<h2>Practice points</h2><ul><li>Dietary caloric restriction is to be maintained over the long term; manage weight regulation with weekly weighing.3</li><li>Advise to be active on most, preferably all days each week to accumulate 150-300 minutes of moderate intensity physical activity or 75-150 minutes of vigorous intensity physical activity, or an equivalent combination of both moderate and vigorous activities, each week. Also recommend muscle strengthening on at least 2 days each week.4 People with specific medical conditions should be medically assessed before commencing any exercise program.</li><li>Vitamin D deficiency is associated with obesity and vitamin D status is marginally improved with weight loss in comparison to weight maintenance.5</li><li>Imbalances in the gut microbiota are central to the pathogenesis of obesity.6</li><li>Soluble fibre such as psyllium may help lower insulin levels, reduce hunger, delay gastric emptying, and increase the sensation of satiety.3</li><li>Meal replacement programs administered by healthcare professionals and run in a community pharmacy setting have demonstrated a mean decrease in weight and also a significant decrease in blood glucose and blood pressure.7</li><li>Green tea and capsaicin supplements have been observed to support weight loss.8</li><li>Mindfulness meditation has been shown in preliminary research to enhance weight loss when added to a program of caloric restriction, increased physical activity, and a standard behaviour weight loss program.9</li></ul><h2>Description</h2><ul><li>Globally, in 2008, 35% of adults aged 20+ years were overweight (BMI &gt;25 kg/m2). The figures were highest in the American region (62% were overweight with 26% obese) and lowest in South East Asia (14% overweight with 3% obese).1</li><li>Being overweight or obese can cause metabolic syndrome with raised blood pressure, cholesterol, triglycerides, and insulin resistance, increasing the risk of developing coronary heart disease, ischaemic stroke, type 2 diabetes mellitus, and several cancers.1</li><li>Excess weight may also promote gallstone formation, fatty liver, gastroesophageal reflux, menstrual abnormalities, infertility, stress incontinence, gout, carpal tunnel syndrome, and lower back pain.2</li><li>Each year at least 2.8 million people die worldwide as a result of being overweight or obese.1</li></ul><h2>Management principles</h2><ul><li>Educate on the importance of healthy eating habits and sustainable, regular exercise.</li><li>Review medications and supplements as some can increase weight or change appetite.</li><li>Evaluate for conditions related to being obese or overweight, such as hypertension, sleep apnoea, hyperlipidaemia, insulin resistance, and diabetes.</li><li>Refer to an appropriate health professional or exercise specialist if required.</li><li>Consider whether stress and psychological factors are impacting eating patterns. Provide support and refer where necessary.</li><li>Use complementary medicines on an individual need basis, e.g. vitamin D in the case of deficiency, probiotics and prebiotics for microbiome support, and where there is a history of restrictive dieting, chromium for blood glucose metabolism, and fish oils with hypertriglyceridaemia or hypertension.</li></ul>

<h2>Primary recommendations</h2><h2>VITAMIN D</h2>Mechanism of action<ul><li>Increased adiposity leads to suboptimal concentrations of circulating vitamin D3</li></ul>Dosage information<ul><li>Assess vitamin D3 levels and supplement as necessary3. In cases of deficiency, recommend 1000 IU - 2000 IU daily</li><li>Adverse effects</li><li>Orally well tolerated.</li><li>Key interactions</li><li>Refer to the <a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">Complementary Medicine Interactions Guide</a></li></ul><h2> </h2><h2>PROBIOTICS AND PREBIOTICS</h2>Mechanism of action<ul><li>May balance gut microbiota to modulate obesity15/li&gt; </li></ul>Dosage information<ul><li>Probiotics: The number of living bacteria in a sample is referred to as colony-forming units (CFUs), and the amount needed appears to be strain-dependent. Best practice is for bacteria to be in concentrations &gt;109 bacteria per dose, unless research shows a specific strain needs a certain level to achieve a therapeutic effect16.</li><li>Prebiotics: Start on a small dose and increase gradually depending on gastrointestinal side effects17.</li></ul>Adverse effects<ul><li>Probiotics: Use with caution in people who are immunocompromised16.</li><li>Prebiotics: Gastrointestinal complaints such as abdominal pain, bloating, diarrhoea, and increased flatulence are commonly reported17.</li></ul>Key interactionsRefer to the <a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">Complementary Medicine Interactions Guide</a>

Primary

<h2>Diet and lifestyle</h2><ul><li>Increase water as some people sense hunger when they are thirsty, and so increasing water consumption may help to reduce hunger.3</li><li>Recommend prolonged caloric restriction maintained over the long term (1300 kcal/day women, 1700 kcal/day men) with conscious weight regulation by weighing once a week. Recommend that most meals are prepared and eaten at home. A significant amount of restraint needs to be shown. Combine diet with one hour per day or more of moderate-intensity exercise.3</li><li>Increase dietary fibre as a systematic review looking at fibre supplements concluded it is more effective to combine fibre with weight-loss interventions to achieve an anti-obesity effect; even though fibre supplements without weight-loss interventions had no anti-obesity effect.16</li><li>Meal replacement programs administered by healthcare professionals can be run in a community pharmacy setting with supportive mobile Apps. A study was carried out in overweight or obese adults who were treated with a partial meal replacement program incorporating high-protein meal replacement shakes and one high-protein meal each day. Consultant support appointments ran for the first 12 weeks followed by only App support for the following 12 weeks. Participants lost weight and showed a significant decrease in blood glucose and blood pressure on active treatment.7 </li><li>Drink green tea as a meta-analysis found that green tea significantly reduced weight, body mass index (BMI) and waist circumference, but not percentage body fat.8 Green tea is likely to work by increasing thermogenesis and fat burning.2 A Cochrane review did not find a clinically meaningful weight loss with green tea preparations in overweight or obese adults.11 However, recommending drinking green tea alongside other weight loss interventions (exercise) could be beneficial.</li><li>Capsaicin (chilli) supplementation is associated with significant weight loss, but not body fat percentage.</li><li>Advise to be active as a Cochrane review supports the use of exercise as a weight loss intervention, particularly when combined with dietary change. Exercise is associated with improved cardiovascular disease risk factors even without weight loss.12</li><li>Avoid or reduce alcohol as it contains ‘empty calories’, i.e. no nutritional value but rich in kilojoules. For instance, a 375 mL bottle of full-strength beer (4.8% alcohol vol.) is equivalent to 564 kJ. Drinking two of these a day is equivalent to adding 37 slices of white bread to daily intake.13</li><li>Recommend regular walking 3 to 4 hours of walking per week is recommended to facilitate healthy weight loss. Further weight loss can be achieved with the addition of a calorie-reduced diet.3</li><li>Enjoy 30 minutes most days of moderate-intensity exercise that raises heart rate to give significant protection from cardiovascular and other diseases. More intensive exercise can be recommended to people if they have successfully managed 30 minutes of moderate-intensity exercise on most days.3 Five hours of moderate-intensity exercise a week is required to prevent progression of overweight to obesity, and 7-10 hours per week to maintain ‘reduced obese’ state, i.e. to prevent weight gain after dieting.3</li><li>Mindfulness and meditation show promise as one study (n=46) compared a standard behavioural weight loss program with and without mindfulness meditation training over 6 months. All participants were instructed to reduce calorie intake (to 1200-1500 kcal/day), increase physical activity (300 min/week) and attend a standard behavioural weight loss program; 22 participants added focused mindfulness training. The group practising mindfulness meditation increased their weight loss by 2.8 kg.9</li></ul>

Diet & lifestyle

<h2>References</h2>1. World Health Organisation. Global Health Observatory data: obesity. https://www.who.int/gho/ncd/risk_factors/obesity_text/en/ Accessed 12 December 2018. 2. Rakel D. Integrative Medicine. Third edition. Elsevier Saunders. 364-375.3. Phelps K et al. General Practice. Churchill Livingstone, 2011, 528-541. Australian Government Department of Health. http:// www.health.gov.au/ internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act- guidelines#apaadult. Accessed 18 December 2018.4. Mallard S et al. Vitamin D status and weight loss: a systematic review and meta-analysis of randomised and nonrandomised controlled weight-loss trials. Am J Clin Nutr. 2016 Oct;104(4):1151-1159.5. Seganfredo FB et al. Weight-loss interventions and gut microbiota changes in overweight and obese patients: a systematic review. Obes Rev. 2017 Aug; 1 (8):832-851.6. Brindal E et al. Cohort analysis of a 24-Week Randomised Controlled trial to assess the efficacy of a novel, partial meal replacement program targeting weight loss and risk factor reduction in overweight/obese adults. Nutrients 2015 March 15.7. Golzarand M et al. Effect of green tea, caffeine and capsaicin supplements on the anthropometric indices: a meta-analysis of randomized clinical trials. Journal of Functional Foods 2018;46:320-328.8. Spadaro K et al. Effect of mindfulness meditation on short-term weight loss and eating behaviours in overweight and obese adults: a randomised controlled trial. J. Complement. Integr. Med. 2017 Dec 5;15(2).9. Namazi N et al. Are isolated and complex fiber supplements good choices for weight management. A Systematic Review. Arch Ian Med. 2017;Nov,20(1):704-713.10. Jurgens T et al. Green tea for weight loss and weight maintenance in overweight and obese adults (Review). Cochrane Database of Systematic Reviews. 2012, Issue 12.11. Shaw K et al. Exercise for overweight or obesity (Review) Cochrane Database of Systematic Reviews 2006, Issue 4.12. Blackmores institute. Complementary medicines interaction guide. 2019 https://www.blackmoresinstitute.org/interactions.13. Australian Guide to Healthy Eating. https://www.eatforhealth.gov.au/guidelines/guidelines Accessed 12 September 2023.14. Braun et al. Vitamin D Herbs &amp; Natural Supplements. And evidence-based guide. 4th edition. Vol 2. Australia, Elsevier, 1125-1149.15. Park S et al. Probiotics for weight loss: a systematic review and meta-analysis. Nutr Res. 2015 Jul; 35(7):56-75.16. Braun et al. Probiotics. Herbs &amp; Natural Supplements. And evidence-based guide. 4th edition. Vol 2. Australia, Elsevier, 771-796.17. Braun et al. Probiotics. Herbs &amp; Natural Supplements. And evidence-based guide. 4th edition. Vol 2. Australia, Elsevier, 760-771.

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