American Dietetic Association - Weight Management Position Paper

7/28/2019 American Dietetic Association - Weight Management Position Paper

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from the association

Position of the American Dietetic Association:

Weight ManagementThis paper endorsed by the American College of Sports Medicine

ABSTRACTIt is the position of the AmericanDietetic Association that successfulweight management to improveoverall health for adults requires alifelong commitment to healthfullifestyle behaviors emphasizing sus-

tainable and enjoyable eating prac-tices and daily physical activity.Given the increasing incidence ofoverweight and obesity along with theescalating health care costs associ-ated with weight-related illnesses,health care providers must discoverhow to effectively treat this complexcondition. Food and nutrition profes-sionals should stay current andskilled in weight management to as-sist clients in preventing weight gain,optimizing individual weight loss in-terventions, and achieving long-termweight loss maintenance. Using the

American Dietetic Associations Evi-dence Analysis Process and Evidence

Analysis Library, this position paperpresents the current data and recom-mendations for weight management.The evidence supporting the value ofportion control, eating frequency,meal replacements, and very-low-en-ergy diets are discussed as well asphysical activity, behavior therapy,pharmacotherapy, and surgery. Pub-lic policy changes to create environ-ments that can assist all populationsto achieve and sustain healthful life-

style behaviors are also reviewed.J Am Diet Assoc. 2009;109:330-346.

POSITION STATEMENT

It is the position of the American Die-tetic Association that successful weightmanagement to improve overall healthfor adults requires a lifelong commit-

ment to healthful lifestyle behaviors em-phasizing sustainable and enjoyableeating practices and daily physical ac-tivity.

Obesity is a condition character-ized by excess accumulation ofadipose tissue (ie, fat stores).

Fat stores can only be changed by a

whole body energy imbalance broughton by a change in energy intake, en-ergy output, efficiency of energy use,or a combination of any of these com-ponents (1). The underlying geneticand physiologic mechanisms govern-ing these three energy-balance com-ponents have been intensely studied(although still far from being com-pletely understood) (2,3). This re-search has greatly expanded since thediscovery of leptin in the early 1990sand has revealed a physiology de-

signed to primarily protect againststarvation (4). Despite the volume ofresearch, there have been only a lim-ited number of obesity cases identi-fied as being directly caused by a sin-gle gene mutation (5).

On a population level, changes inobesity prevalence can also be viewedas an aberration of energy balancebut on a larger scale. Agricultural ad-

vances, changes in economy and tech-nology (6), as well as societal changesinfluencing expectations and valuesystems (7), have lead to a worldwhere the energy of the food supplymost frequently exceeds that of theopportunities for energy expenditurethrough physical activity. The com-plexity of the causal factors at theindividual level combined with thecomplexity of causal factors affecting

This Position of the American Dietetic Association (ADA) uses ADAsEvidence Analysis Process and information from ADAs Evidence AnalysisLibrary. The use of an evidence-based approach provides important addedbenefits to earlier review methods. The major advantage of the approach isthe more rigorous standardization of review criteria, which minimizes thelikelihood of reviewer bias and increases the ease with which disparatearticles may be compared. For a detailed description of the methods used in

the evidence analysis process, access the ADAs Evidence Analysis Processat http://adaeal.com/eaprocess/.Conclusion statements are assigned a grade by an expert work group

based on the systematic analysis and evaluation of the supporting researchevidence. Grade IGood; Grade IIFair; Grade IIILimited; GradeIVExpert Opinion Only; and Grade VGrade is Not Assignable (becausethere is no evidence to support or refute the conclusion).

Recommendations are also assigned a rating by an expert work groupbased on the grade of the supporting evidence and the balance of benefit vsharm. Recommendation ratings are Strong, Fair, Weak, Consensus, orInsufficient Evidence. Recommendations can be worded as conditional orimperative statements. Conditional statements clearly define a specific sit-uation and most often are stated as an if, then statement, whereasimperative statements are broadly applicable to the target populationwithout restraints on their pertinence. Evidence-based information for

this and other topics can be found at www.adaevidencelibrary.com andsubscriptions for nonmembers are purchasable at www.adaevidencelibrary.com/store.cfm.

0002-8223/09/10902-0016$36.00/0doi: 10.1016/j.jada.2008.11.041

330 Journal of the AMERICAN DIETETIC ASSOCIATION 2009 by the American Dietetic Association
http://adaeal.com/eaprocess/http://adaeal.com/eaprocess/http://adaeal.com/eaprocess/http://www.adaevidencelibrary.com/http://www.adaevidencelibrary.com/http://www.adaevidencelibrary.com/store.cfmhttp://www.adaevidencelibrary.com/store.cfmhttp://www.adaevidencelibrary.com/store.cfmhttp://www.adaevidencelibrary.com/store.cfmhttp://www.adaevidencelibrary.com/store.cfmhttp://www.adaevidencelibrary.com/store.cfmhttp://www.adaevidencelibrary.com/store.cfmhttp://www.adaevidencelibrary.com/store.cfmhttp://www.adaevidencelibrary.com/http://adaeal.com/eaprocess/


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the environment within which indi-viduals live leads to a high prevalenceof a condition that is often describedas chronic and refractory with a highrecidivism rate for its treatment (8).

Given the biological tendency toprotect against starvation and the so-

cietal tendency to protect against un-derconsumption and volitional physi-cal activity, there are clear pathwaysfor action. First, the one in threeadults (9) who can currently maintaina healthful body mass index (BMI)are not likely to continue to be able todo so if no action is taken. Curbingthe weight gain trajectory at both theindividual and population levels is vi-tally important. Next, it is crucialthat we find ways to optimize individ-ualized treatments appropriately. Fi-nally, with the most rapidly growing

population category being those whoare severely obese (10), it is necessaryto understand and effectively treatthat portion of the population whosehealth is most greatly compromisedby this condition.

The purpose of this position paperis to outline the evidence supportingThe American Dietetic Associations(ADAs) adult weight managementposition statement. Since 2000, ADAhas used an evidence-based approachfor the development of clinical prac-tice guidelines for nutrition care. Theevidence analysis work for the adult

weight management guidelines formthe basis of the information providedin this position paper (11). The recom-mendation statement from the adultweight management guidelines is in-cluded in this position paper in allsections where there is a correspond-ing major recommendation from theguidelines. A brief description of theevidence analysis process, an expla-nation of the conclusion statementgrading, and the recommendationrating scales is provided in the Side-bar.

GOALS OF WEIGHT MANAGEMENT

The goals of weight management gowell beyond numbers on a scale,whether or not weight change is oneof the management objectives. Thedevelopment of healthful lifestyleswith behavior modification is impor-tant for overall fitness and health. Re-alistic expectations should be definedduring an intake interview in termsof a more healthful weight vs the nor-

mal BMI range. In addition, it is im-portant to set realistic expectationsabout the time required to make asustainable behavior change.

Goals of weight management inter-ventions may include:

prevention of weight gain or stop-ping weight gain in an individualwho has been seeing a steady in-crease in his or her weight;

varying degrees of improvements inphysical and emotional health;

small maintainable weight lossesor more extensive weight lossesachieved through modified eatingand exercise behaviors; and

improvements in eating, exercise,and other behaviors.

Health can be improved with rela-

tively minor weight losses. A weightloss of 10% may ameliorate healthrisks associated with excessive bodyweight (12). Health care providersmust help patients to accept a mod-est, sustainable weight change thatcan be realistically achieved. Appear-ance, in many patients, will be an im-portant motivator; however, it is crit-ical that health care providersemphasize the goal of achieving amore healthful weight and lifestylewhile de-emphasizing cosmetic goals.

The goals of weightmanagement go wellbeyond numbers on ascale, whether or notweight change is one

of the managementobjectives.

ADAs Nutrition Care Process in-

cludes nutrition assessment, nutri-tion diagnosis, nutrition intervention,and nutrition monitoring and evalua-tion. It is essential to include each ofthese steps into weight managementcare plans. ADAs Evidence AnalysisLibrary (EAL) contains evidence-based adult weight managementguidelines, including the recommenda-tions upon which this position paper isbased (11). Food and nutrition profes-sionals should incorporate these funda-mental concepts for managing obesity

into their patients individualized careplans.

ASSESSMENT OF OBESITY

Assessment, the first step of the Nu-trition Care Process (13,14), involves

gathering the necessary informationto formulate a diagnosis and developa care plan. Baseline weight andhealth indexes should guide weightmanagement goals and are necessaryto document outcomes. Clinically use-ful measures of body weight statusare noninvasive, easy to use, inexpen-sive, reliable, capable of reflectingshort- and long-term changes in bodyfat, and must be correlated to healthrisk.

The standard measurement forweight status is BMI, calculated as

kg/m

2

. Overweight is defined as aBMI of 25 to 29, whereas higherBMI values reflect more excessiveamounts of body fat (12). There aredifferences even in the community ofexperts as to the BMI at which anindividual is at greater health risk.Some advocate weight loss by individ-uals with a BMI of 25 to 29 but debatecontinues on how much weight reduc-tion should be recommended (15). TheNational Heart, Lung, and Blood In-stitute (NHLBI) guidelines (16) rec-ommend intervention for overweightindividuals who have two or more

risk factors associated with theirweight status. The Dietary Guidelinesfor Americans 2005 (17) recommendindividuals work toward weight re-duction if they are even mildly over-weight.

Multiple sources of information areavailable, but for most evaluations apatient-centered interview with sup-porting records from primary careproviders and/or referring physiciansremain the most important. A physi-cians evaluation of weight status, in-cluding height, weight, and waist cir-

cumference, provides the informationindicating that a referral to a regis-tered dietitian (RD) is appropriate. Amedical examination should rule outphysiologic causes of increased bodyweight and assess health risks and/orthe presence of weight-related co-morbidities. Cardiorespiratory fit-ness and screening for musculoskele-tal problems may need to be reviewedbefore making physical activity rec-ommendations or referring on to anexercise professional. In addition to a

February 2009 Journal of the AMERICAN DIETETIC ASSOCIATION 331


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medical assessment, a psychologicalevaluation may be indicated. Screen-ing for barriers to successful weightloss such as depression, post-trau-matic stress disorder, anxiety, bipolardisorder, addictions, binge eating dis-order, and bulimia is necessary. Stud-

ies have shown a high frequency ofthese disorders in those with exces-sive weight problems (18-20). Appro-priate treatment should be imple-mented before beginning a nutritionalintervention.

With this information from thehealth care team, an RD can effec-tively begin evaluation.

EAL Recommendation BMI andwaist circumference should be used toclassify overweight and obesity, esti-mate risk for disease, and to identifytreatment options. BMI and waist cir-

cumference are highly correlated toobesity or fat mass and risk of otherdiseases (Rating: Fair, Impera-tive) (11). Data is accumulating re-garding differences in aboriginal and

Asian racial groups that may indicatea downward shift of BMI to define ahealthful weight is indicated (21-23).

Functional and behavioral issues(eg, social and cognitive function, psy-chological and emotional factors, andquality-of-life measures) are impor-tant to address to optimize a weightmanagement intervention. Factorsrelated to food access, food selection,

functional capacity for food prepara-tion, and other physical activity aresignificant for treatment planning.

During an intake interview it is im-portant to observe nonverbal and ver-bal cues. These cues can guide andprompt the interviewing process andhelp determine what informationshould be prioritized and evaluatedfurther. In many dietetic referralsthe only information available is fromthe referring physician; therefore thedepth and exploration required to ad-equately assess nutritional status

and related factors will be an issue ofprofessional judgment and may ex-tend to subsequent consultations. Nu-tritional adequacy established fromdietary history and food intakerecords coupled with anthropometricand biochemical measures providebaseline data. The possible multiplecomponents of a comprehensive inter-

view are summarized in the Figure.The ADA adult weight manage-

ment guidelines advise resting en-ergy expenditure measurement as

part of an assessment. However, met-abolic carts are rarely available inclinical practice and another sched-uled visit may be required to providestandard conditions for cart measure-ment. There is controversy regardingthe applicability of predictive equa-tions of resting energy expendi-ture; however, such information canmake a valuable contribution to goalsetting and intervention strategies(24-26).

EAL Recommendation Esti-mated energy needs should be basedon [resting metabolic rate]. If possi-

ble, [resting metabolic rate] should bemeasured (eg, indirect calorimetry).If [resting metabolic rate] cannot bemeasured, then the Mifflin-St Jeorequation using actual weight is themost accurate for estimating [restingmetabolic rate] for overweight andobese individuals (Rating: Strong,Conditional) (11). The Mifflin-StJeor equations are:

Man: Basal Metabolic Rate (BMR)(10weight in kilograms)(6.25

height in centimeters)(5age inyears)5.

Woman: Basal Metabolic Rate (BMR)(10weight in kilograms)(6.25height in centimeters)(5age inyears)161.

Determining when a problem re-quires consultation with or referral toanother provider may be appropriate.For effective weight management in-tervention, a patient ideally would beassessed by a multidisciplinary team,including a physician, RD, exercisephysiologist, and a behavior thera-

pist. Through the team approach, is-sues such as nutrition, physical activ-ity, and change in eating behavior canbe coordinated. Although this ap-proach may be a gold standard, thereare many barriers such as the in-creased cost of a multidisciplinaryteam, the lack of third-party reim-bursement, and the absence of expe-rienced weight management healthcare professionals. However, once aprimary care physician has deter-mined that a client would benefit

A. Anthropometrics Height Weight Body mass index Waist circumference

B. Medical Identify potential causes: endocrine, neurological; medications; genetics (age of onset,

family history). Identify obesity-associated disorders (current complications and risk of future

complications): metabolic, anatomic, degenerative, and/or neoplastic complications. Evaluate obesity severity and extent of physical disability.

C. Psychological Identify psychological etiology: psychotropic medications, depression, post-traumatic

stress disorder, addictive behavior. Eating disorders: binge eating, bulimia. Assess risk for potential barriers to treatments: psychiatric historysuicidal ideation,

untreated psychological disorders.D. Nutritional

Weight history: age of onset, highest/lowest adult weights, patterns of weight gain andloss, environmental triggers to weight gain, triggers to excessive or disordered eating.

Dieting history:number and types of diets, weight loss medications, complementary and

alternative approaches for weight loss, success of previous weight loss efforts. Current eating patterns: meal patterns (skipped meals, largest meal, snacks/grazing),

24-hour recall/food frequency. Nutritional intake: nutrient density, nutrition supplements, vitamin/mineral supplements. Environmental factors:meals eaten away from home, fast-food meals, restaurant meals,

ethnic foods, lifestyle factors (eg, time and/or financial constraints). Exercise history:activities of daily living, current structured exercise, past exercise,

barriers to exercise. Readiness to change: reasons to lose weight at this time, weight loss goals, readiness for

making changes, current life stressors, support systems.

Figure. Factors to assess during weight management intake interviews.

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from the expertise of a team ap-proach, the appropriate referrals canbe made. Most commonly, RDs as-sume a leadership role to design andactivate the intervention strategydeveloped by the multidisciplinaryteam or in collaboration with the re-

ferring medical provider. The activerole ADA is now taking in establish-ing evidence-based guidelines willcontinue to modify assessment prac-tices.

Nutrition assessment is an ongo-ing, dynamic process that involvesnot only initial data collection, butalso continual reassessment andanalysis. Assessment provides thefoundation for the nutrition diagno-sis, which is the next step of the Nu-trition Care Process.

REGULATION OF FOOD INTAKE

A negative energy balance is the mostimportant factor affecting weight lossamount and rate. The first recom-mendation in obesity treatment isusually a reduction in energy intake:

A reduction of 500 to 1,000 kcal/day isadvised to achieve a 1 to 2 lb weightloss per week (11,12). Dietary energyreduction strategies may vary from afocus solely on energy (ie, caloriecounting), macronutrient composi-tion and/or energy density, or a com-bination of energy and macronutrient

composition along with form consid-erations such as consistency (eg, mealreplacements, very-low-energy diets).In addition, strategies have includedchanges to meal frequency, meal tim-ing (eg, breakfast) and guidance onfood portions. To evaluate the evi-dence supporting these proposedstrategies, it is necessary to first re-

view what is known about the regula-tion of eating behavior in human be-ings.

Eating is a behavior that links theexternal physical environment with

an individuals internal physiologicprocesses (27). Two distinct internalsystems govern food intake: the ho-meostatic system and the hedonicsystem. Although both systems areregulated centrally, they do not ap-pear to be integrated. Reduced appe-tite control may be due to either dis-turbance in homeostatic pathways orto inappropriate sensitization of thehedonic system. The homeostatic sys-tem comprises both long-term signal-ing from the adipose tissue and epi-

sodic signaling primarily from thegut. The long-term signaling useshormones such as leptin and insulinto act as key drivers for initiating foodintake. Generated in response to aneating episode, the episodic signalingsystem is activated from the gastroin-

testinal tract and uses hormones suchas ghrelin, cholescystokinin, gluca-gon-like peptide, and peptide YY,among others. These episodic signalsrise and fall in harmony with eatingpatterns. The interaction betweenthese two sets of homeostatic signalsreflects the brains recognition of thecurrent dynamic state of energystores and the changing nutrient flowderived from eating. This central reg-ulation of energy balance tunes hun-ger and fullness sensations that ac-company eating behaviors.

Unlike the central nervous regula-tion of the homeostatic system (locatedprimarily in the arcuate nucleus ofthe hypothalamus), a cortico-limbicneural network regulates the hedo-nic governance of food intake. Thisneural network (involving signals suchas endocannabinoids, serotonin, anddopamine) deals with the cognitive,motivational, and emotional aspects offood intake (eg, perceived pleasantness,liking, and wanting). This system rep-resents the main interface with theexternal environment as, in the ab-sence of a depletion signal, the initia-

tion of an eating episode often startsas a cognitive decision from the cortex(28). Palatability, via this system, is a

very powerful determinant of food in-take and inappropriate sensitizationof the hedonic network likely leads toweight gain. However, the hedonicsystem is less well-studied than itshomeostatic counterpart and muchmore research is required to fully un-derstand the interactions of these twosystems.

The complexity of eating behaviormakes it difficult to completely eluci-

date the role of any one of the energyreduction strategies. Whereas a ran-domized study with high dietary con-trol helps to evaluate affects of energyreduction on weight loss per se, longi-tudinal studies in free-living individ-uals (albeit with less dietary control)are also required to evaluate theother system components. Unfortu-nately, studies in free-living individ-uals (either longitudinal or cross-sec-tional) often have to rely on self-reported food intake, which, in of

itself, presents confounding factors.For example, under-reporting of en-ergy intake is persistently prevalentin dietary surveys and appears to begreater in overweight vs normal-weight people (29). In addition, littleis understood regarding the physiol-

ogy of eating behaviors in people withsevere obesity, people following a re-cent weight loss, or the influence ofphysical activity on the eating behav-ior systems.

Diet Composition

A low-fat, reduced-energy diet is thebest studied weight-loss dietarystrategy and is most frequently rec-ommended by governing health au-thorities (11,17,30). Fat is the mostenergy-dense macronutrient but is

known to have a weak effect on bothsatiation and satiety (31). These at-tributes make fat a useful target forreducing energy intake. Because dia-betes and cardiovascular disease arefrequent comorbidities of obesity, re-ducing the dietary saturated andtrans-fatty acid content is also recom-mended (30). The effectiveness of low-fat, low-energy diets in combinationwith lifestyle counseling and activityhas been demonstrated in recent mul-ticenter clinical trials where, in addi-tion to 5% to 10% weight loss, thereduction or prevention of comorbidi-

ties such as diabetes and/or hyperten-sion has also occurred (32-35).

Frequently, individuals reduce thecarbohydrate content of their diet as aweight loss strategy. As glycogenstores are depleted in response to low-carbohydrate intake, the resultant di-uresis produces an initial dramaticweight loss. On very-low-carbohy-drate diets (eg, 20 g/day) the bodyproduces ketones to sustain fuel uti-lization in the brain, which may inturn help with diet adherence by de-creasing hunger (36). Individuals as-

signed to the ad libitum low-carbohy-drate diet in recent randomizedcontrolled trials lost more weight at 6months than individuals assigned tothe low-fat, reduced-energy diet, butthis difference was no longer signifi-cant at 12 months (11,37,38). Con-cerns regarding an increase in cardio-

vascular risks with low-carbohydratediets do not appear to be as problem-atic as first thought (37).

EAL Recommendation An indi-vidualized reduced calorie diet is the



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basis of the dietary component of acomprehensive weight managementprogram. Reducing dietary fat and/orcarbohydrates is a practical way tocreate a caloric deficit of 500 to 1,000kcal below estimated energy needsand should result in a weight loss of 1

to 2 lb per week (Rating: Strong,Imperative) (11).

EAL Recommendation Havingpatients focus on reducing carbohy-drates rather than reducing caloriesand/or fat may be a short-term strat-egy for some individuals. Research in-dicates that focusing on reducing car-bohydrate intake (35% of kcal fromcarbohydrates) results in reduced en-ergy intake. Consumption of a low-carbohydrate diet is associated with agreater weight and fat loss than tra-ditional reduced-calorie diets during

the first 6 months, but these differ-ences are not significant after 1 year(Rating: Fair, Conditional) (11).

The EAL also notes that safety hasnot been evaluated for long-term, ex-treme restrictions of carbohydrates(35% of energy from carbohydrates)and specifically recommends thatpractitioners use caution in suggest-ing a low-carbohydrate diet for evenshort-term use in patients with osteo-porosis, kidney disease, or in patientswith increased low-density lipopro-tein cholesterol (11).

Portion distortion is anew term created to

describe thisperception of large

portions asappropriate amounts

to eat at a singleeating occasion.

Additional dietary componentsthought to influence weight (ie, lowglycemic index diets and diets high incalcium) were evaluated. In both in-stances, low glycemic index foods andlow-fat dairy foods can be incorpo-rated but are not essential for dietsappropriate for weight management.

EAL Recommendation A lowglycemic index diet is not recom-mended for weight loss or weightmaintenance as part of a comprehen-sive weight management program,

since it is has not been shown to beeffective in these areas (Rating:Strong, Imperative) (11).

EAL Recommendation In orderto meet current nutritional recom-mendations, incorporate 3-4 servingsof low-fat dairy foods a day as part of

the diet component of a comprehen-sive weight management program.Research suggests that calcium in-take lower than the recommendedlevel is associated with increasedbody weight. However, the effect ofdairy and/or calcium at or above rec-ommended levels on weight manage-ment is unclear (Rating: Fair, Im-perative) (11).

The debate regarding the optimalmacronutrient content of a reduced-energy diet has emphasized the diffi-culty individuals have in following

any weight loss regimen. Whetherrandomized to a low-fat or a low-car-bohydrate diet, study completionrates at 1 year are typically low forboth interventions (37). It is likelythat factors from both the homeo-static as well as the hedonic systemsinfluence an individuals ability to ad-here to any type of weight loss diet.We need to better understand the fac-tors that influence individual adher-ence as well as study attrition rates ingeneral, because these two parame-ters affect interpretation of trial out-comes.

Portion Control

RDs typically recommend portioncontrol to weight loss clients with thegoal of reducing the energy load ofconsumed foods. Strategies may in-clude providing information on theenergy content of regularly consumedfoods (eg, energy content of12 c vs onebowl of ice cream), use of premea-sured foods (eg, frozen entrees, 100-kcal snack packs), replacing higherenergy-density foods with lower ener-

gy-density foods (eg, cereal with milkfor an evening snack), and/or reduc-ing the energy density of foods (eg,increasing vegetable content of entreitems). These strategies may affect ei-ther the homeostatic system (eg, re-duced portions may be more or lesssatiating depending on the strategyused) and/or hedonic system (eg, cog-nitive decisions to choose one foodover another possibly more palatablefood) that govern eating behavior. Ef-fectively reducing portion sizes ap-

pears to be an important weight gainprevention strategy for everybody (re-gardless of weight) as marketplacefood and drink portions now exceedstandard serving sizes by a factor ofat least twofold (39). Portion distor-tion is a new term created to describe

this perception of large portions asappropriate amounts to eat at a singleeating occasion. This distortion is re-inforced by packaging, dinnerware,and serving utensils that have alsoincreased in size (40).

Most of the evidence supporting thevalue of portion control comes fromstudies in normal-weight and/or over-weight subjects using experimentalparadigms such as differences in serv-ing containers, self-refilling bowls, andself-service vs preserved food items(11). These studies show that by in-

creasing portion sizes, energy intakeduring an eating occasion is increasedbut is not compensated for by a de-crease in intake later in the day.Three randomized controlled trialsshowed weight loss in participantsusing specific portion control strate-gies of frozen entrees (vs self-selecteddiet based on the Food Guide Pyra-mid) (11), use of cereal to replaceusual evening snacks (11), and aplate-method education tool (41). Al-though the concept of portion controlis universal in most weight manage-ment programs, the overall strength

of the evidence for portion control toreduce energy intake and produceweight loss is graded as fair (11).More research is needed to determinethe effectiveness of specific portioncontrol strategies on body weight reg-ulation especially for people in differ-ent physiological states (eg, post-weight loss [ie, to prevent a weightregain] or people with severe obesity).

EAL Recommendation Portioncontrol should be included as part of acomprehensive weight managementprogram. Portion control at meals

and snacks results in reduced energyintake and weight loss (Rating:Fair, Imperative) (11).

Eating Frequency

Many RDs encourage weight lossclients to avoid skipping breakfastand to have a regular meal pattern.This advice is prompted by a con-cern for compromised nutrient in-take if breakfast is not consumed (eg,decreased calcium and fiber intake),



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that an erratic schedule leads to poorfood choices from available foods thatare energy dense but nutrient poor(eg, vending machines, office candy

jars, and fast-food restaurants), aswell as concern that evening energyconsumption is more likely to lead to

weight gain. Generically prescribinga certain meal frequency or advocat-ing the inclusion of breakfast as aspecific weight loss (or prevention ofweight gain) strategy must be basedon an understanding of the evidenceof whether the pattern of meal con-sumption affects energy intake andthereby weight loss. Unfortunatelythe evidence is inconsistent as the re-search on eating frequency patternsis not extensive with no randomizedcontrolled studies. A number of cross-sectional studies show equivocal find-

ings on the association of eating fre-quency to body weight regulation(11). Limitations in study design orinconsistency in methodology may bethe reason for this lack of clarity andfair evidence grade (11). These stud-ies have relied on self-reported intakebut as yet it is not clear where theunder-reporting of energy intake (es-pecially prevalent among obese par-ticipants) comes from (ie, mispercep-tion and/or misreporting of mealportions, omission of eating occasions,or a combination of both). The defini-tion of an eating occasion is often in-

consistent between studies (eg, onestudy used 50 kcal separated from an-other eating episode by 15 minuteswhereas another study used mainmeal, beverage meal, light meal, orsnack categories) (11). Finally, thecharacteristics of people who routinelyhave a regular vs irregular meal pat-tern are still unknown, making it diffi-cult to understand the influence of eat-ing frequency per se vs other personalattributes (eg, insulin levels, ghrelinlevels, age, daily work schedule, androutine exercise habits).

Breakfast consumption possiblyplays a role in weight managementthrough an influence on appetite con-trol, dietary quality, and metabolism(42). Like the research on eating fre-quency, the research on the affectof breakfast consumption on bodyweight regulation is primarily fo-cused on cross-sectional studies andis confounded by the same factors ofreliance on self-report, definition ofwhat constitutes a breakfast, andlack of characterization of breakfast

vs nonbreakfast consumers. Threecross-sectional studies show an asso-ciation between skipping breakfastand an increased prevalence or risk ofobesity (11). However, the associationmay vary depending on the breakfastcontent (eg, high-fat breakfast con-

sumers are associated with higherBMIs than high-fiber breakfast con-sumers) and sex (eg, the associationbetween breakfast consumption and aBMI 25 is significant for women butnot for men) (11). In one randomizedcontrolled trial, the habitual break-fast-eating habits of the study par-ticipants interacted with treatmentassignment (breakfast vs no-break-fast treatment) to influence themeasured weight change (11). Fur-ther research on the relationship be-tween breakfast and body weight

regulation is needed.Although the research does not yetsupport making absolute meal fre-quency or breakfast recommenda-tions for optimizing body weight con-trol, it is important that clinical

judgment is used when guiding cli-ents. Helping a client to find a mealpattern that prevents the times whenhigh hunger coincides with an envi-ronment of high-energy food choicesseems pertinent.

EAL Recommendation Total ca-loric intake should be distributedthroughout the day, with the con-

sumption of four to five meals/snacksper day including breakfast. Con-sumption of greater energy intakeduring the day may be preferable toevening consumption (Rating: Fair,Imperative) (11).

Meal Replacements

Choosing a low-energy, nutritiousdiet in an environment that providesa surplus of palatable, energy-dense,nutrient-poor food choices can easilyoverwhelm anyone trying to lose

weight. Meal replacements, contain-ing a known energy and macronutri-ent content, are a useful strategy toeliminate problematic food choices orcomplex meal planning while tryingto attain a 500 to 1,000 kcal/day en-ergy deficit. Several studies compar-ing isocaloric diets have shown equiv-alent or greater weight loss efficacywith structured meal replacementplans compared to reduced-energydiet treatments (11). Three of theserandomized controlled trials included

a weight maintenance phase of theirevaluation and reported a greater ef-fect of one meal replacement per dayover conventional diet for mainte-nance of a weight loss (11). Individu-als adhering to structured meal re-placement plans lose more weight at

both 12 weeks (7% vs 4% of initialbody weight) and 1 year (7% to 8%

vs 3% to 7%) than individuals follow-ing a conventional diet plan, with1-year dropout rates for the struc-tured meal replacement plan signifi-cantly less than the conventional dietplan (47% vs 64%; P 0.001) (11). Todate, structured meal replacementplans and weight loss efficacy in se-

verely obese individuals or as aweight gain prevention strategy havenot been sufficiently studied.

There is concern that this strategy

may mean an over-reliance on artifi-cial nutrients and may prevent cli-ents from learning how to select ap-propriately from typical conventionalfood choices. These specific concernshave not been systematically studied.However, RDs have a role in advisingclients utilizing meal replacementson how to optimize the overall nutri-ent content of their diet by carefulselection of the conventional foodsthat make up the nonmeal-replace-ment portion of the weight loss plan.

EAL Recommendation For peo-ple who have difficulty with self selec-

tion and/or portion control, meal re-placements (eg, liquid meals, mealbars, or calorie-controlled packagedmeals) may be used as part of the dietcomponent of a comprehensive weightmanagement program. Substitutingone or two daily meals or snacks withmeal replacements is a successfulweight loss and weight maintenancestrategy (Rating: Strong, Condi-tional) (11).

Very-Low-Energy Diets

Unlike meal replacements, which aredesigned to replace only one or twomeals per day, a very-low-energy dietis designed to be the only food sourceduring active weight loss. A very-low-energy diet is typically a liquid formu-lation that supplies about 800 kcal (or6 to 10 kcal/kg) or less per day, isenriched with high biologic value pro-tein and provides at least 100% of theDaily Value of essential vitamins andminerals. The purpose of using a

very-low-energy diet is to quickly



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achieve a large weight loss while pro-viding adequate nutrition and pre-serving lean body mass as much aspossible. Medical monitoring is neces-sary during the rapid weight lossphase and the medical risk makes a

very-low-energy diet inappropriate

for individuals with a BMI 30. Al-though there is good evidence thatadherence to a very-low-energy dietresults in significant weight loss of 15to 5% of initial body weight over 12 to16 weeks, maintenance of that weightloss is problematic (11,43). In 1998,the NHLBI expert panel recom-mended against the use of very-low-energy diets. The decision was basedon studies showing no differences inlong-term weight losses between very-low-energy diets and low-energy dietsprimarily because of greater weight

regain with very-low-energy diets(12). Although there have been manystudies evaluating the long-termmaintenance of weight loss following

very-low-energy diets, the majorityhave been case-series with no directcomparison with a low-energy dietculminating in equivocal results (11).

A recent meta-analysis was con-ducted evaluating six randomizedcontrolled trials that each included

very-low-energy diet and low-energydiet comparisons for short-term andlong-term (at least 1 year follow-up)weight loss (43). Despite significantly

greater short-term weight loss withvery-low-energy diets (16.1%1.6%vs 9.7%2.4%; P0.0001), the weightloss was similar between very-low-en-ergy diets and low-energy diets forlong-term weight loss (6.3%3.2% vs5.0%4.0%; P0.2) (43). Overall at-trition in the six studies was not dif-ferent between the very-low-energydiet and low-energy diet groups.

The use of very-low-energy dietshas been increasingly prescribed be-fore bariatric surgery to reduce over-all surgical risk in patients with se-

vere obesity. There is indication thatthe use of very-low-energy diets for atleast 2 weeks reduces liver size al-though up to 6 weeks may be moreideal for clinically significant de-creases in abdominal adiposity (44).Further research is necessary to eval-uate the efficacy of this strategy forsurgery candidates with severe obe-sity.

EAL Conclusion Adherence to avery-low-calorie diet, defined as 800kcal or 6 to 10 kcal/kg or less, results

in significant weight loss (GradeI Good) (11).

EAL Conclusion Adherence to avery-low-calorie results in lower calo-rie intakes and therefore significantlygreater initial weight loss than re-duced-calorie diets (Grade I Good)

(11).EAL Conclusion While adher-

ence to a very-low-calorie results insignificant initial weight loss, studiesreport varying levels of weight regainbased on differences in weight main-tenance strategies (Grade I Good)(11).

Physical Activity

An energy deficit of 500 to 1,000kcal/d is necessary to achieve a 1- to2-lb weight loss per week (11). Pro-

ducing this energy deficit throughphysical activity alone is extremelydifficult for most adults. Few studieshave used a large enough physical ac-tivity dose to achieve a 5% weightloss using a physical activity inter-

vention alone (45). Weight-loss stud-ies have shown only small reductionsin body weight with physical activitytreatment compared to no-treatmentcontrol groups (45). However, themagnitude of weight change due tophysical activity is additive to thatassociated with a dietary interventionachieving energy restriction (45). The

influence of physical activity onweight loss depends on the ability ofan individual to engage in adequatelevels of exercise such that the energycost of exercise is greater than typicalfluctuations or compensatory changesin energy intake. Depending on bodysize, fitness level, and exercise inten-sity, an individual may burn an addi-tional 1,000 kcal per week by exercis-ing 30 minutes 5 days a week. Incomparison, an extra 1,000 kcal couldeasily be consumed by miscalculatingportion sizes and/or a couple of extra

snacks or beverages. However, de-spite its modest impact on weightloss, physical activity is important forimproving health-related outcomesrelated to many obesity comorbidities(eg, heart disease, cancer, and diabe-tes) (45,46) although additional re-search is required to understand thisrelationship in individuals with BMI40. Regular physical activity is alsoassociated with a lower risk of deathregardless of BMI (47). Therefore, it isimportant that physical activity is in-

cluded in obesity treatment pro-grams.

Although its influence on weight lossmay be minimal, physical activity ap-pears to be crucial in the prevention ofweight regain. Many correlation stud-ies show a strong association between

physical activity at follow-up and main-tenance of a weight loss (45,48,49).Doubly-labeled water studies indicatethat physical activity in the range of11 to 12 kcal/kg/day maybe necessaryto prevent weight regain following aweight loss (50). Data from the Na-tional Weight Control Registry alsoindicate that a high level of dailyphysical activity may be necessary toprevent weight regain (51). The Na-tional Weight Control Registry is aregistry of more than 3,000 individu-als who have successfully maintained

at least a 30-lb weight loss for a min-imum of 1 year. These individuals re-port using a variety of methods to loseweight initially, but more than 90%report exercise as crucial to theirlong-term weight-loss maintenance.They report expending, on average,2,682 kcal per week in exercise, anenergy equivalent of walking 4 miles7 days a week (51). It has been pro-posed that high levels of physical ac-tivity allows for a post-reduced indi-

vidual to sustain a lowered energy-balance level without overly restrictingfood intake (52).

Specific physical activity recom-mendations were included for thefirst time in the 2005 Dietary Guide-lines (17). These recommendations in-cluded three categories related toweight management goals. The firstrecommendation, to reduce the risk ofchronic disease in adulthood, is for 30minutes of moderate-intensity physi-cal activity on most days of the week.The second recommendation, to helpmanage body weight and preventweight gain in adulthood, is to engagein 60 minutes of moderate- to vigor-

ous-intensity activity on most days ofthe week. Finally, to prevent weightregain after weight loss, engage in 60to 90 minutes of daily moderate-in-tensity physical activity while not ex-ceeding energy requirements. Thefirst Federal Physical Activity Guide-lines for Americans were issued inlate 2008 (45). These guidelines pro-

vided a comprehensive summary ofthe scientific evidence for the healthbenefits of physical activity and havesimilar recommendations to the 2005



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Dietary Guidelinesall adults shouldavoid inactivity and health benefits(including weight control benefits) in-crease as physical activity increases(45). Unlike the recommendations inthe 2005 Dietary Guidelines (17), thePhysical Activity Guidelines make

recommendations in weekly vs dailydoses: at least the equivalent of 150minutes/week of moderate-intensityaerobic physical activity for substan-tial health benefits and 300 minutes/week of moderate-intensity physicalactivity for more extensive health ben-efits (45). Acknowledging the great in-terindividual variability that existswith physical activity and achieving/maintaining a healthful weight, theseguidelines suggested that many peoplemay need more than the equivalent of150 minutes/week of moderate-inten-

sity physical activity to maintain theirweight and more than 300 minutes/week to meet weight-control goals (45).RDs have a role in reinforcing theserecommendations that will help clientsachieve appropriate physical activitygoals through the different phases ofweight management (ie, prevention ofweight gain, weight loss, and sustain-ing a weight loss).

Pedometers and step counters arefrequently used to promote dailyphysical activity. These small, rela-tively inexpensive devices are wornat the hip and track the number of

steps taken per day. Individualswearing these devices can track theirdaily variability in steps and/or com-pare daily steps against a prescribedstep goal (both behaviors that maypromote problem-solving to preventunnecessarily low step days). 10,000steps per day is an appropriate dailystep goal consistent with the 30 min-utes of moderate-intensity physicalactivity recommendation of the 2005Dietary Guidelines (53); however, ahigher step goal would be necessaryto either produce weight loss by phys-

ical activity alone or to maintain aweight loss. A recent meta-analysis of26 studies (eight randomized con-trolled trials and 18 observationalstudies) evaluating pedometer useshowed that physical activity in pe-dometer users increased 26.9% overbaseline (54). Having a step goal,such as 10,000 steps per day, wasan important predictor of increasedphysical activity (P0.001) (54).Noted limitations of this meta-analy-sis were the lack of long-term follow

up, small study sizes, as well as in-ability to account for the influence ofadditional study components such asstep diaries and physical activitycounseling. In addition, as the meanpreintervention BMI of study partici-pants was 303.4, the efficacy of pe-

dometer use in people with severeobesity (BMI40) was not evaluated.Use of pedometers in severely obese in-dividuals deserves further research.

Behavioral Interventions

Historically, cognitive behavioral treat-ment of obesity developed from the be-lief that obesity was the result of mal-adaptive eating and exercise habits,which could be corrected by the appli-cation of learning principles (55). To-day, it is understood that body weightis affected by factors other than be-

havior, including genetic, metabolic,and hormonal influences (56,57). Al-though behavior modification is onlyone piece of the puzzle, behavior ther-apy can help individuals develop a setof skills to achieve a more healthfulweight (34,58,59).

What Is Cognitive Behavioral Therapy? Cog-nitive behavioral therapy is basedlargely on principles of classical con-ditioning, which assert that eating isoften prompted by antecedent events(ie, cues) that become strongly linkedto food intake (55). Cognitive behav-

ioral therapy helps patients identifycues that trigger inappropriate eating(and activity) behaviors and learnnew responses to them (60). Treat-ment also seeks to reinforce (or re-ward) the adoption of positive behav-iors. Cognitive behavioral therapyhas several distinguishing character-istics (61): it is goal-directed (measur-able outcomes), process-oriented (helpspeople decide how to change), and ad-

vocates small rather than largechanges. The behavior change processis facilitated through the use of a va-

riety of problem-solving tools andusually includes multiple componentssuch as nutrition education, keepingfood and activity records (ie, self-mon-itoring), controlling cues associatedwith eating (ie, stimulus control),problem solving, cognitive restructur-ing, and physical activity (60). Thesecomponents comprise the behavioralpackage. ADAs Nutrition Counselingwork group is currently reviewing theevidence to determine how effectiveindividual components of the behav-

ioral package (ie, self-monitoring,stimulus control, problem solving, so-cial support, and cognitive restructur-ing) are in changing behavior andpromoting weight loss in adults.

Cognitive Behavioral Therapy and WeightLoss. A limited number of studies

have evaluated the intermediate (6 to12 months) effectiveness of cognitivebehavioral therapy on weight loss.

EAL Conclusion One neutralquality, 6-month randomized con-trolled trial (86 obese adults) providesevidence that intermediate duration(6-12 months) behavioral therapy andbehavioral therapy combined with apersonalized system of skill acquisi-tion targeting weight loss is more ef-fective than weight loss educationalone in facilitating weight loss, de-creasing both total energy intake and

percent of calories from fat, and in-creasing physical activity (GradeIII Limited) (11).

Compared to patients with obesityreceiving the weight-loss educationalprogram (ie, 6 monthly education ses-sions on nutrition, behavioral strate-gies for changing eating and exercisehabits, and guidelines for increasingphysical activity), patients with obe-sity who either received standard be-havior therapy (ie, 25 weekly sessionson self-monitoring, goal setting, stim-ulus control, and cognitive restructur-

ing) or behavior therapy plus person-alized skill acquisition (ie, behaviortherapy plus reinforcement [mone-tary rewards] contingent on individ-ual mastery of specific skills related toeating and exercise behaviors) lost sig-nificantly more weight at 6 months.

Small randomized trials evaluatingthe effects of cognitive behavioraltherapy on weight loss over 2 yearshave also shown positive effects onweight control though weight gain istypically observed over time.

EAL Conclusion One neutral

quasi-experimental (84 participantsreceived behavior therapy) and twopositive randomized controlled trials(65 participants received behaviortherapy and a very-low-calorie diet)evaluated behavior therapy as a com-ponent of a weight-loss program oflong-term duration (12 months). Be-havior therapy was not always the

variable of randomization. Partici-pants receiving behavior therapy lostweight at the conclusion of treat-ments. Upon follow-up there was



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some weight regain but participantsremained at a lower weight thanbaseline. Studies that included a

very-low-calorie diet to initiate rapidinitial weight loss, combined with be-havior therapy, also appeared to pro-duce long-term weight loss. [Note:

This is not a statement recommend-ing very-low-energy diets or suggest-ing that very-low-energy diets aremore beneficial than low-energy di-ets.] (Grade II Fair) (11).

A number of large randomizedstudies examined the effects of cogni-tive behavioral therapy on diabetesand cardiovascular disease risk.Given the beneficial effect of weightreduction on these disease states,weight loss is often an outcome that isevaluated. The typical design of manybehavioral studies is group meetings

weekly for the initial treatment phase(approximately 3 to 6 months), bi-weekly (every other week) meetingsfor the maintenance phase (6 to 12months), and monthly or bimonthlyfor the later phases of the study (12 to24 months) (33,61-64).

The PREMIER, Diabetes Preven-tion Program, Finnish Diabetes Pre-

vention, and Look AHEAD studiesare examples of large, multicenter,randomized studies that demonstratethe influence of behavior modificationon weight loss, diabetes, and cardio-

vascular disease risk (33-35,58,59).

Participants in the PREMIER studywere randomly assigned to either acontrol group (single advice-givingsession) or one of two behavior modi-fication intervention groups, whichdiffered in diet prescription (35). Sig-nificantly greater weight losses wereobserved in the intervention groupscompared to the control group at 6months. There were no significant dif-ferences in weight loss between theintervention groups, suggesting thatbehavior modification had a strongerinfluence on weight loss than the pre-

scribed method of energy restriction.The Diabetes Prevention Program

showed that intensive behavior mod-ification is not only more efficacious inproducing weight loss and improvinghealth than general recommenda-tions but also more efficacious thanpharmacotherapy (33). Participantsin the intensive lifestyle group lostsignificantly more weight and alsohad a significantly lower incidence oftype 2 diabetes than those takingmetformin or placebo. Similar find-

ings were observed in the LookAHEAD study, which compared theeffectiveness of a behavioral interven-tion program and enhanced usualcare (ie, diabetes support and educa-tion) on weight loss and the preven-tion of cardiovascular disease in indi-

viduals with type 2 diabetes (32). Notonly did individuals in the behavioralintervention group lose more weightat 1 year, they also observed greaterreductions in medication use, fastingglucose, hemoglobin A1c, blood pres-sure, triglyceride levels, and greaterincreases in high-density lipoproteinlevels.

The Finnish Diabetes Preventionstudy also compared the efficacy oflifestyle modification and usual carein individuals at high risk for type 2diabetes (58). This study was ended

early due to clear differences in out-comes (ie, body weight, plasma glu-cose, risk of type 2 diabetes) betweenintervention and control groups. Theextent to which lifestyle changes andrisk reduction remained after discon-tinuation of active counseling wasstudied in a follow-up to the FinnishDiabetes Prevention study (32). Theincidence of diabetes and body weightwas examined for a total of 7 years.The relative risk for developing type 2diabetes remained significantly lessin individuals who were in the life-style intervention group and was re-

lated to the success in maintainingweight loss; eating a low-fat, high-fi-ber diet; and engaging in physical ac-tivity. These findings are encouragingbut behavior therapys effectivenessfor long-term weight maintenancehas not been shown in the absence ofcontinued behavioral intervention(12). Long-term follow-up of patientsundergoing behavior therapy shows areturn to baseline weight in the greatmajority of subjects in the absence ofcontinued behavioral intervention (12).

Although these studies have limita-

tions (ie, participant-clinician contactand instruction was greater in the in-tervention groups; therefore, thesestudies do not simulate treatment inthe real world because of their highintensity and frequency), these well-designed efficacy studies show thatbehavioral treatment in combinationwith low-energy, low-fat diets havepositive effects on weight controland, more importantly, on comorbidconditions.

As a means to determine whether

the results of lifestyle interventionstudies can be replicated in the realworld, researchers designed the Good

Ageing in Lahti Region Program, alifestyle implementation study de-signed for primary health care set-tings (65). Although the outcomes

were less robust than more intensiveefficacy studies, favorable lifestylechanges were reported and weightgain was prevented, suggesting onoverall positive effect of lifestylecounseling in real-life settings. Addi-tional studies are needed to deter-mine the effectiveness of clinic-basedbehavioral treatment on weight gainprevention, weight loss, and weightmaintenance.

Findings from these studies sug-gest that cognitive behavioral ther-apy combined with a healthful diet

and physical activity results in signif-icant weight loss in the short-term.Individuals lose approximately 8% to11% of their initial body weight dur-ing the treatment phase (24 to 32weeks) but slowly regain weight overtime (ie, approximately 4% to 8% and2% to 4% of their initial body weightafter 48 and 72 weeks, respectively)(66-69). Five years after treatment,50% or more of patients have re-turned to their baseline weight (68);however, there is some evidence tosuggest that individuals who partici-

pate in maintenance therapy (twice amonth for 1 year) after initial treat-ment maintain most of their weightloss at follow-up (ie, approximately10% and 8% of their initial bodyweight after 48 and 72 weeks, respec-tively) (69-73).

Strategies for Augmenting Outcomes. Al-though cognitive behavioral treat-ment provides individuals with a setof skills to handle barriers to eatinghealthfully and being active, over-coming barriers is a difficult endeavorin a fast-paced environment that en-

courages overconsumption of energy-dense, palatable, low-cost foods andpromotes energy-saving devices (8). Ahealthful lifestyle requires significantplanning, proficiency in making ap-propriate choices and estimating por-tion sizes, and diligence in monitoringenergy intake and activity, all ofwhich take time to develop and main-tain. As such, strategies for simplify-ing and making this process morepractical by providing structure andreducing time spent in meal planning



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and decision making (eg, meal re-placements as described above) maybe useful for some people.

EAL Recommendation A com-prehensive weight management pro-gram should make maximum use ofthe multiple strategies for cognitive

behavioral therapy (ie, self-monitor-ing, stress management, stimuluscontrol, problem solving, contingencymanagement, cognitive restructur-ing, and social support). Cognitive be-havior therapy in addition to diet andphysical activity leads to additionalweight loss. Continued behavioral in-terventions may be necessary to pre-

vent a return to baseline weight(Rating: Strong, Imperative) (11).

Further research is needed to iden-tify the most potent components ofthe behavior modification package, as

well as additional interventions (eg,body image therapy) and counselingtechniques (eg, motivational inter-

viewing) that might be added to assistpatients in making behavior changeand to improve efficacy, especially inthe long term. It is possible that thereis no single behavioral tool that worksbest. Instead it may be more impor-tant to match behavioral tools witheach individuals unique set of char-acteristics. These are the type ofquestions that need further attentionand research.

Pharmacotherapy

Current medications that have beenapproved by the Food and Drug Ad-ministration (FDA) for long-termtreatment of clinically significantobesity (BMI 30 or BMI 27 to 29with one or more obesity-related dis-orders) include sibutramine and orl-istat. These two medications havebeen evaluated in multiple random-ized controlled trials (44 for sibutra-mine, 29 for orlistat). Medicationcombined with lifestyle modification

is more effective than placebo withlifestyle modification in promotingweight loss in adults with overweightand obesity (74). The safety and effi-cacy of the currently approved drugtherapies have not been evaluated inchildren or older adults and there islimited information on adolescents(75).

Sibutramine. Sibutramine is a cen-trally acting serotonin and adrenergicreuptake inhibitor. Meta-analysis in-dicates an average loss of 4.5 kg more

per year over placebo (74). Hyperten-sion and increased heart rate are po-tential complications so it is contrain-dicated for individuals with knownheart disease, uncontrolled hyperten-sion, heart failure, stroke, and ar-rhythmias. Sibutramine is also con-

traindicated with monoamine oxidaseinhibitors and other serotonin uptakeinhibitors, which include medicationsfor depression and migraine (76). Theevaluation of the reported cardiovas-cular effects has determined that therisk-benefit ratio remains favorable(77).

Orlistat. Orlistat is a pancreatic lipaseinhibitor that inhibits the absorptionof up to 30% of dietary fat (78). In the22 studies that reported 12-monthdata, those treated with orlistat lost2.89 kg more than those on placebo.

Steatorrhea, bloating and distension,and anal leakage are potential sideeffects if dietary fat is not restricted,and one must be alert for possible fat-soluble vitamin deficiencies. With thelong-term safety record that has beenachieved, orlistat has been approvedfor over-the-counter sales at a re-duced dosage.

Phentermine. Phentermine is a sympa-thomimetic anorexogenic agent andthe most widely prescribed weightloss agent in the United States; how-ever, its use is approved by the FDA

for only 3 months (79). In the sixplacebo-controlled studies available,published between 1975 and 1999,the duration of treatment was be-tween 2 and 24 weeks with an aver-age weight loss of 3.6 kg over pla-cebo. Side effects include insomnia,constipation, and dry mouth. Inter-mittent dosage in a randomized con-trolled trial produced greater weightloss than placebo (80).

The continued increase in the preva-lence of obesity speaks to the unmetmedical needs for safe and effective

medications (81). Pharmacotherapy re-search is currently focusing on: centralnervous system agents that affect neu-rotransmitters, including antidepres-sants (bupropion), antiseizure agents(topiramate, zonisamide), and somedopamine antagonists; leptin/insulin/central nervous system agents, in-cluding leptin analogues or promoters,ciliary neurotropic factor (Axokine, Re-generon Pharmaceuticals, Tarrytown,NY), neuropeptide-Y, and agoutire-lated peptides, -melanocyte ana-

logues, and adiponectin; gastroin-testinal-neural pathway agents toincrease cholecystokin or decreaseghrelin activity; enhancers of energyexpenditure, UCP2 and UCP3 uncou-pling proteins, and thyroid receptoragonists; and inhibitors of fatty acid

synthesis (82).Leptin has undergone phase two

testing, but data at this time do notindicate leptin has the potential to beclinically useful for the modification ofweight status (83). Both Axokine (84)and rimonabant (85,86) are in stagethree trials. Fenfluramine, alone or incombination with phentermine, pro-duced effective weight loss but seriousside effects resulted (87). This volun-tary medication withdrawal slowedeffort for the use of combined medica-tions. Currently three trials of com-

bined medications are in progress:Qnexa (topiramatephentermine)(Vivus, Inc, Mountainview, CA), Ex-calia (bupropionzonisamide) (Orexi-gen Therapeutics, La Jolla, CA [nowcalled Empatic]), and Contrave (bu-propionnaltrexone) (Orexigen Ther-apeutics, La Jolla, CA).

Herbal preparations for weight lossdo not have standardized amounts ofactive ingredients and harmful effectshave been reported (88,89). Certainover-the-counter preparations contain-ing phenylpropanolamine (and related

compounds) have no proven efficacyfor short- or long-term weight lossand are recalled because of the inci-dence of hemorrhagic stroke (90,91).Ephedrine plus caffeine, and fluox-etine have been tested for weightloss, but are not FDA-approved, andover-the-counter and herbal weightloss preparations are currently notrecommended (75).

It has been shown that small reduc-tions in body weight (5%) can affectobesity-related comorbidities (92). Ifsuch reductions are achieved with

medications, data indicate that thosemedications be continued long-termto maintain the change in weight sta-tus (93). For those considering phar-macologic treatment for obesity, itshould be noted that medications canlead to modest weight losses at 1 to 2years, but that data are not availableon long-term effectiveness and safety(77).

When weight loss drugs are pre-scribed they should be only as part ofa comprehensive treatment plan in-



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cluding behavior therapy, diet, andphysical exercise (12).

EAL Recommendation FDA-ap-proved weight loss medications maybe part of a comprehensive weightmanagement program. RDs shouldcollaborate with other members of

the health care team regarding theuse of FDA-approved weight lossmedications for people who meet theNHLBI criteria. Research indicatesthat pharmacotherapy may enhanceweight loss in some overweight andobese adults (Rating: Strong, Im-perative) (11).

Surgery

Surgery, with its inherent structuralchange, clearly has an advantage inthe long-term success of weight main-

tenance. It is reserved for patientswith severe disease who have failed tofind less invasive interventions suc-cessful and are at high risk for obesity-related morbidity and mortality. It isthat group with morbid obesity thathas increased 400% from 1983 to2000 (94). The patient selection crite-rion established by the National In-stitutes of Health for surgery is cur-rently a BMI of 40. If weight-relatedcomorbidities like diabetes, hyperten-sion, and sleep apnea are present, aBMI between 35 and 40 may be con-sidered for a surgical procedure (12).

Extending bariatric surgery to pa-tients with BMIs of 30 to 34.9 whohave comorbid conditions that couldbe cured or markedly improved bysubstantial weight loss is under re-

view at this time (95).All data indicate that for the mor-

bidly obese, bariatric surgery is themost effective therapy available forweight management and can resultin improvement or resolution of theobesity-related comorbidities andimproved quality of life (96). There-fore, it is important that RDs work-

ing in weight management areknowledgeable about the commonsurgical procedures, their mecha-nisms of producing weight loss, aswell as the complications and con-cerns. It is of note that surgical pro-cedures to promote weight loss arecontinually evolving. At the currenttime there are four commonly usedprocedures to assist weight loss byrestricting food intake and/or a com-bination of restricting intake and pro-ducing malabsorption. Food intake

may be reduced by the placement ofan adjustable band that allows only asmall amount of food to enter thestomach or by the removal of part ofthe stomach to produce a gastricsleeve. Gastric bypass operations,Roux-en-Y gastric bypass, and the ex-

tensive gastric bypass (biliopancre-atic diversion, with duodenal switch)create a small pouch by stapling orremoval of portions of the stomach,and also bypass the duodenum andother segments of the small intes-tines, thus producing malabsorptionalong with restriction. These proce-dures have acceptable operative riskfrom 0.5% to 0.6% when performed byskilled surgeons (97-99). A fifth pro-cedure, vertical banded gastroplasty,has decreased in use because weightmaintenance has been problematic

(100,101).Surgeon skill and a medical cen-ters bariatric surgery volume are im-portant factors in evaluating surgicaloutcomes. The American Society ofMetabolic and Bariatric Surgery andthe American College of Surgeonshave established Centers of Excel-lence on the basis of hospital vol-umes and surgical outcomes. Com-pared with centers that had 50cases, high volume centers with 100cases per year had lower mortality,shorter length of stay, lower overallcomplications, lower complications of

medical care and lower costs (102). Anationwide, population-based samplereported 21.9% complications duringthe initial hospitalization, which in-creased to 39.6% during the first 180days (103). The definition of a compli-cation from the insurance records

varied from an outpatient visit to ahospital readmission. Such data witha broad interpretation of what is acomplication contrast sharply withdata from the centers of excellence. ACanadian group has established thatweight-loss surgery significantly de-

creases mortality, 0.68% comparedwith 6.17% in the nonoperated con-trols as well as the development ofnew health-related conditions in per-sons with morbid obesity (104). Swed-ish investigators have recently pub-lished their 10.9-year follow-up ofoperated vs nonoperated controls,which clearly shows long-term weightloss maintenance and decreased over-all mortality in those having a bariat-ric surgical procedure. Mortality fromcardiovascular disease and cancer

were reduced (105). In the UnitedStates, a 7.1-year follow-up of pa-tients with gastric bypass showed thegroup receiving surgery had long-term mortality reduced by 40% com-pared with the control population(106). Vogel and colleagues reported a

reduction in predicted coronary heartdisease after bariatric surgery (107).Their report emphasized the impor-tance of significant and sustainedweight loss as a powerful interventionto reduce future rates of myocardialinfarction and death in the morbidlyobese. Data from the Canadian healthcare system showed that long-termhealth care costs were reduced after abariatric procedure and the initialcosts of surgery were amortized over3.5 years (108). Data are now avail-able that with laparoscopic vs open

procedures, the duration of hospitaliza-tion has been decreased, wound compli-cations are lower, post operative pa-tient pain is reduced, and bowelfunction normalizes more quickly (102,108,109).

The effectiveness of different surgi-cal procedures comparing both openand laparoscopically performed pro-cedures on diverse populations bysurgeons with different levels of ex-pertise is difficult to interpret. Forpurposes of comparison, a range ofweight loss defined as percentage of

excessive weight loss (change in BMI/original BMI24) is commonly used(97). The effectiveness of the surgicalprocedures for weight loss range from47.5% excessive weight loss for theadjustable gastric band, 61.6% for thegastric bypass, 68.2% for gastro-plasty, and 70% for the biliopancre-atic diversion with or without theduodenal switch. As noted above, gas-troplasty is no longer frequently per-formed because a high rate of weightregain is documented. The sleeve pro-cedure is increasing in use as a pri-

mary procedure for high-risk andelderly patients or as an initial proce-dure for weight reduction to reducesurgical risk before a second stage ofa gastric bypass or the duodenalswitch procedure. The excess weightloss reported for the sleeve at 1 yearapproximates 46% (110-113). It is ofnote that surgery appears to rule overthe genetic component of weight sta-tus in regard to weight loss responseswith surgery and weight mainte-nance (114).



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It is important thatRDs working in

weight management

are knowledgeableabout the common

surgical procedures,their mechanisms of

producing weightloss, as well as thecomplications and

concerns.

Before surgery, patients should befully evaluated by a multidisciplinaryteam, including but not limited to amedical doctor, psychiatrist, and anRD. The role of an RD is importantduring screening to evaluate weighthistory, efforts to lose weight, foodpreferences, and food-related behav-iors (ie, binge eating) to assist inelecting the optimal procedure for thepatient. The patient must be in-formed of the lifestyle changes neces-sary to decrease postoperative com-plications and maintain weight loss.Weight loss surgery is more effectivewhen accompanied by pre- and post-

operative comprehensive therapy tomodify eating, smoking, and exercisebehavior. After surgery an RD mayplay a vital role in promoting lifelonghealth behavior change and adjust-ment to postsurgery dietary and sup-plementation requirements. Suchadjunctive therapy increases the like-lihood of long-term success and shouldbe a standard component of surgicalweight management (115,116). All pro-cedures require lifelong medical fol-low-up and monitoring to avoid andmanage possible complications.

Liposuction is another form of sur-gery with a focus on adipose tissue.Its purpose generally is cosmetic, toalter body contours, and it usually isnot considered as a surgical proce-dure for weight loss (117). Investiga-tors in this country have studied theeffects of high-volume liposuction oninsulin action and risk of coronary ar-tery disease. They reported no im-provement in metabolic abnormali-ties (118). This contrasts with thefindings of other workers reporting

improvements in insulin resistanceand inflammatory markers (119,120).

EAL Recommendation Dieti-tians should collaborate with othermembers of the health care team re-garding the appropriateness of bariat-ric surgery for people who have not

achieved weight loss goals with less in-vasive weight loss methods and whomeet the NHLBI criteria. Separate

ADA evidence-based guidelines are be-ing developed on nutrition care in bari-atric surgery (Rating: Strong, Im-perative) (11).

WEIGHT MAINTENANCE

As demonstrated in the preceding sec-tions, it is possible to lose weight us-ing a number of different strategies.However, weight loss is only one

phase of the weight management con-tinuum. Prevention of weight gain (atany BMI level) and prevention ofweight regain (after a weight loss) an-chor either end of this continuum.Each phase of the continuum possiblyrequires a transition to a different setof strategies and/or skill set.

The research on weight-loss main-tenance is relatively new and far fromconclusive with retrospective studiesof successful weight-loss maintainers(121-125) and a small number of pro-spective studies (126-129). Issuesconfounding the evaluation of re-

search in this area include consensuson amount of weight loss, weight lossduration, time between weight lossand evaluation of weight mainte-nance, and minimum length of weightmaintenance (130). Successful weight-loss maintenance may be an outcomethat is determined by multiple vari-ables, each contributing differently toa successful outcome. Such variablesmight include factors impacting met-abolic as well as behavioral responsessuch as initial weight loss, comorbidconditions, presence of depression,

perception of weight loss success,level of self-monitoring, level of phys-ical activity, type of intervention (in-cluding frequency of contact), copingstyle, and stressful life events amongothers (123,129-133).

The best studied metabolic compen-satory responses occurring with weightloss is the concomitant decline in met-abolic rate that results in what hasbeen termed an energy gap (134). Thisenergy gap, estimated to be about 8kcal/lb lost/day, points to a post-weight

loss need to chronically maintain alower energy intake or a combination oflowered energy intake and increasedenergy expenditurehence, the life-long commitment portion of the posi-tion statement. However, as critical asit is for food and nutrition professionals

to support their clients to preventweight regain, it is not yet clear whichmaintenance strategy is best pre-scribed for all individuals.

Responsibilities of Food and NutritionProfessionals in Weight Management

Many of the ideas expressed beloware not evidence-based but are theopinions of this writing group basedon experience and knowledge in thefield.

An individuals body weight is de-

termined by a combination of genetic,metabolic, behavioral, environmen-tal, cultural, and socioeconomic influ-ences. These diverse influences maketreating individuals with overweightand obesity complex. Food and nutri-tion professionals must understandeach of these aspects as they developa shared decision-making relation-ship with clients. Food and nutritionprofessionals should also be aware oftheir own biases regarding individu-als with this condition. In one study ofRDs, 87% viewed individuals with

obesity as self-indulgent and 32% in-dicated that individuals with obesitylacked willpower (135). These charac-terizations could affect the style ofcounseling for clients with obesity.

Food and nutrition professionalsshould understand the importance ofweight gain prevention and the chal-lenge of weight loss maintenance toeffectively help their clients maintainnormal weight and sustain long-termweight loss. Increased physical activ-ity also appears to be key in success-ful weight loss maintenance (36).

RDs, with their understanding of en-ergy balance and energy expenditurealong with their skills in teaching be-havior change, are in key positions to:

educate physicians and other healthcare professionals about the impor-tance of weight-loss maintenance;

help the public, as well as otherhealth care professionals, to under-stand the difference between weightloss and weight-loss maintenance;and



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assist clients in developing strate-gies necessary for achieving weight-loss maintenance (13).

As RDs counsel patients, they shouldbe aware of the Scope of Dietetics Prac-tice Framework that helps them define

what range of services they can providewithin a practice setting. It is the pro-fessional responsibility of RDs to en-sure that competency is maintained toprovide safe and effective services toclients with overweight and obesity(136).

RDs must remain current on topicsrelated to the treatment and manage-ment of patients with obesity, includ-ing the knowledge and skills that arerequired to counsel patients aboutphysical activity.

This may involve an understanding

of when patients with obesity shouldbe referred to a certified exercise pro-fessional or other appropriate healthcare provider. Guidance on the situa-tions that may require a referral to anexercise professional and appropriaterecommendations for physical activ-ity for adults with overweight andobesity are available through the

American College of Sports Medicine,with updated guidelines to be re-leased by the American College ofSports Medicine in February 2009(137). Every opportunity to increaseweight management skills should be

taken. Attending workshops andsymposiums, such as the Certificateof Training in Adult or PediatricWeight Management sponsored bythe ADA Commission on Dietetic Reg-istration, with program content fo-cused on all aspects of obesity, is ad-

vised.

Reimbursement for Obesity Treatment.Third-party payers cover treatmentconditions caused by obesity andsometimes pay for bariatric surgery,but there is little reimbursement for

prevention or treatment of obesitywithout comorbidities. For obesity tobe recognized and covered by third-party payers, health professionals, in-cluding RDs, must supply scientificevidence that a treatment works toimprove health outcomes of the bene-ficiary. Insurers and the public mustbe presented with effective weightmanagement approaches along withproof that they work. RDs should im-plement the science-based weightmanagement practice guidelines that

have been developed for both adultsand children. RDs need to demon-strate the cost-effectiveness of thestrategies with well-designed studiesand should use the medical nutritiontherapy reimbursement strategies fordiabetes and renal diseases as a

model for obesity coverage (138).

Role of RDs in Providing Care

The partnership between RDs andtheir patients should focus on devel-oping strategies that will enhance op-portunities for clients to control theirown behaviors related to overweightor obesity. Incorporating various be-havioral techniques into weight losscounseling is a recommended ap-proach (14). RDs need to use theirskills and knowledge to support and

encourage clients with their weightloss efforts.

If RDs work only with physicians ora team that includes a coordinatedgroup of health professionals with a

variety of skills, they should work ef-fectively with the team to achieve thebest outcome for the patient. Commu-nication with other health care pro-

viders on the team is essential to ac-commodate the different needs ofeach patient. Understanding when torefer patients to other health careproviders is important in managing

patients needs (14).Within the past several years vari-ous committees, foundations, govern-mental agencies, and professionalassociations have addressed the in-creasing prevalence of obesity andoverweight in our country. Each ofthese investigations resulted in a re-port including action steps or recom-mendations, many of them related tohelping the American public achievemore healthful diets and increasingphysical activity. The 2005 DietaryGuidelines addressed the issue by

stressing the necessity of energy bal-ance for weight maintenance and forthe first time the importance of phys-ical activity (19). In F as in Fat: HowObesity Policies are Failing in Amer-ica 2007 (139), there are two recom-mendations that relate directly tofood and nutrition professionals:

helping all Americans become morephysically active, and

helping Americans choose morehealthful foods.

For food and nutrition profession-als to have a substantial influence inachieving these goals, we are chal-lenged to develop new innovative andbold approaches for the preventionand treatment of obesity. The futureparadigm will involve population-

based interventions that will requirethe full cooperation of the entirehealth care community. The coordi-nated integration of expertise fromdifferent health care disciplines, en-compassing a diversity of skills, isnecessary to develop innovative waysto tackle the obesity problem. Be-cause RDs are the primary nutritionpractitioners, they should share theleadership role with other health pro-fessionals in stemming the tide of thisobesity epidemic.

The partnershipbetween RDs and

their patients shouldfocus on developingstrategies that will

enhance opportunitiesfor clients to controltheir own behaviors

related to overweight

or obesity.Much of the literature also stresses

the importance of working coopera-tively with relevant governmentagencies, appropriate medical andscientific organizations, employer or-ganizations, unions, educational au-thorities, and the media. In 2001, theSurgeon Generals Call to Actionidentified a public health approach tohalting the obesity epidemic in ourcountry (140). The Call to Actionidentified key actions, one of which

was to encourage partnerships be-tween health care providers, schools,faith-based groups, and other commu-nity organizations in prevention ef-forts targeted at social and environ-mental causes of overweight andobesity.

RDs are encouraged to participate innutrition advocacy at the local, state,and national levels to encouragehealthful eating and lifestyle behav-iors. More importantly they should be-come involved in action programs that



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support healthful eating at the grass-roots level. RDs have the necessaryskills and broad educational prepara-tion to contribute effectively to partner-ships that are focused on stemming theobesity epidemic.

The authors thank the reviewers fortheir many constructive commentsand suggestions. The reviewers werenot asked to endorse this position orthe supporting paper.

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American Dietetic Association - Weight Management Position Paper

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