It’s been a couple of months since I’ve last checked in! I do apologize, but life’s been extremely busy. As mentioned in my first or second post, I’m currently in graduate school to finish my degree to be a Registered Dietitian. The last bit of work I have to do is complete my clinical rotations, as someone in medical school would, to fulfill everything I need to do. I begin this journey on Monday morning, May 14th, and will be working until the end of this calendar year. Again, if posts are a little sporadic, please forgive me.
Something I’ve been working on throughout my time in school, and more specifically the last year or so, is understanding the Nutrition Care Process within the field of nutrition and dietetics. It’s simply a way to streamline the care process of any client or patient while having the education and treatment they receive be efficient and relatively uniform across the board. I wanted to describe and illustrate this process through a sample interaction with a patient with celiac disease.
Celiac disease is an autoimmune disorder. Its prevalence has been estimated at 1.4% of the global population and 0.5% of the North American population, but this estimate omits undiagnosed celiac disease. In individuals with a genetic predisposition to celiac disease, the condition is characterized by an autoimmune reaction to certain sequences of amino acids found in the prolamin fraction of wheat, barley, and rye. Consumption of these grains by a person with celiac disease triggers an immune response that results in damage to the mucosa of the small intestine. This gastrointestinal damage reduces the absorptive surface area of the small intestine, resulting in the malabsorption of macronutrients (carbs, fat, protein) and micronutrients (vitamins & minerals). Classic extraintestinal manifestations are present in two-thirds of diagnosed cases and include osteoporosis, anemia, hyposplenism, arthritis, aphthous ulcers, dental enamel hypoplasia, ataxia, peripheral neuropathy, headache, recurrent miscarriages and infertility, pancreatic exocrine insufficiency, bloating, and celiac hepatitis. The full symptom list continues…
Patients/clients with celiac disease are advised from diagnosis to adhere to a lifelong, gluten-free nutrition prescription, strictly avoiding the prolamins of wheat, barley, and rye (gliadin, hordein, and secalin, respectively). Strict adherence to a gluten-free nutrition prescription promotes healing of the intestine, improvement of symptoms of malabsorption, improvements in anemia, and reduction in the risk of complications associated with long-term, untreated celiac disease, which may include reduced bone mineral density and lymphoma.
Key Nutrition Interventions for Celiac Disease:
Recommend a gluten-free diet, stressing the importance of strict and lifelong adherence to a gluten-free diet.
Provide education about what foods should be avoided and included on a gluten-free diet.
Discuss oat tolerance and the inclusion of gluten-free oats as part of a gluten-free diet.
Recommend micronutrient supplementation and dietary changes if intake does not meet the DRIs or when the nutrition-focused physical exam and/or laboratory tests indicate nutritional inadequacies.
The Nutrition Care Process:
Nutrition Assessment
The purpose of nutrition assessment is to obtain, verify, and interpret the data needed to identify nutrition-related problems, their causes, and their significance. It is an ongoing, nonlinear, and dynamic process that involves data collection and continual analysis of the patient's or client’s status compared to specified criteria. Areas that should be addressed during the assessment period would be:
Food & Nutrition Related History
Anthropometric Measurements (height, weight, BMI, waist circumference)
Biochemical Data, Tests & Procedures
Nutrition Focused Physical Findings
Client History
Nutrition Diagnosis
Nutrition Diagnosis is a nutrition and dietetics practitioner’s identification and labeling of an existing nutrition problem(s) that the practitioner is responsible for treating. Nutritional diagnoses (eg, inconsistent carbohydrate intake) are different from medical diagnoses (eg, diabetes).
Nutrition and dietetics practitioners write a PES (Problem, Etiology, Signs and Symptoms) statement to describe each problem, the root causes, and the assessment data that provide evidence for the nutrition diagnosis(es). The format for each PES statement is “[Nutrition diagnosis term (problem)] related to [etiology] as evidenced by [signs/symptoms].”
A sample PES (problem, etiology, signs and symptoms) or nutrition diagnostic statement for adults with Celiac Disease might look like the following:
Inadequate mineral intake (iron) related to food- and nutrition-related knowledge deficit and malabsorption, as evidenced by low hemoglobin (<12 g/dL), low hematocrit (<36%), low ferritin (<20 mcg/L), and 24-hour recall supporting inadequate consumption of dietary iron.
Nutrition Intervention
A nutrition intervention is a purposely planned action(s) designed with the intent of changing a nutrition-related behavior, risk factor, environmental condition, or aspect of health status to resolve or improve the identified nutrition diagnosis(es) or nutrition problem(s). Nutrition interventions are selected and tailored to the client or patient’s needs by planning and implementing appropriate interventions.
Determining a Nutrition Intervention: The nutrition diagnosis and its etiology drive the selection of a nutrition intervention. The nutrition intervention is typically directed toward resolving the nutrition diagnosis(es) by altering or eliminating the nutrition etiology(ies). Less often, it is directed at relieving the signs and symptoms of the nutrition problem or problems. Nutrition intervention goals, ideally, developed collaboratively with the client, provide the basis for monitoring progress and measuring outcomes.
A sample intervention/prescription might look like:
(Gluten Free Diet): Recommend the removal of all gluten-containing foods with >20 ppm per serving. Recommend the strict removal of wheat, rye, and barley and their derivatives.
(Lactose-Modified Diet): Secondary lactase deficiency is associated with intestinal inflammation and malabsorption that is seen in celiac disease. Therefore, recommendation of a modified lactose diet may be necessary until the intestine has healed
Nutrition Monitoring & Evaluation
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 interventions. Nutrition Monitoring and Evaluation identifies outcomes/indicators relevant to the diagnosis and nutrition intervention plans and goals.
During the first interaction, appropriate outcomes/indicators are selected to be monitored and evaluated at the next interaction. During subsequent interactions, these outcomes/indicators are used to demonstrate the amount of progress made and whether the goals or expected outcomes are being met. Factors to consider when selecting indicators are the medical diagnosis, health care outcomes, client goals, nutrition quality management goals, practice setting, client population, and disease state and/or severity.
Monitoring and evaluation will focus on the same assessment parameters identified in the Nutrition Assessment section.
In adults with celiac disease, guidelines recommend that the registered dietitian reassess every 3-6 months during the first year of diagnosis and then every 1-2 years. The reassessment should include the following parameters:
Food & Nutrition Related History
Anthropometric Measurements (height, weight, BMI, waist circumference)
Biochemical Data, Tests & Procedures
Nutrition Focused Physical Findings