Topic Page: Weight Management
1 2Obesity is an excess of body fat. The most commonly used method for measuring body composition is the body mass index (BMI; see Appendix H). BMI is expressed as weight in kilograms divided by height in meters squared (kg/m2). Normal weight is defined as a BMI of 18.5 to 24.9 kg/m2; overweight as a BMI between 25 and 29.9 kg/m2; mild obesity as a BMI between 30 and 34.9 kg/m2; moderate obesity, 35 to 39.9 kg/m2; and morbid obesity, greater than 40 kg/m2. Health risks begin to surface with a BMI greater than 25 kg/m2, with the risk increasing as the BMI increases.
Increasingly, a subset of obese patients is being identified with insulin resistant syndrome. This syndrome is a cluster of conditions that can lead to an increased risk of cardiovascular disease and diabetes. Criteria for diagnosis include
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Obesity
BMI greater than 30 kg/m2
Increased visceral adipose tissue, with a waist circumference of greater than 35 inches in women
A small number of persons who do not meet the criteria for obesity but present with laboratory values that identify them as metabolically obese
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Dyslipidemia
Hypertriglyceridemia 150 mg/dL or greater
Decreased high-density lipoprotein cholesterol (HDL-C) levels less than 50 mg/dL in females
Low-density lipoprotein cholesterol (LDL-C) levels may be normal.
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Elevated blood pressure
New Advanced Technology Program III guidelines define elevated blood pressure as 130/85 mmHg or greater (see www.atp.nist.gov/atp/psag-co.htm).
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Impaired glucose function
Fasting blood glucose of greater than 100 mg/dL
Increased fasting insulin levels
Polycystic ovary syndrome (PCOS) is not included in the criteria for diagnosis but is present in a great percentage of women with metabolic syndrome.
Obesity is among the most serious and prevalent health problems in the United States, second only to cigarette smoking. More than 97 million Americans are defined as having a weight problem. Of these, 58 million are obese.
Prevalence continued to rise over the past 10 years, increasing from 25% to 35%. Researchers have shown that prevalence varies greatly by sex, age, race, and socioeconomic status. More than 55% of the population defined as obese are women. Obesity in women is twice more common in lower socioeconomic groups than in women with higher socioeconomic status. Obesity itself is an independent risk factor for many medical conditions and negatively contributes to others.
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Obesity is a multifactorial disorder, based on both genetics and behavior occurring because of an imbalance between energy expended and food consumed and with other contributing factors such as
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Metabolic issues (< 1% of obese)
Hypothyroidism
Cortisol excess (Cushing's syndrome)
Stein–Leventhal syndrome (polycystic ovary disease)
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Medication
Antidiabetics
Antipsychotics
Antidepressants
Antiepileptics
Adrenergic antagonists
Serotonin and histamine antagonists
Steroids
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Food consumption
Portion size
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Selection of foods
Foods high in fat
Foods and beverages high in sugar and complex carbohydrates
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Lifestyles
Sedentary/lack of physical activity
Lack of calorie-burning (aerobic) exercise
Use of food for comfort and to reduce stress
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Other
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Of lesser contribution
Endocrine
Deviant eating patterns (i.e., binge eating, night eating)
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Obesity is associated with increased morbidity and mortality. It has been associated with more than 30 illnesses, among them are
Type 2 diabetes
Hypertension
Stroke
Coronary artery disease
Dyslipidemia
Gallstone formation
Osteoarthritis
Gastrointestinal (GI) disorders
Sleep apnea
Breast inflammation
Respiratory diseases
Some cancers, such as breast, colon, and endometrial
Increased risks in pregnancy, such as miscarriage, preeclampsia, gestational diabetes, infertility, and possibly fetal anomalies such as neural tube defects
Gouty arthritis
Pickwickian syndrome
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Risk assessment
Overweight and obese patients may not present with the stated desire to lose weight.
Presenting complaints most commonly are those associated with the risk factors listed in Risks Associated With Obesity, IV.A.
A weight loss assessment should be part of an annual exam.
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Weight-loss assessment
Patient's recognition of need for weight reduction
Patient's readiness to change
Previous attempts at weight loss
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Dietary assessment
Type and amounts of food typically consumed
Patterns of eating
Meals
Snacks
Spontaneous eating
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Alcohol consumption
Amount
Frequency
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Physical activity
Type
How often, for how long
Obesity-related problems
Family history of weight and weight-related problems
Signs and symptoms of depression
Medications: prescribed; over the counter (OTC), including herbals, homeopathics, and nutritional supplements
Smoker/nonsmoker
As indicated by known problem or presenting complaint or to rule out a secondary cause of obesity
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Regardless of previous statement, exam should include
Height
Weight
Blood pressure
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Head and neck examination for
Moon facies
Hirsutism
Goiter
Buffalo hump
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Skin
Striae
Hirsutism
Edema
Dryness
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Calculation of BMI
BMI may be calculated by dividing the weight in pounds by the square of the height (square inches) and multiplying the result by 703.
BMI may also be assessed by consulting a BMI table (see Appendix H).
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Waist circumference measurement
Waist circumference of greater than 35 cm for women
As indicated by known history or physical exam
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The following should be considered if no underlying physical problem is indicated:
Lipid profile
Thyroid-stimulating hormone (TSH), free thyroxine 4 (T4)
Fasting blood sugar; 2-hour postprandial
Complete blood cell count (CBC)
Baseline electrocardiogram
Sleep studies if indicated
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If insulin resistant syndrome is to be ruled out
Lipid levels
Fasting blood sugar; 2-hour postprandial
Fasting insulin level
Laboratory workup specific for PCOS (see Chapter 19)
Intervention needs to be multifaceted and tailored to meet the patient's needs and readiness for change.
The need for weight loss should be presented to the patient in a nonjudgmental, nonconfrontational manner. Approach the problem as a partnership in an endeavor that will help the patient to enjoy a longer, healthier life.
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Assessment of a patient's willingness to make a change includes the following:
Patient may not be interested in making a change despite the identified risk and potential consequences
Patient may be interested, acknowledge the risk factors, but may not yet be ready to take action
Patient is ready to take on the challenge of weight loss
Assessment of the amount of weight to be lost based on physical findings and risk factors
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Plan
Assessment of caloric intake
Assessment of energy expenditure and level of physical activity
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Assessment of limitations and/or existing factors
Physical limitation
Medications (alternatives may be considered)
Financial limitations
Cues or stimuli that affect eating
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Set realistic goals and expectations regarding the amount of weight to be lost
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Short term
5% to 10% loss in initial weight at a rate of 1 to 2 pounds per week
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Long term
Realization of ideal weight
Maintaining ideal weight
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Contract with patient a framework for realization of goals
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Interventions
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Diet, with emphasis on long-range behavior changes
Nutritionist for evaluation and plan
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Self-help
Weight Watchers
Take Off Pounds Sensibly (TOPS)
Overeaters Anonymous
Community-based programs
Meal-replacement programs
Books, magazine articles
Website weight-loss programs
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Education in food selection and change in eating patterns (National Heart, Lung, and Blood Institute/National Institute of Diabetes and Digestive and Kidney Diseases [NHLBI/NIDDK] guidelines are a good source of information—see www.nhlbi.nih.gov)
Low fats, increase omega 3 fatty acids
Moderate use of complex carbohydrates
Decrease consumption of simple carbohydrates (i.e., sugary drinks, candy)
Moderate use of low-fat protein
Decrease in portion size
Omit late-night eating
Eating more slowly (20 minutes should pass between first and last bites of a meal)
Drinking eight (8-oz) glasses of water a day
Use of daily food diary to keep track of consumption
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Physical activity
Activity needs to be tailored to the patient's needs and limitation. Centers for Disease Control and Prevention (CDC) guidelines for appropriate physical activity according to age and limitations can be found at www.cdc.gov/physicalactivity/everyone/guidelines/adults.html.
A general guideline of 30 to 40 minutes a day of aerobic exercise, three to four times a week for strenuous exercise; four to five times a week for moderate exercise. This may be done at divided times (i.e., three 10-minute sessions).
Moderate-intensity physical activity provides significant health benefits but needs to be done more often.
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Aerobic exercise may include (according to patient's ability)
Running/jogging
Brisk walking (3 mph)
Swimming
Bicycling more than 10 mph for strenuous exercise; less than 10 mph for moderate exercise
Cross-country skiing
Rowing
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Flexibility and resistance/strength training are important components of an exercise program and provide additional health benefits. Activities include
Light weight lifting
Resistance bands
Pilates
Yoga
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Pharmacotherapeutic options
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Pharmaceutic intervention may be helpful in patients with a BMI of greater than 30 kg/m2. This may also be helpful in patients who are slightly less obese (i.e., BMI of 27–29.9 kg/m2) but who have a comorbidity.
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Orlistat (Xenical), a pancreatic lipase inhibitor
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How it works
Blocks absorption of about 30% of ingested dietary fats
Not an appetite suppressant
Improves comorbid conditions related to obesity, especially hyperlipidemia and diabetes
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Dosage
120 mg orally, three times a day, taken just prior to a meal
In patients with side effects, medication may be started by taking one 120-mg tablet with the largest fat-containing meal of the day and gradually titrating up to advised dosage as patient adjusts.
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Side effects are directly related to amount of fat in meal consumed
Soft stools
Diarrhea (may be explosive and foul smelling)
Anal leakage
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Additional information
A daily multiple vitamin should be recommended because orlistat inhibits absorption of fat-soluble vitamins
An OTC preparation, Alli, is now available and U.S. Food and Drug Administration (FDA) approved; dosage is 60 mg three times a day.
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Phentermine (Adipex-P)
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How it works
Appetite suppressant
FDA approved for short-term use (up to 12 weeks) in adults only
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Dosage/administration: 37.5 mg three times a day
Best taken on an empty stomach 1 hour prior to a meal
If a dose is missed, take as soon as possible. Patient should never take two doses to make up for a missed dose.
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Side effects
Blurred vision
Dry mouth
Sleeplessness
Irritability
Stomach upset
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Constipation
Note: These side effects may occur in the first few days of use. The patient should be advised to call her prescriber if these symptoms persist.
Chest pain, nervousness, pounding heart, difficulty urinating, mood changes, or breathing problems—the patient should be instructed to call her prescriber immediately.
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Precautions
Women with high blood pressure, hyperthyroidism, glaucoma, diabetes, or mental health problems should not be prescribed Adipex-P.
Alcohol should not be used when taking Adipex-P. Alcohol can increase side effects, especially dizziness.
Should not be taken in pregnancy or while breastfeeding
Overdose symptoms may include confusion, diarrhea, nausea, rapid breathing, restlessness, GI symptoms (nausea, vomiting). If these symptoms are present, the patient should be instructed to call her local poison control center or hospital emergency room immediately.
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Diethylpropion hydrochloride (Tenuate)
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How it works
Appetite suppressant
FDA approved for short-term use (up to 12 weeks) in adults only
Recommended for use in patients with an initial BMI of greater than 30 kg/m2 who have not responded to a diet and/or exercise regimen
Not for use with another weight-loss medication
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Dosage/administration
Conventional tablets: 25 mg three times daily, taken 1 hour prior to meals. Note: An additional 25-mg dose may be taken midevening if necessary to overcome hunger.
Extended-release tablets: 75-mg tablet taken midmorning; must be taken whole
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Side effects
Dizziness
Headache
Sleeplessness
Blurred vision
Overstimulation
GI complaints, constipation, vomiting
Rash
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Precautions
Should not be taken when pregnant or nursing
Should not be prescribed to patients who have arrhythmias, hypertension, epilepsy, glaucoma, arteriosclerosis, history of drug abuse, known heart murmur, or valvular disorder
Potential for abuse, psychological dependence is possible. Use with caution in patients who have known mental health issues.
Prescribe and dispense in smallest feasible quantities to minimize possibility of overdosage.
Should not be used within 14 days of monoamine oxidase (MAO) inhibitor therapy
Alcohol should not be used while taking diethylpropion HCl.
Should not be used concomitantly with other appetite suppressant preparations, including herbal and OTC preparations
Mental alertness and physical coordination may be impaired. Patients should not operate machinery or drive until they know the effect of the drug.
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Phendimetrazine (Obezine, Bontril PDM, Plegine, and Anorex, to name a few)
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How does it work?
Appetite suppressant
FDA approved for short-term use, up to 12 weeks
Recommended for use in patients with an initial BMI of greater than 30 kg/m2 who have not responded to diet and/or exercise regimen
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Dosage/administration
35 mg (immediate-release tablets), taken three times daily in 4-hour intervals
105 mg (extended-release tablets) are classified by the Drug Enforcement Administration as a Schedule III controlled substance. The extended-release capsule is taken in the morning 30 to 60 minutes before morning meal.
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Side effects
Insomnia
Nervousness/restlessness/agitation
Dizziness
Blurred vision
Dryness of mouth
GI symptoms, nausea, diarrhea, constipation, stomach pain
Palpitations/tachycardia
Elevated blood pressure
Urinary frequency, dysuria
Overdose symptoms include confusion, belligerence, hallucinations, and panic attack and should be handled as an emergency in a hospital emergency room setting.
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Precautions
Should not be used in pregnancy or lactation
Should not be used concomitantly with other appetite suppressant preparations, including herbal and OTC preparations
Should not be prescribed to patients who have hypertension, diabetes, hyperthyroidism, glaucoma, known heart murmur, or valvular disease and to agitated patients or patients with a history of substance abuse. Alcohol use should be avoided.
Should not be used for patients on MAO inhibitors or within 14 days of discontinuing use.
Because mental alertness and physical coordination may be impaired, patients should not drive or operate machinery until they know the effect of drug.
Potential for dependence. Abuse may be associated with intense psychological dependence and severe social dysfunction. Patients exhibiting these symptoms should be seen in a hospital emergency room setting. Overdose can result in convulsions, coma, and death.
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Other medications have been associated with weight-loss pharmacology. They include
Bupropion (Wellbutrin), an antidepressant
Topiramate (Topamax), an antiseizure medication
Zonisamide (Zonegran), an antiseizure medication
Metformin, a diabetes treatment
Note: We have not elaborated on these as first-line weight-loss pharmaceuticals because their use is off label.
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Herbal or alternative medications
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Currently not recommended as alternative medications
Not under any regulation
Ingredients (i.e., ma huang) possess the potential for serious side effects
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Behavioral
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Stimulus control
Identifying factors contributing to overeating and underexercising
Identify ways in which contributory factors may be eliminated
Structuring mechanism for elimination of the negative stimuli
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Stress management
Meditation, progressive relaxation
Guided imagery
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Cognitive restructuring
Identification of inner dialogue (i.e., self-talk, distorted/negative self-image)
Replacement of these negative and self-defeating cognitions with more positive ones
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Social support
Seek out support/educational groups as noted in Treatment, VIII.F.1
Join and participate in exercise groups and other recreation programs geared toward physical well-being and body conditioning
Seek support systems within family or peer group
Daily journal
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Surgical
May be considered for patients who have failed trials of diet, lifestyle changes, pharmacotherapy
Most often used for patients younger than age 55 in good health with a BMI greater than 40 kg/m2 and possessing a significant cofactor
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Prior to surgery, patient should undergo assessment by multidisciplinary team. Assessment should include the following areas:
Medical
Surgical
Psychological
Nutritional
Patient should be well motivated and well informed about potential benefits and risks
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Types of procedures
Gastric banding—restricting gastric volume
Roux-en-Y gastric bypass—in addition to restricting volume alters digestion
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Success rates
Regardless of procedure, most patients lose one half to two thirds their excess weight within 18 months.
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Risks/side effects
Postoperative wound infection
Atelectasis
Dehiscence
Deep vein thromboembolism
Anastomotic leaks
Marginal ulcers
Pouch and distal esophageal dilation
Persistent vomiting
Cholecystitis
Development of dumping syndrome
Vitamin deficiencies (i.e., B12, folate, iron)
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Other
Preconception counseling
Preconception weight stabilization
Counseling of pregnant women regarding micronutrient and vitamin supplementation and close monitoring for appropriate weight maintenance and weight gain
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BMI greater than 40 kg/m2 (morbidly obese)
Psychiatric disorder (bulimia/depression)
Sleep apnea
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Uncontrolled cofactor
Hypertension
Diabetes
Heart disease
Assessment and treatment for insulin resistant syndrome (consider endocrinologist)
Medication
Weight checks on regularly scheduled contracted schedule—4 weeks, if no adverse events and weight loss is being achieved
Measurements as part of weight checks
Review and reassessment of goals on regular schedule
Review of food and exercise diaries
Review and assessment of problems, concerns, and side effects associated with pharmaceutical interventions
The NFP guideline was developed by the late Eleanor Tabeek, RN, PhD, CNM, and is used with her permission and that of her family. Updates for subsequent editions by Nancy Keaveney, BS, RN, Mary Finnigan, BA, MA, and for this edition Melissa K. Perez, MS, RN, WHNP-BC, clinical instructor, W. F. Connell School of Nursing, Boston College.
World Health Organization: Hormonal contraceptive methods for women at high risk of HIV and living with HIV. Recommendations concerning the use of hormonal contraceptive methods by women at high risk of HIV and women living with HIV 2014 guidance statement.
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