Obesity has reached global epidemic proportions, and has become a major health problem of out society. According to Peeters et al. (2007), 32% or 60 million people are now obese in the United States. The condition develops as a result of the interaction between genetics, lifestyle behavior, and cultural and environmental influences. Fat accumulates when more energy is consumed than expended. The National Heart, Lung, and Blood Institute (NHLBI) has adopted a classification system of body mass index (BMI). BMI, the indirect measure of body fat, identifies the overweight and obese individuals. A BMI of 25-29 kg/m2 is considered overweight, 30-34 kg/m2 is mild obesity, 35-39 kg/m2 is moderate obesity, and above 40 kg/m2 is extreme obesity (Palamara, Mogul, Peterson, Frishman, 2006).
Obesity develops due to high-fat, high carbohydrate diet coupled with a decline in physical activity. Modern living conditions, eating habits, and quality of food lead to over-consumption of cheap, super sized portions. More cars, roads, and fast food restaurants at every corner, as well as quick, ready to eat microwavable dinners loaded with fat, salt, and simple carbohydrates are easier and often less expensive than nutritious, quality food products. Furthermore, the technology has made humans rely on mechanical devices. The automated inventions designed to make life easier, perform thousands of tasks that in the past required physical labor. As a result of sedentary life and over-consumption, the excessive fat accumulates in the body, and may have significant health consequences.
Multiple research studies have revealed that excessive weight gain increases the risk of diabetes, hypertension, dyslipidemia, coronary heart disease, stroke, osteoarthritis, and many forms of cancer. In particular, abdominal obesity has been recognized as strongly associated with the development of diabetes and cardiovascular diseases (Behn & Ur, 2006) (Chen et al., 2007) (Balkau et al., 2007) (Despres, 2007). Due to the dangerous health risks of obesity, it is considered a disease that requires treatment (Palamara et al., 2006). The Centers for Disease Control and Prevention (n.d.) estimated that medical expenses related to obesity cost $92.6 billion in the year 2002, and the condition causes 300,000 deaths per year.
Nevertheless, prevention of the multiple health consequences of obesity is possible by weight reduction. Bardia, Holtan, Slezak and Thompson (2007) suggested that: “Even a small decrease in a patient’s weight would result in better control of multiple diseases, enhance quality of life, greatly improve a patient’s morbidity, and result in lower health care use and medical costs”. In addition to preventing many diseases, weight reduction can improve the already present disorders. Research indicates that weight loss of 4% to 8% is associated with a decrease of systolic and diastolic blood pressure by 3 mmHg (Mulrow et al., 1998). The main weight reducing interventions include: diet, exercise, psychological, behavioral, pharmacotherapy, surgery, and alternative therapies (Vlassov, 2001).
However, the long term effectiveness of these interventions has not proven effective, as majority of people regain their weight after losing it (Biaggioni, 2008). Guidelines for weight reduction suggested by NHLBI involve the following: initial reduction of 10% of body weight, low calorie diet (800-1500 kcal/d); 30% calories from fat, 15% calories from protein, and 55% calories from carbohydrates, daily deficit of 500-1000 kcal to lose one to two pounds per week during six months, long term weight maintenance, and physical activity for 30 to 45 minutes three to five days a week (Palamara et al., 2006). Health care providers are faced with the prevention and management of a major cause of morbidity and mortality for which effective life long interventions are desperately needed.
Bob is a 38 year old white male. Except for hypertension, he considers himself healthy. He has seen his family doctor three months ago for regular blood pressure check up, as he does every six months. Bob is married, has four adolescent children, and works as an automobile dealer for fourteen years.
Past medical history: hypertension, obesity, hyperlipidemia
Allergies: none to medications, latex, animals, foods, or environmental
Hospitalizations / surgeries / injuries: tonsillectomy in childhood
Medications: lisinopril 20mg orally daily
Family medical history: mother and brother with hypertension
Social history: lives with wife and children, all very supportive of each other, get along well,
drinks 2 glasses of whiskey socially on weekends, denies smoking or illicit substance use
Physical activities: walks on treadmill for twenty minutes once or twice a week, occasionally plays volleyball with family on weekends
Daily intake patterns: breakfast – four sandwiches with cheese and ham; lunch – home made soup, cooked or fried sausage; dinner – salad, lots of potatoes, 2 portions of steak or meatloaf or chicken, pickled vegetables; supper – pasta with sauce or pizza; snacks – chips, cookies, candy, pretzels and fruits, all throughout the day; fluids – 8 glasses of soda, juice, water or milk.
Review of systems: unremarkable, no complaints.
Weight: 280 pounds, Height: 6’3″, Waist circumference: 52″, BMI: 35kg/m², BP: 150/90 mmHg
Most recent abnormal laboratory tests: total cholesterol – 220, triglycerides – 310
All other results including glucose, blood count, BUN, creatinine, and liver enzymes were within normal range.
Bob admitted that weight loss has been one of the greatest challenges for him. His several previous attempts at weight reduction have been unsuccessful. He expressed willingness and readiness to try again, but was concerned that he would not be able to follow the plan long term. Bob’s family was very supportive, and willing to help with his weight loss attempts. To identify the health risks of obesity, and to determine interventions to reduce those risks, research articles were examined. The search for relevant studies was conducted using OVID MEDLINE, PUB MED, CINAHL, and COCHRANE databases.
SUMMARY OF LITERATURE
Dietary interventions form the fundamental element of the management of obesity. There is a wide variety of possible diets, but no consensus on which is the most effective for weight reduction. A review by Noakes and Clifton (2004) compared the effects of a low carbohydrate diet and a low fat diet. Overall, the studies revealed that a very low carbohydrate diet resulted in significantly more weight loss than low fat diet in the short to medium term. On the other hand, a moderately low carbohydrate diet resulted in similar weight loss as a low fat diet. Moreover, the very low and moderately low carbohydrate diets have been found to more effectively reduce triglyceride, and increase high density lipoprotein (HDL) levels compared to low fat diet.
Again, comparison between the low carbohydrate and low fat diets was performed by Lecheminant et al. (2007). In a quazi-experimental design, 102 participants were assigned either to a low carbohydrate (LC) or a low fat (LF) group. Both groups followed a very low energy diet and lost significant body weight (LC 20.4 kg, LF 19.1 kg) and waist circumference. The differences between the two groups were not statistically significant. In addition to the diet, all participants were involved in brisk walking 300 minutes per week, and all were issued pedometers to monitor their progress. Also, both groups were equally effective at preventing weight re-gain over six months, and both groups were found to have a decreased blood pressure as a result of weight loss.
Similarly, a systematic review by Pirozzo, Summerbell, Cameron and Glasziou (2002) compared the effects of a low fat diet to low calorie diet and low carbohydrate diet. Six randomized controlled trials with a total of 594 participants were analyzed over a period of six to eighteen months. Overall results demonstrated non-significant differences in weight loss, weight maintenance, serum lipids, and blood pressure between all the diets reviewed.
Moreover, a one year randomized trial by Dansinger, Gleason and Griffith (2005) compared Atkins, Zone, Weight Watchers, and Ornish diets. A single center randomized trial assigned 160 participants among the four diet groups. After one year, all diet groups were found to have significantly reduced weight and waist size, without significant differences between groups. Similarly to previous studies, low carbohydrate diets reduced triglycerides and diastolic blood pressure, all except Ornish diet group increased high density lipoprotein (HDL), and all except Atkins diet group reduced low density lipoprotein (LDL).
In addition to energy restriction through the diet, energy expenditure may enhance weight loss. In a meta-analysis by Shaw, Gennat, O’Rourke and Del Mar (2006), 41 randomized controlled clinical trials were analyzed to determine the effects of exercise in overweight and obese adults. The multiple exercise interventions included walking, jogging, cycle ergometry, weight training, aerobics, treadmill, stair stepping, dancing, ball games, calisthenics, rowing, and aqua jogging. The 3476 participants exercised three to five days a week for a median duration of forty five minutes a day. Several of the studies compared exercise to diet either alone or in combination with exercise. The results revealed that exercise alone led to marginal weight loss, but when combined with diet produced significant weight reduction.
Moreover, comparing the intensities of the various types of exercise activities, it was found that both high and low intensity exercises were associated with weight loss. Nonetheless, high intensity induced only slightly more weight reduction than low intensity, but when the diet component was added, the difference between high and low intensity was not significant. Additionally, the findings revealed that systolic blood pressure reduction was favored by diet over exercise, and diastolic blood pressure was reduced equally likely by exercise as by diet. Furthermore, exercise did not reduce cholesterol levels, but was found to reduce triglycerides equally well as diet. Patients involved in the exercise trials improved diastolic blood pressure, triglyceride, high density lipoprotein, and glucose levels regardless of whether they lost weight.
One of the most difficult aspects of weight loss plans is consistent adherence to exercise. A meta-analysis by Richardson et al. looked at the effects of walking on weight reduction (2008). 307 participants in nine interventional studies were provided with pedometers to monitor step count. Pedometers served as motivational tools to self monitor and reach the goals of walking. The participants logged the daily recorded steps, and reviewed their results during group meetings. On average about 0.05 kg was lost per week after walking two thousand to four thousand steps per day. Although the amount of weight lost in the trials was small, adherence to walking programs and increasing step count according to preset goals is important for the beneficial effects on health. The physical activity reduced the risk of cardiovascular events, lowered blood pressure, and helped maintain lean muscle mass of the participants. The studies have shown that the use of pedometer is helpful in monitoring the progress of physical activity, and is a good way to motivate continued increase in walking.
Another meta-analysis compared different psychological interventions and their effects on weight reduction (Shaw, O’Rourke, Del Mar, Kenardy, 2005). 36 randomized controlled clinical trials including 3495 participants were evaluated. The majority of studies assessed the effects of behavioral interventions on weight loss. The duration of clinical contact with the participants ranged from 7 to 78 weeks, with sessions lasting 60 minutes weekly. The techniques included stimulus control, goal setting, and self-monitoring. The therapies enhanced dietary restraints by providing adaptive dietary strategies, and by increasing motivation for physical activities, and to maintain adherence to the healthier lifestyle.
Behavioral therapy was successful at decreasing weight as a stand-alone strategy (2.5 kg), and even greater weight reduction was attained when combined with diet and exercise (4.9 kg). Several evaluated studies also assessed cognitive therapy, psychotherapy, relaxation therapy, and hypnotherapy, but the results of these either did not reveal significant weight reduction, or resulted in weight gain. Moreover, a number of studies found that weight loss was associated with reductions in systolic and diastolic blood pressure, serum cholesterol, triglycerides, and fasting plasma glucose. These findings once again confirm the important health benefits of reducing weight.
Overall, the research suggests that most diets are equally effective at weight reduction. There are multiple more or less popular diets known, and according to Dansinger et al. (2005), more than one thousand diet books are now accessible. Instead of searching for the best available, obese patients should be advised that any diet would be more effective than the one they are currently consuming. Moreover, diet modification has been shown to be more effective than exercise, but both are beneficial in reducing cardiovascular risk factors. Exercise does not have to be intense, and walking on most days of the week is sufficient for risk reduction when continued long term. Finally, addition of behavioral interventions may strengthen motivation and self monitoring, and enhance weight loss maintenance.
INTERVENTIONS AND RESULTS
Bob was presented with the literature findings on health risks and health promotion, and was encouraged to lose weight by diet, and involvement in more physical activities. He was introduced with the possible options, and it was recommended that he participates in designing his weight loss plan. This way Bob could have more control over the interventions, and was able to incorporate his preferences. Bob identified his perceived benefits of losing weight as: improved body image, mood, physical fitness and agility, reduced blood pressure, and reduced risk of comorbidities. The main barriers were mainly the resistance to eliminate favorite foods, and occasional laziness to perform physical activities.
Instead of starting one of the multiple popular diets, Bob decided to reduce his portion sizes initially by 30%, substitute supper and snacks by fruits and vegetables, and eliminate soda and juice. To assure smaller portion sizes, Bob was encouraged to use a smaller plate than usual. He also agreed to drink at least two liters of water a day, especially with meals, to reach satiety sooner. He was encouraged to keep a journal of all his daily intakes of food and drink to monitor his diet, and to identify some hidden sources of excess consumption. Moreover, to avoid excess eating, Bob was instructed to only eat at the table, and to not allow family members to eat any food while sitting on the couch or in front of the computer.
He also decided to become more physically active, and his choice of daily exercise was walking. Bob was encouraged to purchase a pedometer to monitor progress in physical activity, aiming for at least two thousand steps a day. Richardson et al. (2008) informed that a two thousand step walk was estimated to equal one mile. Bob was also encouraged to set weekly walking goals, slowly increasing his step count. Bob’s family was also involved in his attempt to lose weight. To help him attain his goals, family members planned to show support for Bob’s exercise by joining him. Furthermore, Bob was encouraged to identify situations of daily living providing opportunities for more physical activities, for example parking further away from the entrance at work and grocery store.
Weekly meetings evaluated Bob’s progress, and discussed about difficulties of following the plan. Bob remained strongly motivated throughout the eight weeks of intervention, and successfully reached most of his weekly dietary and exercise goals. Portions of his meals decreased steadily until no more than 50% of initial food intake was reached, and the snacks included fruits and vegetables only. Daily step count reached up to six thousand steps on some days, and daily walks through the park with his wife became an enjoyable routine. To everyone’s surprise, during the third week Bob decided to accompany his sons to the health club twice a week, where he swam in the pool for one hour.
He expressed feeling energized after any physical activity. Several small relapses were recorded when Bob missed a couple days of walking, and could not resist eating high calorie or high fat foods. At the end of eight weeks of interventions, Bob has lost nine pounds, reduced his BMI to 33.9 kg/m², and his waist circumference decreased by 1.25 inches. Also, his systolic and diastolic blood pressure was slightly reduced. Unfortunately, the effect on the blood lipid level has not been tested. In conclusion, during only eight weeks Bob turned from moderately obese to mildly obese, and remained motivated to continue the weight loss plan.
Research has revealed that any diet, as long as caloric intake is restricted, will result in weight loss. It has been calculated that to lose one pound a week, one has to restrict food intake by 500 kcal per day. Patients often get discouraged by the slow effects of weight loss. On the other hand, studies point that “more restrictive diets have lower compliance rates and increased weight regain” (Palamara et al., 2006). Unfortunately, losing the weight is not the biggest challenge. What people mostly fail at is maintaining the reduced weight. Effective weight maintenance requires not only decreasing energy intake and increasing energy expenditure, but also modification of behaviors that predispose to weight gain.
Bob monitored his daily dietary intake, and avoided situations leading to overeating. Also, the pedometer monitored the amount of walking, and served as a motivational tool. Moreover, intrinsic motivation for physical activities, as described by Teixeira et al. (2006), is the satisfaction from participating in an activity, while extrinsic motivation describes the desire of slimmer appearance, and weight management. The authors presented that the extrinsic motives correlated with short term weight loss, whereas intrinsic motives predicted long term results. Bob expressed enjoyment of daily walks through the park, which correlates with intrinsic motivation, and therefore he is likely to continue over longer period of time. It is important that diet or exercise is maintained for the pleasure and positive feelings brought on by the activity.
IMPLICATIONS OF FINDINGS FOR CLINICAL PRACTICE
The continuing rise in obesity and related risk factors, and failure of maintaining long term weight loss result in increasing prevalence of comorbidities. Health care costs related to treating ailments resulting from obesity will continue to rise, unless health care providers utilize more effective measures to deal with the problem. Promoting healthy nutrition and lifestyle early in life may prevent the development of obesity. It is a great challenge for nurse practitioners to help patients maintain their weight. Although the recommended compositions of various diets include specific amounts of fats, carbohydrates, and protein, the research revealed that it is the total caloric content that is responsible for weight loss, regardless of nutrient partitioning. Once the patient is ready and willing to commit, the treatment strategy should be devised together. Since the variety of diet options have been shown to have similar effects, the nurse practitioner can help match the nutritional plan with patient’s dietary preferences.
Although diet was found to be more effective in weight reduction than exercise, patients with cardiovascular risk factors should be educated about the benefits of physical activities. It is important to encourage continuous participation in exercise, even when no reduction of weight is observed. Lifestyle changes can be difficult to sustain for the patient, hence continuous support and motivation by a nurse practitioner are necessary. The interventions require dedication of both, the patient and the nurse practitioner. Also, counseling patient’s family, and encouraging to get involved in loved one’s struggle through weight loss and weight maintenance may provide additional support, and contribute to lasting behavior changes. Behavioral strategies such as encouraging setting appropriate goals, self monitoring and evaluation may increase the chance of success. Patient’s satisfaction with the choice of diet and physical activity, and successful long term adherence are the best predictors of lifelong weight maintenance.
The comorbidities associated with obesity substantially lower the individual’s quality of life, and are also becoming an enormous burden on health care. Successful treatment and prevention of obesity can reduce the occurrence of its complications. Dieting is resented by most individuals, therefore it is necessary to assist patients to find appropriate and motivating interventions that can be successfully followed life long. Patient’s willingness to commit to a long term adherence is essential to permanent lifestyle changes. It is a long and difficult journey from deciding to lose weight to the successful long term results, but even small losses of weight can produce important health benefits.
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