Primary care providers can advise patients on nutrition, and flagging personality symptoms can play a role in more comprehensive patient assessment and treatment.
When patients report cravings, cognitive symptoms, or low energy during consultations, it may be useful to assess their nutritional profiles for potential deficiencies or overconsumption.
Soussan Ayubcha, MD, assistant professor of clinical family medicine and community care at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, noted these symptoms could be driven by specific nutritional shortcomings or high intake of ultraprocessed foods and refined carbohydrates.
Sugar cravings. Diets high in ultraprocessed foods and refined carbohydrates, but low in protein and fiber, can lead to blood sugar instability. To address this, ensure adequate intake of vitamin B6, vitamin B9, magnesium, and iron, Ayubcha said. Plus, reduce overall refined sugar intake. “A patient can work with [a registered dietician] to calculate appropriate individualized portions of carbs, healthy fats, protein, calories, and optimal timing of meals for the specific patient,” she said.
Weakness and low blood sugar. Symptoms could include low blood glucose, low caloric or protein intake, and iron deficiency. Further, she said chromium and magnesium deficiency can also impair glucose metabolism. She advises screening for iron deficiency. If positive, screen for causes and then treat accordingly. You can treat mild deficiency with an increase in dietary iron and by pairing it with vitamin C-rich foods, Ayubcha said. “Also, ensure adequate total caloric, protein intake, and suggest the patient add magnesium-rich foods.”
Brain fog or poor concentration. This could be caused by vitamin B12, iron, or folate (vitamin B9) deficiency. And diets high in ultraprocessed foods are independently associated with accelerated cognitive decline, Ayubcha said. “Check B12 levels (often low in patients on metformin, PPIs [proton pump inhibitors], or with vegan/vegetarian diets) and B9,” she said. Dietary vitamin B12 sources or oral supplementation are best as determined by the primary care providers, but the real key is to reduce ultraprocessed food intake and emphasize a Mediterranean-style pattern.
Lethargy and fatigue. Deficiencies in iron, vitamin B12, vitamin D, or magnesium; inadequate total caloric intake; and poor-quality diets worsen fatigue, she said. Iron supplementation improves fatigue even in nonanemic iron-deficient individuals. Ayubcha suggests you order blood tests for ferritin, vitamin B12, 25-hydroxyvitamin D, and magnesium, and prioritize nutrient-dense whole foods and maintain adequate hydration and regular meal timing to sustain energy levels.
Depression. According to Ayubcha, this can be caused by coexisting deficiencies in folate, vitamin B12, vitamin D, and omega-3 fatty acids. Methylfolate and omega-3s (especially eicosapentaenoic acid) have evidence as secondary treatments, she said. Another strategy is to advise patients to adopt the Mediterranean diet as the most evidence-based dietary intervention.
Insomnia, poor sleep. Investigate magnesium deficiency. “Higher dietary magnesium intake is associated with reduced odds of short sleep duration,” she said. Also, vitamins B6, B12, and B9 play a role in serotonin and gamma-aminobutyric acid synthesis, both of which are involved in sleep regulation, she said. Plus, iron deficiency contributes to restless legs syndrome, which can cause major sleep disruptions. Suggest patients consume magnesium-rich foods and tryptophan in the evening to enhance sleep and melatonin production.
Refer to Registered Dietitian?
Registered dietitians (RDs) can be a great resource for patients.
“RDs have immense knowledge regarding nutrition as well nutritional deficiencies and how to manage them,” said Samantha P. Flanagan, DO, assistant professor of Clinical Family and Community Medicine at the Lewis Katz School of Medicine at Temple University and an obesity medicine specialist at Temple Health, both in Philadelphia. Most commercial insurance plans offer coverage for a certain number of dietitian visits per year, usually at no out-of-pocket cost (or a modest copay) to the patient, she said.
Promoting Patient Self-Advocacy
Encouraging patients to discuss any concerns with the provider is a vital first step. Remind them to be as specific as possible with their symptoms, and asking them to keep a list is helpful, said Flanagan.
Conversations about nutritional deficiencies and any testing needed are not always straightforward, so it would be best to plan a visit specifically for this conversation during a routine health-maintenance visit, such as an annual physical exam, she said.
Addressing Appetite Loss Due to GLP-1
Ideally, before starting a GLP-1, patients should already be working with an RD for weight loss, said Ayubcha.
Because GLP-1 therapy can significantly decrease caloric intake, patients may become deficient in protein, vitamins, and minerals, and may also become dehydrated. Some patients will need closer monitoring of their overall intake. A practical approach includes encouraging smaller, nutrient-dense meals, prioritizing protein and hydration, and reinforcing RD support if intake is dropping substantially, Ayubcha said.
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