Practice Nurse

Lifestyle modification

As a nation we are living longer but many people are still dying prematurely, and among the under 75s, an estimated two-thirds of deaths are thought to be avoidable. Many of these deaths could be avoided by achieving an earlier diagnosis and treatment, or by making changes to the wider social determinants of health such as housing and employment, but also through lifestyle modifications. It is widely recognised that changes to lifestyle – especially the four most commonly addressed behaviour change and lifestyle modifications, smoking, exercise, diet and alcohol use – can reduce the risk of disease and help to manage the disease once present.1

Lifestyle modification may be recommended on its own, with or prior to medication depending on the change required, and clear guidance is available on the most effective methods to support people with changes. These methods may be on a population level or an individual basis and it is here that the practice nurse is ideally placed to support the individual to make changes.

This resource, which is based on some typical case scenarios, is offered at intermediate level and includes five assessment questions to support your continuing professional development. Complete the resource, including the further reading and some or all of the suggested activities, to obtain a certificate for one hour of continuing professional development to include in your annual portfolio.

On the completion of this resource you should have an understanding of:

Your role in opportunistic smoking advise

1. Department of Health, Living Well for Longer: A call to action to reduce avoidable premature mortality, 2013. 

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/181103/Living_well_for_longer.pdf

CVD Prevention in Clinical Practice (European Guidelines)

NICE PHG 49. Behaviour change: individual approaches, 2014. 

Cardiovascular disease: what the guidelines say

Statins, CVD prevention and the practice nurse

Preventive medicine: Helping patients alter their lifestyle

Back to basics: assessing cardiovascular risk

As a team you have been discussing working with your patients to modify their lifestyle through a change in behaviour: you recognise it is not something that as a surgery you have not been very proactive about, but have made it one of your priorities for the coming year. What are the key recommended elements to include when designing behaviour change interventions?

There are many examples for changing behaviour widely available, but it is important that with limited resources the services and programmes offered are proven and effective. NICE guidance for Behaviour change: the principles for effective interventions clearly sets out what they are.1 They include goals and planning, feedback and monitoring and social support. NICE guidance on behaviour change: an individual approach2 explains that goals should be agreed for behaviour and resulting outcomes, there should be action plans, coping plans to manage and prevent relapses, and consideration should be given to achievement of outcomes and further goals. It recognises that it is important to encourage self-monitoring, to provide feedback on behaviour and outcomes, and to encourage patients to enlist support, either with friends and families or by establishing ‘buddies’ to provide practical and emotional support.

1. NICE PHG 6. Behaviour change: the principles for effective interventions, 2007. 

http://www.nice.org.uk/guidance/ph6/resources/guidance-behaviour-change-the-principles-for-effective-interventions-pdf

2. NICE PHG 49. Behaviour change: individual approaches, 2014. 

Devise a short survey to identify what training colleagues in your practice have received to support lifestyle modification through behaviour change. You may wish to base this on the recommendations in NICE PH 49: recommendation 12 discusses the range of knowledge and skills required to deliver specific interventions. The results from this survey could then be used as a way to progress your learning.

Question 1

James is 36 years of age and you are seeing him in clinic for his travel vaccinations. You review his records before seeing him and note that he smokes. Your clinic is running 15 minutes behind and you have another 3 people to see after him. What would you do in relation to his smoking?

Smoking is one of the biggest contributors to premature mortality.1 Simple advice from a health professional can have a significant effect on smoking cessation.2 The Department of Health suggests ‘Very Brief Advice’ to be given at every opportunity and suggests this should only take about 30 seconds using a ‘Ask, Advise, Act’ (AAA) approach.3 You should ask if the patient has thought about stopping, advise that it is the single most important thing they can do to improve their health and then act on their response (build confidence, refer, give information).

1. NICE PHG 45. Tobacco: harm-reduction approaches to smoking, 2013. 

2. NHS Stop Smoking Service: service delivery and monitoring guidance 2011/12. 

http://www.ncsct.co.uk/usr/pub/delivery-and-monitoring-guidance-2011-and-2012.pdf

3. NHS England. Making Every Contact Count. 2012 

Reflect on the last 5 people you saw in clinic who smoke. What health education did you give them on smoking cessation? Do you think that it was adequate and what could you improve on?

Question 2

Rebecca has been low in mood due to work related issues for the last 6 months but has recently returned to work and is now feeling brighter in herself. You discuss exercise with her as she used to go to a gym but feels she has lost her confidence to return to exercise. It is an ideal opportunity for you to provide a brief intervention. How would you address this?

Although answers 1-3 may be valid, NICE1 would recommend that a brief intervention for increasing exercise should consist of initially assessing someone’s motivation and readiness for change followed by a discussion on the level of activity and ability they have. This can then be followed up with written goals and a time for review.

Current guidelines1 recommend that adults aged 19 years and over should aim to be active daily, which over a week adds up to at least 150 minutes (2.5 hours) of moderate intensity in bouts of 10 minutes or more. All adults should also undertake physical activity to improve muscle strength on at least 2 days a week. However, recent research indicates that any level of exercise is better than none in reducing all-cause mortality.

1. NICE PHG 44. Brief advice for adults in primary care, 2013. 

NICE PHG 54: Exercise referral schemes to promote physical activity, PHG 54, 2014. Available at: 

http://www.nice.org.uk/guidance/ph54/chapter/what-is-this-guideline-about

Department of Health. Let’s Get Moving: Commissioning Guidance- A physical activity care pathway, March, 2012. 

http://www.gov.uk/government/publications/let-s-get-moving-revised-commissioningguidance

List 10 benefits of exercise and then follow the link below on NHS choices to refresh your knowledge and check your answers. 

http://www.nhs.uk/Livewell/fitness/Pages/whybeactive.aspx

Question 3

Amanda comes to see you in clinic for travel vaccinations and during conversation she says she is concerned that she may be drinking too much. You ask her why she says this and it is because she has listened to a radio programme about alcohol and this has made her question herself. She feels she only has a couple of drinks a week but is unsure how many units this equates to. You work through an average week together and she tells you she has a whiskey every evening before bed and then 2 gin and tonics at the weekend and shares a bottle of wine with her husband on a Saturday night. You establish the spirits are a little larger than a standard pub measure (probably the equivalent of two doubles). How many units would you estimate that she is drinking?

Many people are unaware of the amount of alcohol they are drinking and often convince themselves that they are only drinking one or two units a day. The size of the glass and the percentage of alcohol will affect the amount of units per drink. The recommendations for alcohol consumption are not to exceed 21 units a week for women, and 28 units for men, with a couple of alcohol free days a week.1

1. NHS Choices. Drinking and Alcohol available from: 

http://www.nhs.uk/Livewell/alcohol/Pages/Alcoholhome.aspx

Department of Health, Living Well for Longer: A call to action to reduce avoidable premature mortality, 2013. Available: 

NICE CMG38. Services for the identification and treatment of hazardous drinking, harmful drinking and alcohol dependence in children, young people and adults, 2011 

NHS Choices, Alcohol units calculator, 2015 

http://www.nhs.uk/Tools/Pages/Alcohol-unit-calculator.aspx

Check your understanding of units and alcohol and complete the alcohol diary on yourself or family members to identify any surprises and differences between perception and facts. Then try with patients seen in clinic. A healthy-eating alcohol diary is available from: 

http://www.nhs.uk/Livewell/alcohol/Documents/drink_diary.pdf

 and further information on units of alcohol, harmful effects and reducing alcohol is available from: 

http://www.nhs.uk/Change4Life/Pages/drink-less-alcohol.aspxm:

Question 4

Peter is 30 years of age and overweight. He has tried many diets since he was a teenager, usually based on the most current trend. He seems to be tired of this approach and appears to be ready to adopt a sensible balanced approach to health eating. He has asked you the main food groups he should eat. Would you say?

Carbohydrates, fruit and vegetables, protein, dairy and small amounts of fat, sugar and salt – these food groups will provide all the nutrients needed by the body. The ‘Eat well’ plate (link below) provides a visual guide to the ideal proportions of each group should make up a plate of food. Fruit and vegetables are a good source of vitamins and minerals and at least five portions a day are advised. Carbohydrates – foods such as potatoes, wholegrain rice and pasta – all contain fibre and vitamins and should make up 1/3 of everything we eat. Wholegrain versions are preferred to refined carbohydrates. Proteins are essential for growth and repair and can be found in meat, fish, eggs and pulses; milk and other dairy products are also a source of protein. They also contain calcium which helps to keep bones healthy.

Fats and sugar are sources of energy but can lead to weight gain if more is consumed than used. Unsaturated fats are preferred, and can be found in oily fish, nuts, vegetable and olive oil. It is recommended that we cut down on saturated fats and replace with small amounts of unsaturated fat.

Sugar occurs naturally in foods such as fruit and milk, but it is not advised that we cut down on these but that we do cut down on foods where sugar is added such as cakes, biscuits, fizzy drinks, ice cream.1

1. Davies M et al, for UK National Screening Committee, The Handbook for Vascular Risk Assessment, Risk Reduction and Risk Management (Updated), 2012 

http://www.healthcheck.nhs.uk/commisioners

NHS Choices 2015 Live well ‘Eat well plate’. 

http://www.nhs.uk/livewell/goodfood/pages/goodfoodhome.aspx

https://www.bhf.org.uk/~/media/files/publications/healthy-eating/g186_eating_well.pdf

Have a look around your surgery to find any information that you have available to support people with healthy lifestyle changes. Do you consider this to be up to date and relevant? Does it make attractive reading for people? Explore the link to NHS Choices Live Well for further ideas and following the links below to promotional material. As a practice, you may wish to develop a file/library of materials to support people with healthy eating.

https://www.gov.uk/government/publications/the-eatwell-plate-how-to-use-it-in-promotional-material/the-eatwell-plate-how-to-use-it-in-promotional-material

Department of Public Health 2014, Your Guide to eat well Plate 

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/340869/2014-250_-_eatwell_plate_Final_version_2014.pdf

Lifestyle modification

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