Overview
This Guidelines summary includes information for healthcare practitioners on supporting patients to manage their weight, including discussing body mass index (BMI), eligibility for referral to obesity services, follow up, and further resources.
Why Talk About Weight: the Role of Health and Care Professionals in Adult Weight Management
- This resource offers tips on the conversations you should be having with overweight and obese patients about weight loss. It provides practical advice on how to appropriately discuss this topic and tools to support you in making brief interventions
- As a health or care professional, you are in a unique position to talk to patients about weight management to prevent ill-health. Obesity is a major risk factor for a number of chronic diseases and weight management interventions can support individuals to achieve and maintain a healthier weight
- A key first step in supporting your patients to manage their weight is initiating a conversation. Research shows that well planned, very brief interventions can increase the chances of a patient making a successful weight loss attempt. You don’t need to be an expert in weight management to incorporate this into your routine consultations with patients who are overweight or obese and you don’t need to spend a lot of time to make a difference
- It is important to be familiar with your local obesity care pathway so you are aware of the weight management services available in your area and the referral criteria and process—the Public Health team at your local authority and clinical commissioning group should be your first point of contact.
Algorithm 1: Obesity Services Tier System
- Within each of these tiers, you have a key role to play in providing support and referring your patients to services that are available to them. This resource will support you to refer your patients to tier 2 and tier 3 weight management services for adults
- By brief interventions, Public Health England means very short conversations of around 30 seconds. Identify the patients at risk (ASK), explain how best to change behaviour (ADVISE), and refer to obtain help (ASSIST)
- Many patients will be open to you discussing their weight with them, if addressed appropriately. You can deliver a brief intervention in any consultation, even where weight was not the original reason for the patient’s visit
- Research has shown that brief, opportunistic interventions delivered in primary care can result in a five-fold increase in the proportion of patients engaging in weight management services. Simple advice from a health or care professional to lose weight increases patients’ intentions to lose weight. However, referring people to weight management services can more than double the amount of weight they lose
- People who lose weight tend to regain weight down the line; however this should not deter you from supporting your patients to take action to manage their weight. Even temporary reductions in weight lead to health benefits, as the health risks associated with excess weight depend upon a person’s current level of obesity and the length of time they have been overweight or obese
- It is important to consider that brief intervention with overweight and obese adults may have a positive impact on family health, given that parental obesity is a risk factor for childhood obesity.
ASK: Weighing, Measuring, and Interpretation of BMI Status
- The first step in delivering a brief intervention about weight is to weigh and measure the patient; also known as the ASK component. You should view this as a normal part of a routine consultation
- Routinely weighing and measuring your patients will support the Quality Outcomes Framework related to weight, which recommends the establishment and maintenance of a register of patients aged 18 years and over with a BMI of 30 kg/m2 or greater in the preceding 12 months
- It is important to consider the practicalities of weighing and measuring your patients, and steps you can take to establish this as routine practice. Tips include:
- optimal placement of scales for ease of access
- ensuring scales are suitable for patients with severe obesity
- regularly calibrating your equipment
- There are a number of phrases you could use to initiate the brief intervention, for example:
- ‘Before you leave, could I check your weight today?’
- ‘While you’re here, can I check your weight?’
- ‘Do you mind if I weigh you?’
- Once you have weighed and measured your patient, the next step is to determine the patient’s weight status
- Overweight and obesity in adults is categorised using BMI
- BMI=weight in kg divided by height in metres squared (weight [kg]/height [m2])
- Your local electronic patient record system may calculate and record patients’ BMI routinely; if this function is not available, the NHS Choices website provides a BMI Healthy Weight calculator tool, which enables you to calculate your patients’ BMI
- Assessment of BMI provides an indication of appropriate weight management options for patients.
Table 1: Obesity Classification Criteria
| Classification | BMI (kg/m2) |
|---|---|
| Healthy weight | 18.5–24.9 |
| Overweight | 25–29.9 |
| Obesity I | 30–34.9 |
| Obesity II | 35–39.9 |
| Obesity III | 40 or more |
| Abbreviation: BMI=body mass index | |
Referral
- It is important to be familiar with your local services, as referral criteria may vary locally.
Table 2: Eligibility Criteria for Obesity Services Tier 2–4
| Tier | Eligibility Criteria |
|---|---|
| Tier 2: multi-component lifestyle weight management services | ≥25 kg/m2 where there is capacity[A] |
| ≥30 kg/m2 | |
| [A] Consider referral for tier 2 weight management services from ≥23 kg/m2 for patients of black-African, African-Caribbean and Asian family origin where there is capacity | |
| Tier 3 multidisciplinary specialist weight management services | ≥30 kg/m2 where tier 2 interventions have been unsuccessful |
| ≥35 kg/m2 in the presence of diabetes and/or other significant comorbiditiesOR where tier 2 interventions have been unsuccessful | |
| ≥40 kg/m2 | |
| Tier 4 surgical interventions | ≥50 kg/m2 where the person has been receiving or will receive intensive management in a tier 3 service |
| Consider referral: 30–34.9 kg/m2 in the presence of type 2 diabetes of less than 10-years duration which is poorly controlled ≥35 kg/m2 in the presence of type 2 diabetes and/or other significant comorbidities and where the person has been receiving or will receive intensive management in a tier 3 service ≥40 kg/m2 where the person has been receiving or will receive intensive management in a tier 3 service | |
| NB These criteria should be decreased by 2.5 BMI points for people of Asian family origin | |
| Abbreviation: BMI=body mass index. | |
- Referral decisions should be discussed with patients and should take into account the health status of individuals and the presence of weight-related comorbidities, such as type 2 diabetes, hypertension, cardiovascular disease, osteoarthritis, dyslipidaemia, and sleep apnoea.
ADVISE
- Once you have determined your patient’s weight status, and the suitability of a referral to a weight management service, deliver the ADVISE component of the brief intervention
- You should ADVISE your patient that weight loss can be more achievable with support; discuss with your patient what services are available to them and offer referral
- Consider incorporating the following simple points, which are important elements in the effectiveness of the conversation at this stage:
- state the referral is available FREE in the opening sentences of the conversation, not after offering a referral and asking for a response. Note: it is important to be familiar with your local service provision and care pathway to determine if free referral is an option in your area
- keep interventions brief, 30 seconds seems to be optimal
- give factual information about a specific programme. Avoid making assumptions about a patient’s diet or activity or saying things that could be interpreted as moral judgements about a patient
- confidence is key. Being confident in what you’re saying and your recommendation of the programme you are referring to builds confidence in the patient
- An example of how this conversation could look is:
- One of the best ways to lose weight is with support and [insert name of weight management service] is available free. I can refer you now if you are willing to give it a go?’
ASSIST
- Getting a patient to commit to action and leave the consultation with a plan in place is important; once you have discussed the options with your patient, you should then ASSIST them by making a referral to the service you have agreed on, or offering your continued support
- The following scenarios give examples of how these conversations might go, and what key points you should consider including in your conversations to maximise engagement
Patient Receives Advice Positively
- Let the patient know what the next steps are
- ‘Great. I will refer you to the service now. You’ll get an appointment through the post.’
- Suggest a follow up appointment to monitor the patient and to provide help and encouragement with their weight
- ‘I’d like to see how you’re getting on, so next time you come to see me, I will weigh you again and we can talk some more.’
Patient is Receptive but Non-committal About a Referral (For Example, Wants to Try to Lose Weight Themselves)
- Show acceptance of patient’s wishes, acknowledge their concerns, and recognise the difficulties of weight loss. Re-emphasise the importance of working to achieve a healthier weight; re-offer your support
- ‘Okay, that’s fine; I understand that you think attending a programme might be too time consuming. I know it can be hard to lose weight, but it is important and I’m keen to support you in doing this.’
- Suggest a follow up appointment to monitor the patient and to provide help and encouragement with their weight
- ‘I’d like to see how you’re getting on, so next time you come to see me, I will weigh you again and we can talk some more. If, at that point, you’ve got more time we can consider referral to [insert name of weight management service] again.’
Patient Does Not Want to Engage in Conversation About Weight Management
- Show acceptance of patient’s wishes, re-offer your support should they change their mind. Don’t force the issue but leave the door open
- ‘Okay, that’s fine; I understand that maybe now is not the right time. If this is something you want to talk about in the future, I’m keen to support you in doing this.’
- It is good practice to put a note in your patient’s records of any conversations you have about weight and the outcomes. This will enable another health or care professional to follow up on this conversation if appropriate.
Follow Up
- Follow-up appointments provide an opportunity to review a patient’s situation. Continued engagement is recommended as this may encourage your patients to respond positively
- You may find it helpful to follow the sequence below in these situations, and where referral to a weight management service was initially turned down, to re-offer referral
- ask how your patient’s weight management attempt is going, or where the patient initially was uninterested, ask if this is something they might be interested in now
- weigh the patient
- give feedback, sensitively but clearly—relate to expected weight loss, that is, 1–2 lbs per week
- review the proposed action for weight loss
- re-offer referral where appropriate.
Resources for Further Learning and Information
- Health Education England obesity e-learning modules for practitioners in the NHS and local authorities working in weight management (introduction to obesity, identifying overweight and obesity and risk factors for weight gain, managing obesity treatment options, guiding and enabling behaviour change)
- Cancer Research UK and the Royal College of General Practitioners very brief advice module and associated training videos (VBA e-learning on cancer prevention related to obesity, smoking cessation, and alcohol reduction)
- BWeL trial (evidence of effectiveness of brief intervention on weight management)
- Adult obesity: applying All Our Health
- Royal College of General Practitioners obesity and malnutrition e-learning
- Making Every Contact Count resources (tools to aid implementation and support individuals when considering MECC activity)
References
References