The Department of Health’s project to evaluate weight management services

Journal of Human Nutrition and Dietetics (1999), 12 (Suppl. 1), 1±8

# 1999 Blackwell Science Ltd. 1

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The Department of Health's project to

evaluate weight management services

J. Hughes and S. Martin*Independent Nutrition Consultant, Surrey, UK, and *Department of Health, Room 406A,

Wellington House, 133±155 Waterloo Road, London SE1 8UG, UK

Background: The prevalence of obesity in the UK has reached epidemic proportions and is

continuing to increase. Obesity is one of the most important avoidable risk factors in men

and women for diseases such as coronary heart disease, stroke, non-insulin dependent

diabetes mellitus and hypertension. Modest weight loss of 5±10 kg or 5±10% of initial

body weight maintained for the long term reduces the health risks associated with

obesity. Reducing levels of obesity in the population has proved to be particularly

challenging. The Department of Health (DH) wished to help practitioners in the field by

allocating funding to identify and encourage good practice in weight management.

Aims: The project had two aims: firstly, to promote the skills of evaluation at local level

and to disseminate the results of evaluation more widely. DH's Advisory Group agreed

that the project would identify existing projects on weight management in the regions and

a directory of services would be compiled. The second aim was to contribute up to £5000

to a number of projects to help them to evaluate their work, and disseminate the results.

Methods: Questionnaires were sent out via a number of local networks in each region to

identify suitable projects and services. The responses were compiled into a Directory

which is available as a database at each Regional Office. One hundred and sixteen of the

services identified indicated that some evaluation had been carried out, and were either

available in report form or currently being written up. Those whose services were not

evaluated were invited to submit a proposal. Evaluations of 13 weight management

services involving different types of intervention and various practitioners were

commissioned in September 1997. Expert advice was made available at the start and

throughout the project. The evaluations were completed by the end of March 1998.

Results: The evaluations suggest that: (1) successful sustained clinically significant

weight reduction in obese patients is rare. Most of the interventions evaluated showed

initial weight loss in some patients but this was rarely maintained at follow-up; (2)

successful weight loss is achieved through multicomponent programmes that aim to bring

about lifestyle (behavioural) changes to reduce energy intake and increase energy output

in ways that are practical and easy to sustain. This is achieved through multidisciplinary

teams of health care workers and physical activity instructors; (3) regular contact and

follow-up between patient and practitioners are important for successful weight loss and

weight maintenance. More work is needed to develop strategies that may improve long-

term weight maintenance.

Conclusions: Evaluation of existing and new weight management services and

dissemination of the results will identify the most effective methods for the treatment of

obesity which can be employed by all health care teams. Evaluations need to be

considered at the planning stage for the services so that appropriate data and research

methods are included. Health Authorities should consider how best to provide advice and

help to practitioners whose research experience is limited.

Key words: obesity, weight management services, evaluation.

Correspondence: Dr S. Martin;

e-mail: [email protected]

Paper 01 Disc

2 J. Hughes and S. Martin

# 1999 Blackwell Science Ltd, J Hum Nutr Dietet 12 (Suppl. 1), 1±8

Background

Data from nationally representative surveys in

England have shown a persistent and continuing

rise in prevalence of obesity, both in males and

females, from 6% and 8% in 1980 to 16% and

17%, respectively, in 1996 (Prescott-Clarke &

Primatesta 1997). Obesity is conventionally defined

in adults as Body Mass Index [BMI=wt (kg)/

ht2(m)] in excess of 30. In addition, the prevalence

of overweight, defined as a BMI of 25±29.9 kg/m2 is

also increasing. In 1986/7 the prevalence of over-

weight was 38% in men and 24% in women rising

to 45% for men and 34% for women in 1996

(Prescott-Clarke & Primatesta 1997).

Between 1993 and 1996 the difference in the

prevalence of obesity was greater in men (3.2% for

all men and 2.9% for men aged 16±64 years) than

in women (2.0% for all women and 1.6% for

women aged 16±64 years). This equates to a rise of

22% in men and 10% in women, a huge increase.

The increase was greater in older men (aged 45±54

years and over) than in younger men, and in

women aged 25±34 and 55 years and over than

those in other age groups (Prescott-Clarke & Prima-

testa 1997). The prevalence of obesity increases

with lower socio-economic status in women. The

Health Survey for England in 1996 showed the

prevalence of obesity among women consistently

increased from 14% in Social Class I to 25% in

Social Class V. The association is not as strong in

men; while the prevalence of obesity increased

from Social Class I to IIIM, it was lower in Social

Classes IV and V than in Social Class IIIM.

The causes for this increasing prevalence are

multifactorial. There is strong evidence that there

is a widespread decline in physical activity and

energy requirements, and this, against a back-

ground of plentiful food supplies with a national

diet relatively rich in fat, is likely to be a major

cause (Prentice & Jebb 1995). Though there is a

genetic element to obesity susceptibility, other

individual factors such as upbringing and

environment are also important, and it is the

interaction between individual and environmen-

tal factors which appears to be important.

The health risks associated with obesity are

related to both the amount of body fat and its

localization on the body. Obesity is one of the

most important avoidable risk factors in men and

women for diseases such as, coronary heart di-

sease (CHD), stroke, non-insulin dependent dia-

betes mellitus (NIDDM), hypercholesterolaemia,

hypertension, gallstones, degenerative joint dis-

ease (HEA 1995), and obstructive sleep apnoea

(Grunstein et al. 1995). In addition, in women,

obesity is a risk factor for endometrial, and

postmenopausal breast cancer (Department of

Health 1998a), menstrual irregularities and ovu-

latory failure. Risk of disease is proportional to

an increase in BMI but is particularly marked at

high BMI. For some diseases, excess abdominal

fat with a BMI of only 26 or 27 may lead to

greater risk than a BMI over 30 in a person whose

fat is more evenly distributed (Nutrition &

Physical Activity Task Forces 1995). Achieving

weight loss in overweight and obese people is

beneficial to health. The physical, metabolic,

endocrinological and physiological complications

reduce, often dramatically. Modest weight reduc-

tions of only 5±10 kg or 5±10% of initial body

weight reduces the health risks associated with

obesity (Lean 1998). Insulin sensitivity and

glucose intolerance also improve after weight

loss. In patients with NIDDM marked benefits are

seen in those with elevated, fasting blood glucose

levels if 5±10 kg is lost. A significant fall in

glycosylated haemoglobin (HbA1c) levels follows

(Collins & Anderson 1995). Blood lipid abnorm-

alities, e.g. raised serum triglycerides, raised

serum cholesterol and reduced serum high-

density lipoproteins (HDL) usually return to

normal if there is modest weight loss. Low

density lipoprotein (LDL) levels may reduce by

1% for every 1 kg of weight lost (SIGN 1996).

Additional weight loss may also reduce obesity

related mortality (Lean 1998).

Obesity and overweight generate significant

health service costs. The Office of Health Econom-

ics estimated in 1994 that obesity directly costs the

NHS over £29M per year and indirectly costs the

NHS over £165M if a proportion of the cost of

treating some of the conditions for which obesity

is a risk factor is also included (West 1994). These

estimates amount to 1±5% of total health care.

Obesity also is a cause of social and economic

problems, being associated with increased sick

leave and early retirement on health grounds.

The Health of the Nation Strategy for England

published in 1992 (Department of Health 1992),

included a target, to reduce the percentages of

men and women aged 16±64 years who are obese

by at least 25% for men and at least 33% for

women by 2005 (from 8% for men and 12% for

women in 1986/87 to no more than 6% and 8%,

respectively). Levels of obesity continue to be

Paper 01 Disc

DoH evaluation of weight management services 3


monitored as part of the Government's new

public health strategy, set out in the Green

Paper `Our Healthier Nation' (Department of

Health 1998b).

Despite the health risks associated with

obesity, it has not proved easy to treat effectively

(Glenny & O'Meara 1997). The Report of the Royal

College of Physicians (RCP 1997) concluded that

overweight and obesity require appropriate and

effective management by suitably trained mem-

bers of a multidisciplinary team. It recommends

that the aim of treatment should be modest

weight loss maintained for the long term and

suggests that the first-line strategy for weight

loss and its maintenance should be a combination

of supervised diet, exercise and behaviour

modification. The Report from the Scottish

Intercollegiate Guidelines Network (SIGN 1996)

concluded that, in view of the large numbers of

overweight and obese people, the most suitable

setting for management of obesity is primary

health care, or community or commercial sectors.

Evaluation of existing and new weight man-

agement services and dissemination of the results

will help to identify the most effective methods

for the treatment of obesity which can be

employed by all health care teams.

Evaluating weight management services: pro-

ject aims

The Centre for Reviews and Dissemination

(CRD) review (Glenny & O'Meara 1997) had

concluded that obesity deserved greater invest-

ment both in terms of research and service

provision. In April 1997, DH identified a small

budget (£100K for one financial year) to allocate

to encouraging good practice in the treatment of

obesity. The DH agreed that, within the time

available for funding the project, it would be

more constructive to support people at local level

by helping them evaluate their local weight

management service. The project therefore had

two aims: to promote the skills of evaluation at

local level; and to disseminate the results of

evaluation more widely.

The DH convened a small Advisory Group of

regional representatives to decide how best to use

the money. The group agreed that it would help

people in the field by:

. identifying existing projects on weight man-

agement in the regions and compiling a

directory of services;

. contributing up to £5000 to a number of

projects to help them to evaluate their work;

. disseminating the results.

Evaluating weight management services: pro-

ject methods

Questionnaires were sent out via a number of

local networks in each region, including Directors

of Public Health, Directors of Primary Care,

Health Promotion leads, Medical Directors, Audit

Group chairmen and other key individuals who

might be in a position to identify suitable projects

and services.

The responses were compiled into a directory,

Directory of Weight Management Services in

England (Department of Health 1998c), which is

available as a database at each Regional Office.

The directory also includes information from the

NHS Executive's `Our Healthier Nation', the NHS

Trust project on obesity.

One hundred and sixteen of the services

identified indicated that some evaluation had

been carried out, and was either available in

report form or currently being written up; others

had not been evaluated. Those who had expressed

an interest in evaluating their weight management

service were invited to submit a proposal. The

DH's Advisory Committee met in late September

1997 to consider the 50 applications received. The

Committee agreed that any project chosen had to

have a realistic timetable to complete the evalua-

tion within the financial year; the projects should

have been running for over 6 months; if possible, a

range of projects with different characteristics

would be chosen but any project or service should

deal directly with clients.

Evaluations of 13 weight management services

involving different types of intervention and

various practitioners were commissioned in late

September 1997. Each of the 13 projects required

a slightly different approach to evaluation and

the successful applicants had varying degrees of

experience in evaluation. The DH therefore

agreed to make expert advice available at the

start and throughout the life of the project and

commissioned Dr Mike Rayner, from the British

Heart Foundation Health Promotion Research

Group, to draw together a team. A 2-day seminar

on evaluation methods and report writing for

those concerned was held and is described in the

paper by Rayner and Ziebland (this supplement,

Rayner & Ziebland 1999) and tutorial support

Paper 01 Disc



was available throughout the evaluation.

Most of the evaluations were completed

and reports prepared by the end of March 1998.

The evaluations and outcomes are described in

the following papers. The factors leading to

successful weight loss and maintenance are

summarized below as are the difficulties encoun-

tered when evaluating these weight management

services and advice for those wishing to evaluate

their service.

What the evaluations show about effective

treatments for obesity

Factors associated with recruitment and

initiating weight loss

. An evaluation of a group of successful weight

losers in a GP practice lends support to the idea

of health-related anxiety as the most common

and potent factor initiating weight loss. This

raised anxiety/awareness arose directly from a

doctor or nurse health warning or screening

result in about half the successful group.

. For women from ethnic minorities, verbal

recommendation to join a weight reducing

(exercise and healthy eating) group was found

to be the most effective means of recruitment.

This emphasizes the importance of involving

the local community and link workers in

developing and establishing such a group. As

the group continued verbal recommendations

by women already attending became the most

important route for recruiting.

. Determination of patients' `readiness' for life-

style changes should be carried out prior to

enrolling them into programmes involving

dietary change and increased exercise. Where

lack of `readiness' is found, patients should be

referred back to their GP or for counselling

before embarking on a programme.

. Patients must want to lose weight for themselves.

. There is evidence to suggest that patients may

have an improved likelihood of completing a

weight loss programme if any depression is

successfully addressed before they are allowed

to begin.

. In order to provide the right treatment package

for each individual, a comprehensive assess-

ment is needed. This should include: life-long

dieting history; eating behaviour and patterns

with a screen for eating disorders; shopping

and food preparation habits; physical activity;

anxiety and depression and `readiness for

change'. This can be done by the patient

completing a questionnaire or by consultation

with a member of the health care team, but the

latter requires adequate time.

. The time between assessment and commence-

ment of the programme should be as short

as possible.

Factors associated with successful weight loss

. An evaluation of a group of successful weight

losers suggests that high CHD risk factor

status is associated with success. The sug-

gested mechanism is by raising health-related

anxiety to a critical level to motivate change.

. The emphasis of the weight management

service/programme should be on making life-

style changes to decrease energy intake and

increase energy expenditure rather than on

weight loss. Aiming to return overweight

patients to their ideal weight is unrealistic

and counter-productive. Where weight loss

goals are regarded as necessary, the negotiation

of achievable weight loss goals, of the order of

10% of initial weight, and the avoidance of

weight gain appear to lead to greater success.

. Programmes that can be adapted to meet the

needs of the individual.

. Regular appointments, either one-to-one or in

groups, continuity of programme and practi-

tioners, instructors or counsellors appear to be

important predictors of success in most weight

management services. Unsuccessful patients

cite infrequent contact, and lack of cont-

inuity of programme and/or practitioners as

being causative.

. Patients attending group sessions were more

likely to achieve weight loss.

Dietary interventions

In general there was a lack of detail and data

collection regarding baseline diet and dietary

change in most of the weight management

services evaluated. Most services involved some

dietary advice although some concentrated on

increasing physical activity, e.g. GP Exercise

Prescription Programme, and dietary advice was

secondary to this.

. Combining intensive dietary intervention, e.g. a

low calorie liquid diet (600±800 kcal daily),

Paper 01 Disc



with behaviour therapy, e.g. a group be-

havioural therapy programme, can achieve

medically significant weight loss (on average

4 10% body weight) and appears to offer

patients strategies which enable them to retain

a significant weight loss in the short and

medium term.

. Dietary interventions combined with exercise

sessions, e.g. aquafit classes or gym sessions,

resulted in weight losses greater than,

although not always statistically significantly

greater than, those achieved by diet alone.

. Dietary advice aimed at all the family in order

that the patient's dietary changes are readily

incorporated into the family's eating pattern

appear to improve compliance.

Increasing physical activity (exercise)

. Activities aimed at increasing energy expendi-

ture should not depend on attendance at a

facility. A number of patients gave difficulties

with access to exercise facilities as barriers to

increasing exercise or physical activity. Con-

sideration should be given to educating and

motivating individuals to increase their physi-

cal activity within their particular lifestyles.

. Aquafit sessions appear to be an acceptable

method of increasing exercise for some with

joint problems.

. Exercise needs to have a much higher profile in

the treatment of overweight diabetics. One

evaluation has demonstrated that it is possible

to take overweight diabetics who are consid-

ered to be poorly controlled and get them on to

a programme of regular exercise in gyms and

leisure centres, regardless of age. Furthermore

this activity can be enjoyable and offers the

added benefit of group support.

The evaluations have highlighted the following as

being helpful if the exercise programmes are to be

successful:

. a referral system which will identify those

suitable for the exercise programme and recog-

nizes the responsibilities of all parties involved;

. a stream-lined process to enable individuals to

be referred, assessed and commenced on an

exercise programme in a relatively short time;

. a motivated co-ordinator who is willing to take

part in the exercise programme;

. a supportive health care team, e.g. GPs,

consultants and other health professionals,

who recognize their role not only in promoting

exercise to their patients but also in helping

maintain their efforts to exercise;

. suitable facilities and personnel, including

instructors and reception staff, at leisure

centres conducive to promoting exercise;

. low to moderate intensity exercise classes run

by instructors who will increase the confidence

of the participants by explaining, at initial

consultation, how to exercise and most im-

portantly how to enjoy exercise;

. group sessions: overweight, obese and diabetic

patients prefer to exercise with people who

have similar characteristics or health problems;

. individuals should be encouraged to monitor

their exercise and, if appropriate, initiate

`buddying' among group members;

. a scheme that encourages participation of part-

ners, friends and family improves participation;

. a system to enable those who stop exercising

through injury to return to exercise when

fit again;

. development of coping strategies when faced

with situations that would reduce adherence

to exercise.

Behaviour modification

Only two of the weight management services

evaluated included a clinical psychologist in the

team. Following the launch by the Health

Education Authority of the `Helping People

Change' approach to behaviour change (HEA

1993), the British Dietetic Association Position

Paper on obesity treatment (British Dietetic

Association 1997) and the paper by Rapoport

(1998) on integrating cognitive behavioural ther-

apy skills into dietetic practice, some dietitians

have been using behavioural techniques. How-

ever, the evaluation of the Leicestershire Dietetics

Service found that most dietitians interviewed

felt that there was currently insufficient time in

clinics to put this approach into action.

. A multidisciplinary team (a consultant physi-

cian, a clinical psychologist and a senior

dietitian) was successful in helping patients

achieve medically significant weight loss.

. Using a programme with a lifestyle approach

for female adolescents appears to have

achieved some improvement in confidence

and self-esteem and in the amount of physical

activity taken in most, if not all, of the girls.

Paper 01 Disc



. The evaluation of a programme for overweight

and obese, poorly controlled diabetics sug-

gested that the programme's focus on lifestyle

changes achieved a measure of success in

weight loss and/or improved glycaemic control.

Although it is a slow method of achieving

weight loss, there appears to be good potential

for not only sustained weight loss but also

further weight loss for this patient group.

Factors associated with successful weight

maintenance

. Maintenance of weight loss appears to be

associated mainly with new positive feelings

and perceptions about self.

. Support from family and friends and support

and follow-up by the primary health care team

were significant maintaining factors in about

half the successful group in one of the services.

. Follow-up of those patients who have achieved

a clinically significant weight loss when

attending weight control programmes appears

to be necessary to enable them to maintain their

weight loss. Study results indicate that for a

sector of this population, group sessions are an

acceptable method of maintaining contact.

. As diabetes is a lifelong condition, a pro-

gramme that supports and encourages appro-

priate self-care behaviours in a continuous

model appears to offer potential for long-term

weight management and thus improved health

outcomes for patients with diabetes.

Difficulties encountered in evaluating the

services

Difficulties varied widely between practitioners.

A few practitioners were well equipped, had

relevant research and evaluation experience and

had access to assistance, but the majority had no

previous experience and had limited or occasion-

ally no assistance or access to a computer for

word processing and data analyses. The paper by

Rayner & Ziebland (this supplement, Rayner &

Ziebland 1999) discusses in detail the difficulties

reported by the evaluation participants. The

following is a summary of the difficulties high-

lighted during the training seminar, follow-up

support and in one or two of the reports:

. uncertainty over the need to seek ethical approval

and ensuing difficulties with ethics committees;

. time constraints especially when delays in

obtaining ethical approval reduced the time

available and there was a shortage or lack

of assistance;

. lack of expertise in research methods, especially

in collecting qualitative data through semistruc-

tured interviews; analysing both quantitative

and qualitative data; and report writing;

. problems with access to or missing baseline

and follow-up anthropometric and clinical data

and data on dietary, physical activity and

behavioural patterns and changes;

. difficulties of motivating other people to

contribute to the project.

Advice to others planning to evaluate their

weight management services was given by the

project participants in an interview after the

project reports were submitted. This is described

in detail in the paper by Rayner & Ziebland. That

advice can be summarized as follows:

. know the aims of the weight management

service to be evaluated and define research

questions early;

. ensure management backing and do not under-

estimate funding required;

. seek advice about the need for local ethics

committee's approval at planning stage and

learn the dates of the committee's meetings;

. design the evaluation before the project/weight

management service starts so that the appro-

priate data are collected, but where this is not

possible ensure that available data are adequate;

. be realistic about the time and the assistance

required to carry out the evaluation;

. beware the apparent simplicity of collecting

qualitative information and take advice on the

research methods and analyses used;

. seek advice from those experienced in research

methods, data analyses and report writing.

Recommendations to Health Authorities and

service providers

Weight management services should be evalu-

ated to establish whether they are successful; and

to ensure that the most efficacious treatments for

reducing obesity are identified and implemented.

The benefits of reducing the prevalence of obesity

have been described earlier. The process of

evaluating weight management services requires

adequate personnel, funding and time. In addi-

tion, this project has highlighted that local health

Paper 01 Disc



professionals need expert advice on research

methods, data handling and analysis, and report

writing on an ad hoc basis. This need could be

met at local level by making available expertise

from audit groups, a university or other academic

departments, or research institutes in each health

region. In addition a source of advice on ethical

issues might be identified to advise on the need

for ethical approval and assist with the acquisi-

tion of ethical approval where required. The

existence of this expertise should be made

known to all practitioners involved with the

evaluation of weight management services. Prac-

titioners should be encouraged to seek expert

advice and assistance during the planning stages

and when analysing the data and interpreting the

results. Evaluations should be planned prospec-

tively so that relevant data will be collected and

appropriate follow-up procedures planned.

The current evaluations highlight the need for

long-term monitoring and support of those who

have successfully lost weight. Service providers

need to consider the implications for such long-

term monitoring and support.

Conclusion

The prevalence of obesity in the UK has reached

epidemic proportions and is continuing to increase.

Obesity is one of the most important avoidable risk

factors in men and women for diseases such as

CHD, stroke, NIDDM, hypercholesterolaemia, hy-

pertension, gall stones, degenerative joint disease,

obstructive sleep apnoea and hormone associated

cancers. Modest weight loss of 5±10 kg or 5±10%of

initial body weight maintained for the long-term

reduces the health risks associated with obesity.

The Department of Health remains committed to

reducing the levels of obesity and recently allo-

cated funding to support a number of practitioners

at local level by helping them evaluate their local

weight management services.

The evaluations of the weight management

services reported in this supplement suggest that

successful sustained clinically significant weight

reduction in obese patients is rare. Most of the

interventions evaluated showed initial weight

loss in some patients but this was rarely

maintained at follow-up.

The evaluations suggest that successful

weight loss is achieved through multicomponent

programmes which aim to bring about lifestyle

(behavioural) changes to reduce energy intake

and increase energy output in ways that are

practical and easy to sustain. This can best be

achieved through multidisciplinary teams of

suitably trained health care workers and physical

activity instructors. Regular contact and follow-

up between patient and practitioners are impor-

tant for successful weight loss and may best be

achieved for the majority of obese patients

through a combination of individual and group

sessions. More work is needed to develop

strategies that may improve long-term weight

maintenance following weight reduction. Service

providers need to consider the implications for

long-term monitoring and support.

To determine the most effective weight man-

agement services current services need to be

evaluated. Evaluations need to be considered at

the planning stage for the services so that

appropriate data and research methods are

included. Health Authorities should consider

how best to provide advice and help to practi-

tioners whose research experience is limited.

References

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treatment: future directions for the contribution

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Collins, R. & Anderson, J. (1995) Medication cost

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insulin-dependent diabetic men and women. Prev.

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Department of Health. (1992) Health of the Nation: a

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Department of Health. (1998a) Report on Health &

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Lean, M. (1998) Clinical Handbook of Weight

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The Department of Health’s project to evaluate weight management services

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