Gerald Ellis discusses factors that are important to consider when implementing an obesity care pathway, including patient education, regular audit, and multi-component interventions

Overweight and obesity increase the risk of a wide range of diseases and illnesses, including coronary heart disease, type 2 diabetes, high blood pressure, and certain cancers; and are responsible for up to 9000 premature deaths each year.1 The average life expectancy is reduced by up to 9 years for an individual who is obese.1 A weight loss of 5%–10% in obese people can achieve significant health benefits.2 Therefore, successful development and implementation of a care pathway for adult obesity could have a significant and positive impact on resources and health.

Effective prevention and management of obesity in the population has a significant effect on improving physical health and psychosocial wellbeing. Implementing preventive strategies for obesity is the most sustainable way of reducing the incidence and prevalence of obesity. This article covers the development and implementation of an obesity pathway within NHS Bassetlaw and key lessons that were learnt.

Background

Tackling obesity across the population is detailed within key national strategies such as, Choosing health: making healthy choices easier, published in 2004,3 Healthy weight, healthy lives: a cross-governmental strategy for England (2008),4 and the more recent public health outcomes framework, Improving outcomes and supporting transparency (2012).5 The need to adopt healthy lifestyles and increase levels of physical activity are detailed within the 2010/11 NHS Operating Framework.6

Development of a weight-management programme

Prior to 2008, the approach to tackling obesity in Bassetlaw was inconsistent and piecemeal, and varied a lot in terms of what interventions were offered and provided. Services were often inefficient, with inflexible clinic times and inconsistent data collection.

In 2008, NHS Bassetlaw launched a locally enhanced service (LES) for an adult weight-management programme delivered via primary care.7,8 The objective of the LES was to help address the local priority of tackling adult obesity by providing a weight-management programme for people with a body mass index (BMI) ?30 kg/m2 or ?28 kg/m2 with co-morbidities. The LES was designed to follow the NICE recommendations on the management of obesity as set out in Clinical Guideline (CG) 43.9 The main elements of the service, which is still running, are summarised below:7,8

  • It involves small-group interventions of approximately 12 patients
  • The structured programme lasts for 12 weeks
  • Patient demographics and ethnicity are recorded
  • Baseline measurements of height, weight, BMI, waist, blood pressure, blood tests (including glycated haemoglobin [HbA1c], cholesterol, and thyroid function), and medical history are taken
  • The patient must demonstrate that they are motivated and ready to make changes10
  • Follow-up assessments are performed at 3 and 12 months following programme attendance
  • Payments to primary care are structured according to patient attendance during the programme, at follow-up assessments, and at achievement of target weight loss. This target is set as 5% of the initial weight, which equates to a loss of 0.5–1.0 kg per week for most patients. This is considered manageable, safe, achievable, and appropriate
  • Quarterly audits of results and annual patient survey reports are conducted
  • Care is delivered by appropriately trained and authorised staff.

The approach was to set up a collaborative cross-practice service to achieve economies of scale and to offer a range of days and times for patients to access services. The weight-management programme was designed and launched under the recognisable and branded theme of ‘Chrysalis’—an underlying message of transformation (see Figure 1, below).11

Figure 1: Chrysalis branding

graph


Principles of the weight-management programme

The LES for the Chrysalis programme was developed with close reference to the evidence-based guidance notes as set out in CG43.9 There is a close relationship between the NICE recommendations and the programme. The details and structure of the ongoing weight-management programme are outlined below:

  • Best practice standards from NICE have been adopted9
  • Clinical judgement is used to determine when to measure height and weight (pre-assessment consultation); and degree of obesity is classified
  • General principles of care for adults have been adopted:
    • Regular long-term follow up is offered
    • There is continuity of care with good record keeping
    • The programme is tailored to individual preferences
  • Patients are assessed for readiness for change, with individual circumstances and willingness to make changes considered
  • Multi-component interventions are delivered by trained healthcare professionals to provide behavioural strategies for increasing activity and making dietary changes
  • Behavioural interventions include self-monitoring (with goal setting and social support), problem solving, reinforcement of changes, and managing relapse prevention
  • Implementation of lifestyle changes include consideration of the following:
    • Patient preferences and social circumstances
    • Tailoring to patient needs and capabilities
    • Sufficient time for consultation
    • Encouragement of spouse/partner participation
    • Documentation of discussions and goal setting
    • Provision of opportunities to recognise and praise success (anonymised reporting plus certificates of achievement given to patients)
  • Interventions for physical activity include the following:
    • Assessment of activity level and use of goal setting
    • Advice on the amount and frequency of activity
    • Emphasis on gradual manageable increases in activity and a reduction in inactivity
    • Advice on different types of activity appropriate to patient needs and capabilities
  • Interventions for dietary advice include the following:
    • Assessment of diet before and after the 12-week programme
    • Tailored and flexible advice
    • Encouragement of the patient to monitor his/her dietary habits and to move towards a more balanced diet
    • Goal setting for daily calorie deficits
    • Ensuring that energy intake is lower than output (patients have the option to be monitored using
      the online calorie system).

Key priorities for implementation from the Chrysalis programme are shown in Box 1 (see below).

Box 1: Key implementation priorities from the Chrysalis

weight-management programme and strategy

  • Dedicated resources should be put in place to implement the obesity weight-management programme
  • Healthcare professionals in primary care settings must ensure that preventing and managing obesity is a priority
  • Primary care should recommend that patients attend community weight-management programmes
  • Healthcare professionals should be educated on the benefits of treating obesity and provided with training in motivational interviewing12,13
  • Healthcare professionals should follow the NICE guideline on delivery of interventions to improve diet and increase level of physical activity, including:
    • offering tailored advice and ongoing support, and promoting activities that raise awareness of the benefits of a healthy diet and exercise
    • discussing weight, diet, and activity at times when weight gain is more likely (e.g. during pregnancy or when patients are trying to stop smoking).

Patient education and participation

Patient education is key to successful management of adult obesity. In this programme, education began with effective communication about availability of the services, and what enrolment involved. It was important to build a strong brand—Chrysalis—that patients could associate with positively and recognise in all communications.

A vital component of the LES was the pre-assessment appointment, which provided an opportunity not only to capture baseline measurements, but for staff to acquaint themselves with the patient and to discuss his/her motivation and readiness for making lifestyle changes. This was conducted by a course leader who understood the service fully.

The 12-week programme was structured with course handouts and defined presentation materials in order to ensure that services were delivered consistently. Messages were clear and simple and sessions were designed to be interactive. Each patient had a personal development plan and was encouraged to set personal goals each week that were relevant to the session. Each week, patients were weighed and given an opportunity to raise personal issues or concerns individually or within the group, and to check on weight-loss progress and setting and achievement of goals.

The emphasis of the Chrysalis programme was on supporting patients to make simple, gradual, and achievable changes that were likely to be sustained, through a process of education, motivation, and discussion. Patients were provided with step counters as a way of encouraging them to have an appreciation of their activity levels and to facilitate agreement of activity goals. Specific supplementary patient information was provided as appropriate, which included leaflets published by the British Heart Foundation (www.bhf.org.uk/publications/most-popular-publications.aspx). These covered a range of topics such as a balanced diet, and controlling salt and fat intake. The World Cancer Research Fund was also a useful source of educational resources and healthy recipe ideas (www.wcrf-uk.org/cancer_prevention/publications/download_publications.php).

The Chrysalis programme now provides additional online support so that patients can monitor calories eaten and drunk compared with calories consumed through activity.


Implementation of the initiative locally

Rather than have each surgery develop their own interpretation and delivery of the LES, a collaborative approach was taken and a service was developed that was accessible initially by patients from all four practices in Retford. Patients could be referred by a clinician or self-refer. Patient information leaflets were created, practice information about the service was circulated, and a central administration and management facility was established through Retford Health. A pilot group was established to ensure that processes and materials were appropriate. After a review of processes, the availability of services was promoted. Frequent press releases were sent to the local press and banner promotions were used in surgeries. Local supermarkets were also keen to help raise awareness of the services.

A capacity problem arose as demand soon outstripped capability, and dedicated staff members were recruited to focus on service provision. This permitted a range of session days and times to be offered (i.e. Monday–Thursday, in the morning, afternoon, or evening), which met service demand.

The administration facility handled all enquiries and follow up for patients who had missed sessions, and provided a recall system for assessment following course attendance.

The team held regular multidisciplinary meetings (quarterly) to review progress, audit results, patient feedback, and to look at ways of improving the services. This resulted in patients being able to choose to attend targeted groups, such as:

  • men only
  • patients with learning disabilities
  • patients below the age of 30 years.

As a result of regular audit and review, an introductory exercise class was established, along with opportunities to have regular weigh-ins following completion of the 12-week programme. Modified interventions for patients with a BMI over 40 kg/m2 and for groups where teenagers and their parents can attend together, are being piloted (in line with CG43).

The Chrysalis programme has now been extended so that it is available to four other surgeries in Bassetlaw.

Up to December 2011, the 12-week Chrysalis programme had enrolled 1158 adults of whom 81% were women and 19% were men. The following outcomes were achieved:

  • 91% of patients attending the programme lost weight
  • 73% of patients attended six or more sessions
  • 41% of patients achieved a target weight loss of 5%
  • The reduction in BMI for men and women was -1.9 kg/m2 and -1.4 kg/m2, respectively
  • The average weight loss of people attending six or more sessions was 5.2 kg
  • 58% of patients who attended six or more sessions had lower blood pressure after 12 weeks
  • 82% of patients who attended six or more sessions showed an improvement in dietary habits
  • 71% of patients who attended six or more sessions had confirmed increases in physical activity.

Certain patient groups (e.g. people with a BMI over 40 kg/m2 and patients aged under 30 years) were shown to have below-average success in losing weight.

Of the 206 patients who received an assessment 12 months after attending the initial 12-week programme:

  • 85% of patients were at a lower weight than when they first started the programme
  • 50% of patients had either maintained or lost more weight than at the start of the programme.

The Health Profile of 2011 estimated that 24.5% of adults are currently obese in Bassetlaw (the England average is 24.2%) compared with 27.6% of adults in 2008 (England average of 23.6%).14,15 The local strategy for tackling obesity, of which the LES is one of many components, is having a positive effect.

Case studies

Patient A had regular bouts of migraine and used to attend GP appointments an average of four times a year for the past 3 years. She lost 6.8 kg in 12 weeks and had maintained this weight loss 12 months later. She has only seen her GP once in the past 12 months after attending Chrysalis; her GP commented that the patient was like a different person.

Patient B was recently diagnosed with type 2 diabetes. Following attendance of Chrysalis:

  • her medications were reduced from four items to a single item
  • her cholesterol levels and level of blood pressure were lowered
  • she had lost 5.6 kg.

Patient C lost 13 kg following attendance at Chrysalis and has continued to lose weight 12 months later. He is now running 10 km races frequently, has changed his job, and feels much better about his life and future.

Patient feedback

Feedback on the Chrysalis programme has been very positive:

  • 95% of patients who attended and completed the programmes confirmed that they were pleased with what they have achieved and had made positive lifestyle changes
  • 99% commented that the Chrysalis programme compared favourably with other programmes which they have attended.

A separate internal report summarised written feedback on the weight-loss programme, but the following comment typifies patient feedback: ‘Chrysalis is more personal than other weight groups that I have tried, it does not try and sell you products and staff are more helpful. This is much better, more balanced, more health information, less pressure. It was very informative and enjoyable.’


Key results and benefits

The main cost incurred from developing the Chrysalis weight-management programme was related to staff. Qualified staff needed to put aside dedicated time to be involved in the design of the 12-session presentation materials and handouts, and sourcing of the appropriate supporting booklets. Additional staff were recruited specifically to address the increase in service demand.

Further costs resulted from development of branding, information leaflets, and promotional materials, and purchase of hardware for delivery (e.g. laptop, projector, and screen).

Programme costs

Weight-management programmes led by GPs and delivered in primary care settings can be highly successful, as demonstrated by the Chrysalis programme in NHS Bassetlaw. It delivered sustained weight loss, with excellent patient feedback. Implementation of this programme highlighted a number of important factors. The use of motivational interviewing is important to help patients understand their motivation and confidence to achieve permanent behaviour changes.10 A performance-related payment system that rewards achievement, attendance, and sustained weight loss is an effective way of funding programmes for weight loss. Regular audits led to targeting of specific groups, in particular, men, young people, and patients with a BMI over 40 kg/m2.

Further changes to the LES are expected in terms of enhancing practice rewards for lifestyle improvements and sustained weight loss.8 In addition, we anticipate that further development to include teenage support will be confirmed after a successful pilot.

Conclusion

View the Guidelines summary of the NICE guideline on Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children at: egln.co.uk/link/17

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