Written Evidence Submitted by Dr Elizabeth Roberts (FWM0075)

How well are weight management services functioning in the NHS and are they providing equitable access to treatment?

I am a State Registered Dietitian. Amongst other roles, I spend some of my time working with adults in secure and locked in-patient and forensic mental health settings.

I ask the Committee to give special consideration to those in secure and forensic mental health settings, particularly in respect of access to weight loss medication. I believe this group of people should receive more rapid access to these medications than the planned roll-out by NHS England. Why?

Antipsychotic medication disrupts appetite hormones and appetite signals,[1] one of the key reasons for their weight gain. Increased prolactin also causes leptin resistance, ordinarily a physiological phenomenon to increase food intake in pregnancy.[2] Antipsychotic medications often cause a rise in prolactin,[3] one can assume therefore also leptin resistance. This attenuates the satiety signal in the brain. Leptin and leptin resistance may affect central dopaminergic neurotransmission directly.[4] Added to this, many of the medications used in this population are dopamine antagonists.[5] In in-patient and forensic settings we often take away other sources of dopamine also: drugs, alcohol, nicotine, mobile phones, excess caffeine. This leaves sugar, often in the form of fizzy drinks, and other foods as the primary dopamine stimulant. People taking antipsychotic medication, and particularly those residents in in-patient and/or forensic settings, face an uphill battle, even with the best of motivation and personal responsibility, in battling their biology. Psychiatrists are often unaware of these biological factors, which leads to stigma (“They are not taking personal responsibility”).

These issues lead to obesity in this population, a population that is at risk of poor physical health.

Taking aside the question of whether obesity treatment via diet and exercise is effective or not, people in these settings do not have easy access to interventions available to others in the community. Many do not have authorised leave or unescorted leave. Many have unstable mental health which precludes them joining group interventions. Many do not have access to the internet. Often the buildings themselves are set within retail parks where the only access to food, or the only thing to do, in a half hour leave break is to visit the fast-food outlets in the vicinity. Exercise is difficult as they reside in locked settings and access to physical activity, even going for a walk, is limited by staff availability.

I have seen first-hand the profound effect GLP-1 medication can have on patients in these settings. People describe a reduction in appetite. They have no desire for the second or third helpings they would have previously requested. They are unable to eat the amount they used to. They have no desire for snacks like they did before. One gentleman described how he used to buy two Greggs iced buns and eat them in one sitting on his limited leave. Now, on a GLP-1, he struggles to eat more than one half. People have told me how they no longer crave the sugary and fatty foods they used to. They prefer water. They lose weight without trying. Others have told me, now that they are losing weight and feeling better about themselves, they want to exercise more, move around more, get in the gym (stimulation of GLP-1R POMC neurons?[6]).    

Please consider this group of individuals when drawing up guidelines for access to weight loss medications. In practice, the GPs that service these organisations will often follow existing guidelines to the letter unless there is a specific exemption clause that can be followed.