Dr Alan Stewart MB BS MRCP www.stewartnutrition.co.uk

“..all doctors should be able to diagnose nutritional deficiencies.”
Royal College of Physicians 2002

1. How nutritional deficiencies develop
2. What are the common causes and effects of deficiency
3. The three key stages in Nutritional Assessment:
- history
- examination
- investigation
4. A simple method of dietary assessment
5. The prevalence of nutritional deficiencies in the UK according to the National Diet and Nutrition Surveys
6. The importance of Nutritional Assessment

Macronutrients
• Energy - provided by Carbohydrates, Fats, Protein and Alcohol
• Protein – Essential and non-essential amino acid
Micronutrients
• Minerals: Bulk
Trace
• Vitamins: Fat-soluble
Water-soluble
• Essential Fatty Acids:
Ca, Mg, Na, K, Cl, P
Fe, Zn, Cu, Mn, I, Se, ? others
A,D,E, and K
B group and C n-3 series n-6 series

Deficiencies evolve through five stages:
• Adequacy
• State of Negative Balance
• Decline in Tissue Stores
• Loss of Function
• Death
How was this arrived at?

Experimental Thiamine Deficiency
Brin M. Journal of the American Medical Association 1964;187:762-766
• Group of students volunteered for a 6 week study
• Normal diet but deficient in thiamin (<200ug/day, EAR 1000 ug)
• Test erythrocyte thiamin pyrophosphate TPP Effect – measures increase in enzyme activity when thiamin is added to blood sample
Time in days
Clinical Picture
5 None. Intake<Requirement
10 -20 Fall in blood and urine levels
21- 28 Fatigue, loss of appetite, nausea, insomnia, calf pain, anxiety
30 Ankle swelling, cardiac enlargement, significant weight loss
>30-300 Cardiac failure, loss of balance/coordination, mental decline
TPP
Effect
<1.1
>1.1
1.2
1.35
Dr Brin’s Term
Preliminary
Biochemical
Physiological
Clinical
Est 1.5
Anatomical

Adapted from Brin M 1964
Develop over days to years in a logical and recognizable sequence
• State of Adequacy
• State of Negative Balance
• Decline in Tissue Stores
• Loss of Function:
1. Symptoms
2. Physical Signs
3. Organ Failure
• Death

• Adequacy
• This sequence evolves over: weeks (vitamin B1), months (zinc) or years (calcium and vit. B12)
• State of Negative Balance:
1. Poor Intake
2. Reduced Absorption
3. Increased Losses
4. Increased Demand
5. Altered Metabolism
• Decline in Tissue Stores
• The causes of negative balance can be assessed or suspected from the history
• Tests will assess tissue levels, but not all deficiencies are clinically significant
• Nutritional deficiencies are most common at the extremes of age and some deterioration in nutritional state is a normal part of ageing • Loss of Function:
1. Symptoms
2. Physical Signs
3. Organ Failure
• Death
• More people will have mild symptoms of deficiency than physical signs or complete loss of function and organ failure
• The clinical picture of deficiency will depend on the loss of life function

Life Functions Dysfunction caused by Deficiency
• M ovement
• R espiration
• S ensitivity
• N utrition
• E xcretion
Bone Fracture, Muscle Weakness
Early Muscle Fatigue
Neuropathy, Blindness, Reduced Intelligence
Reduced ability to obtain food and feed self
Liver/Renal Disease
• R eproduction Infertility, Miscarriage, Small-for-date Babies
• G rowth Infant Stunting
• D efence Recurrent or Severe Infection

1. History
2. Physical
Examination
3. Laboratory
Investigation

• Four surveys covering ages 1.5 yrs to >85 yrs
• Random samples of the British population with approximately 2,000 subjects in each
• Field-work conducted between 1990 and 2001
• Collected information on:
- 4-7 day weighed dietary intakes
- laboratory measures of nutrients
- alcohol intake, supplement use
- BP and BMI
• No assessment of symptoms or signs of deficiency
• The surveys provide useful information about the prevalence of nutritional deficiencies and the associated risk factors

The Prevalence of Anaemia: NDNS
30%
25%
20%
15%
Male
Female
10%
5%
0%
1.5-2.5yr
4-6yr 15-18yr 35-49yr 75-84yr Institution
•
World Health Organisation Normal Ranges;
1.5-6.0 yrs >11.0g/dl, adult women >12.0g/dl, adult men >13.0g/dl.
•
Adult ranges have been adopted from ages 15yrs and upward
85+yr
• British laboratories often use a normal range of >11.5g/dl for adult women
•
Levels of 11.5-11.9g/dl in women can result in symptomatic iron deficiency

1. History
2. Physical
Examination
3. Laboratory
Investigation
Intake: diet + supplements
Risk Factors for deficiency
Symptoms of deficiency
Anthropometric Measures
(Body Mass Index - kg/m 2 )
Signs of Deficiency
Signs of Underlying Disease
Blood and Urine Tests
Bone Mineral Density
X-Ray

Medical Diagnosis: History is the Most Important
History
Examination
Investigation
Nottingham 1975 W. Virginia 1992
82.5%
8.75%
8.75%
76%
12%
11%
• Both studies assessed new patients, with no clear diagnosis who were referred to a medical clinic, to determine what information was required to reach the final diagnosis
• Hampton JR et al. BMJ. 1975;2:486-9
• Peterson MC et al. West Med J. 1992;156(2):163-5

• Not as easy (or as quick & accurate) as you might think.
• Two separate questions: Is the diet healthy?
Is the diet adequate?
• World Health Organisation and UK Food Standards
Agency set simple but varying targets for “healthy eating”.
• Formal dietary assessment for adequacy involves:
- prospective diet diaries for several days and
- computerised analysis of macro/micronutrient intakes.
• Simple assessment is needed for use in a clinic setting
• Knowledge of the prevalence of deficiency (poor intakes and sub-normal test results) in the British population:
National Diet and Nutrition Surveys, NDNS (1990-2003)

Food Standards Agency 2006
• Base your meals on starchy foods
• Eat appropriately for your weight
• Fruit and Vegetables >5 portions/day
• Salt <6 g/day
• Sugar: limit intake if overweight
• Saturated fats: limit intake
World Health Organisation 2008
• Eat appropriately for your weight
• Fruit and Vegetables: have a good daily intake of fresh varieties
• Salt <5 g/day
• Sugar: limit intake of free sugars such as sucrose, fructose and glucose
• Saturated fats: limit intake of saturated fats which are derived mainly from animal foods and some tropical oils
• Alcohol: Weekly targets of:
<21 units for men
<14 units for women
•
Breakfast: eating it regularly helps adherence to a healthy diet and weight loss programme

• Recommendations made by each country for:
Protein-rich foods : lean meat and poultry, legumes and fish
Dairy foods : milk/yoghurt and cheese
Carbohydrate-rich foods: wholegrain cereals, potato and rice
Fruit and Vegetables
• Much agreement and some disagreement
• These food groups provide approximately 2/3rds of essential micronutrients in the British adult diet
• If an individual achieves good targets for each group then nutritional inadequacy due to poor intake is very unlikely
• References:
Working Document on Setting Nutrient Profiles 21/10/2008 www.food.gov.uk/multimedia/pdfs/consultation/ecsettingnp.pdf

Dietary Assessment: 6 Simple Targets for Adults
Targets are adapted by the author from various sources
Food Category
Protein-rich foods
Fish*
Dairy Foods or Soya
Fruit and Vegetables*
Quality Carbohydrate and
Alcohol (men/women)*
Target
>1 good portion every day
>2 Portions/week including
>1 Oily type/week
>1.5-2 Portions/day
>5 Portions/day
>1-4 Portions/day
<21/14 units/week
* Target set by UK Food Standards Agency
Other targets based on commonsense and other EU countries’ guidelines
Separate assessments need to be made for fats, sugar and salt

• The UK FSA advises “base your meals on starchy foods”
• This advice does not address the problems of poor intakes of vitamin C, folate and fibre or emphasise the benefits of wholegrain and fibre-rich foods in reducing heart disease and cancer
• Better advice is to recommend Quality Carbohydrates: wholegrain breakfast cereals from wheat, oats and others wholemeal, granary and wheatmeal breads and chappati wholemeal pasta brown rice fresh potatoes with their skins
• Emphasising these foods as opposed to white pasta and white rice will improve nutrient intake for many in the UK
• The number of daily portions, typically 1-4 per day, depends on physical activity and weight

Food Group Main Nutrients Provided or
Nutritional Consequences
Protein-Rich Foods Protein, Iron, Zinc, vitamin B complex including
B12 and vitamin A if liver is consumed
Fish and Oily Fish
Dairy Foods
Protein, n-3 Essential Fatty Acids, vitamins B12 and D, and Iodine
Protein, Calcium, Iodine, Vitamin A – retinol,
Vitamins B2 and B12
Fruit and Vegetables Potassium, Vitamin C, Folate, beta-carotene and Fibre. Iron absorption is greatly enhanced
Quality Carbohydrates Potassium, Magnesium, Copper, B vitamins but not B12, and Fibre. Vitamin C from potato
Alcohol (to Excess) Adverse effect on virtually all nutrients except iron. Vitamin B, Zinc and Calcium deficiencies

Estimated Provision of Micronutrients by Major Food Groups
Percentages of Total Dietary Provision
Author’s estimated from NDNS of British Adults: Data collected 2000/1
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Calcium Iron Zinc Folic A Vit B12
Protein
Fish
Dairy
Frt & Veg
Qual CHO
Total
Vit C

Estimated Provision of Micronutrients by Major Food Groups
Totals from: Proteins, Fish, Dairy Foods, Fruit and Vegetables and Quality Carbohydrates
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Prot Ca Mg K Fe Zn Cu
Adults 19-64 yrs NDNS
I Vit A Vit C Vit B1 Vit B2 Folate Vit
B12 n-3
EFAs

Prevalence of Poor Eating Habits in British Adults
Author’s Estimates from National Diet and Nutrition Survey 2000/1 aged 19 to 64 years of failure to achieve 6 Healthy Eating Targets
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Protein Fish and
Oily Fish
Dairy
Foods
Fruit and
Veg
Quality
Carbs
Alcohol
Men
Women

• Nutritional deficiency can develop from a prolonged low intake
• UK nutrient intake requirements are set out in the report:
Dietary Reference Values for Food Energy and Nutrients for the
United Kingdom (1991 – TSO)
• The report defines The Lower Reference Nutrient Intake, LRNI, for protein or a vitamin or mineral as “An amount of the nutrient that is enough for only a few people in a group who have low needs”.
• In practice this means that if the percentage of a population with an intake below the LRNI for a particular nutrient exceeds 3% then it is likely that a significant percentage of the population will be deficient in the nutrient

Total Intakes (Food and Supplements) below LRNI for males and females
39%
36%
Calcium
33%
30%
27%
24%
21%
18%
15%
12%
Potassium
Magnesium
Iron
Zinc
Vitamin A
Vitamin B12
9%
6%
Folate
Vitamin C
3%
0%
Infants Children Adults Free-living
Elderly
Ins titution
Elderly
• “Lower Reference Nutrient Intake – an amount of the nutrient that is enough for only the few people in a group who have low needs”. Considered to be <3% of the population
• Prevalence rates >3% suggest that a significant percentage of the population could be deficient
• Low iron intakes are observed in 33% of adult women of menstruating age

• Formal dietary assessment is useful but time consuming
• Assess the healthfulness of a person’s diet by asking about intake of: protein-rich foods, fish/oily fish, dairy foods, fruit and vegetables, quality carbohydrates and alcohol
• These groups encompass 2/3rds of micronutrient intake
• Failure to achieve a good standard for these food groups will alert the practitioner to a possibly inadequate intake
• Separate assessments need to be made for salt, sugar and fats
• Assess intake from nutritional supplements and be aware of possibly excessive intake

Nutritional Assessment - Risk Factors
NICE guidelines www.nice.org.uk/cg032 (2006) and others
• Fragile skin
• Poor wound healing
• Apathy
• Wasted muscles
• Poor appetite
• Altered taste sensation
• Impaired swallowing
• Altered bowel habit
• Loose fitting clothes
• Prolonged intercurrent illness: chronic infection, chest disease, cardiac failure, cancer etc.
• Extremes of age
• Receiving benefits
• Living alone – especially men
• Alcohol, tea, coffee in excess
• Reduced mobility
• Lack of sun exposure
• Some drugs and multiple therapy
• Heavy periods
• History of miscarriage
• Recovery from illness/operation
• Pregnant or breastfeeding
• Family history/genetic factors
• Smoking
• Inappropriate use of supplements

[www.nice.org.uk/CG032 February 2006]
Screen all patients to identify those most at risk of being deficient:
• Underweight
A body mass index (BMI) of less than 18.5kg/m 2
• Unintentional weight loss
Greater than 10% within the last 3 – 6 months or
• Combination of:
BMI of less than 20kg/m 2 and
Unintentional weight loss greater than 5% within the last 3 – 6 months
Others at risk:
• Those who have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for 5 days or longer
• Those with a poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism
• Those already identified with one deficiency e.g. anaemia or osteoporosis

2
Adults aged 16 years and older in England, 2006. NHS Information Centre
10.00%
9.00%
8.00%
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
Men
Women
All 16-24 25-34 35-44 45-54 55-64 65-74 75+

Percentage of Male Population 19-64 yrs with deficient intake, <LRNI*
24%
21%
18%
15%
12%
9%
6%
3%
0%
51%
48%
45%
42%
39%
36%
33%
30%
27%
Men No Benefits n=724
Men Benefits n=110
Vit A B1 B2 B3 B6 B12 Fol Vit C Fe Ca P Mg K Zn I
• Data from National Diet and Nutrition Survey British Adults. TSO 2003/4
•
<Lower Reference Nutrient Intakes are likely to be adequate for <3% of the population.
Ref: Dietary Reference Values for Food Energy and Nutrient for the UK. HMSO 1991

Percentage of Female Population 19-64 yrs with deficient intake, <LRNI*
24%
21%
18%
15%
12%
9%
6%
3%
0%
51%
48%
45%
42%
39%
36%
33%
30%
27%
Women No Benefits n=741
Women Benefits n=150
Vit A B1 B2 B3 B6 B12 Fol Vit C Fe Ca P Mg K Zn I
• Data from National Diet and Nutrition Survey British Adults. TSO 2003/4
•
<Lower Reference Nutrient Intake are likely to be adequate for <3% of the population.
Ref: Dietary Reference Values for Food Energy and Nutrient for the UK. HMSO 1991

Influence of Household Income on Average Intake of Nutrients in Elderly Men [NDNS 1998]
160%
140%
120%
100%
80%
60%
40%
20%
0%
Energy
<4K/yr
4-6K/yr
6-10K/yr
>10K/yr
Protein Vitamin C Vitamin
B12
Folate
• Annual income in £000s; upper income bands are compared with lowest <4k/year
•
Increasing income is associated with higher intake of protein and many nutrients

Educational Attainment and Nutrient Intake (LIDNS):
% less intake if education < 5 GCSE grades A-C or equivalent
0%
-5%
-10%
-15%
-20%
Males
Females
-25%
Energy Protein Folate Potassium Magnes'm Copper Zinc
•
In males energy difference significant p <0.031; all other nutrients p <0.004
•
In females all nutrients difference significant p <0.009

Dental Health and Nutrient Intake (LIDNS):
% difference in intake if edentate compared with dentate
35.00%
25.00%
15.00%
5.00%
Males 50-64yrs
Males 65+ yrs
Females 50-64 yrs
Females 65+ yrs
-5.00%
-15.00%
-25.00%
-35.00%
Energy Protein NSP NMES Vitamin C Iron
• NSP Non-starch polysaccharides; NMES Non-milk extrinsic sugars
• No data on differences in intake of potassium, magnesium or folate were presented but are likely to be similar b to but less than those for vitamin C
•
Data on younger age groups were not presented

Daily Alcohol Intake and Nutritional Status: NDNS 65+
% difference in status compared with non/low drinkers
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
-10.00%
-20.00%
Males <10g
Males 10-20g
Males =/>20g
Females <10g
Females =/>10g
-30.00%
Plasma
Vitamin C
Plasma
Vitamin D
Red Cell
Folate
Serum
Vitamin B12
• Intake determined from 4 day diary
• Caution, no adjustment for age, health, diet or supplements was made
• Non-drinkers were more likely to be older and have abnormal liver test

• Specific Symptoms
Delayed dark adaption
Sore tongue
- vitamin A or zinc
- iron, vitamin B12 and other B vitamins
• Non-specific Symptoms*
Fatigue
Cold intolerance
Loss of appetite
Poor immunity
Menstrual irregularity
Muscle cramps and pain
Numbness in feet/hands
Mood change
Cognitive decline
- anaemia, iron, potassium, magnesium, vitamins B and C
- iron
- iron, vitamin B group and zinc
- protein, zinc, vitamins A and B
- protein, vitamin B12 and other nutrients
- potassium, magnesium and vitamin B1
- vitamins B1, 3 and B12
- vitamins C, B, folic acid and magnesium
- vitamins B12, B1 and B3, and n-3 essential fatty acids
* Symptoms may often be due to non-nutritional causes

•
•
•
• Mouth
• Skin
•
Hair
• Nails
• Skeleton
Muscle
Eyes
Neurological
Mouth Ulcers – iron
Cracking at corners of mouth – iron, vitamin B
Dry scaley skin – Essential Fatty Acids
Easy bruising – vitamin C
Scalp hair loss
– iron
Spoon-shaped nails - iron
Spinal curvature – calcium and vitamin D
Low impact fracture – calcium and vitamin D
Calf muscle tenderness – vitamin B1
Loss of strength – potassium, magnesium
Weak hip muscles
– vitamin D
Clouding of the cornea – vitamin A
Loss of sensation in hands and feet – vitamins
B1, B12
Loss of vibration sense – vitamin B12
• All the above signs also have non-nutritional causes

Investigation: Laboratory Tests of Nutritional Status
• GP Tests
Full Blood Count red and white cells, platelets
Serum Ferritin or Serum Iron, Total Iron Binding Capacity + % sat
Serum Vit B12 and serum or Red Cell Folate
Plasma Na, K, vitamin D
Bone Mineral Density (Ca)
• Other Tests
Plasma elements: Zn, Cu, Se, Mn, Mg
Red cell magnesium
Vitamins B1, B2 and B6 – enzyme activation
Plasma retinol, plasma or WBC vitamin C
Urine Na, K, Iodine
• Specialised and Rare Tests
Plasma Homocysteine, MMA, Holo-transcobalamin, Enzyme tests
X-rays (vitamin D and C), Brain MRI (Mn)
Tissue levels – bone marrow, liver biopsy, post-mortem

Test Choice
Negative Balance
Poor Intake etc.
Risk Factor:
Medical or
Social
Physical Sign

The Prevalence of Anaemia: NDNS
30%
25%
20%
15%
Male
Female
10%
5%
0%
1.5-2.5yr
4-6yr 15-18yr 35-49yr 75-84yr Institution
•
World Health Organisation Normal Ranges;
1.5-6.0 yrs >11.0g/dl, adult women >12.0g/dl, adult men >13.0g/dl.
•
Adult ranges have been adopted from ages 15yrs and upward
85+yr
• British laboratories often use a normal range of >11.5g/dl for adult women
•
Levels of 11.5-11.9g/dl in women can result in symptomatic iron deficiency

Prevalence of Iron Deficiency: NDNS
Low Plasma Ferritin: Range < 10-20ug/l
30%
25%
20%
15%
10%
Male
Female
5%
0%
1.5-2.5yr
4-6yr 15-18yr 35-49yr 75-84yr Inst 85+yr
• Normal ranges: infants age 1.5-4.5yrs > 10.0ug/l, females age >4yrs-adult > 15.0ug/l, males age >4yrs-adult > 20.0ug/l
• Plasma ferritin can be elevated by acute or chronic inflammation, infection or liver disease and is not a reliable measure of iron status in ill and elderly people

Prevalence of Vitamin B12 Deficiency: NDNS
Plasma <118 pmol/l
30%
Male
Female
25%
20%
15%
10%
5%
0%
1.5-2.5yr
4-6yr 15-18yr 35-49yr 75-84yr Institution
85+yr
•
A serum vitamin B12 of 118pmol/l is equivalent to 154pg/ml
•
Macrocytosis (MCV >101fl) was seen in: 1-3% of teenagers, 9% of adults,
2% of free-living elderly and 3% of elderly in institutions.
•
Macrocytosis is often due to alcohol excess and not vitamin B12 deficiency

Prevalence of low Red Cell Folate: NDNS
50%
45%
40%
35%
30%
Male
Female
25%
20%
15%
10%
5%
0%
1.5-2.5yr
4-6yr 15-18yr 35-49yr 75-84yr Institution
85+yr
•
The normal ranges for red cell folate and method of analysis varied with each study; infants > 400nmol/l, children and adults > 350nmol/l and the elderly > 345nmol/l
•
Folate status is influenced by alcohol excess and altered metabolism in the elderly
• Pregnant or breast feeding women were excluded from the adult NDNS

Prevalence of Vitamin C Deficiency plasma Vit. C<11.0umol/l - NDNS data
60%
50%
40%
30%
Male
Female
20%
10%
0%
1.5-
3.5yr
2.5-
4.5yr
4-6yr 7-10yr 11-
14yr
15-
18yr
19-
24yr
25-
34yr
35-
49yr
50-
64yr
65-
74yr
75-
84yr
85+yr Inst
65-
84yr
•
Approx. 20% of adults and 12% of the elderly took supplements of vitamin C
Inst
85+yr
•
Approx. 25% of British adults smoke and this declines after the age of 65 years
• Aspirin was taken by 20% of free-living elderly and 24% of institutionalised elderly

Nutritional Deficiencies in Acutely ill Geriatric Patients:
Prevalence of Haematological Deficiencies 1973/75
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Age 65-70yrs (n=16)
70-79yrs (n=53)
80+yrs (n=24)
Anaemia RBC Folate Vitamin B12 % Iron Sat
• 93 acutely ill patients >65yrs: male = 35, female = 58 in Yorkshire
•
Folate and vitamin B12 were measured using micobiological assays
•
9/93 = plasma albumin >28g/l, 29/93 = plasma albumin 28-34g/l
• Refs: Morgan AG et al. Int J Vit and Nut Research. 1973:43;46-471 & 1975:45:448-462

Vitamin Deficiencies in Acutely ill Geriatric Patients:
Prevalence of various vitamin deficiencies 1973/75
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Age 65-70yrs (n=16)
70-79yrs (n=53)
80+yrs (n=24)
Vit A PTT TPP Vit B2 Vit B3 WBC Vit C
•
93 acutely ill patients >65yrs: male = 35, female = 58
• PTT = prothrombin time (Vit K), TPP = thiamin pyrophosphate effect (vit B1)
Vit B2 = whole blood riboflavin, Vit B3 = urine n-methyl nicotinamide level
• References: Morgan AG et al. Int J Vit and Nut Research. 1975:45:448-462

Vitamin B Deficiencies in Newly-Admitted Psychiatric Patients
[Middlesex 1970s]
100%
90%
80%
70%
60%
50%
40%
30%
Vitamin B1
Vitamin B6
20%
10%
0%
Alc/Drug
Abuse
Schizo phrenia
Endog
Depress
Mania Neurot
Depress
Neurosis Organic
Psychosis
Total
•
154 Acute psychiatric patients with a history of poor diet: male = 52, female = 102
•
Vit. B1 Def = Serum Pyruvate >79umol/l (n=154), Trans Ketolase AC > 1.3 (n=74)
• Vitamin B6 deficiency = Aspartate Transaminase Activation Coefficient > 1.75 (n=66)
• Reference: Carney MWP et al. British Journal of Psychiatry 1979;135: 249-54

• There are numerous tests of nutritional status
• An abnormally low result does not always mean that there is a significant deficiency
• There are essentially two types of tests:
- tests that measure the level of a nutrient
- tests that measure the function of the nutrient
• Tests that measure the level of a nutrient are: serum vitamin B12 serum ferritin (iron) serum retinol
• Corresponding test that measure the nutrient’s function are: serum methylmalonic acid MMA (vitamin B12) haemoglobin level dark adaption test
• Occasionally high levels of a nutrient are found
• Test results must always be interpreted with knowledge of the full clinical picture of findings from history and examination

• Ask about diet: type of diet and consumption of major food groups
• Ask about use of supplements
• Assess risk factors: medical – unintentional weight loss, feeding difficulties non-medical – socioeconomic
• Ask about symptoms of possible deficiency
• Measure BMI and examine for signs of possible deficiency
• Decide upon appropriate tests of nutritional state
• Interpret data from: history, examination and investigation carefully
• Treat the deficiency (diet and nutrition support) and underlying causative factors
• Monitor response to treatment

Correct
Undernutrition
Treat
Underlying Disease or Cause
Improve/Change
Food Intake
Add in
Fortified Foods
Use Nutritional
Supplements

“..all doctors should be able to diagnose nutritional deficiencies.”
Royal College of Physicians 2002

Remember the Final Test of a Deficiency is if ..

You have covered
• Nutrition is one of the essential functions of life
• What are the essential nutrients?
• How do we know a nutrient is essential?
• How do nutritional deficiencies develop?
• An outline of nutrition assessment
• What are the common nutritional problems?
References and Further Information

Thank you for your attention
If you would like to be sent the four page handout that accompanies this lecture or would like me to deliver the full illustrated version of this presentation please email me at dr.stewart@stewartnutrition.co.uk
Tel 01273-487003
For additional lectures see related presentations on:
National Diet and Nutrition Surveys
How Safe are Nutritional Supplements? at www.stewartnutrition.co.uk