Serve up a change that lasts for life
Combining weight loss intervention with therapy and medication has led to improved outcomes for obese patients, say Robert Langford and colleagues.
Promoting healthy eating and reducing obesity has become a global public health priority. Shropshire Community Health Trust is meeting this challenge by providing a range of weight management services under the umbrella “Why Weight?”. Among these services, Why Weight? For Tomorrow calls on intensive psychological, clinical and behavioural change intervention for morbidly obese clients, primarily designed to reduce or prevent the need for co-morbidity prescription medication and bariatric surgery.
There are an estimated 4,000 morbidly obese people in Telford and Wrekin, 400 with a body mass index greater than 50. Our largest client had a BMI greater than 80. Most of our patients have a range of medical issues which are both debilitating to the individual and expensive to the NHS. They also have a complicated and emotional relationship with food, which for many stemmed from childhood. They have tried and failed to lose weight many times trying “every diet on offer”.
Initial engagement was emotional and complex where deep rooted beliefs are brought to the surface and clients were encouraged to challenge and modify these. They saw this NHS service as their last chance to live a “normal” life.
The service was by GP referral only and based in community settings. The six-month pilot in 2009-10 was extended to the whole of Telford and Wrekin in 2010-11. The criteria for referral was a BMI greater than 40. The service was also the pre-bariatric surgery pathway.
Initially, an intervention involved a 12-week intensive clinical and behavioural change programme to support patients in making lifestyle changes that would enable them to lose weight by improving their diet and increasing their physical activity levels, with monitored weight loss medication an additional option.
The programme was based around a prescribing nurse and self-management worker assessing the patient’s needs and tailoring a programme to meet them. A cognitive behavioural therapist also provided input. The original programme was modified as it developed and focused on:
- effective prescribing and monitoring of weight loss medication;
- support for lifestyle change issues and helping clients make change a reality;
- ongoing motivational support;
- and group workshops based on cognitive behavioural therapy.
User focus groups were held to evaluate the programme and delivery. All elements were rated very good or excellent, but that support was required for more than 12 weeks. The evaluation of the cognitive behavioural therapy workshops and one to one support confirmed the benefits of using talking therapies, as well as behavioural change, to achieve weight loss.
Why weight? for tomorrow: the findings
- Pre-programme 46 per cent had a BMI greater than 50 compared with 32.4 per cent at 12 weeks
- 13.5 per cent were no longer morbidly obese
- Pre-programme 64 per cent had a total cholesterol under 5 mmol/l compared with 75 per cent at 12 weeks
- 70 per cent of clients reduced total cholesterol
- No clients had a low density lipoprotein below 2 mmol/l pre-programme compared with 9 per cent at 12 weeks
- 73 per cent reduced LDL
- Pre-programme 71 per cent had a cholesterol ratio above the ideal compared with 57 per cent at 12 weeks
- 66.7 per cent reduced their systolic blood pressure
- Target weight loss at 12 weeks was 5 per cent
- 92 per cent lost weight with 62 per cent reducing it by at least 5 per cent
- 15 clients went on to 10 per cent and two achieved 15 per cent weight loss
- Average weight loss was 6.2 per cent (8.5kg) with a largest individual loss of 16 per cent
- Total weight loss for the group of 37 weighed at 12 weeks was 285.4 kg
- Equates to 74 disability adjusted life years
Weight loss medication
- For clients prescribed Orlistat (26/37) 92 per cent lost weight with average weight loss of 9.93kg
- Of those losing weight without Orlistat, average loss was 6.08 kg
- Studies estimate an additional weight loss of 2.5 to 3kg with the use of medication
- Close monitoring of weight loss on medication proved particularly effective with additional weight loss at 3.85kg
- Of the 12 clients with diabetes, five reduced their HBA1C levels
- Six readings were unattainable, one was unchanged
- Pre-programme, 33.3 per cent had a pre-diabetic glucose reading (7-13mmol/l) compared to 13.9 per cent at 12 weeks.
Cardiovascular disease risk
- Importantly, 67 per cent of clients reduced their CVD risk
- 30.5 per cent reduced risk by 2 per cent or more
- 11 per cent reduced their risk by 5 per cent or more
During the pilot, half of the clients were prescribed weight loss medication. The impact of the behavioural change and therapeutic interventions combined with effective medication management resulted in all of these patients achieving weight loss.
Effectiveness was measured by weight loss, disability adjusted life years and improved clinical metrics.
For those clients considering surgery, there was the additional measure of those who felt confident of success through lifestyle change.
In 2009-10, there were 173 clients on the programme. Thirty had a BMI greater than 50 and lost on average 4.61kg at 12 weeks. Disability adjusted life years were 57. Most showed significant reductions in total cholesterol, blood pressure and blood glucose.
Learning from the Why Weight? For Tomorrow pilot played a significant part in developing the 2010-11 programme. Following client feedback and an evaluation of the pilot, the programme was enhanced. The new programme ran for 26 weeks, complying with National Institute for Health and Clinical Excellence recommendations.
Once referred, patients received six weeks of one to one support from the prescribing nurse and self-management workers before commencing a 12-week workshop programme that focused on using cognitive behavioural therapy principles to assist in weight management. One to one reviews took place at week six of the programme and eight weeks after they ended.
T-tests were performed to determine whether there was a significant difference for weight loss, BMI, cholesterol ratio, total cholesterol, cardiovascular disease risk, low-density lipoprotein and glucose levels.
The mean values for weight loss, BMI and cholesterol ratio were not significant. However, there were significant differences for total cholesterol, CVD risk, LDL and glucose.
For bariatric surgery referrals, pre-programme, 43.2 per cent (16/37) of patients wished to have gastric surgery, compared with 29.7 per cent (11/37) at 12 weeks. Since beginning Why Weight? For Tomorrow, 50 people who wish to have gastric surgery have been assessed. At December 2010, only 18 of these still wished to pursue gastric surgery. The cost savings forecast is around £350,000.
Clients completed a wellbeing questionnaire before and after the programme. The questionnaire sought to establish the client’s emotional wellbeing at time of assessment, their confidence and motivation in achieving weight loss, together with their confidence in continuing weight loss post-programme.
It also looked at their mood in relation to their weight. The evaluation showed significant improvement for all of the above. In particular, client levels of depression reduced markedly, as did anxiety, anger and feelings of shame and guilt. Self-belief in their ability to continue losing weight post-programme moved almost all clients into the high/very high category.
We aim to continually develop the programme and integrate evidence based research into our content, structure and delivery.
Robert Langford (firstname.lastname@example.org) is the service manager for adult obesity, Caroline Lacey (email@example.com) and Manpal Singh Bhogal (firstname.lastname@example.org) are health improvement practitioners at Shropshire Community Trust.