INTRODUCTION TO NUTRITION CARE PROCESS

1.0 Introduction to NCP

1.1 Meaning of terms
Nutrient is a substance that provides nourishment essential for the maintenance of life and for
growth.

Nutrition This is the science of food, the nutrients and other substances therein, their action,
interaction, and their balance in relation to health and disease or the process by which the
organism ingests, digests, absorbs, transports, utilizes and excretes food substances.

Nutritional status this refers to the condition of health of an individual as influenced by the
intake and utilization of nutrients
Malnutrition this refers to any condition caused by an excess or deficient of energy or nutrient
intake or by an imbalance of nutrients. It is as a result of an imbalance between dietary intake
and requirements. There are single nutrient deficiencies, and imbalances of two or more required
nutrients.

Nutrition Care Process (NCP) - A systematic problem solving method that food and nutrition
professionals use to think critically and make decisions that address practice related problems.
Nutrition Care Model is a visual representation that reflects key concepts of each step of the
Nutrition Care Process and illustrates the greater context within which the Nutrition Care Process
is conducted. The model also identifies other factors that influence and impact on the quality of
nutrition care provided.

1.2 PURPOSE OF NCP

Nutrition Care Process gives dietetics professionals a consistent and systematic structure
and method by which to think critically and make decisions.
It also assists dietetics professionals to scientifically and holistically manage nutrition
care, thus helping patients to better meet their health and nutrition goals.
consistent use of the Nutrition Care Process increases probability of producing good
outcomes.
The Nutrition Care Process helps to establish a link between quality and professional
autonomy

1.3 Relationship between nutrition and disease

“Interactions of Nutrition and Infection (disease) is a synergistic one

Malnutrition can make a person more susceptible to infection, and infection also contributes to
malnutrition, which causes a vicious cycle. An inadequate dietary intake leads to weight loss,
lowered immunity, mucosal damage, invasion by pathogens, and impaired growth and
development in children
A sick person’s nutrition is further aggravated by diarrhea, malabsorption, loss of appetite,
diversion of nutrients for the immune response, and urinary nitrogen loss, all of which lead to
nutrient losses and further damage to defense mechanisms.
These, in turn, cause reduced dietary intake. In addition, fever increases both energy and
micronutrient requirements. Malaria and influenza, for example, have mortality rates
proportionate to the degree of malnutrition

1.4 Role of health professionals in nutrition care process

A healthcare professional’s role in nutritional care varies depending on the job. Depending on
the nature of the problem, a healthcare team might include physicians, nurses, nutritionists,
dietitians, and others such as pharmacists, mental health counselors, and physical therapists.
A nutrition professional can advise, counsel, coordinate, educate, guide, inform, suggest, and
support. A nutrition professional can develop a comprehensive nutrition program, including
nutrition and lifestyle goals.

The role of a nurse in nutrition care process is to assess and educate. The nurse develops a
nutrition plan and tell the patient what to eat.

1.5 Steps in nutrition care process

Nutrition care process [NCP] is a systematic approach to providing high quality nutrition care
and is visually summarized by the Nutrition Care Model.

Etiology [Causes/ Contributing factors]

 Related factors that contribute to problem

 Identifies cause of the problem
 Helps determine whether nutrition intervention will improve problem
 Note: etiology may not always be clear

Nutrition care model

The Nutrition Care Model is a graphic visualization that illustrates the steps of the Nutrition
Care Process as well as internal and external factors that impact application of the NCP. The
central component of the Model is the relationship of the target client or group and the RDN.
One of two outer rings represents the skills and abilities of the RDN along with application of
evidence-based practice, application of the Code of Ethics, and knowledge of the RDN. The
second of two outer rings represents environmental factors such as healthcare systems,
socioeconomics and practice settings that impact the ability of the target group or client to
benefit from RDN services. Screening and referral and outcomes management are also
components of the model.
2.0 NUTRITION ASSESSMENT
It is a systematic process of obtaining, verifying, and interpreting data in order to make
decisions about the nature and cause of nutrition-related problems.
The process of estimating the nutritional position of an individual or group, at a given point in
time, by using proxy measurements of nutritional adequacy. It provides an indication of the
adequacy of the balance between dietary intake and metabolic requirements
It can be done at the community level OR individual level
Nutritional assessment is the interpretation of anthropometric, biochemical (laboratory),
clinical and dietary data to determine whether a person or groups of people are well nourished or
malnourished (over-nourished or under-nourished)

Components of Nutrition assessment

 Gather data, considering
 Compare to relevant standards
 Identify possible problem areas

Aim: To discover facts useful in guiding actions intended to improve nutritional status and health
at either individual or community level
2.1 Importance of nutrition assessment data
 Diagnostic tool for both individuals or groups of people:
• Does a problem exist?
• Is there a risk of the problem developing?
• What is the magnitude of the problem
 Monitoring tool for both individuals or groups of people:
 Has the situation changed?
 What is the direction and magnitude of change?
 Is there a trend or a pattern?
 Evaluation tool for both individuals or groups of people
 This is applicable where an on-going programme, treatment, or intervention is to be
evaluated.
  It is useful in determining if the intended effect (impact/recovery) has been achieved
e.g. Nutrition Rehabilitation Programme
 Targeting tool (groups only)
 To what group, geographic area, during which period does one focus the
intervention? E.g. Which province had the highest prevalence of malnutrition, which
age group, or what socio-economic status of people have the highest prevalence of a
deficiency etc?
Importance of nutrition assessment
 To identify people at risk of malnutrition for early intervention or referral before they
become malnourished y
 To identify malnourished clients for treatment—malnourished people who are not treated
early have longer hospital stays, slower recovery from infection and complications, and
higher morbidity and mortality
 To track child growth
 To identify medical complications that affect the body’s ability to digest food and utilize
nutrients

2.2 Source of nutrition assessment data

Nutritional assessment can be done using the ABCD methods. These refer to the following:
 A.Anthropometry
 B.Biochemical/biophysical methods
 C.Clinical methods
 D.Dietary methods.

Nutritional assessment can be done using the ABCD methods. These refer to the following:

 A-Anthropometry
 B-Biochemical/biophysical methods
 C-Clinical methods
 D-Dietary methods.

The word anthropometry comes from two words: Anthropo means ‘human’ and metry means
‘measurement’. Anthropometry measurement therefore, means the measurement of size,
weight, body proportions and ultimately the composition of the human body. Anthropometric
indicators measure the impact of both food insecurity and health status on the nutritional status
of individuals. In your community you will be able to use anthropometric measurements to
assess either growth or change in the body composition of the people you are responsible for.
The different measurements taken to assess growth and body composition are presented below.

i) Anthropometric measurements used to assess growth

To assess growth in children you can use several different measurements including length,
height, weight and head circumference.

Length

A wooden measuring board (also called sliding board) is used for measuring the length of
children under two years old to the nearest millimeter. Measuring the child lying down always
gives readings greater than the child’s actual height by 1-2 cm.

Procedure

To measure the length of a child under two years, you need one assistant and a sliding board.

As you can see in Figure below, you need an assistant to help you measure a child using this
method.

1. Both assistant and measurer are on their knees

2. The assistant holds the child’s head with both hands and makes sure that the head touches
the base of the board
3. The assistant’s arms should be comfortably straight
4. The line of sight of the child should be perpendicular to the base of the board (looking
straight upwards)
5. The child should lie flat on the board
6. The measurer should place their hands on the child’s knees or shins
7. The child’s foot should be flat against the footpiece
8. Read the length from the tape attached to the board.
9. Record the measurement on the questionnaire
How to weigh and measure children: assessing the nutrition status of young children)

Height

This is measured with the child or adult in a standing position (usually children who are two
years old or more). The head should be in the Frankfurt position (a position where the line
passing from the external ear hole to the lower eye lid is parallel to the floor) during
measurement, and the shoulders, buttocks and the heels should touch the vertical stand. Either a
stadiometer or a portable anthropometer can be used for measuring. Measurements are recorded
to the nearest millimetre.

Procedure

As with measuring a child’s length, to measure a child’s height, you need to have another person
helping you. Figure below illustrates the procedures,

Both the assistant and measurer should be on their knees.

1. The right hand of the assistant should be on the shins of the child against the base of the
board
2. The left hand of the assistant should be on the knees of the child to keep them close to the
board
3. The heel, the calf, buttocks, shoulder and occipital prominence (prominent area on the
back of the head) should be flat against the board
4. The child should be looking straight ahead
5. The hands of the child should be by their side
6. The measurer’s left hand should be on the child’s chin
7. The child’s shoulders should be levelled.
8. The head piece should be placed firmly on the child’s head
9. The measurement should be recorded on the questionnaire
Weight

A weighing sling (spring balance), also called the ‘Salter Scale’ is used for measuring the
weight of children under two years old, to the nearest 0.1 kg. In adults and children over two
years a beam balance is used and the measurement is also to the nearest 0.1 kg. In both cases a
digital electronic scale can be used if you have one available. Do not forget to re-adjust the scale
to zero before each weighing. You also need to check whether your scale is measuring correctly
by weighing an object of known weight.

Procedures

In Figure below you can see the procedures for weighing a child under two years old using a
Salter Scale. The photo shows a small boy being weighted using the scale.
Weighing a child using a harness and spring balance. (Photo: UNICEF Ethiopia / Indrias
Getachew)

1. Adjust the pointer of the scale to zero level.

2. Take off the child’s heavy clothes and shoes.
3. Hold the child’s legs through the leg holes (arrow 1).
4. Hold the child’s feet (arrow 2).
5. Hang the child on the Salter Scale (arrow 3).
6. Read the scale at eye level to the nearest 0.1 kg (arrow 5).
7. Remove the child slowly and safely.
Improvised way of measuring weight of the child using salter scale. (Source: UNICEF Ethiopia /
Indrias Getachew)

Sometimes you will have to improvise. For example in the field set up, it is difficult to measure
very young children who cannot sit by themselves using the weighing pant attached to the scale.
In addition, some children panic during the measurement and urinate, making the pant dirty.
Therefore, mothers or caregivers may not be happy to let their children be measured in such a
manner. The weighing scale with the pant can be improvised by using a plastic washing-basin
which is attached to the Salter Scale and adjusting the reading to zero. You need to ensure the
basin is as close to the ground as possible in case the child falls out, and to make the child feel
secure during weighing. If the basin is dirty, then you need to clean it with a disinfectant. This is
a much more comfortable and reassuring weighing method for the child and you can use it for ill
children much more easily than the approaches described above.

 How do you know whether your weight measuring scale is correct?

Reveal answer You can check the accuracy of the scale you’re using by measuring an
object of known weight.
 Head circumference

The head circumference (HC) is the measurement of the head along the supra orbital ridge
(forehead) anteriorly and occipital prominence (the prominent area on the back part of the head)
posteriorly. It is measured to the nearest millimetre using flexible, non-stretchable measuring
tape around 0.6cm wide. HC is useful in assessing chronic nutritional problems in children
under two years old as the brain grows faster during the first two years of life. But after two
years the growth of the brain is more sluggish and HC is not useful. In Ethiopia, HC is measured
at birth for all newborn babies.

Now you have looked at how to take different measurements you are going to learn how the
measurements are converted into different indices.

Converting measurements to indices

An index is a combination of two measurements or one measurement plus the person’s age.
The following are a few indices that you may find useful in your work:

Weight-for-age is an index used in growth monitoring for assessing children who may be
underweight. You assess weight-for-age of all children under two years old when you carry out
your community-based nutrition (CBN) activities every month.

Height-for age is an index used for assessing stunting (chronic malnutrition in children).
Stunted children have poor physical and intellectual performance and lower work output leading
to lower productivity at individual level and poor socioeconomic development at the community
level. Stunting of children in a given population indicates the fact that the children have suffered
from chronic malnutrition so much so that it has affected their linear growth.

Stunting is defined as a low height for age of the child compared to the standard child of the
same age. Stunted children have decreased mental and physical productivity capacity.

Weight-for-height is an index used for assessing wasting (acute malnutrition).

Wasting is defined as a low weight for the height of the child compared to the standard child of
the same height. Wasted children are vulnerable to infection and stand a greater chance of dying.

Body mass index is the weight of a child or adult in kg divided by their height in metres squared:
Weight (kg)/(H

eight in metres)2

Body Mass Index (BMI) = Weight (Kg)/Height (M2)

Here is how to calculate each index for children in your community.

Birth weight is weight of the child at birth and is classified as follows:

more than 2500 grams = normal birth weight
1500–2499 grams = low birth weight
less than 1500 grams = very low birth weight

 How does stunting affect socioeconomic development?

Reveal answer You have read that there are a number of ways that stunted children are at
a disadvantage, even into their adult lives. They have poor physical and intellectual
performance and are more likely to have a lower work output. This means that not only
are they less productive at individual level, there are also poor socioeconomic outcomes
at the population level.

What is an indicator?

An indicator is an index (for example, a scale showing weight for age, or weight for height)
combined with specific cut-off values that help you determine whether a child is underweight or
malnourished; for example, a child whose weight for age, or weight for height, falls below the
cut-off values shown in Table 5.1 is considered to be underweight or malnourished.

You will be able to use anthropometric indicators to assess nutritional status, to evaluate the
effects of interventions, to admit children to an intervention (treatment) programme and to
discharge them from a programme. These indicators are therefore very important and knowing
how to use them will help you plan effective nutrition interventions. Table 5.1 summarises how
indicators of underweight, wasting and malnutrition are derived from the weight and height of
children relative to their age, with the cut-off values (column 2) for each indicator (column 1)
based on the standard deviation (SD) of the child’s measurement from the norm for a child of
that age.

The growth chart in each Health Post and on the child health card will help you assess whether a
child is underweight.
 Indicators of underweight and malnutrition derived from the weight and height of
children relative to their age.

Cut-off value based on standard deviation

Index What it indicates
(SD)/percentage
Weight-for-
Less than -2 and more than -3 Moderate underweight
age
Weight-for-
Less than -3 Severe underweight
age
Height-for- Less than -2 and more than -3 (i.e. 70–79.99% of the Moderate acute malnutrition
age norm) (MAM)
Height-for- Less than -3 (i.e. less than 70% of the norm) and/or Severe acute malnutrition
age bilateral pitting oedema (SAM)

 What are the indicators for diagnosing severe acute malnutrition?

Reveal answer Indicators for SAM are a child with standard deviation less than 3 and/or
bilateral pitting oedema. If one of these signs is detected, the child is suffering from
SAM.

Anthropometric measurements used to assess body composition

In assessing body composition (fat content) the body is considered to be made up of two
compartments: the fat mass and the fat free mass. Therefore different measurements are used to
assess these two compartments.

Measurements of fat-mass (fatness)

As you read earlier Body Mass Index (BMI) is the weight of a person in kilograms divided by
their height in metres squared. A non-pregnant adult is considered to have a normal BMI when it
falls between 18.5 and 25 kg/m2. Table below shows you the different categories of nutritional
status based on a person’s BMI.

Cut-off values for BMI for assessing adult nutritional status.

BMI(Kg/m2) cut-offs Nutritional status

more than 40.0 Very obese
30.0-40.0 Obese
25-29.9 Overweight
18.5-24.9 Normal
17-18.49 Mild chronic energy deficiency
16-16.9 Moderate chronic energy deficiency
less than 16.0 Severe chronic energy deficiency

If an adult person has a BMI of less than 16 kg/m2 they will not be able to do much physical
work because they will have very poor energy stores. In addition they will be at increased risk of
infection due to impaired immunity.

Risk of mortality and morbidity is related to the nutritional status as assessed by the BMI. If
people are too fat or too thin their health suffers. The risk of mortality and morbidity increases
with a decrease in the BMI. Similarly, when the BMI increases to over 25 kg/m2, the risk of
mortality and morbidity increases. The relationship between BMI and risk of morbidity and
mortality is shown in Figure

Relationship between BMI and morbidity and mortality.

 What are the problem associated with having high (greater than 25kg/m2) or low (less
than 18.5 kg/m2) BMI?

Reveal answer The risk of mortality and morbidity increases with a decrease in the body
mass index. Similarly, when the body mass index increases over 25 kg/m2, the risk of
mortality and morbidity as well as other diseases such as hypertension, diabetes mellitus
and cancer also increases.

Measuring fat-free mass (muscle mass)

An accurate way to measure fat-free mass is to measure the Mid Upper Arm Circumference
(MUAC). The MUAC is the circumference of the upper arm at the midway between the shoulder
tip and the elbow tip on the left arm. The mid-arm point is determined by measuring the distance
from the shoulder tip to the elbow and dividing it by two. A low reading indicates a loss of
muscle mass.

MUAC is a good screening tool in determining the risk of mortality among children, and people
living with HIV/AIDS. MUAC is the only anthropometric measure for assessing nutritional
status among pregnant women. It is also very simple for use in screening a large number of
people, especially during community level screening for community-based nutrition
interventions or during emergency situations.
MUAC is therefore used as a screening tool for community based nutrition programmes such
as an outpatient therapeutic programme (OTP), for community-based interventions,
supplementary feeding programmes and enhanced outreach programmes throughout Ethiopia.
MUAC is also used for screening target children and pregnant women for severe acute
malnutrition (SAM) and moderate acute malnutrition (MAM).

Measuring the MUAC of children

A special tape is used for measuring the MUAC of a child (see Figure 5.7). The tape has three
colours, with the red indicating severe acute malnutrition, the yellow indicating moderate acute
malnutrition and the green indicating normal nutritional status. Figure 5.8 shows you how to use
the tape to measure a child’s MU

MUAC Tape

Procedures for measuring MUAC using MUAC tape

1. Ask the mother to remove any clothing that may cover the child’s left arm. If possible,
the child should stand erect and sideways to the measurer.
2. Estimate the midpoint of the left upper arm.
3. Straighten the child’s arm and wrap the tape around the arm at the midpoint. Make sure
the numbers are right side up. Make sure the tape is flat around the skin.
4. Inspect the tension of the tape on the child’s arm. Make sure the tape has the proper
tension and is not too tight or too loose. Repeat any step as necessary.
 5. When the tape is in the correct position on the arm with correct tension, read the
measurement to the nearest 0.1 cm.
6. Immediately record the measurement.

Sets out the cut-off values using the MUAC measurement and how these relate to the level of
malnutrition in children and adults.

Cut-off points for screening in the community for SAM and MAM using MUAC

Target Groups MUAC (in cm) Malnutrition

11-11.9 Moderate acute malnutrition (MAM)
Children under five
<11 cm Severe acute malnutrition (SAM)
17-21 cm Moderate malnutrition
18-21 cm with recent weight loss Moderate malnutrition
Pregnant women/adults
<17 cm Severe malnutrition
<18 cm with recent weight loss Severe malnutrition

 Why is MUAC a useful measurement tool?

Reveal answer There are a number of reasons. For pregnant women it is the only
anthropometric measure that can give an accurate reading of their malnutrition status.
Also, because MUAC can be measured quickly and easily, it is also used when screening
large numbers of children and adults.

The Waist-Hip Ratio (WHR)

The Waist-to-hip Ratio (WHR) looks at the proportion of fat stored on your body around your
waist and hip. It is a simple but useful measure of fat distribution. The Waist Hip Ratio is
calculated by dividing your waist measurement by your hip measurement, since the hips are the
widest part of your buttocks.The formula is: WHR= waist circumference / hip
circumference. Having an apple shape (carrying extra weight around the stomach) is riskier for
your health than having a pear shape (carrying extra weight around your hips or thighs). This is
because body shape and health risks are linked. If you have more weight around your waist you
have a greater risk of lifestyle related diseases such as heart disease and diabetes than those with
weight around their hips. Ideally, women should have a waist-to-hip ratio of 0.8 or less,
whereas men should have a waist-to-hip ratio of 0.95 or less.
 Measuring waist

The waist circumference

If you are carrying fat around the middle, mainly around your waist, you are more likely to
develop health problems than if you carry fat mainly in your hips and thighs. This appears to be
true even if your BMI falls within the normal weight range. If you are a woman with a waist
measurement of more than 35 inches (88cm) or a man with a waist measurement of more than 40
inches (102 cm), you may have a higher disease risk than people with smaller waist
measurements because of where their fat lies. It is easy to measure your waist circumference.
Place a tape measure around your bare abdomen just above your hip bone. Be sure that the tape
is snug, but does not squeeze or compress your skin, and is parallel to the floor. Relax, exhale,
and measure your waist. The numbers in the table below count for white adults. Certain ethnic
groups like Hindus or African Americans are extremely sensitive for accumulation of fat in the
belly. These groups are more sensitive to develop diabetes or coronary diseases.
Relation between waistcircumference and the risk for
coronary disease
Low High Increased
risk risk Higher risk
94 - 99
Men < 94 cm > 100 cm
cm
80 - 89
Women < 80 cm > 90 cm
cm
 ii) BIOCHEMICAL ANALYSIS
It involves the analysis of body fluids and tissues to determine the nutrient /stores in there fluids
and tissues. Compared with the others, (ACD) it provides the most objective & quantitative data
on nutritional status. Biochemical tests are important for early detection of a population at risk.
They can detect nutrient deficits long before anthropometric measures are altered and Clinical
signs and symptoms appears. Some of the tests are useful indicators of recent nutrient intake and
can be used in conjunction with Dietary methods to assess food and nutrient consumption.

It is a very expensive method to carry out so it is done as a final confirmation after all other tests
have been done.

Considerations;
 The condition under investigation should be high
 You need to justify that the condition you are dealing with is serious and that treatment is
easier with early detection since they are expensive
 Collection of the specimen should be done by well trained and qualified staff.
 Standardized techniques are essential in order to compare with references and between
groups.
 Caution should be taken in relation to some nutrients as pertaining the time of the day.
Some may reflect recent nutrient intake if taken immediately after a meal. E.g. if tests are
done on plasma, a fasting period of 8 hours is considered to eliminate effects of recent
food & drink intake. For urine samples, the optimum period is 24 hours or first urine on
rising or at least 2-3 hours after a meal
 A note should be taken for use of any medication, supplements which might interfere
with nutrient levels
 Consider the age, sex, physiological state and recent illness.
 Preservation of the specimen; Ensure the use of the best method for & specimen, e.g.
urine is normally acidified with acetic acid or HCL to prevent precipitation but this may
interfere with some tests e.g. uric acid keeps if acidified for 24-48 hours. For spot urine
fresh samples may be needed.
 Make sure that freezing temperatures necessary for some tests do not destroy some
samples e.g. some blood samples are best preserved frozen which can on the other hand
destroy some enzymes which may be important in some analysis.
 In analysis use Standardized techniques. Different methods are used depending on the
nutrient
 In data interpretation results, reference values are used. Values may vary with age, sex,
physiological function, genetics environment so references are needed to account for each
of these. Reference values are usually given as a range. A range is determined by
measuring adequate normal individuals and taking mean ± 2SD =97% of the population.

Factors that may interfere with nutrient values

 Use of the wrong collection technique
 Recent nutrient intake/medication/ supplements
 Body levels of other nutrients
  Intercurrent illness

Advantages of Biochemical analysis

 Provides the most objective and quantitative data on nutritional status
 Useful when used in conjunction with dietary assessment to confirm deficits
 Useful in validating data from other methods
 They often can detect nutrient deficits long before anthropometric measures are altered
and Clinical signs and symptoms appears. (used for early detection of deficiency)
 Detect endemic malnutrition in order to plan for curative measures

Disadvantages of Biochemical analysis

 It’s very expensive to carry out hence done as a final confirmation after all the other tests
have been done
 Not all nutrients can be assessed by biochemical means and the validity of methods for
different nutrients varies
 Tests might reflect only recent or habitual saturation, body stores e.g. vitamin C
 Use of some tissues may be prohibited by ethics or practicability.

Tests involved
Serum retinol-- Vitamin A Serum Albumin—Protein status
Plasma ferritin—Anaemia Enzyme level in blood-- Protein status
Haemoglobin—Anaemia Urea/creatinine-- Protein status
Serum folate—Anaemia Urinary Iodine-- Iodine
Serum glucose levels—Diabetes

Biochemical data
C-reactive protein Presence of inflammation
BUN Dehydration
ALT Liver diseases
Serum retinol Vitamin A
Plasma ferritin Iron
Haemoglobin Anaemia
Serum albumin Protein status
Serum glucose level Diabetes mellitus
Osmolarity Anasarca (edema)
Serum folate Megaloblastic anemia

iii) Clinical methods of assessing nutritional status

Clinical Assessment of nutritional status involves a detailed Nutritional history, a thorough

physical examination and the interpretation of the signs and symptoms associated with
malnutrition. It can be an efficient and effective way for an experienced clinician/nutritionist to
evaluate a patients’ nutritional status without entirely depending on lab tests and diagnostic tests
which may delay initiation of nutritional support.
It is the use of physical signs and symptoms to detect nutritional problem.

Signs are defined as observations made by a qualified examiner of which the patient is usually
unaware.

Symptoms are clinical manifestations reported by the patient.

Parts of the anatomy mainly used are hair, face yes, lips tongue, teeth, gums glands skin nails
subcutaneous tissue muscular and skeletal system GIT and the nervous system etc
They are to used to assess both problems of over nutrition and under nutrition

Nutritional history sought include; recent weight lost/gained, appetite status, Food intolerance,
levels of physical activity, current dietary practices, dental status, substance abuse, persons
responsible for food purchases & preparation and medical history

Purpose
To act as clues in identifying persons with distinct manifestations of nutritional disorders
[diagnosis should be confirmed by other methods e.g. biochemical anthropometry and diet
history.]

Limitations
 Signs may be non specific i.e. may be related to exposure to the environment factors or
deficiencies of more than one nutrient or groupings of signs e.g. in kwashiorkor.
 Lack of reference criteria, It is extremely hard to give an objective description of many
clinical signs especially in their early stages. It’s also difficult to rank as mild, moderate
or severe. Usually Yes or NO
 Observer bias, due to lack of specific reference criteria, there is prejudice from ones own
experiences, practical training and experience.
 Poor correlation with other methods of assessment. Signs usually reflect long term
aspects of disordered nutrition which does not correlate with dietary anthropometry and
biochemical measurements.
  Presentation of data is difficult as signs are hard to quantify, presence or absence of each
signs and not mild, moderate or severe. Interpretation of the results should be done
carefully with regard to other factors that might influence.

NB: The most important limitation of clinical assessment is that of lack of specificity.

Advantages
 Inexpensive
 One does not require much training in assessing experience is what is important hence
even mothers can do it with time.
 It is easy and takes little time

Disadvantages
 Many Clinical findings are not specific for a particular nutrition deficiency hence must be
integrated with other methods

Physical Examination

a) Skin for the following conditions;

Kwashiokor— oedema
Marasmus— wasted muscles, loose skin
Pellagra— flaky paint dermatitis
Anaemia— pale palms, nails & eyes
Scurvey— skin sores
b) Eye Examination for the conditions/ signs of night blindness(Xerophthalmia); Night
blindness test
c) Goitre in Iodine deficiency- Swollen thyroid gland which is in response of the body’s
needs. The gland increases its surface area to obtain as much iodine as possible from the
blood
d) Rickets- (bow legs, knock knees) in the deficiency of Vitamin D, Calcium &
Phosphorous.

Other Clinical signs of nutrient deficiency include: pallor (on the palm of the hand or the
conjunctiva of the eye), Bitot’s spots on the eyes, pitting oedema, goitre and severe visible
wasting (these signs are explained below).

Checking for bilateral pitting oedema in a child

In order to determine the presence of oedema, you should apply normal thumb pressure on both
feet for three seconds (count the numbers 101, 102, 103 in order to estimate three seconds
without using a watch). If a shallow print persists on both feet, then the child has nutritional
oedema (pitting oedema). You must test for oedema with finger pressure (see Figure 5.10)
because you cannot tell by just looking.

Checking for bilateral pitting oedema on a young child in Ethiopia. (Photo: UNICEF/Dr
Tewoldeberhan Daniel)

Grades of oedema

Depending on the presence of oedema on the different levels of the body it is graded as follows.
An increase in grades indicates an increase in the severity of oedema.

0 = no oedema

+ = Below the ankle (pitting pedal oedema)

++ = Pitting oedema below the knee

+++ = Generalised oedema.

Bitot’s spots

These are a sign of vitamin A deficiency. Look at Figure 5.11; as you can see, these spots are a
creamy colour and appear on the white of the eye
Bitot’s spots (signs of vitamin A deficiency). (Photo: UNICEF Ethiopia)

Goitre

Goitre is a swelling on the neck and is the only visible sign of iodine deficiency

Clinical signs and symptoms of nutritional problems.

Sign/symptom Nutritional abnormality

Pale: palms, conjunctiva, tongue
Anaemia: may be due to the deficiency of iron, folic,
Gets tired easily; loss of appetite vitamin B12, acid, copper, protein or vitamin B6
shortness of breath
Bitot’s spots (whitish patchy triangular
Vitamin A deficiency
lesions on the side of the eye)
Goitre (swelling on the front of the neck) Iodine deficiency disorder

 Aster is a one-year-old girl who was brought to your health post by her mother, with a
complaint of body swelling and poor appetite for one month.

Upon anthropometric assessment her weight-for-height was less than 3 SD and on

examination, she has bilateral pitting oedema. What is the nutritional problem Aster is
suffering from and what are the indicators?

Reveal answer Aster’s weight-for-height index is an indicator of severe underweight and

this, combined with the bilateral pitting oedema, tells you that she has severe acute
malnutrition.

iv) DIETARY ASSESSMENT

Assessing dietary status includes the types and amounts of food consumed and the intake of the
nutrients and other components found in food. An understanding of a community’s social-
cultural aspects is necessary. An appropriate sample size which depends on dietary variations
between individuals or between households is important.

Dietary assessment is done for the

 Ascertain availability of food to certain people, process of distribution & preparation

 Ascertain relationship between food eaten and nutritional status of people

 Evaluation of on-going projects

 Provide baseline data for projects

 Establish prevalence of nutritional diseases in relation to diet

 For creation of therapeutic diets

 Assessing and monitoring food and nutrient intake

 Formulating and evaluating government health and agricultural policy,

 Conducting epidemiologic research

 Use data for commercial purposes

Advantages
 Quick and cheap for large populations
  Relatively small time commitment is required hence low respondent burden
 Most of the methods do not require specialized training to carry out

Disadvantages
 Many depend on subjects memory( e.g. the 24-hr recall , food frequency, diet history etc)
hence may not be suitable especially for the elderly and children
 Many tools (e.g. the 24-hr recall) depend on the truthfulness of subjects who may give
false information to give an impression to the researcher.

 Can be biased if done on some days e.g. During pay days

 Underreporting/ over reporting of a person’s usual intake

 Omission of some ingredients used in food preparation can lead to underreporting of

energy intake

Levels of Dietary Assessment

a) International levels
For multi- country comparison peaceful /war torn countries. This provides information on
relationship between food consumption and disease patterns in the development of international
guidelines e.g. construction of food composition tables

b) Regional levels
Mainly involves surveillance of staple foods to determine the dietary patterns. It aims at
examining the impact of regional factors e.g. malnutrition, pests etc. If pest have destroyed crops
in Kenya, East and central Africa would have to plan as the same pests may attack crops in these
countries. Assessment at this level also examines market availability of important foodstuffs e.g.
cereals.

c) National levels
Mainly done through the use of balance sheets where data is collected to provide a national food
account to determine daily per capita nutrient availability. Such information is used in food
planning purposes.

d) Local levels
Focuses mainly on the market basket i.e. what people purchase in terms of variety & quantity.
Assessment at this level determines food & nutrient intake of sub-groups of a household e.g.
slum/ rural/peri-urban, central business Districts.

e) Household levels
This is the most important level for community nutrition, mainly involves detection of:

(a) Household consumption of food

(b) Types & amounts of food grown
(c) Types & amounts of donated
(d) Types & amounts of eaten away from home

DIETARY ASSESSMENT TOOLS

There are 2 main types of quantitative dietary assessment which may be used in conducting or
evaluating nutrition or health promotion programs; these are

1) Short term recall or record methods

These rely on the subject answering question about their dietary intake on specific days in
the past week ( most common in the past day )or recording their intake over short period
usually one, three or seven days.

2) Food frequency techniques and diet history techniques.

These include techniques which attempt to measure “usual” intake over a period of
months or years. The amount of detail gathered can vary. Respondent may provide
information on food consumed in recipe form or as household measures (e.g. spoons
/cups of food eaten) or measured weights and volumes. Details can be requested about
specific brands of foods used and cooking techniques

For food frequencies and diet histories the number of food investigated can be as high
as 200 or limited number of key foods or food groups. Data from the listing of foods and
the information from the qualitative questions can be combined with information from a
food data base to calculate nutrient intake per day.

NB: A diet history follows a similar format to a food frequency assessment but
information is usually gathered on meal- by- meal basis in interview using skilled
nutritionist rather than using self completed questionnaire as is done in food frequency
assessment.
The amount of detail of detail required from any respondent for of these techniques must
be decided by the researcher depending on the purpose of data collection the nature of the
subjects, and accuracy required to the research question.
For any of these approaches results can be expressed either in terms of foods or nutrients
eaten per day.

I. Short term recalls

a) 24 hour recall
Participant is interviewed and asked to recall previous day’s intake.
Interviewer records intake asking for food description and clarifying preparation methods
and portion size. Food models can be used to illustrate.
1) Double check overtime gaps and food groups
2) Participant must be able to recall food consumed on the previous day describe
preparation methods and portion sizes
3) Interviewer / researcher must have skills to obtain history focusing on quantities
preparation methods and portion sizes
Interviewer / researcher must have skill to obtain history focusing on quantities,
preparation methods etc

The method requires 30- 60 minutes to record depending on the subject uses such as:
1) Nutrient analysis – representative of a group-using means
2) Finding out food eaten.

Advantages

 Quick and cheap for larger groups e.g. national surveys

 Will not change eating patterns
 No long term memory needed
 No need for prior knowledge of communities diet pattern
 Relatively small time commitment
 Can give meal pattern information.
Disadvantages
 Accuracy depends on the memory and truthfulness of the subject and also on sex and
age
 Single measure is not typical of usual diet
 Children elderly men etc are not involved in food preparation and shopping so they
may not be conversant with different food.
 Cannot be used to assess percentage of people above or below RDI as it relates to one
or two days intake only.
  Can be biased on specific days e.g. pay days.

Method to improve accuracy

a) Compare to usual intake

b) Mix food records and recalls
c) Use models, photos
d) Use multiple 24-hr recalls on the same subjects several days

b). Weighed Food Records/Dietary Records

Respondents are instructed to weigh all foods and beverages consumed during a specified
time period. Details of food preparation, description of foods and brand names are also
recorded. Measuring cups, spoons or scales may be used. Orientation and instruction of the
procedure requires 10min-1hr depending on the subjects. Recording of meals and snacks
requires time after each meal or snack. Participants must be able to record intake, weigh or
measure food items, provide recipes including ingredients. The researcher must be familiar
with the portion sizes and the preparation methods.

All the food prepared, what is eaten, wasted, left over or discarded is weighed.
The record may be over a 7-day period of 2 consecutive meals, 3-4 days or longer.
It is important to include one day of the weekend as food intake might be different from the
usual week-days.

Dietary Records are used for the nutrient analysis of groups and individuals.

Advantages
 More accurate than the recalls as they do not rely on memory
 More representative of the meal pattern if done over a long period of time
 Most precise method of recording intake – actually measures what is eaten
 No previous knowledge of study population is needed

Disadvantages
 Accuracy depends on the cooperation of the respondents, their literacy and ability to
measure or estimate accurately
 It is a short term measure only so only gives the current intake, It does not account for
seasonal changes which may result in different mal patterns.
 Respondents may alter meal patterns due to perception about what the researcher
considers good or due to the inconvenience of recording. the more the days the more
the inaccuracy of recording as the participants get bored
  Has a high respondent burden
 Requires a literate population
 Some meals may be beaten out of home

It is important that the researcher is present in some of the meals to observe the weighing of the
foods. The researcher should also be able to convert the estimated cups and spoons into actual
weights for ease of data analysis.

c) Food Frequency Questionnaire (FFQ)

A questionnaire is completed by the participants or the interviewer. A list of foods is included
and the participants are supposed to say how often they consume those foods on a daily, weekly,
monthly or occasionally.

 The list of foods are supposed to be the food actually available in that community and of
study interest
 The source of foods in the list is usually obtained from pilot study with food records or
national survey data
 Recall of average consumption may be difficult for those with memory deficits, irregular
food habits or major changes in intake
 Little skill is required by the researcher but for the self administered questionnaire for the
respondent must be reviewed for codability and accuracy.
 A short version of FFQ may take about 10 minutes to complete if researcher-
administered while the longer version may take 45mins if self-administered.

Uses

FFQ are used as a clue –stage to determine whether one is at risk of getting a disease that is
nutrient related based on the frequency of consumption of foods. Used to characterize diets of
individuals or groups

Advantages

 Does not require specific short- term memory skills

 Quick to fill and process out, cost and time efficient.

  More representative of usual intake than a record or 24 hr recalls

 Cheaper than 24 hr recalls or records

 High response and low burden on participants

 Does not require special staff once the questionnaire has been designed

Disadvantages
 Requires detailed prior knowledge of community eating habits

 Difficult to include a wide range of foods from different cultures

 Does not usually give meal patterns ( unlike the weighed Records)

 Requires long term memory and ability to “average” over time

 Representative depends on the foods listed

II. a) Food History (Diet Histories)

This tool attempts to estimate the usual food intake and meal pattern of individuals over a
relatively long period of time. Often a month. The general foods eaten, frequency of certain
items are sought.
 The participant is interviewed to determine typical daily intake over past years
 Method may include psychosocial history with respect to food intake
 A 1- 4 hour interview is required to obtain a comprehensive food history
 The participant must be able to determine average frequency or consumption with little
prompting
 Researcher must have skill to obtain typical pattern for meals and snacks
 Other assessment may include report from family friends’ healthcare providers
 Parents can provide information for children depending on age in combination with the
children’s response.
 May combine with a 24-hr recall which gives typical daily pattern

Uses
 Generally accepted as the most accurate method for individuals to get a representative
measure of usual diet.
 Provides information on meal patterns, food frequency nutrient intake food group intake
seasonal variation likes and dislikes, past and present habits
 Common in clinical settings with individuals
 Becoming less common in research settings because of costs and skills required

Advantages
  Includes an in-depth assessment

 Reflects extended time period

 Do not need a great deal of knowledge of community habits

Disadvantages

 Tends to overestimate as the participants can exaggerate

 Time consuming

 Requires highly skilled and trained interviewers

 Requires integrated assessment of wide range of data

 Depends on awareness and cooperation of subjects

Summary

Dietary assessment tools/instruments are important in epidemiologic studies- in investigating the

relationship of diet and disease, dietary interventions trials evaluation of supplemental food
programs and a variety of other research areas.

Combinations of methods are used to reduce estimate errors due to weaknesses in the different
dietary assessment tools.

 There is no ideal or standard method for evaluating dietary intake as each has its
strengths and weaknesses.
 Use the method that bests suits the purpose and objectives of the study.
 It is important to validate dietary methods for the type of the population to be examined
and the intended use of the dietary data.
  Each assessment instrument used should be validated by some method to minimize errors
of reported dietary data.

Analysis of Dietary data

Many software have been developed for use in analysing Dietary data; they include

Nutri-survey
24hr Food recall soft ware diet Day (www. 24hrrecall.com)
Dietary Diversity Score (Individual and Household)

Weakness of using computer software in Dietary Analysis

 Relies on the food composition tables which are too old and not all inclusive
 Nutrient calculated do not take bioavailability into consideration or Nutrient
interaction
 Portion sizes differ between groups of people
 Skills of researchers crucial in doing estimations and in using equivalent foods
when those in a specific community are not in the food composition tables.

Critical Thinking Skills in nutrition assessment

• Determining appropriate data to collect
• Determining the need for additional information
• Selecting appropriate assessment tools and procedures
• Applying the assessment tools in valid and reliable ways
• Distinguishing relevant from irrelevant data
• Distinguishing important from unimportant data
• Validating the data

TOPIC 2: NUTRITION DIAGNOSIS

Definition of Diagnosis
• The act of identifying a disease or condition from its signs and symptoms
• It is the investigation or analysis of the cause or nature of a condition, situation, or problem.
Purpose of Nutrition diagnosis
The purpose of a nutrition diagnosis is to identify and describe a specific nutrition problem that
can be resolved or improved through treatment/nutrition intervention by a food and nutrition
professional. A nutrition diagnosis (e.g., inconsistent carbohydrate intake) is different from a
medical diagnosis. (e.g. diabetes).

Food and nutrition professionals use nutrition assessment data to identify and label the
patient/client’s* nutrition diagnosis using standard nutrition diagnostic terminology. There is a
reference sheet for each nutrition diagnosis that includes its definition, possible etiology/causes,
and common signs or symptoms identified in the nutrition assessment step

Terminology for nutrition diagnosis is organized in 3 domains (categories)

Intake Clinical Behavioral Environment
Too much or too little of a food or Nutrition problems that Knowledge, attitudes, beliefs,
nutrient compared to actual or relate to medical or physical environment, access to
estimated need physical conditions food, or food safety

Nutrition Dx Domains: Intake

Defined as “actual problems related to intake of energy, nutrients, fluids, bioactive substances
through oral diet or nutrition support (enteral or parenteral nutrition)
 Class: Calorie energy balance
 Class: Oral or nutrition support intake
 Class: Fluid intake balance
 Class: Bioactive substances balance
 Class: Nutrient balance

Nutrition Dx Domains: Clinical

Defined as “nutritional findings/problems identified that relate to medical or physical conditions
 Class: functional balance
  Class: Biochemical balance
 Class: weight balance

Nutrition Dx Domains: Behavioral-Environmental

Defined as “nutritional findings/problems identified that relate to knowledge, attitudes/beliefs,
physical environment, or access to food and food safety
 Class: knowledge and beliefs
 Class: physical activity, balance and function
 Class: food safety and access

Documenting a nutrition diagnosis:

Food and nutrition professionals write a PES (Problem, Etiology, Signs and Symptoms)
statement to describe the problem, its root cause, and the assessment data that provide evidence
for the nutrition diagnosis.

The format for the PES statement is “[Nutrition diagnosis term (problem)] related to [Etiology]
as evidenced by [Signs/Symptoms].”PES
(P) Problem or Nutrition (E)Etiology (S) Signs/Symptoms
Diagnosis Term
Describes alterations in the Cause/Contributing Risk Data or indicators used to
patient/client’s nutritional Factors determine the patient/client's
status nutrition diagnosis.
Linked to the nutrition Linked to the etiology by the
diagnosis term by the words words “as evidenced by.”
“related to.”

No nutrition diagnosis at this time (NO-1.1) may be documented if the assessment indicates that
no nutrition problem exists to justify a nutrition intervention or if further nutrition assessment
data are needed to identify a nutrition diagnosis
Nutritional problem
 Names and describes the problem
 Problem may already exist, or may be at risk of occurring
 Not a medical diagnosis

Components of Nutrition Diagnosis

 Problem
 Etiology
 Signs/Symptoms
o Signs
o Symptoms
Problem
 Describes alterations in pt’s nutritional status
 Diagnostic labels
 Impaired
 Altered
 Inadequate/excessive
 Inappropriate
 Swallowing difficulty
Etiology
 Related factors that contribute to problem
 Identifies cause of the problem
 Helps determine whether nutrition intervention will improve problem
 Linked to problem
 Excessive calorie intake related to regular consumption of large portions of high-fat
meals
 Swallowing difficulty related to stroke

Signs/Symptoms
 Evidence
 Linked to etiology
Etiology
 Excessive calorie intake “related to” regular consumption of large portions of high-fat
meals as evidenced by diet history and weight status
 Swallowing difficulty related to stroke as evidenced by coughing following drinking of
thin liquids
Nutrition Diagnosis
 Excessive calorie intake
 “related to” regular consumption of large portions of high-fat meals
 “as evidenced by” diet history & 12 lb wt gain over last 18 mo

Nutrition Diagnosis Components

 Food, nutrition and nutrition-related knowledge deficit R/T lack of education on infant
feeding practices as evidenced by infant receiving bedtime juice in a bottle
 Altered GI function R/T ileal resection as evidenced by medical history and dumping
syndrome symptoms after meals

Nutrition Diagnosis Statement should be:

 clear, concise
 specific
 related to one problem
 accurate
 based on reliable, accurate assessment data
Guidelines for selecting the nutrition diagnosis and writing a clear PES statement:
Select the most important and urgent problem to be addressed. When writing the PES statement,
food and nutrition professionals can ask a series of questions (identified in the critical thinking
skills section below) that help clarify the nutrition diagnosis.
Critical thinking skills:
P – Can the nutrition professional resolve or improve the nutrition diagnosis of the patient/client?
When all things are equal and ther+e is a choice between stating the PES statement using two
nutrition diagnoses from different domains, consider the Intake nutrition diagnosis as the one
more specific to the role of the RDN.
E – Evaluate whether the etiology is the specific “root cause” that can be addressed with a
nutrition intervention. If addressing the etiology cannot resolve the problem, can the RDN
intervention at least lessen the signs and symptoms?
S – Will measuring the signs and symptoms indicate if the problem is resolved or improved? Are
the signs and symptoms specific enough that the RDN can monitor (measure/evaluate changes)
and document resolution or improvement of the nutrition diagnosis?

4.0 Nutrition interventions

  Purposely-planned actions designed with the intent of changing a nutrition-related
behavior, risk factor, environmental condition, or aspect of health status for an individual,
a target group, or population at large.” –
 Directed at the etiology or effects of a diagnosis

The purpose of a nutrition intervention is to resolve or improve the nutrition diagnosis or

nutrition problem by provision of advice, education, or delivery of the food component of a
specific diet or meal plan tailored to the patient/client’s* needs.

Determining a nutrition intervention:

The nutrition diagnosis and its etiology drive the selection of a nutrition intervention. Nutrition
intervention strategies are selected to change nutritional intake, nutrition-related knowledge or
behavior, environmental conditions, or access to supportive care and services. Nutrition
intervention goals provide the basis for monitoring progress and measuring outcomes

Terminology for nutrition intervention is organized in 4 domains (categories):

Food and/or Nutrition Nutrition Counseling Coordination of
Nutrient Delivery Education Nutrition Care
Individualized A formal process to A supportive process, Consultation with,
approach for instruct or train a characterized by a referral to, or
food/nutrient patient/client in a collaborative counselor- coordination of
provision skill or to impart patient relationship, to nutrition care with
knowledge to help establish food, nutrition other health care
patients/clients and physical activity providers, institutions,
voluntarily manage priorities, goals, and or agencies that can
or modify food, individualized action assist in treating or
nutrition and plans that acknowledge managing nutrition-
physical activity and foster responsibility related problems
choices and behavior for self-care to treat an
to maintain or existing condition and
improve health promote health

Use of nutrition intervention terminology:

Nutrition intervention is accomplished in two distinct and interrelated steps: planning and
implementing.
Planning the nutrition intervention involves:
 a. Prioritizing nutrition diagnoses
b. Consulting the academy's evidence-based nutrition practice guidelines and other practice
guidelines
c. Determining patient-focused expected outcomes for each nutrition diagnosis.
d. Conferring with patient/client/caregivers
e. Defining a nutrition intervention plan and related strategies
f. Defining time and frequency of care
g. Identifying resources needed.
Implementation is the action phase and involves:
a. Communication of the nutrition care plan
b. Carrying out the plan.

Intervention Objectives
Should be patient-centered
 Must be achievable
 Stated in behavioral terms
 Pt and counselor must establish goals together
 What will the patient do or achieve if objectives met

Intervention Objectives
 Problem 1: Involuntary weight loss
 Objectives:
1…
2.
 Problem 2: Inadequate protein-energy intake 2° poor appetite
 Objectives:
1.
Intervention translates assessment data into strategies, activities, or interventions that will
enable the patient or client to meet the established objectives.
Interventions should be specific
  Problem 1: Involuntary Weight loss
 Intervention:
1.
 Problem 2: Inadequate protein-calorie intake 2° poor appetite
 Intervention:
1.
 Should be targeted at etiology
 If not etiology, then signs and symptoms
Four categories of nutrition interventions:
 Food and/or nutrient delivery
 Nutrition education
 Nutrition counseling
 Coordination of nutrition care

Critical thinking skills:

 Setting goals and prioritizing
 Defining the nutrition prescription or basic plan
 Making interdisciplinary connections
 Initiating behavioral and other nutrition interventions
 Matching nutrition intervention strategies with patient/client’s needs, nutrition diagnosis,
and values
 Choosing from among alternatives to determine a course of action
 Specifying the time and frequency of care
5.0 Nutrition monitoring and evaluation
This is the use of selected outcome indicators (markers) that are relevant to the patient defined needs,
nutrition diagnosis, nutrition goals, and disease state.

The purpose of nutrition monitoring and evaluation is to determine and measure the amount of
progress made for the nutrition intervention and whether the nutrition related goals/expected
outcomes are being met. The aim is to promote more uniformity within the dietetics profession in
assessing the effectiveness of nutrition intervention.

Determining what to measure for nutrition monitoring and evaluation:

Practitioners should select nutrition care indicators that will reflect a change as a result of nutrition
care. The monitoring and evaluation phase should be considered during the assessment phase, while
determining the Nutrition Diagnosis and the Nutrition Intervention. Additional factors to consider are
the medical diagnosis, health care outcome goals, nutrition quality management goals, practice setting,
patient/client population, and disease state and/or severity

Terminology for nutrition monitoring and evaluation is organized in 4 domains (categories) **:

Food/Nutrition-Related Anthropometric Biochemical Data, Nutrition-Focused

History Outcomes Measurement Medical Tests, and Physical Finding
Outcomes Procedure Outcomes
Outcomes
Food and nutrient intake, Height, weight, Lab data (e.g., Physical appearance,
food and nutrient body mass index electrolytes, muscle and fat
administration, (BMI), growth glucose) and tests wasting, swallow
medication, pattern (e.g., gastric function, appetite,
complementary/alternati indices/percentil emptying time, and affect
ve medicine use, e ranks, and resting metabolic
knowledge/beliefs, food weight history rate)
and supplies availability,
physical activity,
nutrition quality of life

Collection and use of nutrition monitoring and evaluation outcome data:

This step consists of three components: monitoring, measuring, and evaluating the changes in nutrition
care indicators. Practitioners monitor by providing evidence that the nutrition intervention is or is not
changing the patient/client’s behavior or status. They measure outcomes by collecting data on the
appropriate nutrition outcome indicator(s). Finally, food and nutrition professionals compare the current
findings with previous status, nutrition intervention goals, and/or reference standards (i.e., criteria) and
evaluate the overall impact of the nutrition intervention on the patient/client’s health outcomes. The use
of standardized indicators and criteria increases the validity and reliability of outcome data collection. All
these procedures facilitate electronic charting and aggregation of data for reporting outcomes of food and
nutrition professional's interventions for patient/client care.

Critical thinking skills:

 Selecting appropriate indicators/measures

 Using appropriate reference standards for comparison

 Defining where patient/client is in terms of expected outcomes

 Explaining a variance from expected outcomes

 Determining factors that help or hinder progress

 Deciding between discharge and continuation of nutrition care

Nutrition Monitoring and Evaluation

 Monitor progress and determine if goals are met
 Identifies patient/client outcomes relevant to the nutrition diagnosis and intervention
plans and goals
 Measure and compare to client’s previous status, nutrition goals, or reference standards
Evaluate outcomes
 Compare current findings with previous status, intervention goals, and/or reference
standards

What gets Measured

Nutrition Goals and Objectives

 Are necessary in order to evaluate

 Should be achievable
 Should be directly or indirectly related to nutrition care