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Recommendations Summary

AWM: Medical Nutrition Therapy Amount 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: Number and Frequency of Interactive Contacts

    Registered dietitian nutritionists or international equivalents may provide at least five interactive sessions, when feasible and desired by each adult client with overweight or obesity, to achieve the greatest potential improvement in outcomes. Frequency of contacts should be tailored to each client’s preferences and needs.

    Rating: Level 2(C)
    Conditional

    AWM: Intervention Duration

    Registered dietitian nutritionists or international equivalents should provide overweight and obesity management interventions for a duration of at least one year to improve and optimize cardiometabolic and weight outcomes, as appropriate for and desired by each client.

    Rating: Level 1(C)
    Conditional

    AWM: Follow-Up Contacts

    Following completion of overweight and obesity management interventions, registered dietitian nutritionists or international equivalents should provide follow-up contacts at least every three months, for as long as desired by each client, to facilitate maintenance of weight loss and improved cardiometabolic outcomes.

    Rating: Level 1(C)
    Conditional

    • Risks/Harms of Implementing This Recommendation

      Effective weight management is likely valued by adults with overweight or obesity, but there is potential harm related to financial costs, and diminishing returns, when requiring a specific number of contacts with a dietitian. While some adults may require and benefit from more contact with a dietitian, others may consider more contact or lengthy interventions to be a barrier to participating in overweight and obesity management. Those without health insurance or who are unable to pay out-of-pocket are disadvantaged by a recommendation requiring a greater number of contacts than those recommended. Lack of transportation and/or increased transportation or childcare costs for more contacts could be a possible disadvantage to those with low socio-economic status. Additionally, those employed in certain industries may not have the flexibility to attend frequent visits. There is also a concern about compliance with multiple sessions with a dietitian, as Americans may not have paid time off or sick leave (U.S. Bureau of Labor Statistics 2021) or may have other barriers to care. To adequately address the issue, interventions should be designed to be realistic for clients, including flexibility in modality (e.g., telehealth).

    • Conditions of Application

      Adult clients value flexible overweight and obesity management support (Skea, Aceves-Martins et al. 2019). Thus, the benefit-to-risk ratio of delivering at least five contacts or 12 months of an intervention with a dietitian is ascertained for each individual adult client. For interested adult clients hoping to achieve weight-loss goals, increased contact is likely to provide some benefits. The dietitian and adult client determine an appointment schedule that best suits each client’s values and needs and aligns with the timing of when to evaluate and re-set progress goals. Scheduling more frequent sessions (weekly or bi-weekly) early in the intervention may be beneficial to support and reinforce new behavior changes. A client’s public/private payer coverage of MNT visits may also need to be a consideration when scheduling contacts. Developing rapport and offering flexibility  when and how interventions are delivered may improve longevity of dietitian-client relationships during overweight and obesity management interventions and follow-up (Skea, Aceves-Martins et al. 2019),

      During follow-up contacts, dietitians can address client tensions around changing habits, addressing needs and conflicts with beliefs (Greaves, Poltawski et al. 2017). Adult clients may find value in discussing insights from their overweight and obesity management journeys, working to establish self-regulation, developing strategies to address internal and external influences of dietary intake, and identifying new sources of motivation (Greaves, Poltawski et al. 2017). Adult clients may also benefit from developing new patterns of thinking, meeting needs previously addressed by obesogenic behaviors with more healthy behaviors, and by changing beliefs and self-concepts (Greaves, Poltawski et al. 2017). If a dietitian is working with an adult client who is resistant to continuing in-person follow-up, the dietitian may still want to offer checking-in with this client at least every three months via telephone, email or chat to ensure they are on-track and not in need of further nutrition counseling or resources.

    • Potential Costs Associated with Application

      Scheduling more contacts with a dietitian may increase resources required from the adult client. A change to visit duration or frequency may place time and monetary burdens on both the dietitian and the adult client. For the dietitian, increased visit frequency and length may mean fewer clients can be seen. For the adult client, more in-person visits mean more time spent away from home, work, school, etc. and may result in potential loss of wages and increased transportation or childcare costs. However, interventions with at least five contacts resulted in  nearly 5% weight loss compared to interventions with fewer contacts (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022), which is clinically significant. While more than five contacts with a dietitian may result in more optimal outcomes, public and private payer coverage of these additional outcomes is necessary for this recommendation to be feasible.

    • Recommendation Narrative

      Understanding the impact of the amount of MNT on outcomes is important to optimize care. In the systematic review supporting this EBPG, the authors conducted several sub-group analyses to determine the efficacy of intervention characteristics including number and frequency of contacts with a dietitian and study duration. The systematic review additionally examined intervention efficacy at follow-up after intervention completion (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022). All outcomes examined were significantly improved, compared to controls, in interventions with ≥5 contacts with a dietitian, but those with fewer contacts did not significantly improve systolic blood pressure (SBP) or fasting blood glucose (FBG) (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022). However, for all outcomes, the magnitude of difference between intervention types may not be clinically significant. There were no clear dose-response patterns between frequency of contact with the dietitian and outcomes, except for FBG, for which greater frequency aligned with a greater effect size (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022).

      Long-term contact between an adult client and a dietitian can provide a solid foundation for weight loss and maintenance over time. In the systematic review supporting this EBPG (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021), intervention studies with a dietitian that were at least 12 months in duration resulted in a significant improvement for all outcomes examined, while intervention studies less than 12 months did not result in significant improvement in SBP and FBG compared to controls (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022). Other recent systematic reviews describe that weight lost during interventions is typically regained without extended care following the completion of interventions (Nordmo, Danielsen et al. 2020, Evidence Analysis Center 2021). This is supported by the systematic review conducted by the guideline development team which described that participants did not experience the benefits of the intervention three months after intervention completion (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021). Behavior-based weight maintenance interventions result in less weight regain compared to control conditions (LeBlanc, Patnode et al. 2018). Thus, extended care provided by a dietitian following the intervention is an important part of adult overweight and obesity management to maintain improvements in outcomes.

      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 analyses examining efficacy of interventions with different numbers of contacts, durations and follow-up durations.

    • Minority Opinions

      No minority opinions.