Memorandum by Professor Iain Broom, Counterweight
(OB 23)
INTRODUCTION
1. We would like to submit the following
information on behalf of the Counterweight Project Team[1]The
Counterweight project is a multi-centre obesity project being
conducted in 80 general practices in the UK. The centres are Aberdeen,
Bath, Birmingham, Glasgow, Hammersmith, Leeds and Luton.
2. All of the information detailed below
is original data generated by the project. It is important to
note that this work has been presented at academic conferences
and journals. The Counterweight project has evidence to submit
under the subject headings of "What can be done about it?",
"Are institutional structures in place to deliver an improvement?"
and "Recommendations for national and local strategy".
WHAT CAN
BE DONE
ABOUT IT:
Counterweight Programme Model
3. A national group of consultant physicians
who specialise in obesity management recognised the need to tackle
obesity in primary care. As a result, the idea for a national
obesity pilot in primary care was developed. Roche Products Ltd.
agreed to support the initiative, and the Counterweight Project
Team* was formed in July 1999. The overall aim is to improve the
management of obesity in primary care, thus reducing the disease
burden of obesity in the population. The project has a number
of objectives:
— To collect national anonymised obesity
data from primary care registers
— To develop treatment models for obesity
in primary care
— To facilitate the implementation
of these treatment models into primary care
— To evaluate the impact of these models
of care, and to inform future practice
4. Specialist obesity dieticians conduct
audit, provide staff training, clinical support and facilitate
the implementation of protocols in each practice. Patient screening
and treatment guidelines have been developed to provide structure
and guidance for practices in the management of obese patients.
Clinicians are encouraged to see patients for six appointments
of 10-20 minutes over a three-month period and at least quarterly
thereafter. An integrated package of patient education materials
have been developed to support the intervention programme. These
leaflets cover a wide range of topics from healthy eating and
low fat snacks to physical activity and behaviour change. The
materials have a reading age of 12 years or less, and are designed
to be used selectively and when appropriate.
5. There are two major lifestyle approaches:
goal setting or a more structured prescribed eating plan based
on 500-600 kcal energy deficit (Frost et al 1991; Leslie
et al 2002). These approaches are designed to be used independently
based on the needs and preferences of the patient. A structure
for a three-month group programme for patients has been developed
and is offered as a treatment option for practices. There is considerable
evidence to support the use of such lifestyle approaches, both
individual and group formats, in the management of obesity (SIGN
1996; RCGP 1998; NIH 1998). The usefulness of these materials
and approaches will be evaluated by both clinicians and patients.
6. Evaluation will include re-audit of practice
outcomes following two years of intervention to assess changes
in clinician knowledge, attitude, perceived confidence and willingness
to treat obesity, as well as changes in practice approaches to
obesity management and weight screening rates. The primary end
point for the patient intervention programme will be the percentage
of patients achieving 5% and 10% weight loss. Secondary end
points include changes in obesity-related co-morbidities including
changes in blood pressure, lipids, diabetes control and medication
usage. The Counterweight Programme will provide pivotal data on
the feasibility and effectiveness of a structured approach to
managing obese patients in primary care.
7. Seventy-three practices have been audited
to asses current approaches to obesity management and the health
and resource implications of obesity (see section "Are institutional
structures in place to deliver an improvement?"). To date
48 practices have completed the training programme and 39 practices
are currently providing a structured approach for managing obese
patients. Over 900 obese patients have been recruited nationally
into the intervention programme. The preliminary results from
the intervention programme indicate that clinically beneficial
weight loss can be achieved in high risk obese patients in primary
care. We expect to continue recruiting patients till the end of
2004 and will await the final results before making any conclusions
about the efficacy of the Counterweight approach. These results
will be published in relevant medical journals.
ARE INSTITUTIONAL
STRUCTURES IN
PLACE TO
DELIVER AN
IMPROVEMENT:
8. An audit undertaken in 73 practices nationally
as part of the Counterweight project has provided data on how
general practitioners (GPs) and practice nurses (PNs) are currently
managing obese patients. This includes self-reported practice
and actual practice as determined by audit of medical records.
Data presented here is based on the first 40 practices. Further
analysis of the audit data has shown important health and resource
implications of obesity; this evidence is not presented here however,
as it is awaiting presentation at the European Congress on Obesity
in Helsinki in May 2003.
9. Clinician self-reported approaches
to managing obese patients: 141 GPs and 66 PNs from 40 Counterweight
practices participated in structured interviews in which clinicians
self-reported their approaches to obesity management. 83% of GPs
and 97% of PNs reported that they would raise weight as an issue
with obese patients (P<0.01). Few GPs (15%) reported spending
up to 10 minutes in a consultation discussing weight-related issues,
compared to PNs (76%; P<0.00001). Approaches commonly reported
by GPs were a referral to a PN (78%), dietician (58%), exercise
referral scheme (50%) and commercial weight loss agency (41%).
Similarly PNs referred to a dietician (59% ; P=0.90) or exercise
scheme (56%; P=0.44), but PNs referred more often to commercial
agencies (68%; P<0.001). Three practices (7.5%) held specific
obesity/dietetic clinics, all other practices saw patients opportunistically
at existing clinics/appointments. Lifestyle management in primary
care is based on brief opportunistic intervention undertaken mainly
by PNs. There appears to be a reliance on external sources of
weight management support (Abstract presented at Diabetes UK and
published in Diabetic Medicine, Reckless et al 2003).
10. Clinician knowledge, attitudes and
confidence in managing obese patients: We examined by questionnaire
the knowledge, attitude, confidence and willingness of primary
care staff to treat obesity. 180 General Practitioners (GPs) &
96 Practice Nurses (PNs) participate in the Counterweight Programme,
a seven-centre, 40-practice obesity project. The questionnaire
was returned by 64% of GPs (46% male) and 73% of PNs (all female).
Knowledge scores were poor for GPs and PNs (36.1%: 38.7%; P=0.27).
While both groups recognised medical consequences of obesity and
central fat distribution, knowledge was poor for practical nutrition
and physical activity recommendations. GPs and PNs had relatively
higher scores for attitude (59.4/80: 64.3/80)(GPs<PNs; P<0.001),
confidence (149/225; 147/225; P=0.77) and willingness to treat
scores (8.0/10; 8.6/10)(GP<PN; P<0.05). Females had more
positive attitudes irrespective of clinician type (P<0.05).
Gender, clinician type or years in practice did not influence
other scores. Limited basic nutrition and physical activity knowledge
may limit GP and PN ability to effectively promote lifestyle change.
PNs were more optimistic about lifestyle management. (Abstract
presented at Diabetes UK and published in Diabetic Medicine, Reckless
et al 2003).
11. Audit of obese patient records in
primary care: Medical records were reviewed for 100 randomly
selected obese patients (BMI> 30) from 40 UK practices (n=4,000)
in seven-centre Counterweight programme. Data were collected on
practice-based diet counselling, dietetic or obesity centre referrals,
and anti-obesity medication. Recorded over 18 months were practice-based
diet counselling (20%), dietetic (4%) and obesity centre (1%)
referrals, and any anti-obesity medication (2%). Major obesity-related
co-morbidities (diabetes, dyslipidaemia, hypertension, coronory
heart disease) were independent multi-variate predictors of counselling
(P<0.001) and dietetic referral (P<0.001) as was higher
BMI (P<0.05 for counselling, P<0.001 dietic referral). Patients
referred to obesity centres were younger (42.3: 49.6 yr; P<0.01)
and more obese (BMI 39.8: 34.4;P<0.01) than those not referred.
Patients prescribed anti-obesity medication were more likely to
be female (P<0.01), younger (P=0.07) and more obese (P<0.01)
but with similar co-morbidity prevalence (P=0.98) than those not
prescribed. Practice-based counselling is the most common intervention.
Obesity severity and co-morbidities predict practice-based diet
counselling and dietetic referral. However co-morbidity prevalence
did not influence referrals to obesity centres or the prescribing
of anti-obesity medication. (Abstract presented at Diabetes UK
and published in Diabetic Medicine, Laws et al 2003).
12. Practice Nurses (PNs) provide weight
management screening and advice, an essential component of diabetes
management. Little is known about level of screening and accessibility
to necessary tools. Recording of weight/BMI was assessed by searching
computerised medical records (n=182, 474) in 40 Counterweight
practices. Availability of weighing scales and height measures
were assessed along with source and accessibility of patient literature.
Women were more likely than men to have a weight (69.2%; 57.0%;
P<0.0001) or BMI (70.6%; 57.7%; P<0.0001) ever recorded.
Equipment found in counsulting rooms was: weighing scales (96
per cent), height measures (89%), and accessible literature (36%).
65 leaflet types were found (mean 3.8 leaflets/practice, range
zero-eight). Literature was from food or pharmaceutical industries
(37%), local sources (26%) and Health Education Authority (18.5%),
with small proportions from Health Education Board Scotland (6%),
popular press (5%), Diabetes UK (1.5%), World Cancer Research
Fund (1.5%), British Hypertension Society (1.5%) and unknown sources
(3%). An improvement in recording of weight and BMI is a priority
to meet targets for diabetes prevention and control. Patient literature
was variable in source, accessibility and quality. (Abstract presented
at Diabetes UK and published in Diabetic Medicine, Ross et
al 2003).
RECOMMENDATION FOR
NATIONAL AND
LOCAL STRATEGY
13. Prioritisation of obesity by Primary
Care Trusts: Programme outcomes need to be determined before strategic
recommendations can be made and the usefulness of this model.
An important element of the programme is that practices are not
provided with additional funding for nurse time and implement
the model within existing practice resources. Thirty-nine practices
are currently recruiting patients into the programme; however
nine practices out of the 48 who have completed the training programme
have been unable to implement the Counterweight project. The main
barriers to continued provision of a structured approach to obesity
management have been competing priorities and lack of dedicated
nurse time. Many practices however claim to be prioritising nurse
and GP time to meet the national service frameworks for conditions
such as diabetes and coronary heart disease. Ironically many of
these competing disease areas can be directly improved by obesity
management. The provision of dedicated funds may be required for
obesity to be more effectively tackled in primary care as has
happened in smoking cessation. It may be unrealistic to expect
practices to manage obesity as part of existing funding for disease
areas covered by national service frameworks. The Counterweight
project team will be undertaking further qualitative research
to examine barriers to practice involvement with obesity management.
The aim will be to publish these results in relevant academic
journals to use the findings to guide future strategies in primary
care.
April 2003
REFERENCES
Frost, G, Masters, K, King, C, Kelly, M, Hasan,
U, Heavens, P, White, R and Stanford, J (1991): A new method of
energy prescription to improve weight loss. Journal of Human
Nutrition and Dietetics, 4, 369-374.
Leslie, WS, Lean, MEJ, Baillie HM and Hankey,
CR (2002): Weight management: a comparison of existing dietary
approached in a work-site setting. Int J Obes, 26,
1469-1475.
Scottish Intercollegiate Guidelines Network
(1996): Obesity in Scotland: Integrating Prevention with Weight
Management. Scottish Intercollegial Guidelines Network.
The Royal College of Physicians of London (1998):
Clinical Management of Overweight and Obese Patients, with
particular reference to the use of drugs, RCGP, London.
National Heart, Lung and Blood Institute (1998):
The Practical Guide. Identification, Evaluation and Treatment
of Overweight and Obesity in Adults. National Institute of
Health.
Reckless, JPD on behalf of the Counterweight
Project Team. How does the primary care team intend to tackle
the obesity epidemic in their high risk patients? Diabetic
Medicine, 20, 103.
Reckless, JPD on behalf of the Counterweight
Project Team. Knowlege, attitudes and confidence of general practitioners
and practice nurses in lifestyle management. Diabetic Medicine,
20, 77.
Laws, RA on behalf of the Counterweight Project
Team. How are general practitioners (GPs) and practice nurses
(PNs) currently managing obese patients? Diabetic Medicine,
20, 103.
Ross, HM on behalf of the Counterweight Project
Team. Weight/BMI screening and availability of patient education
literature in general practice. Diabetic Medicine, 20,
77.
APPENDIX 1
Counterweight Project Team:
a: Weight Management Adviser (WMA),
b: Principal Investigator (PI),
c: Research Nurse,
d: Counterweight Project Co-ordinator,
e: Data and statistical analyists.
1: Aberdeen, 2: Bath, 3: Birmingham, 4:
Glasgow, 5: Hammersmith, 6: Leeds, 7: Luton.
Name, Qualifications and Institutional affiliation
of Authors:
1a: Ms Helen Gibbs, PG Dip Diet SRD, Clinical
Research Unit, Grampian University Hospitals Trust.
1b: Professor J Broom, MBChB, MRCP (Glas),
FRCPath, Consultant in Clinical Biochemistry & Metabolic Medicine,
Research & Development, Grampian University Hospitals Trust.
1c: Mrs Jenny Brown, BA (Hons) CNS, Clinical
Research Unit, Grampian University Hospitals Trust.
2a: Ms Rachel Laws, MSc (Nutrition &
Dietetics), SRD, Nutritition & Dietetic Service, Royal United
Hospital, Bath.
2b: Dr John Reckless, MD FRCP, Consultant
Endocrinologist and Hon. Reader in Medicine & Biochemistry,
University of Bath, Royal United Hospital, Bath.
3a: Ms Paula Noble, PGDipDiet, PG Dip (management
studies), SRD, Birmingham Heartlands & Solihull NHS Trust.
3b: Dr Sudhesh Kumar, MD FRCP, Reader in
Human Metabolism, Birmingham University, Heartlands & Solihull
NHS Trust.
4a: Ms Louise McCombie, PGDipDiet, SRD,
Department of Human Nutrition, Glasgow Royal Infirmary.
4b: Professor Mike Lean, MA, MD, FRCP, FRCPS,
Department of Human Nutrition, Glasgow Royal Infirmary.
5a: Ms Felicity Lyons, PGDipDiet, SRD, Nutrition
& Dietetic Research Group, Hammersmith Hospitals NHS Trust.
5b: Dr Gary Frost, PhD SRD, Head of Nutrition
& Dietetic Service, SRD & Honorary Reader in Nutrition,
Hammersmith Hospitals NHS Trust.
6a: Marney Quinn, BSc (Nutrition & Dietetics),
SRD, Leeds General Infirmary, Leeds NHS Trust.
6b: Dr Julian H Barth, MD FRCP FRCPath,
Leeds General Infirmary, Leeds NHS Trust.
7a: Ms Sarah Haynes, PGDipDiet, PGDipHealthSci,
SRD, Centre for Obesity Research, Luton and Dunstable Hospital
NHS Trust.
7b: Dr Nick Finer, FRCP, Consultant Endocrinologist,
Centre for Obesity Research, Luton and Dunstable Hospital NHS
Trust.
7c: Hazel Ross, PGDipDiet, SRD, Roche Products
Ltd.
7d: Professor David Hole, MSc FFPHM, Public
Health and Health Policy, Division of Community Based Sciences,
University of Glasgow.
7e: Dr Ali Montazeri, MPH, PhD FFPHM, Public
Health and Health Policy, Division of Community Based Sciences,
University of Glasgow.
1 Not printed. Back
|
