Nutrition Interventions and Weight Loss Anne Wolf, MS, RDN Academy of Nutrition and Dietetics
Academy s Position Statement: Successful treatment of overweight and obesity in adults requires adoption and maintenance of lifestyle behaviors contributing to both dietary intake and physical activity. These behaviors are influenced by many factors; therefore, interventions incorporating more than one level of the socioecological model and addressing several key factors in each level may be more successful than interventions targeting any one level and factor alone. J Acad Nutr Diet. 2016;116:129-147
Comprehensive Weight Management Program Reduced calorie diet Increased physical activity Behavioral strategies Medication and/or surgery when indicated
Weight Management in the Diabetes Prevention Program 4 Motivated individuals Change in Weight (kg) 2 0-2 -4-6 Structured diet and activity curriculum Frequent visits with a lifestyle interventionalist Use of daily food and activity records Social support/problem solving Placebo Lifestyle -8 0 0.5 1 1.5 2 2.5 3 3.5 4 Year Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393-403.
Combining Lifestyle Modification and Sibutramine Results Across One Year 0 2 4 Sibutramine alone Weight Loss (kg) 6 8 10 12 14 Lifestyle modification alone Sibutramine + brief therapy Combined therapy 16 0 3 6 10 18 26 40 52 Weeks Wadden, Berkowitz, Womble, et al. N Engl J Med. 2005;353:2111-2120.
Addition of RD visit to Bariatric Surgery Greater weight loss at 6 mos 1 (some studies) Lower number of minor complications 2 Reduced readmission due to dietary-related problems 3 Improvement in serum thiamine, HDL & TG 3 1. Nijamkin MP, Campa A, Sosa J et al. J Acad Nutr Diet 2012;112:3(383-90. 2. Singhal R, Kitchen M, Bridgwater S, Super P.. Surg Endosc 2010;24(6)1268-73. 3. Garg, T, Birge K, Bosas BA, Azagury D, Rivas H, Morton JM. Surg Obes Relat Dis 2016;00-00.
Intrapersonal-Level Obesity Intervention All Adults Annually Height, Weight, BMI, Waist Circumference Overweight or Obese Adults Referral to RDN for medical nutrition therapy Nutrition assessment, diagnosis, intervention, monitoring and evaluation Interventions target intrapersonal-level factors that assist with changing energy balance behaviors 7
Intrapersonal-Level Obesity Intervention Assessment Food and nutrition-related history Anthropometric measures Biochemical data, medical tests and procedures Nutrition-focused physical findings Client History Energy intake and nutrient content If indirect calorimetry is not available, use RMR Mifflin-St. Jeor equation; actual weight used Motivation, readiness and self-efficacy Dietary Intervention -- one of the following: 1,200 kcal to 1,500 kcal (women); 1,500 kcal to 1,800 kcal (men) Energy deficit of 500 to 750 kcal/day One of the evidence-based diets that restrict certain food types 8
Evidence-base for Dietary Interventions Diet RCT Evidence Suppor3ve RCT Evidence- Not Suppor3ve Lacking RCT Evidence Increasing fruits & vegetables Decreasing sugar- sweetened beverages Decreasing fast food Por:on Control Low- calorie diet Meal replacement/structured meal plans Very low- calorie diet Low- carbohydrate diet Low glycemic index/load with energy restric:on High Protein with energy restric:on Energy density approach DAHS with energy restric:on Mediterranean with energy restric:on Ea:ng Frequency Timing of ea:ng Breakfast consump:on 9
Physical Activity Weight Loss 150 to 420 minutes or more per week depending on intensity Weight Maintenance 200 to 300 minutes or more per week depending on intensity 10
RDN Change Tools Behavioral Change Self monitoring Motivational interviewing Structured meal plans and meal replacements Portion control Goal setting Problem solving Behavioral Therapy Strategies Cognitive restructuring Contingency management Relapse prevention techniques Slowed rate of eating Social support Stress management Stimulus control and cue reduction 11
Nutrition Intervention Recommendations Weight Loss 14 MNT encounters Individual or group At least 6 months Weight Loss Maintenance Monthly MNT encounters At least 1 year 12
MNT for Weight Management: The Payment Landscape The Good News Expanded coverage under private payers, Medicaid and plans sold in the state marketplaces due to the ACA USPSTF Grade B recommendations for obesity screening and counseling for adults and children 18 state Medicaid programs cover nutrition counseling for obesity No cost-sharing As of 1/1/2011, Medicare covers Intensive Behavioral Therapy for Obesity Alternative payment models provide financially viable opportunities to incorporate MNT services for weight management
MNT for Weight Management: The Payment Landscape The Not-So-Good News No standardized coverage Recognized providers, place of service, number of encounters, length of encounters, CPT/ICD-10 codes vary by payer and by plan Medicare does not recognize RDNs as direct providers for IBT for Obesity services Catch-22 for bariatric surgery patients Surgery not covered without prior attempts at weight loss, but payer may not cover MNT services Payers require pre-op nutrition evaluation but may not cover this service Limitations on provider networks
Alliance Healthier Generation Benefit Prevention, Assessment & Treatment The Alliance for a Healthier Generation convened national medical associations, leading insurers and employers to offer comprehensive health benefits to children and families for the prevention and treatment of childhood obesity. Insurers and employers offer: at least four follow up appointments with a primary care provider at least four visits with a registered dietitian nutritionist
Thank you! Questions?