Examination of Witnesses (Questions 1120-1140)
18 DECEMBER 2003
MS PAULA
HUNT, DR
JACQUIE LAVIN,
MS JACKIE
COX AND
DR HELEN
TRUBY
Q1120 Dr Taylor: We touched on the joint
working between Slimming World, Weight Watchers and the NHS, could
you tell us a little bit more about that and particularly if the
NHS really is getting value-for-money out of this? What sort of
quality assurances do you have in place?
Ms Hunt: For Weight Watchers we
are hearing more and more GPs asking us if we can help them with
this burden, who do not want to medicalise weight control. Patients
have to find a way of taking some sort of responsibility themselves,
it is about life-style change whichever way you look at it. GPs
are saying "we only have ten minutes, our practice nurses
are overburdened with all of the things they have" and a
lot of GPs are saying, "we are not really convinced that
we are doing a great job of managing this ourselves". The
research would support that at the moment, that there is not the
time in primary care. We are very keen to offer a thorough shared
care arrangement whereby this is not about GPs dumping patients
for a certain amount of money with an organisation like Weight
Watchers. We offer a discounted package to primary care teams
and it works out at about £4 per person per week to attend,
for one month that is £16 or for three months it is £48.
That sounds good value compared with the cost of drugs or surgery.
We are doing some pilot work with a couple of practices because
we are keen to look at how the whole system can work whereby the
GP will raise the issue. Obviously people do not usually go to
a GP with just a weight problem, they go with some other issue,
whether it is a physical health issue like a sore leg, painful
hips or an emotional health issue like depression, etc. The GP
raises the issue and says "there are a whole range of options
that we could offer, we happen to like the Weight Watchers approach,
I do not know if that is something that would appeal to you".
The GP can then suggest that the patient might be interested in
talking to the practice nurse briefly, because practice nurses
do not have half an hour to spend going through this in detail,
the practice nurse has vouchers which they can give to the patient,
but it is clear that there is a time specific check by the nurse,
so perhaps the patient comes back in six weeks' time or twelve
weeks' time. Most importantly with computerisation it really ought
to be very simple when the patient does happen to next see the
GP for it to be flagged up on screen and the GP says, "how
is it going with the your weight loss, I know you have been working
really hard".
Q1121 Dr Taylor: That is what I am getting
at. Is there feedback at the moment so that the GP can know if
you are succeeding?
Ms Hunt: This is the sort of system
that we are piloting. People have to go through a lot of effort
to lose a few pounds and it is miserable when the GP does not
even ask how is it going, or worse when you say "I have lost
three pounds" and they say "only three pounds".
This is hard work for people, they need boosting, they need supporting,
they need motivation if they really are to sustain it, it really
does need to be a shared care plan.
Q1122 Dr Taylor: You are working on feedback?
Ms Hunt: We are.
Dr Lavin: To add to that, we ran
a trial two years ago now which was looking at the idea of slimming
on referral with Greater and Central Derby PCTs, the idea of that
trial was to look at the feasibility and the practicalities of
running that sort of scheme. The results do show that it does
work with minimal extra resources required. Certainly at Slimming
World we were providing a lot of the administration, which we
are normally doing anyway, and then feeding back to the GPs. What
came out quite strongly, as Paula referred to, is the actual partnership
and patients were very pleased with the idea of the partnership,
the doctor bringing it up in the first place asking if they would
want something to help them manage their weight and offering them
a solution. In terms of following them up, the GP just asking
how they were getting on when they went back to their surgery
was a very important part, knowing that somebody is actually interested
in their weight loss.
Q1123 Dr Taylor: How would you cope if
your workload went up and up and up?
Dr Lavin: We have coped with that
over the last 30 plus years, we do open up new groups when required
when we have the right person to run them.
Q1124 Dr Taylor: You can get sufficient
trained people to run those groups?
Dr Lavin: Yes, we do in-house
training.
Q1125 Dr Taylor: As well as weight loss
do you emphasise the importance of the health gains that people
get?
Ms Hunt: Absolutely. Within Weight
Watchers typically we set targets and it is always done in consultation
with the client who chooses what the target is to be. The 10%
goal initially we find is very useful because it feels achievable,
it feels doable for many people and of course they get a lot of
positive feedback because of the dress size or whatever other
difference it makes. Importantly we do tell people those benefits
in terms of their health. We say, "even if you could make
that 10% goal that would be fantastic in terms of the health benefits".
Q1126 Dr Taylor: You spell those out
to them.
Ms Hunt: We do indeed, but we
do not want to medicalise obesity. I am just minded to refer back
to what Nick Finer was saying in the first session about his groups,
it struck me that that sort of group scenario where people are
in a clinical environment I imagine is very different from the
sort of thing that we are talking about with an organisation like
Weight Watchers, which is in a local church hall or a community
centre, people have gone along by choice and they know what they
are to expect. I can imagine in a clinical environment that group
thing may be quite uncomfortable for people. It is very difficult,
we have a lot of very big people who go along to Weight Watchers,
it is huge thing for them to even have the confidence to walk
through the door but when they get through the door they feel
supported, they realise they are not the biggest person there
and they do get a real sense of we are all in this together and
this is a real kind of support system for me and however big I
am we can get there.
Q1127 Mr Jones: I want to ask Dr Truby,
I am interested in the comparative work that you have done and
the interesting results which are quite similar, have you done
any work comparing the success or otherwise of dieting? You have
compared the various commercial companies, have you done any work
or seen any work that compares them to people who present themselves
to the health sector?
Dr Truby: There is very little
work done in proper studies looking at the effectiveness of commercial
programmes compared to what we call standard care. There have
been a couple of American studies which have been done by Weight
Watchers and they have compared quite favourably. I do think it
is an important point to make that these are suitable for probably
the healthy overweight, obese subjects but not necessarily people
that have a number of clinical problems that may need to be dealt
with at a specialist level. I think this is important in terms
of what training the people who run commercial weight organisations
have in their ability to manage some more complex cases. It is
very different in terms of a healthy person who is overweight
and needs to manage that problem.
Q1128 Mr Jones: I understand the caveats
but we as a Committee were presented with overwhelming evidence
that there is a general problem with obesity as well as particular
problems involved with obesity and all levels of obesity add to
medical problems. Leaving aside the caveats, because we can leave
them aside for the majority of the population, the evidence, sparse
though it is, indicates that the commercial sector is actually
as good, if not better, than the proper health sector in dealing
with this problem.
Dr Truby: I do not think there
is a great body of evidence to say that. There are very few studies,
Diet Trials is probably the largest one that has been done
in the United Kingdom.
Q1129 Mr Jones: Would you speculate on
why there are not any studies? We are presented with evidence
about how important this is, and for one of the most important
issues there are no studies!
Dr Truby: There are not very many
studies. It is extremely difficult to get research funding for
any type of work that you do and I think obesity and weight management
is not the most sexy of topics in terms of being able to get research
money. I do think there is a limited amount of evidence for those
reasons. If we look at the Atkins diet, which has had an enormous
amount of publicity, the Atkins Foundation has had an enormous
amount of money generated and yet their evidence for the long-term
efficacy of their diet has not been done and one does have to
ask why those commercial sectors are not ploughing back money
into research that would help the evidence base. I do feel strongly
that with those types of diets that are highly commercial there
should be a responsibility for those companies to provide evidence
what they are saying, and I know that does take a long time.
Q1130 Mr Jones: That is a good point,
Dr Truby, the National Health Service spends an enormous amount
of money, an even greater amount of money than the Atkins people,
on all sorts of health issues and really the National Health Service
has to allocate priority, it has pretty strong reason for trying
to find this out as well and a duty to do so.
Dr Truby: I agree with you. I
do think there needs to be a lot more work done in looking at
the efficacy of the various approaches. I do think that a lot
of it is horses for courses in terms of looking at it in terms
of a scientific style, even in Diet Trials although we
had very successful outcomes at twelve months we only managed
to follow up 50% of people, which means that for various reasons
50% have fallen by the wayside. For the people who can do it they
manage well within the commercial sector but for the 50% that
do not they may well be much better suited to having individualised
advice even at primary care or at secondary care, they might do
better that way. There needs to some kind of system where people
who do not do well in one approach are picked up and it is suggested
that they have another approach.
Ms Cox: I want to bring in the
example of the geriatric model where those with morbidities are
treated by various health departments and the commercial sector
and others deal with the day-to-day management. The number of
obese people we are having to work with, the NHS cannot manage
it alone and I must put in a plea for treatment. There has been
a lot of talk here a round prejudice. I think one of the reasons
why there has not been so much research is because of the enormous
prejudice, amongst the medical profession and others, against
obesity, it is not a sexy topic. I would also like to mention
the financing and research complications that exist with the laws
of confidentiality and that research is greatly needed to find
out what is effective, to look at the complications of the problem,
a one-size-fits-all treatment will not work and we need to look
at the various sorts of diets, the various physical reactions
that people have to various food stuffs, as in carbohydrates versus
protein and also the psychological complications and look at the
whole spectrum of treatments that are available ranging from standard
food diets, very low calorie diets and medication and surgery
but also making sure that the prejudice issue is dealt with because
it is a fundamental problem.
Q1131 Chairman: What is your organisation's
experience of how people facing obesity are consulted about what
is most appropriate from their perspective?
Ms Cox: Generally they feel they
are treated as one homogenous blob of people and the fact they
carry access body fat is how they are defined by definition, I
think that is an error. I suggest that we need patient profiling,
and computer systems can come into this. I know you have talked
a lot of about pedometers, and that is excellent, but in Holland
they can link up to a website and get feedback on their activity
using their pedometer material.
Q1132 Chairman: Are you saying support
systems are not in place really to assist people to seriously
address their obesity?
Ms Cox: Yes.
Q1133 Chairman: You mentioned the Holland
model, what other support systems do you feel would be appropriate?
Ms Cox: Counselling.
Q1134 Chairman: By whom? We heard about
the problems in the NHS and we have seen what the private sector
can offer. Who do you feel from your experience is the most effective?
Ms Cox: You touched on it earlier
today, there needs to be work force development, this is a completely
new issue in the sense that even though obesity has been round
forever there has not been any specialist group as far as the
NHS is concerned. There needs to be work force development, even
at government level there needs to be somebody who is there looking
after the special needs of the obese person and the overweight
population when looking at environmental changes. The way that
obesity is hidden in the National Service Framework, it is a 128
page document and there is the odd word in there, most of my experience
tells me that GPs do not even know that it is there.
Q1135 Chairman: Are you inferring another
profession might be appropriate?
Ms Cox: Very definitely.
Q1136 Chairman: What kind of person would
that be?
Ms Cox: That person needs to have
the skills, it needs to be a group of people because the problem
incorporates physical activity and yes nutritional food information
but it also requires psychological support, understanding the
reasons why is it that many people do know that when they open
their fridge they should take out the low fat yoghurt and not
the cheese, why do they not make those choices. That profession
needs to have training and understand why human beings make the
choices that they do.
Q1137 Chairman: Can I ask all of the
witnesses briefly, you have observed some of the sessions that
we have had previously in the last few weeks where we had the
food industry before the Committee and they have been saying they
want to be part of the solution to obesity, not just part of the
problem, how do you think the food industry could help?
Ms Hunt: For Weight Watchers I
think this is about good nutritional labelling.
Q1138 Chairman: The labelling is a key
issue.
Ms Hunt: Because Weight Watchers
is based on a points system—depending on their gender or
size people will have approximately 24 or 26 points of food a
day—which is kind of proxy for calories but based on saturated
fat as well. It would be very, very helpful for Weight Watchers
members if there was a simple summary on pack of per serving calories
and saturated fats.
Q1139 Chairman: To simplify the labelling
system.
Ms Cox: Food labelling. I still
think discussions have gone on here where people do not understand
that when it says on the label 85% fat free it is not saying it
has 15% fat, the food industry have been very clever and we could
learn from the food industry in the way that we can learn from
the addiction industry because they have been very clever at both
motivating change in behaviour and lying frankly on food labels.
I think we could work more closely with them. I understand that
they have been asked to help in research and in passing on their
skills in motivational change but have declined to do so. I think
we should take notice of Marian Nestle and a lot of the stuff
she said.
Dr Truby: I agree the food labelling
issue needs to be dealt with, we need to work in partnership with
the food industry and we need to be able to learn from them. I
would also like to say that the media is incredibly powerful in
terms of health messages. We need to work more effectively with
them and try bring them on board as well about bringing the appropriate
messages to the public.
Dr Lavin: I would agree with the
misleading labelling and that does trick people, by being reduced
fat it does not mean reduced calories. I also think the food industry
could talk to slimmers, people wanting to manage their weight
and ask what they want, producing reduced energy density products
that still have the taste. Slimming World have worked with the
food industry and developed a product which is a high fibre cereal
bar that is not loaded with sugar and is still satiating to the
appetite, so I think we can work together.
Q1140 Chairman: Can I thank you all for
a very interesting session. The time has been very limited and
it may be there are points that you want to come back to us on
with more information, similarly we may come back to you with
specific questions. As this is the last as session before Christmas
can I wish everyone a happy Christmas and a New Year.
Ms Cox: Can I add a caveat to
that, you have such a powerful position, this is a quote, and
I do not know where it comes from, "it is very rare in the
course of living that such a moment comes along when while making
a few changes you can alter the quality and character of every
single day of the rest of your life, even the length of your life".
You are in key position to make a paradigm shift in this country
and you will be affecting millions and millions of lives. Thank
you very much.
Chairman: Thank you, Ms Cox, we are very
grateful.
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