Following publication of the UK government’s obesity strategy, experts are calling for a whole-systems approach covering prevention to treatment, including surgical options for those with the most severe disease, Jennifer Trueland reports

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When the government published its obesity strategy in July, the focus was primarily on encouraging people to live a healthier lifestyle. The aim, according to the Department of Health and Social Care, was to “get the nation fit and healthy” so that people could protect themselves from covid-19 and protect the NHS.

Few would argue that there is a need to take action in this area – almost two-thirds of adults in England are overweight or obese, and illness related to obesity costs the health service a conservative £6 billion per annum in direct costs alone. The covid-19 pandemic also added a new urgency, with patients at greater risk of severe disease or death if they have obesity or were overweight.

But for all that, the reception given to the strategy in some quarters was lukewarm, with clinicians, commissioners, providers and patient groups raising concerns about whether the plan focused enough on those already living with severe and complex obesity.

Improving services

An advisory board meeting hosted by Ethicon (part of Johnson & Johnson Medical Devices Companies) brought together experts with a range of backgrounds, all of whom have an interest in improving services in this area. The company’s metabolic treatment advisory board discussed the key challenges faced by clinical and non-clinical stakeholders who play a role along the metabolic treatment patient pathway. As well as considering the 2020 obesity strategy, they discussed the future of metabolic and obesity treatment – how it was likely to evolve, and what the barriers and drivers were.

One major challenge is current unmet need for bariatric or metabolic surgery, which is a treatment option for people with severe obesity with thresholds depending on factors including co-morbidities and the fitness of the individual

Specifically, the virtual event looked at challenges within the current treatment pathways, commissioning through the patient pathway, the future of bariatric/metabolic surgery and the development of professional educational materials.

The advisory board members suggested there were problems with definitions around obesity, including the terminology used, and with stigma – the political and media narrative was that obesity is “your own fault”, said Naresh Kanumilli, a GP and diabetes network lead for Greater Manchester and East Cheshire.

Barbara McGowan, a consultant and honorary senior lecturer in diabetes and endocrinology at Guy’s and St Thomas’ Hospital, London, said that service provision was pitifully low across all tiers (see box below). “There are massive bottlenecks and you can’t access services easily because they are full,” she said. “We obviously need to have a plan to increase services and join up services.”

Attitudes had been changing in the last six months, probably due to covid, Dr McGowan added. “There’s better awareness and education, and hence the great momentum that we now have to put more money into those services. But ultimately we need more resources.”

One major challenge is current unmet need for bariatric or metabolic surgery, which is a treatment option for people with severe obesity with thresholds depending on factors including co-morbidities and the fitness of the individual. Vinod Menon, a gastrointestinal and obesity surgeon and cancer specialist with University Hospitals Coventry and Warwickshire Trust and honorary secretary of the British Obesity and Metabolic Surgery Society, pointed out that while around 2 million people in the UK would qualify for metabolic surgery, it only reaches around 5,000 per year. BOMSS wants to raise this from a quarter of one per cent to one percent over the next three years, which would mean that 20,000 were carried out annually. “Even that would be a big ask, but having done internal analysis among the membership of the society, we feel that if we did it in a phased manner over the next three years, we would be able to achieve that – more by a general acceptance and internal redesign rather than a massive increase in infrastructure.”

Shane Gordon, director of strategy at East Suffolk and North Essex FT, a GP by background, said the whole question over the clinical barriers to treating obesity needed to be reframed. Rather, we should be asking about the ethical argument for not treating it. If a patient came to his emergency department and was clearly having a heart attack, a clinician who didn’t treat that patient would end up in the coroner’s court and probably be struck off the medical register, he said. “But it seems to me that we’re doing this every single day for patients with a treatable disease, with multi-organ morbidity, which is preventable and treatable. And yet every day for thousands and thousands of people in my area alone, we are failing to treat their obesity.”

Tiers of services for weight management (may vary locally)

Tier 1 – Public Health/universal intervention, includes prevention, health promotion, eg advice on healthy eating and physical activity

Tier 2 – Primary care/individual intervention, includes identification and basic lifestyle advice

Tier 3 – Specialist weight management services

Tier 4 – Secondary surgical care/patients considered for bariatric/metabolic surgery

Source NICE and Royal College of Physicians

 

Criteria for metabolic surgery

NICE says that surgery should be considered for patients with a BMI of more than 40kg/m^2 or between 35 and 40 if other significant diseases are present, and only where other non-surgical weight loss methods have not worked.

NICE says it is the main option for adults with a BMI over 50.

Expedited assessment for surgery can also be considered for people with a BMI over 30 with recent onset type 2 diabetes provided they are receiving or will receive a tier 3 service (NICE).

 

Roundtable participants

  • Annette Donegani: senior service improvement support manager (long-term conditions) with Salford CCG
  • Barbara McGowan: consultant and honorary senior lecturer in diabetes and endocrinology at Guy’s and St Thomas’ Hospital, London
  • Shane Gordon: director of strategy at East Suffolk and North Essex FT
  • Lisa Rickers: bariatric specialist nurse, Imperial College Healthcare Trust
  • Matt Capehorn: GP and head of Rotherham Institute for Obesity
  • Naresh Kanumilli: GP and diabetes network lead for Greater Manchester and East Cheshire
  • Vinod Menon: gastrointestinal and obesity surgeon and cancer specialist with University Hospitals Coventry and Warwickshire Trust and honorary secretary of the British Obesity and Metabolic Surgery Society (BOMSS)
  • Julia Glover (chair) Ipsos
  • Mark Pritchard: metabolic lead, Ethicon UK
  • Gianluca Casali: medical director, Johnson & Johnson Medical Devices Companies, UK & Ireland
  • Alison Hawcroft: thoracic bariatric specialty manager, Ethicon UK

This is an HSJ report on an advisory board organised and managed by Ethicon. Ethicon had no editorial input into the report.

Roundtable: Improving the metabolic treatment patient pathway