More than 64% of U.S. residents are overweight or obese, and the prevalence of obesity is higher in women (34%) than in men (28%).1,2 In addition to this disparity, obesity is disproportionate among ethnic groups: African American and Hispanic women are more likely to be obese than Caucasian women.2,3
Obesity is caused by a number of genetic, metabolic, biochemical, cultural and psychosocial factors.4 Evidence suggests that obesity is not an issue of self-control, but of energy expenditure and appetite regulation.4 Obesity is often associated with several chronic medical conditions, including hypertension, hyperlipidemia, coronary artery disease, type 2 diabetes, sleep apnea, osteoarthritis, gallbladder disease and several forms of cancer.5
Women are challenged with the task of balancing careers, family and friends while maintaining a healthy lifestyle. In today's fast-paced society, it is more difficult for women to prepare healthy meals and keep a healthy weight. This "get-it-and-go" attitude promotes poor nutritional practices, leading to overweight and obesity.
Physical activity levels, the aging process, genetics, socioeconomic status, lifestyle behaviors, psychological factors, metabolic and hormonal factors all contribute to the prevalence of obesity in this country.6,7
Recent studies show that women are particularly susceptible to weight gain during three critical stages of life: puberty, postpartum and postmenopause.
The time of menstruation onset may contribute to obesity later in life.8 During menarche, gonadal steroids exert strong influences on body composition related to adipose tissue growth.8 Early onset is associated with high adiposity in adults.9
Weight after pregnancy may be a factor in obesity among young women. Weight gain may reflect changes in lifestyle rather than the physiologic changes associated with childbirth.7 Postpartum women have a higher intake of food, more accessibility to food during the day, decreased physical activity and decreased social support.10
Weight changes in older women may be associated more with aging than with menopause.7 The reduction in lean body mass that is inherent with aging often causes increased body weight because the metabolism slows, burning less fat.7 After menopause, it is easier for women to gain weight than to lose it.
The onset of obesity occurs gradually. The obese patient may have an excess of fat or adipose tissue, increased glucose levels, elevated blood pressure, complaints of aches and pains with ambulation, and shortness of breath with exertion. Additionally, the patient may have preexisting conditions such as diabetes, hypercholesterolemia or heart disease.6
The evaluation of an obese woman should include a through medical history and physical examination.11 Begin by measuring height and weight to determine body mass index (BMI). Next, measure waist circumference by placing a tape measure at the narrowest point of the waist.
Assess cardiovascular risk factors. The following cardiovascular risk factors place the patient at a higher risk for obesity: high blood pressure, cigarette smoking, hypertension, dyslipidemia and impaired fasting glucose.6,12,13 Table 1 provides a guide to evaluating an obese patient.
history of smoking.
In addition, assess for the use of medications that are associated with weight gain. These include glucocorticoids, megestrol acetate (Megace), cyproheptadine, antipsychotics, sedating tricyclic antidepressants, epilepsy medications (except for topiramate), beta-adrenergics, insulin and drugs that stimulate insulin release.12
Obtain a weight history. Weight gain after the age of 20 is an important health risk. Gaining more than 10 pounds at any point in life increases obesity risk. Children of diabetic mothers are at a higher risk for obesity in adulthood.12
Menopause status is important to note because a redistribution of body fat occurs when menstruation ceases. This distribution is in a more central pattern and is inhibited by estrogen.12 After menopause, estrogen production ceases, and adrenal androgen production continues. This event appears to be linked to changes in fat distribution that occur at this time of life.12 In postmenopause, androgens are associated with upper body fat accumulation.12
Physical Examination
In addition to general features of a thorough physical examination, assess height, weight, waist circumference, BMI, pedal pulses, peripheral edema and blood pressure. Perform a funduscopic examination and abdominal examination, and order an electrocardiogram.6,12
Weight-Management Plan
An effective weight-management plan is designed to achieve and maintain a healthy body weight. Intervention is recommended for patients with a BMI of 25 kg/m2 to 29 kg/m2 and two or more risk factors. It is also recommended for patients with a BMI of 30 or more and no risk factors.6
The overall goals of weight management are to reduce body weight, maintain a lower body weight, prevent further weight gain and control potential risk factors.6 Counsel patients about dietary interventions, increased physical activity, behavior therapy and pharmacotherapy. For some women, a combination of all techniques may be necessary.6
The most effective therapy for weight loss and maintenance is a combination of low-calorie diet, increased physical activity and lifestyle modifications.6 Evidence suggests that a reasonable approach to weight loss is to recommend this combination for at least 6 months — and to set a goal for a 10% reduction in weight.6 Ongoing patient participation is the most important outcome in weight management.13
For women, recent clinical trials suggest that weight management plans should be created according to the current phase of life. Puberty, postpartum and menopause are the times when women are most prone to problems with weight.7
Strategies for Puberty
Addressing obesity in adolescent girls can be a challenge. Teenage girls are impressionable, and implementing a strict diet plan may have psychological implications later in life. Introducing the concept of a family goal for a healthier lifestyle, rather than placing the teen on a specific diet, can be beneficial and more palatable. Diet and behavior modifications are the most important strategies during this time.14 Table 2 lists weight loss interventions for puberty.
Strategies for Adulthood
The prevalence of obesity in women rises significantly between the ages of 20 and 40.15 Federal studies have documented a decrease in physical activity during this age range.15 This may be due to changes in lifestyle, particularly careers and raising children.16 Implementing strength training, a balanced diet and regular exercise can assist in combating obesity during this phase of life.17
Beginning in their mid-30s, women lose a quarter of a pound of muscle or more every year and gain at least that much in fat.18 Because metabolism slows during this period, aerobic conditioning should be the focus. Conditioning prepares the heart and muscles to use oxygen for longer periods of exercise. Walking is an excellent way to increased metabolism.19 Table 3 lists obesity interventions for 20 to 40 years of age.
Strategies for Midlife
Physical activity during midlife (40 to 55) may become more difficult. The joints and muscles are easily injured during this time, and old injuries may flare up and cause problems.18 Increasing fruit and vegetable intake may help slow weight gain and reduce the risk of obesity.19 Table 4 lists interventions for midlife.
Strategies for Postmenopause
Postmenopausal women have higher body fat and central adiposity than other women their age.7 Physical activity and the reduction of dietary saturated fat are the main tools for preventing weight gain at this time.20,21 Weight gain during menopause can be reduced significantly by implementing long-term changes in diet and physical activity.
A study at Tufts University in Boston found that postmenopausal women who ate fewer than 1,000 calories per meal burned fat at the same rate as younger women. However, their ability to burn fat with meals over 1,000 calories was significantly reduced.22 To increase metabolism in postmenopausal women, encourage them to eat four to five smaller meals rather than three large meals each day. Encourage them to avoid foods high in saturated fat, such as fried foods, desserts, dressings, dips and sauces.22
Regular physical activity can increase metabolism and improve health after menopause. Weight training can increase muscle, ligament and tendon strength, as well as bone density. These achievements improve balance and the ability to walk, resulting in maximum independence and decreased falls.23
Combating obesity with weight lifting or resistance exercise can also prevent or slow osteoporosis and reduce arthritis pain. Regular, active exercise such as swimming and walking are excellent ways to raise heart rate and metabolism. Table 5 lists strategies for combating obesity during postmenopause.
Strategies for Postpartum
More than two-thirds of women battle some degree of weight retention at 6 weeks postpartum.24 The average woman retains 7 to 15 pounds of the weight gained during pregnancy, and a considerable number exceed their prepregnancy weights. A 5-year observational study found that women who had given birth gained an average of 20 pounds.21 Therefore, gestational weight gain is a significant factor in predicting retention of weight postpartum.24
There are several ways to influence the possibility of obesity during the postpartum period. Managing weight before conception, maintaining recommended weight during pregnancy, and weight management during the postpartum period can affect whether a woman is likely to retain weight.25 The American College of Obstetricians and Gynecologists has published guidelines for exercise during pregnancy.26
To combat obesity during the postpartum period, women should decrease their food intake, avoid eating as a pastime, decrease sedentary periods and increase the amount of time spent in physical activity.10
The best exercises for pregnant women are those that put minimal stress on the joints, involve smooth movements, and have a low risk of falling or body contact. Good choices include swimming, walking, stationary biking and the use of elliptical machines. Thirty minutes of exercise a day on most days of the week is all that is needed to maintain fitness and achieve related benefits.
Putting It Into Practice
The United States faces a national public health epidemic of obesity, and it is vital that nurse practitioners evaluate and manage women with weight problems. Rapport, awareness and motivation are critical factors in achieving optimal weight management.
For any woman to be successful in achieving weight loss, she must modify attitudes, health and lifestyle behaviors, health beliefs, physical activity and dietary and nutritional intake.
References
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26 American College of Obstetricians and Gynecologists. ACOG Opinion #267. Exercise during pregnancy and the postpartum period. Obstet Gynecol. 2002;99(1):171-173.
Yolanda Hill is a family nurse practitioner at Pennington Biomedical Research Center in Baton Rouge, La., and chairwoman of the political action committee for the Louisiana Association of Nurse Practitioners.