Motivating clinical treatment of obesity : methods, education, supervision and outcome

Sammanfattning: Obesity has become an important health problem worldwide. It increases the medical risks and affects daily living. Environmental factors such as diet and sedentary lifestyle are likely to be the cause. In Sweden, the number of obese people has nearly doubled during the past 20 years and now totals nearly 500 000. Obesity continued to increase in the Swedish population between 1996/97 and 2000/01. In economic terms, the direct health care cost may be approximately 2 % of the total expenditure for health and medical service and corresponds to a cost of approximately three billion SEK per year. The indirect cost due to absence from work and early retirement are at least equally high. The aim of this thesis was to study the effect of education, supervision of health care professionals and the implementation and outcome of a structural behaviourally oriented psycho-educational treatment programme to motivate clinical treatment of obesity. PAPER I describes an extensive structural behavioural treatment programme based on conventional treatment of patients. PAPER II analyses the effects of education, supervision of health professionals and the introduction of a structural behavioural treatment programme, and furthermore studies what factors facilitate the implementation and start up of obesity treatment programmes. PAPER III analyses and describes the results in four different group treatment settings in Swedish health care for long-term treatment of obese subjects. The four programmes included all the behaviour modification but differed regarding components and follow Up. PAPER IV explores analyses and describes the outcome and the problem of dropout among obese o utpatients in an academic obesity unit. It also illustrates the reasons for drop out, and investigates the patients' diagnoses, attendance at group meetings and at the complementary treatment. MAIN RESULTS AND FINDINGS: A structural behavioural treatment programme could motivate and facilitate the implementation of obesity treatment in large scale in health care and also increase the possibility for weight maintenance in the patients. Education of health care professionals is a good investment. Significantly more of those who started the behavioural treatment programme had previous theoretical education and clinical experience of obesity. Guidance and supervision of the health care professionals had a significant positive influence on starting up the treatment program. Significantly more of those who started up the behavioural treatment programme had a go-ahead from the management and support from physicians, and were part of a team or had a colleague to work with. In addition, they could also find the time to organise and plan the treatment. Education, workplace organisation, and a structural behavioural treatment programme, seem to be significant factors in facilitating and increasing the likelihood for a start. Outcome: The structural behavioural treatment programme produced a small weight reduction, maintained after two years, and the programme has been working satisfactorily as a cornerstone in different settings. The programme can be adjusted to various complementary treatments and produced weight reduction for healthy obese subjects as well as for obese subjects with medical complications. We found no significant differences between weight reduction after two years and the type of treatment studied, the amount of complementary treatment available and the number of health care professionals involved in the treatment. The effects of the complementary treatment gradually subside. After two years, the results of the weight reduction of the four treatments programmes are similar. However, this could at least partly be due to the fact that obese patients with more problems were recruited to the more comprehensive programmes. This study has highlighted the difficulties of long-term clinical treatment of obese outpatients even in the specialised obesity clinic. The findings demonstrate that educated and experienced personnel, together with an extended package of treatment options, are not enough to keep patients in treatment for two years. Even though the dropout rate was high, two thirds of the included subjects reduced their weight - a satisfactory result in a clinical setting. These results show that implementation of this structured behavioural treatment model for weight management is feasible and effective in different health care settings.