Obesity: Finding a model that fits

With a new model of care and planned developments in both hospital and primary care settings, David Lynch looks at the future of obesity services in Ireland

With the health service consumed by the pandemic since March 2020, it is understandable that many doctors fear that their own particular specialty will struggle to garner attention and funding during the crisis. “I thought when the pandemic began that ‘now that’s it, obesity is off the table for progress on policy for the next few years’,” Prof Donal O’Shea, HSE National Clinical Lead for Obesity and Consultant Endocrinologist and Physician, told the Medical
Independent (MI).

“But quite the opposite has happened. Because of the link between being overweight, obesity and poor
outcomes with Covid-19, it seemed to have hit the policymakers in the face, with the need to address both prevention and treatment.”

Prof Donal O’Shea

The feedback from ICUs was that Covid-19 patients with obesity “were staying in the ICU longer and their outcomes are poorer and their rehab takes longer”. Prof O’Shea said that because obesity has been linked to poor outcomes with Covid, it has proven “a wake-up call” for many in health management.

The public health challenge posed by obesity was recognised prior to the onset of the Covid crisis. According to HSE figures, 60 per cent of adults and 20 per cent of children in Ireland are living with overweight or obesity. While there are serious issues around funding, policy formation and resources, Prof O’Shea warned that stigma remains a particular concern within obesity care.

Last month, the HSE hosted a virtual event titled ‘Overweight and Obesity… Let’s Talk!’. It was organised by the HSE Obesity Management Clinical Programme, the Association for the Study of Obesity in Ireland (ASOI) and the Irish Coalition for People Living with Obesity (ICPO). The event was for the public and healthcare professionals “to share the science behind obesity” and to “continue to break the stigma of obesity through sharing lived experiences and
explore conversations about weight and health in healthcare settings”.

“There is massive education work to be done,” Prof O’Shea said. While “there has been some progress”, there is a “widely held bias” towards patients with obesity that is found across society, including in medicine.

“Patients with obesity experience almost the most discrimination in the health system,” he told MI. “We have to get in at undergraduate level [in medical schools]. The ICPO and the ASOI are really looking for this to happen. “Then within the HSE, greater awareness also needs to happen with a new module for addressing overweight and
obesity, specifically and especially the stigma and judgement that goes with it.”

Such a module will form part of the HSE’s Make Every Contact Count programme, added Prof O’Shea.

Stigma

“Obesity is a complex chronic disease for which there are a lot of different causes,” he commented. “Many people believe that obesity is a lifestyle choice, which is due to poor self-discipline and lack of motivation. But that is just not the case. The reality is that your body tries to protect its fat stores to maintain your highest weight – meaning that managing obesity is a lifelong process. Genetics are increasingly recognised to be a major contributor to body weight.”

The battle against stigma is not just about creating awareness and education, he underlined. “I think the biggest push has to be around treatment,” said Prof O’Shea. “If you are actively treating the condition, people begin to see it as a disease. Not because their attitude changes to the disease, but because they see people who have been treated and they see how well they are.

“They realise that it wasn’t because they [the patient with obesity] didn’t want to get well. They realise that body weight is not a person’s choice and I think that is the big move in how we are trying to destigmatise the condition. If body weight was a choice, we would not have people living with severe and complex obesity.”

Treatment of obesity is primed for a significant shake-up with the publication of the new HSE Model of Care for the Management of Overweight and Obesity in Ireland on World Obesity Day in March. This model of care sets out how healthcare for children, young people and adults living with overweight and obesity in Ireland should be organised and resourced, now and into the future.

Speaking earlier this year, Minister of State with responsibility for Public Health, Wellbeing and the National Drugs Strategy, Frank Feighan, said the model “will ensure that an end-to-end approach is adopted, defining the way health services are developed over time”. He said it would “ensure that the right care is delivered to individuals with overweight and obesity at the right time and in the right place”.

However, currently bariatric surgery figures remain low (see panel). In the community, primary care has witnessed important changes in recent years withthe roll-out of a new chronic disease management programme, which GPs can opt into. The first phase of the programme targeted GMS patients, aged over 75 years, with specific chronic diseases including type-2 diabetes, asthma and chronic obstructive pulmonary disease (COPD). Cardiovascular disease is also part of the programme and includes heart failure; ischaemic heart disease; cerebrovascular disease (stroke/ transient ischemic attack); and atrial fibrillation.

Obesity is noted by its current absence. However, the HSE has given some indication through the publication of the new model of care that it may feature in the programme in the future. “The HSE National Service Plan 2021 seeks to take forward plans to implement the end-to-end obesity model of care with a joined-up approach towards delivering weight management and obesity treatment,” Ms Sarah O’Brien, National Lead, Healthy Eating and Active Living Programme, HSE Health and Wellbeing, said recently. “A structured programme for chronic disease management and prevention for all general medical/GP visit card patients will be introduced over time.”

“Investment in community services will see community weight management services, delivered by dietitians, available in many areas. Training for healthcare staff to help them talk with patients living with overweight and obesity about
healthy lifestyles will be available as part of Making Every Contact Count by the end of the year.”

GPs’ views

So, what do GPs think? “Chronic disease management is a good idea if general practice can have a significant input into that,” Dr Denis McCauley, Chair of the IMO GP committee, told MI

The Donegal GP said the “reception from doctors and from patients” to the current chronic disease management programme “has been very positive”.

However, he drew attention to the need for availability of other services to undertake a successful programme for obesity care in general practice. “Say you don’t have access to a dietitian, to a metabolic clinic, to surgery, we would sort of be sitting there saying [to the patient], ‘It’s really good to see you, but I’m not so sure what I can do for you, more than give you supportive care and general advice regarding diet and exercise’.

“So yes, I think if we were given ‘weapons’ to use and we had access to services in relation to the treatment of obesity and if we had further education on that, I think it would be very successful.”

However, Dr McCauley told MI that obesity would most likely not be the next area to be added to the chronic disease programme. If the programme was to be expanded in the future, he believes women’s health should be next, then possibly psychiatric and psychological care. He argued there are insufficient support services for patients with obesity to facilitate its addition to the programme.

Dr Denis McCauley

“The thing with the introduction of the other diseases [on the current programme] was there were well-established
pathways, well-established principles of treatment. Does the same format exist for obesity yet? No.

“Does it exist in regards women’s health and, say, some psychological and psychiatric disorders? Yes – although even in psychiatric care you are getting some fraying [in services] as well.” In summary, if obesity is added to the chronic disease programme, it would have to be in the context of “availability of evidence-based treatments that would help”.

Dr McCauley said that current waiting lists for dietitians “are very long” and the lack of specialised obesity clinics in the
country is another challenge. “So if suddenly GPs were told they were looking after it, they would say ‘where’s the clinic?’ and there is a waiting list of two years. That isn’t a great start.”

Despite the challenges, the shifting of chronic disease, including obesity, towards primary care is widely supported across medicine and “is beginning to happen already”, Prof O’Shea said.

He said the trend is in alignment with the goals of Sláintecare. Prof O’Shea pointed to the recruitment of more dietitians and the development of an adult weight management programme and a pre-diabetes programme in the community, as examples of progress.

“They are incredibly positive steps towards acknowledging that obesity is a chronic disease and that we need to address it, not just by telling somebody that they need to eat less and move more.” Despite recent changes in attitudes towards obesity care and a renewed focus on the issue, Prof O’Shea added that he still encounters old ways of thinking.

“I was at a very senior meeting about three or months ago now, while we were on a final push about estimates, and I was met with the line ‘It’s a pity, because we do know if they just ate less and moved more’ [obesity would not be such an issue],” he recounted.

“And I was struck by that. In 2021 a senior health official who was important in decision-making [saying that] and I thought to myself, ‘God, other healthcare systems are moving beyond that’.” Prof O’Shea said that the coming weeks and months will reveal much as to whether the model of care will be fully implemented.

Bariatric surgery: The need for improvement

To date in 2021, there were 42 bariatric surgeries in St Vincent’s University Hospital (SVUH), Dublin and 18 bariatric
surgeries in St Michael’s Hospital, Dún Laoghaire. During the same period (up until October) there were 13 bariatric
procedures at University Hospital Galway (UHG), according to figures provided to the Medical Independent.

All elective surgery has been hit hard by the disruption caused by the pandemic, but bariatric surgery figures were regarded as low prior to Covid-19. “Ireland is way behind the curve,” said Prof Donal O’Shea, HSE National Clinical Lead for Obesity. “We have averaged between about 12 and 20 surgeries per million of our population over the last 10 years and other countries are sitting at 140 or a 180 per million.

So we are hoping to build up to 1,200 surgeries per year. That will build it up to a low level of respectability.

With the approval of the new model of care and the “prioritising of obesity” in the HSE Corporate Plan, he is hopeful
that surgeries will increase. “Obesity surgery needs to happen in the context of a multi-disciplinary team,” he said. “So you cannot do it properly.

if you don’t have the right dietitian, the right psychological support, GP funding.” Speaking in March on World Obesity
Day, Dr John Conneely, Consultant Surgeon specialising in bariatric surgery at the Mater Private Network, Dublin,
warned that Covid-19 is likely to increase the incidence of obesity in Ireland.

Dr Conneely urged the Department of Health and HSE to urgently address the challenges that patients with obesity experience when trying to access weight loss and weight management care. “For those with chronic obesity waiting for bariatric surgery, waiting lists have grown and their condition has worsened,” he said in March. “We have incontrovertible evidence from global experience that bariatric surgery can be transformative for patients and prevent or reduce the incidence of other conditions, such as diabetes or heart disease, making them also more costeffective for our health services.

“As we begin to emerge from Covid-19 our health services now must plan and adequately resource the services
patients suffering from obesity need to quickly access supports to achieve and maintain a healthy weight.

Sugar and influence

One of the most high-profile public health measures introduced in recent years was the Sugar Sweetened Drinks Tax (SSDT), which came into effect on 1 May 2018 and was applied to waterand juice-based drinks, which have added sugar and a total sugar content of five grams or more per 100 millilitres (from 2019 it also applies to certain categories of plant protein drinks and drinks containing milk fats).

Prof Donal O’Shea, HSE National Clinical Lead for Obesity, reflected that “in its short time it has generated
income and driven reformulation… loads of sugar sweet drinks have less sugar… and that’s fantastic.” But he said it was a “huge disappointment” that the money raised from the SSDT “wasn’t ringfenced or wasn’t parked to go into obesity treatment and prevention, even though it was an opportunity when the tax was introduced a few years ago”.

If he had a magic wand and could introduce any other public health policy, what would it be? “I think calories posting on menu boards is a fantastic educational tool. It has been agreed, it has been approved, but the legislation is still stuck. It’s 10 years since we started actively looking for calorie posting.” Prof O’Shea made reference to “massive industry opposition to it.”

As well as major public policy reforms, Prof O’Shea also pointed to the more subtle art of influence. “I think of the likes of [Cristiano] Ronaldo earlier in the year pushing the Coke to one side [during a press conference] and bringing the water in. I think if you could have significant influencers demonstrating just where industry is not behaving, I think that
reaches a big audience.