Counterweight - counter-cost, counter-loss
Michael E. J. Lean, John P.D. Reckless, Nick Finer, Louise McCombie · International Journal of Clinical Practice · 2010
To the Editor: The Counterweight Team (1) has demonstrated that as well as improving wellbeing, the cost of providing evidence-based weight management in primary care is fully offset by savings, which result from delaying or avoiding future complications of obesity. The 1996 SIGN guideline (2) and the licencing requirements for new antiobesity medications both called for structured, multifaceted interventions, in primary care, to optimise weight loss and maintenance. Counterweight was initiated in 2000, led by almost all the UK clinical experts on obesity and obesity research. A team of 13 registered dietitians and 1 registered nutritionist, trained as ‘Counterweight Specialists’, provides in-service training and mentoring for practice staff who actually deliver the programme to obese patients. The programme is based on theoretical models, with evidence for efficacy of its main components: energy-restricted diet and physical activity underpinned by behavioural therapy strategies. The initial target is 5–10 kg weight loss – or whatever can be achieved in 3 months, followed by either a structured maintenance plan or a second 3-month continued weight loss phase, which can be supported by licenced antiobesity medications. The major focus is on maintaining weight loss at 1 and 2 years. There are no misleading gimmicks and no eye-catching testimonials – but very well-designed support materials for both patients and staff. Vitally, continuous audit provides evaluation from a central database in Glasgow University. Results are routinely fed back to practices, compared with anonymised data elsewhere and nationally. The Counterweight network and care-delivery service also provides an ideal setting for research on new, add-on, interventions for Phase 2 Translational Research, when a realistic, routine-care setting is required, with real, unselected patients, facing all the competing demands of 21st century life (3). The original Counterweight evaluation (4) highlighted the difficulties of treatment and the benefits of the modest achievements: about one in six patients entering the programme maintained > 5% loss at 1–2 years, but 70% of attenders do not. Even with these results, cost-effectiveness analysis of the entire programme showed it to be ‘dominant’ (1). That is, patients enjoy more quality-adjusted-life-years (QALYs), and the overall cost of achieving better health was less than the lifetime cost-savings, which result from the delay or avoidance of expensive management of obesity related co-morbidities associated with ongoing weight gain. Exceedingly few other medical interventions are cost-saving rather than just cost-effective. Now the need is implementation. We need proper scrutiny of the obesity treatment services currently being offered and the claims being made for them. If a cost-saving service is available, with peer-reviewed Intention-to-Treat data, alternatives need strong justification. Counterweight was founded on Continuous Improvement Methodology – rather than on randomised control trials (RCTs) – as it is appropriate for service development. Its results are continually reviewed through audit and programme development – e.g. by increasing attendance using qualitative research and by enhancing weight maintenance by improved physical activity advice. Finally, barriers remain in general practice as the Quality and Outcomes Framework(QOF) of the General Medical Services Contract (GMS) (5) does not incentivise evidence-based weight management: indeed there are effective incentives for not treating obesity and for treating its complications such as Type 2 diabetes. It is time to revise healthcare budgets. Some of the funding currently allocated to treating the long-term complications of obesity (Type 2 diabetes, coronary heart disease, cancers, arthritis, depression) need to be re-allocated to treat the underlying cause. Without this, the consequences of obesity will cripple our NHS. Even if we can develop effective preventive strategies with the necessary multi-departmental policy support from government, cost-effective, early treatment of obesity in adults must become a priority across all branches of medicine. Counterweight is a not-for-profit academic organisation. The authors of this invited letter are all members of the Counterweight Board. They have no personal financial interests but their Departments have received cost-price research funding.