A cohort profile and process evaluation of an adult multidisciplinary behavioural and weight management service in a diverse UK population

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The aim of this study is to present a cohort profile and process evaluation of an adult multidisciplinary weight management service in a diverse UK population. Methods : A retrospective cohort study of the 12-month South-East London Healthy Living Programme is reported. The programme included a diet and lifestyle behaviour change or a total meal replacement plus diet and lifestyle intervention. Community-based group sessions were delivered monthly either virtually or face-to-face. Sociodemographic, clinical, anthropometric, and behavioural patient data were collected at baseline. Process outcomes including referrals, engagement and programme completion rates are reported. Data analyses were conducted using independent t-tests for sociodemographic characteristics and multivariate logistic regression was performed to determine predictors of programme completion. Results : 4,499 individuals (47 ± 13.5 years, 78% female, 36% Black African and Caribbean, 49% living in areas of high deprivation) were referred to the service between April 2018-March 2023. Early engagement was 67% and 61% for session 1 and 2 respectively and engagement declined to <50% by session 4. Programme completion rate was 43% (n = 904). Females were more likely to complete (OR 1.509, p= 0.018), whereas people of Black African and Caribbean ethnicity (OR 0.074, p=0.023), and participants with lower relational support (OR 0.701, p=0.045) predicted lower completion rates. Conclusion : Programme completion was below 50% which is consistent with the evidence on Tier 3 interventions. Males and people of ethnic minority ethnic heritage were less likely to complete the programme. While early engagement was relatively high, it declined substantially across the programme. Efforts to increase engagement particularly among ethnic minorities and males are warranted. Health sciences/Health care/Weight management Health sciences/Health care/Nutrition Obesity weight management behaviour change process evaluation Figures Figure 1 Figure 2 Introduction The prevalence of overweight and obesity among UK adults has increased from 61.2% (2015-16) to 64% (2022-23) and obesity prevalence alone is now estimated at 25.9% [1] with further increases projected [2]. The prevalence of obesity is socially patterned with greater prevalence observed among more deprived communities [3] and ethnic minority groups [4]. In England, adult obesity is up to 16% greater in deprived compared to more affluent areas [5] and obesity-related hospital admissions are 2.4 times greater in more deprived communities [6]. Obesity is associated with physical and mental health outcomes, including increased risk of cancer, cardiovascular disease [7] and mortality [8] in addition to reduced psychological wellbeing and diminished quality of life [9]. From a health service perspective, in England over one million hospital admissions were due to obesity (2019-20) and the national health service (NHS) obesity-related expenditure is estimated to reach £10 billion by 2050 [6]. Weight and behavioural interventions result in modest weight loss [10–12] and behaviour change [13] and remain an important part of obesity management even in the context of obesity management medications [14]. Modest improvements in weight (5-10%) improve health outcomes including fasting glucose, triglycerides, total cholesterol and low-density lipoprotein (LDL) cholesterol [11, 15] and support change behaviours linked to excess weight [12, 13]. In England, the NHS has a 4-Tier model of care for adult weight management; Tier 1 services include public health and health promotion strategies, Tier 2 offers community weight management services, and Tier 3 services provide specialist weight management and behaviour change programmes. These programmes are usually delivered by multidisciplinary teams including physicians, nurses, dietitians and psychologists, although availability, referral criteria, team composition and programme structure vary substantially across the UK [10, 11]. Tier 4 is the bariatric surgery pathway and a prerequisite for eligibility is completion of a Tier 3 service. Despite ongoing efforts to standardise adult weight management services, substantial disparities exist in the availability, composition and uptake of Tier 3 services across the UK [16, 17]. The 2025 NICE guideline on overweight and obesity aims to improve equitable access and structured service delivery, while the recent Lancet Commission on Obesity [18] reframes obesity as a chronic, systemic disease requiring a stratified, tiered approach to care. However, variability in service provision and gaps in national reporting persist, making it difficult to evaluate Tier 3 service uptake and effectiveness. This service evaluation reports on the participant characteristics and process outcomes including referrals, engagement, attendance and completion of a specialist Tier 3 behavioural and weight management programme delivered across an ethnically diverse area of Southeast London. The study is the first component of an umbrella service evaluation of the Tier 3 South-East London Healthy Living Programme (SELHLP) that includes cohort profile and process evaluation, described herein and an impact evaluation (O’Keeffe et al., unpublished). The protocol for the Tier 3 services is also reported elsewhere (Shuriye et al., unpublished). Materials and Methods Study design This service evaluation was a retrospective cohort study that is reported in line with the SQUIRE reporting guidelines [19] and was informed by the National Obesity Observatory Standard Evaluation Framework [20]. Population The population in this study consisted of participants enrolled in the Southeast London Healthy Living Programme SELHLP, a Tier 3 specialist behavioural and weight management service for adults. This programme delivers community-based, multidisciplinary support across five boroughs in South-East London: Southwark, Lambeth, Bromley, Bexley, and Lewisham. These boroughs are administrative divisions within Greater London, each governed by a local authority. South-East London demonstrates considerable ethnic diversity compared to Greater London and the national population of England and Wales. In Bexley and Bromley, the majority of the population identifies as white (72% and 76%, respectively), with smaller proportions identifying as Black (12% and 8%) or other ethnicities (16% in both boroughs), according to the Office for National Statistics (2022) [21]. Conversely, the boroughs of Lambeth, Lewisham, and Southwark exhibit different compositions, with 55% of the population in Lambeth identifying as white, 51% in Lewisham and Southwark, and higher Black populations (24% in Lambeth, 27% in Lewisham, and 25% in Southwark). The proportion of other ethnicities is 21% in Lambeth, 22% in Lewisham, and 23% in Southwark. By comparison, Greater London is 51% white, 25% Black, and 23% other ethnicities. At a national level, England and Wales report a predominantly white population (82%), with smaller proportions of Black (4%) and other ethnicities (14%). Socioeconomic deprivation within these boroughs varies according to the Index of Multiple Deprivation (IMD, 2019) [22], which assigns rankings from 1 (most deprived) to 10 (least deprived). Bexley (mean IMD score 6.51 ± 2.46) and Bromley (7.11 ± 2.50) are relatively less deprived, while Lambeth (3.95 ± 1.57), Lewisham (3.76 ± 1.64), and Southwark (4.02 ± 1.98) experience greater levels of deprivation. However, the boroughs of Bexley and Bromley contain areas with an IMD score of 1 and 2, suggesting great variability within boroughs in South-East London [22]. For context, the average IMD score for England is 5.50 ± 2.87. Programme structure The SELHLP is a multidisciplinary specialist weight and behavioural change 12-month intervention, delivered by Guys’ and St Thomas NHS Foundation Trust (GSTT). Two main pathways are offered – Balance and Kickstart – although, as recommended by NICE, an option for one-to-one treatment was available but is not the focus of this evaluation. The Balance programme consists of diet and lifestyle behavioural change intervention only, whereas the Kickstart programme features three months of total meal replacement (800-1200 kcal/d) followed by gradual food reintroduction and lifestyle behavioural change programme. The Kickstart programme is based on the Diabetes Remission Clinical Trial (DiRECT) protocol [23, 24]. Both Kickstart and Balance initially included 12 group sessions delivered over 12 months, which focused on a behavioural change curriculum that was informed by the NICE guidance for weight management programmes [25]. Whilst dietitian-led, the programme utilises a multidisciplinary involvement including medical doctors, psychologists, physiotherapists and physiotherapy and dietetic assistants, in line with NICE guidelines [25]. Sessions were initially delivered face-to-face (F2F) in community locations but transitioned to virtual (V) delivery in September 2020 due to the COVID-19 pandemic. In August 2022, once social distancing regulations were relaxed, a hybrid model was introduced with both virtual and F2F group sessions delivered. Participants were given the choice for V or F2F group delivery. The curriculum for the group-based behaviour change session included SMART goal setting, diet and lifestyle education including identifying hunger and reasons for overeating, motivation and managing relapses, understanding food labels, cooking, and the relationship between healthy eating and sleep quality. Participants were encouraged to increase physical activity. Peer support was established through an app that enabled dietitians and psychologists to respond directly to participant questions. Each session was 60 minutes duration and included recording of actual weight, or participant-reported weight during virtual sessions. Participants with psychological complexity, for example, with binge eating disorder, could access extra individualised support from a clinical psychologist. Referral criteria In line with NICE guidelines, general practitioners (GP) across the five Southeast London boroughs (Bexley, Bromley, Lambeth, Lewisham or Southwark) were the key referral pathway to the SELHLP, but eligible candidates awaiting bariatric surgery can also be referred from Tier 4 and other clinical services in the southeast London area (Figure 1). Eligible participants must have been registered with a GP in one of the five boroughs, be 18 years or older, have a BMI of ≥35 kg/m 2 with type 2 diabetes or ≥BMI 40 kg/m 2 . Upon receipt of referral, participants were screened for inclusion and eligible participants were scheduled for an initial assessment (IA) with a registered dietitian. Participants that did not meet the referral criteria were returned to their GP. Outcomes Process outcomes included conversion rates from referral to initial attendance, and to completion for the 12-month intervention. Participant demographic details including age, gender, ethnicity and postcode were recorded in line with the NICE minimum dataset for Tier 3 programmes [25]. Programme completion was defined as participants who attended one of the last 3 sessions (until August 2020) or one of the last 4 sessions (after August 2020); this outcome was changed due to COVID-19)). Engagement is reported for initial assessment (stage 1), session 1 or 2 (stage 2) and programme completion (stage 3). Early engagement was defined as the proportion of participants who attended session 1 or session 2, following their initial assessment. Impact outcomes including weight change and a host of secondary outcomes including, diet, lifestyle, physical activity and wellbeing, were also recorded in line with the National Obesity Observatory Standard Evaluation Framework [20]. These data are reported elsewhere and not included herein. Data collection This project was conducted as a quality improvement service evaluation, utilising anonymised secondary healthcare data from the Tier 3 service. Following referral and where eligibility criteria were met, participants attended an initial assessment (IA) with a registered dietitian. During this visit, baseline data including demographics, anthropometrics including current weight was recorded by the dietitian. Participants also completed an IA which included the outcome data previously described. Participant preference for the Balance or Kickstart programme was also recorded. The IA was then reviewed by the Tier 3 team, scores for the validated questionnaires were calculated and the data was entered into an Excel spreadsheet, which was anonymised for analysis. Upon initiation of the programme and for each session thereafter, weight, where available, was inputted into the database. Prior to August 2020, at one of the last three sessions, participants of each group were asked to complete an exit assessment (EA) which recorded anthropometry and secondary outcomes data. Due to the impact of COVID-19 on the service and the subsequent move to online delivery, data collection methods changed. With the integration of BlueJeans, an online meeting platform with video, audio, and web conferencing functions used for virtual delivery, participants were emailed a link to complete an online exit assessment between the antepenultimate and the final session. Upon completion of EAs, the service team entered the data into an Excel spreadsheet. The anonymised database was transferred to the service evaluation team for analysis. Data analysis Descriptive statistics were calculated to summarise baseline demographic, anthropometric, and behavioural characteristics of the cohort. Normality of continuous variables was assessed visually using histograms and tested with the Shapiro-Wilk test (p<0.05). Depending on normality, either parametric (t-tests) or non-parametric tests (Mann-Whitney U, Wilcoxon, or Kruskal-Wallis tests) were applied. Continuous data were presented as means ± SD, and categorical data were presented as numbers and percentages, unless otherwise stated. Demographic variables included the Index of Multiple Deprivation (IMD) (high deprivation (deciles 1-3), moderate deprivation (deciles 4-6), and low deprivation (deciles 7-10), gender (male, female), ethnicity (White, Black African/Caribbean, and Other, the latter including Asian, South American, not listed ethnicities and the Prefer not to say category), and age (18-24, 25-34, 35-44, 45-54, 55-64, 65-74 and 75-85 years). For analysis, completion status was collapsed into a binary outcome (yes/no). Programme completion outcomes included "completed," "did not complete," "declined intervention," and "patient not booked in group." Chi-squared (X²) tests for independence were conducted to examine if a statistical association between categorical variables was present. Adjusted residuals with values greater than ±1.96 (p<0.05) were interpreted to indicate statistically significant differences. To identify predictors of programme completion, candidate predictors from three domains were examined: demographic (age, gender, relationship status, ethnicity, and IMD-based deprivation), weight-related (initial weight, initial BMI, and highest weight ever recorded), and psychological (motivation and confidence at baseline and binge eating). Correlation analysis was conducted to determine relationships between programme completion and continuous predictor variables (e.g., baseline weight, BMI, highest weight, deprivation, confidence, and motivation at baseline). Univariate and multivariate forced entry logistic regression models were developed to evaluate predictors of the four intervention conditions (Balance F2F, Balance Virtual, Kickstart F2F, Kickstart Virtual). The Wald test was used to test the significance of predictors within the models, with p<0.05 indicating statistical significance. To explore differences in referral, uptake, and completion across sociodemographic subgroups, one-way ANOVA tests were conducted to assess whether programme completion outcomes varied by age, gender, ethnicity, deprivation level, baseline weight, BMI, highest weight ever, confidence, and motivation. Homogeneity of variances was evaluated using Levene’s test; where significant (p<0.05), the Brown-Forsythe test was reported to account for heterogeneity in variances and sample sizes. All analyses were conducted using SPSS version 29 for Windows (IBM SPSS). Statistical significance was considered at p<0.05 for all tests. Ethical approval This service evaluation was not subject to ethical approval but approval from the Quality Improvement Projects and Patient Safety committee (Reference 14211) at GSTT was obtained. Results Cohort Profile: Participant characteristics At time of analysis, 4,499 participants had attended an initial assessment of the SELHLP. Among these, 24% (n=1,080) were enrolled in Balance F2F, 13.6% (n=612) in Kickstart F2F, 30% (n=1,023) in Balance Virtual, and 19% (n=648) in Kickstart Virtual. Additional enrolments included 5% (n=233) in the one-to-one pathway, 736 participants were on a waiting list, 31 discharged from the programme, 10 who declined the service, and 29 on an exploratory diabetes weight management pathway. The status of 95 referrals was unknown. The overall Tier 3 cohort was predominantly female (78%), with a mean age of 47 ± 13.5 years. In terms of ethnicity, 47% identified as White, and 36% as Black African/Caribbean. 49% of the cohort lived in high-deprivation areas (IMD deciles 1-3), with an average IMD decile of 4 ± 2.5. 47% were single, 37% married, and household composition varied: 22% lived with children, 17% with a spouse/partner and children, and 11% with parents or other relatives. Participant distribution across the boroughs was as follows: 25.1% in Southwark (n=1,127), 29.2% in Lambeth (n=1,314), 20.6% in Bromley (n=924), 11.4% in Bexley (n=513), and 13.7% in Lewisham (n=615). Participant characteristics for both Balance and Kickstart programmes are summarised in Table 1, and both programmes are similar in gender distribution, ethnicity, and deprivation. Two thousand one hundred and eight participants were enrolled in Balance, with 51% in Balance F2F and 49% in Balance Virtual. The combined Balance cohort (F2F and V) was predominantly female (n=1717, 82%), with a mean age of 47.6 ± 13.3 years. Forty six percent identified as White ethnicity, 17% as Black African, and 12% as Black Caribbean. 49.5% were single, while 25.4% lived with children. Area-level deprivation was moderate, with an average IMD decile of 4 ± 2.3. One thousand two hundred and eighty-one participants were enrolled in the Kickstart programme, with a similar distribution across the F2F, 49%, and virtual, 51%, programmes. The combined Kickstart cohort showed similar demographic patterns to the Balance cohort, 75% female, average age 46.4 ± 12.5 years. Ethnic distributions were also similar (Table 1). 44% were single, and 25% lived with children. Area-level deprivation was also moderate, with an average IMD decile of 5 ± 2.5. Anthropometry and clinical status Baseline anthropometry and clinical characteristics were similar across Balance and Kickstart cohorts (Table 2). There was no significant difference in baseline weight (Balance: 124 ± 20.5 kg vs. Kickstart: 124.8 ± 21.5 kg, p=0.285) or BMI (Balance: 45 ± 6.1 kg/m² vs. Kickstart: 44.6 ± 6 kg/m², p=0.098). Analysis across the four programme types (Balance F2F, Balance V, Kickstart F2F, Kickstart V) showed no significant difference in weight (p=0.112) or BMI (p=0.069). Eighty five percent of Balance and 84% of Kickstart had obesity class III. Participants in both programmes were hypertensive (systolic blood pressure: 133 ± 16, diastolic blood pressure: 82 ± 10 mmHg), with a mean HbA1c of 47 mmol/mol. Self-reported type 2 diabetes was similar across Balance (34%) and Kickstart (32%). Process Outcomes Referral sources and geographic patterns of referrals Referral sources were primarily general practitioners (83% for Balance, 88% for Kickstart), followed by referral from a Tier 4 pathways (8% for Balance, 4% for Kickstart). Geographic patterns in referrals showed that 58% of Balance referrals were from Southwark and Lambeth, while referrals for Kickstart were highest from Lambeth (27%) and Bromley (24%). Tier 4 pathway and clinical referrals Regarding the Tier 4 pathway, 24% (n=969) of participants indicated it was not relevant to them, while 21% (n=845) had declined the service, and 381 participants were unsure about bariatric surgery as a therapeutic intervention. At the time of analysis, 16% (n=720) were on the Tier 4 pathway, and 54 participants had previously undergone bariatric surgery. In terms of additional clinical support, 2% (n=105) had been referred for a medical review as part of the programme, and 9% (n=355) had been referred for psychological review. Programme engagement, attendance and completion Participant engagement was tracked across three defined stages: stage 1 (initial assessment), stage 2 (attendance at session 1 or 2) and stage 3 (programme completion). 4,499 participants attended an initial assessment (IA) while a total of 1,253 participants (28%) attended either session 1 or 2. Programme completion data was available for 2019 participants: 904 (43%) completed the programme, 1176 (55.8%) did not, 6 (0.3%) declined intervention, and 23 (1.1%) were not booked on any group. Figure 2 shows key participant characteristics (gender, ethnicity, relationship status, and living arrangements) by programme stage. Early engagement was 67% and 61% for session 1 and 2 and <50% by session 4 with a sustained reduction across sessions thereafter. Supplementary Table 1 provides a detailed breakdown by stage. Completion rates by demographics and programme Programme completion varied significantly by ethnicity (X²= 7.422, df=2, p=0.024) and gender (X²=8.1, df=1, p=0.004) (Table 3). Black African/Caribbean participants had lower completion rates (40% completed vs. 60% did not complete), and males were less likely to complete (38% completed vs. 63% did not complete). Programme completion rates did not differ by deprivation (X 2 =2.06, df(2), p=0.352). Non-completion rates were high across all clinical commissioning groups (CCGs) (range 51-61%) and differed by CCG (X²=11.284, df(4), p=0.024). Additionally, completion rates differed by programme type, with virtual formats showing higher completion rates than face-to-face formats (X²=604, df=3, p<0.001). Table 2 summarises completion rates across demographic categories and programmes. Predictors of programme completion Following univariate analysis, baseline confidence significantly predicted completion (F(1, 1609)=6.3, p=0.012), with females more likely to complete (OR=1.375, p=0.004) and Black African/Caribbean ethnicity associated with lower completion rates (OR=0.817, p=0.041). In multivariate analysis, females were 1.5 times more likely to complete (OR=1.509, p=0.018), while Black African/Caribbean participants and those separated/divorced/widowed were less likely to complete (OR=0.74, p=0.023) and (OR=0.701, p=0.045) respectively. Weight (OR=0.994, p=0.268), BMI (OR=1.023, p=0.163), age (OR=0.995, p=0.313), confidence (OR=0.959, p=0.175), motivation at baseline (OR=0.965, p=0.322), deprivation (OR=1.004, p=0.852), and programme type (OR=1.093, p=0.433), were not associated with programme completion in multivariate analysis (Supplementary tables 2 and 3). Completion of exit assessments Exit assessment (EA) data was available for 1,194 participants in the Balance cohort (both F2F and Virtual). Of those, only 269 participants (22%) fully completed the EA, 151 were recorded as not having completed it. EA completion status data was unavailable for 909 Balance participants. In the Kickstart cohort, EA data was recorded for 701 participants, with only 116 (17%) completing the EA. Discussion This study provides a detailed evaluation of a Tier 3 adult multidisciplinary weight management service in a diverse London population, highlighting the challenges and successes associated with referral, uptake, and completion. Our findings add to the body of evidence on Tier 3 behavioural and weight management services in the UK and underscore the need for improvements at the system level to enhance access, engagement, and outcomes. The overall programme completion rate of 43% is on the higher end of previously reported national figures, which range between 23-55% [12, 26]. While this suggests moderate completion rate compared to similar programmes, over half of participants did not complete the programme, highlighting persistent challenges to maintain engagement across the service. While suboptimal, this completion rate of 43% is noteworthy, given the complexity of the population served, including the significant representation of individuals from socioeconomically deprived areas and minority ethnic groups that have lower engagement rates [27]. Black African and Caribbean participants, in particular, had lower completion rates, consistent with findings from a recent NHS Tier 3 service evaluation showing higher dropout rates and less weight loss among minority ethnic groups receiving liraglutide treatment [28]. Furthermore, international data reports ethnic specific responses to similar behavioural interventions [29]. Recent qualitative research suggests that weight management services designed to be community-centred, culturally aligned, and adaptable to individual needs may be needed to improve engagement among diverse populations [30, 31]. Understanding the mechanisms behind these disparities, whether structural, cultural, or individual, is critical to addressing inequities in programme engagement and outcomes. Potential factors contributing to low completion rates in minority ethnic groups may include cultural attitudes towards health and weight, language barriers, logistical challenges such as transport, and perceived stigma. For example, a recent exploratory study identified systemic barriers, family commitments, and cultural norms as significant obstacles to weight management among ethnically diverse communities in England [32]. A qualitative study among urban minority populations found that women reported limited access to personal transportation as a barrier to participating in weight loss programmes, whereas men noted that vehicle access increased exposure to fast food options [33]. Additionally, weight stigma has been identified as a significant barrier to effective obesity care, leading to avoidance or delay in seeking medical attention, which can adversely affect health outcomes [34]. Addressing these barriers will require targeted interventions, such as improving cultural alignment, enhancing accessibility, and increasing engagement through tailored outreach efforts. Females were more likely to complete the programme compared to males; a trend observed in other health interventions. For example, a recent systematic review of Mediterranean diet interventions for weight loss reported a trend toward higher adherence and retention among women compared to men, though the findings were not statistically significant [35]. The completion rate differences based on gender observed in our study may reflect variations in health-seeking behaviours, with women often demonstrating higher engagement with health services. For example, Ahern et al. (2016) observed that women were significantly more likely to enrol in weight management programmes compared to men, although higher enrolment does not necessarily translate into higher completion rates [36]. Additionally, women may have different motivations or priorities for weight management. A recent study found that women cited family and aesthetic outcomes as important motivators for participation in weight loss interventions, while men prioritised health-related reasons [37]. However, further research is needed to explore the underlying factors contributing to these disparities, including potential barriers for male participants such as time constraints, perceived stigma, or preferences for alternative programme formats. For example, male participants may perceive weight management programmes as less inclusive of their needs or interests, which can lead to feelings of embarrassment or self-consciousness, acting as a barrier to engagement [38]. Addressing these barriers through targeted outreach, gender-sensitive programme adaptations, and gender-focused support strategies could improve completion rates among men. A scoping review suggests that factors such as camaraderie and peer support can influence men’s participation in weight management programmes, suggesting that promoting a sense of community within interventions may enhance male engagement [39]. Moreover, patient engagement in face-to-face services can be enhanced by offering flexible, digital, or telehealth delivery modes, which reduce logistical barriers such as travel and time constraints [40]. Our findings underscore the importance of culturally tailored interventions to improve accessibility and effectiveness for diverse populations. Previous research has highlighted the benefits of culturally sensitive approaches in increasing engagement and improving outcomes in weight management programmes. For example, a culturally tailored weight loss intervention for Hispanic males, which included bilingual and bicultural coaches and culturally relevant dietary guidance, significantly improved programme engagement and outcomes [41]. Incorporating culturally relevant dietary guidance, addressing cultural stigma around obesity, and improving the accessibility of services for non-English speakers are critical areas for improvement. A scoping review that explored barriers and enablers to diet and physical activity interventions among UK minority ethnic groups emphasises the need for cultural adaptations to increase engagement and effectiveness [42]. Thus, tailoring interventions to the lived experiences of minority ethnic groups is essential for reducing disparities in programme engagement and outcomes. The South-East London Healthy Living Programme (SELHLP) is unique in its inclusion of both the Balance and Kickstart pathways. Kickstart, which incorporates a total meal replacement phase followed by gradual food reintroduction, represents an innovative approach within Tier 3 services. Although completion rates were generally low, the structured nature of Kickstart and its group-based delivery model may provide a framework for scaling similar interventions. Group-based interventions are supported in the literature for their effectiveness in managing chronic diseases and promoting behavioural change [43]. Differences between Balance and Kickstart pathways also highlight the need for personalised approaches. Balance participants, who did not engage in total meal replacement, reported higher levels of emotional eating and binge eating behaviours, suggesting a need for additional psychological support in this group. Tailoring pathways to individual behavioural and psychological profiles may enhance outcomes across both models. Clinical research supports the use of Tier 3 interventions to achieve clinically significant weight loss and improve the management of severe and complex obesity. However, translating interventions from controlled research environments to clinical practice can be problematic due to challenges such as fragmented commissioning, variable service composition, and insufficient staffing and resources [11, 43]. Tier 3 services in the UK face significant variability in availability, commissioning, and delivery, often described as a "postcode lottery." As of 2018, only 57% of CCGs provided Tier 3 services, leaving millions without access. Despite four million people being eligible for Tier 3 care, only 35,000 currently receive it. Integrated Care Boards (ICBs), tasked with addressing healthcare inequalities, have largely deprioritised adult obesity, with only 12% including healthy weight as a focus in their five-year plans and most prioritising childhood obesity [44]. This lack of prioritisation reflects a systemic gap in addressing the adult obesity epidemic. Greater standardisation of Tier 3 services is critical to ensuring equitable access and maintaining quality. Currently, the heterogeneity in team composition, service models, and reporting frameworks hinders national-level evaluations and comparisons. Calls for improved transparency, uniform definitions, and standardised reporting have been echoed in the literature [11] and should be actioned to improve outcomes and inform best practices. Of note, digital interventions can help mitigate regional inequities by offering scalable, resource-efficient models that are less reliant on local clinic availability and physical infrastructure [40]. This study highlights the importance of integrating Tier 3 services within the broader continuum of care. Tier 1 (prevention and public health strategies) and Tier 2 (community-based weight management) services play a crucial role in reducing the burden on specialist services by addressing less complex cases. Strengthening these tiers through public health investment and community engagement can reduce the need for Tier 3 services. However, for individuals with severe obesity and complex comorbidities, Tier 3 remains an essential bridge to Tier 4 (bariatric surgery). The Lancet Commission on Obesity [18] provides a transformative framework for redefining obesity as a chronic, systemic disease with distinct clinical and preclinical stages. This paradigm shift underscores the limitations of BMI as a sole diagnostic criterion and highlights the importance of integrating functional and metabolic health indicators into care pathways. By adopting this approach, tiered care models can be tailored to align intervention intensity with disease severity, ensuring that individuals receive appropriate, stratified care. A key recommendation of the Commission is the development of structured, tiered pathways that optimise patient outcomes through evidence-based, multidisciplinary interventions. However, implementing these pathways into routine clinical practice presents substantial challenges, particularly regarding access, engagement, and retention within Tier 3 services. Overcoming these barriers requires a more integrated, patient-centred approach, ensuring that referral pathways are standardised, service delivery is equitable, and patients receive care tailored to their clinical and psychosocial needs. The 2025 NICE guideline on overweight and obesity management [45] reinforces the need for a systematic, tiered approach, advocating for standardised service delivery across Tiers 1-4. The guideline highlights the importance of ensuring accessibility of services without upper BMI or age limits, improving engagement strategies, and addressing health disparities in obesity care. Aligning Tier 3 services with these emerging frameworks will be essential in building a comprehensive, patient-focused model of obesity care that is clinically effective and equitable. While the UK’s tiered model of care is unique, international comparisons offer insights into alternative approaches. For instance, the US and Mexico, have the highest obesity rates among the 12 most populous countries in the world (41.6% and 32.2% respectively), with a total population of around 475 million [46]. Both countries primarily rely on community-based and private weight management programmes and lack a unified tiered system, which limits coordination and integration between levels of care. By contrast, the UK’s tiered system, despite its challenges, provides a structured framework for addressing varying degrees of obesity complexity. Learning from international models and leveraging the strengths of the UK system can inform future improvements. Our retrospective design and reliance on secondary healthcare data limits the ability to establish causal relationships or explore unmeasured variables such as psychosocial factors influencing completion. Second, the findings may not generalise beyond the London context, where the population is highly diverse. Lastly, while the study sheds light on completion disparities, further research is needed to explore participant perspectives and structural barriers that influence engagement and outcomes. Improving the accessibility, engagement, and outcomes of Tier 3 services requires a multifaceted approach. While the Lancet Commission on Obesity [18] provides a conceptual framework for tiered obesity care, its effective implementation will require system-wide investment, policy alignment, and coordinated service delivery. The 2025 NICE guideline [45] on overweight and obesity emphasises the importance of standardising Tier 3 service provision, improving referral pathways, and ensuring equitable access to care across all patient groups. In this context, key recommendations may include enhancing cultural tailoring to improve equity and engagement among minority ethnic groups and personalising interventions to address individual psychological and behavioural needs. In addition, standardising Tier 3 service delivery and reporting to facilitate national evaluations and impartial access, in line with NICE recommendations, and developing integrated referral and treatment pathways across Tiers 1–4 can contribute to ensuring a seamless continuum of care. Further priorities may also include increasing investment in public health strategies to address obesity prevention at the population level, and prioritising sustained engagement by designing interventions that address the psychosocial and contextual drivers leading to programme dropout. Conclusion This process evaluation demonstrated moderate completion rates, in line with higher end UK benchmarks, however, disparities in engagement remain, particularly among minority ethnic groups in our diverse London Tier 3 weight management service. Observed differences in programme completion between females and males emphasise the importance of understanding gender-specific barriers and motivators to improve engagement across all demographic groups. By translating conceptual models into practice, such as those outlined by the Lancet Commission on Obesity (2025) and the 2025 NICE guideline on overweight and obesity, the UK can build a more effective and inclusive obesity care framework. Ensuring the successful implementation of these policies will require addressing structural inequities, tailoring interventions to diverse populations, and strengthening the integration of tiered services to promote sustainable and accessible care. Declarations Conflict of Interest Statement The authors have no conflicts of interest to declare. Funding Sources This service evaluation was funded by Guys and St Thomas’ NHS Foundation Trust. The service evaluation was independently led by the corresponding author. The funder had no role in the design of the evaluation, analysis, interpretation of data or the writing of the manuscript. Author Contributions MOK: Conceptualization, data curation, formal analysis, methodology, original draft preparation; EP: project administration; data curation, original draft preparation, review and editing; SS: project administration; review and editing; DD, project administration; data curation, review and editing; OC: review and editing; RW: review and editing; AD: conceptualization, review and editing. Data Availability Statement The data presented are not publicly available due to fact that the data was collected as part of a clinical service. Reasonable requests for the data can be made via the corresponding author but the release of the data will be subject to approval by the clinical service leads and the Quality Improvement and Patient Safety oversight committee. References Obesity Profile: short statistical commentary May 2023. 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Clin Obes 14:e12649 Davis KK, Tate DF, Lang W, Neiberg RH, Polzien K, Rickman AD, Erickson K, Jakicic JM (2015) Racial Differences in Weight Loss Among Adults in a Behavioral Weight Loss Intervention: Role of Diet and Physical Activity. https://doi.org/10.1123/jpah.2014-0243 Maynard MJ, Orighoye O, Apekey T, Simpson E, van Dijk M, Atherton E, Blackshaw J, Ells L (2023) Improving adult behavioural weight management services for diverse UK Black Caribbean and Black African ethnic groups: a qualitative study of insights from potential service users and service providers. Front Public Health 11:1239668 Odoms-Young A, Stanford FC, Palacios C, et al (2024) Culturally Tailored Dietary Interventions and Diet-Related Psychosocial Factors, Dietary Intake, Diet Quality, and Health Outcomes: An Evidence Scan. USDA Nutrition Evidence Systematic Review, Alexandria (VA) Teke J, Bolarinwa OA, Nnyanzi LA, Giles EL, Ells L, Elliott S, Okeke SR, Okeke-Obayemi DO (2024) “For me, it is for longevity and making sure I am fit and around for my children”: exploring motivations and barriers for weight management among minoritised communities in Medway, England. BMC Public Health 24:796 Coe WH, Redmond L, Parisi JM, Bowie JV, Liu EY, Ng TY, Onyuka AMA, Cort M, Cheskin LJ (2017) Motivators, Barriers, and Facilitators to Weight Loss and Behavior Change Among African American Adults in Baltimore City: A Qualitative Analysis. J Natl Med Assoc 109:79–85 Puhl RM (2023) Weight Stigma and Barriers to Effective Obesity Care. Gastroenterol Clin North Am 52:417–428 Rose L, Wood A, Gill T (2024) Gender differences in adherence and retention in Mediterranean diet interventions with a weight‐loss outcome: A systematic review and meta‐analysis. Obes Rev 25:e13824 Ahern AL, Aveyard P, Boyland EJ, Halford JC, Jebb SA (2016) Inequalities in the uptake of weight management interventions in a pragmatic trial: an observational study in primary care. Br J Gen Pract 66:e258–e263 Susanto A, Fuller NR, Hocking S, Markovic T, Gill T (2023) Motivations for participation in weight loss clinical trials. Clin Obes 13:e12604 Elliott M, Gillison F, Barnett J (2020) Exploring the influences on men’s engagement with weight loss services: a qualitative study. BMC Public Health 20:249 Nguyen HD, Chitturi S, Maple-Brown LJ (2016) Management of diabetes in Indigenous communities: lessons from the Australian Aboriginal population. Intern Med J 46:1252–1259 Huntriss R, Haines M, Jones L, Mulligan D (2021) A service evaluation exploring the effectiveness of a locally commissioned tier 3 weight management programme offering face-to-face, telephone and digital dietetic support. Clin Obes 11:e12444 Garcia DO, Valdez LA, Aceves B, Bell ML, Humphrey K, Hingle M, McEwen M, Hooker SP (2019) A Gender- and Culturally Sensitive Weight Loss Intervention for Hispanic Men: Results From the Animo Pilot Randomized Controlled Trial. Health Educ Behav 46:763–772 Katangwe-Chigamba T, Kantilal K, Hartley-Palmer J, Salisu-Olatunji SO, Seeley C, Naughton F, Chester R (2024) Diet and Physical Activity Interventions for People from Minority Ethnic Backgrounds in the UK: A Scoping Review Exploring Barriers, Enablers and Cultural Adaptations. J Racial Ethn Health Disparities. https://doi.org/10.1007/s40615-024-02112-y Swancutt D, Tarrant M, Pinkney J (2019) How Group-Based Interventions Can Improve Services for People with Severe Obesity. Curr Obes Rep 8:333–339 Building new health system action to reduce obesity: Audit findings of Integrated Care Board Forward Plans. Future Health Overview | Overweight and obesity management | Guidance | NICE. https://www.nice.org.uk/guidance/ng246. Accessed 16 May 2025 World Obesity Federation Global Obesity Observatory. https://data.worldobesity.org/rankings/. Accessed 6 Feb 2025 Tables Tables 1 to 3 are available in the supplementary files section Additional Declarations There is NO conflict of interest to disclose. Supplementary Files SupplTable1CohortProcess260925.xlsx Supplementary Table 1. Participant characteristics of the Southeast London Tier 3 healthy weight programme at initial assessment (stage 3), session 1 or 2 (stage 2) and programme completion (session 9 SupplTable2CohortProcess260925.xlsx Supplementary Table 2. Predictors of programme completion for the Southeast London Healthy Living programme. Continuous variables, statistical significance p<0.005. Univariate logistic regression, d SupplTable3CohortProcess260925.xlsx Supplementary Table 3: Results of multivariate logistic regression analyses to predict programme completion of the Southeast London Healthy Living Programme. Multivariate regression, data as OR (95% Table1CohortProcess260925.xlsx Table2CohortProcess260925.xlsx Table3CohortProcess260925.xlsx Cite Share Download PDF Status: Under Review Version 1 posted Review # 1 received at journal 05 May, 2026 Reviewer # 1 agreed at journal 20 Apr, 2026 Reviewers invited by journal 26 Jan, 2026 Editor assigned by journal 29 Sep, 2025 Submission checks completed at journal 29 Sep, 2025 First submitted to journal 26 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7724834","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":580709655,"identity":"33132633-f8dd-403e-a595-2ab6546cf971","order_by":0,"name":"Majella OKeeffe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIie2RsWrDMBCGDwLJIuo1oZA+QeFCwFPIs/xGYC8NdDS00Ezpkj5A38KPcEEQLy5ZPcpv4Ez11FakWTJE7thBH0iC033wn0QUCPxPQPbRHcqtfEHTc61HAZ+VKqX5XxS6UJJ1X/f9qzQWvKRImZ0VLLKiNJZsfl2JK2gGa5q8bTQL0lVRpUyoPIrrGoMHxAcV3x47sypqFzHZeJSDzTrwi1Oiz07wnfFJ+fIoNVI3viH+2A5JIPhVPI8Q11a7YKWabPfzsUDP3t0sgr0v2EPStvnTNFK6aQXLu5vSNE33fF1x/4HTflETn0A06rkPBAKBwA8Ry1fsKFrDfAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-0204-3835","institution":"University College Cork","correspondingAuthor":true,"prefix":"","firstName":"Majella","middleName":"","lastName":"OKeeffe","suffix":""},{"id":580709656,"identity":"e0d1f217-92e6-407c-bedc-9ede6742454d","order_by":1,"name":"Emiliano Pena Altamira","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Emiliano","middleName":"Pena","lastName":"Altamira","suffix":""},{"id":580709657,"identity":"439cd23d-8377-45c4-a5a1-2e9a96d86235","order_by":2,"name":"Sumaya Shuirye","email":"","orcid":"","institution":"Guy's and St Thomas' NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Sumaya","middleName":"","lastName":"Shuirye","suffix":""},{"id":580709658,"identity":"e21b8582-b2c8-42e8-a7a1-2dc603097307","order_by":3,"name":"Danielle Dunk","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Danielle","middleName":"","lastName":"Dunk","suffix":""},{"id":580709659,"identity":"7f72daf0-504d-4b22-aee4-ef467f60d8ce","order_by":4,"name":"Oliver Canfell","email":"","orcid":"https://orcid.org/0000-0003-2010-3640","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Oliver","middleName":"","lastName":"Canfell","suffix":""},{"id":580709660,"identity":"bfa86493-3189-4fd0-86af-7ccde92f97fc","order_by":5,"name":"Rhys White","email":"","orcid":"","institution":"Guy's and St Thomas' NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Rhys","middleName":"","lastName":"White","suffix":""},{"id":580709661,"identity":"da28a5e9-1e5d-42c6-bdc7-d8bb676668fd","order_by":6,"name":"Alastair Duncan","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Alastair","middleName":"","lastName":"Duncan","suffix":""}],"badges":[],"createdAt":"2025-09-26 21:40:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7724834/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7724834/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101752339,"identity":"b9e953c8-5eb2-4dc0-812e-6a8684c608c2","added_by":"auto","created_at":"2026-02-03 10:26:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":142810,"visible":true,"origin":"","legend":"\u003cp\u003eReferral and service pathway for the Southeast London Healthy Living Programme (SELHLP).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7724834/v1/a71ab6b0be2076b7d63f9b87.png"},{"id":101752225,"identity":"cc3f93df-e5a9-40c4-92e6-91be27bdcd7e","added_by":"auto","created_at":"2026-02-03 10:26:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003eParticipants characteristics of the Southeast London Healthy Living Programme by stage of programme engagement. Characteristics are represented for the full cohort profile at stage 1 initial assessment; stage 2 attendance at session 1 and or 2 and stage 3 programme completion. Figure 1a represents gender, 1b ethnicity, 1c relationship status and 1d living arrangements.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7724834/v1/e29c79f63dfa51c6a7ea577b.png"},{"id":101756292,"identity":"387fadcb-9f7b-4260-ba17-c4b588347760","added_by":"auto","created_at":"2026-02-03 10:57:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":787841,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7724834/v1/759a8926-993a-47cf-939a-16e402561d48.pdf"},{"id":101517019,"identity":"646e428c-0de4-4e84-84bc-93a562e8733a","added_by":"auto","created_at":"2026-01-30 16:22:29","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":12732,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Table 1. Participant characteristics of the Southeast London Tier 3 healthy weight programme at initial assessment (stage 3), session 1 or 2 (stage 2) and programme completion (session 9\u003c/p\u003e","description":"","filename":"SupplTable1CohortProcess260925.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7724834/v1/239bd2b6c6eecdd26160df5d.xlsx"},{"id":101517011,"identity":"56001baa-02b1-4bc1-aad2-6ff0d3b6fb82","added_by":"auto","created_at":"2026-01-30 16:22:28","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":13376,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Table 2. Predictors of programme completion for the Southeast London Healthy Living programme. Continuous variables, statistical significance p\u0026lt;0.005. Univariate logistic regression, d\u003c/p\u003e","description":"","filename":"SupplTable2CohortProcess260925.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7724834/v1/02f9390aced5e87b371b4147.xlsx"},{"id":101517013,"identity":"7341186a-111e-4d90-8953-50358a287cd6","added_by":"auto","created_at":"2026-01-30 16:22:28","extension":"xlsx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":10694,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Table 3: Results of multivariate logistic regression analyses to predict programme completion of the Southeast London Healthy Living Programme. Multivariate regression, data as OR (95%\u003c/p\u003e","description":"","filename":"SupplTable3CohortProcess260925.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7724834/v1/b70ddc6a12f56783454e8f8d.xlsx"},{"id":101517017,"identity":"47cb875d-8306-49c7-b74a-ef31659456ee","added_by":"auto","created_at":"2026-01-30 16:22:28","extension":"xlsx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":11849,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"Table1CohortProcess260925.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7724834/v1/55180b3dc08dd88246039ecd.xlsx"},{"id":101517018,"identity":"62d3b9e1-2e13-47e6-9d0a-c69f694c1c06","added_by":"auto","created_at":"2026-01-30 16:22:28","extension":"xlsx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":11187,"visible":true,"origin":"","legend":"","description":"","filename":"Table2CohortProcess260925.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7724834/v1/6278b78eb35767600e3d62aa.xlsx"},{"id":101752334,"identity":"ebc3f4f2-f6a3-4abb-a7a5-d2771138b6cf","added_by":"auto","created_at":"2026-02-03 10:26:53","extension":"xlsx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":11169,"visible":true,"origin":"","legend":"","description":"","filename":"Table3CohortProcess260925.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7724834/v1/4cd356b5aed4284e16e3f164.xlsx"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"A cohort profile and process evaluation of an adult multidisciplinary behavioural and weight management service in a diverse UK population","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe prevalence of overweight and obesity among UK adults has increased from 61.2% (2015-16) to 64% (2022-23) and obesity prevalence alone is now estimated at 25.9% [1] with further increases projected [2]. The prevalence of obesity is socially patterned with greater prevalence observed among more deprived communities [3] and ethnic minority groups [4]. In England, adult obesity is up to 16% greater in deprived compared to more affluent areas [5] and obesity-related hospital admissions are 2.4 times greater in more deprived communities [6]. \u0026nbsp;Obesity is associated with physical and mental health outcomes, including increased risk of cancer, cardiovascular disease [7] and mortality [8] in addition to reduced psychological wellbeing and diminished quality of life [9]. \u0026nbsp;From a health service perspective, in England over one million hospital admissions were due to obesity (2019-20) and the national health service (NHS) obesity-related expenditure is estimated to reach \u0026pound;10 billion by 2050 [6].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWeight and behavioural interventions result in modest weight loss [10\u0026ndash;12] and behaviour change [13] and remain an important part of obesity management even in the context of obesity management medications [14]. \u0026nbsp;Modest improvements in weight (5-10%) improve health outcomes including fasting glucose, triglycerides, total cholesterol and low-density lipoprotein (LDL) cholesterol [11, 15] and support change behaviours linked to excess weight [12, 13].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn England, the NHS has a 4-Tier model of care for adult weight management; Tier 1 services include public health and health promotion strategies, Tier 2 offers community weight management services, and Tier 3 services provide specialist weight management and behaviour change programmes. \u0026nbsp;These programmes are usually delivered by multidisciplinary teams including physicians, nurses, dietitians and psychologists, although availability, referral criteria, team composition and programme structure vary substantially across the UK [10, 11]. Tier 4 is the bariatric surgery pathway and a prerequisite for eligibility is completion of a Tier 3 service. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite ongoing efforts to standardise adult weight management services, substantial disparities exist in the availability, composition and uptake of Tier 3 services across the UK [16, 17]. The 2025 NICE guideline on overweight and obesity aims to improve equitable access and structured service delivery, while the recent Lancet Commission on Obesity [18] reframes obesity as a chronic, systemic disease requiring a stratified, tiered approach to care. However, variability in service provision and gaps in national reporting persist, making it difficult to evaluate Tier 3 service uptake and effectiveness. \u0026nbsp;This service evaluation reports on the participant characteristics and process outcomes including referrals, engagement, attendance and completion of a specialist Tier 3 behavioural and weight management programme delivered across an ethnically diverse area of Southeast London. The study is the first component of an umbrella service evaluation of the Tier 3 South-East London Healthy Living Programme (SELHLP) that includes cohort profile and process evaluation, described herein and an impact evaluation (O\u0026rsquo;Keeffe et al., unpublished). \u0026nbsp;The protocol for the Tier 3 services is also reported elsewhere (Shuriye et al., unpublished).\u0026nbsp;\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis service evaluation was a retrospective cohort study that is reported in line with the SQUIRE reporting guidelines [19] and was informed by the National Obesity Observatory Standard Evaluation Framework [20].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePopulation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe population in this study consisted of participants enrolled in the Southeast London Healthy Living Programme SELHLP, a Tier 3 specialist behavioural and weight management service for adults. This programme delivers community-based, multidisciplinary support across five boroughs in South-East London: Southwark, Lambeth, Bromley, Bexley, and Lewisham. These boroughs are administrative divisions within Greater London, each governed by a local authority.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSouth-East London demonstrates considerable ethnic diversity compared to Greater London and the national population of England and Wales. In Bexley and Bromley, the majority of the population identifies as white (72% and 76%, respectively), with smaller proportions identifying as Black (12% and 8%) or other ethnicities (16% in both boroughs), according to the Office for National Statistics (2022) [21]. Conversely, the boroughs of Lambeth, Lewisham, and Southwark exhibit different compositions, with 55% of the population in Lambeth identifying as white, 51% in Lewisham and Southwark, and higher Black populations (24% in Lambeth, 27% in Lewisham, and 25% in Southwark). The proportion of other ethnicities is 21% in Lambeth, 22% in Lewisham, and 23% in Southwark. By comparison, Greater London is 51% white, 25% Black, and 23% other ethnicities. At a national level, England and Wales report a predominantly white population (82%), with smaller proportions of Black (4%) and other ethnicities (14%).\u003c/p\u003e\n\u003cp\u003eSocioeconomic deprivation within these boroughs varies according to the Index of Multiple Deprivation (IMD, 2019) [22], which assigns rankings from 1 (most deprived) to 10 (least deprived). Bexley (mean IMD score 6.51 ± 2.46) and Bromley (7.11 ± 2.50) are relatively less deprived, while Lambeth (3.95 ± 1.57), Lewisham (3.76 ± 1.64), and Southwark (4.02 ± 1.98) experience greater levels of deprivation. However, the boroughs of Bexley and Bromley contain areas with an IMD score of 1 and 2, suggesting great variability within boroughs in South-East London [22]. For context, the average IMD score for England is 5.50 ± 2.87.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProgramme structure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SELHLP is a multidisciplinary specialist weight and behavioural change 12-month intervention, delivered by Guys’ and St Thomas NHS Foundation Trust (GSTT). Two main pathways are offered – Balance and Kickstart – although, as recommended by NICE, an option for one-to-one treatment was available but is not the focus of this evaluation. \u0026nbsp;The Balance programme consists of diet and lifestyle behavioural change intervention only, whereas the Kickstart programme features three months of total meal replacement (800-1200 kcal/d) followed by gradual food reintroduction and lifestyle behavioural change programme. The Kickstart programme is based on the Diabetes Remission Clinical Trial (DiRECT) protocol [23, 24]. Both Kickstart and Balance initially included 12 group sessions delivered over 12 months, which focused on a behavioural change curriculum that was informed by the NICE guidance for weight management programmes [25]. Whilst dietitian-led, the programme utilises a multidisciplinary involvement including medical doctors, psychologists, physiotherapists and physiotherapy and dietetic assistants, in line with NICE guidelines [25]. \u0026nbsp;Sessions were initially delivered face-to-face (F2F) in community locations but transitioned to virtual (V) delivery in September 2020 due to the COVID-19 pandemic. In August 2022, once social distancing regulations were relaxed, a hybrid model was introduced with both virtual and F2F group sessions delivered. \u0026nbsp; Participants were given the choice for V or F2F group delivery. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe curriculum for the group-based behaviour change session included SMART goal setting, diet and lifestyle education including identifying hunger and reasons for overeating, motivation and managing relapses, understanding food labels, cooking, and the relationship between healthy eating and sleep quality. Participants were encouraged to increase physical activity. Peer support was established through an app that enabled dietitians and psychologists to respond directly to participant questions. Each session was 60 minutes duration and included recording of actual weight, or participant-reported weight during virtual sessions.\u0026nbsp;Participants with psychological complexity, for example, with binge eating disorder, could access extra individualised support from a clinical psychologist.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReferral criteria\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn line with NICE guidelines, general practitioners (GP) across the five Southeast London boroughs (Bexley, Bromley, Lambeth, Lewisham or Southwark) were the key referral pathway to the SELHLP, but eligible candidates awaiting bariatric surgery can also be referred from Tier 4 and other clinical services in the southeast London area (Figure 1). Eligible participants must have been registered with a GP in one of the five boroughs, be 18 years or older, have a BMI of ≥35 kg/m\u003csup\u003e2\u003c/sup\u003e with type 2 diabetes or ≥BMI 40 kg/m\u003csup\u003e2\u003c/sup\u003e. Upon receipt of referral, participants were screened for inclusion and eligible participants were scheduled for an initial assessment (IA) with a registered dietitian. \u0026nbsp;Participants that did not meet the referral criteria were returned to their GP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProcess outcomes included conversion rates from referral to initial attendance, and to completion for the 12-month intervention. Participant demographic details including age, gender, ethnicity and postcode were recorded in line with the NICE minimum dataset for Tier 3 programmes [25]. \u0026nbsp;Programme completion was defined as participants who attended one of the last 3 sessions (until August 2020) or one of the last 4 sessions (after August 2020); this outcome was changed due to COVID-19)). \u0026nbsp;Engagement is reported for initial assessment (stage 1), session 1 or 2 (stage 2) and programme completion (stage 3). \u0026nbsp;Early engagement was defined as the proportion of participants who attended session 1 or session 2, following their initial assessment.\u003c/p\u003e\n\u003cp\u003eImpact outcomes including weight change and a host of secondary outcomes including, diet, lifestyle, physical activity and wellbeing, were also recorded in line with the National Obesity Observatory Standard Evaluation Framework [20]. \u0026nbsp;These data are reported elsewhere and not included herein.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was conducted as a quality improvement service evaluation, utilising anonymised secondary healthcare data from the Tier 3 service. Following referral and where eligibility criteria were met, participants attended an initial assessment (IA) with a registered dietitian. During this visit, baseline data including demographics, anthropometrics including current weight was recorded by the dietitian. Participants also completed an IA which included the outcome data previously described. \u0026nbsp;Participant preference for the Balance or Kickstart programme was also recorded. The IA was then reviewed by the Tier 3 team, scores for the validated questionnaires were calculated and the data was entered into an Excel spreadsheet, which was anonymised for analysis. Upon initiation of the programme and for each session thereafter, weight, where available, was inputted into the database. Prior to August 2020, at one of the last three sessions, participants of each group were asked to complete an exit assessment (EA) which recorded anthropometry and secondary outcomes data. Due to the impact of COVID-19 on the service and the subsequent move to online delivery, data collection methods changed. \u0026nbsp;With the integration of BlueJeans, an online meeting platform with video, audio, and web conferencing functions used for virtual delivery, participants were emailed a link to complete an online exit assessment between the antepenultimate and the final session. Upon completion of EAs, the service team entered the data into an Excel spreadsheet. The anonymised database was transferred to the service evaluation team for analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were calculated to summarise baseline demographic, anthropometric, and behavioural characteristics of the cohort. Normality of continuous variables was assessed visually using histograms and tested with the Shapiro-Wilk test (p\u0026lt;0.05). Depending on normality, either parametric (t-tests) or non-parametric tests (Mann-Whitney U, Wilcoxon, or Kruskal-Wallis tests) were applied. Continuous data were presented as means ± SD, and categorical data were presented as numbers and percentages, unless otherwise stated.\u003c/p\u003e\n\u003cp\u003eDemographic variables included the Index of Multiple Deprivation (IMD) (high deprivation (deciles 1-3), moderate deprivation (deciles 4-6), and low deprivation (deciles 7-10), gender (male, female), ethnicity (White, Black African/Caribbean, and Other, the latter including Asian, South American, not listed ethnicities and the Prefer not to say category), and age (18-24, 25-34, 35-44, 45-54, 55-64, 65-74 and 75-85 years).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor analysis, completion status was collapsed into a binary outcome (yes/no). Programme completion outcomes included \"completed,\" \"did not complete,\" \"declined intervention,\" and \"patient not booked in group.\" Chi-squared (X²) tests for independence were conducted to examine if a statistical association between categorical variables was present. Adjusted residuals with values greater than ±1.96 (p\u0026lt;0.05) were interpreted to indicate statistically significant differences. To identify predictors of programme completion, candidate predictors from three domains were examined: demographic (age, gender, relationship status, ethnicity, and IMD-based deprivation), weight-related (initial weight, initial BMI, and highest weight ever recorded), and psychological (motivation and confidence at baseline and binge eating). \u0026nbsp;Correlation analysis was conducted to determine relationships between programme completion and continuous predictor variables (e.g., baseline weight, BMI, highest weight, deprivation, confidence, and motivation at baseline). Univariate and multivariate forced entry logistic regression models were developed to evaluate predictors of the four intervention conditions (Balance F2F, Balance Virtual, Kickstart F2F, Kickstart Virtual). The Wald test was used to test the significance of predictors within the models, with p\u0026lt;0.05 indicating statistical significance.\u003c/p\u003e\n\u003cp\u003eTo explore differences in referral, uptake, and completion across sociodemographic subgroups, one-way ANOVA tests were conducted to assess whether programme completion outcomes varied by age, gender, ethnicity, deprivation level, baseline weight, BMI, highest weight ever, confidence, and motivation. Homogeneity of variances was evaluated using Levene’s test; where significant (p\u0026lt;0.05), the Brown-Forsythe test was reported to account for heterogeneity in variances and sample sizes. \u0026nbsp; All analyses were conducted using SPSS version 29 for Windows (IBM SPSS). Statistical significance was considered at p\u0026lt;0.05 for all tests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis service evaluation was not subject to ethical approval but approval from the Quality Improvement Projects and Patient Safety committee (Reference 14211) at GSTT was obtained. \u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eCohort Profile: Participant characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt time of analysis, 4,499 participants had attended an initial assessment of the SELHLP. Among these, 24% (n=1,080) were enrolled in Balance F2F, 13.6% (n=612) in Kickstart F2F, 30% (n=1,023) in Balance Virtual, and 19% (n=648) in Kickstart Virtual. Additional enrolments included 5% (n=233) in the one-to-one pathway, 736 participants were on a waiting list, 31 discharged from the programme, 10 who declined the service, and 29 on an exploratory diabetes weight management pathway. The status of 95 referrals was unknown.\u003c/p\u003e\n\u003cp\u003eThe overall Tier 3 cohort was predominantly female (78%), with a mean age of 47 ± 13.5 years. In terms of ethnicity, 47% identified as White, and 36% as Black African/Caribbean. 49% of the cohort lived in high-deprivation areas (IMD deciles 1-3), with an average IMD decile of 4 ± 2.5. 47% were single, 37% married, and household composition varied: 22% lived with children, 17% with a spouse/partner and children, and 11% with parents or other relatives. Participant distribution across the boroughs was as follows: 25.1% in Southwark (n=1,127), 29.2% in Lambeth (n=1,314), 20.6% in Bromley (n=924), 11.4% in Bexley (n=513), and 13.7% in Lewisham (n=615).\u003c/p\u003e\n\u003cp\u003eParticipant characteristics for both Balance and Kickstart programmes are summarised in Table 1, and both programmes are similar in gender distribution, ethnicity, and deprivation. \u0026nbsp;Two thousand one hundred and eight participants were enrolled in Balance, with 51% in Balance F2F and 49% in Balance Virtual. The combined Balance cohort (F2F and V) was predominantly female (n=1717, 82%), with a mean age of 47.6 ± 13.3 years. Forty six percent identified as White ethnicity, 17% as Black African, and 12% as Black Caribbean. 49.5% were single, while 25.4% lived with children. Area-level deprivation was moderate, with an average IMD decile of 4 ± 2.3.\u003c/p\u003e\n\u003cp\u003eOne thousand two hundred and eighty-one participants were enrolled in the Kickstart programme, with a similar distribution across the F2F, 49%, and virtual, 51%, programmes. The combined Kickstart cohort showed similar demographic patterns to the Balance cohort, 75% female, average age 46.4 ± 12.5 years. Ethnic distributions were also similar (Table 1). 44% were single, and 25% lived with children. Area-level deprivation was also moderate, with an average IMD decile of 5 ± 2.5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnthropometry and clinical status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBaseline anthropometry and clinical characteristics were similar across Balance and Kickstart cohorts (Table 2). There was no significant difference in baseline weight (Balance: 124 ± 20.5 kg vs. Kickstart: 124.8 ± 21.5 kg, p=0.285) or BMI (Balance: 45 ± 6.1 kg/m² vs. Kickstart: 44.6 ± 6 kg/m², p=0.098). Analysis across the four programme types (Balance F2F, Balance V, Kickstart F2F, Kickstart V) showed no significant difference in weight (p=0.112) or BMI (p=0.069). Eighty five percent of Balance and 84% of Kickstart had obesity class III. \u0026nbsp; Participants in both programmes were hypertensive (systolic blood pressure: 133 ± 16, diastolic blood pressure: 82 ± 10 mmHg), with a mean HbA1c of 47 mmol/mol. Self-reported type 2 diabetes was similar across Balance (34%) and Kickstart (32%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcess Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReferral sources and geographic patterns of referrals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReferral sources were primarily general practitioners (83% for Balance, 88% for Kickstart), followed by referral from a Tier 4 pathways (8% for Balance, 4% for Kickstart). Geographic patterns in referrals showed that 58% of Balance referrals were from Southwark and Lambeth, while referrals for Kickstart were highest from Lambeth (27%) and Bromley (24%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTier 4 pathway and clinical referrals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding the Tier 4 pathway, 24% (n=969) of participants indicated it was not relevant to them, while 21% (n=845) had declined the service, and 381 participants were unsure about bariatric surgery as a therapeutic intervention. At the time of analysis, 16% (n=720) were on the Tier 4 pathway, and 54 participants had previously undergone bariatric surgery. In terms of additional clinical support, 2% (n=105) had been referred for a medical review as part of the programme, and 9% (n=355) had been referred for psychological review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProgramme engagement, attendance and completion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipant engagement was tracked across three defined stages: stage 1 (initial assessment), stage 2 (attendance at session 1 or 2) and stage 3 (programme completion). 4,499 participants attended an initial assessment (IA) while\u0026nbsp;a total of 1,253 participants (28%) attended either session 1 or 2. Programme completion data was available for 2019 participants: \u0026nbsp;904 (43%) completed the programme, 1176 (55.8%) did not, 6 (0.3%) declined intervention, and 23 (1.1%) were not booked on any group. Figure 2 shows key participant characteristics (gender, ethnicity, relationship status, and living arrangements) by programme stage. \u0026nbsp;Early engagement was 67% and 61% for session 1 and 2 and \u0026lt;50% by session 4 with a sustained reduction across sessions thereafter. Supplementary Table 1 provides a detailed breakdown by stage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompletion rates by demographics and programme\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Programme completion varied significantly by ethnicity (X²= 7.422, df=2, p=0.024) and gender (X²=8.1, df=1, p=0.004) (Table 3). Black African/Caribbean participants had lower completion rates (40% completed vs. 60% did not complete), and males were less likely to complete (38% completed vs. 63% did not complete). Programme completion rates did not differ by deprivation (X\u003csup\u003e2\u003c/sup\u003e=2.06, df(2), p=0.352). Non-completion rates were high across all clinical commissioning groups (CCGs) (range 51-61%) and differed by CCG (X²=11.284, df(4), p=0.024). Additionally, completion rates differed by programme type, with virtual formats showing higher completion rates than face-to-face formats (X²=604, df=3, p\u0026lt;0.001). Table 2 summarises completion rates across demographic categories and programmes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePredictors of programme completion\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Following univariate analysis, baseline confidence significantly predicted completion (F(1, 1609)=6.3, p=0.012), with females more likely to complete (OR=1.375, p=0.004) and Black African/Caribbean ethnicity associated with lower completion rates (OR=0.817, p=0.041). In multivariate analysis, females were 1.5 times more likely to complete (OR=1.509, p=0.018), while Black African/Caribbean participants and those separated/divorced/widowed were less likely to complete (OR=0.74, p=0.023) and (OR=0.701, p=0.045) respectively. Weight (OR=0.994, p=0.268), BMI (OR=1.023, p=0.163), age (OR=0.995, p=0.313), confidence (OR=0.959, p=0.175), motivation at baseline (OR=0.965, p=0.322), deprivation (OR=1.004, p=0.852), and programme type (OR=1.093, p=0.433), were not associated with programme completion in multivariate analysis (Supplementary tables 2 and 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompletion of exit assessments\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Exit assessment (EA) data was available for 1,194 participants in the Balance cohort (both F2F and Virtual). Of those, only 269 participants (22%) fully completed the EA, 151 were recorded as not having completed it. EA completion status data was unavailable for 909 Balance participants. In the Kickstart cohort, EA data was recorded for 701 participants, with only 116 (17%) completing the EA.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides a detailed evaluation of a Tier 3 adult multidisciplinary weight management service in a diverse London population, highlighting the challenges and successes associated with referral, uptake, and completion. Our findings add to the body of evidence on Tier 3 behavioural and weight management services in the UK and underscore the need for improvements at the system level to enhance access, engagement, and outcomes.\u003c/p\u003e\n\u003cp\u003eThe overall programme completion rate of 43% is on the higher end of previously reported national figures, which range between 23-55% [12, 26]. While this suggests moderate completion rate compared to similar programmes, over half of participants did not complete the programme, highlighting persistent challenges to maintain engagement across the service. While suboptimal, this completion rate of 43% is noteworthy, given the complexity of the population served, including the significant representation of individuals from socioeconomically deprived areas and minority ethnic groups that have lower engagement rates [27]. Black African and Caribbean participants, in particular, had lower completion rates, consistent with findings from a recent NHS Tier 3 service evaluation showing higher dropout rates and less weight loss among minority ethnic groups receiving liraglutide treatment [28]. \u0026nbsp;Furthermore, international data reports ethnic specific responses to similar behavioural interventions [29]. Recent qualitative research suggests that weight management services designed to be community-centred, culturally aligned, and adaptable to individual needs may be needed to improve engagement among diverse populations [30, 31]. \u0026nbsp;Understanding the mechanisms behind these disparities, whether structural, cultural, or individual, is critical to addressing inequities in programme engagement and outcomes. Potential factors contributing to low completion rates in minority ethnic groups may include cultural attitudes towards health and weight, language barriers, logistical challenges such as transport, and perceived stigma. For example, a recent exploratory study identified systemic barriers, family commitments, and cultural norms as significant obstacles to weight management among ethnically diverse communities in England [32]. A qualitative study among urban minority populations found that women reported limited access to personal transportation as a barrier to participating in weight loss programmes, whereas men noted that vehicle access increased exposure to fast food options [33]. Additionally, weight stigma has been identified as a significant barrier to effective obesity care, leading to avoidance or delay in seeking medical attention, which can adversely affect health outcomes [34]. Addressing these barriers will require targeted interventions, such as improving cultural alignment, enhancing accessibility, and increasing engagement through tailored outreach efforts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFemales were more likely to complete the programme compared to males; a trend observed in other health interventions. For example, a recent systematic review of Mediterranean diet interventions for weight loss reported a trend toward higher adherence and retention among women compared to men, though the findings were not statistically significant [35]. The completion rate differences based on gender observed in our study may reflect variations in health-seeking behaviours, with women often demonstrating higher engagement with health services. For example, Ahern et al. (2016) observed that women were significantly more likely to enrol in weight management programmes compared to men, although higher enrolment does not necessarily translate into higher completion rates [36]. Additionally, women may have different motivations or priorities for weight management. A recent study found that women cited family and aesthetic outcomes as important motivators for participation in weight loss interventions, while men prioritised health-related reasons [37]. \u0026nbsp;However, further research is needed to explore the underlying factors contributing to these disparities, including potential barriers for male participants such as time constraints, perceived stigma, or preferences for alternative programme formats. For example, male participants may perceive weight management programmes as less inclusive of their needs or interests, which can lead to feelings of embarrassment or self-consciousness, acting as a barrier to engagement [38]. Addressing these barriers through targeted outreach, gender-sensitive programme adaptations, and gender-focused support strategies could improve completion rates among men. A scoping review suggests that factors such as camaraderie and peer support can influence men’s participation in weight management programmes, suggesting that promoting a sense of community within interventions may enhance male engagement [39]. Moreover, patient engagement in face-to-face services can be enhanced by offering flexible, digital, or telehealth delivery modes, which reduce logistical barriers such as travel and time constraints [40].\u003c/p\u003e\n\u003cp\u003eOur findings underscore the importance of culturally tailored interventions to improve accessibility and effectiveness for diverse populations. Previous research has highlighted the benefits of culturally sensitive approaches in increasing engagement and improving outcomes in weight management programmes. For example, a culturally tailored weight loss intervention for Hispanic males, which included bilingual and bicultural coaches and culturally relevant dietary guidance, significantly improved programme engagement and outcomes [41]. Incorporating culturally relevant dietary guidance, addressing cultural stigma around obesity, and improving the accessibility of services for non-English speakers are critical areas for improvement. A scoping review that explored barriers and enablers to diet and physical activity interventions among UK minority ethnic groups emphasises the need for cultural adaptations to increase engagement and effectiveness [42]. Thus, tailoring interventions to the lived experiences of minority ethnic groups is essential for reducing disparities in programme engagement and outcomes.\u003c/p\u003e\n\u003cp\u003eThe South-East London Healthy Living Programme (SELHLP) is unique in its inclusion of both the Balance and Kickstart pathways. Kickstart, which incorporates a total meal replacement phase followed by gradual food reintroduction, represents an innovative approach within Tier 3 services. Although completion rates were generally low, the structured nature of Kickstart and its group-based delivery model may provide a framework for scaling similar interventions. Group-based interventions are supported in the literature for their effectiveness in managing chronic diseases and promoting behavioural change [43].\u003c/p\u003e\n\u003cp\u003eDifferences between Balance and Kickstart pathways also highlight the need for personalised approaches. Balance participants, who did not engage in total meal replacement, reported higher levels of emotional eating and binge eating behaviours, suggesting a need for additional psychological support in this group. Tailoring pathways to individual behavioural and psychological profiles may enhance outcomes across both models.\u003c/p\u003e\n\u003cp\u003eClinical research supports the use of Tier 3 interventions to achieve clinically significant weight loss and improve the management of severe and complex obesity. However, translating interventions from controlled research environments to clinical practice can be problematic due to challenges such as fragmented commissioning, variable service composition, and insufficient staffing and resources [11, 43].\u003c/p\u003e\n\u003cp\u003eTier 3 services in the UK face significant variability in availability, commissioning, and delivery, often described as a \"postcode lottery.\" As of 2018, only 57% of CCGs provided Tier 3 services, leaving millions without access. Despite four million people being eligible for Tier 3 care, only 35,000 currently receive it. Integrated Care Boards (ICBs), tasked with addressing healthcare inequalities, have largely deprioritised adult obesity, with only 12% including healthy weight as a focus in their five-year plans and most prioritising childhood obesity [44].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis lack of prioritisation reflects a systemic gap in addressing the adult obesity epidemic. Greater standardisation of Tier 3 services is critical to ensuring equitable access and maintaining quality. Currently, the heterogeneity in team composition, service models, and reporting frameworks hinders national-level evaluations and comparisons. Calls for improved transparency, uniform definitions, and standardised reporting have been echoed in the literature [11] and should be actioned to improve outcomes and inform best practices. Of note, digital interventions can help mitigate regional inequities by offering scalable, resource-efficient models that are less reliant on local clinic availability and physical infrastructure [40].\u003c/p\u003e\n\u003cp\u003eThis study highlights the importance of integrating Tier 3 services within the broader continuum of care. Tier 1 (prevention and public health strategies) and Tier 2 (community-based weight management) services play a crucial role in reducing the burden on specialist services by addressing less complex cases. Strengthening these tiers through public health investment and community engagement can reduce the need for Tier 3 services. However, for individuals with severe obesity and complex comorbidities, Tier 3 remains an essential bridge to Tier 4 (bariatric surgery). The Lancet Commission on Obesity [18] provides a transformative framework for redefining obesity as a chronic, systemic disease with distinct clinical and preclinical stages. This paradigm shift underscores the limitations of BMI as a sole diagnostic criterion and highlights the importance of integrating functional and metabolic health indicators into care pathways. By adopting this approach, tiered care models can be tailored to align intervention intensity with disease severity, ensuring that individuals receive appropriate, stratified care.\u003c/p\u003e\n\u003cp\u003eA key recommendation of the Commission is the development of structured, tiered pathways that optimise patient outcomes through evidence-based, multidisciplinary interventions. However, implementing these pathways into routine clinical practice presents substantial challenges, particularly regarding access, engagement, and retention within Tier 3 services. Overcoming these barriers requires a more integrated, patient-centred approach, ensuring that referral pathways are standardised, service delivery is equitable, and patients receive care tailored to their clinical and psychosocial needs. The 2025 NICE guideline on overweight and obesity management [45] reinforces the need for a systematic, tiered approach, advocating for standardised service delivery across Tiers 1-4. The guideline highlights the importance of ensuring accessibility of services without upper BMI or age limits, improving engagement strategies, and addressing health disparities in obesity care. \u0026nbsp; Aligning Tier 3 services with these emerging frameworks will be essential in building a comprehensive, patient-focused model of obesity care that is clinically effective and equitable.\u003c/p\u003e\n\u003cp\u003eWhile the UK’s tiered model of care is unique, international comparisons offer insights into alternative approaches. For instance, the US and Mexico, have the highest obesity rates among the 12 most populous countries in the world (41.6% and 32.2% respectively), with a total population of around 475 million [46]. Both countries primarily rely on community-based and private weight management programmes and lack a unified tiered system, which limits coordination and integration between levels of care. By contrast, the UK’s tiered system, despite its challenges, provides a structured framework for addressing varying degrees of obesity complexity. Learning from international models and leveraging the strengths of the UK system can inform future improvements.\u003c/p\u003e\n\u003cp\u003eOur retrospective design and reliance on secondary healthcare data limits the ability to establish causal relationships or explore unmeasured variables such as psychosocial factors influencing completion. Second, the findings may not generalise beyond the London context, where the population is highly diverse. Lastly, while the study sheds light on completion disparities, further research is needed to explore participant perspectives and structural barriers that influence engagement and outcomes.\u003c/p\u003e\n\u003cp\u003eImproving the accessibility, engagement, and outcomes of Tier 3 services requires a multifaceted approach. While the Lancet Commission on Obesity [18] provides a conceptual framework for tiered obesity care, its effective implementation will require system-wide investment, policy alignment, and coordinated service delivery. The 2025 NICE guideline [45] on overweight and obesity emphasises the importance of standardising Tier 3 service provision, improving referral pathways, and ensuring equitable access to care across all patient groups. \u0026nbsp;In this context, key recommendations may include enhancing cultural tailoring to improve equity and engagement among minority ethnic groups and personalising interventions to address individual psychological and behavioural needs. In addition, standardising Tier 3 service delivery and reporting to facilitate national evaluations and impartial access, in line with NICE recommendations, and developing integrated referral and treatment pathways across Tiers 1–4 can contribute to ensuring a seamless continuum of care. Further priorities may also include increasing investment in public health strategies to address obesity prevention at the population level, and prioritising sustained engagement by designing interventions that address the psychosocial and contextual drivers leading to programme dropout.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis process evaluation demonstrated moderate completion rates, in line with higher end UK benchmarks, however, disparities in engagement remain, particularly among minority ethnic groups in our diverse London Tier 3 weight management service. Observed differences in programme completion between females and males emphasise the importance of understanding gender-specific barriers and motivators to improve engagement across all demographic groups. By translating conceptual models into practice, such as those outlined by the Lancet Commission on Obesity (2025) and the 2025 NICE guideline on overweight and obesity, the UK can build a more effective and inclusive obesity care framework. Ensuring the successful implementation of these policies will require addressing structural inequities, tailoring interventions to diverse populations, and strengthening the integration of tiered services to promote sustainable and accessible care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp id=\"_Toc472330566\"\u003e\u003cstrong\u003eFunding Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp id=\"_Toc472330568\"\u003eThis service evaluation was funded by Guys and St Thomas’ NHS Foundation Trust. The service evaluation was independently led by the corresponding author. \u0026nbsp;The funder had no role in the design of the evaluation, analysis, interpretation of data or the writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMOK: Conceptualization, data curation, formal analysis, methodology, original draft preparation; EP: project administration; data curation, original draft preparation, review and editing; SS: project administration; review and editing; DD, project administration; data curation, review and editing; OC: review and editing; RW: review and editing; AD: conceptualization, review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data presented are not publicly available due to fact that the data was collected as part of a clinical service. \u0026nbsp; Reasonable requests for the data can be made via the corresponding author but the release of the data will be subject to approval by the clinical service leads and the Quality Improvement and Patient Safety oversight committee.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eObesity Profile: short statistical commentary May 2023. 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BMJ Qual Saf 25:986\u0026ndash;992\u003c/li\u003e\n\u003cli\u003eStandard Evaluation Framework for Weight Management Interventions. \u003c/li\u003e\n\u003cli\u003eOffice for National Statistics (2022) Ethnic group, England and Wales: Census 2021. \u003c/li\u003e\n\u003cli\u003eMinistry of Housing, Communities \u0026amp; Local Government (2019) English indices of deprivation 2019. \u003c/li\u003e\n\u003cli\u003eLean M, Brosnahan N, McLoone P, et al (2013) Feasibility and indicative results from a 12-month low-energy liquid diet treatment and maintenance programme for severe obesity. Br J Gen Pract 63:e115\u0026ndash;e124\u003c/li\u003e\n\u003cli\u003eLeslie WS, Ford I, Sattar N, et al (2016) The Diabetes Remission Clinical Trial (DiRECT): protocol for a cluster randomised trial. BMC Fam Pract 17:20\u003c/li\u003e\n\u003cli\u003eNational Institute for Health and Care Excellence (2014) National Institute for Health and Care Excellence (2014) Clinical Guideline 189: Obesity: identification, assessment and management. \u003c/li\u003e\n\u003cli\u003eBlane DN, McLoone P, Morrison D, Macdonald S, O\u0026rsquo;Donnell CA (2017) Patient and practice characteristics predicting attendance and completion at a specialist weight management service in the UK: a cross-sectional study. BMJ Open 7:e018286\u003c/li\u003e\n\u003cli\u003eWeight loss and African\u0026ndash;American women: a systematic review of the behavioural weight loss intervention literature - Fitzgibbon - 2012 - Obesity Reviews - Wiley Online Library. https://onlinelibrary.wiley.com/doi/10.1111/j.1467-789X.2011.00945.x. Accessed 1 Jul 2025\u003c/li\u003e\n\u003cli\u003eDobbie LJ, Coelho C, Mgaieth F, et al (2024) Liraglutide 3.0 mg in the treatment of adults with obesity and prediabetes using real-world UK data: A clinical evaluation of a multi-ethnic population. Clin Obes 14:e12649\u003c/li\u003e\n\u003cli\u003eDavis KK, Tate DF, Lang W, Neiberg RH, Polzien K, Rickman AD, Erickson K, Jakicic JM (2015) Racial Differences in Weight Loss Among Adults in a Behavioral Weight Loss Intervention: Role of Diet and Physical Activity. https://doi.org/10.1123/jpah.2014-0243\u003c/li\u003e\n\u003cli\u003eMaynard MJ, Orighoye O, Apekey T, Simpson E, van Dijk M, Atherton E, Blackshaw J, Ells L (2023) Improving adult behavioural weight management services for diverse UK Black Caribbean and Black African ethnic groups: a qualitative study of insights from potential service users and service providers. Front Public Health 11:1239668\u003c/li\u003e\n\u003cli\u003eOdoms-Young A, Stanford FC, Palacios C, et al (2024) Culturally Tailored Dietary Interventions and Diet-Related Psychosocial Factors, Dietary Intake, Diet Quality, and Health Outcomes: An Evidence Scan. USDA Nutrition Evidence Systematic Review, Alexandria (VA)\u003c/li\u003e\n\u003cli\u003eTeke J, Bolarinwa OA, Nnyanzi LA, Giles EL, Ells L, Elliott S, Okeke SR, Okeke-Obayemi DO (2024) \u0026ldquo;For me, it is for longevity and making sure I am fit and around for my children\u0026rdquo;: exploring motivations and barriers for weight management among minoritised communities in Medway, England. BMC Public Health 24:796\u003c/li\u003e\n\u003cli\u003eCoe WH, Redmond L, Parisi JM, Bowie JV, Liu EY, Ng TY, Onyuka AMA, Cort M, Cheskin LJ (2017) Motivators, Barriers, and Facilitators to Weight Loss and Behavior Change Among African American Adults in Baltimore City: A Qualitative Analysis. J Natl Med Assoc 109:79\u0026ndash;85\u003c/li\u003e\n\u003cli\u003ePuhl RM (2023) Weight Stigma and Barriers to Effective Obesity Care. Gastroenterol Clin North Am 52:417\u0026ndash;428\u003c/li\u003e\n\u003cli\u003eRose L, Wood A, Gill T (2024) Gender differences in adherence and retention in Mediterranean diet interventions with a weight‐loss outcome: A systematic review and meta‐analysis. Obes Rev 25:e13824\u003c/li\u003e\n\u003cli\u003eAhern AL, Aveyard P, Boyland EJ, Halford JC, Jebb SA (2016) Inequalities in the uptake of weight management interventions in a pragmatic trial: an observational study in primary care. Br J Gen Pract 66:e258\u0026ndash;e263\u003c/li\u003e\n\u003cli\u003eSusanto A, Fuller NR, Hocking S, Markovic T, Gill T (2023) Motivations for participation in weight loss clinical trials. Clin Obes 13:e12604\u003c/li\u003e\n\u003cli\u003eElliott M, Gillison F, Barnett J (2020) Exploring the influences on men\u0026rsquo;s engagement with weight loss services: a qualitative study. BMC Public Health 20:249\u003c/li\u003e\n\u003cli\u003eNguyen HD, Chitturi S, Maple-Brown LJ (2016) Management of diabetes in Indigenous communities: lessons from the Australian Aboriginal population. Intern Med J 46:1252\u0026ndash;1259\u003c/li\u003e\n\u003cli\u003eHuntriss R, Haines M, Jones L, Mulligan D (2021) A service evaluation exploring the effectiveness of a locally commissioned tier 3 weight management programme offering face-to-face, telephone and digital dietetic support. Clin Obes 11:e12444\u003c/li\u003e\n\u003cli\u003eGarcia DO, Valdez LA, Aceves B, Bell ML, Humphrey K, Hingle M, McEwen M, Hooker SP (2019) A Gender- and Culturally Sensitive Weight Loss Intervention for Hispanic Men: Results From the \u003cem\u003eAnimo\u003c/em\u003e Pilot Randomized Controlled Trial. Health Educ Behav 46:763\u0026ndash;772\u003c/li\u003e\n\u003cli\u003eKatangwe-Chigamba T, Kantilal K, Hartley-Palmer J, Salisu-Olatunji SO, Seeley C, Naughton F, Chester R (2024) Diet and Physical Activity Interventions for People from Minority Ethnic Backgrounds in the UK: A Scoping Review Exploring Barriers, Enablers and Cultural Adaptations. J Racial Ethn Health Disparities. https://doi.org/10.1007/s40615-024-02112-y\u003c/li\u003e\n\u003cli\u003eSwancutt D, Tarrant M, Pinkney J (2019) How Group-Based Interventions Can Improve Services for People with Severe Obesity. Curr Obes Rep 8:333\u0026ndash;339\u003c/li\u003e\n\u003cli\u003eBuilding new health system action to reduce obesity: Audit findings of Integrated Care Board Forward Plans. Future Health\u003c/li\u003e\n\u003cli\u003eOverview | Overweight and obesity management | Guidance | NICE. https://www.nice.org.uk/guidance/ng246. Accessed 16 May 2025\u003c/li\u003e\n\u003cli\u003eWorld Obesity Federation Global Obesity Observatory. https://data.worldobesity.org/rankings/. Accessed 6 Feb 2025\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the supplementary files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-clinical-nutrition","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"ejcn","sideBox":"Learn more about [European Journal of Clinical Nutrition](http://www.nature.com/ejcn/)","snPcode":"41430","submissionUrl":"https://mts-ejcn.nature.com/cgi-bin/main.plex","title":"European Journal of Clinical Nutrition","twitterHandle":"@ejcneditor","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Obesity, weight management, behaviour change, process evaluation","lastPublishedDoi":"10.21203/rs.3.rs-7724834/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7724834/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Tier 3 weight and behavioural interventions are a core part of the national health service (NHS) model of obesity management in the United Kingdom. The aim of this study is to present a cohort profile and process evaluation of an adult multidisciplinary weight management service in a diverse UK population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A retrospective cohort study of the 12-month South-East London Healthy Living Programme is reported. \u0026nbsp;The programme included a diet and lifestyle behaviour change or a total meal replacement plus diet and lifestyle intervention. Community-based group sessions were delivered monthly either virtually or face-to-face. Sociodemographic, clinical, anthropometric, and behavioural patient data were collected at baseline. Process outcomes including referrals, engagement and programme completion rates are reported. Data analyses were conducted using independent t-tests for sociodemographic characteristics and multivariate logistic regression was performed to determine predictors of programme completion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: 4,499 individuals (47 ± 13.5 years, 78% female, 36% Black African and Caribbean, 49% living in areas of high deprivation) were referred to the service between April 2018-March 2023. Early engagement was 67% and 61% for session 1 and 2 respectively and engagement declined to \u0026lt;50% by session 4. Programme completion rate was 43% (n\u003cem\u003e=\u003c/em\u003e904). Females were more likely to complete (OR 1.509, p= 0.018), whereas people of Black African and Caribbean ethnicity (OR 0.074, p=0.023), and participants with lower relational support (OR 0.701, p=0.045) predicted lower completion rates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Programme completion was below 50% which is consistent with the evidence on Tier 3 interventions. Males and people of ethnic minority ethnic heritage were less likely to complete the programme. While early engagement was relatively high, it declined substantially across the programme. Efforts to increase engagement particularly among ethnic minorities and males are warranted.\u003c/p\u003e","manuscriptTitle":"A cohort profile and process evaluation of an adult multidisciplinary behavioural and weight management service in a diverse UK population","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-30 16:22:23","doi":"10.21203/rs.3.rs-7724834/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"This content is not available.","date":"2026-05-05T12:03:19+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2026-04-20T08:59:10+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2026-01-26T18:59:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-29T11:41:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-29T11:35:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Clinical Nutrition","date":"2025-09-26T21:39:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-clinical-nutrition","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"ejcn","sideBox":"Learn more about [European Journal of Clinical Nutrition](http://www.nature.com/ejcn/)","snPcode":"41430","submissionUrl":"https://mts-ejcn.nature.com/cgi-bin/main.plex","title":"European Journal of Clinical Nutrition","twitterHandle":"@ejcneditor","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"39f1c61c-1c54-404c-86c6-48776ecc9c12","owner":[],"postedDate":"January 30th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"This content is not available.","date":"2026-05-05T12:03:19+00:00","index":1,"fulltext":"This content is not available."}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":61777006,"name":"Health sciences/Health care/Weight management"},{"id":61777007,"name":"Health sciences/Health care/Nutrition"}],"tags":[],"updatedAt":"2026-01-30T16:22:23+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-30 16:22:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7724834","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7724834","identity":"rs-7724834","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}