AWM: Guideline Limitations, Future Research, and Conclusion (2022)

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AWM: Guideline Limitations, Future Research, and Conclusion (2022)

Guideline Strengths and Limitations

The recommendations outlined in this evidence-based practice guideline (EBPG) are primarily based on a supporting systematic review including 66 randomized controlled trials (RCTs) and three non-RCTs examining interventions for adults with overweight or obesity. The systematic review demonstrated a significant impact of overweight and obesity management on most of the outcomes examined, and MODERATE to HIGH certainty of evidence ratings supported many of the updated recommendations. Cardiometabolic outcomes, quality of life (QoL), and weight outcomes have important impacts on health. In addition, most of these outcomes are regularly collected in dietetics practice. The systematic review followed rigorous methods supported by the Academy and GRADE methods and the supporting systematic review adhered to GRADE methods and PRISMSA standards.1-3 There is a paucity of intervention trials that specifically address each individual’s complex contributors to weight status and associated outcomes. Most current research with interventions provided by dietitians targets cardiometabolic and anthropometric outcomes.4 Though there is increasing focus on client-centered outcomes such as QoL and mental health/psychological outcomes, there is still a lack of evidence examining these outcomes.4 

This EBPG was created using the Evidence-to-Decision framework,2, a gold standard for creating client-centered evidence-based recommendations. This updated EBPG aligns with current standards of practice 5,6 and as such will be acceptable to most practitioners and feasible for most dietitians to implement. Recommendations supporting telehealth, group counseling and a variety of contact settings may facilitate improved access to nutrition care for clients. This EBPG includes several suggestions regarding diets that can be adapted for weight management but does not give specific dietary recommendations for any group of individuals (e.g., those with T2DM or dyslipidemia) due to the multitude of factors that must be considered when designing individualized diet interventions. Dietitians can utilize other EBPGs and/or the Academy’s Nutrition Care Manual7 to guide treatment of conditions associated with overweight and obesity.  

The systematic review supporting this updated EBPG utilized sub-group analyses to examine the influence of different intervention components, but the results had overlapping confidence intervals for many outcomes, indicating the need for further research to examine optimal components of medical nutrition therapy (MNT) interventions for adults with overweight or obesity. Heterogeneity of results was high for most outcomes, implying variable effects according to individual adult participants. In addition, there was little data on return on investment or cost-effectiveness, highlighting the significant need for future studies to examine these outcomes, as this could also improve reimbursement for dietitian services for adults with overweight or obesity. There was little research available that focused on interventions tailored to specific groups that may be at increased risk of overweight or obesity, such as adults with low socio-economic status (SES), those who were members of racial or ethnic minority groups, and those with disabilities. There was significant risk of bias due to randomization throughout the studies analyzed, primarily from lack of description of group allocation concealment from investigators until adult participants were assigned to groups. Many studies also demonstrated bias due to deviations from the intended interventions. 

This EBPG panel consisted exclusively of dietitians. This EBPG is directed at dietitians, but input from professional organizations from other disciplines who work in the field of adult overweight and obesity during the development phase of the EBPG would have been beneficial. A significant limitation of this EBPG was that the Academy was not able to secure a trained patient advocate to provide input during guideline development. However, input was sought by providing the opportunity for the public to comment on recommendations during an external review (see methods section above).

Future Research

There was little data on cost effectiveness or return on investment for MNT for adults with overweight or obesity. Therefore, there is a significant need for additional studies in this area to strengthen dietitian advocacy for reimbursement of services specifically for adults with overweight or obesity. Indeed, this updated EBPG outlines the need for at least five contacts with the dietitian over at least one year to improve outcomes as well as follow-up contacts every three months to maintain improvements in outcomes. Currently, very few clients have public or private payer coverage, which would allow for such extensive contact and therefore, studies outlining the return on investment for these services are essential. Recommendations for a blend of group and individual-level delivery methods plus a blend of telehealth and in-person delivery methods may significantly improve the cost burden for payers as well and deserve further study.  

There is a great need for research examining how to address environmental factors, genetic factors, and weight stigma in health care. Randomized controlled trials on adult overweight and obesity management are needed that are tailored to specific groups who may be at increased risk of overweight or obesity, such as adults with low SES, those who are members of racial or ethnic minority groups, adults who have disabilities and older adults. Future research concerning adult overweight and obesity management requires a lens more focused on inclusion, diversity, equity and access (IDEA). Most current research on adults with overweight or obesity has focused on weight loss, and there is a need for more research on the effect of client-centered outcomes beyond weight, including quality of life and mental health. More research is needed on the efficacy of non-diet intervention approaches provided by dietitians on health outcomes associated with overweight and obesity. In addition, research is needed that examines outcomes from interventions, extended care and follow-up for greater than two years.

It will also be important for dietitians in practice to participate in implementation studies, utilizing the EBPG outlined above. These implementation studies will allow assessment of the feasibility of the recommendations, their effectiveness in the real-world, and can help determine if the recommendations are effective and sustainable long-term. 

Conclusion

This updated EBPG describes evidence-based strategies for providing effective, individualized, inclusive MNT for adults managing overweight and obesity. Recommendations in this EBPG highlight the importance of considering complex contributors to overweight and obesity and individualizing interventions to client-centered goals based on specific needs and preferences and shared decision-making. Dietitians can utilize behavioral modification strategies to help clients set small, acceptable goals that encourage adherence and are flexible to meet the changing needs of each client. This guideline shows that overweight and obesity management is a continual, long-term process that requires extended care and follow-up with monitoring and evaluation to adjust interventions to client needs and circumstances as they change over time. The recommendations in this EBPG have the potential to increase access to care for many adults through utilization of telehealth and group counseling as effective delivery methods to foster health improvements, decrease costs, and to address other barriers to overweight and obesity management interventions. It is essential for dietitians to collaborate with clients and interprofessional healthcare teams to provide high-quality MNT interventions using the NCP to promote attainment of client-centered outcomes for adult clients with overweight or obesity. 

References

  1. Handu D, Moloney L, Wolfram T, Ziegler P, Acosta A, Steiber A. Academy of Nutrition and Dietetics Methodology for Conducting Systematic Reviews for the Evidence Analysis Library. J Acad Nutr Diet. 2016;116(2):311-318.
  2. The GRADE Working Group. GRADE handbook for grading quality of evidence and strength of recommendations. Cochrane Collaboration. https://gdt.gradepro.org/app/handbook/handbook.html. Published 2013. Updated October 2013. Accessed April 22, 2021.
  3. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Bmj. 2021;372:n71.
  4. Cheng FW, Garay JL, Handu D. Weight Management Interventions for Adults With Overweight or Obesity: An Evidence Analysis Center Scoping Review. J Acad Nutr Diet. October 2020.  DOI: https://doi.org/10.1016/jand.2020.07.022
  5. Academy of Nutrition and Dietitics. Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist. J Acad Nutr Diet. 2018;118(1):141-165.
  6. Tewksbury C, Nwankwo R, Peterson J. Academy of Nutrition and Dietetics: Revised 2022 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Adult Weight Management. J Acad Nutr Diet. 2022;122(10):1940-1954.e45.
  7. Academy of Nutrition and Dietitics. Nutrition Care Manual. https://www.nutritioncaremanual.org. Published 2021. Accessed April 18, 2021.

 

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