Symptom Relief And Weight Loss From Adherence To A Meal .

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This article is protected by copyright. To share or copy this article, please visit Use ISSN#1543953X. To subscribe, visit imjournal.comoriginal researchSymptom Relief and Weight Loss From Adherenceto a Meal Replacement–enhanced, Low-calorieDetoxification DietJeffrey A. Morrison, MD, CNS; Anita L. Iannucci, PhDAbstractContext: Recently, detoxification (detox) diets have achievednotoriety in the popular press due to celebrity endorsementsand marketing that suggest quick and easy weight loss. Althoughresearchers have done studies to evaluate the weight-lossoutcomes of popular diet programs such as Weight Watchers,Atkins, and others, they have performed no outcomes studiesto support the weight-loss results that detox diets claim.Objective: This study intended to evaluate the changes in weightand medical-symptoms scores in participants who adhered to a4-week, meal replacement–enhanced, low-calorie detox diet.Design: The research team performed a retrospective chartreview.Setting: Office of the first author, New York, New York.Participants: The participants were 31 (13 M, 18 F) patientsthe first author saw consecutively in his private practice. Theirages ranged from 23 to 77, their preintervention weights from134 lbs to 275 lbs, and their preintervention body mass indexes(BMIs) from 23.2 to 38.4.Intervention: The participants followed a meal replacement–Jeffrey A. Morrison, MD, CNS, is medical director, The Morrison Center, NewYork, New York. Anita L. Iannucci, PhD, is an administrative analyst, University of California, Irvine.The incidence of obesity in the United States has risen toan alarming level, resulting in tremendous strain on ourhealth-care system. Chronic and comorbid medical conditions like diabetes, hypertension, high cholesterol, stroke, cancer,arthritis, and heart disease are all more prevalent in obese individuals.1,2 Additionally, obese individuals are more likely to die fromdiabetes, cardiovascular disease, and kidney disease.2 The mostrecent data that the National Health and Nutrition ExaminationSurvey collected from 2007 to 2008, showed that the age-adjustedprevalence of obesity (body mass index [BMI] 30) was 33.8%overall, 32.2% among men, and 35.5% among women. Moreover,Flegal et al estimated that the combined overall prevalence in the USpopulation of being overweight or obese (BMI 25) was 68.0%.3Given these statistics, it is not surprising that the commercialsector has developed numerous diet programs to help peoplewith weight loss. Conventional, structured weight-loss strategies42Integrative Medicine Vol. 11, No. 2 Apr/May 2012enhanced, low-calorie detox diet for approximately 4 weeks.Outcome Measures: The research team examined participants’preintervention-to-postintervention (pre-to-post) changes inscores on the Detox Questionnaire, which measures medicalsymptoms, and its 15 scales; pre-to-post changes in weight; andpre-to-post changes in BMI.Results: On each of 15 toxicity scales (medical symptoms) fromthe questionnaire, the study showed a statistically significantpre-to-post decline. The overall score, containing all 71 itemsfrom the 15 scales, also showed a significant decline, from amedian of 53 at preintervention to 17 at postintervention,P .001. Additionally, the average pre-to-post weight loss equaledapproximately 9 lbs, P .001, and a significant reduction in BMIoccurred, from an average of 29.2 to 27.8, P .001. No significantrelationship existed, however, between the amount of the declinein symptoms scores and the amount of weight lost.Discussion: This meal replacement–enhanced, low caloriedetox diet appears to be a viable option for both weight lossand a reduction in chronic health symptoms.usually involve limiting total calories4 or a major macronutrient,such as protein, fat, or carbohydrates, to achieve weight-losssuccess.5,6 Meal replacement programs are also effective for weightloss and compare favorably with conventional structured diets.7-9Most recently, detoxification (detox) diets have begun to gain agreat deal of attention as a novel approach to losing weight.Detox diets have gone by the name of elimination diets, rotarydiversified diets, the Master Cleanse, and many other names.People use them with the expected effect of ridding the body oftoxins, cleansing the colon, or improving liver detoxification. Theprimary outcome that individuals hope to achieve is eventuallyto feel better. Studies have indicated that these programs can beeffective for improving symptoms.10-12 The current research team,however, was unable to find a study on detox diets to substantiatetheir weight-loss claims.In this study, the primary objectives were to examine the effectsof a meal replacement–enhanced, low-calorie detox diet supplyingfrom 800 kcal to 1200 kcal per day on symptoms scores and weightloss to clarify the amount of success to be expected from thesemeasures for individuals following this version of a detox diet.Symptom Relief and Weight Loss From Detox Diet

This article is protected by copyright. To share or copy this article, please visit Use ISSN#1543953X. To subscribe, visit imjournal.comDESIGN AND METHODSParticipants and MethodsFor this retrospective chart review, the research team selected31 individuals from patients that the first author saw consecutively in his private practice. In brief, after the participantsprovided a medical history and received a physical evaluation, theteam allowed them to participate in the detox program as long asthey were (1) over the age of 18, (2) were not pregnant or nursing,and (3) did not have any serious illness that would contraindicateparticipation in a meal replacement–enhanced, low-calorie, detoxdiet program. While the selected participants did not suffer fromany serious illnesses, they did suffer from chronic health complaintssuch as fatigue, difficulty concentrating, flatulence and bloating,muscle and joint aches, and/or difficulty losing weight.The research team asked each participant whether he or shewould like to address his or her health-care problems by followinga meal replacement–enhanced detox diet for 4 weeks. Eachparticipant expressed interest in following the program, andthe team gave participants both verbal and written instructions,Table 1. Foods to Include and Avoid in Detoxification DietInclude DailyIncludeMorning Only1-2 L waterFruitVegetables:(grapefruit,steamed,berries, kiwi,grilled, or raw apples,Olive oilpapaya,Lemon juicemelon, pears)SpicesGreen teaOnce a day: 4 oz-6 oz ofchicken, turkey, fish (tilapia,red snapper, Alaskansalmon [fresh or canned],sardines, shrimp, catfish,blue crab), organic eggsFoods toAvoidBeveragesto dairySoyPeppersRaw fishGrainsCornCoffeeSodaAlcoholTable 2. Vegetable Suggestions for Inclusion in Detoxification DietFor All Participants: Nonstarchy and mildly starchy vegetables:asparagus, avocado, beans (green/wax), beets and beet greens,bok choy, broccoli, brussels sprouts, cabbage, cauliflower, celery,chard, chicory, collard greens, crookneck squash, cucumber,dandelion, endive, escarole, kale, kohlrabi, leek, mushrooms,mustard greens, okra, onion, parsley, parsnip, radish, romainelettuce, rutabaga, scallion, spinach, summer squash, swiss chard,sprouts, turnip, watercress, and zucchiniSea vegetables: arame, dulse, hijiki, kelp, laver, nori, wakameFor Participants Without Weight Loss As a Goal: Starchyvegetables: artichoke, carrot, delicate squash, potato (sweet, yam),pumpkin, and winter squashSymptom Relief and Weight Loss From Detox Dietemphasizing the necessity of close follow-up during the program.The team provided participants with a handout that comprehensively listed the foods to avoid and include (Tables 1 and 2), andparticipants obtained the meal-replacement shakes from the firstauthor’s office.At the first visit and again after about a month, the researchteam examined each participant to obtain height, weight, andother physical measures. Additionally, on the first visit, eachparticipant completed a Detox Questionnaire (Table 3) to assesshis or her medical symptoms from the previous week. This questionnaire was identical to the Metabolic Screening Questionnairethat Jeffrey Bland, PhD created.10,12 Bland designed his questionnaire to be a succinct form of the Cornell Medical Index, concentrating on symptoms that might be related to toxicity.13 The questionnaire considers a score of 0 to 14 to represent low toxicity, ascore between 15 and 49 moderate toxicity, and a score of 50high toxicity. Table 4 shows the characteristics of the 31 participants (13 M, 18 F) prior to treatment.Participants included in this study followed this program untiltheir follow-up appointments, which occurred between 3 and 5weeks after their initial visit. The research team assessed participants’ progress at this second appointment by recording theirweights and having them complete the Detox Questionnaireagain, rating their symptoms over the past week.A few of the patients remarked that they noticed an increasein their symptoms when they first started the program, but thesymptoms quickly subsided within 3 to 5 days. All 31 participantssuccessfully completed the plan.The DietThe meal replacement was a combination of 2 scoops of DailyDetox Powder, 2 tbsp of lecithin, and 1 tbsp of Daily Fiber that theparticipants added to 8 oz of pure water. Metagenics (San Clemente,California) manufactured the Daily Detox Powder and Daily Fiber,and Douglas Laboratories (Pittsburgh, Pennsylvania) manufacturedthe lecithin for Daily Nutritionals, Inc (New York, New York). Participants could mix the shake by hand, mix it in a container, or blendit with ice cubes. The detox powder consisted of rice-based proteinpowder, and the Daily Fiber consisted of a nongluten fiber from ricebran, apple pectin, and plantain (Table 5).The research team instructed participants to have (1) a shakefor breakfast, (2) an approved fruit for a snack between breakfastand lunch, (3) a shake and approved vegetables for lunch, (4)vegetables as a snack between lunch and dinner, and (5) 4 to 6oz of acceptable protein with vegetables for dinner (Table 6). Theresearch team did not require participants to monitor consumedcalories strictly, allowing participants flexibility in makinghealthful choices within the guidelines of the program. Theresearch team retrospectively determined through self-reportsthat participants generally consumed between 850 to 1000 kcaldaily. The daily minimal amount of macronutrients consumedwhile adhering to the diet was 45 g to 60 g of protein, 22 g to 25 gof fat, and 60 g to 70 g of carbohydrates.RESULTSTo analyze the study’s data, the research team used SPSS 17.0Integrative Medicine Vol. 11, No. 2 Apr/May 201243

This article is protected by copyright. To share or copy this article, please visit Use ISSN#1543953X. To subscribe, visit imjournal.comTable 3. Detoxification QuestionnaireDETOXIFICATION QUESTIONNAIREPatient Name: Date:Rate each of the following symptoms based on your typical health profile for the specified duration: Past monthPoint Scale: Past week Past 48 hours —Never or almost never have the symptom —Occasionally have it, effect is not severe —Frequently have it, effect is not severe —Frequently have it, effect is severe —Occasionally have it, effect is severeI. Medical Symptoms Questionnaire (MSQ)HEADHeadachesDIGESTIVENausea, SConstipationTOTALBloated feelingBelching, passing gasWatery or itchy eyesHeartburnSwollen, reddened orsticky eyelidsIntestinal/stomach painBags or dark circles under eyesBlurred or tunnel visionEARSJOINTS/Pain or aches in jointsMUSCLEArthritisItchy earsStiffness or limitation of movementEaraches, ear infectionsFeeling of weakness or tirednessDrainage from earPain or aches in musclesRinging in ears,hearing lossNOSETOTALTOTALWEIGHTExcessive weightWater retentionHay feverUnderweightSneezing attacksCompulsive eatingMOUTH/Chronic coughingTHROATGagging, frequent need toclear throatENERGY/Fatigue, sluggishnessACTIVITYApathy, lethargyMINDSwollen or discoloredtongue, gums, lipsCanker soresLUNGSTOTALPoor memoryConfusion, poor comprehensionDifficulty in making decisionsTOTALStuttering or stammeringAcneSlurred speechHives, rashes, dry skinLearning disabilitiesHair lossPoor concentrationFlushing, hot flashesPoor physical coordinationExcessive sweatingTOTALHyperactivityRestlessnessSore throat, hoarseness,loss of voiceHEARTBinge eating/drinkingStuffy noseTOTALTOTALCraving certain foodsSinus problemsExcessive mucus formationSKINTOTALTOTALEMOTIONSChest painTOTALMood swingsAnxiety, fear, nervousnessIrregular or skipped heartbeatAnger, irritability, aggressivenessRapid or poundingheartbeatDepressionTOTALOTHERChest congestionTOTALFrequent illnessFrequent or urgent urinationAsthma, bronchitisGenital itch or dischargeTOTALShortness of breathDifficulty breathingTOTALGRAND TOTALTOTAL 2006 Metagenics, Inc.44Integrative Medicine Vol. 11, No. 2 Apr/May 2012Symptom Relief and Weight Loss From Detox Diet

This article is protected by copyright. To share or copy this article, please visit Use ISSN#1543953X. To subscribe, visit, Inc, Chicago, Illinois), examining the changes occurringfrom preintervention to postintervention (pre-to-post) in participants’ medical symptoms and weights. For the Detox Questionnaire, the team summed the scores for the items in each of the 15scales to compute the scale scores and also summed the 15 scalescores to compute the total score for each participant. The individual scales had a possible range of 0 to 32 (4 times the numberof items in the scale). Note that a lower number on each of thesescales represents lower toxicity. Table 7 shows that the mediandropped from pre-to-post for 11 scales (the other four were already0 at preintervention) and for the overall total. The nonparametricWilcoxon signed rank test showed that a statistically significantpre-to-post decline occurred in the detox-symptom scale scoresfor all 15 scales and for the overall totals, representing a decline intoxicity as measured by medical symptoms.Furthermore, from pre-to-post, the overall total for the detox scalescore declined an average of 66.3% across participants (standard deviation [SD] 18.7), from a mean preintervention of 58.1 to a meanpostintervention of 18.9. The median decline was 67.6%, and therange of the decline across subjects was 0% to 95.7%, again showing alarge pre-to-post decline in the medical symptoms of toxicity.Table 4. Questionnaire Scores for Participants’ Baseline (Preintervention) Ages, Weights, and Detoxification SymptomsAge, y Weight, ge134-27523.2-38.413-14141.923-77DISCUSSIONThe objective of this retrospective chart review was to clarifythe amount of weight loss and symptom reduction to be expectedfrom following a low-calorie, meal replacement-enhanced detoxdiet. While this diet generally provides between 800 kcal to 1200kcal per day, with adjustments to provide more as described below,the participants in the current study consumed between 850 kcalto 1000 kcal per day. The results achieved during the 4-week periodcompared favorably with the weight loss and improved symptomsscores that researchers have seen with other diets.The study showed a significant amount of weight loss in participants who followed the detox diet. Participants lost an average ofTable 5. Macronutrient Composition of One MealReplacement ShakeTotal caloriesFatFat from soy lecithinCarbohydratesDietary fiberProteinSodiumPotassiumParticipants lost an average of about 9 lbs from pre-to-post,as Table 8 shows. Twenty-nine participants lost weight and twogained over the approximately 4-week period. A paired samplest-test showed a highly significant weight loss, t (30) 8.085,P .001. Average BMI also declined significantly, from 29.2 atpreintervention to 27.8 at postintervention (Table 8), with apaired samples t-test showing t (30) 8.701, P .001.Finally, the research team calculated Pearson correlations todetermine whether a relationship existed between participants’amount of weight loss and the amount of decline in their overalldetox score. The number of lbs lost correlated only very minimally with the percentage change in overall detox score (r 0.199)and with the pre-to-post difference (obtained by subtraction)in the detox questionnaire scores (r –0.290), and neither relationship was statistically significant. The change in BMI (postminus pre) also correlated minimally with these detox outcomes,r –0.283 and r 0.216, respectively. Thus, while participants’scores declined significantly on toxicity as measured by all 15detox scales and by the overall total detox scale for medical symptoms and while participants showed a statistically significantweight loss, the research team found no relationship between theamount of weight lost and the amount of change in toxicity.The Figure is a visual representation of the relationship betweenweight loss and change in detox symptoms score. It shows the relationship with the Pearson correlation of 0.199 discussed above.Each circle in the scatterplot represents one participant’s weightloss and change in detox symptom scores. If the circles fell intoa linear shape, the scatterplot would show a strong relationshipbetween weight loss and change in toxicity symptoms. The factthat the scatterplot has very little pattern (is a “blob”) shows thatvirtually no relationship exists between the amount of declinein toxicity symptoms as measured by the questionnaire and thenumber of pounds lost.25310.8 g9g25.5 g3.5 g15.5 g76 mg485 mgTable 6. Sample Meal ion shake1/2 c organic blueberries,green tea unsweetened orwith steviaDetoxificationshake and smallleafy green saladwith olive oil andlemonSteamed broccoliwith garlic, salt,and pepper4-6 oz bakedsalmon withsteamedspinach drizzledin olive oilRaw carrotsand celerySymptom Relief and Weight Loss From Detox DietIntegrative Medicine Vol. 11, No. 2 Apr/May 201245

This article is protected by copyright. To share or copy this article, please visit Use ISSN#1543953X. To subscribe, visit imjournal.comTable 7. Preintervention-to-postintervention Change in Symptom Detoxification ScalesItems –4.53–2.28 .001 .001.002 .001.005 .001.002.007 .001 .001 .001 .001 .001 .001.023172-52–4.78 roatSkinHeartLungsDigestive -170-130-110-80-180-121-160-160-190-160-8Overall total715313-141ScaleWilcoxon Signed RankTable 8. Preintervention-to-postintervention (Pre-to-post) Change in Weight and Body Mass Index (BMI)MeanMedianSDRangeLbsBMIPrePostPre-to-post ChangePrePostPre-to-post �8.87–9.006.11–27 to �1.360.90–3.8 to 1.2Abbreviations: Post, postintervention; pre, preintervention; SD, standard deviation.8.9 lbs at 4 weeks, which compared favorably with conventionalweight-loss plans at 4 weeks: a mean weight loss of 9.7 lbs for theAtkins Diet, 6.3 lbs for Weight Watchers, and 5.9 lbs for Slim-Fast (aspublished in the British Broadcasting Corporation diet trials).5 Giventhese results, the current study has shown that a detox diet plan canbe a reasonable alternative to high-protein and conventional dietsand that vegans potentially can use it for a weight-loss solution.Additionally, from the initial visit to the follow-up visit 3 to 5weeks later, all 15 symptoms had statistically significant levels ofimprovement, and the overall total of the detox symptoms scoresdeclined an average of 66.3% across participants. These resultscompare favorably with symptoms scores in other detox studiesusing the same questionnaire, which showed improvement of 47%at 1 week12 and 52% at 10 weeks.10 The research team postulates thatthese changes come from improvements in phase 1 and phase 2detoxification pathways as the result of consuming nutrient-densefoods as previously suggested by Bland.13 Another possible explanation for improvement is that participants eliminated inflammatory substances—allergenic foods or toxic elements—from theirdiets and thereby decreased systemic inflammation, allowing formore effective detoxification. This improvement in symptoms is46Integrative Medicine Vol. 11, No. 2 Apr/May 2012Figure. Each Participant’s Percentage Change in Total Score forDetoxification Symptoms Questionnaire vs Change in WeightSymptom Relief and Weight Loss From Detox Diet

This article is protected by copyright. To share or copy this article, please visit Use ISSN#1543953X. To subscribe, visit imjournal.comGVODUJPOBM BOE TUSVDUVSBM BMUFSBUJPO JO UIFJS OFSWPVT TZTUFNT importantbecause numerous individuals with a constellation of /". DPVME TQBSF UIFTF ZPVOH HJSMT GSPN UIFTF EJTSVQUJPOT BOE seeminglyunrelated symptoms could consider using a detox dietHJWF UIFN B CFUUFS RVBMJUZ PG MJGF in theirtreatment strategies to improve symptom control. Alsoimportant to note is that no significant increase in symptomsConclusionoccurredfrom adhering to the detox diet, so the diet appears to besafe for %FTQJUF JUT TNBMM TBNQMF TJ[Fpatients of doctors in a general UIF QJMPU TUVEZ XJUI IVNBO medical practice.NBHOFUJD ²FMET TUBUJTUJDBMMZ TJHOJ²DBOU FG²DBDZ Furthermore,the TIPXFE study foundno relationshipbetweenthe GPS NJOPS QBJO SFMJFG PG EZTNFOPSSIFB BOE in/". 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MalnickSD, Knobler H. Themedical complications of obesity. QJM. 2006;99(9):565-579. -VTCZ )3 " SFTQPOTF UP B DSJUJDBM FWBMVBUJPO PG UIF UIFPSZ BOE QSBDUJDF PG UIFSBQFVUJD 2. FlegalKM, Graubard BI, Williamson DF, Gail MH. Cause-specific excess deaths associatedUPVDI /VST 1IJMPT with under-weight, overweight,and obesity. JAMA. 2007;298(17):2028-2037. 3PTB - 3PTB & Ogden4BSOFS CL,- Curtin#BSSFUU LR.4 Prevalence" DMPTF MPPL BU UIFSBQFVUJD "." 3. FlegalKM, CarrollMD,and trendsin obesity UPVDI among US adults, 1999-2008. JAMA. 2010;303(3):235-241. #VMMPDL . 3FJLJ B DPNQMFNFOUBSZ UIFSBQZ GPS MJGF "N )PTQ 1BMMJBU BSF 4. SacksFM, Bray GA, Carey VJ, et al. Comparison of weight-loss diets with different composi 7JUBMF " "O JOUFHSBUJWF SFWJFX PG 3FJLJ UPVDI UIFSBQZ SFTFBSDI tions of fat, protein, and carbohydrates. N Engl J Med. 2009;360(9):859-873.)PMJTU /VST 1SBDU 5. TrubyH, Baic S, deLooy A, et al. Randomized controlled trial of four commercial weight BSWJT 85 3FJLJ /BUJPOBM PVODJM "HBJOTU )FBMUI 'SBVE IUUQ XXX ODBIG PSH BSUJDMFT loss programmes in the UK: initial findings from the BBC “diet trials.” BMJ.P S SFJLJ IUNM "DDFTTFE 'FCSVBSZ 2006;332(7553):1309-1314. 6OJUFE 4UBUFT POGFSFODF PG BUIPMJD #JTIPQT (VJEFMJOFT GPS &WBMVBUJOH 3FJLJ BT BO 6. GardnerCD, Kiazand A, Alhassan S, et al. Comparison of the Atkins, Zone, Ornish, and"MUFSOBUJWF IFSBQZ IUUQ PME VTDDC PSH EPDUSJOF &WBMVBUJPO@(VJEFMJOFT@GJOBMUFYU@ LEARNDiet 5forchangein weight and related risk factors among overweight premeno QEG "DDFTTFE 'FCSVBSZ pausalwomen: the A TO Z Weight Loss Study: a randomized trial. JAMA. /P BVUIPS MJTUFE POTVNFS )FBMUI %JHFTU NBTTBHF HSPVQ EFOPVODFT GSJOHF 2007;297(9):969-977.QSBDUJDFT /BUJPOBM PVODJM "HBJOTU )FBMUI 'SBVE IUUQ XXX ODBIG PSH EJHFTU 7. Noakes M, Foster PR, Keogh JB, Clifton PM. Meal replacements are as effective as strucIUNM "DDFTTFE VMZ turedweight-loss diets for treating obesity in adults with features of metabolic syndrome. )FOEFSTPO . 1SJODF PG 8BMFT«T HVJEF UP BMUFSOBUJWF NFEJDJOF ªJOBDDVSBUF« 5IF 4VOEBZ J Nutr. 2004;134(8):1894-1899.5JNFT "QSJM 8. Treyzon L, Chen S, Hong K, et al. A controlled trial of protein enrichment of meal replace-44SymptomRelief andWeight LossUÊ6 Ê ]ÊFrom Detox DietIntegrativeMedicine Ê ÊUÊ iLÉ ÀÊÓä Ó 5V ) /JEEBN %. IBP )5 FU BM #SBJO NPSQIPMPHJDBM DIBOHFT BTTPDJBUFE XJUI DZDMJD mentsfor weightreductionwith retentionof lean body mass. Nutr J. 2008;7(23):1-6.NFOTUSVBM QBJO 1BJO 9. HeymsfieldSB, van Mierlo CA, van derKnaap HC, Heo M, Frier HI. Weight managementusing a meal replacement strategy: meta and pooling analysis from six studies. Int J ObesRelat Metab Disord. 2003;27(5):537-549.10. Bland JS, Barrager E, Reedy RG, Bland K. A medical food-supplemented detoxificationprogram in the management of chronic health problems. Altern Ther Health Med.1995;1(5):62-71.11. Taylor JP, Krondl MM, Csima AC. Symptom relief and adherence in the rotary diversifieddiet, a treatment for environmental illness. Altern Ther He

with weight loss. Conventional, structured weight-loss strategies usually involve limiting total calories4 or a major macronutrient, such as protein, fat, or carbohydrates, to achieve weight-loss success.5,6 Meal replacement programs are also effective for weight loss and

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2 Symptom present - Requires Medication/intervention Care Plan continues, If 3 consecutive symptom scores of 2 are present (for any symptom) A review is required of the patient and the care plan 1 Symptom present - Resolves Spontaneously Care Plan continues, consider adaptations 0 Symptom absent Care Plan continues

programs maintain their weight loss for any significant length of time. 6 It is estimated that 90 percent of all dieters who los 25 pounds in a diet program regain that weight within two years. 7 0 Rapid weight loss and certain weight loss programs may lead to severe gallstone injuries. Rapid weight loss is

Physician-prescribed weight-loss regimen With care plan goal of weight reduction; weight loss is intentional May employ calorie-restricted diet or other weight-loss diets and exercise Includes expected weight loss due to loss of fluid with physician orders for diuretics To code K0300 as 1, Yes, the expressed goal of the weight .

a bas-relief from a new photograph, the input image is relit to match the two standard illumination conditions, and the mapping function is used to produce two bas-relief images. A bas-relief surface is constructed from each bas-relief im-age using SFS, and the resulting two bas-relief surfaces are averaged to give the final bas-relief.

The Weight Loss Challenge Manual, support materials, and Herbalife’s Weight Loss Challenge website for participants ( are based on a 12-week program. Distributor Weight Loss Challenge RULES AND GUIDELINES SECTION ONE: Distributor Weight Loss Challenge Rules and Guidelines *Amount is in U.S. dollars.

7/2017 Stony Brook Medicine Bariatric and Metabolic Weight Loss Center (631) 444-BARI (2274) Bariatric and Metabolic Weight Loss Center Weight Loss Program Questionnaire: Please complete this questio

upon the most current revision of ASTM D-2996 (Standard Specification for Filament Wound Rein-forced Thermosetting Resin Pipe): Ratio of the axial strain to the hoop strain. Usually reported as 0.30 for laminates under discussion. 0.055 lb/in3, or 1.5 gm/cm3. 1.5 150-160 (Hazen-Williams) 1.7 x 10-5 ft (Darcy-Weisbach/Moody) 1.0 - 1.5 BTU/(ft2)(hr)( F)/inch for polyester / vinyl ester pipe .