Healthy weight - local health systems support for pregnant women and young children: research

3. Identification and referral

This chapter addresses the points at which pregnant women and children are weighed, how weight issues are identified, and how health professionals approach raising the issue and referring families.

The main points of potential identification, and brief descriptions of possible interventions, are summarised in Figure 3.1.

Figure 3.1: Points at which a weight issue may potentially be identified and ways in which it may be addressed

Preconception

• Difficult to identify and engage with women with high BMIs pre-conception
• Some opportunity for intervention for those seeking fertility support and those with children who are planning future pregnancies.

Pregnancy

• Identification primarily by midwife at booking in appointment using BMI.
• Interventions may be midwife-led or more clinician-led.

Early years: 0-2

• Identification primarily by health visitor using BMI/centile charts.
• Likely health visitor intervention in the first instance. Possible GP referral to rule out medical causes for high BMI.

Early years: 2-4/5

• Identification primarily by health visitor using BMI/centile charts.
• Likely health visitor intervention in the first instance. Referral to dietician/other interventions (e.g. family-based programmes).

Primary 1 age

• Identification primarily at Primary 1 health review.
• Referral to dietician/other interventions (e.g. family-based programmes).

Across the health boards, and across different health professions, confidence was high when it came to:

• weighing children and pregnant women accurately
• calculating BMI or using centiles to assess weight
• determining whether a patient meets a clear intervention threshold
• providing general advice on healthy eating and physical activity

Areas felt to be more challenging included:

• determining whether families were in a position to make a change
• raising the issue in situations where the health professional did not have an existing relationship with the family (mainly school nurses)
• supporting weight management in pregnancy, while acknowledging that weight loss during pregnancy is not recommended

These issues are considered in more detail throughout this chapter.

Identification in pregnancy

In all health boards, pregnant women had their BMI calculated at their booking-in appointment at 8-12 weeks. Midwives would identify whether an intervention was required based on this initial BMI measurement. In cases of high BMI, midwives would first explain the associated risks for pregnancy and delivery. In island health boards they would also explain that women may have to travel to a mainland hospital, which is better equipped to deal with a high-risk delivery. They favoured mentioning it at this early appointment as it tended not to be the women's preference and gave them more time to adjust to it.

With a BMI over 35 we'd be recommending that they give birth in the mainland, just because of the increased chance of difficulty monitoring the baby in labour, increased chance of bleeding, difficulty with anaesthetics if needed. So, I try and have that conversation early on because if you're recommending someone leaves their home to give birth, it's a big intervention, so you want people to know that's going to be your recommendation from early on really… most people want to stay here.

Midwife

Across the health boards, a BMI of 30 or above would generally trigger monitoring for gestational diabetes, although there were health boards who tested women with a BMI above 25. For other types of interventions (such as referral to weight management services), BMI referral thresholds varied at either 30, 35 or 40. There were health boards that also made a distinction between different levels of high BMI – for example, a BMI of 30 might trigger referral to extra scans, but referral to weight support only happened for a BMI of 40 or above. One health board used colour-themed pathways to indicate level of risk - women with an elevated BMI would be on a 'purple' pathway and receive a mix of clinician and midwife care, and more scans than those on the 'green' pathway. Those with the highest BMIs would be put on a 'red' pathway and receive mainly clinician-led care as well as more scans and tests.

Opportunities and challenges for referral

Where women met intervention thresholds, midwives used a range of approaches to raise the issue sensitively and effectively.

Midwives described taking a person-centred approach, meaning that they made efforts to understand the woman's circumstances and needs, and starting from there. Where midwives had received training on motivational interviewing, they reported finding this useful in helping them assess a woman's level of motivation and empower them to make small, positive changes.

We're trying to move from the 'giving advice' and [move to] exploring where they're at and what they need- like a guided move? That's what I would try to do with feeding is explore their own experiences, and obviously I've got an agenda, but it's finding out what they know and maybe adding in information.

Midwife

They focused on building a relationship with women, to work together on what small changes they could make.

The main thing is to try and build up a relationship with these women because I have to see these women […] right through to delivery. And if I'm phoning them every week, I need them to trust me, I need to have a relationship with them. So, it's not a blame game, it's […] drawing a line under where we are, we're starting from where we are just now, and let's see what we can do to change things as we go on.

Midwife

Midwives stressed the importance of expectant parents not feeling judged by them. They would therefore avoid phrases that focused on what parents were not doing or what they should be doing, and instead use more neutral language.

I tend to use the phrase 'We notice a lot of pregnant women struggle with…certain food types/drinking water' rather than 'You're not/you should' I try to be wishy washy.

Midwife

Another approach was to strike a very direct, factual tone when introducing the issue. This may involve showing women their BMI on a chart, and explaining that, because their BMI had reached a certain threshold, it was standard procedure to offer them a referral. Again, they felt this may help women feel less judged as it seemed like more of an automatic process, rather than the midwife making a judgment that they needed a certain type of care.

To some extent it's quite easy when you're physically sitting in front of the computer with the BMI calculator and you can show them what their BMI is.

Midwife manager

I would just say that because their weight was above a certain weight, that the guidelines mean that they should be monitored for gestational diabetes or referred to the [service].

Midwife

There were a number of factors which affected a midwife's ability to raise the issue of weight, including:

• level of experience – midwives who had been initiating difficult conversations with pregnant women for decades were more comfortable doing so, while those newly qualified were more apprehensive
• training – midwives spoke about how receiving relevant training (on raising the issue or motivational interviewing) had increased their confidence
• caseloads – where midwives had very high caseloads, they didn't always feel there was time to give healthy weight issues due attention.
• support from management – there was some desire for greater managerial support around child healthy weight issues, but a feeling that their team was too busy for it to happen

Women with a raised BMI – it's huge – we see how it affects people's health and birth, but it's not prioritised in terms of our training or offering support with it. I feel I don't have much to offer. For me personally I don't feel supported to do it.

Midwife

When midwives raised the issue of weight, reactions from pregnant women varied. Midwives reported that often the women already know that they are overweight and, while they are not surprised that their midwife has raised this issue, they may not have realised what this means for their pregnancy. Women already aware that they were overweight reacted to midwives raising the issue in two main ways.

First, they may tell the midwife that they are aware of the issue and how to address it, but feel they have enough going on without trying to manage their weight. They may brush off the risks, and focus on their pregnancy and all the life changes associated with pregnancy. They may say that they were overweight (albeit often less overweight) during past pregnancies which went well. It may also be the case that women are already taking steps to manage their weight (through attending local weight loss groups or making changes themselves), and feel that the issue is in hand.

Second, they may feel guilty and find it upsetting to learn about the risks associated with being overweight during pregnancy/the impact their weight could have on their baby. They may have tried to lose weight in the past, and blame themselves or feel embarrassed where it hasn't worked.

Some people are a bit shocked, saying 'I didn't realise how much more risk it would be that I'm slightly overweight'. […] They probably knew they were overweight, but maybe didn't realise the impact it would have on their pregnancy.

Midwife

Midwives also reported that pregnant women who were overweight but on the lower end of the threshold were sometimes less receptive to the conversation. They did not always see themselves as overweight or feel like they needed intervention.

For some people who are just over the 30 mark they think 'well, I'm only just over.'

Midwife

Midwives recognised the complexities involved in a woman's relationship with food, exercise and their weight and were aware that health behaviours are influenced by past traumas and complex life circumstances.

Certainly, some of them have got quite significant histories as well – it's not just a case of an isolated overweight happy person, there's usually something or lots of things they've disclosed in their history.

Midwife manager

Given this complexity, midwives reported having thought about whether pregnancy is, in fact, an appropriate time to raise weight issues. The fact that weight loss is not recommended during pregnancy (although small healthy changes are encouraged) also contributes to this feeling. Furthermore, they stressed that they had so much information to cover in appointments that there was little time to address weight fully anyway. This meant that any conversation on healthy weight management risked raising a difficult issue without being able to fully address it.

I sometimes think these young midwives are so focused on getting the computer systems all done, that they actually don't ever get the opportunity to look at the women eye to eye and say, 'how are you feeling? Tell me about what your thoughts are about the pregnancy. What your thoughts are about your weight, about diet, about exercise'. I think, as the caseloads have risen, these things sometimes take a back seat and I think, at a time when these things should be really important, should be something we should be focusing on.

Midwife

Midwives reported that they would always raise the issue with women, but recognised that it was difficult when a woman's pregnancy was fraught in other ways – for example, if she was experiencing poverty or a relationship breakdown. Although women may not be in a position to address their weight at that point, midwives would still raise the issue in order to follow referral pathways and introduce the possibility of addressing it in the future.

You have a very limited time to intervene and there are lots of things happening so it's not a time women are particularly receptive. It's not a high priority for a number of women. In a way, it's more about planting a seed for after the baby is born.

Public health professional

On the other hand, midwives suggested that anticipating a baby makes for a window of opportunity, as women want to ensure that their family has a healthy active lifestyle for their child.

I would say for talking about healthy weight, [..] we have quite a timely platform there because when the women are pregnant, they are very motivated to do their best for their baby. It's probably a bit easier when they're pregnant that they'll engage easier.

Midwife manager

Identification in the early years

Identifying babies and children with a high BMI

In the early years, babies and children are usually weighed and measured at every core UHVP visit. For the most part, these core visits will be carried out by health visitors. However, there were reports of some core visits (for example the 27-30 month review) being routinely conducted in the 'skills mix' team, usually by nursery nurses. This 'skills mix' approach allows for other health professionals to work as part of the health visiting team and ease health visitors' workloads.

Although children were normally weighed at least at every UHVP core visit, this was disrupted by the COVID-19 pandemic, with some appointments being undertaken by phone instead. Health visitors raised concerns about the weights and measurements missed as a result.

A lot of our work had to move to be just video or phone call… and I think that's quite a difficult way of bringing up weight issues with somebody. And it means also that children weren't always weighed, so we would possibly have not weighed these kids for a long, long time because the only visits they really wanted us to continue with was the birth visit and the 6-8 week check. And then they could go right to 13 months without ever being seen face to face and being measured again… I think that is an issue.

Health visitor

At in-person visits, health visitors reported taking the child's measurements, recording them in the red book (the personal child health record), and plotting their measurements on the centile charts. These would then be recorded in the system upon returning to the office. Health boards used different software for recording these measurements.

Health visitors' use of BMI measurements varied across the different health boards. Where BMI was used, a BMI above the 91^st centile was generally the threshold at which health visitors would identify an issue. In younger infants (under two years), health visitors tended to use the centiles and did not calculate a child's BMI. There were also boards in which health visitors used only centiles, for all ages. Health visitors spoke in different ways about how they used these centiles to identify potential weight issues – either looking at a child's weight centile and comparing it to their height centile (with a weight two or three centiles above their height indicating a disproportionately high weight), or looking at change over time (with a quick rise up the weight centiles causing concern)^[44].

Even in health boards where BMI was routinely calculated, health visitors did not feel they had the tools in place to do this easily. They noted that the 'red book' does not commonly include a BMI chart, meaning that they had to either bring a BMI chart printout, calculate it on an app, or calculate it once they returned to the office. Health visitors felt that this made it less likely that staff would carry out this part of their job consistently. Calculating it in the office meant that health visitors sometimes had to call parents after an appointment to talk about their child's BMI, missing out on the chance to do it in person as part of the visit.

It sounds silly but something as simple as having BMI charts on a laminated chart – it would let us do the calculation and show parents in the appointment rather than having to do it over the phone later – you've missed an opportunity.

Health visitor

Area for consideration (local health board level):

Ensure health visitors are using BMI centiles and have a means of calculating BMI while out on visits

One health visitor also raised the issue of their scales not measuring high enough to capture an accurate weight for all children.

In fact, I have just made a request to my manager actually to get us some scales that measure higher than 20 kilos because so many children…we are not actually able to weigh because our portable scales don't go up high enough, which is not great when you are trying to make a referral and you don't have a weight, but you know that it is over 20 kilos.

Health visitor

Opportunities and challenges for referral

When a weight issue was identified, health visitors reported that they would generally always raise it with a family, but confidence managing that conversation varied. Confidence was higher among those with more experience, those who felt particularly passionate about the issue (and therefore gave it more focus in appointments), and those who had better relationships with staff in relevant roles (for example, health visitors who had friends in dietetics, who had been on relevant steering groups, or who had worked in health improvement in the past). In at least one health board, a 'conversational toolkit' had also been developed to improve health professionals' confidence and consistency of approach.

When health visitors initiate a conversation with parents about their child's weight, they may have several goals:

• to make parents aware of the issue
• to get a greater understanding of the child's lifestyle – how they are eating, moving and sleeping
• to offer intervention either themselves or through referral to another service (for more detail on interventions, see Chapter 4)

Health visitors' approach to the conversation

One factor health visitors used to their advantage when approaching weight issues was the relationship they had built with families throughout the UHVP. They emphasised to parents that their relationship needed to be an honest partnership and this helped promote a feeling that health visitors were working together with parents to reach a shared goal, rather than the health visitor judging or telling parents what to do.

I think it's all about relationships for us. If you go in and be dictatorial with a family, you're going to get nothing. But if you go in and you're almost in a partnership and you celebrate the highs and commiserate the lows and think 'well, what can we do about this then…'

Health visitor

I would say that the universal pathway that we do, all the visits, helps because it means that you know the families a lot better, which makes conversations easier. […] I always have a conversation at the start of the relationship about us being honest with each other, and then when I bring something up like [child healthy weight issues] I always start by saying 'we always said we'd be honest with each other, so I'm just going to say what I think then you can tell me what you think'.

Health visitor

Area for consideration (local health board level):

Maximise the potential of the strong existing relationships health visitors have built with families

Where 'skills mix' staff carried out visits, they did not have such a strong relationship with parents. This may have consequences for how (or if) referral is approached. It is particularly notable that the 27-30 month review was routinely conducted by 'skills mix' staff in at least one health board, as this was identified as a key referral point.

Although an established relationship between parents and health visitor made these conversations easier, health visitors still recognised the importance of approaching the conversation carefully. They were aware that, if the conversation went badly, it could risk that carefully built relationship. In one health board which did not have a tier 2 service to refer to, there was a view that health visitors were less inclined to take that risk as they could disrupt the relationship without actually being able to offer support.

If you've worked very hard to develop a relationship with the family and there's other things going on [it might not be health visitors' priority].

Public health professional

As with midwives, health visitors spoke about trying to establish the family's circumstances and starting from there before deciding on any intervention. This means asking the family about whether they are worried about their child's weight, what they think is behind it, and how it could be improved. It also means following the parents' cues and letting them 'solve their own problems'.

I'd ask if it's something they've had concerns about – it helps me gauge their motivation. Next, I would have an exploration of if they are willing to make a change, and what change would it be. I'd talk about the [intervention] and what it's like. Sometimes when talking to parents, the issue becomes obvious. I find it's most effective to identify one small change they want to make, then follow up – if they're at the motivated stage. If they're in denial and don't want change or referral, I'd say let's review in three months.

Health visitor

Health visitors also used the approach of taking a more factual tone. They tried to use more neutral terms, and emphasise that they have to offer a referral – one health visitor would always say she had a 'duty of care' to raise it with parents. Health visitors would also commonly use the centile or BMI charts to show parents the issue visually. They felt that this made it easier for parents to understand and harder for them to deny the issue. As noted in Chapter 2, health visitors also reported that they showed the centile charts to parents from the very beginning of their relationship, so that by the time a problem arose, parents understood the significance of the charts.

I use the terms 'weight and height are out of alignment' rather than 'overweight'- I'd say their BMI is this (showing them on chart), and that puts them over the 91st centile which means this. Parents can't argue with the facts.

Health visitor

I say it in a respectful way: 'From what I have documented, it's just above a healthy weight'.

Health visitor

Another tactic health visitors took when parents appeared not to take on board the importance of addressing their child's weight issue was to explain the likely health impacts later in life. They felt this made it harder for parents to dismiss the issue or maintain that their child will just grow out of it.

We have to sell it to parents – 'if he gets some more activity now, he's going to have less problems later in life.'

Health visitor manager

While health visitors reported that they would always raise the issue with families, they noted that, if the family was going through complicated and difficult circumstances, they were less likely to intervene fully until their circumstances had improved.

It can be more difficult if the family is in very difficult circumstances – for example, if they have three other children and two of them have additional needs.

Health visitor

Parents' reactions

In terms of how parents respond to the issue of their child's weight, health visitors had experienced a real range of responses.

One type of reaction is for parents to listen fully, recognise the problem, engage in the conversation, and agree to referral. However, health visitors noted that families may be open and willing when the topic is first introduced, but not actually attend the service or implement changes. They may also accept advice happily, but not engage any further than that or accept referral.

It's very difficult - families often stop engaging. They're all quite willing to be referred, but then engagement falls.

Health visitor manager

In other cases, parents recognised the issue but responded more defensively, often blaming others in the family. These parents tended to feel they had less agency to help their child be healthier, as they weren't the only one responsible for their diet and activity.

Parents can be defensive and can blame other family members – they say 'oh he goes to gran's for childcare and she feeds him rubbish' or it can be about the dad when the parents are separated. It can often be that the dad/gran has poor eating habits themselves.

Health visitor

There were also parents who did not accept that their child was overweight, or recognise that this was a problem. Health visitors felt that this was often linked to wider influences (especially the child's grandparents).

Some parents do not want referral, they are happy with their kid and you just cannot change their outlook. Still a lot of families will say 'we had this [when I was young], and I'm alright'. It's difficult because you're trying to change generations of poor eating habits.

Health visitor manager

Health visitors were also conscious of the difference that the parents' weights and their own weight could make to the conversation. Where the child's parents were also overweight, they were particularly careful to approach the topic sensitively. Parents who were overweight themselves reacted in different ways, either feeling more criticised, or feeling that they understand the issue and want to improve things for the health of their whole family.

It can be quite sensitive because sometimes you get parents who are very overweight as well. And sometimes they recognise that, and they don't want their child to be like that, so they'll be on board, but sometimes they get a bit miffed that it's been brought up in the first place. So, you've just got to be very careful.

Health visitor manager

When the health visitors themselves were overweight, there was a feeling that it could make things difficult by showing that losing weight is not easy. A contrasting view was that it made things easier, as it showed parents that they weren't judging them, that they understood the challenges and were just trying to support them.

When I say, 'I'm big myself, I'm not here to judge you', you can see them 'Oh OK then', they relax and as we go through pregnancy, sometimes I'll [only] see them once or twice but others I get on really well with them. You can see them relax 'she's not judging me' and we get on with it.

Healthcare assistant

Identification at Primary 1

As described in Chapter 2, Primary 1 children were weighed and measured as part of the Primary 1 health review. Generally speaking, school nurses carried out the Primary 1 measurements themselves, although there were health boards in which this was done by healthcare assistants due to capacity issues.

Standard procedure tended to be for parents to receive a letter advising them that their child was due to be measured at Primary 1 assessment, but that they could opt out. Opt-out rates were reported to be generally low in health boards taking this 'opt out' approach, with the vast majority of children being weighed.

Other health boards used an 'opt-in' approach which had resulted in much lower proportions of children being measured. This approach had been introduced as a result of issues with data protection (in one health board) or due to complaints from parents (in another health board). In addition, Boards were advised by the Child Health Surveillance National User Group (made up of representatives from NHS Boards, NHS National Services Scotland, Public Health Scotland and Scottish Government) in 2018/19 to take this approach. However, the subsequent fall in responses the following year (particularly among the most disadvantaged families) meant that Boards were asked to return to an 'opt out' approach^[45]. The findings of this study, however, indicate that not all boards had resumed the 'opt out' approach, and that this was reducing the numbers taking part, particularly those considered most in need:

Things have changed, since parents are now asked to opt into the health surveillance survey. Now only 50% of kids get Primary 1 assessment (before COVID-19) – the families that are most vulnerable are missing out on this check, as they don't send the form back.

School nurse

Across the health boards, school nurses framed the assessments to children as 'just seeing how you're growing', and commented that the children were generally curious and happy to be measured. If a child was self-conscious about being weighed, school nurses made efforts to take an even more sensitive and friendly tone, emphasising that everyone is different. Where school nurses had someone else with them to note down the measurements, they would also try to be discreet rather than calling the weight out across the room to the note taker.

There was variation in how measurements were carried out, largely determined by the health board approach and the facilities available within the schools. The two main approaches were:

• taking the children out in small groups of up to six to be weighed
• weighing children in the class, ideally discreetly to the side while the rest of the class is focused on a health-related activity

The COVID-19 pandemic had impacted on the Primary 1 assessments heavily, with many children not being weighed in Primary 1. School nurses were conscious of the impact this would have on their ability to identify and intervene early, and that the data reported to the Scottish Government would be very incomplete.

Last year we didn't do the Primary 1 measurements – we'd only done a handful before the pandemic, so loads last year were missed. This year we didn't do them all either, the children were out of school so much. There will be gaps.

School nurse

Opportunities and challenges for referral

Once a school nurse had determined that a child had a BMI higher than intervention thresholds (typically 91^st centile), they would typically contact parents either by letter (sometimes including their child's BMI chart) or phone. However, there were health boards that were moving away from this approach and were no longer using Primary 1 measurements to identify and refer children.

Where initial contact was by letter, it would either invite them to call the school nurse or advise them to expect a call from them. During that first phone conversation, school nurses would aim to discuss the child's weight with parents, assess how the parents feel about it, and explore possible next steps – either making a plan and agreeing that the school nurse would follow up or offering referral to a different service.

The approach taken by school nurses was similar to that of health visitors in that they would discuss the issue factually and openly, and would alert parents to the possible long term consequences. However, the lack of an existing relationship with the family made the school nurses' experiences of raising the issue different to those of health visitors.

School nurses reported that they were sometimes apprehensive about raising weight issues with parents due to not knowing the parent well, and due to past experiences of parents reacting negatively.

I've actually had a phone call that reduced me to tears once […] I got ranted at by a woman that had just opened her mail because I had measured her child at Primary 1 and sent the letter home saying, 'you realise your child's BMI is outwith the healthy range'. And she just called saying 'How dare you, the BMI is rubbish and not a good way to measure children'. And I think that impacts the way people in the team have practiced. And I'm quite keen to say well look, we send out 2000 letters and get one complaint – we shouldn't be changing our practice for one complaint. […] but that's very difficult for people to tolerate.

School nurse

As discussed in Chapter 2, school nurses also felt that they had limited opportunity to do health promotion and prevention work with parents and pupils, meaning that they were only connecting with parents once a problem had already arisen.

Nonetheless, school nurses reported that, in the main, parents reacted well and understood why the conversation was necessary. They were often already aware of the issue, and appreciated the support of the school nurse. However, a small proportion reacted angrily and denied that their child was overweight, or took issue with the use of BMI to measure a child's weight. As with health visitors, parents of children who were only slightly over the BMI threshold tended to be more likely to react in this way than those whose child had a more serious weight issue.

One school nurse in a health board where a proportion of the Primary 1 assessments were carried out by healthcare assistants said that not having personally seen the child made it even harder to raise the topic with parents.

Parents can be very defensive. They say they don't believe in BMI, that their child 'isn't the biggest', that it's puppy fat, that they're big boned, that it's muscle. It is difficult having these conversations when you're not the one who has actually seen the child.

School nurse