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Obesity management in adults NS MOM
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
obesity is the excessive accumulation of body fat [1,2]
often defined for epidemiological purposes byBMI, which is weight in kilograms divided by height in metres squared (kg/m2; seeBMItable) [1,2]
adults with a BMI of [1,2]:
between25-29.9kg/m2are classified as overweight
30kg/m2 and over are classified as obese
35kg/m2 and over are classified as very obese
over40kg/m2are classified as morbidly obese
the management of motivated obese adults
Out of scope:
population screening − this is not approved in the UK
medical management of related medical conditions − see relevant care map
In 2012, an estimated 62% of adults (aged 16 and over) were overweight or obese
1.8% were underweight and 2.4% had severe obesity
Men and women have a similar prevalence of obesity, but men are more likely to be overweight (42% compared to 32%)
The prevalence of obesity in adults rose from 15% in 1993 to 25% in 2012 (Figure 1)
Many of those in the obese category have a body mass index (BMI) much higher than 30 (Figure 2). There are more women than men with extremely high BMI values
The prevalence of obesity and overweight changes with age. Prevalence of overweight and obesity is lowest in the 16-24 years age group, and generally higher in the older age groups among both men and women
Women living in low-income households have the highest prevalence of obesity and those living in high-income households have the lowest. There is no clear pattern for men
 NICE. Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. Clinical guideline 43. London: NICE; 2006.
An anti-obesity drug should be considered only for those with a body mass index (BMI, individual's body-weight divided by the square of the individual's height) of 30 kg/m2or greater in whom at least 3 months of managed care involving supervised diet, exercise and behaviour modification fails to achieve a realistic reduction in weight. In the presence of risk factors (such as diabetes, coronary heart disease, hypertension, and obstructive sleep apnoea), it may be appropriate to prescribe a drug to individuals with a BMI of 28 kg/m2or greater. Drugs should never be used as the sole element of treatment. The individual should be monitored on a regular basis; drug treatment should be discontinued if the individual regains weight at any time whilst receiving drug treatment.
Combination therapy involving more than one anti-obesity drug is contra-indicated by the manufacturers; there is no evidence-base to support such treatment.
Orlistat,a lipase inhibitor, reduces the absorption of dietary fat. It is used in conjunction with a mildly hypocaloric diet in individuals with a body mass index (BMI) of 30 kg/m2or moreorin individuals with a BMI of 28 kg/m2or more in the presence of other risk factors such as type 2 diabetes, hypertension, or hypercholesterolaemia.
Drug treatment should be considered for patients who have not reached their target weight loss or have reached a plateau on dietary, activity and behavioural changes alone.
Orlistat is available over the counter under the brand name ALLI (GSK) (60mg capsules) at a cost of around £19 per month.
There are special offers available from pharmacies, supermarkets and online retailers). SeeALLI website for more information.
This service provides a non-surgical service for North Somerset patients with severe or complex obesity.
It offers a specialist multi-disciplinary weight management assessment (including psychological, dietician and medical support), followed by a 6-12 month programme of care comprising of MTD assessments, group and individual treatment sessions with the following key aims:
· To encourage long term behaviour change through promoting healthy eating, physical activity and recognising the psychological barriers to unhealthy relationships with food;
· To prevent / reduce / improve the management of any co-morbidities associated with severe obesity together with costs associated with these;
· Where appropriate, refer patients for Tier 4 surgical assessment and prepare these patients by supporting them to understand the risks of the surgery, the need for behaviour change pre and post-operatively and to assist in the decision making process.
Local administrative information
10/12/15 - The service is now open for new referrals
Policy - Criteria to Access Treatment Patients who are able to demonstrate that they meet all of these criteria will qualify for a referral to the Tier 3 Multi-Disciplinary Weight Management service: 1. The patient is aged 18 or over. Patients aged 16-18 years may be able to access the service as exceptions on a case by case basis AND 2. The patient has complied with sustained and coordinated weight loss interventions over a 2 year period, but they have failed to achieve or maintain weight loss goals AND 3. Patients must have – For North Somerset - Attendance at 10/12 consecutive weeks/sessions at a tier 2 weight management programme. In North Somerset, the Tier 2 weight management services currently commissioned are Slimming on Referral (Weight Watchers) and Man v Fat. Patients that have engaged in alternative tier 2 offers including self-funding at Weight Watchers, Slimming World or equivalent, should be considered on an individual basis. Patients should be asked to provide evidence of attendance i.e. letter from facilitator or alternatively, if a commissioned service was attended, the Tier 2 services can be contacted in order to assess against this entry criteria, contact email for this isSlimming.firstname.lastname@example.org. AND 4. Patients must have - 4.1 a BMI≥351 with significant obesity related co-morbidities that could be improved if they lost weight2 OR 4.2 a BMI≥40 (with or without co-morbidities). 5 Patients with a BMI≥50 may be referred directly (without evidence of compliance with Tier 2). Patients for whom surgery is dependent on weight loss and other patients who may benefit from immediate intervention may be considered for the service on a case by case basis. Patients who previously qualified for a referral but are on a ‘time out policy’ which will allow a patient to exit and return into the Tier 3 service once a specific issue has been addressed (e.g. binge eating disorder, bereavement, pregnancy). These patients will be able to access the service without a re-referral. Patients who are not eligible for treatment under this policy may be considered on an individual basis where their GP or consultant believes exceptional circumstances exist that warrant deviation from the rule of this policy. Individual cases will be reviewed at the Commissioner’s Exceptional Funding Panel upon receipt of a completed application form from the patient’s GP, Consultant or Clinician. Applications cannot be considered from patients personally.
Patients who previously qualified for a referral but are on a ‘time out policy’ which will allow a patient to exit and return into the Tier 3 service once a specific issue has been addressed (e.g. binge eating disorder, bereavement, pregnancy). These patients will be able to access the service without a re-referral. Exclusion Criteria: The following patients should not be referred (although the option of seeking Individual Funding approval is available):
· Patients who are currently successfully losing weight with dietetic or reputable evidence based weight management intervention
· Pregnant women - Women become pregnant during the programme will be able to pause the programme (‘time out policy’) and return to the service following the birth
· Patients who have been previously referred into the service and have left the pathway early or have disengaged from the services, who are seeking to re-enter as a re-referral will not be eligible within 12 months.
· Patients who have previously received bariatric surgery.
1 There is a tolerance unit of BMI 2.5 on each element of the criteria above in relation to at risk groups that have higher obesity prevalence rates particularly those with black African or Caribbean and South Asian origin. 2 Obesity related co-morbidities accepted: Established cardiovascular disease; Type 2 diabetes; Metabolic syndrome; Sever hypertension; Obstructive sleep apnoea (OSA); dyslipidaemia; Polycystic ovarian syndrome; Osteoarthritis and on medication; Severe lower limb major joint disease requiring orthopaedic intervention
Regular review is recommended to monitor the effect of drug treatment and to reinforce lifestyle advice and adherence.
Continue treatment beyond 12 weeks only if weight loss since start of treatment exceeds 5% (target for initial weight loss may be lower in patients with type 2 diabetes);
The decision to use drug treatment for longer than 12 months (usually for weight maintenance) should be made after discussing potential benefits and limitations with the patient.
If there is concern about the adequacy of micronutrient intake, a supplement providing the reference nutrient intake for all vitamins and minerals should be
considered, particularly for vulnerable groups such as older people (who may be at risk of malnutrition) and young people (who need vitamins and minerals for growth and development).
NICE Clinical Guideline 43:Obesity- Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children [2006, modified May 2014]
Slimming on Referral The Slimming on Referral service enables surgeries in North Somerset to refer obese adult patients for personalised weight management. This service is funded by North Somerset Council and delivered in partnership with Weight Watchers Health Solutions. The first 12 weeks of the Slimming on Referral service is provided FREE to the patient. Eligibility criteria
Person aged 16 years or more and resident in North Somerset
BMI >=30 (Please check BMI before referring)
BMI >=28 with comorbidity* or from BME population (Please check BMI before referring)
Has not attended a slimming club in the 12 months prior to referral (self funded or referred by health professional) Person ready to lose weight (if not, refer to Get Ready for Change, Tel: 0300 300 0834).
Person has an eating disorder.
Person has underlying medical cause for obesity which requires more intensive support.
Patients with more complex needs, such as learning difficulties and mental health issues should be considered on an individual basis (tier 3).
Person is pregnant (refer to MSHINE programme, Tel: 01934 647082)
Suitability criteria For patients with BMI>50 please consider if the Tier 3 service may provide a more appropriate intervention.
Referral Process 1. Complete and print Patient Referral Letter in node below. 2. Give patient the Slimming on Referral “Patient Referral Letter”
Patient: Patient calls telephone number on “Patient Referral Letter” and quotes code WWRS082 and their NHS number. (Tel: 0345 602 7068, Monday to Sunday 8:00am – 8:00pm) When patient contacts Weight Watchers® they will double check their eligibility, book them on to their preferred group and issue them with their vouchers.
Outcomes Outcomes for patients are good with 74% of those completing 12 weeks of support losing 5% or more of their body weight.
NB: The service is only commissioned and funded for obese patients aged 16+. The consent from is generic and refers to overweight children aged 13+. Please ignore this.
Parent or guardian needs to accompany young person when they attend.
Patient also requires referral letter.
The referral letter is available as an EMIS template
BMI 35+ with co-morbidities
A tolerance of BMI 2.5 on each criteria above forat risk groups: black African, Caribbean and South Asian origin
Obesity related co-morbidities accepted:
Established cardiovascular disease;
Type 2 diabetes;
Impaired glucose tolerance,
Obstructive sleep apnoea (OSA);
Polycystic ovarian syndrome; Osteoarthritis and on medication;
Severe lower limb major joint disease (requiring orthopaedic intervention);
idiopathic intracranial hypertension.
A tolerance of BMI 2.5 on each criteria above for at risk groups: black African, Caribbean and South Asian origin
A tolerance of BMI 2.5 on each criteria above for at risk groups: black African, Caribbean and South Asian origin
The patient needs to have attempted weight loss for at least 2 years
This will be demonstrated by attendance at 10/12 consecutive weeks/sessions at a tier 2 weight management programme.
In North Somerset, the Tier 2 weight management services currently commissioned are Slimming on Referral (Weight Watchers)
Patients that have engaged in alternative tier 2 offers including self-funding at Weight Watchers, Slimming World or equivalent, should be considered on an individual basis.
Patients should be asked to provide evidence of attendance ie. letter from facilitator or alternatively, if a commissioned service was attended, the Tier 2 services can be contacted in order to assess against this entry criteria, contact email for this isSlimming.email@example.com
The following blood test results should be attached to the referral:
Full blood count
B12 and folate
Urea and electrolytes
Thyroid function tests (TSH and free T4)
Liver function tests
Fasting glucose and lipid profile
Calcium and Vitamin D
This form is available as an EMIS template
Referral to Tier 4 surgical assessment can only be made through Tier 3 service