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NIHR Signal Working in groups with ongoing support is valued by people with severe obesity trying to lose weight

Published on 8 January 2020

doi: 10.3310/signal-000859

People with severe obesity, a BMI of 35kg/m² or more, value the support and motivation they get from weight management programmes that include group-based interventions. However, commissioners and service managers should consider how to maintain adequate support and motivation once programmes end.

Although previous studies have assessed the impact of non-surgical weight management programmes for obese adults, this is the first qualitative review to focus on the opinions of providers and adults enrolled in programmes designed to help those with severe obesity lose weight. It follows a related NIHR Health Technology Assessment which evaluated the clinical and cost-effectiveness of such programmes, published in 2018.

This NIHR-funded review included data from 33 studies involving 644 people with severe obesity and 153 providers. It concluded that although group-based interventions are particularly valued, people’s comorbidities could inhibit or restrict their engagement with some activities.

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Why was this study needed?

Around 5% of women and 6% of men in England are severely obese, meaning they have a body mass index (BMI) of between 35 and 40kg/m². Unfortunately, that number is growing – as are obesity-related co-morbidities, such as type 2 diabetes and hypertension.

Severely obese people may be referred to a specialist programme, but current UK weight management guidance doesn’t distinguish between obesity (BMI 30 to 35kg/m²) and severe obesity, and excludes evidence on weight-loss programmes for obese people with comorbidities.

This review aimed to improve understanding of what people with severe obesity think about these programmes and how they engage with them. The review looked for studies that had sought to understand what makes weight loss interventions helpful or unhelpful for them.

What did this study do?

This qualitative review assessed 33 studies which included qualitative data, mostly from interviews or focus group sessions with care providers or adults with a BMI of more than 35kg/m². The review took a realist approach that focused on weight management issues, trying to identify ‘what works’ for weight management for this group of adults and intervention providers, and also ‘for whom and under which circumstances’. Eleven of the studies were conducted in the UK.

Two reviewers read and extracted data from the studies, grouping and comparing them by emerging issues and themes, to gain insights into why severely obese people might decide to join, stay in or drop out of programmes. The papers were independently appraised for methodological rigour and theoretical relevance.

The mean BMI reported across the papers ranged from 36.8 to 44.7 kg/m². However, only two studies described programmes that were specifically designed for people with severe obesity, so the views of some people with lower BMIs may have been included.

What did it find?

  • Participants were attracted to weight management programmes that they perceived to be novel or exciting, and endorsed by healthcare providers. They valued belonging to a group of people with similar physiques and personalities, and who shared similar issues with weight and food – indeed, this seemed to help with motivation and continuing engagement.
  • The participants also valued good relationships with programme providers and the ongoing encouragement and monitoring they provided – although concerns were raised about whether this support would continue once the study interventions ended. Providers also questioned the practicalities and logistics of providing such ongoing and intensive support.
  • Although many participants enjoyed group-based activities, some described struggling with physical activities because of their physical limitations. Others disliked group interaction and discussions with other participants.
  • Flexibility around the scheduling of face-to-face counselling sessions and food choices was valued by participants and programme providers alike. They also welcomed personalised interventions.

What does current guidance say on this issue?

NICE states that weight management programmes may particularly benefit adults who are obese or with comorbidities such as type 2 diabetes (Guideline PH53, 2014). Those referring them should discuss the effort and commitment needed to lose weight and prevent weight regain, and sources of long-term support.

Providers of weight management programmes should discuss any positive or negative experiences of such programmes with participants, any concerns or barriers they may have about joining the programme, and the process of change and meeting their personal goals. They should also discuss opportunities for ongoing support once the programme or referral period has ended.

What are the implications?

Group interventions are a highly valued component of weight management programmes, but commissioners and providers should be aware that severely obese participants may struggle to engage in certain activities because of their physical or mental comorbidities.

Ongoing encouragement and monitoring are also necessary to keep participants motivated and implement long-term behaviour change, so providers need to do more to help participants establish community-based support for when their weight management programme intervention ends.

Citation and Funding

Skea ZC, Aceves-Martins M, Robertson C et al. Acceptability and feasibility of weight management programmes for adults with severe obesity: a qualitative systematic review. BMJ Open 2019;9(9):e029473.

This project was funded by the NIHR Health Technology Assessment Programme (project number 15/09/04).

Bibliography

Avenell A, Robertson C, Skea Z et al. Bariatric surgery, lifestyle interventions and orlistat for severe obesity: the REBALANCE mixed-methods systematic review and economic evaluation. Health Technol Assess. 2018;22(68).

British Obesity and Metabolic Surgery Society. Commissioning guide: weight assessment and management clinics (Tier 3). London: British Obesity and Metabolic Surgery Society; 2014.

NICE. Obesity in adults: prevention and lifestyle weight management programmes. QS111. London: National Institute for Health and Care Excellence; 2016.

NICE. Weight management: lifestyle services for overweight or obese adults. PH53. London: National Institute for Health and Care Excellence; 2014.

Why was this study needed?

Around 5% of women and 6% of men in England are severely obese, meaning they have a body mass index (BMI) of between 35 and 40kg/m². Unfortunately, that number is growing – as are obesity-related co-morbidities, such as type 2 diabetes and hypertension.

Severely obese people may be referred to a specialist programme, but current UK weight management guidance doesn’t distinguish between obesity (BMI 30 to 35kg/m²) and severe obesity, and excludes evidence on weight-loss programmes for obese people with comorbidities.

This review aimed to improve understanding of what people with severe obesity think about these programmes and how they engage with them. The review looked for studies that had sought to understand what makes weight loss interventions helpful or unhelpful for them.

What did this study do?

This qualitative review assessed 33 studies which included qualitative data, mostly from interviews or focus group sessions with care providers or adults with a BMI of more than 35kg/m². The review took a realist approach that focused on weight management issues, trying to identify ‘what works’ for weight management for this group of adults and intervention providers, and also ‘for whom and under which circumstances’. Eleven of the studies were conducted in the UK.

Two reviewers read and extracted data from the studies, grouping and comparing them by emerging issues and themes, to gain insights into why severely obese people might decide to join, stay in or drop out of programmes. The papers were independently appraised for methodological rigour and theoretical relevance.

The mean BMI reported across the papers ranged from 36.8 to 44.7 kg/m². However, only two studies described programmes that were specifically designed for people with severe obesity, so the views of some people with lower BMIs may have been included.

What did it find?

  • Participants were attracted to weight management programmes that they perceived to be novel or exciting, and endorsed by healthcare providers. They valued belonging to a group of people with similar physiques and personalities, and who shared similar issues with weight and food – indeed, this seemed to help with motivation and continuing engagement.
  • The participants also valued good relationships with programme providers and the ongoing encouragement and monitoring they provided – although concerns were raised about whether this support would continue once the study interventions ended. Providers also questioned the practicalities and logistics of providing such ongoing and intensive support.
  • Although many participants enjoyed group-based activities, some described struggling with physical activities because of their physical limitations. Others disliked group interaction and discussions with other participants.
  • Flexibility around the scheduling of face-to-face counselling sessions and food choices was valued by participants and programme providers alike. They also welcomed personalised interventions.

What does current guidance say on this issue?

NICE states that weight management programmes may particularly benefit adults who are obese or with comorbidities such as type 2 diabetes (Guideline PH53, 2014). Those referring them should discuss the effort and commitment needed to lose weight and prevent weight regain, and sources of long-term support.

Providers of weight management programmes should discuss any positive or negative experiences of such programmes with participants, any concerns or barriers they may have about joining the programme, and the process of change and meeting their personal goals. They should also discuss opportunities for ongoing support once the programme or referral period has ended.

What are the implications?

Group interventions are a highly valued component of weight management programmes, but commissioners and providers should be aware that severely obese participants may struggle to engage in certain activities because of their physical or mental comorbidities.

Ongoing encouragement and monitoring are also necessary to keep participants motivated and implement long-term behaviour change, so providers need to do more to help participants establish community-based support for when their weight management programme intervention ends.

Citation and Funding

Skea ZC, Aceves-Martins M, Robertson C et al. Acceptability and feasibility of weight management programmes for adults with severe obesity: a qualitative systematic review. BMJ Open 2019;9(9):e029473.

This project was funded by the NIHR Health Technology Assessment Programme (project number 15/09/04).

Bibliography

Avenell A, Robertson C, Skea Z et al. Bariatric surgery, lifestyle interventions and orlistat for severe obesity: the REBALANCE mixed-methods systematic review and economic evaluation. Health Technol Assess. 2018;22(68).

British Obesity and Metabolic Surgery Society. Commissioning guide: weight assessment and management clinics (Tier 3). London: British Obesity and Metabolic Surgery Society; 2014.

NICE. Obesity in adults: prevention and lifestyle weight management programmes. QS111. London: National Institute for Health and Care Excellence; 2016.

NICE. Weight management: lifestyle services for overweight or obese adults. PH53. London: National Institute for Health and Care Excellence; 2014.

Acceptability and feasibility of weight management programmes for adults with severe obesity: A qualitative systematic review

Published on 11 September 2019

Skea ZC, Aceves-Martins M, Robertson C, de Bruin M, Avenell A, and the REBALANCE team

BMJ Open , 2019

Design A systematic review of qualitative evidence. Data sources Medline, Embase, PsycINFO, CINAHL, SCI, SSCI and CAB abstracts were searched from 1964 to May 2017. Eligibility criteria Papers that contained qualitative data from adults with body mass index (BMI) ≥35 kg/m2 (and/or the views of providers involved in their care) and considered issues about weight management. Data extraction and synthesis Two reviewers read and systematically extracted data from the included papers which were compared, and contrasted according to emerging issues and themes. Papers were appraised for methodological rigour and theoretical relevance using Toye’s proposed criteria for quality in relation to meta-ethnography. Results 33 papers met our inclusion criteria from seven countries published 2007–2017. Findings were presented from a total of 644 participants and 153 programme providers. Participants described being attracted to programmes that were perceived to be novel or exciting, as well as being endorsed by their healthcare provider. The sense of belonging to a group who shared similar issues, and who had similar physiques and personalities, was particularly important and seemed to foster a strong group identity and related accountability. Group-based activities were enjoyed by many and participants preferred WMPs with more intensive support. However, some described struggling with physical activities (due to a range of physical comorbidities) and not everyone enjoyed group interaction with others (sometimes due to various mental health comorbidities). Although the mean BMI reported across the papers ranged from 36.8 to 44.7 kg/m2, no quotes from participants in any of the included papers were linked to specific detail regarding BMI status. Conclusions Although group-based interventions were favoured, people with severe obesity might be especially vulnerable to physical and mental comorbidities which could inhibit engagement with certain intervention components. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

Expert commentary

Obesity is a chronic disease that is challenging to prevent or treat and requires system-wide approaches addressing the multiple simultaneous factors that contribute to obesity. Lifestyle, dietary and behavioural interventions are used widely. While they are successful in achieving meaningful long-lasting weight loss in a small but important proportion of individuals, the majority of people will regain the weight lost, and many will overshoot the baseline weight, over the medium/long term.

This has always been the challenge for weight management programmes and hence understanding the factors that contribute to acceptability is important.

Interestingly, the findings of this systematic review emphasise the notion that there is no one size fits all when it comes to weight management and that individualised and personalised treatment approaches are needed.

Dr Abd A Tahrani, Senior Lecturer in Obesity Medicine, University of Birmingham; Honorary Consultant in Endocrinology and Obesity Medicine, University Hospitals Birmingham NHS Foundation Trust

The commentator declares no conflicting interests