Please use the following 2 statements to provide a response to the following
discussion post.
Compare and contrast viewpoints on the function of the NCP and the role of
the NCP in the public health sphere.
Support your assertions with evidence from the Bible, text, and articles, using
AMA citations. Integrate findings from articles that may add a different
perspective than your classmates' perspectives.
1. DISCUSSION POST
2. Good evening everyone,
Week one and we are jumping right into it! I'd have to say, I did learn a lot
about the Nutrition Care Process (NCP). Seeing the visuals really put things
into perspective. Just like with other professions, let's say personal training,
you have to follow a set of steps in order to understand the client, their
situation and the desired outcome. With the NCP, it isn't any different. There
are four steps to complete and they can be repeated if need be.
Step 1: Nutrition Assessment. In the very first step of a NCP, we will be
gathering data and information that we will use in step two and organize data
collected from the client. How is the client's nutritional status? Let's get into
what nutritional problems are present. Does the client consume undesirable
foods? We will be getting into the nitty gritty within their diet.
Step 2: Nutrition Diagnosis. Here is where we identify possible labels. This
should not be confused with a medical diagnosis. In this step of the NCP, we
are identifying the client's issues in terms of nutrition and to provide care and
pathways to improve their health and nutritional status.
Step 3: Nutrition Intervention. Sitting down with the client and having a
specific conversation about desired goals and expected outcomes. While
conducting the nutrition assessment, we would be identifying and labeling
nutrition diagnoses. In this step we will be organizing and prioritizing the
diagnoses.
Here we will talk about the intervention selected while using the standardized
intervention language. Examples of Nutrition Assessment Standardized
Languages are nutrition-related history, Anthropometric Measurements,
biochemical data, medical tests and procedures as well as nutrition-focused
physical findings and of course the client's history.
We will sit and set goals ideal goals. These goals are science-based and are
intended to control and/or improve specific health conditions and diagnoses
established from step one.
Step 4: Nutrition Monitoring and Evaluation. We will be monitoring the
progress the client, while measure and evaluate the outcomes. Checking on
the client's understanding of the goals set for them, determining if the client is
following and implementing the intervention plans as planned as well as take
note of the clients current condition compared to where we first started.
Remembering that the client is human and this may be a sensitive process to
go through is vital. Using interpersonal communication skills, listening, making
eye contact and not being judgmental will further curate a healthy relationship
with the client. We don't want our clients to get defensive, however, we also
need to be clear and concise when speaking on the current issues, how to
handle them and realistic ways to reach goals as well as staying on track.
References:
1. Chichirez CM, Purc?rea VL. Interpersonal communication in healthcare. J
Med Life. 2018;11(2):119-122.
2. Nelms M, Sucher KP. Nutrition Therapy and Pathophysiology. 4th ed.
Cengage; 2020.
4.2
NUTRITION
PRESCRIPTIONS
As
noted
previously,
nutrition
intervention
involves
two
components:
planning
and
implementation.
The
nutrition
prescription,
an
important
part
of
the
planning,
outlines
nutritional
needs
for
the
patient
and
supports
the
medical
care
that
is
prescribed
by
the
health
care
team.
“The
nutrition
prescription concisely
states
the
patient/client’s
individualized
recommended
dietary
intake
of
energy
and/or
selected
foods
or
nutrients
based
on
current
reference
standards
and
dietary
guidelines
and
the
patient/client’s
health
condition
and
nutrition
diagnosis?”
The
nutrition
prescription
also
should
either
provide
the
path
for
the
nutrition
intervention
or
frame
Evidence-Based
Guidelines
Ethan
A.
Bergman,
PhD,
RD,
CD,
FADA
Central
Washington
University
Susan
N.
Hawk,
PhD,
RD
Central
Washington
University
It
is
important
that
the
RDN
use the
most
up-to-date
information
when
providing
care
for
patients.
This
information
must
be
based
on
evidence
supported
by
well-controlled
research
studies
and
clinical
practice.
Evidence-based
recommendations
or
guidelines
are
scientifically
developed
to
assist
health
care pro-
fessionals
in
making
appropriate
decisions
about
patient
care.
The
following
are
sources
of
evidence-based
research
designed
to
help
health
care
professionals
choose
the
best
clini-
cal
approach
to
patient
care:
1.
Academy
of
Nutrition
and
Dietetics
(AND)
Evidence
Analysis
Library
(EAL):
Available
at
www.andeal.org/.
The
EAL
has
been
created
to
summarize
the
best
available
research
in
dietetics
and
nutrition.
Access
to
the
AND
Evidence
Analysis
Library
is
free
to
AND
members
but
re-
quires
a
subscription
for
nonmembers.
BOX
4.1
RESEARCH TO
PRACTICE
the context
within
which
the
intervention
is
implemented.
As
discussed
in
Chapter
1,
the
Academy
of
Nutrition
and
Dietet-
ics
(AND)
defines
evidence-based
dietetics
practice
as
“the
incorporation
of
systematically
reviewed
scientific
evidence
into
food
and
nutrition
practice
decisions.
It
integrates
pro-
fessional
expertise
and
judgment
with
client,
customer
and
community
values
and
evaluates
outcomes.”*
Throughout
this
text,
as
pathophysiology
and
nutrition
therapies
are
discussed,
evidence
is
provided
to
support
the
efficacy
of
an
appropri-
ate
nutrition
prescription.
Box
4.1
discusses
evidence-based
guidelines.
The
role
of
the
RDN
in
planning
and
implement-
ing
nutrition
interventions
is
summarized
in
Table
4.1.
2.
National
Guideline
Clearinghouse
(NGC):
Available
at
www.guideline.gov.
The
NGC
is
a
resource
for
evidence-based
clinical
practice
guidelines
for
physicians,
nurses,
and
other
health
care
professionals,
including
dietitians.
3.
Cochrane
Library:
Available
at
www.cochranelibrary.
com/.
The
Cochrane
Library
publishes
Cochrane
Reviews,
which
are
based
on
the
best
available
information
about
health care
interventions.
The
reviews
explore
the
evidence
for
and
against
the
effectiveness
and
the
appropriateness
of
various
types
of
medical
treatment.
4.
Agency
for
Healthcare
Research
and
Quality
(AHRQ):
Available
at
www.ahrq.gov.
AHRQ
is
the
research
arm
of
the
U.S.
Department
of
Health
and
Human
Services
(HHS).
It
examines
how
people
access
health
care,
its
cost,
and
the
results
of
this
care.
The
main
goals
of
AHRQ
are
to
identify
the
most
effective
ways
to
organize,
manage,
finance,
and
deliver
high-quality
health
care.
Table
4.1
Standards
of
Practice:
The
Registered
Dietitian’s
Role
in
Nutrition
Intervention
©
Prioritizes
the
nutrition
diagnoses
based
on
problem
severity,
safety,
patient/client
needs,
likelihood
that
nutrition
interven-
tion
will
influence
the
problem,
and
patient/client
perception
of
importance
*
Bases
intervention
plan
on
best
available
evidence
(e.g.,
national
guidelines,
published
research,
evidence-based
libraries,
and
databases)
Refers
to
policies
and
program
standards
*
Confers
with
patient/client
and
caregivers,
interdisciplinary
team,
and
other
health
care
professionals
*
Determines
patient-/client-centered
plans,
goals,
and
expected
outcomes
*
Develops
the
nutrition
prescription
*
Defines
time
and
frequency
of
care,
including
intensity,
duration,
and
follow-up
*
Utilizes
standardized
language
for
describing
interventions
*
Identifies
resources
and/or
referrals
needed
*
Collaborates
with
colleagues,
interdisciplinary
team,
and
other
health
care
professionals
*
Communicates
and
coordinates
the
nutrition
intervention/plan
of
care
*
Initiates
and
individualizes
the
nutrition
intervention/plan
of
care
*
Assigns
activities
to
dietetic
technicians,
registered
(DTR)
and
other
administrative
support
and
technical
personnel
in
accordance
with
qualifications,
organization
policies,
and
applicable
laws
and
regulations
*
Continues
data
collection
*
Follows
up
and
verifies
that
nutrition
intervention
is
occurring
*
Adjusts
intervention
strategies,
if
needed,
as
response
occurs
©
Documents:
Date
and
time;
specific
treatment
goals
and
expected
outcomes;
recommended
interventions;
adjustments
to
the
plan
and
justification;
clien/community
receptivity;
referrals
made
and
resources
used;
other
information
relevant
to
providing
care
and
monitoring
progress
over
time;
plans
for
follow-up
and
frequency
of
care;
rationale
for
discharge,
if
applicable
Source:
Academy
Quality
Management
Committee.
Academy
of
Nutrition
and
Dietetics:
Revised
2017
Standards
of
Practice
for
Registered
Dietitian
Nutritionists.
J
Acad
Nutr
Diet.
2018;
118:
141-65.
78
Part
2.
The
Nutrition
Care
Process
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
it.
4.3
FOOD
AND/OR
NUTRIENT
DELIVERY
(ORAL
DIETS)
The
first
step
in
prevention
or
treatment
of
malnutrition
is
an
adequate
supply
of
acceptable
food
composing
diet
that
has
been
individualized
to
age,
height,
weight,
activity
level,
nutritional
status,
and
medical
condition.
Malnutrition
in
acute
care
may
be
the
result
of
chronic
illness
experienced
by
patients
before
admission
or
an
acute
response
to
inflamma-
tion
and
metabolic
stress,
but
it is
also
exacerbated
by
pain,
anxiety,
depression,
medical
testing,
and
unfamiliar
foods
or
meal
schedules
associated
with
admission
to
a
health
care
setting.
Insufficient
food
intake
may
be
related
to
the
factors
depicted
in
Figure
4.2.
Therefore,
it
is
important
that
these
factors
be
carefully
assessed
prior
to
planning
nutrition
inter-
ventions.
In
a
recent
article,
a
survey
assessing
indicators
for
reduced
food
intake
in
56
countries
revealed
that
the
most
common
factors
that
could
predict
food
intake
were
reduced
intake
during
previous
week,
confinement
to
bed,
females
at
either
end
of the
age
spectrum,
and
low
body
mass
index."
This type
of
research
provides
additional
information
to
iden-
tify
those
individuals
at
risk
for
inadequate
oral
intake.
In
many
instances,
a
healthful
diet—commonly
referred
to as
“regular”
or
“house”
diet
is
served
in
hospitals
and
post-
acute
care
in a
minimum
of
three
meals
each
day
and
will
meet
a
patient’s
nutritional
needs.
Menus
are
written
and
approved
by
a
RDN
and
are
designed
to
provide
the
Dietary
Reference
Intake
for
all
nutrients.
Restaurant-style
menus,
room
service
ordering
systems,
a
la
carte
food
carts,
and
individual-unit
kitchens
and
galleys
are
all
examples
of
methods
to
ensure
patient
satisfaction
and
choice
in
menu
selection.°®
When
patients
have
the
option
to
select
the
food
items
they
prefer,
as
they
do
in
most
institutions,
one
of
the
simplest
yet
most
helpful
interventions
may
be
to
assist
a
patient
with
menu
selection.
Offering
suggestions
and
appropriate
substitutions
can
be
an
efficient
method
of
ensuring
that
the
patient’s
diet
remains
adequate
and
acceptable.
A
2016
study
examined
meals
ordered
within
a
pediatric
hospital
and
found
that
the
majority
did
not
meet
optimal
nutritional
guidelines,
which
further
emphasizes
the
need
for
guidance
in
menu
selection.
Figure
4.2
Factors
Affecting
Nutritional
Intake
during
Illness
Medical
Testing
Inappropriate
Diet
Orders
reer
Food
Intake
Modification
of
Meals
and
Snacks
Modifications
of
a
general
diet
are
often
recommended
as
part
of
the
nutrition
prescription
for
patients
under
the
care of
a
RDN.
These
changes
result
in
“modified
diets”
that
have
several
important
functions.
They
may
be
used
to
maintain
or
restore
health
and
nutritional
status.
They
may
also
accommodate
changes
in
appetite,
digestion,
absorp-
tion,
or
organ
function.
These
diets
can
provide
the
appro-
priate
nutrition
therapy
to
support
weight
loss
or
gain,
or
to
assist
with
treatment
of
a
particular diagnosis.
For
example,
modified
diets
may
be
created
by
altering
the
kilocalorie
(kcal)
level,
levels
of
individual
nutrients,
method
of
preparation,
food
or
ingredient
composition,
and/or
number,
size,
or
frequency
of
meals
and
snacks
of
the
“house”
or
“regular”
diet.
Texture
and
consistency
can
also
be
adjusted
(i.e.,
softer
foods
served)
to
alleviate
mechanical
problems
for
patients
with
impaired
chewing
or
swallowing
ability.
Texture-
altered
diets
contain
foods
that
are
easy
to
chew
and
usually
omit
raw
fruits
and
vegetables.
Individuals
with
dysphagia
(difficulty
swallowing)
may
require
more
specific
modifica-
tions
of
texture
and
consistency.
Diets
for
these
individuals
are
discussed
more
thoroughly
in
Chapter
14.
For
very
short
periods (two
or
three
meals),
liquid
diets
consisting
of broth,
juice,
cream
soups,
and
milk
may
be
served
to
patients
who
are beginning
to
eat
after
a
long
period
without
food
(nil
per
os,
or
NPO).
These
diets
are
often referred
to
as
clear
liquid
diets
or
full
liquid
diets.
A
clear
liquid
diet
is
intended
to
provide
fluid
and
energy
in
a
form
that
requires
minimal
digestion
and
limits
residue
in
the
gastrointestinal
(GI)
tract.
It
may
be
used
during
acute
GI
distress,
during
GI
medical
testing
(such
as a
colonoscopy),
or
prior
to
surgery.
Clear
liquid
diets
are
inadequate
in
kcal,
protein,
vitamins,
and
minerals,
so
they
should
be
used
only
when
medically
necessary.
Historically,
the
clear
liquid
diet
has
been
used
as a
progression
toward
solid
food
after
a
surgical
procedure
or
when
the
GI
tract
required
minimal
stimulation.
Newer
research
has
demonstrated
that
earlier
feeding
with
avoidance
of
this
historical
progression
is
associated
with
decreased
hospitalization
time
with
no
additional
complications.’
A
recent
meta-analysis
of
the
literature
reveals
that,
unfortunately,
current
practice
is
not
consistent
with
the
evidence.*?
full
liquid
diet also
has
been
used
as
a
transitional
diet
between
liquids
and
solid
foods.
This
nutrition
intervention,
like
the
similar
use
of
the
clear
liquid
diet,
is
outdated.
Because
a
full
liquid
diet
includes
milk
and
milk
products,
it
may
cause
intolerance
due
to
the
large
amounts
of
lactose.
Table
4.2
out-
lines
the
basic
principles
of
these
liquid
diets,
but
be
aware
that
these
nutrition
interventions
may
no
longer
be
war-
ranted
in
the
future
as
more
and
more
research
demonstrates
that
the
restrictions
are
not
necessary.
An
important
component
of
ensuring
tolerance
to
oral
diets,
especially
clear
and
full
liquid
diets,
is
the consideration
of the
osmolality
of
the
particular
liquids
that
are
provided.
Hyperosmolar
liquids
may
not be
tolerated
during
these
transitional
periods
or
when
the
GI
tract
has
not
been
stimu-
lated
(see
Chapter
14).
This
is
additional
evidence
that
these
nutrition
interventions
should not be
used
in
most
practice
settings.
Table
4.3
provides
the
osmolality
of
common
liquids
Chapter
4
Nutrition
Intervention,
Nutrition
Monitoring
and
Evaluation
79
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
i
Table
4.2
Principles
of
Clear
and
Full
Liquid
Diets
*
Gelatin,
fruit
ice,
plain
hard
candy,
sugar,
honey
*
Clear
fluids
or
foods
that
are
liquid
at
body
Not
nutritionally
adequate
Should
be
limited
to
24-48
hours
unless
supplements
are
added
Research
evidence
does
not
support
long
term
use
of
this
diet.
*
Commercially
prepared
low-residue,
lactose-free
Clear
liquids
Intended
to
supply
fluid
and
energy
in
a
form
that
requires
temperature
and
leave
minimal
residue
minimal
digestion
and
stimulation.
Cjear
fruit
juices
of
the
Gl
tract
1
~
*
Bouillon,
consommeé,
clear
broth
nutritional
supplements
Full
liquids
Transition
between
clear
liquids
and
solid
food
©
Alll
clear
liquids
*
Cream
soups
*
Consists of
foods
or
fluids
that
are
or
become
liquid
at
body
temperature
*
May
present
problem
with
large
amounts
of
lactose
©
Research
evidence
does
not
support
long
term
use
of
this
diet.
*
Milk,
ice
cream,
pudding, yogurt
Table
4.3
Osmolality
of
Selected
Liquids
Milk*
275
Prune
juice
1265
Malted
milk
940
Grape
juice
863
Ice
cream
1905
Apple
juice
683
Eggnog 695
Orange
juice
614
Fruit
yogurt
871
Tomato
juice
595
Sherbet*
125
Punch
with
sugar
448
Ensure/Boost
590/640
Sugar-free
punch*
29
Ensure
Plus/Boost
Plus
680/720
Mineral
water*
74
Boost
Breeze
920
Broth
445
Enlive!
840
Polycose
900
Resource
fruit
beverage
750
Flavored
gelatin
ES
Enteral
formulas
250-710
Popsicles
720
Note:
Beverages
with
an
asterisk
(*)
are
considered
isotonic.
Source:
Rees
Parrish
C.
The
clinician's
guide
to
short
bowel
syndrome.
Nutrition
issues
in
gastroenterology,
series
#31.
Practical
Gastroenterology.
2005:
88-89.
that are
used
in
these
diets.
Choosing
those
with
a
lower
osmolality
may
help
promote
tolerance
during
the
transition
to oral
feeding.
Nutritional
intake
may
be
modified
to
prepare
patients
for a
specific
medical
test.
For
example,
when
a
patient
is
tested
for
gastroparesis,
a specific
test diet
is
ordered
so
that
there
is
a
reference
value
for
the
test
results
(see
Chapter
14).
Details
of
the
types
of
diets
served
are
recorded
in
an
institu-
tion’s
policies
and
procedures
or
within
a
reference
such
as
the
AND’s
Nutrition
Care
Manual.
Given
adequate
appetite
along
with
sufficient
resources
to
purchase
and
prepare
food,
most
malnourished
individu-
als
can
be
rehabilitated
with
oral diet
alone.
But
maximizing
oral
intake
within
the
hospital
setting
is
often
challenging
because
this
environment
is
not
always
conducive
to
eating.
Add
to
this
environment
thestress,
fear,
pain,
and
isolation
of
illness
and
it
is
a
wonder
that
anyone
who
is
hospitalized
can
eat
adequately.
For
these
individuals,
a
number
of
alterna-
tives
exist.
A
primary
function
of
nutrition
services
in
health
care
institutions
is
to
be
the
patient’s
nutrition
advocate.
80
Part
2.
The
Nutrition
Care
Process
When
patients
present
with
a
suboptimal
intake,
nutrition
services
staff
members
work
with
the
patient
and
health
care
team
to
provide
a
variety
of
nutritional
options.
If
a patient’s
nutrient
needs
are
not
being
met,
it
may
be
necessary
to
enhance
oral
intake
with
between-meal
or
evening
supplemental
feedings
of
nutrient-dense
foods
acceptable
to
the
individual
patient.
For
these
supplemental
feedings,
traditional
foods
such
as
fruit,
crackers,
sandwiches,
milkshakes,
custards,
or
puddings
may
be
served.
Increas-
ing
nutrient
density
without
actually
increasing
volume
can
be
an
effective
tool
for
the
individual
who
is
suffering
from
decreased
appetite.
For
example,
instead
of
using
skim
milk,
the
patient
could
receive
whole
milk with
the
addition
of a
protein
supplement
such
as
Beneprotein™
or
2
tbsp
of
dry
milk
powder
to
boost
both
kcal
and
protein.
Adding
peanut
butter
to
toast
for
breakfast
is
an
simple
method
to
increase
both
keal
and
protein.
Table
4.4
provides
examples
of
meth-
ods
to
increase nutrient
density
using
readily
available
foods,
and
Figure
4.3
presents
two
breakfast
meals
that
were
modi-
fied
in
this
manner.
Table
4.4
Nutrition
Interventions
to
Increase
Nutrient
Density
* Add
butter
or
margarine
to
cooked
cereals,
soups,
vegetables,
or
casseroles.
* Add
jam,
jelly,
or
honey
to
toast
or
other
breads
and
crackers.
©
Use
whole
milk
or
creem
with
soups,
casseroles,
creamed
vegetables,
or
shakes
and
smoothies.
© Add
sour
cream
or
yogurt
to
soups,
casseroles,
creamed
vegetables,
or
shakes
and
smoothies.
© Add
nut
butters
or
cream
cheese
to
raw
vegetables,
bread,
or
crackers.
*
Add
powdered
milk
to
any
beverage,
soup,
or
casserole.
* Add
liquid
egg
substitutes
to
shakes,
soups,
vegetables,
or
casseroles.
*
Wherever
possible,
add
nuts,
nut
butters,
chopped
meats,
cooked
eggs,
cheese,
or
yogurt
to
prepared
foods.
©
Add
tofu
or
soy
crumbles
to
any
prepared
vegetable,
soup,
or
casserole.
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
i
Figure
4.3
Nutrient-Dense
Breakfasts
(a)
Mint-chocolate
chip
avocado
green
smoothie.
Nutrient
analysis:
525
kcal,
33
g
fat,
35
g
carbohydrate
(net
13
g),
22
g
fiber,
34g
protein,
and
9 g
sugar.
Ingredients:
1
avocado,
2
tbsp
chia seeds,
1
cup
almond
milk,
1
scoop
chocolate-flavored
protein
powder,
2
cups
fresh
spinach,
and
2
tbsp dark
chocolate
chips.
(0)
Cinnamon
apple
oatmeal
with
walnuts.
Nutrient
analysis:
600
kcal,
29
g
fat,
82
g
carbohydrate
(net
70
g),
12 g
fiber,
16 g
protein,
15
g
sugar.
Ingredients:
1
cup
dried
rolled
oats,
4
cup
walnuts,
1
cup
almond
milk,
1
medium
apple.
(b)
Source:
Photography
copyright
of
McKel
Hill,
MS,
RD,
LDN
Nutrition
Stripped,
nutritionstripped.com
All
of
these
various
types
of
modifications
as
well
as
a
general
diet
are
listed
within
the
meals
and
snacks
section
of
the
food
and
nutrient
delivery
domain.”
Examples
of
possible
nutrition
diagnoses
for
which
these
interventions
may
be
appropriate
include
the
following:
+
Increased
energy
expenditure
+
Excessive
or
inadequate
(specify)
nutrient
intake
+
Inconsistent
carbohydrate
intake
+
Excessive
or
inadequate
energy
intake
+
Less
than
optimal
intake of
types
(specify)
of
nutrients
(e.g.,
fats,
carbohydrates,
and
proteins)
+
Malnutrition
Supplements
Medical
Food
Supplements
Another
classification
of
possible
interventions
within
the
food
and
delivery
domain
is
medical
food
supplements.
Medical
food
supplements
are
defined
as
commercial
or
prepared
foods
or
beverages
intended
to
supplement
energy,
protein,
carbohydrate,
fiber,
and/or
fat
intake.”
Liquid
meal
replacement
formulas such
as
those
shown
in
Figure
4.4
may
provide
a
convenient
alternative
to
between-meal
snacks.
These
products
typically
come
in
single-portion
containers
providing
250-350
kcal
with
7-15
grams
of
protein
in
250
mL,
and
may
be
available
in a
variety
of
flavors.
They
are
lactose
free.
Some
contain
fiber,
and
oth-
ers
are
more
calorically
dense
or
higher
in
protein.
Examples
of
these
products
include
Ensure®,
Boost®,
MightyShakes®,
Resource®
Health
Shake™,
and
Carnation
Breakfast
Essentials®.
Manufacturers
have
introduced
many
variations
of
these
products
for
specific
medical
conditions,
such
as
wound
Figure
4.4
Oral
Supplement
Beverages
A
selection
of
commercial
oral
supplement
beverages.
Source:
Courtesy
of
Marcia
Nelms.
healing
or
diabetes.
Oral
supplements
may
be
available
in
liquid
form,
as
puddings,
or
as
cereal-type
bars.
Because
unopened
supplement
packages do
not
require
refriger-
ation,
these
products
may
be
served
at
a
time
convenient
to
the
patient.
In
long-term
care
facilities,
they
may
be
Chapter
4
Nutrition
Intervention,
Nutrition
Monitoring
and
Evaluation
81
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
learning
experience.
Cengage
Learning
reserves
the
right
toremove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
it,
administered
in
place
of
water
with
medications
as a
means
of
increasing
nutrient
intake.
Commercial
supplements
are
popular
because
of
their
convenience
and
also
because
patients
and
caregivers
may
be
familiar
with
them
due
to
direct-to-consumer
market-
ing.
However,
acceptability
and
intake
are
highly
individual.
Patients
receiving
oral
supplements
frequently
develop
“taste
fatigue”
after
supplements
are
initiated,
and
supplement
intake
then
decreases.
It is
also
important
to
remember
that
merely
providing
supplemental
feedings
will
not
increase
appetite; in
fact,
many
patients
complain
that
extra
portions,
frequent
meals,
and
supplemental
snacks
are
overwhelming
and
reduce
appetite.
This
is
why
it
is
essential to
include
the
patient
in
the
decision-making
process
for
changes
in
the
meal
plan.
The
patient
needs
to
understand
why
oral
supple-
ments
are
being
offered
and
how
they
could
improve
his
or
her
current
medical
status.
Providing
supplement
taste
tests
could
be
one
way
to
help
patients
decide
which
product
they
would
prefer
to
add
to their
diet.
Developing
a
rotation
for
snacks
or
supplements
and
setting
portion
goals
with
the
patient
may
also
improve
acceptance.
Regular
follow-up
and
monitoring
are
necessary
in
order
to
coordinate
successful
interventions
and
minimize
waste
associated
with
unused
products.
Modified
Beverages
and
Foods
Another
means
to
improve
nutrient
density
within
food
choices
is
to
add
single
nutrients
such
as
protein
or
fiber
through
the
use
of
“mod-
ular”
products.
Manufacturer
websites
can
provide
specific
information
about
the
specific
products
that
are
available.
Protein
modulars,
such
as
ProMod®
or
Beneprotein®,
can
be
added
to
both
foods
and
beverages but
will
need
to
be
mixed
well.
They
change
the
taste
and
consistency
slightly,
as
do
lipid
modulars
such
as
medium-chain
triglyceride
(MCT)
oil.
In
general,
modulars
are
not
as
cost-efficient
as
other types
of
supplements,
and
they
also
increase
the
labor
costs.
Box
4.2
provides
more
information
about
the
MCT
supplement.
Common
nutrition
diagnoses
for
which
medical
food
supplements
might
be
necessary
include
the
following:
+
Inadequate
energy
intake
+
Increased
protein
needs
Vitamin
and
Mineral
Supplements
If
the nutrition
assessment
reveals
that
the
patient’s
diet
is
inadequate
in
essential
vitamins
and
minerals,
supplements
of
these
nutrients
should
be
discussed
with
the
health care
team
and
recommendations
made
(see
Figure
4.5).
Additionally,
many
medical
conditions
interfere
with
digestion,
absorption,
or
utilization
of
these
micronutrients.
Thus,
making
appro-
priate,
evidenced-based
recommendations
for
supplemen-
tation
of
vitamins
and/or
minerals
is
an
expected
step
in
nutrition
intervention
and
is
within
the
RDN
scope
of
prac-
tice.!°
For
example,
if
the
patient
is
diagnosed
with
osteo-
penia,
the
RDN,
along
with
the
medical
providers,
could
recommend
supplementation
for
calcium
and
vitamin
D
using
appropriate
reference
standards
and
evidence-based
guidelines.
Furthermore,
the
RDN,
along
with
the
phar-
macist,
would
support
this
recommendation
with
instruc-
tions
on
appropriate
sources
of
supplements
to
maximize
absorption
and
utilization
as
well
as
any
specific
guidelines
on
potential
drug—nutrient
interactions.
This
is
an
excellent
example
of the
importance
of
interprofessional
care
where
BOX
4.2
CLINICAL
APPLICATIONS
:
A
Review
of
the
MCT
Modular
Supplement
Medium-chain
triglycerides
(MCTs)
are
8-
and
10-carbon-chain
fatty
acids,
liberated
from
coconut
oil
and
then
re-esterified
to
glycerol.
Because
MCTs
do
not
depend
on
pancreatic
lipase
or
emulsification
for
digestion,
they
are
used
clinically
to
supply
kcal
to
patients
with
a
variety
of
pancreatic
and
gastroin-
testinal
disorders.
MCTs
are
hydrolyzed
more
readily
than
long-chain
triglycerides
(LCTs)
by
lipase,
even
in
the
absence
of
emulsifica-
tion
by
bile
salts.
After
transport
into
the
enterocyte,
they
are
not
packaged
into
chylomicrons but
instead
are
absorbed
into
the
portal
bloodstream
and
trans-
ported
bound
to
albumin
to
the
liver,
where
they
can
be
metabolized
to
release
energy.
Medium-chain
fatty
acids
(MCFAs)
and
long-chain
fatty
acids
(LCFAs)
also
differ
in
their
metabolism.
In
the
liver,
LCFAs
must
be
transformed
into
acyl
carnitine
derivatives
before
they can
enter
the
mitochondria
for
subsequent
beta-oxidation.
Carnitine
acyl
transferase
|
(CAT
|)
and
carnitine
acyl
trans-
ferase
II
(CAT
Il)
on
the
inner
mitochondrial
membrane
are
both
necessary
for
the
entry
of
LCFAs
into
the
mitochondria.
MCFAs
do
not
need
CAT
|
or
CAT
II
for
entry
and
their
subsequent
beta-oxidation.
The
oxidation
of
MCFAs
in
the fed
or
fasted
state
will
result
in
increased
production
of
acetoacetate,
3-hydroxybutyrate,
and
acetone,
three
molecules
known
as
ketone
bodies.
LCFAs
only
produce
ketones
in
the
fasted
state
since
malonyl-CoA, an
intermediate
of
carbohydrate
metabolism,
inhibits
CAT
|,
thus
decreasing
the
entry
of
LCFAs
into
the
mitochondria
in
the fed
state.
Although
ketones
have
a
“bad”
reputation
as a
result
of
their
high
blood
concentrations
during
diabetic
ketoacidosis,
they
can
be
efficiently
utilized
as
oxidative
fuels
and
converted
to
fatty
acids.
Examples
of
supplements
that
con-
tain
MCTs
include
MCT
Oil
(Nestlé),
MCT
Fuel
(Twinlab),
and
MCT
Power
(GT
Nutri-
tion
USA).
One
tablespoon
provides
4-15
grams
of
MCTs
and
65-135
kcal.
Abbot
Nutrition
has
developed
a
structured
lipid
featuring
a
combination
of
MCTs
and
LCTs
on
one
triglyceride.
This
allows
the
delivery of
MCTs
to the
peripheral
tissues
where
they
can
be
used
directly
as
sub-
strate
within
cells.
82
Part
2.
The
Nutrition
Care
Process
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
require
i
Figure
4.5
Vitamin
and
Mineral
Supplements
The
registered
dietitian
nutritionist
should
make
recommen-
dations
for
supplementation
using
the
latest
evidence-based
research.
Source:
Courtesy
of
Marcia
Nelms.
recommendations
from
numerous
providers
should
sup-
port
the
patient
care
plan.
Common
examples
of
nutrition
diagnoses
for
which
vita-
min
and
mineral
supplements
might
be
appropriate
include
the
following:
+
Inadequate
or
excessive
vitamin/mineral
intake
+
Food—medication
interaction
+
Food-and
nutrition-related
knowledge
deficit
Bioactive
Substance
Management
Bioactive
sub-
stances
are
defined
as
food
substances
added
to
a
food
product
or
taken
as
supplements
that
have
a
specific
intended
health
purpose.
Examples
of
commonly
used
bio-
active
substances
include
plant
stanol
or
sterol
esters
(see
Figure
4.6),
soy
protein,
psyllium,
beta-glucan,
and
pro-/
prebiotics.
A
patient
with
hyperlipidemia
may
be
instructed
to
consume
stanol
esters
as
a
supplement.
The
RDN,
using
the
American
Heart
Association’s
guideline
for
the
National
Cholesterol
Education
Program,
would
instruct
the
patient
on
the
amount
of
stanol
esters
recommended
for
the
intended
reduction
of
lipid
levels.
Next,
the
RDN
would
describe
the
current
products
available
for
pur-
chase
and
assist
the
patient
with
the
incorporation
of
the
products
into
his
or
her
dietary
plan.
Throughout
this
text,
many
bioactive
substances
are
discussed
as a
component
of
nutrition
therapy
and
medical
care.
Many
of
the
nutrition
diagnoses
for
which
bioactive
substances
are
prescribed
are
similar
to
those
for
vitamin
and
mineral
supplements
as
noted
above;
however,
additional
appropriate
diagnoses
include
the
following:
+
Suboptimal
or
excessive
bioactive
substance
intake
+
Excessive
alcohol
intake
Figure
4.6 Bioactive
Substance
Supplements
Benecol
is
an
example
of
a
bioactive
substance
supplement
pre-
scribed
as part of
the
nutrition
therapy
for
hyperlipidemia.
NEW
LOOK
test
irrart
oe
‘see
ice
totes
matise
ery
e]
Source:
Courtesy
of
Marcia
Nelms.
Feeding
Assistance
and
Feeding
Environment
During
nutrition
assessment
and
the
subsequent
identifi-
cation
of
nutrition
problems,
it
is
not
uncommon
to
dis-
cover
that
even
though
the
appropriate
and
adequate
diet
is
available
to
the
patient,
he
or
she
is
unable
to
consume
ade-
quate
amounts.
Changing
the
environment
to
allow
for
food
choice—for
instance,
organizing
family-style
meals
in a
reha-
bilitation
facility—can
significantly
improve
the
patient's
abil-
ity
to
eat.
Preparing
the
patient
to
eat
may
include
helping
him
or
her
to
sit
at
the
appropriate
height
and
distance
from
the
tray,
optimizing
pain
medication
delivery,
or
scheduling
appropriate
mouth
care
for
the
patient
prior
to
the
meal.
Other
nutrition
interventions
may
include
recommenda-
tions
for
adaptive
equipment
and
providing
assistance
with
eating.
Ensuring
an
appropriate
and
conducive
environment
is
a
team
effort
requiring
the
expertise
of
occupational
and
physical
therapists,
speech-language
pathologists,
pharma-
cists,
and
all
levels
of
nursing
care.
Communication
is
key
to
ensure
that
all
components
of
the
nutrition
intervention
will
be
successful.
These
interventions
are
generally
used
to
address
the
fol-
lowing
types
of
nutrition
diagnoses:
+
Inadequate
energy
intake
+
Unintended
weight
loss
+
Disordered
eating
pattern
+
Self-feeding
difficulty
Nutrition-Related
Medication
Management
During
nutrition
assessment,
each
patient’s
medications
are
evaluated
for
possible
drug—nutrient
interactions.
Chapter
11,
“Pharmacology,”
covers
this
topic
in
depth.
Interventions
can
address
the
effects
of dietary
intake
on
drug
dissolution,
absorption,
metabolism,
and
excretion.
Chapter
4
Nutrition
Intervention,
Nutrition
Monitoring
and
Evaluation
83
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved. May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience,
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
require
it.
Additionally,
interventions
may
target
the
effects
of pre-
scribed
drugs
on
nutrient
ingestion,
absorption,
metabo-
lism,
and
excretion.
The
RDN
may
also
be
involved
in
the
coordination
of
medications
with
meal
planning.
A
common
example
would
be
the
development
of
insulin-to-carbohydrate
ratios
as
the
RDN
assists
the
patient
with
the
more
complex
components
of
medical
nutrition
therapy
for
diabetes
(see
Chapter
17).
Another
example
would
be
the use
of
pancreatic
enzyme
dos-
ages
with
meals.
The
RDN
provides
specific
instructions
for
dosing
of
enzymes
for
individuals
with
cystic
fibrosis
or other
conditions
of
pancreatic
insufficiency.
Chapter
15
discusses
the
role
of
pro-/prebiotics
as a
complement
to
other
nutrition
therapies
and
medical
care
for
a
number
of
GI
conditions—
just
one
more
example
of
the
crucial
role
the
RDN
plays
in
coordination
of
patient
care.
For
patients
who
are
unable
to eat
enough
food
to
main-
tain
their
weight,
it
is
necessary
to
identify
other
factors
that
impair
intake.
Non-nutritional
causes
of
poor
intake
range
from
poorly
fitting
dentures
to
lack
of
interest in
unfamiliar
foods
to
depression.
If
these
factors
cannot
be
resolved
and
poor
intake
persists,
drugs
that
stimulate
appetite
are
some-
times
ordered.
These
drugs,
including
megestrol
acetate
and
dronabinol,
are available
by
prescription.!!"”
Like
all
drugs,
appetile
stimulants
can
produce
significant
side
effects
in
some
patients.
Megestrol
acetate
has
been
shown
to
improve
appe-
tite
and
increase
weight,
especially
in
patients
experienc-
ing
anorexia-cachexia
syndrome.
The
drug
is
expensive,
however—it
can
cost
several
hundred
dollars
per
month.
Moreover,
a
recent
review
found
that
the
use
of
this
drug
was
associated
with
an
increased
risk
of
blood
clots,
sudden
diffi-
culty
in
breathing,
and
fluid
retention.
Approximately
one
in
four
patients
will
experience
an
increase
in
appetite
and one
in
12
will
gain
weight
while
taking
megestrol
acetate.
Data
on
the
long-term
safety
of
its
use
are
limited.!?
Dronabinol
is
a
derivative
of
marijuana
that
may
improve
appetite,
but
it
has
not
been
associated
with
weight
gain.
Dronabinol
is
expensive,
and
users
have
experienced
nausea,
vomiting,
and
mental
status
changes, including
euphoria
and
somnolence.
As
new
information
becomes
available,
drug
doses
may
change.
Thus,
recommendations
to
use
appetite
stimulants
should be
preceded
by
a
discussion
with
a
phar-
macist
on
your
health
care
team
and
a
thorough
review
of
updated
dosing
and
complication
information
from
reliable
sources
such
as
Drug
Facts
and
Comparisons"
or
the
Ameri-
can
Hospital
Formulary
Service’s
AHFS
Drug
Information.““'5
For
more
information
on
appetite
stimulants
and
other
inter-
ventions,
see
Chapters
22
and
23.
Common
examples
of
nutrition
diagnoses
for
which
nutrition-related
medication
management
might
be used
include
the
following:
+
Altered
GI
function
+
Impaired
nutrient
utilization
+
Altered
nutrient-related
laboratory
values
+
Food—medication
interaction
84
Part
2
The
Nutrition
Care
Process
4.4
NUTRITION
EDUCATION
In
addition
to
the
many
types
of
nutrition
interventions
that
focus
on
the
delivery
of
food
and/or
nutrients
and
the
prevention
of
malnutrition,
the
RDN
also
provides
nutrition-
related
information
to
patients
and
clients
in
order
to
change
or
reinforce
eating
behaviors.
This
can
be
provided
as
either
nutrition
education
or
nutrition
counseling;
however,
it
is
important
to
recognize
that
these
are
very
different
processes.
Nutrition
education
focuses
“on
instruction
or
training
intended
to
lead
to
nutrition-related
knowledge”
and/or
“instruction
or
training
intended
to
lead
to
nutrition-
related
result
interpretation
and/or
skills’?
Nutrition
counseling
typically
involves
more
in-depth behavior
change
strategies.
Both
nutrition
education
and
nutrition
counseling
are
intended
to
maintain
or
improve
health.
Nutrition
counseling
is
discussed
in
further
detail
in
the
next
section
of
this
chapter.
Opportunities
for
providing
education
to
patients
and
clients
arise in
nearly
every
encounter
and
with
nearly
every
nutrition
diagnosis.
Nutrition
education
may
occur
in
a
variety
of
environments
or
through
vari-
ous
mediums
including
a group
class,
individual
instruc-
tion,
written
instructions,
or
via
telephone
or
electronic
communication.
The
acute
care
setting
is
certainly
not
as
conducive
to
education
as
the
outpatient
setting
can
be.
Unfortunately,
many
patients
will
have
contact
with
the
RDN
only
while
hos-
pitalized.
Furthermore,
illness,
pain,
and
an
uncomfortable
environment
can
hinder
the
educational
process.
It
is
also
difficult
to
adjust to
illness
and
even
more
difficult
to
under-
stand
numerous
pieces
of
information
from
a
variety
of
indi-
viduals.
If
adequate
education
or
follow-up
is
needed,
referral
to
an
outpatient
RDN
is
optimal.
While
in
the
hospital,
the
RDN
may
initially
provide
basic
education
that
will
allow
the
patient
to
develop
“survival
skills”
until
further
education
is
available.
Basic
guidelines
for
providing
nutrition
education
regardless
of
the
setting
or
diagnosis
include
the
following:
«
Clearly
communicate
the
purpose
of
the
education.
+
Prioritize
the
nutrition
issues
or
problems
so
that
educa-
tion
is
not
too
complex.
+
Explain
the
relationship
of
nutrition
to
health/disease.
+
Tailor
the
education
to
fit
the
individual
patient
by
under-
standing
his
or
her
level
of baseline
knowledge,
skills,
and
learning
style.
The
goal
of
both
types
of
nutrition
education
is
for
the
patient
to
make
appropriate
dietary
and
nutrition-
related
changes
that
promote
positive
health
and
nutrition
outcomes.
The
skills
and
resources
needed
by
the
RDN
include
effective
communication,
use
of
terms
that
can
be
understood
by
patients,
appropriate
reading
materials,
visual
aids
to
support
the
verbal
information
provided,
and
sensitive listening
skills.
Box
4.3
provides
an
overview
of
writing
skills
required
for
developing
nutrition
education
materials.
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
i
BOX
4.3
CLINICAL
APPLICATIONS
Writing
for
Nonmedical
Audiences:
Instructional
Materials
for
Patients,
Their
Families,
and
the
Public
Ralph
G.
Nelms,
PhD
Wright
State
University
Writing
to
the
community
of health
professionals
within
your
institution
or
agency
will
become
easier
with
practice.
But
writing
for
other
health
professionals
is
not the
only
kind of
writing
you
may
be
called
on
to
do.
You
may
also
find
your-
self
writing
for
various
nonprofessional
audiences,
including
the
public
in
general.
This
section
describes
some
of
the
most
common
of
these
forms
of
writing.
The
purpose
of
these
materials
is
to
inform,
sometimes
with
the
goal
of
persuading
the
reader
to
take
action,
if
necessary,
after
reading
the
material.
Examples
include
informational
mate-
rial
outlining
nutrition
therapies
and
lifestyle
changes.
The
audience
for
such
materials
obviously
differs
greatly
from
the
professional
audience
that charting
addresses.
You
should
avoid
most
medical
abbreviations
because
your
readers
will
simply not
be
familiar
with
them.
You
cannot
use
professional
or
even
academic
jargon.
Words
such
as
data
will
need
to
be
replaced
with
more
generally
under-
stood
words
such
as
information.
In
other
words,
use
commonsense
language.
Remember,
the
goal
here
is
to
instruct.
Your
reader
cannot
be
instructed
if
sne
or
he
cannot
understand
what
is
being
said.
Establish
the appropriate
reading
level
and
even
have
a
member
of
your
target
audience
evaluate
your
instructional
material.
Tips
for
Writing
Instructional
Materials
Ask
nonprofessionals
you
know
to
give
you
feedback
on
the
instructional
mate-
rials
you
write
before
you
prepare
them
for
distribution
so
that
you
can
revise
the
text
if
it
is
unclear
to
your
test
audience.
You
can
also establish a
focus
group
that
is
representative
of
your
intended
audi-
ence
for
the
purpose
of
evaluating
and
responding
to
your
writing.
Their
insight
can
help
ensure
that
you
will
meet
the
audience's
needs.
Use
numbering
and
bullets
to
create
easy-to-read
lists.
As
a
model,
consider
the
way
bullets
and
numbers
are
used
in
this
textbook.
Spend
time
planning
the
document
you
want
to
produce
before
beginning
to
actually
write
it.
Put
together
a
rough
plan
for
organizing
the
information.
This
prewriting
planning
will
make
writing
a
lot
easier.
Leave
yourself
plenty
of
time
to
revise
the
document
once
it
is
drafted.
Read
through
it
first
to
make
sure
you
included
all
the
information
(the
content)
that
you
planned
to
convey.
Read
through
it
a
second
time
to
make
sure
that
the
organization
makes
sense—that
informa-
tion
introduced
early
in
the
document,
for
example,
is
explained
immediately
rather
than
much
later
in
the
document.
Read
through
the
document
a
third
time
to
check
the
language
and
make
sure
it
is
understandable
to
your
audience.
Make
sure
you
check
your
spelling,
too.
A
warning:
There
is
one
important
similarity
between
writing
to
professional
peers
and
writing
to
nonmedical
profes-
sionals:
the
need
for
clarity.
Sometimes,
when
shifting
from
technical
writing
intended
for
the
professional
community
to
writing
for
nonprofessionals,
writers
also
shift
from
an
ideal
of
clarity
in
their
writing
to
an
ideal
of
eloquence.
Elo-
quence
is
fine for
novelists,
but
it
is
irrel-
evant
here.
Be
clear,
be
concise,
and
use
language
appropriate
for
your
audience.
4.5
NUTRITION
COUNSELING
Nutrition
education
and
nutrition
counseling
share
the
com-
mon
goal
of
assisting the
patient
to
make
appropriate
diet
and
lifestyle
changes
to
improve
his
or
her
health
and
nutrition
status.
Nonetheless,
there
are
significant
differences
in
how
education
and
counseling
are
provided.
As
discussed
previ-
ously,
nutrition
education
primarily
involves
the
transfer
of
knowledge
and/or
skill
building.
That
does
not
imply
that
nutrition
education
isn’t
important
or
relevant;
however,
hav-
ing
information
and/or
knowing
how
to
complete
a
specific
task
such
as
label
reading
or recipe
modification
alone
does
not
necessarily
translate into a behavior
that
is
sustainable.
In
other
words,
“knowing
is
not
always
doing.’
Nutrition
coun-
seling
is
defined
as:
“A
supportive
process,
characterized
by
a
collaborative
counselor—patient/client
relationship
to
estab-
lish
food,
nutrition
and
physical
activity
priorities,
goals,
and
individualized
action
plans
that
acknowledge
and
fos-
ter
responsibility
for
self-care
to
treat
an
existing
condition
and
promote
health.”
The
role
of
the
RDN
as
counselor
has
evolved
from
that
of
a
clinician
who
mainly
provides
infor-
mation
on what
and
how
to
eat
to
that of
one
who
is
able
to
evaluate
and
take
into
consideration
the
complex
social
and
physiological
factors
that
influence
food
and
lifestyle
choices.
It is
important
that
the
counselor
develop
collaborative
rela-
tionship
with
the
patient/client
that
enables
careful
examina-
tion
of
nutrition
problems
to
establish
goals
and
plans.
The
ultimate
goal
of
counseling
is
for
the
patient/client
to
take
responsibility
for
behaviors
that
improve
his
or
her
nutri-
tional
status
in
order
to
treat
an
existing
condition
and
pro-
mote
health.
Counseling
Skills
Effective
nutrition
counseling
is
greatly
influenced
by
the
relationship
between
the
patient/client
and
the
dietetic
prac-
titioner,
as
illustrated
in
the
central
core
of
the
Nutrition
Care
Model
(see
Chapter
2).
The
definition
of
nutrition
counsel-
ing
in
the
standardized
nutrition
intervention
terminology
supports
the
importance
of
this
relationship
by noting
the
Chapter
4
Nutrition
Intervention,
Nutrition
Monitoring
and
Evaluation
85
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience,
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
i.
following
important
assumptions
and
characteristics
of
the
role
of
the
RDN
as
counselor:
Supportive:
The
counselor’s
role
is
to
encourage
and
positively
guide
the
patient
as
changes
are
made.
Being
a
champion
of
change
and
advocating
for
the
benefits
of
a
healthy
lifestyle
can be
especially
useful
to
patients
who
are
undergoing
dietary
changes.
Process:
Counseling
is
not
a
one-time
encounter
in
which
everything
important
about
nutrition can be
explained.
Counseling
is
a
process
that
involves
important
follow-up
and
continued
contact
in
order
to
be
most
effective.
The
AND's
“Evidence-Based
Guidelines
for
Medical
Nutrition
Therapy
for
Diabetes
Mellitus
(DM)”
conclude
that
there
is
strong
support
for
the
effectiveness
of
an
initial
series
of
three
to
four
encounters
with
an
RD/RDN,
each
lasting
45-90
minutes.
These
encounters should be
completed
within
3-6
months
of
diagnosis
of
DM.
Furthermore,
at
least
one
follow-up
encounter
is
recommended
annually
to
reinforce
lifestyle
changes
and
to
evaluate
and
monitor
progress.'®
Collaborative:
Because
effective
counseling
requires
working
together
with
the
patient/client
as
a
partner
to
solve
problems,
the
role
of
the
counselor
is
more
subor-
dinate
than
authoritarian.
Changes
are
more
likely
to
be
made
when
the
patient
values
the
benefits
of
the
change
and
can
take
personal
ownership
rather
than
only
being
told
what
to
do.
Relationship:
Developing
a
professional
relationship
with
the
patient/client
that
is
built
on
trust
and
honesty
is
extremely
valuable.
Sharing
information
about
one’s
dietary
and
lifestyle
behaviors
is
very
personal.
Many
persons
are
already
aware
that
some
of
their
practices
are
not
necessarily
beneficial
to
health,
and
they
may
feel
ashamed
or
fear
being
judged
when
answering
diet
history
questions.
Therefore,
characteristics
and
communication
skills
that
demonstrate
good
listening
and
acknowledg-
ment
of
the
client
are
essential
to
building
trust
and
pro-
moting
openness.
Tables
4.5
and
4.6
illustrate
many
of
these important
characteristics
and
communication
skills.
Individualized:
Unlike
nutrition
information
that
describes
healthy
eating
guidelines
for
a
group
or
popula-
tion,
such
as
the
Dietary
Guidelines
for
Americans,
nutri-
tion
counseling
can
take
on
many
different
shapes
and
forms,
based
on
well-known
and
researched
counseling
theories
and
strategies
that
are
tailored
to
an
individual's
needs
and
environment.
Self-care:
Even
though
the
nutrition
counselor
is
a
cham-
pion
of
change
and
partner
in
this
process,
the
long-term
expectation
is
that
the
client
him-
or
herself
will
be
able
to
maintain
appropriate
changes
and
solve
problems
in
order
to
make
the
diet
and
lifestyle
choices
long
lasting.
That
does
not
limit
the
opportunity
for
ongoing
support
and
follow-up
by
the
counselor
in
order
to
evaluate
and
monitor
progress.
As
important
as
building
a
positive
relationship
and
demonstrating
active
listening
are,
it is
equally
important
Part
2.
The
Nutrition
Care
Process
Table
4.5
Characteristics
of
Counselors
That
Promote
a
Positive
Relationship
Behave
naturally:
Appear
authentic
and
sincere;
encourages
sponta-
neity
and
openness
on
the
part
of
the
client.
Have
a
sense
of
humor:
Helps
the
client
to
not
take
problems
too
seriously;
helps
break
down
barriers
between
the
counselor
and
the
dient.
©
Be
flexible:
Do
not
have
unrealistic
expectations.
Be
optimistic
and
hopeful:
Clients
respond
well
and
appreciate
the
support.
Encourage
clients
to
talk:
They
may
not
have
had
opportunities
to
in
the
past;
provide
verbal
and
nonverbal
responses
such
as
nods
and
occasional
“hmms.”
¢
Maintain
appropriate
eye
contact:
Look
at
clients
but
do
not
stare.
*
Develop
attentive
body
language:
Use
relaxed
gestures
and
sit
or
stand
with
an
open,
welcoming,
and
calm
posture.
©
Listen
with
an
open
mind
and
spirit
of
inquiry:
Be
sure
that
responses
and
nonverbal
language
are
not
judgmental.
©
Respect,
value,
care,
and
trust
others:
Conveys
the
message
that
cli-
ents
are
valued
and
respected.
Source:
Adapted
from
Bauer
K,
Liou
D,
Sokolik
C.
Nutrition
Counseling
and
Education
Skill
Development.
2nd
ed.
Belmont,
CA:
Cengage;
2012.
Table
4.6
Effective
Communication
Skills
That
Demonstrate
Active
Listening
and
Undivided
Attention
to
Clients
Clarifying
(Probing):
Confirm
the
accuracy
of
a
client's
statement
by
asking
a
question
or
prompting
the
client
to
continue
talking.
¢
"Can
you
explain
further.
.
.?”
¢
“Tell
me
more
about...”
Paraphrasing
(Summarizing):
Lets
clients
know
that
the
counselor
is
listening;
allows
the
cient
to
clarify
any
misunderstanding.
©
“Let
me
summarize
wnat
|
think
you
just
said...”
Responding
with
empathy:
Demonstrates
that
a
counselor
under-
stands
what
a
person
feels
from
their frame
of
reference;
clients
can
feel
they
are
no
longer
alone.
It
is
not
effective
to
simply
state
that
you
know
how
another
person
feels.
“It
sounds
like...”
©
“It
seems
like...”
Conveying
respect:
Show
consideration
and
appreciation
for
the
time
and
information
that
the
client
shares.
¢
"lam
impressed
with
how
you...”
¢
“You have
done
a
great
job
of
..
.”
Source:
Adapted
from
Bauer
K,Liou
D,
Sokolik
C.
Nutrition
Counseling
and
Education
Skill
Development.
2nd
ed.
Belmont,
CA:
Cengage;
2012.
to
obtain
adequate
and
accurate
information
from
patients
and
clients.
Therefore,
developing
communication
skills
of
inquiry
and
appropriate
questioning
techniques
such
as
motivational
interviewing
are
also
essential
for
the
counselor.
Examples
ofthese
types
of
questions
and
skills
are
summa-
rized
in
Box
4.4.
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
require
i
BOX
4.4
CLINICAL
APPLICATIONS
Effective
Communication
Skills
for
Obtaining
Accurate
Information
from
Clients
Questioning
When
used
appropriately,
questioning
can
be
very
effective;
however,
it
is
important
to
know
when
to
ask
a
question
and
what
type
of
question
best
meets
the
need
of
inquiry
at
a
particular
point
in
time
during
the
interview
or
counseling
session.
As
a
general
rule,
it
is
advisable
to
avoid
questions
that
begin
with
“why,”
as
they
are
often
perceived
as
judgmental
and
accusatory.
Clients
can
become
defensive
and
less
willing
to provide accurate
and
truthful
information
if
they
feel
that they
need
to
defend
their
answer. Following
are
examples
of
common
types
of
ques-
tions
used by
nutrition
counselors:
¢
Closed-ended
questions:
Questions
designed
to obtain
either
a
yes
or
no
response
or
a
very
brief
answer.
It
is
gen-
erally
recommended
that
use
of
this
type
of
question
be
limited,
as a
closed-ended
question
tends
to
prompt
a
response
the
client
thinks
is
correct
or
preferred.
¢
Examples
of
how
these
questions
may
begin:
"is,"
“are,” “did,”
“how
many”
°¢
Open-ended
questions:
Although
these
types
of
questions
are
valuable
in
that
they
allow
the
responder
to
provide
a
great
deal
of
information
and
do
not
limit
a
response
to
a
short
answer,
they
do
require
that
the
counselor
listen
very
carefully
to
what
is
being
said.
Answers
may
become
lengthy
and
it
may
be
necessary
to
redirect
the
client.
The
major
advan-
tage
to
using
open-ended
questions
is
that
clients
are
less
likely
to
feel
threat-
ened
and
more
likely
to
provide
honest
responses.
They
may
also
provide
information
that
guides
appropriate
secondary
and
probing
questions.
e
Examples of
how
these
questions
may
begin:
“how,”
“what”
Secondary
questions:
These
are
questions
that
stem from
information
that
has
been
provided
by
the
client,
about
which
further
detail
is
needed.
These
types
of
questions
are
very
sim-
ilar
to
the
clarifying
or
probing
ques-
tions
described
in
Table
4.6.
¢
Examples
of
how
these questions
may
begin:
“tell
me
more,”
“can
you
explain
further”
Funneling
questions: These
are
ques-
tions
that
are
logically
arranged
so
that
a
broad
topic
is
first
introduced
and
then
subsequent
questions
narrow
the
subject
or topic
into
more
specific
and
detailed
information.
Unlike
secondary
questions
that
can
be
asked
at
any
point
in
the
interview,
funneling
questions
assume
a
more
logical
and
sequential
order.
¢
Examples
of
how
these questions
may
be
structured:
e
“What
is
your
usual
meal
and
snack
pattern
throughout
the
day?”
e
“Given
that
you
generally
eat
lunch
at
work,
what
would
you
typically
have?”
e
"What
kind of salads
and
dress-
ings
are
you
likely
to
purchase
at
work?”
Giving
Feedback
or
Noting
Discrepancies
Occasionally
it
is
necessary
to
confront
a
client
who
may
be
providing
information
that
is
either
inconsistent
or
contradictory
or
excuses
for
not
making
changes.
This
form
of
questioning
is
especially
valuable
if
a
client
is
in
denial
or
is
expressing
resistance
to
change.
Bauer
et
al.
note
a variety
of
ways
that
the
counselor
can
bring
these
discrepancies
to
the
attention
of
the
client.
¢
State
an
observation
without
adding
“but”;
use
“and”
as
the
connector.
Following
the
“and”
is
the
observation
of
the
discrepancy.
¢
Begin
the
statement
with
“on
the
one
hand
..
.on
the
other
hand...”
¢
Directly
say
“|
see/hear
an
inconsis-
tency...”
Adapted
from
Bauer
K,
Liou
D,
Sokolik
C.
Nutrition
Counseling
and
Education
Skill
Devel-
opment.
2nd
ed.
Belmont,
CA:
Cengage;
2012.
Theoretical
Basis/Approach
for
Nutrition
Counseling
Counseling
Strategies
The
foundation
and
supporting
principles
used
to
facilitate
behavior
change
in
nutrition
counseling
draw
from
numer-
ous
areas
of
research
within
the
realms
of
education
and
psychology.
Behavior
change
theories
and models
provide
a
research-based
rationale
for
designing
and
tailoring
nutri-
tion
interventions
to
achieve
the
desired
effect.
For
exam-
ple,
if
during
a
nutrition
assessment
interview
the patient
acknowledges
that
he
or
she
does
not
believe
that
making
significant
behavior
changes
will
result
in
a
better
health
outcome,
principles
of
the
health
belief
model
as
well
as
awareness
of
the
stages
of
change
should
influence
how
the
counselor
proceeds
and what
type
of
information
is
appro-
priate
to
promote
a
change
in
belief
and
movement
to
the
next
stage
of
change.
Table
4.7
provides
a
summary
of
the
major
theories
that
support
nutrition
education
and
coun-
seling
methods.
RDNs
can
and
should
use
a
number
of
strategies
to
assist
the
client
in
achieving
healthful
behavior
change.
Whereas
a
theo-
retical
basis
provides
guidance
to
better
understand
a
person's
motivation
and
readiness
to
change,
strategies
are
the
tools
that
can
help
facilitate
change.
Strategies
include
motivational
interviewing,
self-monitoring,
and
cognitive
restructuring.
For
example,
the
major
motivational
strategies
are
giving
advice,
identifying
and
removing
barriers,
providing
choices,
decreasing
desirability
of
a
present
behavior,
practicing
empathy,
providing
feedback,
clarifying
goals,
and
active
helping.
Self-monitoring
may
include
using
a
food
diary
to
increase
the
client’s
awareness
of
actual
food
intake.
Cognitive
restructuring
teaches
the
client
appropriate
steps
in
addressing
failures
in
behavior
change.
Pro-
viding
positive
approaches
to
particular
dietary changesfacili-
tates
the
client's
efforts
to
deal
with
problem
behaviors.”
Boxes
4.5
and
4.6
explore
the
unique
attributes
of
nutrition
education
and
counseling
for
pediatric
and
geriatric
patients.
Chapter
4
Nutrition
Intervention,
Nutrition
Monitoring
and
Evaluation
87
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience,
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
i
3.4
FOOD-
AND
NUTRITION-RELATED
HISTORY
Typically,
food
and
nutrition
information
is
assessed
either
by
collecting
data
retrospectively
or
by summarizing
data
gathered
prospectively.
All
methods
have
their
own
strengths
and
limitations.
The
accuracy
(or
validity)
of the
information
and
the
reliability
of
the
data
depend on
the
experience
and
skill
of
the
clinician,
the
cooperation
and
accurate
reporting
of the
client,
and
the
type
of
assessment
instrument
that
is
used.
Assessment
instruments
vary
by
the
time
frame
assessed,
the
time
that
it
might
take
to
collect data,
the
need
for
an
individual's
memory
to
be
specific
in
nature,
and
the
need
for
a
higher
cognitive
ability.
Information
gathered
will
include,
for
example,
dietary
intake,
food
preparation,
timing
of
meals,
and
meal
environment
and
may
also
include
physical
activity
or
exercise
(PA)
patterns.
There
are
numerous
web-
based
assessment
tools
such
as
the
ASA24
from
the
National
Cancer
Institute.
Demonstration
of
the
ASA24
can
be
found
at
https://asa24.nci.nih.gov/demo/.
The
ultimate
goal
of
collecting
dietary
information
is
to
determine
the
nutrient
content
of
food
that
is
consumed
and
then
compare
this
to
standard
guidelines
appropriate
for
that
individual.
Nutrition
Care
Indicator:
Twenty-Four-Hour
Recall
When
using
a
24-hour
recall
as
the
dietary
assessment
method, the
clinician
guides
the
client
through
recall
of
all
food
and
drink
that
has
been
con-
sumed
in
the
previous
24-hour
period
(see
Figures
3.4
and
3.5).
The
clini-
this
method
can
be
strengthened
by
the
use
of
photographs,
digital
images,
food
models,
or
serving
containers
to
improve
recall
of
portion
sizes.1718
Figure
3.4
Data
Collection
A
Registered
Dietitian
Nutritionist
and
client
review
a
24-hour
recall
during
a
nutrition
counseling
session.
Source:
Courtesy
of
Marcia
Nelms.
Figure
3.5
24-Hour
Recall
Form
cian asks
what
food
or
beverage
was
consumed
most
recently
prior
to
the
interview
and
then
works
in
reverse
order
through
the
previous
24
hours.
The
clinician
can
question
the
client
24-hour
recall
Date:
Patient
Name:
about
activities
during
the
period
in
order
to
stimulate
the
client’s
mem-
ory.
At
the
end
of
the
recall,
the
cli-
nician
reviews
the
information
to
verify
serving
sizes
and
preparation
methods
and
asks
for
clarification
if
needed.
The
USDA
multiple-pass
approach,
a
variation
of
this
method,
Sample
Protocol
for
Completion
of
24-Hour
Recall
is
a
widely
accepted
and
validated
1.
The
24-hour
recall
consists
of
obtaining
information
for
food
and
fluid
intake
for
the
24-hour
method
that
includes
five
standard-
ized
reviews
of
information.!3-1¢
period
preceding
the
interview.
It
is
assumed
that
this
is
a
“typical”
day.
If
not,
clarify.
2.
Patient
may
not
be
able
to
remember
all
foods
eaten.
Begin
by asking
the
sequence
of
Advantages
of
the
24-hour
recall
method
include
short
administration
time,
minimal
cost,
and
negligible
risk
for
the
client.
One
disadvantage
is
that
a
24-hour
recall
does
not
always
reflect
typical
eating
patterns,
since
day-to-day
dietary
intake
may
vary
considerably.
A
second
disadvantage
is
that
clients
may
report
information
they
feel
the
clinician
wants
to
hear.
Research
indicates
clients
may
over-
or
underreport
their
intake.
Reliance
on
the
client’s
memory
also
may
impact
the
accuracy
of the
data.
Accuracy
of
events
for
the
previous
24
hours.
For
example,
“Before
speaking
with
me
today,
when
was
the
last
time
you
ate
or
drank
anything?”;
“What
was
that
__?”;
“How
much
did
you
eat
of
2”
Then
proceed
backward
from
that
time
for
the
entire
24-hour
period.
3.
Use
food
models
and
food
containers
to
assist
patients
in
clarifying
the
serving
amounts.
4.
A
checklist
may
help
the
interviewer
remember
to
ask
or
probe
all
information
for
each
food
or
beverage.
Components
of
24-hour
recall:
¢
Note
the
time
the
food
or
beverage
was
consumed.
+
Record
the
food
or
beverage.
¢
Determine
serving
size
for
food
or
beverage.
*
Determine
how
the
food
was
prepared.
¢
Determine
where
the
patient
had
the
food
or
beverage
item.
¢
Include
any
relevant
notes
to
the
food
or
beverage
report.
Chapter
3
Nutrition
Assessment:
Foundation
of
the
Nutrition
Care
Process
45
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
learning
experience.
Cengage
Learning
reserves
the
right
toremove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
it,
Nutrition
Care
Indicator:
Food
Record/Food
Diary
In
this
method,
the
client
documents
his
or
her
dietary
intake
as
it
occurs
over
a
specified
period
of time.
Typically,
the
record
is
kept
over
a 3-
or
5-day
period
(see
Figure
3.6)
and
should
include
a
sampling
of
both
weekdays
and
weekends.
Clients
estimate
or
measure
their
food
intake.
The
advantage
of
this
method
is
that
it
is
not
totally
reliant
on
the
client’s
memory
and
may
be
much
more
representative
of
the
client’s
actual
intake.
Validity
may
be
low,
however,
because
under-
reporting
is
common,
and
the
client
may
change
food
habits
for
the
recording
period.
Accuracy
is
dependent
on
the
client
accurately
reporting
typical
daily
intakes.
Additionally,
there
is
a
heavier
burden
on
the
client,
who
must
make
a
commit-
ment
to
record
his
or
her
intake.
Many
online
tools
and
appli-
cations
have
been
developed
to
assist
the
individual
client
in
preparing
a
food
record
or
tracking
their
intake
electronically,
such
as
“My
Fitness
Pal™?!°
Figure
3.6
Food
Diary
Nutrition
Care
Indicator:
Food
Frequency
The
food
frequency
data
collection
method
is
a
retrospec-
tive
review
of
specific
food
intake.
Foods
are
organized
into
groups,
and
the
client
identifies
how
often
and
in
what
quantities
he
or
she
consumes
a
specific
food
or
food
group
(see
Figure
3.7).
The method
can
be
self-administered.
Many
food
frequency
instruments
are
specialized
and
validated
to
identify
food
group
intake
for
certain
disease
states
such
as
cardiovascular
disease
(see
Tables
13.10
and
13.11) or
designed
for
use
with
specific
populations.
This
is
the
data
collection
method
used
in
the
National
Health
and
Nutri-
tion
Examination
Survey
(NHANES)
dietary
assessment
and
by
the
MEDFICTS
questionnaire
shown
in
Figure
3.7.
Food
frequency
data
can
be
collected
via
online
applications
using
both
narrative
and
pictorial
representations
of
foods
and
quantities.
Advantages
of
this
methodology
are
that
it
is
inexpen-
sive
and
requires
minimal
time
to
administer.
Disadvantages
Date/Time
List
all
foods
and
drinks
Amount/serving
size
Preparation/
cooking
method
Where
did
you
eat?
Who
were
you
with?
Seasonings/
Condiments
Directions
for
Use
of
Food
Diary
READ
THE
FOLLOWING
INSTRUCTIONS
CAREFULLY
Record
amounts
and
descriptions
of
ALL
food
and
drink (including
water)
for
three
consecutive
days.
These
days
should
be
“typical”
to
the
way
you
eat
on
a
normal
basis.
Please
do
not
try
to
change
your
eating
habits
on
the
days
you
are
recording.
Please
pick
two
weekdays
and one
weekend
day
that
are
most
like
your
usual
daily
intake.
Helpful
Hints:
*
Record
your
intake
immediately
after
you have
eaten
and
NOT
at
the
end
of
the
day.
This makes
it
much
easier
to
remember
and
to
record
accurately.
*
Include
all
meals
and
snacks, granola
bars,
sandwiches,
chocolate,
sweets,
ice
cream,
fruits—whatever
you
eat.
*
Include
all
drinks
(e.g.,
water,
tea,
coffee,
beer,
sports
drinks,
and
fruit
juice).
*
Record any
additions
to
food
such
as
mustard,
ketchup,
mayonnaise,
cream
or
sugar,
steak
sauce,
salsa,
dressings,
gravy,
pickles,
honey,
or
butter.
Describe
foods
accurately:
*
Record
cooking
methods
(e.g.,
fried,
baked,
broiled,
grilled,
frozen,
canned,
added
water,
low
sodium,
and
the
amount
of
fat
or
oil
used
for
cooking).
*
Record
brand
names
and
the
descriptions
(e.g.,
KRAFT,
General
Mills,
Breyers,
Campbell's,
Del
Monte,
and
whether
regular,
2%
reduced
fat,
light,
fat
free,
low
carb,
or
sweetened).
«
Name
the
types
of
cheese,
fish,
or
meat
(e.g.,
cheddar,
American,
cod,
tilapia,
ground,
sirloin,
shredded).
Describe
the
amounts
as
accurately
as
possible:
*
To
help
with
measuring
portion
size,
try
to
avoid
terms
such
as
“one
bowl”
or
“a
handful.”
*
Visualize the
following
comparisons
when
figuring
portion
size:
*3
ounces
of
meat
is
about
the
size
of
a
deck
of
cards
or
audiotape
cassette.
+A
medium-size
piece
of
fruit
is
about
the
size
of
a
tennis
ball.
* 1
ounce
of
cheese
is
about
the
size
of
4
stacked
dice.
*
1/2
cup
of
ice
cream
is
about
the
size
of
a
tennis
ball
* 1
cup
of
mashed
potatoes
or
broccoli
is
about
the
size
of
your
fist.
* 1
teaspoon
of
butter
is
about
the
size
of
the
tip
of
your thumb.
*
Use
weights
marked
on
packages
(e.g.,
half
of
a
425-gram
can
of
cor,
half
of
a
16-ounce
can,
half
of
a
6-ounce
bag
of
frozen
corn).
*
Use
cups,
teaspoons,
and
tablespoons
to
record
amounts.
46
Part
2.
The
Nutrition
Care
Process
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience,
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
require
i
Figure
3.7
Example
of a
Food
Frequency
Instrument:
MEDFICTS
In
each
food
category
for
both
Group
1
and
Group
2
foods
check
one
box
from
the
“Weekly
Consumption” column
(number
of
servings
eaten per
week) and
then
check
one
box
from
the
“Serving
Size”
column.
If
you
check
Rarely/Never,
do
not
check
a
serving
size
box.
See
next
page
for
score.
Weekly
Consumption
Serving
Size
Sor
less
4or
more
Rarely/
never
Small
1pt
Average
Large
<5
oz/d
5
oz/d
2pts
>5
oz/d
3pts
Food
Category
Meats
e
Recommended
amount
per
day:
5 oz
(equal
in
size
to
2
decks
of
playing
cards).
°
Base
your
estimate
on
the
food
you
consume
most
often.
°
Beef
and
lamb
selections
are
trimmed
to
1/8"
fat.
Group
1.
10
g
or
more
total
fat
in
3 oz
cooked
portion
Beef—Ground
beef,
Ribs,
Steak
(T-bone,
Flank,
Porterhouse,
Tenderloin),
Chuck
blade
roast,
Brisket,
Meatloaf
(w/ground
beef),
Corned
beef
Processed
meats—1/4
|b
burger
or
Ig.
sandwich,
Bacon,
Lunch
meat,
Sausage/knockwurst,
Hot
dogs,
Ham
(bone-end),
Ground
turkey
Other
meats,
Poultry,
Seafood—Pork
chops
(center
loin),
Pork
roast
(Blade,
Boston,
Sirloin),
Pork
spareribs,
Ground
pork,
Lamb
chops,
Lamb
(ribs),
Organ
meatst,
Chicken
w/skin,
Eel,
Mackerel,
Pompano
Group
2.
Less
than
10
g
total
fat
in
3 oz
cooked
portion
Lean
beef—Round
steak
(Eye
of
round,
Top
round),
Sirloin*.
Tip
&
bottom
round?,
Chuck
arm
pot
roastt,
Top
Loint
Low-fat
processed
meats—Low-fat
lunch
meat,
Canadian
bacon,
“Lean”
fast
food
sandwich,
Boneless
ham
Other
meats,
Poultry,
Seafood—Chicken,
Turkey
(w/o
skin)§,
most
Seafoodt,
Lamb
leg
shank,
Pork
tenderloin,
Sirloin
top
loin,
Vealcutlets,
Sirloin,
Shoulder,
Ground
veal,
Venison,
Veal
chops
and
ribs#,
Lamb
(whole
leg,
fore-shank,
sirloin)+
a
3
pts
a a
Tpts
x
1pt
a
2pts
o
3
pts
o
6
pts
Eggs
—
Weekly
consumption
is
the
number
of
times
you
eat
eggs
each
week
Check
the
number
of
eggs
eaten
each
time
Group
2.
Low-fat
ice
cream, Frozen
yogurt
1
2
=3
Group
1.
Whole
eggs,
Yolks
a
go
a a a a
3pts
7pts
x
1pt
2pts 3pts
Group
2.
Egg
whites,
Egg
substitutes
(1/2
cups)
a a a 7
Dairy
Milk—Average
serving
1
cup
Group
1.
Whole
milk,
2%
milk,
2%
buttermilk,
imi
fl (= is
is}
el
Yogurt
(whole
milk)
3pts
7pts
x
1pt
2pts
3
pts
o
ooooo
Group
2.
Fat-free
milk,
1%
milk,
Fat-free
buttermilk,
Yogurt
(Fat-free,
1%
low
fat)
a
oaooo
Cheese—Average
serving
1
oz
3pts
7
pts
x
1pt
2pts
3
pts
Group
1.
Cream
cheese,
Cheddar,
Monterey
Jack,
Colby,
Swiss,
American
processed,
Blue
cheese,
Regular
cottage
cheese
(1/2
cup),
and
Ricotta
(1/4
cup)
oooooo
Group
2.
Low-fat
&
fat-free
cheeses,
Fat-free
milk
mozzarella,
String
cheese,
Low-fat, Fat-free
milk
&
Fat-free
cottage
cheese
(1/2
cup)
and
Ricotta
(1/4
cup)
o
ooooo
Frozen
Desserts—Average
serving
1/2
cup
3pts
7pts
x
1pt
2pts 3pts
Group
1.
Ice
cream,
Milk
shakes
o
oooao
(continued)
Source:
NCEP,
National
Heart,
Lung
and
Blood
Institute,
NIH
Reference:
NIH
Publication
no.
02-5215,
Diet
Appendix
A;
available
from:
https:/Avww.nhlbi.
nih.gov/health-pro/guidelines/current/cholesterol-guidelines/final-report.
Chapter
3
Nutrition
Assessment:
Foundation
of
the
Nutrition
Care
Process
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
require
i
47
Figure
3.7
Example
of a
Food
Frequency
Instrument:
MEDFICTS
(continued)
Weekly
Consumption
Serving
Size
Rarely)
3or 4or
Small
Average
Large
never
less
more
<5
oz/d
5
oz/d
>5
oz/d|
1pt
2
pts
3
pts
Food
Category
Frying
Foods
—
Average
servings:
see
below.
This
section
refers
to
method
of
preparation
for
vegetables
and
meat.
a a
ao
Group
1.
French
fries,
Fried
vegetables
(1/2
cup),
a
a
Fae
ime
oa
Roe
pts
P P
pts pts
Fried
chicken,
fish,
meat
(3
oz)
Group
2.
Vegetables,
not
deep
fried
(1/2
cup),
Meat,
oO
a
a a a a
poultry,
or
fish—prepared
by
baking,
broiling,
grilling,
poaching,
roasting,
stewing:
(3
oz)
Baked
Goods
—
1
Average
Serving
Group
1.
Doughnuts,
Biscuits,
Butter
rolls,
Muffins,
Croissants,
a
Qo Qa
aaa
Sweet
rolls,
Danish,
Cakes,
Pies,
Coffee
cakes,
Cookies
DES
pte
Be
2pts 3pts
Group
2.
Fruit
bars,
Low-fat
cookies/cakes/pastries,
Angel
food
cake,
Homemade
baked
goods
with
vegetable
oils,
o o
a a a a
breads,
bagels
Convenience
Foods
Group
1.
Canned,
Packaged,
or
Frozen
dinners:
e.g.,
3
pts
7pts
*
1pt
2pts
ons
Pizza
(1
slice),
Macaroni
&
cheese
(1
cup),
Pot
pie
(1),
Cream
soups
(1
cup),
Potato,
rice
&
pasta
dishes
with
cream/cheese
sauces
(1/2
cup)
Group
2.
Diet/Reduced
calorie
or
reduced
fat
dinners
(1),
a
a
a
a a
Oo
Potato,
rice
&
pasta
dishes
without
cream/cheese
sauces
(1/2
cup)
Table
Fats—Average
serving:
1
Tbsp
Group
1.
Butter,
Stick
margarine,
Regular
salad
dressing,
a a
a a a a
Mayonaisse,
Sour
cream
(2
Tbsp)
3pts 7pts
*
1pt
2pts
3pts
Group
2.
Diet
and
tub
margarine,
Low-fat
&
fat-free
salad
i)
a a
Qa
a a
dressing,
Low-fat
&
fat-free
mayonnaise
Snacks
Group
1.
Chips
(potato,
corn,
taco),
Cheese
puffs,
Snack
mix,
Nuts
(1
0z),
Regular
crackers
(1/2
oz),
Candy
(milk
chocolate,
3pts
7Tpts
x
1pt
2pts 3pts
caramel, coconut)
(about
1
1/2
oz),
Regular
popcorn
(3
cups)
Group
2.
Pretzels,
Fat-free
chips
(1
0z),
Low-fat
crackers
(1/2
02),
o a
o o o o
Fruit,
Fruit
rolls,
Licorice,
Hard
candy
(1
med
piece),
Bread
sticks
(1-2
pcs),
Air-popped
of
low-fat
popcorn
(3
cups)
‘ - ‘
a
Total
from
page
1
+
Organ
meats,
shrimp,
abalone,
and
squid
are
low
in
fat,
but
high
in
cholesterol.
+
Only
lean cuts
with
all
visible
fat
trimmed.
If
not
trimmed
of
all
visible
fat,
score
as
ifin
Group
1.
Total
from
page
2
¥
Score
pts
if
this
box
is
checked.
-
§
All
parts
not
listed
in
Group
1
have
<10
g total
fat.
Final
Score
To
Score:
For
each
food
category,
multiply
points
in
weekly
consumption
box
by
points
in
serving
size
box
and
record
total
in
score
column.
If
Group
2
foods
checked,
no
points
are
scored
(except
for
Group
2
meats,
large
serving
= 6
pts).
Example:
o o
vw
|o
o
of
21
pts
3pts
7pts
x
1pt
2pts
3pts
———
Add
score
on
page
1
and
page
2
to
get
final
score.
Key:
=70
Need
to
make
some
dietary
changes
40-70
Heart-Healthy
Diet
<40
TLC
Diet
48
Part
2.
The
Nutrition
Care
Process
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
require
i
include
a
tendency
toward
lower
response
rates
because
the
instrument
is
self-administered.
Additionally,
foods
on
the
preprepared
list
may
be
inappropriate
for
the
individual
who
is
completing
the
food
frequency
questionnaire.
The
instru-
ment
may
not
include
ethnic or
child-appropriate
foods
or
quantities
that
are
realistic
for
those
eating
larger
amounts,
such
as
athletes.
Nutrition
Care
Indicator:
Observation
of
Food
Intake/"Calorie
Count”
In
an
acute
care
or
long-term
care
setting,
actual
food
intake
can
be
observed
and
recorded
when
kilocalorie
(kcal)
or
kcal-protein
count
is
ordered.
Specific
procedures
for this
method
vary
from
institution
to
institution.
If
very
detailed
information
is
required,
as in
the
case
of
a
research
or
met-
abolic
study,
food
may
be
weighed
before
and
after
the
meal
is
served.
The
patient’s
food
intake
is
then
calculated
from
differences
between
the
two.
Any
food consumed
by
family
members
or
food
brought
in
from
outside
the
hospital
will
also
need
to
be
recorded.
In
most
institutions,
nursing
or
nutrition
staff
document
what
the
patient
eats
from
meal
trays.
The
RDN
or
registered
dietetic
technician
(NDTR)
then
calculates
nutritional
infor-
mation
such
as
keal
or
protein
content
from
this
information.
If
the
RDN
or
NDTR
collects
this
information,
it
provides
an
excellent
opportunity
to
assess
the
patient’s
understanding
of
any
dietary
interventions
and
to
teach
specific
nutrition
information
such
as
portion
control
strategies
or
nutrient
content
of
the
meal.
This
method
also
allows
the
RDN
or
NDTER
to
establish
rapport
and
determine
food
preferences
and
tolerances.
3.5
EVALUATION
AND
INTERPRETATION
OF
DIETARY
ANALYSIS
INFORMATION
After
data
are
collected
and
analyzed,
it
is
the
clini-
cian’s
job
to
compare
the
information
to
established
sci-
entific
reference
criteria.
These
criteria
may
include
the
individual
patient’s
needs
(based
on
age,
gender,
and
nutri-
tion
assessment)
and
may
be
as
general
as
a
comparison
to
the
U.S.
Dietary
Guidelines
or
as
specific as
milligrams
of
vitamin
C
that
should be
consumed.”°
Limitations
of
each
assessment
method
make
the
assessment
of
intake
an
esti-
mation
rather
than
an
exact
measurement,
but
in
general,
the
appropriate
criteria
are
determined
by
how
the
infor-
mation
will
be
used.
For
example,
in
order
to
determine
whether
an
intervention
to
change
the
patient’s
food
choices
has
improved
intake,
a
direct
observation
of
food
intake
may
be
made
and
then
analyzed
by
simply
estimating
the
energy
value
and
protein
content
of
the
food
recorded,
using
an
established
method
such
as
the
Choose
Your
Foods:
Food
Lists
for
Diabetes.
This
is
the
data
that
can
be
used
to
sup-
port
the
documentation
of
a
nutrition
problem,
shown
in
the
Sample
PES
Statement
box.
Sample
PES
Statement
for
Intake
Domain:
Inadequate
protein
intake
related
to
aversion
to
meat
as
evidenced
by
reported
intake
of
45%
of
estimated
protein
requirements
(70-75
g/day).
Nutrition
Care
Criteria:
Evaluation
and
Interpretation
Using
the
U.S.
Dietary
Guidelines
The
2015-2020
Dietary
Guidelines
for
Americans,
published
by
the
Office of
Disease
Prevention
and
Health
Promotion
of
the
U.S.
Department
of
Health
and
Human
Services
(USDHHS),
provide
general
recommendations
for
dietary
intake
that
promote
health
and
prevent
disease.”°
These
guidelines
are
based
on
decades
of
nutrition
research
and
reflect
the
most
up-to-date
evidence-based
information
supporting
the
understanding
of
nutritional
requirements.
The
guidelines
include
five
broad
recommendations
for
the
general
public
designed
to
promote
healthy
eating
patterns
by
emphasizing
the
choice
of
a
variety
of
nutrient-dense
foods.
The
guidelines
stress
the
importance
of
substituting
health-
ier
food
and
beverage
choices
in
order
to
reduce
intakes
of
added
sugars,
saturated
fats,
and
sodium.
Although
the
U.S.
Dietary
Guidelines
are
an
important
tool
in
nutrition
educa-
tion
and
planning,
they
are
not
the
most
precise
tool
available
for
evaluating
an
individual's
diet,
but
they
do
provide
broad
guidance
and
examples
of
recommended
food
patterns.
Nutrition
Care
Criteria:
Evaluation
and
Interpretation
Using
the
USDA
MyPlate
Tools
Dietary
analysis
using
the
MyPlate
recommendations
can
quantify
food
consumed
from
each
of
the
major
food
groups.”!
These
data
give
the
clinician
an
overview
of
ade-
quacy,
variety,
moderation,
and
balance.
A
food
group—based
analysis
does
not
quantify
macro-
or
micronutrients;
on
the
contrary,
when
one
simply
looks
at
total
energy
and
protein
intakes,
there
is
no
way
to
determine
the
source
of
these
nutrients.
Using
the
USDA
MyPlate
eating
plans
in
conjunc-
tion
with
macronutrient
data
allows
the
overall
quality
of
the
diet
to
be
assessed
(see
Box
3.2).
Nutrition
Care
Criteria:
Evaluation
and
Interpretation
Using
Choose
Your Foods:
Food
Lists
for
Diabetes/Weight
Management
This
method
of
analysis
uses
the
food
lists
established
jointly
by
the
American
Diabetes
Association
and
the
AND.”
Use
of
the
lists
provides
a
quick,
rough
estimate
of
kcal,
protein,
carbohy-
drate,
and
fat
in
the
diet.
Carbohydrate
counting
concentrates
on
estimation
of
carbohydrate
and
is
used
primarily
by
indi-
viduals
with
diabetes
who
are
balancing
their
insulin
dosages
with
dietary
intake
of
carbohydrate.
(See
Chapter
17.)
Nutrition
Care
Criteria:
Evaluation
and
Interpretation
Using
Individual
Nutrient
Analysis
The
USDA
first
published
food
composition
values
in
1896.
The
Nutrient
Data
Laboratory
of
the
USDA
maintains
and
updates
the
National
Nutrient
Databank
System
(NDBS).
Historically,
this
information
has
been
published
in
a
series
of
Agriculture
Handbooks,
but
now
this
information
is
available
only
online
(http://ndb.nal.usda.gov).”°
Other
sources
of
data
include
other
online
databases,
nutrition
labels,
food
manu-
facturers,
and
restaurants
and
fast-food
establishments.
Data
on
food
labels
may
not
be
100%
reliable,
especially
for
prod-
ucts
from
small
companies
or
imported
foods.
Chapter
3
Nutrition
Assessment:
Foundation
of
the
Nutrition
Care
Process
49
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
i
BOX
3.2
CLINICAL
APPLICATIONS
Comparison
Assessment
of
Dietary
Intake
Consider
these
two
meal
records,
which
have
similar
kilocalorie
values.
Dietary
assessment
information
may
lead
to
very
different
results
depending
on
the
refer-
standards
that
d
Diet
1
Nutrient
Total
Grains
(5
oz with
=3
oz
4oz
ence
standards
that
are
used.
whole
grain)
0
oz
whole
grain
Diet
1:
1
egg,
1
slice
of
toast,
coffee
with
Kilocalories
1099.3,
Vegetables
(2
cups)
O
cups
2
tbsp
half-and-half
2
oz
ham
sand-
Fi
53.08
Fruits
(1.5
0
wich
on
2
slices
of
white bread
with
"0
(9)
‘
us
(1-5
cups)
sr
1
tbsp
mayonnaise
1
0z
potato
Fat
(g)
51.15
Dairy
(3
cups)
O
cups
chips
4
oz
chicken
breast
(fried), Carb
(g)
106.2
Protein
foods
(5
0z)
602
1
roll,
iced
tea
with 2 tbsp sugar
Solid
fats/added
sugars
Bun
Diet
2:
1
cup
whole-grain
cereal,
1
Diet
2
Nutrient
Total
Grains
(5
oz with
>
3 oz
8.2
oz
banana,
1c.
skim
milk
2
oz
ham
whole
grain)
oz
whole
grain
sandwich,
¥2
cup
chopped
fresh
me
ne
yee
13
vegetables
on
2
slices
of
whole-
aa
a
eseienles
2
cps)
=e
grain
bread
with
1
tbsp
mustard,
Pro
(g)
70
Fruits
(1.5
cups)
2.4
cups
1
oz
pretzels,
1
medium
apple
4
Fat
(g)
24.02
Dairy
(3
cups)
3
cups
oz
chicken
breast
(baked),
1
cup
Carb
(g)
184.18
Protein
foods
(5
oz)
5.4
cups
fresh
broccoli,
asparagus,
carrots
stir-fried
with
1
cup
brown
rice
Web-based
Dietary
Analysis
Nutrition
profession-
als
and
consumers
have
access
to
many
sources
of
digital
dietary
analysis
programs.
These
programs
vary
signifi-
cantly
in
terms
of
number
of
food
items,
nutrients
included
in
the
database,
accuracy
of
the
data,
how
often
the
infor-
mation
is
updated,
cost
to
access
the
program,
and
ease
of
use.
Nutrition
Care
Criteria:
Evaluation
and
Interpretation
Using
Dietary
Reference
Intakes
and
Daily
Values
One
method
of
evaluating
dietary
macro-
and
micronutri-
ent
amounts
is
use
of
the
Dietary
Reference
Intakes
(DRIs)
and
Daily
Values
(DVs).
DRIs
are
standards
established
by
the
National
Academy
of
Sciences.
These
standard
reference
values
allow
evaluation
of
energy,
protein,
vitamin,
and
min-
eral
intakes
for
healthy
people.
There
are
four
different
sets
of
standards
within
the
DRI:
Adequate
Intakes
(Als),
Rec-
ommended
Dietary
Allowances
(RDAs),
Tolerable
Upper
Intake
Levels
(ULs),
and
Estimated
Average
Requirements
(EARs).
The
RDA,
AI,
and
UL
can
be
used
to
assess
diets
of
individuals.”4
It
is
important
when
using
these
standards
to
under-
stand
the
context
in
which
the
references
are
established.
Values
for
RDAs
are
determined
at
approximately
two
standard
deviations
above
the
average
(mean)
requirement
within
the
healthy
population.
This
margin
of
safety
allows
the
value
of
the
RDA
to
meet
the
needs
of
most
healthy
people.
Therefore,
if
the
evaluated
diet
falls
below
the
RDA
or
Al
for
a
specific
nutrient,
it
does
not
necessarily
mean
the
client
is
deficient
in
this
nutrient.
Diagnosis
of
specific
50
Part
2.
The
Nutrition
Care
Process
nutrient
deficiencies
would
require
additional
confirmation
using
other
components
of
nutrition
assessment.
Still,
DRIs
serve
as
important
benchmarks
for
evaluating
the
patient’s
dietary
intake,
not only
from
food,
but
also
from
dietary
supplements.
The
UL
values
assist
in
assessing
a
patient’s
use
of
supplements
and
whether
their
current
dosage
poses
any
potential
health
risk.
In the
clinical
setting,
many
patients
have
specific
dis-
eases
or
medical
conditions
that
may
have
unique
nutrient
requirements.
For
example,
an
individual
with
a
burn
injury
may
require
significantly
higher
doses
of
vitamin
C
and
zinc
to
ensure
appropriate
wound
healing.
Additionally,
med-
ications
and
treatments
may
alter
absorption,
utilization,
excretion,
or
storage
of
specific
nutrients.
In
these
situations,
patients
may
need
higher
or
lower
levels
of
these
nutrients.
The
DRI
are
established
for
the
healthy
population
and
hence
may
not
be
appropriate
in
clinical
situations.
Nonetheless,
they
can
always
be
used
as
a
starting
point
in
dietary
evalu-
ation,
and
as
the
medical
condition
and
subsequent
nutrition
therapy
are
established,
adjustments
can be
made
for
specific
nutrient
requirements.
The
DVs
were
established
by
the
Food
and
Drug
Admin-
istration
to
assist
consumers
in
interpreting
nutrition
labeling
information.
These
standards
set
target
goals
for
fat,
saturated
fat,
cholesterol,
total
carbohydrate,
fiber,
sodium,
potassium,
and
protein
for a
2000-
and
2500-kcal
reference
diet
(note
that
these
are
different
from
the
DRI
goals).
In general,
the
DVs
are
much
more
useful
to
the
consumer
purchasing
gro-
ceries
than
the
dietitian
performing
a
nutrition
assessment.
The
dietitian
will
use
much
more
specific,
individualized
ref-
erence
data
for
assessment
but
certainly
may
use
the
DVs
as
an
educational
tool.
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
i
3.6
ANTHROPOMETRIC/BODY
COMPOSITION
MEASUREMENTS
“Anthropometry
is
the
measurement
of
body
size,
weight,
and
proportions”!
Body
composition
refers
to
the
distribution
of
body
compartments
(e.g.,
muscle
mass
and
body
fat)
as
part
of
the
total
body
weight.
Evaluating
both
anthropometric
and
body
composition
data
allows
the
clinician
to
fully
assess
these
compartments.
Because
nutrition
is
a
crucial
component
of
normal
growth
and
development,
it
is
accepted
practice
to
measure
body
compartments
in
order
to
evaluate
infants
and
children
for
appropriate
growth.
In
a
normal,
healthy
individual,
the
relationships
among
body
storage
compartments
are
rela-
tively
stable.
But
when
disease
or
stress
is
present,
changes
in
the
storage
compartments
are
an
important
aspect
of
nutritional
status
and
risk.
Results
of
anthropometric
assess-
ment
can
be
used
to
both
identify
goals
for
nutrition
inter-
vention
and
monitor
changes
that
occur
as
result
of
either
those
interventions
or
continued
effects
of
disease
and
stress.
NHANES,
the
U.S.
nationwide
survey
used
to
obtain
health
and
nutrition
information,
collects
a
variety
of
anthropomet-
ric
measurements
and
provides
standardized
procedures
for
practitioners
and
researchers
to
apply
as
they
use
these
tech-
niques
in
health
and
disease
assessment.”
Anthropometrics
Nutrition
Care
Indicator:
Height/Stature/Length
Measurement
of
supine
or
standing
height
is
necessary
for
monitoring
growth
of
infants
and
children
and
for
interpreta-
tion of
weight
in
adults.
For
children
under
the
age
of
2
years,
length
is
measured
recumbently
using
a
length
board.
This
device
has
a
stationary
headboard and
a
movable
footboard
(Figure
3.8).
This
measurement
requires
two
clinicians,
one
of
whom
holds
the
child’s
head
against
the
headboard
while
the
other
extends
the
leg
and
bottom
of
the
heel
to
the
foot-
board.
The
child
is
positioned
correctly
when
the
Frankfort
plane
is
parallel
to
the
fixed
headboard.
Length
is
recorded
to
the
nearest
0.1
cm.
It
is
recommended
that
a
second
mea-
surement
be
taken
and
should
agree
with
the
first
measure-
ment
within
1
cm
or
%
inch.
Over
the
age
of
2
years,
standing
height
is
measured
using
a
tape
measure
or
stadiometer
as
long
as
the
child
can
follow
instructions
and remain
stand-
ing
for
the
measurement
(see
Figure
3.9).
The
procedure
for
measuring
height
is
to
have
the
client
stand
barefoot
and
look
forward
with
shoulders,
buttocks,
and
heels
touching
the
vertical
surface
of
either
a
wall
or
the
stadiometer
with
the
Frankfort
plane.2”
This
ensures
the
head
is
not
tilted
incor-
rectly.
Table
3.5
provides
an
example
of
a
standardized
proto-
col
for obtaining
length.
Sometimes
a
client
cannot
stand
for
the
measurement
of
height—for
example,
because
he
or
she
is
disabled
or
confined
to a
wheelchair
or
bed.
In these
cases,
any
of
several
estima-
tion
methods
may
be
used.
One
method
is
arm
span:
The
cli-
ent
extends
the
arms from
the
body
at
a
90-degree
angle
and
distance
is
measured
between
thetips
of
the
two
middle
fin-
gers.
The
length
of the
dominant
arm
can
be
measured
in
the
same
fashion
and
multiplied
by
2
to
estimate
height.
A
lim-
itation
of
this
method
is
that
it
is
an
estimation
of
maximum
adult
height
and
not
actual,
current
height.
Figure
3.8
Measuring
Infant
Length
Children
under
the
age
of
2
are
measured
using
stationary
headboard and
movable
footboard.
Source:
E.
Whitney
and
S.
Rolfes,
Understanding
Nutrition,
10e,
Copyright
©2005,
p.
591.
Figure
3.9
Stadiometer
Source:
Courtesy
of
Marcia
Nelms.
Knee
height
is
another
method
of height
estimation
(Figure
3.10).
Measurement
of
knee
height,
using
a
knee-height
caliper,
can
be
taken
when
the
client
is
sitting
or
in a
supine
position.
(Measuring
supinely
is
considered
to
be
more
accu-
rate.)
The
client
lies
supine
with
right
knee
and
ankle
flexed
to
90
degrees.
The
clinician
should
place
the
fixed
portion
of
the
caliper
under
the
heel
and
position the
other
blade
over
the
anterior
portion
of
the
thigh
above
the
knee.
The
shaft
of
the
caliper
is
parallel
to
the
tibia.
The
measurement
(repeated
Chapter
3
Nutrition
Assessment:
Foundation
of
the
Nutrition
Care
Process
51
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
require
it.
Table
3.5
Procedure
for
Taking
the
Recumbent
Length
10.
We
AZ
13.
14.
15:
16.
17.
.
Cover
the
board
with
table
paper.
Ask
the
assistant
to
remove
hats,
barrettes,
shoes,
and
socks.
“Big”
hairstyles
will
need
to
be
flattened
as
much
as
possible.
If
hair
or
barrettes
interfere
with
placing
the
child’s
head
directly
against
the
measuring
board,
make
a
note
of
this
on
the
questionnaire.
(Do not
attempt
to adjust
the
measurement.)
.
Provide
a
brief
training
to
the
assistant
on
how
to
hold
the
child’s
head.
Place
the
sliding
foot
piece
at
the
end
of
the
measuring
board
and
check
to
see
that
it
is
sliding
freely.
Ask
the
assistant
to
lay
the
child
down
on
his/her
back on
the
measuring
board
and
stand
directly
behind
the
child’s
head.
If
it
is
not
possi-
ble
for
the
assistant
to
stand
behind
the
child's
head,
he/she
may
stand
beside
it.
Position
yourself
on
the
right
side
of
the
child
so
you
can
hold
the
foot
piece
with
your
right
hand.
Note:
While
the
infant
is
on
the
measuring
board,
you
must
hold
and
control
the
child
so
that
he/she
will
not
roll
off
or
hit
his/her
head
on
the
board.
Hold
the
child
securely
at
the
waist while
the
assistant
positions
the
head.
Ask
the
assistant
to
cup
her
hands
over
the
child’s
ears.
The
assistant's
arms
should
be
straight
if
possible
and
she
should
hold
the
child
securely yet
comfortably.
Make
sure
that
the
assistant
is
cupping
her
hands.
Her
hands
should
not
be
flat
against
the
child’s
head
and
her
thumbs
should
not
be
touching
the
child’s
shoulders.
Ask
the
assistant
to
place
the
child’s
head
against
the
headpiece.
If
the
head
is
not
against
the
headpiece,
hold
the
child
at
the
waist
and
lift
or
slide
the
child
toward
the
headpiece.
The
assistant
should
hold
the
child's
head
at
all
times
and
guide
the
head
into
position.
Check
to
be
sure
that
the
child’s
head
is
in
the
correct
position.
The
line
from
the
hole
in
the
ear
to
the
bottom
of
the eye
socket
(Frankfort
plane)
should
be
perpendicular
to
the
board
or
table.
Ask
the
assistant
to
place
her
head
directly
above
the
child’s
head
and
watch
the
position
of
the
child’s
head
during
the
entire
measure-
ment.
Ask
her
to
make
certain
that
the
child’s
chin
is
not tucked
in
against
his/her
chest
or
stretched
too
far
back.
Position
the
child’s
body
so
that
the
shoulders,
back,
and
buttocks
are
flat
along
the
center
of
the
board.
Place
your
left
hand
on
the
child’s
knees.
Hold
the
movable
foot
piece
with
your
right
hand
and
firmly
place
it
against
the
child's
heels.
A
child's
legs
and
feet
can
be
very
strong.
You
may
have
to
straighten
them
with your
hands.
Check
the
child's
position:
head
against
the
headpiece
with
eyes
looking
straight
up,
body
anc
legs
straight
and
flat in
the
center
of
the
measuring
board,
heels,
and
feet
firmly
against
the
foot
piece.
When
the
child’s
position
is
correct,
read
and
call
out
the
length
measurement
to
the
nearest
1/8".
Continue
to
call
out the
measurement
until
the
measurement
is
recorded.
Record
the
measurement
on
the
data
collection
sheet
under
“Recumbent
Length.”
Check
to
make
sure
it
is
accurate
and
legible.
Note:
It
is
acceptable
to
take
two
measurements
that
agree
within
1/8"
and
use
either
one
of
those
measurements.
Source:
Indian
Health
Service.
Infant
guidelines.
https:/Awww.ihs.gov/HWM/infantguidelines/
Figure
3.10
Knee
Height
two
to
three
times)
is
recorded
to
the
nearest
0.1
cm.
Height
is
Knee-height
calipers
are
used
when
height
must
be
measured
for
then
estimated
using
the
following
equations:
28
an
individual
who
cannot
stand.
Age
19-60
years:
+
White
male
= 71.85
+
(1.88
x
knee
height)
+
Black
male
= 73.42
+
(1.79
x
knee
height)
+
White
female
= 70.25
+
(1.87
x
knee
height)
—
(0.06
x
age)
+
Black
female
=
68.10
+
(1.86
x
knee
height)
—
(0.06
x
age)
Age
>60
years:
+
White
male
=
59.01
+
(2.08
x
knee
height)
+
Black
male
= 95.79
+
(1.37
x
knee
height)
+
White
female
= 75.00
+
(1.91
x
knee
height)
—
(0.17
x
age)
+
Black
female
=
58.72
+
(1.96
x
knee
height)
Height
or
length has
been
noted
to
be
one
of the
most
inaccurate
measures.
One
study
indicated
that
inaccuracies
are
introduced
when
shoes
are
not removed,
a
verbal report
is
taken
Source:
Courtesy
of
Marcia
Nelms.
instead
of
a
measurement,
or
the
head,
shoulders, or
heels
are
52
Part
2.
The
Nutrition
Care
Process
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
learing
experience.
Cengage
Learning
reserves
the
right
toremove
additional
content
at
any
time
if
subsequent
rights
restrictions
requize
it,
Figure
3.11
Measuring
Weight
Weight
is
the
most
common
anthropometric
measure.
Source:
Courtesy
of
Marcia
Nelms.
not
in
the
correct
position.
In
clinical
settings,
it
is
often
either
estimated
or
recorded
from
patient
report.”-*!
Nonetheless,
accurate
measurement
is
crucial
because
height
is
used
to
inter-
pret
weight,
measure
growth
for
children,
calculate
energy
and
protein
requirements,
and
calculate
creatinine
height
index
(CHI).
Nutrition
Care
Indicator:
Weight
Weight
can
be
mea-
sured
using
a
variety
of
scales,
including
balance
beam
(Figure
3.11)
and
electronic
scales.
Bathroom
scales
and
those
that
are
moved
frequently
are
not
recommended
due
to
poor
calibration.
Wheelchair
and bed
scales
are
available
for
nonambulatory
patients.
Ideally,
the
client
should be
weighed
with
minimal
clothing
and
without
shoes,
at
the
same
time
daily,
and
after
urination.
For
those
patients
with
an
amputation,
weight
has
histor-
ically
been
adjusted
using
the
following
factors:°”
+
Hand:
0.8%
+
Forearm
and
hand:
3.1%
+
Entire
arm:
6.5%
+
Foot:
1.8%
+
Lower
leg
(below
knee)
and
foot:
7.1%
+
Entire
leg:
18.6%
For
example,
for
an
individual
who
has
had
an
entire
leg
amputated and
currently
weighs
165
Ibs,
weight
would
be
adjusted
by
using
the
following
equation:
Adjusted
body
weight
=
actual
measured
weight
divided
by
100
—
%
amputation.
The
whole
equation
then
is
multi-
plied
by
100.
165
lbs
—————
X
100
=
202
lbs
is
the
estimated
body
weight
(100
—
18.6)
This
calculation
allows
weight
to
be
compared
to
a
criterion
standard
such
as
BMI.
‘Weight
is
the
most
common
measure
of
anthropomet-
rics.
Unfortunately,
it
is
a
gross
measurement
of
all
body
compartments
and
does
not
distinguish
body
composition
or
fluid
shifts.
Nevertheless,
due
to
its
common
availability
and
its
relationship
to
growth,
development,
and
health,
it
remains
a
vital
component
of
nutrition
assessment.
Nutrition
Care
Criteria:
Evaluation
and
Interpretation
of
Height
and
Weight
in
Infants
and
Children
Growth
Charts
Weight
and
height
for
infants
and
children
are
evaluated
using
growth
charts
developed
by
the
WHO,
Centers
for
Disease
Control
and
Prevention
(CDC),
and
the
National
Center
for
Health
Statistics
(see
Box
3.3).
Determination
of
height
for
age
and
weight
for
age
allows
comparison
of
an
infant
or
a
child
to
a
reference
population.
Data
for
the
CDC
growth
charts
are
based
on
the
NHANES
and
were
most
recently
updated
in
2000.**
It
is
recommended
to
use
the
WHO
growth
standards
for
infants
and
children
less
than
two
years
of
age
and
to
use the
CDC
standards
over
age
2.
When
infants
and
children
are
either
<3rd
percentile
or
>97th
percentile,
further
assessment
should be
made
to
confirm
any
health
problems.
Furthermore,
shifts
in pat-
terns
of
growth
should
also
alert
the
practitioner
to
either
an
error
in
measurement
or
cause
for
concern
for
the
child’s
nutritional
status.
There
are
specific
clinical
diagnoses,
such
as
genetic
and
endocrine
disorders,
that
negate use
of
these
standard
growth
charts.
Alternative
growth
charts
have
been
developed
for
children
with
specific
health
care
needs
such
as
cerebral
palsy
or
Down's
syndrome.
Weight
for
height
and
percentile
weight
for
height
can
also
be
evaluated
using
CDC
growth
charts.
These
measure-
ments
allow
evaluation
to
be
independent
of
age
and
can
be
used
to
monitor
acute
malnutrition
(<5th
percentile)
or
the
incidence
of
obesity
(>95th
percentile).
An
additional
assessment
using
growth
chart
data
is
the
calculation
of
a
Z-score.
Z-score
or
standard
deviation score
is
equivalent
to
the
observed
value—the
median
value
of
the
reference
population
divided
by
the
standard
deviation
value
of
the
reference
population.
A
Z-score
of
0
is
the
same
as
the
50th
percentile,
+
1.0
plots
at
the
15th
or
85th
percentiles,
respectively,
+
2
at
roughly
the
3rd
or
97th
percentiles.”
Body
Mass
Index
Revision
of
the
CDC
growth
charts
in
2000
added
the
measurement
of
BMI.
BMI
is
weight
(kg)/
[height(m)]’.3?
Calculation
and
interpretation
of
BMI
in
chil-
dren
and
adolescents
has
increased
in
recent
years.
Assessment
is
not
based
on
adult
standards,
however;
instead,
overweight
is
defined
as
85th
to
<95th
percentile
of
BMI-for-age,
obese
is
defined
as
>95th
percentile
of
BMI-for-age,
and
underweight
is
defined
as
<5th
percentile.
See
Tables
3.6
and
3.7.
Nutrition
Care
Criteria:
Evaluation
and
Interpretation
of
Height
and
Weight
in
Adults
Usual
Body
Weight
In
the
clinical
setting,
variations
from
usual
body
weight
have
been
strongly linked
to
nutritional
risk
and
health
complications.
Such
variations
may
be
more
Chapter
3
Nutrition
Assessment:
Foundation
of
the
Nutrition
Care
Process
53
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part,
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
learning
experience.
Cengage
Learning
reserves
the
right
toremove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
it,
BOX
3.3
LIFE
CYCLE
PERSPECTIVES
Pediatric
Nutrition
Assessment
Colette
LaSalle,
PhD,
RDN
San
Jose
State
University
Dietitians
working
in
pediatric
care
face
the
unique
challenge
of
completing
nutrition
assessments
specific
to
the
nutrient
needs
of
a
fairly
heterogeneous
population
that includes
neo-
nates,
infants,
children,
and
adolescents.
Additionally,
since
children
do
not
typically
plan
menus
or
purchase
or
prepare
foods,
they
are
dependent
on
what
is
supplied
by
their
families/
caregivers.
Childhood
is
a
time
of
incredible
growth and
devel-
opment
with
maturation
from
infancy
to
adulthood;
therefore,
the
primary
goal
of
pediatric
nutrition
care
is
to
optimize
growth and
development. However,
there
are
numerous
con-
genital,
chronic,
and
acute
conditions
that
increase
nutritional
risk
or
impact
nutritional
intake
and
thus
must
be
factored
into
nutrition
assessment
in
terms
of
nutrient
needs,
dietary
intake,
and
social
history.
Nutrition
assessment
components
unique
to
pediatric
nutrition
assessment
are
detailed
below.
Pediatric-Specific
Anthropometric
Measures
Weight
and
growth
are
evaluated to
measure
botn
nutritional
health
and
efficacy
of
nutrition
interventions
since
undernu-
trition
will
result
in
underweight
and/or
poor
growth.
There
are
child-specific
charts
available
through
the
World
Health
Organization
(WHO)
and
the
Centers
for
Disease
Control
and
prevention
(CDC).
Additionally,
there
are
numerous
growth
charts
that
have
been
developed
for
specific
diagnoses
such
as
Down
syndrome.
Typically
growing
children
are
assessed
using
the
following
charts:
¢
Length/height-for-age
¢
Weight-for-age
¢
Weight-for-length
¢
Weight-for-height
¢
Body
mass
index-for-age
(BMI-for-age)
¢
Weight
velocity
(i.e.,
rate
of
change)
e
Length
velocity
¢
Head
circumference
velocity
¢
Head
circumference-for-age
e
Z-scores
Clinical
Information
Related
to
Growth,
Development,
and
Intake
Comprehensive
pediatric nutrition
assessments
must
consider
medical
diagnoses
and
treatments
that
impact
growth
and
development.
For
example,
the
diagnosis
of certain
genetic
or
metabolic
disorders
such
as
phenylketonuria
or
cystic
fibrosis
requires
specialized
nutrition
interventions.
Diet
History
Often
children
are
unable
to
provide
an
accurate
diet
history
due
to
age
or
communication
deficits.
Typically,
in
younger
children,
pediatric
RDNs
rely
mainly
on
parents’
and
caregivers’
reports
related
to
intake
history,
though
reports
from
the
child
or
adoles-
cent
are
also
considered,
especially
regarding
food
preferences,
dislikes,
and
eating
patterns.
Assessment
of
usual
intake,
typical
diet,
history
of
diet
restrictions,
previous
diet
education,
food
pref-
erences,
dislikes,
and
food
intolerances
or
allergies
must
include
the
parent/caregiver
and
child (as
appropriate).
Social
factors
are
an
important
consideration
since
children
usually
have
little
influence
on
food
purchase
or meal
preparation;
therefore,
pediatric
RDNs
must
assess
parental
attitudes,
feeding
strategies,
access
to
food,
cultural
practices,
use
of
supplements/herbal
remedies,
and
partici-
pation
in
nutrition
programs
such
as
Women,
Infants
and
Children
(WIC)
or
the
Supplemental
Nutrition
Assistance
Program
(SNAP).
References
1.
Centers
for
Disease
Control
and
Prevention.
CDC
growth
charts.
http://
www.cdc.gow/growthcharts.
Accessed
July
31,
2018.
2.
Grummer-Strawn
LM,
Reinold
C,
Krebs
NF,
Centers
for
Disease
Control
and
Prevention.
Use
of
World
Health
Organization
and
CDC
growth
charts
for
children
aged
0-59
months
in
the
United
States.
MMWR
Recomm
Rep.
2010;
59(RR-9):
1-15.
3.
Ortiz-Espejo
M,
Pérez-Navero
JL,
Mufoz-Villanueva
MC,
Mercedes
GC.
Nutritional
assessment
in
neonatal
and
prepubertal
children
with
a
history
of
extrauterine
growth
restriction.
Early
Hum
Dev.
2013;
89(9):
763-68.
WHO
Multicentre
Growth
Reference
Study
Group.
WHO
Child
Growth
Standards:
Length/height-for-age,
weight-for-age,
weight-for-
length,
weight-for-height
and
body
mass
index-for-age:
Methods
and
development.
Geneva:
World
Health
Organization;
2006.
Table
3.6
Interpretation
of
BMI
in
Adults
For
adults,
classification
of
weight
based
on
body mass
index
by
the
National
Institutes of
Health
is
as
follows:
Below
18.5
Underweight
With
<16
suggesting
possible
eating
disorder
and
other
disease
risk*
18.5-24.9
Normal
Healthy,
low
health
risk
25.0-29.9
Overweight
Associated
with
increased
risk
of
disease**
30.0
andebove
Obese
Associated
with
further
increased
risk
of disease
*Diseases
associated
with
underweight
include
chronic
obstructive
pulmonary
disease,
cancer,
and
congestive
heart
failure.
**Diseases
associated
with
overweight
and
obesity
include
diabetes
mellitus,
cardiovascular
disease,
and
hypertension.
Source:
www.cdc.gov/healthyweight/assessing/bmi/adult_bmi
/index.html
54
Part
2.
The
Nutrition
Care
Process
Table
3.7
Interpretation
of
BMI
in
Children
and
Adolescents
>
Age
2
<5th
percentile
At
risk
for
underweight
5-85th
percentile
Normal
285th
percentile
but
<95th
percentile
Overweight
295th
percentile
Obese
2120th
percentile
or
235
kg/m2
Extreme
obesity
Source:
Styne
DM,
Arslanian
SA,
Connor
EL,
et
al.
Pediatric
obesity—
assessment,
treatment
and
prevention:
an
Endocrine
Society
clinical
prac-
tice
guideline.
J Clinc
Endocrinol
Metab.
2017;
102:
709-57.
clinically
useful
than
comparison
to
ideal
body
weight
stan-
dards.
In
general,
an
adult
is
considered
at
nutritional
risk
if
there
is
a
>5%
unexplained
weight
change
in
less
than
1
month
or
>10%
in a
6-month
period
(see
Table
3.8).
The
concept
of
unintentional
weight
loss
is
also
included
as
a
criterion
in
the
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
learning
experience.
Cengage
Learning
reserves
the
right
toremove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
it,
Table
2.1
Factors
Affecting
Nutritional
Status
1.
Human
Biological
Factors
(determine
nutrient
requirements—
normal,
increased,
decreased,
change
in
form,
etc.)
a.
Biological
factors
(age,
sex,
genetics)
b.
Physiological
phases
(growth,
pregnancy,
lactation,
aging)
c.
Pathological
factors
(disease,
trauma,
altered
organ
function
or
metabolism)
2.
Lifestyle
Factors
(determine
food,
physical
activity,
and
related
choices)
a.
Attitudes/beliefs
b.
Knowledge
c.
Behaviors
3.
Food and
Nutrient
Factors
(determine
the
type
and
amount
of
nutrients
available
for
use
by
the
body)
a.
Intake/composition
b.
Quantity
c.
Quality
4.
Environmental
Factors
(external
influences
that
impact
consump-
tion
and
lifestyle)
a.
Social
(cultural
food
practices
and
beliefs,
parenting,
peer
influences)
b.
Economic
(household
finances,
economy
of
the
community/
country)
c.
Food
safety
and
sanitation
(contaminated
or
unwholesome
food,
unsafe
food
handling)
d.
Food
availability/access
5.
System
Factors
(external
influences
that
impact
on
delivery
and
services)
a.
Health
care
system
b.
Educational
system
c.
Food
supply
system
(industry,
agriculture,
institutions)
Source:
Adapted
from
Splett
P,
Academy
of
Nutrition
and
Dietetics
Task
Force.
Conceptual
Framework
for
a
Standardized
Nutrition
Language;
2004.
certain
nutrients
such
as
protein,
on
the
other
hand,
can
con-
tribute
to a
compromised
immune
system
and
poor
wound
healing.
Comparing
nutrient
intake
to
nutrient
requirements
alone,
however,
does
not
describe
the
broader
picture
of
nutri-
tional
status.
Even
though
nutrient
balance
implies
that
one
is
consuming
all
of
the
necessary
nutrients
in
their
appropriate
amounts,
assessing
nutritional
status
is
not
merely
a
simple
equation
of
intake
compared
to
needs.
A
positive
nutritional
status
implies
that
a
number
of
internal
and
external
fac-
tors
that
support
optimal
nutritional
health
are
also
present.
Human
biological
factors
such
as age,
sex,
physiological
stage,
illness,
and
physical
and
functional
abilities
determine
nutrient
requirements.
For
example,
a
mother
who
is
breast-
feeding
needs
to
consume
more
kcal
and
protein
compared
to
a
non-breastfeeding
mother.
Infants
and
children require
a
much
higher
kilocalorie
level
per
kilogram
than
an
adult
in
order
to
support
appropriate
growth
and
development.
20
Part
2.
The
Nutrition
Care
Process
Energy
and
protein
needs
are
also
increased
following
major
surgery.
Furthermore,
the
form
of nutrient
may
need
to
be
altered
depending
on
the
degree
of
organ
function.
A
person
who
has
had
large
portion
of
the
small
intestine
removed
may
not
be
able
to
digest or
absorb
large
molecules
such
as
triglycerides
and
would
benefit
from
specialized
nutrient
forms
such
as
medium-chain
triglycerides.
Lifestyle
factors
including
attitudes,
knowledge,
and
behaviors
influence
the
type
of
choices
that
one
makes
about
food
and
physical
activ-
ity.
For
instance,
understanding
which
foods
contain
satu-
rated
fat
can
influence
what
type
and
amount
of
meats
and
added
fats
a
person
consumes.
Food
and
nutrient
factors
are
the
nutrients
that
are
available
for
use
by
the
body.
Obtaining
accurate
information
about
a
person’s
dietary
intake
is
essen-
tial
to
evaluating
nutritional
status
and
adequacy
of
their
diet.
Environmental
factors
such
as
social
and
cultural
food
pref-
erences
and
practices
are
external
influences
that
impact both
food
consumption
and
lifestyle
choices.
For
example,
people
frequently
consume
more
food
than
usual
at
a
social
event
where
food
is
served.
It
is
also
commonthat
adults
prefer
the
types
of
foods
that
were
typically
consumed
in
the
household
where
they
grew
up
as
a
child.
Cultural
background
will
intro-
duce
particular
foods
into
one’s
diet.
Finally,
system
factors
such
as
the
health
system,
educational
system,
and
food
sup-
ply
system
impact
the
delivery
of
food,
nutrition,
and
health
services.
A
family
whose
income
is
near
or
at
the
poverty
level
or
that
lives
in
an
area
with
limited
food
resources
will
likely
purchase
fewer
fresh
foods.
Key
Concepts:
Health
Status
and
Nutritional
Status
©
Nutrition
is
important
to
promote
health
and
prevent
and
treat
disease
states.
¢
Adequacy
of
nutrient
intake
is
important
but
does
not
completely
describe
nutritional
status.
©
Determination
of a
person’s
nutritional
status
is
dependent
on
a
wide
variety
of
factors
(biological,
pathological,
behavioral,
cognitive,
environmental,
and
systems).
It is
important
to
determine
both
a
person’s
health
sta-
tus
and
nutritional
status
because
these
both
guide
the
type
of
nutrition
care
provided.
This
chapter
describes
how
dietetics
practitioners
use the
NCP
developed
by
the
Acad-
emy
of
Nutrition
and
Dietetics
(AND)
to
provide
quality
evidence-based
nutrition
care
to
individuals
and
groups
to
improve
both
health
and
nutritional
status.
2.2
PURPOSE
OF
PROVIDING
NUTRITION
CARE
The
purpose
of
providing
nutrition
care
is
to
restore
a
state
of
nutritional
balance
by
influencing
factors
are
contributing
to
the
imbalance
or
altered
state
of
nutritional
status.
Because
of
the
wide
variety
of
and
interactions
among
the
many
vari-
ables
discussed
previously
and
listed
in
Table
2.1,
identify-
ing
the
underlying
causes
of
a
nutritional
status
imbalance
can
be
a
complex
process.
If
a
person's
caloric
intake
is
less
than
desired,
it is
important
to
determine
which,
if
any,
of
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
i
the
following
are
contributing
to
the
cause
of
this
problem:
a
disease
condition
that
is
increasing
the
nutrient
needs,
a
lack
of
knowledge
as
to
how
many
calories
are
in
certain
foods,
a
lack
of
resources
(money,
food
preparation
skills,
transportation),
or
a
cultural
belief
about
limiting
the
intake
of
certain
foods.
Accurately
determining
the
underlying,
or
“root,”
cause
of the
problem
will
permit
the
selection
of
the
most
appropriate
nutrition
intervention.
For
example,
if
lack
of
financial
resources
is
the
main
reason
why
a
person
is
not
consuming
adequate
kcal,
providing
only
list
of
expensive
oral
supplements
will
not
be
very
effective.
It
might
also
be
necessary
to
coordinate
nutrition
care
and
refer
the
client
for
support
services
and
food
aid.
Thus,
it
is
necessary
to
know
the
factors
that
influence
a
problem
in
order
to
pro-
vide
nutrition
interventions
that
are
most
likely
to
alleviate
the
problem.
Key
Concept:
Nutrition
Care
«
Providing
nutrition
care
can
influence
and
change
the
factors
that
contribute
to
an
imbalance
in
nutritional
status
and
thus
restore
nutritional
health.
2.3
THE
AND’S
STANDARDIZED
NCP
The
nutrition
care
process
(NCP)
is
defined
as
“a
system-
atic
problem
solving
method
that
dietetics
practitioners
use
to
critically
think
and
make
decisions
to
address
nutrition
related
problems
and
provide
safe,
effective,
high
qual-
ity
nutrition
care’?!
This
NCP
consists
of four
distinct
but
interrelated
and
connected
steps:
(1)
nutrition
assessment,
(2)
nutrition
diagnosis,
(3)
nutrition
intervention,
and
(4)
nutrition
monitoring
and
evaluation.!
Subsequent
to
the
development
of
the
NCP
steps
and
model,
workgroups
were
appointed
to
create
a
system
of
standardized
language
for
each
of
the
four
steps
of
the
NCP.
A
Nutrition
Care
Pro-
cess/Standardized
Language
(NCP/SL)
Committee
contin-
ues
to
meet
in
order
to
evaluate
and
revise
the
language
as
needed.
This
committee
also
assists
in
the
development
of
resources
for
implementation
of
the
NCP,
including
the
Academy
of
Nutrition
and
Dietetics.
Nutrition
Terminol-
ogy
Reference
Manual
(eNCPT):
Dietetics
Language
for
Nutrition
Care.
Standardized
Nut
Standardized
language
refers
to
a
uniform
terminology
that
is
used
to
describe
professional
practice.
Many
health
profes-
sionals
including
physicians,
nurses,
and
physical
therapists
use standardized
terminology.
Prior
to
the
development
of
the
NCP,
the
lack
of
a
standardized
nutrition
language
and
common
terminology
made
it
very
difficult
for dietetics
prac-
titioners
to
communicate
consistently
with each
other
and
other
health
professionals.
Nutrition
problems
and
interven-
tions
were
often
charted
using
broad,
nonspecific
language.
For
example,
“poor
nutritional
status,’
“at
risk
for
malnutri-
tion,’
or
“nutritional
imbalance”
might
be
noted
in
the
chart
as
ared
flag
for
nutrition
care;
however,
these
could
refer
to
a
number
of
conditions
such
as a
change
in
weight,
poor
intake,
or
difficulty
with
chewing
or
swallowing.
Nutrition
n
Language
care
plans
likewise
might
have
employed
vague
terms
such
as
“complete
nutrition
assessment,’
“monitor
weight
or
dietary
intake,’
and/or
“provide
nutrition
education.’
These
incon-
sistent
terms
made
it
difficult
to
establish
specific
and
clear
goals.
In
addition,
there
was
no
easy
way
to
classify,
measure,
and
report
on
the
outcomes
of
nutrition
interventions
in
various
patient
populations
in
order
to
demonstrate
the
effectiveness
of
nutrition
care.
The
lack
of
specific
uniform
terminology
also
made
it
impossible
to
gather
data
needed
for
research,
education,
and
reimbursement
justification
via
outcomes
analysis.
Most
notably
missing
was
language
that
described
specific
nutrition
problems.
The
standardized
terminology
now
allows
dietetics
practitioners
to
make
explicit
that
which
had
been
implicit
in
the
past.
The
standardized
language
consists
of precise
phrases
(“terms”)
that
are
organized
into
groups
(“domains”)
and
assigned
unique alphanumeric
code
numbers
(e.g.,
“NC-1.1”).
There
are
sets
of
standardized terminology:
(1)
nutrition
diagnosis;
(2)
nutrition
assessment;
(3)
nutrition
intervention,
and
(4)
monitoring
and
evaluation.
The
use
of
all
sets
of
terms
together
connects each
of the
steps
of
the
NCP.
For
instance,
the
assessment
data
of
the
food/nutrition-related
history
domain
are
likely
to
provide
signs
and
symptoms
that
will
confirm
a
nutrition
diagnosis
in
the
intake
domain,
whereas
if
a
behavioral—environmental
nutrition
problem
is
suspected,
then
further
data involving
knowledge/beliefs
and
attitudes
should
be
obtained
to
rule
in
or
rule
out
the
presence
of
that diagnosis.
The
standardized
terms,
their
classifications,
and
their
use
within
each
step of
the
NCP
are
outlined
in
Figure
2.1
and
discussed
in
more
detail
under
“Steps of
the
NCP”
Use
of
the
NCP
to
Improve
Quality of
Care
The
NCP
is
a
standardized
process—a
consistent structure
and
framework
used
to
provide
nutrition
care—not
stan-
dardized
or
“generic”
care.
When
professionals
use
a
sys-
tematic
process
with
standardized
language,
there
is
less
variation
of
practice
and
a
higher
degree
of
predictability
in
terms
of
outcomes.
The
Institute
of
Medicine
defines
quality
as
“the
degree
to
which
health
services
for
indi-
viduals
and
populations
increase
the
likelihood
of
desired
health
outcomes
and
are
consistent
with
current
profes-
sional
knowledge”?
Quality
performances
can be
assessed
by
measuring
clients’
outcomes
(end
results
of
intervention
and
treatment)
or the
degree
to
which
providers
adhere
to
an
accepted
care
process.
Clients
and
patients
want
service
that
results
in
positive
outcomes.
Health
care
administra-
tors,
payers,
and
the
government
require
cost-effective,
high-quality
service
based
on
current
evidence-based
prac-
tice.
Use
of
the
NCP
greatly
increases
the
dietetics
prac-
titioner’s
potential
to
provide
high-quality
nutrition
care
to
individuals
and
groups.
It
combines
the
process
of
care
(the
systematic
and
consistent
steps
of
the
NCP)
with
the
content
of
care
(incorporation
of
evidence-based
practice
guides)
to
improve
both
quality
of care
and
nutritional
sta-
tus
(see
Figure
2.2).
The
other
significant
benefit of
using
the
NCP
is
the
ability
to
clearly
state
patient
goals
and
eval-
uate
outcomes.
Chapter
2.
Overview:
The
Nutrition
Care
Process
21
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
require
i
Figure
2.1
Overview
of
the
Nutrition
Care
Process
Standardized
Language
=
|
Figure
2.2
Demonstrating
Quality
Source:
Adapted
from
Slide
#8
of
ADA’S
Nutrition
Care
Process
and
Model:
Providing
Quality
Nutrition
Care
in
a
Variety
of
Settings
Power
Point
Prepared by
ADA’S
Nutrition
Care
Process
Task
Force,
2004.
Key
Concepts:
The
AND’s
Standardized
Nutrition
Care
Process
The
four
steps
of
the
nutrition
care
process
(NCP)
are:
¢
Nutrition
assessment
©
Nutrition
diagnosis
¢
Nutrition
intervention
¢
Nutrition
monitoring
and
evaluation
By
using
the
NCP,
dietetics
practitioners
can
demonstrate
that
nutrition
care
improves
outcomes
because
it:
©
sa
systematic
method
used
to
make
decisions
to
provide
safe
and
effective
care.
Provides
a
common
language
for
documenting
and
communicating
the
impact
of
nutrition
care.
Relies
on an
evidence-based
approach.
¢
Uses
specific
critical
thinking
skills
for
each
step.
Critical
Thinking
The
NCP
also
enhances
the
quality
of care
provided by
dietetics
practitioners
through
the use
of
specific
critical
22
Part
2
The
Nutrition
Care
Process
thinking
skills.
Critical
thinking
(see
Chapter
1)
integrates
facts,
informed
opinions,
active
listening,
and
observations;
it
is
creative
and
rational,
and
it
requires
the
ability
to
conceptualize.
Each
step
of
the
NCP
identifies
unique
and
specific
types
of
critical
thinking
that,
when
applied,
improve
the
likelihood
that
the
process
is
being
implemented
in
an
effective
manner.
These
specific
critical
thinking
skills
are
described
in
Table
2.2.
2.4
BIG
PICTURE
OF
NUTRITION
CARE:
THE
MODEL
The
provision
of
nutrition
care
does
not
occur
in a
vacuum.
The
Nutrition
Care
Model
in
Figure
2.3
is
a
visual
represen-
tation that
reflects
key
concepts
of
each
step
of the
NCP
and
illustrates
the
greater
context
within
which
nutrition
care
is
provided.
The
model
also
identifies
other
systems
that
influ-
ence
and
impact
the
quality
of
care.
It
depicts
the
overlapping
relationships
of
these
components
and
how
they
interact
to
result
in
the
best
nutrition
care
possible.
Central
Core
Central
to
providing
nutrition
care
is
the
relationship
between
the
client
and
the
dietetics
practitioner
or
team
of
dietetics
practitioners.
The
client’s
previous
experiences
and
readiness
for
change
as
well
as
the
ability
of
the
dietetics
practitioner
to
establish
trust,
demonstrate
empathy,
and
communicate
effectively
with
the
client
influence
this
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
learning
experience.
Cengage
Learning
reserves
the
right
toremove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
it,
Table
2.2
Critical
Thinking
Used
in
the
Nutrition
Care
Process
Observe
for
nonverbal
and
verbal
cues
to
prompt
effective
interviewing
methods.
¢
Determine
appropriate
data
to
collect.
©
Select
assessment
tools
and
procedures.
Apply
assessment
tools
in
valid
and
reliable
ways.
‘¢
Distinguish
relevant
from
irrelevant
data.
©
Distinguish
important
from
unimportant
data.
Validate
the
data.
Organize
and
categorize
the
data
in
a
meaningful
framework
that
relates
to
nutrition
problems.
¢
Find
patterns
and
relationships
among
the
data
and
possible
causes.
¢ Make
inferences
(e.g.,
“If
this
continues
to
occur,
then
this
is
likely
to
happen").
¢
State
the
problem
clearly
and
singularly.
¢
Suspend
judgment
(be
objective
and
factual)
Make
interdisciplinary
connections.
Rule
in/rule
out
specific
diagnoses.
e
Prioritize
the
relative
importance
of
problems.
Determine
when
a
problem
requires
consultation
with
or
referral
to
another
provider.
Set
and
prioritize
goals.
‘¢
Define
the
nutrition
prescription
or
basic
plan.
Make
interdisciplinary
connections.
‘¢
Initiate
behavioral
and
other
interventions.
Match
intervention
strategies
with
client
needs,
diagnoses,
and
values.
¢
Choose
from
among
alternatives
to
determine
a
course
of
action.
©
Specify
the
time
and
frequency
of
care.
Select
appropriate
indicators/measures.
Use
appropriate
reference
standards
for
comparison.
Define
where
patient/client
is
now
in
terms
of
expected
outcomes.
¢
Explain
variance
from
expected
outcomes.
*
Determine
factors
that help
or
hinder
progress.
¢
Decide
between
discharge
or
continuation
of
nutrition
care.
relationship.
If
a
person
believes that
changing
her
intake
of
saturated
fat
will
decrease
her
risk
of
cardiovascular
disease
and
has
had
previous
nutrition
counseling
that
was
help-
ful,
that
person
is
more
likely
to
want
to
meet
again
with
a
dietitian;
in
contrast,
an
individual
who
believes
that
life-
style
behavior
changes
will
have
little
to
no impact
on
the
risk
of
disease
will
probably be
less
receptive.
It
is
import-
ant
for
the
dietetics
practitioner
to
establish
trust
and
be
able to
communicate
effectively
with
others,
and
it
is
essen-
tial
that
the
client
be
actively
involved
in
the
care
whenever
possible
and
if
culturally
acceptable.
This
means
that
the
client
is
aware
of
the
purpose
of
care
and
participates
in
the
decision-making
process
of
goal
setting
and
interven-
tion
selection.
This
central
core
reinforces
the
importance
of
providing
care
that
is
individualized
and
patient/client
centered.
Two
Outer
Rings
The
outermost
ring of
the
model
identifies
environmen-
tal
factors—including
practice
settings,
health
care
systems,
social
systems,
and
economics—that
can
have
an
impact
on
the
ability
of
the
client to
receive
and
benefit
from
the
interventions
of
nutrition
care.
Dietetics
practitioners
need
to assess
these
factors
and
be
able
to
evaluate the
degree
to
which
they
may
either
be
positive
or
negative
influences
on
the
outcomes
of
care.
A
health
care
plan
that
allows
for
up
to
three
outpatient
nutrition
counseling
sessions
per
year
at
low
cost
(e.g.,
copay
only)
to
the
client
is
a
much
more
positive
external
influence
than
a
health
care
plan
in which
the
client
has
to
pay
all
costs
for
each
visit.
The
inner
adjoining
ring
recognizes
the
strengths
that
dietetics
practitioners
bring
to
the
NCP.
These
include
pro-
fessional
knowledge/skills
and
competencies,
code
of
ethics,
evidence-based
practice,
and
skills
of
critical
thinking,
col-
laboration,
and
communication.
These
are
the
knowledge
and
skills
that
registered
dietitians
and
dietetic
technicians
obtain
through
accredited
didactic
and
supervised
practice
programs.
Providing
nutrition
care
that
is
based
on
sound
sci-
entific
evidence
increases
the
likelihood
that
there
will
be
a
positive
outcome
for
the
client.
Nutrition
care
also
requires
a
great
deal
of
collaboration
with
other
health
care
profession-
als
and
community
services.
Supportive
Systems:
Screening
and
Referral
System and
Outcomes
Management
System
Although
the
two
supportive
systems—the
screening
and
referral
system
and
the
outcomes
management
system—
are
essential
to
providing
effective
and
efficient
nutrition
care,
they
are
not
considered
steps
of
the
NCP
itself,
pri-
marily
because
they
may
not
be
accomplished
solely
by
dietetics
practitioners.
A
screening
and
referral
system
identifies
those
individuals
or
groups
who
would
bene-
fit
from
nutrition
care
provided
by
dietetics
practitioners.
Screening
may
be
completed by
nurses,
by
clients
them-
selves,
or
through
physician
referral.
Regardless
of
whether
dietetics
practitioners
are
actively
involved
in
conducting
the
screening
process,
they
are
still
accountable
for
pro-
viding
input
into
the
development
of
appropriate
screen-
ing parameters
to
ensure
that
the
right
questions
are
asked.
They
should
also
evaluate
how
effectively
the
screening
process
identifies
the
clients
who
require
nutrition
care.
Screening
parameters
need
to
be
tailored
to
the
population
and
to
the
nutrition
care
services
provided.
A
referral
pro-
cess
may
also
ensure
that
clients
are
reliably
connected
with
dietetics
practitioners
who
will
ultimately
provide
the
nutri-
tion
care or
medical
nutrition
therapy
that
is
necessary.
For
example,
using
a
nutrition
screening
tool
at
elderly
congre-
gate
meal
sites
can
identify
those
clients
who
are
at
risk
and
could
then
be
seen
by
the
dietetic
practitioner
employed
at
a
senior
center.
Chapter
2.
Overview:
The
Nutrition
Care
Process
23
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
require
i
Figure
2.3 Nutrition
Care
Process
Model
The
Nutrition
Care
Process
Model
Feearetnersereel>
>
>
Identify
risk
factors
>
Use
appropriate
tools
and
methods
>
Involve
interdisciplinary
collaboration
data
Economics
and
Evaluation
of
diagnosis
ee
<
>
Research
NCP
>
Use
aggregated
data
to
conduct
research
>
Conduct
continuous
quality
improvement
>
Calculate
and
report
quality
indicators
Nutrition
Assessment
and
Reassessment
>
Obtain/collect
important
and
relevant
data
>
Analyze/interpret
collected
Nutrition
Monitoring
>
Select
or
identify
quality
indicators
>
Monitor
and
Evaluate
resolution
practice
Settings
Nutrition
Diagnosis
>
P
-
Identify
problem
>
E
-
Determine
etiology/cause
>
S
-
State
signs
and
symptoms
Swiajshg
aed
yee
Nutrition
Intervention
>
Determine
intervention
and
prescription
>
Formulate
goals
and
determine
action
>
Implement
action
Social
systems
Source:
Swan
WI,
Vivanti
A,
Hakel-Smith
NA,
et
al.
Nutrition
Care
Process
and
Model
Update:
toward
realizing
people-centered
care
and
outcomes
management.
J
Acad
Nutr
Diet.
2017;
117:
2003-14;
Figure
2,
p.
2008.
Key
Concepts:
Nutrition
Care
Process
and
Model
©
Nutrition
care
is
provided
within
the
context
of
a
larger
model
that
includes
a
central
core
focused
on
individualized
care
and
positive
Telationships.
e
Both
external
(environmental)
and
internal
(resources
of
dietetics
practitioner)
factors
influence
the
type
of
nutrition
care
provided.
©
The
steps
of
the
NCP
are
supported
by
two
other
systems:
the
screening
and
referral
system
and
the
outcomes
management
system.
Dietetics
practitioners
participate
in
both
of
these
systems,
but
may
not
have
sole
responsibility
for
accomplishing
these
tasks.
The
other
system
supporting
the
NCP
is
the
outcomes
management
system.
An
outcomes
management
system
is
used
to
evaluate
the
effectiveness
and
efficiency
of
the
entire
24
Part
2.
The
Nutrition
Care
Process
NCP
(assessment,
diagnosis,
interventions,
outcomes,
costs,
and
other
factors)
when
nutrition
care
is
provided
to
a
num-
ber
of
patients.
Outcomes
management
is
different
from
the
fourth
step,
nutrition
monitoring
and
evaluation,
which
refers
to
the
evaluation
of
a single
patient’s/client’s
progress
in
achieving
goals
and
desired
outcomes.
Health
care
organizations
use
complex
information
management
systems
to
manage
resources
and
track
perfor-
mance.
Selected
information
documented
throughout
the
NCP
is
entered
into
these
central
information
management
systems
and
structured
databases.
Relevant
aggregate
data
(data
from
a
number
of
individual
sources
that
have
been
summed
together
to
create
a
larger
whole)
can
then
be
col-
lected
and
analyzed
in
a
timely
manner.
Performance
can
be
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part,
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect the
overall
learning
experience.
Cengage
Learning
reserves
the right
toremove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
it,
adjusted
based
on
this
analysis in
order
to
improve
outcomes.
For
example,
data
collected
over
time
might
reveal
that
fewer
than
45%
of
clients
seen
in
an
outpatient
setting
received
follow-up
appointments,
and
that
of
those
45%,
fewer
than
half
met
desired
outcome
goals.
These
data
would
then
be
used
to
more
closely
examine
the
system
of
access
and
record
keeping
as
well
as
the
type
of interventions
used
to
provide
care.
Such
an
analysis
can
assist
in
the
creation
of
policies
for
increasing
the
number
of
patients
who
receive
follow-up
care
and
in
better
achieving
expected
outcomes.
When
nutrition
services
have
systems
in
place
that
can
measure
and
evaluate
data
from
many
clients
(aggregate
data),
these
data
can
then be
combined
with
data
from
other
nutri-
tion care
providers
and
be
part
of
evidence-based
research
that
demonstrates
the
benefit
and
effectiveness
of
nutrition
care
and
even
contribute
to
additional
research
for
popula-
tion
health.
For
example,
registered
dietitians
using
the
NCP
who
have
collected
outcome
data
on
the
benefits
of
nutrition
counseling
on
blood
glucose
control
in
patients
with type
2
diabetes
mellitus
could
then
tabulate
the data
to
summarize
and
report
on
a larger
number
of
patients.
The
Academy
of
Nutrition
and
Dietetics
Health
Infor-
matics
Infrastructure
(ANDHII)
is
a
web-based
system
pro-
vided
by
the
Academy
for
collecting
health
outcomes
data
from
RDNs
and
NDTRs
in
practice.
ANDHII
is
free
to
all
members
of
the
Academy
and
to
all
RDNs
and
NDTRs
regis-
tered
through
the
Commission
on
Dietetic
Registration.
Any
RDN
may
contribute
to
the
National
Quality
Improvement
Tool,
which
is
used
to
collect
data
on
nutrition
interventions
and
outcomes.
For
students
and
educators, there
is
also
an
Education
and
Practice
project,
which
allows
users
to
practice
entering data
and
using
the
nutrition
care
process
electroni-
cally
(see
Chapter
6).
2.5
STEPS
OF
THE
NCP
Step
1:
Nutrition
Assessment
The
first
step
of
the
NCP
(see
Table
2.3)
provides
important
information
that
helps
determine
a
person's
health
and
nutri-
tional
status.
It
is
initiated
by
the
referral
and/or
screening
of
individuals
or
groups
for
nutritional
risk
factors.
A
nutrition
assessment
is
a
systematic
process
of
obtaining,
verifying,
and
interpreting
data
in
order
to
make
decisions
about
the
nature
and
cause
of
nutrition-related
problems
(see
Chapter
3).
It is
an
ongoing
process
that
involves
initial
data
collection
and
continual
reassessment
and
analysis
of
a
client’s
needs
and
condition.
The
resulting
data
are
used
to
accurately
describe
nutrition
problems
and
facilitate
a
nutrition
diagnosis
at
the
next
step of
the
NCP.
Assessment
data
also
provide
a
means
to
reevaluate
the
nutrition
problem
as
part
of
nutrition
moni-
toring
and
evaluation,
the
fourth
step
in
the
NCP.
Nutrition
assessment
focuses
on
understanding
the
wide
variety
of
factors
(listed
in
Table
2.1)
that
influence
a
person’s
nutritional
status.
Assessment
data
provide
information
about
the
types
of
nutrition
problems
present
as
well
as
their
likely
causes;
they
are
also
used
to
describe
the
severity
of
these
problems. For
example,
if
the
nutrition
problem
is
“undesir-
able
food
choices”
or
a
specific
type
of
food
that
is
undesir-
able,
such
as
“32
ounces
of
sugar-sweetened
fruit
drinks
a
day,’
would
be
used
to
describe
and
quantify
that
problem.
Table
2.3
Overview
of
the
Steps
of
the
Nutrition
Care
Process
1.
Obtain
and
verify
appropriate
data.
2.
Cluster
and
organize
assessment
data
according
to
assessment
domains
and
possible
nutrition
diagnoses.
3.
Evaluate
the
data
using
reliable
standards.
4.
Calculate
estimated
nutrient
needs
(e.g.,
nutrition
prescription
as
appropriate).
1.
Identify
possible
diagnostic
labels.
2.
Complete
nutrition
diagnostic
statements
using
the
PES
format.
3.
Evaluate
the
quality
of
PES
statements.
1.
Prioritize
the
nutrition
diagnoses.
2.
Identify
ideal
goals
and
expected
outcomes.
3.
Plan
the
nutrition
interventions
using
the
standardized
interven-
tion
language.
4.
Implement
the
nutrition
interventions.
1.
Monitor
progress.
2.
Measure
outcomes.
3.
Evaluate
outcomes.
These
data
will
then
determine
what
types
of
outcomes
are
desired.
In
this
case,
the
amount
and
type
of
beverages
con-
sumed
would
be
tracked
over
time.
Once
a
problem
has
been
accurately
defined
and
quantified,
client
goals
can
be
estab-
lished.
If
a client
is
consuming
too
many
sugar-sweetened
fruit
drinks,
the
goal
might
be
to
consume
4
ounces
of
100%
fruit
juice
in
place
of
one
fruit
drink
and
substitute
water
for
the
remainder.
Each
piece
of
nutrition
assessment
data
is
col-
lected
for a
specific
purpose.
It
helps
answer
the
following
types
of
questions:
1.
What
can
be
determined
about
this
person's
nutritional
status
and
all
of
the
possible
factors
that
contribute
to
nutritional
balance?
N
What
possible
nutrition
diagnosis/es are
supported
by
the
available
evidence?
~
‘What
additional
data
might
be
necessary
to
validate
the
suspected
nutrition
diagnoses?
As
dietetics
practitioners
collect
data,
they
should
simul-
taneously
be
thinking
about
the
“why”
(factors
that
contrib-
ute
to
or
cause
imbalance
in
nutritional
status)
and
the
“what”
(possible
nutrition
diagnoses).
Obtain
and
Verify
Appropriate
Data
The
specific
type
of
data
gathered
in
the
assessment can
vary
depending
ona
number
of
factors
such
as
practice
setting
or
the individu-
al’s/
group’s
present
health
status.
Dietetics
practitioners
who
serve
clients
at
a
Women,
Infants,
and
Children
(WIC)
clinic
will
obtain
anthropometric
data
on
head
circumference
and
height
and
weight
plotted
on
growth
charts
in
order
to
assess
the
development
of
infants and
children.
Dietetics
practi-
tioners
in
outpatient
clinics
will
obtain
height
and
weight
Chapter
2.
Overview:
The
Nutrition
Care
Process
25
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
require
i
measurements
for
adults
and
may
also
gather
data
from
a
nutrition-focused
physical
examination.
Recommended
prac-
tices,
as
indicated
in
the
AND’s
evidence-based
guidelines
for
practice
or
from
other
evidence-based
research,
will
influence
the
type
of
data
collected
in a
nutrition
assessment.
Lipid
profiles
would
be
appropriate
for
patients
with
type
2
diabetes
and
cardiovascular
diseases,
whereas
BUN,
creati-
nine,
and
serum
phosphorus
will
be
evaluated
when
provid-
ing
nutrition
care
to
patients
with
renal
disease.
The
type
of data
collected
also
depends
on
whether
an
initial
assessment
or
a
reassessment
is
being
conducted.
For
example,
a
thorough,
detailed
diet
history
is
valuable
during
an
initial
assessment,
but
a
brief
investigation
of
intake
of
a
specific
nutrient
such
as
fiber
might
be
more
valuable
in
a
fol-
low-up
visit
3
weeks
later,
especially
if
inadequate
intake
of
fiber
was
one
of
the
nutrition
problems
identified
during
the
initial
appointment.
The
dietitian
needs
to
know
what
type
of
data
is
most
appropriate
to
collect
and
to
be
able
to
determine
whether
those
data
are
valid
and
accurate.
For
example,
a
stated
weight
may
or
may
not
represent
the current
weight
of
a
client.
Accurate
and
valid
diet
history
information
is
depen-
dent
on
the
ability
of the
dietitian
to
establish
a
trusting
and
nonthreatening
relationship
with
the
client.
In
all
cases,
the
data
that
are
reviewed
should
be
related
to
the
types
of
nutri-
ion
problems
likely
to
be
encountered.
Cluster
and
Organize
Assessment
Data
As
shown
in
Box
2.1,
the
nutrition
assessment
standardized
terms
are
grouped
into
five
domains:
(1)
food-/nutrition-related
his-
tory;
(2)
anthropometric
measurements;
(3)
biochemical
data,
medical
tests,
and
procedures;
(4)
nutrition-focused
physical
findings;
and
(5)
client
history.
Organizing
the
data
accord-
ing
to
the
five
domains
canreveal
possible
nutrition
problem
domains
from
which
a
nutrition
diagnostic
statement
can
then
be
more
accurately
formulated.
The
dietetics
practitioner
will
examine
anthropometric
data
(refer
to
Chapter
3)
with
the
intended
purpose
of
rul-
ing
in
or ruling
out
the
possibility
of
weight
classification
problems:
underweight,
unintended
weight
loss
or
gain,
or
overweight/obesity.
Specific
data
from
dietary
intake
assess-
ment
reveal
important
information
about
the
extent
of
possi-
ble
intake
domain
nutrition
diagnoses.
Information
gathered
in
an
interview
that
reveals
a
person’s
knowledge
and
beliefs
about
health
and
nutrition
allows
the
dietetics
practitioner
to rule
in
or
rule
out
possible
problems
in
the
knowledge
and
behavior
classification
of
the
behavioral-environmental
domain.
Each
piece
of
assessment
data
helps
answer
a
ques-
tion
regarding
the
presence,
severity,
and
cause
of
a
specific
nutrition
problem.
Using an
organized
structure
that
focuses
on
nutrition
problem
areas
assists
dietetics
practitioners
to
think
critically
about
the
meaning
of
the
data
and
logically
move
into
the
next
steps
of
the
NCP.
Evaluate
the
Data
Using
Reliable
Standards
It
is
not
only
important
that
data
be
linked
to specific
types
of
prob-
lems;
it
is
equally
important
that
the
information
obtained
in
a
nutrition
assessment
be
compared
to
evidenced-based
stan-
dards
or
ideal
goals.
Reference
standards
located
in
this
text-
book
or
one
your
instructor
may
require
should
determine
the
nutrient
needs
of
an
individual.
They
include
standards
for
energy,
macronutrient,
fluid,
and
micronutrient
needs
as
well
as
recommendations
for
body
weight
and
growth.
Comparative
standards
are
used
to
formulate
the
nutrition
prescription;
they
may
also
need
to
be
reevaluated
after
an
intervention
in
the
event
that
the
plan
is
adjusted
due
to
out-
comes
(either
positive
or
not
meeting
goals).
The
estimated
needs,
once
appropriately
determined,
provide
the
basis
for
nutrition
goals
and
the
standards
by
which
to
compare
cur-
rent
dietary
intake
and
weight
to
recommendations.**
Key
Concepts:
NCP
Step
1,
Nutrition
Assessment
¢
Nutrition
assessment
should
ensure
that
appropriate
and
reliable
data
are
collected
for
use
in
determining
the
existence
of
specific
nutrition
problems.
©
Organizing
and
categorizing
data
utilizing
the
five
domains
of
the
assessment
standardized
terms
improves
the
efficiency
and
effec-
tiveness
of
nutrition
assessment
and
nutrition
diagnosis.
BOX
2.
CLINICAL
APPLICATIONS
Nutri
ion
Assessment
Standardized
Language:
Domains
and
Examples
¢
Food/Nutrition-Related
History
26
(FH):
Food
and
Nutrient
Intake
(1),
Food
and
Nutrient
Administration
(2),
Medication
and
Complementary/Alter-
native
Medicine
Use
(3),
Knowledge/
Beliefs/
Attitudes
(4),
Behavior
(5),
Factors
Affecting
Access
to
Food
and
Food/
Nutrition-Related
Supplies
(6),
Physical Activity
and
Function
(7),
and
Nutrition-Related
Patient/Client-
Centered
Measures
(8)
Examples:
Total
carbohydrate
intake
from
the
diet,
fat
and
cholesterol
intake,
meal/snack
pattern,
area
and
level
of
knowledge,
eligibility
for
Part
2.
The
Nutrition
Care
Process
community
programs,
type
of
physi-
.
cal
activity
Anthropometric
Measurements
(AD):
Height,
weight,
body
mass
index
(BMI),
growth
pattern
indices/percen-
tile
ranks,
and
weight
history
Examples:
Dosing
weight,
weight
change,
body
mass
index,
measured
height
Biochemical
Data,
Medical
Tests,
and
Procedures
(BD):
Lab
data
(e.g.,
elec-
trolytes,
glucose)
and
tests
(e.g.,
gastric
emptying
time,
resting
metabolic
rate)
Examples:
BUN:
creatinine
ratio;
fast-
ing
glucose;
cholesterol,
HDL
Nutrition-Focused
Physical
Findings
(PD): Findings
from
evaluation
of
body
systems,
muscle
and
subcutaneous
fat
wasting,
oral
health,
suck/swallow/breathing
ability,
appetite.
Examples:
Loss
of
subcutaneous
triceps
fat;
deltoid
muscle
atrophy;
interosse-
ous
hand
muscle
atrophy
Client
History
(CH):
Current
and
past
information
related
to
personal,
medi-
cal,
family,
and
social
history
Examples:
Education,
medical
treatment/therapy,
socioeconomic
factors
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
i
Step
2:
Nutrition
Diagnosis
Nutrition
diagnosis,
the
second
step
of
the
NCP,
consists
of
the
identification
of
a
nutrition
problem
that
dietetics
prac-
titioners
are
responsible
for
treating
independently.
Nutri-
tion
diagnosis
is
the
direct
link
between
nutrition
assessment
and
nutrition
intervention.
A
nutrition
diagnosis
should
not
be
confused
with
a
medical
diagnosis,
which
involves
the
art
and
science
of
distinguishing
one
disease
from
another
and
describes
the
nature
of
that
disease.
A
disease
is
defined
as
any
deviation
from
or
interruption
of
the
normal
structure
or
function
of
a body
part,
organ,
or
body
system.
Treatment
of
a
disease
involves
the
management
and
care
of
a
patient
for
the
purpose
of
healing
and
or
dealing
with
the
disorder.>
Many
diseases
have
profound
effects
on
a
person’s
nutri-
tional
balance.
The
alteration
of
normal
structure
and
func-
tion
of
organs
can
result
in
changes
in
nutrient
intake,
losses,
requirements,
and/or
utilization.
In some
cases,
nutrition
therapy
may
be
one
of the
most
important
ways
of
treating
and
managing
the
disease.
In
contrast
to
a
medical
diagnosis,
a
nutrition
diagnosis
is
written
in
terms
of
a client
problem
for
which
nutrition-
related
activities
provide
the
primary
intervention.
The
goal
of
nutrition
care
is
to
improve
the
health
and
nutritional
sta-
tus
of
a
client/patient
by
impacting
the
underlying
cause
of
the
nutritional
problem.
Nutrition
diagnoses
and
care
focus
on
nutrition
issues that
may
be
consequences
of
or
contribute
to
diseases.
Nutrition
diagnoses
also
address
behaviors
that
impact
food
choices.
Nutrition
diagnostic
terms
are
grouped
into
three
domains:
(1)
intake,
(2)
clinical,
and
(3)
behavioral-environ-
mental
(see
Box
2.2).
The
intake
domain
contains
nutrition
problems
that
are
related
to
the
intake
of
energy,
nutrients,
fluids,
and
bioactive
substances
through
oral
diet
or
nutri-
tion
support.
Labels
such
as
inadequate,
excessive,
or
less
than
optimal
intake
of
are
used
to describe
the
alteration
in
intake
of
a
specific
nutrient
or
substance
(e.g.,
types
of
fats
or
carbohydrates).
The
clinical
domain
contains
nutrition
prob-
lems
that
are
related
to
medical
or physical
conditions.
These
include
functional
problems
such
as
swallowing,
chewing,
digestion,
and
absorption;
biochemical
problems;
and
weight
e
Intake
(NI):
Domain
that contains
standardized
nutrition
diagnostic
terms
that
describe
actual
problems
related
to
intake of
energy,
nutrients,
fluids,
bioactive
substances
through
oral
diet
or
nutrition
support
Examples:
Inadequate
energy
intake,
excessive
oral
intake,
inadequate
fiber
.
intake,
inadequate
vitamin
intake
(folate)
©
Clinical
(NC):
Domain
that
contains
standardized
nutrition
diagnostic
BOX
2.2
CLINICAL
APPLICATIONS
Nutrition
Diagnosis
Standardized
Language:
Domains
and
Examples
terms
that describe
nutritional
prob-
lems
that
relate
to
medical
or
physical
conditions
(functional,
biochemical,
weight,
or
malnutrition
disorder).
Examples:
Swallowing
difficulty,
impaired
nutrient
utilization,
unin-
tended
weight
loss
Behavioral-Environmental
(NB):
Domain
that
contains
standard-
ized
nutrition
diagnostic
terms
that
describe
nutrition
problems
related
to
knowledge,
attitudes/beliefs,
physical
problems.
The
behavioral—environmental
domain
includes
problems
that
are
related
to
knowledge
and
beliefs,
physi-
cal
activity,
and
food
safety
and
access.
Within
each
of these
domains,
nutrition
problems
are
further
grouped
according
to
classifications
and
subclassifications.
Each
nutrition
diagnostic
term
has
a
term
number
anda
standard
definition.
For
example,
“inadequate
protein
intake”
(NI-5.6.1)
is
defined
as
“lower
intake
of
protein-containing
foods
or
substances
compared
to
established
reference
stan-
dards
or
recommendations
based
upon
physiological
needs?”
The
use
of
standard
definitions
helps
dietetics
practitioners
use
the
language
consistently
within
the
profession.
In
addi-
tion
to
the
numerical
coding
and
standard
definition,
the
AND
has
published
a
reference
with each
diagnostic
term
that
also
identifies
possible
etiologies
and
signs
and
symp-
toms
commonly
associated
with
that
nutrition
problem.
These
references
provide
tools
that
the
practitioner
may
use
to
examine
the
appropriate
data
and
ask
key
questions
when
determining
whether
a
nutrition
diagnosis
is
present
or
not.
For
instance,
the
sheet
for
the diagnosis
“inadequate
protein
intake”
names
“Lack
of
or
limited
access
to
food”
as a
poten-
tial
etiology,
and
“Report
or
observation
of
. . .
estimated
intake
of
protein
insufficient
to
meet
requirement”
as a
possi-
ble
sign/symptom
that
might
point
to
this
diagnosis.
As
the
dietetics
practilioner
gathers
nutrition
assess-
ment
data
in
order
to
determine
whether
or
not
a
patient
actually
has
a
nutrition
diagnosis
of
“inadequate
protein
intake,’
she
or
he
should
attempt
to
obtain
information
from
the
diet
and
client
history
that
will
provide
evidence
of
the
problem.
A
problem
should
not
be
identified
unless
there
is
adequate
evidence
to
support
its
presence.
In
this
case,
data
describing
the
amount
of
protein
that
is
consumed
would
be
essential
for
determining
how
far
below
the
recommenda-
tion
the
patient’s
protein
intake
actually
is.
Other
data
from
the
assessment
might
provide
clues
about
the
cause
of
the
problem,
such
as
physiological
reasons
for
increased
need,
lack of
access
to
food,
knowledge
deficit,
or
psychological
causes.
By
using
these
references,
dietetics
practitioners
can
ensure
that
the
diagnostic
terminology
is
used
consistently
and
accurately.°
environment,
access
to
food,
and
food
safety
Examples:
Not
ready
for
diet/Ifestyle
change,
self-feeding
difficulty,
intake
of
unsafe
food
Reference
Academy
of
Nutrition
and
Dietetics.
Nutrition
Terminology
Reference
Manual
(eNCPT):
Dietetics
Language
for
Nutrition
Care.
http:/Avww.ncpro.org,
accessed
July
31,
2018.
Chapter
2.
Overview:
The
Nutrition
Care
Process
27
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
require
i
PES
Statements
Nutrition
diagnoses
are
written
ina
PES
(problem,
etiology,
signs/symptoms)
format
that
lists
the
problem,
its
cause,
and
appropriate
defining
character-
istics.
The
problem
(P)
is
also
referred
to
as
the diagnostic
label.
It
describes
in a
general
way
an
alteration
in
the
cli-
ent’s
nutritional
status.
Words
such
as
excessive,
inadequate,
and
less
than
optimal
are
frequently
found
in
these
labels.
The
etiology
(E)
or
related
factors
are
those
that
contribute
to
the
cause
or
existence
of
a
particular
problem.Finally,
the
signs
and
symptoms
(S)
are
the
defining
characteristics
obtained
from
the
subjective
and
objective
nutrition
assess-
ment
data.
These
data
provide
evidence
that
a
problem
exists
and
describe
the
severity
of
the
problem.
When
these
three
parts
are
used
to
form
the
nutrition
diagnostic
state-
ment,
it
is
generally
stated
in
the following
way:
the
problem
(P)
related
to
the
etiology
(E)
as
evidenced
by
the
signs
and
symptoms(S).
For
example,
consider
these
nutrition
diagnoses:
+
“Inadequate
energy
intake
(P)
related
to
changes
in
taste
and
appetite
secondary
to
chemotherapy
(E)
as
evidenced
by
average
daily
kcal
intake
50%
less
than
estimated
needs
(S)”
+
“Unintended
weight
loss
(P)
related
to
inadequate
energy
intake
(E)
as
evidenced
by
8
pounds
(7%
of
UBW)
weight
loss
within
4
weeks
(S)”
Let’s
examine
how
these
diagnoses
were
made.
A
comprehen-
sive
nutrition
assessment
reveals
the
following
data:
+
Client
is
undergoing
chemotherapy
for
cancer
treatment
(client’s
medical
history).
*
Client
complains
of
meats
tasting
bitter
and
most
bever-
ages
too
sweet
(subjective
data
from
food/nutrient-related
history).
+
Client
states,
“I
have
very
little
appetite
and
no
desire
to
eat”
(subjective
data
from
food/nutrient
intake
history).
+
Three-day
food
records
reveal
average
kcal
intake
of
approximately
50%
of
estimated
needs
(objective
dietary
intake
data
compared
to
estimated
needs).
+
Client
has
experienced
weight
loss
of
8 pounds
since
last
outpatient
visit
1
month
ago
(objective
anthropometric
measurements).
In
order
to
evaluate
the
above
nutrition
assessment
data,
the
dietetics
practitioner
applies
a
number
of
the
critical
thinking
skills
listed
in
Table
2.2.
These
include finding
pat-
terns
and
relationships
between
the
data
and
possible
causes,
stating
each
problem
clearly
and
singularly,
ruling
in/ruling
out
specific
diagnoses,
and
prioritizing
the
importance
of
the
diagnoses.
From
the
relationships
that
exist
among
the
assessment
data
just
noted,
“inadequate
energy
intake”
and
“unintended
weight
loss”
are
selected
as
relevant
nutrition
problems.
It
is
essential
to
focus
on
problems
for
which
nutrition
inter-
ventions
will
be
the
primary
treatment.
Once
the appropri-
ate
problems
have
been
selected,
the
next
step
is
to
describe
accurately
the
signs
and
symptoms.
The
signs
and
symptoms
are
used
to
validate
and
confirm
the
existence
of
problems.
They
also
indicate
the
severity
of
the
problems,
answering
the
questions
“How
much?”
and
“How
do
I
know?”
28
Part
2
The
Nutrition
Care
Process
Finally,
after
the
problem
is
validated
by
identifying
the
appropriate
signs
and
symptoms,
its
etiology
or
cause
is
explored.
To
determine
the
etiology,
related factors
and
addi-
tional
data
from
the
assessment
are
reviewed.
It
is
important
to
seek
the answer
to
the
question
“Why
does
this
problem
exist?”
and
explore
all
possibilities.
It
may
even be
necessary
to
frequently ask
the
question
“Why?”
to
uncover
the
under-
lying
root
cause
of
the
nutrition
problem.
To
summarize:
+
The
problem
is
the
“What?”
+
The
etiology
is
the
“Why?”
+
The
signs/symptoms
are
the
“How
do
I
know?”
or
“How
severe
is
the
problem?”
In
the
present
example,
two
important
points
about
eti-
ology
are
illustrated.
First,
even
though
medical
diagnoses
(cancer)
and/or
medical
treatment
(chemotherapy)
contrib-
ute
to
nutrition
problems,
they should
not
be
used
as
the
pri-
mary
etiology.
Instead,
it
is
best
that
a
nutrition-related
cause
be
part
of
the
etiology.
This
is
consistent
with
the
guiding
principle
that
distinguishes
a
nutrition
diagnosis
from
other
diagnoses.
First,
a
nutrition
diagnosis
is
written
in
terms
of a
client
problem
for
which
nutrition-related
activities
provide
the
primary
intervention.
Second,
nutrition
diagnostic
termi-
nology
is
always
used
to
identify
the
nutrition
problem
(P).
This
language
can
also
be
used
as
etiology
language.
Behav-
iors
and
patterns
of
food
and
nutrient
intakes
that
are
unde-
sirable
(problems
in
and
of
themselves)
can
produce
other
problems
such
as
changes
in
anthropometric,
biochemical,
or
clinical
findings.
In
the
present
example,
inadequate
caloric
intake
is
the
primary
cause
of
unintentional
weight
loss.
Traditionally,
nutrition
care
has
been
driven
by
diet
orders
associated
with
certain
disease
conditions,
such
as
diet
orders
for a
“renal
diet,’
a
“diabetic
diet,’
or
a
“weight-
loss
diet.”
With
the
advent
of the
standardized
nutrition
lan-
guage
and
nutrition
diagnoses,
nutrition
care
can
and
should
be
driven
by
the
extent
of
a
nutrition
problem
rather
than
solely
by
a diet
order
or
medical
condition.
Though
medical
conditions
affect
a
person's
need
for
and
ability
to
consume,
digest,
metabolize,
and
utilize
nutrients,
the
nutrition
diagno-
sis
rather
than
the
medical
diagnosis
determines
the
specific
type
of
nutrition
intervention.
Instead
of
providing
nutrition
care/education
as
a
result
of
a
diet
order
for
a
diabetic
or
renal
diet,
the
dietitian
should
carefully
assess
the
nutritional
status
of
each
patient
to
spe-
cifically
identify
what,
if
any,
nutrition
problems
(diagnoses)
exist.
For
example,
a
patient
with
type
2
diabetes
could
con-
ceivably
have
inconsistent
carbohydrate
intake,
undesirable
food
choices,
self-monitoring
deficit,
or
limited
adherence
to
nutrition-related
recommendations.
A
complete
assessment
may
reveal,
however,
the
absence
of
any
nutritional
problems
at
all.
In
the
case
of
a
patient
with
chronic
renal
disease,
there
could be
problems
such
as
excessive
potassium
intake
or
excessive
fluid
intake;
but
again, a
complete
assessment
may
show
there
are
no
problems.
Another
scenario
might
be
two
patients
with
different
medical
diagnoses
who
present
with
a
similar
nutrition
diagnosis,
such
as
involuntary
weight
loss.
In
summary,
using
the
nutrition
diagnoses
to
clarify
and
iden-
tify
specific
nutrition
problems
may
reveal
(1)
no
nutrition
problems
at
the
present
time,
(2)
different
nutrition
problems
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience.
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
require
i
for
patients
with
similar
medical
diagnoses,
or
(3)
similar
nutrition
problems
for
patients
with
different
medical
condi-
tions.
Note
that
in
cases
where
a
nutrition
assessment
reveals
no
nutrition
problems,
it
is
still
necessary
to
document
these
findings
in
the
patient’s
record
using
the
term
“no
nutrition
diagnosis
at
this time.”
Criteria
for
Evaluating
PES
Statements
Since
the
intent
of
nutrition
diagnoses
is
to
describe
those
problems
for
which
nutrition
intervention
is
the
primary
treatment,
it
is
important
to
develop
PES
statements
that
accurately
reflect
that
intent.
The
following
questions
and
criteria
were
devel-
oped
to
ensure
that
nutrition
diagnoses
are
well
written
and
accurately
represent
the
nutrition
problems:?
Problem
(P)
+
Can
the
dietetics
practitioner
impact,
improve,
or
resolve
the
nutrition
problem?
+
When
all
things
are
equal
and
there
is
a
choice
between
stating
the
PES
statement
using
two
nutrition
diagnoses
from
different
domains,
consider
the
intake
domain
as
more
specific
to
the
role
of
the
RDN.
Etiology
(E)
+
Is
the
etiology
truly
the root
cause?
¢
Isthere
an
intervention
that
will
address
the
root
cause,
thus
increasing
the
likelihood
that
a
positive
change
will
result?
Evaluating
a
Nutrition
Diagnosis
BOX
2.3
CLINICAL
APPLICATIONS
+
Ifitis
not
clear
that
the
problem
will
be
resolved
by
addressing
the
etiology,
can
an
intervention
at
least
reduce
or
lessen
the
significance
of
the
signs
and
symptoms?
Signs
and
Symptoms
(S)
+
Are
the
signs
and
symptoms
that
are
used
to
describe the
problem
specific
enough
to
be
measured?
+
Will
measuring
the
signs
and
symptoms
indicate
if
the
problem
is
resolved
or
improved?
PES
Overall
«
Are
the
problems
clearly
and
singularly
stated?
+
Does
the
assessment
data
used
to identify
the
nutrition
diagnosis
support
and
link
to
the
diagnostic
statement,
etiology,
and
signs
and
symptoms?
Box
2.3
demonstrates
how
these
criteria
are
used
to
evaluate
and
refine
PES
statements
for
a
client
with
diabetes.
Relationship
of
Nutrition
Diagnosis
to
the
Other
Steps
of
the
NCP
Figure
2.4
illustrates
the
relationship
of the
nutrition
diagnosis
to
the
other
steps
of
the
NCP.
As
stated previously,
the
nutrition
diagnosis
links
nutrition
assessment
to
nutrition
intervention.
An
accurate
nutrition
diagnosis
is
generated
from
a
focused
nutrition
assessment
and
sets
the
stage
for
the
next
two
steps
of the
NCP:
Step
3,
nutrition
intervention,
and
Step
4,
nutrition
monitoring
and
evaluation.
When
data
are
obtained
from
a
nutrition
assessment,
a
number
of
findings
can
pro-
vide
clues
to
the
presence
of
a
particular
nutrition
diagnosis.
The
dietetics
practi-
tioner
needs
to
distinguish
among
(1)
data
that
are
associated
with
a
nutrition
prob-
lem
and/or
may
be
a
consequence
of
that
problem,
(2)
data
that
will
be used
to
doc-
ument
the
specific
signs
and
symptoms
that
describe
and
quantify that
problem,
and
(3)
data
that
will
provide
insight
into
the
root
cause
of
the
problem.
Which
of
the
following
nutrition
diagnoses
is
preferred
and
why?
A.
Inconsistent
carbohydrate
intake
related
to
not
following
a
diabetic
diet
as
evidenced
by
elevated
blood
glu-
cose
of
250
mg/dL
B.
Inconsistent
carbohydrate
intake
related
to
inability
to
read
labels
cor-
rectly
for
carbohydrate
content
and
lack
of
knowledge
about
amount
of
grams/carbohydrate
units
as
evidenced
by
carbohydrate
units
in
three
meals
of
1,6,
and
3
Evaluate
the
P:
Can
the
dietetics
pro-
fessional
impact,
improve,
or
resolve
the
nutrition
problem?
In
both
examples,
the
nutrition
problem
“inconsistent
carbohy-
drate
intake”
is
one
that
can
be
improved
or resolved.
Evaluate the
E:
|s
the
etiology
truly
the
root
cause?
Even
though
not
following
a
diet
plan
is
likely
contributing
to
the
incon-
sistent
carbohydrate
intake,
there
needs
to
be
further
understanding
as
to
the
reasons
why
a
meal
plan
is
not
being
followed.
In
other
words,
asking
“why”
uncovers
the
real
reason
for
not
following
the
plan
and
is
more
clearly
stated
in
example
B.
Is
there
an
intervention
that
will
address
the
root cause,
thus
increasing
the
likelihood
that
a positive
change
will
result?
Developing
an
intervention
using
example
A
might
lead
prematurely
to
a
more
traditional
diet
education
of
a
diabetic
diet,
whereas
addressing the
real
reason
for
not
being
able
to
follow
a
meal
plan
gives
both
the
provider
and
the
client
a more
realistic
and
specific
plan
for
education.
Focusing
on
the
two
topics
in
B
should
increase
the
likelihood
that
a
positive
change
will
occur
compared
with
an
education
plan
that
is
more
general.
Can
an
intervention
reduce
the
sig-
nificance
of
the
signs
and
symptoms?
In
the
case
of
example
A,
it
is
not
clear
that
a
change
in
carbohydrate
intake
alone
will
improve
the
blood
glucose.
There
could
be
other
factors
that
are
impacting
on
the
blood
glucose
levels
such
as
medication,
illness,
and
so
on,
whereas
the
signs
and
symptoms
in
B
are
more
descriptive
of
the
problem
itself.
Evaluate
the
S:
Are
the
signs
and
symptoms
used
to
describe
the
problem
specific
enough
to
be
measured?
In
both
cases,
the
signs
and
symptoms
can
be
measured;
however,
improvement
in
car-
bohydrate
units
can
be
evaluated
within
a
shorter
time
frame
than
can
improve-
ments
in
blood
glucose.
Furthermore,
changes
in
meal
patterns
can
be
expected
in
direct
response
to
the
intervention,
whereas
changes
in
blood
glucose
are
(continued)
Chapter
2.
Overview:
The
Nutrition
Care
Process
Copyright
2020
Cengage
Leaming.
All
Rights
Reserved.
May
not
be
copied,
scanned,
or
duplicated,
in
whole
or
in
part.
Due
to
electronic
rights,
some
third
party
content
may
be
suppressed
from
the
eBook
and/or
eChapter(s).
Editorial
review
has
deemed
that
any
suppressed
content
does
not
materially
affect
the
overall
leaming
experience,
Cengage
Learning
reserves
the
right
to
remove
additional
content
at
any
time
if
subsequent
rights
restrictions
requice
i.
Response
Student’s Name
Institutional Affiliations
Course
Date
Response
So far, I have come across several viewpoints about NCP, and they all argue positively
about the role of NCP in public health. I did my research and used several readings about NCP,
and I also agree that NCP is essential in public health as it helps in fixing the nutritional
imbalances that patients suffer from.1 Scientists argue that NCP is utilized to improve the quality
of care to patients because it is a standardized design to address the issue of nutritional
imbalances. According to the reading, practitioners who use NCP to extend care to their patients
always provide high-quality nutrition care to clients because they follow evidence-based practice
procedures. Other scientists argue that nutrition-related medication is important since nutrition
assessment enables practitioners to determine the nutrient composition the patient needs.2 This
can be achieved by employing NCP as a standardized nutrition care method.1 Though other
viewpoints maintain that nutrition education is good for nutrition care, it cannot replace NCP
because only nutrition knowledge is insufficient to help a person with nutrition problems.3 For
instance, a person may know the foods to take but not the quantities necessary to correct nutrient
imbalances. In other words, most viewpoints favor NCP by arguing that NCP and other nutrition
interventions enable practitioners to improve the quality of nutrition care. No single argument
goes against NCP, indicating that the process is helpful.
References
1. The Nutrition Care Process, (n.d). Overview: The Nutrition Care Process.
2. Nutrition Intervention, (n.d). Chapter 4: Nutrition Intervention, Nutrition Monitoring and
Evaluation.
3. Nutrition Assessment, (n.d). Chapter 3: Foundation of the Nutrition Care Process.
