The Academy of Nutrition and Dietetics has recently released “Medical Nutrition Therapy (MNT) Interventions for Adult Overweight and Obesity Treatment: An Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guideline”. These clinical practice guidelines are meant to guide registered dietitian nutritionists to best practices to improve health outcomes based on current research that has been rigorously tested and reviewed. In addition, guidelines should also aim to minimize harm, especially if research is inconclusive or conflicting.
Of the 13 key recommendation statements released by The Academy, three statements related to weight stigma and bias stand out as particularly inappropriate. With research that is conflicting, inconclusive, and harmful to the patient or individual, we must act to protect clients and to voice our concerns. The 3 key recommendations are listed below, along with explanations as to why they are problematic.
Please note that these guidelines use the terms overweight and obesity, as well as mention specific calorie ranges. Although we do not agree with the medicalization of larger bodies and do not support the use of weight stigmatizing language, the terms overweight and obesity will be used below in order to minimize confusion when responding to recommendations. If these terms and numbers may be triggering to you, please scroll all the way to the bottom to access the public comments survey.
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4.1 For adults with overweight or obesity, RDNs should include the following components as part of a comprehensive, multi-component MNT (medical nutrition therapy) intervention to improve anthropometric outcomes, blood pressure and quality of life:
- Reduced calorie diet;
- Behavioral strategies, including self-monitoring (diet, physical activity, weight) (1C).
4.3 For adults with overweight or obesity, RDNs or international equivalents should prescribe a diet individualized to client preferences and health status to achieve and maintain nutrient adequacy and reduce caloric intake based on one of the following caloric reduction strategies to improve BMI, percent weight loss and waist circumference without significant adverse events:
- 1,200-1,500 kcal per day for women and 1,500-1,800 kcal per day for men (kcal levels should be adjusted for the individual clients’ body weight, activity level, and preference);
- Energy deficit of approximately 500-750 kcal per day;
- Evidence-based diets that replace high energy-dense foods with low energy-dense foods (1C).
Research indicates that a reduced calorie diet does not lead to long term (e.g. more than 18 months) sustained weight loss, with some studies indicating that individuals who diet are more likely to regain more weight than they lost on a calorie restrictive diet (Mann et al., 2007). In addition, a reduced calorie diet has shown to have negative health impacts such as distractibility and irritability in the short term and is linked with increased anxiety and depression in the long term (Polivy, 1996). There is no research that indicates that calorie restriction improves quality of life, as suggested by this key recommendation. Extreme calorie restriction can also lead to nutrient deficiencies, metabolic resistance and a higher incidence of eating disorders (Natenshon, 2020). If we are operating under the assumption that weight loss leads to improved health outcomes, it’s also important to note that studies assessing the efficacy of diets do not show evidence of health improvements and are ineffective at obesity prevention (Mann et al, 2007; Fildes et al., 2015). Self- monitoring of diet, physical activity and weight is a risk factor for and predictive of an eating disorder diagnosis (Hahn et al., 2021). To assume that those in larger bodies should accept the health risk associated with calorie restriction and health monitoring in the pursuit of weight loss and absent of other important health markers, is exemplary of the damaging weight stigma that is pervasive in obesity prevention and treatment efforts.
4.6 For adults with overweight or obesity, it is suggested that RDNs or international equivalents not use a Health at Every Size® or Non-Diet approach to improve BMI and other cardiometabolic outcomes or quality of life (2D).
Weight inclusive approaches to health have been shown to improve physical health metrics such as blood pressure, behavioral health outcomes such as reduction in binge eating, and psychological health improvements such as a reduction in depression (Tylka et al., 2014). Furthermore, no research has indicated that a weight neutral approach has ever harmed a client’s health or well-being (Association of Size Diversity and Health, 2022).
Excluding weight inclusive approaches such as Health at Every Size (HAES), ignores and dismisses the very real health benefits these frameworks offer. In addition, weight normative approaches to working with clients and patients (e.g., dieting and calorie restriction) have been shown to have health consequences such as weight cycling and increased risk for eating disorders (Bacon & Aphramor, 2011). Furthermore, weight-based approaches to health foster weight stigma, a correlate of adverse health and well-being (Tylka et al., 2014). As such, there are considerable ethical considerations of promoting treatment that may be damaging and excluding treatment that has no known negative health impacts.
Banning HAES and other non-diet approaches are detrimental to clients and further emphasizes the sizeist approach to body and weight within the nutrition and dietetics field.
To read more about the Association for Size Diversity and Health’s response to this key recommendation, click here.
Take Action!
As these recommendations are harmful, may exacerbate eating disorders or disordered eating, and are not in the best interest of all patients, The Alliance is asking you to provide feedback to The Academy through their public comments survey. Public comments close on March 25th, so please submit your feedback before then.
Suggested responses to the survey questions are:
- Do the recommendations cover issues that patients, their families, and caregivers consider important? No
- Do the recommendations take account of the choices and preferences of people affected by the guideline? No
- Do the recommendations use wording that is clear, easy to follow and respectful? No
- Do the recommendations include anything that people affected by the guideline topic might find unacceptable? Yes
- Please provide additional comments. The key recommendation strategies 4.1 and 4.3 are not grounded in research about the harms of calorie restriction on both physical and mental health. As strategies should reduce risk and harm, calorie reduction strategies should not be included. HAES and non-diet approach principles were mischaracterized in the review and assessment conducted. Furthermore, there were many limiting inclusive and exclusion criteria that biased results and interpretation of the review. The exclusion of HAES in the key recommendation of 4.6 is inappropriate and should be redacted.
References
- Association of Size Diversity and Health (2022) An Open Letter to the Academy of Nutrition and Dietetics. Retrieved from https://asdah.org/an-open-letter-to-and/
- Bacon, L., & Aphramor, L. (2011). Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutrition Journal, 10(9), 13.
- Fildes, A., Charlton, J., Rudisill, C., Littlejohns, P., Prevost, A. T., & Gulliford, M. C. (2015). Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records. American Journal of Public Health, 105(9), e54–e59. https://doi.org/10.2105/AJPH.2015.302773
- Hahn, S., Bauer, K. W., Kaciroti, N., Eisenberg, D., Lipson, S. K., & Sonneville, K. R. (2021). Relationships between patterns of weight‐related self‐monitoring and eating disorder symptomatology among undergraduate and graduate students. The International Journal of Eating Disorders, 54(4), 595–605. https://doi.org/10.1002/eat.23466
- Mann, T., Tomiyama, A. J., Westling, E., Lew, A.-M., Samuels, B., & Chatman, J. (2007). Medicare’s search for effective obesity treatments: Diets are not the answer. American Psychologist, 62(3), 220–233. https://doi.org/10.1037/0003-066X.62.3.220
- Natenshon, A. H. (2020). Discretion or Disorder? The Impact of Weight Management Issues on the Diagnosis and Treatment of Disordered Eating and Clinical Eating Disorders. In H. Himmerich (Ed.), Weight Management. IntechOpen. https://doi.org/10.5772/intechopen.92152
- Polivy, J. (1996). Psychological Consequences of Food Restriction. Journal of the American Dietetic Association, 96(6), 589–592. https://doi.org/10.1016/S0002-8223(96)00161-7
- Tylka, T. L., Annunziato, R. A., Burgard, D., Daníelsdóttir, S., Shuman, E., Davis, C., & Calogero, R. M. (2014). The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss. Journal of Obesity, 2014, 1–18. https://doi.org/10.1155/2014/983495