There is ample and robust evidence of the increasing prevalence of obesity, and the extent to which it is damaging to health.
There is also compelling evidence that weight loss is highly beneficial in reducing risk of serious chronic disease.
The data reported by the Counterweight Programme provide the 'missing link' proving that the induction and maintenance of weight loss is possible across a population 'in the wild' in primary care, and is clinically effective and cost-effective.1-3
The provision of Counterweight in clinical care may well ultimately cost less than ignoring weight management.
The evaluation of the cost-effectiveness of the Counterweight Programme uses the economic model originally developed to provide input to the UK national guidance on obesity, developed by NICE.
The cost per QALY (quality adjusted life year) for patients who complete Counterweight is £57 using a worst-case scenario where all weight lost is assumed to be immediately regained.
In comparison, the cost per QALY for smoking cessation is £700. The accepted benchmark for cost-effectiveness in the UK is £20,000-30,000 per QALY.
Cost-effectiveness analysis is now underway on the intention-to-treat population and results will be available by May.
Obesity affects almost a quarter of the adult population of the UK, and is the main driver behind type-2 diabetes as well as being a major factor in CVD, cancer and many other conditions.
Weight loss in primary care is only of interest as a method of improving a person's health, rather than appearance, and is a means of modifying the cardio-metabolic risk of those in the highest categories.
For such patients, a weight loss target may be set at around 5-10 per cent, a level that, when achieved by lifestyle intervention, has been shown to reduce progression to diabetes by an impressive 58 per cent over four to six years.4,5
The degree of weight loss achieved by Counterweight is comparable with that induced in these studies. A single unit decrease in BMI is associated with a reduction incidence of type-2 diabetes by 13 per cent.6 Multiple other clinical benefits result, such as reductions in CVD risk factors including BP and lipid profile.7,8
Obesity is associated with increasing prescribing costs across all categories of the formulary, and deliberate loss of weight is linked to reduced costs or at worst, avoidance of increased costs of pharmaceutical agents.
The Counterweight intervention programme is a structured pathway for management of obesity in primary care consisting of screening and evidence-based treatment guidelines.
There are three main options for intervention that patients can opt to undertake, including a goal-setting approach, a structured prescribed eating plan or a group programme, all based on 500-600kcal energy deficit.
Based around the clinician and patient agreeing small but permanent changes in behaviour, eating and physical activity habits, this approach 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.
Prescribed eating plan
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 500-600 kcal energy deficit daily.
This approach is suited to patients who want to know about the amounts and types of foods to eat and patients who appear to eat a good quality diet but overdo the portion sizes.
The group programme is based on the goal-setting approach outlined above. This is appropriate for patients who may benefit from social support from the other group members or for patients with low self-efficacy.
Weight management advi-sers, all registered dietitians or public health nutritionists, provide a 12-hour training prog-ramme for practice nurses or other staff responsible for the delivery of the intervention.
They then provide clinical support to nurses treating patients in weight management clinics, groups or opportunis- tically.
So far, 30 per cent of all patients who attend Counterweight appointments achieve [s40]5 per cent loss and this weight loss is maintained at one and two-year follow up. 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 80 per cent of patients who attend Counterweight do not gain weight when reviewed.
Counterweight is commissioned through PCTs in England whereas in Scotland the programme is funded centrally by the government and is available to all health boards across the country.
It not only provides the 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 primary care.
- Dr Haslam is a GPSI in obesity and cardiometabolic disease in Hertfordshire, physician in obesity medicine at the Centre for Obesity Research at Luton & Dunstable Hospital, and clinical director of the National Obesity Forum
- For more information about the Counterweight Programme visit www.counterweight.org
1. The Counterweight Project Team. A new evidence-based model for weight management in primary care: the Counterweight Programme. J Hum Nutr Dietet 2004; 17(3): 191-208.
2. The 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(553): 548-54.
3. The Counterweight Project Team. An Economic Evaluation of the COUNTERWEIGHT Programme in the United Kingdom. Circulation 2007; 116: II_822.
4. Diabetes Prevention Programme Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346(6): 393-403.
5. Tuomilehto J, Lindstrom J, Eriksson 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 (18): 1,343-50.
6. Wei M, Gaskill S, Haffner S, Stern M. 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-a 7-year prospective study. Obes Res 1997; 5(1): 16-23.
7. National Heart, Lung and Blood Institute. The Practical Guide. Identification, Evaluation and Treatment of Overweight and Obesity in Adults. National Institutes of Health; USA,1998.
8. Avenell A, Broom J, Brown T et al. Systematic review of the long term outcomes of the treatments for obesity and implication for health improvement. Health Technology Assessment 2004; 8.