Highlights From the North American Society for the Study of Obesity Annual Meeting: A Physician's View

Raymond A. Plodkowski, MD


December 01, 2003

In This Article

Nutrition Assessment

Before a diet and physical activity program can be implemented, the practitioner must complete a nutrition assessment. Sachiko St. Jeor, PhD, RD, from the University of Nevada, Reno, gave a presentation regarding new trends in nutrition assessment using the medical model.[8] First, comprehensive information must be elicited from the weight-loss candidate. This information includes the motivation for losing weight; exclusionary factors for weight loss (eg, pregnancy); past history of usual, desired, highest, lowest, and preferred body weights; and a history of methods used with past dieting attempts (and results). These factors are important to document and to consider for a personalized weight management plan. In addition, the following should be determined: nutrition/obesity-related signs/symptoms and physical findings such as properly measured height (using a wall-mounted height board or stadiometer); weight (using a calibrated balance-beam scale); body mass index (BMI) in kg/m2; waist circumference; and body composition (% body fat) measured by a bioimpedance scale (eg, Composition Analyzer, Tanita Corporation, Arlington Heights, Illinois). The assessment of energy balance (intake and output) is key to establishing the treatment plan. Energy intake or dietary intake (kcal/d) can be assessed by traditional means using food records or diet recalls. Average weight gain in the past 6 months to 1 year can also be used to derive an estimate of excess energy intake (eg, + 5 lbs/6 months ~+100 kcal/d excess). Energy expenditure can be estimated by using predictive equations, such as the Mifflin-St. Jeor equations (MSJE).[9,10] The formulas for resting energy expenditure (REE) in kcal/day are:

Females:   10 x wt (kg) + 6.25 x ht (cm) - 5 x age (y) - 161 = kcal/d

Males:   10 x wt (kg) + 6.25 x ht (cm) - 5 x age (y) + 5= kcal/d

The REE result is multiplied by an activity factor (AF) of 1.3 for sedentary individuals (eg, office worker) and can be adjusted upward to 1.4 or 1.5 for more active individuals. An estimate of average intentional exercise or other activity per day can also be added to derive the total energy expenditure (TEE) per day.

It is now also possible and practical to measure REE via an office-based portable medical device. The REE is also known as the resting metabolic rate (RMR) and can be measured using the Body Gem (HealthTech, Inc, Golden, Colorado). The hand-held device monitors inspired and expired air flow, oxygen levels, and environmental conditions to measure oxygen consumption and uses the Weir equation to derive kcal or energy expended. In a study of 63 adults, RMR measured using the Body Gem correlated (r = 0.91) with measurements using the Douglas bag technique.[11]

Recommendations then should be made for a balanced deficit diet (BDD) to induce a weight loss of 0.5 to 1 lb/wk, depending on the individual. If a person is not able to adhere to a caloric deficit to lose weight, then a weight-maintenance diet (kcal intake = TEE) should be used to prevent any further weight gain. Dietary strategies should follow individual, tailored approaches for the best success.

Dr. St. Jeor also addressed the issue of reimbursement for medical nutrition services. She stated that documentation of the nutrition assessment should encourage more sophisticated use of the new ICD-9-CM codes for obesity (obesity unspecified [278.00]), morbid obesity (278.01), and dysmetabolic syndrome (277.7), along with codes for primary or associated disease manifestations, such as athersclerosis (414.01) and diabetes (250.00). Key to successful management of obesity is appropriate evaluation, treatment, and reimbursement for the services rendered by medical professionals.


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