Adult weight management: Translating research and guidelines into practice

Authors

  • Laura E. Shay CRNP,

    (PhD Candidate), Corresponding author
    1. Graduate School of Nursing, Uniformed Services University of Health Sciences, Bethesda, Maryland
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  • Jennifer L. Shobert RD, LD,

    (Nutrition Educator)
    1. Health Promotion-Physical Fitness Assessment Department, National Naval Medical Center, Bethesda, Maryland
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  • Diane Seibert PhD, CRNP,

    (Associate Professor)
    1. Graduate School of Nursing, Uniformed Services University of Health Sciences, Bethesda, Maryland
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  • Lauren E. Thomas MS, RD, LD

    (Department Head)
    1. Health Promotion-Physical Fitness Assessment Department, National Naval Medical Center, Bethesda, Maryland
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Laura Shay, CRNP, Graduate School of Nursing, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.
Tel: 301-796-0994; Fax: 301-796-9899;
E-mail: laura.shay@fda.hhs.gov

Abstract

Purpose: To provide a practical approach to managing overweight and obese adult patients based on data from research and recommendations from established guidelines.

Data sources: Comprehensive review articles and original research articles identified through Medline and the Cumulative Index to Nursing and Allied Health Literature (CINAHL).

Conclusions: There is a great deal of research being conducted on new ways to treat obesity; however, despite all this new information, many primary care providers continue to report that they do not address weight or weight control strategies with their patients. Reasons include too little time, not enough training, lack of financial incentive, and failure to believe that patients can be successful.

Implications for practice: Weight management essentially comes down to one key concept: negative energy balance (fewer calories in and/or more calories out). Patients can be taught how to achieve a negative energy balance by using a food/exercise diary to track their daily caloric goal to achieve a 1–2 pound weight loss per week. Nurse practitioners (NPs) can implement safe and effective weight management plans for their patients by teaching them how to self-monitor, eat healthy, and exercise. This method is similar to what NPs commonly use for patients with diabetes mellitus.

Introduction

It is well known that obesity in the United States is a public health epidemic. The cause of obesity is likely a gene–environment interaction: genetically susceptible individuals respond to an environment laden with palatable energy-dense foods and decreased opportunities for energy expenditure (Ogden, Yanovski, Carroll, & Flegal, 2007). A harsh reality of today’s environment is that people who are not devoting substantial conscious effort to manage their body weight are probably gaining weight (Peters, Wyatt, Donahoo, & Hill, 2002). Most people seek out advice on weight management on their own. Unfortunately, despite the plethora of available information on nutrition and exercise, many Americans have limited knowledge of important basic concepts. The Second Annual International Food Information Council (IFIC) Foundation’s Food and Health Survey, Consumer Attitudes toward Food, Nutrition, and Health, found that out of 1000 adults 9 out of 10 Americans did not know how many calories they should consume in a day (IFIC, 2007). Given these results, it is no wonder people are gaining weight.

Evidence suggests that primary care providers can be successful in helping patients manage their weight but often do not address weight or weight control strategies with their patients (Brown, Stride, Psarou, Brewins, & Thompson, 2007; Gardner et al., 2007; McAlpine & Wilson, 2007; McInnis, 2003; Mehrotra, Naimi, Serdula, Bolen, & Pearson, 2004; Scott et al., 2004; Terre, Hunter, Poston, Haddock, & Stewart, 2007; Wadden & Tsai, 2005). The reasons primary care providers do not talk to their patients about weight management include too little time, not enough training, lack of financial incentive, and failure to believe that patients can be successful (Brown et al.; Leverence, Williams, Sussman, & Crabtree, 2007; Lewis, Montes, & Illige-Saucier, 2000; Rippe, McInnis, & Melanson, 2001; Ruelaz et al., 2007; Terre et al.).

Over the past decade, a number of articles have been written by nurse practitioners (NPs) on ways to manage childhood obesity (Barlow & Dietz, 2002; Barlow, Trowbridge, Klish, & Dietz, 2002; Beaudoin, Pellon-Irwin, & Brown, 2004; Berry, Galasso, Melkus, & Grey, 2004; Duderstadt, 2004; Gottesman, 2007; Harbaugh, Jordan-Welch, Bounds, Blom, & Fisher, 2007; Holcomb, 2004; Larsen, Mandleco, Williams, & Tiedeman, 2006; O’Brien, Holubkov, & Reis, 2004; Vaughn, 2005; Vaughn & Waldrop, 2007), but far fewer articles address weight management in adults (Appel, Jones, & Kennedy-Malone, 2004; Clement, Schmidt, Bernaix, Covington, & Carr, 2004; Crouch, 2005; Seals, 2007; Witherspoon & Rosenzweig, 2004). The purpose of this article is to provide NPs a practical approach to managing overweight and obese adult patients based on data from research and recommendations from established guidelines.

Research

Obesity is defined as excess body fat (Korner & Aronne, 2003; Ogden et al., 2007). Three surrogate measures are used to estimate body fat: body mass index (BMI), waist circumference, and bioelectrical impedance analysis (BIA). BMI is calculated using weight and height (weight in kg divided by height in m2) (Field, Barnoya, & Colditz, 2002). See Table 1 for the standards set by the National Heart Lung and Blood Institute (NHLBI, 2000). Many clinics are now routinely recording BMI, which research has shown increases the likelihood that a patient will receive weight-related education (Boardley, Sherman, Ambrosetti, & Lewis, 2007). Waist circumference (measured in a horizontal plane around the abdomen above the iliac crest) is used to evaluate abdominal and therefore visceral fat, which is associated with a greater health risk (Korner & Aronne). Men with a waist circumference greater than 40 inches and women whose waist measurement is greater than 35 inches are at greater risk for diabetes, hyperlipidemia, hypertension, and cardiovascular disease (NHLBI). BIA is becoming more commonly used in the clinical setting and can be performed in the office setting using a scale or a handheld device that analyzes the conductivity of body tissue. Lean tissue contains large amounts of water and electrolytes and is therefore highly conductive, whereas fat and bone contain small amounts of fluid and electrolytes and are therefore poor conductors. The percentage of body fat is estimated based on the ratio of lean and bone tissues to fat (Ricciardi & Talbot, 2007).

Table 1.  Classifications of BMI
 BMI
Underweight<18.5 kg/m2
Normal weight18.5–24.9 kg/m2
Overweight25–29-9 kg/m2
Obese30–39.9 kg/m2
Extremely obese≥40 kg/m2

Adipose tissue is an active endocrine organ that produces hormones and free fatty acids such as TNF-α, IL-6, plasminogen activation inhibitor-1, angiotensin, and others directly related to insulin resistance, hyperlipidemia, inflammation, thrombosis, and hypertension (Korner & Aronne, 2003). The risk of developing diabetes, gallbladder disease, nonalcoholic fatty liver disease, cardiovascular disease, hypertension, sleep apnea, osteoarthritis, and several types of cancers is increased for overweight individuals (Bray & Champagne, 2005; Hill, Catenacci, & Wyatt, 2005; Ogden et al., 2007). Of all cancers that are diagnosed, breast, colon, prostate, uterine, ovarian, pancreatic, gallbladder, and renal cancer appear to have the strongest association to obesity (Hong, Yan, Chen, Li, & Heber, 2007).

The benefit of weight loss is well documented. Even a small reduction in body mass reduces osteoarthritis-induced joint pain (McInnis, 2003) as well as obesity-associated risk factors for chronic diseases such as diabetes, hyperlipidemia, and hypertension (Knowler et al., 2002; McInnis; Moore et al., 2005; Serdula, Khan, & Dietz, 2003). Because weight loss leads to improved health, there is a great deal of research being conducted on new ways to treat obesity. The range of research includes genetic, hormonal, pharmacological, and energy (diet/exercise) and behavioral modification. The majority of research that can be translated into practice is based on pharmacological interventions and energy and behavioral modification; therefore, a brief summary of these research areas is provided.

Pharmacological interventions

Patients who are unable to lose weight with lifestyle modification alone and have a BMI ≥30 kg/m2 or ≥27 kg/m2 in the presence of comorbid conditions are considered eligible for drug treatment (Wadden, Butryn, & Wilson, 2007). Two medications are currently Food and Drug Administration (FDA) approved for long-term use in the treatment of obesity: sibutramine (Meridia) and orlistat (Xenical, Alli).

  • • Sibutramine is a selective serotonin norepinephrine reuptake inhibitor, which acts to increase satiety (McNeely & Goa, 1998). Common side effects include insomnia, constipation, dry mouth, and nausea. Sibutramine is not recommended in patients with uncontrolled hypertension, preexisting cardiovascular disease, or tachycardia because it has been associated with small increases in blood pressure and pulse rate (Padwal & Majumdar, 2007).
  • • Orlistat is a gastric and pancreatic lipase inhibitor that reduces dietary fat absorption by approximately 30% (Bray & Ryan, 2007). Orlistat is also available without a prescription (Alli). Common side effects include fatty, oily stools, fecal urgency, and oily spotting. Taking a daily multivitamin is recommended when taking orlistat because of the reduced fat-soluble vitamin absorbency. Orlistat can also reduce the absorption of amiodarone and cyclosporine and can potentiate the effect of wafarin (Padwal & Majumdar, 2007).

It is important to note that these medications are only recommended as an adjunct to a comprehensive program of diet, exercise, and behavior therapy (Wadden et al., 2007).

Energy modification

Obesity results from energy imbalance: the number of calories consumed exceeds the number of calories expended (Finkelstein, Ruhm, & Kosa, 2005). A reduction of 500–1000 calories (also referred to as kilocalories or kcal) a day generally results in a 1–2 pound weight loss per week (Noel & Pugh, 2002). Short-term weight loss can be achieved by any method that restricts food choices and calories; however, many of the popular diet programs that solely promote restriction are not effective for long-term weight management. There is little definitive evidence regarding dietary interventions that result in sustainable weight loss, but there is considerable evidence to suggest an association between a healthy diet and lifestyle and lasting weight control (Katz, 2005). Popular diets tend to emphasize weight loss while ignoring the dietary patterns that are essential for overall health and long-term sustainability (Katz; Makris & Foster, 2005).

Today, there is a greater emphasis on nutritionally balanced weight loss strategies accomplished by decreasing the consumption of energy-dense foods (Mendoza, Drewnowski, & Christakis, 2007). Energy-dense diets in the United States are characterized by low fruit and vegetable intake and are associated with a high BMI (Kant & Graubard, 2005). The energy density (kcal/g) of a diet can be decreased by decreasing fat intake which has 9 kcal/g compared to carbohydrates and proteins, which have 4 kcal/g. Intake of water-rich food, such as fruits and vegetables, reduces dietary energy density by providing larger amounts of food with a fewer number of calories. Therefore, reducing dietary energy density has also been shown to be an effective strategy for managing body weight while controlling for hunger (Ello-Martin, Roe, Ledikwe, Beach, & Rolls, 2007).

In order to promote and maintain health, The American College of Sports Medicine and the Centers for Disease Control and Prevention recommend that all healthy adults engage in some type of moderate-intensity aerobic (endurance) physical activity for a minimum of 30 min 5 days per week or 20 min of vigorous-intensity aerobic physical activity 3 days per week (Haskell et al., 2007). However, in order to promote and maintain weight loss, 60 min or more of moderate exercise per day is recommended (Tate, Jeffery, Sherwood, & Wing, 2007).

Behavioral therapy

The goal of behavioral therapy in weight management is to improve eating habits by making healthy food choices, increasing activity, and changing thought patterns that contribute to an individual’s excess consumption (Jones, Wilson, & Wadden, 2007). Behavioral treatment of obesity includes self-monitoring (recording food intake and exercise), stimulus control (avoiding situations that lead to poor eating habits such as eating while watching television), cognitive restructuring (learning how to think differently about food and exercise), and relapse prevention (Jones & Wadden, 2006).

Self-monitoring of food intake, exercise, and body weight are the essential features for behavioral treatment in weight management (Berkel, Poston, Reeves, & Foreyt, 2005; Wing, Tate, Gorin, Raynor, & Fava, 2006). The importance of self-monitoring is often overlooked. When used, self-monitoring encourages the individual to develop a sense of accountability and heightens self-awareness (Baker & Kirschenbaum, 1993; Berkel et al.; Burke et al., 2005; Foreyt & Goodrick, 1993; Institute of Medicine, 2004). Unfortunately, the accuracy of self-reported records is known to be poor (Goris, Westerterp-Plantenga, & Westerterp, 2000; Schaefer et al., 2000; Stone, Shiffman, Schwartz, Broderick, & Hufford, 2003). Underreporting of food intake has been observed in many well-controlled clinical trials by comparing the metabolic rate using an isotope to measure carbon dioxide production (doubly labeled water) against self-reported food diaries (Goris et al.; Hise, Sullivan, Jacobsen, Johnson, & Donnelly, 2002; Livingstone & Black, 2003). Even new technology used to record dietary intake, specifically, a personal digital assistant (PDA), has not been shown to improve documentation accuracy (Yon, Johnson, Harvey-Berino, & Gold, 2006). Although accuracy is often poor, the accuracy of reporting does not appear to be as important as self-focusing attention on the behavior. Baker and Kirschenbaum found that the more consistently subjects self-monitored food intake and exercise, the more weight they lost. This positive effect is seen throughout the literature; self-monitoring of food intake is associated with a decrease in food intake and subsequent weight loss (Blundell & Gillett, 2001; Boutelle & Kirschenbaum, 1998; Boutelle, Kirschenbaum, Baker, & Mitchell, 1999; Goris et al.; Guare et al., 1989; Kruger, Blanck, & Gillespie, 2006; Rosenthal & Marx, 1983; Sandifer & Buchanan, 1983; Sperduto, Thompson, & O’Brien, 1986; Stalonas & Kirschenbaum, 1985; Wadden et al., 2005). The consistency of self-monitoring, therefore, appears to contribute more to weight loss than does the accuracy of the recording, although an attempt to be accurate is important.

The ability to maintain healthy behaviors is by far the greatest challenge. Successful weight maintenance is defined as a regain of weight that is less than 3 kg (6.6 lbs) in 2 years with a sustained reduction in waist circumference of at least 1.6 inches (4 cm) (NHLBI, 2000) or the loss of at least 10% of initial body weight and maintaining that weight loss for at least 1 year (Wing & Phelan, 2005). To date, many interventions have been successful in producing short-term improvements in diet, physical activity, and weight, but few, if any, have been found to produce long-term behavior change (Hill, Peters, & Wyatt, 2007; Ogden et al., 2007). Research has placed greater emphasis on initiating and obtaining weight loss even though only an estimated 20% of obese/overweight persons are successful at achieving long-term weight loss (Wing & Phelan). Fortunately, a group of researchers recognized this problem and developed the National Weight Control Registry (NWCR) to study weight loss maintenance. The NCWR is the largest database with the most detailed information on successful adult weight maintainers. The NWCR was founded in 1994 by Dr. James Hill and Rena Wing as a way to investigate the behaviors and characteristics of individuals who have been successful at achieving long-term weight loss. To be eligible, individuals must be 18 years or older, have lost at least 13.6 kg (30 lbs), and have maintained their weight loss for at least 1 year. The database currently contains over 4000 subjects. The average age is 46.8. Seventy-seven percent of the cohort is female and 95% are Caucasian. Factors that contribute to this disproportionate recruitment of Caucasian women are unknown and are described as a study limitation by the researchers. The average reported weight loss is 33 kg (∼73 lbs), and the average duration of weight loss maintenance is 5.7 years (Wing & Phelan). Individuals who have kept their weight off for two or more years markedly increased their odds of continuing to maintain their weight over the following year (Wing & Phelan). Since the start of the program, the following critical attributes for successful weight loss maintenance have been consistently demonstrated: (a) eating a low-fat, low-calorie diet, (b) frequent monitoring of weight (at least weekly), and (c) 1 h of moderate-intensity physical activity per day. Most registry members also reported eating 4.7 meals or snacks a day, and 78% reported eating breakfast daily (Wing & Phelan; Wyatt et al., 2002).

Guidelines

The two major guidelines for the treatment of obesity in adults are the Dietary Guidelines for Americans (http://www.health.gov/dietaryguidelines/dga2005/document/) and The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults (http://www.nhlbi.nih.gov/guidelines/obesity/practgde.htm). Other guidelines have been written and can be found at the National Guideline Clearing House (http://www.guideline.gov/). These guidelines define overweight and obesity and provide various weight management techniques, including diet therapy, physical activity, and behavioral therapy. The general concepts in these guidelines include setting reasonable goals and eating fewer calories while increasing physical activity. These guidelines contain a wealth of information on health and nutrition and provide an excellent foundation for the implementation of safe and effective weight management strategies.

Translating the research and guidelines into practice

Incorporating weight management into a clinical practice can be straightforward. Weight management essentially involves one key concept: attaining a negative energy balance (fewer calories consumed than expended or more calories expended than consumed). Once you have diagnosed your patient as overweight or obese, a weight management plan can be established through four steps:

Step 1: Calculate the patient’s daily caloric goal and ideal weight

The goal is to lose 1–2 pounds per week and achieve a healthy BMI. Table 2 provides a simplified formula that can be used as a rough estimate of the daily caloric requirement for an adult to lose 1–2 pounds per week (Cerniauskas, 2006). Total daily caloric level should not be less than 1200 calories per day for women and 1500 calories for men, and a diet should never be less than 800 calories per day unless under close medical supervision. If you have a patient who is very sedentary, you may have to decrease the daily caloric goal by an additional 200–300 calories.

Table 2.  Calculations of estimated caloric requirements
Estimated Total Daily Caloric Requirement for Weight Loss:
Multiply 10 calories per pound of body weight and subtract 500–1000 calories
10 × Current Body Weight (lbs) – (500 to 1000*) = ______Estimated Daily Calories for Weight Loss
*For someone who is very sedentary subtract an additional 200–300 calories
Total daily caloric level should not be <1200 for women
Total daily caloric level should not be <1500 for men
Estimated Total Daily Caloric Requirement to Maintain Ideal Weight
Multiply 10 calories per pound of body weight (goal weight)
10 × Goal Body Weight (lbs) = ______Estimated Daily Calories to Maintain Weight Lost*
*For active people add 200–300 calories per day

To calculate the ideal weight, use a BMI chart. Determine your patient’s ideal weight based on their height at a BMI of 18.5–24.9 kg/m2. A BMI chart can be obtained from the NHLBI Web site: (http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm). Table 3 provides an additional method of calculating ideal weight based on the Hamwi formula (Harvey, 2006).

Table 3.  Calculation of estimated ideal weight
Estimated Ideal Weight
For men: 106 pounds plus 6 pounds for every inch over 5 feet
For women: 100 pounds plus 5 pounds for every inch over 5 feet
Men: 106 + (6 × Number of inches over 5 feet) = _______Estimated Ideal Weight*
Women: 100 + (5 × Number of inches over 5 feet) = _______Estimated Ideal Weight*
*If small frame, subtract 10% from the estimated ideal weight.
*If large frame, add 10% to the estimated ideal weight.

It is important to set realistic, measurable, achievable, rewarding, and timely (SMART) goals (Costain & Croker, 2005). For example, a good initial weight loss goal would be to instruct a patient to lose 10% of their current body weight in 6 months (e.g., a successful weight loss for a patient who weighs 225 pounds would be 22.5 pounds in 6 months). If this goal is met, then reevaluate the weight loss goal for the next 6 months and so forth until the total weight loss goal is achieved. If the initial weight loss goal is not met in the first 6 months, consider referring your patient for medical nutrition therapy from a registered dietitian.

Step 2: Teach patients how to track caloric intake, expenditure, and body weight

In order to be successful at weight loss, patients need to keep track of calorie intake, expenditure, and body weight. Setting a realistic goal is of little use unless the patient understands how to reach it. Just as patients with diabetes are taught to keep track of their carbohydrates and blood sugars, obese patients can be taught to track their calories and body weight. Be sure that patients have a working scale at home. Instruct them to weigh themselves the same time of the day wearing the same amount of clothes and to keep track of their weight at least once a week.

There are currently three methods for tracking calories: paper food/exercise diary, handheld computer (PDA) food/exercise diary, and Web-based food/exercise diary. The advantage of the PDA and Web-based food/exercise diaries is that they contain extensive food databases including restaurant items that the user can simply select, and the software automatically enters the item into the diary and does the calculations. The same is true for the calorie expenditure based on the amount of time an exercise is performed. Most people are familiar with the paper food/exercise dairy. Companies sell pocket-size diaries in bulk that are quite useful in clinic settings. An example diary is provided (see Figure S1). There are many Web-based food/exercise diaries, some of which are free and others that charge a membership fee. Some companies also offer a downloadable version for PDA use (see Table 4 for more information).

Table 4.  Information on where to obtain food/exercise diaries
  1. Note. Cost involved unless listed as FREE.

PaperWebPDA
www.calorieking.comwww.calorieking.comwww.calorieking.com
DietMinder Personal Food and Fitness Journal Author: Frances E. Wilkinswww.fitday.com (FREE)www.weightbydate.com
The Ultimate Calorie Counter Author: Shelia Buffwww.myfooddiary.com (FREE)www.weightlosssoftware.com
www.weightlosssoftware.com
www.sparkpeople.com (FREE)
www.Nutritiondata.com (FREE)
www.fitnessjournal.org
www.calorie-count.com (FREE)
http://www.webmd.com/content/tools/1/calc_calories.htm (FREE)

Nutrition labels are a useful tool, but can be challenging to understand because they contain a lot of information (e.g., those that contain several servings per container). Keep examples of food labels that contain multiple servings and limit teaching to three basic concepts:

  • 1Always check the serving size first. It is the key to reading the label. The serving size is a unit of measure not a dictation of how much a person should eat. You should also provide examples of serving sizes that are not listed on food labels (e.g., 3 oz of meat is one serving and is the same size as a deck of cards; see Figure 1).
  • 2Calculate the calories based on the number of servings consumed.
  • 3The more fat a food has in it, the greater the number of calories (fat has 9 calories per gram, and carbohydrates and protein each have 4 calories per gram). So limiting fat will be most effective in helping to decrease calories.
Figure 1.

Serving size card.

If a patient wants to understand more about nutrition labels, the FDA has a new Web site: Make your Calories Count (http://www.cfsan.fda.gov/~ear/hwm/labelman.html) which is a self-paced program that uses Label Man to teach the public how to read food labels.

Patients should also be taught that:

  • 1Exercising allows patients to sustain weight loss on a higher daily calorie level. Sixty minutes of physical activity a day is recommended for weight loss. The amount of exercise per day should be increased gradually to reduce frustration of not being able to meet an unrealistic goal. Daily exercise can also be divided into 20- to 30-min periods of activity two to three times a day. Even 10 min of exercise three times a day can be beneficial (Schmidt, Biwer, & Kalscheuer, 2001).
  • 2A healthy, balanced diet is important. Fad diets are not recommended because they are very limiting and therefore unsustainable. Fruits and vegetables are less energy (calorie) dense and contain health-promoting vitamins and antioxidants. Furthermore, foods that are high in fiber promote a lasting feeling of satiety. For more information on eating a balanced diet, direct patients to MyPyramid.com.
  • 3Drinking water or calorie-free beverages in place of calorie-containing beverages can help decrease calories significantly because many drinks have hidden calories (e.g., fruit juice, sodas, and specialty coffees).
  • 4Losing weight rapidly does not result in sustainable weight loss. Remind patients that the goal is 1–2 pounds per week.
  • 5It is best to consume calories over five meals a day (three main meals and two snacks). Avoid feeling very hungry. Snacks should be small (100–150 calories).
  • 6Skipping meals is detrimental because it lowers the metabolism rate. Studies have shown that eating breakfast contributes to better weight management.
  • 7Bring lunch and low-calorie snacks to work.
  • 8Avoid fast food and vending machines.
  • 9Finally, it is important to limit portion sizes. Restaurants generally serve very large portions. When eating out, encourage patients to ask for the to-go container when the food is served and divide the serving in half. By putting half the food in the to-go container when the food is served, the temptation to eat the entire dish will be reduced and they will have a meal for the next day.

For a list of these steps that can be used as a handout, see Figure S2.

Unfortunately, not all food items have a nutrition label. Pocket-sized calorie guides can be purchased in bulk over the Internet and are also available in most bookstores to provide information on unfamiliar or unlabeled foods. The Internet also has a wide array of free calorie calculators, and many restaurants are now publishing nutrition information, which is available upon request or on their Web site.

The more a person weighs, the more calories they will burn during exercise. Obtaining information on calories burned while exercising is not always easy to find although there are Web sites that have this information. A general guide from the U.S. Department of Agriculture is provided in Table 5 which may be used as a handout.

Table 5.  Energy expenditure chartSome examples of physical activities commonly engaged in and the average amount of calories a 154-pound individual will expend by engaging in each activity for 1 h. The expenditure value encompasses both resting metabolic rate calories and activity expenditure. Some of the activities can constitute either moderate- or vigorous-intensity physical activity depending on the rate at which they are carried out (for walking and bicycling).
 Approximate calories/h for a 154-lb person*
Moderate physical activity 
Hiking370
Light gardening/yard work330
Dancing330
Golf (walking and carrying clubs)330
Bicycling (<10 mph)290
Walking (3.5 mph)280
Weight lifting (general light workout)220
Stretching180
Vigorous physical activity 
Running/jogging (5 mph)590
Bicycling (>10 mph)590
Swimming (slow freestyle laps)510
Aerobics480
Waling (4.5 mph)460
Heavy yard work (chopping wood)440
Weight lifting (vigorous effort)440
Basketball (vigorous)440

Step 3: Have patients return every 2–3 weeks for a check in

It is important to see a patient who is attempting to lose weight every 2–3 weeks for at least 3 months or longer as necessary until goal weight is reached. Lifestyle changes take time and people need a lot of encouragement to be successful. Weight management visits are generally reimbursable: check the current listing of ICD-9 and CPT codes. At follow-up visits, it is important to weigh patients and assess their food/exercise diary to see how consistently they are recording and staying within their daily calorie goal. Use this time to reinforce some or all the information listed in step 2. The goal is a 1–2 pound loss per week, but there may be some weeks when no weight loss has occurred, which can be frustrating for everyone. If this pattern of little or no weight loss continues, it is important to take a good look at the patient’s food/exercise diary with particular attention to estimating portion sizes correctly, accounting for all foods and beverages consumed, and exercising an adequate amount. If lifestyle changes are being made without weight loss, the patient may be eligible for one of the antiobesity drugs described above.

It is important to refer patients to a registered dietitian for further counseling when dietary needs are more complex. Continual encouragement is important as are regular reminders that small reachable goals are more effective than large ones. If patients have had a setback because of a recent vacation, holiday, or stressor, reassure them. Let them know that it happens to most people, and the best thing they can do is forgive themselves, move on, and get back on track. Follow-up either in person or by e-mail or telephone once a week is advised until you feel they are over the setback.

Step 4: Develop a weight maintenance plan when goal weight is reached

When patients reach their goal weight, it is time to discuss a weight maintenance plan. This step is very important because so many people experience weight regain, and omission of this step is a major causative factor. There are four basic concepts for maintaining a goal weight:

  • 1Although many people stop keeping a food/exercise diary, it is important to provide an estimate of what the daily calorie intake should be in order to maintain their goal weight. A rough estimate of the daily caloric requirement for an adult is to multiply 10 calories per pound of body weight. For example, if your patient has achieved a goal body weight of 130 pounds, multiply 130 by 10. This provides a rough estimate of a daily caloric intake of 1300 calories in order to maintain the goal weight of 130 pounds. Add 200–300 calories per day for someone who is physically active (see Table 2).
  • 2It is very important to continue eating foods low in calories and fat and monitor body weight at least once a week to detect any weight increases early. If patients experience a weight increase of more than 2–3 pounds, they should be instructed to restart their food/exercise diary for a few weeks in order to get back on track.
  • 3Daily exercise is key to sustaining weight loss. This cannot be stressed enough. The more the better, but up to 60 min a day is recommended. As with weight loss, daily exercise can also be divided into several periods of activity two to three times a day.
  • 4Schedule a return visit in 12 weeks to reassess. If they are doing well, visits can be spaced farther apart. Individuals are more likely to maintain their goal weight if they have been successful at sustaining that weight for two or more years.

Summary

NPs can easily integrate simple, safe, and effective weight management strategies into their practice. Teaching patients how to keep track of their weight and daily calorie goal, eat a balanced meal, and exercise can be established in four steps: (a) calculate your patient’s daily caloric goal and ideal weight, (b) teach your patient how to track caloric intake, expenditure, and body weight, (c) schedule a follow-up every 2–3 weeks for a check in until goal weight is reached, and (d) develop a weight maintenance plan once goal weight is achieved.

Patients with complex nutritional needs such as poorly controlled diabetes, patients with renal disease, or patients refractory to a weight loss plan should be referred to a registered dietitian.

Conflict of interest disclosure

No relationship exists between any of the authors and any commercial entity or product mentioned in this article that might represent a conflict of interest. No inducements have been made by any commercial entity to submit the manuscript for publication. The views expressed in this manuscript are those of the authors and do not necessarily reflect the official policy or position of Uniformed Services University of Health Sciences or the U.S. Government.

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