Obesity Management

There is increasing evidence that the etiology of overweight and obesity is complex, multifactorial, and variable among the population. An increasing acceptance of etiologies rather than simply personal responsibility is allowing obesity clinicians and researchers to identify possible root causes for obesity throughout the energy management system (Weiss, Bremer, & Lustig, 2013). Root cause identification and reasons for variability among patients will then allow more individual patient-specific treatments. In a sense, current obesity treatment for children is where clinicians were 30 years ago with pediatric cancer treatment. As the depth of knowledge regarding cancer etiology grew, so grew the types of treatments that worked best for specific cancers. The goal subsequently became determining the least invasive treatment resulting in the best outcomes. Obesity care for children is advancing quickly, but we have a long way to go. Currently, our professional advice is relatively broad: activity, nutrition, change in habit/behavior, and modification of the individual's environment. On the horizon are medications and devices, along with more tailored surgeries, to match individual patient's root causes of obesity and metabolic disease. Until then, pediatric obesity treatment must be broad in nature. Still, we have learned much in the past few years and can offer hope and advice until our deeper understanding allows more specific treatment. Nurses are on the frontlines of patient care, often caring for children identified with obesity by routine weight and height measurements for procedures. A common concern is whether to address the observed problem of overweight or obesity, knowing that statistically the child or adolescent has a high (often 80%) chance of existing metabolic derangements. Nurses are often in this situation, as their professional education emphasizes holistic evaluation of the child and family rather than a strict focus on the immediate presenting issue. Sensitivity, primary reason for visit (trauma vs. a primary care visit), and relationship with the patient (new or ongoing) are but a few factors guiding the nurse's decision to discuss obesity risks. These factors are no different than other health promotion situations. But what if the family asks for help with weight issues while visiting for another reason or is receptive to a sensitive opening of the conversation by the nurse? In a limited and perhaps episodic encounter, what advice can be given that will have impact, cover many potential etiologies of obesity, and be generalizable to the entire family? Knowing that 40% of normal weight individuals also have unidentified metabolic syndrome, this information may be pertinent to those family members as well. Nurses are sensitive to teachable moments; if encountered, the following is some general, data-driven advice that families can implement themselves or with ongoing support. While an in-depth discussion of goals and interventions is beyond the scope of this column, the reader is encouraged to find more depth and understanding of these concepts in this column's references. General goals to improve the metabolic derangements of obesity are to decrease circulating insulin, ghrelin, and cortisol and increase hormone PYY (Lustig, 2012). These hormones often have been adversely affected by an interaction with our current environment and lifestyles. For some people, working with these hormones is enough to modify weight and metabolic health. For others, these same interventions need further support (medications, endoscopic devices, surgery, and/or therapies not yet devised). At the risk of oversimplifying a complex interaction, the following advice will provide support in improving metabolic health. DECREASE CIRCULATING INSULIN Insulin is the hormone that enables energy to enter the cells, including liver, muscle, and adipose cells. Less insulin means less energy to adipose cells, where much of the excess energy is shunted. The best way to reduce insulin is to reduce exposure to sugars and increase dietary fiber and exercise. Sugar intake increases insulin output. Dietary fiber digestion allows for steady sugar release, resulting in a steady insulin response. In contrast, a large infusion of sugar results in insulin release spikes. Activity improves muscle insulin sensitivity, allowing utilization of fat stored in muscle, liver, and other sites (Weiss, Cali, & Caprio, 2008). DECREASE CIRCULATING GHRELIN Ghrelin is the hunger hormone that assesses cell energy needs. If they are determined to be adequate, it then signals the brain that energy stores are sufficient and energy (food) is not needed at that time. This causes the individual to not feel hungry or seek food. Eating a breakfast that is more protein than simple sugars will positively cycle ghrelin, satisfying the body's energy needs after sleep and the beginning of the day. Without breakfast (energy), the body seeks energy as the day progresses and energy needs increase. Ghrelin will continue to rise, and feelings of hunger will increase. The tendency then is to overeat throughout the remainder of the day (Weiss & Lustig, 2014). DECREASE CIRCULATING CORTISOL Cortisol is released in response to perceived stress. Short, intermittent bursts of stress with resulting cortisol releases are normal and necessary for survival and safety. Frequent and prolonged stress leads to sustained, elevated cortisol levels, which can be counterproductive to metabolism and the individual. Excess cortisol promotes visceral fat deposition and insulin resistance. There are many causes of prolonged stress. Some are the obvious ones found in adults' or children's busy, complex lifestyles. Sadly, many children live in environments where chaos, uncertainty, poverty, and lack of nurturing exists. Decreasing unhealthy stress in children's lives to reduce circulating cortisol is the ultimate goal but often is not fully achievable. The next most effective way to reduce cortisol levels is to add activity/exercise to the child's daily routine. Activity (and resulting cortisol reduction) is very effective in increasing muscle and liver function efficiency (Weiss & Lustig, 2014). INCREASE HORMONE PYY PYY is the satiety hormone that literally causes an individual to feel satisfied (satiated) after a meal. PYY is expressed in the distal small intestine. For most individuals, the transit time for ingested food to reach the distal intestine is about 20 minutes. Eating slowly and increasing insoluble fiber (which increases transit time) hastens the feeling of fullness. Rapidly eating food with minimal insoluble fiber will leave an individual without satiety after completing a serving; this leads to second helpings and increased caloric ingestion (Weiss & Lustig, 2014). The Elevator Speech In the business world, people are encouraged to develop an elevator speech, that is, if they were in the elevator with someone with the power to implement their idea, what concepts could be presented in 2 minutes to effectively and efficiently deliver the best presentation (Peters, 1999)? Nurses are very familiar with short, teachable moments as the hospital or clinic environment is often extremely episodic in nature; elevator speeches are all too common. In summary, the elevator speech for a teachable moment with a family concerned about obesity and its metabolic health consequences emphasizes the following points. 1. Decrease sugar: Eliminate sugar in all drinks, no chocolate milk, read labels, eliminate as many processed foods (anything with a label) as possible, cook your own food or learn how to (cook ahead and freeze for busy days). Decreasing sugar in the diet offers the biggest reward for the least effort (Basu, Yoffe, Hills, & Lustig, 2013). 2. Decrease processed food: Processed food almost always has added sugar (by various names) and minimal fiber. If it has a label, it is processed. Teach families to divide the grams of sugar by 4 to determine the number of teaspoons of sugar per serving. For example, 20 g of sugar per serving = 5 teaspoons of sugar in the serving (Lustig, 2012). 3. Increase fiber (soluble and insoluble): Processing foods almost always eliminates dietary fiber (e.g., white rice is processed, brown rice is unprocessed). Increasing intake of raw vegetables and fruits (and other fiber-rich foods) increases dietary fiber. Soluble fiber delays gastric emptying and causes a feeling of fullness. Insoluble fiber increases the speed of transit through the intestine and generates the PYY signal earlier (Cani et al., 2009). 4. Increase activity: Vigorous exercise is great but not necessary. Effective and beneficial activity can be 10 minutes of walking three times a day. Seek opportunities to add exercise to existing patterns rather than find more time in the day. Activity is more effective in maintaining weight loss than for decreasing weight (DiPietro & Stachenfeld, 2013). 5. Eat breakfast: A breakfast emphasizing protein and fiber and minimizing simple carbohydrates and sugar will satisfy circulating ghrelin, reducing the hunger signal (Olson, Aldrich, Callahan, Matthews, & Gance-Cleveland, 2015). 6. Improve sleep: The effect of disrupted sleep is increasingly being studied. Effects can be functional (awake time and snacking) and/or metabolic (disrupted circadian rhythm; Valrie, Bond, Lutes, Carraway, & Collier, 2015). 7. Wait 20 minutes before contemplating a second serving: This is the time needed for ingested food to reach the distal small intestine and signal PYY to indicate satiety. Increased insoluble fiber increases transit time, achieving satiety more rapidly (release of PYY). Second portions, if needed, should be fruit and vegetable choices (Cani et al., 2009). Many factors have brought our society to a place where our metabolic health is threatened. Addressing these factors on an individual or family basis can be overwhelming. While the above suggestions will certainly help to improve an individual's health, obesity researchers and clinicians are struggling to unlock more intricacies as to why some individuals respond to changes in our environment, diet practices, and epigenetics more than others. In the meantime, advice and modeling are some of the most effective tools available to nurses in the care of all of their patients' metabolic health.