Case study: POWeR+ programme motivates people to engage with online weight management
Addressing the national issue of obesity with online support
According to the 2019 Health Survey for England, more than 60% of adults are either overweight or obese, with around one quarter considered to be obese. Being overweight or obese is linked to a number of serious health conditions including type 2 diabetes, coronary heart disease, stroke and some cancers. Excess weight is therefore a significant health issue but weight loss can help improve a person’s health.
Current NICE guidelines recommend that people with obesity should be referred to a weight management programme to help them lose weight. In support of this, the NHS Long Term Plan aims to provide support for and access to weight management services in primary care for people with a diagnosis of type 2 diabetes or hypertension with a body mass index (BMI) of 30 or more.
In addition to making changes to diet and increasing exercise, intensive behavioural counselling followed by continued support is considered an effective weight loss method. With funding from the NIHR Health Technology Assessment (HTA) Programme, researchers have found that an online behavioural counselling tool with nurse support is effective at helping people lose weight. NIHR Senior Investigators at the University of Southampton, Paul Little, Professor of Primary Care Research and Lucy Yardley, Professor of Health Psychology, led the research team in the development and trialling of the Positive Online Weight Reduction (POWeR)+ online programme. Their results have been published in The Lancet Diabetes & Endocrinology.
This research built upon the team’s previously developed POWeR programme, also funded by the NIHR, which provided an online tool for users to set their own dietary and physical activity goals, record their weight and track their weight loss. The programme supports users with online sessions based on cognitive-behavioural techniques to help alter their behaviours.
In view of the limited NHS staff to support patients’ weight loss, the new study investigated the benefits and costs of different approaches to engage people in an online weight loss programme with minimal support from healthcare professionals. Commenting on the study, Professor Little said: “Primary care teams are very hard pressed at the best of times, and given the need to help patients manage the growing problem of obesity – perhaps one of the most pressing public health problems of our time – it is vital for the NHS to find workable, effective and efficient ways to support patients.”
“We are delighted to have shown that POWeR is one such tool, liked by patients, and requiring minimal support from health care staff – and is now available for use in the NHS.”
Giving patients and practitioners the tools to maintain weight loss
The POWeR+ team went on to recruit more than 800 adults with a BMI of 30 or over and randomly allocated them to one of three interventions. The control group received dietary advice and follow-up sessions with a nurse. The remaining two groups received the web-based POWeR+ programme and either face-to-face nurse support or email or telephone follow-up with a nurse.
After 12 months all three groups had lost weight, with the two groups receiving the POWeR+ intervention losing around 1.5kg more than the control group. More people in the POWeR+ group with email or telephone nurse support had achieved clinically important weight loss of 5% or more by 12 months than in the POWeR+ face-to-face and control groups.
In an analysis of interviews with healthcare professionals involved in the trial, some nurses said that POWeR+ had a positive impact on their practices, making them more aware of the damaging impacts of obesity on physical and mental health. One nurse commented: “We’ve had one lady who’s gone from being hypertensive on two therapies to now on no medication at all ... that was a huge sort of wake-up call to me actually how much difference you could make to someone’s life.”
As POWeR+ was designed to motivate people and alter their behaviours, public and patient involvement and extensive qualitative research into users’ views during its development (using the ‘Person-Based Approach’ pioneered by the Southampton research team) helped ensure it was feasible and engaging for those it intended to help. As a result, there was good uptake by people with a wide range of backgrounds and participants reported that using POWeR+ made them feel significantly more able to manage their condition. One participant commented that: “It gives you choices as well, which way you go. So I feel very positive about it. I thought it was very good actually.” Another participant said:
“I like that it’s a long term plan that you can stick to, rather than a really strict regime that as soon as you stop, it comes back on.”
The results confirmed that when combined with brief nurse support, the POWeR+ programme offered a feasible primary care weight loss intervention that could make a clinically important contribution to the management of obesity.
The positive impact of POWeR+
The team’s research unit is a member of the NIHR School for Primary Care Research, which helps leading primary care researchers across England to collaborate on studies, like POWeR+, that have the potential to impact on both policy and general practice for the whole country. The project’s results are expected to be considered in the next update of the NICE public health guidance on ‘Managing overweight and obesity in adults - lifestyle weight management services’.
A key element of research funded by the NIHR HTA Programme is for healthcare treatments to be tested for their cost-effectiveness before they can be used within the NHS. With regard to weight loss programmes, NICE guidelines state that “12 week interventions costing £100 or less are cost effective if the weight loss is maintained for life and if at least 1kg of weight is lost and this is maintained for life.”
The cost of delivering both POWeR+ interventions was much lower than this threshold, and as brief email and telephone support achieved similar levels of weight loss at a lower cost, it was more cost-effective than providing face-to-face support.
Anthony H Barnett, Emeritus Professor of Medicine at University of Birmingham and Heart of England NHS Foundation Trust, said of the study:
“Novel approaches to weight management, which are both clinically and cost-effective, are to be welcomed and will provide additional management options in a resource-limited NHS.”
Initially POWeR+ was made available to the public through uptake by local authorities. For example, Hampshire County Council incorporated POWeR+ into its wider social media campaign to encourage and support weight loss, offering access to POWeR+ free of charge, by GP referral, to adults living in Hampshire with a BMI of 25 or above.
The team then secured a grant from Innovate UK, which supports the development of pioneering research into successful services, to develop POWeR+ into an app for national and international dissemination. University of Southampton researchers, Dr Judy Joseph and Dr Katherine Bradbury, have worked with Changing Health, an organisation providing digital interventions for diabetes management to the NHS, to adapt the POWeR+ content for sustainable, scalable delivery as an app.
Describing how POWeR+ is being delivered to patients, Professor Yardley said: “The POWeR+ web app is already being delivered to 4,000 patients as part of the NHS Diabetes Prevention Programme, which will be rolled out to a further 12,000 patients over the next 5 years. NHS England has adopted POWeR+ as the weight management element of the National Diabetes Education Programme, delivering POWeR+ to 4,000 patients.”
“POWeR+ will continue be rolled out through the NHS to 600,000 diabetic patients from 2020–2025.”
The success of the POWeR+ design has also led a number of other studies to adapt the programme to encourage weight loss among specific patient groups, for example, for postnatal women and as part of the management of hypertension.
The study was funded by NIHR’s Health Technology Assessment (HTA) Programme.
More information about the study is available on the NIHR’s Funding & Awards website.
The original POWeR programme was funded by the NIHR Research for Patient Benefit Programme.
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