Demystifying Nutrition

Helping Patients Make Small Changes for Big Results

Lisa A. Yarah, M.Ed., RDN, CDN

President, CNY Dietitian Consultants, Inc.

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“Demystifying Nutrition”Objectives

• Provide NPs with quick, real-life, effective nutrition tips to use with patients.

• Provide a review of current, evidence-based, basic nutrition guidelines.

• List general objectives of healthy eating that will help all patients, regardless of diagnoses.

• Provide key “take-home points” that can be used with patients.

• Enhance strategies for dealing with non-compliant patients.

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Lisa A. Yarah, M.Ed., RDN, CDN

• Bachelor’s Degree in Nutrition Management – Rochester Institute of Technology (1994)

• Dietetic Internship – Strong Memorial Hospital, Rochester, NY

• Master of Education – Counseling and Development – George Mason University, Fairfax, VA (2000)

• Counseling Internship – Center for Psychiatric and Addiction Treatment – Prince William Hospital, Manassas, VA

• CNYDA (Central NY Dietetic Association) President, 2003-2004

• NYSDA (NYS Dietietic Association) Recognized Young Dietitian of the Year - 2004

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Overview of Clinical Background

• 1994-2000 – Worked at various hospitals in Northern Virginia. Provided nutritional assessment and counseling in all inpatient units such as ICUs, NICUs, Pediatric Units, Med/Surg, Cardiac, Dialysis, Perinatal, OB/GYN, Oncology, etc.

• Also worked in the outpatient setting providing one-one-one nutrition counseling and taught group nutrition classes (Diabetes Education, Cardiac Rehab, etc.)

• 2000 – Opened CNY Dietitian Consultants, Inc. Consultant in LTC facilities, group homes, homecare, day cares, menu writing and approval, weight loss centers, as well as provide one-on-one nutrition counseling, education and group classes.

• 2012 and 2013 – Obtained advanced certifications in Weight Management and Weight Maintenance from the Academy of Nutrition and Dietetics

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CNY Dietitian Consultants, Inc.September 2014

Fayetteville, NY

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On a Personal Note…I live in Fayetteville with my husband, Eric and nine

year old twins, Colden and Annaliese. We have a newly adopted Chihuahua mix puppy named, Paco.

I enjoy running marathons, hiking, camping, and cooking healthy meals with my family using foods

from our garden.

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Nutritional Considerations

• “I hope I get to limit my food choices and never eat my favorite foods again…said no one ever.”

• My Philosophy…”Real Food for Real Results”

• Begin your day with a big, 16oz glass of water – as soon as you get up – to jump start your metabolism.

• Eat/drink your breakfast/protein shake/bar within 2 hours of awakening – also to jump start your metabolism.

• Eat your calories during the first 12 hours that you are awake (i.e., 6am – 6pm).

• Do not eat 2-3 hours before bedtime.

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Nutritional Considerations, Cont.

• Try to limit your carbs at dinner, for example, focus on just protein and non-starchy veg with a healthy fat.

• Optimize your metabolism by eating every 3-4 hours with protein distributed evenly throughout the day. Aim for at least 10gms of protein at a snack and 20-30gms at a meal.

• Always combine carbohydrate (fruit or starch) with a protein.

• Optimal ratios: 45% carb/25% pro/30% fat

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General Rules of Thumb

• Limit carbs to one choice at a meal and keep this portion to 100-150 calories (men can have two choices per meal). One choice is a 100 calorie sandwich thin or 1/3 cup of cooked pasta.

• If you are still hungry, you can always eat more protein or non-starchy veg (ex- turkey and cheese roll-up or carrots). Just not more starch, for example, another helping of mashed potatoes.

• Protein bar and shake guidelines: <200 cals (<250 cals for men), min of 15gms of protein, and 3-5gms of fiber.

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Exercise Nutritional Considerations

• You should eat 100-200 cals before 60 minutes of exercise, 25gms of carb to sustain one hour of activity.

• For weight loss, replace only 1/3 – ½ of your calories burned.

• Consume these calories with a protein source within 30-45 minutes of activity.

• Encourage patients to be moving every 20 minutes during the day, setting their phone alarm if needed.

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General Weight Management Guidelines

• For weight loss, weigh yourself once per week (on the same scale and at the same time of day).

• For weight maintenance, weighing yourself daily is recommended.

• Consider 1-2 meal replacements/day for weight loss or weight maintenance. Use the guidelines for protein bars/shakes given previously.

• Bottom line: Calories In and Calories Out!

• Accountability – food logging/exercise app

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Calories

• Most Women – 1200-1400 calories for weight loss

• Most Men – 1500-1800 calories for weight loss

• Going below 1000-1200 is not recommended – metabolism will slow down.

• Evidence-based guidelines reveal that these calories should be consumed in 5-6 small meals/day to keep your metabolism stoked.

• Protein should also be distributed evenly throughout the day for maximum utilization of amino acids for muscle tissue synthesis.

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More on Calories…

• Measuring fruit and carb portions is essential to weight loss and weight maintenance (ex – 4” banana or 1/2 cup sweet potato).

• Ensure 2 fruit servings and 4 non-starchy veg servings/day.

• “Trigger foods” – Know them and avoid them!

• Alcohol – can add a significant amount of unwanted calories and will stall weight loss or promote weight gain. Encourage limitation to 1 drink/day for women and 2 for men. Keep calories at 100-150/drink (ex – 12oz light beer or 5oz glass of wine or 1.5 oz distilled spirits = 1 drink).

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Protein

• Protein is imperative to maintaining lean body mass as lean protein is mostly driven into muscles.

• Protein feeds muscle, and muscle drives metabolism.

• Your body will treat 100 cals of chicken breast much differently than 100 cals of potato chips.

• Weight loss without adequate protein = muscle loss = drop in metabolism.

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And Now for Carbohydrates…

• Gentle Reminder: Carbs are broken down and stored as glycogen in the liver. Once we have maximized our glycogen stores, the remaining carbs are stored as fat.

• Carbs are not evil! They are required for brain function and exercise metabolism.

• We just eat too many! Portion control must be exuded.

• 45% Carb = 1200 calorie diet = 135gms/day & 1800 cals = 200gms/day

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More on Carbs…

• Favor 100% whole wheat grains (whole wheat breads, wraps, brown rice)

• Choose good quality carbs: Beans, oatmeal, quinoa, sweet potatoes, etc.

• Limit or avoid liquid carbs/calories – fruit juices, sodas, sugary drinks.

http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyEating/Added-Sugars_UCM_305858_Article.jsp

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Added Sugars

• Because sugar isn’t an essential nutrient and doesn’t have any nutritional value, it doesn’t have an official recommendation. However, the American Heart Association set a recommended limit, so you don’t get too many extra calories in your diet. 

• The average American consumes around 22.2 teaspoons of added sugar every day, and both the World Health Organization and the American Heart Association (AHA) note that we should really be eating a fraction of that amount. The AHA says that adult women should get 6 teaspoons (24 grams) of sugar per day, adult men 9 teaspoons (36 grams), and children 3 teaspoons (12 grams). For comparison, a can of soda can have 40 grams, or about 10 teaspoons of sugar.

• 1 tsp = 4gms of sugar = 16 calories (4 cals/gram)

http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyDietGoals/Sugars-and-Carbohydrates_UCM_303296_Article.jsp

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GroupCalorie of added sugar

Sugar intake(g)Sugar intake(teaspoon)

Women ≤ 100 24 6

Men ≤ 150 36 9

Preschoolers 16 4

Children ages 4-8 12 3

Teenagers 20-32 5-8

How Many Grams of Sugar Per Day?Natural sugar is part of any balanced diet. A diet rich in fruits and vegetables includes natural sugars and will provide a valuable source of vitamins and minerals. These natural sugars are not the source of health problems; the added sugars are responsible for the negative consequences of excess sugar in the diet.

Daily Sugar Intake from American Heart Association

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The Problem…

• The FDA doesn't require that nutrition labels list the amount of naturally occurring sugars separate from the amounts of added sugars, making daily intakes of added sugar difficult to estimate!

• The AHA guidelines, published in a 2009 issue of the journal Circulation, make the point that added sugars, such as high-fructose corn syrup or ordinary table sugar added to sodas, breads, and other processed foods, are likely responsible for the increase in calorie consumption and the subsequent rise in obesity of the past few decades.

• Bottom Line: You should avoid added sugars first and worry less about natural sugars found in fruits (fructose), vegetables, low-fat dairy (lactose), and whole grains. These types of foods give you a variety of vitamins, minerals and sometimes fiber, making them a beneficial part of your diet -- unlike sugary snacks.

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Fats

• Limit to 3-4 portions/day

• Decrease your saturated fat (think butter and whole fat dairy) and replace with light butter, low-fat dairy.

• Increase mono-unsaturated fats – avocados, olive oil, nuts, and nut butters.

• Portion control must also be exuded here (1 Tbsp of peanut butter or oil = 100 cals!).

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Importance of Water

• Encourage 64oz of plain water on top of any other beverages.

• Can add lemon, watermelon, mint, blueberries, or other fresh fruit (fruit infusers).

• Can add non-caloric flavor inhancers.

• Carbonated beverages, coffee/tea (even decaf), iced tea, diet soda, etc., do not count toward the 64oz of water.

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Exercise

• Incredibly important for overall health and well-being.

• Lowers blood glucose, blood pressure, cholesterol, and can aid in the treatment of depression.

• More important in weight maintenance than in weight loss!

• Incorporate resistance work, strength training and interval training to build metabolically-active lean muscle.

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You Can Lead a Horse to Water…

• I know what to eat, BUT…

• The Meanings of Food

• Factors affecting food choices: • Biological – Nutritional needs, Heredity, Physiological Conditions

(e.g., pregnancy), Diseases, Taste Preferences, etc.

• Environmental – Geography, Climate, Economics, Transportation, etc.

• Cultural – Education, Income, Traditions, Beliefs, Values, etc.

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Why Is Counseling So Important?

• We know the facts, but facts do not equal change!

• The Problem-Solving Counseling Method – Typical approach

• Transtheoretical Model/Stages of Change Theory (SOCT)

(Prochaska and DiClemente, 1970s and 1980s)• Change does not occur in one step

• Progress through stages along the way

• Couple this with Motivational Interviewing (MI)

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Precontemplation

• Not ready yet to make change – I may consider “Nutritional Change Motivation Worksheet”

• Counseling Objectives:• Convey acceptance and create a supportive environment – establishment of

therapeutic rapport is imperative here!

• Determine patient’s perception of the problem – “I’m here because my doctor told me to come.”

• Increasing awareness of the patient’s need to change – consider positive aspects of change.

• Assessing current knowledge and motivation – discuss what, if anything, the patient is willing to work on.

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Contemplation

• Patient is considering the change!

• Counseling Objectives:• Identify barriers to change and offer possible solutions

• Identify problematic behaviors

• Work through ambivalence

• Goal setting – baby steps

• Assess continued motivation to make changes

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Preparation

• Patient has decided to take action!

• Counseling Objectives:• Assess knowledge

• Discuss previous attempts to change and ways to succeed this time

• Reinforce skills to help achieve goals

• Affirm the importance of small steps

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Action!

• Patient is taking steps toward change

• Counseling Objectives:• Reinforce decision to change and promote self-confidence

• Assist in developing an action plan

• Help patients identify a support system/non-food related rewards

• Provide education, feedback and problem-solving advice – ask permission first!

• Set goals

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Maintenance

• Patients have maintained their behavior for at least 6 months

• Counseling Objectives:• Discuss relapse prevention and coping mechanisms

• Further identification of non-food rewards

• Continue to provide education with permission

• Plan follow-ups to support changes

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Motivational Interviewing (MI)

• Technique for enhancing motivation for behavior change

• Makes patient feel validated and empowered to make changes

• Four Basic Principles:• Express Empathy – Actively listen and seek to understand patient’s point of

view without criticism. Reflective listening is the most fundamental principle of MI.

• Develop “Discrepancies” – Discuss pros and cons of both current behaviors and new, healthier behaviors.

• “Rolling” with Resistance – Reframe resistance and ambivalence as normal; collaboratively negotiate solutions.

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Motivational Interviewing, Cont.

• Support Self-Efficacy – Reflect positive attributes that will support change and increase motivation to change behavior. Affirmation starts with “you.” Such as , “I am really proud of you.”

• Great Resources:• William Miller and Stephen Rollnick, Motivational Interviewing:

Helping People to Change, 3rd Edition, Guildford Press, 2012.

• William Miller , Stephen Rollnick and Chris Butler, Motivational Interviewing in Health Care: Helping Patients Change Behaviors, 2007.

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Tips for Dealing with Patients in Denial

• Remember: Denial is a defense mechanism!

• Don’t “should” on patients or they will “should” on themselves. There are no absolutes.

• Ask open-ended questions, • “Tell me more about…”

• “Help me understand…”

• To what extent,…”

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Tips for Dealing with Patients in Denial, Cont.

• Closed questions put patients on the defense:• “Did you…?”

• “Will you…?”

• “Can you…?”

• “Is it…?”

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Tips for Dealing with Patients in Denial, Cont.

• Providing Information • Try not to provide too much at one time

• Ask for permission: “It it’s OK with you, I would like to tell you more about some other ways to…” or “Would you like to hear about a few things that have worked for other people in your situation?”

• Distribute printed materials

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Tips for Dealing with Patients in Denial, Cont.

• Expect patients to direct their anger toward you – do not react or argue

• “Tough love” does not work – you may never hear from them again

• Assure patients that recommendations will not harm them and explain treatment will lessen severity of symptoms/prevent further problems

• Get family members involved upfront for support and recommend support groups

• End your meetings on a positive note – summarize, instill self-confidence and ask, “Is there anything I missed?” or “Is there anything you want to add or correct?”

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When to Refer Out

• When patients keep coming back and no progress has been made

• For example, I share clients with a therapist

• When patients just aren’t “getting it.”

• Consider a referral to a Registered Dietitian

• cnydietitian.com

• lisa@cnydietitian.com or 315.440.6159

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CNY Dietitian Consultants, Inc.Expert, Individualized Medical Nutrition Therapy for

All Ages

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References

• Academy of Nutrition and Dietetics Evidence Analysis Library for Weight Loss and Weight Maintenance (eatright.org).

• Katherine Curry and Amy Jaffe: Nutrition Counseling and Communication Skills, 1998, W.B. Saunders Company.

• Ann Constance and Cecilia Sauter: Inspiring and Supporting Behavior Change: A Food and Nutrition Professional’s Counseling Guide. Academy of Nutrition and Dietetics, 2011.

• Jodie Shield and Mary Catherine Mullen: Counseling Overweight and Obese Children and Teens, Academy of Nutrition and Dietetics, 2008.

• My own anecdotes from working with clients.

www.google.com/search?q=mayan+angelou+quote:+ive+learned+that&es_sm=122&tbm=isch&tbo=u&source=univ&sa=X&ei=GFpSVeS

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One Last Note…