Breaking the diet mentality is half the obesity battle

Published on Monday 28 April 2008 20:01

A new weight-loss programme with an emphasis on behavioural adjustments is changing our thinking, reports JULIE GRIFFITHS.

THE stereotype of Scotland as a nation that feasts on chips and deep-fried Mars bars may be outdated, but the obesity level that accompanies such a diet is not.

The country's growing waistline is such that, with an estimated 26 per cent of women and 22.4 per cent of men overweight, Scotland is second only to the US in recorded levels of obesity.

Given that the problem is linked to conditions such as high blood pressure, diabetes and cancer, all of which take a toll on NHS resources, the Scottish Government has pledged to combat the issue.

Earlier this year, it announced 15 million of funding specifically aimed at addressing obesity as part of a 40m package for health improvement initiatives.

Part of that package involves introducing the weight-loss programme Counterweight across Scotland.

The scheme, which is the only evidence-based primary care weight management programme within the UK, was developed and evaluated in 80 general medical practices across Britain between 2000 and 2005.

It has been used in three Scottish health board regions – Lanarkshire, Lothian and Tayside – since April 2006 and is now starting in Ayrshire, Arran, Aberdeen and Fife.

Counterweight's success is such that 40 per cent of patients on the programme have lost at least five per cent of their bodyweight within a year and have maintained the loss after two years.

This may seem a small reduction, but Professor Iain Broom, chair of the Counterweight board and director of the Centre for Obesity Research & Epidemiology at Aberdeen's Robert Gordon University, says it is enough to make a difference.

"It means that, if a patient is not already diabetic, they reduce their risk of developing the disease by 58 per cent over a four-year period," he says.

He notes that, when the weight-loss programme is set in context with smoking cessation schemes (where there is a 7 per cent success rate), then Counterweight is highly effective.

Broom puts the success down to the level of support given to patients on the programme via regular meetings with nurses or dieticians.

Participants are given nine sessions in a year covering issues such as diet, exercise and behavioural change. There are six appointments twice a week for the first three months. This provides intensive support as patients identify specific barriers to weight loss and work towards overcoming them. The remaining three sessions are spread over the rest of the year for ongoing help.

Each appointment lasts about 30 minutes and is on a one-to-one basis, meaning that the advice is tailored to the individual.

Maria McQuigg, a dietician who trains and supports other healthcare professionals to deliver Counterweight, says that this is important because obesity is such a personal and complex issue.

"We are listening to their story, finding out what their struggles are with eating, and the way they think about themselves and food. There is a high emphasis on behaviour change" she explains.

This includes breaking the diet mentality. Instead, the focus is on making small changes that are sustainable for the rest of their lives. Food and exercise plans can be changed throughout the course if they are ill-suited to the patient's life or if they are not working. Mental health issues are also tackled if it's deemed necessary.

McQuigg says that managing expectation is also important, particularly among those who have a history of dieting. "When they're losing weight, they'll think they're not succeeding and will lapse because they feel depressed. Often very negative emotions can trigger the urge to eat."

Louise McCombie, dietician and team leader of Counterweight in Scotland says one of the most valuable elements of the initiative is its flexibility with each of the existing sites in Scotland having adapted it to suit their needs.

Lanarkshire has opted for a centralised service in which the health board employs a team of health care support workers to deliver the programme.

In Lothian, the scheme is mostly provided by existing practice nurses, and Tayside has gone for a combination of both approaches.

McCombie says that regardless of how health boards choose to implement the programme, it is important to support those who are delivering it. Healthcare professionals are given eight hours of training and will often sit in on consultations run by a Counterweight dietician before seeing their first patient.

"It can be hard to see how the theory should be applied in a practical situation after doing all the training, so we support staff to deliver the programme. We give them six months of mentoring," she explains.

The ongoing support enables staff to discuss difficulties they have with patients as they arise.

"A number of nurses have said they find it difficult not to tell patients what to do. We are suggesting that the patient should decide what they will do. That is a shift in mindset," says McCombie.

Patients who are not ready to commit to behavioural change are screened out via a series of questions before being admitted to the programme. Some return at a later date when they feel ready to make the changes needed, others do not.

Sandra Macrae, who has 13 years' experience of nursing, is one of the 80 healthcare professionals in Scotland delivering the programme.

For the past year, she has run Edinburgh Counterweight clinics in Muirhouse and Leith. She identifies suitable patients via GP referrals and through Keep Well clinics, an initiative that targets people in deprived areas to address health inequalities. So far, she has seen about 50 patients.

Macrae believes that the barriers to people losing weight vary. Sometimes it is because of a lack of knowledge – one man fried his chips in olive oil most days of the week because he had heard it was good for you. For others, there are psychological issues.

"One lady has fought with food throughout her life. She has issues with her mother and that is when she turns to food. Now she knows her triggers," says Macrae.

"We are really getting to the nitty-gritty of why people are overweight and that's the key."

Word has gone round about the success of Counterweight in Muirhouse and there is now a waiting list of 15 to participate.

Macrae says that one of the most rewarding aspects of the programme is watching the change in her patients.

"I get a lot of satisfaction in seeing people happier with themselves.

"They thought they could not lose the weight, but they do. And when they do, they know they've done it themselves and are really proud."