Model of Care
People living with higher weights need support from the entire health system.
Using the Model of Care
An effective model of care needs to look across the health system. In this way it can:
- Provide a collaborative, integrated approach to the prevention, identification, and management of overweight and obesity across the healthcare continuum, and
- Identify the key role of stakeholders at each level of care and current practice recommendations.
Health professionals can visit the Clinical Toolkit for support to deliver the best care to children and adults across the lifespan.
Enabling environments, communities and places that encourage positive lifestyle behaviours to promote a healthy weight.
Primary Health Care
Appropriate treatment and management of children and adults who are living with overweight or obesity.
Queensland Government departments and agencies, local government, NGOs, HHSs, PHNs, Academia.
To enable environments, communities and places that encourage positive lifestyle behaviours to promote a healthy weight.
- Increase the proportion of Queenslanders living with a healthy weight.
- Reduce inequities that cause unhealthy weight and growth for Queenslanders, particularly in First Nations people and culturally and linguistically diverse (CALD) people, low Socioeconomic Status (SES), and rural and remote.
Many Queenslanders are living, playing and aging in an obesogenic environment that encourages unhealthy higher weights. In Queensland, 66% of children aged 5-17 years are within the healthy weight range, while 24% are living with overweight or obesity (16% overweight, 8% obesity) and 10% are below the healthy weight range. 
Promotion of healthy weight requires political commitment, collaboration across all sectors of society, and a broad focus that is inclusive of all factors contributing to the obesogenic environment. The approach needs to be equitable, with a particular focus on priority communities. 
Significant health inequities exist across the Queensland population. Certain vulnerable groups, including those of low socioeconomic background or education level, First Nations people, Māori and Pacific Islander people, and some CALD communities, have higher risk of overweight or obesity than the general Queensland population. Rates of obesity in socioeconomically disadvantaged areas are about 80% higher than advantaged areas; 20–40% higher in regional and remote areas, compared to cities; and Indigenous Queenslanders are 39% more likely to live with obesity than non-Indigenous Queenslanders.
Health and Wellbeing Queensland (HWQld) focuses on health promotion and prevention in Queensland. We take a collaborative approach, partnering with the community, NGOs, private sector and all levels of government as well as sectors not typically associated with health care services. HWQld aims to improve the health and wellbeing of Queenslanders, reduce health inequity and reduce the burden of chronic disease through targeting poor nutrition and physical inactivity.
Learn about our Gather and Grow program.
ConnectingQ is a network supported by an online platform, co-designed to empower practitioners from local government, community and health sectors to connect, collaborate and exchange knowledge, with the shared objective of creating active and healthy communities. ConnectingQ provides accessible and engaging content, including practical resources, and learning opportunities across sectors and regions in Queensland. Visit the website and join the network to stay connected and support sustainable, healthy communities across Queensland.
Primary Health Care
Primary care providers, including GPs, child health nurses, practice nurses, First Nations people and Multicultural health workers, allied health, PHNs, NGOs, AMSs and ACCHOs.
Raising the topic of weight, monitoring weight/height, identifying risk to enable early intervention and managing appropriately through healthy habits.
- Routine weight and height checks for adults and discussing weight changes with sensitivity and empathy.
- Engage women and men of childbearing age to identify thoughts around conception to support healthy behaviour change prior to pregnancy.
- Health professionals have the skills and confidence to raise the topic of weight, identify and address unhealthy weight gain to help prevent overweight, obesity and other chronic diseases.
- Identifying unhealthy growth in children prior to the age of five is important to prevent long-term unhealthy weights.
- Utilise a suite of resources and tools to enable health professionals to support children, adults and families in healthy habits to prevent unhealthy weight gain.
Primary Health care is our key to chronic disease prevention
Primary health care has an important role in preventing and managing unhealthy weights and other risk factors such as poor diets, physical activity. Perfectly positioned to support a person’s health needs long term, Primary Healthcare Providers can provide anticipatory guidance to parents, families, children and adults to support healthy weight and weight-related behaviours.[6-10]
Childhood overweight and obesity (without co-morbidities) should be managed in primary health care using multi- disciplinary services coordinated by the PHC provider, unless referral to hospital or specialist services is indicated (with co-morbidities). For further support on management within Primary Care, view the Clinician’s Toolkit.
Preventative health starts early – one if five Australia children are already affected by overweight or obesity by the age of 5. Childhood overweight and obesity can persist into adulthood and increases risk of cardiovascular disease, type 2 diabetes, stroke and poor mental health.
Parents are the primary influence on the development of child eating, physical activity and sedentary behaviours with parenting styles playing a role in developing healthy lifestyles. However, the ability of families to make healthy food choices is challenging in Australia’s obesogenic environment.
Small but sustainable changes can have lifelong positive outcomes. Preventative health is key to this. Support individuals by utilising local programs that may be of benefit.
HWQld is supporting Queenslanders with initiatives that make healthy happen.
Hospital and specialist services
MDT (e.g. Specialist Doctors, Endocrinologist, Dietitian, Psychologist, Physiotherapist/Exercise Physiologist, nurse).
Multi-component lifestyle interventions in combination with medical treatment.
- Improve access to specialist care for children and adults with co-morbidities: weight management/obesity services, specialist multi-disciplinary teams and case management.
- Intensive medical treatment offered when lifestyle changes are not successful and/or when rapid weight loss is required.
Treatment options for managing overweight and obesity in hospital and specialist services include multi-component lifestyle interventions in combination with medical treatment. Multi-component lifestyle interventions are associated with successful outcomes.
Interventions and need to consider the persons living, working and social environment. They need to involve frequent contact with a healthcare professional and this is determined by the level of support required by the individual child or adult. [13-18]
For children, solutions should be family-based, multicomponent behavioural therapy. In children and adults, effective delivery of high-quality care and to achieve clinically meaningful weight loss interventions should include:
- Integrated care model
- Well-trained multidisciplinary care team with medical oversight
- The use of evidence-based protocols, and
- Provide >25 hours of contact over a period of 6 months.
It is acknowledged that this level of contact (frequency and length) may not be achievable in all health services, and hence the goal should be to provide as best a service as you can (even if that means less contact hours).
When lifestyle changes are not successful and/or when rapid weight loss is required additional intervention may be necessary, including pharmacotherapy or very low-caloric/energy diets (VLCDs or VLEDs).
When interventions including very low-caloric/energy diets (VLCDs or VLEDs) and pharmacotherapy (anti-obesity agents) are not successful, bariatric surgery in adults may be necessary.
Education and Research
Health Professionals providing face-to-face care with children and adults.
To upskill in best-practice prevention, treatment and management of higher weights to provide evidence-based specialist care, locally.
Targeted online and face-to-face education modules that incorporate health eating, physical activity, sleep patterns and behavioural modification for children and families.
Healthy Kids ECHO® Learning Series
Our ECHO® Learning Series ‘Healthy Kids’ focuses on supporting professionals to deliver best-practice care to the families in their communities. The series provides mentoring, evidence-based advice, and support to professionals who consult with children and young people who may have overweight or obesity, so they can deliver care with empathy, confidence and success. This is especially important for communities that lack access to specialists due to remoteness, poverty, cultural barriers or other factors.
Each ECHO® session consists of a short didactic presentation by a specialist followed by a case presentation on pediatric overweight and obesity (by a participant). Delivery is through an interactive, online platform—the only requirements for participation are an internet connection and a device with webcam. It is free of charge.
The Healthy Kids ECHO® Series supports health care providers’ skills and knowledge in managing childhood overweight and obesity. It also supports ongoing clinical professional development.
- Mihrshahi S, Gow ML, Baur LA. Contemporary approaches to the prevention and management of paediatric obesity: an Australian focus. Med J Australia. 2018; 209:267-74.
- Queensland Health. Changes in weight status of children and adults in Queensland and Australia 2017-2018. Brisbane: Queensland Government2019.
- Queensland Health. The health of Queenslanders. Report of the Chief Health Officer Queensland 2018. Brisbane 2019.
- Swinburne B, Kraak V, Allender S, Atkins V, Baker P, Bogard J. The global syndemic of obesity, undernutrition, and climate change: the Lancet Commission report The Lancet. 2019; 393:791-846.
- World Health Organisation. Report of the Commission on Ending Childhood Obesity. Geneva: WHO2016.
- Rath SR, Marsh JA, Newnham JP, Zhu K, Atkinson HC, Mountain J, et al. Parental pre‐pregnancy BMI is a dominant early‐life risk factor influencing BMI of offspring in adulthood. Obesity Science & Practice. 2016; 2:48-57.
- Smego A, Woo J, Klein J, Suh C, Bansal D, Bliss S, et al. High Body Mass Index in Infancy May Predict Severe Obesity in Early Childhood. J Peds. 2017; 183:87-93.e1.
- Woo Baidal J, Locks L, Cheng E, Blake-Lamb T, Perkins M, Taveras E. Risk Factors for Childhood Obesity in the First 1,000 Days: A Systematic Review: A Systematic Review. American Journal of Preventive Medicine. 2016; 50:761-79.
- Juonala M, Lau T, Wake M, Grobler A, Kerr JA, Magnussen CG, et al. Early clinical markers of overweight/obesity onset and resolution by adolescence. International Journal of Obesity. 2019.
- Moore T, Arefadib N, Deery A, Keyes M, West S. The first thousand days. An Evidence paper. Melbourne Royal Children’s Hospital Melbourne2017.
- Burrows T, Hutchesson M, Chai L, Rollo M, Skinner G, Collins C. Nutrition Interventions for Prevention and Management of Childhood Obesity: What Do Parents Want from an eHealth Program? Nutrients. 2015; 7:10469-79.
- Australian Institute of Health and Welfare. Nutrition across the life stages. Canberra: AIHW2018.
- Moukhaiber P, Alexander S. Childhood weight issues. Seeking better health outcomes. Endocrinology Today. 2018; 7:26-31.
- National Health and Medical Research Council. Clinical Practice Guidelines for the Management of overweight and obesity in Adults, Adolescents and Children in Australia. Canberra: NHMRC2013.
- Wifley D, Staiano A, Altman M, Lindros J, Lima A. Improving Access and Systems of Care for Evidence-Based Childhood Obesity Treatment: Conference Key Findings and Next Steps. Obesity. 2017; 25:16-29.
- Colquitt JL, Loveman E, O’Malley C, Azevedo LB, Mead E, Al‐Khudairy L, et al. Diet, physical activity, and behavioural interventions for the treatment of overweight or obesity in preschool children up to the age of 6 years. Cochrane Database of Systematic Reviews. 2016.
- Mead E, Brown T, Rees K, Azevedo LB, Whittaker V, Jones D, et al. Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years. Cochrane Database of Systematic Reviews. 2017.
- Al‐Khudairy L, Loveman E, Colquitt JL, Mead E, Johnson RE, Fraser H, et al. Diet, physical activity and behavioural interventions for the treatment of overweight or obese adolescents aged 12 to 17 years. Cochrane Database of Systematic Reviews. 2017.
- Australian and New Zealand Obesity Society. Australian Obesity Management Algorithm. Canberra 2016.
Clinicians Hub is brought to you by Health and Wellbeing Queensland in partnership with Allied Health Profession’s Office of Queensland, Clinical Excellence Queensland.
Last updated 23 October 2023