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Promoting healthy lifestyles is bread and butter for today’s nurses, but recent research indicates Kiwi nurses are more likely to be obese then their patients. FIONA CASSIE discovers more about nursing, obesity, and weight management.

How good are nurses at walking the talk of healthy living?

Nurses know more than most the importance of being active and eating well. They also are aware of the increased health risks of being obese. Yet obesity levels are still growing rapidly in New Zealand, and it appears that nurses are far from immune.

New Zealand obesity levels were just 10 per cent in 1977, 19 per cent in 1997, and have now reached 31 per cent according to the latest 2012-13 New Zealand Health Survey.

One of the first studies to look at the weight of Kiwi nurses – the Nurse eCohort study – found that 28.2 per cent of the 780 New Zealand nurses taking part were obese. Which was 1.7 per cent higher than obesity levels in the general population at the time (2006–2008). The gap was similar or higher for nurse participants from Australia and the United Kingdom.

In all, nearly 62 per cent of the 5000 nurses involved in the three nation eCohort study were overweight or obese – slightly more so than Jane and Joe Average in their home countries.*

Fiona Bogossian, who led the eCohort obesity analysis, found the high percentage of nurses outside the healthy weight range “surprising” given that health professions should have a “more acute understanding” of both the health consequences of obesity and of strategies “to avoid or overcome” obesity. She goes on to say in her 2012 article* that the findings “suggest that nurses and midwives are less able to manage their weight than their age and gender-related cohorts”.

Massey University professor Jenny Carryer says she has often wondered whether nurses are more overweight than the average population and Bogossian seems to have confirmed this. But Carryer, who has a long-standing research and personal interest in the topics of body size and health, says she still can’t see any likely hypothesis for why this would be so.

“For me, it compounds my growing certainty of two things – that we still really poorly understand the notion of obesity, and that just like clothes, I don’t think there’s a one size fits all cause.”

Big bones, muscle and diabetes

The standard and simplest international definition of obesity is a body mass index (BMI) of over 30 (see Apples, pears, and BMI sidebar). One doubts that double Olympic gold medalist Valerie Adams, who reportedly has a BMI of 31.6, is being advised by her health professionals to be more active or eat a better diet. The champion shot-putter would not be alone in being healthy and fighting fit while technically obese.

But crude as BMI may be, a high, long-term BMI is also statistically associated with being as twice as likely to get type 2 diabetes or high blood pressure and being more likely to have heart disease, a stroke, osteoarthritis, and several common cancers, including some breast cancers. It is the growth in type 2 diabetes that is particularly worrying, with a University of Otago analysis of 3300 blood tests from the 2008-09 NZ Adult Nutrition Survey showing that 7 per cent had type 2 diabetes and 20 per cent had pre-diabetes – so more than one in four Kiwi adults either had or were at very high risk of diabetes.

And it appears that it is not genes, big bones, or muscles that are making more and more New Zealanders obese.

The Ministry of Health on its obesity web page says while “some people are more genetically susceptible to weight gain than others, the rapid increase in the prevalence of obesity in recent years has occurred too quickly to be explained by genetic changes”.

“Most experts believe it is due to living in an increasingly ‘obesogenic’ environment – one that promotes over-consumption of food and drinks and limits opportunities for physical activity,” says the ministry.

Carryer would argue that expert research also indicates that weight gain is not as simple as eating too much and exercising too little and the obesity phenomenon is “very, very complex and multifactorial”.

“Nurses being overweight really affirms that complexity for me because many, many nurses are extremely physically active – not all, but many – and extremely health conscious. It is a conundrum.”

The eCohort study found nurses who were part-time or casual were less likely to be overweight or obese compared to their full-time colleagues, no matter what their age. Another related eCohort study, by Isabella Zhao, suggests that staying or changing to shift work can increase a nurse’s BMI.

Bogossian says the associations between work conditions and weight gain is still not fully understood. Though some have proposed that job stress may “promote unhealthy behaviours and/or modify endocrine function”, another hypothesis is that long working hours, shift work, and overtime can lead to fatigue and so hamper preventative and healthy behaviours.

Carryer agrees that many nurses are stressed and there are research studies now pointing to the role of stress hormone cortisol in obesity.

“But again, you can’t apply that to everybody, and we shouldn’t be looking for a single cause – everything including stress, food availability, women’s role in feeding others, juggling multiple roles, lack of sleep … all of those things obviously play a part.”

Bogossian’s analysis also found that nurses were more likely to be overweight as they got older and – with 90 per cent of the study being women – particularly when they were post-menopausal.

Middle-aged women already very aware of weight

Nurses, of course, are not alone in putting on weight in middle age and a recent study has found that weight management is very much on the minds of middle-aged Kiwi women – excessively, in some cases.

The University of Otago study of 1600 women aged 40 to 50 found more than 80 per cent were either trying to lose weight (39 per cent) or prevent weight gain (42 per cent). This included 23 per cent with BMIs of less than 25.

Associate professor and nutritionist Caroline Horwath says the most common methods of weight control were cutting down meal sizes or reducing fat and sugar intake, which is in line with healthy recommendations. About half said they were exercising predominantly to lose weight or control their shape.

“Women in New Zealand are really conscious of attempting to put into practice strategies to lose weight or prevent weight gain,” says Horwath.

“In spite of all of that, when you look at what’s happening with the prevalence of obesity, it’s high and it’s still rising.”

She says overseas longitudinal studies also indicate women can gain 0.6 to 0.7 of a kilo per year through the decades of midlife. For women who are already overweight or obese the weight gains can be even more substantial putting them at increased risk of metabolic syndrome. During the menopause transition, there is evidence of increased body fat levels and a deteriorating lipid profile with women’s risk of cardiovascular disease also increasing markedly post-menopause.

“Clearly, what comes up is that we need more effective solutions to help people deal with extra weight, but we also need to focus more on how to help people prevent weight gain. Menopausal transition time is a particularly important time as it’s an at-risk time for weight gain.”

The cohort was first surveyed in 2009, again in 2012, and a further follow-up is due in May this year when the team will be looking to see any emerging trends in which factors or measures impact on weight change. One area they will be looking at closely is motivation to live a healthy lifestyle to prevent weight gain, with the hypothesis being that the quality of motivation is the key rather than the quantity.

So people saying they were eating healthily because they enjoyed it were more likely to have a healthy BMI than those people who said they ate healthily because they were being ‘nagged to’, says Horwath.

The ‘non-dieting’ approach to weight management has been a research topic of interest to Horwath for some years. With many overweight women knowing as much as, if not more than, the dietitians about the calories, GI, and ‘points’ of every crumb they eat – it is clear that the restricted diet approach does not work for everyone.

She says that clinical trials of weight loss programmes usually show the maximum weight loss in first six months then it’s very common to return to the initial weight in following five years.

Many of the overweight women she had worked with in her research were spurred into their first restricted diet as very young women after comments about their weight but look back now and see they were very healthy young women.

But once started down the restricted diet road the research shows dieting can make you more preoccupied and out of control with food. You diet and lose weight, which makes you feel good, but then the weight goes back on plus a bit more, so you diet and lose weight again, but once again, put back on the weight plus yet a little bit more.

“This ongoing yo-yo pattern of gaining more and more weight over the years continues until finally they really are substantially overweight,” says Horwath.

“Women tell themselves that they have failed on all these diets. They don’t tell themselves that these diets have failed them.”

It can be a discouraging and damaging cycle.

Horwath says it’s all very well to encourage people to get active and eat healthily to protect themselves from weight gain. But the bigger issue is how can people be motivated and empowered to adopt, sustain, and enjoy these behaviours for not weeks or months, but their lives.

“Obviously, we’ve got this food environment, which is making unhealthy choices very, very easy and cheap,” says Horwath.

“Part of the problem is rooted in the environment that makes it easy for people to be sedentary and easy to eat high energy foods in excess.”

She says any answer to the growing obesity rate needs to address environmental issues but also to provide people with the motivation and skills to make more right choices when faced by the inevitable unhealthy options of modern life.

To that end, her team is looking to develop a web-based weight management intervention using their research findings in areas such as learning to eat in response to hunger and satiation signals (intuitive eating); mindfulness and motivation skills; and recognising and dealing with the triggers that can set off overeating or unhealthy eating. The hope is to run a feasibility study on the website later in the year and in time have a resource open to women across the country.

Nurses walking the talk?

That web resource could fill an unmet need and be a helpful tool for both nurses and their clients.

Which begs the question of how easy is it for an obese nurse to counsel an obese client about weight management.

Bogossian says a systematic review suggests that normal-weight nurses are more likely than their overweight colleagues to use preventative strategies and provide general advice to obese or overweight patients. But they were also more likely to have negative attitudes towards their obese patients.

A recently published Australian qualitative study talked to 21 patients who had received healthy eating and exercise advice from their GP, which indicated they felt more confident receiving advice from a doctor who was not overweight themselves.

Carryer says she was quite surprised by the Australian findings as she expected fat people might feel more rapport with a fat GP or nurse.

“But the public assumption remains that thin people have earned their thinness through hard work, diligence, and abstention and that fat people are fat because they lie about stuffing their faces,” says Carryer.

“Generally, that’s the belief everybody has at some level. It very much clouds our ability to work constructively with people.

“If we say the only thing you can do for a fat person is to encourage them to lose weight, then that is why we’ve continued to lose the battle.”

She says such research findings affirm what she has long argued that health professionals need to “stop focusing on body weight, visual size, and BMIs and think very constructively on how every individual can be supported to be as healthy as they possibly can be.”

Carryer says the overweight nurse, rather than feeling hypocritical in giving advice, should be able to share with their overweight and obese patients that although overweight, they exercise four to five days a week and are really fussy about eating healthily.

“They could add that, for them, it hasn’t made them lose weight but it could for the patient. It had certainly made them healthier, and the patient, too, will be healthier if their diet is good and they exercise regularly.”

That’s what walking the talk is all about – promoting healthy living.

Article reference: FIONA BOGOSSIAN et al (2012) A cross-sectional analysis of patterns of obesity in a cohort of working nurses and midwives in Australia, New Zealand, and the United Kingdom. International Journal of Nursing Studies 49 (2012) 727–738