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Rapid Responses: Rapid Responses published:
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Management of obesity in primary care
- Nick Finer, Counterweight Project Team (14 November 2003)
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obesity services in primary care
- Reggie G McAuley (18 November 2003)
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Improving management of obesity in primary care:cluster randomised trial
- Versha Talati, Nicholas Kendall (18 November 2003)
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improving management of obesity in primary care
- Chris Barclay (21 November 2003)
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Primary care central to action on obesity
- Penny A Ross (28 November 2003)
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Nick Finer, Hon Consultant in Obesity Medicine Addenbrooke's Hospital, Cambridge, CB2 2QQ, Counterweight Project Team
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Moore et al report the failure of a 4.5 hr training programme delivered to general practitioners and practice nurses in achieving implementation of their weight management programme and weight change in participating patients. In contrast the Counterweight Programme has reported preliminary results that providing training and treatment protocols to primary care can be effective (1). The Counterweight Programme is a multi-centre primary care obesity project being conducted in 80 practices across seven regions of the UK. The Programme is directed by the National Counterweight Board (2) and implementation is facilitated, but not performed by one full time dietitian in each region with specialist experience in the field of obesity. Preliminary results in 682 recruited patients from the 7 regions shows a weight loss of 3.3 (0.2) kg loss at 3 months (n=316) and 4.3 (0.4) kg at 6 months (n=199). At 6 months 13% of patients had lost >= 10%, and 43% >= 5% of their initial weight. More recent data show that it is possible to achieve appropriate clinical targets for weight reduction in 45% of patients who complete the programme at one year. 1300 patients have now been recruited to the intervention programme and it is aimed that 2000-2500 patients are recruited by the end of 2004. The difference between these two projects lies in the level of support given to Primary Care and the types of weight management interventions delivered. The Counterweight Programme provides an initial 6 hours of intensive training to practice nurses around evidence-based structured protocols. In contrast to the study reported by Moore et al the Counterweight dietitians then continue to provide clinical support for the practice nurses for a minimum of 6 months with continued additional training if required. GPs are offered one hour of training on patient screening, and treatment protocols. The Counterweight programme encourages intervention to be tailored to suit patient needs with a variety of methods that can be selected by individual practices. This includes a group programme, individual intervention of goal setting or eating plans, referral to local exercise schemes and the use of anti-obesity medication. The intervention programme is supported by an integrated package of patient education materials. In contrast the Leeds trial used a prescriptive eating plan only which may not have been appropriate for all patients. (1) The efficacy of a national primary care weight management programme. Ross H, Laws R, Frost G on behalf of the Counterweight project team. Int J Obesity 2003, 27 Suppl 1:S120. (2) Broom J(a), Reckless JPD(b), Kumar S(c), Lean MEJ(d), Frost GS(e), Barth JH(f), Finer N(g), Ross HM(h), Costain L(i) (a)Aberdeen, (b)Bath, (c)Birmingham, (d)Glasgow, (e)Hammersmith, (f)Leeds, (g)Luton, (h)Counterweight Project Co-ordinator, (i)Representative for British Dietetic Association. Competing interests: The Counterweight project is supported by an educational grant in aid from Roche Products Ltd |
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Reggie G McAuley, GP Kilrea Northern Ireland BT56 8DQ
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The paper ‘Improving Management of Obesity in Primary Care’ in the BMJ dated 8/11/03 was particularly informative by demonstrating the ineffectiveness of this common approach to obesity. I would quarrel with what was described as an ‘improvement’ in Primary Care management of obesity since no improvement was noted. The usefulness of this study is that it tests the conventional model of organisation of obesity services whereby therapy is directed towards a narrowly defined outcome (weight loss). The study failed to produce any significant weight loss in the treated group but assuming weight loss is an achievable goal, when services are delivered effectively, it must be legitimate to question the methodology of this study. This, in itself, might be useful in understanding why obesity treatment fails. It seems obvious that the medical model of understanding obesity as a disease entity is, in itself, flawed. Health professionals who organise services within a ‘treatment’ model might inadvertently be building failure into their eventual outcomes. Obesity will not, it seems, easily conform to the pattern of a disease amenable to treatment by others. (However patients can, it seems, lose weight, when and if, they choose to do so themselves.) Obesity, of course, is not a disease. It is a symptom of a process or processes that have as a consequence of their operation, weight gain. If every person, unfortunate enough to find themselves labelled as obese, has individual rationalisations for their obesity generic treatments will fail. Behavioural modification has been shown to be a usefully effective tool towards weight loss. However the use of behavioural modification as a ‘treatment’ for obesity within a medical model,(by delivering services towards a specific outcome) produces helpful but not impressive results. Interventions focused on a specific outcome suggest that a causation of obesity can be rationally understood. Patients, however, may improve their sense of well-being, and may indeed initiate mental or physical health or lifestyle improvement but will not always prioritise weight loss in their individual mental lists of ‘things to do’. These secondary outcomes are not recorded particularly when the desired outcome from the intervention is highly specific. The corruption of medical thinking by pharmaceutical companies has, quite rightly, been courageously highlighted by the BMJ. But what of the corruption of primary care problem solving by the secondary care model of rationalising problems as diseases with interventions directed towards oversimplified outcomes? The problem of obesity demands a rethink on how systems of delivery of disease interventions have contributed to the causation of obesity. Some insight into how medical models fail might be gleaned from how Applied Behavioural Analysis has proved useful to families adjusting to the inclusion of an autistic child. The temptation to rationalise exactly what that child is thinking is dismissed as an altogether impossible, and in many ways, harmful approach. There are no rationalisations that enable the parents to think as their offspring does, yet it remains essential to deliver skills that modify, or normalise, the child’s behaviour. Improved behaviour produces less emotional distress for both parents and child. Individuals who are obese have not deliberately inflicted this problem on themselves. They are behaving normally and, like me, rely on a lifetime’s accumulation of learning experience when relating to the complex array of opportunities and threats they encounter in this, our modern, world. We become orientated both externally and internally for a lifetime of emotional experience through our opportunities to absorb and then mimic the behaviour best rewarded in our childhood. We are primed to replicate the emotional characteristics of the worlds we have been reared within through the replication of those behaviours that generate their emotional consequence. The relationships we have with exercise, food, alcohol, depression, work and self have templates fashioned within our experiential lives. Disease orientated health care relegates longevity to the role of an effect of successful therapy whilst generation after generation greets the expectation of life learnt from the experiences of their parents. Equipped emotionally for this struggle a generation of individuals die needlessly, not from the hardship of existence but from the consolations they are emotionally programmed to feel they need. It is not surprising that those from lower socio-economic groups are the most vulnerable to suffer the excesses of the increasingly accessible consolation of food. In reality the obsession of services with disease management has left the health aspirations of an increasingly affluent population to the mercy of those energetic or paid enough to manipulate a generic sense of well being, for personal or corporate profit. Quite simply the NHS has been absent as a player in any meaningful sense in a consumer society eager to indulge itself as a means to contentment, happiness or success. People consume to feel better, in the pursuit of satiety, and obesity is an unfortunate side effect that condemns sufferers to leper status, in their own eyes. Food is a powerful reinforcer of behaviour and negative rationalisations are equally well reinforced. Obesity reduces self-esteem, increases emotional distress and guarantees ill health and disempowerment. Despite the obvious concentration of obesity within lower socio- economic groups there is considerable disparity of behavioural backgrounds from which these larger human beings appear. It would in essence appear ridiculous to suggest that a ‘one size fits all’ therapy would be an effective counter balance to individualised perceptions of need. The failure of treatment outcomes demonstrated by this paper argues strongly for a less paternalistic approach where individuals intent on solving their own problems are allowed to come face to face with a wide range of therapies, from cognitive and behavioural therapies to nurse managed weigh -ins. Paternalism, quite rightly, is being choked to death in primary care in favour of individually tailored solutions for patients (not numbers) who attend doctors in a primary care setting. The importance of individual psychodynamic therapy as being effective in promoting lifestyle change is increasingly recognised and GP’s must receive support in developing non drug, behavioural and life-style resources within primary care, rather than becoming mini-hospitals brimming with disease management capability. Obesity and it’s sequelae will ensure that there will never be enough disease management capacity within health centres if we fail to prioritise prevention within Primary Care Competing interests: None declared |
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Versha Talati, Health Promotion Nutrition Adviser Public Health Department, AAW Teaching PCT The Causeway,Goring by sea ,worthing BN12 6BT, Nicholas Kendall
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Dear Editor Ref BMJ Volume 327 8 November 2003 Improving management of obesity in primary care: cluster randomised trial Helen Moore et al We hope that this paper will be read in conjunction with the review by Harvey et al. Here, programmes reminding GPs to prescribe diets and a brief educational training intervention for GPs on obesity management, as delivered by behavioural psychologists, were cited as useful interventions. There is otherwise the danger of reinforcing negative attitudes amongst doctors towards managing obesity in primary care. The intervention described by Moore et al was not implemented sufficiently in the practices to be expected to show any realistic changes for patients, despite adequate statistical power to do so. The fact that there was some improved knowledge and small improvements in recording must be a positive move in the right direction. We need to look at obesity as a staged, strategic approach. It may be possible to demonstrate some positive accumulative benefits over time- perhaps to the general GP list population, as well as to persons recruited for the trial. Reference Harvey, E.L, Glenny, A-M, Kirk, S.F.L.and Summerbell, C.D. (2001). Improving health professionals` management and the organisation of care for overweight and obese people (Cochrane Review). Versha Talati
Dr Nicholas Kendall
Competing interests: None declared |
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Chris Barclay, GP 34-36 Nethergreen Road, Sheffield. S11 7PA .UK
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Dear Sir, 'Obesity' said James O. Hill 'is the normal reponse to the American environment' (1). And what America does today we usually follow tomorrow. With this in mind I was facinated to read Moore et al's study of an intervention designed to treat obesity in primary care (2). The authors are to be congratulated on devising and implementing such a comprehensive intervention, which makes its failure to have any impact on the problem particularly illuminating. They are right in that new approaches to the problem need addressing. In my view, expecting GP's and practice nurses to take on significant extra unresorced workloads was and remains impractical. It is to the GP's and nurses credit that so much extra training and work was actually done. The lack of any beneficial change in the subjects studied was breathtaking. This is a highly significant negative outcome study. Obesity, and its nemesis - type two diabetes - will never be successfully remedied in the tradition GP/practice nurse consultation. Obesity and for that matter pre-diabetes mellitus (PDM) with impared fasting glucose and glucose tolerence, are manifestations of the drift in society's food and portion size choices and its attitude to exercise. A strategic approach is need. Recommending primary care take it on without a coherent strategy and funding simply places GP's and community nurses in the role of official scapegoat; a role to which we are well accustomed. Single issue specialists forever require more of GP's, but without provision of resorce or reduction of other duties their guideleines and protocols are wish lists. Novel approaches are needed now and ones that involve motivation techniques, encouragement, education and exercise seem the most logical next step. Perhaps we should look more to the methods of weight reducing clubs rather than the medical consultation as a models for encouraging sustained change. 1 Fat Land; how american became the fattest people in the world. Greg Crister. Pub: Penguine/Allen Lane. 2003. ISBN 0-713-99739-7 2 Moore H, Summerbell CD, Greewood DC, Tovey P et al. Improving management of obesity in primary care: cluster randomised trial. BMJ 2003;327:1085-8 Competing interests: competing interests: I am a clinical research associate of the Institute of General Practice, University of Sheffield and have an interest in obesity and pre-diabetes mellitus |
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Penny A Ross, Self-Employed Registered Public Health Nutritionist South Yeo, Poughill, Crediton, Devon EX17 4LF
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Dear Editor For those of us working to establish systematic treatment protocols for the management of obesity in primary care, the publication of this evaluation, represents a significant setback. The study found that delivery of a training package promoting a brief prescriptive approach to the treatment of obesity resulted in some improvement in practitioners’ knowledge, but implementation levels were low, probably reflecting the very real constraints on staff time, and did not eventually affect the weight of a motivated cohort of patients. The implication is that efforts to tackle obesity in primary care are pointless. It would be a pity if this disappointing conclusion became the lasting legacy of this research. As Dr Nick Finer outlines in his rapid response to the evaluation, evidence from the multi-centre Counterweight Project shows that obesity can be effectively managed in this setting, with as many as 45% of patients who complete the programme at one year achieving a clinically significant weight loss. The final results of this project, which recently won the Association for the Study of Obesity’s Best Practice Award (1) should provide a model of good practice which can be locally implemented, backed up by a tried and tested training package and excellent, affordable (and much needed) patient information resources. With government bodies rallying in recent weeks for action to stem the growing obesity epidemic(2), primary care is surely well placed to take a central role in an integrated system for the prevention and management of obesity, given appropriate resources. This would include raising awareness of overweight and obesity as a health concern, offering brief informed advice, signposting to a choice of safe and effective specialist services both within and beyond the NHS, and monitoring and encouraging patients’ efforts to achieve and maintain a healthy weight. 1. The Counterweight Project Team Association for the Study of Obesity: Best Practice Award , 16/07/2003 www.aso.org.uk 2. Medical Research Council (2003) www.mrc- hnr.cam.ac.uk/NutComms/ALeanerFitterFuture.pdf Competing interests: None declared |
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