Access to weight management (WM) interventions in England has not improved over the last ten years despite obesity rates continuing to rise, according to a study led by researchers from University of Bristol, UK. Their study identified 1.81 million adults who had overweight or obesity documented in their primary care record between 2007 and 2020. Only 3.13% of these adults were referred to publicly-funded weight management programmes during the study period. In addition, only 1.09% of the 436,501 adults with severe and complex obesity underwent bariatric surgery. They also noted that there were regional inequalities to access to these programmes, which may reflect differences in commissioning and provision of WM services across the country.
Nearly two thirds of adults in England live with overweight or obesity, which can affect physical, mental, and social health and well-being. According to NICE guidance, these individuals should be able to access publicly funded weight management programmes, including bariatric surgery for those where weight is having a serious impact on their health.
"This study suggests that access to weight management interventions in England needs improvement. Little has changed over the past decade, yet obesity rates rise,” said Dr Karen Coulman from the University of Bristol. “There are marked regional differences in access to weight management programs including surgery: attention and investment are needed."
Reporting the findings in the paper, ‘Access to publicly funded weight management services in England using routine data from primary and secondary care (2007–2020): An observational cohort study’, published in PLoS Medicine, the study aimed to (1) describe the primary care population in England who (a) are referred for WM interventions and (b) undergo bariatric surgery and (2) determine the patient and GP practice characteristics associated with both.
This observational cohort study was undertaken using routinely collected primary care data in England from the Clinical Practice Research Datalink linked with Hospital Episode Statistics. During the study period (January 2007 to June 2020), 1,811,587 adults met the inclusion criteria of a recording of overweight/obesity in primary care.
Of those with a recording of overweight or obesity (1,811,587), 989,432 (54.62%) were female, 364,084 (20.10%) were aged 45 to 54, and 268,522 (14.82%) had a recording of T2DM. Of adults in England in 2007 (3,503,814), 15.33% (537,266) had a recording of overweight or obesity. This increased throughout each study year until 2015, peaking at 38.33% (884,243 out of 2,306,665). Thereafter, it gradually dropped (35.90% (238,131 out of 663,328) in 2020).
The percentage with a WM referral was highest in adults with a BMI ≥40 kg/m2 (8,685/87,031, 9.98%), and adults living with overweight or obesity with a medical code for whom BMI category was not available (4,131/25,904, 15.95%). It was lowest in adults from Black and Asian ethnic groups with BMI 23.0 to 24.9 kg/m2 (209/30,335, 0.69%). Adults from GP practices in the West Midlands had the highest percentage of WM referrals recorded (13,235/249,143, 5.31%), whereas the East of England had the lowest (1,860/172,177, 1.08%). In 2007, 0.38% (2,067/537,266) of adults active in the study that year had a WM referral recorded; this increased over time to 1.47% (4,886/333,272) of adults active in the study in 2019 having a WM referral that year.
Bariatric surgery
During the study period, 436,501 (7.49%) adults had a recording of severe and complex obesity (as defined by 2014 NICE guidance) out of 5,827,309 adults. The median follow-up time from severe and complex obesity index date was 6.85 years (IQR 3.28 to 10.51). Of the 340,502 eligible for HES linkage, 3,701 (1.09%) underwent NHS bariatric surgery. The percentage undergoing bariatric surgery was highest in adults with a BMI ≥40 kg/m2 (2,872/78,406, 3.66%) and lowest in adults with BMI 27.5 to 29.9 kg/m2 from Black and Asian ethnic groups with T2DM diagnosed in the last ten years (9/41,946, 0.02%).
The highest percentage of bariatric surgery was in adults from GP practices in the North East (193/8,585, 2.25%), with the lowest in the North West (367/59,721, 0.61%), where there were five and three NHS bariatric centres, respectively. Of adults with severe and complex obesity active in the study in 2007, 0.06% (62/99,445) underwent bariatric surgery that year; this was highest in 2018 with 0.51% (355/70,236) of adults active in the study this year undergoing bariatric surgery.
Increasing BMI category was associated with an increased likelihood of referral with people with a BMI ≥40 kg/m2, more than 6 times as likely to have a referral than BMI 25.0 to 29.9 kg/m2. Having obstructive sleep apnoea (OSA), a chronic musculoskeletal condition, gastro-oesophageal reflux disease (GORD), polycystic ovarian syndrome (PCOS), fertility problems, depression, anxiety, or idiopathic intracranial hypertension (IIH) were associated with increased likelihood of referral, whereas people with T2DM, hypertension (HTN), or coronary heart disease (CHD) were less likely to have a referral.
Differences were seen across regions with GP practices from the West Midlands more than twice as likely to refer and practices from the East of England less than half as likely to refer, compared with the North West. Rural GP practices were less likely to refer than urban practices.
Interestingly, the researchers noted that not everyone with overweight and obesity have their weight recorded in their primary care record, and so, the true percentage receiving a WM referral may be even lower. They did not, however, identify individuals who may receive WM advice through other disease programmes.
“Our study agrees with previous research describing the demographic and clinical characteristics of adults who are referred for WM and undergo bariatric surgery. We have importantly highlighted the regional inequalities in access to WM interventions across England,” they concluded. “We recommend that future research considers how to improve regional equity in access to WM across the country, including the evaluation of recent national WM initiatives.”
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