8 JCN 2014, Vol 28, No 2

In each issue of the Journal of Community Nursing we investigate a hot topic currently affecting our readers. In this issue, as we face an obesity epidemic and growing lifestyle-related conditions such as diabetes, JCN takes a look at the community nurses’ role in health prevention and asks the question...

R emember the ‘good old days’, when most people’s idea of a balanced diet was

a cholesterol-laden fry-up for breakfast, topped off by a couple of Benson & Hedges and a strong cup of instant coffee? And, that was before we’d even thought about lunchtime and the two pints we’d have to accompany our steak and kidney pie and chips...

Of course we’ve moved on since then — numerous public health campaigns have urged us to drink and smoke less, eat more healthily and take-up some form of exercise that doesn’t involve running to the chip shop on a Friday night.

So, that’s the good news — we’ve all changed for the better. Gym memberships are a growth industry, we all know that we ought to be eating ‘five-a-day’ and smoking is now banned in most public places.

Unfortunately, the bad news is that there’s a new enemy in town, one which is masquerading as a friend while sending us to an early grave. The name of this hidden evil? It’s sugar, folks. The ‘harmless’ little treat that you stir into your latte or sprinkle on your porridge every morning.

There’s a reason that sugar is particularly dangerous — it’s because half of the time we don’t even know it’s there. According to a new report from the World Health Organization (WHO) (BBC news - ‘Daily sugar intake should be halved’), no more than 10% of an adult’s calorie intake

Is it the job of community nurses to police people’s lifestyles?

Community matters

In over 30 years as a nurse I have seen several nutritional health promotion

strategies come and go, but essentially it comes down to one thing — moderation. This latest sugar ‘scare’ means being more aware of the sugar content in the food we buy and placing an increased emphasis on preparing our own food. We all need to get better at considering what we are eating and what our food contains, for instance, sugar may also be labelled as glucose or fructose. Nutritional status is very important in tissue viability, for instance, in both the prevention and management of wounds. Thus, we do have a responsibility to help patients understand the impact of a poor diet on the risk of developing wounds as well in delayed healing.

Jackie Stephen-HaynesProfessor in tissue viability, Birmingham City University and Consultant Nurse, Worcestershire Health and Care Trust

I absolutely agree that each contact nurses have with patients

should be used to promote health and wellbeing — and the earlier in the life-cycle this starts the better. There is a great amount of skill required to judge the extent of health promotion suitable for each patient — especially in district nursing. It would be easy, for instance, to visit an elderly, housebound patient and suggest they stop smoking and eat more healthily — however, in reality, how successful would this be? Achievable goals are the key and patients require support if they are to be empowered to change. This is where we must work with the relevant professionals within our trusts to ensure our patients are offered the best support possible.

Annette BadesDistrict nursing specialist practitioner and clinical lead cardiorespiratory, Lancashire Care NHS Foundation Trust

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JCN 2013, Vol 27, No 4 11 JCN 2014, Vol 28, No 2 9

As with all these issues, it is a balance. Nurses have to provide

the right level of information at the right time — if you make it your mission in life to ‘educate’ every patient you come into contact with, they will very quickly start avoiding you and potentially deny themselves access to help and advice when they really need it.

Anne PearsonPractice development manager, Queen’s Nursing Institute (QNI)

Media watch

‘WHO: Daily sugar intake “should be halved’’’ — according to BBC News, people will be advised to halve the amount of sugar in their diet, under new World Health Organization (WHO) guidance.

‘Messages about reducing sugar intake unclear, say campaigners’ — The Guardian writes that updated WHO guidance on sugar recommends that no more than 10% of people’s calories should come from sugar, but suggests that less than 5% would be preferable.

‘People should cut their sugar intake to just six teaspoons a day, says World Health Organisation’ — Mail Online focuses on the fact that children should not be given fizzy drinks ‘because they contain dangerous amounts of sugar’, also stating that adults ‘should halve their average intake to six teaspoons a day to avoid obesity, heart disease and other serious illnesses’.

should come from sugar, which sounds reasonable enough until you start looking into how much we are unknowingly consuming — Starbucks’ caramel frappuccinos contain more than 11 teaspoons of sugar; cans of Coca-Cola and Pepsi have nine teaspoons of sugar; a Mars bar has eight teaspoons, etcetera, etcetera, etcetera... (The Guardian — ‘Messages about reducing sugar intake unclear, say campaigners’).

And, what does excessive sugar intake lead to? Well, for starters, how about obesity, type 2 diabetes, heart disease, to name but a few. As the WHO guidance says, we are effectively poisoning ourselves with the sweet stuff. It’s expensive too — health problems associated with obesity and being overweight cost the NHS over £5 billion every year (www.gov.uk — Reducing Obesity and Improving Diet). Yes, that’s £5 billion, without even factoring in the smoking and the drinking and the lack of exercise, which are all contributing to the health time-bomb we hear so much about.

But, apart from providing us with further evidence that modern life is effectively killing us, what are you as community nurses supposed to do with this knowledge?

The government, of course, thinks you should be at the frontline of public health, wielding your sword of truth and handing out gym memberships like sweets — in the previous issue of this

very journal, the Department of Health’s director of nursing, Viv Bennett, said: ‘I have been looking at how nurses can gauge their contribution with regard to making every contact count. It is important to consider how nurses see their role in giving people health advice that contributes to improving wider population health.’ (Journal of Community Nursing — ‘Looking after the health of the nation’).

So, there you have it — part of the community nurses’ remit is improving population health. No pressure then...

Of course, what Bennett says is true — when you go into patients’ homes, or see them in a clinic or care home, it is the ideal time to ask them about their lifestyle choices, or to recommend that they give up smoking or drink less, for example. But does that mean that it should be your job? Is it up to you to tell someone that they need to drink less coca-cola and spend more on Evian? Where does the patient’s individual choice end, and your professional responsibility begin?

As health care increasingly moves from the hospital to the community, there’s going to be far more for community nurses to think about regarding their role in prevention, and whether they are in fact ready to be the guardians of public health. Only you can know, but while you’re thinking, I’ll pop the kettle on. How many sugars do you take...? JCN

Amazing! As if there was not already enough ordering going on in health care —

‘Take this medication!’; ‘Don’t eat that food!’ All with very little explanation, because as nurses we do not have the time. There are simply not enough of us. The government needs to do its own policing — nurses can advise, but I doubt if we can enforce. Instead, government needs to speak ‘very nicely’ to food companies and education authorities about the sugar content in food.

Helen BrewahCommunity matron, Hampshire

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NICORETTE® Invisi Patch Prescribing Information:Presentation: Transdermal delivery system available in 3 sizes (22.5, 13.5 and 9cm2) releasing 25mg, 15mg and 10mg of nicotine respectively over 16 hours. Uses: NICORETTE® Invisi Patch relieves and/or prevents craving and nicotine withdrawal symptoms associated with tobacco dependence. It is indicated to aid smokers wishing to quit or reduce prior to quitting, to assist smokers who are unwilling or unable to smoke, and as a safer alternative to smoking for smokers and those around them. NICORETTE® Invisi Patch is indicated in pregnant and lactating women making a quit attempt. If possible, NICORETTE® Invisi Patch should be used in conjunction with a behavioural support programme. Dosage: It is intended that the patch is worn through the waking hours (approximately 16 hours) being applied on waking and removed at bedtime. Smoking Cessation: Adults (over 18 years of age): For best results, most smokers are recommended to start on 25mg/16 hours patch (Step 1) and use one patch daily for 8 weeks. Gradual weaning from the patch should then be initiated. One 15mg/16 hours patch (Step 2) should be used daily for 2 weeks followed by one 10mg/16 hours patch (Step 3) daily for 2 weeks. Lighter smokers (i.e. those who smoke less than 10 cigarettes per day) are recommended to start at Step 2 (15mg) for

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4 weeks. Temporary Abstinence: Use a NICORETTE® Invisi Patch in those situations when you can’t or do not want to smoke for prolonged periods (greater than 16 hours). For shorter periods then an alternative intermittent dose form would be more suitable (e.g. NICORETTE® inhalator or gum). Smokers of 10 or more cigarettes per day are recommended to use 25mg patch and lighter smokers are recommended to use 15mg patch. Contraindications: Hypersensitivity. Precautions: Unstable cardiovascular disease, diabetes mellitus, renal or hepatic impairment, phaeochromocytoma or uncontrolled hyperthyroidism, generalised dermatological disorders. Angioedema and urticaria have been reported. Erythema may occur. If severe or persistent, discontinue treatment. Stopping smoking may alter the metabolism of certain drugs. Transferred dependence is rare and less harmful and easier to break than smoking dependence. May enhance the haemodynamic effects of, and pain response, to adenosine. Keep out of reach and sight of children and dispose of with care. Pregnancy and lactation: Only after consulting a healthcare professional. Side effects: Very common: itching. Common: headache, dizziness, nausea, vomiting, GI discomfort; Erythema. Uncommon: palpitations, urticaria. Very rare: reversible atrial fibrillation. See SPC for further details. NHS Cost: 25mg packs of 7: (£9.97); 25mg packs of 14: (£16.35); 15mg packs of 7:

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Nicorette QuickMist Prescribing Information:Presentation: oromucosal spray containing 13.2 ml solution. Each 0.07 ml contains 1 mg nicotine, corresponding to 1 mg nicotine/spray dose. Uses: Relieves and/or prevents craving and nicotine withdrawal symptoms associated with tobacco dependence. It is indicated to aid smokers wishing to quit or reduce prior to quitting, to assist smokers who are unwilling or unable to smoke, and as a safer alternative to smoking for smokers and those around them. It is indicated in pregnant and lactating women making a quit attempt. Dosage: Adults and Children over 12 years of age: The patient should make every effort to stop smoking completely during treatment with Nicorette QuickMist. One or two sprays to be used when cigarettes normally would have been smoked or if cravings emerge. If after the first spray cravings are not controlled within a few minutes, a second spray should be used. If 2 sprays are required, future doses may be delivered as 2 consecutive sprays. Most smokers will

require 1–2 sprays every 30 minutes to 1 hour. Up to 4 sprays per hour may be used; not exceeding 2 sprays per dosing episode and 64 sprays in any 24-hour period. Nicorette QuickMist should be used whenever the urge to smoke is felt or to prevent cravings in situations where these are likely to occur. Smokers willing or able to stop smoking immediately should initially replace all their cigarettes with the Nicorette QuickMist and as soon as they are able, reduce the number of sprays used until they have stopped completely. When making a quit attempt behavioural therapy, advice and support will normally improve the success rate. Smokers aiming to reduce cigarettes should use the Mouthspray, as needed, between smoking episodes to prolong smoke-free intervals and with the intention to reduce smoking as much as possible. Contraindications: Children under 12 years and Hypersensitivity. Precautions: Unstable cardiovascular disease, diabetes mellitus, G.I disease, uncontrolled hyperthyroidism, phaeochromocytoma, hepatic or renal impairment. Stopping smoking may alter the metabolism of certain drugs. Transferred dependence is rare and both less harmful and easier to break than smoking dependence. May enhance the haemodynamic effects of, and pain response to, adenosine. Keep out of reach and sight of children and dispose of with care. Pregnancy & lactation: Only after consulting a

healthcare professional. Side effects: Very common: dysgeusia, headache, hiccups, nausea and vomiting symptoms, dyspepsia, oral soft tissue pain and paraesthesia, stomatitis, salivary hypersecretion, burning lips, dry mouth and/or throat. Common: dizziness, vomiting, flatulence, abdominal pain, diarrhoea, throat tightness, fatigue, chest pain and discomfort, toothache. Other: palpitations, atrial fibrillation, dyspnoea, bronchospasm. See SPC for further details. NHS Cost: 1 dispenser pack £12.12, 2 dispenser pack £19.14. Legal category: GSL. PL holder: McNeil Products Ltd, Roxborough Way, Maidenhead, Berkshire, SL6 3UG. PL number: 15513/0357. Date of preparation: October 2013

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.

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Date of preparation: December 2013 UK/NI/13-2374

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