Background to Tier 3 Services

The NICE guidelines1 recommend, that patients with a BMI of 50+ should be offered bariatric surgery if they have exhausted all conventional means of weight management. The NICE guidelines1 also recommend surgery for patients with a BMI 40+ with co-morbidities. However, bariatric surgery is not a magical cure and requires patients to be psychologically robust and able to make long-term fundamental changes in their lifestyle and dietary habits.

With new restrictions on funding for surgery and surgical centres being over-subscribed, Clinical Commissioning Groups are now starting to develop integrated 4 Tier Obesity Management Models. This is to ensure compliance with the new NHS England commissioning policy (April 2013)2, stating that patients only access surgical treatment when they are fully prepared to address change. The new NHS England guidelines state that all patients must now commence specialist treatment in Tier 3 for a minimum period of six months but preferably for 12-24 months, before being offered a surgical intervention. Tier 3 treatment is administered in a community setting by a specialist multi-disciplinary team including bariatric physicians, psychological therapists, dieticians and exercise specialists. Whilst the goal of non-surgical treatment is weight reduction, the underlying psycho-social issues must also be addressed. This includes exploring behavioural change around food, education on healthy lifestyle choices as well as more complex emotional issues which have led to disordered eating patterns.

1. Obesity guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children, 2006

2. Clinical Commissioning Policy: Complex and Specialised Obesity Surgery, April 2013

Obesity, a Psychological Issue?

There is a growing body of literature demonstrating that morbid obesity is associated with high levels of poor mental health and disturbed eating behaviour. For many reasons adults who have experienced crisis and disorder in childhood often lack the ability to self-regulate their emotions as adults. They will often look to external sources such as food, alcohol and drugs as a means to managing their emotions. The relationship most adults have to food is based on their childhood experiences from their psycho-social situation at the time. From birth, there is a knowledge that sustenance equals some form of soothing. An infant becomes emotionally wired to accept that a mother’s milk makes them feel better. Throughout childhood there is a series of often-unconscious messages that repeated enough, become imprinted in memory, and in adulthood become an automatic response around food. For example: -

• “Clear your plate, think of the starving”
• “Don’t waste food”

This primary conditioning can guide an adult’s relationship to food, often leading to overeating and overriding the body’s natural stimuli around hunger and satiety. There is also a far wider social conditioning around food. In many cultures food equals love and belonging. It can also be a means of brining whole communities together. Food can also be used dysfunctionally. In some households it becomes a method of punishment and control. It can represent rebellion or the road to secondary gains. There can also be issues of deprivation, inconsistent availability and even forced consumption. This type of dysfunction around food often manifests in adulthood as disordered eating. This can present along a continuum from Anorexia Nervosa to Obesity. Whatever the diagnosis, the goal of treatment is to restore healthy lifestyle choices and a consistent relationship to food.