In the UK, nearly 50% of the population are either overweight or obese. Obesity, and its associated medical, psychological and social problems, brings huge demand to already stretched healthcare resources.
It is important that there is a provision of a structured and standardised specialist weight management service which is equitable and easily accessible to all. There should be a closer integration between specialist weight management services and other specialties including surgery, orthopaedics, obstetrics, gynaecology, and psychiatry in addition to other medical specialties.
Weight management service includes four tiers of services. Tier 1 (universal intervention), includes prevention and reinforcement of healthy eating and physical activity messages. Tier 2 (lifestyle intervention) involves identification and primary assessment and provision of basic lifestyle intervention. Tier 3 (specialist services) includes specialist assessment, intervention for people who have not succeeded in weight loss following Tier 1 and 2 services. Tier 4 is for patients who are worked up towards bariatric surgery, depending on their suitability.
Guidance on commissioning and delivery of an effective specialist weight management service is available in the RCP working party report, Action on Obesity: comprehensive care for all and Commissioning guide, 2014: Weight assessment and management clinics sponsored by the British Obesity and Metabolic Surgery Society.
NICE, under the topic of weight management: lifestyle services for overweight or obese adults, has provided the following recommendations:
- Adopting an integrated approach to preventing and managing obesity
- Raising awareness of weight management service issues among commissioners and local population
- Improving programme intake and adherence
- Commissioning programmes that include the core components to prevent weight regain.
Specialist weight management service or the Tier 3 service is usually a 12-week programme, with follow-up at 6 and 12 months. GPs can refer patients to this service or in some centres they are referred from the Tier 2 service. The specification and outcome of this service is usually agreed with the commissioners and varies. A multidisciplinary team including a bariatric physician, dietitian, physiotherapist, and access to a clinical psychologist is mandatory to run an effective service. As a default, most patients are seen in groups after initial assessment by a bariatric physician. However, there should be flexibility within the service to care for people who cannot attend group sessions. At the end of the programme patients are assessed for their weight loss and quality of life and a long-term plan is communicated to their GP. People who wish to seek help with surgical intervention and those found suitable are referred to Tier 4 service for further evaluation and bariatric surgery.
Public Health England Obesity’s Collection of Resources on Evaluation (CoRE) covers Obesity’s Standard Evaluation Frameworks (SEF); evaluation data collection tool (including details of local interventions) and other evaluation guidance. All Tier 3 services should ensure they are evaluated against the SEF.
Currently, there is patchy provision of weight management services in the UK and it is not standardised. In order to provide an effective weight management service, the following is recommended:
1. Training for diabetes and endocrine specialist registrars in weight management
2. Standardised training for dietitians, physiotherapists and clinical psychologists
3. Similar specification for all Tier 3 services to be commissioned
4. Evaluation of both weight and non-weight related goals
5. Evaluation of all services using the standard evaluation framework (SEF)
6. Long-term monitoring for weight loss and strategies in place to prevent weight regain.