Contents

1. Introduction to the Counterweight Programme
2. What Counterweight Offers
3. Considerations before implementing Counterweight
4. Counterweight Outcomes
5. Counterweight Resource
6. Structure of Counterweight Team
7. Progress in England and Wales
8. Progress in Scotland
9. 2008 Counterweight Programme Costs
10. Checklist

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Introduction to the Counterweight Programme

Obesity is a major public health concern due to the burden of obesity-related disease, impaired quality of life and implications for health service expenditure now and in the future. United Kingdom (UK) prevalence data indicates that 23.8% of women and 23.6% of men in England and 26.0% of women and 22.4% of men in Scotland are now obese.  The UK is following trends in the USA where 33.2% women and 31.1% of men were obese in 2004. There is overwhelming and consistent evidence that obese patients with no intervention will steadily gain further weight over time.  The obese population attend general practice frequently and obesity is associated with increased prescribing costs.

Lifestyle intervention that produces modest weight loss of 5-10% of initial body weight results in multiple clinical benefits including reductions in cardiovascular risk factors and has been shown to reduce the rate of progression to diabetes by up to 58% over a 4-year period.  A drop of one BMI unit has been shown to reduce incidence of type 2 diabetes by 13%.

The Counterweight Programme has been developed and evaluated between 2000 and 2005 and has been shown to be an effective model for obesity management within general practice.  It incorporates implementation of evidence-based pathways and strategies to empower clinicians and patients. The Counterweight Project extensively audited the burden of obesity to primary care and has published in this area. Using a system of continuous improvement methodology, findings from the Counterweight Project have been used to review and refine the programme.

The model is based on Weight Management Advisers (WMAs; dietitians specialising in obesity management), working across Primary Care Trusts (PCTs) training and supporting healthcare staff to put the Counterweight weight management programme into practice.  It is anticipated that each trained practice could treat an average of 50 patients in a year. Each Counterweight patient is recommended to have nine appointments of 10-30 minutes duration in the first year.

Lifestyle intervention is recommended as a first line approach to weight management, this is delivered individually or in groups; second line interventions may include the use of anti-obesity medications, referral to a dietitian, psychologist and/or a secondary care service.  Weight maintenance is encouraged either following weight loss or as the first option with particular groups of patients.

Counterweight is tailored to suit local priorities, services and available personnel. Counterweight is designed to integrate into a wider obesity management strategy involving key stakeholders from primary and secondary care. Within primary care the whole team including GPs, nurses, assistants, dietitians, practice managers and receptionists should be engaged in decisions regarding implementation of the programme.

Locally employed (buddy) dietitians are involved in order to take over responsibility for Counterweight once the model has been implemented. Training an additional NHS dietitian could provide support for 5 extra practices in the first 18 months and sustain the model in the following years.

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What Counterweight Offers

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Considerations before implementing Counterweight

• The appointment of a minimum 0.4 wte dietitian decated to Counterweight to ensure sustainability of the programme
• Identification of key personnel to lead the programme within PCTs/health boards and practices
• Development of an obesity strategy in each PCT/health board area to include Counterweight as a primary care intervention to address obesity
• Identification of personnel to lead patient education and support within the practice
• Potential overlap or streamlining of any existing local weight management services
• A review of necessary equipment for weight management
• Type of service to be offered including the interventions to be made available within the PCT
• Patient screening and referral criteria
• Structure for appointments to be offered
• Time commitment of the practice to weight management
• Documentation of clinical measures to enable audit of outcomes
• Local factors which may require additional attention prior to programme implementation

The level of patient screening and treatment of patients onto the programme needs to be agreed within each practice. Different surgeries may decide to screen for obesity more aggressively in high risk patient groups.  

General Practitioners

The role of GPs in the weight management service is discussed and agreed depending on local requirements. At a minimum, GPs need to be aware of the Counterweight weight management pathway agreed for use in the practice and be involved in screening and referral of patients to the service. GPs with a particular interest in managing obesity may also be involved in delivering the intervention, patient education and support. All GPs are recommended to attend a one hour practice meeting; topics discussed include patient screening, raising weight as an issue and the stages of change model for selection and identification of motivated patients, as well as the clinical benefits of a 5-10% weight loss in a ‘high risk’ population.

Nursing Staff and Health Care Assistants

Practice Nurses play a key role in the delivery of lifestyle interventions in primary care and were identified as best placed to deliver the weight management intervention for patients in the pilot project. In clinical practice, other practitioners such as healthcare assistants, health visitors and lifestyle counsellors/health trainers may be selected as the key group to give this support.

The WMAs provide 8 hours of training for the practitioners prior to programme implementation. Topics include patient screening and assessment, healthy eating and energy balance, dietary approaches to weight reduction, physical activity guidelines, behaviour change techniques, pharmacotherapy and patient monitoring for weight maintenance. The WMAs provide on-going clinical support and mentoring for 6 months after training, a time deemed appropriate for a recognised level of competency to be reached by those involved.  The WMAs assist the nurses in establishing clinics and groups, and support the conversion of knowledge and skills acquired into clinical practice.

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Counterweight Outcomes

Findings

In the research phase of the project, a quarter of patients had a BMI ≥ 40kg/m2, 76% had at least one obesity related co-morbidity and 47% were classified as high attenders.  Mean weight change at 12 months was -3.0kg in all patients (n=684, p<0.001) and -4.3kg in high attenders (n=422, p<0.001).  At 24 months weight change was -2.4kg in all patients (n=391, p<0.001) and -3.3kg in high attenders (n=225, p<0.001).  Thirty percent of all patients enrolled and followed up in the programme and almost forty percent of high attenders maintained ≥5% loss at 12 months. 
Obesity-related cardiovascular disease (CVD) risk factors improved in the whole cohort.

Interpretation

The Counterweight Programme is an effective evidence-based model for improving the management of adult obesity and associated CVD risk in primary care.

• Moderate weight loss brings significant clinical benefit
• Counterweight provides a pragmatic model for the management of obesity
• Weight loss outcomes compare favourably with higher cost RCTs

Effect of Counterweight Intervention on Prescribing Costs

By applying the mean change in BMI observed in the pilot phase of Counterweight to the costs of prescribing at varying BMI levels expected savings can be estimated. These savings were 6.3% of prescribing costs for all patients and 8.4% of prescribing costs for patients whose attendance with the programme was optimal. Attributable prescribing costs of obesity were calculated by applying cost at BMI> 30kg/m2 minus cost at normal weight, multiplying up by the population of the UK and showing as a proportion of total prescribing costs.

After applying the % savings estimated from weight loss observed with the Counterweight Programme, it can be concluded that in year 1 alone, 10% of the cost of the programme can be offset through prescribing savings (this figure increasing to 25% when programme attendance and follow-up is optimal).

Longer Term Cost Effectiveness

Applying the NICE model to evaluate the long term impact demonstrates that providing Primary Care obesity management is cheaper and more effective than providing no weight management intervention.

• Prescribing costs increase with increasing BMI
• Weight change outcomes observed in the Counterweight programme will bring associated cost savings
• One quarter of all prescribing costs can be attributed to overweight and obesity
• Longer term analysis shows that providing Counterweight is cheaper and more effective than doing nothing

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Counterweight Resource

Currently the Counterweight model in England is funded partly from government money made available to PCTs to undertake obesity management training, with the remaining costs being met by an unencumbered educational grant.  In Scotland the programme is completely funded by the Scottish Executive as part of a roll out alongside the CVD anticipatory care initiative P2010 / Keep Well.

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 Structure of Counterweight Team

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Progress in England and Wales

As of May 2007, the following areas have been covered:

• Bedfordshire
• Heart of Birmingham
• Blackpool
• Buckinghamshire
• City & Hackney
• Durham
• Kirklees
• Lincolnshire
• Luton
• Wiltshire
• Aberdeen City (commissioned for the England and Wales rollout)

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Progress in Scotland

As of May 2007, the following areas have been covered:

• Lanarkshire
• Lothian
• Tayside

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2008 Counterweight Programme Costs

Counterweight Weight Management Advisers (Specialist Dietitians) provide the following input over a 12 month period:

• Introductory meetings to present programme overview and data
• Input to obesity strategic work as required to position Counterweight in local plans
• Delivery of Counterweight training sessions
• Mentoring programme for practitioners held in their usual workplace
• Advice on evaluation of programme outcomes
• Training of a 'buddy' dietitian
• Delivery and management of Counterweight within first 10 practices

Evaluation and Qualitative Outputs are an optional extra cost of between £5000 - £10,000 dependant on requirements

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Checklist

• Secure funding for implementation of Counterweight
• Secure funding for a locally employed NHS dietitian / clinician to act as a “buddy”, minimum 0.4wte
• Secure funding for continued Counterweight resources post 1 year
• Identification or recruitment of “buddy”
• Identification of key stakeholders to lead Counterweight within the PCT/CHP
• Agreement on a clinical accord between PCT/CHP and practices
• Outline clinical measures required to enable audit of outcomes