T. Buter / Nutritional Expert
The Netherlands

Having a practice as a nutritionist involves both regular dietary advice and complementary nutritional therapy. As a nutrition expert I would like to share my experiences in this field.

At times it is remarkable – both for clients and physicians – to experience how strongly diet affects health. It is not always a matter of avoiding certain food products, but often a matter of eating better and choosing a different dietary pattern. Changing heavily ingrained habits and behavioral patterns is often instrumental to achieving this.

As a registered dietitian, I have established contracts with health insurers and GP cooperatives. This has an advantage because patients referred by GPs and specialists receive reimbursement for the consultations. For people with diabetes, COPD (chronic obstructive pulmonary disease) and increased cardiovascular risk, a close cooperation has been established between primary care assistant practitioners, assistants of general practitioners and nurses specialized in lung diseases and diabetes. The developed protocols then form the basis for close cooperation, and besides diet and lifestyle interventions, medication guidelines are included. Furthermore, they comprise clear inclusion criteria and goals. Quite often patients suffer from a combination of diabetes, increased cardiovascular risk and other comorbidities which stress the necessity of a multidisciplinary approach.

‘Quite often, patients suffer from a combination of diabetes, increased cardiovascular risk and other comorbidities, which stresses the necessity of a multidisciplinary approach’

It is surprising that patients appear to have little knowledge about their illness or the medication they – on occasion – have been taking for years despite regular consultations with various healthcare workers.

During the medical anamnesis, the type and dose of medication are determined as they may be relevant in relation to the dietary pattern. Before settling the dosage of insulin or a carbohydrate limitation for an insulin-dependent diabetic, it is important that the patient understands the connection between diet, lifestyle and medication. Explaining their mutual interaction can often be combined with providing further information about the cause and development of a condition, in relation to lifestyle and diet, and the effect (including side effects) of the drug. Patients highly appreciate the account since it provides answers to sporadically long-standing questions and ambiguities.

Since 1998, cellular medicine has been a major focal point of my nutritional counseling. Both preventive supplementation with micronutrients and the application of nutrient synergy as supportive treatment are included as standard practices. Viewed from a cellular medicine perspective – which starts from the premise that the major endemic diseases are the consequence of a chronic deficit of micronutrients – I am usually not surprised by the poor health status of patients after establishing the diet interview and evaluation. Often a poor diet is combined with an unhealthy lifestyle, chronic stress, medication, sleeping disorders and other aspects.

If weight reduction is the main request for help leading to a referral to my practice, prescribing an energy-restricted diet would further exacerbate the existing micronutrient deficiency. In that case, complementation with targeted nutritional supplementation is certainly necessary.

When patients clearly understand the relationship between health issues and the development of diseases, they are often willing to start supplementation. Still, for many people it is difficult to accept that something as simple as a vitamin tablet could provide the solution to many major health problems. Often one starts taking supplements by allowing the micronutrient intervention the benefit of the doubt.

‘When patients received a clear elucidation of the relationship between health pressures and the development of diseases, a willingness to start supplementation is often present’

In addition, patients indicate that they wish to see a confirmation of existing nutrient deficiencies. Usually, a blood test is then performed- though the possibilities are limited. Sometimes, vitamin values are already known due to blood tests results that can be accessed by the multidisciplinary team thanks to the Dutch secured patient record system.

Nowadays, Vitamin D levels are checked more swiftly as many chronic diseases are accompanied by (very) low blood values. Though specialists pursuit vitamin D-values of 80-100 mmol/l, general practitioners are satisfied with a value > 50 mmol/l; specialists consider > 30 mmol/l already good enough. The lowest vitamin D value that I’ve noted so far is 8 mmol/l in a Muslim of Turkish origin who has struggled for years with numerous health problems, before vitamin values were determined. Her startled doctor then prescribed a months-long, very high supplementation with vitamin D. However, supplementation with vitamin D alone is not enough to guarantee a significant health improvement of the woman. Be that as it may, physicians often have limited knowledge of nutrition and limited possibilities for prescribing supplementation. For instance, a vitamin B12 shortage caused by prolonged use of Metformin (a drug that reduces the insulin resistance of our body cells) is rarely checked by doctors and primary care assistant practitioners. Since dietitians are also authorized to require nutrition- related blood levels, patients often leave my practice with an application form for a blood test. The referrer will be informed about the sample blood results. In addition to those who visit my practice with a referral, an increasing number of appointments for nutritional advice are scheduled without the intervention of a physician or other referrer. This often involves complaints for which the client does not want to consult a doctor/ for which he or she doesn’t want to take prescribed medication/ or for which therapy does not have the desired effect.

Due to a growing skeptical attitude towards drugs but also because of an accumulating influence of the media and a changing view on nutrition in relation to health, people are more critical and progressively looking for alternative treatment modalities. Cellular medicine provides these alternatives and I consider it to be a significant asset besides dietary advice. First I focus on eating habits to guarantee an optimal supply of nutrients and to avoid unnecessary ballast. As a second step, I offer supplementation with nutrient synergy- taking into account the health situation and all pressures affecting health including intense sport and the use of stimulants and medication. Use of medication is never stopped or changed without the intervention of the treating physician. Good nutrition with supplementation results in significant improvement in the health situation, whereupon the use of medication can be reduced and the patient feels better. In recent years, referrers have developed an increasingly close interest in the possibilities of dietary intervention that goes beyond a healthy dietary pattern and includes the supporting effect of targeted supplementation. I consider it to be a positive development that I get requests from practitioners who seek collaboration with a dietitian that works ‘differently’ than purely following standard dietary protocols. That clearly shows that profound changes take place within the mainstream medical world as well. We can be glad that there are doctors who give nutrition a prominent place in preventive as well as curative care. This enables us to deal with the cause of disease, stop the condition from progressing and to provide real healthcare.

What does it mean to practice Nutrition and Health (PDF - 609 kB)

What does it mean to practice Nutrition and Health