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 susan.deno@ 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 U.S. Postage PAID Elgin, IL Permit 9 Molly Wangsgaard, MS, RD, LDN Weight Management newsletter editor 1301 22nd Ave. S. TVC Suite 2558 Nashville, TN 37232 Support for Weight Management Newsletter has been provided by: 28
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