For something as fundamental to human existence as feeding oneself, it’s astonishing how poorly the basic concepts of nutrition and health are understood. In a world of fast food and even faster-paced work environments, taking the time to think about what’s being eaten and its potential long-term consequences is often lost in the shuffle, with deleterious results for our national health. But eating right doesn’t have to be hard or boring, say medical professionals, but it does need to be done.
What will spur someone needing to go see a dietitian or nutritionist? Gudrun Novak, Sarasota Memorial HealthCare System and Health Fit: We cover nutrition counseling for heart disease, diabetes, weight loss, gastrointestinal problems and food allergies. Those are probably the big ones. Pamela Strouhal, Doctors Hospital of Sarasota: I’m in-patient clinical, so I have more tube feedings, TPNs and nutritional support, as well as a lot of wound patients – people who need to be fed through tubes through their stomach or their veins, people who have wounds down to their bones. So when you’re already malnourished, I’m there to get that process going, while you’re more preventative. Novak: Right. Or if someone’s been discharged from the hospital with malnutrition, they’ll follow up with me to make sure they’re continuing to improve.
What is the difference between the nutritional needs of a body maintaining and a body in repair? Strahoul: Yes. It depends on what the medical issue is for that specific patient. If they’re diabetic and have a wound, my goal is to not only teach them about healthy eating and carbohydrate counting and not skipping meals and checking blood sugar, but it’s also about teaching them nutrition for wound healing and making them understand that if they don’t keep their blood sugar under control, they’re not going to heal and they’re going to continue to get more problems. For someone that can’t swallow, we usually end up giving them food texture changes or they’re fed through a tube. A patient under a lot of stress needs more calories, a patient on a ventilator needs less. Nutritionally speaking, what intervention can I do to help that patient improve during their stay. Dr. Chippy Nalluri, Sarasota Memorial Hospital: I’m treating generally cardiology patients, so I incorporate a lot of nutrition into my practice because it’s fundamental to not just disease prevention, but secondary prevention, meaning if you’ve already had a heart attack I spend a lot of time talking to my patients about what they need to do lifestyle-wise so they can dramatically reduce their risk of heart disease. I also let patients know it’s a full body nutrition. We’re not just about preventing heart disease, but stroke reduction, reduction in risk of cancer, improvement in arthritis and mobility and improvement in depression. It’s really a more comprehensive approach.
When people think of diet, they make immediate connections to cardiovascular health and weight, but the effects seem to run the gamut. Nalluri: I approach it on a scale of wellness. When people come in and hear me say diet, they think “I have to lose weight.” This discussion has absolutely nothing to do with your weight. Weight is going to be a secondary factor, even a tertiary factor; the primary goal is to give you vitality. It’s about healthful living, vitality, energy and not being in pain. You can get to patients that way. Everyone wants to have energy. Strouhal: It’s a lifestyle change.
Lifestyle changes are difficult. What have you found to be effective methods of keeping patients on track?Novak: Quite often I have to assess what their symptoms are and their energy level. Getting them to focus on weight is not motivation enough. Once they start recognizing how much better they feel and they have improved energy and sleep, those are the things that seem to really motivate people. I start where they’re at, and in my assessment I ask questions about their quality of sleep and stuff like that because those are the things I can tap into as far as motivating factors.
In the media, we’re constantly barraged by bold and sometimes contradictory claims. One day X is good for you, the next it’s the worst thing you can eat. What are the gold standards that you can hang your hat on as nutritionists? Nalluri: There is an absolute central theme, and that theme is nutrient in relation to calorie. You need to eat foods that are incredibly high in nutrient and lower in calorie. There’s absolutely no data out there that says if you eat fruits and vegetable, it’s bad for you. It’s that fundamental. There is unfortunately an incredible amount of poor data out there, and conflicting information for the general public. There are weight loss clinics, pills, shakes – various things that are offered unfortunately to individuals who are vulnerable. You need to focus your diet on vegetables, fruits unprocessed foods. You need to focus on the intake of processed sugar and reduce that. Reduce intake of bad saturated fats and trans fats and gear your diet towards fruits and vegetables. It’s really that simple. Strouhal: What I find is that people have a hard time making that change, so I tell them to take baby steps. You can’t make all these changes all at once. Start with replacing a cake or ice cream dessert every night with a healthier dessert such as a fruit. Take those baby steps, and once you have mastered that then you can go to the next step of choosing high-nutrient fruits and vegetables, making sure you’re getting your fluids in and making sure you’re getting your fiber. All of those will eventually stack up, one after the other, until you’ve mastered all of them. It’s a learning process. I tell people to cut back on the salt and they don’t want to. They love salt. So I say just do it for a month and then eat something with salt and you’ll see that you won’t like it anymore. It’s the same with the fruits and vegetables. It’s a process and you learn it. Novak: The plant-based diet is the golden rule. You need to eat fruits and vegetables and whole grains. I have a lot of clients who eat out every day, so again baby steps. Maybe bring your lunch from home three days a week. If I can get them eating foods prepared at home, then hopefully they’re getting away from some of the processed food. Nalluri: The process is simple, but as these guys know, the implementation is extremely difficult. People probably have an easier time to stop smoking than to fundamentally change their diet. That’s where dietitians and healthcare coaches come in. Unfortunately, not many physicians make this a big part of their practice. Part of this is practicality, but we really need to, as a society, make this change happen. Now the data is that 90 percent of our calories in the average American diet comes from processed foods. The average American eats 30 teaspoons of sugar a day. We are creating disease. What people don’t understand is that what you eat either expresses disease or it suppresses disease. People don’t realize that. They think it’s about weight and that’s it. Strouhal: It comes down to motivation and encouragement. See how you feel when you eat like this, then see how you feel when you eat like this. Tell me which one felt better. And I tell them that it’s not about a number on the scale. You can be overweight and be eating healthy foods, and you’ll find that the more healthy foods you choose, you can eat so much more. Novak: One of the things I focus on is the mindless eating habit. A lot of people just don’t think about what they eat when they’re eating. They’re not in the moment. It’s so important when you have a snack or a meal that you’re not watching TV or driving your car. When you look at other cultures, like the Mediterranean cultures that have very little heart disease, it’s not just what they’re eating, but how they’re socially engaged with family, and activity level.
What’s the greatest mistake or misunderstanding you see patients fall into? Nalluri: There’s a lot of misconception about ‘calories in equals calories out.’ I’ve had people tell me they eat 600 calories a day, and it’s absolutely ridiculous. It’s the type of food that matters. It’s the foods that are nutrient-rich – that’s where health comes in. This concept of calories is such a myth. Yes, if you reduce your calorie intake and you exercise – calories in versus calories out – then you will lose weight. The problem is that once people come off that plan, then there’s a weight regain, a rebound. No one sticks to it, because you cannot sustain yourself on 1,200 calories a day. It’s just not healthy. It’s very important for people to understand that you have to focus on the type of foods. You have to change from processed foods to healthful foods. I encourage people to try to incorporate 5-7 colors a meal and that takes effort, because you have to incorporate a multitude of different food types. And not to count your calories. You will find that if you’re eating these healthful foods, you actually eat a ton more. You eat more and you may end up eating more calories, but these are calories that will not cause diabetes, but will improve your insulin sensitivity, reduce blood pressure, improve appetite in a good way.
How important is timing? If you’re eating healthy, is it still important to stretch it out over the day, or can one big meal suffice? Nalluri: You have to eat, and you can’t get all your calories in one meal. Strouhal: You can’t. You need to eat several – 6-8 feedings a day to get it in there. It helps you digest your food better too. If you don’t have this big [mass] sitting there, you can actually digest your food, move on, have a nice healthy snack, move on, have something else. Your body is breaking your food down all day instead of all at once.
So is the three-meal system we’ve adopted not the optimum arrangement? Nalluri: You could do three meals. Here’s the thing – if you eat nutrient-rich foods, you actually cannot physically eat that amount in one meal. You can only eat so much, and that food is processed so incredibly well in the body and the protein you eat is incorporated so well that you will in fact be hungry so you want to eat again. The issue that people are not understanding is that when you’re hungry and you want to eat, you’re not going to gain weight, you’re going to lose weight because it’s nutrient-rich foods. If you do change from processed foods to nutrient-rich foods, you actually find that you cannot eat one meal a day. You will go hungry the rest of the day, and that’s not a healthful way of being. You want to continually give your body good nutrients. Strouhal: The other thing is, if you eat one meal a day, what ends up happening is that you’re starving later on, so you grab whatever’s there, doesn’t matter what it is, and you eat the bad stuff. Novak: I’ve had clients come to me eating a meal a day and saying they’re not hungry. Then when I finally get them to eat more often, it’s almost like their brain turns on again and they become more in-tune with their hunger cues and their satiety cues, and over time they become hungry when eating more often. It’s these high volume-low calorie foods, the nutrient-rich foods. You’re eating a large amount of food, but when you compare the calories of all those fruits and vegetables to fattening food, you’re getting fewer calories but more volume, so you do have to eat more often.
How do you define success with a patient? Nalluri: They come off their drugs – they come off their blood pressure pills and cholesterol pills. Obviously if they have heart disease then I continue to see them, and there are some drugs that you can’t take them off of, but people who don’t have a defined heart disease, I’ve had individuals who got rid of their arthritis, completely came off of their blood pressure medications, cholesterol medications and many that come off of their insulin because they change their diet. It’s such a fundamental concept – diet is health. You can eat food as a medicine, or you can eat to create disease. That’s a concept we’re going to have to stress again and again – food is medicine. Almost percent of adults in America are either overweight or obese, and by 2048 we expect 100 percent of the American population to be either overweight or obese, if this trend continues.
How do we turn back this tide? Nalluri: At Sarasota Memorial, we are very excited to bring in the Dean Ornish program, a scientifically-proven program. Back in 2010, the science behind it was so strong that Medicare actually approved implementation of this program for individuals with defined heart disease. We are bringing this program into Sarasota Memorial for our community at large. It is a program designed towards change in nutrition, stress relief techniques and teaching people how to eat. We actually take them to the grocery store and teach people how to eat. We have yoga instructors, stress management counselors and exercise physiologists who will go through a program of exercise, diet, yoga and meditation. For us, as a hospital, to do preventive measures is so exciting, and we’re moving in the right direction. Novak: Taking advantage of the programs that we have and will have. We have diabetes education, we have outpatient nutrition counseling, we’re going to have the wonderful Dean Ornish program, and those are venues where patients can get a wealth of information and learn skills to change behavior. Unfortunately, they’re not always taken advantage of.
Fad diets pop up all the time and usually center around removing one thing from the diet entirely or devoting oneself to that thing. Is there any food or drink that you would be on board with everyone just cutting out, something that you don’t see the value in, only the harm? Nalluri: Fruit juices. Unfortunately people think that it’s healthy, and it’s just a nutritionally deficient sugar and water formulation. Ounce for ounce, orange juice has more fructose than Coke. Novak: I would say sodas, but I put fruit juice as the equivalent to soda. So, regular sweetened soda? No. Strouhal: I like to not overwhelm people, and say, in general, to eat healthy. Choose your food right and then have the little sprinkles of “It’s a holiday party,” “It’s someone’s birthday,” once a week, or once every two weeks. I don’t mind someone having a little treat. Sure, encourage them to have a healthier one, but we’re human and it’s going to happen.
Any final comments before we go? Strouhal: People should start making a list before they go grocery shopping. That helps a lot, especially around the holidays. Sit down for thirty minutes before you go shopping. Decide what foods you’re going to make on which nights. Think about leftovers. If you go into the grocery store prepared, you’re not going to grab junk food, you’re not going to grab what’s on sale, you’re going to grab what’s on your list, and you’ve already decided what recipes you’re going to make. So there’s no reason to go off your plan for healthy eating. Novak: To add to that, just planning everything, not just your grocery store trips, but also your meals. Most people know what they’re going to wear tomorrow, they know what the weather’s going to be like tomorrow, they know what their schedule is like tomorrow, but they have no idea what they’re going to eat. They have no plan. Strouhal: It’s part of daily living, just like getting dressed. You have to think about it.
CONTACTS
Chippy Nalluri, MD: Receiving her medical degree from the University of Illinois College of Medicine before completing her residency and fellowship at University Hospitals of Cleveland, Nalluri is board-certified in cardiovascular diseases, nuclear cardiology, advanced cardiac life support and internal medicine. A member physician of Heart Specialists of Sarasota, Nalluri is affiliated with Sarasota Memorial Hospital.
Pamela Strouhal, RDN LDN: A registered dietitian with 23 years of experience, Strouhal graduated Western Michigan University in 1992. Currently working at Doctors Hospital of Sarasota, focusing on critical care and step down units, Strouhal was recently certified in diagnosing malnutrition and is a member of the nutrition support team. Other experience includes the completion of a Pediatric Fellowship, eight years working with pediatrics, cardiac rehab and providing concierge nutrition counseling.
Gudrun Novak, RD A graduate of the University of Connecticut with a focus in dietetics, Novak is a state and nationally certified deietitian/nutritionist and diabetes educator, respectively, with extensive experience with both children and adults, from previous positions with Cleveland Regional Medical Center and St. Peter’s Hospital in New York. Novak currently works with the Sarasota Memorial Health Care System and HealthFit.
