- Email: [email protected]
Understanding Obesity in Women
PRINCIPLES & PRACTICE
M A R Y J E A N V I C K E R S , R N , MS
Urtderstanding Obesity in Women
P
roviding nursing care for obese women can be both frustrating and offensive, but nurses who specialize in women’s health must conceal any emotional response to the obese client and provide care in a professional manner. A research-based understanding of obesity and its multidimensional components may help nurses develop comprehensive and compassionate approaches to the care of obese women.
obesity Dejned Obesity is defined as a condition characterized by excessive body fat (Bray, 1976). The etiology is generally thought to result from a caloric intake that exceeds caloric expenditure-the energy required for physical activities, physical maintenance, and growth of the organism. In the past, behavioral researchers defined obesity as weight that was 10-20% above ideal weight. One expert on obesity recommends using body fat content of greater than 20% for males and 28% for females as the defining criterion for clinical obesity (Bray, 1976). Epidemiologic studies, however, have found little significant increase in health risk at levels of weight below 30% over ideal weight (Bray, 1978).
Prevalence of Obesity
Obesity is a complex health problem and, because of the incidence of obesity in women, a common concern for providers of women’s health care. For many women, obesity becomes an obsession that leads to physiologic, psychologic, and social problems. To address the needs of the obese client better, nurses must acquire a comprehensive, research-based understanding of obesity. To develop a nursing care plan, the nurse must assess the client’s diet history, level of motivation to effect a change in life-style, self image, and self esteem. Accepted: AprZl 1992
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According to national statistics, approximately 25% of the U.S. adult population and 31% of the Canadian adult population is obese (National Center for Health Statistics [NCHS], 1987; Stevens & Craig, 1988). When broken down according to gender, 27% of US. women, 25% of Canadian women, 24% of U S . men, and 36% of Canadian men are obese. In the United States, the prevalence of obesity is greater among black women ( 4 4 % ) than among white women (25%), but rates for black men and white men are similar. The prevalence of obesity in children is uncertain because of a lack of standardized criteria for defining childhood obesity (Price, Desmond, Ruppert, & Stelzer, 1987). Still, an estimated 5-25% of children and adolescents may be obese. Studies support that obesity in infancy does not necessarily result in obesity in later childhood. Yet, the longer children remain obese, the greater is the likelihood that they will become obese adolescents and adults. About 80% of obese adolescents become obese adults (Price et al., 1987).
Hazards of Obesity Many diseases are associated with excess body weight. Research has shown associations between obesity and hypertension, hyperlipidemia, diabetes mellitus, car-
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Because more than 25% of women in the United States and Canada are obese (NCHS, 1987; Stevens & Craig, 1988), obesity is a major health problem among women. Women are constantly bombarded socially and through the media to maintain their figures, lose weight, and become more attractive. Weight control and nutrition are among the topics addressed most frequently in newspaper and magazine articles. When 37 popular magazines were examined for their nutritional, weight control, or food-related content, 67 articles on weight control were found. Little attention to long-term maintenance was found among the magazines studied. In addition, 28% of the articles were partially inaccurate (Parham, King, Bedell, & Martersteck, 1986). Women are especially susceptible to a preoccupation with weight because women constitute the majority of people considered obese (McBride, 1988). But reasons women are more likely to be obese are both physiologic and sociocultural. A woman’s ability to bear children physiologically promotes calorie sparing. Estrogen and progesterone promote the production of adipose tissue and prevent its breakdown (McBride, 1988). Socioculturally, the diet industry, which is aimed at women as the major consumers of
diet advice and remedies, promotes excessive awareness of body size. Little nursing research on weight management has been conducted. Allan (1988), however, has found that women describe their body weight according to three distinct dimensions: appearance, physical feelings, and weight charts. Women also define their normal weight in three distinct ways: an ideal weight, an acceptable weight, and an overweight weight. Contrary to medical health risk warnings, the major consequences of weight for the women studied are not related to health but rather to appearance and selfimage. Allan (1989) also found that motivation for women to lose weight could be categorized as either self-focused (losing weight for oneself) or other-focused (losing weight for someone else). Women more successful at weight loss and maintenance were self-focused. Tactics used by women to lose or maintain their weight, or both, were exercise, skipping meals, decreasing calorie intake, especially by limiting intake of foods thought to be high in calories, developing new eating patterns, and developing new life-styles. Finally, interactions with health-care providers have demonstrated that women are made to feel that food and nutrients could be the source of their problems. Much of the nutrition research has been conducted by men and has tended to exclude issues that arise from the personal experiences of women (McBride, 1988). College women have been the subjects of some weight control research. In one study, one third of women subjects were actively controlling weight with dieting, while half of the subjects had attempted weight control in the 3 years before the study (Salmons, 1987). This finding was particularly interesting in view of the fact that men in the study were significantly more likely to be overweight than women, and women were more likely to be underweight. In a dieting behavior study of college women, 18% had spent more than half of the previous school year dieting (chronic dieters), 45% had dieted 50% or less time (periodic dieters), and 37%were nondieters. The chronic dieters and periodic dieters weighed an average of 1 2 pounds more than nondieters and were more likely to be obese. The average age of the first reducing diet for these subjects was 16 years (Grunewald, 1985). Several studies have found that well-educated women were more concerned about their weight and women of higher socioeconomic status were less likely to be obese than women of lower socioeconomic status. The conclusion drawn from this re-
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More than 25% of women in the United States are obese.
bohydrate intolerance, increased surgical and anesthesia risk, pulmonary and renal problems, and complications during pregnancy (Brownell, 1982). Research fails, however, to clearly identify the significance of the relationship between obesity and health. The psychologic and social effects of obesity may be as serious as the medical hazards. Society has a strong bias against overweight people. Obese people suffer from the stigma of their obesity and are blamed for their condition. Unlike people with other physical disabilities, obese persons often are labeled lazy, weak, and less likable (Brownell, 1982). Not surprisingly, many obese persons are preoccupied with weight and dieting. Often, health-care providers are offended by obese clients, who present problems related to both hygiene and skin integrity. These feelings may be communicated to clients in an unprofessional manner. Such encounters can be counterproductive to the relationship that must be developed between provider and client for comprehensive health care to occur.
obesity as a Women’s Health Issue
Understanding Obesity in Women
Three major physiologic explanations for the development of obesity can be cited.
search is that a perceived need to diet is motivated by factors other than obesity (Grunewald, 1985).
Physiologic Explanations for Obesity Three major physiologic explanations for the development of obesity can be cited. These theories are the set point theory, the fat cell theory, and the theory of weight cycling (Brownell, 1982). Theorists proposed the set point theory after noting the consistency of weight within most individuals over time. According to the theory, each person has an ideal biologic weight, and some individuals have weights set above the culture’s ideal. The most important component of the set point theory is that the body will defend its weight against pressure to change (Brownell, 1982). In other words, the set point is much like a thermostat that regulates temperature; it can be adjusted up and down but remains at an ideal comfort zone. According to the fat cell theory, weight gain can occur through an increase in either the number (hyperplasia) or size (hypertrophy) of fat cells (Brownell, 1982). Physiologic evidence shows that cell number can be increased but not decreased. Also, fat cells enlarge as fat is stored and decrease in size as fat is used. The greater the number of fat cells, the more area available for fat storage and the more weight one is likely to gain. Fat cell size may be the variable that determines the body’s most comfortable weight (Brownell, 1982). This theory may explain why some people reach a specific weight and are not able to lose weight beyond that level. Repeated dieting also has come under criticism for adding to the problem of obesity. Despite the preoccupation to lose weight through dieting, the median weights in the United States continue to rise (Blackburn et al., 1989). Theorists now suggest that repeated dieting with weight loss followed by weight gain, a pattern known as weight cycling, may lead to a metabolic slowdown that makes the body more efficient at fat utilization and storage over time. The prevalence of obesity in our society also may be due, in part, to the western diet. Obese people may have developed an intense fondness for high-fat foods, and our culture provides unlimited access to these foods through the fast food and convenience food industry. Therefore, the western diet, which leads to weight gain, also leads to a physiologic in-
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crease in numbers of fat cells. This increase may prevent weight loss, whereas increases in body weight induced by psychologic, physiologic, or environmental factors may reset the set point (Brownell, 1982). Therefore, a cycle of excess fat intake may lead to weight gain and an increase in the number and size of fat cells that resets the set point and prevents efficient and lasting weight loss. Thus, a combination of these three factors actually may be involved in the development of obesity. Some people may experience a genetic predisposition to the development of obesity. When studying sets of adopted twins, researchers found a strong correlation between the weight and body mass index of the adoptees and their biologic parents. N o relationship between the weight of the adoptees and the body mass index of their adoptive parents existed. These researchers concluded that genetics has an important role in the development of obesity, and environment has a less apparent role (Stunkard et al., 1986).
Dieting strategies The California Dietetic Association reviewed several common dietary approaches for scientific rationale, safety, and nutritional adequacy in comparison with the U.S. Department of Agriculture’s recommended daily allowances (Rock & Coulston, 1988). Based on this review, they concluded that a sound weight control approach should satisfy all nutritional requirements, be palatable, diminish feelings of hunger and fatigue, be easily purchased and socially acceptable, and improve the dietary habits and the health of the individual. A poor outcome of dieting is defined as the inability to comply with dietary restrictions and an inability to maintain weight loss (Rock & Coulston, 1988). Characteristics of diets associated with a poor outcome include very low calories, extreme restrictions on macronutrients, and reliance on formulas or special products (Rock & Coulston, 1988). Exercise Many experts recommend that exercise be a key component of any weight loss program. Regular exercise enhances the loss of adipose tissue while maintaining or accelerating metabolic rate. The five primary reasons exercise is important for weight reduction are to increase energy expenditure, counteract ill effects of obesity, suppress appetite, increase basal metabolism, and minimize loss of lean tissue (Brownell, 1982). Exercise also is said to have other positive physiologic and psychologic effects. Physiologically, exercise can
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decrease plasma lipid levels and blood pressure, even without a loss of weight. Exercise also may improve self-esteem, ease depression, and benefit a person with a negative body image (Brownell, 1982). Researchers believe that sedentary life-styles play a major role in the development of obesity (Rock & Coulston, 1988). Although exercise may be important for improving caloric expenditure and metabolic rate, strenuous exercise actually consumes few calories. The long-term effects of exercise on the cardiovascular system probably are more important than the shortterm effects of exercise that are the goals in a weight loss program. Evaluating the level of physical activity is critical in assessing caloric expenditure. Client self-report is a practical and low-cost method of obtaining data concerning the level of physical activity (‘Jeffrey, Dawson, & Wilson, 1988). Self-recording of recreational activities, such as walking, bicycling, or playing tennis or golf, as well as routine chores, such as housekeeping, gardening, and shopping, allows for a more comprehensive behavioral assessment of physical activity. Although exercise is recommended as part of a weight loss program, research continues on the effect exercise has on weight loss and maintenance. Studies continue to show conflicting results when dieting with and without exercise is compared (Hammer, Barrier, Roundy, Bradford, & Fisher, 1989). A regular exercise program during weight reduction, however, serves to improve cardiovascular function and total health, even if weight and fat loss are affected only marginally (Hammer et al., 1989).
thought to be greater than 65% (McBride, 1988). Because treatment of obesity is so difficult, a 10-pound loss, sustained, is a substantial accomplishment. In addition, this level of loss may be significant enough to improve overall health (Brownell, 1982). Behavioralists have outlined the following components of successful self-management of a behavioral program (Stevens et al., 1989): 1 . setting reasonable short-term goals
2. formulating specific plans to achieve the goals
3. developing reinforcement and social support for carrying out each element of the plan 4 . assessing progress by keeping records, including food diaries, graphs indicating weight change, and daily exercise logs 5 . regularly evaluating and modifying the action plan by using self-management records. These components exhibit many similarities to the nursing strategies used in planning patient care. Weight loss programs Commercial programs to promote weight loss in overweight and obese adults are proliferating. Many offer guaranteed success and high price tags. Some are designed for implementation at the work site. Others are designed for use with low-income populations. Many are designed and promoted as part of a hospital-based health promotion program. Nurses must become aware of the financial and personal costs, quality, and long-term results of programs offered in the community before recommending these programs to clients. Nurses should evaluate these weight loss programs according to the components of a behavioral approach and the criteria of a sound diet. Nurses also should inform their clients of the results they can expect from the individual programs. To mislead clients into believing that a flawless weight loss program exists would be irresponsible.
Behavioral therapy Behavioral therapy is a treatment or intervention strategy that employs techniques to reduce or eliminate negative behavior and replace it with positive behavior. Reviews of more than 100 controlled studies of behavioral treatments for obesity revealed consistent results. Centers that used a behavioral approach consistently reported weight loss of about 11 pounds in each client during a 12-week program, regardless of fees, the therapist’s training, or the subjects’ demographics. Weight losses were larger in studies that also used spousal support, exercise, appetite suppressants, or longer treatment time (Brownell, 1982). Long-term follow-up studies of 1 year or more reveal an average weight loss of 10 pounds for participants in programs that employ a behavioral approach. However, these data show great variability that increases the longer the subjects are followed. Researchers note that treatment programs without a behavioral approach have not produced better results. Recidivism rates for diet programs generally are
The prevalence of obesity and the associated risk of obesity in the development of diabetes, hypertension, cardiovascular disease, and other medical problems makes this condition of special importance to nursing. Nursing’s focus since Florence Nightingale’s time has been on health promotion. Understanding the environment’s effects on the human being is the primary domain of nursing. Obesity is affected by both internal and external environmental factors. Perceived stressors within either the internal or external environment may be partly responsible for eating patterns. Socialization and culture also play a role in the development
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c a r e and the Obese Woman
Understanding Obesity in Women
Nurses must address the problem of obesity without subjecting obese women to more failure.
of eating habits, body image, and self-concept. Women have been socialized to value attractiveness and thinness, often to the exclusion of good health. Obese women often are stigmatized for being overweight and not conforming to society’s definition of petite and dainty female beauty. Adolescent girls are developing abnormal perceptions of body image, possibly because of society’s preoccupation with thinness. Research illustrates this point, showing that some adolescent girls begin dieting as early as 14 years of age. Nurses must address the problem of obesity without subjecting obese women to more failure. First, the truth regarding weight and obesity and the latter’s associated risks to health can be made more available to obese women. As resources for clients regarding health, nurses are in a prime position to make this information available if they are knowledgeable concerning the physiologic theories associated with obesity and the poor outcomes associated with most diet programs. Second, nurses can become actively involved in weight loss treatment programs. The lack of research that nurses have conducted into obesity and weight loss demonstrates the minor role nurses have assumed in this area. Third, nurses can pressure the media and advertisers to promote a more realistic image of women and to decrease the current emphasis on diets and weight loss in the lay press. Fourth, nursing education can give nurses information about the success of weight loss programs. Nurses must not mislead clients into believing that a quick fix diet is available or that obesity is easy to control with just a little willpower. A caring approach
The first and most important step in caring for obese women is assessment. Assessment determines whether the client will benefit from a health promotion approach toward the goal of weight control. Those who may be interested in a health promotion approach are adolescents, postpartum women, and women who recognize weight gain as a problem for themselves. Adolescents have special nutritional needs for optimal maturation. These concerns can be addressed with the assistance of a dietitian. Postpartum women who are lactating are advised not to diet until they have weaned the infant from the breast. Women who are interested in losing weight are counseled regarding
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their motivation and past diet history. Women who are not interested in losing weight deserve to be respected and supported in their decision because theorists now believe that weight cycling has a detrimental effect on weight control. Measuring obesity A woman’s weight and percentage of body fat should
be measured in an initial assessment. Because of its universality, absolute body weight is a useful measure in clinical practice. Percentage over ideal weight is defined by some researchers as current weight minus ideal weight (estimated by use of the Metropolitan Life Insurance Company Tables of ideal weights) divided by the ideal weight (Jeffrey et al., 1988). This calculation is a good reference point for comparisons because both height and ideal weight are considered. The Metropolitan Life Insurance Tables, however, may be an unreliable source for determining ideal weight. The weights given on the tables are generally considered low, even though they were revised in 1987. The weights are based on patient statements about weight and height and are obtained in street clothing and shoes. Percentage of body fat Gross body weight is influenced by the percentage of body fat, body water, and skeletal and muscle structure. Obesity is measured most accurately by determination of the percentage of body fat. Densitometric analysis compares regular weight with underwater weight in calculating the amount of lean body mass and body fat. Anthropometric measurements are more practical assessments for measuring fat. Examples of such measurements are body circumference (wrist measurements) and thickness of skin folds (caliper measurements). These measurements are valid methods for estimating body fat. However, researchers have questioned the reliability of caliper assessments between assessors, as well as the lack of standard locations and body parts to measure (Jeffrey et al., 1988). The body mass index is another method for determining the percentage of body fat. Weight in kilograms is divided by the square of the height in meters [weight (kg)/height (m’)]. The body mass index controls for the strong correlation between weight and
Because theorists believe that weight cycling has a detrimental efect on weight control, nurses should respect and support a woman’s decision not to lose weight.
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height and is more sensitive to the percentage of body fat. If the results of the calculation are greater than 30, the individual has more than 20% body fat. Because this formula is easy to use, weight control experts recommend that health-care professionals begin to use it in place of measurement with calipers and the Metropolitan Life Tables (Altschul, 1987).
Nursing Interventions Developing nursing interventions that promote good health will address the nutritional needs and interests of many women. Addressing weight control in a positive manner, rather than emphasizing past failures, is encouraged. Informing clients of the high rate of recidivism noted in weight management programs helps clients set realistic goals when choosing a weight loss program. More important than what women weigh is their perception of themselves. Acceptance of self is important in preventing unnecessary dieting, a cycle of repeated failure, and the physiologic damage thought to occur with weight cycling. Nursing diagnoses often are misused in addressing obesity. A frequently used nursing diagnosis related to obesity is “Altered nutrition: More than body requirements related to imbalance of intake versus activity expenditures.” This diagnosis is defined “as a state in which the individual experiences or is at risk of experiencing weight gain related to an intake in excess of metabolic requirements” (Carpenito, 1989). The use of this nursing diagnosis is recommended when weight gain is the result of psychologic (such as an altered taste sensation) or pharmacologic interventions (Carpenito, 1989). The condition of obesity is better addressed using the nursing diagnosis “Altered health maintenance related to intake in excess of metabolic requirements.” Because obesity is a complex health concern, the focus of treatment should be on behavioral modification and change in life-style, rather than treating the condition as a strictly nutritional problem. Nurses should use this diagnosis when a client’s weight exceeds 30%of her ideal weight and the client desires to participate in a weight control program. This degree of obesity is recommended because of the high rates of recidivism, the low levels of risk to health associated with body fat composition below 30%, and the To avoid unnecessary dieting, weight cycling, and recidivism, nurses should use 30% body fat composition as the criterion to diagnose obesity.
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potential for harm to the metabolic rate of the body with repeated dieting. When a weight loss program is the desired intervention, the following are outcome criteria for the obese client: 1 . Set realistic goals for weight loss. 2. Recognize the need for weight reduction by
identifying poor eating habits and the psychologic or social stressors that encourage overeating. 3. Remain on an exercise regimen that has been designed by an exercise physiologist in collaboration with the client and addresses both type and amount of activity. 4 . Maintain a moderate calorie-restricted diet with the goal of losing 1 to 2 pounds per week. Intervention strategies include teaching the client about nutrition, helping the client to use diet and exercise diaries and to set realistic goals, teaching the health risks of obesity, examining with the client weight loss programs from a cost-benefit perspective, and exploring with the client potential responses to stressors that aggravate overeating behaviors. Clinicians are cautioned to address obesity in this manner only with clients who demonstrate a desire to change their life-style or who are at risk for developing a health problem such as hypertension. Clinicians should understand that recidivism is a significant problem and that weight cycling may be more harmful than a stable, but elevated, body weight.
Conclusion Nurses should become more actively involved in weight loss programs and bring a research-based perspective to their practice. The difficulty obese women experience in losing and maintaining weight at an acceptable level must be appreciated. Too often, nurses react to the obese client with misunderstanding and disregard for the client’s feelings. Obesity, like many other diseases, has an addictive component, a social component, and an individual component. If nurses are truly to practice in a holistic manner, the complexity of issues like obesity must be understood and addressed professionally.
References Allan, J.D. (1988). Knowing what to weigh: Women’s selfcare activities related to weight. Advances in Nursing Science, 11, 47-60.
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Allan, J.D. (1989). Women who successfully manage their weight. WesternJournal of Nursing Research, 11, 657675. Altschul, A.M. (Ed.). (1987). Weight control: A guide for counselors and therapists. New York: Praeger. Blackburn, G.L., Wilson, G.T., Kanders, B.S., Stein, L.J., Lavin, P.T., Adler, J., & Brownell, K.D. (1989). Weight cycling: The experience of human dieters. American Journal of Clinical Nutrition, 49, 1105-1109. Bray, G.A. (1976). The obese patient. Philadelphia: W.B. Saunders. Bray, G.A. (1978). Definition, measurement, and classification of the syndromes of obesity. International Journal of Obesity, 2, 99-112. Brownell, D.D. (1982). Obesity: Understanding and treating a serious, prevalent, and refractory disorder. Journal of Consulting and Clinical Psychology, 50, 820-840. Carpenito, L.J. (1989). Nursing diagnosis application to clinicalpractice. Philadelphia: J.B. Lippincott. Grunewald, K.L. (1985). Weight control in young college women: Who are the dieters?Journal of the American Dietetic Association, 85, 1445-1450. Hammer, R.L., Barrier, C.A., Roundy, E.S., Bradford, J.M., & Fisher, A.G. (1989). Calorie-restricted, low-fat diet and exercise in obese women. American Journal of Clinical Nutrition, 49, 77-85. Jeffrey, D.B., Dawson, B., &Wilson, G.L. (1988). Behavioral and cognitive-behavioral assessment. In D.M. Donovan & G.A. Marlatt (Eds.), Assessment of addictive behaviors (pp. 239-273). New York: Guilford Press. McBride, A.B. (1988). Fat: A women’s issue in search of a holistic approach to treatment. Holistic Nursing Practice, 3, 9-15. National Center for Health Statistics (NCHS). (1987). Anthropometric reference data: Prevalence of overweight, United States, 1976-1980 (DHHS Publication
No. [PHS] 87-1688). Washington, DC: U.S. Government Printing Office. Parham, E.S., King, S.L., Bedell, M.L., & Martersteck, S. (1986). Weight control content of women’s magazines: Bias and accuracy. International Journal of Obesity, 10, 19-27. Price, J.H., Desmond, S.M., Ruppert, E.S., & Stelzer, C.M. (1987). School nurses’ perceptions of childhood obesity. Journal of School Health, 57, 332-336. Rock, C.L., & Coulston, A.M. (1988). Weight-control approaches: A review by the California Dietetic Association. Journal of the American Dietetic Association, 88, 44-48. Salmons, P.H. (1987). Weight control in university students. The Royal Society of Medicine, 80, 6-8. Stevens, T., & Craig, C.L. (1988). The well-being of Canadians: Highlights of the 1988 Campbell’ssurvey. Ottawa, Ontario: Canada Fitness and Lifestyle Research Institute. Stevens, V.J., Rossner, J., Greenlick, M., Stevens, N., Frankel, H.M., & Craddick, S. (1989). Freedom from fat: A contemporary multi-component weight loss program for the general population of obese adults. Journal of the American Dietetic Association, 89, 1254- 1258. Stunkard, A.J., Sorensen, T.I.A., Hanzs, C., Teasdale, T.W., Chakraborty, R., Schull, W.J., & Schulsinger, F. (1986). An adoption study of human obesity. New EnglandJournal of Medicine, 312, 193-198.
Address for correspondence: Mary Jean Vickers, RN, MS, 4747 Bridle Path Court, Dublin, OH 43017.
Mary Jean VZckers is a clinical associate at Ohlo State University’s College of Nursing in Columbus.
Notice to Copiers Authorizationto photocopy items for internalor personal use, or the internalor personal use of specific clients, is granted by AWHONN, the Association of Women’s Health, Obstetric, and Neonatal Nurses (formerly NAACOG), for libraries and other users registered with the Copyright Clearance Center (CCC), provided that the base fee of $3 per copy is paid directly to CCC, 21 Congress St., Salem, MA 01970.0864-2175193 $3.
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M A R Y J E A N V I C K E R S , R N , MS
Urtderstanding Obesity in Women
P
roviding nursing care for obese women can be both frustrating and offensive, but nurses who specialize in women’s health must conceal any emotional response to the obese client and provide care in a professional manner. A research-based understanding of obesity and its multidimensional components may help nurses develop comprehensive and compassionate approaches to the care of obese women.
obesity Dejned Obesity is defined as a condition characterized by excessive body fat (Bray, 1976). The etiology is generally thought to result from a caloric intake that exceeds caloric expenditure-the energy required for physical activities, physical maintenance, and growth of the organism. In the past, behavioral researchers defined obesity as weight that was 10-20% above ideal weight. One expert on obesity recommends using body fat content of greater than 20% for males and 28% for females as the defining criterion for clinical obesity (Bray, 1976). Epidemiologic studies, however, have found little significant increase in health risk at levels of weight below 30% over ideal weight (Bray, 1978).
Prevalence of Obesity
Obesity is a complex health problem and, because of the incidence of obesity in women, a common concern for providers of women’s health care. For many women, obesity becomes an obsession that leads to physiologic, psychologic, and social problems. To address the needs of the obese client better, nurses must acquire a comprehensive, research-based understanding of obesity. To develop a nursing care plan, the nurse must assess the client’s diet history, level of motivation to effect a change in life-style, self image, and self esteem. Accepted: AprZl 1992
Januury/Februury 1993
According to national statistics, approximately 25% of the U.S. adult population and 31% of the Canadian adult population is obese (National Center for Health Statistics [NCHS], 1987; Stevens & Craig, 1988). When broken down according to gender, 27% of US. women, 25% of Canadian women, 24% of U S . men, and 36% of Canadian men are obese. In the United States, the prevalence of obesity is greater among black women ( 4 4 % ) than among white women (25%), but rates for black men and white men are similar. The prevalence of obesity in children is uncertain because of a lack of standardized criteria for defining childhood obesity (Price, Desmond, Ruppert, & Stelzer, 1987). Still, an estimated 5-25% of children and adolescents may be obese. Studies support that obesity in infancy does not necessarily result in obesity in later childhood. Yet, the longer children remain obese, the greater is the likelihood that they will become obese adolescents and adults. About 80% of obese adolescents become obese adults (Price et al., 1987).
Hazards of Obesity Many diseases are associated with excess body weight. Research has shown associations between obesity and hypertension, hyperlipidemia, diabetes mellitus, car-
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Because more than 25% of women in the United States and Canada are obese (NCHS, 1987; Stevens & Craig, 1988), obesity is a major health problem among women. Women are constantly bombarded socially and through the media to maintain their figures, lose weight, and become more attractive. Weight control and nutrition are among the topics addressed most frequently in newspaper and magazine articles. When 37 popular magazines were examined for their nutritional, weight control, or food-related content, 67 articles on weight control were found. Little attention to long-term maintenance was found among the magazines studied. In addition, 28% of the articles were partially inaccurate (Parham, King, Bedell, & Martersteck, 1986). Women are especially susceptible to a preoccupation with weight because women constitute the majority of people considered obese (McBride, 1988). But reasons women are more likely to be obese are both physiologic and sociocultural. A woman’s ability to bear children physiologically promotes calorie sparing. Estrogen and progesterone promote the production of adipose tissue and prevent its breakdown (McBride, 1988). Socioculturally, the diet industry, which is aimed at women as the major consumers of
diet advice and remedies, promotes excessive awareness of body size. Little nursing research on weight management has been conducted. Allan (1988), however, has found that women describe their body weight according to three distinct dimensions: appearance, physical feelings, and weight charts. Women also define their normal weight in three distinct ways: an ideal weight, an acceptable weight, and an overweight weight. Contrary to medical health risk warnings, the major consequences of weight for the women studied are not related to health but rather to appearance and selfimage. Allan (1989) also found that motivation for women to lose weight could be categorized as either self-focused (losing weight for oneself) or other-focused (losing weight for someone else). Women more successful at weight loss and maintenance were self-focused. Tactics used by women to lose or maintain their weight, or both, were exercise, skipping meals, decreasing calorie intake, especially by limiting intake of foods thought to be high in calories, developing new eating patterns, and developing new life-styles. Finally, interactions with health-care providers have demonstrated that women are made to feel that food and nutrients could be the source of their problems. Much of the nutrition research has been conducted by men and has tended to exclude issues that arise from the personal experiences of women (McBride, 1988). College women have been the subjects of some weight control research. In one study, one third of women subjects were actively controlling weight with dieting, while half of the subjects had attempted weight control in the 3 years before the study (Salmons, 1987). This finding was particularly interesting in view of the fact that men in the study were significantly more likely to be overweight than women, and women were more likely to be underweight. In a dieting behavior study of college women, 18% had spent more than half of the previous school year dieting (chronic dieters), 45% had dieted 50% or less time (periodic dieters), and 37%were nondieters. The chronic dieters and periodic dieters weighed an average of 1 2 pounds more than nondieters and were more likely to be obese. The average age of the first reducing diet for these subjects was 16 years (Grunewald, 1985). Several studies have found that well-educated women were more concerned about their weight and women of higher socioeconomic status were less likely to be obese than women of lower socioeconomic status. The conclusion drawn from this re-
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More than 25% of women in the United States are obese.
bohydrate intolerance, increased surgical and anesthesia risk, pulmonary and renal problems, and complications during pregnancy (Brownell, 1982). Research fails, however, to clearly identify the significance of the relationship between obesity and health. The psychologic and social effects of obesity may be as serious as the medical hazards. Society has a strong bias against overweight people. Obese people suffer from the stigma of their obesity and are blamed for their condition. Unlike people with other physical disabilities, obese persons often are labeled lazy, weak, and less likable (Brownell, 1982). Not surprisingly, many obese persons are preoccupied with weight and dieting. Often, health-care providers are offended by obese clients, who present problems related to both hygiene and skin integrity. These feelings may be communicated to clients in an unprofessional manner. Such encounters can be counterproductive to the relationship that must be developed between provider and client for comprehensive health care to occur.
obesity as a Women’s Health Issue
Understanding Obesity in Women
Three major physiologic explanations for the development of obesity can be cited.
search is that a perceived need to diet is motivated by factors other than obesity (Grunewald, 1985).
Physiologic Explanations for Obesity Three major physiologic explanations for the development of obesity can be cited. These theories are the set point theory, the fat cell theory, and the theory of weight cycling (Brownell, 1982). Theorists proposed the set point theory after noting the consistency of weight within most individuals over time. According to the theory, each person has an ideal biologic weight, and some individuals have weights set above the culture’s ideal. The most important component of the set point theory is that the body will defend its weight against pressure to change (Brownell, 1982). In other words, the set point is much like a thermostat that regulates temperature; it can be adjusted up and down but remains at an ideal comfort zone. According to the fat cell theory, weight gain can occur through an increase in either the number (hyperplasia) or size (hypertrophy) of fat cells (Brownell, 1982). Physiologic evidence shows that cell number can be increased but not decreased. Also, fat cells enlarge as fat is stored and decrease in size as fat is used. The greater the number of fat cells, the more area available for fat storage and the more weight one is likely to gain. Fat cell size may be the variable that determines the body’s most comfortable weight (Brownell, 1982). This theory may explain why some people reach a specific weight and are not able to lose weight beyond that level. Repeated dieting also has come under criticism for adding to the problem of obesity. Despite the preoccupation to lose weight through dieting, the median weights in the United States continue to rise (Blackburn et al., 1989). Theorists now suggest that repeated dieting with weight loss followed by weight gain, a pattern known as weight cycling, may lead to a metabolic slowdown that makes the body more efficient at fat utilization and storage over time. The prevalence of obesity in our society also may be due, in part, to the western diet. Obese people may have developed an intense fondness for high-fat foods, and our culture provides unlimited access to these foods through the fast food and convenience food industry. Therefore, the western diet, which leads to weight gain, also leads to a physiologic in-
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crease in numbers of fat cells. This increase may prevent weight loss, whereas increases in body weight induced by psychologic, physiologic, or environmental factors may reset the set point (Brownell, 1982). Therefore, a cycle of excess fat intake may lead to weight gain and an increase in the number and size of fat cells that resets the set point and prevents efficient and lasting weight loss. Thus, a combination of these three factors actually may be involved in the development of obesity. Some people may experience a genetic predisposition to the development of obesity. When studying sets of adopted twins, researchers found a strong correlation between the weight and body mass index of the adoptees and their biologic parents. N o relationship between the weight of the adoptees and the body mass index of their adoptive parents existed. These researchers concluded that genetics has an important role in the development of obesity, and environment has a less apparent role (Stunkard et al., 1986).
Dieting strategies The California Dietetic Association reviewed several common dietary approaches for scientific rationale, safety, and nutritional adequacy in comparison with the U.S. Department of Agriculture’s recommended daily allowances (Rock & Coulston, 1988). Based on this review, they concluded that a sound weight control approach should satisfy all nutritional requirements, be palatable, diminish feelings of hunger and fatigue, be easily purchased and socially acceptable, and improve the dietary habits and the health of the individual. A poor outcome of dieting is defined as the inability to comply with dietary restrictions and an inability to maintain weight loss (Rock & Coulston, 1988). Characteristics of diets associated with a poor outcome include very low calories, extreme restrictions on macronutrients, and reliance on formulas or special products (Rock & Coulston, 1988). Exercise Many experts recommend that exercise be a key component of any weight loss program. Regular exercise enhances the loss of adipose tissue while maintaining or accelerating metabolic rate. The five primary reasons exercise is important for weight reduction are to increase energy expenditure, counteract ill effects of obesity, suppress appetite, increase basal metabolism, and minimize loss of lean tissue (Brownell, 1982). Exercise also is said to have other positive physiologic and psychologic effects. Physiologically, exercise can
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decrease plasma lipid levels and blood pressure, even without a loss of weight. Exercise also may improve self-esteem, ease depression, and benefit a person with a negative body image (Brownell, 1982). Researchers believe that sedentary life-styles play a major role in the development of obesity (Rock & Coulston, 1988). Although exercise may be important for improving caloric expenditure and metabolic rate, strenuous exercise actually consumes few calories. The long-term effects of exercise on the cardiovascular system probably are more important than the shortterm effects of exercise that are the goals in a weight loss program. Evaluating the level of physical activity is critical in assessing caloric expenditure. Client self-report is a practical and low-cost method of obtaining data concerning the level of physical activity (‘Jeffrey, Dawson, & Wilson, 1988). Self-recording of recreational activities, such as walking, bicycling, or playing tennis or golf, as well as routine chores, such as housekeeping, gardening, and shopping, allows for a more comprehensive behavioral assessment of physical activity. Although exercise is recommended as part of a weight loss program, research continues on the effect exercise has on weight loss and maintenance. Studies continue to show conflicting results when dieting with and without exercise is compared (Hammer, Barrier, Roundy, Bradford, & Fisher, 1989). A regular exercise program during weight reduction, however, serves to improve cardiovascular function and total health, even if weight and fat loss are affected only marginally (Hammer et al., 1989).
thought to be greater than 65% (McBride, 1988). Because treatment of obesity is so difficult, a 10-pound loss, sustained, is a substantial accomplishment. In addition, this level of loss may be significant enough to improve overall health (Brownell, 1982). Behavioralists have outlined the following components of successful self-management of a behavioral program (Stevens et al., 1989): 1 . setting reasonable short-term goals
2. formulating specific plans to achieve the goals
3. developing reinforcement and social support for carrying out each element of the plan 4 . assessing progress by keeping records, including food diaries, graphs indicating weight change, and daily exercise logs 5 . regularly evaluating and modifying the action plan by using self-management records. These components exhibit many similarities to the nursing strategies used in planning patient care. Weight loss programs Commercial programs to promote weight loss in overweight and obese adults are proliferating. Many offer guaranteed success and high price tags. Some are designed for implementation at the work site. Others are designed for use with low-income populations. Many are designed and promoted as part of a hospital-based health promotion program. Nurses must become aware of the financial and personal costs, quality, and long-term results of programs offered in the community before recommending these programs to clients. Nurses should evaluate these weight loss programs according to the components of a behavioral approach and the criteria of a sound diet. Nurses also should inform their clients of the results they can expect from the individual programs. To mislead clients into believing that a flawless weight loss program exists would be irresponsible.
Behavioral therapy Behavioral therapy is a treatment or intervention strategy that employs techniques to reduce or eliminate negative behavior and replace it with positive behavior. Reviews of more than 100 controlled studies of behavioral treatments for obesity revealed consistent results. Centers that used a behavioral approach consistently reported weight loss of about 11 pounds in each client during a 12-week program, regardless of fees, the therapist’s training, or the subjects’ demographics. Weight losses were larger in studies that also used spousal support, exercise, appetite suppressants, or longer treatment time (Brownell, 1982). Long-term follow-up studies of 1 year or more reveal an average weight loss of 10 pounds for participants in programs that employ a behavioral approach. However, these data show great variability that increases the longer the subjects are followed. Researchers note that treatment programs without a behavioral approach have not produced better results. Recidivism rates for diet programs generally are
The prevalence of obesity and the associated risk of obesity in the development of diabetes, hypertension, cardiovascular disease, and other medical problems makes this condition of special importance to nursing. Nursing’s focus since Florence Nightingale’s time has been on health promotion. Understanding the environment’s effects on the human being is the primary domain of nursing. Obesity is affected by both internal and external environmental factors. Perceived stressors within either the internal or external environment may be partly responsible for eating patterns. Socialization and culture also play a role in the development
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Volume 22 Number 1
c a r e and the Obese Woman
Understanding Obesity in Women
Nurses must address the problem of obesity without subjecting obese women to more failure.
of eating habits, body image, and self-concept. Women have been socialized to value attractiveness and thinness, often to the exclusion of good health. Obese women often are stigmatized for being overweight and not conforming to society’s definition of petite and dainty female beauty. Adolescent girls are developing abnormal perceptions of body image, possibly because of society’s preoccupation with thinness. Research illustrates this point, showing that some adolescent girls begin dieting as early as 14 years of age. Nurses must address the problem of obesity without subjecting obese women to more failure. First, the truth regarding weight and obesity and the latter’s associated risks to health can be made more available to obese women. As resources for clients regarding health, nurses are in a prime position to make this information available if they are knowledgeable concerning the physiologic theories associated with obesity and the poor outcomes associated with most diet programs. Second, nurses can become actively involved in weight loss treatment programs. The lack of research that nurses have conducted into obesity and weight loss demonstrates the minor role nurses have assumed in this area. Third, nurses can pressure the media and advertisers to promote a more realistic image of women and to decrease the current emphasis on diets and weight loss in the lay press. Fourth, nursing education can give nurses information about the success of weight loss programs. Nurses must not mislead clients into believing that a quick fix diet is available or that obesity is easy to control with just a little willpower. A caring approach
The first and most important step in caring for obese women is assessment. Assessment determines whether the client will benefit from a health promotion approach toward the goal of weight control. Those who may be interested in a health promotion approach are adolescents, postpartum women, and women who recognize weight gain as a problem for themselves. Adolescents have special nutritional needs for optimal maturation. These concerns can be addressed with the assistance of a dietitian. Postpartum women who are lactating are advised not to diet until they have weaned the infant from the breast. Women who are interested in losing weight are counseled regarding
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their motivation and past diet history. Women who are not interested in losing weight deserve to be respected and supported in their decision because theorists now believe that weight cycling has a detrimental effect on weight control. Measuring obesity A woman’s weight and percentage of body fat should
be measured in an initial assessment. Because of its universality, absolute body weight is a useful measure in clinical practice. Percentage over ideal weight is defined by some researchers as current weight minus ideal weight (estimated by use of the Metropolitan Life Insurance Company Tables of ideal weights) divided by the ideal weight (Jeffrey et al., 1988). This calculation is a good reference point for comparisons because both height and ideal weight are considered. The Metropolitan Life Insurance Tables, however, may be an unreliable source for determining ideal weight. The weights given on the tables are generally considered low, even though they were revised in 1987. The weights are based on patient statements about weight and height and are obtained in street clothing and shoes. Percentage of body fat Gross body weight is influenced by the percentage of body fat, body water, and skeletal and muscle structure. Obesity is measured most accurately by determination of the percentage of body fat. Densitometric analysis compares regular weight with underwater weight in calculating the amount of lean body mass and body fat. Anthropometric measurements are more practical assessments for measuring fat. Examples of such measurements are body circumference (wrist measurements) and thickness of skin folds (caliper measurements). These measurements are valid methods for estimating body fat. However, researchers have questioned the reliability of caliper assessments between assessors, as well as the lack of standard locations and body parts to measure (Jeffrey et al., 1988). The body mass index is another method for determining the percentage of body fat. Weight in kilograms is divided by the square of the height in meters [weight (kg)/height (m’)]. The body mass index controls for the strong correlation between weight and
Because theorists believe that weight cycling has a detrimental efect on weight control, nurses should respect and support a woman’s decision not to lose weight.
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height and is more sensitive to the percentage of body fat. If the results of the calculation are greater than 30, the individual has more than 20% body fat. Because this formula is easy to use, weight control experts recommend that health-care professionals begin to use it in place of measurement with calipers and the Metropolitan Life Tables (Altschul, 1987).
Nursing Interventions Developing nursing interventions that promote good health will address the nutritional needs and interests of many women. Addressing weight control in a positive manner, rather than emphasizing past failures, is encouraged. Informing clients of the high rate of recidivism noted in weight management programs helps clients set realistic goals when choosing a weight loss program. More important than what women weigh is their perception of themselves. Acceptance of self is important in preventing unnecessary dieting, a cycle of repeated failure, and the physiologic damage thought to occur with weight cycling. Nursing diagnoses often are misused in addressing obesity. A frequently used nursing diagnosis related to obesity is “Altered nutrition: More than body requirements related to imbalance of intake versus activity expenditures.” This diagnosis is defined “as a state in which the individual experiences or is at risk of experiencing weight gain related to an intake in excess of metabolic requirements” (Carpenito, 1989). The use of this nursing diagnosis is recommended when weight gain is the result of psychologic (such as an altered taste sensation) or pharmacologic interventions (Carpenito, 1989). The condition of obesity is better addressed using the nursing diagnosis “Altered health maintenance related to intake in excess of metabolic requirements.” Because obesity is a complex health concern, the focus of treatment should be on behavioral modification and change in life-style, rather than treating the condition as a strictly nutritional problem. Nurses should use this diagnosis when a client’s weight exceeds 30%of her ideal weight and the client desires to participate in a weight control program. This degree of obesity is recommended because of the high rates of recidivism, the low levels of risk to health associated with body fat composition below 30%, and the To avoid unnecessary dieting, weight cycling, and recidivism, nurses should use 30% body fat composition as the criterion to diagnose obesity.
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potential for harm to the metabolic rate of the body with repeated dieting. When a weight loss program is the desired intervention, the following are outcome criteria for the obese client: 1 . Set realistic goals for weight loss. 2. Recognize the need for weight reduction by
identifying poor eating habits and the psychologic or social stressors that encourage overeating. 3. Remain on an exercise regimen that has been designed by an exercise physiologist in collaboration with the client and addresses both type and amount of activity. 4 . Maintain a moderate calorie-restricted diet with the goal of losing 1 to 2 pounds per week. Intervention strategies include teaching the client about nutrition, helping the client to use diet and exercise diaries and to set realistic goals, teaching the health risks of obesity, examining with the client weight loss programs from a cost-benefit perspective, and exploring with the client potential responses to stressors that aggravate overeating behaviors. Clinicians are cautioned to address obesity in this manner only with clients who demonstrate a desire to change their life-style or who are at risk for developing a health problem such as hypertension. Clinicians should understand that recidivism is a significant problem and that weight cycling may be more harmful than a stable, but elevated, body weight.
Conclusion Nurses should become more actively involved in weight loss programs and bring a research-based perspective to their practice. The difficulty obese women experience in losing and maintaining weight at an acceptable level must be appreciated. Too often, nurses react to the obese client with misunderstanding and disregard for the client’s feelings. Obesity, like many other diseases, has an addictive component, a social component, and an individual component. If nurses are truly to practice in a holistic manner, the complexity of issues like obesity must be understood and addressed professionally.
References Allan, J.D. (1988). Knowing what to weigh: Women’s selfcare activities related to weight. Advances in Nursing Science, 11, 47-60.
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Allan, J.D. (1989). Women who successfully manage their weight. WesternJournal of Nursing Research, 11, 657675. Altschul, A.M. (Ed.). (1987). Weight control: A guide for counselors and therapists. New York: Praeger. Blackburn, G.L., Wilson, G.T., Kanders, B.S., Stein, L.J., Lavin, P.T., Adler, J., & Brownell, K.D. (1989). Weight cycling: The experience of human dieters. American Journal of Clinical Nutrition, 49, 1105-1109. Bray, G.A. (1976). The obese patient. Philadelphia: W.B. Saunders. Bray, G.A. (1978). Definition, measurement, and classification of the syndromes of obesity. International Journal of Obesity, 2, 99-112. Brownell, D.D. (1982). Obesity: Understanding and treating a serious, prevalent, and refractory disorder. Journal of Consulting and Clinical Psychology, 50, 820-840. Carpenito, L.J. (1989). Nursing diagnosis application to clinicalpractice. Philadelphia: J.B. Lippincott. Grunewald, K.L. (1985). Weight control in young college women: Who are the dieters?Journal of the American Dietetic Association, 85, 1445-1450. Hammer, R.L., Barrier, C.A., Roundy, E.S., Bradford, J.M., & Fisher, A.G. (1989). Calorie-restricted, low-fat diet and exercise in obese women. American Journal of Clinical Nutrition, 49, 77-85. Jeffrey, D.B., Dawson, B., &Wilson, G.L. (1988). Behavioral and cognitive-behavioral assessment. In D.M. Donovan & G.A. Marlatt (Eds.), Assessment of addictive behaviors (pp. 239-273). New York: Guilford Press. McBride, A.B. (1988). Fat: A women’s issue in search of a holistic approach to treatment. Holistic Nursing Practice, 3, 9-15. National Center for Health Statistics (NCHS). (1987). Anthropometric reference data: Prevalence of overweight, United States, 1976-1980 (DHHS Publication
No. [PHS] 87-1688). Washington, DC: U.S. Government Printing Office. Parham, E.S., King, S.L., Bedell, M.L., & Martersteck, S. (1986). Weight control content of women’s magazines: Bias and accuracy. International Journal of Obesity, 10, 19-27. Price, J.H., Desmond, S.M., Ruppert, E.S., & Stelzer, C.M. (1987). School nurses’ perceptions of childhood obesity. Journal of School Health, 57, 332-336. Rock, C.L., & Coulston, A.M. (1988). Weight-control approaches: A review by the California Dietetic Association. Journal of the American Dietetic Association, 88, 44-48. Salmons, P.H. (1987). Weight control in university students. The Royal Society of Medicine, 80, 6-8. Stevens, T., & Craig, C.L. (1988). The well-being of Canadians: Highlights of the 1988 Campbell’ssurvey. Ottawa, Ontario: Canada Fitness and Lifestyle Research Institute. Stevens, V.J., Rossner, J., Greenlick, M., Stevens, N., Frankel, H.M., & Craddick, S. (1989). Freedom from fat: A contemporary multi-component weight loss program for the general population of obese adults. Journal of the American Dietetic Association, 89, 1254- 1258. Stunkard, A.J., Sorensen, T.I.A., Hanzs, C., Teasdale, T.W., Chakraborty, R., Schull, W.J., & Schulsinger, F. (1986). An adoption study of human obesity. New EnglandJournal of Medicine, 312, 193-198.
Address for correspondence: Mary Jean Vickers, RN, MS, 4747 Bridle Path Court, Dublin, OH 43017.
Mary Jean VZckers is a clinical associate at Ohlo State University’s College of Nursing in Columbus.
Notice to Copiers Authorizationto photocopy items for internalor personal use, or the internalor personal use of specific clients, is granted by AWHONN, the Association of Women’s Health, Obstetric, and Neonatal Nurses (formerly NAACOG), for libraries and other users registered with the Copyright Clearance Center (CCC), provided that the base fee of $3 per copy is paid directly to CCC, 21 Congress St., Salem, MA 01970.0864-2175193 $3.
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