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Interdisciplinary versus multidisciplinary treatment of obesity
THURSDAY, OCTOBER 28 I
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INTERDISCIPLINARY VERSUS MULTIDISCIPLINARY TREATMENT OF OBESITY. G. L. Blackburn, M.D., Ph.D., A. E. Peterson, M.S., R.D., and S. L. Gallagher, R.D., C.D.E., Deaconess Hospital, Boston, MA Our goal was to determine if an interdisciplinary clinic was more effective than a multidisciplinary clinic in the treatment of obesity. We compared the retention rates, number of clinic visits, cancellations, no-show appointments, and dietary compliance between two types of nutrition-oriented clinics. The multidisciplinary group of patients was referred to dietetics from physicians through a traditional hospital outpatient program: the Nutrition Counseling Service (NCS). The interdisciplinary group of patients was in the Nutrition Medicine Clinic (NMC), where coordinated dietitian/physician services are provided. A total of 116 patients with medically significant obesity were selected: 65 from NCS and 51 from the NMC. Patients were considered "active' if they had two or more visits in the time period between September 1992 and February 1993, and if they had been seen within the last six weeks of the study period. We first compared age, sex, body mass index (BMI) and the number of comorbidities and their effect on retention. We then compared the total number of patient visits, cancellations and no-shows in each clinic, as well as compliance (measured by average weight lost and the percentage of patients who kept food records). Results indicate that the NMC had a better retention rate than NCS (53 %vs. 42 %). Women had a better retention rate (53 %)than men (32%) in both clinics. Age, BMI and number of comorbidities were not associated with retention rate in either clinic. NMC patients had 50% more visits than NCS patients during the study period. There was no difference in the number of cancellations and no-shows between the two clinics. A large percentage of NMC patients kept food records (52% vs. 34%) and NMC patients lost more weight, on average, than NCS patients (7.2 vs. 2.5 lbs.). We suggest that the higher retention rate, the increased number of patient visits, and the increased compliance among NMC patients may be attributed to the interdisciplinary approach used in this clinic vs. the multidisciplinary approach used in the NCS. The benefits of the NMC include: physician reinforcement, concomitant presentation of expectations by the dietitian and physician, special medical services, team approach of all disciplines, and frequent telephone correspondence with patients. An interdisciplinary approach, as exemplified by the NMC, may be more beneficial than a traditional multidisciplinary approach in the treatment of certain patient populations with medically significant obesity (i.e. those requiring additional reinforcement or specialized medical services).
FRAME SIZE DETERMINATION: A COMPARISON OF FOUR BODY BREADTHS. M.C. Mitchell, PhD,RD, R.L. Uebes and A.J. Pearse Department of Human Nutrition and Food Management, The Ohio State University, Columbus, OH The anthropometric measurements used most extensively in clinical and community practice are height and weight. Accurate determination of frame size, which reflects bone, joint and skeletal breadths, enhances interpretation of these measurements for body weight, fat free mass and fatness. Correlations of four skeletal breadths (elbow, wrist, ankle and knee) with body fat free mass and body fat were determined for 50 adults (33 females and 17 males) between the ages of 19 and 32 yrs. All subjects were in good health and within 15% of their Metropolitan Relative Weight. An accurate estimator of body frame size should be highly correlated with lean body mass. In these subjects lean body mass, determined by densitometry, was significantly correlated with each of the frame measures (p< 0.05) and the correlation persisted after correction for height. Assessment of total body fat is of particular interest in nutritional assessment because of specificity for energy reserves and obesity. Frame size measures should have minimum correlation with body fat so that the variability in frame size reflects lean tissue. None of the correlations between the frame size measures and percent body fat or fat weight, measured by hydrostatic weighing or four separate fatfold measurements, were highly significant. For males, elbow and ankle breadths had the lowest correlations with body fat. For females the lowest correlations with body fat were for ankle and wrist breadths. Elbow breadth in women had the strongest correlation with body fat of the measures studied. Predictors of frame size need to reflect lean body mass and not body fat. Ankle breadth may be a better measure of frame size for women and as good as elbow breadth for men in predicting frame size and therefore body weight and fatness.
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ORIGINAL CONTRIBUTIONS: CLINICAL NUTRITION I
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THE PREVALENCE OF MALNUTRITION AND THE RELATIONSHIP WITH DIETARY COMPLIANCE IN PATIENTS WITH END STAGE RENAL DISEASE M.E.Gann, MS,RD,LD; S.P.Camel, MS,RD,LD; K.M.Masters, MS,RD,LD, Hermann Hospital, Houston, TX The relatively high incidence of malnutrition and resulting increased morbidity and mortality among patients with end stage renal disease (ESRD) is well documented. The rigidity and complexity of the renal diet may contribute to hyperdietism" resulting in inadequate dietary intake. The purpose of this study was to describe the prevalence of malnutrition in ESRD patients referred for renal transplantation and describe any association with the degree of dietary compliance. Biochemical and anthropometric data was collected on 200 patients. A 24 hour dietary recall and food frequency were completed. The degree of dietary compliance was measured subjectively based on definitions described previously (Camel, CRNQ, 1990). The study group consisted of 128 males and 72 females with a mean age of 43 * 13 (range 17-70). Ninety percent of the patients were dialysis dependent (76% hemodialysis/14% peritoneal dialysis). Of the total group, 96% were found to have one or more sub-optimal nutrition indices. Fifty-one percent of the patients presented with sub-optimal visceral and/or somatic protein stores as measured by albumin (<2.8 mgdlI), transferrin (<200 mg/dl) and mid arm muscle area (MAMA) (<15th percentile). The extent of energy malnutrition was less remarkable with 15% of the patients falling below the 15th percentile for triceps skin fold (TSF) and 8% below 85% ideal body weight (IBW). Good dietary compliance was demonstrated by 23% of the patients, which is consistent with previously reported rates. Moderate compliance was demonstrated by 37%, fair by 58%, and poor by 9°%. There is a significant negative correlation between the degree of compliance and serum transferrin (p<0.05) suggesting that the more compliant the patient is the lower the transferrin. This trend persisted with albumin, Fe, MAMA, TSF, and percent IBW although not statistically significant. Patients demonstrating good compliance had a significantly lower albumin, transferrin, MAMA, and TSF when compared to those with poor compliance (pc0.05). Dietary education for protein repletion was required by 34% of the patients compared to 12% of all others. In conclusion, this study confirms the high prevalence of protein malnutrition in patients with ESRD and suggests that patients demonstrating good compliance with the renal diet are at greater risk of malnutrition. Perhaps our educational focus should be shifted from renal diet restrictions, which may perpetuate "hyperdietism" towards greater emphasis on the provision of optimal nutrition.
SUCCESSFUL EARLY ZNTERAL FEEDZNG IN THE THERMALLY INJURED
PATIENT. M.M. Ohara, MS, RD, CNSD, C. Dore', RN, W.B. Hansbrough, RN, and J.F. Hansbrough, MD. UCSD Medical Center, San Diego, California Early enteral feeding has recently been advocated in thermal injury to improve gut blood flow and to reduce risk of bacterial translocation and trauma-induced hypermetabolism. We studied the success of our early enteral feeding protocol in 12 thermally injured patients admitted to the UCSD Regional Burn Center from May 1992 to February 1993. Patients were 36.0 13.1 years of age with a mean burn size of 36.2 17.9% total body surface area. Upon admission, a naso-gastric (NG) feeding tube was passed and feeding was initiated using either halfR R strength Traumacal or Impact . In all patients, initial attempts to feed were via NG tube, however, three patients developed evidence of gastric ileus and placement of a transpyloric feeding tube was required. Estimation of initial nutrient needs were determined using basal energy expenditure (predicted by the HarrisBenedict equation) multiplied by corresponding activity and injury factors based on percent burn size. Protein requirements were determined based on the severity of burn, and calculated in grams of protein/kg/day. The mean interval from time of burn to time at which feeding was initiated was 7.00 5.85 hours. The mean interval from time feeds were initiated to the time feeds reached the goal rate and strength was 20.58 ± 11.28 hours. Daily caloric intake was within 80% of calculated goals and protein intake met approximately 100% of calculated goal by the second day of feeding for all patients. Nitrogen losses analyzed via 24 hour urinary urea nitrogen on postburn day 5 were 21.25 1.06 gms, placing patients in 5.17± 2.67 gms nitrogen balance. We conclude that early enteral feeding circumvented the development of gastric ileus in most patients and permitted continuos enteral feeding with improved nitrogen balance in spite of severe thermal injury.
JOURNA, OF TIlE AMERICAN DIETETIC ASSOCIATION / A-89
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INTERDISCIPLINARY VERSUS MULTIDISCIPLINARY TREATMENT OF OBESITY. G. L. Blackburn, M.D., Ph.D., A. E. Peterson, M.S., R.D., and S. L. Gallagher, R.D., C.D.E., Deaconess Hospital, Boston, MA Our goal was to determine if an interdisciplinary clinic was more effective than a multidisciplinary clinic in the treatment of obesity. We compared the retention rates, number of clinic visits, cancellations, no-show appointments, and dietary compliance between two types of nutrition-oriented clinics. The multidisciplinary group of patients was referred to dietetics from physicians through a traditional hospital outpatient program: the Nutrition Counseling Service (NCS). The interdisciplinary group of patients was in the Nutrition Medicine Clinic (NMC), where coordinated dietitian/physician services are provided. A total of 116 patients with medically significant obesity were selected: 65 from NCS and 51 from the NMC. Patients were considered "active' if they had two or more visits in the time period between September 1992 and February 1993, and if they had been seen within the last six weeks of the study period. We first compared age, sex, body mass index (BMI) and the number of comorbidities and their effect on retention. We then compared the total number of patient visits, cancellations and no-shows in each clinic, as well as compliance (measured by average weight lost and the percentage of patients who kept food records). Results indicate that the NMC had a better retention rate than NCS (53 %vs. 42 %). Women had a better retention rate (53 %)than men (32%) in both clinics. Age, BMI and number of comorbidities were not associated with retention rate in either clinic. NMC patients had 50% more visits than NCS patients during the study period. There was no difference in the number of cancellations and no-shows between the two clinics. A large percentage of NMC patients kept food records (52% vs. 34%) and NMC patients lost more weight, on average, than NCS patients (7.2 vs. 2.5 lbs.). We suggest that the higher retention rate, the increased number of patient visits, and the increased compliance among NMC patients may be attributed to the interdisciplinary approach used in this clinic vs. the multidisciplinary approach used in the NCS. The benefits of the NMC include: physician reinforcement, concomitant presentation of expectations by the dietitian and physician, special medical services, team approach of all disciplines, and frequent telephone correspondence with patients. An interdisciplinary approach, as exemplified by the NMC, may be more beneficial than a traditional multidisciplinary approach in the treatment of certain patient populations with medically significant obesity (i.e. those requiring additional reinforcement or specialized medical services).
FRAME SIZE DETERMINATION: A COMPARISON OF FOUR BODY BREADTHS. M.C. Mitchell, PhD,RD, R.L. Uebes and A.J. Pearse Department of Human Nutrition and Food Management, The Ohio State University, Columbus, OH The anthropometric measurements used most extensively in clinical and community practice are height and weight. Accurate determination of frame size, which reflects bone, joint and skeletal breadths, enhances interpretation of these measurements for body weight, fat free mass and fatness. Correlations of four skeletal breadths (elbow, wrist, ankle and knee) with body fat free mass and body fat were determined for 50 adults (33 females and 17 males) between the ages of 19 and 32 yrs. All subjects were in good health and within 15% of their Metropolitan Relative Weight. An accurate estimator of body frame size should be highly correlated with lean body mass. In these subjects lean body mass, determined by densitometry, was significantly correlated with each of the frame measures (p< 0.05) and the correlation persisted after correction for height. Assessment of total body fat is of particular interest in nutritional assessment because of specificity for energy reserves and obesity. Frame size measures should have minimum correlation with body fat so that the variability in frame size reflects lean tissue. None of the correlations between the frame size measures and percent body fat or fat weight, measured by hydrostatic weighing or four separate fatfold measurements, were highly significant. For males, elbow and ankle breadths had the lowest correlations with body fat. For females the lowest correlations with body fat were for ankle and wrist breadths. Elbow breadth in women had the strongest correlation with body fat of the measures studied. Predictors of frame size need to reflect lean body mass and not body fat. Ankle breadth may be a better measure of frame size for women and as good as elbow breadth for men in predicting frame size and therefore body weight and fatness.
l
I
I
ORIGINAL CONTRIBUTIONS: CLINICAL NUTRITION I
I
I
I
I
llllllllll
II~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-----
THE PREVALENCE OF MALNUTRITION AND THE RELATIONSHIP WITH DIETARY COMPLIANCE IN PATIENTS WITH END STAGE RENAL DISEASE M.E.Gann, MS,RD,LD; S.P.Camel, MS,RD,LD; K.M.Masters, MS,RD,LD, Hermann Hospital, Houston, TX The relatively high incidence of malnutrition and resulting increased morbidity and mortality among patients with end stage renal disease (ESRD) is well documented. The rigidity and complexity of the renal diet may contribute to hyperdietism" resulting in inadequate dietary intake. The purpose of this study was to describe the prevalence of malnutrition in ESRD patients referred for renal transplantation and describe any association with the degree of dietary compliance. Biochemical and anthropometric data was collected on 200 patients. A 24 hour dietary recall and food frequency were completed. The degree of dietary compliance was measured subjectively based on definitions described previously (Camel, CRNQ, 1990). The study group consisted of 128 males and 72 females with a mean age of 43 * 13 (range 17-70). Ninety percent of the patients were dialysis dependent (76% hemodialysis/14% peritoneal dialysis). Of the total group, 96% were found to have one or more sub-optimal nutrition indices. Fifty-one percent of the patients presented with sub-optimal visceral and/or somatic protein stores as measured by albumin (<2.8 mgdlI), transferrin (<200 mg/dl) and mid arm muscle area (MAMA) (<15th percentile). The extent of energy malnutrition was less remarkable with 15% of the patients falling below the 15th percentile for triceps skin fold (TSF) and 8% below 85% ideal body weight (IBW). Good dietary compliance was demonstrated by 23% of the patients, which is consistent with previously reported rates. Moderate compliance was demonstrated by 37%, fair by 58%, and poor by 9°%. There is a significant negative correlation between the degree of compliance and serum transferrin (p<0.05) suggesting that the more compliant the patient is the lower the transferrin. This trend persisted with albumin, Fe, MAMA, TSF, and percent IBW although not statistically significant. Patients demonstrating good compliance had a significantly lower albumin, transferrin, MAMA, and TSF when compared to those with poor compliance (pc0.05). Dietary education for protein repletion was required by 34% of the patients compared to 12% of all others. In conclusion, this study confirms the high prevalence of protein malnutrition in patients with ESRD and suggests that patients demonstrating good compliance with the renal diet are at greater risk of malnutrition. Perhaps our educational focus should be shifted from renal diet restrictions, which may perpetuate "hyperdietism" towards greater emphasis on the provision of optimal nutrition.
SUCCESSFUL EARLY ZNTERAL FEEDZNG IN THE THERMALLY INJURED
PATIENT. M.M. Ohara, MS, RD, CNSD, C. Dore', RN, W.B. Hansbrough, RN, and J.F. Hansbrough, MD. UCSD Medical Center, San Diego, California Early enteral feeding has recently been advocated in thermal injury to improve gut blood flow and to reduce risk of bacterial translocation and trauma-induced hypermetabolism. We studied the success of our early enteral feeding protocol in 12 thermally injured patients admitted to the UCSD Regional Burn Center from May 1992 to February 1993. Patients were 36.0 13.1 years of age with a mean burn size of 36.2 17.9% total body surface area. Upon admission, a naso-gastric (NG) feeding tube was passed and feeding was initiated using either halfR R strength Traumacal or Impact . In all patients, initial attempts to feed were via NG tube, however, three patients developed evidence of gastric ileus and placement of a transpyloric feeding tube was required. Estimation of initial nutrient needs were determined using basal energy expenditure (predicted by the HarrisBenedict equation) multiplied by corresponding activity and injury factors based on percent burn size. Protein requirements were determined based on the severity of burn, and calculated in grams of protein/kg/day. The mean interval from time of burn to time at which feeding was initiated was 7.00 5.85 hours. The mean interval from time feeds were initiated to the time feeds reached the goal rate and strength was 20.58 ± 11.28 hours. Daily caloric intake was within 80% of calculated goals and protein intake met approximately 100% of calculated goal by the second day of feeding for all patients. Nitrogen losses analyzed via 24 hour urinary urea nitrogen on postburn day 5 were 21.25 1.06 gms, placing patients in 5.17± 2.67 gms nitrogen balance. We conclude that early enteral feeding circumvented the development of gastric ileus in most patients and permitted continuos enteral feeding with improved nitrogen balance in spite of severe thermal injury.
JOURNA, OF TIlE AMERICAN DIETETIC ASSOCIATION / A-89