Key Elements of Nutritional Management Patients Dietary Intake

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 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 2 Putnam J et al. USDA Food. Review, Vol 25 (3); 2002. www. restaurant. org/pressroom/pressrelease. cfm? ID=979, obtained 3/14/05.

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 (k. J/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 cous 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 Power. Boost 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 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 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