LTP Priority: Prevention – Obesity
Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service
Type of Interventions: Tier 2 Weight Management Services
Major driver of health inequalities in your area of work
What is the problem?
Obesity disproportionality impacts on several specific adult population groups. There are three main issues facing these groups, increased prevalence of obesity; reduced access to weight management services and problems around retention within these services. Some groups are affected by more than one these issues.
What follows is a precis of the current situation and evidence – to note that is not exhaustive.
The provision of mainstream weight management approaches free at the point of access is variable across the country. Where these are provided, they are typically not designed or targeted to meet the needs (lifestyle; behavioural; cultural; psycho-social) or circumstances of these specific population groups. This, for certain population groups, has contributed to an inequity of access to services and approaches. This inequity may in part be contributing to the observed inequalities experienced by certain population groups.
Which population groups are at greater risk of inequity?
Low income groups – For women there is a link between household income and obesity, with the prevalence of obesity in the lowest quintiles being around twice that of the highest quintiles (38% compared with 18%) Data from: Health Survey for England 2017.
Whilst low income groups might accept a referral to tier 2 weight management services, evidence suggests that retention and therefore weight loss achieved tend to be lower than in high income groups. Data from: The equity impact of brief opportunistic interventions to promote weight loss in primary care: secondary analysis of the BWeL randomised trial
Severe Mental Illness (SMI) – Average life expectancy for those living with SMI is 15-20 years shorter than the general population. A significant physical health inequality, which is associated with an increased risk of several chronic diseases, is the higher rates of obesity, which are almost double in patients living with SMI compared to all patients. For this group, alongside other factors, there is a need to recognise and consider the side effects of psychotropic medications on weight management. Data from: Severe mental illness (SMI) and physical health inequalities: briefing (PHE)
Those with SMI have a low take-up of information and interventions relating to obesity and it is recognised that increasing access to these services is important for this population group. Data from: The Five Year Forward View for Mental Health (NHSE)
Learning Disabilities – Prevalence of obesity is higher for those living with learning disabilities than the general population. 31% of men and 45% of women have obesity compared to 24% of men and 27% of women without a learning disability. Data from: Health and Care of People with Learning Disabilities: Experimental Statistics: 2014 to 2015.
Evidence shows that there are a number of barriers for those with learning disabilities in accessing health services, which is also likely to be relevant to access of weight management support. Data from: Health Inequalities – Mencap
Black and Minority Ethnic (BME) groups – Individuals from Black, Asian and other minority ethnic groups are at an equivalent risk to type 2 diabetes, other health conditions or mortality, at a lower BMI than the white European population. It is therefore recommended that lower thresholds (BMI 23kg/m2 instead of 25kg/m2 for overweight and 27.5kg/m2 instead of 30kg/m2 for obese) are used to trigger action to prevent type 2 diabetes among South Asian, Black African, Black Caribbean
Black African and Black Caribbean adults in the UK generally have a higher risk for obesity than white adults. Data from: Ethnic inequalities in obesity among children and adults in the UK: a systematic review of the literature
Research has identified areas for some minority ethnic groups which may pose a barrier to accessing services including: poor health literacy and the need for culturally compatible information. Data from: PHE Local action on health inequalities Understanding and reducing ethnic inequalities in health.
‘Traditional’ weight management services are not always designed for men and research has consistently shown an under-representation, both in those referred and enrolled in the programme. This inequity of access to services means that men are therefore not routinely receiving the same support with their weight as women. Evidence does show that once men are engaged in the service they remain committed. Data from: Systematic reviews of and integrated report on the quantitative, qualitative and economic evidence base for the management of obesity in men (NIHR).
Pre and post-natal women
About half of women of childbearing age in England are either overweight or obese. There is evidence that maternal obesity is related to health inequalities, particularly socioeconomic deprivation and inequalities within minority ethnic groups.
Research shows an intergenerational effect with higher risks for children whose parents are obese or overweight. There is a clear relationship in child obesity prevalence and social deprivation and a growing gap between most and least deprived deciles. Supporting women to be healthy when they become pregnant is an important precursor to ensuring they are healthy during pregnancy.
- NICE (2010) Weight management before, during and after pregnancy. public health guideline [PH27}.
- Public Health England. Adult obesity and socioeconomic status data factsheet. August 2014
- Public Health England. Adult slide set. 2013. Adult obesity prevalence by ethnic group. Health Survey for England 2006-2010
- Heslehurst, N., Lang, R., Wilkinson, J.R., Summerbell, C.D., (2007). Obesity in pregnancy: a study of the impact of maternal obesity on NHS maternity
Research shows that LGB&T people may be less likely to access mainstream services due to both previous experience as well as fear of discrimination. Data from: Inequality among lesbian, gay, bisexual and transgender groups in the UK: a review of evidence (NIESR)
Research specifically on lesbian and bisexual women and weight management services have highlighted the need for culturally competent approaches and a better understanding of the specific context of weight issues for this group. Data from: Improving the health and wellbeing of lesbian and bisexual women and other women who have sex with women. (PHE)
Gypsy and Traveller populations
Gypsy and Travellers report to have poorer health than the general population and have significant barriers in accessing primary care services, which in turn may impact their ability to access community services such as weight management services. Data from: PHE Local action on health inequalities Understanding and reducing ethnic inequalities in health.
Deprivation and protected characteristics
- Disability (SMI/learning disabilities)
- Sex (Men)
- Race (BME groups)
- Sexual orientation (LGBT-Q)
- Pregnancy and maternal (pre and post)
Lifestyle Tier 2 weight management – targeted to specific population groups at higher risk from obesity
Targeted weight management services and approaches for the groups identified here already exist. Some CCGs and Local Authorities are already commissioning such approaches and providers are working locally to support men living with obesity; people living with severe mental illness and learning disabilities. The positive practice of targeting provision by certain areas provides an opportunity to other CCGs and Local Authorities to do likewise and enable more personalised provision at scale to deliver against the unmet need of these population groups.
Existing services tailor provision to ensure that the needs and circumstances of these groups are met. Many providers adapt or base services on existing evidence-based guides, for the delivery of weight management, adopting novel approaches and techniques to deliver effectively.
Tailoring and targeting tier 2 weight management services to engage groups who are: at higher risk of obesity; at higher risk of the co-morbidities that are associated with obesity; or who are less likely to find weight management services accessible/acceptable (see supportive guidance section for more information on tier 2 weight management services).
This should be done in collaboration with local government through the Health and Wellbeing Board (HWB).
- Where services already exist and are part way through their commissioning cycle, work with HWB to review current service and prioritise the tailoring/targeting of referral routes and the service design
- Where there is no existing service, or it is nearing the end of the commissioning cycle, work with HWB to design and develop specifications
Tailoring and targeting services to reduce health inequalities
- Considerations need to be made at every stage of the weight management service pathway, including:
- Life before the service – understanding population need, making the case and marketing
- Life during the service – recruitment, design, delivery and evaluation
- Life after the service – maintenance
- An equality impact assessment can support assessment of the services potential impact on equality and equity of service provision
NB prevalence for some characteristics may be very low in some areas, therefore commissioners and providers of services will need to practically decide the best way to provide targeted and tailored support to these individuals.
Expected outcomes (the Key Performance Indicators paper in the supportive guidance section will support this. Targets for groups more likely to experience health inequalities should be locally determined, depending on local needs assessment, this includes KPIs):
- Achieving a certain number of referrals from certain groups more likely to experience health inequalities (to be determined locally)
- A set proportion of those referred to the service turn up to the first session
- Similar proportion of participants from groups more likely to experience health inequalities complete the active intervention as from the general population
- Similar proportion of participants from groups more likely to experience health inequalities have lost weight at the end of the service
- Similar proportion of participants have lost 5% of their initial body weight at the end of the service
There is a strong evidence base to support the content, design and effectiveness of tier 2 weight management services for the general population. The evidence for population groups more likely to experience health inequalities is more variable, in particular in relation to the details of what works to tailor/target these services.
There is systematic review level evidence to support the tailoring and targeting of weight management services to better engage men, the key learnings are:
- Policies and services to prevent and treat obesity should take account of sex and gender-related differences. Service providers aiming to improve male uptake should consult men in the development and evaluation of services.
- Weight reduction for men is best achieved and maintained with the combination of three components:
- A reducing diet
- Advice on, or provision of, physical activity
- Behaviour change techniques
- Men prefer simple, fact-based language with individual feedback.
- For some men, but not all, the opportunity to attend men-only groups may enhance effectiveness. Group-based interventions should also provide some individual tailoring and individual feedback to male participants.
- Weight loss programmes for men may be better provided in social settings, such as sports clubs and workplaces, which may be more successful at engaging men than NHS settings.
- Health benefits associated with weight loss could also help motivate men to lose weight.
This provides commissioners with the basis for what a targeted service for men should comprise of – local determination is required to ensure that services tailor and meet the needs of men from minority groups i.e. low income, ethnic minorities or LGBT groups.
Robertson C, et al. Systematic reviews and integrated report on the quantitative, qualitative and economic evidence base for the management of obesity in men. Health Technol Assess 2014; 18(35)
Robertson C, et al. Clinical effectiveness of weight loss and weight maintenance interventions for men: a systematic review of men-only randomized controlled trials (the ROMEO project). American Journal of Men’s Health 2017; 11(4)
There is systematic level evidence to support the effectiveness of nutritional and lifestyle interventions as weight management approaches for those living with SMI.
A systematic review found that those living with SMI who received nutrition interventions (either delivered stand alone of as part of a multidisciplinary intervention) led to a significant reduction in weight, BMI and waist circumference when compared to control groups.
The most effective goals and delivery methods identified were:
- Preventing weight gain from initiation of anti-psychotic therapy
- Delivery by a dietitian
This study specifically focused on the nutritional element of delivery, rather than reviewing the effectiveness of lifestyle interventions however it has applicability to tier 2 weight management interventions.
Scott B, et al. Solving a weight problem: systematic review and meta-analysis of nutrition interventions in severe mental illness. The British Journal of Psychiatry 2017; 210, 110-118
A further systematic review and meta-analysis looked at the effectiveness of lifestyle interventions for weight loss among overweight and obese adults living with SMI.
Lifestyle interventions can support those living with SMI to achieve a small but significant weight loss. Evidence suggests that longer interention of 12 months and over have more consistent outcomes than shorter interventions of fewer than 6 months. However the effect sizes in both length of interventions are similar.
Naslund J, et al. Lifestlye interventions for weight loss among overweight and obese adults with serious mental illness: A systematic review and meta-analysis. General hospital psychiatry 2017; 47
There is currently a paucity of evidence to demonstrate the effectiveness of tier 2 weight management services for those living with Learning Disabilities. PHE has however published a report which provides guidance on making ‘reasonable adjustments’ to weight management services for those living with Learning Disabilities, this is include in the guidance section of this paper.
BME, low income, LGBT-Q, post-natal, Gypsy and Traveller and other marginalised groups
Guidance for Commissioners
A guide to commissioning and delivering tier 2 adult weight management services (PHE) This guide brings together the evidence to support the local commissioning and delivery of effective tier 2 weight management services for adults. It includes recommendations to design and implement services to try and reduce health inequalities i.e. assessing population need; lowering eligibility criteria for high risk ethnic minorities; making reasonable adjustments for those with learning disabilities and/or mental illness.
Key performance indicators: tier 2 weight management services for adults (PHE) This document provides an example of Key Performance Indicators (KPIs) which could be incorporated into a specification for a tier 2 adult weight management service. This includes supporting information on how to capture information on groups at risk of experiencing health inequalities and ensure that the service is engaging and meeting the needs of these groups. Targets around these groups should be locally determined and set.
Changing behaviour: techniques for tier 2 adult weight management services (PHE) This document provided relevant evidence-based behaviour change techniques recommended for inclusion in weight management services for weight loss and weight maintenance.
Let’s talk about weight: a step-by-step guide to brief interventions with adults for health and care professionals (PHE) This document offers tips on the short conversations health and care professionals should be having with people with overweight and obesity about weight loss. Conversations should be tailored and targeted to reach and engage those groups most vulnerable to experiencing health inequalities.
Obesity and weight management for people with learning disabilities: guidance (PHE) This guide, developed by PHE, advises about specific aspects of weight management for people with learning disabilities, including tips on ensuring that mainstream weight management programmes are accessible.
How to make weight-loss services work for men and best practice tips (Men’s Health Forum and PHE) An evidence-based guide and set of best practice tips to support the design and delivery of weight management services to engage men.
NICE CG189 Obesity: identification, assessment and management This guideline covers identifying, assessing and managing obesity in children (aged 2 years and over), young people and adults.
NICE PH46 BMI: preventing ill health and premature death in black, Asian and other minority ethnic groups This guidance assesses how body mass index (BMI) and waist circumference among adults from black, Asian and other minority ethnic groups in the UK links to the risk of a range of non-communicable diseases. The aim was to determine whether lower cut-off points or thresholds should be used for these groups, compared to those used for the white population, as a trigger for lifestyle interventions to prevent conditions such as diabetes, myocardial infarction or stroke.
NICE PH53 Weight management: lifestyle services for overweight or obese adults This guideline makes recommendations on the provision of effective multi-component lifestyle weight management services for adults who are overweight or obese (aged 18 and over). It includes recommendations on adjusting BMI eligibility cut offs for ethnicity and around monitoring and evaluation to assess the effects of any lifestyle intervention on inequalities.
NICE PH27 Weight management before, during and after pregnancy This guideline provides NICE’s formal guidance on dietary interventions and physical activity interventions for weight management before, during and after pregnancy.