The Journal for Nurse Practitioners
Volume 6, Issue 7 , Pages 540-545, July 2010

Weight Management Issues and Strategies for Success

  • Margaret J. Rowberg

      Affiliations

    • Margaret (Peggy) Rowberg, DNP, APN, is an associate professor at California State University in Chico and is an adult nurse practitioner who manages a weight program.

Article Outline

Abstract 

Despite dedicated efforts to reduce the obesity problem in the United States, no state as of 2007 had achieved the Healthy People 2010 objective to reduce the number of people who are obese to 15%. This article discusses the scope of the obesity problem in the United Sates and the issues surrounding weight-loss efforts and provides some insight into simple weight-loss and maintenance help for patients. Furthermore, effective tools and some physical activity strategies to aid this effort are presented.

Keywords:  calories , obesity , overweight , physical activity , weight loss , weight maintenance

 

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Introduction 

Discussions about the obesity epidemic are not new. One can open any magazine or newspaper and find an article that discusses the weight problem in the United States and globally. There are many articles about the latest diet plan, but few articles discuss how to establish a weight management program within your practice. This paper presents the scope of the problem of obesity in the United States and the issues surrounding weight-loss efforts and offers some insight into providing simple weight-loss and weight maintenance help to patients. It also introduces some effective tools and physical activity strategies that can be used to aid in this effort.

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Scope of the Problem 

Despite the Federal government's dedicated efforts to reduce the obesity problem in the United States, no state as of 2007 had achieved the Healthy People 2010 objective to reduce the number of people who are obese to 15%.1 According to the same report, “25.6% of respondents overall in 2007 were obese; the prevalence of obesity among adults remained greater than 15% in all states and greater than 30% in Alabama, Mississippi, and Tennessee.”2 The Centers for Disease Control and Prevention, which collects these data, further reported in 2008 that the prevalence of obesity was race specific.2

Non-Hispanic blacks had the greatest prevalence of obesity (35.7%), followed by Hispanics (28.7%), and non-Hispanic whites (23.7%). These differences were consistent across all census regions and were greater among women than men. Non-Hispanic black women had the greatest prevalence (39.2%), followed by non-Hispanic black men (31.6%), Hispanic women (29.4%), Hispanic men (27.8%), non-Hispanic white men (25.4%), and non-Hispanic white women (21.8%).2

One need only compare the map of the United States showing obesity in 1990 with that in 2008 (Fig. 1) to see that the obesity issue is not going to be solved any time soon, but that does not mean that efforts are futile. Quite the contrary, every attempt should be made to double or triple the efforts of providers to address this problem because the cost to this country in lost time and wages is tremendous. Finkelstein et al.3 reported that health-care costs related to being overweight or obese could be “over $93 billion a year, which represents almost 9.1% of the total US annual health-care expenditures.”3 Given that the original research by Finkelstein et al. is almost a decade old, these costs have probably increased. In fact, Loureiro4 also found that “health-care costs for overweight and obese people were 37% higher than for normal weight people.” Runge5 noted, “In the workplace, employers of the overweight and obese confront these costs if they offer health insurance, but they also face costs of absenteeism, reduced productivity, and other complications.” These numbers make it imperative that health-care providers begin to focus their efforts on the obesity problem. Nurse practitioners are particularly suited in this role, since our focus has always been on disease prevention and health promotion.

(Data from Centers for Disease Control. BRFSS, behavioral risk factor surveillance system. Available online: http://www.cdc.gov/brfss/.)

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The Struggle to Lose Weight–Whose Fault Is It? 

The American diet has been changing and unfortunately not always for the better. “Twenty-five years ago, the average American consumed about 1,850 calories each day. Since then, our daily diet has grown by 304 calories (roughly the equivalent of two cans of soda). That's theoretically enough to add an extra 31 pounds to each person every year.”6 One-third of Americans who eat at home state they have cereal for breakfast, compared to only 9% who have cereal when they eat out.7 The 2005 Behavioral Risk Factor Surveillance System reports showed that only one-third of adults consumed fruit two or more times per day and barely more than one-fourth ate vegetables three or more times per day.7 At the same time, it has been found that when people eat breakfast away from home, their top choices are breakfast sandwiches, sausages, donuts, soft drinks, potatoes, and bagels, one-third of which are eaten in the car.8

Another contributing factor to the obesity issue can be that more meals are being eaten away from home. Only 26% of our food was eaten away from home in 1970 but that number increased to 41%.9 by 2005. Research by the US Department of Agriculture found that several changes contributed to this development. They included “a larger share of women employed outside the home, more two-earner households, higher incomes, more affordable and convenient fast-food outlets, increased advertising and promotion by large foodservice chains, and the smaller size of U.S. households.”9

Mancino et al.10 determined whether certain behaviors or factors influenced weight issues among adults. Some key outcomes were that a smaller proportion of overweight and obese individuals exercised more than once a week compared with that of healthy-weight people; also, the number of hours spent watching TV was significantly higher for overweight and obese individuals than for healthy weight individuals; and overweight and obese women have significantly longer intervals between meals than healthy-weight women and receive more of their daily calories from fast-food restaurants.10

Mancino et al.10 also learned that perceptions about weight may impact a person's willingness to put in the effort to be healthier. In fact, it was found that “nearly 60 % of overweight and obese men believed they have a healthy body weight.”10 This number was significantly disproportionate to the actual weight of these men. It was further discovered by Mancino et al. that “significantly more overweight women indicated that taste and storability are the most important attributes when buying food.”10 It was also found that these women shop once a month or less, which may suggest that overweight women are buying more processed foods than normal-weight women.

Block11 learned that “sweets and desserts, soft drinks, and alcoholic beverages comprise almost 25 % of all calories consumed by Americans. Salty snacks and fruit-flavored drinks make up another 5%, bringing the total energy contributed by nutrient-poor foods to at least 30 % of the total calorie intake.”11 These high-calorie foods obviously have a major impact on a person's ability to maintain or lose weight.

There has been some discussion that indicates that the fast-food industry is at fault for the obesity issue, but these studies show that there are a multitude of issues contributing to this problem. Consequently, it is vital that health-care providers identify the particular barriers to weight loss seen in their patient population and focus efforts on eliminating these barriers through an organized weight-loss program.

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Weight-Loss Program 

Most providers recognize the enormity of the obesity problem but have little time during an office visit to address the many facets of education needed by patients about their individual weight-loss issues. It is important that each of these issues be addressed with compassion and caring so that the patient does not feel embarrassed by the discussion.

In order to appropriately address weight concerns, providers must recognize that these discussions need to take place outside of a regularly scheduled health visit. Discussions about weight loss and maintenance require time. Most initial weight-loss visits last about 1 hour or more. A very detailed weight history should be taken for every new patient. It should be required that all patients complete a medical history and physical examination, including complete blood work before beginning any weight program. Depending on the person's age, one might also consider an electrocardiogram and/or a treadmill stress test. For obvious reasons, all risk factors for hypertension, heart disease, diabetes, thyroid, and other interfering conditions should be addressed before beginning any weight program, although the long-term benefits of weight loss will improve the symptoms and complications of these diseases.

It is imperative that patients commit to a minimum 3-month period of visits during weight loss and to a weight maintenance program of 12 to 18 months after achieving goal weight. The weight-loss visits are weekly, and maintenance visits can be scheduled one to two times a month. Weight loss visits include weight and blood pressure checks as well as a discussion of concerns or issues. These visits include an education component that can be given individually or in a group. Some topics may include diet tips, an eating-out guide, the use of vitamins, portion sizes and control, and tips on how to include more fruits and vegetables in the diet. It can be very helpful to develop a relationship with a local dietitian and physical therapist, both of whom can provide additional education and guidance for the patients.

Since many health-care insurance plans may not provide benefits for health promotion programs such as a weight management program, the best approach is to establish a weight program as part of a primary care practice with patients managed by a nurse practitioner or physician assistant. Having a program within a recognized practice increases the likelihood of patient acceptance because trust has already been established. Although there are many weight programs available to the public, the advantage of this type of program is having a licensed provider who is more likely to recognize health changes in patients and is able to address these issues immediately before they impact the health of the patient. Fees for these patients should be competitive with other local programs.

The most ideal approach to a weight program after the initial health assessment is to meet with the patient to discuss his/her weight goals, previous weight-loss attempts, current eating habits, and physical activity in detail. It is also vital that the provider understands the patient's family, social, and psychological history. Based on the answers to these questions, the provider can then develop a diet and physical activity plan that meets each patient's needs.

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Weight Loss 

Despite the hundreds of books and websites that have been published, the best approach to long-term weight loss is based on calories: calories in and calories out. Though it may be depressing to some who would like the magic pill, calorie counting is the only method that is truly effective for long-term weight loss. In this author's experience, most patients do not understand the number of calories needed to maintain and then ultimately to lose weight. When it is explained that the average adult male consumes approximately 12 calories per pound to maintain weight and must reduce that to actually lose weight, it can be disheartening. For females, the numbers are even less. An adult female may burn 11 calories per pound, but the number of calories for menopausal females drops to 10 and even 9 calories per pound. For example, a male who weighs 250 pounds is probably consuming about 3,000 calories or more per day to maintain that weight. This information alone seems surprising to many individuals.

When developing an appropriate weight-loss plan, putting patients on extremely low-calorie diets can set them up for failure. Patients need to feel satisfied with the amount of food they consume and not feel deprived of some of their favorite foods. A good approach is to reduce calorie intake enough to facilitate weight loss but not so low that patients begin “cheating” on the plan. It is best to recommend three meals and two snacks a day, which allows patients to eat every few hours. Research shows that women who snack frequently are better able to maintain their optimal weight.10 In the case of a 250-pound male, it would be good to establish about 1,800 to 2,000 calories as the initial plan. As he loses weight, the number of calories can be reduced accordingly. This plan would cause a deficit of almost 7,000 calories per week compared to his previous eating habits and allow about a two-pound weight loss each week. Many patients may feel that this loss is too small, but it is important to remind them that a two-pound loss per week equals 100 pounds in a year, a number that patients need to hear to help keep them on track.

For some of the most obese patients, it is not a good idea to set weight-loss goals that aim for ideal weight. If that goal equates to a 100- to 300-pound loss, it can be too daunting a task for some patients. A better approach is to aim for a 10% loss, a more realistic number and one that most patients can achieve. Once that initial goal has been attained, a new 10% loss can be set. Since many overweight and obese patients have made multiple attempts at weight loss and have failed, setting smaller goals can provide an environment of success and create a willingness to strive for further weight loss.

At the same time, patients need to increase their physical activity to assist in the weight-loss process. This is an area that is usually lacking for many obese patients due to issues that may involve knee, back, or joint pain. Many patients also feel that they do not want to join a gym due to embarrassment or cost. Consequently, it is important to discuss the idea of being active compared to “doing exercise.” One of the first steps in this effort is to recommend the use of a pedometer and to advise that the patients aim for 10,000 steps a day. Shape Up America, a nonprofit organization dedicated “to raising awareness of obesity as a health issue and to providing responsible information on healthy weight management,” found that many people walk only about 900 to 3,000 steps a day,12 so encouraging this higher level of activity will have a positive effect on the overall health of the patient.

Most patients have no idea how many calories they burn when they are physically active. The Office of Disease Prevention and Health Promotion, US Department of Health and Human Services, encourages all adult Americans to perform a moderate level of physical activity for 30 minutes five times per week to have the most positive impact on health.13 The problem with this recommendation is patients have no idea what those minutes mean in relation to calorie burning. It is critical for a health-care provider to translate that activity into calorie expenditure so patients can have a clearer understanding of its effect on weight loss. There are several websites that provide calculators to convert exercise time and activity to the number of calories burned.17, 18, 19 There are even free applications available for users of iPods and other personal digital assistant devices.

As patients become more aware of their activity level, it then becomes easier to encourage higher levels of activity every few weeks. The ultimate goal is to encourage burning 2,000 calories each week. Achieving this level of activity requires that patients be active 5 or more days a week, which can be one of the more challenging aspects of a weight-loss program for the patient due to busy work and family schedule. Consequently, it is important to become a partner with the patient so that barriers can be identified.

One of the best ways found to monitor calorie intake and expenditure is through the use of a food and activity journal. Providers can create their own journal or purchase some of the commercially available journals. This author has found that a journal that covers a 10-week period and that is small enough to fit in a purse or briefcase usually will be used. It is key though, that the journal be reviewed and discussed at the weekly visits.

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Weight Maintenance 

Little has been written about weight maintenance, but it has been found that many people regain their weight loss within 1 year, so the goal after weight loss is achieved is to focus on strategies that will maintain that loss for greater than 12 to 18 months. A vital component of the weight management program is the establishment of long-term follow-up.

A study by Dale et al.14 found that a program run by nurses can be as effective as any program that requires other experts or specialists. Through frequent follow-up via phone or in person with the nurse giving encouragement during these visits does provide an environment where patients maintain their weight loss.

Befort et al.15 noted that some of the best strategies for weight maintenance included “eating five or more fruits and vegetables per day, using low-calorie prepackaged meals, practicing portion control, counting fat grams/choosing low-fat foods, exercising 30–60 min per day, keeping records for exercise and planning for exercise.” Those authors also emphasize the importance of maintaining a food and activity journal long after weight loss is obtained.

Sarlio-Lahteenkorva16 best describes the issues surrounding weight maintenance in the following comment, “Permanent weight maintenance requires permanent behavioral changes. Weight loss maintenance requires a constant battle against weight regain and adequate rewards such as improvements in the quality of life to compensate for sacrifices required by sustained weight maintenance. Unfortunately, adequate rewards may be seldom experienced after weight loss, which makes regain understandable.” Consequently, it is vital that any weight program include a weight maintenance plan in its strategies.

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Conclusion 

The obesity problem will continue to be a challenge in the future. Health-care providers, and particularly nurse practitioners, have the experience and knowledge to effect long-term change but must develop realistic programs and strategies that will provide compassionate and nonjudgmental care to these often ostracized people.

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References 

  1. Galuska DA , Gillespie C , Kuester SA , Mokdad AH , Philip CM . State-specific prevalence of obesity among adults: United States, 2007 . MMWR Morb Mortal Weekly Rep . 2008;57(28):765–768
  2. Pan L , Galuska DA , Sherry B , Hunter AS , Rutledge GE , Dietz WH . Differences in prevalence of obesity among black, white, and Hispanic adults: United States, 2006–2008 . MMWR Morb Mortal Weekly Rep . 2009;58(27):740–744
  3. Finkelstein EA , Fiebelkorn IC , Wang G . National medical spending attributable to overweight and obesity: how much, and who's paying? . Health Aff . 2003;W3:220–225
  4. Loureiro ML . Obesity: economic dimensions of a “super size” problem . Choices . 2004;35–39
  5. Runge CF . Economic consequences of the obese . Diabetes . 2007;56:2668–2672
  6. Woolston C . What's wrong with the American diet? Consumer Health Interactive . Available online: http://www.ahealthyme.com/topic/usdiet Accessed September 26, 2009.
  7. Blanck HM . Fruit and vegetable consumption among adults: United States, 2005 . MMWR Morb Mortal Weekly Rep . 2007;56(10):213–217
  8. Kuczynski K , Cleveland L , Goldman J , Moshfegh A . Breakfast in America, 2001-2002 . Available online: http://www.ars.usda.gov/research/publications/publications.htm?SEQ_NO_115=202225 Accessed November 11, 2009.
  9. Lin BH . Diet quality and food consumption: food away from home. Economic Research Service/US Department of Agriculture . Available online: http://www.ers.usda.gov/Briefing/DietQuality/FAFH.htm Accessed September 26, 2009.
  10. Mancino L , Lin BH , Ballenger N . The role of economics in eating choices and weight outcomes. Economic Research Service/US Department of Agriculture . Available online: http://www.ers.usda.gov/publications/AIB791/ Accessed November 11, 2009.
  11. Block G . Foods contributing to energy intake in the us: data from NHANES III and NHANES 1999–2000 . J Agric Food Chem . 2004;17:439–447
  12. Shape Up America. 10,000 Steps . Available at: http://www.shapeup.org/shape/steps.php Accessed November 11, 2009.
  13. Office of Disease Prevention and Health Promotion  , United States Department of Health and Human Services  . At-A-Glance: a fact sheet for professionals. Physical activity guidelines for americans . Available online: http://www.health.gov/paguidelines/factsheetprof.aspx Accessed November 11, 2009.
  14. Dale KS, McAuley KA, Taylor RW, Williams SM, Farmer VL, Hansen P, et al. Determining optimal approaches for weight maintenance: a randomized controlled trial . CMAJ . 2009;180(10):E39–E46
  15. Befort CA , Stewart EE , Smith BK , Gibson CA , Sullivan DK , Donnelly JE . Weight maintenance, behaviors and barriers among previous participants of a university-based weight control program . Int J Obes . 2009;32:519–526
  16. Sarlio-Lahteenkorva S . Determinants of long-term weight maintenance . Acta Paediatrica . 2007;96:26–28
  17. Calories burned, BMI, BMR, and RMR calculatori . Available at: http://www.caloriesperhour.com/index_burn.php Accessed September 26, 2009.
  18. Calories burned estimator . Available at: http://www.healthstatus.com/calculate/cbc Accessed November 11, 2009.
  19. Calorie Control Council  . Lighten Up and Get Moving . Available at: http://www.caloriecontrol.org/healthy-weight-tool-kit/lighten-up-and-get-moving Accessed November 11, 2009.

 In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.

PII: S1555-4155(10)00035-8

doi:10.1016/j.nurpra.2010.01.014

The Journal for Nurse Practitioners
Volume 6, Issue 7 , Pages 540-545, July 2010

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