OBESITY
Quality improvement toolkit
Author: Primary Care Quality and Information Service
Date: Revised November 2010 / Version: 1
Status: Final
Intended audience: Public (Internet) / NHS Wales (Intranet) / Public Health Wales
(intranet)
The former Public Health Wales Primary Care Quality Team, now incorporated within the Primary and Community Care Development and Innovation Hub, developed a series of quality improvement toolkits to assist practices in collating and reviewing information. From information received, practices still find these toolkits useful, therefore they will remain on this webpage for your ease of reference. Please note, however, that the date of publication is clearly stated in the toolkit and that the evidence within may have changed since publication.
Purpose and summary of document:
This document is for use by general practice to ensure that the delivery of service to adult patients who are Obese is such that meets the requirements of best service delivery. The purpose of this quality improvement toolkit is to support practices to review and improve where necessary, the recording of information available when providing a service to these patients.
The audit toolkit will provide the user with a summary of the current evidence directing the safe provision of service, and a schedule of patient review criteria to compare current treatment against those evidence based criteria.
Also included is a practice review section and reflection sheet designed to encourage a whole practice response to the audit findings and an evaluation of the quality and usefulness of the audit itself.
Publication / distribution:
· Publication in Public Health Wales Document Database (Primary Care Quality and Information)
· Link from Public Health Wales e-Bulletin
Preface
Quality improvement toolkits
The Primary Care Quality and Information Service (PCQIS) have developed quality improvement toolkits to assist practices in collating and auditing information.
The quality improvement toolkits produced support the specification requirements of the latest evidence based practice. They should be seen as good practice and cover areas that some or even all practices may not be recording at this stage. It is not expected that all the criteria within the audits will be achieved in year one therefore the PCQIS suggests that the toolkits should be used to aid development within the practice.
This toolkit is designed to assist practices with data quality/quality improvement – practices.
The PCQIS recognises that some of the criteria in the audit summary section may involve data that is not currently kept routinely by all practices. Therefore it is recommended that in year one the practice consider recording this information prospectively (using the data entry criteria and suggested read codes provided, so that these criteria can be successfully audited and improvements highlighted over time.
You can access other quality improvement toolkits that support enhanced services and National Service Frameworks from the Public Health Wales (PHW) website:
Intranet http://howis.wales.nhs.uk/sitesplus/888/page/34030
Internet http://www.wales.nhs.uk/sitesplus/888/page/45127
If you have any queries regarding this document please contact:
Laura Jones, Team Lead - PCQIS
Tel: 01792 607311 / Email:
Contents Page
Preface 2
1 Introduction and background 4
2 Aims 5
3 Objectives 5
4 Methodology 5
5 Diagnosis 5-6
6 Treatment 6-8
7 Audit of adults with obesity 8
8 Data Collection Summary 9-10
9 Practice Review 11
10 Further Information 12-13
Appendix A – Reflection Sheet 14-15
Appendix B – Management of Obesity in Adults 16
Appendix C – Clinical Care Pathway for Adults 17
Appendix D - Quality improvement toolkit - evaluation form 18
Appendix E – Glossary for Obesity 19-23
Appendix F. Read Codes: Obesity in Adults 24
References 25-26
©2010 Public Health Wales
Material contained in this document may be reproduced without prior permission
provided it is done so accurately and is not used in a misleading context.
Acknowledgement to the Public Health Wales to be stated.
1 Introduction and background
The purpose of the Primary Care Quality and Information Service is to assist primary care practitioners improve the quality of the service they deliver by providing access to evidence based quality improvement guidance and tools. This quality improvement toolkit developed by the PCQIS will assist practices to improve the data quality that they need to collect for identifying the most effective method of ensuring that adults who are obese receive the best evidence based care available.
Obesity is the accumulation of fat in the body to a degree that exceeds that which has been calculated as being healthy, when measured against a person’s height, sex and metabolic rate. At its simplest level, obesity can be described as a disease of energy imbalance.
However, obesity should not be considered a consequence of unhealthy living: it is a condition in which weight gain has reached a point where it poses significant health risk. Obesity is a risk factor for other diseases e.g. type 2 diabetes, coronary heart disease (CHD), hypertension, many cancers and osteoarthritis 1,2,3
Body Mass Index (BMI) Definition of Obesity 1,3,5,13
· Obese 30-35 kg/m2
· Severely Obese 35-40 kg/m2
· Morbidly Obese 40 kg/m2 and over
Classification: 3
Health weight / 18.5 – 24.9 kg/m2Overweight / 25 – 29.9 kg/m2
Obesity 1 / 30 – 34.9 kg/m2
Obesity 11 / 35 – 39.9 kg/m2
Obesity 111 / 40 kg/m2 or more
A general practice with a list size of 6000 patients can expect to have approximately 1000 (16.7%) adults who are obese with a BMI ≥ 30 kg/m2 together with another fifty (0.8%) adults who have severe obesity (BMI ≥ 40 kg/m) 2,3
Obesity in Adults within General Practice is usually managed in three ways depending on the degree of obesity and co-morbidities:
· General advice by GP or Practice Nurse on weight control, diet, exercise aimed at influencing lifestyle
· Personal advice on weight loss, lifestyle changes supported by drug therapy
· Onward referral by GP to a weight loss specialist, possibly involving drug therapy and in extreme cases surgery 3
Obesity is a significant health problem affecting much of the western world, however it can be managed in Primary Care by a motivated well-informed multi-disciplinary team1,3,5
2 Aims
The audit aims to reduce the incidence of obesity in general practice by identifying patient’s ≥ 18 years who are clinically obese (those with a BMI ≥ 30 kg/m2 ) and ensuring that they are recorded effectively and are being treated in accordance with best available current evidence 1,3,5
3 Objectives
· To raise awareness of obesity in general practice
· To monitor and assess the recording of information relating to patients with obesity
· To identify areas of potential improvement in the care of patients with obesity
· To educate and improve the skills of practice staff caring for patients with obesity
4 Methodology
· Primary Health Care Team (PHCT) meeting to discuss project from onset
· Practice to agree a start date for the audit
· Practice to agree data collection period, either retrospective or prospective.
· Practice recommended to complete Data Collection Summary. This sets out the criteria taken from evidence based practice
· Practice should use the audit results as the basis of a discussion by the PHCT. It is suggested that the practice use the Practice review form to reflect on the findings of the audit and implement the necessary changes to ensure quality improvement. The practice might like to share its results with other practices to compare progress.
· It is suggested that the practice re-audit annually to ensure that any changes considered to be necessary are having a positive effect on patient care
5 Diagnosis:1
BMI can be calculated by following these three steps.
· Work out your height in metres and multiply the figure by itself
· Measure your weight in kilograms
· Divide the weight by the height squared (the answer to Q1)
For example, you might be 1.6m (5ft 3in) tall and weigh 77.6kg (12st 3lb). The calculation would be; 1.6 x 1.6 = 2.56. BMI would be 77.6 divided by 2.56 = 30.31kg/m 2
Waist measurement
BMI alone is a poor guide to the risk of obesity and cardiovascular disease. Waist circumference may be a more accurate measure of future health indicating where excess weight is carried. People of an “apple” shape are more likely to develop heart disease and diabetes than those with a “pear” shape or those whose weight is more evenly distributed. A waist circumference above 80cm (32in) for women and 94cm (37in) in men indicates raised risk, while a measurement above 88cm (35in) for women and 102cm (40in) for men would be of particular concern 3,5
Waist-hip ratio
An effective measurement of risk is the ratio of waist circumference (the narrowest point on the abdomen) to the hip circumference (the widest point). A ratio of more than 1.0 for a man (where the waist is bigger than the hips) or 0.8 for a woman indicates an urgent need to reduce weight and increase exercise levels. Waist circumference and BMI is the best way to assess obesity in patients with BMI <35kg/m2.
It is used to assess patient’s abdominal fat content / central fat distribution. In people with a BMI above 35kg/m2 waist circumference is less useful. In men, waist circumference of 102 cm and in women waist circumference of 88cm is associated with increased visceral fat and co-morbidities. People of Asian descent have an increased risk at ≥ 90cm in men and ≥ 80 in women 1,2,3,5. Waist circumference thresholds used to assess health risks in obesity 1 in the general adult population1,3,5
At increased risk / Male / FemaleIncreased risk / 94cm (37 inches) or more / 80cm (31 inches) or more
Greatly increased risk / 102cm (40 inches) or more / 88cm (35 inches) or more
BMI may be less accurate in adults who are highly muscular, in Asian or older people3. Stomach obesity where the fat is accumulated around the stomach is the most common type of obesity. Medical conditions are often known as obesity related diseases these include, high blood pressure, high cholesterol, type 2 diabetes2
6 Treatment:
Calorie Control – All primary care professionals involved in preventing and managing obesity should be trained to deliver advice and support. Balanced healthy-eating approach and the potential benefits of interventions in relation to diet and physical exercise to prevent obesity need to be considered 1,2,6,14
Exercise - Guidance from the Chief Medical Officer issued in 2004 states that “Achieving the recommendation of at least 30minutes of at least moderate intensity physical activity on 5 or more days a week (a total of 150 minutes) will represent a significant increase in energy expenditure for most people, and will contribute substantially to their weight management. However, in many people and in the absence of a reduction in energy intake, 45-60 minutes of activity each day may be needed in order to prevent the development of obesity. Those who have been obese in the past and who have lost weight may need to do 60-90 minutes of activity a day in order to maintain their weight loss”17. Examples of moderate exercise include walking, cycling, gardening, house work. 1,2,5,6
Medication – Drug treatment should be considered for patients who have not reached their target weight loss or have reached a plateau 1,3,5,6
Orlistat should be prescribed as part of an overall plan for managing obesity in patients with a BMI of 28.0 kg/m2 with associated risk factor and those patients with a BMI ≥ 30.0 kg/m2.
To be used in conjunction with a low fat diet to achieve greater weight loss. Patients must demonstrate a 5% reduction in weight in 3 months and 10% in 6 months to comply with licensing and NICE guidance. 1,2,3,5,6
Sibutramine (Reductil): marketing authorisation suspended 3,20
On 21st January 2010, the MHRA announced the suspension of the marketing authorisation for the obesity drug sibutramine (Reductil). This follows a review by the European Medicines Agency which found that the cardiovascular risks of sibutramine outweigh its benefits. Emerging evidence suggests that there is an increased risk of non-fatal heart attacks and strokes with this medicine.
Rimonabant is contraindicated in patients with major depressive illness, or severe renal impairment. 2,4,5,10,15 and indeed Clinical Knowledge Summaries (CKS) recommend that rimonabant should not be prescribed in primary care.
Surgery – Bariatric Surgery should be undertaken only by a multidisciplinary team 1,3,10,13
Orilstat and Sibutramine can be used to maintain weight or reduce weight prior to surgery 3,5,10
Bariatric Surgery is recommended for patients who have a BMI between 35 kg/m2 – 40 kg/m2 or someone who is >100% above their ideal weight who have other significant disease that could be improved due to weight loss e.g. type 2 diabetes, high blood pressure. 1,2,10,11
Surgery is recommended for any patient with a ≥ BMI 40 kg/m2 in whom surgical intervention is considered appropriate 1,2,3,6,7,8,9,10,11.
Before surgery the following criteria should be considered: -
· All other appropriate non-surgical methods have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months 3,5,10,13
· Intensive management in a specialist obesity service 3,10,11
· The person is fit for anaesthesia and surgery 3,10
· The person commits to long-term follow-up 3,10
Advice – must be patient specific, especially for people from black and minority ethnic groups, vulnerable groups (those on low income or a disability, older people etc) or at certain life stages i.e. pregnancy, menopause etc. Obesity prevalence is estimated to be around 50% higher in people with serious mental health problems compared with the general population 1,3,5,13
Bariatric surgery is the most effective treatment for long-term reduction of body weight and should at least be considered for patients with a BMI greater than 40 kg/m2 and patients with a BMI greater than 35 kg/m2 with major obesity-related conditions. Recent evidence indicates bariatric surgery for severe obesity is associated with decreased mortality 7,8,9,10,11,12,13
Surgery (most commonly laparoscopic adjustable gastric banding [LAGB], Roux-en-Y gastric bypass or bilio-pancreatic diversion) can result in long-term weight control. Surgery is also associated with significant long-term reductions in co-morbidity and mortality while also carrying substantial risks. It is vital that eligible patient are adequately assessed, counselled, and offered the appropriate type of procedure and long-term follow up. Such patients need to have access to a specialist multidisciplinary service and should understand the requirements for intensive follow-up and lifestyle changes for such surgery to achieve success. 10,12,13