RD Q&A (vol. 32)

Allegra: Thank you so much for sharing your story. I’ve recently been through a dramatic weight loss of 30 lbs after going to see a nutritionist and I feel great. Everyone asks what my secret is, and it’s really just eating healthier and exercising! (Which is, of course, what we’ve all heard all along and never actually tried!) My question is about relating to people. When I first changed my diet, I was shocked at how unsupportive my friends were. When looking at a menu at a bar one time, a friend tried to cajole me into splitting an order of nachos with her. When I said that I was just going to order a salad, she rolled her eyes and said “oh come on – just do it,” and tried to tempt me. I told her that I had gone to see a nutritionist so I was now trying to eat healthier and she got annoyed. I understand that she was looking for a “partner in crime” for her poor eating habit, but it made me feel guilty for making her feel bad about her choice. I really dislike people that get preachy about food, and I don’t ever want to be one of those people or have people think that I feel superior about my eating choices. How would you suggest dealing with situations like this? I still want to be able to go out to bars and partake socially in activities, but I don’t want my diet to suffer.

Prevention RD: Ah, what a wonderful question and a huge congrats on your weight loss!! Rest assured, you’re not alone in this — it is a very common problem…so common that research has actually been performed on this very topic. Women, when they are together with other women, eat more. When a man is added to a group, regardless of feelings towards a man (stranger, lover, acquaintance…whatever), women all eat less. Willpower is a very hard thing to instill in other people — you have it or you don’t. The other curious thing about willpower is that it ebbs and flows. This is why weight loss and weight gain tend to fall hand-in-hand. The truth is, your friend is jealous. We all know what the “right” thing is to do when eating out, or at the very least how to make healthier choices. Yet, few people do so. I’m not a psychologist and I certainly won’t pretend to be, but your ability to make a choice that is getting you results stirs up feelings in your friend because she isn’t able or willing to do the same at that point in time. I am with you about not wanting to be preachy about food and choices, and when I don’t make the best choices, I prefer not to have the commentary myself. If your friend is not respectful of your choices, go with the route of “this is what I’m craving” or maybe even tell a white lie of, “I had a late lunch” or “I’m just not that hungry”. You shouldn’t have to justify your menu selection to your company so do what you feel most comfortable with. In the end, you have to do what’s best for you and a true friend would want that for you…hopefully she’s just working through some issues of her own and will come around. 🙂

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Sharon: What are your thoughts on the Paleo Diet? I have several friends who are on this diet. I ahve several friends on low-carb diets. I am really tired of people blaming wheat/carbs for weight issues. Aren’t whole grains good for you?

Prevention RD: Sharon, what a great question and I know, without a doubt, some other readers have this very same question. I’m fairly “inside the box” when it comes to nutrition, but I know that we have to think “outside the box” when technology has nutrition has changes as much as it has. Wheat has changed a lot through the years — from the growing to the harvesting to the processing, but I still firmly believe that whole grains not only play a vital role in good nutrition, but are also critical to balanced diet. Whole grains supply B-vitamins, folate, and loads of fiber. Perhaps an organic variety would be preferred due to the changes in wheat, but to blame wheat for the obesity epidemic is absurd, in my humble opinion (though I heard recently that Dr. Oz said quite the opposite — *eye roll*). As for the various diets out there, I truly believe that there is more than one way to skin a cat when it comes to good nutrition. That said, the one diet I refuse to even entertain as healthy is a low-carb diet. Simply put, if you are eating the recommended 5-9 servings of fruits and vegetables daily, you are not following a “low carbohydrate” diet (that is assuming 2-3 pieces of fruit and at least 1 starchy vegetable — you’re looking at 70-90 grams of carbohydrate from fruit and vegetable alone). The DRI for adults is 130 grams of carbohydrate daily and so long as that minimum is being met, I’m open to recognizing a lower-carbohydrate diet as healthy. That said, exercise should be a part of a healthy lifestyle, and additional carbohydrates are necessary to support the nutritional demands of exercise. The Paleo Diet wouldn’t be my pick either (here’s another Q&A post on this topic). Cutting out entire food groups always raises red flags. I hope that helps!

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Lena: My mom is regularly taking her blood sugar but can’t seem to figure out what triggers high numbers in the morning. She can have some smarties before bed and have a low blood sugar or she won’t have any snack and it’s high in the morning. Any insight on how your evening eating habits affect tomorrow morning’s blood sugar levels?

Prevention RD: Hi Lena 🙂 Tell mama not to fret — she should be having a snack before bed, ideally, within an hour of bed time. That snack should contain 15-30 grams of carbohydrate with about 1 ounce of protein (I like to recommend toast and peanut butter, cottage cheese and fruit, cheese and crackers, apple and cheese, trail mix, etc.). Diabetes is very confusing and it is frustrating in that it is a “darned if you do (eat too much) and darned if you don’t (eat enough)” situation. Diabetes is a hormonal disease and over night, hormones do funny things. Plus, we all store a lot of sugar (glycogen) in our muscle and liver that can be released during fasts. High morning glucose levels are very common — encourage her to adopt the habit of a snack before bed that includes the above criteria. Almost every time (assuming the treatment regimen is appropriate), this snack resolves those high morning numbers. 🙂

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Tonya: I’ve got one for my fellow dietitians. This is a patient so I will be fairly vague. Elderly (60+) hospice patient with COPD and 85% of his gut removed. This includes about 30% of his colon — he does not have a colostomy. He has severe nausea and vomiting with meals. He refuses a DNR. A J-tube is what we are thinking with an elemental formula. Thoughts/suggestions?

Prevention RD: Hi Tonya, my dear Oklahoma dietitian friend! I love this question because it perfectly showcases all that RD’s are able to do. I agree with your approach 100%, despite it being invasive and expensive. To walk through the scenario, the patient clearly has will to live and live well, so measures should be taken to preserve his strength and improve his recovery process. Sixty is the new 40, right?Many people don’t realize that nutrition and COPD alone can be reason for concern. Many people who struggle with shortness of breath struggle to eat. A satisfied stomach can decrease lung capacity and smaller, frequent meals can be offered. Furthermore, chewing/swallowing can be difficult while short of breath and so many COPD patients lack appetite as it is. The colon is responsible for fluid removal and is the organ that solidifies stool for removal. Without a colon, malnutrition and diarrhea are common struggles. For this reason, in addition to the fact that the patient lacks any substantial amount of small intestine whose main function is absorption of nutrients, an elemental tube feed formula would alleviate the need for the gut to breakdown food components to derive their nutrients (elemental tube feedings contain readily available glucose, amino acids, and medium chain triglycerides versus polysaccharides, proteins, and fats that require breakdown into their “elements” before being absorbed into the bloodstream). The tube placement in the jejunum versus the stomach (which the patient may or may not have) or duodenum (the first portion of the small intestine) decreases the risk of nausea and vomiting. You could try a standard tube feed before going elemental to rule that out as an option. I only say that because elementals are SO expensive. My hunch is that an elemental will be the end result, however. A high-fiber, lower carbohydrate formula may help reduce diarrhea and CO2 levels. Great question – thank you…can’t wait to hear what others think as I certainly do not specialize in GI!

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TGIF! This week has been crazy busy….I’m ready for some R&R over the holidays! After work, it’s on to holiday baking 🙂

Be well,

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7 Comments

  1. December 14, 2012 / 6:49 am

    I completely sympathize with Allegra. I think so many people want to lose weight, but they don’t have the motivation/self-control, and when they see that their friends are doing it, they get jealous. Period. And they try to sabotage (they may or may not know they are doing it, but either way it’s hurtful and difficult to deal with). You answered the question well.

    I really want to get my CDE. I need to understand insulin and diabetes better. I love it more and more each year! Also, we are getting DSME certified at our store (Diabetes Self-Management Ed) and that means I’ll get to have a pharmacist come in to discuss meds and insulin. I’m such a nerd because I can’t wait!

    • Nicole, RD
      Author
      December 14, 2012 / 7:09 am

      I am sitting for my BC-ADM next week because I’m just not accruing enough hours for the CDE. They make it so hard — you pretty much have to work with diabetes exclusively all day (or something like 15 hour a week, which is a lot!). Anyways, let me know if you need anything…our program is DSME certified and approved by Medicare and Medicaid. I haven’t mentioned anything on the blog about it, but I was recently given responsibility of the entire hospital diabetes program, so that’s VERY exciting! Gina, we ARE nerds 😉

  2. December 14, 2012 / 9:00 am

    I love these RD Q&A posts! Tonya, do you know how much of the small bowel your patient has left? If it’s less than 150 cm (indicating short bowel syndrome) and depending on how long ago your patient had the resection, he might need long term TPN in conjunction with an elemental enteral feed. There are 3 different post-op phases in which the small intestine can adapt and increase absorpotion – TPN w/enteral feeding is recommended for the first two. It’s my understanding that you do the enteral feeding to stimulate the GI tract to adapt and the TPN to provide most of the calories in the meantime. You could also recommend consulting GI for your patient too if it hasn’t already been done – I know you said your patient is a hospice patient, so I’m not sure if that would change the course of treatment. I’ve had a few experiences with these types of patients, so I’ve done lots of research within the past year or so. Hope that helps!

  3. Jenn
    December 14, 2012 / 11:41 am

    Funny the Paleo diet should come up! My boyfriend and I just had a rather lengthy discussion about it after some of his coworkers mentioned being on it. I’ve often read that it takes your body much longer to digest meat and that it has to work harder to digest it than with vegetables. So it concerns me that the diet is so high in meat. Also, it’s based on a lifestyle we no longer live. If we were still spending the energy to go out and hunt and gather our food, maybe it would be a good approach. Not a medical opinion, just a personal one. 🙂

  4. STH
    December 14, 2012 / 3:32 pm

    One thing that I think confuses people is that the quality of the carbs you’re consuming matters a lot. If you’re loading up with highly processed carbs and sugar, you aren’t going to be well-nourished and you’ll consume lots of calories! But I think people make a leap from that to “carbs are evil,” which is not at all true.

    And a bit of anecdata: my sister, who’s on a pretty extreme no-carb diet (no dairy, no fruit, no starchy veg–Nicole was kind enough to answer my question about it in a previous Q and A) did initially lose a lot of weight, 80 pounds or so. But now her weight has stabilized with about 50 or 60 pounds to go. I find it pretty ironic that she’s put herself through all this misery for almost two years (and has pressured me to go on the diet, too), is missing out on all this good, healthy food and has ended up the same size I am.

  5. December 15, 2012 / 12:15 am

    Nicole – does your cookbook feature a Q&A session? If it doesn’t, you should really consider it with your next one. It really does highlight all you do and who you are.

  6. Heather
    December 16, 2012 / 10:12 am

    Tonya-You should consult with Jen if you haven’t already. She’s been great to help me with my TF pts:)

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