Empowering primary care to tackle the obesity epidemic: the Counterweight Programme

Subjects: Obese patients (body mass index greater than or equal to30 kg/m2) or BMIgreater than or equal to28 kg/m2 with obesity-related comorbidities in 80 general practices.

Intervention: The model consists of four phases: (1) audit and project development, (2) practice training and support, (3) nurse-led patient intervention, and (4) evaluation. The intervention programme used evidence-based pathways, which included strategies to empower clinicians and patients. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation.

Main outcome measures: Proportion of practices trained and recruiting patients, and weight change at 12 months.

Results: By March 2004, 58 of the 62 (93.5%) intervention practices had been trained, 47 (75.8%) practices were active in implementing the model and 1549 patients had been recruited. At 12 months, 33% of patients achieved a clinically meaningful weight loss of 5% or more. A total of 49% of patients were classed as 'completers' in that they attended the requisite number of appointments in 3, 6 and 12 months. 'Completers' achieved more successful weight loss with 40% achieving a weight loss of 5% or more at 12 months.

Conclusion: The Counterweight programme provides a promising model to improve the management of obesity in primary care.

Sponsorship: Educational grant-in-aid from Roche Products Ltd.

A new evidence-based approach to weight management in primary care: the Counterweight Programme

Background/Aims Obesity has become a global epidemic, and a major preventable cause of morbidity and mortality. Management strategies and treatment protocols are however poorly developed and evaluated. The aim of the Counterweight Programme is to develop an evidence-based model for the management of obesity in primary care.

Methods The Counterweight Programme is based on the theoretical model of Evidence-Based Quality Assessment aimed at improving the management of obese adults (18–75 years) in primary care. The model consists of four phases: (1) practice audit and needs assessment, (2) practice support and training, (3) practice nurse-led patient intervention, and (4) evaluation. Patient intervention consisted of screening and treatment pathways incorporating evidence-based approaches, including patient-centred goal setting, prescribed eating plans, a group programme, physical activity and behavioural approaches, anti-obesity medication and weight maintenance strategies. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation. Eighty practices were recruited of which 18 practices were randomized to act as controls and receive deferred intervention 2 years after the initial audit.

Results By February 2004, 58 of the 62 (93.5%) intervention practices had been trained to run the intervention programme, 47 (75.8%) practices were active in implementing the model and 1256 patients had been recruited (74% female, 26% male, mean age 50.6 years, SD 14). At baseline, 75% of patients had at one or more co-morbidity, and the mean body mass index (BMI) was 36.9 kg/m2 (SD 5.4). Of the 1256 patients recruited, 91% received one of the core lifestyle interventions in the first 12 months. For all patients followed up at 12 months, 34% achieved a clinical meaningful weight loss of 5% or more. A total of 51% of patients were classed as compliant in that they attended the required level of appointments in 3, 6, and 12 months. For fully compliant patients, weight loss improved with 43% achieving a weight loss of 5% or more at 12 months.

Conclusion The Counterweight Programme is an evidence-based weight management model which is feasible to implement in primary care.

An efficacy trial of brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial)

Background
Lifestyle risk factors, in particular smoking, nutrition, alcohol consumption and physical inactivity (SNAP) are the main behavioural risk factors for chronic disease. Primary health care (PHC) has been shown to be an effective setting to address lifestyle risk factors at the individual level. However much of the focus of research to date has been in general practice. Relatively little attention has been paid to the role of nurses working in the PHC setting. Community health nurses are well placed to provide lifestyle intervention as they often see clients in their own homes over an extended period of time, providing the opportunity to offer intervention and enhance motivation through repeated contacts. The overall aim of this study is to evaluate the impact of a brief lifestyle intervention delivered by community nurses in routine practice on changes in clients' SNAP risk factors.

Methods/Design
The trial uses a quasi-experimental design involving four generalist community nursing services in NSW Australia. Services have been randomly allocated to an 'early intervention' group or 'late intervention' (comparison) group. 'Early intervention' sites are provided with training and support for nurses in identifying and offering brief lifestyle intervention for clients during routine consultations. 'Late intervention site' provide usual care and will be offered the study intervention following the final data collection point. A total of 720 generalist community nursing clients will be recruited at the time of referral from participating sites. Data collection consists of 1) telephone surveys with clients at baseline, three months and six months to examine change in SNAP risk factors and readiness to change 2) nurse survey at baseline, six and 12 months to examine changes in nurse confidence, attitudes and practices in the assessment and management of SNAP risk factors 3) semi-structured interviews/focus with nurses, managers and clients in 'early intervention' sites to explore the feasibility, acceptability and sustainability of the intervention.

Discussion
The study will provide evidence about the effectiveness and feasibility of brief lifestyle interventions delivered by generalist community nurses as part of routine practice. This will inform future community nursing practice and PHC policy.

Evaluation of the Counterweight Programme for obesity management in primary care: a starting point for continuous improvement

Background Evaluation for obesity management in primary care is limited, and successful outcomes are from intensive clinical trials in hospital settings.

Aim To determine to what extent measures of success seen in intensive clinical trials can be achieved in routine primary care. Primary outcome measures were weight change and percentage of patients achieving ≤5% loss at 12 and 24 months.

Design of study Prospective evaluation of a new continuous improvement model for weight management in primary care.

Setting Primary care, UK.

Method Primary care practice nurses from 65 UK general practices delivered interventions to 1906 patients with body mass index (BMI) ≥30 kg/m2 or ≥28 kg/m2 with obesity-related comorbidities.

Results Mean baseline weight was 101.2 kg (BMI 37.1 kg/m2); 25% of patients had BMI ≥40 kg/m2 and 74% had ≥1 major obesity-related comorbidity. At final data capture 1419 patients were in the programme for ≥12 months, and 825 for ≥24 months. Mean weight change in those who attended and had data at 12 months (n = 642) was −3.0 kg (95% CI = −3.5 to −2.4 kg) and at 24 months (n = 357) was −2.3 kg (95% CI = −3.2 to −1.4 kg). Among attenders at specific time-points, 30.7% had maintained weight loss of ≥5% at 12 months, and 31.9% at 24 months. A total of 761 (54%) of all 1419 patients who had been enrolled in the programme for >12 months provided data at or beyond 12 months.

Conclusion This intervention achieves and maintains clinically valuable weight loss within routine primary care.