Obesity: assessment and management in primary care.

Obesity is a complex, multifactorial condition in which excess body fat may put a person at health risk. National data indicate that the prevalence of obesity in the United States is increasing in children and adults. Reversing these trends requires changes in individual behavior and the elimination of societal barriers to healthy lifestyle choices. Basic treatment of overweight and obese patients requires a comprehensive approach involving diet and nutrition, regular physical activity, and behavioral change, with an emphasis on long-term weight management rather than short-term extreme weight reduction. Physicians and other health professionals have an important role in promoting preventive measures and encouraging positive lifestyle behaviors, as well as identifying and treating obesity-related comorbidities. Health professionals also have a role in counseling patients about safe and effective weight loss and weight maintenance programs. Recent evidence-based guidelines from the National Heart, Lung, and Blood Institute, as well as recommendations from the American Academy of Pediatrics, American Association of Clinical Endocrinologists/American College of Endocrinology, American Obesity Association, U.S. Clinical Preventive Services Task Force, Institute of Medicine, and World Health Organization can be consulted for information and guidance on the identification and management of overweight and obese patients.     

Factors influencing BMI classifications of Korean adults

[Purpose] This study aimed to identify factors influencing the BMI classifications of 3,583 Korean adults using data from the fifth Korean National Health and Nutrition Examination Survey. [Subjects and Methods] Measures included lifestyle factors, physiologic factors, perceived health state, stress, subjective body recognition, health-related quality of life, and weight control behavior. [Results] Body perception scores were lower with underweight and higher with overweight and obesity than with a healthy weight. There was a lower proportion of underweight men and a higher proportion of overweight or obese men than women. Instances of Alcohol Use Identification Scores (AUDIT) ≥ 9 were proportionately lower with underweight and more with overweight or obesity relative to an AUDIT score < 9 with healthy weight. Hemoglobin A1c and systolic blood pressure were higher with obesity than with healthy weight. The total cholesterol level was greater with overweight and obesity than with healthy weight. [Conclusion] These results suggest that obesity intervention for adults should be based on age and sex and should include drinking habits and physical activity.Key words: Adults, Body mass index, Obesity     

Participants' perspectives of a multi-component, group-based weight loss programme supplement for cardiac rehabilitation: a qualitative study

Addressing overweight and obesity in people with cardiovascular risk factors is an important aspect of cardiac rehabilitation, but minimal implementation of targeted strategies has occurred. The aim of this study was to describe participants' perspectives of a multi-component, group-based weight loss supplement to cardiac rehabilitation programmes. Four focus groups of participants completing the intervention (n = 16) and maintenance phases (n = 19) of the Healthy Eating and Exercise Lifestyle Program (HEELP) were conducted. Interviews were transcribed and thematically analyzed using an inductive process. The overall theme of participants' responses was that HEELP helped them reprogramme their lifestyle behaviours to achieve weight loss. The programme was unique compared with other weight loss programmes because it was delivered and developed by familiar and expert health professionals who tailored the programme to participants' health status. Themes included the process of recognizing and deciding to make a commitment to managing their weight problem and feeling supported by the group and the staff to do this. Participants valued the group-based structure and the specific tools used in the programme. The programme content and structure provides a framework for the development of supplemental programmes for overweight and obese people at high cardiovascular risk.     

XENical in the prevention of diabetes in obese subjects (XENDOS) study: a randomized study of orlistat as an adjunct to lifestyle changes for the prevention of type 2 diabetes in obese patients

OBJECTIVE: It is well established that the risk of developing type 2 diabetes is closely linked to the presence and duration of overweight and obesity. A reduction in the incidence of type 2 diabetes with lifestyle changes has previously been demonstrated. We hypothesized that adding a weight-reducing agent to lifestyle changes may lead to an even greater decrease in body weight, and thus the incidence of type 2 diabetes, in obese patients. RESEARCH DESIGN AND METHODS: In a 4-year, double-blind, prospective study, we randomized 3,305 patients to lifestyle changes plus either orlistat 120 mg or placebo, three times daily. Participants had a BMI >/=30 kg/m2 and normal (79%) or impaired (21%) glucose tolerance (IGT). Primary endpoints were time to onset of type 2 diabetes and change in body weight. Analyses were by intention to treat. RESULTS: Of orlistat-treated patients, 52% completed treatment compared with 34% of placebo recipients (P < 0.0001). After 4 years' treatment, the cumulative incidence of diabetes was 9.0% with placebo and 6.2% with orlistat, corresponding to a risk reduction of 37.3% (P = 0.0032). Exploratory analyses indicated that the preventive effect was explained by the difference in subjects with IGT. Mean weight loss after 4 years was significantly greater with orlistat (5.8 vs. 3.0 kg with placebo; P < 0.001) and similar between orlistat recipients with impaired (5.7 kg) or normal glucose tolerance (NGT) (5.8 kg) at baseline. A second analysis in which the baseline weights of subjects who dropped out of the study was carried forward also demonstrated greater weight loss in the orlistat group (3.6 vs. 1.4 kg; P < 0.001). CONCLUSIONS: Compared with lifestyle changes alone, orlistat plus lifestyle changes resulted in a greater reduction in the incidence of type 2 diabetes over 4 years and produced greater weight loss in a clinically representative obese population. Difference in diabetes incidence was detectable only in the IGT subgroup; weight loss was similar in subjects with IGT or NGT [correction].     

Overweight and perceived health in Mexican American children: a pilot study in a central Texas community.

This study assessed actual and perceived health status of overweight Mexican American clients at a central Texas school-based health center in a predominantly Hispanic school district. It also explored the participants' interest in making lifestyle changes to promote a healthy weight. A medical records review indicated that of the Hispanic children between the ages of 7 and 12 years, 38% had a weight status at or above the 85th percentile. Assessments were conducted in a sample of these overweight Mexican American children to learn about their medical history, eating and activity patterns, perceived health and body size, and general health-risk status. Weight-related conditions, such as elevated blood pressure and cholesterol levels, were found in more than half the sample. Few consumed fruits and vegetables, and many engaged in only sedentary activities. The majority perceived themselves as "big," wanted to make changes in their body size, and wanted family members to participate in making changes with them. Although most of the sample were in the 97th body mass index percentile, many perceived themselves to be as healthy as or healthier than others. These findings substantiate the need to design and implement a culturally appropriate weight management and obesity prevention program in this community. However, the perception of being healthy in the presence of multiple indicators of poor health may pose challenges to successful intervention.     

Obesity: A Focus on Pharmacotherapy

Obesity is a condition associated with a vast number of health complications. Clinicians should initially counsel obese patients (defined as a body mass index ≥ 30 kg/m²) on lifestyle modifications to achieve and sustain weight loss. The addition of pharmacologic therapy can be considered in patients who do not have satisfactory outcomes with this approach. Currently, several pharmacologic therapies have received Food and Drug Administration approval. This article reviews pharmacologic data and relevant clinical literature with which a nurse practitioner should be familiar when prescribing and evaluating the safety and efficacy of weight loss medications in obese patients.     

Counseling for physical activity in overweight and obese patients

Obesity has reached epidemic proportions in the United States. More than 60 percent of U.S. adults are now overweight or obese (defined as at least 30 lb [13.6 kg] overweight), predisposing more than 97 million Americans to a host of chronic diseases and conditions. Physical activity has a positive effect on weight loss, total body fat, and body fat distribution, as well as maintenance of favorable body weight and change in body composition. Many of the protective aspects of exercise and activity appear to occur in overweight persons who gain fitness but remain overweight. Despite the well-known health and quality-of-life benefits of regular physical activity, few Americans are routinely active. Results of research studies have shown that physician intervention to discuss physical activity (including the wide array of health benefits and the potential barriers to being active) need not take more than three to five minutes during an office visit but can play a critical role in patient implementation. This article describes elements of effective counseling for physical activity and presents guidelines for developing physical activity programs for overweight and obese patients.     

The impact of lifestyle counselling on weight management and quality of life among working-age females

ObjectiveOverweight and obesity are increasing globally. General practitioners (GP’s) are at the first point of contact for medical support and consequently have a major role in resolving this overwhelming problem. The aim of this study was to assess the effectiveness of a brief lifestyle counselling on weight management and on the participants’ quality of life (QoL).DesignA cohort study with a one-year follow-up.SettingOccupational health care, city of Pori in southwestern Finland.ParticipantsFemale municipal employees (n = 625) with a mean age of 48 (SD 9) years.InterventionA nurse and a physiotherapist gave lifestyle counselling to all the participants; however, only the overweight/obese subjects were recommended to lose at least 5% of their initial weight.Main outcome measureSuccess in weight management and quality of life.ResultsAt the follow-up visit, 10.4% (95% CI: 7.5–14.0) of the overweight/obese subjects had lost at least 5% of their weight, but 10.0% (95% CI: 6.7–14.3) of the normal-weight participants had become overweight. The mean weight change was +0.1 kg (95% CI: −0.3–0.5) in the overweight/obese group and +0.5 kg (95% CI: 0.2–0.8) in the normal weight group. The change in QoL was inversely correlated with relative weight change in overweight/obese subjects, albeit the effect size was small.ConclusionWeight management counselling should also be directed to individuals with a normal weight. Even with brief lifestyle counselling it may be possible to stabilize weight gain. Successful weight loss may improve the QoL of overweight/obese individuals.

KEY POINTS

• Primary health care has to deal with the increasing problem of overweight and obesity.
• Brief lifestyle counselling performed by a nurse and a physiotherapist seems to be quite effective in weight stabilization, considering the effort needed.
• People with normal weight tend to gain weight and weight management counselling should also be directed to them. Successful weight management may improve the quality of life of overweight/obese people.

     

Look AHEAD (Action for Health in Diabetes): design and methods for a clinical trial of weight loss for the prevention of cardiovascular disease in type 2 diabetes

Overweight and obesity are major contributors to both type 2 diabetes and cardiovascular disease (CVD). Moreover, individuals with type 2 diabetes who are overweight or obese are at particularly high risk for CVD morbidity and mortality. Although short-term weight loss has been shown to ameliorate obesity-related metabolic abnormalities and CVD risk factors, the long-term consequences of intentional weight loss in overweight or obese individuals with type 2 diabetes have not been adequately examined. The primary objective of the Look AHEAD clinical trial is to assess the long-term effects (up to 11.5 years) of an intensive weight loss program delivered over 4 years in overweight and obese individuals with type 2 diabetes. Approximately 5000 male and female participants who have type 2 diabetes, are 45-74 years of age, and have a body mass index >or=25 kg/m(2) will be randomized to one of the two groups. The intensive lifestyle intervention is designed to achieve and maintain weight loss through decreased caloric intake and increased physical activity. This program is compared to a control condition given diabetes support and education. The primary study outcome is time to incidence of a major CVD event. The study is designed to provide a 0.90 probability of detecting an 18% difference in major CVD event rates between the two groups. Other outcomes include components of CVD risk, cost and cost-effectiveness, diabetes control and complications, hospitalizations, intervention processes, and quality of life.     

Nurse provision of healthy lifestyle advice to people who are overweight or obese

A cross‐sectional survey was conducted in a regional area in Australia to measure nurses' perceptions, practices, and knowledge in regard to providing healthy lifestyle advice to people who are overweight or obese. Responses were compared between geographic regions. Participation was voluntary and anonymous. Of the 79 nurse participants, 68% considered that provision of healthy lifestyle advice was within their scope of practice. Only 28% reported frequently estimating body mass index in the practice setting. Nurses often recommended increasing activity levels (44%), but recommended reducing daily caloric intake less often (25%). Nurses' knowledge about weight management was variable and the proportion of correct answers to knowledge items ranged from 33–99%. Nurses have many opportunities to deliver healthy lifestyle advice in a range of practice settings. The variation in practices and knowledge of nurses indicates a need for improved healthy lifestyle education for undergraduate and practicing nurses.     

Social background, aspects of lifestyle, body image, relations, school situation, and somatic and psychological symptoms in obese and overweight 15-year-old boys in a county in Sweden

OBJECTIVE: To compare lifestyle and health aspects among obese, overweight, and normal-weight 15-year-old boys living in the county of V?stmanland, Sweden. DESIGN: A cross-sectional school-based survey. Setting. All schools in the county of V?stmanland, Sweden. SUBJECTS: A questionnaire was completed anonymously by 989 boys. MAIN OUTCOME MEASURES: The relations between body mass index and social factors, eating habits, physical activity, body image, relations, school situation, use of alcohol, drugs and tobacco, somatic and psychological symptoms in boys. RESULTS: Obese boys had a significant negative outcome in 19 out of 31 items studied compared with normal-weight boys, while the overweight boys had a significant negative outcome in 9 out of 31. The obese boys reported more irregular eating habits than normal-weight boys, were less satisfied with their weight and looks, and had fewer friends. A larger proportion of the obese boys reported that they did not like school, were more absent from school, and had been exposed to more violence. They bullied their schoolmates more often. The obese boys had tried sniffing solvents and used illicit drugs more frequently than their peers. They reported more somatic and psychological symptoms as well as suicidal thoughts and attempts. CONCLUSIONS: Obese 15-year-old boys differed from overweight and normal-weight boys in lifestyle and in the frequency of somatic and psychological symptoms. Early and vigorous intervention is necessary, as they may belong to a risk group that could develop not only medically but also socially negative consequences.     

Behavioral techniques for treating the obese patient

With more than 50% of American adults overweight or obese, primary care physicians should play an active role in helping overweight patients lose weight. Modest weight losses of as little as 7% to 10% can produce significant health benefits, such as preventing the development of diabetes. To help individuals achieve this weight loss, behavior change strategies should be emphasized with all overweight patients. Changes in diet and exercise can produce long-term weight loss with tremendous positive impact. Primary care physicians are well positioned to support these behavior changes in their overweight patients.     

Effects of lifestyle intervention and metformin on weight management and markers of metabolic syndrome in obese adolescents

PURPOSE: The purposes of this study are threefold: to determine what components of the metabolic syndrome are present in obese adolescents, to determine what differences exist in the effects of lifestyle intervention versus lifestyle intervention plus metformin on weight management and select markers of metabolic syndrome in obese adolescents, and to determine which factors predict weight loss in obese adolescents treated with lifestyle changes and metformin. DATA SOURCES: The study was a secondary data analysis utilizing a retrospective chart review of 63 obese adolescents aged 11 through 18 who were treated for obesity at the LeBonheur Youth Lifestyle Clinic from January 1, 2000, through June 30, 2005. Lifestyle interventions included diet, exercise, and counseling. The medication utilized was metformin. Outcomes evaluated included body mass index, relative body mass index (RBMI), weight, waist and hip circumference, blood pressure, serum lipid levels, fasting plasma glucose, 2-h oral glucose tolerance tests, and insulin levels. Changes in mean values between groups were evaluated using the General Linear Models procedure. Logistic regression was utilized to determine which factors might predict weight loss. CONCLUSIONS: The metformin group (N= 37) tended to be heavier, older, and had more components of the metabolic syndrome than the nonmetformin group (N= 26). All components of the metabolic syndrome were present in both groups (overall prevalence 55%). Both groups had a downward trend in RBMI, a surrogate marker for weight loss, but only the metformin group had a significant loss in RBMI points from baseline to end. There was a trend toward better diastolic blood pressure at 6 months in the metformin group (p= 0.06), which was not seen in the nonmetformin group. The only predictors of weight loss were higher RBMI (those who were heavier lost more) and the absence of type 2 diabetes mellitus (type 2 DM) (those with type 2 DM were less likely to lose 10 or more points in RBMI). IMPLICATIONS FOR PRACTICE: All components of the metabolic syndrome are present in obese adolescents. The use of lifestyle changes and lifestyle changes plus metformin both produce some degree of weight loss, but subjects on metformin in this study lost significantly more RBMI points than those on lifestyle changes alone. Subjects with type 2 DM are less likely to lose weight than those without type 2 DM. Larger studies and studies with subjects more representative of the general population need to be carried out to assist in the development of evidence-based practice guidelines.     

Lifestyle behaviours and weight among hospital-based nurses

Aims  The purpose of this study was to (i) describe the weight, weight-related perceptions and lifestyle behaviours of hospital-based nurses, and (ii) explore the relationship of demographic, health, weight and job characteristics with lifestyle behaviours.
Background  The obesity epidemic is widely documented. Worksite initiatives have been advocated. Nurses represent an important part of the hospital workforce and serve as role models when caring for patients.
Methods  A sample of 194 nurses from six hospitals participated in anthropometric measurements and self-administered surveys.
Results  The majority of nurses were overweight and obese, and some were not actively involved in weight management behaviours. Self-reported health, diet and physical activity behaviours were low, although variable by gender, age and shift. Reports of co-worker norms supported low levels of healthy behaviours.
Conclusions  Findings reinforce the need to address the hospital environment and culture as well as individual behaviours for obesity control.
Implications for nursing management  Nurse managers have an opportunity to consider interventions that promote a climate favourable to improved health habits by facilitating and supporting healthy lifestyle choices (nutrition and physical activity) and environmental changes. Such efforts have the potential to increase productivity and morale and decrease work-related disabilities and improve quality of life.     

Challenges and strategies: weight management in type 2 diabetes

This article examines the link between obesity and type 2 diabetes and discusses some of the challenges health-care professionals face in helping people with diabetes achieve and maintain a healthy weight. Increasing numbers of people in both developed and developing countries are being classified as overweight or obese, which is resulting in growing numbers of people being diagnosed with type 2 diabetes. Worryingly this includes large numbers of children developing type 2 diabetes as the younger age groups are becoming overweight or obese. The health-care practitioner's role is explored and strategies to promote and achieve a healthy lifestyle for people with type 2 diabetes are offered. Such strategies are linked to obesity management through, diet, exercise and behavioural therapy.     

Obesity and chronic kidney disease

Obesity and overweight are now characterized as epidemics. It is shown that body overweight is associated with functional and structural changes in the kidneys. The results of epidemiological studies indicate that obesity can be the risk factor of chronic kidney disease (CKD) irrespective of the presence or absence of diabetes, arterial hypertension and other comorbidities. Manifestations of renal pathology in obese persons include microalbuminuria and proteinuria, hyperfiltration or impaired renal function. Glomerulomegaly and focal segmental glomerulosclerosis are the most typical structural signs of obesity-related nephropathy. More evidence is accumulated on the link between CKD in obesity and abnormalities in adypokine secretion (hyperleptinemia, lack of adiponectin), activation of rennin-angiotensin system, chronic inflammation, endothelial dysfunction, lipid accumulation, impaired renal hemodynamics and diminished nephron number related to body mass. A decrease of body weight following lifestyle modification or bariatric surgery leads to reduction in albuminuria and eliminates hyperfiltration in obese subjects. Thus, prevention and treatment of obesity may reduce CKD incidence in general population.