The Impact of Advances in Obesity Science on Nursing Care

Course Content

Authors: Mallory Antico 
Contact hours: 4 hours.
Learning objective and out comes.

Learning Objectives

  • Review the pathophysiological factors that contribute to weight.
  • Discuss the relationship between obesity and associated comorbid conditions.
  • Recognize how risk factors, including social determinants of health, impact weight.
  • Describe the assessment and diagnosis of patients with obesity.
  • Identify weight management strategies and discuss their benefits and limitations.
  • Explain nursing interventions in the care of patients with obesity in multiple practice settings.
  • Differentiate how weight affects different populations.

Introduction

Obesity is a chronic relapsing disease with a complex pathophysiology that affects all age groups and is often misunderstood by nurses and other healthcare workers (Jastreboff et al., 2019). The occurrence and burden of obesity among adults and children is a priority for national and global population health. The United States has the highest obesity rates in the world (Mechanick et al., 2019,  Tronieri et al., 2019), making it one of the most common chronic illnesses (Hampl et al., 2023).

Obesity is linked to morbidity and mortality in several disease processes (Ewens, Kemp, Towell-Bernard, & Whitehead, 2022). Obesity has long been incorrectly viewed as an outcome of modifiable lifestyle choices, but recent advances in obesity science require a paradigm shift in how patients with obesity are viewed and most effectively managed (Mechanick, et. al, 2019). Nurses are well-positioned to bridge the gap between clinical practice and the expanding body of evidence to improve patient outcomes through understanding and implementing new best practices. 

Pathophysiology

Society and medicine have historically viewed obesity as a reversible consequence of actions related to nutrition and physical activity, but numerous high-quality studies show that it has a multifactorial etiology including genetic, physiologic, socioeconomic, and environmental factors (Hampl, et. al, 2023).

Genetic Factors

Studies suggest that an individual with obesity has a 40% to 70% genetic contribution to their risk of developing the disease through both rare and common genetic variants impacting one or more genes (Hampl, et. al, 2023; Loos & Leo, 2022). Genetics impacts several individual factors related to obesity, including BMI, waist-to-hip ratio, over- and under-feeding responses, energy expenditure, food choices, hunger, and satiation. Heritable obesity causes can be broken down into two main categories: polygenic and monogenic. Common (multifactorial) obesity, the most frequently occurring heritable cause of obesity, is polygenetic, caused by multiple genic loci (Perreault, 2021).

Monogenic obesity is related to a specific genetic mutation or deficiency and should be considered in patients who have a lifelong history of obesity. Table 1 describes the most common monogenic clinical forms of obesity. Unless monogenic obesity is suspected, genetic testing is not typically used in the diagnosis or treatment of obesity (Perreault, 2021).

Table 1

Common Clinical Forms of Monogenic Obesity

Clinical Disorder Etiology Description
Prader-Willi Syndrome Genetic abnormalities of chromosome 15
  • Disordered eating that changes with age
  • Hyperphagia and impulsiveness around food between about 4-8 years old leading to early-onset obesity
  • Hypogonadism, developmental delay,
  • outbursts, perseveration, insistence on sameness, and rigidity, and characteristic facial features
Bardet-Biedl Syndrome (BBS) Autosomal recessive inheritance pattern
  • Very rare disorder
  • Over 14 different genes that can cause BBS.
  • characterized by vision loss, intellectual disability, early-onset obesity, dysmorphic features, genitourinary abnormalities, and polydactyly
Fragile X Caused by changes in a gene called Fragile X Messenger Ribonucleoprotein 1 (FMR1)
  • Causes a range of developmental problems including learning disabilities and cognitive impairment including autism
  • A subgroup of males with FXS has a phenotype similar to that of Prader-Willi syndrome


(Perreault, 2021).

Recent studies of monogenic and polygenic obesity have revealed that despite having different initial etiology, both conditions have similar underlying pathophysiology that leads to increased weight. The nervous system pathways that influence hunger and satiety and the brain’s reward system are the main influences in both monogenic and polygenic obesity. Some studies show that monogenic obesity may be in part influenced by a polygenic predisposition to obesity. Several of the genes that were identified in early-onset extreme obesity play a role in polygenic obesity too but in more subtle ways. As more genetic loci are identified, it is expected that a clearer understanding of the relationship between the two types of obesity will emerge (Loos & Leo, 2022).

Fetal and Childhood Factors

In addition to genetic factors, epigenetic changes to gene expression can increase the propensity to weight gain without alteration of the genetic code. Epigenetic changes often occur in the prenatal period, and several maternal prenatal risk factors have been associated with obesity. Maternal obesity and undernutrition, as well as gestational excessive weight gain, gestational diabetes, and pre-eclampsia, are associated with obesity in offspring. Maternal stress and tobacco use during the prenatal period were also associated with increased risk for obesity in offspring (Hampl, et. al, 2023).

In the early postnatal period, there are factors that impact obesity risk. Preterm infants have a greater chance of childhood obesity however the exact mechanisms are still unknown. Both very low and very high birth weight infants are at increased risk of obesity (Hampl, et. al, 2023). Some studies show that breastfeeding has a protective effect from obesity developing later on in life (Perreault & Bessesen, 2022; Skelton & Klish, 2023). Other early feeding practices increase the risk for obesity such as inappropriately concentrating formula, putting infants to bed with their bottle, or adding cereal to the bottle (Hampl, et. al, 2023).

Having one birth parent with obesity puts a child at risk for developing obesity at two- to three-fold higher. If both of a child’s birth parents have obesity, the child is 15 times more likely to develop obesity than if their birth parents were not obese. Many children who have obesity continue to have obesity in adulthood, especially in those with one or both birth parents who have obesity (Skelton & Klish, 2023).

Early childhood has been shown to be an important time for the programming of the metabolism (Skelton & Klish, 2023). Adverse childhood experiences are traumatic experiences in childhood that have been shown by an immense body of evidence to lead to physical and mental health issues into adulthood. There are a range of experiences that are included in ACEs such as parental loss, divorce, physical, emotional, or sexual abuse, parental incarceration, and having a parent with mental illness. The risk for ACEs transcends socioeconomic status, however, those affected by poverty have a higher risk of experiencing them. The greater the number of ACEs a person has, the more likely they are to have obesity. It is thought that this is caused by a variety of mechanisms including chronic toxic stress and social disruption (Hampl, et. al, 2023).


Hunger and Satiety

An understanding of how the body stimulates and inhibits food intake can help nurses understand the mediators that impact the disease of obesity. Losing weight works under different mechanisms than keeping the weight off over time. Maintaining a weight loss of greater than 10% of one’s body weight long-term is very difficult. Only about 15% of people can that much weight and keep it off without bariatric surgery or medications. This is due to a variety of metabolic, endocrine, nervous system, and behavioral responses to weight loss that occur in the body in its attempt to maintain weight homeostasis. The usual trajectory of weight loss in most studies is a period of 6-9 months of variable weight loss followed by a plateau and then ending with gaining the weight back (Perreault & Bessesen, 2022).

To avoid large imbalances of energy day-to-day, the body balances weight by coupling the energy that is consumed with energy expenditure. Under normal circumstances, the body sends out hunger and satiety cues based on how much energy is being used to create a balance. Weight loss has a decoupling effect on this balance and individuals will feel like they want food more, take longer to feel full, and their metabolism is slowed down. To maintain this weight loss, an individual must be committed to decreasing energy intake and increasing energy expenditure to counterbalance the decoupling, which is incredibly difficult without multimodal treatment (Perreault & Bessesen, 2022).


Leptin

Fat cells produce a substance called leptin, which is the strongest signal the body has to regulate energy stores. Through afferent pathways, leptin tells the brain how to regulate appetite. Leptin is sensitive to both how much fat there is and the balance of energy. When weight is stable, circulating leptin is proportional to fat mass. In the instance of weight loss when there is more energy being used up than what is being taken in, leptin concentration drops 25-50% more than what circulating levels would be if the body were maintaining a stable weight. When leptin drops, a complex neural pathway tells the brain that the body needs more food and should slow down energy expenditure (Perreault & Bessesen, 2022, Hopkins et al., 2022).


Ghrelin

Ghrelin is a peptide that stimulates growth hormone secretion and an increase in food intake. Gastric distension and food ingestion prompt the body to suppress ghrelin release and anticipating a meal stimulates ghrelin release. After weight loss, there is an increase in the serum levels of ghrelin, suggesting that it plays a role in the compensatory mechanisms that make sustaining weight loss so challenging. Bariatric surgeries have an effect on ghrelin. Some studies found that serum levels of ghrelin decreased after bariatric surgery (Perreault & Bessesen, 2022).


Neuropeptide Y

Neuropeptide Y increases the desire to eat and decreases a feeling of fullness. It predominantly stimulates carbohydrate intake. It is also involved in mediating the effects of leptin (Perreault & Bessesen, 2022).

Glucagon-type Peptide (GLP-1)

GLP-1 is a hormone that is released from cells in the gastrointestinal tract in response to nutrients (Perreault & Bessesen, 2022). It has a role in glucose homeostasis by prompting the release of insulin and is thus useful in the pharmacological treatment of diabetes mellitus. GLP-1 also decreases hunger, increases a feeling of fullness, and delays gastric emptying which is why it is now used to also treat obesity in patients with or without diabetes mellitus (Hopkins et al., 2022).


Cholecystokinin

CCK is a hormone that is released in the small intestine. Food intake (particularly proteins and fats) stimulates the duodenal mucosa cells to release CCK. Once released, it increases a feeling of fullness and delays gastric emptying (Hopkins et al., 2022).


Pancreatic Polypeptides

The family of pancreatic polypeptides includes pancreatic polypeptide (PP), neuropeptide Y (NPY), and peptide YY (PYY) as well as oxyntomodulin (OXM) are released in response to food intake. Their effect is to increase satiety and decrease gastric emptying. Low levels of pancreatic peptides have been seen in patients with obesity (Hopkins et al., 2022).


Other centrally-acting food mediators

There are several other centrally-acting substances that play a role in stimulating eating but are outside of the scope and objectives of this article. These include melanin-concentrating hormone, GH-releasing hormone, norepinephrine, orexin-A and -B. (Perreault & Bessesen, 2022).


Environmental Factors

Nutrition

There are many factors that influence nutrition in the United States. Food and nutrition have changed significantly over the past century to include easier accessibility to higher-calorie and very palatable foods (Perreault & Bessesen, 2022) that are less expensive than more nutrient-dense food (Chatham & Mixer, 2020). These nutrition-related environmental factors contribute to people eating a caloric intake that exceeds what their body needs (Skelton & Klish, 2023).

Sugar-sweetened beverages have been shown in numerous studies to be associated with obesity in both adults and children (Skelton & Klish, 2023). The American Heart Association recommends no more than one eight-ounce serving of sugar-sweetened beverage per week and no more than 25 grams of total added sugar per day. Fruit juice is not a substitute for fresh fruit as it is less nutritious and more energy-dense (Hampl, et. al, 2023).

Food and beverages that are energy-dense and lack nutrients are often marketed in the media. There have been several studies that show exposure to this type of marketing results in increased intake of these foods in children and adolescents. Skipping breakfast, large portion sizes, excess snacking behaviors, and dining out also impact nutrition by leading to more energy intake than is required (Hampl, et. al, 2023).

Activity

Engaging in regular physical activity has health benefits for all individuals regardless of body size (Wharton et al., 2020). With an increase in sedentary behavior and a decrease in physical activity, energy expenditure has gone down (Perreault & Bessesen, 2022).

Screen Time

Screen time can include any media that is delivered on a screen that is for recreational use. This can include phones, tablets, televisions, computers, and video games and continues to evolve over time. Screen time can affect physical activity in several ways, the most obvious is that time spent being sedentary on screens displaces the time spent in physical activity. There are other less commonly thought of mechanisms as well relating screen time to activity, including causing a slowing of the metabolism, affecting sleep, and a change in eating habits during screen time (Skelton & Klish, 2023). The American Academy of Pediatrics recommends no media before 18 months of age, a one-hour time limit for ages two to five years, and a parent-monitored plan for media use in older children that is balanced, avoids excessive use and does not have an upper limit (Hampl, et. al, 2023).

Sleep

There have been numerous studies that link obesity and metabolic disorders with sleep disturbances, late bedtime, night shift, and decreased sleep duration. Some studies have shown that the reward center of the brain is heightened with decreased sleep and those who sleep less eat more food, especially high-fat foods. Levels of satiety hormones decrease with insufficient sleep and ghrelin, the hormone that makes one feel hungry, increases (Perreault & Bessesen, 2022; Skelton & Klish, 2023).


Medications Associated with Weight Gain

There are many medications that cause weight gain. Some classifications of medications that are known for causing weight gain are antipsychotics, mood stabilizers, antidepressants, hormonal contraceptives, anticonvulsants, and some hypoglycemics (Perreault & Bessesen, 2022).


Social Determinants of Health (SDoHs)

SDoHs are the conditions in a person’s environment that impact health outcomes and risk. These include economic factors, education access and quality, physical environment, and social influences (Hampl, et. al, 2023). The accumulation of disadvantages in a person’s life leads to increasing weight


Political, broader economic, and legal factors

Food choices are made within the unique context of a person’s environment. High energy non-nutritious dietary patterns contribute to obesity. The transnational food industry has significant economic power and manufacturing and fast food have a powerful influence on how people eat. Because these huge corporations can flood markets with highly processed and very palatable food and beverages, they can influence food costs. They use targeted marketing, especially towards children, to increase sales. Food and beverage companies also have a voice in political power through lobbying and advocating for regulation that is favorable to them (Chung et al., 2022).

Regulatory changes can be used to change the commercial determinants of obesity not unlike the tobacco and alcohol industries. Governments could fiscally incentivize businesses to provide affordable nutrient-dense food and disincentivize the sale of inexpensive high-energy low-nutrient foods. Following the World Health Organization recommendations, governments can regulate the marketing of calorie-dense, less nutritious foods to children. More widespread efforts can be made to reduce conflicts of interest between legislators and commercial interests (Chung et al., 2022).

The food and beverage industry is not the only area where policy changes can influence health and obesity. Environmental and social policies often have a significant impact on health. Social protections for underserved or traditionally underrepresented groups and those living in poverty, ensuring minimum wage reflects the cost of living, affordable, quality, and accessible healthcare, and support for people with disabilities all play a role in advancing health (Chung et al., 2022).

The United States spends more money on healthcare than anywhere else in the world, yet we have higher rates of disease and shorter lives. People without health insurance struggle to afford vital health services and 37 million people in the United States are uninsured, with 41 million more who are underinsured (Galvani et al., 2020). When people with overweight and obesity are unable to access appropriate care, it risks an increase in obesity-related complications that can be life-threatening (Rice, 2020). Public health initiatives that can provide evidence-based interventions to mitigate obesity are very often government-funded and rely on political support (Westerbury et al., 2023).

The entertainment industry plays an interesting role in perpetuating obesity stigma. Often people with overweight or obesity are portrayed negatively. Representation of people with overweight or obesity in media has been reported to be less than half of what is actually in the general population. Many shows, movies, and books have villains or antagonistic characters as ones with overweight or obesity. This advances the perception that a person’s actions or inactions are the main drivers of overweight and obesity (Westerbury et al., 2023).

Journalists and the media also perpetuate the stigma associated with individuals with overweight or obese by using negative images that include people eating unhealthy foods or depictions in unflattering positions. The media has been shown to provide more coverage of the individual responsibility that influences obesity than they cover the environmental, social, and biological factors (Westerbury et al., 2023).

Social media also plays a role, with some studies showing content that negatively depicts people as overweight or obese gets more engagement. The effects of the misconception of those overweight or obesity as being lazy or not having willpower leads to damaging medical and psychosocial consequences for those living with the disease (Westerbury et al., 2023).

Individual economic factors

The job environment of today often includes longer working hours, more sedentary activities, and automation and technology that decreases the amount of physical activity, leading to an increased obesogenic environment (Grace, 2020). Employment in the United States is a huge factor in access to health care because many receive health insurance benefits from their employers. Those who lack insurance or are underinsured often cannot afford the care they need for obesity and other chronic conditions (Chatham & Mixer, 2020).

There are many factors that influence one’s ability to afford nutritious food including income, employment type and stability, housing, and cost of living. The high cost of food, especially the increased cost of nutrient-dense foods compared to less nutritious foods, is a major factor in what foods are selected to eat (Hampl, et. al, 2023).

Food insecurity is more common in under-resourced communities and is associated with higher rates of obesity. Often low-income areas have fewer fresh food options or none at all compared with ample easy access to fast food. Feeding practices may change with food insecurity to include pressure to eat or restrictive eating habits (Hampl, et. al, 2023). Those who rely on food banks that may only receive groceries monthly are left at the latter end of the month with shelf-stable canned or boxed food choices (Chatham & Mixer, 2020).

In areas where necessities are nearby, there is more opportunity for walking from place to place rather than driving, which naturally increases physical activity (Chatham & Mixer, 2020). Under-resourced communities lack safe spaces for physical activity (Hampl, et. al, 2023). The availability of green spaces, sidewalks, and playgrounds has an impact on physical activity levels (Skelton & Klish, 2023). Weather can influence physical activity, especially in areas with very cold winters. When staying indoors to keep warm individuals may move their bodies less. Likewise in times of extreme heat, it is dangerous to be active outside (Chatham & Mixer, 2020). The availability of public transportation can also decrease walkability in neighborhoods (Westbury et al., 2023).

Those who have immigrated to the United States have a unique background that impacts their experience of overweight and obesity. While newly immigrated individuals adjust to American culture, they often begin to adopt American eating habits over time, and rates of obesity increase with the length of time they live in the United States (Hampl et. al, 2023).

Educational factors

There is consistent evidence that connects lower educational attainment to obesity. It has been proposed that better health literacy and more access to financial and material resources could be reasons for the disparity. Further study is needed in this area because understanding the relationship between obesity and educational attainment can reveal opportunities for targeted educational interventions that may work to decrease risk (Witkam et al., 2021).

Another education-related factor that influences obesity in children and adolescents is that they spend most of their time in school. Primary and secondary schools play a major role in food, nutrition, and activity in childhood. Studies show that when energy-dense foods and beverages with few nutrients are easily accessible in schools, children’s food choices may be negatively impacted (Hampl, et. al, 2023).

Cultural Factors

When caring for patients with obesity who are from diverse cultures, there are many factors that must be considered in order to provide culturally competent care. When it comes to obesity, the two factors most heavily influenced by culture are nutrition and activity. Nurses should be familiar with common cultures in their patient population while avoiding stereotyping and assessing each individual patient for their unique needs (Chatham & Mixer, 2020).

Cultural Values and Beliefs

Cultural values encompass many aspects of life. Understanding foods and food customs is critical to effective nutrition counseling for patients with obesity. Details such as types of foods, eating rituals, and traditions that involve food can help clinicians and patients collaborate on a plan that complements the patient’s life. Activity preferences and sleep and rest patterns should be explored. The patient’s cultural beliefs about health, wellness, illness, and death also impact their perspective on obesity (Chatham & Mixer, 2020).

Kinship and Family

Learning about the patient’s loved ones can help clinicians understand the social influences and support they have. One’s own health is swayed by their relationships, depending on their social network’s norms and values, it can change health for the positive or negative (Cockerham, 2022).

A common cultural value is that of family which may include immediate family, extended family, and friends. Some cultures are more individualistic and others are more collectivist. One example of how family can impact obesity is in some families when one member of the family has to make a dietary change, it may affect how the whole family eats. Lack of family agreement can make dietary changes even more challenging for the patient (Chatham & Mixer, 2020).

Another example of how kinship influences nutrition is how sometimes the patient will be the person who purchases food and prepares meals, but other times a family member is the one responsible. The person who prepares food should be involved in patient education when dietary changes are medically necessary. In many cultures, children are taught to “clean their plates” instead of eating until their bodies feel full. These habits can continue into adulthood and are passed down to future generations (Chatham & Mixer, 2020).

Marital status, gender identity and roles, and sexuality can influence weight. Traditional gender roles impact who is responsible for food preparation, particularly in cultures where women are seen as caretakers and are responsible for feeding the family. In some cultures, female children aren’t encouraged to participate in sports as much as their male counterparts (Chatham & Mixer, 2020).

Women (assigned at birth) with low socioeconomic status are more likely to gain weight over their lifetime compared to women with high socioeconomic status and men regardless of socioeconomic status. Black women with low socioeconomic status are at especially increased risk for overweight or obesity (Cockerham, 2022).

Some literature has shown that gender and sexual minorities may be at increased risk for obesity compared to cisgender, heterosexual individuals with a few notable differences amongst subgroups. Cisgender sexual minority males have less risk for overweight and obesity while cisgender sexual minority females were at greater risk for overweight or obesity. More research needs to be done to make definitive conclusions about the relationship between these characteristics and weight (Grammer et al., 2019).

Religious and Philosophical Practices

Very often food and eating habits have a religious, spiritual, or philosophical relevance, and healthcare workers providing counseling in food and nutrition should always consider these factors when advising patients. Most religious food practices are not detrimental to health and several are beneficial. Some religions prohibit alcohol, have certain food preparation practices, include periods of fasting, and/or animal product restrictions. Some individuals morally object to animals being used as a food source and thus prefer a vegan diet. Others may object to only certain foods, for example, they may allow milk and eggs but not meat and seafood (lacto-ovo-vegetarian diet) (Chouraqui et al., 2021).

Other Possible Factors

The gut microbiome is the trillions of normal flora that live in the gastrointestinal system that impact the absorption and digestibility of the calories taken in. An imbalance of these microorganisms is thought to contribute to obesity. The causal role of the gut microbiome is still an area of study that is growing. There is currently no evidence that suggests manipulating the gut microbiome can treat obesity (Perreault & Bessesen, 2022).

Endocrine-disrupting chemicals are used in the production of many different products that are commonly used. These compounds have been found in the environment, and certain foods, and they can build up in human tissue. Some observational research links these compounds with increased adiposity in both children and adults, but more study is needed to fully understand the impact these chemicals have on humans (Perreault & Bessesen, 2022).

Healthy Equity Considerations

Obesity does not impact all populations equally, and it is imperative that the systems and processes that are drivers that cause and uphold these inequities be researched with implications translated into real practice changes. These inequities are often intersectional so that one disparity potentially impacts another, often compounding inequality. Systemic problems that perpetuate inequity are capable of change and have the potential to make vast improvements in population and individual health (Hampl, et. al, 2023).

Obesity disproportionately affects Black, Indigenous, and Hispanic populations in America, and SDoHs play a significant role in contributing to risk (Hampl, et. al, 2023; Paradies et al., 2015). While Asian Americans are less at risk, they have unique considerations due to a differing distribution of adipose tissue that makes them more at risk for life-threatening comorbid conditions if they have obesity (Hampl, et. al, 2023).

Black Americans

Black Americans are defined as anyone who identifies as non-Hispanic and Black or African American alone or in combination with other races. Overweight and obesity affect nearly one-half of Black Americans, and a multifactorial convergence of factors contributes to its prevalence including genetic, environmental, cultural, behavioral, and socioeconomic influences. Advances in genetic research have demonstrated There are several genetic differences that can predispose Black Americans to obesity, such as leptin desensitization and differences in its production and more numerous loci that are associated with higher BMI and adiposity (Earles, Ard, & Standford, 2023).

Lower socioeconomic status contributes to obesity in Black Americans, who disproportionately experience systemic racism, lack of generational wealth, higher unemployment rates, fewer educational resources, and poverty. As discussed earlier, these factors all lead to worse health outcomes including higher rates of overweight and obesity. Despite the increased prevalence and risk, Black Americans are formally diagnosed with and treated for obesity (Earles, Ard, & Standford, 2023).

Black Americans may experience a mistrust of the healthcare system related to past injustices and both explicit and implicit bias is still prevalent amongst healthcare workers. It is essential for healthcare workers to develop trusting relationships with their Black patients. Learning about and reflecting upon one’s own biases can help advance health quality and equity. Increased representation and inclusion of healthcare workers of color is another vital step in improving the healthcare of Black Americans (Earles, Ard, & Standford, 2023).

Hispanic Americans

Hispanic Americans are an ethnic group in the United States that according to the Department of Health and Human Services (2020) includes people who descend from Cuba, Mexico, Puerto Rico, South or Central America, or other Spanish culture or origin. Hispanic Americans were 1.2 times more likely to have obesity than non-Hispanic White Americans (DHHS, 2020). Childhood obesity is more prevalent in Hispanic children in the United States than in non-Hispanic White children (Skelton & Klish, 2023).

Hispanic Americans have some unique characteristics that can contribute to higher rates of obesity. Although they are more at risk for various chronic health conditions, their life expectancy is slightly longer than non-Hispanic White Americans. They have the highest uninsured rate of any racial or ethnic group in the United States which has a significant impact on access to care, particularly preventative care. While language fluency varies by subgroup, most Hispanic Americans speak a language in addition other than English at home. Language barriers can create barriers in seeking healthcare (DHHS, 2020).

A larger percentage of Hispanic Americans work in the service industry and a lower percentage in managerial or professional occupations compared to non-Hispanic Whites. In 2020, `7% of Hispanic Americans lived in poverty and the median household income in Hispanic families is significantly lower than White Americans. Access to education is also an area of disparity. At all educational levels, Hispanic Americans obtain diplomas and degrees less frequently (DHHS, 2020). As examined previously, these SDoHs have a significant impact on overall health and wellness and are a factor in a higher incidence of obesity in this population.

Indigenous Americans

Indigenous Americans have a higher rate of obesity than non-Hispanic White Americans (Skelton & Klish, 2023; Bullock et al., 2017). Poor health outcomes in Indigenous communities are heavily influenced by the consequences of colonization and systemic disadvantage. It is imperative for nurses to consider these factors when caring for Indigenous people who are obese by exploring their own biases, and engaging in education. Learning about common values and communication in Indigenous contexts and about the ongoing discrimination that occurs within society can help healthcare providers build relationships with Indigenous patients that are based on mutual understanding (Wharton et al., 2020).

During discussions of how obesity uniquely affects Indigenous Americans, it is important to remember that they are not a monolith. There are 566 Indigenous tribes in the United States, each with its own unique characteristics. Nurses should be familiar with Indigenous tribes in their geographical locations and their unique health needs (ANA, 2022). Forming healing relationships with Indigenous patients that position the nurse as a participant in care rather than the expert can help mitigate the mistrust of health systems. It is especially important to explore the health, social, environmental, and cultural factors that influence the capacity for obesity, as well as mental health considerations, which may have unique drivers related to intergenerational trauma. These factors influence the patient’s body size, activity, and food preferences and should be incorporated into nursing care (Wharton et al., 2020).

Asian Americans

Asian Americans are a racial group with origins in East Asian, Southeast Asia, or the Indian subcontinent. Asian Americans tend to have a unique distribution of adipose tissue, they are more at risk for visceral fat around the organs than other Americans and less at risk for peripherally located fat (Lim, 2023). Because visceral fat comes with greater morbidity and mortality risk, their BMI cutoff points are lower than other populations (Mechanick et al., 2019). The rate of obesity is increasing in Asian Americans more than any other race in the United States (Liu et al., 2021).

Clinical Presentation

Assessment

A complete history is imperative to identify the root causes of excess adiposity including physical, psychosocial, and environmental factors. A comprehensive physical exam should be completed and laboratory or imaging diagnostics should be done per the clinical judgment of the healthcare provider (Wharton et al., 2020). If the patient is open to discussing their weight, assess their goals and the reasons for wanting to lose weight, prior attempts at weight loss, and current dietary and physical activity activities (Tucker et al., 2021).


Anthropologic Measurements

It is important to note that anthropologic measurements discussed in this section should be included in the assessment of all patients, not just those with overweight or obesity (Wharton et al., 2020).


Height, Weight, and Body Mass Index (BMI)

An accurate height and weight are important for evaluating obesity. An accurate BMI is critical for the diagnosis and management of overweight and obesity. In children, short stature can indicate a genetic or endocrine etiology for weight gain (Hampl, et. al, 2023).

The measurement used to diagnose obesity and measure excessive adiposity in ages two and up is BMI (Garvey, 2016). BMI is calculated by dividing height in meters squared (m2) by weight in kilograms (kg) (Perreault & Laferrère, 2021). BMI cutoff points should be considered in addition to other factors such as muscularity, hydration status, edema and third spacing, tumors, gender, age, ethnicity, and geographical location. BMI alone cannot convey the impact that adiposity has on an individual’s health and should be considered as part of a comprehensive history and physical exam (Garvey, 2016; Wharton et al., 2020).

In adults 21 years of age and older, overweight is defined as a BMI of 25 to 29.9 kg/m2, obesity as a BMI of greater than 30 kg/ m2, and severe obesity is defined as a BMI of greater than 40 kg/ m2 (Perreault & Laferrère, 2021). Weight classifications based on BMI in adults can be seen in Table 2.

Table 2

BMI and weight classifications for adults 21 years and older

Classification BMI (kg/cm2)
Underweight Below 18.5
Normal 18.5 – 24.9
Overweight 25.0–29.9
Obese Class I 30–34.9
Obese Class II 35–39.9
Obese Class III 40 or greater


In children from two to 20 years of age, BMI is measured in percentiles based on age and sex. In children younger than age two, it is very challenging to accurately measure adiposity. It is recommended that for children under two years old, the World Health Organization’s weight-for-length age and sex-specific charts are used (Hampl, et. al, 2023). Because the percentile curves are not accurate enough at the extremes, and extended BMI chart should be used to classify pediatric patients who are above the 95th percentile (Skelton & Klish, 2023). Weight classifications based on BMI in children can be seen in Table 3.

Table 3

BMI percentile based on sex and age and weight classifications in children ages 2 – 20 years of age

Classification BMI percentile BMI percentile
Underweight < 5
Normal 5 – 85th
Overweight >85th and 95th
Obese Class I* ?95th percentile ?30 kg/m2
Obese Class II* ?120 percent of the 95th percentile values ?35 kg/m2
Obese Class III* ?140 percent of the 95th percentile values ?40 kg/m2


*Note: Classes I – III are based on either BMI percentile or the extended BMI growth chart, whichever is lowest

Waist Circumference

Waist circumference should be measured in all patients with BMI < 35 kg / m2 to evaluate disease risk (Garvey, 2016). With the patient in the standing position, a tape measure that does not stretch is used to measure around the abdomen parallel to the floor at the level of the iliac crest (Perreault & Apovian, 2021). In the U.S. and Canada, greater than or equal to 102 cm for men and greater than or equal to 88 cm for women are consistent with abdominal obesity and should be considered at risk. These measurements are smaller in other populations, many of which use the guideline of greater than or equal to 94 cm for men and greater than or equal to 80 cm for women (Garvey, 2016; Perreault & Apovian, 2021). High waist circumference, even in patients who do not have obesity based on BMI, carries a higher risk for cardiovascular disease and thus screening for those patients is still important (Powell-Wiley et al., 2021).

Ratios using waist circumference are useful predictors for obesity-related conditions such as cardiovascular disease. Waist circumference to height takes body size into consideration. It is calculated by dividing the waist circumference by height. A ratio of 0.5 is generally accepted as a universal cutoff for central obesity in all people ages six and up (Powell-Wiley et al., 2021).

Another anthropologic ratio that is useful in predicting cardiovascular disease and measuring abdominal obesity is the waist-to-hip ratio. To measure the hip ratio, a tape measure that does not stretch is wrapped around the widest part of the patient’s hips. Then the waist circumference is divided by the hip circumference to get the ratio. (Powell-Wiley et al., 2021).

Other Body Composition Measurements

Because the BMI has limited ability to determine actual fat mass, other body composition technology may play a role in obesity diagnosis. Methods including bioelectric impedance, air/water displacement, plethysmography, and dual-energy X-ray absorptiometry (DEXA) are validated methods but are very costly and only available in certain settings (Tucker et al., 2021; Medina-Inojosa, Lavie, & Lopez-Jimenez, 2022).

Metabolic Syndrome

Metabolic syndrome is a group of conditions that puts a person at risk for cardiovascular disease. The NHLBI (2022) defines metabolic syndrome as having at least three of the following conditions:

  • Abdominal obesity
  • Hypertension
  • High triglycerides
  • Low HDL
  • High blood sugar

Metabolic syndrome and obesity share the same risk factors and decreasing weight decreases the effects of metabolic syndrome (NHLBI, 2022).


Diabetes

Diabetes is a condition where the body can’t make enough insulin or the body can’t use it like it should. This leads to hyperglycemia and a myriad of other health consequences. Patients with overweight or obesity and are experiencing weight gain should be screened for diabetes and prediabetes even in the absence of symptoms of hyperglycemia by checking fasting blood glucose and hemoglobin A1C (Garvey, 2016).

Prediabetes and Type II Diabetes Mellitus

Prediabetes and Type II Diabetes Mellitus are caused by increased insulin resistance and an eventual loss of islet cell function in the pancreas. The best test for diagnosing prediabetes is the HgbA1C. Type II Diabetes Mellitus is diagnosed by fasting blood glucose, an oral glucose tolerance test, and a HgbA1C. Type II diabetes is increasingly being diagnosed in children, most commonly between the ages of 12-18 years. Having diabetes increases a person’s risk of cardiovascular disease and stroke (Hampl, et. al, 2023).


Gestational Diabetes

Gestational diabetes is when there is elevated glucose in pregnancy in those who do not already have diabetes, which increases the risk of a larger baby, cesarian section, and future diabetes risk in the child. Gestational diabetes is diagnosed with an oral glucose tolerance test. Pregnant patients with obesity are at greater risk for gestational diabetes (ACOG, 2023).


Other Endocrine Disorders

There are several other endocrine disorders known to cause weight gain, including excess cortisol and Cushing syndrome, hypothyroidism, and growth hormone deficiency (Skelton & Klish, 2023).


Respiratory Conditions

There is a strong association between being overweight or obese and having certain respiratory conditions, including asthma, reactive airway disease, and obstructive sleep apnea. Viral infections that affect the respiratory system are also associated with more severe complications in patients with obesity (Garvey, 2016).

Asthma and Reactive Airway Disease

Those with asthma or reactive airway disease should have a thorough history and physical that closely appraises symptomology. Pulmonary function tests should be considered in high-risk or symptomatic patients (Garvey, 2016).


Obstructive Sleep Apnea (OSA)

Those with asthma or reactive airway disease should have a thorough history and physical that closely appraises symptomology. Pulmonary function tests should be considered in high-risk or symptomatic patients (Garvey, 2016).


Influenza

Influenza, more commonly known as the flu, is an infectious disease that is caused by influenza viruses. Patients with obesity are impacted by influenza in different ways than the general population. It is thought that this is due to inflammatory and immune differences that lead to an altered clinical course. Patients with obesity have been shown to have a slower and less robust immune response to the influenza virus and thus don’t recover as easily. Antiviral medications that are used to treat influenza and the vaccines that are used to prevent it are less efficacious in patients with obesity. It is important for nurses to teach patients with obesity influenza prevention strategies including good respiratory hygiene, handwashing, getting the seasonal influenza vaccine yearly, and seeking testing and treatment early (Honce & Schultz-Cherry, 2019).


COVID-19

COVID-19 is an infectious disease that is caused by the SARS-CoV-2 virus. Some patients present with mild to moderate respiratory symptoms and do not require treatment, while others in high-risk groups can become critically ill or die from the disease. Obesity has emerged as a risk factor for hospitalization, severe illness, and death related to COVID-19 infection. When teaching patients who have obesity about COVID-19, nurses should encourage COVID-19 vaccination and take precautions when transmission in the patient’s region is high including a high-quality mask, social distancing, frequent handwashing, avoiding large crowds, and when symptomatic or exposed seeking testing a treatment early (Yu et al., 2021).


Mood Disorders

Obesity is often associated with mental health problems. Mental health biology shares some of the same pathways as obesity in the nervous, endocrine, and immune systems. Obesity and mood disorders frequently occur together and each is a risk factor for the other. The prevalence of having both mood disorders and obesity is more common in women (assigned at birth). Losing weight may improve mood and mental health conditions. Individual responses to psychiatric medications vary, but some may cause weight gain which should be considered when determining the best treatment (Christiansen et al., 2022).


Eating Disorders

Obesity has been associated with eating disorders, most commonly binge eating disorder and bulimia nervosa. Binge eating disorder is when there are recurrent binge eating episodes that cause distress which may include eating too quickly, getting overly full, overeating when not hungry, eating alone to hide the episodes, and feeling guilt or sadness afterwards. Bulimia nervosa differs in that after binges, there are attempts to compensate for the increased intake such as laxatives, inducing vomiting, fasting, or excessive exercise (da Luz et al., 2019).

Those who have both obesity and eating disorders are at higher risk of certain medical and psychosocial complications such as mood and anxiety disorders and gallbladder disease. Eating disorders are generally best treated with cognitive behavioral therapy, consulting a registered dietitian experienced in treating patients with eating disorders, and sometimes medications (da Luz et al., 2019).


Polycystic Ovarian Syndrome (PCOS)

PCOS is a hormonal imbalance where the ovaries or adrenal glands produce too much testosterone, leading to cysts on the ovaries and a myriad of symptoms including acne, hirsutism, metabolic syndrome, infertility, irregular menstruation, pelvic pain, and weight gain. Premenopausal individuals who are overweight or obese should be screened for PCOS through a comprehensive history and physical. PCOS is more common in individuals with obesity and it can be treated with a healthy dietary pattern, increasing physical activity, and medications (Garvey, 2016).


Conception, Pregnancy, and Birth

It is recommended that weight management is discussed with people who are trying to conceive (Wharton et al., 2020). Obesity increases the risk for gestational hypertension, preeclampsia, gestational diabetes, and sleep apnea. The fetus is at an increased risk for congenital heart defects, neural tube defects, macrosomia, preterm birth, and stillbirth. Losing weight before pregnancy is the best way to mitigate these risks (ACOG, 2023).

People capable of pregnancy who are being counseled about trying to conceive and are overweight or obese should be taught that they are at increased risk for infertility. If they choose to seek assisted reproduction, it should be explained that there is a lower success rate of these procedures from conception to live birth (Garvey, 2016).

Despite the risks of having obesity during pregnancy, a healthy pregnancy is still possible through healthy dietary patterns, prenatal care to monitor for complications, and incorporating physical activity. Pregnant people without contraindications should engage in at least 30 minutes of moderate physical activity most days of the week for a healthy gestational weight gain. Physical activity should be discussed with the patient’s provider to see what activities are best for them (ACOG, 2023).

Pregnant people who are overweight or obese have longer labors and a higher risk of cesarian section. After delivery, they can be at an increased risk for complications such as blood clots and infection (ACOG, 2023). Those who are nursing and have obesity should be offered lactation support. Those with obesity breastfeed at lower rates than those who are not obese (Wharton et al., 2020).


Menopause

Menopause occurs when twelve months have passed since a person’s last menstrual period. The transition into menopause usually happens around the age of 45 - 55 and can last between seven and 14 years. During this time, hormones are changing, causing various symptoms. There is an increase in weight and visceral adiposity in menopause that likely is attributed to the decrease in energy use and the increase in follicle-stimulating hormone. Estrogen therapy in menopause has not been shown to decrease weight (Perreault & Bessesen, 2022).


Male Hypogonadism

Hypogonadism is when the body’s sex glands produce to little hormones. Those with male reproductive organs (assigned at birth) who have an increased waist circumference or obesity should be assessed for hypogonadism. Hypogonadism is diagnosed by a thorough history and physical examination and testing for testosterone deficiency as appropriate. This assessment is particularly important for patients who also have type II diabetes mellitus because they are at a greater risk for hypogonadism (Garvey, 2016).


Gastroesophageal Reflux (GERD)

GERD is when stomach acid frequently backflows into the esophagus, causing heartburn and acid indigestion. Patients who are overweight or obese can experience changes in the mechanisms that keep stomach acid from flowing in the wrong direction and some bariatric surgeries are better than others for patients with both obesity and GERD (Thalheimer, 2021).


Urinary Stress Incontinence

Urinary Stress incontinence is the unintentional leaking of urine during activities that put pressure on the bladder, such as jumping, sneezing, coughing, laughing, or heavy lifting. Excess body weight can increase the pressure on the bladder. Patients who are overweight or obese should be assessed for urinary stress incontinence, which is particularly prevalent in females (assigned at birth) with overweight or obesity (Garvey, 2016).


Non-Alcoholic Fatty Liver Disease (NAFLD)

NAFLD is when there is a fat accumulation in the liver with stenosis and inflammation that occurs after persistent insulin resistance alters how the liver processes fat which increases inflammation and causes damage to the liver (Hampl, et. al, 2023). Screening for NAFLD in patients ages 10 years or older who are overweight or obese should be completed by checking liver function tests. If transaminases are elevated, then additional imaging is necessary and the diagnosis may be later confirmed by biopsy (Garvey, 2016).


Osteoarthritis (OA)

OA is the most common form of arthritis and it occurs when there is wear and tear on a joint that breaks down the cartilage and can change the underlying bone. Even modest excess weight puts increased pressure on the joints over time. Those who are overweight or obese should be assessed for OA of weight-bearing joints, especially the knees and hips (Garvey, 2016).


Cancer

Cancer refers to a large number of diseases where cells divide uncontrollably, impacting healthy body tissue. This is thought to be related to the chronic inflammatory processes, insulin resistance, and hormonal changes that occur with obesity. Excess weight has been associated with several different types of cancer including

  • Endometrial
  • Kidney
  • Gastric
  • Colon
  • Biliary
  • Pancreatic
  • Breast
  • Esophageal adenocarcinoma
  • Ovarian
  • Multiple Myeloma
  • Hepatocellular carcinoma
  • Meningioma

(Perreault & Laferrère, 2021).


Gout

Gout is a type of inflammatory arthritis that is caused by deposits of uric acid crystals that cause symptoms of pain, heat, and swelling and can ultimately result in joint damage. It is a relapsing condition with very painful exacerbations. Overweight and obesity are comorbid conditions that can increase the incidence of gout and exacerbations. Gout is often accompanied by other common conditions including high blood pressure, diabetes, high cholesterol, and insulin resistance. Weight loss and decrease in alcohol consumption have been shown by a number of studies to benefit patients who have gout (Neogi, 2023).


Gallbladder Disease

Obesity is a risk factor for cholesterol-type gallstones and patients with obesity are at higher risk for symptomatic gallstones. Various metabolic pathways are linked to gallstone formation. In obesity, increased cholesterol in the bile is thought to play a significant role. An additional consideration for gallstones in patients with obesity is that rapid weight loss can increase gallstone risk. Losing weight at a slower pace can decrease risk. In the case of bariatric surgery where rapid weight loss is expected, ursodiol may be used to prevent gallstones (Parra-Landazury, Cordova-Gallardo, & Méndez-Sánchez, 2021).

Treatment

Prevention

Because there are so many processes involved in how much a person weighs, healthcare providers must consider many factors when recommending treatment or lifestyle changes for being overweight or obese (Wharton et al., 2020).

Interventions for the prevention of obesity follow primary, secondary, and tertiary phases of disease prevention just as other chronic illnesses do. The goal of primary prevention is to prevent the disease from occurring. Primary prevention of obesity includes the promotion of nutrition and physical activity, the education of patients and the community, and addressing environmental factors (Garvey, 2016).

Secondary prevention involves halting a disease process in its early stages. Secondary prevention of obesity includes screening using body mass index (BMI) and if obesity is identified, diagnosis and treatment should be implemented. Treatment in the early stages of obesity include lifestyle modification which can be implemented with or without pharmacological therapy (Garvey, 2016).

Tertiary disease prevention is aimed at reducing complications from disease and preventing disease advancement. In obesity, this includes lifestyle modification plus pharmacological therapy or bariatric surgery based on specific criteria. In addition to prevention strategies, management of comorbid conditions is critical in patients with overweight or obesity. A summary of goals for each obesity-related complication can be found in table 4. (Garvey, 2016).

Table 4

Treatment of obesity-related complications


BMI Obesity-related complication Goals
Overweight 25-29.9 None Prevent progression to obesity and the development of weight-related complications
Obese ? 30 (or ? 23 for some ethnicities) None Weight loss or prevent additional weight gain
Overweight or Obese ? 25 (or ? 23 for some ethnicities) Metabolic Syndrome
  • Weight loss goal: 10%
  • Prevent Type II Diabetes


Prediabetes
  • Weight loss goal: 10%
  • Prevent Type II Diabetes


Type II Diabetes Mellitus
  • Weight loss goal: 5-15%
  • Reduction in HgbA1C
  • Reduction in need for glucose-lowering medications


Dyslipidemia
  • Weight loss goal: 5-15%
  • Lower triglycerides, LDL, and total cholesterol
  • Increase HDL


Hypertension
  • Weight loss goal: 5-15%
  • Lower both systolic and diastolic BP
  • Reduction in number and dosage of BP lowering medications


Non-alcoholic fatty liver disease Steatosis
  • Weight loss goal: 5% or more
  • Reduction of intrahepatocellular lipid


Non-alcoholic fatty liver disease Steatohepatitis
  • Weight loss goal: 10-40%
  • Reduction in inflammation and fibrosis


PCOS
  • Weight loss goal: 5-15% or more
  • Regular menses
  • Ovulation
  • Reduce hirsutism
  • Enhanced insulin sensitivity
  • Reduce serum androgen levels


Female Infertility
  • Weight loss goal: 10%
  • Ovulation and pregnancy


Male Hypogonadism
  • Weight loss goal: 10%
  • Increase in serum testosterone


OSA
  • Weight loss goal: 7-11% or more
  • Decreased apnea-hypopnea index
  • Decrease in symptoms


Asthma/Reactive Airway Disease
  • Weight loss goal: 7-8% or more
  • Decrease in forced expiratory volume
  • Decrease in symptoms


OA
  • Weight loss goal: ? 10% or 5-10% with exercise
  • Decreased symptoms
  • Increased function


Urinary Stress Incontinence
  • Weight loss goal: 5-10% or more
  • Decreased frequency of incontinence


GERD
  • Weight loss goal: 10%
  • Decreased symptoms


Depression
  • Weight loss goal: 10%
  • Decreased symptoms
  • Improvement in depression scores


(Garvey, 2016).


Nutrition

All patients, regardless of their weight, benefit from well-balanced nutrition. In addition to fulfilling nutritional needs, consider the patient’s preferences, values, culture, and environment when providing nutrition counseling (Wharton, et. al, 2020). MyPlate is the US Department of Agriculture’s guideline for nutritious eating for Americans and Figure 1 outlines nutritional goals. In these recommendations, there are several dietary goals, including eating low amounts of added sugar and concentrated fats, focusing on nutrient-dense foods without excessive energy intake or calorie restriction, and balanced protein and carbohydrates (USDA, 2019; Hampl, et. al, 2023).

A healthy dietary pattern has several elements. For the purposes of discussing dietary goals for people with overweight or obesity, healthy nutrition will be discussed for ages two and up since infants and young toddlers require customized care based on their situation. Core elements of a healthy dietary pattern in all ages and stages of life are included in Table 5. If a person sticks to these simple guidelines most of the time, they can achieve a healthy dietary pattern.

Table 5
Core elements to make up a healthy dietary pattern Elements to limit to make up a healthy dietary pattern
Fruits, especially whole fruits Saturated fats
Vegetables of all types Sodium, less than 2,300 mg/day for ages 14 and up
Grains, half of which are whole grains
Dairy such as fat-free or low-fat milk, yogurt, cheese, and/or lactose-free versions, fortified soy beverages or yogurt Alcoholic beverages, no more than two drinker per day for men and one drink or less for women of drinking age (assigned at birth). Less alcohol is better for health. Pregnant people should not consume alcohol.
Protein foods includes meat, poultry, eggs, seafood, beans, peas, lentils, nuts
Oils includes vegetable oils and oils in foods such as seafood and nuts. Added sugars, avoid in children younger than two and in two and older no more than 10% of the daily calorie intake


MyPlate.gov

USDA & DHHS, 2020

Most traditional diets generally do not work for long-term weight loss because they are not sustainable over time. Commercial programs such as WW (previously known as Weight Watchers), Jenny Craig, Optifast, and Nutrisystem can achieve mild to moderate weight loss in the short or medium term. For chronic health conditions such as hypertension and hyperlipidemia, commercial weight loss programs are not recommended (Wharton et al., 2020). Continued monitoring of dietary habits is essential for successful treatment and return visits with either the provider, a dietician, or a behavioris should occur regularly to assess progress (Perreault & Apovian, 2021).

Calories

Calories are a measurement of energy, and people require the consumption of energy to maintain all of their vital functions. How much energy a person needs depends on age, sex, height, weight, and physical activity. Whether or not a person wants to lose, gain, or maintain weight is also a consideration for caloric needs. Estimates of adult caloric needs are from 1,600-2,400 calories per day for females (assigned at birth) and 2,000 to 3,000 calories for males (assigned at birth). Due to a decrease in metabolic rate that occurs with aging, calorie needs tend to go down as adults grow older (USDA & DHHS, 2020).

For children, caloric needs vary widely by age. Adolescents and older children over eight years of age may vary between 1,400 and 3,200 calories per day with males (assigned at birth) requiring more calories than females (assigned at birth). Children ages two through eight require anywhere between 1,000 and 2,000 calories. The best caloric intake for children and adolescents should be discussed with their pediatric provider (USDA & DHHS, 2020).

During pregnancy or lactation, there is a change in caloric needs and they are based on the patient’s pre-pregnancy weight. Patients who are overweight or obese or are underweight prior to their pregnancy should have customized guidance from their provider for the best amount of caloric intake for them. For patients who are considered a healthy weight, no additional calories are needed during the first trimester. During the second trimester, an additional 340 calories per day should be consumed. During the third trimester, an additional 452 calories are recommended per day. During lactation, 330-400 calories are required per day to account for the energy required for milk production (USDA & DHHS, 2020).

A final note about calories: for years, overweight and obesity have been oversimplified as “calories in, calories out.” It was generally thought that if a person simply reduced their energy intake and increased their energy usage through exercise, that was the key to weight loss. As previously discussed, overweight and obesity are much more complex than that.

Marconutrients

Macronutrients are the nutrients that people need a lot of in order to have enough energy. These include carbohydrates, fat, and protein. Proteins are made up of chains of amino acids and these amino acids are critical to keep to body working properly. According to the MyPlate guidelines, adults should eat about 5.5-6.5 grams of protein daily. Children between ages 2-3 should consume about 2 grams, between ages 4 and 8 should contain 4 grams, and ages 9-18 should consume 5 grams of protein each day. Some protein-rich foods are healthier than others. Some general guidelines are choosing lean cuts of beef, removing skin from poultry, eating nuts and seeds that are unsalted, and limiting highly processed meats such as hot dogs or bacon (USDA, 2022).


Carbohydrates provide the body with energy. There are three main types of carbohydrates: sugars, starches, and fiber. Your body needs all three and carbohydrates should make up about 45-65% of the calories ingested daily. Sugars and most starches are ingested and then broken down into sugar in the body which is then used for energy. Fiber is a type of carbohydrate that cannot be digested in the body. There are two types of fiber, insoluble which bulks up and regulates stools, and soluble which helps control cholesterol and glucose control (USDA, 2022).

Sugars occur naturally in nutrient-rich fruits and milk products. Some foods contain added sugar, especially packaged and processed foods. These generally are low in nutrients and can lead to weight gain. Starches are nutrient-rich foods that are complex carbohydrates and may also be high in fiber. These are beans, starchy vegetables, and whole grains. High-fiber foods are whole grains, beans and legumes, vegetables, fruits, nuts, and seeds. Choosing a variety of foods including whole grains, fruits and vegetables, beans and legumes, and low-fat or non-fat dairy products can help ensure dietary habits meet nutritional needs for different types of carbohydrates (USDA, 2022).

Fats are an important part of the diet – they give your body energy, control inflammation, and clotting, and help absorb key vitamins. There are two main types of fats, saturated and unsaturated and they are categorized by which and how much of the different fatty acids they contain. Saturated fats raise LDL, which increases cardiovascular disease risk so they should be limited. Saturated fats tend to turn solid at room temperature. Many animal products contain saturated fats, such as butter, cheese, fatty meats, and whole milk as do some vegetable oils such as coconut or palm oil (USDA, 2022).

Unsaturated fats can actually lower LDL cholesterol. Most are vegetable oils that stay liquid at room temperature. The two types of unsaturated fats are polyunsaturated and monounsaturated. Monounsaturated includes olive and canola oil and polyunsaturated include sunflower and corn oil. Trans fatty acids are formed when a vegetable oil goes through a process called hydrogenation, which leads the fat to solidify at room temperature. The process is used to preserve some foods, but these fats are known to have harmful effects and should be avoided (USDA, 2022).

Marconutrients

Micronutrients consist of vitamins and minerals that are needed by the body but in small amounts. They are critical for healthy growth and development and without them, they can lead to various nutrient deficiencies that cause morbidity and mortality. The undernutrition of micronutrients is common among obesity to including all of the most important ones except sodium, which tends to be elevated. The following describes the most essential micronutrients that are the most important for overall health (USDA, 2022).

Minerals

Calcium.

Calcium is one of the most plentiful minerals in the body and it has many roles. It makes up the structure of bones and teeth and keeps other tissues strong and flexible. Ionized calcium travels through the body to mediate vasoconstriction, muscle function, clotting, nervous system functioning, and hormones. Vitamin D is required for calcium absorption and calcium has an inverse relationship with phosphorous to balance the bone-making process. Calcium deficiency can lead to bone demineralization. Calcium occurs naturally in dairy such as milk, yogurt, and cheese as well as vegetables like kale, bok choy, and broccoli. many beverages, cereals, and tofu are also fortified with calcium. (NIH Office of Dietary Supplements, 2023).

Phosphorous.

Phosphorous is a mineral that is a key element of phospholipid cell membranes and a component of DNA, RNA, bones, and teeth. It plays a role in energy, pH maintenance, enzyme activation, and gene transcription. Phosphorous deficiency is uncommon but results in bone disease. It is found in dairy, meat, poultry, eggs, grains, and vegetables. Phosphate additives are present in processed foods to stabilize a product and are found in many frozen, canned, and processed foods (NIH Office of Dietary Supplements, 2023).

Magnesium.

Magnesium is an important mineral to blood pressure regulation, protein synthesis, nervous and muscular system function, blood glucose control, and energy production. Magnesium deficiency can lead to osteoporosis, hypertension, diabetes, dysrhythmias, and heart disease. It is found in animal foods and plants such as leafy greens, whole grains, nuts, and seeds. It can also be found in many grains and cereals (NIH Office of Dietary Supplements, 2023).

Sodium.

Sodium is required in small amounts in the nervous system and muscular function to maintain fluid balance. It is found in many foods as salt or sodium chloride, which provides flavor and can be used to stabilize shelf-stable foods. Too much sodium has detrimental effects on blood pressure and cardiovascular function, and increases stroke and heart disease risk. Sodium deficiency is rare in the United States and occurs in those with health conditions. In people with obesity, sodium is usually elevated (Chu et al., 2022).

Potassium.

Potassium is required for normal cell function in body tissues because of its role in fluid balance. In healthy people, potassium deficiencies or elevations are rare. In people with diseases such as kidney disease or on certain medications, such as diuretics, potassium imbalances can occur. It is found in many foods including fruits, vegetables, dairy, grains, and meats (NIH Office of Dietary Supplements, 2023).

Iron.

Iron is an essential mineral that is a component of hemoglobin, the protein on the red blood cells that carry oxygen. It also supports muscle function and healthy connective tissue. Iron deficiency can lead to a decrease in red blood cell production and eventually anemia. It is found naturally in vegetables, meat, seafood, nuts, and fortified grains (NIH Office of Dietary Supplements, 2023).

Folate.

Folate is a water-soluble B vitamin that plays a vital role in DNA and RNA synthesis, the metabolism of amino acids, and cell division. Folate deficiency can lead to megaloblastic anemia and neural tube defects in pregnancy. Folate is naturally present in dark leafy green vegetables, fruits, juice, nuts, beans, peas, and seafood. Many grains in the United States are now fortified with folate (NIH Office of Dietary Supplements, 2023).

Zinc.

Zinc is an important mineral to the immune system because it supports innate immunity and T and B cell function. It also helps decrease injury during times of inflammation due to its antioxidant effects. Zinc is found in red meat, poultry, and oysters. Because supplementation has been shown to cause copper deficiency, the long-term use of zinc supplements is not recommended (Chu et al., 2022).

Iodine.

Iodine is an element that is an important component of thyroid hormones, which regulate many body functions. Iodine deficiency can cause hypothyroidism, goiter, and intellectual disabilities in children. It can be found naturally in some foods such as seaweed, seafood, fish, eggs, and some grains. Salt and infant formulas are fortified with iodine (NIH Office of Dietary Supplements, 2023).

Vitamins

Vitamin A.

Vitamin A is a fat-soluble vitamin, also known as retinol, which is involved in vision, cell division, immunity, and reproduction. It is found in dairy products, liver, fish, fruits, and vegetables. Vitamin A deficiency is the world’s leading cause of preventable blindness in children. It is associated with an increased frequency of infections and contributes to poor outcomes in pregnancy and lactation (Chu et al., 2022).

Vitamin B12.

Vitamin B12 is a water-soluble vitamin that plays an important role in the nervous system, development, and red blood cell formation. Vitamin B12 deficiency can cause central nervous system dysfunction and anemia. Vitamin B12 can be found in meat products, eggs, and dairy (NIH Office of Dietary Supplements, 2023).

Vitamin C.

Vitamin C is a water-soluble vitamin that is important to bone health, immunity, and connective tissue. It is obtained by dietary intake and is found in fruits and vegetables. Vitamin C deficiency can cause poor wound healing, impaired immunity, and gum disease. (Chu et al., 2022).

Vitamin D.

Vitamin D plays a critical role in helping the body absorb calcium and phosphorous and has anti-inflammatory effects. It is a fat-soluble vitamin that comes from sunlight and one’s dietary intake. It can be found in fortified dairy products and fish. Vitamin D deficiency has been shown to increase the risk for bone demineralization and cardiovascular disease (Chu et al., 2022).

Vitamin K.

Vitamin K is a fat-soluble vitamin that plays a critical role in the blood clotting cascade. Those taking anticoagulants that antagonize vitamin K, such as warfarin, must ensure they have consistent vitamin K intake. This is the most clinically significant factor for monitoring Vitamin K. It is mostly found in vegetables, especially leafy greens (NIH Office of Dietary Supplements, 2023).


Physical Activity

To prevent weight gain and improve cardiovascular outcomes, it is generally recommended that physical activity for at least 30 minutes should occur at least five days per week (Perreault & Apovian, 2021). All children should have at least one hour of moderate physical activity daily for overall health (Hampl, et. al, 2023). Clinicians should begin by asking the patient how much physical activity is performed per week as well as the type and intensity of the activity (Tucker et al., 2021).There are many environmental factors that influence a person’s physical activity and they are discussed further in the section titled Social Determinants of Health.

If weight loss is the goal, it is recommended that adults participate in 30-60 minutes of moderate to vigorous aerobic exercise most days of the week to achieve small amounts of weight loss, improve fitness, decrease central adiposity, and maintain their weight loss. Resistance training can increase muscle mass and may help achieve weight maintenance. High-intensity interval training can achieve the same results as moderate aerobic exercise in a shorter period of time (Wharton et al., 2020).

People with disabilities have a greater incidence of obesity, especially if they have lower body weakness (Perreault & Bessesen, 2022). Physical and occupational therapy can be consulted as appropriate if there are physical limitations or difficulties with activities of daily living that can contribute to obesity and comorbid conditions.


Psychological and Behavioral Interventions

The United States Preventive Services Task Force (USPSTF) recommends that patients with a BMI ? 30 kg/m2 are referred to intensive behavioral interventions to improve adherence to altering behaviors that contribute to weight gain. USPSTF defines “intensive” as at least 12 monthly sessions over a one-year period to focus on weight management. Evidence suggests that in order to maintain changes to behavior, it is best to introduce them a little at a time and with long-term follow-up (Tucker et al., 2021).

Behavior modification is when patients learn how to make long-term changes through various activities. Examples of these behaviors include self-monitoring nutrition and activity, goal-setting, reducing the accessibility of certain foods, managing stress, improving sleep, and psychological therapy (Perreault & Apovian, 2021). There are various strategies used to support behavior modification including nutrition education, group sessions, and individual cognitive behavioral therapy (Tucker et al., 2021).

Pharmacotherapy

Pharmacotherapy can be used for weight management in individuals who have a BMI greater than or equal to 30 kg/m2 or a BMI greater than or equal to 27 kg/m2 who also have weight-related complications. Medications should always be used in conjunction with medical nutrition therapy, physical activity, and psychological interventions (Wharton et al., 2020; Perreault, 2022). While there are several sympathomimetics that are approved for weight loss for short-term use, they are generally not recommended due to their adverse effects and potential for misuse. The most effective pharmacological treatments for obesity are those that are approved for long-term use (see Table 7). Over-the-counter weight loss medications are not recommended for those living with obesity (Perreault, 2022).

There are several goals of pharmacological therapy, with the main objective being to lose weight and maintain the weight loss over time. Upon initiating pharmacological therapy, patients should understand that individual responses to treatment may vary and that medication for weight loss is lifelong much like any chronic illness. If the medication is stopped, it is likely that weight gain will occur. Enhancing health outcomes is another goal of therapy, such as the improvement of chronic conditions, perceived well-being, and physical function. These benefits should be weighed against any adverse effects or risks of therapy (Perreault, 2022).

When initiating pharmacological therapy for weight loss, providers must consider multiple factors. First, they will consider comorbid conditions to ensure that the treatments for all conditions complement each other. For example, liraglutide is the preferred drug for patients with obesity who also have diabetes and cardiovascular disease because it has a beneficial effect on glycemia and has been shown to reduce cardiovascular complications (Perreault, 2022).

Patient preference is key to treatment compliance, for example, a patient who is apprehensive about giving themselves an injection might prefer semaglutide which is a once per week injection over liraglutide which is administered daily. Insurance has a particularly significant impact on choosing therapy. Despite the scientific support for GLP-1 agonists, many insurance companies do not cover them and the cost of GLP-1 agonists is very high for self-pay patients (Perreault, 2022).

In the pediatric population, pharmacotherapy is used on occasion in adolescents who do not respond to behavior, nutrition, and activity interventions alone. Adolescents with type 2 diabetes mellitus and severe obesity have clinically significant weight loss with pharmacological therapy, however, those with obesity alone have low efficacy, making surgery a better option for some patients (Skelton, 2023).

Table 6

weight loss Medications*

Generic Name orlistat phentermine-extended release topiramate extended -release bupropion-naltrexone liraglutide semaglutide tirzepatide
US Brand Name Alli, Xenic Qsymia Contrave Saxenda Ozempic, Wegovy Mounjaro
Class Pancreatic lipase inhibitor Anorectics and anticonvulsant Dopamine-reuptake inhibitor and opioid receptor agonist GLP-1 Receptor Agonist GLP-1 Receptor Agonist GLP-1 Receptor Agonist
Dose 120 mg Taper up to 7.5/46 mg 8/90 mg Taper up to 3 mg Taper up to 2.4 mg Taper up to 15 mg
Frequency 3 times daily with fat-containing meals Daily in the morning Twice a day Daily Weekly Weekly
Route Oral Oral Oral Subcutaneous Subcutaneous Subcutaneous
Contraindications Numerous drug interactions Cholelithiasis Cholestasis Gallbladder disease Pancreatitis Liver disease Seizure history Renal disease HIV infection Hepatitis Hypothyroidism Glaucoma Hyperthyroidism Patients taking MAO inhibitors Seizure history Renal or hepatic impairment Uncontrolled hypertension Chronic opioid use Patients taking MAO inhibitors Personal history of pancreatitis Personal or family history of medullary thyroid cancer or multiple endocrine neoplasia 2A or 2B Personal history of pancreatitis Personal or family history of medullary thyroid cancer or multiple endocrine neoplasia 2A or 2B Personal history of pancreatitis Personal or family history of medullary thyroid cancer or multiple endocrine neoplasia 2A or 2B
Adverse effects Intestinal borborygmi Cramps Flatus Fecal incontinence Oily spotting Flatus with discharge Nausea Vomiting Diarrhea Rare incidence of liver and acute kidney injury Decreased absorption of fat-soluble vitamins Dry mouth Taste disturbance Constipation Paraesthesias Depression Anxiety Tachycardia Insomnia Abuse potential May increase risk for kidney stones Seizures Insomnia Dry mouth Dizziness Increased risk of suicidal thoughts Nausea Vomiting Hypertension Tachycardia Headache Nausea Vomiting Diarrhea Hypoglycemia Anorexia Pancreatitis Gallbladder disease Renal impairment Nausea Vomiting Diarrhea Risk of thyroid C-cell tumors Hypersensitivity reactions Acute kidney injury Nausea Vomiting Diarrhea Risk of thyroid C-cell tumors Gallbladder disease Dyspepsia Anorexia Constipation Acute kidney injury
Lactation Unlikely to affect infant (LactMed® 2023d) Not recommended (LactMed® 2023e) Limited data available, use with caution (LactMed® 2023a) Limited data available, use with caution (LactMed® 2023c) Limited data available, use with caution (LactMed® 2023b) Limited data available, use with caution (LactMed® 2023f)
Pregnancy Contraindicated Contraindicated Contraindicated Benefit should outweigh risk Benefit should outweigh risk Benefit should outweigh risk
US DEA Category Rx, OTC C-IV (due to phentermine component) Rx Rx Rx Rx
Patient Education Monitor weight every six weeks Contact health care provider if itching, jaundice, pale color stools, or anorexia develop Take three times each day with meals containing fat For missed meals and meals containing no fat, do not take dose of medication Take a prescribed multivitamin 2 hours before or after orlistat Take multivitamin containing fat-soluble vitamins Monitor weight every six weeks Do not discontinue medication without notifying the provider because it needs to be tapered Monitor weight every six weeks Do not administer with high-fat meals Do not crush, chew, or open capsule Monitor weight every six weeks If medication is discontinued, the weight will be regained Teach self-administration of subcutaneous injection using the pen Monitor weight every six weeks If medication is discontinued, the weight will be regained Teach self-administration of subcutaneous injection using the pen Monitor weight every six weeks If medication is discontinued, the weight will be regained Teach self-administration of subcutaneous injection using the pen
Nursing Considerations Monitor for gastrointestinal side effects Monitor for depression or suicidal thoughts Monitor electrolytes and creatinine Monitor for depression or suicidal thoughts Monitor for symptoms of acute pancreatitis and gallbladder disease Monitor blood glucose for hypoglycemia in patients taking liraglutide concurrent with insulin or a sulfonylurea Monitor for symptoms of acute pancreatitis and gallbladder disease FDA approved for those with diabetes mellitus and obesity. May be used off-label for those with obesity alone.


*All information from (Perreault, 2022) unless noted otherwise

Procedural Options for the Treatment of Obesity

There are endoscopic, laparoscopic, and open-surgical bariatric procedures that are used to treat obesity. Each has its own risk-benefit profile and should be carefully considered to meet each individual patient’s needs (Mechanick et al., 2019). The main methods that bariatric procedures work to reduce weight is through restriction of stomach capacity which restricts food intake, decrease of nutrient absorption by shortening the small intestine, or a combination of the two. (Lim, 2022). All types of bariatric surgery have a unique profile of benefits, risks, and costs. Insurance coverage varies widely for these procedures and there are many factors to consider when deciding which is best for each patient. Laparoscopic procedures generally have less early morbidity and mortality than open procedures and thus laparoscopic procedures are preferred (Mechanick et al., 2019).

The American Society of Metabolic and Bariatric Surgery (ASMBS) maintains a list of bariatric procedures and endorses the procedures that are supported by the existing literature. These endorsements are revised every two years. Procedures not endorsed by ASMBS lack substantial evidence for their use, generally require approval from an Institutional Review Board, and are not covered by health insurance in the United States.

Figure 2

Procedural options for obesity treatment endorsed by ASMBS

Endoscopic Laproscopic or Open Surgical
Intragastic Balloon Biliopancreatic Diversion with Duodenal Switch Roux-en-Y gastric bypass Sleeve Gastrectomy One-Anastomosis Gastric Bypass One-Anastomosis Duodenal Switch

(Mechanick et al., 2019).


Endoscopic Options

Several non-surgical endoscopic procedures are used as treatment for obesity. Endoscopic procedures have been shown to be effective for short-term weight loss, but further study is needed to determine their long-term impact on weight. The intragastric balloon is the main bariatric procedure performed endoscopically in the United States (Mechanick et al., 2019).

An intragastric balloon is a procedure where a soft, saline-filled balloon is placed in the stomach (Lim, 2022) to reduce the stomach capacity causing a feeling of fullness. There are several different brands of intragastric balloons that are approved for use in patients with a BMI of 30 – 40 kg/m2 in the United States (Mechanick et al., 2019). Weight loss can be up to 30% but only about 23% of patients maintain at least 70% of the weight loss (Lim, 2022).

The balloon can only remain in the stomach for about six months because the risk of balloon rupture increases after that, at which point the patient can try to maintain the loss or go on to a surgical procedure for long-term weight loss. There is a risk of the balloon migrating into the small intestine and some devices have an extra balloon that will remain inflated to prevent migration even if the large balloon fails (Lim, 2022).


Bariatric Surgery

The goal of bariatric surgery is to minimize long-term morbidity and mortality related to obesity complications. Bariatric surgery is used to treat individuals with a BMI greater than or equal to 35 kg/m2 or a BMI greater than or equal to 30 kg/m2 with weight-related complications (Wharton et al., 2020). BMI should be adjusted for the ethnicity of Asian Americans whereas bariatric surgery can be considered for a BMI greater than or equal to 27.5 kg/m2 or a BMI greater than or equal to 25 kg/m2 with weight-related complications (Lim, 2023; Mechanick et al., 2019).

Surgical options can significantly improve quality of life and induce remission of most weight-related complications such as hypertension, dyslipidemia, type II diabetes mellitus, and non-alcoholic fatty liver disease (Wharton et al., 2020). There have been numerous high-quality studies that demonstrate the benefits of bariatric surgery for patients with obesity (BMI greater than 35 kg/m2) and type II diabetes mellitus whose high blood sugar is not adequately controlled with medical management alone. After bariatric surgery, these patients experienced improved glycemic control (Mechanick et al., 2019).

Bariatric surgery has several contraindications for mental health and medical conditions (see table ) It is sometimes appropriate for adolescents who have obesity and usually it is undertaken only after other interventions have been consistently unsuccessful (Skelton, 2023). There is no upper age limit for bariatric surgery (Lim, 2023).

Figure 3

Contraindications to bariatric surgery

Untreated major depression or psychosis Uncontrolled or untreated eating disorders Current drug or alcohol abuse
Inability comply with nutrition and vitamin requirements post-operatively Conditions that make anesthesia too risky, such as severe cardiac disease Severe coagulopathy

(Lim, 2023).

Sleeve gastrectomy (SG)

In SG, most of the greater curvature of the stomach is removed, creating a tube-like shape to the stomach that has less stretch, is much smaller, and has significantly fewer ghrelin-producing cells. GLP-1 and PYY levels increase, further reducing hunger. The expected weight loss at two years is about 60% (Lim, 2022). SG is the most common type of bariatric surgery in the United States. It has a long-term risk of GERD and a higher incidence of leaks than some other options (Lim, 2022; Mechanick et al., 2019).

Roux-en-Y Gastric Bypass (RYGB)

In the RYGB, a small gastric pouch is separated from the rest of the stomach and anastomosed to an area of the small intestine, which was also separated. It works by decreasing the stomach’s capacity significantly and shortening the small bowel to limit absorption of nutrients. Patients also see a decrease in Ghrelin and a decrease in glucagon-like peptide-1 (GLP-1) and cholecystokinin (CCK), decreasing the sensation of hunger (Lim, 2022).

After RYGB surgery, the expected weight loss by two years is up to 70%. Patients must avoid concentrated sweets because of the risk of dumping syndrome, which is when food moves too quickly from the stomach to the small intestine causing nausea, vomiting, diarrhea, fullness, cramping sweating, flushing, and tachycardia. These patients may also have difficulty metabolizing alcohol and are at risk for alcohol-use disorder after surgery, therefore alcohol consumption should be eliminated (Mechanick et al., 2019).

Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

The BPD/DS involves creating a sleeve gastrectomy, leaving the pyloric sphincter intact, dividing the duodenum and ileum, and creating a roux limb to the small intestine. It is unclear in the literature how gut hormones affect outcomes in this procedure, although it is likely to play a role. BPD/DS is inconsistently used in the United States. At two years weight loss is expected to be between 70-80% (Lim, 2022). It should be selected with caution because it has the highest risk of nutritional deficiencies due to the amount of the small intestine that is bypassed (Mechanick et al., 2019).

One-Anastomosis Gastric Bypass (OAGB)

The OAGB is a modification of the loop bypass which only requires one anastomosis. The stomach is divided to create a small pouch which is anastomosed to the jejunum. The hormonal changes with this procedure have not been extensively studied. Benefits include the ease of reversal, alteration, and conversion. OAGB showed greater weight loss in patients with a BMI greater than 60 kg/m2. Weight loss at five years is between 68.6 to 85% (Lim, 2022). OAGB is not recommended for patients with a history of GERD or hiatal hernia (Mechanick et al., 2019).

One-Anastomosis Duodenal Switch (OADS)

In OADS, a sleeve gastrectomy is created and the intestines are rerouted similarly to RYGB to make a loop connection that only requires one anastomosis. Weight loss at two years is up to 85% depending on the size of the gastric pouch and the length of the resected small bowel. Because only one anastomosis is required, it has a lower risk of perforation or leaks, but it does have a higher risk of chronic diarrhea (Lim, 2022).

Rare Bariatric Procedures

There are several bariatric procedures that are not endorsed by ASMBS or are rarely used in the United States. Endoscopic procedures that are not routinely performed include aspiration therapy, endoscopic sleeve gastroplasty, and endoscopic gastrointestinal bypass devices. Uncommon surgical options include laparoscopic adjustable gastric bypass and greater curvature plication (Lim, 2022).

Preoperative Considerations

Prior to bariatric surgery, patients undergo pre-procedure evaluation for causative factors and obesity-related complications with a special emphasis on factors that might impact the procedures. The evaluation should include a comprehensive medical, surgical, and psychosocial history, a thorough physical exam, and any pertinent laboratory testing to evaluate pre-operative risk and identification of obesity-related risk factors. (Mechanick et al., 2019).

Figure 3

Bariatric surgery pre-procedure evaluation

Biriatric surgery pre-procedure evaluation

(Mechanick et al., 2019)

Culturally responsive, education should be provided at the patient’s education level in the patient’s language about peri-operative considerations that the patient should be educated about as part of the informed consent process. The risks, benefits, and costs of the procedure should be reviewed as well as the patient’s choice of a surgeon and facility for the procedure itself.

Several identified factors in surgery complications should be identified and addressed prior to surgery to improve outcomes. Pre-procedure weight loss can help improve the technical aspects of the surgery in patients with an enlarged liver or NAFLD. Weight loss may also be recommended prior to the procedure in the case of other comorbidities such as to improve glycemic control. If weight loss is achieved prior to the procedure and the BMI drops below the benchmark appropriate for bariatric surgery, most surgeons go on to perform the surgery anyway (Mechanick et al., 2019).

Contraceptive counseling is part of the pre-operative care of people capable of pregnancy. Pregnancy should be avoided pre-operatively and for 12 – 18 months after surgery and those who get pregnant post-bariatric procedure should be monitored for appropriate weight gain, adequate nutrients, and fetal well-being. Nutrient deficiencies may include iron, folate, vitamin B12, vitamin D, and calcium. Patients should be counseled that fertility status may improve after the procedure. To decrease VTE risk, patients taking any type of estrogen therapy should discontinue the medication (Mechanick et al., 2019).

Tobacco use should be avoided before and after surgery. For patients who use tobacco, preoperative smoking cessation of at least six weeks before surgery to reduce the chance of perioperative complications. Patients preparing for bariatric surgery should be screened for OSA and if it is present, it should be treated prior to surgery (Wharton et al., 2020). Those with lung disease or OSA should be seen for a formal pulmonary evaluation before surgery (Mechanick et al., 2019).

A formal behavioral evaluation must be performed by a mental health professional with specialized training in obesity prior to bariatric surgery. Patients should be evaluated for their ability to comply with post-operative behavior changes before surgery and continue to be monitored for adherence afterward (Mechanick et al., 2019).

Candidates for bariatric surgery should be evaluated by a registered dietitian to explore their history of weight fluctuations, eating behaviors, body composition, energy requirements, and assessment of nutritional deficiencies. The registered dietitian provides patient education including how to read food labels, appropriate portion sizes, and how to prepare meals. They also provide nutritional plans for the patient to use before and after surgery (Lim, 2023).

Postoperative Considerations

Patients who have had bariatric surgery have three major goals: manage comfort, decrease the risk of VTE and respiratory complications, and achieve a return of bowel function. A multimodal approach to comfort, including pain medications and antiemetics for post-operative nausea and vomiting improves patient’s comfort after surgery. Giving antiemetics and non-opioids for pain before or during surgery can help with post-operative pain. Long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided after bariatric procedures due to the risk of ulcerations, perforation, or leaks. If NSAIDs cannot be avoided, they can be given with a proton pump inhibitor (PPI) to decrease risk (Mechanick et al., 2019).

Pulmonary embolism is the leading cause of mortality after bariatric surgery. To decrease the risk of VTE, patients should ambulate early and throughout their recovery. Leg exercises may also be done post-operatively to decrease risk but are not a substitute for ambulation. Sequential compression devices and anticoagulants should be considered, especially in patients who are admitted to the hospital. After surgery, patients should be advised to begin at least 150 minutes of physical activity per week and progress to a goal of 300 minutes weekly. This should include strength training 2-3 times per week. Deep breathing exercises and incentive spirometry can decrease the risk of atelectasis after surgery (Mechanick et al., 2019).

Starting oral intake, usually beginning with clear liquids, can help the bowel regain functioning. Dietary recommendations vary by source, however, clear liquids are generally started by two hours after surgery. The patient can advance to a low sugar clear liquid meal plan within 24 hours and progression to full liquids and then solids should be discussed with the registered dietician. Once the diet is advanced, patients should follow healthy eating guidelines, eat three small meals a day, and chew small bites thoroughly before swallowing (Mechanick et al., 2019).

Upon discharge from bariatric surgery, patients should be encouraged to access behavioral interventions and allied health services in support of their health goals. Patients should be given information about their procedure, post-operative instructions, emergency contact information, any required vitamin or mineral supplements and/or prescribed medications, as well as when and under what conditions follow-up with a provider is necessary (Wharton et al., 2020).

Emerging Technology


Web-based or Mobile App platforms

Behavioral interventions are a significant part of the treatment of obesity and counseling for obesity can now be delivered remotely. Several studies have explored remote behavioral interventions using phone calls and digital meeting platforms via mobile apps or web pages. The existing literature shows that remote-based counseling may enhance weight loss. Entirely digital apps or web-based platforms that provide no provider interaction decrease the burden on providers and show promising results but still require more research. Many commercially available apps that are common do not feature all of the behavioral interventions that are necessary for losing weight in the long term (Tronieri et al., 2019).


Other Technology

Self-monitoring tools that integrate with the electronic health record are helpful in managing obesity. Such tools include activity trackers and digital scales (Tronieri et al., 2019). Even the use of virtual reality software has been shown in some studies to improve self-monitoring and weight loss after bariatric surgery (Mechanick et al., 2019).


Engagement Between Nurses and Patients Living with Obesity

Reducing Weight Bias

Individuals with overweight or obesity face stigma in their communities and workplaces and children with obesity are often bullied and teased (Hampl, et. al, 2023). This can lead to increases in binge eating, decreased socialization, lower levels of physical activity, and increased mood and anxiety disorders, which further exacerbate obesity (Albury et al., 2020; Rubino et al., 2020).

Obesity is often a lifelong chronic disease. Once weight gain occurs, it is normal for the body to respond to weight loss by lowering the metabolic rate and increasing hunger. Even when a person manages to lose weight, they often gain it back. This is not unlike many other chronic diseases that are relapsing in nature, yet individuals with obesity face a stigma that is extraordinary (Albury et al., 2020; Rubino et al., 2020).

Those with overweight and obesity are often met with stigma from clinicians which fosters mistrust of the healthcare system and apprehension about seeking care (Hampl, et. al, 2023). Weight bias in healthcare settings has a significant impact on the quality of care for patients who have obesity. This stigma is pervasive even among healthcare workers as many incorrectly believe that obesity is caused by laziness or a lack of willpower (Albury et al., 2020; Rubino et al., 2020).

The first step in addressing obesity bias in healthcare professionals is education and self-reflection to identify existing biases and address them. There are two major types of biases: implicit and explicit. Explicit bias is overt consciously held negative beliefs about people with overweight or obesity. Implicit biases are automatic negative attributions that are subconscious. These are often rooted in weight-based stereotypes which identify people with overweight or obese as lazy, gluttonous, or lacking self-discipline. Nurses should work to mitigate both conscious and unconscious biases in order to avoid weight-based discrimination in their practice (Rubino et al., 2020).


Ask for Permission

Healthcare workers should not assume all patients with overweight or obese are interested in obesity management. It is best practice for healthcare workers to ask permission before discussing obesity and only proceeding if the patient agrees (Wharton et al., 2020). Start by using an open-ended question about the patient’s weight to give them the opportunity to voice concerns or decline to discuss their weight. Make sure that the patient’s presenting concern is addressed fully before bringing up a discussion about weight (Albury et al., 2020).


Words Matter

Nurses are often uncomfortable discussing weight with patients but there are ways to discuss weight without compromising the integrity of the nurse-patient relationship. Nurses should allow patients to take the lead if they share what terminology they are most comfortable with. The patient’s own words can be mirrored, for example, the patient might say “My weight is higher than it ever was” That language can be used in counseling. As a general guideline and much like many other chronic diseases, it is best to use person-first language with patients living with obesity to avoid labeling individuals with their health conditions (Albury et al., 2020). In this case, one would say “person with overweight or obesity.” Other phrases that are neutral include “unhealthy weight” and “gaining too much weight for age, height, or health.” (Hampl, et. al, 2023).

Despite it being medically accurate, the term obese is often abrasive to patients and should be avoided because of the negative connotations in society. The term morbid obesity was formerly used but should be avoided due to its frequent misuse and derogatory connotation (Skelton & Klish, 2023). Other words that are frequently perceived as offensive include, fat, chubby, and large (Hampl, et. al, 2023).

When it comes to obesity, attempts at humor are inappropriate and can undermine the therapeutic relationship. Words that convey blame or that make assumptions should be avoided. Try to avoid “you” phrases and replace them with “some people” which gives patients the space to decide whether or not the information applies to them. One cannot make any assumptions about dietary patterns and physical activity (Albury et al., 2020).


Shared Decision-Making

Shared decision-making is when a healthcare worker and a patient work together to make the best decision for the patient’s individual needs which takes into account the healthcare worker’s knowledge and expertise and the patient’s values and preferences. The treatment plan should be a collaborative discussion that minimizes the perception of authoritarianism (Albury et al., 2020). Using scare tactics or the threat of long-term consequences be ineffective in long-term behavioral change. Shared decision-making has been shown in numerous studies to improve patient satisfaction and increase their involvement in their care (Albury et al., 2020; Skelton, 2023).


Motivational Interviewing

Motivational interviewing is a patient-centered interviewing strategy that identifies what patients prioritize as important in order to drive changes in behavior. Studies have shown motivational interviewing is an effective way to address weight changes (Hampl, et. al, 2023). This non-judgmental, supporting, and compassionate counseling technique focuses on a few behaviors related to health that inspire behavior change (Skelton, 2023).

There are four processes involved in motivational interviewing: engaging, focusing, evoking, and planning. The first stage, engaging, is when the nurse and patient get to know each other and establish a collaborative relationship. Next is focusing, when the patient identifies that they want to make a change in their weight. At that time the nurse can start to work with the patient to reflect on existing health behaviors and understand readiness for change. Planning is when the change plan is carried out. This includes formulating goals and reevaluating them (Hampl, et. al, 2023).

Goal-setting is only useful if the goals are actually attainable, so clinicians and patients should use “SMART” goals as a guide. SMART is an acronym that represents five qualities that make a robust goal: specific, measurable, attainable, realistic, and timely. (Skelton, 2023). Goals should be personally meaningful rather than percentages or amounts of weight loss. For example, experiencing less shortness of breath during a preferred activity is a more consequential goal than losing 10% of body weight. Patients respond better when goals focus on achieving positive outcomes rather than the negative consequences of not losing weight Even small victories in lifestyle changes should be celebrated and this may include staying the same weight versus gaining additional weight (Albury et al., 2020).


Inclusive Physical Environment

Many healthcare facilities are not sufficiently equipped to care for patients who have obesity (Rubino et al., 2020). When proper equipment is unavailable, it can compromise the comfort, dignity, and safety of patients with obesity (Ewens et al., 2022). An accurate blood pressure relies on the correct size cuff. It is critical for facilities to have varying sizes of BP cuffs available at all times, including manual and automatic equipment. When checking a patient’s weight, do so in a private space and ensure the scale has high weight limits, at least 150 kg, to accommodate a variety of body sizes (Albury et al., 2020).

In waiting areas, provide multiple chair sizes and avoid chairs with arms. Because tight spaces can be challenging to navigate, line up chairs so the aisles are wide. A variety of beds, exam tables, and stretcher sizes with high weight limits should be available (Albury et al., 2020). Imaging equipment such as CT or MRI scanners is another area where the equipment is too small for people with obesity. Doorways and room sizes should be able to accommodate larger equipment (Ewens et al., 2022).

In addition to having the appropriate equipment, staff must be knowledgeable on how to use equipment properly, identify the weight capacity, and proper storage and maintenance to prevent patients and staff from injury. Policies and procedures that are inclusive to all body sizes. Some examples include how to safely evacuate patients, skin care protocols, and mobilizing patients (Ewens et al., 2022). Imagery in healthcare environments, marketing materials, and patient education resources should be inclusive and avoid stigmatizing language (Hampl et al., 2023).


Conclusion

With the many advances in obesity science and the pervasive misunderstanding of obesity as a disease, nurses play an important role in bridging the gap between the evidence and practice to improve patient outcomes. Nurses must understand the many factors that influence weight, reflect on their own biases, and implement evidence-based strategies to effectively care for patients with overweight and obesity. Obesity science is ever changing and it is important for all healthcare workers to keep up with advances over time.

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