Key learning points:
– Openly discuss the subject of people’s weight, assess the impact of this on their lives and their interest in changing
– Apply techniques drawn from motivational interviewing to reduce a person’s resistance to speaking about their weight issues and increase their openness to lifestyle change
– Offer appropriate support or a referral to a weight loss programme
The government’s obesity strategy healthy lives: a call to action on obesity in England1 aims to reduce ‘the level of excess weight averaged across all adults by 2020’.
Nurses are encouraged to use every contact with an individual to help them maintain or improve their mental and physical health and well-being; in particular targeting the four main lifestyle risk factors; diet, physical activity, alcohol and tobacco – whatever their speciality or the purpose of the contact. This recommendation has been called Making Every Contact Count (MECC).
There is still plenty of work to be done to achieve these recommendations and specifically with regards to helping people manage their weight, as in 2012, around a quarter of adults in England (24% of men and 25% of women aged 16 or older) were classified as obese.2 Being overweight can lead to both chronic and severe medical conditions. Nurses are ideally placed to help prevent these problems by discussing weight gain where appropriate and during the following:
- Diabetes clinics.
– Coronary heart disease checks.
– Health checks.
– Family planning.
– Vaccinations.
– Review of medications eg for asthma, migraines and skin conditions.
– Mental health consultations.
Try asking questions such as: “I see from my records that I haven’t checked your weight recently, would you mind if I weighed you today?” The National Institute for Health and Care Excellence (NICE) guideline PH47 named ‘Managing overweight and obesity among children and young people: lifestyle weight management services’ recommends nurses also ensure they provide information about local lifestyle weight management programmes to children and young people identified as being overweight or obese, and their parents or carers as appropriate.3
Identifying excess weight
Body mass index (BMI) is the most commonly used measure to determine whether or not adults are a healthy weight, underweight, overweight or obese. It is defined as weight in kilograms divided by the square of height in metres (kg/m2). Checking a person’s BMI helps nurses identify likely health risks associated with their weight, therefore it is useful to monitor progress. Waist circumference can also be included to identify those with a health risk due to excess weight. Adults with a BMI of 25 kg/m2 to 29.9 kg/m2 are considered to be overweight, and those with a BMI of 30 kg/m2 or above are considered to be obese.
A study revealed the humiliations faced by overweight people
Overweight people reported being insulted by shop assistants, ignored by bar staff, left out by friends, mocked by passers-by and ridiculed by the opposite sex. A survey of 2,573 people by Slimming World found that this weight discrimination did not motivate people to lose weight but led to people feeling ashamed (47%), depressed (41%) and useless (30%). Worse still, 65% reported turning to food for comfort.4
How to raise the issue of weight
Many people coming to the NHS with problems caused by excess weight hope they can be helped with medications. Some people become defensive or withdrawn when the issue of their weight is raised. Although it’s tempting to try persuading a person that the solution to their health problem is to lose weight, sadly this tactic can increase the person’s resistance and lessen the probability of action.
Seeming critical when discussing weight can cause a person to appear ‘unwilling’ to change, while a more understanding approach can build trust and encourage them to consider their weight without feeling judged. Find out their own attitude and belief about their weight by saying: “May I ask how you feel about your current weight?” or “Has your weight changed over the past year?” and “How is this affecting you?”
Communication techniques drawn from motivational interviewing (see Boxes 2 and 3) have been endorsed by NICE.5
Applying these principles in practice means encouraging and allowing your patient to talk about themselves, and showing that you are listening. Start by avoiding closed questions because they stop people thinking for themselves. These are the type of questions that can only be answered by a yes or no response, for example: “You do agree that something needs to be done?” or “Are you happy to go to the exercise class?”
Instead, ask open questions; find out what their size means
to them and any drawbacks they have already experienced, as well as clarifying their understanding of the risks posed to their health.
For example: “What have you heard about the health problems caused by weight?” If they are unsure, describe the
link between their weight and medical problems. Check their understanding and interpretation of the facts you’ve provided. Seek permission to explain the short and long term benefits eg, “May I explain the links between weight and high blood pressure/diabetes to you?
This style of communication helps patients to think about their weight and open up to you. Use reflective listening and feedback to the key points you have heard. Address any resistance to change by emphasising their personal choice. For example: “It is up to you to decide what steps you’ll take” or “What do you think could happen if you do nothing?”
Summarising everything that has been said is important as this helps patients hear themselves from a new and different perspective. People often begin to consider making a change after hearing a summary.
Helping people who are unsure if they want to change
- Ask about the advantages and disadvantages of changing.
– Talk through their ambivalence.
– Ask: “What’s the main thing getting in your way?” or “How would you feel if nothing changed?”
– Explore future concerns if things remain the same.
Helping people who decide to change
Congratulate their decision and check their expectations are realistic, for example:
– “Remind me when you plan to start?”
– “What is the next step you are you going to take when you leave here?”
– “What might get in your way?”
– “What could you do to prevent that?”
– “Who can support you?”
– “Which treatment/programme will you use?”
-“When would you like to see me again?” (see Box 4 for suggested responses).
Lifestyle weight management programmes
Lifestyle weight management programmes for overweight or obese adults need to offer several components to reduce a person’s energy intake and help them to be more physically active by changing their behaviour.6 They may include weight management programmes, courses or clubs that:
– Accept adults through self-referral or referral from a health or social care practitioner.
– Are provided by the public, private or voluntary sector.
– Are based in the community, workplaces, primary care or online.
Although local definitions vary, these are usually called tier two services. Health practitioners looking for weight management programmes for their patients need to find out if their public health teams or clinical commissioning groups have subsidised providers to offer these.
Conclusion
Being overweight is strongly linked to various health risks so it’s important to take the time to discuss a patient’s weight and possible risks, and offer to support them in making lifestyle changes. Raising the issue of a patient’s weight needs to be handled sensitively to avoid causing offense and further damaging someone’s self esteem. Asking for permission to weigh a patient can help to open a discussion. The suggestions offered in this article will also help you talk about a patient’s weight even if you struggle with your own. Using open questions, which avoid any blame, helps you start the discussion with patients. Rather than telling them what they should do – explore their understanding of the relationship between weight and health conditions.
Offer support and identify what the patient would like from you. It’s possible the time isn’t right for them so acknowledge this but let them know you’re there and your door is open. Increasing the number of opportunistic interventions you make in this way will help address the current obesity epidemic and make a difference to the health of the population.
Resources and further reading
The Public Health England obesity website – noo.org.uk
Slimming World – slimmingworld.com/health
NHS Choices – nhs.uk/Livewell/Goodfood/Pages/Goodfoodhome.aspx
Rollnick S, Miller WR, Butler CC, Aloia MS. Motivational Interviewing in Health Care: Helping Patients Change Behavior. The Guildford Press; 2008.
References
1. Department of Health. Healthy lives: a call to action on obesity in England. gov.uk/government/publications/healthy-lives-healthy-people-a-call-to-action-on-obesity-in-england (accessed 7 October 2015).
2. Health and Social Care Information Centre. Statistics on obesity, physical activity and diet. hscic.gov.uk/catalogue/PUB16988/obes-phys-acti-diet-eng-2015.pdf (accessed 7 October 2015).
3. The National Institute for Health and Care Excellence. Managing overweight and obesity among children and young people: lifestyle weight management services. nice.org.uk/guidance/ph47 (accessed 7 October 2015).
4. Stubbs RJ Greenwood L, Caven J, Morris L. Emotional and behavioural responses to perceived weight discrimination before and after substantial weight loss. Obesity Facts 2015;8(1):118.
5. The National Institute for Health and Care Excellence. Behaviour change: the principles for effective interventions. nice.org.uk/guidance/ph6 (accessed 7 October 2015).
6. The National Institute for Health and Care Excellence. Managing overweight and obesity in adults – lifestyle weight management services. nice.org.uk/guidance/ph53 (accessed 7 October 2015).
