Has it really come to the point that apps are the solution to weight loss? With four due to be used by NHS England, journalist Anna Scott asks whether it’s enough.
‘Obesity levels in the UK have not improved and the deprivation gap is widening,’ says Katharine Jenner, director of the Obesity Health Alliance (OHA) – a coalition of more than 50 health organisations advocating for policies to tackle the problem.
The proportion of adults estimated to be overweight or living with obesity has recently increased from 63.3% to 63.8%, according to the latest figures for England (Office for Health Improvement and Disparities, 2023). In Northern Ireland, 27% of adults are living with obesity, and 38% are overweight (House of Commons Library, 2023).
Meanwhile, almost a third of adults (31%) in Scotland are classified as obese (a body mass index (BMI) of over 30kg/m2) and 36% are overweight (a BMI ranging from 25 to 30) (House of Commons Library, 2023). In Wales, 62% are overweight or obese, including 25% living with obesity (Welsh Government, 2022). In England, rates of adult obesity have increased by nearly 14% over the last three decades (House of Commons Library, 2023).
In August, draft guidance* from the National Institute for Care and Health Excellence (NICE) recommended that NHS England use four apps to help deliver specialist weight-management services to support the use of medication aimed at addressing obesity. Weight-management medication – such as semaglutide and liraglutide – can currently only be accessed with specialist services, the provision of which is patchy across the country (NICE, 2023).
Many weight-management apps (both free and paid for) focus on logging meals and exercise, while also recommending diet and fitness plans. But the platforms that will be trialled via app or computer* – Liva, Oviva, Roczen and Second Nature – offer users support and care from a multidisciplinary healthcare team. These teams will give dietetic and psychological support and monitoring to reduce the risk of harm from eating disorders and mental health issues.
Some of the planned programmes will also be able to prescribe weight-management medication, while others can collect and share data as well as provide wraparound services involving diet and exercise. Those eligible – people with at least one weight-related comorbidity, such as type 2 diabetes or high blood pressure, and a BMI of at least 35 kg/m2 – will have a clinical assessment before starting treatment.
NICE calculates that up to 48,000 people will be able to access the virtual services and that – if every eligible person enrolled – up to 145,000 hours of clinicians’ time would be saved. It aims to monitor the programmes’ use and cost effectiveness over the next four years. ‘This is the first time NICE has recommended digitally-enabled technologies to support treatment with weight-management medication in specialist weight-management services,’ says Matthew Brown, NICE’s digital media manager.
The evidence base for the programme consists of 26 studies appearing in 31 publications. ‘This topic has been selected as part of our Early Value Assessment programme, where technologies address an unmet need; assess existing evidence; and can help to identify key gaps in evidence,’ Matthew adds. ‘Further evidence will be generated while the four recommended technologies are used in the NHS in England.’
Research into the efficacy of weight-management apps suggests that they may be ‘useful as low-intensity approaches or adjuncts to conventional weight management strategies’ (Ghelani et al, 2020). However, the paper also notes that there is ‘insufficient evidence to support their use as standalone intensive approaches to weight management’, with further research needed (Ghelani et al, 2020).
BETTER ACCESS TO HELP
Katharine at the OHA says that whether apps work depends on how well resourced they are. ‘Anything that can make sure services are reaching the right people, the better. But NICE does things well and evaluates things well. So [the programme] is being run by the right people,’ she says.
The OHA’s focus is on preventive methods for weight management. ‘It’s incredibly difficult to lose weight once you have put it on,’ Katharine adds. ‘Really the solutions are bariatric surgery and intensive services to help people not put the weight back on.’
The government has introduced a series of preventive measures, such as calorie labelling and restricting the placement of less healthy products in stores and online. It has also invested £20 million in research into new treatments and digital technologies to help people achieve a healthy weight (Department of Health and Social Care, 2022). But more needs to be done.
‘To effectively reduce obesity levels, we need to look at wider systemic issues as well as individual treatment,’ says Shona Goudie, policy and advocacy manager at the Food Foundation charity. ‘What we eat is influenced by a wide variety of factors in our food environments, many of which are outside of our control. Instead, we need to ensure the healthy options are the most affordable, available and appealing.’
Meanwhile, recommendations from the British Dietetic Association’s (BDA) obesity specialist group include increasing access to food demonstration workshops with inexpensive basic items. The aim is to encourage budgeting and healthy eating, cost effective and healthy meal and snack options in supermarkets, and long-term price incentives on healthy foods. The BDA group also recommends targeting population groups that are vulnerable to weight-management issues – including pregnant and menopausal women, and ethnic minority groups, who tend to have higher rates of people affected by weight issues.
‘Better access is needed to community-based support groups (Tier 2 services) and potential treatment options that are appropriate to clinical history and current health status,’ says Deepti Loomba, an obesity specialist dietitian and consultation member of the group.
Dr Adrian Brown, senior specialist dietitian and chair of the group, adds: ‘There should be increased and equitable access to weight management services for people living with overweight and obesity, with increased access to Tier 3 [includes psychologists and specialist dietitians] and Tier 4 [bariatric surgery] weight management services.’
SO CAN A DIGITAL PROGRAMME REALLY WORK?
Apps and digital platforms in general may increase accessibility to weight management services, reducing the need for potentially costly travel time and increase the frequency with which support can be offered. But they could also have a negative impact on care, says Deepti, ‘if support is from non-healthcare professionals, or non-specialist healthcare professionals without the appropriate specialist training to deal with complex medical issue and medication alterations’.
‘The existing evidence base suggests that digital support may be more acceptable to some people than others and the effectiveness will be very dependent on the level of digital literacy of the recipient. Also, compliance may wane over time, though this seems to be the case with face-to-face services as well,’ she adds.
Many current NHS weight management services feature a mixture of face-to-face and virtual consultations for individuals and groups of people living with obesity. Even with apps, Deepti points out, ‘there will still be the need for routine clinical tests to be undertaken including blood tests such as thyroid function, blood glucose, cholesterol levels and vitamin D’.
She adds: ‘Specialist weight management support requires a holistic approach for patients living with severe and complex obesity. Patients will benefit from having a comprehensive assessment by trained healthcare professionals, including a specialist dietitian, psychologist, and an obesity physician and receive ongoing care as a minimum in Tier 3 and Tier 4 services.’
COST OF LIVING IMPACT
Another issue with using a digital programme to tackle obesity is poverty – both the ‘digital poverty’ of people living in deprived areas not having access to the technology to use digital health, and the cost of living crisis. ‘At present the impact of the crisis on obesity prevalence is unknown,’ says Dr Amanda Avery, dietitian and former chair of the BDA’s obesity specialist group.
‘Even in economically developed countries like the UK, families will have to choose between cheap and readily available, energy dense foods, [that fill their children], versus more costly healthier options. Levels of food insecurity are increasing in the UK and are higher in families with children – even if [their] parents are working,’ she adds.
Shona from the Food Foundation, agrees: ‘We’ve found that, per calorie, healthy food is on average more than twice as expensive as less healthy food, clearly demonstrating why the cost of living crisis is likely to push people to eat a less healthy and nutritious diet, which could contribute to a rise in levels of obesity.’
The impact of the crisis on mental health and wellbeing can also decrease people’s motivation to make healthy lifestyle choices and increase the tendency towards ‘emotional eating’. ‘The experience of stress increases the risk of excessive weight gain directly and indirectly,’ Dr Avery adds.
‘This can cause a chronic activation of the stress response system, resulting in greater accumulation of internal body fat (visceral fat) stored in the abdomen and internal organs. Also, stress can influence behaviours such as being more sensitive to food cues and cravings, leading to eating more calorific dense foods.’
THE WAY FORWARD
NICE is carrying out another early value assessment of digitally enabled weight management programmes. This will evaluate technologies providing multidisciplinary support but that do not facilitate weight management medication monitoring or prescribing.
Ultimately, says Dr Brown from the BDA: ‘There is a need for a long-term cross-party strategy around obesity that extends past political terms and focuses on both prevention and treatment. The government needs to invest in addressing obesity across the whole system and ensuring there is equitable access to services across the UK and particularly for those at greatest need.’
*At time of writing, NICE said: ‘Final guidance is expected to be published 26 October 2023 [see Resources]. The recommendations can change following consultation’.
A UK-WIDE ISSUE
OVERWEIGHT OR LIVING WITH OBESITY:
|65% of women
69% of men
In all age groups over 55,
more than 70% of people are
overweight or obese
20% of children aged 2-6, 22%
Obesity is more common in
|58.4% of women
69.1% of men
45 to 84-year olds have highest
estimated prevalence of obesity
Around 10% of children are obese
The highest levels are across north
|60% of women
71% of men
65 to 74 and 45-54-year-olds have
highest obesity rates
7% of children aged 2-10 and
|58% of women
67% of men
45 to 64 age group, obesity is highest
12% of children aged 4-5 are obese
Children living in the most deprived areas are
|HOW CAN YOU HELP?
|Community practitioners play an important role in helping children, young people and families with weight-management issues, and their advice is needed more than ever during the cost of living crisis. Every visit to a family, child or young person provides an opportunity to discuss the importance of a healthy weight and lifestyle, and to signpost people to relevant resources (see above) and community activities. If you’d like to share practice successes and challenges, email editor Aviva Attias: [email protected]
Department of Health and Social Care. (2022) New obesity treatments and technology to save the NHS billions. See: https://www.gov.uk/government/news/new-obesity-treatments-and-technology-to-save-the-nhs-billions (accessed 9 October 2023).
Ghelani DP, Moran LJ, Johnson C, Mousa A et al. (2020) Mobile Apps for Weight Management: A Review of the Latest Evidence to Inform Practice. Frontiers in Endocrinology. See: ncbi.nlm.nih.gov/pmc/articles/PMC7326765/ (accessed 8 October 2023).
House of Commons Library. (2023) Obesity statistics. See: researchbriefings.files.parliament.uk/documents/SN03336/SN03336.pdf (accessed 8 October 2023).
National Institute for Health and Care Excellence. (2023) Digitally enabled technologies to support treatment with weight-management medication in specialist weight-management services: early value assessment. See: nice.org.uk/guidance/indevelopment/gid-hte10007 (accessed 8 October 2023).
Office for Health Improvement and Disparities. (2023) Obesity Profile: short statistical commentary May 2023. See: gov.uk/government/statistics/obesity-profile-update-may-2023/obesity-profile-short-statistical-commentary-may-2023 (accessed 8 October 2023)
Welsh Government. (2022) National Survey for Wales headline results: April 2021 to March 2022. See: gov.wales/national-survey-wales-headline-results-april-2021-march-2022-html (accessed 8 October 2023).