Abstract
The Partnership Overweight Netherlands (PON) is a collaboration between 18 partners, which are national organizations of health care providers, health insurance companies and patient organizations. The PON published an integrated health care standard for obesity in November 2010.
The integrated health care standard for obesity involves strategies for diagnosis and early detection of high-risk individuals as well as appropriate combined lifestyle interventions for those who are overweight and obese and, when appropriate, additional medical therapies.
The PON works towards a standard that transcends traditional boundaries of conventional health care systems and health care professions but, instead, focuses on competences of groups of health professionals who organize care from a patient-oriented perspective.
Introduction
In the Netherlands, overweight and obesity have reached epidemic proportions. The prevalence of overweight including obesity among men has increased from 37% in 1981 to 51% in 2009 and among women from 30% to 42%.1 In children, these prevalences have risen between 1980 and 2003 from 4% to 15% in boys and from 7% to 18% in girls.2
One of the objectives of the Dutch Ministry of Health, Welfare and Sport is to reduce the prevalence of overweight, obesity and related chronic diseases in The Netherlands. The focus is both on prevention and on management.3
In 2008, the Partnership Overweight Netherlands (PON) was established. The PON is a collaboration between 18 partners, which are national organizations of health care providers, health insurance companies and patient organizations.
Objective of the PON is to facilitate the development and implementation of an integrated health care standard for the management and prevention of obesity.
The integrated health care standard for obesity
A care standard is a general framework outlining the treatment of people with a specific condition. It describes the norms (based on guidelines and legislation) that good care for a specific condition must meet in terms of both content and process. This makes it clear to all market parties what they can expect from the treatment course.
The integrated health care standard for obesity involves strategies for diagnosis and early detection of high-risk individuals as well as appropriate combined lifestyle interventions for those who are overweight and obese and, when appropriate, additional medical therapies.
The PON works towards a standard that transcends traditional boundaries of conventional health care systems and health care professions but, instead, focuses on competences of groups of health professionals who organize care from a patient-oriented perspective. The PON collaborates with organizations responsible for prevention and management of related chronic diseases like type 2 diabetes mellitus and cardiovascular diseases (CVDs).
The PON developed flow charts for different age groups and different degrees of overweight and obesity to facilitate the implementation of the national clinical guideline ‘Diagnosis and treatment of obesity in adults and children’ with implications for the organization, quality assurance and reimbursement of care and prevention.4
These flow charts are described for different levels of weight-related health risk that, for adults, is based on BMI, waist circumference and co-morbidity. Figure 1. shows the classification of weight-related health risks for adults. The risk assessment for diabetes and CVD is similar to the STOP-NIDDM risk score5 and includes the waist circumference, family history of type 2 diabetes mellitus, the presence of hypertension, physical inactivity as well as the diagnosis of impaired fasting glucose.
Classification of weight-related health risks for adults based on BMI, risk factors for type 2 diabetes mellitus (DM2) and cardiovascular disease (CVD) and co-morbidities
Classification of weight-related health risks for adults based on BMI, risk factors for type 2 diabetes mellitus (DM2) and cardiovascular disease (CVD) and co-morbidities
These increasing levels of weight-related health risk are related to increasing levels of care following the principles of stepped care. This means that the duration and intensity of treatments increase with the weight-related health risk. The principles of health care are based on self-management that is facilitated by a multidisciplinary team of health care professionals. There is one case manager who coordinates the treatment that is described in an individual health care plan that is developed with the patient. Basically, there is 1 year of initial treatment based on a weight loss goal of 5–10% followed by 1 year of relapse prevention and subsequently by long-term behavioural and weight maintenance support. The preferred treatment is a combined lifestyle intervention, targeting nutrition, physical activity and behaviour change.
Figure 2 illustrates the pyramid of management and prevention of obesity based on the levels of weight-related health risk and the corresponding intensity of interventions for adults.
Obesity prevention and management pyramid based onweight weight-related health risk for adults
Obesity prevention and management pyramid based onweight weight-related health risk for adults
Method of working
All activities of the PON are supported by a management team (the authors of this paper). Yearly four meetings with representatives of the 18 partners take place. All partners have signed a declaration of intent to show their commitment to the shared goals.
Multidisciplinary working groups are formed each year to work on answering diverse questions and on distinctive aspects of the flow charts. The results of the working groups and the meetings of the partners were summarized during a yearly conference in the period 2008–10. In November 2010, the integrated health care standard for obesity (‘Zorgstandaard Obesitas’) was published with the consent of all participating organizations of patients and health care providers as well as the Ministry of Health, Welfare and Sport.6
Partners and associated organizations
In the 18 partners of the PON, the following professions of health care providers are represented: GPs, dieticians, physical therapists, psychologists, doctors and nurses in youth health care, pediatricians, doctors in internal medicine, physicians in occupational health, pharmacists, nurses and surgeons.
The patients are represented by the Dutch Obesity Association and the more general federation for patient and consumer organizations. The Dutch health insurance companies are represented by their national organization.
The partners of the PON are
ActiZ, Association of Health Care Providers
Association of Surgeons of the Netherlands (NVvH)
Community Health Centers (GGD Nederland)
Dutch Association of General Practitioners (LHV)
Dutch Association of Internal Medicine (NIV)
Dutch College of General Practitioners (NHG)
Dutch Dietetic Association (NVD)
Dutch Health Care Insurance Association (ZN)
Dutch Obesity Association (NOV; obese patients organization)
Dutch Professional Association of Psychologists (NIP)
Dutch Society of Physicians in Occupational Health (NVAB)
Dutch Medical Association for Youth Health Care (AJN)
Federation of Patients and Consumer Organizations in the Netherlands (NPCF)
Pediatric Association of the Netherlands (NVK)
Royal Dutch Association for the Advancement of Pharmacy (KNMP)
Royal Dutch Medical Association (KNMG)
Royal Dutch Society for Physical Therapy (KNGF)
V&VN Dutch Nurses’ Association
The participants in the working groups of the PON consist of representatives of the 18 partner organizations and of relevant experts of organizations that are not a partner of the PON. These include for example experts in statistics, medical ethics and self-management. The PON also has close ties with the Dutch platform that is responsible for the coordination of the development of chronic disease management models for related chronic diseases such as obesity, type 2 diabetes mellitus and CVDs.
Role of primary care and family practice in the management of obesity
For the majority of overweight and obese patients, management by primary care health professionals is warranted. Since the Dutch evidence-based guideline for the treatment of obesity in children and adults was published in 2007, subsequent reviews have confirmed that obesity can effectively be managed in primary health care provided that a multidisciplinary team supporting lifestyle changes in patients is available.7,8 This is especially the case in The Netherlands where the primary care physician is an important gatekeeper of referrals to specialized care and plays an important role in providing nutrition guidance.9 Only for a selection of patients with an extreme weight-related health risk, there is the necessity of specialized health care although recent studies suggest that also many of these patients can be successfully managed in primary health care.10,11
Future developments
In the period 2011–12, the PON has taken on some new assignments such as developing quality criteria for the different levels of health care as well as describing the competences for the health care providers. Eventually, the integrated health care standard for obesity will be integrated with those for CVDs and type 2 diabetes mellitus. A more in depth standard for nutritional interventions in chronic disease management and prevention is also planned. Finally, a patient version of the standard will be produced. The aim is to have all levels of care to be covered by basic health care insurance schemes but this will be dependent upon political decision making and availability of financial resources for health care.
It can be concluded that the Dutch integrated health care standard for obesity management and prevention is a unique collaboration of health care professionals and patients.
Declaration
Funding: Dutch Ministry of Health, Welfare and Sport.
Ethical approval: none.
Conflict of interest: none.
The participation of partner organizations and members of the various working groups is greatly appreciated.
