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Obesity: Risk factors, complications, and strategies

for sustainable long-term weight management
Sharon M. Fruh, PhD, RN, FNP-BC (Assistant Professor)
College of Nursing, University of South Alabama, Mobile, Alabama

Keywords Abstract
Obesity; nurse practitioner communication;
weight management; health; effects. Background and Purpose: The aims of this article are to review the effects
of obesity on health and well-being and the evidence indicating they can be
Correspondence ameliorated by weight loss, and consider weight-management strategies that may
Sharon M. Fruh, PhD, RN, FNP-BC, College of help patients achieve and maintain weight loss.
Nursing, Room 3064, University of South
Methods: Narrative review based on literature searches of PubMed up to May
Alabama, 5721 USA Drive North, Mobile, AL
2016 with no date limits imposed. Search included terms such as “obesity,”
36688.
E-mail: [email protected] “overweight,” “weight loss,” “comorbidity,” “diabetes,” cardiovascular,” “can-
cer,” “depression,” “management,” and “intervention.”
Received: 26 April 2017; Conclusions: Over one third of U.S. adults have obesity. Obesity is associated
revised: 20 July 2017;
with a range of comorbidities, including diabetes, cardiovascular disease, obstruc-
accepted: 25 July 2017
tive sleep apnea, and cancer; however, modest weight loss in the 5%–10% range,
doi: 10.1002/2327-6924.12510 and above, can significantly improve health-related outcomes. Many individu-
als struggle to maintain weight loss, although strategies such as realistic goal-
Disclosure
setting and increased consultation frequency can greatly improve the success
Dr. Sharon Fruh serves on the Novo Nordisk
Obesity Speakers Bureau. In compliance with of weight-management programs. Nurse practitioners have key roles in estab-
national ethical guidelines, the author reports lishing weight-loss targets, providing motivation and support, and implementing
no relationship with business or industry that weight-loss programs.
would post a conflict of interest. Implications for Practice: With their in-depth understanding of the research
in the field of obesity and weight management, nurse practitioners are well
placed to effect meaningful changes in weight-management strategies deployed
in clinical practice.

Introduction and support, and supplying patients with the necessary

knowledge and treatment tools to help achieve weight
Obesity is an increasing, global public health issue. Pa-
loss, followed by tools for structured lifestyle support
tients with obesity are at major risk for developing a range
to maintain weight lost, the nurse practitioner is ideally
of comorbid conditions, including cardiovascular disease
positioned to help patient’s achieve their weight-loss—and
(CVD), gastrointestinal disorders, type 2 diabetes (T2D),
overall health—targets.
joint and muscular disorders, respiratory problems, and
psychological issues, which may significantly affect their
daily lives as well as increasing mortality risks. Obesity-
The obesity epidemic
associated conditions are manifold; however, even modest The World Health Organization (WHO) defines over-
weight reduction may enable patients to reduce their risk weight and obesity as abnormal or excessive fat accu-
for CVD, diabetes, obstructive sleep apnea (OSA), and mulation that presents a risk to health (WHO, 2016a). A
hypertension among many other comorbidities (Cefalu body mass index (BMI) ࣙ25 kg/m2 is generally considered
et al., 2015). A relatively small and simple reduction in overweight, while obesity is considered to be a BMI ࣙ
weight, for example, of around 5%, can improve patient 30 kg/m2 . It is well known that obesity and overweight
outcomes and may act as a catalyst for further change, are a growing problem globally with high rates in both
with sustainable weight loss achieved through a series of developed and developing countries (Capodaglio & Liuzzi,
incremental weight loss steps. In facilitating the process 2013; WHO, 2016a, 2016b).
of losing weight for patients, nurse practitioners play an In the United States in 2015, all states had an obesity
essential role. Through assessing the patient’s risk, estab- prevalence more than 20%, 25 states and Guam had
lishing realistic weight-loss targets, providing motivation obesity rates >30% and four of those 25 states (Alabama,

Journal of the American Association of Nurse Practitioners 29 (2017) S3–S14 S3

C 2017 American Association of Nurse Practitioners
Weight-management strategies S. M. Fruh

Figure 1 U.S. obesity epidemic 2015.

Source. Figure adapted from Centers for Disease Control and Prevention (CDC). Retrieved from https://www.cdc.gov/obesity/data/prevalence-maps.html.

Louisiana, Mississippi, and West Virginia) had rates (Berrington de Gonzalez et al., 2010; Kuk et al., 2011;
>35% (Centres for Disease Control and Prevention, 2016; Prospective Studies Collaboration et al., 2009). There is
Figure 1). Approximately 35% and 37% of adult men and evidence to indicate that all-cause, CVD-associated, and
women, respectively, in the United States have obesity cancer-associated mortalities are significantly increased
(Yang & Colditz, 2015). Adult obesity is most common in individuals with obesity, specifically those at Stages
in non-Hispanic black Americans, followed by Mexican 2 or 3 of the Edmonton Obesity Staging System (EOSS;
Americans, and non-Hispanic white Americans (Yang & Kuk et al., 2011; Figure 2). Mortality related to cancer
Colditz, 2015). Individuals are also getting heavier at a is, however, also increased at Stage 1, when the physical
younger age; birth cohorts from 1966 to 1975 and 1976 symptoms of obesity are marginal (Figure 2). Recently, a
to 1985 reached an obesity prevalence of ࣙ20% by 20– large-scale meta-analysis that included studies that had
29 years of age, while the 1956–1965 cohort only reached enrolled over 10 million individuals, indicated that, rela-
this prevalence by age 30–39 years (Lee et al., 2010). tive to the reference category of 22.5 to <25 kg/m2 , the
Additionally, the prevalence of childhood obesity in 2- hazard ratio (HR) for all-cause mortality rose sharply with
to 17-year-olds in the United States has increased from increasing BMI (The Global BMI Mortality Collaboration,
14.6% in 1999–2000 to 17.4% in 2013–2014 (Skinner & 2016). For a BMI of 25.0 to <30.0 kg/m2 , the HR was
Skelton, 2014). Childhood obesity is an increasing health 1.11 (95% confidence interval [CI] 1.10, 1.11), and this
issue because of the early onset of comorbidities that have increased to 1.44 (1.41, 1.47), 1.92 (1.86, 1.98), and 2.71
major adverse health impacts, and the increased likelihood (2.55, 2.86) for a BMI of 30.0 to <35.0, 35.0 to <40.0,
of children with obesity going on to become adults with and 40.0 to <60.0 kg/m2 , respectively.
obesity (50% risk vs. 10% for children without obesity;
Whitaker, Wright, Pepe, Seidel, & Dietz, 1997). Comorbidities
Obesity is a chronic disease that is associated with a wide
range of complications affecting many different aspects of
Association of obesity with mortality physiology (Dobbins, Decorby, & Choi, 2013; Guh et al.,
and comorbid disease 2009; Martin-Rodriguez, Guillen-Grima, Marti, & Brugos-
Larumbe, 2015; summarized in Table 1). To examine these
Mortality
obesity-related morbidities in detail is beyond the scope of
Obesity is associated with a significant increase in this review and therefore only a brief overview of some of
mortality, with a life expectancy decrease of 5–10 years the key pathophysiological processes is included next.

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S. M. Fruh Weight-management strategies

Figure 2 Association between EOSS stage and risk of all-cause (A), CVD (B), cancer (C), and non-CVD or noncancer mortality (D) in men and women. 
C 2011.

Source. Reproduced with permission from NRC Research Press, from Kuk et al. (2011). CVD, cardiovascular disease; NW, normal weight.

The progression from lean state to obesity brings with it a These, in turn, increase the risk for CVD, including stroke
phenotypic change in adipose tissue and the development and venous thromboembolism (Blokhin & Lentz, 2013).
of chronic low-grade inflammation (Wensveen, Valentic, The metabolic and cardiovascular aspects of obesity are
Sestan, Turk Wensveen, & Polic, 2015). This is charac- closely linked. The chronic inflammatory state associated
terized by increased levels of circulating free-fatty acids, with obesity is established as a major contributing fac-
soluble pro-inflammatory factors (such as interleukin [IL] tor for insulin resistance, which itself is one of the key
1β, IL-6, tumor necrosis factor [TNF] α, and monocyte pathophysiologies of T2D (Johnson, Milner, & Makowski,
chemoattractant protein [MCP] 1) and the activation and 2012). Furthermore, central obesity defined by waist cir-
infiltration of immune cells into sites of inflammation cumference is the essential component of the International
(Hursting & Dunlap, 2012). Obesity is also usually allied to Diabetes Federation (IDF) definition of the metabolic
a specific dyslipidemia profile (atherogenic dyslipidemia) syndrome (raised triglycerides, reduced HDL cholesterol,
that includes small, dense low-density lipoprotein (LDL) raised blood pressure, and raised fasting plasma glucose;
particles, decreased levels of high-density lipoprotein International Diabetes Federation, 2006).
(HDL) particles, and raised triglyceride levels (Musunuru, Obesity is also closely associated with OSA. To start, a
2010). This chronic, low-grade inflammation and dys- number of the conditions associated with obesity such as
lipidemia profile leads to vascular dysfunction, includ- insulin resistance (Ip et al., 2002), systemic inflammation,
ing atherosclerosis formation, and impaired fibrinolysis. and dyslipidemia are themselves closely associated with

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Weight-management strategies S. M. Fruh

Table 1 Morbidities associated with obesity (Hamdy, 2016; Petry, Barry, Pietrzak, & Wagner, 2008; Pi-Sunyer, 2009; Sakai et al., 2005; Smith, Hulsey, &
Goodnight, 2008; Yosipovitch, DeVore, & Dawn, 2007)

Class of event Comorbidities associated with obesity

Cancer/malignancy Postmenopausal breast, endometrial, colon and rectal, gallbladder, prostate, ovarian, endometrial
renal cell, esophageal adenocarcinoma, pancreatic, and kidney cancer
Cardiovascular Coronary artery disease, obesity-associated cardiomyopathy, essential hypertension, left
ventricular hypertrophy, cor pulmonale, accelerated atherosclerosis, pulmonary hypertension of
obesity, dyslipidemia, chronic heart failure (CHD), left ventricular hypertrophy (LVH),
cardiomyopathy, pulmonary hypertension, lymphedema (legs)
Gastrointestinal (GI) Gall bladder disease (cholecystitis, cholelithiasis), gastroesophageal reflux disease (GERD), reflux
esophagitis, nonalcoholic steatohepatitis (NASH), nonalcoholic fatty liver disease (NAFLD), fatty
liver infiltration, acute pancreatitis
Genitourinary Stress incontinence
Metabolic/endocrine Type 2 diabetes mellitus, prediabetes, metabolic syndrome, insulin resistance, and dyslipidemia
Musculoskeletal/orthopedic Pain in back, hips, ankles, feet and knees; osteoarthritis (especially in the knees and hips), plantar
fasciitis, back pain, coxavera, slipped capital femoral epiphyses, Blount disease and
Legg-Calvé-Perthes disease, and chronic lumbago
Neurological and central nervous system Stroke, dementia idiopathic intracranial hypertension, and meralgia paresthesia
(CNS)
Obstetric and perinatal Pregnancy-related hypertension, fetal macrosomia, very low birthweight, neural tube defects,
preterm birth, increased cesarean delivery, increased postpartum infection and pelvic dystocia,
preeclampsia, hyperglycemia, gestational diabetes (GDM)
Skin Keratosis pilaris, hirsutism, acanthosis nigricans, and acrochondons, psoriasis, intertrigo (bacterial
and/or fungal), and increased risk for cellulitis, venous stasis ulcers, necrotizing fasciitis, and
carbuncles
Psychological Depression, anxiety, personality disorder, and obesity stigmatization
Respiratory/pulmonary Obstructive sleep apnea (OSA), Pickwickian syndrome (obesity hypoventilation syndrome), higher
rates of respiratory infections, asthma, hypoventilation, pulmonary emboli risk
Surgical Increased surgical risk and postoperative complications, deep venous thrombosis, including wound
infection, pulmonary embolism, and postoperative pneumonia
Reproductive (Women) Anovulation, early puberty, polycystic ovaries, infertility, hyperandrogenism, and sexual dysfunction
Reproductive (Men) Hypogonadotropic hypogonadism, polycystic ovary syndrome (PCOS), decreased libido, and sexual
dysfunction
Extremities Venous varicosities, lower extremity venous and/or lymphatic edema

OSA, and concurrently, the obesity-associated deposition morbidities associated with obesity represents a significant
of fat around the upper airway and thorax may affect clinical issue for individuals with obesity. However, as
lumen size and reduce chest compliance that contributes significant as this array of risk factors is for patient health,
to OSA (Romero-Corral, Caples, Lopez-Jimenez, & the risk factors can be positively modified with weight loss.
Somers, 2010).
The development of certain cancers, including colo-
rectal, pancreatic, kidney, endometrial, postmenopausal Obesity-related morbidities in children
breast, and adenocarcinoma of the esophagus to name a and adolescents
few, have also been shown to be related to excess levels As was referred to earlier, children and adolescents are
of fat and the metabolically active nature of this excess becoming increasingly affected by obesity. This is partic-
adipose tissue (Booth, Magnuson, Fouts, & Foster, 2015; ularly concerning because of the long-term adverse con-
Eheman et al., 2012). Cancers have shown to be impacted sequences of early obesity. Obesity adversely affects the
by the complex interactions between obesity-related metabolic health of young people and can result in im-
insulin resistance, hyperinsulinemia, sustained hyper- paired glucose tolerance, T2D, and early-onset metabolic
glycemia, oxidative stress, inflammation, and the produc- syndrome (Pulgaron, 2013).There is also strong sup-
tion of adipokines (Booth et al., 2015). The wide range of port in the literature for relationships between childhood

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S. M. Fruh Weight-management strategies

obesity and asthma, poor dental health (caries), non- Cardiovascular health
alcoholic fatty liver disease (NAFLD), and gastroe-
Weight loss is associated with beneficial changes in sev-
sophageal reflux disease (GERD; Pulgaron, 2013). Obe-
eral cardiovascular risk markers, including dyslipidemia,
sity can also affect growth and sexual development and
pro-inflammatory/pro-thrombotic mediators, arterial stiff-
may delay puberty in boys and advance puberty in some
ness, and hypertension (Dattilo & Kris-Etherton, 1992;
girls (Burt Solorzano & McCartney, 2010). Childhood obe-
Dengo et al., 2010; Goldberg et al., 2014; Haffner et al.,
sity is also associated with hyperandrogenism and poly-
2005; Ratner et al., 2005). Importantly, weight loss was
cystic ovary syndrome (PCOS) in girls (Burt Solorzano &
found to reduce the risk for CVD mortality by 41% up
McCartney, 2010). Additionally, obesity is associated with
to 23 years after the original weight-loss intervention (Li
psychological problems in young people including atten-
et al., 2014; Figure 4). Evidence including the biologi-
tion deficit hyperactivity disorder (ADHD), anxiety, de-
cal effects of obesity and weight loss, and the increased
pression, poor self-esteem, and problems with sleeping
risk for stroke with obesity indicates that weight loss may
(Pulgaron, 2013).
be effective for primary- and secondary-stroke prevention
Modest weight loss and its long-term (Kernan, Inzucchi, Sawan, Macko, & Furie, 2013).
maintenance: Benefits and risks
Guidelines endorse weight-loss targets of 5%–10% in
Type 2 diabetes
individuals with obesity or overweight with associated
comorbidities, as this has been shown to significantly Three major long-term studies, the Diabetes Preven-
improve health-related outcomes for many obesity-related tion Program (DPP), the Diabetes Prevention Study (DPS),
comorbidities (Cefalu et al., 2015; Figure 3), including and the Da Qing IGT and Diabetes (Da Qing) study, have
T2D prevention, and improvements in dyslipidemia, demonstrated that modest weight loss through short-term
hyperglycemia, osteoarthritis, stress incontinence, GERD, lifestyle or pharmacologic interventions can reduce the
hypertension, and PCOS. Further benefits may be evi- risk for developing T2D by 58%, 58%, and 31%, respec-
dent with greater weight loss, particularly for dyslipidemia, tively, in individuals with obesity and prediabetes (DPP
hyperglycemia, and hypertension. For NAFLD and OSA, Research Group et al., 2009; Pan et al., 1997; Tuomilehto
at least 10% weight loss is required to observe clinical et al., 2001). Long-term benefits were maintained follow-
improvements (Cefalu et al., 2015). ing the interventions; for example, in the DPP, the risk
Importantly, the weight-loss benefits in terms of comor- reduction of developing T2D versus placebo was 34% at
bidities are also reflected in improved all-cause mortality. 10 years and 27% at 15 years following the initial
A recent meta-analysis of 15 studies demonstrated that weight-loss intervention (DPP Research Group, 2015; DPP
relatively small amounts of weight loss, on average 5.5 kg Research Group et al., 2009). Weight loss increased the
in the treatment arm versus 0.2 kg with placebo from an likelihood of individuals reverting from prediabetes to nor-
average baseline BMI of 35 kg/m2 , resulted in a substantial moglycemia (DPP Research Group et al., 2009; Li et al.,
15% reduction in all-cause mortality (Kritchevsky et al., 2008; Lindstrom et al., 2003, 2006; Tuomilehto et al.,
2015). 2001), and also improved other aspects of glycemic

Figure 3 Benefits of modest weight loss. Lines demonstrate the ranges in which weight loss has been investigated and shown to have clinical benefits.
Arrows indicate that additional benefits may be seen with further weight loss.
Source. Figure adapted from Cefalu et al. (2015).

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Weight-management strategies S. M. Fruh

Figure 4 Reduction in cardiovascular mortality with modest weight reduction. Cumulative incidence of CVD mortality during 23 years of follow-up in the Da
Qing study (Li et al., 2014). Figure 
C 2014 Elsevier.

Source. Reproduced with permission from Li et al. (2014).

control including fasting and postprandial glucose, and in- colon in the large-scale Iowa Women’s Health Study
sulin sensitivity (Haufe et al., 2013; Li et al., 2008). (Parker & Folsom, 2003). The overall reduction in the
incidence rate of any cancer was 11% (relative risk,
Sleep apnea 0.89; 95% CI 0.79, 1.00) for participants who lost more
than 9 kg compared with those who did not achieve
Data indicate that weight loss is beneficial, although not
a more than 9 kg weight loss episode. Additionally,
curative, in patients with obesity who experience OSA.
weight loss in participants with obesity has been estab-
Meta-analyses of patients who underwent treatment with
lished to be associated with reductions in cancer biomark-
either intensive lifestyle intervention (Araghi et al., 2013)
ers including soluble E-selectin and IL-6 (Linkov et al.,
or bariatric surgery (Greenburg, Lettieri, & Eliasson, 2009)
2012).
demonstrated improvements in apnea-hypopnea index
(AHI) following treatment. In the first of these meta-
analyses, in randomized controlled trials, lifestyle inter- Additional health benefits
vention lead to a mean reduction in BMI of 2.3 kg/m2 ,
The substantial weight loss associated with bariatric
which was associated with a decrease in mean AHI of
surgery has been shown to improve asthma with a 48%–
6.0 events/h. As expected, weight loss was much higher
100% improvement in symptoms and reduction in medi-
in the second meta-analysis that investigated the effect of
cation use (Juel, Ali, Nilas, & Ulrik, 2012); however, there
bariatric surgery on measures of OSA, and this was associ-
is a potential threshold effect so that modest weight loss
ated with greater reductions in AHI; the mean BMI reduc-
of 5%–10% may lead to clinical improvement (Lv, Xiao,
tion of 17.9 kg/m2 resulted in AHI events being reduced
& Ma, 2015). Similarly, modest weight loss of 5%–10%
by a mean of 38.2 events/h. Once these improvements in
improves GERD (Singh et al., 2013) and liver function
AHI have occurred, they seem to persist for some time,
(Haufe et al., 2013). A study utilizing MRI scanning to
irrespective of a certain degree of weight regain. In one
examine the effects of weight loss on NAFLD has re-
study, an initial mean weight loss of 10.7 kg resulted in
ported a reduction in liver fat from 18.3% to 13.6% (p =
a persistent improvement in AHI over a 4-year period de-
.03), a relative reduction of 25% (Patel et al., 2015).
spite weight regain of approximately 50% by Year 4 (Kuna
Taking an active role in addressing obesity through behav-
et al., 2013).
ioral modifications or exercise can also reduce the symp-
toms of depression (Fabricatore et al., 2011), improve
Cancer
urinary incontinence in men and women (Breyer et al.,
Intentional weight loss of >9 kg reduced the risk for 2014; Brown et al., 2006), and improve fertility
a range of cancers including breast, endometrium, and outcomes in women (Kort, Winget, Kim, & Lathi, 2014).

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S. M. Fruh Weight-management strategies

Additionally, weight loss can reduce the joint-pain symp- Table 2 Lifestyle factors associated with achieving and maintaining weight
toms and disability caused by weight-related osteoarthri- loss
tis (Felson, Zhang, Anthony, Naimark, & Anderson, 1992; Action Percentage
Foy et al., 2011).
Modified food intake 98
Increased physical activitya 94
Mitigating risks Exercised on average for 1 h each day 90
Ate breakfast every day 78
Despite the array of benefits, weight loss can also be Weighed themselves weekly 75
linked with certain risks that may need to be managed. Watched less than 10 h of television weekly 62
One such example is the risk for gallstones with rapid Lost weight with the help of a weight-loss program 55
weight loss, which is associated with gallstone formation
Note. Data from (NWCR, 2016).
in 30%–71% of individuals. Gallstone formation is par- a
Walking was the most common activity undertaken.
ticularly associated with bariatric surgery when weight
loss exceeds 1.5 kg/week and occurs particularly within
the first 6 weeks following surgery when weight loss is Realistic weight-loss targets
greatest. Slower rates of weight loss appear to mitigate
the risk for gallstone formation compared to the gen- From the outset, a patient’s estimate of their achievable
eral population but may not eliminate it entirely; as was weight loss may be unrealistic. Setting realistic weight-loss
noted in the year-long, weight-loss, SCALE trial that com- goals is often difficult because of misinformation from a
pared liraglutide 3.0 mg daily use to placebo and re- variety of sources, including friends, media, and other
sulted in gallstone formation in 2.5% of treated subjects healthcare professionals (Osunlana et al., 2015). Many
compared to 1% of subjects taking placebo. For this rea- individuals with obesity or overweight have unrealistic
son, the risk for cholethiasis should be considered when goals of 20%–30% weight loss, whereas a more realistic
formulating weight-loss programs (Weinsier & Ullmann, goal would be the loss of 5%–15% of the initial body
1993). weight (Fabricatore et al., 2007). Promoting realistic
weight-loss expectations for patients was identified as
a key difficulty for nurse practitioners, primary care
Strategies to help individuals achieve and nurses, dieticians, and mental health workers (Osunlana
maintain weight loss et al., 2015). Visual resources showing the health and
Rogge and Gautam have covered the biology of obe- wellness benefit of modest weight loss may thus be helpful
sity and weight regain within another section of this (Osunlana et al., 2015). Healthcare practitioners should
supplement (Rogge & Gautam, 2017), so here we focus focus on open discussion about, and re-enforcement of,
on some of the clinical strategies for delivering weight realistic weight-loss goals and assess outcomes consistently
loss and weight loss maintenance lifestyle programs. according to those goals (Bray, Look, & Ryan, 2013).
Structured lifestyle support plays an important role
in successful weight management. A total of 34% of
Maintaining a food diary
participants receiving structured lifestyle support from
trained-nursing staff achieved weight loss of ࣙ5% over The 2013 White Paper from the American Nurse
12 weeks compared with approximately 19% with usual Practitioners Foundation on the Prevention and Treat-
care (Nanchahal et al., 2009). This particular structured ment of Obesity considers a food diary as an important
program, delivered in a primary healthcare setting, in- evidence-based nutritional intervention in aiding weight
cluded initial assessment and goal setting, an eating plan loss (ANPF). Consistent and regular recording in a food
and specific lifestyle goals, personalized activity program, diary was significantly associated with long-term weight-
and advice about managing obstacles to weight loss. Ad- loss success in a group of 220 women (Peterson et al.,
ditionally, data from the National Weight Control Registry 2014). This group lost a mean of 10.4% of their ini-
(NWCR), which is the longest prospective compilation of tial body weight through a 6-month group-based weight-
data from individuals who have successfully lost weight management program and then regained a mean of 2.3%
and maintained their weight loss, confirm expectations over a 12-month follow-up period, during which par-
that sustained changes to both diet and activity levels ticipants received bimonthly support in person, by tele-
are central to successful weight management (Table 2). phone, or by e-mail (Peterson et al., 2014). Over the
Therefore, an understanding of different clinical strategies 12-month follow-up, women who self-monitored consis-
for delivery-structured support is essential for the nurse tently (ࣙ50% of the extended-care year) had a mean
practitioner. weight loss of 0.98%, while those who were less consistent

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Weight-management strategies S. M. Fruh

(<50%) gained weight (5.1%; p < .01). Therefore, fre- environmental factors may need to be challenged to help
quent and consistent food monitoring should be encour- facilitate weight loss. A family history of obesity and child-
aged, particularly in the weight-maintenance phase of any hood obesity are strongly linked to adult obesity, which is
program. likely to be because of both genetic and behavioral factors
(Kral & Rauh, 2010). Parents create their child’s early food
experiences and influence their child’s attitudes to eating
Motivating and supporting patients through learned eating habits and food choices (Kral &
Motivational interviewing is a technique that focuses Rauh, 2010). Families can also impart cultural preferences
on enhancing intrinsic motivation and behavioral changes for less healthy food choices and family food choices may
by addressing ambivalence (Barnes & Ivezaj, 2015). Inter- be affected by community factors, such as the local avail-
views focus on “change talk,” including the reasons for ability and cost of healthy food options (Castro, Shaibi,
change and optimism about the intent for change in a sup- & Boehm-Smith, 2009). Alongside this, genetic variation
portive and nonconfrontational setting, and may help in- in taste sensation may influence the dietary palate and
dividuals maintain behavioral changes. influence food choices (Loper, La Sala, Dotson, & Steinle,
For patients that have achieved weight loss, the be- 2015). For example, sensitivity to 6-n-propylthiouracil
havioral factors associated with maintaining weight loss (PROP) is genetically determined, and PROP-tasting abil-
include strong social support networks, limiting/avoiding ity ranges from super taster to nontaster. When offered
disinhibited eating, avoiding binge eating, avoiding eating buffet-style meals over 3 days, PROP nontasters consumed
in response to stress or emotional issues, being accountable more energy, and a greater proportion of energy from
for one’s decisions, having a strong sense of autonomy, fat compared with super tasters. So it is possible that a
internal motivation, and self-efficacy (Grief & Miranda, family’s genetic profile could contribute to eating choices.
2010). Therefore, encouraging feelings of “self-worth” or To address behavioral factors, it is important to ensure
“self-efficacy” can help individuals to view weight loss as that families have appropriate support and information
being within their own control and achievable (Cochrane, and that any early signs of weight gain are dealt with
2008). promptly.
Strengthening relationships with patients with over- A healthy home food environment can help individu-
weight or obesity to enhance trust may also improve ad- als improve their diet. In children, key factors are avail-
herence with weight-loss programs. Patients with hyper- ability of fresh fruit and vegetables at home and parental
tension who reported having “complete trust” in their influence through their own fresh fruit and vegetable in-
healthcare practitioner were more than twice as likely to take (Wyse, Wolfenden, & Bisquera, 2015). In adults,
engage in lifestyle changes to lose weight than those who unhealthy home food environment factors include less
lacked “complete trust” (Jones, Carson, Bleich, & Cooper, healthy food in the home and reliance on fast food
2012). It may be prudent to ensure the healthcare staff (p = .01) are all predictors of obesity (Emery et al.,
implementing weight-loss programs have sufficient time 2015).
to foster trust with their patients. Family mealtimes are strongly associated with better di-
Continued support from healthcare staff may help etary intake and a randomized controlled trial to encour-
patients sustain the necessary motivation for lifestyle age healthy family meals showed a promising reduction
changes. A retrospective analysis of 14,256 patients in pri- in excess weight gain in prepubescent children (Fulker-
mary care identified consultation frequency as a factor son et al., 2015). Another study showed that adolescents
that can predict the success of weight-management pro- with any level of baseline family meal frequency, 1–2, 3–
grams (Lenoir, Maillot, Guilbot, & Ritz, 2015). Individu- 4, and ࣙ5 family meals/week, had reduced odds of being
als who successfully maintained ࣙ10% weight loss over affected by overweight or obesity 10 years later than ado-
12 months visited the healthcare provider on aver- lescents who never ate family meals (Berge et al., 2015).
age 0.65 times monthly compared with an average of Community health advocates have identified the failure of
0.48 visits/month in those who did not maintain ࣙ10% many families to plan meals or prepare food as a barrier to
weight loss, and 0.39 visits/month in those who failed to healthy family eating patterns (Fruh, Mulekar, Hall, Fulk-
achieve the initial ࣙ10% weight loss (p < .001; Lenoir erson et al., 2013). Meal planning allows healthy meals
et al., 2015). to be prepared in advance and frozen for later consump-
tion (Fruh, Mulekar, Hall, Adams et al., 2013) and is as-
sociated with increased consumption of vegetables and
Educational and environmental factors
healthier meals compared with meals prepared on impulse
It is important to consider a patient’s education and (Crawford, Ball, Mishra, Salmon, & Timperio, 2007;
environment when formulating a weight loss strategy as Hersey et al., 2001).

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S. M. Fruh Weight-management strategies

The role of the nurse practitioner liver function, urinary incontinence, fertility, joint pain,
and depression.
The initial and ongoing interactions between patient and
Weight-loss programs that include realistic weight loss
nurse practitioner are keys for the determination of an
goals, frequent check-in, and meal/activity diaries may
effective approach and implementation of a weight loss
help individuals to lose weight. Setting realistic weight-
program and subsequent weight maintenance. The ini-
loss goals can be difficult; however, visual resources show-
tial interaction can be instigated by either the nurse prac-
ing the health and wellness benefit of weight loss may be
titioner or the patient and once the decision has been
helpful in discussing realistic goals, and help motivate the
made to manage the patient’s weight, the evaluation in-
patient in maintaining the weight loss. Techniques such
cludes a risk assessment, a discussion about the patient’s
as motivational interviewing that focus on addressing re-
weight, and treatment goal recommendations (American
sistance to behavioral change in a supportive and opti-
Nurse Practitioner Foundation, 2013). Across this process,
mistic manner may help individuals in integrating these
it may be advantageous to approach this using objective
changes to allow them to become part of normal everyday
data and language that is motivational and/or nonjudg-
life and thus help with maintaining the weight loss. Pos-
mental. Patients may struggle with motivation, and there-
itive reinforcement in terms of marked early-weight loss
fore, ongoing discussions around the health benefits and
may also assist in improving adherence, so this should be a
improvements to quality of life as a result of weight loss
key goal for weight-loss programs. Encouraging feelings of
may be required (American Nurse Practitioner Founda-
“self-worth” or “self-efficacy” can help individuals to view
tion, 2013). It may be valuable to allocate personalized
weight loss as being within their own control.
benefits to the weight loss such as playing with chil-
Nurse practitioners play a major role in helping pa-
dren/grandchildren (American Nurse Practitioner Foun-
tients achieve weight loss through all aspects of the process
dation, 2013). Treatment approaches encompass non-
including assessment, support, motivation, goal-setting,
pharmacological and pharmacological strategies; however,
management, and treatment. With their in-depth under-
it is important to remember that any pharmacological
standing of the research in the field of obesity and weight
agent used should be used as an adjunct to nutritional and
management, nurse practitioners are well placed to effect
physical activity strategies (American Nurse Practitioner
meaningful changes in the weight-management strategies
Foundation, 2013). Pharmacotherapy options for weight
deployed in clinical practice.
management are discussed further in the article by Golden
in this supplement.
List of helpful resources
The Obesity Action Coalition (OAC): This site has educational
Conclusions/summary www.obesityaction.org resources for providers and
The importance of obesity management is underscored patients. It also has
information on advocacy for
both by the serious health consequences for individuals,
patients.
but also by its increasing prevalence globally, and across
Stop Obesity Alliance: This site has many helpful
age groups in particular. Obesity promotes a chronic, low- https://stopobesityalliance.org/ resources to help prevent
grade, inflammatory state, which is associated with vascu- obesity bias and helpful
lar dysfunction, thrombotic disorders, multiple organ dam- educational materials for
age, and metabolic dysfunction. These physiological effects patients. It also has an
ultimately lead to the development of a range of morbidi- excellent tool to help
providers discuss the topic
ties, including CVD, T2D, OSA, and certain cancers along
of obesity with patients.
with many others, as well as causing a significant impact
UConn Rudd Center: This site is an excellent
on mortality. www.uconnruddcenter.org/weight- resource for providers in
However, even modest weight loss of 5%–10% of to- bias-stigma clinical practice. This site
tal body weight can significantly improve health and well- has modules to help
being, and further benefits are possible with greater weight providers improve obesity
loss. Weight loss can help to prevent development of T2D management.
in individuals with obesity and prediabetes and has a posi-
tive long-term impact on cardiovascular mortality. Benefi-
Acknowledgments
cial, although not curative, effects have also been noted on
OSA following >10% weight loss. In addition, weight loss The authors are grateful to Watermeadow Medical for
reduces the risk for certain cancer types and has positive writing assistance in the development of this manuscript.
effects on most comorbidities including asthma, GERD, This assistance was funded by Novo Nordisk, who also had

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a role in the review of the manuscript for scientific accu- fruits and vegetables among women? Public Health Nutrition, 10(3),
racy. The author discussed the concept, drafted the out- 256–265.
Dattilo, A. M., & Kris-Etherton, P. M. (1992). Effects of weight reduction on
line, commented in detail on the first iteration, made crit-
blood lipids and lipoproteins: A meta-analysis. American Journal of Clinical
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