Nutrition for Physicians Assistants

PAST 556: Preventative Medicine & Health Promotion

C. Betty Crocker, MPH, RD BCrocker@MtSAC.edu

My BIO
Registered Dietitian MPH, Nutrition Le Cordon Bleu trained chef Doctorate student Professor: Nutrition, Public Health, and Culinary Arts Chef Instructor/Consultant Public Health Writer: LA Times TheRealBetty@aol.com

True Nutrition Experts

American Dietetic Association (ADA)

www.eatright.org Now Academy of Nutrition and Dietetics (AND) Registered dietitian (RD) Certified diabetes educator Public health nutritionist Dietetic technician
Dietetic technician registered

American Society of Nutrition (ASN)

www.nutrition.org

Nutritional Assessment

Dietary Assessment
24 hour recall 72 hour recall Eating patterns Meal plans Looking for deficiencies Barriers:
Limited recall due to______ Older patients Women vs. Men

Anthropometric Assessment
BMI:
Limitations Overestimate
body fat in athletes High muscular build

Underestimate
Older persons Significant muscle loss

Biochemical Assessment of Nutrition

Most sensitive is Prealbumin: half-life is 2 days
albumin: half life ~20 days PAB improved nutrition increase 10 mg/L/d Inadequate nutritional support Poor response Poor prognosis

Low PAB indicates

Protein energy malnutrition Inflammation + malnutrition

Biochemical Assessment of Nutrition

Insulin life growth factor 1 (IGF1)
Very sensitive marker Associated with increased morbidity Associated with protein intake

No single marker is evidence of overall nutritional status

Older Adults Nutritional Screening

Nutrition Screening Initiative Project of
American Academy of Family Physicians Academy of Dietetics and Nutrition National Council of Aging

Determine Your Nutrition Health checklist

D-E-T-E-R-M-I-N-E
Checklist to help older adults ID symptoms of Nutritional Problems Table 7.2

1. Disease: confusion, memory loss, depression 2. Eating poorly: too little/much, same pattern, skip meals 3. Tooth loss/mouth pain 4. Economic Hardship 5. Reduced Social Contact: living alone 6. Multiple Medicines: nausea, diarrhea 7. Involuntary Weight Loss/Gain 8. Needs assistance in self-care: eat, cooking, shopping 9. Above 80 years

Subjective Global Assessment

Table 7.3

Does NOT utilize objective measurements

Biochemical Anthropometrics

DOES provide
Screening tool Requires clinical judgment
Interpret information

Collected by interviews & observations Correlated well with objective measurements

Table 7.3

Nutrition Counseling

Nutritional Counseling
Healthy Meal Plan Objective

DIET: foods you NORMALLY eat and drink Cho0se whole foods 3 Macronutrient Strategies
Put fiber behind your carbohydrates (CHO) Lean Protein (PRO) Choose Healthy Fat (Lipids)

My Plate Strategies
plate fruits/veg grains whole grains Lean protein

MyPyramid is now

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MyPlate

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Choose MyPlate Menu

Balancing calories
Enjoy your food, but eat less

Avoid oversized portions

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Another name for nutrientdense foods is nutrientrich foods

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Nutrient-dense vs. not nutrient-dense

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Nutrient-dense vs. not nutrient-dense

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Nutrient-dense vs. not nutrient-dense

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Switching to fat-free or low-fat (1%) milk makes a difference!

Whole 165
calories Calories saved

2% 125
calories

1% 100
calories

Fat-free 85
calories

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24

65

80

Meet the Nutrients

Energy-yielding nutrients Carbohydrates 4 cal/g Fats 9 cal/g Proteins 4 cal/g Alcohol 7 cal/g Vitamins and minerals Provide no energy Some are essential

Sex and Age

Not Physically Active <30 min most days moderate - vigorous physical activity

Moderately Active ~30 min most days moderate - vigorous physical activity

Physically Active 60+ min most days moderate - vigorous physical activity

Girls 14-18 Boys 14-18 Females 19-30

1800 Calories 2200 Calories 2000 Calories

2000 Calories 2400 Calories 2200 Calories

2400 Calories 3200 Calories 2400 Calories

Males 19-30
Females 31-50 Males 31-50 Females 51+ Males 51+

2400 Calories
1800 Calories 2200 Calories 1600 Calories 2000 Calories

2600 Calories
2000 Calories 2400 Calories 1800 Calories 2200 Calories

3000 Calories
2200 Calories 3000 Calories 2200 Calories 2800 Calories

Calculate DAILY Caloric Needs

Calorie Level
Grains

1,600 1,800 2,000

2,200

2,400

2,600

2,800

3,000

3,200

5 ounces 6 ounces 6 ounces

7 ounces

8 ounces

9 ounces

10 ounces 10 ounces 10 ounces

Vegetables 2 cups

2.5 cups 2.5 cups

3 cups

3 cups

3.5 cups

3.5 cups

4 cups

4cups

Fruits

1.5 cups 1.5 cups 2 cups

2 cups

2 cups

2 cups

2.5 cups

2.5 cups

2.5 cups

Dairy

3 cups

3 cups

3 cups

3 cups

3 cups

3 cups

3 cups

3 cups

3 cups

Protein Foods

5 ounces 5 ounces 5.5 ounces 6 ounces

6.5 ounces 6.5 ounces 7 ounces

7 ounces

7 ounces

How Much Do I Need From Each Food Group?

COUNTING BY HAND

MACRONUTRIENTS
CARBOHYDRATES (CHO) FAT (LIPIDS) PROTEIN (PRO)

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CARBOHYDRATES

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AMDR
Acceptable Macronutrient Distribution Range

AMDR Recommendations*: CHO: 45-65% Protein: 10-35% Lipids: 20-35%

*Authored by the DRI Committee

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Basically Fiber
Structural form of glucose in plant leaves, stems, and seeds.
Cell wall= 95% fiber

Human digestive enzymes cannot break the chemical bonds holding the sugar units together, i.e. indigestible in human beings.

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Basically Fiber
Polysaccharide
Many sugar units

Held together by indigestible bonds Passes through the GI

Undigested Unabsorbed EXCEPTION: Some fiber is used as an energy source for colonic bacteria
causes gas
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Types of Fiber
Dietary Fiber:
Nondigestible intact plant components Two type:
Soluble Fiber Insoluble Fiber

Functional Fiber:
Nondigestible CHO that have been extracted or manufactured from plants

Both have beneficial physiologic functions

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Insoluble Fiber
Doesnt dissolve in Called roughage water Example = cellulose Insoluble fiber passes Strings of celery through the GI almost Kernels of corn intact Bran layer of Adds bulk to stool whole wheat Acts as a sponge to kernel absorb water
Aids in digestion & elimination Reduces constipation

Increases GI transit time

Tough, fibrous part of plants

Sources: wheat bran, whole grains, many vegetables and skins of fruit

Soluble Fiber
Dissolves in water Attracts water & forms gel in GI (viscous) Slows digestion Slows gastric emptying (stomach) Promotes fullness Slows blood glucose absorption Gives a gummy or gel-like characteristic to food Binds to cholesterol for elimination (lowers LDL)

36 Sources: oats, soy, legumes, nuts, bananas, apples, oranges celery, cucumbers

Functional Fiber
Added to food Extracted, isolated or manufactured from plants Contain both soluble & insoluble fiber Takes on same physiological benefits as soluble insoluble Passes through GI, nondigestable

http://www.aaccnet.org/ news/pdfs/DFreport.pdf

Sources: available throughout the food supply and included in the list of ingredients and fiber 37

Where there is SOLUBLE.there is also INSOLUBLE. They go hand in hand in nature

Fig. 4-5, p. 115

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NLEA
National Labeling & Education Act 1990

Calorie values generally reflect industry practices of calculating calories from 4-4-9 kcal/g for protein, carbohydrate, and fat, respectively or from 4-4-9 kcal/g for protein, carbohydrate minus fiber, and fat. The latter method is frequently used for high-fiber foods. Notice that this presents an opportunity for inconsistency in labeling among different food products and companies. Some food items may include the dietary fiber in the calculation of total calories; others may not."

39s

Benefits of Fiber
Reduces Calorie consumption
Think nutrient dense Displaces Calorie-dense fats & sweets

Promotes a feeling of fullness Slows movement of food from the stomach to the small intestine
Reduce blood glucose
Postprandial (after eating)

Contributes no Calories

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Colonic Benefits of Fiber

PREVENTS: Constipation Impacted Stool: hard, dry bowel movements Can be painful PREVENTS: Straining Difficult to pass impacted stool May result in varicose veins in rectum & hemorrhoids Happy Colon = Healthy Colon: Chronic constipation is associated with a 2x increase in the risk 41 of colon cancer. Prevents: Hemorrhoids painful, swollen veins in the lower portion of the rectum or anus Promotes: Regularity Keeps intestinal contents moist Eases elimination Bulk triggers urge to defecate

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FANTASTIC STOOL:
If LOVING you is WRONG, I dont want to be RIGHT!

8 glasses water daily PATIENT READY Happy Colon = Healthy Colon Yes, these are GI cookies

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Colonic Benefits of Fiber

Prevents bacterial infection of the appendix

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 Keeps GI muscles healthy & toned Prevents Diverticulosis Once diagnosed, high fiber diet paramount to ensure the smooth passage of fecal material Abnormal pockets in the colon wall Caused by weakening of muscles surrounding the colon Prevent bouts of Diverticulitis Inflammation of diverticulum

Colonic Benefits of Fiber

Low fiber diet required during inflammation

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Overall Health Benefits of Fiber

Slows digestion/absorption of other CHO Slows the flow of glucose into blood
Especially good for diabetics

Reduces risk of cardiovascular disease (CVD) Lowers blood cholesterol

Fiber binds cholesterol in bile that is excreted from the liver
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Fiber Recommendations
DRI: Dietary Reference Intake Men 19-50: 38 g/day Women 19-50: 25 g/day Fiber intake should be increased gradually because it may cause bloating or gas These side effects disappear within 2-3 weeks Fiber intake recommended from FOOD Adequate fluid intake with high fiber diet: 8-8oz glasses water/day
Recall DV on label is used as a reference. Label based on 25g/d
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Fiber Supplements can be HARMFUL

Mineral deficiencies Can bind minerals & Prevent Absorption
iron, zinc, and calcium

Dehydration Malnutrition
Can reduce energy intake

Bowel impactions
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Examples of Fiber in Foods

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PUNCHLINE: FIBER FOUND IN PLANTS ONLY

Fig. 4-15a, p. 126 51

Fats
Break DOWN

The Bad Fats

What are Saturated Fatty Acids?

Saturated Fats
The Bad Fats
Maximum number of hydrogen atoms No point of saturation (double bonds between carbon) Triglycerides that contain 3 saturated fatty acids More stable at high temperature

Saturated Fats
The Bad Fats Founds in Animal Products such as: Butter Cheese Whole Milk Ice Cream Fatty Meats Coconut, Palm & Kernel Oil

Saturated Fats
The Bad Fats
Why are they bad?

Saturated Fats
Diets High in Saturated Fats

Heart Attacks Strokes Atherosclerosis the narrowing of arteries

Obesity Heart Disease Cancer Breast & Colon

Saturated Fats
Adequate Amounts of SFA

Cardiovascular Benefits Bone Health Optimal Liver Function Strong Lungs Healthy Brain Nerve Communication Immune System Function

The Bad Fats Trans fat is another name for an unsaturated fat Carries a trans isomer in the fatty acid chain. It has a double carbon bond They are sometimes monounsaturated and polyunsaturated but never saturated. They are known for raising your LDL levels lowering your HDL levels causing coronary heart disease

Trans Fats

Fad Diets
Low Fat & Nonfat

Low Fat and nonfat diets may not be the healthiest for your body Taking the fat out of your diet often removes the flavors of the food you consume Some foods remove fat and add sugar for flavor

The Good Fats

Monounsaturated, Polyunsaturated & Omega-3

Good Fats

Benefits of Healthy Fats

Good fats help fight the very diseases that consuming excess fat was said to cause. good fats are beneficial to cholesterol. Monounsaturated fat helps to lower cholesterol. they are a good source of omega-3 fatty acids (cold water fish, nuts, oils, seeds, dark leafy greens).

http://www.med.umich.edu/umim/food-pyramid/fats.htm

Good Fats

Benefits of Healthy Fats

Omega-3 fatty acids is an essential fatty acid which is NOT manufactured by our bodies, so eating those foods is the only way to get them. Omega -3 fatty acids are also thought to lower blood pressure, combat LDL (bad) cholesterol, fight inflammation and protect the brain and the nervous system.

http://www.med.umich.edu/umim/food-pyramid/fats.htm

Good Fats

Benefits of Healthy Fats

Eating monosaturated fats improves blood cholesterol levels which can decrease your risk of heart disease. Research shows also shows that MUFAS may benefit insulin levels and blood sugar control which is helpful to people who have type two diabetes. Omega-3 fatty acids found in some types of fatty fish, appear to decrease risk of coronary artery disease.

http://www.med.umich.edu/umim/food-pyramid/fats.htm

FLAX MEAL
NUTRITION INFORMATION
The Good Fat

1 Tablespoon of flax meal: 3 grams fiber 2 grams omega-3 (good fat) Recipe: 1-2 Tablespoon/cup flour

http://www.youtube.com/watch?v=_1EbDdAeq7A

CHIA SEEDS
NUTRITION INFORMATION
The Good Fat

1 Tablespoon of CHIA SEED: 4 grams fiber 2.4 grams omega-3 (good fat) Recipe: Gel: 1 cup water: 2T 2t chia seeds, mix, store in refrigerator up to a week

http://www.youtube.com/watch?v=_L4wJ1vadUg

Polyunsaturated
The Good Fat

Corn Oil Soybean Oil Safflower Sunflower, Sesame, pumpkin seeds and flaxseed

Walnuts Soymilk Tofu Fatty fish (salmon, tuna, mackerel, herring, trout, sardines)

Fat & You

Taking Control of Your Health

Cholesterol
blood level indicates increased risk of atherosclerosis Reduce your total blood cholesterol by: 1. Consuming less saturated and trans fat 2. Consuming more fiber 3. Exercising

Low Density Lipoproteins (LDL)

Bad cholesterol Deliver cholesterol from the liver to arteries blood levels indicate increased risk of atherosclerosis Reduce your LDL by:
Consuming less saturated and trans fat

High Density Lipoproteins (HDL)

Good cholesterol Scavenge excess cholesterol from tissues for disposal blood levels indicate decreased risk of atherosclerosis Increase your HDL by:
Exercising regularly

RECIPES TO PROMOTE HEART HEALTH

1. REDUCE SATURATED FAT 2. USE GOOD FAT (OMEGA 3) 3. INCREASE FIBER: fruits, vegetables, and whole grains 4. REDUCE CALORIES

GOOD/BAD EICOSINOIDS
Physiological Event GOOD EICOSANOIDS n-3 DRIVEN
Open Decrease Prevent Decreased

BAD EICOSANOIDS n-6 DRIVEN

Constrict Promote Promote Increased

Blood Vessels Blood Clotting Heart Disease Heart Arrhythmia

Pain
Inflammation Smooth Muscle Immune Function Menstrual Cramps Tumor Cells Gestation (Pregnancy)

Decreased
Decreased Relaxation Increase Decreased Kill Prevent preterm birth

Increased
Increased Contraction Decreased Increased Promote Promote preterm birth

 PREFERRED:
Fish (whole food) NOT fish oil

EXCEPTION:
People who cannot get enough EPA/DHA from their diet

Fish Oil Supplements

MANUFACTURING
Made from skins & liver more likely to contain contaminants Newer processing reduces risk

CAUTION
Interfere with blood clotting: EPA supplements 200 mg/d DHA Fish Oil 300 mg/d Vitamin Toxicity Fish liver oil naturally contains high levels A & D

AMDR
Acceptable Macronutrient Distribution Range

AMDR Recommendations*: CHO: 45-65% Protein: 10-35%

Total Calories *Authored by the DRI Committee 19-50 Years Old

PROTEIN

Importance of PROTEIN

AA must be continuously available to build PRO of new tissues for GROWTH & MAINTENANCE

Embryo, athletic muscles, growing child, new blood cells lost in menstruation, scar tissue to heal wounds, new hair & nails Protein Turnover Constantly make & break down PRO Recycling AA Daily: 25% AA are irretrievably diverted to other tissues to be used for fuel

The Importance of PRO

Providing Structure/Movement: Muscle

MUSCLES contain 40% body PRO Muscles can release EMERGENCY AA for energy Building Compounds: enzymes & hormones ENZYMES: 1000s reside in every cell Recall: enzyme=catalyst to speed up reactions HORMONES: messenger molecules made from AA Recall: Insulin & Glucagon for glucose regulation

The Importance of PRO

3 BUILDING ANTIBODIES

Antibodies are PRO made by PRO

Distinguish foreign PRO from their body PRO When intruder is present, they attack to destroy

Bacterium, virus, toxin, or present in food that causes allergic reaction

Recall celiac disease (autoimmune response to gluten) Each antibody designed to destroy specific invader IMMUNITY: antibody built and successful, available for next attack Different strains of flu require different antibodies built

The Importance of PRO

4 MAINTAINING FLUID BALANCE
PRO regulate quality of fluids in compartments of body Life depends on cells maintaining constant amount of fluid TOO MUCHrupture TOO LITTLEunable to function Recall: Water can diffuse freely in/out cells, PRO Homeostasis: maintaining stores of internal PRO & minerals BLOOD VESSELS mechanism Fluid kept inside blood vessels by PRO too large to move across capillary wall PRO attract water & hold it within vessels, preventing it from flowing into the spaces between cells When blood PRO (albumin) is low: TOO much fluid will between cells will collectEDEMA

The Importance of PRO

5 EMERGENCY ENERGY SOURCE
PRO will be surrendered to provide energy if needed Under conditions of inadequate energy: Starvation, prolonged fasting, and severe calorie restriction No storage of PRO as with CHO/Lipids PRO only present as active working molecular & structural component of body tissue Order PRO dismantled for energy blood, muscle PRO, liver & other organs Goal: maintain steady blood glucose level for brain AA breakdown: Carbon Hydrogen Oxygen used for energy needs Nitrogen excreted or used elsewhere

PRO Transport Summary

When diet supplies an overabundance of PRO: body cannot store AA Excrete AA (amine groups) and use residue for 1. Immediate energy needs 2. Make glucose for storage as glycogen 3. Or make fat for energy storage

RECALL: CHO=energy Lipids=concentrated energy PRO=energy +N

Wasting AA Summary

WASTING: When AA not used to build PRO or make other Nitrogen-containing compounds When wasting occurs
1. 2. 3. 4. Body lacks energy from CHO/Lipids Diet supplies MORE PRO than needed Body has TOO much of any single AA (supplements) Diet supplies PRO of LOW quality (too few essential AA)

Recall NLEA
National Labeling & Education Act 1990 PRO Labeling Must Include: PRO grams in bold print Incomplete PRO: When food is for adults/children over 1 year of age : label should state "0%" in % DV column or state "Not a significant source of protein. Voluntary Labeling: %DV Protein % Daily Value is not required when the food is for adults or children over 4 years of age unless a protein claim is made

http://www.fda.gov/ICECI/Inspections/InspectionGuides/ucm074948.htm

RECALL: AMDR
Acceptable Macronutrient Distribution Range

AMDR Recommendations*: CHO: 45-65% lipids: 20-35% n-6: 5-10% n-3: .6-1.2%
% of Total Calories *Authored by the DRI Committee 19-50 Years Old

QUALITY AA
1. LIMITING AA

An essential AA that is present in dietary PRO in INUSUFFICIENT amount, thereby limiting the bodys ability to build protein Acute shortage: inconsequential as cells resume normal protein activities when limiting AA is provided in next meal (~24 hours) Chronic shortage: lack variety of plant based foods Protein synthesis slows Cells begin to break down protein-making machinery Wasted AA: Amine groups excreted, C,H,O used elsewhere Severe cases: break down organs for AA

QUALITY AA
2 COMPLIMENTARY PRO
Plant-based diet 2 or more PRO whose AA assortments compliment each other in such a a way that the essential AA missing form one are supplied by another AA low in some foods are supplied by other Goal: to consume essential AA in sufficient amount to support health MUTUAL SUPPLEMENTATION: strategy of combing 2 incomplete PRO sources so that the AA in one food make up for those lacking in the other food Example: Beans & Rice

QUALITY AA
3 PRO Digestibility
Method to evaluate: Protein Digestibility Corrected Amino Acid Score (PDCAAS)

Reference AA = egg white (high biological value) Animal based diets have highest digestibility Milk (100%), Beef (92%) Plant based diets have less Soy protein (100%) Legumes (90-70%), Fruits (75%), vegetables (73%), cereals (59%), peanuts (52%), Grains (90-70%0 Cooking with moist heat improves digestibility
http://jn.nutrition.org/content/130/7/1865S.f ull

Remember
A variety of foods, in moderation, can fit into a healthy eating pattern if nutrient needs have been met without exceeding calorie limits. Regular physical activity helps maintain calorie balance.
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Thank you