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Nutrition in Obesity Medicine
Sarah DeLuca, MSPAS, PA-C
PA Foundation Nutrition Outreach Fellow

August 21, 2023

After completing additional training from AAPA for the Obesity Medicine in Primary Care Certificate and the Advanced Training in Obesity Medicine from The Obesity Society, I really wanted additional training to make nutrition a focus in my discussions with patients about their health and management of chronic diseases. The PA Foundation’s Nutrition Outreach Fellowship has allowed me to expand my knowledge and incorporate nutritional recommendations at nearly every patient visit.

Obesity is a chronic progressive disease affecting 108 million U.S. adults as of 2019.1 It is linked to the development of hypertension, diabetes, hyperlipidemia, and cancer, in addition too many other chronic diseases. Obesity is defined by the World Health Organization as a BMI of greater than 30.2 Through additional training, I have learned about another obesity staging system, which in my opinion gives a better prognostic indicator for management and treatment, called the Edmonton Obesity Staging System (EOSS). The EOSS characterizes BMI in addition to obesity-related risk factors, physical symptoms, psychological symptoms, and functional limitations.3 Using either system to diagnose and treat obesity is important in order to prevent further chronic diseases from developing as well as managing established chronic diseases. Once a diagnosis is made, management with lifestyle modifications and/or medication is recommended, as with many other disease states.

There are many approaches to discussing someone’s diet or recommending behavior change. Below is a checklist to help guide productive patient encounters when addressing weight and dietary intake.

  1. Ask the patient permission to discuss their weight: This helps open the conversation about weight and dietary intake.
  2. Assess readiness for change: Use the Transtheoretical Model of Behavior Change and apply it to diet.4
  3. Use a 24-hour dietary recall: This tool provides a picture of how often someone eats, what drinks or foods someone consumes, frequency of eating and snacking, and intake of prepared meals versus fast food. It gives the provider an idea of average calories consumed, as well as information to assess protein, carbs, and fat consumption.
  4. Give specific recommendations and modifications in diet: Provide handouts or write out dietary modifications as a reminder to patients of specific changes they can implement.
    • High-protein foods: Suggest beef, chicken breast, pork, fish, beans/legumes, eggs, nuts, and plain Greek yogurt (serving size: deck of cards, 3-4 ounces of meat, size of palm).
    • Complex carbs: Recommend peas, sweet potatoes, potatoes, whole wheat pasta, whole wheat bread, chickpea pasta, beans, quinoa, wild rice, oats, lentils, (serving size: ½ cup of rice, 1 cup of potatoes). Complex carbs are higher in fiber and protein, keeping you fuller longer. Ideal dietary fiber intake is 25-30 grams a day.
    • Smart snacking: Give ideas for balanced snacks that pair proteins and carbohydrates together (cheese or peanut butter with an apple, boiled egg with avocado, hummus and vegetables, cottage cheese and fruit). This helps avoid sugar spiking and also provides more satiety.
    • Limit intake: Encourage patients to limit intake of dried fruits, processed foods with added sugar, and sugary beverages.
    • Foods high in zinc: Suggest oysters, dark meat chicken, pork chops, lentils, oatmeal, mushrooms, tofu, pumpkin seeds, beef, and low-fat yogurt.
    • Foods high in vitamin C (remember red, orange, green): Recommend guavas, bell peppers, oranges, broccoli, green beans, snow peas, kiwi, strawberries, tomatoes, papayas, and kale.
  5. Recommend small changes first: Suggest making food changes at one meal or setting a goal of decreasing fast food consumption to once a week, versus every day. Then continue to make goals of starting to include new recommendations into your patient’s diet.
  6. Make sure recommendations are cost effective: Take into account someone’s budget for food. As we continue to see grocery prices increase, fresh produce and proteins may be challenging for a patient’s wallet. Frozen and canned vegetables and fruits are cheaper than fresh but can still provide adequate micronutrients. Recommend certain discount grocery stores for cost savings if needed.
  7. Learn how to interpret a food label: Interpreting a label can sometimes be confusing. Help the patient understand the difference between calories, fat, sodium, carbs, sugar, fiber, protein, and micronutrients on a food label.
  8. Schedule follow-up appointments to re-address diet: This is helpful if there is not enough time during a visit to fully discuss dietary intake and recommended modifications or to reassess dietary changes made. Scheduling a follow-up visit creates a mechanism for accountability.

Make nutrition a priority as part of your patient care plan. Changes in dietary intake can make a world of difference for patients in the management of obesity and other chronic diseases.

References
  1. Jaacks, L. M., Vandevijvere, S., Pan, A., McGowan, C. J., Wallace, C., Imamura, F., Mozaffarian, D., Swinburn, B., & Ezzati, M. (2019). The obesity transition: stages of the global epidemic. The lancet. Diabetes & endocrinology, 7(3), 231–240. https://doi.org/10.1016/S2213-8587(19)30026-9
  2. World Health Organization. (n.d.). Obesity. World Health Organization. https://www.who.int/health-topics/obesity#tab=tab_1
  3. Padwal, R. S., Pajewski, N. M., Allison, D. B., & Sharma, A. M. (2011). Using the Edmonton obesity staging system to predict mortality in a population-representative cohort of people with overweight and obesity. CMAJ : Canadian Medical Association journal, 183(14), E1059–E1066. https://doi.org/10.1503/cmaj.110387
  4. Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American journal of health promotion : AJHP, 12(1), 38–48. https://doi.org/10.4278/0890-1171-12.1.38