Assessment of Nutritional Status

Chief Complaint

Often the chief complaint is directly related to the patient's nutrition, which may affect treatment and prognosis. The most commonly voiced nutritional concerns are “loss of appetite,” “weight loss,” “weight gain,” and “weakness.” Changes in dietary intake and in weight are among the earliest signs of medical problems. These complaints should prompt a detailed inquiry about diet and related symptoms in the history of present illness.

History of Present Illness

After asking the patient to describe the symptoms or medical problem that caused him or her to seek medical attention, begin to explore any diet-disease relationship that may exist. The following self-directed questions should guide your inquiry:

• Does nutrition contribute to the cause, severity, or treatment of the illness?

For example, type 2 diabetes is most often seen among patients with obesity and is diet responsive. Inquiry should be made into the patient's body weight history and diet, including calorie content, pattern of consumption and types of foods and beverages consumed, and relationship to blood glucose levels.

• How has the illness affected the patient's diet and nutritional status?

For example, a patient with esophageal cancer typically experiences increasing difficulty swallowing solid foods (dysphagia), pain with swallowing (odynophagia), occasional vomiting, weight loss, and reduced muscle strength.

• Does the patient see a relationship between diet and disease?

For example, is a patient with hypercholesterolemia aware that consumption of dietary saturated fats, trans-fatty acids, and cholesterol raises blood cholesterol, whereas intake of dietary soluble fiber lowers blood cholesterol?

• Was the patient ever advised to follow a special diet or use other nutritional therapy, such as defined formula supplements, tube feedings, or intravenous (parenteral) nutrition? What were the particular aspects of this therapy? What was the patient's understanding of how the treatment works? What was the patient's understanding of its potential efficacy?

For example, a patient with celiac disease must learn to follow a strict gluten-free diet to control the immune response that attacks the small intestine. The patient must become knowledgeable concerning dietary grains that contain gluten (wheat, barley, or rye), how to read food labels, and how to make dietary substitutions. This commonly requires guidance from a registered dietitian nutritionist.

Body Weight History

Body weight is a global indicator for overall health. Any unexplained weight loss is a good general indication of the severity or systemic nature of the presenting symptoms, whether they are acute or chronic. Both low body weight and unintentional weight loss have been shown to be predictive of increased morbidity and mortality. Although the cause of weight loss is often linked to the presenting medical problem, often no identifiable physical cause is apparent. In all cases, the underlying reasons for the weight change should be explored and the amount of weight loss clearly defined. Information-yielding questions include the following:

• “Has your weight changed, either up or down, over the past several weeks or months?” If so , “In what way?”

• “How much weight did you lose or gain?”

• “What was your weight before the symptoms started?”

• “During what period did you experience the weight loss or gain?”

• “How was your appetite over this time?”

• “Do you know what may have contributed to your change in weight?”

Rapid weight gain is often an indicator of fluid retention and may be accompanied by edema or ascites. Common diseases associated with rapid weight gain include congestive heart failure, liver disease, and renal disease. In contrast, rapid weight loss usually signifies loss of body tissue, unless the patient has been undergoing therapeutic diuresis (in which case the patient would report markedly increased urination) or is experiencing dehydration (in which case the patient would report decreased fluid ingestion, dry mouth, weakness, and dizziness). If the patient has experienced weight loss, it is useful to think in terms of the percentage of weight lost over a specific time frame. To convert absolute pounds into percentage lost, the following simple equation is used:

Significant involuntary weight loss is generally defined as more than 5% of usual weight during the preceding 6 months or 10% or more within the year. When a patient has experienced weight loss, it is useful to direct your questions toward the underlying causes. There are four physiologic categories ( Table 7.1 ) for weight loss: (1) decreased caloric intake, (2) malabsorption or maldigestion, (3) impaired metabolism or increased requirements, and (4) increased losses or excretion.

Past Medical History

As patients list their past illnesses, the health care provider should consider the role of nutrition or diet in the cause or treatment. Common diet-related diseases include cardiovascular disease (e.g., coronary artery disease, peripheral vascular disease, cerebrovascular disease), hypertension, diabetes, hyperlipidemia, some forms of cancer, nonalcoholic fatty liver disease, and other gastrointestinal (GI) diseases. In addition to asking how the illness was diagnosed and what treatment was rendered, ask the patient whether he or she received dietary counseling or altered his or her diet in response to the diagnosis. Try to ascertain the patient's understanding of the role that diet plays in the condition.

Past Surgical History

All surgical procedures should be recorded in this section, along with serious surgical complications such as draining fistulas, abscesses, open wounds, and chronic blood loss. These complications often lead to malnutrition and the need for specialized nutritional support, including enteral and parenteral feedings. If the patient is currently in the postoperative period, you should consider the role of nutritional support in the recovery process and how the particular surgery has altered the patient's dietary habits and requirements. For example, a patient with a total gastrectomy needs to alter his or her diet to reduce simple sugars, eat multiple small meals each day, and receive supplemental vitamin B ₁₂ and iron to maintain good nutritional health.

Medications

The medication history should include both prescription and over-the-counter medications. Because complementary and alternative therapies have become popular, many patients take vitamins, minerals, herbs ( Table 7.2 ), and other dietary supplements that they may not mention without prompting. A thorough review of alternative and integrative therapy use should be a standard part of the patient medication and lifestyle history. When eliciting this information, be careful not to be judgmental or accusatory. Many patients do not disclose this information because of fear of being censured. Suggested questions are as follows:

• “Are you taking any vitamins, minerals, herbs, or other dietary supplements, either prescription or over-the-counter?” If so , “What is the dosage?”

• “What is the reason you are taking the supplement?”

• “Have you experienced any side effects or benefits from the supplements?”

• “Is anybody monitoring you, such as your doctor, nutritionist, or herbalist?”

• “What is your consumption of grapefruit and grapefruit juice?”

Drugs and nutrients interact in many ways to affect both nutritional status and the effectiveness of drug therapy. Drugs may influence nutritional status by several physiologic mechanisms: altering food intake (through nausea, changes in appetite, altered taste sensations), producing malabsorption (through alterations in intestinal mucus, motility, or pH; competition with nutrients for absorption sites; binding of bile acids), or modifying excretion (through renal tubular reabsorption or secretion). Drug-induced nutrient deficiencies usually develop slowly and are more likely in patients who use drugs chronically, especially older adults. Other risk factors include high drug dosages, multiple drug dosages, multiple drug regimens, poor diets, and marginal nutrient stores. Table 7.3 lists examples of drug interactions and nutrient metabolism.

Studies by Bailey ³

3 Bailey DG, Malcolm J, Arnold O, et al. Grapefruit juice-drug interactions. Br J Clin Pharmacol. 1998;46:101

and associates in 1998 revealed possible drug interactions involving grapefruit and grapefruit juice (fresh or frozen) with several common medications used to treat high blood pressure, anxiety, depression, cancer, gastroesophageal reflux disease, erectile dysfunction, angina, convulsions, and human immunodeficiency virus infection and acquired immune deficiency syndrome. In general, grapefruit juice tends to increase the drug's effect. Grapefruit juice decreases the activity of the cytochrome CYP ₃ A ₄ enzymes in the liver and intestines that are responsible for breaking down many drugs and toxins. Grapefruit juice contains compounds known as furanocoumarins that block the CYP ₃ A ₄ enzymes. When grapefruit juice is consumed, the enzyme's ability to break down the drug for elimination is decreased, potentially leading to overdosage of the medication. ⁴

4 https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm292276.htm . Updated September 10, 2018. Accessed December 31, 2018.

The advisory also cautioned that sour oranges and tangelos may also interfere with medication blood levels. Other citrus fruits were considered safe. Bailey's study indicated that as little as one 8-oz (0.26-mg) glass of grapefruit juice could increase the blood drug level and the effects could last for 3 days or more. It is recognized today that grapefruit juice can interact with many medications including some statins, ⁵

5 Lovastatin (Mevacor), atorvastatin (Lipitor), simvastatin (Zocor) (Vytorin).

antihistaminics, ⁶

6 Fexofenadine (Allegra)—Blood levels of the drug are lowered, and the effectiveness of this commonly used antihistamine may be reduced. This interaction occurs by a different mechanism than CYP ₃ A ₄ .

calcium channel blockers, ⁷

7 Felodipine (Plendil), nifedipine (Adalat) (Procarida).

psychiatric medications, ⁸

8 Buspirone (BuSpar), triazolam (Halcion), carbamazepine (Tegretol), diazepam (Valium), midazolam (Versed), sertraline (Zoloft).

immunosuppressants, ⁹

9 Cyclosporine (Neoral), tacrolimus (Prograf).

pain medications, ¹⁰

10 Methadone.

medications for erectile dysfunction, ¹¹

11 Sildenafil (Viagra).

HIV medication, ¹²

12 Saquinavir (Invirase).

antiarrythmics, ¹³

13 Amiodarone (Cordarone) (Pacerone).

and corticosteroids. ¹⁴

14 Budesonide (Entocort EC) (Uceris).

^{, 15}

15 https://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM567226.pdf . Updated July 18, 2017. Accessed December 31, 2018.

Allergies and Food Intolerances

In addition to asking about allergies to medications and environmental allergens, the interviewer should inquire about allergies and intolerances to food. The most common allergenic foods among adults are peanuts, tree nuts, shellfish, fish, eggs, soy, wheat, and milk. The first four foods listed may cause life-threatening reactions. If the patient states that he or she has a food allergy, the interviewer should ask what happens when those foods are eaten. Allergic symptoms may affect the respiratory tract (rhinorrhea, sneezing, wheezing, chest tightness, laryngeal edema), skin (urticaria, angioedema, pruritus, erythematous macular rash), or GI tract (nausea, vomiting, diarrhea, abdominal cramping). It is also appropriate to ask if the patient carries an EpiPen® (Epinephrine Auto-Injector) in case of anaphylaxis.

A food allergy needs to be differentiated from food intolerance . Symptoms of food intolerance are usually confined to the GI tract and may be acute or chronic. Upper GI tract symptoms of belching and bloating may be due to aerophagia (swallowing air during the ingestion of food or drink), which is commonly associated with smoking, eating rapidly or talking while eating, chewing gum and hard candy, or ingesting carbonated beverages. Chronic lower GI tract symptoms of bloating, cramping, flatulence, or diarrhea may result from the ingestion of sugar substitutes (e.g., sorbitol, xylitol) or fructose, high fiber intake, or lactase deficiency. The term FODMAP ¹⁶

16 https://www.healthline.com/nutrition/low-fodmap-diet#section1 . Updated March 15, 2017. Accessed December 31, 2018.

is an acronym referring to “ F ermentable O ligo-, D i-, M ono-saccharides A nd P olyols.” These are complex names used to classify groups of fermentable carbohydrates that trigger potentially debilitating digestive symptoms like bloating, gas, and stomach pain in sensitive individuals. FODMAPs are short chain carbohydrates that are poorly absorbed in the small intestine. FODMAPs are found in a wide range of foods in varying amounts. Some foods contain just one type of FODMAP, while others contain several. ¹⁷

17 Oligosaccharides: Wheat, rye, legumes and various fruits and vegetables, such as garlic and onions. Disaccharides: Milk, yogurt, and soft cheese. Lactose is the main carbohydrate. Monosaccharides: Various fruit including figs and mangoes, and sweeteners such as honey and agave nectar. Fructose is the main carbohydrate. Polyols: Certain fruits and vegetables including blackberries and lychee, as well as some low-calorie sweeteners like those in sugar-free gum.

Of these potential causes of lower GI symptoms, lactose intolerance, however, is the most common, affecting 25% of the population in the United States and up to 80% of African Americans. In lactose-intolerant individuals, symptoms occur after the consumption of products containing lactose, including milk, cheese, ice cream, yogurt, and some processed foods.