Exam Room Nutrition: Nutrition Education for Health Professionals

Mini Series | A Provider's Guide to Helping Patients Lose Weight: Part 4 | Calculate and Count Macros

February 09, 2024 Colleen Sloan, PA-C, RDN
Exam Room Nutrition: Nutrition Education for Health Professionals
Mini Series | A Provider's Guide to Helping Patients Lose Weight: Part 4 | Calculate and Count Macros
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Show Notes Transcript

So what does it mean to count your macros? Is it necessary for fat loss?  This week we’re unpacking what macronutrients are, their functions in the body and how to calculate them for your patient.   Join me, Colleen Sloan, on the fourth episode of this 10-part series to help guide your patients on their weight loss journey.

If you're a primary care provider looking to enhance your nutrition counseling skills or simply seeking a refresher, join me as we make our patients healthier, one exam room at a time!

Grab the companion PDF at examroomnutrition.com/weightloss, and let's confidently guide our patients towards their best lives in 2024.


Sources:
Online Calculator: https://reference.medscape.com/calculator/846/mifflin-st-jeor-equation

https://pubmed.ncbi.nlm.nih.gov/25911631/#
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8912699/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7539343/
https://pubmed.ncbi.nlm.nih.gov/20351774/
https://pubmed.ncbi.nlm.nih.gov/31039663/
https://pubmed.ncbi.nlm.nih.gov/34171740
Saturated or Not: Does Type Matter
Trans fatty acids and cardiovascular disease. 

Nutrition Trackers:
Cronometer
MyFitnessPal
LoseIt

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Episode 4 – Macronutrient Breakdown

Should your patients be counting their macros?

This has become a widely popular saying among the fitness world. Counting your macros is just a trendy way to say counting calories, because essentially, that’s all you’re doing. The funny thing is that calculating a patients macros isn’t anything new. Dietitians have been doing this for a long time specifically for a critically ill patient requiring tube-feedings or elite athletes. But it’s not common practice for the general public because for some it can become addicting and for others it can feel too restrictive and complicated. Furthermore, weight loss can be achieved without ever tracking calories consumed. However, for today’s episode you’ll learn what the 3 macronutrients are and how to calculate them for your patient, step-by-step. 

You’re listening to the Exam Room Nutrition podcast mini-series called a Providers Guide to helping patients lose weight. I’m your host, Colleen Sloan, Im an RD turned PA and my goal is to give you the nutrition education you never had in school to help you be a more confident compassionate clinician. 

This is part 4 of a 10-part series, and last week we discussed ways you can help your patient navigate stress and emotional triggers that derail their health journey. If you would like my notes on this series, I have created a companion PDF for you that summarizes each and every episode. You can find that for free at examroomnutrition. com slash weight loss. That's examroomnutrition. com slash weight loss.

 

 

So what does it mean to count your macros?

In the most basic sense, it involves breaking down your total daily calorie needs into individual macronutrients which your body needs in order to function properly. There are 3 macronutrients: carbohydrates, protein and fats. How much of each macronutrient a person needs will vary based on their activity level, gender, weight, age and medical conditions. 

 

Let’s look at each macronutrient individually in detail.

 

Carbohydrates

Let’s start with Carbohydrates … and man oh man has diet culture made us fear carbs! It’s all too common to hear people say “oh yeah my doctor told me to cut out carbs.” Or “I’m avoiding carbs.” But is that actually necessary for fat loss? The research says no. What’s necessary for fat loss is a sustained calorie deficit, regardless of what diet your patient is on. But why do people lose more weight when they stop eating carbs? It just seems like the weight comes off so quickly.

Carbohydrates are stored in the body as glycogen and in order to be stored, every 1 molecule of glycogen needs 3 molecules of water, so when carb intake decreases, people will notice a change in their body weight, but this isn’t necessarily fat loss, it’s just a change in the amount of fluid your body has. Additionally, if the patient is starting to weight train (which is highly recommend), fluid can be shifted toward the muscles for tissue repair, which leads the patient to believe that they aren’t losing “weight’, when in actuality they are gaining muscle mass while losing fat mass, which is exactly what we want. This is why, as discussed in episode 2, it is important measure things besides the patients weight, to understand changes in body composition.

 

Alright on to carbohydrates. Carbs are the primary energy source for your brain, muscles and nervous system. We need them for hormone, brain and thyroid function, energy, sport performance and digestion. They include sugars, starches and fiber and can be broken into simple carbs and complex carbs. Simple carbs, like sweets, white bread/rice and table sugar, are broken down quickly by the body, they don't keep you full for very long and lead to rapid blood sugar spikes, especially when eaten alone. Complex carbs, like fruits and vegetables, whole grains and beans, are broken down more slowly, and as a result, they promote longer satiety and more stable blood sugar levels. Most complex carbohydrates have other nutritional benefits, like B vitamins, iron, and fiber. So if you hear an “expert” telling people to avoid fruit because it has too much sugar, RUN. This is inaccurate and harmful. I’m happy to send you a plethora of studies to prove it.

 

The issue most people have with carbs is they overdo it with the processed refined carbs (like cakes, cookies, breads, etc.) because these tend to be easy to overeat due to their convenience and duh they’re delicious and patients under do fibrous carbs (like fruit, veggies, whole grains,)…. Therefore giving carbs a bad rap.

 

 

Proteins

Let’s move on to everyone’s favorite macronutrient. Protein! This guy has also been featured in a lot of research over the last few years regarding daily requirements and timing. Just like so much about nutrition, how much protein someone needs,  truly depends on the person, that’s why if we are getting to the specifics of calculating how many grams of protein a person is eating, you should be referring them to a Registered Dietitian. 

 

But here’s some protein basics for you. A protein is made up of one or more long, folded chains of amino acids (each called a polypeptide), whose sequences are determined by the DNA sequence of the protein-encoding gene. Proteins provide structure and support for your cells, are critical to forming your muscles, skin, hair, nails, bones and enzymes. Protein also plays an important role in satiety. Proteins are made up of 20 amino acids, and while the body can make some of them, nine are considered essential or indispensable, meaning your body can't produce them on its own and must be consumed through food. 

 

Animal sources of protein include meat, dairy and eggs. Common plant sources of protein include beans, nuts, seeds, tofu and whole grains. While most animal protein sources contain all nine essential amino acids, most plant sources do not. However, if you consume a variety of plant sources throughout the day, they can function as complementary 

 

 

Now we’ll get into the specifics of how much protein patients should consume to promote weight loss and maintain lean muscle mass in a little bit, but here are some source of protein to consider:

 

Protein options: 4 ounces

  • Chicken breast – 26 g
  • Tuna – 24 g
  • Lean ground beef (at least 95% lean) – 21 g
  • Fish – 19 g
  • Ground turkey – 18 g
  • Eggs – 13 g
  • Cottage cheese – 11 g
  • Greek yogurt – 10 g (can vary depending on the brand)
  • Tofu – 10 g
  • Lentils – 9 g
  • Black beans – 9 g
  • Quinoa – 5 g
  • Protein-rich cereal: 20g
  • Whole grain tortilla: 5g
  • Pork loin: 24g

Fats

Alright moving on to dietary Fat. Just like carbs, fat has fallen in and out of popularity for years. And social media is full of opinions on saturated fat and seed oils and their effect on overall health and inflammation. We won’t be getting into the debate of seed oils right now, but I may do an episode in the future reviewing the literature on that topic, because I know Instagram is getting spicy about it. Send me a DM @examroomnutrition and let me know if you’d like me to cover this topic. 

Fats are essential for cell function, energy, organ protection, satiety, insulation and temperature regulation, hormone production and absorption of vitamins A, D, E and K. . The major thing to focus on with fat is the quality. Fat can be categorized as saturated, unsaturated fats or trans fat. And I want to quickly break those down for you.

Saturated fats are solid at room temperature and are primarily found in animal products, like butter, fatty cuts of meat and cheese, but some plant foods are also high in saturated fats, like coconut, coconut oil, palm oil, and palm kernel oil. In the United States, our primary sources of saturated fat are:

·         Pizza and cheese

·         Whole and reduced fat milk, butter and dairy desserts

·         Meat like (sausage, bacon, beef, hamburgers)

·         Cookies and other desserts

·         fast food items

The Dietary Guidelines for Americans recommends getting less than 10 percent of calories each day from saturated fat and actually the American Heart Association goes even further, recommending limiting saturated fat to no more than 7 percent of calories. 

Emerging evidence has shown that saturated fat is not as bad as we once thought, but the literature clearly shows that unsaturated fat remains the healthiest type of fat. Interestingly, cutting back on saturated fat will likely have no benefit, if a person replaces saturated fat with simple carbohydrates. So be careful when telling your patient to limit their fat intake if you arent telling them what to replace it with. We want to encourage limiting saturated fat and replace it with polyunsaturated fats

 

Which brings us to our second type of fat, Unsaturated fats. These are most commonly found in plant foods, like oils, avocados, olives, nuts and seeds. The American Heart Association recommends consuming more unsaturated fats than saturated fats, especially if you are at risk for heart disease. Unsaturated fats, which are liquid at room temperature, are considered beneficial fats because they can improve blood cholesterol levels, decrease inflammation, and stabilize heart rhythms.

Unsaturated fats can be further categorized into: monounsaturated and polyunsaturated 

1. Monounsaturated fats are found in:

o    Olive, peanut, and canola oils

o    Avocados

o    Nuts like almonds, hazelnuts, and pecans

o    Seeds such as pumpkin and sesame seeds

2. Polyunsaturated fats are found in

o    Sunflower, corn, soybean, and flaxseed oils

o    Walnuts

o    Flax seeds

o    Fish

o    Canola oil – though higher in monounsaturated fat, it’s also a good source of polyunsaturated fat.

I want to briefly discuss Omega 3s and omega 6s because they fall under polyunsaturated fats: 

Fun fact if you want to geek out: The terms omega-3 and omega-6 don't signify anything special. They actually describe the position of the first carbon-carbon double bond in the fat's backbone. This influences the shape of a fat molecule which,  affects its function in the body.

The benefits of omega-3 are well known. They help protect the heart from arrythmias, ease inflammation, prevent clot formation and lower levels of triglycerides. Good sources of Omega-3s are fish, flaxseeds and walnuts

Omega 6 fatty acids are what the internet is freaking out about… and I can’t help but touch on it briefly.

Their main issue is that the body can convert the most common omega 6 fatty acid, linolenic acid, into another fatty acid called arachidonic acid, and arachidonic acid is a building block for molecules that can promote inflammation, blood clotting, and the constriction of blood vessels. But the body also converts arachidonic acid into molecules that calm inflammation and fight blood clots, but a plethora of well-documented research shows that Omega-6 fats are not only safe but are beneficial for the heart and circulation. 

Sources of omega 6: Safflower oil, sunflower oil, corn oil, soybean oil, sunflower seeds, walnuts, pumpkin seeds

Most Americans eat more omega-6 fats than omega-3 fats, so encouraging a  balance is a good idea by suggesting they add some extra omega-3s.

And now on to the third type of dietary fat: trans fats: These fats are made by heating liquid vegetable oils in the presence of hydrogen gas and a catalyst, a process called hydrogenation, which makes them more stable and less likely to become rancid. This process also converts the oil into a solid, which makes them function as margarine or shortening. They also can withstand repeated heating without breaking down, making them ideal for frying fast foods. For a long time, only dedicated diet detectives could determine if a food had trans fat due to tricky labeling. Buyers had to search for partially hydrogenated oil and vegetable shortening on the nutrition facts label. However, research in the 1990s revealed its harmful health effects, and a series of policy changes nearly eradicated artificial trans fat from the U.S. food supply by 2018.

Partially hydrogenated oil is not the only source of trans fats in our diets. Trans fats are also naturally found in beef fat and dairy fat in small amounts.

Trans fats are the worst type of fat for the heart, blood vessels, and rest of the body. They have harmful health effects even in small amounts – if you’re multitasking come back to me and listen to this statistic: for each additional 2 percent of calories from trans fat consumed daily, the risk of coronary heart disease increases by 23 percent.

Trans fats Raise LDL and lower HDL, Create inflammation, which can lead to heart disease, stroke, diabetes, and other chronic conditions and they contribute to insulin resistance.

SO there’s your summary of dietary fat but here’s the take home point: recommend your patients cut back on red meat to incorporate more fish, nuts, and seeds, and replace butter when cooking with a variety of liquid vegetable oils, such as olive, canola, and avocado oil.  

Macro Breakdown – so how much do we need

So now that you have a better understanding of what macronutrients are and their role in the body, let’s get to why you’re here. How do I calculate the breakdown of macros for my patient. As I stated in the beginning, in my opinion, following a diet based on macros is not ideal for every patient and it is absolutely contraindicated for those with a history of an eating disorder or any current disordered eating. Also, just being realistic here, but it can be very time-consuming for you to do the calculations in the clinic. The major purpose of counting macros should be for your patient to learn how much they are currently eating versus how much their body actually needs. You can encourage your patients use an online tracker like Cronometer, MyFitnessPal or LoseIt to determine the daily breakdown of protein, carbs, and fats and to help keep them accountable and honest with their macro intake.

 

Alright, We’re gona be doing some math next, so if you want to grab a pen and paper that might help, otherwise, if you’re driving, listen to this part again when you get home. 

 

Please use this as a general guide and I cannot stress how important working with a Registered Dietitian is. Nutrient calculation are not as black and white as one would think because the human body is an amazingly complicated, beautiful thing. 

 

 

Th macronutrients have been nicely broken down for us by The 2020-2025 Dietary Guidelines for Americans, which recommends that 45% to 65% of calories in an adult's diet come from carbohydrates, 20% to 35% from fat and 10% to 35% from protein.

 

As you can tell, these are ranges and where a patient falls within these ranges depends on health conditions, activity levels and overall goals. 

 

Now when calculating macros, there’s a 3 step process

1.    Calculate the patients estimated calorie needs. 

2.    Break down their total calorie needs into calories for each macronutrient (using the percentage ranges from the dietary guidelines) 

3.    Calculate how many grams of each macronutrient they can consume

Are you thinking …..  Colleen, how do I know how many calories my patient needs?

And this is where it can get complicated and why I recommend working with a dietitian. 

But for the sake of being thorough, here’s a quick overview of calorie estimation. 

Your basal metabolic rate (BMR) is the number of calories your body uses to stay alive. Keep in mind that your BMR includes only the energy (calories) necessary for basic, life-sustaining functions. It does not include additional calories needed for daily activities, such as walking, moving, and exercising.

 Your BMR can be calculated using direct calorimetry, indirect calorimetry, or a quick math equation, which there are a few different equations, but most commonly used is the Mifflin-St. Jeor equation, which you can google, but stay with me because I’m going to break this down for you. While it’s useful as a starting point, your BMR is not the number of calories your body needs in a day. It’s only the number of calories your body needs at rest.

To calculate your total daily energy expenditure (the total calories you need each day), you need to multiply your BMR by an activity factor. Activity factors range from 1.2 for sedentary to 1.9 for very active. This number will give you a general idea of how many calories your body needs per day to maintain your current weight. To make your life easier, I have included a link to an online calculator through Medscape that you can use to just plug in your patient’s info to make calculating their baseline calories WAY EASIER. You can thank me later.

Now Since this series is talking about nutrition for weight loss, ideally, patients should aim for 0.5-1kg or 1-2 pounds weight loss per week, however as we’ll see even this is complicated. 

In 1958, a researcher named Dr Max Wishnofsky, calculated that 1 lb of fat stores approximately 3,500 kcal of energy, which is where we get the idea that 1 pound of fat is roughly equal to 3500 calories. So in order to lose 1 pound of fat, you need to accumulate a calorie deficit of 3500 calories. Cut 500 calories per day and that's 1 lb per week. Over the course of one year, that would equal 52 lbs. 

Now I’m gona pause here because the 3,500-calories-per-pound rule isn’t perfect because it fails to account for dynamic changes in energy balance that occur during a dieting intervention. Because of this, some say, the 3,500-calorie-per-pound approach significantly overestimates how much weight people will lose over time, setting them up for disappointment when weight loss slows or stops altogether.

Weight adaptations can happen over time as weight loss isn’t a linear event over time. And How your body burns calories depends on a number of factors, including the type of food you eat, your body's metabolism, and even the type of organisms living in your gut.

As a patient starts to lose weight, their body will burn less energy because a lighter version of themselves requires less energy than a heavier version of themselves. Despite ongoing debates, what truly counts for fat loss is both the total calories you consume and the kinds of foods you choose. However, don't be surprised if the weight comes off more gradually than anticipated. Patience and consistency are vital for weight loss success. 

Other mathematical formulas have been proposed to more accurately predict the rate of weight loss in patients. However, for simplicities sake, we are going to base our calculations using the 3500 calorie rule. 

Okay Back to our math lesson: Here’s an example so all of this comes together, If you calculate that someone needs 2400 calories at baseline, then you can suggest they consume 400 calories less every day, for a total of 2000 calories daily, which will result in a target loss of 1-2 pounds of weight per week. 

Now we have completed step 1. Let’s move on to step 2 which is, where we need to break down the total calorie needs for each macronutrient using the percentage ranges from the Dietary Guidelines. 

 

Using our example patient who we suggested consuming 2,000 calories daily, let’s calculate the number of calories they need from each macronutrient, starting with carbohydrates first. Pro tip, I usually calculate carbs first, then protein and then the rest will be leftover for fat. 

 

Remembering that The 2020-2025 Dietary Guidelines for Americans recommends that 45% to 65% of calories in an adult's diet come from carbohydrates, 

 

Let’s say we aim to have 60% of the calories from carbohydrates and you need 2,000 calories per day, that means you need 1,200 calories from carbohydrates …

Alright Next Lets calculate protein. Remember the range for protein is 10-35%, which is a pretty big range. For someone following 2000 calories, this would be 200-700 calories

And the remainder for fat would be 1200 from carbs + 500 from protein, leaves you with 300 calories for fat. (which is a little under the recommended 20% to 35% from fat, but you can play with the numbers as needed)

 

Step 2 is complete. Moving on to Step 3: we need to determine how many grams each macronutrient provides. 

To do this you need to know that carbs and protein have 4 calories per gram. For fats, there are 9 calories per gram.

So in our example, 1200 calories for carbohydrates (1,200 calories ÷ 4 calories per gram of carbs) equals 300 grams, Protein would be 200-700 calories/ 4) 50-175g per day. 

And fats would be: 300calories / 9 33 gram per day.

A quick note here: For weight loss, it can be beneficial to start on the lower end of this range, or even as low as 150 grams per day. Research however shows going much below 150 grams may increase the risk of nutrient deficiencies, hunger cravings, and mental fatigue. Remind your patient that carbs are not the enemy and they should be enjoying carbs from fruits, veggies and whole grains.

Now I want to back up and have a little discussion about protein calculations. 

Protein is another macronutrient that has been researched quite a bit lately and the guidelines are shifting. Another method for determining protein intake is to calculate grams of protein per kilogram of body weight based on activity level. 

 The Recommended Dietary Allowance (RDA) for protein remains at 0.8 grams per kilogram per day.  However, for patients looking to lose weight and gain muscle, new research shows this amount is not nearly enough to preserve muscle mass (which gradually decreases over time starting at age 30) but these findings have not yet been translated into clear recommendations by authorities. However new studies suggest a higher protein intake, anywhere from 1.2-2.0 grams per kg based on goals, activity level, and overall health status. 

Most registered dietitians can agree on recommending between 1.2-1.6 grams of protein per kg per day. Very active individuals looking to build muscle will need 1.5-2.0g/kg per day.

So using this calculation for our patient, lets say they weigh 175, this would come out to 95-127g per day, which is actually somewhere between what we calculated for 10-35% of total calories. 

 

So to recap, our patient needs 2000 calories a day, of which 1200 calories come from carbs (or 300g), 500 calories comes from protein (or 125g) and 300 from fat or 33 grams. 

So there you have it. But As you can see, actually doing the calculation is somewhat time consuming and will vary from patient to patient. 

Furthermore, there is an additional piece of education required once you determine how many macros they should be eating every day, and that is how to count how many grams are in a serving of the food they’re actually eating. You could tell them okay eat this many grams of carbs, protein, and fat …  but they need to know how to calculate that related to what theyre actually eating. 

I know today was a lot, but thanks for sticking with me and I hope I cleared up any confusion surrounding macros. Be sure to check the show notes because I have included a ton of helpful resources for you and your patients. Including a ton of resources, since nutrition has become quite controversial these days. 

In the next episode, we’ll be discussing different diet options and why one plan might work better for one patient than another. I’ll also review a recent article that’s hot off the press from US News listing the best diets for 2024. See you next week!

As a quick reminder, if you would like my notes on this series, I have created a companion PDF for you that summarizes each and every episode. You can find that for free at examroomnutrition. com slash weight loss. That's examroomnutrition. com slash weight loss.