Weight Management Matters Volume 19

Weight Weight Management Management Matters a dietetic practice group of the

CPEU ARTICLE Weight Stigma: Challenges and Opportunities IN THIS ISSUE

for Progress in Weight Management during CPEU...... 1 Weight Stigma: Challenges and COVID-19 and Beyond Opporunities for Progress in By: Erica M. Howes, MS, MPH, RDN Weight Management during and Valisa E. Hedrick, PhD, RDN COVID-19 and Beyond Foundation...... 8 Registered Dietitian Nutritionists (RDNs) have a professional duty WM DPG’s Investments in Our to practice in a respectful manner that protects the wellbeing Academy Foundation Builds of the patients and clients they serve. An issue of recent interest Critical Research Evidence among RDNs and other health professionals working in weight management is weight stigma and its potential negative impacts. Awards...... 10 On both the individual and population level, weight stigma can act WM DPG Award Recipients as a barrier to health through social, psychological, and physical Research...... 11 Erica M. Howes mechanisms.1 As the coronavirus disease 2019 (COVID-19) has Incorporating Results of Genetic Testing MS, MPH, RDN spread, weight stigma has become an increased concern due into Weight Management Nutrition to its potential to cause additional harm to at-risk groups with overweight and obesity. As part of commitment to the Code of Ethics for the Nutrition and Dietetics Profession, Pediatrics...... 14 Principles 1 and 4, which encourage practicing in a caring and respectful manner When Worlds Collide: The Relationship of and promoting fairness and objectivity,2 dietetic professionals have a responsibility to Feeding Disorders and Obesity in Children understand weight stigma and actively work toward its reduction in professional settings. Physical Exercise...... 18 Defining Weight Stigma Physical Activity and Exercise Stigma, as defined by Goffman, relates to the possession of an attribute that sets a Considerations for the Beginning Exerciser

person apart from societal norms or expectations, and the person possessing that Bariatric...... 21 3 attribute is seen as devalued and discredited by society. In regard to weight, falling Body Composition Assessment in outside of societal expectations for body shape or size can result in weight stigma. Bariatric Surgery Weight stigma most commonly relates to the stigma of overweight or obesity, though it should be noted that weight stigma can also be experienced by people who are Counseling ...... 24 classified as underweight.4 People with overweight and obesity are often assumed to Resolutions the Right Way

possess negative traits due to their weight, such as laziness, lack of willpower, or less Letter from the Chair...... 26 competence in employment settings.5 Letter from the Editor...... 26 (Continued on page 2)

A Quarterly Publication for Weight Management Leaders Volume 19. No. 2 Much of the research on the origins of weight stigma points to the role of attribution in shaping beliefs about overweight and obesity. Attribution theory in relation to weight status suggests that negative beliefs about people with obesity exist due to beliefs that their weight is determined by controllable factors. People with obesity are seen as directly causing their Continuing obesity through personal actions, which falls in contrast with the values of self-determination and willpower prevalent in American culture.6 In a Professional clinical setting, this can manifest as health care providers blaming people with obesity for their condition, and subsequently providing little support for “simple” lifestyle changes.7 Individuals often believe that weight stigma EducationSection is justified because of the belief that weight is entirely under personal Shelly Summar, MSEd, RD, LD control, thus being at a higher weight reflects a personal failure. is the CPEU Section Editor Experiences of Weight Stigma People with obesity may have many experiences with weight stigma. Weight stigmatizing language has become Children with overweight or obesity may experience bullying or teasing. commonplace and it is important for nutrition One study completed among 2,793 middle and high school students healthcare professionals to understand the found that 35.3% of the students surveyed had experienced weight- damaging effects of weight stigma and how related teasing. For students with obesity, the prevalence of weight- to address it, both with patients and the related teasing was significantly higher, at 59.7% for girls and 58.2% public. These experienced authors will define for boys.8 Among adults with overweight and obesity, experiences weight stigma and its negative health effects and will describe of weight stigma can come in the form of a comment from another approaches that can be applied to practice at the individual or person about their weight, being treated differently because of their population level. weight, or feeling undervalued by society as a whole.9 Participants in a qualitative study about experiences of weight stigma reported that the most common sources of stigma were friends or family members.10 In addition to stigmatizing verbal comments from others, stigma can also be experienced through the physical environment. People can experience esteem, and body image dissatisfaction.15 There is also evidence that weight stigma if furniture, seat belts, or medical equipment are not weight stigma can interfere with weight loss efforts. One study used accommodating to a variety of body sizes. Mass media is also a potential ecological momentary assessment to facilitate real-time investigation source of stigma, through portrayals of people with overweight and of the effects of weight stigma on behavioral intentions for dietary obesity that perpetuate negative stereotypes.5,10 behaviors and physical activity and found that experiencing weight stigma led to lower positive affect and less motivation to perform health- Of particular importance to RDNs is the weight stigma experienced promoting behaviors such as healthy eating in the moment the stigma by people with overweight and obesity in the health care setting, as was experienced.16 In contexts in which stigma becomes a chronic life the physical environment can be itself stigmatizing to people with experience, one study proposed a cyclic obesity/weight-based stigma overweight and obesity. Patients may feel alienated by equipment that is model for how weight stigma can lead to further weight gain among not able to accommodate their needs; for example, chairs, blood pressure people with obesity via physiological stress pathways and changes to cuffs, gowns, and scales that are not suitable for a wide range of body eating behaviors.17 sizes may reinforce the belief that health care is not intended for larger bodies.11 Interactions with medical providers may also be stigmatizing if Patients who experience repeated weight stigma in health care settings assumptions are made about a patient’s health or behaviors based solely may be reluctant to seek future care for health issues. A recent review by on weight. For example, a provider may allocate time differently or spend Alberga et al found that many patients with obesity experienced weight less time with patients with obesity12 due to beliefs about the patients’ stigma in health care, and as a result delayed or avoided preventive motivation to change health behaviors.13 Additionally, weight stigma screening or other routine health care services.18 These patients expressed can lead to a physician attributing most of the patient’s health concerns concerns about previous stigmatizing experiences, feelings of shame to their weight, rather than ordering diagnostic testing or providing around their body shape or size, and apprehension about being weighed treatments other than weight loss.14 The net effect of weight stigma can at medical appointments.18 This consequence of weight stigma is of be that patients with obesity receive poorer quality care than patients particular concern with the current COVID-19 pandemic. who fall into the normal weight category.14 Weight Stigma and COVID-19 Consequences of Weight Stigma The Centers for Disease Control and Prevention (CDC) have identified Experiencing weight stigma has been shown to lead to negative obesity, characterized as a body mass index (BMI) ≥ 30, as a risk factor for psychological, physical, and behavioral consequences that can undermine developing severe illness from COVID-19.19 This designation was made health and wellbeing. Psychologically, weight stigma has been associated with the “strongest and most consistent evidence”, due to results from with depressive symptoms, anxiety, binge eating behaviors, low self- several cohort studies and one cross-sectional study.19 Early evidence

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2 Weight Management Matters Volume 19. No. 2 issued public health guidance, many became concerned about weight gain associated with more time at home. Some images and text shared on social media during this time were stigmatizing toward people at higher weights. For example, a trend in social media posts was the idea of the “quarantine-15” or the “COVID-19”, with the underlying sentiment being that weight gain, or experiencing changes in body shape or size, would be a negative side effect of the stay-at-home orders.26 As noted by Pearl, these posts were often accompanied by images that reinforce negative stereotypes about people with obesity.26 Strategies to Reduce Weight Stigma established a relationship between severe obesity (BMI ≥ 40) and Weight stigma, while prevalent during both the COVID-19 pandemic increased risk of complications from COVID-19, which resulted in an and at other times, can be minimized. At the individual level, health abundance of media coverage on the topic. As a result of this increased care providers such as RDNs can take several actions to help their attention on weight and COVID-19, weight stigma became an area of patients receive quality health care without weight stigma.1 RDNs can concern for those with obesity and practitioners who treat obesity. help to ensure that patients with obesity feel welcome in the physical Weight stigma is an important consideration for health care providers environments where care is provided. For example, they can ensure the who treat patients with obesity, particularly during the COVID-19 following are available: seating that can accommodate all body sizes; pandemic.20 One primary concern with COVID-19 is the importance of appropriately sized medical equipment; and scales in areas that allow 11 seeking treatment early, as the disease can lead to rapid decompensation for patient privacy. Providing training to clinical and non-clinical staff in vulnerable populations. People with obesity may be less likely to seek members on avoiding weight stigma can help staff learn how their treatment from a provider or hospital that has provided stigmatizing actions may be perceived by people with obesity and may help to create care in the past. People who get sick may choose to delay treatment as a a professional culture in a facility that supports respect for people of way to avoid further experiences of weight stigma. Additionally, with the various body sizes. Additionally, executives can make inclusivity a priority emphasis in the media on obesity as a risk factor for COVID-19, there is by implementing workplace policies around acceptable language and potential for public perception to shift blame to people with obesity for behavior when working with patients with obesity. contracting COVID-19 due to personal responsibility for their body size. In When providing nutrition counseling to patients with obesity, RDNs reality, there is evidence that COVID-19 has a disproportionate impact on should consider how their words may contribute to weight stigma. racial and ethnic minorities, who are also disproportionately affected by Different disciplines have different preferences on the language used to 21 obesity. Not all groups experience weight stigma in the same ways, thus describe people whose weight would classify them as having overweight intersectionality is an important consideration when thinking about the or obesity. In most medical literature, the words “overweight” and 22 potential consequences of weight stigma during the pandemic. People “obese” are used as clinical definitions of relative body size, defined by who have multiple stigmatized identities can become even less likely to having a BMI from 25 to <30 and ≥30, respectively. However, there has 21 seek potentially life-saving treatment for COVID-19. been a recent push from groups such as the Obesity Action Coalition to 27 Weight stigma also has the potential to result in lower quality care within use people-first language to describe people with obesity, especially 28 the acute care setting. Malnutrition remains a concern for COVID-19 following the classification of obesity as a disease in 2013. People- patients with obesity, and it is important for providers to advocate for first language, or using the phrase “person with obesity,” rather than the initiation of nutrition support for critically ill patients to prevent “obese person”, is lauded as one way to help reduce weight stigma in loss of muscle mass, which could in turn contribute to poorer disease communicating about obesity: in the media; in health care settings; 27 outcomes.23 Previous work in the critical care setting has indicated that and in scientific journals. People-first language has been shown to 29 patients with obesity are more likely to experience delays in initiation of be accepted terminology by individuals seeking bariatric surgery. 30 nutrition support, which may be related to weight stigma.24 Some have proposed the use of the phrase “higher weight” or “higher BMI”31 as a more neutral descriptor of body size, due to the societal and Media coverage of the pandemic and its effect on everyday life also has cultural implications of other terms and phrases,30 however, in health care the potential to lead to greater weight stigma. Some have argued that practice it is imperative to respect patient preferences, acknowledging weight stigma itself may be a major factor underlying the association that preferences may differ widely from person to person. Koball et al between BMI and risk of hospitalization secondary to COVID-19.25 It is noted that patient preferences for language used to discuss weight can important to consider the way in which this relationship is presented to be affected by internalized weight bias, or feeling that stereotypes about avoid blaming people with obesity for the potential medical outcomes of weight apply to them, thus their preferences for talking about weight COVID-19 and further contributing to the stigmatizing belief that people may still be inherently stigmatizing.32 with obesity are personally responsible for their weight due to individual health behaviors alone. RDNs may ask patients about their preferences for discussing weight at their initial visit as a way to build rapport and establish strong Social media has been another potential source of weight stigma during communication between patient and provider (Table 1). In a weight the pandemic. As people were urged to stay home due to government- management setting, weight may be the primary focus of nutrition

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3 Weight Management Matters Volume 19. No. 2 counseling, however setting up shared expectations for how it will be use that show people with obesity depicted in ways that avoid harmful discussed in sessions can help prevent patients from feeling stigmatized. stereotypes or objectification. Two such libraries that are available at Qualitative work indicates that patients sometimes feel stigmatized when no cost are the media library through the UConn Rudd Center for Food discussing weight,32 thus providing space to discuss more helpful forms of Policy and Obesity37 and the Obesity Action Coalition.38 RDNs can set dialogue around weight and health behavior change, particularly among an example by including images in health messages and professional those who have experienced past weight stigma, can promote better presentations that reflect diverse body sizes without association with outcomes in counseling. common stereotypes.

Patient differences should also be considered in counseling patients Finally, RDNs working with people who have obesity should take time for weight management. In keeping with attribution theory, weight to evaluate their own biases about people with obesity. One potential stigma can occur if a patient’s weight is attributed to his or her personal strategy is the use of the “Fat People-Thin People” Implicit Associations choices alone.6 It is crucial to acknowledge that the underlying causes of Test (IAT),39 which measures implicit bias related to weight. The free overweight and obesity can vary and are often related to other factors interactive version of the IAT available from Harvard at implicit.harvard. outside of a person’s control. The Obesity Society summarizes the potential edu uses silhouettes of both higher-weight and lower-weight people contributors to obesity in a graphic that can be helpful in conceptualizing and has the user pair them with positive and negative words, including the underlying causes of obesity.33 There is growing evidence suggesting words associated with stereotypes about people with obesity.40 If the that the pathogenesis of obesity is grounded in biological processes, user is better able to associate negative words with the higher-weight including perturbations of homeostatic energy balance.34 Setting silhouettes, the test indicates a greater degree of implicit bias toward reasonable nutrition goals that consider structural barriers can help build higher-weight people. It is unclear whether the process of completing patient confidence in making dietary changes, while also respecting their the IAT has utility in decreasing weight bias, though it may be a way to individual differences and ability to make change.35 begin a conversation among health care providers about weight bias. More work is needed to develop and evaluate effective interventions to For RDNs involved in health communication, action can be taken to decrease weight stigma in health care providers.41 avoid stigmatizing portrayals of individuals with obesity in public health messages.36 Several photo libraries are available for health professionals to

Table 1. Ways to initiate a conversation about weight in a nutrition counseling session.

“I’d like to take your weight now. Are you comfortable being weighed?”

“Is there any way I can make taking a weight measurement more comfortable for you? For example, you may prefer to be weighed in a private room or without other staff present.” “Is there any way I can make taking a weight measurement more comfortable for you?”

“Do you want to discuss changes in your weight each time we meet?”

“What type of language is most supportive to you when talking about your weight?”

“Are there any things I should avoid discussing related to your weight during our sessions?”

*Adopted from the Rudd Center, “Creating a Comfortable and Welcoming Office Environment for Patients with High Body Weight.” Accessible at http://uconnruddcenter.org

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4 Weight Management Matters Volume 19. No. 2 There are resources available for RDNs seeking to learn more about Available resources to identify and address weight bias weight stigma in health care and in society. Several organizations have CPEU Process developed materials that can be used for training health care providers or Log in to www.wmdpg.org and then link to the CPEU quiz here. students on the nature of weight stigma and ways to prevent it in practice (Table 2). Take the quiz. Quiz results are reviewed at the end of each month. If you score 80% or higher, your CPEU documentation Conclusions will be emailed to you. Weight stigma continues to be a salient issue in discussions of health and health care, especially during the COVID-19 pandemic. It is important for weight management RDNs to understand how weight stigma can be experienced by the patients they serve, and seek to provide respectful, stigma-informed care to people with obesity. Weight management RDNs have an opportunity to take an active role in helping to decrease the weight stigma experienced by the patients they serve through individual health care, health care policy, and through the language they use to discuss obesity.

Table 2. Weight stigma resources aimed at health care providers.

Resources Organization Resource Description How to Access

Handout: Obesity Action Guide for healthcare professionals Available at Coalition describing weight bias, its effects on www.obesityaction.org Weight Bias in Healthcare patients, and ways to decrease weight Guide bias in practice.

Presentation: Rudd Center for Food Educational presentation aimed at health Available at Policy and Obesity at care providers that provides an overview of http://www.uconnruddcenter. Weight Bias in Clinical UConn weight bias and stigmatization and offers org/weight-bias-stigma-health- Care: Improving Health solutions for improving communication care-providers Care for Patients with and health care quality. Overweight and Obesity

Handout: Rudd Center for Food Handout and checklist for preparing a Available at Policy and Obesity at medical office to see patients with obesity http://www.uconnruddcenter. Creating a Comfortable UConn while reducing weight stigma. Includes org/weight-bias-stigma-health- and Welcoming Office suggestions for equipment to include in a care-providers Environment for Patients stigma-informed office.

Erica Howes is a doctoral student at Virginia Tech in the department of Human Nutrition, Foods, and Exercise. She holds an MS in Nutrition and an MPH with a concentration in Health Promotion and Health Behavior, both from Oregon State University. She is a registered dietitian nutritionist with clinical experience counseling patients with eating disorders in structured treatment settings and at the outpatient level. She is an active member of the Academy of Nutrition and Dietetics and her state and regional dietetics groups. Her research interests include weight stigma, dietary intake assessment methodology, and eating disorders and disordered eating.

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5 Weight Management Matters Volume 19. No. 2 References 1. Rubino F, Puhl RM, Cummings DE, et al. Joint international consensus 15. Wu Y-K, Berry DC. Impact of weight stigma on physiological and statement for ending stigma of obesity. Nat Med. March 2020:1-13. psychological health outcomes for overweight and obese adults: doi:10.1038/s41591-020-0803-x A systematic review. J Adv Nurs. 2018;74(5):1030-1042. doi:10.1111/jan.13511 2. Academy of Nutrition and Dietetics, Commission on Dietetic Registra- tion. Code of Ethics for the Nutrition and Dietetics Profession. June 16. Vartanian LR, Pinkus RT, Smyth JM. Experiences of weight stigma 2018. https://www.eatrightpro.org/-/media/eatrightpro-files/career/ in everyday life: Implications for health motivation. Stigma Health. code-of-ethics/coeforthenutritionanddieteticsprofession.pdf?la=en& 20161219;3(2):85. doi:10.1037/sah0000077 hash=0C9D1622C51782F12A0D6004A28CDAC0CE99A032. 17. Tomiyama AJ. Weight stigma is stressful. A review of evidence for the Accessed December 3, 2018. Cyclic Obesity/Weight-Based Stigma model. Appetite. 2014;82:8-15. 3. Goffman E. Stigma: Notes on the Management of Spoiled Identity. doi:10.1016/j.appet.2014.06.108 Simon and Schuster; 2009. 18. Alberga AS, Edache IY, Forhan M, Russell-Mayhew S. Weight bias and 4. Tantleff-Dunn S, Hayes S, Braun CP. How did you get so thin? The ef- health care utilization: a scoping review. Prim Health Care Res Dev. fect of attribution on perceptions of underweight females. Eat Weight 2019;20:e116. doi:10.1017/S1463423619000227 Disord EWD. 2009;14(1):38-44. doi:10.1007/BF03327793 19. CDC. Evidence used to update the list of underlying medical condi- 5. Puhl RM, Brownell KD. Psychosocial origins of obesity stigma: toward tions that increase a person’s risk of severe illness from COVID-19. changing a powerful and pervasive bias. Obes Rev. 2003;4(4):213-227. Centers for Disease Control and Prevention. https://www.cdc.gov/ doi:10.1046/j.1467-789X.2003.00122.x coronavirus/2019-ncov/need-extra-precautions/evidence-table.html. Published February 11, 2020. Accessed August 17, 2020. 6. Crandall CS, Schiffhauer KL. Anti-Fat Prejudice: Beliefs, Val- ues, and American Culture. Obes Res. 1998;6(6):458-460. 20. Townsend MJ, Kyle TK, Stanford FC. commentary: COVID-19 and doi:10.1002/j.1550-8528.1998.tb00378.x Obesity: Exploring Biologic Vulnerabilities, Structural Disparities, and Weight Stigma. Metabolism. 2020;110:154316. 7. Rand K, Vallis M, Aston M, et al. “It is not the diet; it is the mental part doi:10.1016/j.metabol.2020.154316 we need help with.” A multilevel analysis of psychological, emotional, and social well-being in obesity. Int J Qual Stud Health Well-Being. 21. Johnson-Mann C, Hassan M, Johnson S. COVID-19 pandemic 2017;12(1). doi:10.1080/17482631.2017.1306421 highlights racial health inequities. Lancet Diabetes Endocrinol. 2020;8(8):663-664. doi:10.1016/S2213-8587(20)30225-4 8. Bucchianeri MM, Eisenberg ME, Neumark-Sztainer D. Weightism, Racism, Classism, and Sexism: Shared Forms of Harassment in 22. Himmelstein MS, Puhl RM, Quinn DM. Intersectionality: An Under- Adolescents. J Adolesc Health. 2013;53(1):47-53. doi:10.1016/j.jado- studied Framework for Addressing Weight Stigma. Am J Prev Med. health.2013.01.006 2017;53(4):421-431. doi:10.1016/j.amepre.2017.04.003 9. Cossrow NHF, Jeffery RW, McGuire MT. Understanding Weight Stig- 23. Thibault R, Seguin P, Tamion F, Pichard C, Singer P. Nutrition of the matization: A Focus Group Study. J Nutr Educ. 2001;33(4):208-214. COVID-19 patient in the intensive care unit (ICU): a practical guidance. doi:10.1016/S1499-4046(06)60033-X Crit Care. 2020;24(1):447. doi:10.1186/s13054-020-03159-z 10. Puhl RM, Moss-Racusin CA, Schwartz MB, Brownell KD. Weight stig- 24. Borel A-L, Schwebel C, Planquette B, et al. Initiation of nutritional matization and bias reduction: perspectives of overweight and obese support is delayed in critically ill obese patients: a multicenter cohort adults. Health Educ Res. 2007;23(2):347-358. doi:10.1093/her/cym052 study. Am J Clin Nutr. 2014;100(3):859-866. doi:10.3945/ajcn.114.088187 11. Merrill E, Grassley J. Women’s stories of their experiences as overweight patients. J Adv Nurs. 2008;64(2):139-146. 25. Harrison C. Covid-19 Does Not Discriminate by Body Weight. Wired. doi:10.1111/j.1365-2648.2008.04794.x April 2020. https://www.wired.com/story/covid-19-does-not-discriminate-by-body-weight/. Accessed August 26, 2020. 12. Hebl MR, Xu J. Weighing the care: physicians’ reactions to the size of a patient. Int J Obes Relat Metab Disord J Int Assoc Study Obes. 26. Pearl RL. Weight Stigma and the “Quarantine-15.” Obesity. 2001;25(8):1246-1252. doi:10.1038/sj.ijo.0801681 2020;28(7):1180-1181. doi:10.1002/oby.22850 13. Bertakis KD, Azari R. The Impact of Obesity on Primary Care Visits. 27. Kyle TK, Puhl RM. Putting people first in obesity: Obesity Biology and Obes Res. 2005;13(9):1615-1623. doi:10.1038/oby.2005.198 Integrated Physiology. Obesity. 2014;22(5):1211-1211. doi:10.1002/oby.20727 14. Phelan S, Burgess D, Yeazel M, Hellerstedt W, Griffin J, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for 28. Kyle TK, Dhurandhar EJ, Allison DB. Regarding Obesity as a Disease: patients with obesity. Obes Rev. 2015;16(4):319-326. Evolving Policies and Their Implications. Endocrinol Metab Clin North doi:10.1111/obr.12266 Am. 2016;45(3):511-520. doi:10.1016/j.ecl.2016.04.004

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6 Weight Management Matters Volume 19. No. 2 29. Pearl RL, Walton K, Allison KC, Tronieri JS, Wadden TA. Preference for 36. Puhl RM, Peterson JL, DePierre JA, Luedicke J. Headless, hungry, and People-First Language Among Patients Seeking Bariatric Surgery. unhealthy: a video content analysis of obese persons portrayed in JAMA Surg. 2018;153(12):1160-1162. doi:10.1001/jamasurg.2018.2702 online news. J Health Commun. 2013;18(6):686-702. doi:10.1080/1081 0730.2012.743631 30. Meadows A, Daníelsdóttir S. What’s in a Word? On Weight Stigma and Terminology. Front Psychol. 2016;7. doi:10.3389/fpsyg.2016.01527 37. Media Gallery - UConn Rudd Center for Food Policy and Obesity. http://www.uconnruddcenter.org/media-gallery. 31. Ivezaj V, Lydecker JA, Grilo CM. Language Matters: Patients’ Preferred Accessed August 29, 2020. Terms for Discussing Obesity and Disordered Eating with Health Care Providers After Bariatric Surgery. Obesity. 2020;28(8):1412-1418. 38. OAC Image Gallery. Obesity Action Coalition. https://www.obesityac- doi:10.1002/oby.22868 tion.org/get-educated/public-resources/oac-image-gallery/. Accessed August 29, 2020. 32. Koball AM, Mueller PS, Craner J, et al. Crucial conversations about weight management with healthcare providers: patients’ perspec- 39. Greenwald AG, McGhee DE, Schwartz JLK. Measuring individual dif- tives and experiences. Eat Weight Disord - Stud Anorex Bulim Obes. ferences in implicit cognition: The implicit association test. J Pers Soc 2018;23(1):87-94. doi:10.1007/s40519-016-0304-6 Psychol. 1998;74(6):1464. doi:10.1037/0022-3514.74.6.1464 33. The Obesity Society. Potential Contributors to Obesity. 2015. https:// 40. Take a Test. https://implicit.harvard.edu/implicit/takeatest.html. www.obesity.org/wp-content/uploads/2020/05/TOS-Reasons-for- Accessed August 29, 2020. obesity-infographic-2015.pdf. Accessed July 21, 2020. 41. Brown I, Flint SW. Weight Bias and the Training of Health Professionals 34. Schwartz MW, Seeley RJ, Zeltser LM, et al. Obesity Pathogenesis: An to Better Manage Obesity: What Do We Know and What Should We Endocrine Society Scientific Statement. Endocr Rev. 2017;38(4):267- Do? Curr Obes Rep. 2013;2(4):333-340. doi:10.1007/s13679-013-0070-y 296. doi:10.1210/er.2017-00111 35. Hayward LE, Neang S, Ma S, Vartanian LR. Discussing weight with

patients with overweight: Supportive (not stigmatizing) conversations increase compliance intentions and health motivation. Stigma Health. 2019;5(1):53. doi:10.1037/sah0000173

7 Weight Management Matters Volume 19. No. 2 WM DPG’s Investments in Our Academy Foundation Builds Critical Research Evidence Focus: The Food and Nutrition Series

By: Hope Warshaw, MMSc, RD, CDE, BC-ADM

Thanks for reading the second installment of this col- that shows the public health value, economic impact and need for umn initiated in the Fall 2020 issue. This column aims access to MNT. We hypothesize that where there is higher access to provide WM DPG members (YOU!) with a deeper and utilization of RDNs and their services, there are better health and consistent level of information about the invest- outcomes for people with these three morbidities. ments your DPG has and continues to make in the • Background: Prevalence of nutrition-related morbidities in the Academy Foundation. The overarching goal of these U.S. adult population is steadily rising in alignment with the rise of Hope Warshaw synergistic efforts are to build the critical research overweight and obesity. To ameliorate these comorbidities, lifestyle MMSc, RD, CDE, evidence to support the value, both in clinical and cost interventions with healthy eating and physical activity are thought to BC-ADM effectiveness, of the work ew do as nutrition profes- be cost effective. However, most U.S. adults do not routinely receive sionals focused on weight management. care by RDNs. They may receive nutrition care from less qualified health professionals or non-credible sources. Systematic reviews examining The three goals for this column are: the effectiveness of RDNs conducting MNT show improved clinical 1. Let WM DPG members know about the research initiatives WM DPG outcomes in multiple morbidities. Currently, Centers for Medicare has, over the years, and continues to support. and Medicaid (CMS) provide reimbursement for MNT for people with CKD, DM (including gestational); however, use of these services and 2. Promote wider knowledge about the remarkable work, since 1966, appropriated funds to reimburse for them has been pervasively poor. of the Academy’s Foundation and how it supports our professional Similarly, initial studies indicate that use of Diabetes Self-Management development through scholarships, awards, grants, fellowships, and Training (DSMT) benefits are also low. Barriers to usage include low much more. awareness of benefits by beneficiaries and clinicians, lack of availability 3. Encourage WM DPG members to individually contribute to the Acad- of services from RDNs who may perceive the process of CMS burden- emy’s Foundation by setting up (at any point in your career) a long some and complex, inconsistent coverage for MNT by non-Medicare term giving plan. (More about this below.) payers and etc. • WM DPG’s investment: WM DPG made an investment of $10,000 to Regarding goal one, in each column I will put the spotlight on one of the this Academy Foundation project. four initiatives WM DPG has contributed to and continues to invest in. The focus of this column is Academy Foundation’s The Food and • Publications and presentations: The publication, “State of Food and Nutrition Series. Nutrition Series: The Impact of RDNs on Non-communicable Diseases: 2020 Forum Proceedings Paper” has been submitted to our journal. • Project goal(s): Given the high effectiveness but low utilization of • Project benefit to members: This project has the capacity to identify medical nutrition therapy (MNT) by a Registered Dietitian Nutritionist challenges and develop solutions for ensuring individuals have access (RDN), the Academy of Nutrition and Dietetics Foundation (Academy) to high quality MNT. In doing so, it will elevate the work of the RDN and has initiated a multi-year project to examine access by consumers to our effectiveness in improving health outcomes highlighted. and the impact of credentialed nutrition and dietetics practitioners • Significance:While nutrition-related factors are the primary cause on three high-priority non-communicable diseases (NCD): 1) of NCD and studies show that MNT by RDNs is effective in improving hypertension (HTN); 2) type 2 diabetes (T2DM); and 3) chronic outcomes, access is poor. Understanding how people get access kidney disease (CKD). The project kicked off with a forum in February to MNT and the impact of that care can potentially lower overall 2020 held in conjunction with the Department of Nephrology at healthcare cost and improve health outcomes. Understanding the Georgetown University in Washington, DC. Presentations were given systems and processes for referral, the barriers and facilitators to access on the project’s purpose, measures that will inform a series of written and the impact of MNT will provide valuable information on how reports, databases the evidence will be pulled from and analyses that increased access can be achieved and, perhaps equally importantly, the are being considered. The forum’s outcome was a case for support savings in cost and improved health due to increased access.

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8 Weight Management Matters Volume 19. No. 2 • Project status: Currently we are working with epidemiologists to tion. You can make a one-time or recurring gift online at https://eat- answer the question “Do people with hypertension, type 2 diabetes or rightfoundation.org/get-involved/donate/. Please consider making a CKD who have received nutrition care and services from an RDN have contribution today and annually! better outcomes than those who do not?” by analyzing retrospective Acknowledgements: The author appreciates the input from Academy data. Additionally, we are developing a prospective protocol to collect staff members Beth Labrador, Development Director for the Academy data which will allow us to better understand the barriers and facilita- of Nutrition and Dietetics Foundation and Alison Steiber, PhD, RDN, tors to nutrition care. Chief Science Officer, Research, International and Scientific Affairs, at It is my hope that with greater awareness of and insights into the breath the Academy of Nutrition and Dietetics. and impact of the WM DPG support of the Academy Foundation’s projects encourages YOU, as an Academy member, to invest directly in the Acad- emy Foundation. Since I joined the Foundation Board in 2018, I’ve been Hope Warshaw is a Registered Dietitian and Certified Diabetes Care awed by the impressive direct impact of generous contributions to the and Education Specialist (CDCES) who has been involved in weight Foundation from members and other organizations. All of these efforts management and diabetes care, education and support for over forty will put our profession on firm footing well into our second century. years. She applies her credentials as a consultant, book author, freelance writer and media spokesperson within her business, Hope Warshaw The Foundation’s mission is: “Through philanthropy, empower current and Associates, LLC, a consultancy based in Asheville North Carolina. Hope is future food and nutrition practitioners to optimize global health.” The Foun- the author of numerous consumer diabetes-focused books published by dation is living up to this mission through scholarships, awards, disaster the American Diabetes Association and many consumer- and clinician- relief efforts, research grants, fellowships and public nutrition education focused publications. During her career Warshaw has served in several programs. Many food and nutrition professionals, including WM DPG volunteer roles with the Weight Management DPG including being a members, are benefitting from the Foundation’s efforts. Over the last founding member and working on several symposiums. In leadership three years, the Foundation has provided $182,500 to WM DPG members roles Hope served as chairperson of the Diabetes Dietetic Practice through scholarship, award, grant and fellowship programs. Please con- Group (DDPG) and was president of the Association of Diabetes Care sider applying for these opportunities and encouraging your colleagues and Education Specialists (formerly AADE). She currently serves on the to do so. Access this information at https://eatrightfoundation.org/ These Academy of Nutrition and Dietetics Foundation board in the role of have been made possible through the generosity of Foundation donors. secretary. It is in this role that she is writing these articles for WMDPG. I know of no better way to invest in the future of our profession than with a gift to the Foundation. Please consider making an annual contribu-

9 Weight Management Matters Volume 19. No. 2 WM DPG Award Recipients

Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA Michelle Cardel, PhD, MS, RD, FTOS (Excellence in Emerging (Excellence in Research Award) Outcomes Research Award)

Geeta Sikand is Director of Nutrition at the Dr. Cardel is an assistant professor, and obesity University of California Irvine Preventive and nutrition scientist in the Department of Cardiology Program and an Associate Clinical Health Outcomes and Biomedical Informatics at Professor of Medicine (Cardiology Division). the University of Florida (UF), where she is also an Associate Director for the Center for Integrative Geeta is a recipient of multiple honors, including Cardiovascular and Metabolic Diseases. Her research the 2019 Academy of Nutrition and Dietetics focuses on implementing weight management Medallion Award; 2019 Outstanding Dietitian interventions, characterizing psychosocial factors, Award from California Academy of Nutrition and Dietetics; 2019 SCAN including low social status and food insecurity, that influence eating DPG Excellence in Cardiovascular Nutrition Practice Award; and the behavior, implementation science, and health disparities. 2019 Pacific Lipid Association President’s Service Award. Dr. Cardel is a member of the American Society for Nutrition (ASN), and Her research is dedicated to examination of the clinical and Fellow of The Obesity Society. Her research is published in JAMA, JAMA cost outcomes of medical nutrition therapy by dietitians for the Pediatrics, and Obesity. Dr. Cardel has received several awards including management of dyslipidemia, weight management, hyperglycemia the University of Alabama at Birmingham (UAB) Outstanding Woman and hypertension. She is the lead author of “Clinical and Cost Benefit of Award; UAB’s National Alumni Society Young Alumni Rising Star Award; Medical Nutrition Therapy by Registered Dietitians for Management of and the ASN Grand Prize for Young Minority Investigators Award. She has Dyslipidemia: A Systematic Review and Meta-analysis” published in the been co-investigator or principal investigator on several obesity grants, Journal of Clinical Lipidology. including her current NIH K01 career development award.

Geeta serves on the Boards of Governors of the National Lipid Dr. Cardel received her bachelor’s degree in biology at Florida State Association (NLA), is co-chair of the Nutrition Task Force, and co-author University. Her master’s degree in clinical nutrition and doctoral degree in of the “National Lipid Association Recommendations for Patient- Nutrition Sciences were awarded from UAB. Centered Management of Dyslipidemia”. Ginger Cochran, MS, RDN, CEP-ACSM, CDCES Shelly Summar, MSEd, RD, LD (Excellence in Emerging Practice Award) (Excellence in Practice Award) Ginger Cochran is a Certified Diabetes Care and Shelly Summar serves as the Program Manager of Education Specialist and Clinical Educator for Tenet Weighing In, a program at Children’s Mercy Kansas Health Central Coast’s First California Physician City, working to lead community collaboration Partners in San Luis Obispo, California. Ginger supporting healthy lifestyles. graduated from California Polytechnic State University in San Luis Obispo with a BS in Nutrition, Shelly is a registered dietitian with over 25 years and an MS in Kinesiology. Her graduate research of experience treating children and families focused on reducing childhood obesity via a for nutrition related issues. She received her nutrition education program which has become a national program. She undergraduate degree in Nutritional Sciences from Kansas State also interned at Hilton Head Health in South Carolina, where she assisted University, and her Masters in Exercise Physiology from the University the Arts & Entertainment channel for its show, “Heavy.” of Kansas. She is on the editorial board of the Academy of Nutrition and Dietetics Shelly completed a Certificate of Training in Childhood and Adolescent Nutrition Care Manual® and on the San Luis Obispo County Health Weight Management through the Academy of Nutrition and Dietetics, Commission Board. Ginger has served as president of the local dietetic and participated in the Healthy Communities Leadership Academy chapter, contributed to the Commission on Dietetic Registration’s through the Health Forward Foundation in Kansas City. Certified Specialist in Weight and Obesity Management exam, and has She is currently involved in leading the Healthy Lifestyles Initiative, worked on projects for the Today Show Dietitian, Joy Bauer. The California which includes sharing a community message, 12345 Fit-Tastic!. This initiative promotes physical activity through the development of a regional physical activity plan, establishes a hospital supported community garden, and works within the hospital setting to implement a healthy hospital initiative.

10 Weight Management Matters Volume 19. No. 2 Incorporating Results of Genetic Testing into Weight Management Nutrition By: Maria M. Morgan Bathke, MBA, PhD, RD, CD, FAND, Nutrition and Dietetics Department, Viterbo University Bert Herald, MS, RD, Dining and Nutrition Services, Carilion Clinic Ashley J. Vargas, PhD, MPH, RDN, Eunice Kennedy Shriver National Institute of Child Health and Human Development

Nutrigenetics focuses on “the effect of genetic varia- tion on the interaction between diet and disease” and nutrigenomics focuses on “the effect of nutrients on the genome, proteome, and metabolome”. 1 Therefore, so-called personalized or precision nutrition genetic Research Section tests which use genetic information to tell an individual Sarah Henes, PhD, RD, LD is the Maria M. Morgan what they should eat are technically nutrigenetic tests Research Section Editor Bathke, MBA, PhD, but colloquially these tests are often referred to as “nu- RD, CD, FAND Genetic testing has become more trigenomics tests”. The nutrigenomics testing market common in today’s medical and nutrition has been forecast to grow between 11-13% globally communities. Now more than ever it is from 2018-2025.2,3 News reports frequently surface important for Registered Dietitians to discussing this topic,4-7 and some weight management understand the emerging research of programs have begun to refer patients to genetic test- nutrigenomics and how best to guide ing. Noom8 and Orig3n9 use AncestryDNA10 or 23an- their patients, especially in terms of weight management. dMe11 data. DNAFit12 uses its own testing or results from Bert Herald This issue’s Research article delves into the current state 23andMe or AncestryDNA. RDNs are increasingly faced MS, RD of nutrigenomics, best practices for dietitians, and reliable with patients seeking help interpreting the results of resources for our weight management patients in this a genetic test. It is important for practicing dietitians evolving area of research. to be aware of the current state of nutrigenomics as well as reliable resources for patients and appropriate education and interventions.

Review of the current evidence on the observed decrease in body fat percent. This systematic review had Ashley J. Vargas incorporating genetic testing into nutrition enough studies to conduct a meta-analysis which quantified the effect PhD, MPH, RDN counselling and care of incorporating genetic testing into nutrition practice on weight and/ or BMI outcomes using statistical tests across studies. No statistical effect In 2019, the Academy of Nutrition and Dietetics undertook a review of of incorporating genetic testing was observed for these outcomes. From the literature to evaluate the level of scientific evidence for incorporating this systematic review and meta-analyses, the Academy developed a genetic testing into clinical nutrition practice.13 While adults and children position paper on incorporating genetic testing into nutrition practice.14 were included in the literature search, it should be noted no studies in children met inclusion criteria for this systematic review and therefore all Multiple studies measure genetics and there are occasionally observed results presented are for adults only. Overall, this systematic review found associations with an obesity-related outcome with gene(s) of interest. insufficient evidence for supporting genetic testing in weight manage- However, this is observational data, which is a lower level of evidence, as ment nutrition counseling and care. Specifically, the conclusions are: genetics were not tested as part of the intervention itself. While promis- “No significant differences in weight, BMI or waist circumference were ing, these require confirmation by intervention studies. There was one observed when results of genetic testing were incorporated into nutrition major study which did use genetics as part of a dietary intervention.15 counseling as compared to counseling or care that did not incorporate genetic results”. These findings received a Grade II rating indicating mod- The Nutrigenomics, Overweight/Obesity and Weight Management Trial erate certainty in this conclusion statement. The other finding related (NOW) is a randomized control trial of community-dwelling adults (n = to weight management ist: “In participants with non-alcoholic fatty liver 140) recruited from the Group Lifestyle Balance Program (GLB) in Ontario, disease, there was a greater reduction in body fat percent when results of Canada.16 The GLB program is an evidence-based, intensive weight man- genetic testing were incorporated into nutrition counseling as compared agement program. Participants were randomized to receive the standard to counseling or care that did not incorporate genetic results”. However, GLB program and population-based lifestyle advice for weight manage- this finding received a Grade III rating indicating only limited evidence ment or a modified GLB program with genetic-based lifestyle advice for supported this conclusion statement. Further, in this same study, there weight management.16 The GLB program with genetic-based lifestyle was no difference in lean mass percent which seems inconsistent with advice for weight management allowed for greater reductions in percent

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11 Weight Management Matters Volume 19. No. 2 • These genetic tests are highly accurate at determining the presence of a genetic polymorphism (SNP). The technology for genetic sequencing is highly accurate, so companies often advertise this accuracy. • These genetic tests are not accurate at determining a patient’s/client’s risk of disease, meaning these have limited clinical utility, because: • Not all genes are measured so there may be other genes not measured which are associated with risk; • Even if the complete genome is sequenced, scientists do not know and absolute body fat percentage at the 3- and 6-month follow up when what the function is of all the genes or how these work together to compared to the standard GLB group. While the NOW trial and previous alter disease risk; work show promising results for precision nutrition care in weight man- • There are also other factors which ultimately determine if someone agement and utilizing nutrigenetic analyses, there is still more work to will get a disease besides genes (see the CDC and Obesity Society be done to assess the best route of care and recommendations to make resources for further explanation about causes of obesity above); regarding genetic variations. • All of these reasons are supported by the systematic review by the Practicing dietitians should continue to keep current in the literature, Academy which concluded there is currently not enough scientific and follow the most recent developments in this emerging area in evidence to suggest using genetic information in the clinic will research. In addition, RDNs may find the question and answer section positively impact patient outcomes in weight management below useful in their current clinical practice for this ever-evolving field or obesity. of nutrition. 3) Is there a sufficient level of evidence to support incorporating genetic Clinician question and answer testing into nutrition counseling or care for weight management or for disease risk reduction? 1) What would be good resources for RDNs with questions about genetic influence on obesity? Not yet, based on the systematic review and meta-analysis done by the Academy. (Note this review did not look at the evidence for Three great resources are listed below: established genetic testing on infants for inborn errors of metabolism • A summary of the causes of obesity, including a focus on genet- such as Prader-Willi syndrome, phenylketonuria, and maple syrup ics, by the Centers for Disease Prevention and Control at Behavior, urine disease). environment, and genetic factors all have a role in causing people to 4) How does an RDN communicate genetic risk of obesity versus other be overweight and obese.17 risks to patients? • A summary on the role of genetics in obesity by the Obesity Medi- A recent study combining >2 million measurements (SNPs) on the cine Association at Obesity and Genetics - Nature - Nurture.18 genome was only able to predict ~23% of an individual’s BMI, 22 • Clinicians can search “Obesity” here to find scientific publications on and that number was consistent with previous studies. Recall that genetics and obesity at PHGKB: Main|Home.19 genetic tests available to the public often only test one or a few areas 2) To whom and where should RDNs advise patients go to with ques- of the genome for risk of obesity. This suggests the environment tions about a specific test result from a genetic test? and behaviors of an individual are more important predictors of BMI than genetics. In general, family history is a better indicator of risk of There is no one website with accurate, up-to-date and easy to read obesity than genetics alone because it reflects inherited genes and information about each gene and each SNP within each gene. Some likely includes the environment in which an individual grew up, and outstanding examples do exist for specific, commonly sequenced genes. may continue to live in, such as: empty calories available around the For example there are excellent resources on MTHFR20 and MC4R21 for home; availability of fruits and vegetables; relative importance of the informed patient. FTO, APOA2, TCF7L2, and PPARg2 for response diet and health, physical activity preferences, and taste and cooking to diet are genetic variants which have been linked to diet response. preferences.23 RDNs should encourage patients to turn to genetic counselors to aid in interpreting genetic testing results. Genetic counsellors are the best 5) What can an RDN say to patients who may feel genetic results indi- partners, but they are often not easily accessible through the medical cate inevitability for developing a disease state? system. Often companies which provide genetic testing also provide It has been said by many, “your genes are not your destiny”. Genes access to genetic counselors and this may be helpful particularly if are responsible for ~23% of obesity,22 and everyone knows a family patients do not have access to a genetic counselor through traditional where one individual is of a normal BMI while the rest have higher medical pathways. Companies do also provide information on genes via BMIs. It is possible to beat the odds and overcome this probability. websites and reports, but RDNs should review the materials with their Furthermore, it could be said, “your measured genes are not your patients as they would with any marketed product materials. RDNs may destiny”. This is because most genetic tests do not measure all genes, be questioned about the accuracy or validity of these genetic tests. This meaning even if one gene suggests a high risk for obesity, there may is a tricky question because there are two important points to convey to be other few genes which lower risk but were not measured, or are the patient/client: not yet fully understood. (Continued on page 13)

12 Weight Management Matters Volume 19. No. 2 References 1. Ordovas JM, Corella D. Nutritional genomics. Annual Rev Genomics 20. MTHFR gene, folic acid, and preventing neural tube defects. Centers Hum Genet. 2004;5:1-14. for Disease Control and Prevention. https://www.cdc.gov/ncbddd/ 2. Nutrigenomics testing market size by application. Global Market folicacid/mthfr-gene-and-folic-acid.html. Published July 2020. Insights. https://www.gminsights.com/industry-analysis/nutrigenom- Accessed December 3, 2020. ics-testing-market. Published August 2019. 21. MC4R Gene. https://www.mc4r.org.uk/. Accessed December 3, 2020. Accessed December 11, 2020. 22. Khera A, Chaffin M, Wade K, et al. Polygenic prediction of weight and 3. Nutrigenomics testing market industry analysis, size, share, trends, obesity trajectories from birth to adulthood. Cell. 2019;177(3)587-596. segmentation and forecast 2019 – 2025. Medgadget. https://www. medgadget.com/2019/12/nutrigenomics-testing-market-industry- Bert Herald, MS, RD graduated Summa Cum Laude and as a Scholar- analysis-size-share-trends-segmentation-and-forecast-2019-2025. Citizen Fellow from Radford University in 2016 with a BS in Nutrition and html. Published December 2019 Accessed December 11, 2020. Dietetics. He completed his internship program with Lenoir-Rhyne University 4. Miller AM. Should you take a genetic test to find the best diet for you? in 2017 and soon after began work as a clinical dietitian at Carilion Clinic in US News and World Report. https://health.usnews.com/wellness/ Roanoke, VA, where he specializes in outpatient weight management. He has articles/2018-01-16/should-you-take-a-genetic-test-to-find-the-best- a past career as an electrical engineer, with a master’s degree from Arizona diet-for-you. Published January 2018. Accessed December 11, 2020. State University in 1997 and afterwards he worked for the cell phone industry 5. Weisenberger J. Update on genetic testing. Today’s Dietitian. designing networks. Bert changed careers in midlife after having been obese 2019;21(5):36. for most of his life and having successfully lost 115 lbs in 2011. The passion to also help others with reclaiming their lives from obesity remains his focus. He 6. Reinagel M. Personalized nutrition: the latest on DNA-based diets. Sci Am. https://www.scientificamerican.com/article/personalized- enjoys running, hikes, occasional cooking, astrophotography and amateur nutrition-the-latest-on-dna-based-diets/. Published September 2019. radio in his free time at his home in rural Virginia. Accessed December 11, 2020. Maria Morgan-Bathke, MBA, PhD, RD, CD, FAND Maria received a BS in 7. Kirckpatrick K. Do DNA-based diets work? Today. https://www.today. Dietetics with a minor in Spanish from UW-Stout in May 2009. She received com/health/do-personalized-diets-work-t183387. Published June her PhD in Nutritional Sciences with a minor in Cancer Biology from the 2020. Accessed December 11, 2020. University of Arizona in July 2013 and her MBA with an emphasis in health 8. Noom, Inc. https://www.noom.com. Accessed December 4, 2020. care management from Viterbo University in 2020. She also completed a 9. Orig3n. https://orig3n.com/. Accessed December 4, 2020. Medical Nutrition Therapy focused dietetic internship at the Carondelet 10. ancestryDNA. https://www.ancestrydna.com/kits. Health System in Tucson, AZ. Maria completed her postdoctoral research Accessed December 4, 2020. fellowship in the Endocrine Research Unit at the Mayo Clinic with Dr. Michael Jensen. Currently, she is working as an assistant professor, Nutrition 11. 23andMe. https://www.23andme.com. Accessed December 4, 2020. and Dietetics Department Chair and Dietetic Internship Director in the 12. DNAfit.https://www.dnafit.com . Accessed December 4, 2020. Nutrition and Dietetics Department at Viterbo University in La Crosse, WI, 13. Robinson K, Rozga M, Braakhuis A, et al. Effect of incorporating as a research collaborator in the Endocrine Research Unit at the Mayo genetic testing results into nutrition counseling and care on dietary Clinic in Rochester, MN and as a content expert and Registered Dietitian intake: an evidence analysis center systematic review-part 1. for Vida Health. Her current research focus is on obesity, insulin signaling, J Acad Nutr Diet. 2020; S2212-2672(20)30336-1. inflammation, and fat metabolism. 14. Camp K, Trujillo E. Position of the Academy of Nutrition and Dietetics: Nutritional Genomics. J Acad Nutr Diet. 2014;114(2):299-312. Ashley Vargas, PhD, MPH, RDN is a molecular epidemiologist and program 15. Horne J, Gilliland, J, O’Connor C, et al. Change in weight, BMI, and director in NICHD’s Pediatric Growth and Nutrition Branch. Her clinical body composition in a population-based intervention versus genetic- and research experience focuses on improving the precision of nutrition based intervention: the NOW trial. Obesity. 2020;28:1419-1427. risk assessment and the application of nutrition therapy to individuals 16. Horne J, Gilliland J, O’Connor C, et al. Study protocol of a pragmatic across their lifespan. Specifically, she has concentrated her research on the randomized controlled trial incorporated into the Group Lifestyle Bal- relationship between diet and disease that is mediated by the genome and ance™ program: the nutrigenomics, overweight/obesity and weight the microbiome in large human cohorts. management trial (the NOW trial). BMC Public Health. 2019;19:310. Prior to her NICHD appointment, Dr. Vargas served in the Office of Disease 17. Behavior, environment, and genetic factors all have a role in causing Prevention in NIH’s Office of the Director, where she led efforts to identify people to be overweight and obese. Genomics and Precision Health. and address major research gaps in the areas of nutrition, physical activity, Centers for Disease Control and Prevention. https://www.cdc.gov/ obesity, and other leading causes and risk factors for death. She also is genomics/resources/diseases/obesity/index.htm. Published January an alumna of the National Cancer Institute’s Cancer Prevention Fellowship 2018. Accessed December 3, 2020. Program, where she focused her research on diet, microbiome, and cancer. 18. Sicat J. Obesity and genetics: nature and nurture. Obesity Medicine Association. https://obesitymedicine.org/obesity-and-genetics. Dr. Vargas received her doctoral degree in nutritional science from the Published July 2018. Accessed December 3, 2020. University of Arizona, her master’s degree in public health from Harvard University, and her bachelor’s degree in dietetics from Wayne State University, 19. Public Health Genomics and Precision Health Knowledge Base. Centers for Disease Control and Prevention. https://phgkb.cdc.gov/ where she also completed her coordinated dietetic training program. She PHGKB/phgHome.action?action=home. Published December 2020, has experience as a clinical RDN in many different settings, has served in Accessed December 3, 2020. leadership roles in professional societies, and is a fellow of the Academy of Nutrition and Dietetics.

13 Weight Management Matters Volume 19. No. 2 When Worlds Collide: The Relationship of Feeding Disorders and Obesity in Children By: Kathryn A. Benton, PhD and Mark H. Fishbein, MD

Pediatric feeding disorders include a complex spectrum of eating and nutritional concerns frequently observed in children. Historically, pediatric feeding disorders have been broadly conceptualized and categorized, PediatricWeight creating diagnostic confusion and a tendency to oversimplify contributing factors. Recently, Goday and Kathryn A. Benton, Management colleagues proposed a comprehensive definition for PhD Patricia Novak, MPH, RD, CLE, LD is the pediatric feeding disorders as well as a framework for Pediatric Section Editor incorporation of psychosocial factors and medical/ nutritional components.1 Pediatric feeding disorders With newly expanded diagnostic criteria are defined as “impaired oral intake that is not age- for pediatric feeding disorders, dietitians appropriate, and is associated with medical, nutritional, are increasingly involved in the treatment. feeding skill, and/or psychosocial dysfunction”.1 The Pediatric feeding therapy presents a unique Mark H. Fishbein, inclusion of psychosocial factors is a positive step challenge for obesity prevention. Children MD forward in recognizing the complex interplay of who are more likely to have feeding prob- mental, behavioral, social, and environmental factors, even in cases of lems; those with developmental diagnoses, family history of feeding disorders that are largely due to medical issues. These factors eating disorders/obesity or born prematurely; are at high risk may influence the development of a formal feeding disorder as well as for obesity and associated co-morbidities. Yet, intervention contribute to its continuation. for pediatric feeding places an enormous emphasis on eating within caregiver-child interactions, increasing the risk for disor- While definitions of feeding disorders have varied over the years, there dered eating later in life. This article helps to conceptualize the has been a strong consensus among experts that the “gold standard” relationship between early feeding disorders and obesity. approach for evaluation and treatment should be multidisciplinary. Individual facets of pediatric feeding disorders that must be considered include largely gastrointestinal medical conditions, nutritional 6,7 compromise, and oral motor deficits that would typically be addressed surveys. The prevalence of obesity has also increased in the pediatric by the gastroenterologist, dietitian, and speech language pathologist population. In children aged 2 through 19 years, 28.8% were overweight 8 respectively.2 Many multidisciplinary programs also include occupational during 1999-2000 while 35.1% were overweight in 2015-2016. There is therapists to evaluate self-feeding and the presence of any sensory issues no single underlying cause or solution for obesity in America; evidence affecting feeding, and psychologists or other mental health providers for suggests that obesity arises from a combination of genetic and envi- 9 input on psychosocial factors. ronmental variables. Similarly, there is no single solution to the obesity epidemic.10 Therefore, it is necessary to understand all possible factors The new conceptualization for pediatric feeding disorders stipulates that contributing to childhood obesity, including those that may arise from eating disorders such as anorexia nervosa, pica, and rumination should pediatric feeding disorders. be delineated as separate comorbid conditions.1 Pediatric obesity, however, is notably overlooked or dismissed as a possible comorbid condition Currently, data are sparse regarding the prevalence of obesity in pediatric of a pediatric feeding disorder. Revisiting the relationship between feed- feeding disorders. Benton et al reported a prevalence of 5.9 percent in 11 ing disorders and obesity is recommended due to the recent redefinition their broadly defined outpatient feeding clinic referral population. None of pediatric feeding disorders and its implications, and the alarming of these obese children possessed deficits in oral motor skills, such as economic, health, and societal consequences of the obesity epidemic. chewing and swallowing difficulties that are typically represented in a feeding disorder population and predispose them to inadequate caloric Risk of Obesity intake and poor weight gain. Therefore, the remainder of this review will Obesity accounts for roughly 186,000 excess deaths per year.3 The cost focus on children with picky eating and sensory-based feeding disorder in medical care of obesity in the U.S. is $147 billion per year.4 Annual who particularly may be at greatest risk for overnutrition and obesity. obesity-related productivity costs are estimated to be between $3.3 bil- Picky Eating lion and $6.38 billion.5 During the past couple of decades, the obesity rate has risen dramatically. In 1999-2000, 64% of U.S. adults were overweight, Picky eating, also known as neophobia, refers to children who exhibit a sizable jump from 56% in earlier surveys for 1988-1994. Moreover, very strong food preferences, accept only a narrow selection of foods, 42.4% of adults were obese in 2017-2018, compared to 23% in earlier (Continued on page 15)

14 Weight Management Matters Volume 19. No. 2 and show an unwillingness and/or extreme anxiety about trying any new specific food textures, smells, and tastes, and may even react to the tem- foods. Interestingly, while overall food variety may vary between picky peratures of different foods.17 Tactile sensitivity, which includes oral tac- eaters and non-picky eaters, their food preferences do not. Picky eat- tile issues, has been found to be strongly associated with picky eating.18 ers typically prefer fries, chicken nuggets, crackers, ice cream, and pizza, Children with various sensory aversions may gag and vomit with new while children with typical eating habits prefer many of the same foods foods. They may prefer liquids over solids. Contrarily, children with un- (fries, pizza, nuggets) as well as pasta and rice.11,12 Therefore, it may be the der-responsiveness, possess less awareness of sensory input, and require quantity of intake of these foods (versus quality) as the major contributing more stimulation in order to respond.19 These children may prefer foods factor to childhood obesity.13 offering higher sensory input, such as crunchy foods, spicy foods, foods with strong odors, and foods that are served at hot or cold temperatures. The relationship between picky eating and obesity has been explored Both sensory profiles, through distinct and separate mechanisms, may in- previously in several studies yet has not yielded robust findings. A recent crease risk for obesity. In conjunction, heavy reliance on liquids may also longitudinal study compared the growth trajectories of children identified be a pitfall for weight gain, particularly if consuming large quantities of 14 with different degrees of picky eating at 3 years of age. Children classi- unhealthy beverages.20 Children with oral sensory sensitivities also tend fied as somewhat picky and very picky were not found to be at any higher to avoid lower calorie foods such as fruits and vegetables due to their risk for obesity than the children who were not picky at ages 7 through 17 unfavorable sensation and taste.21 Lastly, both groups of children may be years. In fact, some of the children who were identified as “very picky” drawn to high-fat and high-sugar foods that have very pleasing sensory were found to be thin at multiple age points, more so than the non-picky properties.22 Strong sensory preferences about foods may contribute or 14 children. Another large study out of Finland found that being a picky lead to maladaptive eating behaviors, particularly if left unheeded. eater placed pre-adolescents at higher risk for being underweight but not overweight .15 Children with sensory regulation challenges may also develop maladaptive and obesogenic feeding behaviors. Sensory regulation refers to an These studies seem to negate the concern for picky eating leading to individual’s ability to monitor and manage states of arousal, emotions, higher risk for obesity, but it is important to consider that many studies thoughts, and behaviors in ways that support adaptive responses. Self- have used different definitions and criteria for classification and identifica- regulation skills are needed so that one can maintain attention, control tion of picky eating. A systematic review of 41 studies conducted by Brown our bodies, manage our emotions, and respond to internal cues such as et al. noted large variations in how picky eating and food neophobia were hunger, fatigue, and pain. When self-regulation skills are poor, impact on 16 defined. Aside from a trend towards being underweight in some studies, eating behaviors can include a tendency to eat foods too quickly, over- 16 no clear association between obesity and picky eating was determined. stuffing while eating, and not recognizing cues for satiety.23 In a study of 7-12 year-olds conducted by Webber et al, children who exhibited While there is a lack of evidence for the association between picky eating appetitive tendencies such as eating for emotional reasons, eating very and obesity, this is likely due to the variability of children’s characteristics quickly, and having a high desire to drink liquids were more likely to be and diagnoses as included in studies. It is possible that some children overweight or obese.20 These findings suggest a possible connection labelled as picky eaters may carry a higher risk of becoming obese. Based between eating behaviors and emotion regulation in children, although on available literature, possible at-risk subtypes include: 1) those with more research is needed to extrapolate on these findings. In a recent contributory sensory profiles; 2) those exhibiting maladaptive eating study conducted by Hebert, food intake and sensory sensitivity were behaviors and patterns; and 3) those with autism spectrum disorder. A examined in adult women.24 They found that women with high sensory combination of these subtypes would enhance obesity risk. sensitivity displayed higher rates of eating in response to both emotional Sensory-Based Feeding Aversions and external food cues, suggesting that being highly reactive to sensory input may be related to a tendency to regulate emotions differently and/ Sensory-based feeding aversions occur widely in pediatric feeding or to use different strategies to respond to emotions (e.g., over-eating). disorders. Sensory integration describes the interrelationship between Similarly, in another study, adult women with high sensitivity ate more the individual’s environment and his or her senses. Individuals of all ages offered chocolate than their counterparts with low sensitivity.25 Thus, rely upon sensory integration to perform routine daily activities including underlying appetite traits may increase the risk for overeating, especially such basic tasks as bathing, dressing, and brushing one’s teeth. Individu- in individuals who have sensory issues, difficulties with self-regulation, als with impairment in sensory integration or sensory processing disorder and/or picky eating habits. may demonstrate features of over-responsiveness, under-responsiveness, sensory-seeking, and sensory-avoidant behavior. Expressions of over- Autism Spectrum Disorders responsiveness include distress from light touch and the feeling of agita- Children diagnosed with autism spectrum disorders demonstrate food tion from clothing tags or seams. A common example of sensory under- neophobia and selectivity at high rates, and this population also has a responsiveness is having diminished recognition of touch or temperature high rate of obesity.26 Individuals with autism who are at highest risk change. A common example of sensory seeking is craving sensory input for becoming overweight and obese are those with autism severity in in the form of spinning or deep touch. Sensory avoidance may manifest the moderate to severe range.27,28 Some of the contributory factors to in behaviors such as covering of ears for loud noises or refusing to walk the high percentage of obesity in children with autism include lifestyle barefoot on sand or grass. variables such as tendency to spend more time in sedentary activities Children with sensory-based feeding aversion tend to eat foods with ap- pealing sensory qualities and avoid foods based upon perceived unfavorable sensory qualities. For example, many children show sensitivities to (Continued on page 16)

15 Weight Management Matters Volume 19. No. 2 represents a very important subgroup of children who should be closely followed as they are likely to represent a “perfect storm” when it comes to their risk level for obesity. In addition to a tendency towards a strong appetite, preference for high-calorie foods, sedentary life-style, maladaptive behaviors, and sensory processing challenges, many of these children are also exposed to therapies that use foods as a treatment strategy and medications that predispose to weight gain.

Dr. Kate Benton is a pediatric psychologist with Ann & Robert Lurie and less time doing physical activity, and the increased likelihood of Children’s Hospital of Chicago and Clinical Associate with Northwestern being prescribed medications that cause weight gain.29-36 Picky eating is University Feinberg School of Medicine. She holds credentials with the State also extremely common in children with autism. Many foods preferred by of Illinois Early Intervention Program and has 20 years of experience working children with autism are pre-packaged, sugary and salty snack foods, and in pediatrics. Dr. Benton provides services with the Interdisciplinary Feeding other highly processed foods.37-39 These calorically-dense foods may hold Clinic at Lurie Children’s. In addition to her expertise in feeding disorders, appeal as their sensory properties are very consistent, and the packaging Dr. Benton also works within the Division of Developmental & Behavioral may be visually reassuring to children with autism who may not easily Pediatrics, providing diagnostic and consultative services for children trust foods that are less familiar. An additional risk factor for children with presenting with developmental delay, Autism Spectrum Disorders, and other autism is that they are described as having a strong appetite by their par- neurodevelopmental disabilities. In addition to her clinical work, Dr. Benton ents whereas many non-autistic children with picky eating display a poor has been co-investigator for multiple research studies related to feeding appetite, making them less likely to become overweight.40,41 disorders and other health-related behavioral difficulties in young children. Lastly, it is important to consider the frequent use of food as a reward/ Dr. Benton provides continuing education for both physicians and psychology incentive in certain treatment protocols for children with autism. Using trainees, and she has previously taught in the clinical psychology doctoral food as a reward during therapies provides an iatrogenic pathway by program at Loyola University Chicago. which obesity risk becomes heightened for children who may already be predisposed. Applied behavioral analysis (ABA) therapy has been heavily Mark Fishbein MD is a pediatric gastroenterologist. He is an associate researched and found to be one of the most effective treatment strate- professor of Pediatrics at Feinberg School of Medicine at Northwestern gies for children with autism. It involves use of immediate rewards to University. He is on staff at Ann and Robert H Lurie Children’s Hospital reinforce behaviors that approach a target skill. Children practice these of Chicago and Northwestern Medicine at Central DuPage Hospital in skills repeatedly until they master them. Some children receive as many as Winfield IL. He is medical director of both the Pediatric Feeding and 40 hours a week of ABA therapy. Food rewards are common, but caution Swallowing Clinic and Pediatric Fatty Liver Clinic. He is co-author of should be used sparingly and paired with other non-food rewards in order a parent help book for children with feeding disorders entitled “Food to avoid over-reliance.42 Use of food rewards disrupts the normal process Chaining: The Proven 6-Step Plan to Stop Picky Eating, Solve Feeding of recognizing hunger and satiety cues, and they encourage a child to eat Problems, and Expand Your Child’s Diet.” at non-mealtimes. Additionally, many of the foods that serve as rewards are high-calorie, high-sugar and foods dense in carbohydrates.43 With References repeated exposure to these types of foods, children will quickly develop 1. Goday PS, Huh SY, Silverman A, et al. Pediatric feeding disorder: a taste for them and begin to regard them as highly desirable. It has been consensus definition and conceptual framework. J Pediatr demonstrated that children, when given the opportunity, will overeat Gastroenterol Nutr. 2019;68(1):124-129. foods that have been used as a reward in the past.44,45 2. Phalen JA. Managing feeding problems and feeding disorders. Conclusion Pediatr Rev. 2013;34(12):549-57. In summary, research to date has not shown a strong and/or consistent 3. Preston SH, Vierboom YC, Stokes A. The role of obesity in link between picky eating and pediatric obesity. However, studies have exceptionally slow US mortality improvement. Proc Natl Acad Sci U S A. 2018;115(5):957-961. varied considerably in how they have defined and studied picky eating. For some children, picky eating appears to serve as a protective fac- 4. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical tor, making them less likely to become obese. However, there may be spending attributable to obesity: payer-and service-specific additional subsets of children and/or risk factors that may increase the estimates. Health Aff (Millwood). 2009;28(5):w822-31. likelihood that picky eating will lead to weight gain. Children who exhibit 5. Trogdon JG, Finkelstein EA, Hylands T, Dellea PS, Kamal-Bahl SJ. strong sensory preferences about food choices may be at higher risk (e.g., Indirect costs of obesity: a review of the current literature. Obes Rev. preferring crunchy foods, foods with high salt and sugar content, fried 2008;9(5):489-500. foods, and highly processed foods). There is also growing evidence that a 6. Hales C, Fryar CD. Prevalence of obesity and severe obesity among desire to drink large amounts of liquids may also be a risk factor, depend- persons Aged 2-19 years - National Health and Nutrition Examination ing on the caloric content of preferred drinks. Children who are picky and Survey, 1999-2000 through 2017-2018. MMWR. 2020;69(13):390-390. who also exhibit tendencies such as eating very rapidly, showing less 7. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends awareness of satiety cues, and an increased tendency to eat for emotional in obesity among US adults, 1999-2000. reasons may also be high-risk. Lastly, picky eating in children with autism JAMA. 2002;288(14):1723-1727. (Continued on page 17)

16 Weight Management Matters Volume 19. No. 2 8. Skinner AC, Ravanbakht SN, Skelton JA, Perrin EM, Armstrong SC. 29. Must A, Phillips SM, Curtin C, et al. Comparison of sedentary behaviors Prevalence of obesity and severe obesity in US children, 1999-2016 (vol between children with autism spectrum disorders and typically 141, e20173459, 2018). Pediatrics. 2018;142(3) 6 developing children. Autism. 2014;18(4):376-84. 9. Center for Disease Control and Prevention. Adult obesity causes and 30. Mazurek MO, Engelhardt CR. Video game use in boys with autism consequences. Accessed September 17, 2020. spectrum disorder, ADHD, or typical development. Pediatrics. https://www.cdc.gov/obesity/adult/causes.html. 2013;132(2):260-6. 10. Center for Disease Control and Prevention. Strategies to prevent obesity. 31. Macdonald M, Esposito P, Ulrich D. The physical activity patterns of Updated October 29. 2020. children with autism. BMC Res Notes. 2011;4:422. 2 https://www.cdc.gov/obesity/strategies/index.html 32. Bandini LG, Gleason J, Curtin C, et al. Comparison of physical activity 11. Benton K, Swenny C, Cox S, Fraker C, Fishbein M. Pediatric outpatient between children with autism spectrum disorders and typically feeding clinic: if you build it, who will come? JPEN. 2015;39(7):855-9. developing children. Autism. 2013;17(1):44-54. 12. Consumer scorecard: Kids’ full-service favorites. Nation’s Restaurant News 33. Coury DL, Anagnostou E, Manning-Courtney P, et al. Use of 2009;43(15):3. psychotropic medication in children and adolescents with autism 13. Just DR, Wansink B. Fast food, soft drink and candy intake is unrelated spectrum disorders. Pediatrics. 2012;130 Suppl 2:S69-76. to body mass index for 95% of American adults. Obes Sci Pract. Dec 34. Correll CU, Manu P, Olshanskiy V, Napolitano B, Kane JM, Malhotra 2015;1(2):126-130. AK. Cardiometabolic risk of second-generation antipsychotic 14. Taylor CM, Wernimont SM, Northstone K, Emmett PM. Picky/fussy eating medications during first-time use in children and adolescents. JAMA in children: review of definitions, assessment, prevalence and dietary 2009;302(16):1765-73. intakes. Appetite. Dec 2015;95:349-59. 35. De Hert M, Detraux J, van Winkel R, Yu W, Correll CU. Metabolic and 15. Viljakainen HT, Figueiredo RAO, Rounge TB, Weiderpass E. Picky eating cardiovascular adverse effects associated with antipsychotic drugs. - A risk factor for underweight in Finnish preadolescents. Appetite. Nat Rev Endocrinol. 2011;8(2):114-26. 2019;133:107-114. 36. Williamson ED, Martin A. Psychotropic medications in autism: practical 16. Brown CL, Vander Schaaf EB, Cohen GM, Irby MB, Skelton JA. Association considerations for parents. J Autism Dev Disord. 2012;42(6):1249-55. of picky eating and food neophobia with weight: a systematic review. 37. Schmitt L, Heiss C, Campbell E. A comparison of nutrient intake and Child Obes. 2016;12(4):247-262. eating behaviors of boys with and without autism. Top Clin Nutr. 17. Chatoor I. Sensory food aversions in infants and toddlers. Academic 2008;23:23–31. Journal Report. Zero to Three. 2009;29(3):44-49. 38. Schreck KA, Williams K. Food preferences and factors influencing food 18. Smith AM, Roux S, Naidoo NT, Venter DJ. Food choice of tactile defensive selectivity for children with autism spectrum disorders. Res Dev Disabil. children. Nutrition. 2005;21(1):14-9. 2006;27(4):353-63. 19. Dunn W, Westman K. The sensory profile: the performance of a national 39. Evans EW, Must A, Anderson SE, et al. Dietary patterns and body mass sample of children without disabilities. Am J Occup Ther. index in children with autism and typically developing children. Res 1997;51(1):25-34. Autism Spectr Diord. 2012;6(1):399-405. 20. Webber L, Hill C, Saxton J, Van Jaarsveld CH, Wardle J. Eating behaviour 40. Cermak SA, Curtin C, Bandini LG. Food selectivity and sensory and weight in children. Int J Obes (Lond). 2009;33(1):21-8. sensitivity in children with autism spectrum disorders. J Amer Diet Assoc. 2010;110(2):238-246. 21. Dunn W. Infant/Toddler Sensory Profile: User’s Manual. San Antonio, TX: Psychological Corporation; 2002 41. Wright CM, Parkinson KN, Shipton D, Drewett RF. How do toddler eating problems relate to their eating behavior, food preferences, and 22. Carruth BR, Ziegler PJ, Gordon A, Barr Si. Prevalence of picky eaters growth? Pediatrics. 2007;120(4):e1069-75. among, infants and toddlers and their caregivers’ decisions about offering a new food. J Am Diet Assoc 2004;104(1):S57-S64. 42. Matheson BE, Douglas JM. Overweight and obesity in children with autism spectrum disorder (ASD): a critical review investigating the 23. Lashno M. Mixed signals:understanding and treating your child’s sensory etiology, development, and maintenance of this relationship. Rev J processing issues. 1st ed. Bethseda, MD:Woodbine House; 2010 Autism Dev Disord. 2017;4(2):142-156. 24. Hebert KR. Sensory processing styles and eating behaviors in healthy 43. Simpson CG, Swicegood PR, Gaus MD. Nutrition and fitness adults. Brit J Occup Ther. 2018 ;81(3):162-70. curriculum: designing instructional interventions for children with 25. Naish KR, Harris G. Food intake is influenced by sensory sensitivity. PLoS developmental disabilities. Academic Journal Report. Teach Except One. 2012;7(8):e43622. Child. Jul-Aug 2006;38(6):50-53. 26. Bandini LG, Anderson SE, Curtin C, et al. Food selectivity in children with 44. Rollins BY, Loken E, Savage JS, Birch LL. Measurement of food autism spectrum disorders and typically developing children. J Pediatr. reinforcement in preschool children: associations with food intake, 2010;157(2):259-64. BMI, and reward sensitivity. Appetite. 2014;72:21-7. 27. Broder-Fingert S, Brazauskas K, Lindgren K, Iannuzzi D, Van Cleave 45. Lu J, Xiong SH, Arora N, Dube L. Using food as reinforcer to shape J. Prevalence of overweight and obesity in a large clinical sample of children’s non-food behavior: the adverse nutritional effect doubly children with autism. Acad Pediatr. 2014;14(4):408-14. moderated by reward sensitivity and gender. Eat Behav. 2015;19:94-97. 28. Levy SE, Pinto-Martin JA, Bradley CB, et al. Relationship of weight outcomes, co-occurring conditions, and severity of autism spectrum disorder in the study to explore early development. J Pediatr. 2019;205:202-209.

17 Weight Management Matters Volume 19. No. 2 Physical Activity and Exercise Considerations for the Beginning Exerciser By: Joseph Sherman, MS

Regular physical activity is highly beneficial for overall health,1-3 and is a vital tool for weight management.4-9 However, overweight (BMI 25-29.9 kg/m2) and obesity (BMI > 30.0 kg/m2) and those who are new to exercise Physical Exercise require special considerations for safe, yet effective, exercise recommendations. When promoting exercise Felicia Steger, PhD, RD is the Physical Joseph Sherman, to clients, physical limitations, body dissatisfaction and Exercise Section Editor MS low exercise efficacy must be considered.10-12 Proper preparation at the onset of an exercise program can assist clients in The multitude of health benefits that result long-term adoption which, in turn, can improve overall health, increase from engaging in regular physical activity quality of life, and potentially reduce healthcare costs associated with are well-known, including those for weight overweight and obesity. management. However, exercise specialists are not available in many clinical or treatment Physical Activity Recommendations and Weight Loss settings where dietitians are promoting weight The recently released Physical Activity Guidelines for Americans, 2nd control programming. As such, dietitians may be cautious edition continues to highlight the importance of moderate-vigorous about recommending exercise to patients with obesity or for physical activity (MVPA) for weight loss and the prevention of weight re- patients unaccustomed or uncomfortable with physical activity, gain.13 Specifically, for weight loss, Donnelly et la 4 found that to achieve particularly resistance training. Mr. Sherman disseminates clinically significant weight loss (>3%), individuals must perform generalized instruction for the non-exercise professional on between 225 and 420 minutes of MVPA each week, with an appar- how and when to provide prescriptive exercise with patients ent dose-response effect. Several studies have found increased MVPA and clients. Considerations for physical limitations, body alone results in clinically significant weight loss.5-9 The goal for clients at dissatisfaction, and low fitness are discussed. Screening and the onset of a physical activity program should be encouragement to prescriptive guidelines are provided for dietitians to encourage increase activity level in a consistent and safe manner. exercise promotion in most clinical care settings.

The Physical Activity Guidelines for Americans recommends at least two days per week of muscle-strengthening activities involving all major muscles groups.13 Resistance training may not promote weight loss adoption. Clients who are new to exercise face unique challenges when when used alone,4 but improves retention of lean muscle (e.g., muscle beginning a program: lack of exercise self-efficacy; intimidation from mass) when used in conjunction with calorie restriction and/or aerobic taking up a new activity; and embarrassment all compound on the exercise.14-18 potential physical limitations.

A multicomponent program including regular MVPA combined with First, have the client brainstorm activities they feel proficient at perform- caloric restriction may be more successful in promoting weight loss. ing. List off a few examples (walking, cycling, swimming, resistance 5-7,9,18 In a review of 41 randomized clinical trials, Shaw et al5 found that training) to point them in the right direction. Focus on activities the exercise alone marginally improved weight loss, but when combined client mentions they enjoy or have performed in the past and highlight with dietary interventions, weight loss significantly increased (-1 kg). the benefits of each (e.g., walking is the easiest and least expensive Interestingly enough, they found similar weight loss between light ( form or exercise, cycling is low impact and provides the opportunity to e.g., calisthenics, stretching) and moderate activities (e.g., brisk walking, exercise with others). As they are beginning their exercise journey, it is stationary cycling) as compared to vigorous intensity activities (e.g., important to have clients participate in activities they feel confident in jogging/running, interval training) when combined with calorie restric- to build exercise efficacy and a sense of accomplishment. tion. Therefore, prescribing a program including an increase in regular aerobic exercise in conjunction with dietary intervention offers clients A client’s current activity level will determine the volume of physi- the best chance at weight loss and improvements to overall health. cal activity per week they should attempt to achieve at the onset of a program. Examples of progressions for aerobic (Table 1) and resistance Exercise Considerations for Clients with exercise (Table 2) are provided. To use the table, determine the current Overweight and Obesity activity level of the client and find the appropriate prescription for Proper planning and preparation at the onset of an exercise program physical activity. For example, a client who is not currently physically ac- can set clients up for success and improve the chances of long-term tive should begin with “Week 1” whereas a client who is exercising ~90

(Continued on page 19)

18 Weight Management Matters Volume 19. No. 2 minutes per week should progress to “Week 4”. Increasing volume by Figure 1 10-20% each week until the client achieves the recommended amount Aerobic Exercise Modalities will prevent undue soreness and increase the likelihood of long-term adoption. Each client will reach a different level of weekly physical Beginner Intermediate Advanced activity, so it is important to provide encouragement regardless of the volume achieved. Highlighting successes, no matter how small, is of the utmost importance to a beginning exerciser. Providing immediate feedback through weekly check-ins provides clients with much-needed Hill/Incline encouragement as well as reassurance they are on the right track. As Walking Jogging Walking the client becomes more comfortable with exercise, you can begin increasing intensity and adding additional modalities. A good rule of Recumbent Upright Outdoor thumb is to adjust one aspect of an exercise program every 4-6 weeks. Bike Bike Cycling Ideas for adjusting an exercise routine can be found in Figures 1 and 2. Water- Water Lap Physical changes with exercise may be difficult for clients to discern. At Walking Aerobics Swimming the onset of an exercise program it is much more likely clients will experience psychological changes, such as improved mood, increased sleep Chair Bodyweight Step Calisthenics quality, and stress level reduction. Have the client keep a journal or log Aerobics Aerobics of their exercise sessions highlighting how they felt before the session, Ballroom Dance the activity and duration performed, and how they felt after the session. Zumba Dance Aerobics Over time, the journal will allow for pairing the positive psychological effects of exercise with the physical adaptations. Elliptical Stair-stepper Rowing Trainer Machine Ensuring clients who are less comfortable with exercise are free from embarrassment and discomfort is especially important at the beginning of an exercise program. Not all exercise equipment is suitable for every client. For example, weight machines may place clients in an uncom- Table 1 fortable position that will cause an adverse reaction to the exercise. Aerobic Exercise Progression Before prescribing a piece of equipment ensure that it is suitable for the individual. High impact exercises, such as running, jumping, stair step- Days Duration (min) Total (min) ping, and plyometrics, should be avoided in those new to exercise or who are not conditioned for repetitive, high-impact movement due to Week 1 3 15 45 increased stress on joints which can lead to discomfort, or even injury. Other considerations for the beginning exerciser or exerciser with Week 2 3 20 60 overweight/obesity: Week 3 3 30 90 • Wear loose-fitting clothing (e.g., T-shirts, sport shorts, sweat pants). • Proper footwear with good arch support; most running stores will Week 4 3 40 120 perform a free gait analysis to determine which type of shoe works Week 5 4 30 120 best for the client. • Using music, podcasts or books during exercise will provide positive Week 6 4 40 160 reinforcement to increase adherence. Week 7 5 40 200 Conclusion Week 8 5 45 225 Understanding and acknowledging the unique challenges each client presents and incorporating modifications into a prescription can Week 9 5 50 250 improve long-term adoption of a regular physical activity program. While the ultimate goal is to have each client reach the recommended Week 10 5 60 300 amounts of weekly MVPA and resistance exercise, it is important to progress them in a safe manner. Encouragement, feedback, and thoughtful progression enhance the experience for the client.

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19 Weight Management Matters Volume 19. No. 2 Figure 2 References Resistance Exercise Modalities 1. Blair SN, Morris JN. Healthy hearts—and the universal benefits of being physically active: physical activity and health. Ann Epidemiol. 2009;19(4):253-256. Beginner Intermediate Advanced 2. Hills AP, Street SJ, Byrne, NM. Physical activity and health:“what is old (Bodyweight) (Weight Machine) (Free Weights) is new again”. In Adv Food Nutr Res. 2015;75:77-95. 3. Foulds HJ, Bredin SS, Charlesworth SA, Ivey AC, Warburton DE. Exer- cise volume and intensity: a dose–response relationship with health benefits. Eur J Appl Physiol. 2014;114(8):1563-1571. Modified Chest Bench Press 4. Donnelly JE, Blair SN, Jakicic JM, Manore MM, Rankin JW, Smith BK. Push-up Press Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. Supine Lat Pullups 2009;41(2):459-471. Push-up Pulldown 5. Shaw KA, Gennat, HC, O’Rourke P, Del Mar C. Exercise for overweight Arm Shoulder DB Lateral or obesity. Cochrane Database Syst Rev. 2006;4. Raise Circles Press 6. Ross R, Dagnone D, Jones PJ, Smith H, Paddags A, Hudson R, Jans- sen I. Reduction in obesity and related comorbid conditions after Cable Machine diet-induced weight loss or exercise-induced weight loss in men: a Curls Curls Chin Ups randomized, controlled trial. Ann Intern Med. 2000;133(2):92-103. Chair 7. Weiss EP, Albert SG, Reeds DN, et al. Effects of matched weight Triceps Triceps Dips Dips Pressdowns loss from calorie restriction, exercise, or both on cardiovascular disease risk factors: a randomized intervention trial. Am J Clin Nutr. Low Exercise Ball 2016;104(3):576-586. Leg Lifts Plank Crunches 8. Donnelly JE, Honas JJ, Smith BK, et al. Aerobic exercise alone results in clinically significant weight loss for men and women: midwest Chair Knee Kettlebell exercise trial 2. Obesity (Silver Spring). 2013;21(3):E219-E228. Squats Extensions Squats 9. Jakicic JM, Otto AD. Physical activity considerations for the treatment Hip Stiff-leg and prevention of obesity. Am J Clin Nutr. 2005;82(1):226S-229S. Leg Curls Bridges Deadlifts 10. Rubinstein G. The big five and self-esteem among overweight dieting and non-dieting women. Eat Behav. 2006;7(4):355-361.

Table 2 11. Heatherton TF. Body dissatisfaction, self-focus, and dieting status among women. Psychol Addict Behav. 1993;7(4):225.. Resistance Exercise Progression 12. Pearl RL, Puhl RM, Dovidio JF. Differential effects of weight bias experiences and internalization on exercise among women with Days Sets Repetitions overweight and obesity. J Health Psychol. 2015;20(12):1626-1632. 13. Piercy KL, Troiano RP, Ballard RM, et al. The physical activity guidelines Weeks 1-2 2 2 10 for Americans. JAMA. 2018;320(19):2020-2028..

Weeks 3-4 2 3 10 14. Bryner RW, Ullrich IH, Sauers J, et al. Effects of resistance vs. aerobic training combined with an 800 calorie liquid diet on lean body mass Weeks 5-6 2 3 12 and resting metabolic rate. J Am Coll Nutr. 1999;18(2):115-121. 15. Villareal DT, Aguirre L, Gurney, AB, et al. Aerobic or resistance Weeks 7-8 2 3 15 exercise, or both, in dieting obese older adults. N Engl J Med. 2017;376(20):1943-1955. Weeks 9-10 3 3 10 16. Joseph LJ, Trappe TA, Farrell PA, et al. Short-term moderate weight Weeks 11-12 3 3 12 loss and resistance training do not affect insulin-stimulated glucose disposal in postmenopausal women. Diabetes care. 2001;24(11):1863-1869. Joseph Sherman, MS is a Senior Research Coordinator in Kansas City. 17. Rice B, Janssen I, Hudson R, Ross R. Effects of aerobic or resistance He completed undergraduate and graduate training at Missouri State exercise and/or diet on glucose tolerance and plasma insulin levels in University. Currently, he works for the Division of Physical Activity and Weight obese men. Diabetes care. 1999;22(5):684-691. Management at the University of Kansas Medical Center. He specializes in 18. Kraemer WJ, Volek JS, Clark KL, et al. (1999). Influence of exercise physical activity modifications, lab-based exercise testing and behavioral training on physiological and performance changes with weight loss health interventions for special populations including individuals with in men. Med Sci Sports Exerc. 1999; 31(9):1320-1329. intellectual, developmental and physical disabilities.

20 Weight Management Matters Volume 19. No. 2 Body Composition Assessment in Bariatric Surgery By: Kim B Knopp, MS, RD, LD

Ideally, weight loss following bariatric surgery should be primarily from fat mass, minimizing lean mass loss.1 The bariatric team’s dietitian tracked patients’ body composition outcomes for more than 10 years. Observed clinical trends were then published as preliminary BariatricSurgery gender-specific Percent Body Fat (%BF) and lean mass Emily Thevis, RDN, LD, CSOWM, CDE is Kim B Knopp, sparing goals following Roux-en-Y Gastric Bypass (RYGB) the Bariatric Surgery Section Editor MS, RD, LD and Sleeve Gastrectomy (SG).2,3 To help equip the RDN in bariatric surgery to consider incorporating this assessment Weight loss is one of the main goals with into clinical practice, this article shares those two studies’ major goals metabolic surgery, but not all weight loss and findings as well as the tools and evidence-based practices used to is created equally. The aim is to primarily 2,3 achieve outcomes. It also discusses the benefits that body composition reduce fat mass while preserving lean body evaluation offers to patients and RDNs and the impact of preoperative mass. Here, Kim B. Knopp, MS, RD, LD looks at weight loss approaches on body composition. patients’ body composition changes before surgery and at multiple time points in the initial year post- Published Goals and Findings operatively in order to gauge what type of weight patients Twelve-month outcomes showed that body composition for men and were losing and how dietitians can apply this knowledge in women in both surgeries successfully transitioned below the World Health their patient population to better guide their practices. Organization (WHO) obesity thresholds of >25%BF for men and >35% for women.2-4 These outcomes, then, suggest it is possible to consider application of those WHO body composition obesity thresholds to create patient potential 12-month %BF goals as ≤25% for men and ≤35% for women following both surgeries.3 Additionally, lean mass sparing goals were trient intake.9,10 It also provided the opportunity to intervene throughout suggested as Percent Lean Lost (%Lean Lost), the ratio of lean mass loss to the critical first postoperative year by modifying exercise to improve fat total weight loss; %Lean Lost was the single variable whose postoperative mass loss and/or lean mass sparing.11 This coordination of outcomes with changes were not significant for women following both surgeries or for clinical care strengthened authority of RDN recommendations. RYGB men. 2,3 Achievable results suggested a %Lean Lost goal applicable at all points of measure during the first postsurgical year as <25%Lean Lost As part of each patient’s surgical weight loss journey, the team dietitian for RYGB and SG women, and as <33%Lean Lost for RYGB men (i.e., ≥75% provided an education tool. The tool was a %BF graph printed with of weight loss was attributable as fat mass loss for women, and ≥66% each body composition evaluation that included a mini-spreadsheet of for RYGB men).3 The %Lean Lost goal of <33% was also applicable to SG weight and body composition changes (Figure 1)—essential and tangible men, but only as a 12-month goal because while values improved, they feedback as patients worked toward %BF and %Lean Lost goals.3 The %BF did change significantly throughout the first postoperative year.3 For both graph and spreadsheet were created using a Microsoft EXCEL® program, genders following both surgeries, then, the majority of weight loss was however it would currently be more practical to incorporate this tool into due to fat mass loss while sparing lean mass 2,3; awareness of this poten- the electronic medical record. As another education tool, the team dieti- tial encourages and empowers patients who have struggled with weight tian used a 5-pound body fat replica to both help patients visualize the loss, and the outcomes themselves are important given the recognized dramatic amount of fat lost after surgery and to validate their progress. health risk of excessive fat mass and benefits of maintaining lean mass.5-8 For example, the patient represented in Figure 1 lost 60 pounds of body Characteristics of studies’ variables also indicated that evaluating weight fat one year after surgery. This was demonstrated to her as the equivalent and body composition following both surgeries should optimally be of twelve of the 5-pound body fat replicas. The specificity of body com- gender-specific. 2,3 position evaluation itself also serves as a patient education tool with its Tools and Evidence-Based Practices ability to clarify whether or not a lack of weight loss progress is masked by the desirable outcome of fat mass loss coupled with lean mass gain—an Body composition was evaluated on initial visit, when surgery was sched- important distinction to this patient population. uled once preoperative weight loss goals were met, at required 3, 6, and 12-month visits, at the optional 9-month visit, annually, and as clinically Patients are active participants in bariatric teams. On program entry, indicated. This serial analysis equipped the practitioner to define weight patients were encouraged to adopt healthy food choices and eating loss and personalize patient care by coordinating progress with macronu- patterns and to regularly exercise not only to accomplish designated

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21 Weight Management Matters Volume 19. No. 2 preoperative weight loss goals, but also to equip them to optimize their Preoperative Weight Loss Approaches postsurgical weight loss and body composition outcomes. To successfully The impact of preoperative weight loss approaches on body composition accomplish those changes, patients were encouraged to put some should also be considered. From program initiation to time of surgery, the thought and effort into meal planning. Recommendations both before healthy eating and exercise encouraged in our practice helped patients re- and after surgery included whole food choices of lean meat, fish and duce their %BF so that body fat represented the majority of accomplished poultry, fresh vegetables and fruits, whole grains, legumes, and skim preoperative weight loss. Results from a study in which men with obesity or low fat milk-- choices which are nutrient-rich and enhance satiety followed an 8-week preoperative Mediterranean protein-enriched diet while reducing energy intake, maintaining palatability, and limiting showed a highly significant decrease in weight, liver size, visceral fat, and 12-14 the potentially addictive properties of processed additives. Small fat mass with no significant reduction in lean mass.17 In contrast, an Opti- amounts of healthy fats were encouraged at mealtime to enhance satiety fast® regimen instituted 2 weeks prior to surgery produced significant loss and meet nutritional needs, but overall intake of all fat was limited to of weight and fat mass, and a significant lean mass loss which represented 12-14 control calories. Pre-surgically, patients were also encouraged to chew 62% of total weight loss.8 Among the disadvantages of lean mass loss is its thoroughly and eat slowly in order to search for and perceive satiety as association with weight regain.6 well as promote postsurgical meal tolerance. To help meet postoperative macronutrient needs, maximize micro-nutrient intake, and enhance Call to Action satiety, patients were encouraged to eat three meals daily and to include Routinely utilizing body composition assessment offered invaluable coor- a lean protein food with each meal, especially important with postsurgical dination with clinical care and served as a powerful education tool. These reduced gastric capacity.9,10,14 “Dish Up a Healthy Meal” tear-pad handouts suggested body composition guidelines following RYGB and SG helped were provided and discussed as a preoperative education tool to assist to fill a gap in evidence-based practice and provided a reference to guide with meal planning and healthy food choices.15 Strategies to budget for patients toward the goal of losing predominantly fat while sparing lean these foods were also incorporated into patient education. mass. While more research is needed to solidify these preliminary guidelines into definitive goals, RDNs are encouraged to apply this approach Meal planning to enhance satiety was part of the strategy to discourage demonstrated to benefit both patients and practitioners. mindless between-meal grazing, capable of sabotaging pre- and postoperative weight loss. However, a between-meal snack was planned if needed to fuel postoperative physical activity or to help avoid becoming Kim B Knopp, MS, RD,LD The author just celebrated her 40th anniversary overly hungry if anticipated meals were to be >6 hours apart.16 Pre- as an AND member, and spent almost half of that time as the RDN for a surgically, patients were encouraged to drink 2-3 cups of milk daily. Two Bariatric surgical team. She enhanced clinical practice by hosting interns and to three cups of milk were also encouraged as fluid choices between lecturing for undergraduate university programs as well as publishing and meals after surgery to contribute toward patients’ general daily protein contributing to research papers, poster presentations, articles, newsletters, and carbohydrate needs, to contribute electrolytes, and to help provide and a premier international bariatric cookbook. satiety and fuel physical activity.9,10,16 Surprisingly, postoperative lactose intolerance was seldom an issue, but the RDN was available to suggest alternatives as needed.

Figure 1 Spreadsheet to Accompany % Body Fat Graph

Weight Body Body Fat Lean Lean Weight Date Of Loss Fat Fat Loss Lean Lean Loss Loss

Stage (lbs) Measure (lbs) (%) (lbs) (lbs) (%) (lbs) (lbs) (%)

Initial 213 11/4/13 43 92 57 121

Preop 199 5/8/14 14 42 84 8 58 115 6 43%

3 mo 162 9/8/14 37 31 50 33 69 112 4 10%

6 mo 141 12/16/14 58 28 39 44 72 102 14 24%

9 mo 141 58 28 39 44 72 102 14 24%

12 mo 125 9/8/15 74 19 24 60 81 101 14 19%

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22 Weight Management Matters Volume 19. No. 2 References

1. Thibault R, Pichard C. Overview on nutritional issues in bariatric 9. Moizé V, Andreu A, Rodríguez L, Flores L, Ibarzabal A, Lacy A, et al. surgery. Curr Opin Clin Nutr Metab Care. 2016;19(6):484-90. Protein intake and lean tissue mass retention following bariatric surgery. Clin Nutr. 2013;32(4):550-5. 2. Knopp KB, Sloan Stakleff KD, Daigle CR, Chlysta WJ. Gender-specific weight and body composition changes following Roux-en-Y gastric 10. Faria S, Faria O, DeAlmeida M, DeGouvea H, Buffington C, Furtado M. bypass. Bariatr Surg Pract Patient Care. 2016;11(3):131-6. Recommended levels of carbohydrate after bariatric surgery. Bariatric Times. 2013;10(March):1, 16-2. 3. Knopp KB, Sloan Stakleff K, Thomas TM, Mangira C, Chlysta WJ. Gender influence on weight and body composition following sleeve 11. Hassannejad A, Khalaj A, Mansournia MA, Rajabian Tabesh M, gastrectomy: outcomes suggest potential bariatric surgery body Alizadeh Z. The effect of aerobic or aerobic-strength exercise on composition goals. Bariatr Surg Pract Patient Care. body composition and functional capacity in patients with BMI https://doi.org/10.1089/bari.2019.0068. June 12, 2020. ≥35 after bariatric surgery: a randomized control trial. Obes Surg. 2017;27(11):2792-801. 4. De Luca M, Angrisani L, Himpens J, Busetto L, Scopinaro N, Weiner R, et al. Indications for surgery for obesity and weight-related 12. Rolls BJ, Drewnowski A, Ledikwe JH. Changing the energy density diseases: position statements from the International Federation for of the diet as a strategy for weight management. J Am Diet Assoc. the Surgery of Obesity and Metabolic Disorders (IFSO). Obes Surg. 2005;105(5 Suppl 1):S98-103. 2016;26(8):1659-96. 13. Gearhardt AN, Yokum S, Orr PT, Stice E, Corbin WR, Brownell KD. Neu- 5. Maffetone PB, Rivera-Dominguez I, Laursen PB. Overfat and underfat: ral correlates of food addiction. Arch Gen Psychiatry. 2011;68(8):808- new terms and definitions long overdue. 16. Front Public Health. 2016;4:279. 14. Rolls BJ. The Volumetrics Eating Plan: Techniques and Recipes for Feeling 6. Faria SL, Kelly E, Faria OP. Energy expenditure and weight regain Full on Fewer Calories. Washington, D.C.: National Library Service for in patients submitted to Roux-en-Y gastric bypass. Obes Surg. the Blind and Physically Handicapped, Library of Congress; 2007. 2009;19(7):856-9. 15. Academy of Nutrition and Dietetics. Dish Up a Healthy Meal USA. 7. Belfiore A, Cataldi M, Minichini L, Aiello ML, Trio R, Rossetti G, et al. 2018. Short-term changes in body composition and response to micronu- 16. Sports Nutrition Care Manual. Nutrition Care Manual. trient supplementation after laparoscopic sleevegGastrectomy. http://www.nutritioncaremanual.org. Accessed August 15, 2020. Obes Surg. 2015;25(12):2344-51. 17. Schiavo L, Scalera G, Sergio R, De Sena G, Pilone V, Barbarisi A. Clinical 8. Sivakumar J, Chong L, Ward S, Sutherland TR, Read M, Hii MW. Body impact of Mediterranean-enriched-protein diet on liver size, visceral composition changes following a very-low-calorie pre-operative diet fat, fat mass, and fat-free mass in patients undergoing sleeve gastrec- in patients undergoing bariatric surgery. tomy. Surg Obes Relat Dis. 2015;11(5):1164-70. Obes Surg. 2020;30(1):119-26.

23 Weight Management Matters Volume 19. No. 2 Resolutions the Right Way By: Susan Sullivan, RDN, LD

Did you know that the custom of celebrating New Year’s Day and setting resolutions began some four thousand years ago? Historically speaking, the tradi- tion has evolved, but the concept is still relatively the same. People look forward to the new year as a time for Counseling growth and change, expanding upon or implementing Susan Sullivan, positive behaviors. It should come as no surprise that as Section RDN, LD gym memberships surge in January, people also begin Erin Castle RD, LD is the examining their diet. It is not uncommon for a Registered Dietitian Counseling Section Editor Nutritionist (RDN), settled in the world of nutrition counseling, to have clients expect their RDN to provide input on their new year’s resolutions, Some of our clients feel influenced to lose especially as they pertain to food. As professionals and nutrition experts, weight or try a new diet on a daily basis. They it’s every RDN’s responsibility to offer guidance and support while help- feel it from friends, family, social media, or ing the individual set an appropriate resolution or goal for themselves. even other healthcare providers. A new year can bring extra pressure and an urgency How Effective Goal Setting Motivates our Clients to set nutrition related goals. In this article, Scientists believe that the process of setting specific goals serves “as a Susan Sullivan RDN, LD reminds us to help our clients make subconscious primer for the execution of goals”. 1 Priming is thought to realistic resolutions for themselves to ensure sustainable increase the chances of acting on a goal by increasing motivation, focus improvements in their health. She encourages us to be ready and commitment.1 Theoretically, we make more of an effort to achieve a with evidence based strategies to assess and support our goal when we visualize success and challenge ourselves to plan effective- clients in 2021. ly and thoroughly. Furthermore, if we discuss our goals with an accountability partner, for example, a client discussing their new year’s resolution with their RDN, there’s most likely an added element of determination. An accountability partner helps maximize personal accountability and motivation by offering feedback and input.2 For anyone that has attempted lifestyle intervention. Theories and models include Cognitive Behavioral a five o’clock morning workout, it’s much easier to get out of bed when Therapy, the Transtheoretical Model, and the Social Cognitive Theory/So- you’ve committed to attending with a friend. cial Learning Theory.4 Cognitive Behavioral Therapy (CBT) is a type of talk Setting SMART Goals in 2021 therapy that allows a client to become aware of inaccurate or negative An established technique for setting actionable goals is the “SMART” thinking, in hopes that they will view challenging situations more clearly framework. SMART goals are Specific, Measurable, Attainable, Realistic and respond to them more effectively. An example of CBT during nutri- and Time-bound. These consist of practical, concrete actions that are tion counseling is discussing a client’s busy working day, where they usu- intended to improve knowledge, skills, attitudes and outcomes.1 Interest- ally skip meals or order out, then suggesting realistic strategies to incor- ingly, the SMART goal concept was developed by business professionals porate regular meals and avoid convenience foods. The Transtheoretical in the 1980s. Success with determining and communicating objectives, Model (TTM) or Stages of Change model assesses a client’s readiness to 5 along with a catchy acronym, supported its spread to the counseling and develop and act on health behavior interventions. Stages are as follows, self-help industry.3 Gone are the days of generic goal setting. Instead of pre-contemplation, contemplation, preparation, action, maintenance, a simple, “I will eat better” statement, a SMART healthy eating goal is, “On and relapse. Correctly identifying a client’s “stage” is crucial to leading a Sundays, I will create a balanced weekly meal plan that features three successful session. For example, a client with uncontrolled diabetes, in meals each day, five servings of fruits and vegetables each day, and a the precontemplation stage, unaware of the potential health risks associ- source of protein with each meal and snack”. Specific, measurable, attain- ated with their condition and no intent to change their behaviors in the able, realistic, and time-bound, making it a quality New Year’s resolution foreseeable future, is likely to need more education and a discussion on for a nutrition-focused client. the possible benefits of a carbohydrate-controlled diet prior to setting SMART goals. Whereas a client with heart disease, status post bypass sur- Effective Counseling Strategies for the RDN gery, in the action stage, that has begun exercising and has researched The Academy of Nutrition and Dietetics believes a variety of counseling DASH and the Mediterranean diet, may be more motivated and receptive strategies from different behavior change theories should be utilized to nutrition counseling and goal setting. The Social Cognitive Theory when assessing a client’s motivation, readiness, and self-efficacy for (SCT) or the Social Learning Theory proposes that personal factors,

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24 Weight Management Matters Volume 19. No. 2 environmental factors, and behaviors continuously interact through References influencing and being influenced by each other. A client’s eating behav- 1. Aghera A, Emery M, Bounds R, et al. A randomized trial of SMART iors may be dictated by the fact that they live in a food desert. Thus, an goal enhanced debriefing after simulation to promote educational experienced RDN would research grocery stores, farmers’ markets, road- actions. West J Emerg Med. 2018;19(1):112-120. side stands, and food assistance programs within a reasonable distance 2. Publishing Pulse. Why an accountability partner is crucial to achieve versus providing the client with a rigid meal plan. Learning a client’s your goals. https://www.publishingpulse.com/accountability-part- negative thoughts, assessing their stage of change and discussing ner-personal-accountability-goals/. Accessed November 30, 2020. potential barriers, like a food desert, can be done through Motivational Interviewing (MI). MI is a collaborative, goal-oriented method of com- 3. Rutledge T. Beyond SMART: An evidence-based formula for goal munication between an RDN, or other practitioner, and client.4 Thought setting. Psychology Today. https://www.psychologytoday.com/us/ provoking questions from the RDN encourages a client to express their blog/the-healthy-journey/201910/beyond-smart-evidence-based- personal motives and answer their own questions.4 “What’s your favor- formula-goal-setting. Accessed December 1, 2020. ite meal to cook and why?” lends itself to much more of a discussion 4. Cunningham E. What strategies do registered dietitian nutritionists than, “Do you cook dinner every night?” use to assess a patient’s/client’s weight loss readiness? J Acad Nutr Diet. 2016;116(12):2036. Conclusion The season of change is upon us. Traditionally, January is a time of 5. Leer EV, Hapner ER, Connor NP. Transtheoretical model of health be- increased focus on lifestyle behaviors. An RDN can be certain they will havior change applied to voice therapy. J Voice. 2008;22(6):688-698. be approached by clients and asked to provide insight on diet-related goals and New Year’s resolutions. There is no singular method to offer Susan Sullivan, RDN, LD is a graduate of the Food Science and Human effective guidance. During this time, an RDN should focus on building Nutrition program at Clemson University. She completed her dietetic motivation and confidence with the assistance of the following tools: internship at sites in both Augusta, GA and Columbia, SC. Since then she has teaching SMART goals, assessing client’s hopes and fears with CBT, TTM provided medical nutrition therapy in the hospital setting, and has worked and SCT, and utilizing MI techniques. Following a client and individual- as a nutrition educator and counselor in outpatient clinics, including a izing care may be the key to sustaining change. Happy counseling to all bariatric center. Her passion is helping clients achieve their health and in the new year! nutrition-related goals, especially in regards to weight loss and disease management, which she does now for Carolina Nutrition Consultants, LLC located in Lexington, SC.

25 Weight Management Matters Volume 19. No. 2 Letter from the Chair By: Becky Reeves, DrPH, RDN, FAND Holiday Greetings to everyone and many hopes and • Medical consequences of obesity wishes that 2021 will allow us to return to some form of • WM and improved disease outcomes for the medically complex patient: normalcy. Perhaps we will be able to retire our masks for Obesity, DM, HTN, CVD, CKD good!! • Building a business/telehealth/social media Weight Management leadership will proceed through • Tailoring WM for diverse populations these challenging months with projects and programs to broaden the skills and knowledge of our members. To • Obesity prevention/achieving a healthy lifestyle/relationship with food update you on several of these opportunities, let me begin with the webinar • Long term outcomes for bariatric patients showcasing our stipend recipients. This is slated for January 13, 2021 from 6:00 – 7:00 pm CST. The recipients are: The Professional Development team has organized the following webinars for your continued educational interest over the next few months: • Matthew Landry, PhD • “Confused by the Headlines: Can You Spot the Science” with speakers • Domonique Christian, MS Connie Diekman, M.Ed, RD and Tracy Oliver, PhD, RDN. Date: January 19, 2021 @ 12 pm EST. • Jaime J. Larese, MS, RDN, LN • “Supplements in Bariatrics” with speaker Heather Mackie, MS, RD. • Samantha Lalush, RD Date: February 23, 2021 @ 1 pm EST.

• Kelly West Keyser, MS, RD, LD, CDE • “Exercise as Medicine Toolbox” with speaker Julie Schwartz, M.S., RDN. • Ingrid Hill, MS, RDN, CSOWM Date: March 10, 2021 @ 12 pm EST.

During this hour, they will discuss the motivations, methods, and mentors During the summer and fall, Weight Management took steps to reactivate which have helped them find joy, meaning, and impact in their professional its Diversity Liaison (DI) position within the Leadership team. The Chairs are practice. They will also talk about the impact of WM DPG membership and proud to announce Cicely Thomas, M.Ed, RDN, LD, has accepted the invitation leadership roles which have helped shape their careers. to become our DI. She is currently pursuing a Doctorate in Clinical Nutrition at the University of North Florida. Cicely is the Northwest Georgia WIC Service Look for the announcement of this webinar in upcoming eblasts and register Nutrition Services Director and serves as the nutrition section president for for this fascinating program on the professional lives of these members. the Georgia Public Health Association. Her role within WM DPG will include Our Weight Management Virtual Symposium “Weighing the Evidence, Solu- conducting diversity outreach events to promote the profession to diverse tions for Success” is coming in April 2021. Registration for the symposium individuals and/or increase cultural competency of current practitioners. Re- will begin in January 2021. Three sessions are scheduled for each day, April 1 cently a Diversity Inclusion and Equity Survey was sent to members for their and April 8, so save the dates. The Symposium committee asked prospective input on several questions regarding diversity and 264 members completed speakers to submit program proposals based on the following topic areas: it. An overview of the responses and results will be posted to members in the future. Thank you for your participation in this survey.

Until next time, stay safe, wear your mask and when available, get vaccinated!

Letter from the Editor By: Lisa Paige, MBA, RDN, CSOWM, NBC-HWC Greetings to all, and I hope everyone is staying We have a somewhat hefty issue for you this quarter. Our section editors are healthy. One of my gigs is as a consultant dietitian for working diligently to create up-to-date content for you to use right now in your skilled nursing/long-term care. COVID-19 has hit this practice. When you have a moment, please consider giving them a quick “thanks” population extremely hard. It is sobering to observe to let them know your appreciation. the clinical sequelae of this disease. My heart goes We will have two more newsletter issues for this membership year. If you have out to anyone who has suffered through this disease. ideas and recommendations, please be sure to let us know. You can send an email Please, follow the guidelines for physical distancing, to me at [email protected] or our executive director, Barb Pyper, at mask-wearing, and consider the vaccination if it’s offered to you. I hope to get [email protected]. mine before the end of this year. Best regards,

Lisa

26 Weight Management Matters Volume 19. No. 2