NHD Issue 148 - Weight management services and obesity by Alice Fletcher

COVER STORY

WEIGHT MANAGEMENT SERVICES AND OBESITY Worldwide obesity has nearly tripled since 1975 and the provision of NHS weight management (WM) services is likely to increase secondary to this. This article looks at the current provision of WM services in the UK and what is offered to patients in practice.

ATTITUDES TO OBESITY

Nike recently displayed an obese mannequin in its London store, wearing sportswear. On the 6th June, The Telegraph published an article by Tanya Bold, which caused a stir within the media.3 Titled Obese mannequins are selling women a dangerous lie, the article argued that 'the fat-acceptance movement, which says that any weight is healthy if it is yours, is no friend to women, even if it does seem to have found a friend in Nike. It may, instead, kill them, and that is rather worse than feeling sad'. Tanya Bold argues in the article that 'fat should not be a slur, but a warning'. Within newspapers, others (including Dr Nikki Stamp, cardiothoracic surgeon) have praised Nike for using an obese mannequin to showcase its clothing, arguing that it encourages people of all sizes to be more physically active, which cannot be a bad thing.4 A recent Cancer Research campaign aiming to increase awareness of the link between obesity and cancer,5 has also drawn criticism within the media, with many arguing that obesity should not be compared to smoking. Natasha Devon, writer and mental health activist, reported in the newspaper Metro, that 'Cancer Research’s obesity campaign isn’t just misguided - it’s dangerous', arguing that 'body shape and size is around 70% heritable - largely governed by genetics and hormones'. The article continues: 'These billboards - based on questionable assumptions - will serve only to make people ashamed of their bodies, which does nothing to improve their ability to

change their habits.'6 Although obesity is more complex than smoking, the link between obesity and cancer is well established, with more than 1 in 20 cancer cases found to be caused by excess weight.7 Like or loath this campaign, one thing is for sure; it has got people talking about obesity and cancer.

Obese people have been found to be stigmatised by healthcare professionals.

A study from 1987, which included 318 general practitioners, found a notable number of respondents held negative or stereotypical attitudes toward obese patients (ie, obese patients lack selfcontrol, are lazy and sad).8 This was mirrored in an American study from 2003, based upon a confidential and anonymous questionnaire sent to family practice physicians. Shockingly, of the 620 respondents, more than 50% viewed obese patients as awkward, unattractive, ugly and noncompliant.9 In regard to dietitians, a UK-based survey found overall neutral to positive attitudes towards overweight and obesity, but it did suggest that obesity was viewed less favourably to overweight.10

Alice Fletcher RD Countess of Chester NHS Foundation Trust (Community Dietitian) Alice has been a Registered Dietitian for five years, working within NHS community-based teams. She is passionate about evidence-based nutrition, cooking and dispelling diet myths.

REFERENCES Please visit the Subscriber zone at NHDmag.com

MORE THAN JUST CALORIES

Obesity is a very complex issue, as outlined extensively within the Foresight report of 2007.11 It is easy to get stuck on ‘calories in vs calories out’. Research has clearly demonstrated that some people have a greater genetic tendency to obesity than others.12 In experimental overfeeding between sets of identical twins, it has been shown that wide variation exists in the amount of weight gained, despite an www.NHDmag.com October 2019 - Issue 148

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This material is for healthcare professionals only

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References: 1. Dupont C et al. Br J Nutr 2012; 107:325–338. 2. Lothe L et al. Pediatrics 1989; 83:262–266. 3. Baldassarre ME et al. J Pediatr 2010; 156:397–401.

4. Nermes M et al. Clin Exp Allergy 2011; 41:370–377. 5. Canani RB et al. J Pediatr 2013; 163:771–777. 6. Canani RB et al. J Allergy Clin Immunol 2017; 139:1906–1913.

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COVER STORY Figure 1: The UK Obesity Care Pathway15

equivalent feeding of excess calories. Interestingly, contrary to what many may believe, discussing specific genetic predisposition to obesity (FTO gene) has been shown to make patients more determined to lose weight rather than less so.13,14 OVERVIEW OF UK WEIGHT MANAGEMENT (WM) SERVICES

While definitions vary locally, the obesity pathway consists of four tiers and, typically, Tier 1 covers universal services, Tier 2 covers lifestyle WM services, Tier 3 covers specialist multidisciplinary team WM services and Tier 4 covers bariatric surgery (see Figure 1).15 Tier 3 consists of a clinician-led multidisciplinary team of specialists, typically including a physician (consultant physician or GP with a specialist interest in obesity), specialist dietitian, specialist nurse, psychologist or psychiatrist and exercise therapist. Tier 3 forms the first link between community and specialist care, referring service users into Tier 4 services if appropriate. The same team members may be involved in Tiers 2-4.

PROVISION OF SERVICES

Public Health England has mapped the available Tier 2 and 3 services for adults across the UK,16 finding that the majority of Tier 2 services for adults were commissioned by local authorities and were delivered in community, leisure, or school settings. Two-thirds of services were multi-component and most were delivered over 12 weeks in predominantly group sessions. Most

respondents reported a minimum eligibility criteria of BMI>30, and the most popular referral routes were through GPs, practice nurses and/or other healthcare professionals and self-referral.

In the majority of reported services, average costs were less than, or equal to, ÂŁ100 per participant. However, the response rate for Tier 3 adult WM services was poor and the results are not reflective of all services available across England.16 The majority of respondents reported that Tier 3 WM services were commissioned by local authorities, and most followed up participants for 12 months or more. An observation based on respondent feedback was an inconsistency in the reporting of outcomes for WM services. This shows that outcome measures are ever more important in the commissioning of new services we need to show our worth!16 WEIGHT MANAGEMENT IN PRACTICE

Table 1 consists of practicalities that may not always be considered when setting up a new WM service. Before we even begin to assess patients, we need to make sure that they are able to access the clinic without untoward inconvenience and the clinic itself is as inviting as possible.

Assessment Assessment is the foundation of good obesity management and forms the essential first step in dietetic intervention. Without comprehensive understanding of what has contributed to the www.NHDmag.com October 2019 - Issue 148

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COVER STORY Table 1: Practical considerations when setting up a WM clinic17 Seating

Adequate numbers of large chairs with armrests, or regular chairs without arm rests and with sufficient space between chairs to allow easy movement.

Consultation seating arrangement that avoids the practitioner seated behind a desk.

Access

Consider the location and size of clinical rooms and the impact this may have on access for those with mobility issues.

Scales

Scales with a wide base that weigh more than 200kg located in a private area and consider how wheelchair users will be weighed.

Reading material

Magazines and literature with appropriate healthy lifestyle information and if possible positive images of larger people.

Temperature control

The use of portable fans in waiting areas and consultation rooms to maintain ambient temperature.

Telephones/interruption from other staff

Interruptions during consultations to be minimised where possible.

Fluids

Provision of drinking water where possible.

Table 2: Essential information to gather as part of dietetic assessment Essential information to gather as part of dietetic assessment ⇒ The story so far, what led up to the referral, this is an opportunity for the patient to tell their story and to feel heard and understood. ⇒ Understanding patients’ thoughts on referral.

⇒ Expectations of treatment – what they hope to gain from intervention. ⇒ Motivation to change lifestyle.

⇒ Weight history – including age of onset and family history of obesity.

⇒ Dieting history – what has been tried before. ⇒ Patients understanding of obesity and why their weight has increased. ⇒ Potential barriers to change.

⇒ Eating patterns – regular/erratic/binge eating/ only eating in private. ⇒ Current lifestyle: dietary intake and physical activity. ⇒ Support networks – family and friends.

⇒ Reward systems/strategies used to reinforce new behaviours.

The patients perceived importance of changing their behaviour and losing weight.

The patient’s confidence in their self to achieve weight loss through behaviour change.

Clinical information to gather: (This may be collected by the dietitian or the medical team.)

Ensure that the reasons for these tests are fully explained and consent is gained, as per NICE guidance.28 Measures to assess risk: - BMI - Waist circumference - Blood pressure - Fasting blood glucose/HbA1c - Fasting lipid profile - Thyroid function History: - Medical history (physical and psychological) including binge eating/other eating disorders - Medications/pharmacotherapy - Ethnicity - Family history of T2DM, CHD, stroke, endocrine disorders - History of gestational diabetes - History of infertility, PCOS, hirsutism - Contraception history - Smoking - Alcohol use Blood & Urine Tests: - Full blood count, folic acid, B12 - Vitamin D - LFT for non-alcoholic fatty liver disease (NASH) - HbA1c/glucose tolerance test if appropriate - Microalbuminuria if indicated - Hormone profile if indicated - Sleep studies, ECG or other tests as indicated

development of the patient’s obesity, how this impacts upon their life and the factors that influence changing eating and activity behaviours, it is impossible to tailor dietetic interventions to meet the needs of the individual.

Much of what has been written about assessment in obesity, focuses on the evaluation of medical risk and the classification of excess weight and body fat distribution through BMI and waist 14

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circumference measurements. Although these are clearly important areas to consider, they are only a small aspect of dietetic care and have little influence on understanding the patient’s current lifestyle and the approaches most likely to be helpful in altering eating and activity behaviours. It may be valuable for initial appointments to have more allocated time than subsequent ones, to allow all of this information (Table 2) to be gathered in detail.

COVER STORY Aims/ goals of intervention • The priority in WM should be to reduce risk factors for the service user, rather than to return them to an ‘ideal’ or healthy weight range.

• Very small degrees of weight loss produce health benefits, but significant changes result after a loss of 5-10%.18 • The aims should be led by the patient.

The opinion that when people lose large amounts of weight quickly, they will be less able to maintain their new weight in the longer term (and ‘slow and steady wins the race’) is outdated.19,20 • When setting goals it is important to make them SMART: specific, measurable, achievable, relevant and time specific.

• Clarifying the details of what has been agreed between the patient and dietitian by writing down the goal and how it is going to be achieved can be helpful in strengthening commitment, self-efficacy and understanding.

• Specifically working with patients on two or three goals at a time, waiting until these have been achieved before renegotiating on the next stages, can be important to gradually building up the patient’s confidence in their ability to achieve small behavioural goals.21,22 Frequency of follow up: • A recent review of behavioural WM programmes found that contact with a dietitian was one of the key predictors of success, and regular support from healthcare professionals is recognised as a central feature of obesity management.23,24 • The optimal frequency of contact remains unknown, with a recent review (2014) failing to find more frequent contact to predict more effective outcomes.25 • Behavioural WM programmes commonly have treatment durations of 8-12 sessions/ weeks, although debate continues about the potential value of extending beyond this minimum time.26,27 • In a recent study of primary care referrals to a UK commercial programme, an extended 52-week treatment produced greater initial

weight loss and clinical benefits together with less weight regain at two years compared with the brief intervention and the standard 12-week treatment.27 Despite the increased costs of delivering this longer programme, modelling suggested it would prove cost effective over the longer term.

Continuity of care – is this important?

• Services may employ several dietitians within the team; patients may not always be able to see the same person for each review.

• There is a lack of research exploring the importance of the same practitioner being involved in someone’s care in regard to obesity management outcomes.

• NICE guidance recommends continuity of care via meticulous record keeping, which is not suggestive of the same practitioner seeing the same patient consistently.28 • Qualitative research investigating the value of personal continuity in the GP relationship suggests that continuity may enhance trust,29 enablement30 and satisfaction on the part of the patient.31 Through good background knowledge of the patient, the GP can improve quality of care and their job satisfaction.32 • Given the above, it does appear pertinent to strive for consistency within the dietitian and patient pathway wherever possible.

DOES IT HAVE TO BE A DIETITIAN? UTILISING THE WIDER TEAM

Within the NHS Trust I work for, we utilise dietetic assistants (Band 4) to deliver our WM group education and support drop-in sessions, with the one-to-one assessments detailed above undertaken by specialist dietitians. Utilising the wider team may be particularly important during weight patient’s maintenance phase, which is vital for overall success. If capacity within the team is unable to support patients with weight maintenance, drawing on other healthcare professional services, appropriate commercial WM programmes, or encouraging more peer/ family support, may be required.

For further reading visit: www.NHDmag.com/references. www.NHDmag.com October 2019 - Issue 148

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