Introductory Certificate in Obesity, Malnutrition and Health
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sandra.campbell2@nhs.net Introductory Certificate in Obesity, Malnutrition and Health Workbook 1 Introductory Certificate in Obesity, Malnutrition and Health Workbook Software notice Please use Microsoft Word (preferable) or OpenOffice (free to download) to view, save and edit the workbook. If you are using OpenOffice, save the document as a ‘Microsoft Word 97/2000/XP (.doc)’, in the same dialogue box make sure make sure ‘automatic file name extension’ option is clicked. After clicking ‘Save As’, if it asks you either ‘Keep Current Format’ or ‘Save in ODF Format’, click ‘Keep Current Format’. Authors This resource was developed by members of the RCGP Nutrition Group, with input from Royal College of Nursing. Its development evolved after the initial writing of the RCGP Obesity and Malnutrition e-learning sessions referred to on p4. Peer review has been undertaken by GPs and nurses and piloting of the workbook in practice has been undertaken to shape the material for use as an ongoing training resource. Lead author: Rachel Pryke Section authors and editorial contributors: Carly Hughes, Sharon Thompson, Helen Parretti, Berenice Lopez, Zoe Williams, Chris Rufford, Claire Nwosu, Helen Donovan (RCN), Amanda Cheesley (RCN). Review date June 2017 Copyright © 2015 Rachel Pryke. Permission granted to reproduce for personal and educational use only. Commercial copying, hiring, lending is prohibited. May be used free of charge. Obtain permission before redistributing. In all cases this notice must remain intact. 2 Introductory Certificate in Obesity, Malnutrition and Health Workbook Your name [Type within these brackets] Glossary and abbreviations used BMI – Body mass index CPAP – Continuous positive airways pressure DAFNE programme – Dose Adjustment for Normal Eating, structured diabetes education programme DVT – Deep vein thrombosis FBC – Full blood count LELD – Low Energy Liquid Diet MUST – Malnutrition Universal Screening Tool NICE – National Institute for Health and Care Excellence OA – Osteoarthritis ONS – Oral nutritional supplement OSA – Obstructive sleep apnoea OSN – Obesity specialist nurse VLCD – Very Low Calorie Diet 3 Introductory Certificate in Obesity, Malnutrition and Health Workbook Introduction This self-directed blended learning resource covers factual knowledge plus the communication and behaviour change skills to put that knowledge into everyday practice. Behaviour change techniques are generic skills that can be applied to many aspects of health care and this training is suitable for all primary healthcare staff including practice nurses, GPs, school nurses, health visitors and other nonspecialist clinicians. Before completing this workbook it is recommended that you complete the following e-Learning sessions that are available through the RCGP e-learning platform http://elearning.rcgp.org.uk/course/view.php?id=147 1. Pre-course assessment (optional) 2. Community approaches to obesity prevention 3. The nature of adipose tissue and the impact of obesity 4. Understanding nutrition, malnutrition and hydration 5. Understanding eating behaviour 6. Encouraging weight loss using motivational interviewing 7. Obesity management options 8. Post-course assessment (optional) The sessions are free to RCGP and RCN members but require registering and logging on. Completion of these eLearning sessions can accrue 3 SCOPE points (Specialist Certification of Obesity Professional Education, run through the World Obesity Federation) for those wishing to pursue internationally recognised specialist training in obesity management. Further information about this arrangement is given in the resources section of each lesson. In addition, e-learning sessions on child obesity and understanding child growth are available to all NHS employees at https://www.minded.org.uk/ Direct links are at Growth and Nutrition: https://www.minded.org.uk/course/view.php?id=187 Understanding and tackling obesity: https://www.minded.org.uk/course/view.php?id=251 4 Introductory Certificate in Obesity, Malnutrition and Health Workbook Requirements for completing the Introductory Certificate in Obesity Malnutrition and Health A. Completion of 6 e-Learning sessions at http://elearning.rcgp.org.uk/course/view.php?id=147 (Pre and post course assessments are optional) Optional completion of child obesity sessions:Growth and Nutrition: https://www.minded.org.uk/course/view.php?id=187 Understanding and tackling obesity: https://www.minded.org.uk/course/view.php?id=251 B. Attendance at a hands on communication skills training session that covers behaviour change theory and motivational interviewing techniques.* C. Completion of three out of six reflective templates or audit tools in this workbook: Supporting behaviour change in practice Complex obesity scenarios Bariatric follow up Recognising and treating malnutrition Child obesity challenges and opportunities Promoting physical activity across the life course The self-directed learning certificate is at the end of this workbook for completion and can be printed off. * Behaviour change courses may be available in your locality. Alternatively, this workbook can be used to structure informal training sessions for small groups or local training. 5 Introductory Certificate in Obesity, Malnutrition and Health Workbook Workshop 1. Supporting behaviour change in practice Aims Get good conversations started Unlock the patient’s motivation Ensure goals are realistic – avoid setting up to fail. Tools OARS acronym Recognising sustain and change talk The importance ruler The confidence ruler Explore role play scenarios in small groups with patient, health professional and an observer. Exercise 1. Introducing the topic of weight Try these scenarios in role play situations to try out. Assume all patients are evidently overweight and the main presenting complaint has been dealt with. How might you begin to incorporate the patient’s weight into the conversation? What sentences work well? What phrases cause upset or risk a defensive response? Role play patients:- How does it feel to be challenged about a topic that is sensitive or difficult? Role player – patient Role player – health professional Mrs S requests stronger painkillers as [Type ] her arthritis has been really troubling her recently Miss T attends for her contraception [Type ] review and you notice she has gained 6 Introductory Certificate in Obesity, Malnutrition and Health Workbook visible weight since her last appointment Mr U comes in because he has failed his [Type ] driving medical because of high blood pressure Mrs V brings her 9 year old son Luke to [Type ] see you because his asthma is not well controlled at the moment Remember ‘safe starter’ questions – “Is it ok if I ask you about your weight?” “How do you feel about your weight?” “Do you keep an eye on your weight?” Exercise 2. Using the OARS acronym O Open questions - questions that encourage patients to think before answering and allow a choice in how to respond A Affirmation - acknowledge patient’s efforts, strengths and volitional choice R Reflective listening – guess and capture patient’s meaning S Summarise – pull together what’s been said Case scenario Consider Mrs W who is 41 with 3 young children and a new diagnosis of high blood pressure. She has a BMI 36 and a pattern of yo-yo dieting for years and admits feels defeated by her weight. She says ‘I’ve given up - I love eating cakes, the gym leaves me bored and baffled, there’s no point dieting as it never lasts and I hate being hungry.’ How can you address Mrs W’s sustain talk? Sustain Talk 7 How might you Introductory Certificate in Obesity, Malnutrition and Health Workbook How could you respond? encourage Mrs W to move towards Change talk? I love eating cakes and [Type ] [Type ] [Type ] [Type ] [Type ] [Type ] [Type ] [Type ] pastries I find the gym equipment confusing Whenever I’ve dieted before the weight’s always come back on I need to eat what I want otherwise I’ll feel miserable Try out phrases that use the Importance Ruler and the Confidence Ruler. The Importance Ruler On a scale of 0 – 10, 0 being not important and 10 being very important, how important is it for you to lose weight? Why are you at 8 not 4? Avoid the righting reflex – i.e. why are you at 6 not 8? This may prompt defensiveness and despondency The confidence ruler On a scale of 0-10 how confident are you that you can lose weight? Why are you at 7 not 4? What would it take to get you from 7 to 10? Exercise 3. Goal setting Remember SMART goals: SPECIFIC: instead of ‘I’m going to lose weight’ – ‘I’m going to lose 10lb’ 8 Introductory Certificate in Obesity, Malnutrition and Health Workbook MEASURABLE: a particular amount of exercise or number of pounds lost, for example ACHIEVABLE: always keep goals realistic to encourage success RELEVANT: goal must take person towards their stated aim TIME SPECIFIC: add a time scale to enable them to review their progress Use the SMART goals approach to guide your response to the following scenarios:- The patient chooses the following In what ways and when might you change: suggest the success of each action is measured? I am joining the gym [Type ] I’m going to start eating more fruit and [Type ] veg I’m going to start doing more home [Type ] cooking I plan to go swimming with the kids [Type ] Examples of challenging goals How might you respond? Why? sometimes suggested by patients I am going to lose 3 stone before my [Type ] holiday I’m so unhealthy that I’ve decided that [Type ] I’m going to lose weight and stop smoking The family are all unhealthy so I’m going [Type ] to ban all junk food I’ve signed up for a half marathon to [Type ] make me get fit 9 Introductory Certificate in Obesity, Malnutrition and Health Workbook References and Further reading BMJ essay (Free) 2015: Why there’s no point telling me to lose weight http://click.jwatch.org/cts/click?q=227%3B68129007%3BUC9jVnXGaVF%2BNvp3kw GTTeyTTju2w1EQV%2Fr5arsJBNg%3D RCN e-learning module Support behaviour change (First published: June 2014, Review due: December 2015) http://www.rcn.org.uk/development/practice/cpd_online_learning/support_behaviour_ change 10 Introductory Certificate in Obesity, Malnutrition and Health Workbook Reflective template: Supporting behaviour change in practice What What did I learn? How did this alter my previous understanding? List three ways that you could sensitively introduce weight into a conversation with an obese patient [Type ] [Type ] [Type ] So what Reflection / interpretation / analysis / evaluation Importance / impact on individuals and or practice Give examples of how you might respond to change talk [Type ] [Type ] sustain talk [Type ] [Type ] Now what Action points / change in practice / application to other situations In what ways could you encourage your patients to choose appropriate lifestyle change goals in future? [Type ] [Type ] 11 Introductory Certificate in Obesity, Malnutrition and Health Workbook Workshop 2. Complex Obesity Cases Aims To understand about tiered weight management options To understand how to tailor treatment options to individual patients This session will focus on complex cases of people with obesity and multi-morbidity. Severe obesity BMI >40 kg/m2 is the fastest growing category of obesity and adds an additional economic burden. A recent systematic review noted the disproportionate economic burden associated with severe and complicated obesity (1). Tsai et al report that the total healthcare costs of severe obesity account for 35% of the total obesity costs although only 15% of obese population have severe obesity. These people should be assessed and offered the appropriate service, with the expectation that most will attend a Tier 2 service initially. Tier 2 services include NHS and commercial groups, health trainers and some dietetic interventions. Activity interventions such as exercise on referral may also be useful. Commissioned Services Bariatric Surgery Multidisciplinary specialist weight management service; may be co-located with Tier 4, hospital based, or delivered in appropriate community facilities Lifestyle interventions, multicomponent including groups and/or individual interventions Universal interventions; public health, environmental and population wide 12 Clinical Care Tier 4 Pre-op assessment, Surgery, Post-op care Tier 3 Multidisciplinary specialist assessment and treatment, including pharmacotherapy, LELDs, and pre-bariatric surgery care Tier 2 Identification, primary assessment, referral and treatment using evidence based lifestyle intervention Tier 1 Information and advice on healthy eating and physical activity. Opportunistic identification in primary care Introductory Certificate in Obesity, Malnutrition and Health Workbook Those patients who do not achieve their weight loss goals, or are medically complex as well as any patients who wish to be considered for bariatric surgery be referred to a medical Tier 3 service, offering full multidisciplinary team (MDT) and multicomponent interventions. Tier 3 services may be based in secondary care/ bariatric surgery unit, at a local hospital, or based in primary care or the community with appropriate facilities. An example of a primary care service is the Fakenham weight management service (FWMS), which has been evaluated in detail (2). The clinical cases presented are based on patients from that service. Model of care FWMS First appointment (OSN) Data collection and dietary history, diet and exercise diary issues for baseline data Explanation of process and contract Second appointment (OSN/Physician) Discussion of medical risks of Obesity and health benefits of weight loss Target weight agreed 5% weight loss, and calorie allowance explained Discussion of completed diet diary 3 specific behaviours changes agreed Contract signed Dietician Psychologist MDT Discussion Accepted into programme Referral to additional therapists as appropriate Patients were referred back to MDT discussion when problems identified at any stage Health trainer For poor motivation Physician Medical problems, Consider Orlistat/ LELD/surgery Exercise professional Individual assessment, on site gym small groups Exercise referral programme At local gym 12 week Cookery classes Endocrinology/sleep studies OSN appointments (at least monthly) Energy balance and calories Food groups and portion sizes Labelling shopping and planning Increasing activity Specific personal goal setting Common pitfalls and relapse management Triggers for comfort eating, behaviour modification Weight maintenance Once a 5% target achieved a new target was agreed Discharged 1 year (6m IFR) + Optional long-term patient support group GP Care 13 Introductory Certificate in Obesity, Malnutrition and Health Workbook Bariatric Surgery Exercise 1. What Tier of service might the following people be suitable to access? Miss E, 45, chronic depressive illness, diabetic on oral [Type ] hypoglycaemic agents, lost weight on commercial VLCD but put it all back on, BMI 42 kg/m2, HBA1c 65, does not exercise Mr F, 48, has a BMI of 49 and was recently diagnosed with [Type ] diabetes. Ex- rugby player. OA knees. Not keen to attend ‘womens’ slimming group Mrs G, 37, has struggled with yo-yo dieting for years but feels [Type ] keen to try again. Her BMI is 31 and her HBA1c is 38. She has PCOS. Miss H, 28, had a baby 8 months ago and has recently [Type ] stopped breast feeding. Her BMI is 29 Mr J, 23, has been diagnosed with schizoaffective disorder [Type ] and has started on antipsychotic medication. He has gained a stone in 4 months, current BMI 33. Mr K, 52 recently moved from elsewhere. He had gastric [Type ] bypass surgery 5 years ago and you note that he is now newly hypertensive, having been off blood pressure tablets since his gastric bypass operation. He has not seen a specialist for 3 years. His BMI is 36. Exercise 2 - Cases Discuss each of the following cases in small groups, and answer the questions. The clinical history of the patients will be given on accompanying power point slides. Case 1 Mr A is a 46 year old Security Guard referred from his GP for 6 month intensive weight management programme. Initial weight 149.4 kg, BMI 51 kg/m2. 14 Introductory Certificate in Obesity, Malnutrition and Health Workbook Mr A has struggled with his weight for a number of years and now has degenerative changes to his L knee which is affecting his home and working life. The orthopaedic team say they will not operate on his knee until his BMI is < 30. Examination; no signs of endocrine abnormality. It was noted that both arms were significantly scarred. PMH; Asthma, depression and self-harm, impaired fasting glycaemia. Medication; Naproxen 500mg bd, Co-dydramol 8 a day Discussion points What would you want to know about Mr [Type ] A with regard to his ‘weight history’? Would you want to know more about his [Type ] mental health? And why? What first-line bloods would you [Type ] arrange? What would you consider to help him [Type ] lose weight? What do you think about the orthopaedic [Type ] surgeons setting a BMI target? Case 2 Mr C is a 41 year old man referred to Tier 3 weight management service from his GP for help with weight loss. Mr C had been seen at a regional bariatric surgery centre in the previous year but he then declined surgery at the last minute. Initial weight: 159.6 kg, BMI 50.4 kg/m2. He lives with his disabled wife and young family. He was previously a fisherman, now unemployed. Not active, sits at home playing games on computer all day. Examination; no signs of endocrine disease, normal heart sounds 15 Introductory Certificate in Obesity, Malnutrition and Health Workbook PMH; Severe obstructive sleep apnoea, osteoarthritis feet/hands. Medication; Nil Discussion points At his first appointment how would you [Type ] explore Mr C’s expectations for weight loss and his motivation? How could you motivate Mr C to become [Type ] more active? Mr C has severe sleep apnoea. What is [Type ] its relevance? What blood tests would you want to [Type ] arrange prior to referring a patient for bariatric surgery? What other information might the surgical [Type ] centre require? Case 3 Mr D is a 55 year old ex-smoker with type 2 diabetes (T2D) since 2006, who works as car breakdown repair man. Normal weight most of his life and was active and sporty, but increasing over the last 10-15 years, with 12kg weight gain in the last year. Initial weight 139kg BMI 42.9 kg/m2. He is on Insulin, liraglutide and gliclazide for T2D but thinks hospital monitoring ‘is a waste of time’ and does not attend. No hypo’s but he often omits his morning insulin. He does check blood sugars and changes his insulin dose on his own rules. He has not attended DAFNE programme or used Carb counting. He often misses breakfast, then has brunch fry up, followed by ‘garage food’ pies/pasties etc but eats better at home in the evenings. He is interested in bariatric surgery as he ‘wants his life back’ HBA1c 79mmol/l No diabetic nephropathy, normal FBC and renal function, cholesterol 6.7 16 Introductory Certificate in Obesity, Malnutrition and Health Workbook Examination; normal heart and lungs, left leg ulcer (longstanding), decreased vibration sense both ankles, BP 140/85, abdominal striae. PMH; OSA - was on CPAP but he has discontinued it and does not attend monitoring Severe OA both knees and ankles Spinal surgery decompression L4/5 laminectomy 2006 followed by DVT Medication; 200IU lantus insulin bd, Liraglutide 1.2mg daily, Gliclazide 80mg x4 daily Discussion points What are the medical issues that need [Type ] addressing, and how do you start? What dietary advice would be [Type ] appropriate? Is he a suitable candidate for bariatric [Type ] surgery? How would you counsel him about [Type ] bariatric surgery? References and further reading 1. E. Grieve, E. Fenwick, H-C, Yang and M. Lean. Obesity reviews 2013. The disproportionate economic burden associated with severe and complicated obesity: a systematic review. 2. Jennings A, Hughes C A, Kumaravel B, Bachmann M, Steel N, Capehorn M and Cheema K. Evaluation of a multidisciplinary Tier 3 weight management service 17 Introductory Certificate in Obesity, Malnutrition and Health Workbook for adults with morbid obesity, or obesity and co-morbidities, based in primary care. Clinical Obesity Oct 2014 http://onlinelibrary.wiley.com/doi/10.1111/cob.12066/full Responses to Exercise 1 Miss E: Tier 3 Mr F: Dietitian appointment individual or group as a new diabetic, or Tier 3 if he has attended the dietitian and needs more help Mrs G: Tier 2; health trainer or commercial slimming group Miss H: self-help advice or leaflet, health trainer, signpost to local mother and baby groups if appropriate, commercial slimming group Mr J: Tier 2 or may need Tier 3 with specialist psychological help. His medication needs to be reviewed if it is affecting his weight. Mr K: needs shared care protocol annual follow-up with GP and local Tier 3 or original bariatric centre as per NICE CG 189 Responses to Exercise 2 Case 1 Mr A Exploring Mr A’s ambivalence towards bariatric surgery would help shed light on his level of commitment to weight management approaches. Exploring his mental health and possible past history of self-harm would be important in considering which weight loss options would be suitable. A diabetic screen is indicated in view of past impaired fasting glycaemia. A LELD could produce significant and meaningful weight loss, eg around 20kg, in a properly supported individual. Resolution of knee pain and a reduction in analgesia are likely outcomes. The evidence for orlistat or LELD confirms small to modest potential weight loss that would be insufficient to meet the BMI target set by the orthopaedic surgeon. A bariatric procedure in a committed individual could achieve this target and may mean that an orthopaedic procedure was no longer required. Case 2 Mr C Exploring the reasons why Mr C cancelled his previous surgery then re-attended may demonstrate the drivers and barriers influencing his desire for weight loss. 18 Introductory Certificate in Obesity, Malnutrition and Health Workbook Intensive support with patient-led goals can begin to unlock personal motivation in some people. Fatigue and low mood arising from sleep apnoea may be part of a vicious circle resulting in profound inactivity. Treating sleep apnoea might help to boost the patient’s willingness to commit to lifestyle change. Exclude relevant conditions that can result in tiredness and weight gain, (e.g. anaemia, diabetes, thyroid disease, non-alcoholic fatty liver disease,) by checking FBC, HBA1c, thyroid function, kidney and liver function tests. Cholesterol measurement would be relevant in assessing cardiovascular and anaesthetic risk. Nutritional status, especially if bariatric surgery is being considered, could be assessed with ferritin, B12, folate and vitamin D. Ensure any known co-existing conditions, mental health problems or anaesthetic considerations have been reviewed prior to referral and are mentioned on referral. Case 3. Mr D Begin by assessing reasons behind his poor diabetic control and compliance with sleep apnoea treatment. Addressing poor compliance would help with any of the weight management options that he might consider. Dietary advice should be sought from a dietician or obesity specialist nurse in order for comprehensive advice to be given. The decision about bariatric surgery should be deferred until motivation and compliance have been addressed and medical treatment options have been tried. Careful consideration of anaesthetic and thrombotic risks would be relevant. Bariatric surgery may offer long-term health benefits in view of his diabetes, osteoarthritis and OSA. The decision could be revisited at a later point if medical treatment success is not maintained. 19 Introductory Certificate in Obesity, Malnutrition and Health Workbook Reflective template: - Complex Obesity management and post bariatric follow up What What did I learn? How did this alter my previous understanding? Describe how the different tiered weight management options could support obesity management in your practice [Type ] [Type ] [Type ] So what Reflection / interpretation / analysis / evaluation Importance / impact on individuals and or practice Consider an obese patient or family that you know who has complex needs. What patient factors might help you decide which management choices to offer? How easy or difficult might it be to introduce some of these ideas into a consultation? [Type ] [Type ] [Type ] Now what Action points / change in practice / application to other situations How confident are you about the local services available to your patients? Will your own approach to supporting obese patients change? [Type ] What benefits would arise from your practice establishing a register of post bariatric surgery patients? [Type ] 20 Introductory Certificate in Obesity, Malnutrition and Health Workbook Workshop 3. Bariatric follow up Aims To understand essential aspects of long term follow up after bariatric surgery To learn how routine care can be audited in order to improve quality of care Remind yourself of the RCGP Ten Top Tips on managing patients post bariatric surgery in primary care – brief summary 1. Keep a register of bariatric surgery patients and record the type of procedure in the register. Please note that follow up varies according to the type of surgery. 2. Encourage patients to check their own weight regularly and to attend an annual BMI and diet review with a health professional. 3. Symptoms of continuous vomiting, dysphagia, intestinal obstruction (gastric bypass) or severe abdominal pain require emergency admission under the local surgical team. 4. Continue to review co-morbidities post-surgery such as diabetes mellitus, hypertension, hypercholesterolaemia and sleep apnoea as well as mental health. 5. Review the patient’s regular medications. The formulations may need adjusting post-surgery to allow for changes in bio-availability post-surgery. 6. Bariatric surgery patients require lifelong annual monitoring blood tests, including micronutrients. Encourage patients to attend for their annual blood tests. 7. Be aware of potential nutritional deficiencies that may occur and their signs and symptoms. In particular, patients are at risk from anaemia and vitamin D deficiency as well as protein malnutrition and other vitamin and micronutrient deficiencies. If a patient is deficient in one nutrient, then screen for other deficiencies too. 8. Ensure the patient is taking the appropriate lifelong nutritional supplements required post-surgery as recommended by the bariatric centre. Ensure guidance regarding vitamin supplementation has been issued by the bariatric surgery team. Request a copy for the patient’s GP records if this has not been included in the discharge information. 9. Discuss contraception – ideally pregnancy should be avoided for at least 12-18 months post-surgery. 21 Introductory Certificate in Obesity, Malnutrition and Health Workbook 10. If a patient should plan or wish to become pregnant after bariatric surgery alter their nutritional supplements to one suitable during pregnancy. Inform the local bariatric unit of patient’s pregnancy and the obstetric team of the patient’s history of bariatric surgery. The extended version with full details of nutritional monitoring is at http://www.rcgp.org.uk/clinical-and-research/clinicalresources/nutrition/~/media/Files/CIRC/Nutrition/Obesity/RCGP-Top-ten-tips-forpost-bariatric-surgery-patients-in-primary-care-Nov-2014.ashx Discuss the issues in the boxes as you work through these two cases. Case 1 Mrs P. Mrs P, 32 years, had a gastric band fitted privately 5 years ago. She was followed up for one year then discontinued as she could not afford appointments. No comorbidities or medication. No discharge letter or discharge plan was received by her GP. Initial weight 117kg, BMI 40 kg/m2. One year post procedure weight 83kg, BMI 30.5 kg/m2, Weight loss was maintained for 2 years when she became pregnant with band-insitu. She reported telling her GP and Obstetrician but this was not documented in her notes and no review of her band took place. She was aware of the recommendation to have the band deflated during pregnancy but was unable to contact the surgeon to arrange for this to happen. Fetal growth tailed off from 34 weeks and she delivered at 37 weeks. Her baby’s weight was on 25th centile with normal development. She returned to her pre-pregnancy weight. Discussion points 1. What are the appropriate medical management interventions for patients with gastric band in situ in pregnancy? [Type ] 22 Introductory Certificate in Obesity, Malnutrition and Health Workbook What organisational factors might promote appropriate action by GPs and obstetricians in ensuring appropriate review of bariatric surgery in pregnancy? [Type ] Following a GP practice audit of post-bariatric patients, she responded to an invitation from the GP practice to attend for a review appointment. All post-bariatric bloods were normal. However she reported vomiting after normal sized meals at least twice a week. She agreed that her GP should contact the surgeon for advice. The surgeon felt the symptoms were significant, the band may have slipped, therefore he organised a follow up including barium swallow on the NHS. The barium swallow revealed that the band was in a good position with no evidence of pouch dilatation however it was too tight and 0.5mls of fluid was removed. Discussion points 2. Is vomiting twice a week to be expected with a gastric band? [Type ] What complications could be signified by vomiting? [Type ] Should other causes of vomiting should be considered? [Type ] Subsequently she put on 2 kg and then had further NHS follow-up with the surgeon to discuss re-filling the band. Discussion points 3. Where do you think responsibility lies for patients that received private treatment but can no longer afford private follow up? [Type ] 23 Introductory Certificate in Obesity, Malnutrition and Health Workbook Case 2 Mr Q Mr Q, 42 years old, had gastric bypass one year ago partly due to obstructive sleep apnoea. His initial weight was 147 kg, BMI 48 kg/m2. He dropped out of follow-up after 6 months, no letter to GP highlighting this. He came for GP review after invitation from his GP practice. He did not report any problems, but was on a diet with very little protein in it. He had lost a significant amount of weight (64.5kg), not had any blood tests and he had stopped using his CPAP without consulting the Respiratory team. Discussion points 1. How can the risk of being lost to recommended follow up be minimised? [Type ] What issues arise because of stopping use of his CPAP machine without assessment? [Type ] Post Bariatric bloods were done, and were normal. The practice established a bariatric register with a reminder to include bariatric review at the time of annual chronic disease monitoring. The bariatric unit were informed and rearranged further review. He was advised to continue his CPAP until he had had Respiratory clinic review. He was reminded that compliance with his treatment may affect his fitness to drive. He attended the Respiratory clinic and CPAP was withdrawn and then he was discharged. Further review at the Surgical Unit was declined due to the distances involved but the surgical team sent clear guidelines for on-going follow up to the GP practice. He was given advice on increasing dietary protein. Discussion points 2. What are the risks of loss to follow up? 24 Introductory Certificate in Obesity, Malnutrition and Health Workbook [Type ] What aspects of his care might you have done differently? [Type ] He is well, and active, taking his multivitamins to prevent long term nutritional deficiency, and promises to attend the GP annually to support his longer term weight maintenance. His weight has dropped further, and he is on the practice Bariatric surgery recall list to ensure he is recalled appropriately. 25 Introductory Certificate in Obesity, Malnutrition and Health Workbook Managing Patients Post Bariatric Surgery in Primary Care Audit Tool Instructions Introduction This audit tool is based on guidance from NICE guideline CG189 and RCGP guidelines for managing patients post bariatric surgery in primary care. It will support improvements to the management of patients post bariatric surgery in a primary care setting, ensuring appropriate regular review, management and referral for specialist input if required. It is suitable for use by GPs, practice nurses, community dieticians and other health professionals involved in the care of these patients. Aim To measure current practice against recommended standards and assist in implementing RCGP guidance on managing patients following bariatric surgery in primary care Target patient group All patients who have had bariatric weight loss surgery carried out 2 or more years ago and are not receiving regular follow up at their original bariatric unit. Standards Criteria Standard Exceptions 1. Record of date and type of surgery 100% 26 Introductory Certificate in Obesity, Malnutrition and Health Workbook No exceptions Annual monitoring of nutritional status, including: 100% No exceptions 100% No exceptions 100% No exceptions 100% No exceptions 2. annual blood tests 3. review of nutritional supplements (according to bariatric unit advice given for patient) 4. screening for signs and symptoms of nutritional deficiencies A. if present, referred to Tier 3/4 for advice 5. Annual measurement or review of the following: A. BMI B. Diet C. Monitoring of own weight D. Mental health E. Co-morbidities F. Regular medications G. Contraception (for female patients of childbearing age) 6. Screened for concerning symptoms If present, referred appropriately 7. Pregnancy or planned pregnancy discussion (for female patients of childbearing age) A. If yes, referred to O&G and bariatric unit B. If yes, supplements reviewed 27 Introductory Certificate in Obesity, Malnutrition and Health Workbook Audit Tool for Managing Patients Post Bariatric Surgery in Primary Care Aim To measure current practice against recommended standards and assist in implementing RCGP guidance on managing patients following bariatric surgery in primary care. Print off the audit tool to help you plan which aspects of your patient's follow up you will audit. Patient practice ID or NHS number Patient DOB Patient gender Patient ethnicity: 1. Date and Type of Surgery NHS or Private? Discharged from specialist follow up? Follow up guidance issued by specialist team? Date of procedure Gastric Band Sleeve Gastric Gastrectomy Bypass Duodenal Switch 2. Annual Blood Monitoring (as recommended by local bariatric unit or British Obesity and Metabolic Surgery Society) Blood Test Surgical Procedure Gastric Band Sleeve Gastric Gastrectomy Bypass A. LFT 28 Introductory Certificate in Obesity, Malnutrition and Health Workbook Duodenal Switch B. FBC C. Ferritin D. Folate E. Vitamin B12 F. Calcium G. Vitamin D H. PTH I. Vitamin A * J. Zinc, Copper ** *If long limbed bypass, steatorrhoea or night blindness ** Measure if concerns 3. Nutritional Supplements on Repeat Prescription Supplement Gastric Band Sleeve Gastric Gastrectomy Bypass Duodenal Switch Multivitamin and mineral supplement (can be OTC) B12 Injection 3 monthly Calcium and Vitamin D Iron Fat soluble vitamins and possibly Zn and Cu 4. Nutritional deficiencies screen Yes 29 Introductory Certificate in Obesity, Malnutrition and Health Workbook No Screened for signs or symptoms of a nutritional deficiency? Signs or symptoms of a nutritional deficiency present? If present, referred to Tier 3/4 for advice? 5. Annual Health Check Test Result A. BMI Review Tick if reviewed B. Diet C. Monitoring own weight regularly D. Mental health review E. Co-morbidities F. Review of regular medications post surgery G. Contraception 6. Concerning symptoms screen Yes No Yes No Screening for concerning symptoms such as vomiting, abdominal pain, heartburn, etc? Any concerning symptoms present? If present, referred to specialist? 7. Pregnancy 30 Introductory Certificate in Obesity, Malnutrition and Health Workbook Patient pregnant or planning pregnancy? If yes, referred to O&G and bariatric unit? If yes, nutritional supplements reviewed? Action plan Recommendation Actions required (detail action Action by (highlighted by audit as in progress, changes in needing action) practices, problems in date facilitating change, reasons why action not achieved Authors HM Parretti, C Nwosu, CA Hughes and RG Pryke Acknowledgments The authors would like to thank Mary O’Kane and Sean Woodcock, co-authors on the RCGP guidance for managing patients post bariatric surgery in primary care. References National Institute for Health and Clinical Excellence (NICE) (2014) Obesity: identification, assessment and management of overweight and obesity in children, young people and adults. National Institute for Health and Clinical Excellence. Available from: http://www.nice.org.uk/guidance/CG189 Parretti HM, Hughes CA, O’Kane M, Woodcock S and Pryke RG. RCGP Ten Top Tips for the Management of Patients Post Bariatric Surgery in Primary Care. (2014) 31 Introductory Certificate in Obesity, Malnutrition and Health Workbook Available from: http://www.rcgp.org.uk/clinical-and-research/clinicalresources/nutrition/~/media/Files/CIRC/Nutrition/Obesity/RCGP-Top-ten-tips-forpost-bariatric-surgery-patients-in-primary-care-Nov-2014.ashx 32 Introductory Certificate in Obesity, Malnutrition and Health Workbook Workshop 4. Recognising and treating malnutrition Aims To increase awareness of the risk of malnutrition in practice and use a screening tool To consider a variety of ways malnutrition can be addressed and clinical benefits this can bring These cases explore different causes of malnutrition risk and consider how they can be addressed. Review the Malnutrition Universal Screening Tool (MUST) scoring system - http://www.bapen.org.uk/pdfs/must/must-full.pdf Reported weight loss commonly triggers investigation in primary care, but less commonly triggers treatment of the weight loss. Refer to your local guidelines when considering treating malnutrition. Case 1. Mr L, 73, was widowed a year ago. He has chronic kidney disease and hypertension and is on an ACE inhibitor and diuretic. He reports loss of appetite, fatigue, poor sleep and weight loss of 4 kg. His BMI is now 25. He is unsteady and reports 2 falls. You notice several bruises of different ages. His son lives 70 miles away. Discussion points 1 What differential diagnoses might explain [Type ] this story? How would you assess Mr L’s risk of [Type ] malnutrition? How might you assess his level of [Type ] hydration/volume status? What aspects of his social situation [Type ] would you explore? What treatment options or support might [Type ] 33 Introductory Certificate in Obesity, Malnutrition and Health Workbook you consider, assuming no organic cause is found? Mr L reports some memory loss and admits to drinking heavily since he fell out with his son after his wife’s death. Discussion points 2 How would his alcohol intake influence [Type ] your decision about addressing his malnutrition? Who else might you involve in Mr L’s [Type ] care? Case 2. Miss M, 67, is bought in by her daughter with significant recent weight loss of 6kg, change in bowel habit, bloating and pain in her abdomen. She is found to have an abdominal mass and further urgent investigations are arranged. You suspect she is likely to be heading for surgery. Discussion points 1 How will Miss M’s recent weight loss [Type ] affect how she copes with surgery? What malnutrition treatments might you [Type ] consider before surgery? What are the goals of treatment before [Type ] surgery? Miss M is found to have metastatic adenocarcinoma of colon and has a large bowel resection but avoids having a colostomy. She makes a slow initial recovery due to a wound infection, losing further weight post-operatively. 34 Introductory Certificate in Obesity, Malnutrition and Health Workbook Discussion points 2 In what ways will improved nutrition alter [Type ] Miss M’s longer term recovery? What malnutrition treatments might you [Type ] consider over the following weeks and months? How might these change with time? What are the goals of treatment in [Type ] metastatic disease? Case 3. Mrs N, 80, lives in sheltered accommodation with carers twice daily, since she had a stroke a year ago. She has mild dementia, is prone to constipation, recurrent urinary tract infection and chest infections. You notice she is increasingly frail, with marked sarcopenia, visible weight loss and some dehydration. Her daughter lives locally. Discussion points What physical assessment (in addition to [Type ] examining chest, abdomen and urinalysis) would be useful? What social assessment would be [Type ] useful? What benefits would arise from [Type ] improving Mrs N’s nutritional care? Which services might help Mrs N to [Type ] remain independent? Consider ways that the following problems – if found - could be addressed Poor dentition [Type ] Difficulties in swallowing [Type ] 35 Introductory Certificate in Obesity, Malnutrition and Health Workbook Inability to do own shopping [Type ] Unable to cook or feed oneself [Type ] Experiencing financial difficulties [Type ] Excess alcohol intake or other substance [Type ] abuse Social isolation and loneliness [Type ] Further reading Managing adult malnutrition in the community http://www.malnutritionpathway.co.uk/ RCN Position Statement - Malnutrition: what nurses working with children and young people need to know and do. https://www.rcn.org.uk/__data/assets/pdf_file/0006/65499/malnutrition.pdf Responses (check after completion of exercise) Case 1. Mr L. Mr L may have an underlying organic illness including dementia, but equally may be suffering a depressive condition, social isolation with personal neglect or alcohol misuse. Include a medication review and remember to consider coeliac disease, HIV and TB. The MUST score can indicate risk of malnutrition. Hydration requires physical assessment, plus consider testing renal function. Patients who are off their food and drinks but remain on diuretics are at particular risk of hypovolaemia (low circulating blood volume). This is because decreased salt intake and on-going salt loss can result in a negative sodium balance, with consequent drop in blood pressure. Mr L’s independence and ability to self-care should be considered when planning support. A social services assessment may be relevant if self-care ability is inadequate, but some issues may be addressed practically, such as asking friends or neighbours for help with shopping or looking at sheltered accommodation. 36 Introductory Certificate in Obesity, Malnutrition and Health Workbook Putting in alcohol support to reduce alcohol intake is preferable to prescribing nutritional supplement. Improved nutrition from ONS (oral nutritional supplements) may paradoxically reduce impetus to tackle the underlying alcohol problem. Building bridges with the son by suggesting contact through a third party may be the best investment in this patient’s future. Befriending organisations may be relevant. Case 2. Miss M. Malnutrition affects hospital length of stay, wound healing and risk of infection as well as quality of life. Treating weight loss preoperatively may improve surgical outcome and post-operative recovery. Short-term prescribing of oral nutritional supplements should be considered if there is difficulty in consuming an energy-dense and nutritionally complete diet. Hydration should also be assessed and addressed if necessary. The goal is to avoid further weight loss prior to surgery and build up energy reserves to support recovery from surgery. Good nutrition can support more rapid return to independence after surgery, particularly where bowel functioning has been affected. Frailty is associated with increased falls risk, loss of confidence and reduction in mood. Oral nutritional supplement prescribing is appropriate initially but should be regularly reviewed, and tailed off when there is a return to normal eating. ‘Food boosting’ to increase the energy density of the diet without requiring large volumes is an alternative, but ensure adequate protein, vitamin and mineral content. Improved nutrition can support sense of well-being and promote quality of life in end of life care. Case 3. Mrs N. Co-existing infection, constipation and deteriorating dementia may all contribute to progressive weight loss. Consider oral problems such as dentition and dry mouth. Question food provision and intake in view of sarcopenia, which may reflect low protein intake as well as inactivity. Increasing frailty is linked to falls risk, fracture, infection and skin problems (sores, ulceration) any of which may reduce independence further. Support during meals to encourage intake; dietician advice to ensure appropriate foods are provided; social services review of ability to shop and prepare food. 37 Introductory Certificate in Obesity, Malnutrition and Health Workbook Reflective template: - Recognising and treating malnutrition What What did I learn? How did this alter my previous understanding? Describe three scenarios in which malnutrition screening might help with a patient’s care. [Type ] [Type ] [Type ] So what Reflection / interpretation / analysis / evaluation Importance / impact on individuals and or practice Explain why a patient’s care might be improved by addressing underlying malnutrition. [Type ] Now what Action points / change in practice / application to other situations How will your future care of patients at risk of malnutrition change? Who else in the primary healthcare team might you involve in their care? [Type ] [Type ] 38 Introductory Certificate in Obesity, Malnutrition and Health Workbook Workshop 5. Child obesity challenges and opportunities Aims To understand how child growth charts can support childhood weight monitoring To explore challenges in helping families to engage with long-term lifestyle changes. It is recommended to complete e-learning sessions on child obesity and understanding child growth prior to this workshop. https://www.minded.org.uk/ Direct links are at: Growth and Nutrition: https://www.minded.org.uk/course/view.php?id=187 Understanding and tackling obesity: https://www.minded.org.uk/course/view.php?id=251 In childhood, lifestyle change can produce a broad range of health benefits, although weight loss may not be an appropriate measure of those benefits. Tracking growth on an age- and sex- appropriate child growth chart is useful in monitoring progress. Exercise 1. Using UK child growth charts http://www.rcpch.ac.uk/child-health/research-projects/uk-who-growth-charts/ukgrowth-chart-resources-2-18-years/school-age#2-18 You will need copies of the female and male school aged charts aged 2-18 years. Plot the following measurements on an appropriate chart then consider the questions. Abbe, 5 years, girl Height 109cm Weight 18kg Bea, 8 years, girl Height 120cm Weight 28kg Cody, 12 years, boy Height 158cm Weight 50kg Dai, 15 years, boy Height 170cm Weight 85kg 39 Introductory Certificate in Obesity, Malnutrition and Health Workbook Check the centile lines and use the BMI centile ‘look up’ table on the growth chart. Alternatively an electronic calculator producing graphs of BMI is available at http://www.healthforallchildren.com/parents-page/bmi/ What is What is Is it necessary to What BMI range is height weight calculate BMI centile? this? Normal, centile? centile? (Y/N) BMI centile overweight, very overweight, or severely obese? Abbe, [Y/N] Bea, [Y/N] Cody, [Y/N] Dai, [Y/N] In pairs, practice explaining as if to a parent: How height and weight relate to each other, and the importance of looking at growth trends rather than one-off measurements. Whether BMI centile is normal, overweight, very overweight, or severely obese The concept of ‘growing into one’s weight’ for a child yet to reach adult height How a growth chart can help with monitoring weight in a child that has reached adult height. Exercise 2. Case examples Remind yourself of tactics that help children develop a taste for a wide range of healthy foods and to understand about appropriate portion sizes by reading Mealtime Magic! http://www.rcgp.org.uk/clinical-and-research/clinicalresources/nutrition/~/media/Files/CIRC/Nutrition/Obesity/Mealtime-Magic-leafletJune-2009.ashx . 40 Introductory Certificate in Obesity, Malnutrition and Health Workbook Lifestyle improvements for children include Increasing physical activity Encouraging regular family meals at a table Reducing ‘chaotic eating’, unhealthy snacking and sugary drinks Broadening the range of foods a child is happy to eat to improve the nutritional balance of the diet Choosing appropriate portion sizes Stopping eating when full Getting enough sleep Looking after teeth Taking time to share worries and concerns to support resilience and emotional health Case 1. Receptive family Jay, aged 12, and his mother attend. Mum explains that she had a letter from the National Child Measuring Programme (NCMP) last year saying he was ‘overweight’. The family have tried to be healthier and have been swimming a few times, but work pressures and money worries make it hard to ‘do the right thing all the time’. She wonders if you have any ideas as she doesn’t think Jay looks any different really. She says he seems fine in himself so she wonders if it is worth the effort. Where would you start? [Type ] Would you weigh and measure Jay today? How can you address the ambivalence [Type ] expressed here and find ways to evoke the case for change from Jay’s mother? What goals might you explore with Jay? [Type ] What goals might you explore with Jay’s mother? In what ways might a growth chart be [Type ] useful in supporting this discussion? 41 Introductory Certificate in Obesity, Malnutrition and Health Workbook Jay and his mother attend a follow up appointment for a further discussion and to check Jay’s weight and height. Jay is still in the ‘overweight’ range. What positive points about Jay’s ‘weight [Type ] trajectory’ could you explain to them even though Jay remains overweight? How might Jay’s stage of puberty [Type ] influence your discussion? Would you encourage a fitness goal, [Type ] dietary change goal or both? Case 2. Parents in denial The mother of Kay, 11 y brings her in because of a flare up of her eczema. After this has been dealt with she asks Kay to sit outside as she ‘wants a word’. She explains that she received a letter from the National Child Measuring Programme saying that Kay is ‘very overweight’. Mum is upset and defensive, saying that the result is clearly nonsense as Kay is very active and never sits still. She says ‘of course she eats plenty – she has to, to have enough energy for all the things she does. There are plenty of kids in her school that are fat, but she is not fat.’ You remember thinking subconsciously that Kay was quite stocky. How would you respond initially? How [Type ] could you show empathy? How might you begin to elicit change talk [Type ] rather than sustain talk? How might you suggest mum broaches [Type ] the issue with Kay? What follow up might you suggest? 42 [Type ] Introductory Certificate in Obesity, Malnutrition and Health Workbook Kay’s mum comments that the family’s diet is not that healthy and is interested to read about ‘Sugar swaps’ on the Change4Life website. http://www.nhs.uk/change4life/Pages/low-sugar-healthy-snacks.aspx How might the family get a sense of the [Type ] benefits from swapping to lower- sugar options? Would weight loss be a useful measure? How might you respond to a concern that [Type ] Kay is ‘always hungry’? What further ideas might you suggest to [Type ] build on the family’s sugar swap changes? Case 3. Defensive parents. 8 year old Elle comes in with her parents, both of whom are obese. She is an only child, visibly obese, asthmatic and prone to school avoidance due to recurrent abdominal cramps. She has been investigated extensively by the local paediatricians but nothing found other than constipation. She attends for a repeat prescription for asthma medication. Mum starts by saying that Elle’s asthma is terrible and that she needs a note for school so she can be excused from PE because “school are being really difficult”. Where would you head with this [Type ] conversation, assuming you have already discussed her asthma? How might you introduce the topic of [Type ] obesity with this family? Discuss how easy or difficult this [Type ] discussion might be – and reasons why. 43 Introductory Certificate in Obesity, Malnutrition and Health Workbook What services might be relevant and [Type ] acceptable to this family? How might you respond to the ‘note for [Type ] school’ request? Who else might you discuss this with? Elle’s mum explains that she and her husband dislike physical activity and won’t force Elle to do something she hates. “And she won’t eat vegetables even though the specialist told her to.” What realistic goals do you think the [Type ] family could be encouraged to consider? How would you explain ways in which [Type ] children can learn to develop a taste for new foods? What might be a realistic outcome from [Type ] your involvement? Further reading Managing overweight and obesity among children and young people: lifestyle weight management services http://www.nice.org.uk/guidance/ph47 RCPCH growth charts, 0-18 years http://www.rcpch.ac.uk/growthcharts Responses (check after completion of exercise) Exercise 1. What is What is Is it necessary to calculate Which BMI range - height weight BMI centile? normal, overweight, centile? centile? (Y/N) BMI centile very overweight, or severely obese? Abbe, 50th 50th N 50th Normal Bea, 9th 75th Y Above 91st Overweight 44 Introductory Certificate in Obesity, Malnutrition and Health Workbook Cody, 91st 91st Y Between 75th and Normal 91st Dai, 50th Above 98th Y Approaching 99.6th Very overweight (obese) BMI is required when the height and weight centiles are quite different or if weight is above 75th centile. Case 1. Jay Start by building rapport. Offer to measure height and weight once a positive discussion develops to avoid risk of alienation, which may be at a follow up appointment. The family brought up the subject so have concerns. Habits and attitudes learned in childhood commonly persist throughout life and so this is an investment in Jay’s long term health. Build on approaches that the family enjoy and feel are relevant to them. This may include dietary goals, snacking habits, physical activity or family routines. Childhood lasts a long time so small changes that slow down the rate of weight gain can stabilise a child’s weight pattern. A growth chart is useful in illustrating how excess weight gain has led to crossing to a higher centile, and how slowing down further weight gain can reverse this trend. In a child that has yet to reach adult height, weight loss is not an appropriate goal but tracking change in BMI centile is useful. Explaining the timescale for expected change can help families develop a realistic understanding. Avoiding further progression of overweight is a positive goal in itself. The growth chart centile lines reflect expected changes from puberty. Note that girls typically reach adult height much sooner than boys. Encourage the family to develop the goals that feel most relevant to them, but reign in unrealistic goals that risk a sense of predictable failure. Check how the family plan to measure progress of what they choose. Case 2. Kay Building rapport is vital before being able to create a receptive platform for challenging Kay’s mother’s misconceptions. Building on any evident physical activity strengths can open up a positive discussion about other aspects of health such as her weight. 45 Introductory Certificate in Obesity, Malnutrition and Health Workbook Suggest an example such as ‘Take 5’ chart for all the family. Children do lots of work on being healthy in schools, so suggesting that mum asks Kay what she would like to do to be healthy may make this easier than mum expects. A joint appointment with mum and Kay would enable further growth monitoring to be offered and to discuss progress goals together. Swapping sugary foods to more nutritious, starchy ‘slow-release’ options (eg swapping to a healthy breakfast cereal each morning) could improve constipation, concentration at school, reduce tendency for unhealthy snacking, reduce hunger, improve dental care and gradually reduce risk of overweight and obesity. Weight loss may take a long time and so the time scale for expecting this needs to be realistic. Ideas include:- Look at portion sizes, reduce sugary drinks, save treats for special times, check if fruit and vegetable intake meets recommended amounts, set physical activity goals, eat together as a family, and limit screen time. Case 3. Elle This will not be an easy or short discussion so consider bringing the family back to a further appointment. Safeguarding issues should be borne in mind if a child remains symptomatic despite extensive negative investigations. Parental understanding and engagement is important to assess. Explore whether obesity has been explored by the paediatricians already and how the family feel about this. Where sensitivities emerge, discussing dietary change in relation to constipation, irritable bowel symptoms and abdominal pain can provide less sensitive starting points. Where obesity is a significant family issue, multidisciplinary input is likely to be required and so will depend on availability in each locality. Agreeing with a sick note in this situation would, in effect, be collusion with the parents’ denial and should be resisted. Involve the school nurse and possibly the head teacher, to ensure that positive support to overcome concerns can be provided by the school. Realistic goals include moving to a higher fibre diet by giving specific suggestions of higher fibre foods, plus further resource ideas e.g. NHS Choices, plus working with the school to ensure Elle partakes in appropriate physical activities. Helping the family to engage in longer term review of Elle’s health issues would be very valuable. Remaining motivated typically requires ongoing support, particularly if the family were referred to a multidisciplinary service. Change is likely to be slow, but continuity of care in primary care may enable future consultations to build on early positive discussions. 46 Introductory Certificate in Obesity, Malnutrition and Health Workbook Reflective template: - Child Obesity challenges and opportunities What What did I learn? How did this alter my previous understanding? Summarise three positive suggestions as to how you could begin discussing child obesity with families in your practice [Type ] [Type ] [Type ] So what Reflection / interpretation / analysis / evaluation Importance / impact on individuals and or practice Consider an obese child or family that you know. List 3 barriers that a family might face in adopting a healthier lifestyle. [Type ] [Type ] [Type ] List 3 lifestyle change suggestions and how they could be measured by the family. What impact does goal setting have on motivation? [Type ] [Type ] [Type ] Now what Action points / change in practice / application to other situations How confident are you about the local services available to your patients? Will your own approach to supporting families with an obese child change? [Type ] 47 Introductory Certificate in Obesity, Malnutrition and Health Workbook Workshop 6: Promoting physical activity across the life course Aims To compare physical activity guidelines for different circumstances To explore how physical activity advice can be put into context alongside other important health priorities. Physical activity recommendations and fact sheets are available at https://www.gov.uk/government/publications/uk-physical-activity-guidelines Case 1. TT, a 35 year old factory worker, mentions that he would like to lose weight by taking up exercise as he and his partner are hoping to start a family. He has not seen a doctor for 10 years. His waist circumference is 101.5cm (40 inches) and BMI 38. How would you respond to this [Type ] suggestion? What are the risks to this patient in [Type ] undertaking exercise? What problems might TT experience? [Type ] How could you help to maximise TT’s [Type ] chances of continuing with regular exercise? Case 2. DD is a 33 year old solicitor who is 8 weeks pregnant. She is obese and also a heavy smoker. Her main recreational interest is horse riding but she enjoys walking and SCUBA diving too. How do the health priorities, smoking, [Type ] obesity and physical activity, each affect 48 Introductory Certificate in Obesity, Malnutrition and Health Workbook pregnancy? How would you advise her on exercise [Type ] during pregnancy? How would you advise her on weight [Type ] control during pregnancy? What concerns might Debbie have [Type ] regarding physical activity during pregnancy? How might physical fitness influence [Type ] potential problems during the Antenatal period? During labour? Postnatally? Case 3. GG is 60 years old and always enjoyed running, but is now suffering from L knee pain. On examination he has mild quadriceps wasting, reduction in flexion of the knee with patellofemoral joint crepitus. A recent x-ray shows osteoarthritis changes. He is keen to keep running and asks about glucosamine and fish oil. What advice would you give him? [Type ] How does exercise cause osteoarthritis? [Type ] How does exercise help osteoarthritis? [Type ] What type of exercise is recommended? [Type ] Can dietary supplements help? [Type ] Individualising physical activity guidance for different circumstances Compare the following scenarios by considering these four questions for each person:49 Introductory Certificate in Obesity, Malnutrition and Health Workbook 1. How would increasing physical activity 2. How could you help to overcome the help? perceived barriers re being more active? 3. How can you ensure that the goals a 4. Is there any particular support or patient chooses are ‘SMART’*? service that might help? (Specific, measurable, achievable, realistic and time-bound?) KM, a 15 year old student in mainstream [Type ] school, walks with a frame due to cerebral palsy. Weight gain and tends to comfort eat when bored. “I wish I could run around like my mates” ID, 51 year old accountant, who recently [Type ] completed chemotherapy after a mastectomy for breast cancer, attends with her husband, lacking energy and requesting a ‘tonic’. Her protective husband almost cancelled saying ‘She shouldn’t leave the house’. They have a Labrador dog, Molly. VS, 87 years retired nurse who attends for [Type ] medication review for hypertension. Anxious re health, widow, frail and doesn’t often leave the house. She is afraid of becoming a burden on her family. PD, 45 year old bus driver, has had 3 [Type ] raised HBA1c readings and attended DESMOND and dietician. No improvement in HBA1c hence now starting metformin. 50 Introductory Certificate in Obesity, Malnutrition and Health Workbook He used to play football ‘when I was a lad’. References and further reading NICE PH27: Weight management before, during and after pregnancy, (2010). http://www.nice.org.uk/guidance/ph27 Information on physical activity for pregnant patients (updated February 2015): http://www.nhs.uk/conditions/pregnancy-and-baby/pages/pregnancyexercise.aspx#close Information on a range of physical activity topics, including guidelines for different age groups, Couch to 5K programme, plus sitting, balance and strengthening exercises. http://www.nhs.uk/livewell/fitness/Pages/Fitnesshome.aspx A series of free BMJ Learning modules on the health benefits of physical activity are available online:Physical activity in the treatment of long term conditions (Oct 2014) http://learning.bmj.com/learning/courseintro/physical%20activity.html?locale=en_GB&courseId=10051913 Responses to Case 1. TT. Build on the patient’s positive plans by supporting feasible expectations and realistic goals. Within the discussion, raise awareness of the aches and pains that a new regime might trigger and that a gradual programme is recommended, such as the Couch to 5K programme. Explain that exercise, whilst highly beneficial for health over all, will only result in weight loss if there is calorie restriction at the same time. Otherwise the body compensates for increased exercise by feeling hungrier and hence eating more to make up for energy expended. A measure of fitness might be a better measure of success than looking for weight reduction from an exercise programme. Case 2. DD Addressing smoking would bring the largest benefit in pregnancy, but dietary improvements (“putting the good things in”) and increased exercise can all contribute to well-being and health, as well as to fetal health. Restrictive dieting is not recommended in pregnancy, but weight loss that results from making dietary improvements to create a nutritionally healthy diet will be safe for mother and baby. Dispel the myth of ‘eating for two in pregnancy’ – instead eat healthily for one. Increased fitness helps women cope with their changing shape 51 Introductory Certificate in Obesity, Malnutrition and Health Workbook in pregnancy and can reduce problems in later pregnancy, labour and recovery after delivery. Scuba diving is contraindicated in pregnancy. Caution is recommended re horse riding, sports such as skiing or skating, or contact sports because of increased risk of falls or injury to the pregnancy. Case 3. GG Exercise is helpful in arthritis in reducing stiffness, improving joint movement, strengthening muscles, supporting weight management, helping balance and maintaining bone density. It also improves mental health and self-confidence. Signpost to a resource suitable exercise such as at http://www.arthritisresearchuk.org/arthritis-information/exercises-to-managepain.aspx Some evidence supports fish oils (care needed to avoid overdosing of vitamin A) and glucosamine sulphate but the evidence is not strong. Individualising physical activity guidance - themes Address underlying fear of physical activity and perceptions that being more active may harm an existing condition. Fears may stem from carers and family as well as the individual. Explore and encourage what an individual is able to do rather than dwell on their restrictions and limitations Recognise the impact of mental health concerns on engagement and confidence in physical activity. Address low mood or depression to ensure that physical activity goals are part of a positive holistic approach and not perceived as an additional burden. 52 Use motivational interviewing concepts to address ambivalence and priority setting. Introductory Certificate in Obesity, Malnutrition and Health Workbook Reflective template: - Promoting physical activity across the life course What What did I learn? How did this alter my previous understanding? Summarise three approaches that can help your patients increase their participation in physical activities. [Type ] [Type ] [Type ] So what Reflection / interpretation / analysis / evaluation Importance / impact on individuals and or practice Consider one of your patients with multi-morbidity. List 3 ways that you could help them adopt physical activity into their routines. What impact does goal setting have on engagement with physical activity? [Type ] [Type ] [Type ] Now what Action points / change in practice / application to other situations How confident are you about accessing the local services that are available to your patients? Could your healthcare setting improve its signposting towards local facilities? [Type ] 53 Introductory Certificate in Obesity, Malnutrition and Health Workbook Introductory Certificate in Obesity, Malnutrition and Health A. RCGP Obesity and Malnutrition E-learning sessions completed:Date 1. Pre-course assessment [ ]/[ ]/[ ] 2. Community approaches to obesity prevention [ ]/[ ]/[ ] 3. The nature of adipose tissue and the impact of obesity [ ]/[ ]/[ ] 4. Understanding nutrition, malnutrition and hydration [ ]/[ ]/[ ] 5. Understanding eating behaviour [ ]/[ ]/[ ] 6. Encouraging weight loss using motivational interviewing [ ]/[ ]/[ ] 7. Obesity management options [ ]/[ ]/[ ] 8. Post course assessment [ ]/[ ]/[ ] B. Study day/workbook session completed [ ]/[ ]/[ ] C. Reflective Templates or audit tools completed (3 to be completed):1. Supporting behaviour change in practice [ ]/[ ]/[ ] 2. Complex obesity scenarios [ ]/[ ]/[ ] 3. Bariatric follow up [ ]/[ ]/[ ] 4. Recognising and treating malnutrition [ ]/[ ]/[ ] 5. Child obesity challenges and opportunities [ ]/[ ]/[ ] 6. Promoting physical activity across the life course [ ]/[ ]/[ ] This confirms that [Name ] completed the requirements for the Introductory Certificate in Obesity, Malnutrition and Health on [ ]/[ ]/[ 54 Introductory Certificate in Obesity, Malnutrition and Health Workbook ]
