CE Feature: ADULT OBESITY
Use Your Team's Might to Drive Back Obesity
Christie, Catherine RD, LD/N, FADA, PhD; Meires, Jan EdD, FNP, BC; Watkins, Julia A. PhD
Dr. Christie is Director of the Nutrition Program and MSH/ Dietetic Internship, Department of Public Health, Brooks College of Health, University of North Florida, Jacksonville
Dr. Meires is an Assistant Professor in the Colleges of Nursing and Medicine, University of North Florida, Jacksonville
Dr. Watkins is an Assistant Professor in the Department of Public Health, University of North Florida, Jacksonville
AUTHOR DISCLOSURE: The authors disclose that they have no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.
How many patients did you see this week that were slim and fit? Unless your experience is very different from the norm, you probably have not seen many that meet the slim and fit description. Consider the steps you have taken to provide an optimal environment for weight management. If this environment includes a transdisciplinary team, then you are on the right track.
A transdisciplinary team approach inherently combats fragmentation issues and reduces or eliminates service duplication. In its report, Health Professions Education: A Bridge to Quality, the National Academy of Sciences1 listed five core competencies for all health professions, including “work in interdisciplinary teams—cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable.”
Incidence and Prevalence
Obesity represents the most pressing health problem today as prevalence rates reach epidemic levels. Within the United States, the most recent age-adjusted prevalence surveys among adults (older than 20 years of age) report 65% are overweight (body mass index [BMI] higher than 25), 31% are obese (BMI higher than 30),2,3 and 300,000 adult deaths per year are attributed to obesity.3 Compared to normal weight (BMI 20 to 25), the obese have a 50% to 100% increased risk of premature death from all causes and 2 to 5 years less life expectancy.4 Twenty to 30-year-old females and males with a BMI higher than 45 have a reduced life expectancy of as much as 8 and 15 years, respectively.5 Obesity and even moderate weight gain pose a significant risk for developing obesity-related morbidities, such as coronary heart disease, hypertension, and diabetes. Prevention and treatment of weight gain has been shown to directly impact the morbidity and mortality associated with obesity.6
Although all adults are at risk for obesity and obesity-related complications, the poor and some ethnicities, such as African-Americans, are disproportionately affected by many obesity-related health conditions, including metabolic syndrome, diabetes, heart disease, cancer, and infant mortality.7–9 African-American women are more likely to be overweight or obese than white men/women and African-American men.8,10,11 The absolute risk of mortality in women is higher with the presence of three or more obesity-related comorbidities comprising metabolic syndrome. These include a waist circumference of greater than 88 cm, triglycerides equal to or greater than 150 mg per dL, high density lipoprotein cholesterol less than 50 mg per dL, blood pressure equal to or higher than 130/85 mmHg, and fasting glucose equal to or greater than 110 mg per dL.
The consequences of obesity include significant morbidity and mortality. The obese are more prone to develop hypertension, type 2 diabetes mellitus, coronary artery disease (CAD), peripheral arterial disease, depression, hyperlipidemia, degenerative joint disease, certain cancers, gall stones, gastroesophageal reflux disease, renal dysfunction, skin rashes, and metabolic syndrome, which is a prediabetic condition. Metabolic syndrome consists of elevated blood pressure, elevated blood glucose level, increased waist circumference, and lipid abnormalities. In young and middle-aged adults, the relative risks for developing CAD and type 2 diabetes are proportional to the degree of obesity and the presence of metabolic syndrome. Even a modest weight loss (5% to 10%) in these individuals can reduce the mortality and morbidity.6,12
Simply defined, obesity is an excess of adipose tissue in relation to lean body mass. Clinicians judge obesity in adults by calculating the BMI and obtaining a waist circumference. The BMI closely correlates with excess fatty tissue and is calculated by dividing measured body weight in kilograms by the height in meters squared. A healthy adult BMI ranges from 18.5 to 24.9, while an overweight adult BMI ranges from 25 to 29.9. Class 1 obese adults have BMI in the 30 to 34.9 ranges, while Class 2 obese adults have BMI in the 35 to 39.9 range. Class 3 adults are morbidly obese with BMI higher than 40.6
Factors other than the ratio between height and weight help clinicians recognize obesity. A waist circumference greater than 35 inches (88 cm) in female adults and greater than 40 inches (102 cm) in male adults indicates excessive body fat in the form of central obesity. Central obesity is a known risk factor for metabolic syndrome, heart disease, stroke, type 2 diabetes, some cancers, and early death.6,12
The Transdisciplinary Approach
The transdisciplinary approach to managing obesity means multiple medical disciplines working together. The transdisciplinary team reinforces the same information to encourage patients to make positive changes in diet and exercise to manage their weight (see Figure: “Adult Obesity Management: A Trandisciplinary Approach”). The core team may be comprised of a physician, nurse practitioner (NP), and registered dietitian with referral to behavior management specialists and bariatric surgeons, as needed. Although roles may overlap, each specialty has individualized roles in care with specific outcome indicators. For example, the NP may be the initial contact who will conduct a history and physical examination, diagnose overweight/obesity, help the patient set goals, review the family history for disease risk factors, assess readiness, and discuss possible treatments before referring the patient to the registered dietitian for personalized nutrition assessment and counseling.
Figure. Adult Obesit...Image Tools
The U.S. Preventive Services Task Force13 recommends “intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease” and regular moderate to vigorous exercise to prevent and treat obesity. Successful long-term weight-loss interventions include improved nutrition and enhanced exercise with improved self-efficacy.
Studies have determined self-efficacy as a mediator related to the successful adoption of health-promoting behaviors14 including the recommended daily intake of fruits and vegetables, low-fat and high-fiber foods, and moderate levels of physical exercise.15 Bandura's self-efficacy theory16 states that perceived self-efficacy regarding the performance of a specific behavior is extremely predictive of ability to do the behavior, and self-efficacy expectations are situation-specific as well as mediators to change behavior. Overweight or obese individuals have reportedly low self-efficacy regarding the selection of healthy foods and strategies to enable and reinforce physical activity.15,17–19 In order to increase knowledge and skills related to food choice, calorie values, and exercise behaviors, the registered dietitian will focus on education regarding the following topics (to be reinforced by other team members during regular office visits): food calorie values (personalized to the patient's eating habits), portion size reduction, limiting calories from alcohol and other beverages, adequate water intake, over-consumption of high-calorie foods (both high fat and high carbohydrate) when dining out, food preparation skills, new habits of food shopping with grocery store tours and healthy shipping lists, evaluation of food labels to facilitate healthy choices, understanding food composition, including carbohydrate, fiber, fat, and protein content as well as the relationship of those food components to satiety.20,21
Primary care providers may consider prescribing weight-loss medications after organic causes of obesity are excluded and trials of diet and exercise have produced limited results. Currently, the two medications approved for long-term weight loss are the lipase inhibitor orlistat (Xenical) and the mixed neurotransmitter reuptake inhibitor sibutramine (Meridia). Both are to be used as an adjunct to lifestyle changes, including a reduced calorie diet.6,22
Orlistat (Pregnancy Category B and not recommended for nursing mothers) is the first weight-loss medication approved for obesity that works in the gastrointestinal tract to reduce fat absorption through inhibition of intestinal lipase,6,22 thus reducing up to one-third of the amount of dietary fat (150 to 200 kilocalorie per day) that is absorbed.23 Adult patients are instructed to take one 120 mg (capsule) with reduced calorie meals (during or up to 1 hour after meal) three times a day. The dose is omitted if a meal is missed or has no fat. Contraindications for the drug include cholestasis and chronic malabsorption syndrome. Orlistat should be used with caution (if at all) in patients with hyperoxaluria and nephrolithiasis. Those on antidiabetic medication need to be monitored as weight loss may indicate a dose reduction. Unpleasant adverse reactions, such as flatus with discharge, oily spotting and evacuation, fecal urgency, and incontinence may occur, providing additional reinforcement for lowering fat intake. Interactions include a reduction in absorption of fat-soluble vitamins and beta-carotene, thus daily supplementation with a multivitamin/mineral is recommended.6,22,23 Clinicians should monitor patients taking warfarin (Coumadin) and cyclosporine while simultaneously taking orlistat.22
Sibutramine (Schedule IV, Category C [not recommended for nursing mothers]) is a combination serotonin-norepinephrine reuptake inhibitor that acts on the central nervous system to reduce hunger, increase the feeling of fullness, and lessen the drop in metabolic rate often accompanying weight loss.6,22,23 Those taking sibutramine (indicated for patients with a BMI higher than 30 or BMI higher than 27 with cardiovascular risk factors) tend to eat fewer calories per day, resulting in a 5% to 10% weight reduction. Type 2 diabetic patients may have improved lipid and glycemic profiles while on the drug.23 Typically, adults are started on 10 mg of sibutramine (range 5 to 15 mg per day) with dose adjustment according to tolerance and weight-loss results. Contraindications/precautions include organic causes of obesity, impaired liver or renal function, anorexia nervosa, bulimia nervosa, seizure disorder, narrow angle glaucoma, uncontrolled or poorly controlled hypertension, CAD, heart failure, stroke, arrhythmias, use of monoamine oxidase inhibitors, and simultaneous use of central acting appetite suppressants. Patients may complain of dry mouth, insomnia, tachycardia, headache, nervousness, mydriasis, constipation, and other discomforts. Prescribers should obtain a detailed pharmacology history to determine if patients are taking medications and/or other substances that will cause drug-to-drug interactions with sibutramine such as selective serotonin reuptake inhibitors, sumatriptan, opioids, and others. It is important to teach patients the indications and effects of this drug and provide them with written instructions to avoid alcohol and certain over-the-counter preparations (cold medicine, decongestants, antibiotics, such as azoles, mycins, and those metabolized by CYP3A4). Additionally, it is imperative to monitor the effects of the drug (such as weight loss) and potential adverse effects such as elevated pulse rate, blood pressure, and increased intraocular pressure among others.22
Sympathomimetic medications are sometimes used for short-term therapy in conjunction with lifestyle changes but are generally used less frequently as they have significant adverse reactions. Sympathomimetic medications are controlled medications (Schedule III-IV) and include phentermine, phendimetrazine, benzphetamine (Didrex), and diethylpropion.22 Before prescribing such medications, clinicians need to be fully familiar with the medication's name, legal category, class, indications, dose, contraindications, precautions, interactions, adverse actions, and how the medication is supplied. Referral to the physician can facilitate drug therapy if the NP is inexperienced with these medications and/or is not licensed to write scheduled drugs. Although most scheduled drugs have limited utility, they can be used to help some obese patients begin to lose weight as lifestyle changes are initiated.
Alternative treatments such as bariatric surgery are reserved for those with extremely high health risks related to obesity. The National Institutes of Health Consensus Panel Recommendations state that bariatric surgery should be reserved for patients with BMI higher than 35 with extremely high health risk.4
Successful weight-loss maintenance is an intentional loss of at least 10% of initial body weight and keeping it off for at least 1 year.24 A significant decrease in risk of obesity-related morbidity and mortality is correlated with loss and maintenance of 5% to 10% of body weight and is therefore used as a marker of successful weight-loss maintenance.25–28 Overall, weight-loss maintenance success rates are between 20% and 50%.26,29 Individuals receiving extended care following weight-loss treatment are significantly more successful in preventing weight regain.30 Despite the relationship between weight-loss maintenance and reduced obesity-related morbidity and mortality, the majority of adults that lose 10% of their body weight regain two-thirds of that weight within 1 year and essentially all of it within 5 years following treatment.31
The National Weight Control Registry, which follows adults who have been successful in losing and maintaining weight over 5 years,32 reveals that adoption of healthy behaviors including self-monitoring (food intake and physical activity), eating breakfast each day, and following a low-fat three-meal/two-snack-a-day food plan are key factors.
Many studies have demonstrated that the major barrier to successful weight-loss maintenance is insufficient time for long-term behavior change.33 Clinical trials studying weight-loss maintenance have established that frequent physical activity is significantly associated with greater weight-loss maintenance in addition to continued professional contact with the transdisciplinary team, skills training, and social support.25,34,35 Furthermore, long-term weight-loss maintenance improves over time36 and as self-efficacy is increased.37 Factors that impede positive weight-loss maintenance outcomes include binge eating, hunger, eating in response to negative emotions, and stress.34 The transdisciplinary team should continue to monitor both eating and exercise behaviors at each office visit to provide continued skills training and support.
Adult obesity is a common health problem associated with significant adverse health outcomes leading to a vast array of comorbidities and premature death. Evidence-based guidelines support strategies aimed at intensive behavioral counseling and regular, moderate physical exercise for prevention and treatment of adult obesity. Two medications, orlistat and sibutramine, are available to successfully enhance weight-loss efforts for some patients. Newer treatment strategies for combating obesity call for use of a transdisciplinary care team anchored by a registered dietician and a nurse practitioner and supported by primary and specialty care physicians.
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14. Watkins J, Howard-Barr EM, Moore MJ, et al. The mediating role of adolescent self-efficacy in the relationship of parental practices and adolescent alcohol use. J Adolesc Health. 2006;Apr;38(4):448–450.
15. Prodaniuk TR, Plotnikoff RC, Spence JC, et al. The influence of self-efficacy and outcome expectations on the relationship between perceived environment and physical activity in the workplace. Int J Behav Nutr Phys Act. 2004;Mar 15;1(1):7.
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18. Stunkard AJ, Allison KC. Binge eating disorder: disorder or marker? Int J Eat Disord. 2003;34:Suppl:S107–116.
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21. Meires J, Christie C, Kruger B, et al. Rural families: an analysis of focus group data regarding weight management and risk factor reduction. J Am Diet Assoc. 2005;105(8):A-31.
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24. Institute of Medicine: Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.
25. Anderson JW, Konz EC, Frederich RC, et al. Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr. 2001;Nov;74(5):579–584.
26. Blackburn GL, Waltman BA. Evidence-based approach to the evaluation of weight-loss programs. Obesity Management. 2005;Aug;1(4):134–135.
27. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;Feb 7;346(6):393–403.
28. Perri MG, Fuller PR: Success and failure in the treatment of obesity: where do we go from here? Med Exerc Nutr Health. 1995;4:255–272.
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36. Lantz H, Peltonen M, Agren L, et al. A dietary and behavioral program for the treatment of obesity. A 4-year clinical trial and a long-term posttreatment follow-up. J Intern Med. 2003;Sep;254(3):272–279.
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- Articles in PubMed by Catherine Christie, RD, LD/N, FADA, PhD
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