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:

Body Weight History

Body weight is a global indicator for overall health. Any 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:

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 for weight loss: (1) decreased caloric intake, (2) malabsorption or maldigestion, (3) impaired metabolism or increased requirements, and (4) increased losses or excretion (Table 29-1).

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 (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 B₁₂ 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 29-2), and other dietary supplements that they may not mention without prompting. A thorough review of alternative 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:

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 changes in appetite, nausea, 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 29-3 lists examples of drug interactions and nutrient metabolism.

Studies by Bailey and associates (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, the grapefruit or its juice tends to increase the drug’s effect. The advisory also cautioned that sour oranges and tangelos may also interfere with medication blood levels. Other citrus fruits were considered safe. The study stated 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.

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).

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 (sorbitol, xylitol) or fructose, high fiber intake, or lactase deficiency. Of these potential causes, lactose intolerance 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.

Social History

Multiple social factors affect the dietary and nutritional status of patients. For example, low socioeconomic status, low fixed income, homelessness, food insecurity (the uncertainty of having or being able to acquire enough food because of insufficient funds or other resources) or lack of access to a variety of food choices may contribute to nutritional deficiencies. Chronic alcoholism and recreational drug use are two additional conditions that put people at high nutritional risk. The patient’s attitudes about food and nutrition, as well as religious observances, also determine eating patterns and the selection or avoidance of specific foods. This information is important to note and document.

Lifestyle Habits

The lifestyle habits section of the medical history includes the dietary history, physical activity history, alcohol use history, and smoking history. Questions related to alcohol use and smoking are discussed in Chapter 1, The Interviewer’s Questions.