Study flow diagram.

BMI, body mass index; B&A, Black and Asian ethnic groups; HES, Hospital Episode Statistics.</p

Percentage of adults with overweight or obesity in England as recorded in CPRD GOLD.

a, by (a) sex, (b) age categoryb, and (c) regionc. aIncludes data from January 2007 until June 2020. bAge at end of study period (earliest of: death, transfer out from practice, end of practice data collection). cEast Midlands and North East drop out of the dataset after 2015 and 2017, respectively. (DOCX)</p

Adjusted RRs for WM referral within adults eligible for WM referral in England with at least 2 years of follow-up data in CPRD GOLD (2007–2020)—People with unknown ethnicity dropped (<i>n =</i> 284,156).

Adjusted RRs for WM referral within adults eligible for WM referral in England with at least 2 years of follow-up data in CPRD GOLD (2007–2020)—People with unknown ethnicity dropped (n = 284,156).</p

Exposure and outcomes codelists.

BackgroundAdults living with overweight/obesity are eligible for publicly funded weight management (WM) programmes according to national guidance. People with the most severe and complex obesity are eligible for bariatric surgery. Primary care plays a key role in identifying overweight/obesity and referring to WM interventions. This study aimed to (1) describe the primary care population in England who (a) are referred for WM interventions and (b) undergo bariatric surgery and (2) determine the patient and GP practice characteristics associated with both.Methods and findingsAn observational cohort study was undertaken using routinely collected primary care data in England from the Clinical Practice Research Datalink linked with Hospital Episode Statistics. During the study period (January 2007 to June 2020), 1,811,587 adults met the inclusion criteria of a recording of overweight/obesity in primary care, of which 54.62% were female and 20.10% aged 45 to 54. Only 56,783 (3.13%) were referred to WM, and 3,701 (1.09% of those with severe and complex obesity) underwent bariatric surgery. Multivariable Poisson regression examined the associations of demographic, clinical, and regional characteristics on the likelihood of WM referral and bariatric surgery. Higher body mass index (BMI) and practice region had the strongest associations with both outcomes. People with BMI ≥40 kg/m2 were more than 6 times as likely to be referred for WM (10.05% of individuals) than BMI 25.0 to 29.9 kg/m2 (1.34%) (rate ratio (RR) 6.19, 95% confidence interval (CI) [5.99,6.40], p 2 with a comorbidity (0.53%) (RR 5.52, 95% CI [5.07,6.02], p p p p p p ConclusionsBetween 2007 and 2020, a very small percentage of the primary care population eligible for WM referral or bariatric surgery according to national guidance received either. Higher BMI and GP practice region had the strongest associations with both. Regional inequalities may reflect differences in commissioning and provision of WM services across the country. Multi-stakeholder qualitative research is ongoing to understand the barriers to accessing WM services and potential solutions. Together with population-wide prevention strategies, improved access to WM interventions is needed to reduce obesity levels.</div

Characteristics of patients included in adjusted Poisson model versus those in full sample (WM referral as outcome).

B&A, Black and Asian ethnic groups; BMI, body mass index; WM, weight management. aIncluded in adjusted model. bMedical codes indicating diagnosis with overweight or obesity where BMI category not specified. (DOCX)</p

RRs for provision of bariatric surgery within adults eligible for bariatric surgery in England with at least 5 years of follow-up data in CPRD GOLD (2007–2020).^a (MODEL B).

Text in italics indicates the reference group for the Poisson regression model. B&A, Black and Asian ethnic groups; BMI, body mass index; CI, confidence interval; CPRD, Clinical Practice Research Datalink; GP, general practitioner; IMD, Index of Multiple Deprivation; RR, rate ratio. aA total of 21 individuals with bariatric surgery before their severe and complex obesity index date excluded. bVariables included in adjusted model include sex, age group at diagnosis with severe and complex obesity, strategic health authority of GP practice, rural–urban classification of GP practice, year of diagnosis with severe and complex obesity, BMI category at diagnosis with severe and complex obesity, ethnic group, IMD, smoking status, total number of comorbidities. cNumber of individuals included in the crude analysis. dNumber of individuals with complete data for all variables included in the adjusted analysis. (DOCX)</p

Exposure definitions^a.

BackgroundAdults living with overweight/obesity are eligible for publicly funded weight management (WM) programmes according to national guidance. People with the most severe and complex obesity are eligible for bariatric surgery. Primary care plays a key role in identifying overweight/obesity and referring to WM interventions. This study aimed to (1) describe the primary care population in England who (a) are referred for WM interventions and (b) undergo bariatric surgery and (2) determine the patient and GP practice characteristics associated with both.Methods and findingsAn observational cohort study was undertaken using routinely collected primary care data in England from the Clinical Practice Research Datalink linked with Hospital Episode Statistics. During the study period (January 2007 to June 2020), 1,811,587 adults met the inclusion criteria of a recording of overweight/obesity in primary care, of which 54.62% were female and 20.10% aged 45 to 54. Only 56,783 (3.13%) were referred to WM, and 3,701 (1.09% of those with severe and complex obesity) underwent bariatric surgery. Multivariable Poisson regression examined the associations of demographic, clinical, and regional characteristics on the likelihood of WM referral and bariatric surgery. Higher body mass index (BMI) and practice region had the strongest associations with both outcomes. People with BMI ≥40 kg/m2 were more than 6 times as likely to be referred for WM (10.05% of individuals) than BMI 25.0 to 29.9 kg/m2 (1.34%) (rate ratio (RR) 6.19, 95% confidence interval (CI) [5.99,6.40], p 2 with a comorbidity (0.53%) (RR 5.52, 95% CI [5.07,6.02], p p p p p p ConclusionsBetween 2007 and 2020, a very small percentage of the primary care population eligible for WM referral or bariatric surgery according to national guidance received either. Higher BMI and GP practice region had the strongest associations with both. Regional inequalities may reflect differences in commissioning and provision of WM services across the country. Multi-stakeholder qualitative research is ongoing to understand the barriers to accessing WM services and potential solutions. Together with population-wide prevention strategies, improved access to WM interventions is needed to reduce obesity levels.</div

Characteristics of adults with severe and complex obesity in CPRD GOLD undergoing bariatric surgery in England, by BMI group (all years 2007–2020).

Characteristics of adults with severe and complex obesity in CPRD GOLD undergoing bariatric surgery in England, by BMI group (all years 2007–2020).</p

Approved ISAC protocol including statistical analysis plan.

ISAC, Independent Scientific Advisory Committee. (PDF)</p

S3 Fig -

Percentage of adults with severe and complex obesity in CPRD GOLD.aWho underwent NHS bariatric surgery in England by (a) sex, (b) age categoryb, and (c) regionc. aIncludes data from January 2007 until June 2020 in adults eligible for Hospital Episode Statistics linkage. bAge at bariatric surgery. cEast Midlands, North East, and East of England drop out of the dataset after 2015, 2017, and 2019, respectively. (DOCX)</p