Cost-effectiveness and quality of life of a diet intervention postpartum: 2-year results from a randomized controlled trial

How quality of life is measured in studies of nutritional intervention: a systematic review

BACKGROUND

Nutrition care can positively affect multiple aspects of patient's health; outcomes are commonly evaluated on the basis of their impact on a patient's (i) illness-specific conditions and (ii) health-related quality of life (HRQoL). Our systematic review examined how HRQoL was measured in studies of nutritional interventions. To help future researchers select appropriate Quality of Life Questionnaires (QoLQ), we identified commonly-used instruments and their uses across populations in different regions, of different ages, and with different diseases.

METHODS

We searched EMCare, EMBASE, and Medline databases for studies that had HRQoL and nutrition intervention terms in the title, the abstract, or the MeSH term classifications "quality of life" and any of "nutrition therapy", "diet therapy", or "dietary supplements" and identified 1,113 studies for possible inclusion.We then reviewed titles, abstracts, and full texts to identify studies for final inclusion.

RESULTS

Our review of titles, abstracts, and full texts resulted in the inclusion of 116 relevant studies in our final analysis. Our review identified 14 general and 25 disease-specific QoLQ. The most-used general QoLQ were the Short-Form 36-Item Health Survey (SF-36) in 27 studies and EuroQol 5-Dimension, (EQ-5D) in 26 studies. The European Organization for Research and Treatment of Cancer Quality of life Questionnaire (EORTC-QLQ), a cancer-specific QoLQ, was the most frequently used disease-specific QoLQ (28 studies). Disease-specific QoLQ were also identified for nutrition-related diseases such as diabetes, obesity, and dysphagia. Sixteen studies used multiple QoLQ, of which eight studies included both general and disease-specific measures of HRQoL. The most studied diseases were cancer (36 studies) and malnutrition (24 studies). There were few studies focused on specific age-group populations, with only 38 studies (33%) focused on adults 65 years and older and only 4 studies focused on pediatric patients. Regional variation in QoLQ use was observed, with EQ-5D used more frequently in Europe and SF-36 more commonly used in North America.

CONCLUSIONS

Use of QoLQ to measure HRQoL is well established in the literature; both general and disease-specific instruments are now available for use. We advise further studies to examine potential benefits of using both general and disease-specific QoLQ to better understand the impact of nutritional interventions on HRQoL.

Weight Management Interventions Provided by a Dietitian for Adults with Overweight or Obesity: An Evidence Analysis Center Systematic Review and Meta-Analysis

BACKGROUND

Obesity is associated with a multitude of comorbidities and considerable health care costs.

OBJECTIVE

The objective of this review was to examine the efficacy of weight management interventions provided by a registered dietitian or international equivalent (referred to as "dietitian").

METHODS

This systematic review and meta-analysis of randomized controlled trials (RCTs) examined the effect of weight management interventions provided by a dietitian, compared with usual care or no intervention, on several cardiometabolic outcomes and quality of life in adults with overweight or obesity. MEDLINE, Embase, PsycINFO, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and CINAHL databases were searched for eligible RCTs published between January 2008 and January 2021 in the English language. Meta-analyses were conducted using a random-effects model, publication bias was assessed using funnel plots and Egger's statistics, and heterogeneity was assessed by interpreting I2 values. Efficacy of intervention components, such as telehealth or group contacts, were explored in sub-group analyses. Version 2 of the risk-of-bias tool for RCTs was used to assess risk of bias. The Grading of Recommendations Assessment, Development and Evaluation method was used to determine certainty of evidence.

RESULTS

This systematic review included 62 RCTs. Compared with control conditions, weight management interventions provided by a dietitian resulted in improved body mass index (mean difference [MD] -1.5; 95% CI -1.74 to -1.26; moderate evidence certainty); percent weight loss (MD -4.01%; 95% CI -5.26% to -2.75%; high evidence certainty); waist circumference (MD -3.45 cm; 95% CI -4.39 to -2.51 cm; high evidence certainty); blood pressure (MD -3.04 mm Hg; 95% CI -5.10 to -0.98 mm Hg and MD -1.99 mm Hg; 95% CI -3.02 to -0.96 mm Hg for systolic blood pressure and diastolic blood pressure, respectively; moderate and low evidence certainty); and quality of life using the 36-Item Short Form Survey (MD 5.84; 95% CI 2.27 to 9.41 and 2.39; 95% CI 1.55 to 3.23 for physical and mental quality of life, respectively; low and moderate evidence certainty).

CONCLUSIONS

For adults with overweight or obesity, weight management interventions provided by a dietitian are efficacious for improving several examined cardiometabolic outcomes and quality of life.

Dietary treatment postpartum in women with obesity reduces weight and prevents weight gain: a randomised controlled trial

BACKGROUND

Women with pre-pregnancy obesity have an increased risk of retaining or gaining weight postpartum and may benefit from weight loss treatment. However, evidence is lacking for weight loss strategies in women with BMIs in the higher obesity classes. A dietary treatment for postpartum weight loss resulted in a 10% weight reduction in lactating women with a mean BMI of 30 kg/m2. We aimed to examine the effects of this dietary treatment on changes in weight, markers of lipid and glucose metabolism, waist and hip circumference and postpartum weight retention (PPWR) in postpartum women with higher BMIs than tested previously.

METHODS

At baseline, approximately 8 weeks postpartum, 29 women with a mean (SD) BMI = 40.0 (5.2) kg/m2 were randomised to a 12-week dietary treatment (n 14) or to a control treatment (n 15). Measurements were made at baseline and after 3 and 12 months. Data was analysed using mixed model.

RESULTS

The mean weight change in the diet group was -2.3 (3.1) kg compared to 1.7 (3.1) kg in the control group after 3 months (P = 0.003) and -4.2 (5.6) kg compared to 4.8 (11.8) kg in the control group after 12 months (P = 0.02). The dietary treatment led to reduced waist circumference (P < 0.04) and PPWR (P < 0.01) compared to the control treatment at both time points. The treatment lowered fasting blood glucose at 12 months (P = 0.007) as the only effect on markers of lipid and glucose metabolism.

CONCLUSION

The dietary treatment postpartum reduced weight and prevented weight retention or weight gain in women with obesity.

TRIAL REGISTRATION

The trial was retrospectively registered at ClinicalTrials.gov (NCT03579667) 06/07/2018. In a randomised, controlled trial, 29 postpartum women with obesity were allocated to a dietary treatment or a control treatment. The dietary treatment reduced weight and prevented postpartum weight retention or weight gain after 12 months. Reference: Adapted from "Randomized, Placebo-Controlled, Parallel Study Design (2 Arms, Graphical)", by BioRender.com (2022). Retrieved from https://app.biorender.com/biorender-templates .

Addressing inequalities and improving maternal and infant outcomes: the potential power of nutritional interventions across the reproductive cycle

Maternal nutrition is essential for optimal health and well-being of women and their infants. This review aims to provide a critical overview of the evidence-base relating to maternal weight, obesity-related health inequalities and dietary interventions encompassing the reproductive cycle: preconception, pregnancy, postnatal and interpregnancy. We provide an overview of UK data showing that overweight and obesity affects half of UK pregnancies, with increased prevalence among more deprived and minoritised ethnic populations, and with significant health and cost implications. The existing intervention evidence-base primarily focuses on the pregnancy period, where extensive evidence demonstrates the power of interventions to improve maternal diet behaviours, and minimise gestational weight gain and postnatal weight retention. There is a lack of consistency in the intervention evidence-base relating to interventions improving pregnancy health outcomes, although there is evidence of the potential power of the Mediterranean and low glycaemic index diets in improving short- and long-term health of women and their infants. Postnatal interventions focus on weight loss, with some evidence of cost-effectiveness. There is an evidence gap for preconception and interpregnancy interventions. We conclude by identifying that interventions do not address cumulative maternal obesity inequalities and overly focus on individual behaviour change. There is a lack of a joined-up approach for interventions throughout the entire reproductive cycle, with a current focus on specific stages (i.e. pregnancy) in isolation. Moving forward, the potential power of nutritional interventions using a more holistic approach across the different reproductive stages is needed to maximise the benefits on health for women and children.

Medical Nutrition Therapy Interventions Provided by Dietitians for Adult Overweight and Obesity Management: An Academy of Nutrition and Dietetics Evidence-Based Practice Guideline

Overweight and obesity affect most adults living in the United States and are causally linked to several adverse health outcomes. Registered dietitian nutritionists or international equivalents (dietitians) collaborate with each client and other health care professionals to meet client-centered goals, informed by the best available evidence, and translated through a lens of clinical expertise and client circumstances and preferences. Since the last iteration of the Academy of Nutrition and Dietetics guideline on adult weight management in 2014, considerable research has been conducted and circumstances confronting dietitians have evolved. Thus, updated guidance is needed. The objective of this evidence-based practice guideline is to provide recommendations for dietitians who deliver medical nutrition therapy behavioral interventions for adults (18 years and older) with overweight and obesity to improve cardiometabolic outcomes, quality of life, and weight outcomes, when appropriate for and desired by the client. Recommendations in this guideline highlight the importance of considering complex contributors to overweight and obesity and individualizing interventions to client-centered goals based on specific needs and preferences and shared decision making. The described recommendations have the potential to increase access to care and decrease costs through utilization of telehealth and group counseling as effective delivery methods, and to address other barriers to overweight and obesity management interventions. It is essential for dietitians to collaborate with clients and interprofessional health care teams to provide high-quality medical nutrition therapy interventions using the nutrition care process to promote attainment of client-centered outcomes for adults with overweight or obesity.

Addressing Obesity in Preconception, Pregnancy, and Postpartum: A Review of the Literature

PURPOSE OF REVIEW

Reproductive-aged women (aged 19 to 50 years) are a key population warranting focused research for the prevention of overweight and obesity. This review highlights the importance of addressing weight before, during and after pregnancy.

RECENT FINDINGS

Obesity decreases fertility during the preconception period; increases the risk of adverse pregnancy outcomes including gestational diabetes, pre-eclampsia and caesarean section and postpartum weight retention; and increases the long-term health risks for both the mother and offspring. Despite overwhelming efficacy evidence on solutions, there are significant implementation gaps in translating this evidence into pragmatic models of care and real-world solutions. Interventions during preconception, pregnancy and postpartum are likely to be cost-effective or cost-saving, with future investigation needed in the preconception and postpartum period. International clinical guidelines and public health policies are needed for a concerted effort to prevent unhealthy weight gain in these life stages and to reverse the significant adverse health outcomes for women and the next generation.

Executive summary of evidence and consensus-based clinical practice guideline for management of obesity and overweight in postpartum women: An AIIMS-DST initiative

INTRODUCTION

Postpartum obesity is a public health concern. There is a need to counsel women about their postpartum weight management, accounting for various barriers they face. Limited literature in the Indian context underscored the need to develop the clinical practice guideline to be used by healthcare providers in Indian healthcare settings.

METHODS

The guideline was formulated by following the standardised methodology proposed by the National Health and Medical Research Council. Various steps such as identification of the patient population, assembly of the guideline development groups, identification of the key clinical questions, guideline development methods, grading the quality of evidence and recommendations and guideline translation were carried out to develop and validate the clinical practice recommendations.

RESULTS

The evidence and consensus-based clinical practice guideline has been developed, providing recommendations for key topics of interest for first-line treatment of obesity (lifestyle-related management). Recommendations focus on screening and initiating discussion with overweight and obese postpartum women as well as those who had normal pre-pregnancy body mass index but have retained excessive weight in the postpartum period. Recommendations highlight the evaluation and management of dietary, physical activity and breastfeeding behaviour. Recommendations also account for behavioural modification techniques to improve adherence to the prescribed weight management advice. Duration and frequency of follow-ups as well as the advice to be disseminated have also been discussed in the recommendations.

CONCLUSION

The guideline provides clinical practice points that can be used by healthcare providers, postpartum women and policymakers for opportunistic screening and management of postpartum obesity.

How cost-effective is nutrition care delivered in primary healthcare settings? A systematic review of trial-based economic evaluations

CONTEXT

Nutrition care is an effective lifestyle intervention for the treatment and prevention of many noncommunicable diseases. Primary care is a high-value setting in which to provide nutrition care.

OBJECTIVE

The objective of this review was to evaluate the cost-effectiveness of nutrition care interventions provided in primary care settings.

DATA SOURCES

Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Central Register of Controlled Trials, EconLit, and the National Health Service Economic Evaluation Database (NHS EED) were searched from inception to May 2021.

DATA EXTRACTION

Data extraction was guided by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guidelines. Randomized trials of nutrition interventions in primary care settings were included in the analysis if incremental cost-effectiveness ratios were reported. The main outcome variable incremental cost-effectiveness ratios (ICERs) and reported interpretations were used to categorize interventions by the cost-effectiveness plane quadrant.

RESULTS

Of 6837 articles identified, 10 were included (representing 9 studies). Eight of the 9 included studies found nutrition care in primary care settings to be more costly and more effective than usual care . High study heterogeneity limited further conclusions.

CONCLUSION

Nutrition care in primary care settings is effective, though it requires investment; it should, therefore, be considered in primary care planning. Further studies are needed to evaluate the long-term cost-effectiveness of providing nutrition care in primary care settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020201146.

Weight Management Interventions for Adults With Overweight or Obesity: An Evidence Analysis Center Scoping Review

The objectives of this evidence scoping review were to identify and characterize studies investigating weight management interventions provided by a registered dietitian nutritionist or international equivalent (RDN) among adults with overweight or obesity. A medical librarian conducted an electronic literature search in 6 databases-MEDLINE (Ovid), Embase (Ovid), PyscINFO (Ovid), Cochrane CENTRAL (Ovid), Cochrane Database of Systematic Reviews (Ovid), and CINAHL (Ebsco). Except for narrative review, gray literature, and case study or report, all types of peer-reviewed articles published between January 2008 and April 26, 2019 were eligible. Two content advisors, who are experts in adult weight management, guided the process and reviewed the search plan and findings. The literature search resulted in 30,551 records with 16 additional records identified through other sources. A total of 29,756 records were excluded during the first round of screening due to duplication or irrelevancy. Of the 811 full-text articles that were screened, 139 met the criteria and were included. Approximately 51% and 43% of the studies were conducted in the community setting and in the United States or Canada, respectively. Over 97% of the studies were clinical or quasi-experimental trials. A total of 6 different intervention delivery modes were reported, which resulted in 22 combinations of the modes of delivery. RDNs delivered the weight management intervention (especially the nutrition component) in all studies, but some (61%) also involved an interdisciplinary team to deliver other components of the intervention. The average length of the intervention was about 10 months with a follow-up that ranged from 0 to 9 years. The commonly reported outcomes were anthropometrics, endocrine, and cardiovascular measures; dietary intake; and physical activity. Based on the scoping review, there were systematic reviews and evidence-based practice guidelines on weight management interventions but none of them met the a priori inclusion or exclusion criteria. Therefore, it would be beneficial to conduct a systematic review and develop an evidence-based practice guideline on adult weight management interventions provided by an RDN to guide practitioners and to evaluate their effects on health and nutrition-related outcomes.

Economic benefit of dietetic-nutritional treatment in the multidisciplinary primary care team

Introduction

Chronic diseases and aging are placing an ever increasing burden on healthcare services worldwide. Nutritional counselling is a priority for primary care because it has shown substantial cost savings. This review aims to evaluate the evidence of the cost-effectiveness of nutritional care in primary care provided by health professionals. A literature search was conducted using PubMed/MEDLINE between January 2000 and February 2019. The review included thirty-six randomized controlled trials (RCTs) and systematic reviews conducted in healthy people and people with obesity, type-2 diabetes mellitus, cardiovascular risk or malnutrition. All the RCTs and reviews showed that nutritional intervention led by dietitians-nutritionists in people with obesity or cardiovascular risk factors was cost-effective. Dietary interventions led by nurses were cost-effective in people who needed to lose weight but not in people at high cardiovascular risk. Some dietary changes led by a primary care team in people with diabetes were cost-effective. Incorporating dietitians-nutritionists into primary care settings, or increasing their presence, would give people access to the healthcare professionals who are best qualified to carry out nutritional treatment, and may be the most cost-effective intervention in terms of health expenditure. Notwithstanding the limitations described, this review suggests that incorporating dietitians-nutritionists into primary health care as part of the multidisciplinary team could be regarded as an investment in health. Even so, more research is required to confirm the conclusions.

Impact of interventions to reduce overnutrition on healthcare costs related to obesity and type 2 diabetes: a systematic review

CONTEXT

In recent decades, obesity and type 2 diabetes mellitus (T2DM) have both become global epidemics associated with substantial healthcare needs and costs.

OBJECTIVE

The aim of this review was to critically assess nutritional interventions for their impact on healthcare costs to community-dwelling individuals regarding T2DM or obesity or both, specifically using CHEERS (Consolidated Health Economic Evaluation Reporting Standards) criteria to assess the economic components of the evidence.

DATA SOURCES

Searches were executed in Embase, EconLit, AgEcon, PubMed, and Web of Science databases.

STUDY SELECTION

Studies were included if they had a nutritional perspective, reported an economic evaluation that included healthcare costs, and focused on obesity or T2DM or both. Studies were excluded if they examined clinical nutritional preparations, dietary supplements, industrially modified dietary components, micronutrient deficiencies, or undernutrition; if they did not report the isolated impact of nutrition in complex or lifestyle interventions; or if they were conducted in animals or attempted to transfer findings from animals to humans.

DATA EXTRACTION

A systematic review was performed according to PRISMA guidelines. Using predefined search terms, 21 studies evaluating food habit interventions or taxation of unhealthy foods and beverages were extracted and evaluated using CHEERS criteria.

RESULTS

Overall, these studies showed that nutrition interventions and taxation approaches could lead to cost savings and improved health outcomes when compared with current practice. All of the included studies used external sources and economic modeling or risk estimations with population-attributable risks to calculate economic outcomes.

CONCLUSIONS

Most evidence supported taxation approaches. The effect of nutritional interventions has not been adequately assessed. Controlled studies to directly measure economic impacts are warranted.