AWM: Coordination of Care 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.
AWM: Coordinate Care with Interdisciplinary Team
For weight loss and weight maintenance, the registered dietitian nutritionist (RDN) should implement medical nutrition therapy (MNT) and coordinate care with an interdisciplinary team of health professionals (may include specialized RDNs, nurses, nurse practitioners, pharmacists, physicians, physician assistants, physical therapists, psychologists, social workers, and so on), especially for patients with obesity-related co-morbid conditions. Coordination of care may include collaboration on:
- Use of FDA-approved weight-loss medications
- Appropriateness of bariatric surgery for people who have not achieved weight loss goals with less invasive weight loss methods.
Coordination of care with an interdisciplinary team of health professionals promotes the greatest effectiveness of MNT.
AWM: Recommend Use of Community Resources
The registered dietitian nutritionist (RDN) should recommend use of community resources, such as local food sources, food assistance programs, support systems and recreational facilities. Moderately strong evidence indicates a relationship between the food environment and dietary intake.
Risks/Harms of Implementing This Recommendation
Surgery is associated with complications such as pulmonary embolism and post-operative death.
Conditions of Application
Potential Costs Associated with Application
Costs of medical nutrition therapy (MNT) sessions vary; however, MNT sessions are essential for improved outcomes.
Behavioral Counseling in Primary Care to Promote a Healthy Diet
The United States Preventive Services Task Force (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.
From the 2010 Dietary Guidelines Advisory Committee (DGAC) Nutrition Evidence Library (NEL) Evidence-Based Systematic Reviews
What is the relationship between the environment, body weight and fruit and vegetable consumption?
- An emerging body of evidence has documented the impact of the food environment and select behaviors on body weight in both children and adults. Moderately strong evidence now indicates that the food environment is associated with dietary intake, especially less consumption of vegetables and fruits and higher body weight.
- The presence of supermarkets in local neighborhoods and other sources of vegetables and fruits are associated with lower body mass index (BMI), especially for low-income Americans, while lack of supermarkets and long distances to supermarkets are associated with higher BMI
- Limited but consistent evidence suggests that increased geographic density of fast-food restaurants and convenience stores is also related to increased BMI.
Selecting Patients for Bariatric Surgical Treatment for Obesity (Bariatric Surgical Treatment for Obesity)
- 5a. Advise adults with a BMI 40kg/m2 or more or BMI 35kg/m2 or more with obesity-related co-morbid conditions, who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve targeted health outcome goals, that bariatric surgery may be an appropriate option to improve health and offer referral to an experienced bariatric surgeon for consultation and evaluation. NHLBI Grade A (Strong). ACC/AHA Level of Evidence Grade A.
- 5b. For individuals with a BMI less than 35kg/m2, there is insufficient evidence to recommend for or against undergoing bariatric surgical procedures. NHLBI Grade N (No Recommendation). ACC/AHA Level of Evidence Grade is not applicable.
- 5c. Advise patients that the choice of a specific bariatric surgical procedure may be affected by patient factors, including age, severity of obesity and BMI, obesity-related co-morbid conditions, other operative risk factors, risk of short- and long-term complications, behavioral and psychosocial factors and patient tolerance for risk as well as provider factors (surgeon and facility). NHLBI Grade E (Expert Opinion). ACC/AHA Level of Evidence Grade C.
Recommendation Strength Rationale
- The Conclusion Statements for Energy Balance and Weight Management, Food Environment and Dietary Behaviors in support of this recommendation received a grade of Moderate
- ACC/AHA/TOS recommendations given either NHLBI Grade A (Strong), Grade E (Expert Opinion) or Grade N (No Recommendation), ACC/AHA Level of Evidence Grades A, C and Not Applicable. Recommendations 5a, 5b, and 5c were based on Critical Question 5, which analyzed systematic reviews and meta-analyses (the literature search included those published from January 2000 to October 2011) and added some major studies published after 2009.
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 not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
Academy of Nutrition and Diatetics. 2010 Dietary Guidelines Advisory Committee (DGAC) Nutrition Evidence Library (NEL) Evidence-Based Systematic Reviews. Available at http://www.nutritionevidencelibrary.gov/category.cfm?cid=21.
Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity. Cochrane Database Syst Rev. 2009 Apr 15; (2): CD003641.
Flodgren G, Deane K, Dickinson HO, Kirk S, Alberti H, Beyer FR, Brown JG, Penney TL, Summerbell CD, Eccles MP. Interventions to change the behavior of health professionals and the organisation of care to promote weight reduction in overweight and obese people. Cochrane Database Syst Rev. 2010 Mar 17; (3): CD000984.
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. 2014; 63(25 Pt B): 2, 985-3, 023.
Padwal R, Li SK, Lau DC. Long-term pharmacotherapy for obesity and overweight. Cochrane Database Syst Rev. 2004; (3): CD004094.