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Research Request — Weight Management Supports (Obesity)

Brief	Obesity: What weight management supports/services are effective and beneficial? The effectiveness of weight management interventions: surgery, dietetics, exercise physiology, psychology/CBT, community/group based programs etc.
Date	16 December 2019
Requester	Wendy redacted: s47F - pers (Director — TAT)
Researcher	Craig redacted: s47F - personal priv 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

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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:

1. What are the health outcomes associated with weight loss in individuals with overweight or obesity?
2. 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”, focused on the following primary interventions:

1. Lifestyle interventions (including dietary interventions, physical activity/exercise interventions and psychological interventions)
2. Pharmacological interventions
3. Surgical interventions

The study found the effectiveness of each intervention as follows:

Summary of effect	Intervention
Most effective (consistently > 10%
weight loss across studies; weight loss
likely to be maintained > 5 years)	Bariatric surgery

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

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Summary of effect	Intervention
Moderately effective (>10% weight loss
across some but not all studies; weight
loss maintained > 5 years in some but
not all participants)	Combined pharmacotherapy and lifestyle change
Least effective (>10% weight loss in few
studies; weight loss not likely to be
maintained in participants)	Lifestyle change alone

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

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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:

1. Laparoscopic adjustable gastric banding (LAGB),
2. Roux-en-Y gastric bypass (RYGB) and
3. 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.racp.org.au/afp/2013/august/obesit

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• 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

Surgical procedure	Description	Excess weight loss at 3–5 years*	Percentage mean weight loss	Pattern of weight loss	Morbidity at 1 year
Laparoscopic adjustable gastric banding (LAGB)	Involves placing an adjustable band around the gastroesophageal junction, thereby restricting food intake. The band can be tightened and loosened over time to alter the extent of restriction	54%	20–30%	Gradual; usually maximal at 2–3 years	4.6%
Roux-en-Y gastric bypass	Is a combination procedure in which a small stomach pouch is created to restrict food intake and the lower stomach, duodenum and first portion of the jejunum are bypassed to produce modest malabsorption of nutrients and energy intake	60% (75% with banded RYGB)	25–35%	Rapid; maximal at 1–2 years	14.9%
Sleeve gastrectomy	Involves removing the greater portion of the fundus and body of the stomach, reducing its volume from about 2.5 L to about 250 mL	50–60% (limited reports at ≥3 years)	20–30%	Rapid; maximal at 1–2 years	10.8%

Surgical Procedure: Nutritional Concerns, Follow up, Advantages & Disadvantages

Surgical procedure	Nutritional concerns	Follow up requirements	Advantages	Disadvantages
Laparoscopic adjustable gastric banding (LAGB)	Low (deficiencies in iron, vitamin B12, folate)	Lifelong (assessment and nutritional support), frequent in the first 12 months	Effective, with good long term weight maintenance Ability to adjust the degree of restriction Reversible Maintains gastric integrity	Gastric pouch dilatation, erosion of band into the stomach, leaks to the LAGB system, weight regain

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Surgical procedure	Nutritional concerns	Follow up requirements	Advantages	Disadvantages
Roux-en-Y gastric bypass	Moderate (deficiencies in iron, vitamin B12, folate, calcium, vitamin D, copper, zinc)	Lifelong (assessment and nutritional support)	Very effective with good long term weight maintenance Few failures	Abdominal pain, staple line leak, stomach ulcer, intestinal obstruction, gallstones, nutritional deficiency, weight regain
Sleeve gastrectomy	Moderate (deficiencies in iron, vitamin B12, folate, calcium, vitamin D, copper, zinc, thiamine)	Lifelong (assessment and nutritional support)	Allows for rapid weight loss No dumping syndrome as pyloric portion of the stomach is intact Provides fixed restriction and does not require adjustment	Staple line leak, gastroesophageal reflux disease, dilatation of the gastric remnant, weight regain

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

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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
weight loss; most likely to be associated
with sustained weight loss)	Combining dietary change with improved physical
activity
	Reducing total energy intake (variety of means)
	Energy deficit of 500 – 700 kcal/day

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Strength of effect	Intervention
Somewhat effective (results in weight
loss in some studies; evidence regarding
association with sustained weight loss
less well defined)	Increasing intake of low energy-dense foods (especially
fruit / vegetables)
	Reducing intake of sweetened beverages
	High protein diets
	Mediterranean diet pattern
	Limiting number of high energy - dense snacks
	Reduced time spent in sedentary behaviour
Insufficient evidence or inconsistent
effects	Increased incidental or occupational physical activity
	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

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• 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

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• 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

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• 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/ Territory	Programs Information	Links to programs
ACT	The Live Lighter program is targeted at Australian adults and aims to increase awareness of the link between being overweight and chronic disease, while promoting healthy eating and regular physical activity.	https://livelighter.com.au
	Kids at Play is all about advancing the health and wellbeing of ACT children aged 0 – 5 years by promoting healthy eating and physical activity to families and the early childhood sector.	https://health.act.gov.au/about-our-health-system/healthy-living/kids-play-active-play
NSW	The Healthy Kids website provides a one-stop shop of information for parent, teachers and coaches on healthy food, being active and healthy weight for children and young people.	https://www.healthykids.nsw.gov.au/
	The Get Healthy Information and Coaching Service® provides adults with free, evidence-based information and coaching on healthy eating, physical activity and weight loss.	https://www.gethealthynsw.com.au/
NT	Nil
QLD	Queensland government website page on healthy eating with a focus on obesity	https://www.qld.gov.au/health/staying-healthy/diet-nutrition/diet
SA	The Healthy Living website provides consumers with easy-to-understand information to support healthy eating and physical activity. The site also promotes action across the settings where	https://www.sahealth.sa.gov.au wps/wcm/connect/Public+Content/SA+Health+Internet/Healthy+Living/

⁸ Australian Government, Department of Health, “State and Territory links”, [website], 2019, http://tiny.cc/5ihlhz, (accessed 13 December 2019)

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State/ Territory	Programs Information	Links to programs
	people live, learn, work and play, and includes a range of practical tools and case studies.
	The Health Services Finder provides comprehensive information about health and community services from the private, public and community sectors in South Australia.	https://www.sahealth.sa.gov.au wps/wcm/connect/public+content/sa+health+internet/health+services/national+health+services+directory/national+health+services+directory
TAS	Move Well Eat Well provides a comprehensive, yet simple guide on how to create healthier 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.	http://www.movewelleatwell.tas.gov.au/
	The Community Nutrition Unit of the DHHS aims to make healthy food and drink choices the easiest choices for Tasmanians. Online resources are available for early childhood health and community workers, parents, teachers and schools, adults and older adults.	https://www.dhhs.tas.gov.au/pophealth/community_nutrition/the community nutrition unit
WA	Website information: Good nutrition is essential for healthy growth and development in childhood, and ongoing health and wellbeing, but many Western Australians’ diets are inconsistent with national recommendations.	https://healthywa.wa.gov.au/Articles/F_I/Healthy-eating
VIC	VIC Health Healthy Eating website page: The Department of Health and Human Services is making it easier for Victorians to identify and 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.	https://www2.health.vic.gov.au/public-health/preventive-health/nutrition

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

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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/ Territory	Hospital /Health Centre	Brief Details/Program	Eligibility / Referral Process
ACT	Belconnen Community Health Centre	Advice on physical activity and nutrition / Group education / Physical activity programs / Strategies to improve social and emotional wellbeing / Support for long term self-management / Care	Accepts patients who have been referred by their doctor if: * Over 18 years of age * Have a Body Mass Index (a measure of obesity) of 40kg /m2 or over

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)

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State/ Territory	Hospital /Health Centre	Brief Details/Program	Eligibility / Referral Process
		coordination for those patients with a number of complex medical conditions. / In general, 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	* A degree of co-morbidity * Psycho-socially able to participate in the program
NSW	Westmead Hospital Obesity Clinic	Treatments Include: The Australian Guide to Healthy Eating, Low Carbohydrate and High 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	* Patients must have a current referral to Dr Jonathan Marks * No other information given
NSW	Blacktown Hospital Metabolic & Weight Loss Clinic	The program provides: intensive lifestyle coaching, consultations with our dietitian, doctor (endocrinologist),	The referring clinician should be convinced the patient is motivated to commence the significant lifestyle changes required to lose weight and improve their health) Patients should have a BMI > 40 kg/m2

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State/ Territory	Hospital /Health Centre	Brief Details/Program	Eligibility / Referral Process
		psychologist and plus 2 obesity-related exercise physiologist. For some patients, weight loss surgery is also performed by our surgeons at Blacktown Hospital.	comorbidities or characteristics (complete page 2 of our referral form) OR b) ABMI > 35 kg/m2 with co-existing type 2 diabetes - 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).

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State/ Territory	Hospital /Health Centre	Brief Details/Program	Eligibility / Referral Process
VIC	Austin Hospital: The Weight Control Clinic	Austin Health’s Weight Control Clinic is one of the few services in Australia that combines both medical and surgical treatments for obesity. Treats complex cases of obesity, or cases that do not respond to treatment in the primary care environment. Usual treatment regimen is modified very-low-energy diet (VLED) followed by dietician supervised transition to regular 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	GP Referral Guidelines: - When to Refer: >18 years old and BMI >35 kg/m2 or BMI >30 kg/m2 + medical condition related to excess weight (e.g. T2DM, obstructive sleep apnoea, fatty liver) and previous unsuccessful attempt to achieve or maintain weight loss - Include: Diagnostics if available: fasting glucose, electrolytes/renal function, liver function tests, TSH, fasting lipid profile, HbA1c (if has diabetes) - Urgent: within 4-7 weeks, Routine: Patient will be treated in turn

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State/ Territory	Hospital /Health Centre	Brief Details/Program	Eligibility / Referral Process
		obesity is caused and treated.
VIC	Royal Children’s Hospital: Weight Management Service	The clinic consists of a multi-disciplinary team; specialist doctors, a clinic nurse, a dietitian, a psychologist and a social worker. A comprehensive assessment of general health and growth, Clinical investigations as appropriate, Dietary assessment, Psychological and social assessment as required, Specialist advice and education on diet and lifestyle modification. In some cases, medical and or surgical treatments may be discussed	Accepts referrals for complex obesity not over age of 16 years BMI >95th percentile with: Neurological or physical disability (ASD, GDD, ID, Physical Disability) AND restricted eating with risk of micronutrient deficiencies (Iron, Vit A,C,E, B12) OR other medical diagnosis necessitating ongoing specialist paediatric care BMI >95th percentile with NO DISABILTY but with at least one established obesity related comorbidity: 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 Hospital and Health Service	Surgical intervention. This is not a management program.	The hospital gives a list of referral information for practitioners here. 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

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State/ Territory	Hospital /Health Centre	Brief Details/Program	Eligibility / Referral Process
			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:

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• 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

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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-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

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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

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