OBESITY

DSM-IV
316.00 Psychological factors affecting medical condition—maladaptive health
behaviors

Obesity is defined as an excess accumulation of body fat at least 20% over

average weight for age, sex, and height. Although considered to be a type of eating
disorder, obesity is a general medical condition coded on Axis III, with psychological
factors that adversely affect the course and treatment of the medical condition,
creating additional health risks for the individual.

ETIOLOGICAL THEORIES
Psychodynamics
Food is substituted by the parent for affection and love. The child harbors
repressed feelings of hostility toward the parent, which may be expressed inward on
the self. Because of a poor self-concept, the person has difficulty with other
relationships. Eating is associated with a feeling of satisfaction and becomes the
primary defense.

Biological
These disorders may arise from neuroendocrine abnormalities within the
hypothalamus, which cause various chemical disturbances. Familial tendencies have
been identified, but obesity is not clearly identified as being hereditary. People who
are overweight have more fat cells than thin people and are known to be less active.
Although overeating has long been believed to be the cause of obesity, research has
not borne this out. Another popular theory has identified carbohydrates as the
fattening substance. Currently, a high intake of fat in the diet is being identified as
the reason for weight gain/inability to lose weight. The set-point theory proposes
that people are programmed to maintain a certain level of weight to protect fat
stores. Studies reveal that leptin regulates body weight by telling the body how
much fat is being stored. Obese individuals often have higher leptin levels,
suggesting a failure of the body to respond to leptin. This may represent a
deficiency of receptor sites or inadequate amounts of glucagon-like peptide-1 (GPL-
1), which may impair the leptin signaling pathway.
In recent research, genetics, metabolic changes placing some people at risk, and
the way the body stores fat all play a part in the problems of obesity. Rather than a
single, simple cause, obesity appears to be the result of a complex system reflecting
all these factors.

Family Dynamics
Parents act as role models for the child. Maladaptive coping patterns
(overeating) are learned within the family system and are supported through
positive (or even negative) reinforcement. Family systems may sabotage efforts at
changing any part of the system to maintain the status quo.

CLIENT ASSESSMENT DATA BASE

Activity/Rest
Fatigue, constant drowsiness
Inability/lack of desire to be active or engage in regular exercise
Increased heart rate/respirations with activity; dyspnea with exertion

Circulation
Hypertension, edema

Ego Integrity
Weight may/may not be perceived as a problem
Perception of body image as undesirable
Cultural/lifestyle factors affecting food choices; value for thinness/weight
Eating relieves unpleasant feelings (e.g., loneliness, frustration, boredom)
Reports of SO’s resistance/demands regarding weight loss (may sabotage client’s
efforts)

Food/Fluid
Normal/excessive ingestion of food
History of recurrent weight loss and gain
Experimentation with numerous types of diets (yo-yo dieting) with varied/short-lived
results
Weight disproportionate to height; endomorphic body type (soft/round)
Failure to adjust food intake to diminishing requirements (e.g., change in lifestyle
from active to sedentary, aging)

Pain/Discomfort
Pain/discomfort on weight-bearing joints or spine

Respiration
Dyspnea with exertion
Cyanosis, respiratory distress (sleep apnea, pickwickian syndrome)

Sexuality
Menstrual disturbances, amenorrhea

Social Interactions
Family/significant other(s) may be supportive or resistant to weight loss (sabotage
client’s efforts)
Teaching/Learning
Problem may be lifelong or related to life event
Family history of obesity
Concomitant health problems may include hypertension, diabetes, gallbladder and
cardiovascular disease, hypothyroidism

DIAGNOSTIC STUDIES
Metabolic/Endocrine Studies: May reveal abnormalities (e.g., hypothyroidism,
hypopituitarism, hypogonadism, Cushing’s syndrome [increased cortisol or
glucose levels], hyperglycemia, hyperlipidemia, hyperuricemia,
hyperbilirubinemia). The cause of these disorders may arise out of
 neuroendocrine abnormalities within the hypothalamus, which result in various
chemical disturbances.
Anthropometric measurements: Measures fat-to-muscle ratio.

NURSING PRIORITIES
1. Help client identify a workable method of weight control incorporating needed
nutrients/healthful foods.
2. Promote improved self-concept, including body image, self-esteem.
3. Encourage health practices to provide for weight control throughout life.

DISCHARGE GOALS
1. Healthy pattern for eating and weight control identified.
2. Weight loss toward desired goal established.
3. Positive perception of self verbalized.
4. Plan in place to meet needs for future weight-control.

NURSING DIAGNOSIS NUTRITION: altered, more than body

requirements
May Be Related to: Food intake that exceeds body needs
Psychosocial factors
Socioeconomic status
Possible Evidenced by: Weight of 20% or more over optimum body
weight; excess body fat by anthropometric
measurements
Reported/observed dysfunctional eating
patterns; intake more than body requirements
Desired Outcomes/Evaluation Criteria— Identify inappropriate behaviors and
Client Will: consequences associated with overeating or
weight gain.
Demonstrate change in eating patterns and
involvement in individual exercise program.
Display weight loss with optimal maintenance of
health.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Review individual factors for obesity (e.g., organic Identifies/influences choice of
interventions.
or nonorganic).
Implement/review daily food diary (e.g., caloric Provides the opportunity for the individual to
intake, types of food, eating habits). focus on/internalize a realistic picture of the
amount of food ingested and corresponding
eating
habits/feelings. Identifies patterns requiring
changes and/or a base on which to tailor the
dietary program.
Discuss emotions/events associated with eating. Helps to identify when client is eating to satisfy
an emotional need rather than physiological hunger.
Formulate an eating plan with the client. Although there is no basis for recommending one

diet over another, a good reducing diet should

contain foods from all food groups with a focus
on
low-fat intake. It is helpful to keep the plan as
similar to client’s usual eating pattern as
possible.
A plan developed with and agreed to by the
client
is more apt to be successful. Note: It is
important
to maintain adequate protein intake to prevent
loss
of lean muscle mass.
Develop nutritional plan using knowledge of Standard tables are subject to error when applied

individual’s height, body build, age, gender, to individual situations, and circadian rhythms/
individual patterns of eating, and energy and lifestyle patterns need to be considered.
nutrient requirements.
Emphasize the importance of avoiding fad diets. Elimination of needed components can lead to
metabolic imbalances (e.g., excessive reduction
of
carbohydrates can lead to fatigue, headache,
instability and weakness, and metabolic acidosis
[ketosis] interfering with effectiveness of weight
loss program).
Discuss need to give self permission to include Denying self by excluding desired/favorite foods
desired/craved food items in dietary plan. results in a sense of deprivation and feelings of
guilt/failure when individual succumbs to
temptation. These feelings can sabotage weight
loss. Knowing that it is important to include small

portions of these foods can prevent negative

feelings and promote cooperation with weight
loss
program.
Identify realistic increment goals for weekly weight Reasonable weight loss (1–2 pounds/wk)
results
loss. in more lasting effects. Excessive/rapid loss may
result in fatigue and irritability and ultimately
lead
 to failure in meeting weight loss goals.
Motivation
is more easily sustained by meeting “stair-step”
goals.
Weigh periodically as individually indicated, and Provides information about effectiveness of
obtain appropriate body measurements. therapeutic regimen and visual evidence of
success of client’s efforts. During hospitalization
for controlled fasting, daily weight measurement
may be required. Weekly weight measurement is
more appropriate after discharge.
Determine current activity levels and plan Exercise furthers weight loss by burning calories
progressive exercise program (e.g., walking) and reducing appetite, increasing energy, toning
tailored to individual goals and choice. muscles, and enhancing sense of well-being and
accomplishment. Client’s commitment enables
the
setting of more realistic goals and adherence to
the
plan.
Develop an appetite reeducation plan with the client. In these clients, signals of hunger and
fullness
often are not recognized, have become distorted,

or are ignored.
Emphasize the importance of avoiding tension at Reducing tension provides a more relaxed eating

mealtimes and not eating too quickly. atmosphere and encourages more leisurely
eating
patterns. This is important because a period of
time is required for the appestat mechanism to
recognize that the stomach is full.
Encourage client to eat only at a table or designated Techniques that modify behavior may be
helpful
eating place and to avoid standing while eating. in avoiding diet failure.
Discuss restriction of salt intake and diuretic drugs Water retention may be a problem
because of
if used. increased sodium intake, as well as the result of
fat
metabolism.
Reassess caloric requirements every 2–4 weeks to Changes in weight and exercise will
necessitate
determine need for adjustment. Be aware of changes in diet. As weight is lost, changes in
plateaus when weight remains stable for periods of metabolism occur. Plateaus can create
distrust and
time. accusations of “cheating” on caloric intake,
which
are not helpful. Client may need additional
support at this time.

Collaborative
Consult with dietitian to determine caloric/nutrient Individual intake can be calculated by
several
requirements for individual weight loss. different formulas, but weight reduction is based
on the basal caloric requirement for 24 hours,
depending on client’s sex, age, current/desired
weight, and length of time estimated to achieve
desired weight.
Provide medications as indicated:
Appetite-suppressant drugs, e.g., diethylpropion May be used with caution/supervision at the
(Tenuate), mazindol (Sanorex); beginning of a weight loss program to support
client during stress of behavioral/lifestyle
changes. They are only effective for a few weeks
and may cause problems of
tolerance/dependence
in some people.
Hormonal therapy, e.g., thyroid (Euthroid); 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.
Vitamin, mineral supplementation. Obese individuals have large fuel reserves, but
are
often deficient in vitamins and minerals.
Hospitalize for fasting regimen and/or stabilization Aggressive therapy/support may be
necessary to
of medical problems. initiate weight loss, although fasting is not
usually
a treatment of choice. Client can be monitored
more effectively in a controlled setting to
minimize
complications such as postural hypotension,
anemia, cardiac irregularities, and decreased uric

acid excretion with hyperuricemia.

Refer for evaluation of surgical options (e.g., gastric May be necessary to assist the client lose
weight
partitioning, bypass), as indicated. when obesity is life-threatening.

NURSING DIAGNOSIS BODY IMAGE disturbance/SELF ESTEEM,

chronic low
May Be Related to: Biophysical/psychosocial factors, such as client’s
view of self (slimness is valued in this society,
and negative messages may be received when
thinness is stressed)
Family/subculture encouragement of overeating
 Control, sex, and love issues
Possibly Evidenced by: Verbalization of negative feelings about body
(mental image often does not match physical
reality); expressions of shame/guilt
Rejection of positive feedback and exaggeration
of negative feedback about self
Feelings of hopelessness/powerlessness; fear of
rejection/reaction by others
Lack of follow-through with diet plan;
verbalization of powerlessness to change eating
habits; hesitancy to try new things
Preoccupation with change (attempts to lose
weight)
Desired Outcomes/Evaluation Criteria— Verbalize a more realistic self-image.
Client Will: Demonstrate beginning acceptance of self as is,
rather than an idealized image.
Acknowledge self as an individual who has
responsibility for own self.
Seek information and actively pursue appropriate
weight loss.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Determine client’s view of being fat and what it Mental image includes our ideal and is usually
not
does for the individual. up to date. Fatness and compulsive eating
behaviors may have deep-rooted psychological
implications (e.g., compensating for lack of love
and nurturing, or a defense against intimacy).
Provide privacy during care activities. Individual usually is sensitive/self-conscious
about body.
Have client recall coping patterns related to food in Parents act as role models for the child.
family of origin and explore how these may affect Maladaptive coping patterns (overeating)
are
current situation. learned within the family system and are
supported through positive reinforcement. Food
may be substituted by the parent for affection
and
love, and eating is associated with a feeling of
satisfaction, becoming the primary defense.
Determine relationship history and possibility of May contribute to current issues of self-esteem/
sexual abuse. patterns of coping.
Identify client’s motivation for weight loss and set May harbor repressed feelings of hostility,
which
goals. may be expressed inward on the self. Because of
a
poor self-concept, client often has difficulty with
relationships. Note: When losing weight for
some-
one else, client is less likely to be successful/
maintain weight loss.
Be alert to myths the client/SO may have about Beliefs about what an ideal body looks like or
weight and weight loss. unconscious motivations can sabotage efforts at
weight loss. Some of these include the feminine
thought of “If I become thin, men will pursue me
or desire/rape me”; the masculine counterpart of
“I don’t trust myself to stay in control of my
feelings”; as well as issues of strength, power, or
the “good cook” image.
Have client keep a journal noting feelings that lead Awareness of emotions that lead to
overeating can
to compulsive eating. be the first step in behavior change (e.g., people
often eat because of depression, anger, and
guilt).
Develop strategies for doing something besides Replacing eating with other activities helps to
eating for dealing with feelings (e.g., talking with a retain old patterns and establish new
ways to deal
friend). with feelings.
Graph weight on a weekly basis. Provides ongoing visual evidence of weight
changes (reality orientation).
Promote open communication, avoiding criticism/Supports client’s own responsibility for weight
judgment about client’s behavior. loss; enhances sense of control, and promotes
willingness to discuss difficulties/setbacks and
problem-solve. Note: Distrust and accusations of

“cheating” on caloric intake are not helpful.

Outline/clearly state responsibilities of client and It is helpful for each individual to understand
area
nurse. of own responsibility in the program to avoid
misunderstandings.
Be alert to binge-eating, and develop strategies for The client who binges experiences guilt
about it
dealing with these episodes (e.g., substituting other that is counterproductive because
negative
actions for eating). feelings may sabotage further weight loss.
Encourage client to use imagery to visualize self at Mental rehearsal is very useful to help
client plan
desired weight and to practice handling new for and deal with anticipated change in self-
image
behaviors. or deal with occasions that may arise (family
 gatherings, special dinners) in which
confrontations with food will occur.
Provide information about the use of makeup, Enhances positive feelings of self-esteem,
hairstyles, and ways of dressing to maximize figure promotes improved body image.
assets.
Encourage buying clothes instead of food treats as a Properly fitting clothes enhance the body
image as
reward for weight loss. small losses are made and the individual feels

more positive. Waiting until the desired weight

loss is reached can become discouraging.
Suggest client dispose of “fat clothes.” Removes the “safety valve” of having clothes
available “in case” the weight is regained.

Retaining fat clothes can convey the message

that
the weight loss will not occur/be maintained.
Help staff be aware of and deal with own feelings Judgmental attitudes, feelings of disgust, anger,
when caring for client. and weariness can interfere with care/be
transmitted to client, reinforcing negative self-
concept/image.
Help client identify positive self-attributes. Focus on It is important that self-esteem not be tied
solely to
strengths/past accomplishments (unrelated to size of the body. Client needs to recognize that
physical appearance). obesity need not interfere with positive feelings
regarding self-concept and self-worth.

Collaborative
Refer to community support and/or therapy group. Support groups can provide
companionship,
increase motivation, decrease loneliness and
social
ostracism, and give practical solutions to
common
problems. Group therapy can be helpful in
dealing
with underlying psychological concerns.

NURSING DIAGNOSIS SOCIAL INTERACTION, impaired

May Be Related to: Verbalized or observed discomfort in social
situations
Self-concept disturbance
Possibly Evidenced by: Reluctance to participate in social gatherings
Verbalization of a sense of discomfort with others
Desired Outcomes/Evaluation Criteria— Verbalize awareness of feelings that lead to poor
Client Will: social interactions.
 Be involved in achieving positive changes in
social behaviors and interpersonal relationships.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Review family patterns of relating and social Social interaction is primarily learned within the
behaviors. Assess weight issues among family of family of origin. When inadequate patterns are
origin, especially mother/father. identified, actions for change can be instituted.
Encourage client to express feelings and perception Helps client identify and clarify reasons
for
of problems. difficulties in interacting with others (e.g., client
may feel unloved/unlovable or insecure about
sexuality).
Assess client’s use of coping skills and defense May have coping skills that will be useful in the
mechanisms. process of weight loss. Defense mechanisms
used
to protect the individual may contribute to
feelings
of aloneness/isolation, or resistance to change.
Have client list behaviors that cause discomfort. Identifies specific concerns and suggests actions
that can be taken to effect change.
Involve in role-playing new ways to deal with Practicing these new behaviors lets client
become
identified behaviors/situations. comfortable with them in a safe environment.
Discuss negative self-concepts and self-talk (e.g., May be impeding positive social interactions.
“No one wants to be with a fat person,” “Who
would be interested in talking to me?”).
Encourage use of positive self-talk such as telling Positive strategies enhance feelings of comfort
and
oneself “I am OK” or “I can enjoy social activities support efforts for change.
and do not need to be controlled by what others
think or say.”

Collaborative
Refer for ongoing family or individual therapy as Client benefits from involvement of family/SO to
indicated. provide support and encouragement.

NURSING DIAGNOSIS KNOWLEDGE deficit [LEARNING NEED]

regarding condition, prognosis, self care
and treatment needs
May Be Related to: Lack of/misinterpretation of information
Lack of interest in learning, lack of recall
Inaccurate/incomplete information presented
 Possibly Evidenced by: Questions/request for information about obesity
and nutritional requirements
Verbalization of problem with weight reduction
Inadequate follow-through with previous diet and
exercise instruction
Desired Outcomes/Evaluation Criteria— Assume responsibility for own learning.
Client Will: Begin to look for information about nutrition and
ways to control weight.
Verbalize understanding of need for lifestyle
changes to maintain/control weight.
Establish individual goal and plan for attaining goal.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Determine level of nutritional knowledge and what Necessary to know what additional
information to
client believes is most urgent need. provide. When client’s views are listened to, trust

is enhanced.
Identify individual holistic long-term goals for A high-relapse rate at 5-year follow-up suggests
health (e.g., lowering blood pressure, controlling obesity cannot be reliably reversed/cured.
Shifting
serum lipid and glucose levels). the focus from initial weight loss/percentage of
body
fat to overall wellness may enhance rehabilitation.
Provide information about ways to maintain “Smart” eating when dining out or when
traveling
satisfactory food intake in settings away from home. helps client maintain weight and desired
level
while still enjoying social outlets.
Identify other sources of information (e.g., books, Using different avenues of accessing information
tapes, community classes, groups). will further client’s learning. Involvement with
others who are also losing weight can provide
support.
Emphasize necessity to continue follow-up care/ As weight is lost, metabolism changes,
interfering
counseling, especially when “plateaus” occur. with further loss by creating a “plateau” as the
body activates a survival mechanism, attempting

to prevent “starvation.” This requires new

strategies and aggressive support to help client
continue weight loss.
Identify alternatives to chosen activity program to Promotes continuation of program. Note:
Fat loss
accommodate weather, travel, and so on. Discuss occurs on a generalized overall basis, and
there is
use of mechanical devices/equipment for reducing no evidence that spot-reducing or
mechanical
weight. devices aid in weight loss in specific areas.
However, specific types of exercise or equipment

may be useful in toning specific body parts.

Discuss necessity of good skin care, especially during Prevents skin breakdown/yeast infections
in moist
summer months. skinfolds.
Identify alternative ways to “reward” self/family Reduces likelihood of relying on food to deal with

for accomplishments or to provide solace. feelings.

Encourage involvement in social activities that are Provides opportunity for pleasure and
relaxation
not centered on food (e.g., bike ride/nature hike, without “temptation.” Activities/exercise may
attending musical event, group sporting activities, also use calories to help maintain desired
weight.
window shopping).