Chapter 3

Weight Management

from Dietary Guidelines for Americans

Contents

Overview

The prevalence of obesity in the United States has doubled in the past two decades. Nearly one-third of adults are obese, that is, they have a body mass index (BMI ) of 30 or greater. One of the fastest growing segments of the population is that with a BMI ≥ 30 with accompanying comorbidities. Over the last two decades, the prevalence of overweight among children and adolescents has increased substantially; it is estimated that as many as 16 percent of children and adolescents are overweight, representing a doubling of the rate among children and tripling of the rate among adolescents. A high prevalence of overweight and obesity is of great public health concern because excess body fat leads to a higher risk for premature death, type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, stroke, gall bladder disease, respiratory dysfunction, gout, osteoarthritis, and certain kinds of cancers.

Ideally, the goal for adults is to achieve and maintain a body weight that optimizes their health. However, for obese adults, even modest weight loss (e.g., 10 pounds) has health benefits, and the prevention of further weight gain is very important. For overweight children and adolescents, the goal is to slow the rate of weight gain while achieving normal growth and development. Maintaining a healthy weight throughout childhood may reduce the risk of becoming an overweight or obese adult. Eating fewer calories while increasing physical activity are the keys to controlling body weight. While overweight and obesity are currently significant public health issues, not all Americans need to lose weight. People at a healthy weight should strive to maintain their weight, and underweight individuals may need to increase their weight.

Key Recommendations

• To maintain body weight in a healthy range, balance calories from foods and beverages with calories expended.
• To prevent gradual weight gain over time, make small decreases in food and beverage calories and increase physical activity.

Key Recommendations for Specific Population Groups

• Those who need to lose weight. Aim for a slow, steady weight loss by decreasing calorie intake while maintaining an adequate nutrient intake and increasing physical activity.
• Overweight children. Reduce the rate of body weight gain while allowing growth and development. Consult a healthcare provider before placing a child on a weight-reduction diet.
• Pregnant women. Ensure appropriate weight gain as specified by a healthcare provider.
• Breastfeeding women. Moderate weight reduction is safe and does not compromise weight gain of the nursing infant.
• Overweight adults and overweight children with chronic diseases and/or on medication. Consult a healthcare provider about weight loss strategies prior to starting a weight-reduction program to ensure appropriate management of other health conditions.

Discussion

Overweight and obesity in the United States among adults and children has increased significantly over the last two decades. Those following typical American eating and activity patterns are likely to be consuming diets in excess of their energy requirements. However, caloric intake is only one side of the energy balance equation. Caloric expenditure needs to be in balance with caloric intake to maintain body weight and must exceed caloric intake to achieve weight loss (see tables 3 and 4). To reverse the trend toward obesity, most Americans need to eat fewer calories, be more active, and make wiser food choices.

Prevention of weight gain is critical because while the behaviors required are the same, the extent of the behaviors required to lose weight makes weight loss more challenging than prevention of weight gain. Since many adults gain weight slowly over time, even small decreases in calorie intake can help avoid weight gain, especially if accompanied by increased physical activity. For example, for most adults a reduction of 50 to 100 calories per day may prevent gradual weight gain, whereas a reduction of 500 calories or more per day is a common initial goal in weight-loss programs. Similarly, up to 60 minutes of moderate- to vigorous-intensity physical activity per day may be needed to prevent weight gain, but as much as 60 to 90 minutes of moderate-intensity physical activity per day is recommended to sustain weight loss for previously overweight people. It is advisable for men over age 40, women over age 50, and those with a history of chronic diseases such as heart disease or diabetes to consult with a healthcare provider before starting a vigorous exercise program. However, many people can safely increase their physical activity without consulting a healthcare provider.⁷

Monitoring body fat regularly can be a useful strategy for assessing the need to adjust caloric intake and energy expenditure. Two surrogate measures used to approximate body fat are BMI (adults and children) and waist circumference (adults).⁸ BMI is defined as weight in kilograms divided by height, in meters, squared. For adults, weight status is based on the absolute BMI level (fig. 2). For children and adolescents, weight status is determined by the comparison of the individual's BMI with age- and gender-specific percentile values (see fig. 3 for a sample boys' growth curve).

 BMI is more accurate at approximating body fat than is measuring body weight alone. However, BMI has some limitations. BMI overestimates body fat in people who are very muscular and underestimates body fat in people who have lost muscle mass. The relationship between BMI and body fat varies somewhat with age, gender, and ethnicity. In addition, for adults, BMI is a better predictor of a population's disease risk than an individual's risk of chronic disease.⁸ For children gaining excess weight, small decreases in energy intake reduce the rate at which they gain weight (body fat), thus improving their BMI percentile over time. As another surrogate measure, waist circumference can approximate abdominal fat but should be measured very carefully. Fat located in the abdominal region is associated with a greater health risk than peripheral fat.

Some proposed calorie-lowering strategies include eating foods that are low in calories for a given measure of food (e.g., many kinds of vegetables and fruits and some soups). However, when making changes to improve nutrient intake, one needs to make substitutions to avoid excessive calorie intake. The healthiest way to reduce calorie intake is to reduce one's intake of added sugars, fats, and alcohol, which all provide calories but few or no essential nutrients

Special attention should be given to portion sizes, which have increased significantly over the past two decades  Though there are no empirical studies to show a causal relationship between increased portion sizes and obesity, there are studies showing that controlling portion sizes helps limit calorie intake, particularly when eating calorie-dense foods (foods that are high in calories for a given measure of food). Therefore, it is essential that the public understand how portion sizes compare to a recommended amount of food (i.e., serving) from each food group at a specific caloric level. The understanding of serving size and portion size is important in following either the DASH Eating Plan or the USDA Food Guide. When using packaged foods with nutrient labels, people should pay attention to the units for serving sizes and how they compare to the serving sizes in the USDA Food Guide and the DASH Eating Plan.

Lifestyle change in diet and physical activity is the best first choice for weight loss. A reduction in 500 calories or more per day is commonly needed. When it comes to body weight control, it is calories that count—not the proportions of fat, carbohydrates, and protein in the diet. However, when individuals are losing weight, they should follow a diet that is within the Acceptable Macronutrient Distribution Ranges (AMDR) for fat, carbohydrates, and protein, which are 20 to 35 percent of total calories, 45 to 65 percent of total calories, and 10 to 35 percent of total calories, respectively. Diets that provide very low or very high amounts of protein, carbohydrates, or fat are likely to provide low amounts of some nutrients and are not advisable for long-term use. Although these kinds of weight- loss diets have been shown to result in weight reduction, the maintenance of a reduced weight ultimately will depend on a change in lifestyle. Successful and sustainable weight loss and weight maintenance strategies require attention to both sides of the energy balance equation (i.e., caloric intake and energy expenditure).

TABLE 4. Calories/Hour Expended in Common Physical Activities

Some examples of physical activities commonly engaged in and the average amount of calories a 154-pound individual will expend by engaging in each activity for 1 hour. The expenditure value encompasses both resting metabolic rate calories and activity expenditure. Some of the activities can constitute either moderate- or vigorous-intensity physical activity depending on the rate at which they are carried out (for walking and bicycling).

^a Calories burned per hour will be higher for persons who weigh more than 154 lbs (70 kg) and lower for persons who weigh less.
Source: Adapted from the 2005 DGAC Report.

FIGURE 2. Adult BMI Chart

Locate the height of interest in the left-most column and read across the row for that height to the weight of interest. Follow the column of the weight up to the top row that lists the BMI. BMI of 18.5-24.9 is the healthy weight range, BMI of 25-29.9 is the overweight range, and BMI of 30 and above is in the obese range.

Source: Evidence Report of Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, 1998. NIH/National Heart, Lung, and Blood Institute (NHLBI).

FIGURE 3. Example of Boys' BMI Growth Curve (2 to 20 years): Boys' Body Mass Index-For-Age Percentiles

Calculate the BMI for an individual child using the following:
BMI = Weight (kg)/(Height [cm])² x 10,000 or BMI = Weight (lb)/(Height [in])² x 703
Find the age of the child on the bottom, x-axis, and read up the chart from that age to the calculated BMI on the left and right, y-axis. The curve that is closest to the spot where the age and BMI of the child meet on the graph indicate the BMI percentile for this child relative to the population.

Published May 30, 2000 (modified 10/16/00).
Source: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion.