Summary: Background: Detection of the mild ketosis induced by severely energy‐restricted diets may be a clinically useful way to monitor and promote dietary adherence. Mild ketosis is often assessed using urine dipsticks, but accuracy for this purpose has not been tested.Objective: To determine the accuracy of urine dipsticks to detect mild ketosis during adherence to a severely energy‐restricted diet.Methods: Two hundred and sixty three (263) fasting urine and 263 fasting blood samples were taken from 50 women (mean [standard deviation, SD] age 58.0 [4.3] years and body mass index 34.3 [2.4] kg/m²) before and at six time points during or for up to 10 weeks after 16 weeks of severe energy restriction, achieved with a total meal replacement diet. The amount of ketones (acetoacetate) in the urine was classified as ‘0 (Negative)’, ‘+/− (Trace)’, ‘+ (Weak)’ or ‘++ (Medium)’ by urine dipsticks (Ketostix, Bayer). The concentration of ketones (β‐hydroxybutyrate) in the blood was measured with our reference method, a portable ketone monitor (FreeStyle Optium, Abbott). The diagnostic accuracy of the urine dipsticks was assessed from the percent of instances when a person was actually ‘in ketosis’ (as defined by a blood β‐hydroxybutyrate concentration at or above three different thresholds) that were also identified by the urine dipsticks as being from a person in ketosis (the percent ‘true positives’ or sensitivity), as well as the percent of instances when a person was not in ketosis (as defined by the blood monitor result) was correctly identified as such with the urine dipstick (the percent ‘true negatives’ or specificity). Thresholds of ≥0.3mM, ≥0.5mM or ≥1.0mM were selected, because mean blood concentrations of β‐hydroxybutyrate during ketogenic diets are approximately 0.5mM. Sensitivity and specificity were then used to generate receiver operating characteristic curves, with the area under these curves indicating the ability of the dipsticks to correctly identify people in ketosis (1 = perfect results, 0.5 = random results).Results: At threshold blood β‐hydroxybutyrate concentrations of ≥0.3mM, ≥0.5mM and ≥1.0mM, the sensitivity of the urine dipsticks was 35%, 52% and 76%; the specificity was 100%, 97% and 78%; and the area under the receiver operating characteristic curves was 0.67, 0.74 and 0.77, respectively. These low levels of sensitivity mean that 65%, 48% or 24% of the instances when a person was in ketosis were not detected by the urine dipsticks.Conclusion: Urine dipsticks are not an accurate or clinically useful means of detecting mild ketosis in people undergoing a severely energy‐restricted diet and should thus not be recommended in clinical treatment protocols. If monitoring of mild ketosis is indicated (eg, to monitor or help promote adherence to a severely energy‐restricted diet), then blood monitors should be used instead.

There is limited theory or knowledge regarding dietitians’ practice philosophies and how these philosophies are generated and incorporated into their professional practices. For the purposes of this study, a conceptual framework will explain and define the ‘philosophies’ as three different types of knowledge; episteme, techne, and phronesis. This study aimed to develop an explanatory theory of how dietitians in private practice source, utilise, and integrate practice philosophies. A grounded theory qualitative methodology was used to inform the sampling strategy, data collection, and analytical processes. Semi-structured interviews with dietitians in private practice were undertaken and data were collected and analysed concurrently. The results show that dietitians form collaborative relationships with their clients, in order to nurture change over time. They use intrinsic and intertwined forms of episteme, techne, and phronesis, which allow them to respond both practically and sensitively to their clients’ needs. The learning and integration of these forms of knowledge are situated in their own practice experience. Dietitians adapt through experience, feedback, and reflection. This study highlights that private practice offers a unique context in which dietitians deal with complex issues, by utilising and adapting their philosophies.

With obesity being a leading cause of preventable death, it is vital to understand how best to identify individuals with greater risk of metabolic disease, especially those with high visceral adipose tissue (VAT). This study aimed to determine whether three commonly used waist circumference (WC) measurement sites could provide accurate estimations of VAT, as determined by magnetic resonance imaging (MRI), which is a gold standard for measuring VAT, in postmenopausal women with obesity. VAT volume was measured by MRI of the total abdomen in 97 women aged 57.7 ± 0.4 years (mean ± SEM), mean body mass index 34.5 ± 0.2 kg/m². WC was measured at the midpoint between the lowest rib and the iliac crest (WC_mid), the narrowest point of the torso (WC_narrow), and at the level of the umbilicus (WC_umbilicus). WC differed significantly according to measurement site, with WC_narrow (102.1 ± 0.7 cm) < WC_mid (108.3 ± 0.7 cm) < WC_umbilicus (115.7 ± 0.8 cm) (p < 0.001). WC_mid, WC_narrow and WC_umbilicus were all significantly correlated with VAT, as measured by MRI (r = 0.581, 0.563 and 0.390, respectively; p < 0.001 for all), but the relationships between WC_mid or WC_narrow and VAT determined by MRI were stronger than for WC_umbilicus. Measurement of either WC_mid or WC_narrow provides valid estimates of VAT in postmenopausal women with obesity, with WC_narrow being favoured in light of its greater ease and speed of measurement in this population.

Current research around effective recruitment strategies for clinical trials of dietary obesity treatments have largely focused on younger adults, and thus may not be applicable to older populations. The TEMPO Diet Trial (Type of Energy Manipulation for Promoting optimal metabolic health and body composition in Obesity) is a randomised controlled trial comparing the long-term effects of fast versus slow weight loss on body composition and cardio-metabolic health in postmenopausal women with obesity. This paper addresses the recruitment strategies used to enrol participants into this trial and evaluates their relative effectiveness. 101 post-menopausal women aged 45–65 years, with a body mass index of 30–40 kg/m² were recruited and randomised to either fast or slow weight loss. Multiple strategies were used to recruit participants. The total time cost (labour) and monetary cost per randomised participant from each recruitment strategy was estimated, with lower values indicating greater cost-effectiveness and higher values indicating poorer cost-effectiveness. The most cost-effective recruitment strategy was word of mouth, followed (at equal second place) by free publicity on TV and radio, and printed advertorials, albeit these avenues only yielded 26/101 participants. Intermediate cost-effective recruitment strategies were flyer distribution at community events, hospitals and a local tertiary education campus, internet-based strategies, and clinical trial databases and intranets, which recruited a further 40/101 participants. The least cost-effective recruitment strategy was flyer distribution to local health service centres and residential mailboxes, and referrals from healthcare professionals were not effective. Recruiting for clinical trials involving postmenopausal women could benefit from a combination of recruitment strategies, with an emphasis on word of mouth and free publicity via radio, TV, and print media, as well as strategic placement of flyers, supplemented with internet-based strategies, databases and intranets if a greater yield of participants is needed.

Very low energy diets (VLEDs), commonly achieved by replacing all food with meal replacement products and which result in fast weight loss, are the most effective dietary obesity treatment available. VLEDs are also cheaper to administer than conventional, food-based diets, which result in slow weight loss. Despite being effective and affordable, these diets are underutilized by healthcare professionals, possibly due to concerns about potential adverse effects on body composition and eating disorder behaviors. This paper describes the rationale and detailed protocol for the TEMPO Diet Trial (Type of Energy Manipulation for Promoting optimal metabolic health and body composition in Obesity), in a randomized controlled trial comparing the long-term (3-year) effects of fast versus slow weight loss. One hundred and one post-menopausal women aged 45–65 years with a body mass index of 30–40 kg/m² were randomized to either: (1) 16 weeks of fast weight loss, achieved by a total meal replacement diet, followed by slow weight loss (as for the SLOW intervention) for the remaining time up until 52 weeks (“FAST” intervention), or (2) 52 weeks of slow weight loss, achieved by a conventional, food-based diet (“SLOW” intervention). Parameters of body composition, cardiometabolic health, eating disorder behaviors and psychology, and adaptive responses to energy restriction were measured throughout the 3-year trial.