Obesity module 1: management in primary care

Weight management programmes

The various options available – self help, commercial and community organisations – should be discussed with patients and the best option chosen for them in the long term. It is important that you are confident of the evidence for the effectiveness of any programme before discussing it with your patients. Recommending weight loss methods that are not likely to be effective can be extremely detrimental. When someone expresses no preference, then refer people to group rather than individual programmes as these tend to more cost-effective. Make people aware that there is no magic bullet to weight management.

Fully discuss the pros and cons for any weight loss programme and make people aware that:²⁰

• The more weight they lose the greater the health benefits, particularly if they lose 5% of their body weight and maintain this for life. Physical health and mental wellbeing are also improved
• They should try to prevent future weight gain and maintain a lower weight trajectory for health benefits
• The effort and commitment needed will benefit from long-term support from many agencies including healthcare professionals, personnel running weight management programmes, online groups, friends and family; the more support they get, the better.

NHS referral to lifestyle weight management programmes

Many weight loss programmes have been shown to be cost-effective. It has been estimated that the cost per QALY is £1,022 for a group programme (Weight Watchers), £24,431 for medical intervention (with orlistat) and between £6,279–£8,527 for surgical intervention.^3,33

The best weight management results seem to occur when healthcare professionals diagnose obesity and then refer their patients on to group-based lifestyle weight management providers in the community. Jebb et al.²⁹ found that weight management in overweight and obese people was more effective when a primary care professional referred on to a commercial weight loss programme that provided regular weighing, advice about diet and physical activity, motivation and group support (Weight Watchers) compared to usual support  via primary care.

This study was carried out on 772 overweight and obese adults recruited by primary care practices in Australia, Germany and the UK. Mean weight change at 12 months for those who completed the 12-month assessment (61% of those assigned to the commercial programme and 54% of those assigned usual care) was -6.65 kg for those in the commercial programme versus -3.26 kg for those receiving standard care.

Clinical judgment must be used to identify which people are suitable for NHS or Public Health funded referral to lifestyle weight management services. Although they particularly benefit the obese, NICE 2014 recommends that overweight people should be referred if capacity allows and that there should be no upper BMI or age limit for referral.

If people are not ready for referral, then a follow-up appointment should be agreed and organised.

For referral on the NHS or via Public Health pathways, the latest NICE guidance (2014) recommends that programmes are commissioned which have the following core components of best practice:

– programme addresses dietary intake, physical activity levels and behaviour change, and is developed by a multidisciplinary team

– it lasts at least three months with sessions (including a weigh-in) at least weekly or fortnightly

– focus on life-long lifestyle change and prevention of future weight gain

– achievable goals for are agreed at different stages tailored to individuals needs and goals

– specific dietary targets are agreed

– physical activity sessions are led by a qualified instructor

– use behaviour change methods

– programmes are tailored to different ethnic groups.