Introduction

The importance of nutrition in general medical practice has paralleled the increasing prevalence of lifestyle related disorders such as obesity, diabetes, and heart disease. In fact, alongside dermatology and psychological disorders, nutritional disorders are among the most common problems encountered by doctors and there is pressure for the general practitioner to provide competent nutritional assessment, diagnosis and therapy.¹ It has been estimated that over 70% of patients seen in general practice are at high risk of having or developing a nutritional deficiency and many patients will exhibit symptoms suggestive of nutritional inadequacy or imbalance which is contributing to their illness.^2,³

The Australian National Health Survey in 2004–5 reported that 86% of Australians between 18–64 years do not consume the recommended 5 serves of vegetables each day and 46% do not consume the recommended 2 serves of fruit each day.⁴ In 2008 rising petrol and food prices (especially for fresh produce but not for processed/take away foods) were reported to potentially affect shopping trends with less fresh produce being purchased.⁵ Furthermore, the costs of healthy foods such as bread and milk is rising far greater than the cost of nutrient poor energy dense foods (such as cakes, soft drinks and biscuits), which will impact on food choices and the diet in lower socioeconomic groups.⁶

This may be further compounded by emerging evidence from the UK and US (Australian data lacking) that there has been declining levels of minerals in our fruit and vegetables over the last 50 years, especially for magnesium dropping by about 45% (see page 23 ‘Dietary history and assessing food and nutrient intake’). Markovic and Natoli report paradoxical nutrient deficiencies such as zinc, iron, vitamin C and D and folate in the obese and overweight due to eating high-energy foods that are also high in saturated fats, salt and sugar, with poor nutrient content.⁷ The authors note that this condition is under-recognised and therefore not treated. The Public Health Association of Australia released a report in 2009 ‘A Future for our Food: addressing public health, sustainability and equity from paddock to plate’ outlining the urgent need for Australian food policy to encourage food choices that are environmentally sustainable and address the re-emergence of nutrient-deficiency related diseases.⁸

The Australian dietary guidelines and core food groups are currently undergoing revision. The Public Health Association of Australia would like to see the new guidelines address the re-emergence of nutrient-deficiency related disease and food sustainability. Specific recommendations include: reduced total intake of animal products; reduced reliance on ruminant meat; promotion of sustainable proteins, especially legumes, nuts, eggs and chicken; promotion of seasonal fruit and vegetables, legumes and grains that are grown using production methods appropriate to the region. The report highlights that shifting less than 1 day per week’s worth of calories from red meat and dairy products to chicken, fish, eggs, or legume-based diet achieves more green house gas reduction than buying all locally sourced food. In addition, consuming less meat and more plant-based foods may be 1 type of measure that will lead to increased sustainability and reduced environmental costs of food production systems.⁸

The Australian National Children’s Nutrition and Physical Activity Survey also highlights the growing epidemic of obesity in children — estimated at 17% of children considered overweight and 6% obese in Australia — with poor quality diets with significant nutritional shortfalls, particularly vitamin D, E, iodine and iron.⁹

Suboptimal intake of vitamins from diet is common in the general population, particularly children and the elderly, and a risk factor for chronic diseases such as cardiovascular disease, neural tube defects, colon and breast cancer, osteopenia and fractures.¹⁰

Other risk groups identified include vegans, drug and alcohol-dependent individuals, hospitalised patients and patients with malabsorption.

If these trends continue nutritional deficiencies may become more commonplace in the community. Doctors, dietitians, nurses and other allied health professionals may need to become more active and skilled at detecting signs and symptoms of nutritional deficiencies/insufficiencies. Improving the nutritional status of patients will help improve clinical outcomes/wellness and reduce morbidity and mortality and is thus of increasing importance to comprehensive medical care. In order to determine whether a patient’s nutritional status needs improving, a nutritional assessment is required.

Nutritional assessment will identify the high-risk patient (see Table 2.1) for nutrient inadequacies or excesses which in turn will contribute to a nutritional diagnosis. Once the diagnosis is made it is then possible to put in place the nutritional therapy of the patient.

Table 2.1 Identifying patients at high risk of nutrient deficiency or insufficiency

• Patients with chronic illnesses (especially bowel problems, other functional disorders, such as chronic fatigue, psychiatric illness).

• Patients on certain and many medications (poly-pharmacy).

• Senior patients, recent surgery, injured/severe trauma, burns, sepsis, protracted fever, recent discharge from hospital.

• Crash dieters or patients on chronic low calorie diets (<1300kcal/day).

• Poor/altered food intake (e.g. due to restricted food budget, food supply, rising food prices, food storage, poor cooking skills).

• Some vegetarians, some athletes and those with food allergies or sensitivities to particular foods.

• Sedentary patients, especially those who are office/housebound (with little sun exposure or opportunity for incidental activity); the elderly.

• Pregnant/breastfeeding women and those who excessively bleed during menstruation.

• Women with young children.

• Excess alcohol (more than 1 drink per day for women and 2 drinks per day for men), smoking or illegal drug users.

• Disabled patients, dental/chewing problems, widowers, socially isolated/living alone.

(Source: adapted from Wahlqvist M, Kouris-Blazos A. Nutrition — is diet enough? J Comp Med 2002: 46)¹¹

Nutritional assessment is based on information gathered from:

1. medical history and genetic predisposition (see Table 2.3)

2. examination for nutrition-related signs and symptoms (see Table 2.2)

3. anthropometry (weight history, BMI, waist circumference, body composition using electrical impedance or skinfold measurements)

4. socioeconomic history (living arrangements, financial problems) and lifestyle history (physical activity, alcohol, smoking, stress, gambling, sleep)

5. medication (potential adverse or beneficial effects on nutritional status (see also Chapter 37, Herb–nutrient–drug interactions)

6. vitamin and herbal supplement use — potential adverse effects (especially if far exceeding the recommended dietary intakes) or beneficial effects on nutritional status and interaction with medications (see also Chapter 37, Herb–nutrient–drug interactions)

7. dietary history (food pattern, cuisine/culture, food variety, intake and frequency of specific foods like fish, nuts, legumes)

8. laboratory tests (see Table 2.5).

Table 2.2 Presentations and signs (can include) to consider with specific vitamin deficiencies (rare or sub-clinical deficiency in Western populations)

Micronutrient	Signs
Vitamin A	Conjuctival xerosis Bitot spot Perifollicular hyperkeratosis
Vitamin B1	Peripheral neuropathy Cardiac arrythmias Cardiac failure
Vitamin B2	Magenta tongue (Glossitis) Angular stomatitis ‘Shark skin’
Vitamin B3	Strawberry tipped tongue (Glossitis) Swollen gums Dermatitis Peripheral neuropathy Hyperpigmentation
Vitamin B6	Glossitis, seborrhoea Peripheral neuropathy Symmetrical sensory and motor deficits
Vitamin B12	Glossitis Angular stomatitis Hyperpigmentation Peripheral neuropathy and sub–acute combined degeneration
Vitamin B complex/folate	Glossitis Angular stomatitis and hyperpigmentation
Vitamin C	Bleeding and swollen gums Swollen eyelids Perifollicular petechiae Follicular hyperkeratosis Scorbutic rosary and joint pain
Vitamin D	Rickets–bowing of long bone and rachitic rosary Osteoporosis
Calcium (Ca) and/or magnesium (Mg)	Positive Chvostek sign
Iron (Fe)	Koilonychia, leucoplakia, Plummer–Vinson syndrome
Zinc (Zn)	Acne, stretch marks, white spots on nail
Iodine (I)	Weight gain

Medical history

The medical history may reveal a disease that interferes with the patient’s ability to eat (e.g. Cerebrovascular accident and Parkinson’s disease) or the body’s use of nutrients (increased excretion of magnesium and chromium in diabetes or reduced absorption of several nutrients in Crohn’s disease). The genetic predisposition may also provide clues e.g. reported weight loss or diarrhoea could be due to coeliac disease which runs in the family.

Signs and symptoms of nutritional deficiencies

Clinical symptoms and anthropometric measurements will provide further clues to the nutritional puzzle. However, symptoms (manifestations reported by the patient) and signs (observations made by a clinician) can occur late in the development of the nutritional problem. Thus diagnosis of a nutritional deficiency cannot usually be made solely on the basis of a clinical examination. This is mainly because many nutrition-related signs and symptoms are non-specific and can occur for non-nutritional reasons. Usually the presence of a group of related clinical signs and symptoms is a better indication than a single sign or symptom.¹² For example, the finding of follicular hyperkeratosis isolated to the back of a patient’s arms is a fairly common, normal finding. On the other hand if it is widespread on a person who consumes little fruit and vegetables and smokes regularly (increasing vitamin C requirements) vitamin C deficiency is a possible cause. Not surprisingly, the tissues with the fastest turnover rates are the most likely to show signs of nutrient deficiencies or excesses e.g. hair, skin and lingual papillae (an indirect reflection of the status of the villae of the gut)¹³ (see Tables 2.2 and 2.3 for clinical signs and symptoms of possible nutritional deficiencies).

A thorough medical and nutritional history, together with a thorough physical examination is necessary to detect nutrient deficiencies (occasionally this may be subtle i.e. nutritional insufficiency). When taking a nutritional history, if limited by time, ask patients to recall what they ate and drank in the last 24–48 hours and/or ask them to bring a 1-week food diary at their next consultation. If time permits, then a more extensive dietary assessment would be helpful as discussed under Dietary history and assessing food and nutrient intake in this chapter. Examples of symptoms suggestive of nutrient deficiencies include gum bleeding (vitamin C), numbness of feet (folic acid and B1 deficiency), night blindness (vitamin A), poor immunity and recurrent infections (vitamins A, C, D and zinc), poor appetite (B group vitamins and zinc), muscle cramps (calcium, magnesium), tremor (magnesium), poor memory (B group vitamins, folic acid and various minerals e.g. magnesium), loss of libido (B group vitamins, folic acid), tiredness (any nutrient), mood disorders (B group vitamins, vitamin C and zinc), poor wound healing (protein, zinc, vitamin C), sore tongue (several B group vitamins) and loss of taste (zinc). Physical examination of the patient may identify a number of signs suggestive of nutrient deficiency (see Tables 2.2 and 2.3).

Table 2.3 Clinical symptoms and signs of nutrient deficiencies/insufficiencies

Clinical symptoms and signs	Consider low intake/deficiency (may warrant blood/urine/faeces testing)
HEAD
appetite poor	Znⁱ, ^v, Mgⁱⁱⁱ, Feⁱⁱⁱ, B1^vi, B3^vi, folate^vi, excess vit Aⁱ
nausea (esp with fatty foods)	B3^vi
fatigue/tiredness/irritable	B6^vi, B12^vi, folate^vi, Zn^{i, v, vi}, vit C^vi, Fe^{iii, vi}, chromium (Cr)^vi, thyroid, excess vit A^v, protein^vi
sugar cravings/hyperglycaemia	insulin resistance, Mg, Cr^{iii, v, vi}, Zn, vit E
moody/depressed	protein^vi, B1^vi, B3ⁱⁱⁱ, B6^{iii, vi}, B12^vi, vit C^vi, Mg^vi, Znⁱⁱⁱ, iodine, thyroid, vit D
anxiety/agitation	Cr^vi, Mg^vi, vit D^vi
migraine	B2^vi, coenzyme Q₁₀ (CoQ₁₀)
headache	B3ⁱⁱⁱ, B12^vi, folate^vi, Feⁱⁱⁱ, Mg if cervicocranial, excess vit A^{i, iii}
sleep disturbance	B6^vi, Mg^vi, vit C^vi
sleep onset delay	vit D^vi
poor dream recall	B6^vi
insomnia/restless sleep	vit D^vi, Ca^vi, B3ⁱⁱⁱ
non-refreshing sleep	Mg^vi
night sweats-back of head/scalp	vit D^vi
low libido	Fe (women) ⁱⁱⁱ, Zn (men), low testosterone, thyroid
impaired memory/cognition/dementia	B1^{iv, vi}, B12^{iii, iv, vi}, B3^{iii, iv, v}, folate^{iv, vi}, Fe^vi, Zn^vi, iodine
HAIR/SCALP
hair thinning/loss/alopecia	protein^iv, B2^vi, EFA^vi, Zn^{iii, vi}, Fe^vi, Biotin^{i, iii, v, vi}, excess vit Aⁱⁱⁱ, excess selenium (Seⁱⁱⁱ) thyroidⁱ, iodine
dry dull hair	essential fatty acid (EFA)^vi, vit A^vi
easily plucked hair	protein^iv
dry coarse/brittle hair	protein^iv, biotin^iv, Fe^vi, Zn^{i, vi}, Iodine, hypothyroid, EFA^vi, excess vit A^{i, iii}
depigmentation/dyschromotrichia	copper (Cu)ⁱ, Seⁱ
hair growth arrest	Znⁱ
diaphoresis of scalp (night)	vit D^vi
dry flaking hair and scalp	vit A, Zn, Se
dandruff	Zn^vi, Mg^vi, biotin^vi, Se
prematurely graying hair	Cu^vi, Biotin^vi, vit B12^{iii, vi}
coiled/cork screw hairs	vit Cⁱⁱⁱ (hair shaft flat instead of round in cross section)
EYES
tearing/burning/itching	vit B2^v
dark/crimson under eye circles	Fe, allergy^vi, liver problems
dry thickened conjunctiva xerophthalmia/xerosis	vit A^{i, vi}, Znⁱ, Biotinⁱⁱⁱ (conjunctivitis)
pale conjunctiva	Feⁱⁱⁱ
muddy sclera	vit C^vi
yellow sclera	liver function^{i, vi}
photosensitivity	vit B2^{iii, vi}, Znⁱⁱⁱ
bitot spots/white thick patches	vit Aⁱ, Znⁱ
impaired night vision	vit A^{iii, vi}, Znⁱⁱⁱ
long sightedness	vit D^vi
impaired visual acuity/blurred	EFA^vi, xs vit Aⁱ
pterygium (thickness)	vit C^vi, B3^vi, EFA^vi
twitching eye/spasms facial muscles	Mg^{i, iii, vi}, Ca^{i, iii}, Kⁱ
macular/retinal degeneration	age, lutein, zeaxanthin, excess blood sugar
NOSE
scaling/red folds nasolabial seborrhea	vit B2^{iii, vi} (red greasy folds), B6ⁱⁱⁱ, omega-6ⁱⁱⁱ (dry folds)
poor smell/anosmia	Zn^{v, vi}, vit A^v
EARS
noise intolerance	Mg^vi
post aural flush	Zn^vi, EFA^vi
tinnitus	Feⁱⁱⁱ
TONGUE/MOUTH
dark red raw/swollen/glossitis painful ‘raw beef’ appearance	vit B3^{i, iii, iv, v}, B12^{i, iii, iv, v}, folate^{i, iv, v}, Fe^{i, iv, v, vi}
bright red smooth/glossitis	vit B2^{i, iv}, B6^{i, iii, iv, v}, B12^{i, iv}, folate^{i, iv, v}, Fe^{i, iv, v, vi}, biotin^{i, v}
large beefy tongue	hypothyroidⁱ, iodineⁱ
magenta/blue tongue	vit B2^{i, iii, v}, Biotinⁱ
white/pale smooth	Feⁱ
yellow/brown tongue	bowel dysfunction/dysbiosis^vi, low HCL^vi
berry like red tongue	vit B complexⁱ
fissured/creviced tongue	vit B3^{iv, v}
scalloped tongue	Mg^vi, vit B3^vi
strawberry tip/cherry tip tongue	vit B3^vi, B6^vi
burning sensation of mouth/throat	D^vi
lips cheilosis (burning/soreness)	vit B2^{iii, iv, v}, B3^{iii, iv}, B6^{iv, v}
angular stomatitis	vit B1ⁱ, B2^{i, iii, iv, v}, B3^{i, iii, iv}, B6^{iii, iv}, folate^v, B12^{i, v}, Feⁱ
halitosis	vit B3^vi, low HCL, dysbiotic bacteria, hypothyroid; liver problems
periodontal disease/loose teeth	vit C^vi, CoQ₁₀^vi, Ca^vi
bleeding gums/gingivitis	vit C^{i, iii, iv}, B2^iv, vitK^vi, xs vit A (red gingiva around teeth)^{i, iii}
gum recession	protein^vi, CoQ₁₀^vi
mouth ulcers	vit B12^vi, vit A^vi, folate^vi
crimson crescents back of mouth	food sensitivies^vi
intense thirst	xs vit D^vi, B1/wet beri beriⁱⁱⁱ
impaired taste	Zn^{i, v}, vit Aⁱⁱⁱ
loss of tooth enamel	Ca^iv
HANDS/NAILS
finger pulp atrophy	protein^vi
cold hands	Feⁱⁱⁱ, Mg^vi, vit E^vi, EFA^vi, thyroid
vertical corrugations — pronounced (beaded nails)	vit Bⁱⁱ, protein^vi, Zn^vi, diabetesⁱⁱ, thyroidⁱⁱ, Addisonsⁱⁱ
vertical corrugations — unpronounced	Ageⁱ, RAⁱ, PVDⁱ, Lichen planusⁱ
pronounced central ridge	Feⁱ, folateⁱ, proteinⁱ
horizontal grooves/Beau’s lines	protein^vi, past severe illness/surgeryⁱⁱ, MIⁱⁱ, Znⁱ, Seⁱ, Caⁱⁱ
leukonychia (white spots)	Zn^vi
half moons base of nails	vit B6^vi
dry thin brittle nails	protein^vi, malnutritionⁱⁱ EFA^vi, Fe^vi, Ca/osteopeniaⁱⁱ, thyroidⁱⁱ
peeling/splitting nails	Ca^vi protein^vi
spoon shaped/brittle nails	Fe^{i, iii, vi}, low cysteine/methionineⁱ, diabetesⁱ
soft/papery/bitten nails	Zn^vi, protein^vi
growth arrest/thickened nails	protein^vi, Znⁱ
yellow nails	vit E^vi
black/red thickened nails	xs Seⁱ
egg shell nails	vit A^vi
clubbed nails	lung problemsⁱⁱ, IBDⁱⁱ, coeliacⁱⁱ, hyperthyroidⁱⁱ
brown nail beds or skin creases	vit B12ⁱⁱⁱ
white nail beds	Seⁱⁱⁱ
paronychia	excess Seⁱⁱⁱ, Znⁱⁱⁱ
MUSCLE
generalised muscle pain/ache tender muscles	B1 ^iv, vit E^v, Ca^{i, v}, Mg^{i, vi}, potasium (K)^{i, v}, Se^{i, iii}, vit D^{v, vi}, coma, iodine CoQ₁₀ (if on statins), vit C ⁱⁱⁱ
cramps	Ca^{iii, v}, Mg^vi, vit B5^vi, Feⁱⁱⁱ, K, Na, vit Cⁱⁱⁱ, vit D^vi
muscle twitching/spasms (hyper-reflexia)	B6^v, Mg^{i, iii, v, vi}, Ca^{i, iii}, Kⁱ, vit D^vi
muscle atrophy face, hands, chest, loss of tissue recoil back of hand	protein^vi, B1^vi
calf/muscle tenderness	vit E^v (intermittent claudication), B complex^{iv, vi}
muscle weakness/wasting (difficulty up/down stairs)iii	protein^iv, vit D^v, K^v, Ca, thiamin
decreased muscle reflexes	B complex^vi, vit E^vi
SKIN
excessive ageing of skin/wrinkles	vit E^vi
perifollicular hyperkeratosis (toad skin) commonly seen on upper arms/thighs	vit A^{i, iv, vi}, Znⁱ, B complexⁱⁱⁱ, vit C^{iii, v}, EFAⁱⁱⁱ
perifollicular petechiae/haemorrhages	vit C^{i, iii, v}, vit K^{i, iii} (causes petechiae unrelated to hair; sometimes seen with prolonged antibiotic treatment)
shark skin/dyssebacea (sebum plugs in follicles/face/body)	vit B2ⁱⁱⁱ
oily scaly seborrheic dermatitis esp nasolabial folds/eyebrows/forehead	vit B2^{iii, v}(nasolabial/scrotum), vit B3ⁱⁱⁱ, vit B6^{i, iii, v}, Biotin^vi, Cuⁱ, EFA^vi
dry scaly/coarse dermatitis	Zn^{iii, v}, Iodineⁱ, vit B3ⁱⁱⁱ, omega-6^{i, iii}, omega-3^vi, vit C^v, vit E, biotin^{i, v}, vitA^v, vit A excess^{i, iii, v}
dry ‘fish scale’, ‘flaky paint’	vit A^iv, Zn^{iv, v} especially on the legs
hyperpigmentation non scaly macules/patches	insulin resistance^vi, vit A, Zn^{iii, v}, vit C, vit B12ⁱⁱⁱ, vit B6^vi, folateⁱⁱⁱ, EFA, evening primrose oil (EPO), vit B3^iv (see also dermatitis)
hyperpigmented scaly dermal patches on face/limbs (pellagra)	vit B1, vit B3ⁱ, biotin^{i, v}, Zn^{iii, v}, EFA
unusual skin rash	vit B6 or excess supplement use
spider veins	vit C^vi
liver spots (ceroid accumulation)	vit E^vi
eczema	biotin^vi, Znⁱⁱⁱ, omega-3^vi, omega-6/EPO^{i, iii}, glutenⁱ
rosacea	vit B2, hypochlorhydria/gastric dysfunction^vi, dysbiotic bacteria/H pylori infection^vi
psoriasis	vit D^vi, EFA^vi, vit A^iv, Znⁱⁱⁱ
acne	EFA^vi, Zn^vi, vit A^vi, vit Cⁱⁱⁱ, dysbiotic bacteria, bowel dysbiosis^vi, high GI diet/insulin resistance^vi
stretchmarks	Zn^vi, vit E^vi, Bvi^vi
wound healing/lesions on pressure areas	vit A, B6^vi, vit C^{v, vi}, Zn^{i, iii, v}, EFA^vi, protein^vi, biotin^vi
easy bruising	vit K^{iv, vi}, dysbiotic bacteria^vi, protein, vit C^{iv, vi}, blood thinning medication
blood mottling arms/legs	vit B6^vi
itchy skin/rashes	liver problems
NERVES/PAIN/BONES
impaired coordination/balance, disorientation/ataxic gait	vit B1^{i, vi}, B12^{iii, v} (neurological changes can occur without haematologic changes), B3^iv, vit E^{iv, vi}
neuropathy (weakness, ataxia, pins/needles, parasthesia, foot/wrist drop, reduced tendon reflexes, numbness of fingers/feet/lips/tongue fine tactile sense, vibratory sense, position sense)	vit B1^{i, iv, vi}, B2^{iii, vi}, B6^{iii, iv}, B12^{iv, v}, carnitine, EPO, vit B6 toxicityⁱⁱⁱ, folateⁱⁱⁱ, Mgⁱ, Caⁱ, Kⁱ, omega-3ⁱⁱⁱ, Cr^{iii, v} Fe^vi, vit E^{iv, v}, lipoic acid
neuralgia/paralysis/paresthesia	vit B1^iv, B3ⁱⁱⁱ, B12^{iii, iv, v} Mg^{iv, v}
tetany	Ca^{iv, v}, Mg^iv, K^v
diminished reflexes	Iodine^iv
postural hypotension	vit B6/B complex^vi, Fe^vi (general hypotension)
bone/joint pain	vit C^{iv, v, vi}, xs vit A^{iv, v}, vit D^{iv, v}, Ca^v, omega-3^vi, Zn^vi, Boron^vi
low bone density	excess vit A^v Ca^v, Mg^v, vit D^v, Ca^v, Zn, vit K
DIGESTION
constipation/bloating	Feⁱⁱⁱ, B3^vi, low HCL/enzymes, gluten, food intolerances, dysbiosis, candida management, vit D excess
diarrhoea	Feⁱⁱⁱ, excess Mg/vit Cⁱ, Znⁱ, B3^{iii, vi}, B12ⁱⁱⁱ folate^v, biotin^v, fructose, fructans
belching/flatulence/reflux	vit B12ⁱⁱⁱ, low hydrochloric acid (HCL), H Pylori, allergen, lactose, fructose
poor digestion	vit B3^vi, low stomach acid (HCI)^vi
MENSTRUAL
delayed/<flow periods/irregular oligomenorrhoea/sub-fertility	Feⁱⁱⁱ, vit E^vi, EFAs^vi, insulin resistance^vi, Zn^vi
mastalgia	vit E^vi, vit A^vi, omega-3^vi/EFA imbalance^vi
PMS	vit B6^vi, Ca^vi, Mg^vi, EFA^vi
dysmennorrhoea/menorrhagea	Ca^vi
LEGS/FEET
heels — hyperkeratosis/dry/cracked	vit E^vi, EFA^vi
soles — hyperkeratosis	vit A^vi
cold feet/<peripheral perfusion	vit E^vi, EFA^vi, Mg^vi, vit B6, thyroid (vit A, Zn, I, Fe)
burning paresthesias in feet	vit B5ⁱⁱⁱ, B1ⁱⁱⁱ
arch collapse	protein^vi
calf muscle tenderness	vit E^vi, B1ⁱⁱⁱ
oedema	K, Mg, vit B1^{i, iii}, Feⁱⁱⁱ, protein^iv, quercetin
GROWTH
poor	Feⁱ, Zn^{i, vi}, Iodine^{i, iii}, proteinⁱ, energyⁱ, vit Dⁱ, Ca, omega-6ⁱⁱⁱ, vitA^v
IMMUNITY/INFECTIONS/CANCER
immuno-dysfunction	Znⁱⁱⁱ Se^vi, vit C^vi, vit E^vi, vit D

Important note: The list in Table 2.3 is not definitive and is based on combined clinical experience and scientific evidence. Assessment and treatment should be based on your own clinical judgment (i.e. dietary history and physical examination) and confirmed with pathology testing. Symptoms may also occur from other non-nutritional related diseases.

i McLaren DS. A Colour Atlas and Text of Diet-Related Disorders. 2nd edn. London England: Wolfe & Mosby — Year book Europe Ltd, 1992.

ii Medscape. Examining the Fingernails When Evaluating Presenting Symptoms in Elderly Patients. Online. Available: www.medscape.com (accessed 7 Aug 2008).

iii McLaren DS. Clinical manifestations of human vitamin and mineral disorders: a resume. In: Shils M, Olson JA, Shike M, Ross C. Modern Nutrition in Health and Disease. 9th edn. Williams & Wilkins, 1999;485–503.

iv Newton MJ, Halsted CH. Clinical and functional assessment of adults. In: Shils M, Olson JA, Shike M, Ross C. Modern Nutrition in Health and Disease. 9th edn. Williams & Wilkins, 1999;895–902.

v Heimburger DC, Ard JD. Handbook of Clinical Nutrition. 4th edn. Mosby Elsevier 2006.

vi Sydney-Smith M. Nutritional Assessment. J Comp Medicine 2006; Jan-Feb 28–40; and Nutritional Assessment Workshop Seminar slides, March 2008.