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Sound Nutrition Advice

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To open "Nutrition Now," the first column about nutrition for nurse practitioners, I'll start by telling you a little bit about myself.

I had a hard time deciding between being a dietitian and being a nurse practitioner, so in my 20s I took steps to combine these two fields. I have been a nurse practitioner for 11 years and a registered dietitian for 16 years. I have my own nutrition practice, and I am additionally employed by Emerson College in Boston as a nurse practitioner and dietitian.

I was invited by ADVANCE for Nurse Practitioners to write a column on nutrition after the editor spotted a letter I wrote to the Boston Globe. The goal of this new column is to provide scientifically sound information to NPs so that they can guide patients in the areas of weight loss and nutrition. So, welcome to the first edition of Nutrition Now.

A Weighty Subject
Finding time to provide weight loss advice to your overweight or obese patients during a 15- to 20-minute office visit can seem impossible. We are fully aware that obesity is on the rise, but what to do?

It's our responsibility to help our patients lose weight and achieve weight maintenance. Most of our patients are weighed at every appointment, providing clear information about weight status. Often, our patients are the ones to broach the subject of weight loss.

When patients state that they would like to lose weight, ask about their plan to achieve it. Help them set realistic goals based on their lifetime weight history. (A future column will explain how to identify a healthy weight using weight history, body mass index and percent ideal body weight ranges.)

When patients state that they have already begun to lose weight, praise them profusely. This is not easy to do, no matter how few or how high the number of pounds. Most patients I see have needed to incorporate the following four changes for weight loss and weight maintenance: increased physical activity on a regular and consistent basis, journaling of food intake each day, increased intake of fruits and vegetables (minimum five servings per day), and decreased intake of added sugars.

  • Exercise: Ask your patients which activities they enjoy. It might be working out in a gym, walking outdoors or around a track, or taking group fitness classes. People are more likely to stick with exercise they enjoy. Most people need 40 minutes of cardiovascular activity 4 to 5 days per week to maintain or lose weight. Resistance training (weight or muscle work) should be incorporated at least two times per week. Encourage patients to make appointments for exercise; they should view them as important meetings that they cannot miss. Review maximum heart rates and any musculoskeletal problems before a patient begins an exercise program. Inform yourself of exercise programs and offerings in your community.
  • Journaling: Ask your patients to use www.mypyramid.gov and then to go MyPyramid Plan to input their age, height, weight, gender and activity level. Meals plans are available through this tool. Weight Watchers is another weight loss choice that has been effective for millions of patients. If a patient is tracking food intake and exercise specific to calories in and calories out, the overall scope of nutrition moving them toward a weight loss goal is enhanced.
  • Fruits and vegetables: Preparation is helpful to make sure these are ingested daily. Encourage patients to buy only what they need, to control cost and waste. Using local farmers markets or farm cooperatives for fresh produce can be less expensive. Frozen or canned fruits and vegetables are just as healthy and nutrient dense as fresh ones; rinse canned products to reduce sodium. Getting five fruit and vegetable servings in a day requires planning - including taking fruits or vegetables to work. Recommend cleaning and prepping fruits and vegetables on Sundays so that they are ready to eat or ready to cook before the work week starts. Convenience is key.
  • Decreasing added sugars: Counting carbohydrate grams in foods we need (e.g., whole grains, fruits, vegetables, dairy and protein) is not necessary. However, counting added grams of sugar, such as those found in any desserts, soda or candy, is helpful for weight loss. The U.S. Department of Agriculture (USDA), the Institute of Medicine and the Department of Health and Human Services have made recommendations about the use of added sugars. They recommend a maximum intake of 25% of energy per day in the form of added sugars. Note that this amount is on the high end, because the typical 2,000-kilocalorie daily diet would then include 500 kilocalories daily from added sugars. This equates to 125 grams of carbohydrate per day from added sugars (carbohydrates are 4 grams per kilocalorie). Encourage patients to count added sugars daily.

One-to-One Benefits
A simple office visit with a few nutrition pearls can be helpful for patients who need to lose weight. Patients often need just one person to work with them - not tell them - how to help themselves. Using these four tools as lifestyle changes with your patients can begin to help fight the obesity battle.

Robyn Kievit is a family nurse practitioner and registered dietitian in the Boston area. E-mail your nutrition and weight loss questions to robyn@robynkievit.com or visit her website at www.robynkievit.com. On Facebook and Twitter, search for nutritionmentor.

Nutrition Now Archives
 

Hi Meg:

You're letter is welcome and very admirable. There are many patients who don't fit into the above category or recommendations and need much more. I have found this in the clinic and in my private practice. Alternative therapies in conjunction with the recommendations above are necessary for some individuals. This approach is what is described on my website. There is definitely more to weight loss than food, as you wrote and I as can be heard saying and recommending. Future columns can discuss this point further. A great place to begin the column was with a few goals for the primary care clinician to utitlize in a fast paced office visit.

Thank you again for your well though out response and letter. Best, R

Robyn Kievit,  NP, RD,  Emerson CollegeJune 17, 2010
Boston, MA



As a nurse practitioner and someone overweight~ let me restate that ~ obese, I have found, through life experience, that there are two approaches in nutritional counseling. The first one is the person with needed a weight loss "of that last 30 lbs". This is likely someone without a life long struggle with weight issues. The basic approaches to weight loss are very realistic and the strategies outlined in the article are appropriate.

However for the person with lifelong issues of obesity, a clearly different strategy is needed. The clinician should be thinking along the lines of food addiction. Treatment with an antidepressant and professional counseling are an important step. It is important to understand the relationship of food to the person, the stressors, the 'trigger' foods and eating patterns. Changes need to be made slowly, one meal at a time. Frequent office visits are helpful, in essence to communicate that the clinician and patient are a team in the journey. Yes journaling, adopting healthy food plans, reducing sugars and refined carbohydrates are important. Exercise is also. However, in studying 'change' theory, it cannot be initiated all at one time.

Too often, I have left my PCP frustrated with yet another diet instruction in hand, following the empty words of 'you really need to loose weight' feeling more frustrated and lost than when I began.

Despite my education, I had a problem larger than that. I have tried and failed multiple times using many different approaches, MD supervised and commercial. I've heard the speech from the dietitians and nutritionists and failed. I felt empty because they didn't understand my struggle. I have lost the same 80 lbs 3 times. I have spent hours at the gym and failed.

Today with the help of an antidepressant, a therapist educated in food addiction and dietary changes over time, I am gaining a greater understanding of myself but also of food. This was a journey I entered on the advise of my MD ~ a very wise woman. I now have to tools to cope. I am not alone in this journey. As I talk with my patients and peers, I share my experience. They know I understand. I listen and suggest, one change at a time along with journaling. After they have had some success with weight loss then exercise is incorporated.

There is more to weight loss than food. Clinicians need to respect that is is larger than that an seek an more holistic approach to the solution.

Meg ,  MSN, ANP-CJune 13, 2010
Port Orange, FL



Brenda - Are you looking for clinical books or books that although are clinical can also be useful hands on for patients? Robyn

Robyn Kievit,  Nurse Practitioner,  Emerson CollegeJune 11, 2010
Boston, MA



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