The purpose of the Tier 3 Specialist Adult Weight Management Service (SWMS) is to provide evidence-based and quality weight management interventions to adults. This example highlights the importance of a weight management plan to prevent weight re-gain in line with Quality Standard 111: Statement 8.
The service is also relevant to other NICE guidance recommendations including:
CG43: Obesity guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children
Recommendation 220.127.116.11: Interventions to improve diet (and reduce energy intake) should be multicomponent (for example, including dietary modification, targeted advice, family involvement and goal setting), be tailored to the individual and provide ongoing support
CG189: Obesity, identification, assessment and management
Recommendation 1.4.1 Multicomponent interventions are the treatment of choice. Ensure weight management programmes include behaviour change strategies (see recommendations 1.5.1–1.5.3) to increase people's physical activity levels or decrease inactivity, improve eating behaviour and the quality of the person's diet, and reduce energy intake
PH53: Weight management: lifestyle services for overweight or obese adults
Recommendation 10: Commission programmes that include the core components to prevent weight regain
Aims and objectives
Choose to Change (C2C) provides support to adults (18 years and over) who are:
- Severely obese (BMI 40+) (Bury & Tameside & Glossop)
- Obese with severe co-morbidities (BMI 35+) (Bury and Tameside & Glossop)
- Obese (BMI+35) (Oldham, Manchester and Salford)
- Pregnant and obese (BMI 30+)
- Individuals who are eligible for bariatric surgery.
ABL prides itself on adopting a different stance to other weight loss programmes; encouraging lifelong change rather than short term traditional diets. Our approach is targeted at increasing client skills, knowledge and confidence so that they can maintain weight loss and manage their weight without dependence on the support of clinicians or other weight management professionals.
Our approach is not based on gimmicks, calorie counting or rapid weight loss. We provide an integrated and holistic offer which motivates, empowers and increases self-confidence and self-efficacy to prevent relapse.
The programme is personally tailored, accessible, innovative and responsive. It is multicomponent, including advice, information and practical delivery of nutrition, physical activity and behaviour change programmes. The service is evidence-based and includes motivational interviewing, cognitive behavioural therapy, humanistic interventions (e.g. to address bereavement or loss) and the use of peer-supporters to facilitate the behavioural change needed to achieve and maintain weight loss for life.
There is a vast amount of evidence suggesting that weight regain occurs in clients post intervention. To address this issue the C2C programme encourages a period of supported weight maintenance post weight loss (intensive phase). ABL has a client-centered approach and using client feedback the programme has evolved to include a formalised weight management plan. The aim of the plan is to:
prevent weight regain
establish a weight monitoring system
give clients the skills to a) recognize weight changes, b) understand the reasons behind the changes, c) address the changes.
Each client co-produces this personalised care plan with their lifestyle coach, inclusive of short, medium and long term goals. This plan drives their weight loss journey ensuring the client is consistently involved in devising and updating their care needs, empowering them to maintain the positive changes they make.
Reasons for implementing your project
The prevention, identification, assessment and management of overweight and obese adults has increased in importance over the past decade. Obesity and overweight prevalence has increased among adults considerably over the years. The proportion who were categorised as obese (BMI 30kg/m2 or over) increased from 13.2% of men in 1993 to 24% in 2014 and from 16.4% of women in 1993 to 27% in 2014 (Health Survey for England). The resulting NHS costs attributable to overweight and obesity are projected to reach £9.7 billion by 2050, with wider costs to society estimated to reach £49.9 billion per year (Foresight 2007).
Throughout Greater Manchester it is estimated that two thirds of the adult population are overweight and obese. There are major health risks associated with overweight and obesity including; coronary heart disease, type 2 diabetes, cancer, osteoarthritis, respiratory disorders, reproductive disorders and social and psychological problems. The prevalence of these chronic conditions can be greatly reduced by reducing the rate of obesity.
'Choose to Change' is a Specialist Weight Management Service commissioned by Manchester City Council, Oldham CCG, Salford CCG, Tameside & Glossop CCG, and Bury CCG to address the obesity challenge in Greater Manchester. ABL has been successfully delivering this service since 2011.
The service aims to reduce the prevalence of overweight and obese individuals by providing a multidisciplinary and multicomponent programme to improve health outcomes and support and empower people to achieve a range of weight management, behaviour change and motivational outcomes over a 6-18 month period. Most importantly, we provide clients with the tools to sustain these changes long term and prevent weight regain.
How did you implement the project
Weight management is an immediate focus at service entry. Clients receive a multidisciplinary assessment where shared decisions are made recognising the whole person within their context. The assessment recognises the complex biopsychosocial factors influencing choice and addresses personal challenges to devise a tailored treatment plan. A 6-month multi-component intervention is provided along with multidisciplinary team support including peer-supporters (clients who mentor others). Clients receive information handbooks to record their health plan and goals. This integrated, holistic care package empowers and facilitates sustainable weight management outcomes and builds self-help skills.
Following six months of intensive support, clients attend a review session where they evaluate initial health plan/goals and review progress. A coproduced practical and motivational weight maintenance plan is devised (Appendix 1 in the supporting material) and clients receive a supplementary monitoring booklet to identify new goals and highlight the maintenance skills they will use. Clients are also shown how to monitor their weight ensuring control is handed back to them (Appendix 2 in the supporting material).This supports clients to ‘step down’ into ABL’s follow up service ‘Moving Forward’ (MF).
Naturally this period can evoke anxiety because clients can be reluctant to practice maintenance rather than weight loss; however trained coaches and buddying support from peer-supporters, educates that maintenance is a skill to prevent future weight gain, encourages independence and builds confidence. Peer support inspires individuals to develop independent support mechanisms e.g. social media groups, swimming groups and even buddying up to attend exercise classes. This creates another platform that contributes to improving self-efficacy and supporting clients to stay accountable for their weight management.
MF consists of 6-monthly meetings. The sessions are multicomponent, allow learning from the intensive programme to be embedded, support maintenance and set new goals. On completion, a final review is undertaken. Clients create an action plan outlining what strategies/tools/skills they will use to retain weight control and overall health (Appendix 3 in the supporting material).This staged step-down process encourages engagement with other services/assets in the clients local area. Clients also have lifelong access to ABL’s digital platform (app and website) offering ongoing advice/support and connections to other clients building supportive social networks.
In 2014/15, 2149 individuals attended a multidisciplinary assessment. 100% coproduced a personal health treatment plan. Baseline and exit questionnaires and physiological measurements are carried out at this assessment to track outcomes. All outcomes are reported internally monthly and quarterly through commissioner’s reports. Service outcomes include:
- 91% clients who complete the intensive phase of the service achieve weight loss, this portrays how accessing the service and following their personal goals is successful at preventing further weight gain.
- 51% achieve a 5% weight loss and 71% achieve a 3% weight loss, which exceeds NICE guidelines (PH53) “participants are likely to lead to an average weight loss of at least 3%, with at least 30% of participants losing at least 5% of their initial weight”.
- 87% clients completing the intensive intervention achieve 3 or more positive behaviour change outcomes (reduced depression, anxiety, waist circumference & blood pressure, increased self-esteem, self-efficacy and physical activity).
- 96% of clients who complete the follow up service at 12 months then maintain or further improve these outcomes. All outcomes contribute to the prevention on reduction of a variety of obesity related conditions (type 2 diabetes, heart disease etc.)
- 67% reduce depression, 65% increase self-esteem, 51% improve self- efficacy and 51% reduce anxiety.
“People always tell you to lose weight and then you do the opposite because you feel that you shouldn’t have to do what they say. I had no pressure at all this time; it was me at my own pace. It doesn’t feel like a diet, it feels like a change in my lifestyle. I’m doing it differently now and I feel like a new person”.
“Getting diabetes really made me think, I need to do something, and since joining the programme and making changes to my food intake, I am no longer diabetic and now have a healthy Hb1Ac”.
12 months post-completion of the 'Choose to Change' service, an attempt is made to follow up clients and track whether their outcomes have been maintained/improved. Although only small numbers (currently 62%), clients who have attended a post 12 month follow up have lost further weight or maintained their weight loss from the end of the service.
The outcomes demonstrate that clients have the understanding that behaviour change is a lifelong process and does not have an expiration date like their previous attempts had and they are now in control of their weight management plans long term.
Key learning points
- Empowerment and long term change is only achieved when an individual’s current needs are the focal point of all care planning.
- A multi-disciplinary approach is key; by creating a shared language with a range of professionals we support the whole person within the context of their own lives and empower them to make a difference within their community.
- We have taken a traditionally clinical model and moved it into communities, making services accessible and into venues people trust and feel comfortable. This helps to improve engagement and retention.
- Make services engaging and responsive; we are constantly adapting our approach and listening to the people and communities we work with.
- Peer to peer support has been incredibly powerful. Recruiting individuals, who have been through the service to volunteer, provide non-judgmental support and say “I know what it’s like”. People respond to those who have struggled to make similar behaviour changes and are more likely to accept weight maintenance if they hear it from somebody who has experienced the benefits.
- Developing relationships with other community services is vital to ensure an integrated approach to supporting individuals with long term weight management.
- Introducing the concept of weight maintenance early in the process: when the service was first established there was strong resistance from clients to maintain their weight for a specific period of time. Through working with peer supporters we acknowledged that the concept must be referred to throughout to set expectations and allow clients to mentally prepare for this.
- Establish a weight monitoring system – initially the follow on programme was an opportunity for clients to meet casually and clients could opt in to attend / whether to engage with weight maintenance. However, feedback from clients is that they needed more guidance and structure. In response to this we created the weight monitoring handbook and did not promote the sessions as optional.