Alison J. Hudson, RGN, RM.
Practice Nurse, Manor Park Surgery, Leeds, West YorkshireThe incidence of obesity is increasing in the UK (National Audit Office, 2001). Since 50% of obese people have at least one associated health problem, this has significant implications for both the health of the nation and for the NHS (Royal College of Physicians, 2003).
The incidence of obesity is increasing in the UK (National Audit Office, 2001). Since 50% of obese people have at least one associated health problem, this has significant implications for both the health of the nation and for the NHS (Royal College of Physicians, 2003).
It also poses a challenge for health professionals trying to help obese people to lose weight, and improve life quality and expectancy (RCP, 2003). Nurses in primary care are often involved in helping obese people to lose weight and improve their overall health, yet they may feel ill-equipped. Despite their understanding of the serious health consequences of obesity, they have little preparation on the subject. For example, they can be aware of what constitutes a healthy diet, yet lack the skills to support patients who wish to lose weight.
Problems in the care of obese patients
Obese people often feel ashamed of their appearance and find it difficult to discuss their weight openly, even with health professionals. Clinical experience suggests that practice nurses avoid raising this sensitive subject with patients for fear of causing offence. However, while this may make the consultation easier for nurse and patient, it could leave patients with a false impression that obesity is not a problem. The three practice nurses at Manor Park Surgery, Leeds, experienced these problems.
Some patients would seek advice on fashionable diets, seeing the nurses as experts on weight management. Although the nurses knew such diets would be of no real benefit in the long term, they lacked the confidence and knowledge to explain why, or to suggest suitable alternatives.
Appointments for weight management were often brief, and advice on weight loss tended to consist of a list of instructions. Patients were handed information on weight loss, and expected to absorb and act upon it accordingly. Resources available for patients were limited; for example weight loss often took up just a small paragraph within leaflets on heart disease.
Not surprisingly, few patients succeeded. They rarely stuck to a plan for any length of time and many soon stopped seeking further advice. Weight loss was seen as a waste of nurses' valuable time by some members of the practice team, due to the poor success rates. Nurses, however, felt it was an important area for improvement because of the potential effects of obesity, and their regular contact with these patients.
The practice team agreed that lack of direction, time, confidence, equipment and sound knowledge of the subject may have contributed to the poor success rate - a common experience in many general practices (Reckless, 2003).
Despite primary care being cited as an ideal place to tackle obesity, little research has been carried out (Harvey et al, 1999).
The Counterweight programme
In 1999 a group of secondary care physicians set out to fill this gap. The physicians, one from each of seven areas of the UK, specialise in obesity. They noted that their secondary care obesity centres were getting bogged down by inappropriate referrals from primary care and that their minimal resources were being stretched to the limit. They were aware of research showing primary care as being the ideal place to tackle the problem but were also conscious of the fact that there was no support for the primary health-care team to address obesity management - no national service framework (NSF). Hence the Counterweight project was developed. This may lead to a NSF in the future. The aim was to improve the care overweight patients received from general practices.
Counterweight is a structured programme delivered by members of the primary care team. Participating patients are offered support while they make lifestyle changes necessary to lose and maintain weight.
In addition to measuring weight loss achieved, the effect of weight loss on obesity-related co-morbidities is also examined.
At present the programme is being run in 80 general practices in seven regions of the UK: Aberdeen, Glasgow, Bath, Birmingham, London, Leeds and Luton.
In each area running the programme, a weight-management adviser, who is a dietitian, has been appointed as part of the research project. He or she works with the secondary care physician and facilitates the programme in GP surgeries.
Our weight-management adviser works with Dr Julian Barth at Leeds General Infirmary. Initially the practice was audited by the weight-management adviser, and the prevalence of obesity, existing management and incidence of co-morbidities recorded to provide a 'snapshot' of obesity in the practice. She audited a sample of 100 patients on the prevalence and management of obesity and co-morbidities to raise awareness for the practice team.
Three two-hours interactive workshops were run for the nurses involved by the weight-management adviser. These covered:
- Screening and assessment of patients
- Healthy eating
- Energy balance
- Physical activity
- Behavioural change.
The Counterweight programme can be delivered to patients individually or in a group setting. Initially the practice nurses saw patients on an individual basis, with the weight-management adviser present. As the nurses' skills and knowledge developed, the weight-management adviser took a more background role.
At patients' first appointment weight loss is discussed and realistic goals are set. A loss of 5-10% of initial body weight is encouraged. This has shown to be beneficial to health (RCP, 2003). Baseline recordings of weight, waist circumference, blood pressure, blood lipids and glucose are taken and relevant information is gathered and noted on a patient record card.
Initially, patient motivation can be difficult to gauge. A patient questionnaire is provided to assist this, but assessment becomes easier with experience. Regular patient contact helps maintain patient motivation, especially if the programme is delivered with continual enthusiasm.
Patient leaflets and practitioner tools are included in the programme. The practice has 18 leaflets for use during patient consultations, covering topics including:
- Cooking methods
- Reading food labels
- Social pressures to eat
- Eating behaviour.
Often patients know the basics of weight reduction but are deterred by the practicalities of adapting it into family life. Use of the leaflets assist consultations by using everyday examples of foods and situations to which patients can readily relate. Other support materials provided are food diaries, goals booklets, desktop flipcharts and tables to help calculate eating plans.
Patients are offered a choice of two lifestyle approaches:
- Goal-setting (Box 1)
- The prescribed eating plan (Box 2).
Using a food diary with either approach can help the nurse and the patient identify areas requiring change. The diaries help patients see their food intake and balance and identify their eating habits, thus enabling them to realise what changes they need to make.
Either method should enable patients to lose 10-12lb over 12 months. Sometimes patients do not feel this is enough, but if nurses point out the long-term health benefits to be gained from modest sustained weight loss, patients usually understand why the programme encourages small but permanent changes to lifestyle. This is in contrast to unrealistic periods of food restriction, which are likely to be short-lived, as seen in many 'fad' diets.
Patients seen individually are offered fortnightly appointments over a three-month period, which are structured around their choice of goal-setting or prescribed eating plan. Often patients need help in putting weight loss advice into practice and this is where the nurses hope to help by offering the right information, guidance and support.
Weight reduction has tremendous benefits for obese people, but is not achieved quickly. Support and encouragement are vital to maintain motivation. Nurses need to build up a good rapport with patients to make them feel comfortable while discussing what can be an extremely sensitive subject.
A group programme uses the goal-setting method. Patients are offered six sessions, which take place fortnightly, each covering a different aspect of lifestyle change. A practitioner manual is provided to assist in session planning.
The group work is relaxed and interactive. Members are encouraged to mix and support each other, and many share bad or good dieting experiences or swap useful tips, enjoying the peer support offered. If patients ask for relevant subjects to be included in session, group meetings can easily be adapted. Programmes can be tailored to meet specific needs, such as those of people with diabetes.
The impact of the programme
Initially, the practice was inundated with patients wanting to enrol and the nurses' workload increased. However, through liaison with the weight-management adviser the nurses overcame these problems. Running a group programme helped, while the nurses became more proficient over time. Individual appointments take less time as nurses are able to keep patients focused only on weight loss without appearing to rush them.
Recruitment has now slowed to a steady rate of one patient per nurse per month. However, there is the capacity to take on more patients if necessary, for example after a holiday period.
The programme has benefits for both patients and nurses. Three-monthly audit results have supported this, although gaps in the practice's data recording have been identified by the weight-management adviser and need addressing.
The practice has had good attendance at the three-month point, with 96% of patients having either maintained weight or achieved a 5% loss.
At six and nine months, weight loss remains good and the figures show favourable results compared with regional and national audit figures. However, at the 12-month point the practice records are incomplete. Incomplete data arises when patients fail to keep appointments. Nurses are trying to address this by following up patients more actively, through sending letters, highlighting patient records and making opportunistic telephone calls. This has yielded positive results.
Figures from the first 1300 patients recruited into the programme nationally show that 44% of patients who complete the planned intervention over three to six months maintain a loss of 5% at one year (Ross, 2003). We hope that our figures will match this.
These audit results and feedback from patients suggest this programme is worthwhile (Box 3). The nurses no longer shy away from approaching the subject of obesity as they can offer support to patients who are willing to lose weight. They are also better equipped to tackle the subject with patients who are not as receptive to weight loss advice.
It is hoped that the Counterweight programme will become a nationwide initiative, although this will depend on funding.
The new GP contract places strong emphasis on chronic disease management. Counterweight could have an important role to play in primary care, in helping to reduce the incidence of obesity and its associated co-morbidities.
- Readers interested in finding out more about the Counterweight programme should contact Hazel Ross, National Co-ordinator, by email: hazel.ross@ counterweight.com
Harvey, E.L., Glenny, A.M., Kirk, S.F., Summerbell, C.D. (1999) A systemic review of interventions to improve health professionals' management of obesity. International Journal of Obesity Related Metabolic Disorders 23: 1213-1222.
National Audit Office. (2001)Tackling Obesity in England. Report by the Comptroller and Auditor General. London: The Stationery Office.
Reckless, J. (2003)Knowledge, Attitudes and Confidence of General Practitioners and Practice Nurses in Lifestyle Management (poster presentation). London: Diabetes UK.
Ross, H. (2003)A Primary Care Obesity Programme (briefing). Available at: www.aso.org.uk/apps/conferences/briefings_content.asp?HeaderId=361 (Accessed March 2004)
Royal College of Physicians Working Party on Obesity Management. (2003)Anti-obesity Drugs: Guidance on appropriate prescribing and management. London: Royal College of Physicians.