专科护士协调下超重或肥胖患者多学科管理门诊的建设及评价

doi:10.3761/j.issn.0254-1769.2026.11.012

摘要/Abstract

摘要：

目的建设专科护士协调下超重或肥胖患者多学科管理门诊，并评价其实践成效，为优化多学科协作、改善患者的体重管理效果提供参考。方法杭州市某三级甲等医院于2025年设立超重或肥胖患者多学科协作管理门诊，筛选专科护士、构建信息化平台，同时明确专科护士的工作内容，包括健康评估及分诊、诊疗衔接与协调、建立患者档案、体重管理随访、健康教育等。连续选取2025年4月10日—8月31日在该门诊就诊且已接受3个月多学科管理的患者作为研究对象，比较就诊前及就诊3个月后患者的人体测量与身体成分指标、生理及代谢指标正常比例，并收集患者的依从性、随访率及满意度。结果最终纳入139例患者，与就诊前比较，就诊3个月后患者的体重、BMI、腹围、腰围、体脂率及内脏脂肪面积等指标均降低，血压、空腹血糖、总胆固醇、甘油三酯、低密度脂蛋白、尿酸等指标正常比例均升高，差异具有统计学意义（P<0.05）。患者的诊疗路径完成率为100%、饮食依从性为84.17%、运动依从性为69.06%、用药依从性为92.09%、随访率为100%、满意度为100%。结论在专科护士协调下，超重或肥胖患者多学科管理门诊的诊疗效率较高，有助于减轻患者的肥胖程度，提高代谢水平。

关键词: 超重, 肥胖, 多学科协作, 专科护士, 门诊, 护理管理研究

Abstract:

Objective To establish a multidisciplinary clinic for overweight or obese patients coordinated by specialized nurses，evaluate its effectiveness，and provide insights for optimizing multidisciplinary collaboration and improving patients’ weight management outcomes. Methods A tertiary hospital in Hangzhou established a multidisciplinary collaborative management clinic for overweight or obese patients in 2025. The hospital selected specialized nurses，built an information platform，and defined the nurses’ responsibilities，including health assessment and triage，coordinating care transitions，establishing patient records，conducting weight management follow-ups，and delivering health education. Patients who attended this outpatient clinic from April 10 to August 31，2025，and had received 3 months of multidisciplinary management were consecutively enrolled as study subjects. This study compared changes in the proportion of patients with normal anthropometric，body composition，physiological and metabolic indicators before and after the 3-month intervention. In addition，patient compliance，follow-up rates and satisfaction scores were collected. Results A total of 139 patients were ultimately included in the study. Compared with pre-treatment measurements，the patients exhibited statistically significant reductions in body weight，BMI，abdominal circumference，waist circumference，body fat percentage，and visceral fat area at 3 months post-treatment. Concurrently，the proportion of patients who achieved normal levels of blood pressure，fasting blood glucose，total cholesterol，triglycerides，LDL cholesterol，and uric acid increased significantly（P<0.05）. The patient completion rate for the treatment pathway was 100%，with dietary adherence at 84.17%，exercise adherence at 69.06%，and medication adherence at 92.09%. The follow-up and satisfaction rates both reached 100%. Conclusion Under the coordination of specialized nurses，multidisciplinary weight management clinics for overweight and obese patients exhibit high clinical efficacy. This approach helps reduce patients’ obesity severity，improve metabolic health.

Key words: Overweight, Obesity, Multidisciplinary Team, Specialist Nurses, Outpatient, Nursing Administration Research

吴觅之, 魏惠燕, 潘红英, 张燕, 姚单芳, 王佳璐, 李琼琼. 专科护士协调下超重或肥胖患者多学科管理门诊的建设及评价[J]. 中华护理杂志, 2026, 61(11): 1527-1534.

WU Mizhi, WEI Huiyan, PAN Hongying, ZHANG Yan, YAO Shanfang, WANG Jialu, LI Qiongqiong. Establishment and evaluation of a multidisciplinary management clinic for overweight or obese patients coordinated by specialist nurses[J]. Chinese Journal of Nursing, 2026, 61(11): 1527-1534.

图/表 2

表1 就诊前后超重或肥胖患者的人体测量与身体成分指标比较（n=139，$\bar{x}\pm s$）

Table 1 Comparison of body weight-related measurements before and after 3 months of intervention（n=139，$\bar{x}\pm s$）

表2 就诊前后超重或肥胖患者的生理及代谢指标正常比例比较[n=139，例（百分率，%）]

Table 2 Comparison of metabolic indicators before and after 3 months of intervention[n=139，cases（percentage，%）]

参考文献 29

[1]	Chen K, Shen ZW, Gu WJ, et al. Prevalence of obesity and associated complications in China:a cross-sectional,real-world study in 15.8 million adults[J]. Diabetes Obes Metab, 2023, 25(11):3390-3399.
[2]	刘明康, 林思颖, 江剑平. 政策驱动下我国居民体重健康管理困境与应对策略[J]. 福建师范大学学报(自然科学版), 2025, 41(4):73-77.
	Liu MK, Lin SY, Jiang JP. Challenges and coping strategies for weight health management of Chinese residents under policy-driven conditions[J]. J Fujian Norm Univ Nat Sci Ed, 2025, 41(4):73-77.
[3]	Rotunda W, Rains C, Jacobs SR, et al. Weight loss in short-term interventions for physical activity and nutrition among adults with overweight or obesity:a systematic review and meta-analysis[J]. Prev Chronic Dis, 2024,21:E21.
[4]	Anderson JW, Konz EC, Frederich RC, et al. Long-term weight-loss maintenance:a meta-analysis of US studies[J]. Am J Clin Nutr, 2001, 74(5):579-584.
[5]	Rosenbaum M, Foster G. Differential mechanisms affecting weight loss and weight loss maintenance[J]. Nat Metab, 2023, 5(8):1266-1274.
[6]	国家卫生健康委员会,全国爱卫办,教育部,等. “体重管理年”活动实施方案[EB/OL]. (2024-06-06)[2025-10-09]. https://www.gov.cn/zhengce/zhengceku/202406/content_6959543.htm.
	National Health Commission,Office of the National Patriotic Health Campaign Committee,Ministry of Education,et al. Im-plementation plan for the “Weight Management Year” initiative[EB/OL]. (2024-06-06)[2025-10-09]. https://www.gov.cn/zhengce/zhengceku/202406/content_6959543.htm.
[7]	程文迪, 刘佳美, 王海银, 等. 我国公立医院体重管理中心和门诊建设现状研究[J]. 健康发展与政策研究, 2025, 28(4):372-378,385.
	Cheng WD, Liu JM, Wang HY, et al. The current status of weight management centers and outpatient clinics in China’s public hospitals[J]. Health Dev Policy Res, 2025, 28(4):372-378,385.
[8]	宋婷, 张乃芬, 陈敏. 品管圈在提高多学科联合门诊患者就诊满意度中的应用效果[J]. 护理学杂志, 2024, 13(2):181-185.
	Song T, Zhang NF, Chen M. The application effect of quality control circle in improving the satisfaction of multidisciplinary joint outpatient service[J]. Nurs Sci, 2024, 13(2):181-185.
[9]	毛文平, 骆金铠, 王力华, 等. 智能交互出院随访平台的构建与应用研究[J]. 中华护理杂志, 2024, 59(15):1812-1817.
	Mao WP, Luo JK, Wang LH, et al. Construction and application of an intelligent interactive discharge follow-up platform[J]. Chin J Nurs, 2024, 59(15):1812-1817.
[10]	Zhang H, Tong T, Gao Y, et al. Translation of the Chinese version of the Modified Yale Food Addiction Scale 2.0 and its validation among college students[J]. J Eat Disord, 2021, 9(1):116.
[11]	Spitzer RL, Kroenke K, Williams JBW, et al. A brief measure for assessing generalized anxiety disorder:the GAD-7[J]. Arch Intern Med, 2006, 166(10):1092-1097.
[12]	Zuithoff NPA, Vergouwe Y, King M, et al. The Patient Health Questionnaire-9 for detection of major depressive disorder in primary care:consequences of current thresholds in a cross-sectional study[J]. BMC Fam Pract, 2010,11:98.
[13]	国家卫生和计划生育委员会. 学龄儿童青少年超重与肥胖筛查:WS/T 586-2018[S/OL]. (2018-02-23)[2025-03-10]. http://www.nhc.gov.cn/ewebeditor/uploadfile/2018/03/20180330094031-236.pdf.
	National Health and Family Planning Commission of the People’s Republic of China. Screening for overweight and obesity in school-age children and adolescents:WS/T 586-2018[S/OL]. (2018-02-23)[2025-03-10]. http://www.nhc.gov.cn/ewebeditor/uploadfile/2018/03/20180330094031-236.pdf.
[14]	苟晓瑜, 李梦洁, 卢楠, 等. 超重或肥胖患者饮食或运动干预依从性促进和阻碍因素的Meta整合[J]. 中华护理杂志, 2024, 59(18):2269-2276.
	Gou XY, Li MJ, Lu N, et al. Facilitators and barriers to adherence to diet or exercise interventions in patients with overweight or obesity:a Meta-synthesis[J]. Chin J Nurs, 2024, 59(18):2269-2276.
[15]	Wyse J, Mercer T, Ashford B, et al. Evidence for the validity and utility of the Stages of Exercise Behaviour Change Scale in young adults[J]. Health Educ Res, 1995, 10(3):365-377.
[16]	Kroll T, Kehn M, Ho PS, et al. The SCI Exercise Self-Efficacy Scale(ESES):development and psychometric properties[J]. Int J Behav Nutr Phys Act, 2007,4:34.
[17]	向心月, 张冰青, 欧阳煜钦, 等. 短期内科门诊减重对肥胖患者动脉粥样硬化性心血管疾病风险的影响研究[J]. 中国全科医学, 2025, 28(26):3229-3239.
	Xiang XY, Zhang BQ, Ouyang YQ, et al. Impact of short-term medical weight loss on atherosclerotic cardiovascular disease risk in patients with obesity[J]. Chin Gen Pract, 2025, 28(26):3229-3239.
[18]	Markovic TP, Proietto J, Dixon JB, et al. The Australian Obe-sity Management Algorithm:a simple tool to guide the mana-gement of obesity in primary care[J]. Obes Res Clin Pract, 2022, 16(5):353-363.
[19]	Burden S, Jones DJ, Sremanakova J, et al. Dietary interventions for adult cancer survivors[J]. Cochrane Database Syst Rev, 2019, 2019(11):CD011287.
[20]	Malarvizhi D, Dinesh AM. Effectiveness of lumbar flexors and extensors muscle strengthening exercises on waist-hip ratio in overweight adolescents[J]. Ind Jour Publ Health Rese & Deve-lop, 2018, 9(9):21.
[21]	McGill SM, Cambridge EDJ, Andersen JT. A six-week trial of hula hooping using a weighted hoop:effects on skinfold,girths,weight,and torso muscle endurance[J]. J Strength Cond Res, 2015, 29(5):1279-1284.
[22]	Berger AA, Peragallo-Urrutia R, Nicholson WK. Systematic review of the effect of individual and combined nutrition and exer-cise interventions on weight,adiposity and metabolic outcomes after delivery:evidence for developing behavioral guidelines for post-partum weight control[J]. BMC Pregnancy Childbirth, 2014,14:319.
[23]	中华医学会内分泌学分会. 肥胖患者的长期体重管理及药物临床应用指南(2024版)[J]. 中华内分泌代谢杂志, 2024, 40(7):545-564.
	Chinese Society of Endocrinology. Guideline for chronic weight management and clinical practice of anti-obesity medications(2024 version)[J]. Chin J Endocrinol Metab, 2024, 40(7):545-564.
[24]	Collins KA, Kraus WE, Rogers RJ, et al. Effect of behavioral weight-loss program on biomarkers of cardiometabolic disease risk:heart health study randomized trial[J]. Obesity, 2023, 31(2):338-349.
[25]	周晓东, 田娜, 郑明华. 《2023年国际多学科专家共识:代谢相关脂肪性肝病和心血管疾病风险》摘译[J]. 临床肝胆病杂志, 2023, 39(10):2336-2339.
	Zhou XD, Tian N, Zheng MH. Excerpt of an international multidisciplinary consensus statement on MAFLD and the risk of CVD(2023)[J]. J Clin Hepatol, 2023, 39(10):2336-2339.
[26]	杨雁, 陈颖, 张惠杰, 等. 糖尿病患者体重管理专家共识(2024版)[J]. 中华糖尿病杂志, 2024, 16(9):959-971.
	Yang Y, Chen Y, Zhang HJ, et al. Expert consensus on weight management in patients with diabetes mellitus(2024 edition)[J]. Chin J Diabetes Mellit, 2024, 16(9):959-971.
[27]	Díez-Ricote L, Cuadrado-Soto E, Pastor-Fernández A, et al. Ef-fect of a multifactorial weight loss intervention on HDL cholesterol efflux capacity and immunosenescence:a rando-mized controlled trial[J]. J Am Nutr Assoc, 2025, 44(2):166-179.
[28]	Sahebzamani FM. Management of inadequate weight loss or weight regain in post-bariatric surgical patients[J]. J Am Assoc Nurse Pract, 2020, 32(7):490-492.
[29]	冯洁惠, 殷钰, 吴一女, 等. 专科护士主导的跨学科协作照护模式的构建与实践研究[J]. 中华护理杂志, 2025, 60(23):2821-2827.
	Feng JH, Yin Y, Wu YN, et al. Development and implemen-tation of an interdisciplinary collaborative care model led by specialty nurses[J]. Chin J Nurs, 2025, 60(23):2821-2827.