Ninewells Specialist Obesity Service
Some patients with diabetes have a significant problem with obesity, which may require specific 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. The service provides direction on obesity management including the use of a variety of diets, behavioural modification, exercise potential, anti-obesity medicine therapy and very low calorie diets. Please note that at present bariatric surgery is not funded by NHS Tayside Board.
Referral to the Ninewells Specialist Obesity Service
Referral either by a consultant or general practitioner is the accepted route in most circumstances. The service is in much demand but has only one full time dietitian and has, therefore, to place restrictions on those it can accept.
The referral criteria are as follows:
- 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 but are motivated to avail themselves of the intensive therapy provided by the service.
- Only those with diabetes (type 1 or 2) who have a Body Mass Index (BMI) of 35 or greater and where the patient is motivated to lose weight.
NB This service should be considered as an additional facility and is not a substitute for community dietetics. Likewise the service will not accept patients solely for anti-obesity medicines as these should be prescribed and outcome assessed in the community (see later).
Please take note of the discharge policy;
To enable the clinic to continue to provide a service for new referrals it is essential that all patients and healthcare professionals realise at the outset that the service is not designed for long term follow-up. It is envisaged that speciality treatment will be provided for 9-12 months. Certainly all those whose weight loss is less than 10% in that time will be discharged and those who successfully lose more than 10% will be discharged on a case by case basis with their supervision transferred to the community.
Community care
Guidelines for the Use of Orlistat and Sibutramine:
Anti-obesity medicines should be considered for community prescription within the guidance issued by NHS Tayside Board, NICE and Scottish Medicine’s Consortium. www.tayendoweb.co.uk (and then click on obesity section and then NHS Tayside Guidelines). Briefly, the guide suggests that patients should have consulted a health care professional trained in obesity management and have spent a minimum of 3 months on a structured weight management programme including lifestyle advice before consideration is given to anti-obesity medicines. They are indicated for patients with BMI of 27/28 or greater who cannot achieve or maintain an appropriate weight loss (suggested target of 5-10% or more of body weight) over the course of weight management surveillance. If anti-obesity medicines are prescribed then it is important that the patient continues to receive diet and lifestyle advice as they are not a substitute for diet/lifestyle management.
There are contraindications and monitoring requirements for orlistat and especially sibutramine and these are given on the www.tayendoweb.co.uk obesity section guideline and should be strictly applied.
Please note that at this time rimonabant has not had SMC approval for prescribing in Scotland and is therefore not recommended by NHS Tayside Board.
Bariatric Surgery
At present bariatric surgery is not financed by NHS Tayside Board. There is however a leaflet to assist in discussion of the procedures as many patients have seen the technique on television and often enquire in the obesity section on www.tayendoweb.co.uk. It is hoped that finance for the procedure, and the essential dietetics and clinical psychology support will be forthcoming in due course.