Model of Care

A 'how-to' guide for prevention, early intervention, treatment and management of overweight and obesity.

Model of Care

This hub provides a ‘how-to’ guide for health professionals that covers prevention, early intervention, treatment and management. It also provides education and training resources and guidance on research, monitoring and evaluation

Using the Model of Care

The Towards Healthy Growth and Weight in Queensland Children Model of Care (MOC) outlines a systems-wide approach for preventing, identifying and treating overweight and obesity in Queensland children and adolescents . It has been developed by the Paediatric Obesity Working Group (POWG), a sub-group of the Queensland Child and Youth Clinical Network (QCYCN), Clinical Excellence Queensland, Queensland Health.

This Model of Care How to Guide aims to:

  • Provide a collaborative, integrated approach to the prevention, identification and management of overweight and obesity in children across the health care continuum, and
  • Guide health professionals to: identify unhealthy growth patterns and overweight and obesity; develop local supporting initiatives; and deliver the best care to children and their families.

In other parts of our hub you’ll find information about the key role of stakeholders at each level of care and current practice recommendations. Each section is supported by guidelines and resources for health professionals and children and families.

Initiatives in the Model of Care include:

Referral Pathway

A simple clinical pathway for childhood overweight and obesity for Primary Health Care Providers

Referral Pathway
Project ECHO

Education & Training in identifying and managing childhood overweight & obesity for health professionals

Project Echo
Research Guide

Starting, Conducting and Translating Research in childhood overweight and obesity

Research Guide
Health Transformers

Individuals committed to transforming childhood obesity prevention and management in Queensland

Health Transformers
Population-level Prevention

Enabling environments, communities and places that encourage positive lifestyle behaviours to promote a healthy weight.

Population-level Prevention
Primary Health Care

Approriate treatment and management tfor children with overweight and obesity.

Primary Heath Care
Hospital and Specialist Services

Multi-component lifestyle interventions in combination with medical treatment.

Hospital and Specialist Services

Population-level Prevention


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.


Health and Wellbeing Queensland – Initiatives

See the Initiatives

Increase the proportion of Queenslanders living with a healthy weight.

  • Increase the proportion of children and young people living with a healthy weight in Queensland.
  • Reduce inequities in unhealthy growth in Queensland children and families, particularly in First Nations people and culturally and linguistically diverse (CALD) people, low Socioeconomic Status (SES), and rural and remote.

Many children today are growing up in an obesogenic environment that encourages an unhealthy growth in children. 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.[2] [3]

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.[4] [5]

Inequities and unhealthy growth in children

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.

Statewide initiative

Health and Wellbeing Queensland

The recently established Health and Wellbeing Queensland (HWQld) agency focuses on health promotion and prevention in Queensland. HWQld will 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.[6]

Learn about our Gather and Grow program.

3 A’s Matrix for Primary Health Care

The MOC incorporates the 3As approach to weight management as recommended by the National Health and Medical Research Council (NHMRC) for Primary Health Care Settings.[4]

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, promoting healthy, frequent growth monitoring, identifying risk to enable early intervention, and treating and managing appropriately for children with overweight and obesity.


Prevention and Early Intervention:

  • Undertake routine growth monitoring of children up to age 18 years. Health professionals keep families informed of their child’s growth patterns through infancy, childhood and adolescence.
  • Health professionals use gestational weight gain charts in consultation with women throughout their pregnancy.
  • Health professionals have the skills and confidence to raise the topic of weight, identify and address children with unhealthy growth patterns who are at risk of overweight and obesity, particularly before the age of 5 years.[1]
  • Identify and promote a suite of resources and tools to enable health professionals to use with children and their families in identifying and managing those at high risk of overweight and obesity.

Treatment and Management:

  • Health professionals have the skills and confidence to identify unhealthy growth and manage children with overweight and obesity.
  • Increase the capacity of GPs to coordinate multi-disciplinary services to manage childhood overweight and obesity.
  • Project ECHO is used to upskill and empower health professionals in managing childhood overweight and obesity via professional development series.
  • Families have access to evidence-based healthy lifestyle and weight management resources, tools and weight management services/programs for their children.
  • Use of localised referral pathways to specialist services.

Prevention of overweight and obesity in children

Childhood overweight and obesity can persist into adulthood and increases risk of cardiovascular disease, type 2 diabetes, stroke and poor mental health. Obesity prevention strategies need to start before the age of five; one in five Australian children are already affected by overweight or obesity at this age.[1] Primary Health Care (PHC) providers can provide anticipatory guidance to prospective parents, families and children to support healthy weight and weight-related behaviours.[1] [4] [12] [14-16]

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 can be challenging in Australia’s obesogenic environment.[17] [18]

Prevention of overweight and obesity needs to be available across ‘critical time periods’ in the life course: pre-conception and pregnancy; infancy and early childhood; and older childhood and adolescence.[4] [14]

Health and Wellbeing Queensland initiatives targeting prevention

Promote healthy habits during pre-conception and antenatal stages

A woman’s preconception weight and gestational weight gain (GWG) are two of the most important and independent predictors of childhood obesity.[11] In Queensland, half of all women already live with overweight or obesity at conception.[3]

It is recommended that health professionals use GWG charts in consultation with women throughout their pregnancy. The charts should be provided to a pregnant woman during the first ante-natal visit and used to support ongoing discussion about weight at each antenatal visit.[20]

Ask and Assess

  • Pre-conception: Ask women about planning a pregnancy, and ask permission to discuss and assess preconception weight and explain its relevance.
  • Antenatal: Calculate BMI at entry to care, weigh and plot at every antenatal visit.

Advise and Assist

  • Pre-conception: Advise women of their weight range.
  • Antenatal: Advise women of recommended GWG based on their pre-pregnancy BMI. Regularly monitor and discuss pattern and rate of weight gain. Encourage self-monitoring. Provide general information on optimal nutrition, physical activity and sedentary time.

Arrange and Ask Again

Referral to allied health services for women identified as at-risk. Ask women for follow-up appointment for weight monitoring.

Promote breastfeeding and support introduction of healthy first foods

Breastfeeding gives babies the best start to a healthy life and confers life-long protective effects for the health and wellbeing of mothers and babies. All health professionals have a responsibility to encourage, support and promote breastfeeding.[8] [21] [22]

Ask and Assess

  • Ask if mother intends to breastfeed, for how long, any difficulties experienced, any contact with Child Health Services.
  • Ask the family about timing and choice of first foods.

Advise and Assist

  • Encourage exclusive breastfeeding for around the first six months of life, with breastfeeding continuing to at least 12 m and beyond, for as long as mother and baby desire. Where breastfeeding is not desired or possible, infants should be fed infant formula.
  • First foods should be introduced when developmentally appropriate (around 6 m but not before 4 m) with iron -rich foods included first. Avoid ‘baby’ juices.
  • Full cream cows milk can be given as a drink from 12m. Toddler formulas are not required unless medically indicated. Recommend using a cup and discourage use of a feeding bottle.
  • Provide resources to assist family.

Arrange and Ask Again

  • Refer to local child health services or 13 HEALTH: Note must request to speak with a child health nurse.  Provide contact details for the Australian Breastfeeding Association.
  • Ask family for follow-up appointment infant feeding and support.

Measuring growth and monitoring change

Measuring growth is part of standard, routine paediatric clinical practice. Regular growth assessments make it easier to recognise an abnormal growth trajectory and identify children who are at risk of developing overweight and obesity. Serial measurements also normalise growth monitoring and provide an opportunity to discuss growth charts and healthy growth with the family in a standardised, non-stigmatising way.[10] [23]

It is recommended that weight, length/height and BMI are measured, assessed and reviewed at least yearly[24] in addition to the key milestone growth reviews in the Personal Health Record during the first two years of life. Growth should be monitored until age 18 years.[25]

Using percentile charts to measure growth and monitor change

Growth status in children and adolescents (age 0-18 years old) is assessed using age- and sex- specific reference values, as the appropriate ratio of weight to height varies during development. Measuring growth should always be contextualised to a child’s clinical condition.

  • For children 0-2 years, use WHO growth charts (calculate weight, length and weight for length for age) Using the BMI-for-age growth chart is not recommended for children younger than age 2 years.
  • For children 2-18 years, use CDC growth charts** (calculate BMI-for-age, weight and height for age).[26]
  • Link to Growth Charts

**Queensland Health use WHO chart for children 0-2 years and CDC growth charts for children 2-18 years of age

Classification of Overweight and Obesity

Class Age Group Description
Overweight 0 – 2yrs (WHO) Weight-for-height > 2 SD above WHO Child Growth Standards Median
2 – 18yrs (CDC) 85th to 95th %ile
Obese 0 – 2yrs (WHO) Weight-for-height > 3 SD above WHO Child Growth Standards Median
2 – 18yrs (CDC) ≥ 95th %ile
*There is no consensus on the definition of severity of obesity, the most recent International Obesity Taskforce (IOTF) recommendations suggested these definitions:
• Class 2 obesity: BMI ≥120% of the 95th percentile or ≥35 kg/m2 (CDC BMI charts)
• Class 3 obesity: BMI ≥140% of the 95th percentile or ≥40 kg/m2 (CDC BMI charts), or BMI Z score >3.5

Ask and Assess

  • Opportunistically measure growth and plot at every consultation, particularly in the first 5 years of life. Serial measurements are required until 18 years (including with all immunisations).
  • Assess and review at least yearly – is the child maintaining consistent growth velocity?

Advise and Assist

  • Discuss child’s growth pattern regularly with the family (using growth charts) and normalise growth monitoring.
  • Mention that it is part of standard care.
  • Recommend family to also keep child’s growth records until 18 years.

Arrange and Ask Again

  • Ask family for follow-up appointments for growth monitoring (opportunistic at all presentations, minimum yearly).

Identifying risk and early intervention

Primary Health Care Providers are uniquely positioned to identify risk of childhood overweight and obesity and intervene early with children and families to promote prevention. The first 1,000 days (conception-2 years of age) presents opportunity to identify significant risk factors and promote protective behaviours to prevent future childhood overweight and obesity.

Health and Wellbeing Queensland initiatives targeting identification of risk

Identifying risk

Ask and Assess

  • Use growth charts to identify rapid or inconsistent changes in growth patterns and changes in centile ranks (weight-for-length for age <2 years and BMI-for-age > 2 years).
  • Identify simple risk factors, including: maternal pre-pregnancy overweight or obesity, pregnancy and birth history (including birth weight, maternal GDM, maternal smoking during pregnancy); premature birth status, rapid infant growth velocity in the first year of life, infant development milestones; early feeding practices (short breastfeeding exclusivity and duration, timing of introduction to first foods).
  • Using clinical judgment, form an impression of overall risk based on the presence of these risk factors.

Advise and Assist

  • Discuss rapid or excessive weight gain and potential causative factors with the family.
  • Discuss identified risk factors, focusing on those that are modifiable.
  • Use positive, health-focused language that minimises judgment

Arrange and Ask Again

  • Explore dietary, behavioural and parenting practice interventions that may decrease risk, such as breastfeeding promotion, educating parents about responsive feeding practices, formula milk modification (lower protein)
  • Refer children at greater risk of obesity to Child Health Services (Allied Health).
  • Ask family for follow-up appointment for growth monitoring and support.

Early Intervention for children and families

Early intervention is indicated if a child is at-risk of developing overweight or obesity from simple risk factors (see ‘Identifying risk’) identifiable in the first 1,000 days, or later in life if there is a family history of overweight and obesity and the family are demonstrating unhealthy lifestyle behaviours.

Ask and Assess

  • Assess child’s growth (BMI-for-age) and discuss growth pattern with famly (using growth charts)
  • Ask about current lifestyle behaviours (fruit and vegetables, sugary drink intake, family meals, take away/eating out, tv and screen time, physical activity/active play, sleep routines).

Advise and Assist

  • Discuss weight in a non-judgmental, sensitive manner.
  • Empower and encourage families to make healthy lifestyle changes. Provide healthy eating and physical activity advice and resources (increase fruit and vegetables intake, water as the main drink, avoid sugary drinks and fruit juices, promote family meals, reduce screen time, active play and vigorous physical activity , healthy sleep routines).

Arrange and Ask Again

  • Refer identified/at risk children and their families to allied health/healthy lifestyle programs or 13 HEALTH (note must request to speak with a child health nurse. Available 7d/week).
  • Refer to Healthier. Happier. website.

Healthy Eating

The Australian Guide to Healthy Eating is a food selection guide that visually represents the proportion of the five food groups recommended for consumption each day.[27]

The Healthy eating for children resource outlines the amount of food and drinks children are recommended to consume each day, along with other tips and information.

Physical Activity

The Australian 24-Hour Movement Guidelines from birth to five years and for Children and Young People five to 17 years, includes recommendations for incorporating physical activity and minimising sedentary behaviour in a 24-hour period as well as recommendations for sleep.[28]

Treatment and management

Treatment and management should take place when a child has experienced rapid weight gain or weight is identified as being in the overweight or obese category. Goals of treatment include improvements in sustainable healthy lifestyle behaviours, preventing further weight gain (weight maintenance) and in some cases where appropriate, weight reduction, for example:

  • Overweight: weight maintenance rather than weight loss can sometimes be the goal during growth (i.e. to allow gradual decline in BMI as height increases).[10]
  • Obesity: goal is often weight loss. Most children and adolescents with obesity will require multicomponent (dietary, physical activity, behavioural), prescriptive advice to promote a decrease in energy intake.

These recommendations are dependent on the situation and the child’s individual factors. Clinical judgment is also required when recommending weight maintenance or weight loss.

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).

The components of successful clinical treatment and management include[5]:

  • Clinical assessment.
  • Behaviour change strategies (e.g. motivational interviewing).
  • Active parental involvement – “family-based”.
  • Multi-component lifestyle interventions (e.g. diet, physical activity, sleep, screen time).

Clinical Assessment

Relevant history in the context of weight assessment includes developmental history, physical and mental health, and current health behaviours. It is also important to complete a clinical assessment to identify any concerns or potential causes for overweight and obesity and comorbidities.[25] [29]

Additionally, a feeding and sensory assessment should be undertaken and if sensory-motor issues are identified a referral to appropriate services (e.g. speech pathology, occupational therapy or feeding clinic/services) completed.

All of these factors will provide background and information that can be used to form an achievable treatment plan.[25]

Ask and Assess

  • Conduct clinical, developmental, psychosocial and behavioural assessment**
  • Regularly monitor growth by measuring height, weight and BMI using age and sex appropriate percentile charts. (weight-for-age, height/length-for-age, and BMI-for-age).

Advise and Assist

  • Discuss overall assessment and child’s growth pattern with the family (using growth charts) and discuss weight in a non-judgmental, sensitive manner.
  • Recommend family to also keep child’s growth record.

Arrange and Ask Again

  • Refer to local allied health/healthy lifestyle programs.
  • Refer to hospital and specialist services if indicated: e.g. severe BMI classification; and/or comorbidity; and/or suspicion of genetic or secondary obesity.
  • Ask family for frequent follow-up appointments for monitoring and support.

**This may include assessment of the following[25]:

  • Developmental History: pregnancy and birth history (including birth weight, maternal GDM); infant growth and development milestones; early feeding practices.
  • Physical: growth patterns.
  • Family history: e.g. Type 2 diabetes, hypertension, polycystic ovarian syndrome, dyslipidaemia
  • Psychosocial: bullying, school problems; depression and mental health history (e.g. child and parents, including
    parenting stress and mood).
  • Health behaviours: diet history; diet behaviours; sleep routine; physical activity; and family ability to implement changes (e.g. parenting style and behaviour), attempted lifestyle changes.
  • Medical Assessment: comorbidities (including endocrine disorders, hypertension, musculoskeletal and psychological concerns); underlying causes of overweight or obesity and /or evidence of nutrient deficiency.
  • Socioeconomic and environmental history: family and living arrangements, cultural and religious practices, parental occupational status, suburb, exposure to unhealthy behaviours, trauma, and limited health literacy level.

The complexity of the clinical assessment highlights the importance of the team approach to the management of childhood overweight and obesity. If other underlying causes are identified or the child’s health issues are multi-factorial, referral to hospital and specialist services may be indicated.[10] [29]

Intervention for children and families

Encourage a family-centred approach to improving nutrition and physical activity and empower parents to be the agents of change.

Children can remain under the care of the PHC provider if they have a weight classification in the overweight range or obesity weight range with no/or minor co-morbidities.

Referral to hospital and specialist services is indicated for children with[25] [29]:

  • Severe BMI classification*; and/or
  • Co-morbidities; and/or
  • Suspected underlying medical or endocrine cause.

Ask and Assess

  • Ask about previous lifestyle interventions.
  • Assess the family’s readiness and ability to make and sustain behavioural changes.
  • Involve the whole family and emphasise the benefits to the family unit. This is especially important for separated families where a child may live in more than one household.

Advise and Assist

  • Co-design an action plan with the child and family (frame positively, focusing on healthy growth and healthy lifestyle behaviour).
  • Develop SMART goals (healthy eating, family meal behaviours, vigorous physical activity/active play, screen time, healthy sleep routine).

Arrange and Ask Again

  • Refer to local allied health/healthy lifestyle programs.
  • Refer to Growing Good Habits website.
  • Refer to hospital and specialist services if indicated.

Hospital and specialist services


MDT (e.g. Paediatrician, Endocrinologist, Dietitian, Psychologist, Physiotherapist/Exercise Physiologist, nurse).


Multi-component lifestyle interventions in combination with medical treatment.


  • Improve access to specialist care for children with co-morbidities: weight management/obesity services, specialist multi-disciplinary teams and case management.
  • Intensive medical treatment (e.g. very low calorie diet – VLCD) offered when lifestyle changes are not successful and/or when rapid weight loss is required.

Treatment options for childhood 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 be family focused and lifestyle driven. They need to involve frequent contact with a healthcare professional and this is determined by the level of support required by the family.[1] [5] [10] [25] [30-33]

Recommendations for childhood overweight and obesity treatment to ensure effective delivery of high-quality care and to achieve clinically meaningful weight loss include[30]:

  • Family-based, multicomponent behavioural therapy;
  • Integrated care model;
  • Well-trained multidisciplinary care team including medical oversight;
  • The use of evidence-based protocols; and
  • Provide >25 hours of contact with child and/or family 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 (anti-obesity agents) or very low-caloric/energy diets (VLCDs or VLEDs).[34]

When intervention including very low-caloric/energy diets (VLCDs or VLEDs) and pharmacotherapy (anti-obesity agents) and are not successful, bariatric surgery may be necessary.[34]

Education and Research


Health Professionals providing childhood services (e.g. health workers, medical, nursing, practice nurse and allied health professionals).


To upskill in best-practice prevention, treatment and management of children with overweight or obesity and their families to provide 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.


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Aboriginal Community Controlled Health Organisations
Aboriginal Medical Service
Body Mass Index
Centers for Disease Control and Prevention
Extension for Community Healthcare Outcomes
Hospital and Health Service
International Obesity Task Force
Model of Care
Non-government organisation
National Health and Medical Research Council
Primary Health Care Provider
Primary Health Networks
Paediatric Obesity Working Group
Queensland Child and Youth Clinical Network
World Health Organisation

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Last updated 8 March 2023