Download Key Elements of Nutritional Management - Rex Moulton

Key Elements of Nutritional
Management
Patient’s Dietary Intake and Trends
• 70% of American adults say they are eating “pretty much
whatever they want”1
• Caloric intake has increased by 300 calories per person
per day from 1985-20001
–
–
–
–
–
Refined grains accounted for 46% of increase
Added fats: 24% of increase
Added sugars: 23% of increase
Fruits and vegetables: 8% of increase
Meat and dairy declined
• Americans will spend 47% of their food dollar in
restaurants in 20052
1
Putnam J et al. USDA FoodReview, Vol 25 (3); 2002.
www.restaurant.org/pressroom/pressrelease.cfm?ID=979, obtained 3/14/05.
2
Food Portion Size Trends
1977-1978
1989-1991
1994-1998
Food Intake per Eating Occasion, oz
20
15
10
5
0
Salty
Snacks
Desserts
Soft
Drinks
Nielsen & Popkin, JAMA 2003.
Fruit
Drinks
French
Fries
Hamburgers
Cheeseburgers
Pizza
Mexican
Food
They value nutrition
information given by health
professionals the most
Obesity Is Caused by Long-Term
Positive Energy Balance
Fat
stores
Energy
intake
Energy
expenditure
Normal Feeding Mechanism
External Factors
Emotions
Food characteristics
Lifestyle behaviors
Environmental cues
Central signals
CNS
Appetite
= feel hungry
vs
Satiety
= feel full
Food Intake
Blood
GI Tract:
Absorption
Carbohydrate
Peripheral signals
Glucose, CCK, Insulin,
Ghrelin, Leptin
NPY
Galanin
GLP-I
CART
Fat
Protein
The What of Eating
New Food Pyramid &
Dietary Guidelines
www.mypyramid.gov and www.healthierus.gov/dietaryguidelines
Dietary Factors to Address
Fat
Energy Density
Eating Out
Portion Size
Fiber
Caloric
Beverages
Ad Libitum Low-Fat Diets Decrease
Daily Energy Intake
Meta-analysis of 12 Intervention Trials
Lee-Han, 1988
Boyd, 1990
Sheppard, 1991
Kasim, 1993
Pritchard, 1996
Siggaard, 1996
Simon, 1997
Weststate, 1998
Stefanick (M), 1998
Stefanick (F), 1998
Saris SCHO, 2000
Saris CCHO, 2000
Weighted overall
(random effects)
2000
0
-2000
-4000
Change in Energy Intake on Low-fat Diet (kJ/d)
Astrup et al. Int J Obes 2000;24:1545.
-6000
Decreasing Dietary Fat is Associated
With a Decrease in Body Weight
Analysis of 37 Diet Intervention Studies
Change in Body Weight (kg)
4
2
0
-2
-4
-6
-8
-10
-12
-30
-25
-20
-15
-10
-5
0
5
Change in Dietary Fat (% of Energy Intake)
r = 0.46.
Yu-Poth et al. Am J Clin Nutr 1999;69:632.
10
Moderate Fat Intake
• Recommended intake: 45 - 70 grams per day
• How:
– Bake, broil & grill foods
– Choose leaner meats and dairy products
– Add less margarine or butter to your cooking & at
the table
– At restaurants, eat salad (order dressing on the
side) before the meal
Replace High Energy Dense Foods
with Low Energy Dense Foods
• Energy density refers to the calories per gram of food
Food
Peanut Butter
Salad dressing
Graham Crackers
Cheese
Bread
Beans (kidney, lima)
Grapes, apples, blueberries
Strawberries, broccoli, peppers
Calories per Ounce
185
160
130
104
72
35
17
8
Increasing Dietary Fiber Can
Promote Weight Loss
Rate of Weight Loss (g/d)
0
-10
-20
High-fiber diet
-30
-40
Howarth et al. Nutrition Reviews 2001;59:129.
Low-fiber diet
P = 0.003
Increase Fiber Intake
• Recommended intake: 20 - 35 grams per day
• How:
– Include at least one high fiber food per day
− Fiber One cereal: 1/2 cup = 14 grams
− Cooked lentils: 1/2 cup = 16 grams
– More whole grains: whole wheat couscous or bulgur,
100% whole wheat bread
– More fruits and vegetables
Howarth et al. Nutrition Reviews 2001;59:129.
Watch the Calories in Drinks
8 AM – Breakfast Beverage
Orange Juice (8 oz)
112 calories
10 AM – Midmorning Coffee Run
Starbucks Carmel Mocha Coffee
with whole milk and whipped
cream (12 oz)
370 calories
Noon – A Soda with Lunch
Orange Soda
165 calories
2 PM – Afternoon Pick-Me-Up
Jamba PowerBoost
Smoothie (16 oz)
280 calories
5 PM – Gym Break
Glacéau Vitamin Water
Focus Kiwi-Strawberry
125 calories
7 PM – Dinner Drink
Martini (6 oz)
374 calories
You could be packing away 1,426 calories
without taking a single bite!
Self magazine, March 2005, p 154.
The Larger the Portion,
the More We Eat
Calories eaten (kcal)
800
700
600
500
400
0
500
625
750
1000
Amount of Macaroni and Cheese Served (g)
Rolls et al. Am J Clin Nutr.2002;76:1207-13.
How to Eat Out
• Choose restaurants that offer healthier menu options or
low-fat dishes
• Limit fat intake by requesting less fat be used in food
preparation, that butter not to be served, and salad
dressing on the side
• Avoid all-you-can-eat buffets
• Eat a low-calorie, low-energy-density snack before
arriving at the restaurant to reduce hunger
• Request the order to be split or ask for a half order, order
just a salad and an appetizer, leave food on the plate or
ask for a doggie bag
The Behavior of Eating
• How much time do you take to eat a meal?
• What are your beliefs about food and how
do they affect what you eat and the pleasure
you experience while eating?
One “Diet” Does Not Fit All
Comparison of Popular Diets
Mean Changes in Wt and Cardiac Risk at 12 Months
Atkins
Zone
Weight, kg
Weight Watchers
Waist circumference,
cm
Ornish
Total cholesterol,
mg/dl
0
Mean Change
-2
-4
-2.1
-3.2 -3.0 -3.3
-2.5
-2.2
-2.9
-3.3
-3.0
-6
-8
-10
-8.2
-10.1
-10.8
-12
Dansinger, et al. JAMA 2005;293:43-53.
Meal Replacements Promote
Long and Short term Weight Loss
*1200–1500 kcal/d diet prescription
A: conventional foods
B: meal and snack replacement for 1 meal, 1 snack
Fletchner-Mors et al. Obes Res 2000;8:399.
How to Discuss Eating Healthfully
with Your Patients
• Be positive
• Keep it short and simple
• Tailor your message
• Make it specific and manageable
• Talk food and fun
• Provide the payoff
• Give tips: Tell them how to do it
– Example: Pack some sturdy fruits and vegetables, like
carrots, apples and oranges, for your day’s travel
− You’ll feel good and have more energy, too
IFIC, http://ific.org/tools/intro.cfm.
How Do I Do This in 2-3 Minutes?
• Role
• Reinforce
– Healthy behaviors
• Refer
– Registered dietitian – www.eatright.org
– Weight management medical clinics
– Psychologists
• Resources
– Internet (diet.com)
– Weight Watchers
• Respect