FUNCTIONAL NUTRITIONAL ASSESSMENT: AN OPPORTUNITY

1. FUNCTIONAL NUTRITIONAL ASSESSMENT: AN OPPORTUNITY NANCY M. STRANGE, RD, CNSD, CD CLINICAL NUTRITION SPECIALIST GENERAL SURGICAL OUTPATIENT SERVICES INDIANA UNIVERSITY HOSPITAL APRIL 12, 2012

2. FUNCTIONAL NUTRITIONAL ASSESSMENT • OBJECTIVES • Following the completion of this presentation the participant will be able to identify: • DIET HISTORY TECHNIQUES THAT CONTRIBUTE TO IDENTIFICATION OF VITAMIN AND MINERAL DEFICIENCIES • SUBJECTIVE SIGNS AND SYMPTOMS OF VITAMIN MINERAL DEFICIENCIES • PHYSICAL SIGNS OF VITAMIN AND MINERAL DEFECIENCIES

3. FUNCTIONAL NUTRITION ASSESSMENT • TRADITIONAL NUTRITIONAL ASSESSMENT COMPONENTS INCLUDE: • ANTHROPOMETRIC MEASUREMENTS • MEDICAL HISTORY • SOCIAL HISTORY • MEDICATION HISTORY • DIET HISTORY • PHYSICAL EXAM • SUBJECTIVE STATEMENTS

4. FUNCTIONAL NUTRITIONAL ASSESSMENT • COMPONENTS OF ANY NUTRITIONAL ASSESSMENT • ALL ARE IMPORTANT PIECES TO THE PUZZLE • ALL HAVE VARYING LEVELS OF IMPORTANCE AND APPLICATION BASED ON THE AREA OF NUTRITION PRACTICE • ALL COMBINE TO PROVIDE A NUTRITIONAL “PICTURE”

5. FUNCTIONAL NUTRITIONAL ASSESSMENT • WHAT IS IMPORTANT ABOUT THESE COMPONENTS? • DIET HISTORY • SUBJECTIVE SYMPTOMS • PHYSICAL EXAM

6. FUNCTIONAL NUTRITIONAL ASSESSMENT • USE OF DIET HISTORY, SUBJECTIVE SYMPTOMS AND PHYSICAL EXAM TOGETHER CAN IDENTIFY SIGNIFICANT PROBLEMS THAT IMPEDE AN INDIVIDUAL’S FUNCTIONAL CAPACITY. • COMBINATION WILL RESULT IN A HIGH RATE OF IDENTIFICATION OF MICRONUTRIENT DEFICIENCIES • IDENTIFY METHODS FOR IMPROVED OUTCOMES

7. FUNCTIONAL NUTRITIONAL ASSESSMENT • IMPORTANCE OF USE AND INTEGRATION OF THIS KNOWLEDGE: • PROVIDES A SERVICE TO THE MEDICAL TEAM THAT IS NOT PROVIDED IN ANY OTHER DISCIPLINE. • NUTRITION COMPONENTS OF A PHYSICAL EXAM ARE NOT TAUGHT IN MEDICAL SCHOOLS • IMPROVEMENT IN OUTCOMES: • FOR THE PATIENT • REDUCTION IN INSTITUTIONAL EXPENDITURES

8. FUNCTIONAL NUTRITIONAL ASSESSMENT • IF YOU ARE ABLE TO IMPROVE OUTCOMES? • PHYSICIANS CHANGE THEIR OPINIONS ABOUT NUTRITION, INCLUDE RD MORE FREQUENTLY • ADMINISTRATION LISTENS • RD JOB SATISFACTION IS WONDERFUL

9. FUNCTIONAL NUTRITIONAL ASSESSMENT

10. FUNCTIONAL NUTRITIONAL ASSESSMENT • “WE STOPPED BY TO SAY THANK YOU FOR THE EXCELLENT CARE YOU PROVIDE FOR OUR PATIENTS. WHAT IS YOUR NEXT PROJECT YOU ARE WORKING ON? HOW CAN WE HELP? ” • VICE PRESIDENT OF NURSING AND MEDICAL DIRECTOR @ IU HOSPITAL ON ROUNDS – 3/27/2012 • “WE ONLY SAW DIETITIANS GIVING BOOST AND SNACKS SO WE DECIDED THAT WE COULD DO THAT AND STOPPED CALLING THEM. I CAN’T DO THAT FOR WHAT YOU DO. ” • 25 YEAR SURGICAL RN, IU HOSPITAL, 6/2011 • “I HAVE LEARNED MORE FROM YOU IN 15 MINUTES THAN I EVER HAVE IN THE PAST. “ • PATIENT WITH CHRONIC NON HEALING WOUND, 11/2011

11. FUNCTIONAL NUTRITIONAL ASSESSMENT • “THE MORE INFORMED YOU ARE, THE MORE LIKELY YOU ARE TO BE PERFORMING A NUTRITION FOCUSED PHYSICAL EXAM. THIS REAFFIRMS THE DIETITIAN’S ROLE, AREA OF EXPERTISE AND ADVANCED LEVEL OF PRACTICE” • MP Kelly, 2005

12. FUNCTIONAL NUTRITIONAL ASSESSMENT • START WITH THE BASICS • A KNOWLEDGE BASE OF HOW TO USE ALL COMPONENTS OF A NUTRITIONAL ASSESSMENT IS ESSENTIAL • DIET HISTORY, SUBJECTIVE SYMPTOMS AND PHYSICAL EXAM WORK BEST IN THE CONTEXT OF A FULL ASSESSMENT • NUTRITION PLAN OF CARE THAT IS CONCISE AND CLEAR

13. FUNCTIONAL NUTRITIONAL ASSESSMENTS • COMMUNICATE • DEVELOP RELATIONSHIPS WITH NURSES, PHARMACISTS, PHYSICIANS, PHYSICIAN ASSISTANTS, PT, OT, SPEECH THERAPIST • INCLUDE THE NURSE IN YOUR SUGGESTED PLAN OF CARE • TAKE THE TIME TO COMMUNICATE

14. FUNCTIONAL NUTRITIONAL ASSESSMENT • DIET HISTORY • GIVES YOU A CURRENT PICTURE OF THE PATIENT • INCLUDE SUPPLEMENT USE IN THE DIET HISTORY • KNOW THE KEY NUTRIENTS IN FOOD GROUPS • EFFICIENT- WHAT FOOD GROUP HAS TO BE THERE FOR SUFFICIENCY TO HAPPEN • USE USDA.GOV NUTRIENT CONTENT OF FOOD GROUPS. • WHAT FOODS HAVE TO BE PRESENT FOR INTAKE TO BE SUFFICIENT? • EXAMPLE: RIBOFLAVIN • IF DAIRY OR FORTIFIED PRODUCTS ARE NOT USED IN DIET THEN IT IS VERY DIFFICULT TO OBTAIN SUFFICIENT RIBOFLAVIN IN THE DIET

15. FUNCTIONAL NUTRITIONAL ASSESSMENT • DIET HISTORY • IMPORTANT FOR THE PATIENT TO UNDERSTAND WHY YOU ASK THE QUESTIONS. REMOVE THE “MORAL” VALUE OF FOOD FROM THE CONVERSATION

16. FUNCTIONAL NUTRITIONAL ASSESSMENT • DIET HISTORY – • FOCUS TO SPECIFIC POPULATIONS • WOUND HEALING • WIC • LONG TERM CARE • COMPLETE AT ANY POINT IN THE INTERVIEW PROCESS • USE A SIMPLFIED FORM • YOU ARE ONLY LOOKING FOR TRENDS • QUANTIFY WHAT PATIENT STATES

17. FUNCTIONAL NUTRITIONAL ASSESSMENT • SUBJECTIVE SYMPTOMS • ARE KEY IN HELPING TO IDENTIFY NUTRITIONAL ISSUES RELATED TO VITAMIN AND MINERAL DEFICIENCIES • PATIENT’S GAIN CONFIDENCE IN THE SKILLS OF THE RD WHEN SUBJECTIVE SYMPTOMS CAN BE RELATED TO NUTRITION. • PATIENT’S ARE YOUR BEST ADVOCATES, ESPECIALLY WHEN RELATIVELY SIMPLE MEASURES IMPROVE THEIR SYMPTOMS AND QUALITY OF LIFE

18. FUNCTIONAL NUTRITIONAL ASSESSMENT • MOST NUTRIENT DEFICIENCIES HAVE A: • LOOK • SOUND • FEEL SOUND AND FEEL - ARE SUBJECTIVE SYMPTOMS THAT WILL BE EXPRESSED WHEN A DEFICIENCY IS PRESENT USUALLY YOU WILL “HEAR” THE SYMPTOMS BEFORE YOU SEE THE DEFICIENCIES

19. FUNCTIONAL NUTRITIONAL ASSESSEMENT EXAMPLES: FATIGUE- VITAMIN C, A, IRON, B12, B COMPLEX BURNING MOUTH: B12, THRUSH, B COMPLEX SHORT TERM MEMORY ISSUES: B12, B1, IRON, IODINE FOOD CRAVINGS: WHAT IS FOOD GROUP CRAVED? CHOCOLATE, SALTY, STARCHY? TIME OF DAY THE FOOD CRAVING OCCURS?

20. FUNCTIONAL NUTRITIONAL ASSESSMENT NUTRITION PHYSCIAL EXAM STARTING THE PROCESS Routinely check for: - Protein Calorie Malnutrition - Muscle Tissue - Adipose Tissue - Vitamin Deficiencies - Scurvy, Beri-Beri, Pellegra, B 12, Riboflavin, B6 - Mineral Deficiencies - Zinc, Iron, Iodine IF YOU ARE NOT LISTENING AND LOOKING FOR SOMETHING, YOU WILL LIKELY NOT SEE IT.

21. FUNCTIONAL NUTRITIONAL ASSESSMENT PHYSICAL EXAM – GETTING STARTED • LOOK AT THE AVAILABLE PICTURES OF NUTRIENT DEFICIENCIES • KNOW WHAT OTHER DIAGNOSIS’ RESULT IN SIMILAR SKIN CHANGES • MEDSCAPE HAS MULTIPLE EDUCATION TOOLS TO HELP WITH THIS • YOU WILL HAVE TO DEFEND WHAT YOU ARE DESCRIBING – IT IS JUST PART OF THE PROCESS • LEARN WHAT AN EARLY OR LATE DEFICIENCY CAN LOOK LIKE

22. FUNCTIONAL NUTRITIONAL ASSESSMENT • PHYSICAL EXAM • TAKE THE NUTRITION TEXT BOOKS LITERALLY • KNOW “TIME TO DEFICIENCY” • DON’T ASK FOR LABS WITHOUT THE DIET HISTORY, SUBJECTIVE INFORMATION AND THE PHYSICAL EXAM – IT IS WASTEFUL AND UNDERMINES YOUR CREDIBILITY WITH THE MEDICAL TEAM • PRACTICE ON YOURSELF, FAMILY OR YOUR PEERS • THIS IS TO BECOME COMFORTABLE WITH TOUCHING, LOOKING AT SOMEONE ELSE • UNDERSTAND THE PROCESS OF DIFFERENTIAL DIAGNOSIS

23. FUNCTIONAL NUTRITIONAL ASSESSMENT • VITAMIN C/ASCORBIC ACID • DISEASE: SCURVY • PRIMARY ROLES IN THE BODY • ANTIOXIDANT THAT IS REQUIRED FOR THE SYNTHESIS OF NOREPINEPHRINE • REGENERATION OF VITAMIN E • COLLAGEN SYNTHESIS • CARNITINE SYNTHESIS • HISTIDINE SYNTHESIS • ADRENAL STEROID SYNTHESIS • FUNCTIONS IN TYROSINE AND FOLATE METABOLISM

24. FUNCTIONAL NUTRITIONAL ASSESSMENT • VITAMIN C DEFICIENCY IDENTIFIED • NHANES, 1994 • 10-14% • NHANES, 2003-2004 • 7.1% - SMOKERS AND LOWER INCOME AT SIGNIFICANT RISK

25. FUNCTIONAL NUTRITIONAL ASSESSMENT • VITAMIN C DEPLETION • GENERAL OUTPATIENT POPULATION • 6% OF GENERAL POPULATION • 51% OF DIABETIC POPULATION • 40% OF CARDIAC/HLD PATIENTS • Journal of American College of Nutrition; 1998

26. FUNCTIONAL NUTRITIONAL ASSESSMENT • RENAL FAILURE ON RRT • 20-25% RATE OF VITAMIN C DEFICIENCY • HOSPITALIZED PATIENTS • MULTIPLE SINGLE CASE REPORTS • SURGICAL OUTPATIENT POPULATION AT IU: • SCURVY SEEN IN ~ 40% OF PATIENTS SEEN BY RD • ALL AGE GROUPS, DIFFERING SOCIAL ECONOMIC STATUS, NOT ALWAYS POST SURGICAL OR HIGHER RISK CATEGORIES

27. FUNCTIONAL NUTRITIONAL ASSESSMENT • VITAMIN C DEFICIENCY • DIET HISTORY • FRUITS AND VEGETABLES • NEED TO BE SPECIFIC • FORTIFIED FOODS -CEREALS, JUICES, DRINKS, PROTEIN BARS • SOUR CANDIES

28. FUNCTIONAL NUTRITIONAL ASSESSMENT • SUBJECTIVE SYMPTOMS OF SCURVY • FATIGUE • LOWER EXTREMITY PAIN • ARTHRALGIAS • MYALGIAS • LASSITUDE • DEPRESSED MOOD/DEPRESSION • EASILY BRUISED • BLEEDING TENDER GUMS • DIARRHEA • TOBACCO USE

29. FUNCTIONAL NUTRITIONAL ASSESSMENT • HOW DO YOU CORRELATE THE SUBJECTIVE SYMPTOMS WITH THE FUNCTION OF VITAMIN C IN THE BODY? • ASK THIS QUESTION WITH EACH FUNCTION OF THE NUTRIENT • EXAMPLE: FATIGUE WITH SCURVY • BLOOD LOSS FROM CAPILLARY BLOOD LOSS WITH LOSS OF COLLEGEN SYNTHESIS; • UNABLE TO SYNTHESIZE CARNITINE • DECREASED ADRENAL HORMONE SYNTHESIS

30. FUNCTIONAL NUTRITIONAL ASSESSMENT • PHYSICAL ASSESSMENT • FOLLICULAR PETECHIEA • EARLIER- BECOMES DARKER MORE PRONOUNCED AS DEFICIENCY CONTINUES • CAN BE MASKED BY VITAMIN A HYPERKERATOSIS • EMBEDDED CORKSCREW HAIR IN THE HAIR FOLLICLE – LATER APPEARANCE • BRUISING/PURPURA • EARLY AND ONGOING • PEDAL EDEMA • LATER, NON RESPONSIVE TO DIURETICS • OFTEN SEEN WITH LOWER EXTREMITY CELLULITIS • JOINT SWELLING • USUALLY MID TO LATE MANIFESTATION

31. FUNCTIONAL NUTRITIONAL ASSESSMENT

32. FUNCTIONAL NUTRITIONAL ASSESSMENT • PURPURA

33. FUNCTIONAL NUTRITIONAL ASSESSMENT • FOLLICULAR PETECHIEA • SWAN HAIR • DX: WOUND HEALING FAILURE

34. FUNCTIONAL NUTRITIONAL ASSESSMENT • SERUM VITAMIN C LEVEL: UNABLE TO BE MEASURED • DX: SEVERE MALNUTRITION WITH H/O R-N-Y 25 YEARS PRIOR; • HAD NOT BEEN ABLE TO WALK FOR 6 MONTHS DUE TO SCURVY

35. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • NHANES III –35-45% RATE OF DEFICIENT INTAKE IN INDIVIDUALS >60 YEARS OF AGE • DEFICIENCY RATE OF 20-25% AFTER ADJUSTING FOR SUPPLEMENT INTAKE

36. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • HIGHER RISK POPULATIONS • > 50 YEARS OF AGE • GASTROINTESTINAL DISEASES • MALABSORPTION, CHRONIC DIARRHEA, SBS, CELIAC, IFBD • LIVER DISEASE • ALCOHOLICS • HIV/AIDS • SICKLE CELL DISEASE • DIABETES • PREGNANCY • VEGETARIANS • FOOD INSUFFICIENT POPULATIONS • EATING DISORDERS • USE OF GASTRIC ACID REDUCTION MEDICATIONS

37. FUNCTIONAL NUTRITIONAL ASSESSMENT • FUNCTIONS OF ZINC • NEUROPEPTIDE FORMATION • IMMUNE FUNCTION • CATALYTIC ROLE • ~ 100 ZINC DEPENDANT ENZYMES • EXAMPLES: CARBONIC ANHYDRASE; SUPEROXIDE DISMUTASE • REGULATORY ROLE • REGULATION OF GENE EXPRESSION • STRUCTURAL ROLE • ZINC FINGER, STABILIZES THE STRUCTURE • LOSS OF ZINC INCREASES BIOLOGICAL MEMBRANE SUSEPTTIBILITY TO OXIDATIVE DAMAGE, IMPAIRING THEIR FUNCTION • HORMONE STRUCTURE; TESTOSTERONE SYNTHESIS REQUIRES ZINC • ZINC DEPLETION RESULTS IN ESTROGEN SYNTHESIS • CELL SIGNALING • HORMONE RELEASE • NERVE IMPULSE INNERVATION • APOTOSIS

38. FUNCTIONAL NUTRITIONAL ASSESSMENT • FUNCTIONS OF ZINC • STRUCTURAL ROLE • ZINC FINGER, STABILIZES THE STRUCTURE • LOSS OF ZINC INCREASES BIOLOGICAL MEMBRANE SUSEPTTIBILITY TO OXIDATIVE DAMAGE, IMPAIRING THEIR FUNCTION • HORMONE STRUCTURE; TESTOSTERONE SYNTHESIS REQUIRES ZINC • ZINC DEPLETION RESULTS IN ESTROGEN SYNTHESIS • CELL SIGNALING • HORMONE RELEASE • NERVE IMPULSE INNERVATION • CELLULAR APOTOSIS

39. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • ASK THE QUESTION: • HOW DOES EACH FUNCTION DIFFER IF ZINC DEFICIENCY EXISTS? • HOW DOES IT LOOK? • HOW DOES IT SOUND?

40. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • EXAMPLE: IMMUNE FUNCTION • INCREASED CIRCULATING CORTICOIDSTEROIDS • DECREASED LYMPHOCYTES • THYMIC ATROPHY • INDIVIDUAL REFERRED TO YOU BECAUSE OF DESIRE TO LOSE WEIGHT, DIFFICULTY MANAGING GLUCOSE LEVELS; ABDOMINAL OBESITY; FREQUENT INFECTIONS • HOW WOULD THE PHYSICAL EXAM HELP?

41. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • EXAMPLE: GYNOMASTICA, MALE • DECREASED TESTOSTERONE SYNTHESIS WITH INCREASED ESTROGEN SYNTHESIS • COMPLAINT EXAMPLE: “I CAN’T LOSE WEIGHT OR BUILD MUSCLE.”

42. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • DIET HISTORY • VEGETARIAN W/O USE OF LEAVENED GRAINS • ELIMINATION OF ZINC RICH FOODS FROM DIET (CRUSTATIONS/BEEF/PORK) • INFREQUENT USE OF BEAN, LEGUME, NUT FAMILY • HIGH INTAKE OF PHYTATES AND DAIRY

43. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • SUBJECTIVE SYMPTOMS • BLAND TASTE CHANGES • EARLY SATIETY • ANOREXIA/NO INTEREST IN FOOD • LIGHT ADAPTATION ISSUES • DIARRHEA • HAIR LOSS • NIGHT BLINDNESS • DEPRESSION, WITH INADEQUATE RESPONSE TO MEDICATION • ACUTE ONSET? LOOK FOR PRECIPITATING EVENT

44. FUNCTIONAL NUTRITIONAL ASSESSMENT • ZINC DEFICIENCY • PHYSICAL EXAM • DRY FLAKY SKIN- LOWER EXTREMITIES • NASOLABIAL SEBORRHEA • DRY, REDDENED KNUCKLES • LEUKONYCHIA • MALE GYNOMASTICA • HAIR LOSS • ECCHYMOSIS • FRAGILE SKIN DUE TO POOR SYNTHESIS OF COLLEGEN, POOR PROTEIN SYNTHESIS

45. FUNCTIONAL NUTRITIIONAL ASSESSMENT • DRY RED KNUCKLES

46. FUNCTIONAL NUTRITIONAL ASSESSMENT • LEUKONYCHIA

47. FUNCTIONAL NUTRITIONAL ASSESSMENT • SEVERE ZINC DEFICIENCY

48. FUNCTIONAL NUTRITIONAL ASSESSMENT • CASE STUDY • 56 YR OLD FEMALE WITH HISTORY OF BREAST CANCER • 3 MONTHS OUT OF TREATMENT • FAILURE TO THRIVE • NO DISEASE RECURRENCE

49. FUNCTIONAL NUTRITIONAL ASSESSMENT • CASE STUDY 1 • MEDICAL HISTORY • HTN • BREAST CANCER • HYPOTHYROID • SOCIAL HISTORY • SINGLE, LIVES ALONE • CHILDREN LIVING WITH HER CURRENTLY DUE TO HER INABILITY TO CARE FOR HERSELF • WHEEL CHAIR BOUND

50. FUNCTIONAL NUTRITIONAL ASSESSMENT • CASE STUDY 1 • ANTHROPOMETRICS • BMI: 32 • CBW: STABLE • DIET HISTORY • DRINKS ONE STEAK AND SHAKE MILKSHAKE PER DAY • OCCASIONALLY EATS A FEW BITES OF SOUP