Self-reported health parameters compared with clinician measurements: methods in practice-based research.

CONTEXT: Self-reported health data are used by health insurance companies to assess risk. Most studies show underreporting compared with clinical measurements. OBJECTIVE: To compare self-reported height, weight, blood pressure, waist circumference, and dietary intake with registered dietitian's (RD's) measures of the same parameters. DESIGN: This is a secondary analysis of data collected in a larger study on the benefits of Medical Nutrition Therapy from an RD for overweight and obese patients when provided free of charge through an insurance benefit. SETTING: Participants completed a health risk assessment survey at home, from which the self-reported measures were extracted. The clinical measurements were taken by an RD in the office during a visit for Medical Nutrition Therapy. PARTICIPANTS: Participants were 81.4% female, with a mean body mass index of 35.0. All were insured and had a least 1 visit with an RD. MAIN OUTCOME MEASURE(S): Main outcomes were correlation between self-reported and RD-measured height, weight, body mass index, blood pressure, and waist circumference. Blood pressure was categorized as normal or high and the κ statistic was used to examine category agreement between the 2 measures. Servings of food groups were compared between the 2 measures by examining cumulative percent within 0, 1, or 2 servings of the RD-measured value. RESULTS: The 2 measures of height and weight were highly correlated (0.974 and 0.986, respectively). Blood pressure was more weakly correlated and when categorized had low κ scores, as did servings of food groups. CONCLUSIONS: Height and weight were more closely correlated than in previous studies. In an insured population enrolled in a weight management program, self-reported measures may be accurate for determining program impact. Blood pressure may be better collected categorically than continuously. The necessity of food intake assessment on a risk assessment should be reconsidered.

The incremental value of medical nutrition therapy in weight management.

OBJECTIVE: To evaluate the incremental cost of and health benefits attributable to medical nutrition therapy (MNT) for managed care members participating in an obesity-related health management program. DESIGN: Retrospective case-control. METHODOLOGY: Overweight or obese adult managed care members who utilized the MNT benefit (n = 291) were matched, using propensity score matching, with similar individuals (n = 1,104) who did not utilize the MNT benefit. Health outcomes data on weight, body mass index (BMI), waist circumference, and physical exercise were collected via surveys administered at baseline and approximately 2 years later. PRINCIPAL FINDINGS: Both groups experienced statistically significant reductions in weight, BMI, and waist circumference and increases in exercise frequency. Compared with matched controls, individuals who received MNT were about twice as likely to achieve a clinically significant reduction in weight, with an adjusted odds ratio of 2.2 (95% confidence interval, -1.7-2.9; P < .001). They also experienced greater average reductions in weight (3.1 vs. 1.4 kg; beta = -1.75; t[1314] = -2.21; P = .028) and were more likely to exercise more frequently after participating in the program (F[1,1358] = 4.07, P = .044). There was no difference between the groups in waist circumference. The MNT benefit was used by 5% of eligible members and cost $0.03 per member per month. CONCLUSION: MNT is a valuable adjunct to health management programs that can be implemented for a relatively low cost. MNT warrants serious consideration as a standard inclusion in health benefit plans.

Prediction of BMI change in young children with the family nutrition and physical activity (FNPA) screening tool.

BACKGROUND: Youth obesity prevention practices would be enhanced if modifiable risk factors can be identified before children become overweight. PURPOSE: This study evaluated the predictive validity of the Family Nutrition and Physical Activity (FNPA) screening tool, a behaviorally based screening tool designed to assess family environments and behaviors that may predispose youth to becoming overweight. METHODS: Parents from a large urban school district completed the FNPA screening when children were in first grade. One-year change in measured body mass index (BMI) was used as the primary outcome, and this was computed using the relative change in distance from the BMI value at the 50th percentile. Descriptive, correlation, and mixed modeling analyses were used for survey validation. RESULTS: Over half of the participants exhibited an increase in BMI percentile over the 1-year follow-up with an average change of 0.51 +/- 11.5% which is indicative of trends to overweight. Although baseline BMI predicted BMI at follow-up, the FNPA total score explained unique variance in child BMI at follow-up after accounting for baseline BMI, parent BMI, and other demographic variables (p = 0.049). CONCLUSIONS: This study demonstrates the potential validity of a simple, easy-to-use screening tool for identifying children that may be at risk for becoming overweight.

Registered dietitians' coding practices and patterns of code use.

Coding, coverage, and reimbursement are vital to the clinical segment of our profession. The objective of this study was to assess understanding and use of the medical nutrition therapy (MNT) procedure codes. Its design was a targeted, cross-sectional, Internet survey. Participants were registered dietitians (RDs) preselected based on Medicare Part B provider status, randomly selected RDs from the American Dietetic Association database based on clinical practice designation, and self-selected RDs. Parameters assessed were knowledge and use of existing MNT and/or alternative procedure codes, barriers to code use/compensation, need for additional codes for existing/emerging services, and practice demographics. Results suggest that MNT is being reimbursed for a variety of diseases and conditions. Many RDs working in clinic settings are undereducated about code use of any kind, reporting that code selection frequently is determined not by the RD providing the service, but by "someone else." Self-employed RDs are less likely to rely on others to administrate paperwork required for reimbursement, including selection of procedure codes for billable nutrition services. Self-employed RDs are more likely to be reimbursed by private or commercial payers and RDs working in clinic settings are more likely to be reimbursed by Medicare; however, the proportion of Medicare providers in both groups is high. RDs must be knowledgeable and accountable for both the business and clinical side of their nutrition practices; using correct codes and following payers' claims processing policies and procedures. This survey and analysis is a first step in understanding the complex web of relationships between clinical practice, MNT code use, and reimbursement.

Key Findings and Implications of a Recent Systematic Review of the Potential Adverse Effects of Caffeine Consumption in Healthy Adults, Pregnant Women, Adolescents, and Children.

In 2016⁻2017, we conducted and published a systematic review on caffeine safety that set out to determine whether conclusions that were presented in the heavily cited Health Canada assessment, remain supported by more recent data. To that end, we reviewed data from 380 studies published between June 2001 and June 2015, which were identified from an initial batch of over 5000 articles through a stringent search and evaluation process. In the current paper, we use plain language to summarize our process and findings, with the intent of sharing additional context for broader reach to the general public. We addressed whether caffeine doses previously determined not to be associated with adverse effects by Health Canada (400 mg/day for healthy adults, 300 mg/day for pregnant women, 2.5 mg/kg body weight/day for adolescents and children, and 10 g/day for acute effects) remain appropriate for five outcome areas (acute toxicity, cardiovascular toxicity, bone & calcium effects, behavior, and development and reproduction) in healthy adults, pregnant women, adolescents, and children. We used a weight-of-evidence approach to draw conclusions for each of the five outcomes, as well as more specific endpoints within those outcomes, which considered study quality, consistency, level of adversity, and magnitude of response. In general, updated evidence confirms the levels of intake that were put forth by Health Canada in 2003 as not being associated with any adverse health effects, and our results support a shift in caffeine research from healthy to sensitive populations.

Scientific rigor and credibility in the nutrition research landscape.

Scientific progress depends on the quality and credibility of research methods. As discourse on rigor, transparency, and reproducibility joins the cacophony of nutrition information and misinformation in mass media, buttressing the real and perceived reliability of nutrition science is more important than ever. This broad topic was the focus of a 2016 plenary session, "Scientific Rigor and Competing Interests in the Nutrition Research Landscape." This article summarizes and expands on this session in an effort to increase understanding and dialogue with regard to factors that limit the real and perceived reliability of nutrition science and steps that can be taken to mitigate those factors. The end goal is to both earn and merit greater trust in nutrition science by both the scientific community and the general public. The authors offer suggestions in each of the domains of education and training, communications, research conduct, and procedures and policies to help achieve this goal. The authors emphasize the need for adequate funding to support these efforts toward greater rigor and transparency, which will be resource demanding and may require either increased research funding or the recognition that a greater proportion of research funding may need to be allocated to these tasks.

Office-based motivational interviewing to prevent childhood obesity: a feasibility study.

OBJECTIVE: To determine whether pediatricians and dietitians can implement an office-based obesity prevention program using motivational interviewing as the primary intervention. DESIGN: Nonrandomized clinical trial. Fifteen pediatricians belonging to Pediatric Research in Office Settings, a national practice-based research network, and 5 registered dietitians were assigned to 1 of 3 groups: (1) control; (2) minimal intervention (pediatrician only); or (3) intensive intervention (pediatrician and registered dietitian). SETTING: Primary care pediatric offices. PARTICIPANTS: Ninety-one children presenting for well-child care visits met eligibility criteria of being aged 3 to 7 years and having a body mass index (calculated as the weight in kilograms divided by the height in meters squared) at the 85th percentile or greater but lower than the 95th percentile for the age or having a normal weight and a parent with a body mass index of 30 or greater. INTERVENTIONS: Pediatricians and registered dietitians in the intervention groups received motivational interviewing training. Parents of children in the minimal intervention group received 1 motivational interviewing session from the physician, and parents of children in the intensive intervention group received 2 motivational interviewing sessions each from the pediatrician and the registered dietitian. MAIN OUTCOME MEASURE: Change in the body mass index-for-age percentile. RESULTS: At 6 months' follow-up, there was a decrease of 0.6, 1.9, and 2.6 body mass index percentiles in the control, minimal, and intensive groups, respectively. The differences in body mass index percentile change between the 3 groups were nonsignificant (P=.85). The patient dropout rates were 2 (10%), 13 (32%), and 15 (50%) for the control, minimal, and intensive groups, respectively. Fifteen (94%) of the parents reported that the intervention helped them think about changing their family's eating habits. CONCLUSIONS: Motivational interviewing by pediatricians and dietitians is a promising office-based strategy for preventing childhood obesity. However, additional studies are needed to demonstrate the efficacy of this intervention in practice settings.

Insights From the Diabetes in India Nutrition Guidelines Study: Adopting Innovations Using a Knowledge Transfer Model.

This 12-month prospective randomized cluster trial of 20 dietitians in India compared usual care (UC) and evidence-based nutrition practice guideline (EBNPG) care for patients with type 2 diabetes mellitus. Baseline, 6-month, and 12-month data from 238 patients were analyzed. EBNPG implementation was evaluated using the Ottawa Model for Knowledge Transfer. EBNPG and UC groups achieved significant hemoglobin A1C improvements. EBNPG-treated participants were significantly more likely to meet low-density lipoprotein, high-density lipoprotein, and triglyceride goals at 6 or 12 months. Dietitian dropout, implementation barriers, and undetermined EBNPG intervention fidelity are limitations. Future research should assess barriers/supports and degree of EBNPG use.

Implementing Evidence-Based Nutrition Practice Guidelines for Type 2 Diabetes Mellitus in Lebanon.

Lebanon is a Middle Eastern country experiencing a surge in the prevalence of type 2 diabetes mellitus among adults. This pilot study evaluated the feasibility and outcomes of implementing the Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guidelines (EBNPGs) as part of medical care for patients newly diagnosed with type 2 diabetes mellitus. Seventy-five patients were recruited from 3 Lebanese hospitals, received nutrition care according to EBNPGs, and were followed up for 12 months. Patients achieved significant improvement in clinical outcomes between baseline and 3, 6, and 12 months. Further research is recommended to confirm the benefits of using EBNPGs.

Systematic review of the potential adverse effects of caffeine consumption in healthy adults, pregnant women, adolescents, and children.

To date, one of the most heavily cited assessments of caffeine safety in the peer-reviewed literature is that issued by Health Canada (Nawrot et al., 2003). Since then, >10,000 papers have been published related to caffeine, including hundreds of reviews on specific human health effects; however, to date, none have compared the wide range of topics evaluated by Nawrot et al. (2003). Thus, as an update to this foundational publication, we conducted a systematic review of data on potential adverse effects of caffeine published from 2001 to June 2015. Subject matter experts and research team participants developed five PECO (population, exposure, comparator, and outcome) questions to address five types of outcomes (acute toxicity, cardiovascular toxicity, bone and calcium effects, behavior, and development and reproduction) in four healthy populations (adults, pregnant women, adolescents, and children) relative to caffeine intake doses determined not to be associated with adverse effects by Health Canada (comparators: 400 mg/day for adults [10 g for lethality], 300 mg/day for pregnant women, and 2.5 mg/kg/day for children and adolescents). The a priori search strategy identified >5000 articles that were screened, with 381 meeting inclusion/exclusion criteria for the five outcomes (pharmacokinetics was addressed contextually, adding 46 more studies). Data were extracted by the research team and rated for risk of bias and indirectness (internal and external validity). Selected no- and low-effect intakes were assessed relative to the population-specific comparator. Conclusions were drawn for the body of evidence for each outcome, as well as endpoints within an outcome, using a weight of evidence approach. When the total body of evidence was evaluated and when study quality, consistency, level of adversity, and magnitude of response were considered, the evidence generally supports that consumption of up to 400 mg caffeine/day in healthy adults is not associated with overt, adverse cardiovascular effects, behavioral effects, reproductive and developmental effects, acute effects, or bone status. Evidence also supports consumption of up to 300 mg caffeine/day in healthy pregnant women as an intake that is generally not associated with adverse reproductive and developmental effects. Limited data were identified for child and adolescent populations; the available evidence suggests that 2.5 mg caffeine/kg body weight/day remains an appropriate recommendation. The results of this systematic review support a shift in caffeine research to focus on characterizing effects in sensitive populations and establishing better quantitative characterization of interindividual variability (e.g., epigenetic trends), subpopulations (e.g., unhealthy populations, individuals with preexisting conditions), conditions (e.g., coexposures), and outcomes (e.g., exacerbation of risk-taking behavior) that could render individuals to be at greater risk relative to healthy adults and healthy pregnant women. This review, being one of the first to apply systematic review methodologies to toxicological assessments, also highlights the need for refined guidance and frameworks unique to the conduct of systematic review in this field.

American Dietetic Association's Standardized Nutrition Language: Project logic model and current status.

Standardized terminology and digital sources of evidence are essential for evidence-based practice. Dieticians desire concise and consistent documentation of nutrition diagnoses, interventions and outcomes that will be fit for electronic health records. Building on more than 5 years of work to generate the Nutrition Care Process and Model as a road map to quality nutrition care and outcomes, and recognizing existing standardized languages serving other health professions, a task force of the American Dietetic Association (ADA) has begun to develop and disseminate standardized nutrition language. This paper will describe the group's working logic model, the Nutrition Care Process, and the current status of the nutrition language with comparisons to nursing process and terminology.

Limited Agreement on Etiologies and Signs/Symptoms among Registered Dietitian Nutritionists in Clinical Practice.

BACKGROUND: Clinical studies that establish the reliability and validity of nutrition diagnoses are absent from the literature. OBJECTIVE: The purpose of this study was to assess the reliability and validity of the diagnoses, etiologies, and signs/symptoms within the clinical practice of registered dietitian nutritionists (RDNs). DESIGN: Nine pairs of RDNs randomly selected adult patients to diagnose. The two RDNs in each pair independently assessed nutritional data from the same patient. Each RDN chose one nutrition diagnosis and rated the presence or absence of the etiologies and signs/symptoms. Clinical reliability was determined with percentage of agreement for the diagnoses, and percentage agreement, kappa coefficient, and the proportions of positive agreement (p(pos)) and negative agreement (p(neg)) for the etiologies and signs/symptoms. Clinical validity was calculated according to a clinical diagnostic validity score for etiologies and signs/symptoms. RESULTS: These RDNs practiced either in an acute-care facility (n=10; 58.8%), ambulatory/outpatient facility (n=3; 17.6%), or both (n=4; 23.5%). Nutrition diagnoses were selected for 316 patients. Two raters selected the same diagnosis for 121 patients (38% agreement). Agreement was moderate (κ=0.54) for etiologies and at the lower end of substantial (κ=0.63) for signs/symptoms. For etiologies p(pos)=0.71 and p(neg)=0.78 and for signs/symptoms p(pos)=0.82 and p(neg)=0.79, indicating that the raters agreed on the presence of each as well as the absence. The overall clinical diagnostic validity score for etiologies was 0.33 and for signs/symptoms was 0.44, signifying they were not characteristic of the diagnoses. CONCLUSIONS: Although RDNs knew a nutrition problem was present, they were in poor agreement as to the most important diagnosis, etiologies, and signs/symptoms. The lack of agreement indicated inconsistencies in determining a primary diagnosis among these RDNs.

Energy Balance 4 Kids with Play: Results from a Two-Year Cluster-Randomized Trial.

BACKGROUND: Identifying sustainable approaches to improving the physical activity (PA) and nutrition environments in schools is an important public health goal. This study examined the impact of Energy Balance for Kids with Play (EB4K with Play), a school-based intervention developed by the Academy of Nutrition and Dietetics Foundation and Playworks, on students' PA, dietary habits and knowledge, and weight status over 2 years. METHODS: This cluster-randomized, controlled trial took place in four intervention and two control schools over 2 years (n=879; third- to fifth-grade students). PA (fourth and fifth grades only), dietary knowledge and behaviors, school policies, and BMI z-score were assessed at baseline (fall 2011), midpoint (spring 2012), and endpoint (fall 2012 for accelerometers; spring 2013 for all other outcomes). RESULTS: At endpoint, there were no group differences in change in PA or dietary behaviors, although BMI z-score decreased overall by -0.07 (p=0.05). Students' dietary knowledge significantly increased, as did the amount of vegetables schools served. Post-hoc analyses stratified by grade revealed that, relative to control students, fourth-grade intervention students reduced school-day sedentary time by 15 minutes (p=0.023) and third-grade intervention students reduced BMI z-score by -0.2 (0.05; p<0.05). There were no significant differences for older students. CONCLUSIONS: EB4K with Play, which leverages the existing infrastructure of two national programs, increases children's dietary knowledge and may improve weight status and decrease sedentary behaviors among younger children. Future iterations should examine programming specific for different age groups.

Energy Balance 4 Kids with Play: Results from a Two-Year Cluster-Randomized Trial.

BACKGROUND: Identifying sustainable approaches to improving the physical activity (PA) and nutrition environments in schools is an important public health goal. This study examined the impact of Energy Balance for Kids with Play (EB4K with Play), a school-based intervention developed by the Academy of Nutrition and Dietetics Foundation and Playworks, on students' PA, dietary habits and knowledge, and weight status over 2 years. METHODS: This cluster-randomized, controlled trial took place in four intervention and two control schools over 2 years (n=879; third- to fifth-grade students). PA (fourth and fifth grades only), dietary knowledge and behaviors, school policies, and BMI z-score were assessed at baseline (fall 2011), midpoint (spring 2012), and endpoint (fall 2012 for accelerometers; spring 2013 for all other outcomes). RESULTS: At endpoint, there were no group differences in change in PA or dietary behaviors, although BMI z-score decreased overall by -0.07 (p=0.05). Students' dietary knowledge significantly increased, as did the amount of vegetables schools served. Post-hoc analyses stratified by grade revealed that, relative to control students, fourth-grade intervention students reduced school-day sedentary time by 15 minutes (p=0.023) and third-grade intervention students reduced BMI z-score by -0.2 (0.05; p<0.05). There were no signicifant differences for older students. CONCLUSIONS: EB4K with Play, which leverages the existing infrastructure of two national programs, increases children's dietary knowledge and may improve weight status and decrease sedentary behaviors among younger children. Future iterations should examine programming specific for different age groups.

Motivational interviewing and dietary counseling for obesity in primary care: an RCT.

BACKGROUND AND OBJECTIVE: Few studies have tested the impact of motivational interviewing (MI) delivered by primary care providers on pediatric obesity. This study tested the efficacy of MI delivered by providers and registered dietitians (RDs) to parents of overweight children aged 2 through 8. METHODS: Forty-two practices from the Pediatric Research in Office Settings Network of the American Academy of Pediatrics were randomly assigned to 1 of 3 groups. Group 1 (usual care) measured BMI percentile at baseline and 1- and 2-year follow-up. Group 2 (provider only) delivered 4 MI counseling sessions to parents of the index child over 2 years. Group 3 (provider + RD) delivered 4 provider MI sessions plus 6 MI sessions from a RD. The primary outcome was child BMI percentile at 2-year follow up. RESULTS: At 2-year follow-up, the adjusted BMI percentile was 90.3, 88.1, and 87.1 for groups 1, 2, and 3, respectively. The group 3 mean was significantly (P = .02) lower than group 1. Mean changes from baseline in BMI percentile were 1.8, 3.8, and 4.9 across groups 1, 2, and 3. CONCLUSIONS: MI delivered by providers and RDs (group 3) resulted in statistically significant reductions in BMI percentile. Research is needed to determine the clinical significance and persistence of the BMI effects observed. How the intervention can be brought to scale (in particular, how to train physicians to use MI effectively and how best to train RDs and integrate them into primary care settings) also merits future research.

Systems for evaluating nutrition research for nutrition care guidelines: do they apply to population dietary guidelines?

Evidence-based medicine has become accepted as the preferred way to develop clinical practice guidelines for nutrition care. The distinction between nutrition care (ie, medical nutrition therapy) and population dietary guidelines is becoming increasingly blurred. The evidence analysis systems used to develop Medical Nutrition Therapy Guides for Practice, as well as other medical care guidelines, are reviewed. The identification of various methods that evaluate individual research reports and various systems that specify the strength of the evidence supporting a recommendation/conclusion statement are included within the article. The potential application of these systems for development of national dietary guidelines is introduced.