Session 1: Training in nutrition, physical activity and obesity in primary care settings
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WHO training course for nutrition, physical activity and obesity in primary care settings
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Session 1: Training in nutrition, physical activity and obesity in primary care settings
- 1. Training in nutrition, physical activity and obesity in primary care settings Session 1 <insert place of course> <insert date of course> Course devised by: R. Pryke J. Breda J. Jewell X. Ramos Salas
- 2. Course facilitators <insert facilitator names for current course>
- 3. Aims and objectives – overview Five themes … … split into three sections • services overview • communication skills training • developing local facilities • Why discuss • How to influence • What to explain • Which goals and how to measure • Where to get help
- 4. Aims and objectives (1) – services overview • Understand public health context for work in this area. • Explore WHO guidance and key recommendations for daily practice. • Highlight evidence around nutrition, physical activity, body composition and health outcomes. • Review your local resources. • Identify, discuss and debate potential barriers and enablers in this locality. • Devise work plan to fill delivery gaps. • Why discuss • How to influence • What to explain • Which goals and how to measure • Where to get help
- 5. Aims and objectives (2) – communication skills training • Practise communication skills to: o have positive conversations with patients; o identify at-risk target groups and patients; o convey diet and physical activity advice; o understand how behavioural norms develop and can be shaped; o identify realistic patient-centred goals and appropriate indicators of success. • Try out motivational interviewing techniques using case studies and group workshops. • Why discuss • How to influence • What to explain • Which goals and how to measure • Where to get help
- 6. Aims and objectives (3) – developing local facilities • Why discuss • How to influence • What to explain • Which goals and how to measure • Where to get help • Reflect on current resources throughout the course. • Small group discussions to define health priorities and current gaps. • Plenary session to set goals and agree plan of action.
- 7. Nutrition, physical activity and obesity How WHO can support public health Session 1 • Why discuss • How to influence • What to explain • Which goals and how to measure • Where to get help
- 8. Many major challenges remain Most countries have made some good progress in improving the health and well-being of their populations, but there is a high risk of progress not being made in some key areas …
- 9. Premature NCD mortality is declining …
- 10. … but a number of countries still have a high avoidable burden and large gender gap
- 11. And the disease burden attributable to nutrition, physical activity and obesity is high …
- 12. Proportion of European Member States on course to meet global targets for nutrition, physical inactivity and obesity by 2025 – very few! 0% 20% 40% 60% 80% 100% Childhood obesity Physical inactivity Breastfeeding Salt reduction Adult obesity on track off track
- 13. Adolescents – overweight and obesity prevalence in youth according to European subregion 14.1 20.2 11.5 15.5 14.7 21.3 15.6 16.2 15.3 22.5 18.5 17.3 0 5 10 15 20 25 30 Western Europe Southern Europe Eastern Europe Northern Europe % 2002 2006 2010 Sharper increase
- 14. Prevalence of insufficient physical activity among school-aged adolescents 0 10 20 30 40 50 60 70 80 90 100 ITA DNK FRA CHE RUS PRT SWE EST GRC NOR ISR ISL LTU DEU BEL TUR MLT NLD HUN ROM SVN LVA POL HRV GBR LUX SVK ESP UKR MKD FIN CZE ARM AUT BGR IRL % 2010
- 15. Obesity is a chronic disease • International Classification of Diseases, ninth revision (ICD- 9), contains entries for obesity and severe obesity (1948) • US National Institutes of Health (1998) • US Social Security Administration (1999) • US Centres for Medicare and Medicaid Services (2004) • Obesity Society (2008) • American Association for Clinical Endocrinology (2012) • American Medical Association (2013) • Canadian Obesity Network (now Obesity Canada) (2011) • Canadian Medical Association (2015) • National Institute for Health and Care Excellence (NICE) (2014) • European Association for the Study on Obesity (Milan Declaration, 2015)
- 16. Definition • Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health (WHO, 2016). • A crude population measure of obesity is the body mass index (BMI), a person’s weight (in kilograms (kg)) divided by the square of his or her height (in metres (m)). • Obesity is defined as a BMI greater than 30 kg/m2. • Interpret BMI with caution because it is not a direct measure of adiposity (NICE Guidelines, 2014).
- 18. Strategic objectives for public health Improve leadership and governance Reduce inequalities and address social determinants Four main priorities Take a life- course approach and empower people Focus on Europe’s major health challenges: NCDs and risk factors Strengthen people- centred health systems and public health Create supportive communities and healthy environments
- 19. People-centredness is key in prevention and care Base interventions on people: health services should enable people to receive a continuum of different levels of services according to their needs.
- 20. Role of primary health care Both the Food and Nutrition Action Plan 2015–2020 and the Physical Activity Strategy 2016–2025 highlight the importance of primary health care. • Primary health care is underutilized in preventing and managing obesity and in promoting healthy diets and physical activity. • Treating the consequences of obesity is readily accepted by clinicians; however – while there is evidence that primary care interventions can be effective – confidence in addressing risk factors and treating obesity itself is low. • Ensure that all health care settings highlight nutrition, healthy eating and physical activities within people-centred health systems. • Establish brief interventions, and target nutritional and physical activity assessment for different age groups, especially children and the elderly; both primary care and home care services should be included.
- 21. Role of primary health care • Primary care is an ideal setting for chronic disease prevention and obesity management. • Firm interdisciplinary clinic relationships and deliberate communication strategies are the foundation of interdisciplinary care (e.g. long-term weight management). • There is a clear need for shared messaging concerning obesity and its management between members of interdisciplinary teams.
- 23. Role of primary health care – summary • Raise awareness – get good conversations going; explain relevance of a patient’s weight to their comorbidities. • Support prevention approaches and engagement in relevant treatment approaches. • Understand local support services and signpost appropriately. • Build rapport and offer follow-up – obesity is a chronic relapsing condition and its associated comorbidities mean affected patients will present repeatedly over time.
Editor's Notes
- Speaker notes Ask for show of hands, encourage group responses.
- Speaker notes Tailor introductory comments to link particular locality's public health priorities with wider WHO public health priorities. Pre-course recommendation: ask delegates to bring examples of existing tools, resources or service evaluation to inform current practice review and to share good practice with colleagues. Equally, where there are clear gaps in resources, this course will help delegates to focus on how those gaps can be addressed, either locally or using resources available elsewhere.
- Speaker notes The aim is to update our knowledge concerning "Why we should act”; and to practise skills that can help with "What to say” and "How to achieve change in practice”. Cases and group discussion topics in the course workbook will give structured practice in use of communication skills and influencing behaviour change. These are generic skills that – while used here to tackle weight management issues – can also be used in other lifestyle settings, such as smoking cessation and medication compliance.
- Speaker notes Some national progress has been made in the fight against NCDs – primarily in reducing premature cardiovascular mortality. However, these diseases, which include cardiovascular diseases, chronic respiratory diseases, cancers and diabetes, remain the world’s biggest killers and claim the lives of 15 million people aged 30 to 70 years annually Governments must step up efforts to control NCDs to meet globally agreed targets, including preventing the premature deaths of millions of people from these conditions.
- Speaker notes Shows a geographical pattern from east to west. Median for Europe = 14.6%; lowest and highest values are 9.4% and 30.2% – a ratio of 3 : 1. Trends show that the probability of dying decreases over time, with the highest country levels among men (the worst country levels for women are at the same level as median levels for men). Interestingly, the fastest decreases (steepest slopes) are seen among men in the least prosperous countries (coloured red); it will take many years, however, before they “catch up” with women in their respective countries.
- Speaker notes Staggering little progress has been made towards achievement of the WHO global targets. For some indicators, the vast majority of countries are off track, particularly in the case of breastfeeding, obesity, salt reduction and physical activity. Some progress is beginning to be observed in tackling childhood obesity
- Speaker notes The situation in the eastern part of the Region is particularly worrying, given the speed at which the prevalence rates are catching up with those in countries in the western part of the Region. What factors can explain this? (This discussion will vary in relevance according to whether the host country is in eastern Europe.) Are there learning points that can be passed from one subregion to another? Or are solutions more likely to be politically driven? Possible questions to engage group discussion: How might we expect migrant community statistics to be changing? Would such statistics reflect their country of origin or their adopted country?
- Speaker notes The problem of insufficient physical activity is especially problematic among the young. In the European Region more than seven in every 10 adolescents are not achieving the WHO Global recommendations on physical activity for health.
- Speaker notes There is a movement across the globe to treat obesity as a chronic disease. More and more organizations around the world, including WHO, have declared that obesity is a chronic disease. In fact, there has been an ICD code for obesity since 1948. There are many reasons why classifying obesity as a chronic disease is useful. First, it helps policy-makers to set up an infrastructure to prevent obesity and to support patients with obesity. Second, classifying obesity as a chronic disease helps primary health care professionals to support their patients using existing frameworks and tools. The health care system is already used to preventing and treating chronic diseases. We can use the same principles and tools in the case of obesity.
- Speaker notes Historically, we have defined obesity using the body mass index (BMI). This measurement is easy to use when determining levels of obesity at the population level. WHO has developed BMI criteria that help public health policy-makers measure obesity in population-based studies; WHO has also defined obesity as abnormal or excessive fat accumulation that presents a risk to health. The important point is that obesity is defined as a condition that presents a risk to health. This definition is helpful because it allows you to frame the issue of obesity: using this definition, you can focus on patients whose weight is affecting their health, rather than thinking that you need to help every patient who presents with a BMI of 30 or more. While BMI is a useful definition for obesity operationally, it should not be used as the defining characteristic of the disease at the individual level. In the case of individuals who have severe obesity, issues of definition and measurement are not relevant. We cannot generalize about all individuals with severe obesity, but the current evidence suggests that many such people will have some health risks associated with their disease that primary care professionals can address. The most important point to remember is that obesity is considered a chronic disease when it has an impact upon a person’s health. People come in different shapes and sizes, and just because you have a BMI of 30 does not mean that you have a disease. A full assessment is needed before you can determine if a person’s weight is affecting their health: BMI tells you how big a person is, but it does not tell you how sick he or she is.
- Speaker notes To understand why obesity is a chronic disease we must understand its etiology. What causes obesity? Decades of studies demonstrate that obesity is a heterogenous disease – in other words, its drivers are heterogenous. Because people develop obesity for different reasons, they need different treatments. As you can see from the map, at the population level the drivers that cause obesity are complex and interact with each other. To date, over 300 such drivers have been identified. To say that obesity is a matter of “energy in, energy out” is very simplistic. The map shows that the biological regulatory system is anchored on one side by diet and on the other by activity; these operate at both individual and societal levels. In the case of food, this comprises both individual food choices and the wider system of food supply and distribution. Physical activity is affected by a range of individual psychological determinants, including stress and self-esteem, and then is influenced by broader sociological determinants in the wider environment.
- Speaker notes Across the public health continuum from communicable diseases to NCDs, it is important to have common strategic objectives. These include: improving leadership and participatory governance; reducing health inequalities; working together (whole-team approach) to promote health and well-being; addressing the social gradient that is reflected in the onset of NCDs; Using a life-course perspective. We know that there are critical stages in life where we need to be vigilant to maintain health. We also see, however, that there is a trajectory whereby ill health early in life affects your opportunities to be healthy.
- Speaker notes The core principle in delivering public health interventions, whether complex community-based interventions or first-line primary care discussions, is that people are the centre and focus. Base interventions on people’s particular needs and motivations, and understand how behaviour change can best be achieved. Just "telling people what to do” is not enough. We need to understand why and how people make change, in order to support them in achieving their goals. So, for example, an individual should be helped to move forward realistically from their own starting point – it is not necessarily a matter of reaching some "ideal”. But health professionals’ understanding of these "ideals” is also part of our armoury in helping patients to recognize the value of improving health and in assisting public health in benchmarking the effectiveness of interventions. To be able to provide the best care, it is important to promote communication and integration between public health and health policies. It is not feasible for one health worker to provide every service according to a patient’s needs: he or she should be able to refer to services in other settings.
- Speaker notes We, in primary care, are part of an extensive team that shares responsibility for addressing obesity. We do not shoulder all the responsibility, so we should not fear engaging in the fight. The fight is big – but the army is large!
- Speaker notes The onset of NCDs in populations is linked to social determinants such as: socioeconomic status educational status gender. These determinants influence risky behaviours and affect biological risk factors, generating health inequalities with respect to NCDs. To build capacity in primary health care, we need to understand broader as well as behavioural contexts in order to prevent NCDs and reduce health inequalities. This training will focus on health promotion and disease prevention in primary care settings, describing tools to address social determinants as well as explaining how to influence behaviour and prevent disease.