REVI EW

Adult weight management: Translating research and

guidelines into practice
Laura E. Shay, CRNP (PhDCandidate)
1
, Jennifer L. Shobert, RD, LD(Nutrition Educator)
2
, Diane Seibert, PhD, CRNP
(Associate Professor)
1
, & Lauren E. Thomas, MS, RD, LD (Department Head)
2
1 Graduate School of Nursing, Uniformed Services University of Health Sciences, Bethesda, Maryland
2 Health Promotion-Physical Fitness Assessment Department, National Naval Medical Center, Bethesda, Maryland
Keywords
Obesity; weight management; healthy eating;
exercise; translation into practice.
Correspondence
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
Received: September 2007;
accepted: December 2007
doi:10.1111/j.1745-7599.2008.00383.x
Abstract
Purpose: To provide a practical approach to managing overweight and obese
adult patients based on data from research and recommendations from estab-
lished guidelines.
Data sources: Comprehensive review articles and original research articles
identied through Medline and the Cumulative Index to Nursing and Allied
Health Literature (CINAHL).
Conclusions: There is a great deal of research being conducted on newways 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 nancial incentive, and failure to believe that patients can
be successful.
Implications for practice: Weight management essentially comes downto one
key concept: negative energy balance (fewer calories inand/or more calories out).
Patients canbe taught howto achieve a negative energy balance by using a food/
exercise diary to track their daily caloric goal to achieve a 12 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 individ-
uals respond to an environment laden with palatable
energy-dense foods and decreased opportunities for en-
ergy expenditure (Ogden, Yanovski, Carroll, & Flegal,
2007). A harsh reality of todays 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. Unfor-
tunately, 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)
Foundations 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, &
Journal of the American Academy of Nurse Practitioners 21 (2009) 197206 2009 The Author(s)
Journal compilation 2009 American Academy of Nurse Practitioners
197
Journal of the
American Academy of Nurse Practitioners
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 enoughtraining, lackof nancial incentive, andfailure
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; OBrien,
Holubkov, & Reis, 2004; Vaughn, 2005; Vaughn &
Waldrop, 2007), but far fewer articles address weight
management inadults (Appel, Jones, &Kennedy-Malone,
2004; Clement, Schmidt, Bernaix, Covington, &Carr, 2004;
Crouch, 2005; Seals, 2007; Witherspoon & Rosenzweig,
2004). Thepurpose of this article is toprovideNPs a practical
approach to managing overweight and obese adult patients
based on data from research and recommendations from
established guidelines.
Research
Obesity is dened 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 m
2
) (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 hori-
zontal 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, hyperlipid-
emia, hypertension, and cardiovascular disease (NHLBI).
BIAis becoming more commonlyusedinthe clinical setting
and can be performed in the ofce 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 uid and electrolytes
and are therefore poor conductors. The percentage of body
fat is estimated based onthe ratio of leanand bone tissues to
fat (Ricciardi & Talbot, 2007).
Adipose tissue is an active endocrine organ that produ-
ces hormones and free fatty acids suchas TNF-a, IL-6, plas-
minogen activation inhibitor-1, angiotensin, and others
directly related to insulin resistance, hyperlipidemia, in-
ammation, thrombosis, and hypertension (Korner &
Aronne, 2003). The risk of developing diabetes, gallblad-
der disease, nonalcoholic fatty liver disease, cardiovascular
disease, hypertension, sleep apnea, osteoarthritis, and
several types of cancers is increased for overweight indi-
viduals (Bray & Champagne, 2005; Hill, Catenacci, &
Wyatt, 2005; Ogden et al., 2007). Of all cancers that are
diagnosed, breast, colon, prostate, uterine, ovarian, pan-
creatic, gallbladder, and renal cancer appear to have the
strongest association to obesity (Hong, Yan, Chen, Li, &
Heber, 2007).
The benet 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 newways to
treat obesity. The range of research includes genetic, hor-
monal, pharmacological, and energy (diet/exercise) and
behavioral modication. The majority of research that can
be translated into practice is based on pharmacological
interventions and energy and behavioral modication;
therefore, a brief summary of these research areas is
provided.
Pharmacological interventions
Patients who are unable to lose weight with lifestyle
modicationaloneandhaveaBMI30kg/m
2
or 27kg/m
2
in the presence of comorbid conditions are considered
eligible for drug treatment (Wadden, Butryn, & Wilson,
Table 1 Classications of BMI
BMI
Underweight <18.5 kg/m
2
Normal weight 18.524.9 kg/m
2
Overweight 2529-9 kg/m
2
Obese 3039.9 kg/m
2
Extremely obese 40 kg/m
2
Adult weight management L.E. Shay et al.
198
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).
l
Sibutramine is a selective serotonin norepinephrine re-
uptake inhibitor, whichacts toincrease satiety(McNeely&
Goa, 1998). Common side effects include insomnia, con-
stipation, dry mouth, and nausea. Sibutramine is not
recommended in patients with uncontrolled hyperten-
sion, preexisting cardiovascular disease, or tachycardia
because it has been associated with small increases in
bloodpressure and pulse rate (Padwal &Majumdar, 2007).
l
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 modication
Obesity results from energy imbalance: the number of
calories consumed exceeds the number of calories
expended (Finkelstein, Ruhm, &Kosa, 2005). Areduction
of 5001000 calories (also referred to as kilocalories or
kcal) a day generally results in a 12 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 denitive 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-termsustain-
ability (Katz; Makris & Foster, 2005).
Today, there is a greater emphasis on nutritionally
balanced weight loss strategies accomplished by decreas-
ing the consumption of energy-dense foods (Mendoza,
Drewnowski, & Christakis, 2007). Energy-dense diets in
the United States are characterized by low fruit and veg-
etable 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 Preventionrecommend that all healthy adults
engage insome type of moderate-intensityaerobic (endur-
ance) physical activity for a minimumof 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 inweight management is
to improve eating habits by making healthy food choices,
increasing activity, and changing thought patterns that
contribute to an individuals excess consumption (Jones,
Wilson, &Wadden, 2007). Behavioral treatment of obesity
includes self-monitoring (recording food intake and exer-
cise), stimulus control (avoiding situations that lead to
poor eating habits such as eating while watching televi-
sion), cognitive restructuring (learning how to think dif-
ferently 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 im-
portance 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, specically, a personal digital
L.E. Shay et al. Adult weight management
199
assistant (PDA), has not been shown to improve documen-
tation accuracy (Yon, Johnson, Harvey-Berino, & Gold,
2006). Although accuracy is often poor, the accuracy of
reporting does not appear tobeas important as self-focusing
attention on the behavior. Baker and Kirschenbaumfound
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, &OBrien, 1986;
Stalonas &Kirschenbaum, 1985; Wadden et al., 2005). The
consistency of self-monitoring, therefore, appears to con-
tribute 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 de-
ned 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 pro-
ducing short-termimprovements 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 suc-
cessful at achieving long-termweight loss (Wing &Phelan).
Fortunately, a group of researchers recognized this prob-
lem 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 aver-
age 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 main-
tenance is 5.7 years (Wing & Phelan). Individuals who
have kept their weight off for two or more years markedly
increasedtheir odds of continuing tomaintaintheir 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 demon-
strated: (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: Identication, Evaluation and Treat-
ment 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 dene overweight and obesity and
provide various weight management techniques, includ-
ing diet therapy, physical activity, and behavioral therapy.
The general concepts in these guidelines include setting
reasonable goals andeating fewer calories while increasing
physical activity. These guidelines contain a wealth of
information on health and nutrition and provide an excel-
lent foundation for the implementation of safe and effec-
tive weight management strategies.
Translating the research and guidelines into practice
Incorporating weight management into a clinical prac-
tice can be straightforward. Weight management essen-
tially 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 patients daily caloric goal and
ideal weight
The goal is to lose 12 pounds per week and achieve
a healthy BMI. Table 2 provides a simplied formula that
can be used as a rough estimate of the daily caloric require-
ment for anadult tolose12pounds 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 verysedentary, youmayhavetodecrease the dailycaloric
goal by an additional 200300 calories.
Adult weight management L.E. Shay et al.
200
To calculate the ideal weight, use a BMI chart. Deter-
mine your patients ideal weight based on their height at
a BMI of 18.524.9 kg/m
2
. 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).
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 intherst 6months, consider referringyour 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 howto 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 them-
selves 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 dia-
ries 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 PDAuse (see Table 4
for more information).
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 serv-
ings and limit teaching to three basic concepts:
1. Always check the serving size rst. 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).
2. Calculate the calories based on the number of servings
consumed.
3. The 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.
If a patient wants to understand more about nutrition
labels, the FDAhas a newWebsite: Make your Calories Count
(http://www.cfsan.fda.gov/~ear/hwm/labelman.html)
which is a self-paced programthat uses Label Man to teach
the public how to read food labels.
Patients should also be taught that:
1. Exercising 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
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.
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 5001000
calories
10 Current Body Weight (lbs) (500 to 1000*) = ______Estimated
Daily Calories for Weight Loss
*For someone who is very sedentary subtract an additional 200300
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 200300 calories per day
L.E. Shay et al. Adult weight management
201
of exercise three times a day can be benecial (Schmidt,
Biwer, & Kalscheuer, 2001).
2. Ahealthy, balanced diet is important. Fad diets are not
recommended because they are very limiting and there-
fore unsustainable. Fruits and vegetables are less energy
(calorie) dense and contain health-promoting vitamins
and antioxidants. Furthermore, foods that are high in
ber promote a lasting feeling of satiety. For more infor-
mation on eating a balanced diet, direct patients to
MyPyramid.com.
3. Drinking water or calorie-free beverages in place of
calorie-containing beverages can help decrease calories
signicantly because many drinks have hidden calories
(e.g., fruit juice, sodas, and specialty coffees).
4. Losing weight rapidly does not result in sustainable
weight loss. Remind patients that the goal is 12 pounds
per week.
5. It is best toconsume calories over ve meals a day(three
main meals and two snacks). Avoid feeling very hungry.
Snacks should be small (100150 calories).
6. Skipping meals is detrimental because it lowers the
metabolismrate. Studies have shown that eating breakfast
contributes to better weight management.
7. Bring lunch and low-calorie snacks to work.
8. Avoid fast food and vending machines.
9. Finally, it is important tolimit portionsizes. 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 informa-
tion, 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
burnedwhile exercising is not always easytondalthough
there are Web sites that have this information. A general
guide fromthe U.S. Department of Agriculture is provided
in Table 5 which may be used as a handout.
Step 3: Have patients return every 23 weeks for
a check in
It is important to see a patient who is attempting to lose
weight every 23 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 reim-
bursable: 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 12 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 patients 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 com-
plex. Continual encouragement is important as are regular
reminders that small reachable goals are more effective
Table 4 Information on where to obtain food/exercise diaries
Paper Web PDA
www.calorieking.com www.calorieking.com www.calorieking.com
DietMinder Personal Food
and Fitness Journal
Author: Frances E. Wilkins
www.tday.com (FREE) www.weightbydate.com
The Ultimate Calorie Counter
Author: Shelia Buff
www.myfooddiary.com (FREE) www.weightlosssoftware.com
www.weightlosssoftware.com
www.sparkpeople.com (FREE)
www.Nutritiondata.com (FREE)
www.tnessjournal.org
www.calorie-count.com (FREE)
http://www.webmd.com/content/tools/1/calc_calories.htm (FREE)
Note. Cost involved unless listed as FREE.
Adult weight management L.E. Shay et al.
202
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 dis-
cuss a weight maintenance plan. This step is very impor-
tant 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:
1. Although 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 require-
ment 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 200300 calories per day for someone who
is physically active (see Table 2).
Figure 1 Serving size card.
L.E. Shay et al. Adult weight management
203
2. It 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 23 pounds,
they should be instructed to restart their food/exercise
diary for a few weeks in order to get back on track.
3. Daily exercise is key to sustaining weight loss. This
cannot be stressed enough. The more the better, but up
to 60 mina day is recommended. As withweight loss, daily
exercise can also be divided into several periods of activity
two to three times a day.
4. Schedule a return visit in 12 weeks to reassess. If they
are doing well, visits can be spaced farther apart. Individ-
uals 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. Teach-
ing 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 patients daily
caloric goal and ideal weight, (b) teachyour patient howto
track caloric intake, expenditure, and body weight, (c)
schedule a follow-up every 23 weeks for a check in until
goal weight is reached, and (d) develop a weight mainte-
nance 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.
Supporting Information
Additional Supporting Information may be found in the
online version of this article.
Figure S1. Example of food/exercise diary.
Figure S2. Patient handout.
Please note: Wiley-Blackwell Publishing is not respon-
sible for the content or functionality of any supplementary
materials supplied by the authors. Any queries (other than
missing material) should be directed to the corresponding
author for the article.
References
Appel, S. J., Jones, E. D., & Kennedy-Malone, L. (2004). Central obesity and the
metabolic syndrome: Implications for primary care providers. Journal of the
American Academy of Nurse Practitioners, 16, 335342.
Baker, R. C., & Kirschenbaum, D. S. (1993). Self-monitoring may be necessary for
successful weight control. Behavior Therapy, 24, 377394.
Barlow, S. E., & Dietz, W. H. (2002). Management of child and adolescent
obesity: Summary and recommendations based on reports from pediatricians,
pediatric nurse practitioners, and registered dietitians. Pediatrics, 110(1 Pt. 2),
236238.
Barlow, S. E., Trowbridge, F. L., Klish, W. J., &Dietz, W. H. (2002). Treatment of child
and adolescent obesity: Reports from pediatricians, pediatric nurse practitioners,
and registered dietitians. Pediatrics, 110(1 Pt. 2), 229235.
Beaudoin, J., Pellon-Irwin, P., & Brown, N. (2004). Pediatric obesity. Familys role
essential to treatment. Advanced Nursing Practice, 12, 5963.
Berkel, L. A., Poston, W. S., Reeves, R. S., & Foreyt, J. P. (2005). Behavioral
interventions for obesity. Journal of the AmericanDietetic Association, 105(5Suppl. 1),
S35S43.
Berry, D., Galasso, P., Melkus, G., &Grey, M. (2004). Obesity in youth: Implications
for the advanced practice nurse in primary care. Journal of the American Academy of
Nurse Practitioners, 16, 326334.
Blundell, J. E., & Gillett, A. (2001). Control of food intake in the obese. Obesity
Research, 9(Suppl. 4), 263S270S.
Boardley, D., Sherman, C., Ambrosetti, L., &Lewis, J. (2007). Obesityevaluationand
intervention during family medicine well visits. Journal of the American Board
Family Medicine, 20, 252257.
Boutelle, K. N., & Kirschenbaum, D. S. (1998). Further support for consistent
self-monitoring as a vital component of successful weight control. Obesity Research,
6, 219224.
Boutelle, K. N., Kirschenbaum, D. S., Baker, R. C., & Mitchell, M. E. (1999).
How can obese weight controllers minimize weight gain during the high risk
holiday season? By self-monitoring very consistently. Health Psychology, 18,
364368.
Table 5 Energy expenditure chart
Some examples of physical activities commonly engaged in and the
average amount of calories a 154-pound individual will expend by engag-
ing 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
Hiking 370
Light gardening/yard work 330
Dancing 330
Golf (walking and carrying clubs) 330
Bicycling (<10 mph) 290
Walking (3.5 mph) 280
Weight lifting (general light workout) 220
Stretching 180
Vigorous physical activity
Running/jogging (5 mph) 590
Bicycling (>10 mph) 590
Swimming (slow freestyle laps) 510
Aerobics 480
Waling (4.5 mph) 460
Heavy yard work (chopping wood) 440
Weight lifting (vigorous effort) 440
Basketball (vigorous) 440
*Calories burned per hour will be higher for persons who weigh more than
154 pounds (70 kg) and lower for persons who weigh less. From USDA
Dietary Guidelines for Americans 2005, available at www.health.gov/
dietaryguidelines/dga2005/document/default.htm
Adult weight management L.E. Shay et al.
204
Bray, G. A., & Champagne, C. M. (2005). Beyond energy balance: There is more to
obesity thankilocalories. Journal of the AmericanDietetic Association, 105(5Suppl. 1),
S17S23.
Bray, G. A., & Ryan, D. H. (2007). Drug treatment of the overweight patient.
Gastroenterology, 132, 22392252.
Brown, I., Stride, C., Psarou, A., Brewins, L., &Thompson, J. (2007). Management of
obesity in primary care: Nurses practices, beliefs and attitudes. Journal of Advanced
Nursing Practice, 59, 329341.
Burke, L. E., Warziski, M., Starrett, T., Choo, J., Music, E., Sereika, S., et al. (2005).
Self-monitoring dietary intake: Current and future practices. Journal of Renal
Nutrition, 15, 281290.
Cerniauskas, B. (2006). Clinical Q&A. Obesity Management, 2, 194.
Clement, J. M., Schmidt, C. A., Bernaix, L. W., Covington, N. K., &Carr, T. R. (2004).
Obesity and physical activity in college women: Implications for clinical practice.
Journal of the American Academy of Nurse Practitioners, 16, 291299.
Costain, L., &Croker, H. (2005). Helpingindividuals tohelpthemselves. Proceedings of
the Nutrition Society, 64, 8996.
Crouch, J. (2005). Adult obesity inthe United States. Acall to arms. Advanced Nursing
Practice, 13, 5760.
Duderstadt, K. G. (2004). Advocacy for reducing childhood obesity. Journal of
Pediatric Health Care, 18, 103105.
Ello-Martin, J. A., Roe, L. S., Ledikwe, J. H., Beach, A. M., & Rolls, B. J. (2007).
Dietary energy density in the treatment of obesity: A year-long trial comparing 2
weight-loss diets. American Journal of Clinical Nutrition, 85, 14651477.
Field, A. E., Barnoya, J., & Colditz, G. A. (2002). Epidemiology and health and
economic consequences of obesity. In T. A. Wadden & A. J. Stunkard (Eds.),
Handbook of obesity treatment (p. 4). New York: The Guilford Press.
Finkelstein, E. A., Ruhm, C. J., & Kosa, K. M. (2005). Economic causes and
consequences of obesity. Annual Reviews in Public Health, 26, 239257.
Foreyt, J. P., & Goodrick, G. K. (1993). Evidence for success of behavior
modication in weight loss and control. Annals of Internal Medicine, 119(7 Pt. 2),
698701.
Gardner, C. D., Kiazand, A., Alhassan, S., Kim, S., Stafford, R. S., Balise, R. R., et al.
(2007). Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in
weight and related risk factors among overweight premenopausal women: The A
TO Z Weight Loss Study: A randomized trial. Journal of the American Medical
Association, 297, 969977.
Goris, A. H., Westerterp-Plantenga, M. S., & Westerterp, K. R. (2000). Undereating
and underrecording of habitual food intake in obese men: Selective
underreporting of fat intake. American Journal of Clinical Nutrition, 71, 130134.
Gottesman, M. M. (2007). HEAT: Healthy eating and activity together. American
Journal of Nursing, 107, 4950.
Guare, J. C., Wing, R. R., Marcus, M. D., Epstein, L. H., Burton, L. R., &Gooding, W. E.
(1989). Analysis of changes in eating behavior and weight loss in type II diabetic
patients. Which behaviors to change. Diabetes Care, 12, 500503.
Harbaugh, B. L., Jordan-Welch, M., Bounds, W., Blom, L., & Fisher, W. (2007).
Childhood obesity. Part I. Nurses and families rising to the challenge of overweight
children. Nurse Practitioner, 32, 3035; quiz 4133.
Harvey, K. S. (2006). Methods for determining healthy body weight in end stage
renal disease. Journal of Renal Nutrition, 16, 269276.
Haskell, W. L., Lee, I. M., Pate, R. R., Powell, K. E., Blair, S. N., Franklin, B. A., et al.
(2007). Physical Activity and Public Health. Updated Recommendation for Adults
From the American College of Sports Medicine and the American Heart
Association. Circulation, 116, 108193.
Hill, J. O., Catenacci, V., & Wyatt, H. R. (2005). Obesity: Overview of an epidemic.
Psychiatric Clinics of North America, 28, 123, vii.
Hill, J. O., Peters, J. C., &Wyatt, H. R. (2007). The role of public policy in treating the
epidemic of global obesity. Clinical Pharmacology and Therapeutics, 81, 772775.
Hise, M. E., Sullivan, D. K., Jacobsen, D. J., Johnson, S. L., &Donnelly, J. E. (2002).
Validation of energy intake measurements determined fromobserver-recorded food
records and recall methods compared with the doubly labeled water method in
overweight and obese individuals. American Journal of Clinical Nutrition, 75, 263267.
Holcomb, S. S. (2004). Obesity in children and adolescents: Guidelines for
prevention and management. Nurse Practitioner, 29, 9, 12, 1415.
Hong, K., Yan, E., Chen, S., Li, Z., & Heber, D. (2007). Obesity and cancer:
Inammation and molecular pathogenesis. Obesity Management, 3, 115120.
International Food Information Council. (2007). Calories Count, but.. Consumers
Dont Seem to Know How. Food Insight: Current Topics in Food Safety & Nutrition.
Retrieved May/June 2007 from IFIC Foundation http://ic.org/
Institute of Medicine. (2004). Institute of Medicine of the National Academies: Weight
Management: State of the Science and Opportunities for Military Programs: Subcommittee
on Military Weight Management, Committee on Military Nutrition Research Food and
Nutrition Board. Washington, DC: The National Academies Press.
Jones, L. R., & Wadden, T. A. (2006). State of the science: Behavioral treatment of
obesity. Asia Pacic Journal of Clinical Nutrition, 15(Suppl.), 3039.
Jones, L. R., Wilson, C. I., & Wadden, T. A. (2007). Lifestyle modication in the
treatment of obesity: An educational challenge and opportunity. Clinical
Pharmacology and Therapeutics, 81, 776779.
Kant, A. K., & Graubard, B. I. (2005). Energy density of diets reported by American
adults: Association with food group intake, nutrient intake, and body weight.
International Journal of Obesity (Lond), 29, 950956.
Katz, D. L. (2005). Competing dietary claims for weight loss: Finding the forest
through truculent trees. Annual Reviews in Public Health, 26, 6188.
Knowler, W. C., Barrett-Connor, E., Fowler, S. E., Hamman, R. F., Lachin, J. M.,
Walker, E. A., et al. (2002). Reduction in the incidence of type 2 diabetes with
lifestyle intervention or metformin. New England Journal of Medicine, 346,
393403.
Korner, J., & Aronne, L. J. (2003). The emerging science of body weight regulation
and its impact on obesity treatment. Journal of Clinical Investigation, 111, 565570.
Kruger, J., Blanck, H. M., & Gillespie, C. (2006). Dietary and physical activity
behaviors among adults successful at weight loss maintenance. International
Journal of Behavioral Nutrition and Physical Activity, 3, 17.
Larsen, L., Mandleco, B., Williams, M., & Tiedeman, M. (2006). Childhood obesity:
Preventionpractices of nurse practitioners. Journal of the American Academy of Nurse
Practitioners, 18, 7079.
Leverence, R. R., Williams, R. L., Sussman, A., & Crabtree, B. F. (2007). Obesity
counseling and guidelines in primary care: A qualitative study. American Journal
of Preventive Medicine, 32, 334339.
Lewis, B. S., Montes, S. D., & Illige-Saucier, M. (2000). A pilot study examining
patient response to a weight loss workbook designed to be used in a family
medicine outpatient setting. Archives of Family Medicine, 9, 759764.
Livingstone, M. B., & Black, A. E. (2003). Markers of the validity of reported energy
intake. Journal of Nutrition, 133(Suppl. 3), 895S920S.
Makris, A. P., &Foster, G. D. (2005). Dietary approaches to the treatment of obesity.
Psychiatric Clinics of North America, 28, 117139, viiiix.
McAlpine, D. D., & Wilson, A. R. (2007). Trends in obesity-related counseling in
primary care: 1995-2004. Medical Care, 45, 322329.
McInnis, K. J. (2003). Diet, exercise, and the challenge of combating obesity in
primary care. Journal of Cardiovascular Nursing, 18, 93100; quiz 101102.
McNeely, W., & Goa, K. L. (1998). Sibutramine: A review of its contribution to the
management of obesity. Drugs, 56, 10931124.
Mehrotra, C., Naimi, T. S., Serdula, M., Bolen, J., & Pearson, K. (2004). Arthritis,
body mass index, and professional advice to lose weight: Implications for clinical
medicine and public health. American Journal of Preventive Medicine, 27, 1621.
Mendoza, J. A., Drewnowski, A., &Christakis, D. A. (2007). Dietaryenergy density is
associated with obesity and the metabolic syndrome in U.S. adults. Diabetes Care,
30, 974979.
Moore, L. L., Visioni, A. J., Qureshi, M. M., Bradlee, M. L., Ellison, R. C., &DAgostino,
R. (2005). Weight loss in overweight adults and the long-term risk of hypertension:
The Framingham study. Achieves of Internal Medicine, 165, 12981303.
National Heart Lung and Blood Institute. (2000). The Practical Guide: Identication,
Evaluation, and Treatment of Overweight and Obesity in Adults. NIH Publication
00-4084. Author.
Noel, P. H., &Pugh, J. A. (2002). Management of overweight andobese adults. British
Medical Journal, 325, 757761.
OBrien, S. H., Holubkov, R., & Reis, E. C. (2004). Identication, evaluation, and
management of obesity in an academic primary care center. Pediatrics, 114,
e154e159.
Ogden, C. L., Yanovski, S. Z., Carroll, M. D., &Flegal, K. M. (2007). The epidemiology
of obesity. Gastroenterology, 132, 20872102.
Padwal, R. S., & Majumdar, S. R. (2007). Drug treatments for obesity: Orlistat,
sibutramine, and rimonabant. Lancet, 369, 7177.
L.E. Shay et al. Adult weight management
205
Peters, J. C., Wyatt, H. R., Donahoo, W. T., & Hill, J. O. (2002). From instinct to
intellect: The challenge of maintaining healthy weight in the modern world.
Obesity Reviews, 3, 6974.
Ricciardi, R., & Talbot, L. A. (2007). Use of bioelectrical impedance analysis in the
evaluation, treatment, and prevention of overweight and obesity. Journal of the
American Academy of Nurse Practitioners, 19, 235241.
Rippe, J. M., McInnis, K. J., &Melanson, K. J. (2001). Physician involvement in the
management of obesityas a primarymedical condition. Obesity Research, 9(Suppl. 4),
302S311S.
Rosenthal, B. S., &Marx, R. D. (1983). Determinants of initial relapse among dieters.
Obesity and Bariatric Medicine, 10, 9497.
Ruelaz, A. R., Diefenbach, P., Simon, B., Lanto, A., Arterburn, D., & Shekelle, P. G.
(2007). Perceived barriers to weight management in primary careperspectives of
patients and providers. Journal of General Internal Medicine, 22, 518522.
Sandifer, B. A., &Buchanan, W. L. (1983). Relationships between adherence and in
behavioral weight reduction programs. Behavior Therapy 16, 114.
Schaefer, E. J., Augustin, J. L., Schaefer, M. M., Rasmussen, H., Ordovas, J. M.,
Dallal, G. E., et al. (2000). Lack of efcacy of a food-frequency questionnaire in
assessing dietary macronutrient intakes in subjects consuming diets of known
composition. American Journal of Clinical Nutrition, 71, 746751.
Schmidt, W. D., Biwer, C. J., & Kalscheuer, L. K. (2001). Effects of long versus short
bout exercise on tness and weight loss in overweight females. Journal of the
American College of Nutrition, 20, 494501.
Scott, J. G., Cohen, D., DiCicco-Bloom, B., Orzano, A. J., Gregory, P., Flocke, S. A.,
et al. (2004). Speaking of weight: Howpatients and primary care clinicians initiate
weight loss counseling. Preventive Med, 38, 819827.
Seals, J. G. (2007). Integrating the transtheoretical model into the management of
overweight and obese adults. Journal of the American Academy of Nurse Practitioners,
19, 6371.
Serdula, M. K., Khan, L. K., & Dietz, W. H. (2003). Weight loss counseling revisited.
Journal of the American Medical Association, 289, 17471750.
Sperduto, W. A., Thompson, H. S., &OBrien, R. M. (1986). Theeffect of target behavior
monitoring on weight loss and completion rate in a behavior modication program
for weight reduction. Addictive Behavior, 11, 337340.
Stalonas, P. M., & Kirschenbaum, D. S. (1985). Behavioral treatment for obesity:
Eating habits revisited. Behavior Therapy, 16, 114.
Stone,A.A., Shiffman, S., Schwartz, J. E., Broderick, J. E., &Hufford, M. R. (2003). Patient
compliance with paper and electronic diaries. Controlled Clinical Trials, 24, 182199.
Tate, D. F., Jeffery, R. W., Sherwood, N. E., &Wing, R. R. (2007). Long-termweight
losses associated with prescription of higher physical activity goals. Are higher
levels of physical activity protective against weight regain? American Journal of
Clinical Nutrition, 85, 954959.
Terre, L., Hunter, C., Poston, W. S., Haddock, C. K., & Stewart, S. A. (2007).
Treatment of obesity inthe primary care setting: Are we there yet? Eating Disorders,
15, 135143.
Vaughn, K. (2005). A call to pediatric nurse practitioners in battling the childhood
obesity epidemic. Pediatric Nurse, 31, 348, 344.
Vaughn, K., &Waldrop, J. (2007). Childhoodobesity. Part II. Parent educationkey to
beating early childhood obesity. Nurse Practitioner, 32, 3641; quiz 4133.
Wadden, T. A., Berkowitz, R. I., Womble, L. G., Sarwer, D. B., Phelan, S., Cato, R. K.,
et al. (2005). Randomized trial of lifestyle modication and pharmacotherapy for
obesity. New England Journal of Medicine, 353, 21112120.
Wadden, T. A., Butryn, M. L., & Wilson, C. (2007). Lifestyle modication for the
management of obesity. Gastroenterology, 132, 22262238.
Wadden, T. A., & Tsai, A. G. (2005). Weight management in primary care: Can we
talk? Obesity Management, 1, 914.
Wing, R. R., & Phelan, S. (2005). Long-term weight loss maintenance. American
Journal of Clinical Nutrition, 82(1 Suppl.), 222S225S.
Wing, R. R., Tate, D. F., Gorin, A. A., Raynor, H. A., & Fava, J. L. (2006). A self-
regulation program for maintenance of weight loss. New England Journal of
Medicine, 355, 15631571.
Witherspoon, B., & Rosenzweig, M. (2004). Industry-sponsored weight loss
programs: Description, cost, and effectiveness. Journal of the American Academy of
Nurse Practitioners, 16, 198205.
Wyatt, H. R., Grunwald, G. K., Mosca, C. L., Klem, M. L., Wing, R. R., & Hill, J. O.
(2002). Long-term weight loss and breakfast in subjects in the National Weight
Control Registry. Obesity Research, 10, 7882.
Yon, B. A., Johnson, R. K., Harvey-Berino, J., & Gold, B. C. (2006). The use of
apersonal digital assistant for dietaryself-monitoringdoes not improvethe validity
of self-reports of energy intake. Journal of the American Dietetic Association, 106,
12561259.
Conict of interest disclosure
Norelationshipexists betweenanyof theauthors andany
commercial entity or product mentioned in this article that
might represent a conict of interest. No inducements have
been made by any commercial entity to submit the man-
uscript for publication. The views expressed in this manu-
script are those of the authors and do not necessarily reect
the ofcial policy or position of Uniformed Services Uni-
versity of Health Sciences or the U.S. Government.
Adult weight management L.E. Shay et al.
206