Practice Summary Handout: Obesity

Obesity Prevention and Management

1. Scope and Purpose. What are the scope and purpose of this document? What are the objectives, question, and target population (patients, consumers, students, etc.)? In other words, who are the recipients of the services outlined in the document?

The scope of the document is stated in a way such that it embraces all recommendations and findings related both to obesity and to the condition of being overweight. Further investigation reveals that the description of methods used lists literally dozens of factors that were considered to fall under the scope of the document (University of Michigan Health System (UMHS), 2013). These aspects include differences between patients, prevention, screening, history, psychosocial factors, and intervention.

Part of the scope is determining the target population’s characteristics when the targets of the guidelines are patients, as is the case here, and the guidelines claim to be relevant for all non-infant patients (over age two), apparently of any race or gender. However, it seems extremely odd to state that the target population includes those normally of a preliterate age. In truth, these guidelines seem, by their tone, to be aimed at medical staff dealing with any patients, obese or not, over the age of two. These patients would be the recipients of the services subsequently described in the outline. This is a rather broad scope, it is true, but since prevention is a particularly important factor in the treatment of the obesity epidemic in children, it is not surprising that the guidelines do not limit themselves to only patients who have already acquired the relevant disorders.

As for the objectives and the question, the former of these, at least, is answered in a clear-cut and straightforward manner. Under the section entitled “Guideline Objective(s)” there is the following statement: “To provide recommendations for prevention of obesity in patients and weight management in overweight and obese patients” (UMHS, 2013). The question is less clearly laid out, but it can be inferred that the research question suggesting a path for the creation of the guidelines was something along the lines of, “What recommendations can be given to medical workers to help manage weight in their patients in order to prevent overweightness and obesity and to mitigate the effects of existing overweightness and obesity?”

2. Stakeholder Involvement. What professions are represented in the document? Have members of the target population been consulted in the development of the document? What conflicts of interest are possible?

Though not stated where it might be expected, the guidelines do eventually state that the intended users are nurses, physicians and their assistants, dieticians, physical therapists, and behavioral health clinicians (UMHS, 2013). It is a notable positive sign that there is considerable overlap between that list and the one discussing the specialties of those who devised the guidelines, which included physicians specializing in family and general medicine as well as pediatrics. In addition, behavioral health specialists and those who specialize in metabolism, endocrinology, and diabetes were included. The final draft was approved by the Executive Committee for Clinical Affairs at the University of Michigan Hospitals.

It is, unfortunately, however, that no clinicians specializing in bariatric practice—a legitimate field in its own right—could be found to work on the guidelines. As well, physical therapists are represented on the list of intended users (and by inference the actual target population) but none were consulted in the making of the guidelines. These facts are both problematic, and perhaps due to the limitations inherent in a single hospital system putting out guidelines without having access to wider resources.

The conflicts of interest are fairly minimal for these guidelines. It is somewhat possible that a bias toward intervention and treatment, rather than wait-and-see approaches, might exist due to the fact that a hospital would likely prefer to see patients in a way that generates more income. More troubling than this minor possibility, however, is the fact that the guidelines seem to come from a rather small, insular group, thus possibly limiting their ability to clearly examine the fullness of the issues at hand.

3. The rigor of Development. Are the methods, criteria, and selection of articles for the document clear and justified? Have benefits and risks for the target population been considered?

The methods are clearly identified, but not visibly justified anywhere in the document. In addition, the inclusion of “hand-searches” as two out of three methods used to locate articles seems slightly dubious in the year 2013; electronic searches would be much more efficient and give access to a wider breadth of literature more immediately. The inclusion criteria for articles are laid out rather clearly in the “Description of Methods” section, including: “ . . . the topic of obesity, the time frame from 1/1/08–2/14/12; type of publication was guidelines, controlled trials (including meta-analyses), and cohort studies; the population was human ages 2 and above (children and adults); and language was English” (UMHS, 2013). However, no justification is given for these criteria and is left to the reader to supply. Following the narrowing of the field to these articles alone, the selection was apparently based on whether an article fits into a list of more specific topics, but again, justification is lacking.

Benefits and risks are generally discussed in the text following the description of each procedure. The “Benefits and Harms” of following the entire guidelines are neatly summarized under their own subheading. Contraindications, which are a topic that ties heavily into risks, are covered in separate sections. Overall, this aspect of the guidelines is clear.

4. Recommendations. If you were writing a plan based on the document, what are the major recommendations for practice? What would be the nursing role in carrying out the recommendations and what resources would be needed?

The major recommendations for practice begin with the identification of overweight or obese patients using a body-mass index (BMI) calculation and lifestyle assessment as part of a regular screening process. This is something that could be within the scope of a nurse’s role, depending upon both the nurse’s level of certification and the policies of that nurse’s place of employment. Also suggested is the setting of goals and the suggestion of lifestyle changes with the patient such as promoting exercise and proper nutrition, which more appropriately falls under the purview of a doctor. Medications and bariatric surgery are suggested as more extreme interventions, and these would definitely be outside the normal scope of nursing.

As a summary of the major recommendations for nursing practice based on these guidelines would focus on the routine screenings, the resources needed are fairly minimal. It would be normal to take a patient’s weight and health history during an exam. The only additional resource might be a BMI chart or training to help nurses learn how to calculate this number on their own as well as understand its meaning.

5. Application. What are potential barriers to implementing the recommendations? What are the potential costs of following the recommendations? How would you measure whether outcomes would be improved if the recommendations were carried out?

Because the recommendations, from a nursing point of view, are not very far above and beyond the normal call of duty, the potential barriers are practically nonexistent. The costs would also below. Measuring the outcomes could be accomplished by simply tracking the BMI of patients seen versus the number of visits they have received, perhaps taking lifestyle factors into account. Once nurses have been more properly educated on obesity, patients would hopefully either shed excess weight or, if of normal weight, stay that way at a more frequent rate.

Reference

University of Michigan Health System. (2013). Obesity prevention and management. Ann Arbor, MI: University of Michigan Health System.