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How prepared are you to address diet- and nutrition-related issues that come up in your clinical practice? The program directors at the Nutrition in Medicine program at UNC Chapel Hill’s School of Public Health contributed the following quiz, which highlights situations physicians frequently address in their practices. Questions are drawn from the Nutrition in Medicine program’s online curriculum for practicing physicians. Subjects are taken from a range of medical specialties.

(1) A 4th year medical student asks a patient, “Do you take any supplements?” How should the student follow this question in order to collect the most complete and accurate information about the patient’s supplement use?
a. No further questions needed; this general question captures 90 percent of all typical supplements used
b. Ask why the patient takes the supplement mentioned
c. Ask specific questions by category (single or combination vitamins, herbals, etc.), giving examples
d. Go through all of the essential nutrients one by one, asking if the patient takes them
e. Ask the same question again later in the interview; sometimes you will get additional information

(2) Evaluate the appropriateness of asking the following question in taking a dietary supplement history: “Do you use any plant sterols or stanols?”
a. The question is appropriate
b. The question uses jargon that a patient may not understand
c. The question does not ask whether the compound is in pill or food form
d. It is unnecessary to ask about supplements derived from plant sources
e. The question is inappropriate because there are no dietary recommendations for plant sterols/stanols

(3) Joshua is a successful athlete. Lately he has been feeling more tired than usual. He mentions that he has been taking a new dietary supplement. He buys it at a local health food store. Because it is sold commercially, what statement can you make with regard to its quality, purity, composition, safety, or effectiveness?
a. It has been evaluated for efficacy and safety by independent studies before being marketed
b. It has been evaluated for safety only by the FDA
c. The USDA/FDA can assure its purity and composition only
d. The FDA and DEA monitor reports of adverse events and contamination
e. There is no assurance of quality, purity, composition, safety, or effectiveness You are performing an exam on a patient who has
a BMI of 28 and slightly elevated blood pressure.

(4) When you tell the patient you are concerned that her weight could put her at risk for heart disease and cancer, she replies “I can’t lose weight, and I’m tired of trying. I’ve accepted that this is just the way I am.” What is an appropriate response to this patient?
a. Move on with the appointment without making further mention of her weight
b. Give the patient several handouts detailing how she can lose 1-2 pounds per week
c. Refer the patient to a registered dietitian for counseling on how to lose weight
d. Reflect back her frustration empathetically, and provide information about risks of overweight
e. Point out the patient’s negative attitude and tell her that she needs to try to lose weight

(5) You are seeing a 46-year-old female patient with recently confirmed diabetes mellitus, type 2. She is currently following an energy-neutral diet and is doing 150 minutes of aerobic exercise per week. Her BMI is 29.2, and her HbA1c has fallen from 8.2 to 7.6%. She wants to know how she can improve her glycemic control further without the use of medication. Which area should she work on next?
a. Switching from her aerobic exercise to one hour of strength training twice a week
b. Avoiding any sugar or other added sweeteners
c. Skipping one meal and a snack most days
d. Reducing intake by 300-500 kcal/day across all meals
e. Increasing her daily fruit intake

(6) You are seeing a patient with gestational diabetes mellitus in the 16th week of her pregnancy. She was normal weight before becoming pregnant with a BMI of 24. She is gaining weight slightly faster than is desired. Currently she exercises a total of 90 minutes/week and eats three meals and two snacks per day. In order to get her back to her target weight range while still promoting glycemic control, you could suggest:
a. Lose at least one pound before her next visit
b. Tell her to increase total weekly exercise to 180 minutes/week and to eliminate her snacks
c. Find a few high-calorie foods in her diet to replace with healthier, low-calorie options
d. Eliminate all of her snacks and only eat three meals a day
e. Continue her current regimen because energy needs will increase as her pregnancy progresses

(7) Describe the first step for measuring waist circumference properly.
a. Place the measuring tape in a horizontal plane, parallel to the floor, around the abdomen
b. Locate the mid-axillary line
c. Place the measuring tape in a horizontal plane across the navel
d. Have the patient bend forward from the waist, letting the arms fall towards the floor
e. Draw a horizontal mark at the uppermost lateral border of the right iliac crest

(8) Which of the following patients is most likely at risk for refeeding syndrome upon starting oral or enteral feeding?
a. A 40-year-old woman undergoing a complete hysterectomy
b. A 90-year-old woman with dysphagia following a stroke two weeks ago
c. A 13-year-old boy with several long-bone fractures following a car accident
d. A 55-year-old man following a prostatectomy and radiation therapy five days ago

(9) How much of which micronutrient(s) should a month-old breastfed infant get daily?
a. 50 ?g vitamin K
b. 100 IU vitamin D3 and 50 ?g vitamin K
c. 2 mg chelated iron
d. 400 IU vitamin D3
e. 2 mg chelated iron and 400 IU vitamin D3

(10) Body fatness, frequent alcohol intake, and high red/processed meat consumption all increase risk of cancer at which of the following sites?
a. Endometrium
b. Colorectum
c. Breast
d. Lung
e. Stomach

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Answer key - Nutrition quiz

1. The answer is C.
Ask specific questions by category (single or combination vitamins, herbals, etc.), giving examples. Do not just ask patients whether they use dietary supplements. You want to ask targeted questions to get the information you need without wasting time.

2. The answer is B.
The question uses jargon that a patient may not understand. It is appropriate to ask patients about their intake of various categories of dietary supplements, including plant sterols and stanols. However, it is important to use language that patients can understand and to give examples from each category in order to ensure that patients give the most accurate answers. In this case, give examples of popular products (brand names) that contain sterols or stanols, such as Benecol spreads.

3. The answer is E.
There is no assurance of quality, purity, composition, safety, or effectiveness. Dietary supplements are largely exempt from food and drug laws and regulations.

4. The answer is D.
Reflect back her frustration empathetically, and provide information about the risks of overweight. This patient is in the “precontemplation” stage of change. The goal is to move her toward the “contemplation” stage, during which she will begin to consider taking steps toward positive change. Your role is to empathetically validate her feelings about weight loss while providing information about the risks of not changing.

5. The answer is D.
Reduce intake by 300-500 kcal/day across all meals. This reduction should allow her to lose about half a kg (one pound) a week in the long run.

6. The answer is C.
Find a few high-calorie foods in her diet to replace with healthier, low-calorie options. Replacing a high-calorie food with something healthier/low-calorie is a strategy suggested for decreasing total calorie intake and will help slow the rate of weight gain.

7. The answer is E.
Draw a horizontal mark at the uppermost lateral border of the right iliac crest. The first step in measuring waist circumference is locating and marking the uppermost lateral border of the right iliac crest.

8. The answer is B.
A 90-year-old woman with dysphagia following a stroke two weeks ago. Refeeding syndrome can occur with repleting a previously malnourished patient. Dysphagia may have caused suboptimal energy intake for two weeks in this patient.

9. The answer is D.
400 IU vitamin D3. All newborn infants need 400 IU vitamin D3 daily, and breastfed newborns should be given this dosage via oral drops.

10. The answer is B.
Colorectum. Body fatness, alcohol intake and red/processed meat intake all increase the risk of colorectal cancer.