NICE now recognises that talking therapies can succeed where traditional anti-obesity strategies have failed – now let’s see the government back up the new thinking with action, says Matt Capehorn
When the National Instiutute for Health and Care Excellence last month issued their quality standards for obesity services, few noticed the paradigm shift it signalled in the government’s approach to this epidemic.
For the first time, NICE endorsed dedicated obesity centres staffed by weight loss and dietary specialists, fitness instructors… and talking therapists.
This last bit is key, and essential not only to effective weight loss, but to prevent regain by behaviour change – and end yo-yo dieting.
Our relationship with food is complex, and not just physiological. We must overcome psychological hunger – when we eat but are not really hungry
We can make anyone lose weight (lock them in a cupboard and don’t feed them!), but if we don’t address the underlying reasons, they will face precisely the same psychological problems as at the start, and are more likely to put everything straight back on.
Most of us have experienced emotional eating – comfort eating or habit eating – and it’s as responsible for weight gain as our metabolism and “calories in, calories out”.
Our relationship with food is complex, and not just physiological. We must overcome psychological hunger – when we eat but are not really hungry.
How many of us have paid for a meal and been full after the starter, but because we have paid, will override that feeling?
And despite being very full when the dessert menu arrives, we ignore our physiology further and submit to our favourite, fattening, childhood dessert.
For years we were told “eat less fat”, and now the devil appears to be sugar. Hardly surprising the public is confused, and obesity is rising
But instead, until now, the government’s millions have been ploughed into “eat less and move more” publicity campaigns.
Technically, they are right: fewer calories = less weight. And physical activity will not only help us lose weight (albeit not as efficiently) but we will become more fit.
But too much focus has been on what we eat, and its composition.
For years we were told “eat less fat”, and now the devil appears to be sugar. Hardly surprising the public is confused, and obesity is rising.
However, NICE now finally recognises that, for many obese (BMI > 30, or typically more than three stone overweight, and the new “centre ground” of Britain’s battle against obesity), this traditional approach has failed.
Food as friend
Just like an alcoholic doesn’t drink because they’re thirsty, an overweight person doesn’t overeat because they’re hungry. They eat for emotional reasons – a bad day at the office, a row with their partner, money worries, relationship breakdowns, along with boredom and easy availability – and food is their friend.
“Talking therapies”, including cognitive behavioural therapy, address these, and are at last becoming accepted as a frontline treatment, just as they are in alcoholism and smoking.
To understand further, it’s worth looking at the government’s four-tier approach to obesity – broadly, in escalating order:
- Tier 1 – Public health interventions (local versions of Change 4 Life) and primary activity eg healthcare professionals weighing, measuring and giving initial health advice.
- Tier 2 – Community weight management programmes, which may be commissioned locally or from commercial providers; time-limited educational group-based sessions
- Tier 3 – Dedicated specialist centres, mainly for severe and complex obesity, staffed by experts in weight loss, physical activity and talking therapies, who understand that the answer lies not in the ‘what’ but in the ‘why’ - to help obese patients reverse their weight gain, and avoid the need for surgery
- Tier 4 – Bariatric surgery, for those found to need it
NICE has now effectively declared these Tier 3 centres should be everyone’s right – indeed they were already a pre-requisite prior to bariatric surgery, so they should be everywhere.
But the reality is very different.
Weight loss company LighterLife, who have pioneered CBT over the last 25 years, filed 211 freedom of Information requests to England’s clinical commissioning groups and Scotland’s 14 health boards.
The confusion concerned the fact that:
- More than 24 were unaware it was their own responsibility
- There were far too many (31) with no Tier 3 services at all. Without these there is no intensive medical help
- Tier 3 standards varied considerably – 42 shared centres with other CCGs with such massive populations it’s difficult to see how they could cope.
And worryingly, 21 areas said they used centres within, or adjacent to, bariatric units, which smacks of a conveyor belt towards surgery, rather than a real bid to help the obese lose weight by other means
It is a myth to believe the NHS can afford bariatric surgery for all, even though it is cost-effective, and a further myth to believe it will work for everyone.
…Many put weight back on, because they have been unable to address their underlying relationship with food and change their behaviour.
And yet at this crucial time, government is poised to cut support even further - local authorities are even threatening to cut Tier 1 and 2 interventions because obesity is not a mandated service, and they are under financial pressure.
This will simply increase numbers of patients with severe and complex obesity.
It makes financial sense for CCGs to invest in Tier 3. If they don’t, bariatric surgery could bankrupt them, or mean no weight management services at all.
…The latter is an even more costly option - we pay far more treating the consequences of obesity (heart disease, diabetes, cancer etc) than the cause.
NICE has recognised the value of talking therapies – now let’s get the government’s mighty promotional arms behind this, drop the failed approach and turn the tide for good.
Dr Matt Capehorn is head of the flagship Tier 3 Rotherham Institute of Obesity