Key learning points:
– What are the consequences of a poor diet and physical inactivity?
– When to provide healthy eating and exercise advice
- How to give structured and effective advice to promote positive and sustained behaviour change
Eating a healthy balanced diet accompanied by regular exercise is essential in maintaining physical and mental health and well-being. Not only are these effective in preventing excess weight gain or in maintaining weight loss, but healthier lifestyles are also associated with improved sleep and mood. Physical activity particularly improves brain-related function and outcomes.1
Obesity levels remain worryingly high, with nearly 30% of the global population being overweight or obese. This figure is set to rise to almost half of the world’s adult population by 2030, according to the McKinsey Global Institute.2 The fundamental cause of excess weight and obesity is an imbalance between energy intake and energy expenditure. Globally, the intake of energy-dense foods that are high in saturated fat, salt and sugar has increased. We also consume insufficient amounts of fruit, vegetables, dairy, whole grains and oily fish,3 which has an additive effect on the health impact of a poor diet. Our modes of work continue to remain sedentary and we work the longest hours compared to many other European countries.4 In the UK we spend more time sat on public transport, watching television and indoors.
Excess weight and obesity are major risk factors for a number of chronic, non-communicable diseases (NCD) including type 2 diabetes, cardiovascular diseases, musculoskeletal disorders (particularly osteoarthritis) and some cancers.5 The risk for these NCD’s also rises with an increase in body mass index (BMI) and age. To summarise:
1. The UK has one of the highest levels of obesity in western Europe: 67% of men and 57% of women are either overweight or obese.
2. More than half of men and women are at an increased risk of multiple health problems caused by poor diet.
3. The level of childhood obesity is a huge concern. In the UK, one in 10 children are obese when they start school. By the time they leave primary school, nearly 20% of children are obese with a 75-80% risk of obese adolescents becoming obese adults. Childhood obesity is associated with a higher chance of obesity, premature death and disability in adulthood.
4. According to the latest diet surveys, children and teenagers consume around 40% more added sugar than the recommended daily allowance; much of this coming from snacks and sweets.3 We are now seeing type 2 diabetes, hypertension, early markers of heart disease, breathing difficulties, increased risk of fractures and psychological effects in young children.
5. In 2014 Public Health England reported that 12% of children under three have tooth decay and an average of three teeth in these children are decayed, missing or filled.6
6. Obesity can reduce life expectancy by eight to 10 years. This is equivalent to the effects of life-long smoking.7
Obesity is preventable and is the result of a complex, multifactorial integration of environmental and social factors that influence our dietary and physical activity patterns. Lack of supportive policies has led to the creation of an obesogenic environment that simply does not enable the public to make healthy choices easily. The UK are now behind many other western industrialised countries in reducing premature mortality rates.8 This increases the financial burden on local authority and health resources. Those working in primary care are required to work much more through a reactive approach to healthcare as opposed to the more desired proactive approach.
Obesity prevention strategies are beginning to gain traction but to see real strides, positive change must outrun the pace of negative contributors. Prevention policy should target a handful of key behaviours and the role of the primary care nurse is central to its delivery:
– Limiting processed foods (refined grains, processed meat and foods rich in sugar, saturated fat and salt) and beverages (sugary drinks).
– Increasing physical activity.
– Limiting “sit time”.
Over and undernutrition
Most recently, attention has been given to the overconsumption of energy and the resulting obesity crisis, however undernutrition is still a growing concern. Malnutrition, meaning poor nutrition, affects over three million people in the UK,9 93% of these live in the community. It has also been identified in one in four adults on admission to hospital.10 A poor quality diet consumed in inadequate amounts or in excess both contribute to malnutrition, as nutrients are not supplied in sufficient or appropriate proportions. Despite an excess of dietary calorie intake, obese individuals have relatively high rates of micronutrient deficiencies.11,12 One in five people in the UK live below the poverty line and are unable to afford sufficient food to meet their nutritional requirements. Just £2.10 per person per day is spent on groceries by low-income families.13 The increase in nutritional requirements as a result of illness or injury is often underestimated. Upon admission, additional stress and the impact of interventions, surgical procedures and opportunistic infections can all significantly increase energy expenditure. Nutrient requirements develop further, increasing the likelihood of malnutrition occurring while in a care setting if these demands are not met.
Consequences of poor lifestyle choices
All malnutrition is inevitably accompanied by increased susceptibility to illness and clinical complications.
However, these risks can be significantly reduced if it is recognised early and specifically treated with relatively simple measures. Clinical complications associated with malnutrition can be decreased by as much as 70% and mortality reduced by around 40%.14 Poor nutrition and physical inactivity can contribute to the following:
– Type 2 diabetes.
– Heart disease.
– Declining mental health.
– Neurological disorders.
– Muscle atrophy.
– Vision problems.
– Increased risk of falls.
– Poor immune response.
– Increased risk of pressure sores.
– Higher risk of infection.
– Prolonged hospital stays.
– Increased dependency and medications.
– Increased prescription costs.
– More GP visits.
– Readmissions and recurrent hospital stays.
When should nurses promote healthy eating and exercising?
To fulfil NHS’s implementation guidance – Making Every Contact Count (MECC)15 – nurses are expected to promote healthier lifestyle choices from the point of admission through to discharge. Patient and nutritional assessment accompanied by appropriate lifestyle advice and an effective referral system are essential in supporting positive long-term behavioural change.
Which patients should be given advice on diet and exercise?
All patients should be given advice on diet and exercise. However, particular emphasis should be made for the most vulnerable, including:
– The very young and old.
– Post-operative patients.
– Those with gastric/feeding problems.
What happens when patients have unhealthy diets and do not exercise?
The benefits of improving nutritional care and providing adequate hydration are immense, especially for those with long-term conditions. The evidence shows clearly that if nutritional needs are ignored, health outcomes are worse, this is outline in Box 1.16
How can nurses working in the community give advice?
Lifestyle advice should be appropriate, personalised, safe and effective17 as well as ensuring equality, improved outcomes and the best patient experience. Accessing approved documents and resources will empower and equip nurses with the tools to provide clear recommendations on behaviours that will help service users maintain a healthy weight or prevent excess weight gain.
1. The National Institute for Health and Care Excellence (NICE) NG7 guidelines18 are service user centred and focus on the prevention of excess weight gain for children and adults (without particular needs).
2. Additional guidelines (PH53)19 emphasise an integrated approach to preventing and managing obesity, drawing upon local authorities, working with other local service providers, clinical commissioning groups and health and wellbeing boards.
3. Draw on strategies such as Change 4 Life and the more recent Start 4 Life, aiming to inspire anyone working with families and encourage everyone to eat well, move more and live longer.
It is expected that the nurse will draw upon the wider inter-professional team such as registered nutritionists, dieticians, physiotherapists and personal trainers with specialist exercise referral qualifications to ensure a broad and personalised approach to healthcare is achieved. Signposting individuals to local services that support healthy living, for example cooking groups and exercise facilities can enhance the desired outcomes.
Concerning the promotion of physical activity, nurses can encourage service users to identify activities they enjoy doing the most. These may be activities of everyday living such as gardening or doing housework. It is essential to appreciate the service user’s culture and any barriers to behavioural change in order to facilitate increasing physical activity levels. The alternative idea of ‘green exercise’, for example (exercising in a natural environment), appeals to many and has been associated with significant physical and mental benefits.20 To improve exercise adherence, it is important to consider the time required to begin adopting new behaviours (typically around 21 days), and that lapses are to be expected. The most common situations to cause a lapse include travel, holidays, illness, stress, poor weather, and competing family obligations. Service users can be taught how to overcome such barriers and replace negative thoughts with more realistic or positive ones.
Our environment does not sufficiently enable the public to make healthier choices easily. Unhealthy diets and physical inactivity remain among the leading causes of the major NCD’s and contribute substantially to the global burden of disease.
The nurse’s role involves an increasing amount of health promotion and the provision of appropriate, personalised, safe and effective lifestyle advice as part of the wider inter-professional team’s approach to personalised healthcare. Utilising appropriate resources and tools that educate, enable and empower nurses is vital in our approaches to tackle the obesity crisis.
1. Loprinzi et al. Physical activity and the brain: A review of this dynamic, bi-directional relationship. Brain Research 2013;1539:95-104.
2. McKinsey Global Institute. How the world could better fight obesity. mckinsey.com/industries/healthcare-systems-and-services/our-insights/how-the-world-could-better-fight-obesity (accessed 3 March 2016).
3. Public Health England, Food Standards Agency. National Diet and Nutrition Survey: results from Years 1 to 4 (combined) of the rolling programme for 2008 and 2009 to 2011 and 2012. gov.uk/government/statistics/national-diet-and-nutrition-survey-results-from-years-1-to-4-combined-of-the-rolling-programme-for-2008-and-2009-to-2011-and-2012 (accessed 25 February 2016).
4. TUC. Number of commuters spending more than two hours travelling to and from work up by 72% in last decade, says TUC. tuc.org.uk/workplace-issues/work-life-balance/number-commuters-spending-more-two-hours-travelling-and-work-72 (accessed 25 February 2016).
5. World Health Organization. Obesity and overweight. who.int/mediacentre/factsheets/fs311/en/ (accessed 25 February 2016).
6. Public Health England. New PHE survey finds 12% of 3 year olds have tooth decay. gov.uk/government/news/new-phe-survey-finds-12-of-3-year-olds-have-tooth-decay (accessed 25 February 2016).
7. National Obesity Observatory. Briefing Note: Obesity and life expectancy, 2010. noo.org.uk/uploads/doc/vid_7199_Obesity_and_life_expectancy.pdf (accessed 25 February 2016).
8. Public Health England. Public health matters, Tackling the epidemic of non-communicable diseases. publichealthmatters.blog.gov.uk/2014/02/27/tackling-the-epidemic-of-non-communicable-diseases/ (accessed 25 February 2016).
9. Elia M, Russell CA (eds). Combating malnutrition; Recommendations for Action. A report from the Advisory Group on Malnutrition, led by BAPEN. BAPEN, 2009.
10. BAPEN. Nutrition Screening Week – 2011. bapen.org.uk/information-and-resources/publications-and-resources/bapen-reports/nsw-reports/nsw11 (accessed 25 February 2016).
11. Kaidar-Person O, Person B, Szomstein S, Rosenthal RJ. Nutritional deficiencies in morbidly obese patients: a new form of malnutrition? Part A: vitamins. Obesity Surgery 2008;18(7):870-876.
12. Kaidar-Person O, Person B, Szomstein S, Rosenthal RJ. Nutritional deficiencies in morbidly obese patients: a new form of malnutrition? Part B: minerals. Obesity Surgery 2008;18(8):1028-1034.
13. Trussell Trust. Below the breadline, The Relentless Rise of Food Poverty in Britain, 2014. trusselltrust.org/wp-content/uploads/sites/2/2016/01/Below-the-Breadline-The-Trussell-Trust.pdf (accessed 25 February).
14. Stratton RJ, Green C, Elia M. Disease related malnutrition; an evidence-based approach to treatment. CABI, 2003.
15. NHS. Make Every Contact Count, 2014. england.nhs.uk/wp-content/uploads/2014/06/mecc-guid-booklet.pdf (accessed 25 February 2016).
16. BAPEN. Malnutrition Matters Meeting Quality Standards in Nutritional Care, 2010. bapen.org.uk/pdfs/toolkit-for-commissioners.pdf (accessed 25 February 2016).
17. Department of Health. High quality care for all, NHS Next Stage Review Final Report, 2008. gov.uk/government/uploads/system/uploads/attachment_data/file/228836/7432.pdf (accessed 25 February 2016).
18. NICE. Preventing excess weight gain, 2015. nice.org.uk/guidance/ng7 (accessed 25 February 2016).
19. NICE. Weight management: lifestyle services for overweight or obese adults, 2014. nice.org.uk/guidance/ph53/chapter/1-recommendations (accessed 25 February 2016).
20. Pretty et al. The mental and physical health outcomes of green
exercise. International Journal of Environmental Health Research 2005;15(5):319-337.