Tag Archives: obesity

Assessment and management of patients with obesity

Obesity is a disease, not a condition resulting from ill-advised behavioral choices. 1 After all, obesity meets the essential criteria of a disease: It has characteristic signs or symptoms; it manifests as an impairment in the normal functioning of some aspect of the body; and it results in harm or morbidity. As such, healthcare providers (HCPs) need to identify obesity in their patients, assess each patient’s risk for obesity-related complications, begin the weight-loss discussion in a thoughtful and constructive manner, and institute an individualized management plan.

Definitions and prevalence

Obesity can be defined as a body mass index (BMI) ?30 kg/m2 or it can be suggested by a waist circumference (WC) >35 inches (in women).2 But obesity is more than just a calculation or a measurement; it is a primary disease entity that can lead to cardiometabolic, biomechanical, and other complications (Figure 1).3,4CNER_Figure 1

 

 

 

 

 

 

 

 

 

 

 

 

Here is a number that matters: Almost 80 million U.S. adults—almost 35% of the adult population in this country—meet criteria for obesity,5 with certain geographic areas and certain ethnic groups overrepresented. Prevalence of obesity is higher in southern states and some Midwestern states than in other parts of the country,6 as illustrated by this CDC map. Non-Hispanic blacks have the highest age-adjusted rate of obesity (47.8%), followed by Hispanics (42.5%), non-Hispanic whites (32.6%), and non-Hispanic Asians (10.8%).5 Although overall obesity prevalence is similar in women and men at any given age, women have a higher prevalence of class II obesity (BMI, 35.0-39.9) and class III obesity (BMI ?40).7

Risk assessment

Given the high prevalence of obesity, HCPs will likely encounter many patients in their practices who are candidates for weight management. In each case in which obesity is identified, the first step needed is to assess the patient’s risk for obesity-related complications. This assessment includes calculating BMI, measuring WC, and screening for the presence of cardiovascular disease (CVD) risk factors and co-morbidities.8 Compared with body weight alone, BMI is a better, albeit indirect, measure of adiposity, which is associated with a host of cardiometabolic abnormalities. WC, an indicator of abdominal adiposity, should be measured in patients with a BMI ?35 (the WC cutoff of >35 inches in women adds little predictive value in those with a BMI >35), including those who are overweight (BMI, 25-29.9). Women whose WC exceeds 35 inches are at increased risk for developing hypertension (HTN), type 2 diabetes mellitus (T2DM), and CVD.

Therefore, HCPs need to check patients’ blood pressure (BP) to assess for HTN and order a fasting blood glucose (FBG) test, and even a 2-hour oral glucose tolerance test and HbA1c in high-risk individuals, to assess for T2DM and pre-diabetes.9 The metabolic syndrome, which increases risk for T2DM, CVD, and stroke, is identified in women by the presence of at least three of these five risk factors: WC >35 inches, triglycerides ?150 mg/dL, high-density lipo­protein cholesterol (HDL-C) <50 mg/dL, BP ?130/85 mm Hg, and FBG ?100 mg/dL.10

Some obesity-associated diseases and risk factors place patients in a very-high-risk category for subsequent mortality.8 Patients with obesity and co-morbid coronary heart disease (CHD), other atherosclerotic diseases, T2DM, metabolic syndrome, pre-diabetes, or sleep apnea require aggressive modification of risk factors in addition to clinical management of the co-morbid disease. Furthermore, obesity has an aggravating effect on CVD risk factors such as cigarette smoking, HTN, high concentration of low-density lipoprotein cholesterol, low concentration of HDL-C, impaired FBG, family history of premature CHD, and age ?55 years (in women). HCPs need to identify these risk factors to determine the intensity of the clinical intervention that a patient requires.
Obesity takes a toll not just in terms of its effect on CVD risk, but also on cancer risk. The Cancer Research UK study showed that women with obesity had a 25% risk of developing a weight-related cancer—including cancer
of the bowel, gallbladder, uterus, kidney, pancreas, or esophagus, as well as post-menopausal breast cancer—in their lifetime.11 Cancer risk in these women was 40% higher than that in their slimmer counterparts.

Initiating the conversation

Either a patient or an HCP can initiate the conversation regarding the need to lose weight. The situation is generally easier to handle when a patient expresses a desire to lose weight. She has already acknowledged existence of the disease—that is, the obesity—and is seeking treatment for it on her own. However, in many cases, the HCP must broach the topic, usually after a patient has come in for a routine visit and the findings from her history, physical examination, and laboratory tests indicate that steps must be taken to lower her risk for experiencing obesity-related complications—or to treat the complications that already exist.

To avoid discomfiting a patient in this situation, a panel of nurse practitioners convened by the American Nurse Practitioner Foundation (ANPF) recommends that the HCP show her objective data reflecting her disease and her risk for future complications—with an emphasis that obesity is a health problem—and then assess her motivation and readiness for change.7 In this context, the HCP and the patient need to synchronize their expectations and goals for weight loss therapy. HCPs now have reliable tools to help patients lose 5%-10% of their body weight. This weight loss may not produce the desired cosmetic outcome but will no doubt result in clinical benefits. The emphasis is on improving the health of the patient.

To inspire a patient with obesity to want to lose weight and to commit to follow a weight-loss treatment plan, the HCP can help her identify at least one compelling reason to lose weight.7 Common patient-centered reasons include (1) decreasing the risk of having a complicated pregnancy; (2) being able to play with children or grandchildren; (3) walking without becoming short of breath; (4) preventing other chronic diseases such as T2DM; and (5) improving existing weight-related complications such as sleep apnea or T2DM. Of note, some patients may not be aware of the health risks posed by obesity and will be motivated to lose weight once educated about the risks.

Approach to management

Once a patient with obesity is motivated and ready to lose weight, the HCP needs to work with her to devise a management plan. Both of them should agree on the goals of weight-loss therapy and on the purpose of long-term therapy. A realistic initial goal for many patients is a loss of 5% of body weight in 3 months. Three major management options—lifestyle modification, pharmacotherapy, and bariatric surgery—can bring about weight loss and reduce obesity-related morbidity and mortality.1 This article focuses on the first two options.

Lifestyle modification

A comprehensive weight-loss program starts with lifestyle modification comprised of dietary changes, increased activity, and behavioral control.12

Dietary changes

With regard to energy intake, the ANPF recommends a reduction of 500-1,000 kcal/day, which can be accomplished by limiting portion size, reducing fat and sugar intake, and using commercial weight-loss meal replacements.7 The patient can follow one of many diets shown to be safe and effective; examples are a low-carbohydrate diet,13 a low-fat diet,14 a Mediterranean diet,15 a low-glycemic-load diet,16 and a portion-controlled diet.17

Practical dietary tips include avoiding skipping meals and consuming small meals and between-meal snacks every 3-4 hours. With regard to food intake, moderation is the watchword. With regard to fluid intake, however, drinking eight 8-oz glasses of water a day is crucial unless contraindicated (e.g., in patients with renal failure).

Choice of a particular diet is less important than making a commitment and adhering to the diet,18 although following a regimen tailored for a co-morbidity makes sense. Because compliance is the key to success, the diet plan should accommodate the patient’s personal and cultural preferences. Regardless of the diet chosen, patients should monitor their caloric intake via a food diary and weigh themselves at least once a week.19

Increased activity

Choice of a particular activity (e.g., walking, swimming) depends on a patient’s preference and access to, say, a pool, as well as her current weight and health status. An assessment of mobility, cardiovascular (CV) status, and perhaps pulmonary function is needed before a patient embarks on a new exercise program.20 The goal is to increase energy expenditure.20 Exercising for ?150 minutes/week can lead to modest weight loss and help prevent weight regain; doubling this amount will promote more robust weight loss.21 As with food intake, patients should record their daily physical activity.

Exercise not only facilitates weight loss but also improves CV health by reducing BP, lipid levels, and visceral fat. These reductions are linked to improved glucose tolerance and insulin sensitivity in persons without diabetes and improved glycemic control in patients with T2DM.12 Enhanced physical fitness may even lessen obesity-related mortality. Of note, patients with obesity must modify their diet and increase physical activity in order to lose weight and reduce their risk for obesity-related complications. Another note: In addition to traditional exercise, patients can aim to increase energy expenditure throughout the day by reducing sedentary behaviors. For example, car owners can park twice as far from store entrances as they used to; city dwellers can walk instead of taking a bus, subway, or taxi; and office workers can use a standing desk instead of sitting at their desk.

Behavioral therapy

As applied to weight loss, behavioral therapy entails techniques for helping patients replace habits that contribute to excess weight and poor health with those that promote weight loss and good health.12 Key components of behavioral therapy include frequent encounters with HCPs, education, stimulus control, cognitive restructuring, goal-setting, self-monitoring, and social support.20 Group weight-loss programs in community settings, commercial weight-loss programs, and programs delivered by telephone, the Internet, or text message can all be effective, depending on patient preference.12

Pharmacotherapy

If a patient has not lost about 5% of her body weight after 3 months, or if she has lost weight but regained some, most, or all of it over time, she and her HCP should consider use of weight-loss medication as an adjunct to lifestyle modification. In some patients with severe complications who require clinically meaningful weight loss quickly, lifestyle modification and pharmacotherapy can be initiated concomitantly.

Rationale

In all human beings, calorie restriction triggers various biological adaptations designed to prevent starvation.22 These adaptations may even be potent enough to reverse the initial weight-loss success achieved with lifestyle modification. In persons with obesity, additional biological adaptations function to preserve, or even increase, their highest sustained lifetime body weight. As such, more biologically-based interventions are likely to be needed to counter the compensatory adaptations that maintain a person’s highest lifetime body weight.22 Other reasons for pharmacologic intervention in facilitating weight loss include the following:

  • Appetite-suppressing medication enhances a patient’s ability to adhere to a reduced-calorie diet.
  • Addition of a weight-loss medication consistently achieves greater weight loss, and for a longer duration of time, than that achieved by the lifestyle intervention alone.
  • Medication can help achieve the degree of weight loss needed to treat obesity-related complications.
  • The American Association of Clinical Endocrinologists (AACE), the American Society of Bariatric Physicians (ASBP), the American Heart Association (AHA), the American College of Cardiology (ACC), and The Obesity Society (TOS) all recommend use of medication for patients with obesity and sufficient health risk.20,23,24

Principles for use

The FDA indication for use of weight-loss medications is a BMI ?30 or a BMI of 27-29.9 with at least one obesity-related complication. The medication should be stopped if weight loss is <5% after 12 weeks on a maximal dosage. If one agent is ineffective or poorly tolerated, a different one can be tried. All of these agents are contraindicated for use during pregnancy. Pharmacotherapy is individually tailored to each patient’s needs. More data are needed regarding the safety of combination therapy and the use of medications beyond 2 years.

Options

Table 1 lists FDA-approved options for treating obesity.25-31Table 2. Weight-loss medications: Clinical trial information, accessible through this link, shows the results of clinical trials demonstrating the efficacy of these agents.32-39Figure 2 illustrates the comparative efficacy of these weight-loss medications.32-36,38-45
CNe_Table 1

 

CNE Figure 2

Guidelines for practice

The spectrum of obesity treatment guidelines ranges from those that are BMI-centric, wherein treatment indication is based on BMI and the treatment goal is to lose a given amount of weight (e.g., 5%-10%), to those that are complications-centric, wherein treatment indication is based on risk for, presence of, and severity of obesity-related complications and the treatment goal is to treat or prevent the complications.46Obesity treatment guide­lines from the National Heart, Lung, and Blood Institute (NHLBI), at one end of the spectrum, are based primarily on BMI and WC, although risk factors and co-morbidities are taken into account.8 The AACE, at the other end of the spectrum, recommends (1) evaluating patients with obesity for cardiometabolic and biomechanical complications; (2) selecting (a) therapeutic targets for improvements in complications, (b) treatment modality, and (c) treatment intensity; and (3) intensifying lifestyle and/or pharmacologic and/or surgical treatment modalities for greater weight loss if therapeutic targets for improvements in complications are not met.23Table 3 lists percentages of weight loss needed to achieve therapeutic benefits with regard to various obesity-related complications.4CNE_Table3

 

The AHA/ACC/TOS obesity guideline, which is closer to that of the NHLBI, recommends (1) identifying patients who need to lose weight, based on BMI and WC; (2) informing patients with CVD risk factors that lifestyle changes that produce even modest sustained weight loss of 3%-5% can result in clinically meaningful health benefits, and that greater weight loss produces greater benefits; (3) devising dietary strategies for weight loss; (4) devising a comprehensive lifestyle program that helps patients adhere to a lower-calorie diet and increase physical activity through use of behavioral strategies; and (5) selecting patients for whom bariatric surgery is advised—that is, those with a BMI ?40 or a BMI ?35 with obesity-related conditions.24 The approach of the ASBP to obesity management, which is closer to that of the AACE, focuses on treating diseases related to increased body fat and its adverse metabolic and biomechanical consequences, which may improve patient health, quality of life, body weight, and body composition.20

Conclusion

Obesity is a disease that requires permanent lifestyle changes. Lifestyle modification, enabled by dietary changes, increased physical activity, and behavioral therapy, is implemented first. If a patient does not reach her goals in terms of reducing her weight and her risk for obesity-related complications, medication is added. Most medications suppress appetite, enhance a patient’s ability to follow a reduced-calorie diet, and enable significantly greater weight loss than that achieved by lifestyle changes alone. In addition, medication use can help sustain weight loss and prevent weight regain over time.

For patients with obesity and obesity-related co-morbidities, weight loss is used therapeutically to treat the obesity-related complications. The role of the HCP is to diagnose the disease of obesity, assess the patient’s risk for obesity-related complications, discuss weight-loss strategies and goals with the patient, support the patient in implementing these strategies and reaching these goals, and provide regular follow-up and encouragement over the ensuing months, years, and decades.

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Visit http://www.NPWomensHealthcare.com/?p=4144 for a complete list of references.

 

Promoting self-esteem in overweight and obese girls

Childhood obesity has reached epidemic rates in the United States, affecting all socioeconomic classes. At the same time, girls in this country are being bombarded with media images of the ideal female body, which is likely more slender and more muscular than their own. Preadolescence and adolescence are tumultuous periods of development for any girl, but they present a particular challenge for girls who are overweight or obese (OW/O) and who are at risk for experiencing a loss of self-esteem because their own shape and size do not match those of the media portrayed ideal. Providers of healthcare to girls in these age groups are in a position to identify those girls at high risk and guide them and their parents to available interventions and resources to help enhance their self-worth and possibly control their weight or lose weight in the process.

The American Academy of Pediatrics defines obesity as an excess percentage of body weight due to fat that puts persons at risk for many health problems.1 Among children aged 2-19 years, 31.7% are at or above the 85th percentile of body mass index (BMI)-for-age growth charts in weight, defining them as overweight or obese.2Nearly 17% of children in this age range are defined as obese—that is, they have BMIs greater than the 95th percentile. Among children and adolescents in the United States, OW/O prevalence is most concentratedin African American(AA) females, Hispanic males, and Native Americans.1-8

Statement of the problem

A direct link between OW/O and the development of health problems later in life, including cardiovascular, endocrine, pulmonary, renal, and orthopedic disorders, has been well established.1-8 In addition, OW/O can have adverse effects on children’s current physical and emotional health. In pre-adolescent and adolescent girls, for example, OW/O is strongly correlated with low self-esteem, which can lead to depression, anxiety, disordered eating, substance abuse, social isolation, and even suicidal ideation.4,9-11 Jasik and Lustig4 identified the ages of 9-12 years in girls as being key for development of excess adiposity. During this age period, many girls tend to be less active than when they were younger, and they tend to eat less healthy foods, causing the to gain weight. Higher levels of adiposity translate to higher systemic levels of estrogen and to an earlier onset of thelarche. A vicious cycle is set in motion:  Early breast development leads some girls to become self-conscious  and isolate themselves,  perhaps avoiding physical activities and eating extra food to soothe themselves, thereby aggravating the situation. To add to the complexity, this age period can be a challenging one in which to stage interventions because of these girls’ rapidly  changing cognitive and emotional development.

Factors that lower self-esteem or preserve it in girls

According to McClure et al,12 self-esteem represents one’s capacity to feel worthy of happiness. Self-esteem is an important determinant of adolescent mental health and development. One in three girls has a distorted interpretation of her appearance— either that she feels she is overweight when she is normal or that she feels she is normal when she is overweight.10 McClure et al12found that obesity was the most strongly correlated, modifiable risk factor for low self-esteem in pubescent girls.

Documented risk factors for low self-esteem include adolescence itself, female gender, low socioeconomic status, non-traditional family structure, having healthcare/special needs, exposure to school bullying, parental aggravation and family stress, elevated BMI, sedentary behavior, and higher rates of television viewing.13 During pre-puberty, a girl’s self esteem is not significantly tied to BMI; however, by age 13-14 years, the shift to a significant negative correlation exists.13

Low self-esteem does not appear to be a significant contributor to the development of obesity but, rather, a primary result of it.14 Factors that help preserve a girl’s self-esteem include physical activity, perception of good health, family communication and closeness, authoritative parenting, perceived teacher support, being part of a religious community, and feeling safe at school.12

Effects of maternal and societal factors

The initial and most powerful influence on a girl’s self-esteem is her mother.10As a girl enters late childhood/early adolescence, though, an increased desire to fuse with her peer group often takes precedence—with increased attention paid to the media. Pop culture bombards girls with “ideal” female images on television, in movies, in magazines, and on the Internet— girls of today have a much higher exposure to advertising than did previous generations. Girls are also exposed to mixed messages by the media; they are encouraged to love themselves the way they are, but they are also told that being OW/O is undesirable. Susceptibility of an adolescent to all these peer and pop culture pressures largely depends on both her mother’s values and actions and on the relationship she has with mother. For example, if a girl has a strong bond with a mother who has a good image of herself, she is less likely to be vulnerable to outside influences.15

Other factors that increase the risk for psychosocial complications of OW/O are race and ethnicity.15In general, AA girls do not experience as extreme downward spiral in self-esteem as do their Caucasian peers.14Identifying oneself with an ethnic group has been thought to be protective against low self-esteem.14 This theory is demonstrated in the study by McClure et al,12 which showed that even though female Hispanic and AA populations in the U.S. had higher rates of OW/O than their white counterparts, they had higher self-esteem and a more positive body image. AA girls also reported less desire for thinness. This difference ma have been due to a cultural acceptance by AAs, even an admiration, of “curvy” women. These findings warrant further investigation to determine whether the values of a particular ethnic group can overcome the negative self-esteem typically related to being OW/O.

Raising self-esteem in overweight/obese girls

Several studies have shown that programs with a primary focus on exercise as a means to increase self-esteem are detrimental to participants’ body image and have not produced a sustained, significant reduction in BMI.9,14,16 O’Dea9 theorized that the most effective model would focus primarily on building self-esteem itself, with secondary promotion of a healthy attitude toward diet and exercise. As the time period of greatest potential for weight gain coincides with psychological immaturity, the best course of action in girls ma be an early intervention to promote self-esteem and positive body image—starting just before the onset of thelarche, at age 8 or 9.8As these girls enter middle adolescence after menarche at age 12-14, the focus on nutrition and physical activity can gradually increase.11 At this point, the girls’ weight gains will have stabilized and they will have become more emotionally mature.9

According to Piaget’s developmental stages, young adolescents cannot grasp the concept that OW/O may lead to obesity related health problems during adulthood.17These individuals will not understand this concept until their late teenage years, when most of the psychological stigma of obesity has already occurred. This notion reinforces O’Dea’s theory that the most important concern to address in young adolescents is the adverse psychosocial effects of OW/O.9,17In other words, a therapeutic approach should focus on raising self-esteem, not on weight loss or exercise or the potential adverse health consequences of OW/O in the distant future.

Selected approaches

Available programs to address low self-esteem in OW/O girls vary in intensity, strategy, and primary focus. Nurse practitioners must ascertain each patient’s values and goals before recommending a specific approach for her. Options range from patient-centered, motivational interviewing to participation in community- wide programs.

Motivational interviewing— Use of this approach is based on the idea that OW/O is maintained by faulty cognitions and beliefs.18The motivational interviewer must identify, evaluate, and restructure the patient’s maladaptive cognitions and beliefs. In this approach, the NP identifies factors contributing to the patient’s poor self-image and works with both the patient and parents (as indicated) to create an environment to foster a positive body image. Success of this type of intervention depends heavily on a desire to change. Motivational interviewing has been shown to work with adults, but little research has been conducted with younger patients. This intervention may be beneficial for older adolescents, who tend to be more independent and self-motivated. In dealing with pre-adolescent to early adolescent patients, NPs might want to include the parents in the process. Motivational interviewing is a code-able intervention for primary care practitioners, does not require referral and outside expenses to the family,and is minimally invasive.

School-based programs— Many school programs address self-esteem and body image at around the fifth-grade level.19,20In a survey by Wilson,19 adolescents indicated that an ideal obesity prevention program at school would include their peers, take place during school hours, involve “fun” physical activities, and not require family members to participate directly—although they stated that they valued family support outside the program. The Nutrition and Enjoyable Activity for Teen Girls (NEAT Girls) study targeted girls in disadvantaged secondary schools who had been identified as being less active.20No parental involvement was included in the program. The researchers found that the program helped improve participants’ body image, although no significant reduction in BMI was noted between the intervention and control groups. The researchers theorized that parental involvement in the program might have had a significant impact on BMI while preserving the observed improvement in body image.

Female-specific extracurricular programs—Programs such as Girl Scouts of America, Girls on the Run, New Moves, the Memphis Girls Health Enrichment Multi-site Studies (GEMS), GoGirlGo, and Loozit have had a significant positive impact on adolescent participants’ self-esteem. 6-8,10,16,21 Compared with school-based programs, these programs are more tailored to participants’ needs and have a lower leader-to-participant ratio. The main emphasis of many of these programs is to address the issue of low self-esteem and poor body image, with a secondary emphasis in some groups on increased physical activity. Many studies have shown that noncompetitive physical activity improves feelings of self-worth; girls who participate in any kind of physical activity report feeling good about themselves, regardless of their weight.6,16,20 The curricula vary in content and length, for example, from weeklong summer camp (GoGirlGo) to longer, regular involvement through age 17, such as is available in Girl Scouts of America.7,10

According to Walker’s theory of intentionality, a program will have the best outcome if it is tailored to the essential needs and the inherent nature of a particular child.22 Even though the GoGirlGo program lasted only a week, participants stated that they felt empowered and had fun in the process.7 The authors of this report ascribed the program’s success to tailoring discussion topics to participants’ needs and to the mentor having a pre-existing relationship with the participants—establishing a level of trust prior to the camp.7

The GEMS programs were specific to AA girls aged 8-10 years, took place at local YMCAs, and were led by AA women, who were the adults most likely to foster a mother–daughter-type relationship with the girls.16Participants met weekly for 14 weeks and then monthly for the remainder of the 2 years. The intervention group’s goals were to follow a balanced diet, to decrease sedentary behaviors, and to increase physical activity. Psychological interventions included positive reinforcement, social support, and goal setting. The girls’ parents/guardians were encouraged to participate by increasing the availability of healthy foods at home. In the control group, the goal was to improve self-esteem and social efficacy; the family unit was not involved. Despite a rather intensive and well-planned study, the researchers found no significant prevention of weight gain among intervention participants versus the controls.

Family-driven and community-wide programs—NEAT girls, Girl Scouts, and the GEMS are family-oriented programs that rely on a child’s parents, who are often the ones preparing meals, to lead by example with positive attitudes regarding body image and increased physical activity. 10,16,20Perhaps the largest program is Let’s Move, a comprehensive national health initiative spearheaded by First Lady Michelle Obama5 Let’s Move addresses preventive measures for childhood obesity, starting with the mother’s prenatal care and progressing through encouragement of breastfeeding and childrearing practices (e.g., following a healthful diet, limiting exposure to digital media). This program does not specifically address interventions for the social stigma of obesity; rather, it aims to decrease the psychosocial side effects by eliminating the cause.

The U.S. Department of Health and Human Service Office on Women’s Health has constructed websites such as womenshealth.orgA that address body image in children.23This resource offers simple recommendations for parents/ guardians to promote both a healthy body image and a healthy relationship with food. Recommendations from this resource include maintaining open lines of communication, discussing media images, praising the child’s accomplishments, and avoiding negative comments regarding dieting and body shape.

In an effort to combat poor self-image in New York City, the organization New York City Girls placed posters of girls in areas of high visibility (e.g., subways, buses) proclaiming “I’m a Girl; I’m beautiful the way I am.”24The program aimed to counter the media bombardment of stick thin fashion models. The posters featured normal-appearing girls of all ethnic backgrounds. The second phase of the program included outreach, with several in-school and after-school programs as well as free fitness classes for further promotion of a healthful lifestyle.

Role of the nurse practitioner

Most NPs do not have adequate time during a typical well-patient visit to both identify low self-esteem in an OW/O girl and counsel her appropriately. NPs may need to schedule additional appointments with the patient and parents to focus discussions on self-esteem and body image or to make a referral to a mental health specialist when deemed necessary. NPs also need to consider the family’s social background, financial constraints, and goals. Above all, the most successful intervention is one in which the patient feels invested. By encouraging girls’ participation in early interventions, NPs are not only curbing the risk for future health problems, but also helping shape the ideas and attitudes of the future generation by creating strong role models and mothers.

Conclusion

The inverse relationship between BMI and self-esteem escalates as girls enter puberty. Although this phenomenon does not affect all ethnic groups equally, plummeting self-esteem is a widespread occurrence in this age group and, without intervention, may lead to problems such as substance abuse, depression, anxiety, social isolation, and suicidal ideation. Although low self-esteem in the presence of OW/O is common, a higher BMI is more socially acceptable in some cultural subgroups. Participation in motivational interviewing or in school or community programs can lead to improvements in self-esteem and body image. Preadolescent and adolescent girls may also develop a healthy attitude toward nutrition and physical activity. Reduction of BMI should not necessarily be emphasized in this age group unless a patient’s BMI poses immediate risks to her health; she may experience more psychological damage through intense intervention during this fragile period of social uncertainty. Because NP are often trusted primary points of contact within the healthcare field, they are in an ideal position to provide guidance to both the child and parent(s).

Meaghan Eddy is a family nurse practitioner at Cape Fear Center for Digestive Diseases in Fayetteville, North Carolina. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

References

1. American Academy of Pediatrics. Prevention and Treatment of Childhood Overweight and Obesity. 2013. http://www2.aap.org/obesity/about.html

2. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA. 2010;303(3):242-249.

3. Raj M, Kumar RK. Obesity in children & adolescents. Indian J Med Res. 2010;132(5):598-607.

4. Jasik CB, Lustig RH. Adolescent obesity and puberty: the “perfect storm.” Ann N Y Acad Sci. 2008;1135:265-279.

5. White House Task Force on Childhood Obesity. Solving the problem of childhood obesity within a generation. Report to the President. May 2010.

6. Neumark-Sztainer DR, Friend SE, Flaitum CF, et al. New Moves—preventing weight-related problems in adolescent girls: a group-randomized study. Am J Prev Med. 2010;39(5):421-432.

7. Warner S, Dixon, MA, Schuman C. Enhancing girls’ physical activity and self-image: a case study of the GoGirlGo program. Women Sport Phys Activ J. 2009;18(1):28-41.

8. Shrewsbury VA, O’Connor J, Steinbeck KS, et al. A randomized controlled trial of a community-based healthy lifestyle program for overweight and obese adolescents: the Loozit Study protocol. BMC Public Health. 2009;9(119):1-12.

9. O’Dea JA. Self-concept, self-esteem, and body weight in adolescent females: a three-year longitudinal study. J Health Psychol. 2006;11(4):599-611.

10. Girl Scout Research Institute. Weighing In: Helping Girls Be Healthy Today, Healthy Tomorrow: Research Review. New York, NY: Girl Scouts of the United States of America; 2004.

11. Rojas A, Storch EA. Psychological complications of obesity. Pediatr Ann. 2010;39(3):174-180.

12. McClure AC, Tanski SE, Kingsbury J, et al. Characteristics associated with low self-esteem among U.S. adolescents. Acad Pediatr. 2010;10(4):238-244.

13. Strauss RS. Childhood obesity and self-esteem.  Pediatrics. 2000;105(1):1-5.

14. Wang F, Veugelers PJ. Self-esteem and cognitive development in the era of the childhood obesity epidemic. Obes Rev. 2008;9(6):615-623.

15. Franklin J, Dener G, Steinbeck KS, et al. Obesity and risk of low self-esteem: a statewide survey of Australian children. Pediatrics. 2006;118(6):2481-2487.

16. Klesges RC, Obarzanek E, Kumanyika S, et. al. The Memphis Girls Health Enrichment Multi-site Studies (GEMS): an evaluation of the efficacy of a two-year obesity prevention intervention in African-American girls. Arch Pediatr Adolesc Med. 2010;164(11):1007-1014.

17. Piaget J. Inhelder B. Memory and Intelligence. London, UK: Routledge and Kegan Paul; 1973.

18. Walpole M, Dettmer E, Morrongiello B, et al. Motivational interviewing as an intervention to increase  adolescent self-efficacy and promote  weight-loss: methodology and design. BCM Public Health. 2011;11:1-9..

19. Wilson LF. Adolescents’ attitudes about obesity and what they want in obesity prevention programs. J School Nurs. 2007;23(299):229-238..

20. Luban DR, Morgan PJ, Dewar D, et al. The Nutrition and Enjoyable Activity for Teen Girls (NEAT girls) randomized controlled trial for adolescent girls from disadvantaged secondary schools: rationale, study protocol, and baseline results. BMC Public Health. 2010;10:1-14.

21. Girls on the Run website. 2014. http://www.girlsontherun.org/

22. Walker J. Intentional youth programs: taking theory to practice. New Dir Youth Dev. 2006;Winter(112):75-92.

23. U.S. Department of Health and Human Services Office on Women’s Health. Body Image and Your Kids. Last updated September 22, 2009. http://www.womenshealth.gov/bodyimage/kids/

24. Dockterman, E. Bloomberg v. Pop Culture: NYC’s Campaign to Boost Girls’ Self-esteem. October 2, 2013. http://healthland.time.com/2013/10/02/bloombergs-quixotic-campaign-to-boost-girls-self-esteem/?iid=sr-link1

Web resource

A. http://www.womenshealth.gov/bodyimage/kids/

 

Obesity May Make Rheumatoid Arthritis Tough to Spot, Track

Blood tests to diagnose and monitor rheumatoid arthritis may be thrown off by obesity in women, a new study suggests.

“Physicians might assume that high levels of inflammation mean that a patient has rheumatoid arthritis or that their rheumatoid arthritis requires more treatment, when in fact a mild increase in levels of inflammation could be due to obesity instead,” explained study author Dr. Michael George, who’s with the University of Pennsylvania Health System in Philadelphia.

Blood tests for C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) can help physicians check the severity of inflammation in rheumatoid arthritis patients, the researchers said.

Previous studies have suggested that obese women may normally have higher CRP and ESR levels. So, the authors of this study decided to take a closer look at the issue.

The study included information from more than 2,100 people with rheumatoid arthritis. The researchers then compared that information to data from the general population.

A higher body mass index (BMI — an estimate of body fat based on weight and height) was associated with greater CRP in women with rheumatoid arthritis and women in the general population, especially in severely obese women. There was also a modest association between obesity and ESR.

Conversely, in men with rheumatoid arthritis, a lower BMI was associated with greater CRP and ESR.

The findings may help improve understanding of the link between weight and inflammation. It may also help doctors learn more about how this relationship differs between women and men, the study authors added.

The findings were published April 10 in the journal Arthritis Care & Research.

Read more at Medline

Incontinence may reflect body fat, not just weight

Being overweight or obese is an established risk factor for urinary incontinence, but a recent study indicates that body composition may also play a role. A multicenter team of researchers examined data from 1,475 women enrolled in the Health, Aging, and Body Composition Study. The participants ranged in age from 70 to 79 at the beginning of the study.

The research team looked at body mass index (BMI), percentage of body fat, and the frequency and type of incontinence episodes among participants over three years. They found that both stress incontinence—episodes of spilled urine during exercise—and urge incontinence—sudden, uncontrollable urination—were twice as common in women with the highest BMIs or greatest proportion of body fat compared with those in the lowest categories. Women who lost grip strength—an indication of reduced muscle mass—also had increased episodes of stress incontinence. However, overweight women who reduced either their BMI or their body fat by 5% were less likely than women who didn’t lose weight or shed fat to experience new or persistent stress incontinence. The study was published online Dec. 5, 2016, by the Journal of the American Geriatrics Society.

These findings suggest that while weight loss alone may help alleviate both forms of incontinence, activities that increase muscle mass may be especially helpful for women with stress incontinence.

via Harvard Health Publications

CONTINUING EDUCATION: Assessment and management of patients with obesity

PDF 50By Mary Annette Hess, PhD, FNP-BC, CNS and W. Timothy Garvey, MD, FACE

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Obesity is a disease, not a condition resulting from ill-advised behavioral choices.1 After all, obesity meets the essential criteria of a disease: It has characteristic signs or symptoms; it manifests as an impairment in the normal functioning of some aspect of the body; and it results in harm or morbidity. As such, healthcare providers (HCPs) need to identify obesity in their patients, assess each patient’s risk for obesity-related complications, begin the weight-loss discussion in a thoughtful and constructive manner, and institute an individualized management plan.

Key words: obesity, risk assessment, obesity-related complications, dietary changes, weight-loss medications

Definitions and prevalence

Obesity can be defined as a body mass index (BMI) ?30 kg/m2 or it can be suggested by a waist circumference (WC) >35 inches (in women).2 But obesity is more than just a calculation or a measurement; it is a primary disease entity that can lead to cardiometabolic, biomechanical, and other complications (Figure 1).3,4CNER_Figure 1

 

 

 

 

 

 

 

 

 

 

 

 

Here is a number that matters: Almost 80 million U.S. adults—almost 35% of the adult population in this country—meet criteria for obesity,5 with certain geographic areas and certain ethnic groups overrepresented. Prevalence of obesity is higher in southern states and some Midwestern states than in other parts of the country,6 as illustrated by this CDC map. Non-Hispanic blacks have the highest age-adjusted rate of obesity (47.8%), followed by Hispanics (42.5%), non-Hispanic whites (32.6%), and non-Hispanic Asians (10.8%).5 Although overall obesity prevalence is similar in women and men at any given age, women have a higher prevalence of class II obesity (BMI, 35.0-39.9) and class III obesity (BMI ?40).7

Risk assessment

Given the high prevalence of obesity, HCPs will likely encounter many patients in their practices who are candidates for weight management. In each case in which obesity is identified, the first step needed is to assess the patient’s risk for obesity-related complications. This assessment includes calculating BMI, measuring WC, and screening for the presence of cardiovascular disease (CVD) risk factors and co-morbidities.8 Compared with body weight alone, BMI is a better, albeit indirect, measure of adiposity, which is associated with a host of cardiometabolic abnormalities. WC, an indicator of abdominal adiposity, should be measured in patients with a BMI ?35 (the WC cutoff of >35 inches in women adds little predictive value in those with a BMI >35), including those who are overweight (BMI, 25-29.9). Women whose WC exceeds 35 inches are at increased risk for developing hypertension (HTN), type 2 diabetes mellitus (T2DM), and CVD.

Therefore, HCPs need to check patients’ blood pressure (BP) to assess for HTN and order a fasting blood glucose (FBG) test, and even a 2-hour oral glucose tolerance test and HbA1c in high-risk individuals, to assess for T2DM and pre-diabetes.9 The metabolic syndrome, which increases risk for T2DM, CVD, and stroke, is identified in women by the presence of at least three of these five risk factors: WC >35 inches, triglycerides ?150 mg/dL, high-density lipo­protein cholesterol (HDL-C) <50 mg/dL, BP ?130/85 mm Hg, and FBG ?100 mg/dL.10

Some obesity-associated diseases and risk factors place patients in a very-high-risk category for subsequent mortality.8 Patients with obesity and co-morbid coronary heart disease (CHD), other atherosclerotic diseases, T2DM, metabolic syndrome, pre-diabetes, or sleep apnea require aggressive modification of risk factors in addition to clinical management of the co-morbid disease. Furthermore, obesity has an aggravating effect on CVD risk factors such as cigarette smoking, HTN, high concentration of low-density lipoprotein cholesterol, low concentration of HDL-C, impaired FBG, family history of premature CHD, and age ?55 years (in women). HCPs need to identify these risk factors to determine the intensity of the clinical intervention that a patient requires.
Obesity takes a toll not just in terms of its effect on CVD risk, but also on cancer risk. The Cancer Research UK study showed that women with obesity had a 25% risk of developing a weight-related cancer—including cancer
of the bowel, gallbladder, uterus, kidney, pancreas, or esophagus, as well as post-menopausal breast cancer—in their lifetime.11 Cancer risk in these women was 40% higher than that in their slimmer counterparts.

Initiating the conversation

Either a patient or an HCP can initiate the conversation regarding the need to lose weight. The situation is generally easier to handle when a patient expresses a desire to lose weight. She has already acknowledged existence of the disease—that is, the obesity—and is seeking treatment for it on her own. However, in many cases, the HCP must broach the topic, usually after a patient has come in for a routine visit and the findings from her history, physical examination, and laboratory tests indicate that steps must be taken to lower her risk for experiencing obesity-related complications—or to treat the complications that already exist.

To avoid discomfiting a patient in this situation, a panel of nurse practitioners convened by the American Nurse Practitioner Foundation (ANPF) recommends that the HCP show her objective data reflecting her disease and her risk for future complications—with an emphasis that obesity is a health problem—and then assess her motivation and readiness for change.7 In this context, the HCP and the patient need to synchronize their expectations and goals for weight loss therapy. HCPs now have reliable tools to help patients lose 5%-10% of their body weight. This weight loss may not produce the desired cosmetic outcome but will no doubt result in clinical benefits. The emphasis is on improving the health of the patient.

To inspire a patient with obesity to want to lose weight and to commit to follow a weight-loss treatment plan, the HCP can help her identify at least one compelling reason to lose weight.7 Common patient-centered reasons include (1) decreasing the risk of having a complicated pregnancy; (2) being able to play with children or grandchildren; (3) walking without becoming short of breath; (4) preventing other chronic diseases such as T2DM; and (5) improving existing weight-related complications such as sleep apnea or T2DM. Of note, some patients may not be aware of the health risks posed by obesity and will be motivated to lose weight once educated about the risks.

Approach to management

Once a patient with obesity is motivated and ready to lose weight, the HCP needs to work with her to devise a management plan. Both of them should agree on the goals of weight-loss therapy and on the purpose of long-term therapy. A realistic initial goal for many patients is a loss of 5% of body weight in 3 months. Three major management options—lifestyle modification, pharmacotherapy, and bariatric surgery—can bring about weight loss and reduce obesity-related morbidity and mortality.1 This article focuses on the first two options.

Lifestyle modification

A comprehensive weight-loss program starts with lifestyle modification comprised of dietary changes, increased activity, and behavioral control.12

Dietary changes

With regard to energy intake, the ANPF recommends a reduction of 500-1,000 kcal/day, which can be accomplished by limiting portion size, reducing fat and sugar intake, and using commercial weight-loss meal replacements.7 The patient can follow one of many diets shown to be safe and effective; examples are a low-carbohydrate diet,13 a low-fat diet,14 a Mediterranean diet,15 a low-glycemic-load diet,16 and a portion-controlled diet.17

Practical dietary tips include avoiding skipping meals and consuming small meals and between-meal snacks every 3-4 hours. With regard to food intake, moderation is the watchword. With regard to fluid intake, however, drinking eight 8-oz glasses of water a day is crucial unless contraindicated (e.g., in patients with renal failure).

Choice of a particular diet is less important than making a commitment and adhering to the diet,18 although following a regimen tailored for a co-morbidity makes sense. Because compliance is the key to success, the diet plan should accommodate the patient’s personal and cultural preferences. Regardless of the diet chosen, patients should monitor their caloric intake via a food diary and weigh themselves at least once a week.19

Increased activity

Choice of a particular activity (e.g., walking, swimming) depends on a patient’s preference and access to, say, a pool, as well as her current weight and health status. An assessment of mobility, cardiovascular (CV) status, and perhaps pulmonary function is needed before a patient embarks on a new exercise program.20 The goal is to increase energy expenditure.20 Exercising for ?150 minutes/week can lead to modest weight loss and help prevent weight regain; doubling this amount will promote more robust weight loss.21 As with food intake, patients should record their daily physical activity.

Exercise not only facilitates weight loss but also improves CV health by reducing BP, lipid levels, and visceral fat. These reductions are linked to improved glucose tolerance and insulin sensitivity in persons without diabetes and improved glycemic control in patients with T2DM.12 Enhanced physical fitness may even lessen obesity-related mortality. Of note, patients with obesity must modify their diet and increase physical activity in order to lose weight and reduce their risk for obesity-related complications. Another note: In addition to traditional exercise, patients can aim to increase energy expenditure throughout the day by reducing sedentary behaviors. For example, car owners can park twice as far from store entrances as they used to; city dwellers can walk instead of taking a bus, subway, or taxi; and office workers can use a standing desk instead of sitting at their desk.

Behavioral therapy

As applied to weight loss, behavioral therapy entails techniques for helping patients replace habits that contribute to excess weight and poor health with those that promote weight loss and good health.12 Key components of behavioral therapy include frequent encounters with HCPs, education, stimulus control, cognitive restructuring, goal-setting, self-monitoring, and social support.20 Group weight-loss programs in community settings, commercial weight-loss programs, and programs delivered by telephone, the Internet, or text message can all be effective, depending on patient preference.12

Pharmacotherapy

If a patient has not lost about 5% of her body weight after 3 months, or if she has lost weight but regained some, most, or all of it over time, she and her HCP should consider use of weight-loss medication as an adjunct to lifestyle modification. In some patients with severe complications who require clinically meaningful weight loss quickly, lifestyle modification and pharmacotherapy can be initiated concomitantly.

Rationale

In all human beings, calorie restriction triggers various biological adaptations designed to prevent starvation.22 These adaptations may even be potent enough to reverse the initial weight-loss success achieved with lifestyle modification. In persons with obesity, additional biological adaptations function to preserve, or even increase, their highest sustained lifetime body weight. As such, more biologically-based interventions are likely to be needed to counter the compensatory adaptations that maintain a person’s highest lifetime body weight.22 Other reasons for pharmacologic intervention in facilitating weight loss include the following:

  • Appetite-suppressing medication enhances a patient’s ability to adhere to a reduced-calorie diet.
  • Addition of a weight-loss medication consistently achieves greater weight loss, and for a longer duration of time, than that achieved by the lifestyle intervention alone.
  • Medication can help achieve the degree of weight loss needed to treat obesity-related complications.
  • The American Association of Clinical Endocrinologists (AACE), the American Society of Bariatric Physicians (ASBP), the American Heart Association (AHA), the American College of Cardiology (ACC), and The Obesity Society (TOS) all recommend use of medication for patients with obesity and sufficient health risk.20,23,24

Principles for use

The FDA indication for use of weight-loss medications is a BMI ?30 or a BMI of 27-29.9 with at least one obesity-related complication. The medication should be stopped if weight loss is <5% after 12 weeks on a maximal dosage. If one agent is ineffective or poorly tolerated, a different one can be tried. All of these agents are contraindicated for use during pregnancy. Pharmacotherapy is individually tailored to each patient’s needs. More data are needed regarding the safety of combination therapy and the use of medications beyond 2 years.

Options

Table 1 lists FDA-approved options for treating obesity.25-31Table 2. Weight-loss medications: Clinical trial information, accessible through this link, shows the results of clinical trials demonstrating the efficacy of these agents.32-39Figure 2 illustrates the comparative efficacy of these weight-loss medications.32-36,38-45
CNe_Table 1

 

CNE Figure 2

Guidelines for practice

The spectrum of obesity treatment guidelines ranges from those that are BMI-centric, wherein treatment indication is based on BMI and the treatment goal is to lose a given amount of weight (e.g., 5%-10%), to those that are complications-centric, wherein treatment indication is based on risk for, presence of, and severity of obesity-related complications and the treatment goal is to treat or prevent the complications.46Obesity treatment guide­lines from the National Heart, Lung, and Blood Institute (NHLBI), at one end of the spectrum, are based primarily on BMI and WC, although risk factors and co-morbidities are taken into account.8 The AACE, at the other end of the spectrum, recommends (1) evaluating patients with obesity for cardiometabolic and biomechanical complications; (2) selecting (a) therapeutic targets for improvements in complications, (b) treatment modality, and (c) treatment intensity; and (3) intensifying lifestyle and/or pharmacologic and/or surgical treatment modalities for greater weight loss if therapeutic targets for improvements in complications are not met.23Table 3 lists percentages of weight loss needed to achieve therapeutic benefits with regard to various obesity-related complications.4CNE_Table3

 

The AHA/ACC/TOS obesity guideline, which is closer to that of the NHLBI, recommends (1) identifying patients who need to lose weight, based on BMI and WC; (2) informing patients with CVD risk factors that lifestyle changes that produce even modest sustained weight loss of 3%-5% can result in clinically meaningful health benefits, and that greater weight loss produces greater benefits; (3) devising dietary strategies for weight loss; (4) devising a comprehensive lifestyle program that helps patients adhere to a lower-calorie diet and increase physical activity through use of behavioral strategies; and (5) selecting patients for whom bariatric surgery is advised—that is, those with a BMI ?40 or a BMI ?35 with obesity-related conditions.24 The approach of the ASBP to obesity management, which is closer to that of the AACE, focuses on treating diseases related to increased body fat and its adverse metabolic and biomechanical consequences, which may improve patient health, quality of life, body weight, and body composition.20

Conclusion

Obesity is a disease that requires permanent lifestyle changes. Lifestyle modification, enabled by dietary changes, increased physical activity, and behavioral therapy, is implemented first. If a patient does not reach her goals in terms of reducing her weight and her risk for obesity-related complications, medication is added. Most medications suppress appetite, enhance a patient’s ability to follow a reduced-calorie diet, and enable significantly greater weight loss than that achieved by lifestyle changes alone. In addition, medication use can help sustain weight loss and prevent weight regain over time.

For patients with obesity and obesity-related co-morbidities, weight loss is used therapeutically to treat the obesity-related complications. The role of the HCP is to diagnose the disease of obesity, assess the patient’s risk for obesity-related complications, discuss weight-loss strategies and goals with the patient, support the patient in implementing these strategies and reaching these goals, and provide regular follow-up and encouragement over the ensuing months, years, and decades.

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References

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