Metrics details. Control of obesity is an important priority to reduce the burden of chronic disease. Clinical guidelines focus on the role of primary healthcare in obesity prevention. The purpose of this scoping review is to examine what the published literature indicates about the role of hospital and community based health services in adult obesity prevention in order to map the evidence and identify gaps in existing research.
Databases were searched for articles published in English between and and screened against inclusion and exclusion criteria. Further papers were highlighted through a manual search of the reference lists.
The evidence supports screening for obesity of all healthcare patients, combined with referral to appropriate intervention services but indicates that health professionals do not typically adopt this practice. As well as lacking confidence or knowledge about how to integrate prevention into clinical care, health professional judgements about who might benefit from prevention and negative views about effectiveness of prevention hinder the implementation of practice guidelines. This is compounded by an often prevailing view that preventing obesity is a matter of personal responsibility and choice.
This review highlights that whilst a population health approach is important to address the complexity of obesity, it is important that the remit of health services is extended beyond medical treatment to incorporate obesity prevention through screening and referral.
Further research into the role of health services in obesity prevention should take a systems approach to examine how health service structures, policy and practice interrelationships, and service delivery boundaries, processes and perspectives impact on changing models of care.
Peer Review reports. Chronic diseases place a significant burden on the Australian healthcare system. Being obese is a major risk factor for many chronic diseases including heart disease, cancer, kidney failure, pulmonary disease and diabetes [ 3 , 4 ]. Being overweight can impede the management of chronic conditions and is the second highest contributor to burden of disease. Obesity has been shown to reduce quality-adjusted life expectancy [ 5 ]. The World Health Organisation WHO highlights prevention of obesity as an important priority to reduce the impact of non-communicable disease.
Both supporting people who are currently overweight to attain modest weight loss as well as preventing further increases in weight may eventually see a decrease in overall rates of obesity and a reduction in the rates of chronic diseases [ 6 ] and therefore a decrease in associated costs [ 7 ]. However, the prevention role of hospital and community health services is not as clearly articulated, particularly in relation to an adult population.
In this research we present a review of published literature investigating the role of hospital and community based health services in adult obesity prevention. The aim is to improve understanding of the role for hospital and community based health services in prevention as well as the potential enablers and barriers to the delivery of preventive health services in order to inform future research to support the development of obesity prevention guidelines applicable to a range of health service settings.
A scoping review [ 10 ] was conducted to map evidence and identify gaps in the extent, range, and nature of research undertaken in relation to the role of health services in obesity prevention. The focus of the review was on hospital and community based health services as unlike primary care, the roles of these services in obesity prevention are not clearly outlined in clinical guidelines. The overarching question for this scoping study was: What does the peer reviewed literature reveal about the role of adult health services excluding general practice in the provision of obesity prevention and what are the key elements of implementation?
For practical reasons, the scope was limited to articles published in English between and November. As the aim of the review was to highlight clinical interventions as well as issues relating to implementation, papers were included if they fell into any of the following categories: 1 Evaluation of a specific hospital or community health based obesity prevention intervention; 2 Clinical guidelines featuring obesity prevention; 3 Systematic or scoping reviews of health service based obesity prevention or 4 Empirical description of obesity prevention within a health setting.
A fifth category was identified in the process of undertaking the review: 5 Health staff or health service consumer perceptions of and beliefs about obesity and obesity prevention. For each of these categories, the focus of the intervention was on services for adults.
We included primary studies as well as literature reviews. Papers were also excluded if they described obesity or associated disease but did not focus on interventions with a goal of prevention or if the focus was on population health initiatives that were not within the remit of health services, such as introducing food taxes. Opinion pieces and editorials were not included. All articles were reviewed and divided into the categories described above. Information was summarised using a standardised extraction form developed for the review see Tables 1 , 2 , 3 , 4 , 5 to identify the clinical areas where prevention is effective and the fundamental elements of implementation.
The primary aim of analysis was to determine the main factors in delivering adult obesity prevention within a health setting. Analysis commenced with an examination of intervention type, sample size, setting and duration. Studies were then grouped into categories that were empirically derived from the type of studies identified as summarised in Tables 1 , 2 , 3 , 4 , 5. Analysis has been framed with the 5As framework [ 9 ] which is utilised as a preventative healthcare tool to identify risk factors for chronic disease.
It originated as a smoking cessation tool but has been adapted for use with obesity. The first 40 of these articles were screened and found to be highly irrelevant. This produced references, which on initial scan appeared to highlight more relevant documents. CINAHL and Medline searches using the same search terms produced articles which on screening appeared to hold relevant studies. The Cochrane database search resulted in references.
Further references were highlighted through a manual search of the reference list of those references which met the inclusion criteria. In all, 43 articles were included for review. Figure 1 presents the review flow chart. Of the 43 papers included in the review, seven were primary studies of a specific health based obesity prevention intervention Category 1 and seven were scoping or systematic reviews of specific health based obesity prevention interventions Category 2.
Four clinical guidelines were included Category 3 ; two specific to the Australian context [ 9 , 41 ], one from the United States [ 42 ] and one from the United Kingdom [ 43 ]. This framework is frequently utilised in preventive care and though most commonly used in primary care, is one which is applicable to a range of health services. The other three focus on primary healthcare, but also consider other health services.
A group of 12 papers Category 4 provided general descriptions of obesity prevention interventions within health settings. A summary of the papers in each category, and the extracted data can be found in Tables 1 , 2 , 3 , 4 , 5.
The specific health based obesity prevention interventions Category 1 and 2 , were examined using the 5As framework [ 44 ]. The 5As framework is used to identify risk factors for chronic disease, including obesity, and to plan interventions to take into account the behavioural and physiological elements to be addressed [ 45 ].
Whilst not all the papers explicitly referred to the 5As, elements of the framework were noted in each of the seven primary studies and three of the six literature reviews concerned with health service based prevention interventions. In the section below we apply the 5A framework to consider different elements of obesity prevention and how these have been reported in the literature.
For this review, Ask and Assess have been considered together as both focus on gathering the initial information which will determine the next step. A focus on screening is supported by evidence which shows that weighing people and discussing the risks associated with putting on excess weight has an impact on individual knowledge and readiness for change which are basic factors if obesity prevention is to be effective [ 36 , 46 ].
The seven evaluation based papers identified a need to assess for obesity risk factors and the potential impact of these on health but only one [ 12 ] specifically concluded that there is a need to train staff in issues such as health literacy and readiness for change.
This factor was missing all together from the systematic review summarising best practice in applying the framework [ 23 ]. All the primary study papers Category 1 concluded that there is a role for health professionals in the provision of prevention advice and five of these seven studies discussed providing specific training to support this role [ 12 , 13 , 15 , 16 , 17 ]. However, targeted training does not automatically change practice.
Two studies, one with community health staff and one with mental health clinicians, found that training changed practice in terms of assessment of risk factors but did not change practice in relation to providing advice [ 16 , 17 ]. In studies which reported that clinicians did provide advice, in most cases patients could recall that advice but these papers did not report on whether the people receiving the advice changed their behaviour or on the long term retention of that advice [ 11 , 12 , 13 , 15 ].
It did not consider supporting people to set their own goals around their weight or risk factors. The remaining six literature reviews did not report on health professionals providing advice. The next step of the 5As framework is providing intervention aimed at assisting people to set goals to self-manage lifestyle changes. The primary studies category 1 did not address this element, instead framing the role of health services not as providing support but instead referring to other agencies to provide this support.
One literature review concluded that intensive long term support was required to assist people to embed changes but did not provide specific details of what this might look like [ 23 ]. Another concluded that assisting people to set goals related to weight management achieves better outcomes than linking goals to more general improvements in health [ 20 ]. The final step of the 5As framework recommends providing support to help people achieve and maintain their weight goals.
Three of the Category 1 health service evaluations focussed specifically on this step. For example, a recent study undertaken across several community health centres focussed on supporting community health staff to incorporate assessment, brief advice and referral in relation to addressing chronic disease risk factors, including obesity risk factors.
The intervention was successful in getting staff to undertake more assessments for risk factors but did not change practice in relation to brief advice or referral for intervention [ 17 ]. Similar results were obtained within a community mental health setting, concluding that even when clinical guidelines explicitly direct clinicians to incorporate preventive care into interactions, rates of care given around issues such as fruit and vegetable intake or physical activity remain low [ 16 ].
The study concluded that prevention may need to be delivered within a different model of care [ 16 ]. Two of the systematic reviews concluded that successful obesity prevention needs to include the provision of or referral to intensive, multicomponent behavioural interventions which aim to support weight loss and management [ 21 , 23 ].
The empirical studies were therefore analysed to identify the clinical areas where prevention may have the most significant impact and the specific elements key to working with these clinical groups. Fifteen of the papers included in the review focused on a particular life stage or cohort of patients.
The clinical areas identified were maternity, which has received the most focus but has not been rigorously evaluated [ 13 , 14 , 26 , 27 , 31 , 33 , 34 , 36 , 48 ] and mental health [ 37 ]. Definitive evidence of how obesity prevention should be delivered in mental health services was not available. The papers which focussed on maternity based services highlight the immediate consequences of maternal obesity including higher rates of gestational diabetes, high blood pressure and pre-eclampsia and higher risk births.
Excess weight gain in pregnancy combined with not losing the weight after pregnancy are predictors of long-term maternal obesity and increases the risk of the child developing obesity whilst mothers with gestational diabetes are more likely to develop type 2 diabetes later in life [ 36 ].
Along with the individual risks to mother and child, there is an increased demand for services and a requirement for more specialised services to support woman and baby both during and after the birth [ 18 , 26 , 30 , 31 , 33 , 34 ]. Only one of the papers targeting obesity prevention in maternity care settings reported on a specific intervention. This found that women at risk of gestational diabetes who receive advice in relation to limiting weight gain during pregnancy are less likely to develop diabetes despite no significant difference in weight gain compared with a control group [ 13 ].
The other maternity focussed papers were more descriptive, providing a broad overview of implementation factors including the need for a multidisciplinary approach to reinforce the benefits of diet and physical activity beyond weight management. For example, obese pregnant women who are physically active have been shown to experience less depressive symptoms and report higher quality of life to obese women who are not physically active in pregnancy [ 14 ].
Two papers stated that discussions about safe weight gain and weight management needs to be done in a way that does not stigmatise or cause feelings of shame [ 27 , 33 ]. Only one paper looked at a life stage other than child bearing years, namely older adults [ 29 ]. As with similar studies looking at the adult population more generally [ 28 ], it was found that older adults were more likely to receive lifestyle advice if they were already obese or had a number of chronic conditions [ 29 ].
The disadvantage of many of the survey based studies was the reliance on self-reported weight and height. In terms of specific clinical areas, studies have been conducted in mental health and community health services. It was reported that it is very difficult to change the practice of mental health staff to include a focus of physical health risk factors [ 16 ] with mental health clinicians not necessarily seeing this as their role [ 37 ] despite the fact that people with mental illness do want to reduce their risk factors [ 40 ].
Similarly in services delivering general community health care, despite the presence of risk factors and an openness by clients to receive preventive advice, community health staff do not deliver opportunistic prevention, particularly in relation to diet [ 8 , 17 ].
This review found that along with practical barriers to changing practice including a lack of time, resources or clinical guidelines [ 34 , 38 , 39 , 49 ], a key barrier to healthcare based obesity prevention is the perceptions and beliefs of health professionals towards obesity. As well as lacking confidence or knowledge about how to integrate prevention into clinical care, health professionals may simply not see it is their role [ 37 ]. There is also an issue with judgements being made in relation to who might benefit from prevention along with a negative view of the effectiveness of prevention, compounded by a view that preventing obesity is a matter of personal responsibility and choice [ 25 , 38 ].
The 13 studies which specifically looked at this issue are summarised in Category 5 of Tables 1 , 2 , 3 , 4 , 5. These papers used a range of methods to ascertain attitudes, including questionnaires or surveys [ 8 , 32 , 36 , 37 , 39 , 40 , 46 , 49 , 50 ] and semi-structured interviews or focus groups [ 33 , 34 , 35 , 38 ] and were conducted with health professionals [ 33 , 34 , 35 , 37 , 38 , 39 , 49 , 50 ] and consumers [ 8 , 32 , 36 , 40 , 46 ].
Due to the range of methods and small numbers of many of the studies the results are not necessarily generalisable but a recurrence of themes indicates that perceptions and beliefs should be considered when incorporating obesity prevention into health care services.
The view of health professionals, that prevention is not their role, may be reinforced by the fact that they will probably not have had specific training in assessment and advice [ 16 ]. They may make judgements on who would benefit from preventive advice and tend to only raise the issue of weight if they know the patient [ 38 ]. Whilst health professionals are aware of the health implications of excess weight there may be a perception that they cannot be effective in their role due to a lack of patient motivation to enact change [ 25 ].
Other studies have shown that patients may not be told they are overweight or have the health consequences of being overweight discussed [ 21 , 32 ]. When discussions do occur, they are more likely to be with people who are already obese [ 24 , 28 ] or who have more frequent health encounters indicating that they have more complex health problems [ 29 ].
By clinicians not discussing weight and lifestyle with people before it becomes a significant problem there is a missed opportunity to prevent illness development based on known risk factors. The uptake of prevention may also be impacted by a view that obesity is an issue of lifestyle choice and personal responsibility and therefore not the responsibility of health services unless linked to the treatment of a specific clinical condition [ 35 , 38 ]. Clinical guidelines may not be consistently followed because of a lack of knowledge of the guidelines existence or a belief that the guidelines will be ineffective due to pre-conceived ideas about the group of clients being targeted or a lack of confidence in the guidelines [ 19 , 35 ].
Specific to maternity services, clinicians acknowledge that weight gain in pregnancy is an issue but do not perceive that their patients see it as a problem [ 30 ]. These findings occur even in areas where policy is in place directing clinicians to incorporate prevention, highlighting the need for more comprehensive, multi component change management strategies to enable health professionals to develop their practice to incorporate prevention routinely into interventions [ 8 ].
Without further training, baseline knowledge on appropriate interventions to support obesity prevention is generally poor [ 39 ] and advice may be given based on the clinicians own experience of weight management [ 38 ].
Educating staff about prevention may lead to an increase in assessment of risk but not a significant increase in brief advice or referral to other services for prevention intervention [ 15 , 17 ]. Training of staff may need to extend beyond principles of prevention and also include training on communicating complex information to people with low health literacy. This should include teaching techniques to ensure health professionals clarify their patient has understood information, [ 12 ] as this is a significant element in someone being able to adopt and follow preventive care advice [ 45 ].
However, the evidence of what education strategies are most effective, particularly in relation to increasing assessment and referral across all risk factors, is limited [ 52 ]. A systematic review of interventions to change the behaviour of health professionals found just six randomised control trials and the combined results of these were ambiguous [ 19 ].
When specifically looking at factors influencing health professionals decision to provide counselling regarding physical activity, the health professionals own levels of physical activity, whether or not they have specific training, knowing the patient well and the patient having risk factors for chronic disease were all influencing factors [ 22 ]. This review examined the literature in order to ascertain the role of hospital and community- based health services in adult obesity prevention as well as the potential enablers and barriers to the delivery of preventive health services.
Obesity rates among children in the U. Earlier onset of type 2 diabetes, heart and blood vessel disease, and obesity-related depression and social isolation in children and teens are being seen more often by healthcare professionals. The longer a person is obese, the more significant obesity-related risk factors become. Given the chronic diseases and conditions associated with obesity and the fact that obesity is hard to treat, prevention is extremely important.
A primary reason that prevention of obesity is so vital in children is because the likelihood of childhood obesity persisting into adulthood increases as the child ages. This puts the person at high risk of diabetes, high blood pressure, and heart disease. The CDC also reports that the longer babies are breastfed, the less likely they are to become overweight as they grow older. However, many formula-fed babies grow up to be adults of healthy weight.
If your child was not breastfed, it does not mean that he or she cannot achieve a healthy weight. Young people generally become overweight or obese because of poor eating habits and lack of physical activity.
Genetics and lifestyle also contribute to a child's weight status. Gradually work to change family eating habits and activity levels rather than focusing on a child's weight. Be a role model. Parents who eat healthy foods and participate in physical activity set an example so that a child is more likely to do the same.
Encourage physical activity. Children should have 60 minutes of moderate physical activity most days of the week.
More than 60 minutes of activity may promote weight loss and provide weight maintenance. Keep the refrigerator stocked with fat-free or low-fat milk, fresh fruit, and vegetables instead of soft drinks and snacks high in sugar and fat.
In such cases, your waist circumference may be a better guide see below. What's considered a healthy BMI is also influenced by your ethnic background. The scores mentioned above generally apply to people with a white Caucasian background.
If you have an ethnic minority background, the threshold for being considered overweight or obese may be lower. BMI shouldn't be used to work out whether a child is a healthy weight, because their bodies are still developing. Speak to your GP if you want to find out whether your child is overweight.
If you're overweight or obese, visit your GP for advice about losing weight safely and to find out whether you have an increased risk of health problems. As well as calculating your BMI, your GP may also carry out tests to determine whether you're at increased risk of developing health complications because of your weight. People with very large waists — generally, 94cm 37in or more in men and 80cm about Your GP may also take your ethnicity into account because it can affect your risk of developing certain conditions.
For example, some people of Asian, African or Afro-Caribbean ethnicity may be at increased risk of high blood pressure hypertension. Healthy waist measurements can also be different for people from different ethnic backgrounds. After your assessment, you'll be offered an appointment to discuss the results in more detail, ask any questions that you have, and fully explore the treatment options available to you. Your GP can advise you about losing weight safely by eating a healthy, balanced diet and regular physical activity.
If you have underlying problems associated with obesity, such as polycystic ovary syndrome PCOS , high blood pressure , diabetes or obstructive sleep apnoea , your GP may recommend further tests or specific treatment.
In some cases, they may refer you to a specialist. Read more about how your GP can help you lose weight. There's no single rule that applies to everyone, but to lose weight at a safe and sustainable rate of 0. For most men, this will mean consuming no more than 1, calories a day, and for most women, no more than 1, calories a day.
The best way to achieve this is to swap unhealthy and high-energy food choices — such as fast food, processed food and sugary drinks including alcohol — for healthier choices.
Try to avoid foods containing high levels of salt because they can raise your blood pressure, which can be dangerous for people who are already obese. You'll also need to check calorie information for each type of food and drink you consume to make sure you don't go over your daily limit.
Be careful when eating out because some foods can quickly take you over the limit, such as burgers, fried chicken, and some curries or Chinese dishes. Avoid fad diets that recommend unsafe practices, such as fasting going without food for long periods of time or cutting out entire food groups.
This isn't to say that all commercial diet programmes are unsafe. Many are based on sound medical and scientific principles and can work well for some people. These diets can lead to rapid weight loss, but they aren't a suitable or safe method for everyone, and they aren't routinely recommended for managing obesity. VLCDs are usually only recommended if you have an obesity-related complication that would benefit from rapid weight loss.
VLCDs shouldn't usually be followed for longer than 12 weeks at a time, and they should only be used under the supervision of a suitably qualified healthcare professional.
Reducing the amount of calories in your diet will help you lose weight, but maintaining a healthy weight requires physical activity to burn energy. As well as helping you maintain a healthy weight, physical activity also has wider health benefits. The Chief Medical Officers recommend that adults should do at least minutes two-and-a-half hours of at least moderate-intensity activity a week — for example, five minute bouts a week.
Something is better than nothing, and doing just 10 minutes of exercise at a time is beneficial. Moderate-intensity activity is any activity that increases your heart and breathing rate, such as:. Alternatively, you could do 75 minutes one hour, fifteen minutes of vigorous-intensity activity a week, or a combination of moderate and vigorous activity.
During vigorous activity, breathing is very hard, your heart beats rapidly and you may be unable to hold a conversation. Examples include:. You should also do strength and balance training two days a week.
This could be in the form of a gym workout, carrying shopping bags, or doing an activity such as tai chi. It's also critical that you break up sitting sedentary time by getting up and moving around.
Read more about strength and balance exercises. Your GP, weight loss adviser or staff at your local sports centre can help you create a plan suited to your own personal needs and circumstances, with achievable and motivating goals.
Start small and build up gradually. It's also important to find activities you enjoy and want to keep doing. Activities with a social element or exercising with friends or family can help keep you motivated.
Read more about the physical activity guidelines for adults and the physical activity guidelines for older adults. Evidence has shown that weight loss can be more successful if it involves other strategies, alongside diet and lifestyle changes. This could include things like:. Getting psychological support from a trained healthcare professional may also help you change the way you think about food and eating.
Techniques such as cognitive behavioural therapy CBT can be useful. It's important to remember that as you lose weight your body needs less food calories , so after a few months, weight loss slows and levels off, even if you continue to follow a diet. If you go back to your previous calorie intake once you've lost weight, it's very likely you'll put the weight back on. Increasing physical activity to up to 60 minutes a day and continuing to watch what you eat may help you keep the weight off.
Many different types of anti-obesity medicines have been tested in clinical trials, but only one has proved to be safe and effective: orlistat. You can only use orlistat if a doctor or pharmacist thinks it's the right medicine for you.
In most cases, orlistat is only available on prescription. Only one product Alli is available over the counter directly from pharmacies, under the supervision of a pharmacist. Orlistat works by preventing around a third of the fat from the food you eat being absorbed. The undigested fat isn't absorbed into your body and is passed out with your faeces stools.
This will help you avoid gaining weight, but won't necessarily cause you to lose weight. A balanced diet and exercise programme should be started before beginning treatment with orlistat, and you should continue this programme during treatment and after you stop taking orlistat.
Orlistat will usually only be recommended if you've made a significant effort to lose weight through diet, exercise or changing your lifestyle.
Before prescribing orlistat, your doctor will discuss the benefits and potential limitations with you, including any potential side effects see below. Treatment with orlistat must be combined with a balanced low-fat diet and other weight loss strategies, such as doing more exercise. It's important that the diet is nutritionally balanced over three main meals. If you're prescribed orlistat, you'll also be offered advice and support about diet, exercise and making lifestyle changes.
One orlistat capsule is taken with water immediately before, during or up to one hour after, each main meal up to a maximum of three capsules a day. If you miss a meal, or the meal doesn't contain any fat, you shouldn't need to take the orlistat capsule.
Your doctor should explain this to you, or you can check the patient information leaflet that comes with your medicine. It usually starts to affect how you digest fat within one to two days. If you haven't lost weight after taking orlistat for three months, it's unlikely to be an effective treatment for you.
Consult your doctor or pharmacist, as it may be necessary to stop your treatment.
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