5 Obesity Nursing Care Plans

Imbalanced Nutrition: Less Than Body Requirements

Obesity has increasingly been recognized as a risk factor for several nutrient deficiencies, which may seem surprising given the likelihood of overconsumption of calories in these individuals. However, many of these additional calories are not from nutritious sources, and according to surveys conducted in the US and Canada, many individuals do not meet the recommended levels of micronutrients through diet. Contributing to the increasing prevalence of obesity is the greater availability of inexpensive foods that are rich in calories and nutrient deficient (Astrup & Bügel, 2019).

Nursing Diagnosis

• Imbalanced Nutrition: More Than Body Requirements

May be related to

• Food intake that exceeds body needs
• Psychosocial factors
• Socioeconomic status

Possibly evidenced by

• Weight of 20% or more over optimum body weight; excess body fat by skinfold/other measurements
• Reported/observed dysfunctional eating patterns, intake more than body requirements

Desired Outcomes

• The client will identify inappropriate behaviors and consequences associated with overeating or weight gain.
• The client will demonstrate a change in eating patterns and involvement in an individual exercise program.
• The client will display weight loss with optimal maintenance of health.

Nursing Assessment and Rationales

1. Review individual causes for obesity (organic or nonorganic).
This identifies and influences the choice of some interventions. The etiology of obesity is far more complex than simply an imbalance between energy intake and energy output. Nevertheless, the prevalence of inactivity in industrialized countries is considerable and relevant to the rise in obesity. A study also indicated that hypercortisolism associated with recurrent affective disorders increases the risk for metabolic disorders ad cardiovascular risk factors such as obesity, overweight, large waist, high low-density lipoprotein (HDL) levels, and low high-density lipoprotein (LDL) levels (Hamdy & Khardori, 2023).

2. Review daily food diary (caloric intake, types and amounts of food, eating habits).
This provides the opportunity for the individual to focus on a realistic picture of the amount of food ingested and corresponding eating habits and feelings. This also identifies patterns requiring a change or a base on which to tailor the dietary program. Because almost 30% of clients who are obese have eating disorders, screen for these in history. The possibility of bingeing, purging, lack of satiety, food-seeking behavior, night-eating syndrome, and other abnormal feeding habits must be identified because the management of these habits is crucial to the success of any weight-management program (Hamdy & Khardori, 2023).

3. Weigh periodically as individually indicated, and obtain appropriate body measurements.
This provides information about the effectiveness of the therapeutic regimen and visual evidence of the success of the client’s efforts. During hospitalization for controlled fasting, daily weighing may be required. Weekly weighing is more appropriate after discharge. Waist and hip circumference are useful surrogates in estimating visceral fat; serial tracking of these measurements helps in estimating the clinical risk over time (Hamdy & Khardori, 2023).

4. Reassess calorie requirements every two to four weeks; provide additional support when plateaus occur.
Changes in weight and exercise necessitate changes in plan. As weight is lost, changes in metabolism occur, resulting in plateaus when weight remains stable for periods of time. This can create distrust and lead to accusations of “cheating” on caloric intake, which are not helpful. The client may need additional support at this time.

5. Evaluate the degree of fat as indicated.
BMI calculation, waist circumference, and waist/hip ratio are the common measures of the degree of body fat used in routine clinical practice. Les expensive techniques for direct measurement of visceral fat include abdominal ultrasonography and abdominal bioelectrical impedance (Hamdy & Khardori, 2023).

Nursing Interventions and Rationales

1. Explore and discuss emotions and events associated with eating.
This helps identify when the client is eating to satisfy an emotional need, rather than physiological hunger. Stress and other negative emotions, such as depression and anxiety, can lead to both decreased and increased food intake. Emotional eating can be caused by various mechanisms, such as using eating to cope with negative emotions or confusing internal states of hunger and satiety with physiological changes related to emotions (Konttinen, 2020).

2. Formulate an eating plan with the client, using knowledge of the individual’s height, body build, age, gender, and individual patterns of eating, energy, and nutrient requirements. Determine which diets and strategies have been used, results, individual frustrations, and factors interfering with success.
Although there is no basis for recommending one diet over another, a good reducing diet should contain foods from all basic food groups with a focus on low-fat intake and adequate protein intake to prevent loss of lean muscle mass. It is helpful to keep the plan as similar to the client’s usual eating pattern as possible. A plan developed with and agreed to by the client is more likely to be successful.

3. Emphasize the importance of avoiding fad diets.
Elimination of needed components can lead to metabolic imbalances like excessive reduction of carbohydrates can lead to fatigue, headache, instability and weakness, and metabolic acidosis (ketosis), interfering with the effectiveness of a weight loss program. The Atkins diet is a high protein and/or high fat, very low carbohydrate diet that induces ketosis. Ketone bodies tend to be generated when an individual’s daily dietary carbohydrate intake is under 50 g, and sodium diuresis is forced, causing most of the short-term weight loss. No robust data about the safety or long-term effectiveness of this diet are available (Hamdy & Khardori, 2023).

4. Discuss the need to give themselves permission to include desired or craved food items in the dietary plan.
Denying self by excluding desired or favorite foods result in a sense of deprivation and feelings of guilt and failure when an individual “succumbs to temptation.” These feelings can sabotage weight loss. However, even though experimentally induced negative mood state has been found to improve immediately after eating palatable food, the effect tends to be short-term and can be followed by other negative emotions, such as feelings of guilt (Konttinen, 2020).

5. Be alert to binge eating and develop strategies for dealing with these episodes (substituting other actions for eating).
The client who binges experiences guilt about it, which is also counterproductive because negative feelings may sabotage further weight loss efforts. Binge eating disorder (BED) is a mental illness characterized by recurrent binge eating episodes in the absence of appropriate compensatory behaviors. BED is strongly related to obesity due to caloric overconsumption (Aguera et al., 2020).

6. Identify realistic increment goals for weekly weight loss.
Reasonable weight loss (one to two lbs per wk) results in more lasting effects. Excessive and rapid loss may result in fatigue and irritability and ultimately lead to failure in meeting goals for weight loss. Motivation is more easily sustained by meeting “stair-step” goals. However, it is becoming increasingly apparent that the weight-loss goal for each client must be individualized and cannot be unilaterally based on standard weight-for-height norms (Hamdy & Khardori, 2023).

7. Determine current activity levels and plan a progressive exercise program (walking) tailored to the individual’s goals and choices.
Exercise furthers weight loss by reducing appetite; increasing energy; toning muscles; and enhancing cardiac fitness, sense of well-being, and accomplishment. Commitment on the part of the client enables the setting of more realistic goals and adherence to the plan. Aerobic isotonic exercise is of the greatest value for clients who are obese. The ultimate minimum goal should be to achieve 30 to 60 minutes of continuous aerobic exercise five to seven times per week. Increased physical activity and exercise for 300 minutes per week are associated with significant weight reduction and longer maintenance of weight loss (Hamdy & Khardori, 2023).

8. Develop an appetite re-education plan with the client.
Signals of hunger and fullness often are not recognized, have become distorted, or are ignored. Accumulating evidence suggests that appetitive traits, such as food cue responsiveness and satiety responsiveness, are associated with overeating and weight in youth and adults. It is possible that some individuals have a behavioral susceptibility to overeating. It was hypothesized that individuals with obesity or overweight are more reactive to external cues to eat and less sensitive to internal satiety signals compared with individuals with a healthy weight (Boutelle, 2020).

9. Emphasize the importance of avoiding tension at mealtimes and not eating too quickly.
Reducing tension provides a more relaxed eating atmosphere and encourages more leisurely eating patterns. This is important because a period of time is required for the appestat mechanism to know the stomach is full. The appestat is part of the brain that regulates hunger and is found in the hypothalamus. With proper eating habits, the appestat indicates when an individual has had enough to eat. It prevents the client from overeating, which in turn regulates digestion and hormone secretion. Messages are sent to the appestat as soon as blood glucose levels fall below a certain point. When the appestat receives these stimuli, hormones are secreted to make the client feel hungry. Once the client is full the stimuli reverse, as do hormones, which makes the client feel full and is the signal to stop eating. (Real Meal Revolution, 2019)

10. Encourage the client to eat only at a table or designated eating place and avoid standing while eating.
Techniques that modify the behavior may be helpful in avoiding diet failure. Behavioral modification for weight loss addresses learned behaviors that contribute to excessive food intake, poor dietary choices or habits, and sedentary activity habits (Hamdy & Khardori, 2023).

11. Discuss restriction of salt intake and diuretic drugs if used.
Water retention may be a problem because of increased fluid intake and fat metabolism. Energy intake is the most important confounding factor for the link between salt intake and overweight or obesity because high salt intake may stimulate thirst and appetite and lead to more energy intake. Another possible explanation for a valid link between salt intake and obesity is that higher salt intake may result in more fluid intake and may thereby contribute to weight increase (Zhou et al., 2019).

12. Consult with a dietitian to determine caloric and nutrient requirements for individuals’ weight loss.
Individual intake can be calculated by several different formulas, but weight reduction is based on the basal caloric requirement for 24 hours, depending on the client’s sex, age, current and desired weight, and length of time estimated to achieve the desired weight. Note: Standard tables are subject to error when applied to individual situations, and circadian rhythms and lifestyle patterns need to be considered.

13. Administer medications as indicated.

• 13.1. Glucagonlike peptide-1 agonists such as liraglutide and semaglutide
  Glucagonlike peptide-1 (GLP-1) is a physiologic regulator of appetite and caloric intake, and the GLP-1 receptor is present in several areas of the brain involved in appetite regulation (Hamdy & Khardori, 2023).
  
• 13.2. Hormonal therapy like thyroid (Euthyroid), and levothyroxine
  This may be necessary when hypothyroidism is present. When no deficiency is present, replacement therapy is not helpful and may actually be harmful. Note: Other hormonal treatments, such as human chorionic gonadotropin (HCG), although widely publicized, have no documented evidence of value.
  
• 13.3. Orlistat
  Lipase inhibitor blocks the absorption of approximately 30% of dietary fat. This facilitates weight loss and maintenance when used in conjunction with a reduced-calorie diet. This drug also reduces the risk of regain after weight loss. Orlistat should be taken during or up to one hour after a meal containing fat. Orlistat may reduce the absorption of some fat-soluble vitamins (A, D, E, K) and beta carotene, therefore, the client may take a multivitamin daily (Hamdy & Khardori, 2023).
  
• 13.4. Vitamin, and mineral supplements
  Obese individuals have large fuel reserves but are often deficient in vitamins and minerals. Note: The use of Xenical inhibits the absorption of water-soluble vitamins and beta-carotene. The vitamin supplements should be given at least two hours before or after Xenical. For clients with inadequate dietary consumption, a daily multivitamin can help ensure an adequate intake of vitamins and essential minerals with minimal safety concerns. Data showed that the use of dietary supplements decreased the prevalence of inadequate intake of vitamins A, C, and E and magnesium (Astrup & Bügel, 2019).

14. Provide fat substitutes as indicated.
Olestra has been approved for use as a dietary supplement and additive in various foods, such as potato chips and crackers. Olestra has a caloric value of 0 kcal/g, whereas fat has a value of approximately 9.1 kcal/g. In many trials, olestra had fairly good tolerability, although foods containing it are apparently less tasty than foods cooked in regular fat (Hamdy & Khardori, 2023).

15. Hospitalize for fasting regimen and stabilization of medical problems, when indicated.
Aggressive therapy and support may be necessary to initiate weight loss, although fasting is not generally a treatment of choice. The client can be monitored more effectively in a controlled setting, minimizing complications such as postural hypotension, anemia, cardiac irregularities, and decreased uric acid excretion with hyperuricemia. Inpatient programs may offer the convenience of easy access to clients and ease of monitoring, but they are not only expensive to run and difficult to reimburse, and they also generally cause considerable disruption to the client’s regular routine. Additionally, they offer little guarantee of sustained effect (Hamdy & Khardori, 2023).

16. Prepare for surgical interventions (gastric partitioning or bypass) as indicated.
These interventions may be necessary to help the patient lose weight when obesity is life-threatening. Surgical therapy for obesity or bariatric surgery is the only available therapeutic modality associated with clinically significant and relatively sustained weight loss in subjects with morbid obesity associated with comorbidities (Hamdy & Khardori, 2023).