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Weighty problem: The obesity timebomb

With the cost of overweight and obesity predicted to double by 2050, it is a race against time to save the next generation from a lifetime of weight-related problems

England's Chief Medical Officer, Professor Dame Sally Davies, has expressed deep concern at the “profound change” in the nation's health over the past 30 years. She cites the “alarming prevalence” of overweight and obesity and urges concerted action to combat this.1 

We have one of the highest rates of overweight and obesity in the developed world, affecting around two thirds of adults and one third of children aged two to 15 years. Without appropriate intervention, the outlook for these children is chilling. Their health and wellbeing risks being compromised by musculoskeletal problems and cardiovascular damage, as well as low self-esteem and depression. As adults their lives may be blighted by life-shortening conditions related to obesity, such as type 2 diabetes, hypertension, stroke, coronary heart disease and some cancers. 
Every year the health problems associated with obesity 
result in:
 - About 30,000 deaths.
 - 18 million days of sickness.
 - Costs to the NHS of over £5 billion per year.
By 2050 the annual costs to the NHS are forecast to double to £10 billion.2
Government policy is that by 2020 there will be a sustained downward trend in the levels of obesity in adults and children. Achieving this requires a combination of individual efforts and political commitment, in collaboration with public and private sector stakeholders, and significant input from health professionals.3
Prioritising the prevention and management of obesity in primary care is seen as essential. Existing provision to facilitate this is not fully developed or widely available. Services need to be tiered so that there is wide access to primary prevention and early intervention, as well as a pathway by which the most severely affected patients can access highly specialised services such as bariatric surgery4 (see Figure 1).
Levels of obesity vary throughout the country, with the highest rates occurring in the areas with greatest deprivation. While the causes of obesity are complex and subject to ongoing research, there are important evidence-based initiatives that can help adults and children maintain a healthy weight (see Box 1).
The central health promotion messages, as summarised by the World Health Organization, are: 
 - Limit energy intake from total fats and sugars.
 - Increase consumption of fruit and vegetables as well as legumes, whole grains and nuts. 
 - Engage in regular physical activity.  
Achieving these goals relies on people modifying their behaviours and lifestyle in ways that are sustainable. For some people, making the necessary changes can be very difficult. 
Primary care nurses have a key role in the prevention and management of obesity. Working with patients in the community gives them a unique opportunity to encourage and support lifestyle changes within existing clinical relationships. This may, for example, be through contact with patients living with ongoing chronic physical or psychiatric conditions; at specific times of life when excess weight gain may be an issue, such as during or after pregnancy, or at the menopause. Nurses' ongoing contact with their patients can enable them to: 
 - Provide lifestyle advice, focusing on maintaining a healthy weight through good nutrition and appropriate physical activity.
 - Identify patients whose health is affected by, or at risk as a result of, their weight gain.
 - Make appropriate referrals to specialist advice.
 - Support and motivate those patients who are participating in weight management programmes in the community; or have had interventions from secondary care, including bariatric surgery.
The key behavioural goals - increased activity, reduced overall energy intake - can best be achieved by encouraging small incremental changes, not big unmanageable ones. Even modest amounts of weight loss can make a difference if sustained over a period of time; for example, reducing total intake by 100 calories a day can result in 0.5kg weight loss over a month.4 The aim should be to help people consider how they can make small adjustments in their lifestyle through practical examples. 
Successful engagement depends on being patient-centred and culturally sensitive. An initial non-directive approach, and a non-judgemental stance, are essential to prevent patients disengaging from any further discussion. Not all patients are ready to change when the subject of their weight is first raised with them. They need to be given other opportunities to return to the issue in the future. Even if a patient does not lose weight, increasing their physical activity will have a positive impact on their health, as will prevention of further weight gain. 
For some patients, the choices they make in relation to their own diet and that of their family may be heavily influenced by the convenience and availability of fast foods and takeaways, an inability to cook, and a belief that healthy food costs more. A culture of grazing, rather than regular mealtimes, makes it more difficult for people to monitor their intake, as well as reducing their awareness of the foods they consume that have a high calorie content. 
Close reference to a patient's clinical history is important, as it may significantly affect any discussion with the patient about their weight; for example, if they have diabetes or an underlying condition associated with weight gain, such as polycystic ovary syndrome. Similarly, a number of drugs, such as steroids and some of those used for treating mental health conditions, may have the effect of increasing appetite, and are associated with weight gain. Expectations of weight management will need to be tailored accordingly. 
Patients who have successfully lost weight may find that they regain it after a short time because they fail to sustain the necessary changes in behaviour over the longer term. Taking a careful history may identify why earlier attempts did not work, and allow for different strategies to be tried.
Some nurses may need to extend their existing knowledge or wish to develop specific expertise in relation to weight management, including provision of nurse-led clinics. This will be crucial in supporting the increasing number of patients who would benefit from a multi-disciplinary approach from both primary and secondary care.
The essential knowledge base can be summarised as:
 - Why obesity matters, in the context of good health. 
 - Which weight management strategies are effective.
 - How to intervene; for example, using consultation techniques, motivational
interviewing, counselling, and avoiding a one-size-fits-all approach.
It is also important to have a good understanding of the social, psychological and environmental factors that predispose to excessive weight gain. Awareness of the relevant aspects of nutrition will enable practical advice to be given as well as warnings of the 'hidden' calories found, for example, in carbonated soft drinks, smoothies, and other foods often marketed as being 'healthy'. Being familiar with local initiatives that meet best practice standards will enable nurses to signpost patients for self-help in the community (see Resources).
Children present specific challenges, but have the advantage of being subject to universal services such as health visiting and school nursing. It is recognised good practice to weigh and measure children as part of routine care; body mass index can then be plotted on age-appropriate centile charts.  
Health visitors have a vital role in helping to prevent obesity in pre-school children. Just as important as dietary advice to parents is discussion about everyday activity. Practical examples of how this could be achieved include reducing the use of buggies and cars, and encouraging children to walk whenever possible. 
School nurses also have an important contribution to make in relation to health promotion by helping to educate parents as well as school age children. Children who are overweight or obese can be identified when their weight and height are recorded as part of the National Child Measurement Programme in reception (ages four and five) and year six (ages 10 and 11). 
Effective engagement with the family is critical when considering the need to address a child's weight, and in particular the extent to which relevant members of the extended family support the implementation of a weight management programme. Occasionally safeguarding issues may arise, since serious obesity may paradoxically be a sign of neglect, and children's social care may need to become involved.
While there is some evidence that the rate of childhood obesity has stabilised, forecasts suggest that without further effective intervention, around 25% of children will be affected by obesity by 2050, as well as 60% of adult men and 50% of adult women.2 Primary care nurses are among those health professionals who have a pivotal role in helping to counter this ongoing threat to the nation's health and wellbeing.
1. Department of Health. Our Children Deserve Better: Prevention Pays. Annual Report of the Chief Medical Officer 2012. Crown Copyright 
2. McCormick B1, Stone I, Corporate Analytical Team. Economic costs of obesity and the case for government intervention. Obes Rev. 2007;8 Suppl 1:161-4.
3. Ellison J. Reducing Obesity and Improving Diet. Crown Copyright, Published 25th March 2013.
4. Royal College of Physicians. Action on obesity: comprehensive care for all. Report of a working party. London: RCP, 2013.
National Institute for Health and Clinical Excellence. Clinical Guideline 43.
Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children.
National Institute for Health and Clinical Excellence. Clinical Guideline 47.
Managing overweight and obesity among children and young people: lifestyle weight management services.