The problem of growing obesity levels is never far from the headlines. Nurses across the UK are involved in a range of innovative projects designed to tackle the problem, including a controversial scheme that pays people to lose weight. Clare Lomas investigates
Last month health secretary Alan Johnson highlighted the use of financial incentive schemes that encourage people to lose weight as tools that could be used by NHS trusts to fight the obesity problem.
In his speech on public health at the Royal Society of Arts in London, Mr Johnson cited one such scheme currently being piloted in Kent, where adults can earn cash rewards for weight loss. It is just one of a range of initiatives in which nurses are involved in helping patients tackle problems of overweight.
The ‘pounds for pounds’ programme at Eastern and Coastal Kent PCT pioneers the concept of negotiating ‘weight contracts’ with participants.
Developed by independent company Weight Wins, run by former financial analyst Winton Rossiter, the scheme focuses on long-term weight control, and financially rewards gradual safe rates of weight loss through a balanced diet and lifestyle, in line with 2006 NICE guidelines on obesity.
‘Financial incentives for public health are a good investment for everybody when they encourage people to change their behaviour and learn to lead a healthy lifestyle,’ Mr Rossiter told Nursing Times.
‘Incentives also appeal to people, especially men, who do not respond to traditional invitations to join weight loss programmes, or improve their lifestyle,’ he added.
Around 400 people – 41% of whom are men – have signed up to the Weight Wins scheme since it was implemented at the PCT in January 2009. Among those who have signed up are 40 nurses, according to Mr Rossiter.
After deciding how much weight they need to lose to achieve a healthy body mass index and agreeing a set period for which they want to maintain their new weight, participants receive a personal weight plan for up to 13 months, with monthly weigh-ins and targets to aim for. They are paid at the end of course, accumulating money as the go dependent on how much they lose each month with a bonus if they reach their target at the end of their weight loss maintenance period. Participants are not paid if they fail to complete the course.
Although Eastern and Coastal Kent PCT pay £185 per person to Weight Wins for the scheme, all administration is carried out by the company so the programme requires minimum resources from the PCT following the initial outlay, said Mr Rossiter.
Most patients will have their initial weigh-in with a practice nurse at their GP surgery but follow-up weigh-ins can be carried out at other relevant local settings agreed by Weight Wins - such as pharmacies, gyms and weight-loss groups - so there is no extra burden on nurses’ workloads, he added.
‘We have designed a structured programme that maximises an individual’s chance of success but losing weight is hard, so not everyone will reach all their targets and claim the full reward. However, even less successful participants will earn some reward and, most importantly, lose weight,’ said Mr Rossiter.
Claire Martin, a public health specialist for the NHS in East Kent, who commissioned the programme in Eastern and Coastal Kent PCT, said: ‘This scheme is ideal for people who have tried to lose weight before but have found it difficult to make progress. We hope this trial will help establish whether financial incentives can motivate people to shed pounds, and keep them off.’
Although the pilot is still in its early stages, a preliminary report shows an average of 6.9 pounds weight loss per person in the group, with just a 7% drop out rate.
And an audit carried out in February this year – of 76 people who took part in a trial for the scheme before it was set up – showed the average weight loss of those who stayed on the programme for six months was 23.3 pounds, or 10.5% of their body weight.
A spokesperson for the Department of Health said the government would be watching this scheme closely to see whether it worked in the longer term, before deciding whether to roll similar programmes out across England. He added that PCTs in other areas were in the process of setting up pilots.
‘Over the last year, some local areas have commissioned pilots which will help build the evidence base in this area. We will be commissioning a national evaluation which will help us learn from these initiatives,’ he said.
The government first announced its intention to look at using financial incentives to encourage healthier lifestyles in January 2008 in its Healthy Weight, Healthy Lives – a cross-department anti-obesity strategy backed by £372m.
The Department of Health pledged to ‘pilot and evaluate a range of different approaches to using personal financial incentives to encourage healthy living, such as individuals losing weight and sustaining weight loss, eating more healthily or being consistently more physically active’.
The idea of paying people out of the public purse to lose weight may seem a drastic measure for the NHS to be considering but the evidence suggests something drastic is needed to halt the rise in obesity.
A 2007 report from government think tank Foresight predicted that if no action was taken to reduce the increase in the UK rate of obesity, 60% of men, 50% of women would be classed as obese by 2050.
And a study published last month by Oxford University researchers concluded that being severely obese was as bad for health as smoking, and could shorten a person’s life by 10 years.
Perhaps unsurprisingly, the idea of the NHS using financial incentives to encourage people to lose weight has been the subject of some debate. Preventative health measures such as this could prove costly to set up, and the potential benefits for the health service may not be appreciated for many years.
However, a report from government policy group Health England, published in March, said there was evidence that patients were more likely to undertake preventative health care, such as weight loss, and heed medical advice if they were offered a financial incentive. The Health England report cited Germany, where social insurance contributions are reduced if people attend services such as smoking cessation, screening and dieting classes.
As well as the financial incentive model set up in Kent, the government is also monitoring a range of other new initiatives to promote healthier living.
As part of Change4Life – the government’s three-year healthy living campaign launched in January this year – the government announced nine ‘healthy towns’ that would receive a share of £30m government funds to encourage residents to lead healthy lifestyles.
These sites, which include Dudley, Sheffield, Thetford and Tower Hamlets in London, are in the process of implementing a variety of programmes to help people lead healthier lifestyles, including a number of nurse-led initiatives.
For example, Dudley PCT is currently piloting the ‘counterweight’ programme with practice nurses in 10 GP surgeries in the area. This nurse-led programme uses lifestyle intervention as a first-line approach to weight management – delivered individually or in groups – followed by second-line interventions such as the use of anti-obesity medications and referrals to dietitians and psychologists where necessary.
At Sheffield PCT, practice nurses are being trained how to deliver opportunistic brief interventions, based on cognitive behavioural therapy methods, to encourage people to lose weight. The PCT is also setting up nurse-led weight management clinics, and working with local maternity services and health visitors to make Sheffield a breastfeeding friendly city.
Speaking to Nursing Times, Gary McCulloch, health improvement lead for NHS Sheffield, said: ‘Around 22% of people in Sheffield are obese, and 34% are thought to be overweight. But it is not just about diet and weight control, it is about lifestyle change and understanding why people have problems with their weight.
‘Education underpins a lot of this, and the preventative programme will work closely with key nursing staff to deliver our action plan, which includes the work being piloted by practice nurses,’ he said.
Thetford in Norfolk was awarded £900,000 of healthy town funding to implement a programme of health and well-being over three years.
Chris Nelson, interim project manager for healthy towns at NHS Norfolk, said: ‘Almost a quarter of the population of Thetford are migrant workers, and we have higher levels of obesity than the national average. We are operating a mixture of initiatives, in line with the Change4Life agenda, to engage with harder-to-reach communities and understand their health needs.
‘Although there is not a lot of money available to invest in medical-based approaches, we are developing nurse-led advice and guidance services, and are conducting research to determine how harder-to-reach groups can make better links with the existing nurse-led services,’ he added.
As well as the overall population, rates of childhood obesity have soared in recent years, and experts have warned that 90% of today’s children will be obese by 2050 if no action is taken to address the problem.
Since 2005, the government’s national child measurement programme has measured the height and weight of primary and middle school children for inclusion on a national database, and since 2008 the results of the measurements have been sent to parents.
Many NHS trusts are also implementing local strategies to combat the rising rate of childhood obesity, such as the Mind, Exercise, Nutrition …Do it! (MEND) weight-management programme, developed by child health experts at Great Ormond Street Hospital and University College London.
Under this 10-week programme, around 2,000 overweight seven to 13-year-olds in Wales are attending twice-weekly classes – which teach ‘weight management skills’ rather than focusing solely on losing weight. The programme is also being run in more than 100 areas in England.
Hammersmith and Fulham PCT in London is currently finalising the details of a child obesity care pathway, working in partnership with a range of healthcare professionals.
School nurses will be pivotal to this scheme, so NHS Hammersmith and Fulham are to employ a specialist obesity nurse to lead and advise the school nursing team, starting later this year.
The specialist nurse will make a clinical assessment and also be able to refer children to a weight management programme or paediatric dietitian where necessary.
Julia Shaw, NHS Hammersmith and Fulham commissioner for children and young people, said the school nursing service should be used as ‘the first defence in tackling obesity’.
‘The specialist obesity nurse will be a great support to the [school nursing] team, and will be instrumental in bridging the gap with parents to bring up conversations around weight management, healthy eating and how to help children have a better future,’ she said.
While it remains to be seen whether paying patients to lose weight is the answer to the obesity epidemic in the UK, what is clear is that the problem will have to be addressed somehow and that much of the responsibility for implementing initiatives will inevitably fall on frontline nurses – especially those working in primary care.
Dr Ian Brown, a senior lecturer at Sheffield Hallam University, investigated obesity management in clinical practice, including nurses’ beliefs and attitudes, three years ago.
Writing in the Journal of Advanced Nursing, he said nurses had a key role to play in tackling obesity but ‘very few’ had received training in obesity management. Surveying 398 nurses from four PCTs, he found that one in five felt awkward or embarrassed talking to patients about obesity.
‘Nurses have an important role when it comes to helping patients to tackle obesity,’ he concluded. ‘But they clearly need further training and organisational support to provide the help that obese people need to lose weight.’