Evaluating Evidence-Based Nutrition Support Practice Among Healthcare Professionals With and Without the Certified Nutrition Support Clinician Credential.

BACKGROUND: The National Board of Nutrition Support Certification credentials healthcare professionals and certifies that holders of the Certified Nutrition Support Clinician (CNSC) credential have specialized knowledge of safe and effective nutrition support therapy. The purpose of this pilot study was to survey healthcare professionals affiliated with the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) regarding their approaches to nutrition support practice using a complex patient case scenario in accordance with established clinical guidelines. MATERIALS AND METHODS: An electronic survey was emailed to individuals affiliated with A.S.P.E.N. Eight multiple-choice knowledge questions addressed evidence-based nutrition support practice issues for a patient with progressing pancreatitis. Demographic and clinical characteristic data were collected. RESULTS: Of 48,093 email invitations sent, 4455 (9.1%) responded and met inclusion criteria. Most respondents were dietitians (70.8%) and in nutrition support practice for 10.3 years, and 29.3% held the CNSC credential. Respondents with the CNSC credential answered 6.18 questions correctly compared with 4.56 for non-CNSC respondents (P < .001). For all 8 questions, CNSC respondents were significantly more likely to choose the correct answer compared with non-CNSC respondents (P < .001). CONCLUSION: Professionals with the CNSC credential scored significantly higher on a complex case-based knowledge assessment of guideline recommendations for the nutrition support treatment of pancreatitis compared with those without a credential.

Proceedings From FDA/A.S.P.E.N. Public Workshop: Clinical Trial Design for Intravenous Fat Emulsion Products, October 29, 2013.

The development of intravenous fat emulsion (IVFE) is the culmination of physiological, biochemical, nutritional, and medical scientific advancements. IVFEs have the ability to deliver critical nutritional substrates to the patient. Recent literature purports that they may also play roles in modulation of immune functionality and pulmonary physiology, but data supporting these potential benefits are limited. While soybean-based IVFEs have comprised the dominant fat in U.S. markets, a number of other novel IVFEs may prove to optimize the care of children and adults in both hospitalized and home settings. The October 2013 U.S. Food and Drug Administration (FDA)/American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Public Workshop brought together scientists, researchers, and clinical experts to present updated clinical perspectives of IVFEs, including historical development, current state of usage throughout the world, and considerations for the regulatory approval of new IVFEs in the United States.

Characteristics and current practice of parenteral nutrition in hospitalized patients.

BACKGROUND: For 40 years, parenteral nutrition (PN) has provided therapeutic benefits to patients unable to receive oral/enteral nutrition. Very limited published evidence exists to describe modern PN practices or characteristics of patients receiving PN. The aim of this article was to describe the characteristics of hospitalized patients receiving PN in 196 U.S. hospitals to define patient groups at risk for PN-related complications. This will provide researchers a baseline understanding about who is receiving hospital-based PN to maximize generalizability and validity of future research. METHODS: Claims data from the Premier Perspective database, the largest inpatient clinical database in the United States, were used to evaluate hospital-based PN practices. Data gathered between January 2005 and December 2007 included a total of 106,374 patients receiving PN. A total of 68,984 adults (age ≥ 18 years), 34,307 infants (age <1 year), and 3083 pediatric patients (age 1-17 years) were evaluated. Key variables such as admitting diagnosis, infection rates, in-hospital mortality, and costs were extracted. RESULTS: Hospitalized patients requiring PN in the United States are older and more often white than the overall hospitalized population. Hospitalized PN patients are more likely to be admitted emergently and have a higher severity of illness. Bloodstream infection rates in adult PN patients (25.5%) were considerably higher than in pediatric (14.7%) or neonatal patients (1.7%) receiving PN. CONCLUSIONS: These findings are the first large-scale description of "real-world" hospital-based PN practices in the United States, helping set a baseline for future PN research.

Steroidal compounds in commercial parenteral lipid emulsions.

Parenteral nutrition lipid emulsions made from various plant oils contain steroidal compounds, called phytosterols. During parenteral administration of lipid emulsions, phytosterols can reach levels in the blood that are many fold higher than during enteral administration. The elevated phytosterol levels have been associated with the development of liver dysfunction and the rare development of liver failure. There is limited information available in the literature related to phytosterol concentrations in lipid emulsions. The objective of the current study was to validate an assay for steroidal compounds found in lipid emulsions and to compare their concentrations in the most commonly used parenteral nutrition lipid emulsions: Liposyn(®) II, Liposyn(®) III, Lipofundin(®) MCT, Lipofundin(®) N, Structolipid(®), Intralipid(®), Ivelip(®) and ClinOleic(®). Our data demonstrates that concentrations of the various steroidal compounds varied greatly between the eight lipid emulsions, with the olive oil-based lipid emulsion containing the lowest levels of phytosterols and cholesterol, and the highest concentration of squalene. The clinical impression of greater incidences of liver dysfunction with soybean versus MCT/LCT and olive/soy lipid emulsions may be reflective of the levels of phytosterols in these emulsions. This information may help guide future studies and clinical care of patients with lipid emulsion-associated liver dysfunction.

The ratio of energy expenditure to nitrogen loss in diverse patient groups--a systematic review.

BACKGROUND & AIMS: The ratio of energy expenditure to nitrogen loss respectively of energy to nitrogen provision (E/N) is considered a valuable tool in the creation of an enteral or parenteral formulation. Specific E/N ratios for parenteral nutrition (PN) have not yet been clearly defined. To determine the range of energy expenditure, nitrogen (protein) losses, and E/N ratios for various patient groups, we performed a systematic review of the literature. METHODS: Medline 1950-2011 was searched for all studies on patients or healthy controls reporting energy expenditure and nitrogen loss at the same time. RESULTS: We identified 53 studies with 91 cohorts which comprised 1107 subjects. Mean TEE ± standard deviation (SD) was 31.2 ± 7.2 kcal/kg BW/day in patients (n = 881) and 35.6 ± 4.3 kcal/kg BW/day in healthy controls (n = 266). Mean total protein loss (TPL) was 1.50 ± 0.57 g/kg BW/day in patients and 0.94 ± 0.24 g/kg BW/day in healthy controls. A non-linear significant correlation was found between TPL and the E/N ratio. CONCLUSION: The E/N ratio is not a constant value but decreases continuously with increasing protein loss. These variations should be considered in the nutritional support of patients.

Bloodstream infections in patients receiving manufactured parenteral nutrition with vs without lipids: is the use of lipids really deleterious?

BACKGROUND: This study compared overall bacterial and bloodstream infection rates in patients receiving premixed parenteral nutrition (PN) with vs without lipid emulsion. METHODS: Data from hospitalized patients who were ≥18 years of age and receiving premixed PN between 2005 and 2007 were extracted from the Premier Perspective database. Data were categorized into 2 groups: patients who received premixed PN only and those receiving premixed PN with lipids. Multiple logistic regression was used to adjust for risk factors and potential confounders, reporting the probability of risk for an infection. RESULTS: The group without lipids was observed to have lower rates of both overall bacterial infection (43.5% vs 53.5%) and bloodstream infection (14.5% vs 18.9%). However, after adjusting for baseline characteristics, there were no significant differences in overall risk of bacterial infections (51.4% vs 53.5%; odds ratio [OR] = 1.11; 95% confidence interval [CI], 0.96-1.27) or bloodstream infections (19.6% vs 19.2%; 0.97; 0.81-1.16). In a subset of patients in the intensive care unit for ≥3 days, lower overall bacterial infection rates (58.3% vs 67.3%) and bloodstream infection rates (31.0% vs 37.0%) were observed in the group without lipids. After adjustment, there were no significant differences in risk of overall bacterial infection (OR = 0.95; 95% CI, 0.75-1.22) or bloodstream infection (0.92; 0.71-1.19) between the 2 groups. CONCLUSIONS: When administered with premixed PN, lipid emulsion was not significantly associated with an increase in the risk of infectious morbidity when compared to omitting lipids from therapy.

Oleic acid inhibits stearic acid-induced inhibition of cell growth and pro-inflammatory responses in human aortic endothelial cells.

Saturated fatty acids (SFAs), significant components of both enteral/parenteral nutritional formulations (including diet), are linked to cardiovascular disease complications, such as atherosclerosis. We investigated whether oleic acid (C18:1n-9) reduces the growth inhibitory and pro-inflammatory effects of the stearic acid (C18:0) in human aortic endothelial cells (HAEC). Stearic acid induced growth inhibition at concentrations less than 50 µM, whereas higher concentrations invoked cytotoxicity. Stearic acid-induced growth inhibition and cytotoxic effects were eradicated upon cosupplementation with oleic acid (25 µM). Oleic acid (as low as 5 µM) also inhibited the stearic acid-induced increase in intercellular adhesion molecule-1 (ICAM-1) expression. Stearic acid-induced phosphorylation of nuclear factor-kappa B (NF-κB), a transcriptional regulator of ICAM-1, was also reduced by oleic acid. HAECs supplemented with either stearic or oleic acid resulted in cellular incorporation of C18:0 and C18:1n-9, respectively. Stearic acid primarily incorporated into phospholipids without increasing the total fatty acid content in HAECs. In contrast, oleic acid, with or without stearic acid, incorporated into both phospholipids and triglycerides, with a significant increase in total fatty acid amounts in triglycerides. Our data suggest that oleic acid has the ability to reduce the inflammatory effects of long-chain SFAs in HAECs through reducing cellular stearic acid incorporation and NF-κB activation.

How accurate are resting energy expenditure prediction equations in obese trauma and burn patients?

BACKGROUND: While the prevalence of obesity continues to increase in our society, outdated resting energy expenditure (REE) prediction equations may overpredict energy requirements in obese patients. Accurate feeding is essential since overfeeding has been demonstrated to adversely affect outcomes. OBJECTIVES: The first objective was to compare REE calculated by prediction equations to the measured REE in obese trauma and burn patients. Our hypothesis was that an equation using fat-free mass would give a more accurate prediction. The second objective was to consider the effect of a commonly used injury factor on the predicted REE. METHODS: A retrospective chart review was performed on 28 patients. REE was measured using indirect calorimetry and compared with the Harris-Benedict and Cunningham equations, and an equation using type II diabetes as a factor. Statistical analyses used were paired t test, +/-95% confidence interval, and the Bland-Altman method. RESULTS: Measured average REE in trauma and burn patients was 21.37 +/- 5.26 and 21.81 +/- 3.35 kcal/kg/d, respectively. Harris-Benedict underpredicted REE in trauma and burn patients to the least extent, while the Cunningham equation underpredicted REE in both populations to the greatest extent. Using an injury factor of 1.2, Cunningham continued to underestimate REE in both populations, while the Harris-Benedict and Diabetic equations overpredicted REE in both populations. CONCLUSIONS: The measured average REE is significantly less than current guidelines. This finding suggests that a hypocaloric regimen is worth considering for ICU patients. Also, if an injury factor of 1.2 is incorporated in certain equations, patients may be given too many calories.

Inflammatory mediators and home parenteral nutrition.

Individuals who have sustained intestinal failure due to trauma or disease are able to survive through the use of parenteral nutrition (PN). Although home PN (HPN) is a lifesaving therapy, patients may, over the long term, be at risk for liver, bone, and immune dysfunction. A limited number of human studies and a large number of animal studies suggest that there may be a chronic inflammatory condition and additionally a potentially lower T-lymphocyte immune function associated with PN administration. This article will primarily focus on a review of the limited clinical literature that examines the effect of long-term PN on the occurrence of inflammatory mediators in HPN patients, and will discuss the factors that are currently hypothesized to contribute to the potential inflammatory sequelae.

Prediction of resting metabolic rate in critically ill adult patients: results of a systematic review of the evidence.

Metabolic rate is generally assessed by use of equations in critically ill patients, but evidence pertaining to the validity of these equations in this population has not been systematically evaluated. This paper represents the first such systematic analysis in adult patients. A work group created by the American Dietetic Association identified pertinent peer-reviewed articles. The work group systematically evaluated these articles and formulated conclusion statements and grades based on the available evidence. Seven equations plus the Fick method were found to have validation work that met criteria for inclusion in this analysis. The Harris-Benedict equation with and without modifiers had the most validation work behind it (n=13), followed by Ireton-Jones (1992 and 1997) (n=9), Penn State (1998, 2003) (n=2), and Swinamer (n=1). Five studies pertaining to the Fick method met acceptance criteria. Based on these validation studies, the Harris-Benedict, Ireton-Jones 1997, and Fick methods can be confidently eliminated from use in assessment of energy expenditure in critically ill patients. The Penn State 2003, Swinamer, and Ireton-Jones 1992 equations may be useful in critically ill nonobese patients, whereas the Ireton-Jones 1992 and Penn State 1998 equations seem to be useful in obese patients. The strength of these conclusions is moderated because of limited and sometimes inconsistent data. More validation work is needed to confirm and increase the strength of these conclusions.

Systemic inflammatory mediators and bone homeostasis in intestinal failure.

BACKGROUND: A proinflammatory state has been described in patients with intestinal failure. The prevalence of metabolic bone disease in this group is considerable. It is not known whether this proinflammatory state is related to bone parameters, though bone disease is recognized as a proinflammatory process in postmenopausal women. The purpose of this study was to examine whether inflammation was related to bone disease. METHODS: Eight patients with parenteral nutrition (PN)-dependent intestinal failure but no recent infections or immunosuppressive medications had serum assayed for interleukin-6 (IL-6), tumor necrosis factor (TNF)-alpha, and its receptors (TNFR-I and TNFR-II), C-reactive protein, and whole blood for lymphocyte proliferation. Routine clinical laboratory measures of vitamin D, parathyroid hormone, serum calcium, and phosphorus within 3 months of the inflammatory measures were compared by Pearson's correlation to the inflammatory measures. RESULTS: Mean values for calcium, phosphorus, and albumin were normal, but 25-hydroxy vitamin D was reduced and parathyroid hormone and alkaline phosphatase elevated. Serum total calcium was negatively related to TNFR-II, TNF-alpha and positively to T-helper cells. Longer PN dependence was associated with inflammation and negatively with T-helper cells. CONCLUSIONS: These preliminary findings are hypothesis generating only but support an association of low calcium and longer duration of PN with inflammation in patients with intestinal failure. Whether the inflammation results from vitamin D deficiency or the vitamin D deficiency develops secondary to excessive use of activated vitamin D to modulate inflammation from some other cause, such as a component of PN or repeated infectious challenge, requires further study.

Feeding practices of severely ill intensive care unit patients: an evaluation of energy sources and clinical outcomes.

OBJECTIVE: The quantity of nutrition that is provided to intensive care unit (ICU) patients has recently come under more scrutiny in relation to clinical outcomes. The primary objective of this study was to assess energy intake in severely ill ICU patients and to evaluate the relationship of energy intake with clinical outcomes. DESIGN: Prospective cohort study. SUBJECTS/SETTINGS: Seventy-seven adult surgery and medical ICU patients with length of ICU stay of at least 5 days. STATISTICAL ANALYSES PERFORMED: Student's t test and chi2 tests were used to examine ICU populations. To determine the relationship of patient variables to hospital length of stay and ICU, length of stay regression trees were calculated. RESULTS: Both groups were underfed with 50% of goal met in surgical ICU and 56% of goal met in medical ICU. Medical ICU patients received less propofol and significantly less dextrose-containing intravenous fluids when compared to surgical ICU patients (P=0.013). From regression analysis, approaching full nutrient requirements during ICU stay was associated with greater hospital length of stay and ICU length of stay. For combined groups, if % goal was > or =82%, the estimated average value for ICU length of stay was 24 days; whereas, if the % goal was <82%, the average ICU length of stay was 12 days. This relationship held true for hospital length of stay. CONCLUSIONS: Medical and surgical ICU patients were insufficiently fed during their ICU stay when compared with registered dietitian recommendations. Medical ICU patients received earlier nutrition support, on average more enteral nutrition, with fewer kilocalories supplied from lipid-based sedatives and intravenous fluid relative to surgical ICU patients. Based upon length of stay, the data suggest that the most severely ill patient may not benefit from delivery of full nutrient needs in the ICU.

Preliminary evidence for a medical nutrition therapy protocol: enteral feedings for critically ill patients.

The objective of this study was to evaluate the evidence behind specific but common patient care decisions in support of enteral feedings for patients admitted to intensive care units. Six specific questions were developed and refined to address clinical outcomes specific to clinical practice decisions pertinent to enteral feeding of critically ill patients. The data sources consisted of an intensive literature review from five databases, using standardized search terms. Randomized controlled clinical trials, meta-analyses, consensus statements, reviews, US Food and Drug Administration alerts, and case reports were selected for study. Research reports were abstracted in detail and evaluated for research quality using the criteria developed by the American Dietetic Association. Consensus statements regarding the influence of specific enteral feeding methods on key clinical outcomes (ie, infectious complications, cost, length of hospital stay, and mortality) were developed and graded based on the quality of the available evidence. The data support the use of enteral over parenteral nutrition to reduce infectious complications and cost, and the initiation of enteral feedings within 24 to 48 hours of injury or admission to an intensive care unit to reduce infectious complications and length of hospital stay in head injury and trauma patients. Postpyloric tube placement is associated with reduced gastric residual volume and reflux, but adequately powered trials are not available to support prevention of aspiration pneumonia. Acceptance of gastric residual volumes of up to 250 mL may increase volume of formula delivered. Promotility agents are associated with reduced gastric residual volume. Feeding patients in the semirecumbent rather than supine position is associated with reduced aspiration pneumonia and pharyngoesophageal formula reflux. Actual delivery of 14 to 18 kcal/kg/day or 60% to 70% of goal is associated with improved outcomes, whereas greater intake may not be in some populations. Blue food coloring should not be used with enteral feedings due to its limited sensitivity for aspiration and some risk of mortality. Well-designed, adequately powered, randomized controlled clinical trials are needed to evaluate any benefit of tube tip position on aspiration pneumonia or mortality, and of early enteral feedings on mortality.

Inflammatory mediators and immune function are altered in home parenteral nutrition patients.

OBJECTIVES: Patients who used home parenteral nutrition (HPN) and healthy, volunteer control subjects were examined to assess relative immune potential and inflammatory marker expression and to investigate the association between HPN and immune parameters. METHODS: Subjective Global Assessments were performed on all subjects. The peripheral blood concentration of C-reactive protein was determined by enzyme-linked immunosorbent assay. The peripheral blood concentration of systemic inflammatory mediators that included tumor necrosis factor-alpha (TNF-alpha), soluble TNF-alpha receptors p55 and p75, and interleukin-6 were similarly determined. Peripheral blood lymphocytes were isolated and the percentage of circulating CD4+ and CD8+ lymphocytes was determined by flow cytometry. In addition, peripheral blood lymphocytes were cultured in the presence of the T-cell mitogen, phytohemagglutinin, and the proliferative response of the CD3+ population was assessed by flow cytometry. Results of these experiments were obtained for 10 clinically stable patients who had used HPN longer than 2 y and these results were compared by Student's t test with data obtained for 12 normal, volunteer control subjects. RESULTS: Of the 10 patients who used HPN and were examined, seven had short bowel syndrome, two had dysmotility, and one required HPN due to radiation enteritis. Based on Subjective Global Assessments, all patients were well nourished. No difference was observed in TNF-alpha level between groups and C-reactive protein levels were within normal limits (1.2 mg/L in patients, 0.99 mg/L in controls). Soluble TNF-alpha receptors p55 and p75 were significantly increased (P < 0.001), but serum interleukin-6 was not (P = 0.07). The percentage of CD8+ cells and the CD4+/CD8+ ratio were not statistically different between groups. In contrast to this result, the percentage of CD4+ cells and the proliferative T-cell response to phytohemagglutinin were significantly depressed in patients who used HPN versus control subjects. CONCLUSIONS: These data suggest the presence of an underlying inflammatory process and subsequent abnormal T-lymphocyte function in patients who use HPN.

Evidence-based clinical practice: dispelling the myths.

Evidence-based practice merges the best and most relevant clinical research data with clinician experience, pathophysiology of disease state, and the specifics of individual patient care. Currently, there is a significant gap between the best research evidence in healthcare and application of this evidence to clinician practices. Consistent with this finding, nutrition support is not always applied effectively or consistently, despite available scientific evidence that could be used to enhance a given treatment protocol. Cited obstacles that prevent the incorporation of research evidence into daily practice include lack of time, inadequate research skills, and information overload. Identification and application of the most valid primary research and evidence summaries (clinical guides to practice and meta-analyses) should, however, be an integral part of appropriate nutrition care. Consequently, it is important that clinicians develop and improve upon the basic skills required to allow efficient and accurate searches and evaluations of the literature. This review describes the basic and practical components of evidence-based medicine and provides tools to determine whether current nutrition practices are based upon an analysis of valid clinical evidence or anecdotal nutrition traditions and myths.

Number of days, number of subjects, and sources of variation in longitudinal intervention or crossover feeding trials with multiple days of measurement.

Dietary studies are often conducted as longitudinal intervention or crossover trials using multiple days of measurement on each subject during each of several measurement periods, and determining the required numbers of days and subjects is important in designing these studies. Linear mixed statistical models were used to derive equations for precision, statistical power and sample size (number of days and number of subjects) and to obtain estimates of between-subject, period-to-period, and day-to-day variation needed to apply the equations. Two cohorts of an on-going exercise intervention study, and a crossover study of Olestra, each with 14 d of measurement/subject per period, were used to obtain estimates of variability for energy and macronutrient intake. Numerical examples illustrate how the equations for calculating the number of days or number of subjects are applied in typical situations, and sample SAS code is given. It was found that between-subject, period-to-period, and day-to-day variation all contributed significantly to the variation in energy and macronutrient intake. The ratio of period-to-period and day-to-day standard deviations controls the trade-off between the number of days and the number of subjects, and this remained relatively stable across studies and energy and macronutrient intake variables. The greatest gains in precision were seen over the first few measurement days. Greater precision and fewer required days were noted in the study (Olestra) that exerted greater control over the subjects and diets during the feeding protocol.

Effects of a 16-month randomized controlled exercise trial on body weight and composition in young, overweight men and women: the Midwest Exercise Trial.

BACKGROUND: In light of the current obesity epidemic, treatment models are needed that can prevent weight gain or provide weight loss. We examined the long-term effects of a supervised program of moderate-intensity exercise on body weight and composition in previously sedentary, overweight and moderately obese men and women. We hypothesized that a 16-month program of verified exercise would prevent weight gain or provide weight loss in the exercise group compared with controls. METHODS: This was a randomized controlled efficacy trial. Participants were recruited from 2 midwestern universities and their surrounding communities. One hundred thirty-one participants were randomized to exercise or control groups, and 74 completed the intervention and all laboratory testing. Exercise was supervised, and the level of energy expenditure of exercise was measured. Controls remained sedentary. All participants maintained ad libitum diets. RESULTS: Exercise prevented weight gain in women and produced weight loss in men. Men in the exercise group had significant mean +/- SD decreases in weight (5.2 +/- 4.7 kg), body mass index (calculated as weight in kilograms divided by the square of height in meters) (1.6 +/- 1.4), and fat mass (4.9 +/- 4.4 kg) compared with controls. Women in the exercise group maintained baseline weight, body mass index, and fat mass, and controls showed significant mean +/- SD increases in body mass index (1.1 +/- 2.0), weight (2.9 +/- 5.5 kg), and fat mass (2.1 +/- 4.8 kg) at 16 months. No significant changes occurred in fat-free mass in either men or women; however, both had significantly reduced visceral fat. CONCLUSIONS: Moderate-intensity exercise sustained for 16 months is effective for weight management in young adults.

Validation of energy intake measurements determined from observer-recorded food records and recall methods compared with the doubly labeled water method in overweight and obese individuals.

BACKGROUND: Measurements of dietary intake in obese and overweight populations are often inaccurate because food intakes are underestimated. OBJECTIVE: The purpose of this study was to evaluate the validity of the combined use of observer-recorded weighed-food records and 24-h snack recalls in estimating energy intakes in overweight and obese individuals. DESIGN: Subjects were 32 healthy women and 22 healthy men with mean body mass indexes (in kg/m(2)) of 29.5 and 30.3, respectively. Energy intake (EI) was measured over 2 wk in a university cafeteria. No restrictions were made on meal frequency or EI. To document food consumed outside the cafeteria, 24-h snack recalls were conducted before meals. Energy expenditure (EE) was measured with the doubly labeled water (DLW) method (EE(DLW)). Energy balance was determined by measuring body weight at the beginning and end of the 2-wk period. RESULTS: The mean EI in the women (10.40 +/- 1.94 MJ/d) and men (14.37 +/- 3.21 MJ/d) was not significantly lower than the EE(DLW) in the women (10.86 +/- 1.76 MJ/d) and men (14.14 +/- 2.83 MJ/d). The mean EI represented 96.9 +/- 17.0% and 103 +/- 18.9% of the measured EE for women and men, respectively. There were no significant changes in weight in the group as a whole or by sex at the end of the testing period; the men lost 0.23 +/- 1.58 kg and the women lost 0.25 +/- 1.09 kg. CONCLUSION: The combination of observer-recorded food records and 24-h snack recalls is a valid method for measuring EI in overweight and obese individuals.