Volume 24, No 2

57 EditorialAn I l th-hour chance?ITith primary care trusts being abolishedand practice nurse leads/advisers losingtheir roles, Liam Benison urges practicenurses to make themselves heard.

58 Guest EditorialA careful decisionAdrienne lTillcox discusses the EuropeanCommission's decision to approve themeningococcal B vaccine, Bexsero.

60 News FocusLegislation will extendPGDs but support remainsuncertainThe government will introduce legislationto enable existing patient group directionsto be used until new systems are in placefor PGD authorization, but the future ofprofessional support remains unresolved.

68 Weight ManagementMore therapy options forobesity neededTony Leeds identifies the need for a widerrange of evidence-based, cost-effective,and safe interventions for weight loss andweight loss maintenance.

72 Diabetes Series'52The role of practice nursesin the delivery of insulinPumP therapyGillian Morrison and Philip.Westondescribe how insulin pump therapy canallow individuals to achieve targetglycaemic control and stability and allowthem to maximize lifestyle flexibility.

78 Sexual HealthHistory taking for women'scontracePtionNo contraception method is 100%effective. However, Sarah Kipps explainshoq through accurate history taking,practice nurses can ensure the safeprescribing of contraception.

Practice Nursing 20 | 3,Vol 24, No 2

84 Know Your TestUsing the Romberg's test toevaluate dizzinessRomberg's test is an invaluable bedside testthat can pinpoint a sensory deficit. SusanThomas outlines the procedure of the test.

85 Women's HealthAssessing menorrhagia andits treatmentMenorrhagia is a distressing condition withthe potential to bring monthly disruption towomen's lives. Margaret Perry explores theassessment and diagnosis of the condition.

90 Developmental DisordersUnderstanding themechanisms of autismPaul Evans gives an insight into themechanisms at work in autism, illustratinghow a better understanding can help withplanning support and interventions.

95 Red FlagBullous and non-bullousimpetigoJean S7atkins emphasizes the importanceof recognizing the condition and managingit appropriately when it presents.

97 lt Could Be YouCoping with money worriesRoz Hooper looks at how two nurseswent to the RCN welfare service toresolve 6nancial difficulties.

98 Classified

L0L Product News

102 ProfileVerna BalfourVerna Balfour describes being her surgery'slead for diabetes and adviser to the CCG.

Clinical Focus

e

&

lJ

Respiratory

Ensuring support forPeoPIe quittingsmoking

Many people struggle to stopsmoking without professionalsupport. Jennifer Percivalidentifies the role practice nursescan play in helping people quit.

62

Quote of the month

5I became a nurse because I wanted to make adifference. No matter how small or insignificantthe deed or act, I always accept it as anachievement.e

Verna Balfour (p.102)

d=&

Ul

Clinicol

Tony Leeds

identifes the need

for a wider ronge of

evidence-bose4

cost-effective, and

sofe interventions

for weight.loss ond

werght loss

mointenonce

Tony Leeds is asistant physician, Jeffrey

Kelson Diabetres Centre, Central l'liddlesex

Hospital

Jubmitted l6 July 2012; aaepted

for publication following peer review

27 September 2012

Key words:0besity, weight loss solutions,

gastric surgery, dieting

58

More thempy options forobesity needed

besity is a truly global pandemic

expected to affect 1.5 billion people

by 2015 (World Health Organtz-

ation, 2013). It is not a future problem, it is

here and now, blighting lives, and costing the

NHS millions of pounds ({'4.2 blllion pounds

rn 2007) (National Audit Office, 2013).

Practice nurses are in the front line.

Aiso in the front line are the specialists and

gastric surgeons who help prepare patients-

some weighing nearly 250 kg (40 stone)-for

gastric surgery. Our job is to make their sur-

gical iourney safer and improve outcomes.

Specialists also help others who do not qual-

ify for surgery to lose weight through non-

surgical techniques.

Surgeons can help an increasing number of

people, but practice nurses and their col-

leagues in primary care can directly change

the UK's obesity problems by helping patients

take steps to prevent them reaching such a

serious state of ill health and obesity that they

need surgery.

Obesity may be one of the most common

health issues faced by patients in general

practice. It is associated with diabetes, hyper-

tension, heart disease and even cancer ('World

Cancer Research Fund ('!7CRF),2007),yet it

could be argued that, in general across the

UK, the approach to obesity is backward, a

bit like heart medicine in the 1950s.

Obesiry is, for example, one of the subiects

least taught to primary health professionals in

training. Practice nurses will almost certainly

have had more training on nutrition and diet-

related macters than their GP colleagues, and

this is an area where nurses can potentially have

a much greater impact on patients. Practice

nurses could have a positive impact on their

patients' health in r\,vo areas in panicular:

.,.:;' lt.tnttrt a patient with rype 2 diabetes

lose 5-10% of their initial body weight

(up to 10 kg (1.5 stone) can help them

improve their metabolism with probable

reduction of complications (Franz, 2007)

:r'' ".to

tt* a (non-diabetic) patient lose

5-10 kg will help reduce their chance of

heart disease and stroke by lowering their

blood pressure (Harsha et al, 2008).

These achievements could also halt these

patients' year-on-year weight gain if they are

given long-term support.

But it is important to ensure that the strat-

egy chosen is the most appropriate for the

individuai patient. Someone who is 190 kg

(30 stone) may not get far on conventionai

dieting alone-or if they do, it will take them

many months, or even years, to achieve the

weight loss needed.

There are two groups of patients for whom

the NHS has a ready answer: those with up

to 10 kg (1.5 stone) to lose, and the very

obese, i.e. those with a body mass index

(BMI) greater than 40 kg/m'z.

Modest weight loss solutionsFollowing the withdrawal by reguiatory

authorities of two effective drugs, the typical

general practice has iust one drug in its

armoury: orlistat. This can be effective but

needs to be given with good dietary advice to

give the best results and avoid side effects.

Conventional dietary advice provided in a

structured manner and underpinned by behav-

ioural therapy techniques can give good weight

loss and maintenance, particularly in compli-

ant non-impulsive characters in whom there is

scope for change (Elfhag and Rossner,2005).

Options for the severely obeseSurgery is often regarded by clinicians and

patients as the only option for the severely

obese. To qualify for surgery, someone must

have a BMI of 40 kg/m'z or more (or a BMI of

35 kg/m'z if they have a health complaint such

as diabetes) (National Institute for Health and

Clinical Excellence (NICE), 2006). Despite

these recommendations, however, in some

parts of the UK surgery is only funded by the

NHS if the person has a BMI greater than 50

kg/m2. For an average woman of 163 cm (5

foot 4 inches), a BMI of 40 kglm'means a

weight of about 108 kg (about 17 stone).

At that weight the strain on the body is

very great. As well as a risk to her heart, she

will have an increased risk of some cancers'

high blood pressure and type 2 diabetes. Her

knees and hips will probably also be crum-

bline with arthritis.

D'actrce N I c;a8 20 | J,Vol 24. \o 2

lsolation andloneliness

Clinical

t' ' . 1::,:,:,,, :,,j:1,." :,.:,..,Excess werght is debilitating in mony woys. Potients will often not reveol the futl effea on their lives to oheolth professionol for fear of embotossment Effeas on quolity of life include dfficulty climbing stoirsand playing with children ond grandchildren. Other effeas include:

Being overweight can prompt a raprd spiral to disability as exercisebecomes more difflcult, employment becomes impractical and aperson's world centres on the living room, theTV and comforl eating

lmpaired sleep lmpaired sleep from the pain of osteoarthritis, further reducing quality of1ife, but early evidence from Austra{ia (Anandacoomarasamy et al,2012)suggests that osteoarthritis can be slowed down and possibly reversedgiven sufflcient wejght loss

Self-esteem Self-esteem rs impaired fbr a variety of reasons, including practical issuesrelated to personal hygiene

Abuse from others Verbal abuse from others is an unfortunate consequence of obesty andcauses much arsuish

For many, doctors as well as patients, sur-gery is seen as a quick fix. Alarmingly, therehave been anecdotal reports of patientsadmitting that they had put on weight in abid to qualify for surgery. Although shocking,it demonstrates some people's desperatton tofind a way to lose weight.

Gastric surgery is difficult to bear physicallyand can cause emotional difficulties (Kinzl.

2002).The different rypes of surgery-such asthe insertion of a gastric band that narrowsthe stomach to form an'hourglass' and gastricbypass-have different effects but all need tobe managed carefully afterwards.

After this type of surgery a meal will rarelybe any more than a few small cubes of food,

. so there is little opportunity to enjoy a rradi-tional meal with the family, for example. Ifsomeone does eat more than their tiny por-tion they may suffer discomfort and regurgi-tation (Avriel et aL, 201,2\ .

With such a small intake and reducedabsorption they always need additional nutri-ents from supplements (Endocrine Society,2010). Appropriate aftercare is necessary toavoid further problems with malnutritionand often this aftercare is limited.

Those with a bypass will need extra oralvitamins and minerals and regular injections

The 2007 Foresight report predrcted thatthe direct economic costs of overweight and obesitywould be {6.4 llllion a year by 2015, and that the wider costs of elevated body mass index,inciuding the impact on the economy of sickness absence, for example, would be {27 biliion.Thepo.s5ight -eport precicted rhaL in I 0 years:

. 3540% of people in the UK could be obese

. Diabetes cases could soar by 40%, doubling the medicatron bill to { 1,4 miliion'The cost oftreating high blood pressure could rise further beyond the threefold increase ingeneral practice prescriptions for antihypertensives incurred between 2000 and 20 | 0

' A 100% increase in knee replacement surgery and a doubling of annual costs to { 1.5 million(based on f803 million costs in 2009/10 and a 29% rise in 4 years)

F-on: Gover^Tert Ofice to. Sc.erce. 200/

70

of vitamin B,r. There are orher porentialproblems such as bone-thinning, and somefind that the operation-which comes withthe usual risks of surgery, including infec-tions-does not work as well as expected inthe long term.

For some parients surgery can give verygood results with great improvements in dia-betes, blood pressure, sleep problems andreduced risk of heart disease (Picot et aI,2009). However, a gastric band and gastricbypass are charged at berween d8500 and{,1,4,000.Although documentary sources sug-gest lower figures, true cosrs may be higher ifthere are complications (Picot et aI,2009).

Surgery costs can be recouped throughdrug savings in just over 2 years for thosewith diabetes (Picot et al,2009), bur as washighlighted by Martin et al (2012), post-operative medical care is not always perfectbecause there is a iack of recognition of theneed for regular reviews especially 2 yearsafter surgery.

Even if all goes well, patients need to bereviewed regularly and appropriately, and thiscosts money, and is often not fully available.

So it could be asked why is surgery sopopular? One reason is that credible alterna-tives are not offered. !7ith 0.5 million peoplein the UK with a BMI of 40 kg/m2 or greater(Grieve et al,20L1,), there is no way in whichthe NHS has the resources to pay for ail ofthem to have a band or a bvoass.

Mind the gapThe two extremes of traditional weight lossoptions-surgery and conventional dieting-have left a void into which the weightJossneeds of the majority of the obese populationfall. However, programmes such as theScotland-based Counterweight have demon-strated impressive weight loss and mainte-nance delivered in general practice in patientswith a BMI both below and above 40 kglm2.

Counterweight was developed to help peo-ple lose 5-10% of their body weight (as rec-ommended by the Scottish IntercollegiateGuidelines Network (SIGN) (2010) and NICE(2006). This has been delivered to 6700 peopleand has helped many of those srop the weight-gain spiral (Bell-Higgs et aI,2012).

However, it was recognized thatCounterweight was seeing more and morepeople who were heavily overweight (i.e. thosewith a BMI greater than 40 kg/mr), whoneeded to lose more than 5-10"/o of their bodyweight. SIGN (2010) recommends a weight

Practlce Nurs ng 20 | 3,Vol 24, No 2

loss of greater than 15-20'/' for those with aBMI greater than 35 kg/m'z. Veight loss ofgreater than 15 kg or L57, has been shown tonormalize blood glucose and insulin (\7ing

and Phelan,2005; Dixon et al,2008).

These findings have led to the developmentof Counterweight Plus, a non-surgical inter-vention of a total diet replacement liquid for-mula diet 800 kcaUday along with a weightloss maintenance programme to help achieve aminimum weight loss of 15 kg (2.5 stone).

Counterweight took this next step by con-ducting a feasibility trial during 2010-201L,training practice nurses and dietitians todeliver the year-long programme of total dietreplacement, food reintroduction and weightloss maintenance.

Counterweight has shown that by the end of

the 12-month programme, patients who fol-lowed all stages of the programme according

to the protocol had maintained a weight loss

of 15 kg (2.5 stone) compared to a loss of6.5 kg (just over 1 stone) for those who hadnot followed all the stages as per protocol(Lean et aL,201,31. In totai, 33% of all patients

enrolled maintained a weight loss of 15 kg ormore at 12 months (Lean et al,2013\.

This feasibility trial is the latest in a

sequence of research which has shown thatformula diet programmes can give good

weight loss and maintenancb in obese people

with medical problems such as in those withosteoarthritis, sleep apnoea or diabetes(Christensen et aL, 201.L; Johansson et al,2011; Snel, et aL,201,2).

ConclusionsHealth professionals have a need for a widerrange of evidence-based, cost-effective, andsafe interventions for weight loss and weightloss maintenance to offer patients with spe-cific medical conditions. Counterweight Plusis one such option, but more are needed.

Conflict of interest: Tony Leeds is Medical Directorof Cambridge'Weight Plan.

ReferencesAnandacoomarasamy A, Leibman S, Smith G et al

(2012) \Teight loss in obese people has srructure-modifying effects on medial but not on lateral kneearticular cartilage. Ann Rbeum Dis 71,:26-32

Avriel A, \(arner E, Avinoach E et al (2012) Majorrespiratory adverse events after laparascopic gastricbanding surgery for morbid obesity Respir Med106(8\ :1.192-8

Bell-Higgs AE, Brosnahan N! Clarke AM et al (2012\The implementation of the Counterweight pro-gramme in Scotland, UK. Fam Pract 29\Stppl 1):i1.39-i1.44

Pradice Nursing 20 | 3,Vo 24, No 2

Christensen P, Bliddal H, Riecke BI, Leeds AR, AstrupA, Christensen R (2011) Comparison of a low-energy diet and a very low-energy diet in sedentaryobese individuals: a pragmatic randomized control-led trial. Clin Obes 1fl.\: 3140

Dixon JB, O'Brien PE, Playfair J et al (2008 ) Ad justablegastric banding and convenrional therapy for type 2diabetes: a randomised controlled trial. JAMA299(3\ :31.6-23

Elfhag K, Rossner S (2005) ITho succeeds in maintain-ing weight loss? A conceptual review of factorsassociated with weight loss maintenance and weightregain. Obes Reu 6(1.): 67-85

Endocrine Society (2010) Endocrine and NutritionalManagement of the Post-Bariatric Surgery Patient:An Endocrine Society Clinical Practice Guideline.http://tinyurl.com/a384kuw (accessed 22 January2013)

Franz MJ Q007)The dilemma of weight loss in diabe-tes. Diabetes Spectrum 20(3): 133-6

Government Office for Science (2007) TacklingObesities: Future Choices. Project report. http://tinyurl.com/3dj7xtj (accessed 22 lanuary 2013)

Grieve E, Fenwick, E, Lean MEJ (201 1) Estimating theextent of the severly obese population. Poster pres-entation at the European Congress on Obesity,Lyon, France, May 201,1,

Harsha DW, Bray GW (2008) ITeight loss and bloodpressure control. Hypertens 51: 1420-5

Johansson K, Hemmingsson E, Harlid R et al (2011)Longer term effects of very low energy diet onobstructive sleep apnoea in cohort derived fromrandomised controlled trial: prospective observa-tional follow-up study. BM/ 342: d301.7

Kinzl JF, Trefalt E, Fiala M, Biebl V (2002)Psychotherapeutic treatment of morbidly obesepatients after gastric banding. Obes Surg 72(2):2924

Lean M, Brosnahan N, Mcloone P et al (2013)Feasibility and indicative results from a 12 monthLow-Energy-Liquid-Diet treatment and mainte-nance programme for severe obesity. Br .l GenPractice (in press)

Martin IC, Mason M, Butt A (2012) Too lean a serv-ice? A review of the care of patients who underwentbar iatr ic surgery. A repbrt by the Nat ionalConfidential Enquiry into Patient Outcome andDeath. w.ncepod.org.uk/2012bs.htm (accessed22 lanuary 201,3)

National Audit Office (2013) National ObesityObservatory: Obesity and health. http://tinyurl.com/azwchyh (accessed 22 January 2013)

National lnstitute of Clinical Excellen ce (20061 Obesity:guidance on the prevention, identification, assessmentand management of overweight and obesity in adultsand cbildren. CG43 MCE, London

Picot J, Jones, J, Colquitt JL et al (2009) The clinicaleffectiveness and cost effectiveness of bariatric(weight loss) surgery for obesity: a sysrematicreyiew and economic evaluation . Health TechnologyAssessment 13(47)

Scottish Intercollegiate Guidelines Network (2010)Management of obesity: A national clinical guide-line. SIGN, Edinburgh

Snel M, Gastaldelli A, Ouwens DM et al (2012) Effectsof adding exercise to a 16-week very low-calorie dietin obese, insulin-dependent type 2 diabetes mellituspatients. / Clin Endocrinol Metab 97(7):251,2-20

World Health Organization (2013) Chronic diseasesand health promotion. http://tinyurl.com,/agqp2q2(accessed 22 January 2013)

'!7ing RR, Phelan S (2005) Long-term weight loss

maintenance. A/CN 82(1 Suppl): 222S-5S'World

Cancer Research Fund (2007) Food, Nutrition,Plrysical Actiuity, and the Preuention of C.ancer: AGlobal Perspectiue. Second expen repon. WCRF/AICR

KEY POINTS

) Health professionals havea need for a widerrange of therapy optionsfor patients sufferingfrom obesity

) Surgery and conventionaldieting have left a voidinto which the weight-loss needs of themajority of the obesepopulation fall

) Counterueight Plus hasbeen developed as anon-surgical weightmanagement solution forindividuals with greaterweight-los needs

) Practice nurses willalmost certainly havehad more training onnutrition and dietingthan their GP colleagues,and so are in a betterposition to o{fer patientsweight-loss advice