Incorporating a dietician into your practice

By Dr Anita Sturnham / 01 Jan 2015

General practitioner and skin specialist Dr Anita Sturnham shares her experience of incorporating a dietician’s expertise to improve patient results

Nutrition is essential as part of an anti-ageing skincare regimen. There are two main processes that are thought to induce skin ageing: intrinsic and extrinsic factors.8 Extrinsic ageing is caused by environmental factors such as sun exposure, air pollution, smoking and poor nutrition.

Intrinsic ageing generally reflects our genetic background. Various expressions of intrinsic ageing include thinning of the skin with exaggerated expression lines. Extrinsically aged skin is characterised by photo damage, such as lines, wrinkles, pigmented lesions, hypopigmentation and actinic keratoses.7

A network of antioxidants such as vitamins E and C, coenzyme Q10, alpha-lipoic acid, glutathione, and others can reduce signs of ageing. Antioxidants are the body’s defense against free-radical damage and oxidative stress. They fight free radicals by supplying them with the electron that they lack, therefore neutralising their harmful effects. Mitochondrial mutations of DNA accumulate during ageing and can be detected at elevated levels in prematurely aged skin following chronic exposure to UV light. In vitro data provides evidence that dietary micronutrients such as ?-carotene interact with UVA in the cell and prevent the induction of photoageing-associated mitochondrial DNA mutations.9 An antioxidant-rich diet packed full of fruits and vegetables is therefore a crucial component of any patient’s anti-ageing plan.

My practice offers patients skincare, healthcare and nutritional advice all under one roof. It is a medical centre that offers a comprehensive range of facial and body treatments, skin treatments, GP health reviews, nutritional support, skin cancer checks and total body mole mapping, as well as Health MOTs.
My clinical background allows me to provide patients with a specialist medical and
skin assessment, looking not just at skincare but also at their overall health. It is well known that the appearance of your skin can often re ect your inner health and wellbeing. To have great skin, you need to have good health – total wellness is the aim for all of our patients at my practice.
As a general practitioner (GP) with a specialist interest in skin, I understand the importance of having a multidisciplinary approach when managing most health conditions. Over the years I have noticed a strong connection between an individual’s nutrition and their health. For example, those who consume large quantities of sugary foods and drinks have an increased risk of obesity and Type 2 diabetes. In my own practice, I have noticed a connection between diet and skin diseases such as acne and eczema. For example, those who consume diets high in sugar seem to be more prone to outbreaks of these inflammatory skin conditions. It makes sense that if we feed our bodies with the right nutrition, we can reduce our risks of many diseases, including heart disease, strokes, diabetes and even skin disease.

Following this philosophy, I created Nuriss Skincare and Wellness Clinic. Nuriss comes from the French verb ‘nourrir’ (to nourish), meaning ‘to give a person or other living thing the food and other substances necessary for life, growth and good health’. Throughout my career I have been left frustrated when seeing patients in great need of nutritional support, but who are unable to access it easily. In my experience, access to a dietician has been limited due to a lack of available funding and resources. Even within hospital settings, a small team of dieticians are usually spread very thinly, allowing only a select number of patients access to this service. Patients often visit my clinic suffering from health issues such as irritable bowel syndrome, polycystic ovarian syndrome and acne vulgaris. I believe that a well-balanced diet can improve such issues so, as well as including nutritional advice in patients’ treatment plans, I have also incorporated a dietician into my clinic. This service has always been available there and I am fortunate enough to have worked professionally with an excellent registered dietician during my years of practice. Our close working relationship has meant that introducing the role of ‘the dietician’ into our team of experts at Nuriss has been an easy one.
Dietitians are the only nutrition professionals to be regulated by law, and are governed by an ethical code to ensure that they always work to the highest standard.10 It is very much my personal choice to work with a dietitian rather than a nutritionist. Some may say that a nutritionist is just as good as a dietician however, although they have good knowledge about nutrition, as they are not regulated, my preference is to work with a dietitian.
At Nuriss we have allocated two days of every week for appointments designated to general medicine and nutrition. Our dietician, Lucy Jones, is employed by Nuriss on these days. If required, she is also able to offer consultancy-based work on other days of the week. Every Monday our Nuriss medical team also runs their health MOT clinic. The aim of our MOTs is to identify current health issues and screen for potential disease risk factors. During the GP assessment, we talk through all aspects of a patient’s current health, screen for diseases, and perform blood and urine tests. We offer an advanced body composition analysis (called ‘Seca’ Testing), which assesses a number of parameters, including muscle and body fat percentage, body mass index, hydration and cellular activity levels.

This is followed by an in-depth consultation with our dietician, who will advise on all aspects of nutrition, review patients current diet and lifestyle and recommend disease- specific dietary plans. For example, patients with irritable bowel syndrome may be started on the FODMAP diet, while patients with acne may be started on a low glycaemic index diet and one favouring foods known to be beneficial for the skin. According to dietician Lucy Jones, “Your food intake represents the foundations of good skincare. The right nutrition can support healthy skin, reduce acne and even skin ageing. For those wanting to look and feel good, we can address health from the inside out in our comprehensive MOTs and health checks.” Let’s use acne vulgaris as a case study; a common issue seen both in general practice and dermatology clinics. The literature examining the link between diet and acne has been very mixed over the years. However, there is now a growing body of epidemiologic and experimental evidence that suggests there could be a strong relationship between diet and acne.3

The evidence is more convincing for high glycemic diets, compared with other dietary factors such as the dairy-acne connection.1 Dairy ingestion appears to be weakly associated with acne, and the roles of omega-3 fatty acids, antioxidants, zinc, vitamin A, and dietary fibre remain inconclusive.1 Dermatologists and dietitians continue to debate and research the potential relationship between diet and acne. Most experts would agree, however, that diet does have an impact for most patients and the best dietary approach is to address each acne patient individually, carefully considering the possible benefit of dietary counselling.2 Personally, I have seen fantastic results in the management of acne vulgaris. As an example, I have been seeing a 25-year-old female (Patient A) from London, with a history of acne vulgaris since the age of 17. She has been treated with topicals, oral antibiotics and Roaccutane in the past, unfortunately with poor results. At the time of presentation to me, she was taking oral Lymecycline and using topical Benzylperoxide. A low glycaemic index diet, rich in antioxidants and omega-3 fatty acids has totally transformed her skin.

Patient A said, “I have battled with my acne for years. For me, medicine was just one part of the puzzle. Good skin care was another part of the puzzle. Nutrition was the missing piece of the puzzle and now I have great skin.”

By looking at inner wellness, health nutrition and skincare together, we can provide the ultimate skincare programme 

Nutrition and protection against environmental exposure. Other examples of the benefits of using nutrition in skincare can be found by looking at the way in which nutrition can protect our skin from environmental damage. A diet rich in carotenoids is known to prevent cell damage, premature skin ageing, and even skin cancer. Cutaneous carotenoids can be enriched in the skin by nutrition, and a diet rich in antioxidants has been shown to increase free-radical protection after UVA/UVB irradiation.9 Antioxidants naturally occurring in the skin are superoxide dismutase, catalase, alpha-tocopherol, ascorbic acid, ubiquinone, and glutathione, and many of them are inhibited by UV and visible light.4 The antioxidant diet should contain large amounts of vitamins A, E, and C, grape-seed extracts, coenzyme Q10, and alpha-lipoic acid.4 The most highly recommended foods include: avocados, berries, dark green leafy vegetables, orange-coloured fruits and vegetables, pineapples, salmon, and tomatoes.

During the early planning stages of the ‘Nuriss’ brand and my clinic, I believed that having input from a dietician was an essential part of our patient journey. This belief was based on my own working experience, rather than in-depth research on the matter. I wanted to give my patients something that had always been missing from practices where I have worked previously. I was also aiming to create the ‘ultimate’ clinic where patients could access healthcare, skin care and nutrition support under one roof.

In recent years, our patients seem so much more interested in the idea of using nutrition as a medicine and are happy that we endorse that ethos at Nuriss too.

The feedback from patients so far has been fantastic and, whilst not every patient needs to see a dietician, those that don’t need it seem reassured that we are able to offer them access to this service, if required. For those that do need and want nutritional support, the seamless transition from doctor to dietician, works well here.

The only difficulty was working out how to integrate this service into our practice. It was unlikely that we would require a dietician every day, so from a business perspective I also had to assess the costs of time and resources when setting up the clinic. The solution seemed to be to allocate set times/ days of the week for this service, So far, this seems to work well within our clinic.

In summary, I believe that the future of skin care lies in a holistic approach. By looking at inner wellness, health, nutrition and skincare together, we can provide the ultimate skin care programme. 

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