Weight Loss Therapies - an Evidence-Based Practice Approach - Essay Example

? Weight loss therapies: An Evidence-Based Practice (EBP) approach 22 March Table of contents Introduction 3 The Patient History3 Answerable Questions 4 Evidence Resources and Search Strategy 4 Examining the Evidence 4 Evidence Appraisal for Validity, Importance and Applicability 8 Analysis of EBP Usage and Its Limitations 9 References 11 Introduction The notion of evidence-based nursing is an outgrowth from the evidence-based medicine movement. Evidence-based practice (EBP) requires integrating the best available research with clinical expertise and the patient’s distinct values and conditions (Straus, et al., 2005). EBP is an approach that empowers clinicians to give the highest care possible that can meet the diverse needs of their patients and families (Melnyk & Fineout-Overholt, 2005). This paper will apply EBP on the case of Betty. The Patient History Betty is 74 years old with history of hypertension since age 40. She has struggled to lose weight all her life and has given up on her attempts. She has remained active and fairly fit until the past two years. The approach to her hypertension is pharmacological, with metoprolol 100 mg bd, though in the past two years, her blood pressure increased to more than 160/90 in several instances. For the precedent year, she experienced repetitive chest and left arm pain with no evidence of ischaemia. She has had normal ECGs and troponin levels. She complains of increased shortness of breath and wheezing. These symptoms partially improved with inhaled beclomethasone diproprionate. She also has atrial fibrillation. Recent blood tests illustrate that her cholesterol is normal, but her fasting blood sugar is 6.1. Her full blood picture, urea, and electrolytes and liver function tests are normal. Betty also has a history of pernicious anaemia and osteoarthritis. Betty is divorced and has a 51-year-old daughter who also has hypertension. Betty is independent and has lately felt somewhat depressed because of her inability to do everything she would like to do at home without feeling exhausted and short of breath. Answerable Questions The questions for this case are: What is the efficacy of various therapies in producing weight loss in a person who has failed previous attempts? What is the best therapy for the patient? These questions fall into the therapy category. The selected therapy approaches are: pharmacological approach, behavioural approach, complementary and alternative medicine (CAM) approach, and integrated approach. Surgical approaches are no longer included. Evidence Resources and Search Strategy The resources are academic medicine and nursing journals. EBSCO database is searched and related medicine/nursing journals are used. These keywords are used: “complementary and alternative medicine weight loss,” “behavioural therapy weight loss,” and “pharmacological weight loss.” The results are fewer than 50 and are no longer limited to research or interventions, although research, trials, and nursing interventions were selected. There were no restrictions placed on language and years of publication although articles from 2004 onwards were selected. Examining the Evidence Evidence is examined through evaluating the research design and findings, as well as conclusions. Evidence is also compared with other independent and original researches done by other scholars and in other journals. Pharmacological Treatment Pharmacological treatments have been shown to be effective in reducing body weight. Neovius and Narbro (2008) conducted a systematic review on the cost-effectiveness of pharmacological anti-obesity treatments, specifically sibutramine, orlistat and rimonabant. Fourteen unique articles were used with exercise and diet used as comparators. Manufacturing companies funded these studies, except three. Findings showed that sibutramine, orlistat and rimonabant were cost-effective pharmacological treatments. Another study indicates the role of psychology in the efficacy of drug treatments. Elfhag, Finer, and Rossner (2008) examined the psychological correlates for people who lose weight on sibutramine and orlistat. Findings showed that greater weight loss with sibutramine was connected with lower levels of restrained eating and elevated levels of ‘neuroticism’, specifically ‘anxiety’ and ‘depression’. Greater weight loss with orlistat was connected with the trait of ‘conscientiousness.’ One article argued that pharmacological treatment is the future of weight loss treatment. Mark (2006) stressed that behavioural treatments cannot effectively address the biological aspect of obesity. He focused on the genetic factors of obesity that have been proven by studies on adopted children and twins. He emphasized that hypertension, in particular, needs pharmacological treatment. He mentioned that studies prove that pathways regulating arterial pressure and cholesterol biosynthesis among the obese with hypertension need a pharmacological treatment in reducing weight. Behavioural Therapy Behavioural therapy has been proven to have significant success in reducing body weight and preventing weight regain, though certain factors must also be considered. Stahre et al. (2007) conducted a randomized controlled trial of two weight-reducing group treatment programs for obese participants that included a three-year follow up. The program used cognitive therapy and psycho-education. Findings showed that cognitive behavioural therapy was more effective in reducing weight and preventing weight regain than psycho-education alone. Teixeira et al. (2004) examined baseline behavioural and psychosocial differences between successful and unsuccessful participants in a behavioural weight management program. Success was defined by generally used health-related criteria (5%weight loss). Non-completion was also used as an indicator of a failed effort at weight control. The therapy included a 16-week lifestyle weight loss program that was composed of behaviour therapy, diet changes, and increased physical activity, with follow up after a year. Findings showed that 30% of the sampling did not complete initial treatment and/or neglected follow-up assessments. Non-completion was related with past failed weight loss attempts, poorer quality of life, strict weight outcome evaluations, and lesser reported carbohydrate intake at baseline. Other factors that affected non-completion are initial weight, time devoted to exercise, fibre intake, binge eating, psychological health, and body image. Independent baseline predictors of success were “more moderate weight outcome evaluations, lower level of previous dieting, higher exercise self-efficacy and smaller waist-to-hip ratio” (p.1124). Psychosocial and behavioural factors should be considered in designing weight loss programs. Complementary and Alternative Medicine (CAM) Approach Complementary and alternative medicine (CAM) approaches for obesity and weight control are well-accepted and appealing (Pittler & Ernst, 2005, p.1030), although their effectiveness in reducing weight in concurrent and post-test has yet to be proven. Pittler and Ernst (2005) conducted a systematic review of studies on complementary therapies that promise weight loss. They assessed evidence from randomised controlled trials (RCTs) and systematic reviews of complementary therapies for decreasing body weight. Six systematic reviews and 25 RCTs met their inclusion criteria. The evidence focused on acupuncture, acupressure, dietary supplements, homeopathy and hypnotherapy. Authors concluded that aside from hypnotherapy, Ephedra sinica and other ephedrine-containing dietary supplements, CAM lacked effectiveness in reducing body weight. These interventions had small effects compared to placebo. They concluded that for many CAM approaches, there was weak evidence that they can lessen body weight, although hypnotherapy, E. sinica and other ephedrine-containing dietary supplements may contribute to small weight reductions. They warned, however, that E. sinica and ephedrine were linked with an enlarged risk of adverse events. Birch et al. (2004) evaluated systematic reviews on acupuncture as a weight loss therapy. Findings showed that there was not enough evidence that acupuncture prevents weight regain, or is effective in helping people lose weight. Nevertheless, they conceded that acupuncture is a safe therapy for different illnesses and health concerns. Another study focused on acupressure only with more positive results. Elder et al. (2010) conducted a randomised controlled trial to examine the efficacy of an energy psychology intervention, called Tapas Acupressure Technique (TAT), to put off weight regain following effective weight loss. Participants were obese adult members of an HMO who took part in a preliminary weight-loss phase. A training protocol was made to standardise the intervention delivery by TAT facilitators. The study has executed a number of quality-control processes to guarantee correct and consistent observance of the TAT curriculum and protocols. Findings showed successful weight-loss maintenance at 6 and 12 months postrandomisation. Authors concluded that TAT is effective in maintaining weight loss. Integrated Approach Some studies noted the importance of integrating different approaches to improve the efficacy of weight loss programs. Effective weight loss programs mean that participants can maintain weight loss, or continue losing weight on their own after treatment. Fabricatore et al. (2007) studied the effect of the role of patients' expectations and goals in the behavioural and pharmacological treatment of obesity to their actual body weight loss. Participants in all treatment groups anticipated weight loss at week 52 that were considerably greater than the 5–15% of initial weight they were told was reasonable and considerably more than they had ever lost before. Findings showed that failure to meet weight loss goals for the first 26 weeks of treatment resulted to lower satisfaction ratings, but did not have a large role in weight regain or attrition for the succeeding 26 weeks. Depression was lessened, whether participants achieved or did not attain their expected weight losses. CAM can also be combined to behavioural therapy to avoid weight regain after successful weight loss. Elder et al. (2007) studied the feasibility and clinical impact of two mind-body interventions for weight-loss maintenance. Their research design was a randomised, balanced, and controlled trial. The three weight-loss maintenance interventions were qigong (QI), Tapas Acupressure Technique® (TAT®), and a self-directed support (SDS) group as a control group. Findings showed that these mind-body interventions improved weight loss maintenance at 24 weeks after the postrandomisation tests. Evidence Appraisal for Validity, Importance and Applicability The evidence for behavioural treatment is valid, because it consisted of randomized controlled trials. Actual therapies were designed and their results were tested for efficacy. These studies are important, because they already provide exact behavioural designs that includes education component. They are applicable to health teams that want an interdisciplinary approach to help Betty lose weight and maintain weight loss. These articles can be valid for people with hypertension, although these therapies should consider the specific psychological and physical conditions of the patient, such as depression and hypertension. Evidence that support pharmacological treatments are also valid, as it involves systematic reviews. These studies are also important because they underlie the role of genetics in weight loss struggle. It is possible that genetics can also impact weight loss success. Betty has a daughter who also has hypertension and this can indicate possible genetic tendency for weight gain, which is why pharmacological treatment may be important. Two studies are applicable to people with hypertension. This means that sibutramine, orlistat and rimonabant may be effective weight loss drugs for Betty. Evidence for CAM is valid with the use of systematic reviews and randomised controlled trial. The RCT provided evidence that TAT can help maintain weight loss. These studies are important because they point out gaps in evaluating CAM’s role in reducing weight and maintaining weight loss. They are applicable to Betty, if she is open to using CAM as part of her therapy. For integrated approaches, findings are valid, because of the use of randomised controlled trials. They signify the importance of considering integrated approaches to weight loss. They are relevant to Betty who, after failed weight loss attempts, needs a new perspective in losing weight. Analysis of EBP Usage and Its Limitations EBP is best for health illnesses and conditions that have received empirical attention. It is limited when there are not enough studies on the particular conditions and illness of the patient. O'Donohue and Ferguson (2006) also noted the weakened empirical foundation of EBP. It is crucial for health care personnel to be experts in searching and evaluating the validity and usefulness of their collected evidence. In addition, EBP is limited in understanding the interplay of various factors in weight loss. Individual, physical, and social factors should be considered as part of the overall context of the patient. Evidence shows that the patient’s psychology, for instance, can affect weight loss success, but it does not say anything about genetics and social support. Health care professionals still need to consider other factors that the evidence have not included, in order to provide an intensive analysis of the patient’s conditions and make recommendations that will truly help the patient achieve successful weight loss in the long run, while also possibly addressing other health concerns, such as anaemia and osteoarthritis. References Birch, S., Hesselink, J.k., Jonkman, FA.M., & Hekker, T.A.M. (2004). Clinical research on acupuncture: Part 1.What have reviews of the efficacy and safety of acupuncture told us so far? Journal of Alternative & Complementary Medicine, 10 (3), 468-480. Elder, C., Ritenbaugh, C., Mist, S., Aickin, M., Schneider, J., Zwickey, H., & Elmer, P. (2007). Randomized trial of two mind–body interventions for weight-loss maintenance. Journal of Alternative & Complementary Medicine, 13 (1), 67-78. Elder, C., Gallison, C., Lindberg, N.M., DeBar, L., Funk, K., Ritenbaugh, C., & Stevens, V.J. (2010). Randomized trial of Tapas Acupressure Technique® for weight loss maintenance: Rationale and study design. Journal of Alternative & Complementary Medicine, 16 (6), 683-690. Elfhag, K., Finer, N., & Rossner, S. (2008). Who will lose weight on sibutramine and orlistat? Psychological correlates for treatment success. Diabetes, Obesity & Metabolism, 10 (6), 498-505. Fabricatore, A.N., Wadden, T. A., Womble, L. G., Sarwer, D. B., Berkowitz, R. I., Foster, G. D., & Brock, J. R. (2007). The role of patients' expectations and goals in the behavioral and pharmacological treatment of obesity. International Journal of Obesity, 31 (11), 1739-1745. Mark, A.L. (2006). Dietary therapy for obesity is a failure and pharmacotherapy is the future: A point of view. Clinical & Experimental Pharmacology & Physiology, 33 (9), 857-862. Melnyk, B.M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins. Neovius, M. & Narbro, K. (2008). Cost-effectiveness of pharmacological anti-obesity treatments: a systematic review. International Journal of Obesity, 32 (12), 2008, 1752-1763. O'Donohue, W. & Ferguson, K.E. (2006). Evidence-based practice in psychology and behavior analysis. Behavior Analyst Today, 7 (3), 335-350. Pittler, M. H. & Ernst, E. (2005). Complementary therapies for reducing body weight: a systematic review. International Journal of Obesity, 29 (9), 1030-1038. Stahre, L., Tarnell, B., Hakanson, C., & Hallstrom, T. (2007). A randomized controlled trial of two weight-reducing short-term group treatment programs for obesity with an 18-month follow-up. International Journal of Behavioral Medicine, 14 (1), 48-55. Strauss, S. E., Richardson, W. S., Glasziou, P., & Haynes, R. B. (2005). Evidence-based medicine: How to practice and teach EBM (3rd ed.). Edinburgh; New York: Elsevier/Churchill Livingstone. Teixeira, P.J., Going, S.B., Houtkooper, L.B., Cussler, E.C., Metcalfe, L.L., Blew, R.M,, Sardinha, L.B., & Lohman, T.G. (2004). Pretreatment predictors of attrition and successful weight management in women. International Journal of Obesity & Related Metabolic Disorders, 28 (9), 1124-1133. Read More