Medical Nutrition and Disease

A Case-Based Approach

Lisa Hark, Darwin Deen, Gail Morrison

• Publisher: Wiley-Blackwell
• Year: 2014
• ISBN:
  9781118652428
• Edition: 5
• Topic: Medicine
• Subtopic: Medical Education

Medical Nutrition and Disease: A Case-Based Approach is an ideal way for medical students, physician assistant students, dietetic students, dietetic interns, and medical residents to advance their nutrition knowledge and skills. Dietitians in clinical practice and dietetic educators will also benefit from the updated nutrition concepts and case-based approach. The 5th edition of this best-selling text has been fully updated and includes 13 chapters and 29 cases, with 6 brand new cases. Medical Nutrition and Disease:
•Features learning objectives and current references in every chapter and case
•Teaches you how to diagnose and manage nutritional problems, integrate nutrition into clinical practice, and answer your patients' most common questions
•Includes nutritional advice forchildren, teenagers, pregnant women, and older adults
•Includes contributions from nationally recognized nutritionists and physicians who teach nutrition in medical schools, and undergraduate and dietetic programs

Part I
Fundamentals of Nutrition Assessment

1
Overview of Nutrition Assessment in Clinical Care

Lisa Hark¹, Darwin Deen², and Alix J. Pruzansky³

¹ Jefferson Medical College, Philadelphia, PA

² City College of New York, New York, NY

³ The Permanente Medical Group, Oakland, CA

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Objectives

• Recognize the value of nutrition assessment in the comprehensive care of ambulatory and hospitalized patients.
• Obtain an appropriate patient history, including medical, family, social, nutrition/dietary, physical activity, and weight histories; use of prescription and over-the-counter medicines, dietary and herbal supplements; and consumption of alcohol and other recreational drugs.
• Demonstrate how to interpret physical findings that reflect nutritional status, including body mass index, waist circumference, growth and development, and signs of nutritional deficiency.
• Describe the diagnosis, prevalence, health consequences, and etiology of obesity and malnutrition.
• Identify the most common physical findings associated with vitamin/mineral deficiencies or excesses.
• List the laboratory measurements commonly used to assess the nutritional status of patients.

Source: Objectives for chapter and cases adapted from the NIH Nutrition Curriculum Guide for Training Physicians. (www.nhlbi.nih.gov/funding/training/naa)

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Nutrition Assessment in Clinical Care

Nutrition assessment is the evaluation of an individual's nutritional status based on the interpretation of clinical information. Nutrition assessment is important because obesity and malnutrition are common in the clinical setting. The purpose of nutrition assessment is to:

• accurately evaluate an individual's dietary intake and nutritional status,
• determine if medical nutrition therapy and/or counseling is needed,
• monitor changes in nutritional status, and
• evaluate the effectiveness of nutritional interventions.

Accurate nutritional assessment leads to correct diagnosis and treatment. Many patients can benefit from medical nutrition therapy (MNT) using established evidence-based protocols.

Integrating Nutrition into the Medical History and Physical Examination

The following illustrates how nutrition can be integrated into all components of the clinical assessment, including the medical history, diet history, review of systems, physical examination, laboratory data, and treatment plan.

Medical History

Past Medical History

Standard past medical history including immunizations, hospitalizations, surgeries, major injuries, chronic illnesses, and significant acute illnesses may have nutritional implications. Detailed information should be obtained about current or recent medication use including vitamins, minerals, laxatives, topical medications, over-the-counter medications, and products such as nutritional or herbal supplements which patients frequently fail to report as medications. Nutritional supplements include any products that may alter caloric, vitamin, or protein intake. Whether the patient has any known food allergies (i.e., peanut, gluten) or suffers from lactose (milk) intolerance is also important.

Family History

In assessing risk for future diseases, patients are asked to identify their parents, siblings, children, and partner, give their respective ages and health status, and indicate familial occurrences of disease or cause of death of any deceased family members. Family history of diabetes, cancer, heart disease, thyroid disease, obesity, hypertension, osteoporosis, food allergies, eating disorders, or alcoholism should be ascertained. Food sensitivity may be based on inherited immune system characteristics and family history of food intolerance should be assessed.

Social History

The diet history is typically obtained as part of the patients' social history because socioeconomic factors such as who the patient lives with and what resources they have available influence food selection and preparation. Pertinent non-medical information recorded in the social history includes the patient's occupation, daily exercise pattern, and marital and family status. Information should be solicited regarding the patient's education, economic status, residence, emotional response and adjustment to illness, and any other information that might influence the patient's understanding of his or her illness and adherence to a nutritional therapy. Details concerning the duration and frequency of the patient's use of substances such as alcohol, tobacco, illicit drugs, and caffeine are also documented. These data can be extremely useful when formulating the treatment plan. Economic limitations that influence access to an adequate diet, difficulties shopping for or preparing food, participation in feeding programs (e.g. Women, Infants, and Children (WIC), Meals on Wheels) are relevant aspects of the nutritional assessment.

The Importance of Taking a Diet History

The purpose of obtaining dietary information from patients is to assess their nutritional intake and establish a baseline from which to negotiate changes. Infants, children, adolescents, pregnant women, older adults, and patients with a family history of or who have diabetes, hypertension, heart disease, hyperlipidemia, obesity, eating disorders, alcoholism, osteoporosis, gastrointestinal or renal disease, cancer, or weight loss or gain should consistently be asked about their eating habits, even during routine visits. Relative strengths for each method of collecting dietary information are described in this section. In addition, patients' past and/or current dietary patterns, such as vegetarian or kosher diet practices, cultural background, and social situations should be considered during the interview. Family members who purchase and prepare foods should be invited for the interview process whenever possible. Diet-related questions may take a few minutes, if properly directed (See Table 1-1). Registered dietitians typically collect more detailed information from a diet history and make this information available to the physician, nurse practitioner, or physician assistant. This history may include information on food preferences, portion sizes, frequency of eating out, and emotional responses to eating. The detailed intake information can be used to determine calories, fat, protein, sodium, and fiber intake along with adequacy of vitamin and mineral intake can serve as a basis for counseling.

Table 1-1 Key Diet History Questions for Brief Intervention

Source: Lisa A. Hark, PhD, RD. 2014. Used with permission.

Questions for All Patients How many meals and snacks do you eat every day? Do you feel that you eat a healthy balanced diet? Why or why not? What do you like to drink during the day, including alcohol? How many glasses? How often do you eat fruits and vegetables? How often do you eat dairy products? Low-fat or regular type? How often do you eat out? What kinds of restaurants? Do you usually finish what is on your plate or leave food? How often do you exercise, including walking?

In addition to the questions above: Questions for Patients with Hyperlipidemia (Chapter 6) How often do you eat fatty meats? (hot dogs, bacon, sausage, salami, pastrami, corned beef) How often do you eat fish? How ...