Time Stamps

  • 03:10 Trends in weight and dieting
  • 06:01 Counseling patients on diet
  • 09:35 Food group recommendations
  • 14:53 Pre-set diets
  • 20:47 Making sustainable changes

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Show Notes

Workshops Covered from #SGIM21:

Food as Medicine for All: Overcoming Barriers to Healthy Eating

Nutrition Myth-Busters: Socially Just Dietary Counseling and Decoding Common Nutrition Myths

Beyond Diet & Exercise: Addressing Obesity from the Front Lines

Diet and Exercise Matter

  •  Up to half of all premature deaths in the United States are due to behavioral and other preventable factors. 
    • Diet and Exercise top this list causing more premature deaths than influenza, motor vehicle accidents, illicit drug use, and tobacco.
  • Meta-analysis data has shown that higher consumption of fruits and vegetables is associated with a lower all cause mortality, particularly cardiovascular mortality.
  • Mediterranean diets have been shown in a randomized secondary prevention trial to be protective up to 4 years after a myocardial infarction in reducing cardiac death, stroke, heart failure, unstable angina, and hospital admissions. 
  •  Most patients are trying to lose weight!
  • Talk to you patients!
    • A conversation about diet and exercise is just as warranted as a conversation about smoking.

Pre-counseling Considerations

  • Be careful of one’s own bias toward weight. 
    • International surveys have found that a high percentage of individuals have experienced weight stigma from physicians. 
    • This stigma often presents itself as weight shaming which has a detrimental effect on patients
      • Can lead to:
        • Decreased physical activity
        • Increased caloric intake
        • Binge episodes
        • Eating disorders
  • Be mindful of one’s cultural blind spots.

How to Counsel Patients

  • Focus on the DOs! After the top dietary risk factor of decreasing sodium, the most significant thing one can do to improve their diet is not cut out food but get more of foods their diets are low in. 
  • Instead of telling patients not to eat certain things tell them to put these good things into their diet:
    • More Whole Grains
    • More Fruits
    • More Nuts and Seeds
    • More Vegetables
    • More Omega-3 fatty acids
    • More Fiber
  • If it helps them, you can encourage patients to count calories and weigh themselves daily. 
  • Other helpful tips:
    • Wash canned beans to reduce sodium.
    • Switch to long grain rice to get slower glucose absorption.
    • Prepare a vegetable in a different way to improve the flavor.
    •  Beware of false advertising! Certain labels are misleading, and even when reading the back of packaging a zero could represent a rounded down value. 

What if cost is an issue?

  • Use free resources like Oldways to help find alternative meal and snack ideas.
  • Plan out meals for the week to reduce over shopping.  
  • Get creative with Meat Extenders like beans so your meals stretch further. 
  • The difference may not be as large as some people think.

Pitfalls of Fad Diets

  • If a certain type of diet is working on an individual level, then it should be encouraged
    • Ultimately, at the end of the day, a Calorie is a Calorie.
  • Weight loss compared between individuals undergoing intermittent fasting and calorie restriction did not show any statistical difference between the two groups. 
  • Juicing has a dark side
    • Most over the counter juices and even some home made juice is essentially just sugar water.
    • Get a nutrient-extractor blender where the whole fruit goes in and the whole fruit comes out so you can keep all that good fiber. 

Transcript

S: Hey everyone! Last spring Core IM was invited to Society of General Internal medicine, SGIM’s, national conference virtually and we had the privilege of covering parts of the conference and I had the pleasure of working with my colleague Dr. Clem Lee.

C: The pleasure was all mine Shreya. There were a few workshops that stood out to us around the theme of nutrition and obesity.

S: Yeah, some of the points were thought-provoking. Clem and I actually recorded some of those sound bytes from the workshops so you’ll hear them as Clem and I recap what were some of the big takeaways on nutrition and obesity.

C: We will link the info in our show notes and at the end credits if you want details on the specific workshops and presenters. 

S: Great! So as a heads up to our listeners, Clem why don’t you give a rundown of some of the big buckets we are going to cover today.

C: First we will get into what are current trends in weight and dieting, then dive into some nitty gritty recommendations for specific food groups and diets, and with some tips to make these changes longlasting. 

S: Clem, side from having a Nutrition Masters. I’m curious what makes you passionate about this topic? 

C: In medicine there’s a tendency for people to gravitate toward “sexier” things, like stress testing, cathing or transplant listing, but I personally feel like this probably the most important thing we can address 

Speaker: When we look at the risk factors that contribute to death in the US, dietary risk factors actually top the list at number one.

S: Number 1! Yeah and I think that whether or not patients express this or not, they also know that what they eat is important- just take a look at some of these statistics:

Speaker: At any given time, more than half of the us adult population is trying to lose weight. 97% of obese adults have ever attempted a diet and 20% have had more than 20 diet attempts.

C: To make matter worse, we as clinicians are not good at supporting our obese patients and even contribute to weight bias

Speaker: In fact, the two most common places at the top of the list are actually family members and doctors. Those are the top two offenders. It’s kind of a gut punch to be for us to be at the very top of this list of, uh, sources of weight bias for people. If you survey medical students, you’ll find that three fourths of them have an implicit weight bias, which is maybe not surprising, but I think particularly stunning is that two thirds actually report an explicit or consciously held weight bias,  which is just kind of remarkable and unsettling.

C: I didn’t think I was going to be as drawn to that portion of the discussion on bias as I was just because I feel that recently I have been inundating in media about by bias and injustice. But I actually found that portio to be very enlightening and maybe that’s where I needed to check my own biases. Sometimes we think we are motivating our patients by scaring them oe alarming them about the how bad their weight is, but the workshop on Addressing Obesity from the Frontlines sort of debunked that. 

Speaker: So the first thing to know is that stigma actually decreases healthy behaviors. So I think there’s sometimes this thought out there and people are a little afraid to say, but they kind of feel like, Oh, well maybe people with  obesity, they should feel a little ashamed because that’s going to motivate them. It’s been demonstrated that the experience of, of weight bias, shaming and stigma decreases physical activity, increases binge-eating, increases total caloric intake, and increases the risk for eating disorders. Twin studies and adoption studies and studies of familial aggregation confirm the heritability of obesity is equivalent to that of height and exceeds that of many disorders, which a genetic basis is generally accepted. And we don’t usually go around having as much bias about people with, um, depending on their height as we do about their weight.

S: This was good food for thought for me. You know i have to admit i’m kind of like the scare tactic because I feel like ok if I can get my patients to wake up and take things more seriously, if I really warn them about lung cancer and quitting smoking, maybe they will,  or to take their blood pressure medications if I tell them a stroke could happen. But I appreciate that the research a bit more in telling me to be more thoughtful in my approach when it comes to counseling about weight

How can we best counsel our patients on their diets?

S:  Alright Clem, the next big part that, particularly the Food as Medicine workshop dug into was how to talk to patients about nutrition, especially when you are limited on time.

Speaker: We talked about time barriers just in the clinic visit, but I think, um, I’ve found that if you can practice taking just a quick 24 hour dietary recall it’s a really good way to start a conversation.

C: I love using the dietary recall but it doesn’t always capture all of what our patients eat. In the workshop, they brought up this interesting case of a patient who is a truck driver and basically lives two different lives.

Speaker: What is his schedule like when he leaves home? Is he gone for days or is he gone for a day or two days? Can he pack some snacks from home? 

C: So you need to think about what foods he has in life 1 and then the foods has in life 2 so I think it is just a bit more complex and I don’t think I think about that in clinic.

S: I feel like I was pampered in my prior clinic because the front desk would give a sheet for the patients to fill out when they were in the waiting room on what they ate in the last 5 days…It was helpful both bc it saved me time and was a better biopsy of what they were actually eating, but you gotta work with whatever resources you have and the 24 recall is good too.

C: Yeah i cant say ive been lucky enough to have those resources in my clinic but the nutrition myth buster workshop also mentioned how easy it is to have cultural blindspots and recommend that patients from other cultures switch to healthier foods that we are comfortable with, like western food. In that instance, we can actually be doing them some harm. Take a look for example, in these studies looking at mexican food:

Speaker: Those eating a traditional Mexican diet actually improved their insulin resistance significantly compared to those eating a more US healthy diet.  And in another study, looking at Hispanics in the US, those who had access to a more traditional Hispanic food store actually had better health outcomes than those who are purchasing Americanized food. 

S: I actually have easily fallen into that trap… I had a patient from Ethiopia with new diabetes and I told him to stop eating injera. At that time i didnt know what it was but he described it to me as ethiopian bread and so i told him to stop–  but thankfully my preceptor said that’s actually not good medical advice because Injira has tons of protein. I was pretty humbled by that experience.

C: Shreya, it’s good that you learned that early on in training. I’m not entirely sure I still know what Injira is. 

S: We are Learning

C: Ok, I’m going to move us on to probably the most compelling point in all of the talks that I went to at SGIM. If theres one thing i want everyone to take away– its this. 

Speaker: After we get past a diet high in sodium, which is our top dietary risk, everything else that has a significant impact is something that we are missing or not getting enough of. And if we frame our conversation with our patients, not around all the foods we want them to stop having, and instead make the conversation about, Hey, I would love for you to get more fruit. I would love for you to find a way to incorporate seeds into your diet, and you give them specific examples and suggestions. It feels like a much more positive lifestyle shift for them to consider ways to get the good stuff that’s missing.

S: Wow, It is so easy to have nutrition counseling be totally “hey don’t eat this, don’t eat that, don’t take this, do it this way”

C: Yeah it feels like we’re just parents slapping the hands of kids; but  after limiting salt, the most bang for your patients buck is going to be adding nutritious foods, not taking things away from them

What are specific recommendations for the different food groups?

S: Alright so Clem so everyone knows what those nutritious foods are – fruits veggies, etc etc but Clem I’m curious what about the SGIM workshops elevated that conversation for you in regards to healthy food groups? What stood out to you about each of the food groups: fruits/veggies, proteins and carbs?

C: Yeah this was a portion of the talk that really spoke to the data junkie in me– I really appreciated all the information that was presented– andI  just like having tangible numbers to give my patients. 

S: Yeah! That actually reminds me of that great graph from the workshop, I think the Food is Life one, that showed the higher number of fruits and veggies a day, the higher the mortality benefit, which of course no brainer. What i really appreciated is seeing the inflection point and that you get the most bang for your buck at if you can get up to 3-4 servings of fruits/veggies a day. 

C: I changed my practice to tell my patients to aim for 4 servings a day–  there are certain patients where if I give them that exact number it really motivates them. 

S: Absolutely, I’ve shown the graphic that’s linked in the show notes to my family, which has been helpful, but  my husband kindly gave me some initial pushback saying this is helpful but “You know Shreya, I would much rather reach for some pizza than veggies.”

Speaker: Sometimes just changing the way that we cook a vegetable can improve the flavor profile. For example, steamed brussel sprouts have never been my favorite, but roasted brussels sprouts have a wonderful flavor profile.

S: Alright roasted it is! we are gonna try some roasted brussel sprouts! Ok Clem thats vegetables, what about protein food group,  Any good nuggets on proteins?

C: Any good chicken nuggets you mean? I liked learning concept of a meat extender, its something I had never heard of before, but they were explaining it as something like legumes or canned beans that you can add to a meat dish that is cheaper but functionally acts as a meat and makes it last longer.

S: Yeah I think your evidence mind person in you probably liked the how they brought an RCT published by JAMA indicates that eating one serving of legumes daily decreased A1cs significantly. I also appreciated that the SGIM presenters had some practical tips that we can be reminding our patients.

Speaker: Some tips for incorporating legumes into your diet are if you rinse the canned beans, you can not only reduce the amount of sodium, but you can also help minimize the gas producing agents that cause distress. 

S: Also a nice reminder for me to not cut corners and rinse out all that sodium out of those beans thoroughly, so much appreciated all around. What about carbs Clem? Were there anything that stood out to you about the carbs?

C: Yeah, the busting nutrition myths workshop made a really good point to switch from short grain to long grain rice.

Speaker: One of the, perhaps easiest switches to just go from a short grain to a long grain rice, you get a little bit of a slower glucose absorption and a lower spike if you’re doing the long grain rice.

C: The more surface area you have, the higher the glycemic index will be. This is counter interuitave but short grains actually have a higher surface area ratio and so they’re worse for your sugar control. You maybe wondering what short grains are, they are things like sushi rice and rice used in sticky rice. 

S: Ugh unfortunately all things i love

C: I know me too Shrey. Long grains are more spread out and have a lower surface area to glucose ratio. Exmples of this are basmati or jasmine rice.

S: Good, thumbs up Clem have your master’s in nutrition – im curious if there are things you remember from that time and what you learned about different food groups that surprised you that you want everyone else to know about?

C: Yeah, this is one of my pet peeves in the food industry. Food labeling in general can be very misleading. Companies are legally allowed to put “whole-grain” on the box if there’s just 51% of whole grain in the food even if the rest of it is refined,, they can call that whole grain. In addition, tags like “multi-grain” or “made with whole grain” or “a good source of whole grain” can be used for whole grains less than 50%. So when you are trying to buy whole grain foods, look for “100% whole grain” because that guarantees it.

S: Thats wild even someone marking up something that 51% WHOLE GRAIN, yikes.

C: Yeah, that doesnt seem mathematically correct, but don’t even get me started with trans fats- thats even more ridiculous. companies are allowed to round down from 0.5 grams to 0 grams of trans fats per serving.. So, if you are eating a bag of chips and it has 0.5 grams of trans fat per serving in a certain food and that you thought had zero g, and you have for four servings of it, you just ate 2 g of trans fats even though you thought you had zero. 

S: [ugh, and without knowing it!] Yeah I’m always encouraging patients to empower themselves by reading food labels and make good decisions but I kind of feel at a loss when you cant even trust the numbers on the food label.

Which pre-set diets can we recommend for or against?

C: Shrey! Pop quiz, ill give you a low ball- Mediterranean diet, good or bad?

S: Obviously…. Good. I think it’s pretty common knowledge that it has good health outcomes, but i also appreciated hearing how it’s ALSO even cost efficient.

Speaker: The dietary cost of adhering to the Mediterranean diet was about $2 per week per patient, or $100 per year per patient. The money that they spent on vegetables, it was offset by the, to be saved on red meat and processed meats.

S: The hard part about is actually operationalizing cooking a Mediterranean diet I feel like I almost need to consult a chef  but its doesn’t have to be this fancy thing, small things like adding nuts or eating fish can go long way

C: We will link to a website in our show notes that can show your patients who want to take up a mediterranian diet

S: So thats the mediterranean diet, another diet that patients are doing is  is intermittent fasting, which is so prevalent now especially with so many on social media promoting it. Im glad the SGIM presenters covered it. I liked how they went into potential pathophys backing of why it can work.

Speaker:  The crux of this theory of intermittent fasting is that by having periods of fasting. So we’re talking as few as eight to 12 hours as high as 20 or more hours, your body is kind of signaled that you’re in an energy poor state that you’re, you know, evolutionarily yhis is, you know, the times, you know, you had feast and you had famine. So when you were in famine, your body switched from burning glucose, that’s produced in the liver to ketone bodies that are produced by the adipocytes. And the effects of this is that there’s really profound changes in cellular signaling pathways that move your body away from some of those more energy dependent growth and plasticity processes, more towards repair and healing. 

S: So interesting to think our body could be switching from burning glucose to ketones with intermittent fasting . My brother intermittently fasts, but does it where he only eats from 11 to 8. But it sounds like from the SGIM ppresentors some people eat normally for a few days and fast on other days as their intermittent fasting. Clem you were telling how you don’t really buy into intermittent fasting. I’m curious if you can speak a bit about that. 

C: Yea I feel like at the end of the day you’re just cutting down calories either day.. One study that they brought up compared intermittent fasting with daily calorie restriction, and there was no difference in weight loss and metabolic parameters at the end of the study. Maybe thats why im not that excited about it– ultimately, it’s just about eating fewer calories. 

Speaker: So what do we do with that? What do we tell our patients? I think what we can say with relative certainty is that calorie restriction is, is almost certainly a good thing. We’ve been studying that since the 1930s and in species after species and in paper after paper, we see that calorie restriction is good for longevity and for, um, preventing progression of chronic disease and development of chronic disease. I think it’s probably a little too early to say the same thing for intermittent fasting. So we’ll have to keep an eye on the literature for that, but all in all the long-term benefits of intermittent fasting do seem mostly net neutral to net positive. 

S: So intermittent fasting, probably won’t hurt your patient at the end of the day. . For whatever method they can stick to get their health to where they want it to be.

C: Yeah, but word of caution, the SGIM presenters did bring up one diet fad we should  discourage and thats juicing; Juicing can actually lead to insulin resistance.

S: At one point all my friends were juicing and I didn’t know what to tell them from an evidence-based perspective – there is such good marketing about how much antioxidant there are.

Speaker: Just because we’re getting more antioxidants doesn’t necessarily mean it’s all a good thing. The Dark side of juicing as kind of evidence in this huge BMJ study. Now this is a prospective cohort study that came out in 2013, uh, with over 151,000 participants, um, followed up from the eighties until 2009. So really impressive cohort in which they looked at fruit consumption, fruit juice consumption, and the risk of type two diabetes. So what they found was that the more fruit juice you drank, the more likely you were to have type two diabetes.

S: Wow increases your risk of diabetes! Who would have thought. It was interesting about the reason as to why juicing can increase in diabetes

Speaker: We know that when you take a whole apple and you change it from an apple into a juice, you take out all the fiber you’re left with just sugar, antioxidants, sugar, water. So when you take out that fiber, you increase the glycemic index of the food, which means that it leads to bigger changes in vivo of serum glucose and insulin concentrations. And the theory is that over time with this repeated insult, your body responds by having decreased insulin sensitivity

C: I think we have to keep in mind that the study was so large that it probably included patients who were drinking store-bought juices. And they are different– homemade juices probably have less badness overall.

S: Very true but if they are doing homemade juices, i liked the presenter’s point that we should take a moment to ask t how they are making their juices at home 

C: Yeah that’s because juicers are a hard no, they take out all the good stuff. But if they’re using a blender, then it really depends on the type of blender. some blenders are better than other which are essentially juicers that take out the fibers.

S: Right so we wanna recommend patients get a nutrient-extractor blender, something I actually haven’t head or before, which is kinda counter intuitive to the name but these are like your Vitamix or the Ninja which are better for the fiber.

Speaker: The point of these blenders being that they’re super powerful and that the whole fruit goes in and the whole fruit comes out. So you get to keep all the fiber. 

C: And I’m all for people drinking 4 kale smoothies a day, but if your patients aren’t used to that much fiber, you may want to warn them that they may experience a little bit of GI upset afterward.

S: I have learned that the hard way! I’ll save you a TMI story – but yes I always remember to remind patients to up there water intake simultaneously.

How can we make the changes sustainable? 

S: The last bit that we thought was interesting was just a couple tips about how to help our patients make substantial changes substainably.  The first one actually surprised me to hear – that actually weighing yourself daily and counting calories is associated with keeping weight off.

Speaker: And that would be the general trends being patients who weigh themselves every day tend to have more success; having some self monitoring of intake using apps or being in a structured, a weight loss program engaging in regular exercise.

S: I feel the advice in blogs and other places is usually don’t weigh yourself daily, it will get you down and do it more on a weekly basis. But the evidence makes sense that giving yourself more frequent feedback the better.

C: On a similar note, the last big takeaway was around planning ahead and actually writing out your meal plan for the week and how even doing  that even cuts costs.

S: Yeah this came up in my clinic a bunch especially when I was having patients who were low income wage and thought it was buying from the dollar menu – burger fries and a soft drink, and thinking it was much more cost-effective for them. But again,the presenters actually gave a really good example that  if you eat a meal with beans and rice, salsa, steamed vegetables, and half an avocado, all that stuff that you bought actually costs per serving about $2 and 20 cents, so not as high as $3. Ultimately that saves  you $7 per person per week, so it kind of adds up. 

C: 7 dollars! That’s two extra coffees right there! So Shreya, that was a ton of ground from these 3 strong presentations at SGIM. What are some of your biggest takeaways?

S: For me, its really gonna be about after encouraging patients to decrease salt intake, its gonna be about adding good stuff to their diet,really trying to get them to get 4 servings of fruits/veggies/day and game planning with them how that would happen. How about you Clem? What are you biggest take aways?

C: And for me, its about encouraging using meat extenders like legumes, and switching from short to long grains to help with sugar control!

S: And that’s a wrap!

C: A whole-grain tortilla wrap with lots of feta cheese!

References

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