Weight Management Strategies for Women. A Review for Nurses. Giovanna M. Stramiello, MSN, FNP-BC

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2 CNE Weight Management Strategies for Women A Review for Nurses Giovanna M. Stramiello, MSN, FNP-BC

3 Objectives Upon completion of this activity, the learner will be able to: 1. Cite the statistics surrounding overweight and obesity and list the potential health effects of overweight and obesity. 2. List and explain different strategies for weight loss, including their risks and benefits as shown by the current evidence. 3. List effective strategies for maintaining weight loss and cite examples from the literature. Continuing Nursing Education (CNE) Credit A total of 2 contact hours may be earned as CNE credit for reading Weight Management Strategies for Women: A Review for Nurses and for completing an online post-test and participant feedback form. To take the test and complete the participant feedback form, please visit org/. Certificates of completion will be issued on receipt of the completed participant feedback form and processing fees. AWHONN is accredited as a provider of continuing nursing education by the American Credentialing Center s Commission on Accreditation. Accredited status does not imply endorsement by AWHONN or ANCC of any commercial products displayed or discussed in conjunction with an educational activity. AWHONN also holds California and Alabama BRN numbers: California CNE provider #CEP580 and Alabama #ABN0058. Giovanna M. Stramiello, MSN, FNP-BC, is a family nurse practitioner at Express Health Clinic in Dandridge, TN. The authors and planners of this activity report no conflicts of interest or relevant financial relationships. No commercial support was received for this activity. There is no discussion of off-label drug or device use in this article. Address correspondence to: gstramiello@mvrx.com. DOI: /j X x Introduction Excess body weight is associated with four of the 10 leading causes of death in the United States heart disease, stroke, some types of cancer (endometrial, breast, prostate and colon) and type 2 diabetes (U.S. Department of Health and Human Services [DHHS], 2007). It is also associated with other outcomes that negatively affect health and quality of life, such as gallbladder disease, respiratory dysfunction, hypertension, dyslipidemia, congestive heart failure, osteoarthritis, gout, depression, sleep apnea, insomnia and stress urinary incontinence (National Heart, Lung, and Blood Institute [NHLBI], 1998; World Health Organization [WHO], 2008). Health problems related to a poor diet and physical inactivity, two major causes of excess body weight, are second only to health problems associated with smoking as a leading cause of mortality (Mokdad, Marks, Stroup, & Gerberding, 2005). During the past 20 years, the incidence of overweight and obesity in the United States has risen from 58 percent to 68 percent of adults ages 20 years and older (Centers for Disease Control and Prevention [CDC], 2008). According to the National Center for Health Statistics (2007), 35.3 percent of women in the United States are obese. Bottom Line Overweight and obesity are associated with significant morbidity and mortality. Self-monitoring, physical activity and eating a consistent diet are associated with greater success at maintaining weight loss. Health care providers need to have open discussions with clients about weight and health and work with patients who desire weight loss to find the best approach for successful weight loss and maintenance. Gender is the variable most strongly associated with weight maintenance (Institute of Medicine [IOM], 1995). Women are predisposed to gain more weight and have more weight variability during adulthood than men (Williamson, 1993). Changes in reproductive cycles and hormonal fluctuation throughout the adult lives of women contribute to this predisposition (IOM). Men, on the other hand, are less likely to diet and more likely to participate in regular physical activity than women. These combined factors lead to a higher lean body mass for men. Higher lean body mass, along with higher caloric requirements, contributes to the gender disparity in successful weight maintenance (IOM). The purpose of this article is to identify methods of assessing body weight as a risk factor, discuss methods of weight reduction and factors that affect weight maintenance, and assist , AWHONN

4 health care providers in the care of women who desire weight loss. The topic of weight management during pregnancy is beyond the scope of this article and will not be discussed. Assessment Timely diagnosis and treatment of overweight and obesity may be a factor in the prevention of morbidity and mortality in American adults (McTigue, Harris, & Allan, 2004). Body mass index (BMI) is the most commonly used method to assess body weight as a risk factor for health problems (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 2007; WHO, 2008). Evidence suggests that the risk of chronic disease increases progressively as BMI surpasses 21 (WHO) and that mortality rates for all causes, especially cardiovascular disease, generally increase 50 percent to 100 percent for people with a BMI greater than or equal to 30, compared with individuals with a BMI of 20 to 25 (NHLBI, 1998). The major limitation of the BMI is that it only examines body weight; it does not assess body composition or weight distribution. Abdominal obesity, measured by waist circumference, has been associated with an increased risk of cardiovascular disease (National Institutes of Health [NIH], 2008), dementia (Whitmer, Gunderson, Barrett-Connor, Quesenberry, & Yaffe, 2005), diabetes (Wang, Rimm, Stampfer, Willett, & Hu, 2005) and cancer (NIH). This is true even in individuals whose BMI falls within the desired range of 18.5 to 24.9 (NIH). Bigaard et al. (2005) reported that waist circumference was strongly associated with all-cause mortality when adjusted for total body fat. According to the NIDDK (2004), women with a waist circumference greater than 35 inches are at a higher risk of disease. strategies include self-monitoring of behavior through the use of food and activity logs, self-monitoring of body weight, stress management, problem solving and social support (NHLBI, 1998). These strategies can increase individuals ability to adhere to dietary changes and physical activity regimens, thus improving outcomes of weight loss attempts percent of women in the United States are obese Medications Pharmaceutical therapies, such as orlistat and sibutramine, can complement dietary changes, exercise and behavioral therapy to enhance weight loss. However, there are no long-term data on the safety and efficacy of these agents for periods longer than 2 years, and pharmacotherapy is recommended only in combination with other methods of weight loss (Faucher, 2007; Food and Drug Administration [FDA], 2006). Pharmacotherapy also comes with risk of side effects and should not be used by some patients (NHLBI, 1998). Orlistat works in the intestines to block some of the dietary fat from being digested and absorbed. It is available in prescription strength (120 mg) and over-the-counter strength (60 mg). Both strengths of the drug are contraindicated for use in patients who have problems absorbing food or in patients CNE Weight-Reduction Strategies Weight reduction can improve the management of weight-related health problems or decrease the risks of their development (IOM, 1995). The NHLBI (1998) identifies several common approaches to weight reduction, including dietary changes, physical activity, behavior therapy, pharmacotherapy and surgery. Reduced-calorie diets, reduced-fat diets and high-protein/low carbohydrate diets are common dietary approaches to weight reduction. The NHLBI recommends a low-calorie diet of 1,000 to 1,200 calories per day for women. Alteration of macronutrients (i.e., low-fat diet or low-carbohydrate diet) alone has not been shown to be effective. Any such alteration must be accompanied by a reduction of total caloric intake in order to achieve weight loss (NHLBI). Physical activity combined with dietary changes increases the likelihood of successful weight loss, particularly at levels of physical activity reaching 200 to 300 minutes per week (Goldberg & King, 2007). Behavioral Strategies Behavior therapy can give individuals tools for overcoming barriers to dietary changes and/or physical activity. Specific Women are predisposed to gain more weight and have more weight variability during adulthood than men who are not overweight. Caution should be used regarding orlistat in patients who are being treated for diabetes and thyroid disorders or who are on an anticoagulation regimen. Because orlistat can interfere with the absorption of some nutrients, it is recommended that patients taking orlistat take a multivitamin every day at bedtime. The most common side effect of orlistat is a change in bowel habits, most frequently loose stools (FDA, 2007). Sibutramine decreases appetite by blocking the reuptake of norepinephrine, serotonin and dopamine. Sibutramine is recommended for patients with an initial BMI of 30 or higher, or 27 or higher in the presence of other risk factors (e.g., diabetes, dyslipidemia or controlled hypertension). It is contraindicated for use in some patients as it is associated with increases in October November 2009 Nursing for Women s Health 413

5 pulse and/or blood pressure, which can be significant. Blood pressure and pulse should be measured before starting a patient on sibutramine and at regular intervals thereafter. Other potential adverse effects include headache, constipation, dry mouth and insomnia (FDA, 2006) Surgery Surgical intervention is a treatment of last resort. It is indicated only for patients whose BMI is 40 or whose BMI is 35 when accompanied by comorbid conditions (NHLBI, 1998). Surgical options include the Roux-en-Y gastric bypass procedure, which reduces the size of the stomach and bypasses a portion of the small intestine, and gastric banding, which only reduces the size of the stomach (Faucher, 2007). Although surgical procedures have been more effective than medical therapies for weight loss, the potential for significant adverse events remains. Possible adverse events include respiratory complications, reflux, dumping syndrome, gastric pouch leaks, wound infection, stomal stenosis, bleeding, deep vein thrombosis, pulmonary embolism and re-operation (Maggard et al., 2005). Maintenance of Weight Loss Long-term ( 5 years) maintenance of lost weight can be as challenging as the initial weight loss. Estimates of successful long-term maintenance range from less than 5 percent (Faucher, 2007) to 20 percent (Wing & Phelan, 2005). The NHLBI (1998) recommends that weight loss programs set a target weight loss of 10 percent of body weight and suggests that maintenance of weight loss be a priority after the initial 6 months of weight loss therapy. Several factors have been identified as having an effect Women with a waist circumference greater than 35 inches are at a higher risk of disease on maintenance of lost weight, including maintenance support programs, physical activity, method of weight loss, self-monitoring of weight, diet consistency, dietary protein intake and number of attempts at weight loss. Maintenance Support Programs Follow-up maintenance support programs seem to have a positive effect on weight loss maintenance, particularly those that involve personal contact. In a randomized controlled trial of strategies to maintain weight loss, Svetkey et al. (2008) compared monthly personal contact, unlimited access to an interactive Web site, and self-directed control as methods of maintaining weight lost during a 6-month weight loss program. All three groups regained weight during the 30-month maintenance period, but the personal contact group regained significantly less weight than the other two groups. The selfdirected group regained a mean of 5.5 kg (12.1 lb), the interactive Web site group regained a mean of 5.2 kg (11.4 lb) and the personal contact group regained a mean of 4 kg (8.8 lb). Out of 1,032 total participants, 37.1 percent had maintained a 5 percent weight loss at the end of 30 months. The researchers did not find significant differences in results based on gender, age or race (Svetkey et al.). Physical Activity Multiple studies have suggested that physical activity has an important role in maintenance of weight loss. Jakicic, Marcus, Lang and Janney (2008) studied 191 sedentary women ages 21 to 45 years for a period of 24 months. Participants were instructed to reduce their caloric intake to 1,200 to 1,500 calories per day. Participants were also assigned to one of four intervention groups based on physical activity energy expenditure and intensity. Weight loss did not differ significantly among the groups, but post hoc analysis revealed that participants who were successful at achieving and maintaining a 10 percent weight loss at the end of 24 months reported performing more physical activity compared with those who sustained a weight loss of less than 10 percent. The addition of 275 minutes per week of physical activity above baseline activity levels was associated with an increased likelihood of sustaining a weight loss of 10 percent or more (Jakicic et al.). Befort et al. (2007) examined weight loss maintenance among individuals who had participated in a university-based weight management program. Out of 179 participants, 76.9 percent had successfully maintained a weight loss of at least 5 percent from baseline weight at 4 to 24 months following treatment. The most influential factors of successful weight loss maintenance were physical activity and low perceived difficulty of weight management. Physical activity was identified by the researchers as one of the strongest predictors of successful maintenance of weight loss. Self-Monitoring of Weight Self-monitoring of weight allows individuals to track effectiveness of weight management strategies and, in the event of weight gain, to make behavior adjustments as necessary before a significant amount of weight is regained (Butryn, Phelan, Hill, & Wing, 2007). The National Weight Control Registry (NWCR) is a research project that tracks individuals who have lost significant amounts of weight and kept it off for long periods of time (NWCR, n.d.). Seventy-five percent of participants in the NWCR report weighing themselves at least once per week, and 44 percent report weighing themselves daily (Klem, Wing, McGuire, Seagle, & Hill, 1997). In a study of 314 participants who had lost an average of 19.3 kg (42.5 lb) in the previous 2 years, Wing, Tate, Gorin, Raynor, and Fava (2006) found that 414 Nursing for Women s Health Volume 13 Issue 5

6 daily self-monitoring of weight was associated with a decreased risk of regaining 2.3 kg (5 lb) or more. Butryn et al. (2007) examined one-year follow-up assessment surveys of 3,003 members of the NWCR. They found that more frequent self-monitoring of weight was associated with lower BMI. Participants who decreased their frequency of self-weighing were more likely to report increases in fat intake and disinhibition (loss of control over eating). They were also more likely to report decreases in dietary restraint and greater amounts of weight regain. Concerns have been raised about possible adverse effects of daily weighing, such as mood disturbances and increased risk of eating disorders. Wing et al. (2007) did not find that daily weighing was associated with adverse effects. Rather, they found that daily weighing contributed to an increase in dietary restraint, a decrease in disinhibition and a decrease in symptoms of depression. Even participants who reported weighing themselves several times per day did not experience an increased frequency of adverse effects. Diet Consistency Allowing for flexibility in the diet during the holidays or on weekends can increase the opportunity for disinhibition, or lack of restraint. In evaluating whether maintaining a consistent diet was related to maintenance of weight loss, Wing and Phelan (2005) found that participants who reported maintaining the same diet regimen across the week and year were 1.5 times more likely to maintain their weight within 5 pounds over the next year than were participants who allowed more flexibility in their diets on weekends and/or holidays. Dietary Protein Intake Addition of protein to the diet may enhance weight loss maintenance. Lejune, Kovacs, and Westerterp-Platenga (2005) studied 113 participants randomized into either a protein group, who received 30 g of protein per day in addition to their own usual diet (18 percent of daily calories from protein), or a control group (average of 15 percent of daily calories from protein). During the 6-month weight maintenance period, the protein group experienced a lower weight regain and a decreased waist circumference compared to the control group. Weight regain in the protein group consisted only of fat-free mass, whereas the control group experienced a gain in fat mass. The protein group also experienced increased satiety compared with the control group. Number of Weight Loss Attempts It is suggested in the literature that multiple unsuccessful weight loss efforts might increase the likelihood of weight regain. Studies have shown that weight cycling (loss of weight followed by regain) may negatively impact body composition and resting metabolism, making it more difficult to achieve and maintain weight loss in future attempts. Vogels et al. (2005) reported a positive correlation between frequency of weight loss attempts and increase in body weight of an individual. These researchers identified a decrease in resting metabolic rate as a consequence of weight cycling and a possible explanation for the tendency toward weight regain. Kroke et al. (2002) evaluated the influence of recent weight change and weight cycling on subsequent weight changes in a prospective cohort study of 18,001 nonsmoking men and women with a follow-up period of 2 years. In women, prior weight loss was the single greatest predictor of subsequent gain of at least 2 kg (4.4 lb). These findings were consistent with an earlier study that reported that individuals with a history of weight cycling had gained significantly more weight at the time of followup than individuals without such history (Field et al., 1999). Implications for Nurses Many health professionals are hesitant to discuss the need for weight management with patients who are overweight or obese because they fear their patients will be offended. However, open discussions with patients about the health risks associated with Self-monitoring of weight allows individuals to track effectiveness of weight management strategies and, in the event of weight gain, to make behavior adjustments as necessary before a significant amount of weight is regained excess weight are a necessary component of preventative care. Patients who are not yet experiencing weight-related health problems may be able to avoid them entirely if they take action in the early stages, and patients already experiencing problems can improve their health by reducing their weight. Recommending that patients lose weight is only part of the health care provider s responsibility. Without some direction regarding weight loss and maintenance, patients are likely to experience frustration, difficulty losing weight and difficulty maintaining any weight loss achieved. A good starting point for addressing a patient s weight concerns is to have the patient keep a dietary and physical activity journal. This gives both the provider and the patient the opportunity to assess current habits and introduce changes that can be maintained over a long period of time. It is tempting for patients to drastically reduce their caloric intake, but this can lead to increased feelings of hunger and deprivation, which make dietary changes more difficult to maintain. Drastic caloric reduction can also result in loss of CNE October November 2009 Nursing for Women s Health 415

7 muscle mass as the body breaks down lean tissue for a source of energy, thereby lowering metabolic rate. A smaller decrease in calories, though it may result in smaller and slower losses of weight, is less likely to result in loss of lean tissue by muscle catabolism, and is more likely to produce a weight loss that can be maintained over the long term. After examining the food journal, a health care provider can estimate daily caloric intake and recommend a reduction of 300 to 500 calories per day, which would result in an approximate loss of one-half to one pound per week. Referral to a registered dietitian for individualized nutrition counseling may be helpful. Pharmacotherapy is likely a topic that the patient will have questions about. If pharmacotherapy is indicated and no contraindications exist, the patient should be presented with information regarding the options available, the risks and benefits of each and the proper use of the medications. Patients should be cautioned not to take any medication, prescription or over-the-counter, without first discussing it with the provider. Once a medication is selected, if the patient and the provider feel that pharmacotherapy is appropriate, regular follow-up should be done to monitor for effectiveness of therapy and any side effects. Get the Facts National Weight Control Registry NHLBI NIDDK Open discussions with patients about the health risks associated with excess weight are a necessary component of preventative care As mentioned previously, several factors have been identified as having an effect on long-term maintenance of weight loss, including maintenance support programs, physical activity, self-monitoring, increased protein intake and maintaining a consistent diet. It is necessary to work with patients to find an approach that will lead to sustainable weight loss so that future weight problems can be avoided. Conclusion Overweight and obesity are increasing in incidence in the United States and are important risk factors for morbidity and mortality. Weight loss is an effective measure to treat and prevent health problems associated with excess body weight. This can be accomplished through various means, the risks and benefits of which must be examined and discussed with patients so that the most appropriate treatment plan for each individual patient can be implemented and patients can achieve sustainable weight loss and avoid future weight problems. NWH References Befort, C. A., Stewart, E. E., Smith, B. K., Gibson, C. A., Sullivan, D. K., & Donnelly, J. E. (2007). Weight maintenance, behaviors and barriers among participants of a university-based weight control program. International Journal of Obesity, 32(12), Bigaard, J., Frederiksen, K., Tjonneland, A., Thomsen, B. L., Overvad, K., Heitmann, B.L., et al. (2005). Waist circumference and body composition in relation to all-cause mortality in middle-aged men and women. International Journal of Obesity, 29(7), Butryn, M. L., Phelan, S., Hill, J. O., & Wing, R. R. (2007). Consistent self-monitoring of weight: A key component of successful weight loss maintenance. Obesity, 15(12), Centers for Disease Control and Prevention. (2008). Data 2010: The Healthy People 2010 database. Retrieved September 14, 2008, from Faucher, M. (2007). How to lose weight and keep it off: What does the evidence show? Nursing for Women s Health, 11(2), Field, A. E., Byers, T., Hunter, D. J., Laird, N. M., Manson, J. E., Williamson, D. F., et al. (1999). Weight cycling, weight gain, and risk of hypertension in women. American Journal of Epidemiology, 150(6), Nursing for Women s Health Volume 13 Issue 5

8 Food and Drug Administration. (2006). Meridia (sibutramine hydrochloride monohydrate) capsules CS-IV. Retrieved March 22, 2009, from Food and Drug Administration. (2007). FDA approves orlistat for over-the-counter use. Retrieved March 22, 2009, from Goldberg, J. H. & King, A. C. (2007). Physical activity and weight management across the lifespan. Annual Review of Public Health, 28(1), Institute of Medicine. (1995). Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington DC: National Academies Press. Jakicic, J. M., Marcus, B. H., Lang, W., & Janney, C. (2008). Effect of exercise on 24-month weight loss maintenance in overweight women. Archives of Internal Medicine, 168(14), Klem, M. L., Wing, R. R., McGuire, M. T., Seagle, H. M., & Hill, J. O. (1997). A descriptive study of individuals successful at longterm maintenance of substantial weight loss. American Journal of Clinical Nutrition, 66(2), Kroke, A., Liese, A. D., Schulz, M., Bergmann, M. M., Klipstein- Grobusch, K., Hoffmann, K., et al. (2002). Recent weight changes and weight cycling as predictors of subsequent two year weight change in a middle-aged cohort. International Journal of Obesity, 26(3), Lejune, M. P. G., Kovacs, E. M. R., & Westerterp-Platenga, M. S. (2005). Additional protein intake limits weight regain after weight loss in humans. British Journal of Nutrition, 93(2), Maggard, M. A., Shugarman, L. R., Suttorp, M., Maglione, M., Sugerman, H. J., Livingston, E. H., et al. (2005). Meta-analysis: Surgical treatment of obesity. Annals of Internal Medicine, 143(6), McTigue, K. M., Harris, R., & Allan, J. D. (2004). Screening and interventions for obesity in adults. Annals of Internal Medicine, 141(3), 246. Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L. (2005). Correction: Actual causes of death in the United States, Journal of the American Medical Association, 293(3), National Center for Health Statistics (2007). New CDC study finds no increase in obesity among adults; but levels still high. Retrieved March 3, 2009, from pressroom/07newsreleases/obesity.htm National Heart, Lung and Blood Institute. (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Retrieved September 15, 2008, from National Institute of Diabetes and Digestive and Kidney Diseases. (2004). Weight and waist measurements: Tools for adults. Retrieved September 12, 2008, from publications/tools.htm National Institute of Diabetes and Digestive and Kidney Diseases. (2007). Statistics related to overweight and obesity. Retrieved September 16, 2008, from National Institutes of Health. (2008). Excess fat around the waist may increase death risk for women. Retrieved September 8, 2008, from National Weight Control Registry. (n.d.). The National Weight Control Registry. Retrieved July 23, 2009, from ws/ Svetkey, L. P., Stevens, V. J., Brantley, P. J., Appel, L. J., Hollis, J. F., Loria, C. M., et al. (2008). Comparison of strategies for sustaining weight loss: The weight loss maintenance randomized controlled trial. Journal of the American Medical Association, 299(10), U.S. Department of Health and Human Services. (2007). Healthy People 2010: Midcourse review. Retrieved September 11, 2008, from pdf Vogels, N., Diepvens, K., & Westerterp-Plantenga, M. S. (2005). Predictors of long-term weight maintenance. Obesity Research, 13(12), Wang, Y., Rimm, E. B., Stampfer, M. J., Willett, W. C., & Hu, F. B. (2005). Comparison of abdominal adiposity and overall obesity in predicting risk of type 2 diabetes among men. American Journal of Clinical Nutrition, 81(3), Whitmer, R. A., Gunderson, E. P., Barrett-Connor, E., Quesenberry, C. P., & Yaffe, K. (2005). Obesity in middle age and future risk of dementia: A 27 year longitudinal population based study. British Medical Journal, 330(7504), Williamson, D. F. (1993). Descriptive epidemiology of body weight and weight change in U.S. adults. Annals of Internal Medicine, 119(7), Wing, R. R., & Phelan, S. (2005). Long-term weight loss maintenance. American Journal of Clinical Nutrition, 82(1), 222S 225S. Wing, R. R., Tate, D. F., Gorin, A. A., Raynor, H. A., & Fava, J. L. (2006). A self-regulation program for maintenance of weight loss. New England Journal of Medicine, 355(15), Wing, R. R., Tate, D. F., Gorin, A. A., Raynor, H. A., Fava, J. L., & Machan, J. (2007). STOP regain : Are there negative effects of daily weighing? Journal of Consulting and Clinical Psychology, 75(4), World Health Organization. (2008). Obesity and overweight. Retrieved September 16, 2008, from CNE October November 2009 Nursing for Women s Health 417

9 CNE post-test Questions Instructions: To receive contact hours for this learning activity, please complete the online post-test and participant feedback form at CNE for this activity is available online only; written tests submitted to AWHONN will not be accepted. 1. During the past 20 years, the incidence of overweight and obesity in the United States has risen to what percentage of adults ages 20 years and older? a. 58 percent b. 68 percent c. 78 percent 2. Which of the following is not one of the top ten leading causes of U.S. deaths that excess body weight is associated with? a. stroke b. type 1 diabetes c. type 2 diabetes 3. What is a limitation of using body mass index (BMI) to assess for obesity? a. it confuses patients b. it doesn t account for body composition or weight distribution c. it must be measured in kilograms instead of pounds 4. Which type of body composition is a risk factor for cardiovascular disease? a. excess weight around the abdomen b. excess weight around the buttocks c. excess weight in the face 5. At what level is physical activity, combined with dietary changes, likely to affect weight loss? a. 90 to 120 minutes per week b. 120 to 200 minutes per week c. 200 to 300 minutes per week 6. What general calorie level does the NHLBI recommend for weight loss in women? a. 800 to 1,000 calories per day b. 1,000 to 1,200 calories per day c. 1,200 to 1,500 calories per day 7. In a study of weight loss maintenance, which dietary component was associated with lower levels of weight re-gain? a. complex carbohydrates b. monounsaturated fat c. protein 8. What percentage of individuals in the National Weight Control Registry weigh themselves at least once a week as a way to self-monitor their weight? a. 44 percent b. 75 percent c. 90 percent 9. Which treatment for obesity is considered a last resort? a. medically supervised liquid diet b. prescription medication c. surgery 10. What is the recommended BMI to indicate weight-loss surgery in healthy individuals? a. 30 b. 40 c What is the most common side effect of orlistat? a. constipation b. loose stools c. nausea 12. Estimates of successful long-term weight loss maintenance range from less than percent to percent: a. 5 to 20 b. 10 to 30 c. 20 to How much physical activity above baseline levels is associated with sustaining a weight loss of 10 percent or more? a. 150 minutes per week b. 200 minutes per week c. 275 minutes per week 14. Participants of a study who reported maintaining the same diet regimen across the week and year were times more likely to maintain their weight within 5 pounds over the next year than were participants who allowed more flexibility in their diets on weekends and/or holidays: a. 0.5 times b. 1.5 times c. 2.5 times 15. It is important for patients to understand that drastically reducing caloric intake can result in a. anabolic effects on muscle tissue. b. lower metabolic rate c. selective loss of abdominal fat 418 Nursing for Women s Health Volume 13 Issue 5