One must eat to live, and not live to eat.
Jean Baptiste Molière (1622-1673)
Nutrition is one of the most important factors involved in an individual's health and disease, because it affects almost every system. It has been shown that dietary habits contribute importantly to the pathogenesis of many of the major causes of death in the United States.
One of the most challenging nutritional problems in the United States today is obesity. Between 1980 and 2004, the prevalence of obesity doubled among adults. About 97 million adult Americans are overweight or obese. Today, more than 20% of adolescents are overweight. Approximately one third of the American population and more than half of African-American women are overweight.
Obesity is a risk factor for many diseases, including hypertension, coronary artery disease, diabetes, osteoarthritis, cancers of the breast and endometrium, and hepatobiliary disease. There is an increased awareness of obesity, but it remains a major problem. The overall cost to society of obesity is estimated to be more than $100 billion per year.
Malnutrition is also a problem in the United States. Surveys have shown that among general medical and surgical admissions to hospitals, approximately 50% of the patients suffer from some form of malnutrition. Approximately 25% may actually have functional disease related to it, and 10% may have evidence of advanced malnutrition. Malnutrition is a problem that targets a number of specific populations, including elderly persons who live alone, chronically ill patients, adolescents who eat and diet erratically, and patients with recently diagnosed cancer, because chemotherapeutic and radiation therapeutic protocols may promote nutritional problems. Even obese patients may suffer from malnutrition, most commonly secondary to catabolic stress.
Health-care providers have a unique opportunity to educate patients and help modify their behavior. More than half of these health-promoting behaviors are nutrition related. They include balancing caloric intake to match energy expenditure, limiting salt consumption, reducing cholesterol intake, taking vitamins, and decreasing dietary fat consumption. The health-care professional must have a firm understanding of clinical nutrition and its impact on health and illness. A patient's ability to recover from an illness or from surgery depends, in many cases, on his or her past and current nutritional status. Adequate protein-calorie nutrition is important for wound healing, recovery from infection, and responsiveness to
*This chapter was written in collaboration with Robert F. Kushner, MD, Professor of Medicine at Northwestern University Feinberg School of Medicine, Chicago.
treatment, and protein-calorie malnutrition may be a factor in development of decubitus ulcers and wound disruption. Five of the leading causes of death in this country—heart disease, cancer, stroke, diabetes mellitus, and atherosclerosis—are diet related. Therefore, knowing what patients eat, the nutritional adequacy of their diets, and their clinical nutritional status is a necessary component of physical diagnosis.
This chapter focuses on the aspects of the history and physical examination that constitute a nutritional assessment. At present, there is no standardized set of dietary history questions or method for assessing nutritional status. Rather, nutritional assessment requires the integration of information obtained from the medical history and physical examination. Throughout this chapter, nutritionally focused questions and examples of diet-related diseases are provided to assist in building history-taking and physical examination skills. The chapter begins with a review of the medical history and physical examination, demonstrating the integration of nutritionally focused information. Then it covers the nutritional assessment of select patient groups, followed by some pathophysiologic correlations.
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