Position of the Academy of Nutrition and Dietetics ... · lipoprotein cholesterol and blood pressure) and decreases the need for medication to control CVD and type 2 diabetes. Thus,

2212-2672/Copyright ª 2016 by theAcademy of Nutrition and Dietetics.http://dx.doi.org/10.1016/j.jand.2015.10.031

ª 2016 by the Academy of Nutrition and Dietetics. J

FROM THE ACADEMY
Position Paper
Position of the Academy of Nutrition andDietetics: Interventions for the Treatment ofOverweight and Obesity in Adults

ABSTRACTIt is the position of the Academy of Nutrition and Dietetics that successful treatment ofoverweight and obesity in adults requires adoption and maintenance of lifestyle be-haviors contributing to both dietary intake and physical activity. These behaviors areinfluenced by many factors; therefore, interventions incorporating more than one levelof the socioecological model and addressing several key factors in each level may bemore successful than interventions targeting any one level and factor alone. Registereddietitian nutritionists, as part of a multidisciplinary team, need to be current and skilledin weight management to effectively assist and lead efforts that can reduce the obesityepidemic. Using the Academy of Nutrition and Dietetics’ Evidence Analysis Process andEvidence Analysis Library, this position paper presents the current data and recom-mendations for the treatment of overweight and obesity in adults. Evidence on intra-personal influences, such as dietary approaches, lifestyle intervention,pharmacotherapy, and surgery, is provided. Factors related to treatment, such as in-tensity of treatment and technology, are reviewed. Community-level interventions thatstrengthen existing community assets and capacity and public policy to create envi-ronments that support healthy energy balance behaviors are also discussed.J Acad Nutr Diet. 2016;116:129-147.

POSITION STATEMENT

It is the position of the Academy of Nutritionand Dietetics that successful treatment ofoverweight and obesity in adults requiresadoption and maintenance of lifestyle be-haviors contributing to both dietary intakeand physical activity. These behaviors areinfluenced by many factors; therefore, in-terventions incorporating more than onelevel of the socioecological model andaddressing several key factors in each levelmay be more successful than interventionstargeting any one level and factor alone.

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HE PURPOSE OF THIS ARTICLE evidence focuses as much as possible
This Academy position paper includes theauthors’ independent review of the litera-ture in addition to systematic review con-ducted using the Academy’s EvidenceAnalysis Process and information fromthe Academy’s Evidence Analysis Library(EAL). Topics from the EAL are clearlydelineated. For a detailed description ofthe methods used in the Evidence AnalysisProcess, go to www.andevidencelibrary.com/eaprocess.
Recommendations are assigned a rat-ing by an expert work group based on thegrade of the supporting evidence and thebalance of benefit vs harm. Recommen-dation ratings are Strong, Fair, Weak,Consensus, or Insufficient Evidence.

Recommendations can be worded asconditional or imperative statements.Conditional statements clearly define aspecific situation and most often arestated as an “if, then” statement, whileimperative statements are broadly appli-cable to the target population withoutrestraints on their pertinence.

Tis to provide an update to the2009 position paper on adultweight management and

incorporate the revised Academy’sevidence-based adult weight-management guidelines from the Evi-dence Analysis Library (EAL) and the2013 American Heart Association,American College of Cardiology, andThe Obesity Society (AHA/ACC/TOS)Guideline for the Management of Over-weight and Obesity in Adults.1 Thescope of the paper has been expandedto include a socioecological approachand provide evidence regardingcommunity-based and policy-level in-terventions designed to reduce theprevalence of overweight and obesityin communities in the United States.Within those areas in which various in-terventions are described, included

Evidence-based information for this andother topics can be found at www.andevidencelibrary.com and subscriptionsfor nonmembers can be purchased atwww.andevidencelibrary.com/store.cfm.

on systematic reviews and/or meta-analyses, randomized controlled trials(RCTs), and other evidence-basedguidelines.In 2012, 34.9% of adults in the United

States were obese and another 33.6%were overweight.2 The high prevalenceof overweight and obesity in theUnited States negatively affects thehealth of the population, as obese in-dividuals are at increased risk fordeveloping several chronic diseases,such as type 2 diabetes, cardiovasculardisease (CVD), and certain forms ofcancer.1,3 Because of its impact onhealth, medical costs, and longevity,reducing obesity is considered to be apublic health priority.4

Weight loss of only 3% to 5% that ismaintained has the ability to produceclinically relevant health improve-ments (eg, reductions in triglycerides,blood glucose, and risk of developingtype 2 diabetes).1 Larger weight lossreduces additional risk factors of CVD(eg, low-density and high-density

ADEMY OF NUTRITION AND DIETETICS 129

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FROM THE ACADEMY

lipoprotein cholesterol and bloodpressure) and decreases the need formedication to control CVD and type 2diabetes. Thus, a goal of weight loss of5% to 10% within 6 months isrecommended.1

EAL Recommendation: “The regis-tered dietitian nutritionist (RDN)should collaborate with the individualregarding a realistic weight-loss goalsuch as one of the following: up to 2 lbper week, up to 10% of baseline bodyweight, or a total of 3% to 5% of baselineweight if cardiovascular risk factors(hypertension, hyperlipidemia, andhyperglycemia) are present.” (Rating:Strong, Imperative)

GOALS OF ADULT OBESITYTREATMENTWhile intentional weight loss of atleast 3% to 5% improves some clinicalparameters,1 to sustain these im-provements, this degree of weight lossneeds to be maintained. While there isno standard definition for length oftime for maintenance of weight loss forit to be considered successful, durationof 1 year is often used.5 While long-term weight-loss maintenance is oneof the challenges in obesity treatment,it is possible. For example, the LookAHEAD (Action for Health in Diabetes)trial, an RCT with >5,000 adults withtype 2 diabetes, reported that 39.3% ofthe 825 participants who received alifestyle intervention (consisting of areduced-energy dietary and physicalactivity prescription, and a cognitivebehavioral intervention) who lost atleast 10% of their body weight at year 1maintained at least a 10% weight loss atyear 8, and another 25.8% maintained a5% to <10% weight loss at year 8.6

To achieve a reduction in weight thatcan be sustained over time andimprove cardiometabolic health,obesity treatment ideally produceschanges in lifestyle behaviors thatcontribute to both sides of energy bal-ance in adults. Thus, the diet should bealtered so that reductions in excessiveenergy intake and enhancements indietary quality occur, so that the like-lihood of achieving recommendationsprovided in the 2010 Dietary Guide-lines for Americans (DGA)7 isincreased. Along with changes in di-etary intake, obesity treatment shouldencourage increases in physical activ-ity in order to increase energy

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expenditure, in the minimum to meetthe 2008 Physical Activity Guidelinesfor Americans (150 minutes per weekof moderate-intensity, or 75 minutesper week of vigorous-intensity physicalactivity)8 and ideally to meet theAmerican College of Sports Medicine’sPosition Stand for weight-loss mainte-nance (>250 minutes/wk of moderate-intensity physical activity),9 andenhance cardiovascular fitness. Preser-vation of changes in lifestyle behaviorsis required to achieve successfulweight-loss maintenance.10

FACTORS INFLUENCING FOODINTAKEEating behavior is generally believed tobe influenced by both internal andexternal cues.11,12 Internally, two sys-tems have been identified that assistwith regulating intake.11 The first sys-tem is the homeostatic system, inwhich neural, nutrient, and hormonalsignals allow communication betweenthe gut, pancreas, liver, adipose tissue,brainstem, and hypothalamus. Thearcuate nucleus of the hypothalamusintegrates these signals and regulateshunger, satiation, and satiety inresponse to the signals via highercortical centers that influence thesympathetic and parasympathetic ner-vous system, gastric motility and hor-mone secretion, and other processesrelevant to energy homeostasis. Thesecond internal system is the hedonicsystem, which is influenced by thehedonic (“liking”) and rewarding(“wanting”) qualities of food and isregulated by the corticolimbic sys-tem.11,12 It is through the hedonic sys-tem that environmental cues influenceconsumption.11,12 The hedonic systemdoes have a strong impact on intake, asis demonstrated in situations wheneating occurs after reports of satiationand when there is no nutrition need(eg, the dessert effect).12 It is believedthat cross talk does occur betweenthese two internal systems; however,little is known about this process.11

Many external factors influenceconsumption, but environmental vari-ables that appear to greatly influenceintake are food availability and varietyand energy density and portion size offood.12 Research has found that whenavailability, variety, energy density, andportion size increase, intake is height-ened.12 The increased intake appears to

ION AND DIETETICS

be outside of awareness, is not associ-ated with enhanced satiation, andcompensation does not appear to occurover time.

FACTORS INFLUENCINGENGAGING IN MODERATE- TOVIGOROUS-INTENSITY PHYSICALACTIVITYAs with food intake, there are internaland external factors that influence howmuch moderate- to vigorous-intensityphysical activity (MVPA) one engagesin. Internally, physical limitations anddiscomfort and beliefs about howMVPA influences health have beenrelated to amount of MVPA achieved.13

Mood and, specifically, core affectivevalence (eg, good/bad feelings) inresponse to engaging in MVPA arerelated to future physical activity.14

Also as engaging in regular MVPA in-volves consistently making decisions toengage in a behavior that requires coststo achieve the long-term cumulativehealth benefits, it is theorized thatstrong executive control and optimizedbrain structures supporting executivefunctioning (ie, dorsolateral prefrontalcortex) is an important internalfactor.15

The social and physical environ-ments are also believed to be factorsthat influence engaging in MVPA. Howsupportive other individuals are toMVPA efforts and the potential inter-action with others who are active areexternal factors that can promotephysical activity.13 Different physicalenvironmental dimensions, such aswalkability, land use, public trans-portation availability, safety, and aes-thetics, in residential and/or workneighborhoods have also been shownto influence physical activity.16 Finally,within a home or work setting, theoption of engaging in sedentary be-haviors, especially those that arescreen-based, can also influenceMVPA.17

SOCIOECOLOGICAL MODEL OFOBESITY INTERVENTIONThe socioecological model provides aframework that proposes that multiplelevels of influence can impact energy-balance behaviors and weight out-comes. Levels of influence includeintrapersonal factors, community andorganizational factors, and governmentand public policies.18

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FROM THE ACADEMY

Intrapersonal-Level ObesityInterventionThe vast majority of research formingan evidence-based approach to obesitytreatment has focused on interventionat the individual level, in which treat-ment targets intrapersonal-level fac-tors that assist with changing energybalance behaviors. The nutrition careprocess, which includes nutritionassessment, diagnosis, intervention,monitoring, and evaluation, representsan intrapersonal-level of focus. TheAcademy’s evidence-based adultweight-management guidelines fromthe EAL focus on obesity treatmentat the intrapersonal level, incorpo-rating the nutrition care process withinits recommendations.

Assessment. As with any nutritionassessment, applicable informationthat can assist in the development ofa nutrition diagnosis and interventionfor obesity is essential (see Figure 1for suggested data to collect forassessment). Determining body massindex (BMI; calculated as kg/m2) isoften the first step of obesity treat-ment, as it identifies whether a clientis overweight or obese. Using thecurrent criterion for overweight andobesity, individuals with a BMI�25.0-29.9 (overweight) or �30(obese) should be identified and pro-vided with obesity treatment.1 Otheranthropometric and medical mea-sures, such as waist circumference,blood pressure, lipids, and glucose,should be taken to assess for cardio-vascular risk.1 This will assist withmatching obesity treatment benefitswith risk profiles and making appro-priate referrals.1

EAL Recommendation: “The RDN, incollaboration with other health careprofessionals, administrators, and/orpublic policy decision-makers, shouldensure that all adult patients have thefollowing measurements at leastannually: height and weight to calcu-late BMI; and waist circumference todetermine risk of CVD, type 2 diabetes,and all-cause mortality.” (Rating: Fair,Imperative)EAL Recommendation: “The RDN, in

collaboration with other health careprofessionals, administrators, andpublic policy decision makers, shouldensure that overweight or obese adultsare referred to an RDN for medical


nutrition therapy (MNT).” (Rating:Fair, Imperative)Once an RDN initiates the nutrition

care process, data about the client (seeFigure 1) should be collected to assistin individualizing MNT. An assessmentcan include, but is not limited to, di-etary intake; social history, includingliving or housing situation and socio-economic status; and motivation forweight management. Resting meta-bolic rate should be determined, andthat, combined with activity level andcalculation of usual dietary intake interms of energy and nutrient content,can assist with developing dietary pa-rameters that may be appropriate totarget during intervention. In the EAL,physical activity is listed with food-and nutrition-related history, and levelof physical activity is required to esti-mate energy needs. To assist withassessing physical activity, “A PhysicalActivity Toolkit for Registered Di-etitians: Utilizing Resources of Exerciseis Medicine,” was developed by theWeight Management and Sports, Car-diovascular, and Wellness Nutritiondietetic practice groups, in collabora-tion with the American College ofSports Medicine.EAL Recommendation: “The RDN

should assess the following data in or-der to individualize the comprehensiveweight-management program foroverweight and obese adults: food-and nutrition-related history; anthro-pometric measures; biochemical data,medical tests and procedures;nutrition-focused physical findings;and client history.” (Rating: Strong,Imperative)EAL Recommendation: “The RDN

should assess the energy intake andnutrient content of the diet.” (Rating:Strong, Imperative)EAL Recommendation: “If indirect

calorimetry is available, the RDNshould use a measured resting meta-bolic rate (RMR) to determine energyneeds in overweight or obese adults.”(Rating: Consensus, Conditional)EAL Recommendation: “If indirect

calorimetry is not available, the RDNshould use the Mifflin-St. Jeor equationusing actual weight to estimate RMR inoverweight or obese adults.” (Rating:Strong, Conditional)EAL Recommendation: “The RDN

should multiply the RMR by one of thefollowing physical activity factors toestimate total energy needs: sedentary

JOURNAL OF THE ACAD

(1.0 or more to less than 1.4); lowactive (1.4 or more to less than 1.6);active (1.6 or more to less than 1.9);and very active (1.9 or more to lessthan 2.5).” (Rating: Consensus,Imperative)

EAL Recommendation: “The RDNshould assess motivation, readinessand self-efficacy for weight manage-ment based on behavior changetheories and models (such as cognitive-behavioral therapy, transtheoreticalmodel, and social cognitive theory/so-cial learning theory).” (Rating: Fair,Imperative)

Dietary Intervention. As treatingobesity requires achieving a state ofnegative energy balance, all effica-cious dietary interventions for obesitytreatment must decrease consump-tion of energy. There are many di-etary approaches that can reduceenergy intake, with some approachesmore greatly reducing intake thanothers. However, the degree of weightloss generally reflects the size of thedecrease in energy intake achieved.Thus, the reduction in energy intakeis the primary factor to address in adietary intervention for obesitytreatment.1 As many dietary ap-proaches reduce energy intake, a cli-ent’s preference and health andnutrient status should be taken intoconsideration when a dietary inter-vention for obesity treatment is pre-scribed.1 See Figure 2 for dietaryinterventions and a summary of theevidence-base regarding ability toproduce weight loss or not, orwhether evidence is lacking for con-clusions to be drawn.

EAL Recommendation: “Duringweight loss, the RDN should prescribe anindividualized diet, including patientpreferences and health status, to achieveand maintain nutrient adequacy andreduce caloric intake, based on one of thefollowing caloric reduction strategies:1,200 kcal to 1,500 kcal/day for womenand 1,500 to 1,800 kcal/day for men;energy deficit of approximately 500 kcal/day or 750 kcal/day; one of the evidence-based diets that restricts certain foodtypes (such as high-carbohydrate foods,low-fiber foods, or high-fat foods) inorder to create an energy deficit byreduced food intake.” (Rating: Strong,Imperative)

EAL Recommendation: “For weightloss, the RDN should advise overweight

EMY OF NUTRITION AND DIETETICS 131

Assess Monitor and Evaluate

Food- and nutrition-relatedhistory � Beliefs and attitudes, including food preferences and motivation

� Food environment, including access to fruits and vegetables� Dietary behaviors, including eating out and screen time� Diet experience, including food allergies and dieting history� Medications and supplements� Physical activity

� Beliefs and attitudes, including motivation� Food environment, including access to fruits

and vegetables� Dietary behaviors, including eating out and

screen time� Medications and supplements� Physical activity

Anthropometric measurements

� Height, weight, body mass index� Waist circumference� Weight history� Body composition

� Weight, body mass index� Waist circumference� Weight history� Body composition

Biochemical data, medical tests,and procedures � Glucose and endocrine profile

� Lipid profile

� Glucose and endocrine profile� Lipid profile

Nutrition-focused physicalfindings � Ability to communicate

� Affect� Amputations� Appetite� Blood pressure� Body language� Heart rate

� Affect� Appetite� Blood pressure� Body language� Heart rate

Client history

� Appropriateness of weight management in certain populations (such aseating disorders, pregnancy, receiving chemotherapy)

� Client and family medical and health history� Social history, including living or housing situation and socioeconomic status

Figure 1. Data needed to assess, monitor, and evaluate a comprehensive weight-management program from the Academy of Nutrition and Dietetics’ Evidence AnalysisLibrary.

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Diet Investigated using RCTsa

with evidence consideredsupportive for weight loss

Investigated using RCTswith evidence considerednon-supportive for weight loss

Lacking investigation forweight loss using RCTs

Small, food-based

Increasing fruits and vegetables X

Decreasing sugar-sweetened beverages X

Decreasing fast food X

Portion control X

Larger-, energy-, macronutrient- and/or dietary pattern-based

Energy-focused

Low-calorie diet X

Meal replacement/structured meal plans X

Very-low-calorie diet X

Macronutrient-focused

Low-carbohydrate X

Low glycemic index/load without energy restriction X

High protein with energy restriction X

Dietary-pattern focused

Energy density X

DASHb with energy restriction X

Mediterranean with energy restriction X

Dietary-timing focused

Eating frequency X

Timing of eating X

Breakfast consumption X

Figure 2. Evidence-base for dietary interventions for weight loss in adults. Sources include 2013 American Heart Association, American College of Cardiology, and theObesity Society Guideline for the Management of Overweight and Obesity in Adults and the Academy of Nutrition and Dietetics’ Evidence Analysis Library.aRCTs¼randomized controlled trials; bDASH¼Dietary Approaches to Stop Hypertension.

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or obese adults that as long as thetarget reduction in calorie level isachieved, many different dietary ap-proaches are effective.” (Rating:Strong, Imperative)EAL Recommendation: “During

weight maintenance, the RDN shouldprescribe an individualized diet(including patient preference andhealth status) to maintain nutrientadequacy and reduce caloric intake formaintaining a lower body weight.”(Rating: Strong, Imperative)EAL Recommendation: “For weight

maintenance, the RDN should adviseoverweight and obese adults that aslong as the target reduction in calorielevel is achieved, many differentdietary approaches are effective.”(Rating: Strong, Imperative)

Small, food-based changes. It hasbeen proposed that small behaviorchanges, those that shift energy balanceby 100 to 200 kcal/day, may be helpfulforweightmanagement.19 It is importantto recognize that this degree of energydeficit is much smaller than what iscurrently recommended to produceclinically relevant weight loss.1 It is hy-pothesized that small behavior changes,such as reducing intake of sugar-sweetened beverages (SSB), may bemore feasible and sustainable than largerbehavior changes, such as changingmacronutrient composition of the diet.

Fruits and vegetables. Within thecontext of promoting healthy diets, theincreased consumption of fruits andvegetables has gained recognition, inlarge part due to the findings of theDASH (Dietary Approaches to StopHypertension) and DASH-SodiumRCTs.20,21 Increasing fruits and vegeta-bles is a dietary change that can reducedietary energy density, enhance satia-tion, and assist with decreasing overallenergy intake, particularly if fruits andvegetables are consumed instead ofother foods higher in energy density.22

Those RCTs that have examined theinfluence of solely increasing fruits andvegetables with no other dietarychanges on weight management havegenerally not produced weight loss.23

SSB. Reducing SSB should be helpfulfor weight management if compensa-tion to the reduction in energyconsumed from SSB does not occur and


if energy-containing beverages are notconsumed in place of SSB when SSB arereduced. While few studies haveexamined the effect of solely reducingSSB on weight loss, an RCT conductedby Tate and colleagues24 found thatreplacing caloric beverages with wateror diet beverages resulted in weightlosses of 2% to 2.5% during a 6-monthperiod. While concerns have beenraised about increases in hunger, whichmay increase overall energy intakewhen non-nutritive sweetened foodsand beverages are consumed, a recentRCT found that consumption of at least24 oz of non-nutritive sweetened bev-erages during a 12-week behavioralweight-loss intervention reduced sub-jective feelings of hunger as comparedwith a 24-oz water consumptioncomparison.25

Fast food. Food prepared away fromhome, in particular fast food, comprisesan increasing amount of the Americandiet and contributes to the epidemic ofobesity.26 Fast food is generally high inenergy density and commonly pur-chased in large portion sizes, therebycontributing to excessive energyintake.26 Due to the relationship be-tween fast food and increased energyintake, in the context of a weight-lossdietary regimen, avoidance or reduc-tion of the frequency of consumption offoods away from home is typicallyrecommended. However, no RCT hasbeen conducted to examine whetherreducing fast food alone, with no otherchanges in the diet, produces weightloss.

At this time, research conducted inthe area of small, food-based changesindicates that only changes in SSB, andno other small food-based change, canassist with weight management. It isimportant to note that the weight lossfound with reducing SSB alone, whilestatistically significant, is below theamount of weight loss that is recom-mended to improve cardiometabolichealth.1

Portion-control changes. RDNs havelong endorsed skills that includeportion control for lifelong weightmanagement.27 Portion control can beaccomplished in a variety of differentways, including using packages con-taining a defined amount of energy(eg, complete meals, individual food

ION AND DIETETICS

items); portion-controlled utensilswhere food is delivered in specificserving sizes; or communication stra-tegies such as MyPlate, developed as anadjunct to the DGA,7 to assist withconsuming appropriate serving sizes ofspecific foods. The EAL’s Relationship ofSingle Serving Portion Size Meals andWeight Management Project statesthat single-serving portion-sized mealsare a tool that can be used as a part of aweight-management program. Thisproject’s key findings were that eatingone or more single-serving portion-sized meals per day as part of a weight-management program resulted in areduction of energy intake and weightloss in adults.

Larger, energy, macronutrient,and/or dietary pattern-basedchanges. Dietary approaches thattarget larger nutrient (eg, energy and/or macronutrient) and or dietarypattern-based changes (eg, Mediterra-nean diet) are predominantly consid-ered efficacious for weight loss andproduce the recommended amount ofweight loss,1 as many RCTs investi-gating these diets have shown thatthey reduce energy intake enough (500kcal/day to 750 kcal/day) so that thedegree of negative energy balanceachieved produces at least a 3% reduc-tion in percent body weight.1 Thesedietary interventions have either anexplicit energy goal per day or providean ad libitum approach without aformal energy goal that still produces areduction in energy intake, usually byrestriction or elimination of specificfoods and/or food groups, or provisionof prescribed foods (eg, meal replace-ment).1 Outcomes indicate that all ofthe larger, energy, macronutrient, and/or dietary pattern-based approachesproduce a weight loss of about �4to �12 kg at 6-month follow-up.1 After6 months, slow weight regain occurs,and at 1 year, total weight loss is �4to �10 kg, and at 2 years, total weightloss is at �3 to �4 kg.1 As this is thepooled effect of the weight loss ach-ieved with the energy, macronutrientand/or dietary pattern-based changediets, the individual weight-loss out-comes for each diet described in thispaper are not reported (except for thevery-low-calorie diet [VLCD] as thisdiet has a lower energy prescriptionthan all other diets; meal re-placements, as they are a specific form


FROM THE ACADEMY

of the low-calorie diet [LCD] and theirweight loss is included to allow com-parison with the LCD; and timing ofeating, as this diet was not included inthe AHA/ACC/TOS Guideline for theManagement of Overweight andObesity in Adults).1

Although no one diet approach thattargets larger nutrients or dietary pat-terns is considered to be more effica-cious than another diet approach, someof the diets have differential effects oncardiometabolic outcomes and dietaryquality. While research in these differ-ential effects is limited, availableresearch on cardiometabolic outcomesspecific to a diet intervention, aftercontrolling for effects attributable toweight loss, and diet quality aredescribed here for the correspondingdiet. If measures of cardiometabolicoutcomes and diet quality are not re-ported on in a section, this indicatesthat there is very little evidence avail-able to report about the influence ofthe diet alone on these parameters.

Energy focused. Two of the mostwidely investigated dietary pre-scriptions for weight loss are the LCDand the VLCD. Along with varyingin energy goals, these two diets differin the amount of structure theyprovide.

LCD. An LCD is usually >800 kcal/day,and typically ranges from 1,200 to 1,600kcal/day.28 Structure can be increased inthe LCD with the use of a meal plan, inwhich all food choices and portion sizesfor these choices for all meals andsnacks are provided. Use of meal re-placements, usually liquid shakes andbars, containing a known amount ofenergy and macronutrient content alsoincrease structure in the LCD diet. Thesemethods of increasing structure in thediet are believed to be helpful foradherence to an LCD because theyreduce problematic food choices, anddecrease challenges with making de-cisions about what to consume. Inaddition, meal replacements canenhance dietary adherence via portioncontrol, limiting dietary variety, andconvenience.28-30 Meal plans and thepartial meal-replacement plan, whichprescribes two portioned-controlled,vitamin/mineral-fortified meal re-placements per day, with a reducedenergy meal and snack composed of


conventional foods, may producegreater short-term weight loss ascompared with an LCD composed oftraditional foods.28,31 For example, ameta-analysis of six studies comparingan LCD composed of conventional foodsor meal replacements found a 2.54 kgand 2.43 kg greater weight loss inthe meal-replacement group for the3-month and 1-year follow-ups,respectively.28

EAL Recommendation: “For weightloss and weight maintenance, the RDNshould recommend portion control andmeal replacements or structured mealplans as part of a comprehensiveweight-management program.” (Rat-ing: Strong, Imperative)

VLCD. A VLCD provides �800 kcal/dayand provide a high degree of dietarystructure (VLCDs are commonlyconsumed as liquid shakes).32,33 TheVLCD is designed to preserve lean bodymass; usually 70 to 100 g/day of proteinor 0.8 to 1.5 g protein/kg of ideal bodyweight are prescribed.32 VLCDs areconsidered to be appropriate only forthose with a BMI �30, and are increas-ingly used with individuals before hav-ing bariatric surgery to reduce overallsurgical risks in those with severeobesity.32 A meta-analysis of six RCTscomparing weight-loss outcomes ofVLCDs to LCDs found that althoughVLCDs produce significantly greaterweight loss in the short-term (4months), �16.1%�1.6% vs �9.7%�2.4% ofinitial weight, there was no difference inweight loss between the diets in long-term follow-up (>1 year), VLCD¼ �6.3%�3.2%; LCD ¼ �5.0%�4.0%).32

Macronutrient focused. Many RCTshave been conducted to help determinewhich mix of macronutrients best pro-motes weight loss, while includingother positive metabolic benefits. Whatis important to recognize aboutmacronutrient-focused diet prescrip-tions is that when one macronutrient isaltered, there will be a change in theother macronutrients. Thus, prescrip-tions for macronutrient-focused dietshave often targeted changing onemacronutrient, allowing the other twomacronutrients to change as differentfood choices are made. The name of themacronutrient-focused diet is usuallybased on the one macronutrient that istargeted for change.

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Lowcarbohydrate. A low-carbohydratediet is commonly defined as consumingno more than 20 g of carbohydrate perday.34,35 Energy and other macro-nutrients are not restricted in low-carbohydrate diets. Once a desiredweight is achieved, carbohydrate intakecan increase to 50 g per day.36

While amount of weight loss ach-ieved is not considered to be differentbetween a low-carbohydrate and low-fat, LCD especially over 12 months orlonger, research does suggest thatthese diets may produce differences incardiometabolic outcomes duringweight loss.1 For example, a low-fat,LCD produces a greater reduction inlow-density lipoprotein cholesterolthan a low-carbohydrate diet, whilea low-carbohydrate diet produces agreater reduction in triglycerides and alarger increase in high-density lipo-protein cholesterol than a low-fat, LCD.1

� Low-glycemic index/glycemic load.There is currently no standard defini-tion of a low-glycemic index or low-glycemic load diet. The effectivenessof a low-glycemic index diet withoutrestriction of energy intake on weightloss is fairly poor.37 With regard tocardiometabolic outcomes, a recentRCT found that when coupled withenergy restriction, a low-glycemic in-dex diet controlled glucose and insulinmetabolism more effectively than ahigh-glycemic index, low-fat diet.38

High protein. A high-protein diet iscommonly defined as consuming atleast 20% energy from protein, with nostandard amount defined for fat orcarbohydrate.39 For weight loss, high-protein diets also include an energyrestriction. A high-protein diet is oftenachieved through consumption ofconventional foods, but high-protein,portion-controlled liquid and solidmeal-replacement products can also beused on a high-protein diet.

Dietary pattern focused. Dietarypattern�focused prescriptions empha-size the importance of the overall dietby providing recommendations abouttypes of foods to consume, rather thanproviding recommendations aboutamount of energy or macronutrients, toconsume.7,40 The DGA promotesadopting an eating pattern to assistwith weight management and reduce


FROM THE ACADEMY

disease risk.7 As these diets focus ontypes of foods to consume and may notproduce greater weight loss than othertypes of diets, they enhance consump-tion of foods that are generallyconsidered beneficial in the diet andenhance overall dietary quality.41,42

Energy density. Energy density is theratio of energy of a food to the weightof a food (kcal/g). Energy density islargely determined by the water con-tent (higher water content lowers en-ergy density), but is also affected by thefiber and fat content (more fiber lowersenergy density and less fat lowers en-ergy density) of foods and beveragesconsumed. As low-energy densityfoods have fewer kilocalories per gramweight, low-energy density foods allowconsumption of a greater weight offood relative to energy consumed,which may assist with appetite controland reducing energy intake.22,43

Basic eating research has found thatserving meals with foods low in energydensity results in decreased meal en-ergy intake.22 For example, one studyreduced energy density by 20% for en-trées served at breakfast, lunch, anddinner, on three different days, usingthree different methods (reducing fat,increasing fruits and vegetables, oradding water to entrées), with adifferent method used to reduce en-ergy density each day. With thereduction in energy density, energyintake per day decreased, rangingfrom �396�44 kcal/day to �230�35kcal/day, with the largest decreaseoccurring when fat was reduced inentrées.44

Few RCTs have been conducted toexamine the effect of a low-energydensity diet on weight loss andcurrently there is no standard methodknown to best reduce energy density inthe diet.45 Results from these trialsabout weight loss are mixed, and thismay be a consequence of the methodsused to reduce dietary energy density,the degree of reduction in energy den-sity achieved, and whether or not en-ergy restriction was included. To betterunderstand how recommendations toreduce energy density can be imple-mented, guidelines need to be devel-oped regarding what is considered to below-energy density and high-energydensity (currently no definition exists),how best to lower energy density of the


diet, and how dietary energy densityshould be calculated (ie, as energy den-sity is greatly influenced by water,dietary energy density varies greatlydepending on whether and how bever-ages are included in calculations andno standard calculation has beendetermined).46

DASH. DASH is a dietary pattern thatwas developed to reduce hypertensionin individuals with moderate to highblood pressure. DASH encourages theconsumption of fruits, vegetables,whole grains, nuts, legumes, seeds,low-fat dairy products, and lean meatsand limits consumption of sodium, inaddition to caffeinated and alcoholicbeverages.47 A daily energy limit is nota component of the original DASH diet,but when one is provided with theDASH diet, weight loss occurs.48,49 TheDASH diet combined with weight losssignificantly enhances reductions inblood pressure above that achieved byweight loss alone.49

Mediterranean. There is not a stan-dard definition for the Mediterraneandiet, but generally the Mediterraneandiet reflects the dietary patterns ofCrete, Greece and southern Italy in theearly 1960s.50 The traditional Mediter-ranean diet was focused on plant-basedfoods (eg, fruits, vegetables, grains, nuts,seeds), minimally processed foods, oliveoil as the primary source of fat, dairyproducts, fish, and poultry consumed inlow to moderate amounts, and minimalamount of redmeat.51 As with the DASHdiet, the Mediterranean diet can beprescribed with or without an energyrestriction, but if weight loss is desired,it does appear that an energy-restrictioncomponent is needed.52 In addition, theMediterranean diet may improve car-diovascular risk factors, such as bloodpressure, blood glucose, and lipids, moreso than a low-fat diet,53,54 but moreresearch is needed in this area.

In summary, there are several dietaryapproaches that target larger nutrient(eg, energy and/or macronutrient) andor dietary pattern�based changes (eg,Mediterranean diet) that can producethe recommended amount of weightloss.1 At this time, as long as the diethelps to reduce energy intake by 500 to750 kcal/day, there is no one diet thatfalls into this category that has been

ION AND DIETETICS

shown to be more efficacious thananother at producing clinically mean-ingful weight loss.

Dietary-timing focused. While re-search on dietary interventions forobesity have predominantly focused onfood choices that impact energy,macro- and micronutrient, and foodgroup intake,55 dietary interventionscan also address factors that influencethe overall timing of the diet (eg, fre-quency of consumption, timing ofconsumption, and breakfast consump-tion). It is important to note thatresearch on the effect of timing ofintake on obesity treatment outcomesis very limited.

Eating frequency. Eating frequency iscommonly defined as the number ofeating occasions (meals and snacks)occurring per day. A greater number ofeating occasions consumed increasesoverall eating frequency. At this time,there is no standardized definition ofwhat constitutes an eating occasion.56

Common parameters used to definean eating occasion include amount ofenergy consumed, type of substanceingested (eg, food or beverage), and theamount of time that has elapsed sincethe start of the previous eating occa-sion.56,57 Few RCTs have been con-ducted that examine the influence ofeating frequency on weight loss, andthose that have been conducted havenot found that a higher eating fre-quency produces greater weight loss.56

Timing of eating. When and howmuch energy you eat during the daycan also be important for weightmanagement. Potentially consumingmore energy earlier in the day, ratherthan later in the day, can assist withweight management.55 The mecha-nism of action by which timing ofeating might assist with weight man-agement is by influencing circadianrhythm.55 Potentially, eating a greateramount earlier in the day may assistwith synchronization of peripheraloscillators with the suprachiasmaticnucleus, assisting with maintenance ofan appropriate circadian rhythm.55

There is only one RCT that has beenconducted to examine timing of energyintake and weight loss.58 In this 12-week intervention, the overweightand obese women with metabolic


FROM THE ACADEMY

syndromewho were randomized to thegroup that consumed most of theirenergy earlier in the day lost moreweight (�8.7�1.4 kg vs �3.6�1.5 kg).

Breakfast consumption. One dietarypattern factor that has been proposedto influence weight status is regularconsumption of breakfast.59 Similar toeating frequency, there is no stan-dardized definition of breakfast, butcommon parameters that are believedto be important in defining breakfastinclude time of day of consumption,time of consumption after ending dailysleep, and types of foods and beveragesconsumed at breakfast. Only three RCTshave examined the influence of break-fast consumption on weight loss, withall trials being of short duration (�16weeks), and no investigation foundgreater weight loss with breakfastconsumption.60-62

Overall, the results of interventionresearch examining the effect ofdietary-timing focused interventionsdo not suggest that increasing eatingfrequency or consuming breakfastimprove weight-loss outcomes, butconsuming most of an individual’s en-ergy earlier in the day may enhanceweight loss.EAL Recommendation: “For weight

loss and weight maintenance, the RDNshould individualize the meal patternto distribute calories at meals andsnacks throughout the day, includingbreakfast.” (Rating: Fair, Imperative)

Activity Intervention. Activity in-terventions are designed to enhanceenergy expenditure, which assists withthe achievement of negative energybalance that is required for weight loss.However, it is important to recognizethat activity interventions may assistwith weight management via othermechanisms that are not well under-stood (eg, sparing of fat-free mass withweight loss, enhanced ability for en-ergy regulation, and ability to bufferthe negative effects of stress onweight).63 Traditionally, activity in-terventions have focused on increasingMVPA, as this type of activity hashigher energy expenditure than otheractivities (eg, light physical activity)and also improves cardiovascularhealth. Recently, focus has turned to


the role of sedentary behaviors andobesity treatment.

Physical activity. MVPA is defined asactivity that is �3.0 metabolic equiva-lent units (METs; a MET of 1 is gener-ally considered the RMR).9 There is alarge body of research, including RCTs,examining the influence of MVPA onobesity treatment.9 While increasingMVPA alone is not believed to be thebest strategy for weight loss and pro-duces less weight loss than decreasingenergy intake, the combination ofincreasing MVPA with decreasing en-ergy intake produces the largestweight loss.9,64 For example, a recentmeta-analysis of diet or exercise in-terventions vs combined behavioralweight-management programs foundat 12 months that the combined pro-gram had greater weight loss than thediet-only programs (mean difference inweight loss achieved for combinedbehavioral weight management vs dietonly was �1.72 kg) and the exercise-only programs (mean difference inweight loss achieved for combinedbehavioral weight management vs ex-ercise only was �6.29 kg).64 However,for weight-loss maintenance, researchhas consistently demonstrated that ahigh level of MVPA is imperative.9 Thedifference in the roles of MVPA forweight loss and weight-loss mainte-nance is believed to be due to the de-gree of energy deficit required. Weightloss requires a larger energy deficit(approximately �500 to �1,000 kcal/day for 1 to 2 lb of weight loss perweek), which is challenging to achievevia increased MVPA alone. For weight-loss maintenance, equilibrium of en-ergy intake to expenditure is needed;thus, higher levels of MVPA allow en-ergy intake to be greater, which mayhelp long-term adherence to dietarygoals. The current recommendation forphysical activity is a minimum of 30minutes of moderate-intensity activityon most days of the week (150 min/wk).8 However, higher levels of MVPA(>250 min/week) are recommendedfor weight-loss maintenance.9 Toenhance cardiovascular outcomesassociated with increasing MVPA,ideally minutes spent in MVPA isaccumulated in bouts of at least 10minutes.8

EAL Recommendation: “For weightloss the RDN should encourage physical

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activity as part of a comprehensiveweight-management program, individ-ualized to gradually accumulate 150 to420 minutes or more of physical activityper week, depending on intensity, un-less medically contraindicated.” (Rat-ing: Consensus, Imperative)

EAL Recommendation: “For weightmaintenance the RDN should encouragephysical activity as part of a compre-hensive weight-management program,individualized to gradually accumulate200 to 300 minutes or more of phys-ical activity per week, depending onintensity, unless medically contra-indicated.” (Rating: Consensus,Imperative)

Sedentary behavior. Sedentary be-havior is defined as sitting activitieswith a very low level of energyexpenditure (<1.5 METs).65 Sedentarybehavior occurs in a variety of domains(ie, leisure, occupation, transportation,and recreation), and includes working/playing on the computer or tablet,driving a car, and watching television(TV). Given that greater time spent insedentary behavior, independent oftime performing MVPA, has beenassociated with increased risk ofobesity,66 it is now recommended thatsedentary behavior, particularly leisurescreen time (eg, TV watching; com-puter and tablet use), be reduced inadults to improve weight and healthstatus.66,67

There are several mechanisms bywhich reducing sedentary behaviormay assist with weight management.The first is through increasing energyexpenditure. Research indicates thatwhen time engaged in sedentarybehavior is reduced, while little tonone of the newly acquired free time isreallocated to MVPA, a significantamount of time is reallocated to lightphysical activity (1.5 to 2.9 METs).68,69

The reallocation of time spent insedentary behavior to light physicalactivity may increase overall energyexpenditure due to light physicalactivity’s higher MET values ascompared with sedentary behavior.The second mechanism is throughreducing food consumption. Eatingappears to be a complementarybehavior to some sedentary behaviors,particularly TV watching.70 As TVwatching is reduced, energy consumedwhile watching TV decreases, thus


FROM THE ACADEMY

lowering intake.69 Few RCTs haveexamined reducing sedentary behaviorduring obesity treatment, and the twotrials that have were of a small samplesize (<15 participants) and of shortduration (8 weeks), and did not findsignificantly greater weight loss withthe conditions that prescribed reducingsedentary behavior to <10 hours/weekof TV watching (comparison was anintervention that prescribed increasingMVPA to 200 minutes/wk).69

The research on activity interventionsdemonstrate that increasing MVPA is animportant behavioral target in weightmanagement, particularly in weight-loss maintenance. Additional researchis required to understand if reducingsedentary behavior should also be abehavioral target in obesity treatmentinterventions.

Behavior-Change Intervention.Behavior-change theories and modelsprovide an evidence-based approachfor changing energy-balance behaviorsthat are important for obesity treat-ment.71 At this time, it is not knownwhat is the best combination ofbehavior-change strategies and tech-niques to apply in treating obesity.72

Instead, it is believed that a variety ofstrategies from different behaviorchange theories can be applied to assistwith changing behaviors.71 Evidence-based interventions for behaviorchange have developed from behav-ioral theory, which is a theoreticalframework that proposes that with theuse of learning principles, such asclassical and operant conditioning,healthy behaviors can be learned.

Cognitive behavioral therapy.Cognitive behavioral therapy (CBT) usesa directive, action-oriented approachand provides skills to help individualslearn to develop functional thoughtsand behaviors.71 CBT proposes thatthoughts, feelings, and behaviorsinteract to impact health outcomes.Cognitive and behavioral strategiesare emphasized to effect change.Commonly used strategies in CBTinclude self-monitoring, goal setting,problem-solving and preplanning,stimulus control, cognitive restructur-ing, and relapse prevention. Two widelyrecognized obesity intervention trials,the Diabetes Prevention Program (DPP)and the Look AHEAD trial, provide ex-amples of the use of CBT in assisting


with changing eating and activity be-haviors.73,74 In DPP, the lifestyle inter-vention received a reduced-energy dietand a physical activity prescriptionwithin the context of a CBT interven-tion.74 In DPP, during the 2.8 mean yearsof follow-up, the lifestyle interventionlost 5.6 kg of weight, which was signif-icantly greater than the other twoconditions (placebo¼�0.1 kg; metfor-min¼�2.1 kg).74 As mentioned previ-ously, Look AHEAD produced significantweight-loss outcomes in the conditionthat received the CBT intervention, withsignificant weight loss reported acrosstime, even up to 8 years follow-up(lifestyle intervention with CBT¼�4.7%�0.2%; education comparison¼�2.1%�0.2% of initial weight).6 Thematerials for the CBT intervention forboth DPP and Look AHEAD are availableand accessible to the public (DPP:https://dppos.bsc.gwu.edu/web/dppos/dpp; Look AHEAD: www.lookaheadtrial.org/public/home.cfm). RDNs played alarge role in intervention in LookAHEAD.75

Motivational interviewing. Motiva-tional interviewing focuses on the styleof interaction between a practitionerand client. Motivational interviewingemphasizes collaboration, evocation,and autonomy.76 Collaboration guidespractitioners to be “supportive part-ners” rather than “persuasive experts,”which contrasts with the prescriptive,expert-driven style commonly used indietary interventions. Evocation en-courages the practitioner to draw outthe client’s personal motives andvalues regarding behavior change.Finally, autonomy emphasizes a client’spersonal choice, in which the re-sponsibility and decisions aboutbehavior changes fall under the client’s,rather than practitioner’s, control.Motivational interviewing emphasizesthat the intervention for obesity wouldbe driven by the client, rather than thepractitioner. Using this approach,motivational interviewing is believedto enhance motivation and self-efficacy, which are considered to bekey for changing, and sustaining,behavior change.76 Motivational inter-viewing has an additional benefit, inthat it can be delivered at a low in-tensity (ie, shorter and less frequentdosages).77 For example, a review of 10RCTs examining motivational inter-viewing and obesity treatment found

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that participants receiving a medianamount of 60 minutes of motivationalinterviewing in an encounter, withnumber of encounters ranging fromone to five or more, reduced BMI by0.72 more so than participants onlyreceiving usual care.77

Acceptance and commitmenttherapy. A “third wave” of behavioraltherapy has developed, which is basedon the use of acceptance-based strate-gies. These strategies shift the focusfrom reducing the occurrence of aver-sive internal thoughts and feelings tobeing able to experience thesethoughts and feelings to assist withpromotion of behavior that iscongruent with personal values.78 It isbelieved that these approachesenhance mindfulness, which canenhance understanding of the personaldecision that one makes and reducemindless behavior.78 One acceptance-based approach that has recently beenexamined for improving obesity treat-ment is Acceptance and CommitmentTherapy (ACT). While few RCTs haveexamined ACT and obesity treatment,ACT appears to produce an amount ofweight loss similar to CBT and mayproduce greater weight loss in thosemore susceptible to eating cues (eg,have greater food-related thoughts andfeelings when exposed to external foodcues), disinhibited eating, or emotionaleating.78

The research on behavior change in-terventions demonstrates that CBT andmotivational interviewing effectivelychange eating and physical activitybehaviors so that meaningful weightloss occurs. However, not all in-dividuals respond to obesity treatment,even when CBT and/or motivationalinterviewing are implemented; thus,additional strategies, such as ACT,continue to be developed to assist withbehavior change in obesity treatment.

EAL Recommendation: “For weightloss and weight maintenance, the RDNshould incorporate one or more of thefollowing strategies for behaviorchange: self-monitoring; motivationalinterviewing; structured meal plansand meal replacements and portioncontrol; goal setting; and problemsolving.” (Rating: Strong, Imperative)

EAL Recommendation: “For weightloss and weight maintenance, the RDNmay consider using the following


https://dppos.bsc.gwu.edu/web/dppos/dpp

https://dppos.bsc.gwu.edu/web/dppos/dpp

http://www.lookaheadtrial.org/public/home.cfm

http://www.lookaheadtrial.org/public/home.cfm

FROM THE ACADEMY

behavior therapy strategies: cognitiverestructuring; contingency manage-ment; relapse prevention techniques;slowing the rate of eating; social sup-port; stress management; and stimuluscontrol and cue reduction.” (Rating:Fair, Imperative)

Comprehensive Lifestyle Inter-vention. Obesity treatment incorpo-rating a dietary prescription thatresults in an energy deficit of at least500 kcal/day, a physical activity pre-scription of at least 150 minutes ofMVPA per week, and a structuredbehavior-change intervention is classi-fied as a lifestyle intervention.1

Combining all three components—diet, physical activity, and behavioralstrategies—in intervention producesgreater weight loss than an interven-tion that uses these same componentssingularly. The lifestyle interventionsof DPP and Look AHEAD thatproduced significant weight loss areexamples of a comprehensive lifestyleintervention.73,74

EAL Recommendation: “For weightloss and weight maintenance, the RDNshould include the following compo-nents as part of a comprehensiveweight-management program: reduced-caloriediet, increasing physical activity, use ofbehavioral strategies.” (Rating: Strong,Imperative)

Intensity of Intervention. Accordingto the 2013 AHA/ACC/TOS Guideline forthe Management of Overweight andObesity in Adults, frequency of contactappears to be an important character-istic of intervention for weight-lossoutcomes.1 Comprehensive, lifestyleintervention, delivered on site, withface-to-face contact, providing anaverage of one to two treatment ses-sions per month (eg, 6 to 12 sessions in6 months), produces about 2 to 4 kg ofweight loss in 6 to 12 months, which issignificantly greater than usual care(minimal intervention control group).1

Comprehensive, lifestyle interventiondelivered at a high intensity (�14 ses-sions in 6 months) produces greaterweight loss relative to usual care thanthe weight loss that occurs withcomprehensive, lifestyle interventiondelivered at low-to-moderate intensity(eg, intervention delivered in �12 ses-sion in 6 months) relative to usualcare.1


EAL Recommendation: “For weightloss, the RDN should prescribe at least14 MNT encounters (either individualor group) over a period of at least 6months.” (Rating: Strong, Imperative)“For weight maintenance, the RDN

should prescribe at least monthly MNTencounters over a period of at least 1year.” (Rating: Strong, Imperative)

eHealth in Intervention. Interventionsthat can be delivered without face-to-face contact with the use of technologyare believed to have the capability todecrease intervention costs and increasethe reach of the intervention for thosewho are in need of treatment.79 Thedevelopment of efficacious technology-based weight-loss interventions arethought to have the potential for greatpublic health impact.79

Computer-based interventions.The first modern technology-basedintervention developed for weightloss was computer-based programs, inwhich various aspects of the Internetwere used. These programs includethose with an intervention website,which provided many differentInternet-based features (posted edu-cation materials, tracking systems,discussion boards, chat rooms,e-mails), or more e-mail�based pro-grams in which interventionists inter-acted with participants via e-mail. ACochrane Review of computer-basedprograms for weight loss found thatfor interventions lasting 6 months,computer-based interventions pro-duced greater weight loss than mini-mal interventions (�1.5 kg).79

However, face-to-face interventionsproduced greater weight loss thancomputer-based interventions (�2.1kg).79 Only one study in the reviewreported the cost-effectiveness ratio,thus conclusions could not be drawnabout this aspect of computer-basedprograms.79 In agreement with this,the 2013 AHA/ACC/TOS Guidelinesstate that comprehensive interventionsdelivered onsite by a trained interven-tionist produce larger weight loss thancomprehensive interventions deliveredby the Internet or e-mail.1

Smartphone-based interventions. Un-like computers, smartphones are usuallycarried by users everywhere they go andare almost always on. These features ofuse provide the ability for real-time,

JOURNAL OF THE ACAD

on-demand interaction. Thus, it isbelieved that smartphones provide theopportunity for frequent and interactivefeedback, tailored messaging (via text ore-mails), and immediate access to socialsupport.80 Interactive applications, “apps,”can assist with decision making on be-haviors, as they can provide timely feed-back on health behaviors in real time.80

Smartphones are theorized to have theability to maintain important componentsof face-to-face interaction (eg, account-ability, feedback, social support) withoutface-to-face time.80 As this is a new area ofresearch in weight management, it is notclear at this time how efficacious theseprograms will be, but it is believed thatthese types of programs will outperformcomputer-based interventions.80

Supplements. In a 2009 systematicreview of the efficacy and safety ofherbal medicines used for obesitytreatment, Hasani-Ranjbar and col-leagues81 reported on weight changeand body composition outcomes in 17RCTs. Compounds containing ephedra,Cissus quandrangularis, ginseng, bittermelon, and zingiber were found to behelpful in significantly reducing bodyweight (summary data were notincluded in the review); however, sup-plements containing ephedra andbofutsushosan (an oriental herbal med-icine) were found to have some adverseeffects. Food-based supplements, suchas caffeine, carnitine, calcium, choline,chromium, lecithin, fucoxanthin, garci-nia cambogia, capsaicin (cayenne pep-per), green tea extracts, kelp, taurine,conjugated linoleic acid, psyllium, py-ruvate, leucine, forskolin, b-sitosterol,and tea, have been labeled “fat burners”and have been proposed to increaseweight loss by increasing fat meta-bolism.82 However, according to Jeu-kendrup and Randall, only caffeine andgreen tea have shown enhanced fatoxidation, but the effect of the increasedfat oxidation on weight management isnot clear. All other proposed food-basedsupplements lack sufficient evidence ofincreased fat metabolism at this time.82

In 2013, Hasani-Ranjbar and col-leagues83 reported on another 33 RCTsusing herbal- and food-based supple-ments and suggested that the efficacyand safety of these supplements is stillmostly unknown and long-term RCTsare needed to enhance our under-standing of the role of supplements andobesity treatment.


FROM THE ACADEMY

One helpful resource regarding sup-plements comes from the NationalCenter for Complementary and Alter-native Medicine, which houses a vari-ety of fact sheets on a number ofherbal- and food-based supplements(http://nccam.nih.gov/health/atoz.htm).

Commercial Programs. Commercialprograms are weight-loss programsthat are usually not delivered by ahealth care provider and can providevarious options of types of support forweight loss to consumers. Options caninclude face-to-face programs, pre-packaged food, and Internet-basedprograms. Little research has beenconducted on commercial options forweight loss, but what has been con-ducted suggests that commercial-based, comprehensive weight-loss in-terventions delivered in face-to-faceformats have produced an averageweight loss of 4.8 to 6.6 kg at 6 monthswhen conventional foods areconsumed and 6.6 to 10.1 kg at 12months with use of prepackaged food,and that these weight losses aregreater than minimal-treatment con-trol interventions.1 This suggests thatcommercial programs that providecomprehensive programs may be aviable option for treatment.

Medications. Comprehensive lifestyleinterventions are efficacious at pro-ducing weight loss, however, there islarge variability in the ability toimplement and maintain changes rec-ommended in these interventions. Forthose that have difficulty losing weight(BMI �30 or BMI �27 with obesity-related medical issues, such as highblood pressure, high cholesterol, ortype 2 diabetes),84 medications may behelpful for achieving weight loss. Thereare three medications for obesitytreatment approved for long-term use(up to 2 years).85

Orlistat. Orlistat is a lipase inhibitorthat causes dietary fat to be excretedas oil in the stool and is recom-mended to be taken with a diet con-taining 30% fat. The nonprescriptiondose of orlistat provides approxi-mately 80% of the weight loss seenwith the prescription dose. Orlistat isnot absorbed to any significant degreeand the side effects relate to the fatin the stool, including abdominalcramps, flatus with discharge, oily


spotting, and fecal incontinence. Dueto the potential loss of fat-solublevitamins, orlistat should be takenwith a vitamin supplement. A meta-analysis concluded that weight losswith orlistat (60 to 120 mg threetimes/day) was 2.9 kg greater thanplacebo at 12 months.86

Lorcaserin. Lorcaserin is an agonistof the serotonin (5-HT) 2c receptor inthe hypothalamus and enhances feel-ings of satiety. Lorcaserin at a dose of10 mg twice a day resulted in a 3.3%greater weight loss than placebo.85

Lorcaserin was well tolerated withside effects in >5% reported as head-aches, dizziness, fatigue, nausea, drymouth, and constipation. Lorcaserin isa Drug Enforcement Administrationschedule IV drug, with low potentialfor abuse.85

Phentermine/topiramate. Phenter-mine, an appetite suppressant, causes adecrease in food intake by stimulatingthe release of norepinephrine in thehypothalamus. A controlled-releasedformulation of phentermine/top-iramate, a schedule IV drug, isapproved for the treatment of obesity.The dosage begins at a low dose for 14days (3.75 mg phentermine/23 mgtopiramate extended-release once aday), transitions to a mid-dose (doublethe low dose), and then to a high dose(mid-dose twice a day) if weight loss isnot achieved after 12 weeks. If 5%weight loss is still not achieved after 12weeks on the high dose, the medica-tions should be discontinued. Weightloss was 3.5%, 6.2%, and 9.3% greaterthan placebo in the low, mid, and highdoses, respectively.87,88 Adverse eventsoccurring in >5% of patients includeparesthesias, dizziness, dysguesia,insomnia, constipation, and dry mouth.See the section on sleeve gastrectomyfor the EAL recommendation for theuse of medication.

Surgery. While comprehensive life-style interventions are considered themainstay of all weight-managementtreatment, for patients who are un-able to achieve or maintain weight lossthat improves health or for obese pa-tients at high medical risk, adjunctivetreatments are needed.1 Bariatric sur-gery is an option that is increasinglyused in those individuals with extremeobesity, or with those with a lower BMIbut with obesity-related comorbidconditions.1

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Laparoscopic gastric banding. Thelap-band does not permanently alterthe anatomy of the gastrointestinaltract, but instead places a thin, inflat-able band around the top of the stom-ach to create a new and smallerstomach pouch. This surgery requiresextensive follow-up to make sure theband is properly adjusted. Ten-yearfollow-up of lap-band surgery in-dicates maximum weight loss wasabout 20% at 1 to 2 years, with main-tenance of 15% weight loss at 10years.89 Popularity of the lap-band hasdecreased in the United States, pri-marily due to inferior weight loss,complexity of follow-up, a lowerremission rate to diabetes, and agreater need for reoperation due tocomplications.

Gastric bypass. The bypass, longconsidered the gold standard obesityoperation, permanently alters theanatomy of the gastrointestinal tract. Inthe bypass, a small pouch is created atthe top of the stomach and a part of thesmall intestine, the jejunum, isattached to a small hole in the pouch.Thus, the surgery allows food to bypasspart of the stomach and small intestine.The bypass results in a typical weightloss of 35% at 1 to 2 years, which hasbeen shown to be maintained at 30%weight loss at 10 years.89 The bypasshas the highest mortality rate, rate ofcomplications, and the most severemetabolic abnormalities of the threesurgeries. With the bypass, there isgreater need for protein, iron andvitamin supplementation, and moni-toring of calcium and vitamin Dlevels.90

Sleeve gastrectomy. The sleeve, thenewest of the three bariatric pro-cedures, permanently alters the anat-omy of the stomach because a portionof the stomach is removed, producinga tube-shaped stomach or sleeve, andnow has data on more than 5 years offollow-up. The sleeve is gaining inpopularity, as it produces similarweight loss and remission of type 2diabetes (80% of patients with dia-betes before surgery are able to con-trol their blood glucose levels 5 yearsafter bariatric surgery)91 as occurswith the bypass, but at lower cost,with lower rates of complications andmortality.90,92,93 Metabolic complica-tions with the sleeve are also fewerthan with the bypass, however, rec-ommendations still include vitamin


http://nccam.nih.gov/health/atoz.htm

http://nccam.nih.gov/health/atoz.htm

FROM THE ACADEMY

supplementation and monitoring ofiron, calcium, and vitamin D levels.For bariatric surgery, the 2013 AHA/

ACC/TOS Guideline states that for in-dividuals who are obese, weight loss at2 to 3 years after bariatric surgeryranges from 20% to 35% of initial weight,with a greater weight loss of 14% to 37%for bariatric surgery as compared withnonsurgical comparators.12

EAL Recommendation: “For weightloss and weight maintenance, the RDNshould implement MNT and coordinatecare with an interdisciplinary team ofhealth professionals (may includespecialized RDNs, nurses, nurse practi-tioners, pharmacists, physicians, physi-cian assistants, physical therapists,psychologists, social workers, and so on)especially for patients with obesity-related comorbid conditions. Coordina-tion of care may include collaborationon use of US Food and Drug Admin-istration�approved weight-loss medi-cations; and appropriateness of bariatricsurgery for people who have not ach-ieved weight-loss goals with less inva-sive weight loss-methods.” (Rating:Consensus, Imperative)

Monitoring and Evaluation. To de-termine effectiveness of any interven-tion implemented, outcomes need tobe monitored over time and evaluatedfor degree of success achieved. SeeFigure 1 for suggested areas to monitorand evaluate for effectiveness of acomprehensive weight-managementprogram.EAL Recommendation: “The RDN

should monitor and evaluate the effec-tiveness of the comprehensive weight-management program for overweightand obese adults, through the followingdata: food and nutrition-relatedhistory; anthropometric measure-ments; biochemical data, medical tests,and procedures; and nutrition-focusedfindings.” (Rating: Strong, Imperative)If weight loss is not occurring at the

expected rate, total energy needs mayneed to be reassessed.EAL Recommendation: “For weight

loss and weight maintenance, the RDNshould monitor and evaluate total en-ergy needs and consider one of thefollowing (if necessary): re-measureRMR using indirect calorimetry; recal-culate Mifflin-St. Jeor equation; or re-apply a new physical activity factor toRMR to estimate total energy needs.”(Rating: Consensus, Imperative)


Community-Level ObesityInterventionWithin the socioecological modelframework, community-level obesityinterventions focus on utilizing andstrengthening existing communityassets and capacity in changingenergy balance behaviors that canproduce weight loss. These types ofinterventions generally focus onincreasing capacity for providing andenhancing access to intervention, withcommunity-based organizations and/or interventionists providing theintervention, and/or altering the com-munity environment to assist withpromoting energy-balance behaviorshelpful for weight management.One example of a community-level

intervention focusing on increasingcapacity for providing and increasingaccess to intervention is the use ofYMCAs as a site for delivering inter-vention. For example, a comprehen-sive lifestyle intervention modeledafter the DPP delivered to communitymembers at high risk for diabetes byYMCA employees produced 6% weightloss at 6 months.94 A review of faith-based interventions designed forAfrican-American females, which areimplemented in faith-based settingsin the community and are alsodesigned to increase capacity forproviding and access to intervention,also found significant reductions inanthropometric measures across re-viewed studies (for studies reportingchange in weight, the range of changein weight was �3.6 to �9.8 lb).95

Another example that increases ca-pacity and access to intervention andthat often has a focus on changing theenvironment is worksite wellnessprograms. A review of worksite well-ness weight-management programsfound that those programs thatfocused on strategies to increasephysical activity and change dietaryintake were generally successful atassisting with weight maintenance orproducing modest weight loss (forstudies reporting change in BMI therange of change was �0.14 to �1.4).96

For changing the community envi-ronment, it is hypothesized that envi-ronments with a greater density offast-food outlets and/or lower densityof farmers’ markets or other types ofmarkets with fresh produce encouragedietary intakes that are high in energy

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density and, thus, contribute to exces-sive energy intake and obesity.97 Inaddition, it is proposed that environ-ments with reduced access for physicalactivity (few greenways, parks, andsidewalks) produce inactivity, whichalso contributes to obesity.98 Most ofthe research in this area is observa-tional, so it is not clear at this timewhether changing these environ-mental factors will reduce the preva-lence of obesity.98 When communitiesimplement these environmentalchanges to assist with lowering theprevalence of obesity, a “naturalexperiment” is created, and evaluationis needed to understand how theseenvironmental changes influenceweight.

EAL Recommendation: “The RDNshould recommend use of communityresources, such as local food sources,food assistance programs, supportsystems, and recreational facilities.”(Rating: Strong, Imperative)

Policy-Level Obesity InterventionPolicy-level obesity interventions aregenerally framed as interventionsdeveloped at the federal, state, or localgovernment level that implementbroad changes that are believed to helpchange energy-balance behaviors thatcan produce weight loss. The broadchanges are designed to influenceeveryone for whom the policy hasbeen developed. Two policy-level in-terventions that are believed to behelpful for reducing the prevalence ofobesity include menu labeling andtaxing the cost of certain foods. Menulabeling is under Section 4205 of thePatient Protection and AffordableHealth Care Act (www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf). Ideally, consumers canuse the labeling information on menusto make choices that could assist withreducing intake, provided they aremotivated to do so.99,100 Menu labelingdoes seem to influence purchasingdecisions that cause a reduction inoverall energy purchased in some, butnot all, consumers in some types ofrestaurants.101 For example, womenwere found to decreasemean amount ofenergy per purchase at coffee chainrestaurants but men did not, and meanamount of energy per purchase did notdecrease in burger and sandwich res-taurants.101 More research is needed to


http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf



FROM THE ACADEMY

understand what factors influence pur-chasing decisions in restaurants formenu labeling to have a broader impact.Another policy-level intervention

gaining momentum is creating a taxthat can be levied on unhealthy foods(eg, non-nutrient-dense, energy-dense foods) to help reduce theirconsumption. The tax could alsopotentially be combined with a plan tosubsidize healthier foods, thus poten-tially increasing consumption ofhealthy foods. It is not clear at thistime how this type of policy wouldinfluence eating behavior and obesity,but the little research conducted inthis area suggests that small excisetaxes are unlikely to affect obesityrates and that while higher excisetaxes are likely to reduce obesity in at-risk populations, higher excise taxesare believed to be less politicallypalatable or sustainable.102

RESPONSIBILITIES OF FOODAND NUTRITIONPRACTITIONERSTo address obesity, it is believed thatinterventions are needed that canincorporate multiple levels of thesocioecological model that can be sus-tained for many years.103 Thus, in-terventions for obesity need to addresschanging individual-level energy bal-ance behaviors; be delivered in manysettings to increase accessibility tointervention; influence the environ-ment in which clients live, work, andplay; and impact on policy that canassist with providing a context forsupporting engagement in energy-balance behaviors within the popula-tion to improve weight management.

Understanding theSocioecological ModelAlthough obesity is a result of a chronicimbalance of energy intake and energyexpenditure, it is now recognized thatthese individual-level behaviors areinfluenced by determinants at multiplelevels, which enhances understandingthat individual choices are shaped bythe wider context in which theyoccur.103 Thus, ecological models—models that incorporate multiple levelsor systems—of health promotion areincreasingly promoted to addresschronic health conditions.104 For RDNsto be included in the development,


implementation, and evaluation ofthese interventions, an understandingof the SEM is required. Interventionswith a SEM approach will targetchange at one or more levels, eitherdirectly or indirectly, through multi-level, multisectoral interventions.104

For example, an intervention designedto reduce overweight and obesity inadults might be developed in which astate enacts a law targeting worksitesto ensure that worksite cafeterias pro-vide nutrition information aboutavailable food choices to employeesand provides financial incentives tocompanies to encourage the develop-ment of worksite wellness programs; acompany with several worksites de-velops a wellness program that screensemployees for health risks, refers em-ployees who are overweight or obeseto an on-site RDN, and provides finan-cial incentives to employees toencourage improving improve weightstatus; and the worksite RDN providesMNT, incorporating employees’ indi-vidualized needs and preferences, toreferred employees and incorporatesfamily members into sessions to assistwith changing the home environmentand increasing family support. Thisapproach incorporates several levels ofthe socioecological model, allowingthem to intersect, and enhance overallweight-management outcomes. Todevelop an ecological approach,developing collaborative partnershipsamong all stakeholders is key104 andshould be encouraged within the fieldof nutrition.

Addressing Health DisparitiesThe prevalence of overweight andobesity continues to remain higher innon-Hispanic black adults and Hispanicadults, as compared with non-Hispanicwhite adults, indicating a healthdisparity.2 To address these disparities,a greater understanding of the multi-level factors associated with energybalance is needed. While energy bal-ance is influenced by a multitude ofindividual-level factors (eg, genetics,biology, individual behavior, andindividual-level social determinants),research suggests that contextual as-pects of social determinants, particu-larly those related to environmentalfactors, are important to address, aspervasive socioeconomic and racial

ION AND DIETETICS

inequalities found within environ-mental contexts may underlie obesitydisparities.105 This suggests that in-terventions containing multiple levelsof the socioecological model will bemore effective at reducing healthdisparities.

Addressing Weight BiasIndividuals with overweight andobesity can encounter weight bias inhealth care settings by health pro-fessionals.106 Weight bias is demon-strated when health care professionalshave beliefs that those with obesity arelazy, noncompliant to intervention, andlack self-control.106 Those experiencingweight bias from health care pro-fessionals are more likely to avoidhealth screenings, cancel appointments,demonstrate maladaptive eating be-haviors, and experience poorer out-comes when receiving treatment foroverweight or obesity.107,108 Thus, RDNsshould ensure that health care experi-ences for individualswithoverweightorobesity are free of weight bias. Ensuringthat RDNs understand the complex eti-ology of obesity, thus that there arecontributors to obesity that are outsideof personal control, and the difficultiesaround achieving significant, sustain-able weight loss, may increase empathyregarding the challenges of obesitytreatment and reduce weight bias.108

Scope of PracticeIntegrated ecological-based in-terventions will provide solutions thatcover multiple jurisdictions, requiring awide range of skills.103 No one profes-sion will be able to provide all skillsrequired for the development, imple-mentation, and evaluation of these in-terventions to address obesity. Thus,rather than acting independently, RDNswill need to develop relationships withothers to be involved in the SEMapproach. These relationships willinclude traditional health care partners,such as physicians, pharmacists, andpsychologists, but also nontraditionalpartners, such as city planners, archi-tects, and legislators. Within these re-lationships, the role of the RDN is toprovide expertise in the area of nutri-tion, which includes MNT and relatedareas, community and public healthnutrition, foodservice systems, school


FROM THE ACADEMY

nutrition, and sustainable resilienthealthy food and water systems.109

REIMBURSEMENT FOR OBESITYTREATMENT INVOLVING MNTReimbursement for MNT provided byRDNs is essential to the field of di-etetics.110 The Patient Protection andAffordable Health Care Act providescoverage for nutrition services in thearea of obesity counseling for adults.111

However, the role of the RDN inproviding nutrition services covered bythe Patient Protection and AffordableHealth Care Act is open to interpreta-tion by those paying for these ser-vices.110 In addition, the Centers forMedicare & Medicaid Services providescoverage for Intensive BehavioralCounseling for Obesity for eligibleMedicare beneficiaries.112 As with Pa-tient Protection and Affordable HealthCare Act, the role of the RDN in Inten-sive Behavioral Counseling for Obesityis not covered. While RDNs are notspecifically designated as the sole pro-viders of MNT under these reimburse-ment strategies, RDNs can provideservices and receive reimbursement.Third-party payers use a standardizednumeric coding set, and within thissystem the MNT codes, which includethose for obesity, describe the servicesof RDN. The diagnostic codes are usu-ally determined by the referringphysician, as it is not within the scopeof practice for a RDN to make a medicaldiagnosis.110 However, the exception tothis is in the case of BMI codes, as BMIrepresents a mathematical calculationbased on measurements that arewithin the RDN’s scope of practice toperform.113 In a recent survey of codingpractices of RDNs collected by theAcademy, of those RDNs whocompleted the survey, obesity was thesecond highest disease or conditionfrom which reimbursement wasreceived from third-party payers.110

Only diabetes was ranked higher thanobesity for receiving reimbursementfrom third-party players fromresponding RDNs.110

ROLE OF THE RDN ANDNUTRITION AND DIETETICSTECHNICIAN, REGISTERED, INTREATMENT OF OVERWEIGHTAND OBESITY IN ADULTSChanging dietary intake so that areduction in energy intake occurs is a


key component of obesity treatment.1

Thus, the expertise of the RDN andnutrition and dietetics technician,registered (NDTR) is essential for thedevelopment, implementation, andevaluation of any interventiondesigned to reduce overweight andobesity.

MNTThe Academy’s definition of MNT isbroader than other entities.114 MNT, asdefined by the Academy, is an individ-ualized approach to disease manage-ment that incorporates the nutritioncare process and is provided by anRDN.114 Thus, when treatment foroverweight and obesity is being deliv-ered at the individual level, the role ofthe RDN, along with the NDTR, is toprovide evidence-based interventionthat incorporates the nutrition careprocess.

Multidisciplinary TeamsAs stated earlier, interventions foroverweight and obesity that incorpo-rate any level of the socioecologicalmodel will require an intervention thatincludes more than just a focus on di-etary intake. A multidisciplinaryapproach to disease treatment, espe-cially in the case of obesity and chronicdisease, is recommended.115 The typeof intervention will designate whatother disciplines should be involved,and what other training an RDN andNDTR may benefit from.

Medicare and IntensiveBehavioral CounselingThe Centers for Medicare & MedicaidServices approved the provision ofintensive behavioral counseling forobesity when delivered by qualifiedprimary care and other select practi-tioners.112 Intensive behavioral coun-seling includes a maximum of 22face-to-face sessions over 12 months,but a weight-loss goal of 3 kg must bemet by 6 months in order for counselingsessions to continue to 12 months. Fre-quency of contact is one face-to-facevisit every week for the first month,one face-to-face visit every other weekfor months 2 to 6, and one face-to-facevisit every month for months 7 to 12 ifthe weight-loss goal has been met. Eachvisit is to include the five As approachadopted by the US Preventive Services

JOURNAL OF THE ACAD

Task Force. The five As are: 1) assess:ask about behavioral health risk(s) andfactors affecting choice of behaviorchange goals or methods; 2) advise:provide specific and personalizedbehavior change advice; 3) agree:collaboratively select appropriate treat-ment goals and methods that take intoaccount the client’s values and motiva-tion to changes; 4) assist: aid the clientin achieving goals by incorporatingbehavior change techniques, supple-mented with adjunctive medical treat-ments when appropriate; and 5)arrange: schedule follow-up sessions sothat ongoing assistant and support canbe provided.

While RDNs are not specifically out-lined as a practitioner for delivery ofintensive behavioral counseling, if anRDN provides care under conditionsspecified under the regulation, servicescan be billed by the one of the specifiedproviders. RDNs developing relation-ships with the specified providers(general practice, family practice, in-ternal medicine, obstetrics/gynecology,pediatric medicine, geriatric medicine,nurse practitioner, certified clinicalnurse specialist, and physician assis-tant) may create avenues for RDNs toprovide treatment for obesity that isreimbursed.

Wadden and colleagues116 conduct-ed a systematic review of behavioralcounseling for overweight and obeseprimary care patients from RCTs pub-lished between 1980 and 2014, findingno studies in which primary carepractitioners delivered counseling thatfollowed the Centers for Medicare &Medicaid Services guidelines. However,the investigators found that trainedinterventionists (eg, those trained inlifestyle intervention, which includedRDNs) succeeded in producing weightloss within patients from primary care.

AdvocacyTo address the obesity epidemic, in-terventions need to include largerenvironmental and policy changes, orpublic health initiatives, that will pro-vide opportunities to support and be-haviors that assist with weightmanagement.117 These types of strate-gies have shown previous success ataddressing public health concerns (eg,reducing smoking, increasing seat beltuse).118 To develop these strategies,advocacy from RDNs and NDTRs is


FROM THE ACADEMY

required. One advocacy effort in thearea of obesity that is particularlyfocused on nutrition is having acces-sible healthy and affordable foods,which is especially important toaddress health disparities.119 To assistRDNs and NDTRs with advocacy, theAcademy has developed the GrassrootsManager. The Grassroots Manager as-sists RDNs with communicating withtheir legislators, elected officials, andothers who may have the ability toinfluence policy and legislation thatcan assist with reducing obesity.

Outcome DataThe role of diet in obesity treatment isestablished. However, the role of foodand nutrition practitioners in obesitytreatment is not well documented, thusthe need to include an RDN and NDTRin planning or implementing obesitytreatment is not clear to all stake-holders. RDNs and NDTRs can assistwith documenting the importance oftheir role in obesity treatment by col-lecting outcomes related to dietarychange and health status. Comparisonof outcomes can be made between in-terventions including RDNs and thosenot, and with the relationship betweenfrequency of contact with RDNs andoutcomes. Thus, to support establish-ing the role of RDNs and NDTRs inobesity treatment, all practitioners areencouraged to collect and examineoutcomes data. To help increase ca-pacity in this effort, RDNs and NDTRsare encouraged to develop partner-ships with others that may have skillsthat are needed in documenting theimportance of the RDN in obesitytreatment.

CONCLUSIONSThe high prevalence of overweight andobesity in the United States negativelyaffects the health of the population,thus reducing the prevalence of over-weight and obesity is considered to bea public health priority.4 Weight loss ofonly 3% to 5% that is maintained hasthe ability to produce clinically rele-vant health improvement, with largeramounts of weight loss reducing addi-tional risk factors for CVD. Successfultreatment of overweight and obesity inadults requires the ability of adoptingand maintaining lifestyle behaviors,which contribute to both sides ofthe energy-balance equation. Lifestyle


behaviors are influenced by severalfactors at differing levels of the socio-ecological model, which include factorsat the intrapersonal, community andorganizational, and government andpublic level.18 To address obesity, it isproposed that several factors atdiffering levels need to be targeted toassist with the development andmaintenance of behaviors that arenecessary for weight loss and suc-cessful weight-loss maintenance.18

The RDN and NDTR, as part of amultidisciplinary team, need to becurrent and skilled in weight man-agement to effectively assist and leadefforts that can reduce the obesityepidemic. Due to the many factors andlevels of the socioecological modelthat need to be addressed, these teamswill include traditional health carepartners, but also nontraditionalpartners. Within these relationshipsthe role of the RDN is to provideexpertise in the area of nutrition,which includes MNT and related areas,community and public health nutri-tion, foodservice systems, schoolnutrition, and sustainable resilienthealthy food and water systems.109

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This Academy of Nutrition and Dietetics position was adopted by the House of Delegates Leadership Team on October 20, 1996 and reaffirmedon September 12, 1999; June 30, 2005; and March 23, 2012. This position is in effect until December 31, 2020. Position papers should not be usedto indicate endorsement of products or services. All requests to use portions of the position or republish in its entirety must be directed to theAcademy at [email protected].

Authors: Hollie A. Raynor, PhD, RD, LDN (University of Tennessee, Knoxville, TN); Catherine M. Champagne, PhD, RDN, LDN, FADA (PenningtonBiomedical Research Center, Louisiana State University System, Baton Rouge, LA).

Reviewers: Sharon Denny, MS, RD (Academy Knowledge Center, Chicago, IL); Research dietetic practice group (Ashley Jarvis, MS, RDN, FoodSurveys Research Group, US Department of Agriculture, Beltsville, MD); Weight Management dietetic practice group (Juliet M. Mancino, MS, RDN,CDE, University of Pittsburgh School of Nursing, Pittsburgh, PA); Melinda M. Manore, PhD, RD, CSSD, FACSM (Oregon State University, Corvallis,OR); Karin Pennington, MS, RDN, LD, FAND (The University of Alabama, Tuscaloosa, AL); Alison Steiber, PhD, RD (Academy Research & StrategicBusiness Development, Chicago, IL).

Academy Positions Committee Workgroup: Christine A. Rosenbloom, PhD, RDN, LD, CSSD, FAND (chair) (Georgia State University, Atlanta, GA);Karen R. Greathouse, PhD, RDN, LDN (Western Illinois University, Macomb, IL); Angela Makris, PhD, RD (content advisor) (Consultant, HuntingdonValley, PA).

We thank the reviewers for their many constructive comments and suggestions. The reviewers were not asked to endorse this position or thesupporting paper.










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Position of the Academy of Nutrition and Dietetics ... · lipoprotein cholesterol and blood pressure) and decreases the need for medication to control CVD and type 2 diabetes. Thus,