Effective treatment pathway for obesity
Achieving this Higher Ambition will mean that:
Everyone in Suffolk and North East Essex living with obesity has access to effective evidence based treatment to enable them to live well.
As an Integrated Care System we will ensure that:
- We take a whole systems approach to the prevention of obesity
- We provide the full spectrum of weight management services that our local population needs
- People have access to effective support for obesity in their local communities
- People have access to effective local specialist weight management services
- People have access to a comprehensive pathway for bariatric surgery for obesity
- People do not experience stigma and discrimination because of their weight
According to data from the Health Survey for England for 2015, 27% of adults are obese and a further 36% are overweight, making a total of 63% either overweight or obese. Worryingly, the proportion of adults with severe obesity has increased from 1.8% in 2005 to 2.9% in 2015.
There is concern about the rise of childhood obesity and the implications of such obesity persisting into adulthood. The risk of obesity in adulthood and risk of future obesity-related ill health are greater as children get older. Studies tracking child obesity into adulthood have found that the probability of overweight and obese children becoming overweight or obese adults increases with age. The health consequences of childhood obesity include: increased blood lipids, glucose intolerance, Type 2 diabetes, hypertension, increases in liver enzymes associated with fatty liver, exacerbation of conditions such as asthma and psychological problems such as social isolation, low self-esteem, teasing and bullying.
Over the last decade, organisations around the world including the Canadian Medical Association, the American Medical Association, governments in Japan, Portugal and Scotland, and the World Health Organization – have declared obesity to be a chronic disease. This recognition of obesity as a chronic disease is more than a symbolic gesture. It confirms the need to shift away from considering obesity to be merely the result of poor lifestyle choices toward a socio-ecological model of health that carries with it an obligation to health and care systems and society to prevent and treat it as we do other chronic diseases. The Royal College of Physicians has recommended a similar approach in the UK with obesity recognised as a chronic disease, caused by health inequalities, genetic influences and social factors.
Raised BMI is a major risk factor for cardiovascular diseases (in particular heart disease and stroke), type 2 diabetes, musculoskeletal disorders, breathing problems (obstructive sleep apnoea), infertility and some cancers (including endometrial, breast, ovarian, prostate, liver, gallbladder, kidney and colon). The risk of these diseases increases, with increases in BMI. On average obesity reduces life expectancy by 6-7 years while severe obesity reduces life expectancy by 10 years. More worryingly research shows that a person aged 18-30 years with severe obesity loses 11-19 years of healthy life.
An estimated 35,820 premature deaths were attributable to obesity in England and Wales in 2014. Furthermore, the impact of rising weight on the treatment of obesity-related diseases is escalating; 44% of the diabetes burden, 23% of the ischaemic heart disease burden and up to 41% of certain cancer burdens are attributable to overweight and obesity.13 Current costs incurred to treat obesity and its related illnesses are estimated to reach approximately £56.5 billion, which translates to 3% of UK GDP. This economic burden not only comprises the necessary health resources, but the societal impact that reduced productivity, absenteeism, unemployment and shortened life e xpectancy secondary to obesity-related ill-health are having.
As well as its effects on overall health and well-being, obesity also affects people’s social and economic well- being due to the pervasive social stigma associated with it. As common as other forms of discrimination – including racism – weight bias and stigma can increase morbidity and mortality. Obesity stigma translates into significant inequities in access to employment, healthcare and education, often due to widespread negative stereotypes that persons living with obesity are lazy, unmotivated or lacking in self-discipline.
Current licensed pharmaceuticals are of limited efficacy and alternatives are needed. Non-surgical procedures using balloons to reduce stomach volume or plastic s heaths lining the gut to reduce calorie absorption, are still in clinical trial phases and are yet to prove that they are safe and effective enough as long-term strategies to be universally adopted. Targeting gut hormones to develop pharmacological means of regulating appetite and energy intake may be the key to future, less invasive treatment. More likely though, these strategies will complement bariatric surgery as part of ongoing multimodal care.
Bariatric surgery has been demonstrated to be cost effective in the long-run compared to non-surgical intervention for all categories of obesity. The initial cost for bariatric surgery is approximately £6,000 per patient. A local costing template produced by NICE estimates the financial impact of commissioning Tier 4 services to be an estimated additional costs of £48,000 for a population of 100,000. However, this should be offset with the long-term savings generated by improved health after surgery. For example, in the case of type 2 diabetes, an estimated £18.1 million could be saved in the UK over a 4-year period after surgery with the published rates of diabetes remission and lower use of diabetic medications, easily covering the initial surgery costs
Although the best way to prevent the burden of obesity is to prevent it in the first place we are still left with the dilemma of how to help the vast proportion of the population already affected by obesity.
A range of strategies, including public health campaigns, advice and information, reinforce messages about the importance of healthy eating and physical activity, and have some success as part of a whole systems approach to preventing obesity. However, health benefits from weight loss are dependent on the loss being maintained long-term. NICE has deduced that even small reductions in weight are cost-effective but only if weight regain does not occur. But sustaining weight loss, no matter how great a loss or starting point, is difficult and obese adults may attempt to lose weight many times throughout their lives. Multiple systems control food intake and body weight. Eating is necessary for survival but also driven by complex biological systems controlling the enjoyment and reward from consuming food. Genes can determine a body weight ‘set-point’, which the body will continually strive to stay at, but this may become elevated by behaviour and environmental factors. This elevation is usually very persistent. The speed of weight loss may also cause little difference in the likelihood of weight regain; both rapid and gradual weight loss with dietary interventions have led to similar levels of regain over periods up to 3 years.
Multi-component weight management programmes (WMPs), i.e. those that address both diet and exercise, have been shown to be broadly effective for reducing weight among adults with overweight or obesity. However, some programmes are more effective than others. A systematic review of WMPs commissioned by the Policy Research Programme in the Department of Health England showed that supportive relationships between service users and providers, and between services users and their weight management peers, are critical to the success of WMPs. Self-regulation and maintenance of a healthy weight depend upon individuals’ experiencing their own ability to engage in activities such as exercise, and experiencing the various benefits afforded it. Thus relationships are an essential first step in a weight management journey, since they provide a much- needed external motivator or ‘hook’ for people to engage with a WMP and to initiate healthy behaviours.
Tier 3 consists of a clinician-led multi-disciplinary team of specialists typically including a physician (Consultant Physician or GP with a specialist interest in obesity, diabetes or endocrinology), specialist dietitian, specialist nurse, psychologist or psychiatrist and exercise therapist. Tier 3 forms the first link between community and specialist care. The primary roles of Tier 3 are to delineate the cause of obesity, screen for and treat co- morbidities, and provide the treatments recommended by NICE guidance (CG189). Tier 3 clinics are not only for assessing and selecting patients for surgery. They provide an intensive lifestyle intervention important in its own right; not all patients will go on to need or want bariatric surgery after Tier 3 intervention. They offer specialist dietary, medicinal and psychological treatments with, most importantly, detailed and regular follow-up. Without this intensive support, evidence shows that non-surgical interventions alone, or in combination, are ineffective in maintaining long-term weight loss.
Many people eligible for bariatric surgery require assessment and review by a specialised clinic and to have an informed discussion about all treatment options. Tier 3 also provides the ideal forum for this and gives patients a streamlined pathway either back to the GP with a specialised long-term treatment plan or forward onto bariatric surgery.
The National Institute for Health and Care Excellence (NICE) recommend bariatric surgery as the treatment of choice instead of lifestyle interventions for adults with a BMI of more than 50 when other interventions have not been effective.
Around 2.6 million people in the UK meet NICE criteria for bariatric surgery, which are based on thresholds for BMI, obesity-related conditions and previous attempts to lose weight. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the two most commonly performed operations in the UK. Gastric banding has been shown to produce less effective outcomes and therefore performed less frequently recently. These surgeries alter the way in which nutrients pass through the gut. This in turn alters hormones and signals that come from the gut that regulate food intake and blood glucose.
National surveys of surgery in the UK have shown that bariatric surgery is safe. Hospital Episode Statistics for 2000-2008 show the 30-day mortality is 1.6 per 1000 patients, lower than many common laparoscopic operations, such as cholecystectomy.
Health benefits in almost every major organ system have been demonstrated after bariatric surgery evidenced through multiple long-term population studies and randomised-controlled trials.
- Marked weight reduction (25% total weight loss at 5 years)
- Mortality 1 in 1000, length of stay 1-2 days
- Resolution / improvement of co-morbidities – type 2 diabetes, hypertension, cardiovascular disease, liver disease, obstructive sleep, apnoea, cancer and reproductive health.
- Improved quality of life, decreased time off work
- Prevention of T2D, strokes and ischaemic heart disease
A recent report in the Lancet (2015) outlined
“Recent data from the USA suggest that 8% of patients with severe obesity (BMI ≥35 kg/m2) account for 40% of the total costs of obesity, whereas the more prevalent grade 1 obesity accounts for a third of costs.”
In Suffolk, 22.3% of reception children and 31.0% of year 6 children were overweight and obese in 2016/17 (National Child Measurement Programme). A core group of partners from the NHS, education, leisure, Public Health, local councils and the voluntary sector identified 3 key priorities: to improve children and families’ access to healthy food and drink both in and out of home; to improve access to safe environments that encourage physical activity; and to support children and young people to maintain healthy lifestyle behaviours.
Our achievements to date include
- A ten-point initial plan to focus on sugar reduction at home, in schools and in public spaces. In 2018 Suffolk’s top three school meal providers reduced their sugar content by 20%.
- Public Health Suffolk, through Suffolk Community Foundation, offers grants of up to £1,000 to support the work of voluntary, community and social enterprise organisations to support people to reduce sugar intake and develop a healthier lifestyle.
- OneLife Suffolk has developed a programme for schools which the chance to gain a Healthy Schools award. In 2017/18 they delivered 280 school programmes across 95 schools; 56% of those completing the programme were from the 40% most deprived areas.
- The Daily Mile gets children out of the classroom for 15 minutes a day to run or jog, at their own pace, with their classmates, making them fitter, healthier, and more able to concentrate in the classroom. 76 primary and nursery schools are currently registered for the Daily Mile.
- At Fit and Fed clubs, children take part in sports/games followed by a healthy and nutritious lunch. Fit and Fed started in Ipswich in Summer 2018 and in one year achieved 705 attendances. In Summer 2019,the scheme was rolled out across Suffolk.
- The ‘Eat Out Eat Well’ and ‘Take Out Eat Well’ awards encourage food businesses to reduce fats, sugar and salt and supporting customers to make healthier choices. To date over 180 awards have been made.
- The Suffolk Food Plan creates a healthier, fairer and more sustainable food system by encouraging local ownership, capitalising on community assets and encouraging innovation. The plan is being trialled in two localities and one school.
- A new breastfeeding app has been developed by Public Health and a local design team to provide support and advice for new mothers to breastfeed. The app should be ready to test in late September we hope to launch the app in October 2019.
- HENRY (Health, Exercise and Nutrition for the Really Young) is an eight-week programme for parents of infants and toddlers aged 0 to 5 years. Suffolk Council’s children’s centres has started to deliver HENRY in partnership with OneLife Suffolk.
This evidence is also supported by UK reports which shows that
“It is estimated that 23% of spending on all drugs is attributable to overweight and obesity. The minimum annual cost of any drug prescriptions at BMI 20 rose from £50.71 for men and £62.59 for women by £5.27 and £4.20, respectively, for each unit increase in BMI to a BMI of 25.3. Increases for each BMI unit were greater to BMI 30, and greater still, £8.27 (men) and £4.95 (women), to BMI 40.”
Obesity Canada’s 5As of Obesity Management program was designed as a step-by-step framework for busy non-specialists who manage obesity in their patients. The framework was developed with funding from the Public Health Agency of Canada and the Canadian Institutes of Health Research. It is based on several core principles that emerged from extensive consultations with patients, primary care providers and obesity experts:
- Obesity is a chronic and often progressive condition: Successful obesity management requires realistic and sustainable treatment strategies. Short-term “quick-fix” solutions focusing on maximizing weight loss are generally unsustainable and therefore associated with high rates of weight regain.
- Obesity management is not about simply reducing numbers on the scale: The success of obesity management should be measured in improvements in health and well-being rather than in the amount of weight lost. For many patients, even modest reductions in body weight can lead to significant improvements in health and well-being.
- Early intervention means addressing root causes and removing roadblocks: Successful obesity management requires identifying and addressing both the root causes of weight gain as well as the barriers to weight management. Weight gain may result from a reduction in metabolic rate, overeating or reduced physical activity secondary to biological, psychological or socio-economic factors. Many of these factors also pose significant barriers to weight management
- Success is different for every individual: Patients vary considerably in their readiness and capacity for weight management. Success can be defined as better quality-of-life, greater self-esteem, higher energy levels, improved overall health, prevention of further weight gain, modest (5%) weight loss or maintenance of the patient’s ‘best’ weight.
- A patient’s ‘best’ weight may never be an ‘ideal’ weight: Setting unachievable targets simply sets up patients for failure. Instead, help patients set weight targets based on the ‘best’ weight they can sustain while still enjoying their life and reaping the benefits of improved health.
The 5As tool kit provides health practitioners with five steps to better manage their patients’ weight and related health issues:
- ASK for permission to discuss weight and explore readiness
- ASSESS obesity related risks and ‘root causes’ of obesity
- ADVISE on health risks and treatment options
- AGREE on health outcomes and behavioural goals
- ASSIST in accessing appropriate resources and providers
HOW we plan to make a difference
- We will develop a whole systems approach to obesity where partners across the community and local people come together to agree a vision for working in an integrated way to achieve change. The factors that can contribute to obesity, and potentially provide solutions, include societal and cultural influences, food production and consumption, psychological and biological factors, individuals and collective activity, and environmental factors
- We will collect data on obesity prevalence and trends, and map current assets in the community that help prevent and reduce obesity. We will use this data to identify the needs of people of all ages and characteristics, areas where health inequalities are greatest. This helps to determine where we should target different resources and increase capacity.
- We will seek local people’s views on the challenges in preventing obesity and potential solutions. Together we can identify actions that individual, families, communities, businesses and the public sector can take to prevent and reduce obesity, and we can build on what works.
- We will make every contact with health, care and other public services count in helping people and families make positive changes that can prevent obesity. This includes, for example, dentists promoting healthy diets, teaching children about preventing obesity, providing healthy school meals, creating a healthy drinking culture, helping people who are socially isolated to connect and be active together, encouraging people away from sedentary lifestyles and excessive use of screens, and making sport more accessible for everyone.
- We will promote a healthy environment. The places where people live, play and work often encourage inactivity and excess calories consumption. We will work together to create healthier buildings and workplaces, for example improving air quality to encourage people to access open spaces, enabling people to travel more healthily, such as walking or cycling; improving access to healthy food in deprived areas; and encouraging food business to promote healthier food and drink choices and restrict unhealthy choices.
- We will use population health approaches to establish the degree of obesity in our local population, including motivations and attitudes towards obesity, and variations between groups and communities. We will identify the level of local need for, and potential uptake of, each Tier of the service. This will enable us to co-design and deliver services more effectively.
- We will use the NICE local costing template to estimate initial and future expenditure.
- We will explore the funds available from NHS England and allocate budgets accordingly.
- We will explore what services are already available in the region and nationally. Many Tier 2 and exercise referral services are well-established and funded. These may contribute to a specialist Tier 3 weight management service with the additional input of a Consultant Physician or GP with a specialist interest in obesity. Using this learning we will be creative to adapt or use existing services such as the NHS Diabetes Prevention Programme, Diabetes UK support groups and events, postcancer care pathways (treatment summaries, holistic needs assessments, joint patient-doctor derived care plans). A useful resource is the ASO UK Adult Centres for Obesity Management network
- We will evaluate models for effective commissioning of Tier 3 and Tier 4 services, and work with acute providers to commission effective services, ensuring appropriate pathways into bariatric surgery, enough theatre time and effective after-care with at least 2 years follow-up.
- We will implement effective monitoring and evaluation of services, such as the National Obesity Observatory (NOO) Standard Evaluation Framework and report outcomes to the National Bariatric Service Registry (NBSR).
- We will liaise with other CCG regions to explore existing commissioning policies and shared needs with regions of similar population demographics. This will be advantageous in achieving the economies of scale, sharing limited specialist resources and adhering to the IFSO guidelines for safety, quality and excellence in bariatric surgery
- We will produce local primary care guidance to include how to raise the issue of obesity with patients, what the local referral pathways are and what is required from GPs post-surgery.
- Community pharmacists will extend their support people with information, advice and evidence based products to help them achieve and maintain a healthy weight. This includes building on the successes of Healthy Living Pharmacies.
- People will be given advice to help maintain a healthy at every contact with health and care services. Making every contact count helps people to obtain the help and encouragement they need to achieve a healthy weight.
- We will improve access to wellbeing support including mindfulness, through for example apps online, individual support, and classes at school. Positive wellbeing is a key factor in weight loss and maintaining a healthy lifestyle.
- We will encourage employers to champion healthy weight for their employees. Healthy weight ambassadors in the workplace can support colleagues to achieve and maintain healthy weight.
- We will enable access to digital-based weight management support for adults, and possible extension to children and families. Making best use of technology widens access to information and advice to help people monitor and manage their weight.
- We will encourage and support innovation and best practice in weight management and weight loss within communities, such as Sports England initiatives.
- We will identify a champion for obesity care. This may include a clinical champion such as the lead physician for a Tier 3 service, and a commissioning champion who can oversee policy development and co-ordination of local services.
- We will improve access to social prescribing to support weight loss and weight management interventions at Tier 1 and 2.
- We will raise awareness of, and improve access to, weight management services in primary care for people with a diagnosis of type 2 diabetes or hypertension with a BMI of 30+ (adjusted appropriately for ethnicity). Integrated weight management programmes provide support for both mental and physical health.
- For children with obesity and their families, programmes will be designed and delivered in an age-appropriate way, adaptable to people with physical or mental health conditions or learning difficulties. Programmes will incorporate nutrition, activity and behavioural change, and support parents who may not recognise their children are overweight or obese. Children are reliant on their families to provide nutritional food and access to activities, and to adopt the right behaviours and lifestyle to maintain good health, so a whole-family approach is needed.
- Effective treatment will be provided for the physical and mental health complications of obesity in both children and adults. Complications can include such as diabetes, cardiovascular conditions, sleep apnoea and poor mental health. Treating these early prevents more invasive treatments later on
- We will ensure people have access to a comprehensive pathway for bariatric surgery in accordance with NICE guidance and NHS England commissioning guidance. Bariatric surgery can restore good-health as well as lead to cost-savings for the NHS in the long-term and, as scientific studies have shown, the procedure is particularly beneficial for patients who also have diabetes.
- People eligible for bariatric surgery will have full information, guidance and integrated physical and mental health throughout their care and treatment pathway. Integrated personalised care, and choice and control in decision-making and planning, will help ensure people can manage their treatment and the lifelong impacts more effectively.
- We will ensure equality of access to obesity treatments at Tier 3 and 4 including surgery. Improved access can be achieved for example by ensuring referrals are made for all those who may be eligible, and addressing variation between communities and for people with protected characteristics. Access to NHS bariatric surgical treatment should be based on clinical need, and thresholds for services should be applied fairly and consistently.