Further memorandum by Professor Iain Broom,
Counterweight (OB 85)
INTRODUCTION
We would like to provide the following revised
submission to that submitted in April following the initial call
for evidence. The paper gives an overview of some of the key priorities
that we believe need to be out in place and goes on to give the
Committee evidence from the Counterweight programme, including
updated research data from the programme not previously available.
COUNTERWEIGHT RECOMMENDATIONS
The Government, and specifically the Department
of Health, needs to recognise the major threat to the nation's
health posed by obesity and urgently develop and implement a national
strategy to tackle it in the NHS.
The Counterweight Programme, established in
2000 is an example of an obesity programme which could be developed
for use in primary care on national scale. Counterweight is the
only evaluated national evidence-based intervention programme
in the UK supported with training materials for clinicians and
patients. Preliminary findings demonstrate clinically beneficial
weight loss can be achieved in patients attending for weight management.
Government funding is required if obesity is to be more effectively
tackled in primary care. Funding should support training three
main areas: Training of GPs and Practice Nurses, provision of
patient education leaflets and additional nursing time required
with patients.
The Government should ensure that primary care
plays a central role in weight management and where appropriate
sets targets and incentives.
The burden of obesity poses a huge threat to
the NHS, particularly in terms of clinical time and the costs
of drugs to treat the consequences of obesity. The increasing
prevalence of obesity dictates that primary care must be at the
centre of a strategic approach. Specialist clinics in hospitals
cannot cope and have huge waiting lists. Targets should be set
for screening of patients and delivery of weight management in
general practice.
PCT endorsement for a structured approach to
weight management so that GP practices have support to prioritise
this work. Ideally there would be a system of reimbursement for
practices who implement a weight management programme. The initial
financial outlay by the NHS will be off-set by savings in resources
through prevention of increasing numbers of obese patients.
A structured model for weight management should
be available to patients across the UK in all practices. There
are three key components:
— Practice strategy for weight management
A practice strategy should be implemented and
roles and responsibilities agreed involving all parties involved
in the care of the obese population. GPs, Practice Nurses, Practice
Managers and other key stakeholders should all be involved. Actual
treatments and monitoring will depend on local circumstances.
— Structured model for screening and
patient selection
Appropriate equipment such as weighing scales,
height sticks, waist circumference measuring tapes and blood pressure
tapes must be available in practices. This is not in place at
present. All patients should have their weight measured and recorded
on registration.
— Structured model for intervention
Structured treatment algorithm and structured
plan for follow-up appointments
— Patient education materials
Training course delivered on the model and then
supported in practice over a 6/12 period by an obesity specialist
dietitian.
— Recommendation for practice-based
review of outcomes
Clinicians could use practice-based IT system
to review key data related to obesity and audit clinical outcomes.
eg Number of patients weighed, BMI, screening for hypertension
and other conditions in patients who are obese.
THE COUNTERWEIGHT
PROJECT
The Counterweight project is a multi-centred,
dietitian trained, practice nurse led obesity project being conducted
in 80 general practices in seven regions of the UK; Aberdeen,
Bath, Birmingham, Glasgow, Hammersmith, Leeds and Luton.
The Counterweight project is able to provide
evidence to assist the Committee in answering three questions
posed in the initial al call for evidence:
— "What can be done about it?"
— "Are institutional structures
in place to deliver an improvement?"
— "Recommendations for national
and local strategy".
1. What can be done about it?—Counterweight
Programme Model
Using an evidence-based, structured approach
to weight management, clinically beneficial weight loss can be
achieved as demonstrated by preliminary data from the Counterweight
Programme. Almost half of the patients completing the programme
achieved and maintained <5% weight loss at 12 months.
Support to facilitate the implementation of
a weight management programme, following initial training, is
essential to ensure the practicalities of providing weight management
can be established into routine clinical care.
A national group of consultant physicians who
specialise in obesity management recognised the need to tackle
obesity in primary care in 1999. 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 (see Appendix One ) was formed. The overall aim is to improve
the management of obesity in primary care.
The project has a number of objectives:
— To collect national anonymised obesity
data from primary care registers
— To develop a treatment model for
obesity in primary care
— To facilitate the implementation
of this treatment model into primary care
— To evaluate the impact of these models
of care, and lead future practice
Specialist obesity dietitians conducted a review
of baseline medical practice and then provided staff training,
clinical support and facilitated the implementation of protocols.
Patient screening and evidence-based treatment guidelines have
been developed to provide a structured pathway 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 has been developed to support the
intervention programme.
There are two major lifestyle approaches: goal
setting or a more prescriptive 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 three-month group
programme for patients has been developed as another treatment
option. 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, NHS NCCAHTA
2003).
Preliminary data from the first 1300 patients
recruited into the intervention programme shows that 44% of patients
who complete planned intervention over three to six months, maintain
a loss of 5% at one year. Studies have shown that modest weight
loss of 5% leads to significant health benefits. Patient recruitment
will continue until end of 2004.
The Counterweight Programme will provide pivotal
data on the feasibility and effectiveness of a structured approach
to managing obese patients in primary care.
2. Are institutional structures in place
to deliver an improvement?
While there is little evidence of the extensive
scientific knowledge relating to obesity being transferred into
appropriate action in the Primary Care setting it is obvious that
GPs and Practice Nurses are already spending NHS time and resource
on the obese population.
70% of the population has a weight or BMI level
recorded in general practice records and GPs and Practice Nurses
are currently reporting that obesity would be an issue they would
raise where appropriate. However, intervention is likely to be
brief, unstructured and usually given by clinicians with limited
knowledge of the subject.
Of note is the focus on treating consequences
of obesity rather than attempting to deal with the underlying
problem which is a factor in numerous medical conditions and has
a clear impact on the total prescribing cost of Primary Care.
A review of baseline medical practice undertaken
in 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 a review of medical records. Data presented
here is based on the first 40 practices.
Clinician self-reported approaches to managing
obese patients:
Weight management appears to be based on brief
opportunistic intervention undertaken mainly by PNs. While clinicians
report the use of external sources of support, few patients are
referred onwards with practice-based counselling being the most
common intervention. 141 GPs & 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 in issue
with obese patients opportunistically. (P<0.01). Few GPs (15%)
reported spending up to 10 minutes in a consultation discussing
weight-related issues, compared to PNs (76%; P<0.0001).
Clinician knowledge, attitudes and confidence
in managing obese patients: GPs and Practice Nurses were asked
to complete a questionnaire about knowledge, attitude, confidence
and willingness of primary care staff to treat obesity. The questionnaire
was returned by 64% of GPs and 72% of PNs. 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. In comparison GPs and PNs had relatively higher
scores for attitude, confidence and willingness to treat scores.
Limited basic nutrition and physical activity knowledge may limit
GP and PN ability to effectively promote lifestyle change.
Baseline review of obese patient records in
primary care: Recording of weight/BMI was assessed by searching
computerised medical records (n= 182, 474) in 40 practices. 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. Availability
of weighing scales and height measures were assessed along with
source and accessibility of patient literature. Equipment found
in consulting rooms was: weighing scales (96%), height measures
(89%), and accessible literature (36%). 65 leaflet types were
found (mean 3.8 leaflets/practice, range 0-8). 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 and improved access to validated
patient education literature is a high priority for primary care.
The prevalence of obesity related co-morbidites,
prescribing burden and resource usage between obese (BMI>30)
and age and sex matched normal weight controls (BMI 18.5 ¸
<25.0). Obese patients were significantly more likely to have
a recorded diagnosis of type 2 diabetes (12%:3%), hypertension
(24%:12%), dyslipidaemia (8%:4%), vascular disease (10%:6%), back
pain (16%:10%), arthritis (7%:4%) & gallstones (two percent:0.2%),
all p<0.001. A higher percentage of obese compared to normal
weight patients were prescribed at least one drug in the following
disease categories: gastrointestinal (25:17), cardiovascular (38:21),
anti-hypertensives (29:14), lipid regulators (12:5), endocrine
(28:18) diabetes drugs (11:4), musculoskeletal & joint disease
(31:22), central nervous system (44:33) and infections (43:35);
all p<0.001, anti-depressants (16:13; p<0.05), respiratory
(22:18; p<0.05) & skin (24:19; p<0.01). Significantly
more obese patients had four or more GP visits recorded over the
18 month review period compared with the normal weight subjects.
3. Recommendations for national and
local strategy
The NHS can no longer afford NOT to address
the problem of obesity. Primary Care Trusts need to have access
and resource available to undertake training and implementation
of an evaluated effective evidence based programme which would
lead to beneficial outcomes not just in relation to weight loss
but also in reducing the ongoing resource implications associated
with increasing levels of obesity.
The impact of obesity pressurizing NHS resources
demonstrates that the NHS can no longer afford NOT to address
the problem. Counterweight showed not only that clinically beneficial
weight loss can be achieved in patients attending for weight management
but that weight gain continues where patients default from treatment.
Weight management strategy needs to address the lack of structure
identified in the baseline review by using the model developed
and evaluated by the Counterweight programme. Primary Care Trusts
need to have access and resource available to undertake the training
which led to the levels of beneficial outcomes seen in Counterweight.
In the Counterweight pilot programme practices
were not provided with additional funding for nurse time and they
are implementing the model within existing practice resources.
The provision of dedicated funds is required for dietetic time
for training, for nurse time with patients and for patient education
literature for obesity to be more effectively tackled in primary
care. It is unrealistic to expect practices to manage obesity
as part of existing funding for disease areas covered by national
service frameworks.
December 2003
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