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Nutrition a nd We ig ht Ma na g e me nt Disclosure in Offic e Pra c tic e No re le va nt fina nc ia l Robe rt Ba ron, MD MS re la tionships Profe ssor of Me dic ine Assoc iate De an for Gr aduate and Continuing Me dic al E duc a tion

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SLIDE 1

Nutrition a nd We ig ht Ma na g e me nt in Offic e Pra c tic e

Robe rt Ba ron, MD MS

Profe ssor of Me dic ine Assoc iate De an for Gr aduate and Continuing Me dic al E duc a tion F

  • unding Dire c tor, UCSF

Adult We ight Manage me nt Pr

  • gr

am

Disclosure

No re le va nt fina nc ia l re la tionships

Why Do We Ca r e About Wha t We E a t?

US L e a ding Ca use s of De a th, CDC

  • 1. He a rt Dise a se

32.6%

  • 2. Ca nc e r

30.9%

  • 3. Chr
  • nic lowe r

r e spir a tor y dise a se 7.5%

  • 4. Stroke

7.0%

  • 5. Ac c ide nts

6.4%

  • 6. Alzhe ime r’s dise a se

4.3%

  • 7. Dia be te s

3.7%

  • 8. Influe nza a nd pne umonia

2.9%

  • 9. Ne phr

itis, ne phr

  • tic syndr
  • me & ne phr
  • sis

2.7%

  • 10. Inte ntiona l se lf-ha r

m (suic ide ) 2.0%

Why Do We Ca r e About Wha t We E a t?

US L e a ding Ca use s of De a th, CDC

  • 1. He a r

t Dise a se 32.6%

  • 2. Ca nc e r

30.9%

  • 3. Chr
  • nic lowe r

r e spir a tor y dise a se 7.5%

  • 4. Stroke

7.0%

  • 5. Ac c ide nts

6.4%

  • 6. Alzhe ime r’s dise a se

4.3%

  • 7. Dia be te s

3.7%

  • 8. Influe nza a nd pne umonia

2.9%

  • 9. Ne phr

itis, ne phr

  • tic syndr
  • me & ne phr
  • sis

2.7%

  • 10. Inte ntiona l se lf-ha r

m (suic ide ) 2.0%

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SLIDE 2

Lifestyle and Disease

 1/ 3 of pre ma ture de a ths in the U.S. a re

a ttributa ble to poor nutrition a nd physic a l ina c tivity.

 We ll ove r 50% of Ame ric a n a dults do not g e t

the re c omme nde d a mount of physic a l a c tivity.

 Only 10% of Ame ric a ns e a t a die t c onsiste nt

with c urre nt nutrition re c omme nda tions.

Question for Discussion

 How would you de sc ribe your own

die t?

Question for Discussion

 How do you a sk pa tie nts a bout the ir

die ts?

Topics

 T

  • ta l c a lorie s a nd

ma c ronutrie nt ba la nc e

 We ig ht L

  • ss Die ts

 Die ta ry F

ibe r

 Die ta ry Guide line s  Sodium  Ve g e ta ria n Die ts  Me dite rra ne a n Die ts  Othe r Mic ronutrie nts  F

ina l Re c omme nda tions

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SLIDE 3

U.S. Calorie Intake

 Ca lorie c onsumption in the U.S. ha s

inc re a se d 30% ove r the pa st 4 de c a de s.

Year Average calories consum ed 1970 2,057 2008 2,674

Top calorie sources in U.S.

  • 1. Gr

a in- ba se d de sse r ts

  • 2. Ye a st br

e a ds

  • 3. Chic ke n a nd c hic ke n- mixe d dishe s
  • 4. Soda , e ne r

g y dr inks, a nd spor ts dr inks

  • 5. Pizza
  • 6. Alc oholic be ve ra ge s
  • 7. Pa sta a nd pa sta dishe s
  • 8. Me xic a n mixe d dishe s
  • 9. Be e f a nd be e f dishe s
  • 10. Da ir

y de sse r ts

E xtra Ca lorie s F rom E a ting Awa y F rom Home

Calories/ m eal at hom e Calories/ m eal at a restaurant Normal Weight 550 825 Overweight/ Obese 625 900

Public Health Nutrition, 2013

Macronutrient Composition

 Ma c ronutrie nt c omposition: the re la tive

proportions of fa t, c a rbohydra te , a nd prote in in the die t

 Bottom line :

 A wide ra ng e of ma c ronutrie nt c omposition

is c onsiste nt with a he a lthy die t

 In most c linic a l c irc umsta nc e s, tota l c a lorie s

“trump” ma c ronutrie nt c omposition

 Ac hie ving de sire d c a lorie inta ke will

a c hie ve most c linic a l g oa ls

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SLIDE 4

COMPARISON OF WEIGHT LOSS DIETS WITH DIFFERENT MACRONUTRIENTS

< RCT of 811 patients, 4 diets: fat/protein/carbs

20/15/65; 20/25/55; 40/15/45; 40/25/35

< 6 months: 6 kg, 7% weight; < 2 years: completers lost 4 kg. 15% lost 10% of

weight

< Results similar for:

< 15% pro v. 25% pro < 20% fat v. 40% fat < 35% carbs v. 65% carbs

< Weight loss highly correlated with adherence;

satiety, hunger, lipids, insulin all equal

Princ iple s of We ig ht Ma na g e me nt

 Be a s fit a s you c a n be a t your

c urre nt we ig ht

 Don’t g a in a ny mor

e we ig ht

 If hig hly motiva te d, a tte mpt

we ig ht loss

Die ta ry F ibe r

 Pla nt ma tte r  Not dig e ste d by huma n dig e stive e nzyme s  Some c a n be dig e ste d by g ut ba c te ria  Inc lude s  Ce llulose , he mic e llulose , pe c tins, g ums, a nd

muc ila g e s, lig nins

 Cla ssifie d a s soluble or insoluble  IOM: Me n 30- 38 g / da y. Wome n 21- 25 g / da y.

Die ta ry F ibe r:

T he Most Importa nt Nutrie nt?  He a rt: L

  • we rs L

DL , lowe rs trig lyc e ride s

 Dia be te s: Re duc e s blood sug a r  Gut: Pre ve nts c onstipa tion, he morrhoids,

dive rtic ula r dise a se

 We ig ht: Promote s sa tie ty

Baron RB, BMJ 2013

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SLIDE 5

Die ta ry F ibe r:

T he Most Importa nt Nutrie nt?  Me ta - a na lysis of 22 c ohort studie s:  E

ve ry 7 g ra ms of fibe r a ssoc ia te d with a 9% de c re a se in CV e ve nts

 One portion of whole g ra ins a nd one

portion of le g ume s, or from two to four se rving s of fruits a nd ve g e ta ble s.

Threapleton DE, BMJ, 2013

Quantifying Dietary Fiber (per serving)

Apple : 4.4 Blue be rrie s: 3.6 Orange : 3.0 Grape s 0.8 Pe ar: 5.5 R aspbe rrie s 8.0 White bre ad 0.7 Whe at bre ad 1.9 Brown ric e 1.5 White ric e 0.3 Whe at- bran c e re al 7.4 Oatme al 4.8 Shre dde d whe at 6.1 Cornflake s 0.9 Pe anuts 9.1 Kidne y be ans 6.8 Aspara g us 1.4 Broc c oli 1.1 Carrot 1.7 Spinac h 3.5 Powde re d psyllium 3.0

Princ iple s of a He a lthy Die t

Wide va rie ty of foods Hig h food qua lity Mode ra tion (rig ht qua ntity)

Die ta ry Guide line s 2015

 L

imita tions on die ta ry c hole ste rol ha ve be e n re move d

 Consume a die t ric h in fruits a nd

ve g e ta ble s, whole g ra ins, low- fa t da iry, se a food, le g ume s, a nd nuts

 Consume a die t low in re d or proc e sse d

me a ts, sug a r swe e te ne d foods a nd be ve ra g e s, a nd re fine d g ra ins

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SLIDE 6

Die ta ry Guide line s 2015

 L

imit da ily c onsumption of a dde d sug a rs (<10% of c a lorie s), sa tura te d fa t (<10% of c a lorie s), a nd die ta ry sodium (2300 mg )

 Ha lf of a ll g ra in inta ke should c ome from

whole g ra ins

 Mode ra te a lc ohol is fine in most (non-

pre g na nt) a dults

 Up to five c ups of c offe e pe r da y is not

a ssoc ia te d with a dve rse e ffe c ts in most a dults

MyPla te MyPla te T

  • o Ma ny Re fine d Gra ins

 Guide line s re c omme nd six, 1- ounc e

se rving s pe r da y for a 2000 c a lorie die t, a nd ha lf should be whole g ra in.

 T

he a ve ra g e pe rson e a ts 8 se rving s of g ra ins pe r da y, a nd 7 of the 8 a re re fine d.

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SLIDE 7

What is a serving of grain?

 1/ 2 c up c ooke d ric e or othe r c ooke d g ra in  1/ 2 c up c ooke d pa sta  1/ 2 c up c ooke d hot c e re a l, suc h a s oa tme a l  1 six inc h tor

tilla

 1 slic e of bre a d (1 oz.); ½ bun  1 ve r

y small (1 oz.) muffin

 ½- 1 c up r

e a dy- to- e a t c e r e a l (½ c up = ½ a ba se ba ll)

Select whole grains

 L

  • ok for “whole” in the first ing re die nt
  • n the la be l.

 Aim for tota l c a rbs/ fibe r = <10 for

bre a d a nd <5 for c e re a ls.

 Whole g ra ins: whe a t (spe lt, fa rro,

durum, bulg ur, othe rs), ba rle y, buc kwhe a t, c orn, mille t, oa ts, quinoa , ric e , rye )

Wa y T

  • o Muc h Adde d Sug a r

T he a ve r a g e pe r son in US c onsume s 30 te a spoons

  • f sugar

and swe e te ne r s pe r day (up to 600 c a lorie s) (Inc lude s c ane and be e t sugar , high fruc tose c or n syr up, c or n syr up, de xtr

  • se , hone y)
  • T

he Die ta ry Guide line s re c omme nd <10 te a spoons (200 c alor ie s) of adde d sugar pe r day for wome n.

  • Am. He art Asso c iatio n says <6 te aspo o ns (120

c alo rie s)

  • A 20 oz. soda has 240 c alor

ie s from sugar

Salt and Public Policy

 Coronary Heart Disease Policy Model to quantify

benefits of modest salt reduction in U.S.

 Benefit through a reduction in systolic blood

pressure from 1-9 mm Hg in selected populations

 New cases of CHD decrease by 4.7 - 8.3 and

stroke by 2.4 to 3.9 /10,000

 Regulatory change leads to wide benefit and is

cost-effective

Bibbins-Domingo K, et al. NEJM 2010

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SLIDE 8

Sodium

 Ave r

a g e c ur r e nt inta ke 3,400 mg pe r da y (1.5 te a spoon sa lt)

 Institute of Me dic ine , 2013  L

imit e ve ryo ne to 2,300 mg pe r da y (1 te a spo o n)

 E

vide nc e do e sn’ t suppo rt lo we r re c o mme nda tio ns

 Die ta r

y Guide line s, 2015

 L

imit e ve ryo ne to 2,300 mg pe r da y

80% in processed or pre‐ prepared foods

Salt in the US Diet

Sources: Mattes et al.

Top sodium sources in U.S.

  • 1. Ye a st br

e a ds

  • 2. Chic ke n a nd c hic ke n- mixe d dishe s
  • 3. Pizza
  • 4. Soda , e ne r

g y dr inks, a nd spor ts dr inks

  • 5. Cold c uts
  • 6. Condime nts
  • 7. Me xic a n mixe d dishe s
  • 8. Sa usa g e , fr

a nks, ba c on a nd r ibs

  • 9. Re g ula r

c he e s

  • 10. Gr

a in- ba se d de sse r ts

Cla ssific a tion of Die ta ry F a t

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SLIDE 9

Sa tura te d F a t a nd Ca rdiova sc ula r Dise a se (CVD)

  • T

wo re c e nt me ta - a na lyse s of

  • bse rva tiona l studie s: no a sso c ia tio n

be twe e n hig he r sa tura te d fa t a nd CVD

  • But strong e vide nc e from ra ndomize d

tria ls: re plac ing saturate d fat with

unsa tura te d fa t re duc e s to ta l a nd L DL c ho le ste ro l.

  • Re pla c ing sa t fa t with c a rbohydra te s:

re duc e s to tal a nd L DL c ho le ste ro l but inc re a se trig lyc e ride s and lo we rs HDL

Sa tura te d F a t a nd Ca rdiova sc ula r Dise a se (CVD)

  • Cur

r e nt r e c s: L imit sa tur a te d fa t, but be c a re ful wha t re pla c e s it

  • Use oils (soy, c orn, olive , c a nola ) to

re pla c e a nima l fa ts (butte r, c re a m, la rd) or tropic a l oils (pa lm, c oc onut)

Mediterranean Diet:

Healthy fats and good carbs with a big side of fruits and vegetables

slide-10
SLIDE 10

Prima ry Pre ve ntion of Ca rdiova sc ula r Dise a se with a Me dite rra ne a n Die t

7447 Me n and wome n, type 2 diabe te s or at le ast 3 CV risk fac tors. 4.8 ye ars Compar e d 1) Me dite r r ane an die t supple me nte d with 4 T bsp/ day of olive oil or 2) with 1 ounc e of nuts/ day; vs. 3) a low fat die t (the c ontr

  • l)

Re sults: 288 c a r diova sc ula r e ve nts oc c urre d: 3.8% in the olive oil g r

  • up, 3.4% in the nut gr
  • up, and 4.4%

in the c ontr

  • l gr
  • up. (P=0.015)

NEJM, 2013

E a t a bout 1 ounc e of nuts most da ys

 1 ounc e of nuts=1/ 4 c up or a sma ll ha ndful  But be a wa re of the c a lorie s…  1 ounc e =160- 200 c a lorie s

Ve g e ta ria n Die ts

 Ve g a ns  F

ruita ria ns

 L

a c to- ve g e ta ria ns

 L

a c to- ovo ve g e ta ria ns

 Pe sc o- ve g e ta ria ns  Pollo- ve g e ta ria ns  F

le xita ria ns (Se mi- ve g e ta ria ns)

Ve g e ta ria n Die ts: Obse rva tiona l Study

 Adve ntist He a lth Study 2  73,000 pa rtic ipa nts; 2570 de a ths  5.8 ye a rs follow- up  Compa re : ve g a ns, pe sc o- ; la c to- ovo- ;

a nd se mi- ve g e ta ria ns to non- ve g e ta ria nts

 Outc ome : lowe st morta lity in pe sc o-

ve g e ta ria ns a nd ve g a ns (15- 20% ).

Orlic h, JAMA IM, 2013 Ba ron, JAMA IM, 2013

slide-11
SLIDE 11

Mic ronutrie nts in Brie f

 Be ta - c a rote ne  Disc oura g e - ha rmful  Vita min E  Disc oura g e - ha rmful  F

  • la te

 Wome n of c hild- be a ring a g e – pre ve nt

ne ura l tube de fe c ts

Mic ronutrie nts in Brie f

 Ome g a - 3 fa tty a c ids  Disc oura g e – no be ne fit  Vita min D a nd c a lc ium  Olde r, fra il pa tie nts to pre ve nt fa lls  Use with bisphosphona te s  800 IU of vita min D3 pe r da y is suffic ie nt  E

nsure a de qua te c a lc ium inta ke

 1000 mg unde r

50; 1200 mg ove r 50

Dietary Calcium

 Dairy

mg  Pla in Yo g urt

8 o z 448

 Mo zza re lla

1.5 o z 333

 Che ddar

1.5 o z 307

 2% milk

1 c up 293

 Co ttag e c he e se

1 c up 206

 F

r uits and ve ge table s

 F

  • rtifie d OJ

6 o z 261

 K

a le 1 c up 100

 Bo k Cho y

1 c up 74

 Bro c c o li

1 c up 43

Dietary Calcium

 Canne d fish

mg  Sa rdine s

3 o z 325

 Sa lmo n

3 o z 183

 Gra ins

 F

  • rtifie d c e re a ls

1 c up 100-1333

 F

  • rtifie d c o o ke d o a ts

1 c up 187

 Comme r

c ial br e ads

1 slic e 30-73

slide-12
SLIDE 12

Mic ha e l Polla n’s T hre e Rule s  E

a t food

 Not too muc h  Mostly pla nts Ba ron’s Rule s

 E

a t unproc e sse d foods

 E

a t the rig ht a mount to ma inta in your we ig ht

 E

a t some thing c olorful a t e ve ry me a l (a nd e ve ry sna c k)

 Don’t drink c a lorie s  If c a n’t ma ke the “be st” c hoic e , ma ke a

be tte r c hoic e

 Be a s fit a s you c a n be : e xe rc ise da ily  E

a t with your c hildre n; e a t a t home

The “Generic” Diet

 Continue d de ba te : ma c ronutrie nt ba la nc e ,

a mounts of me a t/ fish/ fowl, othe r spe c ific foods

 But a lmost a ll a g re e :

 L

imit: sug a r, re fine d g ra ins, la rg e a mounts of sa tura te d a nd trans fa t.

 E

a t: fruits a nd ve g e ta ble s, he a lthy oils, whole g ra ins, le g ume s a nd nuts

 Bottom line : Ma ste r a “g e ne ric ” die t for

pa tie nts a nd se lf

Baron, R B JAMA Int Me d, 2013

Ba ron’s Rule s

 E

xe rc ise is “biblic a l”

 6 da ys of e xe rc ise , one da y of re st  Ne ve r g o to sle e p without knowing e xe rc ise

pla n for tomorrow (a nd ba c k- up pla n)

 Morning e xe rc ise is be st (to do it whe n

e ne rg y is hig he st)

 Home ma c hine s he lp with a dhe re nc e  F

  • c us on c a rdiova sc ula r fitne ss, stre ng th,

ba la nc e , a nd fle xibility

slide-13
SLIDE 13

F

  • r More Informa tion

Die ta ry Guide line s for Ame ric a ns, 2015 http:/ / he a lth.g ov/ die ta ryg uide line s/ 2015.

USDA’s F

  • od & Nutrition Information Ce nte r:

http:/ / fnic .nal.usda .g ov/ nal_display/ inde x.php?info_c e nt e r=4&ta x_le ve l=1

CDC Division of Nutr ition, Physic a l Ac tivity & Obe sity: http:/ / www.c dc .g ov/ nc c dphp/ dnpa o/ inde x.html

USDA Na tiona l Ag ric ultur a l L ibr a r y: http:/ / www.nutrition.g ov/

Ce nte r for Sc ie nc e in the Public Inte re st (CSPI): http:/ / www.c spine t.org /

Choose MyPla te .g ov: http:/ / www.c hoose mypla te .g ov/

F

  • r More Informa tion

F DA: How to Unde rsta nd a nd Use the Nutrition F a c ts L a be l: http:/ / www.fda .g ov/ F

  • od/ Re sourc e sF
  • rYou/ Consume rs/

NF L PM/ uc m274593.htm

F DA: L a be l Ma n – Ma ke Your Ca lorie s Count: http:/ / www.a c c e ssda ta .fda .g ov/ vide os/ CF SAN/ HWM/ hw mintro.c fm

Nutr ition.g ov: Shopping , Cooking & Me al Planning: http:/ / www.nutrition.g ov/ shopping - c ooking - me a l- planning

He a lthy E a ting Pla te (Ha rva rd): http:/ / www.hsph.ha rva rd.e du/ nutritionsourc e / wha t- should- you- e a t/ pyra mid/