1. Welcome to Seminar on Nutrition Assessment and Management in Family Medicine Part-3 Meera Kaur, PhD, RD Assistant Professor, Family Medicine kaur@cc.umanitoba.ca

2. Estimation of Energy and Protein Requirements Energy requirement are calculated based on height, weight, age, physical activity –Harris Benedict Equation (REE): Well-known and widely used. Derived from healthy adults, calculates resting energy expenditure Additional stress (SF) and activity factors (AF) added –MEN » 66 + [13.7 x wt (kg)] + [5.0 x ht (cm)] - [6.8 x age] = kcal/day x SF X AF –WOMEN » 655 + [9.7 x wt (kg)] + [1.8 x ht (cm)] - [4.7 x age] = kcal/day x SF x AF Mifflin Equation (out patient setting) Practical and simple to use. Derived from a sample representative of current Canadian population covering all weight categories. Least amount of error. –MEN »9.99 (wt) + 6.25(ht) – 4.92 (age) + 5 = kcal/day x SF x AF –WOMEN »9.99 (wt) + 6.25(ht) – 4.92(age) – 161 = kcal/day x SF x AF 18

3. Mifflin Equation MEN 9.99 (wt) + 6.25(ht) – 4.92 (age) + 5 = kcal/day x SF x AF WOMEN 9.99 (wt) + 6.25(ht) – 4.92(age) – 161 = kcal/day x SF x AF Wt = kg Ht= cm SF= Stress Factor 1.0 1.2Infection or fracture 1.4Multiple trauma 1.6Sepsis, respiratory failure AF= Activity Factor 1.0Ventilated 1.2Confined to bed 1.3Able to transport self 1.4-1.6Active individual 19

4. Protein Requirements 0.8-0.9 g/kgHealthy adult 1.0- 1.5Post-operative, cancer patients or heavy-weight trainer 1.8-2.5Major burn victims Based on ideal body weight. 20

5. How am I suppose to have time to do all of this??? 26

6. What is the Family Physician’s role? Brief nutrition assessment should be done at every physical examination Problem Identification –As part of initial screening, assess for nutrition related problems Offer a separate meeting with the dietitian Assess pts readiness to change. 27

7. 4 B’s for Better Eating Body Mass Index Blood pressure and HTN Balanced diet Breakfast 28

8. Nutrition Checklist based on warning signs: DETERMINE assessment tool 30 Disease Eating poorly Tooth loss/mouth pain Economic hardship Reduced Social Contact Multiple medicine Involuntary weight loss/gain Needs assistance in self care Elder years above age 80

9. What if I hate using these tools? Do you look like an apple or a pear? Do you eat breakfast everyday? Do you eat vegetables and fruit everyday? »WHO report estimated that increasing F/V consumption to 5 servings/day, would decrease global disease burden by 18% (Lock et al, 2005, Bulletin of the World Health Organization, Feb 83(2), 100-108). How many times do you eat out each week? What do you drink? Water/pop/juice? 31

10. How to contact me… –Fill out referral form –Include patient’s name, chart #, phone #, reason for assessment and submit to the front desk –Phone call (3452) You are most welcome at any time regarding your nutrition related queries. Please give me call first to make sure that I am at KMC. 32

11. RD’s Follow Up- What is my role? Nutrition Assessment –Establish nutrition focus of the meeting (reason they are there, pts expectations). –5A Model – Assess at risk behaviours, What does the pt think requires change? (pts interpretation) Advise on specific goals, Agree- negotiate an agreement that makes sense for both parties Assist with nutrition plan –Involve patients in planning. –Be specific and realistic. –Write goals down. –Include self-monitoring tools. Arrange- for follow-up –Needs to be specific, measurable, verbal and written. Expect relapse (Stages of Change model). 33

12. Eating Well with Canada’s Food Guide – NEW 2007 34

13. http://www.hc-sc.gc.ca/fn-an/food-guide- aliment/index_e.html 35

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15. Canada’s Guidelines for Healthy Eating Enjoy a variety of foods –All can be enjoyed in moderation. Emphasize vegetables and fruits, and whole grains. Choose lower-fat dairy products, leaner meats, and foods prepared with little/no fat. Enjoy physical activity. Limit salt, alcohol, and caffeine. 37

16. Terri Terri is a 59-year-old retired school teacher new to your clinic. She is here for a check-up. Her blood pressure measures 152/94. After completing a thorough physical exam, which was normal in all respects, you repeat her blood pressure which is now 150/91. Physical Exam:Height 160cm, Weight 69kg (gain of 4kg since retirement 4 years ago) Diet Recall:0730 hrs2 cups black coffee 1 carrot muffin (Robins Donuts) (=2-3 Grains) 1030 hrs10 Ritz crackers ( = 2 Grain) 3 Tbsp Light Cheese Whiz ( = 1 Milk) 1 cup tea with 2% milk 1245 hrs1 sandwich: corned beef thick rye (= 2 Grain, 2 Meat) 1 cup Campbell’s Chicken Noodle soup (= ½ Grain) 1 can Diet Pepsi 1530 hrs1 glass red wine (8oz) Peanuts (1/2 cup) (= 2 Meat) 1800 hrs1 vodka with Diet 7-up Chicken-vegetable stir-fry (1.5 c veg + 50g chicken) (= 3 Veg, and ½ Meat) 1 cup steamed rice, with soy sauce (= 2 Grain) ½ cup frozen vanilla yogurt (=1 Milk) 2 oatmeal cookies ( = 1 Grain) 1 cup tea with 2% milk 2200 hrs1 pear (= 1 Fruit) 2230 hrs1 glass red wine (8oz) 2 slices garlic sausage (= ½ Meat) 1 thick slice of rye bread ( = 1 1/2 Grain) Mustard 29

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18. Questions??