Nutrition Toolkit
‘If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health’
Hippocrates c460-377 BC
Table of Contents
I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. XVI. XVII. XVIII. XIX. XX. XXI. Dedication Background BMI / BMI Table Calorie Guidelines: Quick Reference Complementary and Alternative Medicine (CAM) Complementary Proteins Dietary Reference Intakes (DRI's) Fad Diets Fat Budgeting Food Guide Pyramid: A Guide to Daily Choices Food Label Food and Nutrient Database (USDA) Lifecycle-specific diets Multivitamin / Mineral Supplements: Suggested Use Physical Activity Guidelines Physician Nutrition Assessment Resources for the MD: quick, easy and evidence-based Waist Circumference: Cutoff Values Weight Loss: Quick Calculator Weight Loss Readiness Summary
Prepared by: Tanis V Mihalynuk, PhC, RD For: UWSOM 1st to 4th year students; Revised March, 2003 1
Nutrition Tool-Kit*
I. Dedication This nutrition toolkit is dedicated to all 1st to 4th year medical students at the University of Washington…with your participation, enthusiasm, and interest, we will make a difference in the field of medical-nutrition education… thank-you, best wishes and continued success. Tanis Mihalynuk, PhC, RD Background Over a half a century ago, Dr. Frederick Stare, Harvard Professor and Chairman of the National Health Assembly remarked 'nutrition should be an essential component of the standard medical curriculum...yet in most medical schools, organized instruction in nutrition is sadly neglected, despite lip-service to the contrary' (J Am Diet Assoc, 1949). Today, the situation hasn't changed much. Currently, most US medical schools do not offer a required nutrition course and the majority of medical students continue to report that time devoted to nutrition teaching in medical school was inadequate (Association of American Medical Colleges' All Schools Graduation Report-check out http://www.aamc.org/data/gq/allschoolsreports/start.htm). Even more perplexing is the content and related quality of nutrition information that should be included in medical school and beyond. In response to this, local and national efforts such as the National Institutes’ of Health’s Nutrition Academic Award (NIH-NAA) of which my doctoral dissertation is based. For more information, check out: http://depts.washington.edu/naa. The first arm of my NAA-based dissertation project involved surveying Washington Academy of Family Physicians members (WAFP). Study highlights included:
Self-reported nutrition proficiency was positively correlated with perceived quality of nutrition training in all 5 nutrition factors determined after confirmatory factor analysis (P<0.01). Top ten medical-nutrition requests that the MD would like to be better equipped to answer included obesity, vitamins and minerals, complementary and alternative medicines (CAM), diet prescriptions for health promotion and disease prevention, and lifecycle nutrition, among others. The practicing physician was interested in receiving practical nutrition guidance and related resources that are quick and easy to administer.
II.
This toolkit has been prepared for you in response to these findings and to other insights obtained over the past 3 years, including more recent analyses of UWSOM survey participants. Further plans include comparing the findings from my WAFP study to the findings from my current UWSOM study and summarizing both studies via recommendations for the future UW medical-nutrition curriculum. Please stay tuned for more findings…and I hope you enjoy and find use for this tool-kit in you future practice. * Please send any questions or comments to: tanisvye@u.washington.edu
' He that takes medicine and neglects diet, wastes the skills of the physician'--Chinese Proverb
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IIIa. Body Mass Index (BMI) General Criteria* Cachectic < 17 Underweight 17-19 ‘Normal’ weight 20-24.9 Overweight* 25-30 (*25=median US BMI) Obese >30
* Increased morbidity and mortality with increased BMI over 25 / under 19; BMI is associated with adiposity (0.7).
IIIb. BMI Table: To use this table, find your weight in pounds across the top row. Follow the column
down to meet the box corresponding with your height. The number in this box is your BMI (body mass index). Then use your BMI to assess your health risk.
WEIGHT 100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 205 210 215 220 225 230 235 240 245 250 HEIGHT 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 20 19 18 18 17 17 16 16 15 15 14 14 14 13 13 12 12 21 20 19 19 18 17 17 16 16 16 15 15 14 14 13 13 13 21 21 20 19 19 18 18 17 17 16 16 15 15 15 14 14 13 22 22 21 20 20 19 19 18 17 17 17 16 16 15 15 14 14 23 23 22 21 21 20 19 19 18 18 17 17 16 16 15 15 15 24 24 23 22 21 21 20 20 19 18 18 17 17 16 16 16 15 25 25 24 23 22 22 21 20 20 19 19 18 18 17 17 16 16 26 26 25 24 23 22 22 21 21 20 19 19 18 18 17 17 16 27 26 26 25 24 23 23 22 21 21 20 20 19 18 18 17 17 28 27 27 26 25 24 23 23 22 21 21 20 20 19 19 18 18 29 28 27 27 26 25 24 23 23 22 22 21 20 20 19 19 18 30 29 28 27 27 26 25 24 24 23 22 22 21 20 20 19 19 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20 19 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23 37 36 35 34 33 32 31 30 29 28 27 26 26 25 24 24 23 38 37 36 35 33 32 31 31 30 29 28 27 26 26 25 24 24 39 38 37 35 34 33 32 31 30 30 29 28 27 26 26 25 24 40 39 37 36 35 34 33 32 31 30 29 29 28 27 26 26 25 41 40 38 37 36 35 34 33 32 31 30 29 28 28 27 26 26 42 41 39 38 37 36 35 34 33 32 31 30 29 28 28 27 26 43 42 40 39 38 37 36 34 33 32 32 31 30 29 28 27 27 44 43 41 40 39 37 36 35 34 33 32 31 31 30 29 28 27 45 43 42 41 39 38 37 36 35 34 33 32 31 30 30 29 28 46 44 43 42 40 39 38 37 36 35 34 33 32 31 30 29 29 47 45 44 43 41 40 39 38 36 35 34 33 33 32 31 30 29 48 46 45 43 42 41 40 38 37 36 35 34 33 32 31 31 30 49 47 46 44 43 42 40 39 38 37 36 35 34 33 32 31 30
IV.
Calorie Guidelines: Quick Reference <1200 kcal- Be concerned re: meeting RDA’s / nutrient needs (Food Guide Pyramid) ~1600 kcal- Inactive women / older adults 2000 kcal- Food Label ‘Daily Values’ based on this 2200 kcal- Most children, teenage girls, active women and inactive men 2800 kcal- Teenage boys / active men Complementary and Alternative Medicine (CAM) The field of CAM has been largely neglected in medical education. A note of interest is that the NIH has recently invested significant monies into study of CAM research, including further investigation of the placebo effect. Although we have yet to fully understand the efficacy of CAM regimens, many of your patients will be seeking out information in this area. As a medical practitioner, it is essential to be open to individual and cultural CAM uses while at the same time communicating evidence-based medicine. An example is if a patient discloses to you the use of Ephedra (MaHuang) for weight
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loss. Inform the patient that sudden deaths have occurred form its use, and suggest alternative weight loss strategies. Check out the NCCAM website provided in your list of nutrition resources (p.10) as well as the following for more information:
1. Pinn G. Herbal medicine: what is the evidence? Aust Fam Physician 2001 30;12: 1154-1159. 2. Ernst E, Fugh-Berman A. Complementary and Alternative Medicine: What is it all about? Occup Env Med 2002; 59: 140-144 or go to: http://oem.bmjjournals.com/cgi/reprint/59/2/140.pdf
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Complementary Proteins Interestingly, plant-derived foods that taste good together are often 'complementary', whereby combining two or more items will make up for a deficit of one or more limited essential amino acids and hence promote bioavailability. Some examples include: Beans (legumes) and Rice Grains (ie. Cereal) and Milk Soy, Grains and Nuts or Seeds Sesame and Beans Aside from vegans or strict vegetarians, nutritional deficiencies are not generally a concern if your patients are consuming a variety of foods. Make sure vegans are consuming B12-fortified foods or taking supplements. Lacto- (milk), ovo (egg) or pesca (fish) vegetarians can do just fine without the need for vitamin supplements. For more information, check out http://northonline.sccd.ctc.edu/ntrresources/compleme.htm Dietary Reference Intakes (DRI): http://www.nal.usda.gov/fnic/etext/000105.html DRIs include the RDA, EAR, AI, UL and DV . Although you need not memorize these dietary recommendations, the gist of the message includes: RDA- Recommended Dietary Allowance considers the needs of 97.5% of healthy individuals (mean + 2 SD); EAR= Estimated Average Requirement, for policy, population and research considerations; AI= Adequate Intake, when not enough information is available to establish RDAs; ULTolerable Upper Intake Limits, a consideration for multiple supplement users and DV— Daily Values (Food Label) based on a 2000 kcal diet.
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VIII. Fad Diets: You are likely to be inundated with questions regarding efficacy of fad diets such as the Atkins’ high protein protocol. DC Roberts provides a practical overview of common fad diets, and includes tables for readily assessing fad versus healthy, long-term weight loss prescriptions. Check out: Medical Journal of Australia, 2001 175 (11-12): 637-640 or http://www.mja.com.au/public/issues/175_12_171201/roberts/roberts.html . IX. Fat ‘Budget’ If your patient has a rough estimate of recommended fat gram intakes, he or she can use the food labels--free of charge--to estimate caloric intakes. A point of interest: the new National Cholesterol Education Program (NCEP) Guidelines suggest a 25-35% fat diet in going with current lipid research trends: www.nhlbi.nih.gov/guidelines/cholesterol Calories Approximate Grams Fat (30% Fat Diet) 1200 35 1600 55 2000 65 2200 75 For a quick assessment of your fat intakes, check out the Northwest Lipid Research Clinic’s Fat Intake Scale: http://depts.washington.edu/~nwlrc/fis.html .
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X.
Food Guide Pyramid (FGP): A Guide to Daily Choices The Food Guide Pyramid is based on the Dietary Guidelines . The bottom line: start with plenty of breads, cereals, rice, pasta, vegetables, and fruits. Add 2-3 servings from the milk group and 2-3 servings from the meat group. Remember to go easy on fats, oils, and sweets—the foods at the tip of the Pyramid. Although the FGP is far from a perfect nutrition education tool, it is one of many resources that you can use when preparing a medical-nutrition prescription for your patients. Research has shown that although medical doctors want to provide nutrition information to patients, many are avoiding such encounters due to lack of proficiency or perceived confidence in their knowledge and skills in this area. The FGP is one of many tools that may assist you with 'nutrition proficiency building'. Also, be sure to refer to the list of resources for information on culturally and age-adapted food pyramids that you also may find useful in practice.
Fats, Oils, and Sweets / Milk, Yogurt, and Cheese / Meat, Poultry, Fish, Beans, Eggs, and Nuts Vegetables / Fruits / Breads, Cereal, Rice, and Pasta What Counts as a Serving?* Milk, Yogurt and Cheese 1 cup milk or yogurt 1 ½ ounces of cheese 2 ounces of processed cheese Meat, Poultry, Fish, Dry Beans, Eggs and Nuts 2-3 ounces of cooked lean meat, poultry or fish ½ cup cooked dry beans; 1 egg or 2 tablespoons of peanut butter count as 1 ounce lean meat Vegetable 1 cup raw leafy vegetables ½ cup of other vegetables, cooked or raw ¾ cup vegetable juice Fruit 1 medium apple, banana, orange ½ cup chopped, cooked, or canned fruit ¾ cup of fruit juice Bread, Cereal, Rice and Pasta 1 slice of bread 1 ounce ready-to-eat cereal ½ cup cooked cereal, rice or pasta *For more information on serving sizes, refer to the handout on the following page. XI. Food Label: Know it, Encourage it, Use it…it’s free for you, your patients and consumers. For more info, check out the fine print at: http://www.cfsan.fda.gov/~dms/fdnewlab.html XII. Food and Nutrient Database (USDA): this database has recently been revised (15th release) and is available at the USDA’s Food and Nutrition Information Center website: http://www.nal.usda.gov/fnic/foodcomp/Data/SR15/sr15_doc.pdf
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Seven Ways to Size Up Your Servings*
Measure food portions so you know exactly how much food you're eating. When a food scale or measuring cups aren't handy, you can still estimate your portion. Remember:
1 2 3 4 5 6 7
3 ounces of meat is about the size and thickness of a deck of playing cards or an audiotape cassette. A medium apple or peach is about the size of a tennis ball.
1 ounce of cheese is about the size of 4 stacked dice.
1/2 cup of ice cream is about the size of a racquetball or tennis ball.
1 cup of mashed potatoes or broccoli is about the size of your fist.
1 teaspoon of butter or peanut butter is about the size of the tip of your thumb
1 ounce of nuts or small candies equals one handful.
* Courtesy of the National Dairy Council.
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XIII. Lifecycle-Specific Diets: Resources and Considerations Pediatric Nutrition: although distinctive from adult nutrition, the basic principles of healthy eating, including the use of the Food Guide Pyramid, apply for all persons over 2 years of age. Be aware of NCHS growth chart (height/ weight) trends. For more information, check out: http://webdietitian.com/document/PD Adolescent Nutrition: Screen for eating disorders (DSM IV criteria, including EDNOS) and quality of diet (fruits, vegetables, excess fat, protein). Check out this local website for more: http://faculty.washington.edu/jrees/adnutriinfo/adnutriinfo1.html Adult Nutrition: since the median US BMI is 25, weight will be an overriding clinical issue. Suggest slow, gradual lifestyle changes, including self-monitoring (food diaries) and gradual reduction in dietary intakes / increase in physical activity is suggested. Geriatric Nutrition: Use the Nutrition Screening Initiative (p.9); consider differential diagnosis of microcytic vs macrocytic anemias (Iron, B12, Folate); Mini-Nutritional Assessment (Nestle): Pregnancy and Lactation: Minimum 15# weight gain in pregnancy; encourage use of prenatal supplement; AVOID all herbs; 110-115% increase energy / protein requirements during lactation. http://www.nal.usda.gov/fnic/pubs/bibs/topics/pregnancy/pregcon.html XIV. Multivitamin / Mineral Supplements: Indications For Use (Check): Strict vegetarian Diets often Avoids specific food groups Follows very low fat, calorie restricted diet (ie: less than 1200 kcal) Eats less than 5 servings of fruits and vegetables daily (ie. the majority of Americans); Scheduled for surgery Recovering from major injury illness or trauma Smokes or drinks heavily. For Women Only: Pregnant / breastfeeding Oral contraceptives (folate) Heavy menstrual bleeding. XV. Physical Activity (PA) It is well established that regular physical activity is critical for health promotion and disease prevention. Current recommendations include 30 minutes of regular physical activity. Both anaerobic and aerobic PA are beneficial to health and well-being. The basics that you may want to share with your patients include: Aerobic exercise: ‘any sustained activity (at least 20-30 minutes) using large muscle groups’: walking, cycling, swimming, jogging, etc); Anaerobic exercise- conditioning / toning; ‘weight-bearing exercises’ for bone integrity. The bottom line: ‘Meet the patient where he or she is at’. Check out the Surgeon General Report and related fact sheets on PA for more information: http://www.cdc.gov/nccdphp/sgr/sgr.htm. Physician-Nutrition Assessment Ultimately, a diet history—even a brief probe or two—should be part of every medical history and physical. Having a basic grasp of your patient's nutritional status will serve
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to enhance your care plan by allowing you to be the ultimate medical detective….Read on for more tips for nutrition assessments.
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Suggested Questions and Probes to Include in Diet and Medical History
i. Diet history: Time permitting, the MD may introduce this topic by suggesting to ‘describe a typical day’s intakes, starting with your first meal’… (first meal may not be breakfast). Include important probes such as sodium intake (hypertension) calcium intake (bone health), protein consumption and complementary proteins (vegetarianism / wasting), avoidance of food groups, and age and gender-related nutrition inquiries. ii. Estimated calorie requirements: (Adults) 20 kcal / kg if obese or inactive/chronic dieter 30 kcal / kg if active man /very active women 40 kcal / kg if thin / very active man
iii. Estimated Fluid needs (Adults): 1.0 ml / kcal requirements; MD should also consider: a. Alcohol consumption: ‘Moderate’ = 2 svg / day (men) 1 svg / day women (Serving = svg) where 1 svg = 1.5 oz liquor, 5 oz wine, 12 oz beer / cooler b. Other fluid consumption, including caffeine; excess caffeine intake could cause diuresis / dehydration and leaching of water-soluble vitamins / micronutrients. iv. Use of vitamin / mineral / herbal supplements- to better assess drug / nutrient interactions, diet adequacy and use of toxic herbal products (ie. Ephedra / Ma Huang, Kava-Kava, etc). v. Exercise*: sedentary (<1 x / wk); light (1-2 x /wk), moderate (3-5 x / week), very active (>5x/week)
(*Ideally, patients should engage in at least 30 minutes of regular aerobic exercise. Sedentary individuals will have to work up to this. Individuals with or at risk of heart disease may require a screen pre-exercise. For patients concerned about osteoporosis and bone health, suggest weight-bearing exercises, including light weight training and walking when appropriate).
vi. Stress: Include question regarding coping strategies, social support, added life stressors, etc. If this appears to be concern for patient (ie. ‘stress eating’; ‘type A’ characteristics), consult or refer as necessary.
Sample Brief Diet History Form and Summary Diet / Lifestyle Prescription*
Diet and Lifestyle History Form
☤ Summary: (check for Rx)
Fat? ___ Sat Fat? __ F/V? ______ Etoh? ______ Kcals?______ Fluids? ____ Vita/Mineral? ___________ Herbs/ Supp? ___________ Active? ____ Stress? ____
Breakfast: ________________________________________ am snack : _______________________________________ Lunch: ___________________________________________ pm Snack: _______________________ Supper: ________________________________________ Eve Snack: ________________________
SUMMARY: Nutrition / Lifestyle Rx ____________________________________________________________________________ ____________________________________________________________________________
* Suggestion for use: use the right hand side of the prescription to check the areas that require more attention....and provide a brief nutrition / lifestyle prescription for your patient accordingly.
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XVII. Nutrition Resources: Including Organizations, e-mail and toll-free 1-800 numbers ORGANIZATION WEBSITE TOLL-FREE#
American Academy of Family Physicians www.familydoctor.org N/A American Cancer Society www.cancer.org 1-800-ACS-2345 (Patient education materials) American Diabetes Association: www.diabetes.org 1-800-342-2383 American Dietetic Association: http://www.eatright.org 1-800-877-1600 Reimbursement http://www.eatright.org/gov/reimbursement.html American Heart Association: www.americanheart.org 1-800-242-8721 Dairy Councils (local; ie Washington): www.eatsmart.org N/A Dash Diet (Hypertension) www.healthfinder.gov search for 'DASH Diet' Dietary Guidelines: www.health.gov/dietaryguidelines N/A Dietary Reference Intakes (DRIs) Food and Nutrition Information Center www.nal.usda.gov/fnic N/A (Culturally adapted Food Guide Pyramids; Dietary Guidelines; Dietary Reference Intakes, etc ) HealthFinder (various nutrition resources) www.healthfinder.gov N/A NCCAM: (complementary medicine) www.nccam.nih.gov 1-888-644-6226 Obesity: (NHLBI practical guide) http://hp2010.nhlbihin.net/obgdpalm.htm N/A Surgeon General Report www.surgeongeneral.gov/topics/obesity N/A Tax Breaks www.obesity.org ; click on ‘Tax Breaks’ N/A 5-A-Day Website (Fruits and Vegetables) www.5aday.com N/A Nutrition Screening Initiative (Elderly) www.aafp.org/nsi N/A -Mini-Nutritional Assessment http://www.nestleclinicalnutrition.com/images/MNA_Assessment.pdf
XVIII.
Waist Circumference: Cut-Off Values (Increases CVD Risk / Insulin Resistance) Men > 40 inches Women > 35 inches In terms of body shape, ‘Pears are less risky than apples’
XIX. Weight Loss: Quick Calculator* Multiply 10 * Goal weight >> approximate calories for inactive people Multiply 13 * Goal weight >> approximate calories for moderately active people (*For ½ to 1 pound of weight loss weekly >> subtract 250-500 kcal from this value) XX. Weight Loss Readiness: Your patient may not be ready to lose weight, depending on other life events or stressors occurring simultaneously when he or she comes for a medical visit. To assess patient readiness, consider the following: personal commitment (time / effort) and motivation to lose weight; adopting realistic goals, including slow, gradual lifestyle changes, and willingness to include physical activity. Check out the following online tool: http://www.swmed.edu/naa/quizzes/wt_loss_quiz.htm . XXI. Summary: Medical practice requires a balance of evidence-based medicine and the practical needs of your patients—a melding of both science and art….I hope this nutrition toolkit assists you in your personal and professional pursuit of balance—and in optimizing your future medical-nutrition prescriptions….
The wisdom of life consists of the elimination of nonessentials'
-Lin Yutang
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