Published: Oct 17, 2013

Full Story:  http://www.medpagetoday.com/Endocrinology/Obesity/42338

Full Text Article:  http://www.medpagetoday.com/upload/2013/10/17/clinical-practice-guidelines.pdf

Patients may need help managing metabolic and endocrine disorders with healthy eating and lifestyle choices, and now there’s a comprehensive set of clinical guidelines, issued jointly by the American Association of Clinical Endocrinologists, the American College of Endocrinology, and the Obesity Society, to assist them.

The new guidelines cover topics that include nutritional recommendations for weight management, cardiovascular health, chronic kidney disease, diabetes, bone health, pregnant women and mothers who are breastfeeding, and older patients, according to J. Michael Gonzalez-Campoy, MD, PhD, and colleagues on the joint Task Force on Healthy Eating Clinical Practice Guidelines.

Beyond recommendations for individual patient populations, the guide noted that patients should receive instruction on healthy eating and on proper meal planning from a healthcare professional, and that foods and drinks should provide essential macronutrients, micronutrients, and water in a calorie-controlled meal plan, they wrote online in Endocrine Practice.

“There are many obstacles that preclude patient access to nutritional education,” the authors noted, adding that “Federal institutions have not paid for nutrition education except for a limited number of conditions” and that many patients with morbid conditions — such as patients with obesity, hypertension, malnutrition, and the early stages of chronic kidney disease — “are marginalized from this important component of healthcare.”

These guidelines represent the first comprehensive guide with graded, evidence-based recommendations, Gonzalez-Campoy told MedPage Today, noting that prior research has been piecemeal.

Two key recommendations he noted were that healthy eating with a focus on fresh foods — such as fruits and vegetables — was central to a healthy meal plan, and that there was no evidence to support consumption of vitamin supplements except in deficient populations.

“Good patient care always begins — always — with good nutrition, regardless of the patient population, and continues with it,” he said, adding that medical nutrition therapy does not have the focus it needs in the current medical climate.

The U.S. Department of Agriculture and Department of Health and Human Services last updated the “Dietary Guidelines for Americans” in 2011 with recommendations about consumption quantities for fat, salt, cholesterol, potassium, and fiber, as well as emphasizing the need for consumers to reduce calories acquired through added sugar and to consume more healthy foods.

Additional recommendations from the American Heart Association in 2011 capped daily salt intake at 1,500 mg. That mark was later echoed in the USDA and HHS guidelines and was met with harsh criticism by the salt lobby, who said the 1,500 mg limit could have potentially fatal adverse consequences for patients.

Although those guidelines are educational and useful for patients, there has been “no evidence-based clinical practice guideline to define the standards of care for healthy eating in the management and prevention of metabolic and endocrine disorders.”

The guidelines were developed by combing through existing research and assigning recommendations based on that research a letter grade — with A representing strong and D representing expert opinion without conclusive clinical evidence — based on clinical evidence and supporting factors. The guide itself was styled as a question or statement followed by an answer comprised of recommendations from research with how strong that recommendation was.

All patients, in addition to receiving an education in nutrition and meal preparation, should engage in 150 minutes or more of physical activity weekly, and learn ways to avoid a sedentary lifestyle, receive adequate sleep, and budget time to relax and reduce stress. Patients should also generally consume a mix of animal and plant proteins and carbohydrates. They should reduce the fat consumed with dairy and animal products, and avoid saturated fats.

Obesity and overweight should be managed as a long-term chronic condition through a multidisciplinary team, nutrition that decreases fat mass and adiposity, and with a weight-loss goal of 5% to 10% of current body weight over a 6 to 12 month window. These are aided by modifying existing habits and adhering to a low-calorie or very low-calorie meal plan.

Those with diabetes should consume enough calories to maintain a BMI of 18.5 to 24.9, with a diet of carbohydrates from unprocessed foods and of nonsaturated fats. There were no recommendations to specifically prevent diabetes.

Patients with chronic kidney disease should limit sodium, limit protein intake to 12% to 15% of daily diet, and should receive oral vitamin D. Those with end-stage renal disease should limit potassium to 3 to 4 g daily.

Bone health should be supported with 1,000 mg/day of calcium in premenopausal women and men, and 1,500 mg/day in postmenopausal women.

Gonzalez-Campoy noted that the guide was the first step of a “working and living document,” and that revisions would come with new research. He added that future iterations should include optimal water consumption and recommendations on alcohol consumption.