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Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults

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Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults FROM THE ACADEMY Position Paper Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults ABSTRACT POSITION STATEMENT It is the position of the Academy of Nutrition and Dietetics that successful treatment of It is the position of the Academy of Nutrition overweight and obesity in adults requires adoption and maintenance of lifestyle be- and Dietetics that successful treatment of overweight and obesity in adults requires haviors contributing to both dietary intake and physical activity. These behaviors are adoption and maintenance of lifestyle be- influenced by many factors; therefore, interventions incorporating more than one level haviors contributing to both dietary intake of the socioecological model and addressing several key factors in each level may be and physical activity. These behaviors are fl more successful than interventions targeting any one level and factor alone. Registered in uenced by many factors; therefore, in- terventions incorporating more than one dietitian nutritionists, as part of a multidisciplinary team, need to be current and skilled level of the socioecological model and in weight management to effectively assist and lead efforts that can reduce the obesity addressing several key factors in each level epidemic. Using the Academy of Nutrition and Dietetics’ Evidence Analysis Process and may be more successful than interventions Evidence Analysis Library, this position paper presents the current data and recom- targeting any one level and factor alone. mendations for the treatment of overweight and obesity in adults. Evidence on intra- personal influences, such as dietary approaches, lifestyle intervention, pharmacotherapy, and surgery, is provided. Factors related to treatment, such as in- tensity of treatment and technology, are reviewed. Community-level interventions that strengthen existing community assets and capacity and public policy to create envi- ronments that support healthy energy balance behaviors are also discussed. J Acad Nutr Diet. 2016;116:129-147. HE PURPOSE OF THIS ARTICLE evidence focuses as much as possible This Academy position paper includes the is to provide an update to the on systematic reviews and/or meta- authors’ independent review of the litera- 2009 position paper on adult analyses, randomized controlled trials ture in addition to systematic review con- weight management and (RCTs), and other evidence-based ducted using the Academy’sEvidence T ’ incorporate the revised Academy s guidelines. Analysis Process and information from evidence-based adult weight- In 2012, 34.9% of adults in the United the Academy’sEvidenceAnalysisLibrary management guidelines from the Evi- States were obese and another 33.6% (EAL). Topics from the EAL are clearly delineated. For a detailed description of dence Analysis Library (EAL) and the were overweight.2 The high prevalence the methods used in the Evidence Analysis 2013 American Heart Association, of overweight and obesity in the Process, go to www.andevidencelibrary. American College of Cardiology, and United States negatively affects the com/eaprocess. The Obesity Society (AHA/ACC/TOS) health of the population, as obese in- Recommendations are assigned a rat- Guideline for the Management of Over- dividuals are at increased risk for ing by an expert work group based on the weight and Obesity in Adults.1 The developing several chronic diseases, grade of the supporting evidence and the balance of benefit vs harm. Recommen- scope of the paper has been expanded such as type 2 diabetes, cardiovascular dation ratings are Strong, Fair, Weak, to include a socioecological approach disease (CVD), and certain forms of Consensus, or Insufficient Evidence. 1,3 and provide evidence regarding cancer. Because of its impact on Recommendations can be worded as community-based and policy-level in- health, medical costs, and longevity, conditional or imperative statements. terventions designed to reduce the reducing obesity is considered to be a Conditional statements clearly define a fi prevalence of overweight and obesity public health priority.4 speci c situation and most often are stated as an “if, then” statement, while in communities in the United States. Weight loss of only 3% to 5% that is imperative statements are broadly appli- Within those areas in which various in- maintained has the ability to produce cable to the target population without terventions are described, included clinically relevant health improve- restraints on their pertinence. ments (eg, reductions in triglycerides, Evidence-based information for this and blood glucose, and risk of developing other topics can be found at www. 2212-2672/Copyright ª 2016 by the type 2 diabetes).1 Larger weight loss andevidencelibrary.com and subscriptions Academy of Nutrition and Dietetics. for nonmembers can be purchased at reduces additional risk factors of CVD http://dx.doi.org/10.1016/j.jand.2015.10.031 www.andevidencelibrary.com/store.cfm. (eg, low-density and high-density ª 2016 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 129 FROM THE ACADEMY lipoprotein cholesterol and blood expenditure, in the minimum to meet be outside of awareness, is not associ- pressure) and decreases the need for the 2008 Physical Activity Guidelines ated with enhanced satiation, and medication to control CVD and type 2 for Americans (150 minutes per week compensation does not appear to occur diabetes. Thus, a goal of weight loss of of moderate-intensity, or 75 minutes over time. 5% to 10% within 6 months is per week of vigorous-intensity physical recommended.1 activity)8 and ideally to meet the FACTORS INFLUENCING EAL Recommendation: “The regis- American College of Sports Medicine’s ENGAGING IN MODERATE- TO tered dietitian nutritionist (RDN) Position Stand for weight-loss mainte- VIGOROUS-INTENSITY PHYSICAL > should collaborate with the individual nance ( 250 minutes/wk of moderate- ACTIVITY regarding a realistic weight-loss goal intensity physical activity),9 and As with food intake, there are internal such as one of the following: up to 2 lb enhance cardiovascular fitness. Preser- and external factors that influence how per week, up to 10% of baseline body vation of changes in lifestyle behaviors much moderate- to vigorous-intensity weight, or a total of 3% to 5% of baseline is required to achieve successful physical activity (MVPA) one engages weight if cardiovascular risk factors weight-loss maintenance.10 in. Internally, physical limitations and (hypertension, hyperlipidemia, and discomfort and beliefs about how hyperglycemia) are present.” (Rating: FACTORS INFLUENCING FOOD MVPA influences health have been Strong, Imperative) 13 INTAKE related to amount of MVPA achieved. Mood and, specifically, core affective Eating behavior is generally believed to valence (eg, good/bad feelings) in GOALS OF ADULT OBESITY be influenced by both internal and response to engaging in MVPA are TREATMENT external cues.11,12 Internally, two sys- related to future physical activity.14 While intentional weight loss of at tems have been identified that assist Also as engaging in regular MVPA in- least 3% to 5% improves some clinical with regulating intake.11 The first sys- volves consistently making decisions to parameters,1 to sustain these im- tem is the homeostatic system, in engage in a behavior that requires costs provements, this degree of weight loss which neural, nutrient, and hormonal to achieve the long-term cumulative needs to be maintained. While there is signals allow communication between health benefits, it is theorized that no standard definition for length of the gut, pancreas, liver, adipose tissue, strong executive control and optimized time for maintenance of weight loss for brainstem, and hypothalamus. The brain structures supporting executive it to be considered successful, duration arcuate nucleus of the hypothalamus functioning (ie, dorsolateral prefrontal of 1 year is often used.5 While long- integrates these signals and regulates cortex) is an important internal term weight-loss maintenance is one hunger, satiation, and satiety in factor.15 of the challenges in obesity treatment, response to the signals via higher The social and physical environ- it is possible. For example, the Look cortical centers that influence the ments are also believed to be factors AHEAD (Action for Health in Diabetes) sympathetic and parasympathetic ner- that influence engaging in MVPA. How trial, an RCT with >5,000 adults with vous system, gastric motility and hor- supportive other individuals are to type 2 diabetes, reported that 39.3% of mone secretion, and other processes MVPA efforts and the potential inter- the 825 participants who received a relevant to energy homeostasis. The action with others who are active are lifestyle intervention (consisting of a second internal system is the hedonic external factors that can promote reduced-energy dietary and physical system, which is influenced by the physical activity.13 Different physical activity prescription, and a cognitive hedonic (“liking”) and rewarding environmental dimensions, such as behavioral intervention) who lost at (“wanting”) qualities of food and is walkability, land use, public trans- least 10% of their body weight at year 1 regulated by the corticolimbic sys- portation availability, safety, and aes- maintained at least a 10% weight loss at tem.11,12 It is through the hedonic sys- thetics, in residential and/or work year 8, and another 25.8% maintained a tem that environmental
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