Introduction to Macronutrients and Nutritional Assessment

Virginia E. Uhley, PhD, RD Integrative Medicine vuhley@umich.edu

INTRODUCTION

Nutrition:
The science of food, nutrients, and the substances therein, their action, interaction, and balance in relation to health and disease, and the process by which the organism ingests, digests, absorbs, transports, utilizes, and excretes food substances.
AMA, Council on Food and Nutrition

Chronic Disease Prevention and Diet

Poor dietary intake is linked to leading

causes of adult deaths:

heart disease stroke hypertension diabetes cancer

Famous Quote
If we could give every individual the right

amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.
Hippocrates c. 460-377 B.C.

Macronutrients
Carbohydrates Proteins Fats (lipids)

Major Functions of Macronutrients

Provide energy (kcalorie)

Kcal: measure of the amount of heat needed to raise the temperature of 1000 grams (1 liter) of water to 1 degree C. (approximately the same as 4 cups of water to 2 degrees F)

Major Functions of Macronutrients, cont

Important for growth and development Act to keep body functioning normally

Definitions
Deficiency: lack of nutrients
biochemical deficiency symptoms
nutrition deficiency symptoms measured in blood or urine (such as low levels of a nutrient or enzyme activities) clinical symptoms appear as a result of severe or prolonged lack of nutrients (changes seen in physical examination in skin, hair, nails, tongue, and eyes.

Definitions, cont
Overnutrition:

nutritional intake exceeds

needs. Undernutrition: nutritional intake falls below needs to maintain health, results from long-term reductions in nutrients.

Nutritional Assessment
5 components

A. Anthropometry B. Biochemical C. Clinical Examination D. Dietary Evaluation E. Energy Expenditure (Physical Activity)

Diet History
24-hour recall Food Frequency Usual Intake Food Record

24-Hour Recall
Documents a patients intake of all food and beverages during the previous 24-hour period. Many patients do not remember what they ate and can not accurately estimate quantities consumed. Ideal for patients with diabetes-ability to assess timing of meals, snacks, and insulin injections

Food Frequency Method

Estimate the frequency and quantity of foods eaten during a weekly or monthly period. Ideal method to estimate fat, sodium, sugar, dairy, fruit and/or vegetable intake. Ideal for patients with CVD, HTN, osteoporosis, those that question whether they should take a vitamin supplement, and elderly who avoid food groups.

Usual Intake Method

Documents a patients usual intake, including breakfast, lunch, dinner, and snacks. Many patients are not consistent with their eating habits and state that that there is no usual pattern. Ideal for elderly patients in order to assess number of meals eaten (or skipped), and infants, children, and adolescents whose diets may not be as varied.

Food Record Method

Written record by the patient of everything they ate and drank over a 2 to 7 day period. Many patients are not motivated to write down everything. (although those who do, may lose weight.) Difficult for physicians to take the time to review and comment, especially if not trained. Ideal for patients who have difficulty losing weight, those who are eating out of control and gaining weight, brittle diabetics, emotional eaters.

Assessing Nutrient Intake

Assess energy requirements via Harris

Benedict Equation. Compare current caloric intake with calculated requirements.

Estimation of Resting Energy Requirements (REE)

Harris Benedict Equation

derived from healthy adults calculates resting energy expenditure additional stress and activity factors added REE for males: 66+[13.7 x wt (kg) ] + [5.0 x ht (cm) ] - [6.8 x age] = kcal/day REE for females: 655 + [9.7 x wt (kg)] + [1.8 x ht (cm)] - [4.7 x age] = kcal/day

Calculation to Estimate Caloric Needs to Maintain Body weight

(Current Weight, in lbs) x (A) = Daily Caloric

Needs.
A= activity level
Not very active Moderately active Very Active Extremely Active 12 15 20 25

Calculation for Estimate of Basal Metabolic Rate

Men = 1 x body weight (kg) x 24 Women = .9 x body weight (kg) x 24

calculates basic expenditure of calories in a 24 hour period.

Assessment of Nutrient Intake

Dietary Reference Intakes (DRIs)

Reference values that are quantitative of nutrient intakes to be used for planning and assessing diets for healthy people.

Recommended Dietary Allowance(RDAs)

Recommended nutrient intakes that meet the needs of essentially all people of similar age and gender.

Estimated Average Requirement (EARs)

Estimated nutrient intakes that meet the needs of essentially all people of similar age and gender.

Assessment of Nutrient Intake, cont

Adequate Intakes (AIs)

Adequate intake to maintain health

Estimated Energy Requirements (EERs)

Set for daily energy requirements based on defined levels of activity (Different from RDA)
Upper levels (ULs)

The maximum level of daily nutrient intake that is likely to pose no risk or adverse effects

Current American Dietary Guidelines

Recommendations:

55% of total kcals to come from carbohydrates

Sugars no more than 10%

15% of total kcals to come from proteins 30% or less to come from fat

ADA exchange system

Designed as a quick way to estimate total kcals, carbohydrate, protein, and fat intake.

Six different categories:

milk fruit vegetables starch/bread meat fat

Milk (serving size 1 cup)

Carbohydrate Protein (grams) (grams) Fat (grams) Kcalories

12

Skim: trace Lowfat: 5 Whole: 8

90 120 150

Fruit (serving size 1 small)

Carbohydrate Protein (grams) (grams) Fat (grams) Kcalories

15

60

Vegetable (serving size -1 cup)

Carbohydrate Protein (grams) (grams) Fat (grams) Kcalories

25

Starch/Bread (1 slice, c raw,

cooked)
Carbohydrate Protein (grams) (grams) Fat (grams) Kcalories

15

Trace

80

Meat (1 ounce)
Carbohydrate (grams) Protein Fat (grams) (grams) Kcalories

Lean: 3 Medium: 5 High: 8

55 75 100

Fat (1 teaspoon)
Carbohydrate Protein (grams) (grams) Fat (grams) Kcalories

45

Exchange food patterns (total

Kcals: 55% CHO, 30% fat, 15% protein)
Kcal/day 1200 1600 2000 2400 2800 Exchange group
Milk (lowfat) Vegetables Fruit Starch/Bread Meat (medfat) Fat 2 2 5 4 2 4 2 2 4 8 2 7 2 3 5 11 3 8 2 3 8 11 5 9 2 3 8 15 5 12

Food Guide Pyramid

Food Group Serving Major Foods/ contributions Serving sizes Milk, 2 adult Carbohydrate 1 C milk 11/2 oz yogurt, 3 children, Calcium cheese And cheese Pregnant Riboflavin 1 c yogurt or Protein 2 cups lactating Potassium cottage women cheese Zinc

Food Guide Pyramid, cont

Food Group Serving Major Foods/ contribution Serving s sizes 2-3 oz cooked Protein meat Niacin, Iron 1-1 c cooked Vitamin B6, dry beans B12 2 T peanut butter Zinc 2 eggs Thiamin
-1 c nuts

Meat, poultry, fish, dry beans, eggs, nuts

2 -3

Food Guide Pyramid, cont

Food Group Serving Major Foods/ contributions Serving sizes Carbohydrate c dried c cooked Vitamin C cup juice Dietary Fiber
1 small 1 melon wedge

Fruits

2-4

Food Guide Pyramid, cont

Food Group Serving Major Foods/ contributions Serving sizes Vegetables 3 - 5 Carbohydrate c raw or cooked Vitamin A 1 c raw leafy Vitamin C Folate Magnesium Dietary fiber

Food Guide Pyramid, cont

Food Group Serving Major contributions Bread, Cereal, Rice, Pasta 6-11
Carbohydrate Thiamin Riboflavin Iron, Niacin Folate, Zinc Magnesium Dietary Fiber

Foods/ Serving sizes

1 sl bread 1 oz dry cereal -3/4 c cooked cereal, rice,pasta 3-4 small crackers

Food Guide Pyramid, cont

Food Group Serving Major contributions Foods/ Serving sizes

Fats, Oils, Based on And Sweets individual energy needs.

Use Foods from sparingly this group should not replace any from the other groups.

Food Guide Pyramid vs ADA Exchange List

Food Guide Pyramid

recommendations based on approximately 2,500 kcal intake/day based on nutrient needs (vitamins/minerals)

ADA Exchange List

lists based on total kcal intake based on modulating carbohydrate, protein, and fat intake

Carbohydrates
Simple:

monosaccharides - glucose, fructose, galactose disaccharides

sucrose: (table sugar) glucose + fructose lactose: (milk sugar) glucose + galactose Maltose: ( malt sugar) glucose + glucose

Carbohydrates, cont
Complex Carbohydrates:

polysaccharides:

amylose, glycogen

Starch, composed of many glucose molecules

Dietary fiber (nonstarch polysaccharides):

Insoluble - lignins, cellulose, hemicellulose
basically insoluble in water, not metabolized by intestinal bacteria.

Soluble - pectins, gums, mucilages

Major functions of Carbohydrates

Supply energy: 4 kcal/gram

Brain, nerve cells, and red blood cells require glucose for energy Storage form: Glycogen in liver (adult: ~ 120 g) and muscle (<2%, 2-500g)
~3 g water/g glycogen stored Glycogen concentration in liver4% after an overnight fast; 8% after meals. After a meal,1/4 1/3 dietary carbohydrate converted to liver glycogen. After a meal, 1/3 1/2 converted to muscle glycogen.

Excess can be converted to fat and stored.

Carbohydrate functions, cont

Protein sparing

Prevents lean body mass from being used for energy

Antiketogenic 50-100 g carbohydrate/d

Key roles of Dietary Fiber

Insoluble fiber:

increases fecal bulk, decreases intestinal transit time. Soluble fiber: delays stomach emptying; slows glucose absorption; can lower blood cholesterol level.

Example of a 25-gram Fiber Diet (1500 Kcal)

Breakfast Orange Juice,1 c Wheaties, c 1% Milk, 1/2c Whole Wheat toast, 1 sl Coffee Lunch Lean turkey Whole Wheat bread, 2 sl Baked Beans, 1/2c Mayonnaise,2 tsp Lettuce, c Pear, with skin

Fiber g 3.0 1.9

3.8 3.5 0.2 4.3

25 g Fiber Diet, cont

Dinner

Fiber g
3.6
2.0 3.0

Broiled chicken (no skin), 3oz Baked Potato, with skin, 1 lg Margarine/butter, 1 1/2tsp Green Beans, 1 c 1% milk, 1 c Apple, with peel,1 med

Total fiber grams =

25

Carbohydrate Recommendations
RDA: 130 g/day for adults 50-100 g/day to prevent ketosis

1 orange juice = 25g, 1 apple = 20

DRI: 45-60% from total Carbohydrate Fiber: general recommendation 20-35 grams/day

New guidelines:
Under 50 yrs old: Men 38 g/day, Women 25 g/day Over 50 yrs old: Men 30g/day, Women 21 g/day

Calculation of Dietary Intake of Carbohydrate Kcals

1).

Calculate total grams of Carbohydrate intake.

Note: did you meet the RDA? Note: did you consume 50-100 g and prevent ketosis?

2). Multiply total grams of carbohydrate x

4= total kcals of carbohydrate intake

Popular Low-Carbohydrate Weight loss diets

Most common form Forces depletion of body stores to provide

glucose to needed cells such as red blood cells. Forces depletion of muscle and other lean tissues to provide carbons for glucose. Water is lost rapidly (as glycogen stores are depleted)

Examples of Low-Carbohydrate Diets

Dr. Atkins,

Dr. Stillman, Calories dont Count, Scarsdale Diet, Drinking mans diet, Four day wonder diet, Air Force diet, Sugar Busters, The zone, etc.

Historical Low-Carbohydrate Diet

William Banting

Letter on Corpulence, 1864. William Harveys 1872 publication On corpulence in relation to disease, with some remarks on diet.

Typical Menu

Breakfast: 4-5 ounces of beef, mutton, kidneys, broiled fish, bacon, or cold meat of any kind but pork. 1 small biscuit or 1 ounce of dry toast, 1 large cup tea without milk or sugar. Lunch: 5-6 ounces of any fish except salmon, any meat except pork, any vegetable except potato Any kind of poultry or game. 1 ounce of dry toast. Fruit 2-3 glasses of good claret, or sherry. 2-3 ounces of fruit. 1-2 rusks (cut from bread and rebaked). 1 cup tea without milk or sugar. Supper: 3-4 ounces of any meat except pork, any fish except salmon, 1-2 glasses of claret. Night-cap: 1 tumbler of grog(gin, whiskey or brandy without sugar added) or 1-2 glasses of claret or sherry.

Current Research Evidence

A Randomized Trial Comparing a Very Low

Carbohydrate Diet and a Calorie-restricted Low-Fat Diet on Body Weight and Cardiovascular Risk Factors in Healthy Women.
Brehm BJ et al, J Clinical Endocrinology & Metabolism, 2003

Study Design
53 Women were randomized to a diet

intervention group for 6 months

27 to a calorie-restricted low fat diet (30 %) 26 to a ad libitum very low carbohydrate diet
Maximum intake of carbohydrates to be 20 g/d After 2 weeks, could increase to 40-60 g/d only if self-testing urinary ketones indicated ketosis.

Study inclusion Criteria

At least 18 yrs of age Moderate obesity (BMI 30-35)

BMI = weight (kg)/height (m)2

Stable weight over the past 6 months

No weight loss or gain > 10% of their body weight

Study Exclusion Criteria

Cardiovascular Disease Untreated hypertension Diabetes Hypothyroidism

Substance abuse
Pregnancy or lactation

Results

Women on both diets reduced caloric intake by comparable amounts at 3 and 6 months.
Decreased by approximately 450 calories.

The very low Carbohydrate diet group lost more weight than the low fat diet group.
(8.5 + 1.0 vs.3.9 + 1.0 kg; P < 0.001)

The very low carbohydrate diet group lost more body fat than the low fat diet group.
(4.8 + 0.67 vs, 2.0 + 0.75 kg; P <0.01)

Results, cont
No differences in mean levels of blood pressure, blood lipids, fasting glucose, insulin, all were in normal ranges. At 3 months the Very low carbohydrate diet group was consuming a mean level of 1156 Kcal/d, 15% Carbohydrate, 28 % protein, 57% fat. At 3months the Low fat diet group was consuming a mean level of 1245 Kcal/day, 54% carbohydrate, 18% protein,and 28 % fat.

Results, cont
At 6 months the Very low carbohydrate diet group was consuming 1302 Kcal/day, 30% carbohydrate, 23% protein, 46% fat. At 6 months the low fat group was consuming 1247 Kcal/day, 53% carbohydrate, 18 % protein, and 29 % fat. The very low carbohydrate diet group consumed significantly less carbohydrate, vitamin C, calcium, and fiber, and significantly more protein, total fat.

Results, cont.
The very low carbohydrate diet group

developed significant ketonemia, but this was only seen at 3 months and not at 6 months.

Conclusions
A very low carbohydrate diet is more effective than a low fat diet for short term weight loss, and over six months is not associated with deleterious effects on important cardiovascular risk factors in healthy women. The gradual increase in carbohydrates in the very low carbohydrate diet group after 3 months suggests recidivism is likely in persons following this diet, long term weight maintenance may be difficult.

Current Research Evidence

A Low-Carbohydrate as Compared to a Low-

Fat Diet in Severe Obesity.

Samaha FF. et al, NEJM, 2003

Study Design
132 severely obese subjects (including 77 blacks and 23 women) Mean BMI: 43, with high prevalence of diabetes (39%) or metabolic Syndrome (43%). Were randomly assigned to either a carbohydrate restricted diet (low-carbohydrate) (n= 64) or a calorie and fat restricted diet (low-fat diet) (n=68) for 6 months.

Study Design, cont

Subjects on the low carbohydrate diet were instructed to consume 30 g or less/day of carbohydrate.
Vegetables and fruits with high ratios of fiber to carbohydrate were recommended.

Subjects the low fate diet were instructed to consume 30 % or less/day of their total Kcal intake as fat and to reduce their total Kcal intake by 500 Kcals.
Followed Obesity Guidelines from NHLBI.

Inclusion Criteria
Age at least 18 yrs BMI: of at least 25.

Exclusion Criteria
Serum creatinine level of more than 1.5

mg/deciliter Hepatic disease Severe,life-limiting medical illness. Inability of diabetic subjects to monitor their own glucose levels Active participation in a dietary program Use of weight loss medications.

Study Results

79 subjects completed the 6 month study,

Low-fat group = 36 low carbohydrate group =43

The low carbohydrate diet group lost more weight than the low-fat group
Mean [+ SD] 5.8+8.6 kg vs. -1.9+4.2 kg,P=0.002

The low carbohydrate diet group had greater decreases in triglyceride levels
Mean -20+43 % vs -4+31%;P=0.001

Study Results, cont

Results, cont
Insulin sensitivity, measured only in those

subjects without diabetes, improved more in the subjects on the low carbohydrate diet than those on the low fat diet.
6+9% vs -3+8%; P=0.01
Serum glucose levels were markedly

reduced in the low carbohydrate diet group compared to the low fat group.

Conclusions
Severely obese subjects with a high prevalence of diabetes or metabolic syndrome lost more weight on the low carbohydrate diet. Overall, there was only a small magnitude of difference in weight loss between the two diet groups, so longer studies are needed to evaluated the impact on cardiovascular disease.

Current Research Evidence

Efficacy and Safety of Low-Carbohydrate

Diets: A systematic review.

Bravata DM et al, JAMA, 2003.

Study Design
Included articles describing adult, outpatient recipients of low carbohydrate diets of 4 days or more in duration, and 500 kcal/d or more (carbohydrate content and total calories consumed had to be reported) 107 articles describing 94 dietary interventions reported data for 3268 participants; 663 received diets of 60 g/d or less of carbohydrate, of which 71 received 20 g/d or less of carbohydrates.

Results
No study evaluated diets of 60 g/d or less for participants with a mean age older than 53.1 yrs. Only 5 studies ( nonrandomized and no comparison group) evaluated these diets for more than 90 days. Among obese patients, weight loss was associated with longer diet duration, restriction of caloric intake, but not with reduced carbohydrate content.

Results, cont
Low carbohydrate diets had not significant

adverse effects on serum lipids, fasting serum glucose, fasting insulin levels,or blood pressure.

Conclusions
There is insufficient evidence to make recommendations for or against the use of low carbohydrate diets, particularly among participants older than 50 yrs, for use longer than 90 days, or for diets of 20 g/d or less of carbohydrates. Among the published studies, participant weight loss while using low carbohydrate diets was principally associated with decreased caloric intake and increased diet duration but not with reduced carbohydrate content.