DOCUMENT 4 FOI 24/25-1213
Research Request – Weight Management Supports (Obesity)
Obesity: What weight management supports/services are effective and beneficial? The effectiveness of weight management interventions: surgery, Brief dietetics, exercise physiology, psychology/CBT, community/group based programs etc.
Date 16 December 2019
s47F- pers Requester Wendy (Director – TAT)
s47F- persona Researcher Craig (Tactical Research Advisor – TAT)
Contents
Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia …………………………………………………………………………………………………………. 2
Overview …………………………………………………………………………………………………………………………… 2
Effectiveness Hierarchy ……………………………………………………………………………………………………. 2
Key points from the NHMRC Guidelines ………………………………………………………………………………… 3
Surgical Interventions (Bariatric Surgery) ………………………………………………………………………………. 4
Bariatric Surgery Types ……………………………………………………………………………………………………. 4
Pharmacological Interventions (Weight Loss Medications) ……………………………………………………… 6
Orlistat ………………………………………………………………………………………………………………………….. 6
Other Medications ………………………………………………………………………………………………………….. 7
Lifestyle Interventions ………………………………………………………………………………………………………… 7
Diet ……………………………………………………………………………………………………………………………….. 8
Exercise & Exercise Physiology …………………………………………………………………………………………. 9
Psychological Therapies …………………………………………………………………………………………………. 10
Community Group Based Programs …………………………………………………………………………………. 11
Complimentary Medicines & Nutritional Supplements ………………………………………………………. 12
Obesity Management Services in the public system/ Multidisciplinary Programs ………………………… 13
Public Hospitals offering Obesity Management Services / Eligibility & Referral Process …………….. 13
Effectiveness of Interventions for those with clinical conditions ………………………………………………… 18
Bariatric Surgery ……………………………………………………………………………………………………………….. 18
Patients with Cognitive Impairment or Developmental / Intellectual Disability …………………….. 19
Reference List ………………………………………………………………………………………………………………………. 20
Research Request – Weight Management Supports: Obesity Page 1 of 21
Page 52 of 72
FOI 24/25-1213
Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia
Overview
In 2013 The Department of Health and Ageing, commissioned The National Health and Medical Research Council (NHMRC) to review the 2003 “Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia”. The review methodologist prepared a review protocol that outlined the key questions to be addressed in the systematic review and the methods to be used. Essentially the review focused on:
- What are the health outcomes associated with weight loss in individuals with overweight or obesity?
- What are the impacts of weight reduction interventions on degree and duration of weight loss?
Note that participants in the review were:
Studies involving participants of any age with any degree of overweight or obesity were considered for inclusion. Studies involving participants with overweight or obesity due to a specific clinical condition e.g. Prader Willi Syndrome, were excluded.
Effectiveness Hierarchy
The resulting substantial 2013 review study “Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia”1, focused on the following primary interventions:
- Lifestyle interventions (including dietary interventions, physical activity/exercise interventions and psychological interventions)
- Pharmacological interventions
- Surgical interventions
The study found the effectiveness of each intervention as follows:
Summary of effect Intervention
Most effective (consistently > 10% Bariatric surgery weight loss across studies; weight loss likely to be maintained > 5 years)
1 Australian Government, National Health and Medical Research Council, Department of Health and Ageing, “Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia: Systematic Overview”, 2013, https://www.nhmrc.gov.au/about‐us/publications/clinical‐practice‐guidelines‐management‐ overweight‐and‐obesity#block‐views‐block‐file‐attachments‐content‐block‐1
Research Request – Weight Management Supports: Obesity Page 2 of 21
Page 53 of 72
FOI 24/25-1213
Summary of effect Intervention
Moderately effective (>10% weight loss Combined pharmacotherapy and lifestyle change across some but not all studies; weight loss maintained > 5 years in some but not all participants)
Least effective (>10% weight loss in few Lifestyle change alone studies; weight loss not likely to be maintained in participants)
Key points from the NHMRC Guidelines
Multicomponent interventions that address all three lifestyle areas related to overweight and obesity—nutrition, physical activity and psychological approaches to behavioural change—are more effective than single component interventions.
Lifestyle approaches should focus on creating an energy deficit. This can be achieved through reducing energy intake, increasing energy expenditure, or both. Creating an energy deficit needs to be supported by measures to assist behavioural change.
For many overweight and most obese adults, achieving a ‘healthy’ weight is an unrealistic expectation—weight loss of 5% is achievable and will result in health benefits. Treatment goals should focus on behavioural change and improved health.
More intensive weight management interventions—such as very low‐energy diets, weight loss medication and bariatric surgery may need to be considered as adjuncts to lifestyle approaches, especially when a person is obese and/or has risk factors or comorbidities, or has been unsuccessful reducing weight using lifestyle approaches. The decision to use intensive weight loss interventions is made based on the individual situation.
Individuals should be well informed and supported in changing health behaviours, and be assisted to manage overweight and obesity in partnership with one or more healthcare professionals. Interventions need to be individualised, and supported by self‐management principles and regular review by a healthcare professional.
Influences on health behaviours (e.g. social, physical and psychological factors) should be taken into account when planning interventions with individuals. 2
2 Australian Government, National Health and Medical Research Council, Department of Health and Ageing, “Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia”, p. 30, 2013, https://www.nhmrc.gov.au/about‐ us/publications/clinical‐practice‐guidelines‐management‐overweight‐and‐obesity#block‐views‐ block‐file‐attachments‐content‐block‐1
Research Request – Weight Management Supports: Obesity Page 3 of 21
Page 54 of 72
FOI 24/25-1213
Surgical Interventions (Bariatric Surgery)
The NHMRC study found that:
Bariatric surgery is more effective than other treatment options in achieving significant weight loss in adult and adolescent patients with obesity. In adults, all classes of obesity are improved with various bariatric surgical types; in adolescents, available data from high quality research shows improvements in Class II and III obesity with LAGB. There are no high quality data available regarding the indications for bariatric surgery in children and the long‐ term impacts when bariatric surgery is performed.
Weight regain after bariatric surgery occurs regardless of the bariatric surgical type. Achieving long‐term weight loss therefore requires weight maintenance strategies to be applied after bariatric surgery has been performed.
The extent of the initial weight loss and the degree and rapidity of weight regain varies according to the specific bariatric procedure.
Bariatric surgery is associated with significant short‐term improvements in some cardio‐ metabolic risk factors and in short‐term resolution of metabolic syndrome and newly developed (< 2 years) type 2 diabetes. However, data from over ten years or greater duration follow‐up suggest that these benefits are not maintained long‐term. Numerous unanswered questions remain regarding the role of bariatric surgery in managing type 2 diabetes
Bariatric Surgery Types
According to the Australian Family Physician, the scholarly journal of the Royal Australian College of General Practitioners (RACGP), bariatric surgery is the most effective available treatment for obesity in terms of achieving and maintaining substantial weight loss long term. The research article “Recommendations for management in general practice and beyond” suggests that:
“Bariatric surgery should be considered for patients with a BMI >40 or with a BMI >35 with obesity related comorbidities. The three most commonly performed procedures in Australia include:
- Laparoscopic adjustable gastric banding (LAGB),
- Roux‐en‐Y gastric bypass (RYGB) and
- Sleeve gastrectomy (SG).
The article asserts that “alterations to the gastrointestinal tract, induced by bariatric surgery, reduce hunger, increase satiety and confer other metabolic benefits as well as sustained weight loss” 3 In other considerations, the article continues that:
3 Australian Family Physician, “Obesity: Recommendations for management in general practice and beyond”, Vol 42, No 8, pp. 532‐541, 2013, https://www.racgp.org.au/afp/2013/august/obesity
Research Request – Weight Management Supports: Obesity Page 4 of 21
Page 55 of 72
FOI 24/25-1213
To date, the long term safety of LAGB and RYGB has been documented.
Evidence on long term safety is lacking for the SG.
Each procedure is accompanied by its own advantages and disadvantages, and these need to be taken into consideration when assessing a patient’s suitability for surgery.
Current medical and psychological comorbidities, as well as ability to provide informed consent, will all influence a patient’s suitability for undergoing a particular procedure.
Patients considering bariatric surgery should be made aware of the commitment to indefinite post‐surgical care and long term monitoring from an experienced team.
The article summarizes the characteristics of current conventional bariatric procedures in the tables below:
Surgical Procedure: Description & Weight Loss
Excess weight Percentage Surgical Pattern of weight Morbidity at Description loss at mean weight procedure loss 1 year 3–5 loss years* Laparoscopic Involves placing an adjustable 54% 20–30% Gradual; usually 4.6% adjustable band around the maximal at 2–3 years gastric gastroesophageal junction, banding thereby restricting food (LAGB) intake. The band can be tightened and loosened over time to alter the extent of restriction Roux‐en‐Y Is a combination procedure in 60% 25–35% Rapid; maximal at 1–2 14.9% gastric which a small stomach pouch (75% years bypass is created to restrict food with intake and the lower stomach, banded duodenum and first portion of RYGB) the jejunum are bypassed to produce modest malabsorption of nutrients and energy intake Sleeve Involves removing the greater 50–60% 20–30% Rapid; maximal at 1–2 10.8% gastrectomy portion of the fundus and (limited years body of the stomach, reducing reports its volume from about 2.5 L to at ≥3 about 250 mL years)
Surgical Procedure: Nutritional Concerns, Follow up, Advantages & Disadvantages
Surgical Follow up Nutritional concerns Advantages Disadvantages procedure requirements Laparoscopic Low (deficiencies in Lifelong Effective, with good long Gastric pouch dilatation, adjustable iron, vitamin B12, (assessment and term weight maintenance erosion of band into the gastric folate) nutritional Ability to adjust the stomach, leaks to the LAGB banding support), degree of restriction system, weight regain (LAGB) frequent in the Reversible first 12 months Maintains gastric integrity
Research Request – Weight Management Supports: Obesity Page 5 of 21
Page 56 of 72
FOI 24/25-1213
Surgical Follow up Nutritional concerns Advantages Disadvantages procedure requirements Roux‐en‐Y Moderate Lifelong Very effective with good Abdominal pain, staple line gastric (deficiencies in iron, (assessment and long term weight leak, stomach ulcer, bypass vitamin B12, folate, nutritional maintenance intestinal obstruction, calcium, vitamin D, support) Few failures gallstones, nutritional copper, zinc) deficiency, weight regain Sleeve Moderate Lifelong Allows for rapid weight Staple line leak, gastrectomy (deficiencies in iron, (assessment and loss gastroesophageal reflux vitamin B12, folate, nutritional No dumping syndrome as disease, dilatation of the calcium, vitamin D, support) pyloric portion of the gastric remnant, weight copper, zinc, stomach is intact regain thiamine) Provides fixed restriction and does not require adjustment
Pharmacological Interventions (Weight Loss Medications)
According to the NHMRC Guidelines4 :
The use of weight loss medications in addition to lifestyle approaches has been found to increase weight reduction in adults who are overweight or obese.
Medications that have been shown to increase weight loss include orlistat (Horvath et al. 2008), sibutramine (Horvath et al. 2008), rimonabant (Curioni & André 2006; Nissen et al. 2008; van Gaal et al. 2008), taranabant (Proietto et al. 2010), metformin (Knowler et al. 2009) and lorcaserin (Smith et al. 2010).
Many of these medications have been associated with adverse effects and have been withdrawn (e.g. sibutramine) or were never approved (e.g. rimonabant, taranabant) in Australia.
The evidence on the effects of weight loss medications on health outcomes other than weight loss is limited.
Orlistat
Orlistat is currently the only medication registered for use in treating overweight (with comorbidities) and obesity that has been evaluated for long‐term safety. Although it is listed on the Repatriation Pharmaceutical Benefits Scheme, it is not listed on the Pharmaceutical Benefits Scheme (PBS).
Cost‐effectiveness studies of orlistat use show that it is not cost‐effective for population‐ based outcomes (Vos et al. 2010), but other data suggest that it is more cost‐effective in
4 Australian Government, National Health and Medical Research Council, Department of Health and Ageing, “Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia”, p. 49, 2013, https://www.nhmrc.gov.au/about‐ us/publications/clinical‐practice‐guidelines‐management‐overweight‐and‐obesity#block‐views‐ block‐file‐attachments‐content‐block‐1
Research Request – Weight Management Supports: Obesity Page 6 of 21
Page 57 of 72
FOI 24/25-1213
individuals who have numerous comorbidities (type 2 diabetes, hypertension, hypercholesterolaemia) (Lamotte et al. 2002).
Recommendations: For adults with BMI ≥ 30 kg/m2 or adults with BMI ≥ 27 kg/m2 and comorbidities, orlistat may be considered as an adjunct to lifestyle interventions, taking into account the individual situation.
There are contraindications for pregnant woman and those with reduced gall bladder function.
Adverse effects include: steatorrhoea (oily, loose stools with excessive flatus due to unabsorbed fats reaching the large intestine), fatty faecal incontinence, frequent or urgent bowel movements.
Therapy with orlistat should be continued beyond 12 weeks only if at least 5% of initial body weight has been lost since starting medication (SIGN 2010). Therapy should then be continued for as long as there are clinical benefits (e.g. prevention of significant weight regain). Continuing risks and benefits should be discussed.
Other Medications
Phentermine is registered for use as a short‐term (e.g. 3‐month) adjunct to dietary management of obesity, under medical supervision.
A number of medications for the treatment of other conditions have been found to have an effect on weight (e.g. fluoxetine, topiramate, metformin, glucagon‐like peptide agonists). When relevant comorbidities are present, these medications may also be beneficial for weight management.
Lifestyle Interventions
The NHMRC guidelines review found that within the lifestyle therapies group, a variety of different approaches to lifestyle modification can be prescribed. The strength of evidence for lifestyle therapies and their impact on weight loss from studies included in this review are as follows:
Strength of effect Intervention
Most effective (most likely to result in Combining dietary change with improved physical weight loss; most likely to be associated activity with sustained weight loss) Reducing total energy intake (variety of means)
Energy deficit of 500 – 700 kcal/day
Research Request – Weight Management Supports: Obesity Page 7 of 21
Page 58 of 72
FOI 24/25-1213
Strength of effect Intervention
Somewhat effective (results in weight Increasing intake of low energy‐dense foods (especially loss in some studies; evidence regarding fruit / vegetables) association with sustained weight loss Reducing intake of sweetened beveragesless well defined) High protein diets
Mediterranean diet pattern Limiting number of high energy ‐ dense snacks
Reduced time spent in sedentary behaviour
Insufficient evidence or inconsistent Increased incidental or occupational physical activity effects Exercise in the absence of dietary change
Diet
According to the NHMRC Guidelines5:
Very low‐energy diets are a useful intensive medical therapy that is effective in supporting weight loss when used under medical supervision. They may be a consideration in adults with BMI > 30 kg/m2, or with BMI > 27 kg/m2 and obesity related comorbidities, taking into account the individual situation.
Very low‐energy diets involve replacing one or more meals each day with foods or formulas providing a specified number of kilojoules (e.g. 1675–3350 kilojoules).
Meal replacements are defined in the Australia New Zealand Food Standards Code as ‘a single food or pre‐packaged selection of foods sold as a replacement for one or more of the daily meals, but not as a total diet replacement’.
Meal replacements are largely protein based, and contain essential fatty acids, vitamins and minerals, but very little carbohydrates. They reduce portion size and, consequently, energy intake.
Food Standards Australia and New Zealand is currently reviewing the regulations surrounding meal replacement products for weight loss.
5 Australian Government, National Health and Medical Research Council, Department of Health and Ageing, “Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia”, pp. 47‐49, 2013, https://www.nhmrc.gov.au/about‐ us/publications/clinical‐practice‐guidelines‐management‐overweight‐and‐obesity#block‐views‐ block‐file‐attachments‐content‐block‐1
Research Request – Weight Management Supports: Obesity Page 8 of 21
Page 59 of 72
FOI 24/25-1213
Advantages of very low‐energy diets include the motivating effect of rapid weight loss and a mild ketosis that may suppress hunger (Delbridge & Proietto 2006). Very low‐energy diets have been associated with weight loss (Nield et al. 2007; Norris et al. 2005b; Tuomilehto et al. 2009), improvements in sleep apnoea (Tuomilehto et al. 2009) and improved glycaemic control in adults with type 2 diabetes (Nield et al. 2007; Norris et al. 2005b). They are commonly used in medically supervised weight reduction programs for people with BMI > 30 kg/m2 (or > 27 kg/m2 with obesity related comorbidities), or for whom rapid weight loss is necessary (Sumithran & Proietto 2008).
Costs are associated with the use of very low‐energy diets: Purchasing very low‐energy diet items to replace meals may be costly for individuals and their use requires frequent monitoring by healthcare professionals. The relevant healthcare professional to monitor use may be a GP, dietitian or specialist nurse, depending on access to the type of provider.
Contraindications include: pregnancy or advanced age, history of severe psychological disturbance, alcohol misuse or drug abuse, the presence of porphyria, recent myocardial infarction or unstable angina.
Common adverse effects include cold intolerance, dry skin, hair loss, constipation, headaches, fatigue and dizziness. Other potential effects are gallstones, increased serum uric acid levels and precipitation of gout, and reduced bone mineral density (Sumithran & Proietto 2008). Although restrictive eating has been strongly associated with onset of binge eating (Polivy 1996), there is insufficient available evidence of an association between medically supervised very low‐energy diets and new‐onset eating disorders (Mustajoki & Pekkarinen 2001).
Treatment length varies but is usually 8–16 weeks (Mustajoki & Pekkarinen 2001). There is evidence that in certain obese individuals and under close medical supervision, very low energy diets may be used safely for 12 months (Sumithran & Proietto 2008).
Careful monitoring of people on very low‐energy diets is required.
Exercise & Exercise Physiology
The NHMRC Guidelines asserts that6:
Although it is accepted that physical activity is integral to weight management, the evidence for a specified duration and intensity of exercise is unclear given high individual variability in baseline levels of activity, eating patterns, medication use, and other lifestyle factors and comorbidities.
6 Australian Government, National Health and Medical Research Council, Department of Health and Ageing, “Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia”, pp. 42‐44, 2013, https://www.nhmrc.gov.au/about‐us/publications/clinical‐practice‐ guidelines‐management‐overweight‐and‐obesity#block‐views‐block‐file‐attachments‐content‐block‐1
Research Request – Weight Management Supports: Obesity Page 9 of 21
Page 60 of 72
FOI 24/25-1213
Studies that focus on the association between physical activity and weight loss have found that: increasing physical activity has a range of health benefits even if no weight is lost. Physical activity has little effect on weight unless it is combined with dietary change, a dose response exists between amounts of activity and weight lost, maintaining high levels of physical activity (approximately 60 minutes per day), combined with other behavioural strategies may reduce weight regain.
Consensus‐Based Recommendation:
For adults who are overweight or obese, prescribe approximately 300 minutes of moderate‐ intensity activity, or 150 minutes of vigorous activity, or an equivalent combination of moderate‐intensity and vigorous activities each week combined with reduced dietary intake.
Cost and resource implications:
Brief advice on physical activity, delivered through primary health care in person, or by phone or mail, for sedentary people at risk of developing disease has a small beneficial effect, and has been shown to be cost‐effective.
While tools such as Lifescripts can help with physical activity assessment and prescription, exercise referral schemes may also provide a cost‐effective option if no in‐house program is available.
Costs to the individual will vary depending on the selection of physical activity type that is appropriate, accessible and likely to be sustainable.
Exercise Physiology
If functional mobility is an issue, referral to an exercise physiologist or physiotherapist may also incur costs to the individual and healthcare system.
Psychological Therapies
The NHMRC Guidelines7 suggest that:
In the context of overweight and obesity, the goal of psychological therapies is to assist individuals to make long‐term changes to their lifestyle.
A range of psychological interventions (e.g. behavioural therapy, cognitive‐behavioural therapy) can facilitate weight loss and have been shown to have a more beneficial effect when combined with other lifestyle approaches.
Individual or group‐based psychological interventions may improve the success of weight management programs.
7 Australian Government, National Health and Medical Research Council, Department of Health and Ageing, “Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia”, pp. 45‐46, 2013, https://www.nhmrc.gov.au/about‐us/publications/clinical‐practice‐ guidelines‐management‐overweight‐and‐obesity#block‐views‐block‐file‐attachments‐content‐block‐1
Research Request – Weight Management Supports: Obesity Page 10 of 21
Page 61 of 72
FOI 24/25-1213
Psychological and behavioural therapies should be tailored to the individual and his or her situation.
Lifestyle interventions can also be augmented by measures to reinforce behavioural aspects of care or provide incentives for adherence. Internet‐based information and programs are increasingly popular. Delivery of evidence‐based weight management programs via the internet should be considered as part of a range of options for people with overweight and obesity.
Community Group Based Programs There appears to be no substantial community based weight management programs offered by commonwealth or state governments or other organisations. However, state and territory governments fund a range of activities that aim to educate and encourage Australians to adopt and maintain behaviours that will support healthy weight. The table below summarizes these services8:
State/ Programs Information Links to programs Territory ACT The Live Lighter program is targeted at Australian https://livelighter.com.au/ adults and aims to increase awareness of the link between being overweight and chronic disease, while promoting healthy eating and regular physical activity.
Kids at Play is all about advancing the health and wellbeing of ACT children aged 0 – 5 years by https://health.act.gov.au/about‐ promoting healthy eating and physical activity to our‐health‐system/healthy‐ families and the early childhood sector. living/kids‐play‐active‐play
NSW The Healthy Kids website provides a one‐stop https://www.healthykids.nsw.go shop of information for parent, teachers and v.au/ coaches on healthy food, being active and healthy weight for children and young people.
The Get Healthy Information and Coaching Service® provides adults with free, evidence‐ based information and coaching on healthy https://www.gethealthynsw.com eating, physical activity and weight loss. .au/
NT Nil QLD Queensland government website page on healthy https://www.qld.gov.au/health/s eating with a focus on obesity taying‐healthy/diet‐ nutrition/diet SA The Healthy Living website provides consumers https://www.sahealth.sa.gov.au/ with easy‐to‐understand information to support wps/wcm/connect/Public+Conte healthy eating and physical activity. The site also nt/SA+Health+Internet/Healthy+l promotes action across the settings where iving/
8 Australian Government, Department of Health, “State and Territory links”, [website], 2019, http://tiny.cc/5ihlhz, (accessed 13 December 2019)
Research Request – Weight Management Supports: Obesity Page 11 of 21
Page 62 of 72
FOI 24/25-1213
State/ Programs Information Links to programs Territory people live, learn, work and play, and includes a range of practical tools and case studies. https://www.sahealth.sa.gov.au/ The Health Services Finder provides wps/wcm/connect/public+conte comprehensive information about health and nt/sa+health+internet/health+se community services from the private, public and rvices/national+health+services+ community sectors in South Australia. directory/national+health+servic es+directory TAS Move Well Eat Well provides a comprehensive, http://www.movewelleatwell.tas yet simple guide on how to create healthier .gov.au/ environments for children within early childhood services, primary schools and families. Move Well Eat Well Awards are available to Tasmanian early childhood services and primary schools.
The Community Nutrition Unit of the DHHS aims https://www.dhhs.tas.gov.au/po to make healthy food and drink choices the phealth/community_nutrition/th easiest choices for Tasmanians. Online resources e_community_nutrition_unit are available for early childhood health and community workers, parents, teachers and schools, adults and older adults. WA Website information: Good nutrition is essential https://healthywa.wa.gov.au/Art for healthy growth and development in icles/F_I/Healthy‐eating childhood, and ongoing health and wellbeing, but many Western Australians’ diets are inconsistent with national recommendations. VIC VIC Health Healthy Eating website page: The https://www2.health.vic.gov.au/ Department of Health and Human Services is public‐health/preventive‐ making it easier for Victorians to identify and health/nutrition choose healthier food and drink options in settings where they learn, live, work, dine and play. The Victorian Government’s mandatory kilojoule labelling scheme and Healthy Choices policy guidelines are helping to better inform Victorians about available food choices and to create health‐promoting environments throughout the state.
Complimentary Medicines & Nutritional Supplements
The NHMRC Guidelines suggest that “the use of complementary therapies is increasingly common in Australia. However, there is little evidence from recent reviews or randomised trials to support their use in assisting weight loss”. 9
9 Australian Government, National Health and Medical Research Council, Department of Health and Ageing, “Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia”, p. 46, 2013, https://www.nhmrc.gov.au/about‐us/publications/clinical‐practice‐ guidelines‐management‐overweight‐and‐obesity#block‐views‐block‐file‐attachments‐content‐block‐1
Research Request – Weight Management Supports: Obesity Page 12 of 21
Page 63 of 72
FOI 24/25-1213
Obesity Management Services in the public system/ Multidisciplinary Programs
There appears to be limited opportunity for people with obesity to seek support through the public health system. A recent 2018 research paper 10 investigated the availability of services within the Australian public health system, and found:
The vast majority of Australians living with clinically severe obesity cannot access specialist healthcare in the public hospital system.
Of the small number of specialist obesity services available, patient access is limited by strict entry criteria, prolonged wait times, lack of regional and rural services and out‐of‐pocket costs.
Many services that do exist have more than 300 patients on waiting lists.
Patients with severe obesity often had multiple health conditions that cannot be met by a GP alone.
The researchers also identified gaps in clinic staff and services, as well as patient access to publicly‐funded weight loss medication and surgery — approximately 88 per cent of bariatric surgery is performed in private hospitals. 11
Public Hospitals offering Obesity Management Services / Eligibility & Referral Process
Below is a selection of public hospitals offering obesity management services including eligibility and referral process where given. Note that this is just an example and not all hospitals are listed.
State/ Hospital Brief Details/Program Eligibility / Referral Process Territory /Health Centre ACT Belconnen Advice on physical Accepts patients who have been Community activity and nutrition / referred by their doctor if: Health Centre Group education / Physical activity Over 18 years of age programs / Strategies to improve social and Have a Body Mass Index (a emotional wellbeing / measure of obesity) of 40kg Support for long term /m2 or over self‐management / Care
10 E. Atlantis et al., “Clinical Obesity Services in Public Hospitals in Australia: a position statement based on expert consensus”, Clinical Obesity, Vol 8, No 3, pp. 203‐210, 2018, https://onlinelibrary.wiley.com/doi/abs/10.1111/cob.12249
11 ABC News, “Australian public hospitals cannot meet rising demand for obesity care, experts warn”, [website], 2018, https://www.abc.net.au/news/health/2018‐04‐24/hospitals‐cannot‐meet‐demand‐ for‐obesity‐care‐study/9689494, (accessed 13 December 2019)
Research Request – Weight Management Supports: Obesity Page 13 of 21
Page 64 of 72
FOI 24/25-1213
State/ Hospital Brief Details/Program Eligibility / Referral Process Territory /Health Centre coordination for those A degree of co‐morbidity patients with a number of complex medical Psycho‐socially able to conditions. / In general, participate in the program the
Service will provide 12 months support. The service will not take over primary care from your general practitioner, nor provide specialist care for conditions other than obesity NSW Westmead Treatments Include: The Patients must have a current Hospital Obesity Australian Guide to referral to Dr Jonathan Marks Clinic Healthy Eating, Low Carbohydrate and High No other information given Protein Diet, The 5 : 2 Diet, Very Low Calorie Diet, Appetite suppressant medication, Individual exercise program
Most patients will be seen initially fortnightly, then monthly for 2‐3 months then every 2‐3 months for the long‐ term.
As obesity is not curable, we believe follow‐up should continue for years.
Clinic Staff Include: Endocrinologist, Dietitians, Exercise physiologist NSW Blacktown The program provides: The referring clinician should Hospital intensive lifestyle be convinced the patient is Metabolic & coaching, consultations motivated to commence the Weight Loss with our dietitian, significant lifestyle changes Clinic doctor required to lose weight and (endocrinologist), improve their health) Patients should have a BMI > 40 kg/m2
Research Request – Weight Management Supports: Obesity Page 14 of 21
Page 65 of 72
FOI 24/25-1213
State/ Hospital Brief Details/Program Eligibility / Referral Process Territory /Health Centre psychologist and plus 2 obesity‐related exercise physiologist. comorbidities or characteristics (complete page 2 of our For some patients, referral form) OR b) A BMI > 35 weight loss surgery is kg/m2 with co‐existing type 2 also performed by our diabetes surgeons at Blacktown Hospital. Patients with psychological (e.g. depression, anxiety), psychiatric (e.g. eating disorders, psychosis, bipolar disease), substance and/or alcohol excess/abuse issues, must be in active treatment and must have been assessed as clinically stable by their treating health professional. Letters of support from their treating professional(s) are required
Generally, patients should be non‐smokers or must have quit smoking for at least 6 months prior to enrolling in the program. Current smokers can enrol in the program, provided they commence treatment to quit smoking. If indicated, metabolic‐bariatric surgery will be delayed by at least 6 months from the date they quit smoking
Patients should not be planning pregnancy within the next 18‐ 24 months
Patients must be able to attend the University Clinics at Blacktown Hospital at least twice a month
Patients should live within the Blacktown catchment area (e.g. Blacktown, Marayong, Mount Druitt, St Marys, Whalan, Quakers Hill, Rouse Hill, Seven Hills, Toongabbie, Prospect).
Research Request – Weight Management Supports: Obesity Page 15 of 21
Page 66 of 72
FOI 24/25-1213
State/ Hospital Brief Details/Program Eligibility / Referral Process Territory /Health Centre VIC Austin Hospital: Austin Health’s Weight GP Referral Guidelines: The Weight Control Clinic is one of When to Refer: >18 years old Control Clinic the few services in and BMI >35 kg/m2 or BMI >30 Australia that combines kg/m2 + medical condition both medical and related to excess weight (e.g. surgical treatments for T2DM, obstructive sleep obesity. apnoea, fatty liver) and previous unsuccessful attempt Treats complex cases of to achieve or maintain weight obesity, or cases that do loss not respond to treatment in the Include: Diagnostics if primary care available: fasting glucose, environment. electrolytes/renal function, liver function tests, TSH, fasting Usual treatment lipid profile, HbA1c (if has regimen is modified diabetes) very‐low‐energy diet (VLED) followed by Urgent: within 4‐7 weeks, dietician supervised Routine: Patient will be treated transition to regular in turn foods. For maintenance of weight loss, pharmacotherapy may be used if required, or if contraindicated or not tolerated, referral for bariatric surgery is made.
Treatments focus on what evidence shows to be effective at reducing the hormonal drive to eat. Doctors who work in the Weight Control Clinic are also researchers within the Diabetes and Obesity Research Group at The University of Melbourne’s Department of Medicine at Austin Health. They are at the forefront of global research efforts to better understand how
Research Request – Weight Management Supports: Obesity Page 16 of 21
Page 67 of 72
FOI 24/25-1213
State/ Hospital Brief Details/Program Eligibility / Referral Process Territory /Health Centre obesity is caused and treated. VIC Royal Children’s The clinic consists of a Accepts referrals for complex obesity Hospital: multi‐disciplinary team; not over age of 16 years Weight specialist doctors, a Management clinic nurse, a dietitian, BMI >95th percentile with: Service a psychologist and a social worker. Neurological or physical disability (ASD, GDD, ID, Physical Disability) A comprehensive assessment of general AND health and growth, Clinical investigations as restricted eating with risk of appropriate, Dietary micronutrient deficiencies (Iron, Vit assessment, A,C,E, B12) OR other medical diagnosis Psychological and social necessitating ongoing specialist assessment as required, paediatric care Specialist advice and education on diet and BMI >95th percentile with NO lifestyle modification. In DISABILTY but with at least one some cases, medical established obesity related and or surgical comorbidity: treatments may be discussed LFT abnormality Hyperlipidaemia Hypertension Impaired glucose tolerance Obstructive sleep apnoea (please also refer to Respiratory at the time of referral to Weight Management, faxed as separate referral) Orthopaedic complication (NB: SUFE must have Endocrinology referral and assessment prior to being referred to Weight Management Service) QLD Metro North Surgical intervention. The hospital gives a list of referral Hospital and information for practitioners here. Health Service This is not a management program. Minimum referral criteria (three categories):
Category 1 ‐ Appointment within 30 days is desirable:
Patients with a serious obesity‐related comorbidity that is likely to deteriorate quickly, if urgent weight loss is not achieved / Patients requiring urgent lifesaving operation/procedure that
Research Request – Weight Management Supports: Obesity Page 17 of 21
Page 68 of 72
FOI 24/25-1213
State/ Hospital Brief Details/Program Eligibility / Referral Process Territory /Health Centre requires immediate weight loss for surgery/procedure to proceed (e.g. organ transplantation or assessment for organ transplantation, angiogram or cardiac surgery) / Serious obesity related comorbidities include (not an exhaustive list): severe liver disease with potential treatment,, severe pulmonary hypertension, recurrent venous thromboembolism, benign intracranial hypertension.
Category 2 ‐ Appointment within 90 days is desirable:
Patients with severe obesity‐related comorbidities such as (not an exhaustive list): nephrotic range proteinuria or rapidly progressing renal impairment, chronic respiratory failure or obesity hypoventilation syndrome, severe OSA, recurrent cellulitis or venous ulcerations, recurrent hospital admission for an obesity related condition, patients requiring weight loss for a semi urgent or elective operation/procedure, poorly controlled diabetes with HbA1c > 9% with BMI
50, Patients with Prader Willi Syndrome (PWS) unless meet the criteria for Cat 1
Category 3 ‐ Appointment within 365 days is desirable:
BMI >55 younger age i.e. 18‐55 without co‐morbidities listed in Cat 1 or 2
Effectiveness of Interventions for those with clinical conditions Bariatric Surgery Research into Bariatric Surgery for patients with cognitive impairment or developmental / intellectual disability is plentiful. Most of the research is general on the subject, however there is quality cohort focused research mainly on Prada Willi Syndrome, Down syndrome and Autism.
The general theme amongst the literature and research is that:
Research Request – Weight Management Supports: Obesity Page 18 of 21
Page 69 of 72
FOI 24/25-1213
Bariatric surgery among individuals with intellectual impairment is a controversial topic. Weight loss using Bariatric Surgery is successful for this population. Determining use for this population needs to be a case by case basis. Further research is necessary to deepen observations.
Patients with Cognitive Impairment or Developmental / Intellectual Disability
With concerns that youth with cognitive impairment or developmental disability (CI/DD) face higher rates of obesity and secondary medical issues, a recent 2019 observational study looked at bariatric surgery for adolescents with CI/DD and explored the association between cognitive functioning and weight loss outcomes. The results showed there was no significant difference between adolescents with or without CI/DD in terms of preoperative BMI, age, and sex, and having CI/DD did not significantly impact weight loss or weight loss trajectory in the 2 years after surgery, although modelling revealed a trend toward individuals with CI/DD losing more weight over time. It concluded that “Bariatric surgery may be a helpful tool for adolescents with severe obesity and CI/DD. They could benefit from the surgery as much as those with typical development, and having CI/DD should not be used as a criterion to deny surgery. Continuing research with this population can be used to determine long‐term outcomes in addition to defining best practices“. 12
A 2018 case study observed two cases of a 25 year old patient with Prader‐Willi syndrome who presented a 55% loss of excess weight one year after the surgery, and a 28‐year‐old with Down syndrome who presented a 90% loss of excess weight one year after the surgery. In concluding there observations the authors suggested that“ Bariatric surgery among individuals with intellectual impairment is a controversial topic. There is a tendency among these individuals to present significant weight loss and comorbidity control, but less than what is observed in the general obese population. The severity of the intellectual impairment may be taken into consideration in the decision‐making process regarding the most appropriate surgical technique. Bariatric surgery is feasible and safe among these individuals, but further research is necessary to deepen these observations“. 13
A comprehensive 2019 literature review investigated the outcomes of Bariatric Surgery for youth with cognitive impairments and/or developmental delays. The paper reviewed the literature on bariatric surgery within this population. “Fourteen studies published from 1975 to 2019 were identified. The majority (93%) of studies included patients with genetic disorders. Most studies reported no peri‐operative complications (69%) and improved health outcomes (79%), with variable weight‐loss results (29.2–86.2% excess weight loss). No significant differences were reported for youth with and without cognitive impairment and/or developmental delay in two studies”. The study concluded that “bariatric surgery may promote weight loss and improve health comorbidities for
12 S. Hornack et al., “Sleeve Gastrectomy for Youth With Cognitive Impairment or Developmental Disability”, American Academy of Pediatrics, Vol 144, No 6, 2019, https://pediatrics.aappublications.org/content/early/2019/04/11/peds.2018‐2908
13 E. Cazzo et al., “ Bariatric surgery in individuals with severe cognitive impairment: report of two cases“, Sao Paulo Med J, Vol 136, No 1, pp. 84‐88, 2018, https://www.ncbi.nlm.nih.gov/pubmed/28443951
Research Request – Weight Management Supports: Obesity Page 19 of 21
Page 70 of 72
FOI 24/25-1213
youth, irrespective of cognitive or developmental functioning“. 14
Reference List
Australian Family Physician, “Obesity: Recommendations for management in general practice and beyond”, Vol 42, No 8, pp. 532‐541, 2013, https://www.racgp.org.au/afp/2013/august/obesity
Australian Government, National Health and Medical Research Council, Department of Health and Ageing, “Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia”, p. 30, 2013, https://www.nhmrc.gov.au/about‐ us/publications/clinical‐practice‐guidelines‐management‐overweight‐and‐obesity#block‐views‐ block‐file‐attachments‐content‐block‐1
Australian Government, Department of Health, “State and Territory links”, [website], 2019, http://tiny.cc/5ihlhz, (accessed 13 December 2019)
ABC News, “Australian public hospitals cannot meet rising demand for obesity care, experts warn”, [website], 2018, https://www.abc.net.au/news/health/2018‐04‐24/hospitals‐cannot‐meet‐ demand‐for‐obesity‐care‐study/9689494, (accessed 13 December 2019)
E. Atlantis et al., “Clinical Obesity Services in Public Hospitals in Australia: a position statement based on expert consensus”, Clinical Obesity, Vol 8, No 3, pp. 203‐210, 2018, https://onlinelibrary.wiley.com/doi/abs/10.1111/cob.12249
S. Hornack et al., “Sleeve Gastrectomy for Youth With Cognitive Impairment or Developmental Disability”, American Academy of Pediatrics, Vol 144, No 6, 2019, https://pediatrics.aappublications.org/content/early/2019/04/11/peds.2018‐2908
E. Cazzo et al., “ Bariatric surgery in individuals with severe cognitive impairment: report of two cases“, Sao Paulo Med J, Vol 136, No 1, pp. 84‐88, 2018, https://www.ncbi.nlm.nih.gov/pubmed/28443951
14 B. Matheson et al., “Bariatric Surgery in Children and Adolescents with Cognitive Impairment and/or Developmental Delay: Current Knowledge and Clinical Recommendations”, C. OBES SURG, October 2019, pp. 1‐13, https://link.springer.com/article/10.1007/s11695‐019‐04219‐2
Research Request – Weight Management Supports: Obesity Page 20 of 21
Page 71 of 72
FOI 24/25-1213
B. Matheson et al., “Bariatric Surgery in Children and Adolescents with Cognitive Impairment and/or Developmental Delay: Current Knowledge and Clinical Recommendations”, C. OBES SURG, October 2019, pp. 1‐13, https://link.springer.com/article/10.1007/s11695‐019‐04219‐2
Research Request – Weight Management Supports: Obesity Page 21 of 21
Page 72 of 72