Introduction

The importance of nutrition in general medical practice has paralleled the increasing prevalence of lifestyle related disorders such as obesity, diabetes, and heart disease. In fact, alongside dermatology and psychological disorders, nutritional disorders are among the most common problems encountered by doctors and there is pressure for the general practitioner to provide competent nutritional assessment, diagnosis and therapy.¹ It has been estimated that over 70% of patients seen in general practice are at high risk of having or developing a nutritional deficiency and many patients will exhibit symptoms suggestive of nutritional inadequacy or imbalance which is contributing to their illness.^{2, 3}

The Australian National Health Survey in 2004–5 reported that 86% of Australians between 18–64 years do not consume the recommended 5 serves of vegetables each day and 46% do not consume the recommended 2 serves of fruit each day.⁴ In 2008 rising petrol and food prices (especially for fresh produce but not for processed/take away foods) were reported to potentially affect shopping trends with less fresh produce being purchased.⁵ Furthermore, the costs of healthy foods such as bread and milk is rising far greater than the cost of nutrient poor energy dense foods (such as cakes, soft drinks and biscuits), which will impact on food choices and the diet in lower socioeconomic groups.⁶

This may be further compounded by emerging evidence from the UK and US (Australian data lacking) that there has been declining levels of minerals in our fruit and vegetables over the last 50 years, especially for magnesium dropping by about 45% (see page 23 ‘Dietary history and assessing food and nutrient intake’). Markovic and Natoli report paradoxical nutrient deficiencies such as zinc, iron, vitamin C and D and folate in the obese and overweight due to eating high-energy foods that are also high in saturated fats, salt and sugar, with poor nutrient content.⁷ The authors note that this condition is under-recognised and therefore not treated. The Public Health Association of Australia released a report in 2009 ‘A Future for our Food: addressing public health, sustainability and equity from paddock to plate’ outlining the urgent need for Australian food policy to encourage food choices that are environmentally sustainable and address the re-emergence of nutrient-deficiency related diseases.⁸

The Australian dietary guidelines and core food groups are currently undergoing revision. The Public Health Association of Australia would like to see the new guidelines address the re-emergence of nutrient-deficiency related disease and food sustainability. Specific recommendations include: reduced total intake of animal products; reduced reliance on ruminant meat; promotion of sustainable proteins, especially legumes, nuts, eggs and chicken; promotion of seasonal fruit and vegetables, legumes and grains that are grown using production methods appropriate to the region. The report highlights that shifting less than 1 day per week’s worth of calories from red meat and dairy products to chicken, fish, eggs, or legume-based diet achieves more green house gas reduction than buying all locally sourced food. In addition, consuming less meat and more plant-based foods may be 1 type of measure that will lead to increased sustainability and reduced environmental costs of food production systems.⁸

The Australian National Children’s Nutrition and Physical Activity Survey also highlights the growing epidemic of obesity in children — estimated at 17% of children considered overweight and 6% obese in Australia — with poor quality diets with significant nutritional shortfalls, particularly vitamin D, E, iodine and iron.⁹

Suboptimal intake of vitamins from diet is common in the general population, particularly children and the elderly, and a risk factor for chronic diseases such as cardiovascular disease, neural tube defects, colon and breast cancer, osteopenia and fractures.¹⁰

Other risk groups identified include vegans, drug and alcohol-dependent individuals, hospitalised patients and patients with malabsorption.

If these trends continue nutritional deficiencies may become more commonplace in the community. Doctors, dietitians, nurses and other allied health professionals may need to become more active and skilled at detecting signs and symptoms of nutritional deficiencies/insufficiencies. Improving the nutritional status of patients will help improve clinical outcomes/wellness and reduce morbidity and mortality and is thus of increasing importance to comprehensive medical care. In order to determine whether a patient’s nutritional status needs improving, a nutritional assessment is required.

Nutritional assessment will identify the high-risk patient (see Table 2.1) for nutrient inadequacies or excesses which in turn will contribute to a nutritional diagnosis. Once the diagnosis is made it is then possible to put in place the nutritional therapy of the patient.

Table 2.1 Identifying patients at high risk of nutrient deficiency or insufficiency

• Patients with chronic illnesses (especially bowel problems, other functional disorders, such as chronic fatigue, psychiatric illness). • Patients on certain and many medications (poly-pharmacy). • Senior patients, recent surgery, injured/severe trauma, burns, sepsis, protracted fever, recent discharge from hospital. • Crash dieters or patients on chronic low calorie diets (<1300kcal/day). • Poor/altered food intake (e.g. due to restricted food budget, food supply, rising food prices, food storage, poor cooking skills). • Some vegetarians, some athletes and those with food allergies or sensitivities to particular foods. • Sedentary patients, especially those who are office/housebound (with little sun exposure or opportunity for incidental activity); the elderly. • Pregnant/breastfeeding women and those who excessively bleed during menstruation. • Women with young children. • Excess alcohol (more than 1 drink per day for women and 2 drinks per day for men), smoking or illegal drug users. • Disabled patients, dental/chewing problems, widowers, socially isolated/living alone.

(Source: adapted from Wahlqvist M, Kouris-Blazos A. Nutrition — is diet enough? J Comp Med 2002: 46)¹¹

Nutritional assessment is based on information gathered from:

Table 2.2 Presentations and signs (can include) to consider with specific vitamin deficiencies (rare or sub-clinical deficiency in Western populations)

Micronutrient	Signs
Vitamin A	Conjuctival xerosis Bitot spot Perifollicular hyperkeratosis
Vitamin B1	Peripheral neuropathy Cardiac arrythmias Cardiac failure
Vitamin B2	Magenta tongue (Glossitis) Angular stomatitis ‘Shark skin’
Vitamin B3	Strawberry tipped tongue (Glossitis) Swollen gums Dermatitis Peripheral neuropathy Hyperpigmentation
Vitamin B6	Glossitis, seborrhoea Peripheral neuropathy Symmetrical sensory and motor deficits
Vitamin B12	Glossitis Angular stomatitis Hyperpigmentation Peripheral neuropathy and sub–acute combined degeneration
Vitamin B complex/folate	Glossitis Angular stomatitis and hyperpigmentation
Vitamin C	Bleeding and swollen gums Swollen eyelids Perifollicular petechiae Follicular hyperkeratosis Scorbutic rosary and joint pain
Vitamin D	Rickets–bowing of long bone and rachitic rosary Osteoporosis
Calcium (Ca) and/or magnesium (Mg)	Positive Chvostek sign
Iron (Fe)	Koilonychia, leucoplakia, Plummer–Vinson syndrome
Zinc (Zn)	Acne, stretch marks, white spots on nail
Iodine (I)	Weight gain

Medical history

The medical history may reveal a disease that interferes with the patient’s ability to eat (e.g. Cerebrovascular accident and Parkinson’s disease) or the body’s use of nutrients (increased excretion of magnesium and chromium in diabetes or reduced absorption of several nutrients in Crohn’s disease). The genetic predisposition may also provide clues e.g. reported weight loss or diarrhoea could be due to coeliac disease which runs in the family.

vit B3^{i, iii, iv, v}, B12^{i, iii, iv, v}, folate^{i, iv, v}, Fe^{i, iv, v, vi} bright red smooth/glossitis vit B2^{i, iv}, B6^{i, iii, iv, v}, B12^{i, iv}, folate^{i, iv, v}, Fe^{i, iv, v, vi}, biotin^{i, v} large beefy tongue hypothyroidⁱ, iodineⁱ magenta/blue tongue vit B2^{i, iii, v}, Biotinⁱ white/pale smooth Feⁱ yellow/brown tongue bowel dysfunction/dysbiosis^vi, low HCL^vi berry like red tongue vit B complexⁱ fissured/creviced tongue vit B3^{iv, v} scalloped tongue Mg^vi, vit B3^vi strawberry tip/cherry tip tongue vit B3^vi, B6^vi burning sensation of mouth/throat D^vi lips cheilosis (burning/soreness) vit B2^{iii, iv, v}, B3^{iii, iv}, B6^{iv, v} angular stomatitis vit B1ⁱ, B2^{i, iii, iv, v}, B3^{i, iii, iv}, B6^{iii, iv}, folate^v, B12^{i, v}, Feⁱ halitosis vit B3^vi, low HCL, dysbiotic bacteria, hypothyroid; liver problems periodontal disease/loose teeth vit C^vi, CoQ₁₀^vi, Ca^vi bleeding gums/gingivitis vit C^{i, iii, iv}, B2^iv, vitK^vi, xs vit A (red gingiva around teeth)^{i, iii} gum recession protein^vi, CoQ₁₀^vi mouth ulcers vit B12^vi, vit A^vi, folate^vi crimson crescents back of mouth food sensitivies^vi intense thirst xs vit D^vi, B1/wet beri beriⁱⁱⁱ impaired taste Zn^{i, v}, vit Aⁱⁱⁱ loss of tooth enamel Ca^iv HANDS/NAILS finger pulp atrophy protein^vi cold hands Feⁱⁱⁱ, Mg^vi, vit E^vi, EFA^vi, thyroid vertical corrugations — pronounced (beaded nails) vit Bⁱⁱ, protein^vi, Zn^vi, diabetesⁱⁱ, thyroidⁱⁱ, Addisonsⁱⁱ vertical corrugations — unpronounced Ageⁱ, RAⁱ, PVDⁱ, Lichen planusⁱ pronounced central ridge Feⁱ, folateⁱ, proteinⁱ horizontal grooves/Beau’s lines protein^vi, past severe illness/surgeryⁱⁱ, MIⁱⁱ, Znⁱ, Seⁱ, Caⁱⁱ leukonychia (white spots) Zn^vi half moons base of nails vit B6^vi dry thin brittle nails protein^vi, malnutritionⁱⁱ EFA^vi, Fe^vi, Ca/osteopeniaⁱⁱ, thyroidⁱⁱ peeling/splitting nails Ca^vi protein^vi spoon shaped/brittle nails Fe^{i, iii, vi}, low cysteine/methionineⁱ, diabetesⁱ soft/papery/bitten nails Zn^vi, protein^vi growth arrest/thickened nails protein^vi, Znⁱ yellow nails vit E^vi black/red thickened nails xs Seⁱ egg shell nails vit A^vi clubbed nails lung problemsⁱⁱ, IBDⁱⁱ, coeliacⁱⁱ, hyperthyroidⁱⁱ brown nail beds or skin creases vit B12ⁱⁱⁱ white nail beds Seⁱⁱⁱ paronychia excess Seⁱⁱⁱ, Znⁱⁱⁱ MUSCLE generalised muscle pain/ache tender muscles cramps Ca^{iii, v}, Mg^vi, vit B5^vi, Feⁱⁱⁱ, K, Na, vit Cⁱⁱⁱ, vit D^vi muscle twitching/spasms (hyper-reflexia) B6^v, Mg^{i, iii, v, vi}, Ca^{i, iii}, Kⁱ, vit D^vi muscle atrophy face, hands, chest, loss of tissue recoil back of hand protein^vi, B1^vi calf/muscle tenderness vit E^v (intermittent claudication), B complex^{iv, vi} muscle weakness/wasting (difficulty up/down stairs)iii protein^iv, vit D^v, K^v, Ca, thiamin decreased muscle reflexes B complex^vi, vit E^vi SKIN excessive ageing of skin/wrinkles vit E^vi perifollicular hyperkeratosis (toad skin) commonly seen on upper arms/thighs vit A^{i, iv, vi}, Znⁱ, B complexⁱⁱⁱ, vit C^{iii, v}, EFAⁱⁱⁱ perifollicular petechiae/haemorrhages vit C^{i, iii, v}, vit K^{i, iii} (causes petechiae unrelated to hair; sometimes seen with prolonged antibiotic treatment) shark skin/dyssebacea (sebum plugs in follicles/face/body) vit B2ⁱⁱⁱ vit B2^{iii, v}(nasolabial/scrotum), vit B3ⁱⁱⁱ, vit B6^{i, iii, v}, Biotin^vi, Cuⁱ, EFA^vi dry scaly/coarse dermatitis Zn^{iii, v}, Iodineⁱ, vit B3ⁱⁱⁱ, omega-6^{i, iii}, omega-3^vi, vit C^v, vit E, biotin^{i, v}, vitA^v, vit A excess^{i, iii, v} dry ‘fish scale’, ‘flaky paint’ vit A^iv, Zn^{iv, v} especially on the legs hyperpigmentation non scaly macules/patches insulin resistance^vi, vit A, Zn^{iii, v}, vit C, vit B12ⁱⁱⁱ, vit B6^vi, folateⁱⁱⁱ, EFA, evening primrose oil (EPO), vit B3^iv (see also dermatitis) hyperpigmented scaly dermal patches on face/limbs (pellagra) vit B1, vit B3ⁱ, biotin^{i, v}, Zn^{iii, v}, EFA unusual skin rash vit B6 or excess supplement use spider veins vit C^vi liver spots (ceroid accumulation) vit E^vi eczema biotin^vi, Znⁱⁱⁱ, omega-3^vi, omega-6/EPO^{i, iii}, glutenⁱ rosacea vit B2, hypochlorhydria/gastric dysfunction^vi, dysbiotic bacteria/H pylori infection^vi psoriasis vit D^vi, EFA^vi, vit A^iv, Znⁱⁱⁱ acne EFA^vi, Zn^vi, vit A^vi, vit Cⁱⁱⁱ, dysbiotic bacteria, bowel dysbiosis^vi, high GI diet/insulin resistance^vi stretchmarks Zn^vi, vit E^vi, Bvi^vi wound healing/lesions on pressure areas vit A, B6^vi, vit C^{v, vi}, Zn^{i, iii, v}, EFA^vi, protein^vi, biotin^vi easy bruising vit K^{iv, vi}, dysbiotic bacteria^vi, protein, vit C^{iv, vi}, blood thinning medication blood mottling arms/legs vit B6^vi itchy skin/rashes liver problems NERVES/PAIN/BONES impaired coordination/balance, disorientation/ataxic gait vit B1^{i, vi}, B12^{iii, v} (neurological changes can occur without haematologic changes), B3^iv, vit E^{iv, vi} neuropathy (weakness, ataxia, pins/needles, parasthesia, foot/wrist drop, reduced tendon reflexes, numbness of fingers/feet/lips/tongue fine tactile sense, vibratory sense, position sense) vit B1^{i, iv, vi}, B2^{iii, vi}, B6^{iii, iv}, B12^{iv, v}, carnitine, EPO, vit B6 toxicityⁱⁱⁱ, folateⁱⁱⁱ, Mgⁱ, Caⁱ, Kⁱ, omega-3ⁱⁱⁱ, Cr^{iii, v} Fe^vi, vit E^{iv, v}, lipoic acid neuralgia/paralysis/paresthesia vit B1^iv, B3ⁱⁱⁱ, B12^{iii, iv, v} Mg^{iv, v} tetany Ca^{iv, v}, Mg^iv, K^v diminished reflexes Iodine^iv postural hypotension vit B6/B complex^vi, Fe^vi (general hypotension) bone/joint pain vit C^{iv, v, vi}, xs vit A^{iv, v}, vit D^{iv, v}, Ca^v, omega-3^vi, Zn^vi, Boron^vi low bone density excess vit A^v Ca^v, Mg^v, vit D^v, Ca^v, Zn, vit K DIGESTION constipation/bloating Feⁱⁱⁱ, B3^vi, low HCL/enzymes, gluten, food intolerances, dysbiosis, candida management, vit D excess diarrhoea Feⁱⁱⁱ, excess Mg/vit Cⁱ, Znⁱ, B3^{iii, vi}, B12ⁱⁱⁱ folate^v, biotin^v, fructose, fructans belching/flatulence/reflux vit B12ⁱⁱⁱ, low hydrochloric acid (HCL), H Pylori, allergen, lactose, fructose poor digestion vit B3^vi, low stomach acid (HCI)^vi MENSTRUAL delayed/<flow periods/irregular oligomenorrhoea/sub-fertility Feⁱⁱⁱ, vit E^vi, EFAs^vi, insulin resistance^vi, Zn^vi mastalgia vit E^vi, vit A^vi, omega-3^vi/EFA imbalance^vi PMS vit B6^vi, Ca^vi, Mg^vi, EFA^vi dysmennorrhoea/menorrhagea Ca^vi LEGS/FEET heels — hyperkeratosis/dry/cracked vit E^vi, EFA^vi soles — hyperkeratosis vit A^vi cold feet/<peripheral perfusion vit E^vi, EFA^vi, Mg^vi, vit B6, thyroid (vit A, Zn, I, Fe) burning paresthesias in feet vit B5ⁱⁱⁱ, B1ⁱⁱⁱ arch collapse protein^vi calf muscle tenderness vit E^vi, B1ⁱⁱⁱ oedema K, Mg, vit B1^{i, iii}, Feⁱⁱⁱ, protein^iv, quercetin GROWTH poor Feⁱ, Zn^{i, vi}, Iodine^{i, iii}, proteinⁱ, energyⁱ, vit Dⁱ, Ca, omega-6ⁱⁱⁱ, vitA^v IMMUNITY/INFECTIONS/CANCER immuno-dysfunction Znⁱⁱⁱ Se^vi, vit C^vi, vit E^vi, vit D

Important note: The list in Table 2.3 is not definitive and is based on combined clinical experience and scientific evidence. Assessment and treatment should be based on your own clinical judgment (i.e. dietary history and physical examination) and confirmed with pathology testing. Symptoms may also occur from other non-nutritional related diseases.

i McLaren DS. A Colour Atlas and Text of Diet-Related Disorders. 2nd edn. London England: Wolfe & Mosby — Year book Europe Ltd, 1992.

ii Medscape. Examining the Fingernails When Evaluating Presenting Symptoms in Elderly Patients. Online. Available: www.medscape.com (accessed 7 Aug 2008).

iii McLaren DS. Clinical manifestations of human vitamin and mineral disorders: a resume. In: Shils M, Olson JA, Shike M, Ross C. Modern Nutrition in Health and Disease. 9th edn. Williams & Wilkins, 1999;485–503.

iv Newton MJ, Halsted CH. Clinical and functional assessment of adults. In: Shils M, Olson JA, Shike M, Ross C. Modern Nutrition in Health and Disease. 9th edn. Williams & Wilkins, 1999;895–902.

v Heimburger DC, Ard JD. Handbook of Clinical Nutrition. 4th edn. Mosby Elsevier 2006.

vi Sydney-Smith M. Nutritional Assessment. J Comp Medicine 2006; Jan-Feb 28–40; and Nutritional Assessment Workshop Seminar slides, March 2008.