The obesity crisis shows no sign of abating. Research shows that referring people to weight management services more than doubles the weight they lose, but what provision is out there for your customers and how effective is it? Sarah Purcell looks at what’s available.
The number of obese people in England has almost doubled in the past two decades, from 6.9 million to 13 million, according to the latest report from Diabetes UK. In England, 29 per cent of adults and 20 per cent of 10 to 11-year-olds are obese. It’s the main driver behind the surge in type 2 diabetes and accounts for 80 to 85 per cent of the risk factor. There are now 2.85 million people with type 2 diabetes in England.
Some 10,660 hospital admissions were directly attributable to obesity in 2017/18 and for a further 711,000, obesity was a factor (NHS Digital, 2019). Fewer prescriptions are being issued to treat obesity – 371,000 in 2018, 8 per cent fewer than 2017 and compared with 1.45 million in 2009.
The government plans to halve childhood obesity by 2030. Among 10 to 11-year-olds, six children in a class of 30 are obese and a further four are overweight, twice as many as 30 years ago. Forecasts suggest if this trend continues, up to a third of children in the most deprived areas of the UK will be obese by 2030.
It’s not just poor diet and overeating that are to blame for the obesity crisis. It’s our sedentary lifestyles. Government guidelines recommend adults aged 19 to 64 should do 150 minutes of moderate physical activity a week, yet 20 million of us don’t achieve this, says the British Nutrition Foundation.
We know that getting people to engage with a weight management service, either funded or private, makes a big difference. Public Health England’s Let’s Talk About Weight report says that referring people to weight management services can more than double the amount of weight they lose. Research has shown that brief, opportunistic interventions delivered in primary care can result in a five-fold increase in the percentage of patients engaging in weight management services.
This is good to know, but with all the cuts made to public health services, how readily available are referred and funded weight management services for patients? According to a review by NHS England of current tier 2 weight management services, the provision of free services is variable across the country. Where provided they are typically not designed to meet the needs of the specific population groups most at risk, including those on low income, with severe mental illness or learning disabilities, BME groups, men and pre/post-natal women.
“The public health grant has been reducing since 2013 and increasing numbers of local authorities are finding they cannot afford to provide weight management services,” says Paul Sharpe, head of partnerships at Slimming World. “Slimming World is campaigning for government to take responsibility for commissioning local, effective programmes that deliver an effective low cost intervention on a national scale.”
“Keep in line with NICE guidelines and remember you’re not selling a product, but expertise,” says Mr Evans. “Take it seriously if you’re going to offer a service and ensure you have all the knowledge and training you need first. Weight management could be one of your biggest categories if it’s done properly.”
“In terms of weight management, don’t just think weight loss products,” says Ms Morris. “Consider a healthy lifestyle and nutrition category that covers weight management, nutritional deficiencies, cholesterol, diabetes, etc. Show your customers you’re there to support their nutritional needs. Also think about other products that relate to these categories to encourage additional purchases, for example, BP monitors and blood glucose tests.”
For healthy adults with a BMI of 25 or more (not pregnant women), the NHS online 12-week weight loss plan promotes safe and sustainable weight loss. It helps participants make healthier food choices, gives a weekly progress chart, includes exercise plans and includes support from an online community. The plan aims to help people lose weight at a rate of 0.5 to 1kg per week by sticking to a daily calorie allowance. For most men, this is 1,900kcal a day and 1,400kcal for women. The guide is delivered through 12 weekly information packs that can be downloaded free.
The programme, which gives advice on dieting, exercise and healthy lifestyle, is being doubled over the next few years to treat 200,000 people at risk of type 2 diabetes. An online version of the programme, which includes wearable technologies and apps, is available for patients who find it difficult to attend sessions. Providers appointed to roll out the service include ICS Health & Wellbeing, Weight Watchers, Reed Momenta, Ingeus and Living Well Taking Control. Recently released figures show that those who attended most of the healthy living sessions lost an average of 3.4kg.
There is a range of free or subsidised weight management services across the country. Patients can be referred by their GP, practice nurse or other health professionals. Here is a selection of what’s available.
Weight Watchers referral scheme A 12-week subsidised service, compliant with NICE guidance, working with health organisations, has been available since 2005. The local authority receives feedback about every patient’s attendance and weight loss outcomes. Using an evidence-based behavioural approach, patients are encouraged to aim for an initial weight loss goal of 5 per cent of their starting weight, then 10 per cent. Physical activity is a core part of the programme.
Independent research showed that 31 per cent of those who did the 12-week programme sustained their weight loss after a year. An audit of 30,000 patients found it delivered average weight loss of 3.3 to 5 per cent of initial weight. Two independent trials found WW offered the best value for money of any of the NHS or commercial weight management services under evaluation.
Slimming World service Slimming World works with more than 70 commissioning bodies. Most of those who complete their 12-week programme lose more than 5 per cent of their starting weight. This service can be accessed by GPs, nurses and pharmacists who can offer referred patients free access to a local Slimming World group. The cost to the commissioner is subsidised by Slimming World. The referral package includes weekly group weight management sessions plus additional support in between as required. “Eligibility criteria are determined by the commissioners, which means no two of our Slimming World on Referral schemes are the same,” says Mr Sharpe. “Some commissioners may wish to target people over a certain BMI in a particular area, others may want to focus on patients with a specific diagnosed co-morbidity.”
A research trial in County Durham, where 21 pharmacies were able to refer patients to Slimming World’s free 12-week programme, was extremely successful. “Pharmacists see a vast number of patients daily and are in a great position to offer lifestyle advice and signpost patients in need to relevant services,” says Mr Sharpe.
A study of diabetes patients referred to the service found that after one year more than 80 per cent of patients saw improvements in their diabetes control and a quarter of patients lost more than 10 per cent of their body weight.
Counterweight Counterweight-Plus has been hailed for its success in helping people achieve remission of type-2 diabetes and is one of the programmes offered by Counterweight. The programme aims at 15 per cent weight loss or more for individuals with a higher BMI and involves a total diet replacement phase, followed by stepped, structured food reintroduction and then a weight maintenance phase. It’s widely available in Scotland and Wales. “Our research trial published in The Lancet has shown that targeting remission is a viable treatment for T2DM,” says CEO Justin Slabbert.
ICS Health The tier 2 community adult weight management service adheres to NICE guidelines and focuses on diet and healthy eating, physical activity, reducing sedentary time, strategies for changing behaviour and adopting a positive approach. The programme is delivered by health and wellbeing coaches and supported by a multi-disciplinary team, including a dietician and clinical psychologist.
Foodwise for Life In this eight-week structured programme written by public health dieticians in Wales for those with a BMI of at least 25, the programme is delivered by a range of community-based staff. The programme covers portion sizes, being more active, dealing with hunger cravings, food labels and overcoming barriers.
LEAP This free 10-week weight management programme for adults in Leicestershire combines nutrition sessions led by a registered dietician followed by exercise with an activity instructor. The course covers topics including emotional eating, why diets don’t work, which exercises suit you best, eating out the healthy way and how to read food labels.
Some of your customers will benefit from specialist advice on how to eat more healthily and manage their calorie intake. Many people claim to be experts, so who is best qualified to help your customers?
Dietician Registered dieticians are the only qualified health professionals who assess, diagnose and treat dietary and nutritional problems. They are regulated by law and work in the NHS and private practice. They often work as part of a multi-disciplinary team to treat conditions such as diabetes, food allergy and intolerance, eating disorders and IBS. They can give advice and help to maintain nutritional status.
Nutritionists are qualified to provide information about food and healthy eating, but not about special diets for medical conditions. They work in public health and the private sector. While anyone can call themselves a nutritionist, only registrants with the UK Voluntary Register of Nutritionists can call themselves registered nutritionists.
Nutritional therapists can advise on recommendations for diet and lifestyle to alleviate or prevent ailments, often based on complementary medicines. This can include guidance on detox, colonic irritation, avoiding allergens and use of supplements. Voluntary regulation is possible but not compulsory. They work on a private basis only.
Pharmacist Gareth Evans runs Waistaway weight loss service at Wansford Pharmacy in Peterborough. “The main advantage of a pharmacy-based setting is safety, because you have a health professional on hand through the whole process,” he says. “There’s also easy access and convenient appointment times, plus we have more time for each patient than a GP usually does.” He believes pharmacists can deal with weight loss in an opportunistic way, while it takes patients five to nine years to broach the topic with their GP. “We have that expertise on every high street, plus we are used to dealing with comorbidities such as diabetes and high blood pressure,” he says.
Mr Evans uses the Lipotrim programme. “We have various non-medical options too, such as the Eatwell plate and food diaries, which can help spot problems,” he says. He’s noticed orlistat has declined in popularity in recent years. They rarely see prescriptions for it. “We get an average of 10 per cent weight loss for our customers, which is higher than most referred services,” he says. An observational study to evaluate 17 years of data is being published this month.
He says that MURs are a great way of engaging customers about weight loss. “Try and have a sit-down conversation if you can because it really helps,” he says. “When you’re dispensing, talk about your service. Try to move away from all the online services out there. Get customers engaged and coming into your pharmacy.”
In Mr Evans’ area, most services are private. “There seems to be no joined-up thinking in the NHS about how to tackle obesity,” he says. “The advice seems to be just ‘Eat less, exercise more’, which we all know. A 12-week plan, for instance, will be no good if you’re six stone overweight because it won’t be long enough. Plus, you need support to sustain weight loss.”
Numark pharmacy services manager Lucy Morris says pharmacies are often the only healthcare facility in deprived areas and a weight management service is an opportunity for a face-to-face conversation with a healthcare professional. “This may just be dietary advice or signposting to local support groups, but the availability of private PGDs and independent pharmacist prescribers means prescription medicines not routinely available on the NHS for weight management are becoming more widely available through pharmacy.”
Broach the subject sensitively. “Think how to give your pharmacy a health promotion image,” says Ms Morris. “Leaflet displays can help initiate conversations on how customers feel about lifestyle and fitness. This then gives you the opportunity to discuss weight management and the support you can offer.”
PHE recommends health professionals initiate conversations. “You don’t need to be an expert in weight management to incorporate this into your routine consultations with patients who are overweight or obese and you don’t need to spend a lot of time to make a difference. It is important to be familiar with your local obesity care pathway, so you are aware of the services available in your area and the referral criteria and process.”
Lila Thakerar, Shaftesbury Pharmacy, Harrow
“This has become less important in terms of sales. We used to sell quite a lot of Alli, but it’s now so expensive for customers to buy. If they need it, they’ll get it prescribed. We do offer advice in terms of diet and lifestyle, and we can signpost to places where they can get more help. Customers ask if there’s a pill they can take to lose the weight. It’s much more important to focus on healthy lifestyle to lose and maintain weight than to rely on a pill. I think people are more aware of weight and the need to be a healthy weight, but they just don’t know where to start.”
Jaimini Modi, locum in Harrow, mainly for Clinidirect
“Weight management is not that prominent in the pharmacies I work in and we don’t get many queries about how to lose weight. On the rare occasions customers do come in for weight management issues, we advise them on healthy lifestyle options before resorting to the use of products. Some patients ask for Slimfast powdered shakes, but again this is rare. There are opportunities to offer patients health checks and identify what could help them as a result. This may create some openings for pharmacists to discuss weight issues where appropriate.”
Mital Thakrar, Well Pharmacy, Birmingham
“Customers commonly talk about weight loss in clinical conversations, but the past 18 months has been a massive opportunity, thanks to HLP accreditation. Our vision is to be approachable. If patients want to talk about weight, diet and their exercise routines this is the easiest and best way to grow the category. Growth does not always lead to financial benefit, but the secondary benefit is a customer who feels comfortable visiting the pharmacy team and discussing other health issues. Through this trust we can build value and gain a loyal customer.”