Kenneth Clare

ABSTRACT

This review highlights the important role primary care plays in obesity management, using England as an example. It includes a comprehensive summary of current management and referral options for primary care clinicians, a discussion of the most up‐to‐date clinical guidelines for the use of GLP‐1 receptor agonists in England, and the evolving ways in which obesity is identified and defined. Reflections from people living with obesity are considered. Despite the potential of primary care to engage with patients regarding obesity prevention and treatment, several factors have limited this, including low prioritisation by clinicians, workload pressures, regional variations in services, insufficient specialist training and ongoing weight stigma. The introduction of new pharmacotherapies, such as GLP‐1 receptor agonists, offers both an opportunity and a challenge for primary care providers. These treatments could help patients access more effective obesity management strategies via primary care. However, there is concern about non‐specialist clinicians keeping up to date with evolving strategies and understanding how new medications fit into broader care. The current complex referral pathways hinder timely access to appropriate treatment. The need for more straightforward pathways, improved clinician education and a reduction in the stigma associated with obesity is critical for better outcomes. In summary, while primary care could play a pivotal role in addressing obesity, several issues need to be resolved for this potential to be fully realised. Addressing these challenges, via enhancing clinician training, improving referral pathways and ensuring access to new treatments, will be crucial for advancing the care of people living with obesity.

Summary Introduction Glucagon‐like peptide‐1 receptor agonists, dual glucose‐dependent insulinotropic peptide receptor agonists and sodium‐glucose cotransporter‐2 inhibitors are used increasingly in patients receiving peri‐operative care. These drugs may be associated with risks of peri‐operative pulmonary aspiration or euglycaemic ketoacidosis. We produced a consensus statement for the peri‐operative management of adults taking these drugs. Methods This multidisciplinary consensus statement included surgeons, anaesthetists, physicians, pharmacists and people with lived experience relevant to these guidelines. Following the directed literature review, a three‐round modified Delphi process was conducted to generate and ratify recommendations. Results Patients taking glucagon‐like peptide‐1 receptor agonists and dual glucose‐dependent insulinotropic peptide receptor agonists should: continue these drugs before surgery; have full risk assessment and stratification; and receive peri‐operative techniques that may mitigate risk of pulmonary aspiration before, during and after sedation or general anaesthesia. Patients taking sodium‐glucose cotransporter‐2 inhibitors should omit them the day before and the day of a procedure. All patients should have risks and mitigation strategies discussed with a shared decision‐making approach. Discussion Until more evidence becomes available, this pragmatic, multidisciplinary consensus statement aims to support shared decision‐making and improve safety for patients taking glucagon‐like peptide‐1 receptor agonists, dual glucose‐dependent insulinotropic peptide receptor agonists and sodium‐glucose cotransporter‐2 inhibitors during the peri‐operative period.

Background: Obesity is highly stigmatized, with negative obesity-related stereotypes widespread across society. Internalized weight stigma (IWS) is linked to negative outcomes including poor mental health and disordered eating. Previous evidence examining population groups at higher risk of experiencing IWS comes from small, nonrepresentative samples. Here, we re-assess previously reported associations of IWS with demographic, socioeconomic, and wider social factors in a large general population birth cohort study for the first time. Methods: In the Avon Longitudinal Study of Parents and Children (ALSPAC), we explored differences in IWS at age 31 years by sex, ethnicity, socioeconomic factors, sexual orientation, and family and wider social influences, using confounder-adjusted multivariable regression. Findings: In models adjusted for potential confounders and BMI in childhood, adolescence, and adulthood (N = 4060), IWS was higher for females (standardized beta: 0.56, 95% CI: 0.50, 0.61), sexual minorities (0.17 S.D. higher, 95% CI: 0.09, 0.24), and less socioeconomically advantaged individuals (e.g., 0.16 S.D. higher (95% CI: 0.08, 0.24) for participants whose mothers had minimum or no qualifications, compared to a university degree). The social environment during adolescence and young adulthood was important: IWS was higher for people who at age 13 years felt pressure to lose weight from family (by 0.13 S.D., 95% CI: 0.03, 0.23), and the media (by 0.17, 95% CI: 0.10, 0.25), or had experienced bullying (e.g., 0.25 S.D., 95% CI: 0.17, 0.33 for bullying at age 23 years). Interpretation: Internalized weight stigma differs substantially between demographic groups. Risk is elevated for females, sexual minorities, and socioeconomically disadvantaged adults, and this is not explained by differences in BMI. Pressure to lose weight from family and the media in adolescence may have long-lasting effects on IWS. Funding: The ESRC, MRC, NIHR, and Wellcome Trust.

Introduction: Metabolic and bariatric surgery (MBS) has been an established treatment option for patients with Type 2 diabetes mellitus (T2DM), but there is a relative paucity of evidence-based guidelines on preoperative, operative, and postoperative considerations concerning metabolic surgery for T2DM patients. To address this gap, we initiated a Delphi consensus process with a diverse group of international multidisciplinary experts. Method: We embarked on a Delphi consensus-building exercise to propose an evidence-based expert consensus covering various aspects of MBS in patients with T2DM. We defined the scope of the exercise and proposed statements and surveyed the literature through electronic databases. The literature summary and voting process were conducted by 52 experts, who evaluated 44 statements. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Results: Consensus, defined as > 80% agreement, was reached for 43 out of 44 statements. The experts reached an agreement on the nature, terminology, and mechanisms of action of MBS. The currently available scores for predicting remission of T2DM after surgery are not robust enough for routine clinical use, and there is a need for further research to enable more personalized treatment. Additionally, they agreed that metabolic surgery for T2DM is cost-effective, and MBS procedures for treating T2DM vary in their safety and efficacy. Conclusion: This Delphi expert consensus statement guides clinicians on various aspects of metabolic surgery for T2DM and also grades the quality of the available evidence for each of the proposed statements.

Summary

Bariatric surgery is an effective treatment for obesity, but long‐term can lead to health‐related issues. Guidelines highlight the importance of long‐term post‐bariatric surgery follow‐up. However, in the UK, there is currently no specific funding to support the delivery of this care. Our aim was to understand the views and experiences of healthcare professionals (HCPs) around long‐term post‐bariatric surgery follow‐up, and barriers and enablers to care. Semi‐structured interviews with HCPs in UK primary care or specialist weight management services were conducted. The topic guide was theoretically informed by the Capability‐Opportunity‐Motivation‐Behaviour model and the Theoretical Domains Framework. Thematic analysis was undertaken. Twenty‐six HCPs were interviewed. Three core themes were interpreted: Existing Challenges, Mediating Factors and Future Directions. While there was agreement on the need for long‐term support, current provision was variable and hampered by a paucity of referral options. Follow‐up care could be contingent upon the patients' surgical pathway and the culture and expertise within the general practitioner surgery. Participants discussed potential ways to improve care, including using technology, adapting approaches used in other chronic conditions, shared care models and harnessing the potential for peer‐based support to improve wellbeing and quality of life. Healthcare professionals' views and experiences shared in this study highlight the complex issues associated with long‐term bariatric surgery follow‐up. The findings will inform future research to design and implement care pathways that are urgently needed to improve service provision for these patients.

Summary

The lack of standardization in patient‐reported outcome measures (PROMs) has made measurement and comparison of quality of life (QoL) outcomes in research focused on obesity treatment challenging. This study reports on the results of the second and third global multidisciplinary Standardizing Quality of life measures in Obesity Treatment (S.Q.O.T.) consensus meetings, where a core set of PROMs to measure nine previously selected patient‐reported outcomes (PROs) in obesity treatment research was established.

The S.Q.O.T. II online and S.Q.O.T. III face‐to‐face hybrid consensus meetings were held in October 2021 and May 2022. The meetings were led by an independent moderator specializing in PRO measurement. Nominal group techniques, Delphi exercises, and anonymous voting were used to select the most suitable PROMs by consensus. The meetings were attended by 28 and 27 participants, respectively, including a geographically diverse selection of people living with obesity (PLWO) and experts from various disciplines.

Out of 24 PROs and 16 PROMs identified in the first S.Q.O.T. consensus meeting, the following nine PROs and three PROMs were selected via consensus: BODY‐Q (physical function, physical symptoms, psychological function, social function, eating behavior, and body image), IWQOL‐Lite (self‐esteem), and QOLOS (excess skin). No PROM was selected to measure stigma as existing PROMs deemed to be inadequate.

A core set of PROMs to measure QoL in research focused on obesity treatment has been selected incorporating patients' and experts' opinions. This core set should serve as a minimum to use in obesity research studies and can be combined with clinical parameters.

Childhood obesity levels continue to rise, with significant impact on individuals and the NHS. The ‘Complications of Excess Weight’ (CEW) clinics provide support to young people with complications of their weight. Our objective was to co-develop, with young people, a new intervention; AIM2Change, to enable young people to develop their intrinsic motivation to manage weight, using Acceptance and Commitment Therapy (ACT), with a person-centred approach. Young people from the Care of Childhood Obesity (CoCO) clinic in Bristol, UK, were recruited to co-develop this intervention. The study was registered on ISRCTN (ISRCTN16607863). The seven-session, ACT-based intervention was delivered one-to-one, securely online. Qualitative interviews were conducted after each intervention session was delivered. Qualitative data were coded and reviewed regularly to make iterative changes to individual sessions and the overall programme. Fourteen co-developers were recruited, of whom nine completed the co-development process (female = 4; median age (IQR)=15(1.5); 4 with a parent; Indices of Multiple Deprivation (IMD) median = 3.5, range = 1–10). Iterative changes made during co-development included introducing an earlier focus on eating behaviour and body image, with more practical activities to increase engagement. Thematic analysis of co-developer feedback identified four themes: theoretical understanding; delivery and receipt of therapy; view of strategies and engagement; real world benefits of co-development process. Framework analysis was conducted to map data pertaining to these themes into matrices according to each participant and session. Insights from the co-development process have shaped AIM2Change to optimise the intervention’s value, relevance and acceptability. Findings suggest that AIM2Change meets an unmet need in delivery of current childhood weight management services.

Summary

Bariatric surgery can facilitate weight loss and improvement in medical comorbidities. It has a profound impact on nutrition, and patients need access to follow‐up and aftercare. NICE CG189 Obesity emphasized the importance of a minimum of 2 years follow‐up in the bariatric surgical service and recommended that following discharge from the surgical service, there should be annual monitoring as part of a shared care model of chronic disease management. NHS England Obesity Clinical Reference Group commissioned a multi‐professional subgroup, which included patient representatives, to develop bariatric surgery follow‐up guidelines. Terms of reference and scope were agreed upon. The group members took responsibility for different sections of the guidelines depending on their areas of expertise and experience. The quality of the evidence was rated and strength graded. Four different shared care models were proposed, taking into account the variation in access to bariatric surgical services and specialist teams across the country. The common features include annual review, ability for a GP to refer back to specialist centre, submission of follow‐up data to the national data base to NBSR. Clinical commissioning groups need to ensure that a shared care model is implemented as patient safety and long‐term follow‐up are important.

Background: Adherence to post-bariatric surgery nutritional supplements can be poor and is associated with higher micronutrient deficiency rates. There is currently no available study specifically seeking patients’ perspectives on the reasons behind poor adherence and how to address it. Methods: Bariatric surgery patients living in the UK were invited to take part in an anonymous survey on SurveyMonkey®. Results: A total of 529 patients (92.61% females, mean age 47.7 years) took part. Most of these patients had undergone either a Roux-en-Y gastric bypass (63.0%) or sleeve gastrectomy (24.0%). Most of the patients were in full-time (49.0%, n = 260/529) or part-time (15.7%, n = 83/529) employment. Approximately 54.0% (n = 287/529) of the respondents reported having trouble taking all their supplements. Males were significantly more likely to report complete compliance. The most important reported reason for poor compliance was difficulty in remembering (45.6%), followed by too many tablets (16.4%), side effects (14.3%), cost (11.5%), non-prescribing by GP (10.8%), bad taste (10.1%), and not feeling the need to take (9.4%). Patients suggested reducing the number of tablets (41.8%), patient education (25.7%), GP education (24.0%), reducing the cost (18.5%), and more information from a healthcare provider (12.5%) or a pharmacist (5.2%) to improve the compliance. Conclusions: This study is the first attempt to understand patient perspectives on poor adherence to post-bariatric surgery nutritional recommendation. Patients offered a number of explanations and also provided with suggestions on how to improve it.

In spite of the somewhat disordered development of day care for the mentally ill, the Psychiatric Day Hospital (PDH) has become accepted as an essential element in the mental health services. Several recent studies have defined a role for the PDH in the management of more acute psychiatric disorders (Creedet al, 1989), and this is likely to become increasingly important with the continuing reduction in the availability of in-patient facilities.

Background: Obesity is a chronic disease linked to over 200 health conditions, reduced quality of life, and increased mortality. Despite the availability of multimodal treatments, there is a lack of standardised, patient-centred outcome measures to effectively assess and improve clinical care. This project aimed to define a core set of standardised outcome measures for adults with obesity, incorporating both patient-reported and clinician-reported outcomes. Additional objectives included determining the optimal measurement frequency and identifying case-mix variables essential for risk adjustment. Methods: The International Consortium for Health Outcomes Measurement (ICHOM) established the Obesity Working Group (OWG), composed of 29 international experts and individuals living with obesity. Members were selected based on their expertise in obesity care and research and represented 21 countries. The development process, conducted from May 2023 to July 2024, began with a kick-off meeting to define scope, followed by eight virtual meetings. A comprehensive literature review informed the identification of relevant clinical outcomes, patient-reported outcomes, treatment-related complications, and case-mix variables. A three-round Delphi process was used to reach consensus on key outcomes and follow-up intervals. Outcomes were included in the final set if at least 80% of OWG members rated them between 7 and 9 on a 9-point scale. Validation was conducted through surveys with 95 patients and 106 healthcare professionals from fields such as dietetics, obesity medicine, and general practice. Findings: The OWG developed a standardised set of 20 outcome measures, comprising 17 core measures and 3 population-specific measures. These span domains including physical health, psychosocial well-being, health behaviours, body functioning, and adverse events. Specific measures were also developed for bariatric surgery and female reproductive health (both pregnant and non-pregnant individuals). Key case-mix factors and appropriate follow-up periods were defined to support global consistency in reporting. Interpretation: Adoption of this standardised outcome set enables clinicians, patients, and stakeholders to identify care gaps, monitor outcomes, and evaluate the quality of obesity care against global benchmarks. Implementation can support the creation of a robust international data resource to guide research, inform clinical practice, and shape policy and guidelines for adult obesity treatment. Limitations include limited geographical diversity in validation surveys, the exclusion of internalised weight bias due to a lack of validated measurement tools, and limited applicability to individuals with obesity and multiple comorbidities. Funding: Novo Nordisk, Eli Lilly, and Boehringer Ingelheim International GmbH.

Global obesity rates have risen dramatically, now exceeding deaths from starvation. Metabolic and bariatric surgery (MBS), initially for severe obesity (BMI ≥35 kg/m2), is performed globally over 500 000 times annually, offering significant metabolic benefits beyond weight loss. However, varying eligibility criteria globally impact patient care and healthcare resources. Updated in 2022, ASMBS and IFSO guidelines aim to standardise MBS indications, reflecting current understanding and emphasising comprehensive preoperative assessments. Yet, clinical variability persists, necessitating consensus-based recommendations. This modified Delphi study engaged 45 global experts to establish consensus on perioperative management in MBS. Experts selected from bariatric societies possessed expertise in MBS and participated in a two-round Delphi protocol. Consensus was achieved on 90 of 169 statements (53.3%), encompassing multidisciplinary team composition, patient selection criteria, preoperative testing, and referral pathways. The agreement highlighted the critical role of comprehensive preoperative assessments and the integration of healthcare professionals in MBS. These findings offer essential insights to standardise perioperative practices and advocate for evidence-based guidelines in MBS globally. The study underscores the need for unified protocols to optimise outcomes and guide future research in MBS.

Background: Bariatric and metabolic surgery tourism (BMT) is becoming an increasingly popular route to treatment for patients living with obesity. Recent reports have highlighted that some patients travelling abroad for bariatric surgery have received inadequate care, fraudulent care, and, tragically, some cases have resulted in death. This study aimed to define consensus in Europe regarding safe practices concerning BMT. Materials and methods: IFSO-EC, EASO and ECPO initiated a task force to delineate safe practices in BMT. Two expert European panels were convened, one comprised of healthcare professionals (identified from EASO and IFSO-EC) and the other of patient representatives (identified from ECPO). The study utilized a modified Delphi consensus methodology, and 135 questions were administered. Surveys were conducted anonymously online, and consensus was defined as 70% agreement. Themes analyzed regarding BMT included regulation, pre-operative evaluation, operative care, post-operative care, advertising and online information. Results: One hundred and nineteen healthcare professionals and 88 patient representatives participated from 26 countries. The healthcare professional panel included 66 bariatric surgeons, 28 endocrinologists, 18 dietitians, three nurses, two psychologists, one general practitioner and one gastroenterologist. Three questionnaire rounds were conducted for the healthcare professional panel, and two were performed for the patient representative panel. Consensus recommendations were given across all themes relevant to BMT. These included evaluating and managing psychological health, sleep apnea, cardiovascular disease, liver health and dietetic assessment. The recommendations covered the requirements for regulatory standards, including surgeon accreditation and procedural volume. They also included recommendations regarding patient education, standardized operative care, online information provision, and follow-up. Conclusions: Through collaboration with healthcare professionals and patients living with obesity, we provide European recommendations regarding safe practices concerning BMT. Further evaluation is required regarding outcomes following BMT. These data, alongside the Delphi consensus recommendations, will inform BMT clinical guideline development.

Background

Bariatric surgery is the most effective treatment for obesity, but access is limited. Endoscopic obesity treatments are potentially cheaper and less invasive options, which may be similarly effective. There is currently a lack of evidence to inform decisions on whether such treatments should be considered for people living with obesity.

Background: With over 1 billion individuals affected globally, obesity and obesity related diseases is now a leading cause of death. Metabolic and bariatric surgery (MBS) has emerged as a cornerstone intervention for severe obesity and its associated comorbidities. Despite its efficacy, postoperative care and follow-up after MBS remains highly variable worldwide. Objective: The PARTNER study aimed to evaluate global clinical practices in the postoperative management following MBS by surveying multidisciplinary healthcare professionals. Methods: This study was an international online survey conducted between October 2024 and January 2025. A multidisciplinary team developed the questionnaire based on existing literature and international guidelines. The survey assessed five domains: follow-up care, postoperative treatment, dietary management, patient support, and measurement of surgical outcomes. Responses were analysed descriptively. Results: A total of 262 responses were received from 62 countries. Most respondents were bariatric surgeons (72.1%) working in public healthcare systems (73.3%). While 78.7% reported conducting three-month postoperative reviews, only 23.7% offered indefinite follow-up. Hybrid models of care (virtual and in-person) were common (56.9%). VTE prophylaxis and postoperative PPI use were recommended by 64.1% and 84.3% respectively. Nearly all respondents (98.1%) provided dietary advice, with protein and micronutrient supplementation widely endorsed. Only 56.1% routinely referred patients for psychological follow-up. Definitions of surgical success and failure varied widely, with inconsistent objective outcome measures. Conclusion: The PARTNER study reveals significant international variation in postoperative management practices following MBS. These findings underscore the need for more standardized, evidence-based guidelines to improve long-term outcomes and equity of care worldwide.

Background: Child and adolescent overweight and obesity have increased globally and are associated with significant short- and long-term health consequences. Objectives: To assess the effects of surgery for treating obesity in childhood and adolescence. Search methods: For this update, we searched Cochrane Central Register of Controlled Trials, MEDLINE, Latin American and Caribbean Health Science Information database (LILACS), World Health Organization International Clinical Trials Registry Platform (ICTRP)and ClinicalTrials.gov on 20 August 2021 (date of the last search for all databases). We did not apply language restrictions. We checked references of identified studies and systematic reviews. Selection criteria: We selected randomised controlled trials (RCTs) of surgical interventions for treating obesity in children and adolescents (age < 18 years) with a minimum of six months of follow-up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or which included participants with a secondary or syndromic cause of obesity, or who were pregnant. Data collection and analysis: We used standard methodological procedures expected by Cochrane. Two review authors independently extracted data and assessed the risk of bias using the Cochrane Risk of Bias 2.0 tool. Where necessary, we contacted authors for additional information. Main results: With this update, we did not find any new RCTs. Therefore, this updated review still includes a single RCT (a total of 50 participants, 25 in both the intervention and comparator groups). The intervention focused on laparoscopic adjustable gastric banding surgery, which was compared to a control group receiving a multi-component lifestyle programme. The participating population consisted of Australian adolescents (a higher proportion of girls than boys) aged 14 to 18 years, with a mean age of 16.5 and 16.6 years in the gastric banding and lifestyle groups, respectively. The trial was conducted in a private hospital, receiving funding from the gastric banding manufacturer. For most of the outcomes, we identified a high risk of bias, mainly due to bias due to missing outcome data. Laparoscopic gastric banding surgery may reduce BMI by a mean difference (MD) of -11.40 kg/m

2

Objectives The Awareness, Care and Treatment In Obesity maNagement (ACTION) Teens study explored attitudes, behaviours, perceptions and barriers regarding effective obesity care among adolescents living with obesity (ALwO), caregivers and healthcare professionals (HCPs). Design Cross-sectional online survey study. Setting Study across 10 countries; here, we report data from UK respondents. Participants Overall, 416 ALwO (aged 12 to <18 years; body mass index ≥95th percentile for age and sex (WHO charts)), 498 caregivers and 250 HCPs in the UK completed the survey (August–December 2021). Primary and secondary outcome measures Survey questions addressed key aspects of obesity management for ALwO. Results Overall, 46% of ALwO perceived their weight as normal or below normal and 86% believed their health was at least good; 56% and 93% of caregivers responded similarly for their ALwO. Despite this, most ALwO (57%) had attempted to lose weight in the past year and 34% felt highly motivated to lose weight. YouTube and social media were most often used by ALwO for information about weight management (41% and 39%); few ALwO and caregivers sought information from a doctor (13% and 22%). Among ALwO who had discussed weight with an HCP (n=122), 49% trusted their weight-management advice. Only 10% of ALwO and 8% of caregivers were told by a doctor that they/their child had obesity. For HCPs, obesity-related comorbidities were the most common reason for initiating weight conversations with ALwO (73%), while short appointment times were the most common barrier (46%). Overall, 30% of ALwO and 11% of caregivers did not feel comfortable bringing up weight with an HCP. Conclusions Improved education and communication are needed among ALwO, caregivers and HCPs in the UK to help improve awareness of obesity, its aetiology and its impact on health, and to support HCPs to proactively initiate weight-related conversations and build trust with ALwO and caregivers.

Unlike various countries and organisations, including the World Health Organisation and the European Parliament, the United Kingdom does not formally recognise obesity as a disease. This report presents the discussion on the potential impact of defining obesity as a disease on the patient, the healthcare system, the economy, and the wider society. A group of speakers from a wide range of disciplines came together to debate the topic bringing their knowledge and expertise from backgrounds in medicine, psychology, economics, and politics as well as the experience of people living with obesity. The aim of their debate was not to decide whether obesity should be classified as a disease but rather to explore what the implications of doing so would be, what the gaps in the available data are, as well as to provide up-to-date information on the topic from experts in the field. There were four topics where speakers presented their viewpoints, each one including a question-and-answer section for debate. The first one focused on the impact that the recognition of obesity could have on people living with obesity regarding the change in their behaviour, either positive and empowering or more stigmatising. During the second one, the impact of defining obesity as a disease on the National Health Service and the wider economy was discussed. The primary outcome was the need for more robust data as the one available does not represent the actual cost of obesity. The third topic was related to the policy implications regarding treatment provision, focusing on the public's power to influence policy. Finally, the last issue discussed, included the implications of public health actions, highlighting the importance of the government's actions and private stakeholders. The speakers agreed that no matter where they stand on this debate, the goal is common: to provide a healthcare system that supports and protects the patients, strategies that protect the economy and broader society, and policies that reduce stigma and promote health equity. Many questions are left to be answered regarding how these goals can be achieved. However, this discussion has set a good foundation providing evidence that can be used by the public, clinicians, and policymakers to make that happen.

This article provides an account of the positive contribution of a patient and public involvement (PPI) team involved in research evaluating the National Health Service (NHS) in England’s low-calorie diet pilot aiming to reduce levels of type-2 diabetes. The article has been co-written by the PPI team and academics from the Re:Mission study. The PPI team members’ voice and experiences are included throughout the article and are reflected using terms ‘our’ and ‘we’.

Summary

The challenge of managing the epidemic of patients with severe and complex obesity disease in secondary care is largely unmet. In England, the National Institute of Health and Care Excellence and the National Health Service England have published guidance on the provision of specialist (non‐surgical) weight management services. We have undertaken a systematic review of ‘what evidence exists for what should happen in/commissioning of: primary or secondary care weight assessment and management clinics in patients needing specialist care for severe and complex obesity?’ using an accredited methodology to produce a model for organization of multidisciplinary team clinics that could be developed in every healthcare system, as an update to a previous review. Additions to the previous guidance were multidisciplinary team pathways for children/adolescent patients and their transition to adult care, anaesthetic assessment and recommendations for ongoing shared care with general practitioners, as a chronic disease management pathway.

Background: Depression and obesity are two of the most highly prevalent global public health concerns. Obesity and poor mental health are strongly associated, and it is likely that mental health needs are common in people seeking weight management services. Aims: To identify what psychological support is provided and required in tier 2 adult weight management services (T2 WMS). Methods: Online survey: quantitative data was summarised, and open-ended free-text questions were coded and thematically analysed. Results: Participants were current or recent service users with self-reported mental health needs (n = 27), commissioners (n = 9) or providers (n = 17). Over half of service users did not feel their mental health needs were met and 60% said they would like additional psychological support within T2 WMS. Findings highlight the lack of psychological and emotional support. Psychological support and behaviour change techniques are conflated, with a lack of clear understanding or definition of what psychological support is, either between or within service users, providers, and commissioners. Conclusions: Moving towards more person-centred care, better identification and triaging of those living with mental health issues, together with improved resources and training of providers, is crucial to improve outcomes for people living with obesity and poor mental health.

Introduction: The National Health Service (NHS) Low Calorie Diet (LCD) pilot programme aimed to support people with type 2 diabetes (T2DM) to lose weight, reduce glycaemia and potentially achieve T2DM remission using total diet replacement alongside behaviour change support. The Re:Mission study seeks to provide an enhanced understanding of the long-term cost-effectiveness of the programme and its implementation, equity, transferability and normalisation across broad and diverse populations. This article presents an overview of the methods used in the Re:Mission study. Methods and analysis: A mixed method approach was used to draw together service user insights from across longitudinal and cross-sectional online surveys and semi-structured interviews supported by a modified photovoice technique. Insights were captured from active service users across the three phases of the programme (total diet replacement, food reintroduction and maintenance) in addition to those discharged prematurely. Survey data were analysed using descriptive statistics and qualitative data were thematically analysed and interpreted through a realist informed lens to understand which aspects of the service work and do not work, for whom, in what context and why. Results: Results from the study are presented elsewhere, with recommendations for policy practice and research.

Background: The food reintroduction phase of the NHS Low Calorie Diet (LCD) programme aims to support service users to reintroduce food gradually back into their diet. Understanding experiences of food reintroduction from a broad and diverse range of service users is critical in helping to improve service delivery and commissioning and equity in care. Methods: This was a co-produced qualitative study underpinned by a realist informed approach, using interviews and photovoice techniques. Service users (n=43) of the NHS LCD Programme were recruited from three delivery models across 21 pilot sites in England. Data were analysed using a thematic approach. Results: The food introduction phase required control and planning that challenged the behaviours of participants. Around a third of participants continued use of Total Diet Replacement products, or considered doing so, for convenience and to maintain calorie control. The coach–service user relationship was important to understanding of session content and translation into behaviour change. Physical activity increased during this phase, which contributed to positive health outcomes. Conclusions: The paper reports insights from the food reintroduction phase of the LCD programme. Key messages include the need for increased frequency of support and the need for tailored and culturally representative education.

Background: The National Health Service (NHS) Low Calorie Diet (LCD) programme in England aims to support people with type 2 diabetes (T2DM) to lose weight, improve glycaemic parameters and potentially achieve diabetes remission. The programme pilot launched in 2020 using three different delivery models: one-to-one, group and digital via an App. Service users begin the programme with 12 weeks of Total Diet Replacement (TDR). This study aims to understand the experience of this TDR phase from the service user perspective. Methods: This was a co-produced qualitative longitudinal and cross-sectional study, underpinned by a realist informed approach using semi-structured interviews and photovoice techniques. Service users (n=45) from the NHS LCD programme were recruited across the three delivery models and 21 pilot sites in England. Data were analysed using a thematic approach. Results: Participant demographics were representative of the overall LCD pilot population sample and included experiences from a mix of delivery models and providers. Three themes were presented chronologically. 1) life pre-LCD: the LCD programme was viewed as an opportunity to reset eating behaviours and improve quality of life; 2) experience of TDR: flexibility in allowing supplementary non-starchy vegetables and adapting the flavour and texture of TDR products supported adherence; 3) looking ahead to food reintroduction: at the end of the TDR phase, weight and glycaemia had reduced, while subjective energy levels and mobility improved. Some participants were concerned about progressing to the food reintroduction phase and the possibility of weight regain. Conclusions: The paper reports insight from the TDR phase of the LCD programme. The co-production of this work has resulted in several recommendations for policy and practice which have informed the national roll out of the programme.

Background: The weight maintenance phase of the NHS Low CalorieaDiet (LCD) programme focuses on embedding long- term dietary and physical activity changes. Understanding individual experiences of this phase is crucial to exploring long- term effectiveness and equity of the intervention approach. Methods: This was a coproduced qualitative study underpinned by a realist informed approach, using interviews and photovoice techniques. Service users (n=25) of the NHS LCD programme were recruited from three delivery models, across 21 sites in England. Data were analysed using a thematic approach. Results: The experiences reported were largely positive, with many participants reporting changes in their diet and physical activity. Some service users expressed a need for additional support and there appeared variation in their experiences of the service providers and the wider available support network. Fear of weight regain and its glycaemic consequences was expressed by many; various mitigations were employed, including participating in other weight loss services and continuing use of Total Diet Replacement products. Conclusions: The NHS LCD programme has been life-changing for some people. However, service user insights suggest that a stronger person-centred focus might further improve effectiveness and service user experience.

Aims: This study presents data gathered as part of the Re:Mission evaluation of the NHS low-calorie diet programme pilot for Type 2 Diabetes, to address two research questions: 1) What is the presence and severity of emotional and binge eating within this population? 2) Are demographic and health factors associated with the presence of binge eating or the severity of emotional eating? Methods: An online survey gathered data from n = 580 individuals who were enrolled on the programme but had not yet begun total diet replacement. The survey assessed emotional eating (TFEQ-R21), potential Binge Eating Disorder diagnosis (BEDS-7), wellbeing (Short Warwick-Edinburgh Mental Wellbeing Scale), quality of life (EQ-5D-5L), frequency of weight cycling and demographic factors (collected via NHS England programme monitoring). Descriptive statistics and regression analyses were used to address the research questions. Results: The mean emotional eating score from the TFEQ-R21 was 2.58 (0.96), and the presence of potential Binge Eating Disorder diagnosis was demonstrated in 26.0% of the sample. Regression analyses suggested that being female and engaging in more frequent weight cycling was associated with higher emotional eating and greater likelihood of binge eating. Lower wellbeing and lower quality of life were associated with emotional and binge eating, respectively. Conclusions: Rates of emotional and binge eating in the NHS low-calorie diet pilot sample are higher than in the general public, and in other similar samples. Consideration should be given to screening for emotional and disordered eating, and for additional tailored support and monitoring for such individuals.

Member led symposium at UK Congress on Obesity 2022

Obesity is a major public health challenge which continues to increase and disproportionally affects vulnerable population groups, resulting in widening health inequalities. There is consequently an urgent need for innovative approaches to identify and implement evidence-based policy and practice to prevent and treat obesity which has been accelerated by the COVID-19 pandemic. The population levels of obesity are driven by numerous interacting political, economic, environmental, social, cultural, digital, behavioural, and biological determinants. However, causal links between determinants and how they vary between different groups of individuals are not well defined. The identification, implementation, and evaluation of effective responses to the prevention and treatment of obesity require a set of approaches that work within this complexity. The limited efforts to date reflect a misunderstanding of the nature of the chronic and complex nature of obesity, and importantly a limited understanding of how the multifaceted nature of the problem should influence how research, policy, and practice approach it. To date, the evidence underpinning the current approach does not reflect the complexity of the condition: Evidence is largely generated by tools and methods developed to answer questions about the effectiveness of isolated interventions, commonly grounded in linear models of cause and effect. This is the pathway between a cause, for example, exposure to fast food restaurants, and the outcome, obesity, is assumed to be linear, when it is far more complex than this. There is a focus on individual behaviour, yet social and structural determinants of health have a far greater influence on obesity and contribute more to health inequalities. It is acknowledged that we live in an obesogenic environment, yet most approaches to addressing obesity are focused on behaviour change to support individuals adopt healthy weight behaviours, with little (or no) consideration of the environment in which they live. Outcomes are largely measured in the short term and the effects of efforts to reduce population obesity will take many years to be realised. Effectiveness is primarily determined by a narrow focus on weight change, which fails to capture the underlying complexity. Instead of investigating whether a single intervention is (cost-)effective in terms of fixing the problem (i.e. obesity), we need to understand how actions drive positive changes within the system. A systems approach captures and responds to complexity through a dynamic way of working: bringing together academic, policy, practice, and community representatives to develop a ‘shared understanding of the challenge’ and to integrate action to bring about sustainable, long-term systems change. The benefit of a systems approach to addressing population levels of obesity has been outlined: in 2013, the EPODE logic model retrospectively provided insight into the system dynamics of the programme; the ‘Improving the Health of the Public by 2040’ report acknowledged that responses to major public health challenges require a wider set of approaches; in 2017, Rutter et al. called for ‘a complex systems model of evidence for public health’, which was echoed in 2019, as part of The Lancet commission on obesity. More recently, the logic model underpinning the Amsterdam Healthy Weight Approach (AHWA) was published. There are also examples of projects that have embraced system approaches in an applied setting, as well as toolkits, guidance documents, and operational frameworks. These resources demonstrate that the concept of a systems approach to obesity is not new, and importantly that systems methods do not have to replace traditional methods, but instead incorporate and enhance them. Despite this activity and rhetoric, systems approaches are rarely operationalised in ways that generate relevant evidence or effective policies.

Background National Health Service England piloted a low-calorie diet programme, delivered through total diet replacement and behaviour change support via 1 : 1, group or digital delivery, to improve type 2 diabetes in adults with excess weight. Aim To coproduce a qualitative and economic evaluation of the National Health Service low-calorie diet pilot, integrated with National Health Service data to provide an enhanced understanding of the long-term cost-effectiveness, implementation, equity and transferability across broad and diverse populations. Research questions What are the theoretical principles, behaviour change components, content and mode of delivery of the programme, and is it delivered with fidelity to National Health Service specifications? What are the service provider, user and National Health Service staff experiences of the programme? Do sociodemographics influence programme access, uptake, compliance and success? What aspects of the service work and what do not work, for whom, in what context and why? Can the programme be improved to enhance patient experience and address inequities? What are the programme delivery costs, and policy implications for wide-spread adoption? Methods A mixed-methods study underpinned by a realist-informed approach was delivered across five work packages, involving: semistructured interviews with service users (n = 67), National Health Service staff (n = 55), service providers (n = 9); 13 service provider focus groups; and service user surveys (n = 719). Findings were triangulated with clinical data from the National Health Service England’s first cohort analysis (n = 7540). Results Fifty-five per cent of service users who started total diet replacement completed the programme and lost an average of 10.3 kg; 32% of those with data available to measure remission achieved it. Examination of programme mobilisation identified barriers around referral equality and the impact of COVID-19, while effective cross-stakeholder working and communication were key facilitators. Service delivery and fidelity assessments identified a drift in implementation fidelity, alongside variation in the behaviour change content across providers. Perceived barriers to programme uptake and engagement aligned across service providers and users, resulting in key learning on: the importance of person-centred care, service user support needs, improvements to total diet replacement and the social and cultural impact of the programme. Early National Health Service quantitative analyses suggest some socioeconomic variation in programme uptake, completion and outcomes. Insights from the evaluation and National Health Service data were combined to develop the programme theory and underpinning context, mechanisms and outcomes. These were used to develop a list of recommendations to improve the cultural competency of programme delivery, total diet replacement delivery, peer support and address psychological support needs. Cost-effectiveness analyses using short-term follow-up data indicated there is potential for the programme to be cost-effective, but not cost saving. Conclusions The National Health Service low-calorie diet can provide a clinically effective and potentially cost-effective programme to support weight loss and glycaemic control in adults with type 2 diabetes. However, this evaluation identified areas for improvement in referral equity, uptake and completion, and fidelity of delivery, which have informed the development of the programme, which has now been rolled out nationally. Ongoing programme monitoring and long-term follow-up are now required. Future work and limitations The real-world setting limited some data collection and analysis. Future work will focus on the analysis of long-term clinical and cost-effectiveness, and addressing inequalities. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR132075.

Purpose of Review: This article discusses what person-centred care is; why it is critically important in providing effective care of a chronic, complex disease like obesity; and what can be learnt from international best practice to inform global implementation. Recent Findings: There are four key principles to providing person-centred obesity care: providing care that is coordinated, personalised, enabling and delivered with dignity, compassion and respect. The Canadian 5AsT framework provides a co-developed person-centred obesity care approach that addresses complexity and is being tested internationally. Summary: Embedding person-centred obesity care across the globe will require a complex system approach to provide a framework for healthcare system redesign, advances in people-driven discovery and advocacy for policy change. Additional training, tools and resources are required to support local implementation, delivery and evaluation. Delivering high-quality, effective person-centred care across the globe will be critical in addressing the current obesity epidemic.