Algorithm for Incorporating Nutrition into Clinical Practice

As a physician-in-training, you're taught a model of clinical practice that is fairly standard across the US. We're going to look at how nutrition can be easily incorporated into this practice model.

History taking is a very important early step in information gathering in clinical practice. Patients are asked specific questions and answers noted in the medical record. Many times patients are asked to complete medical history questionnaires in the waiting room or before they come to the office. Key nutrition questions should be incorporated into this aspect – the next module will focus on this subject in depth. For our purposes here, the following is a tool developed especially for primary care physicians that is being used nationwide. It was developed in concert with the American Medical Association, the American Academy of Family Practice, and the Society for General Internal Medicine. "How Does Your Pyramid Stack Up" is a brief questionnaire designed to assess general dietary patterns and takes less than 5 minutes to complete. It is written at a 4th to 6th grade reading level, which is the average reading level of adults in the U.S. Try it out for yourself!

 

How does your pyramid stack up? The Surgeon General's Report on Nutrition and Health links what we eat to our health. The USDA's Food Guide Pyramid teaches us to make wise food choices. Does the way that you eat promote good health? Check those that apply to the way you usually eat. I eat whole grain or enriched breads, cereals, rice, or pasta daily. I eat 2-3 pieces of fruit or drink 1-2 cups of juice daily. I eat 2-3 cups of raw or cooked vegetables daily. I drink skim milk and eat low-fat or fat-free dairy products daily. I trim fat from meat and take the skin off chicken and turkey or I do not eat meat. I eat small servings (the size of a deck of cards) of meat, poultry, and fish or I do not eat meat. Most food and snacks that I eat are not fried or are made with no added fat. I add very little fat (butter, margarine, oil, or salad dressing) to my foods. Most dessert and snacks that I eat have no added sugar in them. Most of what I drink is made without sugar or has no added sugar. I rarely cook with salt or add it at the table. I do not drink alcohol or I drink nor more than 1-2 beers, 1-2 glasses of wine, or 1-2 mixed drinks daily. Please add up the number of statements you've checked and compare that number with the scores listed below: 9-12 Great job! Eating "right" is one of the best things you can do to ensure good health. Daily exercise helps too. 5-8 You make some very good choices. Keep trying! Small changes in food habits can make a big difference. 0-4 Those first steps toward good eating are often the hardest to take. Making healthy choices gets easier every day. You can do it! Used with permission from the Learning Center at the American Dietetic Association.

How did you do? Check those areas that you need work in. More will be discussed on how to use this tool later.

On physical examination, there may be observable signs of nutritional problems that should be noted on the medical record if present. Examples are listed below:

• dry, scaly skin
• pallor
• muscle wasting, especially in the calf, thenar, and temporal muscles
• spongy, bleeding gums
• ecchymoses, or bruises
• lipid xanthomas

These are just a few examples of physical signs and symptoms of nutritional problems. They are not definitive for diagnosis but when correlated with other diagnostic tools such as laboratory tests, medical and dietary histories, anthropometric measures, etc., a pattern emerges leading to a diagnosis. You will learn more about this in another module you will receive during your Physical Diagnosis course.

Making a nutritional diagnosis is like making a medical diagnosis for any problem or condition the patient may have. By having the patient complete the "How Does Your Pyramid Stack Up?" nutrition screening tool or a similar tool, and looking at where there are potential problems or issues, you can then diagnose a specific nutritional concern. Once the diagnosis is made, it is time to prescribe treatment, which may include education, counseling, and advice. What is your nutritional diagnosis based on "How Does Your Pyramid Stack Up?

 

Content questions should be directed to: Marilyn.S.Edwards, Ph.D., R.D.
or Maggie McQuiggan, M.S.
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The University of Texas Health Science Center at Houston
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