Background
Methods
Trial design
Participants
Interventions
Recommendation | Determinants | Interventions | |
---|---|---|---|
1 | Determining degree of overweight and overweight | Acceptable ways to raise and discuss the issue with patients (patients’ values in relationship to professional values or those in the recommendation)a
| Training—presentation, followed by team discussion Model scripts on discussing weight with patients, e.g. ‘Mr X, could we talk about your weight? What are your thoughts about your weight right now?’ ‘Mrs X, I’m concerned about your weight because I think it is causing health problems for you.’ |
How to effectively measure waist circumference (The extent to which the targeted healthcare professionals have pre-existing knowledge or expertise about the targeted condition)a
| Training in waist measurement—information provided, demonstration followed by practise | ||
2 | Assessment of lifestyle and willingness to change | Ways to assess willingness to change (patient motivation)a
| Presentation, discussion, sample questions provided, e.g. ‘What are you goals concerning your weight?’ ‘What changes are you willing to make to your eating or physical activity habits right now?’ ‘What kind of help would you like from me regarding your weight?’ ‘On a scale of 1 to 10, 10 being 100 % ready to take action, how ready are you to lose weight?’ |
Resources to motivate and inform (patients’ beliefs or knowledge or ability to learn, or the targeted healthcare professionals’ ability or perceived ability to inform or teach patients necessary knowledge and skills)a
| Booklet for patients containing clear, proscriptive information (Weight Loss You Can See). Posters for practices to invite patients to discuss their weight with a member of the practice team | ||
3 | Management of overweight and obesity | Lack of prescriptive information (patients’ beliefs or knowledge or ability to learn, or the targeted healthcare professionals’ ability or perceived ability to inform or teach patients necessary knowledge and skills)a
| Presentation, provision of summary of the guidelines, and booklet for patients |
Lack of knowledge (the extent to which the targeted healthcare professionals have pre-existing knowledge or expertise about the targeted condition)a
| Discussion with practices on delegation and the role for practice nurses (an action plan) | ||
4 | Referral | Lack of information on referral pathways (the extent to which the resources that are needed to adhere are available)a
| We collected details on local weight loss and lifestyle services and provided this \]information to practice teams |
Training and resources for professionals
Resources for patients
Identification of an obesity lead
Randomisation
Blinding
Outcomes
Primary outcome
Secondary outcomes
Process evaluation
1. What made you participate in the project in the first place? What where your reasons and what were your expectations? 2. Did the implementation program help you to adhere to the recommendations? a) If yes, what components did you find helpful and why? b) If no, why not and what strategies would have been more helpful? 3. Were there any other factors or developments which made it difficult for you or helped you to adhere to the recommendations? 4. Having experienced the program, what would you recommend for the future? You may think of further development, wider implementation or perhaps research. |
Statistical methods
Sample size
Results
Recruitment
Baseline data
Practice level | Control (n = 16) | Intervention (n = 12) |
Single handed | 1 | 3 |
Duo practice | 0 | 0 |
Group practice | 15 | 9 |
Rural area | 6 | 3 |
Urban area | 10 | 9 |
Deprivation score | 24.7 (9.8) | 26.2 (12.0) |
Practice list size | 5968 (3543–13,390) | 4065 (2191–7373) |
Patient level | ||
Weight (kg) | [n = 20,955] 86.1 (17.9) | [n = 12,171] 87.0 (18.1) |
BMI (kg/m2) | [n = 8948] 30.2 (5.4) | [n = 4481] 30.5 (5.8) |
Waist circumference (cm) | [n = 1922] 98.5 (13.0) | [n = 818] 101.6 (18.0) |
Age | [n = 32079] 50.1 (18.6) | [n = 17728] 53.4 (17.8) |
Sex | ||
Male | 32,538 (47.5 %) | 17,675 (47.6 %) |
Female | 35,969 (52.5 %) | 19,476 (52.4 %) |
Ethnicity | ||
White | 21,451 (65.6 %) | 14,972 (72.9 %) |
South Asian | 5474 (16.7 %) | 2184 (10.6 %) |
Black | 2055 (6.3 %) | 1367 (6.7 %) |
Mixed | 650 (2.0 %) | 399 (1.9 %) |
Other | 3060 (9.4 %) | 1626 (7.9 %) |
Comorbidities | ||
Ischaemic heart disease | 2226 (6.9 %) | 1405 (7.9 %) |
Hypertension | 8647 (27.0 %) | 5205 (29.3 %) |
Disorder of lipid and lipoprotein metabolism | 3315 (10.3 %) | 1919 (10.8 %) |
Cerebrovascular disease | 1315 (4.1 %) | 857 (4.8 %) |
Diabetes | 5371 (16.7 %) | 3264 (18.4 %) |
Highest BMI classification throughout the trial | ||
Number of patients with a BMI | 35,686 | 19,847 |
Number overweight or obese | 32,079 (89.9 %) | 17,728 (89.3 %) |
Overweight | 17,136 (48.0 %) | 8960 (45.1 %) |
Obese | 14,943 (41.9 %) | 8768 (44.2 %) |
Principal results
Primary outcome
Control | Intervention | Odds ratio | |||
---|---|---|---|---|---|
(n = 32079; 16 practices) | (n = 17728; 12 practices) | ICC | OR (95 % CI) |
p value | |
Primary outcome | |||||
Weight management | 15.1 % (10.8 %) | 13.2 % (5.9 %) | 0.094 | 1.17 (0.72, 1.89) | 0.53 |
Secondary outcomes | |||||
BMI or waist circumference measureda
| 42.7 % (10.3 %) | 39.6 % (10.6 %) | 0.031 | 1.15 (0.89, 1.48) | 0.28 |
Referral to external weight loss services | 5.1 % (3.4 %) | 3.7 % (3.4 %) | 0.026 | 1.45 (0.81, 2.63) | 0.21 |
Internal weight management | 9.6 % (9.1 %) | 8.7 % (6.7 %) | 0.123 | 1.09 (0.55, 2.15) | 0.81 |
Lifestyle assessment | 23.1 % (7.6 %) | 23.9 % (6.1 %) | 0.025 | 0.98 (0.76, 1.26) | 0.88 |
Weight loss of at least 1 kgb
| 42.2 % (4.1 %) | 41.7 % (4.1 %) | 0.003 | 0.98 (0.87, 1.09) | 0.67 |
Mean difference | |||||
Mean (95 % CI) | p-value | ||||
BMIc
| 30.4 (0.9) | 30.5 (1.1) | 0.000 | 0.08 (−0.12, 0.28) | 0.43 |
Weightb
| 85.3 (3.2) | 87.5 (1.2) | 0.002 | 0.05 (−0.32, 0.41) | 0.81 |
Secondary outcomes
Weight management and lifestyle advice change from baseline
Control (n = 13) | Intervention (n = 12) | Mean difference | ||||
---|---|---|---|---|---|---|
Baseline (imputed) | Follow-up | Baseline (imputed) | Follow-up | Mean (95 % CI) |
p value | |
Weight management | 8.8 % (8.5 %) | 14.7 % (11.9 %) | 5.1 % (2.8 %) | 13.6 % (6.4 %) | 3.7 (−2.5, 9.9) | 0.23 |
Referral to external weight loss services | 4.5 % (5.8 %) | 4.3 % (3.0 %) | 2.8 % (3.0 %) | 3.8 % (3.6 %) | 0.5 (−2.2, 3.1) | 0.73 |
Internal weight management | 4.2 % (4.0 %) | 9.9 % (10.1 %) | 2.3 % (2.0 %) | 9.0 % (7.1 %) | 3.3 (−1.7, 8.3) | 0.18 |
Lifestyle assessment | 0.0 % (0.0 %) | 23.4 % (8.2 %) | 0.9 % (2.1 %) | 24.3 % (5.8 %) | −0.2 (−6.9, 6.5) | 0.95 |
Predictive variables for adherence to the NICE guidelines
Outcome variable | Predictor | Odds ratio (95 % CI) |
---|---|---|
Weight management | BMI at baselinea
| 1.03 (1.02, 1.05) |
Agea
| 1.02 (1.01, 1.03) | |
BMI or waist circumference measured | Sex (male)b
| 0.70 (0.57, 0.87) |
Waist circumference [cm]a
| 1.01 (1.01, 1.02) | |
Referral to external weight loss services | Weight at baseline [kg]a
| 1.01 (1.01, 1.02) |
Internal weight management | Sex (male)b
| 1.09 (0.99, 1.20) |
Ethnicity (mixed)c
| 0.71 (0.51, 0.99) | |
Agea
| 1.01 (1.00, 1.02) | |
Lifestyle assessment | BMI at baselinea
| 1.02 (1.01, 1.03) |
Weight loss of at least 1 kg | Ethnicity (mixed)c
| 0.45 (0.20, 1.00) |
Weight at baselinea
| 1.02 (1.01, 1.02) | |
BMI at baselinea
| 1.03 (1.01, 1.06) | |
Agea
| 1.02 (1.01, 1.02) | |
Increase in outcome (95 % CI) | ||
BMI | Ethnicity (South Asian)c
| −0.47 (−0.97, 0.02) |
BMI at baselined
| 0.74 (0.66, 0.82) | |
Aged
| −0.01 (−0.02, −0.00) | |
Weight | BMId
| −0.17 (−0.22, −0.12) |
Weight at baseline [kg]d
| 0.95 (0.92, 0.97) | |
Aged
| −0.07 (−0.08, −0.06) |
Process evaluation
I genuinely think the intervention was well received by the practice. (GP).
I just think it’s been helpful for me to be able to speak to patients about; it’s really quite difficult for the likes of me to say to somebody that you are obese, that you are big, so something visually I can draw their attention to without actually having to say you’re fat and you got to do something about it and bring it down. (health care assistant)
I think it is something that actually conceptualises weight loss in a very patient friendly realistic, real life type of way which is digestible by people. (GP)
Majority of the patients really appreciated the literature, they appreciated that it wasn’t just a leaflet given to them, there was follow-up. (practice nurse)
To be translated but you’d also need to look at the foods for that particular culture. (practice nurse).
I wanted an idea of having a group of say up to ten patients go through all of this with them in a spiel, you know do like a thirty minute, twenty minute presentation and then make sure I got time to bring them in or get somebody to weigh them, height them and work out you know a calorie thing for them to continue. (practice nurse).