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Position of the American Dietetic Association:

Weight Management

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BSTRACTt is the position of the Americanietetic Association that successfuleight management to improveverall health for adults requires aifelong commitment to healthfulifestyle behaviors emphasizing sus-ainable and enjoyable eating prac-ices and daily physical activity.iven the increasing incidence ofverweight and obesity along with thescalating health care costs associ-ted with weight-related illnesses,ealth care providers must discoverow to effectively treat this complexondition. Food and nutrition profes-ionals should stay current andkilled in weight management to as-ist clients in preventing weight gain,ptimizing individual weight loss in-erventions, and achieving long-termeight loss maintenance. Using themerican Dietetic Association’s Evi-ence Analysis Process and Evidencenalysis Library, this position paperresents the current data and recom-endations for weight management.he evidence supporting the value ofortion control, eating frequency,eal replacements, and very-low-en-

rgy diets are discussed as well ashysical activity, behavior therapy,harmacotherapy, and surgery. Pub-ic policy changes to create environ-

ents that can assist all populationso achieve and sustain healthful life-tyle behaviors are also reviewed.Am Diet Assoc. 2009;109:330-346.

OSITION STATEMENTt is the position of the American Die-etic Association that successful weightanagement to improve overall health

or adults requires a lifelong commit-

0002-8223/09/10902-0016$36.00/0

adoi: 10.1016/j.jada.2008.11.041

30 Journal of the AMERICAN DIETETIC ASSOCIATIO

ent to healthful lifestyle behaviors em-hasizing sustainable and enjoyableating practices and daily physical ac-ivity.

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

at stores can only be changed by ahole body energy imbalance broughtn by a change in energy intake, en-rgy output, efficiency of energy use,r a combination of any of these com-onents (1). The underlying geneticnd physiologic mechanisms govern-ng these three energy-balance com-onents have been intensely studiedalthough still far from being com-letely understood) (2,3). This re-earch has greatly expanded since theiscovery of leptin in the early 1990s

This Position of the American DEvidence Analysis Process and inforLibrary. The use of an evidence-basebenefits to earlier review methods. Tthe more rigorous standardization olikelihood of reviewer bias and incrarticles may be compared. For a detathe evidence analysis process, accessat http://adaeal.com/eaprocess/.

Conclusion statements are assibased on the systematic analysis andevidence. Grade I�Good; GradeIV�Expert Opinion Only; and Gradthere is no evidence to support or re

Recommendations are also assigbased on the grade of the supportingharm. Recommendation ratings arInsufficient Evidence. Recommendaimperative statements. Conditional suation and most often are statedimperative statements are broadlywithout restraints on their pertinethis and other topics can be foundsubscriptions for nonmembers are pucom/store.cfm.

nd has revealed a physiology de- c

N © 2009

igned to primarily protect againsttarvation (4). Despite the volume ofesearch, there have been only a lim-ted number of obesity cases identi-ed as being directly caused by a sin-le gene mutation (5).On a population level, changes in

besity prevalence can also be vieweds an aberration of energy balanceut on a larger scale. Agricultural ad-ances, changes in economy and tech-ology (6), as well as societal changes

nfluencing expectations and valueystems (7), have lead to a worldhere the energy of the food supplyost frequently exceeds that of the

pportunities for energy expenditurehrough physical activity. The com-lexity of the causal factors at thendividual level combined with the

tic Association (ADA) uses ADA’stion from ADA’s Evidence Analysisapproach provides important addedmajor advantage of the approach isview criteria, which minimizes theses the ease with which disparated description of the methods used ine ADA’s Evidence Analysis Process

d a grade by an expert work groupaluation of the supporting researchFair; Grade III�Limited; Grade�Grade is Not Assignable (becausee the conclusion).d a rating by an expert work groupidence and the balance of benefit vstrong, Fair, Weak, Consensus, ors can be worded as conditional or

tements clearly define a specific sit-an “if, then” statement, whereas

pplicable to the target populatione. Evidence-based information for

www.adaevidencelibrary.com andasable at www.adaevidencelibrary.

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he environment within which indi-iduals live leads to a high prevalencef a condition that is often describeds chronic and refractory with a highecidivism rate for its treatment (8).

Given the biological tendency torotect against starvation and the so-ietal tendency to protect against un-erconsumption and volitional physi-al activity, there are clear pathwaysor action. First, the one in threedults (9) who can currently maintainhealthful body mass index (BMI)

re not likely to continue to be able too so if no action is taken. Curbinghe weight gain trajectory at both thendividual and population levels is vi-ally important. Next, it is crucialhat we find ways to optimize individ-alized treatments appropriately. Fi-ally, with the most rapidly growingopulation category being those whore severely obese (10), it is necessaryo understand and effectively treathat portion of the population whoseealth is most greatly compromisedy this condition.The purpose of this position paper

s to outline the evidence supportinghe American Dietetic Association’s

ADA’s) adult weight managementosition statement. Since 2000, ADAas used an evidence-based approachor the development of clinical prac-ice guidelines for nutrition care. Thevidence analysis work for the adulteight management guidelines form

he basis of the information providedn this position paper (11). The recom-

endation statement from the adulteight management guidelines is in-

luded in this position paper in allections where there is a correspond-ng major recommendation from theuidelines. A brief description of thevidence analysis process, an expla-ation of the conclusion statementrading, and the recommendationating scales is provided in the Side-ar.

OALS OF WEIGHT MANAGEMENThe goals of weight management goell beyond numbers on a scale,hether or not weight change is onef the management objectives. Theevelopment of healthful lifestylesith behavior modification is impor-

ant for overall fitness and health. Re-listic expectations should be defineduring an intake interview in terms

f a more healthful weight vs the nor- m

al BMI range. In addition, it is im-ortant to set realistic expectationsbout the time required to make austainable behavior change.Goals of weight management inter-

entions 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; andimprovements in eating, exercise,and other behaviors.

Health can be improved with rela-ively minor weight losses. A weightoss of 10% may ameliorate healthisks associated with excessive bodyeight (12). Health care providersust help patients to accept a mod-

st, sustainable weight change thatan be realistically achieved. Appear-nce, in many patients, will be an im-ortant motivator; however, it is crit-cal that health care providersmphasize the goal of achieving aore healthful weight and lifestylehile de-emphasizing cosmetic goals.

The goals of weightmanagement go wellbeyond numbers on ascale, whether or notweight change is oneof the management

objectives.

ADA’s Nutrition Care Process in-ludes nutrition assessment, nutri-ion diagnosis, nutrition intervention,nd nutrition monitoring and evalua-ion. It is essential to include each ofhese steps into weight managementare plans. ADA’s Evidence Analysisibrary (EAL) contains evidence-ased adult weight managementuidelines, including the recommenda-ions upon which this position paper isased (11). Food and nutrition profes-ionals should incorporate these funda-

ental concepts for managing obesity e

February 2009 ● Journa

nto their patients’ individualized carelans.

SSESSMENT OF OBESITYssessment, the first step of the Nu-

rition Care Process (13,14), involvesathering the necessary informationo formulate a diagnosis and develop

care plan. Baseline weight andealth indexes should guide weightanagement goals and are necessary

o document outcomes. Clinically use-ul measures of body weight statusre noninvasive, easy to use, inexpen-ive, reliable, capable of reflectinghort- and long-term changes in bodyat, and must be correlated to healthisk.The standard measurement foreight status is BMI, calculated asg/m2. Overweight is defined as aMI of 25 to 29, whereas higherMI values reflect more excessivemounts of body fat (12). There areifferences even in the community ofxperts as to the BMI at which anndividual is at greater health risk.ome advocate weight loss by individ-als with a BMI of 25 to 29 but debateontinues on how much weight reduc-ion should be recommended (15). Theational Heart, Lung, and Blood In-

titute (NHLBI) guidelines (16) rec-mmend intervention for overweightndividuals who have two or moreisk factors associated with theireight status. The Dietary Guidelines

or Americans 2005 (17) recommendndividuals work toward weight re-uction if they are even mildly over-eight.Multiple sources of information are

vailable, but for most evaluations aatient-centered interview with sup-orting records from primary careroviders and/or referring physiciansemain the most important. A physi-ian’s evaluation of weight status, in-luding height, weight, and waist cir-umference, provides the informationndicating that a referral to a regis-ered dietitian (RD) is appropriate. Aedical examination should rule out

hysiologic causes of increased bodyeight and assess health risks and/or

he presence of weight-related co-orbidities. Cardiorespiratory fit-

ess and screening for musculoskele-al problems may need to be reviewedefore making physical activity rec-mmendations or referring on to an

xercise professional. In addition to a

l of the AMERICAN DIETETIC ASSOCIATION 331

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edical assessment, a psychologicalvaluation may be indicated. Screen-ng for barriers to successful weightoss such as depression, post-trau-

atic stress disorder, anxiety, bipolarisorder, addictions, binge eating dis-rder, and bulimia is necessary. Stud-es have shown a high frequency ofhese disorders in those with exces-ive weight problems (18-20). Appro-riate treatment should be imple-ented before beginning a nutritional

ntervention.With this information from the

ealth care team, an RD can effec-ively begin evaluation.

EAL Recommendation “BMI andaist circumference should be used to

lassify overweight and obesity, esti-ate risk for disease, and to identify

reatment options. BMI and waist cir-umference are highly correlated tobesity or fat mass and risk of otheriseases” (Rating: Fair, Impera-ive) (11). Data is accumulating re-arding differences in aboriginal andsian racial groups that may indicatedownward shift of BMI to define a

ealthful weight is indicated (21-23).Functional and behavioral issues

eg, social and cognitive function, psy-hological and emotional factors, anduality-of-life measures) are impor-ant to address to optimize a weightanagement intervention. Factors

elated to food access, food selection,unctional capacity for food prepara-ion, and other physical activity areignificant for treatment planning.During an intake interview it is im-

ortant to observe nonverbal and ver-al cues. These cues can guide andrompt the interviewing process andelp determine what informationhould be prioritized and evaluatedurther. In many dietetic referralshe only information available is fromhe referring physician; therefore theepth and exploration required to ad-quately assess nutritional statusnd related factors will be an issue ofrofessional judgment and may ex-end to subsequent consultations. Nu-ritional adequacy established fromietary history and food intakeecords coupled with anthropometricnd biochemical measures provideaseline data. The possible multipleomponents of a comprehensive inter-iew are summarized in the Figure.The ADA adult weight manage-ent guidelines advise resting en-

rgy expenditure measurement as

32 February 2009 Volume 109 Number 2

art of an assessment. However, met-bolic carts are rarely available inlinical practice and another sched-led visit may be required to providetandard conditions for cart measure-ent. There is controversy regarding

he applicability of predictive equa-ions of resting energy expendi-ure; however, such information canake a valuable contribution to goal

etting and intervention strategies24-26).

EAL Recommendation “Esti-ated energy needs should be based

n [resting metabolic rate]. If possi-le, [resting metabolic rate] should beeasured (eg, indirect calorimetry).

f [resting metabolic rate] cannot beeasured, then the Mifflin-St Jeor

quation using actual weight is theost accurate for estimating [restingetabolic rate] for overweight and

bese individuals” (Rating: Strong,onditional) (11). The Mifflin-Steor equations are:

an: Basal Metabolic Rate (BMR)�

A. Anthropometrics● Height● Weight● Body mass index● Waist circumference

B. Medical● Identify potential causes: endocrine, ne

family history).● Identify obesity-associated disorders (cu

complications): metabolic, anatomic, deg● Evaluate obesity severity and extent of p

C. Psychological● Identify psychological etiology: psychotro

stress disorder, addictive behavior.● Eating disorders: binge eating, bulimia.● Assess risk for potential barriers to treat

untreated psychological disorders.D. Nutritional

● Weight history: age of onset, highest/lowloss, environmental triggers to weight ga

● Dieting history: number and types of diealternative approaches for weight loss, s

● Current eating patterns: meal patterns (s24-hour recall/food frequency.

● Nutritional intake: nutrient density, nutrit● Environmental factors: meals eaten awa

ethnic foods, lifestyle factors (eg, time a● Exercise history: activities of daily living,

barriers to exercise.● Readiness to change: reasons to lose w

making changes, current life stressors, s

igure. Factors to assess during weight mana

(10�weight in kilograms)�(6.25� m

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

Determining when a problem re-uires consultation with or referral tonother provider may be appropriate.or effective weight management in-ervention, a patient ideally would bessessed by a multidisciplinary team,ncluding a physician, RD, exercisehysiologist, and a behavior thera-ist. Through the team approach, is-ues such as nutrition, physical activ-ty, and change in eating behavior cane coordinated. Although this ap-roach may be a gold standard, therere many barriers such as the in-reased cost of a multidisciplinaryeam, the lack of third-party reim-ursement, and the absence of expe-ienced weight management healthare professionals. However, once arimary care physician has deter-

logical; medications; genetics (age of onset,

t complications and risk of futurerative, and/or neoplastic complications.ical disability.

medications, depression, post-traumatic

ts: psychiatric history—suicidal ideation,

adult weights, patterns of weight gain andtriggers to excessive or disordered eating.eight loss medications, complementary and

ess of previous weight loss efforts.ed meals, largest meal, snacks/grazing),

supplements, vitamin/mineral supplements.m home, fast-food meals, restaurant meals,r financial constraints).rent structured exercise, past exercise,

t at this time, weight loss goals, readiness forort systems.

ent intake interviews.

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rom the expertise of a team ap-roach, the appropriate referrals cane made. Most commonly, RDs as-ume a leadership role to design andctivate the intervention strategyeveloped by the multidisciplinaryeam or in collaboration with the re-erring medical provider. The activeole ADA is now taking in establish-ng evidence-based guidelines willontinue to modify assessment prac-ices.

Nutrition assessment is an ongo-ng, dynamic process that involvesot only initial data collection, butlso continual reassessment andnalysis. Assessment provides theoundation for the nutrition diagno-is, which is the next step of the Nu-rition Care Process.

EGULATION OF FOOD INTAKEnegative energy balance is the most

mportant factor affecting weight lossmount and rate. The first recom-endation in obesity treatment issually a reduction in energy intake:reduction of 500 to 1,000 kcal/day is

dvised to achieve a 1 to 2 lb weightoss per week (11,12). Dietary energyeduction strategies may vary from aocus solely on energy (ie, “calorieounting”), macronutrient composi-ion and/or energy density, or a com-ination of energy and macronutrientomposition along with form consid-rations such as consistency (eg, mealeplacements, very-low-energy diets).n addition, strategies have includedhanges to meal frequency, meal tim-ng (eg, breakfast) and guidance onood portions. To evaluate the evi-ence supporting these proposedtrategies, it is necessary to first re-iew what is known about the regula-ion of eating behavior in human be-ngs.

Eating is a behavior that links thexternal physical environment withn individual’s internal physiologicrocesses (27). Two distinct internalystems govern food intake: the ho-eostatic system and the hedonic

ystem. Although both systems areegulated centrally, they do not ap-ear to be integrated. Reduced appe-ite control may be due to either dis-urbance in homeostatic pathways oro inappropriate sensitization of theedonic system. The homeostatic sys-em comprises both long-term signal-

ng from the adipose tissue and epi- r

odic signaling primarily from theut. The long-term signaling usesormones such as leptin and insulino act as key drivers for initiating foodntake. Generated in response to anating episode, the episodic signalingystem is activated from the gastroin-estinal tract and uses hormones suchs ghrelin, cholescystokinin, gluca-on-like peptide, and peptide YY,mong others. These episodic signalsise and fall in harmony with eatingatterns. The interaction betweenhese two sets of homeostatic signalseflects the brain’s recognition of theurrent dynamic state of energytores and the changing nutrient flowerived from eating. This central reg-lation of energy balance tunes hun-er and fullness sensations that ac-ompany eating behaviors.Unlike the central nervous regula-

ion of the homeostatic system (locatedrimarily in the arcuate nucleus ofhe hypothalamus), a cortico-limbiceural network regulates the hedo-ic governance of food intake. Thiseural network (involving signals suchs endocannabinoids, serotonin, andopamine) deals with the cognitive,otivational, and emotional aspects of

ood intake (eg, perceived pleasantness,iking, and wanting). This system rep-esents the main interface with thexternal environment as, in the ab-ence of a depletion signal, the initia-ion of an eating episode often startss a cognitive decision from the cortex28). Palatability, via this system, is aery powerful determinant of food in-ake and inappropriate sensitizationf the hedonic network likely leads toeight gain. However, the hedonic

ystem is less well-studied than itsomeostatic counterpart and muchore research is required to fully un-

erstand the interactions of these twoystems.The complexity of eating behaviorakes it difficult to completely eluci-

ate the role of any one of the energyeduction strategies. Whereas a ran-omized study with high dietary con-rol helps to evaluate affects of energyeduction on weight loss per se, longi-udinal studies in free-living individ-als (albeit with less dietary control)re also required to evaluate thether system components. Unfortu-ately, studies in free-living individ-als (either longitudinal or cross-sec-ional) often have to rely on self-

eported food intake, which, in of v

February 2009 ● Journa

tself, presents confounding factors.or example, under-reporting of en-rgy intake is persistently prevalentn dietary surveys and appears to bereater in overweight vs normal-eight people (29). In addition, little

s understood regarding the physiol-gy of eating behaviors in people withevere obesity, people following a re-ent weight loss, or the influence ofhysical activity on the eating behav-or systems.

iet Compositionlow-fat, reduced-energy diet is the

est studied weight-loss dietarytrategy and is most frequently rec-mmended by governing health au-horities (11,17,30). Fat is the mostnergy-dense macronutrient but isnown to have a weak effect on bothatiation and satiety (31). These at-ributes make fat a useful target foreducing energy intake. Because dia-etes and cardiovascular disease arerequent comorbidities of obesity, re-ucing the dietary saturated andrans-fatty acid content is also recom-ended (30). The effectiveness of low-

at, low-energy diets in combinationith lifestyle counseling and activityas been demonstrated in recent mul-icenter clinical trials where, in addi-ion to 5% to 10% weight loss, theeduction or prevention of comorbidi-ies such as diabetes and/or hyperten-ion has also occurred (32-35).Frequently, individuals reduce the

arbohydrate content of their diet as aeight loss strategy. As glycogen

tores are depleted in response to low-arbohydrate intake, the resultant di-resis produces an initial dramaticeight loss. On very-low-carbohy-rate diets (eg, �20 g/day) the bodyroduces ketones to sustain fuel uti-ization in the brain, which may inurn help with diet adherence by de-reasing hunger (36). Individuals as-igned to the ad libitum low-carbohy-rate diet in recent randomizedontrolled trials lost more weight at 6onths than individuals assigned to

he low-fat, reduced-energy diet, buthis difference was no longer signifi-ant at 12 months (11,37,38). Con-erns regarding an increase in cardio-ascular risks with low-carbohydrateiets do not appear to be as problem-tic as first thought (37).EAL Recommendation “An indi-

idualized reduced calorie diet is the

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asis of the dietary component of aomprehensive weight managementrogram. Reducing dietary fat and/orarbohydrates is a practical way toreate a caloric deficit of 500 to 1,000cal below estimated energy needsnd should result in a weight loss of 1o 2 lb per week” (Rating: Strong,mperative) (11).EAL Recommendation “Having

atients focus on reducing carbohy-rates rather than reducing caloriesnd/or fat may be a short-term strat-gy for some individuals. Research in-icates that focusing on reducing car-ohydrate intake (�35% of kcal fromarbohydrates) results in reduced en-rgy intake. Consumption of a low-arbohydrate diet is associated with areater weight and fat loss than tra-itional reduced-calorie diets duringhe first 6 months, but these differ-nces are not significant after 1 year”Rating: Fair, Conditional) (11).

The EAL also notes that safety hasot been evaluated for long-term, ex-reme restrictions of carbohydrates�35% of energy from carbohydrates)nd specifically recommends thatractitioners use caution in suggest-ng a low-carbohydrate diet for evenhort-term use in patients with osteo-orosis, kidney disease, or in patientsith increased low-density lipopro-

ein cholesterol (11).

Portion distortion is anew term created to

describe thisperception of large

portions asappropriate amounts

to eat at a singleeating occasion.

Additional dietary componentshought to influence weight (ie, lowlycemic index diets and diets high inalcium) were evaluated. In both in-tances, low glycemic index foods andow-fat dairy foods can be incorpo-ated but are not essential for dietsppropriate for weight management.EAL Recommendation “A low

lycemic index diet is not recom-ended for weight loss or weightaintenance as part of a comprehen-

ive weight management program, f

34 February 2009 Volume 109 Number 2

ince it is has not been shown to beffective in these areas” (Rating:trong, Imperative) (11).EAL Recommendation “In order

o meet current nutritional recom-endations, incorporate 3-4 servings

f low-fat dairy foods a day as part ofhe diet component of a comprehen-ive weight management program.esearch suggests that calcium in-

ake lower than the recommendedevel is associated with increasedody weight. However, the effect ofairy and/or calcium at or above rec-mmended levels on weight manage-ent is unclear” (Rating: Fair, Im-erative) (11).The debate regarding the optimalacronutrient content of a reduced-

nergy diet has emphasized the diffi-ulty individuals have in followingny weight loss regimen. Whetherandomized to a low-fat or a low-car-ohydrate diet, study completionates at 1 year are typically low foroth interventions (37). It is likelyhat factors from both the homeo-tatic as well as the hedonic systemsnfluence an individual’s ability to ad-ere to any type of weight loss diet.e need to better understand the fac-

ors that influence individual adher-nce as well as study attrition rates ineneral, because these two parame-ers affect interpretation of trial out-omes.

ortion ControlDs typically recommend portionontrol to weight loss clients with theoal of reducing the energy load ofonsumed foods. Strategies may in-lude providing information on thenergy content of regularly consumedoods (eg, energy content of 1⁄2 c vs oneowl of ice cream), use of premea-ured foods (eg, frozen entrees, 100-cal snack packs), replacing highernergy-density foods with lower ener-y-density foods (eg, cereal with milkor an evening snack), and/or reduc-ng the energy density of foods (eg,ncreasing vegetable content of entréetems). These strategies may affect ei-her the homeostatic system (eg, re-uced portions may be more or lessatiating depending on the strategysed) and/or hedonic system (eg, cog-itive decisions to choose one foodver another possibly more palatableood) that govern eating behavior. Ef-

ectively reducing portion sizes ap- d

ears to be an important weight gainrevention strategy for everybody (re-ardless of weight) as marketplaceood and drink portions now exceedtandard serving sizes by a factor oft least twofold (39). Portion distor-ion is a new term created to describehis perception of large portions asppropriate amounts to eat at a singleating occasion. This distortion is re-nforced by packaging, dinnerware,nd serving utensils that have alsoncreased in size (40).

Most of the evidence supporting thealue of portion control comes fromtudies in normal-weight and/or over-eight subjects using experimentalaradigms such as differences in serv-ng containers, self-refilling bowls, andelf-service vs preserved food items11). These studies show that by in-reasing portion sizes, energy intakeuring an eating occasion is increasedut is not compensated for by a de-rease in intake later in the day.hree randomized controlled trialshowed weight loss in participantssing specific portion control strate-ies of frozen entrees (vs self-selectediet based on the Food Guide Pyra-id) (11), use of cereal to replace

sual evening snacks (11), and alate-method education tool (41). Al-hough the concept of portion controls universal in most weight manage-

ent programs, the overall strengthf the evidence for portion control toeduce energy intake and produceeight loss is graded as fair (11).ore research is needed to determine

he effectiveness of specific portionontrol strategies on body weight reg-lation especially for people in differ-nt physiological states (eg, post-eight loss [ie, to prevent a weight

egain] or people with severe obesity).EAL Recommendation “Portion

ontrol should be included as part of aomprehensive weight managementrogram. Portion control at mealsnd snacks results in reduced energyntake and weight loss” (Rating:air, Imperative) (11).

ating Frequencyany RDs encourage weight loss

lients to avoid skipping breakfastnd to have a regular meal pattern.his advice is prompted by a con-ern for compromised nutrient in-ake if breakfast is not consumed (eg,

ecreased calcium and fiber intake),

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hat an erratic schedule leads to poorood choices from available foods thatre energy dense but nutrient pooreg, vending machines, office candyars, and fast-food restaurants), asell as concern that evening energy

onsumption is more likely to lead toeight gain. Generically prescribingcertain meal frequency or advocat-

ng the inclusion of breakfast as apecific weight loss (or prevention ofeight gain) strategy must be basedn an understanding of the evidencef whether the pattern of meal con-umption affects energy intake andhereby weight loss. Unfortunatelyhe evidence is inconsistent as the re-earch on eating frequency patternss not extensive with no randomizedontrolled studies. A number of cross-ectional studies show equivocal find-ngs on the association of eating fre-uency to body weight regulation11). Limitations in study design ornconsistency in methodology may behe reason for this lack of clarity andair evidence grade (11). These stud-es have relied on self-reported intakeut as yet it is not clear where thender-reporting of energy intake (es-ecially prevalent among obese par-icipants) comes from (ie, mispercep-ion and/or misreporting of mealortions, omission of eating occasions,r a combination of both). The defini-ion of an eating occasion is often in-onsistent between studies (eg, onetudy used 50 kcal separated from an-ther eating episode by 15 minuteshereas another study used maineal, beverage meal, light meal, or

nack categories) (11). Finally, theharacteristics of people who routinelyave a regular vs irregular meal pat-ern are still unknown, making it diffi-ult to understand the influence of eat-ng frequency per se vs other personalttributes (eg, insulin levels, ghrelinevels, age, daily work schedule, andoutine exercise habits).

Breakfast consumption possiblylays a role in weight managementhrough an influence on appetite con-rol, dietary quality, and metabolism42). Like the research on eating fre-uency, the research on the affectf breakfast consumption on bodyeight regulation is primarily fo-

used on cross-sectional studies ands confounded by the same factors ofeliance on self-report, definition ofhat constitutes a breakfast, and

ack of characterization of breakfast r

s nonbreakfast consumers. Threeross-sectional studies show an asso-iation between skipping breakfastnd an increased prevalence or risk ofbesity (11). However, the associationay vary depending on the breakfast

ontent (eg, high-fat breakfast con-umers are associated with higherMIs than high-fiber breakfast con-umers) and sex (eg, the associationetween breakfast consumption and aMI �25 is significant for women butot for men) (11). In one randomizedontrolled trial, the habitual break-ast-eating habits of the study par-icipants interacted with treatmentssignment (breakfast vs no-break-ast treatment) to influence theeasured weight change (11). Fur-

her research on the relationship be-ween breakfast and body weightegulation is needed.Although the research does not yet

upport making absolute meal fre-uency or breakfast recommenda-ions for optimizing body weight con-rol, it is important that clinicaludgment is used when guiding cli-nts. Helping a client to find a mealattern that prevents the times whenigh hunger coincides with an envi-onment of high-energy food choiceseems pertinent.EAL Recommendation “Total ca-

oric intake should be distributedhroughout the day, with the con-umption of four to five meals/snackser day including breakfast. Con-umption of greater energy intakeuring the day may be preferable tovening consumption” (Rating: Fair,mperative) (11).

eal Replacementshoosing a low-energy, nutritiousiet in an environment that providessurplus of palatable, energy-dense,

utrient-poor food choices can easilyverwhelm anyone trying to loseeight. Meal replacements, contain-

ng a known energy and macronutri-nt content, are a useful strategy toliminate problematic food choices oromplex meal planning while tryingo attain a 500 to 1,000 kcal/day en-rgy deficit. Several studies compar-ng isocaloric diets have shown equiv-lent or greater weight loss efficacyith structured meal replacementlans compared to reduced-energyiet treatments (11). Three of these

andomized controlled trials included v

February 2009 ● Journa

weight maintenance phase of theirvaluation and reported a greater ef-ect of one meal replacement per dayver conventional diet for mainte-ance of a weight loss (11). Individu-ls adhering to structured meal re-lacement plans lose more weight atoth 12 weeks (�7% vs 4% of initialody weight) and 1 year (�7% to 8%s 3% to 7%) than individuals follow-ng a conventional diet plan, with-year dropout rates for the struc-ured meal replacement plan signifi-antly less than the conventional dietlan (47% vs 64%; P� 0.001) (11). Toate, structured meal replacementlans and weight loss efficacy in se-erely obese individuals or as aeight gain prevention strategy haveot been sufficiently studied.There is concern that this strategyay mean an over-reliance on artifi-

ial nutrients and may prevent cli-nts from learning how to select ap-ropriately from typical conventionalood choices. These specific concernsave not been systematically studied.owever, RDs have a role in advising

lients utilizing meal replacementsn how to optimize the overall nutri-nt content of their diet by carefulelection of the conventional foodshat make up the non–meal-replace-ent portion of the weight loss plan.EAL Recommendation “For peo-

le who have difficulty with self selec-ion and/or portion control, meal re-lacements (eg, liquid meals, mealars, or calorie-controlled packagedeals) may be used as part of the diet

omponent of a comprehensive weightanagement program. Substituting

ne or two daily meals or snacks witheal replacements is a successfuleight loss and weight maintenance

trategy” (Rating: Strong, Condi-ional) (11).

ery-Low-Energy Dietsnlike meal replacements, which areesigned to replace only one or twoeals per day, a very-low-energy diet

s designed to be the only food sourceuring active weight loss. A very-low-nergy diet is typically a liquid formu-ation that supplies about 800 kcal (or

to 10 kcal/kg) or less per day, isnriched with high biologic value pro-ein and provides at least 100% of theaily Value of essential vitamins andinerals. The purpose of using a

ery-low-energy diet is to quickly

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chieve a large weight loss while pro-iding adequate nutrition and pre-erving lean body mass as much asossible. Medical monitoring is neces-ary during the rapid weight losshase and the medical risk makes aery-low-energy diet inappropriateor individuals with a BMI �30. Al-hough there is good evidence thatdherence to a very-low-energy dietesults in significant weight loss of 15o 5% of initial body weight over 12 to6 weeks, maintenance of that weightoss is problematic (11,43). In 1998,he NHLBI expert panel recom-ended against the use of very-low-

nergy diets. The decision was basedn studies showing no differences inong-term weight losses between very-ow-energy diets and low-energy dietsrimarily because of greater weightegain with very-low-energy diets12). Although there have been manytudies evaluating the long-termaintenance of weight loss following

ery-low-energy diets, the majorityave been case-series with no directomparison with a low-energy dietulminating in equivocal results (11).

recent meta-analysis was con-ucted evaluating six randomizedontrolled trials that each includedery-low-energy diet and low-energyiet comparisons for short-term andong-term (at least 1 year follow-up)eight loss (43). Despite significantlyreater short-term weight loss withery-low-energy diets (16.1%�1.6%s 9.7%�2.4%; P�0.0001), the weightoss was similar between very-low-en-rgy diets and low-energy diets forong-term weight loss (6.3%�3.2% vs.0%�4.0%; P�0.2) (43). Overall at-rition in the six studies was not dif-erent between the very-low-energyiet and low-energy diet groups.The use of very-low-energy diets

as been increasingly prescribed be-ore bariatric surgery to reduce over-ll surgical risk in patients with se-ere obesity. There is indication thathe use of very-low-energy diets for ateast 2 weeks reduces liver size al-hough up to 6 weeks may be moredeal for clinically significant de-reases in abdominal adiposity (44).urther research is necessary to eval-ate the efficacy of this strategy forurgery candidates with severe obe-ity.EAL Conclusion “Adherence to a

ery-low-calorie diet, defined as 800

cal or 6 to 10 kcal/kg or less, results i

36 February 2009 Volume 109 Number 2

n significant weight loss” (Grade�Good) (11).EAL Conclusion “Adherence to a

ery-low-calorie results in lower calo-ie intakes and therefore significantlyreater initial weight loss than re-uced-calorie diets” (Grade I�Good)11).

EAL Conclusion “While adher-nce to a very-low-calorie results inignificant initial weight loss, studieseport varying levels of weight regainased on differences in weight main-enance strategies” (Grade I�Good)11).

hysical Activityn energy deficit of 500 to 1,000cal/d is necessary to achieve a 1- to-lb weight loss per week (11). Pro-ucing this energy deficit throughhysical activity alone is extremelyifficult for most adults. Few studiesave used a large enough physical ac-ivity “dose” to achieve a 5% weightoss using a physical activity inter-ention alone (45). Weight-loss stud-es have shown only small reductionsn body weight with physical activityreatment compared to no-treatmentontrol groups (45). However, theagnitude of weight change due to

hysical activity is additive to thatssociated with a dietary interventionchieving energy restriction (45). Thenfluence of physical activity oneight loss depends on the ability ofn individual to engage in adequateevels of exercise such that the energyost of exercise is greater than typicaluctuations or compensatory changes

n energy intake. Depending on bodyize, fitness level, and exercise inten-ity, an individual may burn an addi-ional 1,000 kcal per week by exercis-ng 30 minutes 5 days a week. Inomparison, an extra 1,000 kcal couldasily be consumed by miscalculatingortion sizes and/or a couple of extranacks or beverages. However, de-pite its modest impact on weightoss, physical activity is important formproving health-related outcomeselated to many obesity comorbiditieseg, heart disease, cancer, and diabe-es) (45,46) although additional re-earch is required to understand thiselationship in individuals with BMI40. Regular physical activity is alsossociated with a lower risk of deathegardless of BMI (47). Therefore, it is

mportant that physical activity is in- s

luded in obesity treatment pro-rams.Although its influence on weight lossay be minimal, physical activity ap-

ears to be crucial in the prevention ofeight regain. Many correlation stud-

es show a strong association betweenhysical activity at follow-up and main-enance of a weight loss (45,48,49).oubly-labeled water studies indicate

hat physical activity in the range of1 to 12 kcal/kg/day maybe necessaryo prevent weight regain following aeight loss (50). Data from the Na-

ional Weight Control Registry alsondicate that a high level of dailyhysical activity may be necessary torevent weight regain (51). The Na-ional Weight Control Registry is aegistry of more than 3,000 individu-ls who have successfully maintainedt least a 30-lb weight loss for a min-mum of 1 year. These individuals re-ort using a variety of methods to loseeight initially, but more than 90%

eport exercise as crucial to theirong-term weight-loss maintenance.hey report expending, on average,,682 kcal per week in exercise, annergy equivalent of walking 4 milesdays a week (51). It has been pro-

osed that high levels of physical ac-ivity allows for a post-reduced indi-idual to sustain a lowered energy-alance level without overly restrictingood intake (52).

Specific physical activity recom-endations were included for the

rst time in the 2005 Dietary Guide-ines (17). These recommendations in-luded three categories related toeight management goals. The first

ecommendation, to reduce the risk ofhronic disease in adulthood, is for 30inutes of moderate-intensity physi-

al activity on most days of the week.he second recommendation, to helpanage body weight and preventeight gain in adulthood, is to engage

n 60 minutes of moderate- to vigor-us-intensity activity on most days ofhe week. Finally, to prevent weightegain after weight loss, engage in 60o 90 minutes of daily moderate-in-ensity physical activity while not ex-eeding energy requirements. Therst Federal Physical Activity Guide-

ines for Americans were issued inate 2008 (45). These guidelines pro-ided a comprehensive summary ofhe scientific evidence for the healthenefits of physical activity and have

imilar recommendations to the 2005

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ietary Guidelines—all adults shouldvoid inactivity and health benefitsincluding weight control benefits) in-rease as physical activity increases45). Unlike the recommendations inhe 2005 Dietary Guidelines (17), thehysical Activity Guidelines makeecommendations in weekly vs dailyoses: at least the equivalent of 150inutes/week of moderate-intensity

erobic physical activity for substan-ial health benefits and 300 minutes/eek of moderate-intensity physicalctivity for more extensive health ben-fits (45). Acknowledging the great in-erindividual variability that existsith physical activity and achieving/aintaining a healthful weight, these

uidelines suggested that many peopleay need more than the equivalent of

50 minutes/week of moderate-inten-ity physical activity to maintain theireight and more than 300 minutes/eek to meet weight-control goals (45).Ds have a role in reinforcing these

ecommendations that will help clientschieve appropriate physical activityoals through the different phases ofeight management (ie, prevention ofeight gain, weight loss, and sustain-

ng a weight loss).Pedometers and step counters are

requently used to promote dailyhysical activity. These small, rela-ively inexpensive devices are wornt the hip and track the number ofteps taken per day. Individualsearing these devices can track theiraily variability in steps and/or com-are daily steps against a prescribedtep goal (both behaviors that mayromote problem-solving to preventnnecessarily low step days). 10,000teps per day is an appropriate dailytep goal consistent with the 30 min-tes of moderate-intensity physicalctivity recommendation of the 2005ietary Guidelines (53); however, aigher step goal would be necessaryo either produce weight loss by phys-cal activity alone or to maintain aeight loss. A recent meta-analysis of6 studies (eight randomized con-rolled trials and 18 observationaltudies) evaluating pedometer usehowed that physical activity in pe-ometer users increased 26.9% overaseline (54). Having a step goal,uch as 10,000 steps per day, wasn important predictor of increasedhysical activity (P�0.001) (54).oted limitations of this meta-analy-

is were the lack of long-term follow i

p, small study sizes, as well as in-bility to account for the influence ofdditional study components such astep diaries and physical activityounseling. In addition, as the meanreintervention BMI of study partici-ants was 30�3.4, the efficacy of pe-ometer use in people with severebesity (BMI �40) was not evaluated.se of pedometers in severely obese in-ividuals deserves further research.

ehavioral Interventionsistorically, cognitive behavioral treat-ent of obesity developed from the be-

ief that obesity was the result of mal-daptive eating and exercise habits,hich could be corrected by the appli-

ation of learning principles (55). To-ay, it is understood that body weights affected by factors other than be-avior, including genetic, metabolic,nd hormonal influences (56,57). Al-hough behavior modification is onlyne piece of the puzzle, behavior ther-py can help individuals develop a setf skills to achieve a more healthfuleight (34,58,59).

hat Is Cognitive Behavioral Therapy? Cog-itive behavioral therapy is based

argely on principles of classical con-itioning, which assert that eating isften prompted by antecedent eventsie, cues) that become strongly linkedo food intake (55). Cognitive behav-oral therapy helps patients identifyues that trigger inappropriate eatingand activity) behaviors and learnew responses to them (60). Treat-ent also seeks to reinforce (or re-ard) the adoption of positive behav-

ors. Cognitive behavioral therapyas several distinguishing character-

stics (61): it is goal-directed (measur-ble outcomes), process-oriented (helpseople decide how to change), and ad-ocates small rather than largehanges. The behavior change processs facilitated through the use of a va-iety of problem-solving tools andsually includes multiple componentsuch as nutrition education, keepingood and activity records (ie, self-mon-toring), controlling cues associatedith eating (ie, stimulus control),roblem solving, cognitive restructur-ng, and physical activity (60). Theseomponents comprise the behavioralackage. ADA’s Nutrition Counselingork group is currently reviewing thevidence to determine how effective

ndividual components of the behav- m

February 2009 ● Journa

oral package (ie, self-monitoring,timulus control, problem solving, so-ial support, and cognitive restructur-ng) are in changing behavior andromoting weight loss in adults.ognitive Behavioral Therapy and Weightoss. A limited number of studiesave evaluated the intermediate (6 to2 months) effectiveness of cognitiveehavioral therapy on weight loss.EAL Conclusion “One neutral

uality, 6-month randomized con-rolled trial (86 obese adults) providesvidence that intermediate duration6-12 months) behavioral therapy andehavioral therapy combined with aersonalized system of skill acquisi-ion targeting weight loss is more ef-ective than weight loss educationlone in facilitating weight loss, de-reasing both total energy intake andercent of calories from fat, and in-reasing physical activity” (GradeII�Limited) (11).Compared to patients with obesity

eceiving the weight-loss educationalrogram (ie, 6 monthly education ses-ions on nutrition, behavioral strate-ies for changing eating and exerciseabits, and guidelines for increasinghysical activity), patients with obe-ity who either received standard be-avior therapy (ie, 25 weekly sessionsn self-monitoring, goal setting, stim-lus control, and cognitive restructur-

ng) or behavior therapy plus person-lized skill acquisition (ie, behaviorherapy plus reinforcement [mone-ary rewards] contingent on individ-al mastery of specific skills related toating and exercise behaviors) lost sig-ificantly more weight at 6 months.Small randomized trials evaluating

he effects of cognitive behavioralherapy on weight loss over 2 yearsave also shown positive effects oneight control though weight gain is

ypically observed over time.EAL Conclusion “One neutral

uasi-experimental (84 participantseceived behavior therapy) and twoositive randomized controlled trials65 participants received behaviorherapy and a very-low-calorie diet)valuated behavior therapy as a com-onent of a weight-loss program ofong-term duration (�12 months). Be-avior therapy was not always theariable of randomization. Partici-ants receiving behavior therapy losteight at the conclusion of treat-

ents. Upon follow-up there was

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ome weight regain but participantsemained at a lower weight thanaseline. Studies that included aery-low-calorie diet to initiate rapidnitial weight loss, combined with be-avior therapy, also appeared to pro-uce long-term weight loss. [Note:his is not a statement recommend-

ng very-low-energy diets or suggest-ng that very-low-energy diets are

ore beneficial than low-energy di-ts.]” (Grade II�Fair) (11).A number of large randomized

tudies examined the effects of cogni-ive behavioral therapy on diabetesnd cardiovascular disease risk.iven the beneficial effect of weight

eduction on these disease states,eight loss is often an outcome that isvaluated. The typical design of manyehavioral studies is group meetingseekly for the initial treatment phase

approximately 3 to 6 months), bi-eekly (every other week) meetings

or the maintenance phase (6 to 12onths), and monthly or bimonthly

or the later phases of the study (12 to4 months) (33,61-64).The PREMIER, Diabetes Preven-

ion Program, Finnish Diabetes Pre-ention, and Look AHEAD studiesre examples of large, multicenter,andomized studies that demonstratehe influence of behavior modificationn weight loss, diabetes, and cardio-ascular disease risk (33-35,58,59).articipants in the PREMIER studyere randomly assigned to either a

ontrol group (single advice-givingession) or one of two behavior modi-cation intervention groups, whichiffered in diet prescription (35). Sig-ificantly greater weight losses werebserved in the intervention groupsompared to the control group at 6onths. There were no significant dif-

erences in weight loss between thentervention groups, suggesting thatehavior modification had a strongernfluence on weight loss than the pre-cribed method of energy restriction.The Diabetes Prevention Program

howed that intensive behavior mod-fication is not only more efficacious inroducing weight loss and improvingealth than general recommenda-ions but also more efficacious thanharmacotherapy (33). Participantsn the intensive lifestyle group lostignificantly more weight and alsoad a significantly lower incidence ofype 2 diabetes than those taking

etformin or placebo. Similar find-

38 February 2009 Volume 109 Number 2

ngs were observed in the LookHEAD study, which compared theffectiveness of a behavioral interven-ion program and enhanced usualare (ie, diabetes support and educa-ion) on weight loss and the preven-ion of cardiovascular disease in indi-iduals with type 2 diabetes (32). Notnly did individuals in the behavioralntervention group lose more weightt 1 year, they also observed greatereductions in medication use, fastinglucose, hemoglobin A1c, blood pres-ure, triglyceride levels, and greaterncreases in high-density lipoproteinevels.

The Finnish Diabetes Preventiontudy also compared the efficacy ofifestyle modification and usual caren individuals at high risk for type 2iabetes (58). This study was endedarly due to clear differences in out-omes (ie, body weight, plasma glu-ose, risk of type 2 diabetes) betweenntervention and control groups. Thextent to which lifestyle changes andisk reduction remained after discon-inuation of active counseling wastudied in a follow-up to the Finnishiabetes Prevention study (32). The

ncidence of diabetes and body weightas examined for a total of 7 years.he relative risk for developing type 2iabetes remained significantly lessn individuals who were in the life-tyle intervention group and was re-ated to the success in maintainingeight loss; eating a low-fat, high-fi-er diet; and engaging in physical ac-ivity. These findings are encouragingut behavior therapy’s effectivenessor long-term weight maintenanceas not been shown in the absence ofontinued behavioral intervention12). Long-term follow-up of patientsndergoing behavior therapy shows aeturn to baseline weight in the greatajority of subjects in the absence of

ontinued behavioral intervention (12).Although these studies have limita-

ions (ie, participant-clinician contactnd instruction was greater in the in-ervention groups; therefore, thesetudies do not simulate treatment inhe real world because of their highntensity and frequency), these well-esigned efficacy studies show thatehavioral treatment in combinationith low-energy, low-fat diets haveositive effects on weight controlnd, more importantly, on comorbidonditions.

As a means to determine whether r

he results of lifestyle interventiontudies can be replicated in the realorld, researchers designed the Goodgeing in Lahti Region Program, a

ifestyle implementation study de-igned for primary health care set-ings (65). Although the outcomesere less robust than more intensive

fficacy studies, favorable lifestylehanges were reported and weightain was prevented, suggesting onverall positive effect of lifestyleounseling in real-life settings. Addi-ional studies are needed to deter-ine the effectiveness of clinic-based

ehavioral treatment on weight gainrevention, weight loss, and weightaintenance.Findings from these studies sug-

est that cognitive behavioral ther-py combined with a healthful dietnd physical activity results in signif-cant weight loss in the short-term.ndividuals lose approximately 8% to1% of their initial body weight dur-ng the treatment phase (24 to 32eeks) but slowly regain weight over

ime (ie, approximately 4% to 8% and% to 4% of their initial body weightfter 48 and 72 weeks, respectively)66-69). Five years after treatment,0% or more of patients have re-urned to their baseline weight (68);owever, there is some evidence touggest that individuals who partici-ate in maintenance therapy (twice aonth for 1 year) after initial treat-ent maintain most of their weight

oss at follow-up (ie, approximately0% and 8% of their initial bodyeight after 48 and 72 weeks, respec-

ively) (69-73).trategies for Augmenting Outcomes. Al-hough cognitive behavioral treat-ent provides individuals with a set

f skills to handle barriers to eatingealthfully and being active, over-oming barriers is a difficult endeavorn a fast-paced environment that en-ourages overconsumption of energy-ense, palatable, low-cost foods andromotes energy-saving devices (8). Aealthful lifestyle requires significantlanning, proficiency in making ap-ropriate choices and estimating por-ion sizes, and diligence in monitoringnergy intake and activity, all ofhich take time to develop and main-

ain. As such, strategies for simplify-ng and making this process moreractical by providing structure and

educing time spent in meal planning

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nd decision making (eg, meal re-lacements as described above) maye useful for some people.EAL Recommendation “A com-

rehensive weight management pro-ram should make maximum use ofhe multiple strategies for cognitiveehavioral therapy (ie, self-monitor-ng, stress management, stimulusontrol, problem solving, contingencyanagement, cognitive restructur-

ng, and social support). Cognitive be-avior therapy in addition to diet andhysical activity leads to additionaleight loss. Continued behavioral in-

erventions may be necessary to pre-ent a return to baseline weight”Rating: Strong, Imperative) (11).

Further research is needed to iden-ify the most potent components ofhe behavior modification package, asell as additional interventions (eg,ody image therapy) and counselingechniques (eg, motivational inter-iewing) that might be added to assistatients in making behavior changend to improve efficacy, especially inhe long term. It is possible that theres no single behavioral tool that worksest. Instead it may be more impor-ant to match behavioral tools withach individual’s unique set of char-cteristics. These are the type ofuestions that need further attentionnd research.

harmacotherapyurrent medications that have beenpproved by the Food and Drug Ad-inistration (FDA) for long-term

reatment of “clinically significant”besity (BMI �30 or BMI 27 to 29ith one or more obesity-related dis-rders) include sibutramine and orl-stat. These two medications haveeen evaluated in multiple random-zed controlled trials (44 for sibutra-

ine, 29 for orlistat). Medicationombined with lifestyle modifications more effective than placebo withifestyle modification in promotingeight loss in adults with overweightnd obesity (74). The safety and effi-acy of the currently approved drugherapies have not been evaluated inhildren or older adults and there isimited information on adolescents75).ibutramine. Sibutramine is a cen-rally acting serotonin and adrenergiceuptake inhibitor. Meta-analysis in-

icates an average loss of 4.5 kg more l

er year over placebo (74). Hyperten-ion and increased heart rate are po-ential complications so it is contrain-icated for individuals with knowneart disease, uncontrolled hyperten-ion, heart failure, stroke, and ar-hythmias. Sibutramine is also con-raindicated with monoamine oxidasenhibitors and other serotonin uptakenhibitors, which include medicationsor depression and migraine (76). Thevaluation of the reported cardiovas-ular effects has determined that theisk-benefit ratio remains favorable77).rlistat. Orlistat is a pancreatic lipasenhibitor that inhibits the absorptionf up to 30% of dietary fat (78). In the2 studies that reported 12-monthata, those treated with orlistat lost.89 kg more than those on placebo.teatorrhea, bloating and distension,nd anal leakage are potential sideffects if dietary fat is not restricted,nd one must be alert for possible fat-oluble vitamin deficiencies. With theong-term safety record that has beenchieved, orlistat has been approvedor over-the-counter sales at a re-uced dosage.hentermine. Phentermine is a sympa-homimetic anorexogenic agent andhe most widely prescribed weightoss agent in the United States; how-ver, its use is approved by the FDAor only 3 months (79). In the sixlacebo-controlled studies available,ublished between 1975 and 1999,he duration of treatment was be-ween 2 and 24 weeks with an aver-ge weight loss of 3.6 kg over pla-ebo. Side effects include insomnia,onstipation, and dry mouth. Inter-ittent dosage in a randomized con-

rolled trial produced greater weightoss than placebo (80).

The continued increase in the preva-ence of obesity speaks to the unmet

edical needs for safe and effectiveedications (81). Pharmacotherapy re-

earch is currently focusing on: centralervous system agents that affect neu-otransmitters, including antidepres-ants (bupropion), antiseizure agentstopiramate, zonisamide), and someopamine antagonists; leptin/insulin/entral nervous system agents, in-luding leptin analogues or promoters,iliary neurotropic factor (Axokine, Re-eneron Pharmaceuticals, Tarrytown,Y), neuropeptide-Y, and agouti–re-

ated peptides, �-melanocyte ana- a

February 2009 ● Journa

ogues, and adiponectin; gastroin-estinal-neural pathway agents toncrease cholecystokin or decreasehrelin activity; enhancers of energyxpenditure, UCP2 and UCP3 uncou-ling proteins, and thyroid receptorgonists; and inhibitors of fatty acidynthesis (82).Leptin has undergone phase two

esting, but data at this time do notndicate leptin has the potential to belinically useful for the modification ofeight status (83). Both Axokine (84)nd rimonabant (85,86) are in stagehree trials. Fenfluramine, alone or inombination with phentermine, pro-uced effective weight loss but seriouside effects resulted (87). This volun-ary medication withdrawal slowedffort for the use of combined medica-ions. Currently three trials of com-ined medications are in progress:nexa (topiramate�phentermine)

Vivus, Inc, Mountainview, CA), Ex-alia (bupropion�zonisamide) (Orexi-en Therapeutics, La Jolla, CA [nowalled Empatic]), and Contrave (bu-ropion�naltrexone) (Orexigen Ther-peutics, La Jolla, CA).Herbal preparations for weight loss

o not have standardized amounts ofctive ingredients and harmful effectsave been reported (88,89). Certainver-the-counter preparations contain-ng phenylpropanolamine (and relatedompounds) have no proven efficacyor short- or long-term weight lossnd are recalled because of the inci-ence of hemorrhagic stroke (90,91).phedrine plus caffeine, and fluox-tine have been tested for weightoss, but are not FDA-approved, andver-the-counter and herbal weightoss preparations are currently notecommended (75).It has been shown that small reduc-

ions in body weight (5%) can affectbesity-related comorbidities (92). Ifuch reductions are achieved withedications, data indicate that thoseedications be continued long-term

o maintain the change in weight sta-us (93). For those considering phar-acologic treatment for obesity, it

hould be noted that medications canead to modest weight losses at 1 to 2ears, but that data are not availablen long-term effectiveness and safety77).

When weight loss drugs are pre-cribed they should be only as part of

comprehensive treatment plan in-

l of the AMERICAN DIETETIC ASSOCIATION 339

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luding behavior therapy, diet, andhysical exercise (12).EAL Recommendation “FDA-ap-

roved weight loss medications maye part of a comprehensive weightanagement program. RDs should

ollaborate with other members ofhe health care team regarding these of FDA-approved weight lossedications for people who meet theHLBI criteria. Research indicates

hat pharmacotherapy may enhanceeight loss in some overweight andbese adults” (Rating: Strong, Im-erative) (11).

urgeryurgery, with its inherent structuralhange, clearly has an advantage inhe long-term success of weight main-enance. It is reserved for patientsith severe disease who have failed tond less invasive interventions suc-essful and are at high risk for obesity-elated morbidity and mortality. It ishat group with morbid obesity thatas increased 400% from 1983 to000 (94). The patient selection crite-ion established by the National In-titutes of Health for surgery is cur-ently a BMI of 40. If weight-relatedomorbidities like diabetes, hyperten-ion, and sleep apnea are present, aMI between 35 and 40 may be con-idered for a surgical procedure (12).xtending bariatric surgery to pa-

ients with BMIs of 30 to 34.9 whoave comorbid conditions that coulde cured or markedly improved byubstantial weight loss is under re-iew at this time (95).All data indicate that for the mor-

idly obese, bariatric surgery is theost effective therapy available foreight management and can result

n improvement or resolution of thebesity-related comorbidities andmproved quality of life (96). There-ore, it is important that RDs work-ng in weight management arenowledgeable about the commonurgical procedures, their mecha-isms of producing weight loss, asell as the complications and con-

erns. It is of note that surgical pro-edures to promote weight loss areontinually evolving. At the currentime there are four commonly usedrocedures to assist weight loss byestricting food intake and/or a com-ination of restricting intake and pro-

ucing malabsorption. Food intake c

40 February 2009 Volume 109 Number 2

ay be reduced by the placement ofn adjustable band that allows only amall amount of food to enter thetomach or by the removal of part ofhe stomach to produce a gastricleeve. Gastric bypass operations,oux-en-Y gastric bypass, and the ex-

ensive gastric bypass (biliopancre-tic diversion, with duodenal switch)reate a small pouch by stapling oremoval of portions of the stomach,nd also bypass the duodenum andther segments of the small intes-ines, thus producing malabsorptionlong with restriction. These proce-ures have acceptable operative riskrom 0.5% to 0.6% when performed bykilled surgeons (97-99). A fifth pro-edure, vertical banded gastroplasty,as decreased in use because weightaintenance has been problematic

100,101).Surgeon skill and a medical cen-

er’s bariatric surgery volume are im-ortant factors in evaluating surgicalutcomes. The American Society ofetabolic and Bariatric Surgery and

he American College of Surgeonsave established “Centers of Excel-

ence” on the basis of hospital vol-mes and surgical outcomes. Com-ared with centers that had �50ases, high volume centers with �100ases per year had lower mortality,horter length of stay, lower overallomplications, lower complications ofedical care and lower costs (102). A

ationwide, population-based sampleeported 21.9% complications duringhe initial hospitalization, which in-reased to 39.6% during the first 180ays (103). The definition of a compli-ation from the insurance recordsaried from an outpatient visit to aospital readmission. Such data withbroad interpretation of what is a

omplication contrast sharply withata from the centers of excellence. Aanadian group has established thateight-loss surgery significantly de-

reases mortality, 0.68% comparedith 6.17% in the nonoperated con-

rols as well as the development ofew health-related conditions in per-ons with morbid obesity (104). Swed-sh investigators have recently pub-ished their 10.9-year follow-up ofperated vs nonoperated controls,hich clearly shows long-term weight

oss maintenance and decreased over-ll mortality in those having a bariat-ic surgical procedure. Mortality from

ardiovascular disease and cancer n

ere reduced (105). In the Unitedtates, a 7.1-year follow-up of pa-ients with gastric bypass showed theroup receiving surgery had long-erm mortality reduced by 40% com-ared with the control population106). Vogel and colleagues reported aeduction in predicted coronary heartisease after bariatric surgery (107).heir report emphasized the impor-ance of significant and sustainedeight loss as a powerful intervention

o reduce future rates of myocardialnfarction and death in the morbidlybese. Data from the Canadian healthare system showed that long-termealth care costs were reduced after aariatric procedure and the initialosts of surgery were amortized over.5 years (108). Data are now avail-ble that with laparoscopic vs openrocedures, the duration of hospitaliza-ion has been decreased, wound compli-ations are lower, post operative pa-ient pain is reduced, and bowelunction normalizes more quickly (102,08,109).The effectiveness of different surgi-

al procedures comparing both opennd laparoscopically performed pro-edures on diverse populations byurgeons with different levels of ex-ertise is difficult to interpret. Forurposes of comparison, a range ofeight loss defined as percentage of

xcessive weight loss (change in BMI/riginal BMI�24) is commonly used97). The effectiveness of the surgicalrocedures for weight loss range from7.5% excessive weight loss for thedjustable gastric band, 61.6% for theastric bypass, 68.2% for gastro-lasty, and 70% for the biliopancre-tic diversion with or without theuodenal switch. As noted above, gas-roplasty is no longer frequently per-ormed because a high rate of weightegain is documented. The sleeve pro-edure is increasing in use as a pri-ary procedure for high-risk and

lderly patients or as an initial proce-ure for weight reduction to reduceurgical risk before a second stage of

gastric bypass or the duodenalwitch procedure. The excess weightoss reported for the sleeve at 1 yearpproximates 46% (110-113). It is ofote that surgery appears to rule overhe genetic component of weight sta-us in regard to weight loss responsesith surgery and weight mainte-

ance (114).

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It is important thatRDs working in

weight managementare knowledgeableabout the common

surgical procedures,their mechanisms of

producing weightloss, as well as thecomplications and

concerns.

Before surgery, patients should beully evaluated by a multidisciplinaryeam, including but not limited to aedical doctor, psychiatrist, and anD. The role of an RD is importanturing screening to evaluate weightistory, efforts to lose weight, foodreferences, and food-related behav-ors (ie, binge eating) to assist inlecting the optimal procedure for theatient. The patient must be in-ormed of the lifestyle changes neces-ary to decrease postoperative com-lications and maintain weight loss.eight loss surgery is more effectivehen accompanied by pre- and post-perative comprehensive therapy toodify eating, smoking, and exercise

ehavior. After surgery an RD maylay a vital role in promoting lifelongealth behavior change and adjust-ent to postsurgery dietary and sup-

lementation requirements. Suchdjunctive therapy increases the like-ihood of long-term success and shoulde a standard component of surgicaleight management (115,116). All pro-

edures require lifelong medical fol-ow-up and monitoring to avoid and

anage possible complications.Liposuction is another form of sur-

ery with a focus on adipose tissue.ts purpose generally is cosmetic, tolter body contours, and it usually isot considered as a surgical proce-ure for weight loss (117). Investiga-ors in this country have studied theffects of high-volume liposuction onnsulin action and risk of coronary ar-ery disease. They reported no im-rovement in metabolic abnormali-ies (118). This contrasts with the

ndings of other workers reporting k

mprovements in insulin resistancend inflammatory markers (119,120).EAL Recommendation “Dieti-

ians should collaborate with otherembers of the health care team re-

arding the appropriateness of bariat-ic surgery for people who have notchieved weight loss goals with less in-asive weight loss methods and whoeet the NHLBI criteria. SeparateDA evidence-based guidelines are be-

ng developed on nutrition care in bari-tric surgery” (Rating: Strong, Im-erative) (11).

EIGHT MAINTENANCEs demonstrated in the preceding sec-

ions, it is possible to lose weight us-ng a number of different strategies.owever, weight loss is only onehase of the weight management con-inuum. Prevention of weight gain (atny BMI level) and prevention ofeight regain (after a weight loss) an-

hor either end of this continuum.ach phase of the continuum possiblyequires a transition to a different setf strategies and/or skill set.The research on weight-loss main-

enance is relatively new and far fromonclusive with retrospective studiesf successful weight-loss maintainers121-125) and a small number of pro-pective studies (126-129). Issuesonfounding the evaluation of re-earch in this area include consensusn amount of weight loss, weight lossuration, time between weight lossnd evaluation of weight mainte-ance, and minimum length of weightaintenance (130). Successful weight-

oss maintenance may be an outcomehat is determined by multiple vari-bles, each contributing differently tosuccessful outcome. Such variablesight include factors impacting met-

bolic as well as behavioral responsesuch as initial weight loss, comorbidonditions, presence of depression,erception of weight loss success,evel of self-monitoring, level of phys-cal activity, type of intervention (in-luding frequency of contact), copingtyle, and stressful life events amongthers (123,129-133).The best studied metabolic compen-

atory responses occurring with weightoss is the concomitant decline in met-bolic rate that results in what haseen termed an energy gap (134). Thisnergy gap, estimated to be about 8

cal/lb lost/day, points to a post-weight

February 2009 ● Journa

oss need to chronically maintain aower energy intake or a combination ofowered energy intake and increasednergy expenditure—hence, the life-ong commitment portion of the posi-ion statement. However, as critical ast is for food and nutrition professionalso support their clients to preventeight regain, it is not yet clear whichaintenance strategy is best pre-

cribed for all individuals.

esponsibilities of Food and Nutritionrofessionals in Weight Managementany of the ideas expressed below

re not evidence-based but are thepinions of this writing group basedn experience and knowledge in theeld.An individual’s body weight is de-

ermined by a combination of genetic,etabolic, behavioral, environmen-

al, cultural, and socioeconomic influ-nces. These diverse influences makereating individuals with overweightnd obesity complex. Food and nutri-ion professionals must understandach of these aspects as they develop

shared decision-making relation-hip with clients. Food and nutritionrofessionals should also be aware ofheir own biases regarding individu-ls with this condition. In one study ofDs, 87% viewed individuals withbesity as self-indulgent and 32% in-icated that individuals with obesityacked willpower (135). These charac-erizations could affect the style ofounseling for clients with obesity.Food and nutrition professionals

hould understand the importance ofeight gain prevention and the chal-

enge of weight loss maintenance toffectively help their clients maintainormal weight and sustain long-termeight loss. Increased physical activ-

ty also appears to be key in success-ul weight loss maintenance (36).Ds, with their understanding of en-rgy balance and energy expenditurelong with their skills in teaching be-avior 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

l of the AMERICAN DIETETIC ASSOCIATION 341

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

As RDs counsel patients, they shoulde aware of the Scope of Dietetics Prac-ice Framework that helps them definehat range of services they can provideithin a practice setting. It is the pro-

essional responsibility of RDs to en-ure that competency is maintained torovide safe and effective services tolients with overweight and obesity136).

RDs must remain current on topicselated to the treatment and manage-ent of patients with obesity, includ-

ng the knowledge and skills that areequired to counsel patients abouthysical activity.This may involve an understanding

f when patients with obesity shoulde referred to a certified exercise pro-essional or other appropriate healthare provider. Guidance on the situa-ions that may require a referral to anxercise professional and appropriateecommendations for physical activ-ty for adults with overweight andbesity are available through themerican College of Sports Medicine,ith updated guidelines to be re-

eased by the American College ofports Medicine in February 2009

137). Every opportunity to increaseeight management skills should be

aken. Attending workshops andymposiums, such as the Certificatef Training in Adult or Pediatriceight Management sponsored by

he ADA Commission on Dietetic Reg-stration, with program content fo-used on all aspects of obesity, is ad-ised.

eimbursement for Obesity Treatment.hird-party payers cover treatmentonditions caused by obesity andometimes pay for bariatric surgery,ut there is little reimbursement forrevention or treatment of obesityithout comorbidities. For obesity toe recognized and covered by third-arty payers, health professionals, in-luding RDs, must supply scientificvidence that a treatment works tomprove health outcomes of the bene-ciary. Insurers and the public muste presented with effective weightanagement approaches along with

roof that they work. RDs should im-lement the science-based weight

anagement practice guidelines that

42 February 2009 Volume 109 Number 2

ave been developed for both adultsnd children. RDs need to demon-trate the cost-effectiveness of thetrategies with well-designed studiesnd should use the medical nutritionherapy reimbursement strategies foriabetes and renal diseases as aodel for obesity coverage (138).

ole of RDs in Providing Carehe partnership between RDs andheir patients should focus on devel-ping strategies that will enhance op-ortunities for clients to control theirwn behaviors related to overweightr obesity. Incorporating various be-avioral techniques into weight lossounseling is a recommended ap-roach (14). RDs need to use theirkills and knowledge to support andncourage clients with their weightoss efforts.

If RDs work only with physicians orteam that includes a coordinated

roup of health professionals with aariety of skills, they should work ef-ectively with the team to achieve theest outcome for the patient. Commu-ication with other health care pro-iders on the team is essential to ac-ommodate the different needs ofach patient. Understanding when toefer patients to other health careroviders is important in managingatients’ needs (14).Within the past several years vari-

us committees, foundations, govern-ental agencies, and professional

ssociations have addressed the in-reasing prevalence of obesity andverweight in our country. Each ofhese investigations resulted in a re-ort including action steps or recom-endations, many of them related to

elping the American public achieveore healthful diets and increasing

hysical activity. The 2005 Dietaryuidelines addressed the issue by

tressing the necessity of energy bal-nce for weight maintenance and forhe first time the importance of phys-cal activity (19). In F as in Fat: Howbesity Policies are Failing in Amer-

ca 2007 (139), there are two recom-endations that relate directly to

ood and nutrition professionals:

helping all Americans become morephysically active, andhelping Americans choose more

healthful foods. c

For food and nutrition profession-ls to have a substantial influence inchieving these goals, we are chal-enged to develop new innovative andold approaches for the preventionnd treatment of obesity. The futurearadigm will involve population-ased interventions that will requirehe full cooperation of the entireealth care community. The coordi-ated integration of expertise fromifferent health care disciplines, en-ompassing a diversity of skills, isecessary to develop innovative wayso tackle the obesity problem. Be-ause RDs are the primary nutritionractitioners, they should share theeadership role with other health pro-essionals in stemming the tide of thisbesity epidemic.

The partnershipbetween RDs and

their patients shouldfocus on developingstrategies that will

enhance opportunitiesfor clients to controltheir own behaviors

related to overweightor obesity.

Much of the literature also stresseshe importance of working coopera-ively with relevant governmentgencies, appropriate medical andcientific organizations, employer or-anizations, unions, educational au-horities, and the media. In 2001, theurgeon General’s Call to Action

dentified a public health approach toalting the obesity epidemic in ourountry (140). The Call to Actiondentified key actions, one of whichas to encourage partnerships be-

ween health care providers, schools,aith-based groups, and other commu-ity organizations in prevention ef-orts targeted at social and environ-ental causes of overweight and

besity.RDs are encouraged to participate in

utrition advocacy at the local, state,nd national levels to encourageealthful eating and lifestyle behav-

ors. More importantly they should be-

ome involved in action programs that

srstso

Ttant

R

upport healthful eating at the grass-oots level. RDs have the necessarykills and broad educational prepara-ion to contribute effectively to partner-hips that are focused on stemming thebesity epidemic.

he authors thank the reviewers forheir many constructive commentsnd suggestions. The reviewers wereot asked to endorse this position orhe supporting paper.

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44 February 2009 Volume 109 Number 2

ilehto J. Prevention of diabetes mellitus insubjects with impaired glucose tolerance inthe Finnish Diabetes Prevention Study:Results from a randomized clinical trial.J Am Soc Nephrol. 2003;14:S108-113.

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ADA Position adopted by the House of Delegates Leadership Team on October 20, 1996 and reaffirmed onSeptember 12, 1999 and June 30, 2005. This position is in effect until December 31, 2013. ADA authorizesrepublication of the position, in its entirety, provided full and proper credit is given. Readers may copy anddistribute this paper, providing such distribution is not used to indicate an endorsement of product or service.Commercial distribution is not permitted without the permission of ADA. Requests to use portions of the positionmust be directed to ADA headquarters at 800/877-1600, ext 4835, or ppapers@eatright.org.

Authors: Helen M. Seagle, MS, RD (consultant, Denver, CO); Gladys Witt Strain, PhD, RD (Weill College ofMedicine of Cornell University, New York, NY); Angela Makris, PhD, RD (consultant, Huntingdon Valley, PA);Rebecca S. Reeves, DrPH, RD (Behavioral Medicine Research Center, Houston, TX).

Reviewers: Sharon Dalton, PhD, RD (New York University, New York, NY); Sharon Denny, MS, RD (ADAKnowledge Center, Chicago, IL); Molly Gee, MEd, RD (Baylor College of Medicine, Houston, TX); NutritionEntrepreneurs dietetics practice group (Cathy Leman, RD, LD, NutriFit, Inc, Glen Ellyn, IL); Sports, Cardiovas-cular, and Wellness Nutritionists dietetics practice group (Pamela M. Nisevich, MS, RD, LD, Nutrition for theLong Run, Beavercreek, OH, and Dayton Children’s Medical Center, Dayton, OH); Esther Myers, PhD, RD, FADA(ADA Scientific Affairs, Chicago, IL).

Association Positions Committee Workgroup: Helen W. Lane, PhD, RD (chair); Naomi Trostler, PhD, RD; JamesO. Hill, PhD (content advisor).