Quick Links

  • Increase Font Size
  • Decrease Font Size
  • View as PDF

Recommendations Summary

AWM: Medical Nutrition Therapy Approach for Adult Overweight and Obesity Management 2022

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: Utilize the Nutrition Care Process

    It is reasonable for registered dietitian nutritionists or international equivalents to utilize the Nutrition Care Process to provide effective, client-centered interventions based on shared decision-making and clinical judgement and individualized to each client’s needs, circumstances, and goals.

    Rating: Consensus
    Conditional

    AWM: Provide Medical Nutrition Therapy

    Medical Nutrition Therapy provided by registered dietitian nutritionists or international equivalents is recommended for adults with overweight or obesity to improve cardiometabolic outcomes, quality of life, and weight outcomes, as appropriate for and desired by each client.

    Rating: Level 1(B)
    Imperative

    AWM: Adapt Goals and Interventions

    It is reasonable for registered dietitian nutritionists or international equivalents to monitor and evaluate client outcomes and adapt goals and interventions, including those for weight maintenance, and provide resources as needed for each client.

    Rating: Consensus
    Conditional

    AWM: Minimize Weight Bias and Stigma

    It is reasonable for registered dietitian nutritionists or international equivalents to minimize the effects of weight bias and weight stigma and its consequences by targeting client-centered goals, individualizing interventions according to complex contributors of overweight and obesity, communicating using client-preferred terms, and providing an inclusive physical environment.

    Rating: Consensus
    Conditional

    • Risks/Harms of Implementing This Recommendation

      There are few adverse events reported with overweight and obesity management interventions provided by a dietitian (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022). In contrast to supervised evidence-based treatment, self-directed dieting or caloric restriction may increase disordered eating behaviors (Cardel, Newsome et al. 2022). However, in some cases, mean effects from interventions provided by dietitians were small and, in comparison to the resources used for the intervention, this level of reduction may not be as beneficial for some adults with overweight or obesity as others. 

    • Conditions of Application

      Individualized Interventions Using the NCP

      When conducting overweight and obesity management interventions, dietitians adhere to scope and standards of practice(2018, Tewksbury, Nwankwo et al. 2022) and use the Nutrition Care Process (NCP) framework (Swan, Vivanti et al. 2017). A description of key elements to consider for each stage of the NCP when providing adult overweight and obesity management interventions is described in the NCP Figure. All interventions are initiated following a full nutrition assessment. During the assessment process, dietitians collect client information on factors that indicate if an intervention may be contraindicated due to other client health conditions (i.e., active eating disorders including overeating due to loss of control, women who are currently pregnant, those undergoing chemotherapy, etc.), a client's motivation level, and other socio- and economic factors. SA focus on weight loss is not always indicated and may not always result in overall health improvement. Rather, a focus on overall healthy eating habits coupled with increased physical activity and improved clinical outcomes such as reduction in blood pressure or cholesterol levels may be the goal. Following nutrition assessment, dietitians refer clients to complementary practitioners as needed, such as to a dietitian or mental health counselor specializing in eating disorders or an exercise specialist.

      During the initial session, the dietitian collaborates with the client to identify the client’s goals. Working together, the dietitian and the client establish and prioritize goals that are specific, measurable, attainable, relevant and time-based (S.M.A.R.T.). Factors such as genetics, social determinants of health (SDoH), knowledge, skills, abilities, and availability of cooking appliances may affect nutrition recommendations and client adherence. These are given consideration, when information is available, to best inform the development of the intervention. In all cases, MNT interventions is individualized to each client’s values, health status, environment, nutrition literacy, medications and other factors (Tewksbury, Nwankwo et al. 2022). In overweight and obesity management interventions, clients value specific, tailored, and usable diet and exercise plans (Bloom, Adler et al. 2018). The novelty or tailored aspect of a nutrition program or setting can motivate clients to participate, as can meaningful relationships with healthcare providers and other clients (in group settings) (Skea, Aceves-Martins et al. 2019). It is also important for the dietitian to incorporate proven counseling methods, such as motivational interviewing, to help clients facilitate desired behavior change (Tewksbury, Nwankwo et al. 2022). Dietitians work with clients to make small, acceptable changes towards their goals to sustain intervention adherence. Monitoring and evaluation of anthropometric and other outcomes can occur at scheduled sessions to track progress, when possible. Following the intervention, dietitians  monitor and evaluate client outcomes to adapt to changing client needs over time (Swan, Vivanti et al. 2017). Critical thinking is used when determining the appropriateness of each recommendation for each client (Swan, Vivanti et al. 2017). More detailed information on nutrition assessment, monitoring and evaluation can be found in the 2014 Academy AWM guideline (Academy of Nutrition and Dietitics' Evidence Analysis Center 2014).

      Inclusive, Non-Biased Care

      There are many factors that contribute to overweight and obesity beyond lifestyle behaviors, including genetics, SDoH and the environment (Centers for Disease Control and Prevention 2021, Tewksbury, Nwankwo et al. 2022). Thus, dietitians should not assume that a client’s weight status implies a lack of motivation, willpower, or unhealthy lifestyle behaviors. Dietitians should ask clients with overweight or obesity if and how they would like to talk about their weight, utilizing what terms they prefer to use when describing weight status or body size (Puhl 2020). Dietitians can ensure they are targeting outcomes important to the client by conducting a thorough nutrition assessment including motivational interviewing. Additional guidance to address internalized weight bias and weight stigma in the healthcare setting includes ensuring furniture, equipment and facilities can accommodate diverse body sizes (Howes, Harden et al. 2021). These techniques are also important when working with adults with disabilities. When conducting overweight and obesity management sessions, dietitians should strive to use inclusive, non-stigmatizing language and use a people-first approach (Ananthakumar, Jones et al. 2020, Howes, Harden et al. 2021). Dietitians are encouraged  to assess their own weight bias or other biases (Project Implicit 2011). All dietitians should provide compassionate, evidence-based and client-centered care to actively address weight stigma and end diet culture by prioritizing health over weight (Cardel, Newsome et al. 2022). Dietitians working with clients who are members of groups with high rates of overweight or obesity or who are under-represented may consider using resources and materials tailored to that group, such as those with low socio-economic status (U.S. Department of Agriculture 2022),  who are members of racial or ethnic minority groups, (National Organization of Blacks in Dietetics and Nutrition 2022, National Organization of Blacks in Dietetics and Nutrition 2022) or who are transgender or gender diverse (Linsenmeyer 2020).

    • Potential Costs Associated with Application

      Dietitian visits are less costly for insurers compared to visits to primary care physicians (Academy of Nutrition and Dietitics 2021). LOW certainty evidence demonstrated that overweight and obesity management interventions provided by dietitians may be cost-effective (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022).  Given the benefits demonstrated with overweight and obesity management interventions provided by a dietitian, the cost-benefit ratio of MNT provided by a dietitian is unlikely to be very high, and if MNT is successful, benefits may outweigh financial costs. Public and private payers may not be willing to cover overweight and obesity management interventions, particularly those provided by an interprofessional healthcare team. However, interventions provided by a dietitian may be less expensive and more cost-effective than visits to a medical doctor or more intensive therapies such as prescription drugs or surgery to treat co-morbidities (Academy of Nutrition and Dietitics 2021).

    • Recommendation Narrative

      Approximately 70% of the U.S. population is classified as having overweight or obesity by BMI (Fryar CD 2020) and individuals across all weight categories gain weight over time.(Botoseneanu and Liang 2012, Malhotra, Ostbye et al. 2013, Song, Hu et al. 2016). Thus, all healthcare practitioners, including dietitians, will likely work with adults with overweight or obesity. Consequences of overweight are less severe than obesity, but both increase risks for adverse health outcomes such as cardiometabolic diseases including cardiovascular disease and type 2 diabetes mellitus, mental health conditions, decreased quality of life (QoL) and, with obesity, decreased life expectancy (Centers for Disease Control and Prevention 2021). Interventions provided by dietitians have the potential to mitigate high rates of overweight and obesity and associated outcomes by tailoring interventions to the individual needs of each client to improve the likelihood of efficacy.

      The systematic review supporting this guideline demonstrated that interventions provided by dietitians may improve cardiometabolic outcomes, quality of life, and weight outcomes. Evidence certainty ranged from MODERATE to HIGH for cardiometabolic and weight outcomes and LOW to MODERATE for QoL (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022). However, heterogeneity in outcomes demonstrated that efficacy of interventions may vary in important ways across individuals and sub-populations (Summary of Findings Table, Relationships between Recommendation Statements and Evidence Table).(Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022) Recent systematic reviews have described that personalized nutrition interventions can improve dietary intake and cost-effectiveness compared to non-personalized interventions.(Galekop, Uyl-de Groot et al. 2021, Jinnette, Narita et al. 2021) In addition, many other factors outside of the client’s control such as environment, SDoH, health literacy and medications may impact intervention adherence and outcomes.(Centers for Disease Control and Prevention 2021) Thus, for interventions to be effective, they must be tailored to each individual client based on their needs, preferences and circumstances. Dietitians systematically assess, diagnose, intervene with, monitor and evaluate each individual client within the NCP framework to ensure consistent, high-quality nutrition care.(Swan, Vivanti et al. 2017) Interventions delivered with a team of health professionals, such as qualified exercise practitioners, mental health professionals, obesity medicine specialists, or primary care providers, may provide solutions to address complex etiologies of overweight and obesity. 

      Adults with overweight and obesity may experience internalized weight bias, which is described as negative ideologies associated with obesity, and weight stigma, which are discriminatory acts and ideologies targeted at an individual based on their weight and size.(World Obesity 2022) Experiencing weight stigma is associated with increased diabetes risk, depression, anxiety, lowered  self-esteem and increased C-reactive protein levels, among other outcomes.(Wu and Berry 2018, Alimoradi, Golboni et al. 2020) Addressing weight stigma in obesity treatment interventions may reduce weight bias, (Pearl, Wadden et al. 2020) though internalized weight bias may be difficult to address.(Mensinger, Calogero et al. 2016) Very low quality evidence describes that healthcare professionals, including dietitians, report both implicit and explicit weight-biased attitudes toward people with obesity.(Panza, Armstrong et al. 2018, Lawrence, Kerr et al. 2021) Clients’ engagement with health services can be negatively impacted when they perceive weight bias from healthcare professionals.(Alberga, Edache et al. 2019)  However, providing compassionate, client-centered care and providing evidence-based overweight and obesity management interventions are not mutually exclusive.(Cardel, Newsome et al. 2022) Dietitians and other healthcare providers have a responsibility to recognize weight stigma and weight bias as some of the many complex contributors to negative health outcomes related to overweight and obesity and consider how these factors may affect or be addressed in nutrition interventions.

    • Recommendation Strength Rationale

      The recommendation to provide medical nutrition therapy to adults with overweight or obesity, when appropriate and desired, is supported by evidence of beneficial effects on several outcomes including anthropometrics, blood pressure and quality of life. Evidence certainty ranged from HIGH to LOW. 

      Consensus recommendations are "best practice" recommendations. Effects of these practices are not easily or typically examined in research. However, expert panel members determined, based on clinical experience and related evidence, that these recommendations are important to consider when delivering weight management interventions. 

    • Minority Opinions

      No minority opinions.