By Traci Haynes, MSN, RN, BA, CEN
Obesity is one of the greatest public health challenges of this century. It affects more than 600 million people worldwide. The United States leads the world in the number of obese individuals (Khan, 2016). By 2025, a study in the Lancet estimates 43 percent of women and 45 percent of men in the United States will be obese (Lancet, 2016).
There are many tools used to assess for obesity. They include body mass index (BMI) also known as the Quetelet Index, waist circumference, waist-to-hip ratio (WHR), duel-energy x-ray absorptiometry (DEXA), underwater weighing (hydrostatic weighing), isotope dilution, skin calipers, and bioelectric impedance analysis (BIA). The most commonly used tool is BMI, although there is increased use of waist circumference and WHR because of their significance to certain comorbidities.
BMI is weight divided by height in inches squared. There are graphs to calculate BMI or if Internet access is available, then the two measurements can be typed into a BMI calculator. Results less than 18.5 indicate underweight, while 18.5-24.9 is normal, 25-29.9 is overweight, 30-34.9 is obese level I, 35-39.9 is obese level II, and over 40 is extreme, severe, or morbidly obese. For people with severe obesity, life expectancy is reduced by as much as twenty years in men and by about five years in women. The greater reduction in life expectancy for men is consistent with the higher prevalence of android (abdominal) obesity and the higher percent of body fat in women.
BMI is not a perfect measurement, however. Although it typically correlates closely with percent of body fat, some important caveats apply to its interpretation. In mesomorphic or muscular individuals it is not considered accurate as muscle weighs more than fat. It’s important to note that athletes typically skew higher on their BMI index. Also, in some individuals a typically normal BMI may conceal underlying excess adiposity characterized by an increased percent of fat mass and reduced muscle mass.
WHR is calculated as waist measurement divided by hip measurement. The WHO defines obesity in females as being greater than 0.85 and greater than 0.90 in men. Waist circumference should not exceed 35 inches in women and 40 inches in men. Waist circumference and WHR have been used as an indicator or measure of health and the risk of developing serious health conditions. Research shows that people with “apple-shaped” bodies (more weight around the waist), face more health risks than those with “pear-shaped” bodies who carry more weight around the hips. The WHR has been shown to be a better predictor of mortality in older people than waist circumference or BMI. However, other studies have found waist circumference, not WHR, to be a good indicator of cardiovascular risk factors and hypertension in type 2 diabetes.
Obesity carries a negative connotation in numerous societies because of the emphasis that society places on the importance of physical appearance. As a result, individuals with obesity often face prejudice and discrimination (stigmatization) at work, at school, and in the community. Consequently, they may engage in maladaptive eating patterns, binge-eating behaviors, avoidance of physical activity, and increased calorie consumption.
Stigmatization can also occur in the healthcare setting. Physicians, nurses, and other healthcare professionals have self-reported bias and prejudice against overweight and obese patients. Patients who feel stigmatized are more likely to avoid routine preventive care or they may cancel appointments. They may receive compromised care, or there may be a delay in seeking medical attention, which can lead to delayed discovery or treatment of a comorbid condition.
The Rudd Center for Food Policy and Obesity in association with Yale University developed a toolkit for healthcare professionals to help improve clinical practice. Another resource is the Stop Obesity Alliance, which offers “Why Weight? A Guide to Discussing Obesity & Health With Your Patients.” Appreciating the complexity of this disease is an important prerequisite for productive and positive conversation about weight. More and more resources are available for individuals with obesity. One example is the National Obesity Care Week, which is a collaborative effort of the STOP Obesity Alliance, the American Society for Metabolic and Bariatric Surgery (ASMBS), the Obesity Action Coalition (OAC), and the Obesity Society (TOS).
Now, more than ever, healthcare professionals, policymakers, industry, and patient communities must examine their personal perspectives and biases related to obesity and take action to treat obesity as the serious and complex disease it is. The bad news is 80 percent of all diets fail. Of the 20 percent of dieters who do lose weight, approximately 95 percent regain what they lost (or more). Only 5 percent of dieters who lose weight maintain weight-loss. Many diets are not nutritionally balanced, fast food and convenience foods are readily available, and passive entertainment has become the norm (Kline, D., Goedkoop, S., & Bhimji, S., 2014).
The good news is weight loss will bring added energy and better health. A weight loss of 3 percent will reduce blood glucose levels, while a weight loss of 5-10 percent will begin to lower blood pressure, raise HDL, and diminish sleep apnea. A sustained weight loss results in significant health gains. Losing weight and sustaining weight loss is a challenging balance. The average weight loss for most people is 5 to 15 percent and research shows that weight loss takes longer than expected. It sometimes takes a year or more (Kline, D., Goedkoop, S., & Bhimji, S., 2014).
Treatment includes behavior changes especially related to diet and exercise. Unless an individual acquires new eating and physical activity habits, long-term weight reduction is unlikely to succeed. Behavior therapy includes reinforcement that changing eating and physical activity habits will result in a change in body weight. Patterns of eating and physical activity are learned behaviors and can be modified. To alter these patterns over the long term, the environment must be changed.
Learning self-monitoring, stress management, stimulus control, problem solving, contingency management, and cognitive restructuring, especially in setting specific goals, will result in a greater chance of being accomplished. Evidence from the National Weight Control Registry (NWCR), which tracks indices and predictors in individuals who have lost at least thirty pounds and have maintained weight loss for at least one year suggests that patterns associated with successful weight maintenance include self-monitoring of weight, consumption of a low-fat diet, daily physical activity of approximately sixty minutes, minimal sedentary “screen time,” and consumption of most meals at home (NWCR, 2015).
Beyond changing eating habits and increasing physical activity is becoming educated about the body and how to nourish it appropriately, engaging in a support group or extracurricular activity, and setting realistic goals. Individuals who are more actively involved in their healthcare experience have better health outcomes and incur lower costs. This requires educating individuals about their condition and involving them more fully in making decisions about their care, engagement, and activation.
There are numerous diets available. However, it is important to note that many diets don’t provide adequate nutrition. An excellent source for assessing the myriad of diets is available from WebMD. The best way to lose weight and keep it off is a commitment to a lifelong process of proper diet and regular exercise. A diet should include all of the recommended daily allowances (RDAs) for vitamins, minerals, and protein. It should contain plenty of water and fiber and be low in calories. A weight loss program should be directed toward a slow, steady weight loss and include plans for weight maintenance after the weight loss phase is over.
One pound is equal to 3500 calories. Therefore, an individual has to burn 3500 calories more than they consume to lose one pound. Current guidelines recommend lowering energy intake by 500-1000 kcal per day to achieve a weight loss of one to two pounds per week (Goldsmith, C. & Lehrman, S., 2014). Paying attention to the energy value of different foods is essential. Energy dense foods generally have a high caloric value in a small amount of food, while low energy dense foods contain relatively few calories per unit of weight or fewer calories in a large amount of food. Examples of high-energy dense foods include foods that contain animal fats, fried foods, fast foods, sweets, butter, and high-fat salad dressings. Low energy dense food includes vegetables, fruits, lean meat, fish, grains, and beans. It is important to keep in mind portion control and portion distortion and how it has dramatically changed over the years contributing to this disease.
Recommendations for physical activity include at least thirty minutes of moderate-intensity aerobic activity at least five days per week for a total of 150 minutes. Or at least twenty-five minutes of vigorous aerobic activity three days per week for a total of seventy-five minutes. Or a combination of moderate- and vigorous-intensity aerobic activity and moderate- to high-intensity muscle-strengthening activity at least two days per week for additional health benefits.
For lowering blood pressure and cholesterol, an average of forty minutes of moderate- to vigorous-intensity aerobic activity three or four times per week is recommended. Benefits of exercise include improved blood sugar control, increased insulin sensitivity (decreased insulin resistance), reduced triglyceride levels, increased HDL levels, lowered blood pressure, reduction in abdominal fat, reduced risk of heart disease, and release of endorphins (AHA, 2015).
Treatment may involve the addition of medications or ultimately surgery. Medications may amplify adherence to behavior change and may improve physical functioning or make increased physical activity easier in those who cannot exercise initially. However, they are only used in individuals who have health risks related to obesity and only used as an adjunct to dietary modifications and an exercise program.
If an individual’s response to weight loss medications is deemed effective (a weight loss of greater than or equal to 5 percent of body weight at three months) and safe, it is recommended that the medication be continued. If deemed ineffective, or if there are safety or tolerability issues, it is recommended that it is discontinued.
Medicare does not cover medications for obesity, nor do most other insurers. Currently, the three major groups of medications to manage obesity are: 1) centrally acting medications that impair dietary intake; 2) medications that act peripherally to impair dietary absorption; and 3) medications that increase energy expenditure. There are medications that cause weight loss as a side effect and include a diabetic medication an anti-depressive medication and an anti-seizure medication (Endocrinology Advisor, 2015).
Weight loss surgery, known as bariatric surgery, is recommended for people who have clinically severe obesity and have failed to lose weight through diet and exercise. It is recommended for people with a BMI of 40 or greater or BMI over 35 with a serious health problem linked to obesity, men who are one hundred pounds overweight and women who are eighty pounds or more overweight. Weight loss surgery provides clinically significant and relatively sustained weight loss in individuals with severe obesity associated with comorbidities. However, it is expensive, highly procedure, and surgeon specific and not the solution for the growing obesity epidemic.
Emerging research suggests that some complementary and alternative medicine (CAM) therapies may help manage obesity-related conditions. More can be found at The National Center for Complementary and Alternative Medicine’s website, which is part of the National Institutes of Health (NIH).
The disease of obesity is recognized as a growing epidemic, and there is a tremendous amount of research being conducted for the population affected. Building awareness of the disease has also contributed to support groups, coalitions, an increase in educational resources, and health coaching.
Care delivery through an integrated mix of healthcare providers and practitioners, such as physicians, nurses, and dietitians, could play an effective role in combatting obesity and its related chronic diseases. Having a health coach that has knowledge of this disease, its etiology, and contributing factors as well as associated comorbidities, an understanding of stigmatization and bias, past behaviors and those behaviors necessary for change can engage and activate the individuals with obesity and make an enormous impact on helping them to achieve and maintain change for a healthier lifestyle.
A health coach can also provide resources of all types, such as support groups, social services, referrals, and educational documents. A key part of health coaching is utilizing motivational coaching techniques in seeking to understand the person’s frame of reference. The objective is not to solve the individual’s problem but to help them begin to believe change is possible. Techniques are designed to help motivate the individual in a collaborative nature, understand their perspective, and assist them in finding their own solutions, while affirming the freedom to change, thereby allowing them to discover their own motivation.
Having a software solution that provides the framework for coaching interactions and allows the frequency of contact specific to the individual’s needs is one approach in care delivery. It should also include comorbidity coaching, health information, referral capabilities, and a mechanism to set goals and follow-up on these goals, outcome reporting including adherence, and follow-up letters to both the patient and their providers.
The prevalence of obesity continues to grow in the US and worldwide. It affects everyone in some way, but most profoundly affects those with the disease. Interventions are necessary to help control and reverse this epidemic. Health coaching is one way in which to facilitate ongoing interventions with the individuals whom so desperately need clinician oversight.
Traci Haynes, MSN, RN, BA, CEN, is the director, clinical services at LVM Systems, Inc.
[Part 1 of this article was in the April/May issue of AnswerStat.]
- American Heart Association (AHA). (2015). American heart association recommendations for physical activity in adults.
- Endocrinology Advisor (2015). Guidelines on pharmacological management of obesity released.
- Goldsmith, C. & Lehrman, S. (2014). Weight management: Facts not fads. com. 27(8), 44-49.
- Khan, A. (2016). America tops list of 10 most obese countries. US News & World Report.
- Kline, D.A., Goedkoop, S., & Bhimji, S. (2014) Regulation of body weight. com. 27(7), 42-47.
- National Weight Control Registry (NWCR). (2015).
- Trends in adult body-mass index in 200 countries from 1975 to 2014: A pooled analysis of 1698 population-based measurement studies with 19.2 million participants. The Lancet 387(10026), 1377-1396.