1. Position of the Academy of Nutrition and Dietetics: Weight Management
Katie Spychalski and Kaley Dewey
NFS 230, Fall 2016

2. Position Statement
“It is the position of the Academy of Nutrition and Dietetics that successful treatment of overweight and obesity in adults requires adoption and maintenance of lifestyle behaviors contributing to both dietary intake and physical activity. These behaviors are influenced by many factors; therefore, interventions incorporating more than one level of the socioecological model and addressing several key factors in each level may be more successful than interventions targeting any one level and factor alone.”

3. Purpose of the Paper U.S. ADULTS IN 2015
High prevalence of overweight and obesity in adults
Obesity increases the risk of several chronic diseases including:
Type 2 diabetes
Cardiovascular disease
Certain forms of cancers
Reducing obesity is a public health priority
MEN AGES 25-54
_______________________________________________
WOMEN
AGES 25-54
First bullet: total of 71.5% were overweight or obese
Third bullet: Due to its impact on health, medical costs, and its longevity…..

4. Weight Loss
3%-5%: Reductions in triglycerides, blood glucose, and the risk of type 2 diabetes
Larger weight loss reduces additional risk factors of CVD
LDL cholesterol, blood pressure
Decreases the need for medication to control CVD and type 2 diabetes
Goal of 5%-10% within 6 months is recommended for the best health results
Evidence Analysis Library (EAL) Recommendation: the RDN should talk with the client to create a realistic weight-loss goal
Last bullet: ex. Up to 2 lb per week, up to 10% of baseline body weight, or a total of 3-5% of baseline weight if CV risks are involved

5. Goals of Adult Obesity Treatment
Weight loss must be maintained to sustain health improvements
No particular time frame, 1 year is common
Changes in lifestyle behavior (maintenance)
Reduce excessive energy intake as well as enhance dietary quality to meet recommendations in The Dietary Guidelines
Encourage increases in physical activity to increase energy output
Second bullet: no standard definition for length of time for maintenance of weight loss to be considered successful
Overall: preservation of changes in lifestyle behaviors is required to achieve successful weight-loss maintenance

6. Intrapersonal-Level Obesity Intervention
Socioecological Model of Obesity Intervention
Multiple levels of influence: intrapersonal factors, community and organizational factors, along with government and public policies.
Intrapersonal-Level: Intervention at the individual level.
Nutrition Care Process
Assessment
Diagnosis
Intervention
Monitoring and Evaluation

7. Assessment EAL Recommendations for RDNs:
BMI to determine overweight or obese
Other body fat and medical measurements
Waist circumference, blood pressure, lipids, and glucose (CV risk)
Food- and nutrition-related history
Calculation of total energy intake needs
Motivation for weight loss and management
Third bullet: assess dietary intake; social history, living or housing situation and socioeconomic status, client and family medical and health history
Fourth bullet: determine resting metabolic rate, multiply by physical activity level to calculate total energy needs. Use usual dietary intake in terms of energy and nutrient content to come up with dietary plan
Fifth bullet: readiness, and self-efficacy

8. Dietary Intervention
Reduction in energy intake is the most important factor
Client’s preference and health and nutrient status should be considered
EAL Recommendations for RDNs:
Prescribe an individualized diet:
1,200 kcal to 1500 kcal/day for women
1,500 kcal to 1,800 kcal/day for men
Diets may also restricts certain food types
(ex. high-carb, low-fiber, or high-fat foods)
Encourage that as long as the target reduction in calorie level is achieved, many different dietary approaches are effective

9. Small, Food-Based Changes
Fruits and Vegetables
May decrease dietary energy density, increase satiation, assist with decreasing overall energy intake, doesn’t produce weight loss on its own
Sugar-Sweetened Beverages (SSB)
Reduce intake
Replace with water, diet beverages, or non-nutritive sweetened beverages
Fast Food
High in energy density and large portion sizes; contribute to excessive energy intake
Avoidance or reduction is advised, but little research on fast food alone
Small behavior changes, those that shift energy balance by kcal/day may be helpful for weight management
SSB only evidence for weight loss alone, but still under weight loss recommendations

10. Portion Control Changes
Packages contain specific amount of energy
Complete meals
Portion-controlled utensils
Containers, plates, etc.
Communication strategies such as My Plate
Eating one or more single-serving portion-sized meals per day has resulted in a reduction in energy intake and weight loss

11. Larger Changes
Numerical energy goal per day and usually restricts or eliminates specific foods or food groups, meal replacements are common
Most efficient changes, produce the recommended amount of weight loss
3 types
Energy Focused
Macronutrient Focused
Dietary Pattern Based

12. Energy Focused Changes
Low Calorie Diet (LCD)
>800 kcal/day, usually ranges 1,200 to 1,600 kcal/day
Meal plan: food choices and portion sizes are provided for meals and snacks, meal replacements used
Very Low Calorie Diet (VLCD)
<800 kcal/day, higher degree of structure, usually liquid shake consumption
Designed to preserve lean body mass
BMI > or = to 30
Prepping for surgery
VLCD greater short term weight loss than LCD, no difference long term
LCD: reduces problematic food choices, decrease challenged with making decisions about what to consume, meal replacements enhances dietary adherence

13. Macronutrient Focused Changes
Low carbohydrate
No more than 20g of carbs/day
Desired weight is achieved, 50g carbs/day
Low-glycemic index/glycemic load
Controls glucose and insulin metabolism effectively with energy restriction
Fairly poor effectiveness on weight loss
High Protein
At least 20% energy from protein
Conventional foods and/or high protein meal replacements
When one macronutrient is restricted a change in the other ones occurs

14. Dietary Pattern Based Changes
Energy Density
Ratio of energy of a food to its weight (kcal/gram)
Low-energy density foods allow for greater consumption with appetite control and a reduction in overall energy intake
DASH
Reduces hypertension in individuals with moderate to high blood pressure
Limits consumption of sodium, and caffeinated and alcoholic beverages
Mediterranean Diet
Plant-based focused, minimal processed foods and red meat, olive oil as the primary source of fat, dairy, fish, and poultry consumed in moderation
Improves CVD risks
Focus on types of foods to consume
Emphasize consumption of foods that are generally considered beneficial in the diet and enhance overall dietary quality

15. The Mediterranean Diet

16. Dietary-Timing Focused
Eating frequency
Very little research, ones conducted have not shown that a higher eating frequency produces greater weight loss
Timing of eating
Consuming more earlier in the day may assist with weight loss
Influences circadian rhythm
Breakfast consumption
No investigation found greater weight loss with breakfast consumption
EAL Recommendation: the RDN should individualize the meal pattern to distribute calories at meals and snacks throughout the day, including breakfast
Research is very limited

17. Activity Intervention
Helps with weight loss (enhances energy expenditure, increases energy output)
Focus on increasing MVPA (moderate to vigorous physical activity) which also improves CV health
MVPA & decreasing energy intake has been found to produce the largest amount of weight loss
Minimum 150 min/week, 75 min/week for vigorous activity >250 min per week for weight-loss maintenance.
Weight loss requires a large energy deficit which is challenging to achieve via increased MVPA alone

18. Sedentary Behavior
Defined as sitting activities with a very low level of energy expenditure
Associated with increased risk of obesity
Recommendations to reduce, especially screen time
Eating is a behavior that usually is associated with watching TV
Increasing MVPA is a key behavioral target in weight management

19. Behavior-Change Interventions
Cognitive behavioral therapy
Thoughts, feelings, and behaviors interact to impact health outcomes
Self monitoring, goal setting, problem-solving, and preplanning
Motivational interviewing
Style of interaction between an RDN and client, involves teamwork, analysis of past experiences/memories, self-direction.
Driven by the client, not the RDN
Enhances motivation and self efficacy
Acceptance and commitment therapy
“I have a problem, but I can fix it”
Enhances mindfulness, reduces mindless behavior

20. Comprehensive Lifestyle Intervention
Obesity treatment is more than a dietary “prescription”
Energy deficit of at least 500 kcal/day
Physical activity at least 150 minutes of MVPA per week
Structures behavior-change intervention
Lifestyle intervention
Diet, physical activity, and behavioral strategies combined produces greater weight loss than an intervention that uses these same components by themselves

21. Comprehensive Lifestyle Intervention

22. Intensity of Intervention
Frequency of contact is an important characteristic of intervention for weight-loss outcomes
Face to face with one or two treatment sessions per month is standard
Frequency of contact is an important factor in intervention for weight loss outcomes

23. Technology Based Interventions
eHealth in intervention
May decrease intervention costs and increase the reach of the intervention for those in need
Potential for great public health impact
Computer-based interventions
Intervention websites with discussion boards and chat rooms, or based programs.
Face-to-face showed to produced greater weight loss
Smartphone-based interventions
Provides immediate access to social support
Apps can assist with decision making on behaviors

24. Miscellaneous Interventions
Supplements
The efficiency and safety of most supplements are mostly unknown
National Center for Complementary and Alternative Medicine
Commercial Programs
Not delivered by a health care provider but can offer support for weight loss customers
Face-to-face programs, prepackaged food, and Internet-based programs (ex. Weight Watchers)
If it provides a comprehensive program, it may be a viable option for treatment
NCCAM is a helpful resource regarding supplements. Houses a variety of fact sheets on a number of herbal- and food-based supplements.

25. Medications
Helpful for those who have difficulty losing weight (BMI >30, obesity related medical issues such as high blood pressure, type 2 diabetes, etc.)
Orlistat
Lipase inhibitor (causes dietary fat to be excreted as oil in the stool and is recommended to be taken with a diet containing 30% fat)
Lorcaserin
Agonist of a serotonin receptor in the hypothalamus, enhances feelings of satiety
Phentermine
Appetite suppressant, causes a decrease in food intake by stimulating the release of norepinephrine in the hypothalamus
All of these have a variety of side effects that need to be considered

26. Surgery Laparoscopic gastric banding
Thin, inflatable band around the top of the stomach to create a new and smaller stomach pouch, does not permanently alter the stomach
20% weight loss at 1-2 years, 15% at 10 years
Gastric bypass
Permanently alters the anatomy of the GI tract- allows food to bypass part of the stomach and small intestine
35% weight loss 1-2 years, 30% at 10 years
Highest mortality rate and rate of complications
Sleeve gastrectomy (new)
Portion of the stomach is removed, permanently altering the stomach
Similar results as bypass-lower cost, rates of complications & mortality
For patients unable to achieve or maintain weight loss, extreme obesity, high medical risk

27. Monitoring and Evaluation
To determine effectiveness of any intervention, outcomes need to be monitored over time and evaluated for degree of success.
EAL Recommendation:
The RDN should monitor and evaluate the effectiveness of the weight management program
If weight loss is not occurring at the expected rate, total energy needs may need to be readjusted.
Same assessments as before to compare, standardized, to see if progress has been made

28. Community-Level Obesity Intervention
Using and strengthening community programs to change energy balance behaviors for weight loss
Better access to intervention
Community-based organizations
Alter environment to promote positive behaviors
Ex. YMCA
Workplace wellness programs
EAL Recommendation: The RDN should recommend use of community resources, such as local food sources, food assistance programs, support systems, and recreational facilities
Environments with a greater density of fast food places and/or a lower density of farmer’s markets encourage dietary intakes high in energy density and thus contribute to excessive energy intake and obesity
Environments with reduces access for physical activity produce inactivity which also contributes to obesity

29. Policy-Level Obesity Intervention
Interventions from the government that can create big changes believed to help change behaviors to produce weight loss
Menu labeling
Could help with making choices that reduce intake
Influence decisions
Taxing the cost of certain foods
Creating a tax on unhealthy foods to help reduce their consumption (possibility but unlikely)
Little research

30. Understanding the Socioecological Model
Obesity is usually a result of factors that contribute a client to have an imbalance of energy intake to energy expenditure
Thus, it is appropriate to have multiple levels of interventions
To address obesity, interventions need to incorporate multiple levels of the socioecological model that can be sustained for many years.
RNDs have the responsibility to: address changing individual-level energy balance behaviors; be delivered in many settings to increase accessibility to intervention; influence the environment in which clients live, work, and play; and impact on policy that can assist with providing a context for supporting engagement in energy-balance behaviors within the population to improve weight management

31. Responsibilities of Food and Nutrition Practitioners
Addressing health disparities
Prevalence of overweight and obesity remains higher in non-Hispanic black adults and Hispanic adults, as compared with non-Hispanic white adults
Individual-level factors and environmental factors
Addressing weight bias
Health care professionals associate obesity with laziness, noncompliance to intervention, and lack of self control
Scope of practice
RDNs need to develop relationships with others to be involved in the SEM approach: physicians, pharmacists, legislators, school nutrition services, etc.
1st bullet: persuasive socioeconomic and racial inequalities found within environmental contexts may underlie obesity disparities
2nd bullet: RDNs need to understand the complexity of obesity

32. Reimbursement for Obesity Treatment (MNT)
The Patient Protection and Affordable Healthcare Act provides coverage for nutrition services in the area of obesity counseling for adults
Based on a survey completed by RDNs, obesity was the second highest disease or condition from which reimbursement was received by a third-party payers
Diabetes was ranked #1

33. Role of RDN and DTR Medical Nutrition Therapy (MNT)
Individualized approach to disease management
Evidence-based intervention with nutrition care process
Multidisciplinary Teams
Intervention includes more than just a focus on dietary intake
Recommended in the case of obesity and chronic disease
What other disciplines need to be involved
In treatment of overweight and obesity in adults

34. Advocacy
To address the obesity epidemic, interventions need to include larger environmental and policy changes, or public health initiatives
These have shown previous success at addressing public health concerns, eg. reducing smoking and increasing seat belt use!
The Grassroots Manager (from the academy) assists RDNs with communicating with legislators and others who may have the ability to influence policy and legislation assisting with reducing obesity

35. Outcomes Data
The role of food and nutrition practitioners in obesity treatment is not well documented
Including an RDN and NDTR in assisting with obesity treatment is not understood by participants (doctors and patients)
Practitioners are encouraged to examine outcomes data
Show the relationship between frequency of contact with RDNs and success
Establish the role of RDNs and NDTRs in obesity treatment

36. Outside Source #1: Obesity Rates Per State Purple: 35%+ Red: 30-34.9%
Orange: %
Yellow: %
Light Green: %
Green: %
Blue: 0-9.9%

37. Outside Source #2: How is Obesity Treated? Setting goals
How is Obesity Treated?
Setting goals
Making lifestyle changes
Medicines and weight-loss surgery
Balance energy IN (calories from food and drinks) with energy OUT (physical activity)
Manage Portion Sizes
Following a healthy eating plan
Losing 5-10% of body weight in 6 months to lower risk of coronary heart disease
Lose weight slowly (1-2lbs a week, will help keep off weight and make healthy lifestyle changes)
Behavioral Changes
Therapy
Find Support: friends, family, health care providers, support groups

38. Outside Sources #3 and #4:
Obesity increases the risk of Type 2 Diabetes
“When you have diabetes, being overweight or obese increases your risk for complications. Losing just a few pounds through exercise and eating well can help with your diabetes control and can reduce your risk for other health problems. You will also have more energy and feel better in general!”
________________________________________________________________________
Diabetes MAY be reversible, RD establishing role in weight management

39. Conclusions
High obesity rates negatively affects the health of the US population, making reducing obesity a public health priority
Weight loss of 3%-5% that is maintained produces clinically relevant health improvement, while greater weight loss reduces additional risk factors for CVD
Successful intervention includes the ability of adopting and maintaining lifestyle behaviors, which are influenced by intrapersonal, community, organizational and public government factors
RDNs and NDTRs need to create a team of traditional health care partners as well as nontraditional partners

40. Review of Position Paper
Vision: Optimizing health through food and nutrition
Mission: Empowering members to be food and nutrition leaders

41. References
Pianin, Eric. "US Obesity Rate Hit a Record High in 2015." The Fiscal Times. Thefiscaltimes, 12 Feb Web. 01 Dec
"New York." New York State Obesity Data, Rates and Trends: The State of Obesity. N.p., n.d. Web. 01 Dec
Gibbons, Gary H. "How Are Overweight and Obesity Treated?" National Institutes of Health. U.S. Department of Health and Human Services, 12 Nov Web. 14 Nov
"Clipart - High Quality, Easy to Use, Free Support." Clipart - High Quality, Easy to Use, Free Support. Openclipart, n.d. Web. 01 Dec
"More American Adults Overweight than a Healthy Weight."
American Institute for Cancer Research. AICR's Cancer
Research Update., 8 July Web. 01 Dec
“Weight Loss.” American Diabetes Association. N.p., n.d. Web. 01 Dec.2016