Objective: To improve the management of obese adults (18-75 y) in primary care.Design: Cohort study.Settings: UK primary care.Subjects: Obese patients (body mass index >= 30 kg/m(2)) or BMI >= 28 kg/m(2) with obesity-related comorbidities in 80 general practices.Intervention: The model consists of four phases: (1) audit and project development, (2) practice training and support, (3) nurse-led patient intervention, and (4) evaluation. The intervention programme used evidence-based pathways, which included strategies to empower clinicians and patients. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation.Main outcome measures: Proportion of practices trained and recruiting patients, and weight change at 12 months.Results: By March 2004, 58 of the 62 (93.5%) intervention practices had been trained, 47 (75.8%) practices were active in implementing the model and 1549 patients had been recruited. At 12 months, 33% of patients achieved a clinically meaningful weight loss of 5% or more. A total of 49% of patients were classed as 'completers' in that they attended the requisite number of appointments in 3, 6 and 12 months. 'Completers' achieved more successful weight loss with 40% achieving a weight loss of 5% or more at 12 months.Conclusion: The Counterweight programme provides a promising model to improve the management of obesity in primary care.

BACKGROUND/AIMS:Primary care is expected to develop strategies to manage obese patients as part of coronary heart disease and diabetes national service frameworks. Little is known about current management practices for obesity in this setting. The aim of this study is to examine current approaches to obesity management in UK primary care and to identify potential gaps in care.METHOD:A total of 141 general practitioners (GPs) and 66 practice nurses (PNs) from 40 primary care practices participated in structured interviews to examine clinician self-reported approaches to obesity management. Medical records were also reviewed for 100 randomly selected obese patients from each practice [body mass index (BMI) >/=30 kg m(-2), n = 4000] to review rates of diet counselling, dietetic or obesity centre referrals, and use of anti-obesity medication. Computerized medical records for the total practice population (n = 206 341, 18-75 years) were searched to examine the proportion of patients with a weight/BMI ever recorded.RESULTS:Eighty-three per cent of GPs and 97% of PNs reported that they would raise weight as an issue with obese patients (P < 0.01). Few GPs (15%) reported spending up to 10 min in a consultation discussing weight-related issues, compared with PNs (76%; P < 0.001). Over 18 months, practice-based diet counselling (20%), dietetic (4%) and obesity centre (1%) referrals, and any anti-obesity medication (2%) were recorded. BMI was recorded for 64.2% of patients and apparent prevalence of obesity was less than expected.CONCLUSION:Obesity is under-recognized in primary care even in these 40 practices with an interest in weight management. Weight management appears to be based on brief opportunistic intervention undertaken mainly by PNs. While clinicians report the use of external sources of support, few patients are referred, with practice-based counselling being the most common intervention.

BACKGROUND/AIMS:Obesity has become a global epidemic, and a major preventable cause of morbidity and mortality. Management strategies and treatment protocols are however poorly developed and evaluated. The aim of the Counterweight Programme is to develop an evidence-based model for the management of obesity in primary care.METHODS:The Counterweight Programme is based on the theoretical model of Evidence-Based Quality Assessment aimed at improving the management of obese adults (18-75 years) in primary care. The model consists of four phases: (1) practice audit and needs assessment, (2) practice support and training, (3) practice nurse-led patient intervention, and (4) evaluation. Patient intervention consisted of screening and treatment pathways incorporating evidence-based approaches, including patient-centred goal setting, prescribed eating plans, a group programme, physical activity and behavioural approaches, anti-obesity medication and weight maintenance strategies. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation. Eighty practices were recruited of which 18 practices were randomized to act as controls and receive deferred intervention 2 years after the initial audit.RESULTS:By February 2004, 58 of the 62 (93.5%) intervention practices had been trained to run the intervention programme, 47 (75.8%) practices were active in implementing the model and 1256 patients had been recruited (74% female, 26% male, mean age 50.6 years, SD 14). At baseline, 75% of patients had at one or more co-morbidity, and the mean body mass index (BMI) was 36.9 kg/m(2) (SD 5.4). Of the 1256 patients recruited, 91% received one of the core lifestyle interventions in the first 12 months. For all patients followed up at 12 months, 34% achieved a clinical meaningful weight loss of 5% or more. A total of 51% of patients were classed as compliant in that they attended the required level of appointments in 3, 6, and 12 months. For fully compliant patients, weight loss improved with 43% achieving a weight loss of 5% or more at 12 months.CONCLUSION:The Counterweight Programme is an evidence-based weight management model which is feasible to implement in primary care.

Like all other peripheral cells types thus far studied in culture, endothelial cells derived from the rabbit aorta bind, internalize and degrade low density lipoprotein (LDL) at a significant rate. At any given LDL concentration, the metabolism by rabbit endothelial cells was slower than that by fibroblasts or smooth muscle cells. Thus, longer incubations were required to achieve a net increment in cell cholesterol content or to suppress endogenous sterol synthesis; after 18–24 h incubation in the presence of LDL at 100 μg LDL protein/ml inhibition was greater than 80% relative to the rate in cells incubated in the absence of lipoproteins. High density lipoproteins (HDL) were also taken up and degraded but did not inhibit sterol synthesis. Studies of LDL binding to the cell surface suggested the presence of at least two classes of binding sites; the high-affinity binding sites were fully saturated at very low LDL concentrations (about 5 μg LDL protein/ml). However, the degree of inhibition of endogenous sterol synthesis increased progressively with increasing LDL concentrations from 5 to 100 μg LDL/ml, suggesting that uptake from the low affinity sites in this cell line contributes to the suppression of endogenous sterol synthesis. The internalization and degradation of LDL also increased with concentrations as high as 700 μg/ml. Thus, in vivo, where the cells are exposed to LDL concentrations far above that needed to saturate the high affinity sites, most of the LDL degradation would be attributable to LDL taken up from low affinity sites. As noted previously in swine arterial smooth muscle cells and in human skin fibroblasts, unlabeled HDL reduced the binding, internalization and degradation of labeled LDL. Cells incubated for 24 h in the presence of high concentrations of LDL alone showed a net increment in cell cholesterol content; the simultaneous presence of HDL in the medium significantly reduced this LDL-induced increment in cell cholesterol content. The possible relationship between LDL uptake and degradation by these cells in vitro is discussed in relationship to their transport function in vivo.