Key Elements of Nutritional Management. Patient’s Dietary Intake and Trends 70% of American adults say they are eating “pretty much whatever they want”

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. 2 www.restaurant.org/pressroom/pressrelease.cfm?ID=979, obtained 3/14/05.

Nielsen & Popkin, JAMA 2003.

Food Portion Size Trends

0

5

10

15

20

SaltySnacks

Desserts SoftDrinks

FruitDrinks

FrenchFries

Ham-burgers

Cheese-burgers

Pizza MexicanFood

Foo

d In

take

per

Ea

ting

Occ

asio

n,

oz

1977-19781989-19911994-1998

They value nutrition information given by health

professionals the most

Obesity Is Caused by Long-Term Positive Energy Balance

Fatstores

Energyintake

Energyexpenditure

Normal Feeding Mechanism

Food Intake Blood

Appetite= feel hungry

Satiety= feel full

GI Tract:Absorption

CNS

vs

Protein

Fat

Carbohydrate

External FactorsEmotionsFood characteristicsLifestyle behaviorsEnvironmental cues

Central signalsNPYGalaninGLP-ICART

Peripheral signalsGlucose, CCK, Insulin, Ghrelin, Leptin

The What of Eating

New Food Pyramid &Dietary Guidelines

www.mypyramid.gov and www.healthierus.gov/dietaryguidelines

Dietary Factors to Address

Fat

Energy Density

FiberPortion Size

Caloric Beverages

Eating Out

Ad Libitum Low-Fat Diets Decrease Daily Energy Intake

Meta-analysis of 12 Intervention Trials

Astrup et al. Int J Obes 2000;24:1545.

Change in Energy Intake on Low-fat Diet (kJ/d)

2000 0 -2000 -4000 -6000

Lee-Han, 1988Boyd, 1990

Sheppard, 1991Kasim, 1993

Pritchard, 1996Siggaard, 1996

Simon, 1997Weststate, 1998

Stefanick (M), 1998Stefanick (F), 1998Saris SCHO, 2000Saris CCHO, 2000

Weighted overall (random effects)

Decreasing Dietary Fat is Associated With a Decrease in Body Weight

Analysis of 37 Diet Intervention Studies

r = 0.46.Yu-Poth et al. Am J Clin Nutr 1999;69:632.

4

2

0

-2

-4

-6

-8

-10

-12

Cha

nge

in B

ody

Wei

ght

(kg)

-30 -25 -20 -15 -10 -5 0 5 10

Change in Dietary Fat (% of Energy Intake)

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 Calories per Ounce

Peanut Butter 185

Salad dressing 160

Graham Crackers 130

Cheese 104

Bread 72Beans (kidney, lima) 35Grapes, apples, blueberries 17Strawberries, broccoli, peppers 8

Increasing Dietary Fiber Can Promote Weight Loss

Howarth et al. Nutrition Reviews 2001;59:129.

Rat

e of

Wei

ght

Loss

(g/

d)

P = 0.003

0

-20

-10

-30

-40

Low-fiber diet

High-fiber diet

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

Self magazine, March 2005, p 154.

You could be packing away 1,426 calories without taking a single bite!

500 625 750 10000

400

500

600

700

800

Amount of Macaroni and Cheese Served (g)

Cal

orie

s ea

ten

(kc

al)

The Larger the Portion, the More We Eat

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

Dansinger, et al. JAMA 2005;293:43-53.

Mean Changes in Wt and Cardiac Risk at 12 Months

-3.3

-2.2

-10.8

-2.1-2.5

-3.0

-3.2 -2.9

-10.1

-3.0 -3.3

-8.2

-12

-10

-8

-6

-4

-2

0

Weight, kgWaist circumference,

cmTotal cholesterol,

mg/dl

Mea

n C

han

ge

Atkins Zone Weight Watchers Ornish

Meal Replacements Promote Long and Short term Weight Loss

*1200–1500 kcal/d diet prescriptionA: conventional foodsB: 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