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2: PUBLIC HEALTH GUIDELINES
beyond the control of any one client or provider. For example,
cities with an inadequate supply of Section 8 housing will not
be able to provide people experiencing homelessness with a
place to live. Furthermore, the disparity between federal and
state minimum wages and the living wage translates to people who work 40 hours or more per week not being able to
secure housing due to the number of hours working.
PREDISPOSING FACTORS
A. Chronic illnesses: People who experience homelessness suf-
fer from chronic illnesses at rates that exceed those in the general
population. In many cases, overlapping and negatively interacting manifestations of illness exacerbate each other, leading to
several complicated comorbidities whose management may tax
the resources available to both the client and the provider.
COMMON COMPLAINTS
A. Refer to chapter-specic conditions, complaints, and
treatments.
B. Chronic illnesses:
1. Hypertension.
2. Diabetes.
3. Coronary artery disease.
4. Congestive heart failure.
5. Peripheral vascular disease.
6. Hypercholesterolemia.
C. Respiratory:
1. Bronchitis.
2. Pneumonia.
3. Tuberculosis.
4. Inuenza.
5. Asthma.
6. Chronic obstructive pulmonary disease (COPD).
7. Cough.
D. Infections:
1. COVID-19: Infections with severe acute respiratory
syndrome coronavirus may spread easily during the
global pandemic.
2. HIV/AIDS.
3. Sexually transmitted infections.
4. Hepatitis A, B, and C.
5. Wound and skin infections.
6. Tetanus.
E. Dental abscesses, gingivitis, and tooth loss.
F. Problems being outdoors:
1. Sleep deprivation.
2. Animal bites.
3. Food insecurity/poor nutrition.
4. Dehydration.
G. Weather-related illnesses:
1. Heat-related illnesses:
a. Cramps.
b. Heat exhaustion.
c. Heat stroke.
2. Cold-related illnesses:
a. Frostbite.
b. Hypothermia.
H. Skin and foot problems:
1. Lice.
2. Scabies.
3. Abrasions, abscesses, corn calluses, onycho mycosis,
and tinea pedis.
4. Ulcerations and cellulitis from edema and venous stasis.
5. Immersion foot.
I. Mental health-related complaints:
1. Physical violence/sexual abuse.
2. Anger.
3. Major depression.
4. Schizophrenia.
5. Bipolar disorders.
6. Posttraumatic stress.
7. Suicide.
8. Substance abuse problems:
a. Opioid-related overdose and death.
b. Alcoholism.
J. Cognitive and functional impairment.
K. Traumatic brain injury.
L. Unintended pregnancies.
M. Children-related issues:
1. Lead poisoning.
2. Behavioral problems (e.g., anxiety, depression, with-
drawal, aggression, and hostility).
3. Delayed development.
4. Growth delays.
5. Learning disabilities.
6. Separation from family.
OTHER SIGNS AND SYMPTOMS
A. Does the client smell of smoke, as if they have been sleep-
ing outdoors by a re? If so, this would trigger a chest x-ray
and detailed pulmonary examination.
B. Does the client smell of urine, suggesting a possible uri-
nary tract infection? If so, this would trigger a genitourinary
skin examination, urinalysis, and social work consult regarding access to clean clothing.
C. Unilateral lower extremity pitting edema, pain, and ten-
derness suggest the presence of a deep vein thrombosis (DVT),
which is considered a medical emergency.
D. Bilateral lower extremity pitting edema may be a sign of
heart failure. This nding would trigger a thorough clinical
examination for the following: S3 and S4 heart sounds, jugular
venous pulse, and jugular venous distension.
E. Brawny edema and venous stasis ulcerations would trig-
ger a thorough peripheral vascular examination and a sensory
examination of the plantar surfaces of both feet.
F. Itchiness suggests pest infestation, and needs treatment,
shower, washcloth, and new clothes. Contact the shelter to
treat the environment.
G. Unusual behavior, for example, hallucination, visible
depression, intoxication, and so on, needs referral to mental
health.
SUBJECTIVE DATA
A. Factors to consider when evaluating people experiencing
homelessness:
1. Where did the client sleep last? Does the client have a
safe place to sleep tonight?
2. When was the last time the client had a place that they
considered their own home?
3. When was the last time the client was able to bathe?
4. When was the last time the client ate?
5. Is the client able to nd bathrooms when needed?
6. Are symptoms of depression and anxiety interfering
with survival?
7. Is the client being physically, sexually, or emotionally
abused?
8. Is the client being forced to engage in behaviors against
their will in exchange for food and shelter?
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9. Does the client have a safe way to manage medications
on the street, such as insulin or inhalers?
10. Assess/discuss current substance abuse.
a. Refer to “Substance Use Disorders” section in this
chapter.
B. See Client Teaching Guide for Chapter 22, “Psychiatric
Guidelines.”
PHYSICAL EXAMINATION
A. Providers should be aware that, due to past trauma, many
people experiencing homelessness are reluctant to touch. Take
your time with the physical examination, ask permission for
each step of the physical examination, and explain what you
are doing and why.
1. Check temperature (as indicated), pulse, respirations,
blood pressure, and height and weight to calculate body
mass index.
2. Inspect:
a. Inspect the scalp: Assess for nits.
b. Inspect the oral cavity: Assess for caries or active
oral abscesses.
c. Assess the skin for burns, abrasions, trauma, and
evidence of accidental or intentional injury. Visualize
both feet for infection and trauma.
3. Palpate:
a. Palpate the abdomen for tenderness or masses.
b. Perform pelvic examination as appropriate. This
may not be possible on the rst examination. For some
females, intentionally poor hygiene is viewed as protection against male assault.
4. Auscultate:
a. Heart.
b. Lungs.
c. Abdomen.
5. Perform neurologic examination:
a. Assess for neuropathy in the feet.
b. Assess hearing and vision as these faculties are cen-
tral to survival when living on the street.
6. Perform mental health examination:
a. Perform depression/anxiety screening. See depres-
sion/anxiety in Chapter 22, “Psychiatric Guidelines,
for screening.”
b. Evaluate suicidal ideation. See Chapter 22,
“Psychiatric Guidelines, for assessment/screening.”
c. Assess for active audio/visual hallucinations.
d. Assess for paranoia.
DIAGNOSTIC TESTS
A. Complete blood count (CBC).
B. Comprehensive metabolic panel (CMP).
C. B
/folate.
12
D. Urine: urinalysis for protein/glucose and Neisseria
gonorrhoeae/chlamydia.
E. Rapid plasma reagin (RPR).
F. HIV.
G. Hepatitis A virus (HAV)/Hepatitis B virus (HBV) prole
and hepatitis C virus antibody.
H. Glycosylated hemoglobin A1c.
I. Puried protein derivative (PPD)/T-SPOT.
DIFFERENTIAL DIAGNOSES
A. Substance use/abuse.
B. Depression.
C. Malnutrition.
D. Schizophrenia.
PLAN
A. General interventions:
1. There are no disease-based standards of care that spe-
cically address people who are experiencing homelessness. Rather, providers must be creative and resourceful,
working with clients toward higher levels of self-efcacy
within the resource bounds imposed on the situation by
society at large.
2. Community-based care: No single provider or ancil-
lary service organization (ASO) can provide all of the care
needed by people experiencing homelessness. In order to
maximize care, providers should make an effort to identify
and be in communication with their local ASOs before a
crisis so that resources can be coordinated and maximized
when acute issues arise.
3. Identifying and assisting the client with current health
needs is imperative. In addition to homelessness, the client
may have other acute and chronic health conditions that
should be addressed and treated as appropriate.
4. Immunize according to standard guidelines for u,
pneumonia, hepatitis A and B, tetanus, and so forth.
5. Safety plan: For suspected violence or abuse, man-
datory reporting and referral to social services are
recommended.
6. Housing: Refer to social services for shelter placement,
medical respite care, or permanent housing.
B. Client teaching:
1. Lifestyle modications, focusing on diet, exercise, and
smoking cessation, form the cornerstone of APRN client
teaching for chronic disease management. The following
principles should be used to guide the teaching of these
principles in the homeless population:
a. People experiencing homelessness rarely have
access to exercise facilities. In addition, they often
lack a safe place to store their belongings while they
exercise.
b. People experiencing homelessness have little to
no control over their food selection. Dependence on
volunteer-driven, charity-led food banks and meal
programs is a signicant impediment to healthy
eating as many of these programs assume that a
high-carbohydrate, calorie-dense meal, such as spaghetti and bread, is what people experiencing homelessness like and want to eat.
c. The prevalence of poor dentition among the
homeless greatly exceeds that of the stably housed,
employed population. Accordingly, people experiencing homelessness may not be able to eat fresh fruits
and vegetables.
d. The rates of substance abuse among the chroni-
cally homeless exceed those in the general population.
Some people may be successfully clean and sober from
alcohol yet continue to smoke tobacco. Although this
situation is not ideal, focus on client strengths, praise
sobriety, and acknowledge that smoking cessation is
perceived as being more difcult than sobriety from
alcohol and may need to have a lower priority in a client’s overall plan of care.
e. Blanket dietary and exercise recommendations
developed around stably housed, fully employed
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2: PUBLIC HEALTH GUIDELINES
people will likely not translate well to people experiencing homelessness. Failure to account for the unique
challenges of people experiencing homelessness will
exacerbate feelings of depression, low self-worth, and
decreased self-efcacy.
f. Caring for individuals experiencing homelessness
requires a team approach. Successful teams include
clinicians, social workers, behavioral health providers, psychiatric providers, and nursing staff. No one
provider or discipline can address all of the needs of
people experiencing homelessness. It is critical that the
care team work well together and prioritize the work
of building rapport with the client, whose life experiences have likely reinforced their distrust of the systems that we all depend on to deliver care.
FOLLOW-UP
A. One of the primary challenges facing providers of those
experiencing homelessness is the deep-seated lack of trust that
homeless people have in the healthcare system within which
most providers operate. In order to encourage people to return
to the clinic for appropriate follow-up care, every effort must be
made during the rst visit to establish a true therapeutic relationship with the client. Providers should attempt to work with
clients to identify and address concerns that are important to the
client. Providers should remember that topics such as smoking
cessation and sobriety from alcohol may best be deferred during
an initial visit. All clinic staff should be trained to treat all clients
with a professional, welcoming, and empathetic manner.
likely to become homeless. Many homeless youth and
young adults have experienced signicant trauma before
and after becoming homeless and are particularly vulnerable to sexual trafcking and exploitation. Youth who identify as LGBTQ, pregnant and parenting youth, youth with
special needs or disabilities, and youth of color, particularly African American and Native American youth, are
also more likely to become homeless.
3. Homeless children and youth report that school is a
home to them—a place they see the same faces, sit in the
same seat, and receive meals.
4. A lot of young people do not seek out services because
of fear that they will be turned into the child welfare or
juvenile justice system or refused services. The more information they have about what they can directly access,
the more likely they are going to seek the services again.
Providers should make contact with their community
YMCA/YWCA resources to develop a referral plan should
a homeless minor present for care.
B. Pregnancy:
1. All pregnant individuals who are experiencing home-
lessness and present for care should be seen by a social
worker before leaving the site. In cases where abuse is suspected, law enforcement must be notied.
C. Older adults:
1. All people older than 60 years of age who are experi-
encing homelessness and present for care should be seen
by a social worker before leaving the site. In cases where
abuse is suspected, law enforcement must be notied.
CONSULTATION/REFERRAL
A. Referring clients to specialists is an everyday part of pri-
mary care, and advanced practice nurses serve important
screening and gatekeeper functions in this role. However, the
insurance-based system that we rely on for care is not available to most people experiencing homelessness as they lack
health insurance. Should insurance be available, then providers must still identify specialists willing to take specic
insurances and work with people experiencing homelessness. Effective providers will identify specialists in their local
communities and seek to build relationships that will facilitate referrals. Given the lack of access to transportation in this
population, it is important to set an expectation that a missed
appointment does not mean that the client does not want or
need care and that specialists may need to be exible regarding missed appointments with people in this population.
INDIVIDUAL CONSIDERATIONS
A. Pediatrics/Minors:
1. The National Runaway Safeline estimates that on any
given night there are approximately 1.3 million homeless
youth living unsupervised on the streets, in abandoned
buildings, with friends (couch surng), or with strangers. Homeless youth are at a higher risk of physical abuse,
sexual exploitation, mental health disabilities, substance
abuse, and death. It is estimated that 5,000 unaccompanied
youth die each year as a result of assault, illness, or suicide.
2. The National Alliance to End Homelessness (2019)
notes youth homelessness is often rooted in family conict. Other contributing factors include economic circumstances such as poverty and housing insecurity, racial
disparities, and mental health and substance use disorders
(SUDs). Young people who have had involvement with
child welfare and juvenile justice systems are also more
RESOURCES
A. Federal.
HUD Exchange: Homelessness Assistance: www.hudex-
change.info
National Coalition for the Homeless: www.national-
homeless.org
National Health Care for the Homeless Council: www.
nhchc.org
National Conference of State Legislatures: www.ncsl.org
U.S. Interagency Council on Homelessness: www.usich.
gov/
B. State.
1. Providers should use the internet search engine of
choice to locate emergency shelters and care for people
experiencing homelessness in their locale. There is no centralized database of state/local shelters. Many larger shelters will have a list of local places for people to nd food
and community assistance, and this information can be
invaluable for providers to keep on hand.
Homeless Shelter Directory: www.homelessshelterdire
ctory.org/
BIBLIOGRAPHY
Baggett, T. P. (2021, January 13). Healthcare of people experiencing home-
lessness in the United States. https://www.uptodate.com/contents/
health-care-of-people-experiencing-homelessness-in-the-unitedstates#H12138154
FYSB Family & Youth Services Bureau. (n.d). About runaway and homeless
youth. RHYi National clearinghouse on homeless youth & families. https:/
/rhyclearinghouse.acf.hhs.gov/about-runaway-and-homeless-youth
National Alliance to End Homelessness. (2019). Youth and young adults.
https://endhomelessness.org/homelessness-in-america/whoexperiences-homelessness/youth/
National Conference of State Legislatures. (2016, April 14). Homeless and
runaway youth. http://www.ncsl.org/research/human-services/
homeless-and-runaway-youth.aspx
OBESITY
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21
Singer, M. (2009). Introduction to Syndemics: A critical systems approach to
public and community health. Jossey-Bass Publishers.
The U.S.Department of Housing and Urband Development Ofce of
Community Planning and Development. (2021, January). The 2020
Annual Homeless Assessment Report (AHAR) to Congress. Part 1: Point-intime estimates of homelessness https://www.huduser.gov/portal/sites/
default/les/pdf/2020-AHAR-Part-1.pdf
United States Interagency Council on Homelessness. (2018, August).
HOMELESSNESS IN AMERICA: Focus on chronic homelessness among
people with disabilities. https://www.usich.gov/resources/uploads/as
set_library/Homelessness-in-America-Focus-on-chronic.pdf
OBESITY
DEFINITION
A. Obesity is a multifactorial disease with physical, psycho-
logical, and social consequences. The body mass index (BMI)
is a standard measuring tool. BMI is the most commonly used
approach to determine if adults are overweight or obese and
is also the recommended measure to determine if children are
overweight. BMI is calculated by using the formula weight in
kilograms divided by height in meters squared (weight [kg]/
height [m]2). In adults, obesity is dened as a BMI >30 kg/m2.
B. BMI for children is calculated the same way as for adults,
but is interpreted using age- and gender-specic percentages
(BMI-for-age) clinical charts (Tables 2.1 and 2.2). The Centers
for Disease Control and Prevention (CDC) denes childhood
obesity by percentiles. The CDC recommends that healthcare
providers use the World Health Organization (WHO) growth
charts to monitor growth of infants and children ages 0 to 2
years in the United States and recommends the use of the CDC
growth charts to monitor growth of children 2 years and older
TABLE 2.1 CHILDHOOD OBESITY BY PERCENTILES
Childhood Obesity
Category
Underweight <5th percentile
Healthy weight 5th to <85th percentile
Overweight 85th to <95th percentile
Obese ≥95th percentile
BMI, body mass index.
TABLE 2.2 ADULT OBESITY BY BMI FOR ADULTS
20 YEARS OLD AND OLDER
Classification of Adult Obesity by BMI BMI (kg/m2)
Underweight <18.5
Normal 18.5–24.9
Overweight (preobese) 25.0–29.9
Obesity Level I: 30.0–34.9
Super morbidly obese >50.0
Super-super morbidly obese ≥60.0
BMI, body mass index.
BMI Definitions by
Percentiles
Level II: 35–39.9
Level III: 40.0–49.9
in the United States. The CDC charts for children are available on the CDC website at www.cdc.gov/growthcharts/
clinical_charts.htm. The BMI percentile calculator for children and teens is available at www.cdc.gov/healthyweig
ht/bmi/calculator.htmlgov/growthcharts/who_charts.ht
m. The adult BMI calculator is available at www.cdc.gov/
healthyweight/assessing/bmi/adult_bmi/english_bmi_calc
ulator/bmi_calculator.html.
INCIDENCE
A. Obesity now affects one in ve children and adolescents in
the United States. Data from the 2015 to 2016 National Health
and Nutrition Examination Survey note the prevalence of obesity is 42.4% in adults and 19% in youth. The prevalence of
obesity was higher among middle-aged adults (44.8%) than
among younger adults (40.0%). The prevalence of obesity
was higher among youth aged 6 to 11 years (20.7%) and adolescents aged 12 to 19 years (22.2%) compared with children
aged 2 to 5 years (12.7%). Obesity rates cross all groups in the
society, regardless of age, sex, race, ethnicity, socioeconomic
status, educational level, or geographic group. Hispanics and
non-Hispanic blacks have the highest age-adjusted prevalence
of obesity, followed by non-Hispanic whites and non-Hispanic
Asians.
PATHOGENESIS
A. Numerous factors contribute to the development of obe-
sity, including biological, genetic, behavioral, social, cultural,
and environmental inuences.
1. Imbalance between energy intake and energy output.
2. Genetics (e.g., Prader–Willi syndrome).
3. Medical conditions (e.g., Cushing syndrome and poly-
cystic ovary syndrome [PCOS]).
4. Age.
5. Pregnancy.
6. Environmental factors.
7. Drug-induced obesity:
a. Antidepressants (amitriptyline, doxepin, imip-
ramine, mirtazapine, nortriptyline, paroxetine,
phenelzine).
b. Antihistamines (cyproheptadine).
c. Antipsychotics (clozapine, haloperidol, olanzapine,
quetiapine, risperidone, thioridazine).
d. Antidiabetics (insulin, sulfonylureas,
thiazolidinediones).
e. Anticonvulsants (sodium valproate, carbamaze-
pine, gabapentin).
f. Steroids (contraceptives, glucocorticoids, progesta-
tional steroids).
g. Beta- or alpha-adrenergic blockers (propranolol,
doxazosin).
h. Glucocorticoid steroids.
8. Sleep disturbance-induced obesity.
9. Quitting smoking.
PREDISPOSING FACTORS
A. Consuming too many calories/high-fat diet.
B. Poor dietary choices.
C. Readily available food sources, especially fast foods.
D. Lack of exercise/sedentary lifestyle.
E. Decreased/eliminated physical education requirements in
public schools.
F. Television, computer, handheld electronic devices, and
video game use more than a total of 3 hours a day.
G. Increased leisure time.
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2: PUBLIC HEALTH GUIDELINES
H. Lack of funding and planning for community parks and
recreation areas.
I. Ethnic background: African American and Hispanic.
J. Family history of obesity.
K. Poverty.
L. Insomnia, difculty staying asleep, and frequent
wakefulness.
COMMON COMPLAINTS
A. Difculties with activities of daily living (ADLs) or func-
tional impairment.
B. Lack of interest/inability to tolerate exercise.
C. Shortness of breath and/or asthma exacerbations.
D. Difculty with personal hygiene.
E. Urinary incontinence.
F. Lack of desire to lose weight.
G. Decreased quality of life (e.g., depression, disability, shame
and guilt, and social isolation).
OTHER SIGNS AND SYMPTOMS
A. Obstructive sleep apnea (OSA).
B. Increased asthma symptoms.
C. Infertility/PCOS.
D. Symptoms associated with cholelithiasis.
E. Hypertension.
F. Gynecologic problems (e.g., irregular periods and early
sexual maturity in females).
G. Joint pain (osteoarthritis): cartilage and joint breakdown of
the lower extremities.
H. Other complications: type 2 diabetes, gallbladder disease,
depression/anxiety, dyslipidemia, stroke, coronary artery disease, metabolic syndrome, cancer (colon, endometrial, lung
cancer), erectile dysfunction, and nonalcoholic steatohepatitis
(NASH).
change in occupation or marital status, recent illness, pregnancy, menopause, stressful events, or smoking cessation.
PHYSICAL EXAMINATION
A. Check pulse, respirations, and blood pressure while
supine, sitting, and standing.
B. Measurements:
1. Determine height and weight to calculate BMI.
2. Measure waist and hip circumferences to calculate the
waist-to-hip circumference ratio. The waist-to-hip ratio is
the strongest anthropometric measure that is associated
with myocardial infarction risk and is a better predictor than BMI. A waist-to-hip ratio that is >0.8% usually
has some form of premetabolic syndrome or insulin
resistance.
3. Measure neck circumference to evaluate risk factor
for OSA.
C. Inspect:
1. Observe overall appearance and note body fat
distribution.
2. Examine the skin.
3. Examine the mouth and teeth: Assess dental enamel
for signs of purging.
D. Auscultate:
1. Heart.
2. Lungs.
3. Carotid arteries.
4. Abdomen.
E. Palpate:
1. Neck and thyroid.
2. Extremities, noting edema.
3. Abdomen for masses, tenderness, and rebound
tenderness.
SUBJECTIVE DATA
A. Review the onset of weight gain and duration of obesity.
Identify when the client rst noticed the weight gain.
B. Ask the client about other symptoms secondary to obesity.
C. Review full medical history.
D. Review medications, including over-the-counter (OTC)
herbals and diet products.
E. Review the client’s history of weight-loss attempts.
F. Assess ADLs and functional limitations and the presence
of exercise intolerance.
G. Elicit history of sleep disorders (e.g., snoring and obstruc-
tion, sleep apnea).
H. Review 24-hour dietary recall. Review the client’s normal
average meals per day, including snacks and portion sizes.
I. Review consumption of high-calorie drinks and alcohol
intake.
J. Review frequency of fast food consumption.
K. Assess for history of binge eating, purging, night eating
syndrome, lack of satiety, food-seeking behaviors, and other
abnormal feeding habits.
L. Assess for depression.
M. Assess for readiness and commitment for weight loss.
People who voluntarily enroll in a weight-loss program generally lose weight.
N. Ask the client to describe their activity level, exercise rou-
tine, and daily activity (work activity).
O. Ask about screen time.
P. Ask about family history of obesity.
Q. Ask about possible biopsychosocial and behavioral risk
factors for weight gain, such as starting a new medication,
DIAGNOSTIC TESTS
A. Thyroid function.
B. Lipid panel.
C. Liver enzymes.
D. Complete blood count.
E. 25-hydroxy vitamin D test.
F. Pregnancy test.
G. Fasting blood sugar/3-hour glucose tolerance test.
H. Consider fasting insulin level.
I. Sleep study (if indicated).
J. Consider genetic testing.
K. Nocturnal hypoxemia study.
DIFFERENTIAL DIAGNOSES
A. Pseudotumor cerebri.
B. Binge eating.
C. Genetic syndrome (e.g., Prader–Willi syndrome).
D. Cushing syndrome.
E. Diabetes.
F. Insulin resistance syndrome.
G. Primary pulmonary hypertension.
PLAN
A. Manage obesity as a chronic relapsing disease, includ-
ing the comanagement of other diseases secondary to obesity
(e.g., diabetes and hypertension).
1. General interventions:
a. Treat any underlying cause of obesity.
b. Reinforce the positive impact that weight-loss mea-
sures (diet, exercise) can have and the overall health
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benets of weight loss. Weight loss of even 5% to 15%
can provide a signicant reduction in obesity-related
complications.
c. Identify and monitor any cardiovascular
complications.
d. Implement behavior modications. Intensive behav-
ior therapy has been shown to lead to better success
with weight loss and sustainable weight loss for longer periods of time. Behavior therapy includes weekly
meetings with healthcare professionals for at least 6 to
8 weeks.
i. Dietary plan:
1) Consume 500 to 1,000 fewer calories per
day for 1- to 2-lb-per-week weight loss.
2) Most diets have good short-term efcacy
but limited sustainability.
3) Diets shown to be effective include
portion control, low-fat, Mediterranean,
low-carbohydrate, low glycemic index, and
commercial weight-loss diets.
4) Reduce the amount of processed foods in
diet.
5) Increase water intake, particularly drinking
500 mL of water before meals approximately
64 oz/d.
6) Protein-dense and high-ber foods increase
satiety with fewer calories.
ii. Exercise for children:
1) Sixty minutes or more of moderate-to-vig-
orous physical activity daily is recommended
for children and adolescents of age 6 to 17.
a) Within the 60 minutes of daily physical
activity, children and adolescents should
engage in muscle strengthening, bone
strengthening, and vigorous-intensity physical activities at least 3 days per week.
iii. Exercise for adults:
1) Single episodes of physical activity promote
acute improvements in executive function for a
period of time. Physical activity also improves
other components of cognition, including memory, processing speed, attention, and academic
performance.
2) Approximately 150 minutes (2½ hours) of
moderate-intensity aerobic physical activity is
recommended per week for adults; 155 to 180
minutes per week for children.
3) Multiple short sessions (four 10-minute
sessions per day, 5 days per week) may have
the same benet as fewer longer sessions (one
40-minute session, 5 days per week). At least two
times a week of strength exercises (push-ups,
sit-ups, lifting weights) are also recommended.
4) Walking 30 minutes per day has been shown
to prevent weight gain; higher amounts of exercise promote weight loss.
5) The combination of exercise and diet is
more effective than either alone.
iv. Wide range of benets of exercise and weight
loss:
1) Helps lower blood pressure.
2) Improves cholesterol count.
3) Helps lower hemoglobin A1c in diabetes.
4) Helps strengthen bones.
5) Promotes weight loss.
6) Improves depression (reduces depressive
symptoms among people both with and without clinical depression).
7) Boosts immune system.
8) Reduces stress.
9) Reduces symptoms of anxiety, both chronic
levels of anxiety and acute feelings.
10) Improves sense of well-being.
11) Believed to be a major driving force in life-
style change.
12) Improves joint pain.
13) Improves the quality of sleep.
14) Improves the ability to more easily accom-
plish tasks of daily living, such as climbing
stairs or carrying groceries.
15) Reduces risk of falls and fall-related injuries.
16) Single episodes of physical activity promote
acute improvements in executive function for a
period of time. Physical activity also improves
other components of cognition, including memory, processing speed, attention, and academic
performance.
17) For children ages 5 through 13, evidence
indicates that both acute bouts and regular
moderate-to-vigorous physical activity improve
cognition, including memory, processing speed,
attention, and academic performance.
18) Among older children and youth through
high school age, evidence continues to demonstrate that moderate-to-vigorous physical
activity improves cardiovascular and muscular
tness, bone health, weight status, and cardiometabolic risk factor status.
v. Obtain counseling on stimulus control, goal
setting, self-monitoring, and contracts that reward
behaviors.
vi. Perform preexercise medical evaluation.
1) Before beginning a sport or vigorous exer-
cise program, children and adults should
undergo screening (i.e., a history and physical
examination), with emphasis on detecting cardiovascular risks.
vii. There are several contraindications to starting
an exercise:
1) Individuals with recent myocardial
infarction (2 weeks).
2) Unstable angina.
3) Severe aortic stenosis.
4) Decompensated congestive heart failure
(low ejection fraction).
5) Left ventricular outow obstruction.
6) Uncontrolled dysrhythmias.
7) Uncontrolled diabetes or diabetic
complications.
8) Uncontrolled hypertension.
9) Uncontrolled respiratory conditions such
as asthma and chronic obstructive pulmonary
disease.
viii. Key guidelines for safe physical activity:
1) Understand the risks and yet be condent
that physical activity is safe for almost everyone.
2) Choose to do types of physical activity that
are appropriate for the client’s current tness
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2: PUBLIC HEALTH GUIDELINES
level and health goals, as some activities are
safer than others.
3) The risk of injury is directly related to the
rate of progression or change in volume of physical activity. Increase physical activity gradually
over time whenever more activity is necessary
to meet guidelines or health goals. Inactive people should “start low and go slow” by gradually
increasing how often and how long activities
are done.
4) Tell the client to protect self by using appro-
priate gear and sports equipment, looking for
safe environments, following rules and policies, and making sensible choices about when,
where, and how to be active.
5) People with disabilities should try to get the
same amount of physical activities.
2. Client teaching on obesity treatment modalities:
a. Teach the client the overall health benets of weight
loss.
i. The risk of sudden death increases by 16% for
every ve-unit increment in BMI.
ii. Lifestyle changes as guided by the National
Diabetes Prevention Program can be as effective as
medications in reducing body fat.
iii. Cardiovascular disease is best predicted by
using the waist circumference-to-height ratio than
by waist circumference alone.
b. Advise the client to keep a food diary to identify food
triggers and for accountability. Clients who maintain a
food diary have been shown to have as much as 90%
more weight loss than those who do not keep a diary.
c. Teach the client to read food labels.
d. Healthy dietary programs that are most successful
include the following:
i. Protein intake of 0.8 to 1.5 g/kg of body weight,
maximum of 100 g/d.
ii. Total fat intake of 30% of total calorie per day
iii. Carbohydrate intake of 50 g/d.
iv. Water intake of 64 oz or more per day.
v. Intake of micronutrients and macronutri-
ents should be based on recommended dietary
allowances.
vi. Low-carbohydrate diets should include heart
healthy fats and protein sources.
vii. Diets with low glycemia index and increased
protein intake help maintain weight loss.
e. Encourage weight loss goals of losing 1 to 2 lbs/wk
with lifestyle changes.
f. Counsel clients about pharmaceutical therapy drug
side effects and the lack of long-term safety data. Stress
to the client the temporary nature of weight-loss medication. Typical weight loss is modest, <5 kg (10–11 lbs)
at 1 year.
3. Pharmaceutical therapy:
a. After an adequate trial (minimum of 6 months) of
diet and exercise therapy, consider adding pharmaceutical therapy. Pharmacologic intervention is not covered by some health plans. State statutes should be
considered before prescribing weight-control products.
b. Studies lack evidence to support whether one drug
is more efcacious than another; the literature does not
support the use of combination therapy for increased
weight loss.
c. The choice of a pharmaceutical agent depends on
the side effects prole of the drug and tolerance of the
side effects.
d. There are no OTC appetite suppressant drugs
that have been approved by the Food and Drug
Administration (FDA). Medications approved by
the FDA include Qsymia (phentermine and topiramate extended release [ER]) and Belviq (lorcaserin) for adults at least 18 years of age with a BMI of
30 or greater or for clients with BMI of 27 or greater
and have at least one other weight-related condition.
Qsymia and Belviq are considered lifelong therapies
in clients who respond to and tolerate them when
used in conjunction with a balanced diet and exercise.
Other appetite suppressants that are FDA-approved
for weight-loss medications for use up to 2 years in
adults include the following:
i. Phentermine, diethylpropion, benzphetamine,
and phendimetrazine are approved for short-term
(12 weeks) use.
ii. Sibutramine (Meridia, Reductil) is FDA-
approved for 1-year use.
iii. Orlistat (Xenical) is FDA-approved for 2-year
use.
e. Appetite suppressants:
i. Qsymia (phentermine and topiramate ER),
starting with 3.75/23 mg ER per day for initial
BMI >30 kg/m2, or BMI >27 kg/m2 in the presence of risk factors; may gradually increase dose to
15/92 mg.
1) Avoid evening dose.
2) It should not be taken by adolescents
younger than 18 years of age.
3) Avoid in pregnancy. Weight loss offers
no potential benet to a pregnant individual.
Qsymia carries a risk of birth defects (cleft lip
with or without cleft palate) in infants exposed
during the rst trimester.
4) Monitor for hypersensitivity to phenter-
mine and Topamax.
5) This drug is not recommended in the pres-
ence of hypertension, hyperthyroidism, cardiovascular disease, drug or alcohol abuse, or
history of kidney stones (Topamax).
6) Do not use if there is history of glaucoma
or hyperthyroidism, or within 14 days of use of
monoamine oxidase inhibitors (MAOIs).
ii. Lorcaserin (Belviq), 10 mg BID for initial
BMI >30 kg/m2, or BMI >27 kg/m2 in the presence
of risk factors.
1) Discontinue if 5% weight loss is not
achieved by week 12.
2) It should not be taken by pediatric patients
below the age of 18 years.
3) Avoid in pregnancy. Weight loss offers
no potential benet to a pregnant individual.
Qsymia carries a risk of birth defects (category
X drug classication).
4) Do not use if there is history of valvular heart
disease, type 2 diabetes with hypoglycemia that
requires assistance of another person, or within
14 days of use of MAOIs or antipsychotics.
5) Discontinue in clients who experience sui-
cidal thoughts or behaviors.
OBESITY
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25
iii. Phentermine (Adipex-P) 37.5 mg orally once
daily before or 1 to 2 hours after breakfast, or 18.75
mg one to two times per day for initial BMI >30 kg/
m2, or BMI >27 kg/m2 in the presence of risk factors
such as controlled elevated blood pressure, diabetes, and high cholesterol.
1) Avoid late-evening dosing.
2) It is not recommended for children younger
than 16 years.
3) It is not recommended in the presence of
hypertension, hyperthyroidism, cardiovascular
disease, and drug or alcohol abuse.
4) Do not prescribe during or within 14 days
of MAOIs.
iv. Benzphetamine (Didrex) 25 to 50 mg orally, ini-
tially in the midmorning or midafternoon; increase
if needed to 25 to 50 mg one to three times a day.
1) It is not recommended for children or
adole scents.
2) It is not recommended in the presence of
hypertension, hyperthyroidism, cardiovascular
disease, and drug or alcohol abuse.
3) Do not prescribe during or within 14 days
of MAOIs.
4) It is a pregnancy category X drug known to
cause fetal abnormalities or toxicity in animal
and human studies.
v. Diethylpropion (Tenuate) 25 mg one tablet
Q8H, 1 hour before meals; may add one additional
dose for night hunger; half-life of 4 to 6 hours.
1) Avoid late-evening dosing.
2) It is not recommended for children younger
than 16 years.
3) It is not recommended in the presence of
hypertension, hyperthyroidism, cardiovascular
disease, and drug or alcohol abuse.
4) Do not prescribe during or within 14 days
of MAOIs.
vi. Phendimetrazine (Bontril PDM) 35 mg orally two
or three times daily 1 hour before meals; may reduce
to 17.5 mg/dose, maximum dose 210 mg/d in three
evenly divided doses; also available in slow-release
105 mg taken in the morning 30 to 60 minutes before
breakfast.
1) It is not recommended for children or
adolescents.
2) It is not recommended in the presence of
hypertension, hyperthyroidism, cardiovascular
disease, and drug or alcohol abuse.
3) Do not prescribe during or within 14 days
of MAOIs.
f. Lipase inhibitor:
i. Orlistat (Xenical) for use with a low-fat diet;
recommend 30% of calories spread over three main
meals.
1) Take one 120-mg capsule orally during or
up to 1 hour after the main meals, up to three
times per day.
2) If a meal is missed or had no fat, skip
dosage.
3) Orlistat may reduce the absorption of
fat-soluble vitamins and beta carotene.
4) Orlistat carries an FDA warning regarding
safety and efcacy for use in clients younger than
12 years and during pregnancy and lactation as
it interferes with the absorption of fat-soluble
vitamins.
5) Supplement diet with a multivitamin.
6) It is FDA-approved for up to 2 years’ use in
adults.
7) Gastrointestinal side effects include fatty/
oily stools, oily spotting, atus with discharge,
fecal urgency, and fecal incontinence.
8) It is contraindicated in chronic malabsorp-
tion syndrome and cholestasis.
9) It may affect doses for antidiabetic
medications.
10) Monitor warfarin and cyclosporine levels.
ii. Alli is the only FDA-approved lipase inhibitor
OTC weight-loss product.
g. Glucagon-like peptide-1 (GLP-1) receptor agonist:
i. Semaglutide (Wegovy) is FDA-approved for
adults with a BMI ≥30 kg/m2 (obesity). It is also
approved for BMI ≥27 (overweight) with at least one
or more comorbid conditions that are weight-related,
such as diabetes, hypertension, and dyslipidemia.
1) Wegovy comes in a prelled pen.
2) Wegovy should not be used with any other
GLP-1 receptor agonist.
3) Weekly subcutaneous injection, injected the
same day each week, with or without meals.
4) Starting dose 0.25 mg weekly x 4 weeks,
increase dose in 4-week intervals, reaching a
maximum dose of 2.4 mg weekly; maintenance
dose 2.4 mg weekly.
5) Contraindicated in clients with personal or
family history of medullary thyroid carcinoma
or those with multiple endocrine neoplasia syndrome type 2.
6) Wegovy delays gastric emptying time and
may interfere with absorption of other medications being taken concomitantly.
ii. Liraglutide (Saxenda) subcutaneous was
FDA-approved for chronic weight management as an
adjunct to a reduced-calorie diet and increased physical exercise in December of 2014 for use in adults
with BMI of 30 kg/m2 or greater or 27 kg/m2 or
greater with at least one weight-related comorbidity.
1) Start with 0.6 mg once daily for a week; may
increase by 0.6 mg daily at weekly intervals, up to
3 mg once daily.
2) Delay dose increase if tolerance is an issue.
3) If 3 mg once daily is not tolerated, discon-
tinue drug. Efcacy has not been established for
lower doses.
4) Evaluate at 16 weeks of therapy; discon-
tinue if at least 4% of baseline body weight loss
has not been achieved.
5) It is a pregnancy category X drug and is
contraindicated in clients with multiple endocrine neoplasia syndrome type 2 (MEN2).
h. Off-label medications used for obesity: These med-
ications are not FDA-approved for weight loss. The
client should be counseled regarding off-label medications and to use at discretion.
i. Metformin (Glucophage) is used to reduce cen-
tral adiposity in weight loss, lower insulin levels,
and slow down the process of gluconeogenesis.
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2: PUBLIC HEALTH GUIDELINES
1) Start metformin 500 mg at the evening meal.
The dosage can be increased by 500 mg/wk in
divided doses up to a maximum of 2,000 mg/d.
2) Titrate slowly due to the gastrointestinal
side effects.
3) Check metabolic panel before and every 3 to
6 months to evaluate for lactic acidosis.
4) Metformin is contraindicated in clients with
renal impairment; assess renal function before
instituting metformin and monitor regularly.
5) Metformin must be stopped before any pro-
cedure with radiographic dye.
6) Metformin may be used in children with cen-
tral adiposity, especially those with signs of premetabolic syndrome.
7) Metformin may be used in clients with a
waist-to-hip ratio >0.8%.
ii. Topiramate (Topamax) is used to treat seizures
and several types of headache. In small doses, it
can be used alone or as adjunct to phentermine to
suppress appetite longer. Be familiar with the risks
associated with the use of Topamax.
1) If used alone, the drug may start at 25 mg
daily in the morning. Increase up to two or three
times a day. Topamax has a long half-life of 19 to
25 hours.
2) Topamax may be used as adjunct to phen-
termine. Start client at 18.75 mg of phentermine
and 12.5 mg of Topamax. Gradually increase the
dose to 37.5 mg of phentermine and 25 mg of
Topamax.
3) Always give the phentermine in the morn-
ing, preferably 30 minutes before meals. Topamax
should be dosed in the afternoon or evening.
4) Give phentermine (Adipex-P) 37.5 mg orally
once daily before or 1 to 2 hours after breakfast,
or 18.75 mg one to two times per day for initial
BMI >30 kg/m2 or BMI >27 kg/m2 in the presence of risk factors such as controlled elevated
blood pressure, diabetes, or high cholesterol.
5) Avoid late-evening dosing.
6) It is not recommended for children younger
than 16 years.
7) It is not recommended in the presence of
hypertension, hyperthyroidism, cardiovascular
disease, drug or alcohol abuse, or history of kidney stones.
8) Do not prescribe during or within 14 days
of MAOIs.
iii. Trulicity is a GLP-1 receptor agonist that may be
prescribed weekly. Dose begins at 0.75 mg/0.5 mL
weekly with subcutaneous injection and may
increase after 4 to 8 weeks up to 1.5 mg/0.5 mL
weekly maximum dose.
FOLLOW-UP
A. Reevaluate the client every week for 6 to 8 weeks, and
then monthly if pharmaceutical therapy is used until goal is
achieved.
B. Maintain the recommended schedule for comorbid
conditions.
C. If the client is a candidate for bariatric surgery, follow rec-
ommended pretreatment/reauthorization guidelines required
by the payer and the bariatric center.
CONSULTATION/REFERRAL
A. Refer to a nutritionist/registered dietitian for consultation.
B. Consider a referral to a bariatric center/surgical consulta-
tion and evaluation of bariatric surgery.
C. Consider a psychology consultation (may be required
before bariatric surgery).
D. If the family is eligible, refer to the Women, Infants, and
Children program. Referral to some commercial weight-loss
programs may be benecial. See www.fns.usda.gov/wic/
women-infants-and-children-wic.
INDIVIDUAL CONSIDERATIONS
A. Pregnancy:
1. Category X drugs include phentermine and topira-
mate ER (Qsymia), lorcaserin (Belviq), and benzphetamine
(Didrex). Avoid use during pregnancy.
2. Wegovy and Trulicity should not be prescribed during
pregnancy.
3. Weight loss should never be a goal during pregnancy.
4. Counsel clients regarding appropriate weight gain and
healthy eating habits during pregnancy.
B. Pediatrics:
1. The goal of treating childhood obesity is to reduce
weight gain to adjusting the weight-to-height ratio to
match normal growth curves.
2. The cornerstone for management of obesity in children
is modication of dietary and exercise habits.
3. The rst step for overweight children older than 2 years
is maintenance of baseline weight if there is no secondary
complication of obesity (e.g., diabetes and hypertension).
Any dietary modication must ensure adequate nutrients
for the growing child (MyPlate Kids’ Place can be accessed
at www.choosemyplate.gov/kids).
4. The weight-loss goal should be approximately 1 lb per
month for a BMI below the 85th percentile.
5. Reduce sedentary behaviors (e.g., watching television,
use of handheld electronic devices, surng the internet,
and playing video games more than a total of 3 hours a
day).
6. Increase physical activity and incorporate exercise into
family time.
7. Long-term safety and effectiveness of low-carbohydrate,
high-protein diets, such as the Atkins diet, have not been
adequately studied in children.
8. Use of pharmacotherapies in children and adolescents
requires further research, unless previously noted under
drug therapies.
C. Geriatrics:
1. All adults should avoid inactivity. Some exercise is bet-
ter than none. Any dietary modication must ensure adequate nutrients for the aging adult (The USDA resources
for nutrition and health can be accessed at www.choosem
yplate.gov).
RESOURCES
American Heart Association: www.heart.org
American Heart Association Go Red for Women: www.goredforwomen
.org
Centers for Disease Control and Prevention (CDC). Overweight and obesity:
www.cdc.gov/obesity/index.html
National Institute on Aging. Exercise: A guide: www.nia.nih.gov/HealthIn
formation/Publications/ExerciseGuide
President’s Council on Fitness, Sports & Nutrition: www.tness.gov
The Obesity Society: www.obesity.org/home
SHAPE America, Society for Health and Physical Educators: www.shap
eamerica.org/
POSTBARIATRIC SURGERY LONG-TERM FOLLOW-UP
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27
BIBLIOGRAPHY
Physical Activity Guidelines Advisory Committee. (2018, February 2018).
2018 physical activity guidelines advisory committee scientic report. U.S.
Department of Health and Human Services. https://health.gov/pa
guidelines/second-edition/report/pdf/PAG_Advisory_Committee_
Report.pdf
Centers for Disease Control and Prevention. (updated May 17,2022).
Prevalence of Childhood Obesity in the United States. https://www.cdc.
gov/obesity/data/childhood.html
Centers for Disease Control and Prevention. (2022, May 17). Adult obesity
facts. https://www.cdc.gov/obesity/data/adult.html
Centers for Disease Control and Prevention. (2022, February 22).
Overweight and obesity. https://www.cdc.gov/obesity/
FRAC: Food Research & Action Center. (2019). Factors contributing to obe-
sity. http://frac.org/obesity-health/factors-contributing-obesity
Hamdy, O. (2021). Obesity guidelines. Medscape. https://emedicine.medsc
ape.com/article/123702.guidelines
POSTBARIATRIC SURGERY LONG-TERM FOLLOW-UP
DEFINITION
A. The number of obese people in the United States has more
than doubled in the past 50 years, with severe obesity increasing
more rapidly than nonsevere obesity. The traditional management of obesity, a combination of diet, exercise, and behavioral
modication, often results in moderate success with limited
sustainability. Increasing prevalence of obesity combined with
improvements in surgical weight-loss procedures and improved
insurance coverage has resulted in the exponential growth of
the number of people opting for surgical management. Clients
who undergo surgical weight-loss procedures have unique
healthcare needs and require lifelong follow-up. Although the
bariatric treatment team is the ideal source of follow-up and
monitoring, primary care providers can play a critical role and
need to be cognizant of the unique needs of this population.
B. The primary mechanism of action for surgical weight-loss
procedures is either restriction or a combination of restric-
tion and malabsorption (Table 2.3). All procedures have some
form of restriction that reduces the volume of food that can
be ingested. Restriction can occur by means of a physical bar-
rier such as a laparoscopic adjustable gastric band (LAGB;
Figure 2.1) or an intragastric balloon (Figure 2.2), or by remov-
ing a portion of the digestive tract, such as with the gastric
sleeve (GS; Figure 2.3). Malabsorptive procedures cause
weight loss by changing the way nutrients are absorbed,
which is accomplished by removing portions of the stomach
and/or small intestine and sometimes by rerouting the diges-
tive tract (Roux-en-Y gastric bypass [RYGB]; Figure 2.4). The
success of surgical weight loss is dened by initial weight loss,
maintenance of weight loss, and prevention of complications.
Success is directly related to the aftercare a person receives.
FIGURE 2.1 Laparoscopic
adjustable gastric band.
Source: Reproduced from Cash,
J. C., & Glass, C. A. (2019).
Adult-gerontology practice guidelines
(2nd ed.). Springer Publishing
Company.
TABLE 2.3 SURGICAL WEIGHT-LOSS PROCEDURES AND MECHANISM OF ACTION
Procedure
LAGB (Figure 2.1) Restriction No cutting or rerouting of digestive tract
Intragastric balloons
(Figure 2.2)
GS (Figure 2.3) Restriction
RYGB (Figure 2.4) Restriction and
BPD/DS Malabsorption
BMI, body mass index; BPD/DS, biliopancreatic diversion with duodenal switch; GS, gastric sleeve; LAGB, laparoscopic adjustable gastric band; RYGB, Roux-en-Y gastric
bypass.
Mechanism
of Action Advantages Disadvantages
Reversible and adjustable
Lowest risk of nutritional deficiencies
Restriction Approved for BMI 30–40
and some
malabsorption
malabsorption
and some
restriction
Placed endoscopically under conscious
sedation or general sedation
Can be adjunctive therapy to achieve
weight-loss reduction prior to bariatric
surgery
No rerouting
Hormonal hunger suppression, appetite
reduction, and increased satiety
Reduces appetite, enhances satiety
Better initial and long-term weight loss
compared with LAGB
Greatest weight loss overall
Reduces appetite, improves satiety
Most effective for treatment of diabetes mellitus
Slower (more gradual) weight loss
Greater chance of failure to lose 50% of excess
weight
Foreign device in body; slippage and erosion
possible
Highest rate of reoperation
Designed to remain implanted for 6 months and
allow adjustments in fluid volume to address client
symptoms and weight-loss plateaus
Not reversible
Potential for nutrient deficiencies
Higher complication rate than LAGB
Long-term nutritional deficiency risk
Lifelong adherence to diet and supplementation
required
Higher complication rate compared with LAGB and GS
Greatest risk of nutritional deficiencies
Strict lifetime adherence to diet and supplements
Highest complication rate
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