Ninewells Specialist Obesity Service
Many patients with diabetes have a significant problem with obesity, which may require focused attention. The Specialist Obesity Service is available for those adults whose obesity is of such severity as to be an immediate significant risk to their health and who have failed to lose sufficient weight with professional assistance in the community or with the specialist dietitians attached to the hospital-based diabetes service. In Tayside the three arms of the service (dietetic, medical, surgical) act in a co-ordinated way; the Obesity multi-disciplinary team (MDT) meets every two weeks, and referrals may be re-directed if that will expedite weight loss. Thus some patients referred for, say, gastric banding, may be allocated initially to the dietetic or medical arms of the service. The service provides advice on various aspects of obesity management including the use of diet, behavioural modification including exercise, anti-obesity drugs and bariatric surgical procedures. For the first time, NHS Tayside Board approved a programme of bariatric surgery in May 2010.
Referral to the Ninewells Specialist Obesity Service
Referral either by a consultant or general practitioner is the accepted route in most circumstances. The service has two full-time dietitians based in Ninewells and a third part-time dietitian based at Perth Royal Infirmary. Two medical obesity clinics and two surgical obesity clinics are held every calendar month, in addition to dietetic assessment clinics. The specialist weight management service is substantially over-subscribed, and it is necessary to have specific referral criteria. These are outlined below.
The referral criterion for patients with diabetes is as follows:
- Body mass index (BMI) must be at least 35 kg/m2, and the patient must want to lose weight.
- All diabetes patients should have been seen during the previous year by health care professional trained in obesity management e.g. a hospital/community dietitian or practice nurse with nutritional experience in advising on weight loss (e.g practice weight loss clinic) but have failed to lose 10% of their weight. As stated above, they must be motivated to avail themselves of the more intensive support provided by the specialist service.
NB The specialist obesity service is not a substitute for community dietetic services. It is aimed at those patients who are at highest risk, and who have not lost adequate weight with other services.
The specialist obesity service is not designed for long term follow-up. It is envisaged that speciality treatment will be provided for a year in the first instance. Serial non-attendance (failure to attend more than one successive appointment with any arm of the service) will result in discharge. Re-referral in these circumstances will not guarantee re-admission to the service.
Orlistat is the only preparation currently licensed for prescription in the UK. It should be considered for community prescription within the guidance issued by NHS Tayside Board, NICE and Scottish Medicine’s Consortium. This information is available on www.tayendoweb.co.uk (click on obesity section, then NHS Tayside Guidelines). Briefly, the guide suggests that patients should have consulted a health care professional trained in obesity management and have spent at least three months on a structured weight management programme including lifestyle advice before consideration is given to orlistat. It may be indicated in patients with BMI of less than or equal to 27 kg/m2 who cannot achieve or maintain weight loss (suggested target of 5-10% or more of body weight) over the course of weight management surveillance. If orlistat is prescribed, it is important that the patient continues to receive diet and lifestyle advice; it is not a substitute for diet/lifestyle management.
Bariatric surgery has been available in NHS Tayside for selected patients since May 2010. Patients are normally referred for surgery internally, from the medical or dietetic arms, after discussion at fortnightly obesity multi-disciplinary team (MDT) meetings. Local criteria are evolving but broadly reflect guidance from SIGN (2010) and NICE (2006). There is a patient leaflet to assist in discussion of the procedures.