COVID-19 Points to Need for Integrated Obesity Services

Liam Davenport

November 17, 2020

The COVID-19 pandemic may have forced changes to the delivery of an obesity management programme but it has also shone a light on the potential for better integration of specialist weight management services for severely obese individuals, says the clinical lead for obesity and diabetes in England.

Professor Jonathan Valabhji, national clinical director for diabetes and obesity, NHS England, was speaking at a session dedicated to weight management interventions at the Diabetes Professional Care Virtual 2020 meeting on November 11.

The discussion was led by Prof John Wilding, Obesity and Endocrinology Research, University of Liverpool, and president of the World Obesity Federation.

He said that, in recent years, greater importance has been placed on weight management in type 2 diabetes, not just in terms of management but also prevention. He asked Prof Valabhji how that will develop “over the next 5 years or so?”.

Prof Valabhji replied that there had previously been a “focus on the medicalisation” of blood glucose control, “but the emphasis on lifestyle hadn’t perhaps been at the fore, and we had a few marvellous opportunities…over the last 6 years or so” to make that shift.

Prevention

The first opportunity was the NHS Diabetes Prevention Programme, launched in 2015, which is a lifestyle intervention focusing on weight loss, physical activity and nutrition. It is thought to be one of the largest programmes of its kind in the world, with more than 600,000 individuals already referred to it.

That was the “first foray” into expanding the use of lifestyle interventions in relation to diabetes, Prof Valabhji said, and another opportunity was to build on the landmark DiRECT trial.

As reported by Medscape News UK, the study involved a calorie-restricted liquid diet followed by gradual food reintroduction and a weight loss maintenance programme, enabling 36% of type 2 diabetes patients to achieve remission of their diabetes and sustain this remission for 24 months.

“I don’t think many of us can recall a research output that has quite captured the imaginations of the public and healthcare professionals” as much as these results, Prof Valabhji added.

He continued that this approach is now to be initially piloted in 5000 people in 10 areas of the country. “If we can get anywhere [near] to reproducing the successful outcomes of the trial, then there will be an opportunity to scale that up nationally.”

Long Term Plan

The next opportunity was via the publication of the NHS Long Term Plan, “which gave us additional resources for the diabetes prevention programmes” and the low-calorie diet pilot programme, Prof Valabhji said.

However, it “has also given us the resources” to establish a weight management intervention for individuals who are obese and also have hypertension or type 2 diabetes, or both conditions.

“We always planned on the back of the Long Term Plan to spend this year [2020] procuring providers to expand access to such services, but obviously COVID-19…has had a huge impact and that has caused us to change our approach somewhat.”

Consequently, Prof Valabhji’s team are looking at a “digital weight management innovation platform” to offer remote or digital services for individuals with obesity and comorbidities.

Obesity

Prof Wilding next turned to the “more complex end of the spectrum” of weight management, which includes “a really important group of people”, numbering around a million in the UK, who have either a body mass index over 40 kg/m2 or one of 35 kg/m2 plus 'significant' comorbidities.

He highlighted that “most of them have already tried what you might term a tier 2 intervention,” such as weight management classes and diet plans, and even the NHS Diabetes Prevention Programme.

“They’ve tried really, really hard, often for all their lives, to try and support their weight but, as we increasingly recognise that obesity is a disease with both genetic and environmental components, these people are…genuinely struggling.”

Prof Wilding said that they often need “a lot more detailed support than can be provided in a relatively short and constrained programme”.

These patients then move to a tier 3 service, in which a multidisciplinary team, including dieticians, nurses, occupational therapists, and psychologists, can offer them “the support they need before they’re even ready to come into a weight management programme”.

Prof Wilding said that a limited number of patients in these services may also be prescribed weight management medications, which can be “very effective”.

The tier 3 service can also offer support to patients who may progress to bariatric surgery, “which is at the moment, I think it’s fair to say…not available everywhere”.

Extra Support

He therefore asked Prof Valabhji whether there will be extra NHS support for tier 3 services, as the provision in some areas of the country is “very limited, and so people cannot access these effective treatments”.

He added: “The reality is that…if you look at the data, the best way” of controlling diabetes in individuals with severe obesity, “even if you’ve tried lifestyle and the new drugs that we have, is actually still bariatric surgery.”

Prof Valabhji replied that COVID-19 “has undoubtedly shone a much brighter spotlight, if you like, on obesity and its impact on health, not least because it’s panning out, unfortunately, as an…independent risk factor for the more severe outcomes related to COVID-19, including, unfortunately, COVID-related mortality”.

He continued that as a result the Government has stated its ambition to improve access to weight management services, although the details have not yet been made available.

However, Prof Valabhji said that “we would all like to see” more resources and investment made available to the 'specialist end' of the weight management spectrum.

Another issue he raised was over the separation of tier 3 weight management services from bariatric surgery in tier 4, and whether or not that was appropriate.

Prof Wilding noted that the question of whether those two levels might be integrated “a little bit better than they are” had come up previously, and was also raised in the Q&A section of the session.

Lottery

Dr Christopher Walton, a diabetes consultant at Hull University Teaching Hospitals NHS Trust, said there is a postcode “or more accurately” a clinical commissioning group lottery in the provision of these services, adding that a “combined Tier 3 and 4 service which can work at scale is needed”.

Prof Partha Kar, associate national clinical director for diabetes for NHS England and a consultant in diabetes medicine at Portsmouth Hospitals NHS Trust, agreed, saying that “for sure” tier 3 and tier 4 “need to be one service”.

Prof Valabhji wondered whether “we could make a case that there is some repetition in what happens in those two tiers” and therefore there being potentially “some cost-savings if we were to merge” them.

He added that, for the physician, “the concept of being able to triage someone according to their individual need, to therapeutics, or [to] clinical psychology support, or [to] more elaborate and detailed dietetic support, or to a low calorie diet intervention…or indeed onto bariatric surgery, is quite attractive”.

Prof Valabhji believes that such an ability “would perhaps break down those barriers a little between what is seen as a dedicated tier 3 service and a separate dedicated tier 4 service”.

Prof Wilding agreed that this is “really important” and underlined that the individuals in these services “need a lot more support than maybe somebody who has just been diagnosed with pre-diabetes who has a lower BMI (body mass index) and no other complications”.

Dr Maria Drakou, a GP at Morden Hall Medical Centre in London.

Dr Kate Elliott, a GP at North Baddesley GP Surgery, near Southhampton.

Dr Ehtasham Ahmad, Diabetes Research Centre, University of Leicester and Leicester General Hospital, Leicester.

No funding declared.

No relevant financial relationships declared.

Diabetes Professional Care Virtual 2020: Abstract Weight Management & Obesity Interventions - what is most effective? Presented November 11.

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