Download RDI lect1 2008

Clinical Application of
Qualitative and Quantitative
Dietary Methods
Overview
♦RDIs & NRVs
♦Food guides
♦Qualitative & Quantitative assessment of dietary
intake
Melissa Armstrong, APD, CDE
St Vincent’s Hospital Diabetes Centre
Jenny McQueen, AdvAPD
SWAHS community dietitian
♦Break
♦Case studies
♦Discussion
Next week….Quantitative assessment with
Ready Reckoners
Medical Nutrition Therapy
Clinical Situations - location
♦ Assessment
♦Hospital settings
Medical
Dietary intake

Psychosocial

Physical Activity
♦ Education/treatment:

prescription
• energy, nutrients (macro & micro), fibre and fluid

implementation
• diet plan/ provision of diet (in hospital)
• strategies
• practical issues
♦ Monitoring & evaluation and of outcomes




Wards
Outpatient department
♦Outpatient facility



Diabetes Centre
Community Health Centre
Private practice rooms
♦Client’s home
♦Aged care facilities
Clinical Situations - format
How do we assess “adequacy”?
♦The aim of the intervention is to ensure the patient’s
♦Start with a dietary assessment of the individual
dietary intake is “adequate” for their individual
requirements
♦Compare this to a criteria specifically determined to
measure suitability of intake
♦May include interventions via:



Group education
One-to-one counseling

What is a balanced diet? – not “a bit of
everything”, but enough of everything from each
food group
What is an adequate diet? – meets energy &
nutrient (macro/micro) requirements
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Assessing individual needs
Tools to assess intake
♦Gender
♦Age
♦Weight
♦Medical conditions/diagnoses
♦Medications
♦Psychosocial issues
♦Physical activity
♦ Nutrient Reference Values
♦ Schofield Equation
♦ Core Food Groups (now rescinded)
♦ Healthy Living Pyramid
♦ Dietary Guidelines for Australians -
e.g. thin, sedentary,
35yo woman with
T1 diabetes, poor
income
Adults/Children & Adolescents (DGs for Older Aust - rescinded)
♦ CSIRO 12345+ plan
♦ Australian Guide to Healthy Eating (AGHE)
Nutrient Reference Values
Nutrient Reference Values
♦ Rather than just setting an RDI, the NH&MRC have adopted a
♦For each nutrient an Upper Intake Level (UL) was set.
new system of reference values to identify average
requirements for individuals
♦ For each nutrient there is:
 an Estimated Average Requirement (EAR)
 from which:
•
•
a Recommended Dietary Intake (RDI) can be derived
RDI = EAR + 2CV (coefficient of variation)
♦ If insufficient or inconsistent evidence to set EAR an Adequate
Intake (AI) level was set e.g. Vitamin E
This is the highest level of intake unlikely to pose a
risk to health
♦For energy,an Estimated Energy Requirement (EER)
was set for a range of activity levels
♦For macronutrients an Acceptable Macronutrient
Distribution Range (AMDR) was recommended that
would allow for an adequate intake of all the other
nutrients
 Expressed as % contribution to energy
NRVs vs “old” RDIs
NRV - Individuals vs Groups
♦Previous RDIs for 19 nutrients
♦ Individuals

♦New NRVs for 33 nutrients

♦Include recommendations for chronic disease
prevention - Suggested Dietary Targets (SDTs) &
AMDRs


♦Age groups changed

adults 19 – 30, 30 – 50; 51 – 70; 70+
EAR - use to examine the
probability that usual
intake is inadequate
RDI - usual intake at or
above this level has a low
probability of inadequacy
AI - usual intake at or
above this level has a low
probability of inadequacy
UL - Usual intake above
this level may place an
individual at risk of
adverse effects from
excessive nutrient intake
♦ Groups




EAR - use to estimate the
prevalence of inadequate
intakes within a group
RDI - do not use to assess
intakes of groups
AI - mean usual intake at
or above this level implies
a low prevalence of
inadequate intakes
UL - use to estimate the %
of the population at
potential risk of adverse
effects from excessive
nutrient intake
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Use of NRVs
Use of NRVs
♦Can be difficult to accurately assess “usual intake”
♦For individuals

♦When the AI is based on median intakes of healthy
populations, the assessment of “adequacy” is made
with less confidence
♦For groups

♦UL - Upper Limit of Intake
Usually not occurring through food intake - but
through inappropriate supplementation
Moving towards the SDTs & below the ULs makes a lot
of sense!
Using the AI is OK or placing the curve of intakes
between EAR & UL looks “right”
♦Accept that the scientific basis of the NRVs is not as
strong as we might wish!!
Chronic Disease Prevention
Food Guides
♦AMDR: Acceptable Macronutrient Distribution Range
Evolved over time….

Estimated range of intake of macronutrients which
provide adequate intakes whilst maximising general
health outcomes
♦SDT: Suggested Dietary Target

Daily average intake from food and beverages for
certain nutrients that may help in prevention of chronic
disease

NOTE: these AMDRs and SDTs apply only to adults
and adolescents >/= 14yrs
♦Five Food Groups
♦Dietary guidelines for Australians
♦Healthy Living Pyramid
♦CSIRO 12345+ guide (1991-2005)
♦Australian Guide to Healthy Eating (2003)
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Food Guides
Food Guides
♦ Aim: simple guide for healthy eating
♦help consumers put dietary guidelines into a healthy
♦ Uses:


Health promotion & chronic disease prevention
• Nutrient-focused recommendations expressed in terms of food
choices
• Modeled to assist food choice & national teaching tool
(consistent message)
Clinical setting
• Basis for assessment & education tool
• Basis for simple dietary modifications
• Framework for therapeutic objectives
• Often used in group education programs
eating pattern
♦emphasises proportions
♦flexibility – many different foods; age groups;
cultural preferences; cost; availability
♦balance – variety of foods
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Food Guides - limitations
Food Guides - limitations
♦New NRVs make previously used food guides
♦ Complex dietary modelling is now possible, enabling more
obsolete
♦Changes in the food supply and current public
health issues also make old models inappropriate
♦Example 1: AGHE - the current recommended
number of meat & alternatives serves fail to meet
current EARs for iron, Zn, vitamin B12 & omega 3 fa
in some people
♦Example 2: AGHE - the “extras” group are actually
major contributors to dietary intakes of some
essential fatty acids, vitamins D & E
accurate guides to be developed
♦ Some issues…





devising a separate food guide for vegetarians or pregnant
women
Should legumes be positioned with meat or vegetables?
Do we need a “healthy fats” group?
Are 5 food groups enough? Check reasons for decisions
made for the AGHE & NRVs - NHMRC website
Check reasons for decisions made for the AGHE & NRVs NHMRC website
The future?
Food Guides - Limitations
♦Federal budget 2007
♦ Refs:


Food guide to support the new NRVs

National Nutrition Survey



Gillen LJ, Tapsell LC. Development of food groupings to
guide dietary advice for people with diabetes. Nutr Diet 2006;
63: 36-47.
Shrapnel B, Baghurst K. Adequacy of fatty acid, vitamin D
and vitamin E intake: Implications for the ‘core’ and ‘extras’
food group concept of the Australian Guide to Healthy
Eating. Nutr Diet 2007: 64: 78-85.
Shrapnel B, Baghurst K. Lack of nutritional equivalence in
the “meat and alternatives” group of the Australian Guide to
Healthy Eating. Nutr Diet 2007: 64: 254-260.
Rangan A, Hector D, Randall D, Gill T, Webb K. Monitoring
consumption of “extra” foods in the Australian diet:
Comparing two sets of criteria for classifying foods as
extras. Nutr Diet 2007: 64: 261-267.
Adequate diet - definition
Qualitative vs Quantitative
♦meets all the nutritional needs of an individual for
♦Qualitative Assessment of Intake
maintenance, repair, living processes, growth &
development

•
•
♦provides energy & all nutrients in proper amounts
♦reduces the risk of developing chronic degenerative
diseases & conditions
Looking at the overall QUALITY of the diet
i.e. comparing intake to a general measure of appropriate
intake e.g. Core Food Groups
e.g. health promotion/public health approach;
general/brief overview of diet
♦Quantitative Assessment of Intake

Looking at the measurable QUANTITY of the diet
•
•
i.e. ensuring an absolute quantity is being provided
e.g. Computerised nutrient analysis or using Ready
Reckoner to check amount ingested/provided/prescribed
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Assessing Nutrition Adequacy
What do you need to ask…?
Assessing Nutrition Adequacy
What do you need to calculate…?
• Quantitative (quantity / HOW MUCH)
 Be specific re food items:
Qualitative (quality / type)


150g meat/fish/chicken, 2 tsp of fat, 1/2 cup peas,
200 ml of supplement, etc
How many serves/day, size of serve
Food type: lean vs fatty meat, type of added
fat, high vs low fibre cereal products,
cooked vs salad vegetables, etc

Then calculate:


Energy – e.g. 5000kJ (1200kcal)
Nutrients – e.g. 60g protein, 50 mmol K+, 5ug of
folate, 25g fibre
When would you use this
method?
When would you use this method?
Ways to assess intake
Assessing Nutrition Adequacy individuals
♦Qualitative
General Nutrition:
♦Meet AMDR
 energy (P/F/CHO)
Therapeutic diets:
♦Meet RDI for:
nutrients that require
modification eg protein
for renal failure, fat for
GI malabsorption etc
& meet RDI for:
 nutrients
 fluid
 fibre



Healthy Eating
Pyramid
Dietary Guidelines for
Australians
CSIRO 12345+ plan
♦Quantitative




Nutrient Reference
Values
Schofield Equation
CSIRO 12345+ plan
AGHE



nutrients
fluid
fibre
e.g. Diet Hx & discussion of class volunteer
(for specific conditions)
♦Meet energy & protein
♦Meet requirements for
Nutrition adequacy - Qualitative
Nutrition adequacy – Quantitative
♦General guidelines (population/ public health
♦When greater accuracy required
messages) - not specific enough to meet RDIs of
individuals e.g.
 Dietary Guidelines for Australians
 Healthy Eating Pyramid
♦Other methods - can meet RDIs and can be modified
for individual needs (correct serving sizes must be
observed) e.g.
 12345+ plans
♦Used for



Individualised assessments
Diet calculation
Diet prescription
♦Important clinical tools


Ready Reckoners
Computerised nutrient intake analysis
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Useful Hints / Practice Tips
Useful hints
♦Adequate servings from the 5 food groups will meet
♦Always combine qualitative and quantitative
RDIs for nearly all essential nutrients, but not
necessarily for
 Vitamins D & E
 Iron
 Potassium
 Folate
 Zinc
• depending on age, gender, food choices (small
amounts of specific nutrient-dense foods may
help to overcome these problems, eg.
Nuts/seeds, oily fish, unsatd oils)
Messages → MNT
Clinical prescription
Diet advice / plan
Eat less salt
80 –100 mmol Na+ /d
Balanced diet with
total Na+ 80 –100
mmol /d
Eat less fat
Ca 2+ 1000-1300 mg/d
Fat < 30% total energy
with sat. fat <10%



Do not assume serving size – check carefully!
Practise calculating diets until you are very good
at it
Be practical – effective use of time
Target requirements
Public Health
message
Eat more calcium
methods for assessment and diet prescription/plan
Weight loss

current energy intake & energy expenditure
weight loss target (5-10%)
Calculate:
 Energy deficit required to reach target weight loss
Provide:
 Balanced diet & optimal variety/amount of food in the
meal plan
 Exercise goals


•
Balanced diet with
3 serves/d dairy
products
1 serve = 1c milk or
200g yoghurt or 40g
cheese
Balanced diet with
modified total fat
intake/fat types
Assess:
•

Don’t
•
•
Tell patient to “eat less fat”, “eat less sugar”
Advise “do more exercise”
Target requirements
Target requirements
Nutritional support (oral)
Wound healing


Diet calculation • Energy: xxxx kJ/d
• Protein: xx g/d (or x g/kg BW/d)
Assess current intake & provide a DIETARY
PRESCRIPTION
• INCLUDE the right amount of additional food
and/or supplements to meet requirements (meal
plan)
Don’t just advise “try some supplements” or “eat
more food”
Consider: Are the energy & protein intakes adequate?
•
•
•

Calculate
 protein req’ments i.e.. ~1.5g/kg IBW/d
 energy req’ments - use Schofield
Develop a dietary prescription
Include: balanced diet & optimal variety/amount of food in
the menu plan
Don’t just advise “eat more protein foods”
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Target requirements
Diabetic diet and malnutrition

Assess:
Energy: intake and req’ment
 Protein: intake; ~xxg /kg IBW/d (prescription)
Provide:
 Balanced diet & optimal variety/amount of food in the
meal plan

•


Appropriate amount and distribution of CHO
Don’ts
•
•
Give only general low fat/high fibre advice
Advise to restrict energy intake
Practice Tips
♦Nutrient levels can vary a lot depending on the
“type” of foods included in each food groups
 e.g. for a low K diet, appropriate choices of
“type and amount” of fruit /vegetables/ can
lower K, but maintain other nutrients
 e.g. for a high fibre diet the choices within the
bread and cereal group will effect fibre intake
♦In general : a diet <1500 Kcal/d (~6000KJ) &
<60g/d protein becomes marginal in some
vitamins & minerals
Art of Dietetics
♦ Be able to effectively:
 Assess
 Prescribe
 Implement
 Monitor outcomes
♦ Activities:


Today - Case studies – do these diets meet RDIs (basic) & are
balanced?
Next session: Ready Reckoner – a more quantitative method
(quick and practical)
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