Spotting Eating Disorders with Nutrition Focused Physical Exams
What are Nutrition Focused Physical Exams (NFPE) and How Do They Work?
NFPE or Nutrition Focused Physical Examination is a way health care professionals examine clients and patients for malnutrition and nutritional status. A health care professional looks and touches different parts of the patient to check for any abnormalities that could be caused by malnutrition. The results of an NFPE are used to help determine a person’s overall health and what they need nutritionally.
There are many signs and symptoms a health care professional will be looking for, but all of the signs and symptoms can be categorized into three categories: subcutaneous fat loss, muscle loss, and other.
Subcutaneous Fat Loss
Subcutaneous fat is found right under the patient's skin and is actually a part of the skin. The body uses it to protect bones and muscles, to control body temperature, and attach the skin to tissue underneath like bones and muscles.
When a health care professional is checking a patient using the methods in a NPFE, subcutaneous fat loss is something they are checking for. The areas a health care professional will look for subcutaneous fat loss are: the orbital fat pads, the Buccal fat pads, the triceps, and the midaxillary line at the iliac crest.
A health care professional will visually look at these areas and palatate them using their fingers to check for subcutaneous fat loss. If subcutaneous fat loss is found, that is a sign of malnutrition.
Muscle Loss/Muscle Wasting
Muscle loss is the loss of skeletal muscle. Skeletal muscles are the muscles that connect bones and allow for movement. When a health care professional is using NFPE methods on a patient they are checking different areas on the patient's body for muscle loss by palpitating the skin and visually looking.
The areas a health care professional would check for muscle loss are: The Temporalis Muscle, the Pectoralis Major, the Trapezius muscles, the Acromion process, the Deltoid Muscle, the Trapesius, the Supraspinatus, the Infraspinatus, the Dorsal Hand region (Interosseous Muscle), the Patellar Region (Quadriceps), and the Gastrocnemius Muscles (Calf Muscle). Decrease in muscle in these areas is a sign of malnutrition.
Other Signs & Symptoms of Malnutrition
When performing a NFPE on a patient there are other signs and symptoms that do not fall under subcutaneous fat loss and muscle loss but can still inform the health care professional about a patient's nutrition status.
Many of these signs and symptoms can tell a health care professional that the patient is having more specific nutritional deficiencies, like iron anemia, than malnutrition. But there are signs and symptoms that are specifically used to examine for malnutrition. These signs and symptoms can be split up into different parts of the body including: hair, teeth/mouth, face, nails, and skin.
Hair
There are three main symptoms when looking for malnutrition. The first one is hair loss. Hair loss can be seen visually without needing to touch. For example, if a person has a lot of hair on their clothes. It also can be tested for tough touch by running a comb or tongue depressor through the person’s hair to see if it easily falls out.
The next symptom is flag sign. Flag sign is described as horizontal stripes in a person’s hair. These stripes will alternate between light and dark colored hair. In an NFPE, flag sign is only tested visually.
The last symptom for hair is lanugo or very soft fine hair. Lanugo, like hair loss, can be tested for both visually and through touch. The hair can visually look fine and soft, or a health care professional can use a tongue depressor or comb to run through the patient’s hair to check the hair.
Teeth/Mouth
The main tooth/mouth symptom to look out for when performing a NFPE, that can only relate to overall malnutrition, is delayed tooth eruption and reduced tooth size. This is found mainly in younger children who are still developing. Both of these are examined visually.
Face
When looking at the face there are two main symptoms when checking for overall malnutrition during an NFPE. The first one is Moon Face. This is described as a full, round, and swollen face. Moon Face can be examined visually if the face looks round and swollen, but it can also be tested for by palpitating the swollen looking areas.
The second symptom is sialadenosis or enlarged salivary glands. This symptom can be examined for through visually looking for swelling in the parotid salivary gland (near the lower cheek bone) and the submandibular salivary gland (under the chin). It also can be examined by feeling the face, where the salivary glands are, to check for swelling.
Nails
The nails have two symptoms to look for when checking for overall malnutrition during an NFPE. The first one is Beau’s lines. This symptom is described as horizontal grooves on the nail. It can be observed visually by looking at the patient's nails, or it can be observed by feeling the patient's nails for the horizontal grooves.
The second symptom is muehrcke lines, which are two horizontal lines on the nail near the nail bed. Muehrcke lines will disappear temporarily with pressure.
Skin
There are three main symptoms when focusing on skin: delayed wound healing, ecchymosis or bruising, and bilateral edema. Delayed wound healing is observed by seeing how long a cut or bruise is taking to heal compared to the normal healing time. Delayed wound healing can be observed visually.
Ecchymosis or bruising is not just regular bruising due to someone bumping their knee or dropping something on their foot, but instead, abnormally easy bruising or someone having many bruises. Ecchymosis can be observed visually.
Bilateral edema is edema or swelling, many times seen in the ankles, that is on both limbs or on both sides of the body. Bilateral edema can be observed visually but for a health care professional to check for severity they would need to touch the patient to see how deep of an indentation the edema causes.
How Do NFPE Relate to Eating Disorders?
In severe cases, eating disorders can lead to malnutrition. Some people experiencing eating disorders, depending on the severity, will show the signs and symptoms a health care professional looks for in a Nutrition Focused Physical Exam.
Many parts of the NFPE can be done through visually looking at a person, so it can be useful for non-health care professionals to use. Having school teachers, coaches, family members, and other adults in people’s lives being aware of the signs and symptoms you can visually see could help children receive needed medical attention.
What Signs and Symptoms Should the Everyday Person Know?
Ideally all signs and symptoms would be known by everyone working with high risk individuals, but there are limitations to what each individual can do. Many parts of an NFPE requires palpitating of the muscles or subcutaneous fat, which means the health care professional is required to touch their patient.
Of course there are many everyday individuals who can not touch the people they are working with, for example school teachers. So, it is important to count on the signs and symptoms that can be seen visually, without the need to touch.
Subcutaneous Fat
The main two symptoms someone can see at all times and do not require touch to examine for are in the face. Both the orbital fat pads and buccal fat pads are on the face, meaning that they will not be covered by long sleeves or long pants.
Muscle Wasting
There are four main muscles a person can look for signs of muscle wasting in a person though just looking. The main one that is usually not covered by long sleeves or long pants in the temporal region. This region is on the side of the face and will look sunken in if there is any malnutrition in the person.
Another muscle that could be observed is the interosseous muscle. This muscle is in the hand so it might not be the most observable for everyone, but it can still be observed. For example, if a teacher is doing a handwriting class and has one-on-discussions with the students they might be able to see their hands. So although this muscle might not always be useful to check, there are situations where it can be seen.
The next two muscles are in the legs. The gastrocnemius muscle and the patellar region or the quadriceps. The quadriceps, being on the upper part of the leg, will be more difficult to examine and might not always be appropriate to examine. But, the quadriceps can be visually seen as diminishing especially if the person is wearing shorts or a short skirt.
Lastly, there is the gastrocnemius muscle or the calf muscle. This muscle is on the lower leg and is more likely to be seen compared to the quadriceps. Again, this muscle will have visual restrictions based on clothing but it is more likely to be shown when a person is wearing shorts or a short skirt compared to the quadriceps.
Other Signs and Symptoms
There are five main other signs and symptoms a person can check for without the need to touch the person. The five symptoms are hair loss, flag sign, moon face, delayed wound healing, and bruising/ecchymosis.
Some of these symptoms are more likely to be noticed than others. Also, many of these symptoms can have other medical reasons for happening so these symptoms alone could be a sign of something other than malnutrition.
Hair loss, moon face, delayed wound healing, and ecchymosis can all be caused by other medical conditions and environmental conditions. Flag sign, which is in the hair, is the only symptom that is usually related to a nutritional deficiency like malnutrition. This means that one sign or symptom alone can not be used when diagnosing malnutrition but can still be noted by an everyday person to check on.
Conclusion
When eating disorders are included in the conversation, malnutrition often comes along with. This means that knowing all the common signs and symptoms for malnutrition can be extremely useful for eating disorder identification and getting people the help they need.
Understanding all of the signs and symptoms of malnutrition is important for everyone, even if certain signs and symptoms can not be used due to the person's inability to touch or see certain areas of the body. The goal is to make it so the everyday person becomes more confident in what is a concern when an eating disorder has entered the conversation.