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 Nutri)on Experts

American Diete)c Associa)on (ADA)

www.eatright.org Now Academy of Nutri)on and Diete)cs (AND) Registered die))an (RD) Cer)ed diabetes educator Public health nutri)onist Diete)c technician
Diete)c technician registered

American Society of Nutri)on (ASN)

www.nutri)on.org

Nutritional Assessment

Dietary Assessment
24 hour recall 72 hour recall Eating patterns Meal plans Looking for deciencies 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 Signicant 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 Inammation + 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

 Checklist to help older adults ID symptoms of Nutritional Problems Table 7.2

D-E-T-E-R-M-I-N-E

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 ber 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 por)ons

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 Another name for nutrient- dense foods is nutrient- rich 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 dierence!

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 essen)al

Sex and Age

Not Physically Ac8ve <30 min most days moderate - vigorous physical ac8vity

Moderately Ac8ve ~30 min most days moderate - vigorous physical ac8vity

Physically Ac8ve 60+ min most days moderate - vigorous physical ac8vity

Girls 14-18 Boys 14-18 Females 19-30 Males 19-30 Females 31-50 Males 31-50 Females 51+ Males 51+

1800 Calories 2200 Calories 2000 Calories 2400 Calories 1800 Calories 2200 Calories 1600 Calories 2000 Calories

2000 Calories 2400 Calories 2200 Calories 2600 Calories 2000 Calories 2400 Calories 1800 Calories 2200 Calories

2400 Calories 3200 Calories 2400 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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Acceptable Macronutrient Distribution Range

AMDR!

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% ber

Human diges)ve enzymes cannot break the chemical bonds holding the sugar units together, i.e. indiges)ble in human beings.

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Basically Fiber
Polysaccharide
Many sugar units

Held together by indiges)ble bonds Passes through the GI

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

Func8onal Fiber:
Nondiges)ble CHO that have been extracted or manufactured from plants

Both have benecial physiologic func)ons

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Insoluble Fiber
Doesnt dissolve in Called roughage water Example = cellulose Insoluble ber 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 diges8on & elimina8on Reduces cons8pa8on

Increases GI transit 8me Tough, brous part of plants

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

Soluble Fiber
Dissolves in water AZracts water & forms gel in GI (viscous) Slows diges8on Slows gastric emptying (stomach) Promotes fullness Slows blood glucose absorp8on Gives a gummy or gel-like characteris8c to food Binds to cholesterol for elimina8on (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 ber Takes on same physiological benets as soluble insoluble Passes through GI, nondigestable

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

37 Sources: available throughout the food supply and included in the list of ingredients and ber content. No labeling required func8onal ber.

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

Fig. 4-5, p. 115

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National Labeling & Education Act 1990

NLEA

Calorie values generally reect 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 ber, and fat. The latter method is frequently used for highber foods.! Notice that this presents an opportunity for inconsistency in labeling among different food products and companies. Some food items may include the dietary ber in the calculation of total calories; others may not."

39s

Benets of Fiber
Reduces Calorie consump8on
Think nutrient dense Displaces Calorie-dense fats & sweets

Promotes a feeling of fullness Slows movement of food from the stomach to the small intes8ne
Reduce blood glucose
Postprandial (aeer ea8ng)

Contributes no Calories

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Colonic Benets of Fiber

PREVENTS: Cons8pa8on Impacted Stool: hard, dry bowel movements Can be painful PREVENTS: Straining Dicult to pass impacted stool May result in varicose veins in rectum & hemorrhoids Happy Colon = Healthy Colon: Chronic cons3pa3on is associated with a 2x increase in the risk 41 of colon cancer. Prevents: Hemorrhoids painful, swollen veins in the lower por8on of the rectum or anus Promotes: Regularity Keeps intes8nal contents moist Eases elimina8on 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 Benets of Fiber

Prevents bacterial infec)on of the appendix

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 Keeps GI muscles healthy & toned Prevents Diver3culosis Once diagnosed, high ber 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 Diver3culi3s Inamma)on of diver)culum

Colonic Benets of Fiber

Low ber diet required during inamma)on

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Overall Health Benets of Fiber

Slows diges)on/absorp)on of other CHO Slows the ow of glucose into blood
Especially good for diabe)cs

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 bloa)ng or gas These side eects disappear within 2-3 weeks Fiber intake recommended from FOOD Adequate uid intake with high ber 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 deciencies Can bind minerals & Prevent Absorp8on
iron, zinc, and calcium

Dehydra8on Malnutri8on
Can reduce energy intake

Bowel impac8ons
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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

The Bad Fats

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

Saturated Fats
Why are they bad?

Saturated Fats
Heart Attacks Strokes Atherosclerosis the narrowing of arteries Obesity Heart Disease Cancer Breast & Colon

Saturated Fats
Cardiovascular Benets Bone Health Optimal Liver Function Strong Lungs Healthy Brain Nerve Communication Immune System Function

Trans 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

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

The Good Fats

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

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

Good 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, ght inammation and protect the brain and the nervous system.

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

Good Fats
Eating monosaturated fats improves blood cholesterol levels which can decrease your risk of heart disease. Research shows also shows that MUFAS may benet 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 sh, appear to decrease risk of coronary artery disease.

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

FLAX MEAL
The Good Fat

NUTRITION INFORMATION
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
The Good Fat

NUTRITION INFORMATION
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 Saower Sunower, Sesame, pumpkin seeds and axseed Walnuts Soymilk Tofu Fatty sh (salmon, tuna, mackerel, herring, trout, sardines)

Fat & You

Cholesterol
blood level indicates increased risk of atherosclerosis Reduce your total blood cholesterol by: 1. Consuming less saturated and trans fat 2. Consuming more ber 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 )ssues 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 Decreased Decreased Relaxa)on Increase Decreased Kill Prevent preterm birth

BAD EICOSANOIDS n-6 DRIVEN

Constrict Promote Promote Increased Increased Increased Contrac)on Decreased Increased Promote Promote preterm birth

Blood Vessels Blood Clorng Heart Disease Heart Arrhythmia Pain Inamma)on Smooth Muscle Immune Func)on Menstrual Cramps Tumor Cells Gesta)on (Pregnancy)

Acceptable Macronutrient Distribution Range

AMDR

PROTEIN

Importance of PROTEIN

AA must be con8nuously available to build PRO of new 8ssues for GROWTH & MAINTENANCE
Embryo, athle8c muscles, growing child, new blood cells lost in menstrua8on, scar 8ssue to heal wounds, new hair & nails Protein Turnover Constantly make & break down PRO Recycling AA Daily: 25% AA are irretrievably diverted to other 8ssues to be used for fuel

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 reac8ons HORMONES: messenger molecules made from AA Recall: Insulin & Glucagon for glucose regula8on

The Importance of PRO

3 BUILDING ANTIBODIES An8bodies are PRO made by PRO Dis8nguish foreign PRO from their body PRO When intruder is present, they aZack to destroy Bacterium, virus, toxin, or present in food that causes allergic reac8on Recall celiac disease (autoimmune response to gluten) Each an8body designed to destroy specic invader IMMUNITY: an8body built and successful, available for next aZack Dierent strains of u require dierent an8bodies built

The Importance of PRO

4 MAINTAINING FLUID BALANCE
PRO regulate quality of uids in compartments of body Life depends on cells maintaining constant amount of uid TOO MUCHrupture TOO LITTLEunable to func8on Recall: Water can diuse 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 aZract water & hold it within vessels, preven8ng it from owing into the spaces between cells When blood PRO (albumin) is low: TOO much uid will between cells will collectEDEMA

The Importance of PRO

5 EMERGENCY ENERGY SOURCE
PRO will be surrendered to provide energy if needed Under condi)ons of inadequate energy: Starva)on, prolonged fas)ng, and severe calorie restric)on No storage of PRO as with CHO/Lipids PRO only present as ac)ve working molecular & structural component of body )ssue 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

 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

PRO Transport Summary

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

Was)ng AA Summary

WASTING: When AA not used to build PRO or make other Nitrogen-containing compounds When was8ng 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 essen8al 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 signicant 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

Acceptable Macronutrient Distribution Range

RECALL: AMDR

QUALITY AA
1. LIMITING AA
An essen8al AA that is present in dietary PRO in INUSUFFICIENT amount, thereby limi8ng the bodys ability to build protein Acute shortage: inconsequen8al as cells resume normal protein ac8vi8es when limi8ng 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

2 COMPLIMENTARY PRO

QUALITY AA

Plant-based diet 2 or more PRO whose AA assortments compliment each other in such a a way that the essen8al AA missing form one are supplied by another AA low in some foods are supplied by other Goal: to consume essen8al AA in sucient 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 Diges8bility
Method to evaluate: Protein Diges8bility Corrected Amino Acid Score (PDCAAS)

Reference AA = egg white (high biological value) Animal based diets have highest diges8bility 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 diges8bility
http://jn.nutrition.org/content/ 130/7/1865S.full

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