let me hear your body talk the nutrition-focused physical...

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