Health promotion: quick wins
Health promotion – preventing illness and promoting health to enable people to achieve their optimal wellbeing for life is the essence of primary care. Sometimes, though, in our busy professional lives do we just pay lip service to the fundamentals of people’s health?
Obesity, physical inactivity, smoking and excessive alcohol intake are all lifestyle choices which have a significant and serious impact on wellbeing and are huge risk factors for poor health and premature death.
Some consultations naturally lend themselves to discussing lifestyle choices: discussing smoking habits during an asthma review, for example, or measuring Body Mass Index (BMI) in a contraceptive consultation to aid choices. NHS health checks and management of chronic disease are so much about promoting a healthier lifestyle and working with patients to find ways to improve their diet or increase activity on an individual basis. But what about the patient who attends with a minor injury? All nineteen stone of him is sitting in your room and you can smell the cigarettes on his breath. He just wants you to patch up his wound – he hasn’t come for a lecture on his 30-a-day habit and sedentary lifestyle. We’re supposed to make every contact count. However, do we, and should we?
Opportunity, time, and, it has to be said, inclination, can affect how we tackle the often thorny issues of someone’s obesity, heavy smoking habits or complete lack of desire to do any physical activity as they are not always easy subjects to broach. We have heard all the reasons under the sun why someone can’t lose weight, or why they’ve restarted smoking after five attempts at giving up, but that doesn’t mean we should stop trying. Let’s revisit the basics, look at the most recent guidance for our adult population and find ways in which we can try and implement health promotion in our consultations.
FACTS AND FIGURES
The scale of the life-style related disease in adults
Obesity is on the rise. Data published this year by the Health and Social Care Information Centre (HSCIC) shows that 58% of women and 65% of men in England were overweight or obese, with obesity being the fourth largest risk factor for death.1 It is a major public health issue contributing to serious chronic disease and premature death (see Table 1) and the greatest risk factor for type 2 diabetes (T2D). If current rates continue, one in ten people will develop T2D by 2034.2
A recent study published in the Lancet, as part of its Physical Activity Series, calculated that in Europe one in seven premature deaths could be prevented if people maintained a healthy weight.3 According to Public Health England (PHE), a quarter of the adult population are physically inactive, doing less than 30 minutes of moderate physical activity each week.4 Inactivity – whether a person is overweight or not – is a significant risk factor for preventable chronic disease and mortality, and is a global pandemic.3
Smoking, clearly a significant public health issue, is the primary cause of preventable disease and death.5 Although the number of adults smoking in the UK has reduced dramatically from its height in the 1970s when 46% of the population smoked, to around 19% in 2014, there are still 9.6 million adult smokers in Great Britain with the highest incidence in those aged 25-34.6 Approximately 96,000 people die in the UK annually due to smoking-related diseases.5
More than 9 million people consume more than the recommended daily limits for alcohol in England with an estimated 7.5 million oblivious to the effects of alcohol on their health.7 Alcohol costs the NHS in the region of £3.5 billion per year.8 In 2014-15 an estimated 1.1 million people were admitted to hospital with an alcohol-related condition or injury with 6,831 deaths attributed to alcohol consumption.9
Conversely, losing weight, becoming more active, stopping smoking and reducing alcohol intake is going to have a positive effect on physical and mental health and wellbeing, as well as reducing the risk of serious disease and illness whilst also reducing the cost to the NHS.
OBESITY
Becoming overweight and obese – abnormal or excessive fat accumulation that can impair health – is, in theory, preventable.10 Tackling obesity, however, is a huge challenge for society and no less so in primary care. Improving diets high in energy-dense foods, and instigating or building on physically active behaviour is integral to controlling weight. BMI, despite its limitations with age, ethnicity and muscle mass, is still considered the measurement of choice in adults of both sexes to give a rough guide of what is considered overweight. WHO10 definitions are:
- Overweight – BMI greater than or equal to 25kg/m2
- Obesity – BMI greater than or equal to 30kg/m2
An excess of abdominal fat around the waist, seen in ‘apple-shaped’ people, is known to increase a person’s risk of heart disease, T2D and stroke; therefore waist measurement is also a useful indicator of determining obesity. Men who have a waist measurement of more than 102cm are five times more likely to develop T2D, whereas women are three times more likely to develop the condition with a waist measuring more than 88cm.11 Healthy eating is at the heart of preventing ill-health and reducing the risks of overweight and obesity. The following principles are behind NICE’s 2015 Guidance for preventing excess weight gain:12
- Maintain a combination of increased physical activity and healthier dietary habits;
- Follow national guidance of healthy eating to ensure appropriate energy intake;
- Avoiding extreme physical activities or dietary behaviours which are difficult to sustain and have little evidence to support long term health benefits;
- Identification of habits, situations and perceptions regarding food and eating habits which can undermine efforts to maintain or prevent weight gain;
- Encouraging self-monitoring through weight checks, note taking, apps and web-trackers.
PHE’s ‘Eatwell Guide’, launched in March of this year, is based on the Government’s new recommendations for an overall balance for a healthy diet.13 It replaces the ‘Eatwell Plate’ to reflect updated evidence. The guide recommends that portion size and frequency of meals should be tailor-made to individual requirements based upon each patient’s current diet and food preferences.
There are numerous resources to help patients understand more about nutrition, healthy eating behaviours and weight loss plans. The British Dietetic Association (BDA) looks at some of the more popular weight loss plans in the UK on the NHS Choices website, which may be useful to discuss with patients who may be embarking on the latest fad.14 The principles of healthy eating may be straightforward but tackling weight loss is far from it and making a meaningful lifelong commitment to change needs support, huge amounts of encouragement and positive feedback.
PHYSICAL ACTIVITY
Society has changed: in today’s world, technological advances have taken over both our home and work lives, we rely more on transport and fewer people do manual work. Consequently, we are more sedentary. We are the first generation having to make a conscious decision to actively incorporate physical activity into our daily lives. But not enough of us are doing it. PHE ‘Health Matters’ guidance was published this summer with the aim of ‘getting every adult active every day’. The recommendations for all adults, overweight or not, are:
- 150 minutes of moderate intensity physical activity each week in bouts of at least 10 minutes (walking, gardening, hiking, dancing, swimming, cycling, active recreation); or
- 75 minutes of vigorous aerobic activity each week (running, playing sport such as tennis, climbing stairs, fast swimming, skipping, fast cycling); or
- A combination of moderate and vigorous activity each week; and
- Strength exercises on two or more days a week that work all the major muscles (legs, hips, back, abdomen, chest, shoulders and arms).
One in ten cases of stroke and cardiovascular disease in the UK could be prevented by helping inactive people to become active.15 Particularly noteworthy is that physical inactivity is a serious risk factor whether an individual is overweight or not. Being seated for long durations, regardless of exercise, can still be detrimental to health.16 Making these facts known and encouraging patients to find ways of incorporating exercise into their daily life – taking the stairs, getting off the bus one stop early and walking, getting up from the desk to speak to colleagues rather than sending an email – it all helps. Seeking out local resources such as free gym passes, exercise on prescription schemes or directing patients to physical activity podcasts, apps and activity trackers to monitor daily exercise can be really motivating. Even Pokemon Go – a reality game for smartphone users who walk for miles searching for virtual creatures in nearby locations – has drawn the attention of the medical press.17,18 It is not backed by research, but it appears Pikachu and his friends are getting people off their sofas, out into the fresh air and becoming active. Whatever it takes.
SMOKING
Practice nurses need to be ever mindful of the impact of helping patients to stop smoking. The primary cause of preventable illness, smoking affects almost every organ in the body.5 Not only the major cause of preventable death, smoking-related conditions can cause a lifetime of debilitating illness and poor health. And not just for the smoker: odourless, invisible second-hand smoke increases the risks of smoking-related disease in non-smokers.19 Essentially there is no safe way to use tobacco, for anyone. On a positive note, within 3-9 months of stopping, lung function improves by up to 10%. In addition, heart disease risk is almost halved after one year and lung cancer risk falls to half after 10 years compared to someone who is still smoking. After 15 years the risk of myocardial infarction falls to the same as someone who has never smoked.20
Every consultation provides an opportunity to broach a patient’s smoking habits and seize the moment to help them stop. Time, reluctance and embarrassment mustn’t be a reason for not mentioning it. Be bold! Finding what the motivating factors are for a patient to stop smoking and whether they are in the correct ‘headspace’ to stop precipitates success. Evidence suggests that combining professional support with pharmacological intervention is the most successful way to stop smoking.21 We need to have the ability to provide that support and/or signpost patients to specialist services, pharmacy clinics, smoking cessation resources, one-to-one services or group sessions and apps, while having the knowledge of what is available in the local area. Beyond the scope of this article, there is a plethora of information about the options of prescription medication to help patients stop smoking, helping patients make individual choices, the pros and cons of e-cigarettes and preparing patients for the effects of withdrawal and likely pitfalls to be aware of along the way.22–24 Accessing training – whether online or through local agencies and CCGs – is essential to understanding the fundamentals of supporting our patients to stop smoking. Whether the patient has smoked 30 cigarettes a day for 50 years or has made numerous attempts to stop smoking but is back to a 5-a-day habit again, we mustn’t lose momentum in trying to encourage, in a positive supportive way, each and every individual to stop smoking. That one occasion might just be the very occasion where it resonates with the person sitting in front of you and makes a difference.
ALCOHOL
New guidance for low risk drinking was published by the Chief Medical Officers for the UK earlier this year, and is based on a wealth of international and UK evidence, expert consultations, data for UK morbidity and mortality as well as public consultation.25,26 The guideline brings clarity to the risks of alcohol intake to help people make an informed choice with regards to their drinking habits and behaviours and in relation to their way of life.
With no level of alcohol consumption considered safe, the recommendations are set out below for ‘low-risk’ drinking:25
Weekly drinking guideline for regular drinkers (for men AND women)
- Less than 14 units of alcohol per week on a regular basis;
- Risks increase if consuming more than 14 units of alcohol per week;
- Spread drinking over 3 or more days (if drinking as much as 14 units per week);
- Risks increase with 1–2 heavy drinking episodes per week;
- Aim for several ‘drink free’ days per week.
Single occasion drinking (no specific amounts are detailed in the recommendations)
- Limit the total amount of alcohol on any single occasion;
- Drink more slowly, with food, and alternate alcoholic drinks with water;
- Plan ahead – can you get home safety and trust people around you?
- Increased alcohol consumption increases the risk of accidents, misjudging risky situations and losing self-control;
- The risk of injury is 2–5 times greater when 5–7 units of alcohol are drunk in a 3–6 hour period.
Pregnancy
The safest option in pregnancy or pre-pregnancy is not to drink alcohol;
Drinking in pregnancy increases long term harm to the fetus.
If alcohol is consumed pre-conceptually or before knowledge of pregnancy, the risk of harm to the baby is likely to be low.
A guide to alcohol content by volume for wine and lager is shown in Table 2. Table 1 specifies risks involved in drinking alcohol. The guidance provides practice nurses with up-to-date information to discuss with patients to determine those risks, for patients to make informed decisions regarding their drinking behaviour and to enable discussions and information giving as deemed appropriate.
PROMOTING HEALTH
NICE has produced guidance on behaviour change which highlights ways in which health professionals can promote lifestyle changes through a variety of interventions – from very brief, brief, extended brief and high intensity interventions – depending on the opportunity, time available and the receptiveness of the patient.27 Often we are having to seize the moment while engaged with a patient’s other priorities. So how do we do that? NICE suggests a ‘very brief’ intervention may only take between 30 seconds to 2 minutes, to ask about lifestyle, provide essential risk information, offer encouragement to change and provide resources. It’s short and snappy. As long as the patient doesn’t retaliate with an abundance of questions, that is. However, even on our busiest days 30 seconds could be achievable. Sometimes that’s all we have – but it might just hit the spot.
CONCLUSION
General practice nurses are in a prime position to offer advice and support about a whole range of lifestyle issues. Recognising when people are open to change and acting on that moment is key. Knowing local information is also vital. As with any consultation, the approach is not ‘one size fits all’; and we need the skills to adapt conversations, vary approaches and techniques as well as having perpetual patience. Equally, we can find ourselves battling against the influence of media headlines or friends and family members whose knowledge, it sometimes appears, is greater than the world-renowned body of evidence. Making life-style changes is ongoing and maintaining patients’ motivation, is challenging. Even harder is when there is no desire to change. But life-style choices affect health - in a negative and positive way - and we, as primary care nurses, have a responsibility to address it
REFERENCES
1. Health & Social Care Information Centre. Statistics on Obesity, Physical Activity and Diet. England 2016. 28 April 2016
http://digital.nhs.uk/catalogue/PUB20562/obes-phys-acti-diet-eng-2016-rep.pdf
2. Diabetes UK State of the Nation 2016. Time to take control of diabetes. England. 2016.
3. The Global BMI Mortality Collaboration. Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents. The Lancet. [Published online] 13 July 2016
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30175-1/fulltext
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http://www.noo.org.uk/NOO_about_obesity/obesity_and_health/health_risk_adult
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10. World Health Organization. Fact sheet 311. Updated June 2016. http://www.who.int/mediacentre/factsheets/fs311/en/
11. Public Health England. Adult obesity and type 2 diabetes, 2014.
12. NICE. Preventing excess weight gain [NG7], 2015
https://www.nice.org.uk/guidance/ng7
13. Public Health England. Eatwell Guide, 2016. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/528193/Eatwell_guide_colour.pdf
14. NHS Choices. Top diets review for 2016. http://www.nhs.uk/Livewell/loseweight/Pages/top-10-most-popular-diets-review.aspx#5%3a2
15. Public Health England. Health matters: getting every adult active every day, 2016.
16. Ekelund U, Steene-Johannsessen J, Brown W, et al. Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women. The Lancet. [Published Online] 27 July 2016. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30370-1/fulltext
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18. McCartney, M. Game on for Pokemon Go. BMJ 2016;354:i4306 http://www.bmj.com/content/354/bmj.i4306
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20. Smokefree NHS. What happens when you quit? https://www.nhs.uk/smokefree/why-quit/what-happens-when-you-quit
21. Kotz D, Brown J, West R. Prospective cohort study of the effectiveness of smoking cessation treatments used in the “real world”. Mayo Clin Proc 2014; 89 (10);1360-1367 Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194355/
22. NICE. Stop smoking services [PH10]. Updated November 2013. https://www.nice.org.uk/Guidance/ph10
23. NICE. Smoking: supporting people to stop [QS43], 2013. https://www.nice.org.uk/guidance/qs43
24. Action on smoking and health. Briefing: Electronic cigarettes. February 2016. http://www.ash.org.uk/files/documents/ASH_715.pdf
25. Department of Health. UK Chief Medical Officers’ Alcohol Guidelines Review. Summary of the proposed new guidelines. January 2016. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/489795/summary.pdf
26. Department of Health, Llywodraeth Cymru Welsh Government, Department of Health Northern Ireland, Scottish Government. UK Chief Medical Officers’ Low Risk Drinking Guidelines. August 2016. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/545937/UK_CMOs__report.pdf
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