1. Adult Obesity: Recommendations to Achieve a Healthier Weight
Presented By:
Cynthia McGalliard
Auburn University School of Nursing
Hello everyone! My name is Cynthia McGalliard and I will be presenting information about appropriate treatment recommendations for obesity among our adult population.

2. Overview Introduction Small Test of Change Background PICO
Literature Search
Recommendations
Small Test of Change
Methods
Results
Conclusion
Throughout this presentation I will be discussing adult obesity including a brief description, the effects, and treatment options for the disease. I will be reviewing the PICO question that was developed to guide my evidence-based practice project, as well as information regarding the literature search and summary of evidence. Then, I will present the evidence-based practice recommendations that were gathered from professional literature reviews and current clinical practice guidelines that reflect the PICO question.
After introducing the project focus of adult obesity, I will describe the small test of change that has been implemented. This will include the clinical setting that I have selected for implementation of the evidence-based practice project including the population, setting assessment, the components of the small test of change, and a summary of the project. I will welcome any questions that you may have regarding the presented information at the end of this presentation.

3. Intro: What is Obesity? Obesity = Body mass index (BMI) ≥ 30 kg/m2
Healthy Weight
BMI 18.5 – kg/m2
Overweight = BMI 25 –29.9 kg/m2
Obesity = BMI ≥ 30 kg/m2
To begin, let’s first identify the meaning of obesity. Obesity is defined as an individual’s body mass index or BMI to equal or exceed 30 kg/m2. As seen in the diagram, healthy weight ranges from a BMI of kg/m2. A BMI of kg/m2 is classified as overweight, and obesity (as mentioned) is determined as one’s BMI to equal or exceed 30 kg/m2. For a more in-depth study, obesity is divided among three different categories, such as mild, moderate, and morbid obesity. For the intent of this evidence-based project, we will address obesity as a general classification.
As you probably know, body mass index is a measurement of an individual’s body fat based on his or her weight and height. The formula used to calculation BMI is weight in kg divided by height in meters squared.

4. PICO Question
In obese patients over 18 years old (P), when is it appropriate to implement pharmacological and/or surgical interventions (I) in comparison to limiting treatment to lifestyle modifications alone (C) in order to achieve a healthier weight (0)?
Here are some alarming facts about obesity. According to Centers for Disease Control and Prevention (2014), more than 1/3 of adults in the United States are obese. More specifically, 33% of Alabama’s adult population are obese. With a growing number of our nation’s population developing obesity and the detrimental effects of the preventable disease, I have developed the PICO question as presented.

5. Literature Search
As you are familiar, this pyramid presents the level of evidence from 1, which is at the top, to 7 with the 1 being the highest level of evidence. My EBP project includes studies ranging from levels 1 to 5. The types of literature included in the search were studies regarding adult obesity in order to gain an in-depth comprehension of this particular disease among the specified population. The Centers for Disease Control and Prevention (CDC) website was found to be useful in the collection of statistical data throughout the United States, including analysis within each individual state (Centers for Disease Control and Prevention, 2014).

6. EBP Recommendations Grade D Grade A
Include physical activity, dietary restrictions, and behavioral components
Orlistat for BMI>30 kg/m2 or >28 kg/m2 (with comorbidities)
Consider bariactric surgery for BMI> 40 kg/m2 or >35 kg/m2 (with comorbidities)
Grade D
Assess patient’s willingness to change and treat accordingly
Based on current literature reviews, these evidence-based practice recommendations are included in the project. The letter grades presented is guided by the Oxford Centre for Evidence-based Medicine:
Weight management programs should include physical activity, dietary restrictions, and behavioral components (U.S. Department of Health & Human Services, 2010). 
Orlistat should be considered is an adjunct to lifestyle modifications for management of weight loss for patients with a BMI > 28 kg/m2 (with comorbidities) or a BMI >
30 kg/m2 based on an individual assessment of risks and benefits (U.S. Department of Health & Human Services, 2010).
Patients with a BMI that equal or exceeds 40kg/m2 without coexisting medical problems and would not be undertaking an excessive risk should be eligible for bariatric
surgery (Mechanick et al., 2013).
Patients with a BMI that equal or exceeds 35 kg/m2 would benefit from bariatric surgery considering a therapeutic target of weight control and improving factors
associated with the risk of cardiovascular disease (Mechanick et al., 2013).
Healthcare professionals should assess a patient’s willingness to change and target weight loss interventions according to his or her willingness regarding lifestyle
modifications (diet and physical activity) (U.S. Department of Health & Human Services, 2010).

7. Clinical Setting Assessment
Express Care Clinic
Rural community
8 patient rooms
Healthcare Professionals
1 Physician
1 Nurse Practitioners
1 Registered Nurses
1 Medical Assistant
The practice setting chosen to be relevant for the implementation of my evidence-based practice project (EBP) is an express care clinic that provides quality services to patients seeking medical care for numerous conditions including acute care and family medicine. The mission of this clinic is to care for the most basic illnesses and injuries, to the most complex disease processes. Healthcare services are provided to patients with both scheduled appointments and walk-in needs. Services are rendered to patients of all ages at two clinic locations, as well as a mobile care clinic. As the physician oversees all locations and is often at the primary site, he only presents as needed to my selected site. This express care clinic averages approximately 40 patients per day.

8. Project Participants Participant Gender Age 1 M 48 2 F 52 3 67 4 19 561 6 43 7 60 8 38
In the chosen clinical setting, I was able to recruit eight consenting participants for the ‘small test of change’ portion of the project. The ages of the participants ranges from 19 to 67 years of age. The project is equal in gender participants with 4 males and 4 females. All of these individuals expressed a desire to achieve and maintain a healthier weight due to their current state of obesity.

9. Diet Physical Activity STOC: Implementation
Healthy lifestyle behaviors play a large role in maintenance of an individual’s weight and BMI. Diet and physical activity are major components that attribute to successful weight management. These are considered the first line treatments of obesity, as well as necessary components to any selected treatment for obesity. With that being said, lifestyle modifications is the focus of my small test of change project.

10. STOC: Implementation
A small test of change has been implemented at the selected clinical site and consists of pre- and post dietary and physical activity assessment with the use of two questionnaires, in addition to BMI assessments. Here you can see the SNAQ questionnaire for dietary assessment. It consists of 4 questions. Each answer ranges from 1-5 points for a total score ranging from A total score that is <14 indicates a high risk of at least 5% wt loss within 6 months.

11. STOC: Implementation
RAPA 1: Aerobic To score, choose the question with the highest score with an affirmative response. Any number less than 6 is suboptimal. For scoring or summarizing categorically: Score as sedentary: 1 - I rarely or never do any physical activities. Score as under-active: 2 - I do some light or moderate physical activities, but not every week. Score as under-active regular – light activities: 3 - I do some light physical activity every week. Score as under-active regular: 4 - I do moderate physical activities every week, but less than 30 minutes a day or 5 days a week. 5 - I do vigorous physical activities every week, but less than 20 minutes a day or 3 days a week. Score as active: 6 - I do 30 minutes or more a day of moderate physical activities, 5 or more days a week. 7 - I do 20 minutes or more a day of vigorous physical activities, 3 or more days a week.
This is the Rapid Assessment of Physical Activity (RAPA). This questionnaire categorizes an individual’s activity level ranging from 1-7, with 1 being sedentary and 6 and 7 being active. A score of 6 or 7 is desirable with this assessment.
The use of these tools will be informative for the evidence-based project as both will provide a baseline assessment upon implementation, reflect patient improvements, and confirm any correlation that diet and activity may have with the patient’s BMI.

12. Evaluation Desired Pre Post Outcomes Assessment Diet score
Activity score
BMI
Post
Improved diet score
Improved activity score
Improved BMI
Desired
Outcomes
Obese patient achieves a healthier weight status
The expected outcomes for the chosen project will aid in the determination of whether the implementations made are effective. Two assessment questionnaires and a BMI assessment were performed upon initiation of the project, and will be repeated 4-6 weeks thereafter. Each patient has been encouraged to improve diet and activity.

13. STOC: Pre-BMI
This chart shows the pre-assessment of body mass index on the eight participants. As you can see in the figure above, the initial BMIs range from 26 to nearly 43 kg/m2. I am in the process of collecting post-assessment data from the project participants. Unfortunately, I will not be able to present the post-assessment data including BMI and questionnaire results that you will see in the next 2 slides at this point due to pending information.

14. STOC: Results
The information presented reveals the results of the pre-SNAQ scores of each participant. As previously mentioned, the Simple Nutritional Assessment Questionnaire consists of 4 questions. Each answer ranges from 1-5 points for a total score ranging from Each shaded area represents a particular question. A total score that is <14 indicates a high risk of at least 5% wt loss within 6 months. You can see that the total scores on the preliminary assessments range from 14 to 16.

15. STOC: Results
This figure provides a visual comparison of each participants self-perceived category according to the Rapid Assessment of Physical Activity or RAPA questionnaire. Again, this assessment ranges from 1 to 7, with the lower score indicating a more sedentary or less active lifestyle. A 6 or 7 is the recommended physical activity level for adults. Each shade of color represents a participant. As shown, the RAPA scores range from the lowest possible score of 1 to the highest of 7. Fifty percent of participants ranked themselves at a level of 4 which indicates moderate activity each week, but less than 30 minutes or 5 days a week.

16. Conclusions Healthy Weight Lifestyle modifications
Pharmacological treatment
Surgical interventions
The American Society for Metabolic and Bariatric Surgery (2010) reports a % increase risk of death for people with obesity compared to adults within the normal weight recommendations. It is imperative that we, as Advanced Practice Nurses, consider effective treatment options for obese adults to achieve a healthier weight such as lifestyle modification, pharmacological and/or surgical interventions. Although lifestyle modifications are the primary focus of this small test of change, a larger project with consideration of pharmacological treatment and surgical interventions would be informative to the primary project of appropriate treatment recommendations for obese adults.

17. References
American Society for Metabolic and Bariatric Surgery. (2010). Bariatric surgery society takes on new name, new mission, and new surgery. Retrieved on June 3, 2014 from
Center for Disease Control and Prevention. (2014). Overweight and obesity. Retrieved from adult.html
Mechanick, J., Youdim, A., Jones, D., Garvey, W., Hurley, D., McMahon, M., & ... Brethauer, S. (2013). Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery*. Obesity ( ), 21S1-s27. doi: /oby.20461

18. References
U.S. Department of Health & Human Services. (2010). Management of obesity. A national clinical guideline. Retrieved on June 20, 2014 from gov/content. aspx?id=15597

19. Questions
Thank you all for your attention throughout this presentation. Does anyone have a question about the information presented? I also welcome any comments or suggestions that you may have regarding this information.