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Individualization may aid endocrinologists’ approach to nutritional therapy
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American Association of Clinical Endocrinologists 20th Annual Meeting
SAN DIEGO - Nutritional therapy can be a complex issue and is an important focal point for endocrinologists in patient care. To help physicians address the unique problems associated with nutrition, especially those pertaining to vitamin D deficiency and overweight patients, a presenter here discussed strategies for approaching treatment.
Vitamin D deficiency has recently garnered a great deal of attention, leading many physicians to test for deficiency because of its common occurrence in the general population. However, primary care physicians often wonder when testing is necessary and, if deficiency is discovered, how to proceed with therapy. According to Daniel Hurley, MD, FACE, consultant in the department of medicine and the division of endocrinology, diabetes, metabolism and nutrition at the Mayo Clinic, Rochester, Minn., the newly released 2011 Institute of Medicine (IOM) guidelines may not fully alleviate some of this uncertainty.
The recommended dietary allowance for vitamin D increases with age. The IOM guidelines suggest 600 IU daily for people aged 1 to 70 years and 800 IU daily thereafter, with the tolerable upper limit of intake set at 4,000 IU daily. However, there is still controversy as to the goal level for 25-hydroxyvitamin D, or 25(OH)D, among experts in vitamin D metabolism (30 ng/mL) and the IOM guidelines (20 ng/mL). Raising the 25(OH)D blood level from 20 ng/mL to 30 ng/mL would require about 1,000 additional IU daily. To achieve a 25(OH)D goal of 30 ng/mL, Hurley advised physicians to ensure that patients are receiving a total of 2,000 IU of vitamin D3, daily and assess the need for supplement use based on patients' dietary intake. Monitoring 25(OH)D levels to assess adequacy of vitamin D replacement is also essential. In low-risk patients, checking these levels at the end of winter (during limited sun exposure) is suitable but should occur 2 to 3 months after initiating therapy for patients at higher risk or being treated for vitamin D deficiency, Hurley said.
The IOM guidelines do not recommend routine 25(OH)D screening, but Hurley suggested that physicians check levels in patients at risk for vitamin D deficiency, including those with poor oral intake, decreased sun exposure, impaired gut absorption, bone loss or osteoporosis, kidney insufficiency and older age.
Overweight and obese patients also have unique nutritional needs, according to Hurley. Finding the appropriate balance between caloric intake and energy expenditure may be a challenge, and he recommended a multidisciplinary approach to healthy eating and increasing physical activity. Meeting with a dietitian, for example, is essential, and encouraging patients to consume healthier foods, especially whole grains, fruits and vegetables, is beneficial.
However, a major obstacle to weight management is poor adherence to a daily mindfulness for healthy eating and physical activity. To combat this problem, Hurley recommended consulting with psychologists to identify unhealthy behaviors, lifestyle stressors, and other triggers or barriers that prevent patients from making healthy lifestyle changes. He also emphasized individualizing therapy through motivational interviewing by asking patients what type of physical activity they prefer instead of suggesting exercise regimens without their input. Frequent follow-up also helps provide support and address relapse that can occur in treating any chronic disease, Hurley said.
Although these recommendations will likely aid physicians in tackling some of the more complex issues associated with nutrition, Hurley noted that clinical judgment is important and advised physicians to carefully assess each patient before treating. – by Melissa Foster
For more information:
- Hurley D. Workshop 7: Nutrition therapy for the endocrinologist. Presented at: American Association of Clinical Endocrinology 20th Annual Meeting; April 13-17, 2011; San Diego.
Disclosure: Dr. Hurley reports no relevant financial disclosures.
Nutritional problems in our patients, particularly with obesity and diabetes, are really much more common than we recognize and we have to be very alert to screen for nutritional deficiencies in our patients. This goes for whether the patients have type 1 or type 2 diabetic patients or other endocrine diseases. We have to be very alert to nutritional deficiencies in our population, particularly in people who are trying to lose weight. They are on calorically restricted diets and they may have deficiencies related to that. We also spent a lot of time talking about vitamin D deficiency. Vitamin D deficiency is much more prevalent than anybody ever thought, and we have all suddenly become aware of it.
– Edward S. Horton, MD
Senior
Investigator, Joslin Diabetes Center
Professor of Medicine, Harvard Medical
School
Disclosure: Dr. Horton reports no relevant financial disclosures.
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