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In recent years, intraabdominal adipose tissue (IAAT) has proven to be strongly related to metabolic abnormalities associated with obesity. Weight reduction programs have promoted weight loss and reduced the health risks that go along with IAAT. Waist circumference correlates well with IAAT and is often used for a marker of visceral adipose tissue, as it appears to accurately reflect the relation between visceral adipose tissue and health risk. Racial differences exist in regards to the risk of obesity-related health problems and therefore attention has focused on the association between risk factors and abdominal fat distribution in white and black populations. Based upon previous research, black women and children appear to have lower distribution of adipose tissue as IAAT than as subcutaneous abdominal adipose tissue (SAAT) than do white women and children. At present, little is known about the effect of weight loss on changes in visceral and subcutaneous abdominal fat distribution in overweight white and black individuals.

The purpose of a recent intervention was to prospectively examine the abdominal fat distribution patterns of overweight weight and black women, before and after weight loss, in relationship to those of never-overweight control women. Subjects included white and black pre-menopausal women between the ages of 20 and 46 years. 23 overweight white women and 23 overweight black women participated. Overweight was defined as having a body mass index (BMI) between 27 and 30 and a family history of obesity in a least one first-degree relative. Twenty-three white and 15 black, never-overweight women served as controls. Subjects were evaluated at baseline when they were overweight, and again at normal weight and underweight, following dietary intervention. Subjects were maintained in a weight-stable state for four weeks, during the final two-week were given meals providing 20 percent of energy as fat, 16 percent as protein, and 64 percent as carbohydrate. All prepared meals for weigh reduction afforded 800 kcal/day. Adherence and body weight were monitored twice weekly until subjects lost 10kg and reached a normal weight, defined as a BMI of <25. On reaching a normal BMI, subjects repeated the protocol to achieve a weight even further below that previously attained. The subjects were sedentary and not instructed to increase physical activity during the intervention period. In each of the weight phases (overweight, normal weight and under normal weight) body composition was determined using the four-compartment model. This model included the analysis of bone mineral content, total body water, and total body density to take into consideration the fact that black women generally have a greater bone mineral content than do white women. The model is used to calculate the percentage of body fat from independent measure of total body density, total body water, and bone mineral content.

Weight loss, losses of total fat, trunk fat and waist circumference were similar in both the white and black women. White women were found to have lost more IAAT and less SAAT than did black women. Changes in waist circumference correlated with changes in IAAT in white women, but not in black women.

This data indicates that white women had significantly more IAAT and significantly more IAAT relative to SAAT than did black women despite comparable decreases in total and trunk fat. Further studies investigating the changes in metabolic risk factors associated with weight loss and gain and body fat distribution in both black and white individuals are needed to gain understanding of the clinical significance of these different racial responses in abdominal fat utilization.

How do carb blockers work, and are they safe?–L.Y., INDIANAPOLIS, IN

Okay, get your Sony Clie out. The active ingredient in many carb-blocking products is a protein called phaseolamin that’s extracted from white kidney beans. The protein attaches to carbohydrates, preventing them from breaking down, thus prohibiting them from being absorbed into the body during digestion.

However, regardless of what’s contained in carb blockers, it’s what you don’t put in your mouth that helps keep your weight in check. So says Melinda Safir, R.D., L.D., staff nutritionist with the Cooper Clinic in Dallas. “If carbohydrate blockers were the magic bullet for achieving weight loss, the epidemic of obesity would never have become the problem that it is today,” she says. “The ability to choose what foods move from your plate into mouth is the most powerful carbohydrate blocker and weight-loss aid on the market. Every product touted as a weight-loss miracle pales in comparison to our own ability to control food selection and intake amount.”

The 65 million Americans who are trying to lose weight spend an estimated $44 billion on their weight-reduction efforts each year. Little is known about the costs of providing weight-loss programs of varying intensity as integral components of healthcare. The levels of weight-loss program intensity described in the National Academy of Science include: self-help, non-clinical, and clinical. Survey data suggests that self-help is the most common weight control approach used in the United States, but clinical trial data suggests that intervention intensity predicts weight loss. The traditional nonclinical approach used by most commercial weight-reduction programs involves an open-group format in which support is provided by the leader and those attending the session. The goal of the current study was to evaluate weight-loss outcomes and the effect on CVD risk factors, and the resources required (from the perspective of a managed care organization) of the self-help, nonclinical, and clinical approaches to weight control. The research evaluated the metabolic effect and costs of a do-it-yourself approach, using a workbook as the minimal intervention control, an expert computer system together with the workbook to optimize use of resources, and the addition of staff consultation to the computer system and workbook as the most intensive intervention.

The randomized, controlled clinical trial evaluated the metabolic effects and costs of three levels of intervention intensity for providing cognitive behavioral weight control intervention in a managed care environment. The study was conducted in a freestanding Health Maintenance Organization (HMO) with an enrollment of 25,000 patients.

Participants were recruited from the HMO’s patient population, and from the surrounding community. The study included 588 individuals (BMI >25 kg/sq m), and achieved an 81 percent completion rate.

The mean energy intake and percent of energy from fat decreased from baseline in all three-intervention groups; there was not a statistically significant difference in the mean nutrient intake change by intervention group. All of the intervention groups reported a mean increase in walking time, as well as in the number of blocks walked each day. All of the groups achieved a statistically significant weight loss. The most intensive intervention group (workbook with computer and staff added) lost significantly more weight than the least intensive (workbook-alone) group. The mean weight loss in the intermediate group (workbook and computer) was not significantly greater than the weight loss in the workbook-alone control group.

The most intensive intervention group had a significant increase in the mean HDL cholesterol levels and a decrease in the mean diastolic blood pressure level. The mean amount of clerical time utilized per participant in each of the randomization groups was 1.35 minutes for the least intensive group. 2.28 minutes for the intermediate intensive group. and 2.47 minutes for the most intensive group. The mean amount of professional staff time utilized in conducting the most intensive intervention was 227.1 minutes per participant. The cost of staff time per participant for each intervention group over the 12-month study period, was $0.35 for the least intensive group. $0.59 for the intermediate intervention group, and $92.33 for the intensive intervention group.

The findings suggest that the computer tailoring of weight-control programs may facilitate implementation of weight-control programs in HMOs. In the current randomized trial, the most intensive intervention resulted in a significantly greater mean weight loss compared with the do-it-yourself control arm. The computer tailoring system promoted diary keeping, which in turn was associated with greater weight loss. Although the cost per pound lost was the lowest in the least intensive intervention group, the satisfaction with the program increased as the intervention intensity increased.

Dietitians and other healthcare professionals should consider using computer-based communications to maintain frequent contact, promote self-monitoring, and tailor behavioral goals. Managed care organizations could potentially incorporate all three options as preventive health services. Patients could opt for an approach based on availability and personal preference for learning method and time.

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Michael Schooff, M.D., presents a clinical scenario and question based on the Cochrane Abstract, along with the evidence-based answer and a full critique of the abstract.

Clinical Scenario

A 40-year-old overweight woman seeks advice on weight loss.

Clinical Question

Are low-fat diets better than other weight-reducing diets in achieving long-term weight loss?

Low-fat diets are no better than low-calorie diets in achieving weight loss in overweight or obese people. In studies, the average weight loss after 18 months on either diet was less than 5 lb.

Cochrane Critique

Did the authors address a focused clinical question? Yes.

Were the criteria used to select articles for inclusion appropriate? Yes.

Is it likely that important relevant articles were missed? No.

Was the validity of the individual articles appraised? Yes.

Were the assessments of studies reproducible? Yes.

Were the results similar from study to study? No. Five of the six trials had very similar results (a nonsignificant greater weight loss in patients on low-calorie diets compared with those on low-fat diets). In one study, the greater weight loss on low-calorie diets was significant at each time point. One way in which this trial differed from the others is that the patients on the low-calorie diet reduced both their fat and carbohydrate consumption, instead of restricting only carbohydrates.

Can the results be applied to patient care? Yes.

Do the conclusions make biological and clinical sense? Yes.

Practice Pointers

In the trials reviewed, patients lost an average of 11 to 14 lb after six months on either diet, but by 18 months their net weight loss averaged zero to 5 lb. This review demonstrates the challenge that overweight and obese patients face as they attempt to lose weight.

The National Heart, Lung, and Blood Institute issued evidence-based recommendations to identify, evaluate, and treat overweight and obese adults. According to the recommendations, a variety of methods can be used to initiate weight loss. However, a long-term weight maintenance program is needed to sustain weight loss. Long-term success after initial weight loss requires a program of dietary therapy, physical activity, and behavior therapy. Drug therapy also might be useful but has not been studied beyond one year. Weight maintenance should begin after the initial six months of weight-loss therapy. Frequent contacts between the patient and practitioner over the long term are more successful. (2)

Overall, there is no evidence that low-fat diets are any better than low-calorie diets in achieving weight loss in overweight or obese people. This review did not address the addition of pharmacotherapy to fat or calorie restriction, nor did it evaluate trials of restricted carbohydrate (high-protein) diets, which seem to be gaining popularity in the lay population and provoking controversy among some experts. (3-6) There also is little evidence that either diet produces clinically significant weight loss beyond a few months’ duration if patients do not follow a weight maintenance program after the initial weight loss. Weight management requires a long-term commitment beyond the initial weight-loss period. As I tell my patients, if there were an easy way to keep weight off, I’d look more like Superman and less like the Michelin Man.

REFERENCES

(1.) Pirozzo S, Summerbell C, Cameron C, Glasziou P. Advice on low-fat diets for obesity. Cochrane Database Syst Rev 2002;2: CD003640.

(2.) Clincial guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Accessed September 2002 at: www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm.

(3.) Astrup A. Dietary fat is a major player in obesity–but not the only one. Obes Rev 2002;3:57-8.

(4.) Willett WC. Dietary fat plays a major role in obesity: no. Obes Rev 2002;3:59-68.

(5.) Taubes G. What if it’s all been a big fat lie? New York Times Magazine July 7, 2002. With free registration, accessed September 2002 at: www.nytimes.com/2002/07/07/magazine/07FAT.html (password required).

(6.) Turning the food pyramid upside down. Harvard Health Publications. Accessed September 2002 at: http://www.health.harvard. edu/tools/pyramid.htm.

RELATED ARTICLE: Cochrane Abstract

Background. Overweight and obesity are global health problems contributing to an ever-increasing disease burden. Calorie restriction can achieve short-term weight loss, but the loss has not been shown to be substantial in the long term. An alternative approach to calorie restriction is to lower the fat content of the diet. However, the long-term effects of fat-restricted diets on weight loss have not been established.

Objectives. To assess the effects of advice about low-fat diets as a means of achieving sustained weight loss, using all available randomized clinical trials. This review (1) focused primarily on participants who were overweight or clinically obese and were dieting for the purpose of weight reduction. Because the authors were particularly interested in the ability to sustain weight loss over a longer period of time, they focused on studies of “free living” men and women who were given dietary advice rather than provision of food or money for food.

Congressional hearings in the early 90s revealed that some commercial weight-loss programs made false and misleading claims in marketing their products. These hearings led the Federal Trade Commission (FTC) to file consent degrees with several companies, which agreed to stop airing questionable advertisements. Companies were required to provide data to support claims of long-term weight control, and any testimonials had to be accompanied by a disclaimer that `results may not be typical.’ Some groups, including the Center for Science in the Public Interest, believed that these measures did not go far enough to protect consumers. In response to this concern, the FTC convened a panel comprising members from academia, industry, consumer advocacy, the National Institutes of Health, and the FTC to develop voluntary guidelines for the disclosure of information concerning weight-loss programs. The panel recommended that commercial weight-loss programs voluntarily provide to consumers information about the risks of overweight and obesity, staff qualifications and the central components of their interventions, and the safety and costs of their programs, in response to these panel meetings, the Partnership for Healthy Weight Management was established in February 1999. Soon thereafter, the Partnership issued the Voluntary Guidelines for Providers of Weight Loss Products or Services, which specified the content and tone of the information that should be provided to consumers. The guidelines drew on earlier efforts of an expert panel convened by the Institute of Medicine, however, they were drafted without the benefit of specific data from consumers concerning the information they desired when choosing a weight-loss program.

This pilot study sought to determine the type of information that obese individuals would like to be provided when choosing a commercial weight-loss program. The researchers were trying to determine whether the disclosure guidelines proposed by the Panel reflected the actual interests of consumers. Participants were 90 women, 65.6% white, with a mean age of 44 years, weight of 97 kg, and body mass index (BMI) of 36 kg/[m.sup.2]. They were consecutive enrollees in two randomized controlled trials on the behavioral treatment of obesity.

Before treatment, participants completed a questionnaire called Choosing a Weight-Loss Program and were asked to rate how important each of the 16 factors would be in helping them select a plan. Ratings were made using 5-point scales, anchored by `not at all important’ and `extremely important’ (scored 1 and 5 respectively). Participants also identified the five factors that they thought were the most important, as well as the single most important.

The mean rating for the importance of safety was significantly greater than that for each of the 15 other variables. In addition, significantly more respondents (27.8%) selected safety as the single most important factor than any other variable. Other factors that were consistently judged as very important included information about diet, behavior modification, cost, and maintenance of weight loss. Staff credentials were among the lowest rated items. When asked what data they would want if they could only have 5 pieces of information, participants most frequently selected the following items: cost (selected by 62.22% of respondents): prescribed diet (58.89%); safety (55.56%); typical weight loss (52.22%); and behavior modification (50.00%). Information about types of meetings and exercise was also important to participants, however information on exercise was rated as significantly less important than that concerning diet, possibly reflecting the greater emphasis that weight-loss advertisements place on diet.

The results generally support the disclosure guidelines proposed by the Partnership for Healthy Weight Management. Consumers, however, seem to desire information about weight loss, in addition to that concerning safety, cost, and general program components. The researchers encourage additional providers of commercial weight-loss programs, as well as manufacturers of weight-loss products, to report data on the safety and efficacy of their interventions to assist consumers in making fully informed decisions.

Many drugs used in the chronic management of neuropsychiatric disorders, including certain anticonvulsants and mood-stabilizing agents, can cause significant weight gain in adults. Because even modest degrees of sustained weight gain are associated with increased risk of complications, drug-induced weight gain may represent a potential safety issue, especially in patients with pre-existing health risks that could be aggravated by added weight. For such patients, therapies that have positive effects on weight control by not causing inappropriate weight gain or by producing weight loss in overweight/obese patients should be considered.

Topiramate is a neurotherapeutic agent approved to treat epilepsy and under investigation for the treatment of other disorders. In previous studies, topiramate was associated with weight loss, suggesting a correlation between the degree of weight loss and both topiramate dose and pretreatment weight. However, these studies were short and were not specifically designed to evaluate the effect of topiramate on weight or factors correlating with weight loss. Therefore, a recent study published in Obesity Research assessed the effects of topiramate on weight and associated physiological and metabolic measures in adults with epilepsy to identify potential predictors of weight loss.

A total of 49 adults with epilepsy were included in this prospective one-year study. Topiramate was added to existing anticonvulsant therapy at a starting dose of 25 mg/ day and increased biweekly in 25- or 50-mg increments to the best tolerated dosage providing maximum seizure control. At the baseline visit and two subsequent visits, body weight was measured and food intake data were collected. Body composition was also measured. Laboratory studies included a 75 g oral glucose tolerance test, thyroid hormones ([T.sub.3], r[T.sub.3], [T.sub.4], TSH), a fasting lipid profile and a leptin radioimmunoassay.

The mean topiramate dose after three months was 81 mg/day. Seizure frequency was reduced by 59%. A clinically significant response was recorded in 53% of patients, with 35% reporting no seizures during the first three months, in patients completing one year of topiramate treatment, mean weight loss was 3 kg after three months and 5.9 kg after one year. In obese patients, mean weight loss was 4.2 kg at 3 months and 10.9 kg at one year. Weight loss was primarily caused by reduction in body fat mass. Early in the therapy, caloric intake paralleled weight loss. However, with continued topiramate treatment, caloric intake returned to baseline levels, whereas weight loss continued. Topiramate treatment was also associated with a significant reduction in fasting total cholesterol at three months and one year and leptin levels were also significantly reduced after one year.

This is the first prospective study specifically evaluating weight change as a result of topiramate treatment. The results suggest that weight loss occurs in most adults and is sustained for at least one year. As expected, weight loss was associated with expected improvements in glucose, insulin, and total cholesterol levels. The combination of weight loss and metabolic improvements seen with topiramate may be the reason to evaluate the potential benefits of this drug for the metabolic syndrome and type 2 diabetes.

At least two diet-aid tablet manufacturers are hoping to parlay their relative success in the weight-loss segment across the aisle into dietary supplements.

The makers of TrimSpa are hoping to drive multivitamin sales by appealing to a younger demo graphic with a marketing campaign that features motor sport sponsorships, a strategy the company has used to great success with its diet-aid brand. Earlier this year, the company launched three SKUs of its WinFuel line: Men’s Formula, Women’s Formula and GenNext, a supplement for young children.

Window Rock Health, which distributes CortiSlim, has introduced three SKUs–the cholesterol health supplement Relesterol, PreMS for relief of premenstrual symptoms and Estramin to help with post-menopausal symptoms–in a move to diversify its portfolio.

It may not be a bad move–sales of diet aids fell 19.8 percent to $65.9 million in chain drug for the 52 weeks ended July 16, according to ACNielsen data. And that fall would have been a lot sharper if not for Trimspa and CortiSlim-a pair of diet aids that are still growing.

Only one simple and often overlooked step can drastically change how successful you are in losing weight and shaping your body, as well as eliminating those nagging health problems like bloating, constipation and low energy levels.

If you have ever unsuccessfully battled any of these health concerns, or others, this may be the most important article you will ever read …

Why Most People Have Trouble Losing Weight And Improving Their Health …

“It’s not your fault!” proclaims Jim Caras, author of the weight loss and corrective health book How to Completely Reshape Your Body! “Most people unknowingly and ineffectively end up using extreme diets, rigorous exercise programs, harmful stimulants, diuretics, laxatives and prescription drugs to find relief from overweight conditions and other common health problems like bloating. They just have never been told that one of the underlying reasons for being overweight and having nagging health problems is the formation and build-up of intestinal toxins.”

Caras continues, “Once we truly understand that the single greatest challenge our body faces is the effective removal of wastes and toxins, we will never again underestimate the importance of cleansing and proper elimination. For these reasons, I frequently counsel that all my clients consider taking a quality colon cleansing formula to help prevent the formation and aid in the removal of intestinal toxins …”

“For those wanting to lose weight and shape their body, this is absolutely crucial as it creates the environment for more rapid and successful results. It will also help to flatten the waistline and eliminate bloating in most cases.”

The “First Step” To Optimal Health

Those starting or currently on any weight loss, body shaping or anti-aging program should consider cleansing as the first step. Colon cleansing is one of the most important steps–and usually the most overlooked–when attempting to lose weight, shape the body, flatten the waistline, improve the immune system, digestive and eliminative systems, help certain health problems, and achieve optimum health.

… Caused By Everyday Living?

Every day when we eat foods, drink water (including bottled) and breathe air, we are exposed to and ingest preservatives, toxins, chemicals and pollutants–they are everywhere. And, no matter how careful we are in the foods we choose to eat and in our lifestyles, we cannot avoid them.

A frightening fact is that most people do not realize that the typical, everyday foods and beverages that we consume, cause our bodies the most problems. These are processed foods like bread, pasta, pizza, white rice, any food containing white flour; mucus forming foods such as some dairy products; sugar and alcohol products; and even fruits and vegetables exposed to pesticides and other chemicals. Many of these have just become commonplace in our lives with everyone having consumed them at one time or another.

The Silent Problem Inside You …

The problem is that the body cannot properly digest and eliminate some of these foods and the substances they contain–and they can become lodged or stuck in the lining of our intestinal tract in the form of old, dried fecal matter and mucus. It is estimated that the average person can have between 4-25 pounds of this “built-up” intestinal matter in their colon–and it can just keep accumulating over the years!

“The intestines can store a vast amount of this partially digested, putrefying matter,” claims natural health expert, Richard Anderson, N.D., N.M.D. “Some intestines, when autopsied, have weighed up to 40 pounds and were distended to a diameter of 12 inches with only a pencil-thin channel through which the feces could move. That 40 pounds was due to caked layers of encrusted mucus, mixed with fecal matter, bizarrely resembling hardened blackish-green truck tire rubber or an old piece of dried rawhide.”

Dr. Anderson calls this accumulation “mucoid plaque.” “This mucoid plaque,” he says, “when it is removed during an intensive colon cleanse, often shows ropelike twists, striations, overlaps, folds, creases–the shape and texture of the intestinal wall.”

Mucoid plaque may vary considerably, depending on the chemical conditions in a person’s intestines. It may be hard and brittle; it may be firm and thick; tough, wet, and rubbery; soft, thick, and mucoid; or soft, transparent, and thin; it can range in color from light brown, black, or greenish-black to yellow or grey, and sometimes emits an intensely foul odor.

The trouble is once mucoid plaque is created, it is not routinely excreted from the intestines, affirms Dr. Anderson. “Instead, it lodges in the numerous folds and crevices of this large organ and can remain there for many years. Over time, the mucoid plaque grows thicker, firmer, and more widespread–colonizing throughout the tennis court-sized interior of the intestines. Old feces adhere to the plaque and are not removed even during normal bowel movements.”

Confounding our need to experience the normal two to three complete bowel movements daily as well as receiving optimal nutrition from the foods and supplements we consume, the plaque slows down intestinal action, effecting waste excretion and also interfering and preventing nutrient absorption. It can harbor pathogens, including bacteria and parasites, which actually hide underneath the plaque; it may block the normal outflow of lymph and mucin drainage. Also, it can bind toxins to itself and emit them into the bloodstream.

Preventing weight loss and malnutrition–and the occurrence of pressure ulcers that these can contribute to–is a hot topic for long-term care facilities. As a result, survey citations, civil lawsuits, and Medicare fraud prosecutions related to nutrition have become routine risk-management issues. Facilities across the country, however, have implemented successful strategies for managing nutrition, and we have incorporated their “best practices” into a scorecard (Figure). Although this scorecard has not been scientifically tested, facilities might find it useful in assessing and improving their nutritional programs, as well as giving them new ideas.

Managing nutrition requires a multidisciplinary approach, involving administration, the rehab/therapy-departments, the nutrition professional, nursing, and the medical director. This article will highlight some of the nutritional best practices as they relate to each of these key players on the facility “nutrition team.”

“Nutrition Team” Members’ Roles

Administration. The facility administrator has an important leadership role in the caregiver team. By being present in the dining room at least once weekly, he or she demonstrates to other staff members that mealtime is an important activity. Regular visits by the administrator also have a positive effect on resident satisfaction and families’ initial impressions when touring the facility.

In addition, these routine visits are important because the dining room is one of a facility’s major cost centers. The hours spent there by certified nursing assistants (CNAs) alone, especially on the day shift, represent a significant cost. Add to that the wages of the dietary staff, costs of food, and supplement expenses, and it becomes obvious that the dining room deserves and requires the administrator’s attention.

The administrator must make it a point to know who’s in charge of the dining room. This would seem obvious, but although in some facilities it is supervised by the dietary director and in others by the assistant director of nursing, the dining room often has no particular staff person in charge. For all practical purposes, this means that the employees working there determine the rules– certainly not an advisable way for a business to operate one of its major cost centers. Each facility needs to decide who would be the best person to oversee its dining room, but someone definitely should be in charge.

One method to help administration stay on top of important issues in the dining room is to use a checklist that includes issues surveyors look for there. Daily checking ensures that potential or existing problems are addressed in a timely manner. Issues to consider in the dining room are:

* availability of adaptive equipment;

* correct diets for residents;

* correct food/fluid textures; and

* availability of substitutes for residents not eating planned menu items.

Using a checklist and having a specific person in charge of the dining room will help ensure that dining needs–such as food dislikes, a decline in a resident’s ability to feed him/herself, or behavior problems–are being communicated to the appropriate staff member who can help.

Rehab/therapy departments. A rehabilitation dining program is an important resource for residents with declining self-feeding skills. By being present regularly in the dining room, occupational-and speech-therapy staff can screen for eating, swallowing, and positioning difficulties. This can help maintain and prevent declines in residents’ ability to feed themselves. In addition to maintaining the best quality of life possible for residents, identifying their needs in these areas can lead to additional Medicare Part B therapy referrals, as well.

Nutrition professionals. The registered dietitian, who generally serves the facility on a consultant basis, and the facility’s dietary department form a vital component of the team that oversees nutrition. The administrator usually decides how many hours each week the facility needs a consultant dietitian. A minimum of eight hours weekly for every 100 residents is generally recommended. Allowing adequate time for consultation is essential to positive outcomes. It is also recommended that the consultant dietitian communicate with both the DON and the food-service director during each consultation visit. It should go without saying that to benefit from the consultant dietitian’s recommendations, the facility must implement them.

The dietary department plays a critical role in meeting residents’ needs for food and fluids. The dietary staff needs to make critical information regarding residents’ nutritional needs and problems available to the consultant dietitian.

One area of concern for nutrition professionals is residents’ end-of-life wishes regarding nutrition and hydration. When residents are first admitted, it is important to determine whether they have completed advance directives regarding these issues, which specify the nutritional support they want or don’t want to receive if they later become unable to make their own medical decisions. Determining this at admission provides an opportunity for the resident and family to discuss the resident’s future wishes if advanced directives have not already been completed prior to admission. Making the best decisions for residents regarding such weighty matters requires presence of mind; therefore, the best time to discuss them is at admission, not after the resident already has begun to lose weight or has trouble eating.

In obesity, changes in the heart structure can be partially explained by the increase of total blood volume leading to volume overload, hypertension, left ventricular hypertrophy (LVH), and/or left ventricular dysfunction (LVD). Although patients with LVH have improved survival rates when medicated in the early stages of the disease, diagnosis may be difficult. Aminoterminal pro-brain natriuretic peptide (NT-proBNP), secreted from the left cardiac ventricle as a response to overload and ventricular damage, correlates with echocardiographic results. Therefore, the introduction of a serum assay that provides accurate information on the cardiac status of a patient may be useful. Because of the superiority of bariatric surgery, including laparoscopic adjustable gastric banding (LAGB), for the reduction of comorbidities, the researchers evaluated the effect of weight loss on NT-proBNP levels.

Thirty-four patients were enrolled (5 men, 29 women; mean age 40.65 [+ or -] 9.86 years) when they were referred to the Outpatient Obesity Department for surgery (LAGB group). All patients underwent LAGB (Lap-Band, BioEnterics, Carpinteria, CA). A healthy, non-obese, age- and sex-matched group of 34 participants was recruited from the hospital staff. All enrolled subjects were examined at the beginning of the study period, and the LAGB group again after a follow-up period of 12.13 [+ or -] 4.7 months. Blood samples were gathered after a 12-hour fast and a 10-minute rest in a lying position.

The cumulative weight loss in the LAGB group was 18.37 kg for the mean study period of 12 months. Subjects with LAGB weighed 127.3 [+ or -] 18.41 kg before and 107.75 [+ or -] 17.45 kg after surgery, which resulted in a reduction of BMI from 43.22 [+ or -] 3.42 kg/[m.sup.2] to 37.08 [+ or -] 5.86 kg/[m.sup.2] and a percentage of excess weight loss of 31.81 [+ or -] 18.51%. Systolic and diastolic blood pressure were lowered significantly after LAGB, but was still significantly higher after surgery when compared with controls. Plasma NT-proBNP concentration was significantly higher before LAGB than in normal-weight subjects. At 12 months post-LAGB, NT-proBNP concentration decreased significantly. Compared with normal weight subjects, NT-proBNP levels still remained significantly elevated in the LAGB group.

This study demonstrated elevated levels of NT-proBNP in morbidly obese patients and its decrease as an effect of significant weight reduction after LAGB. Recently, BNP and NT-proBNP have received major attention as cardiovascular markers because these peptides are secreted in cases of volume overload and increased ventricular wall tension. Because the morbidly obese subjects in the present study were still moderately overweight at the end of the study, NT-proBNP levels remained significantly higher compared with lean subjects. The extent of weight loss might contribute to the reduction of NT-proBNP because changes in NT-proBNP levels were significantly lower in the group of poor responders than in the group with greater weight loss. Therefore, in obesity, NT-proBNP might be useful as a routine screening method for identifying left ventricular hypertrophy and/or left ventricular dysfunction.