Reducing the prevalence of obesity one consultation at a time. Paul Aveyard Professor of behavioural medicine

Transcription

1 Reducing the prevalence of obesity one consultation at a time Paul Aveyard Professor of behavioural medicine

2 Conflicts of interest In this research and in other similar research, commercial weight loss companies and pharmaceutical companies have donated their products free of charge to the NHS to allow the trial to proceed.

3 GPs and other health or social care professionals should: Raise the issue of weight loss in a respectful and non-judgemental way. Recognise that this may have been raised on numerous occasions and respect someone's choice not to discuss it further on this occasion. Identify people eligible for referral to lifestyle weight management services.

4 THE BWeL TRIAL Lancet Nov 19;388(10059):

5

6

7

8

9

10

11 THE INTERVENTION

12 The brief intervention Offer help Book them in Create accountability To create momentary motivation To capitalise on the moment To create lasting motivation

13 Advice increases quit attempts by 24% Offering support on how to quit increases them by 68% to 117% Direct comparison offer help vs offer advice increases quit attempts by 39% to 69%

14 JAMA Intern Med. 2013;173(6):

15 I need to go regularly to keep me on track It isn t that I need educating, it s more that I need motivating Accountability was engendered by attending either type of session, especially through the act of being weighed rather than weighing themselves. It was identified by many as the key motivating factor for successful weight loss, accompanying a sense of obligation and that they would be letting someone else down if they had not lost weight: For me what works is the fact that I know I ve got to go and see somebody and I ve got to explain why I haven t lost any weight Ann Fam Med May; 11(3):

16 THE CONSORT FLOW DIAGRAM

17

18 Screened and potentially eligible Inelligible Potentially eligible

19 What happened to the potentially eligible Not willing - No anon data Not willing + Anon data Not Eligible GP WD Eligible & Enrolled

20 Reasons for non-eligibility Pregnant Weight loss programme within 3 months Poor English Current weight loss programme GP visit for weight BMI<30

21 Reasons for GP exclusion Not appropriate in consultation Clinically inappropriate Other Unknown

22 BASELINE CHARACTERISTICS

23 BMI of participants

24 Age of participants

25 Ethnic group of participants

26 Gender of participants

27 HOW PEOPLE FELT

28 Ratings of appropriateness by trial arm

29 Ratings of helpfulness by trial arm

30 ACCEPTING HELP TO LOSE WEIGHT AND THE IMPACT ON WEIGHT AT 1 YEAR

31 Acceptance of referral

32 Of those who accepted referral No booking Did not attend Start but not complete course Complete course

33 0 Control Weight change at 3 months Intervention (95%CI -2.17; -1.35), p<

34 0 Control Weight change at 12 months Intervention (95%CI -1.97; -0.89), p<

35 100 Percentage losing 5% and 10% of baseline weight at 12 months Odds ratio 2.11 (95% CI 1.67; 2.68), p<0.001 Odds ratio 2.41 (95%CI 1.72, 3.38), p< % 10% Control Intervention

36 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percentage of people taking action and type of action taken by 12 months in the two arms of the trial Control intervention Active intervention No action Self-help action Effective action

37 BWeL AGAIN

38

39 12 months prolonged abstinence 7.3% vs 1.8% Preventive Medicine 62 (2014) Addiction Jul;111(7):1257-6

40 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percentage of people taking action and type of action taken by 12 months in the two arms of the trial Control intervention Active intervention No action Self-help action Effective action

41 GENDER AND PREFERENCE

42 Intervention preference at baseline No preference Abrupt Gradual Ann Intern Med 2016 May 15;164(9):585-92

43 1.2 Relative risk of quitting with gradual cessation compared with abrupt cessation by baseline preference Prefer gradual No preference Prefer abrupt

44 Percentage of women and men attending (commercial) weight management services Stubbs 2015 Ahern Stubbs 2012 Women Men BMC Public Health 2015, 15; 822 BMC Public Health :434 Clinical Obesity 2012; 2: 6-14.

45

46

47

48 Overcoming bias- offer help in writing Women 8.5% Men 4.4% Odds ratio 2.01 ( ) Ratio 1.9:1 British Journal of General Practice 2016, 66(645):e258-63

49 Uptake of support by gender 100% 90% 80% 70% 60% 50% Ratio 1.6:1 40% 30% 20% 10% 0% Men Women No referral No booking Did not attend Start but not complete course Complete course

50 Percentage of women and men attending (commercial) weight management services Stubbs 2015 Ahern Stubbs 2012 Ahern 2015 Aveyard unpublished Women Men

51 Advice Support Total N Treatment Effect (95% C.I.) Gender Male 0.68 (5.71) 2.39 (5.71) (-2.65; -0.95) Female 1.31 (5.33) 2.46 (6.32) (-1.87; -0.48)

52 Marginal Treatment Effects by Gender with 95% CIs Interaction test p-value = 0.29 CP52, Male CP52, Female CP12, Male CP12, Female BI, Male BI, Female Change in Weight (kg) Ahern et al submitted

53 WORDS MATTER

54 Advice increases quit attempts by 24% Offering support on how to quit increases them by 68% to 117% Direct comparison offer help vs offer advice increases quit attempts by 39% to 69%

55 Charlotte Albury Sue Ziebland Liz Stokoe

56 DOC: Mister Summertown: u:m (1.3) c-commercial: weight management (.) er: c-can help you: lo:se weight, is that something you would like me to refer you for; PAT:.hh yes.

57 DOC: PAT: and we ca:n refer you to (0.4) a 12-week course (0.4) for that if: you would like.hh yu[p. DOC: you, [U:m and that would be free of charge to DOC: do you think that would be something t-.hhh [that would b-be of interest to you, PAT: to do it yes; [O:h I d love

58 DOC: >but it s been shown< that (0.5) losing weight (0.7) e::r by going to a (.) em weight management (1.4) class if you like is the most (.) effective way to lose weight its been shown that that s the case; DOC:.hhh and as part of the trial um: (.) >you know< we can enrol you in that class if you d like to do that;= PAT: =yes ok. DOC: a-and obviously th- and the trial would actually fund it for you [so you don t have to pay for it. PAT: [Oh ok,

59 Patient total = 246 Oh-prefaced response Patient total = 16 Non-Oh-prefaced response Patient total = 230 Attenders = 14 Nonattenders = 2 Attenders = 97 Nonattenders = % of oh-prefaced responders attended 42% of non-oh-prefaced responders attended

60 Conversational Positioning

61 DOC:it s a question of >you< know utilising the education you.= package that they can give PAT: =mhm. DOC:.hh and then taking that on (.) on a (.) indefinite basis= PAT: =mhm. DOC:because it is a lifestyle change that you need, (.) DOC: and they seem to be able to get the message over better than you doing it on your own. PAT: mhm.

62 DOC:And they are prepa:red to actually (.) fund you though our local slimming (.) world club, which is run locally, at one of the schools:, for a series of sessions to: get you into the swing of what you should and shouldn t be doing, (.) So that might tie up with helping you with gout as well; (1.6) So it s it s totally up to you;

63 Despite GPs expressed views that a preferred way of topicalising smoking is to make links to a patients current medical problems this commonly results in explicit resistance from patients of a kind that is rarely seen in other medical conditions.

64 DOC: We d li- we d like t- offer you some free (.) as part of the trial (.) er-.hh weight loss supported sessions w- with slimming world locally. PAT: with slimming word? Yeah? Yeah sure, Free Treatment recommendation

65 DOC: If you re interested we could refer you to no:w, through the- through the study nurse here for free. so it won t cost you a bean;.hh if you re >interested<. PAT: I would do anythi:ng; within reason, Free Treatment recommendation

66 DOC: Would you be keen on doing that; Something like rosemay Connelly, PAT: o I don t know nothing about her o 25 seconds omitted DOC: Ye:s for free you don t have to pay for it. Would you be keen or not; Treatment recommendation Free

67 IMPLEMENTATION

68 GP 08-3: I: OK. And anything else? The value of (enforced) practice R: Yeah, I, I think [um] I don t know, I think you ve just, it s made me more confident of bringing it up as I say in a, at a, in a consultation that may have, you know, have absolutely nothing to do weight. GP 09-3 I: were there any occasions when BWeL required to, you to bring up weight with patients when you wouldn t normally have done so? R: Yeah, it did, no, definitely, because we, we [um] you know, because it was there one had to do it, so there are I: Hmm. R: patients that I certainly wouldn t have done it to otherwise. I: And how did that feel? R: As I Say, it, it, it was fine. I: Hmhm. R: And, and, and the more you did it, the easier it got, and that s why this is, that s why it was helpful.

69 The value of pre-weighing GP 30-2 R: Straightforward [um] and because I think the patients had already been weighed and measured and they knew. I don t think they were surprised when they came with their documents they weren t surprised. So it was relatively easy. I think it was easier than if they hadn t gone through that prior to coming into the room.

70 The value of simplicity GP 09-3 R: A brief interventions saying adjust your diet, da, da, da, it s far too complicated. [um] And they need, you know, the whole social group saying, I, I suspect the answer will, will show you quite clearly that patients will benefit from [um] the group sessions through Slimming World or whatever [um] that s my feeling

71 The value of positive responses to raising the issue GP 11-3 I: And how did you feel about advising on their weight in particular was it? R: I think most people appreciate it and [um] realise that there is a problem and if we can offer to help then people sometimes are grateful for that, sometimes they re not. GP 02-3 R: [I] realised that patients were fully expecting, they need to be, to have it addressed, and talked about

72 The value of feedback GP 08-3 R: And I think it s [um] you know, that we can, we do have something we can offer and our local Slimming World group has just been phenomenal really. So, you know, our, our patients are just doing really, really well on it. Have had really positive feedback. So I think that as the time s gone on you re able to be more confident in what you re referring people on to because you ve got a I: Hmhm. R:..you ve got other patients that have gone through, through it now.

73 But things don t change as a result GP 14-2 I: Yeah. Great. Would you say that your thoughts about raising the issue of obesity with your patients have changed over the course of the study at all? R: I d like to say yes but they haven t. I: No, OK. R: Actually. Because, I mean, the study we did for a period of weeks and maybe at the time when I was doing it it may have but I ve gone back to my usual bad ways now. [um] And I do forget again. We re, we re sort of limited for time and you whizz through and you just prioritise in, you re in the consultation, I don t think I: Yeah. R: I always bring up weight as much as I should. [um] And there, it hasn t really changed my practice.

74 When GPs do it GP 06-7 I: when do you think it s appropriate to raise the issue of weight? R: Right, so, so, I, yes, I, I think if somebody comes in with, so when I would be particularly comfortable is if somebody comes in with diabetes, near diabetes or pre-diabetes or something like that R: [um] because they re non-insulin dependent sort, because I can, I feel very [um] very much on firm ground that I can say, Look, if you, if you lost the weight, you might be off tablets or you might avoid having to take them. I m less good at raising it in back ache and so on [um] just again really because I m a, afraid of offending someone and raising a complaint. GP 20-1 R if they re grossly obese [uh] but a lot of those, they re very sensitive those patients, you look at them and they re huge. I: Hmm. R: [um] But they, they, so in context of as I say associated condition it s easier. But if people with no other condition with them but they re just hugely overweight or even obese or slightly overweight then you re a bit reluctant.

75 THE IMPACT

76

77 35 Modelled change in proportion with BMI>30 to Baseline

78 35 Modelled change in proportion with BMI>30 to 2035 if brief interventions were given once per year Baseline Support

79 The benefits By 2020 Cost/QALY is 782 By 2035 Lead to a net saving of 1.5million/100,000 = 1 billion annually in England 1% of NHS budget Incidence of coronary heart disease hypertension and diabetes would be 22%, 23%, and 17% lower QALY gain 894/100,000 population

80 Thank you