The position paper of the ADA on Weight Management states:
Diet and Lifestyle Modifications
There exists a continuum in philosophy and clinical practice as
to what extent externally controlled modification of weight
status should be attempted (58,59). This continuum ranges
from complete reliance on internal control to increased external
structural supports provided by the prescription of diets,
meal plans and exercise protocols. Internally regulated approaches
are referred to by various names including nondieting,
normalized eating, or intuitive eating. These approaches
are based on an assumption that the body knows best and have
in common that they urge that food intake be guided by
internal clues to hunger and satiety. There may be great
variability among individuals in the extent to which they are
able to perceive and act upon internal cues. Lengthy intervention
may be required to learn to perceive internal signals of
hunger and satiety and to develop the trust to allow these
signals to guide food intake. Emotional associations with food
and eating complicate the sensations that offer internal guidance;
when these associations are extreme, therapy for emotional
issues is indicated. The body?s regulatory systems resist
changes in fatness by adjusting control systems. In addition,
there may be a failure of the regulatory system in the body that
controls either hunger or satiety or both, making it difficult for
an individual to rely on this method. Internal regulation of food
intake is most often used with patients who are seeking to
stabilize their weight and to address other issues associated
with their eating and weight. Programs that have utilized it
have demonstrated short-term improvements in self-esteem,
body image, and other parameters associated with psychological
well-being (53,60). Long-term, randomized, controlled
studies with sufficient numbers of participants are not available
to validate this approach.
Moderate or mixed approaches promote internally guided
eating in combination with limited external guidance systems.
Based on the observation that internal guidance of food behavior
is difficult given most peoples? experiences and environment,
this moderate approach provides structural supports
even while urging that individuals respond to their own cues of
hunger and satiety. There is no available data to support the
proposition that adults experience food or nutrient-specific
appetites that lead infallibly to a balanced diet. Readily available
foods tend to be high in fat, calories, salt, and sugar,
making the consumption of such foods more likely. A moderate
approach would teach patients to provide themselves with
high volume, nutrient-dense but not calorie-dense foods in a
balanced array and to then allow their hunger and satiety to
guide them in choosing quantities. Teaching awareness of
one?s eating, both the amount eaten and the sensations produced,
is important. This approach emphasizes moderation,
balance, and common sense and should reduce feelings of
deprivation (61). It is most often accompanied by advice
concerning exercise, stress management, and self-acceptance.
The outcomes of these approaches depend upon the original
goals. Theoretically, such a moderated approach should lead to
changes in eating and exercise behaviors that can be sustained
and will lead to slow continued weight losses. There has been
little documentation of the long-term effectiveness of this
combined approach. However, data from the Continuing Survey
of Food Intakes by Individuals 1994-1996 was analyzed to
look at dietary patterns and selected measures of nutritional
status and Body Mass Index. This analysis found that individuals
on a moderate fat, high-carbohydrate diet as recommended
by the Food Pyramid Guide were more likely to maintain
weight loss (62).
Externally based systems range from severe caloric restriction,
very low calorie diets (< 800 calories per day), to lowcalorie
diets (estimated energy expenditure minus 500-1,000
calories per day) to guide food intake. These systems are based
on the assumption that not all individuals are able to internally
control their food intake to the extent of achieving a healthier
weight and therefore must rely on external guidance and
increased structural supports. Data regarding severe energy
restricted diets, such as very low calorie diets (VLCDs), show
that despite the short-term success of achieving significant
weight losses, there is poor long-term maintenance of losses
(63). It has been well documented that use of the low-calorie
diets, typical of a modified approach, can produce mean weight
losses in the range of 8% to 10% of body weight over a period
of 6-12 months (64). Unfortunately, it is also well documented
that unless individuals sustain the diet plus exercise indefinitely, most of the losses are regained (65). Patients who have
realistic weight loss goals (5% to 10% weight loss), have never
dieted, are trying to modify very poor food habits, are seeking
external supports and increased structure, and accept the
need for a sustained effort may benefit from diets mildly
reduced in calories accompanied by a regular exercise program.
