A novel, culturally appropriate approach to weight management in Aboriginal and Torres Strait Islander people

Programmed medical yarn ups can reduce Aboriginal and Torres Strait Islander peoples’ weight by meeting individual patients’ needs in a supportive group setting

In 2017, the Australian Bureau of Statistics1 reported that 69% of Indigenous adults are overweight or obese compared with 63% of the broader community. Of the Aboriginal and Torres Strait Islander population, 29% are overweight and 40% are obese. This compares with 36% overweight and 28% obese in the broader Australian community.2,3 Obesity is the second highest contributor to disease burden after tobacco use among Aboriginal and Torres Strait Islander people.2,3 Being overweight or obese, being physically inactive and consuming a diet low in fruit and vegetables has been shown to contribute 16%, 12% and 5%, respectively, to the overall health gap observed between Aboriginal and Torres Strait Islander people and the broader Australian community.3

The reason for the rise in overweight and obesity throughout the world, as well as in the Aboriginal and Torres Strait Islander community, is very simple in principle — more energy is taken into the body than is expended. The causes and determinants of this principle, however, are far more complex.

Lower socio-economic status has been consistently one of the main enablers of obesity.4 Mediators include the relatively low price and ready availability of high energy, dense foods and poorer access to fresh nutritious food for people who live remotely;3,5 labour-saving devices; and the rise in consumerism and free market-based economies.6 For indigenous populations around the world, there are also shared experiences of psychological distress from meaninglessness, alienation and loss of culture that are considered to be determinants of overweight and obesity and chronic disease.7

The financial cost

Direct financial costs to the community were calculated in 2005 to be as much as $21.0 billion annually; when government subsidies and welfare were also considered, the total increased to $56.6 billion per year.8 If the cost of overweight and obesity in Aboriginal and Torres Strait Islander people is approximated at 2.8% of the population2 multiplied by 1.47 (the higher rate of health expenditure for Indigenous people),9 then $2.3 billion was being spent each year in 2005 currency. In 2018 currency, the dollar equivalent could be as high as $3.1 billion.

What makes a successful weight loss program

Individual health practitioners are generally not able to alter the socio-political and socio-economic factors that are considered to be significant drivers in the rise in overweight and obesity,6 nor are they in charge of national health promotion campaigns. However, they can offer or refer to treatments and programs that have the potential to help overweight and obese patients and communities. To be successful, programs for Aboriginal and Torres Strait Islander people must be culturally acceptable, conveniently located, easily incorporated into the daily schedule and show goal attainment that is realistic and appropriate.10 These programs appear to be even more effective when they are run by locally identified Aboriginal and Torres Strait Islander health services and people.5,11

Shared medical appointments

Shared medical appointments (SMAs), also known as group visits, are defined as a series of individual consultations, sequentially attending to each patient’s unique medical needs in a supportive group setting where all can listen, interact and learn.12,13 SMAs have been shown to increase efficiencies and patient outcomes as well as improve provider and patient satisfaction over traditional one-on-one consultations.12,14

We have completed and reported on a trial of SMAs in Aboriginal and Torres Strait Islander men.15 The result has seen the development of a culturally acceptable and safe process to deliver health care generally, as well as a mechanism to deliver specific health programs to Aboriginal and Torres Strait Islander people.

Shared medical appointments for Aboriginal and Torres Strait Islander people

The SMA process has been given the name “medical yarn ups” (MYUs) by Aboriginal and Torres Strait Islander participants. The process involves a single-gendered group of up to 12 men or women managed by an Aboriginal or Torres Strait Islander coordinator and a trained SMA facilitator (ultimately, after training these would be the same person), consulting with a health professional such as a general practitioner, nurse practitioner and or Aboriginal health worker.

A feature of the SMA is that each member of the group has a one-on-one consultation with the health professional, but with all other group members listening and interacting. A facilitator manages the consultation flow and group dynamics. The facilitator can also deliver essential information and education in collaboration with, or in the absence of, the health provider.15

MYUs offer a culturally sustainable model not only for the delivery of health care generally to Aboriginal and Torres Strait Islander people but also for the delivery of specific programs such as weight control and smoking cessation. These specific programs are called “programmed medical yarn ups” (PMYUs).

We have defined PMYUs as a sequence of SMAs in a semi-structured form providing discrete educational input relating to a specific topic.13 PMYUs allow for a set number of SMAs (eg, six) within an extended time period (eg, 3 months) using a doctor in some sessions but run by a facilitator with extra training in a specific chronic disease area.

PMYUs provide a novel opportunity for managing chronic diseases with structured educational input. The programs are developed by experts in the field in an attempt to provide a rigorous evidence-based standard. Programs can then be customised to meet local community needs. The programs come with appropriate learning materials, handouts, exercises, activities and data collection tools. The facilitator (an Aboriginal or Torres Strait Islander health worker, practice nurse or allied health professional) trained in the specific topic runs the educational program and manages the individual consultations with a doctor as per the SMA model.

Weight control

PMYUs in weight control are led by a trained Aboriginal or Torres Strait Islander health worker (or equivalent) facilitator. The PMYU weight control facilitator leads and manages a group of six to 12 participants, who attend six 90-minute sessions, in a convenient location, every 2 weeks for 2–3 months. Each session may be attended by a GP (or other health professional) associated with Aboriginal and Torres Strait Islander people’s health.

Facilitators are trained to deliver a specific weight control program as well as to guide each participant to consult with the GP about aspects of their health related to weight control, their comorbidities and future health. The GP’s presence is generally limited to about 30–60 minutes of the session. The facilitator ensures the programmed weight control session is delivered by the end of the time allocated.

The weight control program that we use is based on Gut Busters, which has been used in Aboriginal and Torres Strait Islander people’s communities since the 1990s and which was reported to have produced sustained weight and waist circumference reductions of > 5% and 4 cm, respectively, in those communities for at least 4 years.11

This delivery method is then repeated for the remaining sessions. Once trained, facilitators not only facilitate ongoing Indigenous and non-Indigenous weight control programs but also have the skills to facilitate SMAs more generally and to deliver other PMYU programs (Box).

PMYUs represent an innovative approach to chronic disease management as a procedure in lifestyle medicine. The model is available to all primary care centres and can be selectively used as an adjunct process for appropriate chronic ailments.

Although in their early development in Australia, PMYUs in weight control (and other chronic disease areas of need) appear to offer what the Aboriginal and Torres Strait Islander Health Performance Framework2 has called for — programs that are culturally acceptable, conveniently located and easily incorporated into the daily schedule, with goal attainment that is realistic and appropriate, and led by identifiable Indigenous health services and health care providers. PMYUs continue to be trialled and more evidence is being gathered to support their utility.16