Transcript functional nutritional assessment

FUNCTIONAL NUTRITIONAL
ASSESSMENT: AN OPPORTUNITY
NANCY M. STRANGE, RD, CNSD, CD
CLINICAL NUTRITION SPECIALIST
GENERAL SURGICAL OUTPATIENT SERVICES
INDIANA UNIVERSITY HOSPITAL
APRIL 12, 2012
FUNCTIONAL NUTRITIONAL
ASSESSMENT


OBJECTIVES
Following the completion of this presentation the participant
will be able to identify:



DIET HISTORY TECHNIQUES THAT CONTRIBUTE TO
IDENTIFICATION OF VITAMIN AND MINERAL DEFICIENCIES
SUBJECTIVE SIGNS AND SYMPTOMS OF VITAMIN MINERAL
DEFICIENCIES
PHYSICAL SIGNS OF VITAMIN AND MINERAL DEFECIENCIES
FUNCTIONAL NUTRITION
ASSESSMENT

TRADITIONAL NUTRITIONAL ASSESSMENT
COMPONENTS INCLUDE:
–
–
–
–
–
–
–
ANTHROPOMETRIC MEASUREMENTS
MEDICAL HISTORY
SOCIAL HISTORY
MEDICATION HISTORY
DIET HISTORY
PHYSICAL EXAM
SUBJECTIVE STATEMENTS
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 COMPONENTS
OF ANY NUTRITIONAL
ASSESSMENT
 ALL
ARE IMPORTANT PIECES TO THE PUZZLE
 ALL HAVE VARYING LEVELS OF IMPORTANCE AND
APPLICATION BASED ON THE AREA OF NUTRITION
PRACTICE
 ALL COMBINE TO PROVIDE A NUTRITIONAL
“PICTURE”
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 WHAT
IS IMPORTANT ABOUT THESE
COMPONENTS?
– DIET HISTORY
– SUBJECTIVE SYMPTOMS
– PHYSICAL EXAM
FUNCTIONAL NUTRITIONAL
ASSESSMENT



USE OF DIET HISTORY, SUBJECTIVE SYMPTOMS
AND PHYSICAL EXAM TOGETHER CAN IDENTIFY
SIGNIFICANT PROBLEMS THAT IMPEDE AN
INDIVIDUAL’S FUNCTIONAL CAPACITY.
COMBINATION WILL RESULT IN A HIGH RATE OF
IDENTIFICATION OF MICRONUTRIENT
DEFICIENCIES
IDENTIFY METHODS FOR IMPROVED OUTCOMES
FUNCTIONAL NUTRITIONAL
ASSESSMENT

IMPORTANCE OF USE AND INTEGRATION
OF THIS KNOWLEDGE:
– PROVIDES A SERVICE TO THE MEDICAL TEAM
THAT IS NOT PROVIDED IN ANY OTHER
DISCIPLINE.
 NUTRITION
COMPONENTS OF A PHYSICAL EXAM ARE
NOT TAUGHT IN MEDICAL SCHOOLS
 IMPROVEMENT IN OUTCOMES:
– FOR THE PATIENT
– REDUCTION IN INSTITUTIONAL EXPENDITURES
FUNCTIONAL NUTRITIONAL
ASSESSMENT
– IF YOU ARE ABLE TO IMPROVE
OUTCOMES?
 PHYSICIANS
CHANGE THEIR OPINIONS
ABOUT NUTRITION, INCLUDE RD MORE
FREQUENTLY
 ADMINISTRATION LISTENS
 RD JOB SATISFACTION IS WONDERFUL
FUNCTIONAL NUTRITIONAL
ASSESSMENT
FUNCTIONAL NUTRITIONAL
ASSESSMENT

“WE STOPPED BY TO SAY THANK YOU FOR THE EXCELLENT
CARE YOU PROVIDE FOR OUR PATIENTS. WHAT IS YOUR
NEXT PROJECT YOU ARE WORKING ON? HOW CAN WE
HELP? ”


“WE ONLY SAW DIETITIANS GIVING BOOST AND SNACKS
SO WE DECIDED THAT WE COULD DO THAT AND STOPPED
CALLING THEM. I CAN’T DO THAT FOR WHAT YOU DO. ”


VICE PRESIDENT OF NURSING AND MEDICAL DIRECTOR @ IU
HOSPITAL ON ROUNDS – 3/27/2012
25 YEAR SURGICAL RN, IU HOSPITAL, 6/2011
“I HAVE LEARNED MORE FROM YOU IN 15 MINUTES THAN I
EVER HAVE IN THE PAST. “

PATIENT WITH CHRONIC NON HEALING WOUND, 11/2011
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 “THE
MORE INFORMED YOU ARE,
THE MORE LIKELY YOU ARE TO BE
PERFORMING A NUTRITION
FOCUSED PHYSICAL EXAM. THIS
REAFFIRMS THE DIETITIAN’S ROLE,
AREA OF EXPERTISE AND ADVANCED
LEVEL OF PRACTICE”
 MP
Kelly, 2005
FUNCTIONAL NUTRITIONAL
ASSESSMENT

START WITH THE BASICS
– A KNOWLEDGE BASE OF HOW TO USE ALL
COMPONENTS OF A NUTRITIONAL
ASSESSMENT IS ESSENTIAL
 DIET
HISTORY, SUBJECTIVE SYMPTOMS AND
PHYSICAL EXAM WORK BEST IN THE CONTEXT OF A
FULL ASSESSMENT
– NUTRITION PLAN OF CARE THAT IS CONCISE
AND CLEAR
FUNCTIONAL NUTRITIONAL
ASSESSMENTS
–COMMUNICATE
– DEVELOP RELATIONSHIPS WITH
NURSES, PHARMACISTS, PHYSICIANS,
PHYSICIAN ASSISTANTS, PT, OT,
SPEECH THERAPIST
– INCLUDE THE NURSE IN YOUR
SUGGESTED PLAN OF CARE
– TAKE THE TIME TO COMMUNICATE
FUNCTIONAL NUTRITIONAL
ASSESSMENT

DIET HISTORY
– GIVES YOU A CURRENT PICTURE OF THE PATIENT
– INCLUDE SUPPLEMENT USE IN THE DIET HISTORY
– KNOW THE KEY NUTRIENTS IN FOOD GROUPS


EFFICIENT- WHAT FOOD GROUP HAS TO BE THERE FOR
SUFFICIENCY TO HAPPEN
USE USDA.GOV NUTRIENT CONTENT OF FOOD GROUPS.
– WHAT FOODS HAVE TO BE PRESENT FOR INTAKE TO BE
SUFFICIENT?

EXAMPLE: RIBOFLAVIN
– IF DAIRY OR FORTIFIED PRODUCTS ARE NOT USED IN DIET
THEN IT IS VERY DIFFICULT TO OBTAIN SUFFICIENT
RIBOFLAVIN IN THE DIET
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 DIET
HISTORY
– IMPORTANT FOR THE PATIENT TO
UNDERSTAND WHY YOU ASK THE
QUESTIONS.
REMOVE THE “MORAL” VALUE OF FOOD FROM
THE CONVERSATION
FUNCTIONAL NUTRITIONAL
ASSESSMENT

DIET HISTORY –
– FOCUS TO SPECIFIC POPULATIONS
 WOUND
HEALING
 WIC
 LONG
TERM CARE
– COMPLETE AT ANY POINT IN THE INTERVIEW
PROCESS
– USE A SIMPLFIED FORM
 YOU
ARE ONLY LOOKING FOR TRENDS
 QUANTIFY WHAT PATIENT STATES
FUNCTIONAL NUTRITIONAL
ASSESSMENT

SUBJECTIVE SYMPTOMS
– ARE KEY IN HELPING TO IDENTIFY
NUTRITIONAL ISSUES RELATED TO VITAMIN
AND MINERAL DEFICIENCIES
 PATIENT’S
GAIN CONFIDENCE IN THE SKILLS OF THE
RD WHEN SUBJECTIVE SYMPTOMS CAN BE RELATED
TO NUTRITION.
 PATIENT’S
ARE YOUR BEST ADVOCATES, ESPECIALLY
WHEN RELATIVELY SIMPLE MEASURES IMPROVE
THEIR SYMPTOMS AND QUALITY OF LIFE
FUNCTIONAL NUTRITIONAL
ASSESSMENT

MOST NUTRIENT DEFICIENCIES HAVE A:
– LOOK
– SOUND
– FEEL
SOUND AND FEEL - ARE SUBJECTIVE SYMPTOMS THAT
WILL BE EXPRESSED WHEN A DEFICIENCY IS PRESENT
USUALLY YOU WILL “HEAR” THE SYMPTOMS BEFORE
YOU SEE THE DEFICIENCIES
FUNCTIONAL NUTRITIONAL
ASSESSEMENT
EXAMPLES:
FATIGUE- VITAMIN C, A, IRON, B12,
B COMPLEX
BURNING MOUTH: B12, THRUSH, B COMPLEX
SHORT TERM MEMORY ISSUES: B12, B1, IRON,
IODINE
FOOD CRAVINGS: WHAT IS FOOD GROUP
CRAVED? CHOCOLATE,
SALTY, STARCHY?
TIME OF DAY THE FOOD CRAVING OCCURS?
FUNCTIONAL NUTRITIONAL
ASSESSMENT
NUTRITION PHYSCIAL EXAM STARTING THE PROCESS
Routinely check for:
- Protein Calorie Malnutrition
- Muscle Tissue
- Adipose Tissue
- Vitamin Deficiencies
- Scurvy, Beri-Beri, Pellegra, B 12, Riboflavin,
B6
- Mineral Deficiencies
- Zinc, Iron, Iodine
IF YOU ARE NOT LISTENING AND LOOKING FOR SOMETHING, YOU
WILL LIKELY NOT SEE IT.
FUNCTIONAL NUTRITIONAL
ASSESSMENT
PHYSICAL EXAM – GETTING STARTED
– LOOK AT THE AVAILABLE PICTURES OF NUTRIENT
DEFICIENCIES
– KNOW WHAT OTHER DIAGNOSIS’ RESULT IN SIMILAR
SKIN CHANGES
 MEDSCAPE HAS MULTIPLE EDUCATION TOOLS TO
HELP WITH THIS
 YOU WILL HAVE TO DEFEND WHAT YOU ARE
DESCRIBING – IT IS JUST PART OF THE PROCESS
– LEARN WHAT AN EARLY OR LATE DEFICIENCY CAN
LOOK LIKE
FUNCTIONAL NUTRITIONAL
ASSESSMENT

PHYSICAL EXAM
– TAKE THE NUTRITION TEXT BOOKS LITERALLY
– KNOW “TIME TO DEFICIENCY”
– DON’T ASK FOR LABS WITHOUT THE DIET HISTORY,
SUBJECTIVE INFORMATION AND THE PHYSICAL EXAM – IT IS
WASTEFUL AND UNDERMINES YOUR CREDIBILITY WITH THE
MEDICAL TEAM
– PRACTICE ON YOURSELF, FAMILY OR YOUR PEERS
 THIS IS TO BECOME COMFORTABLE WITH TOUCHING,
LOOKING AT SOMEONE ELSE
– UNDERSTAND THE PROCESS OF DIFFERENTIAL DIAGNOSIS
FUNCTIONAL NUTRITIONAL
ASSESSMENT

VITAMIN C/ASCORBIC ACID

DISEASE: SCURVY

PRIMARY ROLES IN THE BODY
– ANTIOXIDANT THAT IS REQUIRED FOR THE SYNTHESIS
OF NOREPINEPHRINE
– REGENERATION OF VITAMIN E
– COLLAGEN SYNTHESIS
– CARNITINE SYNTHESIS
– HISTIDINE SYNTHESIS
– ADRENAL STEROID SYNTHESIS
– FUNCTIONS IN TYROSINE AND FOLATE METABOLISM
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 VITAMIN
C DEFICIENCY IDENTIFIED
– NHANES, 1994
 10-14%
– NHANES, 2003-2004
 7.1%
- SMOKERS AND LOWER INCOME AT
SIGNIFICANT RISK
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 VITAMIN
C DEPLETION
– GENERAL OUTPATIENT POPULATION
 6%
OF GENERAL POPULATION
 51% OF DIABETIC POPULATION
 40% OF CARDIAC/HLD PATIENTS
 Journal
of American College of Nutrition; 1998
FUNCTIONAL NUTRITIONAL
ASSESSMENT

RENAL FAILURE ON RRT
– 20-25% RATE OF VITAMIN C DEFICIENCY

HOSPITALIZED PATIENTS
– MULTIPLE SINGLE CASE REPORTS

SURGICAL OUTPATIENT POPULATION AT IU:
– SCURVY SEEN IN ~ 40% OF PATIENTS SEEN BY RD
– ALL AGE GROUPS, DIFFERING SOCIAL ECONOMIC
STATUS, NOT ALWAYS POST SURGICAL OR HIGHER
RISK CATEGORIES
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 VITAMIN
C DEFICIENCY
– DIET HISTORY
 FRUITS
AND VEGETABLES
– NEED TO BE SPECIFIC
 FORTIFIED
FOODS
-CEREALS, JUICES, DRINKS, PROTEIN
BARS
 SOUR CANDIES
FUNCTIONAL NUTRITIONAL
ASSESSMENT

SUBJECTIVE SYMPTOMS OF SCURVY
–
–
–
–
–
–
–
–
–
–
FATIGUE
LOWER EXTREMITY PAIN
ARTHRALGIAS
MYALGIAS
LASSITUDE
DEPRESSED MOOD/DEPRESSION
EASILY BRUISED
BLEEDING TENDER GUMS
DIARRHEA
TOBACCO USE
FUNCTIONAL NUTRITIONAL
ASSESSMENT

HOW DO YOU CORRELATE THE
SUBJECTIVE SYMPTOMS WITH THE
FUNCTION OF VITAMIN C IN THE BODY?
– ASK THIS QUESTION WITH EACH FUNCTION
OF THE NUTRIENT

EXAMPLE: FATIGUE WITH SCURVY
– BLOOD LOSS FROM CAPILLARY BLOOD LOSS
WITH LOSS OF COLLEGEN SYNTHESIS;
– UNABLE TO SYNTHESIZE CARNITINE
– DECREASED ADRENAL HORMONE SYNTHESIS
FUNCTIONAL NUTRITIONAL
ASSESSMENT

PHYSICAL ASSESSMENT
– FOLLICULAR PETECHIEA



EARLIER- BECOMES DARKER MORE PRONOUNCED AS DEFICIENCY
CONTINUES
CAN BE MASKED BY VITAMIN A HYPERKERATOSIS
EMBEDDED CORKSCREW HAIR IN THE HAIR FOLLICLE – LATER
APPEARANCE
– BRUISING/PURPURA

EARLY AND ONGOING
– PEDAL EDEMA

LATER, NON RESPONSIVE TO DIURETICS
– OFTEN SEEN WITH LOWER EXTREMITY CELLULITIS
– JOINT SWELLING

USUALLY MID TO LATE MANIFESTATION
FUNCTIONAL NUTRITIONAL
ASSESSMENT
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 PURPURA
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 FOLLICULAR
 SWAN
PETECHIEA
HAIR
 DX: WOUND HEALING FAILURE
FUNCTIONAL NUTRITIONAL
ASSESSMENT
SERUM VITAMIN C LEVEL: UNABLE TO BE
MEASURED
 DX: SEVERE MALNUTRITION
WITH H/O R-N-Y
25 YEARS PRIOR;
 HAD NOT BEEN
ABLE TO WALK FOR
6 MONTHS DUE TO
SCURVY

FUNCTIONAL NUTRITIONAL
ASSESSMENT
 ZINC
DEFICIENCY
– NHANES III –35-45% RATE OF
DEFICIENT INTAKE IN INDIVIDUALS
>60 YEARS OF AGE
– DEFICIENCY RATE OF 20-25% AFTER
ADJUSTING FOR SUPPLEMENT INTAKE
FUNCTIONAL NUTRITIONAL
ASSESSMENT

ZINC DEFICIENCY

HIGHER RISK POPULATIONS
– > 50 YEARS OF AGE
– GASTROINTESTINAL DISEASES

–
–
–
–
–
–
–
–
–
–
MALABSORPTION, CHRONIC DIARRHEA, SBS, CELIAC, IFBD
LIVER DISEASE
ALCOHOLICS
HIV/AIDS
SICKLE CELL DISEASE
DIABETES
PREGNANCY
VEGETARIANS
FOOD INSUFFICIENT POPULATIONS
EATING DISORDERS
USE OF GASTRIC ACID REDUCTION MEDICATIONS
FUNCTIONAL NUTRITIONAL
ASSESSMENT
– FUNCTIONS OF ZINC

NEUROPEPTIDE FORMATION

IMMUNE FUNCTION



CATALYTIC ROLE
– ~ 100 ZINC DEPENDANT ENZYMES
– EXAMPLES: CARBONIC ANHYDRASE; SUPEROXIDE DISMUTASE
REGULATORY ROLE
– REGULATION OF GENE EXPRESSION
STRUCTURAL ROLE
– ZINC FINGER, STABILIZES THE STRUCTURE
– LOSS OF ZINC INCREASES BIOLOGICAL MEMBRANE SUSEPTTIBILITY
TO OXIDATIVE DAMAGE, IMPAIRING THEIR FUNCTION
– HORMONE STRUCTURE; TESTOSTERONE SYNTHESIS REQUIRES ZINC
 ZINC DEPLETION RESULTS IN ESTROGEN SYNTHESIS
– CELL SIGNALING
 HORMONE RELEASE
 NERVE IMPULSE INNERVATION
– APOTOSIS
FUNCTIONAL NUTRITIONAL
ASSESSMENT

FUNCTIONS OF ZINC

STRUCTURAL ROLE
– ZINC FINGER, STABILIZES THE STRUCTURE
– LOSS OF ZINC INCREASES BIOLOGICAL MEMBRANE
SUSEPTTIBILITY TO OXIDATIVE DAMAGE, IMPAIRING
THEIR FUNCTION
– HORMONE STRUCTURE; TESTOSTERONE SYNTHESIS
REQUIRES ZINC
 ZINC DEPLETION RESULTS IN ESTROGEN
SYNTHESIS
– CELL SIGNALING
 HORMONE RELEASE
 NERVE IMPULSE INNERVATION
– CELLULAR APOTOSIS
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 ZINC
 ASK
DEFICIENCY
THE QUESTION:
– HOW
ZINC
– HOW
– HOW
DOES EACH FUNCTION DIFFER IF
DEFICIENCY EXISTS?
DOES IT LOOK?
DOES IT SOUND?
FUNCTIONAL NUTRITIONAL
ASSESSMENT

ZINC DEFICIENCY
– EXAMPLE: IMMUNE FUNCTION
 INCREASED
CIRCULATING CORTICOIDSTEROIDS
 DECREASED LYMPHOCYTES
 THYMIC ATROPHY
 INDIVIDUAL
REFERRED TO YOU BECAUSE OF DESIRE
TO LOSE WEIGHT, DIFFICULTY MANAGING GLUCOSE
LEVELS; ABDOMINAL OBESITY; FREQUENT
INFECTIONS
 HOW WOULD THE PHYSICAL EXAM HELP?
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 ZINC
DEFICIENCY
– EXAMPLE: GYNOMASTICA, MALE
 DECREASED
TESTOSTERONE SYNTHESIS
WITH INCREASED ESTROGEN SYNTHESIS
 COMPLAINT EXAMPLE: “I CAN’T LOSE
WEIGHT OR BUILD MUSCLE.”
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 ZINC
DEFICIENCY
– DIET HISTORY
 VEGETARIAN
W/O USE OF LEAVENED
GRAINS
 ELIMINATION OF ZINC RICH FOODS FROM
DIET (CRUSTATIONS/BEEF/PORK)
 INFREQUENT USE OF BEAN, LEGUME, NUT
FAMILY
 HIGH INTAKE OF PHYTATES AND DAIRY
FUNCTIONAL NUTRITIONAL
ASSESSMENT

ZINC DEFICIENCY
– SUBJECTIVE SYMPTOMS
 BLAND
TASTE CHANGES
 EARLY SATIETY
 ANOREXIA/NO INTEREST IN FOOD
 LIGHT ADAPTATION ISSUES
 DIARRHEA
 HAIR LOSS
 NIGHT BLINDNESS
 DEPRESSION, WITH INADEQUATE RESPONSE TO
MEDICATION
 ACUTE ONSET? LOOK FOR PRECIPITATING EVENT
FUNCTIONAL NUTRITIONAL
ASSESSMENT

ZINC DEFICIENCY

PHYSICAL EXAM
–
–
–
–
–
–
–
–
DRY FLAKY SKIN- LOWER EXTREMITIES
NASOLABIAL SEBORRHEA
DRY, REDDENED KNUCKLES
LEUKONYCHIA
MALE GYNOMASTICA
HAIR LOSS
ECCHYMOSIS
FRAGILE SKIN DUE TO POOR SYNTHESIS OF COLLEGEN,
POOR PROTEIN SYNTHESIS
FUNCTIONAL NUTRITIIONAL
ASSESSMENT
 DRY
RED KNUCKLES
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 LEUKONYCHIA
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 SEVERE
ZINC DEFICIENCY
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 CASE
STUDY
– 56 YR OLD FEMALE WITH HISTORY OF
BREAST CANCER
3
MONTHS OUT OF TREATMENT
 FAILURE TO THRIVE
 NO DISEASE RECURRENCE
FUNCTIONAL NUTRITIONAL
ASSESSMENT

CASE STUDY 1
– MEDICAL HISTORY
 HTN
 BREAST
CANCER
 HYPOTHYROID
– SOCIAL HISTORY
 SINGLE,
LIVES ALONE
 CHILDREN LIVING WITH HER CURRENTLY DUE TO
HER INABILITY TO CARE FOR HERSELF
 WHEEL CHAIR BOUND
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 CASE
STUDY 1
– ANTHROPOMETRICS
 BMI:
32
 CBW: STABLE
– DIET HISTORY
 DRINKS
ONE STEAK AND SHAKE
MILKSHAKE PER DAY
 OCCASIONALLY EATS A FEW BITES OF
SOUP
FUNCTIONAL NUTRITIONAL
ASSESSMENT

CASE STUDY 1
– SUBJECTIVE SYMPTOMS
 FATIGUE
 TASTE
CHANGES, DRY, SAWDUST
 UNABLE TO MAINTAIN BALANCE
 PAINFUL FEET
 NO DESIRE TO EAT
 BLOATING
 DIARRHEA
 HAIR LOSS
 NIGHT VISION ISSUES
 FAMILY REPORTS DECREASED ABILITY TO PROCESS
INFORMATION
 DEPRESSED AFFECT
FUNCTIONAL NUTRITIONAL
ASSESSMENT

PHYSICAL EXAM
– THRUSH
– FRAGILE SKIN WITH CELLOPHANE
APPEARANCE
– BRUISING
– FOLLICULAR PETECHIEA
– 3+ LOWER EXTREMITY EDEMA
– ECCHYMOSIS
– DRY FLAKY SKIN
– ATAXIA
– ANGULAR STOMATITIS
– CHEILOSIS
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 CASE
STUDY 1
 LABS: ANEMIA WITH MACROCYTIC
PARAMETERS
 ALBUMIN: 2.7 GM/DL
FUNCTIONAL NUTRITIONAL
ASSESSMENT
 ASSESSMENT:
– INADEQUATE ORAL INTAKE DUE TO
MICRONUTRIENT DEFICIENCIES AS
EVIDENCED BY TASTE CHANGES,
SUBJECTIVE SYMPTOMS AND PHYSICAL
EXAM RESULTS
FUNCTIONAL NUTRITIONAL
ASSESSMENT

PLAN OF CARE
–
–
–
–
–
–
–
TREATMENT OF THRUSH
THIAMINE 100 MG/DAY X 7
MVI WITH MINERALS Q DAY WITH FOOD
B COMPLEX 1X/DAY
ZINC 25 MG BID X 2 WEEKS
VITAMIN C 500 MG TID X 2 WEEKS
EDUCATION ON USE OF ORAL SUPPLEMENTS,
FRUIT SMOOTHIES WITH PROTEIN,
HYDRATION ADEQUACY
– CHECK B12, VITAMIN D LEVEL
– USE OF ACTIVE CULTURE YOGURT Q DAY
FUNCTIONAL NUTRITIONAL
ASSESSMENT

MONITORING AND EVALUATION
– RETURN TO CLINIC IN 2 WEEKS
– CALL RD IF ANY ISSUES

OUTCOME
– RETURNED TO CLINIC, DRIVING HERSELF
– NO LONGER REQUIRED HELP FROM FAMILY MEMBERS
– LOST 20. ALL OF FLUID FROM HER LOWER EXTREMITIES IS GONE.
SHE WAS ABLE TO USE HER NORMAL SHOES INSTEAD ONLY HOUSE
SLIPPERS.
– HAS RETURNED TO EATING 3 MEALS/DAY WITH NORMAL
VARIETY/VOLUME OF FOOD
– PATIENT WAS CONTINUED ON MVI WITH MINERALS, REDUCED DOSE
OF VITAMIN C TO 200 MG/DAY, ZINC CONTINUED FOR ADDITIONAL
14 DAY, B COMPLEX DISCONTINUED
– MD INCREASED REFERRALS
– RD HAD A REALLY GOOD DAY 
REFERENCES





Gropper, S.; Advanced Nutrition and Human
Metabolism, Fourth Edition, 2005
Schleicher,R.;Carroll,M.; Serum Vitamin C and
the prevalence of Vitamin C deficiency in the
United States; 2003-2004 NHANES
Schectman, G.; Byrd, J.; Gruchow, H. The
Influence of Smoking on Vitamin C Status in
Adults. Am J Pub Health,1989
Johnston, C.; Thompson, L.; Vitamin C Status of
an Outpatient Population. J AM Col Nutr, 17, No.
4, 366-370
Olmedo, J.; Yiannias, J.; Scurvy: a Disease
Almost Forgotten. Int J Derm 2006, 45, 909-913
REFERENCES





Mahan, K.L.; Escott-Stump, S.; Krause’s Food,
Nutrition and Diet Therapy
Prasad, A.; Beck, F.; Bao, B.; Zinc
Supplementation decreases incidence of
infections in the elderly; effect of zinc on
generation of cytokines and oxidative stress. Am
J Clin Nutr, 2007, 85, No.3, 837844
NIH Office of Dietary Supplements, Dietary
Supplement Fact Sheet
Fraker, Pamela J.; King, L.; Reprogramming of
the Immune System During Zinc Deficiency.
Annu Rev Nutr 2004, 24:277-298
Mohammad, M., et al; Zinc in Liver Disease Nutr
Clin Pract 2012, 27: 8-20