Weight management, defined as deliberate actions to reduce and maintain healthy body weight, is classified as formal and informal. Formal weight management consists of paying for organized services to assist individuals with weight reduction, such as health center-based and commercial programs. Informal weight management includes personal weight-loss methods without professional assistance. Weight management usually is targeted at reducing weight (versus gaining) because of societal pressures to be thin and growing epidemic incidences of overweight, obesity, and comorbidities. For adults 20 years or older, overweight is defined as having a body mass index (BMI) of 25 to 29.9 kg/m2 and Class 1 obesity is defined as having a BMI of 30 to 34.9 kg/m2 (National Heart, Lung, and Blood Institute [NHLBI], 1998). Class 2 obesity is defined as having a BMI of 35 to 39.9 kg/m2, and Class 3 is having a BMI of greater than 40 kg/m2 (World Health Organization Expert Committee on Physical Status, 1995).
Overweight and obesity are a grave health care epidemic despite efforts and national initiatives to abate this growing dilemma. Progress in the past 10 years toward Healthy People 2010 objectives for overweight and obesity was of little consequence, thus requiring retention and revision for the new Healthy People 2020 objectives for healthy weight and obesity (Sondik, Haung, Klein, & Satcher, 2010). According to the National Health and Nutrition Examination Survey (NHANES) U.S. data from 2007 to 2008, overall prevalence of overweight and obesity for adults was 68% (approximately 72% among men and 64% among women; Flegal, Carroll, Ogden, & Curtin, 2010). Overall, obesity prevalence was 35.5% for women and 32.2% for men. Class 3 obesity was reported to have increased at greater rates than any other class of obesity in the United States (Blackburn, Wollner, & Haymsfield, 2010).
Over the past three decades, childhood obesity has more than doubled among children ages 2 to 5 years, has tripled among youth ages 6 to 11 years, and has more than tripled among adolescents ages 12 to 19 years (Flegal et al., 2010). Approximately 17% of American children ages 2 to 19 years were obese—a 1 in 6 incidence. Overweight and obesity have a greater effect on minorities; Blacks had 51% and Hispanics had 21% higher obesity prevalence compared with Whites. National study of costs attributed to overweight and obesity revealed that medical expenses accounted for over 9% of total U.S. medical expenditures in 1998 or approximately $78.5 billion (Finkelstein, Fiebelkorn, & Wang, 2003). In 2002, expenses rose to $92.6 billion, half of which were paid by Medicaid and Medicare.
Overweight and obesity are multifactorial conditions. Etiological influences include bio-psycho-sociocultural factors and toxic, obesogenic environmental factors (Apovian, 2010; Blackburn et al., 2010). Experts agree that obesogenic environmental factors, more than biological reasons, explain the obesity epidemic over the past four decades. Four conditions account for the environmental stimulus–response nature of the rise in obesity in the United States: (1) a fast-paced eating style consisting of fatty, glycemic “fast foods” and super sizing; (2) excessive calorie intake; (3) reduced physical activity and technological dependency; and (4) heightened responsiveness to food as a stimulant (Hill, Wyatt, Reed, & Peters, 2003).
Unfortunately, failure rates for weight loss treatments in the United States, once estimated to be as high as 90% to 95%, have not improved. Long-term habits of overeating without hunger and with minimal regular physical exercise in a fast-paced society have been described as chronic and refractory with high recidivism for treatment (Wadden, Brownell, & Foster, 2002). Most weight-loss treatments in the United States have not helped reduce weight over the long term and have even contributed to the overweight problem (Hill & Wyatt, 2005). As obesity increased, so did many associated comorbid conditions, including hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and endometrial, breast, prostate, and colon cancers. Insulin resistance syndrome (metabolic syndrome) is positively correlated with excess weight and lack of physical activity and affects approximately 24% of American adults (Ford, Giles, & Dietz, 2002; National Institute of Diabetes and Digestive and Kidney Diseases, 2010). The safest, most effective way to reverse insulin resistance and most obesity comorbidities is through physical activity, dietary intake (less glycemic, more fiber), and weight loss (National Institute of Diabetes and Digestive and Kidney Diseases, 2010).
The challenge that continues to face America is not so much achievement of weight loss but rather weight loss maintenance. The most known unidimensional physical strategies for losing weight have been successful, including reduced dietary volume, calories, fat, and carbohydrates and increased energy expenditure through physical exercise. Medicines to reduce fat metabolism (orlistat) and suppress appetite (sibutramine, phentermine, and herbal preparations) have been found to be effective, especially combined with lifestyle modifications (American Dietetic Association [ADA], 2009). Bariatric surgical treatments for obese individuals that reduce intake volume (vertical banded gastroplasty) and reduce food absorption (gastric bypass) have been found to successfully reduce comorbidities (Buchwald et al., 2004). These unidimensional strategies are consistently based on energy balance theory, as it stresses the physiological balance between energy in and energy out needed for weight loss, maintenance, and gain (Hill & Wyatt, 2005; NHLBI, 2010).
Few weight management programs use a holistic, multidimensional approach to lifestyle changes with strategies that address and correct underlying overeating, lack of exercise, and poor self-esteem (Popkess-Vawter, Yoder, & Gajewski, 2005). Often, weight management strategies used in clinical trials research place greater emphasis on eating, exercise, or psychosocial aspects rather than holistic emphasis on all three dimensions. Treatments that do not permit individuals to tailor weight management to their preferences and lifestyles cannot be lasting. Weight loss treatments fail when program directives are too stringent for individuals to feel ownership and acceptance of weight management strategies as a way of life (Hill et al., 2003).
The 2009 ADA position statement defined multidimensionality for long-term weight management. Comprehensive programs should make maximum use of multiple cognitive–behavioral strategies (self-monitoring, stress management, stimulus control, problem solving, contingency management, cognitive restructuring, and social support) in addition to dietary and physical activity strategies to lose and maintain weight loss. Successful weight management programs, therefore, are multidimensional, flexible, and also focus on internal motivations for overeating and not exercising regularly.
Behavioral strategies have gained recognition as being important to promote long-term weight management, such as the PREMIER, Diabetes Prevention Program, Finnish Diabetes Prevention, and Look AHEAD studies (ADA, 2009). Confusion, however, exists in recognizing differences between behavioral strategies and cognitive–behavioral strategies. Behavioral strategies use behavior modification, which focuses on changing individuals’ behaviors with little or no concern for their underlying reasons for overeating, not exercising, and unhealthy coping behaviors (Popkess-Vawter, 2008). Behavioral weight management strategies emphasize stimulus control of intake and output by dieting and weight-related behavior modification, which are unidimensional and focus mainly on calorie reduction. A stimulus response mentality (emphasis on overweight behaviors) without regard for individuals’ beliefs, thinking, feelings, and related behaviors (cognitive–behavioral theory) may be partly responsible for continued escalation of the overweight–obese epidemic. Dietary, pharmacological, and surgical treatments that reduce intake and restrict calories, choices, and when to eat offer temporary modifications that are unrealistic for the long term and often are accompanied by rebound weight gain and detrimental psychological consequences (Popkess-Vawter et al., 2005).
Strategies that concentrate on modifying behavior by differentiating stimuli before, during, and after eating are a healthy start toward lasting weight management (i.e., identifying stimuli other than hunger that trigger eating, monitoring amounts and conditions during eating, and rewarding appropriate actions). One reason why behavioral techniques have limited success is because they seek to control the diet and environment without considering eating as a coping mechanism to manage unpleasant feelings (Popkess-Vawter, Brandau, & Straub, 1998). Few current weight management behavioral approaches, cognitive restructuring, or combinations thereof directly address how negative beliefs about self and irrational perceptions of the world can trigger negative self-talk with resultant responses of overeating, skipping regular exercise, and feeling bad about self (Popkess-Vawter, 2008). Increasing numbers of researchers have reported findings from weight management studies based on psychosocial theories such as self-efficacy, transtheoretical model, self-determination theory, and health belief model, which suggest progress in using holistic strategies for eating, exercise, and psychosocial aspects.
Stringent recommendations of the past have only fueled the obesity epidemic (Hill et al., 2003). NHLBI weight management programs like “America on the Move” and the 2005 Dietary Guidelines for Americans are national initiatives that have accommodated people's busy lives by suggesting “real world, do-able” eating and exercise goals for reversing the obesity epidemic. Consistent research findings have shown that 60 to 90 minutes per day of moderate intensity physical activity is needed to maintain a significant weight loss (Hill & Wyatt, 2005). Despite these promising findings, most people, normal weight or overweight, will find exercising 60 to 90 minutes daily difficult and unrealistic over the long term. Jakicic, Winters, Lang, and Wing (1999) found that 10-minute exercise bouts done three to six times daily can be effective for weight management and more practical for busy people's lifestyles. Small targeted behavioral changes (e.g., walking 15–20 minutes daily) can significantly contribute toward sustained weight loss. There is growing evidence that 5% to 7% of maximum weight lost is associated with lower incidence of diabetes, reduced blood pressure, and improved dyslipidemia (Yanovski & Yanovski, 2002). Modest weight loss and improved fitness can lower comorbidity risk and ultimately lead to sustained weight management (Blackburn et al., 2010).
Convenient and practical means to offer multidimensional weight management approaches include use of telehealth videoconferencing, telephone, and the Internet, which in turn offer greater access for study participants and future applications for formal programs (Enwald & Huotari, 2010; Kim et al., 2010). Research is needed to develop and test community-structured and work-related multidimensional programs (Apovian, 2010; Greener, Douglas, & vanTeijlingen, 2010). Collaboration among researchers, health professionals, policy makers, and community leaders is essential for tailoring meaningful research (Flegal et al., 2010).
The ultimate goal of weight management is to prevent obesity and its comorbidities (Serdula, Khan, & Dietz, 2003). Research agendas must include the refractory nature and high recidivism to assure long-term weight management. Primary care clinics are frontline settings to approach people about weight management, but structured and practical treatments are still lacking. Providers may not be aware of their powerful influence in helping patients with weight management (Clark et al., 2010; Heintze et al., 2010). Health professionals and patients need to be educated about the benefits of modest weight loss using evidence-based methods (Phelan, Nallari, Darroch, & Wing, 2009). To promote healthy weight among Americans, long-term, lifestyle-change intervention studies are vital, using qualitative and quantitative measurements of physical and psychosocial weight management strategies.
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