Nutrition support for the critically obese patient Weight Management

Summer 2007
Volume 5, Number 1
Nutrition support for the
critically obese patient
By Britta Brown, RD, LD, CNSD
This article was reprinted with permission
from the Dietitians in Nutrition Support
DPG and originally appeared in the
February 2007 (Vol. 29, No. 1) issue of
Support Line.
Forward
Overweight and obesity are a concern
for registered dietitians (RDs) working
in the acute care setting. The Weight
Management (WM) Dietetic Practice
Group (DPG) is pleased to reprint this
article by Britta Brown, RD, CNSD
from Support Line, a publication of
Dietitians in Nutrition Support DPG.
The article highlights the medical and
metabolic impact of obesity during
critical illness and reviews research on
the selection of appropriate nutrition
interventions to optimize patient outcomes.
4. Identify potential benefits of a
hypocaloric feeding strategy for critically ill obese patients
5. Describe metabolic alterations
observed in the stressed obese patient
vs. the non-obese patient.
besity is a significant health
problem in the United States
and worldwide, with the numbers of people overweight (BMI [body
mass index] > 25.0 kg/m2) and obese
(BMI > 30.0 kg/m2) increasing annually.
Obese patients are predisposed to a wide
variety of comorbid conditions which
are exacerbated during critical illness.
Specialized nutrition support regimens
(SNS) required by critically ill obese
patients should provide needed nutrients
without causing or aggravating complications. The following article includes a
case study and a review of current
research addressing nutrition support
for critically ill obese patients.
O
Weight
Management
DPG’s
five-year
anniversary!
In this issue ...
Nutrition support for the
critically obese patient
1
CPEU questionnaire
10
CPE credit
questionnaire
10
Bariatric Surgery
Section
11
First Weight Management
DPG Symposium
highlights
12
Legislative Update
14
Chair’s Column
15
Member Spotlight
16
Learning objectives
Incidence of obesity
Meet the award winner
16
After reading this article the reader will
be able to:
Recent estimates published by the
Centers for Disease Control and
Prevention, using data from the 19992002 National Health and Nutrition
Examination Survey (NHANES), indicate that 65% of United States adults are
either overweight or obese (1). The
greatest increases are among individuals
with a body mass index (BMI) >35
kg/m2. It is estimated that 23 million
PID Update
17
Counseling for
Behavior Change
18
Network Activities Update
19
From the Editor
20
Pediatric Weight
Management
21
Upcoming Events
22
2006-2007 officer roster
28
1. Identify common challenges experienced when providing care for critically ill obese patients
2. Describe methods for estimating
energy needs for critically ill obese
patients
3. Outline typical energy and protein
goals for a hypocaloric feeding strategy in this setting
See Patient, page 2
Patient, from page 1
individuals have a BMI >35 kg/m2 and 8
million have a BMI >40 kg/m2 (2).
Medical complications related to obesity
are becoming more prevalent and complex and must be addressed when providing care for critically ill obese
patients.
Weight Management Newsletter
Medical and metabolic effects
of obesity
Obesity is associated with a wide array of
medical conditions that can be categorized into the broad categories of cardiovascular, pulmonary, gastrointestinal,
endocrine, skin and integument, immunity and cancer risk, musculoskeletal,
and psychosocial issues (3–5). Examples
of specific challenges facing clinicians
when providing care for the critically ill
obese patient are summarized in Table 1.
Furthermore, critically ill obese
patients appear to have altered metabolism, which can complicate the provision
of SNS. Jeevanandam and colleagues (6)
studied metabolic changes that occur
with injury-induced stress in traumatized obese patients (BMI >30 kg/m2).
In this study, 17 multitrauma patients
(seven with BMIs >30 kg/m2 and 10 with
BMIs <30 kg/m2) who were NPO,
mechanically ventilated, and did not
have sepsis or multi-organ failure, were
studied two to four days after injury.
The mean BMI of the obese group
was 36.2 kg/m2 and the mean BMI of the
nonobese group was 25.0 kg/m2. During
the course of the study, patients received
intravenous fluid and electrolytes, but
none of the treatments provided calories
or protein. Study measures included
indirect calorimetry (IC), 24-hour urine
urea nitrogen, calculation of energy
needs from the Harris Benedict equation, glycerol infusion (to determine
whole-body lipolysis rate), and [N] ??
glycine infusion (to determine wholebody protein turnover rate).
Key observations among patients with
BMIs greater than 30 kg/m2 compared
with the nonobese group included
increased free fatty-acid levels; decreased
glycerol levels; increased levels of
glucagon, insulin, cortisol, and C-pep-
Table 1. Critical care challenges
associatedwith obesity (3–5)
Respiratory
••
•
•
•
•
•
Cardiac
• Increased blood volume, cardiac output, stoke volume
• Decreased left ventricular contraction, ejection fraction
Medical dosing
•
•
•
•
Mechanics of breathing
CO2 retention
Obstructive sleep apnea
Aspiration pneumonia
Pulmonary embolism/deep vein thrombosis
Choosing a weight to use
Lipophilicity of medication
Decreased hepatic clearance of some medications
Creatinine clearance for renal dosing
• Difficulty placing and finding anatomical “landmarks”
Vascular access
• Difficulty placing at bedside and difficulty confirming
location
• Weight limits for fluoroscopy tables and endoscopy suites
Enteral access
• Weight limits for computed tomography scans, magnetic
resonance imaging, fluoroscopy, and interventional
radiology
• Radiography of poor quality
Imaging
General patient care
• Changing bed linens, bathing, bowel movements
• Clean skin/wound care
• Transporting patient out of the intensive care unit
• Lack of equipment (e.g., beds, lifts, chairs) designed for
obese patients
• Number of staff required to move patient in bed
• Injuries to nursing and other staff from moving/lifting
patient
tide; and overall increase in whole-body
protein turnover and synthesis rates
when expressed as a function of lean
body mass. Although there was no significant difference in measured resting
energy expenditure (REE) between the
two groups, the obese patients had a net
fat oxidation that accounted for only 39
± 3% of their REE, compared with a net
fat oxidation accounting for 61 ± 4% of
REE among nonobese patients. Net carbohydrate and protein oxidation rates
were significantly higher in the obese
patients compared to the nonobese
patients. The authors concluded that
under stress conditions, obese patients
could not take advantage of their abundant fat stores and had to depend on
endogenous glucose synthesized from
the breakdown of body protein. They
2
also hypothesized that the statistically
significant increase in C-peptide levels,
indicating a higher insulin production,
may inhibit fat mobilization. The
researchers concluded that the aim of
adequate feedings for stressed obese
patients should be “effective in preserving the functional lean body mass and
efficient in mobilizations of fat fuel
resources” (6).
Determination of energy
needs
In addition to altered metabolism,
another challenge related to the provision of SNS is determining an appropriate energy level. Because IC is not available in all health-care settings and it is
See Patient, page 4
Table 2. Predictive equations using obese and nonobese subjects (7-15)
Study design
Comments and outcomes
•
Author(s)
Number of patients
Frankenfield
2003 (7)
130;
nonhospitalized adults
grouped by degree of
obesity
Barak
2002 (8)
567;
individual IC measurements over nine years
Retrospective
review
Flancbaum
1999 (9)
36;
ICU patients,
mechanically ventilated
and on PN
Cohort
• Measure REE with IC
• Compare REE with Fick equation and predictive equations by HB, Ireton Jones, Fusco, and Frankenfield
• Poor correlation between REE and all predictive equations
• Advocate IC as the most appropriate clinical tool
Cutts
1997 (10)
110;
82 > IBW, 28 < IBW
Cohort
• Measure REE with IC
• Compare REE with HB equation
• Multiple diagnoses associated with variability in kcal
needs
• Use of HB with actual body weight resulted in
overfeeding
Amato
1995 (11)
113;
118 IC measurements
from 113 obese
mechanically ventilated
patients
Cohort
•
•
•
•
•
Ireton-Jones,
Turner
1991 (12)
130;
65 hospitalized and 65
non-hospitalized, both
groups at least
30% > IBW
Cohort
• Measure REE using IC
• Regression analysis to develop predictive equation
• Actual body weight better predictor of energy
expenditure than IBW
Ligget
1987 (13)
19;
65 hospitalized and 65
non-hospitalized, both
groups at least
30% > IBW
Cohort
•
•
•
•
• Measure REE with IC
• Compare with HB, HB with adjusted body weight, Owen,
and Mifflin equations
• Mifflin equation accurate for the largest proportion of
obese and nonobese patients
• Use of HB with adjusted body weight less overestimation, but increased incidence of underestimation
• Use of HB with actual weight led to overestimation of
energy needs
Cohort
• Use REE from IC to develop disease-specific stress
factors
• Advocate use or adjusted body weight of IBW plus 50%
of excess body weight
Measure REE using IC
All patients had FIO2 of 50% or less
Compare with Fick equation and fixed RQ of 0.85
Largest difference between methods was 276 kcal./day
Continued on page 4
3
Volume 5, Number 1, Summer 2007
Measure REE with IC
Compare REE with 7 predictive equations
2
2
BMI ranged from 35 to 73 kg./m (mean=52 kg./m )
Bias, lack of precision with predictive equations
Advocate IC as the most appropriate clinical tool
Table 2. Predictive equations using obese and nonobese subjects (7-15)
(Continued)
•
Author(s)
Number of patients
Study design
Comments and outcomes
Pavlou 1986
(14)
31
Cohort
• Compare HB equation with REE from IC
• Measured REE was less than HB equation using actual
body weight (92±10% predicted)
• Measured REE was greater than HB equation using
IBW (119 ±12%)
Feurer 1983
(15)
112
Cohort
• Measure REE with IC prior to gastric bypass surgery
• Compare with HB equation using current and ideal weight
• Measured REE significantly less than expected (P<0.01)
with current weight and significantly greater than expected (p<0.01) with ideal weight
• Wide variation: only 13% within 10% of expected REE
REE=resting energy expenditure, RQ=respiratory quotient, IC=indirect calorimetry, FIO2=fraction of inspired oxygen, HB=Harris-Benedict
equation, PN=parenteral nutrition, ICU=intensive care unit, IBW=ideal body weight, BMI=body mass index
Patient, from page 2
Weight Management Newsletter
Table 3. Published studies on nutrition
support in obese patients (19–23)
Author(s)
Study
design/route
of feeding
Hypocaloric/
control (n)
Protein
(g./kg.day)
Total
(g./kg.day)
HC
Dickerson,
2002 (23)
Retrospective/
enteral
28/12
1.3/1.6 IBW
~2.0 adj BW
18.6/27.2 IBW
Liu, 2000
(22)
Prospective/
Parenteral
30/0
0.74/1.0 ABW
1.64 adj BW
~18/24 ABW
Choban,
1997 (21)
Prospective/
Randomized
DB
16/14
2.0/2.0 IBW
1.2/1.2 ABW
~22/36 IBW
13.5/22.4 ABW
Burge, 1994
(20)
Prospective/
Randomized
DB
9/7
2.0/2.2 IBW
1.2/1.3 ABW
22/42 IBW
14/25 ABW
Dickerson,
1986 (19)
Prospective/
Parenteral
13/0
2.1 IBW
1.2 ABW
N/A
(Provide 51.5% of
REE as nonprotein
kcal.
DB = double-blind, H = hypocaloric, C = control, IBW = ideal body weight, ABW = actual
body weight, adj BW = adjusted body weight.
Adapted from Choban PS, Dickerson RN. Morbid obesity and nutrition support: is bigger different? Nutr Clin Pract. 2005;20:480–487. Reprinted with permission from the American
Society of Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N. does not endorse the use
of the material in any form other than its entirety.
4
not necessarily ideal to provide 100% of
energy needs based on the measured
REE, clinicians have relied on predictive
equations. One common concern related
to the use of predictive equations is
choosing which weight to use with the
equation. Actual body weight use may
overestimate energy needs, and adjusted
body weight lacks rigorous validation;
ideal or desirable body weight may
underestimate energy needs.
Furthermore, equations such as the
Harris-Benedict equation were developed using primarily healthy normalweight people, which may make the
equation inappropriate to use in critically ill obese patients.
Frankenfield and colleagues (7) compared several predictive equations for
obese and nonobese subjects and found
that the Mifflin equation is more accurate more often than the Harris-Benedict
equation among obese subjects (7).
Moreover, the Harris-Benedict equation
failed to predict resting metabolic rate
67% of the time for men with BMIs over
50 kg/m2.
Multiple investigators have studied
the use of predictive equations for
nonobese and obese individuals, and
there is no consensus on which weight
and which predictive equation should be
used for critically ill obese patients.
Some of the predictive equations developed or studied in obese populations
included subjects who were healthy or
not hospitalized. It may not be appropriate to apply the findings from these
studies to a group of critically ill obese
patients. Clinicians and researchers must
examine whether the goal of using a predictive equation for critically ill obese
patients is to maintain an obese patient’s
current body mass, promote modest
weight reduction, minimize metabolic
intolerances to SNS, or a combination of
these factors.
Key findings from research examining
the use of predictive equations for obese
subjects are summarized in Table 2
(7–15). For a more detailed analysis of
studies addressing predictive equations
for obese patients and the use of actual
body weight versus adjusted body
weight, refer to the American Dietetic
Association’s Evidence Analysis Library
for the evidence summaries: HarrisBenedict Individual Errors: Obese
Adults, Harris-Benedict Mean Errors:
Obese Adults, and Harris-Benedict
Formula Overview Table (16–18).
Hypocaloric feeding strategies
Admit weight
317.2 kg.
Current weight
262.0 kg. (hospital day 4, following ultrafiltration for
anasarca)
Usual body weight
~ 270 kg.
% Usual body weight
97%
Weight history
Four years ago: 258 kg.; two years ago: 286 kg.
Ideal body weight
65 kg. ± 10% (Hamwi equation)
% Ideal body weight
403% (current weight)
Body mass index
93 kg./m2
Height
5 feet 6 inches (167.6 cm)
Physical examination
findings on admission
Morbidly obese male, anasarca of the abdomen and
extremeties, skin intact
published studies on nutrition support
in obese patients (19-23).
Early studies examining a hypocaloric
feeding strategy typically based total
energy needs on providing approximately 50% of REE derived from IC measurements (20). Later studies (21) used a
fixed proportion of amino acids, dextrose, and lipid and provided 2.0
kcal./kg. per ideal body weight (IBW),
with limited use of IC measurements.
Using this approach, Choban and colleagues (21) demonstrated no difference
between obese patients being fed using
this approach and the obese controls
who received an isonitrogenous, normoenergetic PN formula. There was no
difference between each PN group’s
albumin levels, and both groups were
able to achieve positive nitrogen balance
(21).
Furthermore, patients with type 2
diabetes mellitus required significantly
fewer days on insulin with a hypocaloric
feeding regimen compared with those
receiving the standard PN solution (21).
Patients were excluded from this study if
renal or hepatic issues prevented tolerance of this protein level (21).
Liu and associates studied two groups
of postsurgical patients receiving PN
who had a current body weight greater
than 120% IBW and less than or equal
5
to 150% IBW (22). Group I consisted of
patients younger than 60 years of age,
and group II consisted of patients 60
years of age and older. Group I had a
mean age of 39 ± 12 years and Group II
had a mean age of 69 ± 6 years. The
researchers found that significantly fewer
of the older patients achieved positive
nitrogen balance (P < 0.06), compared
with the younger patients when both
groups received a hypocaloric PN regimen.
However, most patients in both
groups were able to achieve positive
nitrogen balance, and there was no difference in morbidity and mortality
between age groups (22). The authors
hypothesized that obese patients older
than age 60 may be less able to mobilize
their fat stores for energy when receiving
hypocaloric feedings, and they urged
caution when feeding this subset of
patients (22).
The first study examining hypocaloric
enteral feedings was published by
Dickerson and colleagues in 2002 (23).
In this retrospective study, 40 trauma or
surgical patients, ages 18 to 69 years,
began enteral feedings within five days of
intensive care unit (ICU) admission.
The patients were divided into eucaloric
(25 to 30 kcal./kg. adjusted body weight)
See Patient, page 7
Volume 5, Number 1, Summer 2007
Due to inherent flaws with predictive
energy equations and observations that
traditional nutrition support practices
are not effective among critically ill
obese patients, “hypocaloric” or “permissive underfeeding” strategies have been
advocated. Such regimens were developed based on observations that traditional approaches used for nonobese
patients led to metabolic abnormalities
such as hyperglycemia and hypercapnia
among obese patients. The general goal
of a hypocaloric nutrition support strategy is to provide low-calorie, high-protein feedings that minimize the effects of
“overfeeding”, while minimizing the loss
of lean body mass. Initial studies
involved primarily surgical and trauma
patients receiving parenteral nutrition
(PN), but favorable results have now
been demonstrated among enterally fed
patients as well. Table 3 summarizes
Table 4. JT’s weight history and physical
examination findings
Weight Management Newsletter
Table 5. JT’s hospital course
Hospital
day
Key medical events
Pertinent laboratory
data
Nutrition support regimen
1 through 4
• Intubated and sedated
• Propofol at 72 mL./hour = 1,900 kcal.
• Difficulty placing central line due to
anasarca and adipose tissue in neck
• Placed on rotating bariatric bed
• IC reveals REE = 3928, RQ = 0.69
•
•
•
•
• NPO
• IVF: D5NS 50 mL./hour
= 204 kcal.
5 through 7
•
•
•
•
•
On SCUF (ultrafiltration)
Temperature 102.4° F
Renal function worsening
Propofol discontinued
Triglycerides elevated, but plan to
re-check after stopping propofol
• IV lipid provided in PN
•
•
•
•
BUN: 36 mg/dL
Creatinine: 2.8 mg./dL.
Glucose: 154 mg./dL.
Liver function tests
(LFTs) within normal
limits
• Triglycerides:
445 mg./dL.
• PN: D14AA6.8 at 65 mL./hr. and
20% lipid emulsion at 12 mL./hr.
x 18 hr.
= 1599 kcal., 106 g. pro
Standard MVI-12® and trace elements (copper, selenium, zinc,
manganese, chromium) provided
8
• Insulin drip 10 U/hour
• Continuous venovenous hemodialfiltration
(CVVHD) started for renal failure
• Attempting to place feeding tube at bedside
• BUN: 43 mg./dL.
• Creatinine: 3.1 mg./dL.
• Glucose: 235 to 492
mg./dL.
• Potassium and phosphorus controlled with
CVVHD
• PN off until blood glucose can be
controlled ~100 to 140 mg./dL.
9 through 15
• Remains on CVVHD
• PN changed to decrease dextrose kcal.
• Unsuccessful attempt to place feeding
tube at the bedside
• Percutaneous tracheostomy placed at
bedside
• 150 U insulin added to PN, in addition to
insulin drip
• Skin red, but intact
• BUN: 58 mg/dL
• Creatinine: 2.7 mg/dL
• Glucose: 107 to 174
mg./dL.
• Prealbumin: 13.8
mg./dL.
• PN: D10AA7 at 65 mL./hr. and
20% lipid emulsion, 10 mL./hr. x
18 hr. = 1,326 kcal., 109 g. pro
• Standard MVI-12® and trace
elements (copper, selenium,
zinc, manganese, chromium)
provided
16 through
35
• Still unable to place feeding tube
• PN adjusted to provide additional protein
• CVVHD discontinued, changed to intermittent hemodialysis, and then discontinued
• Insulin drip up to 23 U/hr. + 100 U insulin
in PN
• Nitrogen balance = -4.77 g.
• IC reveals REE = 3,970, RQ = 0.68
• Stage II to III skin breakdown on buttocks,
coccyx, shoulders and tracheostomy site
• BUN: 57 mg./dL.
• Creatinine: 0.6 mg./dL.
• Glucose: 107 to 136
mg./dL.
• LFTs, potassium, and
phosphorus within
normal limits
• Triglycerides: 245
mg./dL.
• PN: D10AA9 at 65 mL./hr. and
20% lipid emulsion at 8 mL./hr.
x 18 hr. = 1,378 kcal., 140 g.
protein
BUN: 13 mg/dL
Creatinine: 0.9 mg./dL.
Glucose: 127 mg./dL.
Albumin: 3.3 g./dL.
Continued on page 7
6
Table 5. JT’s hospital course (Continued)
Hospital
day
Key medical events
Pertinent laboratory
data
Nutrition support regimen
36 through
51
• Gastrointestinal service places feeding
tube with endoscope
• IC reveals REE = 3,572, RQ = 0.77
• Insulin drip 10-22 U/hr.
• Stooling 500-950 mL./day, rectal tube
placed (to protect skin)
• Clostridium difficile negative
• Stage III to IV skin breakdown
• Plastic surgery service unable to intervene
surgically
• Becomes septic from presumed skin
infection
• BUN: 35 mg./dL.
• Creatinine: 0.7 mg./dL.
• Glucose: 135 to 204
mg./dL.
• PN: Weaned off
• Enteral tube feeding: Highprotein polymeric formula at 55
mL./hr. with protein powder =
1,500 kcal., 117 g. protein,
1,118 mL. H2O
• Plan to increase protein level
once tolerating current goal tube
feeding
• 750 mL. H2O 4 x/day
• Multivitamin plus minerals once
daily via feeding tube
52 through
55
• Ileus develops, nasogastric tube to
suction
• Primary team and all consulting teams
agree no other medical or surgical options
remain
• Distant relatives and close friends agree
to withdraw support
• BUN: 53 mg./dL.
• Creatinine: 1.2 mg./dL.
• Glucose: 103 to 142
mg./dL.
• Chloride: 113 mg./dL.
• CO2: 18 mEq/L.
• Albumin: 2.6 mg./dL.
• Alkaline phosphatase:
414 U/L.
• Aspartate aminotransferase: 113 U/L.
• Enteral tube feeding
discontinued
• Intravenous fluids: D5W + 3
ampules HCO3 at 75 mL./hour =
306 kcal.
Patient, from page 5
7
gen balance for patients receiving
hypocaloric feedings and adjusting the
protein level as clinically indicated (2).
Renal and hepatic tolerance to the provided protein must be monitored. These
authors advocate use of IC for patients
who are not achieving expected clinical
outcomes.
Significant positive findings from the
original van den Berghe trial, which
evaluated tight glycemic control for critically ill surgical patients (24), as well as
the more recent van den Berghe trail
that included patients from medical
intensive-care units (25), highlight
improved patient outcomes associated
with maintaining euglycemia. Studies
that evaluated the metabolic changes
that occur among stressed obese patients
(e.g., increased concentrations of
glucagon, insulin, cortisol, and C-peptide) (6) and improved clinical indicators (number of ICU days, number of
See Patient, page 8
Volume 5, Number 1, Summer 2007
and hypocaloric (<20 kcal./kg. adjusted
body weight) groups, both of which
received 2.0 g./kg./IBW protein. During
the four weeks of data collection, the
eucaloric group received a weekly range
of 18.5±4.4 kcal./kg. current weight per
day during week 1 up to 25.9 ± 5.5
kcal./kg. current weight/day during week
3.
The hypocaloric feeding group
received 13.4±4.1 kcal/kg current
weight/day during week 1 and up to
19.2±4.6 kcal/kg current weight per day
during week 4. The hypocaloric enteral
feeding involved a high-protein enteral
formula with the addition of a protein
powder supplement. Positive findings
from the hypocaloric group (compared
with the eucaloric group) included 10
fewer ICU days (P≤0.03), 10 fewer
antibiotic days (P≤0.03), and a trend
toward 8 fewer ventilator days that did
not reach the level of significance
(P≤0.09) (23). There was no difference
between groups for complications such
as pneumonia, intra-abdominal abscess,
empyema, or sepsis, and there was no
difference in study parameters, including
nitrogen balance, albumin, prealbumin,
or length of stay (23).
The study of hypocaloric feeding
strategies continues to evolve, and recent
efforts have focused on better understanding the protein requirements for
obese patients who have class III obesity
(BMI > 40 kg./m2). In a report published
in 2005, Choban and Dickerson (2)
combined their databases from previous
studies and used regression analysis to
determine that a minimum of approximately 1.9 g. of protein per kilogram of
IBW per day is needed to achieve nitrogen equilibrium in patients with class I
or II obesity, but a higher intake of
approximately 2.5 g. of protein per kilogram of IBW per day is likely needed for
patients with class III obesity. They
advocated weekly monitoring of nitro-
Patient, from page 7
antibiotic days, number of ventilator
days, insulin requirements) associated
with hypocaloric feeding regimens (21,
23) suggest this feeding approach may
improve glycemic control in conjunction
with continuous insulin infusions.
Preventing metabolic complications
from SNS is extremely important in this
patient population and may be a key to
improving patient outcomes.
The current body of research supports the routine use of hypocaloric
feeding regimens for obese patients who
can tolerate approximately 2 g. of protein per kilogram of IBW. Future studies
should include larger sample sizes,
longer time periods of study, more
emphasis on enteral route of feeding,
stratification of different ICU populations (e.g., trauma, surgical, burn, medical, sepsis), and a focus on patients with
class III obesity.
Weight Management Newsletter
Case study
JT is an obese 42-year-old male admitted
to the medical intensive-care unit with
admitting diagnoses of anasarca, cellulitis of his abdominal pannus, and hypercapnic respiratory failure.
JT has been living in a nursing home
one year prior to this hospitalization due
to an inability to care for himself. Before
residing at the nursing home, he was
intermittently homeless or living with
friends. He has seen outpatient RDs,
physicians, and bariatric surgeons
regarding weight-loss treatments, but he
was not considered a surgical candidate
due to his BMI of 93 kg./m2 and his history of alcohol abuse.
His past medical history includes
obesity, alcohol abuse, anasarca requiring ultrafiltration, sleep-related
hypoventilation and obstructive sleep
apnea, asthma, cellulitis, hyperlipidemia,
hypertension, left ventricular hypertrophy, and depression. He is single, has no
siblings, and his parents are deceased.
He has an intermittent history of binge
drinking, but has never received chemical dependency treatment.
Previous medications include a multivitamin with minerals, spironolactone,
Table 6. Assessment of JT’s
nutritional status
Estimated energy
needs
• Harris-Benedict (IBW and SF of 1.4) = 2,125 kcal.
• 25 kcal./kg. IBW = 1,625 kcal.
• Ireton-Jones (Actual weight) = 2,876 kcal.
• 21 kcal./kg. adjusted weight (114 kg.) = 2,394 kcal.
• 50% of REE = ~1,745 to 1,985 kcal. (20)
• 50% of REE (non-protein kcal) = ~1,500 to 1,700 kcal (19,21)
Very difficult to estimate kcal. needs in severely obese patients.
Measured energy
needs
• REE = 3,928, RQ = 0.69
• REE = 3,970, RQ = 0.68
• REE = 3,572, RQ = 0.77
Estimated protein
needs
2.0-2.5 g./kg. IBW = 130-162 g. protein (2,19,21,23)
(CVVHD, skin breakdown, sepsis, increased needs with
hypocaloric feeding strategy)
Estimated fluid
needs
Varied with renal function (urine output, type of dialysis,
and recovery of renal function), temperature, and losses
from stool and decubitus ulcers
Hypocaloric
feeding regimen
~ 1,500 kcal./day (minimum goal) (19,21)
Vitamin and
mineral needs
• Standard vitamins, minerals, and trace elements while
receiving PN
• Multivitamin and minerals via feeding tube
• Separate vitamin C, zinc, or arginine supplements were
not used
Limited data regarding the specific micronutrient needs of
this patient population.
Adequacy of
intake
Challenging to define the calorie and protein levels that
would have been “adequate” for this patient. Despite using a
hypocaloric, high-protein feeding regimen, multiple challenges occurred including: difficulty placing central lines and
feeding tubes and managing hyperglycemia and insulin
resistance. These issues prevented the team from increasing calorie intake beyond 1,300 to 1,500 kcal./day. When
receiving nutrition support, provided 106 to 140 g.
protein/day (1.6 to 2.2 g./kg./IBW)
Nutrition risk
factors
• OBESITY-BMI of 93 kg./m
• Periods of delayed or interrupted SNS due to lack of
access
• Skin breakdown/wound healing nutritional needs
• Immobility
• Presumed losses of fluid, vitamins, minerals from stool
and decubitus ulcers that were unable to be quantified
• Renal failure requiring CVVHD and hemodialysis
• Hyperglycemia associated with obesity, sepsis, presumed infection originating from decubitus ulcers, and
intermittent steroid use
2
8
furosemide, topiramate, and sertraline.
Currently he is receiving all of his medications intravenously. He is receiving a
multivitamin, heparin, ranitidine, calcitriol, spironolactone, furosemide, ceftazidime, topiramate, potassium chloride, and fentanyl. He is sedated with
propofol at 72 mL./hour, which provides
approximately 1,900 calories from the
lipid emulsion used to deliver this medication.
His weight history and findings on
physical examination are noted in Table
4. For the last year, meals have been provided by the nursing home. Typically, JT
slept through breakfast and only ate one
to two meals per day. He drank up to 32
oz. of juice or regular soda daily and
snacked on potato chips or pretzels.
Friends brought him fast food once or
twice a month. JT was taking a multivitamin with minerals, but no other vitamin, mineral, herbal, or other supplements.
On the first hospital day, JT was intubated, sedated, and placed on a rotating
bariatric bed (Table 5). His energy
requirements were assessed using IC,
which revealed an REE of 3,928 kcal. and
a respiratory quotient (RQ) of 0.69
(Table 6). The nutrition support team
set the following goals for the treatment
of JT:
■ Achieve
Renal function worsened over the
next few days. A standard high-protein
PN solution used at the facility was initiated. The initial PN included D14AA6.8
at 65 mL./hour and 20% lipid emulsion
at 12 mL./hour for 18 hours and provided 1,500 kcal. and 106 g. protein. JT was
no longer receiving lipid calories from
propofol, and all intravenous fluids provided were dextrose-free. On day 8, continuous venovenous hemodiafiltration
(CVVHD) using a dialysate solution
containing negligible dextrose was begun
to address his renal failure, and attempted placement of a feeding tube at the
bedside failed. PN was discontinued
until blood glucose (235 to 492 mg/dL)
could be controlled.
Further attempts to place a feeding
tube were unsuccessful because of difficulty with auscultation and radiography
to confirm feeding tube location and
challenges in passing the feeding tube
down the esophagus because of excess
adipose tissue in the neck. PN was reinstated, with decreased dextrose and
added insulin. Improving renal function
prompted the discontinuation of
CVVHD and change to intermittent
hemodialysis, which was eventually discontinued. After approximately three
weeks of hospitalization, skin breakdown
became evident on the buttocks, coccyx,
shoulders, and at the tracheostomy site.
Skin breakdown could be attributed primarily to JT’s inadequate circulation,
immobility, and the pressure resulting
from his body weight. However, citing
current research (2), the PN was adjusted to provide additional protein and the
9
insulin drip was increased.
More than five weeks after admission,
the gastrointestinal service successfully
placed a feeding tube endoscopically, and
PN was discontinued. A standard highprotein enteral formula and protein
powder was initiated and titrated to a
goal rate of 55 mL./hour. Enteral feeding
provided 1,500 kcal., 117 g. protein, and
1,118 mL. water. Additionally, 750 mL/
water was provided four times daily for
the patient’s fluid needs associated with
increased insensible losses. The plan was
to increase the protein concentration
once JT was tolerating the current volume of tube feeding to achieve at least 2
g. protein per kilogram IBW. Skin breakdown worsened, and plastic surgery was
unable to intervene because JT could not
be moved consistently while on the ventilator, making it difficult for any skin
grafts to heal. Sepsis developed followed
by an ileus. After consultation with the
medical team, regarding limited options
for ongoing intensive medical interventions and JT’s grave prognosis, distant
relatives and close friends agreed to
withdraw the ventilator and all aggressive therapies, including nutrition support.
Although JT’s renal failure caused by
See Patient, page 26
Volume 5, Number 1, Summer 2007
enteral route of feeding as
soon as possible
■ Normalize blood glucose and electrolytes
■ Control blood glucose with insulin
drip and/or insulin added to PN
■ Attempt to prevent vitamin and mineral deficiencies
■ Provide hypocaloric, high-protein
feeding to minimize the effects of
hyperglycemia and the consequences
of overfeeding
■ Provide adequate protein for skin
integrity and losses from hemodialysis
Figure 1. JT’s predicted and measured
energy needs
CPE Credit
PhD, RD, to receive your certificate of completion: article title,
request for CPEU credit, name, address, telephone number, email address, and American Dietetic Association (ADA) member registration number.
Instructions
The Commission on Dietetic Registration (CDR) has
approved the article, “Nutrition Support for the Critically Ill
Obese Patient” for one hour of continuing professional education (CPE) credit. CPE unit (U) eligibility is based on
active Weight Management (WM) Dietetic Practice Group
(DPG) membership status from June 1, 2007 to May 31,
2008.
Paula Peirce, PhD, RD
14901 E. Hampden Ave., Suite 110
Aurora, CO 80014
[email protected]
4) Once this information has been received, Paula will e-mail
your certificate of completion for the CPE credit. Retain the
certificate for your records in case CDR audits you.
Instructions to receive credit:
1) Read the article, “Nutrition Support for the Critically Ill
Obese Patient.”
5) WM members receive credits by contacting Paula Peirce
within one year of the original publication of this article. Since
this article was originally published in Support Line in
February 2007, member participants may obtain CPEU credit
until February 29, 2008.
2) Answer the following single-answer, multiple-choice questions. For each question, select one best response. Compare
your answers to the answer key on page 29.
3) Mail or e-mail the following information to Paula Peirce,
CPEU self-assessment questionnaire
“Nutrition Support for the Critically Ill Obese Patient”
Weight Management Newsletter
Answer the following questions. Follow the directions above
to obtain CPEUs for reading this article.
1. Provision of specialized nutritional support (SNS) in critically ill obese patients presents certain challenges which
include all of the following EXCEPT:
A. lowered fat oxidation rates
B. metabolic alterations
C. accurately predicting energy needs
D. decreased cortisol levels
2. Current research indicates that among the predictive equations for estimating energy needs in critically ill obese patients
that the _________ equation appears to be the most accurate.
A. Harris-Benedict
B. Harris-Benedict with adjusted body weight
C. Mifflin
D. Owen
3. In comparing metabolic changes that occur in obese vs.
nonobese injury-induced trauma patients, Jeevanandam and
colleagues found that obese patients had:
A. higher net protein oxidation rates
B. significantly lower measured resting energy expenditure
C. decreased levels of glucagon and C-peptide
D. no significant difference in percentage of fat oxidation of
their REE
4. Considerations in determining an appropriate energy level in
critically ill obese patients include all of the following EXCEPT:
A. BMI
B. choosing an appropriate weight for predictive energy
estimation equations
C. necessity of providing 100% of energy needs based on
measured REE
D. metabolic intolerances
5. In patients with class III obesity (BMI > 40 kg./m2),
Choban and Dickerson determined that ______ g. of protein
per kilogram of IBW per day is needed to achieve nitrogen
equilibrium.
A. 1.2
B. 1.9
C. 2.5
D. 3.0
6. A possible goal(s) of using a predictive equation to estimate
energy needs in critically obese patients clinicians would be:
A. maintenance of current body mass
B. promotion of modest weight reduction
C. minimizing metabolic intolerance to SNS
D. all of the above
7. Potential benefits of hypocaloric feeding strategies in critically ill obese patients include:
A. improved glycemic control
B. dependence on endogenous glucose
C. increased lean body mass.
D. negative nitrogen balance.
10
Outcomes: bariatric surgery patient quality of life measurement
A
Team tasks
Our team included two workshop leaders who guided us through the process,
two of our bariatric surgeons, a physician skilled in outcome measures, the
nurse who manages the bariatric surgery
program, a coding specialist, a biostatistician, a health researcher, and a registered dietitian (myself).
We divided our work into three
groups: one group identified post-operative complications, the second worked
on minimizing duplicate efforts in the
collection of data for our patients (e.g.,
how many places were a weight, medication or allergy recorded?), and the third
group looked at the patient experience as
it relates to health outcomes and quality
of life measures.
Bariatric
Surgery
Section
n an effort to understand and
meet the health and quality of life
goals of the bariatric surgery
clients, this article by Susan Deno,
RD/LD, addresses processes used
to obtain information from both
pre- and post-surgical clients
about what mattered most to them
in their weight loss pursuit.
I
Deanna Duvall, RD, is
is the Bariatric
Surgery Section editor.
Currently, most bariatric surgery
programs meet the clients’ needs
for weight management education
prior to surgery. Specific to the
RD, the author found that there
was also a great need for us to
provide long-term post-surgical
weight management education
and support.
Data collection
Patient input
I was part of the third group that
looked at health outcomes and quality
of life measures. To collect this information, we investigated patients’ goals
and expectations of bariatric surgery.
Our methods of collection included
examining patients’ written documentation and interviewing post-surgery
patients.
To better understand patients’ goals
as they approached bariatric surgery,
we used the “Letter of Intent” composed by each patient prior to surgery.
In this letter, patients are asked to
include information about how their
obesity is affecting their health, mental
well-being and quality of life; how they
expect their life to change after weight
loss surgery; and why they consider
themselves a good candidate for obesity
surgery.
For the post-surgery interviews, we
developed a brief questionnaire to conduct standardized telephone interviews.
Findings from a literature review of
outcomes and quality of life measures
in bariatric surgery patients, as well as
clinician knowledge, were used to
develop the questionnaire.
We conducted a content analysis of 51
patient letters of intent. From the analysis, we identified eight areas of concern:
disease management, joint/back pain,
mental health, physical activity/mobility,
numerous failed diet attempts, social
issues, public distress, and prevention of
future health problems.
Next, I conducted nine telephone
interviews with patients who were two to
three years post-surgery and had not
returned for annual follow-up. I felt
privileged to hear their stories about
goals they had set for themselves prior to
surgery, whether those goals were met or
not, and their current goals in regard to
health and quality of life. The patients
recalled many goals concerning health
improvement, weight loss, improving
back and joint pain, increasing mobility,
learning to use their weight-loss tools
(e.g., modified stomach pouch), improving mental health, and increasing activity.
The final step was to evaluate how we
gathered this information. We wanted to
streamline this process, as well as verify
that what we were measuring and
11
See Bariatric, page 25
Volume 5, Number 1, Summer 2007
s clinicians,
we know that
bariatric surgery improves the
health and quality of
life of our patients.
However, one major
challenge is showing
Susan Deno,
our patients these
RD/LD, is the manbenefits in a meanager of nutrition
ingful way. Park
services in Health
Education
Nicollet Health
Services, the health- Department at the
Park Nicollet
care organization
Institute in St.
where I work, is com- Louis Park, Minn.,
mitted to understand- where she has
worked with the
ing the “measures that bariatric surgery
matter” to our
program for eight
patients. The organi- years. Contact her
at [email protected]
zation has adopted
parknicollet.com.
the process improvement methodology of kaizen. (Learn
more about kaizen at www.lean.org and
www.gemba.com.) The goal is to create
highly reliable processes that efficiently
and effectively meet the needs and
requirements of our customers. Recently,
I participated in a kaizen event which
included, as part of the task, beginning
to define and answer the question,
“What matters to patients who are pursuing bariatric surgery?”
First Weight Management DPG Symposium highlights: Changing
the Weight Management Landscape—Redefining Success
By Chris Weithman, MBA, RD, LDN.
Chris is the WM professional development
director.
he inaugural Weight Management
(WM) Symposium was held May
4-6 at the Firesky Resort and Spa
in Scottsdale, Ariz. The setting was intimate and relaxing as the resort catered
to our every need. Over 150 attendees
had the opportunity to relax, enjoy the
desert setting, and learn and participate
in an amazing symposium. To get us
started, there was an exercise session
every morning led by Cathy Leman, RD,
who is also a certified personal trainer.
Dr. Sam Klein, (credentials) set the
tone for the meeting with a scientific but
humane view of obesity treatment. Dr.
Klein took questions throughout his
talk, which encouraged the attendees to
ask thoughtful questions in this session
and throughout the meeting.
The Evidence Analysis Library (EAL)
and the Adult Weight Management
Evidence Analysis Project were referenced in most talks throughout the
weekend. Dr. Deborah Cummins, PhD,
RD, American Dietetic Association
(ADA) director of research and evidence
analysis, provided a thorough explanation of what a critical tool this is for all
practitioners. Dr. Cummins also donated
two copies of the Adult Weight
Management Toolkit to the raffle held at
the opening reception and announced
that this important tool would be available in June for members to purchase. To
learn more about the EAL, all WM
members should look for a free tutorial
on the EAL Web site at www.adaevidencelibrary.com; completing the tutorial provides one continuing professional
education unit (CPEU).
The event provided practice applications in all of the following areas: the
role of protein in medical nutrition therapy (MNT), pediatric issues when treating the entire family in a cross-cultural
setting, incorporating exercise into an
Weight Management Newsletter
T
adult treatment plan, use of medications
for weight management, issues with
regard to MNT after bariatric surgery,
research on the use of meal replacements, prevention programs in a school
setting, and behavioral counseling techniques. The weekend was complete with
two presentations that discussed the
political and financial aspects of obesity
and how registered dietitians can stay
abreast on these issues.
Congratulations to the 20 WM members who received $100 stipends to put
toward their symposium registration
expenses: Brenda Buck, Heather Cherry,
Karen Creswell, Cynthia Davis, Patricia
Friedlander, Dolores Galaz, Nancy Marie
Harvin, Patricia Howell, Martha Kratzer,
Lou Kupka-Schutt, Devora Lattimore,
Carolyn Marchie, Melissa Martilotta,
Katherine Michalski, Beverly Miller,
Deborah Pfeiffer, Sharon Salomon, Staci
Stone, Lisa Talamini, and Franne Wilk.
(need credentials for all)
Networking, sharing ideas, increasing
knowledge, learning practice applications, and taking time to relax all contributed to attendees feeling charged
with new information to take back to
their jobs and practices. The stage is set
for future symposiums to achieve these
goals and more. Look for information in
blast e-mails and our updated Web site
regarding the 2008 symposium as plans
develop this summer.
Thank you to all of our speakers,
sponsors, exhibitors, our meeting planner and the symposium committee for
this fabulous inaugural event. It will
remain “a must-attend event” for our
members and all of those who practice
in the field of weight management.
2007 Weight
Management
Symposium sponsors
Platinum Sponsors
Lean Cuisine
Kellogg Company—ADA Premier
Sponsor
Gold Sponsors
Quaker/Tropicana
Silver Sponsors
Accusplit
Enova ADM/Kao
General Mills Bell Institute of Health
and Nutrition
Health Management Resources
H.J. Heinz
Microlife
National Cattleman’s Beef
Association **
McNeil Nutritionals, Inc
Slimfast/Unilever—ADA Partner
Wrigley’s Science Institute
Exhibitors
Acusplit
Bob’s Red Mill
Enova ADM/Kao
Fruit Research Center
Quaker/Tropicana
Health Management Resources
Kellogg Company—ADA Premier
Sponsor
Lean Cuisine
Lifesteps
Microlife
National Cattleman’s Beef
Association
Novartis/Optifast
Nutrafit, Inc
Slimfast/Unilever—ADA Partner
Walden Farms
Wrigley’s Science Institute
Raffle Donations
Cabot Cheese
American Dietetic Association
Joanne Ikeda, RD
A special thank you to
Slimfast/Unilever for sponsoring our
first Weight Management Excellence
Award!
12
nt DPG Symposium highlig
e
m
e
g
a
n
a
M
t
h
h ts
Weig
Volume 5, Number 1, Summer 2007
13
Legislative Update
Report from the 2007 Public
Policy Workshop
he 2007 American Dietetic
Association (ADA) Public Policy
Workshop (PPW) titled
“Champion Nutrition” was held April 2325, 2007 in Washington, D.C. Over 400
ADA members attended, including the
following Weight Management (WM)
Dietetic Practice Group (DPG) Executive
Committee members attended: Chris
Biesemeier, MS, RD, LDN, FADA, 20062007 chair; Monica Krygowski, MS, RD,
LD, 2006-2007 chair-elect; and me as public policy director. As usual, this event was
inspiring and motivating to all attendees
(particularly the approximately 100 students who attended), and provided an
opportunity to showcase how the ADA is
a leader in public policy on Capitol Hill
and to learn the specifics of the ADA legislative agenda. Nearly 500 Congressional
offices were visited by ADA members, asking for support of these two priority
issues:
Weight Management Newsletter
T
Medical nutrition therapy
(MNT) expansion
Rep. Xavier Becerra, D-Calif., and Rep.
Diana DeGette, D-Colo., are sponsoring
an MNT expansion and the addition of
pre-diabetes. In the Senate, Sen. Jeff
Bingaman, D-N.M., is again the lead
sponsor of MNT expansion, and Sen.
Charles Schumer, D-N.Y., is the primary
sponsor of legislation (S.755) to put MNT
in Medicaid legislation. S. 755 will require
state Medicaid programs to cover the
screening of persons with diabetes risk
factors and treatment for those diagnosed.
Other champions involved with MNT
expansion are Rep. Fred Upton, R-Mich.,
and Sen. Larry Craig, R-Idaho.
The Farm Bill
Several speakers discussed this, but our
very own ADA member Margaret Bogle,
PhD, RD, spoke brilliantly on the role of
the registered dietitian (RD), in the Farm
Bill. This bill is a major piece of legislation
that widely impacts the land we live on,
the foods we grow, and most United States
Department of Agriculture (USDA) programs, including the Food Stamp
Program. It also highly relates to funding
of nutrition research. The writing of this
bill began in May and should be completed by the end of summer. Specific components of which ADA members were
trained to ask for support include:
■ Support Peterson/Boustany/Graves Bill
and S. 971, establishing the National
Institute for Food and Agriculture.
■ Preserve and adequately fund USDA’s
Human Nutrition Research Centers.
■ Issue Dietary Guidelines for Americans
every 10 years rather than every five
years. Use the intervening five years to
build public education and acceptance
and conduct research for future needs
of guidelines in this cycle.
■ Support improvements to USDA’s
food assistance programs, including
food stamps, to better serve those in
need and utilize incentives and education to help beneficiaries consume
diets consistent with the Dietary
Guidelines for Americans.
ADA staff members report having
received many contacts by congressional
offices within hours of our Capitol Hill
visits, seeking additional information and
offering assistance in support of stronger
nutrition policies and programs.
Included in the packed agenda, ADA
staff invited several elected officials to
address our group. All seemed to have
been well informed about whom RD are,
what we do, and why we were in D.C.
Some take-home “pearls of wisdom” for
14
Anne Daly, MS, RD,
BC-ADM, CDE, is the
Weight Management
Dietitic Practice
Group public policy
director
me were as follows—
Rep. Jo Bonner, R-Ala.,
member House Agriculture
Committee:
■ Stated this is an opportune time for
RDs to be in D.C. talking to their legislators due to the timing of the Farm
Bill.
■ Noted we’re losing lots of lush farmland due to building expensive homes
(i.e., Florida), which is presenting a
challenge to farmers.
■ Urged us to explain to Congress the
importance of our knowledge of good
nutrition and convey our concern that
good nutrition is an investment that
saves money.
Nancy Johnson, former
Connecticut Congresswoman
and member of Ways and
Means Committee
■ Chronic disease management is now
being piloted; she predicts the first
report will be obscured by start-up
costs.
■ The average patient visit to an MD is
seven minutes; people deserve time.
■ Better technology for health records is
the answer; using electronic health
records makes it easier to assess patient
populations and saves money from
duplications (i.e., we currently pay for a
second set of X-rays because no one
could find the first set). She also cited
overmedication of our seniors as priority issue.
■ Our current reimbursement laws are
ridiculous; an MD gets paid whether a
patient needs to see him or not, but
other health-care professionals are
See Legislative Update, page 25
Monica Krygowski,
MS, RD, LDN, is the
2007–2008 chair of
the Weight
Management DPG.
Contact her at
[email protected]
Chair’s
Column
The power of yes
T
ward to working with them this year.
Many others contribute to the ongoing work of the WM DPG. Others functioning in appointed positions are contributing a great deal of time and energy, and the DPG could not be meeting
your requests for subunits, symposium,
volunteer opportunities, research, networking liaisons, awards and honors,
marketing, and continuing professional
education units (CPEUs) without the
efforts of these people. They are our
unsung, “behind the scenes” heroes and
we are most grateful to them. Watch for
their introductions in future articles.
The Hedgehog Concept
Seventeen of the above-mentioned individuals met in May to discuss the WM
DPG strategic plans for the next one to
five years. Keeping in mind the mission
and vision of the DPG and taking into
account the results of the recent membership survey, Marianne Smith Edge,
past ADA President, facilitated an
extremely productive planning session
incorporating the concepts of Jim
Collins in his book, Good to Great. The
first key concept is to have the right
people “on the bus and in the right
seats.” From the previous introductions,
you can see that this has already been
done. The next key concept is to identify our Hedgehog Concept. That comprises our core values, what we are passionate about, what we are best at, and
what drives our resource engine. The
consensus of the group was that the
WM DPG will embrace opportunities
that directly improve your ability to be
recognized as THE weight management
15
expert. To that end, the following goals
were formulated by the team:
■Provide
members with the latest and
most up-to-date information to
enhance their knowledge, skills and
techniques in the practice of weight
management.
■ Improve member recruitment and
retention by 2% in the 2007-2008 fiscal year.
■ Provide expanded professional development opportunities.
■ Increase membership in Bariatric
Surgery and Pediatric Weight
Management subunits and develop
new services to meet the professional
requests and needs of the participating
individuals.
■ Continue to support and promote
members involved in weight management outcomes and evidenced-based
research and to update membership
on current WM research findings.
■ Develop and promote leadership qualities among the WM DPG members.
■ Increase the recognition of WM DPG
members who have made outstanding
contributions to the profession and to
the field of weight management
through creation of additional awards
and honors for these members.
■ Expand activities, programs and services related to external affairs, public
policy and reimbursement for services.
These goals build upon those set
forth last year. The categories have not
changed, but the tactics to accomplish
these goals have, by necessity, changed.
That’s because we were able to make
great strides in setting the foundation for
See Chair’s Column, page 20
Volume 5, Number 1, Summer 2007
he Weight Management (WM)
Dietetic Practice Group (DPG) is
officially beyond its infancy and
well into its childhood as it enters its
fifth year of existence. This could not be
possible without the foresight and commitment of our “birth mothers,” Becky
Reeves, DrPH, RD; and Molly Gee, MEd,
RD, LD; who worked tirelessly to bring
this group from concept to reality from
2002-2004. Nine individuals said “yes” to
Becky’s invitation to help found the
DPG, and a few of those people are still
here five years later continuing to contribute to the promotion of excellence in
the practice of weight management.
I am privileged to join Anne Daly,
MS, RD, BC-ADM, CDE, WM DPG
public policy director; Pat Harper, MS,
RD, LDN, WM DPG external relations
director; Chris Biesemeier, MS, RD,
LDN, FADA, WM PDG past chair; and
Ruth Ann Carpenter, MS, RD, LD, WM
DPG chair-elect, in the distinction of
being among the original founding
Executive Committee (EC).
Additionally, several of this past year’s
EC members have agreed to remain
active in 2007-2008 by undertaking
new roles, while others are continuing
in their current role. Each of these EC
members has said “yes” many times
over, and I am profoundly grateful for
all that they have contributed to the
WM DPG in the past and will continue
to contribute during this coming year.
I also welcome our newly elected secretary, Susan Burke, MS, RD, LD/N, CDE,
and Nominating Committee director,
Anne Wolfe, MS, RD, and thank them for
saying “yes” to this new opportunity and
responsibility. All bring their very unique
expertise to this DPG and we look for-
Member Spotlight
2007-2008 WM DPG Chair Monica
Krygowski, MS, RD, LD
f you attended elementary school in
Rochester, N.Y., Denver, Colo., or
Plano, Texas in the mid 1970s or
early 1980s, there is a chance that I was
your (very youthful) teacher. After teaching for a few years, the decision to apply
the knowledge afforded me by my bachelor of science degree in elementary education to raising my own children was an
easy one to make. Once they were well
into middle school, the search began for
a new career. Blending my love for gourmet cooking and the belief that food is
the main source for good health, nutrition and dietetics became the obvious
choice. Upon completion of my master’s
degree in nutrition and dietetics from
Texas Woman’s University in 1993, I
began my career as the sole clinical registered dietitian (RD) in a small medical
center north of Dallas.
Moving to Austin disrupted one
career track, but presented the opportunity to become the nutrition health education coordinator for University Health
Services at the University of Texas (UT)
at Austin. This rapidly became my
“favorite” job, and I held it for over
seven years. While at UT, I interacted
with students, faculty and medical staff
to provide wellness outreach programs.
Other job duties involved coordinating
the eating disorders treatment team, providing one-on-one counseling, and
supervising student assistants, interns
and student volunteers; never a dull
moment!
During my years of service to UT,
Becky Reeves, XX, XX, invited me to be a
part of a brand new dietetic practice
group (DPG) that she was forming. The
American Dietetic Association approved
the formation of the Weight
Management DPG in 2002 and it was
Weight Management Newsletter
I
offered as an option for membership
beginning in June 2003. I served as the
appointed treasurer on the first
Executive Committee. The following
year when the first elections were held, I
was elected treasurer and served in that
position until 2006.
Relocating to Houston in 2005 set the
stage for a new job search. After trying
my hand at being a consulting RD in
long-term care and rehab facilities, I
began work with The Methodist
Hospital Weight Management Center in
Houston and the YMCA of Greater
Houston. These positions provided me
with an entirely different population
and I learned that one approach to
weight management certainly does not
fit all. Now, instead of working with students at UT or the aging population in
long-term care facilities, my population
tended to include individuals who were
battling Class I and higher obesity levels.
After learning first hand about liquid
diets and ketosis, and honing my coaching skills, our final move occurred late
in 2006.
Now back in Denver, I am blending
my 15 years as an RD, with my earlier
elementary education experience to hold
the position of professional research
assistant with the University of Colorado
at Denver and Health Sciences Center in
the Center for Human Nutrition.
Specifically, my work is with America On
the Move, which is an exciting program
that stimulates me to continue to learn
new skills, rediscover old ones and open
my mind to new challenges. My goal as
chair for this next year is to guide this
DPG so that you, too, will learn new
skills, rediscover old ones and open your
minds to the many new challenges that
lie ahead.
16
Meet the Excellence in
Weight Management
Practice Award winner
aren
Holtmeier,
MPH, RD, LN,
of Minnesota is the
first recipient of the
Weight Management
(WM) Dietetic
Practice Group (DPG)
Excellence in Weight
Management Practice Award. The award
recognizes exceptional performance and
contributions to the advancement of
weight management practice.
Karen’s 28-year distinguished career
includes clinical, community, corporate
and private practice settings where she has
created innovative programs and products
to treat obesity. As manager of nutrition
education at Park Nicollet Medical
Foundation, she coordinated and taught a
12-week group weight-loss program, provided individualized medical nutrition
therapy to clients from diverse socioeconomic backgrounds, and was responsible
for delivery of nutrition services at 44
affiliated clinics.
Ten years ago, Karen left Park Nicollet
to co-found the Medical Weight
Management Centers (MWMC) with
three sites in the Twin Cities area and
recently bought out her physician partner.
The success of the program she created for
the MWMC is evidenced by outcomes
data showing average weight loss of 3 to 5
pounds per week and clinically significant
reductions in glucose, lipid, and bloodpressure levels as well as medication use.
Karen is active in the Twin Cities District
Dietetic Association and in the American
Society of Bariatric Physicians where she
is director of the Assistant’s Program for
Continuing Education.
Karen works tirelessly to increase
awareness of obesity as a human- and
public-health condition through publications, lectures and media presentations. She is an outstanding example of
excellence in weight management practice.
K
P I D Update
Spring 2007 House of Delegates meeting
By Linda Delahanty, MS, RD, LDN
he House of Delegates (HOD)
met March 17–18, 2007, in
Chicago, Ill. to conduct its 77th
meeting. The HOD received an update
on the current activities of the American
Dietetic Association (ADA), the financial
status of the ADA, the work of ADA
headquarters and the achievements of
the ADA Foundation. Delegates also participated in a training session related to
sustainable food systems. The HOD discussed the following issues: 1) the vision
of future dietetics practice 2) image of
dietetics and registered dietitians (RDs)
and 3) public policy and advocacy. As
delegate for the Weight Management
(WM) Dietetic Practice Group (DPG), I
want to thank all WM DPG members
who shared their views and opinions on
these topics so that I could represent
them at the meeting.
What were the outcomes of the spring
2007 HOD meeting?
T
■ The Future Vision of Dietetics:
What other issues did the
HOD address?
Sustainable Food Systems Task Force:
The HOD conducted a dialogue on Oct.
21, 2005, to identify the role of ADA
members in supporting a sustainable
food supply that is healthful and safe.
Following the dialogue, a motion was
adopted on Nov. 30, 2005, to appoint a
Sustainable Food Systems Task Force.
The Task Force met from February 2006
through March 2007 and developed a
Primer on Sustainable Food Systems
titled Healthy Land, Healthy People:
Building a Better Understanding of
Sustainable Food Systems for Food and
Nutrition Professionals. The Task Force
conducted a training session on the
17
Primer at the Spring 2007 HOD
Meeting. The objective of the session was
to provide tools for delegates to use with
ADA members regarding sustainable
food systems. Also, the session was
intended to encourage members to
assume leadership roles in the many
areas of sustainable food systems. The
Primer on Sustainable Food Systems can
be accessed at www.eatright.org/cps/rde/
xchg/ada/hs.xsl/governance_11647_ENU
_HTML.htm.
When is the next hod HOD
meeting and what are the topics for discussion?
The fall 2007 HOD meeting is scheduled
for Sept. 28-29, 2007, in Philadelphia,
Pa., in conjunction with the Food &
Nutrition Conference & Expo (FNCE).
All ADA members are invited to participate.
The topics for the dialogue sessions
are membership dues, health disparities,
and possibly the report from the Phase 2
Future Practice & Education Task Force.
HOD backgrounders on these topics
will be available in late June or early July
2007.
Please feel free to contact me via email at [email protected] or
phone at 617/724-9727 for more information on these very important issues.
Volume 5, Number 1, Summer 2007
Practice: The purpose of the dialogue
session was to provide the Phase 2
Future Practice & Education Task
Force with input on future practice
roles for the registered dietitian (RD)
in 2017. The input from the session
was forwarded to the Task Force for its
April 4 conference call and focused on
discussing future practice roles utilizing the HOD and member input.
Based on these discussions, the Task
Force released an update on its activities which was posted to the ADA Web
site on April 30 and can be found at
www.eatright.org/ada/files/April30.pdf.
■ Image of Dietetics: ADA members
and credentialed practitioners are
requested to participate in promoting
the value of the RD and dietetic technician, registered (DTR) in local communities and employment settings
with assistance from delegates. In
addition, affiliates, DPGs, the
Commission on Dietetic Registration
(CDR), the Commission for Advocacy
of Dietetics Education (CADE), ADA
Student Council and student dietetics
clubs are asked to develop plans to
promote the RD and DTR in various
practice settings. Suggestions for promoting the RD and DTR, which were
identified in the pre-meeting and
meeting dialogue sessions will be
shared with members and ADA organizational units for their consideration
and are posted on the WM DPG Web
site. The HOD Leadership Team will
monitor changes in the perceived
image of the profession over the next 5
years.
■ Public policy and advocacy: Delegates
identified ways to support the public
policy and advocacy efforts of affiliates
and DPGs and to promote member
participation on these activities. All
ADA members are encouraged to participate in public policy and advocacy
efforts which advance the ADA legislative agenda.
Working with ambivalence to change
By Molly Kellogg, RD,
LCSW
Conditions for
creativity are to be
puzzled;
to concentrate; to
accept conflict and
tension;
to be born everyday; to
feel a sense of self.
—Erich Fromm
mbivalence is
an inherent
part of the
change process.
Acknowledging and
working with these
internal conflicts
make change more
likely.
A
Counseling for
Behavior Change
Molly Kellogg, RD,
LCSW, is the author
of Counseling Tips
for Nutrition
Therapists: Practice
Workbook and trains
and supervises RDs
around the country.
Her free e-mail
newsletter is available at www.molly
kellogg.com. She
has a private nutrition and psychotherapy practice in
Philadelphia, Pa.
Contact her at
[email protected]
Examples of ambivalence in
weight control counseling
I want to be in good shape, and I hate
to exercise.
■ I want to lose weight, and I don’t want
to stop eating for comfort.
■ I want to weigh less, and I’m scared of
attracting men if I do.
Weight Management Newsletter
■
Often a client is not yet aware of the
conflict among his or her various beliefs,
desires, and behaviors. It is as if the part
of the person that wants the positive
outcome is not in communication with
the part that is not willing to do the new
behavior. We have all met the person
who seems wholly committed to weight
loss and who does not make changes. In
this case, you have only heard the side
that wants to change. The other side is
there, it just has not spoken to you yet.
It may be tempting when you hear
ambivalence in your client to jump in
and support the part that wants to
change. It is not your job to hand the
client a solution to the internal conflict.
As a matter of fact, if you do, you will
likely encounter resistance. The resistant
side will become stronger. How to avoid
Ida Laquatra, PhD, RD, LDN
lients often feel ambivalence
about changing their behaviors. They may not even be aware
of the conflict between their value
system and their behavior.
C
this? Slow down when you notice these
internal conflicts and bring them up
with the client. You can work with the
discrepancies you hear between goals
and behavior, and you and your client
can look together for areas of flexibility.
The most respectful and effective way
to begin is to mirror what you hear,
possibly with a tone of curiosity and an
open-ended question designed to elicit
more exploration. “Oh, so you really
want to have better blood glucose control. You also love good food and it ruins
the experience of a meal when you
measure your portions. Is there more
that I missed?”
You are most likely to get cooperation
in this exploration if you ask permission. For example, once a discrepancy
comes up, you could say, “This sounds
important and maybe even a reason you
feel so stuck. Would you be willing to
take a look at this together?”
Holding ambivalence is not easy and
takes shifting to a different perspective.
If you observe closely, you may even
notice the client staring off into space or
blinking, all signs that a shift may be
happening. Allow time for this rather
than jumping in with your suggestions.
When you have agreement to work
on ambivalence, begin to tease out what
is behind the initial conflicting statements. For instance, in the example
above, you may discover that the client
18
Counselors who
know how to
work with ambivalence are likely
to be more effective change
agents.
knows she will have more energy, will
likely live longer, and possibly see that
wonderful grandson of hers graduate
from high school if she loses weight and
better controls her blood glucose.
You could also ask this client some
open-ended questions about her enjoyment of food. During this open, nonjudgmental exploration, most clients will
discover some flexibility they had not
seen yet, or they will generate some solutions on their own. This is due to the
fact that when someone is locked into a
conflict (whether internal or external),
curiosity and creativity are absent. Your
invitation to explore without judgment
allows for an untangling of the knots
and a vision to see a way out. The fun
part for you is that you need only focus
on the process of exploration. The client
does most of the work of coming up
with solutions. You may offer a few suggestions here and there, but it’s amazing
how often this is not necessary. The best
solutions come from the client because
he or she knows his or her life and circumstance much better than you do.
Expect that some clients will not
accept their ambivalence or not even be
able to see it, even though it is obvious
to you. They are in the early stages of the
change process and are not ready for
that leap. Offer to revisit this discussion
at a later time.
See Counseling, page 24
Network Activities
Update
WM DPG begins relationship with the North
American Society for the Study of Obesity
By Eileen Stellefson Myers, MPH, RD,
LDN, FADA
WM DPG Network and Alliance chair
T
his year, the WM DPG will provide a professional development
stipend to attend The Obesity Society
Annual Scientific Meeting through a
lottery process. A description of the
stipend, eligibility criteria and applications are available on the WM
R
accepted. Sue Cummings, RD, recently
served on the committee that is developing The Obesity Society’s bariatric CME
(spell out) course.
The Obesity Society’s 2007 Annual
Scientific Meeting will be held in New
Orleans, La. Oct. 20–24. Sessions will be
presented in five thematic tracks:
Cell and molecular biology
Integrative biology
■ Clinical studies
■ Population studies
■ Clinical/professional practice
■
■
Visit the Obesity Online Web site at
www.obesityonline.org and view the
“Dyslipidemia of Obesity and the
Metabolic Syndrome” slide show by
Ronald M. Krauss, MD. This slide show
Connect
www.wmdpg.org
Discover
Explore
19
DPG Web site at www.wmdpg.org.
Go to the “About WM DPG” section
to learn more.
Please take advantage of this
opportunity and member benefit.
Don’t delay—the deadline to apply is
Monday, Aug. 27!
presents data on how weight loss, combined with treatment for the other risk
factors associated with metabolic syndrome, has been shown to reverse all
components of atherogenic dyslipidemia and reduce the risk of onset of
adverse cardiovascular events.
I also encourage you to visit Obesity
Online to view the Virtual Meeting
Collection; click on “Case Studies in
Unique Approaches to Weight
Management” by Robert Kushner, MD;
Louis Aronne, MD; and Judith Loper,
PhD, RD. Through the use of case
studies, this virtual meeting looks at
clinical results achieved in behavioral
modification techniques, very low
calorie diets (VLCDs) and bariatric
surgery.
Volume 5, Number 1, Summer 2007
ecently, the American Dietetic
Association (ADA) approved
Weight Management (WM)
Dietetic Practice Group’s (DPG) request
to form a network relationship with the
North American Society for the Study of
Obesity (NAASO, The Obesity Society).
During the WM DPG Symposium,
Morgan Downey, Executive Vice
President of The Obesity Society, met
with members of the WM DPG
Executive Committee and voiced his
support of a network relationship
between the two organizations. A “network” is defined by the ADA as a communication opportunity. The opportunity is designed for the purpose of sharing information between the two
groups.
Examples of current network activities with The Obesity Society include
communicating through Judy Loper,
PhD, RD, who serves on the Program
Committee to submit potential topics
for the NAASO 2007 scientific meeting.
Three of our suggested topics were
Just your luck! Attend a great meeting!
Molly
Wangsgaard,
MS, RD, LDN,
is the 2007–
2008 Weight
Management
DPG newsletter
editor.
From the
Editor
It’s all about the people
or me, it’s the people. What’s “the
people” you ask? The people, in
my mind, are the main member
benefit for joining a dietetic practice
group (DPG)—specifically the Weight
Management (WM) DPG. Networking
with other professionals who have an
interest in, or more often a passion for
weight management is the
foundation for all this
DPG has to offer.
Having just recently
attended the WM DPG
2007 Spring
Symposium, my preference for networking
is definitely face-to-face
interaction. I encourage
you all to try and attend at
least one WM event each year:
spring symposium, member reception at
the Food & Nutrition Conference &
Expo (FNCE), WM booth at the FNCE
DPG showcase, and/or WM-sponsored
session at FNCE (talking with other
members before or after the session).
The networking opportunities extend
well beyond the in-person interactions.
Everyone should join the electronic
mailing list (EML) to be a part of the
interaction; read as little or as much of
the correspondence as you like. The
EML is a great resource to get input
from other professionals and often-times
you can even “get to know” other members and continue your correspondence
individually, beyond the full-member
setting. The Membership Directory on
the WM DPG Web site at
www.wmdpg.org provides a great
resource for finding members in a certain location.
Weight Management Newsletter
F
Are you planning on relocating and
need help finding weight managementrelated work? Do you have a client who is
moving away whom you want to refer to
another registered dietitian (RD)? Use the
Membership Directory. The two WM
Subunits provide communities of interest
(CoI) where interaction with other members within the bariatric surgery
or pediatric weight management fields is
enhanced beyond the
EML format.
In my experience,
the WM members are
an extremely friendly
and helpful bunch. It is
has been exciting for me to
interact in person and electronically with the “big names” I hear
about so frequently: researchers, authors,
spokespeople, etc. I encourage you all to
take advantage of the opportunities to
network; a “key” member benefit.
Now don’t get me wrong; I love that
Weight Management Newsletter is viewed
as the top member benefit (according to
the member survey results from the last
two years). As the newsletter editor,
knowing you value this publication
makes my work even more rewarding;
however, if you have not yet taken
advantage of the networking opportunities and human-element of your DPG
membership, start now. According to the
American Dietetic Association (ADA)
Web site, DPGs were made for this purpose: “A DPG is a professional-interest
group of ADA members who wish to
connect with other members within
their areas of interest and/or practice.”
It’s all about the people!
20
Get money
to learn!
Did you know the WM DPG
offers five professional development stipends for continuing education opportunities?
These are dispersed by lottery each year. Receive
money to attend one of the
following events:
■ The Obesity Society’s
Annual Scientific Meeting
(2 stipends)
• application deadline:
Aug. 27
■ American Dietetic
Association Public Policy
Workshop (1 stipend)
• application deadline:
Nov. 15
■ WM DPG Annual
Symposium (2 stipends)
• application deadline:
Nov. 15
Visit the WM DPG Web site
(www.wmdpg.org) and click
on “About WM DPG” to learn
more.
Chair’s Column, from page 15
each goal. Now we are in a position to
expand upon these services and improve
them. This can’t happen without your
involvement. We need to hear from our
membership.
Please explore the newly expanded
Web site at www.wmdpg.org, and then
communicate your needs, thoughts,
ideas, and select an area of interest in
which you would be willing to volunteer.
Stay informed via the newsletter, the
Web site, the electronic mailing list and
blast e-mails. Become involved so that,
together, we will be THE weight management experts.
Preventing childhood obesity: a look at local wellness policies
O
The Introduction of Local
Wellness Policies
Due to these sobering developments,
interventions focused on battling the
war against childhood obesity have
abounded. The public school system is
the setting that has the largest number of
Pediatric Weight
Management
amara Busby, MS, RD, is a
researcher and curriculum
developer for the Mendez
Foundation in Atlanta, Ga. For
almost 30 years, the Mendez
Foundation has created drug and
violence prevention education.
T
children and is an environment where
children can be taught about the importance of regular physical activity and
proper nutrition.
In 2004, the United States Congress
passed a law that mandated “each local
educational agency participating in a
program authorized by the Richard B.
Russell National School Lunch Act or the
Child Nutrition Act of 1966 shall establish a local school wellness policy by
School Year 2006” (5). The responsibility
for developing the wellness policy was
placed at the level of each local school.
As part of the mandate each school was
to:
Include goals for nutrition education,
physical activity, and other schoolbased activities that promote student
wellness.
■ Establish nutritional guidelines for all
foods available on campus during the
school day.
■ Designate personnel responsible for
measuring adherence to guidelines.
■ Include parents, students, representatives of the local school food authority,
the school board, school administrators and the public in the development
of the wellness policy.
■
Each school district then had the
responsibility for creating its own Local
Wellness Policy. On the United States
21
Tamara is currently working
with a team that is developing a
comprehensive nutrition education program for kindergarten to
12th grades, as well as an afterschool curriculum. Contact her at
[email protected]
Department of Agriculture Food and
Nutrition Web site, resources could be
found to help give the local authorities
direction when creating the wellness
policies. Some suggestions included
assessing the district needs, building
awareness and support of the new policy,
and measuring and evaluating the policy
(6).
Example of local wellness
policy: Christina School
District
Since the fall of 2006, some child advocate organizations have reported on local
wellness policies (7– 8). There is a vast
difference in the detail that school districts outlined in their policies. While
some school districts did not do much
more than copy the mandated guidelines
from the law passed by Congress, other
districts went several steps further. One
school district that put much detail into
its local wellness policy is the Christina
School District, which is located in the
Wilmington, Del. area. It has about
19,500 students and is the largest school
district in the state.
The Christina School District outlined several goals for healthy school
nutrition (9). The first section of goals
outlines the policy to adhere to the fed-
See Pediatric, page 24
Volume 5, Number 1, Summer 2007
verweight and obesity have
become major public health
concerns in the United States.
The “obesity epidemic” has not been discriminate of age. In the past several
decades, childhood obesity has become
an emerging issue. The Centers for
Disease Control and Prevention (CDC)
reports the incidence of overweight in
children aged 6 to 11 has increased from
7% in 1980 to 18.8% in 2004.
Adolescents, or children aged 12–19
years old, have had an even greater
increase: from 5% to 17.1% in the same
time frame (1).
The consequences of overweight in
childhood are very serious. Children
who are obese are at a higher risk of
becoming overweight or obese as adults.
These children are also at higher risk of
developing many chronic diseases,
including cardiovascular diseases, hyperlipidemia, obstructive sleep apnea, asthma, and orthopedic complications (2).
What has led to this alarming increase
in childhood obesity? It is widely agreed
that children have been conditioned to
live in a way that promotes weight gain,
leading to the increase in overweight and
obesity. Society is now living a technology-dependent lifestyle that greatly
reduces the amount of physical activity
in children. It is recommended that children get at least 60 minutes of physical
activity a day. In a survey of high school
students, it found that only 27.8% of
girls and 43.8% of boys get this amount
of recommended physical activity (3).
Also, healthy eating patterns are not followed by the majority of the American
population, including children. Eighty
percent of high school students eat fewer
than five fruits and vegetables per day
(4).
Upcoming Events
Sept. 6–8, 2007
Oct. 4–7, 2007
Nov. 15–17, 2007
Certificate of Training in Adult Weight
Management
Flamingo Las Vegas Hotel and Casino
Las Vegas, Nev.
www.cdrnet.org
Healthy Kitchens, Healthy Lives: Caring
for Our Patients and Ourselves
The Culinary Institute of America at
Greystone. Napa Valley, Calif.
www.cme.hms.harvard.edu
Certificate of Training in Adult Weight
Management. Sheraton Meadowlands
Hotel & Conference Center
East Rutherford, N.J.
www.cdrnet.org
Oct. 20–24, 2007
Nov. 30–Dec. 2, 2007
NAASO, The Obesity Study
Annual Scientific Meeting
Ernest N. Morial Convention Center
New Orleans, La. www.naaso.org
Counseling Intensive and Eating
Disorders Boot Camp
(Two workshops, 18 credits)
Molly Kellogg, RD, LCSW and
Jessica Setnick, MS, RD/LD
Georgetown University
Washington, D.C.
www.mollykellogg.com
Sept. 25–29, 2007
57th Annual Obesity and Associated
Conditions Symposium
Las Vegas, Nev.
www.asbp.org
Sept. 26-30, 2007
American College of Nutrition's 48th
Annual Meeting. Hilton in the Walt
Disney World Resort. Orlando, Fla.
www.amcollnutr.org
Sept. 28, 2007
Counseling Intensive Workshop
Thomas Jefferson University Hospital
Philadelphia, Pa.
www.mollykellogg.com
Sept. 29–Oct. 2, 2007
Weight Management Newsletter
The Food & Nutrition Conference &
Expo (FNCE). Pennsylvania Convention
Center. Philadelphia, Pa.
www.eatright.org/fnce
Oct. 20–24, 2007
Counseling Intensive and Eating
Disorders Boot Camp
(Two workshops, 18 credits)
Molly Kellogg, RD, LCSW, and
Jessica Setnick, MS, RD/LD
San Jose State. San Jose, Calif.
www.mollykellogg.com
Do you have a weight managementrelated event to post? If you do, please
send the information to Associate
Newsletter Editor Julie Schwartz, MS, RD,
LD, at [email protected]
Nov. 4–6, 2007
Certificate of Training in Childhood
Adolescent Weight Management
Sheraton Read House Hotel
Chattanooga; Chattanooga, Tenn.
www.cdrnet.org
Have You Moved?
If you have recently moved or had a change of name, please update your membership information with the American
Dietetic Association (ADA) to ensure that you don’t miss out on any WM newsletters or other communications. Because
ADA maintains our address data, you must notify the association directly before you move, or your WM newsletters may be
delayed. To update your member profile information you may:
6
Use ADA’s Web site (www.eatright.org) and Member Profile secured server. Using your member ID number and
Web password, which was provided to you on your ADA membership card, view your existing member profile at the
Online Business Center, make necessary changes, and submit changes to update ADA’s records immediately.
■ Print a change-of-address form from ADA’s Web site (www.eatright.org/addresschange.html), complete the form, and
fax (312/899-4899) or mail to American Dietetic Association, Attention: Membership Team, 120 South Riverside Plaza,
Suite 2000, Chicago, IL 60606-6995.
■
Mail in the Change-of-Name and/or Address card found in the back of each Journal of the American Dietetic
Association.
■ E-mail changes to the ADA Membership Team at [email protected]
■
22
Available
Volume 5, Number 1, Summer 2007
23
Weight Management Newsletter
Pediatric, from page 21
eral nutritional guidelines for reimbursable meals. There was also a focus
on portion sizes, including recommendations for appropriate portion sizes of
snacks such as chips and cereal bars.
Elementary schools have restrictions on
the amount of sugar and fats in snack
foods.
The Christina School District Local
Wellness Policy also includes unique
guidelines for the students’ eating environment. There are to be at least 10 minutes for breakfast time and 20 minutes
for lunchtime. To allow students enough
time to eat breakfast, bus schedules and
morning breaks should be coordinated
carefully. There are to be only three to
five hours between breakfast and
lunchtimes. If at all possible, physical
education should be scheduled before
lunchtime. The dining room area is to be
attractive and have adequate space for all
students.
The Christina School District Local
Wellness Policy also includes guidelines
related to food safety, sales of minimally
nutritious foods, beverage vending
machines, nutrition education curriculum, training school faculty and staff,
and physical activity. The Christina
School District further outlined a plan to
create a District Wellness Policy
Committee that would serve as a liaison
between the community and school district, as well as assess each school’s
implementation of the wellness policy.
The part registered dietitians
play in local wellness policies
As mentioned above, not every school
district has a wellness policy that is as
comprehensive as the Christina School
District. This may be due to the fact
that although the creation of the local
wellness policies was a federal government mandate, there is little to no
funding at the federal level for program
implementation. Therefore, school districts that do not have registered dietitians (RDs) and/or physical activity
professionals at their disposal may face
challenges in the implementation and
evaluation of their local wellness policies. The assistance from these professionals is critical to the success of the
local wellness policies, considering the
challenges that may face some districts
that do not receive funding at the state
level. RDs would do well to contact
their local district and/or school to
determine if they can be of any assistance. The continued success of the
local wellness policies and other initiatives working against childhood obesity
will depend on the collaboration of
whole communities.
References
1. Prevalence of overweight among children
and adolescents: United States 1999-2000.
Hyattsville, Md.: National Center for Health
Statistics; 2004.
2. Taras H, Potts-Datema W. Obesity and student performance at school. The Journal of
School Health. 2005;75:291–294.
3. Physical activity and the health of young
people. Atlanta, Ga.: Centers for Disease
Control and Prevention. 2006.
4. Youth Risk Behavior Surveillance SurveyUnited States, 2005. Atlanta, Ga.: Centers for
Disease Control and Prevention; 2006.
Morbidity and Mortality Weekly Report 55
(ss-5): 1-108.
5. Child Nutrition and WIC Reauthorization
Act of 2004. Washington, D.C: U.S.
Department of Agriculture; 2004.
6. The local process: How to create and
implement a local wellness policy.
Washington, D.C.: U.S. Department of
Agriculture, Food and Nutrition Service;
Available at: www.fns.usda.gov/tn/Healthy/
wellnesspolicy_steps.html. Accessed on April
24, 2007.
7. Foundation for the future: analysis of the
local wellness policies from the 100 largest
school districts. Alexandria, Va.: The School
Nutrition Association; 2006.
8. Foundation for the future II: analysis of
the local wellness policies from 140 school
districts in 49 states. Alexandria, Va.: The
School Nutrition Association; 2006.
9. Christina School District Wellness Policy.
Wilmington, Del. Available at: www.christina.
k12.de.us/SchoolBoard/WellnessPolicy/
PrinterFriendly.pdf. Accessed April 24, 2007.
24
WM DPG
Excellence
Awards
Do you know a colleague
who should be recognized
for his or her excellence in
an area of weight management practice?
Do you deserve to be recognized for your excellence
in an area of weight management practice?
The Weight Management
(WM) Dietetic Practice
Group (DPG) is currently
offering awards to members
for Excellence in Weight
Management Practice and
Excellence in Weight
Management Outcomes
Research.
You can’t win if you don’t
apply. Go to the “About WM
DPG” section of the WM
Web site (www.wmdpg.org)
to learn more.
Counseling, from page 18
It may be uncomfortable to be in the
presence of a client holding conflicting
intentions. Ask yourself what about it
makes it so uncomfortable. Is it pressure
you place on yourself to “fix it” or to
make the client change? If so, remind
yourself that your job does not include
making people change, but rather only
helping clients move toward readiness to
change. You will find more language and
support for this process in the archives at
www.mollykellogg.com.
Bariatric, from page 11
reporting was the information that truly
mattered. We also wanted to explore
ways to keep our post-surgical patients
connected to our program.
Results
Prior to this process improvement initiative, we were documenting information
about medial outcomes in several places,
including two databases. We looked at the
type of information we were collecting
and compared it with what clinicians and
patients told us they needed. For clinicians, we found that we were gathering
information on 150 items, when we actually only needed to gather 50 (much of the
excess was captured elsewhere or duplicated). Our patients were interested in 40
items, but we were only gathering data on
36 of those items. Patients also indicated
that several of the items for which we
were gathering data did not matter to
them, including participation in vigorous
activities and perception of ill health.
Furthermore, we were using the Well
Being Profile Short-Form 36 (SF-36) to
Legislative Update, from page 14
sonal definition of lobbying: “Lobbying
is a conversation that is in sound bites,
which are memorable and not too
long.”
Rep. Debbie Wasserman
Schultz, D-Fla.
Back for her second time to speak at the
PPW Congressional Breakfast, Rep.
Wasserman Schultz is an enthusiastic
supporter of RDs and nutrition. She
spoke of her own personal experience
when one of her twin infants had failure-to-thrive and how helpful an RD
was to her at that time.
My personal perspective
Having attended PPW a total of five
times now, I love to watch the “firsttimers” as their eyes are opened wide
watching public policy in action. This is
the real deal, and many become hooked
to this work on their first experience. I
am thrilled to see many new RDs
25
cal function, self-esteem, sexual life,
work and public distress (2).
Application
Eight of the nine patients interviewed on
the telephone cited a current goal to
work on weight loss. We see this as an
opportunity to direct our patients to our
Medical Weight Management Program
(currently in development). We are looking into tailoring a portion of this program for our long-term post-bariatric
surgery patients to meet their needs and
keep them connected with our program
and staff.
We propose to continue to measure
the outcomes that matter to our patients
so that we are meeting their needs in a
meaningful way.
References
1. Kolotkin RL, Meter K, Williams GR.
Quality of life and obesity. Obes Rev.
2001;2:219–229.
2. Kolotkin RL, Crosby RD, Pendleton R, et
al. Health-related quality of life in patients
seeking gastric bypass surgery vs. non-treatment seeking controls. Obes Sur.
2003;13:371–377.
becoming involved and loving what they
see. I am honored I am able to secure
appointments easily with our two Illinois
Senators; we even saw Senator Dick
Durbin, D-Ill., personally despite his
position as assistant majority whip.
Remember, in 2008, WM is offering
our first professional development stipend
for a member to attend PPW. The process
will be a random drawing, so everyone
has an equal chance of winning. In addition, after our attendance this year, the
WM Executive Committee has voted to
create an award for Excellence in Public
Policy and Advocacy. Stay tuned for more
information on the award.
I welcome comments and questions
about PPW and/or ADA Political Action
Committee (ADAPAC). And I strongly
encourage you to make plans to attend
PPW in the future if you can and contribute to ADAPAC at any level possible.
ADA is doing good things for us as members, and we MUST support these activities.
Volume 5, Number 1, Summer 2007
often denied reimbursement.
extraordinary
change, where we will be able to deliver
the technology of modern medicine.
■ We should pay MDs a higher rate for
meeting standards of quality care.
■ We don’t want to penalize MDs for
taking on hard-to-manage patients.
■ Perhaps we should divert some money
now being spent on bussing to increase
walking to school (to prevent obesity);
money saved could be used to hire security guards to make walking paths safe.
■ Congressional Budget Office (CBO)
scoring techniques to estimate costs of
proposed legislation are outdated; even
things that are absolutely rational can
be scored poorly.
■ She urged us to get 200 signatures on
our MNT bills so we can get hearings
on them.
■ In reference to our upcoming visits to
Capitol Hill, she offered her own per■ We are at a time of
assess health-related quality of life. This
assessment is widely used and appeared
to provide the potential for further assessment in our follow-ups; however, it was
never used this way in our program (1).
From the telephone interviews, we
matched the data for patient goals with
the data on achieving those goals. Most of
the patient goals were met, and they were
highly satisfied with their personal results;
however, we identified an unmet need for
weight management counseling in
patients two to three years post-surgery.
We are now reviewing measurement
tools to accurately capture this information pre-operatively and periodically
post-operatively in a standardized format. A review of the literature completed
by one of our team members revealed
several quality of life assessment tools
currently available. We propose to
administer a quality of life measure presurgically and regularly post-surgically.
We are reviewing use of the Impact of
Weight on Quality of Life-Lite (IWQOLLite) as a replacement for the SF-36 as
this identifies more of the items that
appear to matter to our patients: physi-
Weight Management Newsletter
Patient, from page 9
acute tubular necrosis ultimately resolved,
he died from sepsis related to extensive
decubitus ulcers. His inability to be
weaned from mechanical ventilation and
immobility (despite the use of a rotating
bariatric bed and being turned by eight
staff members) did not allow any options
for intervention by the plastic surgeons.
Diagnostic measures were limited because
JT was extremely high-risk for surgery,
transporting him out of the ICU was
almost impossible, and his overwhelming
obesity made many tools (e.g., computed
tomography scan, magnetic resonance
imaging, radiography) impossible to use
or of poor quality. In addition, his nutritional status could not be optimized during interruptions or delays providing SNS
due to severe insulin resistance and hyperglycemia as well as challenges gaining
enteral access and placing central lines.
Assessing the adequacy of the SNS provided was also challenging, because hepatic
proteins are not nutritional indicators,
providing energy at the level of REE is not
feasible (may actually be harmful), protein
needs are difficult to quantify in the setting of renal failure requiring dialysis, and
extensive decubitus ulcers.
This case represents an extreme and
complex example of SNS in a critically ill
obese patient with a BMI of 93 kg./m2.
Very limited research is available to
guide clinicians in providing SNS under
these circumstances, but obese patients
with less extreme BMIs may have more
positive clinical outcomes.
Conclusions and applications
Obesity is a national epidemic, with
NHANES (1999 through 2002) data
indicating 65% of United States adults
age 20 to 74 years are overweight (BMI
>25 kg./m2) and 31% are obese (BMI
>30 kg/m2) (1). As a greater proportion
of Americans become obese, with the
fastest increase seen among individuals
with class III obesity (BMI >40 kg./m2)
(1–2), clinicians are faced with the challenge of providing complex medical and
surgical care to this patient population.
Much remains to be learned about providing optimal SNS to this subset of
patients, but a growing body of research
supports the use of hypocaloric, highprotein feeding regimens.
In the future, evidence-based guidelines may assist clinicians in providing
care for critically ill obese patients and
could include: SNS regimens and monitoring guidelines, use of medical equipment and supplies designed for obese
patients, skin/wound care, imaging
options and procedures and medication
dosing.
Future areas of nutrition research for
this heterogeneous patient group should
address: EN as the preferred route of feeding, the use of standard polymeric enteral
formulas versus immune-enhancing
enteral formulas, best practices for obtaining enteral access, monitoring the effectiveness of nutrition support, stratification
of diverse patient groups (e.g., burn, surgical, trauma, medical), and treatment for
patients with class III obesity. The RD is a
vital member of the medical team and is
likely to encounter these types of clinical
dilemmas with increasing frequency.
Providing optimal nutrition support during critical illness can be a key component
in recovery and ideally, a future that
includes weight reduction and improved
health.
Britta Brown, RD, CNSD is a critical care
dietitian at Hennepin County Medical
Center, Minneapolis, Minn. Contact her at
[email protected]
References
1. Centers for Disease Control, National
Center for Health Statistics. Prevalence of
overweight and obesity among adults: United
States, 1999–2002. Available at www.cdc.gov/
nchs/products/pubs/pubd/hestats/obese/
obse99.htm. Accessed Nov. 27, 2005.
2. Choban PS, Dickerson RN. Morbid obesity
and nutrition support: is bigger different?
Nutr Clin Pract. 2005;20:480–487.
3. Levi D, Goodman ER, Patel M, Savransky
Y. Critical care of the obese and bariatric surgical patient. Crit Care Clin. 2003;19:11–32.
4. Saltzman E, Shah A, Shikora SA. Obesity.
In: Gottschlich M, Fuhrman MP, Hammond
KA, et al, eds. The Science and Practice of
Nutrition Support: A Case-Based Core
Curriculum. Dubuque, Iowa: Kendall/Hunt
26
Publishing Co.; 2001:575–599.
5. Shikora S, Naylor M. Nutritional support
for the obese patient. In: Shikora S,
Martindale R, Schwaitzberg S, eds.
Nutritional Considerations in the Intensive
Care Unit: Science, Rationale, and Practice.
Dubuque, Iowa: Kendall/Hunt Publishing Co;
2002:209–217.
6. Jeevanandam M, Young DH, Schiller WR.
Obesity and the metabolic response to severe
multiple trauma in man. J Clin Invest. 1991;
87:262–269.
7. Frankenfield DC, Rowe WA, Smith JS.
Validation of several established equations
for resting metabolic rate in obese and
nonobese people. J Am Diet Assoc.
2003;103:1,152–1,159.
8. Barak N, Wall-Alonso E, Sitrin MD.
Evaluation of stress factors and body weight
adjustments currently used to estimate energy expenditure in hospitalized patients. J
Parent Enteral Nutr. 2002;26:231–238.
9. Flancbaum L, Choban PS, Sambucco S, et
al. Comparison of indirect calorimetry, the
Fick method, and prediction equations in
estimating the energy requirements of
critically ill patients. Am J Clin Nutr.
1999;69:461–466.
10. Cutts ME, Dowdy RP, Ellersleck MR, Edes
TE. Predicting energy needs in ventilatordependent critically ill patients: effect of
adjusting weight for edema or adiposity. Am J
Clin Nutr. 1997;66:1,250–1,256.
11. Amato P, Keating KP, Quercia RA,
Karbonic J. Formulaic methods of estimating
calorie requirements in mechanically ventilated obese patients: a reappraisal. Nutr Clin
Pract. 1995;10:229–232.
12. Ireton-Jones CS, Turner WW. Actual or
ideal body weight: which should be used to
predict energy expenditure? J Am Diet Assoc.
1991;91:193–195.
13. Ligget SB, St. John RE, Lefrak SS.
Determination of resting energy expenditure
utilizing the thermodilution pulmonary
artery catheter. Chest. 1987;91:562–566.
14. Pavlou KN, Hoefer MA, Blackburn GL.
Resting energy expenditure in moderate obesity: predicting velocity of weight loss. Ann
Surg. 1986;203:136–141.
15. Feurer ID, Crosby LO, Buzby GP, et al.
Resting energy expenditure in morbid obesity. Ann Surg. 1983;197:17–21.
16. American Dietetic Association. Evidence
Analysis Library. Harris-Benedict equation
individual errors: obese adults. Available at
www.adaevidencelibrary.com/evidence.
cfm?evidence_summary_id=124&highlight=
obesity&home=1. Accessed April 5, 2006.
Over-the-counter weight-loss drug now available
By Anne Wolf, MS, RD, WM Nominating
Committee chair
vailable at local pharmacies
since June 2007, Alli is the first
and only Food and Drug
Administration-approved weight-loss
medication that is sold over-the-counter (OTC). Alli is the lower dose (60
mg.) version of Xenical (Orlistat), a
prescription medication indicated for
obesity and tested in more than 100
clinical trials (lasting up to four years)
involving 30,000 patients.
Alli and Xenical work in the digestive tract by binding to intestinal lipase,
preventing approximately 25%–30%
(in Alli, about 25%) of fat absorption
and creating a mild calorie deficit. For
every 5 pounds of weight lost by diet
alone, Alli has been shown to help
A
patients lose an additional 2 to 3
pounds more. This OTC medication is
indicated for weight loss among overweight adults (BMI > 25 kg./m2) and is
to be used with a low-calorie, low-fat
diet.
GlaxoSmithKline (GSK), the makers
of Alli, has developed a patient support
program (www.myalli.com) that promotes a dietary change plan in combination with the use of the medication.
GSK has created a partnership with
American Dietetic Association to
create both professional resources and
consumer resources featuring the
registered dietitian as the nutrition
expert.
Disclosure statement: Anne Wolf has
received honorarium and consultant
money from GSK within the past year.
CPEU answer key
1. D
4. C
2. C
5. C
3. A
6. D
7. A
See the continuing professional education article on page 1 and the
credit self-assessment questionnaire on page 10.
Newsletter information
WM DPG. © 2007.
Weight Management Newsletter is the
official publication of the Weight
Management (WM) Dietetic Practice
Group (DPG) of the American Dietetic
Association (ADA). It is published quarterly and is distributed to over 4,000 dietetics professionals working in weight management. Members of the DPG Executive
Committee as well as expert content
reviewers review all articles. Mention of
product names in this publication does not
constitute endorsement by the ADA or the
Upcoming deadlines:
Fall 2007 issue
Articles due by June 25, 2007
Fall 2007 issue
Articles due by June 25, 2007
All materials should be sent to
[email protected]
Subscription year is from June 1 to May
31.
Weight Management Newsletter is
27
mailed Standard Class (aka., 3rd
class) mail and as such is not forwarded by the United States Post Office.
Please keep your contact information
updated with ADA by calling
800/877-1600 ext. 5000 to receive
newsletters even after you move or
change your name.
Please contact Paula Peirce at
[email protected] if you are missing
issues.
Volume 5, Number 1, Summer 2007
17. American Dietetic Association Evidence
Analysis Library. Harris-Benedict equation
group mean errors: obese adults. Available at
www.adaevidencelibrary.com/evidence.cfm?
evidence_summary_id=122&highlight=
obesity&home=1. Accessed April 5, 2006.
18. American Dietetic Association Evidence
Analysis Library. Harris-Benedict formula
overview table. Available at www.adaevidence
library.com/topic.cfm?cat=1248. Accessed
April 5, 2006.
19. Dickerson RN, Rosato EF, Mullen JL. Net
protein anabolism with hypocaloric
parenteral nutrition in obese stressed
patients. Am J Clin Nutr. 1986;44:747–755.
20. Burge JC, Goon A, Choban PS,
Flancbaum L. Efficacy of hypocaloric total
parenteral nutrition in hospitalized obese
patients: a prospective, doubleblind randomized trial. J Parenter Enteral Nutr.
1994;18:203–207.
21. Choban PS, Burge JC, Scales D,
Flancbaum L. Hypoenergetic nutrition
support in hospitalized obese patients: a simplified method for clinical application. Am J
Clin Nutr. 1997;66:546–550.
22. Liu KJM, Ja Cho M, Atten MJ, et al.
Hypocaloric parenteral nutrition
support in elderly obese patients. Am Surg.
2000;66:394–400.
23. Dickerson RN, Boschert KJ, Kudsk KA,
Brown RO. Hypocaloric enteral tube feeding
in critically ill obese patients. Nutrition.
2002;18:241–246.
24. van den Berghe G, Wouters P, Weekers F,
et al. Intensive insulin therapy in critically ill
patients. N Engl J Med. 2001;345:1,359–1,367.
25. van den Berghe G, Wilmer A, Hermans
G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006;354:449–461.
2007–2008 Weight Management DPG officer directory
Chair
Public policy director
Subunits director
Monica B. Krygowski, MS, RD, LD
Cell phone: 303/862-0115
E-mail: [email protected]
Anne Daly, MS, RD, BC–ADM, CDE
Office phone: 217/787-6799
E-mail: [email protected]
Jennifer Garland, MPH, RD, LDN, CDE
Office phone: 615/831-4391
E-mail:
[email protected]
External relations director
Chair-elect
Ruth Ann Carpenter, MS, RD, LD
Cell phone: 972/890-3970
E-mail: [email protected]
Pat Harper, MS, RD, LDN
Office: 412/692-2971
E-mail: [email protected]
Communications director
Past chair
Chris Biesemeier, MS, RD, LDN, FADA
Office phone: 615/343-2028
E-mail:
[email protected]
Treasurer
Anne E. Mathews, MS, RD
Office phone: 412/692-2967
E-mail: [email protected]
Secretary
Susan Burke, MS, RD, LD/N, CDE
Cell phone: 2511-874/459
E-mail: [email protected]
Nominating Committee director
Ann Wolf, MS, RD
Office phone/fax: 434/977-285
E-mail: [email protected]
Diane Heller, MMSc, RD
Cell phone: 770/289-1915
E-mail: [email protected]
Newsletter editor
Molly Wangsgaard, MS, RD, LDN
Office phone: 615/322-2136
E-mail: [email protected]
Web site editor
Kim Gorman, MS, RD, LD
Office phone: 303/315-9036
E-mail: [email protected]
Professional development director
Member recruitment and retention
director
Michele Doucette, PhD
Office phone: 404/808-3768
E-mail: [email protected]
Research coordinator
Lori Greene, MS, RD, LD
Office phone: 205/348-0205
E-mail: [email protected]
ADA staff liaison
Danielle Bauer
Office phone: 800/877-1600 ext. 4778
E-mail: [email protected]
Executive coordinator
Paula Peirce, PhD, RD
Office phone: 303/627-9207
E-mail: [email protected]
Chris Weithman, MBA, RD, LDN
Office phone: 617/357-9876 ext. 217
E-mail: [email protected]
Weight Management Newsletter
Viewpoints and statements in this newsletter and accompanying insert do not necessarily reflect policies and/or official positions of the American
Dietetic Association. © 2007 Weight Management Dietetic Practice Group of the American Dietetic Association.
Presort Standard
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Elgin, IL
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Molly Wangsgaard, MS, RD, LDN
Weight Management newsletter editor
1301 22nd Ave. S.
TVC Suite 2558
Nashville, TN 37232
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