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Recommendations Summary

AWM: Dietary and Lifestyle Intervention Approaches 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: Dietary Patterns

    Registered dietitian nutritionists or international equivalents should advise adult clients with overweight or obesity that many different dietary patterns can be individualized to support client-centered goals. Prescribed dietary approaches should achieve and maintain nutrient adequacy and be realistic for client adherence. Prescribed calorie levels should be tailored based on estimated or measured needs and should be adjusted to improve weight outcomes, as appropriate for and desired by each client.

    Rating: Level 1(C)
    Imperative

    AWM: Components of a Comprehensive Intervention

    Registered dietitian nutritionists or international equivalents should advise the following components as part of a comprehensive adult overweight and obesity management intervention to improve cardiometabolic outcomes, quality of life, and weight outcomes, as appropriate for and desired by each client:

    • Nutritionally adequate diet with adjusted calories to improve weight outcomes and a nutritionally adequate, energy-balanced diet for weight maintenance; 
    • Behavioral strategies, including self-monitoring (diet, physical activity, weight);
    • Appropriate physical activity to meet client goals (within the RDN’s scope of practice or referral to an exercise practitioner). 

    Rating: Level 1(C)
    Imperative

    • Risks/Harms of Implementing This Recommendation

      Overweight and obesity management interventions provided by a dietitian are efficacious in improving cardiometabolic outcomes and reducing weight outcomes (MODERATE to HIGH certainty evidence), with few adverse events reported (VERY LOW certainty evidence). Thus, the benefits of these recommended interventions likely outweigh the potential risks. However, in some cases, the mean intervention effect was 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 for others.

      When weight loss occurs, up to 25% of the weight lost may come from lean body tissue (i.e. muscle) rather than fat tissue.(Willoughby, Hewlings et al. 2018) This is of greatest concern among older adults who are already at increased risk of sarcopenia due to age-accelerated muscle wasting, and weight loss may be contraindicated for this population. Weight loss may also not be indicated for adults with conditions for which weight loss may result in adverse outcomes, such as for adults who are pregnant, those with eating disorders or those with conditions such as chronic kidney disease or cancer.

      Some individuals may object to focusing on weight loss and caloric restriction to improve overall health. Current evidence does not suggest that supervised weight management interventions result in eating disorders (Curry, Krist et al. 2018, Stewart, Martin et al. 2022). While research is not clear, for clients with current eating disorders, overweight or obesity management interventions may not be appropriate. Similarly, there is some controversy regarding the negative effects of overweight and obesity management interventions on psychological outcomes (National Task Force on the Prevention and Treatment of Obesity 2000). However, a recent systematic review examining the psychological effects of weight loss interventions found improvements in depression, mental health related quality of life (QoL)and self-efficacy after 12 months of weight loss interventions. There was no effect on anxiety, binge eating, body image, emotional eating, life satisfaction, self-esteem or stress at the intervention’s end (Jones, Lawlor et al. 2021). Another recent systematic review found that interventions resulted in improved QoL with or without weight loss, but that improvements in body image and health-related QoL were closely related to weight loss (Lasikiewicz, Myrissa et al. 2014). There is discussion that self-directed dieting may increase disordered eating behaviors, but supervised, evidence-based treatment can result in sustainable improvements in health outcomes and self-worth (Cardel, Newsome et al. 2022). There is some speculation that a sub-set of individuals may be biologically vulnerable to negative effects from dietary restriction (Stewart, Martin et al. 2022). More research on long-term psychological effects of weight-loss interventions is needed.

    • Conditions of Application

      Counseling Approach

      Dietitians are skilled in the use of advanced behavior change techniques to assist clients in meeting their goals. When working with healthcare providers, adults with overweight or obesity value positive, friendly and non-judgmental encouragement (Skea, Aceves-Martins et al. 2019). It is important for dietitians to meet their adult clients where they are at, assess their readiness to change, and encourage changes that are small and acceptable to the clients. Effective listening skills and motivational interviewing techniques should be employed during MNT sessions to help ensure that the adult client’s experiences and preferences are properly considered when developing goals and strategies (Jortberg, Myers et al. 2015, Tewksbury, Nwankwo et al. 2022). During the initial session, the dietitian and client identify the adult client’s goals as they relate to weight loss, blood pressure and other outcomes, and establish and prioritize goals that are Specific, Measurable, Attainable, Relevant and Time-Based (S.M.A.R.T.).

      In adults with overweight or obesity, dietitians include behavior modifying strategies in interventions, such as collaborative goal setting, accountability, meal planning, stimulus control (ex: altering environment) and problem solving/troubleshooting. Evidence indicates that successful overweight and obesity management interventions include behavior modifying therapies (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021). Self-monitoring of diet and physical activity is supportive of weight loss in adults with overweight or obesity, particularly if participants receive tailored advice (Berry, Kassavou et al. 2021). Dietitians use advanced behavior change techniques to facilitate client self-management (Tewksbury, Nwankwo et al. 2022).

      Dietary Intake

      Adult clients value flexibility and variety in dietary intake when undergoing overweight and obesity management (Skea, Aceves-Martins et al. 2019). A flexible approach to eating may help stabilize dietary intake for individuals with past negative experiences with or relationships to dieting (Skea, Aceves-Martins et al. 2019). However, some adult clients may value more prescriptive or structured eating plans (Skea, Aceves-Martins et al. 2019). During an initial appointment with an adult client, dietitians discuss any specific dietary preferences, including cultural or religious food traditions, cooking skills and access to cooking equipment, to provide more customized recommendations. In addition, dietitians assess an adult client’s food access to facilitate realistic and implementable dietary recommendations. More resources on overweight and obesity management, including client education materials and sample menus, can be found in the Nutrition Care Manual (NCM) (Academy of Nutrition and Dietitics 2021).

      The dietitian may consider providing education on MyPlate at one of the first sessions with an adult client. The MyPlate method is an appropriate way for clients to reduce calorie intake as it allows for appropriate proportions of intake from each of the food groups (U.S. Department of Agriculture 2021). However, MyPlate should be adapted to individuals from cultures that primarily use bowls or eat from shared dishes. An overview of dietary approaches that may be effective for improving outcomes, including weight loss if accompanied by caloric reduction, can be found in the Dietary Approaches Table. All diets described have potential pros and cons, and dietary approaches are tailored to the needs and preferences of each client. Generally, dietitians will suggest that clients focus on consumption of foods that are nutrient-dense but not energy-dense (e.g., fruits and vegetables and other high fiber foods) while limiting foods that are energy-dense but not nutrient dense (e.g., foods with high amounts of added sugar). It is important to remain up to date on current literature regarding the efficacy of dietary approaches to manage overweight and obesity.

      The RDN individualizes the meal pattern to distribute calories at meals and snacks throughout the day (Academy of Nutrition and Dietitics' Evidence Analysis Center 2014). Research reports inconsistent results regarding the association between eating frequency and body weight, which may be due to the role of portion size, energy density or compensation of energy intake at subsequent eating occasions (Canuto, da Silva Garcez et al. 2017). The role of advising on breakfast in overweight and obesity management is unclear and should be individualized to each client (Sievert, Hussain et al. 2019).

      For weight loss goals and energy prescription, dietitians individualize care based on each client’s preferences and needs. Weight loss as little as 3-5% may result in cardiometabolic health benefits, while a weight loss goal of 10% may be appropriate for adults with obesity or co-morbidities (Jensen, Ryan et al. 2014, Wharton, Lau et al. 2020). Prescribed energy intake ranges should be realistic for adherence during the intervention. The dietitian may want to precede an intervention by having an adult client track their food intake and monitor portion sizes, which can increase client awareness of dietary intake. Use of energy estimating equations such as Mifflin St. Jeor (Mifflin, St Jeor et al. 1990) can be used to understand the energy needs for the adult client’s current body weight and activity level. The dietitian can then use the usual dietary intake information and the results of the equations or indirect calorimetry to determine an appropriate calorie range that will result in weight loss through a reduction in intake relative to needs. While caloric reduction is recommended for weight loss, methods of communicating this principle will be dependent on the clinician and client. For example, dietitians may recommend a meal plan that describes portion sizes of specific foods, but not calorie content.

      For all clients, and older adults in particular, body composition should be monitored to ensure that the adult client is not experiencing a significant loss of muscle mass with weight loss. Dietitians use valid methods of body composition analysis to track changes in the client’s body composition. Dietitians understand the limitations of different body composition analysis tools when selecting an appropriate method. Physical activity and/or resistance training may help reduce muscle loss, as can consuming protein regularly throughout the day (instead of primarily at one meal) (Cava, Yeat et al. 2017). In addition, education is provided to the adult client about body composition and the physiology of weight loss to help them create an appropriate goal related to weekly or overall weight loss.

      Dietitians working with adult clients who have a history of disordered eating or history of an eating disorder may suggest clients are assessed by a mental health professional prior to initiating a weight loss program. In addition, dietitians may want to weigh the clients in such a way so they do not see the actual weight number (Wiedemann, Ivezaj et al. 2020, Hahn, Bauer et al. 2021). Care should also be taken not to overly emphasize the amount of weight lost relative to other improvements related to overweight and obesity management, such as cardiometabolic outcomes, body composition, and QoL.

      Dietitians wishing to pursue non-diet approaches for adult clients with overweight or obesity work with the client to establish goals other than weight loss that reflect progress towards healthy eating habits. Strategies such as promoting mindful eating may be used to help the client in lieu of prescribing caloric restrictions. However,  little evidence is available that supports the premise that mindful eating reduces energy intake or enhances dietary quality (Grider, Douglas et al. 2021). The dietitian should be transparent with the adult client regarding the strength of the evidence for non-diet approaches as a treatment for overweight and obesity compared with the evidence for traditional MNT for adult overweight and obesity management.

      Physical Activity

      Dietitians consider their professional scope of practice when providing education and recommendations related to physical activity (Academy of Nutrition and Dietitics 2018, Tewksbury, Nwankwo et al. 2022). Dietitians can utilize general physical activity recommendations from guidelines, such as the Physical Activity Guidelines for Americans, when appropriate (J Piercy, Troiano et al. 2018, Tewksbury, Nwankwo et al. 2022). Individualized recommendations should only be made if the dietitian is also a credentialed fitness professional. Dietitians should develop a network of fitness professionals in their vicinity to whom they can refer clients. 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 (Academy of Nutrition and Dietitics 2021). Academy members can also access a free case study, “Recommendations by RDN for Physical Activity” from the EatRightStore (Dietitics 2020). Dietitians can find tips, tools and resources in “Physical Activity Toolkit for RDs: Exercise is Medicine”, which was recently updated by several Dietetic Practice Groups (Weight Management, Cardiovascular Health and Well-Being, Sports and Human Performance Nutrition) in partnership with the American College of Sports Medicine’s Exercise is Medicine program (Kruskall L 2020).

      Weight Maintenance

      As described in the section on MNT Amount, dietitians regularly follow-up with and monitor and evaluate clients following a behavioral intervention to help them reprioritize goals and identify barriers and facilitators to achieving goals. Results of monitoring and evaluation may be to adjust the intervention intensity (e.g., frequency and types of contacts with the dietitian), focus of the dietary intervention, physical activity-related goals and which behavioral strategies to implement, as needed based on client needs and preferences. 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). Methods for troubleshooting common challenges in overweight and obesity management interventions are discussed in the NCM (Academy of Nutrition and Dietitics 2021).

    • Potential Costs Associated with Application

      Few trials have been conducted that test implementation of specific intervention components and their associated costs. However, the interventions described in the recommendations above require no special costs to the client beyond dietitian services and the regular cost of food.

      Costs to a practitioner include training and tools to monitor body composition which may be relatively inexpensive, such as bioelectrical impedance analysis, or may be very costly, such as dual-energy x-ray absorptiometry. Overweight and obesity management interventions provided by a dietitian may be cost-effective (LOW certainty evidence) (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021).

    • Recommendation Narrative

      Contributors to overweight and obesity are complex and healthcare providers recognize and address the multi-factorial etiologies of overweight and obesity when possible. This section is focused specifically on the lifestyle behaviors of dietary intake and physical activity. Modifying dietary intake is a key component of overweight and obesity management, and a healthy dietary pattern can improve metabolic health and risk of inflammation and non-communicable disease risk (Vilela, Fonseca et al. 2021). 

      Those adults valuing and seeking overweight and obesity management interventions will benefit from an integrated approach that includes nutrition, physical activity, and behavior change (Bloom, Adler et al. 2018, Skea, Aceves-Martins et al. 2019, Ananthakumar, Jones et al. 2020). Effective interventions included in the supporting systematic review were examined for common intervention components. Current research describing overweight and obesity management interventions typically include caloric reduction as a means to weight loss (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022). This approach is based on extensive literature describing that excess weight, typically assessed with BMI, is prospectively associated with mortality, cardiovascular disease risk, pre-diabetes, and type 2 diabetes mellitus, and weight loss is prospectively associated with beneficial health outcomes including quality of life, even in adults who are metabolically healthy (Kritchevsky, Beavers et al. 2015, Peckmezian and Hay 2017, Jayedi, Rashidy-Pour et al. 2018, Yeh, Chen et al. 2019, Opio, Croker et al. 2020, Yu, Ho et al. 2022). However, weight outcomes are only one measure of health and dietitians work with clients to improve other health and well-being outcomes by advising an individualized diet that is nutritious, culturally acceptable and feasible for long-term adherence (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022). Behavior tracking and modification strategies and physical activity are also common components of overweight and obesity management interventions (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022). These components have been tested extensively, with little uncertainty in beneficial influence on outcomes. These recommendations provide feasible and sustainable options to achieve and maintain positive health outcomes that are flexible according to the needs of each adult client.

      Weight Maintenance

      A major challenge for clients who participate in overweight and obesity management interventions is maintaining weight loss following behavioral interventions (Nordmo, Danielsen et al. 2020). Maintaining lifestyle changes following an intervention can be difficult as adult clients navigate the co-existence of new behaviors with old habits. Without extended care interventions, weight lost during behavioral interventions is often gained back in the follow-up period (Nordmo, Danielsen et al. 2020, Academy of Nutrition and Dietetics' Evidence Analysis Center 2021). Behavior-based weight maintenance interventions result in less weight regain than control conditions (LeBlanc, Patnode et al. 2018). Several studies support the long-term effect of behavioral interventions, including weight loss, on long-term health outcomes (Knowler, Fowler et al. 2009, Lindström, Peltonen et al. 2013, 2014, 2015, Willis, Huang et al. 2020). Recent systematic reviews have examined determinants to weight maintenance following behavioral interventions. Consistent evidence suggests sociodemographic characteristics such as age, gender and socioeconomic status are not associated with weight loss maintenance (Varkevisser, van Stralen et al. 2019). Among behavioral determinants, self-monitoring of dietary intake and weight were strong determinants of weight loss maintenance and self-monitoring of physical activity was a moderate determinant (Varkevisser, van Stralen et al. 2019, Spreckley, Seidell et al. 2021). Other strong behavioral determinants of weight maintenance include eating behaviors such as portion control, limiting intake of energy-dense foods including sugar-sweetened beverages and increasing fruit and vegetables intake (Varkevisser, van Stralen et al. 2019, Paixão, Dias et al. 2020, Spreckley, Seidell et al. 2021). Self-efficacy for exercise, weight management and dietary intake and having high physical self-worth were strong and moderate predictors of weight loss maintenance (Varkevisser, van Stralen et al. 2019).

      Non-Diet Approaches

      Most research examining interventions for adults with overweight or obesity has been focused on calorie reduction with a goal of weight loss (Cheng, Garay et al. 2020). However, non-diet approaches that do not focus on caloric restriction have been proposed as methods to improve health and well-being without specifically targeting weight loss. Practitioners following these approaches describe that standards of care for the management of overweight and obesity may be harmful and lead to adverse health outcomes (Penney and Kirk 2015). On the other hand, obesity is a serious medical condition, and those seeking management deserve compassionate, evidence-based care. For the systematic review supporting this EBPG, the EBPG team attempted to identify non-diet interventions provided by dietitians for adults with overweight or obesity, and four RCTs were identified (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021). In line with the intended framework, study authors reported no effect of interventions on BMI, percent weight loss, or waist circumference, but evidence certainty was LOW or VERY LOW (Hawley, Horwath et al. 2008, Katzer, Bradshaw et al. 2008, Provencher, Bégin et al. 2009, Gagnon-Girouard, Bégin et al. 2010, Carroll, Marshall et al. 2012, Leblanc, Provencher et al. 2012, Academy of Nutrition and Dietetics' Evidence Analysis Center 2021). Additionally, two RCTs each described there was no effect of the interventions on BP, or QoL, and certainty of evidence was LOW or VERY LOW (Hawley, Horwath et al. 2008, Katzer, Bradshaw et al. 2008, Provencher, Bégin et al. 2009, Gagnon-Girouard, Bégin et al. 2010, Ingraham, Harbatkin et al. 2017, Academy of Nutrition and Dietetics' Evidence Analysis Center 2021). No evidence was identified for the outcome of fasting blood glucose (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021). Other recent systematic reviews examined the effect of non-diet approaches and were more inclusive regarding the interventionists delivering the interventions (e.g., included mental health professionals) and the outcomes reported (e.g., included food behavior and psychological outcomes). Results of these systematic reviews agreed that interventions that did not include dietary restriction did not result in improved CVD risk factors or results were inconsistent. Ulian, Aburad et al. 2018, Khasteganan, Lycett et al. 2019). However, both of these systematic reviews concluded that these approaches may be associated with body satisfaction as well as psychological and physical activity outcomes (Ulian, Aburad et al. 2018, Khasteganan, Lycett et al. 2019). The question of how to approach weight loss most effectively and compassionately is challenging, and dietetics practice will depend on client needs and values and the practitioner's perspective. Many other behavioral changes can improve health beyond weight loss, such as increases in physical activity; increased consumption of whole grains, low-fat dairy, and fruits and vegetables; and improvements in sleep and stress management (Cardel, Newsome et al. 2022).

      More information on components of interventions that supported this guideline can be found in the supporting systematic review ((Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke et al. 2022). Results of interventions supporting these recommendations can be found in the Summary of Findings Table and Relationships between Recommendation Statements and Evidence Table.

    • Recommendation Strength Rationale

      Dietary and lifestyle intervention recommendations were based on characteristics of successful interventions included in the systematic review supporting this guideline (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022). Evidence was translated into practice recommendations by expert panel members translating research through an evidence-to-decision framework that includes patient values, feasibility, resources used, equity, and other factors (please see Methods section for more information). More information on components of interventions that supported this guideline can be found in the supporting systematic review ((Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke et al. 2022). Results of interventions supporting these recommendations can be found in the Summary of Findings Table and Relationships between Recommendation Statements and Evidence Table.

    • Minority Opinions

      No minority opinions.