Nancy Krebs, MD, MS, professor of pediatrics at the University of Colorado School of Medicine, has worked for decades to emphasize the importance of nutrition to overall health and to medical practice, including incorporating nutrition into the curriculum for CU medical students and residents.
As associate editor for “Nutrition for the Clinician,” a new article series in The American Journal of Clinical Nutrition, Krebs’s dedication to the topic will reach even farther. Inspired by the White House National Strategy on Hunger, Nutrition, and Health, the new series aims to expand the nutrition knowledge and skills of health care providers, ranging from primary care doctors to specialists.
“We know that diet has an impact on every system in the body,” Krebs says. “Whether it’s arthritis or metabolic diseases, prediabetes or hyperlipidemia, it cuts across everything. Too often we tend to reach for medications and think less about the impact of diet.”
Clinical examples
Articles in the “Nutrition for the Clinician” series will be published in the journal’s regular issues periodically throughout the year, and each will spotlight a clinical case. Krebs says the series will provide continuing education that enhances clinical reasoning and use of the best nutrition evidence in practice. Each clinical case will feature a clearly identified nutrition problem, either as the primary diagnosis or contributing to the presenting problem, and defined learning objectives.
“We’re hoping to solicit from both adult and pediatric providers from across the country,” Krebs says. “The goal is to demonstrate to physicians that they don’t have to be nutrition experts with subspecialty training, but to recognize that nutrition should be incorporated into general medical practice at different levels, both basic and complex.”
The first article in the series, “A Perfect Storm in a Pandemic – A Child with Complex Medical History and Special Diet Encounters COVID,” was written by Krebs and CU pediatric nutrition fellow Stephanie Waldrop, MD. It details the case of a 6-year-old male with undernutrition and acute COVID-19 infection who was treated by Waldrop and other CU School of Medicine providers at Children’s Hospital Colorado.
“The patient had a history of prematurity and necrotizing enterocolitis that necessitated bowel resection as an infant,” Waldrop says. “Depending on which part of the intestine is resected, there can be consequences with respect to absorption of nutrients.”
The child’s clinical presentation was further complicated by a seizure disorder, that was managed in part with a ketogenic diet.
“One of the main features of the ketogenic diet is its high fat content, which requires an intact intestine for absorption,” Waldrop says. “With the patient’s history of bowel resection, his ability to absorb fats was not optimal.”
The combination of his risk for malabsorption, special diet, and other health factors, plus an acute COVID-19 infection, resulted in critical illness, with severe malnutrition and multiple micronutrient deficiencies that presented with rashes, edema, and other medical complications — some of them life threatening. His condition improved with supportive care, targeted treatment of micronutrient deficiencies, and adjustments to his dietary regimen.
“A dietary regimen better tailored to his acute and chronic nutritional needs proved to be his ultimate defense in the context of a perfect clinical storm,” the authors write in their conclusion.
Social concerns
The next planned article in the series will highlight the case of an adult patient with chronic illness and health disparities — a case that illustrates the degree to which social determinants of health affect nutrition, Krebs says.
“Physicians need to recognize the impact of food insecurity, health disparities, and access to healthy foods,” she says. “There are community and federal programs to help, but accessing and navigating your way through them can be difficult. That’s why interdisciplinary teams to support patients and families are critical.”
Waldrop says the Growth in Parenting/Nutrition Clinic and the Lifestyle Medicine Clinic at Children’s Colorado make it a point to integrate with social workers.
“We screen patients for social determinants of health, and if there’s any evidence of food insecurity, a social worker will follow up with the family to inquire about their needs and put them in touch with useful resources.” she says.
Integral to care
Response to the first article in the “Nutrition for the Clinician” series has been encouraging, Krebs says, and points to a desire for information about nutrition from providers at all levels.
“Registered dietitians are an integral part of the health care team and do a wonderful job educating patients and families,” Krebs says. “But I think we’re missing the boat if physicians and other providers do not also recognize their role. As the ones making diagnoses and directing treatment, providers need tools and confidence to routinely incorporate nutrition into clinical care. That’s our goal with these articles.”
