Community nursing and weight management
Alan Jackson MSc, FCIMSPA
Director, Discovery Learning & Weight Management Centre [Further information]
I am not a nurse, but I have observed enough nurses at work to conclude that it is a busy role where time is a valuable and sometimes rare commodity. How then can nurses find the time to help people lose weight when the overwhelming emphasis is on essential care for their primary condition(s)? More pertinently, why would they? Obesity is a chronic relapsing condition where few people experience successful long term weight loss [1]. Furthermore it’s a tricky one to tackle, and telling someone with obesity to eat less is about as effective as asking someone with depression to cheer up!
Factors influencing obesity
It is suggested that the appetite mechanisms are orchestrated to sustain an exquisite symphony in normal weight people, yet are a chaotic dissonance in those that are overweight or obese. The causal milieu of influences of obesity includes:
- psychological
- physiological
- neurological
- endocrinological
- behavioural
- environmental
- nutritional
- genetic
- social
- pathological or drug related (occasionally)
Intervention
Approaches to obesity intervention have had limited success and no successful model has emerged. Dr Arthur Frank in his paper Futility and Avoidance said: “Medical Professionals systematically avoid the problem of obesity. They send them to a dietitician who reinforces a recurrent litany of menu planning that has been therapeutically unsuccessful for the patient’s last 30 years” [2]. Therefore is the investment of precious time in attempting a weight management intervention really realistic for nurses? Well I would say it is.
Virtually all obese people will develop symptoms of chronic disease by the age of 40, and the majority will require medical intervention for obesity related disease before they are 60 [3], so the ethical reasons are beyond doubt. Furthermore, whilst the literature shows that very few people maintain clinically significant weight loss after 5 years, this may be missing the point. Weight Watchers demonstrated in a randomised controlled trial (RCT) [4] that people who lose a little weight every now and then perform significantly better in the long run than a control group that don’t ever lose weight.
Being in a position to help someone to lose a little weight, to eat more healthily and to take more exercise may have a profound effect on their physical and psychological wellbeing and may be sufficient to improve significantly the quality of their life. No one expects nurses within the time limitations that they have to cure someone’s obesity (even bariatric surgery seldom does that), but a well-timed brief intervention that gives someone the encouragement and motivation to make a few lifestyle changes, may make a world of difference. Below is a ten minute approach on raising the issue of weight and framework for a discussion that you may find helpful.
Raising the issue
Ask the patient something along the lines of:
"Do you have any concerns about your weight and your condition? Is this something that you have been able to discuss with a health professional previously?"
If a discussion about the patients’ weight ensues and they seem comfortable to continue, then your next point may be:
“Tell me what has worked for you in the past? Why do you think that was successful? How did the weight loss make you feel? Is weight loss something that you have considered recently?”
If the patient seems open to further discussion, you may wish to say:
“Actually I think now would be a good time to think about healthy eating and planning for some gentle exercise (obviously clinical judgement is important here). “The weight loss may be secondary to the benefits that a few lifestyle changes might bring.” What sort of changes do you think may be the most beneficial over the coming weeks as part of your recovery?”
At this point you can guide them and ensure their approach is appropriate for their condition and current health. A good idea would be to jot down for them your joint ideas into a ‘mini action plan’ with some SMART (specific, measurable, achievable, realistic, timely) goals, which may look something like this:
- Action 1: On returning home I will write out a shopping list (with no naughty items) and stick to it for at least six weeks. I will aim for at least 5 fruit and vegetables each day and drink at least one glass of water each day.
- Action 2: Continue with my walking programme and aim to increase by 2 minutes each day over the next few weeks until I can manage 30 minutes of walking over the day.
- Action 3: Avoiding snacking in between meals unless it is fruit and stick to no more than two glasses of wine Friday and Saturday only.
- Action 4: Weekly monitoring of my weight with a target of half a pound of weight loss each week and 2 inch off my waist over a month.
Conclusion
Patients hold nursing staff in high esteem and the accompanying trust and respect this brings, offers the foundations for a strong therapeutic alliance. Therefore, time permitting, nurses are extremely well placed to engage with patients with a view to encouraging a few simple lifestyle modifications that will support their recovery or improve their condition. The partnership approach as described above, will often provide sufficient impetus for the patient to adopt any agreed new lifestyle habits, particularly when there has been a recent health scare.
…Telling someone with obesity to eat less is like telling someone with depression to cheer up.