NACCHO Aboriginal Health and Obesity : Should Doctors be taught how to discuss their patients’ excess weight ?

ATSI Obesity

” Being overweight or obese increases the risk of a range of health conditions, including coronary heart disease, Type 2 diabetes, some cancers, respiratory and joint problems, sleep disorders and social problems. The excess burden of obesity in the Indigenous population is estimated to explain 1 to 3 years (9% to 17%) of the life expectancy gap in the NT .

Obesity is estimated to contribute 16% of the health gap between Aboriginal and Torres Strait Islander peoples and the total Australian population

Obesity is associated with risk factors for the main causes of morbidity and mortality among Aboriginal and Torres Strait Islander peoples. It impacts largely through diabetes (half of the obesity burden) and ischaemic heart disease (40%) “

Aboriginal and Torres Strait Islander Health Performance Framework 2014 Report

Download the report ATSI Overweight and Obesity

Download ANPHA Obesity Prevalence Trends

 “With 80% of adults and close to one-third of children expected to be overweight or obese by 2025, doctors are increasingly likely to be working with people who are overweight or obese.

An individual’s weight is a complex and sensitive issue, which may be related to many factors that are not only medical but social, environmental and emotional. The skills to address the issue in a way that communicates the health risks of being overweight without judgement and without inciting negative responses are not easy to acquire or universally taught.”

From The Conversation Adrienne Gordon  Neonatal Staff Specialist, NHMRC Early Career Research Fellow, University of Sydney and Kirsten Black Associate Professor & Joint Head of Discipline Obstetrics, Gynaecology and Neonatology, University of Sydney see full article below (2)

The 2012–13 Health Survey included height and weight measurements to allow body mass index (BMI) scores to be calculated. In 2012–13, 66% of Indigenous Australians aged 15 years and over had a BMI score in the overweight or obese range (29% overweight and 37% obese). Indigenous adults were 1.6 times as likely to be obese as non-Indigenous Australians (after adjusting for differences in the age structure of the two populations).

Indigenous obesity rates varied geographically. Obesity was highest in inner regional areas (40%) and lowest in very remote areas (32%). Rates were similar in major cities (37%) and in outer regional and remote areas (38%). By jurisdiction, obesity rates ranged from 41% in NSW to 29% in the NT. Indigenous women had higher rates of obesity (40%) and lower rates of overweight (26%) compared with Indigenous men (34% and 31% respectively). Of those adult Indigenous women who had an underweight or normal measured BMI, 44% had a waist circumference of 80cm or more, indicating increased risk of developing chronic disease. For both Aboriginal and Torres Strait Islander males and females, the rates for overweight/obesity increased with age, with 80% of the population aged 55 years and over being overweight or obese. Higher proportions of Torres Strait Islanders were overweight/obese than in the Aboriginal population (73% versus 65%).

The 2012–13 Health Survey showed obesity was strongly associated with chronic disease biomarkers (being obese increased the risk of abnormal test results for nearly every chronic disease tested for in the survey). Indigenous obese adults were 7 times more likely to have diabetes than those of normal weight/ underweight (17% compared with 2%). Those who did not meet the physical activity guidelines were more likely to be obese (44%) than those who met the guidelines (36%).

Childhood is a critical period in which inequalities in health determinants such as socio-economic status and overweight/ obesity emerge (Jansen et al. 2013). In 2012–13, Aboriginal and Torres Strait Islander children aged 2–14 years were more likely than non-Indigenous children to be underweight (8% compared with 5%); were less likely to be in the normal weight range (62% compared with 70%); and more likely to be overweight or obese (30% compared with 25%). Obesity rates for Indigenous children increased from the age of 5, with the highest rates at 10–14 years of age (12%). High BMI is found to be a predictor of short sleep duration for children (Magee et al. 2014), which impacts on school performance (measure 2.04) and engagement in physical activity (measure 2.18). It is not possible to compare 2012–13 Health Survey results with previous surveys as the latest results are based on measured BMI rather than self-reported height and weight (as was done before). Research shows rates of overweight/ obesity have increased more rapidly in Aboriginal than non-Aboriginal school-aged children in NSW (Hardy et al. 2014).

In December 2013, national Key Performance Indicators data provided by Australian Government-funded Indigenous primary health care organisations, found that 27% of clients aged 25 years and over were overweight, and 41% were obese (AIHW 2014w).

Obesity is associated with other health risk factors and social determinants of health. One example is prolonged financial stress, which is a predictor of obesity (Siahpush et al. 2014) (see measure 2.08). Low income is associated with food security problems (Markwick et al. 2014) and subsequent dietary behaviour (see measure 2.19). Evidence also shows that incarceration is associated with weight gain and obesity in Indigenous youth (Haysom et al. 2013) (see measure 2.11).

Implications

Given the health risks associated with being obese or overweight, the situation for Aboriginal and Torres Strait Islander peoples requires urgent attention. It is second only to tobacco consumption in terms of contribution of modifiable risk factors to the health gap experienced by Aboriginal and Torres Strait Islander peoples (Voset al. 2007).

An evaluation of a school-based health education programme for urban Indigenous youth found promising results in physical activity, breakfast intake and fruit and vegetable consumption (Malseed et al. 2014), all of which are core components of healthy weight management. Likewise, opportunities exist for obesity prevention in young children through practice-nurse brief interventions (Denney-Wilson et al. 2014).

Reversal of obesity is difficult even in the absence of environmental and social barriers. Therefore, early intervention to prevent the onset of excessive weight gain is likely to be the most effective strategy (Thurber et al. 2014). Studies reporting success in reducing obesity have a number of common characteristics, including: a focus on physical activity and diet opposed to diet alone; the ability to accommodate the preferences of participants; a group focus; and choice between a number of physical activities. Programmes must also be culturally acceptable, conveniently located, easily incorporated into the daily schedule and show goal attainment that is realistic and appropriate (Canuto et al. 2011).

The Australian Government’s Indigenous Australians’ Health Programme aims to actively promote healthier lifestyle choices with culturally secure community education, health promotion and social marketing activities. A Healthy Weight Guide consisting of an interactive website and printed resources is currently being developed to provide guidance and information for consumers to help them achieve and maintain a healthy weight. The guide includes information for Aboriginal and Torres Strait Islander peoples.

Doctors need to be taught how to discuss their patients’ excess weight

Health professionals repeatedly report a lack of confidence in knowing how to address obesity in their patients. They report minimal, if any, training on obesity as well as limited resources for effective conversations and insufficient clinical time to be able to do this well.

Starting a conversation about weight requires not only empathy but awareness of strategies people can use to manage weight issues and an understanding of the range of local services available to assist. It has been shown that although behavioural and medical strategies can be effective, uninformed discussion in the clinic can disengage, stigmatise or shame patients, which then has negative impacts on the outcomes.

Many patients do expect weight-loss guidance from health professionals and the discussion can influence outcomes. In fact, having the conversation and formally diagnosing and documenting excess weight or obesity is the strongest predictor of having a treatment plan and weight-loss success.

Choice of language is crucial

Research has identified the terms “fat” and “fatness” are the least preferred terms. The words “obese” and “obesity” have also been found to arouse negative responses. The National Institute of Clinical Excellence in the UK suggests patients may be more receptive if the conversation is about achieving or maintaining a “healthy weight”.

The STOP Obesity Alliance in the US suggests using “people first” language such that a person “has” obesity rather than “is” obese, similar to “having” cancer or diabetes.

This is part of a debate about whether obesity should be labelled as a disease rather than a risk factor.

Regardless of how this issue is classified, doctors and patients both require the knowledge to understand effective therapies do exist and obesity treatment is not futile. Losing 5-10% of body weight can have a significant impact on risk factors such as blood pressure and can lower the risks of later health problems such as heart disease or type 2 diabetes.

This sort of weight loss also often improves other factors more immediately beneficial to the patient, such as energy levels, mood and mobility.

 

A communication style that encourages shared decision-making and helps people change their behaviour is key. The objective is not to solve the problem but to help the patient begin to believe change is possible and develop a plan about health goals.

Let’s take the case of a woman who presents with urinary incontinence. The woman may describe the problem of needing to wear sanitary pads because of daily leaking of urine. Factors such as obesity will worsen the problem, but the woman may not be aware of this.

The doctor might say:

I hear you’re concerned about your loss of urine, is that correct? Let’s talk about that; and would it be OK to discuss your weight too, as that may be related?

The practitioner might listen for a willingness to have further discussion and then pose a goal-orientated question:

If, as part of our plan to help your urinary symptoms, you decide to work on getting to a healthier weight, what might be a first step?

Repercussions for our kids

For men and women of reproductive age the conversation is potentially not just about their own health but also about that of their children. Women who have higher pre-conception weight and pregnancy weight gain are at increased risk of developing diabetes and heart disease in later life and are less likely to lose weight after they give birth.

This vicious cycle results in larger babies that are predisposed to short-term risks as newborns, longer-term risks of increased childhood obesity and an increased lifetime risk of obesity, diabetes and heart disease.

Between 1985 and 1995 the rate of excess weight and obesity in childhood increased by 50% and obesity tripled in Australia. Animal studies also suggest obesity in the male parent can increase the chance of their offspring developing obesity or diabetes.

The intergenerational nature of obesity therefore means until we address overweight and obesity in adults who are planning a pregnancy, it may be impossible to lower rates of childhood obesity.

The framing of the issue as a problem for patients’ own health as well as for the health of their children is even more complex. However, unless there is a greater understanding of this risk and more training of doctors in talking to patients about obesity this will be difficult to tackle.

Currently, many health professionals remain uncomfortable and unsure in this area of practice. Ensuring the workforce is skilled will also mean there is the ability to discuss weight when it is not the primary issue a patient presents with, but where an important conversation at a critical life stage may actually have lasting effects on patients’ health and that of their children.


Adrienne Gordon will be online for an Author Q&A between 4 and 5pm AEST on Wednesday, 17 August, 2016. Post any questions you have in the comments below.

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