P
AULH
OLMANThere is no gold standard for determining nutritional status.
This chapter considers issues of nutritional assessment through history- taking, examination, and biochemical investigation. It is important to note at this stage that there are no absolute standards by which we may define mal- nutrition. The onset of nutritional deficiency is usually insidious and often obscured by coexistent illness, medication, and drug use. No one assessment technique, either clinical or biochemical, is a reliable indicator of deficiency except in the most severe cases. There is also a lack of comparative data among different assessment approaches.
DIETARY ASSESSMENT
Figure 6-1 is a shorthand overview of nutritional biochemistry that is useful to bear in mind when thinking about nutrients and their roles, but it is not an exhaustive treatment. The middle equation describing structure and reg- ulation is particularly useful in summing up the rationale behind many of our nutritional interventions.1It explains that essential fatty acids and amino acids are converted into structural and regulatory substances by means of enzymes that are usually dependent on B group vitamins and trace miner- als. Temperature, pH, and antioxidant status are all variables that affect the process. A host of other endogenous and exogenous substances including toxins, hormones, and phytochemicals may influence any one enzymatic process.
In the assessment of nutritional intake, there are two areas for considera- tion: the quantity of nutrients ingested and the adequacy of this intake for the individual. Genetic makeup is an important factor here (see Organic Acid Analysis).
The estimation of actual dietary intake is fraught with difficulties.
Retrospective methods of data collection, such as 24-hour recall, are depend- ent on memory and one can assume that there is underreporting of energy and nutrient intake by as much as 20%—even when a computer-assisted method is used. Accuracy may be improved somewhat by food frequency
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questionnaires, but this is time-consuming and still dependent on the vagaries of recall. Prospective methods such as food diaries may cause the subject to change eating habits or to consciously or unconsciously edit the record.
Having obtained an estimate of the dietary intake, one must decide how to process it. The data can be analyzed with a computer or “eyeballed” for a general impression of the number of portions from major food groups and the quality of food eaten. The former method is obviously more accurate but is still compromised by a number of factors including the following:
● The adequacy of the database for local conditions
● The variation in the nutrient content of foods and changing bioavailability
CARBOHYDRATES
FATS
B1, B2, B3, B5 Fe, Mg, Mn, CoQ10, lipoate B5, Carnitine
B1, B2, B3, B6, BiotinMg PROTEIN
B1, Mg
ENERGY
KREBS and Respiratory Chain
Amino acids
EFA's
B vitamins
Structural Components Enzymes, Nucleotides Hormones, etc
Membranes, Prostanoids, etc Trace Elements
STRUCTURE & REGULATION
FREE RADICAL CONTROL LIVER DETOX
PROTECTION & DETOXIFICATION
B gp C Mo S aminos phytonutrients A
C E Se Zn
Phytonutrients
FIG. 6-1 Overview of nutritional biochemistry. EFAs, Essential fatty acids; Se,selenium; Zn,zinc.
● Changing fortification patterns
● The production of “new” foods
● The use of supplements
● Many other confounding variables
In practice, I use 24-hour recall and then ask for a five-day diary before the next visit. I then “eyeball” the records for adequacy of portions and supple- ment this evaluation with a more detailed estimate of protein intake, using an abbreviated table of protein values. I emphasize protein because it is fre- quently inadequate in the patients that I encounter most often (i.e., women with chronic fatigue syndrome [CFS] or depression).
An estimate of nutrient intake level says nothing, of course, about the bioavailability of a nutrient for a particular individual. Usually, we cannot know about the issues of absorption, transport, cellular utilization, and loss.
Ultimately, an answer can only be found through a therapeutic trial of the nutrient concerned. The recommended daily allowance (RDA) is a very approximate guide to adequacy in any one individual. RDAs set by different expert committees across the world vary by a factor of two or greater. This reflects the ambiguity inherent in a blanket recommendation that is then applied to individuals. Thus the RDA is a sort of necessary fiction against which we can test the therapeutic and potentially toxic effects of our prescriptions.
It is almost routine for clients to be taking either herbal or nutritional sup- plements. It is essential for one to actually look at the bottles for content fig- ures, because there is a vast array of preparations that go by generic titles such as B complex. The actual content of similar-sounding preparations can vary 20-fold or more.
While discussing a client’s dietary pattern, it is also useful to ask about hypoglycemic symptoms. I do not attribute a great deal of etiologic signifi- cance to functional hypoglycemia but do regard it as an indicator of the ade- quacy of protein/carbohydrate ratios, as well as a manifestation of excess refined carbohydrate intake, stimulant use, and stress. Functional hypo- glycemia most commonly manifests as tiredness, irritability, and carbohy- drate or caffeine craving in the late morning or afternoon.
At this point, it is usually convenient to ask about medication and drug use, especially in view of the frequency and significance of medication- nutrient interactions. Possible problems should be flagged at this point in the history.
Nutrient Deficiency Symptoms
Figure 6-2 is a schema representing the progressive development of malnu- trition. Clinical symptoms of deficiency arise at a fairly advanced stage of the process. In prosperous, urbanized populations, gross deficiency symp- toms and signs will be uncommon. The subtle manifestations of deficiency will appear as changes in subjective feelings of well-being, especially in
regard to psychologic state and energy levels. The often progressive and insidious nature of nutritional deficiency means there is no clear-cut point at which malnutrition can be defined. There is no gold standard for determin- ing nutritional status because2:
● There is no universally accepted definition of malnutrition.
● Assessment parameters are affected by illness and injury.
● It is difficult to isolate the effects of malnutrition (on outcome) from coex- istent diseases.
● It is not clear which of the commonly used nutritional assessment tech- niques is the most valuable because of the paucity of comparative data.
As physicians, we must bear in mind these caveats while remaining cog- nizant of the fact that the symptoms and signs that we gather in our history- taking may be a reflection of disordered nutrition and may require further
Decreased availability of nutrient
Depletion of tissue reserve
Altered biochemical and physiological function
Subtle clinical symptoms/signs
Gross clinical symptoms/signs with tissue changes
Irreversible changes death
intake, absorption, utilization loss
Biochemical and metabolic studies
Clinical assessment
FIG. 6-2Progressive development of malnutrition.
investigative effort. Ultimately, however, it is the process of enlightened experimentation that will guide our therapeutic direction.
Table 6-1 is a list of symptoms and signs of deficiency compiled from a variety of sources, but especially textbook descriptions of classic severe defi- ciency syndromes such as beriberi and scurvy. Readers are strongly advised to familiarize themselves with the basic deficiency syndromes. The best and most detailed descriptions are to be found in older textbooks. Lonsdale3 found that the older descriptions provided a wealth of detail for his research into the effects of vitamin B1deficiency. The greater one’s familiarity with a deficiency syndrome, the more likely it is that one will recognize the highly attenuated versions of the syndromes that we see in everyday practice.
Occasionally, one will see an unambiguous deficiency sign such as angular stomatitis, especially among at-risk populations such as alcoholics or the elderly.
This table is not meant to be comprehensive and should be supplemented with other available information.4It has also been necessary to draw some arbitrary boundaries in a simple format like this. Thus the symptom of “dull hair” is mentioned with only protein and essential fatty acid deficiencies.
Since other nutrients, such as vitamin B6and zinc, contribute to healthy pro- tein synthesis, deficiencies of vitamin B6and zinc might also be associated with lusterless hair. It is axiomatic that nutrients work in teams and that there will frequently be overlap in their activities and therefore in the mani- festations of their deficiency. However, for clarity’s sake, I have largely con- fined myself to symptoms and signs that are described in the classic deficiency states. It is also for this reason that I have omitted a specific sign, white spots on the nails, because this manifestation is probably less specifi- cally attributable to zinc deficiency than originally thought.5
A number of anthropometric measures can be useful. Weight and height can be related in the body mass index (BMI), which acts as a guide to risks associated with obesity. Changes in body weight can result from a number of factors, including differences in hydration, edema, and fullness of the gas- trointestinal (GI) tract and bladder. Loss of muscle mass may be obscured by an increase in fat, as in age-related sarcopenia.
BMI = Weight (kg) / Height (m2)
Subcutaneous fat measurements do not necessarily reflect body stores.
There are numerous technical sources of error conspiring to produce inter- and intra-observer error. There is, of course, considerable research on skin- fold thickness variation, with triceps skinfold thickness tending to correlate with estimates of total body fat in women and children and subscapular skinfold thickness correlating with total body fat in men. Individuals with values above the tenth percentile for waist/hip ratio are at very high risk for adverse health consequences, especially cardiovascular disease and diabetes.
In a detailed constitutional assessment, triceps, subscapular and supraspinale (above the anterior superior iliac spine) are the key skinfold
TABLE 6-1 ■ Nutritional Deficiency: Symptoms and Signs
SYMPTOM PR EFA B1 B2 B3 B5 B6 B12 FOL BIOT C
Fatigue ✓ ✓ ✓ ✓ ✓ ✓ ✓
Mental Slowness ✓ ✓ ✓ ✓ ✓ ✓
Poor Memory ✓ ✓ ✓
Depression ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Anxiety ✓ ✓
Irritability ✓
Insomnia ✓ ✓ ✓ ✓ ✓ ✓
Sensitive to light ✓
Sensitive to sound ✓
Headache ✓ ✓
Burning sensation ✓ ✓
↓Taste/smell Night blindness
Burning eyes ✓
↓Appetite ✓ ✓ ✓ ✓
Indigestion ✓ ✓ ✓ ✓ ✓
Nausea ✓ ✓
Constipation ✓ ✓ ✓
Diarrhea ✓ ✓ ✓ ✓
Bleeding gums ✓
Muscle pain ✓
Leg cramps ✓
Calf pain ✓
Muscle weakness
Muscle twitching ✓
Joint pain ✓
↓Wound healing ✓ ✓ ✓ ✓
Dry skin ✓
Oily skin/acne ✓
Dermatitis ✓ ✓ ✓
Sebomhoeic dermatitis ✓ ✓ ✓ ✓
Excess perspiration
Hair loss ✓ ✓
Dull hair ✓ ✓
SIGN
Anemia ✓ ✓ ✓
↓Blood pressure ✓ ✓
Cardiac arrhythmia ✓
Glossitis ✓ ✓ ✓ ✓ ✓ ✓ ✓
Angular stomatitis ✓ ✓ ✓ ✓
Magenta tongue ✓ ✓ ✓
Papillary atrophy ✓ ✓ ✓
Koilonychia
Brittle nails N O N S P E C I F
Follicular keratosis ✓
Petechiae ✓
Perifollicular
hemorrhage ✓
Hyperpigmentation ✓ ✓ ✓ ✓
Parotid gland ✓
enlargement
Peripheral neuropathy ✓ ✓ ✓ ✓ ✓ ✓ ✓
E A D CA MG NA K ZN MN CU FE SE CR
✓ ✓ ✓ ✓ ✓ ✓ ✓
✓ ✓ ✓ ✓
✓ ✓ ✓ ✓
✓ ✓ ✓
✓ ✓ ✓
✓ ✓ ✓ ✓ ✓
✓ ✓
✓ ✓✓
✓ ✓ ✓ ✓
✓ ✓✓
✓ ✓ ✓
✓ ✓
✓ ✓ ✓
✓ ✓ ✓ ✓ ✓
✓ ✓ ✓ ✓ ✓
✓ ✓
✓ ✓
✓ ✓
✓ ✓
✓ ✓
✓ ✓
✓ ✓
✓ ✓
✓ ✓ ✓ ✓ ✓
✓✓
✓✓
I C
✓✓
measurements; maximum calf and biceps circumferences are taken for indices of muscle development and biepicondylar breadth of the femur and humerus as indices of bone size.6Height divided by the cube root of weight is taken as an index of linearity. However, for most clinical purposes, this measure of detail is not required to form an idea of constitutional type.
Since there is a relationship between enzyme kinetics and temperature, it would seem logical to get an idea of a patient’s average daily reading.
Surprisingly, there is little information on the relationship between body temperature and health; thus, we must rely on the clinical experience of the few investigators who have examined this topic. Barnes and Galton,7on the basis of results of metabolic studies, considered that early morning temper- ature reflected the basal metabolic rate and therefore thyroid function. This seems to be true in some cases, but it is apparent that low early morning tem- peratures may also reflect a poor adrenal response or a phase shift in the daily temperature cycle resulting from severe mood or sleep disturbance.
Low energy intake, a low early morning blood sugar level, or iron deficiency may produce a slight temperature change. Barnes and Galton recommend that the underarm temperature be taken with a mercury thermometer for 10 minutes before the individual leaves bed or stirs around much. Menstruat- ing women should do this on days 2, 3, and 4 of their cycle; all other indi- viduals may record their temperature at any time. Temperatures below 36.5˚C are considered less than optimal.
Wilson8prefers temperatures to be taken during the day 3 hours after ris- ing and at two subsequent 3-hour periods. Menstruating women should not record their temperature 3 days before menstruation when it is highest.
Wilson’s benchmark is 37.0˚C, taken orally with a mercury thermometer for 5 minutes. The problem with this approach is that there are clearly many variables that affect daytime temperature, including activity level, environ- mental temperature, food intake, body build, circadian and reproductive rhythms, and stress levels. However, Wilson believes that with a chart of suf- ficient duration, one can discern a pattern of substantially low temperatures, which can be used to guide therapy.
One can use both approaches, asking patients to record early morning temperature and having them obtain two subsequent readings at 3-hour intervals. A persistently low temperature tends to indicate hypometabolism, the cause of which needs to be investigated within the context of the other aspects of the clinical picture. Thus a modestly overweight, unstressed, ade- quately nourished, 40-year-old woman who has low temperatures in sum- mer is likely to have hypothyroidism. On the other hand, low temperatures in a chronically stressed, young, ectomorphic woman on a low-protein diet are likely to be of a nutritional or adrenal origin. Daily temperature record- ing can also be very useful for monitoring treatment. Successful treatment strategies are often reflected in an increase in average body temperature, a testimony to overall improvement in metabolic efficiency. The accurate lab- oratory determination of basal metabolic rate would be ideal for assessment and follow-up, but this is not usually practical.
Acid-base balance is the other crucial factor that can affect enzyme func- tion and many other facets of biochemical activity. Naturopathic literature, as well as some of the metabolic typing methods, places great emphasis on acid-base balance, often suggesting that unhealthy diets produce unfavor- able acidic conditions in the body. There is no evidence for these assertions.
The main determinant of blood and tissue pH is the blood carbon dioxide level, which is controlled largely by respiration. Carbon dioxide contributes 15 to 20 moles of volatile acid per day to the body. Contributions from other sources are minimal—about 1 mmol/kg from lactic acid with only 20 to 30 mmol from dietary protein. This underscores the importance of assessing respiration. Individuals with transient or chronic hyperventilation may experience a significant respiratory alkalosis with widespread effects on metabolism.9,10
Desktop capnometers that give a good estimate of lung arterial carbon dioxide levels are available. Individuals who are stressed frequently have alkalosis, and breath re-education is an absolute priority in their rehabilita- tion. In fact, other treatment methods will be of little value until a very faulty breathing pattern is corrected.
Typical Day
It is important to get a sense of the shape and content of daily life. A sim- ple chronological account from waking to retiring can be filled out with appropriate detail as necessary. It is particularly relevant to know whether a person eats regularly in a relaxed way or erratically in a rushed manner.
Are there mini-breaks during the day or does the person plough through till the evening in a mad rush? Does the person have time for herself and her enjoyment, or is she over-focused and constantly moving on to the next task?
The sleep history is conveniently taken at this point. Dement,11 who is probably the world’s leading authority on sleep disorders, has concluded that 50% of the North American population mismanage their sleep to the point at where it negatively affects health and safety. Dement also notes that Westerners tend to sleep 1 to 1¹⁄₂hours less than their great-grandparents. He believes that the majority of individuals need 1 hour of sleep for every 2 hours spent awake. Individuals apparently needing less are often building a massive sleep debt whose consequences may be anything from a serious accident to health problems such as myocardial infarction or CFS.
An individual’s biorhythmic style, whether that of a “lark” or an “owl,”
may give some idea as to his or her resilience to seasonal changes and travel over different time zones. Larks seem to be able to adjust their clocks rapidly, whereas owls need extra help to adapt to a new rhythm; consequently they may experience more sleep, mood, and health problems with a change in season, especially during autumn and spring. Seasonal mood changes are, of course, very common, and it is essential to ask whether an individual expe- riences a lowering of mood during the winter months.
The account of an individual’s typical day will also give some idea of the sort of stress levels that he or she is experiencing. One can draw conclusions about coping style and resilience as one gets to know the person concerned.
Food Sensitivity
Food sensitivity is an important and vast subject, and the summary here is only of an introductory nature. This section does not cover the areas of inhalant and chemical problems, but it is important to remember that diffi- culties in these areas can precipitate or exacerbate food sensitivity.
The terms food allergy, intolerance, and sensitivity are often confused.
Normally, a distinction is made between food allergy and food intolerance.
The term food allergydescribes an immediate reaction to small amounts of a food or food substance, and such reactions are usually immunoglobulin E mediated and persist for life. Individuals are usually well aware that they have the problem, and a limited number of foods such as fish, shellfish, eggs, nuts, milk, strawberries, and soy are involved. Physical manifestations involve atopic dermatitis, oral allergy syndrome, urticaria, asthma, upper respiratory problems, GI disturbance, migraines, and anaphylaxis. Food intolerance, on the other hand, tends to involve a larger number of foods and a delayed onset of symptoms. It involves foods consumed regularly in the diet, and symptoms will disappear if the food is avoided. There is a much broader range of clinical manifestations, and symptoms seem to fluctuate and affect different organ systems over time. Most of our discussion here concerns the phenomenon of food intolerance, although it should be said that the distinction between food allergy and food intolerance is not clear- cut.
The incidence of food intolerance in the general population is unknown but may be up to 25%. There is increasing evidence from well-controlled investigations that food sensitivity plays a role in a wide spectrum of condi- tions. Particularly strong evidence is to be found in studies on irritable bowel syndrome, eczema, migraine, rheumatoid arthritis, and serous otitis media.
However, it is important to remember that almost any medical condition may involve food intolerance as a contributing factor.
Any food may be involved and some are more commonly implicated than others (e.g., gluten, cow’s milk, egg, orange, yeast, soy, and peanuts), although there is no completely safe food. Most individuals react to less than six or so foods, although there is a tendency for the phenomenon to general- ize. Symptoms may appear up to several hours after ingestion, and a delay of 48 hours is not unusual in the case of GI symptoms. In the overall course of food intolerance, onset may be gradual, beginning with, for example, headaches and progressing to slow deterioration of general health with symptoms referable to different body systems. On the other hand, onset may be acute after a viral illness, administration of antibiotics, psychological stress, or inhalant or chemical exposure. Fluctuation is the rule, with psy- chological stress playing a major part. Sometimes the problem disappears