Obesity poses a serious risk to health. This article is an introduction to, and taster of, our online learning unit on obesity management in adults
Citation: Brown J (2012) Managing obesity in adults. Nursing Times [online]; 108: 48, 18-19.
Author: Jenny Brown is honorary clinical research fellow, Centre for Obesity Research and Epidemiology, Robert Gordon University, Aberdeen.
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Obesity is viewed by some as simply a cosmetic problem; in reality it is a serious health issue. In England, it is estimated that 47% of males and 36% of females will be obese by 2025, and this will rise to 60% of males and 50% of females by 2050 (Butland et al, 2007).
The many serious health consequences of obesity are already creating a huge burden on NHS resources, which can only increase as the number of people who are obese rises. National guidelines on conditions such as heart disease and type 2 diabetes recommend that obesity be tackled as part of treatment and as a preventive intervention.
Primary care nurses, especially those involved in managing long-term conditions, and nurses involved in health promotion are particularly well placed to address obesity.
Some health consequences of obesity include: hypertension, dyslipidaemia, type 2 diabetes, obstructive sleep apnoea and depression. Obesity occurs when energy intake exceeds energy expenditure on a regular basis. Causes include rare genetic syndromes, hypothalamic injury and some prescribed medications.
However, the greatest influence on the development of obesity is lifestyle.
Obesity is measured by body mass index (BMI), calculated by weight(kg)/height (m2). Having a BMI of <35.0 does not mean an individual is necessarily at less risk of obesity-related diseases (Table 1); for these people, adding waist circumference to assessment should be considered, as abdominal fat is an important risk factor (National Institute for Health and Clinical Excellence, 2006).
Weight loss of 5-10% has health benefits. In patients with a BMI of >35.0, weight loss of >15-20% will be required to obtain a sustained improvement in comorbidity (Scottish Intercollegiate Guideline Network, 2010). The usual weight loss target is 0.5-1kg a week (NICE, 2006).
Obesity management is complex, as energy intake and expenditure are influenced by physical, social, emotional and environmental factors. Working in partnership with patients encourages them to develop confidence, a sense of control and self-management skills. They usually know broadly what influences their weight, but may need help to identify specific factors.
After motivation and barriers to losing weight are identified, individualised SMART (specific, measurable, attainable, realistic and time-bound) goals and actions should be agreed and provided in written format (NICE, 2006).
Obesity tends to run in families. Although genetics play a part, the greatest influence is family structure, roles and relationships. Individuals with a history of repeated dieting may believe they will never succeed; they tend to have unrealistic expectations and opt for “quick-fix” diets. Addressing these beliefs is important if long-term weight management is to be achieved.
Our reasons for intervening may be to improve health, but those who are obese may have different reasons for wishing to lose weight, such as being able to play with their children.
A food and drink diary is a useful tool and should cover 24 hours a day. People with obesity often skip breakfast and eat late in the day; the diary will help identify those who snack at night or who may have night-eating syndrome. Quantities of food and high-calorie drinks, including alcohol, should be identified, as should convenience foods and take-away meals.
The SIGN guideline on obesity states that international consensus guidelines recommend 45-60 minutes of moderate-intensity physical activity per day for adults (SIGN, 2010a). While this may be the eventual aim, it is important to assess current activity so appropriate goals can be set. Inactivity, such as watching television, should be addressed.
Emotional wellbeing can be affected by cultural values. There is a general belief that obesity is the fault of the individual (Puhl and Brownell, 2003). Obese people often take on these prejudices, which result in self-blame, guilt and shame.
Identifying sources of support among family, friends and colleagues is important for people with obesity. Different types of support may come from different people.
Various supportive additional options are recommended if they are based on principles including healthy eating and realistic targets, focus on long-term lifestyle changes and have ongoing support (NICE, 2006). This includes weight-loss interventions such as formula diets and diet plans.
As an example, for those at moderate risk of diabetes, NICE (2012) guidance suggests slimming clubs or structured weight-loss programmes. People with certain medical conditions - such as type 2 diabetes, heart failure, uncontrolled hypertension or angina - should check with their GP or hospital specialist before starting a weight-loss programme.
Very-low-calorie diets (defined in legislation as 800kcal/day or less) may be used for a maximum of 12 weeks continuously by people with obesity and a medical condition requiring greater amounts of weight loss, for example obstructive sleep apnoea (Johansson et al, 2011) and diabetes (Snel et al, 2012).
Programmes that follow a diet of <600kcal/d should only be carried out under clinical supervision (NICE, 2006).
Patients following commercial or self-help weight-management programmes should be monitored and supported by health professionals (NICE, 2006).
As well as lifestyle interventions, the drug orlistat (Xenical) may be prescribed for those who have a high fat intake. They should have a BMI of >28.0 and comorbidities, or a BMI of >30.0. If, after at least six months’ intervention, there has been no beneficial weight loss, referral to a specialist clinic may be considered (SIGN, 2010). Treatment may include bariatric surgery.
Nurses are in an ideal position to discuss obesity with patients. Assessment and intervention should not be limited to eating and physical activity but should include: comorbidity risk; weight history; expectations of weight loss; motivation; and psychological, emotional, social and environmental issues. Obesity management is complex and requires a holistic and person-centred approach.
Boost your CPD and work towards your next revalidation with our learning unit on obesity management in adults
Nursing Times subscribers have free access to a range of learning units, including one on Obesity: An Introduction to Management in Adults. Once you have been through the learning unit, you will be able to:
- Explain the importance of addressing obesity and linked comorbidities
- Identify how to approach the topic of obesity with a patient
- Assess a patient for obesity
- List the current principles of managing obesity
- Identify some of the barriers to making long-term changes
- Describe the need for individualised care
Butland B et al (2007) Foresight. Tackling Obesities: Future Choices. Project Report. Government Office for Science.
Johansson K et al (2011) Longer term effects of very low energy diet on obstructive sleep apnoea in cohort derived from randomised controlled trial: prospective observational follow-up study. BMJ; 342:d3017 doi: 10.1136/bmj.d3017
National Institute for Health and Clinical Excellence (2012) Preventing Type 2 Diabetes - risk Identification and Interventions for Individuals at High Risk (PH38). London: NICE.
National Institute for Health and Clinical Excellence (2006) Obesity: Guidance on the Prevention, Identification, Assessment and Management of Overweight and Obesity in Adults and Children. London: NICE.
Puhl R, Brownell K (2003) Psychosocial origins of obesity stigma: toward changing a powerful and pervasive bias. Obesity Reviews; 4: 4, 213-227.
Scottish Intercollegiate Guidelines Network (2010) Management of Obesity. Guideline 115. Edinburgh: SIGN.
Snel M et al (2012) Effects of adding exercise to a 16 week VLCD diet in obese insulin dependent type 2 diabetes mellitus. Endocrinology Research; 97: 7, 2512.