A Dietitian’s Nugget of Knowledge By Beverly Prentice, MS, RDN/LD

A good doctor recognizes and treats illness, while a great doctor promotes overall health and wellness with an integrative/functional medicine approach.  Traditionally, physicians, physician’s assistants, nurses, and nurse practitioners were the primary medical team members who performed health and physical assessments, yet other allied health professionals are specifically trained to provide critical portions specific to their disciplines.  For example, registered dietitians are trained to offer nutrition-focused physical exams that consider body systems, muscle and fat stores, oral health, swallow/breathing, appetite, and the affect of pharmaceuticals in food and drug interactions and nutrient depletion.  Enhancing your SHAPE practitioner toolbox with continuing education that enables you to provide nutrition-focused physical assessments may improve patient outcomes in your practice.  Healthcare practitioners working with SHAPE patients may wish to consider investing in Nutrition Focused Physical Assessment: Making Clinical Connections by Mary D. Litchford, PhD, RDN, LDN as a reference text or a 14 CE Level III self-study course.  The book is intended to provide science-based information to assist advanced level practitioners in identifying and addressing potential macro and micronutrient deficiencies associated with recognizable changes in skin, hair, mouth, tongue, and nails.  I realize that medical professionals are often pressed for time, but providing nutrition-focused physical exams and considering the possible impact of medications causes practitioners to recognize outward signs of macro or micronutrient deficiencies.

Many “chronic dieters” come in with hormone imbalances and metabolic dysfunction due to years of yo-yo dieting.  They may not be successful, even with the SHAPE program, until some of their under-lying issues are effectively addressed.  Physicians are encouraged to refer patients to registered dietitians (RDs) who act as medical nutrition therapists for a host of ICD-10 codes that qualify for coverage under nutrition-related consultation and treatment to improve patient outcomes.  In-depth screening, identifying and addressing underlying contributing factors, and collaboration between team members can achieve personalized nutrition and mental health care, yielding meaningful results for patients such as described in a case study of mine, BHN Case Study 2016-6, that was published last fall in the Behavioral Health Nutrition newsletter. (The Behavioral Health Nutrition is a dietetic practice group of the Academy of Nutrition and Dietetics.)  When patients question various specific eating lifestyles such as Paleo/Ancestral, Ketogenic, Vegan, or following the basic Dietary Guidelines, I most often recommend the SHAPE anti-inflammatory meal plan because I have found it to be the most effective for addressing various medical conditions that have underlying dietary components.

Beyond that, as a general rule, the first piece of advice I give is to stop referring to any recommendations as a “diet.”  The further away practitioners can get from the “diet mindset,” the more peace patients will have with themselves.  Weight is just a number.  Any sustainable health improvements must be rooted in lifestyle change.  Encourage patients to practice mindful eating, such as the program laid out by SHAPE.  Also, ensure that patients get enough to drink.  Free fluid is needed in a ratio of 30mL/kg, which works out to be about half of body weight times ounces up to 100 ounces.  For example, a 150-pound person needs 75-ounces of water a day to meet his/her free fluid requirement. The most beneficial fluid for the body is pure, filtered water.  Green teas are known to help regulate blood glucose.  Teas can be flavorful, beneficial/medicinal (such as Fenugreek for lactation, chamomile or lavender for sleep, and a blend with senna, fennel, coriander, and ginger for constipation), and they can be enhanced with Stevia as well.  Speaking of sleep, I remind patients to get enough rapid eye movement (REM) sleep (7 hours) to allow their bodies time for healing and repair (such as resetting insulin receptor sites and blood pressure).  If sleep, mood, or digestion is a problem, check for vitamin B or D deficiencies, as outlined in the NFPA that might identify a methylation problem or a food and drug interaction, such as those caused by the use of serotonin reuptake inhibitors and proton pump inhibitors.

I specialized in nutrition because I believed in the healing power of foods.  In biochemistry, we learned a “calories in, calories out” concept—when one eats too much and exercises too little, he/she will become obese, and if one does the opposite, he/she will lose weight.  In my opinion, this concept is essentially untrue.   After many years of practice and continued education and research, I RARELY calculate macronutrient/calorie needs for a patient. Instead, I review his/her biochemistry, health status, personal goals, and consider the impact of medications to personalize a plan that sets him/her on a path to optimal health.   Even though it is just a guide and can be misleading, such as in body builders, I sometimes check BMI against the standard norms to help establish goal weight.  For SHAPE patients, we usually suggest they strive to be within 10% of the norm to prevent co-morbidities associated with excessive weight. Many healthcare professionals agree that going more plant based is the wave of the future, especially for cardiac patients.  Plant consumption increases fiber and provides good quality nutrients in their preferred states.  You may recall that fiber, along with enough fluid, helps regulate the GI tract.  As a general rule, the majority of food (about 70%) should come from plants, such as fruits and vegetables—the more colorful the better.  The Shape program fits well into these guidelines and also stipulates good quality protein.  As a practitioner, I recommend protein be divided throughout the day, included at every meal, throughout a 10-hour “eating window” for optimal metabolism and blood glucose control.

Don’t be blind-sided.  Traditional labs may not reveal a complete picture.   For example, a patient with an MTHFR allele polymorphism may have high serum levels of folate and B12 due to a genetic inability to convert them to their active, methylated form.  As a part of the medical team, the distinctive knowledge base of the clinical dietitian makes him/her the qualified individual responsible for informing the physician of an individual’s unique nutrient needs.  Likewise, health professionals trained to offer nutrition-focused physical exams prevent nutrient-specific problems from being overlooked and left unidentified and untreated.  Most registered dietitians hold a master’s degree, and all dietitians have at least four years of specific training.  All registered dietitians, except those with doctoral degrees in nutrition, must complete an approved internship program upon graduation and pass national boards in five areas of practice.  Thus, dietitians and other healthcare professionals are critical components to medical teams and offer unique perspectives to improve patient outcomes.

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