Better nutrition tools for better patient outcomes

You are not what you eat, but rather what you digest and absorb, said Ashley Koff, RD, CEO of the Better Nutrition Program, at the 2019 Integrative Healthcare Symposium in New York City.

The current nutrition assessment landscape is challenging, said Koff. Patients are facing an epidemic of “infobesity,” or too much nutrition information, and it’s negatively affecting patient care efforts and outcomes.

“We have so much information on nutrition, fitness, genetics, and all of these testing modalities,” said Koff. “We’ve moved far from actually asking someone what they get in from a food standpoint and how they’re taking in nutrients in totality for the day.”

Our nutrition assessment tools, like body mass index (BMI), do not accurately predictive of health status and risk. A 2019 study in the International Journal of Obesity found that nearly half of individuals who are considered healthy by way of BMI were metabolically healthy, as were 19 million people with a BMI associated with obesity. However 30 percent of individuals in the normal or healthy BMI range were metabolically unhealthy.

In addition, current health checkups and tools are not necessarily helpful for better patient outcomes, according to the New England Journal of Medicine, which in 2015 included a study that found annual physical exams did not lead to improvements or longer, healthier lives.

It can be frustrating for practitioners using current assessment tools, because bloodwork only tells us nutrients in the blood, genetic testing only shows the potential risk for some conditions, BMI doesn’t tell us anything about body composition, and food journals are not as comprehensive as they should be.

We deserve better, said Koff, including better data for practitioners and better options for patients that are doable, delicious, and deliver better results.

The World Health Organization defines “good nutrition” as follows:

Nutrition is the intake of food, considered in relation to the body’s dietary needs. Good nutrition—an adequate, well-balanced diet combined with regular physical activity—is a cornerstone of good health. Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.

That’s not better, said Koff, who offers her signature definition of “better nutrition.”

“Giving a body what it needs to run better while avoiding ingredients that can irritate, overwhelm or disrupt its’ functions,” she said.

So how do we assess nutrition in a better way? The average nutrition assessments look at food and beverage consumption, BMI, age, and gender, and may extend to include medications and preferences. However, the better nutrition assessment, Koff says, should look at all of the following:

• Food and beverage
• Supplements
• Health (current, history, goals, labs, and genetics)
• BMI
• Age
• Gender
• Medications
• Preferences
• Lifestyle

This can be broken in to three stages of patient questions and assessment: what goes in and on their body, including food, beverages, supplements, skincare, and medications; whether nutrition getting where it needs to go, as in digestion, absorption, and elimination; and what is interfering with their nutrition, such as sleep, stress, support, affordability, and doability.

The better assessment includes current nutrition assessment, digestive assessment, and lifestyle assessment, specifically what are they taking in and when, how do they feel, and how do they perceive their current sleep, activity, and health choices, Koff said.

The better nutrition assessment must comprehensively look at:

• Food choices
• Drink choices
• Supplements
• Medications
• Beauty and skincare choices

“If you are not assessing all of these,” Koff said, “your assessments have flaws in them.”  

Koff strongly emphasizes assessing digestion, specifically whether nutrients the patient is taking in gets to where the body can use them, and how they are being eliminated. She says patients should track frequency of urination and bowel movements, as well as color, shape, smell, and any concerns.

When assessing lifestyle, Koff suggests asking patients a series of questions about where they eat most often, whether they’ve cooked recently, their nutrition budget, what items they are and are not willing to spend money on, if they can swallow pills, and if they avoid any foods, food groups, ingredients due to preferences, or have allergies, intolerances, or concerns.

Koff offers a checklist for an ideal nutrition check-up. Have patients send this to you ahead of tiem, she said.  

• Photos of supplements (front and back)
• Nutrition Journal
• Digestive Assessment
• Lifestyle Assessment
• Optional: What makes them laugh?

Walking through a case study, Koff said a patient, Mary, age 49, presented with excess body fat, was perimenopausal, and experiencing sleep issues and fatigue. In her assessment, she sent pictures of her supplements, CLA, calcium, vitamin D, and a multivitamin gummy with no minerals. Pictures allow the practitioner to see exactly what their patients are consuming with “extras” like supplements.

In her journal, Mary said she felt tired and stressed upon waking. She doesn’t eat until noon, avoids carbohydrates, and drinks wine with dinner. She often takes Ambien to sleep. She reports minimal activity except on weekends.

For her digestive assessment, Mary reported gassy and foul-smelling bowel movements and said she was often constipated with some acid reflux but takes over-the-counter medications.

In her lifestyle assessment, Mary said she used to love to cook, but it now single and eats out more to be social. She mostly drinks wine and snacks if home. She has no set budgets and will spend anything if it makes her lose weight. She did a genetic test and it says she is predisposed to obesity.

For her bonus assessment, Mary noted dog videos and the Ellen Show make her laugh.

So, what does a practitioner do with this information? Here is how Koff puts it in practice. First, before considering supplement nutrients, look at Mary’s food choices and her “total” nutrition picture:

• Is she getting in calcium from non-dairy fortified or dairy sources?
• What about magnesium sources of food?
• Does she need her calcium supplement, or would a magnesium supplement be better?
• Does she like dark chocolate or cacao?
• Is she open to eating hemp seeds or hemp seed oil most days, or do you add a GLA supplement?
• Could she try deglycyrrhizinated licorice, glutamine, or digstive enzymes for acid reflux in lieu of over-the-counter medications?
• What kind and how much carbohydrates?
• How much carbohydrates after 3 p.m.?
• Does she feel victim to her genetic profile? It may be good to talk to her about lifestyle choices versus genetics.
• Would she like a weekly email scheduled to motivate her? Note in her chart to include funny dog or Ellen Show GIFs or videos.

“When you have better information, you can develop better recommendations,” Koff said. “I don’t claim to have the one right answer here, but I know we can do better.”