Nutrition-focused Physical Exams: The Past and Future of Dietetics Practice

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In cold winter months, red sores that won’t heal and appear on the corners of a patient’s mouth might be dismissed as dry skin. A physician would likely prescribe a skin ointment. This may treat the problem on a superficial level, but the actual issue could lie much deeper, and it’s in these moments that a dietitian can bring an essential perspective.

Where a physician may see an underlying disease as the cause, the dietitian will hypothesize that these sores could be related to a nutritional deficiency or excess. In this particular scenario, the dietitian sees evidence of a riboflavin deficiency.

Among dietitians, the old saying, “You are what you eat,” is taken to heart. As knowledgeable professionals, dietitians understand that the quantity, quality and type of nutrient taken into the body will impact a person’s physical health in a positive or negative way.

Being a relatively young science, the field of dietetics continues to develop and grow. Along with this growth, the dietitian’s role within the medical team is expanding. A recent example of this is the standardization of the assessment process used to establish a nutrition diagnosis. These guidelines were created so that dietitians can uncover all the evidence needed to pinpoint specific problems that can be resolved with nutritional intervention.

Subjective information — including diet recalls, food frequency questionnaires and patient statements — is some of the first evidence gathered during a nutritional assessment. Although useful, this information should be taken with a grain of salt since it runs the risk of containing inaccuracies and it must be tempered with objective data such as the patient’s diet specifics and history, weight and anthropometrics, clinical data such as medical history and a nutrition-focused physical exam (NFPE), biochemical data and nutrient/drug interactions and depletions.

A dietitian working in the hospital or clinical setting will have access to laboratory values such as serum albumin (plasma protein) to establish nutritional status. But in recent years, research has found that this lab value has more to do with a patient’s state of inflammation than it does nutritional status. Knowing the limitations of laboratory values, more dietitians are now actively practicing physical examination abilities to determine signs and symptoms of nutrient depletions and excesses. This advance in practice is opening new assessment avenues and creating new knowledge within the profession and essentially better nutritional care for patients.

NFPE is not a new concept. Since the 1400s, sailors who were out to sea for long periods of time feared scurvy when they noticed their sunken eyes, tender gums and swollen limbs. Many physicians at the time linked scurvy to poor hygiene on the boat, even declaring it to be contagious. It was not until the 1700s that James Lind revealed that lack of vitamin C was the actual cause, and he began treating the men with citrus fruit.

Some nutrient deficiencies or excesses are more obvious. For example, consider a patient with a cirrhotic liver. He may appear to have a normal body mass index due to ascites — an abnormal accumulation of fluid in the abdominal cavity. But a dietitian who takes a closer look at his arms could see that he also has tricep and bicep muscle wasting, which is a clear sign that he is not getting enough nutrients.

Dietitians provide a unique and useful health focus that other professions do not possess. Conducting a nutrition-focused physical examination is an undeniable way to show this to the medical community and, at the same time, better help those they care for. The more dietitians put its usefulness into practice, the more impact this type of advanced nutrition assessment is sure to have.

NOTE: Dr. W. James Brewer, DCN, RD, Chief of Nutrition and Environmental Services for Aleda E. Lutz VAMC, and co-creator and presenter of the “Nutrition-Focused Physical Examination — Enhancing Your Clinical Toolbox”, helped provide source content for this blog post.

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Bethany Oxender
Bethany Oxender, MS, RDN, is a clinical dietitian based in Ann Arbor, MI, specializing in weight management. Follow her on Twitter or Instagram and read her blog, Bethany Grey.