Date of Last Review: May 2017 Page 1 of 12 Date Next Review: June 2018

Effective: 2 June 2017

Dietetic Referral Pathways for Elevated BMI in Adults Admitted to Acute Services Guideline

1. Guiding Principles

Overweight and obesity is a complex chronic health issue affecting people of all ages. Having an elevated Body Mass Index (BMI) is strongly associated with several chronic conditions including type 2 diabetes, cardiovascular disease, some cancers, as well as with mental health and eating disorders [1]. Obesity is particularly prevalent among the most disadvantaged socioeconomic groups, Indigenous populations and in rural and remote areas [1]. Results from the 2011–12 Australian Bureau of Statistics Australian Health Survey show that almost two-thirds (63%) of the population aged 18 and over are overweight or obese (35% overweight, 28% obese) [2]. Weight management requires a long term and multifactorial approach to ensure ongoing success for the patient. This includes a combination of dietary strategies to reduce energy intake, encourage regular physical activity and ongoing behavioural changes [1]. The community setting is recommended in the literature as most appropriate for long term, effective weight management [1,3,4]. Health professionals in primary health care should be the first line of intervention for weight management [1]. Evidence suggests the acute care setting is sub-optimal for weight management interventions. This is due to [5]: - short stay in hospital - not able to offer ongoing dietetic support - patient may have higher priorities on acute medical condition - not eating usual diet - limited ability to exercise - poor setting for education due to interruptions, lack of privacy etc. Patients admitted into WA Country Health Service (WACHS) facilities should have their risk for obesity and chronic disease assessed using simple measurements of weight, height, waist circumference and BMI. This is documented on the MR111 WACHS Nursing Admission, Screening and Assessment Tool – Adults. Based on the WACHS Dietetics Clinical Prioritisation Framework and Nutrition Clinical Practice Standard, referrals for non-complex obesity are lower priority and are not routinely assessed by dietitians in an acute care setting. This guideline provides referral pathways for adult inpatients with an elevated BMI to dietetics, with key components being the development of healthy lifestyle education packs and referrals to local outpatient dietetic services. This guideline promotes integration of acute care with community services to ensure improved health outcomes for the patient.

WACHS Dietetic Referral Pathways for Elevated BMI in Adults Admitted to Acute Services Guideline

Date of Last Review: May 2017 Page 2 of 12 Date Next Review: June 2018

2. Guideline 1. On admission, record weight, height and calculate BMI. This should be

documented on MR111 WACHS Nursing Admission, Screening and Assessment Tool – Adults and in the patient’s medical file. BMI is calculated as weight (kg) / height (m²) Refer to Appendix 4 for BMI charts or Health Direct online BMI calculator.

2. If unable to obtain an accurate height, you can calculate height using Ulnar length (refer to Appendix 5).

3. If unable to take accurate weight or height, measuring waist circumference will indicate a patients risk for obesity and associated chronic diseases. For instructions on taking accurate waist circumference, please refer to Appendix 3.

4. If a patient has BMI > 30 or waist circumference greater than 88cm in women and 102 cm in men, the following must be determined prior to commencing this referral pathway:

· Patient requires support with weight control · Patient consents to referral to dietetics (inpatient or outpatient)

- If consent is received by the patient, please document this in the patient’s medical file using Elevated BMI Interventions stickers (if available at your site) and on dietetic referral.

5. If the patient declines referral to dietetics, please document this in the patient’s

medical file using Elevated BMI Interventions stickers (if available at your site) and offer a Healthy Lifestyle Pack on discharge.

6. For maternity patients, please refer to the WACHS Maternity BMI Risk Management Policy [6].

7. For mental health patients, screening for obesity and related co-morbidities is recommended on all patients admitted with acute mental health issues. For details on specific guidelines for management of mental health clients, please refer to the Officer of the Chief Psychiatrist Standard’s for Clinical Care.

8. Referral by allied health professionals and medical staff: other clinical staff can

refer into this pathway if they assess the patient to have an elevated BMI, and client consents to referral to dietetics.

9. Based on BMI +/- waist circumference and evidence for acute complications and

co-morbidities, the following is recommended:

WACHS Dietetic Referral Pathways for Elevated BMI in Adults Admitted to Acute Services Guideline

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BMI > 30 OR Waist > 88cm for women and 102cm for men With no complications, admission not related to weight status

BMI> 30 OR Waist > 88cm for women and 102cm for men With acute complications or related comorbidities impacting on admission and nutritional status

Clinical examples Well controlled diabetes, patient mobile, chronic condition only, surgeries unrelated to weight (i.e. knee replacement, colonoscopy).

Cardiac, renal or respiratory failure, uncontrolled diabetes, pressure injuries, rehab impacted by poor mobility due to weight status, acute CVA/ MI with lifestyle risk factors

Dietetics Priority Level 5 –low priority

Level 3 - 4 – medium - high priority

Referral to Acute Dietetic services

No Yes If no onsite dietitian, please refer to visiting dietetic services for appropriate action.

Referral to OP Dietetic services

Yes Yes if no on site dietitian

Nursing Role - If available commence Weight Management diet if deemed appropriate and patient admitted > 3 days

- Offer healthy lifestyle education packs with details of local dietitians and groups available in the community

- Complete MR29 Referral Record and Leaving Hospital Checklist – Adults with referral to local outpatient dietetic services

- Document intervention taken using Elevated BMI Intervention stickers

- Refer to inpatient (IP) dietitian - Document intervention taken

using Elevated BMI Intervention stickers

Medical Officer Role

- Discuss with patient options for weight management in the community o Discharge summary:

recommends general practitioner (GP) commence chronic disease management plan if other chronic conditions present

- Management of current acute complications

- Discharge summary: recommends GP commence chronic disease management plan

WACHS Dietetic Referral Pathways for Elevated BMI in Adults Admitted to Acute Services Guideline

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For details on the recommended contents for the healthy lifestyle packs please refer to Appendix 2. Local dietitians are to provide the health sites with access to these packs based on local site pathways and local consumer group feedback.

10. Referrals to dietetics:

· To be completed based on local health services processes · Referrals to include weight, BMI and/or waist circumference of patient; details

of their current health condition/s and consent to referral to dietetics. · If there is no on-site dietitian, please refer to visiting dietetic services for

outpatient follow up or utilise Telehealth for initial assessment while still an inpatient for high priority referrals.

11. Documentation of pathway:

Nursing staff can complete Elevated BMI Intervention stickers and place in patients’ medical record file indicating the interventions taken. Local dietitians are responsible for providing stickers to health service sites.

12. Local site Implementation:

· It is recommended local sites develop processes based on their established referral pathways to dietetics and current service structures.

· If there is no on site dietitian, please refer to visiting dietetic services for outpatient follow up.

· Telehealth can be utilised for initial assessment while still an inpatient for high priority referrals.

Please refer to Appendix 1: Referral Pathway for Summary Chart

For all relevant resources regarding implementation of this policy, please refer to the WACHS Elevated BMI Referral Pathway to Dietetics intranet page:

For recommended information on discussing BMI and healthy lifestyle management for Medical and Nursing staff, please refer to NHMRC Clinical Practice Guideline [1]. Local dietitians are responsible for providing nursing and clinical staff with education on the pathway, resources to implement and tips for discussing weight with patients.

3. Definitions

BMI Body Mass Index. This is calculated as: weight (kg) / height (m)²

Obesity cut offs using BMI

BMI = 30-35 Class 1 BMI =35-40 Class 2 BMI = >40 Class 3

Waist circumference Valid measure of abdominal fat mass and disease risk in individuals. It is measured half way between the bottom of the last rib and top of the iliac crest approximately in line with the umbilicus [3].

Cut offs for increased risks of chronic disease using waist circumference (1,3)

Women: Increased risks >80cm and high risk > 88cm Men: Increased risks >94cm and high risk > 102cm

WACHS Dietetic Referral Pathways for Elevated BMI in Adults Admitted to Acute Services Guideline

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4. Roles and Responsibilities All Staff are required to work within policies and guidelines to make sure that WACHS is a safe, equitable and positive place to be. Nursing Staff

· Complete MR111 WACHS Nursing Admission, Screening and Assessment Tool – Adults and record weight, height, BMI and waist circumference (if appropriate)

· Refer to dietetics based on this referral pathway · Offer healthy lifestyle education packs to patients on discharge · If available, commence weight management diet if deemed appropriate and patient

admitted more than three (3) days · Complete MR29 WACHS Referral Record and Leaving Hospital Checklist – Adults

with referral to local outpatient dietetic services. Medical Staff

· Can refer to dietetics based on these referral pathways. · Manage acute complications. · Encourage patients to follow up with their GP for weight management in the

community. · Recommend GPs commence a Chronic Disease Management Plan (CDMP) on the

discharge summary if they have other chronic health conditions. Allied Health and other clinical Staff

· Can refer to dietetics based on these referral pathways.

Dietitians · Conduct nutrition assessment in acute setting and treat accordingly. · Refer to appropriate community services and outpatient dietetic services for

ongoing weight management on discharge. · Ensure acute care services have access to Healthy Lifestyle Education Packs and

Elevated BMI Intervention stickers. · Provide education and resources to clinical staff on the pathway.

5. Compliance

Failure to comply with this policy may constitute a breach of the WA Health Code of Conduct (Code). The Code is part of the Employment Policy Framework issued pursuant to section 26 of the Health Services Act 2016 (HSA) and is binding on all WACHS staff which for this purpose includes trainees, students, volunteers, researchers, contractors for service (including all visiting health professionals and agency staff) and persons delivering training or education within WACHS. WACHS staff are reminded that compliance with all policies is mandatory.

WACHS Dietetic Referral Pathways for Elevated BMI in Adults Admitted to Acute Services Guideline

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6. Evaluation Monitoring of compliance with this document is to be carried out by Dietetics Area Coordinator in conjunction with regional dietitians every six months to ensure referral pathways are appropriate for local sites using the following options: · Referrals to dietetics for elevated BMI · Number of healthy lifestyle packs provided by nursing staff · Use of weight management diet.

7. Standards National Safety and Quality Health Care Standards - 1.1, 1.2, 1.5, 2.1 EQuIPNational Standards - 12.1, 12.2, 12.3

8. References

1. National Health and medical Research Council (2013). Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Melbourne: NHMRC

2. Australian Bureau of Statistics (ABS) 2013. Australian Health Survey: updated results, 2011–2012. ABS cat. no. 4364.0.55.003. Canberra: ABS

3. Dietitians Association of Australia. DAA Best Practice Guidelines for the Treatment of Overweight and Obesity in Adults; DAA Canberra 2012.

4. Hillier- Brown FC et al. A systematic review of the effectiveness of individual, community and societal-level interventions at reducing socio-economic inequalities in obesity among adults; International Journal of Obesity (2014) 38, 1483–1490

5. Fremantle Health and Hospital Service Policies and Procedures Manual Dietetic and Nutrition Department; Referrals – Overweight and Obesity, 2014.

6. WACHS Maternity Body Mass Index Risk Management Policy

9. Related Forms MR111 WACHS Nursing Admission, Screening and Assessment Tool – Adults MR29 WACHS Referral Record and Leaving Hospital Checklist – Adults

10. Related Policy Documents WACHS Management of Surgical and Obstetric Patients with Elevated BMI Procedure WACHS Maternity Body Mass Index Risk Management Policy WACHS Nutrition Clinical Practice Standard WACHS Risk Assessment For Admission of the Heavier Patient Policy WACHS Risk Assessment for Admission of the Heavier Patient – Site Assessment Form

11. Resources WACHS Dietetic Clinical Prioritisation Framework, 2017

WACHS Dietetic Referral Pathways for Elevated BMI in Adults Admitted to Acute Services Guideline

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12. Related WA Health Policies

Office of the Chief Psychiatrist Standard’s for Clinical Care

13. WA Health Policy Framework Clinical Governance, Safety and Quality Policy Framework

14. Appendices Appendix 1 - Dietetic Referral Guidelines - Elevated BMI in Adults Admitted to Acute

Services Appendix 2 - Suggested Contents for Healthy Lifestyle Education Packs Appendix 3 - Measuring Waist Circumference Appendix 4 - BMI Charts Appendix 5 - Ulnar Length

This document can be made available in alternative formats on request for a person with a disability

Contact: WACHS Dietetic Coordinator (C.Michael) Directorate: Allied Health TRIM Record # ED-CO-17-31421

Version: 1.00 Date Published: 2 June 2017 Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia.

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Appendix 1: Dietetic Referral Guidelines - Elevated BMI in Adults Admitted to Acute Services

If patient weight >120kg, refer to WACHS Risk Assessment For Admission of the Heavier Patient Policy. If maternity patient, please refer WACHS Maternity Body Mass Index Risk Management Policy For mental health patients, please refer to the Office of the Chief Psychiatrist Standards for Clinical Care Health Direct Online BMI Calculator

BMI> 30 or waist > 88cm women and 102 cm men + acute complications or related comorbidities

impacting on admission and nutritional status. For example, cardiac, renal or respiratory failure,

uncontrolled diabetes, pressure injuries, rehab impacted by poor mobility due to weight status,

acute CVA/ MI with lifestyle risk factors

Level 3 - 4 – medium - high priority *

Nursing role: · refer to IP dietitian · Document intervention taken using Elevated

BMI Intervention stickers · If no onsite dietitian, please refer to visiting

dietetic services Dietitian role: · Refer to appropriate Outpatient services and

offer Healthy lifestyle education packs if not assessed as an inpatient.

· Assess, treat and educate patient accordingly · Refer to appropriate services in acute or

community setting (diabetes educator, physiotherapist, mental health, counselling, Telehealth services)

Doctor's role: · Management of current acute complications · Discharge summary: recommends GP

commence chronic disease management plan

Staff to check prior to commencing referral pathway ÿ Patient consent/willingness to engage – document

in patient’s medical file. ÿ Patient requires support for weight control

No IP referral to Dietetics, OP referral only Nursing role: · If available commence Weight Management

diet if deemed appropriate and patient admitted > 3 days

· Offer healthy lifestyle education packs with details of local Dietitians and groups available in the community

· Complete MR 29 Referral Record and Leaving Hospital Checklist – Adults with referral to local Outpatient Dietetic services

· Document intervention taken using Elevated BMI Intervention stickers

Doctor's role: · Discuss with patient options for weight

management in the community · Discharge summary: recommends GP

commence chronic disease management plan if other chronic conditions present.

Level 5 – low priority *

BMI > 30 or waist > 88cm women and 102 cm men +/- comorbidities, admission not related to

weight status or complications. For example, well controlled diabetes, patient mobile, chronic condition only,

surgeries unrelated to weight (i.e. knee replacement, colonoscopy).

Obtain weight and height to calculate BMI [weight (kg) / height (m)²] OR Waist circumference Document in Nutrition section MR 111 Nursing Admission, Screening and Assessment Tool or patients medical file

If BMI > 30 or waist circumference > 88cm women and 102 cm for men, commence pathway

* Based on WACHS Dietetic Clinical Prioritisation Framework, 2017

If patient declines dietetic intervention (IP or OP),

please document in patient's medical file

For mental health and maternity patients, please refer to specific guidelines for management

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Appendix 2: Suggested Contents for healthy Lifestyle Education packs These are to be developed by local dietitians and provided to health services sites. Examples of what to include:

1. Referral details to local dietitians (WACHS, Primary Health Networks / GP division, private therapists)

2. Referral details for local community groups 3. Numbers for Diabetes Telehealth 4. Standard GP letter for GP Management plan 5. Resources (include a mixture of the following)

- AGTHE - Food diaries - Hunger Fullness scale - NEMO: Getting Started: guidelines for shaping up - Live lighter – meal planner and recipe books - Exercise tips - Diabetes WA: Healthy Eating resource - Baker IDI resources - Portion Plate guide (example) - Resource for choosing appropriate foods whilst an inpatient

6. Information on appropriate web based resources; for example:

- DAA Smart Eating (recipes / information) - Healthy Food Guide (recipes / information) - Kids Spot (recipes) - MLA Main Meal (recipes) - Eat for Health (Nutrition calculator and food intake quiz – can include copy in

the pack) - Healthy Eating quiz: online quiz to assess people’s intake

7. Examples of monitoring apps:

- Fitness Pal (diet and exercise tracker) - Calorie King (diet and tracker) - Food Switch (make healthier options at the supermarket) - Easy Diet Diary (diet and exercise tracker) - Eating Mindfully (Mindful eating tips) - Stand Up! The Work Break Timer (encourages regular standing during long

periods of sitting) - Apple Health (pedometer, heart rate, energy burned, blood sugar, cholesterol

trackers)

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Appendix 3: Measuring waist circumference This is a valid measure of abdominal fat mass and disease risk in individuals. It is measured half way between the bottom of the last rib and top of the iliac crest approximately in line with the umbilicus [3]. To take an accurate measure of a patient’s waist circumference, the following steps are recommended:

1. Place the tape measure directly on to skin, or over no more than one layer of light clothing.

2. The correct place to measure the waist is halfway between the lowest rib and the top of the hipbone. This is roughly in line with the belly button.

3. Breathe out normally and measure. 4. Make sure the tape is snug, without squeezing the skin

Body Mass Index BMI and Waist Circumference

Measuring Tape Position for Waist (Abdominal) Circumference

Guidelines on overweight and Obesity: Electronic Textbook

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Appendix 4: BMI charts

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Appendix 5: Ulnar Length CALCULATING HEIGHT: Using Ulnar Length to Calculate BMI

Estimating height in bedridden patients