The problem
Obesity is a complex, chronic condition influenced by genetic, environmental, physiological, and behavioural factors. If left untreated, it contributes significantly to individual morbidity and health system burden, costing the Australian government $11.8 billion annually.
Obesity disproportionately impacts disadvantaged communities. Currently in Australia, access to evidence-based treatments is inequitable, fragmented, and inconsistent.
Our evidence-based, comprehensive, obesity program, the Tertiary Obesity Management Service (TOMS) was commissioned to improve health outcomes beyond weight loss and to improve access to healthcare services. TOMS brings together physiological (physiotherapy, pharmacy) and behavioural (psychology, dietetics) specialists to solve this complex healthcare problem and improve health outcomes.
Summary of the research
TOMS includes a 12-week very-low-energy-diet (VLED) plus supervised exercise and group education/support, a 3-month step-down phase with supervised exercise and group support, and a 6-month maintenance phase embedding long-term diet and exercise behaviours. Using Procter’s implementation science framework and prospective data collection, outcomes, implementation, and research-capacity-development were measured.
Weight loss achieved in TOMS leads to improved health outcomes and improves access to healthcare. 84% of eligible participants have received or been waitlisted for their non-emergent surgical procedures. Health service use decreases after TOMS. From the 12 months prior to TOMS enrolment to the 12 months after TOMS completion, emergency presentations, inpatient-admissions and total-bed-days reduced by 28%, 13% and 25% respectively for TOMS participants.
12-week and 12-month weight change were -9.8% and -9.6% (both p<0.001) demonstrating significant and sustained weight loss. TOMS is effective for building aerobic capacity, muscular endurance, reducing BP and improving glycaemic control. Six-minute-walk-test (+61.1m) and 30-second-sit-to-stand (+3.6 reps) improved. Systolic and diastolic blood pressure decreased by 6.8mmHg and by 3.2mmHg respectively (p<0.01). HbA1c decreased from 7.7% to 6.4% at 3 months, and all improvements were sustained at 12 months. 70% of participants reduced their insulin dosage, and 17% ceased insulin entirely, and 64% of participants discontinued sulfonylureas.
Consumer evaluation using thematic analysis of semi structured interviews identified that whilst participants initially engaged with TOMS for chronic disease management and surgical preparation, they reported that the most valued aspects of the program were the supportive structures, multidisciplinary team involvement, peer support, and external accountability. Participants suggested extended support and longer follow-up would be beneficial for long-term behaviour change.
TOMS is an effective health practitioner led complex obesity management pathway which improves health outcomes beyond weight loss and reduces health service use and costs. TOMS has achieved feasibility, fidelity, adoption, acceptability and safety key performance indicators.
The impact
- A scalable HP model of care for treating complex obesity across specialities. A modified version of TOMS has been implemented in Mackay HHS using existing dietetics resources and referrals to local providers for Clinical Exercise Physiology and Psychology support.
- Clear pathways for transitioning from weight loss to weight maintenance. The Monthly recharge pathway was the most acceptable program for weight loss maintenance, and pathways including transition to obesity medications and bariatric surgery are in place to support ongoing weight maintenance.
- Significantly reduced overall healthcare service utilisation.
- Increased research capacity in allied health practitioners with all clinicians authoring conference abstracts and incorporating research into usual practice.
Our researchers
Helen MacLaughlin, Kelsey Pateman, Mala McHale, Robin Hay, Andrea Cawte, Caitlin Merz, Gemma Woodruff, William Benningfield, Scott Ruddell, Abby Yu, Helen d’Emden, Matthew Seymour, Keren Singh.