IDNT and the Nutrition Care Process: Part 1- Nutrition Assessment

Posted on March 23, 2014May 6, 2022 by kalix_dev

Nutrition Assessment

This post is Part 1 of IDNT and the Nutrition Care Process.

It’s an adventure through the world of IDNT (International Dietetic and Nutrition Terminology) and the Nutrition Care Process. I said it is an adventure right? So I hope to make it a fun experience for all. My aim to explain to you (in my own way) what the Nutrition Care Process is all about. I also plan to convert all you nonbelievers to the ways of IDNT. Tough task I have set myself…but I will give it my best.

If there is questions or topics around IDNT and the Nutrition Care Process you want me to cover, please let me know.

So here goes.

I hope you find it useful.

What is NCP and IDNT?

In a nutshell, the Nutrition Care Process (NCP) is a model for providing high-quality nutrition care and International Dietetics and Nutrition Terminology (IDNT) is the standardized language used to describe the NCP.

I have written about the benefits of NCP and IDNT a few times before, so I will not repeat myself here, but I will mention one of the uses for IDNT. IDNT is used for the documentation of clients’ (or patients’) nutrition care, i.e. medical note documentation. And this is how we use IDNT in Kalix. The standardized documentation format for NCP is ADIME (A-Assessment, D-Diagnosis, I- Intervention, ME-Monitoring, and Evaluation). And again this is the format we use in Kalix. In saying that, you can use IDNT to write notes in whatever format you like including SOAP, ABCD, etc.

Nutrition Assessment

The first stage in the Nutrition Care Process is the Nutrition Assessment, and hence, this is the first section in ADIME. Assessment contains the data you collect about a client/patient during the consultation, from medical records, food records, weight records, client observations, from discussions with other healthcare providers, carers or family members, etc.

There is one crucial point I would like everyone to understand about Nutrition Assessment in NCP. But, before I explain it, I would like to ask, a fundamental question:

Why do Dietitians conduct nutritional assessments with clients?

Sure, there is not one answer to this, but many. Some of the reasons include:

• To confirm clients’ medical history
• Collect anthropometric measurements
• Gather information about their diet and food intake
• Learn clients’ personal preferences to assist with providing tailored advice

The list can go on… but now I ask you, why do Dietitians collect this information and what do we do with it?

Dietitians conduct nutritional assessments to obtain client data, which we verify (check that it is accurate) and interpret (compare it to relevant reference standards). We determine whether the dietary modifications are required or not, i.e., that a nutrition-related problem exists (this problem is the Nutrition Diagnosis). Dietitians then examine this client data to identify the cause/s of the nutrition-related problem (its etiology) and its significance (the effect the nutrition-related problem has on client’s health and wellbeing). All of this information then used to determine how to go about resolving (this is the Nutrition Intervention) the nutrition-related problem.

Makes sense…so what is my important point?

Nutrition Assessment, should not be just list of assessment information, it should contain only relevant information that is used to demonstrate;
• Whether a nutrition-related problem exists
• The cause/s of the nutrition-related problem
• It’s significance (the effect the nutrition-related problem has on client’s health and wellbeing).

As Dietitians, our time as is too precious to be wasted writing irrelevant information in the Nutrition Assessment. So I recommend to you to only enter relevant information in the Nutrition Assessment section.

Now we have that clear, it will talk a bit about what makes up the Nutrition Assessment section.

In the ADIME the Nutrition Assessment is ordered a little bit different compared to other note writing formats, with Food/Nutrition-Related History listed first.

Food/Nutrition-Related History

This section includes all information about your client’s oral intake, as well as nutritional support plus enteral and parental nutrition. Basically, any diet-related information i.e., the client’s diet history (and your analysis of it), complementary/alternative medicine use, knowledge/beliefs about food and eating, access to adequate healthful food and nutrition quality of life. Physical activity history also lives here.

Ok, a common comment I hear about this section, is why isn’t Anthropometric first?

In ADIME, we list the most important stuff first. We know medical staff do not always read every part of a Dietitian’s notes, they may read the first part then skim the rest. Food/Nutrition-Related History is the most important part of a Dietitian’s documentation, right? A Dietitian’s ability accurate gather nutrition and diet-related information and interpret it, is what makes us unique as a profession. Other professionals measure weight and other anthropometric measurements (even doctors do it sometimes), all health professionals collect medical histories, most check the biochemical/lab data, but only dietitians assess dietary and nutrition-related history. That’s why is section is first.

Anthropometric Measurements

We all know what goes here, height, weight, body mass index (BMI), growth pattern indices/percentile, and weight history, etc.

Something I would like to talk about (and it’s something that I have touched on previously) is Nutrition Care Indicators. Nutrition Care Indicators are client data gathered during the nutrition assessment that is used to identify a client’s Nutrition Diagnosis and its etiology and signs/symptoms. i.e., they are indicators that nutrition care is required. Any Nutrition Assessment data can be a Nutrition Care Indicator, including anthropometric measurements e.g. the client’s BMI. If a client’s BMI is in the obese category, for example, this is an indicator that nutrition care is warranted for weight management. In this case, the client’s BMI will be used as a sign and symptom for the Nutrition Diagnosis of Excessive Energy Intake (the reason for why it is a sign and symptom and not the Nutrition Diagnosis will be explained in the next blog).

Biochemical Data (Blood Tests), Medical Tests and Procedures

Includes laboratory data, (e.g., electrolytes, blood glucose levels, and lipid panel) and tests (e.g., gastric emptying time, resting metabolic rate).

The critical thing to remember here, is the Nutrition Care Process supports evidenced-based practice, it is not enough to say client A has an HbA1c of 10%, you need to show what this means (interpret it). It does not have to be a long description…all you have to do is compare your client results against some relevant standard. It can be a reference standards, i.e., the Diabetes Society recommended HbA1c target or the client’s goal, e.g., reduce HbA1c by 1%.

Client A’s HbA1c is 11% [The client’s result and the Nutrition Care Indicator], which is above [the comparison- it does not need to be long] the recommended range of < 7% [the reference range].

Nutrition-Focused Physical Findings

These are findings obtained from the evaluation of “body systems” including overall appearance, cardiovascular, digestive system, skin and vital signs. The results should be nutrition-related physical characteristics, such as nausea, loss of subcutaneous fat and temporal wasting, and they should be associated with pathophysiological states e.g. cancer cachexia, malnutrition. So again, I emphasise only including relevant information. Nutrition-focused physical findings can be derived from a nutrition-focused physical exam, medical records, direct observation, client reports, etc.

Client History

This section includes current and past information related to personal, medical, family, and social history. Personal History includes general client information such as age, gender, race/ethnicity, language, education, and role in family. Medical history can be a history of the client or the family history. Medical history should only contain conditions that may have a nutritional impact, so no irrelevant information. Social History includes items such as socioeconomic status, living situation, medical care and involvement in social groups.

Client information is often used as part of the etiology for a Nutrition Diagnosis e.g., economic constraints, cultural practices and depression (etiology), can be the cause of Inadequate Energy Intake (Nutrition Diagnosis).

So that is all for Nutrition Assessment, next blog I will talk about Nutrition Diagnosis and PES Statements. Below are some final tips.

P.S. I would love to hear what you think about this blog, please share your thoughts below.

Tips

1. Decide on what data is appropriate to collect (consider the client, your setting, the referral reason, etc.)
2. Collect data using applicable validated assessment tools
3. Distinguishing relevant between relevant and irrelevant data (only include relevant data)
4. Validate your data by comparing it against relevant standards or client goals.

Why Dietitians are Effective!

Posted on August 2, 2013May 6, 2022 by kalix_dev

This post is by Claire Nichols, Co-founder of Kalix and Accredited Practising Dietitian. These are my personal thoughts about the article “Doubt over dietitian referrals for diabetes”. In Australia, over the last few weeks there has been much discussion about the effectiveness of Medicare-subsidised dietetic services (EPC plans) for Type 2 Diabetic patients. This came about after the publication of an article in the Australian Doctor titled “Doubt over dietitian referrals for diabetes”

It’s sad dietitians need to defend their role in the management of diabetes patients. Other than IDNT online, I do some private practice work and the vast majority of my patients are Type 2 Diabetics on EPC plans. From my personal experience, these patients have complex nutrition issues with many social, environmental, behavioural and economic influences. The 1-5 appointments (2 is my average) allowed on a EPC plan, is no where near enough. Sure, there is time to provide a bit of nutrition education, set some goals then review their progress. But to equip these patients with the knowledge and skills they need to make and then maintain nutrition related behaviour change long term, many more appointments are required.

But do I think I ‘m not effective as a dietitian? No, of course not. I know I am effective! But does everyone else know this? No, maybe not. The Australian study by Ball et al (2013) examined 38 individuals’ with chronic diseases (or high risk of) preferences for receiving nutrition care. General practitioners were the preferred provider of nutrition care (n=21) not dietitians! GPs were thought to give the “most trustworthy and personalised nutrition care'” as they had “the most detailed understanding of participants’ medical conditions.” Dietitians were second (n= 12) but there was confusion about the differences between dietitians and nutritionists. Dietitians were also perceived by some be overly strict, some participants “…referred to dietitians as health professionals that ‘punish’ individuals through restrictive eating, and also use negative counselling styles.” We all know that ‘food nazi’ stereotype.

Doubt over dietitian referrals for diabetes

The author of the offending article, a medical journalist called Michael Woodhead, based his piece on a research paper by Spencer et al (2013) published in the Australian Journal of Primary Health. The paper is titled “Attendance, weight and waist circumference outcomes of patients with type 2 diabetes receiving Medicare-subsidised dietetic services” and briefly, it is a prospective observational study conducted over a 9 month period in 2011. Three private practice dietitians in Queensland were involved. The participants in the study were 129 Type 2 Diabetes referred to the dietitans on EPC plans. Mr Woodhead argues that because most of the participants failed to achieve 5% loss of body weight over an average of 2 appointments, the benefits of attending the appointments were “limited.” The other point he makes is, the non-attendance rate was high (29%), and “high rates of non-attendance have the potential to cost several hundred million dollars per year.” Yes, GPs receive money for developing EPC plans, but I am yet to receive a Medicare payment for seeing a patient after they fail to attend.

Non-attendance

So, patients never fail to attend GP appointments? No, of course not, non-attendance is a major issue for everyone in healthcare. A systematic review found the non-attendance rate in US primary care ranged from 5 to 55% (George & Rubin 2003). An Australian randomised controlled trial comparing the different methods for following up diabetic patients, had a 65% drop out rate for GP care (the drop out rate for clinic care was 47% and 28% for shared care) (Hoskins et al 1993).

The benefits of dietetic care

I also disagree with Mr Woodhead’s first point, that the benefits of dietetic care to participants were “limited”. Five out of the 51 participants (9.8%) who returned for review appointments and had their weight remeasured (60 returned within the study period but 9 did not have their weight remeasured) lost greater than 5% of body weight. That’s a great result! Overall the average amount of weight loss between first and last appointment was 1.9 +/-2.9 kg. Participants who attended more than two consultations lost significantly more weight than those who attended two only (3.7 +/-4.2kg vs -1.1+/-1.6 kg, respectively). Unfortunately the study did not report blood glucose measures, HbA1c, blood lipids or blood pressure measurements, so it is unknown whether the participants achieved metabolic improvements. In another study, participants (Type 2 Diabetics on diabetic medication with HbA1c >7% and at least 2 co-morbidities) undergoing dietetic intervention achieved significant improvements in glycaemic control despite the amount of weight loss equalling less than 5%. The group on average lost only 2.4kg over a 6 month period, but achieved a significant reduction in HbA1c (0.5%) compared to no change in the control group (diabetic medication only) (Coppell et al 2010). So sure, Spencer et al (2013) should have recorded glucose levels, HbA1c, blood pressure etc. But you have to remember, EPC appointments are often only 20 minutes long, it’s very hard, if not impossible to review patients’ goals, answer questions, provide education and take all these measurements within the time frame. Also, accessing reliable patient data in a private setting is difficult! As a dietitian, I cannot order blood tests. Yes, I can ask the patient’s GP nicely to order tests. It does not mean I receive a copy. Any results received are often self reported by patients. The likelihood that they are reported incorrectly is high. Also I don’t know how many times I have heard “oh I’m sorry I forgot my glucose monitoring book.”

Dietitans are effective

My interpretations of the findings of Spencer et al (2013) research is- Dietitans are effective. If patients were give more appointments with us, we would be even more effective! While, Mr Woodhead’s article may be damaging short-term, the silver lining is-We are now talking about how we can do things better! We are talking about how we can include more research in private practice and how we can align research and the needs of dietitians in private practice better. That’s fantastic!

References

Ball, L., Desbrow, B., Leveritt, M. (2013), An exploration of individuals’ preferences for nutrition care from Australian primary care health professionals, Australian Journal of Primary Health, [Online]

Coppell KJ, Kataoka M, Williams SM, Chisholm AW, Vorgers SM and Mann J (2010), Nutritional intervention in patients with type 2 diabetes who are hyperglycaemic despite optimised drug treatment- Lifestyle Over and Above Drugs in Diabetes Study (LOADD): randomised controlled trial BMJ: 341:c3337.

George A and Rubin G (2003), Non-attendance in general practice: a systematic review and its implications for access to primary health care. Family Practice; 20: 178–184.

Hoskins, P.L., Fowler, P.M., Constantino, M., Forrest, J., Yue, D.K. and Turtle, J.R. (1993), Sharing the Care of Diabetic Patients between Hospital and General Practitioners: Does it Work?. Diabetic Medicine, 10: 81–86.

Spencer L, O’Shea M-C, Ball L, Desbrow B and Leveritt M (2013), Attendance, weight, waist circumference outcomes of patients with type 2 diabetes receiving Medicare-subsidised dietetic services, Australian Journal of Primary Health [Online].

Woodhead, Michael (2013), Doubt over dietitian referrals for diabetes, Australian Doctor, https://www.australiandoctor.com.au/news/latest-news/doubt-over-dietitian-referrals-for-diabetes [contact-form]

The Story of Kalix

Posted on June 25, 2013May 6, 2022 by kalix_dev

This post is by Claire Nichols, Co-founder of Kalix and Accredited Practising Dietitian.
Hi everyone. I am very excited to be sitting here writing our first ever blog post. Well, I actually have to admit, coming up with a topic for the blog was a bit daunting. I mean there are lots of things to write about really, our new features, for example, but what I really wanted to do was to start with something a bit different compared to our newsletter. I so thought I would try to answer some of the big questions; who are we, what are we doing, how we got here and the meaning of life (well maybe not that one). So here goes…

Two years ago I would have never guessed, I would be a co-founder of a software company. My knowledge of IT was little to none. Sure, I could turn on a computer, make a Word document, google a topic, but I didn’t know where, to begin with making a blog, let alone a website. Then came a problem, followed by an idea and then an opportunity.

The problem arose just after starting my previous job as Early Intervention Service Dietitian in North West Tasmania. The position was funded with a special government grant, so there was a lot of pressure to measure and evaluate the effectiveness of my professional practice. Evaluating the effectiveness of dietetic practice, is easy enough, isn’t it? When you see a patient, you measure their weight and the next time you see them, you measure it again. If they’ve lost weight you’ve done a good job if they haven’t, you then haven’t…Hopefully, you are all screaming NO right now.

For the non-Dietitians reading this;

1) Dietitians do not only see patients for weight control.

2) Weight loss is hard! Improving overall diet quality, and improved patient health is what we want to achieve as healthcare professionals, right? But how does one measure healthy lifestyle?more active and establishing a healthy lifestyle are all positive achievements. They all result in improved health, irrespective of the amount of weight loss.

The idea So I went about investigating how to measure and evaluate professional practice. I came across International Dietetics and Nutrition Terminology (IDNT) and the Nutrition Care Process (NCP). Well, actually I was using IDNT at the time and I had been since 2009 but only to write PES statements. There is a lot more to IDNT than PES statements.

For non-Dietitians NCP is a problem-solving method that Dietitians use to “think critically and make decisions that address practice-related problems”. IDNT is a “standardized set of terms used to describe the results of each step of the NCP model.” PES is a statement about the Nutrition Diagnosis or nutrition issue. Clear? If not that’s ok, I will talk about it more in future posts.

Why I like IDNT

There are lots of terms, getting to close to 1000 now I think (yes I actually like that).
They cover all the stages of the Nutrition Care Process (Assessment, Diagnosis, Intervention and Monitoring/Evaluation) i.e. initial and review assessments.
They include most factors in dietetics e.g. Food variety is a term, as well as Meal or snack pattern, Nutrition quality of life responses, Frequency, Consistency, Duration, and Intensity of physical activity and of course, good old Food intake, to name a few.

So my light bulb moment….because IDNT is standardized and covers all the data a dietitian would collect during initial and review assessments if I was to write all my patient documentation using IDNT then I could use a software system to track changes in the variables associated with IDNT terms. Tracking the changes in these variables would be an easy, sensitive and efficient way of evaluating professional practice. I could even use IDNT to evaluate the effectiveness of particular interventions by correlating Intervention terms with changes in the variables associated with Assessment and Monitoring/Evaluation terms.

By using IDNT I could evaluate my professional practice without having to spend extra time measuring, recording and analyzing data. The statistical analysis would be built into patient documentation and patient documentation is something I had to do anyway!

The problem was finding a software system that uses IDNT in this way. I needed a software system that supports quick electronic documentation using IDNT terms, tracks of changes in patient data over time and correlate changes in variables.

There must be something like that out there, right? No, not really. Why? My best guess is because 1) software developers are really really expensive to hire, and 2) actual building software with this functionality would take a long time.

The opportunity- I was very lucky to have my own software developer on hand, Felix Jorkowski. So we embarked on this little project together and it has grown and grown.

So I might be the most unlikely co-founder of a software company but win or lose I am glad I took the risk to try something new. I will finish this blog with a quote which I think sums things up really well.

“You can’t make footprints in the sands of time by sitting on your butt. And who wants to leave buttprints in the sands of time?” Bob Moawad

References

Nutrition Care Process and Model Part I. The 2008 Update. J Am Diet Assoc. 2008; 108:1113-1117.

Nutrition Care Process Part II: Using the International Dietetics and Nutrition Terminology to Document the Nutrition Care Process J Am Diet Assoc. 2008; 108:1287-1293.