Working together to tackle obesity in adult mental health secure units

reported that they believed it was morally wrong to place restrictions on patients as food was
one of their few pleasures.28

Most units (68.3%) were reported to provide access to NICE recommended levels of physical
activity.10 Reported barriers included staff shortages and low patient motivation. The most
commonly reported interventions for weight management were nutritional advice (77.6%),
fitness programmes (71%), healthy living groups (39.9%), gym (36.6%), weight loss groups
(26.2%), walking/cycling (23.5%) and sports (18%). Nearly a quarter of consultants rated
interventions as mainly ineffective, 55.2% modestly effective, 15.8% moderately effective and
0.5% highly effective.28

Views about the possibility of switching medication to an effective alternative with lower risk of
weight gain ranged from never possible (1.1%), through to possible for up to 25% of patients
(24%) to possible for up to 50% of patients (11.5%). Nearly 15% did not know the answer to
this question. The authors of this paper reported that consultants’ perceptions that using
alternative medication was not of potential benefit could be a lost opportunity.28

One study26 assessed the impact of changes in disposable income, following increases in UK
incapacity and severe disability allowance in April 2006, on food expenditure in a high secure
unit. Five months after these changes, 251 patients had received an increase in benefits. After
one month, total revenue from benefits had increased by £12,089. There was a 45% increase
in spending at the shop and a 129% increase at the snack bar between March 2005 and
August 2006. The shop stocked 26% more foodstuffs in total, including 26% of foods high in fat
or sugar. Of these, 62% were sweets, 16% crisps and 37% chocolate products. Following the
increase in benefits, 35% more fish, meat, protein, 90% drinks or soups and 79% more packed
fruit and vegetables were stocked.

Shop requisitions rose by a quarter following the increase in benefits, with chocolate and
sweets accounting for 4,030,121 kcals of shop requisitions, rising to 5,034,838 kcals following
the increase (p=0.005). If only patients who received extra benefits were included in analyses,
calories equalled an extra 4,003 calories per week per patient. Dividing the extra calories
between all patients (a more conservative estimate) equalled 2,956 extra calories per week per
patient.26

Harper et al.26 recognise that a clear connection cannot be made between increased benefit
and spending at an individual level. However, they conclude that in terms of calorie
requirements, the equivalent of two days’ worth per week per person are being purchased
following the changes to benefits. This is on top of meals already provided within the unit that
are calculated to provide optimum daily calories. Given the likelihood that spending on extra
food will continue, the authors have some suggested ways of addressing this issue. One
suggestion is to stock low calorie and healthier options at the shop, another is to also stock
non-food items such as clothing, CDs, DVDs and reading material, and yet another is to
provide advice on financial management and encourage saving money. These suggestions

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Working together to tackle obesity in adult mental health secure units

could be introduced alongside healthy lifestyle initiatives that aim to improve diet and physical
activity rates.

McCrarren,34 in an unpublished thesis, used an established questionnaire44 to assess the

nutritional knowledge of nurses working in Irish forensic mental health settings in an
unpublished doctoral study. Achieving a response rate of 85.7% (n=95), the sample consisted
of 43 male and 52 female nurses.

The nurses had a mean nutritional knowledge score of 76 (SD 12.7) out of 110. Almost a third
(31) scored more than 83 and only eight scored less than 55. The majority of nurses were
categorised as having adequate nutritional knowledge with scores between 56 and 82. Female
nurses achieved a higher mean score than males (78 vs 73 p=0.048). The author reported no
significant association between nutritional knowledge and years of qualification, length of
service, educational level or age. There was a significant difference in scores between clinical
nurse manager 1 and 2 grades, but not between clinical nurse manager and staff nurse grades.
All four sections of the questionnaire received good scores with the lowest scores attributed to
questions about the relationship between diet and disease. The author suggests that future
research could be carried out to explore how nurses in secure units educate patients and guide
them in their dietary choices.34

Two studies30,35 assessed the availability of healthy lifestyle promoting facilities in UK secure
units and reported the changes made as a result of the findings. Long et al. 30 used observation
and self-report to assess the eating habits of female patients in three UK secure units (level of
security not given). A total of 41 women across the sites agreed to participate. Their mean age
was 32.7 years (SD 8) and diagnoses included personality disorder (51%),
schizophrenia/schizo-affective disorder (24%) and affective disorder (12%). All had a history of
offences ranging from acquisitive to major violence and mean duration of stay was 4.4 years.
Sixty per cent were obese and the remaining 40% had a mean BMI of 27.2. Twenty-eight
women participated in the self-report part of the study using a 15-item lifestyle questionnaire
(response rate 68%). Twenty-seven “typical” mealtimes were observed over three months.

The mealtime observed to have the highest attendance was dinner in the evening, followed by
lunch, and the lowest attended was breakfast. It is therefore clear that most patients consumed
a large proportion of their calorie intake in the evening and very little in the morning. Patients
had the freedom to choose whatever food they preferred and could have second helpings.
Portion sizes appeared appropriate although there was no guidance provided about the
contents of a balanced meal. Most patients chose meals that were high in carbohydrate and fat
compared to vegetables. Two carbohydrate rich puddings were served every day. Fruit was
less frequently eaten and, although provided on the ward, was often only served at particular
times.30

The authors30 report that the caloric value of meals was high so that snacking on top of this
would lead to weight gain. Water was more expensive in the shop than fizzy drinks and 40% of

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Working together to tackle obesity in adult mental health secure units

meals were eaten without a drink. Squash was consumed in preference to water and the
amount of milk consumed amounted to a mean of 2 pints per person. Food rich in Omega 3
was served once during the observation period. Takeaway meals, some of which have a very
high calorific content, could be ordered up to four times per week. Food was also eaten quickly
(mean 10.2 minutes). Opportunities for staff to model eating behaviour were limited as they sat
at different tables or ate at different times to patients.

The self-report questionnaire showed that over 80% of patients reported a desire to better
manage their weight, eat healthier and exercise more. Whilst 51% reported having been
advised by a dietician, only 35% followed that advice. Some 57% reported having at least two
takeaway meals per week, as well as provided meals. Sixty per cent had at least 2 teaspoons
of sugar in hot drinks and 65% reported drinking at least two carbonated drinks per day. Typical
food purchased at the shop included crisps (46%); chocolate (36%); sweets (25%); chips
(21%); non-diet carbonated drinks (46%); fruit (1.9%). Twenty-one per cent reported taking part
in organised physical activities. There was a reported dislike of the evening meal being served
at five o’clock, this seeming too early.30

Long et al.30 also report that changes to policy were made as a result of the study to establish a
healthy eating culture, including staff training, food provision and weight maintenance. Food
choices, discussed with the chefs, could be made ahead of time and were labelled in respect of
health values. Food was also available that was culturally sensitive, with 20% ethically
produced or organic. More oily fish was made available. Food preparation was carried out next
to the units rather than centrally and heated through. Meals were dispensed by trained staff that
could provide advice on balanced diet and portion size. Dinner was served later in the evening.
Milk and takeaway meal intake were restricted, fruit was available all day and smoothie
machines were available to provide drinks with meals. Trained staff ate with patients and
catering staff attended patient meetings to provide food education and discuss choices. A
dietician led motivational nutritional group sessions and a hospital-wide obesity pathway was
established so that patients with a BMI of more than 30 were provided with support. Patient
food satisfaction was monitored. A physically fit member of staff was available on each ward to
encourage uptake of physical activity.

Meiklejohn35 collected routine data from all patients residing at one UK medium secure mental
health unit to assess physical health needs. Interviews were carried out with patients to explore
their desire to lead a healthier lifestyle. Routine data were collected for all patients on the unit
and semi-structured interviews were carried out with 56 patients (mean length of stay 18
months). Seven patients were interviewed further about body image, self-esteem, fitness and
healthy lifestyle prior to being discharged. Here, we focus only on findings relating to weight
management.

Data analysis showed a correlation between increased BMI and length of stay, as well as
limited opportunities to carry out physical activity or develop food options. Over half of patients
were positive about opportunities for physical activity though it was uncertain to what extent

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Working together to tackle obesity in adult mental health secure units

interventions offered by occupational therapists were taken up. A similar number of patients
also expressed a wish for more physical health care although 71% reported that their health
was well managed and nearly a quarter reported difficulties in finding someone to consult about
their physical health.35

The researchers organised a fair to provide an opportunity for patients to speak to healthy
lifestyle experts and to have assessments carried out such as BMI. The study findings resulted
in a number of initiatives. A full-time fitness instructor was recruited at the unit to provide sport
and ward gym sessions. Physicians assessed the medication regimen of patients to identify
alternatives to weight gain inducing antipsychotics. The canteen manager was invited to ward
meetings to discuss healthy food options with patients. An occupational therapist commenced
weight management sessions and patient education is being developed. Group weight
management sessions were not well attended at first so were replaced by individual sessions.
A practice nurse employed at a nearby prison is delivering health promotion sessions for
patients at the unit in exchange for specialist psychiatric sessions delivered by unit staff at the
prison. Plans were put in place to recruit a permanent part time practice nurse at the unit.35

Meiklejohn35 concludes that more work needs to be done around training nurses about physical
health care. They acknowledge the importance of assessing patients on admission and
monitoring physical health throughout their stay, working closely with individuals to provide
education about medication and healthy lifestyle.

Addressing obesity in mental health secure units: Intervention and policy change
evaluations

Of the eight included intervention studies, only one was carried out using a randomised
controlled study design.29 The authors report on a cluster RCT with a sample of six long-stay
inpatient facilities in Denmark. Three facilities received the active awareness and motivational
interviewing intervention based on psychological theories relating to motivation and stages of
change. The intervention was delivered by the project leader and a research nurse and
involved sessions with staff members to raise awareness and service users to facilitate health
planning. The three control facilities received usual care and physiological data was collected at
all six sites at baseline and 12 month follow up. Staff and service-user measures included waist
circumference, BMI, weight, lung function, blood pressure, physical fitness, alcohol and tobacco
consumption. Service users also underwent blood glucose, lipid, ECG and medication
assessments.

All patients from the six facilities were invited to participate (n=174) although 44% declined so
that a total of 85 participants entered the trial (intervention n=45, control n=52). The authors
note that this affected the power of the study, which could have had an impact on results. A
further 12% of patients dropped out of the study prior to the 12-month follow-up, resulting in a
total of 85 analysed datasets (intervention n= 40, control n=45). At baseline, similar proportions

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Working together to tackle obesity in adult mental health secure units

of patients in both groups were diagnosed with schizophrenia (72% / 73%) and most (over
three-quarters) were obese with 44% having BMI> 30kg/m.2,29

At 12-months follow-up the intervention group showed a non-significant decrease in mean waist
circumference of 0.75cm (95% CI -2.79 to 1.23). Decreases in blood pressure and
LDL/cholesterol levels were also reported. The control group showed an increase in mean
waist circumference of 2.17cm (95% CI -0.37 to 4.71) and a decrease in mean LDL/cholesterol
levels. Mean HDL and blood glucose levels did not change in either group. Adjusting for cluster
randomisation, sex, body fat and age, the difference in change of mean waist circumference
attributed to the intervention group was reported as -3.1cm (p=0.018). However, the authors
report that the difference could have been limited by the control group having regular
measurements recorded, which may have inadvertently raised awareness of weight
management issues and resulted in some form of intervention. The authors conclude that the
intervention was not able to reduce waist circumference but prevented further increase.29

Seven studies reported in eight papers20,22,23,32,37,39,40,41 used a pre-post evaluation design and
a range of methods to assess interventions in secure mental health units. Two of these
studies32,39 were carried out within the same UK charitable healthcare organisation. Three
studies20,37,41 used mixed methods to identify views about implementation as well as
quantitative outcomes.

Vasudev et al.40 piloted a physical health monitoring sheet on a 15-bed male UK medium
secure forensic rehabilitation unit. The monitoring sheet was designed within the trust and
introduced into patient records with the aim of prompting HCPs to implement 6-monthly
physical health screening. The sheet had columns for recording health measures such as
weight, BMI, waist circumference, BP, blood test results, ECG, diabetes status, smoking status,
cholesterol ratio and calculated 10-year cardiovascular risk. Measurement and recording were
carried out by the patient’s primary nurse and the junior doctor. In addition, patients were
encouraged to increase their physical activity under supervision of a sports instructor and to
attend ‘healthy lifestyle’ groups that were designed to address diet, physical activity and
smoking behaviours and were delivered by trained nurses. An audit tool was designed to
collect data on monitoring sheet completion and other demographic information. Data was
statistically analysed at 12 months.

The majority of the 15 male patients were diagnosed with schizophrenia and were prescribed
antipsychotic medication. At 12 months, eight of the original 15 patients remained on the unit;
there were no significant differences between the characteristics of these and subsequently
admitted patients. At baseline 80% had increased BMI and waist circumference. Feedback
about health risks was given and physical activity or “healthy lifestyle” group attendance
encouraged.40

At 12 months, all monitoring sheets were complete and up-to-date. There was no change in
obesity rates although there was a reduction in cholesterol ratio (possibly due to raised

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Working together to tackle obesity in adult mental health secure units

awareness and increased medication prescribing) and 10-year cardiovascular risk. The authors
highlight reluctance in patients to adopt healthy lifestyle modifications, perhaps due to illness
severity and/or low motivation. Initially, it is reported that some patients refused to undergo
measurements and equipment had to be made available to the ward. Consideration of
alternative medication could also have an impact on weight management although this might
be difficult due to resistance to other medications. Authors also mentioned the lack of primary
care support within the unit. This small pilot study showed that regular monitoring of physical
parameters can have some impact on health although, in this case, not on weight
management.40

In terms of quality, the study did not include a comparator so it is difficult to judge whether
outcomes were related to the intervention. As over half the patients at 12-month follow-up were
not from the original cohort, they were not followed up for the full duration of the intervention,
which could have affected the results. The authors suggest that time was required for patients
to become engaged with physical activity and healthy lifestyle interventions, therefore 12
months (at the most for this sample) may be too short a time to establish whether these
interventions were having an impact.40

Cormac et al.22 evaluated a 10–12 week weight management and fitness programme that was
repeated within a UK high security mental health unit three times per year. The programme
targeted patients who were already obese, or overweight with related co-morbidities such as
hypertension or type 2 diabetes. Completion of the programme was dependent on attending at
least five group educational sessions consisting of nutritional and physical activity components
as well as one hour of tailored (according to fitness levels) physical activity per week with the
option of an extra hour. A range of exercises were offered as part of the programme, including
swimming, walking, curling, aerobics, circuit training and ball games. Physical and fitness
measurements such as BMI, waist circumference, blood pressure, heart rate, flexibility, aerobic
capacity and hand strength were recorded at baseline and after 10–12 weeks.22

Seventy per cent of those invited to participate started the programme and, of these, 46 (48%)
completed at least five sessions. More women withdrew from the programme than men. The
mean age of participants was 37 years (range 20-63) and 88% referred to themselves as
having White ethnicity. The mean number of attended sessions was five. Following the
programme, a mean weight loss of 1.3kg (SD 2.73, range 12kg gain to 9kg loss) and mean
waist size reduction 2.0cm (SD 3.73, range 8cm gain to 8cm loss) were recorded. The cost of
providing the programme was reported as exceeding £250,000 with savings of £15,000 being
recorded in year 2 (no further information was provided).22

Males (especially those with a learning disability) responded better to the programme than
females, maybe because the females were more obese at baseline. Many participants reported
that they enjoyed both the nutritional and physical fitness sessions. The results were affected
by problems of adherence to the programme, with some participants not wishing to have their

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Working together to tackle obesity in adult mental health secure units

physical dimensions or fitness levels measured. The authors report that staff training,
enthusiasm and commitment were important factors in the success of the programme.22

As a result of positive outcomes, the intervention was continued and evaluated again after the
provision of 16 programmes over seven years.23 Of these programmes, data on 14 were
available for assessment. The total number of participants referred at this point was 206, with
102 (58%) completing at least five sessions. As before, highest attrition was in females (56%)
and lowest in males with LD (21%). There were staff shortage issues during the delivery of
three programmes.

Mean age of participants was 36 years and mean BMI was 34(SD 6.1, range 24.9-56.0). On
completion, 63% had lost weight; 21 patients lost at least 5kg after 10–12 weeks. Mean weight
loss was 1.3kg (SD 3.7, range 12kg gain to 11kg loss). Females and males with learning
disability were reported to have lost most weight, possibly due to higher level of commitment or
a higher mean weight at baseline. The authors report no association between amount of weight
lost and number of sessions attended.23

Challenges reported by the authors include designing a programme that was accessible to
patients who had a wide range of psychiatric and long-standing problems such as severe
psychosis and substance misuse. However, they report that findings are promising given the
challenges faced. They reported a mean loss of 1.3kg at three months and again at seven
years, highlighting consistent effects. It is not known how many patients continued to lose or
manage their weight long term; it is likely that many patients left the unit at some point following
the intervention.23

Savage et al.39 focused on female patients in their evaluation of an initiative to encourage take-
up of physical activity on one ward within a UK medium secure forensic unit. The intervention
consisted of 12 weekly, one-to-one sessions of physical assessment, education about the
benefits of exercise, weight training and aerobics delivered by a physically active professional,
goal setting, financial reward, therapeutic input regarding body image issues, and regular,
immediate feedback on the effect of the exercise on mood and wellbeing. Measurements
included attendance, physical measurements, mood following physical activity and post-
intervention views measured against five statements.

Of the 14 patients resident on the ward, eight were eligible and a further two dropped out. Mean
age of participants was 34 years (range 20-48) and 50% had a BMI > 30. All included women
had a diagnosis of personality disorder and two had a secondary mental illness diagnosis. At
baseline all the participants were assessed as being at the “contemplative” or “pre-
contemplative” stage of change. The total number of sessions attended was 39, with a mean of
6.5 (SD 3.0, range 3-12) per patient. Mean pre-post mood scores indicate that participants
were more relaxed, happy and calm after the training session than before it began. No
significant differences were found on the energetic/exhausted scores. Mean attendance
increased from 39.5 (SD 21.7) in the final four sessions to 52.0 (SD 23.4) during the four

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Working together to tackle obesity in adult mental health secure units

sessions after the 12 weeks had been completed. Feedback from patients was mean 5.4 (SD
1.14) for enjoyment, 6.0 (SD 0.71) for feeling more motivated to attend other sessions, 4.6 (SD
2.07) for value of completing MMM score, 5.0 (SD 2.35) for motivation to attend further activity
sessions and 6.6 (SD 0.55) for benefits felt from attendance, where 1=strongly disagree and
7=strongly agree. The authors point out that increased enjoyment and motivation for exercise
has the potential to reduce the extent of disturbed behaviour in mentally ill patients.
Improvement in mood scores was reported to signify that this could be the case though with the
acknowledgement that these effects may also be due to medication. Resource implications
were one barrier to implementation reported by the authors.39

Long et al.32 also report on a pre-post intervention evaluation carried out in female low and
medium secure wards within the same healthcare organisation as the previous study. The
female patients were on personality disorder and intellectual disability pathways. The three-
month intervention was based on reinforce appropriate, implode disruptive (RAID), positive
behavioural support (PBS) and nudge principles. In practice, 30 minutes of physical activity was
offered each day with encouragement from prompt cards and small monetary rewards. Access
to exercise was increased and physical activity supervision was made available in courtyards.
Staff were trained using recognised sport, psychology, physiotherapy and nutritional principles.
Participants were taught to set targets and report activities, whilst staff provided feedback.

The NZPAQ-SF was used to assess frequency, duration and intensity of activity. Biological
measures such as BMI, body fat, muscle, peak expiratory flow and resting pulse rate were
recorded. Mood was monitored using the MMM measure and attendance categorised as
vigorous, moderate or low intensity. The BREQ-2 was used to measure decisions whether to
engage in physical activity and the extent to which behaviour is internalised or amotivational.
Two additional questions about general weight and health and the importance of improving
physical activity levels (10 point scale, not good/important – very good/ important) were
asked.32

Authors report 100% uptake. The mean age of the participants was 27.6 years (SD 11.3; range
18-48). Most of the participants had been admitted from medium secure units or prison and had
diagnoses of personality disorder (79%), schizophrenia (15%), depressive disorder (6%) and all
but 28% had a secondary diagnosis of learning disability, PTSD or ASD. The main changes
post-intervention were a significant reduction in mean pulse rate (p<0.01), improvement in
motivation (p<0.01) and increase in attendance to physical activities at all levels of intensity
(low intensity 2.4 hours vs 6.78 hours, p<0.01; moderate intensity 1.65 vs 3.45 hours, p<0.05;
vigorous intensity 1.3 vs 5.5 hours, p<0.01) per week. Although approximately one third had
lost weight, increased muscle mass and improved metabolic age, these results were not
statistically significant. Positive mood changes were evident post-intervention.32

Long et al.32 also report that staff, who initially may not regard encouraging physical activity as
their job, may have become more involved due to the ward-based activities. They also aimed to
target motivation in patients given the likelihood that motivation to engage in physical activity

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Working together to tackle obesity in adult mental health secure units

may be low in this population. The findings that BMI and weight were not significantly reduced
following the intervention was not seen as a unduly concerning given that the participants
showed significant benefits in other health-related and motivational parameters. Factors such
as enjoyment, for example, could be important motivators leading to behaviour change.
However, the authors suggest that longer-term benefits cannot be reported here and that follow
up at six months is planned. Given that this article was published recently, there has not been a
follow-up paper to date.

A mixed method study, using a combination of accelerometer readings, observation and

interviews, was carried out to explore the impact of access to Wii Fit in an Australian secure
forensic mental health hospital.20 Duration of stay in the unit ranged from two months to several
years. Patients with a BMI 25–32 were invited to a group Wii Fit session running twice a week
for eight weeks. Staff and participants were trained in use of the Wii Fit and patients had the
option of using it alone. An accelerometer was worn by those participating for 12–96 hours (1–4
days), where possible at the same time every week, to monitor activity. Due to patient
movement out of the unit, only two participants provided sufficient informed consent for use of
data. These patients were also interviewed about their participation.

One participant was a 28-year-old male (‘Andrew’) diagnosed with schizophrenia and
prescribed Clozapine. He had been resident at the unit for six years during which time he
gained 51.9kg. Wii Fit was new to him though he had previously used computer games.
Andrew used the Wii Fit at least once per week (range 1–3) for 7–127 minutes per session.
During the first two weeks he played alone at night, although in week two he started to join the
group, preferring this due to his “competitive gene”. Researchers observed and encouraged
Andrew through weeks 3–8; he was sceptical at first as it wasn’t the “real thing”. Once started,
Andrew found using the Wii Fit to be “awesome”, enjoying the range of activities and ease of
use. The Wii Fit was also an educational tool, teaching Andrew ways to become more fit and
healthy (through dietary change as well as physical activity) as he felt unfit at the beginning.
Andrew lost 3.4kg at the end of the eight-week intervention.20

‘Becky’, aged 43, was diagnosed with schizo-affective disorder and mild intellectual disability.
She was admitted eight months prior to starting the intervention and had gained 7.3kg since
commencing Clozapine. She had no previous experience of Wii Fit. Her participation lasted 5
weeks before being transferred to another unit. Becky spent a total 570 minutes (mean 114
minutes per week, range 14–60 minutes per session), playing 2–3 days per week, sometimes
twice a day. She preferred to play with researchers present, for encouragement rather than
competition. Initially, she found many of the games difficult but gradually came to learn more
and enjoy the activities. Becky lost 1kg over five weeks and reported that she now enjoyed
exercise and wanted to do more as it was fun.20

The authors assessed total energy expenditure in more detail, reporting that Andrew and Becky
could expend more kilocalories during other activities such as art and hospitality classes or
during sport than using the Wii Fit. However, more energy was used playing Wii Fit than on

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Working together to tackle obesity in adult mental health secure units

other types of console games, and using Wii Fit added to the total amount of daily energy
expenditure. Becky and Andrew were also reducing the time spent in their room sleeping or
watching TV and had undergone attitudinal changes in respect of physical activity. The authors
caution the overemphasis on weight loss as the main goal, since lifestyle changes can impact
overall wellbeing.20

The part played by researchers as role models, as ‘company’, and in encouraging activity on
the Wii Fit was reported as a facilitator to maintenance of physical activity. However, the nurses
were observed not to engage in Wii Fit with the patients, attributing resistance to their
perceived lack of ability or reluctance to wear sports gear. Researchers observed no reluctance
in nurses to join patients sitting outside smoking.20 The small sample in this study was partly
due to patients leaving the unit during the intervention phase and also to difficulty gaining
informed consent. The findings, therefore, have limited generalisability. However, the qualitative
data highlights the added psychological impact that can result from a small change in
behaviour. Perceiving the intervention as “fun” rather than just a way to lose weight was an
important motivator. Observations showed that role modelling could be an important influence
on behaviour change in the unit.20

Wynaden et al.41 also used mixed methods to evaluate a healthy lifestyle programme in an
Australian forensic mental health setting. The intervention consisted of physical activity and
nutritional education as well as stress relieving sessions and daily supervised an exercise
classes. Patients were physically assessed before and following completion of the intervention
and asked for feedback using questionnaire and qualitative methods.

A total of 56 patients were assessed (47 female and 9 male, mainly aged less than 35 years).
Length of stay ranged from one month to two years. Response rate for the questionnaire was
53%. Less than one half of respondents (40.6%) reported that the programme was enjoyable,
26.4% that it was useful and 21.7% that it made them feel better. Negative responses (11.3%)
came from females, suggesting that for them the programme was difficult, not enjoyable,
boring, not useful, or made them feel worse.41

The main reported reason for attending the gym was to stay healthy (15%), followed by keeping
fit (14.5%), enjoyment (14.1%), to reduce stress (13.2%), to pass time (11.9%), to get a routine
(11%) and to help with psychiatric problems (9.2%). Some respondents (11%) reported that
they thought attending a gym might influence their length of stay. The most useful activity
reported was indoor cricket (19.2%) followed by circuit exercises (13.4%), stretching exercises
(12.9%), volleyball (12.3%), basketball (10.2%), indoor soccer (8.6%), outdoor exercise (8%),
and group exercise sessions (7.5%). Only 6.4% responses suggested that relaxation sessions
were useful. The remaining 1.5% preferred all round exercise, table tennis and weights.41

Fifteen patients contributed to the qualitative evaluation; the authors grouped responses into
five main themes. Patients reported that the programme helped them to manage stress and
anxiety, and to relax. The programme also provided a structure and meaning to the day, and

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Working together to tackle obesity in adult mental health secure units

gym sessions were anticipated in a positive way. New relationships were formed as a
consequence of participating, and patients appreciated the input of exercise physiologists.
Skills such as anger and frustration management were learned, allowing patients to clear their
mind and achieve more focus. Finally, patients reported that the programme taught them to
become more involved in their own care and monitor their results. The authors conclude that
nurses have an important role in facilitating such programmes and supporting patients in health
promotion activities, ensuring that they link with relevant services following discharge from
units.41

Qualitative methods were used by Prebble et al.37 to evaluate two Healthy Living Programmes
(HLPs) carried out in New Zealand mental health secure units. One programme (A) was
implemented in a medium secure rehabilitation unit with nine beds. The programme uses a
treatment approach in which staff define new dietary and physical activity behaviours and direct
their implementation. The second programme (B) was carried out in a minimum secure unit
with 20 beds. This programme provides small group educational and practical sessions in food,
exercise and social skills using a health promotion approach in which staff and patients define
new behaviours.

Thirty-two patients who had engaged with either of the HLPs were invited to participate in
interviews of which 15 accepted (14 male and one female). Twenty healthcare professionals,
who had been involved in developing or facilitating the HLPs, were also invited to participate, of
which 17 consented. Interviews with patients were carried out by service-user researchers (one
from each HLP) and explored experiences of participation, impact on physical and mental
health and lifestyle, self-efficacy and recovery as well as barriers to participation within a secure
unit setting. Interviews with healthcare professionals were carried out by study researchers,
exploring experiences of developing and facilitating the HLPs as well as barriers, challenges
and enablers and their perceived effect on service user health, self-efficacy and recovery.
Patient case notes were assessed for how health status details were recorded and how the
programmes were evaluated, not to assess the effects of the programmes.37

From Programme A, which had been accessible for four years, seven service-user participants
were recruited (5 males, mean age 47 years) who had spent a mean 39.5 months on the
programme (range 6-52). The programme had been initiated following the death of a young,
obese patient, after which it was recognised that physical health needs were an important
aspect of care. Two nurses, an occupational therapist and a consultant psychiatrist
championed the programme in its early days. The programme was compulsory and became
embedded into ward routines, although some flexibility was introduced to allow ability-
appropriate physical activities and food choices.37

Staff reported that access to records encouraged enthusiasm and engagement on the
programme. Both staff and patients reported that the programme had a positive impact on
patient self-esteem, confidence and life skills, with involvement increasing social interaction and
peer support. Staff also indicated that the programme was beneficial for them as they

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accompanied patients on walks. Staff initially met with resistance from patients at the changes
made, though this diminished over time. Staff costs to meet extra support were a barrier,
especially where funding was being cut. The effects of medication were also discussed, though
it was acknowledged that weight loss could be achieved despite these side effects. Concerns
included the tension between changing health-related behaviour and imposing restrictions on
patients, for whom treats were an important aspect of life within the unit; promoting choice was
a way of addressing this issue. The long-term effects of intervention were uncertain given that
patients might not continue to eat healthily or exercise regularly once they left the unit.
Physiologically, records showed that patient health had stabilised over 12 months, with some
modest improvements. After six months no weight gain was identified and for two patients,
blood pressure readings had improved.37

Programme B was initiated following identification of a high level of metabolic syndrome on the
unit (78%) with concerns about future health. Two nurses championed the programme, which
was based on the Clubhouse Model of rehabilitation that encourages a strong group culture,
facilitating peer support and education. Enjoyment and fun were also important for maintaining
involvement with the programme. Both staff and patients noticed positive changes in patients’
health, confidence and mood. The HLP was reported to promote a sense of vibrancy that
extended beyond the ward, with other wards taking up aspects of the programme and
requesting recipes or advice. Patients planned to continue activities following discharge, using
tools and skills developed from the programme. Barriers identified by both staff and patients
included staff resistance to change, the idea that facilitating HLPs did not form part of the
nurse’s job description, and that the HLP contradicted some of the forensic care protocols.
Resentment was also identified due to the intervention being delivered to only a section of the
ward. A reported lack of available space and resources to support the programme was evident,
for example, small kitchens or no available freezer. Lack of a multi-disciplinary team approach
was another weakness, with one ward having no access to a dietician.37

The HLP evolved over time, becoming less authoritative regarding patients who did not comply
with the HLP protocol and the tension between control and autonomy was managed day-to-
day, with patients eventually recognising the benefits of the programme. Physiological
measures were not recorded as consistently as for Programme A and no blood pressure
records were identified. Weight was only recorded for one patient who gained 2kg over six
months. Two patients with high blood glucose levels at baseline showed no change at 6 and 12
months.37

The authors conclude that a consistent, multi-disciplinary team is an important factor to the
success of a HLP. Both programmes were initiated by champions who encouraged change and
provided education, an important factor in addressing entrenched attitudes and routines on the
wards. Champions also secured funding, the extent of which determined how the programmes
could develop. Differences between the two approaches (compulsory or empowerment) were
identified, with the former potentially suiting a particular sub-population such as patients with
learning disabilities. The latter approach was potentially beneficial to patients preparing for

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discharge, with improved mental wellbeing. However, in this case the effects of the intervention
could not be properly evaluated due to inconsistent data recording.37

Mental health staff perceptions of delivering physical health care

Three included studies24,25,38 were carried out using qualitative methods to assess mental
health nurse perceptions about the role of physical activity, their role in carrying out physical
health care, their confidence in delivering nutritional advice, and how healthy lifestyle
interventions have been established in mental health secure units.

Rylance et al.38 used semi-structured interviews to explore how six nurses perceive their role in
physical care of patients within a UK secure mental health unit. All the nurses perceived
physical health assessment as an important part of the care pathway, though this was generally
initiated by physicians. Physical health concerns might be raised by patients during ‘named
nurse’ sessions but nurses doubted whether routine regular monitoring was carried out. There
was a reported lack of equipment on wards for assessing physical health and a prioritisation of
mental health needs that took up most of a nurse’s time and effort.

Health promotion activities were planned or opportunistic and delivered to individuals or groups.
There was concern over women’s health and the effect of medication on weight. A suggested
approach was to train nursing assistants to carry out physical assessments. The interviewed
nurses felt that they had a low level of knowledge about physical conditions such as diabetes.
When patients were unwell, a physician or specialist was called in to the unit. The authors
suggest that the approach being described is at odds with current thinking, to provide holistic
care. The findings imply that a ward culture of not physically monitoring patients routinely could
prevail. In addition, although nurses seemed keen to care holistically for patients, they may lack
the knowledge and confidence to carry out assessments, revealing a need for training in this
area.38

Forsyth et al.25 used interviews and a nutritional knowledge questionnaire to assess nurse
confidence and training needs in providing nutritional advice to patients. A total of nine nurses
(6 female, 8 qualified) were recruited at a rehabilitation forensic unit in New Zealand. The
dietician was a major source of information, supplemented by internet resources, TV
programmes and previously developed local protocols. They therefore perceived that they held
basic nutritional knowledge but lacked the confidence to convey this to patients, whom they
perceived as having low levels of knowledge. Particular areas of confusion were food labelling
and portion size. Staff members were reported to hold different views about nutrition due to
inconsistent messages from specialists. Nurses were also wary of imposing too many
restrictions on patients and contravening their human rights. Patients were reported to be
resistant to change, avoiding responsibility for healthy eating and holding habits that were
difficult to break. The effect of medication on weight gain was also a reported barrier for
patients.

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The nutritional knowledge questionnaire yielded an average score of 50% (range 41%–68%).
Three nurses scored less than 50%. Knowledge of nutritional value attracted the highest scores
whilst knowledge of major food groups, adequacy of intake, effect of mental health problems on
appetite, food labelling, cost-saving, fibre content and risk for metabolic disease scored lowest.
However, nurses reported feeling more confident about advising patients about aspects of
nutrition that they knew least about.25

Faulkner et al.25 assessed mental health nurses’ perceptions of the role of physical activity in
addressing weight management in one UK secure unit. Face-to-face and telephone interviews
were carried out with 12 nurses (nine female, three male) with a mean age of 35 years. All
participants reported having been involved to some extent in promoting physical activity
(planned or infrequent) as part of their role. Involvement included providing advice, helping to
set goals and encouraging sedentary patients to become more active. Walking was the most
commonly reported activity with some sports involvement. All the nurses were positive about
being involved in this role, citing examples of patients recovering much more quickly when they
had been engaging with physical activity, and even single episodes of activity having an impact
on alertness. Physical activity was also reported to relieve frustration and stress as well as
provide structure to the day and social interaction. However, the authors suggest that caution is
needed to ensure that physical activity is not carried out to fill the day rather than as a way of
achieving health benefits, since sedentary activities can also fill time. The tension between
lifestyle choice for patients and healthy lifestyle promotion was mentioned, given that physical
activity was being promoted to address health risks. If patients did not want to participate in
exercise and felt they were being coerced, this could negatively affect mental wellbeing.25

Additional reported barriers for patients included the relatively constrained environment of
secure units for participation in exercise compared to outside and poor motivation due to
mental health issues. For staff, the prioritisation of mental health, health and safety and suicide
prevention within the units as well as the resistance of staff to co-participating in activities not
regarded as “work” were reported issues. Whilst there was a reported move toward holistic
care, staff faced challenges that continue to separate the needs of mind and body, particularly
when dealing with mental health crises. The authors conclude that nurse participants framed
physical activity promotion as diversion rather than therapy, which could serve to marginalise
physical activity and weaken the argument for more provision within units. Researching the
therapeutic role of physical activity also requires theorisation of the mind-body relationship
rather than treating them as separate entities.25

Grey literature – unevaluated activities

In addition to retrieving evidence from published and unpublished literature, we consulted with
our advisory team to identify information about interventions that might be available in the grey
literature. The June 2015 Forensic CCQI newsletter45 ran a special edition that highlighted 17
physical health promotion initiatives being implemented in UK secure mental health units.
These examples illustrate how units are responding to the call for improved physical health

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care for patients with severe mental health problems. Other editions46,47 focus on physical
healthcare and provision of high quality meals secure units, the latter citing six examples of
change policies within low secure units.

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2. Stakeholder engagement
Stakeholder consultations

Consultation with our advisory panel and stakeholders including commissioners, clinicians and
service users raised a number of issues to take into account when identifying and implementing
interventions to address obesity in secure mental health units. They included:

Organisational

 access to primary care input in secure units

 the role of the Care Quality Commission (CQC) in monitoring activities such as ‘blanket’
restrictions
 staff availability – this may affect feasibility of staff training for physical activity facilitation
and staff availability at mealtimes. (Meals were served over the period of time that most
staff were on duty, with a long interval between dinner and breakfast the following day.
This could lead to patients snacking during the evening.)
 tension between controlling access to foods and autonomy; respecting human rights and
the role of food as treats
 extend physical care to life-course where a range of services will be accessed, not just
the duration of stay in a secure unit
 the potential impact of smoke free units on eating behaviours – patients focus on
smoking breaks and mealtimes
 food can be brought in by family and friends

Intervention

 the importance of intervention accessibility (eg acute wards, where patients cannot
obtain leave, may not have sufficient space for physical activity)
 the importance of integrating patient choice and preference
 the importance of a balanced healthy diet. This affects mental health as well as physical
health outcomes
 the need to include staff behaviour change in interventions because staff can have
similar lifestyle behaviours to patients with regard to food and physical activity. (This
issue was picked up in research into smoking behaviours in mental health secure units.)
 staff and service user attitudes can focus on short-term benefits whereas behaviour
change requires long-term thinking
 duration of response to interventions rather than dose effect
 the impact of medication on weight, appetite and alertness, and the extent to which
clinicians are aware of alternative medications

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Patient

 the need to take into account the stage of a patient’s illness and what to prioritise when
modifying lifestyle
 gender differences in the level of engagement with physical activity and dietary changes
(women less engaged with physical activity, difficulty maintaining healthy eating) and
obesity levels (women more obese)
 snacking takes place in evening when dinner is served early
 comfort eating to relieve boredom and stress
 patients can resist attempts to change behaviour if restrictions are regarded as punitive
 change more likely if service users want to change rather than need to change

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3. Thematic synthesis
Data from all identified sources as described in the preceding sections were categorised
thematically. Themes will be presented in detail in a publication to be submitted to a peer-
reviewed journal. An outline is included in Table 2 below, along with sub-themes and data
sources.

Table 2. Themes from included studies

Theme Subtheme / detail Papers
Extent of obesity in Higher than general population Cormac 2005; Long 2014;
secure units Haw
Higher in females Cormac 2005; Long 2014;
Haw
Weight management strategies:
Physical health / Planned (routine) or opportunistic Haw 2011b; Rylance
weight monitoring monitoring
Physical health monitoring sheet Vasudev
Availability of equipment Rylance
Availability of trained staff Rylance
Staff level of knowledge Rylance; Forsyth
Staff confidence in educating Rylance; Forsyth
patients
Food policies Canteen: portion size, healthy Oakley
options, care planning (restrict high
calorie food and drink), plating Haw 2011b;
meals, restrict second helpings
Shop: healthy snacks, limited
access; sell other types of goods Oakley; Haw 2011b; Harper;
Take-aways; care plans, “rights”, Long 2009
outright ban
Comparison to school policy Oakley; Kasmi;
Haw 2011b;
Oakley
Facilities for Access to NICE recommended PA: Oakley
physical activity Sufficient staff, access to facilities
and interventions (gym, fitness Haw 2011b
programmes, activities / sports) Hjorth
Employ fitness instructor

Meiklejohn; Vasudev
Positive Modelling Staff behaviour (eating practices) Oakley; Long 2009
Staff behaviour (PA involvement)
Staff champions (trigger and Bacon
maintain intervention)
Prebble
Specialist input Practice nurse (primary care) Meiklejohn
Physician / specialist Rylance
Dietician Forsyth
Patient education Money management Harper;

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and advice Nutrition (staff; dietician) Haw 2011b; Long 2009

Motivational group Long 2009
Weight management Meiklejohn
Health planning Hjorth
Group or individual Meiklejohn; Rylance
Patient advocacy:
Human Rights Limiting choices Oakley; Prebble; Forsyth;
Immoral to restrict treats Faulkner
Comparison with anorexia (urgent Haw 2011b; Prebble
health need) Oakley
Community Discuss policies with patients Haw 2011b; Long 2009;
meetings Meiklejohn
Ward Culture:
Changing practice Extent to which ward adopts a Long 2009; Rylance
culture of healthy eating, physical
activity, weight maintenance,
supported by staff training (holistic
care).
Staff training (nutrition) McCrarren;
Staff awareness and motivational Hjorth
interviewing
Interventions:
Healthy lifestyle Diet, physical activity Vasudev; Wynaden; Prebble
interventions Weight management / fitness Cormac 2008 / 2013;
Savage; Long 2015; Bacon
Intervention Stages of change Savage
theories Clubhouse Prebble
Active Awareness Hjorth
Motivational Interviewing Hjorth
Reinforce Appropriate Long 2015
Implode Disruptive (RAID) Long 2015
Positive Behavioural Support (PBS) Long 2015
Nudge Long 2015
Long 2015
Barriers and facilitators to intervention:
Intervention factors Motivators
Researcher / staff interaction Bacon
Holistic, not only for weight Bacon
management
Compulsory or voluntary? Prebble
Less authoritative approach Prebble
Benefits
Enjoyment, fun Savage; Long 2015; Bacon
Educational / skills Bacon; Wynaden; Prebble
Competitive Bacon
Fills time / adds structure to day Wynaden; Faulkner
(though this not main aim)
Provides social interaction Wynaden; Prebble
Improves mood, self-esteem, Savage; Long 2015; Prebble
confidence
Barriers
Accessibility for broad range of MH Cormac 2013
problems
Lack of available space Prebble; Faulkner

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Lack of support resource Prebble

Contradicts forensic care protocol Prebble
Staff factors Facilitators
Can link patients with services to
continue after discharge Wynaden
Positive when they see benefits to
patients Faulkner
Barriers
Lack of primary care input Vasudev
Lack of multidisciplinary team Prebble
Staff shortages Cormac 2013
Low level of knowledge Rylance
Not recognising PA encouragement Long 2015; Bacon; Prebble;
as part of job Faulkner
Prioritisation of MH care Rylance; Faulkner
Resistance to change Prebble
Not wanting to wear sportswear Bacon
Insufficient funding Prebble
Patient factors Patient resistance
To having measurements taken Vasudev; Cormac 2008
To change Prebble; Forsyth
Low motivation / reluctance Haw 2011b; Long 2015;
Not taking responsibility Faulkner
Habitual behaviour Forsyth
Intervention difficult Forsyth
Patient drop out
No reason given Wynaden
More females drop out Hjorth
Transfer to other units / discharge Cormac 2008/2013
Outcomes Vasudev; Bacon
Effect of medication
Maintenance after discharge Prebble; Rylance; Forsyth
Prebble

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