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Recommendations Summary

AWM: Coordination of Care 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: Collaborate with Interprofessional Healthcare Team

  Registered dietitian nutritionists or international equivalents should collaborate with an interprofessional healthcare team to provide comprehensive, multi-component care for adults with overweight or obesity, as appropriate for and desired by each client.

  Rating: Level 1(C)
  Imperative

  AWM: Coordinate Care in a Variety of Settings

  Registered dietitian nutritionists or international equivalents providing medical nutrition therapy interventions for adults with overweight and obesity should coordinate care in a variety of settings, including primary care/outpatient, community and workplace settings, to access and support each client with resources in the environment that best suits individualized needs.

  Rating: Level 1(B)
  Imperative

  • Risks/Harms of Implementing This Recommendation

    Interventions involving physical activity with an exercise practitioner may carry an additional risk of adverse events, but evidence certainty was VERY LOW (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022) and risk of harm may not be greater than if individual clients attempted a physical activity intervention on their own (i.e., not under supervision).

    Data from the systematic review supporting this evidence-based practice guideline suggests that a blended format of one-on-one and group counseling may be most efficacious (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021). Thus, if only primarily group counseling is available in community and workplace settings, outcomes may not be as robust. Depending on the workplace culture, employees may not feel comfortable engaging in discussions about their personal eating habits with co-workers and/or supervisors. There may be distrust regarding how information obtained from a workplace wellness program could be used negatively against them for health insurance costs.

  • Conditions of Application

    Interprofessional Healthcare Team

    Use of an interprofessional healthcare team is considered when working with adults with specialized needs that are not within the scope of practice of the dietitian, such as working with an exercise practitioner for clients with specialized physical needs or a mental health professional for clients with specialized psychological needs.(Tewksbury, Nwankwo et al. 2022) Adults with a variety of life stressors (e.g., work-life balance, family caretaking responsibilities) may also benefit from inclusion of both mental health and physical activity professionals along with dietitian services to address overweight and obesity.(Cochrane, Dick et al. 2017) Referrals to other health professionals are standard practice, (Tewksbury, Nwankwo et al. 2022) and can increase client engagement and success.(Bloom, Adler et al. 2018) Potential members of the interprofessional healthcare team serving adults with overweight and obesity are described in Interprofessional Team Figure. To determine if an aspect of an intervention is within one’s scope of practice, dietitians can consult the Academy’s Scope of Practice Decision Algorithm tool (Academy of Nutrition and Dietitics 2021, Scope of Practice Decision Algorithm).

    Dietitians should maintain regular communication with other members of the healthcare team regarding client progress. Development of a joint care plan may be appropriate to ensure consistent strategies and messages are delivered by each member of the healthcare team working with the client. Dietitians can be key advocates for adults with overweight or obesity by providing education to other healthcare practitioners regarding the complex contributors to weight status. This collaboration may facilitate an improved physician perspective regarding client circumstances and motivation and improve empathy with the client (Ananthakumar, Jones et al. 2020).

    Primary Care Interventions

    Dietitians in private practice should seek to establish a relationship with primary care/outpatient providers in their local area who can provide MNT referrals for adult clients with overweight or obesity (Academy of Nutrition and Dietitics 2017). To the extent possible, the dietitian should have a physical presence in the primary care/outpatient setting to facilitate contact with adult clients and lessen client burden to attend separate appointments for MNT. This will also lead to improved communication between the dietitian and the primary care/outpatient provider and increase the likelihood that the dietitians will have access to the client’s medical records. The Intensive Behavioral Therapy for Obesity toolkit provides a detailed description of how to establish healthy partnerships with primary care/outpatient providers to treat obesity.(Academy of Nutrition and Dietitics 2017) Public and private payer reimbursement for overweight and obesity management is needed to ensure individuals have access to interventions.

    Community Interventions

    When developing adult overweight and obesity management interventions for community and public settings, dietitians should reach out to various community stakeholders (either individuals or organizations) to better understand the needs of the community and both challenges and opportunities in delivering such interventions.(Bruening, Perkins et al. 2022) Examples of community stakeholders may be a local government official, the county Cooperative Extension staff, a staff member or administrator from the local school district, or clergy from local places of worship. In addition, dietitians should stay updated on the availability of related programs and resources within the community that can support overweight and obesity management interventions (e.g., community gardens, exercise classes, etc.).

    When it is time to enroll participants in interventions in community and public settings, dietitians should network with community leaders and peer influencers to help with recruitment and encourage participation. Depending on the target population for the intervention, individuals who desire weight loss but who do not have overweight or obesity may seek to enroll. Dietitians should be aware of the baseline status of all participants in the intervention to tailor messages and goals appropriately. Dietitians working in community and public settings should consider standards of practice that can contribute to intervention efficacy (Bruening, Perkins et al. 2022).

    Adult clients encountered in community and public settings may be more likely to have food insecurity, which may be associated with overweight and obesity.(Hernandez, Reesor et al. 2017) Understanding the prevalence of food insecurity, availability of cooking equipment, and the existing food assistance programs available (e.g., the Supplemental Nutrition Assistance Program, food pantries), can improve rapport with clients and facilitate their ability to access and prepare healthy food.(Bruening, Perkins et al. 2022) The two-item Hunger Vital Sign tool has been validated for accuracy in identifying food insecurity (Makelarski, Abramsohn et al. 2017), and can be found on the Food Research & Action Center website (Food Research & Action Center 2022).

    Workplace Interventions

    Prior to beginning an intervention in the workplace setting, the dietitian should observe the workplace environment to better understand dynamics between employees. This knowledge can be used to design a custom intervention that factors in the unique barriers and/or facilitators to effective programs for that specific workplace. Conducting a baseline survey of employees may also yield insights regarding past attempts at weight loss as well as what employees are looking for in such a program. The dietitian should also consider a blended format of individual- and group-level counseling as well as in-person and telehealth contacts in the workplace setting to allow for the most robust outcomes (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022).

    Past research has demonstrated mixed results when providing incentives to increase participation in overweight and obesity management programs within the workplace (Cawley and Price 2013, Patel, Asch et al. 2016). However, depending on the employee population, incentives may be an effective way to encourage continued participation. The dietitian may wish to develop a unique, creative incentive program for each workplace, keeping in mind that incentives may become less appealing over time, and individuals may resort to unhealthy tactics to achieve designated weight-loss goals. Dietitians can collaborate with supervisors and human resource representatives in the workplace to devise a program whereby participant attendance/completion can contribute to a reduction in health care premiums.

  • Potential Costs Associated with Application

    Costs may ultimately be higher for an interprofessional approach, but cost-efficacy, in relation to improved outcomes, is not known. Public and private payers may not be willing to cover overweight and obesity management interventions, particularly those provided by an interprofessional healthcare team.

    If dietitians are located within a primary care/outpatient setting, few additional resources, aside from additional payments to the dietitian, would be needed. It would likely be cost-effective as dietitian visits are not as expensive as visits to primary care providers.(Academy of Nutrition and Dietitics 2021) While increased reimbursement may increase costs for public and private payers in the short- term, if weight loss can be maintained, interventions may be cost-effective. Implementing dietary interventions in community and public settings is generally less expensive than individual-level contacts and allows dietitians to reach a broader population, making them feasible to implement. Interventions provided in the workplace will most likely vary in cost to the organization and the employees, depending on the scale and type of intervention. However, the potential health benefits as well as the return on investment seen in productivity will likely outweigh the costs associated with any intervention, making it a potentially feasible investment for organizations.

  • Recommendation Narrative

    Dietitians systematically assess, diagnose, intervene with, monitor and evaluate each individual client within the Nutrition Care Process (NCP) framework to ensure consistent, high-quality nutrition care (Swan, Vivanti et al. 2017). Interventions delivered by 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.Improving public health through addressing the high prevalence of adult overweight and obesity will require approaches in multiple settings. In the systematic review supporting this EBPG, successful interventions were delivered in a range of settings, including primary care/outpatient, community and workplace settings (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021).

    Primary care/outpatient providers may not provide adult weight loss counseling for a variety of reasons including lack of time, perception that clients with obesity are not motivated, and lack of training and expertise (Glauser, Roepke et al. 2015, Kaplan, Golden et al. 2018, Simon and Lahiri 2018, Ananthakumar, Jones et al. 2020).  Therefore, primary care/outpatient providers would likely utilize a dietitian if they had an established system for referrals and knew services could be covered by public and private payers. Individuals always have the option of not participating when offered dietitian services in the primary care/outpatient setting. The primary care/outpatient setting may be more accessible than other types of specialized healthcare settings, as adults may already have an established relationship with a primary care/outpatient provider (Tucker, Bramante et al. 2021). Including dietitians in primary/outpatient care would likely improve coordination of care and compliance with attending multiple sessions with the dietitian. In addition, billing for services is already a part of standard medical practice.

    Interventions provided in community and workplace settings allow a broader population to receive nutrition interventions to improve weight outcomes, and thus could potentially reduce the impact on health inequities in disadvantaged groups. Literature demonstrates that community interventions are acceptable to adult participants (Domel, Alford et al. 1992, Domel, Alford et al. 1992).  Overweight and obesity management interventions provided by dietitians in a variety of community and public settings (such as places of worship, neighborhood centers, community centers, beauty shops, barber shops, schools, public libraries) and in the workplace may be more accessible and viewed as less threatening and more convenient than medical settings, and possibly help provide “ready-made” support groups to help with weight management during and after interventions. Negative effects of obesity on overall health may have important implications for employers, such as higher rates of absenteeism (VanWormer, Linde et al. 2012). Therefore, employers may benefit by providing employees access to overweight and obesity management interventions. While more evidence is needed on the impacts of interventions in the workplace setting, current evidence demonstrates positive impacts on health while being cost-effective for organizations (Jacobs, Yaquian et al. 2017, Fitzgerald, Murphy et al. 2018, Academy of Nutrition and Dietetics' Evidence Analysis Center 2021).

    More information on the evidence supporting these recommendations can be found in the Summary of Findings Table and Relationships between Recommendation Statements and Evidence Table.

  • Recommendation Strength Rationale

    The recommendation of the interprofessional team was based on LOW level evidence from sub-group analysis of interventions utilizing interprofessional teams with dietitians or dietitians alone.

    The recommendation for providing care in a variety of settings is from LOW-HIGH evidence that dietitians are efficacious at improving client outcomes in the settings indicated. 

  • Minority Opinions

    No minority opinions. 

• 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).

  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent, compared to usual care or no intervention from an RDN, on body mass index?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent, compared to usual care or no intervention from an RDN, on percent weight loss?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent, compared to usual care or no intervention from an RDN, on waist circumference?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent, compared to usual care or no intervention from an RDN, on blood pressure?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent, compared to usual care or no intervention from an RDN, on fasting blood glucose?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent, compared to usual care or no intervention from an RDN, on quality of life?
  
  In adults with overweight or obesity, what is the cost-effectiveness of weight management interventions provided by an RDN or international equivalent, compared to usual care or no intervention from an RDN?
  
  In adults with overweight or obesity, what is the adverse events of weight management interventions provided by an RDN or international equivalent, compared to usual care or no intervention from an RDN?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the community setting, compared to usual care or no intervention from an RDN, on BMI?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the community setting, compared to usual care or no intervention from an RDN, on percent weight loss?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the community setting, compared to usual care or no intervention from an RDN, on waist circumference?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the community setting, compared to usual care or no intervention from an RDN, on blood pressure?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the community setting, compared to usual care or no intervention from an RDN, on fasting blood glucose?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the community setting, compared to usual care or no intervention from an RDN, on quality of life?
  
  In adults with overweight or obesity, what is the cost-effectiveness of weight management interventions provided by an RDN or international equivalent in the community setting, compared to usual care or no intervention from an RDN?
  
  In adults with overweight or obesity, what are the adverse events of weight management interventions provided by an RDN or international equivalent in the community setting, compared to usual care or no intervention from an RDN?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the workplace setting, compared to usual care or no intervention from an RDN, on BMI?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the workplace setting, compared to usual care or no intervention from an RDN, on percent weight loss?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the workplace setting, compared to usual care or no intervention from an RDN, on waist circumference?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the workplace setting, compared to usual care or no intervention from an RDN, on blood pressure?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the workplace setting, compared to usual care or no intervention from an RDN, on fasting blood glucose?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the workplace setting, compared to usual care or no intervention from an RDN, on quality of life, cost-effectiveness and adverse events?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the primary care or outpatient setting, compared to usual care or no intervention from an RDN, on BMI?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the primary care or outpatient setting, compared to usual care or no intervention from an RDN, on percent weight loss?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the primary care or outpatient setting, compared to usual care or no intervention from an RDN, on waist circumference?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the primary care or outpatient setting, compared to usual care or no intervention from an RDN, on blood pressure?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the primary care or outpatient setting, compared to usual care or no intervention from an RDN, on fasting blood glucose?
  
  In adults with overweight or obesity, what is the effect of weight management interventions provided by an RDN or international equivalent in the primary care or outpatient setting, compared to usual care or no intervention from an RDN, on quality of life?
  
  In adults with overweight or obesity, what is the cost-effectiveness of weight management interventions provided by an RDN or international equivalent in the primary care or outpatient setting, compared to usual care or no intervention from an RDN?
  
  In adults with overweight or obesity, what are adverse events of weight management interventions provided by an RDN or international equivalent in the primary care or outpatient setting, compared to usual care or no intervention from an RDN?

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