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Supporting patients to lose weight: how you can help

Michele Wynne provides an overview of how practice nurses play a pivotal role in obesity management, shares best-practice techniques surrounding weight management services, and discusses how obese patients can be treated and motivated to make life-enhancing changes

Michele Wynne
RGN
Senior Practice Nurse
Southview Park Surgery
Basildon
Essex

Practice nurses are exceptionally well placed to safeguard the health of patients by helping them to lose weight. Due to this relationship, practice nurses are able to offer support and advice to obese patients, or those concerned about their weight. In 1980, 8% of women in England were classified as obese, compared with 6% of men. By 1998, the prevalence of obesity had nearly trebled to 21% of women and 17% of men and there is no sign that the upward trend is moderating.(1)  Currently, over half of women and about two-thirds of men are either overweight or obese. The growth of obesity in England reflects a worldwide trend, which is most marked in, though not restricted to, developed countries. Most evidence suggests that the main reason for the rising prevalence is a combination of less active lifestyles and changes in eating patterns.(1)
Professor Klim McPherson, Oxford University, and Tim Marsh, National Heart Foundation, predict that within 15 years 86% of men will be overweight - but not necessarily obese - and within 20 years, 70% of women.(2)

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Initial target group
One of the first steps in implementing a weight management service is to select a target group of patients that might be appropriate for the service. This can be initiated by reviewing the height and weight register and identifying those patients with a body mass index (BMI) of over 35. Along with weight, and the measurement of waist circumference, BMI recording gives a clear indication of the potential risks to the patient of developing obesity-related conditions such as type 2 diabetes, heart disease, stroke, renal and liver disease, to name but a few.
By targeting a specific group of patients, the practice staff are able to concentrate on providing an efficient and effective service that benefits both the patient and practitioner.
Many of the benefits of engaging people in living healthier lives occur in the long term, but there are also immediate and short-term benefits such as reducing the demand for health services, especially in those areas where capacity is seriously constrained such as acute services.(3)

First visit
The first visit to a dedicated weight management service is often a traumatic experience. Many patients will have been battling with their weight for many years and often find it very difficult knowing that they are about to confront this particular "demon". A large number of patients tend to feel humiliated that their weight is being made such an important focus in their lives, something they may previously have tried to ignore.
Keeping this in mind, it is important that the patients feel comfortable discussing such an intimate topic. It is essential that the patient is not rushed and that they are given a sufficient amount of time to discuss the issues that are important to them.
During the first appointment a baseline record should be made of the patient's height, weight, blood pressure, waist measurement and BMI. A blood test should also be arranged for full blood count, urea and blood chemistry analysis to rule out any organic cause of their weight problem.
Once all the baseline observations are recorded, time is spent discussing the patient's relationship with food, their perceptions of how they have gained weight, and what they think the main issues are.
Obesity is a complex medical problem, and it is clear that superficial interventions such as the distribution of a diet sheet to an obese patient are unlikely to work. Specialist skills and knowledge are needed to fully engage with obesity as a psychological and behavioural as well as a physiological problem. It has been likened by some to alcoholism, and requires similarly holistic treatment programmes.(4)

Questioning
A good way for the practitioner to understand the patient's relationship with food is to use frivolous/indirect questioning, eg, "Do you prefer sweet or savoury?" or "What would your death-row meal be?" This may give the practitioner clear indications of where the patient's problems lie and what treatment approaches may be necessary, which in turn enhances the possibility of a patient being given advice that is tailored to their needs.
After the initial questions an individual weight loss goal is usually set. A rule of thumb is that the goals set for any task must be realistic; because of this the goals may seem easily achievable. However, if a patient with a high BMI is told that they must lose half their body weight, they immediately become disinterested and unmotivated. A patient will not in reality lose any weight, and some may even gain weight as they view their situation to be hopeless.

Portion control
In the clinic, the necessity of portion control and monitoring nutritional value should be reinforced to the patient. It is important to highlight that patients should not try to eliminate food groups but eat foods with a high nutritional content until satiety is reached. It is at this stage that a patient will find changing their behaviour to be a large and often difficult step. Patients therefore need to be encouraged to eat only until they are full, eat foods that provide them with nourishment and help them change their attitude towards food. If a patient is able to change their behaviour towards the size of their portions, noticeable results will be achieved.
It is often good practice to encourage patients to read food labels for fat content. By having examples of labels in the clinic for the patient to see, they are able to understand what information to look for and will be clear about their task ahead. It is advisable to tell the patient to allow extra shopping time, so that they are able to read as they shop!

Pharmacotherapy
Pharmacotherapy has an important role to play in the management of the obese patient, and for medically suitable patients (those with no contraindications) very positive results are achievable.
The National Institute for Health and Clinical Excellence (NICE) recommends two treatments for obesity: sibutramine (Reductil [Abbott]) and orlistat (Xenical [Roche]). Rimonabant (Acomplia [Sanofi-Aventis]) is also available in the UK.
Sibutramine can aid the patient in achieving very substantial, sustained losses. This is achieved through helping the patient to regain a normal eating cycle by enhancing satiety and making patients who overeat feel full with less food. Orlistat works by inhibiting the action of the GI tract and so reduces the absorption of dietary fat. Orlistat has also shown some success in the Basildon clinic.(5) Rimonabant acts both centrally and peripherally by blocking CB1 receptors within the brain. Although available rimonabant has not been used to date. (See Peter Burrill's article on the RIO-Diabetes study on page 42 for more information on rimonabant.)
Pharmacotherapy has a positive effect on the motivation of the patient, because it makes them view their weight problem in a different light. They suddenly see their weight problem as a real health issue rather than them just being overweight. The general attitude is that "if I need pills, it must be serious".

Follow-up and sustainability
After the first visit patients are seen very regularly. Visits are encouraged every two weeks and the patients are also told that they are able to contact their practitioner at anytime if they need to.
Patients are encouraged to use self-help tools, such as the Change for Life website (see Resources). Change for Life is a web resource created by medical and behavioural change experts for healthcare professionals that provides an online programme to help patients take charge of their eating behaviour and make positive changes to support healthy weight loss. Websites such as Change for Life give patients comprehensive, reliable and specific information and can provide valuable tools such as downloadable food diaries, portion guides, goal setting tips and motivational information. Such tools can be useful to keep patients focused and motivated between visits. Well-motivated patients become a sponge for knowledge and information surrounding weight management, but care must be taken to ensure that the patients don't become confused by the vast amount of information available.
In addition to websites, subscriber slimming clubs are also available, but a conflict of information can occur if a patient decides to combine both types of programmes.
Once the patient begins to lose weight, it is important that they are congratulated and that they remain motivated. It is common for most patients to have an impressive weight loss in the first few weeks of a weight management programme, but it is important to stress to the patient that large weight losses are common at the beginning and that these usually slow down fairly quickly. Nurses should inform patients that this is common so that they do not become demotivated. With this in mind, once the patient becomes comfortable with their new attitude to food, follow-up appointments can become less frequent. The patient is still free to contact the practitioner whenever necessary, but routine appointments are usually monthly.

"Food crises"
It can be argued that the society we live in revolves around food, whatever the situation; food is usually offered or expected. Special events such as christenings, birthdays and weddings can prove difficult for patients striving to lose weight; if food is offered, they may struggle to decline.
With encouragement and motivation, the patient becomes more confident at dealing with these situations, although it is not uncommon for a patient to contact the clinic when faced with a "food crisis" situation. This is something the practitioner should promote - often all that is needed by that patient is a little bit of encouragement and reassurance to help them stay focused, which will in turn reinforce the confidence the patient has in themselves and the confidence in their practitioner.

Food diaries
Food diaries can be very useful for a patient who seems to be "doing all the right things" but is not losing weight. Keeping a food diary is often a good way of finding out the main reasons behind a person's weight gain, the foods they are eating and the hurdles that hinder their weight loss. By suggesting the use of a food diary, the nurse will be able to monitor the progress of the patient and highlight any areas that need tackling.
Food diaries are a great tool in self-assessment. The Change for Life website produces a number of different food diaries all of which aid patients in becoming better placed to evaluate different aspects of their lifestyle. Food diaries raise questions such as whether a patient eats when they are hungry, whether they tend to eat breakfast, at what time of the day they usually eat less healthy foods and many other food-related behaviours.

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Conclusion
The management of obesity is both a daunting and lengthy task, which may often be very difficult for healthcare practitioners to tackle. The role of nurses in obesity management both supports GPs and enhances the life of patients, putting nurses in an exclusive position to drive forward progress in weight management.
The implementation of weight management services goes a long way toward improving the obesity situation. Dedicated weight management programmes allow patients to receive optimal care by experienced nurses who understand the tools and treatments that will be best suited to individual needs.
Nurses are able to provide patients with the right type of information at a time when it is most relevant to them. By helping patients understand their relationship with food, the different treatment approaches that are available to them and the resources that can be used, patients will recognise how to change their current eating habits, when they have reached satiety, if their behaviour needs to be modified and what foods are healthy.
 Although the management of obese patients provides the practitioner with enormous challenges, the positive results that can be achieved are hugely rewarding. The benefits are substantial for the patient as they can develop a whole new outlook on life, with extensive health benefits.

References

  1. National Audit Office. Tackling obesity in England. London: The Stationery Office; 2001.
  2. McPherson K, Marsh T, Brown M. Tackling obesities: future choices - modelling future trends in obesity and their impact on health. Foresight. Available from: http://s3.amazonaws.com/foresight/14.pdf
  3. Wanless D. Securing good health for the whole population. London: The Stationery Office; 2004.
  4. House of Commons Health Select Committee. Obesity: third report of session 2003-04. London: The Stationery Office; 2004.
  5. Internal audit. April 2007.


Resources

Change for Life
W: www.changeforlifeonline.com