Nutritional counselling in general practice: a cost effective analysis

STUDY OBJECTIVE: To study the clinical and cost outcomes of providing nutritional counselling to patients with one or more of the following conditions: overweight, hypertension and type 2 diabetes. DESIGN: The study was designed as a random controlled trial. Consecutive patients were screened opportunistically for one or more of the above conditions and randomly allocated to one of two intervention groups (doctor/dietitian or dietitian) or a control group. Both intervention groups received six counselling sessions over 12 months from a dietitian. However, in the doctor/dietitian group it was the doctor and not the dietitian who invited the patient to join the study and the same doctor also reviewed progress at two of the six counselling sessions. SETTING: The study was conducted in a university group general practice set in a lower socioeconomic outer suburb of Perth, Western Australia. PATIENTS: Of the 273 patients randomly allocated to a study group, 198 were women. Age ranged from 25 to 65 years. Seventy eight per cent of patients resided in the lower two socioecnomic quartiles, 56 per cent described their occupation as home duties and 78 per cent were partnered. RESULTS: Both intervention groups reduced weight and blood pressure compared with the control group. Patients in the doctor/dietitian group were more likely to complete the 12 month programme than those in the dietitian group. Patients in the doctor/dietitian group lost an average of 6.7 kg at a cost of $A9.76 per kilogram, while the dietitian group lost 5.6 kg at a cost of $A7.30 per kilogram. CONCLUSION: General practitioners, in conjunction with a dietitian, can produce significant weight and blood pressure improvement by health promotion methods.     

One year follow-up of overweight and obese hypertensive adults following intensive lifestyle therapy

OBJECTIVE: To examine the long-term effect on weight maintenance and dietary habits of participants in a clinical trial for weight loss. SETTING: Community-based residents living in Maryland. PARTICIPANTS: Forty-four hypertensive, overweight adults who participated in a randomized clinical trial of weight loss. Participants were randomized to an intensive 'lifestyle' intervention or a 'monitoring' group. MAIN OUTCOME MEASURES: Weight, self-reported current intake of fat and fruit/fibre and self-reported barriers to maintain weight loss were assessed 1 year after the completion of the Diet, Exercise and Weight-loss Intervention Trial (DEW-IT) trial. ANALYSIS: t-tests were used to compare groups for differences in continuous variables and chi-square tests were used to compare groups for categorical variables. RESULTS: Fourty-two of the 44 DEW-IT subjects participated in the follow-up study. Overall, 55% (12/19) of the lifestyle intervention group remained at or below their baseline weight at 1 year, compared with 48% (11/23) of the monitoring group (P = 0.32). However, during that year, 95% (18/19) of the lifestyle intervention group and 52% (12/23) of the monitoring group gained weight from the end of the study. Both groups reported similar intake of fruits/vegetables (servings day(-1)), dietary fibre (g day(-1)) and fat (g day(-1)). CONCLUSIONS AND IMPLICATIONS: The majority of participants who lost weight during the trial regained weight during the course of 1 year. A successful intensive 2-month programme of lifestyle modification (DEW-IT) was ineffective for long-term maintenance of weight loss.     

Cost‐effectiveness of Weight Watchers and the Lighten Up to a Healthy Lifestyle program

Objective: Intensive weight loss programs that incorporate dietary counselling and exercise advice are popular and are supported by evidence of immediate weight loss benefits. We evaluate the cost‐effectiveness of two weight loss programs, Lighten Up to a Healthy Lifestyle and Weight Watchers. Methods: Health gains from prevention of chronic disease are modelled over the lifetime of the Australian population. These results are combined with estimates of intervention costs and cost offsets (due to reduced rates of lifestyle‐related diseases) to determine the dollars per disability‐adjusted life year (DALY) averted by each intervention program, from an Australian health sector perspective. Results: Both weight loss programs produced small improvements in population health compared to current practice. The time and travel associated with attending group‐counselling sessions, however, was costly for patients, and overall the cost‐effectiveness ratios for Lighten Up ($130,000/DALY) and Weight Watchers ($140,000/DALY) were high. Conclusion: Based on current evidence, these intensive behavioural counselling interventions are not very cost‐effective strategies for reducing obesity, and the potential benefits for population health are small. Implications: It will be critical to consider other strategies (e.g. changing the ‘obesogenic’ environment) or explore alternative methods of intervention delivery (e.g. Internet) to see if they offer a more cost‐effective approach by effectively reaching a high number of people at a low cost.     

Dietitian intervention improves lipid values and saves medication costs in men with combined hyperlipidemia and a history of niacin noncompliance

We asked if medical nutrition therapy (MNT) administered by registered dietitians could lead to beneficial clinical and financial outcomes in men with combined hyperlipidemia (hypercholesterolemia and hypertriglyceridemia). A retrospective chart review was conducted on 73 men with combined hyperlipidemia who were being considered for statin therapy because of a previous history of noncompliance with niacin therapy. Subjects participated in an 8-week dietitian intervention program as a qualifying requirement, before statin therapy. Patient records were reviewed to determine the beginning and ending serum lipid concentrations and the number and length of dietitian sessions. Complete information was available on 43 subjects, aged 60.7 +/- 10.1 years (mean +/- standard deviation). Total dietitian intervention time was 169 +/- 19 minutes in 2.7 +/- 0.6 sessions (range = 2 to 4 sessions) during 6.5 +/- 2.2 weeks of MNT (range = 4 to 8 weeks). MNT lowered levels of total cholesterol 11% (P < .001), low-density lipoprotein cholesterol 9% (P < .001), and triglycerides 22% (P < .0001) and body mass index 2% (P < .0001); MNT raised high-density lipoprotein cholesterol levels 4%. After dietitian intervention, only 15 of 30 eligible patients required antihyperlipidemic medications, which led to an annual cost savings of $27,449.10 or $638.35 per patient. A cost saving of $3.03 in statin therapy was realized for each dollar spent on MNT. We conclude that an average of 3 individualized dietitian visits of 1 hour each over an 8-week period has a beneficial effect in treating patients with combined hyperlipidemia and recommend consideration of MNT as a cost-effective intervention.     

An audit of dietary treatment modalities and weight loss outcomes in a specialist obesity clinic

Background: Obesity resistant to conventional treatment is often treated in specialist obesity clinics. Very little is known about treatment outcome or best management in this sector of the obese population and there appears to be a deficit of published audits from specialist obesity clinics. Method: Our clinic population was characterized in terms of BMI, gender, ethnicity and age as well as previous weight loss attempts, referral source and reasons for referral. The treatment modality was noted and outcome measured in terms of weight change; losses of 5% or more from presenting body weight were defined as weight loss. Results: It was found that 33% of the attending clinic population ( n =166) lost weight during their treatment phase, although no data was available on the long-term maintenance of this loss. Forty-three per cent lost 0–4% of their body weight, while 25% gained weight during their treatment phase. In the group that gained weight a greater number of patients (24%) reported depressive symptoms and required psychiatric or psychological intervention and/or antidepressive medication compared to only 4% of those patients who had lost weight. The most frequently used dietary modality was the low-fat diet, however, all of the treatment methods resulted in weight loss in some patients but not in others. Of particular interest were those patients who tried a number of different treatment methods before finding one which resulted in weight loss. Conclusion: This audit confirms that different treatment methods suit different individuals and highlights the importance of tailoring dietary advice to the individual patient.     

Comparison of Program Costs for Parent-Only and Family-Based Interventions for Pediatric Obesity in Medically Underserved Rural Settings

ABSTRACT:  Purpose: To compare the costs of parent-only and family-based group interventions for childhood obesity delivered through Cooperative Extension Services in rural communities. Methods: Ninety-three overweight or obese children (aged 8 to 14 years) and their parent(s) participated in this randomized controlled trial, which included a 4-month intervention and 6-month follow-up. Families were randomized to either a behavioral family-based intervention (n = 33), a behavioral parent-only intervention (n = 34), or a waitlist control condition (n = 26). Only program costs data for the parent-only and family-based programs are reported here (n = 67). Assessments were completed at baseline, post-treatment (month 4) and follow-up (month 10). The primary outcome measures were total program costs and cost per child for the parent-only and family interventions. Findings: Twenty-six families in the parent-only intervention and 24 families in the family intervention completed all 3 assessments. As reported previously, both intervention programs led to significantly greater decreases in weight status relative to the control condition at month 10 follow-up. There was no significant difference in weight status change between the parent-only and family interventions. Total program costs for the parent-only and family interventions were $13,546 and $20,928, respectively. Total cost per child for the parent-only and family interventions were $521 and $872, respectively. Conclusions: Parent-only interventions may be a cost-effective alternative treatment for pediatric obesity, especially for families in medically underserved settings.     

Symposium on Advances in Clinical Nutrition. The American College of Nutrition's 29th annual meeting. September 14-16, 1988, New Orleans,Louisiana. Abstracts.

Objective: To examine the safety and efficacy of a chitosan dietary supplement on body composition under free-living conditions.

Design: In a randomized, double-blinded, placebo-controlled dietary intervention protocol, subjects were assigned to a treatment group (TRT), a placebo group (PLA) and a control group (CTL).

Subjects: A total of 150 overweight adults enrolled; 134 (89.3%) completed the study; 111 (82.8%) were women who were similarly distributed in the three groups.

Intervention: The TRT group took six 500 mg chitosan capsules per day and both TRT and PLA groups wore pedometers during their waking hours and recorded daily step totals. The CTL group followed weight loss programs of their choice, and took the same baseline and ending tests.

Measures of Outcome: Outcome measures were Dual Energy X-ray Absorptiometry tests, fasting blood chemistries, and self-reported daily activity levels and caloric intakes.

Results: Compared to CTL, the TRT group lost more weight (?2.8 lbs vs. +0.8 lbs, p < 0.001) and fat mass (?2.6 lbs vs. +0.1 lbs, p = 0.006). Compared to PLA, the TRT group lost more weight (?2.8 lbs. vs. ?0.6 lbs, p = 0.03), % fat (?0.8% vs. +0.4%, p = 0.003), fat mass (?2.6 lbs vs. +0.6 lbs, p = 0.001) and had a greater body composition improvement index (BCI) (+2.4 lbs vs. ?1.9 lbs, p = 0.002).

Conclusions: These data provide evidence for the efficacy of a chitosan compound to facilitate the depletion of excess body fat under free-living conditions with minimal loss of fat-free or lean body mass.     

Enzyme-specific activities and mineral concentrations of the exocrine pancreas from female SHR/N-corpulent (cp) rats.

The purpose of this study was to evaluate a simplified weight loss program in which subjects were provided a widely available meal replacement product and its package insert information (Ultra Slim-Fast).

Weekly follow-up visits were carried out by non-physician personnel for weight measurement, distribution of product, and completion of a subjective questionnaire. No dietary counseling was provided. A total of 273 of 301 subjects (91%) completed 12 weeks of study. Men lost 50% (from 119 to 108% of ideal body weight) and women lost 35% (from 122 to 111% of ideal body weight) of excess body weight. Thirty-five patients who lost < 9 lbs in 12 weeks were considered non-adherent and were excluded from the next phase of the study during which 238 subjects were followed biweekly.

Despite a $25/week payment for participation nearly 44% of subjects dropped out or were judged non-compliant prior to the end of the study. At 116 weeks, 133 (97 females, 36 males) of 238 subjects remained in the study (44% of the initial population), with average weight loss from baseline of 13.6 +/? 10.5 lb in females and 14.0 +/? 10.5 lb in males.

The weight loss observed (approximately 10% of body weight) is significant and has been associated with important health benefits particularly for patients with hypertension and non-insulin dependent diabetes. The potential advantages of using meal replacements for mild obesity include wide availability to aid compliance, low cost and minimal professional intervention.     

E‐mail contact as an effective strategy in the maintenance of weight loss in adults

Background: Professional face‐to‐face contact is known to be beneficial in effective weight management, but costly, in supporting weight maintenance. Within the UK, studies have examined using the Internet to achieve weight loss; however, there is a need to evaluate the use of dietetic intervention via e‐mail to support the maintenance of weight loss in a National Health Service (NHS) setting. The present study aimed to assess the effects of dietetic support through e‐mail on weight loss maintenance on individuals who were successful in weight loss. Methods: Fifty‐five patients, who had lost ≥5% body weight, were assigned to either an intervention group (weekly e‐mail messages and monthly personal e‐mail message with reporting of weight, n = 28) or a control group (n = 27). The level of weight maintenance, plus dietary changes and the ability to maintain a level of activity, were recorded after 6 months. Results: At 6 months, the e‐mail group maintained an average weight loss of 10%, which was significantly (P = 0.05) greater than the mean percentage weight loss maintained by the control group (7.3%). The control group regained weight at a statistically significant greater velocity (P = 0.02) than the intervention group. There were correlations between the amount of fruits and vegetables (P = 0.07) eaten and exercise episodes (P = 0.01) against weight change in maintenance. Conclusions: The present study showed that dietetic support using e‐mail can be used effectively in reducing weight gain velocity and assisting in the maintenance of weight loss. It is a system that can be used in the UK NHS to reach many people.     

Comparing Costs of Telephone vs Face-to-Face Extended-Care Programs for the Management of Obesity in Rural Settings

BackgroundA major challenge after successful weight loss is continuing the behaviors required for long-term weight maintenance. This challenge can be exacerbated in rural areas with limited local support resources.ObjectiveThis study describes and compares program costs and cost effectiveness for 12-month extended-care lifestyle maintenance programs after an initial 6-month weight-loss program.DesignWe conducted a 1-year prospective randomized controlled clinical trial.Participants/settingThe study included 215 female participants age 50 years or older from rural areas who completed an initial 6-month lifestyle program for weight loss. The study was conducted from June 1, 2003 to May 31, 2007.InterventionThe intervention was delivered through local Cooperative Extension Service offices in rural Florida. Participants were randomly assigned to a 12-month extended-care program using either individual telephone counseling (n=67), group face-to-face counseling (n=74), or a mail/control group (n=74).Main outcome measuresProgram delivery costs, weight loss, and self-reported health status were directly assessed through questionnaires and program activity logs. Costs were estimated across a range of enrollment sizes to allow inferences beyond the study sample.Statistical analyses performedNonparametric and parametric tests of differences across groups for program outcomes were combined with direct program cost estimates and expected value calculations to determine which scales of operation favored alternative formats for lifestyle maintenance.ResultsMedian weight regain during the intervention year was 1.7 kg for participants in the face-to-face format, 2.1 kg for the telephone format, and 3.1 kg for the mail/control format. For a typical group size of 13 participants, the face-to-face format had higher fixed costs, which translated into higher overall program costs ($420 per participant) when compared with individual telephone counseling ($268 per participant) and control ($226 per participant) programs. Although the net weight lost after the 12-month maintenance program was higher for the face-to-face and telephone programs compared with the control group, the average cost per expected kilogram of weight lost was higher for the face-to-face program ($47/kg) compared with the other two programs (approximately $33/kg for telephone and control).ConclusionsBoth the scale of operations and local demand for programs are important considerations in selecting a delivery format for lifestyle maintenance. In this study, the telephone format had a lower cost but similar outcomes compared with the face-to-face format.     

Examination of costs for a lay health educator-delivered translation of the Diabetes Prevention Program in senior centers

Objective

Older adults in the U.S. have high rates of obesity. Despite the demonstrated efficacy of lifestyle interventions among older adults, lifestyle interventions are not widely implemented in community settings. Program delivery by lay health educators (LHEs) might support greater dissemination because of lower delivery cost and greater accessibility. We examined the costs of a LHE-delivered translation of the Diabetes Prevention Program (DPP) evidence-based lifestyle intervention for older adults in Arkansas senior centers.

Methods

This examination of costs used data from a cluster randomized control trial (conducted 2008–2010) in which 7 senior centers (116 participants) were randomized to implement a LHE-delivered 12-session translation of the DPP lifestyle intervention. We compiled direct lifestyle intervention implementation costs, including training, recruitment, materials, and ongoing intervention implementation support. Weight loss data (at 4-month follow-up) were collected from participants.

Results

Participant weight loss averaged 3.7 kg at 4-months. The total estimated cost to implement the lifestyle intervention is $2731 per senior center, or $165 per participant. The implementation cost per kilogram lost is $45.

Conclusions

A LHE-delivered DPP translation in senior centers is effective in achieving weight loss at low cost and offers promise for the dissemination of this evidence-based intervention.     

A Pilot Randomized Controlled Trial of a Partial Meal Replacement Preconception Weight Loss Program for Women with Overweight and Obesity

About half of Australian women have a body mass index in the overweight or obese range at the start of pregnancy, with serious consequences including preterm birth, gestational hypertension and diabetes, caesarean section, stillbirth, and childhood obesity. Trials to limit weight gain during pregnancy have had limited success and reducing weight before pregnancy has greater potential to improve outcomes. The PreBabe Pilot study was a randomised controlled pilot trial to assess the feasibility, acceptability and potential weight loss achieved using a commercial online partial meal replacement program, (MR) vs. telephone-based conventional dietary advice, (DA) for pre-conception weight-loss over a 10-week period. Women 18–40 years of age with a BMI ≥ 25 kg/m² planning pregnancy within the next 6 to 12 months were included in the study. All participants had three clinic visits with a dietitian and one obstetric consultation. In total, 50 women were enrolled in the study between June 2018 and October 2019–26 in MR and 24 in DA. Study retention at the end of 10 week intervention 81% in the MR arm and 75% in the DA arm. In the-intention-to-treat analysis, women using meal replacements lost on average 5.4 ± 3.1% body weight compared to 2.3 ± 4.2% for women receiving conventional advice (p = 0.029). Over 80% of women in the MR arm rated the support received as excellent, compared to 39% in the DA arm (p < 0.001). Women assigned to the MR intervention were more likely to achieve pregnancy within 12 months of the 10 week intervention (57% (12 of 21) women assigned to MR intervention vs. 22% (4 of 18) assigned to the DA group (p = 0.049) became pregnant). The findings suggest that a weight loss intervention using meal replacements in the preconception period was acceptable and may result in greater weight loss than conventional dietary advice alone.     

Can sustained weight loss in overweight individuals reduce the risk of diabetes mellitus?

Although rates of adult-onset diabetes mellitus increase with increasing obesity, there is little evidence that weight loss in overweight individuals can reduce their risk of developing diabetes. Using data from the Framingham Study, we examined the effects of sustained and nonsustained weight loss on risk of diabetes mellitus among 618 overweight (body mass index > or =27) subjects 30-50 years of age. To separate sustained from nonsustained weight loss, we examined weight change in two consecutive 8-year periods. Subjects who had stable weight (+/- 1 lb per year) during both periods served as the referent group for all analyses. Sustained weight loss led to a 37% lower risk of diabetes [relative risk (RR) = 0.63; 95% confidence interval = 0.34-1.2], and this effect was stronger for more obese (body mass index > or =29) subjects (RR = 0.38; 95% confidence interval = 0.18-0.81). Those who lost 8.1-15 lb had a 33% reduction in diabetes risk, whereas those losing more had a 51% reduction in risk. Regardless of the amount of weight lost, those who regained the lost weight had no reduction in diabetes risk (RR = 1.1 and 1.2 for those who lost 8.1-15 and >15 lb, respectively). We conclude that a modest amount of sustained weight loss can substantially reduce the risk of diabetes mellitus in overweight individuals.     

Effect of the Lifestyle,Exercise, and Nutrition (LEAN) Study on Long-Term Weight Loss Maintenance in Women with Breast Cancer

Lifestyle interventions among breast cancer survivors with obesity have demonstrated successful short-term weight loss, but data on long-term weight maintenance are limited. We evaluated long-term weight loss maintenance in 100 breast cancer survivors with overweight/obesity in the efficacious six-month Lifestyle, Exercise, and Nutrition (LEAN) Study (intervention = 67; usual care = 33). Measured baseline and six-month weights were available for 92 women. Long-term weight data were obtained from electronic health records. We assessed weight trajectories between study completion (2012–2013) and July 2019 using growth curve analyses. Over up to eight years (mean = 5.9, SD = 1.9) of post-intervention follow-up, both the intervention (n = 60) and usual care (n = 32) groups declined in body weight. Controlling for body weight at study completion, the yearly weight loss rate in the intervention and usual care groups was –0.20 kg (−0.2%/year) (95% CI: 0.06, 0.33, p = 0.004) and −0.32 kg (−0.4%/year) (95% CI: 0.12, 0.53, p = 0.002), respectively; mean weight change did not differ between groups (p = 0.31). It was encouraging that both groups maintained their original intervention period weight loss (6% intervention, 2% usual care) and had modest weight loss during long-term follow-up. Breast cancer survivors in the LEAN Study, regardless of randomization, avoided long-term weight gain following study completion.     

A randomized controlled trial of a public health nurse directed treatment program for rural patients with high blood cholesterol

BACKGROUND: Many rural residents do not have access to high-quality nutrition counseling for high blood cholesterol. The objective of this study was to assess the effectiveness of an intervention program designed to facilitate dietary counseling for hypercholesterolemia by rural public health nurses. METHODS: Eight health departments (216 participants) were randomized to give the special intervention (SI) and nine (252 participants) to give the minimal intervention (MI). The SI consisted of three individual diet counseling sessions given by a public health nurse, using a structured dietary intervention (Food for Heart Program), referral to a nutritionist if lipid goals were not achieved at 3-month follow-up, and a reinforcement phone call and newsletters. Diet was assessed by the Dietary Risk Assessment (DRA), a validated food frequency questionnaire, at baseline, 3-, and 12-month follow-up; blood lipids and weight were assessed at baseline, 3-, 6-, and 12-month follow-up. RESULTS: Participants were largely female (71%), older (mean age 55), and white (80%). At 3-month follow-up, the average reduction (indicating dietary improvement) in total Dietary Risk Assessment score was 3.7 units greater in the SI group (95% confidence interval [CI] 1.9 to 5.5, P = 0.0006), while both groups experienced a similar reduction in blood cholesterol, 14.1 mg/dL (0.37 mmol/L) for SI and 14.5 mg/dL (0.38 mmol/L) for minimal intervention group (difference -0.4 mg/dL [-0.010 mmol/L], 95% CI -12.5 to 11.7 [-0.32 to 0.30], P = 0.9). At 12-month follow-up, the reduction in total Dietary Risk Assessment score was 2.1 units greater in the SI group (95% CI 0.8 to 3.5, P = 0.005), while the reduction in blood cholesterol was similar in both groups, 18.4 mg/dL (0.48 mmol/L) for SI and 15.6 mg/dL (0.40 mmol/L) for minimal intervention group (difference 2.8 mg/dL [0.07 mmol/L], 95% CI -7.5 to 13.1 [-0.19 to 0.34], P = 0.6). During follow-up, weight loss was greater in the SI group; the difference between groups was statistically significant at 3 (1.9 lb [0.86 kg], 95% CI 0.3 to 3.4 [0.14 to 1.55], P = 0.022) and 6 months (2.1 lb [0.95 kg], 95% CI 0.1 to 4.1 [0.04 to 1.86], P = 0.04). At 12 months, the difference was not significant (1.6 lb [0.73 kg], 95% CI -0.05 to 3.7 [-0.02 to 1.68], P = 0.13). CONCLUSIONS: Improvement in self-reported dietary intake was significantly greater in the SI group, while reduction in blood cholesterol was similar in both groups.     

新生儿体重下降与分娩期产妇输液量的相关性探讨

目的:探讨产妇在分娩过程中的输液量与新生儿产后72 h内体重下降的相关性。方法:记录109名产妇分娩过程中经口以及经静脉的液体入量,在产后3天内每隔12 h测量新生儿体重,此后每天测1次至第14天;此外还需要称量新生儿3天的排出量(大小便)。结果:96例出生后60 h新生儿的平均体重下降(6.57±2.51)%;根据产妇输液量进行分组之后两组比较,低输液量组(≤1 200 ml)新生儿体重下降5.51%,高输液量组(>1 200 ml)新生儿体重下降6.93%,差异有统计学意义(P=0.03)。在第24 h新生儿排出量与新生儿体重下降百分比正相关(P<0.001),分娩期间最后2 h产妇输液量与新生儿排出量正相关(P=0.012),在第72 h新生儿体重下降重量与产妇总输液量正相关(P=0.007)。结论:产妇静脉输液时间及输液量与新生儿排出量及体重下降相关。新生儿在出生后24 h内通过排尿调节体内的液体状态,因此建议衡量新生儿体重改变的基础体重在出生后24 h测量而不是使用出生时体重。     

Buying time II: an economic evaluation of a joint NHS/Social Services residential rehabilitation unit for older people on discharge from hospital

The study's aim was to investigate the cost-effectiveness of an NHS/Social Services short-term residential rehabilitation unit (a form of intermediate care) for older people on discharge from community hospital compared with 'usual' community services. An economic evaluation was conducted alongside a prospective controlled trial, which explored the effectiveness of a rehabilitation unit in a practice setting. The aim of the unit was to help individuals regain independence. A matched control group went home from hospital with the health/social care services they would ordinarily receive. The research was conducted in two matched geographical areas in Devon: one with a rehabilitation unit, one without. Participants were recruited from January 1999 to October 2000 in 10 community hospitals and their eligibility determined using the unit's strict inclusion/exclusion criteria, including 55 years or older and likely to benefit from a short-term rehabilitation programme: potential to improve, realistic, achievable goals, motivation to participate. Ninety-four people were recruited to the intervention and 112 to the control group. Details were collated of the NHS and Social Services resources participants used over a 12-month follow-up. The cost of the resource use was compared between those who went to the unit and those who went straight home. Overall, costs were very similar between the two groups. Aggregated mean NHS/Social Services costs for the 12 months of follow-up were pound 8542.28 for the intervention group and pound 8510.68 for the control. However, there was a clear 'seesaw' effect between the NHS and Social Services: the cost of the unit option fell more heavily on Social Services (pound 5011.56, whereas pound 3530.72 to the NHS), the community option more so on the NHS (pound 5146.74, whereas pound 3363.94 to Social Services). This suggests that residential rehabilitation for older people is no more cost-effective over a year after discharge from community hospital than usual community services. The variability in cost burden between the NHS and Social Services has implications for 'who pays' and being sure that agencies share both pain and gain.     

Evaluation of attendance and weight loss in an intensive weight management clinic compared to standard dietetic care

Background:  With increasing rates of obesity, the effectiveness of weight reduction programmes come under increasing scrutiny. This nonrandomized study aimed to review the effectiveness of two weight loss clinics in terms of percent and rate of weight loss, and attendance.
Methods:  Data were collected on consecutive obese patients, attending either an intensive weight management clinic (IWMC) or a general dietetic outpatient clinic. The IWMC had a structured approach with six once-a-month appointments, a signed agreement to attend, an initial screening of readiness to change and consistent advice from one dietitian. The general clinic was less structured, had more ad hoc follow up and did not guarantee one dietitian.
Results:  Seventy percent of patients referred were female [mean (SD) age 48 (14.2) years]. Thirty-three percent (103/313) of all patients referred did not book an appointment. Of those attending with a body mass index ≥ 32 kg m⁻², 55% were seen in the general and 45% in the intensive clinic, but only 19% and 53%, respectively, completed the programmes. The total amount and rate of weight loss did not differ significantly between clinics. However, analysis using the last recorded weight revealed a median weight reduction of 1.8% (interquartile range = −5.6–0) at the median rate of −0.4 kg month⁻¹(−1–0) in the intensive clinic, compared to no overall weight loss in the general clinic ( P  ≤ 0.001).
Conclusions:  A more structured approach and initial screening of readiness to change is likely to achieve better weight loss results and therefore will comprise a better use of dietetic time than including obese patients in general clinics.