Interventions to prevent or manage obesity in Maori and Pacific adults: a systematic review and narrative synthesis.

OBJECTIVES: Obesity and its sequelae are an increasing problem, disproportionally affecting Maori and Pacific peoples, secondary to multifactorial systemic causes, including the effects of colonisation and the impact of globalisation. There is limited synthesised evidence on interventions to address obesity in these populations. The objective of this review is to identify evaluated interventions for prevention and management of obesity amongst Maori and Pacific adults, assess the effectiveness of these interventions, and identify enablers and barriers to their uptake. DESIGN: Systematic review of databases (Medline, PubMed, EMBASE, CINAHL, Scopus, CENTRAL), key non-indexed journals, and reference lists of included articles were searched from inception to June 2021. Eligibility criteria defined using a Population, Intervention, Control, Outcome format and study/publication characteristics. Quantitative and qualitative data were extracted and analysed using narrative syntheses. Study quality was assessed using modified GRADE approach. RESULTS: From the 8190 articles identified, 21 were included, with 18 eligible for quantitative and five for qualitative analysis. The studies were heterogenous, with most graded as low quality. Some studies reported small but statistically significant improvements in weight and body mass index. Key enablers identified were social connection, making achievable sustainable lifestyle changes, culturally-centred interventions and incentives including money and enjoyment. Barriers to intervention uptake included difficulty in maintaining adherence to a programme due to intrinsic programme factors such as lack of social support and malfunctioning or lost equipment. CONCLUSIONS: Normal weight trajectory is progressive increase over time. Modest weight loss or no weight gain after several years may have a positive outcome in lowering progression to diabetes, or improvement of glycaemic control in people with diabetes. We recommend urgent implementation of Maori and Pacific-led, culturally-tailored weight loss programmes that promote holistic, small and sustainable lifestyle changes delivered in socially appropriate contexts.

Pharmaceutical utilisation and costs before and after bariatric surgery.

OBJECTIVE: To determine whether pharmaceutical utilisation and costs change after bariatric surgery. SUBJECTS: Total population of Australians receiving Medicare-subsidised laparoscopic adjustable gastric banding (LAGB) in 2007 (n=9542). DESIGN: Computerised data linkage with Medicare, Australia's universal tax-funded health insurance scheme. Pharmaceuticals relating to obesity-related disease and postsurgical management were assigned to therapeutic categories and analysed. The mean annual numbers of pharmaceutical prescriptions for each category were compared over the 4-year period from the year before LAGB (2006) to 2 years after LAGB (2009) using utilisation incidence rate ratios (IRRs). RESULTS: The population was mainly female (77.7%) and age was normally distributed with the majority (60.7%) of subjects aged between 35-54 years. Utilisation rates decreased significantly after LAGB in the following therapeutic categories: diabetes (IRR 0.51, IRR 95% CI 0.50-0.53, mean annual cost differences per person $30), cardiovascular (0.81, 0.80-0.82, $29), psychiatric (0.95, 0.93-0.97, $13), rheumatic and inflammatory disorders (0.51, 0.49-0.53, $10) and asthma (0.78, 0.75-0.81, $9). In contrast, significantly greater utilisation was observed in the pain (1.28, 1.23-1.32, $12), gastrointestinal tract disorder (1.04, 1.02-1.07, $5) and anaemia/vitamins (2.34, 2.01-2.73, $4) therapeutic categories. When the defined categories were combined, a net reduction in pharmaceutical utilisation was observed, from 10.5 to 9.6 pharmaceuticals prescribed per person/year, and costs decreased from $AUD517 to $AUD435 per year in 2009 prices. CONCLUSION: Relative to the year before LAGB, overall pharmaceutical utilisation was reduced in the 2 years after the year of LAGB surgery, demonstrating that bariatric surgery can lead to reductions in pharmaceutical utilisation in the 'real world' setting. The greatest absolute cost reductions were observed in the therapies to treat diabetes and cardiovascular disease.

Experiences and challenges in implementing complex community-based research project: the Pacific Obesity Prevention in Communities project.

Policy makers throughout the world are struggling to find effective ways to prevent the rising trend of obesity globally, particularly among children. The Pacific Obesity Prevention in Communities project was the first large-scale, intervention research project conducted in the Pacific aiming to prevent obesity in adolescents. The project spanned four countries: Australia, New Zealand, Fiji and Tonga. This paper reports on the strengths and challenges experienced from this complex study implemented from 2004 to 2009 across eight cultural groups in different community settings. The key strengths of the project were its holistic collaborative approach, participatory processes and capacity building. The challenges inherent in such a large complex project were underestimated during the project's development. These related to the scale, complexity, duration, low research capacity in some sites and overall coordination across four different countries. Our experiences included the need for a longer lead-in time prior to intervention for training and up-skilling of staff in Fiji and Tonga, investment in overall coordination, data quality management across all sites and the need for realistic capacity building requirements for research staff. The enhanced research capacity and skills across all sites include the development and strengthening of research centres, knowledge translation and new obesity prevention projects.

Maintenance of traditional cultural orientation is associated with lower rates of obesity and sedentary behaviours among African migrant children to Australia.

BACKGROUND: Migrants from developing to developed countries rapidly develop more obesity than the host population. While the effects of socio-economic status on obesity are well established, the influence of cultural factors, including acculturation, is not known. OBJECTIVE: To examine the association between acculturation and obesity and its risk factors among African migrant children in Australia. DESIGN AND PARTICIPANTS: A cross-sectional study using a non-probability sample of 3- to 12-year-old sub-Saharan African migrant children. A bidimensional model of strength of affiliation with African and Australian cultures was used to divide the sample into four cultural orientations: traditional (African), assimilated (Australian), integrated (both) and marginalized (neither). MAIN OUTCOME MEASURES: Body mass index (BMI), leisure-time physical activity (PA) and sedentary behaviours (SBs) and energy density of food. RESULTS: In all, 18.4% (95% confidence interval (CI): 14-23%) were overweight and 8.6% (95% CI: 6-12%) were obese. After adjustment for confounders, integrated (beta=1.1; P<0.05) and marginalized (beta=1.4; P<0.01) children had higher BMI than traditional children. However, integrated children had significantly higher time engaged in both PA (beta=46.9, P<0.01) and SBs (beta=43.0, P<0.05) than their traditional counterparts. In comparison with traditional children, assimilated children were more sedentary (beta=57.5, P<0.01) while marginalization was associated with increased consumption of energy-dense foods (beta=42.0, P<0.05). CONCLUSIONS: Maintenance of traditional orientation was associated with lower rates of obesity and SBs. Health promotion programs and frameworks need to be rooted in traditional values and habits to maintain and reinforce traditional dietary and PA habits, as well as identify the marginalized clusters and address their needs.

A review of factors affecting fat absorption in hot chips.

Consumption of hot chips is a convenience food in most countries. Unfortunately, these are high in fat and contribute to fat-related diseases in societies with a high fat consumption. There is substantial scope through best-practice deep-frying techniques for producing lower fat, high-quality chips. From a review of the literature, the main factors associated with a lower-fat content of chips are thick (>12 mm), straight cut chips; cryogenic freezing methods; low moisture content of potatoes (specific gravity >1.1); frying fat: chip volume ratio of 6:1; frying at optimal temperature (180 to 185 degrees C) during cooking and turning the temperature down (approximately 140 degrees C) and covering the vats during slack periods; vigorously shaking the basket and hanging it over the deep fryer to drain after frying; maintaining the quality of the frying fat by regularly skimming the cracklings, filtering the fat, and topping up the fryer with fresh fat; keeping the fat turnover <5 days; regular cleaning of frying equipment. It is important that all deep frying operators are adequately trained in these techniques. It is also important that the frying medium is low in saturated and trans fatty acids (<20%) because of their effects on blood lipids and low in linolenic acid (<3%) because it is readily degraded. The widespread implementation of best-practice deep-frying would reduce fat content of hot chips and thus lower overall fat consumption.

Effects of reduced-fat diets consumed ad libitum on intake of nutrients, particularly antioxidant vitamins.

OBJECTIVES: To determine whether a reduced-fat diet consumed ad libitum can achieve the recommended intakes of other macronutrients, fiber, and cholesterol and whether such a diet affects intake of other important micronutrients such as fat-soluble vitamins. DESIGN: Twelve-month, randomized, controlled trial of a reduced-fat, ad libitum diet vs usual diet. SUBJECTS: One hundred ten adults older than 40 years with glucose intolerance (2-hour blood glucose concentration = 7.0 to 11.0 mmol/L) who were selected from a previous workforce survey. INTERVENTION: Monthly small-group meetings aimed at identifying sources of dietary fat and ways to reduce fat consumption. MAIN OUTCOME MEASURES: Nutrient intakes derived from 3-day food diaries at the beginning and end of the study. Blood levels of retinol, alpha-tocopherol, and beta carotene at the end of the study. STATISTICAL ANALYSES PERFORMED: Unpaired t tests for determining changes in nutrient intake and antioxidant vitamin concentrations. Separate analyses were conducted with users of mineral and vitamin supplements and people who changed smoking status to reduce potential confounding. RESULTS: Fat intake decreased from 35% to 26% of energy in the reduced-fat diet group compared with a 2% decrease in the control group (P < .0001). Total energy intake also decreased in the 2 groups (-362 vs -59 kcal/day, P < .02). Those changes were reflected in a 3.1 +/- 4.7 kg (mean +/- standard deviation) weight loss in the intervention group compared with a 0.4 +/- 3.0 kg weight gain in the control group (P < .0001). There were no differences between groups in the changes in micronutrient intakes, except for an energy-adjusted increase in beta carotene intake in the reduced-fat diet group. Serum retinol and alpha-tocopherol concentrations were not different between the groups, but the reduced-fat diet group had higher beta carotene concentrations (P = .009). APPLICATIONS: A reduced-fat, ad libitum diet can be prescribed to improve overall macronutrient intake and achieve modest weight loss without sacrificing micronutrient intakes.

Dexfenfluramine as an adjunct to a reduced-fat, ad libitum diet: effects on body composition, nutrient intake and cardiovascular risk factors.

OBJECTIVE: To investigate the specific effects of dexfenfluramine (dF) as an adjunct to a reduced-fat, ad libitum diet. DESIGN: Double-blind, randomized, placebo-controlled study. Subjects were stabilized on the dietary program during a 12 w run-in period, and then were randomized to receive dF (15 mg) or placebo bd for an additional 12 w. One follow-up was conducted 12 w after cessation of treatment. SUBJECTS: 84 obese subjects (57 F; 27 M, mean body mass index = 34.7 +/- 3.2 kg/m2). MEASUREMENTS: Body composition (by DEXA), fat distribution (by circumferences and DEXA), nutrient intake (by 7 d food diaries), blood lipids, blood glucose and blood pressure. RESULTS: Mild side effects were reported by 19 dF subjects, and in seven subjects lethargy or dry mouth persisted for the 12 w of treatment. Relative to placebo, treatment with dF was associated with significantly greater reductions in body weight (-3.8 kg, 95% confidence interval [CI] = -4.9, -2.7), fat mass (-2.5 kg, 95% CI = -3.6, -1.4) and fat-free mass (-1.2 kg, 95% CI = 1.8, -0.7). Waist and hip circumferences also decreased (P < 0.01) but the waist:hip ratio remained unchanged. The ratio of waist:hip fat mass as measured by DEXA decreased more in the dF group (P < 0.01). Lower total energy intake (-439 kJ/d, 95% CI = -932, 54) and fat intake (-5.1 g/d, 95% CI = -10.8, 0.6) were also seen but were of borderline statistical significance. After adjusting for changes in fat intake, dF treatment was associated with lower cholesterol and triglyceride concentrations (P < 0.01). Twelve weeks following cessation of treatment, the rate of weight gain was not significantly different between the dF and the placebo groups (1.7 kg and 0.7 kg respectively), but the dF group remained significantly lighter than the placebo group (P < 0.01). CONCLUSIONS: Dexfenfluramine treatment augments weight and fat loss on a reduced-fat, ad libitum diet, with some evidence for preferential loss of waist fat compared with hip fat. The decreases in total energy and fat intake with dF seem insufficient to explain the significant decreases in body weight and fat mass.

Hepatic veno-occlusive disease associated with comfrey ingestion.

A 23 year old man presented with hepatic veno-occlusive disease and severe portal hypertension and subsequently died from liver failure. Light microscopy and hepatic angiography showed occlusion of sublobular veins and small venous radicles of the liver, associated with widespread haemorrhagic necrosis of hepatocytes. The patient had been on a predominantly vegetarian diet and, prior to his illness, took comfrey leaves which are known to contain hepatotoxic pyrrolizidine alkaloids. Comfrey is widely used as a herbal remedy, but so far has only been implicated in two other documented cases of human hepatic veno-occlusive disease. A possible causal association of comfrey and this patient's veno-occlusive disease is suggested by the temporal relationship of the ingestion of comfrey to his presentation, the histological changes in the liver and the exclusion of other known causes of the disease.