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Donald F. Kirby, MD Chief, Section of Nutrition

Division of Gastroenterology

MIIIMIIICore Lecture on Core Lecture on

Clinical NutritionClinical Nutrition

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Why is Nutrition Why is Nutrition important?important?

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Nutrition is Important in 8/10 Nutrition is Important in 8/10 Leading Causes Leading Causes

of Death in the U.S.of Death in the U.S.1)1) Heart DiseaseHeart Disease

2)2) CancerCancer

3)3) StrokeStroke

4)4) Car AccidentsCar Accidents

5)5) Lung DiseaseLung Disease

6)6) PneumoniaPneumonia

7)7) DiabetesDiabetes

8)8) SuicideSuicide

9)9) HomicideHomicide10)10) Liver Disease/ Liver Disease/

CirrhosisCirrhosis

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What does M.D. What does M.D. really mean?really mean?

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M.D. = Mediocre DietM.D. = Mediocre Diet

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Levine BS, et al. Survey of Levine BS, et al. Survey of Attitudes and Practices of Attitudes and Practices of

PrimaryPrimary--Care Physicians Relating Care Physicians Relating to Nutrition. to Nutrition.

Am J Am J ClinClin NutrNutr 1993;57:1151993;57:115--119.119.

3416 Physicians responded 3416 Physicians responded to a survey about nutrition to a survey about nutrition in their practice and their in their practice and their

own livesown lives88

Levine et al. #2

•• Bottom line: They did not practice what Bottom line: They did not practice what they preached!!!they preached!!!

•• What we need: Specific nutritional What we need: Specific nutritional resourcesresources–– Regional list of specialists in clinical nutritionRegional list of specialists in clinical nutrition–– Monographs of latest nutritional researchMonographs of latest nutritional research

Foreign medical graduates were better Foreign medical graduates were better than U.S. graduates in thinking and than U.S. graduates in thinking and

acting more favorably towards nutrition.acting more favorably towards nutrition.

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American College of PhysiciansAmerican College of PhysiciansPosition Paper on Nutrition: Position Paper on Nutrition:

ConclusionConclusion

““Nutrition may be one of Nutrition may be one of the most important the most important

factors affecting health.”factors affecting health.”1010

ACP ACP –– Positions on Nutrition #1Positions on Nutrition #1Improper nutrition can precipitate or Improper nutrition can precipitate or

exacerbate disease, and proper nutrition exacerbate disease, and proper nutrition can promote health or prevent disease. It can promote health or prevent disease. It is incumbent upon physicians to advise is incumbent upon physicians to advise patients of particular diets where there patients of particular diets where there exists significant medical evidence of a exists significant medical evidence of a relationship between diet and disease, relationship between diet and disease,

and physicians should advise patients of and physicians should advise patients of guidelines for a healthful, well balanced guidelines for a healthful, well balanced

diet.diet.

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What is improper nutrition?What is improper nutrition?

A diet that is deficient in essential A diet that is deficient in essential nutrients or caloriesnutrients or calories

OROROvernutritionOvernutrition where excess calories where excess calories

are consumed with little respect to are consumed with little respect to essential nutrientsessential nutrients

e.g., alcohol and sweets to excesse.g., alcohol and sweets to excess1212

Example of improper nutrition?Example of improper nutrition?Fad Diets Fad Diets

All promise rapid weight loss with All promise rapid weight loss with “Minimal Pain”“Minimal Pain”

Burn glycogen stores which hold Burn glycogen stores which hold waterwater

Most are nutritionally inadequate and Most are nutritionally inadequate and based on unsound or unproven based on unsound or unproven

principlesprinciples

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DietDietThe definition of diet is a manner of The definition of diet is a manner of

living with regards to food.living with regards to food.•• e.g., Regular Diet e.g., Regular Diet –– unrestrictedunrestricted

–– Low SaltLow Salt–– Low CholesterolLow Cholesterol–– Low FatLow Fat–– Low Low CarbsCarbs!!–– Weight Reduction Diet Weight Reduction Diet –– “The Enemy”“The Enemy”

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Examples of Diets

55--10%10%1515--20%20%ProteinProtein

Reduce fat from Reduce fat from 40 to 30%40 to 30%

55--10%10%40%40%FatFat

Complex Complex carbscarbsfrom 28from 28 48%48%

RefinedRefined sugar from sugar from 55 55 30%30%

80%80%4040--45%45%CarbsCarbs

20102010U.S. GoalsU.S. Goals

PritikinPritikin//OrnishOrnish DietDiet

AverageAverageAmerican DietAmerican DietNutrientNutrient

Avoid being overweight - Limit Sodium to 5g/dayEat a variety of foods

1515 1616

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What questions are you likely to What questions are you likely to be asked by patients, family be asked by patients, family

and/or friends? Should you have and/or friends? Should you have some basic answers???some basic answers???

•• Questions about Obesity.Questions about Obesity.•• Questions about “Dieting”.Questions about “Dieting”.•• How to feed the hospitalized patient.How to feed the hospitalized patient.•• Complications of feeding such as Complications of feeding such as

RefeedingRefeeding SyndromeSyndrome1818

ObesityObesity

A condition characterized A condition characterized by excess body fat, by excess body fat,

usually defined as 20% usually defined as 20% above desirable body above desirable body

weight.weight.

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Body Mass IndexBody Mass Index

BMI = BMI = Weight (Kg)Weight (Kg)Height (M)Height (M)22

2020

Classification Based on BMIClassification Based on BMI•• Morbid Obesity > 40Morbid Obesity > 40•• Obese > 30Obese > 30•• Overweight > 27 Overweight > 27 –– 29.929.9•• Normal 19Normal 19--26.926.9•• Underweight <18.5Underweight <18.5•• Severe Malnutrition < 16Severe Malnutrition < 16

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Nutrition AssessmentNutrition Assessment

Not a single test, but an Not a single test, but an information gathering information gathering

exerciseexercise2222

Nutrition AssessmentNutrition Assessment1.1. History & Physical History & Physical –– Weight HistoryWeight History2.2. Diet HistoryDiet History3.3. Anthropometric MeasurementsAnthropometric Measurements4.4. Plasma ProteinsPlasma Proteins

-- Albumin/ Albumin/ TransferrinTransferrin/ / PrealbuminPrealbumin5.5. Immunologic StatusImmunologic Status

-- Total Lymphocyte Count (TLC)Total Lymphocyte Count (TLC)-- Skin TestsSkin Tests

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Health Risks Associated Health Risks Associated With ObesityWith Obesity

•• Diabetes MellitusDiabetes Mellitus•• HyperlipidemiaHyperlipidemia•• COPDCOPD•• Sleep ApneaSleep Apnea•• Increased risk of Increased risk of

certain cancerscertain cancers

•• HypertensionHypertension•• Heart DiseaseHeart Disease•• OsteoarthritisOsteoarthritis•• Job PrejudiceJob Prejudice

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DOC, DOC, how do I how do I

lose weight?lose weight?

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LavoisierLavoisier 17801780

∆∆ E = Q E = Q -- WWChange in Energy = Intake Change in Energy = Intake -- WorkWork

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Suggested ScenarioSuggested Scenario•• Determine BMIDetermine BMI•• Identify Identify ComorbiditiesComorbidities

•• Judge patient’s Judge patient’s interestinterest

•• Review resourcesReview resources•• Set a reasonable Set a reasonable goalgoal

•• Dietary goals Dietary goals •• Behavior therapy ?Behavior therapy ?•• Exercise Exercise prescriptionprescription

•• Weight loss Weight loss medicationsmedications

•• Referral for surgical Referral for surgical weight lossweight loss

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Treatment Modalities Treatment Modalities for Obesityfor Obesity

•• AcupunctureAcupuncture•• ExerciseExercise•• Behavior ModificationBehavior Modification•• Intragastric BalloonsIntragastric Balloons•• Quick Fixes Quick Fixes •• HerbalsHerbals

•• DietDiet•• DrugsDrugs•• HypnosisHypnosis•• Jaw WiringJaw Wiring•• LiposuctionLiposuction•• SurgerySurgery

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How to evaluate a How to evaluate a weight loss programweight loss program

•• 9 Questions to ask9 Questions to ask•• 1. Is this a diet you could live with 1. Is this a diet you could live with

indefinatelyindefinately??•• 2. What is the recommended rate of 2. What is the recommended rate of

weight loss?weight loss?•• 3. Does the program take individual 3. Does the program take individual

differences into account to differences into account to determine caloric needs?determine caloric needs?

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9 Questions to ask9 Questions to ask•• 4. To what extent does the plan 4. To what extent does the plan

educate the client about nutrition, educate the client about nutrition, behavior modification, and the behavior modification, and the importance of exercise?importance of exercise?

•• 5. Does the program put you in contact 5. Does the program put you in contact with professionals such as physicians, with professionals such as physicians, R.Ds, and psychologists?R.Ds, and psychologists?

•• 6. What percentage of clients reach 6. What percentage of clients reach goal weight and maintain their losses?goal weight and maintain their losses?

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9 Questions to ask9 Questions to ask•• 7. Does the program offer a 7. Does the program offer a

maintenance plan once the maintenance plan once the weight is lost?weight is lost?

•• 8. What is the nature of the 8. What is the nature of the advertisements and advertisements and endorsements?endorsements?

•• 9. How much does it cost?9. How much does it cost?

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Rating the Popular DietsUnacceptableUnacceptable•• Atkin’sAtkin’s DietDiet•• Protein PowerProtein Power•• Sugar BustersSugar Busters•• The Carbohydrate The Carbohydrate

Addict’s DietAddict’s Diet

AcceptableAcceptable•• The ZoneThe Zone•• South Beach DietSouth Beach Diet•• Dieting with the Dieting with the

DuchessDuchess•• Eat more, Weigh lessEat more, Weigh less•• The The PritikinPritikin PrinciplePrinciple•• VolumetricsVolumetrics•• Choose to loseChoose to lose

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Unacceptable: Unacceptable: Dr. Dr. Atkin’sAtkin’s New Diet RevolutionNew Diet Revolution

Claim: Only Claim: Only carbscarbs make you fat!make you fat!

•• Strict limits on Strict limits on carbscarbs enable the body enable the body to burn fat.to burn fat.

•• What you eat: Meats, poultry, seafood, What you eat: Meats, poultry, seafood, eggs, cheese, butter, cream, oil, nuts, eggs, cheese, butter, cream, oil, nuts,

some (nonsome (non--starchy vegetables), starchy vegetables), artificial sweetenersartificial sweeteners..

3333

Unacceptable: Unacceptable: Dr. Dr. Atkin’sAtkin’s New Diet Revolution New Diet Revolution

•• Calories: 1,800 Protein 135g (30%)Calories: 1,800 Protein 135g (30%)•• Fat: 110g (55%) Fat: 110g (55%) CarbsCarbs: 60g (15%): 60g (15%)•• Sat Fat: 36g (18%) Fiber 10gSat Fat: 36g (18%) Fiber 10g

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Unacceptable:Unacceptable:Dr. Dr. Atkin’sAtkin’s New Diet RevolutionNew Diet Revolution

CommentsComments•• Too high in saturated fatToo high in saturated fat•• Low in calcium and fiberLow in calcium and fiber•• Low in fruits and vegetablesLow in fruits and vegetables•• May cause bad breath and May cause bad breath and

constipationconstipation•• If patients want to do “Low If patients want to do “Low CarbsCarbs”, ”,

have them consider South Beach Diethave them consider South Beach Diet

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Unacceptable:Unacceptable:Sugar BustersSugar Busters

Claim: Refined Claim: Refined carbscarbs cause obesity cause obesity by raising blood sugarby raising blood sugar

•• What you eat: No sugar, white What you eat: No sugar, white flour, carrots, corn, or beets.flour, carrots, corn, or beets.

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UnacceptableUnacceptable: Sugar BustersSugar Busters

•• Calories: 1,600 Protein 100g (25%)Calories: 1,600 Protein 100g (25%)•• Fat: 70g (40%) Fat: 70g (40%) CarbsCarbs: 140g (35%): 140g (35%)•• Sat Fat: 20g (10%) Fiber 20gSat Fat: 20g (10%) Fiber 20g

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Unacceptable:Unacceptable:Sugar Busters Sugar Busters

CommentsComments

•• Advice is inconsistent Advice is inconsistent -- especially especially with saturated fatwith saturated fat

•• Daily menus range from 7Daily menus range from 7--44g of 44g of saturated fatsaturated fat

•• Low in calciumLow in calcium

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Acceptable: The ZoneAcceptable: The ZoneBarry Sears, Ph.D.Barry Sears, Ph.D.

•• Claim: The correct ratio of Claim: The correct ratio of carbscarbs to to protein to fat (40:30:30) promotes weight protein to fat (40:30:30) promotes weight loss (and health) because it keeps insulin loss (and health) because it keeps insulin levels in “The Zone.”levels in “The Zone.”

•• What you eat: LowWhat you eat: Low--fat protein (like fat protein (like chicken breast, fish, or cottage cheese) chicken breast, fish, or cottage cheese) the size of your palm, and fruits and the size of your palm, and fruits and vegetable on the rest of the plate, with a vegetable on the rest of the plate, with a small amount of olive or canola oil.small amount of olive or canola oil.

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Acceptable Acceptable -- The ZoneThe Zone

•• Calories: 1,000 Protein 70g (30%)Calories: 1,000 Protein 70g (30%)•• Fat: 30g (30%) Fat: 30g (30%) CarbsCarbs: 115g (40%): 115g (40%)•• Sat Fat: 8g (8%) Fiber 20gSat Fat: 8g (8%) Fiber 20g

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Acceptable Acceptable -- The ZoneThe Zone

CommentsComments

•• Low calorie density and reasonably Low calorie density and reasonably healthy (low in sat fat, with ample healthy (low in sat fat, with ample fruits and vegetables).fruits and vegetables).

•• Low in whole grains and calciumLow in whole grains and calcium

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Acceptable:Acceptable:Eat More, Weigh LessEat More, Weigh Less

Dr. Dean Dr. Dean OrnishOrnish•• Claim: If you eat fatClaim: If you eat fat--free, healthy foods, free, healthy foods,

you can feel full and still lose weight.you can feel full and still lose weight.•• What you eat: Vegetables, fruits, whole What you eat: Vegetables, fruits, whole

grains, beans, limited nongrains, beans, limited non--fat dairy fat dairy (yogurt, cottage cheese), egg whites.(yogurt, cottage cheese), egg whites.

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Acceptable:Acceptable:Eat More, Weigh LessEat More, Weigh Less

•• Calories: 1,500 Protein 60g (15%)Calories: 1,500 Protein 60g (15%)•• Fat: 10g (6%) Fat: 10g (6%) CarbsCarbs: 290g (80%): 290g (80%)•• Sat Fat: 2g (1%) Fiber 40gSat Fat: 2g (1%) Fiber 40g

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Acceptable:Acceptable:Eat More, Weigh LessEat More, Weigh Less

CommentsComments•• Low calorie density and healthy (low in Low calorie density and healthy (low in

sat fat, ample fruits and vegetables).sat fat, ample fruits and vegetables).•• Restricts healthy foods like seafood and Restricts healthy foods like seafood and

low fat poultry and dairylow fat poultry and dairy•• Low in calciumLow in calcium•• If your triglycerides are high (above 200), If your triglycerides are high (above 200),

cut back on cut back on carbscarbs and add more and add more unsatunsatfats.fats.

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South Beach DietSouth Beach Diet•• Claim: HighClaim: High--glycemicglycemic foods cause a spike in foods cause a spike in

blood sugar and insulin that lead to hunger blood sugar and insulin that lead to hunger and weight gain. Eliminating these foods will and weight gain. Eliminating these foods will stabilize blood sugar and reduce cravings, stabilize blood sugar and reduce cravings, making weight loss easier.making weight loss easier.

•• UNCLEAR if this holds true for everyone, but UNCLEAR if this holds true for everyone, but some experts believe that it can benefit those some experts believe that it can benefit those patients with the Metabolic Syndromepatients with the Metabolic Syndrome

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South Beach DietSouth Beach Diet

•• Emphasizes balance of food groups (except 1Emphasizes balance of food groups (except 1stst

phase)phase)•• Emphasizes “good” highEmphasizes “good” high--fiber, wholefiber, whole--food food carbscarbs

over processed, sugary over processed, sugary carbscarbs•• Favors heartFavors heart--healthy fatshealthy fats•• Promotes regular meals and snacksPromotes regular meals and snacks•• Provides adequate caloriesProvides adequate calories•• Doesn’t leave you deprivedDoesn’t leave you deprived•• Includes detailed meal plans and recipesIncludes detailed meal plans and recipes

Pros

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South Beach DietSouth Beach Diet

•• Promises quick weight loss (13lbs in 2 weeks)Promises quick weight loss (13lbs in 2 weeks)•• Too many foods eliminated in Phase 1Too many foods eliminated in Phase 1•• Unnecessarily restricts some healthful foods Unnecessarily restricts some healthful foods

during all phases (carrots and bananas) during all phases (carrots and bananas) –– ban ban on fruit at breakfast???on fruit at breakfast???

•• Theory may not hold for everyoneTheory may not hold for everyone•• Hard for vegetariansHard for vegetarians•• Does not discuss exercise or psychosocial Does not discuss exercise or psychosocial

issuesissues

Cons

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Also AcceptableAlso Acceptable•• VolumetricsVolumetrics•• Choose to LoseChoose to Lose•• Weight WatchersWeight Watchers•• The The PritikinPritikin PrinciplePrinciple

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What has been successful?What has been successful?National Weight Control RegistryNational Weight Control Registry•• >3500 people >3500 people –– lost 30lb kept it off for 1 yrlost 30lb kept it off for 1 yr

•• Average caloric intake 1381Kcal/d (24% fat; Average caloric intake 1381Kcal/d (24% fat; 56% 56% carbscarbs))

•• <1% low <1% low carbcarb (90g or less) diet(90g or less) diet•• Monitored their weight frequentlyMonitored their weight frequently•• 80% had breakfast daily80% had breakfast daily•• Averaged 1 hr/day of moderate physical Averaged 1 hr/day of moderate physical

activityactivity

9

494949 505050

515151 525252

535353 545454

10

555555 5656

The EndThe End

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