The Nutrition-Focused Physical Examination: Added Value for Patients and Clinicians

Robert Luby, MD, Director of Medical Education Initiatives for The Institute for Functional Medicine (IFM), has nearly 30 years of experience as a board-certified family physician. Also board certified in holistic medicine, Dr. Luby, in 2013, was among the first IFM-certified practitioners. One of his main interests is the nutrition-focused physical examination. In this column, he discusses the importance of utilizing the physical examination to its full potential to identify underlying nutritional deficiencies.

Q: How important is a general physical examination as part of patient care? It seems that in some settings, the value of the physical examination has been replaced by ordering tests and prescribing medications.

Robert Luby, MD: This is true; in fact, I have heard many patients complain that they come to my office because they have seen other doctors, some of whom did not even examine them. Interestingly, research has demonstrated that the value of a complete physical examination on an annual basis is not necessarily cost-effective ¹ ; it is, however, still very important in the eyes of the patient that we perform a physical examination.

So what is the right balance? The evidence seems to point out that a focused physical examination based on the patient's complaints, concerns, current conditions and comorbidities is what is really important and most effective in identifying underlying disorders. So a focused physical examination is still very important.

In this context, it is important to note that the nutrition-focused physical examination that the Institute for Functional Medicine (IFM) teaches is such an examination. This is taught in depth during the IFM's introductory “Applying Functional Medicine in Clinical Practice” course, and is reinforced in several other programs on the learner's path to certification. IFM has also developed the signature “NSight” video series, allowing for further clinical skill development in the nutrition-focused physical examination using an online platform. It is notable that demographic data indicate that a nutrition-focused physical examination is probably applicable to the great majority of patients.

Q: What is the added value, then, of doing a nutrition-focused physical examination?

Dr. Luby: The prevalence of micronutrient deficiency in the general population is extremely high. Such deficiencies are important to uncover because micronutrients serve many functions in the body and deficiencies contribute to the high prevalence of chronic complex disease. Patients often seek functional medicine care to understand more about micronutrient deficiencies, and a nutrition-focused physical examination can provide clues for the clinician about nutritional interventions without necessarily having to rely on laboratory testing.

A nutrition-focused examination is also important because most patients do not know that they have nutritional deficiencies. Moreover, many nutritional deficiencies are clinically silent, so both the patient and the physician will not recognize them without an intentional targeted physical examination.

Nutritional deficiencies can be challenging to assess by laboratory means. Blood testing is the most common form of testing in clinical practice; however, a blood examination is not always where the nutrient is most well represented. So in this context, a well-done thorough nutrition-focused physical examination can allow a doctor to accurately diagnose hidden or silent nutrient deficiencies or imbalances and order fewer tests. Since the nutrition-focused physical examination will change as the nutrient imbalance becomes balanced, progress can be readily tracked. In fact, both the patient and the clinician can track progress in this way, and with cell phone cameras and remote video, face-to-face visits are not always necessary.

The other added value of the nutrition-focused examination is its motivational value for the patient. First of all, by examining the patient carefully and intentionally, you are helping to develop a therapeutic partnership. As I have said, it is very important in the eyes of the patient that the physician does an examination. So really focusing with intent on a nutritional examination can have great value in the eyes of the patient. Once the patient becomes aware of the findings, the changes that they will see with dietary and other lifestyle interventions can be very motivating.

Q: Please discuss in general some of the basic elements of conducting a nutrition physical examination.

Dr. Luby: At the IFM, and in functional medicine, we teach that the most important nutrition findings are found in the tissue with the cells that turn over the most rapidly. This would include the skin, the nails, the hair, the oral mucosa, the gums, the tongue, and the special senses of smell and taste. That is what we focus on teaching. Those are where the bulk of the important nutrition-focused physical examination findings can be found and tracked.

Q: What are some common findings that point to nutritional deficiencies when conducting such an examination, and what are some commonly missed findings?

Dr. Luby: One commonly overlooked part of the examination is the hair, which most physicians do not examine with any regularity. Dry hair and dandruff, for example, are often indications of essential fatty acid deficiencies. Many physicians also do not perform a focused skin examination. Follicular hyperkeratosis, or keratosis pilaris, is often a sign of essential fatty acid or vitamin A deficiency. There are many findings on the skin, which are important indications of essential fatty acid, zinc, biotin, or vitamin A deficiencies.

If we consider the nails, koilonychia, or spoon nails, can represent protein, iron, chromium, and copper or zinc deficiencies. Leukonychia can indicate zinc or selenium deficiencies. Brittle or cracking nails can indicate a wide variety of nutrient deficiencies including iron, vitamin A, vitamin C, vitamin B₆, protein, essential fatty acids, biotin, zinc, or calcium. Beau's lines can be an indication of zinc, protein, or niacin deficiencies. Pale nail beds, just like pale ocular epithelium, can indicate iron deficiency. Splinter hemorrhages can indicate a vitamin C deficiency. Onycholysis can indicate iron and niacin deficiency.

In the mouth, a careful examination of the gums can reveal periodontitis. This is associated with inflammatory conditions such as diabetes, asthma, and cardiovascular disease, and often improves with dietary interventions alone, suggesting nutrient imbalances as contributory factors. Aphthous ulcers (aka canker sores) may be indicative of food sensitivities or autoimmune disease, but they are also associated with deficiencies of vitamin B₆, folate, zinc, and iron. I could go on, but the list is long, and these are just a sample of some of the nutritional deficiencies that can be detected from commonly missed areas of the body that physicians often do not monitor well.

An exciting concept with potential to elevate the importance of the nutrition-focused examination is the discovery of single nucleotide polymorphisms (single base pair alterations of genes) that render specific nutrient deficiencies more likely. If these turn out to be reliably correlated with examination findings, many clinical applications will follow.

We also know with the epidemic of cognitive decline, cognitive impairment, and dementia that the loss of smell and sometimes the loss of taste are also important early indicators of cognitive decline. This is especially true of a loss of smell. So developing the ability to test the sense of smell in the clinical examination is very important.

Q: What do you hope for the future regarding clinicians having a better understanding of the value of a nutrition-focused physical examination?

Dr. Luby: In terms of the costs of health care, I think that the nutrition-focused physical examination has great potential for impact, because most Americans are deficient in at least one important nutrient. Most chronic diseases, which constitute the bulk of health care costs, are in large part based on nutrient deficiencies or imbalances and are significant contributors to the chronic condition.

If the medical profession as a whole develops the ability to perform accurate nutrition-focused physical examinations, we can cut the costs of health care. As I mentioned before, we can rely on the physical examination rather than laboratory tests as a more accurate means, perhaps, of doing this. This, however, is going against that current trend, which was mentioned earlier, of using tests rather than the physical examination to make a diagnosis.

It is also important to perform nutrition-focused physical examinations as we move from office-based medicine to telemedicine. In a virtual visit, it is more difficult to incorporate a physical examination because you are not sitting with the patient. However, interestingly, technology may enable us to perform nutrition-focused physical examinations very well using telemedicine and emerging wearables and technology. Even an iPhone, with its photo capability, can convey nutrition-focused physical examination findings from the patient to the physician very rapidly and very accurately.

If you combine the emergence of artificial intelligence with the simple iPhone camera, we can predict a day whereby these rapidly changing tissues, the tissues with rapid turnover, could be photographed and monitored over time with artificial intelligence not only to diagnose, but also to track meaningful changes in the status of the nutritional deficiency.

It is noteworthy that many individuals with limited access to medical care represent the population at greatest risk for nutrient deficiencies. This is a component of the widespread health disparities, which is a focus of the IFM's mission. I have great hopes that artificial intelligence combined with telemedicine can actually have a very big impact on providing access to care for many more individuals, and especially access to accurate nutritional findings and interventions, which can help prevent and improve chronic disease and hopefully have a meaningful impact on improving health disparities.

To Contact Dr. Robert Luby

Robert Luby, MD

Director of Medical Education Initiatives

IFM

Federal Way, Washington, USA

Website: www.ifm.org

Q: Do you have any final advice for our clinicians regarding the added value of a nutrition-focused examination?

Dr. Luby: Finally, I think the nutrition-focused physical examination is a great motivator for the patient. In the health care transformation that we all hope to see, physicians are less at the center of the care, and patients are directing their own care. In other words, health becomes a skill set, and that skill set for the patients will include the ability to observe and track their own nutrition-focused physical examination findings.

This is very motivating and empowering for the patient, and I think it can help us get to that day in the future where we hope to see that patients are not only engaging more in their health care, but also directing their health care. So it is a great hope of mine that the nutrition-focused physical examination will become a part of that health care transformation. ■