FUNCTIONAL NUTRITIONAL ASSESSMENT: AN OPPORTUNITY NANCY M. STRANGE, RD, CNSD, CD CLINICAL NUTRITION...

FUNCTIONAL NUTRITIONAL FUNCTIONAL NUTRITIONAL ASSESSMENT: AN OPPORTUNITYASSESSMENT: AN OPPORTUNITY

NANCY M. STRANGE, RD, CNSD, CDNANCY M. STRANGE, RD, CNSD, CDCLINICAL NUTRITION SPECIALISTCLINICAL NUTRITION SPECIALIST

GENERAL SURGICAL OUTPATIENT SERVICESGENERAL SURGICAL OUTPATIENT SERVICESINDIANA UNIVERSITY HOSPITALINDIANA UNIVERSITY HOSPITAL

APRIL 12, 2012APRIL 12, 2012

FUNCTIONAL NUTRITIONAL FUNCTIONAL NUTRITIONAL ASSESSMENTASSESSMENT

OBJECTIVESOBJECTIVES

Following the completion of this presentation the Following the completion of this presentation the participant will be able to identify:participant will be able to identify:

DIET HISTORY TECHNIQUES THAT CONTRIBUTE TO IDENTIFICATION DIET HISTORY TECHNIQUES THAT CONTRIBUTE TO IDENTIFICATION OF VITAMIN AND MINERAL DEFICIENCIESOF VITAMIN AND MINERAL DEFICIENCIES

SUBJECTIVE SIGNS AND SYMPTOMS OF VITAMIN MINERAL SUBJECTIVE SIGNS AND SYMPTOMS OF VITAMIN MINERAL DEFICIENCIESDEFICIENCIES

PHYSICAL SIGNS OF VITAMIN AND MINERAL DEFECIENCIESPHYSICAL SIGNS OF VITAMIN AND MINERAL DEFECIENCIES

FUNCTIONAL NUTRITION FUNCTIONAL NUTRITION ASSESSMENTASSESSMENT

TRADITIONAL NUTRITIONAL ASSESSMENT TRADITIONAL NUTRITIONAL ASSESSMENT COMPONENTS INCLUDE:COMPONENTS INCLUDE:– ANTHROPOMETRIC MEASUREMENTSANTHROPOMETRIC MEASUREMENTS– MEDICAL HISTORYMEDICAL HISTORY– SOCIAL HISTORYSOCIAL HISTORY– MEDICATION HISTORYMEDICATION HISTORY– DIET HISTORYDIET HISTORY– PHYSICAL EXAMPHYSICAL EXAM– SUBJECTIVE STATEMENTSSUBJECTIVE STATEMENTS


COMPONENTS OF ANY NUTRITIONAL COMPONENTS OF ANY NUTRITIONAL ASSESSMENT ASSESSMENT

ALL ARE IMPORTANT PIECES TO THE PUZZLE ALL ARE IMPORTANT PIECES TO THE PUZZLE ALL HAVE VARYING LEVELS OF IMPORTANCE AND ALL HAVE VARYING LEVELS OF IMPORTANCE AND

APPLICATION BASED ON THE AREA OF NUTRITION APPLICATION BASED ON THE AREA OF NUTRITION PRACTICEPRACTICE

ALL COMBINE TO PROVIDE A NUTRITIONAL “PICTUREALL COMBINE TO PROVIDE A NUTRITIONAL “PICTURE” ”


WHAT IS IMPORTANT ABOUT THESE WHAT IS IMPORTANT ABOUT THESE COMPONENTSCOMPONENTS??

– DIET HISTORYDIET HISTORY– SUBJECTIVE SYMPTOMSSUBJECTIVE SYMPTOMS– PHYSICAL EXAMPHYSICAL EXAM


USE OF DIET HISTORY, SUBJECTIVE SYMPTOMS USE OF DIET HISTORY, SUBJECTIVE SYMPTOMS AND PHYSICAL EXAM AND PHYSICAL EXAM TOGETHER CAN IDENTIFY CAN IDENTIFY SIGNIFICANT PROBLEMS THAT IMPEDE AN SIGNIFICANT PROBLEMS THAT IMPEDE AN INDIVIDUAL’S FUNCTIONAL CAPACITY.INDIVIDUAL’S FUNCTIONAL CAPACITY.

COMBINATION WILL RESULT IN A HIGH RATE OF COMBINATION WILL RESULT IN A HIGH RATE OF IDENTIFICATION OF MICRONUTRIENT IDENTIFICATION OF MICRONUTRIENT DEFICIENCIESDEFICIENCIES

IDENTIFY METHODS FOR IMPROVED OUTCOMESIDENTIFY METHODS FOR IMPROVED OUTCOMES


IMPORTANCE OF USE AND INTEGRATION IMPORTANCE OF USE AND INTEGRATION OF THIS KNOWLEDGE: OF THIS KNOWLEDGE:

– PROVIDES A SERVICE TO THE MEDICAL TEAM PROVIDES A SERVICE TO THE MEDICAL TEAM THAT IS NOT PROVIDED IN ANY OTHER THAT IS NOT PROVIDED IN ANY OTHER DISCIPLINE.DISCIPLINE.

NUTRITION COMPONENTS OF A PHYSICAL EXAM ARE NUTRITION COMPONENTS OF A PHYSICAL EXAM ARE NOT TAUGHT IN MEDICAL SCHOOLSNOT TAUGHT IN MEDICAL SCHOOLS

IMPROVEMENT IN OUTCOMES:IMPROVEMENT IN OUTCOMES:– FOR THE PATIENT FOR THE PATIENT – REDUCTION IN INSTITUTIONAL EXPENDITURES REDUCTION IN INSTITUTIONAL EXPENDITURES


– IF YOU ARE ABLE TO IMPROVE IF YOU ARE ABLE TO IMPROVE OUTCOMES? OUTCOMES? PHYSICIANS CHANGE THEIR OPINIONS PHYSICIANS CHANGE THEIR OPINIONS

ABOUT NUTRITION, INCLUDE RD MORE ABOUT NUTRITION, INCLUDE RD MORE FREQUENTLY FREQUENTLY

ADMINISTRATION LISTENSADMINISTRATION LISTENSRD JOB SATISFACTION IS WONDERFULRD JOB SATISFACTION IS WONDERFUL


““WE STOPPED BY TO SAY THANK YOU FOR THE EXCELLENT WE STOPPED BY TO SAY THANK YOU FOR THE EXCELLENT CARE YOU PROVIDE FOR OUR PATIENTS. WHAT IS YOUR CARE YOU PROVIDE FOR OUR PATIENTS. WHAT IS YOUR NEXT PROJECT YOU ARE WORKING ON? HOW CAN WE NEXT PROJECT YOU ARE WORKING ON? HOW CAN WE HELP? ”HELP? ”

VICE PRESIDENT OF NURSING AND MEDICAL DIRECTOR @ IU VICE PRESIDENT OF NURSING AND MEDICAL DIRECTOR @ IU HOSPITAL ON ROUNDS – 3/27/2012HOSPITAL ON ROUNDS – 3/27/2012

““WE ONLY SAW DIETITIANS GIVING BOOST AND SNACKS SO WE ONLY SAW DIETITIANS GIVING BOOST AND SNACKS SO WE DECIDED THAT WE COULD DO THAT AND STOPPED WE DECIDED THAT WE COULD DO THAT AND STOPPED CALLING THEM. I CAN’T DO THAT FOR WHAT YOU DO. ”CALLING THEM. I CAN’T DO THAT FOR WHAT YOU DO. ”

25 YEAR SURGICAL RN, IU HOSPITAL, 6/201125 YEAR SURGICAL RN, IU HOSPITAL, 6/2011

““I HAVE LEARNED MORE FROM YOU IN 15 MINUTES THAN I I HAVE LEARNED MORE FROM YOU IN 15 MINUTES THAN I EVER HAVE IN THE PAST. “EVER HAVE IN THE PAST. “

PATIENT WITH CHRONIC NON HEALING WOUND, 11/2011PATIENT WITH CHRONIC NON HEALING WOUND, 11/2011


““THE MORE INFORMED YOU ARE, THE THE MORE INFORMED YOU ARE, THE MORE LIKELY YOU ARE TO BE MORE LIKELY YOU ARE TO BE PERFORMING A NUTRITION FOCUSED PERFORMING A NUTRITION FOCUSED PHYSICAL EXAM. THIS REAFFIRMS PHYSICAL EXAM. THIS REAFFIRMS THE DIETITIAN’S ROLE, AREA OF THE DIETITIAN’S ROLE, AREA OF EXPERTISE AND ADVANCED LEVEL EXPERTISE AND ADVANCED LEVEL OF PRACTICE”OF PRACTICE”

MP Kelly, 2005MP Kelly, 2005


START WITH THE BASICSSTART WITH THE BASICS– A KNOWLEDGE BASE OF HOW TO USE ALL A KNOWLEDGE BASE OF HOW TO USE ALL

COMPONENTS OF A NUTRITIONAL ASSESSMENT COMPONENTS OF A NUTRITIONAL ASSESSMENT IS ESSENTIALIS ESSENTIAL

DIET HISTORY, SUBJECTIVE SYMPTOMS AND DIET HISTORY, SUBJECTIVE SYMPTOMS AND PHYSICAL EXAM WORK BEST IN THE CONTEXT OF A PHYSICAL EXAM WORK BEST IN THE CONTEXT OF A FULL ASSESSMENTFULL ASSESSMENT

– NUTRITION PLAN OF CARE THAT IS CONCISE NUTRITION PLAN OF CARE THAT IS CONCISE AND CLEARAND CLEAR

FUNCTIONAL NUTRITIONAL FUNCTIONAL NUTRITIONAL ASSESSMENTSASSESSMENTS

– COMMUNICATECOMMUNICATE– DEVELOP RELATIONSHIPS WITH NURSES, DEVELOP RELATIONSHIPS WITH NURSES,

PHARMACISTS, PHYSICIANS, PHYSICIAN PHARMACISTS, PHYSICIANS, PHYSICIAN ASSISTANTS, PT, OT, SPEECH THERAPISTASSISTANTS, PT, OT, SPEECH THERAPIST

– INCLUDE THE NURSE IN YOUR INCLUDE THE NURSE IN YOUR SUGGESTED PLAN OF CARESUGGESTED PLAN OF CARE

– TAKE THE TIME TO COMMUNICATETAKE THE TIME TO COMMUNICATE


DIET HISTORYDIET HISTORY– GIVES YOU A CURRENT PICTURE OF THE PATIENTGIVES YOU A CURRENT PICTURE OF THE PATIENT– INCLUDE SUPPLEMENT USE IN THE DIET HISTORYINCLUDE SUPPLEMENT USE IN THE DIET HISTORY

– KNOW THE KEY NUTRIENTS IN FOOD GROUPS KNOW THE KEY NUTRIENTS IN FOOD GROUPS EFFICIENT- WHAT FOOD GROUP HAS TO BE THERE FOR EFFICIENT- WHAT FOOD GROUP HAS TO BE THERE FOR

SUFFICIENCY TO HAPPENSUFFICIENCY TO HAPPEN USE USDA.GOV NUTRIENT CONTENT OF FOOD GROUPS.USE USDA.GOV NUTRIENT CONTENT OF FOOD GROUPS.

– WHAT FOODS HAVE TO BE PRESENT FOR INTAKE TO BE WHAT FOODS HAVE TO BE PRESENT FOR INTAKE TO BE SUFFICIENT? SUFFICIENT?

EXAMPLE: RIBOFLAVINEXAMPLE: RIBOFLAVIN– IF DAIRY OR FORTIFIED PRODUCTS ARE NOT USED IN DIET IF DAIRY OR FORTIFIED PRODUCTS ARE NOT USED IN DIET

THEN IT IS VERY DIFFICULT TO OBTAIN SUFFICIENT RIBOFLAVIN THEN IT IS VERY DIFFICULT TO OBTAIN SUFFICIENT RIBOFLAVIN IN THE DIET IN THE DIET


DIET HISTORYDIET HISTORY– IMPORTANT FOR THE PATIENT TO IMPORTANT FOR THE PATIENT TO

UNDERSTAND WHY YOU ASK THE UNDERSTAND WHY YOU ASK THE QUESTIONS.QUESTIONS.

REMOVE THE “MORAL” VALUE OF FOOD FROM REMOVE THE “MORAL” VALUE OF FOOD FROM THE CONVERSATIONTHE CONVERSATION


DIET HISTORY – DIET HISTORY – – FOCUS TO SPECIFIC POPULATIONSFOCUS TO SPECIFIC POPULATIONS

WOUND HEALINGWOUND HEALING WICWIC LONG TERM CARELONG TERM CARE

– COMPLETE AT ANY POINT IN THE INTERVIEW COMPLETE AT ANY POINT IN THE INTERVIEW PROCESS PROCESS

– USE A SIMPLFIED FORM USE A SIMPLFIED FORM YOU ARE ONLY LOOKING FOR TRENDSYOU ARE ONLY LOOKING FOR TRENDS QUANTIFY WHAT PATIENT STATES QUANTIFY WHAT PATIENT STATES


SUBJECTIVE SYMPTOMSSUBJECTIVE SYMPTOMS– ARE KEY IN HELPING TO IDENTIFY NUTRITIONAL ARE KEY IN HELPING TO IDENTIFY NUTRITIONAL

ISSUES RELATED TO VITAMIN AND MINERAL ISSUES RELATED TO VITAMIN AND MINERAL DEFICIENCIESDEFICIENCIES

PATIENT’S GAIN CONFIDENCE IN THE SKILLS OF THE PATIENT’S GAIN CONFIDENCE IN THE SKILLS OF THE RD WHEN SUBJECTIVE SYMPTOMS CAN BE RELATED RD WHEN SUBJECTIVE SYMPTOMS CAN BE RELATED TO NUTRITION. TO NUTRITION.

PATIENT’S ARE YOUR BEST ADVOCATES, ESPECIALLY PATIENT’S ARE YOUR BEST ADVOCATES, ESPECIALLY WHEN RELATIVELY SIMPLE MEASURES IMPROVE WHEN RELATIVELY SIMPLE MEASURES IMPROVE THEIR SYMPTOMS AND QUALITY OF LIFETHEIR SYMPTOMS AND QUALITY OF LIFE


MOST NUTRIENT DEFICIENCIES HAVE A: MOST NUTRIENT DEFICIENCIES HAVE A: – LOOK LOOK – SOUNDSOUND– FEELFEEL

SOUND AND FEEL -SOUND AND FEEL - ARE SUBJECTIVE SYMPTOMS THAT ARE SUBJECTIVE SYMPTOMS THAT WILL BE EXPRESSED WHEN A DEFICIENCY IS PRESENTWILL BE EXPRESSED WHEN A DEFICIENCY IS PRESENT

USUALLY YOU WILL “HEAR” THE SYMPTOMS BEFORE YOU USUALLY YOU WILL “HEAR” THE SYMPTOMS BEFORE YOU SEE THE DEFICIENCIESSEE THE DEFICIENCIES

FUNCTIONAL NUTRITIONAL FUNCTIONAL NUTRITIONAL ASSESSEMENTASSESSEMENT

EXAMPLES: EXAMPLES:

FATIGUEFATIGUE- VITAMIN C, A, IRON, B12, - VITAMIN C, A, IRON, B12, B COMPLEXB COMPLEX

BURNING MOUTHBURNING MOUTH: B12, THRUSH, B COMPLEX: B12, THRUSH, B COMPLEX

SHORT TERM MEMORY ISSUESSHORT TERM MEMORY ISSUES: B12, B1, IRON, : B12, B1, IRON, IODINE IODINE

FOOD CRAVINGSFOOD CRAVINGS: WHAT IS FOOD GROUP : WHAT IS FOOD GROUP CRAVED? CHOCOLATE, CRAVED? CHOCOLATE,

SALTY, STARCHY?SALTY, STARCHY? TIME OF DAY THE FOOD CRAVING TIME OF DAY THE FOOD CRAVING

OCCURS?OCCURS?


NUTRITION PHYSCIAL EXAM STARTING THE PROCESSNUTRITION PHYSCIAL EXAM STARTING THE PROCESS

Routinely check for:Routinely check for:- Protein Calorie Malnutrition- Protein Calorie Malnutrition - Muscle Tissue- Muscle Tissue

- Adipose Tissue- Adipose Tissue- Vitamin Deficiencies- Vitamin Deficiencies - Scurvy, Beri-Beri, Pellegra, B 12, Riboflavin,- Scurvy, Beri-Beri, Pellegra, B 12, Riboflavin, B6B6- Mineral Deficiencies- Mineral Deficiencies - Zinc, Iron, Iodine- Zinc, Iron, Iodine

IF YOU ARE NOT LISTENING AND LOOKING FOR SOMETHING, YOU IF YOU ARE NOT LISTENING AND LOOKING FOR SOMETHING, YOU WILL LIKELY NOT SEE IT.WILL LIKELY NOT SEE IT.


PHYSICAL EXAM – GETTING STARTEDPHYSICAL EXAM – GETTING STARTED

– LOOK AT THE AVAILABLE PICTURES OF NUTRIENT LOOK AT THE AVAILABLE PICTURES OF NUTRIENT DEFICIENCIESDEFICIENCIES

– KNOW WHAT OTHER DIAGNOSIS’ RESULT IN SIMILAR KNOW WHAT OTHER DIAGNOSIS’ RESULT IN SIMILAR SKIN CHANGESSKIN CHANGES

MEDSCAPE HAS MULTIPLE EDUCATION TOOLS TO MEDSCAPE HAS MULTIPLE EDUCATION TOOLS TO HELP WITH THISHELP WITH THIS

YOU WILL HAVE TO DEFEND WHAT YOU ARE YOU WILL HAVE TO DEFEND WHAT YOU ARE DESCRIBING – IT IS JUST PART OF THE PROCESSDESCRIBING – IT IS JUST PART OF THE PROCESS

– LEARN WHAT AN EARLY OR LATE DEFICIENCY CAN LEARN WHAT AN EARLY OR LATE DEFICIENCY CAN LOOK LIKELOOK LIKE


PHYSICAL EXAMPHYSICAL EXAM

– TAKE THE NUTRITION TEXT BOOKS LITERALLYTAKE THE NUTRITION TEXT BOOKS LITERALLY

– KNOW “TIME TO DEFICIENCY”KNOW “TIME TO DEFICIENCY”

– DON’T ASK FOR LABS WITHOUT THE DIET HISTORY, DON’T ASK FOR LABS WITHOUT THE DIET HISTORY, SUBJECTIVE INFORMATION AND THE PHYSICAL EXAM – IT IS SUBJECTIVE INFORMATION AND THE PHYSICAL EXAM – IT IS WASTEFUL AND UNDERMINES YOUR CREDIBILITY WITH THE WASTEFUL AND UNDERMINES YOUR CREDIBILITY WITH THE MEDICAL TEAMMEDICAL TEAM

– PRACTICE ON YOURSELF, FAMILY OR YOUR PEERS PRACTICE ON YOURSELF, FAMILY OR YOUR PEERS THIS IS TO BECOME COMFORTABLE WITH TOUCHING, THIS IS TO BECOME COMFORTABLE WITH TOUCHING,

LOOKING AT SOMEONE ELSELOOKING AT SOMEONE ELSE

– UNDERSTAND THE PROCESS OF DIFFERENTIAL DIAGNOSISUNDERSTAND THE PROCESS OF DIFFERENTIAL DIAGNOSIS


VITAMIN C/ASCORBIC ACIDVITAMIN C/ASCORBIC ACID

DISEASE: SCURVYDISEASE: SCURVY

PRIMARY ROLES IN THE BODYPRIMARY ROLES IN THE BODY– ANTIOXIDANT THAT IS REQUIRED FOR THE SYNTHESIS ANTIOXIDANT THAT IS REQUIRED FOR THE SYNTHESIS

OF NOREPINEPHRINEOF NOREPINEPHRINE– REGENERATION OF VITAMIN EREGENERATION OF VITAMIN E– COLLAGEN SYNTHESISCOLLAGEN SYNTHESIS– CARNITINE SYNTHESISCARNITINE SYNTHESIS– HISTIDINE SYNTHESISHISTIDINE SYNTHESIS– ADRENAL STEROID SYNTHESISADRENAL STEROID SYNTHESIS– FUNCTIONS IN TYROSINE AND FOLATE METABOLISMFUNCTIONS IN TYROSINE AND FOLATE METABOLISM


VITAMIN C DEFICIENCY IDENTIFIEDVITAMIN C DEFICIENCY IDENTIFIED

– NHANES, 1994NHANES, 199410-14%10-14%

– NHANES, 2003-2004NHANES, 2003-20047.1% - SMOKERS AND LOWER INCOME AT 7.1% - SMOKERS AND LOWER INCOME AT

SIGNIFICANT RISKSIGNIFICANT RISK


VITAMIN C DEPLETIONVITAMIN C DEPLETION

– GENERAL OUTPATIENT POPULATIONGENERAL OUTPATIENT POPULATION6% OF GENERAL POPULATION6% OF GENERAL POPULATION51% OF DIABETIC POPULATION 51% OF DIABETIC POPULATION 40% OF CARDIAC/HLD PATIENTS40% OF CARDIAC/HLD PATIENTS

Journal of American College of Nutrition; 1998Journal of American College of Nutrition; 1998


RENAL FAILURE ON RRTRENAL FAILURE ON RRT– 20-25% RATE OF VITAMIN C DEFICIENCY20-25% RATE OF VITAMIN C DEFICIENCY

HOSPITALIZED PATIENTSHOSPITALIZED PATIENTS– MULTIPLE SINGLE CASE REPORTSMULTIPLE SINGLE CASE REPORTS

SURGICAL OUTPATIENT POPULATION AT IU:SURGICAL OUTPATIENT POPULATION AT IU:– SCURVY SEEN IN ~ 40% OF PATIENTS SEEN BY RDSCURVY SEEN IN ~ 40% OF PATIENTS SEEN BY RD– ALL AGE GROUPS, DIFFERING SOCIAL ECONOMIC ALL AGE GROUPS, DIFFERING SOCIAL ECONOMIC

STATUS, NOT ALWAYS POST SURGICAL OR HIGHER RISK STATUS, NOT ALWAYS POST SURGICAL OR HIGHER RISK CATEGORIESCATEGORIES


VITAMIN C DEFICIENCY VITAMIN C DEFICIENCY – DIET HISTORYDIET HISTORY

FRUITS AND VEGETABLESFRUITS AND VEGETABLES– NEED TO BE SPECIFIC NEED TO BE SPECIFIC

FORTIFIED FOODSFORTIFIED FOODS

-CEREALS, JUICES, DRINKS, PROTEIN -CEREALS, JUICES, DRINKS, PROTEIN BARSBARS

SOUR CANDIESSOUR CANDIES


SUBJECTIVE SYMPTOMS OF SCURVYSUBJECTIVE SYMPTOMS OF SCURVY– FATIGUEFATIGUE– LOWER EXTREMITY PAINLOWER EXTREMITY PAIN– ARTHRALGIASARTHRALGIAS– MYALGIASMYALGIAS– LASSITUDELASSITUDE– DEPRESSED MOOD/DEPRESSIONDEPRESSED MOOD/DEPRESSION– EASILY BRUISEDEASILY BRUISED– BLEEDING TENDER GUMSBLEEDING TENDER GUMS– DIARRHEADIARRHEA– TOBACCO USETOBACCO USE


HOW DO YOU CORRELATE THE SUBJECTIVE HOW DO YOU CORRELATE THE SUBJECTIVE SYMPTOMS WITH THE FUNCTION OF SYMPTOMS WITH THE FUNCTION OF VITAMIN C IN THE BODY? VITAMIN C IN THE BODY? – ASK THIS QUESTION WITH EACH FUNCTION OF ASK THIS QUESTION WITH EACH FUNCTION OF

THE NUTRIENTTHE NUTRIENT

EXAMPLE: FATIGUE WITH SCURVYEXAMPLE: FATIGUE WITH SCURVY– BLOOD LOSS FROM CAPILLARY BLOOD LOSS BLOOD LOSS FROM CAPILLARY BLOOD LOSS

WITH LOSS OF COLLEGEN SYNTHESIS; WITH LOSS OF COLLEGEN SYNTHESIS; – UNABLE TO SYNTHESIZE CARNITINEUNABLE TO SYNTHESIZE CARNITINE– DECREASED ADRENAL HORMONE SYNTHESISDECREASED ADRENAL HORMONE SYNTHESIS


PHYSICAL ASSESSMENTPHYSICAL ASSESSMENT– FOLLICULAR PETECHIEAFOLLICULAR PETECHIEA

EARLIER- BECOMES DARKER MORE PRONOUNCED AS DEFICIENCY EARLIER- BECOMES DARKER MORE PRONOUNCED AS DEFICIENCY CONTINUESCONTINUES

CAN BE MASKED BY VITAMIN A HYPERKERATOSISCAN BE MASKED BY VITAMIN A HYPERKERATOSIS EMBEDDED CORKSCREW HAIR IN THE HAIR FOLLICLE – LATER EMBEDDED CORKSCREW HAIR IN THE HAIR FOLLICLE – LATER

APPEARANCEAPPEARANCE

– BRUISING/PURPURA BRUISING/PURPURA EARLY AND ONGOINGEARLY AND ONGOING

– PEDAL EDEMAPEDAL EDEMA LATER, NON RESPONSIVE TO DIURETICSLATER, NON RESPONSIVE TO DIURETICS

– OFTEN SEEN WITH LOWER EXTREMITY CELLULITISOFTEN SEEN WITH LOWER EXTREMITY CELLULITIS

– JOINT SWELLINGJOINT SWELLING USUALLY MID TO LATE MANIFESTATIONUSUALLY MID TO LATE MANIFESTATION


PURPURAPURPURA


FOLLICULAR PETECHIEA FOLLICULAR PETECHIEA SWAN HAIRSWAN HAIR DX: WOUND HEALING FAILUREDX: WOUND HEALING FAILURE


SERUM VITAMIN C LEVEL: UNABLE TO BE SERUM VITAMIN C LEVEL: UNABLE TO BE MEASUREDMEASURED

DX: SEVERE MALNUTRITION DX: SEVERE MALNUTRITION WITH H/O R-N-Y WITH H/O R-N-Y 25 YEARS PRIOR;25 YEARS PRIOR; HAD NOT BEEN HAD NOT BEEN ABLE TO WALK FORABLE TO WALK FOR6 MONTHS DUE TO6 MONTHS DUE TOSCURVYSCURVY


ZINC DEFICIENCYZINC DEFICIENCY– NHANES III –35-45% RATE OF DEFICIENT NHANES III –35-45% RATE OF DEFICIENT

INTAKE IN INDIVIDUALS >60 YEARS OF INTAKE IN INDIVIDUALS >60 YEARS OF AGEAGE

– DEFICIENCY RATE OF 20-25% AFTER DEFICIENCY RATE OF 20-25% AFTER ADJUSTING FOR SUPPLEMENT INTAKEADJUSTING FOR SUPPLEMENT INTAKE


ZINC DEFICIENCYZINC DEFICIENCY

HIGHER RISK POPULATIONSHIGHER RISK POPULATIONS– > 50 YEARS OF AGE> 50 YEARS OF AGE– GASTROINTESTINAL DISEASESGASTROINTESTINAL DISEASES

MALABSORPTION, CHRONIC DIARRHEA, SBS, CELIAC, IFBDMALABSORPTION, CHRONIC DIARRHEA, SBS, CELIAC, IFBD– LIVER DISEASELIVER DISEASE– ALCOHOLICSALCOHOLICS– HIV/AIDSHIV/AIDS– SICKLE CELL DISEASESICKLE CELL DISEASE– DIABETESDIABETES– PREGNANCYPREGNANCY– VEGETARIANSVEGETARIANS– FOOD INSUFFICIENT POPULATIONSFOOD INSUFFICIENT POPULATIONS– EATING DISORDERSEATING DISORDERS– USE OF GASTRIC ACID REDUCTION MEDICATIONSUSE OF GASTRIC ACID REDUCTION MEDICATIONS


– FUNCTIONS OF ZINCFUNCTIONS OF ZINC

NEUROPEPTIDE FORMATIONNEUROPEPTIDE FORMATION

IMMUNE FUNCTIONIMMUNE FUNCTION

CATALYTIC ROLECATALYTIC ROLE– ~ 100 ZINC DEPENDANT ENZYMES~ 100 ZINC DEPENDANT ENZYMES– EXAMPLES: CARBONIC ANHYDRASE; SUPEROXIDE DISMUTASEEXAMPLES: CARBONIC ANHYDRASE; SUPEROXIDE DISMUTASE

REGULATORY ROLEREGULATORY ROLE– REGULATION OF GENE EXPRESSIONREGULATION OF GENE EXPRESSION

STRUCTURAL ROLESTRUCTURAL ROLE– ZINC FINGER, STABILIZES THE STRUCTURE ZINC FINGER, STABILIZES THE STRUCTURE – LOSS OF ZINC INCREASES BIOLOGICAL MEMBRANE SUSEPTTIBILITY TO OXIDATIVE LOSS OF ZINC INCREASES BIOLOGICAL MEMBRANE SUSEPTTIBILITY TO OXIDATIVE

DAMAGE, IMPAIRING THEIR FUNCTIONDAMAGE, IMPAIRING THEIR FUNCTION– HORMONE STRUCTURE; TESTOSTERONE SYNTHESIS REQUIRES ZINCHORMONE STRUCTURE; TESTOSTERONE SYNTHESIS REQUIRES ZINC

ZINC DEPLETION RESULTS IN ESTROGEN SYNTHESISZINC DEPLETION RESULTS IN ESTROGEN SYNTHESIS

– CELL SIGNALINGCELL SIGNALING HORMONE RELEASEHORMONE RELEASE NERVE IMPULSE INNERVATIONNERVE IMPULSE INNERVATION

– APOTOSISAPOTOSIS


FUNCTIONS OF ZINCFUNCTIONS OF ZINC STRUCTURAL ROLESTRUCTURAL ROLE

– ZINC FINGER, STABILIZES THE STRUCTURE ZINC FINGER, STABILIZES THE STRUCTURE – LOSS OF ZINC INCREASES BIOLOGICAL MEMBRANE LOSS OF ZINC INCREASES BIOLOGICAL MEMBRANE

SUSEPTTIBILITY TO OXIDATIVE DAMAGE, IMPAIRING SUSEPTTIBILITY TO OXIDATIVE DAMAGE, IMPAIRING THEIR FUNCTIONTHEIR FUNCTION

– HORMONE STRUCTURE; TESTOSTERONE SYNTHESIS HORMONE STRUCTURE; TESTOSTERONE SYNTHESIS REQUIRES ZINCREQUIRES ZINC

ZINC DEPLETION RESULTS IN ESTROGEN ZINC DEPLETION RESULTS IN ESTROGEN SYNTHESISSYNTHESIS

– CELL SIGNALINGCELL SIGNALING HORMONE RELEASEHORMONE RELEASE NERVE IMPULSE INNERVATIONNERVE IMPULSE INNERVATION

– CELLULAR APOTOSISCELLULAR APOTOSIS



ASK THE QUESTION: ASK THE QUESTION: – HOW DOES EACH FUNCTION DIFFER IF HOW DOES EACH FUNCTION DIFFER IF

ZINC DEFICIENCY EXISTS? ZINC DEFICIENCY EXISTS? – HOW DOES IT LOOK? HOW DOES IT LOOK? – HOW DOES IT SOUND? HOW DOES IT SOUND?



– EXAMPLE: IMMUNE FUNCTIONEXAMPLE: IMMUNE FUNCTION INCREASED CIRCULATING CORTICOIDSTEROIDSINCREASED CIRCULATING CORTICOIDSTEROIDS DECREASED LYMPHOCYTESDECREASED LYMPHOCYTES THYMIC ATROPHYTHYMIC ATROPHY

INDIVIDUAL REFERRED TO YOU BECAUSE OF DESIRE INDIVIDUAL REFERRED TO YOU BECAUSE OF DESIRE TO LOSE WEIGHT, DIFFICULTY MANAGING GLUCOSE TO LOSE WEIGHT, DIFFICULTY MANAGING GLUCOSE LEVELS; ABDOMINAL OBESITY; FREQUENT LEVELS; ABDOMINAL OBESITY; FREQUENT INFECTIONS INFECTIONS

HOW WOULD THE PHYSICAL EXAM HELP? HOW WOULD THE PHYSICAL EXAM HELP?



– EXAMPLE: GYNOMASTICA, MALEEXAMPLE: GYNOMASTICA, MALEDECREASED TESTOSTERONE SYNTHESIS DECREASED TESTOSTERONE SYNTHESIS

WITH INCREASED ESTROGEN SYNTHESISWITH INCREASED ESTROGEN SYNTHESISCOMPLAINT EXAMPLE: “I CAN’T LOSE COMPLAINT EXAMPLE: “I CAN’T LOSE

WEIGHT OR BUILD MUSCLE.”WEIGHT OR BUILD MUSCLE.”


ZINC DEFICIENCYZINC DEFICIENCY– DIET HISTORYDIET HISTORY

VEGETARIAN W/O USE OF LEAVENED VEGETARIAN W/O USE OF LEAVENED GRAINSGRAINS

ELIMINATION OF ZINC RICH FOODS FROM ELIMINATION OF ZINC RICH FOODS FROM DIET (CRUSTATIONS/BEEF/PORK)DIET (CRUSTATIONS/BEEF/PORK)

INFREQUENT USE OF BEAN, LEGUME, NUT INFREQUENT USE OF BEAN, LEGUME, NUT FAMILYFAMILY

HIGH INTAKE OF PHYTATES AND DAIRY HIGH INTAKE OF PHYTATES AND DAIRY


ZINC DEFICIENCYZINC DEFICIENCY– SUBJECTIVE SYMPTOMSSUBJECTIVE SYMPTOMS

BLAND TASTE CHANGESBLAND TASTE CHANGES EARLY SATIETYEARLY SATIETY ANOREXIA/NO INTEREST IN FOODANOREXIA/NO INTEREST IN FOOD LIGHT ADAPTATION ISSUESLIGHT ADAPTATION ISSUES DIARRHEADIARRHEA HAIR LOSS HAIR LOSS NIGHT BLINDNESSNIGHT BLINDNESS DEPRESSION, WITH INADEQUATE RESPONSE TO DEPRESSION, WITH INADEQUATE RESPONSE TO

MEDICATIONMEDICATION ACUTE ONSET? LOOK FOR PRECIPITATING EVENTACUTE ONSET? LOOK FOR PRECIPITATING EVENT



PHYSICAL EXAMPHYSICAL EXAM

– DRY FLAKY SKIN- LOWER EXTREMITIESDRY FLAKY SKIN- LOWER EXTREMITIES– NASOLABIAL SEBORRHEANASOLABIAL SEBORRHEA– DRY, REDDENED KNUCKLESDRY, REDDENED KNUCKLES– LEUKONYCHIALEUKONYCHIA– MALE GYNOMASTICA MALE GYNOMASTICA – HAIR LOSSHAIR LOSS– ECCHYMOSISECCHYMOSIS– FRAGILE SKIN DUE TO POOR SYNTHESIS OF COLLEGEN, FRAGILE SKIN DUE TO POOR SYNTHESIS OF COLLEGEN,

POOR PROTEIN SYNTHESISPOOR PROTEIN SYNTHESIS

FUNCTIONAL NUTRITIIONAL FUNCTIONAL NUTRITIIONAL ASSESSMENTASSESSMENT

DRY RED KNUCKLESDRY RED KNUCKLES


LEUKONYCHIALEUKONYCHIA


SEVERE ZINC DEFICIENCYSEVERE ZINC DEFICIENCY


CASE STUDYCASE STUDY– 56 YR OLD FEMALE WITH HISTORY OF 56 YR OLD FEMALE WITH HISTORY OF

BREAST CANCERBREAST CANCER

3 MONTHS OUT OF TREATMENT3 MONTHS OUT OF TREATMENTFAILURE TO THRIVEFAILURE TO THRIVENO DISEASE RECURRENCENO DISEASE RECURRENCE


CASE STUDY 1CASE STUDY 1– MEDICAL HISTORYMEDICAL HISTORY

HTNHTN BREAST CANCERBREAST CANCER HYPOTHYROIDHYPOTHYROID

– SOCIAL HISTORYSOCIAL HISTORY SINGLE, LIVES ALONESINGLE, LIVES ALONE CHILDREN LIVING WITH HER CURRENTLY DUE TO HER CHILDREN LIVING WITH HER CURRENTLY DUE TO HER

INABILITY TO CARE FOR HERSELFINABILITY TO CARE FOR HERSELF WHEEL CHAIR BOUND WHEEL CHAIR BOUND


CASE STUDY 1CASE STUDY 1– ANTHROPOMETRICSANTHROPOMETRICS

BMI: 32BMI: 32CBW: STABLECBW: STABLE

– DIET HISTORYDIET HISTORYDRINKS ONE STEAK AND SHAKE MILKSHAKE DRINKS ONE STEAK AND SHAKE MILKSHAKE

PER DAYPER DAYOCCASIONALLY EATS A FEW BITES OF SOUPOCCASIONALLY EATS A FEW BITES OF SOUP


CASE STUDY 1CASE STUDY 1– SUBJECTIVE SYMPTOMSSUBJECTIVE SYMPTOMS

FATIGUEFATIGUE TASTE CHANGES, DRY, SAWDUST TASTE CHANGES, DRY, SAWDUST UNABLE TO MAINTAIN BALANCEUNABLE TO MAINTAIN BALANCE PAINFUL FEETPAINFUL FEET NO DESIRE TO EATNO DESIRE TO EAT BLOATINGBLOATING DIARRHEADIARRHEA HAIR LOSSHAIR LOSS NIGHT VISION ISSUESNIGHT VISION ISSUES FAMILY REPORTS DECREASED ABILITY TO PROCESS FAMILY REPORTS DECREASED ABILITY TO PROCESS

INFORMATIONINFORMATION DEPRESSED AFFECT DEPRESSED AFFECT


PHYSICAL EXAMPHYSICAL EXAM– THRUSHTHRUSH– FRAGILE SKIN WITH CELLOPHANE APPEARANCEFRAGILE SKIN WITH CELLOPHANE APPEARANCE– BRUISINGBRUISING– FOLLICULAR PETECHIEAFOLLICULAR PETECHIEA– 3+ LOWER EXTREMITY EDEMA 3+ LOWER EXTREMITY EDEMA – ECCHYMOSISECCHYMOSIS– DRY FLAKY SKINDRY FLAKY SKIN– ATAXIAATAXIA– ANGULAR STOMATITISANGULAR STOMATITIS– CHEILOSISCHEILOSIS


CASE STUDY 1CASE STUDY 1 LABS: ANEMIA WITH MACROCYTIC LABS: ANEMIA WITH MACROCYTIC

PARAMETERSPARAMETERS ALBUMIN: 2.7 GM/DLALBUMIN: 2.7 GM/DL


ASSESSMENT:ASSESSMENT:– INADEQUATE ORAL INTAKE DUE TO INADEQUATE ORAL INTAKE DUE TO

MICRONUTRIENT DEFICIENCIES AS MICRONUTRIENT DEFICIENCIES AS EVIDENCED BY TASTE CHANGES, EVIDENCED BY TASTE CHANGES, SUBJECTIVE SYMPTOMS AND PHYSICAL SUBJECTIVE SYMPTOMS AND PHYSICAL EXAM RESULTSEXAM RESULTS


PLAN OF CAREPLAN OF CARE– TREATMENT OF THRUSHTREATMENT OF THRUSH– THIAMINE 100 MG/DAY X 7THIAMINE 100 MG/DAY X 7– MVI WITH MINERALS Q DAY WITH FOOD MVI WITH MINERALS Q DAY WITH FOOD – B COMPLEX 1X/DAY B COMPLEX 1X/DAY – ZINC 25 MG BID X 2 WEEKSZINC 25 MG BID X 2 WEEKS– VITAMIN C 500 MG TID X 2 WEEKSVITAMIN C 500 MG TID X 2 WEEKS– EDUCATION ON USE OF ORAL SUPPLEMENTS, EDUCATION ON USE OF ORAL SUPPLEMENTS,

FRUIT SMOOTHIES WITH PROTEIN, HYDRATION FRUIT SMOOTHIES WITH PROTEIN, HYDRATION ADEQUACYADEQUACY

– CHECK B12, VITAMIN D LEVELCHECK B12, VITAMIN D LEVEL– USE OF ACTIVE CULTURE YOGURT Q DAYUSE OF ACTIVE CULTURE YOGURT Q DAY


MONITORING AND EVALUATIONMONITORING AND EVALUATION– RETURN TO CLINIC IN 2 WEEKSRETURN TO CLINIC IN 2 WEEKS– CALL RD IF ANY ISSUESCALL RD IF ANY ISSUES

OUTCOMEOUTCOME– RETURNED TO CLINIC, DRIVING HERSELFRETURNED TO CLINIC, DRIVING HERSELF– NO LONGER REQUIRED HELP FROM FAMILY MEMBERSNO LONGER REQUIRED HELP FROM FAMILY MEMBERS– LOST 20. ALL OF FLUID FROM HER LOWER EXTREMITIES IS GONE. SHE LOST 20. ALL OF FLUID FROM HER LOWER EXTREMITIES IS GONE. SHE

WAS ABLE TO USE HER NORMAL SHOES INSTEAD ONLY HOUSE WAS ABLE TO USE HER NORMAL SHOES INSTEAD ONLY HOUSE SLIPPERS.SLIPPERS.

– HAS RETURNED TO EATING 3 MEALS/DAY WITH NORMAL HAS RETURNED TO EATING 3 MEALS/DAY WITH NORMAL VARIETY/VOLUME OF FOODVARIETY/VOLUME OF FOOD

– PATIENT WAS CONTINUED ON MVI WITH MINERALS, REDUCED DOSE OF PATIENT WAS CONTINUED ON MVI WITH MINERALS, REDUCED DOSE OF VITAMIN C TO 200 MG/DAY, ZINC CONTINUED FOR ADDITIONAL 14 DAY, VITAMIN C TO 200 MG/DAY, ZINC CONTINUED FOR ADDITIONAL 14 DAY, B COMPLEX DISCONTINUEDB COMPLEX DISCONTINUED

– MD INCREASED REFERRALS MD INCREASED REFERRALS – RD HAD A REALLY GOOD DAY RD HAD A REALLY GOOD DAY

REFERENCESREFERENCES Gropper, S.; Advanced Nutrition and Human Gropper, S.; Advanced Nutrition and Human

Metabolism, Fourth Edition, 2005Metabolism, Fourth Edition, 2005 Schleicher,R.;Carroll,M.; Serum Vitamin C and the Schleicher,R.;Carroll,M.; Serum Vitamin C and the

prevalence of Vitamin C deficiency in the United prevalence of Vitamin C deficiency in the United States; 2003-2004 NHANESStates; 2003-2004 NHANES

Schectman, G.; Byrd, J.; Gruchow, H. The Schectman, G.; Byrd, J.; Gruchow, H. The Influence of Smoking on Vitamin C Status in Influence of Smoking on Vitamin C Status in Adults. Am J Pub Health,1989Adults. Am J Pub Health,1989

Johnston, C.; Thompson, L.; Vitamin C Status of Johnston, C.; Thompson, L.; Vitamin C Status of an Outpatient Population. J AM Col Nutr, 17, No. an Outpatient Population. J AM Col Nutr, 17, No. 4, 366-3704, 366-370

Olmedo, J.; Yiannias, J.; Scurvy: a Disease Almost Olmedo, J.; Yiannias, J.; Scurvy: a Disease Almost Forgotten. Int J Derm 2006, 45, 909-913Forgotten. Int J Derm 2006, 45, 909-913

REFERENCESREFERENCES Mahan, K.L.; Escott-Stump, S.; Krause’s Food, Mahan, K.L.; Escott-Stump, S.; Krause’s Food,

Nutrition and Diet TherapyNutrition and Diet Therapy Prasad, A.; Beck, F.; Bao, B.; Zinc Prasad, A.; Beck, F.; Bao, B.; Zinc

Supplementation decreases incidence of Supplementation decreases incidence of infections in the elderly; effect of zinc on infections in the elderly; effect of zinc on generation of cytokines and oxidative stress. Am J generation of cytokines and oxidative stress. Am J Clin Nutr, 2007, 85, No.3, 837844Clin Nutr, 2007, 85, No.3, 837844

NIH Office of Dietary Supplements, Dietary NIH Office of Dietary Supplements, Dietary Supplement Fact SheetSupplement Fact Sheet

Fraker, Pamela J.; King, L.; Reprogramming of the Fraker, Pamela J.; King, L.; Reprogramming of the Immune System During Zinc Deficiency. Annu Immune System During Zinc Deficiency. Annu Rev Nutr 2004, 24:277-298Rev Nutr 2004, 24:277-298

Mohammad, M., et al; Zinc in Liver Disease Nutr Mohammad, M., et al; Zinc in Liver Disease Nutr Clin Pract 2012, 27: 8-20Clin Pract 2012, 27: 8-20

FUNCTIONAL NUTRITIONAL ASSESSMENT: AN OPPORTUNITY NANCY M. STRANGE, RD, CNSD, CD CLINICAL NUTRITION...

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