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
Cha
nge
in W
eigh
t (kg
)
Year
Placebo
Lifestyle
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
-8
-6
-4
-2
0
2
4
0 0.5 1 1.5 2 2.5 3 3.5 4
Wei
ght L
oss
(kg)
0
2
4
6
8
10
12
14
16
Weeks 0 3 6 10 18 26 40 52
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
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
9
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
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
• 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!
Top Related