Are meal replacement plans better than low calorie diets?

Meal replacement plans such as Slimfast and Medifast have been around a long time now. Is there any evidence on their effectiveness? The hesitant answer is yes. Why hesitant? Many of these studies are funded by these vendors. Certain populations are excluded that are very important in today’s society.

In a 2010 publication, the VP of Scientific and Clinical Affairs at Medifast was the lead author on a study of adults aged 18-65. Both diet plans were restricted to 1000 kilocalories a day, a seemingly good recipe for success to begin with. Early weight loss favored the meal replacement plan (12.3% vs. 6.9%). At week 40 there were no significant differences in the BMI reduction (7.8 vs. 5.9%) nor the biochemical markers studied.

A 2004 study was funded by Slimfast and also focused on adults aged 20-65. Here, again, both groups lost weight. The authors noted that the meal replacement plan subjects found it easier to understand and follow the food amounts.

A 2007 study funded by Slimfast found mean weight lost was not difference between groups. The low calorie group lost 8.4% of their original weight and the meal replacement group lost 6.2%. Both groups reduced calorie and fat consumption and increased protein intake over one year. Women 50 years and under were the subjects.

Ahrens was another Slimfast funded study from 2003. Again, both groups lost over 5% of their base body weight, the marker of significant body weight reduction set by the CDC. Further, there were no differences in biomarkers, including blood pressure, cholesterol, triglycerides or lipids. This study spanned 22 weeks.

A 2003 meta-analysis was provided by a member of the Slimfast nutritional institute. This meta-analysis combined six studies but two of these included diabetics that may have been quite different. Again the age was limited to those under 65. 88% of the population were women. Attrition was a problem in many studies and sometimes approached 50%. All six individual studies showed significant weight lost in both groups. Pooling the data had interesting results. More participants lost over 5% of their baseline body weight in the meal replacement group p<0.0001) at one year. The low calorie diet group lost between 2.61 and 4.35 Kg and the meal replacement plan lost 6.97 to 7.31 Kg and this difference was statistically significant. Was this influenced by including the diabetic patients? We do not know.

An interesting study came from Australia (Truby, 2008). Again the population was adults 65 years and under. Four diet plans were assessed including the Atkins, Weight Watchers, Slim Fast and a local product. Although they only followed patients for two months, they found all diet groups lost significantly more weight than the control group. Differences were found in the levels of minerals and vitamins in patients. Slimfast showed a decrease in niacin and an increase in zinc in this older study.

An obvious conclusion is that bias may well have influenced this body of literature. The elderly are conspicuously absent from these studies. All studies involved calorie reductions for both groups. Weight loss was evident in almost all cases. The conundrum is the meta-analysis. We leave that to your assessment. We have validated our literature search with the assistance of a medical librarian. It is possible that we did not locate all relevant studies . Reported here is a summary of some of the best found for adults.

Ahrens, R. A., Hower, M., & Best, A. M. (2003). Effects of Weight Reduction Interventions by Community Pharmacists. Journal of the American Pharmacists Association, 43(5), 583-589.

Ashley, J. M. et al. (2007). Nutrient adequacy during weight loss interventions: A randomized study in women comparing the dietary intake tin a meal replacement group with a traditional food group. Nutrition Journal, 6, 12. doi: 10.1186/1475-2891-6-12

Davis, Coleman, et al. (2010). Efficacy of a meal replacement diet plan compared to a food-based diet plan after a period of weight loss and weight maintenance: a randomized controlled trial. Nutrition Journal 9:11.

Heymsfield (2003). Weight management using a meal replacement (PMR) strategy: meta and pooling analysis from six studies. International Journal of Obesity.

Noakes, Foster, et al.(2004). Meal replacements are as effective as structured weight-loss diets for treating obesity adults with features of metabolic syndrome. Journal of Nutrition. 134: 1894-1899. (AUSTRALIA)

Truby, Hiscutt, et al. (2008). Commercial weight loss diets meet nutrient requirements in free living adults over 8 weeks: a randomized controlled weight loss trial. Nutrition Journal, 7:25. (AUSTRALIA) 

Submitted by:
Kathy Russell-Babin, MSN, RN, ACNS-BC, NEA-BC
Sr. Manager, Institute for Evidence-Based Care
Meridian Health System
Posted: 4/2/2012 7:43:15 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Evidence-Based Practice

An Integrative Review of the Evidence on IM and SC Injection Aspiration

Thirty years ago, when I was in my Bachelor's program for nursing, I was taught to aspirate for intramuscular (IM) injections to make sure I didn't puncture an artery or vein. I am confident that all of you reading this post were taught the same technique. The question we need to ask is, is the technique based on evidence or is it just the way it has always been done. 

In an integrative review published in the March issue of Nursing2012, To aspirate or not: An integrative review of the evidence, researchers examined the literature to determine if there was any evidence supporting the practice of aspiration for injections. The researchers used an Integrative review methodology to review the literature.  The integrative approach answers a targeted clinical question using a systematic search strategy and a rigorous appraisal method (Crawford & Johnson, 2012). 

The results were not surprising; there was no research evidence to support the use of aspiration in giving IM or SC injections. The researchers recommended the following for consideration:
  • Aspiration is not indicated for subcutaneous injections of immunizations, heparin, and insulin
  • Aspiration is not indicated for IM injections of vaccines and immunizations
  • Aspiration may be indicated for IM injections of medications such as penicillin
  • Until a standard can be established, injection techniques must be individualized to the patient to prevent incorrect needle placement (Crawford & Johnson, 2012). 
Unfortunately in nursing, we often practice a certain way because that is the way it has always been done. I applaud the work of the researchers who did this study; they are truly moving nursing practice forward based on evidence. Translating evidence into practice is a series of steps and the researchers have taken the first steps to appraise the evidence and recommend practice changes based on the evidence. It is up to each of us to take the evidence presented and integrate it into practice. 
Crawford, C., Johnson, J., 2012. To aspirate or not: An integrative review of the evidence. Nursing2012, (42), 3, 20-25. 
Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC

Posted: 3/16/2012 11:01:58 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Evidence-Based Practice

Specialty certification

5-Reasons-to-get-Certified-250.pngMarch 19th is Certified Nurses Day. A large number of nursing certification programs exist (I count 92!). This number alone tells me that this is something important that all nurses should consider. I was proud to use the credential CCRN during my days working in a medical ICU. The exam was tough and maintaining the necessary continuing education requirements was challenging, but my own sense of pride and the respect I received from patients, my colleagues, and my employer made it worth it.   

So what is specialty certification exactly? The American Nurses Credentialing Center (ANCC) defines certification as “a process by which a nongovernmental agency validates, based upon predetermined standards, an individual nurse’s qualifications for practice in a defined functional or clinical area of nursing.” Many other definitions exist, depending on where you look or from which organization you are seeking certification. In general, being certified demonstrates that you have advanced knowledge and competence in a given specialty. 

Barriers to certification have been identified as time, cost of preparation and examinations, test anxiety, lack of support from supervisors, and continuing education requirements (Valente, 2010). Overcoming these barriers, both on personal and professional levels, are important because of the value and benefits associated with specialty certification. Kaplow (2011) categorized this value associated with certification into three realms: value to patients, value to employer, and value to self. 

With regard to value to patients, certified nurses demonstrate greater confidence in decision making, increased patient safety (including less falls and decreased pressure ulcers), and higher patient satisfaction. Also, certified nurses have been shown to be more likely to provide care based on evidence-based guidelines (Kaplow, 2011). 

Specialty certification sends a message of commitment to a current or potential employer. Nurses who are certified demonstrate a personal responsibility to their education, and in turn, patient care and outcomes. Some studies have even shown an association between certification and turnover, vacancy, staffing, nurse retention, job satisfaction, higher nurse performance, and patient satisfaction (Watts, 2010). 

Finally, the personal benefits that come with certification are numerous. The sense of accomplishment, feeling of empowerment, and validation of knowledge had a great impact on my confidence. Other benefits can include an impact on salary and career advancement, as well as improved marketability (Kaplow, 2011).

If you’re interested in learning more about certification, take a moment to explore our Guide to Certification. This handy table of specialty certification boards and contact information along with the associated credential and requirements is a good place to start your journey to certification. Good luck!
American Nurses Credentialing Center. (2012). What is Nurse Certification.  
Kaplow, R. (2011). The Value of Certification. AACN Advanced Critical Care, 22(1). 
Valente, S.M. (2010). Improving Professional Practice Through Certification. Journal for Nurses in Staff Development, 26 (5). 
Watts, M.D. (2010). Certification and Clinical Ladder as the Impetus for Professional Development. Critical Care Nursing Quarterly , 33(1).
Posted: 3/12/2012 10:19:51 AM by Lisa Bonsall, MSN, RN, CRNP | with 4 comments

Categories: Evidence-Based PracticeEducation & Career

​Patient Education of Hospitalized Cardiovascular Patients

We all know the importance of patient and family education. Many tools have been developed over the years, strategies have been explored, and recommendations have changed. We know that our approach must be individualized for each patient regardless of diagnosis, prognosis, age, gender, etc. We also are aware of barriers to providing patient education in the hospital setting – time, staffing, and access to resources – among others. 

In Patient Education Strategies for Hospitalized Cardiovascular Patients: A Systematic Review, the authors sought to identify and examine the characteristics and outcomes of cardiovascular (CV) health education interventions for hospitalized CV patients. Of the 25 studies that met the inclusion criteria, 80% (n = 20) were randomized controlled trials and 20% (n = 5) were quasi-experimental studies. A summary of the study population, intervention elements, outcomes, and results for each study as well as a synopsis of the characteristics of the educational interventions are presented. 

Based on the interpretation of their results, the authors share 3 clinical pearls at the conclusion of their article:
1. Evidence suggests that, compared with single-session interventions, programs that incorporate scheduled follow-up sessions as a core component are generally more effective.
2. Interventions designed to build self-care, communication, and problem-solving skills may be more effective in improving behavioral and clinical outcomes than those focused solely on increasing knowledge.
3. Patient education strategies that fit with the patient's learning styles, cognitive level, and motivation by using tailored interventions offer a more directed way to enhance compliance among patients.

Do you have a particular strategy for patient education? What types of educational interventions do you use most often? 
Commodore-Mensah, Y., Himmelfarg, C.R. (2012). Patient Education Strategies for Hospitalized Cardiovascular Patients: A Systematic Review. Journal of Cardiovascular Nursing, 27(2). 
Posted: 3/2/2012 2:28:00 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Evidence-Based Practice

Family Presence on Rounds

Family presence has always been a hot topic in the healthcare community. I can remember when family presence in an ICU meant visiting for 15 minutes three times per day. At least that was the policy in the local hospital where my grandparents were patients when I was a kid. We’d wait and wait for the clock to strike that magic moment and then take turns, two at a time, to visit. I’m not sure that communication with the staff even occurred during those minutes, or if it did, it may have been just a quick word or two.

It just so happens that later on, as a nurse in the medical intensive care unit (MICU) at a large teaching hospital, our unit transitioned from set visiting hours to open visiting hours from 11 am to 8 pm. It was then up to the discretion of the staff if family could come in earlier or stay later, even all night. Interdisciplinary rounds, led by the attending physician, took place each morning outside of each patient’s room. If family members were present, sometimes the attending updated them at that time and teaching of interns and residents occurred in front of the patient and family. More often, however, he or she told the family that they’d get an update when rounds were completed.

Much has been written about family presence, especially with regard to visitation and emergency care and resuscitation efforts, however little has been studied about including family members in medical or interdisciplinary rounds. In Family Presence on Rounds, the author performed a systematic review of 17 studies on this topic. The PICO question guiding this study was “In critical and noncritical pediatric and adult patients, does family presence on rounds compared with non-inclusion of family members lead to positive outcomes and increased satisfaction?”

While it is clear that further research is warranted on this topic, the author does a nice job of organizing results from the review based on family members’ outcomes, both positive and negative, and health care staff outcomes, both positive and negative. She even takes it one step further, by dividing the health care staff outcomes among nurses (although only 5 of the 17 studies addressed nurses’ perceptions) and medical staff.

Positive outcomes outnumbered the negative outcomes for all groups, but interestingly, the nurses did not perceive any negative outcomes to family presence on rounds.

What is the policy where you practice? What’s been your experience with family presence during interdisciplinary rounds?
Cypress, B.S. (2012). Family Presence on Rounds: A Systematic Review of the Literature. Dimensions of Critical Care Nursing, 31(1).
Posted: 2/4/2012 6:58:44 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Evidence-Based Practice

Ghosts in the Machine

When you appraise research, do you look at who was the principle investigator and wrote the article? I recently attended a session at a symposium that has made me question how I review articles for credibility. Inappropriate authorship (honorary and ghost authorship) and the resulting lack of transparency and accountability have been a substantial concern for the academic community for decades (Wislar, Flanagin, Fontanarosa, & DeAngelis, 2011). For those of you who are unfamiliar with the definitions, an honorary author is someone who is named as an author but did not meet authorship criteria and did not contribute substantially to take public responsibility for the work (Wislar, et al. 2011). A ghostwriter is someone who has made substantial contributions to the writing of the article but was not named as an author (Wislar, et al. 2011). These types of authors call into question the validity and credibility of the published work due to a lack of transparency on what they did or did not contribute to the article. 

In the latest issue of BMJ, Wislar, Flanagin, Fontanarosa, and DeAngelis, explored the issue of ghost writing and honorary authorship in their study "Honorary and ghost authors in high impact biomedical journals: a cross sectional survey."  They used a sample size of 896 authors from the top 2008 high Impact Factor medical journals in the industry, Annals of Internal Medicine, JAMA, Lancet, Nature Medicine, New England Journal of Medicine, and PLoS Medicine. Of the 896 authors, 630 responded to the survey for a 70.3% response rate. The prevalence of honorary and ghost authorship in articles published in major medical journals in 2008 was 21% (Wislar, et al. 2011). This number was a decline from identical study the group did in 1996 looking at the same publications. In 1996, the prevalence of honorary and ghost authorship was 29% (Wislar, et al. 2011). 

Clearly, these results demonstrate a need for the scientific community and peer-reviewed publications to increase their efforts to promote the responsibility, accountability, and transparency in authorship, and to maintain integrity in scientific publication (Wislar, et al. 2011). As healthcare providers who depend on the research evidence to guide our practice, we must carefully appraise the evidence to make sure it is credible and trustworthy; this includes scrutinizing the authors as well as the methodology and the research results, before using the information to change our practice. I applaud the efforts of the study authors to educate the healthcare community on the important issue of inappropriate authorship. It is through their efforts and the efforts of authors, editors, and publishers that we can continue to improve the integrity of the scientific publishing industry. 

By Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC


Wislar, J., Flanagin, A., Fontanarosa, P., DeAngelis, C. 2011. Honorary and ghost authorship in high impact biomedical journals: a cross sectional survey. BMJ.

Posted: 11/18/2011 1:30:10 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Evidence-Based Practice

What is your question?

Along the lines of my recent posts on evidence-based practice, I have one more thing I’d like to share. It’s something I wish I had known back in nursing school and especially in graduate school while working on my final research paper before graduation. It’s called a PICOT question.

PICOT is an acronym to help you formulate a clinical question and guide your search for evidence. Using this format can help you find the best evidence available in a quicker, more efficient manner. Take a look:

P = patient population



I = intervention or issue of interest

C = comparison intervention or issue of interest

O = outcome

T = time frame

Try using the PICOT format to help you formulate your next clinical question and search for relevant studies and publications. For example, if you wanted to know the effect of flu vaccination on the development of pneumonia in older adults, you could fill in the blanks like this:

In _________(P), how does __________ (I) compared to _________ (C) influence _________ (O) over ________ (T)?


In patients ages 65 and older,  how does the use of an influenza vaccine  compared to not receiving the vaccine  influence their risk of developing pneumonia during the flu season?

What’s your question? Try using the PICOT format and see how it affects your search results! You can find more information, including other templates to help you formulate your question in Asking the Clinical Question: A Key Step in Evidence-Based Practice.

Stillwell, S., Fineout-Overholt, E.,  Melnyk, B., & Williamson, K. (2010). Evidence-Based Practice, Step by Step: Asking the Clinical Question A Key Step in Evidence-Based Practice. American Journal of Nursing, 110(3), 58-61.  
Posted: 10/29/2011 1:32:50 PM by Lisa Bonsall, MSN, RN, CRNP | with 32 comments

Categories: Evidence-Based Practice

Systematic review

During my days of nursing school and research classes, we did literature reviews to determine relevant research surrounding a topic of interest. While we did learn about ensuring that studies in our literature reviews were solid, with appropriate sample, design, methods, etc., we didn’t actually compare the findings from the studies with the same intensity that we do today. 

A recent webinar about evidence-based practice (EBP) really cleared up some concepts and terms for me, including the importance of using systematic reviews when examining evidence. A systematic review is an essential component for basing change in practice on current evidence. So how does a systematic review differ from a literature review?

  • Peer review is a critical part of the process. A systematic review looks at evidence reported in peer-reviewed journals and the systematic review itself is peer-reviewed.
  • The evidence is rigorously reviewed, using the same manner and standards that were used to produce the evidence.

We know that changing practice based on one research study is not enough. It’s not even enough to change nursing practice based on several studies. Available evidence must be investigated and interpreted using scientific review methods. A well-conducted systematic review summarizes existing research, defines the boundaries of what is known and what is not known, and helps resolve inconsistencies among diverse pieces of research evidence (Duffy, 2005).

Here’s a good example of a systematic review from the October issue of American Journal of Nursing. As you read Deactivation of ICDs at the End of Life: A Systematic Review of Clinical Practices and Provider and Patient Attitudes, pay particular attention to Table 1 where the sample, methods, and findings of each study are summarized. 


Duffy, M. (2005). Using Research to Advance Nursing Practice: Systematic Reviews: Their Role and Contribution to Evidence-based Practice. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 15-17.

Woods, A. (2011). Implementing Evidence Into Practice. Webinar. Philadelphia: Lippincott Williams & Wilkins.

Posted: 10/10/2011 2:13:35 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Evidence-Based Practice

An equation for EBP

I recently had the pleasure of attending a webinar on evidence-based practice (EBP) hosted by our own Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC. Anne brought the concept of evidence-based practice into a whole new light for me with this simple equation:

Research + Clinical Expertise + Patient Preference = EBP

One research study is not sufficient to support change in practice. Nor are three research studies, or 10, or 100… Solid research is only one piece of the puzzle. Three components are essential to true EBP and are critical to improve outcomes and quality of life:

1. External evidence includes systematic reviews, randomized control trials, best practice, and clinical practice guidelines that support a change in clinical practice. 
2. Internal evidence includes health care institution based quality improvement projects, outcome management initiatives, and clinical expertise. 
3. Accounting for patient preferences and values is the third component of this critical equation.

Another approach to understanding EBP is to compare what EBP isn't with what EBP is: 

  • EBP is NOT a research project. EBP is examination of completed research studies.
  • EBP is NOT simply supporting national evidence-based practice projects. EBP is a complete review and recommendation process.
  • EBP is NOT having research articles as references for policies. EBP is critical analysis of research, in the context of your organization, and with perspectives and judgment of clinicians and patients.

How familiar are you with systematic reviews and PICOT questions? Look for upcoming posts on these topics this week. Also, coming soon is Lippincott’s Evidence-Based Practice Network! We are very excited to be close to sharing this new resource with you!


Russell-Babin, K.  (2009). Seeing through the clouds of evidence-based practice. Nursing Management, 40(11), 26-32.

Woods, A. (2011) Implementing Evidence into Practice. [Webinar] Philadelphia: Lippincott Williams and Wilkins.

Posted: 10/2/2011 2:16:21 PM by Lisa Bonsall, MSN, RN, CRNP | with 3 comments

Categories: Evidence-Based Practice

A tour of the Skin Care Network

I am very excited to introduce our new microsite, the Skin Care Network! This site was developed by the clinical and editorial team of Lippincott's in collaboration with the Dermatology Nurses' Association and the American Society of Plastic Surgical Nurses. Our goal is to share with you all the dermatology and skin care content from Lippincott's vast collection of nursing journals and keep you up-to-date with the latest research, news, and information your patients may be reading or hearing about in the media.

Here are some highlights of the Skin Care Network that I don't want you to miss:

Take some time to explore the site ~ I hope you find the Skin Care Network to be a valuable resource to meet your professionals needs!

Posted: 7/13/2011 1:22:57 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Evidence-Based Practice

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