BOSTON—Three simple questions can often elicit volumes of information about a patient’s eating habits and nutritional status, said Dr. Judy Shabert, at a conference on alternative medicine and its implications for clinical practice, sponsored by Harvard Medical School.
Given the time pressures of most office visits, the opportunity to take an in-depth dietary history and nutritional profile is a rare luxury. But by measuring body mass index and asking the right questions, you can learn quickly whether a new patient is among the 12% of Americans eating well, or among the 88% slowly eating their way toward a myriad of chronic diseases. The patient’s answers will help you determine whether to recommend multivitamins or, in some cases, other dietary supplements.
Dr. Shabert, a member of the Department of Obstetrics, Gynecology and Reproductive Biology at Harvard, is also a registered dietitian. She recommends routinely asking new patients the following simple questions:
1) “Other than juices, how many servings of fruit and vegetables did you eat yesterday?” The answer will give you a sense of the patient’s intake of fiber, phytonutrients, and naturally-occurring antioxidants. It will also give you some idea about his or her level of consciousness or interest in healthy eating. “Servings” constitute pieces of fresh produce, or in the case of canned or cooked produce, half a cup.
The reason for excluding juices is, many people consider “high Vitamin C juice drinks” or other fortified soft-drinks as juices and by extension, fruit servings. Even pure juices, while rich in vitamins, minerals and other nutrients, are not complete stand-ins for the whole fruit or vegetable: juices lack fiber, and may be missing important phytonutrients.
You may also want to ask patients about whole grains, another key component of a healthy diet. But generally, those who eat lots of fresh produce also eat whole grains. The point of this question is not to get an in-depth diet profile, but to get a general sense of how much plant-based food the person eats.
2) “Do you drink milk on a daily basis?” This is a “trick” question, in that the issue it addresses is not calcium but vitamin D intake. For many Americans, fortified milk is the only regular source of vitamin D. It is important to ask about milk independent of other dairy products, since cheeses, yogurts and other dairy foods do not contain vitamin D, said Dr. Shabert.
Vitamin D is essential for calcium absorption. Without adequate daily intake, an individual will only absorb a fraction of the calcium he or she gets from dairy foods or supplements. If the patient is not drinking milk, encourage him or her to try vitamin D and calcium-fortified soy milk.
For some patients, vitamin D supplementation makes sense, especially in the winter months. Shoot for 400 IU’s per day.
3) “Do you take a multivitamin with minerals every day?” If the answer is “Yes,” it is a good indicator that the patient is at least conscious of the need to improve nutrition. While vitamin tablets are not perfect substitutes for plant-rich diets, people on good multivitamin regimens probably do get recommended daily allowances of essential vitamins and minerals.
The problem is, the content and quality of once-daily multivitamin products vary widely, and do not always provide adequate amounts of the essentials, especially minerals like calcium and magnesium. If a patient is already using multivitamins, find out which brand and review the product label, said Dr. Shabert at the conference, also sponsored by the Department of Medicine, Beth Israel Deaconess Medical Center, Boston.
Consider the patient’s answers to the three questions in light of body mass index (weight (Kg)/height (m)2). “Get BMI’s on all your patients,” Dr. Shabert insisted. A BMI over 25 constitutes grade I obesity, and puts the patient at increased risk for hypertension, coronary artery disease, and diabetes.
Should all patients use nutritional supplements? Maybe not all. But the sad truth is, most Americans eat very poorly. According to data from the American College of Nutrition, 68% of US citizens do not meet federal recommendations for daily vegetable consumption; 83% do not get the daily allowance for fruit.
Given the absence of whole grains, fruits and vegetables in most folks’ daily bread, supplementation makes very good sense, Dr. Shabert said.
THE REDUX: To get a good thumbnail sketch of a patient’s nutritional status and diet consciousness, measure BMI and ask the following three questions: • Other than juices, how many servings of fruit and vegetables did you have yesterday? • Do you drink milk every day? • Do you take a daily multivitamin?
