4/12/13 Nutrition and Your Patient: Disclosures Practical Strategies to Help Your Patients Eat Right • I have no conflicts of interest to disclose. Beth Gonzales, MSPH, RD Nutrition Specialist and Counselor Cardiovascular Center of Marin Larkspur, CA Objective Outline • To present practical approaches to help your Nutrition in primary care-why does it matter? patients eat healthier, achieve their nutrition Nutrition assessment and goal setting. related goals, and improve health outcomes. Which diet is best for weight loss and/or better health. Practical messages and strategies for your patient-the low hanging fruit. 1
4/12/13 Nutrition in Primary Care The importance of lifestyle on -Why does it matter? disease • 1/3 of premature deaths in the U.S. are attributable to poor nutrition and physical inactivity. • The link between diet and chronic diseases, • 50% of American adults do not get the recommended including type 2 diabetes, cardiovascular amount of physical activity. diseases, metabolic syndrome, and nonalcoholic • Only 10% of Americans eat a healthy diet consistent with fatty liver disease is well established. 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 Nutrition in Primary Care The Solution: • A Healthy People 2010 objective was to increase the proportion of office visits that addressed Exercise and Diet are the low cost and effective nutrition for patients with CV disease, DM, or solution to this epidemic of metabolic disease. 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 2
4/12/13 Primary Care Providers influence Audience Response on eating and exercise behaviors • How often do you address nutrition for your • Short 3 to 5 minute conversations during routine patients with cardiovascular disease, diabetes, or visits can contribute to patient behavior change. hypertension? • Obese patients who were advised by their PCP to 1. 0-19% lose weight were three times more likely to try than patients not advised. 2. 20-39% 3. 40-59% • Patients who were counseled about the benefits of healthy eating and exercise lost weight and 4. 60-79% exercised more than patients who were not. 5. 80-100% Reference: Talking with patients about weight loss: Tips for Primary Care Professionals U.S. Department of Health and Human Services Assessing Body Mass Index Determine current weight and weight history Assessing Nutritional Status BMI: Formula: weight (kg) / [height (m)]2 • BMI and weight history • BMI Weight Status • Below 18.5 Underweight • Waist circumference • 18.5 – 24.9 Normal • Laboratory assessment • 25.0 – 29.9 Overweight • Diet assessment • 30.0-34.9 Class I Obesity • 35.0-39.9 Class II Obesity • 40+ Class III Obesity http://nhlbisupport.com/bmi/ 3
4/12/13 Assessing Metabolic Status The short-coming of only addressing BMI Waist Circumference: • BMI doesn ’ t always reveal the underlying ▫ Increased disease risk is associated with >35 ” for culprit of metabolic diseases: visceral fat women, >40 ” for men. • As many as 50% of women and 20% of men with a normal BMI have unhealthy amounts of visceral fat. Setting the tone for a productive Setting the tone for a productive discussion about nutrition goals discussion about nutrition goals and behavior change and behavior change Assess readiness to change . Meet the patient where he or she is. • Many people who are stuck in an unhealthy pattern want to change, but they don't feel that Ask open-ended questions, listen, and they can. Clinicians can help tip that decisional summarize. balance. • If your patient is not ready to change, help them identify the important link between disease risk and diet and exercise behaviors. 4
4/12/13 Opening the discussion to Examples of open-ended address BMI and weight status questions for your patient: • Patients prefer terms such as “weight,” “excess • "What are your goals regarding your weight? ” weight,” “unhealthy body weight,” and “BMI ” instead of “obesity and ideal weight”. • “ What are your goals regarding your diet ” ? • For example, you might say: "Ms. Brown, your BMI is above the healthy • “ Have you tried to lose weight or change your range. Excess weight could increase your risk for diet in the past? ” If so, what worked well and some health problems. Would you mind if we what did not work well? ” talked about it?" Health Effects of Lifestyle Changes-Small changes, Big Goal setting for weight results management • Agree on a weight goal: losing 5-10% over 6 Losing 7% of weight and exercising 30 minutes per day cut diabetes risk by nearly 60% in patients at months at a rate of 0.5-2.0 pounds per week is high risk for developing diabetes after 3-4 years of appropriate for most patients who are ready to follow-up. lose weight. • A goal of maintaining current weight and not 60-90 minutes of walking/week=51% decreased risk gaining weight may also be appropriate for some of CHD vs. non-regular walkers patients. References: Diabetes Prevention Program, NEJM, 2002; 346 Women ’ s Health Study, JAMA, 2001; 285 5
4/12/13 Sample Nutrition Profile Form Assess current diet pattern Initial Current Target • Diet can be assessed with a 24-hour recall, food frequency questions, or by administering a brief Weight 190 lbs 205 lbs 195 lbs food frequency questionnaire (REAP-Rapid BMI 27 29 28 Eating Assessment for Patients). Waist 43 ” 45 ” <35 ” women; <40 ” men Blood Pressure 128/75 135/93 <130/<90 Pertinent Labs LDL: 129 LDL: 143 LDL: <100 Triglycerides: 130 Triglycerides: 160 Triglycerides<150 HDL: 39 HDL: 35 HDL: >50 http://med.brown.edu/nutrition/acrobat/REAP%206.pdf Glucose: 94 Glucose: 111 Glucose: <100 ALT: 35 ALT: 40 ALT: <30 Goal setting for behavior change Weight loss basics You might ask: • To understand what it takes to lose or maintain “ What changes are you willing to make to your weight, it often helps patients to understand eating and physical activity habits right now? ” energy balance, including one ’ s calorie needs, • Have them identify 1-2 specific changes they will calories consumed, and calories burned. 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. 6
4/12/13 How many Calories does one need? Quick estimate for calorie needs • Mifflin St Jeor Equation -To estimate calories for weight maintenance : If you are moderately active, multiply current 10*wt(kg) + 6.25*Ht(cm) - 5*Age(yrs) + 5 = resting energy weight (pounds) x 15 expenditure (male) -To estimate calories for weight loss : 10*wt(kg) + 6.25*Ht(cm) - 5*Age(yrs) -161 = resting energy Subtract 500-1000 calories to lose expenditure (female) approximately 1.0-2.0 pounds per week; usually This estimates resting energy expenditure (REE). Multiply REE 7-10 calories per pound of current weight by an "activity factor ” : 1.3=sedentary 1.4=walking/standing, no exercise 1.5=exercise 1.6=walking&exercise 1.8=heavy lifting Calorie intake shouldn ’ t be <1200 for women or <1500 for men. For weight loss, subtract 500-1000 calories Extra calories from eating away How Many Calories do we from home Consume? Public Health Nutr.16: 87, 2013 • According to the Dietary Guidelines Advisory Calories/meal at Calories/meal at a Committee, calorie consumption in the U.S. has home restaurant Normal Weight 550 825 increased 30% over the past 4 decades. Overweight/Obese 625 900 Year Average calories consumed 1970 2,057 2008 2,674 7
4/12/13 What in our diet is making us Top sources of calories in the U.S. fatter and sicker? • 1. Grain-based desserts • 2. Yeast breads • Too many refined grains: • 3. Chicken and chicken-mixed dishes ▫ Federal guidelines recommend six 1 ounce servings per day for a 2000 calorie diet, and half • 4. Soda, energy drinks, and sports drinks should be whole grain. The average person eats 8 • 5. Pizza servings of grains per day, and 7 of the 8 are • 6. Alcoholic beverages refined. • 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 A primary contributor to the rise in What is a serving of grain? visceral fat and metabolic syndrome • 1/2 cup cooked rice or other cooked grain • Way too much added sugar • 1/2 cup cooked pasta The average person consumes 30 teaspoons of sugar • 1/2 cup cooked hot cereal, such as oatmeal and sweeteners per day (~ 15% of calories). • 1 six inch tortilla The AHA recommendations < 6 teaspoons (24 • 1 slice of bread (1 oz.); ½ bun grams) of added sugar per day for women, and < 9 • 1 very small (1 oz.) muffin (36 grams) for men . A 20 oz soda has twice that. • ½ -1 cup ready-to-eat cereal ( ½ cup = ½ a baseball) Nutrition Action Health Letter, CSPI, March, 2013 8
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