Obesity: A weighty problem for the NHS

The Health Survey for England Report published in 2012, showed that in 2010, obesity rates rose again to 26 per cent of women and 26 per cent of men aged 16 or over classified as obese (BMI > 30kg/m2). In total 58 per cent of women and 68 per cent of men were classified as either overweight (BMI 25-30kg/m2) or obese. This suggests that the majority of the population are more likely to have a weight problem than be of a healthy weight.

The National Child Measurement Programme (NCMP) for 2010/11 showed 1 in 4 (23.1 per cent) children aged 4-5 years, and over 1 in 3 (33.4 per cent) children aged 10-11 years, are overweight. This is of concern, not just because of the immediate risks to health for these children, but also because evidence suggests that obese children have a high risk of becoming obese adults. The NCMP should begin at an earlier age, and measurements taken every year.

Causes of obesity
Foresight highlights over 100 different factors involved in why we, as individuals or as a society, may be obese and getting bigger. Therefore, unless we tackle all of these different factors, we will not solve this problem, and this will require planning and resources.

Critics often suggest that treating obesity, especially in an obesogenic environment, is a waste of time, as any weight loss will return.

However, obesity is a chronic relapsing condition, and whether it is due to genetics, learned behaviour, our society, or a mix, we have to accept some people may have a predisposition to weight regain. However, morbidity and mortality is dependant on weight at any given time, and those who have undertaken weight loss programmes will be at a lower weight at any given time than those who have not, even if their weight slowly creeps back on, and therefore at lower risks of comorbidities. Obesity is associated with causing, or aggravating, over 50 common medical conditions, including important life‑threatening conditions such as diabetes and cardiovascular disease, obstructive sleep apnoea and other respiratory conditions, and many cancers. Rather than treat the consequences of these conditions we should focus our attention on dealing with the cause.

Prevention or Treatment
Common sense would suggest a need to focus on prevention; however the evidence base for effective preventative measures just does not exist. The discussion as to whether we need a ‘nanny state’ or ‘nudge’ tactics is a good one. A ‘nudge’ towards healthy behaviour can be very effective, eg, an attractive staircase in your field of view may entice you away from seeking a lift or escalator. Our obesogenic environment can be changed but requires the will, suitable planning, and sufficient resources.

The fat tax
A proposed 20 per cent fat tax will not cure the obesity problem. It makes no sense to tax fat in isolation, ignoring other food groups such as sugar. There is no such thing as a bad food is true in this context, as you can eat high fat/sugar foods on occasion as part of a nutritionally balanced calorie controlled diet. Any tax on food will therefore penalise the poor and discriminate against those of normal weight. It may not even have the desired effect of changing eating patterns, eg, if craving a chocolate bar, a patient would pay a subsidy possibly greater than 20 per cent at a vending machine. Ultimately it does not educate the patient on healthy eating or lifestyle change. Because there is no such thing as a bad food, manay weight management clinics do not propose a specific ‘diet’ that many patient find it difficult to adhere to. Instead they focus on small, achievable, and more importantly sustainable changes in the existing diet that has the overall effect of reducing calorie consumption and overall health improvements.

Healthy food subsidies: A subsidy on healthy foods, such as fruit and vegetables, may help promote ‘5-a-day’. However, without education this could result in additional calorie consumption. Studies, eg, Interheart, show that abdominal obesity is a more important modifiable risk factor for myocardial infarction that diet, and so over-consumption of even ‘healthy’ foods may be harmful.

Limiting take-aways: A meal from a take‑away, or Quick Service Restaurant (QSR) can be eaten as part of a nutritionally balanced calorie controlled diet. The important factor for local authorities will be to ensure that sufficient choice is available, to allow the consumer a ‘healthy’ alternative, and not, for example, place a row of QSRs outside a school.

Portion size limits and calorie information: A sensible proposal would be to restrict portion sizes served by QSRs (Quick Service Restaurants) as recently proposed in New York, and to further encourage calorie information on menus.

Advertising: This could be limited to avoid any unnecessary and inappropriate targeting of children, and used for health promotion education.

Food labels: The controversy over different food labelling system is unhelpful. For weight management, the calorie content is most important. We should ensure that calorie content is displayed in large print on the front of labels, and perhaps a combination of GDA/traffic light nutritional information available, wherever possible, elsewhere on packaging. 

Cooking skills: As Jamie Oliver demonstrated in Rotherham, in his ‘Ministry of Food’ television programme, there are many people that do not have basic cooking skills, such as being able to boil an egg. It is futile for weight management service providers to educate on the benefits of cooking from raw ingredients if patients then go home without the skills. It is important that all weight management services work in partnership with teams that can deliver cooking skills.

Education in schools: The core curriculum should have lessons on health and wellbeing that include education on obesity, its importance, effects on the body and consequences, social impact etc as well as teaching of correct portion sizes, knowledge about calories and the Eat Well plate, cooking, benefits of physical activity and knowledge of local services available etc

This should form part of weight management programmes despite the body of evidence suggesting that it has little effectiveness as a weight loss intervention. There is evidence for physical activity being beneficial for weight maintenance. Furthermore, we want to aim for a healthy weight in order to improve health, and as part of that we should encourage physical activity as part of the lifelong behaviour change to promote the cardiovascular benefits. Previous and on-going studies by The Early Bird Diabetes organisation have cast doubt on whether additional compulsory physical activity in the school setting will result in increased physical levels.

Use of the word obesity
Recent debate has surrounded the use of the word obesity. It is true that in certain circumstances, referring to a patient ‘not being at a healthy weight’ may be preferable, we must not lose sight of the fact that the word obesity carries important beneficial connotations, eg, one of my own clinic patients insisted they did not have to worry about their child’s weight because their NCMP letter said he was only ‘very overweight’ and not ‘obese’. She understood the importance of obesity, and would ask for help if ‘Little Johnny’ was obese but he was not. It took some time to explain that very overweight’ was a politically correct way of saying that he was in fact obese.

The health-economic argument
Health-economic data suggests that focussing all of our resources on prevention may not be the most cost-effective. There is no evidence currently available to suggest that preventative measures work, and Foresight proposed that the cost of a preventative intervention may be as costly as doing nothing. However, we do have evidence that treatment interventions work, and that this does convey health‑economic benefits. Furthermore, we should consider obesity management as secondary prevention, as we do with cardiovascular disease. In this sense the management of the obese prevents further obesity, morbid obesity, and the super-obese, and so on.

This management should be done in the primary care setting. Incentivising GPs to focus attention on obesity is achievable through the existing Quality and Outcome Framework (QOF), which represents the performance related pay element to a GP’s income. At present the only QOF indicator that directly targets obesity rewards GPs for registering the number of obese people that they see. Merely drawing a register will not prevent a single overweight person from developing type-2 diabetes or a single obese person from having a heart attack.

In addition to QOF incentives in primary care, there needs to be investment in structured frameworks, to help provide local areas with integrated interventions at all levels, such as the award-winning NHS Rotherham Healthy Weights Framework. This investment needs to be long-term (10 years+) rather than in the form of short-term commissions to providers, which currently inhibits service development. Albeit based on crude extrapolation of costs for the NHS Rotherham framework, similar services could be developed to cover the UK for an estimated £240m per year (considerably less than the anticipated direct and indirect costs of obesity).

The NHS Rotherham Obesity Strategy
In 2008, NHS Rotherham made £3.5m available to fund their obesity strategy for a 3 year period. NHS Rotherham’s Healthy Weight Framework proceeded to win the 2009 NHS Health and Social Care Award. Since this time, and despite financial pressures on the NHS, funding has been made available to continue the services, based on proven success and the health-economic argument that it will save more money in the long-run. Total cost for all interventions is currently £1m per year for the population of Rotherham which is approximately 253K.

The NHS Rotherham Obesity Strategy for the management of healthy weight in adults and children involves 4 tiers of intervention. The initial level of intervention is the activity most often done in the primary care setting, which involves identifying those patients that have weight problems, and who are motivated to change, especially those with medical conditions that are likely to worsen with increased weight. It is important to clarify that this primary activity, and any associated health promotion advice, can be delivered by any healthcare professional from primary or secondary care, or in the pharmacy, council, leisure services, or private sector.

The 2nd tier of intervention is a community based, time limited, weight management programme of diet, nutrition, lifestyle and exercise advice delivered by trained staff. For adults this is the Reshape Rotherham programme delivered by the Rotherham dietetics department, and for children this is the More Life (formerly Carnegie) Clubs programme delivered by DC Leisure. Patients can be referred, or self-refer, to these services.

Those patients who do not meet their healthy weight targets in this level of intervention, or those who are considered to be more at risk of comorbidities and/or require more specialist intervention, are referred into the 3rd tier, which is the specialist service delivered by the Rotherham Institute for Obesity (RIO).

The Rotherham Institute for Obesity (RIO)
RIO is the specialist tier of intervention for adults and children with weight management problems, as part of the overall NHS Rotherham Healthy Weights Framework. It has a multidisciplinary team approach to managing weight problems by providing specialists that can provide different approaches. This includes Health Trainers, dedicated Obesity Specialist Nurses (OSNs), Healthcare Assistants (HCAs), Dietetics input for complex dietary needs, “Rotherham Cook & Eat” skills education, Talking Therapies including psychological input, Exercise Therapists, group work for exercise, therapies and nutritional advice, and a General Practitioner with a Specialist Interest in Obesity (GPwSI) for any medication issues.

Patients’ referrals are initially triaged to assess which, if not all, of the services offered by RIO are required. In all cases, blood pressure, weight, height, BMI, and fat composition using bio-impedence scales, are recorded. Increased risk associated with South Asian origin is taken into account. If no recent blood tests have been performed these are requested in order to exclude previously undiagnosed metabolic conditions, eg, diabetes and pre-diabetic states, hypothyroidism etc.

All patients receive further basic dietary and nutritional advice as well as lifestyle and exercise therapy and education throughout the length of time they are in the service. This may include further explanation of the specific roles of calories, portion sizes and nights off the diet, or education on basic cooking skills in order to complement nutritional advice given (provided in on-site kitchen facilities). Talking Therapists are proficient in techniques such as Cognitive Behavioural Therapy (CBT), Neuro Linguistic Programming (NLP),

Emotional Freedom Techniques (EFT), and Hypnotherapy. Patients are seen by the GPwSI (GP with Specialist Interest) if there is need for a review of current medications that may have more weight-friendly alternatives, or for the prescribing of weight loss pharmacotherapy. Consultations are performed on a one‑to‑one basis in dedicated consulting rooms, although group work is available.

Meal Replacement Systems and Very Low Calorie Diets (VLCDs) are not funded by NHS Rotherham, but RIO does educate individuals on their benefits and when appropriate they are recommended. RIO patients benefit from a subsidy offered directly by commercial sector providers.

Appointments can be made with one of two exercise therapists, who provide tailored programmes in on-site gym facilities. Patients are offered a minimum of six sessions with one of the exercise therapists, during which time the aim is to educate and motivate the individuals. Patients are then encouraged to engage with free and subsidised local leisure facilities that have been arranged through partnerships with RIO.

Further facilities within the Institute include a dedicated meeting room which allows for educational meetings, for patients and/or healthcare professionals. This room provides a resource library with computer terminals, books/journals and educational tools, as well as additional “exer-gaming” facilities (ie, gaming systems that encourage physical activity, such as the Wii-Fit). RIO is already very well established as a centre for education and research, with links to several academic institutions, and is currently conducting several studies.

All NHS Rotherham patients meeting local Specialist Commissioning Group criteria for NHS funding of (tier 4) bariatric surgery are encouraged to come through the RIO service. RIO has demonstrated a reduction in inappropriate referrals to surgical centres, and a 50 per cent reduction in the numbers needing referral for bariatric surgery (compared to anticipated numbers), suggesting considerable financial savings. Similarly, RIO works with the morbidly obese children (and parents) who may request attendance at the (tier 4) residential weight management camps.

RIO has recently become the first centre in the UK, based in primary care, which is routinely screening for Obstructive Sleep Apnoea (OSA) in high risk populations, incorporating the use of overnight oximetry. It is the long-term plan for this centre to offer a more cost-effective, and primary care based, sleep service. RIO is currently developing facilities to become the first centre in the UK, to offer endoscopic surgical procedures, such as the bariatric intra-gastric balloons (and possibly endobarriers), in the primary care setting.

Further information
www.rotherhaminstituteforobesity.co.uk