Affecting both children and adults, obesity is a priority healthcare issue.1 The World Health Organization (WHO) predicts that the obesity crisis will eventually surpass the more traditional public health concerns of inadequate nutrition and infectious diseases as a substantial contributing factor to poor health.2 Poor dietary intake and lack of physical activity are two of the major contributing factors that have led to this health crisis in the United States and internationally.1,3 In the United States alone, the obesity trend has increased over the last 20 years, with all states having an obesity prevalence of at least 20%.4 In addition, approximately 73% of men and 65% of women are obese or overweight, constituting about one-third of American adults, with rates increasing yearly.5

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Obesity and its associated health issues have greatly impacted the cost of healthcare in the United States, with an estimated cost of more than $90 billion each year.6 It affects individuals irrespective of sex, age, race, or ethnicity, increasing the affected person's risk of developing several chronic health problems, including type 2 diabetes, cardiovascular disease, hypertension, coronary heart disease, cancer, and osteoporosis.7-11 Obesity can also affect individuals emotionally and psychologically, leading to altered body image, hopelessness, helplessness, embarrassment, isolation, and social stigmatization.12

One of the national objectives for 2010 was to decrease the prevalence of obesity to less than 15%; however, data show that the incidence has since increased.6 The prevalence of obesity in children and adolescents has rapidly increased alongside adult obesity and has led to a rise in the numbers of bariatric surgeries.13 Although awareness of the obesity phenomenon has improved, challenges to formulate a uniform approach to aggressively arrest this trend continue.14,15 Variable choices in an instant gratification society contribute to difficulty managing weight and combating obesity. Specifically, eating healthy and incorporating exercise into daily routines are often viewed as expensive and time consuming, although the healthy lifestyle approach to weight loss is clinically supported.

Nurses, as patient, family, and community educators, have a critical role in increasing awareness of obesity and its associated diseases. An overall focus should include integrating and teaching the benefits of a healthy lifestyle, such as healthy diets, physical activity, and behavioral strategies, beginning with children in elementary schools. Healthy lifestyle choices should be emphasized, and people of all ages should be encouraged to become more physically active and decrease their dietary intake of processed and high-fat foods and sugar-sweetened beverages.1 The development of a consistent obesity training regimen will heighten the understanding of contributing factors and proper treatment, which allows nurses to become change agents for healthcare policy across variable and diverse healthcare settings.

Obesity defined

Obesity is defined as a medical condition in which an excessive accumulation of lipids is stored in the adipose tissue, characterized by excessive weight accumulation that can hinder health; typically resulting from a diet high in calories and a lifestyle of decreased physical activity.2,16,17 Specifically, body fat has accumulated to the extent that it negatively affects a person's health. Body mass index (BMI) is used to classify overweight and obesity in adults and children.1,2,6,11,18-20 BMI is described as an individual's weight in kilograms divided by the square of his or her height in meters (kg/m2), correlating with body fat.17 The WHO defines overweight in adults as a BMI greater than or equal to 25 kg/m2 and obesity as a BMI greater than or equal to 30 kg/m2.2,4,15 (See Table 1.) Children from ages 2 to 19 are classified as obese if they have a BMI equal to or above the 95th percentile, with respect to age and sex.1 Overweight or obese adults and children are at a greater risk for death due to associated health risk, at an approximate rate of 2.8 million deaths yearly.2

Table 1: Classification of BMI and obesity

Although body weight is an indicator of obesity, the location of body fat storage affects the individual's risk of disease.21Android obesity relates to the tendency for individuals to store fat in the trunk or abdominal area, which produces an apple shape. Gynoid obesity relates to the tendency for individuals to store fat in the hips or thighs, which produces a pear shape.21 Individuals with android obesity or increased stores of fat in the abdomen are at greater risk for developing heart disease, hypertension, type 2 diabetes, and stroke than individuals with gynoid obesity.21 Individuals with fat deposits located around the internal organs are at an even greater risk for developing associated diseases.

Waist circumference is a simple measure that can be used to assess this risk.22 A waist circumferences of more than 40 inches (101.6 cm) in men and 35 inches (88.9 cm) in women indicates a greater risk of developing comorbidities.22 (See Table 2.) Waist circumference has been found to be a better predictor of disease risk when compared with BMI. Using waist circumference and BMI together provides the best tool for identifying individuals who are at greater risk for disease from excessive body fat.23

Table 2: Disease risk associated with waist circumference

The primary cause of overweight and obesity is an energy imbalance between caloric intake and expenditure. Globally, there has been an increase in the amount of energy-dense foods that are high in fat, salt, and sugars, but low in essential vitamins, minerals, and other micronutrients. Another trend that has greatly impacted individuals' fat accumulation has been a decrease in physical activity due to the sedentary nature of many occupations, urbanization, and transportation.2 Societal and environmental changes have significantly impacted dietary and physical activity behaviors.

Contributing factors

Several contributing factors have been identified in the development of overweight and obesity in adults, including insufficient sleep (less than 7 hours of sleep per night), environmental pollutants that interfere with lipid metabolism, increased use of medications that cause weight gain, pregnancy at an older age, and genetic risk factors.24 Medications that typically induce weight gain include antidepressants, corticosteroids, beta-blockers, oral hypoglycemics, insulin, antiepileptic drugs, antihistamines, contraceptives, selective serotonin reuptake inhibitors, and monoamine oxidase inhibitors.25 There are also medical conditions that predispose an individual to become overweight, including hypothyroidism, Cushing syndrome, growth hormone deficiency, eating disorders, genetic syndromes, diabetes, psychiatric illness, polycystic ovarian syndrome, and illnesses that lead to physical disabilities that limit mobility.

Globally, more than 42 million children are overweight, leading to future health problems such as diabetes and cardiovascular disorders.5 In the United States, 2.5 million children and adolescents are obese.4 Several contributing factors have been identified in the development of overweight and obesity in children, including environmental influences and surroundings, such as an increased sedentary lifestyle resulting in decreased participatory (physical) activity. Increased technologic advances have made an impact on the amount of physical activity that children encounter daily. A deficient economy also affects childhood obesity. For instance, foods high in nutritional value tend to be more costly than foods high in fats, oils, and sugar.25 A deficient economy also causes parents to work longer hours or seek additional employment to avoid declines in their households, which may lead to stress and poor lifestyle choices for both parents and their children.25

Associated health risks

Overweight and obese adults who have a BMI of 25 kg/m2 or above are at risk for developing numerous health problems, such as:

* stress incontinence.6,8,11,26-28

Obesity is one of the leading causes of preventable deaths worldwide.29 Many of the leading causes of death in the United States are comorbidities related to obesity, including heart disease, stroke, and diabetes.30 There's an enormous amount of available measures that can be used to combat obesity, yet these measures are being used inconsistently.15 Obesity rates can be decreased with appropriate and consistent methods of training for healthcare professionals, especially nurses, and should be approached using an educationally appropriate and focused plan.

Nursing management

One of the most important noninvasive aspects of preventing and managing obesity is the provision of supportive environments and communities.2 This is fundamental in influencing individuals' choices, thereby helping them to recognize the need to choose healthier foods and integrate regular physical activity into their activities of daily living. Nurses interact with overweight and obese patients across a variety of healthcare settings and can greatly impact their care and outcomes.

The initial recommended target for weight loss should be a 10% loss over the first 6 months.22 Weight-loss rates of 1 to 2 pounds/week are desirable. The aim is to reduce energy intake by 500 to 1,000 cal/day. Caloric intake should be divided throughout the day. Flexibility and choice help patients develop dietary intake patterns that fit their lifestyle. Individuals should limit their energy intake from "red" foods, and increase their intake of "green" and "yellow" foods. For individuals for whom weight loss or a reduction in body fat can't be achieved, a goal to prevent further weight gain should be established.22 Caloric intake shouldn't be less than 800 cal/day. The typical daily intake for women is 1,200 calories and for men, 1,800 calories.10,22 (See Table 3.) Using a daily food diary can help individuals recognize unseen sources of excess caloric intake. Specifically for obese children, the focus should be on increased consumption of low energy-dense food instead of decreased food consumption.25

Table 3: Estimated calorie needs per day by age, sex, and physical activity level

Physical activity is an integral part of weight loss and healthy living. The initial level of physical activity should include at least 30 minutes of exercise, three to five times per week.22 Sustained physical activity aids in the maintenance of long-term weight loss. Physical activity reduces the risk of cardiovascular disease and the development of type 2 diabetes in a greater capacity than weight loss alone.22 Individuals may require supervision to help maintain motivation and prevent injury as they begin exercise regimens. Persons who are obese should begin activity slowly and gradually increase various forms of exercise as endurance is improved. Examples of appropriate activities include taking the stairs instead of elevators, walking, or swimming. Initially, individuals should start out walking 10 minutes three to five times a week and gradually increase to 30 to 45 minutes. Adults should set a long-term goal to increase activity to moderate-intensity activities at least 5 days/week.22 Moderate-intensity activities include walking, bicycling, jumping rope, or aerobic dance. These same activities are also appropriate for children. Exercise regimens should include activities that individuals enjoy that will fit well into daily routines. The overall goal of physical activity should be to reduce the effects of a sedentary lifestyle. Keeping a daily activity log along with a food intake diary is a helpful way to monitor exercise.

Lifestyle change and behavior modification is the third important component of weight loss and long-term maintenance of weight loss. Nurses should maintain a nonjudgmental perspective, which will help open lines of communication with patients. It's crucial to build a partnership with the patient; goal setting is a collaborative effort and the patient should be allowed to select the activities that help him or her reach the desired goals. Children should collaboratively develop their goals with their parents. Patients should be encouraged to set short- and long-term weight-loss goals. Self-monitoring, rewards, and controlling environmental stimuli that trigger undesired eating are useful tools for increasing self-awareness. This can be achieved through journaling about feelings and environmental factors and keeping food intake and exercise logs. Positive reinforcement and emotional support should be encouraged for obese children in lieu of punishment.25 Rewards should be contingent on meeting particular goals and may include desirable items whether tangible or intangible. Eating slower and using smaller plates helps to control portions and allows times for the hypothalamus to respond to food intake, increasing satiety.22

Evidence shows that although physiology plays a role in weight loss, individuals can change their behavior, resulting in the achievement and maintenance of a healthy body weight.31,32 Researchers for the National Weight Control Registry have found some common characteristics that can be utilized by nurses and nurse leaders to help patients reach and maintain their weight-loss goals. First, most participants in this research used both diet and exercise to lose weight.31 This was a significant finding because many formal weight loss programs focus on diet alone. Four common behaviors were demonstrated by participants: consumption of a low-fat, high-carbohydrate diet; eating breakfast daily; monitoring weight frequently; and engaging in a high level of physical activity. Participants consumed around 1,300 to 1,500 cal/day, with fat constituting around 23% to 24% of the daily intake. Walking was the most common form of physical activity and individuals walked approximately 11,000 to 15,000 steps daily, which is equal to about 5.5 to 6 miles/day.31 Individuals with a history of childhood obesity have reported successful weight loss and maintenance using dietary and exercise strategies.32

According to the American Diabetes Association, children and their families' experience high levels of recidivism after weight loss.33 Individuals who lose weight often regain it. As nurse leaders, it's imperative to maintain contact with patients throughout the continuum of care and educate them about behavior modifications essential to the prevention of recidivism, or a return to undesirable behaviors. This means that the focus needs to shift from diet and weight-loss to physical activity and long-term weight-loss maintenance. To prevent recidivism from occurring, it's important for nurses to help patients develop a plan for success to maintain a healthy lifestyle. Without a plan, patients may continue with or resort to their old habits.

The SAFE method is a best practice model that can be effective in assisting nurses to help patients with this lifestyle change.33 The SAFE acronym discourages beverages that are high in sugar, recommending noncaloric drinks and low-fat milk beverages. After meal snack choices should include fresh fruits and vegetables and other low-fat/low-calorie snacks. Fast foods and the super-size option should be avoided when possible, and healthy side items in lieu of French fries should be encouraged. Finally, replacing sedentary activities with physical exercise is encouraged. To assist with the success of the SAFE method, nurses can identify a few key areas of focus for the patient and set incremental, measurable goals in collaboration with the patient and his or her family or support system. A checklist method or a diary in which exercises and caloric intake can be documented will help bolster success.

Combating obesity

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