The complete guide to nutriton in primary care

COMPLETE GUIDE TO

EDITED BY

Darvvin Deen, MD, MS

Lisa Hark, PhD, RD

Blackwell

Publishing

I

The Complete

Guide to Nutrition

in Primary Care

Edited by

Dan/vin Deen, MD, MS

Proíessor of Clinicaỉ Family and Social Medicine

Department of Family and Social Medicine

Albert Einstein College of Medicine, New York

www.drdeen.com

Lisa Hark, PhD, RD

Director, Nutrition Education and Prevention Program

University of Pennsylvania School of Medicine

www.lisahark.com ----------------- ■_

Ể ^ k Blackwell

Publishing

c 2007 Bìackv/ell Publishing Ltd

Black well Publíshing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA

Blackwell Publishing Ltd, 9600 Garsington Roađ, Oxtord 0 X 4 2DQ, L'K

Blacku ell Science Asia Pty Ltđ, 550 Swanston Street, Carlton, Victoria 3053, Australia

The nght cứ the Author to be identìried as the Author of this VVork has been asserted in accordance

with the C opvnght. Designs and Patents Act 1988.

All nghts reserved. \ o part of this publication m av be reproduced, stored in a retneval svstem.

or transmitteđ, m anv form or bv anv means, electromc, mechanical, photocopving, recordins or

other.\*ise, except as permitted bv the L'K Copvright, Designs and Patents Act 1988, without the

pnor permission of the publisher.

First published 2007

1 2007

Librarv of Congress Cataloging-in*Publication Data

The >w ...........on in prim arv care edited bv Danvin Deen, Lisa Hark

f ỉI -

ĩiiđuurr. ,• _ reíerences and index.

ISư.. í-......................... -6 íp b k .: alk. papen 1. Diet therapv. 2. Nutrition.

1.1-)«-“<• 1, I Lisa.

[Da l .vi. j . . \ u m n o n inerapv. 2. N u tn tìo n . 3. Patient Education - m ethods.

4. P n m a rv Health Care. \VB 4CKj C737? 2007]

RC216.C666 2007

615.^ 54 - dc22

2006027576

ISBN 97-S-l -4'!’? 1 -0474-6

A catalogue record íor this tntle 1S available íTom the Bntish Librarv*

Sct in 9." 12 Palatinu bv A ptara Inc., \ e u - Delhi. India

Pnnted and bound in Singapore bv Fabulous Printers Pte Ltd

Commissioning Editor: Vicki \ o v e s

Eđitonal As>ií-tant: Robin H a m e ĩ

Developmtnt Editor: Lauren Bnnđlev

Production ContrnỊỊer: Debbie \\ver

For rurther ìm orm ation on Black-.vell P u b h íh in g . uur website:

h t tp : bl a c k ] p u b 115 h m £. o_’ m

The pubhsht-r f pulic\ li? to UH' p e r m a n tn ỉ p a p e r rrom miils that operate a sustainable tortr-rr.

pnlicv and v.-hich ha> been iran u ra ctu red rrom p u lp proce->sed using aciđ-lret: and elem entarv

chlonnc-rrev pracuce-. Furthẽrmore. the pubỉishtrr en^ures that the text paptr and cover tva rđ

UH-đ ha', tr mnrt accertabìe rnvirorrr.trntal accređỉtatior Standard^.

BltKkv.-L-iỉ P u b h -h ir.í rr.akt^ n.> rerrc>er;arji.T! e x p r e ^ OT im p h cđ . that the đ r u g đo>a£e> in th 15

book aĩK' corrt-ct Rea rr.Uít thereíV-re ahvavs cbeck that anv p ro d u c t m entioneđ in this p ’jb -

iication li-cd :r a;:« ■rò.ĩrvTc v.-;th :ht- rrtrrcnbir.s irữ orm anon p rep ared bv the m a n u ía c tu re rs

The đutbvr arđ rurii-rcr^ d>'- r.‘ ■: â:ct-rt r<L-?ror.s:c;ì:t\' Oĩ ỉe^al habilitv for anv errors in the

tt-xt nr tí<r ứ V - >r m-iapplicar.i -r li: rrừter.âl ;n tbij K>ok.

Contents

Editors, vii

Contributors, viii

Preíace, xi

Section 1 Nutrition as preventive medicine

1 Nutrition and the primary care clinician, 3

Danvin Deen and Kữtherine Mar^o

2 Changing the office culture to make it work, 15

Arỉo Kahn and Ịane White

3 Methods of vveight control, 31

Cathy Nonas, Ịemiifer Vỉiỉỉiams, and Vaỉentine / Burroughs

Section 2 Nutrition through the life-cycle

4 G ro w in g u p healthy, 57

Susan Konek and Dianc Barskỵ

5 Feeding the mother-to-be, 85

Ịames M Nicholson, Catherine Suỉlivan and Morghan B Hoỉt

6 Staying healthy in later life, 109

Connie Watkins Bales and Heidi K White

Section 3 Improving health by changing diet and

lifestyle behaviors

7 Dyslipidemia, hypertension and metabolic syndrome, 135

F ran CCS Burke and Philippc Szaparỵ

8 D iabetes, pre-diabetes and hypoglycemia, 161

Morion I Franz and Richard Vỉender

9 Gastrointestinal disorders, 179

Marianne AIoupis and Tììonms Faust

10 Everything else, 201

Marion Vcttcr and Katìỉcrinc Chaunccy

vi Contents

Section 4 Vìtamins, minerals, supplements

and alternative nutrition

11 V itam ins, 223

Randee Sỉlverman and Ịeremy Brauer

12 Minerals, 249

Randee Siỉverman and Ịeremy Brauer

13 Dietary and nutritional supplements, 275

Ịoeỉ s Edman and Eliiabeth Horviti

14 Considering the altematives, 293

Benịamin Kỉigler, Ịoel s Edman and Mary Beth Augustine

Section 5 Successtul changes to the environment

15 It7s all about changing behaviors, 311

Darunn Deen and Aỉice ĩornari

16 CornrniiniHr 327

ì' •

'dí «. j;>: ........ ations, 341

; ■ harles B Eaton

Appendices, 365

Revievv questions, 385

Revievv answers, 428

Index, 435

Editors-in-Chief

Darwìn Deen, MD, MS

Professor of Clinical Family and Social

Medicine

Department of Family and Social

Medicine

Albert Einstein College of Medicine

Bronx, New York

Lisa Hark, PhD, RD

Director

Nutrition Education and Prevention

Program

University of Pennsvlvania

School of Medicine

Philadelphia, Pennsylvania

Associate Editors

Jeremy Brauer, MD

Nutrition Education and Prevention

Program

University of Pennsylvania

School of Medicine

Philadelphia, Pennsylvania

Frances Burke, MS, RD

Clinical Dietitian Specialist

Cardiovascular Risk Intervention Program

University of Penn Health Svstem and

Nutrition Education and Prevention

Program

University of Pennsylvania

School of Medicine

Philadelphia, Pennsylvama

Elizabeth Horvitz, BS

Nutrition Education and Prevention

Program

ưniversity of Pennsylvania

School of Medicine

Philadelphia, Pennsylvania

Randee Silverman, BSN, RN

Senior Research Coordinator

University of Pennsylvania Health System

Philadelphia, Pennsylvania

■ •

vi ỉ

Contributors

Maríanne Aloupis, MS, RD, CMSO

Clmical Dietitian 5peoalist

CLinicai Nutntion Support Service

Hospital of the Universitv of Pennsvlvania

Philadelphia. Pennsvlvarua

Mary Beth Augustine, RD

Clinical Oietitian

Continuum Center for Health and Healing

Beth Israel Medicai Center

New York, N ew York

Connie WatkJns Bales, PhD, RD

Assođatp ' V

Durha.on ’

Associ^tí-" '

oí Gf?i Mi'> if

Duke Ui.LÚc'^'*' .......................ìter

Diufi.ir.Ji. V. 1; _____

Diane Barsky, MD

Assistant Proressor oí Pediatrics

Umversitv of Pennsvlvarúa School of Medicine

Attendins Phvsiãan

—' -

Division of Gastroenterolo^v and Nutrition

Chilđren'3 Hospital oi Philadelphia

Phiỉađeỉphia. Pennsvlvania

Jeremy Brauer, MD

Nutritior. Educatior, and Prever.rion Prosrarr,

Universitv oi Pennsvỉvania

School of Mediar:t

pnila d e] r h: a . Pennsv ì v a ria

Frances Burke, MS, RD

Valentine J Burroughs, MD, MBA

Chieí Medical Officer

Chairman, Department of Medidne

N‘orth General Hospital

N ew York, N ew York

Katherine Chauncey, PhD, RD, FADA

Associate Proíessor

Department oí Familv and Comiĩiunin- Medicne

Texas Tech School of Medicine

Lubbock. Texas

Charles B Eaton, MD, Ms

Proíessor of Farm]v Medicine

BrouTi Universitv

Proũdence; 2 nd

Director, Heart Disease Prevention Cliruc

Nlemorial Hospital oí Rhode Island

PaT.\'tucket, Rhode lsìand

Joel s. Edman, DSc, FACN, CHS

Dưector of Integrative Nutritìon

Clinical Assistant Proíessor

Mvma Bnnd Center oi Intecrative Međicme

Thomâs íeồerson Universitv and Hospital

Philadelphia. Pennsvlvania

Thomas Faust, MD

Assistant Proíessor of Medicine

Division oi Gastroenterolo^v

Universitv of Pennsvlvaiua Health Svstem

Philadelphia. Pennsvlvania í ,

Alice Fomarí, EdD, RD

.A-SSOÓaté Proíes&or of Familv and SocLal MeáicLT.

Dừector. Medica! Education

Derartmer.í oi Famiỉv and Social Međicir.c 1

Aìberí Einsteữi College oi Mediane

Bronx. N e .% York

M a r io n J F r a n z , Ms, RD, LD, CDE

Presiđer.t

V-mticT. Ccncept bv Franz. Lnc.

M -

Mir.r.earoliĩ. Mmnesota

Contributors ix

Kim M Gans, PhD, MPH, LDN

Associate Proíessor of Community Health

Deputy Directory

Institute for Community Health Promotion

Brovvn University

Providence, Rhode Island

Morgan B Holt, MD

Department of Fami]y Practice

and Community Medicine

University of Pennsylvania

School of Medicine

Philadelphia, Pennsylvania

James M Nicholson, MD, MSCE

Assistant Proíessor, Department of Family

Practice and Community Medicine

University of Pennsvlvania

School of Medicine

Philadelphia, Pennsylvania

Cathy A Nonas, MS, RD, CDE

Director, Diabetes and Obesity Programs

North General Hospital

N ew York, New York

Randee Silverman, ĐSN, RN

Senior Research Coordinator

Urũversity of Pennsylvania Health System

Philadelphia, Pennsylvania

Elizabeth Horvitz, BS

Nutrition Education and Prevention Program

ưniversity of Pennsylvania

School of Medicine

Philađeỉphia, Pennsylvania

Arlo Kahn, MD

Proíessor of Family and Preventive Medicine

University of Arkansas for Medical Sciences

Little Rock, Arkansas

Benjamin Kligler, MD, MPH

Co-Director, Fellowship Programs

Continuum Center for Health and Healing

Beth Israel Medical Center and

Associate Proíessor of Family and Social Medicine

Department of Family and Social Medicine

Albert Einstein College of Medicine

Bronx, Nevv York

Kathryn M Kolasa, PhD, RD, LDN

Proíessor

Nutrition Services and Patient Education

Department of Familv Međicine

Brody School of Medicine at East Carolina

University; and

Nutrition Consultant

University Health Systems

Greenville, North Carolina

S u s a n Konek, MA, RD, CNSD, LDN

Inpatient Clinical Nutrition Manager

Childrens Hospital of Philadelphia

Philadelphia, Pennsylvania

Katherine Margo, MD

Pre-Doctoral Director, Department of

Pamily Practiceand Community Medicine

University of Pcnnsvlvania

School of Medicine

Philadelphia, Pennsvlvanid

Catherine Sullivan, MPH, RD, LDN,

IBCLC, RLC

AÔHliate Faculty, East Carolina University

State Breastíeeding Coordinator

Nutrition Services Branch

Division of Public Health

North Carolina Department of Health

and Hu man Services

Raleigh, North Carolina

P h ilip p e Szapary, MO, MSCE

Cardiovascular Risk Intervention Program

University of Pennsylvania Health System

Philadelphia, Pennsylvania

Marion Vetter, MD, RD

Endocrine Fellow

Division of Endocrinologv, Diabetes and

Metabolism

University of Pennsylvania

School of Medicine

Philadelphia, Pennsylvania

Richard Wender, MD

Alumni Proíessor and Chair

Department of Family and Community Medicine

Thomas Jefferson Universitv

Philadelphia, Pennsylvania

Heidi K VVhite, MD, MHSc

Associate Proíessor of Medicine

Duke University School of Medicine

Durham, North Carolina

X Contnbutors

Jane V White, PhD, RD, FADA, LDN

Proíessor, Department of Fami]v Medicine

Graduate School of Mediane

Lmversitv of Tennessee

Knơxville, Tennessee

Jennifer Williams, MS, RD, CHSO

Senior Clmical Dietitian Speciahst

Universitv of Pennsvlvarua Health Svstem + + m

Philadelphia, Pennsvlvama

Preíace

For the past 15 years, we ha ve devoted our respective careers to educating

medical students, physicians, and other healthcare proíessionals about the im￾portance of nutrition for the prevention and management of chronic diseases.

Medicaỉ Nutrition and Disease, Dr. Hark's first book for students is now in its 3rd

edition and is one of the most vvidely used nutrition texts for medical, nursing,

physician assistant, and dietetic training programs across the country. Frus￾trated by the lack of sound, common-sense nutrition resources for patients

and consumers, we collaborated on Nutritỉon For Life, which is now published

worldwide in 10 languages.

For years, we have been encouraged by our peers to develop a quality text

for practicing proíessionals who have told us that their training in nutrition

was inadequate. Thus, we created The Complete Guiảe to Nutrition in Primary

Care, which is aimed at health proíessionals working in the primary care setting

and registered dietitians. We believe that the primary care environment o£fers

optimal opportunities to impact patients' diet and liíestyle behaviors on a daily

basis. The Complete Guide to Nutrition in Primary Care was developed using a

multidisciplinary approach and provides accurate, scientiíically sound, and

much needed, practical iníormation for primary care clinicians to effectively

counsel patients. Contributors include well-known nutrition experts who are

physicians, nurses, and registered dietitians from each discipline.

The book begins vvith case vignettes that serve as examples of how to provide

brieí nutrition counseling in the office setting. Next we discuss how to change

the office culture to successíully incorporate nutrition into everyday practice.

VVith obesity and diabetes increasing morbidity and healthcare costs, we íocus

on various methods of vveight control, inclưding diet programs, surgery, and

the latest advances in medications.

Part 2 addresses nutrition throughout the liíecyele, covering requirements

and recommenđations speciíic to children, adolescents, pregnant and lactating

women, and older adults.

Part 3 reports on ways to improve diet and liíestyle behaviors when treat￾ing dyslipidemia, hypertension, metabolic syndrome, diabetes, hypoglycemia,

GI disorders, urinary tract iníections, kidney stones, chronic kidney disease,

nutritional anemias, and patients who are HIV positive.

Part 4 includes up-to-đate iníormation about vitamins, minerals, and dietary

supplements, including both evidence-based íindings and opinions based on

clinical experiences. We also provide some paradigm-challenging dietary pro￾tocols to be considered as part of a complimentary and alternative medicine

approach.

xii Preíace

Finallv, Part 5 encompasses wavs to implement all the knouiedge and skills

to successíullv rnodiív a patient's behavior. VVith the ever-grcnving multicul￾tural population in the us, it is crucial to expand cultural competence bv un￾derstanding and appreciating the iníluence of culture on diet and liíestvle

behaviors. \Ve can make an even greater impact bv becoming involved in our

communities to advocate for healthv behaviors in schools, resources for active *

neighborhoods, and reimbursement for nutrition and preventive services.

ỉn conclusion, The Complete Gưide to Nutrition in Primary Care provides the

tools to assist vou in helping vour patients achieve a healthv lifest\rle. Through

role modeling, eating a healthv diet, leading an active lifest\;le, and advocating

for these behaviors in vour practice and community, vou can produce meaning￾ful changes in vour patient's liíestvle. Help vour patients bv being supportive,

understanding, and above all, setting a good example. Talk to vour patients

about their diet, emplov a registered dietitian in vour oííice, and vvrite exercise

prescriptions everv dav.

For more míormation about us:

Darvvin Deen, MD, MS (vvww.DrDeen.com)

Lisa Hark, PhD, RD (www.LisaHark.com)