Obesity prevention and the role of hospital and community-based health services: a scoping review

Self-management not only means to deal with the current condition, but also pursuing a holistic approach to mental and physical wellbeing. Self-management complements medical treatment to become more effective and successful. “Self-management has empowered me to better know and understand myself on so many levels” explains Jacqueline Bowman-Busato in her contribution.

For at least the past 23 years, I’ve been living with two complex chronic, relapsing diseases: Autoimmune Hashimoto’s and obesity. And yet, I can only say that it’s been the last 18 months where I have finally felt in control of my two diseases in any meaningful way. And this has been due to finally understanding and embracing responsible self-management.

Let me explain from a patient’s perspective. When I consciously started the journey of firstly realising that I had “a thyroid problem” which eventually was diagnosed as autoimmune hashimotos, I didn’t understand that a simple pill wasn’t enough to minimise symptoms. Critically, none of my medical specialists seemed to know or care about this fact either. The resultant search for energy in the wrong places aggravated my hashimotos symptoms (severe malabsorption of vitamin D and B as well as iron which all present as depression and severe anxiety). And all very quickly led to developing obesity. I never discussed obesity with my GP for 20 years (the average is 6 years according to a new study Action IO). I “dealt with it” by following holistic diets which always had a beginning, middle and very quick end!

Self-management has empowered me to better know and under-stand myself on so many levels.

It´s time to change

It was not until 18 months post bariatric surgery on 4 July 2016 that everything finally clicked into place for me. I realised that regardless of the good intentions of the public health environment, the sad fact of today’s chronic disease environment is medical treatment of physical manifestations rather than a holistic approach to mental as well as physical wellbeing, not to mention a lack of positive motivation to work together with health professionals in an empowering and empowered way.

Self-management has meant that I have had to take a very long and hard look at myself, the good, the bad and the very ugly truths in order to forge a personal pathway towards managing my life in such a way to optimise my mental health and wellbeing. Armed with my newly gained (and acknowledged) self-knowledge, I forged my own objectives-driven processes for achieving my goal of “mental clarity”. For me, brain fog has been my biggest barrier to sustainable management of both hashimotos and obesity. Having an objective of brain clarity rather than weight or specific blood values has meant that I’ve been able to take control of my health much more than if I solely relied on medication and then wondered why I was still malnourished to the point of continuing to seek energy in foods which are basically poison to me. Giving myself parameters with well-defined processes has significantly empowered me and raised my confidence levels to collaborate with my health care team. I am now listened to and heard.

Jacqueline Bowman-Busato

As a patient representative, Jacqueline has advised the Innovative Medicines Initiative (IMI) on patient engagement strategy, and provides expert advice to the European Commission on self-care policies. She works extensively on European as well as global projects bringing the key stakeholders together to build lasting consensus on global, regional and national levels.

Empowerment through self-management

Science very clearly states that obesity is a chronic relapsing disease. It‘s not the fault of one or other individual. In my world, that does not mean that I have to accept whatever medication I’m given in isolation. It means that I use the treatment (in my case the radical treatment of bariatric surgery) as a tool and I supplement with my own process for mental and physical wellbeing to put me on an even playing field to be able to optimise the medical treatment. Self-management empowers me to engage with the system and my health professionals. It allows me to give myself a bit of certainty which is not anxiety causing. It allows me to feel a partner in my own health. Self-management has empowered me to better know and understand myself on so many levels.

16. December 2019

The costs and benefits of reducing Obesity through self-management

Achieving weight loss serves a purpose: to lead a long and healthy life. In COMPAR-EU, we investigate the cost-effectiveness of self-management programs for obesity, among others. This means that we aim to compare the costs that come along with these programs to the short and long-term health effect that they realize.

Greatest longevity, according to a landmark US study, is achieved with a body mass index (BMI) between 23 and 25. High BMI (>35) is associated with a reduced life span with 9 to 13 years in men, an effect which is less pronounced in women. It goes to show, obesity is a serious and life-threatening condition and it is a risk factor for diabetes, cardiovascular diseases and cancer. Following a forecast scenario, up to 57.8% of the world population could be overweight or obese in 2030. While obese individuals consume more health care, the above-mentioned reduced longevity means that health care is consumed over a reduced period of time and as such, life-time spending may not be reduced when reducing obesity.

Anyone who has tried knows that losing weight in the short-term is more likely than maintaining this weight loss in the long term. A large study with a 10-year follow-up published in The Lancet indicated that lifestyle changes resulted in impressive short-term weight loss, but that within 10 years weight was similar to the placebo group (figure 1). Nonetheless, the incidence of diabetes was reduced in the lifestyle group compared to the placebo group with 34%, indicating that a lifestyle intervention in obesity, even when weight is regained in the long run, can prevent or delay onset of diabetes.

Figure 1: Mean BMI changes in three intervention groups (Lancet study)

Source: Supplement to: Diabetes Prevention Program Research Group. 10-year follow-up of Diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 2009; published online Oct 29. DOI:10.1016/S0140-6736(09)61457-4.

In two years’ time, we hope to provide you with a list of self-manage-ment interventions that are most value for money.

Increased health comes at a price

We know that patients can gain length and quality of life following increased physical activity and weight loss, through preventing chronic diseases such as Diabetes later in life. Which self-management interventions achieve the most health gain will be identified by the COMPAR-EU project. We do know, however, from some previous studies, that the increased health comes at a price. In general, despite not generating savings to a health care system, it is a good investment to buy Quality Adjusted Life Years (QALYs) through reducing obesity at about €6,000 per QALY. These values compare very favourably to what societies are willing to spend for pharmacological and technological treatments, which are often well above €50,000 per Quality Adjusted Life Years. Preventive measures such as lifestyle interventions (of which self-management is a key factor) generally generate health at low costs. Author Over et al. showed that the use of a pedometer combined with counselling increased physical activity (11,000 € per QALY). Van der Bruggen et al. showed that an intensive lifestyle intervention could improve health at between 3,100 € and 5,500 € per QALY. The efficiency with which health, in terms of QALYs, can be purchased, is relevant information: in a finite budget, you can choose to spend resources in a manner that yields a lot of health in return, or you can direct resources to interventions that are very costly at very little (health) return. Investing in effective weight loss programs, from a purely efficiency point of view, disregarding ethical concerns about responsibility and moral hazard, is a very good investment.

Dr Matthijs Versteegh

Matthijs Versteegh is the Director at the institute for Medical Technology Assessment (iMTA) of Erasmus University Rotterdam. Matthijs Versteegh worked for the consultancy firm Ecorys on projects for the European Commission, the World Health Organisation, the World Bank and on large regional variation studies for the Dutch National Health Care Institute.

All costs and benefits of reducing Obesity must be considered

We already know that the basic benefit package of health insurance rarely covers non-surgical weight loss programs, although recently, the Dutch health insurance package included life-style interventions. Nevertheless, obesity is often considered a problem of the individual and hence seeking help comes at own cost and responsibility in the form of either out-of-pocket expenditures or supplementary health insurance. Health insurers in turn have little incentive to invest, at own costs, in prevention since a) the benefit of a weight loss program will fall far into the future, when an insured may have left the health insurer for a competitor and b) the weight loss program may not necessarily reduce health care spending on the insureds, since increased longevity will result in additional years of health care consumption.

Reducing obesity will improve the healthy life expectancy of many, but contrary to popular opinion, will not reduce health care expenditures: living longer in good health is associated with other non-obesity related health care consumption later in life. Part of these additional costs are offset in wider society: a 2015 study in Germany showed that weight loss increases the chance of women to remain employed resulting in societal gains. In COMPAR-EU, we aim to take into account all costs and benefits related to reducing obesity, and in two years’ time, we hope to provide you with a list of self-management interventions that are most value for money.

Cochrane Colloquium 2019

This year´s face-to-face Cochrane Colloquium was cancelled due to unprecedented situation of civil unrest across Santiago. However, the event was held online from 2-6 December 2019. Virtual CochraneSantiago highlighted the theme of ‘Embracing Diversity’. The Colloquium explored ways in which Cochrane could address the challenge of diversity in many areas: how to inform complex health decisions with diverse types of evidence; how to engage people with low health literacy; how to reach non-English-speaking audiences; how to explore new ways of delivering evidence from reviews (e.g., podcasts, videos); and how to incorporate diverse types of evidence in reviews (qualitative evidence, mixed methods evidence, etc.).

Our five poster presentations are still available online:

9. December 2019