Tuesday, October 26, 2010

Signs & Symptoms: A Nutrition-Focused Physical

My late grandmother, to whom this blog is dedicated and a nurse by profession, used to sit on her porch in Brooklyn watching neighbors and passersby, proclaiming that they had various health conditions.  As we would sit with her and chat, she would say "see that young man, he has scoliosis," "see that lady, she has a thyroid problem," "that child has a vitamin D deficiency, so sad", and so on.  When I was a young girl, she would have us undress down to our undergarments as we stood before her so she could see our legs, ankles, and spines and make sure we did not have scoliosis, vit D deficiency, or other health problems.  She was the type of person that listened to alternative health radio shows, jotting down lots of information that sometimes even became mainstream consensus (like the benefits of omega 3 and probiotics and the dangers of trans-fat).

So I read with excitement, last week's New York Times article about Dr. Abraham Verghese reviving the lost art of the physical exam.  The NYT says of Dr. Verghese:

"At Stanford, he is on a mission to bring back something he considers a lost art: the physical exam. The old-fashioned touching, looking and listening — the once prized, almost magical skills of the doctor who missed nothing and could swiftly diagnose a peculiar walk, sluggish thyroid or leaky heart valve using just keen eyes, practiced hands and a stethoscope."

I hope that he includes nutritional aspects of the physical exam as well, since most nutritional deficiencies and excesses manifest outwardly in various signs and symptoms. A nutrition-focused physical exam is one component of a complete nutritional assessment incorporating dietary history, medical/social/environmental background, and lab values.

I first learned of physical symptoms related to nutrient deficiencies when I was in high school and I read my mother's copies of Adelle Davis's books Let's Eat Right to Keep Fit and Let's Have Healthy Children.  Although most of the information in her book is not evidenced-based and has sometimes proven dangerous, some of the information was correct and insightful. I remember reading about tongue and lip problems related to Vitamin B2 (riboflavin) deficiency.  She described some symptoms such as cracked/red lips, cracked corners of the lips and mouth (angular cheilosis), a red or magenta tongue, eye sensitivity to light...  In another chapter, she described vitamin D deficiency beyond the classic symptoms of rickets, to include sub-par bone development.  Pictured of children's faces with large foreheads, eyes closely spaces or sunken in, narrow faces, irregular teeth, no chin or protruding chin, and descriptions of bowed legs, knock-knees... (all with no genetic predisposition).  And many other nutrition-related physical examples.  I was hooked.  If many of today's ailments can be fixed with nutrition, then that was what I wanted to study.

Well I was disappointed when I realized that Nutrition-Focused Physical Exams were not taught during my training to become a Registered Dietitian (RD) are still not routinely taught to mainstream RD students, however that is hopefully changing.  I think the rationale was that we would leave that sort of stuff to doctors, but as we can see from this article, doctors may not have been taught this as well.  For RD's who are interested in learning more, there are advanced training session RD's could attend, such as the full-semester option or the 3-day course offered by UMDMJ this coming March 2011, which I hope to attend.  I am especially interested in women's nutritional status and how it affects their hormonal health, pregnancy and labor, and even their looks, as well as the effects of nutrient deficiencies on the growing bodies of fetuses and young children.  I hope to report back soon on what I learn!

Here is some more information about Nutrition-Focused Physical exams:

Written by a committee of Medical Doctors (MD) and Registered Dietitians (RD):
A list of Physical Signs and Symptoms  in Appendix B of the University of Washington Medical Center's Resource Book for Enteral and Parenteral Nutrition.

Written by Naturopathic Doctor's L. Vicky Crouse, ND and James S. Reiley, ND:
Natural Opinion's Nutritional Physical Exam (list of signs and symptoms)

An overview article by a Registered Dietitian, Wendy Hamilton, MS, RD, CNSD:
The Nutrition-Focused Physical Exam

Oral Health and Nutrition by Riva Touger-Decker, PhD:
Oral Manifestations of Nutritional Deficiencies

A home-health care article by a Registered Nurse:
Nutrition-Focused Physical Assessment

Some Books:

Note: I would love to link to Adelle Davis's books but since a lot of her information turned out to be wrong and sometimes dangerous, I cannot recommend her books, although I do thank her for inspiration to study evidenced-based nutrition.


  1. Awesome. I definitely need to brush up my skills in this area. We actually were taught this in my internship (though not in school). The mouth stuff is very easy to spot in a clinical setting and I have caught some deficiencies from time-to-time.

  2. Nutrition isn't focused on enough in any phase of a person's education. They touch on it briefly in high school and that's it. Everything I ever learned about nutrition I only learned on my own after I was already out of high school... and there was so much I didn't know too, basic things like what a calorie is and how calories work.

    It's no wonder we have an obesity epidemic when we don't even teach people anything about proper nutrition.