Section 4 - Management of diagnosed conditions

1. What is overweight or obesity in adults? ^1,5

• Defined as body fat accumulation higher than that required for healthy and optimal functioning of the body
• Primarily caused by an imbalance between energy consumed and energy expended (i.e. a high fat, energy dense diet and a sedentary lifestyle)
• Less common causes include hormone imbalances, medicines and poor sleep hygiene
• Risk of acquiring, and mortality from preventable chronic conditions increases as waist circumference and BMI increases, independent of age, sex and ethnicity
• > 50% Australians are overweight or obese
• People with obesity face lifelong bias, stigma and assumptions about being irresponsible, lacking willpower or blamed and shamed, making some reluctant to seek help

2. Diagnosis of overweight or obesity in adults ^1,3,5–7

• Request permission to discuss obesity before any intervention. Not all patients are prepared to engage in discussions about their weight
• Overweight and obesity is identified by assessing (see Table 1.):
  • BMI: weight in kilograms divided by height in metres squared (kg/m²)
  • waist circumference: measured in centimetres (cm) during expiration at the mid-point between the bottom of the person’s ribs and the top of the hipbone
  • waist-to-height ratio: used to measure central adiposity by dividing waist circumference by height in centimetres (cm). Higher ratios indicate higher risks of diabetes, hypertension and CVD
  • dietary habits and activity levels
  • root weight gain causes, physical complications and barriers to addressing lifestyle behaviours

3. Management of adults who are overweight or obese ^1,2,3,6

• The goals of managing overweight and obesity is for patients to lead active healthy lives and maintain target goals (see Table 1.) by:
  • reducing energy intake and optimising Diet and nutrition
  • increasing energy expenditure. See Physical activity and sleep
  • Alcohol reduction and Smoking cessation
  • providing ongoing counselling and psychotherapy
  • identifying and addressing key comorbidities in relation to Australian cardiovascular disease risk calculator:
    • Stroke and transient ischaemic attack
    • Dyslipidaemia
    • Depression
    • Anxiety disorders
    • Diabetes
    • Chronic kidney disease
    • Hypertension
    • Coronary heart disease,
    • Heart failure

1. Support patient self-management ^1,2,3,5,6
   • Discuss overweight and obesity and:
     • its association with chronic conditions
     • the benefits of Diet and nutrition and Physical activity and sleep
     • achieving and maintaining a weight loss of ≥ 5% will result in:
       • delayed progression or improved Diabetes control
       • improvements to kidney function and sleep apnoea
       • reduction in cardiovascular disease risk
       • reduction in knee and hip Osteoarthritis risk
     • the greater the weight loss, the greater reduction in health risks
     • self-monitoring is associated with greater weight loss. See Resource 1.
   • Use person first supportive language to reduce stigma
   • Encourage the patient to identify barriers to adequate lifestyle modification and clinical adherence and provide goals to overcome those barriers. See Engaging our patients
2. Social-emotional support ^1–3,6
   • Depression and eating disorders are associated with overweight and obesity. If suspected, refer to a dietitian or psychologist
   • See Social-emotional wellbeing
3. Lifestyle plan ^3,6,8
   • In partnership, develop a documented lifestyle plan supporting the patient to:
     • set their own achievable goals e.g. initial weight loss target of ≥ 1–5 %
     • use a diary to monitor food intake and activity levels. See Resource 1.
     • monitor and record their own BMI, waist circumference and waist-to-height ratio
     • take action and seek a health professional if weight is regained
   • Review the plan every 2 weeks for the first 3 months to assess for suitability or modification and reinforce lifestyle behaviour strategies
4. Diet and nutrition ^1–3,5,6,8
   • Reducing energy intake by improving Diet and nutrition is the single most effective means to reduce weight. See Resources 2–6.
   • When discussing dietary approaches for a lifestyle plan consider:
     • what has already been tried, its success and lessons learned
     • readiness and confidence to make changes
     • influence of cultural values and family beliefs on health behaviours
     • dietary preferences of the family and brainstorming healthy food alternatives
     • availability, affordability and ability to store perishable fresh food
     • identifying and managing triggers for emotional eating
     • strategies to control or reduce portion sizes e.g. use smaller plates
     • maintaining routine eating patterns and mindful eating
     • strategise situations that encourage unhealthy eating e.g. inactivity, parties.
   • Refer to dietitian for a tailored low-energy diet if not meeting targets. See Table 1.
5. Physical activity ^1,2,5,6,9
   • When discussing Physical activity and sleep goals to a lifestyle plan consider:
     • the influence of cultural values or family beliefs on health behaviours
     • time or support to undertake physical activity e.g. child care or chores
     • the patient’s fitness level
     • mobility impairment due to age, disability, comorbidity or size
   • Refer to a physiotherapist or exercise physiologist for a tailored exercise program

6. Psychotherapy ^1–3,6
   • Cognitive behaviour therapy (CBT) and interpersonal psychotherapy (IPT) are considered first line treatment
   • Psychotherapy:
     • benefits weight loss when combined with a weight loss plan (Resource 1.)
     • provides skills which reduce risk of relapse
     • requires commitment by the person
     • requires referral to a social worker, mental health worker, psychologist or GP/NP
   • General principles of psychotherapy are to:
     • assist patient to problem-solve cravings at the time they occur
     • resist thoughts of pessimism and self-criticism and taking control by replacing them with realistic thoughts. An example might be:
       • “I am hungry. If I eat a pie and a soft drink my hunger will be satisfied and I will gain weight"
       • “I am hungry. If I eat a sandwich and drink a glass of water my hunger will be satisfied and I will not gain weight"
     • practice behavioural activities frequently to improve mood
7. Obstructive sleep apnoea (OSA) ^1–3
   • Obesity is a primary contributor to OSA
   • Accepted treatment for OSA is:
     • weight loss
     • CPAP therapy
   • Assess a patient’s daytime sleepiness and OSA risk by using a validated tool. If they score highly refer to a sleep specialist. See Resource 7.
8. Home modifications
   • Refer to a physiotherapist or occupational therapist for home supports to assist activities of daily living such as:
     • bariatric shower chairs
     • slip and fall hazard removal
     • shower and toilet handrails
9. Surgery ^1–3,6
   • Bariatric surgery is an efficient weight loss intervention
   • Refer patients to a specialist to consider surgery if:
     • BMI > 40 kg/m²
     • BMI > 35 kg/m²  with comorbidities
     • BMI > 30 kg/m²  with poorly controlled diabetes or increased cardiovascular risk
     • Not recommended for 12–18 months prior to planning to conceive or if pregnant

4. Medicines for adults who are overweight or obese

• Lifestyle modifications is sufficient for moderately overweight patients
• Only use medicines in conjunction with lifestyle modification and counselling
• Be mindful of medicines that cause weight gain. See Table 2.

5. Cycle of care

6. References

• All Chronic Conditions Manual references are available via the downloadable References PDF

7. Resources

1. Exercise and weight loss monitoring chart and Queensland Health's Weight loss planning
2. Hunger level scale
3. Fats, oils and heart health
4. National Heart foundation Nutrition Position Statements
5. My health for life and CSIRO Total wellbeing diet
6. The Queensland Governments Staying healthy diet and nutrition resources and Dieting and weight management guidance
7. The Epworth Sleepiness Scale and STOP-Bang questionnaire