Silent witness to an emerging population

Worryingly, there is little evidence to support policy and practice for morbidly obese client groups, district nurse Kath Williamson finds

Worryingly, there is little evidence to support policy and practice for morbidly obese client groups, district nurse Kath Williamson finds

Recently I attended the UK Congress on Obesity 2016, the annual conference for the Association for the Study of Obesity (ASO). The programme was diverse – ranging from genetics to emotional over-eating.

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Morbid obesity has more than trebled since 1995, according to Health Survey for England
Picture: Getty Images

As a practising district nurse, I noticed that an emerging population, increasingly prevalent on caseloads, was conspicuous by its absence: those who are morbidly obese (BMI ≥ 40kg/m2) and housebound. With obesity constantly hitting the headlines, where is the evidence base supporting policy and practice for this client group? There is worryingly little.


morbid obesity rates since 1993

The primary reason is simple: a lack of high weight scales in clinical areas, including GP surgeries, makes getting accurate weights difficult. It is not uncommon for people to be weighed by standing on two sets of scales.

Clinical recording systems document the presenting comorbidity – such as diabetes or wound care – rather than the underlying causative obesity. This means the resulting demands on health and social services are not easily identifiable from the available data (Grieve et al 2013).

A higher proportion of women than men are obese

Effectively this group is nearly invisible when looking at current NHS statistics. Contemporary media reports based on Freedom of Information (FOI) requests (Scotsman 24/9/15, Sky News 23/10/15) are arguably the best insight into the specific costs.

Increasing numbers

Evidence from population studies, such as the Health Survey for England and the Scottish Health Survey (2015), show that the number of morbidly obese adults has more than trebled to 3% since 1995, increasing faster than lower BMI categories. Yet this is likely to be an underestimate. Interviewers could not weigh those unable to weight bear or who were likely to exceed 130kg – half of those with morbid obesity on the caseload.

Clinicians’ confirm the rise, especially around increasing numbers of morbidly obese individuals presenting with bariatric care needs, due to their extreme size.

I have attended to patients with a BMI ≥ 90 kg/m2. These individuals often have complex needs that no single professional group can manage in isolation. Issues encountered include complex manual handling requirements, specialist equipment, stigmatisation, social isolation, delayed discharge and increasing social care need (Lumley et al 2015).


obesity rates for men were 0.3% and women 1.4%


obesity rates for men were 2% and women 4%

Management often focuses on the functional disabilities and multiple chronic comorbidities (musculoskeletal problems, depression, respiratory and cardiovascular disease) associated with morbid obesity, rather than the underlying obesity itself. For district nurses this often includes diabetic, continence and tissue viability management.

The burgeoning literature on obesity is dominated by clinical trial data on weight management interventions (Read and Logue 2016), or bariatric surgery that is only available to a few. There is little research to guide front-line clinicians managing those with bariatric care needs, leaving room for improvement in both clinical and quality of life outcomes.

Current service use, costs, outcomes, patient experience, weight management access and strategic planning for this patient group are all unknown (Grieve et al 2013). NHS Boards have no robust data on numbers of individuals with morbid obesity or indeed the total costs of caring for this potentially resource-intensive client group.

Indicative costs

Anecdotal evidence indicates costs of more than £25,000 per person for structural housing alterations (floor strengthening, door widening). This highlights the potential financial significance of providing appropriate integrated care for such individuals. Given intense financial pressures, managers need more than anecdotal evidence to inform their spending decisions.

Disturbingly, obesity is now so widespread that it is seen as near normal (Royal College of Physicians (RCP) 2013). Despite calls for strategic leadership in organisations and governments (RCP 2013), the lack of evidence regarding the use of resources across health and social care systems means this remains unrealised (Lumley et al 2015).

6-14 years

Amount morbid obesity shortens life expectancy. Equivalent to lifelong smoking

Drawing together evidence from multiple services about care provision for this growing population may help stimulate positive strategic leadership to combat obesity, in the same way as action around smoking. 

As a newly appointed clinical academic, this client group is my research focus. Clinicians need relevant research to inform practice. Given the emerging nature of this population, there is huge potential for new knowledge to help improve service delivery.

'Uncharted population'

Researchers need clinicians to identify gaps in knowledge. In networking conversations over coffee with fellow delegates at the obesity conference, there was genuine surprise and interest regarding this uncharted population.

Severely obese people are more than three times more likely to need social care than healthy people  

Just as The King’s Fund (2016) report highlighted the difficulties of measuring district nursing care due to its invisible nature, this emerging population risks remaining invisible due to problems of measurement.

Along with others who care for those who are housebound, district nurses have a powerful story to tell here.  

Common features of housebound individuals with morbid obesity (BMI ≥ 40kg/m2) on a district nurse caseload
  • Often younger than typical DN population: > 40 years.
  • Type 2 diabetic, often requiring insulin.
  • Chronic bilateral leg lymphoedema associated with non-healing lower leg venous ulceration.
  • Osteoarthritis in knees and hips.
  • Mobility is limited to short distances in the house with help. Often a wheelchair is required when outside.
  • Continence issues related to poor mobility. If catheterised, can be prone to bypassing or expelling catheter with balloon intact, necessitating frequent re-catheterisation. This procedure can require two staff due to large body habitus.
  • Skin infections and breakdown in skin folds.
  • Requires social care to assist with personal care/skin care.
  • Not in weight management treatment.


  • Grieve E, Fenwick E, H-C Yang, Lean M (2013) The disproportionate economic burden associated with severe and complicated obesity: a systematic review. Obesity Reviews. 14, 883-894.
  • King’s Fund (2016) Understanding quality in district nursing services. Learning from patients, carers and staff. The King’s Fund, London.
  • Lumley E, Homer C V, Palfreyman S et al (2015) A qualitative study to explore the attitude of clinical staff to the challenges of caring for obese patients. Journal of Clinical Nursing
  • Royal College of Physicians (2013) Action on Obesity: comprehensive care for all. Royal College of Physicians, London.
  • Read S, Logue J (2016) Variations in weight management services in Scotland: a national survey of weight management provision. Journal of Public Health. 38, 3, e325-e335.

Kath Williamson Kath Williamson is a district nurse in Edinburgh and nurse researcher/ NRS research fellow at NHS Lothian weight management team, Astley Ainslie Hospital, Edinburgh

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