Opportunistic health promotion

Transcription

1 Opportunistic health promotion (or how do I tell my pa1ent they are fat? ) Dr KE Leedham-Green Department of Primary Care and Public Health Sciences, KUMEC

2 A quick survey Hold your hand to your chest and (privately) show me 1, 2, or 3 fingers 1. You have 1 member of your close family who is obese 2. You have 2 or more members of your close family who are obese 3. None of your close family are obese

3 A quick survey What most closely describes your attitude? 1. Obesity is concentrated among people from difficult socioeconomic backgrounds and we have a duty to address this health issue 2. Obesity is self-inflicted and the tax-paying public should not have to pay for their care 3. If people over-eat that is their choice, not my problem

4 A quick survey JB aged 11y, 100kg, in A&E for an ankle sprain What do you think happened next? 1. The medical student was able to raise the issue with their senior colleagues who confidently addressed the issue, arranging follow up with their primary care physician 2. Neither the medical student, nor any of their senior colleagues knew where to begin and the child was sent home with a bandaged ankle

5 A quick survey Your GP tutor asks you to give health advice to an obese woman who came in for a BP check Would you 1. Tell her to eat less and exercise more 2. Launch into your well-practised motivational interviewing techniques and agree a SMART goal with follow-up 3. Feel sick with fear

6 Barriers to addressing obesity Our judgemental attitudes Our nervousness at raising a sensitive topic Our uncertainty about what to say/advise Our lack of role models among senior colleagues

7 Why should we bother? 5 th leading risk for death worldwide (WHO) One of the fastest rising chronic diseases (DoH) 1.3bn direct costs to NHS (DoH) 4.2bn total costs incl overweight (DoH) 15.8bn cost to UK economy (DoH) Diabetes alone could bankrupt the NHS within 20 years (Daily Mail )

8 BRFSS, 1985 No Data <10% 10% 14%

9 BRFSS, 1986 No Data <10% 10% 14%

10 BRFSS, 1987 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%

11 BRFSS, 1988 No Data <10% 10% 14%

12 BRFSS, 1989 No Data <10% 10% 14%

13 BRFSS, 1990 No Data <10% 10% 14%

14 BRFSS, 1991 No Data <10% 10% 14% 15% 19%

15 BRFSS, 1992 No Data <10% 10% 14% 15% 19%

16 BRFSS, 1993 No Data <10% 10% 14% 15% 19%

17 BRFSS, 1994 No Data <10% 10% 14% 15% 19%

18 BRFSS, 1995 No Data <10% 10% 14% 15% 19%

19 BRFSS, 1996 No Data <10% 10% 14% 15% 19%

20 BRFSS, 1997 No Data <10% 10% 14% 15% 19% 20%

21 BRFSS, 1998 No Data <10% 10% 14% 15% 19% 20%

22 BRFSS, 1999 No Data <10% 10% 14% 15% 19% 20%

23 BRFSS, 2000 No Data <10% 10% 14% 15% 19% 20%

24 BRFSS, 2001 No Data <10% 10% 14% 15% 19% 20% 24% 25%

25 BRFSS, 2002 No Data <10% 10% 14% 15% 19% 20% 24% 25%

26 BRFSS, 2003 No Data <10% 10% 14% 15% 19% 20% 24% 25%

27 BRFSS, 2004 No Data <10% 10% 14% 15% 19% 20% 24% 25%

28 BRFSS, 2005 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

29 BRFSS, 2006 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

30 BRFSS, 2007 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

31 BRFSS, 2008 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

32 BRFSS, 2009 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

33 BRFSS, 2010 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

34 Why should we bother? Condi&on Mortality Diabetes Lipids Blood pressure Health benefits of modest (10%) weight loss 20 25% fall in overall mortality 30 40% fall in diabetes- related deaths 40 50% fall in obesity- related cancer deaths up to a 50% fall in fas@ng blood glucose over 50% reduc@on in risk of developing diabetes 10% fall in total cholesterol, 15% in LDL, and 30% in TG, 8% increase in HDL 10 mmhg fall in diastolic and systolic pressures Department of Health

35 When should we do this? When the patient asks for advice about losing weight? When the patient presents with obesityrelated pathology (e.g. diabetes)? At every opportunity?

36 How are you going to do it? Also ask about exercise and social/family factors

37 Motivational interviewing Explore their own reasons for change, don t preach Emphasise what positives the patient could get from change Explore, don t ignore reasons for resistance Resource: motivational interviewing for diet exercise and obesity toolkit/module-2/2-08-motivationalscripts.pdf

38 NICE guidelines Assess secondary reasons for obesity Medication (antidepressants, antipsychotics) Hypothyroid (low voice? coarse features?) PCOS (Hairy chin? Irregular periods?) Consider causal factors New baby? Just stopped smoking? Psychological factors, including early life events? Assess for obesity-related pathology Fasting glucose, lipid profile

39 Steer clear of anything extreme Balanced diets are realistic and achievable Fad diets can be dangerous and are not sustainable Very low calorie diets should only be attempted under specialist supervision Aim for 5-10% weight loss, not miracles e.g. 10kg over 20 weeks (0.5kg per week) Skipping breakfast is associated with weight gain

40 Exercise alone is not the answer 500 kcals = 1 hour high impact aerobics Burger, fries + soft drink = 2.5 hours But it complements and enhances the health benefits of dietary changes

41 Negotiate SMART goals

42 Encourage self-management Encourage the patient to come up with their own plan Suggest Keeping a food diary Starting a weekly weight chart Finding a friend to lose weight with Information sources for them to explore NHS LiveWell website British Heart Foundation Eating Well booklet DoH Your Health, Your Weight pamphlet dh_ pdf

43 Social prescribing Requires local knowledge Exercise programmes Weight loss support groups Ask your GP tutor and practice colleagues Do your own research Learn from your patients What worked / didn t work for them?

44 Follow-up Short term: to kick start change and to explore barriers Phone them in 2 weeks? Medium term: have they achieved their SMART goal? An appointment in 3 to 6 months? Long term: arrange for regular review (they are not out of danger) with maintenance as a goal

45 The 5 A s of behavioural intervention Your mental (and OSCE) checklist Ask Assess Advise (Agree) Assist Arrange Have a go at raising the issue opportunistically - What have you got to lose?

46 Some quotes from last year One of the things that worried me was how I would broach the subject of the patient s weight without disrupting rapport. However, I found in practice it was not actually as difficult as I had perceived I then spoke to the patient about her weight and took a dietary history using the ACTS mnemonic which was introduced to us in campus block. I thought it was a useful tool and provided me with starting questions from which I could take the history further. I think when discussing someone s weight in future, I would ask their dietary history sooner, I waited until we were quite far into the consultation to ask her, and I think it would have been more useful to know earlier on and discuss how it could be improved

47 Any questions? Department of Health