David Hughes The incidence of obesity‐related co‐morbidities continues to increase throughout the world. Uncomplicated obesity can be considered a complex disease with biological, social, environmental and behavioural aspects. The complications of obesity and their consequences add another dimension to this multifaceted clinical scenario, including the possibility of end organ damage in multiple systems. Thus, organising treatment for obesity can become an intricate network of overlapping layers of interventions, each tailored towards tackling a predisposing aspect of the condition. This is further influenced by the need to focus on primary prevention, secondary prevention or even palliation of these complications. A flexible, integrated system approach is required to effectively manage complex obesity care. The first challenge lies in establishing responsibility for the commissioning and funding of the multiple interventions for prevention or palliation of patients with complex obesity needs. Costs can easily escalate, but wider system savings can be made through preventing obesity‐related complications. Unfortunately, such cost savings are hard to quantify and occur over a medium to long period (~10 years or longer). This leads to limited commercial interest in providing preventative services without appropriate funding from governments. In order to spread the responsibility for commissioning and funding complex obesity care, most developed nations divide the responsibility of commissioning services between different governmental departments. Public health governmental bodies are usually tasked with developing primary prevention strategies with funding either devolved to local government budgets (e.g. UK, Italy and Poland) or coordinated nationally (e.g. Germany and Moldova). National or local health authorities are usually tasked with providing treatment of obesity‐related disorders (e.g. obesity‐related diabetes, obesity‐related sleep apnoea, obesity‐related NAFLD, etc.). Obesity‐related palliative services are generally poorly developed throughout the world but commonly involve an ad hoc approach shared between social care departments run by local government and local healthcare organisations. The unfortunate effect of this division of responsibility can be the creation of artificial barriers that prevent some individuals accessing the correct level of support they require (Figure 6.1). Figure 6.1 Image displaying different groups: Group 1: local government public health policy on primary prevention; Group 2: local healthcare provision for complication of obesity; Group 3: specialist services palliating obesity‐related disease. All being separated. Source: iQoncept/Adobe Stock. If we were to think of obesity and its complications as a pyramid, then the majority of individuals living with obesity would be free of complications (see diagram) with only a small percentage suffering severe life‐shortening obesity complications such as organ failure (Figure 6.2). Figure 6.2 Population with obesity and the prevalence of complications. The cost of preventing these complications needs to be weighed against the cost of managing them and the effectiveness of the intervention under consideration (see diagram) (Figure 6.3). Figure 6.3 Population with obesity and the cost of managing the complications. Low‐cost public health interventions that use a combination of government policy (e.g. housing policy, provision of public spaces, licencing of food outlets, taxation of high sugar/high fat foods and restrictions on food advertising to children) and low‐cost behaviour modification programmes (e.g. diabetes prevention programmes, promotion of healthy eating, exercise and diet‐related apps) are used for the prevention of mild/moderate disease. High‐cost interventions (e.g. structured individualised behavioural modification interventions and bariatric surgery) are reserved for use in prevention and treatment of severe disease. Deciding when to intervene and evaluating costs for each preventive intervention is critical to governmental budgets and to the health of a nation. Crude decision‐making algorithms utilising a BMI, age, risk factors and economic benefits are employed by national governments, with costs escalating each year. The cornerstone of all obesity‐related intervention lies in behavioural modification of eating. Each type of intervention in this field attracts multiple advocates and critics. The most widely used interventions involve health coaches, health apps or dietitians promoting and then reinforcing healthy eating. Unfortunately, these strategies only provide long‐term weight loss for a minority of individuals, although short‐term weight loss does occur in the majority. Thus, early and then repeated intervention through behaviour modifications is advocated to delay the onset of obesity‐related complications. It is fairly common for individuals to require cyclical input from weight management programmes throughout their life to halt disease progression. This should not be considered a failure of the intervention but a failure of government policy to limit the obesogenic environment beginning in childhood. Complex obesity care has no set definition, but it is generally considered to refer to obesity care focused on individuals with either obesity level 3 (BMI > 40) or obesity level 2 (BMI > 35) plus moderate to severe obesity‐related co‐morbid conditions. In the UK, obesity services are conceptualised into tiers of treatment, with complex obesity care being provided by the top two tiers (Tier 3 and Tier 4). These top two tiers are funded via local health organisations and fulfil slightly different roles. The ‘Tier 3 services’ provide an evidence based, multi‐professional, community‐based behaviour modification programme, with access to specialist diets (e.g. very low calorie diets and low carbohydrate diets) and weight‐loss medications (e.g. GLP‐1 agonists and orlistat). The ‘Tier 4 services’ provide a similar service, but with additional access to bariatric surgical services in hospitals. It is usual for multiple ‘Tier 3 services’ to work with one or two ‘Tier 4 services’ to provide treatment pathways according to the needs of the patient (Figure 6.4).
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Organisation of Care for Complex Obesity
Introduction to Complex Obesity Care
Complex Obesity Care
MDT Intervention Programme (Tier 3)
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