittert, Catherine Spooner

Outline• Introduction

– The development of the NHMRC guidelines

– Epidemiology of obesity• The NHMRC guidelines:

– What works?– Ask & Assess– Advise– Assist– Arrange

• Discussion Q&A

The development of the NHMRC guidelinesThe "Appraisal of Guidelines Research and Evaluation"(AGREE) collaboration dimensions:-1. scope/purpose: primary health care clinical practice2. clarity/presentation: structured around the 5As.3. rigor of development: strict evidence approach

building on SIGN guidelines4. stakeholder involvement: consultation with

consumers, government, providers5. applicability: based on Australian practice with adults

and children6. editorial independence: conflict of interest carefully

declared and managed.AGREE COLLABORATION Quality & Safety in Health Care 2003, 12:18-23

Rise of obesity across all ages

Disparities in Obesity (%) by IRSD Quintile, Males and Females Aged 25-64, 1989 to 2001

Impacts of obesityBurden attributable to high body mass, by specific cause, Australia, 2003

• 7.5% of the total burden of disease• Between 1-5% of total health cost• Over $1000 per person per annum

excess health costs

What works?Guidelines – Part A – Chapter 3

What works• Seek to change both diet and physical activity• Use problem solving, self-monitoring, goal-

setting, action plans, relapse prevention.• Encourage social support (i.e. engage others

who are important such as family, friends, and colleagues)

Greaves et al. Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health 2011, 11:119

Modest weight loss of 5-10% is sufficient to achieve clinically significant benefits

• Blood pressure-1% fall in weight: 1% fall in SBP, 2% fall in DBP

• LDL reduces by 1% for every kg lost• 15-20% weight loss can reverse morbidity of

type 2 diabetes• Reduced risk of CVD• Particularly significant if reductions in visceral fat

occur

Multidisciplinary approach

• Range of health professionals including practice nurses, dietician, exercise physiologists and psychologists.

• May involve range of health and non-health services and programs available in the community

• May be in person, by phone or on-line

Intervention pathway for adults: 5As Model

* All patients but especially higher risk patients: physiological risk factors (hypertension, high cholesterol, pre-diabetes) ; indigenous and CALD groups; family history of CVD, diabetes, renal disease, OA

Ask and Assess

Guidelines – Part B – Chapter 4

Classification(WHO)

BMI (kg/m2) Risk of co-morbidities

Normal range 18.5-24.9 Average

Overweight 25-29.9 Increased

Obese class I 30-34.9 Moderate

Obese class II 35-39.9 Severe

Obese class III ≥ 40 Very severe

Waist circumference is a surrogate measure of abdominal or visceral fat

WomenIncreased risk >80cmGreatly increased risk >88cm

www.measureup.gov.au

MenIncreased risk >94cmGreatly increased risk >102cm

%

Assessment (% of GP records)

25.6

6

74.3 72.9

22.2

4.30

10

20

30

40

50

60

70

80

BMI WC Smoking BPPEP MAGNET

Advise

Guidelines – Part B – Chapter 5

Advise that:

• Overweight & obesity associated with increased risk of cardiovascular disease, type 2 diabetes and some cancers

• Even small amounts of weight loss have health benefits. Modest weight loss of 5-10% associated with:– Blood pressure-1% fall in weight: 1% fall in SBP, 2%

fall in DBP– LDL reduces by 1% for every kg lost– 15-20% weight loss can reverse morbidity of type 2

diabetes– Reduced risk of CVD

• Particularly significant if reductions in visceral fat occur

Effective communication• Prioritise what needs to be discussed to 3-5 key

points• Use plain language, be specific and concrete not

general• Be positive, hopeful, empowering• Draw pictures, use illustrations or demonstrate with

models• Engage patients to ask questions What questions

do you have rather than do you have any questions• Follow up with patients

Communication...

• Ask patients to repeat in their own words what they need to know or do, in a non-shaming way

• NOT a test of the patient, but of how well you explained a concept

• A chance to check for understanding and if necessary, re-teach the information

From “Beyond Advice: Becoming a Motivational Practitioner” by R.J. Botelho

Reasons to stay the same Reasons to change

1. What are the benefits of staying the same?

2. What are your concerns about staying the same?

3. What are your concerns about change?

4. What are the benefits of change?

Resistance Motivation

Decision Balance:Clarifying Issues About Change

Assessment Vs Advice (Population Survey)

0102030405060708090

100

Bloodpressure

Bloodcholesterol

Bloodglucose

Diet advice :low fat

Diet advice:fruit/veg

Physicalactivityadvice

Assist

Guidelines – Part B – Chapter 6

Multicomponent • Seek to change both diet and physical activity• Use problem solving, self-monitoring, goal-

setting, action plans, relapse prevention.• Encourage social support (i.e. engage others

who are important such as family, friends, and colleagues)

Greaves et al. Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health 2011, 11:119

CS1

Slide 23

CS1 Mark - did you mean to repeat this slide?Catherine Spooner, 7/10/2014

AssistWeight management plan• Goal setting• Tailoring to culture, circumstances, access, health status• Self monitoring Referral1.Referral and navigation to lifestyle program or behaviour

change – individual, group, health program, community, phone, internet

2.>28 + co-morbidities or 30+: Consider VLED or pharmacotherapy

3. 35+ comorbidities or 40+ Surgery

Mean Weight Change According to Randomized Group.

Appel LJ et al. N Engl J Med 2011;365:1959-1968

-6

-5

-4

-3

-2

-1

0

1

2

3

3m

6m 12m 24 m

Weig

ht C

hang

e kg

-2.3

-4.2

-3.3 -3.0

One in 6 achieve >5% weight loss at 12 or 24 months

The Counterweight Programme

Br J Gen Pract. 2008; 58: 548-554

Counterweight

Advice and referral for lifestyle interventions (diet, PA or weight loss) over past 3 months in general practice

(PEP audit baseline)

%

8.1

15.3

26.4

1.85

11

0

5

10

15

20

25

30

Normal wt Overweight ObeseAdvice Referral

Pharmacotherapy• May be considered if BMI>30 or BMI>27 with comorbidities.Orlistat not on PBS.• Usually <12 weeks • Contraindications: malabsorption, gall bladder dysfunction• Side effects: steatorrhoea, faecal incontinence, frequent urgent

bowel movements • May require fat soluble vitamin supplementations (Vit A D E K) if

used long termPhenteramine not on PBS• registered for short term use• Has a range of side effects

(hypertension, tachycardia, insomnia) and risk of tolerance.

VLEDBMI >28 + comorbidities or 30+ unsuccessful in weight managementAssess: LFTs, lipid profile, FBC and iron studies, electrolytes, creatinine and uric acid.Contraindications: history of severe psychological disturbance, alcohol misuse or drug abuse, porphyria, recent myocardial infarction or unstable angina. Relative: insulin or hypoglycaemics (except metformin).Treatment: usually 8–16 weeks. Options in the food replacement regime (e.g. replace 3 meals, or 2 and one of protein, non-starchy veg and salad)Important to achieve ketosis to suppress hunger and test for it. Need a small quantity of fat (e.g. 1 tablespoon olive oil on salad or vegetables/day) to contract gall bladder and prevent gallstones. Need to drink when thirsty and fibre supplementationRegular follow-up during the period of the diet (about 12 weeks) and gradual weaning off the diet (over about 8 weeks)Costs

Bariatric surgery

• Adjustable lap band most common but roux en y bypass or sleeve may be more effective

• Consider bariatric surgery for adults with BMI >40 kg/m2 or with BMI >35 kg/m2 and comorbidities that may improve with weight loss, taking into account the individual situation

Influences on GP referral for surgery

GP attitudes

Normativeinfluences

External factors

Intention toRefer (<1%)

Patient expectation

Professional

Previous case experience

Perceived efficacy

Practice

Patient

System

Motivation

Comorbidity

Ability to pay

Medico-legal

Guidelines

Nurse capacity

Availab/transport

Health Literacy

Follow up• Follow up after 2 weeks

then frequently over 3 months

• Continuing monitoring and support

• Review and revision of plan• Relapse prevention and

management of regain

Case studyA 42-year-old woman with BMI 40.1 kg/m2, diabetes and a history of difficulty in managing her weight says she is struggling with her diet and physical activity regimen after 1 month and her diabetes has not improved. She says that she has considered gastric banding but cannot afford it.Assess: Control of diabetes and other co-morbidities. Advise: Explain the importance of weight loss in diabetes control. Discuss available intensive interventions. A very low energy diet will have an immediate effect on her diabetes and achieve weight loss and may be followed by medication to assist with weight maintenance. Assist: Review medication as this may contribute to her weight gain.Agree on weight goals, interventions and provide advice on risks and benefitsArrange: Referral to specialist (e.g. dietitian, weight management clinic, diabetes educator). Another appointment in 2 weeks to review progress and monitor comorbidities

http://www.nhmrc.gov.au/guidelines/publications/n57

COMPaRE-PHC is funded by the Australian Primary Health Care Research Institute, which is supported by a grant from the Commonwealth of Australia as represented by the Department of Health and Ageing

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