Canadian Adult Obesity Clinical Practice Guidelines 1

KEY MESSAGES FOR HEALTHCARE PROVIDERS

• Healthy eating is important for all Canadians, regardlessofbodysize,weightorhealthstatus.KeymessagesfromCanada’s Food Guide for Healthy Eating can be used as a foundation fornutritionandfood-relatededucation.Useevidence-based nutrition resources to give your patientsnutrition and behaviour-change advice that aligns withtheirvalues,preferencesandsocialdeterminantsofhealth(Figure1).

• Thereisnoone-size-fits-alleatingpatternforobesityman-agement.Adults livingwithobesitymayconsidervariousnutrition interventionoptions that are client-centredandflexible.Evidencesuggeststhisapproachwillbetterfacilitatelong-termadherence(Table1,Figure2).

• Nutritioninterventionsforobesitymanagementshouldfo-cusonachievinghealthoutcomesforchronicdiseaseriskreductionandqualityoflifeimprovements,notjustweightchanges.Table2outlineshealth-relatedoutcomestosup-portpatients/clientsinobesitymanagement.

• Nutrition interventions for obesity management shouldemphasize individualized eating patterns, food qualityand a healthy relationshipwith food. Includingmindful-ness-basedeatingpracticesthatmayhelplowerfoodcrav-ings,reducereward-driveneating,improvebodysatisfactionandimproveawarenessofhungerandsatiety.

• Caloric restriction can achieve short-term reductions inweight(i.e.,<12months)buthasnotshowntobesustain-ablelong-term(i.e.,>12months).Caloricrestrictionmayaffectneurobiologicalpathwaysthatcontrolappetite,hun-ger,cravingsandbodyweightregulationthatmayresultinincreasedfoodintakeandweightgain.

• Peoplelivingwithobesityareatincreasedriskformicronu-trientdeficienciesincludingbutnotlimitedtovitaminD,vi-taminB12andirondeficiencies.Restrictiveeatingpatternsandobesitytreatments(e.g.medications,bariatricsurgery)may also result in micronutrient deficiencies and malnu-trition. Assessment including biochemical values can helpinform recommendations for food intake, vitamin/mineralsupplementsandpossibledrug-nutrientinteractions.

• Collaborate carewith a registered dietitianwho has ex-perience in obesity management and medical nutritiontherapy.Dietitianscansupportpeople livingwithobesitywhoalsohaveotherchronicdiseases,malnutrition, foodinsecurityordisorderedpatternsofeating.

• Futureresearchshouldusenutrition-relatedoutcomesandhealthbehavioursinadditiontoweightandbodycompo-sition outcomes. Characterization of population samplecollections should use the updated definition of obesityas“a complex chronicdisease inwhichabnormalor ex-cessbodyfat(adiposity) impairshealth, increasestheriskoflong-termmedicalcomplicationsandreduceslifespan”ratherthanBMIexclusively.Qualitativedata isneededtounderstandthelivedexperienceofpeoplewithobesity.

Medical Nutrition Therapy in Obesity Management JenniferBrownRDMSci,CarolClarkeRDMHScii, CarleneJohnsonStoklossaiii,JohnSievenpiperMDPhDiv

i) TheOttawaHospitalBariatricCentreofExcellenceii) Privatepracticeiii) AlbertaHealthServicesiv) FacultyofMedicine,UniversityofToronto

Cite this Chapter

BrownJ,ClarkeC,JohnsonStoklossaC,SievenpiperJ.CanadianAdultObesityClinicalPracticeGuidelines:MedicalNutritionTherapyinObesityManagement.Availablefrom:https://obesitycanada.ca/guidelines/nutrition.Accessed[date].

Update History

Version1,August4,2020.AdultObesityClinicalPracticeGuidelinesarealivingdocument,withonlythelatestchapterspostedat obesitycanada.ca/guidelines.

Canadian Adult Obesity Clinical Practice Guidelines 2

RECOMMENDATIONS

1.We suggest that nutrition recommendations for adults ofallbodysizesshouldbepersonalizedtomeetindividualval-ues,preferencesand treatmentgoals to supportadietaryapproachthatissafe,effective,nutritionallyadequate,cul-turallyacceptableandaffordable for long-termadherence(Level4,GradeD).5

2.Adultslivingwithobesityshouldreceiveindividualizedmedi-calnutritiontherapyprovidedbyaregistereddietitian(whenavailable)toimproveweightoutcomes(bodyweight,BMI),waistcircumference,glycemiccontrol,establishedlipid,andbloodpressuretargets(Level1a,GradeA).6

3.Adults living with obesity and impaired glucose tolerance(prediabetes)ortype2diabetesmayreceivemedicalnutritiontherapyprovidedbyaregistereddietitian(whenavailable)toreduce bodyweight andwaist circumference and improveglycemiccontrolandbloodpressure.(Level2a,GradeB.)7,8

4.Adults livingwithobesitycanconsideranyofthemultiplemedical nutrition therapies to improve health-related out-comes, choosing thedietarypatterns and food-basedap-proachesthatsupporttheirbestlong-termadherence:

a. Calorie-restricteddietary patterns emphasizing variablemacronutrient distribution ranges (lower,moderate, orhighercarbohydratewithvariableproportionsofproteinand fat) toachievesimilarbodyweight reductionover6–12months(Level2a,GradeB).9

b. Mediterraneandietarypatterntoimproveglycemiccon-trol,HDL-cholesterol and triglycerides (Level 2b,GradeC),10reducecardiovascularevents(Level2b,GradeC),11 reduceriskoftype2diabetes; (Level2b,GradeC),12,13 andincreasereversionofmetabolicsyndrome(Level2b,GradeC)14with littleeffectonbodyweightandwaistcircumference(Level2b,GradeC).15

c. Vegetariandietarypatterntoimproveglycemiccontrol,establishedbloodlipidtargets,includingLDL-C,andre-ducebodyweight,(Level2a,GradeB),16riskoftype2diabetes(Level3,GradeC)17andcoronaryheartdiseaseincidenceandmortality(Level3,GradeC).18

d. Portfolio dietary pattern to improve established bloodlipid targets, including LDL-C, apo B, and non-HDL-C(Level1a,GradeB),19CRP,bloodpressure,andestimated10-yearcoronaryheartdiseaserisk(Level2a,GradeB).19

e. Low-glycemic index dietary pattern to reduce bodyweight(Level2a,GradeB)20glycemiccontrol,(Level2a,GradeB),21establishedbloodlipidtargets,including

LDL-C(Level2a,GradeB),22andbloodpressure(Level2a,

GradeB)23andtheriskoftype2diabetes(Level3,GradeC)24andcoronaryheartdisease(Level3,GradeC).25

f. DietaryApproachestoStopHypertension(DASH)dietarypatterntoreducebodyweightandwaistcircumference;(Level1a,GradeB),26improvebloodpressure(Level2a,Grade B),27 established lipid targets, including LDL-C(Level2a,GradeB),27CRP(Level2b,GradeB),28glyce-miccontrol;(Level2a,GradeB),27andreducetheriskofdiabetes,cardiovasculardisease,coronaryheartdisease,andstroke(Level3,GradeC).27

g. Nordicdietarypatterntoreducebodyweight(Level2a,GradeB)29andbodyweightregain(Level2b,GradeB)30

improvebloodpressure(Level2b,GradeB)30 and estab-lishedbloodlipidtargets,includingLDL-C,apoB,(Level2a, Grade B),31 non-HDL-C (Level 2a, Grade B)32 and reducetheriskofcardiovascularandall-causemortality(Level3,GradeC).33

h. Partialmealreplacements(replacingonetotwomeals/dayaspartofacalorie-restrictedintervention)toreducebodyweight,waist circumference, bloodpressure andimproveglycemiccontrol(Level1a,GradeB).34

i. Intermittentorcontinuouscalorierestrictionachievedsimi-larshort-termbodyweightreduction(Level2a,GradeB).35

j. Pulses(i.e.beans,peas,chickpeas,lentils)toimprovebodyweight(Level2,GradeB)36improveglycemiccontrol,(Lev-el2,GradeB),37establishedlipidtargets,includingLDL-C,(Level2,GradeB),38systolicBP(Level2,GradeC),39 and re-ducetheriskofcoronaryheartdisease(Level3,GradeC).40

k. Vegetables and fruit to improve diastolic BP (Level 2,

GradeB),41glycemiccontrol(Level2,GradeB),42 reduce theriskoftype2diabetes(Level3,GradeC)43 and car-diovascularmortality(Level3,GradeC).44

l. Nuts to improve glycemic control, (Level 2,Grade B)45 establishedlipidtargets,includingLDL-C(Level3,GradeC),46andreducetheriskofcardiovasculardisease(Level3,GradeC).47

m.Wholegrains(especiallyfromoatsandbarley)toimproveestablishedlipidtargets, includingtotalcholesterolandLDL-C(Level2,GradeB).48

n. Dairyfoodstoreducebodyweight,waistcircumference,bodyfatandincreaseleanmassincalorie-restricteddietsbutnotinunrestricteddiets(Level3,GradeC)49 and re-ducetheriskoftype2diabetesandcardiovasculardisease(Level3,GradeC).43

Canadian Adult Obesity Clinical Practice Guidelines 3

Introduction

Peoplelivingwithobesity1andpeoplewithlargerbodiesareoftenstigmatizedandscrutinizedfor their foodchoices,portionsandeatingbehaviours.1–3Muchofthesocialmarketingefforts,publichealthandclinicalmessagingaroundfoodandeatingbehaviourshas focused on “eating less” or choosing “good” foods. As aresult of thesemessages, dieting andweight-loss focused out-comes perpetuate the notion thatweight loss and/or “health”canbeachievedpurelybycaloricrestriction,fooddeprivationand/or “dieting” practices. These simplistic narratives often neglecttheevidencethatweightlossmaynotbesustainablelong-term,notbecauseofpersonalchoicesorlackofwillpower,butratherfromstrongbiologicalorphysiologicalmechanismsthatprotectthebodyagainstweight loss.Thediet industryandweight lossfocusedresearchfieldhasthusfalselyadvertiseddietorfoodandeatinghabitsas theculprit forweightgain,contributingto thebiasandstigmareviewedintheReducing Weight Bias in Obesi-ty Management Practice and Policychapter.Aparadigmshift isneededinallaspectsofnutritionandeatingbehaviourresearch,policies, education and health promotion to support people ofallweights,bodyshapesandsizestoeatwellwithoutjudgment,criticismorbiasregardingfoodandeatingbehaviours.

Thischapterprovidesevidence-informedinformationonnutritioninterventions conducted in clinical and/or epidemiological stud-ies inthecontextofobesitymanagementforadults.Caution is

neededwheninterpretingmuchofthenutrition-specificevidenceas weight loss is often a primary outcome in nutrition-relatedstudies,andmoststudieshaveusedthedefinitionofobesityac-cording to bodymass index (BMI) classifications instead of thecurrentdefinition(Obesityisachronic,progressiveandrelapsingdisease characterized by the presence of adiposity that impairshealthandsocialwell-being)reviewedinthesummaryarticleoftheseguidelines(publishedintheCanadian Medical Association Journal)chapterandtheAssessmentofPeopleLivingwithObesity chapter.Recommendationsandkeymessagesinthischapterarespecificforpeoplelivingwithobesityandmaynotbeapplicableorappropriateforpeoplewithlargerbodieswhodonothavehealthimpacts from theirweight. Furthermore, this chapter is specificforprimarycareproviders(i.e.,generalpractitioners)andtosup-portcoordinationofcarewithregulatednutritionprofessionalsinCanada(i.e., registereddietitians [RD]orregistereddietitian/nu-tritionist[RDN],diététistes[Dt.P.orP.Dt.]).Futureresearchshouldassess nutrition-related outcomes, health-related outcomes andbehaviourchangesinsteadofweightlossoutcomesaloneacrossallweightspectrums.

Traditional nutrition interventions for obesity have focused onstrategiesthatpromoteweightlossthroughdietaryrestriction.Al-thoughacaloricdeficitisrequiredtoinitiateweightloss,sustain-ing lostweightmaybedifficult long termdue to compensatory

KEY MESSAGES FOR PEOPLE LIVING WITH OBESITY

• Nutritionisimportantforeveryone,regardlessofbodysizeorhealth.Yourhealthisnotanumberonascale.Whenyouarereadytomakeachange,choosebe-haviour-relatedgoalstoimproveyournutritionstatusandhealth(medical,functional,emotionalhealth)(Table2).

• Thereisnoone-size-fits-allhealthyeatingpattern.Chooseaneatingpatternthatsupportsyourbesthealthandonethatcanbemaintainedovertime,ratherthanashort-term“diet.”Talktoyourhealthcareprovidertodiscusstheadvantagesanddisadvantagesofdifferenteatingpatternstohelpachieveyourhealth-relatedgoals.

• Howyoueatisasimportantaswhatandhowmuchyoueat.Practiceeatingmindfullyandpromoteahealthy relationshipwithfood.

• “Dieting”orseverelyrestrictingtheamountyoueatmaycausechangestoyourbodythatcanleadtoweightregainovertime.

• Seearegistereddietitianforanindividualizedapproachandongoingsupportforyournutritionandhealth-relatedneeds.

5.Adults livingwith obesity and impaired glucose tolerance(prediabetes) should consider intensive behavioural inter-ventionsthattargeta5%–7%weightlosstoimprovegly-cemiccontrol,bloodpressureandbloodlipidtargets(Level1a, Grade A),50 reduce the incidence of type 2 diabetes,(Level1a,GradeA),51microvascularcomplications(retinopa-thy,nephropathy,andneuropathy)(Level1aGradeB)52 and cardiovascularandall-causemortality(Level1a,GradeB).52

6.Adultslivingwithobesityandtype2diabetesshouldcon-siderintensivelifestyleinterventionsthattargeta7%–15%

weight loss to increase the remission of type 2 diabetes(Level1a,GradeA)53andreducetheincidenceofnephrop-athy(Level1a,GradeA)54obstructivesleepapnea(Level1a,GradeA),55anddepression(Level1a,GradeA).56

7.Werecommendanon-dietingapproachtoimprovequal-ity of life, psychological outcomes (general well-being,body image perceptions), cardiovascular outcomes, bodyweight,physicalactivity,cognitiverestraintandeatingbe-haviours(Level3,GradeC).57

Canadian Adult Obesity Clinical Practice Guidelines 4

mechanisms that promote positive calorie intake by increasinghungerandthedrivetoeat.64–66Providers,policymakers,patients/clientsandthegeneralpublicshouldbeawarethatnutritioninter-ventionsaffecteveryonedifferently,andthereforethereisnoonebestnutritionapproachor intervention.67Assuch,somepeoplemayfavouranapproachthat ismacronutrient-based(consistingof higher, moderate or lower intake of carbohydrates, proteinand/orfat),caloricrestricted,food-basedornon-dieting.Nutritionandhealthyeatingareimportanttothehealthandwell-beingofallCanadians,regardlessofweight,bodysizeorhealthstatus.Inthecontextofobesitymanagement,thebestnutritionapproachisoneanindividualcanmaintainlongtermtoachievehealth-re-latedand/orweight-relatedoutcomes.9Table1andFigure2pro-vide an overview of the various nutrition interventions used toinfluenceweightchange,healthandqualityoflifeindicators,aswellasadvantagesanddisadvantagesofeach.

Individualized medical nutrition therapy

Nutrition interventionsshoulduseashareddecision-makingap-proachtoimproveoverallhealth,promoteahealthyrelationshipwithfood,considerthesocialcontextofeatingandpromoteeat-ingbehavioursthataresustainableandrealisticfortheindividual.AnRDshouldbeinvolvedintheassessment,deliveryandevalua-tionofcarewhereverpossible.MNTprovidedbyaregistereddieti-tianhasdemonstratedimprovementsinweightoutcomes(bodyweightandBMI),waistcircumference,glycemiccontrol,reductioninLDL-C,triglyceridesandbloodpressure.6–8

Systematic reviewsandmeta-analysesof randomizedcontrolledtrialshaveshownthat individualizednutritionconsultationbyaregistered dietitian decreasesweight by an additional -1.03 kgandBMIby-0.43kg/m2inparticipantswithBMI≥25kg/m2com-paredwithusualcareorwrittendocumentation.6Inadultslivingwith type 2 diabetes,MNT by a registered dietitian resulted insignificant reductions of HgA1c, weight, BMI, waist circumfer-ence,cholesterolandsystolicbloodpressurereportedbysystematicreviewsandmeta-analyses.8Inaddition,MNTdeliveredbyanRDtoindividualsand/orgroup-basedsessionsforthepreventionoftype2diabeteshasalsofoundaweightlossrangeof-1.5to-13kg(3–26%weightloss)withapooledeffectof-2.72kgbymeta-anal-ysis.7Table1providesoutcomesmeasuresforweightandhealthparameterswhenusingindividualizedMNTbyanRD.

Nutrition interventions

Nutrition interventionsthataresafe,effective,nutritionallyade-quate,culturallyacceptableandaffordablefor long-termadher-enceshouldbeconsideredforadultslivingwithobesity.5Health-careprovidersshouldadaptnutritioninterventionsand/oradjuncttherapytomeettheirpatient/clients’individualvalues,preferenc-esandtreatmentgoals.However,todate,nosinglebestnutritionintervention has been shown to sustainweight loss long-term,andliteraturecontinuestosupporttheimportanceoflong-termadherence,regardlessoftheintervention.9,68

Definitions of Terms Used in This Chapter

Obesity: Historically, obesity has been defined using abodymass index (BMI)of≥30kg/m2.TheAssessmentofPeopleLivingwithObesitychapterreviewsthe limita-tionsandbiasesassociatedwithusingthisBMIdefinition.Althoughincreasedbodyfatcanhaveimportantimplica-tionsforhealthandwell-being,thepresenceofincreasedbodyfatalonedoesnotnecessarilyimplyorreliablypredictillhealth.Forthisreason,evidencereviewedinthischap-ter that includedparticipantswithoverweightorobesityusingBMIcategories(≥25kg/m2or≥30kg/m2,respec-tively)withoutany reportedadiposity-relatedhealthandsocialwell-being impairmentsare referredtoas“peoplewithaBMI≥25kg/m2”(descriptivecharacteristicsofsize,nothealth).TheCanadianAdultObesityClinicalPracticeGuidelinesdefineobesity as“a complex chronicdiseaseinwhichabnormalorexcessbodyfat (adiposity) impairshealth, increasestheriskof long-termmedicalcomplica-tionsandreduces lifespan.”Weuse thisdefinition rath-erthanweightorBMIbyreferringto“adultslivingwithobesity” using people-first language1 and in support ofchangingthenarrativeaboutobesity.3,4Werecognizethatthismaybecontroversialandacknowledgethatfurtherre-searchisneededtocomparenutritioninterventionsusingnewdefinitionsofobesity;howeveradiagnosisofobesityinclinicalpracticerequiresacomprehensiveassessmenttomitigateunintentionalweightbiasorstigmathatmayexistifusingBMIalone.

Obesity management: The term “obesity manage-ment” isused todescribehealth-related improvementsbeyondweight-loss outcomes alone. Ifweight loss oc-curredasaresultoftheintervention,thisshouldnotbethe focus over the health and quality of life (QoL) im-provements.

Medical Nutrition Therapy:Medicalnutritiontherapy(MNT) is an evidence-based approach used in the nu-trition care process (NCP) of treating and/ormanagingchronic diseases, often used in clinical and communitysettings,thatfocusesonnutritionassessment,diagnos-tics,therapyandcounselling.MNTisoftenimplementedandmonitoredbyaregistereddietitianand/orincollabo-rationwithphysiciansandregulatednutritionprofession-als.Fortheseguidelines,MNTwillbeusedasastandardlanguageinnutritionaltherapeuticapproachesforobe-sityinterventions.

Nutrition interventions: This term is used instead of“diet” to refer to evidence-based, nutrition-related ap-proaches for improving health outcomes instead ofweight-lossfocusedidealsthatareoftenassociatedwiththeterm“diet.”

Canadian Adult Obesity Clinical Practice Guidelines 5

Caloric restriction

Studiesoncaloric restrictiongenerally fall into threecategories:moderate calorie (1300–1500 kcal/day), low-calorie (900–1200kcal/day)andverylow-calorie(<900kcal/day),withinterventionperiodsrangingfromthreemonthstothreeyears.

Arandomizedclinicaltrialofwomen(25–75yearsold)withBMI37.84+/-3.94kg/m2foundprescribing1000versus1500kcal/dayalongwithbehaviouraltreatmentproducedgreaterweightlossatsixmonths,buttherewassignificantweightregainat12monthsascomparedwiththe1500kcal/daygroup.69At12months,asig-nificantlygreaterpercentageofparticipantsprescribed1000kcal/day hadbodyweight reductions of 5%ormore than those as-signed1500kcal/day.69However,a1000kcal/dayprescriptionmaybemoredifficulttosustain,especiallyforindividualsforwhomthecaloricreductionis50%ormorefromtheirusualintake.69

A randomizedclinical trialofolderadults (≥65yearsold)whowereadvised to reduce their caloric intakeby500kcal/daybe-lowtheirestimatedcaloricneedswithaminimumintakeof1000kcal/day had a significant decrease in bodyweight (4%) at 12months,aswellassignificantimprovementsinbloodglucoseandHDL-cholesterol.70

A systematic review and meta-analysis of randomized controltrials using very low-calorie diets (VLCD),withorwithoutmealreplacements, forweight loss foundusingaVLCDwithinabe-haviouralweightlossprogramproducedgreaterweightlossat12months(-3.9kg)and24months(1.4kg)thanabehaviouralpro-gramalone.71TherewasnoevidenceaVLCDinterventionwithoutbehaviouralsupportiseffective.71

AlthoughMNTthatachievesacaloricdeficitcanresult inweightlossintheshort-term(6–12months),theweightchangeisoftennotsustainedovertime.Furthermore,thecommonrecommenda-tionthatacaloricdeficitof500kcal/dayor3500kcal/weekwouldproduce1lb(0.45kg)ofweightlossisnotvalid,inthatweightlossisnotlinear.72,73Polidoriandcolleaguesfirstquantifiedtheamountofcalorieintakecompensatedforweightlosschangesinfreelivinghumansandestimated that appetite increasedby~100kcal/dayforeverykilogramofweightlost,contributingtoweightgainovertime.74Caloric restrictionmay in some individuals lead topatho-physiologicaldriverstopromoteweightgainviaincreasedhunger,appetite and decreased satiety.66 In addition, caloric restrictionsmayhavenegativeconsequencesforskeletalhealth75andmusclestrength,76contributingtotheroleofindividualizingnutritioninter-ventionsthataresafe,effectiveandmeetthevaluesandpreferenc-esofthepatient/client.Indirectcalorimetryshouldbeconsideredifenergyexpenditureand/orcalorictargetsareindicated.58

Macronutrient-based approaches

Macronutrients are themain sourceof calories in thediet. Thedietary reference intakes (DRIs) are a comprehensive set of nu-trientreferencevaluesforhealthypopulationsthatcanbeused

for assessing and planning eating patterns. (Formore informa-tion, refer to: https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/dietary-reference-intakes.html) Thedietary reference intakes permitwide acceptablemacronutrientdistributionranges.Theyallow,forexample,45%to65%ofcal-ories fromcarbohydrate,10%to35%of calories fromproteinand20%to35%ofcaloriesfromfat(with5%to10%ofcaloriesderivedfromlinoleicacidand0.6%to1.2%ofcaloriesderivedfromalphalinolenicacid).77

Severalmacronutrient-basedapproacheshavebeeninvestigatedwithinandoutsidetheseranges.Researchershaveevaluated,forinstance, lowcarbohydratediets that substitute fatandproteinat the expense of carbohydrate but include adequate protein(15%–20%ofcalories).Studieshavealsoinvestigatedextremelylow-carbohydrate (≤10%ofcalories)variants, includingvariantslike the ketogenic diet which are extremely high in fat (≥75%of calories). No meaningful advantages of one macronutrientdistribution over another have reliably been shown.A networkmeta-analysiswas undertaken of 48 randomized controlled tri-als (involving7,286participants) thatprovideddietaryadvicetoconsume varying macronutrient distributions under free-livingconditions. Thismeta-analysis showednodifferences inweightlossatsixmonthsand12monthsoffollow-upbetweendietscat-egorizedbroadlyby theirmacronutrientdistributionas lowcar-bohydrate, moderate-macronutrient, or low-fat, or categorizedby their 11popular diet names encompassing awide rangeofdistributions.9Subsequentlargerandomizedcontrolledtrialshaveconfirmedthesefindings.78

The lackofmeaningfuldifferencesbetweendifferentmacronu-trientdistributionshasbeenshowntoextendtocardiometabolicriskfactors.Systematicreviewsandmeta-analysesofrandomizedtrialshaveinvestigatedglycemiccontrol inpeoplewithdiabetes(inclusiveofpeoplewithBMI≥25kg/m2).Thesetrialshavefailedtoshowthattheearlyimprovementsseeninglycemiccontrolatsixmonthsaresustainedat12monthsonlow-carbohydratedi-ets (≤40%ofcalories fromcarbohydrateor21g–70g) inwhichthecarbohydratehasbeenreplacedwithfatand/orprotein.79Re-searchershavealsoassessedtheeffectsoflow-carbohydratedietsthatreplacecarbohydratewithproteininpeoplewithorwithoutdiabeteswhohaveaBMI≥25kg/m2.Theyreportasimilarattenu-ationofeffectsonfastingbloodglucoseandtriglyceridesandlackofeffectonbloodpressureandC-reactiveproteinoverfollow-upperiods thatextendbeyond12months.80Any improvements intriglyceridesandHDL-Chavealsobeenfoundtocomeattheex-penseofincreasesinthemoreatherogenicandestablishedlipidtargets forcardiovascular risk reduction,LDL-C,non-HDL-CandapoB.79,81Accordingtoavailablerandomizedcontrolledtrials,themost importantdeterminantsof achievinganybenefitover thelong-term are adherence to any onemacronutrient distributionandclinicattendance.9,80,82,83

Thisdata from randomized controlled trials is supportedbyev-idence from large prospective cohort studies that allowmacro-nutrientexposurestobeassessedinrelationtodownstreamclin-ical outcomes of cardiometabolic diseases. No single approach

Canadian Adult Obesity Clinical Practice Guidelines 6

appearssuperior,withharmobservedattheextremesofintake.A systematic reviewandmeta-analysiswereundertakenof fiveprospectivecohortstudies involving432,179participantsoveramedianfollow-upof25years.TheevidenceshowedaU-shapedrelationshipbetweencarbohydrateandmortality,withlower-car-bohydrate (<40%of calories) andhigher carbohydrate (>70%of calories) diets associated with increased mortality, and thewide rangebetween (40–70%ofcalories)associatedwith low-ermortality.84 The Prospective Urban and Rural Epidemiological(PURE)cohortstudyinvolved135,335participantsfrom18low-,middle-andhigh-incomecountries;theparticipantswerefreeofcardiovasculardisease.PUREdidnotshowanadverseassociationwithlower-carbohydrateinterventions,andemonstratedonlythathighercarbohydrateinterventions(>70%ofcalories)wereassoci-atedwithincreasedcardiovascularandall-causemortalityover10yearsoffollow-up.85

Thequalityofthemacronutrientssubstitutedappearstobeamoreimportantconsiderationthanthequantity.TheEco-Atkinsrandom-izedtrialshowedthatalower-carbohydrateintervention(26%oftotalcalories)reducedLDL-Cin47participantswithBMI>27kg/m2andhyperlipidemiaoverfourweeks,duringwhichfoodswereprovided,andanothersixmonthsduringwhichfoodswereself-se-lected.86,87This intervention replaced refined,high-glycemic indexcarbohydratesourceswithhigh-qualityunsaturatedfatfromnutsandcanolaoilandplant-basedproteinfromsoyandpulses.

Systematic reviewsandmeta-analysesof randomizedcontrolledtrialsofinterventionsthatfocusonthequalityofthefatorpro-tein separately have also shown advantages. Researchers havealso investigated isocaloric replacementof refinedcarbohydratesourceswith high-qualitymonounsaturated fatty acids (MUFAs)fromcanolaoilandoliveoil88oranimalproteinwithsourcesofplant-basedprotein.89,90Thesestudieshaveshownimprovementsinmultiple cardiometabolic risk factors in peoplewith diabetesandaBMI≥25kg/m2,overaveragefollowupsof19weeksandeightweeks, respectively.88 Similarly, dairywheyprotein supple-mentssubstitutedforlargelyotherproteinsourcesand/orcarbo-hydratehaveshownreductionsinbodyweightandfatmass,andimprovementsinbloodpressure,bloodglucoseandbloodlipidsoverfollow-uprangingfromtwoweeksto15monthsinpeoplewithBMI≥25kg/m2.91Othersystematicreviewsandmeta-analy-sesofrandomizedcardiovascularoutcomestrialshaveshownthatthebeneficialeffectof lowsaturatedfattyacids (SFAs)dietsoncardiovasculareventsisrestrictedtothereplacementofsaturat-edfattyacidswithpolyunsaturatedfattyacids,92especiallymixedn-3/n-6sourcessuchassoybeanoilandcanolaoil.93

The importanceof thequalityofmacronutrientshasbeenseenin the observational evidence from prospective cohort studies.Pooled analyses of the Harvard prospective cohort studies andlargeindividualprospectivecohortstudieshaveevaluatedthein-cidenceofcardiovasculardisease.Theseanalysessuggestthatre-placementofSFAswithhigh-qualitysourcesofMUFAs(fromoliveoil,canolaoil,avocado,nutsandseeds)andhigh-qualitysourcesofcarbohydrates(fromwholegrainsandlow-glycemicindexcar-bohydrate foods) isassociatedwithdecreased incidenceofcoro-

naryheartdisease.94,95Whereas the substitutionof animal fatoranimalproteinforcarbohydratewasassociatedwithanincreaseinmortality,thereplacementofcarbohydratewithplant-basedunsat-uratedfatsandproteinisshowntobeassociatedwithareductioninmortality.84Thesourceofcarbohydratehasalsobeenshowntobeimportant.AnanalysisofthePUREstudyshowedthatthesourceofcarbohydratemaymodifytheassociation.Thehighestintakeofcarbohydrate(fromsourcessuchaslegumesandfruit)wasassoci-atedwithlowercardiovascularmortalityandall-causemortality.96

Takentogether,theavailableevidencerelatedtomacronutrientssuggeststhatthereisawiderangeofacceptableintakes,empha-sizingtheroleofindividualizedMNT.Thedataalsosuggestthatqualitymaybeamoreimportantfocusthanquantityintheevalu-ationoftherelationshipbetweenmacronutrientdistributionsandcardiometabolicoutcomes.This theme is reflected inthesubse-quentdiscussionsofdietarypatternsandfood-basedapproaches.

Dietary fibre

High intakes of dietary fibre are recommended for the generalpopulation. TheDRIshave set anadequate intake (AI) for totalfibre from naturally occurring, added or supplemental sourcesof25g/dayand38g/day forwomenandmen19–50yearsofage,respectively,and21g/dayand30g/dayforwomenandmen≥51 years of age, respectively.77 Several advantages have beenshown for dietary fibre. TheWorldHealthOrganization (WHO)commissioned a series of systematic reviews andmeta-analysesofprospectivecohort studies, inclusiveofpeoplewithoutacuteorchronicdiseases(includingindividualswithprediabetes,mildtomoderatehypercholesterolaemia,mildtomoderatehypertension,ormetabolicsyndrome).Theevidenceshowedthathigherintakesoftotaldietaryfibrewereassociatedwithdecreasedincidenceofdiabetes, coronaryheartdiseaseandmortality, strokeandmor-tality, colorectal cancer, and total cancer andmortality. Theau-thorsdidnotobservedifferences in risk reductionbyfibre type(insoluble,solubleorsolubleviscous)orfibresource(cereals,fruit,vegetables or pulses).97Meta-regression dose response analysesshowedthatbenefitswereassociatedwith intakesgreater than25g–29gperday.97Similarresultshavebeenshowninsystematicreviewsandmeta-analysesofprospectivecohortstudiesthatdidnotexcludepeoplewithdiabetes.98

Despite the lack of interaction by fibre type and source in theprospective cohort studies, the evidence from randomized con-trolledtrialsdiffers.Thisdatasupportsthebenefitsofdietaryfibreon intermediatecardiometabolic risk factorsandsuggests thesearerestrictedlargelytofibrefromasolubleviscousfibre.Solubleviscousfibre is theonlyfibre supportedbyHealthCanadawithapprovedhealth claims for lowering cholesterol fromoats, bar-ley,psylliumandpolysaccharidecomplex(glucomannan,xanthangum,sodiumalginate),99–101andpostprandialglycemiainthecaseofthepolysaccharidecomplex(glucomannan,xanthangum,sodi-umalginate).102Systematicreviewsandmeta-analysesofrandom-izedcontrolledtrialshaveevaluatedspecifictypesofsolubleviscousfibre.Theevidence fromoats (beta-glucan),barley (beta-glucan),

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psyllium,konjacmannan(glucomannan)andfruitandvegetables(pectin) shows improved glycemic control by HbA1c and fastingblood glucose, insulin resistance by HOMA-IR, blood pressure,andbloodlipids,includingtheestablishedtherapeuticlipidtargetsLDL-C,non-HDL-CandapoB.103–108Thestudiesalsohighlightedthatinsolublefibre,otherthancontributingtostoolbulking,109hasnotshown cardiometabolic advantages in comparisonwith low-fibrecontrolsorindirectcomparisonswithviscoussolublefibre,whereitisoftenusedasaneutralcomparatorofsolubleviscousfibre.110–113

Mixedfibre interventionsemphasizinghigh intakesofdietaryfibrefromacombinationoftypes(insoluble,soluble,andsolubleviscous)andsources(cereals,fruit,vegetablesand/orpulses),however,haveshowncardiometabolicadvantages.TheWHOcommissionedaseriesofsystematicreviewsandmeta-analysesofrandomizedcontrolledtri-alsinclusiveofpeoplewithoutacuteorchronicdiseases(includingin-dividualswithprediabetes,mildtomoderatehypercholesterolaemia,mildtomoderatehypertension,ormetabolicsyndrome),andearlierpooledanalysesofrandomizedandnon-randomizedcontrolledtri-alsinpeoplewithdiabeteshaveevaluatedmixedfibreinterventions.ThesehaveshownthatmixedfibreinterventionsresultinreductionsinbodyweightandimprovementsinHbA1C,postprandialglycemia,bloodpressureandbloodlipids.97,114Dosethresholdsforbenefitareunclearbutgenerallysupportoptimalbenefitsatintakesof≥25g/dayoftotalfibreinmixedfibreinterventionsproviding10g/dayto20g/dayofsolubleviscousfibre.97,114

Low-calorie sweeteners

Recentsynthesesoftheevidenceforlow-caloriesweetenersandhealthoutcomeshavecome todifferentconclusions. Importantsourcesofdisagreementappeartobethefailuretoaccountforthenatureofthecomparatorintheinterpretationofrandomizedcontrolledtrialsandthehighriskofreversecausalityinthemodelsfavouredbyprospectivecohortstudies.115–117

Systematic reviewsandmeta-analysesof randomizedcontrolledtrialsandindividualrandomizedcontrolledtrialsinvestigatingtheeffectof low-caloriesweetenersinsubstitutionforwater,place-boormatchedweight-lossdiets(conditionsunderwhichthereisnocaloricdisplacement)havenotshownweightlossorimprove-mentsincardiometabolicriskfactors,118,119withfewexceptions.120

Systematic reviewsandmeta-analysesof randomizedcontrolledtrialsandindividualrandomizedcontrolledtrialshavealsoevalu-atedtheeffectoftheintendedsubstitutionoflow-caloriesweet-eners for sugars or other caloric sweeteners (conditions underwhichthereiscaloricdisplacement,usuallyfromsugar-sweetenedbeverages).Thisresearchhasshowntheexpectedmodestweightlossandattendant improvements incardiometabolicriskfactors(bloodglucose,bloodpressureandliverfat) inpeoplewithBMI≥25kg/m2.119,121–123Similardisagreementsareseendependingonthemodelsusedintheprospectivecohortstudies.

Systematic reviews and meta-analyses of prospective cohortstudiesandindividuallargeprospectivecohortstudiesthathave

modelledbaselineorprevalent intakeof low-caloriesweetenershaveshownanassociationwithweightgainandanincreasedin-cidenceofdiabetesandcardiovasculardisease.118,119Otherstudieshaveusedanalyticalapproachestomitigatereversecausalitybymodellingchangeinintakeorsubstitutionoflow-caloriesweet-enedbeveragesforsugar-sweetenedbeverages.Thisresearchhasreportedassociationswithweightlossandadecreasedincidenceofdiabetes,cardiovasculardisease,andall-causemortality116,124,125 inpopulationsinclusiveofpeoplewithBMI≥25kg/m2.Takento-gether,thesedifferentlinesofevidenceindicatethatlow-caloriesweetenersinsubstitutionforsugarsorothercaloricsweeteners,especially in the formof sugar-sweetenedbeverages,mayhaveadvantageslikethoseofwaterorotherstrategiesintendedtodis-placeexcesscaloriesfromaddedsugars.

Dietary patterns

Several interventionsusingspecificdietarypatternshaveshownadvantagesforweightlossandmaintenancewithimprovementsincardiometabolicriskfactorsandassociatedreductionsinobesity- related complications (Table 1). TheMediterranean dietary pat-ternisaplant-baseddietarypatternthatemphasizesahighintakeofextravirginoliveoil,nuts, fruitandvegetables,wholegrainsandpulses;amoderateintakeofwine,fishanddairy;andalowintakeofredmeats.Thisdietarypatternhasshownweight lossandimprovementsinglycemiccontrolandbloodlipidscomparedwithotherdietarypatternsinpeoplewithtype2diabetes.10Theseimprovementshavebeenreflectedinbenefitsinimportantclinicaloutcomes.ThePREvenciónconDIetaMEDiterránea (PREDIMED)studywasalargeSpanishmulticentrerandomizedtrialwhichwasrecently retracted and republished.11 PREDIMED investigated acalorie-unrestrictedMediterraneandietarypattern,supplementedwitheitherextravirginoliveoilormixednuts,comparedwithacontroldiet(calorie-unrestrictedlow-fatAmericanHeartAssocia-tion) in7447participantsathighcardiovascularrisk.Morethan90%of theparticipantshadaBMI≥25kg/m2.The researchersconcluded that theMediterranean dietary pattern reducedma-jor cardiovascular events by~30%,diabetes incidence by 53%(single-centrefinding),andincreasedreversionofmetabolicsyn-dromeby~30%,withlittleeffectonbodyweightoveramedianfollow-upof4.8years.11–14,126

Numerousotherdietarypatternshavebeeninvestigatedfortheireffects on bodyweight, cardiometabolic risk factors, and obesity- relatedcomplications.Theseinclude:

• Low-glycemicindex:Adietarypatternthatemphasizestheex-change of low-glycemic index foods (temperate fruit, dietarypulses,heavymixedgrainbreads,pasta,milk,yogurt,etc.)forhigh-glycemicindexfoods.20–25,127–129

• Dietaryapproachestostophypertension(DASH):Adietarypat-ternemphasizingahigh intakeoffruit, low-fatdairy,vegeta-bles,grains,nuts,anddietarypulsesanda low intakeof redmeat,processedmeat,andsweets.27,28

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• Portfolio:Aplant-baseddietarypatternemphasizingtheintakeof a portfolio of cholesterol-lowering foods (e.g. nuts; plant-basedproteinfromsoyandpulses;viscousfibrefromoats,bar-leyandpsyllium;andplantsterols,plusMUFAsfromextravirginoliveoil or canolaoil), all ofwhichhave FoodandDrugAd-ministration(FDA),HealthCanadaand/orEuropeanFoodSafe-tyAuthorityapprovedhealthclaimsforcholesterol-loweringorcardiovasculardiseaseriskreduction.19

• Nordic: A Nordic dietary translation of the Mediterranean,Portfolio, DASH and National Cholesterol Education Programdietarypatterns.Nordicemphasizes foods typicallyconsumedaspartofatraditionaldietinNordiccountries.29–33,130,131

• Vegetarian: A plant-based dietary pattern that includes fourmainvariants (lacto-ovovegetarian, lactovegetarian,vegetar-ianandvegan).16–18

Systematicreviewsandmeta-analyseshaveshownthatthesedif-ferent dietary patterns improved cardiometabolic risk factors inrandomizedcontrolledtrials.Theyareassociatedwithdecreasedincidenceofdiabetesandcardiovasculardiseaseinlargeprospec-tivecohortstudiesinclusiveofpeoplewithaBMI≥25kg/m2.

Meal replacements

Partialmealreplacementsareusedtoreplaceonetotwomealsper day as part of a calorie-restricted intervention. These cal-orie-restricted interventions have been shown to reduce bodyweight,waistcircumference,bloodpressureandglycemiccontrolcomparedwithconventional,calorie-restrictedweightlossdietsinasystematicreviewandmeta-analysisofninerandomizedcontroltrialsinpeoplewithaBMI≥25kg/m2andtype2diabetesoveramedianfollow-upofsixmonths.34Anothersystematicreviewandmeta-analysisof23randomizedcontroltrialsreportedprogramsthat include partialmeal replacements achieved greaterweightlossatoneyearcomparedwithweightlossprogramswithoutuseofpartialmealreplacements,withorwithoutbehaviouralchangesupport.132Theseresultsareconsistentwithanearliermeta-analy-sis.133Atoneyear,attritionrateswerehigh,butbetterforthepar-tialmealreplacementgroupcomparedwiththecalorie-restrictedgroup(47%vs.64%,respectively)withnoadverseeffects.133

Mealreplacementshavealsoshownadvantagesaskeyfeaturesofintensivelifestyleinterventionprogramstargeting≥5%–15%ofweightloss.Thelargestcomprehensivelifestyleinterventioninpeoplewithtype2diabetes,theLookAHEAD(ActionforHealthinDiabetes)trial,targeted≥7%weightlossusingmealreplacements(with instruction to replace twomealsperdaywith liquidmealreplacementsandonesnackperdaywithabarmealreplacement)duringweeksthreeto19onthe intensive lifestyle intervention.Higheradherencetotheuseofmealreplacementswasassociatedwithapproximatelyfour-timesgreaterlikelihoodofachievingthe≥7%weight loss goal at one year, comparedwith participantswith loweradherenceatoneyear,134 contributing tobettergly-cemiccontrolandlesshealth-relatedcomplicationsoverthe9.6

yearsoffollow-up.50,54,56ThemorerecentDiabetesRemissionClin-icalTrial(DiRECT)includedtotalliquidmealreplacementsforthefirst12–20weeksoftheintensivelifestyleinterventionprogram.DiRECT showedanearly20-foldgreater likelihoodofachievingdiabetesremissionat12monthsoffollow-upinparticipantslivingwithobesityandtype2diabetes.53Fullmealreplacementsaspartof intensive lifestyle programs are discussed in theCommercialProductsandProgramsinObesityManagementchapter.

VLCDsusingmealreplacementsincludemedicalsupervisionandextensive support (nutrition, psychological, exercise counselling)aspartoftheintervention.Long-termstudiesusingVLCDinter-ventions with partial meal replacements reported weight out-comesof -6.2%atyearoneand-2.3%at threeyears in thosewhoattendedoverthreeyearsanddidnothaveaddedpharma-cotherapy treatment.135 As previously reported, weight loss orweightcyclingcanleadtobiologicalcompensatorymechanismsthatcanpromotelong-termweightgaininsomepeople.64–66De-spitelackofweightmaintenancelongterm,withouttreatment,higherweight trajectoriescouldbeexpected.Therefore,addingothertreatments(e.g.pharmacotherapyand/orsurgeryforappe-titeregulation)overtimecouldbeconsideredtosupportobesitymanagementratherthanweightlossalone.

Note: In Canada, meal replacement products for use in calo-rie-restricted interventions are regulated by the Canadian Foodand Drug Regulations. (https://laws-lois.justice.gc.ca/eng/regula-tions/c.r.c.,_c._870/FullText.html)

Intermittent fasting

Intermittentfastingincludesavarietyofmealtimingapproachesthatalternateperiodsofextendedfasting(nointake,orlessthan25%of needs) and periods of unrestricted intake. Intermittentfastingisalsodescribedastime-restrictedfeeding,alternate-dayfastingorintermittentenergyrestriction;however,therearemul-tiplevariationsreportedintheliterature.59Therewaslimitedevi-denceinhumanphysiologyandmetabolismstudies.Inasystemat-icreviewandmeta-analysisofrandomizedcontrolledtrials,Cioffietal. (2018)35 identified11 trials (eight-24weeks)which foundcomparable outcomes between interventions using intermittentenergy restriction compared with continuous energy restriction(weight, fat mass, fat freemass, waist circumference, glucose,HbA1C, triglyceridesandHDL-C). Intermittentenergy restrictionwas identifiedtoreducefasting insulin levels (pooleddifference-0.89uU/mL)comparedtocontrols;however,thestudyauthorsquestionedtheclinicalsignificanceof thisas therewerenodif-ferencesinglucose,HbA1CorHOMA-IR.Adherencewassimilarbetweencontinuousand intermittent energy restrictiongroups,withhigherattritionratesandadverseeventsintheintermittentenergyrestrictiongroups.35Similarresultsforweightlossandgly-cemiccontrolwerereportedintworecentpapers(onesystematicreviewandmeta-analysis,andasystematicreview)publishedaftertheliteraturereviewforthischapter(June2018).59,60

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Food-based approaches

Several dietary patterns emphasizing specific food-based ap-proacheshave shownadvantages (Table1). These includepuls-es (beans, peas, chickpeas, and lentils),36–40 fruit and vegeta-bles,41,42,44nuts,45–47,136–138wholegrains (especiallyfromoatsandbarley) 43,48,97,107,139,140 and dairy.49,141–143 These food-based ap-proaches have shownweight loss and/or weightmaintenance,withimprovementsincardiometabolicriskfactors,inrandomizedcontrolledtrials.Thereisalsoevidenceofassociatedreductionsintheincidenceofdiabetesandcardiovasculardiseaseinlargepro-spectivecohortstudiesinclusiveofpeoplewithaBMI≥25kg/m2.

Intensive lifestyle intervention programs

Intensivelifestyleintervention(ILI)programsconsistofresource-in-tensive, comprehensive, multi-modal behavioural interventionsthat are delivered by interprofessional teams (e.g. physicians,RDs, nurses and kinesiologists). These programs combinenutri-tion interventions with increased physical activity. The intensi-tyof follow-upvariedfromweeklytoeverythreemonths,withgraduallydiminishingcontactoverthecourseoftheprogram.ILIprogramsthattarget≥5%to15%weightlosshaveshownsus-tainedweightlosswithmarkedimprovementsincardiometabolicriskfactorsandobesity-relatedcomplications.Large,randomizedcontrolledtrialshaveshownthat ILIprograms improveglycemiccontrol,bloodpressureandbloodlipidsinadultslivingwithobesi-tywhohaveimpairedglucosetoleranceprediabetes144–146ortype2diabetes.50TheserandomizedcontrolledtrialshavealsoshownimportantclinicalbenefitsofILIprograms,including:

• Type2diabetes;51,52,144–147

• Microvascular complications (retinopathy, nephropathy, andneuropathy);52

• Cardiovascularmortality,andall-causemortalityinadultslivingwithobesitywhohaveimpairedglucosetolerance;52 and

• Increasesintheremissionoftype2diabetes;53 and

• Reductionsintheincidenceofnephropathy,54obstructivesleepapnea55anddepression56inadultswithaBMI≥25kg/m2whohavetype2diabetes.

TheavailableevidencesuggestsanoverallbenefitofdifferentILIprogramsinadultslivingwithobesity.However,thefeasibilityofimplementingtheseprogramsisdependentupontheavailabilityof resourcesandaccess toan interprofessional teamtoachievethetargetweightlossoutcome(i.e.,≥5%to15%).

Non-dieting approaches

Non-dieting approaches include an umbrella of concepts de-scribedintheliteraturethatofferhealthcareprovidersalternatives

toweight-loss focused interventions.148 Theseapproachesoftenrejectweight-lossordietingpracticesandtypicallyuseconceptsofmindfulness in response to internal hunger, satiety, cravingsand appetite insteadof caloric restrictionor cognitive restraint.Componentsofanon-dietingapproachmayincludethefollow-ing concepts: weight neutral, weight inclusive, mindful eating,mindfulness-basedinterventions,sizeorbodyacceptance,and/orHealthatEverySize®(HAES®).

Evidence is limited for non-dieting approaches. A systematicreview and meta-analysis of nine studies (involving 1194 par-ticipants,BMI≥25kg/m2and follow-upover three–12months)compared weight-neutral approaches to weight-loss interven-tions.AuthorsconcludedthatthetwoRCTsandsevennon-ran-domizedcomparativestudiesfoundnosignificantdifferences inweightloss,BMIchanges,cardio-metabolicoutcomes(includingbloodpressure,glycemiccontrol,lipidprofile)orself-reportedde-pression,self-esteem,QoLordietquality.Smalldifferenceswerefoundinself-reportedbulimiaandbinge-eatingbehaviours.61 One systematic review examined theHealth at Every Size approach.HAES®doesnotsupportthemedicalizationorpathologicalnarra-tivethatobesityisadisease.It’saphilosophycentredonrespectingbodyshapeandsizediversity,health,andpromotingeatingandex-ercisebehavioursbasedonnon-weightcentricgoals.149Thereviewfound this approach improvedQoL and psychological outcomes(general well-being, body image perceptions) withmixed resultsfor cardiovascular outcomes (blood lipids, blood pressure), bodyweight,physicalactivity,cognitiverestraintandeatingbehaviours.57

Another systematic reviewof randomized and non-randomizedtrialsfoundvariousnon-dietingapproacheshaveevidencetopos-itively influence eating behaviours (including disordered eatingpatterns),biochemicaloutcomes,fitness,dietquality,bodyimageandmentalhealth.57,150

Mindfulness-basedinterventionstargetingself-awareness,specif-icallyhunger, satietyand tastesatisfaction,havebeen foundtobeeffectiveforbingeeatingbehaviours,151–153eatingdisorders,151 positively affecting eating behaviours148 and weight loss.154,155 However, caution is needed when interpreting results fromnon-dietingapproaches.Therearevariousnon-dietinterventionsreportedinliteraturewithalackofcontrolgroups,ahighriskofbias in trials, and inconsistent valid tools used tomeasureout-comes.Nonetheless,interventionsfocusingonnon-weightlossorweight-neutraloutcomesmayhavelessimpactonweightstigmaandmaysupporthealthbehavioursacrossallweightspectrums,emphasizingtherolenon-dietingapproachescouldhaveonindi-vidualizednutritioninterventions.

Clinical nutrition implications for acute weight-loss

Inmanyclinicalsettings(primarycare,acuteortertiarycare,long-termcare,etc.),someindividualslivingwithobesitymaybenefitfromacuteweightloss.Acuteweightlosscanbedesirableforthepreservationoflife,preventionoforganfailureand/orforimproving

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functional QoL (i.e., compromised activities of daily living). De-spite therisk forpossiblenegativeconsequencesofweight loss(i.e.weightgain, increasedappetite, leanmass loss,etc.),acuteweight loss via nutrition interventionsmaybe anecessary and/orpreferredtreatmentoptionaswithotheracuteinterventions.Forexample,someonewithanischemicbowelmayrequiremul-tiple bowel resections, resulting in parenteral nutrition support,intravenous vitamins/minerals, changes to macronutrient needsand lifelongmonitoring of health,whichmay includemonitor-ingweightforindicatorsofmalnutrition.Likewise,someonewithend-stage renaldisease that requires renal replacement therapymayrequiremedicalnutritiontherapyandfoodchoiceadjustmenttomaintainelectrolytes,kidneyfunctionandorganpreservation.Likeobesity,nutritioninterventionsmaybeindicatedforimprove-mentsinweightoutcomesorcardiometabolicfactors.Healthcareprovidersshouldusenon-judgementalapproacheswheneducat-ingpatients/clientsaboutthebenefitsandrisksofanynutritionintervention,includingweight-lossinterventions.Likewise,familymembers and/or thepublic shouldnot judgeor scrutinize indi-vidualizedinterventionsindicatedorselectedbythepatient/clientandtheirhealthcareprovider.

Healthcareprovidersshouldpracticecaution,though,ifusingnu-tritioninterventionsforacuteweightloss,assomeindividualsmaybeathighriskformalnutritionand/orsarcopenicobesity.156–159Forexample,weightreductionforpeoplewithkneeosteoarthritisisoftenrecommendedtoreducepainanddecreasetheriskofinfec-tionforsurgery(ratesarehigherinpatientswithBMI>30kg/m2

aftertotalkneereplacement).160However,BMIisnotagoodindi-catorofhealthorbodycomposition,andweightreductionmaynot improve riskoroutcomesdue tomuscleweakness,musclemassloss,orsarcopenicobesityormalnutritionduetoinadequateoralintake.160Nutritioninterventionsthereforeshouldbeusedforoptimizingnutritional,medicalandfunctionalhealthratherthanfacilitatingweight lossspecificgoals.Conductingacomprehen-siveassessment (asoutlined in the AssessmentofPeopleLivingwithObesitychapter)andcollaboratingwitharegistereddietitianisrecommendedforthesafetyandefficacyofusingnutritionin-terventionsinacuteweightloss.

Other considerations

Micronutrient deficiencies

People livingwithobesityareat increasedriskformicronutrientdeficiencies includingbutnot limited tovitaminD, vitaminB12and iron. Theprevalenceof vitaminDdeficiency inobesityhasbeenreportedtobeashighas90%,161 theorizedbydecreasedbioavailabilityofvitaminDasitissequesteredinadiposetissue162 or due to volumetric dilution.163 Systematic reviews and me-ta-analysesof randomizedclinical trials indicate thathigherad-iposity levels (% fatmass or fatmass) is associatedwith lowerserumvitaminD25(OH)D levels,164–166 suggesting theneed forhealthcareproviders tomonitorvitaminD levelsaspartof rou-tineassessmentforobesity.VitaminDsupplementationhasnotbeeneffectiveintreatingobesityorforimprovingcardiometabol-

ic outcomes as shown bymeta-analyses of randomized clinicaltrials.165,167,168However,vitaminDsupplementationforcorrectionand/orpreventionofdeficiency(<50nmol/LasdefinedbytheIn-stituteofMedicine169)isrecommended,especiallyinindividualsathigherriskforvitaminDdeficiency(Table3).

Restrictiveeatingpatterns,obesitytreatments (e.g.medications,bariatricsurgery)anddrug-nutrientinteractionsmayalsoresultinmicronutrientdeficiencies,specificallyvitaminB12andirondefi-ciencies.161,170,171Thereisalsogrowingevidenceforthiamine(vi-taminB1)andmagnesiumdeficiencies.172VitaminB12deficiencyhasbeenshowntobeassociatedwithhigherBMIcategories,173 however,interpretationofobservationalstudiesiscautioneddueto large heterogeneitywithin studies. Poor iron status has alsobeenassociatedwithobesitywitha1.31-fold increasedrisk forirondeficiencyinpeoplelivingwithobesity.170Assessmentinclud-ingbiochemicalvaluescanhelpinformrecommendationsforfoodintake, vitamin/mineral supplements, andpossibledrug-nutrientinteractions(Table3).

Disordered eating patterns

Healthcare providersmay be hesitant to recommend restrictingintakeorVLCDs,asanearlyliteraturereviewfoundthedevelop-mentofeatingdisordersincollege-agedwomenwasassociatedwithahistoryof intentionalcaloricrestrictionforweight loss.174 Currentevidenceshowsmixedresults,however,aslimitedstudieshavespecificallyassessedwhether“dieting”practices(forpursuitofanidealbodyweightorshape,driveforthinnessandgoalsofweightloss)precipitateeatingdisorders(suchasbingeeatingdis-orderordisorderedeatingbehaviours).Epidemiologicaldataovera20-yearlongitudinalstudyindicatedthateatingdisorders,driveforthinness,useofdietpills,laxativesanddietingmethodstocon-trolweightdeclinedinadultwomenbutincreasedforadultmen.175

A systematic review176 foundvery low-caloriediets canbeusedwithoutexacerbatingexistingeatingdisordersorbingeeatingep-isodes inmedically supervisedprograms.Da Luz et al.176 foundbingeeatingdecreasedinVLCDinterventions.Aprospectiveran-domizedcontroltrialfoundnodisorderedeatingbehaviours,nobingeeatingdisorderanddecreasedsymptomsofdepressionincaloriclyrestrictedgroups(1200kcal–1500kcal/daywithconven-tionalfood,or1000kcal/daywithfullmealreplacements)whencompared to a non-caloric restricted approach.177 Symptoms ofpoorself-esteemandnegativebodyimagethoughtsdeclinedinallthreegroupsovertime.Furthermore,areviewpaperofcross-sec-tionalandprospectivestudiesondietary restrictionandthede-velopment of eating disorders or disordered eating behavioursconfirmedminimal to no evidence to support the causation.178

Cautionisrecommendedwheninterpretingfindingsfromthisre-port,asstudyintentionswerenotdesignedtospecificallyinvesti-gatedietingandeatingdisordersordisorderedeatingbehavioursinpeoplelivingwithobesity.

ArecentsystematicreviewbytheAustralianNationalEatingDisor-derCollaborationconcludedthatprofessionalobesitymanagement

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interventions(usingmedicalnutritiontherapy,physicalactivity,be-haviour therapy,pharmacotherapyor surgical interventions)doesnotprecipitateeatingdisordersorincreaseriskforeatingdisordersinpeoplewithBMI≥25kg/m2.63However,eatingdisordersareof-tenunderdiagnosedanduntreated,andsomeevidencesuggestingthatpeoplewitheatingdisordersaremorelikelytoseekweight-loss interventions.62 Healthcare providers should consider referraltomentalhealthprofessionalsand/oreatingdisorderprogramsforassessmentandtreatmentifsymptomsaresuspected.(RefertotheRoleofMentalHealthinObesityManagementchapter).

Assess risk for malnutrition prior to bariatric surgery

Limitedhigh-qualityevidencehasreviewedpreoperativemalnutri-tion status inpatients seekingbariatric surgery.Nonetheless,ob-servational studieshave indicated thatpatients livingwithobesi-tyhaveahigherriskforinadequatenutritionalstatus156,179,180 and malnutrition.156–158Alarge,multicentre,retrospective,observationalstudy(n=106,577)foundthat~6%ofpatientsundergoingbariat-ricsurgeryweremalnourishedandhadincreasedriskofdeathorseriousmorbidity(DSM)and30-dayreadmissionrates.157Thisstudyalsofoundthat>10%weightlosspriortosurgerywasassociatedwithnine-timeshigherratesofDSMinpatientswithmildmalnu-tritionand10timeshigherDSMinthosewithseveremalnutrition.Similarly,aretrospectivecohortstudy158concludedthat32%ofthecohort(n=533)hadmalnutritionpriortosurgery.HigherBMIwasassociatedwithincreasedriskformalnutrition.Post-operativenau-seaand vomitingwasassociatedwithpreoperativemalnutrition.PreoperativeevaluationandcollaborativesupportfromanRDarerecommended for all patients considering bariatric surgery.161,181 RefertotheBariatricSurgery:SelectionandPreoperativeWork-upchapterforfurtherbariatricsurgeryconsiderations.

Limitations and opportunities

To support evidence-based practice, guideline chapter authorsexaminedtheliteraturetofindthehighest-qualityevidencetoin-formgradedrecommendations.High-qualityevidencewasiden-tifiedforspecificnutrition-relatedtopicsincludingMNTdeliveredbyanRD,specificdietarypatterns,certainfood-basedapproach-es, and intensive lifestyle interventions. There was limited evi-dencefornon-dietingapproaches.Gapsintheliteratureincludedassessmentofbaselinenutritionstatusandsocialdeterminantsofhealth.Moststudieswithanutritioncomponentwereshort-tomedium-terminterventions,limitingourknowledgeoflong-termoutcomes.

StudiesusingBMI>25kg/m2asinclusioncriteriatoselectpartic-ipantsforobesityinterventionsmaybeconfoundedwithhealthypeoplewithlargerbodiesandmisrepresentclinicaloutcomesforpeoplewiththechronicdiseaseofobesity,andmaynotidentifythoseatnutritionrisk.

Weight loss was a common outcome measure of interventionstudies;however,thereasonforweightchangeisdifficulttoas-

certain.Thesuccessorfailureoftheinterventiononweightout-comes is confoundedby thephysiological defensemechanismsinresponsetoadipositychanges,asdiscussedintheScienceofObesitychapter.

Tomovenutritionandobesitypracticeforward,wesuggestthefollowing:

• Developassessmenttoolsfortheprimarycareenvironmenttosupport theuseofahealth-complication-centricdefinitionofobesity, rather than relying on anthropometric measures forBMIcategories.

• Improve accuracy of nutrition interventions for people withobesity with measurements of energy, macro/micronutrientneedsandbodycomposition.

• Nutritionisaboutmorethanthefoodweeat.Explorethere-lationshipswith food, food security, internalizedweightbias,weightstigmaand/ordiscrimination,eatingbehavioursandso-cialdeterminantsofhealthaspartofpatientcareandresearch.

• Includethepatient/clientvoiceinnutritionresearchandpatientcaretohelpaligntheinterventionsforpeoplelivingwithobesityandpeoplewithlargerbodieswiththeirlivedexperiences.

Evidencecontinuestoemergethatimpactsourunderstandingofnutritionandchronicdisease.Providersmaylooktoenhancetheirprofessionalknowledgeonemergingevidenceinnutrition-relatedtopics,including:

• Neurophysiologic pathways that affect hunger, appetite and reward;

• Metabolicadaptationofcaloricrestriction;

• Gutmicrobiota;

• Nutrigenomicsandpersonalizednutrition;

• Socialdeterminantsofhealth;and

• Mentalhealth.

Conclusion

Nutrition interventions showbenefitswithcardiometabolicout-comes,includingglycemiccontrol,hypertension,lipidprofileandcardiovascularrisk(Table1andFigure1).MNTandcoordinationofcarewithanRDcanhelppatients/clientsimprovehealthandQoL.Findinganutritionapproachapatient/clientcanincorporateintotheirlivesthatisnutritionallyadequate,culturallyacceptable,affordable, enjoyable and effective for lifelong health improve-ments(Figure2)shouldbethefocusofallnutritioninterventions.

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Figure 1: Medical Nutrition Therapy for Obesity Management – Quick Reference Guide182,183

ASK/ASSESS:Isyourpatient/clientinterestedinmakingnutritionchanges?

AGREE AND ASSIST: Explore Options, Collaborate CareRefertoaRegisteredDietitian(RD)

Monitor and Evaluate Health-Related Outcomes*, including:Healthbehaviours,Nutritionstatus,Qualityoflife,Mentalhealth,Cardiovascular,Metabolic,Functionalstatus,Body

Reassess intervention,plan,readiness,barriersandsupports;

*RefertoTable2:HealthIndicatorsforEvaluatingNutritionInterventionswithPatients/Clients

ADVISE: Provide/Reinforce Key Nutrition Messages for all Adults

•Meetindividualvalues,preferencesandgoalsthatareculturallyacceptable,affordableandsustainable•Useperson-firstlanguage,patient-centred,weight-inclusiveandnon-dietingapproaches•FollowCanada’FoodGuideforHealthyEatingrecommendations(asapplicabletotheindividual)

ASK/ASSESSIspatient/clientinterestedinmakingfurthernutritionchangesORrequestsadditionalsupporttomake/sustainchanges?

Healthy eating is more than the foods you eat.

•Bemindfulofyoureatinghabits

•Cookmoreoften•Enjoyyourfood•Eatmealswithothers•Usefoodlabels•Limitfoodshighinsodium,sugarsorsaturatedfat

•Beawareoffoodmarketingandhowitcaninfluenceyourchoices.

Make it a habit to eat a variety of healthy foods each day.

•Haveplentyofvegetablesandfruit

•Eatproteinfoodsandchooseproteinfoodsthatcomefromplantsmoreoften

•Makewateryourdrinkofchoice

•Choosewholegrainfoods

Build a healthy relationship with food and eating

•Taketimetoeat•Noticewhenyouarehungryandwhenyouarefull

•Planwhatyoueat• Involveothersinplanningandpreparingmeals.

•Cultureandfoodtraditionscanbepartofhealthyeating

•Reconnecttotheeatingexpe-riencebycreatingawarenessofyourfeelings,thoughts,emotionsandbehaviours

Food Based Approaches

•Pulses•Vegetablesandfruit•Nuts•Wholegrains•Dairyfoods

Dietary Patterns

•Calorie-restrictedpatternswithvariablemacronutrientranges

•Mediterranean•Vegetarian•Portfolio•Lowglycemicindex•DASH•Nordic•Partialmealreplacements• Intermittentfasting

Intensive Lifestyle Interventions with a Multidisciplinary Team

•Behaviourmodification•Nutrition(RD)•Partialmealreplacements•Physicalactivity•Education•Self-monitoring/self-care•Medications•Frequentfollow-upvisits

YES

YES

NO

NO

Monitorandevaluateforreadiness in follow-upvisits.

Canadian Adult Obesity Clinical Practice Guidelines 13

Figure 2: Summary of Clinical Outcomes for Nutrition Interventions

MedicalNutritionalTherapy(RD)

Intensivelifestyleinterventions

Calorierestriction

Lowercarbohydrate

Dietaryfibre(25–29mg)

Low-caloriessweeteners

Higherprotein(25–40%)

Increasedprotein+calorierestriction

Wheyproteinsupplement

Replacefatorcarbwithprotein

Lowerfat

Mediterranean

Vegetarian

Portfolio

Lowglycemicindex

DASH

Mealreplacements

Intermittentfasting

Pulses

Vegetablesandfruits

Nuts

Wholegrains

Dairy

HAES®

Mindfullness-basedapproaches

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Canadian Adult Obesity Clinical Practice Guidelines 14

Table 1: Summary of Nutrition Interventions used in Obesity Management

Intervention

Dietary pattern approaches

Outcomes/Impact

Health and quality of life

Weight change

Advantages Disadvantages

Medicalnutritiontherapybyaregistereddietitian(RD)

Intensivelifestyle interventions

Calorierestriction*

Dietaryfibre(25gto29g)

Low-caloriesweeteners

Higherprotein(25%–40%ofcaloriesfromprotein),nocalorierestrictionprescribed

Lowercarbohydrate

i 0.43%HgAlci 2.16cmwaistcircumferencei 4.06mg/dLcholesteroli 8.83mg/dLtriglyceridesi 4.43mg/dLLDL-Ci 7.90mmHgsystolicbloodpressurei 2.60mmHgDSP

T2DMincidence58%51 i 0.22A1c,i 1.9mmHg systolicbloodpressure,h 1.2mg/dLHDL-C50 i Cardiovasculardisease(HR0.67)andall-causemortality(HR0.74)52 h RemissionofT2DM53 i Nephropathyincidence(HR0.69)54

i Obstructivesleepapneaincidence55

i Depression(HR0.85)56

i Bloodpressure,lipids, glucose69,184,185 i Bonedensity75 i Musclestrength76 i BMR186

Higherintakes:i Cardiovasculardisease mortality15–30%i Coronaryheartdisease,strokeincidencei T2DMi Systolicbloodpressurei Totalcholesterol97

Mayiweightandcardiometabolicdisease118,193

iTG(-0.60mmol/L)80

Carb-to-proteinratioof1.5:1iChol,LDL194

Nochange(withorwithoutexercise)forHDL,FBG,fastinginsulin194

i 1.03kg6

ForT2DM:i 1.54kg8

ForT2DMprevention:i 2.72kg7

i 8.6%1yri 6%13.5years50

Higherintakesi weight

i0.39kgBWi0.44kgFM80

i 8kgat6mo;i 6–7kgat1year9

UseRDsasanadjunctorstand-alonetherapyoption forimprovementsincardiometabolicandweightoutcomes

Multi-modalapproachwithintensivecounsellingandstrategiesprovidessupporttoindividualsforlonger-termbehaviourchangeandsuccessfuloutcomes

Largeinitialweightloss69,71,135,187

Fibresupplementsmayhelpiweightshort-term108,188–192

Asareplacementforsugar(e.g.SSB)mayhelp iweight121

Greater satiety195

WomenwithMetSynhad iweight,ifatmasswithHPvs.low-fat/highcarb194

Randomizedcontroltrialsdonotsupportuseforobesitymanagement118

AccesstoRDstrainedinobesitymanagementmaybelimited;feeforservicesfromprivatepracticeproviders

Requiressignificantresourcesacrossmultiplehealthcaredisciplines

Difficulttosustain,weightregainexpected,long-termweightloss<5%69,71,135,187

Nodifferencesinotherlipidsorleanmass,attritionrates30–40%80

Canadian Adult Obesity Clinical Practice Guidelines 15

Increasedprotein(1.1g/kgor30%proteinintake),withcalorierestriction

Wheyproteinsupplement(20–75g/day,2weeks–15months)

Mediterranean

Vegetarian

Portfolio

Low-glycemicindex

DietaryApproachestoStopHypertension(DASH)

Partialmealreplacements*

Intermittentfasting

Increaseproteintoreplaceother macronutrients

Lowerfat

Short-term(12+-9.3weeks):i TG195

iCardiovasculardiseaseriskfactors(systolicbloodpressure,DBP,HDL,TChol,glucose91

i A1C0.45,i TG0.21mmol/L,hHDL-C0.07mmol/L10 i Cardiovascularevents(HR0.69–0.72)11

i T2DMrisk52%12,13

h ReversionofMetSx14

iA1C29%,iLDL-C0.12mmol/L,↑non-HDL-C0.13mmol/L16 i T2DMincidence(OR0.726)17

i Coronaryheartdisease incidence(RR0.72)i Coronaryheartdisease mortality(RR0.78)18 i LDL-C17%i ApoB15%i Non-HDL-C14%,i CRP32%,isystolicbloodpressure1%,i10-yrcoronaryheartdiseaserisk13%19

h HDL-C199

i T2DMrisk24 i Coronaryheartdisease25

i CRP1.0128 i LDL-C0.20mmol/Li A1C0.53%i T2DMriskRR0.82i CardiovasculardiseaseriskRR0.80i CoronaryheartdiseaseriskRR0.79i StrokeriskRR0.8127

i BloodglucoseinDM201

h HRQOL202

i Systolicbloodpressure4.97mmHgi DBP1.98mmHgi A1C0.45%at24weeks34

i 0.61kgat24weeks35

Replacesomecarbohydratei Waistcircumferenceover5years198 ReplacesomefatNoeffect198

30%proteinintake:Nodifferenceinwtloss,h lean mass196 iWeight197

1.1g/kgproteinintake:short-term(12+-9.3weeks):i Weighti FatmassLess i fat-freemass,195

i Weight(meandiff-0.56kg)i Fatmass(meandiff-1.12kg91

i Leanmass(meandiff-0.77kg)

Littleeffectonweightorwaistcircumference11

i 2.15kg<6mo16

Nochange

i 2.5kg18months200

i1.42kg,iwaist circumference1.05cmin 24weeks26

i2.37kgi Waistcircumference2.24cmat24weeks34

Largeinitialwtloss Wtregain3yearweightloss<5%202

Noeffectonlong-termweightoutcomes198

i 8kgat6mo;i 6–7kgat1yr9

Greater satiety195

Benefitsfoundwithorwith-outcalorierestriction91

Shortterm(12+-9.3weeks)195

Limitedhealthdatacollected

Lackofevidencetoguidedoseorlengthoftimeforuse91

Riskofvitamin/mineral deficiencies(iron,calcium,zinc,vitaminB12,vitaminD)

Individualsmayfinditdifficulttomeettherecom-mendedfoodcomponenttargets**

Dietary pattern approaches

Canadian Adult Obesity Clinical Practice Guidelines 16

Pulses

Vegetablesandfruit

Nuts

Wholegrains

DairyFoods(withcalorierestriction)

i FBG0.8237 i LDL-C0.17mmol/L38

i Systolicbloodpressure2.25mmHg39

i CoronaryheartdiseaseriskRR0.8640

i DBP0.29mmHg41

i A1C5.7%42

i T2DMrisk42%43 i CardiovascularmortalityHR0.9544

i A1C0.07%i FBG0.15mmol/L45

i LDL-C7.4%46 i CoronaryheartdiseaseriskHR0.74

i totalcholesterol(TC)0.12mmol/Li LDL-C0.09mmol/L48

i T2DMrisk42%43 i 0.64kgBWi 2.18cmwaist circumferencei 0.56kgFMh 0.43kgleanmass49

i 0.34kgat6weeks36

Food-based approaches

Non-dieting approaches

LDL-C:low-densitylipoproteinC;BMI:bodymassindex;FG:fastingglucose;TC:totalcholesterol;HDL;highdensitylipoprotein;A1C;kg:kilogram;BW:bodyweight;FM:fatmass;T2DM:type2diabetes

*Thesearetypicallycombinedwithextensivebehaviouralmodificationsupport.

**ThePortfoliodietarypattern=1gto3g/dayplantsterols(plant-sterolcontainingmargarines,supplements),15gto25g/dayviscousfibres(gel-formingfibres,suchasfromoats,barley,psyllium,legumes,eggplant,okra),35–50g/dayplant-basedprotein(suchasfromsoyandpulses)and25gto50g/daynuts(includingtreenutsandpeanuts).

HealthatEverySize(HAES®)

Mindfuleating

i LDL-Ch Bodyimageperceptionsh Qualityoflife(QOL)scores(depression)h Eatingbehaviourscoresi Hungerh Aerobicactivity

i 3.1mg/dl(i 0.2mmol/L)inbloodglucose203preventionofincreasingFGovertime

NochangeinBMIorweightloss

i3.3%weightatpost-treat-menth3.5%weightinfollow-up154 i4.2–5.0kg(4.3–5.1%)meanweightat18mo203

iWeightbias

iSweetfoodintake204

EvidencelimitedtowomenwithBMI>25ordisorderedeatingpatterns.

Lackofconsistencyfor validatedmindfulnesstools

Canadian Adult Obesity Clinical Practice Guidelines 17

Table 2: Health Indicators for Evaluating Nutrition Interventions with Patients/Clients

Health Improvement

Cognitiveimprovements

Functionalimprovements

Medicalimprovements

Bodycompositionimprovements

Appetite-relatedimprovements

Mentalhealth

Health indicator

Memory,concentration,attention,problemsolving,sleephygiene

Strength,flexibility,mobility,coordination,physical activitycapacity,endurance,pain

Cardiometabolic,endocrine,gastrointestinal,woundcare,nutrientdeficiencies,changestomedications

Bodyfat,musclemass,bonehealth,waistcircumference

Hunger,satiety,cravings,drivetoeat,palatabilityoffoods

Disorderedeatingbehaviours,self-esteem,self-efficacy,emotionalregulation,mood/anxiety,addiction

Example

Askclient/patienttorateeachofthesehealthoutcomesusinga0–10scale,where0islow/poorand10ishigh/great: EnergylevelStressSleephygieneMobilityStrengthPainBowelhealthMoodRelationshipwithfoodHungerCravingsOverallhealth

Healthcareprovidersareencouragedtousehealthandqualityoflife(QoL)-relatedgoalsforevaluatingeffectivenessofnutritionin-terventions.Askclients/patientswhathealth improvementstheyare hoping to achieve by following or changing their nutritionapproachhelps toredirectweight-centricoutcomeswithasking

whathealth improvements thisweight changemeans to them.Examples: energy level, cognitive improvements, functional im-provements, cardiometabolic improvements, mental health andqualityoflife(mobility,self-hygiene,etc.),

Canadian Adult Obesity Clinical Practice Guidelines 18

Table 2: Health Indicators for Evaluating Nutrition Interventions with Patients/Clients

Micronutrient

Vitamin D

Vitamin B12

Iron

Screen for Deficiency Risks

1. Elevatedadiposity

2.Medicalconditionsassociatedwithfatmalabsorption: •Crohn’sdisease •Ulcerativecolitis •Celiacdisease •Liverdisease •Cysticfibrosis •Short-bowelsyndrome

3. Previousbariatricsurgery(RYGB,SG,BPD,DS)

4. Lowintakeofcalcium-richfoods

5. Limitedsun-lightexposure(i.e.Night-shiftworkers,wearinglong-sleevedclothing,northernclimate)

6. Darkerskinpigmentation

1. Elevatedadiposity

2.Medicalconditions: •IBD(Crohn’sdisease,ulcerativecolitis) •Type2diabetes(long-termuseofmetformin) •GERD •PositiveHelicobacterpylori •Perniciousanaemia •Alcoholism

3. Restrictiveeatingpatterns: •Vegetarianeatingpatterns •VLCD/mealreplacements •Lowercarbohydrateintake

4. Previousbariatricsurgery(LAGB,RYGB,SG,BPD,DS)

1. Elevatedadiposity

2.Medicalconditions: •Crohn’sdisease •Ulcerativecolitis •Celiacdisease •Liverdisease •Pepticulcers •Chronickidneydisease

3. Restrictiveeatingpatterns: •Vegetarianeatingpatterns •Lowproteinintake •VLCD/mealreplacements

4. Frequentblooddonors

5. Bloodloss(menstruation,GItractbleeding)

6. Previousbariatricsurgery(LAGB,RYGB,SG,BPD,DS)

Drug or Nutrient Interactions

•Corticosteroids

•Orlistat

•Cholestyramine

•Phenobarbital

•Phenytoin

•Metformin•Proton-pumpinhibitors

•Interactionswithcalcium, polyphenols(coffee/tea)

•Excessivezincintake(lozenges)

•NSAIDs

•Proton-pumpinhibitors

•H2blockers

Canadian Adult Obesity Clinical Practice Guidelines 19

Correspondence:guidelines@obesitynetwork.ca

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