MODULE 5C - Nutrition Science, Assessment and Prescription
Objectives:
  • Summarize the major nutrition studies and evidence-base for nutrition prescriptions
  • Apply the science behind making nutrition prescriptions to address the pathophysiology of most chronic diseases, including inflammation, oxidation, glycosylation, and epigenetic expression
  • Summarize the role of nutrition in preventing, treating and reversing hyperlipidemia, cardiovascular disease, pre-diabetes, diabetes, hypertension obesity and cancer
  • Demonstrate ability to make nutrition prescriptions for health maintenance.

nutrition assessment

Although the value of healthy diets and lifestyles in preventing and treating disease is well established, too few health care providers raise these issues with their patients.  The Behavioral Risk Factor Surveillance System surveyed approximately 13,000 obese individuals in 50 states in the US, and found that only 42% had been advised by a health care provider to lose weight.

Surveys show that physicians and medical students feel ill-prepared to address nutritional questions.  Aside from a lack of information, physician's are often concerned about patients' ability to stick to lifestyle changes.  They may also face a lack of reimbursement and significant time pressures, among other problems.  Despite these reservations, the fact that patients seek out, respect, and are motivated by advice from physicians indicates that clinic visits and hospital stays present important opportunities to effect major nutritional changes that improve health.

Partly in response to a growing consensus that practicing physicians and medical students should learn about nutrition, the National Institutes of Health developed the Nutrition Guide for Training Physicians.  This publication is designed to help physician-educators integrate essential medical nutrition knowledge and behavioral skills into undergraduate and graduate medical curricula in the United states.  Unfortunately, there is no similar initiative implemented in the Philippines. 
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  • Nutrition assessment provides in-depth evaluation of both objective and subjective data related to patient's nutrition, lifestyle, and medical history so the clinician can assess and evaluate the patient's nutritional status.
  • Performed by LM clinician with follow-up by registered dietician or done by registered dietician in the collaborative team

ABCD OF NUTRITION ASSESSMENT
  • Anthropometric data
  • Biochemical data
  • Clinical assessment
  • Dietary assessment

Anthropometric Assessment
  • Body measurements and composition most commonly include height, weight and waist circumference
  • Other less common assessment includes body composition (bioelectrical impedance, hydrostatic underwater weighing, calipers)

Assessing Body Weight
  • Body Mass Index does not account for muscle/bone mass
  • Percent body fat is more accurate assessment of nutritional status
  • Using accurate height and weight, calculate Body Mass Index (BMI):
          
Biochemical Assessment
  • Laboratory assessment as indicators of the body's condition
  • Almost every laboratory test is affected by nutritional status, some more rapidly than others
  • Consider the impact of disease or dehydration or laboratory values
  • Interpret laboratory results in the context of the patient's overall status
  • Primary testing usually includes sodium, potassium, hemoglobin, hematocrit, glucose, Hgb A1C, albumin, cholesterol, LDL, HDL, and triglyceride.
  • Secondary testing, based on primary results and clinical assessment may include Vitamin D, Vitamin B12, calcium, magnesium, and iron/ferritin.
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Clinical Assessment
  • Vital signs
  • Review of medical record and medical history
  • Basic history collected from the patient (age, gender, activity level)
  • Physical examination (condition of skin, hair, nails, muscle status, swelling, etc.)
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Diet Assessment
  • Comprehensive interview about food intake and dietary patterns as well as physical activity patterns as well as physical activity patterns/habits
  • Diet history should be taken in order for nutrition counseling to be successful as you have to first find out what the patient's lifestyle is like at the baseline.  The more you know about the patient's eating habits, schedule, lifestyle, etc., the better you can help them set realistic goals.  It is important to listen first, then advice
  •  Data collection mostly subjective, but extremely important (24-hour recall, 3-day food record, food frequency questionnaire)

TAKING A NUTRITION HISTORY
  • Before you can write a nutrition prescription, you have to know what people are currently eating
  • There are many ways to take a nutrition history including the usual or typical daily intake (the most practical practical)
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24-hour Recall
  • Ask patient what they ate over the last 24 hours or during the previous day from the time they woke up to the time they went to sleep.
  • First Pass Goal are the quick list of foods.  Ask the open-ended questions like "What was the first thing you ate after you woke up?" and avoid leading questions like "What did you have for breakfast?"
  • Second Pass Goal are the forgotten foods.
  • Third Pass Goal includes time and occasion.
  • Fourth Pass Goal describes food and amount.  You need to fill in details including questions like:
          How was food prepared?
          Portion size?
          Did you eat or drink between meals?
          Did you drink anything with the meal?
  • ​Fifth Pass Goal is the final probe.
3-Day Food Recall
  • Ask the patient to record 3 days of food intake, preferably 2 work days and 1 day off.  Bring to next appointment for your interview.
Food Frequency Questionnaire
  • Ask patient to indicate consumption frequency of a list of foods.
Diet History Interview
  • Other considerations include how typical is the 24-hr recall?
  • Weight and diet history
  • Meal planning and grocery shopping patterns
  • Cultural or religious aspects
  • Economics and food budget
  • Functional ability (chewing, intolerances, etc.)
  • Digestive health
  • Food avoidances

Nutrition Prescription Guidelines
  • Written nutrition prescriptions must be very specific and focus on a particular food or food category.  Prescribing a nutritional category (ie. saturated fat) does not tend to work.
  • Consider using SMART concepts (Specific, Measurable, Accountable, Realistic/Forgiving, Time connected)
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S - simple/specific
  • A food name ("an apple a day")
  • A type of food (cruciferous vegetables, citrus fruits)
M - measurable
  • How many? (Three, One medium)
A - accountable
  • Who makes food decisions? (shopping, preparation)
  • In what settings does eating occur? (Home, work, on the road)
R - realistic/forgiving
  • What is available (location, budget, time)
  • What currently happens (what do they eat now? what do they like? what are they willing to actually try?)
T - time connected
  • How frequent? (daily, each meal, weekly)
  • How long? (for three months, "the new you")
General Health Prescription​
  • Prescription should include target weight, chronic disease prevention and treatment including predominantly whole, plant-based foods (fruits, vegetables, legumes, whole grains, nuts and seeds).  There should be a focus in low-processed ingredients (nothing bad added and nothing good taken away) with plenty of hydrating fluids.
  • Limit or eliminate refined grains, refined sweeteners, high-fat foods, high-sodium foods and alcohol.
  • Other considerations should include variety of food groups and ingredients, adjacent familiar to current dietary intake, aligned patient's current nutrition and lifestyle needs and aligned patient's stage of behavior change.
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Nutrition Prescription Format
Like any traditional prescription, it should include patient name, date, and your signature.  The core prescription should include:
  • T - type of food (be specific)
  • A - amount of food to be eaten (be exact)
  • F - frequency with which the food should be eaten (may be time limited as well)
Acronym is the opposite of FAT
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Types of Nutrition Prescriptions
Positive prescriptions
  • Prescribing more of a type of food
  • black beans, 3/4 cup, four times/week for 12 weeks
Negative prescriptions
  • Prescribing less of a type of food
  • cheese, 3/4 cup, no more than once/week for 12 weeks
Helping Patients Adopt Healthy Habits
  • Identify patient's stage of behavior change based on Transtheoretical Model (TTM)
  • Identifying patient's current stage of readiness to change gives clinician a path for how to best help move the patient to the next stage.
  • Remember that it's normal for people to move both forward and backward through the stages.
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Stage of Change
Resource/Support
Pre-contemplation
Personalize meal plan
Contemplation
Support group for fresh ideas and ongoing relapse prevention
Preparation
Educational handout on impact of food choices on diabetes
Action
Help patient weigh pros and cons of making dietary changes
Maintenance
Setting and monitoring goals
Setting Realistic and Specific Goals (SMART)
  • This SMART goal setting is appropriate for the preparation and action stages.  Focus on positive (what to add to diet)
  • Base goals on patient's nutrition assessment data
  • SMART Goals examples

Nutrition Counseling is Complex
  • Due to the complex nature of behavior change, a variety of strategies are employed to help patients achieve success.
  • Long-term follow up and support is key.
  • It is not your job to convince your patients to make dietary changes to improve health.  Healthcare providers are simply facilitators and guides.

Collaboration Nutrition Assessment
  • A team approach will produce the best outcomes
  • Physician does physical exam and basic nutrition assessment and prescription
  • Registered dietician does follow up for comprehensive assessment and counseling
Eat 2 pieces of fresh fruit for snacks on weekdays
Take a 15 minute walk on your lunch break daily
Add one green vegetable to your dinner
Cook dinner at home 2 more times per week
ROLE OF THE PHYSICIAN IN NUTRITION ASSESSMENT
  • Obtain a baseline history and perform physical exam
  • Determine patient' risk factors and comorbidities
  • Create framework for treatment with nutrition being the primary, and often most effective treatment
  • Emphasize the importance of nutrition as the focus of assessment and treatment
  • Introduce recommended dietary/lifestyle goals to patient
  • Oversee and reinforce recommendations made by dietitian

ROLE OF THE REGISTERED DIETITIAN (RD/RDN)
  • Assess and monitor nutritional status
  • Determine appropriate diet pattern  and composition
  • Provide individualized meal planning
  • Coach patients towards goals
  • Track progress and impact of diet on biomarkers
  • Provide ongoing education and support (Nutrition education, individualized meal plans, behavior change strategies, accountability)

MEDICAL NUTRITION THERAPY (MNT)
  • An evidence-based nutrition service provided by RDs to prevent, delay or manage diseases and conditions
  • Involves a personalized, in-depth assessment, nutrition diagnosis and intervention treatment plan
  • Requires multiple visits to positively impact nutrition behaviors and allow for continued personalized monitoring of the patient/client.
  • Covered by insurance of patient with high risk conditions, such as renal failure.
  • MNT is a component of effective disease management and treatment, lessens chronic disease risk, slows disease progression, reduces symptoms, cost-effective and patient/client satisfaction

Medical Nutrition Therapy for Cardiovascular Disease
  • Less than 6 months leads to significant reductions in blood pressure of approximately 5 mmHg for both systolic and diastolic blood pressure.
  • 6-12 months yields similar significant reductions in blood pressure that is sustained beyond one year.
  • MNT resulted to 8.6% reduction in hospital utilization
  • MNT resulted to 16.9% reduction in physician visits

Medical Nutrition Therapy for Diabetes
  • Provided over 3-6 months yields reductions in A1C ranging from 0.25 to 2.9%
  • Sustained improvements in A1C at 12 months and longer
  • resulted to 9.5% in hospital utilization
  • resulted to 23.5% reduction in physician visits

Medical Nutrition Therapy for Overweight and Obesity
  • Less than 6 months yields significant weight loss of 1-2 lbs per week
  • 6-12 months yields significant mean weight loss of up to 10% body weight with maintenance beyond one year.
  • Other improvements: BMI, waist circumference, FBG, total cholesterol, HDL-C, LDL-C, and triglycerides

Practice Processes for Improved Outcomes
  • Each patient has a practical discussion with you about the role of nutrition in treating their current chronic conditions and in preventing additional conditions.
  • Each patient who is ready for action leaves the visit with a specific written nutrition plan and/or is referred to a registered dietician.
  • Each patient is provided online, digital, and online community resources to support ongoing healthy dietary practices.

clinical application

  • Start the conversation and gain framed messaging.  It is important to remember that change occurs through inspiration, hope, and support.
  • Individual screening must be  done.
  • Discuss long term implications 
  • Informed consent provides a unique opportunity to discuss the benefits of lifestyle intervention
  • Focus on the positive aspect of lifestyle (cost effective, co-morbid risk reduction, general well being, daily health, achievable)
  • Offer real support, guidance, resources (coping strategies improve blood glucose control)
  • Emotional wellness (diabetes link to depression)
  • Discuss challenges/solutions and opportunity for success (sustainable lifestyle, provide success stories) 
ARTICLES REVIEW
Insulin Resistance, Lipotoxicity, Diabetes Type 2
​Saturated Fat and the Endothelium
Plant-based Diet and Hypertension
Plant-based Nutrition and Cancer Prevention
Plant-based diet and Plasma Lipids

VIDEO REVIEW
TASK
Task 1
  • Using the INTAKE FORMS you gathered from your patients, create a nutrition prescription using the learnings you got from this module.

Task 2
  • Reflective Journal