Weight Management Matters
Transcription
Weight Management Matters
Weight Management Matters CPEU article Managing Overweight and Obesity in Adults: A Summary of the Systematic Evidence Review from the Obesity Expert Panel, 2013 By Cathy A. Nonas, MS, RD and Barbara E. Millen, DrPH, RD, FADA Learning Objectives: After reading this, RDNs will be able to: 1. Describe the process used by AHA/ACC/ TOS and NHLBI to develop these Cathy A. Nonas, guidelines. MS, RD 2. Delineate the key principles of the 2013 Management of Overweight and Obesity Guidelines and how RDNs can apply them to the prevention and Barbara E. Millen, management of DrPH., RD, FADA overweight and obesity. 3. Identify the evidence-based options for weight loss that can be recommended to patient/clients based upon their health risk profile and individual needs and desires. 4. Discuss the key assets RDNs bring to the prevention and management of overweight and obesity. History, Background and Context Overweight and obesity is at epidemic proportions in the U.S., tipping the proverbial scales at 69%, 36% of these individuals are obese and the remainder are classified as being overweight (3). The leading cause of death in the U.S. remains cardiovascular disease (CVD). Approximately 68 million Americans have hypertension, 71 million have elevated LDL-Cholesterol which puts them at risk for CVD (4). Every organ of the body is affected by excess body weight and the heart is no exception. Overweight and obesity can lead to ventricular hypertrophy, higher risk of fatal and non-fatal stroke, high blood pressure and prediabetes and type 2 diabetes. These concerning facts led the National Heart Lung and Blood Institute (NHLBI) in 2005 to bring together thought leaders from clinical areas relevant to CVD to establish a process to integrate the science and clinical recommendations for CVD. This step led to the updating and integration of the blood pressure, cholesterol and obesity guidelines that had, in the past, been researched and disseminated through the NHLBI (3). (Continued on page 8) A Quarterly Publication for Weight Management Leaders In this Issue CPEU Article: Managing Overweight and Obesity in Adults: A Summary of the Systematic Evidence Review from the Obesity Expert Panel, 2013 1 Practice Points The Look AHEAD Trial: Look Beyond the Headlines 2 Bariatric Surgery: Options for Treating Weight Regain After Roux-en-Y Gastric Bypass 5 From the Chair: A Year of Growth 12 Physical Activity: Practical Sports Nutrition: The Four R’s of Recovery 13 Students Corner: Comparison of Weight-Loss Programs 15 Policy and Advocacy Report: Agriculture Act of 2014 18 Member Benefits: Member Services Update 19 From the Editor 20 Research: Improving Outcomes of a Worksite Wellness Program with a ClientCentered Nutrition Intervention 21 Book Review: Too Busy To Diet 24 Stipend Winners 25 WM DPG 2014 Excellence Awards 29 Upcoming Events 30 2013-2014 Weight Management Dietetic Practice Group Leadership Directory 31 Spring 2014 Volume 12 No. 4 Practice Points The Look AHEAD Trial: Look Beyond the Headlines Interview by Hope Warshaw, MMSC, RD, CDE, BC-ADM Introduction To date, the Look AHEAD (Action for Health in Diabetes) trial is the largest and longest National Institutes of HealthHope Warshaw, funded multicenter (16 MMSC, RD, CDE, BC-ADM sites), randomized study focusing on the use of intensive lifestyle intervention to promote weight reduction in an overweight population of people with relatively earlyonset type 2 diabetes. The primary trial endpoint focused on the question: Can an intensive lifestyle intervention (ILI) program which achieves and maintains weight loss and fitness help prevent or delay the cardiovascular events (including death, nonfatal myocardial infarctions, nonfatal strokes or hospitalization for angina), the most common complication of type 2 diabetes? (1). Look AHEAD was planned for 13.5 years and expected to conclude in 2014 but was halted after 11.5 years late in 2012 after the study’s overseeing body determined, on the basis of a futility analysis, that further study would not lead to additional findings (1). Initial primary results were presented at the American Diabetes Association Scientific Sessions 2013, (2) which I attended. Concomitantly the publication with the final results was published in the New England Journal of Medicine (NEJM) (1). As is often the case today, NEJM began a social media push to publicize this article. Within their initial tweet (on Twitter) was the statement: “Intensive lifestyle intervention did not reduce CV events in overweight adults w/ type 2.” Consumer publications followed suit. The Wall Street Journal headline read: “Disappointing Results for Weight Loss and Diabetes.” As I’ve attended programs since the NEJM publication where the Look AHEAD results have been presented or discussed, these negative headlines continue to resonate. However, numerous long-term benefits of weight management and improved fitness in the Look AHEAD trial have been reported (1,2). Registered Dietitian Nutritionists (RDNs) involved with counseling people who are overweight and at risk of type 2 diabetes and those with early-onset type 2 diabetes should be well versed in the initial (3) and final results (1) of the Look AHEAD trial as well as the strategies for weight management that were found to be successful, (4-6) as detailed in this review. Study Details A large ethnically and geographically diverse population (5,145) of overweight and obese (mean body mass index [BMI] >35) adults (45 to 76 years of age) diagnosed with type 2 diabetes (6.8+6.5 years, with range of 3 months to 13 years (7)) were randomly assigned to the study group (ILI) or the control group (diabetes support and education [DSE]) (3). Briefly, the goals for the ILI group were 7% or greater weight loss at year 1, greater than 175 minutes of physical activity per week, and consumption of 1,200 to 1,800 kcal/ day with 30% or fewer kilocalories as fat. ILI group participants received extensive support, with weekly support for 0 to 6 months, 3 times per month support from 6 months to 1 year, and less frequent but continued support throughout the trial. Parameters for the DSE control group were designed to mimic usual care for individuals diagnosed with type 2 diabetes, but in reality, these individuals received significantly more education and support than most people with type 2 diabetes do. The DSE subjects were provided with standard guidance for eating and physical activity but received no focus on behavioral strategies. They were invited to three group sessions per year separate from the ILI group. Overall medical care for study participants was provided by their primary care providers. Additional details about the study design and subjects are available (6,8). Key Results for Weight Loss and Fitness The median length of follow-up was 9.6 years, with a retention rate of 96% of study participants (1). Weight Loss: As has been observed in other long-term weight loss studies, including the Diabetes Prevention Program Trial (DPP), (9) maximum weight loss was achieved by year 1, with the ILI group losing 8.6% of initial body weight versus 0.7% for the DSE group (3). At year 4, ILI participants had lost an average of 4.7% of their initial weight compared with 1.1% for DSE participants (5). Eight-year results showed that ILI participants maintained the same average weight loss of 4.7% from initial weight at year 4 compared with a 2.1% weight loss for the DSE group (6). Losing a large amount of weight the first year was by far the strongest determinant of achieving a large loss at years 4 (5) and 8 (6). Of note, the study design implemented intensive support to achieve maximal weight loss during year 1 due to findings from previous studies, such as the DPP (9), that early weight loss predicts long-term weight control success. As is also often observed in long-term weight management, the ILI group experienced gradual weight regain through years 1 to 5 of the study, and the weight regain subsequently stabilized through year 8, (6) with a mean weight loss of 6% for ILI and 3.5% for DSE groups (1). One factor conjectured for this additional weight loss in the later years of the trial is the aging process (2) and diabetes (6). A valuable article by Raynor and associates (10) detailed behaviors of subjects who entered the study at a lower BMI. These included weekly self-weighing, regular breakfast consumption, decreased intake of 2 Weight Management Matters Spring 2014 fast foods, decreased portions, and use of meal replacements. Wadden and colleagues (4) concluded that factors associated with success at year 1 included greater use of meal replacements, more favorable food intake, and greater attendance at treatment sessions. At year 4, more favorable food intake and frequent attendance at treatment sessions continued to be factors associated with success (5). At year 8, weight-maintenance behaviors associated with 10% or greater weight loss included high levels of physical activity, reduced calorie intake, and frequent monitoring of weight (6). Use of Insulin and Weight Loss Although ILI participants who took insulin at baseline or initiated insulin by year 4 lost less weight than participants not using insulin, they did achieve significant weight loss (5). According to Wadden and associates, (5) differences in weight loss between insulin users and nonusers were not clinically meaningful and should mitigate concerns that insulin users cannot lose weight, although the point was made that these individuals do require sufficient support to achieve or maintain weight control. Fitness ILI participants had greater improvements in physical fitness at years 1 (3) and 4 (11). Factors associated with greater weight loss and improved physical fitness were at least 175 minutes of aerobic activity per week (the goal for the ILI group) (3) and resistance training 2 to 3 days per week (5). Glycemic Control Results show that glycated hemoglobin (A1c) was maximally lowered at year 1 in the ILI group (-0.64%) (3). Over the course of the trial, A1c gradually rose, but it remained below the baseline mean of 7.3±1.2% in the DSE group and 7.2±1.1% by the end of the trial. Final results showed that the ILI group achieved an estimated mean A1c lowering of 0.2% (1). It’s important to note that there was less use of insulin and other glycemic-lowering medications in the ILI than the DSE group (1). A modest number (7.3%) of ILI subjects achieved partial or complete diabetes remission at year 4 (12). Blood Pressure Systolic blood pressure improved substantially in the ILI group, but diastolic blood pressure did not. However, the ILI group was less likely to use antihypertensive medication (1). Lipids The ILI group had a greater increase in high-density lipoprotein cholesterol. Both groups experienced a decrease in lowdensity lipoprotein cholesterol, although the ILI group required less statin medication (1). One reason hypothesized for the lack of greater reduction in cardiovascular events in the ILI group was that many DSE participants were prescribed statin medication during the trial by their primary care providers. Additional Health Improvements in the ILI Group: (1,2) • 31% reduction in chronic renal disease • Reduced self-reported symptoms of retinopathy • Less depression • Less sleep apnea • Less urinary incontinence In addition, the ILI group used less health care resources, with reduced cumulative hospitalizations, less use of medications, and less cumulative health care services (1,3). Conclusion Although the overall weight loss achieved and maintained during Look AHEAD was relatively minimal, this weight loss achieved myriad health and health care benefits. An important factor to keep in mind is that in contrast to the approximately 2 lb/year (13). that the average American adult gains, both DSE and ILI participants in Look AHEAD maintained long-term weight loss over the course of the study. ILI participants who had the shortest duration of disease, were not using insulin, and had good baseline glycemic control received the most health benefits from the intervention (12,14). These results support the critical importance of early intensive lifestyle intervention in the prevention and management of type 2 diabetes. Look AHEAD is continuing as an observational trial (1). Many additional articles will be published detailing various aspects of the trial that will be important to RDNs involved in weight management and/ or diabetes care, including a commentary by Delahanty (15). We owe a debt of gratitude to all health care providers involved in Look AHEAD, including a number of our Weight Management Dietetic Practice Group (DPG) and Diabetes Care and Education DPG colleagues. References: 1.Look AHEAD Research Group; Wing RR, Bolin P, Brancati FL, et al. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013;369:145–154. 2.Wing RR, Knowler WC, Faulconbridge LF, Glick H; The Look AHEAD Research Group. Primary results of the Look AHEAD randomized controlled trial of a lifestyle intervention in overweight and obese individuals with type 2 diabetes. Presented at the American Diabetes Association Scientific Sessions, 2013. 3.Look AHEAD Research Group. Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes. Diabetes Care. 2007;30(6):1374-1383. 4.Wadden TA, West DS, Neiberg RH, et al; Look AHEAD Research Group. One-year weight losses in the Look AHEAD study: factors associated with success. Obesity (Silver Spring). 2009;17:713–722. 5.Wadden TA, Neiberg RH, Wing RR, et al; The Look AHEAD Research Group. Fouryear weight losses in the Look AHEAD study: factors associated with long-term success. Obesity (Silver Spring). 2011;19:1987–1998. 6.Look AHEAD Research Group. Eight-year weight losses with an intensive lifestyle intervention: the Look AHEAD Study. Obesity (Silver Spring). 2014;22:5-13. 7.Bertoni AG, Clark JM, Feeney P, et al; The Look AHEAD Research Group. Suboptimal control of glycemia, blood pressure, and LDL cholesterol in overweight adults with diabetes: the Look AHEAD Study. J Diabetes Complications. 2008;22:1-9. (Continued on page 4) 3 Volume 12 No. 4 Weight Management Matters (Continued from page 3) 8.The Look AHEAD Research Group; Wadden TA, West DS, Delahanty L, et al. The Look AHEAD Study: a description of the lifestyle intervention and the evidence supporting it. Obesity (Silver Spring). 2006;14:737–752. 9.Diabetes Prevention Program Research Group; Knowler WC, Fowler SE, Hamman RG, et al. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009;374:1677–1686. 10.Raynor HA, Jeffery RW, Ruggiero AM, Clark JM, Delahanty LM; Look AHEAD Research Group. Weight loss strategies associated with BMI in overweight adults with type 2 diabetes at entry into the Look AHEAD (Action for Health in Diabetes) trial. Diabetes Care. 2008;31:1299–1304. 11.The Look AHEAD Research Group; Wing RR. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: four-year results of the Look AHEAD trial. Arch Intern Med. 2010;170:1566-1575. 12.Gregg EW, Chen H, Wagenknecht LE, et al; Look AHEAD Research Group. Association of an intensive lifestyle intervention with remission of type 2 diabetes. JAMA. 2012;308:2489–2496. 13.Hill JO, Wyatt HR, Reed GW, Peters JC. Obesity and the environment: where do we go from here? Science. 2003;299:853855. 14.Evert AB, Boucher JL, Cypress M, et al; American Diabetes Association. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2013;36:38213842. 15.Delahanty LM. The Look AHEAD Study: implications for clinical practice go beyond the headlines. J Acad Nutr Diet. April 2014 (In press). Acknowledgements: The author wishes to thank Linda Delahanty, MS, RD, and Hollie Raynor, PhD, RD, LD, for their thoughtful review of this article. Get Involved in Research that Matters The Dietetics Practice Based Research Network (DPBRN) consists of registered dietitians from various backgrounds who conduct and promote practical research in real-world settings. Join the DPBRN and be part of a network committed to improving patient and client outcomes. Learn how by visiting www.eatright.org/members/dpbrn. Dietetics Practice Based Research Network – Advancing dietetics through outcomes research. 4 Weight Management Matters Spring 2014 Options for Treating Weight Regain After Roux-en-Y Gastric Bypass By Kathryn Valentine, RD B ariatric surgery is a widely accepted and effective treatment for weight loss. While most patients successfully lose weight after Kathryn Valentine, surgery, approximately RD 20-30% of patients do not achieve their desired weight or regain weight years after surgery (1). As food and nutrition professionals and weight management experts, it is important that we understand the full scope of options that exist to help these individuals. This article will explore some underlying causes of post-bariatric surgery weight regain, review existing nutrition recommendations and treatment modalities, and discuss new surgical procedures to treat post-surgical weight gain with endoscopic techniques. Weight Regain after Gastric Bypass Surgery Roux-en-Y gastric bypass surgery (RYGB) is a common and effective surgical weight loss procedure with >60% excess body weight loss (EBWL) expected within the first two years (2). Unfortunately, many patients regain weight with 20-30% of patients either not achieving their weight loss goals or regaining weight (1). Weight regain after RYGB can result from any of the following (1): • Exercise non-compliance • Decreased resting metabolic rate (RMR) • Alcohol intake or abuse • Hormonal changes (ghrelin, PYY, GLP-1, leptin) • Surgical defects (gastro-gastric fistula, enlarged pouch or anastamosis) • Lack of adequate nutrition follow-up and adherence to recommendations • Poor self-monitoring or education Many of the above issues are interrelated; frequently metabolism, food intake, gastric pouch and anastomotic (stoma) dilation are involved. Stoma dilation has been linked Bariatric Surgery Nina Crowley, MS, RD, LD, is the bariatric surgery section editor. Weight regain is probably the biggest fear that our patients have when they undergo weight loss surgery, and with good reason, research shows it is a very real phenomenon. As registered dietitian nutritionists, we have many nutrition tools to offer our patients when they experience weight regain. We also must be equipped with tools and referrals to offer our patients who do not keep their weight off. Katherine keeps us in the loop by discussing some new endoscopic options. with weight regain after bariatric surgery (3). Non-compliance to nutrition recommendations may alter pouch anatomy or stoma dilation. “Stretching,” or dilation of the pouch or stoma may lead to decreased satiety and increased hunger, which in turn may further perpetuate noncompliance with eating behaviors. In addition to weight gain, patients may have abdominal complaints related to a dilated stoma as rapid transit into the small bowel may cause dumping syndrome. Another complication that can affect weight maintenance after RYGB is a fistula between the gastric pouch and gastric remnant, a gastro-gastric fistula (GGF). This is more commonly seen in older surgeries where surgeons did not divide the stomach pouch completely from the excluded remnant stomach. A GGF may inhibit a patient from achieving adequate weight loss because food can pass from the pouch to the excluded stomach, following the non-bypassed original anatomy, and there is complete absorption of macronutrients. This allows patients to ingest larger volumes of food and may render their surgery ineffective. Nutrition Recommendations for Weight Regain To the RDN, the fight against weight regain begins with nutrition counseling. A thorough evaluation by the bariatric team is recommended; measurement of resting metabolic rate using indirect calorimetry or predictive equations can give patients a more accurate goal for their calorie needs. Education and counseling by the dietitian are critical in the patient’s ability to follow post-bariatric nutrition guidelines; dietitians should monitor patients’ energy intake, activity, and weight closely (1). A variety of methods can be used to help patients achieve negative energy balance and weight loss: very low calorie diets (VLCD) or a return to the immediate post-operative full liquid diet for a period of time may help patients kick-start weight loss again. Behavioral health is vital for those who have regained weight after surgery. The dietitian can play an integral role in coordinating care to help patients receive appropriate psychosocial counseling to address possible reasons for weight regain (1). Major life changes, injuries or tragedies causing stress and anxiety may be triggers that lead patients back to emotional eating and sedentary habits. To achieve long-term weight loss, patients must be able to manage behavioral issues that impede their success. Procedures to Treat Weight Regain with Surgical Repair Two common revision procedures include Duodenal Switch conversion or band placement over an existing RYGB pouch. The Duodenal Switch is a malabsorptive procedure that works by rerouting the intestines to create a very short common (Continued on page 6) 5 Volume 12 No. 4 Weight Management Matters (Continued from page 5) limb, approximately 100 centimeters (3). It is often done in conjunction with a Biliopancreatic Diversion as a primary bariatric surgery. The Duodenal Switch works as a revision procedure by bypassing a longer segment of small bowel than an original RYGB in order to reduce absorption of calories from fat (4). The “Band over Bypass”, also known as “Salvage Banding”, places an adjustable gastric band over the stomach pouch to further restrict the volume of food the pouch can hold and slow gastric emptying. Salvage Banding has been effective in some studies (5), however, surgical options carry a high complication rate of up to 50% and a mortality rate of 2% (6). The Duodenal Switch is a highly complex procedure that carries an even greater risk than other bariatric surgeries. Pictures provided with permission of Apollo Endosurgery and USGI Medical. Figure 1: Illustration of the ROSE procedure-gastric tissue plication secured with suture and anchors StomaphyX and Restorative Obesity Surgery, Endoluminal (ROSE) procedures StomaphyX and ROSE procedures are endoscopic techniques performed by gastroenterologists and bariatric surgeons specially trained in advanced endoluminal therapeutics. StomaphyX uses suction to create pleats or folds in gastric tissue to reduce a dilated stoma. The folds are anchored with polypropelene implants, which are non-absorbable H-shaped fasteners. The ROSE procedure also uses a plication technique performed with large graspers rather than suction. Folds are fixed with nitinol anchor sutures. Folds are created circumferentially around the gastric pouch or stoma. The StomaphyX procedure has been ineffective as a treatment for sustainable weight loss (7). The ROSE procedure is feasible and safe; studies report average weight loss of 7.8 to 8.8 kgs after 3 months (8,9). Further studies are needed to assess long-term results. Sclerotherapy Sclerotherapy is a technique used by bariatric surgeons and gastroenterologists to reduce the size of a dilated stoma with a sclerosing agent. Sodium morrhuate is a sclerosant typically used to treat varicose veins by creating inflammation when injected and causing a blood clot to form, occluding blood flow and destroying the vein. When injected at the anastomosis, the Figure 2: Illustration of endoscopic suturing procedure-gastric outlet reduction and pouch reduction using interrupted and running stitches. drug induces scarring which may reduce the outlet diameter. The procedure may require repeat injections, typically performed after 3 months. In some studies, patients have lost 18-61% of their regained weight (10,11). Risks of sclerotherapy include bleeding, an increase in diastolic blood pressure and pain. Endoscopic suturing One of the newest techniques for postbariatric surgery weight regain involves gastric bypass remodeling with endoscopic suturing. This procedure is performed by interventional gastroenterologists as well as bariatric surgeons. This endoscopic surgery uses interrupted and running sutures to approximate tissue. The gastric pouch and/ or outlet are reduced to the original RYGB anatomy dimensions—approximately 5 cm and 4-12 mm, respectively. During this procedure, areas of gastric tissue may be prepared with Argon Plasma Coagulation (APC) or other tissue ablation methods, which de-epithelializes the tissue— theoretically allowing two prepared areas to adhere to each other once sutured. In one trial, patients lost 69.5% of their regained weight at 6 months and 89% at 12 months (5). In another study, 96% of subjects who underwent endoscopic suturing for stoma reduction experienced weight loss or stabilization (12). Because this is a novel procedure, limited data is 6 Weight Management Matters Spring 2014 Pictures provided with permission of Apollo Endosurgery and USGI Medical. available and further studies are currently underway. understand their options and prepare for another chance at successful weight loss. Post Revisional Procedure Diet Advancement Kathryn Valentine, RD, earned her degree in Dietetics from Rutgers University. She completed her dietetic internship with Sodexo’s New York area program. She has over 4 years of experience as an RD and has a private practice, Valentine Nutrition, LLC. She is the Patient Relations Director for the National Institute for Bariatric Repair in northern New Jersey and study coordinator for the Primary Obesity Multicenter Incisionless Suturing Evaluation (PROMISE) trial in NJ. She specializes in out-patient bariatric nutrition counseling, including postrevision and bariatric complication nutrition therapy with a special attention to weight gain after gastric bypass. For more information, visit www.BariatricRepair.com or email [email protected] Nutrition counseling is an integral part of the interdisciplinary treatment plan for bariatric patients before and after primary and revisional procedures. In general, after revision, patients should return to a postoperative bariatric diet and advance through the diet stages within approximately 4-6 weeks. Patients progress through clear liquids, full liquids, and purees/soft solids with specific recommendations from their physician and dietitian. They eventually progress to a modified regular diet low in carbohydrates and high in lean protein with a focus on small portions of food. When equipped with a good understanding of available revisional procedures, RDNs can more effectively counsel patients who experience post-bariatric surgery weight gain and help make any chosen procedure more successful. Conclusion Bariatric surgery patients may experience weight regain after successful weight loss for a number of complex reasons. Endoscopic procedures present alternatives for traditional surgical revision. These may prove advantageous for patients seeking less invasive procedures to address weight regain, especially those who may have a contraindication to trans-abdominal surgery such as scarring or adhesions. The field of endoscopic bariatrics is expected to grow, with new revisional and primary endoscopic therapies emerging (13). Bariatric nutrition needs to grow along with these advancements. Coupled with the support and guidance of RDNs these procedures offer a viable second chance for patients to achieve their goal weight. By staying abreast of developments in the field, RDNs can help patients better References: 1.Johnson Stoklossa, C and Atwal, S. Nutrition Care for Patients with Weight Regain after Bariatric Surgery. Gastroenterology Research and Practice. 2013;2013:1–7 2.Buschwald H, Avidor Y, Braunwalked E et al. Bariatric surgery: a systemic review and meta-analysis. JAMA. 2004;292: 1724–1737 3.Abu Dayyeh B, Lautz DB, Thompson CC. Gastrojejunal Stoma Diameter Predicts Weight Regain after Roux-en-Y Gastric Bypass. Clin Gastroenterol Hepatol. 2011;9:228–233 4.Anthone G, Lord R, DeMeester T, et al. The duodenal switch operation for the treatment of morbid obesity. Ann Surg. 2003;238(4):618–628 5.Vijgen GH, Schouten R, Bouvy ND, et al. Salvage banding for failed Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2012;8:803–808 6.Jirapinyo P, Slattery J, Ryan MB, et al. Evaluation of an endoscopic suturing device for transoral outlet reduction in patients with weight regain following Roux-en-Y gastric bypass. Endoscopy. 2013;45:532–536 7.Goyal V, Holover S, Garber S. Gastric pouch reduction using StomaphyX in post Roux-en-Y gastric bypass patients does not result in sustained weight loss: a retrospective analysis. Surg Endosc. 2013;9:3417–3420 8.Mullady DK, Lautz DB, Thompson CC. Treatment of weight regain after gastric bypass surgery when using a new endoscopic platform: initial experience and early outcomes (with video). Gastrointest Endosc. 2009;70:440–444 9.Ryou MK, Mullady DK, Lautz DB et al. Pilot study evaluating technical feasibility and early outcomes of second-generation endosurgical platform for treatment of weight regain after gastric bypass surgery. Surg Obes Relat Dis. 2009;5:450–454 10.Abu Dayyeh BK, Jirapinyo P, Weitzner Z, et al. Endoscopic sclerotherapy for the treatment of weight regain after Rouxen-Y gastric bypass: outcomes, complications, and predictors of response in 575 procedures. Gastrointest Endosc. 2012;76:275–282 11.Madan AK, Martinez JM, Khan KA, et al. Endoscopic sclerotherapy for dilated gastrojejunostomy after gastric bypass. J Laparoendosc Adv Surg Tech A. 2010;20:235–237 12.Thompson CC, Chand B, Chen YK et al. Endoscopic Suturing for Transoral Outlet Reduction Increases Weight Loss Following Roux-en-Y Gastric Bypass Surgery. Gastroenterology. 2013;145: 129–137 13.Brigham and Women’s Hospital; Apollo Endosurgery. Primary Obesity Multicenter Incisionless Suturing Evaluation. In: clinicaltrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2013- [cited 2014 Jan 17]. Available from: http:// clinicaltrials.gov/ct2/show/ NCT01662024 NLM Identifier: NCT01662024 7 Volume 12 No. 4 Weight Management Matters (Continued from the cover) Panels of experts were selected to update these blood pressure, cholesterol and obesity guidelines. For the first time, panel members were also placed on two cross cutting work groups for the purpose of integrating the work of all of the expert panels. These cross cutting panels included a lifestyle panel to examine diet and physical activity related risks for CVD without weight loss and another panel to examine methods for assessing CVD risk. The tasks assigned to these panels were to develop guidelines that reflected the most recent evidence, determine where updates to the last set of guidelines were needed and to answer new questions that would enrich clinical practice and identify areas for future research. Unique to the work of these panels and work groups was that the development of these NHLBI guidelines would use the same methods and structure to allow them to blend together as easily as possible when published. In all, there were 16 questions answered by the five panels; each of the 16 questions were further deconstructed into many sub-questions. The expert panels reviewed the evidence and then rated the strength of the evidence after an independent team rated the quality of thousands of peer reviewed published articles. Depending upon the last updated information, (in the case of the overweight and obesity panel it was 1998), data was culled from the last update until 2010/11. It took five years, 23 meetings (conducted both virtual and in-person) and the examination of thousands of articles, to identify a sufficiently sound body of literature to answer each of the critical questions discussed in this summary. The expert panel for overweight and obesity included both practitioners and researchers. Summary of the Research Literature Reviews After the expert panel for overweight and obesity was selected and the questions and criteria identified, an independent, external company was hired by NHLBI to search the literature for each question, using criteria developed by the panel members. This external group then rated the quality of Continuing Professional Education Section Hope Warshaw, MMSc, RD, CDE, BC-ADM, is the continuing professional education section editor In late 2013, Guidelines for the Management of Overweight and Obesity in Adults were jointly released by American Heart Association (AHA), the American College of Cardiology (ACC) and the Obesity Society (TOS) (1,2). The WM DPG leadership believes it is important for the WM DPG membership to be knowledgeable about these guidelines, understand the context within which they were developed and be aware of their implications. This CPE article, written by two members of the expert panel for overweight and obesity, both registered dietitians and members of WM DPG, summarizes the development, findings and recommendations of these recently released overweight and obesity guidelines. each of the studies as good, fair and poor with additional review and insight from the panel. From here, evidence tables were created. The panel then graded the evidence with the help of the external company to ensure that the grades were based on the evidence, not the clinical experience of expert panel members. When possible, only randomized clinical trials (RCTs) with either a “good” or “fair” rating were used as evidence. In some cases, RCTs were not available. If this was the case or in the case of certain questions where resources were not sufficient to review the original literature, then systematic reviews and observational studies were used. The study quality ratings were based on certain criteria such as: 1. Was the method of randomization adequate (i.e., use of randomly generated assignment)? 2. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? 3. Was the overall drop-out rate from the study 20% or lower? (This was particularly difficult criteria for weight loss intervention studies.). 4. Was the differential drop-out rate (between treatment groups) 15 % or lower? 5. Were all randomized participants included in the analysis of the group to which they were originally assigned, i.e., did the researchers use an intention-to-treat analysis? The following are examples of the criteria for the quality ratings as well as some of the common flaws seen in the study designs: A well-designed, well-executed RCT that adequately represented populations to which results were applied and directly assessed effects on health outcomes, was rated “high.” If, however, there were any differences in the treatment between randomized groups of subjects, this could result in a “fair” rating if there was a minor difference but not sufficient to invalidate the study, or “poor” rating if egregious and indicating significant risk of bias. For example, if one intervention group received dietary information and coupons to purchase certain foods, and the other group was given food but the group given food was also telephoned a couple of times, this would reduce the quality of the RCT because the two groups received different levels of treatment. Another factor leading to a lower rating was the lack of inclusion of an intent-to-treat analysis. Many studies had analysis strategies that did not include drop-outs, even when the drop-out rate in the study was substantial. This made the results look strong, but they 8 Weight Management Matters Spring 2014 were positively biased. Again, this led to certain studies being rated as “poor” and omitted from consideration by the panels and workgroups. It is the reason why from the thousands of studies culled a much smaller number were considered relevant in this systematic review. Updating the 1998 Evidence Report on Overweight and Obesity The first set of clinical guidelines for the treatment of overweight and obesity in adults was published in 1998 (5). The charge to that 1998 expert panel was twofold: 1) to cull the scientific literature from 1980-1997 and 2) to create recommendations for treatment for the practicing physician and other health care providers dealing with overweight and obese patients. The 2013 guidelines add to the 1998 guidelines by reevaluating the association of body mass index (BMI) to CVD and its CVD risk factors. These updated guidelines used the same cutpoints for BMI because the Committee determined that there was insufficient data to recommend a change in criteria for overweight and obesity. In addition, the 2013 guidelines answer some new, relevant questions such as which dietary strategies are most successful for weight loss, which components of lifestyle modification treatment are most efficacious and which surgical procedures produce better outcomes. The 2013 panel used a rigorous evidence-based approach that involved a systematic review of the evidence with priority given to RCTs. The treatment algorithm directs those in clinical practice to consider various types of weight loss treatment or weight maintenance, not just based on BMI, but also dependent upon the patient’s own interest, the individual’s health profile, and success or failure of methods already attempted. Therefore, although there are commonalities between the algorithms from 1998 and 2013, one result of the 2013 guidelines was to encourage health practitioners to think differently about obesity. Clinicians should consider overweight and obesity as a chronic metabolic disorder associated with significant morbidity and mortality. It requires long-term treatment and has a high rate of relapse. Nonetheless, while the amount of weight that most people can lose and maintain is relatively limited, available evidence demonstrates that even modest weight loss, 3-5% (6), confers significant health benefits and greater amounts of weight loss are associated with better outcomes. The 2013 guideline focused recommendations on five specific critical questions (CQ): the first two dealt with the risks of overweight and obesity and the benefits of losing weight. The latter three questions dealt with treatment and include the work RDNs do to help patients/clients survive within an obesigenic environment. CQ 1: Benefits of weight loss – Is weight loss good for your patient/client? CQ2: Risks of overweight – How do you identify who is at risk sufficiently to mandate weight loss efforts? CQ3: Diets for weight loss – What is the efficacy/effectiveness of the different dietary intervention strategies to promote weight loss? CQ4: Comprehensive Lifestyle Intervention (Diet+Physical Activity + Behavioral Therapy) – What is the efficacy/ effectiveness of a combined approach to achieving and maintaining weight loss? CQ5: Bariatric surgery – What are the benefits and risks of the various procedures? In exploring each of these questions, subquestions were developed and examined (for example, did effectiveness of the intervention differ by demographic or ethnic characteristics of the population?). The following are some of the evidence statements that were graded “high.” – the greater the individual’s BMI, the greater the risk of CVD and type 2 diabetes (7,8); – sustained weight loss of as little as 3-5% can result in meaningful improvements in the health profile (6); – six months or more of lifestyle counseling produces the most successful outcomes (9–10); – advise overweight and obese individuals who have lost weight to participate in a long-term (≥ 1 yr) comprehensive weight loss maintenance program (11,12,13); – Weight loss at 2 to 3 years following a variety of surgical procedures in adults with presurgical BMI ≥ 30 varies from a mean of 20% to 35% of initial weight and mean difference from nonsurgical comparators of 14% to 37% depending on procedure (14–15). – s ome 15 dietary regimens were found to be evidence-based and equally effective in inducing weight loss as long as they were calorie-restricted; All of the above statements and references are detailed in the guidelines (1,2). The research evidence demonstrated that all 15 evidence-based diets (see Table 1) reviewed performed equally well in promoting short and long-term weight loss in adults as long as the calorie intake was sufficiently restricted to induce weight reduction. For example, people following an “ad libitum” diet that severely restricted carbohydrates, still resulted in a lowercalorie intake and it was this calorie reduction, not the lower-carbohydrate intake, that seemed to result in weight loss. These important findings indicate that RDNs and other health care providers, as appropriate, have a wide array of dietary intervention options to offer their clients for weight loss management. The 2013 overweight and obesity expert panel recommended that weight loss programs be tailored to the individual’s preferences and needs. It underscored that a “one size fits all” approach should be avoided in order to achieve long-term compliance and success. Among the challenges for the practitioner are to fully assess each individual’s health needs and lifestyle characteristics and to interpret them fully in establishing a sound, personalized approach to weight management. (See for the purpose of one example, www.healthmain.com for an evidencebased approach to personalize weight management and other nutrition-related interventions and medical nutrition therapy.) (Continued on page 10) 9 Volume 12 No. 4 Weight Management Matters (Continued from page 9) A comprehensive lifestyle intervention, consisting of diet, physical activity and behavioral therapy, providing onsite (in person) treatment in either group or individual sessions, weekly for the first month and then biweekly for 6 months, produced the greatest weight loss. Longterm programs, consisting of additional visits for more than a year, were most successful in reducing the amount of weight regain (12,13). An interesting addition to the literature was the use of electronically delivered, comprehensive weight loss interventions (that is, web or other resources used in conjunction with health care professional contact). Although less efficacious than onsite, intensive comprehensive lifestyle intervention, electronic strategies/tools carried out in academic settings with the use of interactive websites, text messaging and/or emails as well as personalized feedback from trained interventionists (dietitians, behaviorists, and exercise specialists) have been shown to result in Table 1. 15 Dietary Approaches Associated with Weight Loss by Expert Panel (1,2) All of the following dietary approaches (listed in alphabetical order below) are associated with weight loss if reduction in dietary energy intake is achieved: A diet from the European Association for the Study of Diabetes Guidelines, which focuses on targeting food groups, rather than formal prescribed energy restriction while still achieving an energy deficit. Descriptions of the diet can be found in the Full Panel Report Supplement. Higher protein (25% of total calories from protein, 30% of total calories from fat, 45% of total calories from carbohydrate) with provision of foods that realized energy deficit. Higher protein Zone-type diet (5 meals/day, each with 40% of total calories from carbohydrate, 30% of total calories from protein, 30% of total calories from fat) without formal prescribed energy restriction but realized energy deficit. Lacto-ovo-vegetarian-style diet with prescribed energy restriction. Low-calorie diet with prescribed energy restriction. Low-carbohydrate (initially <20 g/day carbohydrate) diet without formal prescribed energy restriction but realized energy deficit. Low-fat (10% to 25% of total calories from fat) vegan style diet without formal prescribed energy restriction but realized energy deficit. Low-fat (20% of total calories from fat) diet without formal prescribed energy restriction but realized energy deficit. Low-glycemic load diet, either with formal prescribed energy restriction or without formal prescribed energy restriction but with realized energy deficit. Lower fat (< 30 % fat), high dairy (4 servings/day) diets with or without increased fiber and/or low-glycemic index/load foods (low-glycemic load) with prescribed energy restriction. Macronutrient-targeted diets (15% or 25% of total calories from protein; 20% or 40% of total calories from fat; 35%, 45%, 55%, or 65% of total calories from carbohydrate) with prescribed energy restriction. Mediterranean-style diet with prescribed energy restriction. Moderate protein (12% of total calories from protein, 58% of total calories from carbohydrate, 30% of total calories from fat) with provision of foods that realized energy deficit. Provision of high-glycemic load or low-glycemic load meals with prescribed energy restriction. The AHA-style Step 1 diet (with prescribed energy restriction of 1,500-1,800 kcal/day, <30% of total calories from fat, <10% of total calories from saturated fat). weight loss of up to 5 kg at 6-12 months in comparison to no or minimal intervention (16–18). The Registered Dietitian Nutritionist The 2013 guidelines are an important milestone for RDNs. They specifically recommend, for the first time, that primary care and other health care providers refer overweight and obese patients to food and nutrition professionals (e.g., RDNs) for counseling on calorie-restricted dietary interventions. They also acknowledge the RDN as one of the qualified providers of comprehensive lifestyle interventions, the “gold standard” for weight management (weight loss and weight loss maintenance). This acknowledgement reflects the substantial evidence base reviewed by the expert panel including key professional backgrounds of providers of effective interventions for weight loss and weight loss maintenance. In exploring CQs 3 (diet strategies) the expert panel considered whether the RCTs of dietary interventions implemented largely by food and nutrition professionals in academic and health care environments were effective in promoting weight loss. These studies typically controlled physical activity and behavioral intervention methods across study arms. CQs 4 studies (comprehensive intervention) were typically conducted by trained interventionists (e.g., teams of RDNs, exercise specialists, and behaviorists) in university or health care settings and compared to “usual care” protocols (19). It’s an opportune time for RDNs involved in weight management to embrace these 2013 overweight and obesity guidelines and advocate for their visibility and roles in the prevention and treatment of overweight and obesity in the population. No professional group was more strongly identified in this report as key in management of these conditions than RDNs. Multidisciplinary approaches were advocated and there is an opportunity for RDNs to lead and collaborate with others in seeking reimbursement for services and carrying out programs and initiatives in clinical, public health, worksite and educational settings where it is important to address the needs and problems facing Americans as they attempt to address weight-related issues. 10 Weight Management Matters Spring 2014 Thank you to the individuals who reviewed and provided input to this article: Catherine M. Champagne, PhD, RDN, LDN, FADA, FAND, FTOS, Eileen Ford, MS, RD and Linda M. Gigliotti, MS, RD, CDE. References: 1.Jensen MD, Ryan DH, Apovian CM, Loria CM, Ard JD, Millen BE, Comuzzie AG, Nonas CA, Donato KA, Pi-Sunyer FX, Hu FB, Stevens J, Hubbard VS, Stevens VJ, Jakicic JM, Wadden TA, Kushner RF, Wolfe BM, Yanovski SZ. 2013 AHA/ACC/ TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol. Access at: http://jaccjacc.cardiosource. com/acc_documents/2013_FULL_ Guideline_Obesity.pdf 2.Jensen MD, Ryan DH, Apovian CM, Loria CM, Ard JD, Millen BE, Comuzzie AG, Nonas CA, Donato KA, Pi-Sunyer FX, Hu FB, Stevens J, Hubbard VS, Stevens VJ, Jakicic JM, Wadden TA, Kushner RF, Wolfe BM, Yanovski SZ. 2013 AHA/ACC/ TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. Access at: https://circ.ahajournals.org/content/ early/2013/11/11/01. cir.0000437739.71477.ee.full. pdf+html?sid=6af28578-67b4-4bb19a4d-91ebab818a98 3.Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among U.S. adults, 1999-2010. Jour Am Med Assoc. 2012;307(5):491–507. 4.http://www.cdc.gov/features/vitalsigns/ cardiovasculardisease/ Centers for Disease Control and Prevention 2011. Accessed: March 4, 2014. 5.National Institutes of Health. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults— The Evidence Report. National Institutes of Health. Obes Res. 1998;6 Suppl 2:51S-209S. 6.Jensen MD, Ryan DH New obesity guidelines: promise and potential. Jour Am Med Assoc.;2014; 311(1):23–4. 7.McGee DL. Body mass index and mortality: a meta-analysis based on person-level data from twenty-six observational studies. Ann Epidemiol. 2005;15:87–97. 8.Whitlock G, Lewington S, Mhurchu CN. Coronary heart disease and body mass index: a systematic review of the evidence from larger prospective cohort studies. Semin Vasc Med. 2002;2:369–81. 9.Stevens VJ, Obarzanek E, Cook NR et al. Long-term weight loss and changes in blood pressure: results of the Trials of Hypertension Prevention, phase II. Ann Intern Med. 2001;134:1–11. 10.Subak LL, Wing R, West DS et al. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med. 2009;360:481–90. 11.Perri MG, Nezu AM, McKelvey WF, Shermer RL, Renjilian DA, Viegener BJ. Relapse prevention training and problem-solving therapy in the longterm management of obesity. J Consult Clin Psychol. 2001;69:722– 6. 12.Wing RR, Tate DF, Gorin AA, Raynor HA, Fava JL. A self-regulation program for maintenance of weight loss. N Engl J Med. 2006;355:1563–71. 13.Wing RR. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: four-year results of the Look AHEAD trial. Arch Intern Med. 2010;170:1566–75. 14.Mingrone G, Panunzi S, De Gaetano A et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366:1577–85. 15.Schauer PR, Kashyap SR, Wolski K et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366: 1567–76. 16.Hunter CM, Peterson AL, Alvarez LM et al. Weight management using the internet a randomized controlled trial. Am J Prev Med. 2008;34:119–26. 17.Morgan PJ, Lubans DR, Collins CE, Warren JM, Callister R. The SHED-IT randomized controlled trial: evaluation of an Internet-based weight-loss program for men. Obesity (Silver Spring) 2009;17:2025–32. 18.Tate DF, Jackvony EH, Wing RR. Effects of Internet behavioral counseling on weight loss in adults at risk for type 2 diabetes: a randomized trial. Jour Am Med Assoc. 2003;289:1833–6. 19.Svetkey LP, Stevens VJ, Brantley PJ et al. Comparison of strategies for sustaining weight loss: the weight loss maintenance randomized controlled trial. Jour Am Med Assoc. 2008;299: 1139–48. CPEU Process Access the CPE Assessment and obtain your Certificate via the online WM DPG CPE Assessment Center at www.wmdpg.org. Once logged in to our WM DPG member site, go to the CPE Assessment Center and take the CPE quiz for this newsletter article. You need to obtain a minimum 70% correct score to receive your CPE certificate. 11 Volume 12 No. 4 Weight Management Matters From the Chair Julie Schwartz, MS, RDN, 2013-2014 WM DPG Chair A year of growth W hat a year this has been! I’ve had the fortune to work with a group of inspirational, talented, and incredibly knowledgeable professionals on the WM DPG Executive Committee, and in our membership. I’m humbled to have been “the leader” of this group, however it’s truly been a team effort. This job is one of the most rewarding in my 25+ year career! The Weight Management (WM) Dietetic Practice Group (DPG) leadership has been busy putting the finishing time line on our five-year strategic plan which focuses our work on three pillars: knowledge, leadership, and communication. These three pillars touch on every aspect of the work the WM DPG is involved in with both our internal stakeholders, as well as with our external stakeholders. The responses that you, the members of our DPG provide on the member survey give the foundation for this strategic plan. This year, as most years, many new volunteers have joined committees to add depth and varying perspectives to the work we do as WM DPG. If you want to become more involved, please contact us, as there is always room for more volunteers at a variety of time commitments. In previous articles, I’ve written about the WM DPG involvement in advocating for The Treat and Reduce Obesity Act (TROA). I had the honor to present at the Public Policy Workshop about TROA and also on the collaborative involvement between the WM DPG, state affiliates, the Academy of Nutrition and Dietetics and the Academy’s Policy Initiatives and Advocacy (PIA) team! It has been a year of collaboration on this important legislation and there will be continued calls to action. We need to hear the voice of our membership on this issue. Regardless of your work setting or job description, and whether you accept insurance, work with Medicare patients, or are political, this is one bill that has the potential to impact our profession on every level. Reimbursement begins with Medicare coverage and trickles down from there. Clinical jobs tend to set the base salaries for our profession; reimbursement, or lack there of, impacts salaries. You can see where this is going! I challenge you to learn more and don’t wait for the Academy to be your voice. YOU are the voice of the Academy. YOU are the Academy. For more information, reach out to either Chris Weithman, Policy and Advocacy Leader (PAL), or the committee members Betsy Anderson and Amanda Meadows. Our website is becoming more robust on a weekly basis. The directory has the potential to be a go to resource of experts in varying areas of weight management. Are you an expert? Are you a member? Consider updating your directory listing so that you’re more easily found. And check out our mini webinars on the depth of information and navigation of the website, or peruse for yourself! Our 2014 Symposium was a huge success! Thank you to Paul Allen, MBA, MS, RDN, WM DPG symposium chair, and his committee and advisors: Angie Hasemann, RD, CSP, Christina Scott, RDN, LD, Lisa Talamini, RD, Hollie Raynor, PhD, RD, LDN, and Hope Warshaw, MMSC, RD, CDE, BC-ADM. And, a big thank you to Academy Meetings for enabling the logistics to run smoothly. I learned something new in every session and there was depth and variety to meet everyone’s needs. If you missed it live, you can purchase the recordings and receive CPE. Consider joining us live next year in Portland, OR! I also want to thank Paul Moore, MS, RD, CSSD, LDN, CSCS*D, NSCA-CPT*D, for his leadership as the Newsletter Editor for the past few years! This is a big job, and I know he’s mentored Betsy Hirschy, RD, LD, well to be ready to take the reins in June. Paul has published 8 information-packed newsletters and dedicated countless hours to provide you with the number one member benefit. Want to be involved with a low time commitment? Consider joining the newsletter editing team! A special thank you to our numerous sponsors as they provide valuable information for our members. Many sponsors have made resources available, including educational materials for informing our clients, pedometers or step counters and accelerometers to motivate our clients to move, tasty food to nourish our clients, and even stylish dishes designed to aid portion control! There are countless other people to thank for their support and hard work. Every committee chair and director, as well as each committee member, has been a contributor to providing the resources to deliver an incredible newsletter, webinars, a symposium, a website chock full of resources, and so much more. I’m excited about the future of the WM DPG as Anne Wolf, MS, RD, takes the reins and Kristine Clark, PhD, RD, FACSM, steps into her role of chair-elect. So much is still in progress that will positively impact our DPG and our profession. Keep your ears open for news on the Board Certified Specialist in Obesity and Weight Management (CSOWM). 12 Weight Management Matters Spring 2014 Practical Sports Nutrition: The Four R’s of Recovery By Liz Broad, PhD Reprinted with permission from SCAN’S PULSE, 2014;33(1):1-3 Sports, Cardiovascular, and Wellness Nutrition (SCAN), Academy of Nutrition and Dietetics, Chicago, IL. T he translation of research findings into practical sports nutrition concepts for athletes is a critical part of the sports dietitian’s role. Because Liz Broad, PhD optimal recovery is essential to good health and subsequent athletic performance, the promotion of proper recovery nutrition is often a key focus for the practitioner. This article presents simple tips that registered dietitian nutritionists (RDNs) can incorporate into the training regimens of high-performance athletes; it is not intended to provide a comprehensive review of each component discussed. The needs for adequate carbohydrate and rehydration after exercise have long been recognized, with recommendations typically involving rapid replenishment of water and carbohydrates. More recently, emerging evidence has highlighted the role of protein in promoting muscle repair, stimulating muscle protein synthesis, and supporting the adaptations to all training stimuli. As such, the “four R’s of recovery”— repair, refuel, rehydrate, and revitalize— provide easy-to-remember guidelines that can promote the recovery of an athlete. Repair Evidence supports the beneficial role of consuming protein soon after completion of exercise to enhance repair of damaged muscle and stimulate muscle protein synthesis, both in terms of muscle fiber generation as well as the adaptive process such as increasing mitochondria, capillarization, and metabolic changes (1). The key “trigger” appears to be leucine, an essential amino acid. The amount of protein consumption required for an optimal recovery response is approximately 20 g to 25 g during the initial post-exercise period. While scientists have yet to determine the variation in this amount according to Physical Activity Meagan Moyer, MPH, RD, LD, is the Physical Activity Perspective Section Editor. Physical activity is a cornerstone of weight management. Liz Broad, PhD, reviews the 4 R’s of sports nutrition that every weight management practitioner should know to help their clients achieve healthier, more active lifestyles. athlete size, it is unlikely to be an exceedingly large variation. Benefits have been detected for a variety of protein sources, and inclusion of a highquality protein such as whey may be optimal. There may be beneficial effects of combining whey with other proteins such as casein or perhaps even casein and soy protein (2). Because dairy foods contain both whey and casein, the use of products such as milk and yogurt has become an inexpensive solution to promote repair during recovery. Muscle protein recovery occurs over 24 to 48 hours, so repeated small doses of protein (20-25 g/ dose) appear to be a better option than one large dose followed by a long period without protein (3). Refuel Carbohydrate is the primary fuel for higherintensity exercise. Total carbohydrate requirements and, hence, the need for post-exercise refueling are determined by the intensity and duration of the training session (4). For athletes who train more than once a day, it is important to take the opportunity to replenish muscle glycogen quickly after training in order to maintain stores throughout the training week. Recommendations are as follows: include 1 g to 1.2 g of carbohydrate per kg body mass during the immediate post-exercise period, following this up at regular intervals (i.e., each hour for first 4 hours) and then resuming daily fuel needs (4). It is important to use the refueling strategies both during days of competition and days of vigorous training. Use of convenient carbohydraterich foods and beverages may help athletes to meet their goals. Many whole foods can serve this purpose and at the same time help to meet daily micronutrient needs. Rehydrate Replacement of 120% to 150% of fluid losses incurred during exercise is typically recommended. The joint position statement on nutrition for athletic performance from the American Dietetic Association (now the Academy of Nutrition and Dietetics), the American College of Sports Medicine, and the Dietitians of Canada recommended consuming approximately 16 oz to 24 oz of fluid for every pound of weight lost (5). Any amount over the loss in weight is meant to compensate for increased urine production during the recovery period. It is also suggested that fluid and electrolyte replacement can be accomplished through the consumption of rehydration beverages and salty foods at meals/snacks. Understanding fluid losses during exercise and minimizing the degree of dehydration are key elements to optimizing hydration status. By weighing themselves before and after training, athletes can gain an understanding of fluid losses, which can (Continued on page 14) 13 Volume 12 No. 4 Weight Management Matters (Continued from page 13) then guide their post-exercise rehydration strategies. For example, if 1 kg of sweat is lost during training, the athlete would be encouraged to consume 1.2 L to 1.5 L of fluid within the next 1 to 3 hours post-exercise to optimize rehydration and approach a state of euhydration. Revitalize Athletes are encouraged to incorporate a range of vitamins, minerals, and other nutrients during the post-exercise period through the use of whole foods rather than single nutrient supplements. Whole foods deliver additional nutrients, including antioxidants and other phytonutrients, while also providing the key nutrients for recovery. One example is the use of flavored milk, which provides protein, carbohydrate, and fluid together with calcium and B vitamins to support the overall health needs of an athlete. By taking a food-first approach, athletes help to ensure they meet their needs for essential nutrients, thus helping to avoid deficiencies that could hinder athletic performance. Conclusions It is important to note that these recovery principles must fit within an athlete’s daily energy requirements. For some athletes, especially those trying to lose body fat, it may be necessary to prioritize recovery after training by manipulating the time of training (so that a meal follows immediately after) or by adjusting the volume and composition of other meals over the day (e.g., reducing serving sizes). For those needing to gain weight, the addition of a recovery snack in addition to the usual eating plan can provide the additional energy required to stimulate body mass gain. The use of “protein powders” and other supplements may be considered in circumstances where athletes find it difficult or impractical to utilize food and other fluid sources. Tailoring dietary guidance to help athletes meet their dietary needs during recovery is a key challenge for the sports dietitian. Liz Broad, PhD, is a senior sports dietitian working with the Paralympic Program for the United States Olympic Committee, in Chula Vista, CA References: 1.Phillips SM. Dietary protein requirements and adaptive advantages in athletes. Br J Nutr. 2012;108:S158–S167. 2.Reidy PT, Walker DK, Dickinson JM, et al. Protein blend ingestion following resistance exercise promotes human muscle protein synthesis. J Nutr. 2013; 143:410–416. 3.Areta JL, Burke LM, Ross ML, et al. Timing and distribution of protein ingestion during prolonged recovery from resistance exercise alters myofibrillar protein synthesis. J Physiol. 2013;591: 2319–2331. 4.Burke LM, Hawley JA, Wong SHS, et al. Carbohydrates for training and competition. J Sports Sci. 2011;29: S17–S27. 5.Rodriguez NR, DiMarco NM, Langley S. Position of the American Dietetic Association, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and athletic performance. J Am Diet Assoc. 2009;109:509–527. As surgeons keep their instruments and knives always at hand for cases requiring immediate treatment, so shouldst thou have thy thoughts ready to understand divine and human, remembering in thy every act, even the smallest, how close is the bond that unites the two.” –Marcus Aurelius Recently I had a client exclaim, “I went from zero to 10 in 60 seconds!” While this may sound like the words of a mis-driven NASCAR driver, (they use the more fitting term to accelerated speed, zero to 60 in 10 seconds) it came out of the mouth of a 56 yr old overweight housewife who had been unsuccessful at dieting for many years. She was describing her new awareness of recognition in her hunger to fullness rating. She now has a new tool with which to objectively rate her stomach sensations. Shannon Heffern, RD, CDE Do you hear similar phrases from your clients when they are encouraged to focus more on their body when developing mindfulness to their body and eating habits? How do you respond? What tools are you teaching to clients so they can more easily (and in our fast past world) more quickly acquire the intuitive eating that aids them in losing weight through a non-diet approach? As the new counseling section editor, I want to hear your approaches and techniques for the counseling section of the Weight Management practice group. Please consider sharing your style and words of success with your colleagues. Many of those in science are soldiering into new and exciting technology for assisting clients towards better health. But still, in counseling, we need to focus on the tiniest of actions so as to recognize and understand the bonds that better unite our minds to our bodies in order to succeed in offering our clients with long and lasting change. 14 Weight Management Matters Spring 2014 Comparison of Weight-Loss Programs By Jenna Rae Carlson W ith the rise in obesity, commercial weight-loss programs are one avenue that consumers are using to battle the epidemic (1). Jenna Rae Carlson The North American weight-loss industry has reached $50 billion dollars annually, fueled by claims of products and programs that promise quick, easy, and long-lasting results (2-4). To help increase the popularity of the weight-loss industry, celebrities such as Jessica Simpson, Jennifer Hudson, Melissa Joan Hart, and Mariah Carey have joined to show the world what program they used to lose weight (5-7). Two-thirds of adults in Western populations are trying to lose weight or avoid weight gain (8). Recently, surveys reported that approximately 30-40% of adults are concerned with their weight and report using some type of structured diet (liquid diet supplements, commercial weight-loss diets, or a special diet) to manage weight (8). Some of the most common commercial weight-loss programs today are Weight Watchers, Jenny Craig, Medifast, and Nutrisystem. Background of Weight-loss Programs Weight Watchers Weight Watchers was established in 1961 by Jean Nidetch, after inviting some friends over each week to talk about their weight, and feelings about food, this setting of mutual support and understanding helped the women begin to lose weight (5, 9-12). Today, Weight Watchers is the world’s largest support group for weight loss , hosting over 1.5 million members with over 50,000 meetings in over 30 countries worldwide (5, 11, 13). Weight Watchers focus is behaviorally oriented by including four central aspects: a food plan, an activity plan, a behavior modification plan that uses cognitive reconstructing, and group support (14-15). Today, the heart of Weight Watchers is its food point system; foods are assigned points depending on the calories and fat grams, which increase point value, and fiber grams, which decrease point Students Corner Meredith Leigh Johnson is the section editor for the Students Corner In this quarter’s student article, dietetic intern, Jenna Carlson, reviews several popular weight management programs (Jenny Craig, Nutrisystem, Medifast, and Weight Watchers) and discusses their effectiveness. **Only selected commercial weight loss programs are discussed in this article. Expert obesity panel 2013 guidelines are available in this issue in the CPEU article. value, and then each member is given a range of allowable daily points (5, 10, 16). Jenny Craig Jenny Craig was established in 1983 by Australians Sid and Jenny Craig with a mission to help their clients achieve their weight management goals through a behavioral change approach, which includes healthy eating, an active lifestyle, and a balanced approach to living (7, 9, 17-18). The Jenny Craig program offers two plans, Jenny In Center and Jenny Anywhere with weight management recommendations that are developed by registered dietitians in consultation with a multidisciplinary medical advisory board to help participants lose 1-2 pounds per week (7, 18-19) through an energy-reduced diet ranging from 1200 to 2000kcal/day. The Jenny Craig program membership also includes weekly one-onone meetings with trained peer consultants who are located in community-based facilities, and help to tailor the program to the members’ food, menu, and physical activity (7, 17, 19). The physical activity goals are to achieve 150+ minutes/week of physical activity (17, 19). Medifast Medifast was established in 1980 by Dr. William Vitale of Johns Hopkins Hospital, who was using his precise formulated meal replacements (MRs) for his patients who needed to lose life-saving weight (20-21). The Medifast program is a low-calorie meal plan that is composed of individual MRs packets, which are nutrient dense and fortified with 24 vitamins and minerals (20) that are mixed with water and refrigerated or microwaved (22). The program is assessed by a scientific advisory board, which reviews the effectiveness, safety, and nutritional benefits of products and programs (20). Members also have the option to visit a Medifast Weight Control Center that offers weekly-individualized counseling, and support with medical oversight (21) Nutrisystem Nutrisystem is a program based on MRs, which serve as the core of the home-based program and are available to purchase online or by telephone (6, 18). This program was designed by an advisory council of physicians, and obesity researchers over 40 years ago, and is tailored for the busy, on-the-go client (6, 18). The Nutrisystem membership offers seven, 28-day food package options to choose from, which revolve around the glycemic index (23). Also, included in the membership are the internet-education based components (6, 18). Conclusions on effectiveness With the exception of Weight Watchers, evidence to support the effectiveness of other commercial weight-loss programs is limited, due to the lack of studies in both short and long term (24, 25). (Continued on page 16) 15 Volume 12 No. 4 Weight Management Matters Program Weight Loss Claim 1-2lbs per week 1-2lbs per week Length of Program Best for Patient Who Until weightloss is met Looking for structured program w/flexibility built in Entry Requirements Medical history background questionnaire Credentials for Leaders Internally trained consultants (former members successful in the program) who attend 48-hour training session with monthly education classes 4 Internally trained NONE Looking for more 28-day cycles and phoneof other private weight-loss until weightWith the exception of Weight Watchers, evidence to support internet the effectiveness consultants experience that loss is met includesis MRs diet due to the lack of studies in both short and long commercial weight-loss programs limited, NONE Optional health Patients with a 2-5lbs-first 2 weeks term (24,Chosen 25). review if higher BMI (>30) program plan 1-2lbs- after 2 weeks Medifast who work until weight-has been Weight-loss seen towith lower mortality rate Weight up to 24%. Also, losing 10% of total Control Center guidance and loss is met is available supervision a body weight can considerably improveofblood pressure, diabetic control, lipids, and arthritis (2, 4, physician 1-2lbs per week 26). Weight-loss interventions that involve attention to food intake such as diet alone, diet and Lifetime members NONE Forever- healthy Looking for weekly members who meetings, peer and behaviors are exercise, MRs, and weight-loss medications combined with diet have(former been shown to produce the reached their goal group support, taught weight and6 complete insbut then weight-loss often plateaus most promising short-term weigh results, around months (4). The 6-week maintenance phase, stay w/in andwho maintain a lower goals of a successful weight management programs should be to reduce 2lbs of goal) that receive leadership body weight over a long period of time (over 1 year) training According to Consumer Reports, the four most popular diets weight-loss diets were (Continued from page 15) rankedvariety, on whether they incorporated the variables into there weight-loss, loss, rateprogram: of weight initial loss, physical activity, encouragement of fruits and self-monitoring, uncontrolled factors such vegetables, and exercise, which was based maintenance, calorie food variety, of fruits vegetables, and Weight loss has been seen to lower as stress, and socialand support. Initial weight on a scale of 1 toawareness, 5, 1 being the worst, 3 encouragement mortality rate up to 24%. Also, losing 10% of loss has been identified as a predictor for being neutral, and 5 being the best, as which waschart based on a(27). scale of 1 to 5, 1 being the worst, 3 being and 5 and being the total body weight can considerably improveexercise, additional weight loss,neutral, weight regain, shown in the below blood pressure, diabetic control, lipids, and weight-loss maintenance (28-29). Typically, seen by the chart below arthritis (2, 4, 26). Weight-loss interventionsbest, asFactors when an individual loses a large amount of affecting weight loss(27). maintenance, that involve attention to food intake such as weight rapidly, like those seen on a diet that whether a commercial weight-loss program diet alone, diet and exercise, MRs, and contains MRs (Nutrisystem, Jenny Craig, is used or not include (28): initial weight weight-loss medications combined with diet have been shown to produce the most Nutrisystem promising short-term results, but then 5 Best Jenny Craig weight loss often plateaus around 6 months Medifast (4). The goals of a successful weight 4 Weight Watchers management programs should be to reduce and maintain a lower body weight 3 over a long period of time (over 1 year) According to Consumer Reports, the four most popular weight-loss diets were ranked on whether they incorporated the variables into their program: initial weight loss, maintenance, calorie awareness, food 2 Worst 1 Initial Wt. Loss Calorie Awareness Fruit & Vegetables 16 Weight Management Matters Spring 2014 Medifast), they are more likely to regain weight (6-7, 20, 30). In a two year trial study conducted by Heshka and associates, researchers found that the commercial weight loss (Weight Watchers) group maintained a weight loss of 9-11lbs at the end of the first year, and 6-7 lbs weight loss at the end of the second year, along with improvements in waist circumference, and BMI compared to when they began (31). Along with slow and steady weight loss, physical activity has been shown to relate to long-term weight loss maintenance. Physical activity assists weight maintenance by influencing clients to expend energy, and in turn improving health, (32), which commercial weight-loss programs like Weight Watchers, Medifast, and Jenny Craig emphasize (5-6, 20). The most effective strategies to maintain the slow and steady weight loss and maintenance is through a lower total calorie intake, smaller portion sizes, a decrease in snacking, less dietary fat (28, 33), and the consumption of fruits and vegetables (16), which is also encouraged by Weight Watchers, Jenny Craig, and Nutrisystem (5-6). Another factor that goes hand in hand with weight loss maintenance is the act of self-monitoring, which can be done through recording food intake, physical activity, and regular weigh-ins, which helps the individual stay aware of their body weight (32). Self-monitoring can be seen in programs such as Weight Watchers and Jenny Craig (5-6). Even factors that cannot be controlled, such as stress, affect whether an individual will maintain the weight loss, and research shows that the best way to battle these factors is through social support (one-on-one or group focused) (34), which can be seen in commercial weight loss programs like Weight Watchers, Jenny Craig, and Medifast (5-6, 20). Due to the lack of data in regards to longterm studies effectiveness, Medifast, Jenny Craig (10), and Nutrisystem have yet to be able to prove that their program claims help their members keep their weight off. Good health is always a work in progress (35). To be successful in weight loss maintenance requires long-term commitment to making healthy changes in eating and exercise habits (36). Developing healthy eating and exercise habits can help lower the health risks associated with obesity (37). Jenna Rae Carlson is currently a graduate student and dietetic intern at Eastern Illinois University. She completed her bachelor of arts degree in food, nutrition and dietetics at Concordia College, Moorhead in Minnesota. References: 1.Collins C, Morgan P, Jones, P, et al. Evaluation of a commercial web-based weight loss and weight loss maintenance program in overweight and obese adults: A randomised controlled trial. BMC Public Health. 2010;10:669-676. 2.Koche L. Obesity and its treatments: An overview. Your Weight Matters Magazine. n.d.; Retrieved from http://www. obesityaction.org/educational-resources/ resource-articles-2/weight-loss-surgery/ obesity-and-its-treatments-an-overview. Accessed December 10, 2013. 3.Freedhoff Y, Sharma A. “Lose 40 pounds in 4 weeks”: Regulating commercial weight-loss programs. Can Med Assoc J. 2009;180(4):367. 4.Franz M, VanWormer J, Crain A, et al. Weight-loss outcomes: A systematic review of meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up. J Am Diet Assoc. 2007;107(10):1755-1767. 5.Weight watchers homepage. website. http://www.weightwatchers.com/index. aspx. Accessed: 12/10/13 6.Nutrisystem homepage. website. http://www.nutrisystem.com/jsps_hmr/ home/index.jsp. Accessed: 12/10/13 7.Jenny Craig homepage. website. http://www.jennycraig.com. Accessed: 12/10/13 8.Leske S, Strodl E, Hou X. A qualitative study of the determinants of dieting and non-dieting approaches in overweight/ obese Australian adults. BMC Public Health. 2012;12(1):1086-1098. 9.Hamilton M, Greenway F. Evaluating commercial weight loss programmes: An evolution in outcomes research. Obes Rev. 2004;5(4):217-232. 10.Witherspoon B, Rosenzweig M. Industry-sponsored weight loss programs: Description, cost, and effectiveness. J Am Acad Nurse Pract. 2004;16(5):198-205. 11.Vignali C, Henderson S. Weight watchers: Social event centered marketing. Journal of Food Products Marketing. 2008;14(2):99-112. 12.Shuman J. Weight-loss programs: Is one right for you?. Am J Nurs.1993;93(5):7073. 13.Moisio R, Beruchashvili M. Questing for well-being at weight watchers: The role of the spiritual-therapeutic model in a support group. J Consum Res. 2010;36(5):857-875. 14.Pinto A, Fava J, Hoffmann D, Wing R. Combining behavioral weight loss treatment and a commercial program: A randomized clinical trial. Obesity (Silver Spring). 2013;21(4):673-680. 15.Lowe M, Kral T, Miller-Kovach K. Weightloss maintenance 1,2, and 5 years after successful completion of a weight-loss programme. Br J Nutr. 2008;99(4):925930. 16.Ma Y, Pagoto S, Griffith J, et al. A dietary quality comparison of popular weightloss programs. J Am Diet Assoc. 2007;107(10):1786-1791. 17.Finley C, Barlow C, Greenway F, et al. Retention rates and weight loss in a commercial weight loss program. Int J Obes. 2007;31(2):292-298. 18.Hubbard B. Commercial program and product review: Meal replacement-based weight-loss programs. Obes Manag. 2007;292-295. 19.Martin C, Talamini L, Johnson A, et al. Weight loss and retention in a commercial weight-loss program and the effort of corporate partnership. Int J Obes. 2010;34(4):742-750. 20.Medifast homepage. website. http://www.medifast1.com/index.jsp. Accessed: 12/10/13 21.Arroyo A. Medifast: Losing weight to win. Equities. 2004;52(2):16-18. 22.Leavell A. Commercial program and product review. Obes Manag. 2008;250256. 23.Mayo Clinic Staff. Glycemic index diet: What’s behind the claims. Collect Papers Mayo Clinic Mayo Found. 2011;1-2. 24.Tsai A, Wadden T. Systematic review: An evaluation of major commercial weight loss programs in the United States. Ann Intern Med. 2005;42(1):56-66. 25.Dansinger M, Gleason J, Griffith J, et al. Comparison of the atkins, ornish, weight watchers, and zone diets for weight loss and heart disease reduction. JAMA. 2005;293(1):43-53. 26.Ahern A, Olson A, Aston L, Jebb S. Weight watchers on prescription: An observational study of weight change among adults referred to weight watchers by the NHS. BMC Public Health. 2011;11(1):434-438. 27.Pick your ideal diet. Consumer Reports. 2011;76(6):14-16. (Continued on page 18) 17 Volume 12 No. 4 Weight Management Matters (Continued from page 17) 28.Elfhag K, Rossner S. Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain. Obes Rev. 2005;6(1):67-85. 29.Berzins L. Protecting the consumer through truth-in-dieting laws. J Soc Issues. 1999;55(2):371-382. 30.DeLegge M, Keith J. Medical weight management. In: C. Thompson (Ed). Bariatric Endoscopy. New York: Springer; 2013:19-35. 31.Heskha S, Anderson J, Atkinson R, et al. Weight loss with self-help compared with a structured commercial program. JAMA. 2003;289(14):1792-1798. 32.Weight-control Information Network. Choosing a safe and successful weightloss program. National Institute of Health. 2012;8:1-5. 33.Truby H, Hiscutt R, Herriot A, et al. Commercial weight loss diets meet nutrients requirements in free-living adults over 8 weeks: A randomised controlled weight loss trial. Nutr J. 2008;7(25):1-13. 34.Middleton K. M. R., Patidar S. M., Perri M. G. The impact of extended care on the long-term maintenance of weight loss: A systematic review and meta-analysis. Obes Rev. 2012;13:509-517. 35.Gustafson, T. For kinder, gentler approach to weight loss. Auburn-Reporter. 2014;1 36.Mayo Clinic Staff. Weight loss: Choosing a diet that’s right for you. Collect Papers Mayo Clinic Mayo Found. 2012;1-2. 37.Rohrer, J., Cassidy, H., Dressel, D., & Cramer, B. Effectiveness of a structured intensive weight loss program using health educators. Disease Management and Health Outcomes. 2008;16(6):449-454. Agriculture Act of 2014 By Amanda Meadows, MS, RD/LD, CDE, NASM-CPT P resident Obama signed into law the Agriculture Act of 2014 ( i.e. “Farm Bill”) into law on February 7th. The new five-year, one trillion Amanda Meadows, dollar Farm Bill has MS, RD/LD, CDE, NASM-CPT been supported by the Academy throughout the bill’s legislative process. The final bill will provide essential nutrition assistance and education, increase funding for nutrition and agriculture research, and introduce new initiatives that will improve the health of the country. The final bill protects the SNAP program which includes the following highlights; SNAP-Ed funding being restored to Health Hunger-Free Kids Act (HHFKA) levels, SNAP eligibility criteria are maintained from 2008, Community Supported Agriculture (CSA) businesses can now be authorized as SNAP retailers, and incentives to purchase fruits and vegetables with SNAP dollars. In addition, SNAP can be used for homebound seniors and disabled participants using nonprofit home delivery services. Other key initiatives that focus on community-based and regional agriculture will be expanded, including new investments for beginning farmers and Policy and Advocacy Report Amanda Meadows, MS, RD/LD, CDE, NASM-CPT, is the section editor for the Policy and Advocacy Report Did you know the Farm Bill has a formal name? Did you know that an incredible amount of effort was put forth by many including our Academy leaders as well as members of Congress to finalize this legislation? SNAP and SNAP Ed funding were just 2 of the key areas the Academy was working to influence. The Academy’s website policy section should be one of your bookmarks to keep up-to-date on all of the Academy Public Policy priority areas. ranchers that provide incentives to grow healthy food. Funding was maintained and/or reauthorized for all of the following programs or agencies: National Institute of Food and Agriculture (NIFA), Agricultural Research Service (ARS), Human Nutrition Research Centers (HNRC), Specialty Crop Block Grants, Senior Farmers Market Program, Fresh Fruit and Vegetable Program, Farmers Market Promotion Program, Seniors Farmer’s Market. The completed version of the bill took over two years for Congress to finalize and will not need to be reauthorized for the next five years. Over this period of time, Nutrition Professionals [RDN’s and DTR’s] can continue to engage their Congressperson on the role they play in the well-being of their constituents. The Academy will continue to support and pursue initiatives that provide overall wellbeing of the nation. As the Farm Bill is implemented through the US Department of Agriculture look for opportunities for Academy members in Eat Right Weekly. For information from the academy website on the Farm Bill see: http://www.eatright.org/ Members/content.aspx?id=6442479879. 18 Weight Management Matters Spring 2014 Member Benefits Member Survey 2014 Results By Juliet Mancino, MS, RD, CDE A copy of the WM DPG Annual Member Survey was sent to all members via email with a link in February 2014. We would like to thank the Juliet Mancino MS, 880+ members who RD, CDE completed the survey and shared your valuable input with the Executive Committee (EC). All feedback is reviewed and used to shape our plan of work and activities for the following membership year. Below is a summary of the questions and key answers. With respect to the value of various services offered by the DPG (Question 1), the top three services most valued were the Weight Management Matters newsletter, our webinars and the website. More than 800 respondents (88.6%) Strongly agreed or Agreed that our DPG seeks and values member opinions (Question 2). Comments of members who disagreed were forwarded to the appropriate committee chairs. Over 300 comments were received regarding newsletter topic suggestions (Question 3). We are glad to have these ideas and they were forwarded to Paul Moore and Betsy Hirschy, Newsletter Editors. Question 4 yielded over 250 comments and ideas for webinars and these ideas were forwarded to Kristin Walters who heads our Professional Development Committee. The Research Committee specifically requested questions about research needs of members for this year’s survey. Over 500 members rated their number one research interest for newsletter articles as understanding research, followed by how to collect outcomes. About 60% of members had visited the new WM DPG website at the time of the survey. Our blast email team asked what day is best for members to received blast emails, and the top choice was Monday. The subject line is what holds the greatest influence as to whether members open blast emails. Our survey asked about social media use. About 25% of survey takers accessed Facebook daily, but used other social media less frequently. About half of respondents rarely used LinkedIn and 75% rarely used Pinterest or Twitter. With respect to starting a coaching special subunit, about 75% of respondents were interested; our goal for 2014-15 is to start a coaching special interest group. Many names were submitted for our WM DPG awards and those were forwarded to Jackie Ballou and the Nominating Committee. Many members volunteered to become more involved in WM DPG and also to be state liaisons. These names have been forward to the appropriate EC teams (expect an email). We are eager to get you involved and thank you for your support and interest! Lastly, about 25% of survey respondents have been to the WM DPG Symposium. Ideas of topics, place, and time of year were collected and forwarded to Paul Allen and the 2015 Symposium Committee. Again, the EC thanks you for your input. We truly value your input and want this DPG to serve your needs. Please keep your feedback coming – contact any person on the EC via the website. No need to wait for the annual survey! Got Data? Update on the new Member Benefit Award By Kristine Clark, PhD, RD, FACSM C ompare these two WM members: Lori has been an RDN for 5 years and a WM DPG member for 5 years while Renee has been an RDN for 38 years and a Kristine Clark, PhD, WM DPG member for 10 (the DPG is only 11 years RD, FACSM old). But where the true common thread runs is that both have been involved in research for only 1 year, inspired to collect data in their work environments by the new WM DPG award for emerging researchers. Keep in mind that neither RDN is employed as a “researcher.” Rather, Lori works as a bariatric dietitian and Renee is the Director of a university-based weight management program, yet both are eligible to apply for the new emerging researcher award. The new WM DPG member benefit award (Excellence in Research Outcomes Award for the Emerging Researcher), established in 2013, is intended to promote data collection in all work environments, demonstrating how nutrition services impact weight management outcomes. When Lori read about the award for the first time she said she was, “always interested in research, but inspired to take the next steps necessary to apply for the award.” She looked into where she could get involved in a work-based research project, and then became part of a research team, collecting weight loss outcomes data post-surgically. She wrote an abstract reflecting the study outcome for her upcoming presentation at the Society of Nutrition Education and Behavior meeting in June 2014. Only one published abstract is required to become eligible to apply for the Emerging Researcher Award. So many WM DPG members engaged in collecting outcomes data in their own work environments could turn that data into beneficial research projects further demonstrating the effectiveness of their work. So, be inspired! Eligibility criteria for this award can be found on the WM DPG website under awards and honors. This member benefit may truly apply to you! 19 Volume 12 No. 4 Weight Management Matters From the Editor Paul Moore, MS, RD, CSSD, LDN, CSCS*D, NSCA-CPT*D 2013-2014 WM DPG Newsletter Editor All Good Things Must Come to an End A incredible group of volunteers, members, authors, editors and everyone associated with the WM DPG. I could not have asked or imagined a better experience or being able to work with a more professional group of individuals. s the spring season symbolizes the end to the long and relentless winter, the Weight Management Matters spring newsletter symbolizes the end of the member year and my term as the Editor for this wonderful publication. I have enjoyed the last two years of being blessed to work with an The WM DPG Nominating Committee is pleased to announce the results of the 2014 Election! Congratulations and a warm welcome to our new elected members of the Executive Committee: Chair Elect: Kristine Clark, PhD, RD, FACSM Kristine Clark, PhD, RD, FACSM Treasurer: Lori F. Greene, MS, RD, CSSD, LD Lori F. Greene, MS, RD, CSSD, LD Monica Lebre, MS, RD, LDN Nominating Committee Director-Elect: Monica Lebre, MS, RD, LDN Congratulations to Mary Lynn Vassar and Beth Cecil, who won WM DPG 2014-2015 memberships, and Kris Mogensen, who won a $50 gift card by completing their WM Member Surveys and entering the drawing. Thanks to all of you who participated. Your input is so valuable to to plan the activities and direction of the WM DPG. J ulie Schwartz, Chair, and the entire Executive Committee of the WM DPG send congratulations to the following WM DPG members, who are celebrating 50 years as Academy members in the year 2014: Nancy C. Blaydes Celia M. Darland Carol D. Kourany Maryann Meade Sachiko St. Jeor Jean A. Trainor Celia M. Darland Carol D. Kourany Maryann Meade Jean A. Trainor 20 Weight Management Matters Spring 2014 Improving Outcomes of a Worksite Wellness Program with a Client-Centered Nutrition Intervention By Seletha Poole, MPH, Becka Wilson, MS, ACSM-CPT, and Hollie Raynor, PhD, RD, LDN Research Hollie Raynor, PhD, RD, LDN, is the research section editor. Seletha Poole, MPH R Becka Wilson, MS, ACSM-CPT egistered Dietitian Nutritionists (RDNs) can provide their expertise to improve the population’s health in a variety of settings. One setting in which RDNs are increasingly providing their expertise is in the worksite, particularly in how a healthy diet can enhance employee wellness. Places of employment use worksite wellness as an initiative to promote health within an organization. These initiatives are designed to influence health behaviors through altering environmental factors, changing worksite policy, and incorporating various programs to influence individual health behaviors (1). Programs commonly incorporated into worksite wellness initiatives include health fairs, health education seminars, medical screenings, health coaching, weight management programs, newsletters, and fitness programs. Ideally, worksite wellness initiatives improve employee health, which in turn increases worker productivity and decreases health care costs (1). Within the worksite setting, RDNs can plan, implement, and evaluate worksite wellness programs. Steps in program planning include conducting a needs assessment to identify needs and priorities, identifying evidence-based techniques that can be incorporated into programs to target identified needs and priorities, and developing goals and objectives that can be met by developed programs. Program implementation involves overseeing delivery of the developed programs. Finally, process and outcome evaluations should The Academy proposes that research is the foundation of the dietetics profession, as research provides the basis for practice, education, and policy. This article by Seletha Poole, MPH, Becka Wilson, MS, ACSM-CPT and myself, is an example of program planning, implementation and evaluation. Ideally, programs are developed from evidence-based practice and outcomes are collected to demonstrate the effectiveness of the program. Collecting outcomes from programs in which RDNs are involved is important for demonstrating the value of RDNs. This article describes the process of how a Worksite Wellness program, which included a nutrition component, was developed using evidence-based practices, and how outcome data were collected. be conducted to understand how well programs have been implemented and if planned goals and objectives were met. nutrition intervention component to be included in the program. The purpose of this article is to provide an example of the process of planning, implementing, and evaluating a clientcentered nutrition counseling component that was added to an existing worksite wellness program. In particular, this article focuses on the evaluation design, which compared dietary changes of employees who participated in the nutrition counseling component to those who did not. To address the need to include a clientcentered nutrition intervention component, the Worksite Wellness Coordinator contacted a professor at the University of Tennessee’s (UT) Department of Nutrition, a RD who specializes in weight management, about the possibility of strengthening the worksite wellness program by incorporating a clientcentered nutrition component. Employee feedback indicated that employees at RSC needed group sessions that provided nutrition education on the Dietary Guidelines and healthy eating in restaurants. Additionally, individual sessions were needed to help employees set individual goals around the Dietary Guidelines (2), establish self-monitoring methods for individual dietary goals, develop action plans to assist with meeting individual dietary goals, and problem-solve barriers to meeting goals. Radio Systems® Corporation (RSC) Worksite Wellness Program Radio Systems® Corporation (RSC) is a company with approximately 300 employees and is the largest manufacturer of electronic pet training products in the U.S. RSC employs a Worksite Wellness Coordinator who developed a worksite wellness program to increase the amount of physical activity employees engaged in to reduce employee health risk factors. However following an assessment of employee satisfaction of the RSC worksite wellness program, employee feedback indicated a desire for a client-centered Program Planning Planning discussions led to the decision to develop a two-month intervention consisting of group and individual nutrition counseling sessions. As all RSC employees (Continued on page 22) 21 Volume 12 No. 4 Weight Management Matters (Continued from page 21) participate in a bi-yearly health screening, it was decided that employees with two or more health risk factors (i.e., overweight/ obese and have high blood pressure) would be recommended to attend two group and four individual nutrition sessions. Employees with one risk factor were recommended to attend one group and two individual nutrition sessions, and employees without any risk factors were recommended to attend one group nutrition session. Further, RSC provided an insurance credit to employees that attended all recommended sessions to motivate employee engagement in the nutrition component of the wellness program. The team identified four group session topics to meet the needs of employees (Table 1). These topics were offered during nine group sessions over the course of the two-month program. Each topic was offered two or three times during the workday so that employees would have multiple opportunities to attend sessions. Group sessions were designed to be 30-45 minutes in length and started with a check-in, in which the group leader discussed progress towards meeting dietary goals with group members, followed by a planned session topic that included general nutrition education and evidence-based cognitive behavioral strategies that assisted with making and maintaining behavioral changes. Over the course of the program, 138 individual sessions were offered to employees. The individual sessions were designed to be 20-30 minutes in length and were based upon a Motivational Interviewing (MI) approach. The MI approach is an evidencebased, client-centered approach that is used to produce behavior change in individuals by helping clients work through ambivalence and commitment to change (3). The counselor guides the client toward goal setting using reflective listening and a combination of closed-ended and openended explorative questions to better understand the client’s goals, motivation, and barriers to making a behavior change. The goal of MI is for clients to identify reasons for ambivalence to change, problem-solve, and to make their own decisions on how to move forward (3). This approach allows clients to make informed decisions regarding behavior change. To evaluate the impact of adding clientcentered nutrition counseling to the program, process and outcome evaluation measures were identified. The process evaluation included collecting attendance at both group and individual nutrition sessions. The outcome evaluation was designed to evaluate improvements in dietary intake, particularly regarding reductions in energy, fat, and sugar sweetened beverage (SSB) intake and increases in fruit and vegetable consumption. Dietary outcomes were assessed via threeday food records. The dietary measures were to be collected from all RSC employees, regardless of participation in the nutrition intervention component of the wellness program. This would allow comparisons in changes in dietary intake in those receiving the nutrition component part of the wellness program versus those not. Participation in the evaluation component was optional for all RSC employees and was separated from participating in the wellness program. To assist with motivation to participate in the evaluation component, those who completed all evaluation questionnaires prior to and after implementation of the nutrition counseling program were entered into a drawing to receive a $100 gift card. Program Implementation Beginning March 2012, all RSC employees were invited via email to participate in the evaluation component of the wellness program. Employees were notified that participating in this component was optional and would not impact on intervention received in the wellness program. This email also included an informed consent form approved by the Institutional Review Board at UT. All employees providing consent were given the evaluation questionnaires (i.e., threeday food record and two-dimensional, portion-size estimation tools). The nutrition counseling component was delivered from May to June 2012. At the beginning of the program, all employees were emailed the group session schedule and a schedule of the available individual sessions. The day prior to each individual and group session, all employees who were signed up for a session were sent reminder emails. All group and individual sessions were provided by a master’s level nutrition graduate student, who was supervised by an RDN. Program Evaluation For the process evaluation, attendance rates for the three risk groups (≥ 2 health risk factors, 1 health risk factors, and no health risk factors) were collected and analyzed using a one-way analysis of variance (ANOVA) to determine if employees in the high-risk category (≥ 2 health risk factors) attended more group or individual sessions than employees in the other risk groups. For the outcome evaluation, dietary intake, measured by three-day food records, was assessed both prior to the start and at the end of the 2-month program. Complete records were entered into Nutrition Data System for Research (NDS-R) version 2011 for analysis (4). Energy and energy from fat; along with fruit, vegetable, and SSB servings consumed per day were averaged and change scores were computed for each variable. Additionally, at the end of the program, employees who participated in the wellness program and provided consent were asked to complete an evaluation survey. This survey included questions on the overall helpfulness of the program in meeting personal goals and how often employees implemented information/behaviors that were learned in group and individual sessions. Furthermore, the survey included an option for employees to write in specific comments on their likes and dislikes of the program. Outcomes Sixty employees engaged in the nutrition counseling component for the worksite wellness program (see Table 1). Of these 60 employees, 55.0% were in the high-risk category, 36.6% were in the low-risk category, and 8.3% did not have any riskfactors. Of the employees in the high-risk and low-risk categories, only two employees from each category engaged in the recommended number of group and individual sessions. However, all employees without any risk factors met and exceeded group session attendance recommendations. Employees with ≥ 2 health risk factors attended 1.8 ± 1.2 individual sessions and 1.2 ± 1.0 group sessions, while employees with one risk factor attended an average of 1.3 ± 1.0 individual and 0.7 ± 0.6 group sessions. Employees without any risk factors did not attend any individual sessions; however, they attended an average of 1.2 ± 0.4 group sessions. Results from the 22 Weight Management Matters Spring 2014 Table 1. Group Intervention Session Topics and Attendance Number of Times Offered and Weeks During the Group Session Concepts Introduced Program When Offered Average Number of Employees Attending (M + SD) 1. Self-Monitoring and Goal Setting – How to set goals – Identifying problematic behaviors – How to keep track of behaviors – How to read a food label – 3 times: Weeks 1 and 3 3.6 ± 4.0 2. What Exactly Is Healthy Eating? – Carbohydrates, protein, and fat – Healthy eating behaviors – Serving sizes – 2 times: Weeks 5 and 6 13.0 ± 1.4 3. Working With What’s Around You – Identifying eating cues – Identifying social cues – How to avoid/change eating and social cues – Adding helpful eating and social cues – 2 times: Weeks 3 and 8 11.0 ± 5.6 4. Healthy Eating in Restaurants – Meal planning – Eating at fast food restaurants – Healthy food options – 3 times: Weeks 5, 6, and 8 13.3 ±1.5 Total Participants Attending Group: 51* *9 employees did not attend group sessions, but only attended individual sessions. one-way ANOVA revealed that employees with ≥ 2 health risk factors and participants with one risk factor attended significantly (p < 0.05) more individual sessions than employees without any risk factors. There was no significant difference between employees with ≥ 2 risk factors and employees with one risk factor in number of individual sessions attended. No significant difference occurred in number of group sessions attended between the three risk factor categories. Twenty-nine employees provided dietary data prior to the start of the worksite wellness program, and 15 employees provided dietary data prior to and at completion of the worksite wellness program. Of the 15 employees providing pre- and post-intervention data, 8 employees participated in the nutrition counseling component of the program. For the 15 employees providing pre- and postintervention information, they were age 40.0 ± 9.2 years, 37.5% male, 87.5% nonHispanic White, 62.5% married, and 75% with some college education. For health conditions, 75.9% were overweight or obese, 51.7% had elevated blood pressure, 27.6% had elevated cholesterol, 27.6% had low levels of high-density lipoproteins, 10.3% had elevated triglycerides, and 24.5% had elevated blood glucose. Almost 50% had at least two of the risk factors. Prior to the start of the program, self-reported daily dietary intake was 2533 ± 980 kcal/day with 24.9 ± 11.6% energy from fat. Employees also reported consuming 1.5 ± 1.3 servings/ day of fruit, 2.4 ± 1.2 servings/day of vegetables, 0.9 ± 1.3 servings/day of SSB, with 0.5 ± 1.1 servings/day of SSB in the form of soft drinks. While not significant, evaluation of change scores found several important trends. For example, employees who engaged in the wellness program on average reduced their energy intake (–200 ± 631 kcal/day vs. –20 ± 629 kcal/day) and sugar sweetened beverage intake in the form of soft drinks (–0.7 ± 1.6 servings/day vs. +0.2 ± 0.3 servings/day) more so than employees who did not engage in the wellness program. No trends were found in changes in percent energy from fat or servings of fruits and vegetables. A total of seven employees completed the evaluation survey. Of these employees, 71.5% reported finding the nutrition counseling component of the wellness program as being useful, and 57.0% reported finding the individual nutrition sessions being the most helpful in working towards goals. Furthermore, 57.0% of employees found that monitoring behaviors (such as eating and physical activity behaviors) was useful in working towards goals. For the group sessions, 43% of employees reported that hearing suggestions from peers was useful. Furthermore, 71.5% of employees reporting using information provided in group nutrition sessions at least one to two days per week. Frequent comments included program scheduling issues and the desire to have a more structured, individualized program. Conclusion Previous RSC wellness programs focused on physical activity, which did not satisfy the needs of all employees. The incorporation of a client-centered nutrition intervention allowed for RSC to improve the existing wellness program to better meet employee needs. Approximately 20% of RSC’s employees participated in the new clientcentered nutrition intervention. While only a small number of employees participated in the outcome evaluation, collected measures suggested that employees engaging in the program improved their diet by reducing overall energy intake and consumption of SSBs. Increasing employee incentives to participate in outcome evaluations may lead to improvement in participation and allow for significant dietary changes to be detected. Employee feedback indicated that the individual nutrition counseling sessions were more helpful for employees in making behavior changes than the group sessions, thus increasing the number of individual nutrition counseling sessions offered to all RSC employees, not just those at higher risk, to increase future participation in the program. To better ascertain long-term impact of the client-centered nutrition intervention, follow-up measures on physiological outcomes and health care (Continued on page 24) 23 Volume 12 No. 4 Weight Management Matters (Continued from page 23) utilization are needed to ascertain changes to employees’ health and overall health care costs. This program was partially supported by an Outreach and Engagement Grant from the University of Tennessee. Seletha Poole, MPH, is currently a doctoral student in Nutrition Sciences and Dietetic Intern at the University of TennesseeKnoxville. She graduated with her Masters of Public Health in Community Health Education in May 2014 and will complete the Dietetic Internship in June 2014. Seletha is primarily interested in research, focusing on pediatric weight management and basic eating research investigating environmental factors that impact on food consumption. Becka Wilson, MS, ACSM-CPT, has a Master of Science in Exercise Physiology from the University of Tennessee and is currently the Wellness & Associate Engagement Manager for Radio Systems® Corporation. In the 5 years she’s been there, the wellness program has grown from being primarily activities based to having an Onsite Medical Clinic and programing tied to the benefits plan. Becka is passionate about getting people engaged in their own health, to take personal ownership. She enjoys learning how other companies strive towards this and sharing best practices. References: 1.Centers for Disease Control and Prevention. Workplace Health Model. http://www.cdc.gov/workplacehealth promotion/model/index.html. Accessed November 9, 2013. 2.U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th edition. Washington, D.C. U.S. Government Printing Office; 2010. 3.Emmons KM, Rollnick S. Motivational interviewing in health care settings: Opportunities and limitations. Am J Prev Med. 2001; 20:68–74. 4.Schakel S: Maintaining a Nutrient Database in a Changing Marketplace: Keeping Pace with Changing Food Products—A Research Perspective. J Food Comp and Anal. 2001; 14:315–22. Book Review Review by Amy Giffin, MS, RD, CD Too Busy To Diet Author: Jacqueline King, MS, RDN, CDE, FADA and Monica Joyce, MS, RDN, CD “ Don’t do anything while dieting that you can’t do for the rest of your life” is one of the main points emphasized by Jacqueline King, MS, RDN, CDE, FADA and Monica Joyce, MS, RDN, CD, in their new book “Too Busy to Diet.” Amy Giffin, MS, The book provides science-based nutritional information in an easy to RD, CD read format that anyone can use daily to make healthier lifestyle choices. The format is refreshing; you don’t need to read the book cover to cover to get the information you need. Each chapter covers a specific topic so the book can be picked up as needed to answer your most pressing nutritional questions. Chapter topics range from fiber and the glycemic index to sushi, carnival fare, and superfoods. Throughout the book, the authors provide inspirational quotes, quizzes to test your knowledge, and useful tips, tricks, and lists to help you calculate calories in the food you eat or calories burned per type of exercise. They provide simple and helpful resources for planning your meals and logging your food intake, as well as suggested meal plans for breakfast, lunch, and dinner. Unfortunately, while this book is filled with resources, being in a hard copy format is limiting. The authors do have an online blog that they post to regularly; however, they could also improve their book by creating an electronic version. This would allow readers to easily connect to the websites and additional resources included and give them the option to print and utilize all of the lists and tools provided. Overall, the book is a handy resource for anyone looking to eat healthier or lose weight and is short on time. Too Busy to Diet provides readers with the well-researched and current information they need to balance good nutrition with a busy lifestyle. 24 Weight Management Matters Spring 2014 Stipend Winners WM DPG SYMPOSIUM: turning the obesity epidemic around one student at a time. Jan Abdelnour, MS, RD, LD, CDE Jan is a Dietitian/ Diabetes Educator in the outpatient Diabetes and Nutrition Resources Department at Baptist Health in Jacksonville, Florida. She graduated from the Coordinated Undergraduate Program in Dietetics, University of Alabama, Tuscaloosa, AL and with a Masters of Science in Human Nutrition from the University of Florida, Gainesville, FL. She has been a Registered Dietitian for over 30 years, and a Certified Diabetes Educator for over 10 years. She has worked in inpatient and outpatient settings in many areas of dietetics over the years, including renal, critical care, cardiac care, diabetes, weight management and recently bariatrics. The most rewarding part of her work is helping people make lifestyle changes to improve their health and manage their weight. Jan was thrilled to find out she had won a stipend to the Weight Management DPG Symposium 2014! One of her goals for this year was to attend a professional meeting. This gave her the opportunity to network and stay up to date with the latest research and practice in the area of weight management, especially bariatrics. Jill Englett, MS, RD, LD, RN Jill Goode Englett joined the faculty at the University of North Alabama in September 2005 as an Instructor of Food and Nutrition. She is responsible for teaching nutrition courses offered in the Department of Human Environmental Sciences. She has a Certificate of Training in Childhood and Adolescent Weight Management and has a passion for teaching students of all ages about the benefits of healthy eating with the hope of Mrs. Englett has been a registered dietitian for over twenty years. As a longtime member of the Academy of Nutrition and Dietetics she held various leadership roles on a national level, including chair of the Renal Dietitians DPG (RPG). Mrs. Englett holds a BS in Foods and Nutrition and a BSN in Nursing from the University of North Alabama, an MS in Clinical Nutrition for East Tennessee State University, and is currently working towards a DCN in Clinical Nutrition at Rutgers University. Mrs. Englett completed her dietetic internship at University Hospital in Augusta, Georgia. Lynn Umbreit, MS, RD, LD Lynn Umbreit MS, RD, LD, has specialized in the areas of weight management and sports nutrition during her years as a Registered Dietitian. She is presently a Care Manager & Diabetes Educator with the Southwest Endocrinology Associates in Albuquerque, NM where she sees weight loss and diabetic clients. Previous employments also include at Clinical Nutrition Center in Denver, CO (weight management), Diet Modification Clinic (Houston, TX) and St. Joseph’s Hospital & Medical Center (Phoenix, AZ). She has also been a nutrition consultant to numerous community and corporate clients, and has taught graduatelevel and adult education nutrition classes. Lynn has a Master’s degree in Sports Medicine from Chapman University (Chapman, CA) and a BS in Nutrition from Colorado State University (Ft. Collins, CO) Lynn is Past-Chair of the WM (Weight Management) and SCAN (Sports, Cardiovascular, & Wellness Nutrition) dietetic practice groups of the Academy of Nutrition and Dietetics, and has served in numerous other capacities in local, state & national dietetic organizations. Lynn’s personal interests complement her professional ones. She is a recreational athlete who enjoys running, biking & hiking as well as loves to garden, travel & spend time with her husband. Meridan Zerner, MS, RD, CSSD, LD Meridan Zerner joined the Cooper Clinic Nutrition Department in 2007, and has more than 25 years of experience in health and fitness. She specializes in weight management, exercise and sports nutrition, cardiovascular health and nutrition through the life cycle. Meridan is a member of the Academy of Nutrition and Dietetics, and the SCAN and WM DPGs, and was a continuing education provider for the American Council on Exercise. A marathoner and a former national aerobic champion, Meridan is also a group exercise instructor at Cooper Fitness Center. She is a Certified Wellness Coach and holds a Master of Science in nutritional science with an emphasis in health promotion from the University of Oklahoma and a Bachelor of Science from Syracuse University. Elaine Minden, RD Elaine Minden works as a Registered/Licensed Dietitian for Kersh Health, a corporate wellness company based out of Dallas, TX. She counsels clients participating in a weight management program, called Right Weigh. She earned her bachelor of science degree in Nutritional Sciences from Texas A&M University and completed her dietetic internship at Saint Louis University with an emphasis in Nutrition and Physical Performance. Elaine has a passion for wellness and loves to help others strive towards a healthy lifestyle. She was grateful for the opportunity to attend the 2014 WM DPG Symposium because, as a new dietitian, she feels that she has so much more to learn from experienced dietitians (Continued on page 26) 25 Volume 12 No. 4 Weight Management Matters (Continued from page 25) and practitioners about weight management counseling. Elaine hopes to advance her practice skills so that she can be successful in helping her clients make positive changes in their nutrition, physical activity, and overall health. Jenna Abrassart, MPH, RD Jenna Abrassart currently reside in Redlands, CA, which is known as the “Gem of the Inland Empire.” She graduated from Loma Linda University with a master’s in Public Health-Nutrition and Dietetics in December of 2012. She has gained experience in a variety of dietetic fields in her first year; ranging from Skilled Nursing facilities, an AIDS clinic, hospice, and some long-term pediatrics. Currently, she works in two fields, one as a dietitian in a pharmacy working with the parents of children on formulas and enteral feeding and the other as a consultant dietitian for a Bariatric/Weight management privatebased surgery group in Corona/Murrieta, CA. As a bariatric dietitian, she works closely with the clients who are planning on having the surgery in the hopes of improving their overall health. She leads clients through a 6-month weight management program, which includes designing handouts and leading the lecture portion of the support group. Additionally, she conducts initial assessments, monthly follow-ups, and postop consultations. The organization’s vision is that bariatric surgery can be used as a “tool” which when coupled with proper nutritional habits, physical activity, and lifestyle changes can lead to overall wellness. She enjoyed the informational and networking opportunities that were available at the symposium. She hopes to be able to add new knowledge and skills to her repertoire to better serve her clients, as well as further her own ambition to learn more in the field of weight management nutrition. She is eager to learn and meet new people who share her passion for weight management. Danielle Mach, RDN, LD Danielle Mach graduated from the University of Illinois Champaign Urbana with a BS in Dietetics and completed her dietetic internship at Saint Louis University. After passing the RD exam, she continued to pursue graduate school at Saint Louis University to achieve a Master’s degree in Nutrition and Physical Performance to achieve more knowledge in both nutrition and exercise physiology. She plans on working with a weight loss camp for children for her thesis in hopes to complete the project by the end of 2014. Her goal after receiving her master’s degree is to work with adults and children in the community to educate them on proper nutrition and exercise protocols to aid in achieving a consistently, healthy lifestyle. She is very grateful and appreciative to have received a stipend for the 2014 WM DPG Symposium to learn more about up and coming research related to weight management for both adults and children to utilize in future career opportunities. Nataliia Johnson, student at Tennessee State University Nataliia Johnson just graduated Summa Cum Laude with B.S. in Dietetics from Tennessee State University, TN. Nataliia was born into a military family in Russia. When she was about 5 years old, her family moved to Ukraine. Throughout her middle and high school years, Nataliia took part in various academic competitions, such as chemistry, biology, reading and writing Olympiads. In addition, she was very active playing badminton, basketball, and volleyball. At 17 years old, Nataliia graduated from the specialized school of History with high honors. Then, she enrolled in Nikolayev State University to study linguistics. She speaks Russian, English, and Ukrainian fluently. In 2007, Nataliia Johnson moved to the U.S. in pursuit of knowledge. Her lifelong fascination with health, nutrition, and the dream of becoming a Registered Dietitian, led her to choose a career in Foods and Nutrition at TSU. Nataliia is currently working as a research assistant on a USDA-Funded research project at her university. In addition, she has a part-time job as a Dietary Aid at The Heritage at Brentwood, TN. Although, at times it is challenging to juggle work and a personal life, Nataliia still finds time to volunteer. She is extremely proactive when it comes to advocating for nutrition, bringing awareness about a healthy lifestyle, emphasizing the issue of hunger, and paying it forward by volunteering in places that make a difference in people’s lives. She is also currently teaching nutrition education classes for preschool children at the Martha O’Bryan Center. Nataliia’s short term goal is to complete an internship program. She persistently seeks to prepare herself for the competitive internship application by regularly reading subject-relevant books, scientific journals, and attending meetings and seminars. She is working to get her master of science degree within 4 years of graduation in order to deepen the knowledge of the field and to be able to better compete in the workplace. Another career goal is to work for the Academy of Nutrition and Dietetics as a valuable contributor and a spokesperson. Finally, the highlight of Natallia’s career would be to open her own health and wellness clinic to contribute to the wellbeing of the community. Her preparation for a lifetime career as a nutritionist is ongoing. She has determination and patience to take on any task that may arise along her way to fulfill her life plan. Nataliia has been a fan of the Weight Management Practice Group for a long time and winning this stipend means the world to her. She admires their commitment to optimizing the nation’s health through weight and lifestyle management. The stipend enabled her to meet the Weight Management Symposium. It gave her a chance to meet new people in her field of interest. The symposium helped her to further her understanding of the complicated issues involved in weight management. 26 Weight Management Matters Spring 2014 Christine Chan, MBA, student in Kansas State University Distance Didactic Program Pui Lun Christin Chan resides in Las Vegas and is currently a senior in Kansas State University’s Distance Didactic Program. She will be graduating in May 2014. She is a non-traditional college student, looking for a career shift to become a Registered Dietitian after having spent several years in another field. She has a BA in English Literature from the University of Nevada, Las Vegas, and an MBA from the University of Wisconsin, Whitewater. In her former career, she worked in e-commerce retail and IT product management. As a dietetics student, she tried to obtain as much experience as she could in the profession by volunteering and working for different facilities. Some of the experiences include working as a diet clerk at a local hospital, delivering nutrition education to over 1,000 children for the Southern Nevada Health District, participating in the recipe analysis committee for the Flavors of the Heart Annual Event for the American Heart Association, packing lunches and helping at a youth homeless shelter on behalf of the Three Square Food Bank. Finally, she also recently published an article on the benefits of prenatal and postnatal yoga in the latest book by Bridget Swinney, RD, Eating Expectantly, 4th edition. She is thrilled to be the recipient of the Weight Management Symposium 2014 student stipend. One of the practice areas of dietetics that she is most interested in is weight management. This award allowed her to attend the event and meet industry professionals. Without the award, she would not have been able to afford to do so. She was very excited to have the opportunity to gain an in-depth understanding of the subject of weight management. Not only did this award enhance her knowledge, it also helped prepare her to become a better dietitian. Public Policy Workshop: Wendy Baier, RD Wendy is a new registered dietitian, recently graduated from the University of Maryland College Park Dietetic Internship. Since her graduation, she has been an active member of the Connecticut Dietetic Association on their communications committee, focusing on their blog. She has just begun her first RD job with the Mid-Fairfield AIDS project in Norwalk, CT providing nutritional counseling and working with their food pantry. Last year, she was able to attend a day of the Public Policy Conference as an intern. She was very excited to get the full experience this year and see nutrition advocates in action. She firmly believes that if nutrition is your profession, politics is your business! Stella Uzogara, PhD, MS, RDN, LDN, CFS Dr. Stella Gladys Uzogara is a nutritional epidemiologist in the Bureau of Family Health and Nutrition at the Massachusetts Department of Public Health, in Boston, Massachusetts and recipient of a Public Policy workshop stipend. Stella earned her PhD degree in food science from Kings College, University of London, UK. She has an MS degree in nutrition and food science from Drexel University in Philadelphia, PA and a BS degree in biochemistry from University of Ibadan, Nigeria. Stella had her training in nutrition and dietetics at Simmons College in Boston MA and at Iowa State University in Ames Iowa. Stella is a certified food scientist (CFS), a registered dietitian nutritionist (RDN) & a licensed dietitian nutritionist (LDN) in the Commonwealth of Massachusetts. She resides in Lexington, Massachusetts with her husband and children. Susan Burke March, MS, RD, LDN, CDE Susan Burke March is a registered dietitian with advanced certificates in adult and pediatric & adolescent obesity management and is a certified diabetes educator. She graduated magna cum laude from Queens College of the City University of New York, where she also earned her Masters Degree in Nutrition & Exercise Sciences. Susan was an important contributor to the development of commercial online weight management programs. As Vice President of Nutrition Services and Chief Nutritionist for industry leader eDiets.com, she managed the creation and administration of the technology-enabled nutritional and wellness components of products, programs and services. Susan is the author of Making Weight Control Second Nature: Living Thin Naturally, (2009, Mansion Grove House), plus the study guide, published by Wolf Rinke Associates, providing professionals with 26 continuing education credits (CPEUs). Her recent eBook (2011 Amazon.com) is called The Common Cent$ Diet, a smart, budgetfriendly and convenient way to practice portion control by utilizing healthy frozen entrees plus daily fresh fruits, vegetables and dairy choices. In her private consultant and counseling practice, Susan works with individuals on a one-to-one basis to incorporate lifestyle modifications and improve health and reduce risk for diseases associated with overweight and obesity. She consults with corporations to create and deliver innovative strategies designed to improve health and accomplish weight goals. Susan is a media spokesperson for the Florida Dietetic Association and is a founding member of the Weight Management Dietetic Practice Group of the Academy of Nutrition and Dietetics, where she served a two-year elected position as Secretary, and served a three-year term as Sponsorship Relations Director. (Continued on page 28) 27 Volume 12 No. 4 Weight Management Matters (Continued from page 27) She was honored to be able to attend The 2014 Academy of Nutrition and Dietetics Public Policy Workshop on behalf of the WM DPG. She would like to thank Weight Management for their generous stipend. She had never attended this workshop. It was a great networking and educational experience and she was thankful for learning about the critical policies that impact the health of the nation and the dietetics profession, and having the opportunity to meet with members of Congress and voicing her opinion was a chance of a lifetime. She would like to thank the Weight Management DPG for fulfilling her dream. Mehr Cox, MS, RDN Mehrshid (Mehr) Cox, is a Registered Dietitian Nutritionist and is licensed to practice in the State of Texas. She has her Bachelor and Master Degrees in Food, Nutrition and Institution Management from East Carolina University, and has been a resident of Coppell, Texas for the past 20 years. Mehr started her career as a clinical dietitian in Greenville, NC at Pitt County Memorial Hospital. Following that, she and her husband purchased and operated an upscale, fine-dining restaurant in the same city prior to moving to Texas in the early 1980s. Once in Texas, Mehr accepted a position with Parkland Memorial Hospital in Dallas, as an administrative and purchasing dietitian for this 1000 bed hospital. Several years later, Mehr was offered a position to serve as the Director of Nutrition Services for the USDA Child and Adult Care Food Program at ChildCareGroup, a not for profit organization serving over 20,000 low income children with an operating budget of over 50 million dollars. After 10 years in that capacity, Mehr was promoted to VP of Marketing and Community Outreach overseeing 5 operating divisions. In December 2012, after serving the organization for over 26 years, Mehr resigned from her position to spend more time with her family, travel the United States, and continue to help and consult with the facilities that care for low income children to promote healthy nutritional habits and fight against childhood obesity. Throughout the years, Mehr has been an advocate for low income families to receive the best nutritional care for their children. As a member of the Weight Management DPG and the recipient of the stipend for the Public Policy Workshop in 2014, Mehr was thrilled to have the opportunity to attend this worthy conference to learn as much as she can in order to continue her passion and advocate for critical policies affecting the health and well-being of millions of Americans. Her mission has and will always be to find and share the resources needed for families to access proper nutrition. CDR Certificate of Training in Weight Management: Allison Rueff, RD, LD Allison is a registered dietitian with The Christ Hospital in Cincinnati Ohio. Through the hospital she provides outpatient nutrition counseling, runs a community weight loss program and provides corporate wellness services to companies throughout the TriState. Along with being a member of the Weight Management DPG, she is also a member of the Sports, Cardiovascular & Wellness Nutrition DPG. She is grateful for receiving the Weight Management Certification stipend because it gives her the opportunity to enhance her knowledge of weight management which will help to increase the success of the clients she works with. Elaine C Souza, MPH, RD Elaine received her BS in Community Nutrition from University of California Davis, and completed her Master’s in Public Health Nutrition and Dietetic Internship at the University of Minnesota Twin Cities campus. Currently, she works as a Senior Dietitian at the University of California Davis Medical Center’s Bariatric Surgery Clinic. Most recently she participated as primary author on an accepted poster at Obesity Week 2013. She worked for several years in research; first, at the University of Pittsburgh, School of Public Health working on nutrition epidemiology studies, then for the USDA Western Human Nutrition Research Center. While at the WHNRC she had the opportunity to work on many research studies focusing on diet assessment, and ultimately became project manager on a weight loss study grant, from which she has been fortunate to have shared authorship on several manuscripts. During this time, she also worked per diem for Kaiser Permanente as a health educator for their Healthy Ways and Medically Supervised Weight Loss Programs. Elaine is a member of Northern Area Dietetic Association, California Dietetic Association, the Academy of Nutrition and Dietetics (Weight Management Dietetic Practice Group and Women’s Health Practice Group) and an affiliate member of ASMBS. Receiving this stipend allowed her the opportunity to continue her education in obesity treatment, a field that she is passionate about. She was thankful for this chance, and would like to express sincere gratitude to the Weight Management Dietetic Practice group for providing a great support for professional development. 28 Weight Management Matters Spring 2014 WM DPG 2014 Excellence Awards Congratulations to the 2014 WM DPG Excellence Award winners. Excellence in Weight Management Outcomes Research: Susan Raatz, PhD, MPH, RD Excellence in Weight Management Practice: Eileen Stellefson Myers, MPH, RD, FAND Dr. Susan Raatz completed a BS in Nutrition at Northern Michigan University in Marquette, MI; her internship at the VA Hospital in Saginaw, MI; a MS in Foods & Nutrition at Eastern Michigan University in Ypsilanti, MI; and a MPH in Epidemiology and PhD in Human and Clinical Nutrition at the University of Minnesota in Minneapolis, MN. She’s been a WM DPG member since 2009. Eileen has been an Academy of Nutrition and Dietetics member since 1980 and WM DPG member since 2007. She completed her undergraduate degree at Penn State, her dietetic internship at the Peter Bent Brigham Hospital in Boston, and her MPH at the University of North Carolina. Eileen developed a weight management gram at the Faulkner Hospital near Boston and developed and ran a wellness program at St. Francis Xavier Hospital in Charleston, South Carolina. In 1990, Eileen was recruited to the Medical University of South Carolina where she was Associate Director of Weight Management and the Nutrition Specialist for the Eating Disorders Program. Prior to her current position as Vice President, Affiliations and Patient Centered Strategies for The Little Clinic, Eileen ran a successful private practice focused on patient counseling, writing, speaking and mentoring. Dr. Raatz currently is a Research Nutritionist at the USDA Agricultural Research Service and Grand Forks Human Nutrition Research Center in Grand Forks, ND. She also serves as an Adjunct Associate Professor for the Department of Food Science and Nutrition at The University of Minnesota, St. Paul, MN and an Adjunct Scientist at the Neuropsychiatric Research Institute in Fargo, ND. Dr. Raatz’s research focuses on the evaluation of the role of dietary macronutrient distribution in the promotion of optimal health and the prevention of chronic diseases. She primarily works with the utilization of whole foods diets to modify energy distribution from macronutrient substrates. Her work is focused primarily on macronutrient (carbohydrate, protein and fat) modification for metabolic control, body weight management, and the prevention of chronic diseases. Eileen spent many years teaching and mentoring dietetic interns, medical students, nurse midwifery students, psychology interns and psychiatry residents about nutrition, weight management and eating disorders at programs in Massachusetts, South Carolina and Tennessee. She pioneered incorporating cognitivebehavioral therapy and motivational interviewing into nutrition counseling in the early 1990s. Eileen has served as Network Chair, Secretary, and Nominating Chair for the Weight Management Dietetic Practice Group and currently serves as co-chair for the committee developing the Standard of Practice/Standard of Professional Performance for weight management. The WM DPG recognizes McNeil Nutritionals, LLC for sponsoring the 2014 Excellence in Weight Management Outcomes Research Award 29 Volume 12 No. 4 Weight Management Matters Upcoming Events for 2014-2015 June 26-28, 2014 CDR Certificate of Training in Adult Weight Management Columbus, OH www.cdrnet.org September 25-28 Obesity Action Coalition National Convention Orlando, FL www.obesityaction.org October 18-21, 2014 Academy of Nutrition and Dietetics Food & Nutrition Conference & Expo (FNCE) Atlanta, GA www.eatright.org/fnce July 9-12, 2014 NSCA Annual Conference Las Vegas, NV www.nsca.com November 2-7, 2014 Obesity Week Boston, MA www.obesityweek.com September 4-6, 2014 CDR Certificate of Training in Childhood and Adolescent Weight Management Newport Beach, California www.cdrnet.org April 17-19, 2015 WM DPG Symposium Portland, OR www.wmdpg.org/symposium Weight Management Dietetic Practice Group Mission Empower members to be the nation’s weight management and lifestyle change leaders. Vision Optimize the nation’s health through weight and lifestyle management. Viewpoints and statements in this newsletter do not necessarily reflect policies and/or official positions of the Academy of Nutrition and Dietetics. © 2014 Weight Management Dietetic Practice Group of the Academy of Nutrition and Dietetics. 30 Weight Management Matters Spring 2014 2013-2014 Weight Management Dietetic Practice Group Leadership Directory Chair Julie Schwartz, MS, RDN, CSSD, LD [email protected] Special Projects Chair Emily Korns, MBA, RD [email protected] Student Services Coordinator Meredith Johnson, MS, RDN, LD [email protected] Chair-Elect Anne Wolf, MS, RD [email protected] CPEU Chair Amanda (Amy) Giffin, RD, CD [email protected] Volunteer Chair Barbara J. Ivens, MS, RD, FADA [email protected] Past-Chair Linda Gigliotti, MS, RD, CDE [email protected] Communications Director Lori F. Greene, MS, RD, LD [email protected] Sponsorship Relations Director Kristen Smith, MS, RD, LD [email protected] Secretary Eileen Ford, MS, RD [email protected] Website Editor Ashley Mullins, RD, LD, CNSC [email protected] Sponsorship Relations Assistant Director Meghan Ariagno, RD [email protected] Treasurer Monica Lebre, MS, RD, LDN [email protected] Associate Website Editor Caroline Luck, RD, LD [email protected] Bariatric Surgery Subunit Chair Stacy Paine, RD, LD [email protected] HOD DPG Delegate Pat Harper, MS, RD, LDN [email protected] Newsletter Editor Paul Moore, MS, RD, CSSD, LDN [email protected] Pediatric Subunit Chair Samantha Weiss, RD [email protected] Nominating Committee Director Jackie Ballou, MS, RD, LDN [email protected] Associate Newsletter Editor Betsy Hirschy, RD, LD [email protected] Reimbursement and Public Policy Amanda Meadows, MS, RD/LD, CDE, NASMCPT [email protected] Awards and Honors Chair Lynn Grieger, RD, CDE, CPT [email protected] Assistant Newsletter Editor Emily Stern [email protected] Policy and Advocacy Leader Chris Weithman MBA, RDN, LDN [email protected] Professional Development Director Kristin Walters, RD [email protected] Electronic Mailing List (EML) Chair Sandra Carpenter, MS, RD, LDN, CDE [email protected] Network Director Sue Cummings, MS, RD, LDN [email protected] 2014 Symposium Chair Paul Allen, MBA, MS, RDN [email protected] Blast eMail Chair Laura Andromalos, RD, LDN [email protected] Network Director Assistant Kellene Isom, MS, RD, LDN [email protected] Research Chair Hollie Raynor, PhD, RD, LDN [email protected] Member Services Director Juliet Mancino, MS, RD, LDN, CDE [email protected] Weight Management DPG Administrative Manager Lisa Sands, MS [email protected] 800.877.1600 x 1150 Member Recruitment & Retention Chair Angie Hasemann, RD, CSP [email protected] 31 Volume 12 No. 4 Weight Management Matters Paul Moore, MS, RD, CSSD, LDN, CSCS*D, NSCA-CPT*D Weight Management Matters 232 Boone Heights Drive Boone, NC 28607