Obesity and Weight Management
Manual of Clinical Nutrition Management III- 84 Copyright © 2013 Compass Group, Inc.
meats are recommended (15,16). The AHA recommends that children consume adequate amounts of dietary
fiber (equal to the child’s age plus 5 g) each day (16,17).
Adequate physical activity also is encouraged (9,15,16,18). The US Surgeon General’s Report on Physical
Activity and Health recommends 30 minutes per day of moderate to vigorous physical activity for children
and adults (18).
Adults
Weight management is defined as the adoption of healthful and sustainable eating and physical activity
behaviors indicated for a reduced disease risk and improved feelings of energy and well-being (6). Weight loss
therapy should be based on a comprehensive weight management program including diet, physical activity,
and behavior therapy. The combination therapy is more successful than any one intervention alone (Grade I) (7).
A nonrestrictive approach to eating based on internal regulation of food (hunger and satiety), physical
activity, and healthful eating habits should be emphasized (6). Data on lifestyle weight loss interventions
indicate that they produce low levels of sustained loss. Typically reported weight losses remaining after 4 to
5 years are about 3% to 5% of initial body weight (6). Based on data from the National Weight Control
Registry, long-term maintenance of weight loss and goals is increased in persons who have specific health
habits and behaviors. These habits include eating a lower energy diet (average = 1,381 kcal/day) that is low
in fat and high in carbohydrates, regular self-monitoring of food intake and activity level, and participating in
regular physical activity comparable to 1 hour per day of moderate-intensity physical activity, such as brisk
walking (4,19). The National Weight Control Registry registrants who have documented these behaviors have
demonstrated sustained weight loss of 10% of initial body weight for at least 1 year (19). Weight loss of 5% to
10% of initial body weight can lead to a substantial improvement in risk factors for diabetes and heart
disease and can lead to reductions in or discontinuations of medications for these conditions (4). The results
of the Diabetes Prevention Program have provided the most definitive evidence of the health benefits of
modest weight loss (20). In this study, the lifestyle intervention group had a 58% reduced risk of developing
type 2 diabetes when compared to the placebo group and a 39% reduced risk when compared to the
pharmacotherapy intervention group that used metformin (20). Individualized goals of weight loss therapy
should be to reduce body weight at an optimal rate of 1 to 2 lb/week for the first 6 months and to achieve an
initial weight loss goal of up to 10% from baseline. These goals are realistic, achievable, and sustainable (Grade
I) (4,7).
Energy: Energy requirements should be based on individual needs to promote gradual and safe weight loss.
Estimated energy requirements should be based on resting metabolic rate (RMR) (7). If possible, RMR should
be measured (eg, indirect calorimetry). If RMR cannot be measured, then the Mifflin–St. Jeor equation using
actual body weight is the most accurate for estimating RMR for overweight and obese individuals (Grade I) (7).
The prescribed energy level should promote a weight loss of 0.5 to 1.5 lb/week (Grade I) (4,7). The
recommended minimum energy levels are 1,200 kcal/day for women and 1,400 to 1,500 kcal/day for men (4,
2 1). Evidence suggests that moderation in total energy is the key variable in promoting weight loss, rather
than modification of the diet’s macronutrient composition (21). Consideration of a realistic energy goal is
important for successful patient compliance with a weight-management program (4). Total energy intake
should be distributed throughout the day, with the consumption of four to five meals/snacks per day
including breakfast (Grade II) (6,7). Consumption of greater energy intake during the day may be preferable to
evening consumption (Grade II) (6,7). (See the “Calorie-Controlled Diet for Weight Management” in Section IC.)
Protein: To preserve lean body mass, daily protein intake should be in the range of 0.8 to 1.2 g/kg of body
weight (22). During energy restriction, it is generally suggested that 72 to 80 g of high-quality protein be
consumed per day (23). Patients who ingest too little protein (<40 g/day) are at risk for ventricular arrhythmias
(23).
Fat: Fat should account for 20% to 30% of total energy. Saturated fats should be limited to less than 6% to
8% of total fat energy. The US Department of Agriculture has found that diets with low to moderate fat intake
(15% to 30% of total energy) tend be lower in total energy and highest in diet quality when compared to low-
carbohydrate diets (21).
Carbohydrates: Carbohydrates should account for 50% to 60% of total energy. Carbohydrates can help
prevent the loss of lean tissue (23). It has been suggested that at least 100 g of carbohydrates should be
consumed per day to minimize ketosis (23). Hyperuricemia can result from low-carbohydrate diets (23).
Maintaining a minimum level of carbohydrate intake (>100 g/day) reduces the risk of increased uric acid
levels that may predispose the patient to gout (23). High-fiber carbohydrate sources, such as fruits, vegetables,