Ten to Amend: A Clinician's Guide to Weight Loss and Chronic Diseases

Monday, 30 October 2017

Krystina L. Kienast, BSN
Masters of Science in Nursing Student, Alverno College, Pewaukee, WI, USA


The leading causes of death in the United States of America all have in common one risk factor. A risk factor that has become so prevalent our society is morphing to accommodate those affected. This deadly risk factor is obesity. 36.5 percent of the nation’s population is obese and nationwide the cost of healthcare related to obesity in 2008 was estimated at 147 billion dollars (CDC, 2016). Individuals within the obese classification are at greater risk for chronic diseases such as hypertension, hyperlipidemia, type II diabetes, coronary heart disease, obstructive sleep apnea, and subsequent complications. These individuals are also at greater risk for many forms of cancer, along with psychological disorders, reproductive issues, strokes and an overall lower quality of life (CDC, 2016). A collection of evidence based guidelines for practice, as noted in the literature review, endorse a weight loss of 7-10 percent as having a measurable effect for management of hypertension, hyperlipidemia, type II diabetes, chronic pain, and many other chronic conditions. Lifestyle modifications such as alterations to nutrition, exercise, and other daily habits will lead to this 7-10 percent weight loss. With this weight loss an individual can expect to see a hemoglobin A1C level decreased by 2 percent, blood pressure by up to 10mmHg, and triglycerides by at least 20 mg per dL (Academy of Nutrition and Dietetics, 2014).  A survey of providers in a metropolitan area, accompanied by research of large healthcare companies, found that there were no policies, guidelines, or procedures on how to assist a patient in their weight loss goals. Many responded with smart phone applications, programs with extensive lab work, or referrals to other specialties. The barriers with these methods are that each one incurs extra cost to the patient as it may or not be covered by insurance and the patient may or may not have access to necessary technology. The suggestions were not evidence based, had no research or literature supporting them, and had no follow up recommendations to ensure success. “10 to Amend” is a program that establishes an evidence based practice pathway utilizing the relationship between a provider, presented in this case as an Advanced Practice Nurse (APN), and the patient. The overarching goal is to decrease overall weight by 10 percent in order to improve and/or reduce the risk of further development of chronic diseases. The pathway is presented as an algorithm. The algorithm flows by diagnoses so the provider and patient have an evidence based guide to dietary, physical activity, and laboratory follow up recommendations. The later portion of the algorithm is individualized per patient. Success is measured through the use of laboratory data. This data is collected per the patient’s insurance guidelines or ability to pay. This is done so there is no additional cost accrued by the patient. For example, an obese or overweight individual is diagnosed with type II diabetes. The patient has a baseline Hemoglobin A1C of 8.4%. 90 days post baseline their insurance will cover another Hemoglobin A1C. The APN and patient decide to enact lifestyle modifications prior to pharmaceutical intervention. It is within this 90 days when the program will occur, with the Hemoglobin A1C after the 90 days as a unit of measurement of success. The same type of scenario can be used for hyperlipidemia, hypertension, and many other common chronic disorders. As APN’s we seek not to dictate care, but form relationships with our patients to achieve health goals. For this reason, Imogene M. King’s Theory of Goal Attainment was used as a theoretical basis for this program. Utilizing the Theory of Goal Attainment and the “10 to Amend” algorithm, the APN and patient dyad encompasses all aspects of the patient’s life in order to attain the goal of a ten percent reduction in weight which in turn improves overall health and prevents further complications of chronic diseases. (George, 2011)