Weekly Telehealth Weigh-in for BMI Reduction

Practice Problem: The citizens of the United States are known for being overweight or obese. The Centers for Disease Control and Prevention (CDC, 2021) reported that approximately 74% of adults are either overweight or obese. PICOT: The PICOT question that guided this project was In overweight adults (P), does telemonitoring weekly for counseling and weigh-in (I) compared to current practice (C) decrease BMI over an 8-week period of time (T)? Evidence: The citizens of the United States are known for being overweight or obese. The Centers for Disease Control and Prevention (CDC, 2021) reported that approximately 74% of adults are either overweight or obese and it is hard to lose weight. Lifestyle interventions are more effective if the patient has one on one support with a medical provider (Kempf et al., 2018). Intervention: The intervention to improve BMI is weekly weigh-ins through weekly telemonitoring visits with the medical provider. Outcome: The results showed there is not a statistically significant improvement in BMI using telehealth for weekly weigh-ins over an eight-week period of time. Conclusion: This project was to use telehealth for weekly weigh-ins and support to reduce BMI by one point over an eight-week period of time. The results did not show a statistically significant improvement in BMI even though there was an overall improvement in the average BMI and weight of the participants. To improve this project in the future, further research will need to be conducted to identify additional interventions that may yield better results. One of the changes I would suggest is a longer period of time (than 8 weeks) for the project to be conducted to get better results. WEEKLY WEIGHT-IN FOR BMI REDUCTION 3 Weekly Telehealth Weigh-in for BMI Reduction The citizens of the United States are known for being overweight or obese. The Centers for Disease Control and Prevention(CDC, 2021) reported that approximately 74% of adults are either overweight or obese. A person is determined to be underweight, of a healthy weight, overweight, or obese based off a screening tool called the body mass index (BMI) (CDC, 2020). The BMI is a formula that is calculated by using a person’s weight in kilograms and then divided by the square of a person’s height in meters. The BMI interprets normal or healthy weight between 18.5-24.9, overweight between 25.0 to 29.9, and obese is 30.0 or greater. Obesity is a chronic health issue that puts a person at increased risk for cardiovascular disease, diabetes, cancer, and mental health issues (Jensen et al., 2014; Mylona et al., 2020). Obesity is a complex condition that encompasses genetic factors, environmental factors, cultural, and socioeconomic factors (Lemstra et al., 2020). Baer et al., (2020) reports that it is difficult for people who are overweight to lose weight with diet and exercise alone. There are different types of interventions that have been tried to improve weight loss. Two different types of interventions include face to face meetings and virtual meetings. Face-to-face interventions to treat obesity is very time-consuming and costly to the individual and the healthcare system (Beleigoli et al., 2019). Significance of the Practice Problem It is estimated that over two thirds of Americans who are 25 years or older are overweight or obese (CDC, 2021). In the United States obesity prevalence increased from 30.5% to 42.4% from 2000 to 2017 (CDC, 2021). Locally, in Lee County, 66.3% of adults are overweight and approximately 31.2% are obese (Community-Report, n.d.; Lee-County-HealthProfiles-2019, n.d.). People who are overweight or obese have increased risk for comorbidities such as hypertension, hyperlipidemia, diabetes, coronary heart disease, stroke, sleep apnea, and some cancers (Jensen et al., 2014; Mylona et al., 2020). WEEKLY WEIGHT-IN FOR BMI REDUCTION 4 Overweight and obese individuals have higher incidence of chronic pain. Twenty to forty percent of individuals who are overweight or obese report chronic pain (Higgins et al., 2016). Data from the 2010 National Health Interview Survey (2014) identified 18.2% of overweight people and 25% of obese people in the United States reported pain for more than three months (Kennedy et al., 2014). A retrospective case control study was conducted by Jain et al., (2021) and confirmed that obese patients have higher rates of medical complications after spine surgery compared to nonobese patients. Epstein,(2017) recommends weight loss prior to elective spine surgery in morbidly obese patients because obesity led to longer anesthesia times (30 minutes), longer surgical times (24 minutes), 2.8 times more wound complications (4.2% vs. 1.5%), and 2.5 times more major medical complications (7.8% vs. 3.1). Mylona et al., (2020), used the largest healthcare network medical record database in Rhode Island to evaluate the burden of obesity and its complications among government funded programs (Medicare), state funded programs (Medicaid) and commercial insurances. Medicare and Medicaid provide health coverage to 40% of adults with obesity and to 45% of adults with obesity-related comorbidities and complications. They concluded that state and federal health care programs need to support and expand obesity related services. These policies should extend preventive measures and treatments against obesity and reduce the burden of obesity and obesity-related conditions. Wang et al., (2015) analyzed data from 2013 which indicated that severe obesity cost the nation approximately $69 billion, which accounted for 60 percent of total obesity-related costs. To understand the economic burden of obesity, Kim and Basu, (2016) conduced a systematic review of 12 articles that reported the cost of obesity. The conclusion was that there is a significant variation amongst the existing literature. The literature ranged from $1,239$2,582 per person in 2010 in the United States, accounting for $149.4 billion at a national level. Hayes et al.,(2017) reported a cost of approximately $1,429 more per year for healthcare cost by obese people who are affected by obesity, which is 42% higher than someone who is of WEEKLY WEIGHT-IN FOR BMI REDUCTION 5 normal weight. Morbid obesity resulted in an 10-fold rate of wound complications after spine surgery and greater cost, approximately $9078 (Epstein, 2017). Overall, severe obesity cost state Medicaid programs almost $8 billion a year, ranging from $5 million in Wyoming to $1.3 billion in California (Wang et al., 2015).


Weekly Telehealth Weigh-in for BMI Reduction
The citizens of the United States are known for being overweight or obese. The Centers for Disease Control and Prevention(CDC, 2021) reported that approximately 74% of adults are either overweight or obese. A person is determined to be underweight, of a healthy weight, overweight, or obese based off a screening tool called the body mass index (BMI) (CDC, 2020).
The BMI is a formula that is calculated by using a person's weight in kilograms and then divided by the square of a person's height in meters. The BMI interprets normal or healthy weight between 18.5-24.9, overweight between 25.0 to 29.9, and obese is 30.0 or greater.
Obesity is a chronic health issue that puts a person at increased risk for cardiovascular disease, diabetes, cancer, and mental health issues (Jensen et al., 2014;Mylona et al., 2020).
Obesity is a complex condition that encompasses genetic factors, environmental factors, cultural, and socioeconomic factors (Lemstra et al., 2020). Baer et al., (2020) reports that it is difficult for people who are overweight to lose weight with diet and exercise alone. There are different types of interventions that have been tried to improve weight loss. Two different types of interventions include face to face meetings and virtual meetings. Face-to-face interventions to treat obesity is very time-consuming and costly to the individual and the healthcare system (Beleigoli et al., 2019).

Significance of the Practice Problem
It is estimated that over two thirds of Americans who are 25 years or older are overweight or obese (CDC, 2021). In the United States obesity prevalence increased from 30.5% to 42.4% from 2000 to 2017 (CDC, 2021). Locally, in Lee County, 66.3% of adults are overweight and approximately 31.2% are obese (Community-Report, n.d.;Lee-County-Health-Profiles-2019, n.d.). People who are overweight or obese have increased risk for comorbidities such as hypertension, hyperlipidemia, diabetes, coronary heart disease, stroke, sleep apnea, and some cancers (Jensen et al., 2014;Mylona et al., 2020).
Overweight and obese individuals have higher incidence of chronic pain. Twenty to forty percent of individuals who are overweight or obese report chronic pain (Higgins et al., 2016).
Data from the 2010 National Health Interview Survey (2014) identified 18.2% of overweight people and 25% of obese people in the United States reported pain for more than three months (Kennedy et al., 2014). A retrospective case control study was conducted by Jain et al., (2021) and confirmed that obese patients have higher rates of medical complications after spine surgery compared to nonobese patients. Epstein,-(2017) recommends weight loss prior to elective spine surgery in morbidly obese patients because obesity led to longer anesthesia times (30 minutes), longer surgical times (24 minutes), 2.8 times more wound complications (4.2% vs. 1.5%), and 2.5 times more major medical complications (7.8% vs. 3.1). Mylona et al., (2020), used the largest healthcare network medical record database in Rhode Island to evaluate the burden of obesity and its complications among government funded programs (Medicare), state funded programs (Medicaid) and commercial insurances. Medicare and Medicaid provide health coverage to 40% of adults with obesity and to 45% of adults with obesity-related comorbidities and complications. They concluded that state and federal health care programs need to support and expand obesity related services. These policies should extend preventive measures and treatments against obesity and reduce the burden of obesity and obesity-related conditions. Wang et al., (2015) analyzed data from 2013 which indicated that severe obesity cost the nation approximately $69 billion, which accounted for 60 percent of total obesity-related costs.
To understand the economic burden of obesity, Kim and Basu, (2016) conduced a systematic review of 12 articles that reported the cost of obesity. The conclusion was that there is a significant variation amongst the existing literature. The literature ranged from $1,239-$2,582 per person in 2010 in the United States, accounting for $149.4 billion at a national level. Hayes et al.,-(2017) reported a cost of approximately $1,429 more per year for healthcare cost by obese people who are affected by obesity, which is 42% higher than someone who is of normal weight. Morbid obesity resulted in an 10-fold rate of wound complications after spine surgery and greater cost, approximately $9078 (Epstein, 2017). Overall, severe obesity cost state Medicaid programs almost $8 billion a year, ranging from $5 million in Wyoming to $1.3 billion in California (Wang et al., 2015).

PICOT Question
In overweight adults (P), does telemonitoring weekly for counseling and weigh-in (I) compared to current practice (C) decrease BMI over an 8-week period of time (T)?

Population/Problem
The population for this project will include any person who is 18 years of age or older from a local primary care office in South West Florida who is overweight as defined by a BMI > 25 (CDC, 2020). The overweight individual also needs to have a desire to lose weight to improve their BMI. They will also need to have access to either a smart phone or a computer in a private setting. Nearly 2 in 3 adults in Lee County (66.3%) are overweight and approximately 31.2% are obese (Community-Report. Pdf, n.d.;Lee-County-Health-Profiles-2019.Pdf, n.d.).

Intervention
The intervention to improve BMI is weekly weigh-ins and weekly telemonitoring with the medical provider. Telephone-based counseling or telehealth for weight management typically consists of regularly scheduled appointments, such as weekly weigh-ins. The evidence suggests that this type of counseling reveals moderately effective treatment as compared to minimal or no contact interventions (VanWormer et al., 2009;) (Perri et al., 2020) According to Kempf et al., (2018), lifestyle interventions are more effective if the patient has one on one support with a medical provider. Johnson et al.,-(2019) reports due to limited provider accessibility and resources using telehealth or telephone consultations for health coaching and weight management will cause an increase in physical activity. This will also provide a more favorable change in weight reduction. Lifestyle interventions, such as diet and exercise, have shown to be effective if continuous personal support is provided (Kempf et al., 2018). It is difficult for people who are overweight to lose weight with diet and exercise alone. Weight loss seems to be affected by daily routines (Baer et al., 2020).

Comparison
The comparison will be the BMI from every participant from the first weigh-in on week one and the last weigh-in on week 8.

Outcome
The anticipated outcome will be a one point reduction in BMI after 8 weeks of weekly weigh-ins using telemonitoring. Appel et al.,-(2011) conducted a similar study that lasted 24 months and the results yielded a 5% reduction in weight.

Timing
The timing of this project will eight-weeks.

Evidence-Based Practice Framework & Change Theory
The theoretical framework for this project will be the Johns Hopkins Evidence-Based Practice Model. This model uses a problem solving approach to help make clinical decisions (Vera, n.d.). It is designed using a 3-step process called "PET". PET stands for: practice question, evidence, and translation. The goal of the Johns Hopkins Evidence-Based Practice Model is to ensure the most up to date research and best practices are incorporated into patient care quickly and appropriately (Seal, n.d.).
The PET Process Guide (see Figure 1) starts with a practice problem statement. Once a problem has been identified the second and third steps are to see if the evidence supports that a practice change is needed. If a practice change is needed, then it needs to be determined if the problem is a concern for the organization. Is it relevant? Does the evidence synthesis exist internally or externally to the organization? The final step is to determine if the problem is feasible to incorporate it into practice.

PET Process Guide
The change theory that will be used for this project is Lippitt, Watson, and Westley's Seven Phases of Change. This theory focuses more on the role and responsibility of the change agent than the process of the change itself by using a seven step process and emphasizing the participation of the person affected (in this case by being overweight) (Udod & Wagner, 2018). This theory has seven steps to the planned change model. The seven steps are: (1) diagnosing the problem; (2) assessing the motivation and capacity for change in the system; (3) assessing the resources and motivation of the change agent; (4) establishing change objectives and strategies; (5) determining the role of the change agent; (6) maintaining the change; and (7) gradually terminating the helping relationship as the change becomes part of the organizational culture.
The step-by-step process of this change theory would look like the following: First the medical provider would identify and diagnose the patient as being overweight or obese based on their BMI during their annual exam. Secondly, the provider would discuss with the patient what the BMI tool is and how it is interpreted. They would also discuss what the patients individual BMI is and the risk factors associated with being overweight or obese. Third, the medical provider would assess the resources that the patient has and if they were motivated to change. Some of the resources would include a scale for weekly weighing and if they have a device to participate in telehealth. Fourth, the medical provider and patient would discuss goals as well as strategies to meet those goals. In this project it would include weekly weigh-ins with counseling reassessment of BMI every four weeks. Fifth, the project lead will discuss with everyone who is working on the project, what their role is and what is expected of them. Sixth, once successful with weight loss, maintaining the weight loss until the patient is within a normal BMI. Finally, once the patient establishes a normal BMI, the patient continues to maintain their weight without weekly interventions. They would be reevaluated with their primary care provider quarterly and at their annual physical.
Overweight and obesity is a global problem. It is no longer an adult or high-income issue. Overweight and obesity is starting earlier and earlier in childhood. Obesity is not only a weight issue, but it also encompasses psychological, behavioral, and social issues. Many solutions have been tried but nothing seems to be revering or slowing down this global pandemic. This evidence-based project is being implemented at this practice and when successfully completed it will be offered to all the clients at this out patient practice.

Evidence Search Strategy
The initial search was conducted in CINAHL Complete using the key terms obesity, weight loss, telemedicine and adults. The modifiers that were used included obesity or overweight or fat or obese or unhealthy weight or high bmi AND weight reduction or weight loss or weight management AND telehealth or telemedicine or telemonitoring or telepractice or telenursing or telecare AND adults or adult or middle aged or young adult between 2017-2022.
This search revealed 408 results. Next, I limited geographical location to USA or United States.
This reduced the search to 30. Then, peer reviewed articles were selected, which did not change the results.
A MeSH database search was performed to identify the proper MeSH keywords. The correct MeSH keywords are "Obesity"[Mesh] AND "Weight Loss"[Mesh] AND "Telemedicine" [Mesh] AND "United States" [Mesh]. Using the MeSH keywords the database search yielded 17 results. Next, a limit was set for articles within the last five years. This reduced the results to six articles. Four of the six results were excluded because they did not pertain to the topic. One article was eliminated because it was not related to telemedicine. Another article was eliminated because it was related to weight loss for endometrial cancer patients. The last two article were eliminated because they were related to type two diabetes and a commercial weight loss program.
The articles that were initially excluded in CINAHL were articles that did not have full text availability, in English language and conducted in the United States of America. Additional literature search was conducted on google for potential interventions. Some articles were identified from the reference section of articles that were found in CINAHL.

Evidence Search Results
This paper uses Johns Hopkins Nursing Evidence-Based Practice guideline for evaluating the evidence level and quality level (Appendix C evidence level quality guide, n.d.).
Evidence levels are broken down by numbers one through five. The lower the number, the better the article is considered. For instance, Level one has randomized controlled trials whereas articles that are level five, may be opinions and do not have scientific evidence to support the article. The quality of an article is broken down between letters A, B and C. Articles that are "A quality" are high quality articles. Quality B articles are considered good quality and C are lower quality or have major flaws.

Themes with Practice Recommendations
After a thorough evaluation of the studies listed in the evidence table (See Appendix A below) there are three themes that repeatedly appeared in the literature. The themes were: 1. Overweight and/or Obesity 2. Web or telemedicine-based interventions increased the amount of weight loss 3. Weight loss is more effective with supervision The next three paragraphs will go into more detail for each item. Of those randomized control trial articles, most of the articles were either Quality A or Quality B (see Appendix A).

Overweight or Obesity and Weight Loss
The primary focus of the articles that are listed in the "Summary of Primary Research Evidence" table is on people who are overweight or obese with a goal of losing weight. People who are overweight or obese have increased risk for comorbidities such as hypertension, hyperlipidemia, diabetes, coronary heart disease, stroke, sleep apnea, and some cancers (Jensen et al., 2014;Mylona et al., 2020). These comorbidities increase the financial burden on the patient and society. People who suffer from weight disorders are at a greater risk for mental health issues including social, emotional, depression, poor self-esteem and social isolation (Sorgente et al., 2017). Of the five randomized control trials that were reviewed two of the articles focused on people who are overweight which is defined by a BMI > 25 (Baer et al., 2020;Kemp et al., 2018). Three of the five articles focused on obesity or a BMI > 30 (Appel et al., 2011;Johnson et al., 2019;Perri et al., 2019). One of the articles included anyone with a BMI > 27 but the mean BMI was 32.5, so this included both overweight and obese subjects (Baer et al., 2020). As we focus on weight loss, it is important to set tangible goals. Jensen et al., (2014), discovered that a realistic and meaningful weight loss goal is a weight loss reduction of 3-5% of body weight with a goal of 5-10% weight loss in a 6-month period of time. Puhl et al., (2020) reported that lifestyle modification is the first line of treatment for obesity. These modifications include diet and exercise. These behavioral changes can produce weight loss of 5-10% of body weight, which can significantly improve cardiovascular health benefits. The CDC (2022a), reported that people who lose weight gradually about 1-2 lbs a week are more likely to keep the weight off and a modest amount of weight loss is between 5-10% of body weight (CDC, 2022a).

Web or Telemedicine-based Interventions
Web based or telemedicine-based interventions were used in the primary research articles in this paper. In these articles there were several methods that were used to improve weight loss using web-based interventions. The different methods that were used in the primary research articles to improve weight loss remotely included: telephone, email, telemedicine, video coaching and online weight management programs. Perri et al.,-(2020) used telephone counseling and educational control program via email for weight loss. The findings were that providing extended care for obesity management via individual telephone counseling decreased weight regain and increased the proportion of participants who sustained clinically meaningful weight losses. Kempf et al., (2018)

Weight Loss is more Effective with Supervision
Weight loss is more effective with supervision or health coaching. The CDC (2021) estimated that 70% of Americans are either overweight or obese. Millions of Americans are currently attempting weight loss, mostly through mobile health self-help programs yet, success rates tend to be low (Forman et al., 2019). Appel et al.,-(2011) explains that patients who have continued monitoring have better results with weight loss in both the short and long term.
Additionally, the amount of weight loss is greater with supervision. Baer et al., (2020) discussed that it is difficult for people who are overweight to lose weight without support.
Based on a thorough and rigorous review of the articles in Appendix A, the evidence supports for patients who have a BMI > 25, telemonitoring weekly (for weigh-in and counseling), will improve their BMI in both the short term and long term. Eighteen articles were evaluated, of those 18 articles eight were primary quantitative studies. The articles evidence level was a mixture of 1-4 and the quality was primarily quality A or B. The articles were consistent and supported the PICOT question that routine medical support through telemonitoring improves BMI. The recommendation is for patients who have a BMI > 25 and want to improve their overall health by making lifestyle changes (diet and exercise). These participants will weight themselves every week on the same scale and report it via telemonitoring with the goal to reduce their BMI and improve their overall health. The counseling will be diet information based off the MyPlate recommendations and exercise as recommended by the CDC.

Setting, Stakeholders, and Systems Change
The location fort this project is a private family practice office in Southwest Florida. This office currently offers services that would be expected in family practice office. The mission for this practice is dedicated to the pursuit of excellence in health care. To achieve this purpose preventative medicine must be implemented in a progressive fashion with each patient from newborns to adults. Not only do the providers treat existing conditions, but they also work to maximize prevention strategies to improve quality of life and achieve wellness goals. To meet these goals, it is important to improve the BMI in patients who are overweight or obese. The typical participant in this project will be an overweight or obese adult who is interested in reducing their BMI. This will improve their overall health and wellness.
This outpatient clinic consists of one medical doctor, one nurse practitioner, one medical assistant, one billing/marketer and one office manager who also checks in and out the patient.
The current work culture in this office is one where all the employees are encouraged to work together as a team. The staff is encouraged to vocalize questions or concerns they may have.
This organizational need was established because it is estimated that more than 50% of the patients in this office are either overweight or obese and many of them have comorbidities associated with being overweight or obese.
The stakeholders who will benefit from this project will be the patients, their families, the medical providers and the insurance companies. The organization is in full support of this project. The medical providers are willing to help identify which patients will be good candidates for this project. Once identified they will be entered into the project. The office staff will be responsible for scheduling the telehealth appointments. They will also be responsible to call the participants the day before their scheduled telehealth visit to confirm their appointments.
If an appointment is missed, the office staff will follow up to get them scheduled as soon as possible. Upon completion of this project, if it is deemed successful, then a weight management clinic will be implemented full time for this practice.
One of the strengths of having the setting in a private practice office is it limits some of the aggressive regulations or formal rules that are put in place in a larger corporate facility. It will also provide ease in communication with the staff. The weakness the project will be if there are technology barriers for the participants. The participants will need to perform telehealth on their computer or smart phone. Education will need to be provided to make sure during the telehealth visits the participant is in a secure location so privacy is not an issue. However, in the long run it will save the insurance companies money by improving health and reducing the need for medications.

SMART Objectives
This objective of this project is to reduce the BMI of participants who are overweight or obese. This will be accomplished by weekly weigh-ins via Telehealth with the nurse practitioner over an eight-week period of time. During these weekly meetings diet and exercise will be discussed. It is anticipated that there will be a one-point reduction in BMI after eight weeks. A reduction in BMI aligns with the organization's current vision of improving health and preventive medicine. The SMART objective in one sentence is: There will be a one-point reduction in BMI for the participants who completes weekly weigh-ins via telehealth with a nurse practitioner over an eight-week period of time.

Implementation of Plan
The implementation of this project is guided based off the change theory by Lippitt, Watson, and Westley's, Seven Phases of Change.

Diagnosing the problem
The primary care provider, or the staff identifying if a patient has a BMI > 25 based off review of the electronic medical record.

Assess the motivation and capacity for change in the system
Once the potential participant is identified by a BMI > 25, the nurse practitioner will discuss what the BMI tool is, what the ranges are, what it means, and how it adversely affects the patient.

Assessing the motivation
The nurse practitioner will assess if the patient is willing and motivated to participate in the project. This will be accomplished by asking the patient if they are interested in reducing their BMI and if they are willing to commit to an eight week program to improve their BMI.

Assessing the resources and motivation of the change agent
The nurse practitioner will assess if the potential participant has access to a computer or a smartphone and if they are capable to use the technology appropriately. The participant will also need to have access to the same scale and use it weekly for weigh-in.

Establishing change objectives and strategies
The medical provider and the potential participant will discuss goals and strategies so the participant can be successful. Some of the goals and strategies will be discussing diet and exercise. At the initial discussion of joining the program the nurse practitioner will provide a handout on diet and exercise. The information on diet will come from the myplate.gov website.
The participants will also be advised to go to the myplate.gov website. Additional links will be to the CDC website for physical activity https://www.cdc.gov/physicalactivity/index.html. The CDC recommends that adults have at last 150 minutes a week of moderate intense activity such as brisk walking and at least two days of muscle strengthening (CDC, 2022b). The nurse practitioner will review exercise options for each participant to find something that is suitable and interesting for the patient.
The participants of this project will be notified of potential risks. One of the potential risks are that the patient may gain weight and become sick despite participating in telehealth. There could be a breach in privacy. The participants could be discouraged if he/she is not successful in reducing the BMI. The benefits of the project outweigh the potential risks.

Determining the role of the change agent
The nurse practitioner who will oversee this project will discuss with the team members of this project what their roles are and what is expected from them. The medical scheduling department will be responsible for scheduling the telehealth visits and calling ahead the day before the appointment to remind them of their appointment. The scheduling department will also be responsible for calling the participants if the miss their appointment and then rescheduling them. The nurse practitioner will be responsible for recruiting the participants. The nurse practitioner will also be responsible for weekly telemedicine visits which will include counseling and weigh-in weekly.

Maintaining the change
After the participant is successful with reducing their BMI by one point, the participant will develop new goals and strategies to continue working towards a normal BMI of <25.

Gradually terminating the helping relationship as the change becomes part of the organizational culture
After the participant has a normal BMI, the patient will continue with the new lifestyle that they created. The practice would continue to reevaluate the patient every quarter and at their annual physical.

Attrition
There will be a certain percentage of participants who will join the project and will need to drop out for various reasons. The nurse practitioner who will be conducting this program will be motivational through the process. Diet and lifestyle changes are hard. If someone misses their telehealth appointment, the nurse practitioner will follow up with a telephone call to try to keep them motivated.

Project Schedule
The project schedule for NUR 7801 started with meeting with the preceptor during week one and continued weekly. It is also anticipated that we will continue to have weekly meetings throughout the year. Preparing the project proposal has been an ongoing process since the start of week one and will continue until week twelve when the proposal will be competed. Week thirteen the project will be submitted for approval. By week fifteen it is expected to have an approval from the review board to start the project.
Beginning of NUR 7802, week one will be orientation for the staff to discuss their roles and responsibilities for this project. The nurse practitioner will recruit patients as she sees them until the end of week 3. During that time at the end of each week she will review the charts of the patients that were seen to identify if they may be potential candidates. The physician, medical assistant and office manager will also be educated to look at the charts of the patients they see to identify if the patients they are seeing have a BMI>25. If they do, they will give the patients name to the nurse practitioner who will discuss with the patient that the office is doing a project to improve BMI. The nurse practitioner will assess if they would be a good candidate to participate in this project. Once the participants are officially entered into the project, the office manage will be responsible for scheduling the patients for weekly telehealth appointments for eight weeks. The office manager or the medical assistant will call the participants a day ahead of time to remind them of their telehealth visit that is scheduled with the nurse practitioner. The goal will be to start all the participants by week four and complete by week twelve. If possible, all the participants will be scheduled to be seen on the same day, once a week ex: Tuesday. Week twelve and thirteen will be analyzing the data.

Project Budget
The project budget will be minimal. There will be the cost of handouts on diet and exercise. There will be no changes in the salaries or overtime for the staff who will be participating in the project. The time and efforts for the staff will be during their normal working hours. The nurse practitioner who will be overseeing the project will be doing this during her regular scheduled office time. The participants who participate in the project will be required to have access to a computer or a smartphone for telehealth visits. They will also need to have access to a scale. The scale that they use will be the same scale for weekly weigh-ins for all eight weeks of this project. The participants will be instructed to weigh themselves the first thing in the morning, naked or wearing the same clothing to help reduce variation in weight.

Communication Plan
If the staff (doctor, office manage or medical assistant) identifies a patient who has a BMI > 25 there will be a list in a folder where they will write down the patients name, date of birth and BMI. The nurse practitioner will review the list of potential participants and if they qualify she will call them to discuss the project and determine if they want to participate. If the nurse practitioner identifies a patient with a BMI > 25 she will discuss it with them at the current visit. She will discuss what the BMI is. What normal ranges are and the risk factors of being overweight or obese. Then she will assess their readiness to change. If they are interested in working on a diet, exercise and weekly weigh-ins via telehealth then they will be entered into the program.
During the weekly weigh-in the questions the nurse practitioner will ask the participant will be: • Did you exercise this week? If so what kind of exercise did you do? And How much time was spent exercising?
• Are you following the Myplate guidelines?
• Do you feel like you are making good food choices? If not how can you improve?
• What is an example of what you ate? How was it cooked?
• How are you feeling?
• How do you feel like you are doing?
• How much did you weigh today?
The nurse practitioner will reassess the participants BMI at week 4 and week 8 of the project.

Evaluation Plan
The nurse practitioner kept an excel spreadsheet that logged the patients baseline height, weight, and BMI. Each week the nurse practitioner had a weekly telehealth visit with each participant. During the weekly telehealth visits, the nurse practitioner logged the patient's weight as well as documented the following questions: After the project was completed, a statistical analysis was compared using the paired t-test. It was used to compare the Pre and Post measurements to assess if the interventions made a statistically significant change.
There was a total of 17 participants in this project. There were 10 females and 7 males.
The attrition rate was one and that participant dropped out after week one. The attrition rate was low I think this is because the participants really wanted to lose weight and improve their health.
There were two participants who missed one week of weigh-ins and one person missed two weeks of weigh-ins.
The ages of the participants ranged between 30 years of age and 72 years of age. The mean age was 51.35. The median age was 54. The BMI range at the start of the project was between 25.5-37.6. The BMI range at the end of the project was 24.5-36.1. The average BMI at the start of the project was 30.0. The average BMI at the end of the project was 29.56. The weight range at the start of the project was between 137lb-262lb. The weight range at the end of the project was 134.6lb-265lb.
At t-test was conducted to examine whether there was a difference between the Pre and Post BMI. The result of the paired t-test was not significant based on an alpha value of .05, t(15) = 1.45, p = .168, indicating the null hypothesis cannot be rejected. This finding suggests the difference in the mean of Pre BMI and the mean of Post BMI was not significantly different from zero.
A two-tailed paired samples t-test was conducted to examine whether the mean difference of Pre weight and Post weight was significantly different from zero. The result of the two-tailed paired samples t-test was not significant based on an alpha value of .05, t(15) = 1.28, p = .221, indicating the null hypothesis cannot be rejected. This finding suggests the difference in the mean of Pre weight and the mean of Post weight was not significantly different from zero. Three participants lost 1 BMI point.
At the end of the project all of the participants were asked how they felt the project went.
The consensus was the participants felt that they were making healthier food choices and exercising more. There were a few factors that should have been considered prior to this project starting. One factor was there several participants who acquired COVID during this project or had other unexpected health issues. This affected their diet and exercise abilities. Also, this project was conducted over the summer. During this time there were several participants who were traveling on holiday. They expressed how difficult it was to work on these lifestyle changes during holiday.

Impact
The goal of this project was to have a one-point decrease in BMI after weekly telemonitoring weigh-ins for eight weeks. After the project was completed, there was a net decrease in the average BMI but statistically speaking, this project did not have a significant impact. This information shows that performing this intervention alone, did not provide the results that were anticipated. This could be the results of the limitations of this project. One of the limitations of this project was there a small sample size. There were 17 participants. This leads to the question if this study was underpowered? Another limitation of this project was the length of time that the project was implemented for (eight weeks). The research shows that losing weight is a difficult task and it takes time and effort to create the necessary lifestyle changes to improve weight loss. This project required the participants to self-report their weight.
They were also advised prior to the start of the project to use the same scale every week for the weekly weigh-ins. Self-reporting can impact the objectivity of the quantitative data. One of the major impacts that was not anticipated was the enthusiasm of telehealth visits. Since COVID-19, telehealth visits have been more prominent than ever. The combination of busy lifestyles and technology savvy society telehealth will be the way of the future of medicine. This type of project may be implemented in this practice in the future. The results of this project indicate research will need to completed on additional interventions that can be implemented for better outcomes.

Dissemination Plan
Now that the project has been completed, it is important to disseminate the results.
Initially, the dissemination process will start internally at the facility that the project was conducted at. The person who would attend this presentation would be the medical director and the staff who participated in the project. It will be presented in the conference room using PowerPoint. It will also be presented to my peers/fellow students at the University of St.
Augustine using a poster presentation. Finally, I will submit the manuscript to SOAR at the University of St. Augustine for publication. Other ways this information could be disseminate could be a professional conference or in a professional journal such as the Journal for Nurse Practitioners. This project would be beneficial for all providers who are managing the care of people who are overweight or obese.

Conclusion
Overweight and obesity are major problems in the United States. The financial impact of this disease is putting a strain on the medical community. The purpose of this paper is to provide a discussion of the significance of being overweight, present a clinical question in PICOT format, discuss the theoretical framework and how this project was conducted, implemented, and evaluated. With lifestyle interventions, the support of medical staff, and weekly weigh-ins it was anticipated there would be a one-point reduction in BMI with weekly weigh-ins over an 8-week timeframe. The results indicated a practice change was not statistically significant. Further research will be needed to identify if additional interventions would provide better outcomes. Legend: NUR7801 NUR7802 NUR7803