Key Elements of Nutritional Management

1. Key Elements of Nutritional Management

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

3. 1977-1978 1989-1991 1994-1998 20 15 10 Food Intake per Eating Occasion, oz 5 0 Salty Snacks Desserts Soft Drinks Fruit Drinks French Fries Ham- burgers Cheese-burgers Pizza Mexican Food Food Portion Size Trends Nielsen & Popkin, JAMA 2003.

4. They value nutrition information given by health professionals the most

5. Fat stores Obesity Is Caused by Long-Term Positive Energy Balance Energy expenditure Energy intake

6. Normal Feeding Mechanism Central signals NPY Galanin GLP-I CART External Factors Emotions Food characteristics Lifestyle behaviors Environmental cues CNS Appetite = feel hungry Satiety = feel full vs Food Intake Blood GI Tract: Absorption Carbohydrate Fat Peripheral signals Glucose, CCK, Insulin, Ghrelin, Leptin Protein

7. The What of Eating

8. New Food Pyramid &Dietary Guidelines www.mypyramid.gov and www.healthierus.gov/dietaryguidelines

9. Dietary Factors to Address Fat Energy Density Eating Out Portion Size Fiber Caloric Beverages

10. Ad Libitum Low-Fat Diets Decrease Daily Energy IntakeMeta-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 -6000 Change in Energy Intake on Low-fat Diet (kJ/d) Astrup et al. Int J Obes 2000;24:1545.

11. 4 2 0 -2 -4 -6 -8 -10 -12 Change in Body Weight (kg) -30 -25 -20 -15 -10 -5 0 5 10 Change in Dietary Fat (% of Energy Intake) Decreasing Dietary Fat is Associated With a Decrease in Body WeightAnalysis of 37 Diet Intervention Studies r = 0.46. Yu-Poth et al. Am J Clin Nutr 1999;69:632.

12. 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

13. 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 72 Beans (kidney, lima) 35 Grapes, apples, blueberries 17 Strawberries, broccoli, peppers 8

14. 0 -10 High-fiber diet -20 Rate of Weight Loss (g/d) Low-fiber diet -30 P = 0.003 -40 Increasing Dietary Fiber Can Promote Weight Loss Howarth et al. Nutrition Reviews 2001;59:129.

15. 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.

16. 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 Watch the Calories in Drinks You could be packing away 1,426 calories without taking a single bite! Self magazine, March 2005, p 154.

17. 800 700 600 Calories eaten (kcal) 500 400 0 500 625 750 1000 Amount of Macaroni and Cheese Served (g) The Larger the Portion, the More We Eat Rolls et al. Am J Clin Nutr.2002;76:1207-13.

18. 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

19. 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?

20. One “Diet” Does Not Fit All Low Calorie Diet Low Fat Diet Low Carb Diet

21. Comparison of Popular Diets Mean Changes in Wt and Cardiac Risk at 12 Months Dansinger, et al. JAMA 2005;293:43-53.

22. 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.

23. 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 howto 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.

24. 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