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Food Talk: What your patients don’t tell you and why you need to ask

Diane Stadler, PhD, RD, LD

Associate Professor & Director

Graduate Programs in Human Nutrition

Bob & Charlee Moore Institute for

Nutrition & Wellness

Oregon Health & Science University

Portland, OR

Conflicts of Interest/Disclosures

I have no conflicts of interest to disclose

Images obtained from Google Images with

designation of “noncommercial, reuse”

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Objectives

• Crucial conversations

– Ask about food preferences

– Identify collaborative

solutions

– Support success

• Summarize popular fad diets and

food trends and their nutritional

implications

• Review healthy dietary patterns

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Crucial conversations about Food and Nutrition

“What do you say when a patient asks

you for nutritional advice?”

“I change the subject!”

Conversation between Kent Thornburg, Director, OHSU Bob & Charlee Moore Institute and physician colleague

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Starting the conversation…“If you ask just one question…”

Precautionary guidance…

“Do you use a seat belt when you’re

driving?”

“What type of car seat do you use?

“When you ride a bike, do you wear a

helmet?”

“Are you planning to become pregnant in

the next year?”

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We need to use the same strategies to talk about diet...

“Tell me about the foods you usually eat?”

“Are there foods that you tend to avoid?”

“Where do you shop for food?”

“How many times a week do you eat foods that you didn’t prepare at home?”

“What are your favorite go-to meals?”

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Food Choices among Asian WIC Participants in Oregon

“We usually have noodles, like rice noodles, for

breakfast and rice for dinner.”

“We know brown rice is very healthy but the kids is

not liking it. Because the brown rice is very, very dry

and very hard. Not easy to eat.”

I don’t know how to cook tortillas. So I haven’t

bought them.”

“The canned fish we never buy, cause we want the

fresh one. I always like the fish is still swimming.”

Tsai, C. Influences on Food choices, Postpartum Traditions and Breastfeeding

Among Asian WIC Participants in Oregon. OHSU Master’s Thesis, 2018. OHSU

Research Best Poster Award.

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Screen for food insecurity

“Within the past 12 months, we worried

whether our food would run out before

we got money to buy more.”

“Within the past 12 months the food we

bought just didn’t last and we didn’t

have money to get more.”

A response of “Yes” to either or both

questions identifies “food insecurity”

with 97% sensitivity and 83% specificity.

https://www.ers.usda.gov/topics/food-nutrition-assistance/food-

security-in-the-us/measurement

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Children and Adolescents Reporting Food Insecurity in Rural Oregon

“Usually I have enough food because of school, but

if it’s on the weekends, I usually [get food] probably

from a tree or a bush” [Girl, 13 YO]

“Since I eat with my friends a lot and I eat at school,

I was just gonna let my mom eat my dinner.” [Girl,

14 YO]

“I have to run errands with my parents…I guess I

have to do it more when there is less food…because

we need more…I can’t study, I can’t work on my

homework.” [Boy, 12 YO]

Massey, E. Altered Activities and Shame Resulting from Children Experiencing

Food Insecurity in Rural Oregon. OHSU Master’s Thesis, 2016; OHSU

Outstanding Thesis Award

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In looking for ‘zebra,’ doctors are stumped by toddler’s painful legs, rash and bleeding gums

2 ½ YO boy, 6-week history bilateral leg pain, unable to walk

• Quiet, normal growth

• Cried when legs were touched; agitated, irritable

• Legs in odd, froglike position

• Gums were swollen, bleeding, black spot between his two front teeth that bled when wiped

• Petechial rash, swollen thumbs

• X-rays revealed bleeding beneath the top lining of the leg bone

• Mom reported, picky eater, delayed speech

Hafez D. A Deficient Diagnosis. NEJM. 2016; 374:1369-74

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Work up included ruling out…

• Guillain-Barré syndrome

• Tumor pressing on spinal cord

• Fractures → Abuse → child protective services

• Head injury

• Cancer, osteomyelitis

• Lead poisoning

• Polio

• Arthritis, leukemia, lymphoma

Work up included…

• Guillain-Barré syndrome

• Tumor pressing on spinal cord

• Fractures → Abuse → child protective services

• Head injury

• Cancer, osteomyelitis

• Lead poisoning

• Polio

• Arthritis, leukemia, lymphoma

Complete metabolic screen

Complete blood count with Diff

Vit A, D, E

Vit B1, B2, B3, B6, B12

Vit K (PT, PTT elevated)

Vit C (ascorbic acid)

< 0.1 mg/dl

nl: > 0.6 mg/dl

Folate

2.4 ng/ml

nl: >3 ng/ml

Mild anemia…. Hypochromic, microcytic

↑milk, ↓Fe → lead poisoning

Lucent metaphyseal bands…seen

in patients with leukemia, metabolic

conditions, nutritional deficiencies

Bleeding beneath the top lining of the leg

bone → very painful

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Why it’s important to ask about diet…

• “Picky eater”

– 1 ½ qt chocolate milk

• 13.2 mg Vit C (RDA: 25 mg/d)

• 3.6 mg iron (RDA: 10 mg/d)

– 2-4 graham crackers

• 0 mg Vit C

• 1-2 mg iron

• Food aversions among children, adolescents,

adults with autism

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Not just a ‘picky eater’

• 6 YO boy with autism, refused to walk due to severe

leg pain.

• Multiple spinal MRIs, blood labs, spinal fluid

tests…all unremarkable

• Routine X-rays of hips showed “deficient hardening

of bones”

• Requested dietary history:

• Variety of juices and flavored corn chips…for past 2

years

• Low [Vitamin D] confirmed rickets

• Responded to ‘dietary shakes’ and Vitamin D

supplements

• “Some children with autism can develop major

issues with food selectivity way beyond being a

“picky eater”

Weig, S. Letter to the Editor, Washington Post, July 2016

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64% of people worldwide follow a

diet that prohibits certain ingredients

or foods

50% of people in North America

report following a restrictive diet

The Nielsen Global Health & Ingredient-Sentiment Survey, Q1, 2016. Slide courtesy of Robyn Flipse, MS, RDN

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Circumvent Public Health Efforts to improve Nutritional Status through Food Fortification

• Salt

• Fluid milk

• Flour and Bread

• Cereals, Grains

• Orange Juice

• Breads, flour, rice, corn meals, noodles, macaroni other grain products

• Corn Masa

• Iodine (1924)

• Vitamin D (1933), Vitamin A

• Thiamin, niacin, riboflavin, and iron (1940, 1952)

• B-vitamins, folic acid, iron

• Calcium, Vitamin D

• Folic acid (1998)

• Folic acid (2016)

Dietary Reference Intakes: Guiding Principles for nutrition Labeling and Fortification.

National Academy of Sciences, 2003

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Marketing: simplicity, variety, choice & claims

“Focus on variety, nutrient density

and amount. To meet the nutrient

needs with caloric limits,

choosing a variety of nutrient

dense foods across and within all

food groups in recommended

amounts.”

“Atkins 40 is an easy low carb

diet plan based on portion

control and eating 40g net carbs

per day. If you have less than

40 pounds to lose, are pregnant

or breastfeeding, or want a

wider variety of food choices

from the first day of your diet,

Atkins 40 could be a great fit for

you.”

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First, do no harm…Find common ground…

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Low-Carb Eating fewer simple sugars

Paleo Eating more home cooking

Gluten-Free Eating more ancient grains

Raw-Foods Eating more nuts & seeds

Clean-Labels Eating less processed foods

Juicing Eating more fruits & veggies

Longevity Good at counting calories

“Tell me more about this…”

Adapted from a slide by Robyn Flipse, MS, RDN

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The Power of Active Listening and Empathy

“Obese…, he told me I was obese…and his

only advice was to each more celery and

carrots!”

“He didn’t ask what I thought contributed

to my weight gain.”

“And, he wants to see me back in 6

months…6 months, what good is that going

to do?”

“I don’t even like celery!”

First Seek to Understand

“My husband is following a low-carb diet…He’s been doing this for 2 years. He says he feels great…I’m concerned…He won’t talk with his physician…I don’t know what to do.”

“Why did they contact you?”

“What do they think you’re going to do for them?”

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Paleo Diet (a.k.a., Caveman, Stone-age Diet)

“Eating like our prehistoric ancestors leads to weight loss & lower risk of developing diabetes, heart disease, cancer other health conditions”

Nutrients of concern: Calcium, B-vitamins, Iodine, Vitamin D

Foundational Foods:

• Lean meats, fish, eggs

• Nuts, seeds

• Fruits, vegetables

• Oils

Foods to avoid:

• Processed foods

• Wheat, other grains, legumes

• Dairy

• Potatoes

• Refined sugar

• Salt

• Refined oils

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Atkins 20-40-100

• Low carbohydrate, high fat (LCHF)

• 20 g carbohydrate; 12-15 g from “foundational

vegetables”

• Beef, pork, poultry, fish, eggs, cheese, sources

of fat

• 4-6 oz protein at each meal

• Limits starchy vegetables, grains, legumes,

simple sugars, fluid milk

• “Nutrients of concern: Vitamin C, B-vitamins

including folate, calcium, magnesium, fiber

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Low Carbohydrate Diets & Folic Acid IntakeWomen who consume carbohydrate

restricted diets (<5th %ile of sample studied):

• Consumed less than half the dietary

folate of other women (67.4 ± 67.8 µg/d

vs 183.0 ± 185.4 µg/d)

• Were slightly more likely to have an infant

with a neural tube disorder (AOR 1.30

95% CI 1.02-1.67)

• Derived National Birth Defect Registry

Data, 1998-2011

Tania, et al, Birth Defects Research. 2018; 110:901-909

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Ketogenic Diets

• Extreme carbohydrate restriction ketosis

• 20 g metabolizable carbohydrate/day

• “Skin-on” poultry, fattier beef, poultry,

pork, fish

• Green leafy vegetables

• Oils & solid fats

• Avoid starchy root vegetables, bread,

pasta, other grains, fruit

• Nutrients of concern: Vitamin C, B-

vitamins including folic acid, calcium,

fiber

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US News & World Report: 2019 Diet Rankings

• How easy is it to follow

• Likelihood of losing significant weight

– In the first 12 months

– For 2 years or more

• How well it helps prevent/manage cardiovascular disease

• How well it helps prevent/manage diabetes

• Nutritional completeness

• Safety

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What do healthy dietary patterns have in common?

• Dietary diversity

• Focus on whole foods vs processed foods

• Rich in…

– Vegetables & fruits (7-11 servings/d)

– Whole grains & complex carbohydrates

– Healthy fats (mono & polyunsaturated fats)

– Lean meats & dairy products

– Healthy fish

– Plant-based protein (legumes, nuts)

– Higher water content foods

• Easy to follow

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Mediterranean Eating Pattern

• Associated with lower risk of:

– CVD and overall mortality, cancers, cognitive diseases in

older adults

• Ranked “best overall in 2019” by US News & World Report

• Key components

– Plant-based foods

• Vegetables, fruits, whole grains, legumes, nuts

• Herbs and spices instead of salt

– Mono-unsaturated fatty acids-olive oil

• Up to 40% of calories from fat

• Quality not Quantity of fat

– Fish and poultry at least twice a week

– Red meat a few times a month

– Red wine with dinner—by choice

– Meals with family & friends

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DASH Eating PatternDietary Approaches to Stop Hypertension

• One of the most studied dietary patterns in the US:

– Weight loss

– Lower BP

– Improved cholesterol profile

– Lower CVD risk

– Lower bone loss

• Ranked “best diet overall in 2018” by US News & World

Report—healthy eating and heart disease prevention

• “Complete” nutritional profile…supplements (except

Vitamin D) not needed

• Key components:

– “Balanced higher complex carbohydrate (58%),

lower fat (28%), moderate protein (18%) content”

– High in fiber, calcium, phosphorous, magnesium,

potassium

– Low in cholesterol, fat, sodium

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My Plate

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Flexitarian Diet

• “Vegetarian most of the time”

• Add foods rather than take them away

• 5-food groups: “new meat”, fruits & vegetables, whole

grains, dairy, “sugar & spice”

• Eat more vegetable-, whole grain- and plant-

based/non-meat proteins (beans, peas, eggs)

• Consume meats and dairy in moderation, if at all

– Convenient, balanced, nutrient dense, high in fiber

– Sustainable due to flexibility

– Lower BP and cholesterol; weight

– Lower risk of heart disease (70% food from plant

sources; 20% lower risk) and stroke; diabetes (20%

vs 34% strict vegetarian)

– Focus on home-prepared meals (≤ 5 ingredients)

– Depending on foods individual choices, may need

to focus on Calcium, Vit B12, Iron

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Nordic DietA way of eating that focuses on locally sourced foods in the Nordic

countries — Norway, Denmark, Sweden, Finland, and Iceland.

Popularized in 2004 to address rising rates of overweight & obesity;

associated with weight loss, lower BP, lower inflammatory markers

compared to typical Scandinavian food patterns.

Similar to the Mediterranean Diet (canola oil vs olive oil)

Contains less sugar and fat but twice the fiber and seafood as the

typical American Diet.

• Eat often: fruits (apples), berries, vegetables, legumes, potatoes,

whole grains, nuts, seeds, rye breads, fish, seafood, low-fat dairy,

herbs, spices, and canola oil

• Eat in moderation: game meats, free-range eggs, cheese, and

yogurt.

• Eat rarely: other red meats and animal fats

• Don't eat: sugar-sweetened beverages, added sugars, processed

meats, food additives, and refined fast foods32

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Do we have time for SMART Goals?

• Specific

• Measureable

• Achievable

• Relevant

• Time-bound

“I’m going to eat salmon once a

week for the month of May”

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“Smart Goals & Food Rules”

• Create rules that are going to work

• Focus on whole, unprocessed foods and

beverages

• Fill your plate, bowl, lunch bag with fruits and

vegetables

• Drink mostly water and drink water throughout

the day

• Cut back on/eliminate beverages with calories

but no protein

• Build in accountability & support—someone to

check in and keep you moving forward

• Celebrate success34

My food rules…

• Eat breakfast…at least a piece of fruit

• Take my lunch to work

• Eat a “salad in a sandwich”

• Buy bread with 5-6 g fiber per slice

• Eat a salad with dinner

• Eat 4-5 whole pieces of fruit a day

• Order grilled fish when I go out to eat

• Request a take-home box whenever I go

out to eat; share meals

• Cereal for dessert…on occasion

• DRINK MORE WATER!!

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Summary Points

1. It’s important to ask and talk about diet

2. Adherence to certain restrictive dietary

patterns is associated with

lower/insufficient consumption of

essential nutrients (folic acid, iodine, B-

vitamins, iron, B12)

3. Find common ground, identify strengths

and areas for improvement

4. Collaborate to create individualized,

stepwise, achievable goals

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Recipe for a Health…

• Begin with an early rise

• Mix in a light two-mile walk

• Add a healthy breakfast

• Sprinkle in laughter, smiles, and good cheer

• Stir well

• Continue on medium

• Gradually mix in hard work and a sense of

accomplishment

• Cool down frequently…

• Flatten and let rest for eight hours

Kaiser Permanente Thrive Campaign

Thank You

Diane Stadler, PhD, RD

stadlerd@ohsu.edu