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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 1 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♦Psychosocial issues ♦Physical activity ♦ Nutrient Reference Values ♦ Schofield Equation ♦ Core Food Groups (now rescinded) ♦ Healthy Living Pyramid ♦ Dietary Guidelines for Australians - e.g. thin, sedentary, 35yo woman with T1 diabetes, poor income Adults/Children & Adolescents (DGs for Older Aust - rescinded) ♦ CSIRO 12345+ plan ♦ Australian Guide to Healthy Eating (AGHE) Nutrient Reference Values Nutrient Reference Values ♦ Rather than just setting an RDI, the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 2 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) 3 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 4 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 5 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 6 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” 7 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) 8