Physical Examination for Nutrition Deficiencies

Adequate nutrient intake and nutritional status affect mental health as well as physical health. A complete nutritional assessment needs to include a nutrition-focused physical examination if the diet and medical histories indicate the potential of high-calorie malnutrition or induced malnutrition from other causes.

Three topics of special interest to Dr. Leyse-Wallace are a) the nutritional status of patients suffering from anorexia nervosa, 2) the nutritional consequences of high-calorie malnutrition and 3) “programmed malnutrition” associated with gastric by-pass surgery.

A nutrition exam includes checking eyes

Assessing hair pluckability

Measure Height, Weight, Girth

Measure Height, Weight, Girth

Examining the fingernails is helpful

Examining the fingernails is helpful

Anorexia Nervosa

The starvation pattern in anorexia nervosa can lead to multiple nutrient deficiencies. Since individuals with anorexia nervosa fear fat and foods that contain fat, essential fatty acids may became deficient. These fatty acids are linked to the function and structure of the central nervous system, the brain, cell membranes, and the presence of depression. A low blood cholesterol level may be an indicator (or biochemical marker) that the brain may have an insufficient supply of essential fatty acids. Deficiency-caused lesions may also appear on the skin (called cutaneous lesions). Lesions related to inadequate essential fatty acids may occur at sites around the ears or the folds at the base of the nose (nasolabial seborrhea).

Whether suffering from anorexia nervosa or merely altering the diet to lose weight, an individual who severely restricts carbohydrates (fearing they are too “fattening”), is also limiting B-vitamins (thiamin, riboflavin, niacin, folate) and minerals (iron, magnesium, zinc and chromium) found in whole grain foods. The restrictions can lead to lesions on the tongue and lips. The tongue may be sore, reddened (glossitis) and appear slick and shiny (atrophy of filiform papillae); the lips may have sore spots at the corners (angular stomatitis) or vertical cracks (cheilosis), depending on which nutrient(s) is deficient. It may take only 6 weeks of deprivation in some individuals to develop signs of deficiency. The appearance of cutaneous lesions is accompanied by biochemical changes in the metabolism of food and energy.

Even with use of vitamin-mineral supplements and weight gain, it can take months before all body systems are restored to normal functioning, even though lesions may disappear in 1-3 weeks.

High-Calorie Malnutrition

Individuals may have an adequate intake of calories and protein and still have an inadequate intake of vitamins and minerals. For instance, a diet* of mostly hamburgers, french fries and soft drinks will be low in vitamin A, ( follicular hyperkeratosis) vitamin C (scurvy), folic acid (filiform papillary atrophy) and riboflavin (angular stomatitis). These lacks will alter the efficiency of metabolism and will also be evident in the listed nutrient-based lesions. A nutrition-focused physical examination of the tongue and skin can detect these lesions and serve as an indicator of effectiveness of treatment with appropriate nutrients. A diet* with a high percentage of calories from alcohol or sugar, which are often called “empty calories”, also has the potential for causing high-calorie malnutrition.

Some medical and health conditions may also induce malnutrition due to inadequate vitamins and/or minerals. An adequate intake requires adequate absorption and metabolism to maintain optimum nutritional status.

*diet” refers to an individual’s total food and beverage intake

 “Programmed Malnutrition” : Bariatric (Gastric bypass) Surgery

Since major absorptive sites in the gastrointestinal tract are by-passed, and dietary intake is restricted, nutritional inadequacy is a strong probability. The vitamins and minerals of special concern are vitamin B-1 (thiamin), folate, vitamin B-6 (pyridoxine) , vitamin B-12 ( cobalamin) , fat-soluble vitamins A, D, E, K, and minerals iron and zinc. Regular monitoring of nutritional status is recommended.

Additional Resources

Allis, Linda, Jeanne Blankenship, Cynthia Buffington, Margaret Furtado, and Julie Parrott. Bariatric Nutrition: Suggestions for the Surgical Weight Loss Patient. March, 2008 (A white paper from the American Society for Metabolic and Bariatric Surgery).

Glorio Roberto, Miguel Allevato, Ana De Pablo, Mario Abbruzzese, Luz Carmona, Mario Savarin, Monica Ibarra, Corina Busso, Ana Mordoh, Carolina Llopis, Roxana Haas, Mabel Bello, and Alberto Woscoff. Prevalence of cutaneous manifestations in 200 patients with eating disorders. International Journal Dermatology. 2000 39 (5):348–353.

Kight, Mary Ann and Kelly, Mary Pat. Conducting Physical Examination Rounds for Manifestations of Nutrient Deficiency or Excess: An Essential Component of JCAHO Assessment Performance. Diagnostic Nutrition Network. October 1995;4 (2).

Kight, Mary Ann. The nutrition physical examination. Council on Renal Nutrition Quarterly. 1987; 11(3).

McLaren, Donald S. A Colour Atlas of Nutritional Disorders. Wolfe Medical Publications, LTD, London, 1981.

McLaren, Donald S. A Colour Atlas and Text of Diet-Related Disorders, 2nd edition. Mosby-Year Book Europe Limited, Aylesbury, England, 1992.

Phillipp E, Pirke K-M, Seidl M, Tuschl R, Fichter MM, Eckert M, and Wolfram G. Vitamin status in patients with anorexia nervosa and bulimia nervosa. International Journal of Eating Disorders. 1988; 8(2):209–218.

Sandstead, HH, How to diagnose nutritional deficiencies. Nutrition Teaching Aid No. 5, Nutrition Today, Washington DC, 1969.

Sauberlich, Howerde E. Laboratory Tests for Assessment of Nutritional Status, 2nd ed. New York: CRC Francis & Taylor, 1999.

Skroubis G, Sakenaropoulos G, Pouggouras K, Mead N, Nikiforidis G, and Kalfarentzos F. Comparison of nutritional deficiencies after Roux-en-Y gastric bypass and after biliopancreatic diversion with Roux-en- Y gastric bypass. Obesity Surgery, 2002; 12 (4): 551–558.

Strumia R. Dermatologic signs in patients with eating disorders. American Journal Clinical Dermatology, 2005; 6 (3):165–173.

Waters, Gregory S. Walter J. Pories, Melvin S. Swanson, Helen D. Meelheim, Edward G. Flickfinger and Harold J. May. Long-term studies of mental health after the Greenville gastric bypass operation for morbid obesity. The American Journal of Surgery, 1991; 161:154-158.

See also:

www.NutritionFocusedExam.com – web site of Adele Huls, PhD

*Featured Images in Clinical Medicine. An internet-only publication. New England Journal of Medicine. http://content.nejm.org/misc/eicm.shtml

Examples: Jan 4, 2008 – Excess vitamin C; renal patient

Dec 1, 2005 – Ecchymoses; deficiency in vitamin C

May 12, 2005 – Wernicke’s encephalopathy

Sept 5, 2002 – Binge eating distention

*Public Health Image Library of the Department of Health and Human Services – Centers for Disease Control and Prevention Website at http://phil.cdc.gov

*The image library of the National Library of Medicine of the National Institutes of Health at http://wwwihm.nlm.nih.gov/

*Williams, Mark E. Examining the Fingernails When Evaluating Presenting Symptoms in Elderly Patients. Medscape March 26, 2008. http://www.medscape.com/viewprogram/8996_pnt