Preclinical obesity curriculum: audit, implementation, and evaluation.

BACKGROUND: This study aimed to (1) evaluate the current status of obesity education at Case Western Reserve University School of Medicine (CWRU) (2), introduce a comprehensive first-year curriculum on obesity, and (3) assess the impact of the curriculum on self-reported attitudes and knowledge regarding obesity among first-year medical students. METHODS: The preclinical curriculum at CWRU was reviewed to determine the degree of coverage of Obesity Medicine Education Collaborative (OMEC) competencies for healthcare professionals, and recommendations were provided for revising the curriculum to better adhere to these evidence-based competencies. A survey on obesity attitudes and knowledge was given before and after the implementation of the new curriculum to measure intervention-related changes. Changes in obesity attitudes and knowledge were compared (1) before and after the intervention for the class of 2025 and (2) after the intervention for the class of 2025 to a historical cohort that did not receive the intervention. RESULTS: Among the 27 competencies examined in the audit, 55% were unmet and 41% were partially met. Of 186 first-year medical students (M1s), 29 (16%) completed the baseline survey and 26 (14%) completed the post-intervention survey. Following the intervention, there was a notable improvement in attitudes and knowledge regarding obesity. Specifically, there was a significant decrease in the belief that obesity is caused by poor personal choices, and knowledge of obesity in fourteen out of fifteen areas showed significant improvement from pre- to post-intervention. Additionally, obesity attitudes and knowledge were significantly better post-intervention when compared to the historical cohort. CONCLUSIONS: The improvements made to the preclinical curriculum through this project improved obesity attitudes and knowledge among first-year medical students. This method provides a practical approach for evaluating and enhancing obesity education in medical school curricula.

Preliminary content and construct validity of a new model to differentiate research skills from evidence-based practice skills: Core, Evidence Application, Research (CEAR) Model.

BACKGROUND: Research is the scientific basis for the profession of dietetics, as it must be located and applied in evidence-based practice (EBP). EBP is often presented as a foundational skill for research. CEAR - Core, Evidence Application, Research - is a newly proposed model that separates Research and Evidence Application skills into distinct domains, jointly supported by a set of Core skills, thus acknowledging that education and advancement in one domain neither requires nor precipitates education and advancement in the other. The goal was to investigate the content and construct validity of the new CEAR Model. METHODS: A cross-sectional online survey of randomly selected dietitians in the United States was used to collect CEAR domain scores, validated measures of research or EBP skills and self-reported characteristics. Exploratory factor analysis, Cronbach's α and Pearson correlation between various tools and CEAR domains were used to assess validity and reliability. Analysis of variance (ANOVA) and multiple linear regression between CEAR domains and participant characteristics were used to assess convergent and divergent validity. RESULTS: One hundred and fifty-four responses with a valid CEAR score were received and led to a three-factor solution, supporting the theorised differentiation of research from evidence application skills (content validity). Internal reliability for the CEAR Model overall and for each domain was high. The hypothesised correlations between existing research or EBP measurement tools and the relevant CEAR domains were found (construct validity). Known groups analysis demonstrated the expected differences in CEAR domain scores based on participant characteristics. CONCLUSIONS: The CEAR Model demonstrates preliminary validity and internal reliability. It adds to the current literature by acknowledging the separateness of evidence application skills from research skills.

Obesity preclinical elective: a qualitative thematic analysis of student feedback.

BACKGROUND: Education about the prevalent chronic disease of obesity is still minimal and variable in medical school curricula. In a student-led effort with faculty support, the authors designed and implemented an obesity medicine elective at Case Western Reserve University School of Medicine (CWRU). The 10-week elective, taught by seven physicians and one dietitian, was offered in January 2023 to medical students and included: weekly lectures, an interactive session with a patient, shadowing in obesity medicine practices, attendance at a distance-learning intensive behavioral lifestyle program, student presentations, and a final written reflection. The purpose of this study was to analyze the elective reflections and identify themes about the elective's value and areas to improve. METHODS: The authors analyzed reflections from the 20 medical students that completed the elective via qualitative thematic analysis. The analysis was performed using the Braun and Clarke six-phase framework: (1) become familiar with the data, (2) generate initial codes, (3) search for themes, (4) review themes, (5) define themes, and (6) write-up. RESULTS: The themes identified were improved: (1) understanding of obesity as a chronic disease, (2) knowledge about treatment options for obesity (3) confidence in compassionate obesity counseling skills, and (4) skills to confront weight bias. Theme (5) consisted of highlights (hearing from experts, practicing evidence-based medicine, and interacting with patients), and areas to improve (session length, presentation format, more peer-to-peer interaction, and more diverse patient interactions). CONCLUSIONS: Medical student assessments of a new obesity medicine elective described improved attitudes, knowledge, and skills to address obesity and obesity bias. Students were very satisfied and contributed ideas for improvements. This elective structure and evaluation method is a feasible model to provide medical students with meaningful experiences related to obesity.

Team-Based Learning Intervention to Improve Obesity Education in Medical School.

Introduction: Obesity is a multifactorial chronic disease and a major contributor to numerous health conditions. Despite the high prevalence, costs, and health effects of obesity, physicians are largely unprepared to treat it. Most medical students and residents lack sufficient training in obesity and obesity management. Methods: We evaluated a two-part team-based learning seminar (TBL) on obesity pathogenesis and treatment for first-year medical students at Case Western Reserve University School of Medicine (CWRU SOM). A questionnaire on attitudes toward obesity and self-perceived knowledge of obesity was administered before and after the TBL, utilizing Likert scales. Results: Of 183 medical students who attended both TBLs, 155 (85%) completed the baseline questionnaire, and 127 (69%) completed the postintervention questionnaire. Confidence in treating obesity increased significantly from preintervention (M = 2.7, SD = 1.0) to postintervention (M = 3.7, SD = 0.8). The attitude that obesity is caused by poor personal choices decreased significantly from preintervention (M = 2.8, SD = 0.9) to postintervention (M = 2.1, SD = 0.9). Self-perceived knowledge of obesity in all nine areas-epidemiology, energy homeostasis, etiologies, nutrition, physical activity, behavior, pharmacology, surgery, and language-increased significantly. Discussion: Despite obesity being one of the most prevalent health concerns, obesity education in medical school is scant. This TBL resulted in improved attitudes toward obesity and self-perceived knowledge of obesity among first-year medical students at CWRU SOM and offers a practical mechanism to introduce more obesity education into undergraduate medical curricula.

Implementation Science in Evidence-based Nutrition Practice: Considerations for the Registered Dietitian Nutritionist.

Nutrition and dietetics practice should be based on the highest-quality and most recent available evidence. Unfortunately, translating research to day-to-day practice often involves long lag times. Implementation science is an emerging field that evaluates methods that promote uptake of research findings into daily practice. Numerous theories and frameworks have been developed to provide guidance for implementation research and operationalization of recommendations. This paper provides a broad overview of implementation science and highlights frameworks such as the Normalization Process Theory that can be used by registered dietitian nutritionist (RDNs) to encourage systematic uptake of evidence into practice.

Adolescents' and Parents' Perspectives of a Revised Protein-Sparing Modified Fast (rPSMF) for Severe Obesity.

The purpose of this pilot study was to assess the acceptability to adolescents (11-18 years old) and their parents using a revised protein-sparing modified fast (rPSMF) for 12 months as an intervention for severe obesity in a tertiary pediatric weight management clinic (PWMC). To assess acceptability (satisfaction, confidence) with the rPSMF protocol, surveys were completed by adolescents and parents at baseline, 1, 3, 6, and 12 months, with adolescent height and weight measured. Analyses were conducted to assess differences in satisfaction and confidence based on adolescent response (weight loss) and adherence to the rPSMF. Adolescents' adherence with the rPSMF was close to 50% in the first 3 months, but dropped to 14.7% at 6 months. Adolescents were most confident with choosing low carbohydrate foods at baseline. Over 12 months, adolescents and parents reported weight loss as "the most liked" part of the rPSMF. Adolescents who were adherent were more satisfied with their weight loss than their non-adherent peers. Parents and adolescents reported lack of food variety and difficulty following the protocol as challenges with the rPSMF. Adolescents and their parents were able to follow the rPSMF protocol, with weight loss, but with decreased adherence over time.

Using a Revised Protein-Sparing Modified Fast (rPSMF) for Children and Adolescents with Severe Obesity: A Pilot Study.

Treatment options are limited for children and adolescents with severe obesity. One alternative treatment is the protein-sparing modified fast (PSMF), a low-carbohydrate, high-protein diet that can result in substantial weight loss. The aim of the study is to evaluate the adherence and efficacy of a revised PSMF (rPSMF) for severe obesity in a pediatric tertiary care weight-management program. The rPSMF with 1200-1800 calories, 40-60 g of carbohydrate/day and 1.2-1.5 g protein/kg of ideal bodyweight was implemented over 12 months. Twenty-one participants enrolled in the study. Mean age 16.2 ± 1.4 years, females (76.2%) and mean weight at baseline was 119 ± 19.9 kg. Regardless of adherence to the rPSMF, the mean weight change at 1 month was -3.7 ± 3.5 kg, (range -13.5 kg to 0.9 kg); at 3 months was -5.5 ± 5.1 kg, (range -19.3 kg to 1.8 kg) and at 6 months was -4.7 ± 6.6 kg, (range -18.3 kg to 8.6 kg). At 12 months, the mean weight change was -1.3 ± 10.6 kg (range -17.7 kg to 14.8 kg). Parent and child-reported physical and psychosocial quality of life (HRQOL) improved. Despite limited adherence, the rPSMF diet resulted in clinically significant weight loss and improved HRQOL for children and adolescents with severe obesity.

Nutrition Counseling for Hypertension Within a Grocery Store: An Example of the Patient-Centered Medical Neighborhood Model.

OBJECTIVE: To evaluate the effectiveness of nutrition counseling for patients with hypertension, provided in a grocery store setting. DESIGN: Single-arm pretest-posttest design implementing a 12-week dietary intervention. SETTING: Grocery store. PARTICIPANTS: Thirty adults with hypertension recruited from a primary care practice. INTERVENTION: Registered dietitian nutritionists provided counseling based on the Dietary Approaches to Stop Hypertension diet. MAIN OUTCOME MEASURES: Dietary intake patterns and Healthy Eating Index-2010 (HEI-2010) scores measured via food-frequency questionnaire. Change in systolic blood pressure (SBP) was a secondary outcome. ANALYSIS: Paired t tests were used to test for differences between HEI-2010 scores, intake of key food pattern components, and SBP at baseline compared with follow-up. Statistical significance was established at P ≤ .05. RESULTS: Eight HEI-2010 component scores increased significantly from baseline to follow-up (a change toward a more desirable eating pattern): total fruit, whole fruit, greens and beans, whole grains, fatty acids, refined grains, and empty calories. Sodium (P < .001), saturated fat (P < .001), discretionary solid fat (P < .001), added sugars (P = .01), and total fat (P < .001) all decreased significantly. The change in SBP was not significant. CONCLUSIONS AND IMPLICATIONS: Grocery store-based counseling for patients with hypertension may be an effective strategy to provide lifestyle counseling that is not typically available within primary care.

Development of a tool to measure the number of foods and beverages consumed by children using National Health and Nutrition Examination Survey (NHANES) FFQ data.

OBJECTIVE: There is currently no standard, objective definition of selective eating. This is partially because normative values for the number of different foods eaten by US children have not been established. The present study objectives were to: (i) perform exploratory analysis on the number of different foods, beverages, and total foods and beverages consumed by US children aged 2-18 years over a year's time, and the types of foods consumed by those in the lowest 2·5th percentile; and (ii) determine whether those values differ according to demographic variables and weight status. DESIGN: Secondary analysis of cross-sectional FFQ data. Differences in number of foods, beverages, and total foods and beverages were analysed using one-way ANOVA. SETTING: National Health and Nutrition Examination Survey (NHANES) for the years 2003-2006. SUBJECTS: Non-institutionalized US children aged 2-18 years. RESULTS: The mean number of different foods and beverages consumed across the sample was 83·2. There were no significant differences by gender, BMI, race or food security categories. There was a difference in beverage consumption by age category, with children aged 12-18 years consuming a significantly higher number of different beverages compared with each of the other two age categories (i.e. 2-5 years and 6-11 years). CONCLUSIONS: Normative values for the number of foods and drinks reported as consumed by children over the past 12 months may be a useful measure for researchers. Future research validating this measure is needed before cut-off values can be used to develop a definition of selective eating.

Shelf to Health: Does Product Innovation Change National Estimates of Dietary Impacts?

This paper presents a simulation process to augment nutrition surveillance in the United States which incorporates product innovation data. Traditional point-estimates of nutritional quality in a food category are compared to those based on distributions of nutrient compositions using product-level variability seen in the market. Nationally representative consumption patterns provide dietary intakes. Cookies are used as an example food category. Nutrient composition data from Global New Product Database (GNPD) for 5259 cookies launched 2005 to 2012 were matched to dietary intakes from 2005 to 2012 National Health and Nutrition Examination Survey (NHANES) over the 2 y cycles of NHANES for 8284 cookie consumers. Average dietary intakes from traditional NHANES and GNPD-based estimations produced similar mean values for energy, carbohydrates, sugars, total fat, and protein. Saturated fat, fiber and cholesterol contributions using new product compositions were significantly higher than traditional NHANES approaches, estimates of sodium were significantly lower. These differences become pronounced when comparing adult and child consumption patterns and over time. This process also simulated trans fat consumption estimates not traditionally available within NHANES. On average cookies contributed 0.3 g/d (range 0 to 4.1 g/d). Much variability in food composition is seen in the market which is shown to influence estimates of the national diet. PRACTICAL APPLICATION: Numerous factors drive changes in the food supply, including health trends, firm strategic choices, and food policy. This evolution presents a challenge for dietary assessments and nutrition monitoring. The public health impact of variability in nutritional composition, subpopulation consumption patterns and market dynamics are particularly difficult to evaluate and are shown to influence estimates of the national diet.

Contribution of snacks to dietary intakes of young children in the United States.

Nutritional quality of children's diets is a public health priority in the fight against childhood obesity and chronic diseases. The main purpose of this study was to determine contribution of snacks to energy and nutrient intakes and to identify leading snack food sources of energy, total fat, and added sugars amongst young children in the United States. Using the 2005-2012 NHANES data, dietary intakes of 2- to 5-year-old children were analysed from a parent-reported 24-hour dietary recall (n = 3,429). Snacking occasions were aggregated to determine the proportion of total food/beverage intake obtained from snacks, estimate energy, and nutrient intakes, and identify the leading snack food sources of energy, added sugars, and total fat. Nearly all children consumed a snack on the reported day (62% morning, 84% afternoon, and 72% evening). Snacks accounted for 28% of total energy intake, 32% of carbohydrates, 39% of added sugars, and 26% of total fat and dietary fiber intakes for the day. Snacking occasions accounted for 46.6% of all beverages consumed on the reported day. Snacks and sweets food category (i.e., cookies and pastries) were the leading sources of energy (44%), total fat (52%), and added sugars (53%) consumed during snacking occasions. Sweetened beverages (e.g., fruit and sport drinks) contributed 1-quarter of all added sugars obtained from snacks. Snacks contribute considerable amount of energy and nutrients to young children's diets, with a heavy reliance on energy-dense foods and beverages. Targeted interventions are needed to improve the nutritional quality of snacks consumed by young children.

Dietary Intake Contributions of Food and Beverages by Source and Food Security Status in US Adults.

OBJECTIVE: To compare the consumption patterns and diet quality of foods and beverages obtained from various sources by food security status. DESIGN: Cross-sectional analysis of 2011-2012 National Health and Nutrition Examination Survey data. PARTICIPANTS: A total of 4,789 adults (aged >19 years) with dietary intake and food security data. MAIN OUTCOME MEASURES: The contribution of foods and beverages to energy, nutrients, and diet quality by locations where food was obtained was compared across food security status. ANALYSIS: Descriptive analysis and logistic regression. RESULTS: Almost all US adults consumed food and beverages obtained from grocery stores, regardless of food security status (about 95%), which accounted for one half to two thirds of total macronutrient intakes. The diet quality of foods from grocery stores was better in highly food-secure adults. Convenience stores are used most by very low food-secure adults; those foods had the poorest diet quality profile. Dietary patterns of marginally food-secure adults more closely resembled sources and intakes of low and very low food-secure adults. CONCLUSIONS AND IMPLICATIONS: Food-insecure adults use food sources differently, resulting in diet quality differences of foods and beverages obtained. Place-based interventions in the food environment may have differential effects by food security status.

Targeting Feeding and Eating Behaviors: Development of the Feeding Dynamic Intervention for Caregivers of 2- to 5-Year-Old Children.

Targeting feeding dynamics, a concept centered on the roles and interaction of the caregiver and child in a feeding relationship, may have significant potential for obesity intervention. The aim of this paper is to describe the 3-phase development of the Feeding Dynamics Intervention (FDI), an acceptability and feasibility study on implementing the feeding dynamic roles (Study 1), development of the FDI content (Study 2), and a pilot study on use of the 6-lesson FDI to promote behaviors consistent with a feeding dynamic approach (Study 3). Sample population was mothers with young children, 2-5 years old. An effect size (Hedges' g) greater than 0.20 was seen in more than half (57%) of maternal feeding behaviors, with the largest effect sizes (Hedges' g ≥ 0.8) occurring with behaviors that represent the mother adopting her roles of determining what food is served, not using food as a reward, and not controlling her child's intake. There was a significant decline in Pressure to Eat behaviors (2.9 versus 2.2, p < 0.01) and Monitoring (4.1 versus 3.5, p < 0.001). The FDI emerged as an acceptable and implementable intervention. Future studies need to investigate effects of the FDI on the child's eating behaviors, self-regulation of energy intake, and anthropometrics.

Energy Contribution of Beverages in US Children by Age, Weight, and Consumer Status.

BACKGROUND: Messaging to reduce unhealthy beverage intake is often targeted to overweight and obese children; however, there is little evidence to show that healthy weight children have healthier beverage intake patterns. Further, data on consumers only may further elucidate beverage intake patterns. PURPOSE: The aim of this study was to update the current body of literature describing beverage intake in children by weight category, with the addition of consumer-only data. METHODS: Day one 24-hour recalls from the National Health and Nutrition Examination Survey 2005-2010 were analyzed to assess beverage intake of children 2-18 years old and differences by weight category. Beverages were coded as water, milk, 100% juice, coffee/tea, fruit drinks, soda, or low-calorie/diet drinks. RESULTS: On average, 18.7% of total daily calories for 2- to 18-year-old children came from beverages; 60% of total daily calories from added sugar came from beverages. Mean calories from beverages were 359, 358, and 386 kcal for normal weight, overweight, and obese children, respectively. Across all weight categories, there were clinically significant differences between overall means and means for consumers only. There were overlapping confidence intervals for intake of calories from soda and fruit drinks consumed by 2- to 5-year-olds and 12- to 18-year-olds, suggesting nonsignificant differences in intake across weight categories for these age groups. CONCLUSIONS: Messaging around beverage intake may be beneficial for children of all weights, particularly for those known to consume sugar-sweetened beverages. The per-consumer estimates may represent a better measure of intakes in future examinations of 24-hour recall data.

Rationale and design of the Feeding Dynamic Intervention (FDI) study for self-regulation of energy intake in preschoolers.

In 2011, the Institute of Medicine Early Childhood Prevention Policies Report identified feeding dynamics as an important focus area for childhood obesity prevention and treatment. Feeding dynamics includes two central components: (1) caregiver feeding practices (i.e., determining how, when, where, and what they feed their children) and (2) child eating behaviors (i.e., determining how much and what to eat from what food caregivers have provided). Although there has been great interest in overweight and obesity prevention and treatment in young children, they have not focused comprehensively on feeding dynamics. Interventions on feeding dynamics that reduce caregivers' excessive controlling and restrictive feeding practices and encourage the development of children's self-regulation of energy intake may hold promise for tackling childhood obesity especially in the young child but currently lack an evidence base. This manuscript describes the rationale and design for a randomized controlled trial designed to compare a group of mothers and their 3-to 5-year old children who received an intervention focused primarily on feeding dynamics called the Feeding Dynamic Intervention (FDI) with a Wait-list Control Group (WLC). The primary aim of the study will be to investigate the efficacy of the FDI for decreasing Eating in the Absence of Hunger (EAH) and improving energy compensation (COMPX). The secondary aim will be to examine the effect of the FDI in comparison to the WLC on maternal self-reported feeding practices and child satiety responsiveness.

A comparison of beverage intakes in US children based on WIC participation and eligibility.

OBJECTIVE: To compare beverage intakes for 2- to 4-year-olds based on Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation. METHODS: Data from National Health and Nutrition Examination Survey, 2005-2010 were analyzed to assess beverage intakes for 2- to 4-year-olds. Children were classified as WIC participants, low-income nonparticipants, and higher-income nonparticipants. All beverages were manually coded into 6 categories: water, milk, 100% juice, fruit drinks, soda, and low-calorie/diet drinks. Grams, calories, and percent consumers of each beverage were compared across groups. RESULTS: Special Supplemental Nutrition Program for Women, Infants, and Children participants had the highest 100% juice consumption (P = .001) and their milk consumption was similar to higher-income children. Higher-income nonparticipants drank significantly less fruit drink (P < .001) and soda (P = .001) than both the WIC participants and low-income nonparticipants. CONCLUSIONS AND IMPLICATIONS: Participation in WIC was related to higher intakes of the beverages provided in food packages for 2- to 4-year-olds. Intakes of fruit juice and sugar-sweetened beverages should be addressed during the WIC nutrition education counseling sessions.

Lifestyle behaviors of obese children following parental weight loss surgery.

BACKGROUND: Following weight loss surgery (WLS), patients are expected to make diet and lifestyle changes which may lead to children mimicking the changing behaviors of their parents. The purpose of the study was to identify the differences in diet and lifestyle behaviors between obese children with and without a parent who received WLS. METHODS: Medical records of 45 children whose parents had undergone WLS and 90 age- and gender-matched control children were reviewed from a weight loss program in a large Midwest children's hospital. Differences in dietary choices and behaviors, perceived barriers, and sedentary behaviors were examined between both groups. RESULTS: The mean age for the sample was 12.8 years. Children in the parental weight loss surgery (PWLS) group were more likely to eat two or more helpings of food at each sitting (p = 0.02) and less likely to play outdoors for more than an hour each day (p = 0.01). Compared to the control group, the PWLS group more frequently reported eating fast food on most days (45.2 vs. 27.0 %), soda consumption several times a week (48.6 vs. 29.4 %), and no vegetable intake (9.5 vs. 1.1 %). The top three barriers to exercise for both groups were lack of self-discipline, lack of interest, and lack of energy. CONCLUSIONS: Obese children who live with a parent that had undergone WLS reported several unhealthy lifestyle behaviors, in some cases worse than the children who live with parents who had not had WLS. Being cognizant of these findings will help obesity providers focus their counseling and expectations appropriately.