Losin' It
Tailor-made weight-loss plans that address individual needs and lifestyles help patients—and nurses—win the battle of the bulge

By Cathryn Domrose
January 13, 2004

It's time again to make that famous New Year's resolution: I'm going to lose weight. Time to stock up on vegetables and frozen diet entrées. Buy a gym membership. Sign up for a program such as Weight Watchers or Jenny Craig. Buy the latest best-selling diet book.

We all know how important it is to eat a balanced diet, to exercise, to not gain excessive weight. We know the health dangers associated with obesity-increased risk for hypertension, diabetes and cancer; joint aches; increased stress on the cardiovascular system; low energy; difficulty breathing. Many of us have gone on diets in the past, even lost some weight for a little while.

Yet here we are, after the holidays, 20 or 50 or 100 or more pounds above our healthy target weight, wondering if we'll ever be able to get it off and keep it off. Hoping, despite everything we've learned about weight loss and management, for a quick fix to magically melt away the pounds and keep them off forever.

In 1999, more than 60 percent of adult Americans were overweight or obese, and 13 percent of children and adolescents were overweight. Health officials are calling obesity the country's biggest health problem. A number of research centers on weight control and obesity have been established around the country, but the gist of their findings will produce few cries of surprise or elation from most people who ever have tried to lose weight.

Research shows that people gain weight because they take in more calories than they expend. They lose it when they expend more than they take in. In other words, in order to lose weight and keep it off, you need to watch what you eat and exercise.

How to do this successfully, however, is an individual matter, according to research and health professionals who run weight-loss programs.

People who want to lose or manage their weight must look beyond diet books and into their own lives and habits. Health professionals who want to help their patients lose weight must go beyond referring them to a session with a dietitian or suggesting they join a community weight-loss program and instead help them find programs or regimens that are right for them, offer support and follow up with their weight-management efforts. >>

Livin' large

Weight management and widespread obesity are relatively new concepts for Americans, said Linda Gigliotti, MS, RD, CDE, weight management program coordinator for the University of California, Irvine, Corporate Health Services. "It really wasn't a problem before World War II," she said.

After the war came fast food, women in the workplace, two-income households and technological innovations like television. Time-strapped families stopped sitting down to regular meals. Instead of playing outside, children gathered around the television set.

"It really has continued to escalate," as children and grandchildren who grew up on technology and fast food became adults battling unhealthy weight gains in the 1980s and '90s, Gigliotti said. Activity has decreased by 75 percent during the last 100 years, she said, as food consumption has increased. The average person eats 300 to 400 more calories per day than he or she did in the 1980s, Gigliotti said. "We're not talking about ages ago,' she said. "We're talking about fairly recent history."

Large portions, constant access to food and cultural changes that make it socially acceptable to eat anywhere-in the car, while walking, even in church-have created what she considers a "toxic environment" for people trying to control their weight.

Although people in all professions have challenges that make it difficult to control eating and find time to exercise, nurses face some particular difficulties.

Stress, irregular work schedules, long hours, no real break or meal times, vending machines full of junk food, tables of cookies and candy brought in as thank-you's from patients and families all contribute to cycles of hunger followed by gorging on high-calorie foods.

"I hate food at work," said Penny Weismuller, DrPH, RN, a recently retired division manager for epidemiology and disease control for the County of Orange Health Care Agency. "People bring in junk. They don't bring in a beautiful basket of fruit. They bring in doughnuts and cookies and junk food. That's deadly when you're tired and busy and you don't get a break."

Nurses and teachers also are prone to overeating when get they home from work around 4 p.m., said Meredith Medeiros, RN, a certified diabetes outpatient educator and educator and research nurse at the Miriam Hospital weight management program in Providence, R.I. Many nurses go home after a stressful day and immediately want to eat, she said.

Nurses also may put off exercising or eating well-something most people say takes planning and scheduling-because they are too busy taking care of others. "Physically and emotionally, nursing is a hard job," said Kathleen Jones, MSN, CNP, a nurse practitioner with the nutrition, fitness and weight management programs at Northwestern Memorial Hospital Wellness Institute in Chicago. Nurses need to make taking care of themselves a priority, she said.

Less is best

The sure way to lose weight is deceptively simple in concept and has been around for thousands of years. "You can lose weight on any diet that restricts your calorie intake," said Jodee Dorsey, Ph.D., RD, LD/N, associate professor of nutrition in the Nutrition, Food, and Exercise Sciences Department at Florida State University in Tallahassee. For instance, she said, Atkins-style high-protein, low-carbohydrate diets work for short-term weight loss partly because they cut out calorie-dense foods like desserts and muffins.

Calorie restriction accounts for why most diets work for a while and why new diet books come out every year with some variation on the theme, say nutritionists and dietitians. Unrestricted single-food diets may work for a week or so because people get so tired of the allowed food that they don't want to eat it any more, even if the food is ice cream or jelly beans.

How much people should eat and what kinds of foods they should eat is individualized and still somewhat controversial, even among experts.

"One of the real challenges that's going to be in the health profession is that we're finally going to grow out of the idea of one diet fits all," said Donald Layman, Ph.D., professor of nutrition in the Department of Food Science and Human Nutrition at the University of Illinois, Urbana-Champaign. Health professionals need to realize that there are a range of foods people can eat and that the key is trying to decide what diet fits what person, he said.

For example, he said, a high-carbohydrate, low-fat diet might work well for some people, but for those with high triglycerides and low HDL cholesterol, "that's exactly the wrong diet." Many adult women near menopause are not satisfied with the high-carbohydrate diet and always feel hungry, he said. They may need more protein.

A recent study showed that people lost weight equally and reaped nearly equal health benefits on four different types of diets-Atkins (low carbohydrate), Ornish (high carbohydrate, low fat, vegetarian), Weight Watchers (restricted calories) and Zone (moderate carbohydrate).

"The good news about this study is that we have demonstrated that all these diets work," said the study's author, Michael Dansinger, MD, assistant professor of medicine at Tufts-New England Medical Center, in Boston, at an American Heart Association press conference. "That means that physicians can work with patients to select the diet that is best suited to the patient."

If you can eat only 1,200 calories in a day-the amount an inactive woman needs to lose weight-you have to choose calories that will leave you the most satisfied, Layman said. He recommended starting with protein, then adding fruits and vegetables and using whatever is leftover for carbohydrates and fats. Other nutritionists favored diets with higher amounts of carbohydrates, mostly from fruits, vegetables and whole grains.

Layman and other nutritionists did not recommend any diet that eliminated entire categories of foods, including fat, carbohydrates and fruits and vegetables.

"It's a red flag when total groups of foods are eliminated," Gigliotti said. She asks people in her weight management program classes, "Did anybody really get here because you ate too many carrots?" Most people have problems, she said, because they eat too many foods that are "calorie dense."

For instance, a cup of broccoli has 50 calories, a cup of rice has 200 calories and a cup of fettuccine Alfredo has 500 calories.

"A cup is a cup. We eat based on volume," she said. "If you eat fruits and vegetables, you will be more satisfied on fewer calories."

Join the movement

Exercise and activity also contribute to how much weight a person loses and even more to how long and how well weight loss is maintained, research shows. Participants in the National Weight Control Registry based at the University of Colorado, which includes more than 3,000 people who have lost at least 30 pounds and kept it off for at least a year, exercise an average of 60 to 90 minutes a day at moderate intensity. Most of them report doing at least two types of exercise, such as cycling and weight training or walking and yoga.

People who exercise more or are more physically active can have more flexibility in their diets, Layman said. But "if you're a couch potato and you decide you want to be a couch potato, you can have no flexibility in your diet."

To increase and measure activity, Layman suggested getting a pedometer and walking at least 10,000 steps a day. He also suggested establishing a regimen of stretches and weight-training exercises. If you're still gaining weight with this amount of exercise, he said, "then you're overeating."

Choosing exercise is as important as choosing a diet. For any exercise plan to work, it has to be something you like and something you will do regularly. For obese or morbidly obese people, "it's movement," said Abby Hyman, RN, coordinator for the Cooper Institute Weight Management Program in Dallas. Many in her program start with walking, then progress to treadmills and other forms of exercise.

Medeiros, who is actively managing her weight, drives with her son for 20 minutes to a path along a river where she walks and he rollerblades. The drive is worth it, she said, to exercise in a place they both enjoy.

Get with the program

Circuit-training programs especially for women, such as Curves, have become popular with many people who are trying to manage their weight. "Those programs are good for someone who has the strength and who wants to get out and socialize," Hyman said. But you have to do any physical activity consistently, she said. "If you join a gym and never use it, it's not right for you." Most people cannot lose weight through exercise alone, nutritionists and weight control researchers say. They need to limit calorie intake as well.

Research shows that people can lose weight and keep it off, but it is difficult work and takes constant vigilance, at least for a while.

About half the participants in the National Weight Control Registry reported losing weight through a program and half lost weight on their own. Regardless of how they lost weight, most reported that they ate breakfast; ate a low-fat, high-carbohydrate diet; frequently monitored their weight; and exercised regularly. Registry members who had maintained long-term weight losses said keeping to their diet and exercise program became easier and more automatic over time.

A 1999 study of participants in Medeiros' Rhode Island weight management program showed that they lost an average of 67 pounds. After a year, 10 percent gained the weight back; 30 percent gained back more than half; 30 percent kept more than half off; and 30 percent kept all the weight off.

Those who were successful at keeping weight off attributed their success to exercise, keeping food diaries, starting again after a five-pound gain, completing the program and practicing their skills at home, Medeiros said.

Those who gained the weight back reported problems with stress, such as work or marital problems, and unexpected events like a death in the family.

"People deal with stress in different ways," she said. Planning for stressful situations should be part of any weight management plan. People can keep problem foods out of the house, walk or exercise instead of eating, have set portions of food for their meals and avoid workplace areas where food is laid out, she said.

Because losing or managing weight is a lifetime proposition, fad diets will never work, no matter how much we would like them to, nutritionists and those who work in weight management say.

"For anything to work long term, it has to affect behavior for a long time," Gigliotti said. "Regardless of the plan or program, there has to be a behavioral component to it." Which is why health professionals should treat their overweight patients with respect and support, she said. "Culturally, for so long we tended to blame the patient for a weight problem. Often, health care providers have looked at it as the patient's problem, the patient has no willpower."

Studies in the last four years have shown that 24 percent of nurses say they are "repulsed" by obese people, that physicians and other health care providers view obese people as lazy and lacking in self control, and that many obese people avoid seeking health care because they are afraid of being judged because of their weight.

In a study of 1,200 physicians, only 18 percent reported they would discuss weight management with overweight patients and 42 percent would discuss it with mildly obese patients.

Jones, who has understood the importance of weight management for some time, said she used to refer patients to a dietitian or give them written information about weight control. As part of a wellness center weight-management program, she is able to give them specific help and follow their progress.

"We don't just say, 'OK, go do these things.' We give them the people with whom they can work," she said.

"It's really important for health care providers to see obesity as a chronic disease," Gigliotti said. "If someone with high blood pressure came back with hypertension again, would you refuse to see them? Just because a person struggles and has a hard time, you don't give up on them."

Many people in the National Weight Control Registry said they lost and regained weight several times before finally keeping the weight off. Few said they were able to maintain their weight loss on the first try.

Brain food

Sometimes, people have much deeper reasons for a weight problem than too little exercise and too much food. People with psychological disorders, sexual abuse and eating disorders need therapy beyond what a weight-management program can give them, and may need to deal with these problems before successfully losing weight, Medeiros said. "A lot of people use weight to protect themselves."

Health care providers, including nurses and nurse practitioners, can help patients set reasonable goals, including goals that have nothing to do with a number on a scale, said those who work in weight management. Research shows that losing just 10 percent of body weight has huge health benefits.

When Dorsey attended Weight Watchers' meetings, she saw people who were thrilled when they could buy clothing off the rack at a store.

Hyman has seen people who wouldn't ever consider activity start exercising. She had one client who hated exercise because she didn't like the idea of getting sweaty and messing up her hair.

Over time, the woman started walking on a track and became so determined to exercise that she climbed over a hurdle and started walking when the track was closed for repairs. One of Gigliotti's clients is a diabetic man who weighed more than 300 pounds. He lost 80 pounds on the program, kept it off during the 18-week maintenance program and has since maintained his weight around 250 pounds.

"He's still pretty portly by most standards," she said, "but he made significant behavior changes and did a great job of keeping off 70 to 75 pounds. You have to look at that as a success. When he's ready to lose more weight, I'll be the first to support him. But I'm not going to have him feeling bad about where he is now."

Hospital nurses, who usually see patients for a few days, can help overweight and obese patients with diet selection, note their condition in care plans and speak to the physician about following up, Medeiros said. They should be open with patients and ask if they have thought about losing weight, what they are doing about it and if they are concerned and want to make changes.

"If they are not ready to make a change, this isn't the right time to talk about it," she said. "But if you don't get asked, it will never get addressed."

Contact Cathryn Domrose at kaguilar@well.com