Big Story | Obesity

Overview of Obesity Management in Primary Care

Maria Dow
Counterweight Specialist, Counterweight Project Team

Introduction
Obesity is a chronic, progressive, and relapsing disease, defined as having a body mass index (BMI) 30kg/m2. The health risk associated with excess body fat can also be measured using waist circumference measurements. A measure of 102cm and 88cm in Caucasian, and 90cm and 80cm in Asian men and women respectively, indicate significant health risk. Over the past two decades the prevalence of obesity has trebled, with approximately a quarter of adults in the UK obese.1, 2 It is further predicted that 40 per cent of the population could be obese by 2025 and 60 per cent by 2050.3 Obesity is the primary aetiological factor in the development of many chronic diseases such as diabetes, hypertension, coronary heart disease (CHD) and cardiovascular disease (CVD)4, 5 and has a negative impact on patients quality of life.6 The treatment of obesity has huge implications for both public health and health service expenditure. The projected cost of obesity to the NHS could double to 10 billion a year by 2050. The wider cost to employers and the economy will be much greater and is estimated at approximately 50 billion at todays prices.3

Guidelines
Clinical guidelines for obesity in primary care have been published in the UK. The Scottish Intercollegiate Guidelines Network (SIGN) recently published their reviewed guidelines on the Management of Obesity.7 Most health boards and primary care trusts (PCTs) will have a well established National Service Framework (NSF) to manage CHD,8 and a delivery strategy for the diabetes NSF9 in which weight management is a component. In 2004, the Department of Health published its White Paper Choosing health (2004): Making healthy choices easier, providing commitments for action on obesity.10 The Scottish Government produced their own action plan Healthy Eating Active Living (HEAL) to improve diet, and increase physical activity.11 The National Institute for Clinical Excellence (NICE)12 produced the first national guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children in England and Wales. The aim of this guidance was to stem the rising prevalence of obesity and diseases associated with it, and increase the effectiveness of interventions to prevent overweight and obesity. It aims to improve the care provided to adults and children with obesity, particularly in primary care. These recommendations, like SIGN, are based on the best available evidence of effectiveness, including cost effectiveness and provide recommendations on the clinical management of overweight and obesity in both NHS and non NHS settings. The NICE guidelines support the implementation of the

Choosing Health White Paper in England,13 Designed for Life in Wales,14 the revised GP contract,15 and the existing NSFs. The clinical management of obesity cannot be viewed in isolation from the environment in which people live.12 A comprehensive and integrative primary care-led approach to weight management is possible, but needs a shift of resources, organisation, training and attitudes in order to maximise its potential impact.16 The 2004 Wanless Report Securing Good Health for the Whole Population17 also stressed that a substantial change will be needed to produce the reductions in preventable diseases such as obesity that will lead to the greatest reductions in future healthcare costs, recommending a more effective delivery framework for health services providers. The way in which general practice is reimbursed for patient care changed in 2004 with the renegotiation of the General Medical Services (GMS) contract, the Quality and Outcomes Framework (QOF). Practitioners aim to achieve points consequent to treating patients for particular conditions, which are weighted according to Government priority. Unfortunately, the treatment of obesity has not been recognised to a great degree within QOF, in which eight out of a total of 1000 points are awarded for an obesity register, and recording a BMI 30 kg/m2. In practice this provides little incentive for primary care to prioritise weight management delivery and achieve the aim of the NICE guideline to stem the rising prevalence of obesity and associated diseases. There are a further 177 QOF points, influenced by providing appropriate advice and treatment

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for weight management for the management of cholesterol, hypertension, CHD secondary prevention, diabetes and kidney disease. These patients with pre-existing obesity related disease would benefit from effective evidence-based weight management interventions to improve disease outcomes. Many practitioners prioritise the treatment of patients with disease secondary to obesity yet do not consider treating obesity. Research into primary care management in the UK, however, shows that 55 per cent of respondents believe obesity is a top priority, yet fewer than half have been involved in setting up weight management clinics. A Dr Foster report in 2005 found the majority of general practices (69%) had not established weight management clinics.18 Primary care remains the publics preferred source of food and health information.19 Over three quarters of the population attend general practice over the course of a year,20 which presents primary care practitioners with an opportunity for obesity management. Many General Practitioners (GPs) are concerned, however, following the publication of the NICE guidelines about the expectation of primary care in future obesity management, including fear of a fundamentally societal problem being foisted on general practice.21 Despite the publication of these clinical guidelines for obesity management and related disease there is little evidence of effective weight management interventions in primary care. Practitioners feel uncertain about their effectiveness in managing obesity with lack of time, confidence, training, patients non-concordance, lack of patient motivation, and inadequate reimbursement being the main perceived barriers.16, 22 interventions for weight management should have relevant competencies and have undergone specific training. The provision of training alone to GPs and Practice Nurses (PNs) has been shown not to improve weight management outcomes for patients.23 The Counterweight Programme has a well tested programme of training and mentoring in practice to enable practitioners to identify motivated patients and deliver an effective structured programme of weight management (see Figure 1). This enables them to achieve a level of competency to deliver weight management services in practice. 2008. PCTs in other parts of the country are able to commission weight management programmes from a directory of services produced by the Department of Health.

Weight loss & weight management

The NICE guidelines recommend that health professionals should discuss the range of available weight management options with people who want to lose or maintain their weight, or are at risk of weight gain, and help them decide what best suits their circumstances, and what they will be able to sustain in the long term. The guidelines recommend that practitioners make patients aware of the distinction between losing weight and maintaining weight loss, and the importance of developing skills for both. Weight loss trials indicate that maximum weight loss is generally achieved over the first six months of intervention, with varying amounts of weight regain thereafter.25 Practitioners must have the skills to successfully manage the weight loss expectations of patients and enable them to embrace the clinically beneficial weight loss targets of approx 5-10kg2 or 5-10 per cent3 based on an average patient of 100kg (see Figure 2). Some patients who went through the Counterweight programme reported that they felt a 5-10kg target for weight loss was too little. However, those that lost this amount of weight reported they felt better, and had lost inches from their waists.26 This is against the background that the mean weight gain for an overweight or obese individual is approximately 1kg per year.27 The NICE guidelines recommends for those persons who are not ready to engage in change, to explain the benefits of small modest weight losses. This would also be an opportune time to discuss the benefits of weight maintenance, a key feature of weight management but a concept that is not well adopted in primary care.21 NICE recommends the benefits of physical activity both in conjunction with weight management programmes, but also independently. A Cochrane review of the effects of exercise on overweight and obesity showed that taking part in exercise demonstrated cardiovascular benefits even in the absence of any weight loss.28

Research
As part of a Continuous Improvement Programme, the Counterweight project team conducted a qualitative study to explore factors affecting programme implementation in practices that were successful and unsuccessful in the recruitment and follow up of patients in primary care. Successful practices had a general commitment from a wide range of practice staff especially GPs, when the programme was being established. There was also a committed and enthusiastic PN to take responsibility for the ongoing support and delivery of weight management in practice. The provision of training materials and patient education resources that were tailored to a structured weight management programme were seen as important to prevent the use of ad-hoc and often non evidence-based literature distribution. Successful practices were able to integrate structured weight management into practice routine. The barriers in practice were very much the competing priorities for practice time, low level of commitment from GPs, high turnover of staff, and scepticism about the likely success of obesity management in practice.24

Counterweight
The Counterweight weight management project was set up to determine to what extent measures of success could be achieved in routine primary care, with the primary outcome measures being weight change at 12 and 24 months. The SIGN guidelines7 were used to help create screening and treatment pathways for use by practice nurses for the management of their obese patients. Primary care nurses from 65 UK general practices delivered interventions to 1906 patients with BMI 30kg/m2 or BMI 28kg/m2 with an obesity related disease. The mean baseline weight was 101.2kg (BMI 37 kg/m2 ); 25 per cent of patients had a BMI 40kg/m2 and 74 per cent had 1 obesity related disease. 1419 patients were in the programme for 12 months. Mean weight change in those who attended and had data at 12 months was -3.0kg and at 24 months was -2.3kg. Among attenders 30.7 per cent had maintained a clinically significant weight loss of 5 per cent at 12 months, and 31.9 per cent at 24 months. The Counterweight weight management programme was able to evidence that clinically significant weight loss of 5 per cent and weight maintenance was achievable within routine primary care.22

Funding
The Scottish Government have further shown their commitment to their HEAL action plan by funding the Counterweight weight management programme. This is the only peer reviewed, evidence-based weight management programme to be made available and implemented throughout primary care in 13 of the 14 health board areas in Scotland from

Figure 1: Treatment Pathway

Discuss weight loss target: 5-10% weight loss First Line - Lifestyle Intervention Group Programme or 1:1 Goal setting or 1:1 Calorie deficit plan with exercise referral scheme, if available Second Line- Additional Interventions Pharmacotherapy Dietitian referral Psychologist referral Secondary Care referral Weight Maintenance

Figure 2: Benefits of 5-10kg Weight Loss

Lung function in asthma (10kg)1 Arthritis related disability (5%)2 Blood pressure3, 4, 5, 6, 7, 8 0.5 - 1.0mmHg drop per kg weight loss 58% in development of DM in IGT at 3 years (5kg)9, 10 Total cholesterol 0.21mmol at 12m (5kg) 0.25mmol at 2-5yr (10kg)3, 11 Total mortality3 diabetes-related deaths (5kg) obesity-related cancer death (5-20kg)

Training healthcare professionals

The NICE guidelines recommend that healthcare professionals involved in the delivery of

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Big Story | Obesity

Health boards and PCTs are encouraged to have an obesity management strategy (see Figure 3) outlining how primary care is going to manage their obese patients, with many of these strategies informed by the clinical guidelines as already mentioned. Some primary care organisations are endorsing commercial and community weight management programmes which NICE guidelines encourage, but recommend they follow best practice by helping patients decide on a realistic healthy target with the aim to lose 510 per cent of their original weight, and focusing on long-term lifestyle changes. It is suggested that practitioners follow up patients on commercial or community weight management programmes when they return to primary care. Within general practice, many obesity strategies encourage the targeting of treatment groups, such as BMI 30kg/m2 or BMI 28kg/m2 with an obesity related disease, or those patients attending chronic disease clinics such as a hypertensive clinic, or diabetes clinic.29 Studies like the Diabetes Prevention Programme30 and the Finnish Diabetes Study,31 showing that 7 per cent weight losses achieved through lifestyle measures in a cohort of patients with Impaired Glucose Tolerance (IGT) can reduce the onset of diabetes by 58 per cent, may be a useful incentive for targeting patients in primary care most at risk. Weight management interventions are recommended by the NICE guidelines to incorporate the use of behaviour change strategies that serve to enable patients to manage their own environment and cues, and challenge the thinking and lifestyle habits which are responsible for their energy imbalance; over-consumption and inactive behaviours that result in weight gain. Strategies include self monitoring and the use of food diaries, lapse management, stimulus control, slowing down eating at mealtimes, stress management, social support and cognitive restructuring. Studies indicate that weight management interventions that incorporate these strategies are more successful.32 If patients have a BMI 35 kg/m2 with obesity related disease or BMI 40kg/m2 then referral on to a specialist multi-disciplinary obesity clinic would be appropriate. Less than 2 per cent of patients who were seen in primary care for the Counterweight weight management programme were referred on to secondary care clinics. Reasons cited for such low referral was that these services were not available in many regions, or there were long waiting times associated with such referrals.

Pharmaceutical aids
The only pharmaceutical aid currently available for the management of obesity is orlistat (Xenical [Roche pharmaceuticals] or Alli [GSK]) available over the counter. This drug is a Lipase enzymes inhibitor, which is not absorbed by the GI tract. This reduces the fat absorbed from the intestine, causing fat malabsorption. It is recommended that patients on these agents choose products that contain less than 3 per cent fat. If foods are higher in fat, the patient consequently experiences oily or fatty stools. It is recommended that these drugs are used as part of an overall pathway for the management of obesity in primary care, and as an adjunct to lifestyle changes made by the patient. It is not recommended that patients are prescribed these medications with no other support to make changes to their eating and activity levels.

Referral
Patients who have not achieved a 5 per cent or 5kg weight loss following an intervention programme of weight management, but are still motivated to make lifestyle changes should be referred to their local dietetic departments. Dietitians often have strict referral criteria, with the use of standard protocols for patients on weight management programmes, and are proficient in the use of behaviour change therapy. The Counterweight programme found that only 8 per cent of patients who were still in the programme for a year were referred on to a dietitian for further support.

Figure 3: Example of Weight Management Strategy

Community/Environmental Activity (BMI 25 upwards) Public Health initiatives, Health Promotion campaigns, Commercial slimming organisations

Surgery
Patients referred for bariatric surgery are often done so via the secondary care obesity clinics, where these services are available. The NICE guidelines, however recommend that patients who have a BMI >50kg/m2 be referred directly for consideration for bariatric surgery services.12 In many regions, referral to bariatric surgical services remains ad-hoc, and demand often outstrips resources for these services.

Primary Care Intervention (BMI 30+) Counterweight (One-to-One/Group)

Conclusion
It can be seen that the prevalence of obesity and consequent rise in obesity related diseases has both a profound affect on patients health and quality of life, but also on the treatment of this disease in primary care. It is important that PCTs and health board areas have an obesity strategy to allow appropriate referral of motivated patients through an organised pathway of evidence based treatments to the appropriate health professional for maximal impact.

Specialist Obesity Intervention (BMI 30/40+ plus obesity associated disease) Physician, Psychologist, Specialist Dietitian, Physiotherapist Decreasing patient numbers Decreasing resource/personnel available

Surgery (as above) Referral option from secondary care service

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A qualitative study of general practitioners' and practice nurses' attitudes to obesity management in primary care. Department of General Practice, University of Glasgow. Health Bull (Edinb).; 59(4): 248-53. 17. Wanless Report (2004) Securing good health for the whole population. Accessed online: http://www.dh.gov.uk/en/Publicationsandstatistics/P ublications/PublicationsPolicyAndGuidance/DH_4074426 (Feb 2010). 18. Dr Foster (2005). Primary care management of adult obesity. London. 19. Hiddink, G.J., et al (1997). Consumers expectations about nutrition guidance: the importance of primary care physicians. Am J. Clin Nutr.; 65 (Suppl 6): 1974S-1979S. 20. House of Commons Select Committee (2004). Obesity. Third Report of Session 2003-04. London. The Stationery Office Ltd. 21. Pryke R, Docherty A (2008). Obesity in primary care: evidence for advising weight constancy rather than weight loss in unsuccessful dieters. British Journal of General Practice; 58: 112-117 22. The Counterweight Project Team (2008). Evaluation of the Counterweight programme for obesity management in primary care: a starting point for continuous improvement. The British Journal of General Practice; 58(553): 548-554. 23. Moore, H., et al. (2003) Improving the management of obesity in praimry care: cluster randomised trial. BMJ; 327: 1085-1088. 24. The Counterweight Project Team (2008). Engaging patients, clinicians and health funders in weight management: the Counterweight Programme. Family Practice.; 25(S1): I79-I86. 25. Rossner S, et al (2008). Long-term weight loss and weight-loss maintenance strategies. Obesity reviews; 9(6): 624-630. 26. Management of Obesity in Adults (2004): Project for European Primary Care: IJO.; 28: S226-231. 27. Haitman BL & Garby L (1999). Patterns of long term weight changes in overweight developing Danish men and women aged between 30 and 60 years. Int J Obes Relat Metab Disord.; 23: 1074-78. 28. Shaw K, et al (2006). Exercise for overweight or obesity. Cochrane Database Syst Rev.; 4: CD003817. 29. National Obesity Forum. Guidelines on Management of Adult Obesity and Overweight in Primary Care. Accessed online: www.nationalobesityforum.org/uk (Jan 2010). 30. Diabetes Prevention Program Research Group (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. NEJM 346: 393-403. 31. Tuomilehto J, et al. (2001) Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with imparired glucose tolerance. NEJM.; 344: 1343-49. 32. Avenell A, et al (2004). Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technol Assess.; 8(21): iii-iv, 1-182.

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