Engaging patients, clinicians and health funders in weight management: the Counterweight Programme

Public policy interventions for preventing and treating obesity: scoping review

CONTEXT

Obesity is a multicausal social problem and a pandemic, and it presents a public health challenge in many countries. Hence, public health interventions have been used in an endeavour to prevent and/or control increased obesity among populations.

OBJECTIVE

This review study aimed to provide an overview of the academic literature and to analyze the strategies involved in the main public policies focused on preventing and controlling obesity in a number of countries.

DATA SOURCES

MEDLINE/PubMed, Web of Science, and LILACS databases were searched.

DATA EXTRACTION

Original studies were included for which the core objective was related to real-life public policy interventions for obesity.

DATA ANALYSIS

The studies were organized according to their characteristics, and the qualitative analysis was based on the categorization proposed by the author Poulain. The review included 41 studies and identified 15 types of interventions focused on obesity; the largest proportion of actions were developed in school and city environments and were geared toward behavioral change, supported by direct or indirect government action. It was observed that many strategies focused on environmental line through regulatory and legislative measures, and health promotion geared toward the individual was based on the dissemination of information as a means for behavioral change. A smaller focus was given to individual care and treatment, and participative actions in the community.

CONCLUSION

The design of public health strategies applicable to obesity as proposed by Poulain provides a valid model for evaluating interventions. The behavioral approach involving guidance through health education toward a healthy lifestyle prevails in public policies, indicating a movement toward accountability of individuals. However, it is necessary to deepen the debate on the social structures that determine obesity (and which limit possibilities of choice), aligned with cultural change regarding its occurrence, and to employ care strategies based on scientific evidence and which focus on the needs of the subjects.

Acceptability and feasibility of weight management programmes for adults with severe obesity: a qualitative systematic review

OBJECTIVES

To improve our understanding of the acceptability of behavioural weight management programmes (WMPs) for adults with severe obesity.

DESIGN

A systematic review of qualitative evidence.

DATA SOURCES

Medline, Embase, PsycINFO, CINAHL, SCI, SSCI and CAB abstracts were searched from 1964 to May 2017.

ELIGIBILITY CRITERIA

Papers that contained qualitative data from adults with body mass index (BMI) ≥35 kg/m² (and/or the views of providers involved in their care) and considered issues about weight management.

DATA EXTRACTION AND SYNTHESIS

Two reviewers read and systematically extracted data from the included papers which were compared, and contrasted according to emerging issues and themes. Papers were appraised for methodological rigour and theoretical relevance using Toye's proposed criteria for quality in relation to meta-ethnography.

RESULTS

33 papers met our inclusion criteria from seven countries published 2007-2017. Findings were presented from a total of 644 participants and 153 programme providers. Participants described being attracted to programmes that were perceived to be novel or exciting, as well as being endorsed by their healthcare provider. The sense of belonging to a group who shared similar issues, and who had similar physiques and personalities, was particularly important and seemed to foster a strong group identity and related accountability. Group-based activities were enjoyed by many and participants preferred WMPs with more intensive support. However, some described struggling with physical activities (due to a range of physical comorbidities) and not everyone enjoyed group interaction with others (sometimes due to various mental health comorbidities). Although the mean BMI reported across the papers ranged from 36.8 to 44.7 kg/m², no quotes from participants in any of the included papers were linked to specific detail regarding BMI status.

CONCLUSIONS

Although group-based interventions were favoured, people with severe obesity might be especially vulnerable to physical and mental comorbidities which could inhibit engagement with certain intervention components.

Preconception management of women with obesity: A systematic review

The prevalence of women of child-bearing age with obesity continues to rise at an alarming rate. This has significant implications for both the short-term and long-term health of mother and offspring. Given the paucity of evidence-based literature in this field, the preconception management of women with obesity is highly variable both between institutions and around the world. This systematic review aims to evaluate studies that inform us about the role of preconception weight loss in the fertility and pregnancy outcomes of women with obesity. Current therapeutic interventions are discussed, with a specific focus on the suitability of weight loss interventions for women with obesity planning pregnancy. There are significant knowledge gaps in the current literature; these are discussed and areas for future research are explored.

Bariatric surgery, lifestyle interventions and orlistat for severe obesity: the REBALANCE mixed-methods systematic review and economic evaluation

BACKGROUND

Adults with severe obesity [body mass index (BMI) of ≥ 35 kg/m2] have an increased risk of comorbidities and psychological, social and economic consequences.

OBJECTIVES

Systematically review bariatric surgery, weight-management programmes (WMPs) and orlistat pharmacotherapy for adults with severe obesity, and evaluate the feasibility, acceptability, clinical effectiveness and cost-effectiveness of treatment.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials and the NHS Economic Evaluation Database were searched (last searched in May 2017).

REVIEW METHODS

Four systematic reviews evaluated clinical effectiveness, cost-effectiveness and qualitative evidence for adults with a BMI of ≥ 35 kg/m2. Data from meta-analyses populated a microsimulation model predicting costs, outcomes and cost-effectiveness of Roux-en-Y gastric bypass (RYGB) surgery and the most effective lifestyle WMPs over a 30-year time horizon from a NHS perspective, compared with current UK population obesity trends. Interventions were cost-effective if the additional cost of achieving a quality-adjusted life-year is < £20,000-30,000.

RESULTS

A total of 131 randomised controlled trials (RCTs), 26 UK studies, 33 qualitative studies and 46 cost-effectiveness studies were included. From RCTs, RYGB produced the greatest long-term weight change [-20.23 kg, 95% confidence interval (CI) -23.75 to -16.71 kg, at 60 months]. WMPs with very low-calorie diets (VLCDs) produced the greatest weight loss at 12 months compared with no WMPs. Adding a VLCD to a WMP gave an additional mean weight change of -4.41 kg (95% CI -5.93 to -2.88 kg) at 12 months. The intensive Look AHEAD WMP produced mean long-term weight loss of 6% in people with type 2 diabetes mellitus (at a median of 9.6 years). The microsimulation model found that WMPs were generally cost-effective compared with population obesity trends. Long-term WMP weight regain was very uncertain, apart from Look AHEAD. The addition of a VLCD to a WMP was not cost-effective compared with a WMP alone. RYGB was cost-effective compared with no surgery and WMPs, but the model did not replicate long-term cost savings found in previous studies. Qualitative data suggested that participants could be attracted to take part in WMPs through endorsement by their health-care provider or through perceiving innovative activities, with WMPs being delivered to groups. Features improving long-term weight loss included having group support, additional behavioural support, a physical activity programme to attend, a prescribed calorie diet or a calorie deficit.

LIMITATIONS

Reviewed studies often lacked generalisability to UK settings in terms of participants and resources for implementation, and usually lacked long-term follow-up (particularly for complications for surgery), leading to unrealistic weight regain assumptions. The views of potential and actual users of services were rarely reported to contribute to service design. This study may have failed to identify unpublished UK evaluations. Dual, blinded numerical data extraction was not undertaken.

CONCLUSIONS

Roux-en-Y gastric bypass was costly to deliver, but it was the most cost-effective intervention. Adding a VLCD to a WMP was not cost-effective compared with a WMP alone. Most WMPs were cost-effective compared with current population obesity trends.

FUTURE WORK

Improved reporting of WMPs is needed to allow replication, translation and further research. Qualitative research is needed with adults who are potential users of, or who fail to engage with or drop out from, WMPs. RCTs and economic evaluations in UK settings (e.g. Tier 3, commercial programmes or primary care) should evaluate VLCDs with long-term follow-up (≥ 5 years). Decision models should incorporate relevant costs, disease states and evidence-based weight regain assumptions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016040190.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit and Health Economics Research Unit are core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorate.

Health consequences for mother and baby of substantial pre-conception weight loss in obese women: study protocol for a randomized controlled trial

BACKGROUND

Current guidelines for the management of obesity in women planning pregnancy suggest lifestyle modification before conception. However, there is little evidence that lifestyle modification alters pregnancy outcomes. Bariatric surgery results in significant weight loss. This appears to reduce the risk of adverse pregnancy outcomes for the mother but may increase the risk of adverse outcomes for the infant. In order to reduce the risks of obesity-related adverse pregnancy outcomes for both mother and offspring, alternative approaches to the management of obesity in women planning pregnancy are needed.

METHODS/DESIGN

This study, a two-arm, parallel group, randomized control trial, will be conducted at the Metabolic Disorders Centre, University of Melbourne. This trial will recruit 164 women aged 18-38 years with a body mass index of 30-55 kg/m² who plan to conceive in the next 6-12 months. Women will be randomized to one of two 12-week interventions (Group A and Group B). Group A will aim for modest weight loss (MWL; ≤ 3% body weight) using a hypocaloric diet. Group B will aim for substantial weight loss (SWL; 10-15% body weight) using a modified very low energy diet (VLED) program. All participants will be asked to comply with National Health and Medical Research Council (NHMRC) guidelines for exercise and will be provided with standard pre-pregnancy advice according to Royal Australian and New Zealand College of Obstetrics and Gynaecology guidelines. All participants will then be observed for the subsequent 12 months. If pregnancy occurs within the 12-month follow-up period, data on weight and metabolic status of the mother, and pregnancy outcomes of mother and offspring will be recorded. The primary outcome is maternal fasting plasma glucose at 26-28 weeks' gestation, given that this is known to correlate with pregnancy outcomes. Time to conception, live birth rate, gestational weight gain, and a composite of adverse pregnancy outcomes for mother and baby will comprise the secondary outcomes.

DISCUSSION

There is increasing emphasis on obese women losing weight before conception. To date, no randomized controlled trial has demonstrated an effective means of weight loss that results in improved pregnancy outcomes for both mother and baby. This study intends to determine if substantial pre-conception weight loss, achieved using a VLED, improves pregnancy outcomes for mother and baby when compared with standard care. This research will potentially change clinical care of an obese woman planning pregnancy.

TRIAL REGISTRATION

ANZCTR, 12,614,001,160,628 . Registered on 5 November 2014.

Role of the family doctor in the management of adults with obesity: a scoping review

OBJECTIVES

Obesity management is an important issue for the international primary care community. This scoping review examines the literature describing the role of the family doctor in managing adults with obesity. The methods were prospectively published and followed Joanna Briggs Institute methodology.

SETTING

Primary care. Adult patients.

INCLUDED PAPERS

Peer-reviewed and grey literature with the keywords obesity, primary care and family doctors. All literature published up to September 2015. 3294 non-duplicate papers were identified and 225 articles included after full-text review.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data were extracted on the family doctors' involvement in different aspects of management, and whether whole person and person-centred care were explicitly mentioned.

RESULTS

110 papers described interventions in primary care and family doctors were always involved in diagnosing obesity and often in recruitment of participants. A clear description of the provider involved in an intervention was often lacking. It was difficult to determine if interventions took account of whole person and person-centredness. Most opinion papers and clinical overviews described an extensive role for the family doctor in management; in contrast, research on current practices depicted obesity as undermanaged by family doctors. International guidelines varied in their description of the role of the family doctor with a more extensive role suggested by guidelines from family medicine organisations.

CONCLUSIONS

There is a disconnect between how family doctors are involved in primary care interventions, the message in clinical overviews and opinion papers, and observed current practice of family doctors. The role of family doctors in international guidelines for obesity may reflect the strength of primary care in the originating health system. Reporting of primary care interventions could be improved by enhanced descriptions of the providers involved and explanation of how the pillars of primary care are used in intervention development.

Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in children and adults with overweight or obesity

BACKGROUND

The prevalence of overweight and obesity is increasing globally, an increase which has major implications for both population health and costs to health services. This is an update of a Cochrane Review.

OBJECTIVES

To assess the effects of strategies to change the behaviour of health professionals or the organisation of care compared to standard care, to promote weight reduction in children and adults with overweight or obesity.

SEARCH METHODS

We searched the following databases for primary studies up to September 2016: CENTRAL, MEDLINE, Embase, CINAHL, DARE and PsycINFO. We searched the reference lists of included studies and two trial registries.

SELECTION CRITERIA

We considered randomised trials that compared routine provision of care with interventions aimed either at changing the behaviour of healthcare professionals or the organisation of care to promote weight reduction in children and adults with overweight or obesity.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane when conducting this review. We report the results for the professional interventions and the organisational interventions in seven 'Summary of findings' tables.

MAIN RESULTS

We identified 12 studies for inclusion in this review, seven of which evaluated interventions targeting healthcare professional and five targeting the organisation of care. Eight studies recruited adults with overweight or obesity and four recruited children with obesity. Eight studies had an overall high risk of bias, and four had a low risk of bias. In total, 139 practices provided care to 89,754 people, with a median follow-up of 12 months. Professional interventions Educational interventions aimed at general practitioners (GPs), may slightly reduce the weight of participants (mean difference (MD) -1.24 kg, 95% confidence interval (CI) -2.84 to 0.37; 3 studies, N = 1017 adults; low-certainty evidence).Tailoring interventions to improve GPs' compliance with obesity guidelines probably leads to little or no difference in weight loss (MD 0.05 (kg), 95% CI -0.32 to 0.41; 1 study, N = 49,807 adults; moderate-certainty evidence).It is uncertain if providing doctors with reminders results in a greater weight reduction than standard care (men: MD -11.20 kg, 95% CI -20.66 kg to -1.74 kg, and women: MD -1.30 kg, 95% CI [-7.34, 4.74] kg; 1 study, N = 90 adults; very low-certainty evidence).Providing clinicians with a clinical decision support (CDS) tool to assist with obesity management at the point of care leads to little or no difference in the body mass index (BMI) z-score of children (MD -0.08, 95% CI -0.15 to -0.01 in 378 children; moderate-certainty evidence), CDS tools may lead to little or no difference in weight loss in adults: MD -0.095 kg (-0.21 lbs), P = 0.47; 1 study, N = 35,665; low-certainty evidence. Organisational interventions Adults with overweight or obesity may lose more weight if the care was provided by a dietitian (by -5.60 kg, 95% CI -4.83 kg to -6.37 kg) or by a doctor-dietitian team (by -6.70 kg, 95% CI -7.52 kg to -5.88 kg; 1 study, N = 270 adults; low-certainty evidence). Shared care leads to little or no difference in the BMI z-score of children with obesity (adjusted MD -0.05, 95% CI -0.14 to 0.03; 1 study, N = 105 children; low-certainty evidence).Organisational restructuring of the delivery of primary care (i.e. introducing the chronic care model) may result in a slightly lower increase in the BMI of children who received care at intervention clinics (BMI change: adjusted MD -0.21, 95% CI -0.50 to 0.07; 1 study, unadjusted MD -0.18, 95% CI -0.20 to -0.16; N=473 participants; moderate-certainty evidence).Mail and phone interventions probably lead to little or no difference in weight loss in adults (mean weight change (kg) using mail: -0.36, 95% CI -1.18 to 0.46; phone: -0.44, 95% CI -1.26 to 0.38; 1 study, N = 1801 adults; moderate-certainty evidence). Care delivered by a nurse at a primary care clinic may lead to little or no difference in the BMI z-score in children (MD -0.02, 95% CI -0.16 to 0.12; 1 study, N = 52 children; very low-certainty evidence).Two studies reported data on cost effectiveness: one study favoured mail and standard care over telephone consultations, and the other study achieved weight loss at a modest cost in both intervention groups (doctor and doctor-dietitian). One study of shared care reported similar adverse effects in both groups.

AUTHORS' CONCLUSIONS

We found little convincing evidence for a clinically-important effect on participants' weight or BMI of any of the evaluated interventions. While pooled results from three studies indicate that educational interventions targeting healthcare professionals may lead to a slight weight reduction in adults, the certainty of these results is low. Two trials evaluating CDS tools (unpooled results) for improved weight management suggest little or no effect on weight or BMI change in adults or children with overweight or obesity. Evidence for all the other interventions evaluated came mostly from single studies. The certainty of the included evidence varied from moderate to very low for the main outcomes (weight and BMI). All of the evaluated interventions would need further investigation to ascertain their strengths and limitations as effective strategies to change the behaviour of healthcare professionals or the organisation of care. As only two studies reported on cost, we know little about cost effectiveness across the evaluated interventions.

The role of primary care in adult weight management: qualitative interviews with key stakeholders in weight management services

Background

Primary care has a key role to play in the prevention and management of obesity, but there remain barriers to engagement in weight management by primary care practitioners. The aim of this study was to explore the views of key stakeholders in adult weight management services on the role of primary care in adult weight management.

Methods

Qualitative study involving semi-structured interviews with nine senior dietitians involved in NHS weight management from seven Scottish health boards. Transcripts were analysed using an inductive thematic approach.

Results

A range of tensions were apparent within three key themes: weight management service issues, the role of primary care, and communication with primary care. For weight management services, these tensions were around funding, the management model of obesity, and how to configure access to services. For primary care, they were around what primary care should be doing, who should be doing it, and where this activity should fit within wider weight management policy. With regard to communication between weight management services and primary care, there were tensions related to the approach taken (locally adapted versus centralised), the message being communicated (weight loss versus wellbeing), and the response from practitioners (engagement versus resistance).

Conclusions

Primary care can do more to support adult weight management, but this requires better engagement and communication with weight management services, to overcome the tensions highlighted in this study. This, in turn, requires more secure, sustained funding. The example of smoking cessation in the UK, where there is a network of well-resourced NHS Stop Smoking Services, accessible via different means, could be a model to follow.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2729-7) contains supplementary material, which is available to authorized users.

Eliciting Provider and Patient Perspectives on New Obesity Management Services in a Team-Based Primary Care Organization

PURPOSE

Both providers and patients may have important insights to inform the development of obesity prevention and management services in Canadian primary care settings. In this formative study, insights for new obesity management services were sought from both providers and patients in 1 progressive citywide organization (150 physicians, team services, separate offices).

METHODS

Seven focus groups with interprofessional health providers (n = 56) and 4 focus groups with patients (n = 34) were conducted. Two clinical vignettes (adult, child) were used to focus discussion. Four analysts coded for descriptive content and interpretative themes on possible tools and care processes using NVivo.

RESULTS

Participants identified numerous strategies for care processes, most of which could be categorized into 1 or more of 11 themes: 6 directed at clinical care of patients (raising awareness, screening, clinical care, skill building, ongoing support, and social/peer support) and 5 directed at the organization (coordination/collaboration, creating awareness among health professionals, adding new expertise to the team, marketing, and lobbying/advocacy).

CONCLUSIONS

The approach was successful in generating an extensive list of diverse activities to be considered for implementation studies. Both patients and providers identified that multiple strategies and systems approaches will be needed to address obesity management in primary care.

Management of Overweight during Childhood: A Focus Group Study on Health Professionals' Experiences in General Practice

Background. Because of the increasing prevalence of overweight and obesity in childhood in the Western world, focus on the management in general practice has also increased. Objective. To explore the experiences of general practitioners (GPs) and practice nurses participating in a randomised controlled trial (RCT) comparing two management programmes in general practice for children who are overweight or obese. Methods. Three focus groups with GPs and nurses participating in the RCT. Transcribed data were analysed using systematic text condensation followed by thematic analysis. Results. Health professionals considered it their responsibility to offer a management programme to overweight children. They recognised that management of overweight during childhood was a complex task that required an evidence-based strategy with the possibility of supervision. Health professionals experienced a barrier to addressing overweight in children. However, increasing awareness of obesity in childhood and its consequences in society was considered helpful to reach an understanding of the articulations concerning how best to address the issue. Conclusions. Health professionals in general practice recognised that they have a special obligation, capacity, and role in the management of obesity in childhood. Implementation of future management programmes must address existing barriers beyond an evidence-based standardised strategy.

Educating the clinical trainer: professional gain for the trainee? A controlled intervention study in general practice

The aim of this study was to establish whether a 'teach-the-trainer' course leads to improvements in, firstly, the knowledge and attitude of clinical trainers and their trainees, and, secondly, the role model behaviour of the clinical trainers. A controlled intervention study was performed with GP trainers and GP trainees from four training institutes in the Netherlands. Clinical trainers in the two intervention institutes received two 3-h training sessions on weight management, focusing on knowledge and attitudes towards obesity, and on conveying the correct professional competency as a positive role model for trainees. This was measured using questionnaires on knowledge, attitude, and role model behaviour (the role model apperception tool; RoMAT). GP trainers showed an increase in knowledge and several characteristics could be identified as being related to positive role model behaviour. A small correlation was found between the trainer's score on the RoMAT and the attitude of the trainee. A teach-the-trainer course in which knowledge, attitudes, and role modelling are integrated proved to be a first step toward improving the knowledge of clinical trainers, but did not result in a measurably better professional outcome for the trainee, maybe due to a more objective level of assessment.

Enhancing delivery of health behaviour change interventions in primary care: a meta-synthesis of views and experiences of primary care nurses

OBJECTIVE

To systematically find and synthesise qualitative studies that elicited views and experiences of nurses involved in the delivery of health behaviour change (HBC) interventions in primary care, with a focus on how this can inform enhanced delivery and adherence to a structured approach for HBC interventions.

METHODS

Systematic search of five electronic databases and additional strategies to maximise identification of studies, appraisal of studies and use of meta-synthesis to develop an inductive and interpretative form of knowledge synthesis.

RESULTS

Nine studies met the inclusion criteria. Synthesis resulted in the development of four inter-linking themes; (a) actively engaging nurses in the process of delivering HBC interventions, (b) clarifying roles and responsibilities of those involved, (c) engaging practice colleagues, (d) communication of aims and potential outcomes of the intervention.

CONCLUSION

The synthesis of qualitative evidence resulted in the development of a conceptual framework that remained true to the findings of primary studies. This framework describes factors that should be actively promoted to enhance delivery of and adherence to HBC interventions by nurses working in primary care.

PRACTICE IMPLICATIONS

The findings can be used to inform strategies for researchers, policymakers and healthcare providers to enhance fidelity and support delivery of HBC interventions.

Attitudes towards obesity treatment in GP training practices: a focus group study

BACKGROUND

Both patients and government expect the GP to treat obesity. Previous studies reported a negative attitude of GPs towards this task. Little is known about the attitude of GP trainees.

OBJECTIVES

To assess the attitude and other factors that influence the willingness and ability of GP trainees to provide lifestyle interventions for overweight patients.

METHODS

A qualitative study was performed using focus groups, consisting of first- and third-year trainees, GP trainers and teachers. Two researchers analysed the data independently.

RESULTS

First-year trainees lack knowledge and a positive attitude. Third-year trainees, although trained in motivational interviewing techniques, lack specific knowledge and feel cheated when discussing eating habits. Trainers are despondent as they rarely observe long-lasting results. Teachers warn the trainees not to have high hopes. The trainers and trainees fear ruining the relationship with their patient, and all make a request for evidence-based multidisciplinary treatment programmes, joint responsibility and an image change in society to stop the epidemic.

CONCLUSIONS

Trainees do not feel more competent in treating overweight patients successfully over the course of their GP specialty training and GP trainers are not convinced of the success of the treatment of overweight patients. Therefore, it could be equally important to reflect on the GP trainer as a role model as to concentrate on the education of the trainee. Both need a revived attitude and evidence-based treatment programmes, help from policy makers and an attitude change in society are desired.

General practitioners' and district nurses' conceptions of the encounter with obese patients in primary health care

Background

Primary health care specialists have a key role in the management of obesity. Through understanding how they conceive the encounter with patients with obesity, treatment may be improved. The aim of this study was thus to explore general practitioners' and district nurses' conceptions of encountering patients with obesity in primary health care.

Method

Data were collected through semi-structured interviews, and analysed using a phenomenographic approach. The participants were 10 general practitioners (6 women, 4 men) and 10 district nurses (7 women, 3 men) from 19 primary health care centres within a well-defined area of Sweden.

Results

Five descriptive categories were identified: Adequate primary health care, Promoting lifestyle change, Need for competency, Adherence to new habits and Understanding patient attitudes. All participants, independent of gender and profession, were represented in the descriptive categories. Some profession and gender differences were, however, found in the underlying conceptions. The general staff view was that obesity had to be prioritised. However, there was also the contradictory view that obesity is not a disease and therefore not the responsibility of primary health care. Despite this, staff conceived it as important that patients were met with respect and that individual solutions were provided which could be adhered to step-by-step by the patient. Patient attitudes, such as motivation to change, evasive behaviour, too much trust in care and lack of self-confidence, were, however, conceived as major barriers to a fruitful encounter.

Conclusions

Findings from this study indicate that there is a need for development and organisation of weight management in primary health care. Raising awareness of staff's negative views of patient attitudes is important since it is likely that it affects the patient-staff relationship and staff's treatment efforts. More research is also needed on gender and profession differences in this area.

Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese people

BACKGROUND

The prevalence of obesity is increasing globally and will, if left unchecked, have major implications for both population health and costs to health services.

OBJECTIVES

To assess the effectiveness of strategies to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese people.

SEARCH STRATEGY

We updated the search for primary studies in the following databases, which were all interrogated from the previous (version 2) search date to May 2009: The Cochrane Central Register of Controlled Trials (which at this time incorporated all EPOC Specialised Register material) (The Cochrane Library 2009, Issue 1), MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), and PsycINFO (Ovid). We identified further potentially relevant studies from the reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared routine provision of care with interventions aimed either at changing the behaviour of healthcare professionals or the organisation of care to promote weight reduction in overweight or obese adults.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

We included six RCTs, involving more than 246 health professionals and 1324 overweight or obese patients. Four of the trials targeted professionals and two targeted the organisation of care. Most of the studies had methodological or reporting weaknesses indicating a risk of bias.Meta-analysis of three trials that evaluated educational interventions aimed at GPs suggested that, compared to standard care, such interventions could reduce the average weight of patients after a year (by 1.2 kg, 95% CI -0.4 to 2.8 kg); however, there was moderate unexplained heterogeneity between their results (I(2) = 41%). One trial found that reminders could change doctors' practice, resulting in a significant reduction in weight among men (by 11.2 kg, 95% CI 1.7 to 20.7 kg) but not among women (who reduced weight by 1.3 kg, 95% CI -4.1 to 6.7 kg). One trial found that patients may lose more weight after a year if the care was provided by a dietitian (by 5.6 kg, 95% CI 4.8 to 6.4 kg) or by a doctor-dietitian team (by 6 kg, 95% CI 5 to 7 kg), as compared with standard care. One trial found no significant difference between standard care and either mail or phone interventions in reducing patients' weight.

AUTHORS' CONCLUSIONS

Most of the included trials had methodological or reporting weaknesses and were heterogeneous in terms of participants, interventions, outcomes, and settings, so we cannot draw any firm conclusions about the effectiveness of the interventions. All of the evaluated interventions would need further investigation before it was possible to recommend them as effective strategies.