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Recommendations Summary

AWM: Caloric Reduction and Nutrient Adequacy 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: Achieve Nutrient Adequacy During Weight Loss

    During weight loss, the registered dietitian nutritionist (RDN) should prescribe an individualized diet, including patient preferences and health status, to achieve and maintain nutrient adequacy and reduce caloric intake, based on one of the following caloric reduction strategies:

    • 1, 200kcal to 1, 500kcal per day for women and 1, 500kcal to 1, 800kcal per day for men (kcal levels are usually adjusted for the individual's body weight)
    • Energy deficit of approximately 500kcal per day or 750kcal per day
    • One of the evidence-based diets that restricts certain food types (such as high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake.

    Several studies report changes in nutrient adequacy with caloric restriction, however the extent of nutrient inadequacy and the nutrients affected are dependent on the composition of the diet followed, as well as on the nutritional needs of the individual. Limited research reports reductions in nutrient adequacy with weight loss through an energy restriction of at least 500kcal per day or daily consumption below 1, 200kcal per day.

    Rating: Strong
    Imperative

    AWM: Maintain Nutrient Adequacy during Weight Maintenance

    During weight maintenance, the RDN should prescribe an individualized diet (including patient preferences and health status) to maintain nutrient adequacy and reduce caloric intake for maintaining a lower body weight. Several studies report changes in nutrient adequacy with caloric restriction, however the extent of nutrient inadequacy and the nutrients affected are dependent on the composition of the diet followed, as well as on the nutritional needs of the individual. Limited research reports reductions in nutrient adequacy with weight loss through an energy restriction of at least 500kcal per day or daily consumption below 1, 200kcal per day.

    Rating: Strong
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      The RDN should consider patient preferences, health status, medications, socioeconomic status and individual factors (such as age, sex, actual body weight) when individualizing the diet. Strategies to achieve nutrient adequacy may include:

      • Consider including a variety of foods
      • Consider a vitamin and mineral supplement when appropriate
      • Consider increasing physical activity rather than further caloric restriction
      • Consider extending the weight loss timeframe to reach goal weight.

    • Potential Costs Associated with Application

      Costs of medical nutrition therapy (MNT) sessions vary, however MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      • Several studies report changes in nutrient adequacy with caloric restriction, however the extent of nutrient inadequacy and the nutrients affected are dependent on the composition of the diet followed, as well as on the nutritional needs of the individual (Ma et al, 2007; Truby et al, 2008)
      • Limited research reports reductions in nutrient adequacy with weight loss through an energy restriction of at least 500kcal per day or daily consumption below 1, 200kcal per day (Ashley et al, 2007; Noakes et al, 2004; Gardner et al, 2010)
      • Additional long-term studies in this area are needed.

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

      • Diets for weight loss (dietary strategies for weight loss)
        • 3a. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss as part of a comprehensive lifestyle intervention. Any one of the following methods can be used to reduce food and calorie intake
          • a. Prescribe 1, 200kcal to 1, 500kcal per day for women and 1, 500kcal to 1, 800kcal per day for men (kcal levels are usually adjusted for the individual's body weight)
          • b. Prescribe 500kcal per day or 750kcal per day energy deficit
          • c. Prescribe one of the evidence-based diets that restricts certain food types (such as high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake.
          • NHLBI Grade A (Strong). ACC/AHA Level of Evidence, Grade A.
        • 3b. Prescribe a calorie-restricted diet, for obese and overweight individuals who would benefit from weight loss, based on the patient's preferences and health status and preferably refer to a nutrition professional for counseling. A variety of dietary approaches can produce weight loss in overweight and obese adults, as presented in CQ3, ES2. NHLBI Grade A (Strong). ACC/AHA Level of Evidence, Grade A.
      • Lifestyle Intervention and Counseling (Comprehensive Lifestyle Intervention)
        • 4d. Some commercial-based programs that provide a comprehensive lifestyle intervention can be prescribed as an option for weight loss, provided there is peer-reviewed published evidence of their safety and efficacy. NHLBI Grade B (Moderate). ACC/AHA Level of Evidence, Grade A.
        • 4e. Use a very-low-calorie-diet (defined as less than 800kcal per day) only in limited circumstances and only when provided by trained practitioners in a medical care setting where medical monitoring and high-intensity lifestyle intervention can be provided. Medical supervision is required because of the rapid rate of weight loss and potential for health complications. NHLBI Grade A (Strong). ACC/AHA Level of Evidence, Grade A.
        • 4g. For weight loss maintenance, prescribe face-to-face or telephone-delivered weight loss maintenance programs that provide regular contact (monthly or more frequent) with a trained interventionist who helps participants engage in high levels of physical activity (i.e., 200 to 300 minutes per week), monitor body weight regularly (i.e., weekly or more frequent) and consume a reduced-calorie diet (needed to maintain lower body weight). NHLBI Grade A (Strong). ACC/AHA Level of Evidence, Grade A.

    • Recommendation Strength Rationale

      • The Conclusion Statement in support of this recommendation received Grade II
      • ACC/AHA/TOS recommendations either given NHLBI Grade A (Strong) or Grade B (Moderate), ACC/AHA Level of Evidence Grade A. Recommendations 3a, 3b, 4d, 4e and 4g were based on Critical Questions 3 and 4, which analyzed systematic reviews and meta-analyses (the literature search included those published from January 2000 to October 2011) and added major RCTs published after 2009 with greater than 100 people per treatment arm.

    • Minority Opinions

      Consensus reached.