Obesity and overweight is arguably the largest and most complex non-communicable disease of the 21st century, threatening future progress in reducing preventable ill health, premature death and addressing unacceptable health inequalities in the UK. Around two-thirds (63%) of adults are above a healthy weight and, of these, half are living with obesity. In England, one in three children leaving primary school are overweight or living with obesity. Living with overweight or obesity is linked to a wide range of diseases, most commonly type 2 diabetes, hypertension, some cancers, heart disease, stroke and liver disease (Department of Health and Social Care (DHSC), 2020; Hancock, 2021). Overweight and obesity terms and body mass index (BMI) ranges are set out in Table 1 and Table 2.
Table 1. Common terms and classification relating to overweight and obesity
| Term | Explanation |
|---|---|
| Excess weight | Classified by the National Institute for Health and Care Excellence as an adult living with overweight, obesity or severe obesity with a BMI ≥25 kg/m2. BMI cut-off for treatment services are lower for certain minority ethnic groups than white groups; 23kg/m2 indicates increased risk and 27.5kg/m2 indicates high risk, respectively |
| Obesity | Obesity is assessed using the Body Mass Index (BMI) method (person's weight (kg)/person's height (in metres²). Waist circumference alongside BMI gives a more detailed assessment of an individual's health risk |
Source: NICE, 2014
Table 2. BMI ranges and categories
| BMI range | BMI category |
|---|---|
| Less than 18.5kg/m2 | Underweight |
| 18.5 to <25kg/m2 | Healthy weight |
| 25 to <30kg/m2 | Overweight |
| 30 to <40kg/m2 | Obesity |
| 40kg/m2 | or more Severe obesity |
Source: NICE, 2014
A complex public health challenge, overweight and obesity is driven by social, economic, biological, environmental and cultural factors that influence people's lives and behaviour (Butland et al, 2007). These drivers, compounded by the wider social determinants of health, affect people differently, resulting in inequalities. This means that the prevalence of obesity is greater for people living in more deprived areas, among older adults, and in some ethnic communities (Public Health England (PHE), 2020a; Hancock, 2021; Tedstone and McManus, 2021).
Nurses in all sectors are likely to engage daily with people living with overweight or obesity. It is therefore imperative that they understand the complex causative factors, can listen empathetically and provide these people with the support needed to reduce or manage potential poor health outcomes.
As England progresses along the roadmap to recovery from the COVID-19 pandemic, taking steps to create health-promoting environments has never been more important. Clear opportunities for this are outlined in the Government's Obesity Strategy (DHSC, 2020). As the largest registered professional workforce within the health and care system and the most trusted, nurses, play a vital role in the strategy's success.
Obesity and the pandemic
Research during the COVID-19 pandemic has illustrated the serious impact that obesity has on a person's physical and psychological health (PHE, 2020b; 2020c; Brown et al, 2021). It also plays a significant role in health outcomes for people coping with a life-limiting disease (Newton et al, 2015). For example, people living with excess weight who contracted COVID-19 were more likely to experience severe illness, which required intensive care or resulted in death (PHE, 2020b).
During the pandemic, nurses have adapted service delivery practices to accommodate the need for social distancing and isolation. For example, the use of internet-based (online) delivery mechanisms enabled nurses to support people in their homes. In addition, people's increased familiarity with the use of smartphone technology has also allowed nurses to share health information using apps. For example, the Better Health campaign, developed by PHE, supports adults living with overweight or obesity to look after their physical and mental health in combination rather than in isolation (PHE, 2021a). The Better Health campaign provides practical approaches to increasing physical activity, positive mental health and losing weight.
For example, the NHS 12-week weight loss app provides easy to follow information and support to help people manage their physical and mental health when losing weight. It includes information about calorie intake, dietary choices and food preparation, as well as how to manage mental health through lifestyle changes, including daily exercise.
However, some people may not have access to the internet or own a smartphone or computer and so therefore apps are only part of the solution. As such, local approaches to promote a healthier weight, which can be tailored to how people live their lives, remain vital (DHSC, 2021). Such place-based approaches can help design ways to enable underserviced communities to access, engage and maximise the benefits provided (Blackshaw and Van Dijik, 2019; PHE, 2020a). This is particularly important as people living in more deprived areas may have limited access to safe and quality green spaces. Moreover, local high streets may be saturated with outlets providing and marketing foods and drinks high in fat, salt, sugar and calories, with less prominence given to healthier options. This means that, despite good intentions, the people most in need of public health strategies and services are often the ones least likely to be able to access or use them. The principle of the ‘inverse care law’ has been recognised for more than 50 years; however, the pandemic has made the impact more explicit (Hart, 1971).
Enhancing knowledge and confidence to act
To support all health and care professionals to enhance their knowledge and act to help the population address overweight and obesity, PHE has published online e-learning resources. The All Our Health (PHE, 2019) framework is a call to action for all health and care professionals to embed prevention, early intervention and health improvement in their day-to-day practice. Current resources include content focusing on obesity in children and adults, and an interactive townscape that explores a place-based approach to tackling childhood obesity. These resources have been purposely designed for health and care professionals to provide bite-sized learning and action-based summaries to enhance their public health impact.
Conclusion
As we start to focus on the recovery phase of the COVID-19 pandemic, nurses must appraise the lessons learnt and consider the changes needed to ensure that we truly build back better and fairer. It will be essential that we use the 2020s as a decade of transformation, which allows our nursing profession to challenge the way that we work—to pay the same attention to preventing, protecting and promoting the health and wellbeing of the public as we do to treating ill health and disease. In this way, we will be able to adapt the nursing model so it enables the workforce to address health inequalities and the unacceptable outcome differences that have been amplified by the pandemic. Given the threat that overweight and obesity poses to the public's health, they must be central to any future model.
CASE STUDY
Priya, aged 57, was originally from India, and has now lived in England for more than 40 years. She is the carer for her elderly mother, husband and five children, who all live at home.
As the practice nurse, you have been seeing Priya monthly because her GP was concerned about her increasing weight. With a BMI of 28kg/m2, you know that Priya is at increased risk of developing type 2 diabetes, and having recently completed PHE's (2019) All Our Health Adult Obesity e-learning resource, you are aware that this also puts Priya at increased risk of several other diseases, including heart disease, stroke and liver disease.
Through monthly contact you have got to know Priya and see that she has very little time for herself. She recounts the time spent preparing family meals, and how her husband does the food shopping so she can supervise her mother. In the pandemic, you have relied on telephone conversations to assess her progress.
During the pandemic, Priya's weight has increased. She has been too worried to focus on her diet and has found it hard to exercise due to caring responsibilities. Today you calculate her BMI is now 31kg/m2, and the results of her recent HbA1c blood test suggests that she has developed prediabetes.
During your telephone conversation, you know you must explain the diagnosis to Priya and use a health-coaching approach to agree on what action she would like to take. You recognise the complexity of this issue, so decide to offer Priya twice-weekly telephone appointments over the next 2 months, rather than covering this in one appointment.
You want to establish a way that will help Priya to identify for herself that integrating lifestyle changes relating to diet and physical activity into her daily routine will help her to reduce her weight. Recognising that it is also important to monitor the prediabetes, you decide that your first task is to address the most likely cause of the prediabetes (excess weight). Addressing both major issues concurrently may leave Priya at risk of not being able to manage either problem.
Priya is worried about her weight and tells you that she wants to focus on eating less and has arranged with her sister-in-law to walk in the local park each day. Her daughter, who is 18, has agreed to supervise her grandmother at those times. When you next talk to Priya, she tells you that she has been using the ‘Couch to 5k’ app that you recommended and had managed to walk each day for the past week (PHE, 2021b). She is also using a smaller dinner plate at mealtimes to reduce her portion sizes. Her weight has reduced by 1 kg.
Despite having little impact on her BMI, you know that this is a significant breakthrough for Priya, because it illustrates her ability to take control and engage with the health information you have shared.