We hear repeatedly that obesity is one of the biggest public health problems in the UK today. Yet there is a stark mis-match between the newspaper column inches devoted to the nation’s waistline and the resources spent on NHS adult weight management services.
ON the 26th October 2017, the Minister for Public Health and Sport, Aileen Campbell, launched the Scottish Government’s Consultation on a Diet and Obesity Strategy for Scotland. There is much to commend in the Strategy - prevention is better than cure, and targeting resources on more ‘upstream’ determinants of obesity (changing the so-called obesogenic environment) is rightly the focus of the new Strategy (and of Obesity Action Scotland’s advocacy).
However, for a country with one of the highest obesity rates in the world (where 1 in every 4 adults lives with obesity), there is a need for action at multiple levels. As a recent Lancet commentary argued, the distinction between population-level and individual-level approaches is a false dichotomy. Yes, we should be restricting advertising and price promotions of junk food, but we also need high quality, accessible, multi-disciplinary treatment services for those with severe and complex obesity – and not just people with type 2 diabetes (the target of the Strategy).
Current issues with adult weight management services
A recent survey of NHS adult weight management services across Scotland found large disparities in the provision of services. In general, they are under-resourced and under-evaluated. My PhD research, which included interviews with key stakeholders (senior dietitians) involved in adult weight management, as well as patients and primary care practitioners (GPs and practice nurses), identified a number of issues with adult weight management services.
First, there is a lack of awareness of existing services among both patients and practitioners. It’s hard to refer someone to a service that neither of you know much about. Second, there is a lack of confidence in weight management services amongst primary care practitioners. In short, GPs and practice nurses don’t think they work. This is partly related to unrealistic expectations (a 5-10% weight loss is a good outcome, with clinically significant health benefits), but also due to lack of feedback about the overall success rates of the services. In the Glasgow and Clyde Weight Management Service (GCWMS), the largest NHS adult weight management service in Scotland, roughly a third of people who complete the group classes achieve that 5% weight loss target.
However, third and most significantly, there are real barriers to attendance, and the majority of people who are referred do not stay the course. These barriers include process factors, such as initial telephone opt-ins and 1 year ‘lock-out’ periods prior to re-referral, and structural factors, such as transport links (having to take 3 buses to get somewhere is a bit of a turn off), and other aspects of access such as classes only being available during working hours, or groups not being adapted to meet different ethnic or cultural needs. A “one size fits all” approach clearly does not fit all.
The role of primary care
Primary care is often seen as a delivery mechanism for public health interventions. Almost everyone is registered with a GP and most people will see their GP or practice nurse at least once in a five year period. With regard to obesity, we are told on the one hand that “every healthcare contact is a health improvement opportunity”, and on the other hand that, if we keep mentioning people’s weight they will be put off coming to the doctor. Relationships and trust are the silver bullets of general practice, and GPs are understandably wary of offending their patients. If we are going to raise the issue, we need decent solutions to offer.
A 2013 report from the Royal College of Physicians stated that training for GPs in weight management has been minimal and poorly coordinated, “reflecting a lack of focus on obesity throughout medical training as a whole”. But while training has its place – to help doctors and nurses understand the complexity of obesity and to give them the skills and confidence to discuss weight sensitively – what we really need is adequate investment in accessible treatment and support services. GPs and practice nurses are well placed to identify people who would like support to change health behaviours, but we lack the time or skills to provide that support, particularly for those with binge eating disorder or other complex physical or mental health co-morbidities.
A way forward – invest in services?
Adult weight management services should ideally be local, familiar, and relatively quick and easy to access (think smoking cessation services). This is particularly important in areas of high socio-economic deprivation, which have the highest proportion of referrals to GCWMS but the lowest likelihood of attendance.
To improve attendance following referral, we need better communication between weight management services and primary care, and improved accessibility of services. GCWMS has recently undergone a period of significant reform, with some patients now being given 12 weeks free membership to Weight Watchers. This may improve access for some (e.g. more local, flexible hours), but with the Government’s proposed focus on people with, or at risk of, type 2 diabetes, there is a concern that many other people with severe and complex obesity will not get the support they need. After all, equity of access can only be achieved if available services are acceptable to diverse populations of potential users.
*The Scottish Government’s Consultation on a Diet and Obesity Strategy for Scotland closes on 31st January 2018.
Blog from Dr David Blane who is the RCGP representative on Obesity Action Scotland. He is a GP and researcher at the University of Glasgow, but writes here in a personal capacity.