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Recommendations Summary

AWM: Screening and Referral for MNT 2014

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    AWM: Annual Screening for Overweight/Obesity

    The registered dietitian nutritionist (RDN), in collaboration with other health care professionals, administrators and public policy decision-makers, should ensure that all adult patients have the following measurements at least annually:

    • Height and weight to calculate BMI, classified as overweight (BMI more than 25.0kg/m2 to 29.9kg/m2) or obese
      • Class I obesity: BMI 30kg/m2 to 34.9kg/m2
      • Class II obesity: BMI 35kg/m2 to 39.9kg/m2
      • Class III (extreme) obesity: 40kg/m2 or higher.
    • Waist circumference to determine the risk of CVD, type 2 diabetes and all-cause mortality
      • NIH/NHLBI
        • Men: More than 102cm (more than 40 inches)
        • Women: More than 88cm ( more than 35 inches).
    Annual BMI screening will identify adults who are overweight or obese and therefore may be at elevated risk of CVD and all-cause mortality. In addition, the greater the waist circumference, the greater the risk of CVD, type 2 diabetes and all-cause mortality.

    Rating: Fair
    Imperative

    AWM: Referral to RDN for Medical Nutrition Therapy

    The RDN, in collaboration with other health care professionals, administrators and public policy decision-makers, should ensure that overweight or obese adults are referred to an RDN for medical nutrition therapy (MNT). Intensive counseling and behavioral interventions promote sustained weight loss and reduce known risk factors for diet-related chronic disease.

    Rating: Fair
    Imperative

    • Risks/Harms of Implementing This Recommendation

      Adequate evidence indicates that the harms of screening for obesity are small.

    • Conditions of Application

      Body mass index is calculated from the measured weight and height of an individual. Waist circumference may be an acceptable alternative to BMI measurement in some patient sub-populations.

    • Potential Costs Associated with Application

      Costs of MNT sessions vary, however MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      From Screening for Obesity in Adults (2012)

      The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a BMI of 30kg/m2 or higher to intensive, multi-component behavioral interventions. Grade B

      From Behavioral Counseling in Primary Care to Promote a Healthy Diet (2003)

      The USPSTF recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians. Grade B

      From AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults (2013)

      Identifying patients who need to lose weight (BMI and waist circumference):

      • 1a. Measure height and weight and calculate BMI at annual visits or more frequently
        • NHLBI Grade E (Expert Opinion)
        • ACC/AHA Level of Evidence Grade C.
      • 1b. Use the current cut-points for overweight (BMI more than 25.0kg/m2 to 29.9kg/m2) and obesity (BMI 30kg/m2 or more) to identify adults who may be at elevated risk of CVD and the current cut-points for obesity (BMI 30 kg/m2 or more) to identify adults who may be at elevated risk of mortality from all causes
        • NHLBI Grade A (Strong)
        • ACC/AHA Level of Evidence Grade B.
      • 1c. Advise overweight and obese adults that the greater the BMI, the greater the risk of CVD, type 2 diabetes and all-cause mortality
        • NHLBI Grade A (Strong)
        • ACC/AHA Level of Evidence Grade B.
      • 1d. Measure waist circumference at annual visits or more frequently in overweight and obese adults. Advise adults that the greater the waist circumference, the greater the risk of CVD, type 2 diabetes and all-cause mortality. The cut-points currently in common use (from either NIH/NHLBI or WHO/IDF) may continue to be used to identify patients who may be at increased risk until further evidence becomes available.
        • NHLBI Grade E (Expert Opinion)
        • ACC/AHA Level of Evidence Grade B.

    • Recommendation Strength Rationale

      • The Academy of Nutrition and Dietetics Adult Weight Management Work Group concurs with the references cited
      • United States Preventive Services Task Force recommendations both given Grade B
      • ACC/AHA/TOS recommendations given either NHLBI Grade A (Strong) or Grade E (Expert Opinion), ACC/AHA Level of Evidence Grades B and C. Recommendations 1a, 1b, 1c and 1d were based on Critical Question 2, which analyzed systematic reviews and meta-analyses. The literature search included those published from January 2000 to October 2011.

    • Minority Opinions

      Consensus reached.

  • Supporting Evidence

    The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

    • References
    • References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

      • Jensen MD, Ryan DH, Apovian CM, Loria CM, Ard JD, Millen BE, Comuzzie AG, Nonas CA, Donato KA, Pi-Sunyer FX, Hu FB, Stevens J, Hubbard VS, Stevens VJ, Jakicic JM, Wadden TA, Kushner RF, Wolfe BM, Yanovski SZ. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults. J Am Coll Cardiol. 2013 Nov 7. doi: 10.1016/j.jacc.2013.11.004.
      • United States Preventive Services Task Force. Screening for and Management of Obesity in Adults. Release date: June 2012. Accessible at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsobes.htm
      • United States Preventive Services Task Force. Behavioral counseling in primary care to promote a healthy diet: recommendations and rationale. Am J Prev Med. 2003 Jan; 24(1): 93-100.