Tier 3 specialist weight management service and pre-bariatric multicomponent weight management programmes for adults with obesity living in the UK: A systematic review

The Potential of a Digital Weight Management Program to Support Specialist Weight Management Services in the UK National Health Service: Retrospective Analysis

BACKGROUND

Digital weight management interventions (DWMIs) have the potential to support existing specialist weight management services (SWMS) in the National Health Service (NHS) to increase access to treatment for people living with obesity and type 2 diabetes. At present, there is limited real-world evidence and long-term outcomes on the potential effectiveness of DWMIs to support such services.

OBJECTIVE

This study aimed to examine real-world data to evaluate the impact of Second Nature's 12-month DWMI for patients living with obesity with or without type 2 diabetes, referred from NHS primary care services, on sustained weight loss over a 2-year period.

METHODS

Retrospective data were extracted in August 2023 for participants who participated in the program between January 1, 2017, and January 8, 2021. Eligible participants were adults with a BMI ≥35 kg/m2, with or without type 2 diabetes. The primary outcomes were weight change in kilograms and percentage weight change at 2 years. Secondary outcomes were weight loss at 1 year, program engagement, and the proportion of participants who achieved >5% and >10% weight loss. Differences in weight loss between baseline and the 1- and 2-year follow-up points were compared using paired 2-tailed t tests. Linear regression models were used to examine whether participants' ethnicity, indices of multiple deprivation, presence of type 2 diabetes, or program engagement were associated with weight loss at 1 year or 2 years.

RESULTS

A total of 1130 participants with a mean baseline BMI of 46.3 (SD 31.6) kg/m2 were included in the analysis. Of these participants, 65% (740/1130) were female (mean age 49.9, SD 12.0 years), 18.1% (205/339) were from Black, Asian, mixed, or other ethnicities, and 78.2% (884/1130) had type 2 diabetes. A total of 281 (24.9%) participants recorded weight readings at 2 years from baseline, with a mean weight loss of 13.8 kg (SD 14.2 kg; P<.001) or 11.8% (SD 10.9%; P<.001). A total of 204 (18.1%) participants achieved ≥5% weight loss, and 130 (11.5%) participants reached ≥10% weight loss. Weight loss did not significantly differ by ethnicity, indices of multiple deprivation, presence of type 2 diabetes, or engagement in the program.

CONCLUSIONS

The findings suggested that Second Nature's DWMI has the potential to support people living with obesity and type 2 diabetes remotely to achieve clinically significant and sustained weight loss at 2 years from baseline. Further research is needed to compare the intervention to standard care and assess integration with multidisciplinary clinical teams and pharmacotherapy in order to support this study's findings.

Liraglutide 3.0 mg (Saxenda©) for Weight Loss and Remission of Pre-Diabetes. Real-World Clinical Evaluation of Effectiveness among Patients Awaiting Bariatric Surgery

OBJECTIVE

The effectiveness of liraglutide 3.0 mg (Saxenda) therapy to induce weight loss among obese patients prior to bariatric surgery remains uncertain.

METHODS

Clinical data was retrospectively obtained from patients with prediabetes (HbA1c 42-47 mmol/mol) and selected patients on the waiting list for bariatric surgery at the Royal Derby Hospital. Clinical data was collected retrospectively at 6, 12, 26 and 52 week intervals. The outcomes included mean weight change, proportion of patients achieving ≥ 5% and ≥ 10% weight loss and achieving HbA1c reduction to normal range values.

RESULTS

Fifty patients (mean age of 46.2 ± 10.5 years; 76% female and 94% had Class III obesity) who completed 52 and/or 26 weeks of treatment were included. Liraglutide 3.0 mg produced a consistent and statistically significant reduction in weight (kg), BMI (kg/m2) and HbA1c (mmol/mol) across all four time intervals. Average ± SD reduction for weight, BMI and HbA1c respectively at 26 weeks were: -10.9 ± 9.1 (P < 0.01), -3.67 ± 3.5 (P < 0.01), -4.7 IQR 4.95 (P < 0.001), and at 52 weeks were: -14 ± 9.2 kg (P < 0.001), -4.64 ± 4.0 (P < 0.001 and -5.5 IQR 4 (P = 0.009). 85.7% and 33.3% of patients achieved ≥ 5% and 10% weight loss target respectively at 52 weeks. 92.3% and 72.2% achieved remission of pre-diabetes by 6 and 12 months respectively. Liraglutide 3.0 mg was well-tolerated with only 10% discontinuing medication due to tolerability issues.

CONCLUSION

Liraglutide 3.0 mg, with lifestyle management, reduced weight and improved glycaemic control. These results support liraglutide's application in certain high-risk populations, including patients waiting for bariatric surgical intervention.

Bariatric surgery tourism in the COVID-19 era

Background

Since the start of the Covid-19 pandemic primary and secondary health care services in Northern Ireland have observed an increase in the number of patients who have had bariatric surgery outside of the UK. This study sought to estimate the frequency of bariatric surgery tourism and to audit indications, blood monitoring and medical complications.

Methods

All primary care centres within the Western Health Social Care Trust (WHSCT) were invited to document the number of patients undergoing bariatric surgery between January 1, 2017 and December 31, 2022. For one primary care centre, patients who underwent bariatric surgery were assessed against the National Institute of Health and Clinical Excellence (NICE) guideline indications for bariatric surgery. In addition, the blood monitoring of these patients was audited against the British Obesity and Metabolic Surgery Society (BOMSS) guidelines for up to two years following surgery. Medical contacts for surgical complications of bariatric surgery were recorded.

Results

Thirty-five of 47 (74.5%) GP surgeries replied to the survey, representing 239,961 patients among 325,126 registrations (73.8%). In the six year study period 463 patients had reported having bariatric surgery to their GP. Women were more likely to have had bariatric surgery than men (85.1% versus 14.9%). There was a marked increase in the number of patients undergoing bariatric surgery with each year of the study (p<0.0001 chi square for trend). Twenty-one of 47 patients (44.7%) evaluated in one primary care centre fulfilled NICE criteria for bariatric surgery. The level of three-month monitoring ranged from 23% (for vitamin D) to 89% (electrolytes), but decreased at two years to 9% (vitamin D) and 64% (electrolytes and liver function tests). Surgical complication prevalence from wound infections was 19% (9 of 44). Antidepressant medications were prescribed for 23 of 47 patients (48.9%).

Conclusions

The WHSCT has experienced a growing population of patients availing of bariatric surgery outside of the National Health Service. In view of this and the projected increase in obesity prevalence, a specialist obesity management service is urgently required in Northern Ireland.

UK cost-effectiveness analysis of endoscopic sleeve gastroplasty versus lifestyle modification alone for adults with class II obesity

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure that has been demonstrated in the MERIT randomised, controlled trial to result in substantial and durable additional weight loss in adults with obesity compared with lifestyle modification (LM) alone. We sought to conduct the first cost-effectiveness analysis of ESG versus LM alone in adults with class II obesity (BMI 35.0-39.9 kg/m2) from a national healthcare system perspective in England based on results from this study.

METHODS

A 6-state Markov model was developed comprising 5 BMI-based health states and an absorbing death state. Baseline characteristics, utilities, and transition probabilities were informed by patient-level data from the subset of patients with class II obesity in MERIT. Adverse events (AEs) were based on the MERIT safety population. Mortality was estimated by applying BMI-specific hazard ratios from the published literature to UK general population mortality rates. Utilities for the healthy weight and overweight health states were informed from the literature; disutility associated with increasing BMI in the class I-III obesity health states was estimated using MERIT utility data. Disutility due to AEs and the prevalence of obesity-related comorbidities were based on the literature. Costs included intervention costs, AE costs, and comorbidity costs.

RESULTS

ESG resulted in higher overall costs than LM alone but led to an increase in quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) for ESG vs LM alone was £2453/QALY gained. ESG was consistently cost effective across a wide range of sensitivity analyses, with no ICER estimate exceeding £10,000/QALY gained. In probabilistic sensitivity analysis, the mean ICER was £2502/QALY gained and ESG remained cost effective in 98.25% of iterations at a willingness-to-pay threshold of £20,000/QALY.

CONCLUSION

Our study indicates that ESG is highly cost effective versus LM alone for the treatment of adults with class II obesity in England.

Impact of specialized obesity management services on the reduction in the use of acute hospital services

Severe obesity affects 4% of Australians and is associated with increased use of healthcare services and higher healthcare costs. This study evaluates the effect of attending a public tertiary obesity service on acute hospital use. This record-linkage study included people aged ≥16 years with severe obesity who attended the Nepean Blue Mountains Family Metabolic Health Service (FMHS), New South Wales, Australia between January 2017, and September 2021. Emergency department (ED) presentations and acute hospital admissions and respective costs in the 1-year and 3-years pre-and-post first FMHS attendance were compared, overall and for adequate attendance (≥5 visits). A total of 640 patients (74% female, 50% <45 years) attended the FMHS, totalling 15 303 occasions of service, average 24 per person. There was a 31.0% and 17.6% reduction in acute admissions and ED presentations, respectively, translating into 34.0% and 23.4% decrease in costs. Adequate engagement was associated with a 48% decreased risk of acute admission (odds ratio 0.52; 95% confidence interval 0.29-0.94). Over 3-years, there was a 19.8% and 20.7% reduction in acute hospital admissions and ED presentations, respectively. Findings indicate that tertiary obesity services reduce acute hospital use. Improved access to specialized obesity management may offload hospitals and contribute to acute healthcare cost avoidance.

The forgotten patient: A psychological perspective on the implementation of bariatric surgery guidelines

There is strong evidence demonstrating the impact of bariatric surgery on weight-loss and comorbidity improvement. In the UK, there is specific guidance to facilitate the assessment of a person's suitability for bariatric surgery. This paper highlights the clinical reality of routinely implementing this guidance, supported by literature and the perspectives of practicing psychologists. The consequences of the implementation of clinical guidelines within the context of the typical biopsychosocial profile of those referred for bariatric surgery are discussed. The ramifications of a screening approach rather than a clinical formulation-based approach to assessment, impact of a possible unconscious bias in commissioning and an overemphasis on a biomedical model approach to treatment are also presented. These contextual factors are argued to contribute to a population of "forgotten patients" that is, patients who have been assessed as not suitable for bariatric surgery, and thus "stuck" in their journey toward better health. For these individuals the only option left are energy balance only approaches, which are the very same approaches to weight-loss and comorbidity improvement that have been attempted, often for many years. Not only have these approaches not resulted in weight-loss and health improvement, they also fail to address the underlying psychological causes of obesity. Consequently, this lack of support means that patients continue to suffer from poor quality of life, with no clear pathway to improved health and wellbeing. This paper illuminates the clear gaps in weight management service provision, the implementation of guidelines in practice, and offers practical suggestions to reduce the unintended consequences of clinical guidelines for bariatric surgery.

EMBIO trial study protocol: left gastric artery embolisation for weight loss in patients living with obesity with a BMI 35-50 kg/m2

INTRODUCTION

Left gastric artery embolisation (LGAE) is a well-established treatment for major upper gastrointestinal (GI) bleeding when control is not established via upper GI endoscopy and recently has shown promising results for weight loss in small single arm studies. LGAE could be a treatment option in between our current tier-3 and tier-4 services for obesity. EMBIO is a National Institute for Health Research funded trial, a multicentre double-blinded randomised controlled trial between Imperial College National Health Service Trust and University College London Hospital, comparing LGAE versus Placebo procedure. The key aims of the trial is to evaluate LGAE efficacy on weight loss, its mechanism of action, safety profile and obesity-related comorbidities.

METHODS AND ANALYSIS

76 participants will be recruited from the existing tier-3 database after providing informed consent. Key inclusion criteria include adults aged 18-70 with a body mass index 35-50 kg/m2 and appropriate anatomy of the left gastric artery and coeliac plexus on CT Angiogram. Key exclusion criteria included previous major abdominal and bariatric surgery, weight >150 kg, type 2 diabetes on any medications other than metformin and the use of weight modifying medications. Participants will undergo mechanistic visits 1 week prior to the intervention and 3, 6 and 12 months postintervention. Informed consent will be received from each participant and they will be randomised in a 1:1 ratio to left gastric artery embolisation and placebo treatment. Blinding strategies include the use of moderate doses of sedation, visual and auditory isolation. All participants will enter a tier-3 weight management programme postintervention. The primary analysis will estimate the difference between the groups in the mean per cent weight loss at 12 months.

ETHICS AND DISSEMINATION

This trial shall be conducted in full conformity with the 1964 Declaration of Helsinki and all subsequent revisions. Local research ethics approval was granted by London-Central Research Ethics Committee, (Reference 19/LO/0509) on 11 October 2019. The Medicines and Healthcare products Regulatory Agency (MHRA) issued the Letter of No Objection on 8 April 2022 (Reference CI/2022/0008/GB). The trial's development and progress are monitored by an independent trial steering committee and data monitoring and ethics committee. The researchers plan to disseminate results at conferences, in peer- reviewed journals as well as lay media and to patient organisations.

TRIAL REGISTRATION NUMBER

ISRCTN16158402.

eHealth in obesity care

Obesity in adults is a growing health concern. Although effective, current treatment options have not been able to overcome the various factors that contribute toward rising obesity rates. eHealth might hold the capacity to improve the effectiveness, delivery and flexibility of some of these treatments. Here, we show that eHealth lifestyle change interventions delivered through smartphones (mHealth) can facilitate significant weight loss, making mHealth an attractive adjunct to clinical obesity care. However, evidence is currently limited to short-term effects, and is also lacking with regards to effectiveness based on socioeconomic status and ethnic group. This raises concerns around the potential and inadvertent widening of obesity prevalence disparities between groups as mHealth lifestyle change interventions are increasingly used in obesity care. Thus, we also describe opportunities to address these concerns and gaps in evidence.

Clinical characteristics of patients undergoing primary bariatric surgery in the United Kingdom based on the National Bariatric Surgery Registry

Baseline demographic characteristics and operations undertaken for patients having bariatric surgery in the United Kingdom are largely unknown. This study aimed to describe the profile of patients having primary bariatric surgery in the National Health Service (NHS) or by self-pay, and associated operations performed for both pathways. The National Bariatric Surgery Registry dataset for 5 years between January 2015 and December 2019 was used. 34 580 patients underwent primary bariatric surgery, of which 75.9% were NHS patients. Mean patient age and initial body mass index were significantly higher for NHS compared to self-pay patients (mean age 45.8 ± 11.3 [SD] vs. 43.0 ± 12.0 years and initial body mass index 48.0 ± 7.9 vs. 42.9 ± 7.3 kg/m² , p < .001). NHS patients were more likely to have obesity-related complications compared to self-pay patients: prevalence of Type 2 diabetes mellitus 27.7% versus 8.3%, hypertension 37.1% versus 20.1%, obstructive sleep apnoea 27.4% versus 8.9%, severely impaired functional status 19.3% versus 13.9%, musculoskeletal pain 32.5% versus 20.1% and being on medication for depression 31.0% versus 25.9%, respectively (all p < .001). Gastric bypass was the most commonly performed primary NHS bariatric operation 57.2%, but sleeve gastrectomy predominated in self-pay patients 48.7% (both p < .001). In contrast to self-pay patients, NHS patients are receiving bariatric surgery only once they are older and at a much more advanced stage of obesity-related disease complications.

Barriers and Facilitators of Physical Activity

Background Physical inactivity accounts for 16.6% of deaths in the United Kingdom. This study aims to review the recent (2016–2021) systematic reviews (SRs) on the facilitators and barriers to physical activity (PA) participation among (UK)-based adults.

Methods Using the Participants, Interventions, Comparators, and Outcomes framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses strategy, a SR of SRs of studies on the facilitators and barriers to PA among (UK)-based adults, published between 2016 and December 3, 2021, in the PubMed, SCOPUS, or Cochrane Database of Systematic Reviews, was done.

Results Three SRs (each published in 2016, 2019, and 2021) were included and reviewed in the study. None of the reviewed SR included a study conducted during the coronavirus disease 2019 (COVID-19) pandemic; also, a paucity of primary studies on PA among (UK)-based adult black, Asian, and ethnic minorities populations was recorded. Having a knowledge/appreciation of the benefits of PA, having the opportunity for social interaction/participation and PA-related support, and having a safe environment for PA were the persistently reported facilitators to PA among (UK)-based adults. On the other hand, having language difficulties/language barrier, lack of time, and having underlying health problems were the persistently reported barriers to PA among them. Not all the included SRs received project funding.

Conclusion The outcomes of this study had identified contemporary research gaps regarding the current challenges related to PA among (UK)-based adults. It is a fact that COVID-19 has come to stay in the (UK) and, as a result, it has affected ways of living, especially PA; hence, there is an imminent need for a SR to collate current primary evidence, with regards to the COVID-19 pandemic, on the facilitators and barriers of PA among (UK)-based adults.

Health-related outcomes in patients enrolled on surgical and non-surgical routes in a weight management service

BACKGROUND AND AIMS

This study evaluates a specialist weight management service and compares outcomes in participants referred to the service undergoing either surgery or non-surgical routes to support weight loss.

METHODS

Four hundred and forty eight participants were assessed on various weight-related outcomes (body mass index [BMI], psychological distress, quality of life, nutrition, weight-related symptoms, physical activity) on referral to the service and on discharge. The effect of group (surgery or non-surgery) and time in the service were facilitated by doubly multivariate analyses of variance models.

RESULTS

Between referral and discharge, participants improved significantly on a combination of outcomes (P < .001) and on each outcome assessed individually. The magnitude of overall improvement was moderate (partial-η2 = 0.141). Individual improvement components varied; including a moderate reduction of 3.2% in the BMI outcome measure and a substantive gain of 64.6% in quality of life. Participants on non-surgical routes performed significantly better than participants on surgical routes on a linear combination of outcomes (P < .001) and on all outcomes except nutrition; with an effect of route small-to-moderate in magnitude (partial-η2 = 0.090).

CONCLUSIONS

Weight management services are successful in achieving weight management-related outcomes in the short- and long-term, with large overall improvements between referral and discharge averaged over all participants observed. Non-surgical routes appear to confer benefits between referral and discharge compared to surgical routes.

The Effect of Participation in Tier 3 Services on the Uptake of Bariatric Surgery

Background

Despite the recognised advantages of bariatric and metabolic surgery, only a small proportion of patients receive this intervention. In the UK, weight management systems are divided into four tiers. Tier 3 is a clinician-lead weight loss service while tier 4 considers surgery. While there is little evidence that tier 3 has any long-term benefits for weight loss, this study aims to determine whether tier 3 improves the uptake of surgery.

Method

A retrospective cohort study of all referrals to our unit between 2013 and 2016 was categorised according to source—tier 3, directly from the general practitioner (GP) or from another speciality. The likelihood of surgery was calculated using a regression model after considering patient demographics, comorbidities and distance from our hospital.

Results

Of the 399 patients, 69.2% were referred directly from the GP, 21.3% from tier 3, and 9.5% from another speciality of which 69.4%, 56.2%, and 36.8% progressed to surgery (p = 0.01). On regression analysis, patients from another speciality or GP were more likely to decide against surgery (OR 2.44 CI 1.13–6.80 p = 0.03 and OR 1.65 CI 1.10–3.12 p = 0.04 respectively) and more likely to be deemed not suitable for surgery by the MDT (OR 6.42 CI 1.25–33.1 p = 0.02 and OR 3.47 CI 1.11–12.9 p = 0.03) compared with tier 3 referrals.

Conclusion

As patients from tier 3 were more likely to undergo bariatric and metabolic surgery, this intervention remains a relevant step in the pathway. Such patients are likely to be better informed about the benefits of surgery and risks of severe obesity.

Developing Integrated Clinical Pathways for the Management of Clinically Severe Adult Obesity: a Critique of NHS England Policy

PURPOSE OF THE REVIEW

Pathways for obesity prevention and treatment are well documented, yet the prevalence of obesity is rising, and access to treatment (including bariatric surgery) is limited. This review seeks to assess the current integrated clinical pathway for obesity management in England and determine the major challenges.

RECENT FINDINGS

Evidence for tier 2 (community-based lifestyle intervention) and tier 3 (specialist weight management services) is limited, and how it facilitates care and improve outcomes in tier 4 remains uncertain. Treatment access, rigidity in pathways, uncertain treatment outcomes and weight stigma seems to be major barriers to improved care. More emphasis must be placed on access to effective treatments, treatment flexibility, addressing stigma and ensuring treatment efficacy including long-term health outcomes. Prevention and treatment should both receive significant focus though should be considered to be largely separate pathways. A simplified system for weight management is needed to allow flexibility and the delivery of personalized care including post-bariatric surgery care for those who need it.

The Relevant Perspective of Economic Evaluations Informing Local Decision Makers: An Exploration in Weight Loss Services

Since 2013, obesity services in the UK National Health Service (NHS) have focused on a tiered structure, with tiers 3 (specialist weight management services) and 4 (primarily bariatric surgery) commissioned by Clinical Commissioning Groups (CCGs) and widely reported as cost effective and recommended by national guidelines. However, CCGs have been reluctant to fully conform to the guidance. We explore how the different evaluative perspective of those generating evidence from local decision makers has contributed to this failure of the CCGs to provide services considered cost effective. We explore four elements where the conventional economic evaluation framework, as applied by the National Institute for Health and Care Excellence (NICE), differ from the reality faced by local decision makers: the cost-effectiveness threshold, the implications of decision uncertainty and budgetary excess, the valuation of future costs and outcomes, and the scope of included costs. We argue that the failure of the conventional framework to reflect the reality faced by local decision makers is rendering much of the existing literature and guidance inappropriate to the key commissioners. Our analysis demonstrates that it is not reasonable to assume that the framework of economic evaluation used to inform national guidance applies to local decision makers, such as in the commissioning of weight loss services. This failure is likely to apply to the majority of cases where evidence is generated to inform national decision makers but commissioning is at a local level.

Effectiveness and cost of integrating a pragmatic pathway for prescribing liraglutide 3.0 mg in obesity services (STRIVE study): study protocol of an open-label, real-world, randomised, controlled trial

INTRODUCTION

In the UK and Ireland, severe and complex obesity is managed in specialist weight management services (SWMS), which provide multicomponent lifestyle interventions to support weight loss, and use of medication if available. Liraglutide 3 mg (LIRA 3 mg) is an effective weight-loss medication, but weight loss in individual patients is variable, and its efficacy has not been assessed in SWMS. This study aims to investigate whether a targeted prescribing pathway for LIRA 3 mg with multiple prespecified stopping rules could help people with severe obesity and established complications achieve ≥15% weight loss in order to determine whether this could be considered a clinically effective and cost-effective strategy for managing severe and complex obesity in SWMS.

METHODS AND ANALYSIS

In this 2-year, multicentre, open-label, real-world randomised controlled trial, 384 adults with severe and complex obesity (defined as body mass index ≥35 kg/m² plus either prediabetes, type 2 diabetes, hypertension or sleep apnoea) will be randomised via a 2:1 ratio to receive either standard SWMS care (n=128) or standard SWMS care plus a targeted prescribing pathway for LIRA 3 mg with prespecified stopping rules at 16, 32 and 52 weeks (n=256).The primary outcome is to compare the proportion of participants achieving a weight loss of ≥15% at 52 weeks with a targeted prescribing pathway versus standard care. Secondary outcomes include a comparison of (1) the weight loss maintenance at 104 weeks and (2) the budget impact and cost effectiveness between the two groups in a real-world setting.

ETHICS AND DISSEMINATION

The Health Research Authority and the Medicines and Healthcare products Regulatory Authority in UK, the Health Products Regulatory Authority in Ireland, the North West Deanery Research Ethics Committee (UK) and the St Vincent's University Hospital European Research Ethics Committee (Ireland) have approved the study. The findings of the study will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov-Identifier: NCT03036800.European Clinical Trials Database-Identifier: EudraCT Number 2017-002998-20.