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Unlocking the Power of Nutrition: A Guide to Balanced Diets Across Life Stages with Dietitian Nick Wray

• Dr Gavin Nimon • Season 4 • Episode 66

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Discover the transformative power of a balanced diet across all life stages with insights from our expert guest, Clinical Dietitian Nick Wray. With nearly three decades of experience in dietetics, Nick joins us to shed light on the importance of macronutrients and micronutrients tailored to individual needs. We promise you'll gain a clear understanding of how dietary requirements shift with age, activity level, and health conditions, as well as the complexities faced when essential food groups are eliminated. Together, we navigate the challenges of maintaining a nutritious diet amidst dietary restrictions and explore the vital roles that proteins, fats, and carbohydrates play in our health.

Hosted by Dr Gavin Nimon (Orthopaedic Surgeon and Host of Aussie Med Ed) the conversation unpacks the nuances of macronutrients and micronutrients, focusing on how these components support energy, muscle building, and overall wellbeing. We emphasize the art of balancing dietary needs for those with specific lifestyles, such as vegans or pescatarians, and why diverse plant-based protein sources are crucial. The discussion takes a closer look at exercise and its impact on nutrient demands, particularly highlighting the increased necessity for protein in muscle-building and carbohydrates for endurance activities. Moreover, we delve into the heart health benefits of healthy fats, especially those found in the Mediterranean diet, and how these contribute to essential fatty acid intake.

Nutrition plays a pivotal role not just in general health, but also in surgical recovery, especially for those who are sarcopenic or malnourished. Nick shares valuable insights into the use of oral protein supplements and multivitamins for aiding recovery, while also addressing common dietary habits that could hinder health, such as excessive carbohydrate and sugary drink consumption. We discuss strategies for managing insulin levels with lower-carb diets and provide practical advice on tailoring nutritional plans based on exercise levels and individual needs. Wrapping up, we touch on the intricacies of food allergies and intolerances, reinforcing the need for personalized dietary assessments to ensure optimal health outcomes.

Aussie Med Ed is sponsored by OPC Health, an Australian supplier of prosthetics, orthotics, clinic equipment, compression garments, and more. Rehabilitation devices for doctors, physiotherapists, orthotists, podiatrists, and hand therapists. If you'd like to know what OPC Health offers.

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Dr Gavin Nimon:

We all have to eat, but it's becoming increasingly clear how crucial what you put on your plate is to you both in the short and long term. From fueling growth in childhood to optimising recovery after surgery, a well balanced diet is a cornerstone of good health. But what exactly makes up a good diet? It's more than just eating your greens. Today I'm bringing you the latest insights from specialist dietitian Nick Wray, who'll guide us through the components of a healthy diet and the shifts required for different stages of life. Whether you're managing patients or refining your own dietary advice, Nick This episode is packed full of practical insight you won't want to miss. Welcome to Aussie Med Ed. G'day and welcome to Aussie Med Ed, the Australian Medical Education Podcast. Designed with a pragmatic approach to medical conditions by interviewing specialists in the medical field. I'm Gavin Nimon, an orthopaedic surgeon based in Adelaide, and I'm broadcasting from Kaurna Land. I'd like to remind you that this podcast podcast players, and is also available as a video version on YouTube. I'd also like to remind you that if you enjoy this podcast, Please subscribe, or leave a review, or give us a thumbs up, as I really appreciate the support and it helps the channel grow. I'd like to start the podcast by acknowledging the traditional owners of the land on which this podcast is produced, the Kaurna people, and pay my respects to the Elders both past, present, and emerging. It's my pleasure now to introduce Nick Wray, a clinical dietitian with almost 30 years of experience in both hospital dietetics and private practice. He has extensive experience with sports teams and also in private practice. Wray Nutrition. And he specializes in gastro and obesity surgery, but also sees anyone who may need dietitian intervention. In the last five years, he's commenced a new business with another dietitian, Dr. Penny Taylor, a business called 360Me Nutrition, where they employ, mentor and train dietitians, placing them in various medical and allied health clinics around Adelaide. Welcome Nick, thank you very much for coming on Aussie Med Ed. Pleasure, Gavin. Good to be here. More and more during these podcasts, we get to interview different specialists and hear about how important the diet is to health. And so it's great to have you on board. Can you explain what the fundamental components of a well balanced diet are and why they're really important to overall health?

Nick Wray - Dietitian:

Yeah, it's a tough question to start with because, you know, a well balanced diet varies enormously depending on the person's situation. You know, obviously, their age and their physical activity level and their Medical history, etc. But the basics. You've got to cover the macronutrients and the micronutrients. And that's the part that varies so much from individual to individual. So people who limit huge, you know, key food groups, like they cut out dairy or something like that, that does make our job as a dietitian a lot more difficult because it's, it's wiping out a lot of calcium and a lot of protein and things like that. So really the goal is to, I guess, provide enough Basic macronutrients to give that person their basic requirements, which is going to vary enormously from individual to individual. So, but as a rule, um, enough fruit and vegetables to get their vitamins and minerals, enough breads and cereals to get their carbs, enough protein foods to get their protein. So nothing's changed over a hundred years of this, but I think we've got better at bringing in all the variables of a person and As to how to achieve this because no two people are the same. Let's face, um, everyone's different. Perhaps you can just explain what a macronutrient is. Yeah. So your macronutrients are, are simply your, your protein and your fats and your carbohydrates. The basics for energy and for building blocks, blocks for protein and essential fats, et cetera. And then your micronutrients, of course, are your vitamins and your minerals. You know, the more restrictive a person's diet, the more difficult it is to achieve adequacy.

Dr Gavin Nimon:

So, basically, there's three main macronutrient groups, and you mentioned micronutrients too, what makes up those as well?

Nick Wray - Dietitian:

Well, all your vitamins and minerals, you know, the basics are your iron and your vitamin D's for bone health and calcium for bone health and certainly in nutrition deficiencies we see quite a lot of these. Restrictive diets very often wipe out a lot of those micronutrients because, and that makes our life more difficult and then you have to rely more on. Nutrition supplements and things like that, which you can take a whole bunch of vitamins, but better to try and get it in your food.

Dr Gavin Nimon:

Right. So the two main areas are macronutrients, which provide protein, fat, and carbohydrates. Mm-Hmm. micronutrients is, are the vitamins and minerals which help you develop. What sort of levels of macronutrients are you needing in a basic diet that you wanna try and maintain? Like I've, I've gone pescatarian. How does that affect my. Maintenance of my general health, given the fact that I've reduced my meat intake, in fact, stopped my meat intake.

Nick Wray - Dietitian:

Well, it does. I mean, this is where, um, you have to look at a person's, um, dietary restrictions or choices. Um, you know, it might just be their simple choices. As you said, you've chosen to go pescatarian. Well, that's fine. We can work around that easy enough. That's not difficult. Getting adequate protein is the goal and we can still achieve that. But if you, for example, decided to be vegan, that's more difficult again because We're very limited with how, how much protein we can get and we can pretty much cover most people's, you know, protein requirements and, and macronutrients if someone's very restrictive like a vegan would be. Unless they're then doing tons of exercise, um, that then becomes really difficult because their protein and energy needs are far greater. So, uh, N I M O N O N. Achieving that within the boundaries of them choosing to be vegan, um, becomes more challenging. So this is where you have to take every variable into account.

Dr Gavin Nimon:

What other food types can actually get protein from? I understand tofu is a very good source of it.

Nick Wray - Dietitian:

Look, any animal product contains all the essential amino acids. And if you want to build new protein, you need all the essential amino acids. Vegetable protein will lack at least one essential amino acid, but if you combine different vegetable proteins, you can still get adequacy. So, It's not out of the question to be able to do that, it just makes our job as the dietitian a little trickier, but we can live with that. So it really boils down to how much exercise are you doing? What type of exercise are you doing? How old are you? What's your physical stature? Um, and then we can have a good feel for, right, well this person needs X grams of protein and how do we achieve that?

Dr Gavin Nimon:

Right. So as you exercise more, you need more protein because you're building muscle, is that correct? Well, particularly

Nick Wray - Dietitian:

depending on the exercise, yes. Particularly if you're doing weight bearing type exercise, weights or running triathlons or, you know. Weightlifting etc. If you're more of an endurance athlete, well, hey, then we got to talk carbs, right? So then we have to talk petrol in the tank and that's what carbs are. So, you know, a carbohydrate requirement can vary enormously from a very sedentary arthritic person compared to a an AFL footballer saying chalk and cheese how much carbs you would need to give the AFL footballer compared to the arthritic quite immobile person.

Dr Gavin Nimon:

So generally proteins for muscle. Yep. Carbohydrates for energy. Yep. And fats, I understand, are for hormones and brain development and other aspects.

Nick Wray - Dietitian:

That's right. And of course, we, we get careful with fats because of heart disease risk. So we look at the types of fats. Um, so we try and encourage the Mediterranean diet type fats, you know, the healthy poly and mono and saturated fats, which are not dangerous for our heart and are very good sources of essential fatty acids. So. That's why the Mediterranean diet is very popular and for good reasons. It's got some very good aspects.

Dr Gavin Nimon:

So while we're on the macronutrient sort of pathway, if we look at the proteins, we've mentioned obviously a standard diet with meat is the best way of producing or allowing income of protein. If someone was vegan, and you mentioned various vegetable products, and I presume nuts as well, how to maintain the amino acids, what in general, I know everyone's requirements vary and you need a specialist dietician advice for personal situations. But in general, someone who is vegan and is avoiding milk product as well as fish and meat, how would they make up the amino acids that you would like as a general generalisation for the average person?

Nick Wray - Dietitian:

They'll have to pretty much eat every single vegetable source of protein to cover their bases. They'll need their legumes and lentils. They'll need their tofu and their TPP and those types of proteins. They'll need their nuts and their seeds, and they'll have to cover every, every sort of vegetable source of, or non meat source of protein we can get. We, we make sure that, uh, It's a big part of their diet and they're getting all of those essential proteins. So unlike, you know, I'm not vegan, so if I just one day eat a steak and the next day eat a piece of fish, well, they contain all the essential amino acids, so I don't need to worry so much about whether I've eaten nuts and whether I've eaten seeds and whether I've had tofu and things. It's just more difficult, but plenty of vegans out there that are very healthy.

Dr Gavin Nimon:

Excellent. So if we look at the. Scenarios where you, we took it nuts, obviously every nut varies. You get the almonds, which are nice and enjoyable, but then you get cashews who somehow you seem to want to eat them not until the cows come home. Is that because they contain a different levels of fat that actually make you enjoy them more or they're all, each nuts exactly the same?

Nick Wray - Dietitian:

Well, they're not exactly the same, but they're very similar. I mean, you're splitting hairs if you're worrying too much about. One nut versus another nut. You know, they contain slightly different mixes of the poly versus the monounsaturated fats. Slightly different nutrition profiles, but you know, at the end of the day, all nuts are pretty healthy, let's face it. It's just, you know, I think the ones that people like the most are the cashews and the almonds and the pistachios, probably are the ones that people enjoy the most.

Dr Gavin Nimon:

Right, so it's not because it contains more fat in it that actually is more unhealthy for you, they're basically all healthy. There's little, there's subtle differences, but not enough to get too concerned about. If we look at the carbohydrates then, with the exception of actually needing a fuel source to maintain daily life, what are the other positives of having carbohydrates, or I know that your program talks about trying to reduce carbohydrate levels to help reduce fat and obesity and the complications that go with that. Is there any other negatives or positives of carbohydrates that you need them for? Generally, you could survive with a protein and fat diet and just eat carbohydrates to the minimal amount. Well,

Nick Wray - Dietitian:

the only thing that they, other than fuel, that they, that they do or give you, of course, is glucose for your brain to function. So, your brain's not very good at converting other fuel sources into glucose, so it has to run on either glucose or ketones. So, Keto diet, the brain will function on ketones. Your other organs don't have a problem. They'll convert other nutrients into glucose, but for the brain to work, and a lot of people who try keto diets do notice that their They're not as sharp and they get, they describe it as brain fog and things like that, um, purely and simply because that is what carbs will give you. They will give a fuel source to the brain and a fuel source to your body to go and do your Pilates class or your run or whatever you're doing.

Dr Gavin Nimon:

Yeah, I've looked at the intermittent fasting sort of diets, the way of maintaining health, but was always concerned about the risk of the fact that if I was intermittent fasting while I'm doing an operating list, it wasn't such a good idea. Yeah, I know myself. Where when I've haven't eaten a great breakfast, sometimes when I've been assisting when I was a medical student, I'd feel a bit more faint. And so I've actually been reluctant to go down that path, particularly when I'm doing operating lifts on a regular basis. Would you

Nick Wray - Dietitian:

agree with that? 100%. Um, I'm not a fan of keto diets because I just think they're too restrictive, they're too low. You know, they're 20 grams of carbs or less. You know, that's a piece of bread, right? That's it for the day. Then everything else you eat has to contain no carb. So I think most people, let's face it, need more carbohydrate than that just to have basic energy levels and, and brain functions. So I wouldn't want the operating on me. If you are on a keto diet and uh, and you know, your judgment might be a bit clouded. So I'm not a big fan of them. I know a lot of people try them and a lot of people get good success with weight loss with them because you're not producing much insulin, but I think for general health and having to go to work and do your job and be a normal person, I'm not sure they're sustainable. They're very difficult to sustain for long periods of time.

Dr Gavin Nimon:

Right. If we go on to the micronutrients, let's talk about the importance of that in maintaining a healthy lifestyle. Obviously, I'm aware of the importance of folic acid required for a pregnant lady who's developing a fetus inside them and needs that for the development of brain function. What other importance are there of the micronutrients?

Nick Wray - Dietitian:

Well, this is a difficult question because they just about do everything. Huge implications in wound healing. So our zinc and our vitamin C as antioxidants and selenium as antioxidants. These are extremely important functions in the body to keep us healthy. We have our vitamin A and retinols that are involved in our vision. We have Iron, of course, to carry oxygen around our body, or we're pretty stuffed without, without that. Bees, of course, to help glucose metabolism and carbohydrate metabolism, so therefore energy. So, and, you know, things like selenium we didn't know much about until, you know, 10, 15 years ago. So, if you look at a multivitamin preparation now, there's a lot more in them than they used to be. Um, so they pretty much do everything. Um, and this is the problem when, when someone's on a very restrictive diet, we've got to look at what that food group they're not eating is going to wipe out of their diet. I'm not a fan of some of these very restrictive generic diets that are handed out by various people, you know, with a jar of expensive vitamins to take. You sort of think, well Why am I following such a rigid regime if I need to then go and spend a lot of money on vitamins and minerals? It sort of doesn't make much sense to me.

Dr Gavin Nimon:

So Nick, um, obviously people's, uh, uh, dietary requirements differ during different age groups. I know when you see the young child who can eat as whatever they want and they seem to do really well and maintain a good healthy lifestyle. At my age, I've got to be extra careful what I eat, otherwise I'm feeling lousy or putting on weight easily. So how does the dietary requirements change between different age groups and what the activity levels as well?

Nick Wray - Dietitian:

Look, age, gender and, and activity levels are the big three. I mean, um, in theory, Males have a bigger muscle mass than females, and that's, we know muscle mass is metabolically active and fat mass is not. So, but that's a generalization. You can have very lean, strong women who have equally large muscle masses as men. As some of the men, but as a rule, you know, we are built slightly differently. So men typically have higher energy requirements and higher protein requirements as a result of that. Age is another one where, you know, we can generalize sometimes about age. We talk about bone density reducing as we get older and muscle mass deteriorating as we get older and hence, therefore, need less calories and less protein. But then, you know, you see some incredibly active. Older people who are into their 70s and probably doing more exercise than they've ever done in their life. So again, that can be a little bit of a generalization, but exercise is the big one. If you've got a strength athlete, or even just someone who goes to the gym, you know, the weekend warrior who goes to the gym five times a week and for an hour and absolutely smashes it at the gym, you know, they need a lot more protein than, uh, than somebody who's more sedentary. A typical protein intake is one gram per kilogram of ideal body weight. But if you've got someone doing a huge amount of exercise, well, we might go up to 1. 5 grams per kilogram of protein. So it's a significant increase. And as I said before, if you've got an endurance athlete, you know, someone who's running, you know, six times a week doing 200 kilometers a week of running, then they're going to need enormous amounts of carbohydrates. So you're right, those three factors are key factors, and any dietitian who sees a patient has to take them into account, as well as their medical history, of course, and their social history. You know, this is where we, you know, Need to know about things in the family that are influencing food choices. So that's another whole, whole, uh, category we could talk about for a long time.

Dr Gavin Nimon:

Excellent. When you're talking about increasing protein, I know there's a lot of protein powders out nowadays. Is that basically ground up nuts and things like that to produce a protein?

Nick Wray - Dietitian:

Depends what they are, um, if they're whey protein, they'll be milk based. If they're pea protein, or yes, of course, they're going to be, um, there's plenty of vegan proteins around, there's rice bran protein, there's pea proteins, there's soy proteins, but all of the whey protein and whey protein isolates are milk based, so they're not vegan, but they're very good amino acids because they contain all the essential amino acids.

Dr Gavin Nimon:

What about prior to surgery? When I'm seeing a patient prior to surgery, is it Something I should be doing to try and increase their nutrition status prior to going down that path?

Nick Wray - Dietitian:

I think this is a key area that there's no doubt in undernourished patients more likely to have post operative wound healing problems and no surgeon wants that, of course. But it depends on the surgery, doesn't it? Let's face it. You know, doing a knee arthroscopy and probably the nutritional status of the person's not as significant given their wound risk is, is less. But if you've got someone who's about to have a liver transplant, I used to work in the liver transplant unit at Flinders and every single patient that comes through that clinic sees a dietician because we have to assess their nutrition status and we know that pre operatively, if they're in a poor nutrition condition, we need to do something about it before they have their surgery. Um, All their outcomes and their complications post surgery, particularly with wounds, is the biggest issue.

Dr Gavin Nimon:

And is this purely something that can be maintained usually through a diet? Or is there anything that's needed intravenously or supplements such as the protein powders or tablets?

Nick Wray - Dietitian:

I think it depends. For protein and carbs and fats, I think we can pretty much get them in the diet. Unless the person has reasons they can't consume those foods, you know, they're entrally fed or something like that, then obviously. We would give it to them in that format. But with vitamin deficiencies, if you had a pre operative patient who was vitamin C deficient, taking oral C might not be good enough. We might need to do that intravenously, and this is when we'd do it. Get out the intensive care team in because they, they do all of the sort of home TPN type patients and they give these vitamins and minerals, um, IV. There are some GP clinics that do that too, but we as dieticians, we can't do that. So we would be referring them on to the experts who do that type of thing. But, you know, if someone's iron deficient, let's face it, and their surgery's in a week, Taking oral iron is not going to, you don't have time, you know, you're going to, they're going to need an iron infusion. Whereas if someone was a bit low in vitamin D, it might be as simple as to give them the 100, 000 unit syringe that they just take orally and you've given them, given them a nice mega dose, um, I do that a lot in our bariatric clinic where a lot of bariatric patients are vitamin D deficient, um, pre surgery, something like two thirds of them. So it's quite a significant, um, problem and our GP will typically just give scripts for the, the oral vitamin D. But we would obviously correct that before surgery.

Dr Gavin Nimon:

With those sort of patients, are they having a routine blood test to assess their levels of different vitamins? Is there a vitamin screen they would generally tend to use? And what are the ones we should be thinking about ordering if we're doing a sort of particularly complex patient?

Nick Wray - Dietitian:

So our surgeons, when they do the pre operative endoscopy, so they'll take blood off them at the endoscopy, and we measure just about everything. Yes, we measure, you know, the usuals, the LFDs and the blood glucose, and we check thiamine because post operatively thiamine deficiency is a disaster if that happens. We check their HbA1c, pick up a lot of diabetics that didn't know they were diabetic. We do zinc, we do magnesium, we do selenium. So these are not routine blood tests, as you can imagine. So, but they're the guidelines for bariatric surgery. Now, whether other types of surgeries have similar guidelines, I'm not sure, because it's not my space. But you know, you sort of think to If I've got a undernourished person who's about to have a fairly major operation, I think that's something that you should take seriously and run some bloods, and if you're concerned, you should refer them on to a dietician before they have their surgery. I know sometimes time doesn't permit because the surgery is urgent, but it's something that should be done.

Dr Gavin Nimon:

What about after the surgery then? Say the patient is able to eat okay, they've had surgery that allows an oral intake, what's, what are the important things that I should be considering on my menu when I've had my surgery to help me recover better?

Nick Wray - Dietitian:

So typically, you know, again, if someone's sarcopenic or malnourished before surgery, and we might still feed them up before surgery, but they're still obviously in a relatively poor nutritional state. Okay. We would be certainly giving them oral protein supplements, without doubt. There is some evidence with using specific proteins like arginine and that, and there's some, you know, pre prepared drinks that have arginine, which are meant to be extremely good for wound healing, but the problem with them is their expense. So, not too many situations can you use those. So, just using Cheaper protein supplements is probably as good as you're going to get and multivitamins, you know There's no harm in pumping people full of a good multivitamin. bariatric sector We have very good vitamins that are made specifically for bariatric patients again I don't know if you're doing liver transplants whether these days whether they have specific ones for that But for our bariatric patients, we know they've got more iron in them. They've got more vitamin D in them They've got calcium in them. They've got a lot of the things that A normal multivitamin potentially won't have.

Dr Gavin Nimon:

What other research is there in this area that looks at requirements and how you can improve health?

Nick Wray - Dietitian:

Most of the research, to be quite honest, has been on specific amino acids, you know, such as arginine. But I think making sure that the person is actually in a good nutrition state in the first place is probably the biggest. Prophylactic thing you can do. I mean, if you've got a big burly footballer and you're going to do a shoulder on them, I don't think you've got much to worry about. But if you've got a little old lady who's, you know, 50 kilos, well, gee, you'd be starting to think, how's she going to go healing, you know? Should I be building her up a little bit before I do her operation? And does she need some vitamins pre surgery? I think post surgery is really all about just getting enough fat and carbohydrate in. Patients, because if we don't get enough energy in, your body will start using other fuel sources to make glucose, such as protein, and that's not what we want. The last thing we want is for that to happen. We want protein to be spared. We don't want it to be utilized as a fuel source. So we need to give these at risk patients much more calories, fats and carbs so that they're not using their body. You know, their muscle stores and things like that.

Dr Gavin Nimon:

You talked about the Mediterranean diet has been really important. And obviously what we're seeing here in Adelaide is a more common Western style diet, which has probably gone away from that to some degree with a lot of fast foods and, uh, what we call comfort type foods. Would you, Avoid the fast food type food or is that okay for the occasional bit of fun?

Nick Wray - Dietitian:

I mean, of course, fast food is fine for anyone to have on occasions. It can be part of a very healthy, well balanced diet. You know, we know most fast foods aren't overly nutritious and aren't overly good for us, but if they're not a regular part of the diet, that's not a problem. But the problem we've got is, as a country, we're You know, teenagers in particular are just consuming these types of convenience and take away foods at rates we've never seen before, and drinking sugary drinks like we've never seen before, and we're seeing enormous over consumption of carbs for the activity level that these people are doing. So, you know, if you're eating 400 grams of carbohydrate a day and you should only be eating 50, that's a problem. You're going to be making massive amounts of insulin. We know insulin plays a role in fat deposition, so this is a big problem.

Dr Gavin Nimon:

Right, so the more carbohydrates you put in, the more insulin is made, the more it puts down fat. The less carbohydrates, less insulin, you have to use it as a fuel source, it burns the fat.

Nick Wray - Dietitian:

Yep, and this is why lower carb diets, and I'm not talking keto now, I'm just talking healthy lower carb diets, like the CSIRO diet, they've done a lot of research. This is why they've seen good results, because they've been able to manage insulin levels better. And, you know, I used to work in a clinic where we saw obese teenage kids and the paediatrician would measure their fasting insulin levels and just about all of them had enormous insulin levels. So when they eat carbs, they're going to be producing just huge amounts of insulin. That's half the problem for these kids, you know.

Dr Gavin Nimon:

So put that in perspective, if you have the average ham, cheese, tomato sandwich, how much carbohydrate would you consume in that sort of scenario? Is that bad, just having one sandwich?

Nick Wray - Dietitian:

Well, it's not, but that, that'd be 30 grams of carbohydrate. And let's say you're for the day on a 75 to 90 gram carbohydrate day, you've got to think, okay, well, that's a third, you know. But if you then change that to Helga's do a very good, uh, 50 percent reduced carb bread, for example, then your sandwich is all of a sudden only 15 grams of carbohydrate. So you've still enjoyed a sandwich, but you've saved some carbohydrate. You can then spend that on a piece of fruit or something that's very healthy. But this is where we as dieticians, I think, are getting a lot better at almost predicting how much carbohydrate someone needs. Depending on all of the variables we've already talked about, in particular, exercise levels and training loads. So, you know, I've got patients who I might put on 45 to 60 grams of carbohydrate. That would be fairly typical for an elderly, inactive person who's overweight and trying to shed some weight. Or I might have someone on, um, 300 grams of carbohydrate who, you know,

Dr Gavin Nimon:

So carbohydrates, I think of bread. I'm thinking of protein as a meat and fish and the nuts. And I think of fat as oils, like chocolate and things like that. Where does things like milk and fruit fit into that picture? What makes up, what is fruit? Is that carbohydrate? Is it, there's a lot of fiber

Nick Wray - Dietitian:

in it. Pure carbohydrate, natural sugar, even milk is, it milks a double. You're getting protein in milk, but you're also getting carbohydrate. There's lactose in milk and that's the carbohydrate. You eat a yogurt, you're getting carbohydrate. You eat. Even legumes and lentils, we know they're a good source of protein, but they've also contained carbohydrate. So, a lot of people only think that, you know, like a dollar for every time someone said, I don't eat many carbs because they, they don't eat much bread or they don't eat much pasta and rice. But then you look at their diet and they're eating half a watermelon a day or, you know, and their carbohydrate intake is actually very high. So these sort of hidden carbs are a part of the problem and convenience foods are notoriously high in them, let's face it.

Dr Gavin Nimon:

If we look at, um, calories and carbohydrate levels, do they, are they basically the same? Is it another way of measuring carbohydrate when you look at calories?

Nick Wray - Dietitian:

No, because calories encompass all of your macronutrients. So, carbohydrates, fats and proteins all have a, and alcohol, all have a caloric value. So, if you're on a 1200 calorie diet, it's, it's adding up all of those. Sources of calories, right? And this is an important point. A lot of people, I think, might be on a calorie restricted diet. So, say, they're counting their calories, they're on 1200, and they're not losing weight. You put them on the exact same calorie diet, 1200, but you lower the proportion coming from carbs and you increase the proportion coming from healthy fats and proteins, they start losing weight. Even though they're on exactly the same calorie diet. Purely and simply because they're They're not making as much insulin.

Dr Gavin Nimon:

Well, you've touched on alcohol actually, which I haven't talked about. Obviously, I don't advocate large amounts of alcohol, but in society, people do tend to drink alcohol. On the AFL grand final day coming up, what alcohol would you choose to drink as a healthy diet? Would you choose red wine, which everyone promotes as a antioxidant? Or is it, would you go for a pure spirit as a pure alcohol, but avoiding the fizzy juice? Or would you go for a fizzy juice one, which actually dilutes it? Or would you consider beer, which would obviously have a high carbohydrate level, but choose a low carbohydrate?

Nick Wray - Dietitian:

Well, good question. And they all have the same alcohol value, right? If you compare a stubby of beer to a shot of whiskey to a glass of wine, they all have around 10 grams of alcohol in them, right? 10 maybe as much as 15, but around 10. But the carbohydrate value varies enormously. You know, a low carb beer is 2 grams of carbs. A normal beer is 10. A glass of red wine won't have much carb in it at all, because it's a very dry wine. A glass of sweet, um, Moselle or something could have huge amounts of carbs in it. So, to answer your question, I will probably have a few drinks on Grand Vinyl Day, and I will drink low carb beer and probably a little bit of red wine. That would be my choice. But I think people just got to be careful when, you know, we all know the guidelines on not having too much alcohol, that's obvious, but a lot of alcoholic drinks are full of carbs, so you've got to be very careful with what you choose. And a lot of these pre made, you know, cans of drinks have a lot of sugar in them, yes.

Dr Gavin Nimon:

What about the

Nick Wray - Dietitian:

caffeine in these drinks, too? Where does caffeine fit into this? Caffeine is certainly added to energy drinks and things like that, absolutely. Purely and simply, it's a stimulant, so we all know caffeine does that and picks you up a little bit. That's why they put them in energy drinks. It doesn't really have a metabolic function in our body. It could certainly upset people with bad reflux disease, because it's a gastric irritant. So, I see a lot of people with reflux and of course we have to be very careful how much caffeine they drink and alcohol for that matter, because they're the two biggest triggers for acid production in the stomach. But for people without that, modest amounts of caffeine are fine because of its stimulatory effect. Of course, the sports industries use them, use caffeinated drinks. A long time ago, they made caffeine no longer a banned substance. Because everyone's absorption was different, so they decided let's just lift the ban. So, yeah, a lot of sporting teams tried using caffeine and using higher doses of caffeine and, you know, the experience I've had is it helps some people, but You know, when you play a night game, for example, then they can't get to sleep. Dry mouth, uh, is a common complaint. So, you know, a lot of players, a lot of people are, sort of, used it in May have tried it and used it for a little while, but I don't think I don't think it's that widely used these days. But it is legal, you know, caffeine is not an illegal substance.

Dr Gavin Nimon:

What about carbonated drink? Does that have a negative effect on nutrition or metabolism? Not to my knowledge.

Nick Wray - Dietitian:

Certainly after certain surgeries, we avoid anything carbonated because of discomfort and things like that. But no, I'm not, I'm not aware of any, correct me if I'm wrong out there, people out there, but I'm not aware of anything that carbon dioxide is going to do in a fizzy drink. Of course, most of the energy drinks, some of them are fizzy, but some of them are not, but most of the sports drinks, of course, they're not carbonated only because of comfort reasons.

Dr Gavin Nimon:

And what's your approach to actually dealing with patients who have allergies? How do you provide nutrition in that scenario if they're on a restricted diet for other reasons too?

Nick Wray - Dietitian:

Yeah, look, it depends on, of course, what allergy they have. If they're anaphylactic to peanuts, well, you've got to take that pretty seriously, obviously. But someone would be very unlucky to have allergies. Multiple allergies that would restrict huge food groups in their diet. It's very unusual to come across someone who's got, you know, eight allergies and they're all anaphylactic and the poor person can barely eat anything. That would be a very unlucky person. But food intolerances is an interesting one because We can't test for food intolerances. Of course, we can test for allergies, but food intolerances we can't test for, but they're quite prevalent. I see a lot of people in the irritable bowel group of patients and we use low FODMAP diet very successfully to treat most people with IBS, but 20 percent will fail FODMAP. So I see a lot of those having salicylate intolerances because Salicylate is a classic food chemical that can affect the gut, so they can get bloating and tummy pains and all the typical irritable bowel symptoms. But this group of patients also will typically have other symptoms, you know, they'll have nausea, they'll have very nasty skin irritation or itchy patches, they'll have, you know, Shortness of breath that's not explained. They'll have fatigue and irritability. So, unfortunately, they're a much more difficult group because it's trial and error. You have to remove that salicylate from their diet and see if it, if it helps them. But, um, but again, you know, these are legitimate allergies and tolerances out there that people do suffer from that I think the average person thinks, you know, is easy to manage, but they're not.

Dr Gavin Nimon:

What's the best way to sort of determine exactly how good or bad general health and diet. What would you recommend, is there some sort of CSIRO measurements you can use or some sort of a recommendation that the average person could do before coming to see someone like yourself?

Nick Wray - Dietitian:

Not that I'm aware of! That's a very good question. I guess you can put your diet through one of these free apps that people can download and it will tell you your Your nutrient profile, et cetera, et cetera, and that the app itself will set you targets of what they think is appropriate for your age and your weight and things like that. But none of that's personalized, that you couldn't really make a good nutrition assessment based on something like that. It would just give you a guideline as to what you're eating and, and, um, what targets perhaps that they set you. But I, often I look at those targets that are set for people who come to me. And I disagree with them, you know, the, the algorithms that they use have way overestimated their calorie intake, for example. So I'm not aware of anything that you can just plug in and get a good health assessment of yourself. It's really difficult, you know, you've got to look at, as we've already discussed, we've got to look at everything about you, your exercise levels, your medical history. Your social history, all of that. And then we've got to actually take a diet history off you to see what you're currently eating. Is there an excess of carbs in your diet if you've got a fatty liver, for example? Well, we would need to reduce that because we know that That insulin will push fat into your liver because your liver has fat cells in it. Or, are you not having enough carbs because you're an elite athlete and you're telling me how tired you are? You've had a blood test with your GP and it's come back perfectly normal, but you're just not consuming enough carbs because you're running 80 kilometers a week. These are the sorts of things that we see. So, it really is not a simple task to come up with the right approach for each personal individual.

Dr Gavin Nimon:

Obviously in the media at the moment there's medications that help you with previous satiety,

Nick Wray - Dietitian:

Zempik,

Dr Gavin Nimon:

one of the ones that's well known. Are there any natural forms of things you can do to help that? There's no

Nick Wray - Dietitian:

magic pill or powder or, you know, you and I would invest in them heavily and make a fortune because this is huge business, obviously, to try and control people's appetites. All we know, I guess, is protein has the best satiety, best feeling of fullness. So do fats. So Eating a protein and fat rich. meal will certainly keep you fuller for longer compared to just a high carbohydrate meal. You think of it, if you come home from work and you're really hungry and you start eating some rice crackers before you know it, you've eaten the whole tWray, you know, because they just don't fill you up. But you start chewing on a piece of leftover chicken in the fridge, it sort of hits the spot. So, we know that protein and fats are important. Orthopaedics have better satiety, but there's really no preparations, natural preparations that will do what these new GLP 1 drugs are doing, which are extremely effective. So Azembig's obviously only meant to be for type 2 diabetics, but now we have Wegovy, which is Azembig's version for weight loss, and we have other medications. Sexender and Monjaro that are now specifically designed just for weight loss. But they come at a cost because they're, of course, not on PBS. So, you know, they come at a big cost to the consumer, unfortunately.

Dr Gavin Nimon:

What's the role of things like carrots and celery? And I know they produce fiber. And I presume they've got low carbohydrate levels. What's the nutrition value for those things? And do they have any sense of filling you up as well? Or is that more of it as something to chew on?

Nick Wray - Dietitian:

Well, a bit of both. I mean, chewing, yes. Just the action of doing that is useful, but they do contain fibre. So they, that plays some role in, in filling you up to a degree. And they do, of course, all contain various vitamins and minerals that are of use to us. So they're not just inert sort of things. But. Again, you know, how many carrots can you eat when you're really, really hungry to fill you up? It's, uh, you know, you're going to turn orange at some stage. But they play a good role, absolutely. A lot of people that I help try and manage carbs better, they'll take a little box to work with them. And in there, they've got a little bit of carb, but they've got lots of carrot sticks and celery sticks, and maybe a little bit of cheese, maybe some hummus, maybe some protein. So they've got a bit of everything, but they're Not eating, you know, a hamburger and chips for lunch. They're trying to fill up on things, nuts and seeds and things that in their little bento box that, that will get them through the day without being starving hungry within the realms of the right amount of carbs for them.

Dr Gavin Nimon:

Probably the last question I've got for you today, Nick, and I really appreciate your time. Is the use of artificial intelligence, does it have a role as a dietitian?

Nick Wray - Dietitian:

Well, good question. For me, as a clinical dietitian, I've not yet seen anything that we could use that for. I'm sure my research dietitian colleagues will disagree with me, and so I have no doubt that in this space, We will be using AI at some stage that will be incredibly useful, I'm sure. Maybe that will be a screening type tool that you mentioned before, that you can sort of get a health profile and things like that of yourself. At this point in time, I haven't been able to, to find anything that would help me clinically. Was there anything else you'd like to add? Just, um, nutrition. It's not one size fits all. It is a complicated area. Obviously, everyone's an expert on nutrition. This is the, this is the point. You know, it's one of those very general topics that everyone's got an opinion and everyone's got experience with. So, You know, sometimes it's not easy to get out of people's heads things that they've read that perhaps aren't right for them. Because we all read stuff about nutrition and everyone's an expert and it's a fascinating thing for the food industry to get involved in. But at the end of the day, I think when you've got people who are at risk from a surgical point of view, they should be assessed. And when you've got people with, of course, chronic diseases, well, nutrition plays a big role. But for every day fit, healthy people, I'm sure they can find, you know, enough information themselves about what they should be doing. But one thing is for sure, the more research on one of the oldest diets in the world, the Mediterranean diet, seems to be a very good way to eat. We should be eating cleaner, we should be having less added sugars, we should be enjoying the healthy fats, having less red meat, having more fish. Exactly what the Mediterranean diet sort of is. involved. Even now, I work with Crohn's disease and we're seeing some evidence coming out about the use of Mediterranean diets in inflammatory bowel disease. So that's the first time I've ever seen that type of research. So, you know, it's one of the oldest diets in the world, but it's probably still the healthiest one I would, I would suspect.

Dr Gavin Nimon:

Excellent. Well, look, I really appreciate your time. Much, much appreciated. And, uh, Nick Wray, a clinical dietitian with 30 years of experience, co founder of 360Me Nutrition, and I really appreciate his experience on this. So thank you very much, Nick, for coming on Aussie Med Ed. Thank you, Gavin. No problem. I'd like to remind you that all the information presented today is just one opinion and that there are numerous ways of treating all medical conditions. It's just general advice and may vary depending upon the region in which you are practicing or being treated. The information may not be appropriate for your situation or health condition. And you should always seek the advice from your health professionals in the area in which you live. Also, if you have any concerns about the information raised today, please speak to your GP or seek assistance from health organisations such as Lifeline in Australia. Thanks again for listening to the podcast, and please subscribe to the podcast for the next episode. Until then, please stay safe.

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