Successful weight loss intervention can be delivered in primary care, writes Dr David Haslam.
Obesity affects almost a quarter of the UK adult population. It is the main driver behind type-2 diabetes, as well as being a major factor in CVD, cancer and many other conditions. Obesity is also associated with increasing prescribing costs across all categories of the formulary.
Deliberate loss of weight is linked to reduced long-term NHS costs Weight loss in primary care is of interest for the purposes of improving a person's health, and as a means of modifying the cardiometabolic risk of those in the highest risk categories.
The Counterweight programme
A weight loss target of 5-10 per cent, achieved through lifestyle intervention, has been shown to reduce progression to diabetes by an impressive 58 per cent over four to six years.1,2
A single unit decrease in BMI is associated with a reduction in the incidence of type-2 diabetes of 13 per cent.3
Furthermore, many other clinical benefits result, such as reductions in CVD risk factors including blood pressure and lipid profile.4,5
The Counterweight programme (www.counterweight.org) is a structured pathway for the management of obesity in primary care that consists of screening and evidence-based treatment guidelines.
Counterweight is commissioned through PCTs in England, and in Scotland the programme is funded centrally by the government and has been made available to all health boards.
There are three main options for Counterweight intervention that patients can opt to undertake (see box); all are based on a 500-600kcal energy deficit.
The goal-setting approach is based around the clinician and patient agreeing small but permanent changes in behaviour, eating and physical activity habits.
It is suited to patients who are averse to dieting, those who display an 'all or nothing' approach to change, and those who need to make many dietary and lifestyle changes.
The prescribed eating plan specifies the number of servings a patient should aim to eat from each of the food groups in the 'Eatwell' plate. The servings are specified by Counterweight and are calculated to produce a 500-600kcal energy deficit daily.
This approach is suited to patients who want to know about the amounts and types of foods to eat and those who appear to eat a good quality diet but overdo portion sizes.
The group programme is based on the goal-setting approach outlined above. It is appropriate for patients who may benefit from social support from other group members, or for people with low self-motivation.
Weight management advisers, all registered dietitians or public health/registered nutritionists, provide a 12-hour training programme for practice nurses or other staff responsible for the delivery of the intervention. They then provide clinical support in practice for nurses who are treating patients in weight management clinics, in groups, or opportunistically.
Effective weight loss
So far, 30 per cent of all patients who attend for follow-up Counterweight appointments achieve a 5 per cent weight loss that is maintained at one and two years. One in six of all patients who ever enter the programme achieve the 5 per cent loss and this takes account of those who drop out.
Some 70 per cent of patients who attend Counterweight do not gain weight when reviewed. Data reported by the programme prove that the induction and maintenance of weight loss is possible across a population in a routine primary care setting, and that this is both clinically and highly cost-effective.6-8
The evaluation of the cost-effectiveness has used the same economic model originally developed to provide input to the UK national guidance on obesity developed by NICE. The accepted benchmark for cost-effectiveness in the UK is pounds 20,000-30,000 per quality adjusted life year (QALY).
The cost per QALY for patients who complete Counterweight indicates that the intervention is dominant (meaning the programme is both clinically effective and cost saving over a patient's lifetime).8 In comparison the cost per QALY for smoking cessation is pounds 700 and bariatric surgery is between pounds 6,000-8,000.
The Counterweight programme not only provides evidence that weight reduction can take place across a population in primary care within a tiered obesity management model, but also that it is highly cost-effective to embrace weight management in this setting.
- Dr David Haslam is a GP in Hertfordshire, member of the National Counterweight Board and clinical director of the National Obesity Forum.
There are three options for intervention (all based on 500-600kCal energy deficit):
- Goal-setting approach.
- Structured prescribed eating plan.
- Group programme.
1. Knowler WC, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346: 393-403.
2. Tuomilehto J, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001; 344: 1,343-50.
3. Wei M, et al. Waist circumference as the best predictor of noninsulin dependent diabetes mellitus (NIDDM) compared to body mass index, waist/hip ratio and other anthropometric measurements in Mexican Americans. Obes Res 1997; 5: 16-23.
4. National Institutes of Health. The practical guide: identification, evaluation and treatment of overweight and obesity in adults. October 2000. www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf
5. Avenell A, et al. Systematic review of the long-term effects and economic consequences of treatments for obesity and implication for health improvement. Health Technol Assess 2004; 8:1-182.
6. Laws R, Counterweight Project Team. A new evidence-based model for weight management in primary care: the Counterweight Programme. J Hum Nutr Diet 2004; 17: 191-208.
7. Counterweight Project Team. Evaluation of the Counterweight Programme for obesity management in primary care: a starting point for continuous improvement. Br J Gen Pract 2008; 58: 548-54.
8. Counterweight Project Team. An economic evaluation of the Counterweight Programme in the United Kingdom. Abstract 3623. Circulation 2007;116: II 822.
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"Independent Nurse: Clinical - Public health - Diet plan to achieve effective weight loss." GP 21 Sept. 2009: 40. Academic OneFile. Web. 20 Nov. 2009.
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