Page 894 - Cardiac Nursing

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870 PA R T V / Health Promotion and Disease Prevention
while those viewed as too easy will not be taken seriously. Pro- Acknowledging the chronicity of obesity and the limitations of
viding the patient with regular feedback on goal attainment in- conventional clinical settings to assist patients to manage their
stills a sense of learning and mastery. 95 weight, alternative approaches have been evaluated that might
■ Stimulus control—considered the hallmark of behavioral ther-l l reach a larger number of people and could provide ongoing sup-
apy. 53 It is based on the assumption that environmental an- port. 53,103,104 Use of the Internet to deliver a behavioral weight
tecedents control behaviors, and that changing the environment loss program permits weekly contacts and individualized feedback
to include positive cues for appropriate eating and exercise be- to participants and has been successful in achieving weight loss;
haviors leads to desired behavior, for example, remove high-fat however, interventions delivered by e-mail or the Internet gener-
food and replace them with attractive fruits that are ready to eat, ally are not as effective as on-site or face-to-face weight loss treat-
store other tempting food out of sight, restrict places of eating. 59 ment programs. 55,105 Moreover, most of these programs enrolled
■ Problem solving—using the approach described by D’Zurillag g White, well-educated women, limiting the generalizability of their
96
and Goldfried, patients are taught four specific steps: identify findings.
the problem situation leading to inappropriate eating or exer- Although the use of technology reduces participant burden by
cise behavior, generate solutions, select one solution to test, not requiring frequent visits to a study or clinical center, it does
and evaluate the use of the solution in resolving the problem. not reduce the expense of professional counselors. The widely
It is important that the provider or interventionist permit the available structured, commercial weight loss programs that advo-
participant or patient to generate the potential solutions and cate the use of sound, balanced eating plans as well as exercise and
when possible, have the person role play or practice how he or behavioral change serve a valuable role in supporting the large
she will implement one or two of the potential solutions, for number of people who need guidance in weight loss. Although
example, interact with another person in a social setting when large numbers of individuals enroll in commercial programs such
the person is insisting that the patient eat some food that are as Weight Watchers, which increasingly applies the behavioral
high in fat. strategies tested in the clinical trials conducted at academic cen-
■ Relapse prevention—patients are taught that lapses are a natu- ters, only one study has examined these programs. 103 While these
ral occurrence and should be anticipated and planned for with programs require a fee payment and thus might not be an option
strategies that can be used in coping with the situation, and for some segments of the population, they do provide ongoing
thereby prevent relapses. 97 Relapse may become an issue dur- support for weight loss and achieve good results. Thus, they fill a
ing high-risk situations such as the holidays or vacations and it gap for needed long-term treatment that is not yet readily avail-
is helpful if the provider can discuss this in advance. able in the primary care setting.
■ Cognitive restructuring—entails teaching patients about neg-g g There are emerging findings from Great Britain of nurse-led
ative thoughts, rationalizations, comparisons with others, and programs for weight management in primary care settings. 106,107
all-or-none thinking, and how these thoughts serve the pa- Preliminary reports from the Counterweight Programme reveal
tient, for example, the person who sees that overeating once that 34% of the patients who completed 12 months of treatment
results in his or her “blowing the diet” and then proceeds to achieved a 5% weight loss. 107 In the United States, researchers
overeat for the remainder of the day because of feelings of dis- and clinicians are collaborating to translate the findings of the
gust or despair. This strategy teaches patients how to counter highly successful DPP trial to practice settings, 108 and one small
these negative thoughts with more positive thinking and self- trial was successful in reducing weight and improving aerobic fit-
statements. 53,59 ness and triglycerides in a workplace setting. 109 Yet, little transla-
tion of the DPP into practice has been reported.
Other strategies that can be used include contingency man-
agement, reinforcement, dealing with high-risk situations, stress Pharmacotherapy
management, and enlisting social support. Patient-centered coun- Drug therapy for the treatment of obesity has a tainted history.
seling, an approach that focuses on encouraging patients to set Adverse events associated with the use of phentermine/
goals, with input from the provider if needed, has been successful fenfluramine, phenylpropanolamine, and ma huang include car-
in helping patients make dietary behavioral changes and has po- diac valvular abnormalities, stroke, and myocardial infarction, re-
tential in the treatment of these patients in primary care set- spectively. Only sibutramine and orlistat remain available for
tings. 98 MI, a therapeutic strategy implemented to diminish use. 110 Subsequently, the approval process of other antiobesity
ambivalence about behavior change and increase a person’s moti- agents has been slowed. At the same time, these events brought at-
vation to take action, 45 is another strategy found to be beneficial tention to obesity as a chronic disorder, requiring ongoing treat-
in promoting weight loss. In this technique, the interventionist ment. Individuals who have markedly increased medical risks and
uses reflective listening to help patients identify and resolve un- who have been unsuccessful with nonpharmacologic therapy could
certainty and increase internal motivation to change. 99 MI has benefit from adjunctive drug therapy. However, pharmacologic
been associated with increased adherence to a behavioral weight therapy for treatment of obesity has limited indications, which are
2
loss intervention in women with type 2 diabetes, 100 to dietary be- treatment for patients with a BMI of 30 kg/m in the absence of
havior changes, 101 and to more than an hour of additional weekly comorbid conditions, or for patients with a BMI of 27 kg/m 2
exercise in sedentary adults compared with those who did not re- with concomitant morbidities such as diabetes, hypertension, or
ceive MI. 102 In summary, the best results for treatment success are sleep apnea.
attained through a combination of dietary therapy, exercise and There are two categories of medications approved by the Food
physical activity, and use of behavioral therapy. 53,59,83 In addition, and Drug Administration (FDA) for the treatment of obesity:
recognition that obesity is a chronic disorder and requires ongo- those that suppress appetite and those that reduce nutrient ab-
ing treatment is the most important step to achieving long-term sorption. A third type of medication works through the endo-
weight control. 6 cannabinoid system (ECS), which influences food intake and the