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Believe in better: opportunistic screening for obesity

Debbie Cook Bsc(Hons)
Nurse Practitioner
Chingford Medical Practice, London
Trustee, National Obesity Forum

Obesity is a major precursor of all the co-morbidities and can lead to social isolation and exclusion. Nurses in primary care may need to discuss a patient's weight when they attend surgery for health advice

With a billion overweight adults living in the UK, the obesity epidemic is the most easily recognisable complex chronic disease, and is set to become the most prevalent nutritional disorder of the Western world. This is a major drain on the health economy; and yet it is frequently ignored by both patients and health professionals. There is a myriad of reasons for this; not least a failure on the part of the nurse or the patient to recognise the severity of the condition.

Metabolic syndrome, driven by abdominal and central obesity, together with insulin resistance, is a constellation of risk factors which lead to the development of diseases including diabetes, ischaemic heart disease, hypertension and stroke. The economics are devastating and modelled projections from the National Audit Office project that the indirect costs of overweight and obesity could be as much as £28 bn by 2015.
In 2006/7, obesity and obesity-related illness was estimated to have cost £148 m in inpatient hospital stays alone.1
In 2008 the Department of Health (DH) proposed that a single, universal, integrated check for patients aged 40-74 years would be introduced to help identify such chronic diseases as obesity, vascular diseases and diabetes.2 Watered down by the primary care trusts (PCTs), these have yet to happen in many areas, partly due to the strains on the health economy and the fact that the mandate to see gains in life expectancy otherwise at risk is not yet in place.3

The Ideas and Development Agency is now anxious to promote improving the health of local communities by supporting and developing partnership working and reducing health inequalities.4

GPs will shortly become the new commissioners of healthcare and are already putting in place their public health plans for next year via the clinical commissioning boards. However, obesity as a long-term condition is taken seriously by primary healthcare staff. Part of the problem is the perception that somehow the obese person is to blame and that society has no ethical imperative to try to help. This is combined with a perception that as it is a self-inflicted condition and not a medical complaint it cannot be medically managed. The sequelae of obesity are profound and contribute to other conditions that GPs are actively treating.5

Overweight is defined as a body mass index (BMI) of 25-29.9 kg/m2, and obesity is defined as a BMI of over 30 kg/m2, and individuals with a high waist circumference (over 102 cm for men and over 88 cm for women) are also classed as high or very high risk.6 The Foresight report highlighted the multifactorial nature of the development of overweight and obesity; Blakemore and Froguel also identify perhaps 30 genes which are responsible.7,8

These include the so-called ‘thrifty gene', disruption in the leptin-melanocortin pathway and neuroregulatory disruptive mechanisms. These complex processes drive obesity-related disorders such as diabetes, cardiovascular disease, depression and sleep apnoea, largely by increasing insulin resistance.

When to bring up the conversation
Nurses in general practice are very well placed to initiate conversations about weight, obesity and risk, but many feel unsupported and confused about how to manage and where to refer patients.9

A study also highlighted that nurses may feel unsure about when to broach the subject with a patient, for fear of disrupting an otherwise harmonious relationship with the patient.10 Mercer and Tessier identified certain ambivalence among nurses to bring up the subject due to a frustration among nurses that patients were seldom motivated and so interventions were unlikely to lead to positive outcomes.11
Yet 90% of patients will visit their surgery within five years and primary care staff are ideally placed to start conversations about weight management.9 Haslam believes that after a visual assessment of their weight, patients should receive screening and brief intervention about their weight even if they consulted for an unrelated matter.12

How to discuss obesity with a patient who may not be aware it is a problem
Raising the subject of obesity takes sensitivity and tact. It is universally recognised that obese people suffer from grave, health-related quality of life issues, often connected to specific problems with pain, mobility and discomfort but also as a result of the existence of diabetes, ischaemic heart disease and even respiratory problems such as sleep apnoea and COPD.13

Budd et al point out that there are still many negative attitudes from healthcare professionals towards obesity, with GPs and nurses not always prepared to raise the question of weight for fear of reducing established good rapport with patients.14 A King's Fund report, published in 2011, found that many GPs do not view obesity as a medical problem, considering it to be a lifestyle issue.15 A small study also captured thoughts from obese patients trying to access help for their obesity.

Participants typically felt hesitant and reluctant to attend initially and then were very ambivalent about the quality of the services received.16 They were also very underwhelmed by the resources available to them; typically, general practice settings lack scales capable of weighing patients over 150 kg and waiting room chairs are often not suitable, without appropriate and sensitive facilities.

Raising such a sensitive issue takes empathy and good communication skills not always possessed in abundance by overworked, time-poor primary care staff.9 Dedicated clinics may be the answer, where patients could be directed to the ‘vascular risk clinic' or the ‘metabolic clinic' via the practice website. These terms are often seen to be less emotive and may be more acceptable to patients who are already facing social isolation and the worry that they will be similarly judged on contact with general practice professionals.8

It must be acknowledged that there is a contribution of socio-economic status to higher obesity prevalence, with overweight being relatively common among Turkish and Moroccan migrants, especially women. There is also a relevant causative link to education and unemployment.17 Obesity prevalence, and waist circumference and waist:hip ratio, vary substantially among populations in the UK, with black African women having the highest obesity prevalence using waist circumference.1 Advice must be timely, robust and given in a culturally sensitive fashion.18

Children who are obese at a young age potentially face the dual disadvantage of poor health and societal disapproval coupled with a low socio-economic background; parents lack the education and supportive measures to tackle the problem. Charities such as MEND offer inspirational help for obese children and their families, providing another resource that nurses can refer to if it is funded in the area (see Resources).
 
Symptoms
Breathlessness, sweating, intertrigo (inflammation of the skin folds), joint problems, hypertension, hyperglycaemia and snoring can all be caused by obesity. The lag-phase between developing simple obesity and the development is probably about ten years. Weight can have a dramatic effect on mood, with feelings of depression and frustration.19 One of the more hidden signs of obesity and the ensuing risks is obstructive sleep apnoea (OSA), an important corollary to insulin resistance and visceral obesity.20

Symptoms of overweight and obesity are obvious. But patients find it hard to understand that a ‘beer belly' can denote toxic visceral obesity. Or that those from ethnic minorities are significantly more at risk with a waist circumference that may appear to be in the ‘normal' range - Asians with a BMI of >23 should be considered as obese.

A lack of physical exercise can mean that patients are more at risk than their BMI or even waist circumference can suggest - many are put off by gyms and do not realise that even 10-15 minutes a day of sustained, moderate exercise like walking can reduce their risks.9 Some research shows the beneficial effects of increasing energy expenditure and the benefits of losing 10 kg in weight, with a corresponding drop in mortality of 20-25%.21,22

Giving the right advice
The treatment of a disease may be more difficult for patients to cope with than the short-term effects of the condition itself. When someone is severely obese, eating may be their only pleasure, and encouraging motivation to stick to a dietary regimen can be an uphill struggle. For patients from economically deprived backgrounds, fresh nutritional produce doesn't seem cheap.

It is an uphill struggle to persuade patients that they should be eating 60% carbohydrate, low-fat meals (as exemplified by the ‘Eatwell plate', see Resources) when they know as well as the healthcare professional that these meals are often more expensive, less palatable and less available. Eating either a low-fat diet, a very low calorie diet or even the post-bariatric surgery diet, can alter family dynamics so much that the patient, or their parent, gives up.

Further controversy exists. There is a body of evidence that low-carbohydrate diets and the advice from the last 50 years to choose foodstuffs from the ‘Eatwell' plate are, in fact, fuelling the obesity epidemic and accounting for much of the rise in diabetes in the Western world. Tattershall uses convincing evidence that deaths from diabetes (and those related to obesity) reduced during times of war, directly due to shortages in foodstuffs.23 Trying to deconstruct healthcare beliefs that may be ingrained form childhood are hard.
A unique aspect of treating those with obesity and overweight is that there is an enormous amount of information available from friends, family, the media and the internet. Desperate people get themselves into desperate situations and can be seduced into trying to find an answer and a quick fix (which could be potentially unsafe) rather than seeking support and advice from dietitians, medics and nurses.

Physical activity targets can seem impossible for many people (the current government recommendation is 225-300 minutes a week of moderate intensity, but even this is not enough on its own; dietary restriction is also required).24 Small changes moving towards an active lifestyle are reasonable suggestions.
Advice given must be realistic - we are asking patients to make huge changes to the very fabric of their lives and while they may agree absolutely with the desire to change, back in the outside world they find it impossible. This is a process known as ‘splitting', where they do not actually carry out their activity or diet to completion, despite their best efforts.25

Challenges
The government has pledged to try to improve the health of the nation with various initiatives. Patients who are overweight or obese may have unrealistic expectations of the amount of weight loss they can achieve. Dow encourages healthcare professionals to help embrace the clinically beneficial weight loss targets of 5-10%, based on an average weight of 100 kg.26 The challenge of dealing with obesity is the lack of confidence that anything will work. The measures taken by the government to tackle smoking have resulted in a decrease (finally - it has taken 30 years) in a decline in tobacco use and smoking-related deaths; yet, despite the latest NICE guidelines for obesity (updated in 2010), the prevalence of overweight and obesity continues to increase.

NICE recommends that healthcare professionals undergo relevant training and have competency assessments; but so far there is little evidence of this due to a lack of funding for education in general practice.6 There are many pockets of excellence, including Rotherham's Institute of Obesity where patients are treated holistically with access to a whole range of services. However, on the whole, many GPs and their clinical staff are left uncertain as to which interventions are the most effective in preventing and treating obesity, and unsure where to refer patients.27,28

In the wide-ranging recommendations provided by NICE, surgery is recommended if the patient has a BMI of >40 kg/m2, or a BMI of 35-40 kg/m2 and other significant disease. However, many PCTs are refusing to send patients for bariatric surgery even if they fulfil the criteria, and there are examples of patients being told to go away and put on more weight to get to a BMI of 50 before they will be accepted. These headlines hit the tabloids, further enhancing the despondency surrounding obesity management in primary care for both patients and healthcare professionals alike.

The evidence for the effect of bariatric surgery on obesity is convincing. The Swedish Obese Subjects trial demonstrated a clear benefit in morbidity and a study by Dixon showed not only a clear benefit to the weight of the patient but also a reduction in the prevalence of diabetes in this population.29,30 In 2008, Rubino proposed that diabetes should be treated as an operable intestinal disease, citing that the obesity-mediated diabetes would be ‘cured' by the surgical rearrangement of the gastrointestinal anatomy.31

Five years ago there were three pharmaceutical weapons to use in the fight against obesity, but since then rimonabant (a cannabinoid receptor) and sibutramine (an appetite suppressant) have been withdrawn, leaving only orlistat, a mildly effective lipase inhibitor.6 For other chronic, relapsing, long-term conditions we have a dearth of pharmacotherapy and access to a wide range of services.

Potential solutions for obesity include social support networks and working collaboratively with other agencies, including the commercial sector. Certainly, it is important that NHS staff and nurses in particular are trained to a high standard to deliver complex interventions for weight management, but doing nothing is no longer an option - we have to believe we can do better.

References
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4.    Improvement and Development Agency. Healthy Communities: Our Core Offer. London: IDA; 2010
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27.    Capehorn M. The award-winning integrated obesity service in Rotherham. Diabetes & Primary Care 2010;12(6).
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30.    Dixon (2008)
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