Let Me Hear
Your Body
Talk The Nutrition-Focused Physical
Coco Newton, MPH, RD, CCN www.coconewton.com
Webinar, Dietitians in Integrative & Functional Medicine September 18, 2014
VALUE of Nutrition-Focused Physical
Enhances successful outcomes
Enhances therapeutic relationship
Collective Wisdom
• Adele Huls, PhD, RD nutritionfocusedexam.com
• Cindy Hamilton, MS, RD, CNSD (webinar, eatright.org)
The Use of Nutrition Focused Physical Exam & Functional
Parameters to Determine Malnutrition Dietitians in
Nutrition Support DPG (10/20/11)
• Kathie Swift, MS, RD (instructor) Nutrition-Focused
Physical Exam in “Nutrition in Practice” Food As Medicine,
Center for Mind-Body Medicine cmbm.org/fam (2012)
• Kathleen Mahan, Sylvia Escott-Stump, Janice L.
Raymond. Krause’s Food & The Nutrition Care Process,
13th Ed. pp.1075-1099, ( 2012)
Collective Wisdom
• Mary Ann Kight. et al. Conducting Physical
Examination Rounds for Manifestations of Nutrient
Deficiency or Excess: An Essential Component of
JCAHO Assessment Performance. Nutrition In Clinical
Practice; 14(2):93 (April 1, 1999)
• Mary D. Litchford, PhD, RD, LDN (author)
casesoftware.com
Nutrition Focused Physical Assessment: Making
Clinical Connections (2012)
Collective Wisdom
• Michael Stone, MD, MS (instructor)
Nutrition-Related Physical Exam for Nutrition
Professionals Applying Functional Nutrition for
Chronic Disease Prevention & Management Course
at Institute for Functional Medicine (2010-2012)
• Ruth Leyse-Wallace, PhD, RD Nutrition Focused
Physical Examinations ruthlysewallace.com
Adele Huls, PhD, RD, LMNT
Diana Noland, MPH, RD, CCN
• Nutrition-focused physical exam: checklist http://www.dietetics.kumc.edu/events/nutrition-focused-physical-exam-checklist.pdf
• Key terms for performance of nutrition-focused physical exam http://www.dietetics.kumc.edu/events/Key-Terms-Performance%20-Nutrition-focused-Physical-Exam.pdf
• Resources for the nutrition-focused physical exam http://www.dietetics.kumc.edu/events/Nutrition-focused-physical-exam-Resources.pdf
• Most commonly observed clinical signs and symptoms http://www.dietetics.kumc.edu/events/Clinical-Signs-Symptoms-Nutritional-Deficiencies.pdf
• Nutrition-focused physical examination: observations http://www.dietetics.kumc.edu/events/Nutrition-focused-Physical-Examination-Observations.pdf
KUMC Clinical Nutrition Seminar (11/4/11) http://www.dietetics.kumc.edu/events/clinical-nutrition-seminar.html
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Nutrition-Focused Physical Exam
Deborah Ford, MS, RD; Sudha Raj, PhD, RD, CDN; Rita Kashi Batheja, MS, RD, CDN; Ruth DeBusk, PhD, RD, LDN; Dave Grotto, RD, LDN; Diana Noland, MPH, RD; Elizabeth Redmond, PhD, MMSc, RD, LD; Kathie Madonna Swift, MS, RD, LDN. American Dietetic Association: Standards of Practice and Standards of Professional Performance for registered dietitians (competent, proficient, and expert) in Integrative and Functional Medicine. J Am Diet Assoc. 2011;111:902-913
Tools
1. 2. 3.
5. 6.
8. 9.
1. Bioelectrical Impedance Analysis
2. Tape measure 3. ETOH glass or
Temporal Artery thermometer
4. Blood pressure 5. Pen light 6. Pulse oximeter 7. Reflex hammer 8. Scale 9. Tongue depressor
4.
7. 8.
1st impression?
Looking for Nutritional Imbalances
Body Composition
Skin
Hair
Nails
Eyes
Mouth
BODY
COMPOSITION
Waist:Height better CVD predictor than BMI
• 300,000 people
• Goal = waist circumference ≤ ½ height
19th conference on Obesity in Lyon, France (May 12, 2012)
http://www.health-calc.com/body-composition/waist-to-height-ratio
Osteoporosis/Fatty Bone
OBESITY- 30% trabecular bone volume, porosity, stiffness
ANOREXIA- fat in bone marrow
Ecklund K et al. Bone marrow changes in adolescent girls with anorexia nervosa
J Bone Min Res Feb 2010
Cohen A, et al. Abdominal fat is associated with lower bone formation and inferior bone quality in healthy
premenopausal women: A transiliac bone biopsy study. J Clin Endocrinol Metab 2013
SKIN
Skin
• Color
• Temperature
• Moisture
• Texture
• Turgor
• Rashes
• Wounds &
Ulcers
• Lesions
• Scars
• Bruising
• Vascularity
Mary D. Litchford, PhD, RD, LDN Nutrition-Focused Physical Assessment: Making Clinical Connections 2012
Low EFA’s: skin function & appearance
– Hyper-proliferation of
epidermis
– Dermatitis
– Photo-damage
– Wound healing
– Sensitivity
– Trans-epidermal water loss
crucial to barrier function
– Eicosanoids (signaling)
Stress: “psycho-dermatology”
• Nerve endings from organs are
connected to skin.
• As emotions play out neurologically,
they can be expressed through the skin.
Examples: acne, hives, psoriasis,
eczema, rosacea, alopecia, vitiligo
Karen Mallin, PsyD Univ of Miami/Jackson Memorial Hospital
webmd.com July 27, 2012
Skin - gut connection
Signs Acne Hives Eczema Chronic vaginitis Fungal nails Easily bruised skin Rosacea Dilated cheek capillaries Dermatitis Herpetiformis
CHECK IF POSITIVE FOR:
BACTERIA PARASITES
YEAST
Symptoms Arthritis Fatigue Fibromyalgia Autoimmune Food Allergies Psoriasis Depression/anxiety IBD Chronic infections Pancreatic function Celiac/gluten Malabsorption Hashimoto’s
Gluten & Dermatitis Herpetiformis
>90% of patients
IgA, neutrophils
HLA-A1, HLA-B8, HLA-DR3, HLA-DQ2
Gut Tissue Transglutaminase (t-TG) cross-reacts
w/ Epidermal Tissue Transglutaminase (e-TG)
Atopic Dermatitis aka Eczema
Red, scaly areas Small, rough bumps Thick, leathery patches Bumps that leak fluid and crust over In darker-skinned people, the affected area might be lighter or darker.
FOOD ALLERGIES
Acne & Traditional Chinese Medicine
Raynaud’s Syndrome
• Vasospasms- triggered by cold, stress
• Pain, numbness
• Skin color (red, white, blue)
• Consider auto-immune diseases and food allergies
• Consider Magnesium, Fish Oil, Niacin, L-Carnitine,
L-Arginine
Nutritional Medicine by Alan Gaby, MD 2011
Skin: B12 deficiency signs
Hyperpigmentation
Rajendran, K. et al. Can Fam Physician 2008 April; 54(4):529-532
Polymorphic maculo-papular lesions
Angular stomatitis Vitiligo
SYMPTOMS
Depression
Fatigue
Poor memory
Numbness
Tingling
Skin & Cardio-Metabolic Syndrome
Diabetic dermopathy
Digital sclerosis
Disseminated granuloma annulare
Diagonal earlobe crease
Scleroderma diabeticorum
Eruptive xanthoma
Skin Tags & Diabetes
Van Hattem MD, Simone; Bootsma MD PhD, Aart H; Thio MD PhD, H Bing. Skin Manifestations in Diabetes. Cleveland Clinic Journal of Medicine 2008 75(11):772-787
25% of people have DM Insulin Resistance Abnormal Blood Fats
Acanthosis Nigricans
• Insulin resistance
• Type 11 Diabetes
• PCOS
• Addison’s disease
• Hypothyroidism
• Oral contraceptives
• Other drug induced,
idiopathic, familial
resolves when
causes are treated
Hereditary Hemachromotosis
1 in 200 Caucasians
Increases chances of DM, CHF, OA, Hypothyroid
Skin’s “chemical barrier” defends
against Metabolic Syndrome!
3 systems
1. Xenobiotic/drug biotransformation system
2. ROS scavenging system
3. Sweat & sebaceous glands excretion systems
Zhou et al. The skin function: a factor of anti-metabolic syndrome. Diabetology & Metabolic Syndrome 2012 4:15
CK. Svensson Drug Metabolism & Disposition. 2009 Feb 37(2):247-253
Biotransformation http://www.eoearth.org/view/article/150674/
Met Syn
Skin
Detox
Antiox
Wrinkle score Bone Density (suggests that collagen contributes to both) The Endocrine Society June 6, 2011
Vitamin K2 Wrinkles (fewer GLA matrix proteins that prevent calcification of elastin) Lab Invest. 2007 Oct;87(10):998-1008.
Vitamin K2 Bone Density Mol Nutr Food Res. 2014 Aug;58(8):1647-57
Wrinkles: Bone Density and Vitamin K2
Dehydration: fluid loss as % body wt. 5% = mild 10% = moderate 15% = severe
Hypothenar eminence test
Skin pinch test more difficult to assess in elderly
Capillary nail refill test
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HAIR
Hair
• Loss
(alopecia)
• Breakage
• Easy pluck
• Shine
• Color
• Strength
• Thin/thick
• Course/fine
• Curliness
• Elasticity
Lack of shine, thin, sparse, loss
–protein, zinc ,iron, biotin, linoleic acid
– Thyroid/Adrenal imbalances, PCOS
– Color treatment (H202 + monoethanolamine)
–stress
– Very low calorie diets
– Rapid weight loss after bariatric surgery
Mary Litchford, PhD, RD, LDN Nutrition Focused Physical Assessment: Making Clinical Connections
p.105-109 (2012)
Krause’s Food & The Nutrition Care Process p.1075-1076 (2012)
Hair, Skin: Eating Disorders
1. Xerosis
2. Lanugo-like body hair
3. Telogen Effluvium
4. Carotenoderma, Acne
5. Russell’s signs
6. Acrocyanosis
7. Petechiae
8. Livedo Reticularis
9. Nail dystrophies
1.
2.
3.
5.
Strumia, Renata. Dermatologic Signs in Patients with Eating Disorders. Am J Clin Dermatol (2005) 6(3): 165-73
8.
Hirsutism
• Hirsutism PCOS causes excess hair growth
(coarse, dark) where typically hair is very fine or
non-existent.
• androgens, insulin resistance, DM, cholesterol,
sleep apnea.
• Also causes frontal baldness & acne
Male Pattern Baldness CHD
9% risk frontal baldness
36% risk vertex baldness
79% risk vertex baldness + HTN
Latufo PA, et al. Male pattern baldness and coronary heart disease: the Physicians’ Health Study.
Arch Intern Med 2000;160:165-171
Arck, Petra, et al. Towards a “free radical theory of graying”: melanocyte apoptosis in the aging human hair follicle is an indicator of oxidative stress induced tissue damage. The FASEB Journal 20(9): e908-920 July 2006
Oxidative Stress plays a major role in
the aging process
and development of
gray hair.
Hair & Stress
2-3 years of constant stress can cause gray hair
scientificamerican.com 10/24/07
Schallreuter, Karin. et al. The redox-biochemistry of human hair pigmentation. Pigment Cell & Melanoma Research. 24(1): 51-62, Feb 2011
Gray…. “hair today gone tomorrow?”
Gray Hair & Diet/Nutrition
CATALASE: proanthocyanadins from green apples, cinnamon, cocoa Cysteine: eggs, sesame seeds Methionine: sesame seeds, pistachios, macadamias, brazil nuts, kidney beans, black beans, fish, meat Sulfur: cruciferous veggies, garlic, onions
SUPPLEMENTS: N-Acetyl Cysteine, Alpha-Lipoic Acid, Selenium, B12, B6, Folate, other antioxidants, Glutathione
NAILS
All nutritional imbalances affect nails!
J Biomed Opt. 2011 May;16(5):057002
Clin Dermatol. 2010 Jul-Aug;28(4):420-5.
Leukonychia
Muehrcke’s Lines
Zinc Albumin
Protein Zn
Beau’s lines Malnutrition DM PVD Zinc
Spoon nails
CVD
Anemia
Hypothyroid
Terry’s nails
DM
CHF
Fungal nails
DM
Erythema
Clubbing
IBD
CHD
Cirrhosis
Iodine deficiency
DM
Onycholysis
Bacteria Fungus Thyroid Fe anemia
Soft, flaky, split easily
Mg Biotin
Vertical Ridges Aka “nail wrinkles” Ridges are thinnest spot so don’t buff!
Age
Fungal Nails
Also, check: Athlete’s foot Anal itching Itchy skin rashes Itchy ears Vaginal yeast infection Dandruff Muscle twitching IBS UTI Chronic fatigue Etc.
EYES
EYES & latent nutrient deficiency
• Ocular signs of systemic disease may occur before other manifestations or diagnosis.
• Occasionally arteriosclerosis is recognized exclusively by eye signs.
• This also applies to generalized pathologic conditions, infections, metabolic disturbances
and vitamin deficiencies.
Arthur Alexander Knapp. The eye as a guide to latent nutritional deficiency diseases. The New York Academy of Medicine, Feb 19, 1945
Carbohydrate nutrition is associated with changes in the retinal vascular structure and branching pattern in children, B. Gopinath, et. al, Am J Clin Nutr May 2012
2,353 12 y olds studied Narrowing of retinal arteries- precursor to CVD High risk = 1+ glasses soft drinks daily Most significant in girls
Bitot Spots
Vit A
Dry Eye
Auto-immune Vit A DM
Eyes: nutritional & metabolic imbalance
Anemia
Iron
Oxidative stress
Eyes: cardio-metabolic disease
Corneal Arcus < 60yrs
Arterial Narrowing Cataracts
CVD
CHD
Chol
Xanthelasma
Eyes
Conjunctivitis
Blepharitis
Dry eyes
Type 2 DM sometimes the 1st signs of a
prolonged subclinical course
Correlation HbA1C and dry eye in
70% of patients
Polak BC, et al. Eye symptoms and latent diabetes. Ned Tihdschr Geneeskd 1997 Jan 11:141(2):73-5 Rahman A, et al. Diagnostic value of tear films tests in type 2 diabetes. J Pak Med Assoc. 2007 Dec:57(12):577-81
Seifarat U, et al. The dry eye and diabetes mellitus. Opthalmolge. 1994 Aapr:91(2):235-9
DRY EYE
Invest Opthalmol Vis Sci. 2011 July;52(8):5408-5413
Ocular microbiome contributes to infectious and autoimmune diseases of the eye.
http://www.the-scientist.com/?articles.view/articleNo/39945/title/Visualizing-the-Ocular-Microbiome/ (May 2014)
Meibomian Gland Dysfunction
Oxidative stress lipid peroxidation, stagnation, bacterial overgrowth, inflammation
Invest. Opthalmol. Vis. Sci. March 30, 2011 52(4):1979-1993
Wakamatsu TH et al. Tearful relations: oxidative stress, inflammation and eye disease.
Arq Bras Oftalmol. 2008;71(6 Supl):72-9
MOUTH
Look inside the mouth
Halitosis
• fungal or bacterial infections
• sinus, GI tract dysbiosis, GERD, respiratory infections, periodontal pockets, tonsil stones
The trapped debris combines with volatile sulfur compounds (produced by anaerobic bacteria beneath tongue surface) and putrefies in the back of the throat.
Tongue
Yellow/white coating, fissures
Fungus Bacteria Biotin
Courtesy Dr. David Regiani
Oral Health & Nutrients
Taste Bud Atrophy B12, Fe
Glossitis B12, Fe, Folate
Geographic Tongue Chemical sensitivity, allergies, B Vit, Zn
Candida Cheilitis “thrush” B12, Fe
Taste, Smell & Nutritional Imbalances
80% taste due to loss of smell Food allergies Zinc Vit A B12
Sally P. Stabler, M.D. Vitamin B12 Deficiency. N Engl J Med 2013;368:149-160 Russell RM, et al. Zinc and the special senses. Ann Intern Med 1983;99:227-239
Fein BT, et al. The loss of sense of smell in nasal allergy. Ann Allergy 1966;24:312 Duncan RB, et al. Treatment of uncomplicated anosmia by vitamin A. Arch Otolaryngol 1962;75:116-124
Testing for Smell & Taste
Taste test for zinc adequacy, insufficiency or deficiency
Weak sense of taste linked to weaker immune system. Weak sense of smell linked to Alzheimer’s and Parkinson’s.
http://www.anh-usa.org/studies-delicious-smells-and-tastes-are-directly-linked-to-a-strong-immune-system/
http://neurology.ufl.edu/2013/10/14/uf-researchers-find-that-peanut-butter-test-can-help-diagnose-alzheimers-disease/
Stewart R, et al. J Am Geriatr Soc. 2013 Feb;6(2):177-84 Poole S, et al. J Alzhemers Disease . 2013 May; 36(4):665-667
1,053 randomly selected individuals aged 70 - 79 from the Health ABC Study Gingival inflammation was most strongly associated with cognitive impairment and was the only factor that predicted cognitive decline.
Oral Health & Brain
Treponema denticola, Tannerella forsythia, and Porphyromonas gingivalis crosses the blood brain barrier and only found in dementia patients.
Mouth- Eating Disorders
Enamel erosion Cavity formation
Mouth: elemental mercury vapor exposure
Mood swings
Insomnia
Headache
Tremors
Weakness
Increased risk neurological,
CHD, DM
Ziff, S et al. Dental Mercury Detox International Academy of Oral Medicine and Toxicology (IAOMT) pg. 9 (2007)
He K, Xun P, Liu K, et al. Mercury Exposure in Young Adulthood and Incidence of Diabetes Later in Life: The CARDIA trace element study. Diabetes Care. 2013 Feb 19. View Abstract
amalgams
Periodontal Disease
2X risk of CHD
“6th complication of diabetes” Newly Identified Oral Bacterium Linked to Heart Disease and
Meningitis. ScienceDaily Feb. 20, 2012
Ali M. Tavana Heart failure and oral bacteria: How could be
prevented? J Cardiovasc Dis Res. 2010 Jul-Sep; 1(3): 161
Plaque
Dissected pathologic carotid plaque with bacterial
contents from same patient with periodontal plaque surrounding existing dentition are identical.
Bacterial Mouth Infections May 23, 2012 medscape.com
Nutrition-Focused Physical and Toxins
Signs of heavy metal toxicity “Mees’ Lines” Arsenic, Flouride
Gingivostomatitis Mercury
Erythematous papules Mercury
Sandeep Chauhan, et al. Mees’ lines. The Lancet 372(9647):1410 October 18, 2008 Paul I. Dantzig. A new cutaneous sign of mercury poisoning? J Am Acad Dermatol December 2003 Scott Moses, MD. fpnotebook.com 9/4/12
Lead lines Amalgam tattoos
Endocrine: Thyroid
Hashimoto’s
Grave’s
Sub-clinical
Outer eyebrow loss
Thyroid Exam
Looking for puffiness, nodules/cysts, enlargement
Achilles tendon reflex- delayed return
courtesy Dr. David Brownstein
Hypothyroid
Hair loss
Outer eyebrow thinning Peri-orbital edema
Scalloped tongue Thin brittle nails
Hyperthyroid Plummer’s Nails
Exophthalmos Goiter
Endocrine: Adrenal
Addison’s Cushing’s Sub-clinical
Hyperpigmentation in Addison’s Disease
Cushing’s Syndrome
Key Nutrients
Thyroid • Protein
• Iron
• Selenium
• Iodine
• Vit A
• Zinc
• L-Tyrosine
Adrenals • B vits (B5, B6)
• Vit E
• Mg
• Celtic sea salt
• Vit C
• Trace minerals
Hearing Loss & Nutritional Imbalances
Homocysteine B6, B12, Folate Zn, Mg COQ10 Vit D Omega-3 fatty acids Vitamin C Hypothyroidism, Hypoglycemia
Seidman, MD, et al. Resveratrol Decreases Noise-Induced Cyclooxygenase-2 Expression in the Rat Cochlea. Otolaryngol Head and Neck Surg 2013 Mar Gopinath, B et al. Consumption of omega-3 fatty acids and fish and risk of age-related hearing loss. Am J Clin Nutr. 2010 Aug;92(2):416-21. Durga J, et al. Effects of folic acid supplementation on hearing in older adults. Annals of Internal Medicine Jan 2, 2007, 146(1);1-9. Khan, M, et al. A pilot clinical trial of the effects of Coenzyme Q10 on chronic tinnitus aurium. Otolaryngol Head and Neck Surg 2007 ;136:72-77 Gordin A, et al. Magnesium: a new therapy foridopathic sudden sensineural hearing loss. Otol Neurotol 2002;23:447-451 Shemesh Z, et al. Vitamin B-12 deficiency in patients with chronic tinnitus and noise induced hearing loss. Am Otolaryngol 1993 Mar-Apr;14(2):94-99. Shambaugh GE Jr. Zinc and Presbycusis. J Am Otol 1985;6:116-117 Brooks GB, Vitamin D deficiency and otosclerosis. Otolaryngol Head and Neck Surg 1985;93:313-321 Am J Clin Nutr June 2014 vol. 99 no. 6 1407-1413 http://ajcn.nutrition.org/content/early/2014/09/10/ajcn.114.091819.full.pdf+html
Food Allergies & Sensitivities: Signs & Symptoms
Head: chronic headaches, migraines, difficulty sleeping, dizziness
Mouth, throat: coughing, sore throat, hoarseness, swelling/pain, gagging, frequent clearing throat, sores (gums, lips, tongue)
Eyes, ears, nose: runny/stuffy nose, post-nasal drip, ears ringing, blurred vision, sinus problems, watery/itchy eyes, hay fever, excessive mucus, dark circles, swollen/red/sticky eyelids
Elizabeth Lipski, PhD, CCN, CHN Digestive Wellness 4th Ed. 2012 (exclusive of photos)
Food Allergies & Sensitivities: Signs & Symptoms
Heart, lungs: irregular heartbeat, asthma, chest pain and congestion, bronchitis, SOB, difficulty breathing
Skin: hives, rashes, psoriasis, eczema, dry skin, excessive sweating, acne, hair loss, irritation around eyes
Muscles, joints: general weakness, aches, pains, swelling, stiffness, arthritis
ALS Body Talk…. when speech can’t tell the story
2011 2014
Ensure Diabetes/Insulin GI distress
Liquid Hope No Diabetes/Insulin GI happiness
functionalformularies.com Tube & Oral Formulas
Nutrition for inflammation, immunity, gut, mitochondria, detoxification, personalized…
“The body never lies”.
- Martha Graham (1894 -1992)
“I speak two languages, Body and English”.
- Mae West (1893-1980)
Thank you
for attending!
Coco