1. Options to offer Ninoshi Palihawadana

2. Four Tiers in the weight management programme Tier 1: Things you can offer people with a BMI > 25 i.e supported self management www.nhs.uk/Livewell/loseweight/Pages/Loseweighthome.aspx Active Living. www.activederbyshire.co.uk details of local events and activities, walking groupswww.activederbyshire.co.uk Local Slimming World : ~£.9.50 to join and £4.50 per week Can refer to community dietician Change 4 Life: Support material re diet and exercise. www.nhs.uk/change4life www.nhs.uk/change4life Health 4 Life: Support for families to make +ve lifestyle changes Book: Overcoming Bulimia Nervosa and Binge-Eating by Peter Cooper: <£10 or via the library. Helpful book for the right patient

3. Tier 2: BMI > 30 or >28 with Co-morbidities www.waistwisederbyshire.co.uk Weight management and gentle activity. 12 week course, group setting, separate for males and females. Each session lasts 2h. Exercise is tailored to patients needs/abilities including chair based exercise. Based at Greenback Leisure Centre. Small charges apply (Aprox £3/week) Refer via the combined Derbyshire Health Referral and Waistwize referral form (General Referrals Folder on the intranet) Referral criteria: Age over 16y, BMI 30+ (28+ if co-morbidities) + motivated. Patients cannot self-refer Exclusions: Unstable angina, BP > 180/100, ventricular or aortic aneurysm, significant exertional hypotension, resting tachycardia or other uncontrolled arrhythmia, unstable heart failure Progress report will be sent back to the GP. Patients can be re- referred to 3 times with 6m gaps in-between re-referral

4. Tier 2 continued… Orlistat Treatment. Consider after diet and exercise via WaistWise Should only be continued if >5% weight loss at 3 months. Should be stopped if weight gains>3kg after initial weight loss (but be less strict with criteria in diabetics) Usual dose 120mg taken immediately before, during or upto 1 hr after a main meal upto TDS The vast majority of patients receiving up to four full years of treatment with orlistat in clinical studies had vitamin A, D, E and K and beta-carotene levels that stayed within normal range. In order to ensure adequate nutrition, patients on a weight control diet should be advised to have a diet rich in fruit and vegetables and use of a multivitamin supplement could be considered. If a multivitamin supplement is recommended, it should be taken at least two hours after the administration of orlistat or at bedtime. Patients prescribed xenical can register with an on-line support programme via www.MAPassist.co.ukwww.MAPassist.co.uk

5. Tier 3 BMI>35 and failed to maintain 5% weight loss after Tier 2 after 3 attempts 1 attempt at Tier 2 which failed and BMI >40 BMI >45 with co-morbidity BMI >50 without comorbidity Refer via the Weight Reduction Services referral Form Exclusions: unstable angina, BP > 180/100, P > 100, unstable CCF or arrhythmia, excessive alcohol use or substance misuse

6. Tier 3 continued… Intensive, individually tailored programme with a weight reduction support worker Can involve : Dietician, OT, physical activity interventions and psychologist. Pre-and post bariatric surgery assessment. If more intensive psychotherapy is indicated their psychologist can refer on for CBT etc. 24 week programme with follow-up for 2 years Patient is sent a questionnaire which they must sent back. Assessment appointment follows 4 to 8w later

7. Tier 4 Bariatric Surgery. Patients must have first been through Tier 3. If surgery is being considered at the outset of the Tier 3 referral, tick the box on the form re considering bariatric surgery. Otherwise, the option of surgery may be advised by Tier 3. They will assess and send GP back a report after minimum of 2 months of their intervention. This report should be attached to the Derby Obesity Surgery Proforma The criteria are: Non-smokers (for at least 6w), age 18 to 64, BMI>45 with co-morbidity or >50 without co-morbidity, committed to the need for long-term follow-up. Have tried to lose weight with appropriate support over 12-18m period. Must have undergone a trial of drug therapy.

8. Tier 4 continued… Epworth score. If >10, the patient must be referred to the Sleep Clinic before referring to Bariatric Surgery. If OSA is diagnosed, surgery is delayed until it is under control with CPAP Recent U+E, glu, LFT, lipids, TSH, FBC