An educational tool for managing obesity in primary care

It is well recognised that obesity substantially increases the risk of morbidity and mortality, particularly in relation to conditions involving the cardiovascular, respiratory and endocrine systems (Conway and Rene, 2004). Primary care organisations are now at the forefront of the management of long-term conditions and as levels of obesity continue to increase so too will the burden of care associated with this complex condition. Those working in a primary care setting are ideally placed to detect, monitor and manage obesity; however, few practitioners have received formal training on this topic (Astrup et al, 2004) and there is a lack of suitable educational resources compared with other areas of chronic disease management.

The rationale for developing an educational CD-ROM
The purpose of producing an educational CD-ROM was to make available a comprehensive, flexible and interactive tool which would aid practitioners in developing the necessary knowledge and skills to manage obesity in primary care.

The specific aims of the National Obesity Forum’s (NOF) CD-ROM are as follows.

• To inform and update health professionals (primarily GPs and practice nurses) on the causes, consequences and prevalence of obesity.
• To highlight the importance of treating obesity and to recommend a treatment algorithm which will guide practitioners to approach weight management in a structured and cohesive manner.
• To provide detailed guidance on the treatments available to manage adult obesity.
• To outline a framework on how obesity management could be integrated into the existing responsibilities of a primary care team.
• To improve understanding of childhood obesity.
• To provide support materials and suggestions for further reading, and other resources, which aid in the management of obesity.

CD-ROM technology has allowed the information to be presented in two parts. The first part provides for those with limited time and gives practical guidance on all aspects of the obesity management algorithm. The information is presented in an interactive summary format (Figure 1 illustrates the menu screen), enabling users to work through each clearly defined section at their own pace and order of preference/need; this includes video clips of role-played patient–practitioner scenarios as well as graphics and voice-over demonstrations of various techniques, such as how to measure waist circumference (Figure 2). The second part of the CD-ROM is presented in the form of in-depth PDF articles and supports the interactive layer by providing the user with more detailed information and references.

Using the educational tool
Primary care practitioners already manage a wide variety of chronic conditions in their practice populations. The addition of obesity management can therefore be a daunting prospect and many GPs and practice nurses have expressed concern about their level of skill and the capacity of primary care to manage this condition effectively. The NOF educational package provides those working in primary care with a tool which reflects modern technology, is comprehensive in nature and is structured for flexible learning to enable them to better manage obesity in their practices.

The management algorithm can be adapted to fit with local strategies. Users can download tools (such as food and activity recording sheets, and information leaflets for patients) from within the package. The CD-ROM would also complement any relevant obesity training accessed by staff and could serve to update and consolidate any knowledge gained.

The management algorithm
The educational package is built around a management algorithm, which provides guidance on how obesity interventions can be structured in primary care (Figure 3). Simplicity and utility were key concepts in terms of the development of the algorithm. Users are guided through each step of the algorithm and explanations are provided on how to:

• screen and target groups
• raise the issue of obesity and discuss options for intervention
• conduct a clinical and behavioural assessment.

The evidence relating to treatment options, including diet, physical activity, medication and surgery, are outlined in the in-depth PDF files with practical guidance on each of these treatments provided in the interactive part. Non-NHS treatments (such as commercial slimming clubs, self-help books and internet sites) are also considered. The important aspect of long-term weight maintenance is included in the management algorithm.

Screening and targeting groups
Obesity is a serious condition with adverse affects on health. Since the 1980s the prevalence of both overweight and obese people has increased markedly in both adults and children (Rennie and Jebb, 2005). With data from the Health Survey for England showing that 23% of men and 25% of women are obese it could be anticipated that at least one in four of a practice population will be obese (Joint Health Survey Unit, 2002). However, this will vary depending on factors such as ethnic diversity and levels of social deprivation within a population. For example, data from the Health Survey for England showed that Black Caribbean women were twice as likely to have morbid obesity compared with women in general (Joint Health Survey Unit, 2002). Obesity has also been shown to be associated with poverty (James et al, 1997) and poor levels of education (NHS Centre for Reviews and Dissemination, 1997). There are a number of factors accounting for the association between deprivation and obesity; for example, dietary surveys show that lower income families have less variety in their diet, eat fewer essential nutrients and have a diet that contains high fat and sugar levels (Henderson and Gregory, 2002).

Currently, a primary care practice is not compelled to collect data on the body mass index (BMI) of each registered patient, but without these data it is difficult to gauge the extent of the problem and to consider who should be prioritised and targeted for treatment. It has been reported that obese patients visit their GP significantly more often than normal-weight patients and account for a greater proportion of the prescribing budget (Laws, 2004). This highlights the potential benefits of targeting this group for treatment but with potentially large numbers of such patients the educational tool emphasises that it is important to prioritise.

It may be more practical to initially target groups that already attend the practice regularly, for example those attending diabetes clinics, cardiovascular disease (primary and secondary prevention) clinics, hypertension clinics or those attending smoking cessation clinics who wish to receive additional support with weight management. Alternatively, a practice could focus its attention on prevention of obesity, such as for those with a BMI>28kg/m² who have a strong family history of diabetes, have impaired glucose tolerance or are at increased risk of any associated chronic conditions/co-morbidities. It is also important to offer support to those patients who request help with weight management.

Raising the issue and discussing options
Having agreed a target group, users of the educational tool are guided to the next step, which is to consider what options are available for treating obesity within the practice in the wider locality and to consider how to offer help.

Offering help
Within society, obesity has many negative connotations and health professionals may feel uncomfortable in raising or discussing the issue of body weight. It is therefore important to consider how to broach the subject of weight management with individual patients. A health professional should examine their own attitudes toward obesity and ensure that the topic is raised in an open and empathic manner. It is important to acknowledge past attempts at weight loss, to recognise the complexity of the condition and to offer help in a supportive manner.

Explaining how weight is linked with an existing health concern can help to set discussions about weight loss in context for the patient. The educational tool provides written and video examples of how to raise the issue and offer help with weight management.

Discussing options
Having raised the issue of weight management, it is recognised that not all patients will express an interest and for some it may not be practicable to consider an intervention at this time. If the patient does express an interest in proceeding with a weight management programme, the educational tool prompts the practitioner to consider all of the available options. For example, many localities can avail of an exercise referral scheme or there may be links with a commercial slimming club or other group programmes. If patients are directed to options out-with the practice, it is important that baseline data (such as BMI, waist circumference, blood pressure, blood glucose and lipids) are recorded by practice staff for future monitoring, audit and evaluation purposes. If treating within the practice, consideration needs to be given to how this is organised, implemented and evaluated. Decisions about when to refer to dietetic services and other specialists should be agreed. Additional training for practice staff and how this can be provided is also an important consideration.

Assessment
Obesity is a complex condition and the importance of conducting a comprehensive assessment cannot be overemphasised. The CD-ROM outlines the primary functions of the assessment stage, which are as follows.

• To listen to the patient’s experience of his/her weight and to establish a rapport.
• To elicit the patients’ beliefs and understanding about obesity.
• To gather information that will help to characterise the health risks for the patient.
• To gain understanding of the factors that have led to weight gain.
• To gain a picture of current lifestyle habits.
• To identify any potential difficulties or barriers to change.
• To have the opportunity to discuss the expectations from treatment and to agree a way forward.

In conducting a clinical assessment it is important to have available the appropriate equipment, for example higher-capacity scales and larger blood pressure cuffs. As well as measures of weight, height, waist circumference, blood pressure, blood glucose, lipids and thyroid function, it is important to document any physical effects such as reduced mobility, joint pain and breathing or sleep difficulties. Psychological effects such as low self-esteem and depression should also be considered.

The CD-ROM supports practitioners through each step of the assessment phase and includes video demonstrations of how to take appropriate anthropometric measurements as well as examples of how to explore past attempts at weight loss, gain information about current lifestyle habits and discuss expectations from treatment.

Treatment options
Obesity is a condition that responds to a variety of treatment strategies. What is clear, however, is that a combination of strategies incorporating diet, exercise and behavioural approaches are more effective in the treatment of obesity than any strategy used in isolation (National Institutes of Health, 1998). The goals of any treatment should be to:

• prevent further weight gain
• promote a clinically significant weight loss, for example 5–10%
• support long-term weight maintenance.

The educational tool guides practitioners through each of the treatments including diet, physical activity, medication and surgery.

Within the dietary treatment section, advice is provided on how to help patients stabilise their eating behaviour, improve the nutritional content of their diet and achieve negative energy balance. Information on meal replacements and very low energy diets, as well as popular diets, is also provided.

The benefits of physical activity in terms of improving general health and weight are outlined, with practical guidance on recommended levels of activity, common barriers, specific tools and useful organisations.

Drug therapy is viewed as an adjunct to lifestyle change and the educational package provides information on the mode of action, efficacy, side effects and contraindications of the medications currently available to treat obesity. How to select patients for drug treatment and the importance of discussing expectations from such treatments is given consideration. Over-the-counter weight loss products are discussed; information is also provided on drugs that commonly cause weight gain.

Bariatric surgery is an effective procedure for achieving weight loss, but can currently only be considered for a minority of patients, primarily those with a BMI>40kg/m2 (National Institute for Clinical Excellence [NICE], 2002). The availability of specialist surgeons, the financial implications and the medical risks associated with the procedure currently restrict the number of patients who can be treated. The education package details the type of procedures which are performed and advises on the guidelines issued by NICE on the use of surgery for people with morbid obesity (NICE, 2002). The information that GPs can provide, as well as reliable information sources that patients can access if considering surgery, are outlined. Patients who have undergone bariatric surgery will require life-long follow-up and the role of primary care in this process is considered.

Long-term weight maintenance strategies
Support is recognised as a crucial component of achieving successful long-term weight loss. As obesity is a condition where individuals are prone to relapse, there are implications for practitioners about how best to provide continued contact and support over an extended period of time. In the educational tool, the factors linked with risk of weight re-gain are considered and strategies which have been evaluated for long-term weight maintenance are discussed. Physical activity, continued changes to diet and extended support are recognised as key factors in those who have been successful at maintaining weight loss (Perri and Corsica, 2002).

Childhood obesity
The management algorithm focuses primarily on a pathway for the treatment of adult obesity, but steps such as screening, targeting, assessment and treatment options will also apply in the management of childhood obesity. The educational package provides practitioners with information on how to define childhood obesity, as well as what the causes, risk factors and health effects are. The evidence relating to treatments for childhood obesity, NICE guidelines and how to develop an intervention plan are all discussed.

Conclusion
Obesity is a condition with significant human and financial costs. As the prevalence of obesity continues to increase, healthcare providers will be challenged to find more effective ways to manage obesity and the resultant co-morbidities. The NOF educational package is designed to support primary care practitioners in the management of obesity by providing information and guidance on how to structure this care.

To be effective, primary care must organise and structure its approach to obesity management. Target groups should be identified, an appropriate assessment should be made and all treatment options should be considered in a stepwise fashion. Changes to diet and physical activity remain the cornerstone of treatment but medication and, for some, surgery will offer the best chance of achieving success.

The educational package will provide practitioners with the necessary guidance to support their patients in losing weight, and ultimately should improve the delivery of health care in this area of management of long-term conditions. As new treatment options are developed the management algorithm will evolve, but the basic concepts on which it is formed will not change.

Acknowledgments
Dympna Pearson, Freelance Dietitian, managed the development and production of the CD-ROM. The CD-ROM content was written by Karen Allan (nee Slevin) and produced by TVF Communications (London, UK). The project also had input from general practitioners, a specialist and practice nurse, and a pharmacist. The project was supported by an educational grant from Abbott Laboratories and Roche Ltd.

CD-ROM information
The CD-ROM is available from the National Obesity Forum at a cost of £10 by: Post: National Obesity Forum, PO Box 6625, Nottingham, NG2 5PA

Telephone/fax: 0115 846 2109 Web: http://www.nationalobesityforum.org.uk Email: national_obesity.forum@ntlworld.com

The CD-ROM will run on any PC with a CD drive. It has not been tested on Apple Macintosh computers.