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Nutrition and Your Patient: Practical Strategies to Help Your Patients Eat Right

Beth Gonzales, MSPH, RD

Nutrition Specialist and Counselor Cardiovascular Center of Marin Larkspur, CA

Disclosures •  I have no conflicts of interest to disclose.

Objective •  To present practical approaches to help your

patients eat healthier, achieve their nutrition related goals, and improve health outcomes.

Outline   Nutrition in primary care-why does it matter?   Nutrition assessment and goal setting.   Which diet is best for weight loss and/or better

health.   Practical messages and strategies for your

patient-the low hanging fruit.

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Nutrition in Primary Care -Why does it matter?

•  The link between diet and chronic diseases, including type 2 diabetes, cardiovascular diseases, metabolic syndrome, and nonalcoholic fatty liver disease is well established.

The importance of lifestyle on disease •  1/3 of premature deaths in the U.S. are attributable to

poor nutrition and physical inactivity. •  50% of American adults do not get the recommended

amount of physical activity. •  Only 10% of Americans eat a healthy diet consistent with

federal nutrition recommendations. ▫  The typical American diet is too high in saturated and trans fat,

salt, and refined sugars and too low in fruits, vegetables, whole grains, calcium, and fiber.

National Alliance for Nutrition and Activity http://cspinet.org/new/pdf/cdc_briefing_book_fy10.pdf

The Solution:

 Exercise and Diet are the low cost and effective solution to this epidemic of metabolic disease.

Nutrition in Primary Care

• A Healthy People 2010 objective was to increase the proportion of office visits that addressed nutrition for patients with CV disease, DM, or hypertension to 75%.

• At midcourse review, the proportion actually decreased from 42% to 40%

• Barriers cited: ▫  Lack of time and compensation ▫  Lack of knowledge and resources

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Audience Response • How often do you address nutrition for your

patients with cardiovascular disease, diabetes, or hypertension? 1. 0-19% 2. 20-39% 3. 40-59% 4. 60-79% 5. 80-100%

Primary Care Providers influence on eating and exercise behaviors •  Short 3 to 5 minute conversations during routine

visits can contribute to patient behavior change. • Obese patients who were advised by their PCP to

lose weight were three times more likely to try than patients not advised.

•  Patients who were counseled about the benefits of healthy eating and exercise lost weight and exercised more than patients who were not.

Reference: Talking with patients about weight loss: Tips for Primary Care Professionals U.S. Department of Health and Human Services

Assessing Nutritional Status • BMI and weight history • Waist circumference •  Laboratory assessment • Diet assessment

Assessing Body Mass Index Determine current weight and weight history BMI: Formula: weight (kg) / [height (m)]2 •  BMI Weight Status •  Below 18.5 Underweight •  18.5 – 24.9 Normal •  25.0 – 29.9 Overweight •  30.0-34.9 Class I Obesity •  35.0-39.9 Class II Obesity •  40+ Class III Obesity

http://nhlbisupport.com/bmi/

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The short-coming of only addressing BMI

• BMI doesn’t always reveal the underlying culprit of metabolic diseases: visceral fat

• As many as 50% of women and 20% of men with a normal BMI have unhealthy amounts of visceral fat.

Assessing Metabolic Status

Waist Circumference: ▫  Increased disease risk is associated with >35” for

women, >40” for men.

Setting the tone for a productive discussion about nutrition goals and behavior change  Assess readiness to change. • Many people who are stuck in an unhealthy

pattern want to change, but they don't feel that they can. Clinicians can help tip that decisional balance.

•  If your patient is not ready to change, help them identify the important link between disease risk and diet and exercise behaviors.

Setting the tone for a productive discussion about nutrition goals and behavior change

 Meet the patient where he or she is.

 Ask open-ended questions, listen, and summarize.

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Opening the discussion to address BMI and weight status •  Patients prefer terms such as “weight,” “excess

weight,” “unhealthy body weight,” and “BMI” instead of “obesity and ideal weight”.

•  For example, you might say: "Ms. Brown, your BMI is above the healthy range. Excess weight could increase your risk for some health problems. Would you mind if we talked about it?"

Examples of open-ended questions for your patient: •  "What are your goals regarding your weight?”

•  “What are your goals regarding your diet”?

•  “Have you tried to lose weight or change your diet in the past?” If so, what worked well and what did not work well?”

Health Effects of Lifestyle Changes-Small changes, Big results

  Losing 7% of weight and exercising 30 minutes per day cut diabetes risk by nearly 60% in patients at high risk for developing diabetes after 3-4 years of follow-up.

  60-90 minutes of walking/week=51% decreased risk of CHD vs. non-regular walkers

References: Diabetes Prevention Program, NEJM, 2002; 346 Women’s Health Study, JAMA, 2001; 285

Goal setting for weight management • Agree on a weight goal: losing 5-10% over 6

months at a rate of 0.5-2.0 pounds per week is appropriate for most patients who are ready to lose weight.

• A goal of maintaining current weight and not gaining weight may also be appropriate for some patients.

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Sample Nutrition Profile Form Initial Current Target

Weight 190 lbs 205 lbs 195 lbs

BMI 27 29 28

Waist 43” 45” <35” women; <40” men

Blood Pressure 128/75 135/93 <130/<90

Pertinent Labs LDL: 129 Triglycerides: 130 HDL: 39 Glucose: 94 ALT: 35

LDL: 143 Triglycerides: 160 HDL: 35 Glucose: 111 ALT: 40

LDL: <100 Triglycerides<150 HDL: >50 Glucose: <100 ALT: <30

Assess current diet pattern • Diet can be assessed with a 24-hour recall, food

frequency questions, or by administering a brief food frequency questionnaire (REAP-Rapid Eating Assessment for Patients).

http://med.brown.edu/nutrition/acrobat/REAP%206.pdf

Goal setting for behavior change

You might ask: “What changes are you willing to make to your

eating and physical activity habits right now?” • Have them identify 1-2 specific changes they will

make. ▫  For example:

-Order a side of fruit or salad instead of fries or potatoes when eating out.

-Walk 30 minutes at least 5 days per week and record steps with a pedometer.

Weight loss basics •  To understand what it takes to lose or maintain

weight, it often helps patients to understand energy balance, including one’s calorie needs, calories consumed, and calories burned.

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How many Calories does one need? • Mifflin St Jeor Equation

10*wt(kg) + 6.25*Ht(cm) - 5*Age(yrs) + 5 = resting energy expenditure (male)

10*wt(kg) + 6.25*Ht(cm) - 5*Age(yrs) -161 = resting energy expenditure (female)

This estimates resting energy expenditure (REE). Multiply REE by an "activity factor”: 1.3=sedentary 1.4=walking/standing, no exercise 1.5=exercise 1.6=walking&exercise 1.8=heavy lifting

For weight loss, subtract 500-1000 calories

Quick estimate for calorie needs -To estimate calories for weight maintenance:  If you are moderately active, multiply current

weight (pounds) x 15 -To estimate calories for weight loss:  Subtract 500-1000 calories to lose

approximately 1.0-2.0 pounds per week; usually 7-10 calories per pound of current weight

 Calorie intake shouldn’t be <1200 for women or <1500 for men.

How Many Calories do we Consume? • According to the Dietary Guidelines Advisory

Committee, calorie consumption in the U.S. has increased 30% over the past 4 decades.

Year Average calories consumed

1970 2,057

2008 2,674

Extra calories from eating away from home Public Health Nutr.16: 87, 2013

Calories/meal at home

Calories/meal at a restaurant

Normal Weight 550 825

Overweight/Obese 625 900

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Top sources of calories in the U.S.

•  1. Grain-based desserts •  2. Yeast breads •  3. Chicken and chicken-mixed dishes •  4. Soda, energy drinks, and sports drinks •  5. Pizza •  6. Alcoholic beverages •  7. Pasta and pasta dishes •  8. Mexican mixed dishes •  9. Beef and beef dishes •  10. Dairy desserts

Source: Report of the Dietary Guidelines Advisory Committee, 2010

What in our diet is making us fatter and sicker?

•  Too many refined grains: ▫  Federal guidelines recommend six 1 ounce

servings per day for a 2000 calorie diet, and half should be whole grain. The average person eats 8 servings of grains per day, and 7 of the 8 are refined.

What is a serving of grain? •  1/2 cup cooked rice or other cooked grain •  1/2 cup cooked pasta •  1/2 cup cooked hot cereal, such as oatmeal •  1 six inch tortilla •  1 slice of bread (1 oz.); ½ bun •  1 very small (1 oz.) muffin • ½-1 cup ready-to-eat cereal

(½ cup = ½ a baseball)

A primary contributor to the rise in visceral fat and metabolic syndrome

• Way too much added sugar  The average person consumes 30 teaspoons of sugar

and sweeteners per day (~ 15% of calories).  The AHA recommendations < 6 teaspoons (24

grams) of added sugar per day for women, and < 9 (36 grams) for men .

 A 20 oz soda has twice that.

Nutrition Action Health Letter, CSPI, March, 2013

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Added sugar is found in much more than just sodas

•  Sugar has many names: cane and beet sugar, high fructose corn syrup, corn syrup, dextrose, honey

Weight loss basics

•  Thermodynamics says that a calorie is a calorie, regardless of its source, so to lose weight, you simply eat less and exercise more.

•  Yet emerging research suggests that some foods and eating patterns may make it easier to keep calories in check, while others may make people more likely to overeat.

http://www.hsph.harvard.edu/obesity-prevention-source/obesity-causes/diet-and-weight/

Dietary Reference Intakes for Macronutrients

•  Protein: 10% to 35%

• Carbohydrate: 45% to 65%

•  Fat: 20% to 35%

Institute of Medicine

AUDIENCE RESPONSE Which diet is most effective for weight loss?

Is it…..?? A.  High protein, high animal fat, low carbohydrate

(Atkins, Paleo/Caveman) B.  Low glycemic (Zone, South Beach) C.  High protein, moderate fat, moderate carbs (Biggest

loser) D.  Very Low fat, Vegetarian (Ornish) E.  Plant based, high unsaturated fat, low saturated fat

(Mediterranean Style) F.  Flexible but Calorie controlled (Weight Watchers)

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Studies suggest that the type of diet is less important than total calories for Weight Loss JAMA, 2005; 293

Diet/%Completed Diet Characteristics Weight loss at 1 year (pounds)

Atkins/ 53% 20-50 grams of carbs/day 4.8

Zone /65% 40% carb, 30% protein,30% fat 6.0

Weight Watchers/65% 1200-1600 calories 4.9

Ornish/50% 10% fat, vegetarian 7.3

Perhaps the best weight loss diet is the one you can adhere to? N Engl J Med. 2009; 360

Diet Composition

% fat % protein % carbs Weight loss at 2 years(lbs)

Low fat, average protein

20 15 65 6.6

Low fat, high protein

20 25 55 8.8

High fat average protein

40 15 45 7.0

High fat high protein

40 25 35 7.5

Is a calorie a calorie? • When people eat controlled diets, the proportion

of calories from fat, protein, and carbohydrate do not seem to matter for weight loss.

• When people can freely choose what they eat, there may be some benefits to a higher protein, lower carbohydrate approach.

•  For chronic disease prevention, the quality and food sources of nutrients matter.

Healthy Solutions to Lose Weight and Keep it Off. A Harvard Medical School Special Health Report, 2012

Effect of dietary and lifestyle factors on long-term weight gain N Engl J Med 2011; 364 •  Participants followed prospectively gained an average of

3.35 pounds per 4-year period, or 17 pounds over 20 years.

•  Weight gain was most strongly associated with intake of potato chips, potatoes, sugar sweetened beverages, red meats, and processed meats.

•  Weight loss or maintenance was associated with vegetables, whole grains, fruits, nuts, and yogurt.

•  Other factors associated with weight change were sleep, smoking, TV watching, physical activity and alcohol.

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Effects of Dietary Composition on Energy Expenditure During Weight-Loss Maintenance JAMA, 2012; 307

21 overweight and obese adults tried 3 isocaloric diets for 4 weeks each time, after a 10-15% weight loss: low fat: 60% carbohydrate, 20% fat, 20% protein low-glycemic: 40% carbohydrate, 40% fat, 20% protein very low carb: 10% carbohydrate, 60% fat, 30% protein Results: The low-glycemic index diet had the best results, with regards to changes in resting energy expenditure and favorable changes in lipids and inflammatory markers.

Which diet is best for health? JAMA, 2005;294(19):2455-2464

• OmniHeart - Optimal Macronutrient Intake Trial to Prevent Heart Disease tested 3 variations of the DASH diet in people with HTN

 Higher carb (58% carb, 15% protein, 27% fat)  Higher protein (48% carb, 25% protein, 27% fat)  Higher unsaturated fat (48% carb, 15% protein, 37%

fat) ▫  All 3 diets were low in saturated and trans fat (7%

calories), sodium (2300mg), and added sugar (2-5 tsp/day).

Results of the Omni Heart Trial After six weeks all 3 variations: • Lowered systolic BP by 13 to 16 points. • Lowered LDL by 20 to 24 points. • Lowered triglycerides by 9 to 16 points.  Partial substitution of carbohydrate with protein or unsaturated fat further reduced blood pressure, improved lipids, and reduced estimated cardiovascular risk.

Mediterranean Diet-Healthy Fats and good carbs with a big side of fruits and vegetables

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Primary Prevention of Cardiovascular Disease with a Mediterranean Diet NEJM, Feb. 25, 2013 Participants: Men and women without CV disease at

enrollment, but with type 2 diabetes or at least 3 risk factors.

Randomly assigned diets: a Mediterranean diet supplemented with 4 Tbsp/day of olive oil; or with 1 ounce of nuts/day; vs. a low fat diet (the control)

Results: 7,447 participants were followed for a median of 4.8 years. Drop out rates for the control were 11.3% and for the Mediterranean diets 4.9%. 288 primary outcome events occurred: 3.8% in the olive oil group, 3.4% in the nut group, and 4.4% in the control group. (P=0.015)

Practical Messages for Your Patients-The Low Hanging Fruit

• Nutrition advice you can deliver in less than 5 minutes.

Eat at least 5 servings of Vegetables and Fruits every day • Aim for at least 2 fists (2 cups) of vegetables and

1 fist of fruit each day. More is better!

Eat about 1 ounce of nuts most days •  1 ounce of nuts=1/4 cup or a small handful

• But be aware of the calories! ▫  1 ounce=160-200 calories

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Select whole grains

•  Look for “whole” in the first ingredient on the label. Aim for total carbs/fiber = <10 for bread and <5 for cereals.

Eat your calories, don’t drink them! • Eat fiber-rich whole fruit, not fruit juice.

• Drink calorie free beverages (especially water) or low sugar, nutrient dense beverages such as non-fat or low fat milk, almond milk, or soy milk.

Know what you’re eating! Read labels! Estimating Portion Sizes of Food

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Beware of the Calories in Restaurant Foods

Source: Center for Science in the Public Interest, 2012

Extreme Eating is not always obvious-know the nutrition facts! Reference: Center for Science in the Public Interest, 2012 •  The Cheesecake factory’s Bistro Shrimp Pasta:

3,120 calories and 89 grams of saturated fat. •  It's the nutritional equivalent of three orders of

Olive Garden's Lasagna Classico plus an order of Tiramisu

Watch the Sodium •  < 2300 mg/day is recommended (<1500 mg for

higher risk patients) • Americans consume an average of 4000 mg/day,

with 70% from processed food •  The leading source of sodium is bread •  2400 mg of sodium=1 tsp of table salt • Aim for sodium to not exceed calories per

serving •  Shop on the perimeter of grocery stores What We Eat in America, National Health and Nutrition Examination Survey, 2007–2008.

To help regulate appetite, go for lean protein and/or heart healthy (unsaturated) fat, plus high fiber with each meal or snack

Lean Protein Fiber

Egg (up to 4/week) or Egg whites Fresh fruit and whole grain toast with a spread that is free of trans fats and <2.5 grams of saturated fat per Tbsp

Chicken breast or Pork tenderloin Green salad with olive oil and vinegar, quinoa or lentils

Plain, non-fat Greek-style yogurt Berries and kashi go lean crunch

Black beans Stone ground corn tortilla, salsa and avocado

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Let the plate be your guide…and make it a small plate!

Make the easy choice the healthy choice

Set up your environment for success

•  Eat from smaller plates •  Make healthy food accessible and unhealthy food

inaccessible

Keep it simple…. “Eat Food, not too much, mostly plants.”

Michael Pollan, The Omnivores Dilemma

Track your diet • Diet tracking ▫  Diet Journals ▫  Computer based and Mobile apps   Lose it, My Fitness Pal

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Summary • Do address diet and exercise with your patients-

even brief messages and small, gradual behavior changes can be effective.

•  For weight loss, the most effective diet is the one your patient can adhere to long-term.

•  To prevent weight gain and to decrease disease risk, the quality of the diet is important.

“Eat food, mostly plants, not too much.”