Nurse practitioner Sally Coburn, MSN, FNP, RN, knew she had a challenge on her hands when a middle-aged businesswoman walked into her office wanting to shave off 40 pounds.

The 5-foot-2-inch woman was eager to drop from 170 to 130 pounds-not an easy task given her lifestyle of frequent traveling, social functions with not-so-healthy foods and little time for exercise.

But Coburn was up for the test. She is one of many nurses who specialize in bariatrics, a field of medicine that's drawing more and more attention as Americans become increasingly heavy.

About 55 percent of adults in the United States are overweight or obese, according to the National Institutes of Health. The prevalence of overweight and obesity jumped almost 10 percent from the late 1970s to the early 1990s, according to the American Society of Bariatric Physicians.

The causes of this growing problem are far from simple, said several nurses who work in bariatrics. Patients often need help to change not only their eating and exercise habits, but also emotional patterns that set them up for overeating.

Yet some nurses acknowledge that even these types of interventions don't always work. For patients who struggle consistently with morbid obesity, surgical options such as gastric bypass surgery are available. The nurses who work with these patients can face a different set of challenges.

Changing bad habits

For Coburn, who works in Alaska, natural methods of weight loss seem to work for her patients-if they're willing to change their habits.

With the businesswoman, she suggested strategies to avoid greasy hors d'oeuvres and heavy dinners when the woman was socializing at business functions. She could eat a protein bar or piece of fruit before heading to the engagement, so she'd have less room for a heavy dinner. Coburn also recommended scraping off that rich sauce on a piece of steak or chicken and leaving the starchy potatoes served with it.

She also advised the woman to dust off the treadmill in her home and start using it six days a week. The woman began with 20 minutes a day of brisk walking on the machine in the mornings and slowly increased her time and speed. After about seven months, the woman was down to her goal of 130-and she could fit into a size 6 dress.

"I love the shining smiles I get when people come in and they've lost several pounds," Coburn said. "My favorite part of the job is putting people on 'maintenance' when they've lost everything they need to."

She said many people gain weight because they haven't made eating a high priority. Habits such as eating in front of the television can be dangerous because people are watching a program instead of paying attention to what they eat.

Coburn said one of the keys to losing weight is portion control.

She teaches patients to eat frequent, smaller meals. She also advocates a balanced diet, especially with plenty of protein and not too much starch. She also encourages patients to buy a calorie counter book that lists the number of calories and serving size for different foods.

She's also careful not to overload patients with too many things to change at once. Some patients don't have the time to exercise for 30 minutes on a treadmill daily, so she suggests ideas like taking 10-minute walks several times a day.

Like Coburn, Gail Walker, RN, a nurse at Southwest Bariatric >> Nutrition Center in Scottsdale, Ariz., counsels patients to fill themselves with healthy calories so the fat-filled goodies won't seem as appetizing.

"I've found that patients' work environments seem to be a big factor," Walker said. "It's always someone's birthday or there's a new person or new baby. If you have kids, that can be hard because you want to have the snacks and goodies they can eat."

She advises patients to drink three to four glasses of water about four times a day within a half-hour period. This gives the body the feeling that it's full. "I can't stress that enough. Water is key," Walker said. She encourages patients to lose about one to two pounds a week, which increases the chances that people will keep the weight off more than if they lose too much, too fast.

"The challenge is that it isn't instant gratification," she said. "Once you start losing, then you'll feel better in your clothes, and if you feel good about yourself, it has a ripple effect and you'll keep losing."

Before Walker worked in bariatrics, she was an outpatient surgery and endoscopy nurse, but she felt rushed with patients and rarely had enough time to talk with them.

"In this field, you really have a chance to get to know people," she said. She usually sees patients six months to a year at a time. The majority are women in their 40s and 50s who want to lose at least 50 pounds.

For some patients, though, 50 pounds is only a small percentage of the amount of weight they need to lose to become functional in life. Nadia Hansen, RN, program director of the bariatric surgery program at Kaiser Permanente South San Francisco, works with people who come into the clinic weighing anywhere from 300 to 600 pounds, and they've usually already tried a minimum of five diets.

Her clinic offers these patients the option of gastric bypass surgery, a procedure in which surgeons close off all but a small portion of the patient's stomach.

Surgery as a 'gift'

The new stomach, or pouch, is the size of a thumb and can fit a meal the size of an egg. This gives patients a sense of fullness quickly and cuts down on the amount of food a person can eat.

The surgeon also bypasses the duodenum, or the first section of the small intestine, so patients absorb less of the food they eat.

"The surgery is literally a tool, a gift," Hansen said. "We use the analogy that they get the stomach of an infant, and they have to learn how to feed themselves. It brings a consciousness to their eating habits."

To qualify for the surgery, patients must be a minimum of 100 pounds overweight and have two serious medical problems related to their weight, such as diabetes, hypertension or sleep apnea.

People without related medical problems can have the surgery, but they need to be even more obese to qualify.

One of the challenges Hansen sometimes faces is persuading the medical team that the hospital equipment can handle certain patients. Last spring, a 6-foot-4-inch man weighing 840 pounds came to see her. The medical team hadn't operated on people weighing more than about 600 pounds, but Hansen knew it was unrealistic to expect this man to lose almost 250 pounds before surgery.

As she talked with this patient, Hansen could see that he was committed to working hard to meet the program requirements. He faithfully visited the emergency room in his city to weigh in on the only scale that could handle his weight: a freight scale.

Radical lifestyle change

To prepare for the radical lifestyle change after the surgery, he started practicing new habits before the procedure: only three meals a day, no snacking, less junk food. His weight dropped to 710 pounds.

The hospital staff still had reservations about operating on him. How would they move him to the operating table, and would the table hold him? Hansen asked the team to let him come in for a dry run to practice these maneuvers, and the team agreed.

"I had to lobby for him every step of the way," Hansen said. "I believed in him because I could see that he wanted to make his life better, and he didn't have a lot of other options."

To tackle the problem of transferring him to the operating table, the team experimented with letting the man move himself by walking up to the table with a stool. Luckily, the idea worked.

The man underwent surgery in early January. Like other gastric bypass patients, he's had to adopt a new way of eating. He can eat only small meals, and has to avoid foods such as bread that expand in his tiny pouch stomach.

He also has to wait to drink until one hour after eating because the pouch is too small for both food and drink. He's also required to take vitamins the rest of his life to make up for the nutrients that would have been absorbed in his duodenum.

Although the new eating habits may be extreme, Hansen said the man will likely lose 300 to 400 pounds within a year after the surgery. For Hansen, patients like this are the people who make her job so enjoyable.

"I like working with people to help them make a significant change in their lives," she said. "I love seeing patients come back. Some lose 200 to 300 pounds. They go from being very limited in mobility to being functional and healthy with a better quality of life, and I love seeing them change."

Contact Heather Stringer at heathers@nurseweek.com