Empowering primary care to tackle the obesity epidemic: the Counterweight Programme

Community-Clinical Linkages With Community Health Workers in the United States: A Scoping Review

Despite the proliferation of community-clinical linkage (CCL) interventions with community health workers (CHWs), little is known about the components of these programs or how linkages are realized. In this scoping review, we synthesize evidence concerning the role of CHWs in creating and sustaining CCLs aimed at improving individual health outcomes. Our inclusion criteria included peer-reviewed articles that described a CHW intervention in the United States that used a CCL model. A total of 2,776 titles and/or abstracts were screened and 47 articles underwent full text review. Two independent reviewers rated the screened articles based on additional criteria including the CHW connection to community and evidence of linkage follow up rather than simple referral. For the 11 peer-reviewed articles included in the final review, we describe the CHW's relationship to the community, training, and role within the intervention, linkage, and outcomes. We used a standardized framework to determine commonalities in CHW roles across the interventions. CCLs with CHWs positively affect the delivery of both clinical care and community resources across a range of disease areas in a variety of contexts. To identify effective CCL models, additional information on CHW training, CCL follow-up methods, and the CHW role in CCLs is recommended.

Role of the family doctor in the management of adults with obesity: a scoping review

OBJECTIVES

Obesity management is an important issue for the international primary care community. This scoping review examines the literature describing the role of the family doctor in managing adults with obesity. The methods were prospectively published and followed Joanna Briggs Institute methodology.

SETTING

Primary care. Adult patients.

INCLUDED PAPERS

Peer-reviewed and grey literature with the keywords obesity, primary care and family doctors. All literature published up to September 2015. 3294 non-duplicate papers were identified and 225 articles included after full-text review.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data were extracted on the family doctors' involvement in different aspects of management, and whether whole person and person-centred care were explicitly mentioned.

RESULTS

110 papers described interventions in primary care and family doctors were always involved in diagnosing obesity and often in recruitment of participants. A clear description of the provider involved in an intervention was often lacking. It was difficult to determine if interventions took account of whole person and person-centredness. Most opinion papers and clinical overviews described an extensive role for the family doctor in management; in contrast, research on current practices depicted obesity as undermanaged by family doctors. International guidelines varied in their description of the role of the family doctor with a more extensive role suggested by guidelines from family medicine organisations.

CONCLUSIONS

There is a disconnect between how family doctors are involved in primary care interventions, the message in clinical overviews and opinion papers, and observed current practice of family doctors. The role of family doctors in international guidelines for obesity may reflect the strength of primary care in the originating health system. Reporting of primary care interventions could be improved by enhanced descriptions of the providers involved and explanation of how the pillars of primary care are used in intervention development.

Tackling obesity in areas of high social deprivation: clinical effectiveness and cost-effectiveness of a task-based weight management group programme - a randomised controlled trial and economic evaluation

BACKGROUND

An increasing number of people require help to manage their weight. The NHS recommends weight loss advice by general practitioners and/or a referral to a practice nurse. Although this is helpful for some, more effective approaches that can be disseminated economically on a large scale are needed.

OBJECTIVE

To assess whether or not a task-based weight management programme [Weight Action Programme (WAP)] has better long-term effects than a 'best practice' intervention provided in primary care by practice nurses.

DESIGN

Randomised controlled trial with cost-effectiveness analysis.

SETTING

General practices in east London, UK.

PARTICIPANTS

Three hundred and thirty adults with a body mass index (BMI) of ≥ 30 kg/m² or a BMI of ≥ 28 kg/m² plus comorbidities were recruited from local general practices and via media publicity. Those who had a BMI of > 45 kg/m², had lost > 5% of their body weight in the previous 6 months, were currently pregnant or taking psychiatric medications were excluded. Participants were randomised (2 : 1) to the WAP or nurse arms.

INTERVENTIONS

The WAP intervention was delivered in eight weekly group sessions that combined dietary and physical activity, advice and self-monitoring in a group-oriented intervention. The initial course was followed by 10 monthly group maintenance sessions open to all participants in this study arm. The practice nurse intervention (best usual care) consisted of four one-to-one sessions delivered over 8 weeks, and included standard advice on diet and physical activity based on NHS 'Change4Life' materials and motivational support.

MAIN OUTCOME MEASURES

The primary outcome measure was weight change at 12 months. Secondary outcome measures included change in BMI, waist circumference and blood pressure, and proportion of participants losing at least 5% and 10% of baseline body weight. Staff collecting measurements at the 6- and 12-month follow-ups were blinded to treatment allocation. The primary outcome measure was analysed according to the intention-to-treat principle, and included all participants with at least one recorded outcome at either 1, 2, 6 or 12 months. The analysis employed a mixed-effects linear regression model, adjusted for baseline weight, age, sex, ethnicity, smoking status and general practice. The European Quality of Life-5 Dimensions-5 Levels questionnaire was completed and used to estimate quality-adjusted life-years (QALYs) within the cost-effectiveness analysis.

RESULTS

There were 330 participants (WAP arm, n = 221; nurse arm, n = 109; 72% women). A total of 291 (88%) participants (WAP arm, n = 194; nurse arm, n = 97) were included in the main analysis for the primary outcome. Weight loss at 12 months was greater in the WAP arm than in the nurse intervention arm [-4.2 kg vs. -2.3 kg; difference -1.9 kg, 95% confidence interval (CI) -3.7 to -0.1 kg; p = 0.04]. Participants in the WAP arm were more likely than participants in the nurse arm to have lost at least 5% of their baseline body weight at 12 months (41% vs. 27%; odds ratio 14.61, 95% CI 2.32 to 91.96; p = 0.004). The incremental cost-effectiveness ratio for WAP over and above the nurse arm is £7742 per QALY.

CONCLUSIONS

A WAP delivered in general practice better promotes weight loss over 12 months than a best usual practice nurse-led weight loss programme.

LIMITATIONS

The trial recruited mostly women. Research is needed into factors that would make weight loss programmes more attractive to men.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN45820471.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 79. See the NIHR Journals Library website for further project information.

Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in children and adults with overweight or obesity

BACKGROUND

The prevalence of overweight and obesity is increasing globally, an increase which has major implications for both population health and costs to health services. This is an update of a Cochrane Review.

OBJECTIVES

To assess the effects of strategies to change the behaviour of health professionals or the organisation of care compared to standard care, to promote weight reduction in children and adults with overweight or obesity.

SEARCH METHODS

We searched the following databases for primary studies up to September 2016: CENTRAL, MEDLINE, Embase, CINAHL, DARE and PsycINFO. We searched the reference lists of included studies and two trial registries.

SELECTION CRITERIA

We considered randomised trials that compared routine provision of care with interventions aimed either at changing the behaviour of healthcare professionals or the organisation of care to promote weight reduction in children and adults with overweight or obesity.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane when conducting this review. We report the results for the professional interventions and the organisational interventions in seven 'Summary of findings' tables.

MAIN RESULTS

We identified 12 studies for inclusion in this review, seven of which evaluated interventions targeting healthcare professional and five targeting the organisation of care. Eight studies recruited adults with overweight or obesity and four recruited children with obesity. Eight studies had an overall high risk of bias, and four had a low risk of bias. In total, 139 practices provided care to 89,754 people, with a median follow-up of 12 months. Professional interventions Educational interventions aimed at general practitioners (GPs), may slightly reduce the weight of participants (mean difference (MD) -1.24 kg, 95% confidence interval (CI) -2.84 to 0.37; 3 studies, N = 1017 adults; low-certainty evidence).Tailoring interventions to improve GPs' compliance with obesity guidelines probably leads to little or no difference in weight loss (MD 0.05 (kg), 95% CI -0.32 to 0.41; 1 study, N = 49,807 adults; moderate-certainty evidence).It is uncertain if providing doctors with reminders results in a greater weight reduction than standard care (men: MD -11.20 kg, 95% CI -20.66 kg to -1.74 kg, and women: MD -1.30 kg, 95% CI [-7.34, 4.74] kg; 1 study, N = 90 adults; very low-certainty evidence).Providing clinicians with a clinical decision support (CDS) tool to assist with obesity management at the point of care leads to little or no difference in the body mass index (BMI) z-score of children (MD -0.08, 95% CI -0.15 to -0.01 in 378 children; moderate-certainty evidence), CDS tools may lead to little or no difference in weight loss in adults: MD -0.095 kg (-0.21 lbs), P = 0.47; 1 study, N = 35,665; low-certainty evidence. Organisational interventions Adults with overweight or obesity may lose more weight if the care was provided by a dietitian (by -5.60 kg, 95% CI -4.83 kg to -6.37 kg) or by a doctor-dietitian team (by -6.70 kg, 95% CI -7.52 kg to -5.88 kg; 1 study, N = 270 adults; low-certainty evidence). Shared care leads to little or no difference in the BMI z-score of children with obesity (adjusted MD -0.05, 95% CI -0.14 to 0.03; 1 study, N = 105 children; low-certainty evidence).Organisational restructuring of the delivery of primary care (i.e. introducing the chronic care model) may result in a slightly lower increase in the BMI of children who received care at intervention clinics (BMI change: adjusted MD -0.21, 95% CI -0.50 to 0.07; 1 study, unadjusted MD -0.18, 95% CI -0.20 to -0.16; N=473 participants; moderate-certainty evidence).Mail and phone interventions probably lead to little or no difference in weight loss in adults (mean weight change (kg) using mail: -0.36, 95% CI -1.18 to 0.46; phone: -0.44, 95% CI -1.26 to 0.38; 1 study, N = 1801 adults; moderate-certainty evidence). Care delivered by a nurse at a primary care clinic may lead to little or no difference in the BMI z-score in children (MD -0.02, 95% CI -0.16 to 0.12; 1 study, N = 52 children; very low-certainty evidence).Two studies reported data on cost effectiveness: one study favoured mail and standard care over telephone consultations, and the other study achieved weight loss at a modest cost in both intervention groups (doctor and doctor-dietitian). One study of shared care reported similar adverse effects in both groups.

AUTHORS' CONCLUSIONS

We found little convincing evidence for a clinically-important effect on participants' weight or BMI of any of the evaluated interventions. While pooled results from three studies indicate that educational interventions targeting healthcare professionals may lead to a slight weight reduction in adults, the certainty of these results is low. Two trials evaluating CDS tools (unpooled results) for improved weight management suggest little or no effect on weight or BMI change in adults or children with overweight or obesity. Evidence for all the other interventions evaluated came mostly from single studies. The certainty of the included evidence varied from moderate to very low for the main outcomes (weight and BMI). All of the evaluated interventions would need further investigation to ascertain their strengths and limitations as effective strategies to change the behaviour of healthcare professionals or the organisation of care. As only two studies reported on cost, we know little about cost effectiveness across the evaluated interventions.

A brief intervention for weight control based on habit-formation theory delivered through primary care: results from a randomised controlled trial

BACKGROUND

Primary care is the 'first port of call' for weight control advice, creating a need for simple, effective interventions that can be delivered without specialist skills. Ten Top Tips (10TT) is a leaflet based on habit-formation theory that could fill this gap. The aim of the current study was to test the hypothesis that 10TT can achieve significantly greater weight loss over 3 months than 'usual care'.

METHODS

A two-arm, individually randomised, controlled trial in primary care. Adults with obesity were identified from 14 primary care providers across England. Patients were randomised to either 10TT or 'usual care' and followed up at 3, 6, 12, 18 and 24 months. The primary outcome was weight loss at 3 months, assessed by a health professional blinded to group allocation. Difference between arms was assessed using a mixed-effect linear model taking into account the health professionals delivering 10TT, and adjusted for baseline weight. Secondary outcomes included body mass index, waist circumference, the number achieving a 5% weight reduction, clinical markers for potential comorbidities, weight loss over 24 months and basic costs.

RESULTS

Five-hundred and thirty-seven participants were randomised to 10TT (n=267) or to 'usual care' (n=270). Data were available for 389 (72%) participants at 3 months and for 312 (58%) at 24 months. Participants receiving 10TT lost significantly more weight over 3 months than those receiving usual care (mean difference =-0.87kg; 95% confidence interval: -1.47 to -0.27; P=0.004). At 24 months, the 10TT group had maintained their weight loss, but the 'usual care' group had lost a similar amount. The basic cost of 10TT was low, that is, around £23 ($32) per participant.

CONCLUSIONS

The 10TT leaflet delivered through primary care is effective in the short-term and a low-cost option over the longer term. It is the first habit-based intervention to be used in a health service setting and offers a low-intensity alternative to 'usual care'.

A Randomized Clinical Trial of a Tailored Lifestyle Intervention for Obese, Sedentary, Primary Care Patients

PURPOSE

The aim of the study was to test a tailored lifestyle intervention for helping obese primary care patients achieve weight loss and increase physical activity.

METHODS

We conducted a 24-month randomized clinical trial in Rhode Island. Primary care physicians identified obese, sedentary patients motivated to lose weight and increase their moderate to vigorous physical activity. These patients were randomized to 1 of 2 experimental groups: enhanced intervention (EI) or standard intervention (SI). Both groups received 3 face-to-face weight loss meetings. The enhanced intervention group also received telephone counseling calls, individually tailored print materials, and DVDs focused on diet and physical activity. Active intervention occurred in year 1 with a tapered maintenance phase in year 2.

RESULTS

Two hundred eleven obese, sedentary patients were recruited from 24 primary care practices. Participants were 79% women and 16% minorities. They averaged 48.6 years of age, with a mean body mass index (BMI) of 37.8 kg/m(2), and 21.2 minutes/week of moderate to vigorous physical activity. Significantly more EI participants lost 5% of their baseline weight than SI participants (group by visit, P <.001). The difference was significant during active treatment at 6 months (37.2% EI vs 12.9% SI) and 12 months (47.8% vs 11.6%), but was no longer significant during the maintenance phase at 18 months (31.4% vs 26.7%,) or 24 months (33.3% vs 24.6%). The EI group reported significantly more minutes of moderate to vigorous physical activity over time than the SI group (group by visit, P = 0.04). The differences in minutes per week at 6 months was 95.7 for the EI group vs 68.3 minutes for the SI group; at 12 months, it was 126.1 vs 73.7; at 18 months, 103.7 vs 63.7, and at 24 months, 101.3 vs 75.4. Similar trends were found for absolute weight loss and the percentage reaching national guidelines for physical activity.

CONCLUSION

A home-based tailored lifestyle intervention in obese, sedentary primary care patients was effective in promoting weight loss and increasing moderate to vigorous physical activity, with the effects peaking at 12 months but waning at 24 months.

Missing an opportunity: the embedded nature of weight management in primary care

The 5As Team study was designed to create, implement and evaluate a flexible intervention to improve the quality and quantity of weight management visits in primary care. The objective of this portion of the study was to explore how primary care providers incorporate weight management in their practice. 5AsT is a randomized controlled trial (RCT) on the implementation of a 6-month 5 As Team (5AsT) intervention designed to operationalize the 5As of obesity management in primary care. Data for the qualitative portion of the study presented here included semi-structured interviews with 29 multidisciplinary team providers and field notes of intervention sessions. Thematic analysis was undertaken. A key pattern that emerged from the data was that healthcare providers usually do not address obesity as a primary focus for a visit. Rather, obesity is embedded in a wide range of primary care encounters for other conditions. Implications were it can take extra time to discuss weight, it can be inappropriate to bring up weight as a topic, and treating risk factors and root causes of obesity have indirect benefits to patient weight management. Our findings have implications for obesity treatment approaches and tools that assume a discreet weight management visit. The embedded nature of obesity management in primary care can be harnessed to leverage multiple opportunities for asking and assessing root causes of obesity, and working longitudinally towards individual health goals.

Research protocol: Management of obesity in patients with low health literacy in primary health care

Background

Socioeconomically disadvantaged adults are both more likely to be obese and have lower levels of health literacy. Our trial evaluates the implementation and effectiveness of primary care nurses acting as prevention navigators to support obese patients with low health literacy to lose weight.

Methods/Design

A pragmatic cluster randomised trial will be conducted. Twenty practices in socioeconomically deprived areas, 10 each in Sydney and Adelaide, will be recruited and randomised to intervention and control groups. Twenty to 40 eligible obese patients aged 40–70 years with a BMI ≥ 30 kg/m² and with low health literacy will be enrolled per practice. The intervention is based on the ‘5As’ of the chronic disease model approach – Assess, Advise, Agree, Assist and Arrange – and the recommendations of the 2013 Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. In the intervention practices, patients will be invited to attend a health check with the prevention navigator who will assess the patient’s risk and provide brief advice, assistance with goal setting and referral navigation. Provider training and educational meetings will be held. The providers’ attitudes to obesity, confidence in treating obesity and preventive care they provide to obese people with low health literacy will be evaluated through questionnaires and interviews. Patients’ self-assessment of lifestyle risk factors, perception of preventive care received in general practice, health-related quality of life, and health literacy will be assessed in telephone interviews. Patients’ anthropometric measures will be recorded and their health service usage will be determined via linkage to the Australian government-held medical and pharmaceutical data.

Discussion

Our trial will provide evidence for the effectiveness of practice nurses as prevention navigators to support better weight management for obese patients with low health literacy.

Trial registration

This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614001021662). Date registered 24/09/2014.

Impact of an integrated obesity management system on patient's care - research protocol

BACKGROUND

The majority of obese subjects are treated by primary care physicians (PCPs) who often feel uncomfortable with the management of obesity. In a previous study, we successfully developed, implemented and evaluated an obesity management system based on training and coaching of health professionals of family medicine groups (FMGs) by a team of experts in obesity management. Using a pre/post design, this study suggested a positive impact on health professionals' perceptions and reported obesity care. The current research project is aimed at evaluating the impact on obesity screening and care of this integrated obesity management system. We hypothesize that our program combining preceptorships with a virtual community and on-site coaching will improve: (1) management and weight loss of obese/overweight subjects treated by PCPs for hypertension, type 2 diabetes or impaired glucose tolerance; and (2) screening and initial management of obesity among a regular follow-up group of patients of PCPs who practice in FMGs.

METHODS/DESIGN

Ten FMGs will be approached for a practice monitoring project and will be randomised to receive the intervention developed in our previous project or will only be provided clinical practice guidelines. In the participating FMGs, we will enrol 22 patients per FMG with weight related targeted disease and 24 patients with regular follow-up. These patients will be evaluated for the care they received regarding screening and/or management of obesity using medical chart reviews, and will fill out a questionnaire on their lifestyle and satisfaction. They will also be examined for anthropometric measures, vital signs, blood markers for chronic diseases and physical fitness. The same patients will be assessed again after 18 months. The impact of the program on health professionals will be evaluated at baseline, and at 1 year. Qualitative data will also be collected from both professional and patient participants. Direct and indirect costs and QALYs will be evaluated as indicators of cost-effectiveness.

DISCUSSION

In the context of the dramatic increase in obesity prevalence and the low perception of PCPs' self-efficacy, providing efficient strategies to PCPs and interdisciplinary health care teams for management of obesity is crucial.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT00991640.

Tailored weight loss intervention in obese adults within primary care practice: rationale, design, and methods of Choose to Lose

Although there are efficacious weight loss interventions that can improve health and delay onset of diabetes and hypertension, these interventions have not been translated into clinical practice. The primary objective of this study is to evaluate the effectiveness and cost effectiveness of a tailored lifestyle intervention in primary care patients. Patients were recruited by their primary care physicians and eligible participants were randomized to an enhanced intervention or standard intervention. All participants met with a lifestyle counselor to set calorie and physical activity goals and to discuss behavioral strategies at baseline, 6 and 12 months. During the first year, enhanced intervention participants receive monthly counseling phone calls to assist in attaining and maintaining their goals. Enhanced intervention participants also receive weekly mailings consisting of tailored and non-tailored print materials and videos focusing on weight loss, physical activity promotion and healthy eating. The second year focuses on maintenance with enhanced intervention participants receiving tailored and non-tailored print materials and videos regularly throughout the year. Standard intervention participants receive five informational handouts on weight loss across the two years. This enhanced intervention that consists of multiple modalities of print, telephone, and video with limited face-to-face counseling holds promise for being effective for encouraging weight loss, increasing physical activity and healthy eating, and also for being cost effective and generalizable for wide clinical use. This study will fill an important gap in our knowledge regarding the translation and dissemination of research from efficacy studies to best practices in clinical settings.

A comparison of the provision of the My Choice Weight Management Programme via general practitioner practices and community pharmacies in the United Kingdom

This study aimed to assess the effectiveness of a novel, community-based weight management programme delivered through general practitioner (GP) practices and community pharmacies in one city in the United Kingdom. This study used a non-randomized, retrospective, observational comparison of clinical data collected by participating GP practices and community pharmacies. Subjects were 451 overweight or obese men and women resident in areas of high socioeconomic deprivation (82% from black and minority ethnic groups, 86% women, mean age: 41.1 years, mean body mass index [BMI]: 34.5 kg m(-2)). Weight, waist circumference and BMI at baseline, after 12 weeks and after 9 months were measured. Costs of delivery were also analysed. Sixty-four per cent of participants lost weight after the first 12 weeks of the My Choice Weight Management Programme. There was considerable dropout. Mean percentage weight loss (last observation carried forward) was 1.9% at 12 weeks and 1.9% at final follow-up (9 months). There was no significant difference in weight loss between participants attending GP practices and those attending pharmacies at both 12 weeks and at final follow-up. Costs per participant were higher via community pharmacy which was attributable to better attendance at sessions among community pharmacy participants than among GP participants. The My Choice Weight Management Programme produced modest reductions in weight at 12 weeks and 9 months. Such programmes may not be sufficient to tackle the obesity epidemic.

Feasibility and indicative results from a 12-month low-energy liquid diet treatment and maintenance programme for severe obesity

BACKGROUND

There is no established primary care solution for the rapidly increasing numbers of severely obese people with body mass index (BMI) > 40 kg/m(2).

AIM

This programme aimed to generate weight losses of ≥15 kg at 12 months, within routine primary care.

DESIGN AND SETTING

Feasibility study in primary care.

METHOD

Patients with a BMI ≥40 kg/m(2) commenced a micronutrient-replete 810-833 kcal/day low-energy liquid diet (LELD), delivered in primary care, for a planned 12 weeks or 20 kg weight loss (whichever was the sooner), with structured food reintroduction and then weight-loss maintenance, with optional orlistat to 12 months.

RESULT

Of 91 patients (74 females) entering the programme (baseline: weight 131 kg, BMI 48 kg/m(2), age 46 years), 58/91(64%) completed the LELD stage, with a mean duration of 14.4 weeks (standard deviation [SD] = 6.0 weeks), and a mean weight loss of 16.9 kg (SD = 6.0 kg). Four patients commenced weight-loss maintenance omitting the food-reintroduction stage. Of the remaining 54, 37(68%) started and completed food reintroduction over a mean duration of 9.3 weeks (SD = 5.7 weeks), with a further mean weight loss of 2.1 kg (SD = 3.7 kg), before starting a long-term low-fat-diet weight-loss maintenance plan. A total of 44/91 (48%) received orlistat at some stage. At 12 months, weight was recorded for 68/91 (75%) patients, with a mean loss of 12.4 kg (SD = 11.4 kg). Of these, 30 (33% of all 91 patients starting the programme) had a documented maintained weight loss of ≥15 kg at 12 months, six (7%) had a 10-15 kg loss, and 11 (12%) had a 5-10 kg loss. The indicative cost of providing this entire programme for wider implementation would be £861 per patient entered, or £2611 per documented 15 kg loss achieved.

CONCLUSION

A care package within routine primary care for severe obesity, including LELD, food reintroduction, and weight-loss maintenance, was well accepted and achieved a 12-month-maintained weight loss of ≥15 kg for one-third of all patients entering the programme.

Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults

Background  Cardiovascular disease is the leading cause of death for adults in Australia. In recent years there has been a shift in health service delivery from institutional to community-based care for chronic conditions, including cardiovascular disease. The general practice setting is seen to offer greater flexibility, higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector. It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management. To date, significant descriptive research has been conducted exploring the demographics, roles, educational needs and issues facing practice nurses. However, there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes, clinician satisfaction and cost-effectiveness. Objectives  This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults, as well as those with established cardiovascular disease or known cardiac risk factors. Search Strategy  A systematic literature search was performed using Medline (1966 - 2005), CINAHL (1982 -2005), Cochrane Controlled Trials Register (Issue 4, 2005) and the Joanna Briggs Institute Evidence Library. In addition, the reference lists of retrieved papers, conference proceedings and the Internet, were scrutinised for additional trials. Selection Criteria  This review considered any English language randomised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors. Interventions conducted by specialist cardiac nurses in general practice were excluded. Outcomes measured included blood pressure, smoking cessation, total cholesterol, exercise, body weight/body mass index and cost-effectiveness. Results  Eighteen trials, reported in 33 papers, were included in the review. Ten trials investigated multifaceted interventions, while the remaining eight trials reported targeted interventions. Of the trials that reported multifaceted interventions, three trials investigated risk reduction in those with established cardiovascular disease, four trials focused on those with known cardiovascular disease risk factors and three trials included the general community. The eight trials which examined the efficacy of targeted interventions focused upon dietary intake (two trials), smoking cessation (three trials), weight reduction (one trial) and physical activity (two trials). The effect of both the multifaceted and targeted interventions on patient outcomes was variable. However, both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables. Improvements were demonstrated by most studies in blood pressure, cholesterol level, dietary intake and physical activity. The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions. Conclusions  While interventions to reduce cardiovascular disease risk factors have produced variable results, they offer significant potential to assist patients in modifying their personal risk profile and should be developed. The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals. Further well-designed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost-effectiveness.

Behavioral approaches to weight control: a review of current research

Weight management is a salient issue for women. Studies of behavioral, pharmacological and surgical interventions indicate that women comprise the majority of patients presenting for weight-loss treatment. In this review we discuss the health impact of obesity for women, review behavioral treatments for adult overweight and obesity, and address topics of particular relevance for women, including concerns that weight-loss treatment may precipitate the development of eating pathology, as well as time periods of high risk for weight gain such as pregnancy and menopause.

Preparing medical students to facilitate lifestyle changes with obese patients: a systematic review of the literature

PURPOSE

Doctors will increasingly encounter opportunities to support obese patients in lifestyle change efforts, but the extent to which medical schools prepare their students for this challenge is unknown. Further, despite evidence indicating theory-based techniques are effective in facilitating patients' behavioral changes, the methods taught to medical students and the means of content delivery are unclear. The authors reviewed the literature to investigate how effective educational interventions are in preparing medical students to facilitate lifestyle changes with obese patients.

METHOD

The authors systematically searched Excerpta Medica (EMBASE), PsycINFO, MEDLINE, and Scopus for educational interventions on obesity management for medical students published in English between January 1990 and November 2010 and matching PICOS (Population, Interventions, Comparators, Outcomes, Study design) inclusion criteria.

RESULTS

Results of a narrative synthesis are presented. Of 1,680 studies initially identified, 36 (2%) full-text articles were reviewed, and 12 (1%) were included in the final dataset. Eleven (92%) of these studies had quantitative designs; of these, 7 (64%) did not include control groups. Nine (75%) of the 12 studies were atheoretical, and 4 (33%) described behavior management strategies. Despite positive reported outcomes regarding intervention evaluations, procedures to control for bias were infrequently reported, and conclusions were often unsupported by evidence.

CONCLUSIONS

Evidence from this systematic review revealed data highly susceptible to bias; thus, intervention efficacy could not be determined. Additionally, evidence-based strategies to support patients' obesity-related behavior changes were not applied to these studies, and thus it remains unknown how best to equip medical students for this task.

Linkages between clinical practices and community organizations for prevention: a literature review and environmental scan

OBJECTIVES

We conducted a literature review and environmental scan to develop a framework for interventions that utilize linkages between clinical practices and community organizations for the delivery of preventive services, and to identify and characterize these efforts.

METHODS

We searched 4 major health services and social science electronic databases and conducted an Internet search to identify examples of linkage interventions in the areas of tobacco cessation, obesity, nutrition, and physical activity.

RESULTS

We identified 49 interventions, of which 18 examples described their evaluation methods or reported any intervention outcomes. Few conducted evaluations that were rigorous enough to capture changes in intermediate or long-term health outcomes. Outcomes in these evaluations were primarily patient-focused and did not include organizational or linkage characteristics.

CONCLUSIONS

An attractive option to increase the delivery of preventive services is to link primary care practices to community organizations; evidence is not yet conclusive, however, that such linkage interventions are effective. Findings provide recommendations to researchers and organizations that fund research, and call for a framework and metrics to study linkage interventions.

Weight loss from three commercial providers of NHS primary care slimming on referral in North Somerset: service evaluation

BACKGROUND

The aim of this study was to analyse the effect of provider, gender and obesity class on outcomes of National Health Service (NHS) slimming on referral.

METHODS

Service evaluation in 12 UK general practices. Obese patients aged ≥16 were referred for 12 sessions to one of three commercial providers. Outcomes at 12 weeks were attendance, BMI, total and percentage weight loss, 5% and 5 kg weight loss and comparison across providers. Linear and multiple regression analyses were used, adjusting for confounders.

RESULTS

One thousand four hundred and forty patients were referred; 1047 receiving vouchers and 880 attending at least one session. The mean weight change was -4.8 kg (95% CI: -5.1 to -4.5) and the percentage bodyweight loss was -4.6% (standard deviation: 3.7). Weight Watchers patients lost more weight [-1.15 kg (95% confidence interval, CI: -1.25, -1.04), P < 0.001] and were more likely to lose 5% bodyweight [odds ratio: 1.81 (95% CI: 1.78, 1.83), P < 0.001] than those attending the provider with the least weight loss.

CONCLUSIONS

NHS slimming on referral can successfully achieve short-term weight loss. Patients attending Weight Watchers were most likely to lose weight than those attendingother providers.

Primary care and public health a natural alliance? The introduction of the guidelines for obesity and undernutrition of the Dutch College of General Practitioners

The prevalence of obesity and overweight is increasing globally and forms a huge public health problem. On the other hand, the prevalence of malnutrition or undernutrition is substantial, especially in nursing homes or in the elderly at home. Primary care and public health are separate disciplines. But in the field of nutrition and other lifestyle-related interventions, there are many direct and indirect interfaces for over- as well as undernutrition. The Dutch College of General Practitioners (NHG) published the Practice Guideline Obesity in adults and children to lead GPs in this process and to bridge the gap with public health. The same applies for the recently published National Primary Care Cooperation Agreement Undernutrition on the collaboration of primary care workers to enhance awareness and early intervention in case of nutritional impairment. This article goes into the background as well as the content of these two NHG products and the implications for daily practice. An attempt is made to connect primary care and public health in this matter. Particularly in the case of obesity, a close relationship with public health is of vital importance.

The implementation of the Counterweight Programme in Scotland, UK

BACKGROUND

The Counterweight Programme is a proven model for the management of obesity in the UK, evaluated over 5 years (2000-05) and demonstrating clinical and cost effectiveness. The Scottish Government commissioned three phases of Counterweight implementation during the period 2006-08. The first two phases linked the Counterweight Programme to a primary care cardiovascular disease prevention programme; the third phase was commissioned independent of other interventions. Aim. To assess the implementation of the Counterweight Programme in 13 Health Boards in Scotland and compare 12-month outcomes with published Counterweight data.

METHODS

Patients with a body mass index (BMI) ≥ 30 kg/m(2) or BMI ≥ 28 kg/m(2) with at least one co-morbidity were screened for the Counterweight Programme. Patients were asked to attend nine structured appointments with a trained Counterweight Programme practitioner over 12 months.

RESULTS

Six thousand seven hundred and fifteen patients from 184 general practices, 16 pharmacies and one centralized community-based service in 13 Health Boards, with a mean BMI of 37 kg/m(2) were enrolled in the Counterweight Programme. Twenty-six per cent had a BMI ≥ 40 kg/m(2). Attendance for patients at 3, 6 and 12 months follow-up was 55%, 37% and 28%. Of those who attended at 12 months, 35.2% had maintained a weight loss of ≥5% compared to 30.7% in the original evaluation.

CONCLUSIONS

Evaluation of the Counterweight Programme in Scotland demonstrated consistency in characteristics of patients enrolled into the programme. There was evidence of higher loss to follow-up in a population not routinely engaging with primary care but evidence of greater weight losses among those who attended.

Comparison of range of commercial or primary care led weight reduction programmes with minimal intervention control for weight loss in obesity: lighten Up randomised controlled trial

OBJECTIVE

To assess the effectiveness of a range of weight management programmes in terms of weight loss.

DESIGN

Eight arm randomised controlled trial.

SETTING

Primary care trust in Birmingham, England.

PARTICIPANTS

740 obese or overweight men and women with a comorbid disorder identified from general practice records.

INTERVENTIONS

Weight loss programmes of 12 weeks' duration: Weight Watchers; Slimming World; Rosemary Conley; group based, dietetics led programme; general practice one to one counselling; pharmacy led one to one counselling; choice of any of the six programmes. The comparator group was provided with 12 vouchers enabling free entrance to a local leisure (fitness) centre.

MAIN OUTCOME MEASURES

The primary outcome was weight loss at programme end (12 weeks). Secondary outcomes were weight loss at one year, self reported physical activity, and percentage weight loss at programme end and one year.

RESULTS

Follow-up data were available for 658 (88.9%) participants at programme end and 522 (70.5%) at one year. All programmes achieved significant weight loss from baseline to programme end (range 1.37 kg (general practice) to 4.43 kg (Weight Watchers)), and all except general practice and pharmacy provision resulted in significant weight loss at one year. At one year, only the Weight Watchers group had significantly greater weight loss than did the comparator group (2.5 (95% confidence interval 0.8 to 4.2) kg greater loss,). The commercial programmes achieved significantly greater weight loss than did the primary care programmes at programme end (mean difference 2.3 (1.3 to 3.4) kg). The primary care programmes were the most costly to provide. Participants allocated to the choice arm did not have better outcomes than those randomly allocated to a programme.

CONCLUSIONS

Commercially provided weight management services are more effective and cheaper than primary care based services led by specially trained staff, which are ineffective. Trial registration Current Controlled Trials ISRCTN25072883.

A randomised controlled trial to compare a range of commercial or primary care led weight reduction programmes with a minimal intervention control for weight loss in obesity: the Lighten Up trial

BACKGROUND

Developed countries are facing a huge rise in the prevalence of obesity and its associated chronic medical problems. In the UK Primary Care Trusts are charged with addressing this in the populations they serve, but evidence about the most effective ways of delivering services is not available. The aim of this study is to determine the effectiveness of a range of weight loss programmes for obese patients in primary care and to determine the characteristics of patients who respond to an invitation to a free weight management programme.

METHODS/DESIGN

Lighten Up is a randomised controlled trial comparing a range of 12-week commercial and NHS weight reduction programmes with a comparator group who are provided with 12 vouchers enabling free entrance to a local leisure centre. The weight reduction programmes are: (i) Weight Watchers, (ii) Slimming World, (iii) Rosemary Conley, (iv) a group-based dietetics-led programme (Size Down), (v) general practice one-to-one counselling, (vi) pharmacy-led one-to-one counselling, (vii) choice of any of the 6 programmes. People with obesity or overweight with a co-morbid disorder are invited to take part by a letter from their general practitioner. The sample size is 740 participants.The primary outcome is weight loss at programme-end (3 months). Secondary outcomes are weight-loss at one year, self-reported physical activity at 3 and 12 months follow-up and percentage weight-loss at 3 months and one year.

DISCUSSION

This trial will provide evidence about the effectiveness of a range of different weight management programmes in a primary care population.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN25072883.

Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese people

BACKGROUND

The prevalence of obesity is increasing globally and will, if left unchecked, have major implications for both population health and costs to health services.

OBJECTIVES

To assess the effectiveness of strategies to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese people.

SEARCH STRATEGY

We updated the search for primary studies in the following databases, which were all interrogated from the previous (version 2) search date to May 2009: The Cochrane Central Register of Controlled Trials (which at this time incorporated all EPOC Specialised Register material) (The Cochrane Library 2009, Issue 1), MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), and PsycINFO (Ovid). We identified further potentially relevant studies from the reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared routine provision of care with interventions aimed either at changing the behaviour of healthcare professionals or the organisation of care to promote weight reduction in overweight or obese adults.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

We included six RCTs, involving more than 246 health professionals and 1324 overweight or obese patients. Four of the trials targeted professionals and two targeted the organisation of care. Most of the studies had methodological or reporting weaknesses indicating a risk of bias.Meta-analysis of three trials that evaluated educational interventions aimed at GPs suggested that, compared to standard care, such interventions could reduce the average weight of patients after a year (by 1.2 kg, 95% CI -0.4 to 2.8 kg); however, there was moderate unexplained heterogeneity between their results (I(2) = 41%). One trial found that reminders could change doctors' practice, resulting in a significant reduction in weight among men (by 11.2 kg, 95% CI 1.7 to 20.7 kg) but not among women (who reduced weight by 1.3 kg, 95% CI -4.1 to 6.7 kg). One trial found that patients may lose more weight after a year if the care was provided by a dietitian (by 5.6 kg, 95% CI 4.8 to 6.4 kg) or by a doctor-dietitian team (by 6 kg, 95% CI 5 to 7 kg), as compared with standard care. One trial found no significant difference between standard care and either mail or phone interventions in reducing patients' weight.

AUTHORS' CONCLUSIONS

Most of the included trials had methodological or reporting weaknesses and were heterogeneous in terms of participants, interventions, outcomes, and settings, so we cannot draw any firm conclusions about the effectiveness of the interventions. All of the evaluated interventions would need further investigation before it was possible to recommend them as effective strategies.

Practice Guideline Dissemination and Implementation Strategies for Healthcare Teams and Team-Based Practice: a systematic review

OBJECTIVES

The objective of this systematic review is to describe and identify the effectiveness of different practice guideline implementation strategies on team-based practice and/or patient outcomes.

METHODS

A systematic review was conducted, using a comprehensive, reproducible search strategy that revealed 88 studies that met the inclusion criteria.

RESULTS

A descriptive analysis revealed multiple approaches using teams of health care providers with 72.7% of the studies reporting statistically significant results in knowledge, practice and/or outcomes. Of 10 dissemination strategies the most effective were reminders, and audit and feedback. The most popular strategy was education meetings. A secondary analysis revealed different populations with chronic or complex disorders where a team approach was effective in practice guideline dissemination and implementation.

CONCLUSIONS

Many of the studies provided caveats to explain how or why the strategies did or did not demonstrate improvements. Overall, authors described complex health care requiring increasingly complex approaches to ensure evidence based guidelines were utilised in practice, including using multiple dissemination and implementation strategies. The review has provided evidence that a multi-pronged approach to dissemination and implementation of practice guidelines will assist in gaining significant improvements in change in knowledge, practice and patient outcomes.

Engaging patients, clinicians and health funders in weight management: the Counterweight Programme

BACKGROUND

The Counterweight Programme provides an evidence based and effective approach for weight management in routine primary care. Uptake of the programme has been variable for practices and patients. Aim. To explore key barriers and facilitators of practice and patient engagement in the Counterweight Programme and to describe key strategies used to address barriers in the wider implementation of this weight management programme in UK primary care.

METHODS

All seven weight management advisers participated in a focus group. In-depth interviews were conducted with purposeful samples of GPs (n = 7) and practice nurses (n = 15) from 11 practices out of the 65 participating in the programme. A total of 37 patients participated through a mixture of in-depth interviews (n = 18) and three focus groups. Interviews and focus groups were analysed for key themes that emerged.

RESULTS

Engagement of practice staff was influenced by clinicians' beliefs and attitudes, factors relating to the way the programme was initiated and implemented, the programme content and organizational/contextual factors. Patient engagement was influenced by practice endorsement of the programme, clear understanding of programme goals, structured proactive follow-up and perception of positive outcomes.

CONCLUSIONS

Having a clear understanding of programme goals and expectations, enhancing self-efficacy in weight management and providing proactive follow-up is important for engaging both practices and patients. The widespread integration of weight management programmes into routine primary care is likely to require supportive public policy.

Longitudinal changes in GPs' task perceptions, self-efficacy, barriers and practices of nutrition education and treatment of overweight

BACKGROUND

GPs play a role in prevention by giving nutrition education and advice on overweight. Over the years, GP's tasks and working environment changed.

OBJECTIVE

To know how task perceptions, perceptions of own ability and perceived barriers regarding nutrition education and treatment of overweight of Dutch GPs have developed from 1992 to 2007.

METHODS

In all, 488 GPs, first included in study in 1992, were asked in 2007 to return the Wageningen PCPs Nutritional Practices Questionnaire. Crohnbach's alphas and sum scores were calculated and differences between 1992 and 2007 were investigated using a paired t-test.

RESULTS

In all, 247 GPs responded (51%). 'Noticing patients overweight and guidance of treatment' did not change in GPs from 1992 to 2007. The task perception about health education and prevention did not change and the perception of daily activities shifted from the curative to the preventive side. Interest in the influence of nutrition on health increased in 2007. GPs less often managed to counsel on nutrition in daily practice. Their perceived capacity to counsel and their self-efficacy regarding overweight management declined over the years. In 2007, more GPs perceived the barriers 'lack of time' to treat overweight and to give nutrition education. The most important barrier in 2007 was lack of patient motivation.

CONCLUSIONS

The GPs perceived overweight and nutrition education as important and were still favourable towards prevention. However, their potential to give nutrition education or guide in treatment of overweight was not fully utilized because of decreased self-efficacy factors and perceived barriers.

The development of a minimal intervention strategy to address overweight and obesity in adult primary care patients in The Netherlands

BACKGROUND

Currently, overweight and obesity do not receive the attention they deserve from the Dutch GPs, mostly because of a lack of an effective intervention strategy to tackle this difficult health problem.

OBJECTIVE

To develop a minimal intervention strategy (MIS) addressing overweight and obesity among adult primary care patients, resulting in a prototype.

METHODS

Following the intervention mapping protocol, the MIS is based on literature study, existing interventions, psychosocial theories, stakeholder interviews and a questionnaire study among stakeholders. This led to the development of a prototype of the MIS materials: a screening flow chart and a treatment flow chart, a manual and patient education materials. A pre-test among 42 general practitioners and practice nurses was conducted to investigate the usefulness of the MIS materials at first sight.

RESULTS

The stakeholder interviews and the questionnaire study resulted in insight on what the MIS should look like. For instance, the stakeholders indicated that the treatment needs to focus on helping patients to eat more healthy and exercise more, using techniques like motivational interviewing. The pre-test showed that most participants were enthusiastic about the materials, although they made some suggestions on improvements.

CONCLUSION

The MIS materials seem to be useful and promising. A future pilot test is needed to investigate its usefulness in daily practice and to further improve the materials in preparation for a process and effect evaluation.

Evaluation of the Counterweight Programme for obesity management in primary care: a starting point for continuous improvement

BACKGROUND

Evaluation for obesity management in primary care is limited, and successful outcomes are from intensive clinical trials in hospital settings.

AIM

To determine to what extent measures of success seen in intensive clinical trials can be achieved in routine primary care. Primary outcome measures were weight change and percentage of patients achieving >or=5% loss at 12 and 24 months.

DESIGN OF STUDY

Prospective evaluation of a new continuous improvement model for weight management in primary care.

SETTING

Primary care, UK.

METHOD

Primary care practice nurses from 65 UK general practices delivered interventions to 1906 patients with body mass index (BMI)>or=30 kg/m2 or>or=28 kg/m2 with obesity-related comorbidities.

RESULTS

Mean baseline weight was 101.2 kg (BMI 37.1 kg/m2); 25% of patients had BMI>or=40 kg/m2 and 74% had >or=1 major obesity-related comorbidity. At final data capture 1419 patients were in the programme for >or=12 months, and 825 for >or=24 months. Mean weight change in those who attended and had data at 12 months (n=642) was -3.0 kg (95% CI=-3.5 to -2.4 kg) and at 24 months (n=357) was -2.3 kg (95% CI=-3.2 to -1.4 kg). Among attenders at specific time-points, 30.7% had maintained weight loss of >or=5% at 12 months, and 31.9% at 24 months. A total of 761 (54%) of all 1419 patients who had been enrolled in the programme for >12 months provided data at or beyond 12 months.

CONCLUSION

This intervention achieves and maintains clinically valuable weight loss within routine primary care.

Obesity in primary care: evidence for advising weight constancy rather than weight loss in unsuccessful dieters

In view of the limited success rates of all weight-loss strategies to date, this article hypothesises that in situations where previous dieting attempts have failed, better outcomes and health improvements will arise from advocating weight-stability goals. This means the promotion of weight maintenance (to ensure any reduction in weight is maintained) and weight constancy (where steps are taken to maintain existing weight without attempting weight loss), rather than advocating existing 5-10% weight-loss targets for these patients. The majority of approaches to obesity focus on weight reduction despite poor evidence of effectiveness. Primary care remains reluctant to engage in ineffective approaches, yet is well placed to give advice, and would undoubtedly adopt effective obesity-management approaches if they were developed. Despite guidance for overweight or obese people to aim for a 5-10% weight reduction, current trends demonstrate escalation of average weights and obesity. A literature review found little information about evaluation of weight-stability approaches (either weight maintenance or weight constancy), despite theoretical support for them. Yet taking steps to protect weight reduction where it is achieved, and to promote weight constancy (without weight loss) where further dieting is predicted to fail, would have a beneficial effect on preventing further growth of obesity-related morbidity in the population. Some evidence exists to support simple behavioural approaches to improve weight stability, but these measures do not feature in current advice and hence are not widely advocated.

Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults

BACKGROUND

Cardiovascular disease is the leading cause of death for adults in Australia. In recent years there has been a shift in health service delivery from institutional to community-based care for chronic conditions, including cardiovascular disease. The general practice setting is seen to offer greater flexibility, higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector. It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management. To date, significant descriptive research has been conducted exploring the demographics, roles, educational needs and issues facing practice nurses. However, there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes, clinician satisfaction and cost-effectiveness.

OBJECTIVES

This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults, as well as those with established cardiovascular disease or known cardiac risk factors.

SEARCH STRATEGY

A systematic literature search was performed using Medline (1966 - 2005), CINAHL (1982 -2005), Cochrane Controlled Trials Register (Issue 4, 2005) and the Joanna Briggs Institute Evidence Library. In addition, the reference lists of retrieved papers, conference proceedings and the Internet, were scrutinised for additional trials.

SELECTION CRITERIA

This review considered any English language randomised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors. Interventions conducted by specialist cardiac nurses in general practice were excluded. Outcomes measured included blood pressure, smoking cessation, total cholesterol, exercise, body weight/body mass index and cost-effectiveness.

RESULTS

Eighteen trials, reported in 33 papers, were included in the review. Ten trials investigated multifaceted interventions, while the remaining eight trials reported targeted interventions. Of the trials that reported multifaceted interventions, three trials investigated risk reduction in those with established cardiovascular disease, four trials focused on those with known cardiovascular disease risk factors and three trials included the general community. The eight trials which examined the efficacy of targeted interventions focused upon dietary intake (two trials), smoking cessation (three trials), weight reduction (one trial) and physical activity (two trials). The effect of both the multifaceted and targeted interventions on patient outcomes was variable. However, both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables. Improvements were demonstrated by most studies in blood pressure, cholesterol level, dietary intake and physical activity. The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions.

CONCLUSIONS

While interventions to reduce cardiovascular disease risk factors have produced variable results, they offer significant potential to assist patients in modifying their personal risk profile and should be developed. The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals. Further well-designed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost-effectiveness.