1. BEN PCT Primary Care Specialist Obesity Service Linda Hindle Consultant Dietitian in Obesity March 08

2. Format  Why the service was developed  About the specialist Obesity Service  Results after 12 months  Preliminary results after 24 months  Learning points  Client feedback  Future Plans

3. BEN PCT’s Obesity Strategy Strategic framework developed to coordinate efforts to tackle obesity and overweight. Aims  Halt rise in childhood and adult obesity within the BEN PCT  Ensure actions undertaken to reduce levels of obesity are taken forward by a range of public and private sector agencies in addition to the NHS  Develop information systems for collection and use of data relating to overweight and obesity  Address inequalities between social groups including BME communities and local areas, in access to and provision of a dedicated weight management service  Develop and implement a high quality, evidence based care pathway for the prevention, management and treatment of obesity

4. Level 4 Secondary Care Morbid Obesity Service Level 3 Primary Care Specialist Obesity Service Level 2 Community/Primary Care Weight Management Service Level 1 Early Intervention and Prevention Physical activity Strategy Exercise on Prescription, Walking, Cycling programmes etc. Leisure Services Food Skills Courses, Food Access projects Smoking Cessation Service Front line Staff (NHS, Council, Vol. Sector), Health Trainers, On-line advice Commercial Slimming Clubs Tobacco Strategy Pharmacy Services Food Strategy Commercial Slimming on Prescription Adult Obesity Service Pathway

5. About the Level 3 Service Specialist Obesity Service Service to treat people with morbid obesity within a Primary Care setting. Run by a multi – professional team including a GP, Specialist Dietitian and Cognitive Behavioural Psychologist, the service aims to be able to provide a more intensive approach than would generally be possible in Primary Care. Suitable for patients with morbid obesity for whom interventions in Primary Care have been unsuccessful. This service will ensure that all options have been tried before someone is considered for bariatric surgery.

6.  Target Group BMI >40 (37.5 Asian population) BMI > 35 with co-morbidities (32.5 Asian population) Emotional Eating Previous attempts to lose weight Aim is to provide specialist support to facilitate 5– 10% weight loss in those who have failed to control their weight at level 2 and to provide a gateway to level 4

7. Physician assessment  Possible medical causes for obesity, e.g. hypothyroidism, Cushing’s syndrome.  The type of obesity, i.e. central or lower-body.  The impact of obesity on existing co-morbidity, including mental health.  Relevant medical history.  Patients’ understanding of obesity and its causes.  Patients’ aims and expectations.  Patients’ motivation to lose weight including details of previous attempts to lose weight and reasons for failure.

8. Physician Input  The likely cause of obesity.  The impact of the type of obesity per se and its impact on existing co-morbidity.  Any misconceptions about obesity  Patient’s aims and expectations and their motivation to lose weight.  Discuss a management strategy to achieve goals with particular emphasis on the long-term nature of such a strategy. need for and impact of good dietary habits and regular exercise. role of drug therapy. help of other members of the multidisciplinary team.  Referral to appropriate members of the multidisciplinary team and request referring GP to prescribe medication if appropriate.  The physician will feedback to the referring practice on behalf of the team.

9. Dietetic assessment  Weight history (as child and adult).  Dieting history (previous regimes tried).  Dieting successes – why did this approach work well?  Family history.  Disordered eating.  Motivation and confidence.  Nutritional knowledge.  Current activity/exercise levels.  Assess current nutritional intake.  Calculate Body Mass Index and assess energy requirements.

10. Dietetic input  Once the initial assessment is complete, the dietician will discuss the following issues with each patient. The level will depend on what has been covered by the physician : 1. Benefits of weight loss. 2. Motivation for behaviour change (using decisional balance – look at pros/cons). 3. A suitable healthy eating plan and set targets for weight loss including 5% weight loss at 6 months and 10% at 12 months.  The following may be used to help achieve target weight loss: a) prescribed energy deficit (600kcal deficit) b) low fat and anti-obesity agent c) change programme d) Very Low Calorie Diet (VLCD) e) Protein sparing modified fast

11. Dietetic input continued 4. Advice on: energy balance. active living. reading nutritional labels. shopping and cooking tips. healthy choices when eating out. maintaining weight loss and preventing relapses.. 5. Organise individual follow up appointments and attendance at group sessions as appropriate in order to: a) Provide support to help patient make changes to achieve and maintain goals. b) Discuss any concerns that the patient has. c) Clarify any misconceptions re: diet. 6. Aid the patient in overcoming barriers to changes in lifestyle.

12. Psychology input  Assessment and treatment for mental health issues associated with obesity such as anxiety and depression  Support to recognise and manage complex relationships with food  Identification and management of other psychological issues impacting on obesity – may require referral to mental health services

13. REFERRALS  Approximately 20 per month  Source% GP58 Practice nurse 6 Physiotherapy 21 Community Dietetics 6 Occupational therapist 1 Level 4 obesity service 7 C.P.N. 0.5  Current caseload = 160

14. General Information of current caseload (march 08):  Male 35(22%)  Female 125(78%)  Average Age 47 yrs  Mean waiting time 12 weeks

15. Initial Weight and Psychometric Information  Mean wt kg (range) 130 (80 – 203)  Mean BMI (range)47.5(33 – 70)  Mean excess weight to lose 61kg  HADs (range)  A =11 (2 – 19)  D =9 (3 – 18)

16. Mean results of caseload n=160 – at March 08  Weight kg – 124kg  BMI - 45.7  A – 9 (-2)  D – 7 (-2)  Weight loss – 6kg  % weight loss – 6%  Excess weight loss – 10%

17. Mean weight loss related to duration of attendance Duration of attendance Year 1Year 2 Mean weight loss % 3-6 months2- 6-9 months42 9-12 months61 12+ months1110

18. Client feedback  Feedback from patients is positive and attendance rates are good for this client group, average attendance = 80.5%.  86% of patients believe that this service has allowed them to achieve what they wanted to achieve.  92% of patients would recommend this service to others.

19. Learning points  Need to be clear to referrers how this links to other services  Opt in appointments  Reminder phone calls  Link between capacity, frequency of follow-up and effectiveness – outcomes have decreased as time between appointments has increased

20. Future Plans  Succession planning for psychology support  Further develop links with level 4  Refine / develop assessment criteria for surgery  Include support for increasing activity  Expansion to North part of PCT  Develop a model for weight maintenance  Publish