Australia’s rising obesity burden: can pharmacists help?

This is another epidemic that must be addressed – through active living and nutrition policies.

Australia’s health and productivity is at risk with the overweight and obesity epidemic. At the current trend, it is estimated that approximately 1.75 million deaths in adults over 20 years old will be caused by overweight and obesity between 2011 to 2050.¹

Pharmacists must take up the growing opportunity and need to champion preventive health interventions and deliver impactful public health campaigns.

Rising overweight and obesity

Overweight and obesity are defined as an abnormal or excessive fat accumulation that risks compromising an individual’s health.² Commonly, body mass index (BMI) is used to classify adults as overweight if their BMI is 25 or greater and obese if their BMI is 30 or greater.² The prevalence of overweight and obesity has increased over the past 40 years in Australia. Almost two-thirds of Australian adults and almost a third of Australian children are either overweight or obese.³

The burden of overweight and obesity is significant, imposing a total health burden of 7% in 2011 and an estimated cost of $8.6 billion to the Australian economy. ³

Whether or not obesity is classified as a chronic condition, as has been the case internationally, overweight and obesity are important risk factors for type 2 diabetes, cardiovascular disease and many cancers.⁴

As an independent risk factor for cardiovascular disease, obesity increases the risk of dyslipidaemia, hypertension and insulin resistance.⁵

Additionally, the increased adipose tissue seen in obesity influences the pathogenesis of atherosclerosis.⁵

Public health policy solutions for a complex problem

In 2018, to address the growing health priority of overweight and obesity, the Council of Australian Governments (COAG) agreed to develop a National Obesity Strategy, on which public consultation recently closed in December 2019.

The causes of overweight and obesity are complex and multifaceted. Individual, social and environmental factors all contribute to the increased prevalence of overweight and obesity.⁶

Key drivers on a population level include the availability of increasingly cheap energy-dense foods alongside a shift to more sedentary lifestyles.

Solutions for tackling Australia’s obesity epidemic must equally address broader public health issues relating to nutrition and active living policies.

National consensus around nutrition policy in Australia seeks to reduce exposure of children to unhealthy food marketing, promote reformulation of packaged and processed foods, and instigate mandatory front-of-pack labelling systems supported by public education programs.¹

Adding a 20% tax on sugary drinks can be part of a holistic approach to discourage and decrease consumption.¹

Alongside food policy changes, comprehensive national active travel strategies should seek to promote walking, cycling and use of public transport.¹

The Heart Foundation’s 2019 Blueprint for an Active Australia outlines compelling evidence for action to increase physical activity.⁷

This includes supporting active environments, incorporating physical activity programs into school and workplace settings, increasing support for sporting and active recreational clubs as well as using public education programs to raise awareness about the benefits of physical activity.

Preventive healthcare role of pharmacists

The PSA’s Pharmacists in 2023 report recognises the important role of pharmacists in preventive healthcare. In addition to having a unique point of access within the community, pharmacists are in a good position to provide preventive health services because of their skills and exposure to such strategies.

On average, there are more than 440 million individual patient visits to community pharmacies across Australia each year.⁸ Early disease prevention and health assessment services are well within the skill set of community pharmacists and have already been embraced by many pharmacies across the country.

Preventive health checks delivered by community pharmacy often involve the assessment of cardiovascular and metabolic risk factors such as blood pressure, point-of-care cholesterol tests, blood glucose tests, BMI and lifestyle assessments. Detection of these risk factors must critically lead to the provision of lifestyle counselling on improved diet and greater physical activity.

Comprehensive weight loss and lifestyle management programs have been trialled within a community pharmacy context in many ways, encompassing risk factor assessment, lifestyle management counselling and sometimes connecting with local allied health professionals.⁹ One such program involved nine consultations of 10–30 minutes delivered over 12 months by community pharmacists to adults at high risk of cardiovascular disease.¹⁰

Patients were offered prescribed healthy eating plans and weight management strategies. More than 40% of participants lost 5% of their initial body weight by the end of the 12-month study.

Overall results are mixed as they relate to improvements in health outcomes related to lifestyle intervention programs delivered in community pharmacy. Some were able to show weight loss and reduced lipid and blood pressure measures but many did not show sustained improvements after the program ceased.⁹

As with many other health services offered in community pharmacy, preventive health services are limited by lack of time and reimbursement. Funding of these services is variable and largely dependent on federal government support through the Sixth Community Pharmacy Agreement or via individual community pharmacy private billing.¹¹

Community pharmacists must take up the challenge of delivering preventive health services that address the rising obesity crisis. Funding for these preventive services has never been so critical.

Pharmacies are a valuable channel to deliver public health campaigns

Community pharmacy must be better mobilised to deliver public health campaigns. Pharmacists will increasingly play a larger health promotion and education role in weight management.

The position of pharmacists in the community allows for opportunistic screening and education of individuals who may otherwise not be willing to seek advice from their doctor about weight management.¹² Screening in many instances consists of weight and waist measurements, BMI calculation and nutrition and physical activity questionnaires.

In the context of community pharmacy, health promotion or public health campaigns include provision of health education, awareness raising activities, referral pathways and lifestyle counselling.

Internationally, public health education campaigns delivered within community pharmacy have demonstrated improvements in patient knowledge around self-care needed to prevent disease.¹³ There is a need to distil the focus of such campaigns and unify the community pharmacy sector around common public health goals – healthy eating and physical activity being the core preventive health recommendations for most conditions.

Federal government funding to deliver national healthy eating and physical activity campaigns via community pharmacy would help pharmacies move away from product specific weight loss initiatives to focus on broader public health principles with greater health benefits.

At the very least, pharmacists should champion freely available lifestyle management programs and activities for their patients including the Heart Foundation walking program. Walking groups that meet at their local pharmacies not only encourage consumers to stay active, but also increase exposure to the pharmacy.

Forward thinking ideas in this area demand a shift in the way community pharmacies engage in health promotion activities. Rather than having each pharmacy or chain delivering ad hoc health promotion activities, federal funding for a mass healthy eating and physical activity campaign has the potential to maximise the benefits of such an approach.

This funding is more likely to be granted to disease-specific health bodies but must mandate the community pharmacy sector as one of the channels of delivery. Such a program must also off er support, financially or otherwise, to enable participation of busy pharmacists and front-of-store staff.

The role of pharmacological interventions for weight loss

The benefits of improved diet and physical activity extend beyond changes in weight.

As such, lifestyle management remains the foundation for maintaining a healthy weight.¹⁴ Pharmacotherapy for weight loss should be seen as an adjunct to lifestyle changes. Medicines for weight loss currently available in Australia include phentermine, orlistat and liraglutide.¹⁴

Patients should be monitored closely to assess safety, tolerability and efficacy for the first 3 months following initiation of pharmacotherapy for weight loss (4 months for liraglutide).¹⁴ Monitoring would involve assessing the extent of weight loss against targets and asking patients about adverse effects. Adherence to medicines used for weight loss is often poor. Reasons for cessation include cost, adverse effects and the perception that the medicine is not needed after initial weight loss is achieved.¹⁵

In fact, if therapy is well tolerated, it should be continued, which is something that pharmacists need to reinforce with their patients. Pharmacists have a critical role in supporting patients who are prescribed pharmacotherapy for weight loss. This role includes providing advice on the safety and tolerability of these agents. That and administration advice for liraglutide, are key to supporting this patient group.

Currently, weight management support offered in community pharmacies centres largely around product-specific promotion. This often includes complementary or commercial products with little evidence to support their efficacy. The evidence base behind weight loss programs and products delivered in community pharmacy has come under question in the past, citing undue focus on products that provide financial gain for the pharmacy.¹⁶

The challenge for pharmacists in the future will be to ensure that they offer weight management programs which are more holistic and extend beyond a specific product. Federal funding for weight loss programs described above will help shift the focus away from individual products or medicines.

Conclusion

The burden of overweight and obesity in Australia is increasing, with the combined burden of diet and weight now exceeding that posed by tobacco smoking.¹ Strategies to address the growing obesity crisis must critically target nutrition and physical activity policies in Australia.

Pharmacists are well placed to drive behaviour change in this area through preventive health interventions, support of pharmacotherapy and delivery of public health campaigns.

Funding to support such preventive and public health services is critical to ensure a united and impactful utility of the community pharmacy sector.

References

1. Obesity Policy Coalition & Global Obesity Centre, Tipping the scales: Australian obesity prevention consensus. 2017, Deakin University Victoria
2. World Health Organization. Obesity and overweight 2020 At: www.who.int/news-room/fact-sheets/detail/obesity-andoverweight.
3. Australian Institute of Health and Welfare. A picture of overweight and obesity in Australia 2017. Canberra: AIHW; 2017. At: www.aihw.gov.au/getmedia/172fba28-785e-4a08-ab37-2da3bbae40b8/aihw-phe-216.pdf.aspx?inline=true.
4. Forouzanfar, M.H., et al., Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet, 2016. 388(10053): p.1659-1724.
5. Cercato, C. and F.A. Fonseca, Cardiovascular risk and obesity. Diabetology & Metabolic Syndrome, 2019. 11(1): p. 74.
6. Sacks, G., et al., Population-level strategies to support healthy weight: an Evidence Check rapid review brokered by the Sax Institute for Queensland Health 2019.
7. National Heart Foundation of Australia, Blueprint for an active Australia. 2019, National Heart Foundation of Australia
8. Pharmacy Guild of Australia, Vital facts on community pharmacy 2018, Pharmacy Guild of Australia Canberra
9. Jordan, M.A. and J. Harmon, Pharmacist interventions for obesity: improving treatment adherence and patient outcomes. Integrated pharmacy research & practice, 2015. 4: p.79-89.
10. Morrison, D., et al., A community pharmacy weight management programme: an evaluation of effectiveness. BMC Public Health, 2013. 13(1): p. 282.
11. Department of Health. Pharmacy Trial Program. 2018 [cited 2020 15 March]; Available from: www1.health.gov.au/internet/main/publishing.nsf/Content/pharmacy-trialprogramme
12. Um, I.S., et al., Weight management in community pharmacy: what do the experts think? International Journal of Clinical Pharmacy, 2013. 35(3): p. 447-454.
13. Agomo, C., et al., Community pharmacists’ contribution to public health: assessing the global evidence base. The Pharmaceutical Journal 2018.
14. Ching Lee, P. and J. Dixon, Pharmacotherapy for obesity. Australian Family Physician, 2017. 46: p. 472-477.
15. Jain, P., et al., Weight loss experiences and willingness to intervention with pharmacotherapy among obese and very obese Danish people. Phys Sportsmed, 2016. 44(3): p. 201-7.
16. Fakih, S., J.L. Marriott, and S.Y. Hussainy, Exploring weight management recommendations across Australian community pharmacies using case vignettes. Health Education Research, 2014. 29(6): p. 953-965.