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Obesity- Tipping Back the Scales of the Nation 19th April, 2017

  1. Disordered Eating Group Nicole Allison Specialist Dietitian NHS Lothian Weight Management Service Eat, Think, Change
  2. Contents • Causes of obesity • Current weight management programme • What are we missing? • What is Binge Eating Disorder (BED) • How could this be treated? • What is Eat, Think, Change?- Ethos/aims/outcomes • Starting to redress the balance
  3. RisingBodyMassIndex Number of Affected People “Get Lighter in Lothian” The Lothian Weight Management Service (Adults) 2017 Tier 1: Get Thinking Tier 2: Get Moving with Counterweight Tier 3 Tier 4 Bariatric Surgery Patient information seminar 12 week ‘IPIC’ programme Further 12 week 1:1 if required Specialist Weight Management Team Advanced Weight Management Group 1:1 consultations with specialist dietitian Orlistat/Pilot Counterweight Plus Tier 5 Community Dietetic Team and Specialist Weight Management Team 14 week core group programme 9 month maintenance group programme 12 week Exercise group programme Eat.Think.Change (disordered eating group) Local Council and Leisure Trust Health Coaches 12 week dietary (Counterweight) and physical activity group programme Follow up at 6, 9 and 12 months General population- based advice and services e.g. websites, apps, community initiatives
  4. Current Weight Management Programme As a Weight Management Service our aims are: • Treatment of overweight and obesity by diet and lifestyle interventions • Where required/appropriate the treatment of obesity by pharmacological therapy and bariatric surgery • Prevention of weight regain following treatment (SIGN, 2010)
  5. Current Weight Management Programme Structured weight management programme which includes: • Physical Activity - reducing sedentary behaviour • Dietary changes - Eatwell guide/portion sizes/food choices • Behavioural components - Mindful eating/food diaries/SMART goals (SIGN, 2010)
  6. Current Weight Management Programme However…. Q: How would this group environment feel if you could not relate to the information provided or other group members?
  7. Current Weight Management Programme I’m not the same as the people in the group No-one seems to be in the same situation as me This is my 2nd time through the weight management programme and I have failed both times I understand the information but it’s too difficult to make changes
  8. What are we missing? Q: So, what is going wrong? Q: What can we offer these people who are genuinely struggling? Q: Is bariatric surgery the simple solution?
  9. What are we missing? • There is a population out there for whom this evidence based tiered approach is not effective • At initial assessment, we carry out an ‘Eating Behaviours Questionnaire’ which includes the following 4 questions – Are there times during the day when you could not have stopped eating, even if you wanted to? – Do you ever find yourself eating unusually large amounts of food in a short period of time? – Do you ever feel extremely guilty or depressed afterwards? – Do you ever feel more determined to diet or to eat healthier after the eating episode? (SIGN, 2010)
  10. What are we missing? • From this information, it was apparent that Binge Eating Disorder (BED) was prevalent within this population; data in line with literature which estimated that 30% of patients within weight management services are likely to have BED (SIGN 2010) • In addition to the impact this eating behaviour was having on their weight and their ability to lose weight it was also a source of great distress – often impacting on day to day life. • Work, relationships, mood and mental health all affected detrimentally. • However, the Lothian Eating Disorder Service does not currently accept referrals for those with a BMI >40kg/m2 • A gap existed within the healthcare pathway
  11. What is Binge Eating Disorder (BED) Binge Eating Disorder Criteria (DSM 5, 2013) BED is characterised by recurrent episodes* of binge eating that occur at least once a week for 3 months (*eating an unusually large amount of food in a discrete period of time, having a sense of lack of control & causing marked distress) Episodes are also associated with 3 of the following behaviours: • Eating more rapidly • Eating until uncomfortable full • Eating large amounts of food when not physically hungry • Eating alone due to embarrassment • Feeling disgusted, depressed and guilty afterwards (SIGN, 2010)
  12. How could this be treated? • A ‘gap’ or inequality had been identified… BED is more prevalent that Anorexia Nervosa but help available did not reflect this. (De Zwaan, 2001) • The question at this time was ‘what support could we provide with the very limited resources available? – Initial pilot study identified patients referred to Weight Management Service (WMS) with disordered eating or binge eating disorder – BED affects approximately 30% of WMS patients (SIGN, 2010) – In Lothian 58% of those assessed by psychology (30% of overall referred) presented with significant disordered eating symptoms
  13. What is Eat, Think, Change • Group setting, co facilitated by Psychologist and Specialist WM Dietitian • Appropriate for patients with clinically significant disordered eating/BED who meet Tier 3 criteria • Patients are referred to the group by: – Community Dietitians at initial Tier 3 assessment – Patients identified at Tier 4 stage – At point of triage – All assessed by Psychologist
  14. What is Eat, Think, Change (Aims) • Main aim of the group is to provide an intervention which helps individuals work towards stabilisation of eating behaviour in preparation for the standard Tier 3 weight management programme (which focuses on weight loss and lifestyle change) • The group aims to address the main mechanisms maintaining the patients disordered eating (or BED) • The main outcomes for the group are: – Reduction in binge frequency – Reduction in binge duration
  15. What is Eat, Think, Change Areas Covered -Education on: -Balanced eating -Binge Eating Disorder -Obesity -Diet/Binge cycle -Impact of dieting -Impact on weight -Cognitive restructuring (Padesky) - Self esteem (Fennel) - Self Compassion (Gilbert) - Anxiety/ Stress - Depression and low mood - Body image (Cash) - Mindfulness (Kabat-Zinn) - Sleep - Applied relaxation - Physical Activity -Introducing self-monitoring eating - Identifying disorganised eating/BED - Identifying emotional eating
  16. What is Eat, Think, Change (to patients) “Before the group I felt hopeless and a failure – assuming something needed to ‘click’ in my head. I had no intentions for surgery. The size of the group was perfect and there was time to discuss and feedback. The members were patient; I was sceptical – could this fix me? I have learned I am not broken, I want to be aware of the changes I need to make, of the habits I want to change. Reflection is so helpful, I am bingeing less and less and gaining focus and control” “I haven’t lost weight but I am very aware of what I am choosing and the effect it will have. I know successful weight loss and sustained loss- is more to do with my mind than my body” (patient reflection at the end of E.T.C)
  17. Eat, Think, Change - Outcomes • Binge Frequency (From 2 groups) • (EDEQ x in previous 28 days) – 6 out of 10 patients reported no binge eating episodes in previous 28 days post group – ALL patients reported a reduction in binge frequency in previous 28 days post group – 73% (8 out of 11) patients reported a reduction in binge frequency in the 6 months post group – 18% (2 out of 11) patients reported an increase in binge frequency in the 6 months post group
  18. Starting to redress the balance… • Further development and funding of this programme will provide a more cost effective and efficient Weight Management Service. – From a service point of view, prevents a cycle of patients completing the same weight management programme with limited or no success. In the past this has led to an increased risk of further weight related co-morbidities and therefore further expense to NHS services – From a ‘service user’ point of view, the appropriate intervention at the initial stage of treatment could prevent increased feelings of failure and low self esteem and ultimately prevent episodes of BED/disordered eating being exacerbated
  19. Starting to redress the balance… • These personal feelings are damaging enough to an individuals self esteem, confidence and ability to live their day to day lives but are also frequently exacerbated by ongoing and incessant feelings of judgement and shaming in a society that continues to consider this as acceptable for the overweight/obese population • How often do we see this judgement and fat shaming? • Would we ever engage in this behaviour??...
  20. Starting to redress the balance…
  21. Thank you for listening… …Any questions??
  22. References • Foresight Report. Tackling obesities: future choices—project report. The Stationery Office, London; 2007 [Accessed 11 April 2017] • Scottish Intercollegiate Guidelines Network (SIGN) (2010). Management of Obesity. A National Clinical Guideline [online] Available at [Accessed 11 April 2017] • De Zwaan, M (2001). Binge eating disorder and obesity. International Journal of Obesity and Related Metabolic Disorders. Journal of the International Association for the Study of Obesity 25(1), p51-5