Weight management in primary care

Transcription

1 Weight management in primary care Professor Susan Jebb Nuffield Department of Primary Care Health Sciences University of Oxford Declaration: Funding for some of the interventions in this presentation has been provided by weight management companies. I receive no personal renumeration from any private company.

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3 How effective are interventions suitable for use in routine care with non-specialist staff and realistic NHS resources? Meta-analysis for NICE PH53 Intervention vs minimal contact control (BOCF): kg (95% CI: -3.61, -2.07); p < Hartmann-Boyce, Johns, Jebb, Summerbell, Aveyard. Obes Rev (11): Intervention Control Mean Difference Mean Difference Study or Subgroup Appel 2011 (in person) Appel 2011 (phone) Bertz 2012 Dale 2008 (intense) Dale 2008 (modest) DPP 2002 Eriksson 2009 Fitzgibbon 2010 Foster-Schubert 2012 Hersey 2012 (arm 2) Hersey 2012 (arm 3) Heshka 2003 Jebb 2011 Jolly 2011 (GP) Jolly 2011 (pharmacist) Jolly 2011 (RC) Jolly 2011 (SD) Jolly 2011 (SW) Jolly 2011 (WW) Kuller 2012 Lindstrom 2003 Mensink 2003 Morgan 2011 Munsch 2003 (clinic) Munsch 2003 (GP) Nanchahal 2011 Patrick 2011 Penn 2009 Rejeski 2011 Rock 2010 (in person) Rock 2010 (phone) Ross 2012 Silva 2010 Stevens 1993 Stevens 2001 Vermunt 2011 Villareal 2011 Vissers 2010 (fitness) Vissers 2010 (vibration) Wadden 2011 Total (95% CI) Mean SD Total Mean SD Total Weight 2.6% 2.6% 1.6% 1.4% 1.6% 3.0% 2.6% 2.7% 2.8% 2.2% 2.2% 2.2% 2.2% 2.2% 2.2% 2.8% 2.8% 2.3% 2.2% 2.2% 2.8% 2.7% 2.4% 2.5% 2.5% 2.8% 2.5% 1.9% 1.8% 2.7% 100.0% IV, Random, 95% CI [-5.57, -2.23] [-5.87, -2.53] [-10.71, -2.49] 3.60 [-1.01, 8.21] 4.10 [-0.01, 8.21] [-6.65, -5.55] [-1.45, 0.25] [-4.09, -0.75] [-9.59, -6.81] [-1.37, -0.03] [-1.28, 0.08] [-4.12, -1.88] [-3.00, -1.58] 0.30 [-2.47, 3.07] 0.40 [-2.31, 3.11] [-3.73, 1.73] [-4.09, 1.29] [-3.42, 1.82] [-5.18, 0.38] [-6.18, -4.02] [-4.05, -2.55] [-3.27, -0.83] [-4.46, 0.26] [-3.35, 1.95] [-6.16, -0.64] [-1.18, 0.58] [-1.96, 0.56] [-3.51, -0.69] [-7.61, -3.39] [-9.57, -5.63] [-8.05, -3.95] [-2.19, -0.21] [-5.55, -3.29] [-5.48, -3.52] [-3.12, -1.68] [-0.82, 0.42] [-9.84, -5.76] [-10.85, -3.95] [-11.99, -4.61] [-2.35, 0.75] [-3.61, -2.07] IV, Random, 95% CI Heterogeneity: Tau² = 5.12; Chi² = , df = 39 (P < ); I² = 93% Test for overall effect: Z = 7.25 (P < ) Favours intervention Favours control

4 Effectiveness of treatment in primary care or in community weight loss groups Primary care vs control: kg (95% CI: -0.87, 0.44); p = 0.52 Community weight-loss groups vs control: kg (95% CI: -2.81, -1.73); p< Hartmann-Boyce, Johns, Jebb, Summerbell, Aveyard. Obes Rev Nov;15(11):

5 Weight(kg) Primary care referral to a commercial provider significantly increases weight loss: BOCF WW SC kg p < kg Time (months) Jebb et al Lancet. 2011;378(9801):

6 The WRAP trial: Weight-loss Referrals for Adults in Primary care (n = 1267, 23 practices) Aims To evaluate the clinical and cost effectiveness of three weight loss interventions that can be delivered in primary care: CP52; referral to a commercial provider for 52 weeks (approx 200) CP12; referral for 12 weeks (approx 50) BI; a brief intervention (approx 7) Participants 68% female, Mean age = 53 Mean BMI = 34.5 HbA1c = 42 mmol/mol Ahern, Aveyard, Halford, Mander, Cresswell, Cohn, Suhrcke, Marsh, Thomson, Jebb. BMC Public Health Jun 18;14:62

7 Weight change over 1y BI CP12 CP52 CP vs BI CP52 vs CP12 MAR * (-3.53, -0.89) -2.65* (-3.99, -1.32)

8 Change in cardiovascular risk factors Mean (SE) Change Adj Difference (95%CI) BI CP12 CP52 CP52vs BI CP52vsCP12 Glucose (mmol/l) (0.20) (0.10) (0.08) -0.46* (-0.88,-0.03) -0.29* (-0.58, ) HbA1c (mmol/mol) 0.15 (0.69) (0.37) (0.47) -2.65** (-4.28, -1.01) -1.31* (-2.47,-0.15) Triglycerides (mmol/l) (0.07) (0.05) (0.03) (-0.25, 0.07) (-0.14, 0.09) Cholesterol (mmol/l) (0.10) (0.05) (0.05) (-0.24, 0.14) (-0.17, 0.09) HDL Cholesterol 0.01 (0.10) 0.02 (0.05) 0.02 (0.05) 0.00 (-0.19, 0.19) 0.00 (-0.13, 0.14) LDL Cholesterol (0.04) (0.03) (0.03) 0.01 (-0.12, 0.13) (-0.11, 0.07)

9 Weight change over 2 years BI CP12 CP No. Participants Primary Analysis Weight change Month Standard error bars shown around mean estimates BI CP12 CP52

10 % Opportunistic interventions for weight management: how do patients feel? N = Appropriate Helpful Very unhelpful Unhelpful Neither helpful or unhelpful Helpful Very unhelpful Aveyard et al. Lancet Oct 21. pii: S (16)

11 77% of patients accepted the referral Aveyard et al. Lancet Oct 21. pii: S (16)

12 More than half attended the programme No booking Did not attend Start but not complete course Complete course Aveyard et al. Lancet Oct 21. pii: S (16)

13 Opportunistic interventions can increase weight lost at 1 y 0 Control Weight change at 12 months Intervention (95%CI -1.97; -0.89), p< Aveyard et al. Lancet Oct 21. pii: S (16)

14 Very low energy diets enhance weight loss at 1 y VLED vs BWMP: kg (95% CI: -7.41, -1.14); p < Parretti, Jebb, Johns, Lewis, Christian and Aveyard, Obes Rev Jan 18. doi: /obr

15 Weight regain in BWMP over extended followup (BOCF analysis) NICE reviiew

16 Diabetes Prevention Programme: Sustained reductions in diabetes incidence - despite weight regain DPP. Lancet, 14 (2009), pp

17 Weight management in primary care Brief advice from a doctor to encourage weight loss is acceptable can motivate effective action More than a third of patients lose at least 5% initial weight following referral to a commercial weight loss group Increased duration of support significantly increases health benefits Very low energy formula diets lead to greater weight loss but, as yet, are rarely used in routine settings Weight regain is common but does not invalidate the benefits of initial losses Size matters: need to scale-up to achieve population-level impact A brief intervention, resulting in 1.5 kg weight loss, delivered once a year to all eligible people visiting their GP, could halve the prevalence of obesity by 2035

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