Care Study

Obesity: A Public Health Issue

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This care study will explore the public health issue of obesity in the care of a patient with type 2 diabetes nursed in the community. It will explore the nursing role in the care and support of the patient, local and national strategies to address the issue and the importance of effective communication and record keeping. To protect the patients identity within this care study, the patients name has been replaced with a fictitious name (Nursing and Midwifery Council (N.M.C.) 2009).

Winslow (1920) defines public health as "the science and art of preventing disease, prolonging life and promoting health through the organised efforts and informed choices of society, organizations, public and private, communities and individuals." Acheson (1991) definition of public health is the science and art of preventing disease, prolonging life and promoting health through organised efforts of society.

John James is a 56 year old male, who lives independently in a two bedroom bungalow. He is employed as a delivery driver for a local appliance company. He is single, and often visits his mother who lives independently close by. As John did not attend his doctors surgery for over 10 years, he was invited by letter from his doctors surgery to attend a National Health Service (N.H.S.) Health Check (see page 6). As a result of the Heath Check John was diagnosed with type 2 diabetes. At the time of diagnosis, it was undetermined how long he had the condition for. Initially, the diagnosis was unexpected from Johns perspective. Although he admitted he was overweight, he did not display any symptoms of diabetes. With further conversations between John and the practice nurse who performed the health check, he explained that on a daily basis he consumed three litres of apple and orange juice, three chocolate bars, five doughnuts as well as three meals a day.

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To demonstrate to John that his weight, age and diet were a contributory factor to the development of his type 2 diabetes, it was explained to him that type 2 diabetes is most common in those who are over weight or obese (Williams and Pickup 2004), and it is more likely to develop in those who are middle aged or older (Tuomilehto 2001). John was told that his excess weight was due to the amount of calories he regularly consumed exceeded the calories used for exercise, resulting in fat (white adipose tissue (W.A.T.)) collecting around the abdomen (Frayn et al 1995). This is described by Gregoire et al (1998) as positive energy balance. John confirmed he understood his eating and physical activity habits are responsible for his body weight. John was told that due to his excessive calorific consumption, combined with the build up of fat (adiposity) causes a negative effect on the insulin, resulting in high levels of glucose remaining in the blood (Hill and Peters 1998). This condition is known as type 2 diabetes or insulin resistance (Diabetes U.K. 1995).

The practice nurse explained to John that by changing his lifestyle, he could reduce the risk of developing complications due to type 2 diabetes (Tuomilehto 2001). John was also told that it is recommended by the Department of Health (2004) that everyone should participate in at least thirty minutes of moderate physical activity a day for at least five days a week. As John had a Body Mass Index (B.M.I.) of 34kg/m2, he was classed as being obese. Obesity is described by Nair and Peate (2009) as a term used when a person has excess amount of adipose (fat) tissue in relation to the body mass. A person is defined as obese when the B.M.I. is over 30kg/m2.

The Department of Health (2010) say the Government is concerned with the increase of obesity in the United Kingdom (U.K.). The data from the 2008 survey conducted by Health Survey for England (H.S.E.) shows that nearly 1 in 4 adults are obese. Based on data from 2004 to 2007, the Foresight Report (2007) commissioned by the government
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predicted 60% of men, 50% of women and 25% of children would be obese by 2050. At present, this report estimates the cost of obesity to the N.H.S. amounts to 4.2 billion per year. If no changes are done, the report forecasts the cost to more than double by 2050. The Foresight Report (2007) highlighted the importance of dealing with obesity. It is said within this report that messages regarding obesity portrayed in the media can be misleading. For example, the government describes the increase of obesity as an epidemic, whereas others say the situation regarding obesity is not that bad. The Foresight Report (2007) explains how our way of life and changed significantly over the last few decades, resulting in more labour saving devices in our homes, as well as driving more, eating more convenience foods and having groceries delivered directly to customers homes from supermarket chains.

John talked about his diet, and he explained that he was not aware of the impact his diet had on his health. He was under the impression that manually handling the appliances he delivered as part of his job was adequate exercise to burn off the calories he consumed from his daily diet. Although he ackowleged he was aware of being overwieght, John was not aware of being obese, and asked what complications are associated with obesesity. The practice nurse explained that the N.H.S. (2010) list the complications as, hypertention, heart desease, stroke, asthma, osteoarthritis, chronic back pain and type 2 diabetes. When John then asked what complications may be the result of his diabetes, the practice nurse explained that good management of diabetes reduces the risk of complications. However, serious complications resulting from poor management of diabetes include heart disease, stroke, blindness, kidney disease, nerve damage and amputations leading to disability and premature death (Stratton et al (2000). The practice nurse advised John to regularly check his feet for ulcers. Diabetes U.K. (2010) explains that 10% of diabetics will be affected by foot ulcers. Serious infections can develop from ulcers leading to possible limb amputation. John became
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concerned about this procedure, as he may miss something as he would find it difficult to check his feet. John was recommended a referral to a chiropodist, which can be made by a General Practitioner, practice nurse or health visitor. General Practitioner, practice nurse or health visitor can do (N.H.S. 2010). A referral to an optician was recommended to John, as retinopathy is a common complication of diabetes (damage to the retina at the back of the eye). The N.H.S. (2010) recommends newly diagnosed diabetics are referred to an optician for further and regular checks. When John asked what these checks would include, the practice nurse explained that a photograph would be taken of the retina. She explained if retinopathy is left untreated it can cause impaired vision or blindness, however if detected early the outlook is good, and 90% of such cases are treated successfully.

After discussing these issues with John, he explained that he was concerned that as he does not feel as though he had diabetes, what measures are in place to monitor his condition. The practice nurse explained that he will be invited to regularly attend a oneto-one diabetic consultation with the practice nurse. When John asked what the consultation would entail, the practice nurse explained it would include analysis of blood and urine from the pathology laboratory to indicate glucose and cholesterol levels, as well as simple physical tests carried out by the practice nurse. These tests would include: Blood pressure B.M.I. Sensation tests to both feet Examining pulses to both legs and feet

This reassured John, and he was happy to proceed with these recommendations.

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The practice nurse carried out the referrals using an electronic system called SystemOne. The systems database contains all the patient medical data in one central place, enabling any health care professional with access rights to view the patients medical records. As Johns referrals were made to health care professionals who are only required to view sections of Johns medical records relevant to their speciality, filters are put in place to prevent any irrelevant medical data about John being accessed. This enforces the Department of Healths (2010) Caldicott Principles and maintains patient confidentiality.

Feeling more comfortable with the monitoring of his diabetes, John was concerned he would not know how to managed his diet effectively in order to lose weight. John was recommened by the practice nurse to attend a local Weight Watchers programme. This would include attending regular meetings where he would receive support and guidence to achieve and maintain weight loss (Weight Watchers 2010). In addition to Weight Watchers, the practice nurse also recommended a referral to a registered dietician (R.D.). When John asked what benefit this would be to him, the practice nurse explained that dieticians are qualified health professionals who assess, diagnose and treat nutrition and diet problems. This can be done at an individual level or at a wider public health level. Dieticians use the most up to date research on food, health and disease to enable them to give guidance to people to make appropriate lifestyle and food choices (The British Diabetic Association (B.D.A.) 2010).

The practice nurse explained to John that by looking at the labels when purchasing food would be a good contribution to improving his diet. John told the practice nurse that he found such information too confusing. The practice nurse explained that the Food Standards Agency (F.S.A.) have introduced a traffic light system to assist consumers to see how a particular food products fit into a healthy diet at a glance. This is
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complimented by the Five-a-Day campaign, which increases consumers awareness of how foods affects health, and explains how to consume five portions of fruit and vegetables a day. These campaigns are included in a white paper, Choosing Health: Making Healthy Choices Easier, published by the government in 2004. This was intended for the collaboration between government bodies such as the Department of Health, Department of Culture, Media and Sport, Department for Education and Skills and the Food Standards Agency as well as the food industry and the media to achieve the goal of better public health. The F.S.A. is working together with the food industry to produce healthier foods, and already a lot of manufacturers have reduced the salt content within their food produces by 10%. Manufacturers are also reducing the sugar and fat content.

The practice nurse explianed that with the combination of a healthier diet and regular exercise, John would begin to lose weight and improve his health as well as manage his diabetes. John was concerned how he would be sure he achieved sufficient exercise to make a sufficient impact to improve his health. John was reminded that the Department of Health (2004) recommends adults to achieve 30 minutes of exercise a day. Choosing Heath endorses the use of pedometers, recommending individuals to achieve a total of 10,000 steps a day. To achieve weight loss, Choosing Health recommend 15,000 steps a day.

The government have implemented other key initiatives to help deal with obesity by introducing the Change4Life and N.H.S. Health Check programme, to which John was invited to attend. The N.H.S. Health Check, launched in April 2009, is a free N.H.S. national initiative to detect the early onset of stroke, heart disease, diabetes, and kidney disease (N.H.S. 2009). The health check normally takes 20-30 minutes. The patient will be asked about their family medical history and to list any medication they are currently
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taking. The patients height, weight, age, sex and ethnicity are recorded. The patients blood pressure will be taken, and a blood sample sent for analysis. Using the data from the patients height and weight, their Body Mass Index (B.M.I.) is recorded. Once the results of the blood test were received from the laboratory, the patient is invited back to discuss. In Johns case, his blood results indicated a high level of glucose, which in turn indicated type 2 diabetes. He underwent a further blood test, which in turn confirmed that John had the condition. Johns B.M.I. was worked out to be 34, which was in the obese range. In a response to the rise in public health issues secondary to obesity, including diabetes, the Government launched a society-wide movement called Change4Life in January 2009 (The Department of Health 2010). This movement educates people on how a change to their lifestyle can make a difference to their health, by eating healthier foods and participating in regular exercise. A Public White Paper published later this year by the Department of Health will explain how the Government will provide the public with clear, consistent messages on why they should change their lifestyle, how to do so, and put in place ways to make this easier.

After the consultation with the practice nurse, John felt very comfortable with the information given to him, and the way the information was conveyed in order for him to fully understand his condition. Laverack (2009) explains the importance of one-to-one communication, as it allows a dialogue to develop between the patient and health care professional. It is important for the health care professional to choose the most ethical acceptable style of communication according to the type of patient.

In conclusion, the role of the practice nurse is clearly defined within this care study as a source of information and support for the patient who is obese with type 2 diabetes. The care study discussed how type 2 diabetes has been recognised as a condition secondary to obesity, and how both these conditions generate a high cost to the N.H.S..
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The government initiatives to prevent and reduce obesity alongside with the early detection of type 2 diabetes, as well as other conditions secondary to obesity have been explored. These initiatives have been successful in promoting awareness to the public, therefore reducing the complications caused by public health issues. This in turn is reducing costs to the N.H.S.. Effective communication between the practice nurse and the patient is displayed throughout, and the importance of this is has been explained. With the implementation of electronic data systems, communications between disciplines are more accurate and instant. Confidentiality is maintained by the placements of filters which ensure a need-to-know policy is maintained. The advantage of which, complete up-to-date patient records are immediately accessible, giving health care professionals an up to date patient profile.

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References

Department of Health, 2004, At least five a week: Evidence on the impact of physical activity and its relationship to health. A report from the Chief Medical Officer. Department of Health, 2004. Choosing Health: Making healthy choices easier Department of Health, 2006, Turning the corner improving diabetes care. Report from Dr Sue Roberts, National Clinical Director for Diabetes to the Secretary of State for Health Department of Health, 2010, Change4Life [online] Available at: <http://www.dh.gov.U.K./en/Publichealth/Change4Life/index.htm> [Assessed 14 November 2010] Department of Health, 2010, Confidentiality [online] Available at: <http://www.dh.gov.U.K./en/Publicationsandstatistics/Publications/PublicationsPolicyAndG uidance/Browsable/DH_5133529> [Assessed 14 November 2010] Diabetes U.K., 1995, What is diabetes? [online] Available at <http://www.diabetes.org.U.K./Guide-to-diabetes/Introduction-todiabetes/What_is_diabetes/> [Accessed 2 November 2010] Diabetes U.K., 2010, Diabetes and Foot Care [online] Available at: <http://www.diabetes.co.U.K./diabetes-footcare.html> [Assessed 16 November 2010] Fee, E, Acheson, R, 1991, A history of education in public health. Health that mocks the doctors rules. Oxford: Oxford University Press. Frayn, KN, Coppack, SW, Fielding, BA and Humphreys, SM, 1995, Coordinated regulation of hormone sensitive lipase in human adipose tissue invivo: implications for the control of fat storage and fat mobilization. Oxford Lipid Metabolism Group, Nuffield Department of Clinical Medicine, Radcliffe Infirmary, U.K.. Government-commissioned Foresight , 2007, Led by Professor Klim McPherson. Oxford University, pp11. Gregoire, FM, Smas, CM, and Sul, HS, 1998, Understanding adipocyte differentiation. Department of Nutritional Sciences, University of California, Berkeley, USA. Health Survey for England, 2008, Physical activity and fitness. Edited by Rachel Craig, Jennifer Mindell, Vasant Hirani. Hill, JO and Peters, JC, 1998, Environmental contributions to obesity. Colorado Clinical Nutrition Research Unit, University of Colorado Health Sciences Center, Denver, CO 80262, USA.

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Laverick, G, 2009, Public Health, 2nd Ed. Macmillan Publishers Limited. Nair, M and Peate, I, 2009, Fundamentals of Applied Pathophysiology. Chichester: John Wiley & Sons. National Health Service (N.H.S.), 2009, Free N.H.S. Health Check: Helping you prevent heart disease, stroke, diabetes and kidney disease. D.H. Publications. National Health Service (N.H.S.), 2010, Obestity - Complications [online] Available at <http://www.N.H.S..U.K./Conditions/Obesity/Pages/Complications.aspx> [Accessed 2 November 2010] National Health Servive (N.H.S.), 2010, Can I get chiropody on the N.H.S.? [online] Available at: <http://www.N.H.S..U.K./chq/Pages/1099.aspx?CategoryID=68&SubCategoryID=154> [Assessed 17 Novemeber 2010] National Health Servive (N.H.S.), 2010, Diabetic retinopathy [online] Available at: <http://www.N.H.S..U.K./conditions/diabetic-retinopathy/Pages/Introduction.aspx> [Assessed 17 Novemeber 2010] National Health Servive (N.H.S.), 2010, N.H.S. Health Check [online] Available at: <http://www.N.H.S..U.K./Planners/N.H.S.HealthCheck/Pages/N.H.S.HealthCheck.aspx> [Assessed 17 Novemeber 2010] Stratton, IM, Adler, AI, Neil, HAW et al , 2000. Association of glycaemia with macrovascular and microvascular complications of Type 2 diabetes (U.K.PDS 35): prospective observational study. BMJ 321; pp405412 The British Diabetic Association (B.D.A.), 2010, The Role of Dieticians and How to Find One [online] Available at <http://www.bda.U.K..com/> [Assessed 15 November 2010] The Nursing and Midwifery Council (N.M.C.), 2009, The Code Available at http://www.N.M.C.U.K..org/Documents/Standards/N.M.C.TheCodeStandardsofConduct PerformanceAndEthicsForNursesAndMidwives_TextVersion.pdf [Accessed 28 February 2010] Tuomilehto, J, Lindstrm, J, Eriksson, JG et al, 2001, Prevention of Type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. The New England Journal of Medicine, 344(18); pp13431350 Weight Watchers, 2010, [online] Available at <http://www.weightwatchers.co.U.K./plan/mtg/index.aspx> [Accessed 2 November 2010] Williams, G, and Pickup, JC, 2004, Handbook of diabetes, 3rd Ed. Blackwell Publishing Winslow, CA, 2002, Encyclopedia of Public Health, Gale Group, Inc.
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