Obesity in Ireland
In Ireland, as in the rest of the UK, rates of obesity are increasing. Data from the North/South Ireland Food Consumption Survey (2001), which studied over 1300 subjects, found that weight, height and body mass index (BMI) had significantly increased since last measured in 1988 and 1990. Within 10 years obesity in men had more than doubled, from 8% to 20%, and in women obesity rates had increased from 13% to 16%. Weight has increased dramatically more in men than women, equating to an increase of 0.55kg per year for men and 0.33kg per year for women. A high waist circumference was identified in almost half the population (47%) indicating an increased risk of coronary heart disease. These figures are similar for both North and South Ireland.
However, despite the statistics, it appears that “obesity is underrecognised in primary care’ and ‘weight management appears to be based on brief opportunistic intervention undertaken mainly by practice nurses. While clinicians report the use of external sources of support, few patients are referred, with practice-based counselling being the most common intervention” (Gibbs et al, 2004). This recent study highlights the essential role nurses play in the treatment of obesity and, in addition, nurses are well placed to recognise those at risk and can therefore help in the prevention of obesity.
Obesity and those at Risk of Developing Obesity
The World Health Organisation (2000) has defined ‘overweight’ or ‘preobese’ as those with a Body Mass Index (BMI = weight/height2) between 25–29.9kg/m2 and ‘obesity’ as those with a BMI over 30kg/m2. However BMI considers total body weight in relation to height and does not take body composition into account. Therefore a very muscular man could have the same BMI as a very fat man but have very different health risks. Alternatively, a measure of waist circumference can assess central obesity and hence health risk. The categories for assessing central obesity with recommendations for action are presented below (SIGN, 1996).
|Waist Circumference||Risk/action to be taken|
|Men||Greater than 94 cm||Prevent further weight gain|
|Greater than 102 cm||Encourage weight loss|
|Women||Greater than 80 cm||Prevent further weight gain|
|Greater than 88 cm||Encourage weight loss|
This quick and simple measure of waist circumference (measured halfway between the lower rib and the top of the hip bone) can indicate to the nurse whether the patient has central obesity or is at risk of developing it.
the Health Risks
The risks of being overweight or obese are substantial and these risks increase with increasing weight. It has been estimated that for every kilogram of weight gain, the risk of type 2 diabetes increases by almost 5%. The obese, and in particular those who are centrally obese, are also at greater risk of cardiovascular disease, cancers, osteoarthritis, joint and back pain, infertility, sexual dysfunction and psycho-social problems. The National Audit Office (2001) has linked deaths caused by obesity to a shortened lifespan of nine years. It may be that the overweight or obese patient is unaware of these risks and this may be a place to start in the counselling of the patient by the nurse. The benefits of moderate weight loss should also be emphasised and should not be under-estimated. A 5–10% reduction in weight has been associated with health benefits such as reduced cardiovascular risk factors, improved glucose tolerance, reduced angina and reduced joint pain.
What has caused the Obesity Epidemic?
The causes of obesity are multi-factorial and result from a combination of genetics, environment and lifestyle. Although it is accepted that genetics are not responsible for the exponential rise in obesity over the last 20–30 years, it is acknowledged that some individuals are more susceptible to weight gain than others. The environment we live in has been termed ‘obesogenic’ owing to the huge availability of energy dense, high fat foods promoting excess energy intakes, and the number of labour saving devices limiting our energy expenditure. However, the individual can take responsibility for their lifestyle—in order to maintain a healthy weight and ultimately maintain their health. In order to make the appropriate lifestyle choices, the individual must have access to information and advice which is effective. Nurses are in an excellent position to disseminate such advice.
The Role of the Diet
Every day the public is being bombarded with messages to cut down on this, that and the other, so it is not a surprise to learn that they are confused about what they can eat. In addition, every week there appears to be a new ‘fad’ diet in the media, promising miraculous ‘quick-fix’ weight losses. The role of the nurse, therefore, is to advise on dietary strategies, which are evidence-based and have been shown to be most effective for weight loss in the long term. The most commonly accepted strategy for weight loss is a low-fat (<30% energy from fat) diet (Lindstrom et al, 2005). A recent meta analysis of over 16 studies has shown that even without conscious energy restriction, weight losses of over 4kg can be achieved by reducing the fat content by 10% (Astrup et al, 2001).
Foods that are high in fat tend to be energy dense, i.e. contain a high number of calories per gram (fat = 9 kcals/g). Energy dense diets tend to promote over-consumption of energy, resulting in weight gain. Therefore by substituting foods which are less energy dense, such as protein foods (protein = 4 kcals/g) and carbohydrate foods (starches and sugars = 3.75 kcals/g) results in a diet which is less energy dense, limiting total energy intake.
In addition, fatty foods have a very weak effect on satiety—they don’t fill you up—whereas carbohydrate and protein foods have a stronger affect on satiety, again helping to limit total energy intake. Epidemiological evidence confirms a strong positive association between high fat diets and high BMI, whereas there is a negative association between carbohydrate intake and BMI. There also appears to be an inverse relationship between dietary fat and simple carbohydrates—sugar—where individuals achieving a low fat diet tend to consume a higher proportion of sugar than those consuming a high fat diet (Bolton-Smith & Woodward, 1994). It may be that the inclusion of sugar improves the palatability of a low fat diet and promotes long-term compliance.
The challenge for the nurse is to come to a consensus with the patient on realistic dietary changes. The advice must be personalised, practical and realistic for it to be effective. Suggesting healthy alternatives rather than just highlighting the foods to avoid is a positive approach and may be more effective in changing the behaviour of the patient. Diets which are overly restrictive and unpalatable are difficult to comply with. Less restrictive dietary strategies which prioritise a reduction in dietary fat, whilst promoting carbohydrate (including sucrose) have been shown to be effective long term (Drummond et al 2004; Saris et al, 2000).
The advice given by the nurse could start by encouraging small achievable dietary changes based on the patient’s likes and dislikes as patients will find it difficult to comply with a diet which is very different from their habitual diet. For example:
- Focus on foods which should be included in the diet—lean
cuts of meat, bulky low energy dense carbohydrate foods such as fruit
and vegetables, pasta, boiled rice, baked potatoes, breads and cereals.
- Encourage a high carbohydrate breakfast to start the day—whether
it is toast and marmalade, Frosties, Weetabix or Muesli or Crunchy
Nut Cornflakes with low fat milk—all are low fat options.
- Advise to switch to a lower fat version of milk and dairy products—if
currently taking full fat milk—switch to semi-skimmed; if taking
semiskimmed—switch to fully skimmed.
- Avoid the ‘starve and binge’ approach to dieting! Do not skip meals!
There is evidence to suggest that a few small meals and snacks rather
than two or three large meals help to control appetite. However ensure
portion sizes are small—there is also evidence to suggest that
the ‘normal’ portion size has increased in recent years.
- Include one or two low-fat, high-carbohydrate snacks per day, such
as fruit, low fat yogurt, bagel with jam, dried raisons or apricots,
current bun, low fat cereal bar. This will improve the palatability
of the diet.
- Fat on meat is easy to recognise, as is butter on bread, but also
highlight high fat foods which are more difficult to recognise, such
as pies and pastries, sausages and burgers, mayonnaise and salad dressings.
- Encourage healthier cooking methods—fried streaky bacon should
be avoided but grilled lean back bacon is very acceptable.
- Encourage variety in the diet—at least 5 portions of fruit and vegetables should be eaten a day—encourage the patient to try new fruits and vegetables (fresh, tinned or frozen) for variety.
By focusing on a reduction of dietary fat and allowing other foods which may not normally be associated with a ‘diet’ (such as a small scone and jam for a mid morning snack), allows the adoption of an eating pattern more in line with the patient’s normal eating pattern and is more likely to succeed in the long term.
Although the Irish population is getting fatter, there has not been much change in reported energy intake in the Irish population over the past 10–12 years (McGowan et al 2001). However there is evidence that obese individuals have a reduced physical activity (both work activity and recreational activity) and view more television than the non-obese (Livingstone et al 2001). It is commonly accepted that as a nation we should be more active, but how much activity is enough to promote weight loss and prevent weight gain? Although the jury is still out on this one, the consensus appears to be between 45–60 minutes of moderate intensity activity per day (Wareham et al, 2005) will help prevent the transition from overweight to obesity. This may appear daunting to the patient who currently does little or no activity. The advice, therefore, would be to work up to this level of activity over a few weeks. In addition, the activity can be accumulated over the course of the day, so a brisk 20 minute walk three times a day may be more acceptable and easier to fit into a busy lifestyle than a solid hour of walking.
Again, as with dietary advice, the nurse must give practical advice tailored to the individual. If the patient mentions a favourite activity such as football or swimming, encourage them to get the whole family involved or team up with an ‘activity buddy’ as activity is more easily sustainable if exercising with others. Or if the patient has a garden, encourage more labour intensive gardening. If the patient works full-time and protests that they have no time to exercise, encourage them to be active in their lunch or coffee breaks or walk part of the way to work. Or if they have a dog, advise them to walk the dog more often! It is important that they agree on a strategy they feel they can fit into their lifestyle – if it is too ambitious it is more likely to fail. The effect of increased activity (or reducing the amount of time they are sedentary) on energy expenditure in promoting weight loss and weight control, can not be stressed enough. Studies have shown that those who include exercise in a weight reducing strategy maintain the weight lost and are less likely to regain the weight in the long term (Van Baak et al, 2003).
The scale of the obesity problem in Ireland is now so large that it cannot be dealt with by a few specialists alone. The potential role for nurses in the treatment of weight problems in the primary care setting should not be underestimated. By providing simple positive advice on diet and activity, nurses can offer the help and support patients need to motivate themselves to bring their weight under control and to reap the health benefits.