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Nutrition in Clinical Medicine

by Adrienne Youdim, MD, FACP

Nutritional deficiencies can often worsen health outcomes (whether a disorder is present or not), and some disorders (eg, malabsorption) can cause nutritional deficiencies. Also, many patients (eg, elderly patients during acute hospitalization) have unsuspected nutritional deficiencies that require treatment. Many medical centers have multidisciplinary nutrition support teams of physicians, nurses, dietitians, and pharmacists to help the clinician prevent, diagnose, and treat occult nutritional deficiencies.

Overnutrition may contribute to chronic disorders, such as cancer, hypertension, obesity, diabetes mellitus, and coronary artery disease. Dietary restrictions are necessary in many hereditary metabolic disorders (eg, galactosemia, phenylketonuria).

Evaluation of Nutritional Status

Indications for nutritional evaluation include undesirable body weight or body composition, suspicion of specific deficiencies or toxicities of essential nutrients, and, in infants and children, insufficient growth or development. Nutritional status should be evaluated routinely as part of the clinical examination for infants and children, the elderly, people taking several drugs, people with psychiatric disorders, and people with systemic disorders that last longer than several days.

Evaluating general nutritional status includes history, physical examination, and sometimes tests. If undernutrition is suspected, laboratory tests (eg, albumin levels) and skin tests for delayed hypersensitivity may be done (see Testing). Body composition analysis (eg, skinfold measurements, bioelectrical impedance analysis) is used to estimate percentage of body fat and to evaluate obesity (see Obesity : Diagnosis).

History includes questions about dietary intake, weight change, and risk factors for nutritional deficiencies and a focused review of systems (see Table: Symptoms and Signs of Nutritional Deficiency). A dietitian can obtain a more detailed dietary history. It usually includes a list of foods eaten within the previous 24 h and a food questionnaire. A food diary may be used to record all foods eaten. The weighed ad libitum diet, in which the patient weighs and writes down all foods consumed, is the most accurate record.

A complete physical examination, including measurement of height and weight and distribution of body fat, should be done. Body mass index (BMI)—weight(kg)/height(m)2, which adjusts weight for height (see Table: Body Mass Index (BMI)), is more accurate than height and weight tables. There are standards for growth and weight gain in infants, children, and adolescents (see Physical Growth of Infants and Children).

Distribution of body fat is important. Disproportionate truncal obesity (ie, waist/hip ratio > 0.8) is associated with cardiovascular and cerebrovascular disorders, hypertension, and diabetes mellitus more often than fat located elsewhere. Measuring waist circumference in patients with a BMI of < 35 helps determine whether they have truncal obesity and helps predict risk of diabetes, hypertension, hypercholesterolemia, and cardiovascular disorders. Risk is increased if waist circumference is > 102 cm (> 40 in) in men or > 88 cm (> 35 in) in women.

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