Key learning points:
- Nurses in primary care can have an effective role in the identification and assessment of those at risk of weight problems and to signpost them to weight management support
- Nurses may require training in a person-centred approach with attention to rapport and empathy so that they can involve the patient in shared decision-making
- For patients at risk from excess weight, structured multi-component lifestyle programmes are effective
Obesity is a public health priority and the focus of intense media interest.1,2 Not a week goes by without a new obesity story – and often there is contradictory information about the risks, benefits and interventions for weight. Weight-related stigma is a feature of our society and has its own health impact.3 Along with concerns about excess fat we have an increase in eating and body image disorders. In this context it is essential we maintain a balanced and evidence-based approach.
Epidemiology
A body mass index (BMI) equal to or more than 30kg/m2 indicates ‘obesity’ – a useful category for summarising the epidemiology of excess body fat. The rapid increase in obesity in the last decades is a global phenomenon in which the UK ranks in the top five and top 10 for men and women respectively.4 The data for each country in the UK are available online and this is updated regularly as accessible reports, slides and infographics (noo.org.uk). A degree of excess body fat affects a majority of the population now (almost two-thirds are overweight or more).
The prevalence of obesity in the UK rises with age to peak (about a third of adults) in late middle age. Prevalence varies across regions and social class groupings – essentially obesity is still present in those who are better off, but is less of a problem for them.
Obesity (as in a BMI of 30kg/m2) also varies between ethnic groups. BMI as an accurate indicator of body fat differs between ethnic groups and the risks to health of body fat also differ between groups. Hence a fixation on the official ‘obesity’ category can be misleading within diverse societies and with a fuller appreciation of how body fat affects health. A more nuanced approach is better for understanding risks for health and recommended interventions. About quarter of all adults are at increased risk of weight-related health problems.
The national epidemiology provides a useful comparison in understanding patterns of local needs in your practice area.
For effective practice you should know your practice area. This leads to better judgments about effective interventions to support for individual patients. Public Health England and the equivalents in other parts of the UK provide useful local data on patterns of weight and health (fingertips.phe.org.uk).
Evidence-based guidelines
The most recent guidance from NICE for adults was published in 2014 and is linked to a pathway and standards.5 The guidance and pathway broadly categorise people according to risk of health problems and thereby make recommendations about the intensity and type of intervention. Effective lifestyle change underpins all levels and should incorporate multiple components.
Actually, there are significant gaps in the ‘evidence’ knowledge.5 A key gap is knowledge of the effectiveness of interventions for groups other than those that typically take part in trials. The trials are biased towards those who are better off and involve more women than men. Surprisingly, there is also a lack of evidence about how to train practitioners to deliver effective weight management programmes. So care is required, first in thinking whether a programme is suitable for a particular patient and second, whether your training is a suitable preparation to deliver effective weight management yourself. Key practice skills are discussed below.
In the NHS, the concept of ‘tiers’ of weight management support is widely employed but is not delivered in any standardised form. Again, it is essential to become familiar with the local pathways and resources. This is because signposting and referral to more intense support with weight management is a priority for primary care effectiveness. If people attend and complete these programmes they will benefit. However, non-attendance after referral and early quitting are significant problems.2 There is also evidence of patient dissatisfaction with weight-related consultations in healthcare.6 So, this brings us to a particular focus for improving weight management in primary care.
In practice
Despite limitations in the evidence base, the elements of good practice for primary care can be identified. The emphasis is on communication and motivation skills and less about (for example) detailed knowledge of diets. One useful framework to help guide a consultation discussion about weight is the 5A’s model.7 Another useful approach is motivational interviewing – an approach already familiar to those working in primary care. What these have in common is the emphasis on person-centred communication and attention to maintaining rapport and demonstrating empathy and shared decision-making.8
Ask
The foundation for being effective is to establish rapport and to explore the patient’s concerns, ideas and expectations. Clearly the nurse has to judge whether or how to raise issues of weight if they are not directly on the patient’s agenda. Care is required with language – observe and respond to verbal and non-verbal cues to arrive at a constructive discussion with meaningful terminology. Most patients do not like the term obese. If your priority is to get them to accept the label you will probably do little to help them with their health.3
Communication techniques to show empathy, to anticipate and manage obesity stigma, to reduce patient resistance and elicit motivation are crucial. There are two routes to a weight review agenda if this is not directly raised by the patient. One is the legitimacy of screening for and asking about general health issues, including weight. The second is where the patient has a condition that is either a complication of excess weight or likely to be exacerbated by weight. Patients do not mind being asked about weight in either of these contexts if it is approached non-judgmentally.
Assess
Accurate measurement of height and weight are required for BMI and a basis for assessment of body fat. An assessment of muscle mass and consideration of the patient’s ethnic group and age are required to make sense of BMI.
Additionally, waist measurement with reference to values for gender and ethnic group are useful.
In parallel with the physical assessment it is possible to explore the patient’s experiences, perspectives and motivation in relation to weight. Open-ended questions, attentive listening, reflection and summaries are helpful techniques to build rapport, reduce ambivalence and increase engagement in decision-making for weight management.
Advise
How, then, do we advise about the risks of weight for health? An informed discussion is quite distinct from a ‘we need to scare them to motivate them’ approach that tends to overstate the risks of overweight and the benefits of management. Patient decision aids and visual aids can help for an informed discussion – with benefits for patient engagement and expectations.
In the advice stage, also consider needs and preferences for the components of the ‘lifestyle’ intervention; and make reference to your detailed local knowledge of support options available.
Is it appropriate to launch into your own take on lifestyle advice at this point? It might be, depending on your training. But when we examine the research evidence it is apparent that none of the effective programmes are based on a few minutes of lifestyle advice from a nurse. Very consistently, the advice delivery is over a period of months or longer with regular and substantial contact; and delivered within well-resourced programmes led by experienced staff specifically trained in relation to the components.
This highlights again that an effective role is more about identifying and motivating and signposting rather than the more traditional sense that we must educate the patient on the spot about how many calories there are in a pizza or a portion of chips.
Agree and Assist
It is best to be clear minded about what is effective use of time. Shared decision-making with realistic goals oriented to health and leading to signposting or referral are likely to be most helpful. Ask the patient what type of information they need and involve them in choices. Arrange follow-up.
A nuanced appreciation of how body fat affects health is necessary for assessment of patients in a diverse society. Local knowledge is needed to make practical judgments about the implementation of national evidence guidelines. The evidence directs us to the stage of identification and assessment of those at risk of health problems and how they are engaged and signposted to resources. This is a key role for primary care nurses and one that requires advanced communication and consultation skills. A person-centred approach that builds rapport and demonstrates empathy with shared decision-making is vital. Indeed, this is so important that the role should not be undertaken by those who have not been trained in the necessary communication skills.
References
1. Foresight: Tackling obesities: Future choices. London: Government Office for Science 2007.
2. Royal College of Physicians: Action on Obesity: Comprehensive Care for All. RCP 2013.
3. Phelan SM et al. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews 2015;16:
319-26.
4. National Obesity Observatory. Good epidemiology resources available at www.noo.org.uk.
5. NICE. CG189. Obesity: Identification, Assessment and Management. London: 2014.
6. Mold F, Forbes A: Patients ‘and professionals’ experiences and perspectives of obesity in health-care settings: a synthesis of current research. Health Expectations 2011.
7. Ogunleye A et al. The 5As team intervention: bridging the knowledge gap in obesity management among primary care practitioners. BMC Research Notes 2015;8:810.
8. Silverman J, Kurtz S and Draper J. Skills for Communicating with Patients. Third Edition. Radcliffe 2013.
