Nutrition for Physician’s Assistants

PAST 556: Preventative Medicine & Health PromotionC. Betty Crocker, MPH, RDBCrocker@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-EChecklist to help older adults ID symptoms of Nutritional

ProblemsTable 7.2

1. Disease: confusion, memory loss, depression

2. Eating poorly: too little/much, same pattern, skip meals

3. Tooth loss/mouth pain4. Economic Hardship5. Reduced Social Contact: living alone6. Multiple Medicines: nausea, diarrhea7. Involuntary Weight Loss/Gain8. Needs assistance in self-care: eat,

cooking, shopping9. Above 80 years

• 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

Subjective Global AssessmentTable 7.3

Table 7.3

Nutrition Counseling

• 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– ½ plate fruits/veg– ½ grains whole grains– Lean protein

Nutritional CounselingHealthy Meal Plan Objective

16

MyPyramid is now …

17

MyPlate

18

Choose MyPlate “Menu”

Balancing calories– Enjoy your food, but

eat less

– Avoid oversized portions

19

20

Another name for “nutrient-dense” foods is “nutrient-rich” foods

21

Nutrient-dense vs. not nutrient-dense

22

Nutrient-dense vs. not nutrient-dense

23

Nutrient-dense vs. not nutrient-dense

24

Whole 2% 1% Fat-free

165 calories

125 calories

100calories

85calories

Calories saved

40 65 80

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

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

Calculate DAILYCaloric Needs

How Much Do I Need From Each Food Group?

Calorie

Level

1,600 1,800 2,000 2,200 2,400 2,600 2,800 3,000 3,200

Grains 5 ounces6 ounces 6 ounces 7 ounces 8 ounces 9 ounces 10 ounces 10 ounces 10 ounces

Vegetables2 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 ounces5 ounces 5.5 ounces6 ounces 6.5 ounces6.5 ounces7 ounces 7 ounces 7 ounces

CO

UN

TIN

G B

Y H

AN

D

29

MACRONUTRIENTS

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

30

CARBOHYDRATES

31

AMDRAcceptable Macronutrient Distribution Range

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

*Authored by the DRI Committee

32

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.

33

Basically Fiber

PolysaccharideMany “sugar units”

Held together by indigestible bondsPasses through the GI

Undigested UnabsorbedEXCEPTION: Some fiber is used as an

energy source for colonic bacteriacauses gas

34

Types of Fiber

Dietary Fiber: Nondigestible intact plant componentsTwo type:

Soluble FiberInsoluble Fiber

Functional Fiber: Nondigestible CHO that have been

extracted or manufactured from plantsBoth have beneficial physiologic

functions

Insoluble Fiber

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

36

Dissolves in water Attracts water & forms gel in GI (viscous) Slows digestion

Slows gastric emptying (stomach)Promotes fullnessSlows blood glucose absorption

Gives a gummy or gel-like characteristic to food Binds to cholesterol for elimination (lowers LDL)

Soluble Fiber

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

37

Functional Fiber

Sources: available throughout the food supply and included in the list of ingredients and fiber content. No labeling required “functional” fiber.

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

38

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

Fig. 4-5, p. 115

39s

“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."

NLEANational Labeling & Education Act 1990

40

Reduces Calorie consumptionThink nutrient denseDisplaces Calorie-dense fats & sweets

Promotes a feeling of fullnessSlows movement of food from the

stomach to the small intestineReduce blood glucose

Postprandial (after eating)

Contributes no Calories

Benefits of Fiber

41

Colonic Benefits of Fiber

Happy Colon = Healthy Colon:

Chronic constipation is associated with a 2x increase in the risk of colon cancer.

42

43

Happy Colon = Healthy ColonYes, these are GI cookies

PATIENT READY

FANTASTIC STOOL:If LOVING you is WRONG, I don’t want to be RIGHT!

8 glasses water daily

44

Prevents bacterial infection of the appendix

Colonic Benefits of Fiber

45

Colonic Benefits of Fiber

46

Slows digestion/absorption of other CHOSlows the flow of glucose into blood

Especially good for diabeticsReduces risk of cardiovascular disease

(CVD)Lowers blood cholesterol

Fiber binds cholesterol in bile that is excreted from the liver

Overall Health Benefits of Fiber

47

48

DRI: Dietary Reference IntakeMen 19-50: 38 g/dayWomen 19-50: 25 g/day

Fiber intake should be increased gradually because it may cause bloating or gasThese side effects disappear within 2-3

weeksFiber intake recommended from FOODAdequate fluid intake with high fiber diet:

8-8oz glasses water/day

Fiber Recommendations

Recall DV on label is used as a reference. Label based on 25g/d

49

Mineral deficienciesCan bind minerals & Prevent

Absorptioniron, zinc, and calcium

DehydrationMalnutrition

Can reduce energy intakeBowel impactions

Fiber Supplements can be HARMFUL

50

Examples of Fiber in Foods

51Fig. 4-15a, p. 126

PUNCHLINE:FIBER FOUND IN PLANTS ONLY

FatsBreak DOWNBreak DOWN

The Bad FatsWhat are Saturated What are Saturated Fatty Acids?Fatty Acids?

Saturated FatsThe Bad FatsThe 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

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 FatsThe Bad FatsThe Bad Fats

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

Saturated FatsThe Bad FatsThe Bad Fats

Why are they bad?

Saturated FatsDiets High in Saturated FatsDiets High in Saturated Fats

• Heart Attacks• Strokes• Atherosclerosis –

the narrowing of arteries

• Obesity• Heart Disease• Cancer – Breast &

Colon

Saturated FatsAdequate Amounts of SFAAdequate Amounts of SFA

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

• 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 FatsThe Bad FatsThe Bad Fats

• 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

Fad DietsLow Fat & NonfatLow Fat & Nonfat

The Good FatsMonounsaturated, Monounsaturated, Polyunsaturated & Polyunsaturated & Omega-3Omega-3

Good FatsBenefits of Healthy FatsBenefits 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 FatsBenefits of Healthy FatsBenefits 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 FatsBenefits of Healthy FatsBenefits 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 INFORMATIONThe 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 SEEDSNUTRITION INFORMATIONThe 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

• Walnuts• Soymilk• Tofu• Fatty fish (salmon,

tuna, mackerel, herring, trout, sardines)

PolyunsaturatedThe Good Fat

• Corn Oil• Soybean Oil• Safflower• Sunflower, Sesame,

pumpkin seeds and flaxseed

Fat & YouTaking Control ofTaking Control of

Your HealthYour Health

Cholesterol

• blood level indicates increased risk of atherosclerosis

• Reduce your total blood cholesterol by:1. Consuming less saturated and trans

fat2. Consuming more fiber3. 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 FAT2. USE GOOD FAT (OMEGA 3)3. INCREASE FIBER: fruits, vegetables, and

whole grains4. REDUCE CALORIES

GOOD/BAD EICOSINOIDSPhysiological Event GOOD EICOSANOIDS

n-3 DRIVENBAD EICOSANOIDS

n-6 DRIVEN

Blood Vessels Open Constrict

Blood Clotting Decrease Promote

Heart Disease Prevent Promote

Heart Arrhythmia Decreased Increased

Pain Decreased Increased

Inflammation Decreased Increased

Smooth Muscle Relaxation Contraction

Immune Function Increase Decreased

Menstrual Cramps Decreased Increased

Tumor Cells Kill Promote

Gestation (Pregnancy) Prevent preterm birth Promote preterm birth

AMDRAcceptable Macronutrient Distribution Range

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

Importance of PROTEIN

The Importance of PRO

2 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 PRO4 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

PRO Transport Summary• When diet supplies an overabundance of PRO: body cannot store AA

– Excrete AA (amine groups) and use residue for1. Immediate energy needs2. Make glucose for storage as glycogen3. 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 occurs1. Body lacks energy from CHO/Lipids2. Diet supplies MORE PRO than needed3. Body has TOO much of any single AA (supplements)4. Diet supplies PRO of LOW quality (too few essential

AA)

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

Recall NLEANational Labeling & Education Act 1990

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

RECALL: AMDRAcceptable Macronutrient Distribution Range

QUALITY AA

1. LIMITING AA– An essential AA that is present in dietary PRO in INUSUFFICIENT

amount, thereby limiting the body’s 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 AA2 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.full

91

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.

Thank you