Anne Wolf, MS, RDN Academy of Nutrition and Dietetics

Nutrition Interventions and Weight Loss

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

•  Reduced calorie diet

•  Increased physical activity

•  Behavioral strategies •  Medication and/or surgery when

indicated

Comprehensive Weight Management Program

Weight Management in the Diabetes Prevention Program

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Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393-403.

•  Motivated individuals

•  Structured diet and activity curriculum

•  Frequent visits with a lifestyle interventionalist

•  Use of daily food and activity records

•  Social support/problem solving

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Sibutramine alone

Lifestyle modification alone Sibutramine + brief therapy

Combined therapy

Wadden, Berkowitz, Womble, et al. N Engl J Med. 2005;353:2111-2120.

Combining Lifestyle Modification and Sibutramine – Results Across One Year

•  Greater weight loss at 6 mos1 (some studies)

•  Lower number of minor complications2

•  Reduced readmission due to dietary-related problems3

•  Improvement in serum thiamine, HDL & TG3

Addition of RD visit to Bariatric Surgery

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

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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

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Diet   RCT  Evidence  Suppor3ve  

RCT  Evidence-­‐Not  Suppor3ve  

Lacking  RCT  Evidence  

   Increasing  fruits  &  vegetables   X  

   Decreasing  sugar-­‐sweetened  beverages   X  

Decreasing  fast  food   X  

Por:on  Control   X  

Low-­‐calorie  diet   X  

Meal  replacement/structured  meal  plans   X  

Very  low-­‐calorie  diet   X  

Low-­‐carbohydrate  diet   X  

Low  glycemic  index/load  with  energy  restric:on  

X  

High  Protein  with  energy  restric:on   X  

Energy  density  approach   X  

DAHS  with  energy  restric:on   X  

Mediterranean  with  energy  restric:on   X  

Ea:ng  Frequency   X  

Timing  of  ea:ng   X  

Breakfast  consump:on   X  

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

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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

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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

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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

•  at least four follow up appointments with a primary care provider

•  at least four visits with a registered dietitian nutritionist

Insurers  and  employers  offer:  

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.  

Questions?

Thank you!