Managing Obesity

INTRODUCTION

Understanding the most effective management strategy for obesity—including diet, activity, counseling, technology, acupuncture, and economic incentives—can improve clinical skills and the patient—provider relationship. This article reviews and summarizes up-to-date information on the treatment of obesity while focusing on communication and counseling techniques.

EPIDEMIOLOGY

In 2013, the worldwide prevalence of obesity was 36.9% in men and 38% in women. This prevalence is significantly higher in developed countries than in developing countries and increased dramatically between 1980 and 2013.¹Obesity is associated with myriad complications including an overall poorer health-related quality of life.²

DIAGNOSIS

Obesity is defined as a body mass index (BMI) of greater than or equal to 30. BMI is a measure of body fat based on height and weight. A healthy adult should have a BMI between 18.5 and 24.9. Overweight adults have a BMI between 25 and 29.9. Obesity is divided into 3 classes.

COMPLICATIONS

Obesity results in an increased risk of overall mortality and lifetime impact of disability and morbidity.^3,4It is associated with a greater risk of cardiovascular disease, specifically coronary heart disease, stroke, heart failure, atrial fibrillation, and venous thromboembolism.⁵Obesity during pregnancy increases the risk for complications that accompany other conditions, such as pregnancy-induced hypertension, antepartum venous thromboembolism, labor induction, cesarean delivery and wound infection, and fetal and neonatal mortality.⁶

Furthermore, obesity and lack of exercise increase a person’s risk for type 2 diabetes as well as many types of cancers in both men and women.^7,8Obesity in middle and late life is also associated with an increased risk for dementia, gastrointestinal disease, and liver disease.^9-11

TREATMENT

The primary treatment for obesity is weight loss through diet and exercise. Weight loss of 5% to 15% greatly reduces complications in obese persons.¹²Other strategies include behavioral and cognitive behavioral therapy.¹³Acupuncture and medication have also demonstrated some efficacy in treating obesity.¹⁴

DIET

When counseling obese patients, explain that their caloric expenditure must exceed caloric intake for any diet to effectively result in weight loss. Specifically, an adult can lose 1 to 2 pounds per week if they consume 500 to 1000 fewer calories per day. In general, diets that consist of low-carbohydrate and high-protein foods are associated with more weight loss than other diets.¹⁵Patients increasing their vegetable and fruit intake can help contribute to weight loss as well.¹⁶In addition, reducing the amount of dietary sugar consumed can result in significant weight loss.¹⁷Other effective ways to lose weight include following a Mediterranean diet.^18,19Encouraging patients to use portion control can also be effective.²⁰

Finally, research suggests that drinking 500 mL of water before meals results in increased weight loss in obese and overweight adults.²¹

ACTIVITY

The American College of Sports Medicine recommends exercise and diet to treat obesity in adults. This combination is more likely to reduce weight than either intervention alone.²²Moderate intensity exercise, such as a brisk walk or a gentle swim for greater than 150 minutes per week, can result in sustained weight loss.²³Although prolonged resistance training is not effective for weight loss, it can improve the patient’s cholesterol profile, insulin resistance, and blood pressure.²⁴Furthermore, some study results suggest that lifestyle physical activity (ie, raking leaves, using stairs instead of the elevator, and brisk walking) can be as effective as a structured exercise program in promoting weight loss over 2 years.²⁵

COUNSELING

A 2006 study mailed surveys to US residents and asked about their successful and unsuccessful weight-loss strategies. With 6207 responses, the study results showed that the most successful strategies reported by participants included²⁶:

• Exercising more than 30 minutes per day
• Adding physical activity to daily life
• Using fewer nonprescription diet products
• Meal planning on most days of the week
• Tracking calories
• Tracking fat
• Measuring food on the plate
• Weighing oneself daily
• Lifting weights

Similarly, research suggests that regular self-weighing improves weight loss without increased adverse psychological outcomes.²⁷Providing individual obesity-management education and counseling in the primary care setting can result in modest weight loss, and research demonstrates that this is actually more effective than medication.²⁸

Counseling in the primary care setting often involves brief monthly visits that include measuring the patient’s BMI and providing diet and activity education. Advice can increase the patient’s awareness of the health risks of obesity and motivate patients to continue pursuing their weight-loss goals.

TECHNOLOGY-BASED COUNSELING

Over the past decade, numerous computer-based weight-loss programs and nutritional applications have been developed. A 2012 systematic review evaluated the efficacy of computer-based interventions for weight loss in 2537 adults. The study found that computer interventions have a modest benefit compared with no intervention; however, they are not as effective as in-person counseling from the patient’s primary care provider.²⁹

Another recent 2016 study analyzed the main features of 13 nutrition-related mobile phone apps and compared their strategies for dietary assessment and user feedback.³⁰This study found that a majority of apps offered a food diary, portion size selection, physical activity tracking, and motivational coaching. One app called Fat Secret connected patients with their health care provider, and another called S Health provided a unique nutrient balance score. Although research suggests that patients who use apps are not more or less likely to lose weight than those who do not, other study results reveal that combining apps with weight-loss groups leads to significant sustained weight loss.^31,32

ECONOMIC INCENTIVES

A newer approach to weight loss includes economics incentives. A 2013 randomized trial published in theAnnals of Internal Medicinecompared a control group with individuals who received $100 per month for meeting weight-loss goals and groups who split $500 per month for meeting weight-loss goals.³³The study found that group-based financial incentives increased weight loss more than individual-based incentives or none at all.

ACUPUNCTURE

Although often forgotten, acupuncture can help patients achieve their weight-loss goals as well. A systematic review published in 2009 found that acupuncture was associated with significant weight loss in obese patients compared with conventional treatments alone.³⁴In the study, acupuncture resulted in the loss of an additional 4.2 pounds. Self-applied acupressure, on the other hand, is not as effective as acupuncture and is not a recommended treatment for obesity.³⁵

FOLLOW-UP

For patients with weight-loss goals, follow-up is essential. Monthly appointments offer primary care providers the opportunity to reassess vital signs, weight circumference, and BMI and reinforce health education.

Here are the ICD-10 codes related to obesity. ICD-10 is a medical classification list by the World Health Organization:

• Z71.3 dietary counseling and surveillance
• E66 obesity
• E66.0 obesity due to excess calories
• E66.1 drug-induced obesity
• E66.2 extreme obesity with alveolar hypoventilation
• E66.8 other obesity (use for morbid obesity)
• E66.9 obesity, unspecified

Melissa DeCapua, DNP, PMHNP-BC, is a psychiatric nurse practitioner with a clinical background in psychosomatic medicine. She now works as a design researcher in the technology industry, guiding product development by combining her clinical expertise and creative thinking. She is a strong advocate for empowering nurses, and she fiercely believes that nurses should play a pivotal role in shaping modern health care. For more about Dr. DeCapua, visit her website at melissadecapua.com and follow her on Twitter @melissadecapua.

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