EVALUATION OF THE SPECIALIST WEIGHT MANAGEMENT SERVICE FINAL REPORT Helen Cording Shelina Visram Ann Crosland July 2005 Primary Care Development Centre Northumbria University, Kielder House, Coach Lane Campus, Newcastle upon Tyne, NE7 7XA
Evaluation of the specialist weight management service (SWiMS)
Contents Executive Summary Introduction Background Public Health Context of Overweight and Obesity Models of Weight Reduction Effectiveness of Interventions Barriers to Effective Weight Management Background of the Specialist Weight Management Service Methodology Aims and Objectives Analysis Ethical Approval Findings Profile of Referrals to the Service Profile of Discharges from the Service Motivational Factors to Accessing the Service Previous Experiences of Weight Gain and Loss Experiences of Accessing the Service Views on the Content of the Programme What Worked About the Programme Concerns About the Programme Maintaining Weight Loss After SWiMS Staff Views and Experiences of SWiMS Lessons About the Need for, and Motivations of, those who are Overweight or Obese to Lose Weight Lessons About the Organisation and Management of SWiMS 27 Lessons for Evaluation in the Future Recommendations Administration and Data Collection Communication Issues Organisation Issues Providing Additional Support from the SWiMS Programme References Appendices
Evaluation of the specialist weight management service (SWiMS)
EXECUTIVE SUMMARY Introduction
This report details the findings from a research study funded by Newcastle
Primary Care Trust. The aim of the study was to evaluate the innovativeSpecialist Weight Management Service (SWiMS) in Newcastle upon Tyne byexploring the physical effects, such as changes in weight and BMI, andparticipants’ views of the programme. Methodology
The evaluation combined quantitative measures to judge the effectiveness of
the interventions with qualitative data collection in the form of semi-structuredinterviews to explore the views, perceptions and experiences of patients andstaff.
Between November 2002 and May 2005, a total of 1,522 have been referred
Complete datasets were collected on 51 discharges which showed that while
some people gained weight, the vast majority lost weight, with the greatestweight loss being 31.7 kg. The overall mean weight loss in this group was8.9kg.
The risk of illness was commonly reported as the most important motivational
factor for losing weight in both the interviews and surveys (n=20 of 33surveys). This was followed by concerns about being overweight (n=13), lackof energy and being tired (n=12), and the fact that they had been sent by aGeneral Practitioner or other health professional (n=11).
Over-eating was rarely acknowledged as a major contributory factor in
participants’ weight becoming a problem. Rather than focussing on poor dietor physical inactivity, participants gave factors such as gaining weight afterchildbirth, recovering from an operation or developing an illness as the maincauses or contributing factors in their weight gain.
The SWiMS programme encouraged participants to think of the nutritional
education component of the sessions as part of a wider change to a healthier,more balanced lifestyle, rather than a traditional ‘diet’ consisting of good andbad foods. Participants seemed to think that this would make the changesmore sustainable in the long -term.
The biggest criticism of the service was feeling ‘dropped off’ at the end of the
SWiMS programme. Most felt they needed the motivation of the group andSWiMS staff to continue with their attempts to lose weight, and also missedthe opportunity to socialise with one another on a regular basis.
At the time of the six-month follow-up interview, several participants described
themselves as being at a ‘standstill’ in terms of their attempts to continue tolose weight since leaving SWiMS. This was generally attributed to eitherhealth problems or seasonal effects such as the colder weather, as mostinterviews were completed during autumn/winter.
Participants reported experiencing a range of health and other benefits as a
result of their increased physical activity levels, for example, being able towalk further or stand for longer periods of time, having more energy andgenerally feeling on a ‘high’. Engaging in exercise also had a positive impacton participants’ self-esteem and confidence levels, providing them with someincentive to continue to follow and maintain a healthier, more active lifestyle.
All staff interviewed felt there had been some real success stories for
participants who had been through the SWiMS programme. Staff felt that the
Evaluation of the specialist weight management service (SWiMS)
hard work and enthusiasm of programme staff had contributed to thedevelopment of the scheme and the aforementioned success stories.
Problems associated with funding were reported as a barrier to the
Poor communication between staff members within the programme was often
cited as a barrier to the development of SWiMS. This stemmed from the factthat staff members were based at different places and often worked part-time. One of the most commonly cited areas to improve this was to have some sortof central base for SWiMS where all staff could be accommodated.
Staff felt that key data was not being collected on participants going through
the SWiMS programme and that this was something that could be collectedroutinely with the correct protocols in place.
Maintaining the ‘specialist’ role of the SWiMS programme in dealing with
those who were obese or morbidly obese was seen as important.
There was also a perceived need to prioritise health promotion and the
prevention of obesity, as these were felt to be lacking within the currentservice. Recommendations There is a need for increased administration input into the programme to
improve data collection and storage, and to facilitate communication withinthe team.
It is recommended that there be one central database, which is easily
accessible to all programme staff. This database should include standardisedrecordings of weight, height, BMI, blood pressure, waist circumference, highand low density lipid levels, cholesterol levels, fasting glucose and any pre-existing co-morbidities both at the first appointment and following completionof the programme. All relevant staff should be trained to collect this data.
We recommend that a communication strategy be developed involving the
input from key staff to ensure better communication between staff andtransparency of the decision -making process at the steering group level.
Recruitment of a link worker or the adaptation of a current role could improve
links into other services in the area, such as services for black and ethnicminority populations, and the diabetes and cardiac rehabilitation programmes.
It appears there is a need to develop protocols for scheme staff, GP’s and
others who may refer into the service to ensure that only overweightindividuals with co-morbidities and obese individuals access the service. Thiswould enable the specialist service provided by SWiMS to be targeted to theneeds of the specific population.
The high drop-out rate of the service indicates the need for a screening
process to identify those people who are and those who are not ready toattend the programme. This screening process could assess the patient’smotivation to adhere to a programme of diet and physical activity and wouldconsequently serve to protect the scarce resources.
A system of peer support was proposed at the start of the SWiMS programme
but has not been developed because of other demands. It is recommendedthat this part of the programme be developed to help individuals overcometheir sense of isolation and help build relationships.
Participants reported a need for ongoing support to help them stay motivated.
One suggestion was the development of a monthly drop-in clinic, which couldbe made available to past members of the SWiMS programme.
Evaluation of the specialist weight management service (SWiMS)
INTRODUCTION
This report details the findings from a research study funded by Newcastle PrimaryCare Trust. The aim of the study was to evaluate the innovative Specialist WeightManagement Service (SWiMS) in Newcastle-upon-Tyne by exploring the physicaleffects, such as changes in weight and BMI, and participants’ views of theprogramme. The Specialist Weight Management Service has been highlighted in theWanless Report (2002) as an example of good practice.
The SWiMS evaluation sought to explore the impact of the service on individuals whoare morbidly obese and those who are overweight with existing co -morbidities. Theevaluation examined people’s motivation to lose weight and take part in physicalactivity, and the factors that positively or negatively impacted on the sustainability ofthis weight loss and activity levels over a six-month period. In addition, the evaluationexamined the process of establishing and operating the service in order to informfuture developments.
Key findings are presented in four sections. The first looks at the profile of thosereferred to the service and the effectiveness of SWiMS, in terms of changes in weightand BMI. The second looks at motivational factors related to accessing the service. The third section examines participants’ views and experiences of SWiMS. The finalsection outlines staff experiences of working within the SWiMS programme. The keyfindings are then discussed and recommendations made. Acknowledgements The project team wishes to acknowledge the help of Wendy Hicks and Denise Armstrong who assisted in the development and operation of the project. We would also like to thank all of the participants who gave up their time to take part in the interviews.
Evaluation of the specialist weight management service (SWiMS)
2.0 BACKGROUND Public Health Context of Overweight and Obesity
Obesity is currently one of the most pervasive health problems in the country, with 24million adults – more than half of the adult population in England – now considered tobe either overweight or obese (Sproston and Primatesta 2004). Since the 1980sthere has been a three-fold increase in the number of adults classed as clinicallyobese (having a BMI greater than 30kg/m2), with 22% of men and 23% of women inEngland currently falling into this category (Sproston and Primatesta 2004).
Public health concerns about obesity relate to its link to numerous chronic diseases,many of which are life limiting. An estimated 9,000 premature deaths per year inEngland can be attributed to obesity (6% of all deaths) and the lifespan of an obeseperson is nine years less than that of someone of lower weight (National Audit Office2001). Obesity doubles the risk of all-cause mortality, coronary heart disease, strokeand type 2 diabetes, and increases the risk of some cancers, musculoskeletalproblems and loss of function (National Heart 1998; National Heart Lung and BloodInstitute 1998; National Audit Office 2001).
In addition to the physical effects, obesity has considerable social and psychologicalconsequences, such as anxiety and mood disorders (Becker, Margraf et al. 2001), aswell as financial implications. It has been estimated that the cost to the NHS oftreating obesity in England alone is around £500 million, although many believe theactual figure to be far higher (Lewis 2003). In 1998, over 18 million days of sicknesswere attributed to obesity and the total estimated cost of obesity for England was£2.6 billion. If the prevalence of obesity continues to rise at the present rate until2010, this annual cost would increase by almost a third to £3.6 billion (Mulvihill andQuigley 2003).
As the prevalence of childhood obesity in Europe and the USA has doubled in thelast 10 to 15 years, adult overweight and obesity is expected to increase further incoming years (Troiano and Flegel 1998) . Obesity has overtaken smoking as thenumber one public health issue in England and is a key priority of both the WanlessReport (2002)
and the government’s recent Choosing Health White Paper
(Department of Health 2004), which aims to reduce the risk of major chronic diseasesand premature death by helping people to make healthier choices. Models of Weight Reduction
As well as being a risk factor for several other chronic diseases, obesity itself is acomplex, multifactorial disease of appetite regulation and energy metabolism,involving genetics, physiology, biochemistry and the neurosciences, as well asenvironmental, psychosocial and cultural factors. Unfortunately the lay public andhealth care providers often view it simply as a problem of eating too much andexercising too little, which has implications for both prevention and treatment(Committee to Develop Criteria for Evaluating the Outcomes of Approaches toPrevent and Treat Obesity 1995) .
According to Sobal (1995), fatness and thinness are the outcome of biological,psychological and social processes that occur within relationships and socialinstitutions. For many years, research and practice in the field of weight managementhave been based largely on a simplistic, unidimensional weight -loss paradigm(Senekal, Albertse et al. 1999). Weight-management programs have tended toemphasise the importance of personal control and little attention has been paid toenvironmental context. The long -term success rate for persons using this paradigm
Evaluation of the specialist weight management service (SWiMS)
has been low and so Senekal et al present a multidimensional paradigm that focuseson all aspects of the prevention, treatment, and management of weight -relatedproblems. Figure 1: A Multidimensional Weight-Management Paradigm (adapted from Senekalet al 1999)Environmental influences on weight management Weight Management Continuum Interpersonal characteristics and skills central to weight management Stage of Change Techniques to effect change: Long-term weight management
This paradigm presents weight management as a continuum on which five prominentpoints are identified. It is further suggested that: the whole continuum of weightmanagement is influenced by interactions with the environment; certain interpersonalcharacteristics and skills form an integral part of the continuum; and in most caseschange, which can be brought about using specific methods or techniques, isnecessary to acquire the ability to sustain optimal weight (Senekal, Albertse et al. 1999). Ability to change may depend on the individual’s stage of change (Prochaskaand DiClemente 1982). This model states that individuals experiencing healthbehaviour problems can be categorised into one of five discrete stages –Precontemplation, Contemplation, Preparation, Action or Maintenance – on the basisof their response to a short series of questions about current and past efforts tochange behaviour and intentions to change in the future.
Evaluation of the specialist weight management service (SWiMS)
Changing sedentary behaviour is an integral part of successful weight loss programs. Self-efficacy for exercise, or the individuals’ judgement of his or her ability tosuccessfully perform an activity, has been shown to be a strong predictor for theadoption and maintenance of exercise (Bandura 1977; Sallis, Haskell et al. 1986;Reynolds, Killen et al. 1990). An individual’s perception of the relative benefits andcosts, as well as the resulting decisional balance (benefits minus costs) are alsoassociated with exercise adoption (Marcus, Eaton et al. 1994). Studies have shownthat individuals who are in more advanced stages of motivational readiness forexercise report higher self-efficacy and a more positive decisional balance forexercise adoption (Marcus and Owen 1992; Marcus, Selby et al. 1992; Marcus,Eaton et al. 1994).
Self-efficacy for managing eating is also important to weight loss efforts. Eating self-efficacy, i.e. an individual’s confidence in their ability to successfully follow a healthydiet, has been shown to increase following treatment, and higher eating self-efficacyappears to improve weight loss (Clark, Cargill et al. 1996; King, Clark et al. 1996). Furthermore, eating and exercise are interrelated in that data suggest that exerciseappears to compliment dieting by increasing dietary adherence (Rodin and Plante1989). Preliminary data from a study by Clark et al (1996) supported improvements ineating self-efficacy following participation in a clinic-based weight managementprogram. However, a different study found self-efficacy judgements not to bepredictive of short-term obesity treatment outcomes (Fontaine and Cheskin 1997). Effectiveness of Interventions
There is strong scientific evidence to suggest that obese individuals who lose evenrelatively small amounts of weight are likely to decrease their blood pressures, bloodglucose levels, blood concentration of cholesterol and triglycerides, sleep apnoea,risk of osteoarthritis of the weight-bearing joints and depression, and increase theirself-esteem (Committee to Develop Criteria for Evaluating the Outcomes ofApproaches to Prevent and Treat Obesity 1995). Clinical practice has targetedweight loss of 10% as this has been shown to bring about substantial improvementsin blood pressure, blood lipids and glucose tolerance (National Heart Lung and BloodInstitute 1998) .
For the treatment of obesity in adults, the aim is generally to use diet, physicalactivity and behavioural strategies, in combination where pos sible. Modest, regularbouts of physical activity can lead to weight loss and additional health benefits, suchas improved cardiovascular function (Health Development Agency 2002). Researchhas shown that those who achieve and maintain regular physical activity are morelikely to sustain a higher percentage of their weight loss for several months after aweight management programme (Klem, Wing et al. 1997). The type of exercise is notimportant but a gradual, step-wise approach seems to have the most beneficial long-term effect (Health Development Agency 2002).
A systematic review of the evidence (Mulvihill and Quigley 2003)
increased physical activity is effective in producing a modest total weight loss,although diet alone was found to be more effective than exercise alone. Evidencewas found to support the effectiveness of low calorie diets (1000-1500 kcal/day), lowfat diets (where 30% or less of total energy is derived from fat), and low fat and lowenergy diets combined with energy restriction (NHS Centre for Reviews andDissemination 1997; National Heart Lung and Blood Institute 1998; Astrup, Grunwaldet al. 2000; Pirozzo, Sumerbell et al. 2002) . There is also evidence to suggest thatclinically prescribed very low calorie diets (400-500 kcal/day) are more effective thanlow calorie diets for acute weight loss.
Evaluation of the specialist weight management service (SWiMS)
Behavioural interventions are based on the premise that behaviour is learned andreinforced by particular social circumstances. This method involves techniques suchas cue avoidance and role-play to rehearse resistance, which can then be used insituations where individuals tend to overeat. However, a systematic review found littlereliable evidence that behavioural interventions when used alone are effective atreducing obesity (Effective Health Care 1997) . Most studies have explored the useof diet with behavioural interventions and found that this approach is more effectivethan diet alone (Wadden and Stunkard 1986; Wadden, Sternberg et al. 1989) .
In a review of medical literature from the United States for effectiveness of adultobesity screening and treatment, pharmaco-therapy or counselling interventions werefound to produce modest weight loss (generally 3 to 5kg) over at least 6 or 12months respectively (McTigue, Harris et al. 2003). Counselling was more effectivewhen intensive and combined with behavioural therapy. Selected surgical patientslost substantial amounts of weight (10 to 159 kg over one to five years). Weightreduction resulted in improved blood pressure, lipid levels and glucose metabolism,and decreased incidence of diabetes.
In some adults the additional use of anti -obesity drugs may enhance weight loss butit is recommended that these should only be used where patients have already lost acertain amount of weight by changing their diet and levels of physical activity(National Institute for Clinical Excellence 2001a; 2001b). In addition, NICE guidanceemphasises the need to use these anti-obesity drugs alongside diet, physical activityand behavioural strategies. Surgery for obesity is rarely performed in the UK and isusually reserved for the extremely obese patient with life threatening comorbidities,although evidence of its effectiveness is good (Glenny, O'Meara et al. 1997).
There has been little research carried out into the efficacy and cost -effectiveness ofcommercial weig ht loss programmes. Although anecdotal evidence from clients isgood, patients who self -select by paying for specialist slimming products or to attendslimming clubs may be different to those using primary care services for obesitymanagement (Health Development Agency 2002).
It is now realised that prevention of weight gain, as well as weight loss and improvinghealth status, are important goals. However, the evidence on effective interventionsfor the maintenance of weight loss is of poorer quality compared with that for thetreatment of obesity. This evidence suggests that overweight and obese peopleshould be encouraged to integrate changes to their lifestyle over an extended periodof time to maintain the benefit of initial weight loss (Tremblay, Doucet et al. 1999). Maintenance strategies should include continued support; for example, self-help peergroups, relapse prevention strategies and continued therapist contact. Barriers to Effective Weight Management
It is estimated that some 70% of successful weight losers regain at least half of theweight they lost within two years (Heffernan 2003). A number of factors, such ashaving unrealistic weight goals, poor coping or problem-solving skills, and low self-efficacy (i.e. an individual’s estimate of his/her ability to effect change), may have animportant effect on the behaviours involved in weight management and relapse inobesity (Byrne 2002) . A study by Tod and Lacey (2004) examined the factors thatmotivate or hinder people in taking action about their weight. Their findings reveal thevulnerability of people at the point at which they request help and the complex, fragilenature of their weight loss decisions.
Participants in the aforementioned study reported that the decision to take action tolose weight was reached gradually, and preceded with stages of pre -contemplation
Evaluation of the specialist weight management service (SWiMS)
and contemplation. Triggers to action included embarrassment and humiliation,health concerns, critical events (e.g. weddings, holidays, birthdays), and imagefactors. Barriers to action centred on denial and previous bad experiences. Anadditional problem involved allegations of negative attitudes of health professionalstowards obese people, including a perception of personal responsibility and blame.
Health professionals working in primary care have a number of problems workingwith overweight and obese people, including: resource constraints; lack of dedicatedtime; lack of staff training; high levels of non-attendance for some interventions;confusion regarding roles and responsibilities; and poor use of evidence-basedprotocols (Tod and Lacey 2004). A survey of 345 primary care organisations in theUK (Dr Foster 2003) found that more than half had not organised weight-management clinics and a third of GP practices did not have direct access to adietician. In 13% of primary care organisations there was direct access to neither adietician nor a weight management clinic.
Other barriers to effective obesity management may include: lack of access toappropriate support services; efficacy of treatments; and lack of awareness of thesignificance of obesity in health terms. Acknowledgement of excess weight and anunderstanding of its health consequences are essential first steps in tackling obesity. However, overweight goes largely unrecognised for reasons that might includedenial, reluctance to admit a weight problem, or desensitisation to excess weightbecause being overweight has become ‘normal’ (Jeffery, Voss et al. 2005) . Thelayperson’s perception of average weight now conflicts with the clinical definition, anda label of overweight from a health professional may be insufficient motivation for achange in lifestyle.
It is difficult for an obese person to return to a ‘normal’ body weight and it is morerealistic to aim for modest degrees o f weight loss, such as 5-10% of body weight. Asuccessful programme is often defined as one that produces maintenance of loss ofat least 5% of body weight. Successful weight management to improve overall healthfor adults requires a lifelong commitment to healthful lifestyle behaviours,emphasising sustainable and enjoyable eating practices and daily physical activity. Patients also tend to respond better to treatments that are directed towards theirpersonal needs (Heffernan 2003). Background of the Specialist Weight Management Service
The Newcastle Primary Care Trust Specialist Weight Management Service (SWiMS)aims to provide structured support, including advice about diet and physical activity,to individuals with overweight and obesity (defined as a BMI >25). The servicecompliments existing provision (Level 1) offered by Newcastle Nutrition and PrimaryCare Teams, and provides services at an additional two levels:
Overweight individuals (BMI > 25) with existing co-morbidities
Provided they meet the above criteria, individuals can be referred to SWiMS from anysource, including self-referral. Level 2 interventions involve input from a NurseSpecialist, Dietician/Nutrition worker, Exercise Instructor and, where necessary, froma Psychologist. Individuals undergoing the Level 2 intervention are seen in groups ofbetween 15 and 20 people at a local venue for a period of 8 to 14 weeks.
Level 3 participants are offered the option of either attending a group or being seenon a one-to-one basis. Individuals seen at home will usually have a co-existing healthor social problem, which means they are unable or unwilling to attend the clinic.
Evaluation of the specialist weight management service (SWiMS)
Following the group programme, individuals are supported at a distance and followedup by the service at 3 months and again at 6 months. The service is also exploringthe development of Peer Support Training as a way of encouraging the sustainabilityof weight loss and exercise once the initial 8-week programme has ended. It isenvisaged that the Peer Support Training will be developed and delivered by theSWiMS team, with the Clinical Psychologist taking a lead role in this element of theservice.
Evaluation of the specialist weight management service (SWiMS)
3.0 METHODOLOGY Aims and Objectives
The overall aim of this study was to evaluate how effective and acceptable theSpecialist Weight Management Service has been in helping people to lose weightand maintain this weight loss. More specifically, the objectives were:
1. To measure the effectiveness of the service and its interventions in reducing
an individual’s weight and BMI, when compared with baseline data;
2. To examine motivational factors ass ociated with weight loss;3. To explore patients’ perceptions and experiences of the SWiMS programme,
in order to gain an understanding of factors that influence adherence to dietand exercise as well as to obtain their views of the service;
4. To explore the experiences of staff working within or into the service to
establish what has worked well and where improvements could be made.
The evaluation combined quantitative measures to judge the effectiveness of theinterventions with qualitative data collection in the form of semi-structured interviewsto explore the views, perceptions and experiences of patients and staff. Objective 1: To measure the effectiveness of the service and its interventions in reducing an individual’s weight and BMI when compared with baseline data Each individual had his or her weight and BMI recorded during induction to the programme and again eight weeks later, after the programme had been completed. This data was presented to the research team in an anonymised format by service staff and used to identify the average reduction in weight and BMI on discharge from the service. Objective 2: To examine motivational factors associated with weight loss and the sustainability of weight loss In line with the requirements of data protection legislation, consent forms and information sheets for the evaluation were distributed via the service manager during the induction programme. All members of the SWiMS programme were invited to take part in the evaluation. If participants were happy to take part and had all of their questions answered, they completed a consent form and contact details form which were then returned to the research team.
Those who agreed to take part were given the option to participate only in the initialmotivation survey or to complete the survey and undergo two interviews, one aftercompleting the SWiMS programme and another approximately six months later. Allparticipants were informed that they were free to withdraw at any point during theresearch and that they would be supported in this choice.
Each individual’s reported cues to action and motivation to commence and adhere toa diet and programme of physical activity were collected during the service inductionusing the cues to action survey. These were further explored with those whoconsented to interview. Objective 3: To explore patients’ perceptions and experiences of the SWiMS programme Semi-structured interviews were conducted with a sample of participants taking part in either the Level 2 or Level 3 intervention after completion of the eight-week programme. This was done in order to explore their views, perceptions and experiences of SWiMS.
Evaluation of the specialist weight management service (SWiMS)
Six-month follow-up interviews were also conducted in order to examine any reasonsindividuals gave for discontinuing their participation in the SWiMS programme orbarriers they had experienced in attempting to maintain their weight loss efforts. Objective 4: To explore the experiences of staff working within or into the SWiMS programme Semi-structured interviews were conducted with members of the SWiMS team and other staff. These stakeholders were recruited via the service manager and interviewed at a time and place convenient to them.
The interviews were used to examine issues around the continued operation of theSW iMS programme, what had worked well and stakeholders’ views about the futureof the service, including suggestions for potential improvements. All interviews weretape-recorded, transcribed verbatim and analysed using thematic content analysis. Analysis
Data from the survey were entered onto SPSS (Statistical Package for the SocialSciences, version 11.0) and analysed descriptively. Qualitative data was analysedusing a thematic content analytical approach.
All interviews were audio taped with informants’ consent and transcribed verbatim,with
independently by the research team and the main concepts within the data wereidentified. Trustworthiness of data interpretation was addressed by having threemembers of the research team independently analyse the transcripts, i.e. triangulation
Ethical Approval
Ethical approval for the project was granted by Newcastle and North Tyneside LocalResearch Ethics Committee in December 2003. All members of the research teamwere also granted honorary contracts with Newcastle Primary Care Trust. Datacollection began in April 2004 and ended in February 2005.
Evaluation of the specialist weight management service (SWiMS)
4.0 FINDINGS
Since starting in November 2002, a total of 1,522 have been referred to the SWiMSprogramme. The first section of the findings provides a profile of these people withthe data available from the service database.
Subsequent sections then draw on information from the motivational questionnaires(completed by 33 participants) to report on motivations for accessing the SWiMSservice, and the experiences of the 20 participants who were interviewedimmediately after completing the programme and again six months later. Thisinterview data highlights key themes relating to their previous experiences of losingweight; their experiences of accessing the programme; their views on the content;what worked for them; and their experience of maintaining weight reduction aftercompletion of the programme. This findings section concludes with an outline of theviews of staff involved with the development and implementation of the programme. Profile of Referrals to the Service Age Of the 1,522 participants referred to the programme, data on age was available for 1,455 participants. The mean age was 47 years, and ranged from 16 to 86 years. Weight Data on pre-intervention weight was available for 952 participants. The mean weight was 106.50kg, and ranged from 52kg to 216kg. BMI Data on pre-intervention BMI was available for 1,008 participants. The mean BMI was 38.9kg/m2, and ranged from 22kg/m2 to 68kg/m2. Figure 2 below outlines the proportions of participants who were overweight, obese and morbidly obese.
Evaluation of the specialist weight management service (SWiMS)
Co-morbidities Hypertension was the most commonly reported co-morbidity amongst participants, followed by Type 2 Diabetes (Figure 3). However, the prevalence of all co-morbidities appeared to be lower than anticipated. Figure 3: Prevalence of co-morbiditiesCo-morbidity Profile of Discharges from the Service
Full data discharge data was provided for 51 participants , 44 (86%) women and 7(14%) men.
The mean age was 46 years with a range of 21 to 70 years. The
majority of these 43 (84%) received one to one support, 2 had taken part in thegroups and 6 had received both one to one and group support. The majority of thisgroup 47 (92%) had been referred to the SWiMS service by their GP. Length of time in the service Participants had spent between 4 and 90 weeks with the SWiMS service with a median of 32 weeks, and an inter-quartile range of 20 to 60 weeks. Impact of the scheme Pre- and post- intervention weight data on the 51 discharges shows that while some people gained weight, with one person increasing their weight by 8.7 kg, the vast majority lost weight, with the greatest weight loss being 31.7 kg. The overall mean weight loss in this group was 8.9kg. Motivational Factors to Accessing the Service
The risk of illness was commonly reported as the most important motivational factorfor losing weight in both the interviews and surveys (n=20 of 33 surveys). This wasfollowed by concerns about being overweight (n=13), lack of energy and being tired(n=12), and the fact that they had been sent by a General Practitioner or other healthprofessional (n=11). Other reasons for wanting to lose weight included wanting to bea ‘good example’ to children and to ‘be around’ for as long as possible.
Older participants tended to be more concerned with maintaining rather thanimproving their health status, or preventing particular conditions from worsening. Forsome of the female participants, weight loss was important for cosmetic as well ashealth reasons. Many individuals expressed feelings of low self-esteem, which werecompounded by a sense that overweight and obese people are stigmatised and thatthis can lead to discrimination. “Yeah I want to be slimmer, I don’t want to be thin, I just want to be more, itkills me to say, acceptable to society.
All participants interviewed had been referred to the service by either their GP orpractice nurse, although there was some variation as to whether this was at theindividual’s request or the doctor’s/nurse’s recommendation. Most had been battlingwith their weight problem for a considerable length of time and some expressedfeelings of depression or isolation as a result.
Evaluation of the specialist weight management service (SWiMS)
I was just getting fed up, I felt cooped up, swollen, couldn’t get very fa r and Ithought if I brought me weight down a bit it might help us a bit, you know. But,er, me doctor asked us if I would like to try for it, and I said yes, anything.
The fact that SWiMS had been recommended by a medical professional not onlyvalidated the programme but actually seemed to alert some individuals to the factthat their weight had become a serious problem. When somebody says you’ve got seriously high blood pressure and it’s yourlife type thing, you get off your backside and you do try to do something aboutit.Previous Experiences of Weight Gain and Loss
Over-eating was rarely acknowledged as a major contributory factor in participants’weight becoming a problem. In fact, many of those interviewed insisted that they hadnever been ‘big eaters’ or had always eaten quite healthily. Rather than focussing onpoor diet or physical inactivity, participants gave factors such as gaining weight afterchildbirth, recovering from an operation or developing an illness as the main causesor contributing factors in their weight gain. …about six years ago I had two mini-strokes so I kind of got to watch theweight, em, or, I wouldn’t think so much the weight but the furring of thearteries and the thickening of the arteries and things, you know, for the fatcontent and whatever. Em, so I think that was why because I have put a lot ofweight on over the last two years. But I had an accident to my leg which didn’thelp and I lay around for about six months and I just went bigger and bigger.
It is clear that a key factor in weight gain involved becoming more sedentary either asa result of a significant life event, such as leaving school or entering retirement, orbecoming less mobile due to back pain, arthritis, sporting injuries, etc. Manyparticipants found themselves unable to carry out activities they had previously takenfor granted and this had often become a source of anxiety and frustration, particularlywhere individuals were continually in pain or housebound. I was 15 stone and I went to 11 ½ and I kept it off for a long long time, andthen I had stopped work, and I suppose that was why maybe and of coursenot dashing about so much.
All participants had previously attempted to lose weight and while many had beensuccessful the effects were generally short lived. Reasons given for previous failuresincluded:
Discomfort with mixed weight management sessions; Concerns about the motives of weight loss programmes that charge
membership fees; one participant said, “these diet clubs are only out for whatthey can get to me” [Interview 48, Level 3 Participant];
Lack of incentive to continue with programmes; Difficulty with motivation when attempting to diet on their own;
Problems with the content of classes, especially those that told participants
what to do rather than provided advice and information about nutrition, etc;
Evaluation of the specialist weight management service (SWiMS)
Problems with attending gyms which were felt to be expensive, made
participants feel uncomfortable, and about which they had concerns,especially with regards to exercising without supervision. Experiences of Accessing the Service
In terms of accessing the service, there was a great deal of variation in the length oftime it took for participants to be placed with a SWiMS group. Those who had beenon long waiting lists tended not to have received any form of contact from the serviceduring the time they were waiting. This fuelled apprehension amongst someparticipants who were already uncertain about how they may be judged byprofessionals for being overweight or obese, and this view was reinforced byprevious negative experiences of health professionals
Most interviewees reported initial fears about entering a new situation and beingunsure of what to expect from the programme. Some individuals were notcomfortable with the idea of group sessions and greatly appreciated being given theopportunity to attend on a one-to-one basis or with their partners. Other individualswere wary of the classes at first but this changed with time and experience
I think I suppose in a way, it’s like anything new, I wasn’t sure exactly whatwas going to be happening and who you were going to be meeting, an d was itgoing to be a continuous thing, and how much help it was going to be…Views on the Content of the Programme
The SWiMS programme encouraged participants to think of the nutritional educationcomponent of the sessions as part of a wider change to a healthier, more balancedlifestyle, rather than a traditional ‘diet’ consisting of good and bad foods. Participantsseemed to think that this would make the changes more sustainable in the long-term,not least because they were less likely to get bored and give in to the temptation to‘cheat’, as had been the case with previous attempts to lose weight. …it made us realise how easy it is to change and not hard. Becausesometimes, I think people go on a diet and they don’t change their life, theygo on a diet and they lose weight and then they get sick after a while andthat’s when the weight comes on. It’s all about change, like walking instead oftaking the car. Em, instead of, you know, when you get bored I eat, nibble,even just taking [the dogs] out now, get meself away and put me mind offfood, that’s how they used to show wu’.
Learning how to interpret the nutritional information found on food labels and judgeappropriate portion sizes seemed to be thought of as the most valuable lessons fromthe SWiMS programme. Other important changes made to participants’ dietaryintakes included eating more fruit and vegetables, and cutting down on snacks, friedfood, takeaways, alcohol, etc. But now every label’s read to see what the fat content and sugar content is,you know, things like that…I used to eat the occasional piece of fruit everynow and then but em, now, we buy bulk.
The exercise component of the classes was felt to be suitable for participants of allabilities and was widely considered in a very positive light. Many of the participantsreported having previously been sedentary and subsequently increased their physical
Evaluation of the specialist weight management service (SWiMS)
activity levels as a result of SWiMS. This often involved simple exercises within thehome or walking more around the local area, although some participants had begunattending the gym on a regular basis. I mean the er, doing like the fitness er every week was really good, which youjust wouldn’t do that every week…after I’ve been up about an hour I do a littlefew exercises, just gentle, which I never did before.
There was a general feeling amongst participants of having more energy and being‘on the go more’, although some interviewees noticed specific improvements in theirlevels of mobility and fitness. I've got me exercise bike upstairs and use that ‘cos I can walk so far, but I'mwalking further and further every time I walk, not getting out of breath as easynow.What Worked in the SWiMS Programme
Having the option of attending either one-to-one or group sessions was greatlyappreciated by the level three participants, as this made them feel that the servicewas tailored to their individual needs. Some participants were self-conscious aboutattending mixed sessions but many participants valued the social aspect of thegroups. This gave them a much-needed opportunity to talk to people ‘in the sameboat’ and provide support for one another, particularly as many were of similar ages. …for all you were a group, you felt you were getting individual attention, youknow, and that’s great. And if anybody in the group was down, the rest of uswould pick them up and that, you know, and we’ve made a lot of friends andit’s, it’s just great.
Some of the participants were attempting to keep the groups going and work togetherto maintain their own weight loss efforts, which suggests that the programme hadsubstantially increased participants’ confidence levels and created strong socialnetworks. There is four of us now…we meet up on a Tuesday…[name of friend] hasn’tbeen to a gym before so we are all going to try the gym together today, and ifshe likes it we are going to make a regular thing going to the gym andswimming, you know.
Losing weight at a steady rate in itself provided an incentive to continue with theprogramme, particularly for some of the level three participants on weight lossmedication such as Orlistat. As a consequence of their weight loss and increasedactivity levels, participants experienced increases in their self-esteem and confidencelevels, and seemed to be empowered to try different things. …with the other diets that I’ve done before and you get so far then the lineand you give up. Because I can still say I’m losing weight it’s an incentive tocontinue to be careful.
Evaluation of the specialist weight management service (SWiMS)
Service staff were highly praised for being friendly, supportive and good at motivatingparticipants. This was done without pressurising participants or being judgementalwhen they hadn’t lost any weight, which was perceived to be one of the advantagesof SWiMS over many of the commercial weight management programmes. Themultidisciplinary SWiMS team was felt to be a good balance of representatives fromdifferent specialisms, such as nutrition workers, fitness instructors and psychologists. …I feel I'm understood. I don’t for the first time feel as if I'm just a fat womanwho can't stop eating, I feel like I'm actually getting some understanding fromthis SWiMS thing, and that’s a good thing in itself, its got to be a good thing.
Participants felt that the groups were kept quite informal and that i nformation wasexplained in a way that was easy to understand for everyone. They felt comfortableabout asking questions and were able to contribute to the sessions. Manyparticipants also appreciated having their weights measured and recorded discretely. …they don’t baffle you with science. That’s the type of thing that would worrysome people, and if you don’t understand something, if you say to them “youknow I'm not sure how that’s supposed to work” they will explain it all to you
The case study on the following page illustrates the potential impact the programmecan have on previously sedentary, socially isolated individuals. 4.8 Concerns about the Programme The biggest criticism of the service was feeling ‘dropped off’ at the end of the SWiMS programme. Some wanted the weekly sessions to be ongoing, whereas others would have appreciated a series of regular update sessions or a one-off refresher session at a later date. Most felt they needed the motivation of the group and SWiMS staff to continue with their attempts to lose weight, and also missed the opportunity to socialise with one another on a regular basis. Eight weeks, I don’t think it was long enough, if I had a fault. It should’ve beenongoing for the rest of me life. […] I think if they’d been, like, possibly longer,probably for double, 16 weeks, I think it would’ve made a bigger impact on meeating than it did.
Participants tended to appreciate the fact that SWiMS could not continue indefinitelydue to funding limitations but suggested that they would be willing to make acontribution themselves, in the form of a weekly fee for the classes. Othe rs acceptedthat, because the service had such long waiting lists, they had to leave in order forothers to have the opportunity to experience the same benefits. However, the highnon-completion rate of the programme caused some frustration amongst participantswho had themselves waited a long time to get a place in a SWiMS group. I thought, they’ve waited a long time and there’s probably others who arewaiting a long time, and yet there’s people you can see sitting here andthey’ve got no intention of doing what they’re gonna be asked to do. And Ithought, well, you know, that’s just a waste of time, you either come and youwant the help or you don’t want the help and don’t bother coming.
Evaluation of the specialist weight management service (SWiMS)
Case Study One
Mrs W was referred to SWiMS by her GP after struggling with a weight problem forseveral years. The social aspect of the group sessions was extremely important, asMrs W lived alone and had little contact with her family. As a result of attendingSWiMS, she had made new friends, lost weight and started cooking for herself again. She had also joined an AquaFit class, which she had known about previously but hadnot had the motivation or confidence to try. “I think I eat more healthily than I was doing, em, I'm doing more homecooking again, which I think when you're on your own you sort of tend to buyin ready-made meals and things and…I think I'm eating more vegetables nowand pasta and stuff, so yes I think it has changed.”
Six months after completing the programme Mrs W had gained weight as aconsequence of taking steroids, but felt that she was continuing to eat ‘properly’ andwas feeling better within herself. She was still swimming regularly and had increasedher distance from 10 to 20 lengths of the pool. She was also walking more and usinga stepper at home every day.
Some participants found it difficult to stick to the dietary advice and physical activityencouraged by the SWiMS programme. Temptation could be hard to resist at times,particularly for those who were required to cook for others on a regular basis. Therecommended portion sizes were not always felt to be sufficient, particularly by someof the male participants, one of whom said, “…if you do what they said you wouldstarve” [Interview 35, Level 2 Participant].
Despite participants feeling that gradual changes would be easier to maintain in thelong-term, some were disappointed with the slow nature of their weight loss andfound this quite demotivating. Participants were conscious of letting oth ers down andsome also seemed to feel guilty about using public resources and requiringprofessional help to lose weight. I’m embarrassed about the amount of resources that are being put into place. I still think I should be able to do this on my own without someone there.
Participants spoke highly of the SWiMS team and were upset when individualmembers of staff left and were replaced with new, unfamiliar faces. This disturbedthe routine of the programme and had a potentially detrimental effect on participants’attempts to lose weight, as illustrated by the case study below.
Evaluation of the specialist weight management service (SWiMS)
Case Study Two
Mrs B had a longstanding weight problem and asked her GP to refer her to SWiMSas she was taking a long time to recover from operations. She felt SWiMS had madeher ‘more aware’ of what she was eating and motivated her to try new activities. MrsB appreciated not feeling pressurised to join a group and being supported by a teamof non-judgemental staff. However, changes to the team had interrupted herschedule of activities and left her feeling worried and uncertain. …it’s the waiting for other new guy to phone and not knowing if I'm going tolike that one as much as I liked the other one…I would have like to havefinished the six weeks with the person I’d got to know and got the confidencewith em, cos I don’t know what this other person is going to be like and I don’tknow if they are going to teach us the same way, be as enthusiastic…
Mrs B lost a lot of weight over Christmas due to having contracted food poisoning,which she felt had interrupted all of the ‘good changes’ she had been making. Sixmonths after completing the programme, she was swimming twice a week and hadstarted power walking with a friend. However, doing shift-work and not having regularmealtimes meant that she found sticking to a healthy diet difficult and was often tootired to go to the gym after work. Maintaining Weight Loss After SWiMS
At the time of the six-month follow-up interview, several participants describedthemselves as being at a ‘standstill’ in terms of their attempts to continue to loseweight since leaving SWiMS. This was generally attributed to either health problemsor seasonal effects such as the colder weather, as most interviews were completedduring autumn/winter. However, maintaining the same weight was not always viewedin a negative light, as many individuals felt they had put on less weight over thefestive season than they would normally have done. I didn’t put any weight on at Christmas but I had stuck the same weight, sowhen I went to see the lady at the clinic for me tablets and that she was, shewas quite pleased that I had stuck the same over Christmas and everything.
Follow-up interview 45, Level 2 participant
There was some disappointment with the gradual nature of the weight loss,particularly amongst those participants that had made significant changes to theirdiets or activity levels as a result of attending SWiMS. Some participants found itmore difficult than others to stay active and maintain a healthy eating regime. I felt unhappy with meself, put it that way. Em, that I had been doing so welland suddenly I found it, when I thought about the way I was eating and thatagain and, with everything that was going on, I sort of felt a bit down about it.
Follow-up interview 07, Level 2 Participant
None of the participants had been weighing themselves on a regular basis andinstead gave subjective measures of their weight loss, for example, clothes feelingless tight. This made it difficult for participants themselves to judge exactly how muchthey had achieved since leaving the SWiMS programme.
Since completing the SWiMS programme, most participants felt they had been ableto maintain the changes to their diets mentioned previously. With the exception of
Evaluation of the specialist weight management service (SWiMS)
those that had suffered a specific setback (e.g. an illness or death in the family), themajority of participants felt they had increased their activity levels as a result ofattending SWiMS. The preferred activities were walking, swimming, going to the gymand exercising at home. Yes, yes, I walk practically everywhere. Everywhere, and I mean it. Youknow, where I would jump on the bus and go up the top to Benwell to theshops, I walk it, I don’t bother waiting. I go to the gym now twice a week,which I never done before.
Follow-up interview 21, Level 2 Participant
Participants reported experiencing a range of health and other benefits as a result oftheir increased physical activity levels, for example, being able to walk further orstand for longer periods of time, having more energy and generally feeling on a‘high’. Engaging in exercise also had a positive impact on participants’ self-esteemand confidence levels, providing them with some incentive to contin ue to follow andmaintain a healthier, more active lifestyle. …I think I feel more positive now than I’ve done in the last twenty years. I feelreally positive and aiming to get me weight, not so much me weight as mewhole, it’s, it’s just sort of affect ed me whole life, not just me weight loss. It’saffected me whole life, I feel fitter, I’m able to do more, I don’t know, I’ve got abetter outlook on life. You know, I thought I was ready to die at 72, 73, but no,now I’m ready to gan’ til I’m 90 now!
Follow-up interview 32, Level 2 Participant
On the negative side, many interviewees continued to feel that they had been“dropped off” by the programme and that this had acted as a barrier to progress. They talked of wanting some sort of drop-in access to the service after completion ofthe programme to seek help and advice when needed. Some of the group membersremained in touch with each other and valued this peer support.
support and advice of professionals was also needed but no longer a vailable. Staff Views and Experiences of SWiMS
Seven key stakeholders in the development and implementation of the SWiMSprogramme were recruited into the evaluation and took part in semi-structuredinterviews. Successes All staff interviewed felt there had been some real success stories for participants who had been through the SWiMS programme. These included examples of significant weight loss and increased confidence. We certainly have had what I would regard as some great successes. Peoplelosing significant amounts of weight or people feeling better aboutthemselves, people becoming more sociable, feeling like they can go out.
Conversely, there had been a significant number of dropouts since the inception ofthe programme and a number of participants for whom the scheme had not worked. This was perceived to be due to the fact these participants were not ‘ready’ to tackletheir weight problem. If you talk about successes, you have to talk about the opposite of that. Idon’t really like to think about people failing but there are some people, for
Evaluation of the specialist weight management service (SWiMS)
whatever reason, it’s not the right time for them to address their weightproblem and I think we have to live with that and hope they will eventuallycome back into the system.
Staff felt that the hard work and enthusiasm of programme staff had contributed tothe development of the scheme and the aforementioned success stories. …the team were really, enthusiastic, really, really enthusiastic about wor kingwith obese and overweight people, you know, and they were verycompassionate about it as well…
Whilst the multi-agency approach was perceived to facilitate the SWiMS programme,it was acknowledged that initially this had been difficult to implement. I think coming from a multi-agency approach, sort of different service, it’sdefinitely helped, but I think it hinders things initially because often, you know,partnerships take time to work out and people need to work out what theirroles are and learn to work with one another […] it makes a slower processbut a better process in the long run.
The ability to be able to individualise participant treatment was often reported asbeing a factor that had contributed to the success of the scheme. Probably the fact that we’ve got this opportunity to individualise things but stillwork within the structure of the programme […] I believe in trying topersonalise the service.Problems in developing the programme Problems associated with funding were reported as a barrier to the development of the SWiMS programme. Uncertainties about future funding were perceived as preventing the forward planning of groups and hindering the recruitment of staff into the programme. We don’t know where our next funding is coming from so therefore it hashindered the progression of the programme as much as we can’t arrange thegroups. We’ve had to postpone them, we’re trying to hold on until we knowwhat is happening with the funding, we can’t take on more staff and we’regetting more and more referrals. The service isn’t going anywhere basically.
Participants reported that there had been a significant number of changes within thePrimary Care Trust. This had resulted in feelings of uncertainty amongst staff, bothabout their roles and the future of SWiMS, which had made it difficult for theprogramme to develop.
Evaluation of the specialist weight management service (SWiMS)
I think it’s been a difficult time because there’s been so many changes in thePrimary Care Trust that, to be fair staff within SWiMS and within lots of otherservices, they haven’t themselves exactly, you know, known what they weregoing to be asked to do next, or where they were going to sit within thesystem.
Poor communication between staff members within the programme was often citedas a barrier to the development of the SWiMS programme. This stemmed from thefact that staff members were based at different places and often worked part-time. There was a perception that this had improved since the inception of the programmebut that there was still scope for improvement. You’ve got people based at the hospital, people based here, people based atthe Lightfoot Centre, and then at Arthur’s Hill, so it’s sometimes difficult to geta hold of people and you’re not quite sure where to pass information on.
Staff often reported that communication from the steering group and the PCT aboutthe rationale behind decision-making was lacking. Staff felt that, if cons ulted, theywould be able to contribute to the decision-making process or at the very least beable to understand why key decisions were being made. There’s a lot of issues at a higher level that we’re not really kept really intouch with that we don’t know where we’re going with the service. It would benice to know more. I think that really holds the service back.Gaps in current service provision Staff identified a number of gaps in current service provision. These included a lack of services for individuals from black and minority ethnic groups, people with mental health problems, children and young people, and people with a disability. There certainly isn’t a service for children or young people and I think that issomething that the trust needs to address […] We certainly do see peoplefrom black and minority ethnic groups but I’m not sure that there wouldn’t bemore appropriate ways of meeting their very specific needs. I’m just trying tothink… we see people with mental health problems but again there isprobably more that could be done with that group.
There was a shared feeling that, at the current level of capacity, it would be eitherdifficult or impossible to consider addressing these gaps. Rather than creating newservices for these groups, it was suggested that it might be useful to introduce a linkworker to work into other services and create a network of services acrossNewcastle.
Evaluation of the specialist weight management service (SWiMS)
Areas for improvement One of the most commonly cited areas for improvement was to have some sort of central base for the SWiMS programme where all staff could be accommodated. It was perceived that this lack of a base contributed to many of the aforementioned communication problems. I suppose, in an ideal world, there would be a central base for the SpecialistWeight Management Service.We would have, employ our own peoplewhatever and we would all be based in one place.
Staff felt that key data was not being collected on participants going the th rough theSWiMS programme and that this was something that could be collected routinely withthe correct protocols in place. The gathering data after each group had happened and presenting it, I felt itwasn’t there at all […] I just felt that you needed something after each groupto say that we’d had 80% attendance with 3% weight loss. Or you know, justto have some qualitative data to say that this lady might not have lost thatmuch weight but she can bend over and tie her shoelaces.
Attrition from the SWiMS programme was seen as a real problem by staff andsomething that should be addressed. Staff felt there should be a system in place toassess motivation prior to participants commencing the programme in an attempt tostop limited resources being wasted. This would potentially enable SWiMS to targetindividuals who are motivated to make the lifestyle changes required by theprogramme but who have a need for specialist input from the service. We might start off with fifteen people and end up with five and by the timeyou’ve done the third session, it’s a closed group. It’s just a huge waste ofresources. I think we could improve.
There was a strong view amongst staff that there was scope for improvement in theorganisation of the groups. It was perceived that there were often long gaps betweenthe eight-week courses, whilst at other times two or three groups would runconcurrently. This caused problems for staff providing part-time input into the schemein terms of organising their workloads. The lack of forward planning of the groupswas often perceived to be a result of funding problems. I think a bit of forward planning, if we could get sort of six or twelve monthsplanned out, I think it would be helpful for people to divide their time up betterwith only working part-time and we need to have some control of our time andjust for your piece of mind, just knowing where you’re going to be and whatyou’re going to be doing for the next six months, I think that would be helpful.
Staff acknowledged that it was not feasible to increase the length of the SWiMSprogramme. However, there was a commonly held view that participants needongoing support after leaving SWiMS, the belief being that this would help to keepindividuals motivated to maintain the lifestyle changes initiated by the programme. Itwas perceived that this support could take the form of a monthly drop-in session.
Evaluation of the specialist weight management service (SWiMS)
We get a lot of feedback from the eight-week sessions, people come to thelast session and they say they’re just starting to make the changes. We’vetried offering longer sessions, we tried a twelve week programme and wedecided the eight was better but it’s not necessarily giving them a group, aweight management group to go to, it’s just offering them something else […]Even if we just had a drop in where the scales were if they wanted to getweighted.Maybe we could arrange a one-off activity for them or one-offguest speaker to come and talk to them. Some sort of drop-in session.
There was a perception amongst staff that there was a need for a more co-ordinatedservice, which could link in with other local services such as cardiac rehabilitationand the programme for those with type 2 diabetes. I think it’s very much isolated, er… and I don’t know in the future if it shouldbe working alongside the diabetes programme and cardiac rehab.
Maintaining the ‘specialist’ role of the SWiMS programme in dealing with those whowere obese or morbidly obese was seen as important. There was a perception thatsome individuals who did not require specialist treatment were being referred to theservice when they could potentially be seen in primary care. If we could train some primary care staff and encourage primary care staff tosee those people at the lower end of the weight spectrum and leave us to bea far more specialised service. Working with overweight with co-morbiditiesand the obese and the morbidly obese because we do see people from thewhole range of overweight, people with BMI’s of 26, which, arguably, could bedealt with in primary care.
There was also a perceived need to prioritise health promotion and the prevention ofobesity, as these were felt to be lacking within the current service. This would includeliasing with GP practices and other primary care organisations to ensure that up-to-date, accurate information was available within communities. I think the groups have worked fine and then there’s been the one-to-onesbut there’s a level around, em, much more awareness out in the community,much more information, and much more linking with other communityprojects. I feel we need to concentrate much more on getting information outand making more links that way into the community.
Evaluation of the specialist weight management service (SWiMS)
5.0. LESSONS
A number of lessons have been identified from the key findings of this evaluation,including: lessons about the motivation and need for individuals to lose weight;lessons about the organisation and management of the Newcastle SWiMS service;and lessons to inform future evaluations. These are outlined below. Lessons About the Need for, and Motivations of, those who are Overweight or Obese to Lose Weight
Obesity is a complex phenomenon that is increasing in the UK, and leads to
Obesity increases the risk of coronary heart disease, stroke, type 2 diabetes,
It is estimated that treating obesity costs the NHS around £500 million
Evidence indicates that a combination of diet, physical activity and
behavioural strategies are most effective in helping individuals lose weight
Regular physical activity has also been identified as important in the
The main motivations for participants to lose weight in this study were to
improve health, to increase energy, to be a good example to others and to besocially acceptable
Referral from a GP or other primary care professional is important as it
legitimises a weight management service and the need for weight loss
Most people interviewed in this study reported major life events or a change
in health status (leading to being less active) as triggers to weight gain
Lessons About the Organisation and Management of SWiMS
The success of recruitment to SWiMS indicates a high level of need for such
The approach adopted by SWiMS is acceptable to those motivated to make
Rates of referral from primary care suggest that the service is acceptable to
Lack of contact during the period from referral to acceptance onto a
programme heightened anxiety in those with existing weight-related anxiety
The combined approach of nutritional advice and introduction to exercise is
Building relationships with non-judgemental staff is important to participants,
especially those who have past negative experiences of stigmatisation byhealth care professionals
Involvement in groups provides opportunities for peer support and can reduce
Staff were seen as friendly and approachable by the 20 people interviewed as
Consistency of staff is important to participants
Staff perceive that the short term nature of funding has made forward
It is unclear to some staff and patients what criteria are used for recruitment
The length of time people are involved with the service varies widely and
Evaluation of the specialist weight management service (SWiMS)
One to one support is resource intensive but does appear to increase weight
It is unclear what criteria is used for the prescription of medication such as
Orlistat and where this fits within the SWiMS programme
There is no follow-up or opportunity for participants to seek help following
Criteria for referral to the service remains unclear and some people with a
BMI below the 25 threshold had been accepted into the service
The administrative resources allocated at the start are no longer sufficient to
meet the increasing demands of the expanding service
No standard data is collected on referrals and it is impossible to track the
progress of individuals through the service under the current system
There is no standard database that staff can access for information; paper-
Communication within the SWiMS team has been difficult with staff working
Some staff have not felt involved in the decision-making process about how
the service operates and its future directions
There have been no clear lines of communication with other related services
such as diabetes or cardiac rehabilitation services
Lessons for Evaluation in the Future
The collection of data is essential for assessing the value and effectiveness of
A simple database incorporating age, before and after weights, BMI’s, co-
morbidities, and date of entry into, and discharge from, the programme isneeded
The collection of data should be negotiated with project staff to ensure that
appropriate data is collected in a standardised format and that staff have theconfidence, skills and resources to collate data in an anonymised format forevaluation purposes
The recruitment process should always be transparent to ensure that
participants are not pre-selected in any way
It would be useful to have a project steering group that involves
commissioners, as well as service staff and evaluators
Evaluation of the specialist weight management service (SWiMS)
6.0 RECOMMENDATIONS Administration and Data Collection
There is a need for increased administration input into the programme to
improve data collection and storage, and to facilitate communication withinthe team.
It is recommended that there be one central database, which is easily
Data to be collected should include standardised recordings of weight, height,
BMI, blood pressure, waist circumference, high and low density lipid levels,cholesterol levels, fasting glucose and any pre-existing co-morbidities both atthe first appointment and following completion of the programme.
All relevant staff should be trained to collect this data.
Data on attendance should be recorded at each group or one-to-one session.
Four pro formas for data collection have been designed for guidance and can
Communication Issues
We recommend that a communication strategy be developed involving the
input from key staff to ensure better communication between staff andtransparency of the decision-making process at the steering group level. Thiswould need to involve all levels of staff to work through any potentialproblems.
Improved information at the point of referral, outlining length of time
participants may have to wait and suggestions for activities they could engagewith in preparation for joining the programme, may improve attendance andhelp reduce the drop-out rates. This may also improve satisfaction with theservice.
Including contact details for participants to access further information whilst
on the waiting list could further help allay some of the fears and anxietiesexpressed by a number of participants in this evaluation
Increasing links with other services may help SWiMS to target the current
gaps in service provision reported by staff.
Recruitment of a link worker or the adaptation of a current role could improve
links into other services in the area, such as services for black and ethnicminority populations, and the diabetes and cardiac rehabilitation programmes. This link worker could also work into GP practices to encourage obesityprevention, in terms of providing accurate and up -to-date information tosurgeries, and information about the role of SWiMS.
Evaluation of the specialist weight management service (SWiMS)
Organisational Issues
It appears there is a need to develop protocols for scheme staff, GP’s and
others who may refer into the service to ensure that only overweightindividuals with co-morbidities and obese individuals access the service. Thiswould enable the specialist service provided by SWiMS to be targeted to theneeds of the specific population.
The high drop-out rate of the service indicates the need for a screening
process to identify those people who are and those who are not ready toattend the programme. This screening process could assess the patient’smotivation to adhere to a programme of diet and physical activity, and wouldconsequently serve to protect the scarce resources.
Once staffing and funding issues are resolved, protocols should be
developed to ensure the planning of group sessions at least six months inadvance. Providing Additional Support from the SWiMS Programme
A system of peer support was proposed at the start of the SWiMS programme
but has not been developed because of other demands. It is recommendedthat this part of the programme be developed to help individuals overcometheir sense of isolation and help build relationships.
Participants reported a need for ongoing support to help them stay motivated.
One suggestion was the development of a monthly drop-in clinic, which couldbe made available to past members of the SWiMS programme. This cliniccould provide one-off exercise classes, dietary advice and the opportunity forparticipants to be weighed if they wished. Participants reported that just thechance to meet up with others in a similar situation would serve as motivationto continue with their weight loss efforts.
A planning session could be incorporated towards the end of the SWiMS
programme to allow participants to plan strategies to help improve motivationlevels once the programme has ended
Evaluation of the specialist weight management service (SWiMS)
7.0 REFERENCES
Astrup, A., G. K. Grunwald, et al. (2000). "The role of low-fat diets in body weight control: a meta-analysis of ad libitum dietary intervention studies." International Journal of Obesity 24: 1545-1552.
Bandura, A. (1977). "Self-efficacy: towards a unifying theory of behaviour change." Psychological Review 84: 191-215.
Becker, E. S., J. Margraf, et al. (2001). "Obesity and mental illness in a representative sample of young women." International Journal of Obesity and Related Metabolic Disorders 25(suppl. 1): S5-9.
Byrne, S. M. (2002). "Psychological aspects of weight maintenance and relapse in obesity." Journal of Psychosomatic Research 53(5): 1029-1036.
Clark, M. M., B. R. Cargill, et al. (1996). "Changes in self-efficacy following obesity treatment." Obesity Research 4: 179-181.
Committee to Develop Criteria for Evaluating the Outcomes of Approaches to Prevent and Treat Obesity (1995). "Weighing the Options: criteria for evaluating weight-management programs." Obesity Research 3(6): 591-604.
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Evaluation of the specialist weight management service (SWiMS)
8.0 APPENDICES Appendix 1: Pro Forma for Initial Participant Intake Appendix 2: Pro Forma for Group Session Appendix 3: Pro Forma for One-to-One Sessions Appendix 4: Pro Forma for Participant Discharge
Evaluation of the specialist weight management service (SWiMS)
Appendix 1: Pro Forma for Initial Participant Intake All fields must be completed and in the designated units. _____________________________ _____________________________ Date of Birth: _____________________________ _____________________________ Date of Referral: _____________________________ Route of Referral: Practice nurse Other HCP Hospital _______ Kg Height: _______ cm BMI: ________ Abdominal girth: ________ cm Obesity drugs currently prescribed? List: ______________________________________________________ HDL levels: ________ ___________ Cholesterol: ________ Fasting glucose: ________ Blood Pressure: ________ Co-morbidities: (tick each box that applies) Type 1 Diabetes Type 2 Diabetes Hypertension Hypertension Hyperlipidaemia Sleep Apnoea Other co-morbidities _____________________________________________________ ______________________________________________________________ GHQ Score: ________ Hospital Anxiety and Depression Score: _________ Any other comments: (e.g. social isolation) ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Appendix 2: Pro Forma for Group Session Date: ____________ Group Location: ____________________ Attended? Abdominal Girth (Yes/No) Any other comments: (anecdotal evidence for health/social improvements) ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________
Evaluation of the specialist weight management service (SWiMS)
Appendix 3: Pro Forma for One-to-One Sessions Name: _____________ DOB: _____________ Date of session Attended? Abdominal Girth (Yes/No) Any other comments: (anecdotal evidence for health/social improvements) ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________
Evaluation of the specialist weight management service (SWiMS)
Appendix 4: Pro Forma for Participant Discharge All fields must be completed and in the designated units. _____________________________ _____________________________ Date of Birth: _____________________________ Date of Discharge: _____________________________ _______ Kg Height: _______ cm BMI: ________ Abdominal girth: ________ cm Obesity drugs currently prescribed? List: ______________________________________________________ HDL levels: ________ ___________ Cholesterol: ________ Fasting glucose: ________ Blood Pressure: ________ Co-morbidities: (tick each box that applies) Type 1 Diabetes Type 2 Diabetes Hypertension Hypertension Hyperlipidaemia Sleep Apnoea Other co-morbidities _____________________________________________________ ______________________________________________________________ ______________________________________________________________ GHQ Score: ________ Hospital Anxiety and Depression Score: _________ Any other comments: (e.g. other improvements or any deterioration in health) ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________
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EVALUATION OF THE SPECIALIST