Information intended for UK healthcare professionals only.
This supplement has been funded through an arm’s-length sponsorship by Novo Nordisk Limited. Guidelines in Practice approached Novo Nordisk Limited to fund the production of the supplement. Please see bottom of page for full disclaimer.
Two out of three adults in England are living with overweight. This includes 28% living with obesity.1,2 The highest rates of obesity are found in people who live in socially deprived areas.1 Obesity is a risk factor for long-term conditions such as cardiovascular disease, type 2 diabetes, and cancer; it impacts mental health, and reduces life expectancy.1 Conditions related to overweight and obesity have been estimated to cost the NHS around £6.1 billion a year.1
Patients living with overweight or obesity have had worse outcomes from COVID-19 than patients with a healthy weight: they have experienced a greater risk of serious illness or death, with this risk increasing as body mass index (BMI) increases.1,3 The World Obesity Federation has made a declaration for all countries to address obesity to ensure ‘better, more resilient and sustainable health for all, now and in our post-COVID-19 future’.4
During the COVID-19 pandemic in 2020, the UK government introduced new policies to reduce obesity, including plans to expand NHS weight management services and the NHS Diabetes Prevention Programme, and increase interventions for obesity in primary care.1 In 2021, the aim has been extended to ensure that everyone living with obesity is able to access support for weight loss.3
Clinicians in primary care are well placed to identify and support people living with obesity, and opportunistic support for weight management offered by healthcare professionals (HCPs) has been found to be acceptable to patients.5 Having a brief conversation about weight can be enough for some people living with obesity to lose weight.6
An enhanced service for weight management has been introduced to support practices to develop and implement a proactive approach to identifying patients living with obesity and to refer patients wanting support to weight management programmes.3 Participating practices are entitled to claim £11.50 for every referral of a patient living with obesity to a weight management service (see Box 1 for acceptable referrals), up to the limit of their referral allocation.3
Guidelines algorithm on managing obesity in primary care
A multidisciplinary working party met in October 2020 to develop a best practice guideline on ‘Managing obesity in primary care’ (see box below for details).7 The guideline outlines the role of the GP in managing obesity, the importance of language in avoiding stigma, which weight management options are currently available, and what support is needed by patients who have undergone bariatric surgery. It includes a simple algorithm that is designed to enable healthcare professionals to support patients with obesity and to understand when and where to refer patients for specialist help.
Following the algorithm, in conjunction with the recommendations given in this supplement, will help HCPs and commissioners to support the management of patients with obesity in primary care.
Obesity management pathway
The clinical pathway for patients with obesity in England is via a four-tiered system with interventions/treatments stepping up from Tier 1 to Tier 4. It is important that HCPs understand which services are available in each tier and their referral criteria. Local authorities are responsible for commissioning Tier 1 and 2 services, while CCGs commission Tier 3 and 4 services (Figure 1).8 Services vary substantially from region to region, so it is important that general practices are kept up to date with what weight management support is available locally, as well as with local referral criteria to guide management.6
Figure 1. Tiered weight management service structure.8
Figure adapted from Wilding J. Clin. Obes. 2018. 8: 211–225.
Tier 1 is universal services aimed at preventing obesity, reinforcing healthy eating and physical activity messages, and encouraging behavioural changes. This includes public health campaigns, such as, the recent Public Health England Better Health campaign,1 and identification and advice carried out by HCPs, pharmacists, and organisations such as leisure centres, in primary care and the community.9
Tier 2 is time-limited, non-specialist community weight management services, which typically provides advice on diet, nutrition, physical activity, and behavioural changes, and may be delivered by a variety of local support staff, usually in a group setting. Within Tier 2, GPs may have the option to refer patients free of charge to 12 week commercial weight management programmes.9 Box 2 (the Guidelines algorithm) the best practice guideline on ‘Managing obesity in primary care’ gives more information about possible local services covered in Tier 2.7
Box 2. Possible local services for referral and local support staff
Tier 3 is specialist weight management services for patients with severe or complex obesity led by a multidisciplinary team, usually including a specialist physician, specialist nurse, specialist dietitian, specialist psychologist, and physiotherapist. Tier 3 services can be delivered in primary or secondary care.9 They provide non-surgical intensive medical management, including access to specialist psychology therapy and dietetics, review for comorbidities related to obesity and management of current comorbidities. Patients are screened for hormonal and genetic causes of obesity. Tailored dietary and physical activity advice is given, and very low calorie diets and/or pharmacotherapy may be considered.9–11
Patients wanting to undergo bariatric surgery are usually required to spend at least 12 months following a weight management programme in a Tier 3 service. The service prepares patients in terms of what to expect from surgery, including the need to adhere to nutritional requirements after surgery, for lifelong follow up and the maintenance of eating behaviours.11–13
Tier 4 is severe and complex obesity services including bariatric surgery supported by a multidisciplinary team before and after surgery.9 The aim of Tier 4 services is to achieve a significant risk reduction in obesity-related comorbidities for patients with severe or complex obesity, including when this has not been achieved in other weight management services.14
Post-bariatric surgery patients are referred back to Tier 3 for follow-up support for a minimum of two years, but it is recommended that patients have lifelong follow-up support as part of a shared care arrangement with primary care.11,13,14
Table 1 gives an overview of the NICE eligibility criteria for weight management services, but HCPs will likely need to follow local referral criteria. Patients should be involved in shared decision making about referrals for weight management.16
|Table 1. Main eligibility criteria for referral to weight management services11,15–17|
Tier 2 services
≥30 or ≥27.5 for patients of Black African, African-Caribbean, and South Asian descent
Consider if capacity:
≥25 or ≥23 for patients of Black African, African-Caribbean, and South Asian descent
Tier 3 services
≥40 if no comorbidities
≥35 if type 2 diabetes and/or other comorbidities[A]
≥30 if Tier 2 interventions unsuccessful
Tier 4 services[B]
≥50 first line
≥40 if no comorbidities
≥35 if type 2 diabetes and/or other comorbidities[A]
30–34.9 and recent onset of type 2 diabetes
These criteria should be decreased by 2.5 BMI points for patients of Asian family origin
[A] Examples of obesity-related comorbidities include hypertension, obstructive sleep apnoea, functional disability, infertility, and depression.
[B] All patients require intensive management in a Tier 3 service before undergoing bariatric surgery.
Enhanced service specification for weight management
The enhanced service specification includes two components for service delivery:
- developing a supportive environment
- patient support and referral.
Developing a supportive environment
The specification for the enhanced service for weight management outlines the importance of training practice and primary care network (PCN) staff in the skills required for referral and signposting conversations for weight management, with protected learning time supported by commissioners.3
Participating practices should develop and implement a protocol to identify and support patients living with obesity.
The enhanced service specification states that this practice-based approach should aim for HCPs:3
- to normalise conversations about weight and weight management in all consultations, while remaining sensitive when talking to patients about their weight
- to use shared decision making with patients to assess whether they are interested in referral to a weight management service
- to maximise the ways in which they identify people living with obesity, whether by telephone, virtual, or face to face consultations
- to encourage patients to provide information on their weight, BMI, and other self-reportable health information
- to record the patient’s BMI annually, with a BMI recorded in their record, indicating they are living with obesity
- to record and maintain details of locally available weight management services and how to refer to them.
GP practices must also commit to restoring the practice obesity register.
Patient support and referral
Patients identified as living with obesity should be assessed for readiness to engage with weight management services, with an offer of a referral to the appropriate service made by a trained HCP, and the outcome should be recorded in the patient record.3
Challenges to managing obesity in primary care
There are several challenges to managing obesity in primary care.
There is increasing recognition of the significant stigma that can be experienced by patients living with obesity, including in healthcare settings.12 Experiences of stigma can have negative effects on people’s mental and physical health, potentially lead to further weight gain, and can impact on engagement with healthcare.6
Availability of Tier 3 services
With wide variations in the provision of Tier 3 services, patients in some areas may not have access to these services and, consequently, will not easily be able to access bariatric surgery.13 Practices in these areas will therefore struggle to refer patients with complex obesity in line with the enhanced service specification. Other patients may only have access to a Tier 3 service several miles from their home and may not have the means or ability to attend. With the high prevalence of obesity, demand for weight management services could potentially outstrip supply.12
Lack of referral to available services
Some HCPs may not have training in the structure of obesity services and their intended clinical outcomes, and may not be aware of which services are available for patients with obesity in their area. Practices may also lack clear referral criteria.12
A lack of service commissioning may be a result of funding constraints from commissioners.12
Inflexible clinical pathway
The rigid referral criteria for the different tiers and time limits during which patients may attend services make it hard for patients to move through tiers flexibly in line with their clinical needs and response to treatment. It can be difficult to tailor treatment effectively to individual patients, and delays in waiting to move up a tier when a patient requires more intensive management may result in failed weight loss attempts, which can have a significant negative impact.12
Patients who do not fit the referral criteria
Some patients with a BMI lower than the eligibility criteria for referral to weight management services may have obesity-related complications and would benefit from support with weight loss but cannot be supported with a referral.12
Follow up after bariatric surgery
In the NHS, patients tend to have at least two years of specialist follow up after bariatric surgery in a Tier 3 or 4 service before being discharged to primary care, as is recommended by NICE.15 Some patients may opt for private bariatric surgery and may not have access to either two years’ follow up post-surgery, or similar pre-surgery input as that provided by NHS Tier 3 services. Patients at any stage post surgery may develop a surgery related issue and GPs may not be confident in how to manage this, including when and how to access support from specialist services.
Reports that people living with obesity have been at greater risk of serious complications from COVID-19, have brought some focus to the health risks associated with obesity. The first COVID-19 lockdown in the UK had a detrimental impact on many people living with obesity in terms of their health-related behaviours, mental health, and access to weight management services.18
Primary care, along with the rest of the NHS, has been under enormous strain since the COVID-19 pandemic began so it is not an easy matter for practices to provide the necessary support or referrals to everyone living with obesity who would like to lose weight.
Recommendations to support practices
Obesity should not just be the responsibility of HCPs working in primary care, but should include all HCPs. Some suggested ways to support primary care in the management of patients with obesity are given in this section.
The clinical environment
To support patients living with obesity to feel comfortable in engaging with health services, it is important to ensure that the clinical environment is accessible and appropriate. Suggested examples of actions that can be taken by practices include:
- training practice staff to be aware of obesity stigma and to treat people living with obesity with respect
- using words and language that avoid stigma and prejudice to help people living with obesity engage in conversations about obesity (for example, wording used in text messages)6
- ensuring HCPs are sensitive to the anxiety some patients with obesity may have about being weighed
- providing information/posters about patient organisations such as Obesity UK and Obesity Empowerment Network in public areas
- making sure chairs in the waiting room and surgery rooms can easily accommodate people living with obesity—similarly, ensuring couches and toilets are fit for purpose for patients with obesity
- having practice equipment suitable for patients with obesity: such as weighing scales measuring up to 200 kg, measuring tapes for waist measurement, and blood pressure cuffs that fit patients living with obesity should be readily available
- if providing weighing scales in a waiting room or public area, ensure that they are positioned in such a way that provides privacy for patients to weigh themselves.
It would be useful for commissioners to speak to people living with obesity to learn about their support needs when commissioning services. Patients need accessible services. If no Tier 3 service is available locally, then one possibility could be that another Tier 3 provider subcommissions or trains local services. In this way, the Tier 3 service might act as a specialist centre (hub) in a hub-and-spoke model and develop relationships with the non-specialist referring practices (spokes) to support GPs and reduce variations in practice around the country.19
Different ways of working/commissioning
CCGs and local authorities could work together to support more integrated health and social care in obesity services.20 Better integration between primary and secondary care in the referral pathway is also important to ensure that patients are able to move smoothly between tiers when necessary.
Clarifying the referral pathway
HCPs in primary care need to understand the referral pathway for patients with obesity, be aware of what weight management services are available locally, and know what the referral criteria are for the different tiers. Education about the current structure of obesity services in the UK is therefore important to make sure that practice staff have a good understanding. If commissioners are unable to arrange this training, then it would be worth them liaising with weight management service providers to ask them to provide some educational sessions/outreach.
CCGs should disseminate to practices what is locally available, including referral criteria and forms, and take responsibility for keeping information on available weight management services up to date (including digital weight management programmes) (Box 5).
The learning aspects of the enhanced service specification for weight management require practice and PCN staff involved in referral and signposting conversations to have the necessary skills and training. Some suggestions for training are:
- CCGs could highlight to their practices the availability of online training resources in obesity management (Box 3)
- the obesity algorithm by Tahrani et al. (see box on page 3 for details) could be used as a basis to train practice staff in managing obesity
- practices could organise teaching sessions for staff about having conversations about obesity with patients—there are several resources available that might help (Box 4).
The Royal College of Surgeons of England produced a commissioning guide for Tier 3 services sponsored by the British Obesity and Metabolic Surgery Society, which provides some helpful tips for GPs on managing and referring patients with obesity that may be used as a training aid:11
- use every opportunity to identify patients who are living with overweight or obesity, including opportunistic case finding and routine health checks
- discuss the patient’s understanding of the likely resulting health problems, assess individual health risks, and engage with the patient in a partnership to modify the risks as part of a holistic approach that includes emotional wellbeing
- encourage training for doctors and practice nurses so that they are able to provide support for patients who are living with overweight or obesity
- provide a set of scales capable of weighing up to 200 kg in every surgery, and offer to refer patients over this weight to a service capable of weighing and monitoring them
- record the patient’s current weight and height to calculate BMI and measure waist circumference if BMI <35 kg/m2
- discuss previous attempts at weight loss with the patient and encourage those who have never successfully lost weight to participate in a community or commercial Tier 2 weight management plan, if appropriate
- recognise the patient with a long history of cyclical weight loss and regain and consider direct referral to a Tier 3 service
- discuss the benefits of weight maintenance if the patient is not yet ready to engage with a programme, and encourage them to return at any point if they decide they need help.
Patients who have had bariatric surgery should be offered yearly monitoring of nutritional status and appropriate supplementation, as part of a shared care model of chronic disease management.16 Box 6 gives information on resources for GPs and nutritional guidance in supporting patients post bariatric surgery. The GP’s role includes:21
- keeping a register of patients
- recalling patients for an annual review
- checking weight and bloods
- assessing and managing comorbidities and mental health
- monitoring for nutritional deficiencies
- ensuring the patient is taking nutritional supplements recommended by the bariatric team
- arranging access to supportive behaviours
- liaising with specialist services for advice
- referring back to the specialist team if required.
Changes in practice due to the COVID-19 pandemic
With the negative impact of COVID-19 on the health-related behaviours of patients with obesity, it is important that strategies to increase access to weight management services and mental health support for these patients should be prioritised during the recovery from the COVID-19 pandemic.18
Face-to-face weight management services were suspended during the COVID-19 lockdowns and some services adapted well to providing support remotely. Patients without internet access were generally satisfied with one-to-one telephone support services.22
Continuing with remote services may suit people who do not have ready access to a suitable weight management service in their area, as well as those who may be unable to attend a service in person.22 It is important to ensure, however, that such service adaptation takes into account health inequalities so that groups such as older adults, people living in areas of deprivation, and vulnerable people are not unfairly excluded from weight management services because of a lack of online access.22
The ideal weight management service would offer a range of delivery options to ensure a tailored approach to suit people’s different needs and preferences.22
The government introduced new policies during the COVID-19 pandemic in 2020 to reduce obesity. The aim has been extended to ensure that all people living with obesity are able to access support for weight loss. A multidisciplinary working party developed a best practice guideline on ‘Managing obesity in primary care’, which includes a simple algorithm to guide HCPs to support patients with obesity and to understand when and where to refer patients for specialist help. The algorithm can be used in conjunction with the recommendations in this supplement to help HCPs and commissioners support the management of patients with obesity in primary care.
- HCPs in primary care are well placed to identify people living with obesity and to offer support for weight management
- An enhanced service for weight management has been introduced to support practices to develop and implement a proactive approach to identifying patients living with obesity and to refer patients to weight management programmes
- Some challenges to managing obesity in primary care are availability of Tier 3 services, obesity stigma, low rates of referral to available services, funding constraints, inflexibility of the tiered weight management system, patients who fall outside the eligibility criteria for referral to weight management services, lack of training and support in follow up after bariatric surgery, and issues relating to the COVID-19 pandemic
- Practices should make efforts to ensure that the clinical environment is accessible and appropriate for patients living with obesity to support engagement
- Weight management services need to be accessible to patients with obesity so new ways of working and commissioning may need to be sought to provide services in all areas
- HCPs may not have a full understanding of the obesity referral pathway so should be provided with the necessary information and education to be able to support patients with obesity.
- GOV.UK Department of Health and Social Care. Tackling obesity: empowering adults and children to live healthier lives. www.gov.uk/government/publications/tackling-obesity-government-strategy/tackling-obesity-empowering-adults-and-children-to-live-healthier-lives (accessed on 4 November 2021).
- NHS Digital. Statistics on obesity, physical activity and diet, England, 2020. Part 3: Adult overweight and obesity. www.digital.nhs.uk/data-and-information/publications/statistical/statistics-on-obesity-physical-activity-and-diet/england-2020/part-3-adult-obesity-copy (accessed on 4 November 2021).
- NHS England. Enhanced service specification: Weight management 2021/22. England; NHS, 2021. Available at: www.england.nhs.uk/publication/enhanced-service-specification-weight-management-2021-22/
- World Obesity Federation. COVID-19 and obesity: the 2021 atlas. World Obesity; London, 2021. Available at: www.worldobesity.org/resources/resource-library/covid-19-and-obesity-the-2021-atlas
- Aveyard P, Lewis A, Tearne S et al. Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial. Lancet 2016; 388: 2492–2500.
- Albury C, Strain WD, Le Brocq S et al. The importance of language in engagement between health-care professionals and people living with obesity: a joint consensus statement. Lancet Diabetes Endocrinol 2020; 8 (5): 447–455.
- Guidelines online algorithm: Tahrani A, Parretti H, O’Kane M et al. Managing obesity in primary care. www.guidelines.co.uk/algorithms/managing-obesity-in-primary-care/455702.article (accessed 4 November 2021).
- Wilding J. Beyond lifestyle interventions: exploring the potential of anti-obesity medications in the UK. Clin Obes 2018; 8: 211–225.
- Obesity Empowerment Network. NHS Tiered Care Weight Management Pathway. www.oen.org.uk/managing-obesity/nhs-tiered-care-weight-management-pathway/ (accessed on 4 November 2021).
- Alkharaiji M, Anyanwagu U, Donnelly R, Idris I. Tier 3 specialist weight management service and pre-bariatric multicomponent weight management programmes for adults with obesity living in the UK: a systematic review. Endocrinol Diab Metab 2019; 2: e00042.
- Royal College of Surgeons of England. Commissioning guide: Weight management and management clinics (tier 3). British Obesity and Metabolic Surgery Society; London, 2014. Available at: www.rcseng.ac.uk/library-and-publications/rcs-publications/docs/weight-assessment-guide/
- Hazelhurst JM, Logue J, Parretti HM et al. Developing integrated clinical pathways for the management of clinically severe adult obesity: a critique of NHS England policy. Curr. Obes. Rep 2020; 9: 530–543.
- NHS England. Report of the working group into: Joined up clinical pathways for obesity. England; NHS England Publications, 2014. Available at: www.england.nhs.uk/wp-content/uploads/2014/03/owg-join-clinc-path.pdf
- NHS England. Appendix 9 guidance for clinical commissioning groups (CCGs): service specification guidance for obesity surgery. England; NHS England Publications, 2016. Available at: www.england.nhs.uk/wp-content/uploads/2016/05/appndx-9-serv-spec-ccg-guid.pdf
- NICE. Obesity: identification, assessment and management. Clinical Guideline 189. NICE, 2014. Available at: www.nice.org.uk/cg189
- Public Health England. Let’s talk about weight: a step-by-step guide to brief interventions with adults for health and care professionals. London; PHE Publications, 2017. Available at: www.assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/737903/weight_management_toolkit_Let_s_talk_about_weight.pdf
- NICE. BMI: preventing ill health and premature death in black, Asian and other minority ethnic groups. Public health guideline 46. NICE, 2013. Available at: www.nice.org.uk/ph46
- Brown A, Flint S, Kalea A et al. Negative impact of the first COVID-19 lockdown upon health-related behaviours and psychological wellbeing in people living with severe and complex obesity in the UK. EClinicalMedicine 2021; 34: 100796.
- Elrod J, Fortenberry Jr J. The hub-and-spoke organization design: an avenue for serving patients well. BMC Health Serv Res 2017; 17 (Suppl 1): 457.
- The King’s Fund. What is commissioning and how is it changing? www.kingsfund.org.uk/publications/what-commissioning-and-how-it-changing (accessed on 4 November 2021).
- Royal College of General Practitioners. Ten top tips for the management of patients post bariatric surgery in primary care. England; RCGP, 2014. Available at: www.rcgp.org.uk/clinical-and-research/resources/a-to-z-clinical-resources/obesity.aspx
- Public Health England. Supporting weight management services during the COVID-19 pandemic: Phase I insights. London; PHE Publications, 2020. Available at: www.assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/915274/WMS_Report.pdf
This supplement has been funded through an arm’s-length sponsorship by Novo Nordisk Limited. Guidelines in Practiceapproached Novo Nordisk Limited to fund the production of the supplement. Novo Nordisk Limited has had no influence over the selection of the authors or the content of the supplement and has reviewed it for technical accuracy only and to ensure compliance with regulations. The sponsorship fee included an honorarium for the authors, who were contracted and paid by MGP. The views and opinions of the authors are not necessarily those of Novo Nordisk Limited, or of Guidelines in Practice, its publisher, advisers, or advertisers. No part of this publication may be reproduced in any form without the permission of the publisher.
Date of preparation: December 2021