Nutrition Diagnosis - CGMH Diagnosis from... · Nutrition Diagnosis: ... Using the NCP Even though ADA’s ... (14,26). MNT is but one speciﬁc type of nutrition care. The NCP articulates

Nutrition Diagnosis: A Critical Step in the Nutrition Care Process


ISBN: 0-88091-358-4

Copyright 2006, American Dietetic Association. All rights reserved. No part of this

publication may be reproduced, stored in a retrieval system, or transmitted in any form or

by any means without the prior written consent of the publisher. Printed in the United

States of America.

The views expressed in this publication are those of the authors and do not necessarily

reflect policies and/or official positions of the American Dietetic Association. Mention of

product names in this publication does not constitute endorsement by the authors or the

American Dietetic Association. The American Dietetic Association disclaims

responsibility for the application of the information contained herein.

10 9 8 7 6 5 4 3 2 1


Table of Contents

Section I: The Nutrition Care Process

Nutrition Care Process and Model Article ....................................................................1

Section II: Development of Standardized Language

American Dietetic Association’s Standardized Language Model: Current Status.....13

Section III: Introduction to Nutrition Diagnosis

Introduction to Nutrition Diagnoses/Problems ...........................................................17

Section IV: Nutrition Diagnosis Reference Sheets

Single Page List of Nutrition Diagnostic Terminology................................................22

Section V: Nutrition Diagnosis Terms and Definitions

Nutrition Terms and Definitions ..................................................................................23

Section VI: Appendix

Procedure for NutritionControlled Vocabulary/Terminology Maintenance/Review 154

Acknowledgements Task Force Members..................................................................................................160

Consultants ................................................................................................................161

Research Reviewers ...................................................................................................162

Additional Reference on Implementation of Nutrition Care Process ....................................165

Feedback Form ......................................................................................................................171

Camera Ready Pocket Guide .................................................................................................173

Please check the ADA Web site for additional materials

http://www.eatright.org. Sign in as a member and select Research from sidebar.

http://www.eatright.org. Sign in as a member and select Quality Management and Outcomes

from the sidebar.

iii

Nutrition Care Process and Model: ADA adopts roadmap to quality care and outcomes managementKAREN LACEY, MS, RD; ELLEN PRITCHETT, RD

The establishment and implementation of a standardizedNutrition Care Process (NCP) and Model were identified aspriority actions for the profession for meeting goals of the

ADA Strategic Plan to “Increase demand and utilization of ser-vices provided by members” and “Empower members to com-pete successfully in a rapidly changing environment” (1). Pro-viding high-quality nutrition care means doing the right thing atthe right time, in the right way, for the right person, and achiev-ing the best possible results. Quality improvement literatureshows that, when a standardized process is implemented, lessvariation and more predictability in terms of outcomes occur(2). When providers of care, no matter their location, use aprocess consistently, comparable outcomes data can be gener-ated to demonstrate value. A standardized Nutrition Care Pro-cess effectively promotes the dietetics professional as theunique provider of nutrition care when it is consistently used asa systematic method to think critically and make decisions toprovide safe and effective nutrition care (3).

This article describes the four steps of ADA’s Nutrition CareProcess and the overarching framework of the Nutrition CareModel that illustrates the context within which the NutritionCare Process occurs. In addition, this article provides the ratio-nale for a standardized process by which nutrition care is pro-vided, distinguishes between the Nutrition Care Process andMedical Nutrition Therapy (MNT), and discusses future impli-cations for the profession.

BACKGROUNDPrior to the adoption of this standardized Nutrition Care Pro-cess, a variety of nutrition care processes were utilized by prac-titioners and taught by dietetics educators. Other allied health

professionals, including nursing, physical therapy, and occupa-tional therapy, utilize defined care processes specific to theirprofession (4-6). When asked whether ADA should develop astandardized Nutrition Care Process, dietetics professionalswere overwhelmingly in favor and strongly supportive of havinga standardized Nutrition Care Process for use by registereddietitians (RD) and dietetics technicians, registered (DTR).

The Quality Management Committee of the House of Dele-gates (HOD) appointed a Nutrition Care Model Workgroup inMay 2002 to develop a nutrition care process and model. Thefirst draft was presented to the HOD for member input andreview in September 2002. Further discussion occurred duringthe October 2002 HOD meeting, in Philadelphia. Revisionswere made accordingly, and the HOD unanimously adopted thefinal version of the Nutrition Care Process and Model on March31, 2003 “for implementation and dissemination to the dieteticsprofession and the Association for the enhancement of thepractice of dietetics.”

SETTING THE STAGE

Definition of Quality/Rationale for a StandardizedProcessThe National Academy of Science’s (NAS) Institute of Medi-cine (IOM) has defined quality as “The degree to which healthservices for individuals and populations increase the likelihoodof desired health outcomes and are consistent with currentprofessional knowledge” (7,8). The quality performance of pro-viders can be assessed by measuring the following: (a) theirpatients’ outcomes (end-results) or (b) the degree to whichproviders adhere to an accepted care process (7,8). The Com-mittee on Quality of Health Care in America further states thatit is not acceptable to have a wide quality chasm, or a gap,between actual and best possible performance (9). In an effortto ensure that dietetics professionals can meet both require-ments for quality performance noted above, the American Di-etetic Association (ADA) supports a standardized NutritionCare Process for the profession.

Standardized Process versus Standardized CareADA’s Nutrition Care Process is a standardized process fordietetics professionals and not a means to provide standardizedcare. A standardized process refers to a consistent structureand framework used to provide nutrition care, whereas stan-

K. Lacey is lecturer and Director of Dietetic Programs

at the University of Wisconsin-Green Bay, Green Bay. She

is also the Chair of the Quality Management Committee.

E. Pritchett is Director, Quality and Outcomes at ADA

headquarters in Chicago, IL.

If you have questions regarding the Nutrition Care Pro-

cess and Model, please contact Ellen Pritchett, RD, CPHQ,

Director of Quality and Outcomes at ADA,

[email protected]

Copyright © 2003 by the American Dietetic Association.

0002-8223/03/10308-0014$35.00/0

doi: 10.1053/jada.2003.50564

OF PROFESSIONAL INTEREST

Journal of THE AMERICAN DIETETIC ASSOCIATION / 1061

Edition: 2006 1

dardized care infers that all patients/clients receive the samecare. This process supports and promotes individualized care,not standardized care. As represented in the model (Figure 1),the relationship between the patient/client/group and dieteticsprofessional is at the core of the nutrition care process. There-fore, nutrition care provided by qualified dietetics profession-als should always reflect both the state of the science and thestate of the art of dietetics practice to meet the individualizedneeds of each patient/client/group (10).

Using the NCPEven though ADA’s Nutrition Care Process will primarily beused to provide nutrition care to individuals in health care set-tings (inpatient, ambulatory, and extended care), the processalso has applicability in a wide variety of community settings. Itwill be used by dietetics professionals to provide nutrition careto both individuals and groups in community-based agenciesand programs for the purpose of health promotion and diseaseprevention (11,12).

Key TermsTo lay the groundwork and facilitate a clear definition of ADA’sNutrition Care Process, key terms were developed. These def-initions provide a frame of reference for the specific compo-nents and their functions.

(a) Process is a series of connected steps or actions to

achieve an outcome and/or any activity or set of activities thattransforms inputs to outputs.

(b) Process Approach is the systematic identification andmanagement of activities and the interactions between activi-ties. A process approach emphasizes the importance of thefollowing:■ understanding and meeting requirements;■ determining if the process adds value;■ determining process performance and effectiveness; and■ using objective measurement for continual improvement ofthe process (13).

(c) Critical Thinking integrates facts, informed opinions, ac-tive listening and observations. It is also a reasoning process inwhich ideas are produced and evaluated. The Commission onAccreditation of Dietetics Education (CADE) defines criticalthinking as “transcending the boundaries of formal educationto explore a problem and form a hypothesis and a defensibleconclusion” (14). The use of critical thinking provides a uniquestrength that dietetics professionals bring to the Nutrition CareProcess. Further characteristics of critical thinking include theability to do the following:■ conceptualize;■ think rationally;■ think creatively;■ be inquiring; and■ think autonomously.

FIG 1. ADA Nutrition Care Process and Model.


1062 / August 2003 Volume 103 Number 8

Edition: 2006 2

(d) Decision Making is a critical process for choosing the bestaction to meet a desired goal.

(e) Problem Solving is the process of the following:■ problem identification;■ solution formation;■ implementation; and■ evaluation of the results.

(f) Collaboration is a process by which several individuals orgroups with shared concerns are united to address an identifiedproblem or need, leading to the accomplishment of what eachcould not do separately (15).

DEFINITION OF ADA’S NCPUsing the terms and concepts described above, ADA’s Nutri-tion Care Process is defined as “a systematic problem-solvingmethod that dietetics professionals use to critically think andmake decisions to address nutrition related problems and pro-vide safe and effective quality nutrition care.”

The Nutrition Care Process consists of four distinct, but in-terrelated and connected steps: (a) Nutrition Assessment, (b)Nutrition Diagnosis, (c) Nutrition Intervention, and d) Nutri-tion Monitoring and Evaluation. These four steps were finalizedbased on extensive review and evaluation of previous worksdescribing nutrition care (16-24). Even though each stepbuilds on the previous one, the process is not linear. Criticalthinking and problem solving will frequently require that die-tetics professionals revisit previous steps to reassess, add, orrevise nutrition diagnoses; modify intervention strategies;and/or evaluate additional outcomes. Figure 2 describes eachof these four steps in a similar format consisting of the follow-ing:■ definition and purpose;■ key components or substeps with examples as appropriate;■ critical thinking characteristics;■ documentation elements; and■ considerations for continuation, discontinuation, or dis-charge of care.

Providing nutrition care using ADA’s Nutrition Care Processbegins when a patient/client/group has been identified at nutri-tion risk and needs further assistance to achieve or maintainnutrition and health goals. It is also important to recognize thatpatients/clients who enter the health care system are morelikely to have nutrition problems and therefore benefit fromreceiving nutrition care in this manner. The Nutrition CareProcess cycles through the steps of assessment, diagnosis, in-tervention, and monitoring and evaluation. Nutrition care caninvolve one or more cycles and ends, ideally, when nutritiongoals have been achieved. However, the patient/client/groupmay choose to end care earlier based on personal or externalfactors. Using professional judgment, the dietetics professionalmay discharge the patient/client/group when it is determinedthat no further progress is likely.

PURPOSE OF NCPADA’s Nutrition Care Process, as described in Figure 2, givesdietetics professionals a consistent and systematic structureand method by which to think critically and make decisions. Italso assists dietetics professionals to scientifically and holisti-cally manage nutrition care, thus helping patients better meettheir health and nutrition goals. As dietetics professionals con-sistently use the Nutrition Care Process, one should expect ahigher probability of producing good outcomes. The NutritionCare Process then begins to establish a link between quality

and professional autonomy. Professional autonomy resultsfrom being recognized for what we do well, not just for who weare. When quality can be demonstrated, as defined previouslyby the IOM (7,8), then dietetics professionals will stand out asthe preferred providers of nutrition services. The NutritionCare Process, when used consistently, also challenges dieteticsprofessionals to move beyond experience-based practice toreach a higher level of evidence-based practice (9,10).

The Nutrition Care Process does not restrict practice butacknowledges the common dimensions of practice by the fol-lowing:■ defining a common language that allows nutrition practice tobe more measurable;■ creating a format that enables the process to generate quan-titative and qualitative data that can then be analyzed and in-terpreted; and■ serving as the structure to validate nutrition care and show-ing how the nutrition care that was provided does what it in-tends to do.

DISTINCTION BETWEEN MNT AND THE NCPMedical Nutrition Therapy (MNT) was first defined by ADA inthe mid-1990s to promote the benefits of managing or treatinga disease with nutrition. Its components included an assess-ment of nutritional status of patients and the provision of eitherdiet modification, counseling, or specialized nutrition thera-pies. MNT soon became a widely used term to describe a widevariety of nutrition care services provided by dietetics profes-sionals. Since MNT was first introduced, dietetics professionalshave gained much credibility among legislators and otherhealth care providers. More recently, MNT has been redefinedas part of the 2001 Medicare MNT benefit legislation to be“nutritional diagnostic, therapy, and counseling services for thepurpose of disease management, which are furnished by a reg-istered dietitian or nutrition professional” (25).

The intent of the NCP is to describe accurately the spectrumof nutrition care that can be provided by dietetics profession-als. Dietetics professionals are uniquely qualified by virtue ofacademic and supervised practice training and appropriatecertification and/or licensure to provide a comprehensive arrayof professional services relating to the prevention or treatmentof nutrition-related illness (14,26). MNT is but one specifictype of nutrition care. The NCP articulates the consistent andspecific steps a dietetics professional would use when deliver-ing MNT, but it will also be used to guide nutrition educationand other preventative nutrition care services. One of the keydistinguishing characteristics between MNT and the other nu-trition services using the NCP is that MNT always involves anin-depth, comprehensive assessment and individualized care.For example, one individual could receive MNT for diabetesand also nutrition education services or participate in a com-munity-based weight loss program (27). Each service woulduse the Nutrition Care Process, but the process would be im-plemented differently; the components of each step of the pro-cess would be tailored to the type of service.

By articulating the steps of the Nutrition Care Process, thecommonalities (the consistent, standardized, four-step pro-cess) of nutrition care are emphasized even though the processis implemented differently for different nutrition services. Witha standardized Nutrition Care Process in place, MNT should notbe used to describe all of the nutrition services that dieteticsprofessionals provide. As noted above, MNT is the only appli-cation of the Nutrition Care Process (28-31). This change in



Edition: 2006 3

STEP 1. NUTRITION ASSESSMENT

Basic Definition &Purpose

“Nutrition Assessment” is the first step of the Nutrition Care Process. Its purpose is to obtainadequate information in order to identify nutrition-related problems. It is initiated by referral and/orscreening of individuals or groups for nutritional risk factors. Nutrition assessment is a systematicprocess of obtaining, verifying, and interpreting data in order to make decisions about the nature andcause of nutrition-related problems. The specific types of data gathered in the assessment will varydepending on a) practice settings, b) individual/groups’ present health status, c) how data are relatedto outcomes to be measured, d) recommended practices such as ADA’s Evidence Based Guides forPractice and e) whether it is an initial assessment or a reassessment. Nutrition assessment requiresmaking comparisons between the information obtained and reliable standards (ideal goals). Nutritionassessment is an on-going, dynamic process that involves not only initial data collection, but alsocontinual reassessment and analysis of patient/client/group needs. Assessment provides thefoundation for the nutrition diagnosis at the next step of the Nutrition Care Process.

Data Sources/Tools forAssessment

� Referral information and/or interdisciplinary records� Patient/client interview (across the lifespan)� Community-based surveys and focus groups� Statistical reports; administrative data� Epidemiological studies

Types of Data Collected � Nutritional Adequacy (dietary history/detailed nutrient intake)� Health Status (anthropometric and biochemical measurements, physical & clinical conditions,

physiological and disease status)� Functional and Behavioral Status (social and cognitive function, psychological and emotional

factors, quality-of-life measures, change readiness)

Nutrition AssessmentComponents

� Review dietary intake for factors that affect health conditions and nutrition risk� Evaluate health and disease condition for nutrition-related consequences� Evaluate psychosocial, functional, and behavioral factors related to food access, selection,

preparation, physical activity, and understanding of health condition� Evaluate patient/client/group’s knowledge, readiness to learn, and potential for changing behaviors� Identify standards by which data will be compared� Identify possible problem areas for making nutrition diagnoses

Critical Thinking The following types of critical thinking skills are especially needed in the assessment step:� Observing for nonverbal and verbal cues that can guide and prompt effective interviewing

methods;� Determining appropriate data to collect;� Selecting assessment tools and procedures (matching the assessment method to the situation);� Applying assessment tools in valid and reliable ways;� Distinguishing relevant from irrelevant data;� Distinguishing important from unimportant data;� Validating the data;� Organizing & categorizing the data in a meaningful framework that relates to nutrition problems;

and� Determining when a problem requires consultation with or referral to another provider.

Documentation ofAssessment

Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.Quality documentation of the assessment step should be relevant, accurate, and timely. Inclusion ofthe following information would further describe quality assessment documentation:� Date and time of assessment;� Pertinent data collected and comparison with standards;� Patient/client/groups’ perceptions, values, and motivation related to presenting problems;� Changes in patient/client/group’s level of understanding, food-related behaviors, and other clinical

outcomes for appropriate follow-up; and� Reason for discharge/discontinuation if appropriate.

Determination forContinuation of Care

If upon the completion of an initial or reassessment it is determined that the problem cannot bemodified by further nutrition care, discharge or discontinuation from this episode of nutrition caremay be appropriate.

FIG 2. ADA Nutrition Care Process.



Edition: 2006 4

STEP 2. NUTRITION DIAGNOSIS


“Nutrition Diagnosis” is the second step of the Nutrition Care Process, and is the identification andlabeling that describes an actual occurrence, risk of, or potential for developing a nutritional problemthat dietetics professionals are responsible for treating independently. At the end of the assessmentstep, data are clustered, analyzed, and synthesized. This will reveal a nutrition diagnostic categoryfrom which to formulate a specific nutrition diagnostic statement. Nutrition diagnosis should not beconfused with medical diagnosis, which can be defined as a disease or pathology of specific organsor body systems that can be treated or prevented. A nutrition diagnosis changes as thepatient/client/group’s response changes. A medical diagnosis does not change as long as thedisease or condition exists. A patient/client/group may have the medical diagnosis of “Type 2diabetes mellitus”; however, after performing a nutrition assessment, dietetics professionals maydiagnose, for example, “undesirable overweight status” or “excessive carbohydrate intake.”Analyzing assessment data and naming the nutrition diagnosis(es) provide a link to setting realisticand measurable expected outcomes, selecting appropriate interventions, and tracking progress inattaining those expected outcomes.

Data Sources/Tools forDiagnosis

� Organized and clustered assessment data� List(s) of nutrition diagnostic categories and nutrition diagnostic labels� Currently the profession does not have a standardized list of nutrition diagnoses. However ADA

has appointed a Standardized Language Work Group to begin development of standardizedlanguage for nutrition diagnoses and intervention. (June 2003)

Nutrition DiagnosisComponents (3distinct parts)

1. Problem (Diagnostic Label)The nutrition diagnostic statement describes alterations in the patient/client/group’s nutritional status.

A diagnostic label (qualifier) is an adjective that describes/qualifies the human response such as:� Altered, impaired, ineffective, increased/decreased, risk of, acute or chronic.2. Etiology (Cause/Contributing Risk Factors)The related factors (etiologies) are those factors contributing to the existence of, or maintenance of

pathophysiological, psychosocial, situational, developmental, cultural, and/or environmentalproblems.

� Linked to the problem diagnostic label by words “related to” (RT)� It is important not only to state the problem, but to also identify the cause of the problem.▫ This helps determine whether or not nutritional intervention will improve the condition or correct

the problem.▫ It will also identify who is responsible for addressing the problem. Nutrition problems are either

caused directly by inadequate intake (primary) or as a result of other medical, genetic, orenvironmental factors (secondary).

▫ It is also possible that a nutrition problem can be the cause of another problem. For example,excessive caloric intake may result in unintended weight gain. Understanding the cascade ofevents helps to determine how to prioritize the interventions.

▫ It is desirable to target interventions at correcting the cause of the problem whenever possible;however, in some cases treating the signs and symptoms (consequences) of the problem may alsobe justified.

� The ranking of nutrition diagnoses permits dietetics professionals to arrange the problems in orderof their importance and urgency for the patient/client/group.

3. Signs/Symptoms (Defining Characteristics)The defining characteristics are a cluster of subjective and objective signs and symptoms

established for each nutrition diagnostic category. The defining characteristics, gathered duringthe assessment phase, provide evidence that a nutrition related problem exists and that theproblem identified belongs in the selected diagnostic category. They also quantify the problemand describe its severity:

� Linked to etiology by words “as evidenced by” (AEB);� The symptoms (subjective data) are changes that the patient/client/group feels and expresses

verbally to dietetics professionals; and� The signs (objective data) are observable changes in the patient/client/group’s health status.

Nutrition DiagnosticStatement (PES)

Whenever possible, a nutrition diagnostic statement is written in a PES format that states theProblem (P), the Etiology (E), and the Signs & Symptoms (S). However, if the problem is either a risk(potential) or wellness problem, the nutrition diagnostic statement may have only two elements,Problem (P), and the Etiology (E), since Signs & Symptoms (S) will not yet be exhibited in the patient.A well-written Nutrition Diagnostic Statement should be:1. Clear and concise2. Specific: patient/client/group-centered3. Related to one client problem4. Accurate: relate to one etiology5. Based on reliable and accurate assessment dataExamples of Nutrition Diagnosis Statements (PES or PE)� Excessive caloric intake (problem) “related to” frequent consumption of large portions of high fat

meals (etiology) “as evidenced by” average daily intake of calories exceeding recommendedamount by 500 kcal and 12-pound weight gain during the past 18 months (signs)

FIG 2 cont’d.



Edition: 2006 5

� Inappropriate infant feeding practice RT lack of knowledge AEB infant receiving bedtime juice in abottle

� Unintended weight loss RT inadequate provision of energy by enteral products AEB 6-poundweight loss over past month

� Risk of weight gain RT a recent decrease in daily physical activity following sports injury

Critical Thinking The following types of critical thinking skills are especially needed in the diagnosis step:� Finding patterns and relationships among the data and possible causes;� Making inferences (“if this continues to occur, then this is likely to happen”);� Stating the problem clearly and singularly;� Suspending judgment (be objective and factual);� Making interdisciplinary connections;� Ruling in/ruling out specific diagnoses; and� Prioritizing the relative importance of problems for patient/client/group safety.

Documentation ofDiagnosis

Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.Quality documentation of the diagnosis step should be relevant, accurate, and timely. A nutritiondiagnosis is the impression of dietetics professionals at a given point in time. Therefore, as moreassessment data become available, the documentation of the diagnosis may need to be revised andupdated.Inclusion of the following information would further describe quality documentation of this step:� Date and time; and� Written statement of nutrition diagnosis.


Since the diagnosis step primarily involves naming and describing the problem, the determination forcontinuation of care seldom occurs at this step. Determination of the continuation of care is moreappropriately made at an earlier or later point in the Nutrition Care Process.

STEP 3. NUTRITION INTERVENTION


“Nutrition Intervention” is the third step of the Nutrition Care Process. An intervention is a specificset of activities and associated materials used to address the problem. Nutrition interventions arepurposefully planned actions designed with the intent of changing a nutrition-related behavior, riskfactor, environmental condition, or aspect of health status for an individual, target group, or thecommunity at large. This step involves a) selecting, b) planning, and c) implementing appropriateactions to meet patient/client/groups’ nutrition needs. The selection of nutrition interventions is drivenby the nutrition diagnosis and provides the basis upon which outcomes are measured and evaluated.Dietetics professionals may actually do the interventions, or may include delegating or coordinatingthe nutrition care that others provide. All interventions must be based on scientific principles andrationale and, when available, grounded in a high level of quality research (evidence-basedinterventions).Dietetics professionals work collaboratively with the patient/client/group, family, or caregiver tocreate a realistic plan that has a good probability of positively influencing the diagnosis/problem. Thisclient-driven process is a key element in the success of this step, distinguishing it from previousplanning steps that may or may not have involved the patient/client/group to this degree ofparticipation.

Data Sources/Tools forInterventions

� Evidence-based nutrition guides for practice and protocols� Current research literature� Current consensus guidelines and recommendations from other professional organizations� Results of outcome management studies or Continuous Quality Index projects.� Current patient education materials at appropriate reading level and language� Behavior change theories (self-management training, motivational interviewing, behavior

modification, modeling)

Nutrition InterventionComponents

This step includes two distinct interrelated processes:1. Plan the nutrition intervention (formulate & determine a plan of action)� Prioritize the nutrition diagnoses based on severity of problem; safety; patient/client/group’s need;

likelihood that nutrition intervention will impact problem and patient/client/groups’ perception ofimportance.

� Consult ADA’s MNT Evidence-Based Guides for Practice and other practice guides. Theseresources can assist dietetics professionals in identifying science-based ideal goals and selectingappropriate interventions for MNT. They list appropriate value(s) for control or improvement of thedisease or conditions as defined and supported in the literature.

� Determine patient-focused expected outcomes for each nutrition diagnosis. The expectedoutcomes are the desired change(s) to be achieved over time as a result of nutrition intervention.They are based on nutrition diagnosis; for example, increasing or decreasing laboratory values,decreasing blood pressure, decreasing weight, increasing use of stanols/sterols, or increasingfiber. Expected outcomes should be written in observable and measurable terms that are clearand concise. They should be patient/client/group-centered and need to be tailored to what isreasonable to the patient’s circumstances and appropriate expectations for treatments andoutcomes.

FIG 2 cont’d.



Edition: 2006 6

� Confer with patient/client/group, other caregivers or policies and program standards throughoutplanning step.

� Define intervention plan (for example write a nutrition prescription, provide an education plan orcommunity program, create policies that influence nutrition programs and standards).

� Select specific intervention strategies that are focused on the etiology of the problem and that areknown to be effective based on best current knowledge and evidence.

� Define time and frequency of care including intensity, duration, and follow-up.� Identify resources and/or referrals needed.2. Implement the nutrition intervention (care is delivered and actions are carried out)� Implementation is the action phase of the nutrition care process. During implementation, dietetics

professionals:▫ Communicate the plan of nutrition care;▫ Carry out the plan of nutrition care; and▫ Continue data collection and modify the plan of care as needed.� Other characteristics that define quality implementation include:▫ Individualize the interventions to the setting and client;▫ Collaborate with other colleagues and health care professionals;▫ Follow up and verify that implementation is occurring and needs are being met; and▫ Revise strategies as changes in condition/response occurs.

Critical Thinking Critical thinking is required to determine which intervention strategies are implemented based onanalysis of the assessment data and nutrition diagnosis. The following types of critical thinking skillsare especially needed in the intervention step:� Setting goals and prioritizing;� Transferring knowledge from one situation to another;� Defining the nutrition prescription or basic plan;� Making interdisciplinary connections;� Initiating behavioral and other interventions;� Matching intervention strategies with client needs, diagnoses, and values;� Choosing from among alternatives to determine a course of action; and� Specifying the time and frequency of care.

Documentation ofNutrition Interventions

Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.Quality documentation of nutrition interventions should be relevant, accurate, and timely. It shouldalso support further intervention or discharge from care. Changes in patient/client/group’s level ofunderstanding and food-related behaviors must be documented along with changes in clinical orfunctional outcomes to assure appropriate care/case management in the future. Inclusion of thefollowing information would further describe quality documentation of this step:� Date and time;� Specific treatment goals and expected outcomes;� Recommended interventions, individualized for patient;� Any adjustments of plan and justifications;� Patient receptivity;� Referrals made and resources used;� Any other information relevant to providing care and monitoring progress over time;� Plans for follow-up and frequency of care; and� Rationale for discharge if appropriate.


If the patient/client/group has met intervention goals or is not at this time able/ready to make neededchanges, the dietetics professional may include discharging the client from this episode of care aspart of the planned intervention.

STEP 4. NUTRITION MONITORING AND EVALUATION


“Nutrition Monitoring and Evaluation” is the fourth step of the Nutrition Care Process. Monitoringspecifically refers to the review and measurement of the patient/client/group’s status at a scheduled(preplanned) follow-up point with regard to the nutrition diagnosis, intervention plans/goals, andoutcomes, whereas Evaluation is the systematic comparison of current findings with previous status,intervention goals, or a reference standard. Monitoring and evaluation use selected outcomeindicators (markers) that are relevant to the patient/client/group’s defined needs, nutrition diagnosis,nutrition goals, and disease state. Recommended times for follow-up, along with relevant outcomesto be monitored, can be found in ADA’s Evidence Based Guides for Practice and other evidence-based sources.The purpose of monitoring and evaluation is to determine the degree to which progress is beingmade and goals or desired outcomes of nutrition care are being met. It is more than just “watching”what is happening, it requires an active commitment to measuring and recording the appropriateoutcome indicators (markers) relevant to the nutrition diagnosis and intervention strategies. Data fromthis step are used to create an outcomes management system. Refer to Outcomes ManagementSystem in text.

FIG 2 cont’d.



Edition: 2006 7

Progress should be monitored, measured, and evaluated on a planned schedule until discharge.Short inpatient stays and lack of return for ambulatory visits do not preclude monitoring, measuring,and evaluation. Innovative methods can be used to contact patients/clients to monitor progress andoutcomes. Patient confidential self-report via mailings and telephone follow-up are some possibilities.Patients being followed in disease management programs can also be monitored for changes innutritional status. Alterations in outcome indicators such as hemoglobin A1C or weight are examplesthat trigger reactivation of the nutrition care process.

Data Sources/Tools forMonitoring andEvaluation

� Patient/client/group records� Anthropometric measurements, laboratory tests, questionnaires, surveys� Patient/client/group (or guardian) interviews/surveys, pretests, and posttests� Mail or telephone follow-up� ADA’s Evidence Based Guides for Practice and other evidence-based sources� Data collection forms, spreadsheets, and computer programs

Types of OutcomesCollected

The outcome(s) to be measured should be directly related to the nutrition diagnosis and the goalsestablished in the intervention plan. Examples include, but are not limited to:� Direct nutrition outcomes (knowledge gained, behavior change, food or nutrient intake changes,

improved nutritional status);� Clinical and health status outcomes (laboratory values, weight, blood pressure, risk factor profile

changes, signs and symptoms, clinical status, infections, complications);� Patient/client-centered outcomes (quality of life, satisfaction, self-efficacy, self-management,

functional ability); and� Health care utilization and cost outcomes (medication changes, special procedures,

planned/unplanned clinic visits, preventable hospitalizations, length of hospitalization, prevent ordelay nursing home admission).

Nutrition Monitoringand EvaluationComponents

This step includes three distinct and interrelated processes:1. Monitor progress� Check patient/client/group understanding and compliance with plan;� Determine if the intervention is being implemented as prescribed;� Provide evidence that the plan/intervention strategy is or is not changing patient/client/group

behavior or status;� Identify other positive or negative outcomes;� Gather information indicating reasons for lack of progress; and� Support conclusions with evidence.2. Measure outcomes� Select outcome indicators that are relevant to the nutrition diagnosis or signs or symptoms,

nutrition goals, medical diagnosis, and outcomes and quality management goals.� Use standardized indicators to:▫ Increase the validity and reliability of measurements of change; and▫ Facilitate electronic charting, coding, and outcomes measurement.3. Evaluate outcomes� Compare current findings with previous status, intervention goals, and/or reference standards.

Critical Thinking The following types of critical thinking skills are especially needed in the monitoring and evaluation step:� Selecting appropriate indicators/measures;� Using appropriate reference standard for comparison;� Defining where patient/client/group is now in terms of expected outcomes;� Explaining variance from expected outcomes;� Determining factors that help or hinder progress; and� Deciding between discharge or continuation of nutrition care.

Documentation ofMonitoring andEvaluation

Documentation is an on-going process that supports all of the steps in the Nutrition Care Processand is an integral part of monitoring and evaluation activities. Quality documentation of themonitoring and evaluation step should be relevant, accurate, and timely. It includes a statement ofwhere the patient is now in terms of expected outcomes. Standardized documentation enablespooling of data for outcomes measurement and quality improvement purposes. Qualitydocumentation should also include:� Date and time;� Specific indicators measured and results;� Progress toward goals (incremental small change can be significant therefore use of a Likert type

scale may be more descriptive than a “met” or “not met” goal evaluation tool);� Factors facilitating or hampering progress;� Other positive or negative outcomes; and� Future plans for nutrition care, monitoring, and follow up or discharge.


Based on the findings, the dietetics professional makes a decision to actively continue care ordischarge the patient/client/group from nutrition care (when necessary and appropriate nutrition care iscompleted or no further change is expected at this time). If nutrition care is to be continued, the nutritioncare process cycles back as necessary to assessment, diagnosis, and/or intervention for additionalassessment, refinement of the diagnosis and adjustment and/or reinforcement of the plan. If care does notcontinue, the patient may still be monitored for a change in status and reentry to nutrition care at a later date.

FIG 2 cont’d.



Edition: 2006 8

describing what dietetics professionals do is truly a paradigmshift. This new paradigm is more complete, takes in more pos-sibilities, and explains observations better. Finally, it allowsdietetics professionals to act in ways that are more likely toachieve the results that are desired and expected.

NUTRITION CARE MODELThe Nutrition Care Model is a visual representation that re-flects key concepts of each step of the Nutrition Care Processand illustrates the greater context within which the NutritionCare Process is conducted. The model also identifies other fac-tors that influence and impact on the quality of nutrition careprovided. Refer to Figure 1 for an illustration of the model asdescribed below:■ Central Core: Relationship between patient/client/group anddietetics professional;■ Nutrition Care Process: Four steps of the nutrition care pro-cess (Figure 2);■ Outer rings:■ Middle ring: Strengths and abilities that dietetics profession-als bring to the process (dietetics knowledge, skills, and com-petencies; critical thinking, collaboration, and communication;evidence-based practice, and Code of Ethics) (32);■ Outer ring: Environmental factors that influence the process(practice settings, health care systems, social systems, andeconomics);■ Supporting Systems:■ Screening and Referral System as access to Nutrition Care;and■ Outcomes Management System as a means to provide contin-uous quality improvement to the process.

The model is intended to depict the relationship with whichall of these components overlap, interact, and move in a dy-namic manner to provide the best quality nutrition care possi-ble.

Central to providing nutrition care is the relationship be-tween the patient/client/group and the dietetics professional.The patient/client/groups’ previous educational experiencesand readiness to change influence this relationship. The edu-cation and training that dietetics professionals receive havevery strong components devoted to interpersonal knowledgeand skill building such as listening, empathy, coaching, andpositive reinforcing.

The middle ring identifies abilities of dietetics professionalsthat are especially applicable to the Nutrition Care Process.These include the unique dietetics knowledge, skill, and com-petencies that dietetics professionals bring to the process, inaddition to a well-developed capability for critical thinking, col-laboration, and communication. Also in this ring is evidence-based practice that emphasizes that nutrition care must incor-porate currently available scientific evidence, linking what isdone (content) and how it is done (process of care). The Codeof Ethics defines the ethical principles by which dietetics pro-fessionals should practice (33). Dietetics knowledge and evi-dence-based practice establish the Nutrition Care Process asunique to dietetics professionals; no other health care profes-sional is qualified to provide nutrition care in this manner. How-ever, the Nutrition Care Process is highly dependent on collab-oration and integration within the health care team. As statedabove, communication and participation within the health careteam are critical for identification of individuals who are appro-priate for nutrition care.

The outer ring identifies some of the environmental factors

such as practice settings, health care systems, social systems,and economics. These factors impact the ability of the patient/client/group to receive and benefit from the interventions ofnutrition care. It is essential that dietetics professionals assessthese factors and be able to evaluate the degree to which theymay be either a positive or negative influence on the outcomesof care.

Screening and Referral SystemBecause screening may or may not be accomplished by dietet-ics professionals, nutrition screening is a supportive systemand not a step within the Nutrition Care Process. Screening isextremely important; it is an identification step that is outsidethe actual “care” and provides access to the Nutrition CareProcess.

The Nutrition Care Process depends on an effective screen-ing and/or referral process that identifies clients who wouldbenefit from nutrition care or MNT. Screening is defined by theUS Preventive Services Task Force as “those preventive ser-vices in which a test or standardized examination procedure isused to identify patients requiring special intervention” (34).The major requirements for a screening test to be consideredeffective are the following:■ Accuracy as defined by the following three components:� Specificity: Can it identify patients with a condition?� Sensitivity: Can it identify those who do not have the condi-tion?� Positive and negative predictive; and■ Effectiveness as related to likelihood of positive health out-comes if intervention is provided.

Screening parameters need to be tailored to the populationand to the nutrition care services to be provided. For example,the screening parameters identified for a large tertiary acutecare institution specializing in oncology would be vastly differ-ent than the screening parameters defined for an ambulatoryobstetrics clinic. Depending on the setting and institutionalpolicies, the dietetics professional may or may not be directlyinvolved in the screening process. Regardless of whether die-tetics professionals are actively involved in conducting thescreening process, they are accountable for providing inputinto the development of appropriate screening parameters toensure that the screening process asks the right questions.They should also evaluate how effective the screening processis in terms of correctly identifying clients who require nutritioncare.

In addition to correctly identifying clients who would benefitfrom nutrition care, a referral process may be necessary toensure that the client has an identifiable method of being linkedto dietetics professionals who will ultimately provide the nutri-tion care or medical nutrition therapy. While the nutritionscreening and referral is not part of the Nutrition Care Process,it is a critical antecedent step in the overall system (35).

Outcomes Management SystemAn outcomes management system evaluates the effectivenessand efficiency of the entire process (assessment, diagnosis,interventions, cost, and others), whereas the fourth step of theprocess “nutrition monitoring and evaluations” refers to theevaluation of the patient/client/group’s progress in achievingoutcomes.

Because outcomes management is a system’s commitment toeffective and efficient care, it is depicted outside of the NCP.Outcomes management links care processes and resource uti-



Edition: 2006 9

lization with outcomes. Through outcomes management, rele-vant data are collected and analyzed in a timely manner so thatperformance can be adjusted and improved. Findings are com-pared with such things as past levels of performance; organiza-tional, regional, or national norms; and standards or bench-marks of optimal performance. Generally, this information isreported to providers, administrators, and payors/funders andmay be part of administrative databases or required reportingsystems.

It requires an infrastructure in which outcomes for the pop-ulation served are routinely assessed, summarized, and re-ported. Health care organizations use complex informationmanagement systems to manage resources and track perfor-mance. Selected information documented throughout the nu-trition care process is entered into these central informationmanagement systems and structured databases. Examples ofcentralized data systems in which nutrition care data should beincluded are the following:■ basic encounter documentation for billing and cost account-ing;■ tracking of standard indicators for quality assurance and ac-creditation;■ pooling data from a large series of patients/clients/groups todetermine outcomes; and■ specially designed studies that link process and outcomes todetermine effectiveness and cost effectiveness of diagnosticand intervention approaches.

The major goal of outcomes management is to utilize col-lected data to improve the quality of care rendered in the fu-ture. Monitoring and evaluation data from individuals arepooled/aggregated for the purposes of professional account-ability, outcomes management, and systems/processes im-provement. Results from a large series of patients/clients canbe used to determine the effectiveness of intervention strate-gies and the impact of nutrition care in improving the overallhealth of individuals and groups. The effects of well-monitoredquality improvement initiatives should be reflected in measur-able improvements in outcomes.

Outcomes management comprehensively evaluates the twoparts of IOM’s definition of quality: outcomes and process. Mea-suring the relationship between the process and the outcome isessential for quality improvement. To ensure that the quality ofpatient care is not compromised, the focus of quality improve-ment efforts should always be directed at the outcome of care(36-43).

FUTURE IMPLICATIONS

Impact on Coverage for ServicesQuality-related issues are gaining in importance worldwide.Even though our knowledge base is increasing, the scientificevidence for most clinical practices in all of medicine is modest.So much of what is done in health care does not maximizequality or minimize cost (44). A standardized Nutrition CareProcess is a necessary foundation tool for gathering valid andreliable data on how quality nutrition care provided by qualifieddietetics professionals improves the overall quality of healthcare provided. Implementing ADA’s Nutrition Care Processprovides a framework for demonstrating that nutrition careimproves outcomes by the following: (a) enhancing the healthof individuals, groups, institutions, or health systems; (b) po-tentially reducing health care costs by decreasing the need formedications, clinic and hospital visits, and preventing or delay-

ing nursing home admissions; and (c) serving as the basis forresearch, documenting the impact of nutrition care providedby dietetics professionals (45-47).

Developing Scopes and Practice StandardsThe work group reviewed the questions raised by delegatesregarding the role of the RD and DTR in the Nutrition CareProcess. As a result of careful consideration of this importantissue, it was concluded that describing the various types oftasks and responsibilities appropriate to each of these creden-tialed dietetics professionals was yet another professional issuebeyond the intent and purpose of developing a standardizedNutrition Care Process.

A scope of practice of a profession is the range of servicesthat the profession is authorized to provide. Scopes of practice,depending on the particular setting in which they are used, canhave different applications. They can serve as a legal documentfor state certification/licensure laws or they might be incorpo-rated into institutional policy and procedure guidelines or jobdescriptions. Professional scopes of practice should be basedon the education, training, skills, and competencies of eachprofession (48).

As previously noted, a dietetics professional is a person who,by virtue of academic and clinical training and appropriate cer-tification and/or licensure, is uniquely qualified to provide acomprehensive array of professional services relating to pre-vention and treatment of nutrition-related conditions. A Scopeof Practice articulates the roles of the RD, DTR, and advanced-practice RD. Issues to be addressed for the future include thefollowing: (a) the need for a common scope with specializedguidelines and (b) recognition of the rich diversity of practicevs exclusive domains of practice regulation.

Professional standards are “authoritative statements thatdescribe performance common to the profession.” As such,standards should encompass the following:■ articulate the expectations the public can have of a dieteticsprofessional in any practice setting, domain, and/or role;■ expect and achieve levels of practice against which actualperformance can be measured; and■ serve as a legal reference to describe “reasonable and pru-dent” dietetics practice.

The Nutrition Care Process effectively reflects the dieteticsprofessional as the unique provider of nutrition care when it isconsistently used as a systematic method to think critically andmake decisions to provide safe and effective care. ADA’s Nutri-tion Care Process will serve as a guide to develop scopes ofpractice and standards of practice (49,50). Therefore, the workgroup recommended that further work be done to use the Nu-trition Care Process to describe roles and functions that can beincluded in scopes of practice. In May 2003, the Board of Di-rectors of ADA established a Practice Definitions Task Forcethat will identify and differentiate the terms within the profes-sion that need clarification for members, affiliates, and DPGsrelated to licensure, certification, practice acts, and advancedpractice. This task force is also charged to clarify the scope ofpractice services, clinical privileges, and accountabilities pro-vided by RDs/DTRs based on education, training, and experi-ence.

Education of Dietetics StudentsIt will be important to review the current CADE EducationalStandards to ensure that the language and level of expectedcompetencies are consistent with the entry-level practice of



Edition: 2006 10

the Nutrition Care Process. Further work by the Commissionon Dietetic Registration (CDR) may need to be done to makerevisions on the RD and DTR exams to evaluate entry-levelcompetencies needed to practice nutrition care in this way.Revision of texts and other educational materials will also needto incorporate the key principles and steps of this new process(51).

Education and Credentialing of MembersEven though dietetics professionals currently provide nutritioncare, this standardized Nutrition Care Process includes somenew principles, concepts, and guidelines in each of its steps.This is especially true of steps 2 and 4 (Nutrition Diagnosis andNutrition Monitoring and Evaluation). Therefore, the implica-tions for education of dietetics professionals and their practiceare great. Because a large number of dietetics professionals stillare employed in health care systems, a comprehensive educa-tional plan will be essential. A model to be considered whenplanning education is the one used to educate dietetics profes-sionals on the Professional Development Portfolio (PDP) Pro-cess (52). Materials that could be used to provide memberswith the necessary knowledge and skills in this process couldinclude but not be limited to the following:■ articles in the Journal of the American Dietetic Associa-

tion;■ continuing professional education lectures and presentationsat affiliate and national meetings;■ self-study materials; case studies, CD-ROM workbooks, andothers;■ hands-on workshops and training programs;■ Web-based materials; and■ inclusion in the learning needs assessment and codes of theProfessional Development Portfolio.

Through the development of this educational strategic plan,the benefits to dietetics professionals and other stakeholderswill need to be a central theme to promote the change in prac-tice that comes with using this process to provide nutritioncare.

Evidence-Based PracticeThe pressure to do more with less is dramatically affecting all ofhealth care, including dietetics professionals. This pressure isforcing the health care industry to restructure to be more effi-cient and cost-effective in delivering care. It will require the useof evidenced-based practice to determine what practices arecritical to support outcomes (53,54). The Nutrition Care Pro-cess will be invaluable as research is completed to evaluate theservices provided by dietetics professionals (55). The NutritionCare Process will provide the structure for developing themethodology and data collection in individual settings, and thepractice-based research networks ADA is in the process of ini-tiating.

Standardized LanguageAs noted in Step 2 (Nutrition Diagnosis), having a standardtaxonomy for nutrition diagnosis would be beneficial. Work inthe area of articulating the types of interventions used by die-tetics professionals has already begun by the Definitions WorkGroup under the direction of ADA’s Research Committee. Fur-ther work to define terms that are part of the Nutrition CareProcess will need to continue. Even though the work groupprovided a list of terms relating to the definition and key con-cepts of the process, there are opportunities to articulate fur-

ther terms that are consistently used in this process. The Boardof Directors of ADA in May 2003 approved continuation andexpansion of a task force to address a comprehensive systemthat includes a process for developing and validating standard-ized language for nutrition diagnosis, intervention, and out-comes.

SUMMARYJust as maps are reissued when new roads are built and riverschange course, this Nutrition Care Process and Model reflectsrecent changes in the nutrition and health care environment. Itprovides dietetics professionals with the updated “road map” tofollow the best path for high-quality patient/client/group-cen-tered nutrition care.

References1. American Dietetic Association Strategic Plan. Available at: http://eatright.org(member only section). Accessed June 2, 2003.2. Wheeler D. Understanding Variation: The Key to Managing Chaos. 2nd ed.Knoxville, TN: SPC Press; 2000.3. Shojania KG, Duncan BW, McDonald KM, Wachter RM. Making HealthCare Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43 (Prepared by the University of California atSan Francisco-Stanford Evidence-based Practice Center under Contract No.290-97-0013). Rockville, MD: Agency for Healthcare Research and Quality;2001. Report No.: AHRQ Publication No. 01-E058.4. Potter, Patricia A, Perry, Anne G. Basic Nursing Theory and Practice. 4thed. St Louis: C.V. Mosby; 1998.5. American Physical Therapy Association. Guide to Physical Therapist Prac-tice. 2nd ed. Alexandria, VA; 2001.6. The Guide to Occupational Therapy Practice. Am J Occup Ther. 1999;53:3.Available at http://nweb.pct.edu/homepage/student/NUNJOL02/ot%20process.ppt. Accessed May 30, 2003.7. Kohn KN, ed. Medicare: A strategy for Quality Assurance, Volume I. Com-mittee to Design a Strategy for Quality Review and Assurance in Medicare.Washington, DC: Institute of Medicine. National Academy Press; 1990.8. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a SaferHealth System. Washington, DC: Committee on Quality of Health Care inAmerica, Institute of Medicine. National Academy Press; 2000.9. Institute of Medicine. Crossing the Quality Chasm: A New Health System forthe 21st Century. Committee on Quality in Health Care in America. RonaBriere, ed. Washington, DC: National Academy Press; 2001.10. Splett P. Developing and Validating Evidence-Based Guides for Practice:A Tool Kit for Dietetics Professionals. American Dietetic Association; 1999.11. Endres JB. Community Nutrition. Challenges and Opportunities. UpperSaddle River, NJ: Prentice-Hall, Inc; 1999.12. Splett P. Planning, Implementation and Evaluation of Nutrition Programs.In: Sharbaugh CO, ed. Call to Action: Better Nutrition for Mothers, Children,and Families. Washington, DC: National Center for Education in Maternal andChild Health (NCEMCH); 1990.13. Batalden PB, Stoltz PA. A framework for the continual improvement ofhealth care: Building and applying professional and improvement knowledgeto test changes in daily work. Jt Comm J Qual Improv. 1993;19:424-452.14. CADE Accreditation Handbook. Available at: http://www.eatright.com/cade/standards.html. Accessed March 20, 2003.15. Alfaro-LeFevre R. Nursing process overview. Applying Nursing Process.Promoting Collaborative Care. 5th ed. Lippincott; 2002.16. Grant A, DeHoog S. Nutrition Assessment Support and Management.Northgate Station, WA; 1999.17. Sandrick, K. Is nutritional diagnosis a critical step in the nutrition careprocess? J Am Diet Assoc. 2002;102:427-431.18. King LS. What is a diagnosis? JAMA. 1967;202:154.19. Doenges ME. Application of Nursing Process and Nursing Diagnosis: AnInteractive Text for Diagnostic Reasoning, 3rd ed. Philadelphia, PA: FA DavisCo; 2000.20. Gallagher-Alred C, Voss AC, Gussler JD. Nutrition intervention and patientoutcomes: a self-study manual. Columbus, OH: Ross Products Division,Abbott Laboratories; 1995.21. Splett P, Myers EF. A proposed model for effective nutrition care. J AmDiet Assoc. 2001;101:357-363.22. Lacey K, Cross N. A problem-based nutrition care model that is diagnosticdriven and allows for monitoring and managing outcomes. J Am Diet Assoc.2002;102:578-589.23. Brylinsky C. The Nutrition Care Process. In: Mahan K, Escott-Stump S,



Edition: 2006 11

eds. Krause’s Food, Nutrition and Diet Therapy, 10th ed. Philadelphia, PA:W.B. Saunders Company; 2000:431-451.24. Hammond MI, Guthrie HA. Nutrition clinic: An integrated component of anundergraduate curriculum. J Am Diet Assoc. 1985;85:594.25. Final MNT Regulations. CMS-1169-FC. Federal Register, November 1,2001. Department of Health and Human Services. 42 CFR Parts: 405, 410,411, 414, and 415. Available at: http://cms.hhs.gov/physicians/pfs/cms1169fc.asp. Accessed June 27, 2003.26. Commission on Dietetic Registration CDR Certifications and State Licen-sure. Available at: http://www.cdrnet.org/certifications/index.htm. AccessedMay 30, 2003.27. Medicare Coverage Policy Decision: Duration and Frequency of the Med-ical Nutrition Therapy (MNT) Benefit (No. CAG-00097N). Available at: http://cms.hhs.gov/ncdr/memo.asp?id�53. Accessed June 2, 2003.28. American Dietetic Association Medical Nutrition Therapy Evidence-BasedGuides For Practice. Hyperlipidemia Medical Nutrition Therapy Protocol. CD-ROM; 2001.29. American Dietetic Association. Medical Nutrition Therapy Evidence-Based Guides for Practice. Nutrition Practice Guidelines for Type 1 and 2Diabetes Mellitus CD-ROM; 2001.30. American Dietetic Association. Medical Nutrition Therapy Evidence-Based Guides for Practice. Nutrition Practice Guidelines for Gestational Dia-betes Mellitus. CD-ROM; 2001.31. American Dietetic Association Medical Nutrition Therapy Evidence-BasedGuides For Practice. Chronic Kidney Disease (non-dialysis) Medical NutritionTherapy Protocol. CD-ROM; 2002.32. Gates G. Ethics opinion: Dietetics professionals are ethically obligated tomaintain personal competence in practice. J Am Diet Assoc. May 2003;103:633-635.33. Code of Ethics for the Profession of Dietetics. J Am Diet Assoc. 1999;99:109-113.34. US Preventive Services Task Force. Guide to Clinical Preventive Services,2nd ed. Washington, DC: US Department of Health and Human Services,Office of Disease Prevention and Health Promotion; 1996.35. Identifying patients at risk: ADA’s definitions for nutrition screening andnutrition assessment. J Am Diet Assoc. 1994;94:838-839.36. Donabedian A. Explorations in Quality Assessment and Monitoring. Vol-ume I: The Definition of Quality and Approaches to Its Assessment. Ann Arbor,MI: Health Administration Press; 1980.37. Carey RG, Lloyd RC. Measuring Quality Improvement in Health Care: AGuide to Statistical Process Control Applications. New York, Quality Re-sources; 1995.38. Eck LH, Slawson DL, Williams R, Smith K, Harmon-Clayton K, Oliver D. Amodel for making outcomes research standard practice in clinical dietetics.J Am Diet Assoc. 1998;98:451-457.39. Ireton-Jones CS, Gottschlich MM, Bell SJ. Practice-Oriented NutritionResearch: An Outcomes Measurement Approach. Gaithersburg, MD: AspenPublishers, Inc.; 1998.40. Kaye GL. Outcomes Management: Linking Research to Practice. Colum-bus, OH: Ross Products Division, Abbott Laboratories; 1996.41. Splett P. Cost Outcomes of Nutrition Intervention, a Three Part Mono-graph. Evansville, IN: Mead Johnson & Company; 1996.

42. Plsekk P. 1994. Tutorial: Planning for data collection part I: Asking theright question. Qual Manage Health Care. 2:76-81.43. American Dietetic Association. Israel D, Moore S, eds. Beyond NutritionCounseling: Achieving Positive Outcomes Through Nutrition Therapy. 1996.44. Stoline AM, Weiner JP. The New Medical Marketplace: A Physician’sGuide to the Health Care System in the 1990s. Baltimore: Johns HopkinsPress; 1993.45. Mathematica Policy Research, Inc. Best Practices in Coordinated CareMarch 22, 2000. Available at: http://www.mathematica-mpr.com/PDFs/bestpractices.pdf. Accessed February 22, 2003.46. Bisognano MA. New skills needed in medical leadership: The key toachieving business results. Qual Prog. 2000;33:32-41.47. Smith R. Expanding medical nutrition therapy: An argument for evidence-based practices. J Am Diet Assoc. 2003;103:313-314.48. National Council of State Boards of Nursing Model Nursing Practice Act.Available at: http://www.ncsbn.org/public/regulation/nursing_practice_model_practice_act.htm. Accessed June 27, 2003.49. Professional policies of the American College of Medical Quality (ACMQ).Available at: http://www.acmq.org/profess/list.htm. Accessed June 27, 2003.50. American Dietetic Association. Standards of professional practice. J AmDiet Assoc. 1998;98:83-85.51. O’Neil EH and the Pew Health Professions Commission. RecreatingHealth Professional Practice for a New Century. The Fourth Report of the PewHealth Professions Commission. Pew Health Professions Commission; De-cember 1998.52. Weddle DO. The professional development portfolio process: Settinggoals for credentialing. J Am Diet Assoc. 2002;102:1439-1444.53. Sackett DL, Rosenberg WMC, Gray J, Haynes RB, Richardson WS.Evidence based medicine: What it is and what it isn’t. Br Med J. 1996;312:71-72.54. Myers EF, Pritchett E, Johnson EQ. Evidence-based practice guides vs.protocols: What’s the difference? J Am Diet Assoc. 2001;101:1085-1090.55. Manore MM, Myers EF. Research and the dietetics profession: Making abigger impact. J Am Diet Assoc. 2003;103:108-112.

The Quality Management Committee Work Group devel-

oped the Nutrition Care Process and Model with input

from the House of Delegates dialog (October 2002 HOD

meeting, in Philadelphia, PA). The work group members

are the following: Karen Lacey, MS, RD, Chair; Elvira

Johnson, MS, RD; Kessey Kieselhorst, MPA, RD; Mary Jane

Oakland, PhD, RD, FADA; Carlene Russell, RD, FADA; Pa-

tricia Splett, PhD, RD, FADA; Suzanne Bertocchi, DTR,

and Tamara Otterstein, DTR; Ellen Pritchett, RD; Esther

Myers, PhD, RD, FADA; Harold Holler, RD, and Karri

Looby, MS, RD. The work group would like to extend a

special thank you to Marion Hammond, MS, and Naoimi

Trossler, PhD, RD, for their assistance in development of

the Nutrition Care Process and Model.



Edition: 2006 12

American Dietetic Association’s Standardized Nutrition Language:

Current Status

Introduction

Evidence-based dietetic practice relies on

concise, consistent, and standardized terminology to

create and retrieve digital sources of evidence.1 This

is essential for documenting nutrition diagnoses,

interventions and outcomes in electronic health

records. A task force of the American Dietetic

Association (ADA) has begun to refine and

disseminate standardized nutrition language. The

language is built on the Nutrition Care Process and

Model that maps quality nutrition care and outcomes,

and recognizes several existing terminologies used by

other health professions. This paper will describe the

logic model for the development of the standardized

nutrition language, the Nutrition Care Process it is

built upon, and its current status.

The project goal is to support nutrition practice,

education, research, and policy with data. It is

assumed that practicing dietitians, educators, and

researchers will use the standardized nutrition

language to document care, aggregate data, and study

the evidence. Standardized terminology will provide

the foundation for developing a national dietitian

care database.

The Nutrition Care Process

The ADA Nutrition Care Model workgroup

published the Nutrition Care Process (NCP) and

Model in August 2003.2 It provides a definition of

the NCP and describes its steps and framework. The

NCP is “a systematic problem-solving method that

dietetics professionals use to critically think and

make decisions to address nutrition related problems

and provide safe and effective quality nutrition

care.”2, p1063 The four steps of the NCP, similar to

those of other clinical professions, are: (a) Nutrition

Assessment, (b) Nutrition Diagnosis, (c) Nutrition

Intervention, and (d) Nutrition Monitoring and

Evaluation. Allowing for the reality of an iterative

and comprehensive clinical process, the NCP is not

linear and it includes, but is not limited to, Medical

Nutrition Therapy. Medical Nutrition Therapy is

“nutritional diagnostic, therapy, and counseling

services for the purpose of disease management,

which are furnished by a registered dietitian or

nutrition professional.”3 The context of the NCP and

surrounding influences are captured in the Model

framework.

Standardized terms are being developed for each

step of the NCP. Nutrition Assessment is “a

systematic process of obtaining, verifying, and

interpreting data in order to make decisions about the

nature and cause of nutrition-related problems.”2 The

Nutrition Assessment includes signs and symptoms.

Nutrition Diagnosis is “the identification and labeling

that describes an actual occurrence, risk of, or

potential for developing a nutritional problem that

dietetics professionals are responsible for treating

independently.”2

Nutrition Interventions are “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,

target group, or the community at large.”2,

Interventions are directed to influence the etiology or

effects of a diagnosis. Nutrition Monitoring is “the

review and measurement of the patient/client/group’s

status at a scheduled (preplanned) follow-up point

with regard to the nutrition diagnosis, intervention

plans/goals, and outcomes.” Evaluation is “the

systematic comparison of current findings with

previous status, intervention goals, or a reference

standard.”2 Evaluation may measure changes in signs

and symptoms. The NCP steps guide the delivery of

nutrition health services, education, and research and

define categories for documentation of nutrition care.

Development: Comparison with Nursing

In comparison with the development of various

nursing terminologies, the ADA nutrition language

development has been much more rapid and

centralized, due perhaps to comparatively smaller

numbers of nutrition professionals and growing

sophistication in information technology. Nursing

terminology work began in the 1970s, including the

North American Nursing Diagnosis Association

(NANDA)4 terminology, the Clinical Care

Classification (CCC),5 and others. NANDA is

specific to nursing diagnoses, while the CCC

addresses diagnoses, interventions, and outcomes.

The Nursing Minimum Data Set,6 which includes

patient information, nursing diagnoses, nursing

interventions, nursing outcomes, intensity level of

nursing care, and a unique provider number, is an

overarching framework for the various discrete

nursing terminologies, similar to the NCP.

Edition: 2006

Portions of this document have been submitted for publication elsewhere

13

Why Does Dietetics Practice Need a Standardized

Language?

There is currently no agreed upon mechanism by

which dietetics professionals can communicate with

each other or other health care professionals. Because

of this lack of agreement, there is no easy way to

classify, measure, and report on the outcomes of

nutrition interventions in various patient populations.

The Nutrition Care Process includes nutrition

diagnosis and nutrition intervention as unique steps

that provide registered dietitians a mechanism to

consistently document and communicate the work of

dietetics. There is currently no agreed upon

terminology used in dietetics practice which makes it

impossible to gather and aggregate data needed for

research, education, and reimbursement justification

via outcomes analysis.

Logic Model

A Logic Model is a simplified picture that

describes the logical relationships among the

resources invested, the activities that take place, and

the benefits to be realized from the project and the

environment in which the system/project occurs.

With the help of an informatics consultant, the

Standardized Language Task Force adopted a Project

Logic Model that identifies the expected outcomes

and impact of the Standardized Language of

Dietetics. The goal of the dietetics terminology was

seen to be "To provide data to foster nutrition

practice, education, research, and policy.”

Three time frames for evaluating the impact of

the standardized language were agreed upon. The

most immediate impacts were thought to include

recommendations for coordination with existing

terminologies, review of the structure of the dietetics

terminology, to "cross-walk" the new terminology

with existing terminologies to see if overlap exists, to

review existing intervention terms, and to identify

relevant policy issues regarding standardized

nutrition language. Intermediate impacts were

thought to include selection of a structure for the

nutrition diagnostic labels, cross-walk of the

intervention terms, to plan for generation of nutrition

outcomes measures, create strategies for ongoing

maintenance and updates of the language, to design

and implement pilot testing of the standardized

language, and to draft legislative and policy agendas.

The ultimate impact was agreed to include delivery

of quality, cost-effective nutrition care, national

growth of nutrition care, inclusion of the standardized

language in dietetics education and research,

development of a national data warehouse for

nutrition research, and support of policies designed to

foster nutrition practice, education, and research.

Several assumptions were necessary in

development of this logic model. The Task Force was

in agreement that nutrition is an essential component

of high quality health care. There was heightened

awareness of the need for data to document the

processes and outcomes of nutrition care in a variety

of settings. It was also assumed that educators,

practicing dietitians, and researchers would accept

and implement the standardized language and would

be willing to share data using the terminology for

targeted studies and ultimately a national database.

Nutrition Diagnostic Labels

To date, over 60 Nutrition Diagnostic Labels

have been defined by ADA work with focus groups,

domain experts, and membership committees.

Standardized Language Task Force members judged

the match between nutrition diagnoses terms and

similar terms listed in the National Library of

Medicine’s Unified Medical Language System

(UMLS);7 many terms have synonyms. One of the

robust terminologies in the UMLS is SNOMED-CT.8

Staff from SNOMED-CT were contacted to discuss

the process of submitting nutrition terms.

The Nutrition Diagnostic Labels include 3

domains: Clinical, Behavioral-Environmental, and

Intake. The domains, sub-classes, and specific

diagnoses are defined in the most recent version, a

summary of which follows.

DOMAIN: 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: Caloric Energy Balance

Defined as “actual or estimated changes in energy

(kcal)”

Class: Oral or Nutrition Support Intake

Defined as “actual or estimated food and beverage

intake from oral diet or nutrition support compared

with patient goal”

Class: Fluid Intake BalanceDefined as “actual or estimated fluid intake compared

with patient goal”

Class: Bioactive Substances Balance Defined as “actual or observed intake of bioactive

substances, including single or multiple functional

food components, ingredients, dietary supplements,

alcohol”

Class: Nutrient Balance

Defined as “actual or estimated intake of specific

nutrient groups or single nutrients as compared with

desired levels”

Sub-Class: Fat and Cholesterol Balance

Sub-Class: Protein Balance

Edition: 2006


14

Sub-Class: Carbohydrate and Fiber Balance

Sub-Class: Vitamin BalanceSub-Class: Mineral Balance

DOMAIN: CLINICAL

Defined as “nutritional findings/problems identified

that relate to medical or physical conditions”

Class: Functional Balance

Defined as “change in physical or mechanical

functioning that interferes with or prevents desired

nutritional consequences”

Class: Biochemical BalanceDefined as “change in capacity to metabolize

nutrients as a result of medications, surgery, or as

indicated by altered lab values”

Class: Weight Balance

Defined as “chronic weight or changed weight status

when compared with usual or desired body weight”

DOMAIN: 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

Defined as “actual knowledge and beliefs as reported,

observed, or documented”

Class: Physical Activity Balance and Function

Defined as “actual physical activity, self-care, and

quality of life problems as reported, observed or

documented”

Class: Food Safety and AccessDefined as “actual problems with food access or food

safety”

© ADA

Problem-Etiology-Signs/Symptoms Statements

A Nutrition Diagnosis is best written as a PES

statement pertaining to one patient/client or group,

specific to one problem (P) and one etiology (E), and

based on assessment of signs and symptoms (S).2

Implementation of PES statements in clinical practice

is being tested in two pilot studies by ADA members.

Examples of PES statements are

(a) “Overweight/obesity (problem) related to

continued intake of high fat foods (etiology) resulting

in ~300 extra kcal/day as evidenced by a BMI of 30

(sign/symptom), and (b) Impaired ability to prepare

foods/meals (problem) related to fatigue (etiology) as

evidenced by patient/client only consuming one meal

per day.” Interventions are often guided by the

etiology of each problem. Signs and symptoms may

provide measures to evaluate outcomes and the

effectiveness of care. It is possible that the

standardized terms for assessments will be

considered relevant outcome measures.

Nutrition Interventions

Following principles for standardized

terminologies,9 the ADA has begun to identify and

define Nutrition Intervention terms. A Task Force

meeting in February 2005 identified categories of

interventions including: Treatments/Procedures,

Education, Counseling, and Referral/Coordination.

These categories are similar to those in nursing

terminologies but differing by not including

monitoring/assessment as an intervention, which is a

separate step in the Nutrition Care Process.

Synonyms to the intervention terms will be searched

in the UMLS and domain experts will judge the

extent of the matches. The Nutrition Intervention

Labels will be submitted SNOMED-CT or other

existing coding system that will be included in the

UMLS.

Future Work

Definition of Nutrition Assessment terms and

their relationship with Outcome terms is planned. In

addition, activities to communicate the standardized

language to educators, administrators, clinicians, and

researchers are planned. The ADA believes that

consistent standardized terminology will improve

patient care by enhancing the education, practice, and

research of nutrition professionals. The use of

standardized nutrition language by nutrition

professionals in the United States is in synch with

similar international efforts.

References

1. Bakken S. An informatics infrastructure is

essential for evidence-based practice. J Am MedInform Assoc. 2001;8:199-201.

2. Lacey K, Pritchett E. Nutrition care process and

model: ADA adopts road map to quality care and

outcomes management. J Am Diet Assoc.

2003;103:1061-72.

3. Final Medical Nutrition Therapy regulations.

CMS-1169-FC. Federal Register, Nov.1, 2001.

DHHS 42 CFR Parts: 405, 410, 411, 414, and 415.

Available

at:http://cms.hhs.gov/physicians/pfs/cms1169fc.asp?

Accessed: March 7, 2005.

4. North American Nursing Diagnosis Association.

Available at: http://www.nanda.org. Accessed Mar.

7, 2005.

5. Saba V. Clinical Care Classification System.

Available at http://www.sabacare.com. Accessed

March 7, 2005.

6. Werley H, Lang NM. Identification of the Nursing

Minimum Data Set. New York:NY: Springer; 1988.

Edition: 2006


15

7. National Library of Medicine. Unified Medical

Language System. 2005. Available at: http://

www.nlm.nih.gov/research/umls/umlsmain.html.

Accessed March 7, 2005.

8. College of American Pathologists. SNOMED

International Clinical Terms. Available at

http://www.snomed.org/. Accessed March 7, 2005.

9. Cimino JJ. Desiderata for controlled medical

vocabularies in the twenty-first century. Meth InformMed; 1998;37:394-403.

Edition: 2006


16

Introduction to Nutrition Diagnoses/Problems:

The New Component of the Nutrition Care Process

Introduction

The ADA has embarked on an extensive project to identify and define nutrition

diagnoses/problems for the profession of dietetics. This standardized language of nutrition

diagnoses/problems is an integral component in the Nutrition Care Process, a process designed to

improve the consistency and quality of individualized patient/client care and the predictability of

the patient/client outcomes. In fact, several other allied professional, including nursing, physical

therapy, and occupational therapy, utilize defined care processes (1).

Not only will creating this standard language help dietetic professionals better document their

nutrition care, it will serve to help achieve Association strategic goals of promoting demand for

dietetic professionals and help them be more competitive in the market place. It will also provide

a minimum data set and common data elements for future research that includes services of

dietetic professionals.

ADA’s Standardized Language Task Force developed a conceptual framework for the

standardized nutrition language and identified the nutrition diagnoses/problems. The framework

outlines the domains within which the diagnoses/problems would fall and the flow of the

nutrition care process in relation to the continuum of health, disease and disability. Sixty-two

diagnoses/problems have been identified. A worksheet has been developed for each

diagnosis/problem and expert has been incorporated.

The methodology for developing sets of terms such as these includes systematically collecting

data from multiple sources simultaneously. We collected data from a selected group of dietitians

prior to starting the project (from recognized ADA leaders and award winners), from the 12

member task force during the development, from several small group discussions (community,

ambulatory, acute care, and long term care), and from expert researcher reviewers.

The methodology for continued development and refinement of these terms has been identified.

As with the ongoing updating of the American Medical Association Current Procedural

Terminology (CPT) codes, these will also be published on an annual basis. The process to

submit your suggested changes is included in this packet. In addition, the terms have been

included in one ongoing research project in an ambulatory setting. A second descriptive research

study identifying the use of the terms will be planned and conducted through the Dietetics

Practice Based Research Network in 2005-2006. As each of the research studies is completed,

their findings will be incorporated into future versions of these terms. Future iterations and

changes to the diagnoses/problems and the worksheets are expected as this standard language

evolves. Once the initial research is completed we will formally submit these terms to become

part of nationally recognized health care databases. We have already begun the dialogue with

these groups to let them know the direction that we are headed and to keep them appraised of our

progress.

Edition: 2006 17

Nutrition Care Process and Nutrition Diagnosis

ADA’s new nutrition care process for the profession has four steps—nutrition assessment,

nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation (1).

Textbooks often describe nutrition assessment in detail and then move directly into intervention

or therapy. Nutrition diagnosis is a critical step between assessment and intervention. The

nutrition diagnosis is the identification and labeling of the specific nutrition problem that

dietetics professionals are responsible for treating independently.

Naming the nutrition diagnosis provides a way to document the link between nutrition

assessment and nutrition intervention and set realistic and measurable expected outcomes for

each patient/client. Identifying the diagnosis also assists practitioners in establishing priorities

when planning an individual patient/client’s nutrition care.

Nutrition diagnosis differs from medical diagnosis. Medical diagnosis is a disease or pathology

of specific organs or body systems (e.g., diabetes) and does not change as long as the condition

exists. A nutrition diagnosis may be temporary, altering as the patient/client’s response changes

(e.g., excessive carbohydrate intake).

Categorization of the Nutrition Diagnoses

The sixty-two nutrition diagnoses/problems have been given labels that are clustered into three

domains: intake, clinical, and behavioral-environmental. Each domain represents unique

characteristics that contribute to nutritional health. Within each domain are classes and, in some

cases, sub-classes of diagnoses. A definition of each follows:

The Intake domain lists actual problems related to intake of energy, nutrients, fluids,

bioactive substances through oral diet, or nutrition support (enteral or parenteral nutrition.)

Class: Caloric Energy Balance (1)—Actual or estimated changes in energy (kcal).

Class: Oral or Nutrition Support Intake (2)—Actual or estimated food and beverage intake from oral diet

or nutrition support compared with patient/client’s goal.

Class: Fluid Intake Balance (3)—Actual or estimated fluid intake compared with patient/client’s goal.

Class: Bioactive Substances Balance (4)—Actual or observed intake of bioactive substances, including

single or multiple functional food components, ingredients, dietary supplements, and alcohol.

Class: Nutrient Balance (5)—Actual or estimated intake of specific nutrient groups or single nutrients as

compared with desired levels.

Sub-Class: Fat and Cholesterol Balance (51)

Sub-Class: Protein Balance (52)

Sub-Class: Carbohydrate and Fiber Balance (53)

Sub-Class: Vitamin Balance (54)

Sub-Class: Mineral Balance (55)

The Clinical domain is nutritional findings/problems identified that relate to medical or

physical conditions.

Class: Functional Balance (1)—Change in physical or mechanical function that interferes with or prevents

desired nutritional consequences.

Edition: 2006 18

Class: Biochemical Balance (2)—Change in the capacity to metabolize nutrients as a result of medications,

surgery, or as indicated by altered lab values.

Class: Weight Balance (3)—Chronic weight or changed weight status when compared with usual or desired

body weight.

The Behavioral-Environmental domain includes nutritional findings/problems identified

that relate to knowledge, attitudes/beliefs, physical environment, access to food, and food

safety.

Class: Knowledge and Beliefs (1)—Actual knowledge and beliefs as reported, observed, or documented.

Class: Physical Activity Balance and Function (2)—Actual physical activity, self-care, and quality of life

problems as reported, observed, or documented.

Class: Food Safety and Access (3)—Actual problems with food access or food safety.

Examples of nutrition diagnoses and their definitions include:

INTAKE DOMAIN Caloric Energy Balance

Inadequate energy intake NI-1.4 Energy intake that is less than energy expenditure or recommended

levels. Exception: when the goal is for the client to lose weight or

during end of life care.

CLINICAL DOMAIN Functional Balance

Swallowing difficulty NC-1.1 Impaired movement of food and liquid from the mouth to the stomach.

BEHAVIORAL-ENVIRONMENTAL DOMAIN Knowledge and Beliefs

Not ready for diet/lifestyle change NB-

1.3

Lack of perceived value of nutrition-related care benefits compared to

consequences or effort required to making the change; inconsistencies

with other value structure/purpose; antecedent to behavior change.

Nutrition Diagnosis Statements (or PES)

Whenever possible, a nutrition diagnosis statement is written in the PES format that states the

problem (P), the etiology (E), and the signs/symptoms (S).

Examples Swallowing difficulty (problem) related to stroke (etiology) as evidenced by coughing

following drinking of thin liquids (sign/symptoms).

Inadequate energy intake (problem) related to lack of financial resources to purchase sufficient

food (etiology) as evidenced by weight loss of 6 pounds in the last 2 months (signs/symptoms).

Nutrition Diagnosis Worksheet

A worksheet has been developed for each diagnosis. It contains four distinct components:

nutrition diagnosis label, definition of nutrition diagnosis label, etiology, and signs/symptoms.

These worksheets will assist practitioners with consistently and correctly utilizing the nutrition

diagnoses. Below is a description of the four components of the worksheet.

The Problem or Nutrition Diagnosis Label describes alterations in the patient/client’s nutrition status that

dietetics professionals are responsible for treating independently. Nutrition diagnosis differs from medical

diagnosis in that a nutrition diagnosis changes as the patient/client response changes. The medical diagnosis

Edition: 2006 19

does not change as long as the disease or condition exists. A nutrition diagnosis allows the dietetics professional

to identify realistic and measurable outcomes, formulate interventions, and monitor and evaluate change.

The Definition of Nutrition Diagnosis Label briefly describes the Nutrition Diagnosis Label to differentiate a

discrete problem area.

The Etiology (Cause/Contributing Risk Factors) are those factors contributing to the existence of, or

maintenance of pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental

problems. It is linked to the diagnosis label by the words “related to.”

The Signs/Symptoms (Defining Characteristics) consist of subjective and/or objective data used to determine

whether the patient/client has the nutrition diagnosis specified. These are the signs and symptoms gathered

through nutrition assessment. It is linked to the etiology by the words “as evidenced by.”

Organization of Data in Signs/Symptoms (Defining Characteristics)Dietetics professionals use clinical judgment to determine the nutrition diagnosis based on data

collected from the first step of the nutrition care process: nutrition assessment. Therefore, the

items listed in the signs/symptoms (defining characteristics) are organized according to nutrition

assessment category.

Nutrition assessment is the systematic process for obtaining, verifying, and interpreting data

needed to make decisions about the nature and cause of the nutrition-related problem. The

process of nutrition assessment consists of collecting biochemical data, anthropometric

measurements, physical examination findings, food/nutrition history, and client history. On the

nutrition diagnosis worksheet, the signs/symptoms are classified by nutrition assessment

categories.

Biochemical Data include laboratory data, for example, electrolytes, glucose, hemoglobin A1C, thyroid, and lipid

panel.

Anthropometric Measurements include, for instance, height, weight, body mass index (BMI), growth rate, and

rate of weight change.

Nutrition-Focused Physical Examination includes oral health, general physical appearance, muscle and

subcutaneous fat wasting, and affect.

Food and Nutrition History consists of four areas: Food consumption, nutrition and health awareness and

management, physical activity and exercise, and food availability.

Food consumption may include factors such as, food and nutrient intake, meal and snack patterns,

environmental cues to eating, and current diets and/or food modifications.

Nutrition and health awareness and management includes, for example, knowledge and beliefs about

nutrition recommendations, self-monitoring/management practices, and past nutrition counseling and

education.

Physical activity and exercise consists of activity patterns, amount of sedentary time (e.g., TV, phone,

computer), and exercise intensity, frequency, and duration.

Food availability encompasses factors such as, food planning, purchasing, preparation abilities and

limitations, food safety practices, food/nutrition program utilization, and food insecurity.

Edition: 2006 20

Client History consists of four areas: Medication and supplement history, social history, medical/health history,

and personal history.

Medication and supplement history includes, for instance, prescription and over the counter drugs,

herbal and dietary supplements, and illegal drugs.

Social history may include such items as socioeconomic status, social and medical support, cultural and

religious beliefs, housing situation, and social isolation/connection.

Medical/health history includes chief nutrition complaint, present/past illness, disease or complication

risk, family medical history, mental/emotional health, and cognitive abilities.

Personal history consists of factors including age, occupation, role in family, and education level.

Summary

Nutrition diagnosis is the critical link in the nutrition care process between assessment and

intervention. Interventions can then be clearly targeted to address either the etiology or signs and

symptoms of the specific nutrition diagnosis/problem identified. Using a standardized

terminology for identifying the nutrition diagnosis/problem will make one aspect of the critical

thinking that dietetics professionals do visible to other professionals as well as provide a clear

method of communicating among dietetics professionals. Implementation of a standard language

throughout the profession, with tools to assist practitioners, will make this bold initiative a

success. Ongoing input is critical as the standardized language is created to ensure a proper

foundation for its future implementation.

Reference

1. Lacey K, Pritchett E. Nutrition care process and model: ADA adopts road map to quality care

and outcomes management. J Am Diet Assoc. 2003;103:1061-1072.

Edition: 2006 21

Edition: 2006 22

INTAKE NI Defined as “actual problems related to intake of energy, nutrients, fluids, bioactive substances through oral diet or nutrition support”

Caloric Energy Balance (1) Defined as “actual or estimated changes in energy (kcal)”

Hypermetabolism NI-1.1 (Increased energy needs)

Increased energy expenditure NI-1.2 Hypometabolism NI-1.3

(Decreased energy needs) Inadequate energy intake NI-1.4 Excessive energy intake NI-1.5

Oral or Nutrition Support Intake (2) Defined as “actual or estimated food and beverage intake from oral diet or nutrition support compared with patient goal”

Inadequate oral food/ NI-2.1 beverage intake

Excessive oral food/ NI-2.2 beverage intake

Inadequate intake from NI-2.3 enteral/parenteral nutrition infusion

Excessive intake from NI-2.4 enteral/parenteral nutrition

Inappropriate infusion of NI-2.5 enteral/parenteral nutrition (use with caution)

Fluid Intake (3) Defined as “actual or estimated fluid intake compared with patient goal”

Inadequate fluid intake NI-3.1 Excessive fluid intake NI-3.2

Bioactive Substance Intake (4) Defined as “actual or observed intake of bioactive substances, including single or multiple functional food components, ingredients, dietary supplements, alcohol”

Inadequate bioactive NI-4.1 substance intake

Excessive bioactive NI-4.2 substance intake

Excessive alcohol intake NI-4.3

Nutrient Intake (5) Defined as “actual or estimated intake of specific nutrient groups or single nutrients as compared with desired levels”

Increased nutrient needs NI-5.1 (specify) ____________________________

Evident protein-energy NI-5.2 malnutrition

Inadequate protein- NI-5.3 energy intake

Decreased nutrient needs NI-5.4 (specify) ____________________________

Imbalance of nutrients NI-5.5

Fat and Cholesterol (51) Inadequate fat intake NI-51.1 Excessive fat intake NI-51.2 Inappropriate intake NI-51.3

of food fats (specify) ______________________ Protein (52)

Inadequate protein intake NI-52.1 Excessive protein intake NI-52.2 Inappropriate intake NI-52.3

of amino acids (specify)_______________________ Carbohydrate and Fiber (53)

Inadequate carbohydrate NI-53.1 intake

Excessive carbohydrate NI-53.2 intake

Inappropriate intake of NI-53.3 types of carbohydrate (specify)_______________________

Inconsistent NI-53.4 carbohydrate intake

Inadequate fiber intake NI-53.5 Excessive fiber intake NI-53.6

Vitamin (54) Inadequate vitamin NI-54.1

intake (specify)Excessive vitamin NI-54.2

intake (specify)A CThiamin DRiboflavin ENiacin KFolate Other _______

Mineral (55) Inadequate mineral intake NI-55.1

(specify) Calcium IronPotassium Zinc Other _______________

Excessive mineral intake NI-55.2 (specify)

Calcium IronPotassium Zinc Other _______________

CLINICAL NC Defined as “nutritional findings/problems identified as related to medical or physical conditions”

Functional (1) Defined as “change in physical or mechanical functioning that interferes with or prevents desired nutritional consequences”

Swallowing difficulty NC-1.1 Chewing (masticatory) difficulty NC-1.2 Breastfeeding difficulty NC-1.3 Altered GI function NC-1.4

Biochemical (2) Defined as “change in capacity to metabolize nutrients as a result of medications, surgery, or as indicated by altered lab values”

Impaired nutrient utilization NC-2.1 Altered nutrition-related NC-2.2

laboratory values (specify) _____________ Food-medication interaction NC-2.3

Weight (3) Defined as “chronic weight or changed weight status when compared with usual or desired body weight”

Underweight NC-3.1 Involuntary weight loss NC-3.2 Overweight/obesity NC-3.3 Involuntary weight gain NC-3.4

BEHAVIORAL- ENVIRONMENTAL NB Defined as “nutritional findings/problems identified as related to knowledge, attitudes/beliefs, physical environment, or food supply and safety”

Knowledge and Beliefs (1) Defined as “actual knowledge and beliefs as reported or documented”

Food, nutrition, and NB-1.1 nutrition-related knowledge deficit

Harmful beliefs/attitudes NB-1.2 about food or nutrition- related topics (use with caution)

Not ready for diet/ NB-1.3 lifestyle change

Self-monitoring deficit NB-1.4 Disordered eating pattern NB-1.5 Limited adherence to nutrition- NB-1.6

related recommendations Undesirable food choices NB-1.7

Physical Activity and Function (2) Defined as “actual physical activity, self-care, and quality of life problems as reported, observed, or documented”

Physical inactivity NB-2.1 Excessive exercise NB-2.2 Inability or lack of desire NB-2.3

to manage self-care Impaired ability to NB-2.4

prepare foods/meals Poor nutrition quality of life NB-2.5 Self-feeding difficulty NB-2.6

Food Safety and Access (3) Defined as “actual problems with food access or food safety”

Intake of unsafe food NB-3.1 Limited access to food NB-3.2

NUTRITION DIAGNOSTIC TERMINOLOGY

#1 Problem ____________________________________________________________________________________________________________

Etiology ____________________________________________________________________________________________________________

Signs/Symptoms _____________________________________________________________________________________________________

#2 Problem ____________________________________________________________________________________________________________

Etiology ____________________________________________________________________________________________________________

Signs/Symptoms _____________________________________________________________________________________________________

#3 Problem ____________________________________________________________________________________________________________

Etiology ____________________________________________________________________________________________________________

Signs/Symptoms ___________________________________________________________________________________________

Date Identified Date Resolved

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

Nu

trit

ion

Dia

gn

os

tic

Te

rm

Te

rmN

um

be

rD

efi

nit

ion

of

Dia

gn

os

tic

Te

rmR

efe

ren

ce

Sh

ee

tP

ag

eN

um

be

rs

DO

MA

IN:

IN

TA

KE

Defi

ned

as “

actu

al p

rob

lem

s r

ela

ted

to

in

take o

f en

erg

y, n

utr

ien

ts, fl

uid

s, b

ioacti

ve

su

bsta

nces t

hro

ug

h o

ral d

iet

or

nu

trit

ion

su

pp

ort

(en

tera

l o

r p

are

nte

ral n

utr

itio

n)”

NI

Cla

ss:

Calo

ric E

nerg

y B

ala

nce (

1)

Defi

ne

d a

s “

actu

al o

r esti

mate

d c

han

ges in

e

ne

rgy

(k

ca

l)”

Hyperm

eta

bolis

m (

Incre

ased e

nerg

y n

eeds)

NI-

1.1

Resting m

eta

bolic

rate

(R

MR

) above p

redic

ted r

equirem

ents

due

to s

tress, tr

aum

a, in

jury

, sepsis

, or

dis

ease. N

ote

: R

MR

is the

su

m o

f m

eta

bo

lic p

roce

sses o

f a

ctive

ce

ll m

ass r

ela

ted

to

th

e

ma

inte

nan

ce

of n

orm

al bo

dy fu

nctio

ns a

nd

re

gu

lato

ry b

ala

nce

during r

est.

32

-33

Incre

ased e

nerg

y e

xpenditure

NI-

1.2

Resting m

eta

bolic

rate

(R

MR

) above p

redic

ted

requirem

ents

due

to b

ody c

om

positio

n, m

edic

ations, endocrine, neuro

logic

, or

genetic c

hanges. N

ote

: R

MR

is the s

um

of m

eta

bolic

pro

cesses

of active c

ell

mass r

ela

ted

to the m

ain

tenance o

f norm

al body

functions a

nd r

egula

tory

bala

nce d

uring r

est.

34

Hypom

eta

bolis

m (

Decre

ased e

nerg

y n

eeds)

NI-

1.3

Resting m

eta

bolic

rate

(R

MR

) be

low

pre

dic

ted r

equ

irem

ents

due

to b

ody c

om

positio

n, m

edic

ations, endocrine, neuro

logic

, or

ge

ne

tic c

ha

ng

es

35

-36

Inadequate

energ

y inta

ke

NI-

1.4

Energ

y inta

ke

that is

less than e

nerg

y e

xpenditure

, esta

blis

hed

refe

rence s

tandard

s, or

recom

mendations b

ased u

pon

physio

logic

al needs. E

xception: w

hen the g

oal is

weig

ht lo

ss o

r

37

-38

Ed

itio

n:

20

06

23

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

during e

nd o

f lif

e c

are

.

Excessiv

e e

nerg

y inta

ke

NI-

1.5

Calo

ric inta

ke that exceeds e

nerg

y e

xpenditure

, esta

blis

hed

refe

rence s

tandard

s, or

recom

mendations b

ased u

pon

physio

logic

al needs. E

xception: w

hen w

eig

ht gain

is d

esired.

39

-40

Cla

ss:

Ora

l o

r N

utr

itio

n S

up

po

rt In

take (

2)

Defi

ned

as “actu

al o

r esti

mate

d f

oo

d a

nd

b

evera

ge in

take f

rom

ora

l d

iet

or

nu

trit

ion

su

pp

ort

co

mp

are

d w

ith

pa

tie

nt

go

al”

Inadequate

ora

l fo

od/b

evera

ge inta

ke

NI-

2.1

Ora

l fo

od/b

evera

ge inta

ke that is

less than e

sta

blis

hed r

efe

rence

sta

ndard

s o

r re

com

mendations b

ased u

pon p

hysio

logic

al needs.

Exception: w

hen r

ecom

mendation is

weig

ht lo

ss o

r during e

nd o

f lif

e c

are

.

41

-42

Excessiv

e o

ral fo

od/b

evera

ge inta

ke

NI-

2.2

Ora

l fo

od/b

evera

ge inta

ke that exceeds

energ

y e

xpenditure

,esta

blis

hed r

efe

rence

sta

ndard

s, or

recom

mendations b

ased

upon p

hysio

logic

al needs. E

xception: w

hen w

eig

ht gain

is

de

sire

d.

43

-44

Inadequate

inta

ke fro

m e

nte

ral/pare

nte

ral

nutr

itio

n infu

sio

nN

I-2

.3E

nte

ral o

r pa

ren

tera

l in

fusio

n th

at p

rovid

es fe

we

r ca

lorie

s o

rn

utr

ien

ts c

om

pa

red

to

esta

blis

he

d r

efe

ren

ce

sta

nda

rds o

r re

co

mm

en

da

tio

ns b

ase

d u

po

n p

hysio

log

ica

l ne

eds. E

xce

ptio

n:

when r

ecom

mendation is for

weig

ht lo

ss o

r during e

nd o

f lif

e

ca

re.

45

-46

Excessiv

e inta

ke fro

m e

nte

ral/pare

nte

ral

nutr

itio

nN

I-2.4

Ente

ral or

pa

rente

ral in

fusio

n that pro

vid

es m

ore

calo

ries o

r n

utr

ien

ts c

om

pa

red

to

esta

blis

he

d r

efe

ren

ce

sta

nda

rds o

r re

co

mm

en

da

tio

ns b

ase

d u

po

n p

hysio

log

ica

l ne

eds

47

-48

Inappro

priate

infu

sio

n o

f ente

ral/pare

nte

ral

nutr

itio

n

US

E W

ITH

CA

UT

ION

ON

LY

AF

TE

R

DIS

CU

SS

ION

WIT

H O

TH

ER

ME

MB

ER

S O

F

TH

E H

EA

LT

H C

AR

E T

EA

M

NI-

2.5

En

tera

l o

r pa

ren

tera

l in

fusio

nth

at p

rovid

es e

ith

er

few

er

or

mo

recalo

ries a

nd/o

r nutr

ients

or

is o

f th

e w

rong c

om

positio

n o

r ty

pe, is

not w

arr

ante

d b

ecause the p

atient is

able

to tole

rate

an

ente

ral

inta

ke, or

is u

nsafe

be

cause o

f th

e p

ote

ntial fo

r sepsis

or

oth

er

co

mp

lica

tion

s

49

-50

Ed

itio

n:

20

06

24

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

Cla

ss:

Flu

id In

take (

3)

Defi

ne

d a

s “

actu

al o

r esti

mate

d f

luid

in

take

co

mp

are

dw

ith

pa

tie

nt

go

al”

Ina

de

qu

ate

flu

id in

take

NI-

3.1

Lo

we

r in

take

of flu

id c

on

tain

ing

fo

ods o

r su

bsta

nces c

om

pare

d to

e

sta

blis

he

d r

efe

rence

sta

nd

ard

s o

r re

com

me

nda

tio

ns b

ase

d

up

on

ph

ysio

log

ica

l n

ee

ds

51

-52

Excessiv

e flu

id inta

ke

NI-

3.2

Hig

her

inta

ke o

f fluid

com

pare

d to e

sta

blis

hed r

efe

rence

sta

nda

rds o

r re

co

mm

en

da

tio

ns b

ased

up

on

ph

ysio

log

ica

l ne

eds

53

-54

Cla

ss:

Bio

ac

tiv

e S

ub

sta

nc

es

(4

)

De

fin

ed

as

“a

ctu

al o

r o

bs

erv

ed

in

take

of

bio

acti

ve s

ub

sta

nces, in

clu

din

g s

ing

le o

r m

ult

iple

fu

nc

tio

nal fo

od

co

mp

on

en

ts,

ing

red

ien

ts, d

ieta

ry s

up

ple

men

ts, alc

oh

ol”

Inadequate

bio

active s

ubsta

nce inta

ke

NI-

4.1

Low

er

inta

ke

of bio

active s

ubsta

nces

conta

inin

g foods o

r substa

nces c

om

pare

d to e

sta

blis

hed r

efe

rence

sta

ndard

s o

r re

com

mendations b

ased u

pon p

hysio

logic

al needs

55

-56

Excessiv

e b

ioactive s

ubsta

nce inta

ke

NI-

4.2

Hig

her

inta

ke o

f bio

active s

ubsta

nces o

ther

than tra

ditio

nal

nutr

ients

, such a

s functional fo

ods, bio

active food c

om

ponents

,d

ieta

ry s

up

ple

me

nts

, fo

od

co

ncen

tra

tes c

om

pa

red

to

esta

blis

he

dre

fere

nce s

tandard

s o

r re

com

mendations b

ased u

pon

ph

ysio

log

ica

l n

ee

ds

57

-58

Excessiv

e a

lcohol in

take

NI-

4.3

Inta

ke a

bove the s

uggeste

d lim

its for

alc

ohol

59-6

0

Cla

ss:

Nu

trie

nt

(5)

Defi

ne

d a

s “

actu

al o

r esti

mate

d in

take o

f sp

ecif

ic n

utr

ien

t g

rou

ps o

r sin

gle

nu

trie

nts

as c

om

pare

d w

ith

desir

ed

levels

”

Incre

ased n

utr

ient needs

(specify)

NI-

5.1

Incre

ased

need for

a s

pecific

nutr

ient com

pare

d to e

sta

blis

hed

refe

rence s

tandard

s o

r re

com

mendations based u

pon

61

-62

Ed

itio

n:

20

06

25

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

ph

ysio

log

ica

l n

ee

ds

Evid

ent pro

tein

-energ

y m

aln

utr

itio

nN

I-5.2

Inadequate

inta

ke o

f pro

tein

and/o

r en

erg

y63-6

4

Inadequate

pro

tein

-energ

y inta

ke

NI-

5.3

Inadequate

inta

ke o

f pro

tein

and/o

r energ

y c

om

pare

d to

esta

blis

hed r

efe

rence

sta

ndard

s o

r re

com

mendations based

upon p

hysio

logic

al needs

of short

or

recent dura

tion

65

-66

Decre

ase

d n

utr

ien

t n

eed

s(s

pe

cify)

NI-

5.4

Decre

ase

dne

ed

fo

r a

sp

ecific

nu

trie

nt co

mp

are

d to

esta

blis

hed

refe

rence s

tandard

s o

r re

com

mendations based u

pon

ph

ysio

log

ica

l n

ee

ds

67

-68

Imbala

nce o

f nutr

ients

NI-

5.5

An u

ndesirable

com

bin

ation o

f in

geste

d n

utr

ients

, such that th

e

am

ount of one n

utr

ient in

geste

d inte

rfere

s w

ith o

r alters

a

bso

rption

and

/or

utiliz

ation

of a

no

the

r n

utr

ien

t

69

-70

Su

b-C

lass:

Fat

an

d C

ho

leste

rol (5

1)

Inadequate

fat in

take

NI-

51.1

Low

er

fat in

take c

om

pare

d to e

sta

blis

hed

refe

rence s

tandard

s o

r re

com

mendations b

ased u

pon p

hysio

logic

al needs. E

xception:

when r

ecom

mendation is for

weig

ht lo

ss o

r during e

nd o

f lif

e

ca

re.

71

Excessiv

e fat in

take

NI-

51.2

Hig

her

fat in

take

co

mpare

d to e

sta

blis

hed r

efe

rence

sta

ndard

s o

rre

co

mm

en

da

tio

ns b

ase

d u

po

n p

hysio

log

ica

l ne

eds

72

-73

Inappro

priate

inta

ke o

f fo

od fats

(specify)

NI-

51.3

Inta

ke

of w

rong type o

r qualit

y o

f fo

od fats

com

pare

d to

esta

blis

hed r

efe

rence

sta

ndard

s o

r re

com

mendations based

upon p

hysio

logic

al needs

74

-75

Su

b-C

lass:

Pro

tein

(52)

Ina

de

qu

ate

pro

tein

in

take

NI-

52

.1L

ow

er

inta

ke

of

pro

tein

co

nta

inin

g fo

ods

or

sub

sta

nces c

om

pare

dto

esta

blis

hed

re

fere

nce

sta

nd

ard

s o

r re

co

mm

en

da

tion

s b

ased

upon p

hysio

logic

al needs

76

Excessiv

e p

rote

in inta

ke

NI-

52.2

Inta

ke a

bove the r

ecom

mended level and/o

r ty

pe o

f pro

tein

co

mpa

red

to

esta

blis

he

d r

efe

ren

ce

sta

nd

ard

s o

r7

7-7

8

Ed

itio

n:

20

06

26

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

reco

mm

en

da

tio

ns b

ase

d u

po

n p

hysio

log

ica

l ne

eds

Ina

pp

ropria

te in

take

of a

min

o a

cid

s (

specify)

NI-

52

.3In

take

th

at is

mo

re o

r le

ss th

an

recom

men

de

d le

ve

l and

/or

typ

e

of a

min

o a

cid

s c

om

pare

d to

esta

blis

he

d r

efe

ren

ce

sta

nd

ard

s o

rre

co

mm

en

da

tio

ns b

ase

d u

po

n p

hysio

log

ica

l ne

eds

78

-80

Su

b-C

lass:

Carb

oh

yd

rate

an

d

Fib

er

(53)

Inadequate

carb

ohydra

te inta

ke

NI-

53.1

Low

er

inta

ke

of carb

ohydra

te-c

onta

inin

g foods o

r substa

nces

co

mpa

red

to

esta

blis

he

d r

efe

ren

ce

sta

nd

ard

s o

rre

co

mm

en

da

tio

ns b

ase

d u

po

n p

hysio

log

ica

l ne

eds

81

Excessiv

e c

arb

ohydra

te inta

ke

NI-

53.2

Inta

ke a

bove the r

ecom

mended level and type o

f carb

ohydra

teco

mpa

red

to

esta

blis

he

d r

efe

ren

ce

sta

nd

ard

s o

rre

co

mm

en

da

tio

ns b

ase

d u

po

n p

hysio

log

ica

l ne

eds

82

-83

Inappro

priate

inta

ke o

f ty

pes o

f carb

ohydra

te(s

pe

cify)

NI-

53.3

Inta

ke o

r th

e type o

r am

ount of carb

ohydra

te that is

above o

r b

elo

w th

e e

sta

blis

he

d r

efe

ren

ce

sta

nd

ard

s o

r re

co

mm

en

da

tion

sb

ase

d u

po

n p

hysio

log

ica

l ne

eds

84

-85

Inconsis

tent carb

ohydra

te inta

ke

NI-

53.4

Inconsis

tent tim

ing o

f carb

ohydra

te inta

ke thro

ughoutth

e d

ay,

day to d

ay, or

a p

attern

of carb

ohydra

te inta

ke that is

not

co

nsis

ten

t w

ith

re

co

mm

en

de

d p

att

ern

base

d u

po

n p

hysio

log

ica

ln

ee

ds

86

-87

Inadequate

fib

er

inta

ke

NI-

53.5

Low

er

inta

ke

of fiber-

conta

inin

g foods o

r substa

nces c

om

pare

d to

esta

blis

hed r

efe

rence

sta

ndard

s o

r re

com

mendations b

ased

upon p

hysio

logic

al needs

88

-89

Exce

ssiv

e fib

er

inta

ke

NI-

53

.6H

ighe

r in

take o

f fib

er-

co

nta

inin

g fo

ods o

r su

bsta

nces c

om

pare

dto

recom

mendations b

ased u

pon p

atient/clie

nt conditio

n9

0-9

1

Su

b-C

lass:

Vit

am

in (

54)

Inadequate

vitam

in inta

ke (

specify)

NI-

54.1

Low

er

inta

ke

of vitam

in-c

onta

inin

g foods o

r substa

nces

co

mpa

red

to

esta

blis

he

d r

efe

ren

ce

sta

nd

ard

s o

rre

co

mm

en

da

tio

ns b

ase

d u

po

n p

hysio

log

ica

l ne

eds

92

-94

Ed

itio

n:

20

06

27

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

Excessiv

e v

itam

in inta

ke (

specify)

NI-

54.2

Hig

her

inta

ke o

f vitam

in c

onta

inin

g foods o

r substa

nces

co

mpa

red

to

esta

blis

he

d r

efe

ren

ce

sta

nd

ard

s o

rre

co

mm

en

da

tio

ns b

ase

d u

po

n p

hysio

log

ica

l ne

eds

95

-96

Su

b-C

las

s:

Min

era

l (5

5)

Ina

de

qu

ate

min

era

l in

take

(sp

ecify)

NI-

55

.1L

ow

er

inta

ke

of m

ine

ral con

tain

ing

fo

ods o

r su

bsta

nce

sco

mpa

red

to

esta

blis

he

d r

efe

ren

ce

sta

nd

ard

s o

rre

co

mm

en

da

tio

ns b

ase

d u

po

n p

hysio

log

ica

l ne

eds

97

-98

Excessiv

e m

inera

l in

take

(specify)

NI-

55.2

Hig

her

inta

ke o

f m

inera

l fr

om

foods, supple

ments

, m

edic

ations o

rw

ate

r,com

pare

d to e

sta

blis

hed r

efe

rence s

tandard

s o

rre

co

mm

en

da

tio

ns b

ase

d u

po

n p

hysio

log

ica

l ne

eds

99

-10

0

DO

MA

IN:

CL

INIC

AL

Defi

ned

as “

nu

trit

ion

al fi

nd

ing

s/p

rob

lem

sid

en

tifi

ed

that

rela

te t

o m

ed

ical o

r p

hys

ical

co

nd

itio

ns

”

NC

Cla

ss:

Fu

ncti

on

al (1

)

Defi

ne

d a

s “

ch

an

ge in

ph

ysic

al o

r m

ech

an

ical fu

ncti

on

ing

th

at

inte

rfere

s w

ith

o

r p

reven

tsd

esir

ed

nu

trit

ion

al

co

nseq

uen

ces”

Sw

allo

win

g d

ifficulty

NC

-1.1

Impaired m

ovem

ent of fo

od a

nd liq

uid

fro

m the m

outh

to the

sto

mach

10

1

Chew

ing (

masticato

ry)

difficulty

NC

-1.2

Impaired a

bili

ty to m

anip

ula

te o

r m

asticate

food for

sw

allo

win

g102-1

04

Bre

astfeedin

g d

ifficulty

NC

-1.3

Inabili

ty to s

usta

in n

utr

itio

n thro

ugh b

reastfeedin

g105-1

06

Altere

d G

I fu

nction

NC

-1.4

Changes in a

bili

ty to d

igest or

absorb

nutr

ients

107-1

08

Cla

ss:

Bio

ch

em

ical (2

)

Defi

ned

as “

ch

an

ge in

cap

acit

y t

om

eta

bo

lize

nu

trie

nts

as

a r

es

ult

of

Ed

itio

n:

20

06

28

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

med

icati

on

s, su

rgery

, o

r as in

dic

ate

d b

y

alt

ere

d lab

va

lues” Im

paired n

utr

ient utiliz

ation

NC

-2.1

Changes in a

bili

ty to a

bsorb

or

me

taboliz

e n

utr

ients

and b

ioactive

su

bsta

nces

10

9-1

10

Altere

d n

utr

itio

n-r

ela

ted labora

tory

valu

es

NC

-2.2

Changes in a

bili

ty to e

limin

ate

by-p

roducts

of dig

estive a

nd

me

tab

olic

pro

cesse

s1

11

-11

2

Fo

od-m

ed

ica

tio

n in

tera

ction

NC

-2.3

Un

de

sira

ble

/ha

rmfu

l in

tera

ctio

n(s

) b

etw

ee

n fo

od

an

do

ve

r th

e

counte

r (O

TC

) m

edic

ations, pre

scribed

medic

ations, herb

als

,bota

nic

als

, and/o

r die

tary

supple

ments

that dim

inis

hes,

enhances, or

alters

effect of nutr

ients

and/o

r m

edic

ations

11

3-1

14

Cla

ss:

We

igh

t (3

)

Defi

ned

as “

ch

ron

ic w

eig

ht

or

ch

an

ged

weig

ht

sta

tus w

hen

co

mp

are

d w

ith

us

ual o

r d

esir

ed

bo

dy w

eig

ht”

Underw

eig

ht

NC

-3.1

Low

body w

eig

ht com

pare

d to e

sta

blis

hed r

efe

rence s

tandard

s o

r re

com

mendations

11

5-1

16

Involu

nta

ry w

eig

ht lo

ss

NC

-3.2

Decre

ase in b

ody w

eig

ht th

at is

not pla

nned o

r desired

117-1

18

Overw

eig

ht/obesity

NC

-3.3

Incre

ased a

dip

osity c

om

pare

d to e

sta

blis

hed r

efe

rence s

tandard

so

r re

co

mm

end

atio

ns

11

9-1

20

Involu

nta

ry w

eig

ht gain

NC

-3.4

Weig

ht gain

above that w

hic

h is d

esired

or

expecte

d121-1

22

DO

MA

IN:

BE

HA

VIO

RA

L-

EN

VIR

ON

ME

NT

AL

Defi

ned

as “

nu

trit

ion

al fi

nd

ing

s/p

rob

lem

sid

en

tifi

ed

that

rela

te t

o k

no

wle

dg

e,

att

itu

des/b

eliefs

, p

hysic

al en

vir

on

men

t, o

r a

cc

es

s t

o f

oo

d a

nd

fo

od

sa

fety

”

NB

Cla

ss:

Kn

ow

led

ge a

nd

Beliefs

(1)

Ed

itio

n:

20

06

29

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

Defi

ned

as “

actu

al kn

ow

led

ge a

nd

be

liefs

as r

ep

ort

ed

,o

bserv

ed

, o

r d

ocu

men

ted

”

Food a

nd n

utr

itio

n-r

ela

ted k

now

ledge d

eficit

NB

-1.1

Incom

ple

te o

r in

accura

te k

now

ledge a

bout fo

od, nutr

itio

n o

r nutr

itio

n-r

ela

ted info

rmation a

nd g

uid

elin

es, e.g

., n

utr

ient

requirem

ents

, consequences o

f fo

od b

ehavio

rs, lif

e s

tage

requirem

ents

, nutr

itio

n r

ecom

mendations, dis

eases a

nd

co

nd

itio

ns, p

hysio

log

ica

l fu

nction

, o

r p

rod

ucts

12

3-1

24

Harm

ful belie

fs/a

ttitudes a

bout fo

od o

r nutr

itio

n-r

ela

ted topic

s

US

E W

ITH

CA

UT

ION

TO

BE

SE

NS

ITIV

E T

O

PA

TIE

NT

CO

NC

ER

NS

NB

-1.2

Belie

fs/a

ttitudes a

nd p

ractices a

bout fo

od, nutr

itio

n, and n

utr

itio

n-

rela

ted

to

pic

s th

at a

re in

com

pa

tib

le w

ith

so

un

d n

utr

itio

nprincip

les, nutr

itio

n c

are

, or

dis

ease/c

onditio

n

12

5-1

26

No

t re

ad

y fo

r d

iet/

life

sty

le c

ha

nge

NB

-1.3

La

ck o

f p

erc

eiv

ed

va

lue

of n

utr

itio

n-r

ela

ted

care

ben

efits

com

pare

d to c

onsequences o

r effort

required to m

akin

g the

change; in

consis

tencie

s w

ith o

ther

valu

e s

tructu

re/p

urp

ose;

ante

cedent to

behavio

r change

12

7-1

28

Self m

onitoring d

eficit

NB

-1.4

Lack o

f data

record

ing to tra

ck p

ers

onalpro

gre

ss

129-1

30

Dis

ord

ere

d e

ating p

attern

NB

-1.5

Belie

fs, attitudes, th

oughts

and b

ehavio

rs r

ela

ted to food, eating,

and w

eig

ht m

anagem

ent, inclu

din

gcla

ssic

eating d

isord

ers

as

well

as less s

evere

, sim

ilar

conditio

ns that negatively

im

pact

he

alth

13

1-1

33

Lim

ited a

dhere

nce to n

utr

itio

n-r

ela

ted

recom

mendations

NB

-1.6

La

ck o

f n

utr

itio

n-r

ela

ted

cha

ng

es a

s p

er

inte

rve

ntio

n a

gre

ed

up

on

by c

lient or

popula

tion

13

4-1

35

Un

de

sira

ble

fo

od

ch

oic

es

NB

-1.7

Fo

od

and

/or

be

ve

rag

e c

ho

ices th

at a

re in

con

sis

ten

t w

ith

US

R

ecom

mended D

ieta

ry Inta

ke, U

S D

ieta

ry G

uid

elin

es, or

with the

My P

yra

mid

or

with targ

ets

defined

in the n

utr

itio

n p

rescription o

r n

utr

itio

n c

are

pro

cess

13

6-1

37

Cla

ss:

Ph

ysic

al A

cti

vit

y a

nd

Fu

ncti

on

(2)

Defi

ned

as “

actu

al p

hysic

al acti

vit

y, self

-care

, an

d q

uality

of

life

pro

ble

ms a

s

Ed

itio

n:

20

06

30

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

rep

ort

ed

, o

bserv

ed

, o

r d

ocu

men

ted

”

Physic

al in

activity

NB

-2.1

Low

level of activity/s

edenta

ry b

ehavio

r to

the e

xte

nt th

at it

red

uces e

ne

rgy e

xp

en

ditu

re a

nd

im

pacts

he

alth

1

38=

139

Excessiv

e e

xerc

ise

NB

-2.2

An a

mount of exerc

ise that exceeds that w

hic

h is n

ecessary

to

impro

ve h

ealth a

nd/o

r ath

letic p

erf

orm

ance

14

0-1

41

Inabili

ty o

f la

ck o

f desire to m

anage s

elf c

are

NB

-2.3

Lack o

f capacity o

r unw

illin

gness to im

ple

ment m

eth

ods to

support

healthfu

l fo

od a

nd n

utr

itio

n-r

ela

ted b

ehavio

r1

42

-14

3

Impaired a

bili

ty to p

repare

foods/m

eals

NB

-2.4

Cognitiv

eor

physic

al im

pairm

ent th

at pre

vents

pre

para

tion o

f fo

ods/m

eals

14

4-1

45

Poor

nutr

itio

n q

ualit

y o

f lif

eN

B-2

.5D

imin

ished N

utr

itio

n Q

ualit

y o

f Life (

NQ

OL)

score

s r

ela

ted to food

imp

act,

se

lf-im

ag

e, p

sycho

log

ica

l fa

cto

rssocia

l/in

terp

ers

on

al

facto

rs, physic

al (f

acto

rs),

or

self-e

ffic

acy

14

6-1

47

Self feedin

g d

ifficulty

NB

-2.6

Impaired a

ctions to p

lace food in m

outh

148-1

49

Cla

ss:

Fo

od

Safe

ty a

nd

Access (

3)

Defi

ned

as “

actu

al p

rob

lem

s w

ith

fo

od

ac

ces

s o

r fo

od

sa

fety

”

Inta

ke o

f unsafe

food

NB

-3.1

Inta

ke o

f fo

od a

nd/o

r fluid

s inte

ntionally

or

unin

tentionally

co

nta

min

ate

d w

ith

to

xin

s, p

ois

on

ous p

rod

ucts

, in

fectiou

s a

ge

nts

,m

icro

bia

l ag

en

ts, a

dd

itiv

es, a

llerg

en

s, a

nd

/or

ag

en

ts o

fb

iote

rro

rism

15

0-1

51

Lim

ited a

ccess to food

NB

-3.2

Dim

inis

hed a

bili

ty to a

cquire food fro

m s

ourc

es (

e.g

., s

hoppin

g,

gard

enin

g, m

eal deliv

ery

), d

ue to fin

ancia

l constr

ain

ts, physic

al

impairm

ent, c

are

giv

er

support

, or

unsafe

liv

ing c

onditio

ns (

e.g

. crim

e h

inders

tra

vel to

gro

cery

sto

re).

Lim

itin

g food inta

ke

because o

f concern

s a

bout w

eig

ht or

agin

g.

15

2-1

53

Ed

itio

n:

20

06

31

INTA

KE

DO

MA

IN C

aloric

Ener

gy

Bal

ance

HY

PE

RM

ET

AB

OL

ISM

(NI-

1.1

)

Edit

ion:

20

06

32

De

fin

itio

n

Res

tin

g m

etaboli

c ra

te (

RM

R)

above

pre

dic

ted r

equir

emen

ts d

ue

to s

tres

s, t

raum

a, i

nju

ry,

sepsi

s, o

r dis

ease

. N

ote

: R

MR

is

the

sum

of

met

aboli

c pro

cess

es o

f

acti

ve

cell

mas

s re

late

d t

o t

he

mai

nte

nan

ce o

f n

orm

al b

od

y f

un

ctio

ns

and r

egula

tory

bal

ance

duri

ng r

est.

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•C

atab

oli

c il

lnes

s

•In

fect

ion

•S

epsi

s

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•In

suli

n r

esis

tan

ce (

dif

ficu

lt t

o c

on

trol

blo

od g

luco

se)

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

inati

on F

indin

gs

•F

ever

•In

crea

sed h

eart

rat

e

•In

crea

sed r

espir

atory

rat

e

•M

easu

red R

MR

> e

stim

ated

or

expec

ted R

MR

Food/N

utr

itio

n H

isto

ry

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t of,

e.g

., A

IDS

/HIV

, burn

s, c

hro

nic

obst

ruct

ive

pulm

on

ary d

isea

se,

hip

/lon

g b

on

e fr

act

ure

, in

fect

ion,

surg

ery,

tra

um

a, h

yper

thyr

oid

ism

(pre

- or

untr

eate

d),

som

e ca

nce

rs (

spec

ify)

•M

edic

atio

ns

asso

ciate

d w

ith

RM

R

INTA

KE

DO

MA

IN C

aloric

Ener

gy

Bal

ance

HY

PE

RM

ET

AB

OL

ISM

(NI-

1.1

)

Edit

ion:

20

06

33

Refe

ren

ces:

1.

Bit

z C

, T

ou

bro

S,

Lar

sen

TM

, H

ard

er H

, R

enn

ie K

L, Je

bb

SA

, A

stru

p A

. In

crea

sed

24

hou

r en

erg

y e

xp

end

itu

re i

n T

yp

e 2

dia

bet

es m

elli

tus.

Dia

bet

es C

are

. 2

00

4;2

7:2

41

6-2

24

1.

2.

Dic

ker

son

RN

, R

oth

-You

sey

L.

Med

icat

ion

eff

ects

on

met

aboli

c ra

te;

a sy

stem

atic

rev

iew

(P

art

2).

J A

m D

iet

Ass

oc.

2

00

5;1

05

:10

02

-10

09

.

3.

Dic

ker

son

RN

, R

oth

-You

sey

L.

Med

icat

ion

eff

ects

on

met

aboli

c ra

te:

a sy

stem

atic

rev

iew

(P

art

1).

J A

m D

iet

Ass

oc.

2

00

5;1

05

:83

5-8

41

.

4.

Fra

nk

enfi

eld D

, R

oth

-You

sey L

, C

om

pher

C.

Com

par

iso

n o

f pre

dic

tive

equ

atio

ns

to m

easu

red r

esti

ng m

etaboli

c ra

te i

n h

ealt

hy n

onob

ese

and o

bes

e in

div

iduals

: a

syst

emat

ic r

evie

w.J

Am

Die

t

Ass

oc.

20

05

;10

5:7

75

-78

9.

INTA

KE

DO

MA

IN C

aloric

Ener

gy

Bal

ance

INC

RE

AS

ED

EN

ER

GY

EX

PE

ND

ITU

RE

(NI-

1.2

)

Edit

ion:

20

06

34

De

fin

itio

n

Res

tin

g m

etab

oli

c ra

te (

RM

R)

above

pre

dic

ted r

equir

emen

ts d

ue

to b

od

y c

om

posi

tion

, m

edic

atio

n,

endocr

ine,

neu

rolo

gic

, or

gen

etic

chan

ge(

s).

Note

: R

MR

is

the

sum

of

met

aboli

c pro

cess

es o

f ac

tive

cell

mas

s re

late

d t

o t

he

mai

nte

nan

ce o

f n

orm

al b

od

y f

un

ctio

ns

and r

egula

tory

bal

ance

duri

ng r

est.

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•A

naboli

sm o

r gro

wth

•V

olu

nta

ry o

r in

volu

nta

ry p

hys

ical

act

ivit

y/m

ovem

ent

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

•U

nin

ten

tional

wei

ght

loss

of

10%

in 6

month

s, 5

% i

n 1

mon

th

•E

vid

ence

of

nee

d f

or

acc

eler

ated

or

catc

h u

p g

row

th o

r w

eight

gai

n i

n c

hil

dre

n;

abse

nce

of

norm

al

gro

wth

•In

crea

sed p

roport

ional

lean

bod

y m

ass

Phys

ical

Exam

inati

on F

indin

gs

•M

easu

red R

MR

> e

stim

ated

or

expec

ted R

MR

Food/N

utr

itio

n H

isto

ry•

Incr

ease

d p

hys

ical

act

ivit

y,

e.g., e

ndura

nce

ath

lete

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., P

arkin

son

’s d

isea

se,

cere

bra

l pal

sy,

Alz

hei

mer

’s d

isea

se,

oth

er

dem

enti

a

Refe

ren

ce:

1.

Fra

nk

enfi

eld D

, R

oth

-You

sey L

, C

om

pher

C.

Com

par

iso

n o

f pre

dic

tive

equ

atio

ns

to m

easu

red r

esti

ng m

etaboli

c ra

te i

n h

ealt

hy n

onob

ese

and o

bes

e in

div

iduals

: a

syst

emat

ic r

evie

w.J

Am

Die

t

Ass

oc.

20

05

;10

5:7

75

-78

9.

INTA

KE

DO

MA

IN C

aloric

Ener

gy

Bal

ance

HY

PO

ME

TA

BO

LIS

M(N

I-1

.3)

Edit

ion:

20

06

35

De

fin

itio

n

Res

tin

g m

etab

oli

c ra

te (

RM

R)

bel

ow

pre

dic

ted r

equir

emen

ts d

ue

to b

od

y c

om

posi

tion

, m

edic

atio

ns,

en

docr

ine,

neu

rolo

gic

, or

gen

etic

chan

ges

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•L

oss

of

lean

bod

y m

ass

, w

eight

loss

•M

edic

atio

ns,

e.g

., m

idaz

ola

m,

pro

pra

nal

ol,

gli

piz

ide

•E

ndocr

ine

chan

ges

, e.

g., h

ypoth

yroid

ism

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•In

crea

sed T

SH

, dec

reas

ed T

4, T

3 (

hyp

oth

yroid

ism

)

Anth

ropom

etri

c D

ata

•D

ecre

ased

wei

gh

t or

mid

-arm

mu

scle

cir

cum

fere

nce

•W

eigh

t gai

n

(e.g

., h

ypoth

yroid

ism

)

•G

row

th s

tun

tin

g o

r fa

ilure

, bas

ed o

n N

atio

nal

Cen

ter

for

Hea

lth S

tati

stic

s (N

CH

S)

gro

wth

sta

ndar

ds

Phys

ical

Exam

Fin

din

gs

•D

ecre

ased

or

norm

al a

dip

ose

an

d s

om

atic

pro

tein

sto

res

•M

easu

red R

MR

< e

stim

ated

or

expec

ted R

MR

Food/N

utr

itio

n H

isto

ry

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., h

ypoth

yroid

ism

, an

orex

ia n

ervosa

, m

aln

utr

itio

n,

fail

ure

to t

hri

ve,

Pra

der

-Wil

li s

yndro

me,

hyp

oto

nic

con

dit

ion

s

•B

rad

ycar

dia

, h

ypote

nsi

on,

dec

reas

ed b

ow

l m

oti

lity

, sl

ow

bre

ath

ing r

ate,

low

bod

y t

emper

ature

(in

sig

nif

ican

t w

eight

loss

)

•C

old

into

lera

nce

, h

air

loss

, dec

rease

d e

ndura

nce

, dif

ficu

lty c

on

cen

trat

ing,

dec

rease

d l

ibid

o,

feel

ings

of

anxie

ty/d

epre

ssio

n

INTA

KE

DO

MA

IN C

aloric

Ener

gy

Bal

ance

HY

PO

ME

TA

BO

LIS

M(N

I-1

.3)

Edit

ion:

20

06

36

Refe

ren

ces:

1.

Bro

zek

J.

Sta

rvat

ion a

nd n

utr

itio

nal

reh

abil

itat

ion;

a quan

tita

tiv

e ca

se s

tud

y.

J A

m D

iet

Ass

oc.

19

52

;28

:91

7-9

26

.

2.

Coll

ins

S.

Usi

ng m

iddle

up

per

arm

cir

cum

fere

nce

to a

ssess

sev

ere

adult

mal

nutr

itio

n d

uri

ng f

am

ine.

JAM

A.

19

96

;27

6:3

91

-39

5.

3.

Det

zer

MJ,

Lei

tenb

erg

H,

Po

ehlm

an E

T, R

ose

n J

C,

Sil

ber

g N

T,

Var

a L

S.

Res

tin

g m

etab

oli

c ra

te i

n w

om

en w

ith

bu

lim

ia n

erv

osa

: a c

ross

sec

tio

nal

and

tre

atm

ent

stu

dy.

Am

J C

lin

Nu

tr.

19

94

;60

:327

-33

2.

4.

Dic

ker

son

RN

, R

oth

-You

sey

L.

Med

icat

ion

eff

ects

on

met

aboli

c ra

te:

a sy

stem

atic

rev

iew

(P

art

2).

J A

m D

iet

Ass

oc.

2

00

5;1

05

:10

02

-10

09

.

5.

Dic

ker

son

RN

, R

oth

-You

sey

L.

Med

icat

ion

eff

ects

on

met

aboli

c ra

te:

a sy

stem

atic

rev

iew

(P

art

1).

J A

m D

iet

Ass

oc.

2

00

5;1

05

:83

5-8

41

.

6.

Fra

nk

enfi

eld D

, R

oth

-You

sey L

, C

om

pher

C.

Com

par

iso

n o

f pre

dic

tive

equ

atio

ns

to m

easu

red r

esti

ng m

etaboli

c ra

te i

n h

ealt

hy n

onob

ese

and o

bes

e in

div

iduals

: a

syst

emat

ic r

evie

w.J

Am

Die

t

Ass

oc.

20

05

;10

5:7

75

-78

9.

7.

Ker

ruis

h K

P, O

’Co

nn

er J

O,

Hu

mp

hri

es I

RJ,

Koh

n M

R,

Cla

rke

SD

, B

rio

dy

JN

, T

ho

mso

n E

J, W

rig

ht

KA

, G

ask

in K

J, B

aur

LA

. B

ody

co

mpo

siti

on

in

ado

lesc

ents

wit

h a

no

rexia

ner

vo

sa.

Am

J C

lin

Nu

tr. 2

00

2;7

5:3

1-3

7.

8.

Mo

llin

ger

LA

, S

pu

rr G

B,

el G

hat

il A

Z, B

arb

ori

ak J

S, R

oon

ey C

B, D

avid

off

DD

. D

aily

en

erg

y e

xpen

dit

ure

and

basi

l m

etab

oli

c ra

tes

of

pat

ien

ts w

ith

spin

al c

ord

in

jury

.A

rch

Ph

ys M

ed R

eha

bil

.

19

85

;66

:420

-42

6.

9.

Obar

zanek

E,

Les

em

MD

, Ji

mer

son D

C. R

esti

ng m

etab

oli

c ra

te o

f anore

xia

ner

vo

sa p

atie

nts

duri

ng w

eig

ht

gai

n.

Am

J C

lin

Nu

tr.

19

94

;60

:66

6-6

75

.

10

. P

avlo

vic

M,

Zav

alic

M,

Co

rov

ic N

, S

tili

no

vic

L,

Mal

inar

M. L

oss

of

bo

dy

mass

in

ex

pri

son

ers

of

war

.E

ur

J C

lin

Nu

tr. 1

99

3;4

7:8

08

-81

4.

INTA

KE

DO

MA

IN C

aloric

Ener

gy

Bal

ance

INA

DE

QU

AT

E E

NE

RG

Y I

NT

AK

E(N

I-1

.4)

Edit

ion:

20

06

37

De

fin

itio

n

En

ergy in

take

that

is

less

th

an e

ner

gy e

xpen

dit

ure

, es

tabli

shed

ref

eren

ce s

tan

dar

ds,

or

reco

mm

endat

ions

bas

ed u

pon p

hysi

olo

gic

al n

eeds.

E

xce

pti

on:

wh

en t

he

goal

is

wei

gh

t lo

ss o

r duri

ng e

nd o

f li

fe c

are.

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

ath

olo

gic

or

ph

ysio

logic

cau

ses

that

res

ult

in i

ncr

ease

d e

ner

gy r

equir

emen

ts o

r dec

reas

ed a

bil

ity t

o c

on

sum

e su

ffic

ien

t en

ergy,

e.g., i

ncr

ease

d n

utr

ien

t

nee

ds

due

to p

rolo

nged

cat

aboli

c il

lnes

s

•L

ack o

f ac

cess

to f

ood o

r ar

tifi

cial

nutr

itio

n,

e.g., e

con

om

ic c

on

stra

ints

, cu

ltura

l or

reli

gio

us

pra

ctic

es r

estr

icti

ng f

ood g

iven

to e

lder

ly a

nd/o

r ch

ildre

n

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r dis

ord

ered

eat

ing

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

• C

hol

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

inati

on F

indin

gs

•W

eig

ht

loss

•P

oor

den

titi

on

INTA

KE

DO

MA

IN C

aloric

Ener

gy

Bal

ance

INA

DE

QU

AT

E E

NE

RG

Y I

NT

AK

E(N

I-1

.4)

Edit

ion:

20

06

38

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•In

suff

icie

nt

ener

gy inta

ke

from

die

t co

mpar

ed t

o n

eeds

bas

ed o

n e

stim

ated

or

mea

sure

d r

esti

ng m

etab

oli

c ra

te

•R

estr

icti

on o

r om

issi

on o

f en

ergy d

ense

foods

from

die

t

•F

ood a

void

an

ce a

nd/o

r la

ck o

f in

tere

st i

n f

ood

•In

abil

ity to i

ndep

enden

tly c

on

sum

e fo

ods/

fluid

s (d

imin

ished

join

t m

obil

ity o

f w

rist

, h

and,

or

dig

its)

•P

aren

tera

l or

ente

ral

nutr

itio

n i

nsu

ffic

ien

t to

mee

t n

eeds

bas

ed o

n e

stim

ated

or

mea

sure

d r

esti

ng m

etab

oli

c ra

te

Cli

ent

His

tory

•E

xce

ssiv

e co

nsu

mp

tion

of

alco

hol

or

oth

er d

rugs

that

red

uce

hunger

Refe

ren

ce:

1.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r E

ner

gy,

Ca

rbo

hyd

rate

, F

iber

, F

at,

Fa

tty

Aci

ds,

Ch

ole

ster

ol,

Pro

tein

, a

nd

Am

ino

Aci

ds.

Was

hin

gto

n, D

C:

Nat

ion

al A

cad

em

y P

ress

; 2

00

2.

INTA

KE

DO

MA

IN C

aloric

Ener

gy

Bal

ance

EX

CE

SS

IVE

EN

ER

GY

IN

TA

KE

(NI-

1.5

)

Edit

ion:

20

06

39

De

fin

itio

n

Calo

ric

inta

ke

that

exce

eds

ener

gy e

xpen

dit

ure

, es

tabli

shed

ref

eren

ce s

tandar

ds,

or

reco

mm

endat

ion

s bas

ed u

pon p

hys

iolo

gic

al n

eeds.

Ex

cepti

on:

wh

en w

eight

gai

n i

s des

ired

.

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•H

arm

ful

bel

iefs

/att

itudes

about

food,

nutr

itio

n,

and n

utr

itio

n-r

elat

ed t

opic

s

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•L

ack o

f ac

cess

to h

ealt

hfu

l fo

od c

hoic

es,

e.g., f

ood p

rovid

ed b

y c

areg

iver

•L

ack o

f val

ue

for

beh

avio

r ch

ange,

com

pet

ing v

alues

•M

enta

l il

lnes

s, d

epre

ssio

n

•M

edic

atio

ns

that

incr

ease

appet

ite,

e.g

., s

tero

ids

•O

ver

feed

ing o

f par

ente

ral/

ente

ral

nutr

itio

n (

TP

N/E

N)

•U

nw

illi

ng o

r un

inte

rest

ed i

n r

educi

ng e

ner

gy inta

ke

•F

ailu

re t

o a

dju

st f

or

life

styl

e ch

anges

an

d d

ecre

ased

met

aboli

sm,

e.g., a

gin

g

•R

esolu

tion o

f pri

or

hyp

erm

etaboli

sm w

ith

out

reduct

ion i

n i

nta

ke

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

INTA

KE

DO

MA

IN C

aloric

Ener

gy

Bal

ance

EX

CE

SS

IVE

EN

ER

GY

IN

TA

KE

(NI-

1.5

)

Edit

ion:

20

06

40

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•O

ver

feed

ing o

f T

PN

/EN

(usu

ally

see

n e

arly

aft

er i

nit

iati

on o

f fe

edin

g):

•H

yper

gly

cem

ia

•H

yp

okal

emia

< 3

.5 m

Eq/L

•H

yp

oph

osp

hate

mia

<1.0

mE

q/L

•A

bnorm

al l

iver

fun

ctio

n t

ests

Anth

ropom

etri

c M

easu

rem

ents

•B

od

y f

at p

erce

nta

ge

> 2

5%

for

men

an

d >

32%

for

wom

en

•B

MI

> 2

5

•W

eigh

t gai

n

Phys

ical

Exam

Fin

din

gs

•In

crea

sed b

od

y a

dip

osi

ty

•O

ver

feed

ing T

PN

/EN

:

•In

crea

sed r

espir

atio

ns

Food/N

utr

itio

n H

isto

ry•

Obse

rvat

ion

s or

report

s of

inta

ke

of

calo

rica

lly d

ense

foods/

bev

erages

or

larg

e port

ion

s of

foods/

bev

erag

es

•O

bse

rvat

ion

s, r

eport

s, o

r ca

lcula

tion o

f T

PN

/EN

above

esti

mat

ed o

r m

easu

red (

e.g., i

nd

irec

t ca

lori

met

ry)

calo

ric

expen

dit

ure

•M

etab

oli

c ca

rt/i

ndir

ect

calo

rim

etry

mea

sure

men

t, e

.g., r

espir

atory

quoti

ent >

1.0

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t of,

e.g

., o

bes

ity,

over

wei

gh

t, m

etaboli

c sy

ndro

me,

dep

ress

ion,

or

anx

iety

dis

ord

er

Refe

ren

ces:

1.

McC

lav

e S

A,

Lo

wen

CC

, K

leb

er M

J, M

cCo

nn

ell

JW, Ju

ng

LY

, G

old

smit

h L

J. C

lin

ical

use

of

the

resp

irat

ory

qu

oti

ent

ob

tain

ed f

rom

in

dir

ect

calo

rim

etry

.J

Pa

ren

ter

En

tera

l N

utr

. 2

00

3;2

7:2

1-2

6.

2.

McC

lav

e S

A,

Lo

wen

CC

, K

leb

er M

J, N

ich

ols

on

JF

, Ji

mm

erso

n S

C,

McC

on

nel

l JW

, Ju

ng

LY

. A

re p

atie

nts

fed

ap

pro

pri

atel

y a

ccord

ing

to

th

eir

calo

ric

requ

irem

ents

?J

Pa

ren

ter

En

tera

l N

utr

.

19

98

;22

:375

-38

1.

3.

Over

wei

ght

and O

besi

ty:

Hea

lth C

on

sequence

s. w

ww

.surg

eon

gen

eral

.gov/t

opic

s/ob

esit

y/c

allt

oac

tio

n/f

act_

con

sequen

ces.

htm

. A

ccess

ed A

ugu

st 2

8, 20

04

.

INTA

KE

DO

MA

IN O

ral o

r N

utr

itio

n S

upport

Inta

ke

INA

DE

QU

AT

E O

RA

L F

OO

D/B

EV

ER

AG

E I

NT

AK

E(N

I-2

.1)

Edit

ion:

20

06

41

De

fin

itio

n

Ora

l fo

od/b

ever

age

inta

ke

that

is

less

than

est

abli

shed

ref

eren

ce s

tandar

ds

or

reco

mm

endat

ion

s bas

ed u

pon p

hysi

olo

gic

al n

eeds.

E

xce

pti

on

: w

hen

th

e goal

is

wei

ght

loss

or

duri

ng e

nd o

f li

fe c

are.

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses,

e.g

., i

ncr

ease

d n

utr

ien

t n

eeds

due

to p

rolo

nged

cat

aboli

c il

lnes

s

•L

ack o

f ac

cess

to f

ood,

e.g

., e

con

om

ic c

on

stra

ints

, cu

ltura

l or

reli

gio

us

pra

ctic

es, re

stri

ctin

g f

ood g

iven

to e

lder

ly a

nd/o

r ch

ildre

n

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledge

defi

cit

con

cern

ing s

uff

icie

nt

ora

l fo

od/b

ever

age

inta

ke

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r dis

ord

ered

eat

ing

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

inati

on F

indin

gs

•D

ry s

kin

, dry

mu

cous

mem

bra

nes

, poor

skin

turg

or

•W

eigh

t lo

ss, in

suff

icie

nt

gro

wth

vel

oci

ty

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•In

suff

icie

nt

inta

ke

of

ener

gy o

r hig

h-q

ual

ity p

rote

in f

rom

die

t w

hen

com

par

ed t

o r

equir

emen

ts

•E

conom

ic c

on

stra

ints

that

lim

it f

ood a

vai

labil

ity

INTA

KE

DO

MA

IN O

ral o

r N

utr

itio

n S

upport

Inta

ke

INA

DE

QU

AT

E O

RA

L F

OO

D/B

EV

ER

AG

E I

NT

AK

E(N

I-2

.1)

Edit

ion:

20

06

42

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t of

cata

boli

c il

lnes

s su

ch a

s A

IDS

, tu

ber

culo

sis,

an

orex

ia n

ervosa

,

sepsi

s, o

r in

fect

ion f

rom

rec

ent

surg

ery)

, dep

ress

ion

, ac

ute

or

chro

nic

pai

n

•P

rote

in a

nd/o

r nutr

ient

mal

abso

rpti

on

•E

xce

ssiv

e co

nsu

mp

tion

of

alco

hol

or

oth

er d

rugs

that

red

uce

hunger

•M

edic

atio

ns

that

cau

se a

nore

xia

Refe

ren

ces:

1.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r E

ner

gy,

Ca

rbo

hyd

rate

, F

iber

, F

at,

Fa

tty

Aci

ds,

Ch

ole

ster

ol,

Pro

tein

, a

nd

Am

ino

Aci

ds.

Was

hin

gto

n, D

C:

Nat

ion

al A

cad

em

y P

ress

; 2

00

2.

2.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

Inta

kes

for

Wa

ter,

Po

tass

ium

, S

od

ium

, C

hlo

rid

e, a

nd

Su

lfa

te. W

ash

ingto

n,

DC

: N

ati

onal

Aca

dem

y P

ress

; 20

02

.

INTA

KE

DO

MA

IN O

ral o

r N

utr

itio

n S

upport

Inta

ke

EX

CE

SS

IVE

OR

AL

FO

OD

/BE

VE

RA

GE

IN

TA

KE

(NI-

2.2

)

Edit

ion:

20

06

43

De

fin

itio

n

Ora

l fo

od/b

ever

age

inta

ke

that

exce

eds

ener

gy e

xpen

dit

ure

, es

tabli

shed

ref

eren

ce s

tandar

ds,

or

reco

mm

endat

ion

s bas

ed u

pon p

hys

iolo

gic

al n

eeds.

E

xce

pti

on

:

wh

en w

eigh

t gai

n i

s des

ired

.

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•H

arm

ful

bel

iefs

/att

itudes

about

food,

nutr

itio

n,

and n

utr

itio

n-r

elat

ed t

opic

s

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•L

ack o

f ac

cess

to h

ealt

hfu

l fo

od c

hoic

es,

e.g., f

ood p

rovid

ed b

y c

areg

iver

•L

ack o

f val

ue

for

beh

avio

r ch

ange,

com

pet

ing v

alues

•In

abil

ity to l

imit

or

refu

se o

ffer

ed f

oods

•L

ack o

f fo

od p

lann

ing,

purc

has

ing, an

d p

repar

ati

on s

kil

ls

•L

oss

of

appet

ite

awar

enes

s

•M

edic

atio

ns

that

incr

ease

appet

ite,

e.g

., s

tero

ids,

anti

dep

ress

ants

•U

nw

illi

ng o

r unin

tere

sted

in r

educi

ng i

nta

ke

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•V

aria

ble

hig

h b

lood g

luco

se l

evel

s

•A

bn

orm

al H

gb A

1C

Anth

ropom

etri

c M

easu

rem

ents

•W

eig

ht

gai

n n

ot

attr

ibute

d t

o f

luid

ret

enti

on o

r n

orm

al g

row

th

Phys

ical

Exam

Fin

din

gs

•E

vid

ence

of

acanth

osi

s n

igri

cans

INTA

KE

DO

MA

IN O

ral o

r N

utr

itio

n S

upport

Inta

ke

EX

CE

SS

IVE

OR

AL

FO

OD

/BE

VE

RA

GE

IN

TA

KE

(NI-

2.2

)

Edit

ion:

20

06

44

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•In

take

of

calo

rica

lly d

ense

foods/

bev

erag

es (

juic

e, s

oda,

or

alco

hol)

at

mea

ls a

nd

/or

snac

ks

•In

take

of

larg

e port

ion

s of

foods/

bever

ages

, fo

od g

roups,

or

spec

ific

food i

tem

s

•In

take

that

exce

eds

esti

mat

ed o

r m

easu

red e

ner

gy n

eeds

•H

igh

ly v

aria

ble

dai

ly c

alori

c in

take

•B

inge

eati

ng p

atte

rns

•F

requen

t, e

xce

ssiv

e in

take

of

fast

food o

r re

stau

rant

food

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., o

bes

ity,

over

wei

ght,

or

met

aboli

c sy

ndro

me,

dep

ress

ion

, an

xie

ty

dis

ord

er

•R

esti

ng m

etaboli

c ra

te m

easu

rem

ent

refl

ecti

ng e

xce

ss i

nta

ke,

e.g

., r

espir

atory

quoti

ent

> 1

.0

Refe

ren

ces:

1.

Over

wei

ght

and O

besi

ty:

Hea

lth C

on

sequence

s. w

ww

.surg

eon

gen

eral

.gov/t

opic

s/ob

esit

y/c

allt

oac

tio

n/f

act_

con

sequen

ces.

htm

. A

ccess

ed A

ugu

st 2

8, 20

04

.

2.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Wei

ght

man

agem

ent.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

14

5-1

15

5.

3.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Tota

l die

t appro

ach

to c

om

munic

atin

g f

ood a

nd n

utr

itio

n i

nfo

rmat

ion.J

Am

Die

t A

sso

c. 2

00

2;1

02

:10

0-1

08

.

4.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

The

role

of

die

teti

cs p

rofe

ssio

nal

s in

hea

lth p

rom

oti

on a

nd d

isea

se p

reventi

on.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

68

0-1

68

7.

INTA

KE

DO

MA

IN O

ral o

r N

utr

itio

n S

upport

Inta

ke

INA

DE

QU

AT

E IN

TA

KE

FR

OM

EN

TE

RA

L/P

AR

EN

TE

RA

L (

EN

/TP

N)

NU

TR

ITIO

N IN

FU

SIO

N(N

I-2

.3)

Edit

ion:

20

06

45

De

fin

itio

n

En

tera

l or

par

ente

ral

infu

sion t

hat

pro

vid

es f

ew

er c

alori

es o

r n

utr

ien

ts c

om

par

ed t

o e

stab

lish

ed r

efer

ence

sta

ndar

ds

or

reco

mm

endat

ion

s bas

ed u

pon p

hysi

olo

gic

al

nee

ds.

E

xce

pti

on

: w

hen

th

e goal

is

wei

gh

t lo

ss o

r duri

ng e

nd o

f li

fe c

are.

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•A

lter

ed a

bso

rpti

on o

r m

etaboli

sm o

f n

utr

ients

, e.

g., m

edic

atio

ns

•F

ood a

nd n

utr

itio

n-r

elat

ed k

now

ledge

def

icit

(pati

ent/

clie

nt,

car

egiv

er,

suppli

er),

e.g

., i

nco

rrec

t fo

rmu

la/f

orm

ula

tion

giv

en s

uch

as

wro

ng e

nte

ral

feed

ing,

or

mis

sin

g c

om

ponen

t of

TP

N

•L

ack o

f, c

om

pro

mis

ed,

or

inco

rrec

t ac

cess

for

del

iver

ing E

N/T

PN

•In

crea

sed b

iolo

gic

al d

eman

d o

f n

utr

ien

ts,

e.g., a

ccel

erat

ed g

row

th,

woun

d h

eali

ng,

chro

nic

in

fect

ion

, m

ult

iple

fra

cture

s

•In

tole

ran

ce o

f E

N/T

PN

•In

fusi

on v

olu

me

not

reac

hed

or

sched

ule

for

infu

sion i

nte

rrupte

d

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•C

hole

ster

ol

< 1

60 m

g/d

L (

4.1

6 m

mol/

L)

•V

itam

in/m

iner

al ab

norm

ali

ties

•C

alci

um

< 9

.2 m

g/d

L (

2.3

mm

ol/

L)

•V

itam

in K

--P

rolo

nged

pro

thro

mbin

tim

e (P

T),

par

tial

thro

mbopla

stin

tim

e (P

TT

)

•C

opper

< 7

0 µ

g/d

L (

11 µ

mol/

L)

•Z

inc

< 7

8 µ

g/d

L (

12 µ

mol/

L)

•Ir

on <

50 µ

g/d

L (

9 n

mol/

L);

iro

n b

ind

ing c

apac

ity <

250 µ

g/d

L (

44.8

µm

ol/

L)

INTA

KE

DO

MA

IN O

ral o

r N

utr

itio

n S

upport

Inta

ke

INA

DE

QU

AT

E IN

TA

KE

FR

OM

EN

TE

RA

L/P

AR

EN

TE

RA

L (

EN

/TP

N)

NU

TR

ITIO

N IN

FU

SIO

N(N

I-2

.3)

Edit

ion:

20

06

46

Anth

ropom

etri

c M

easu

rem

ents

•G

row

th f

ailu

re, bas

ed o

n N

atio

nal

Cen

ter

for

Hea

lth S

tati

stic

s (N

CH

S)

gro

wth

sta

ndar

ds

and f

etal

gro

wth

fai

lure

•In

suff

icie

nt

mat

ern

al w

eight

gai

n

•L

ack o

f pla

nn

ed w

eight

gai

n

•U

nin

ten

tional

wei

ght

loss

of

5%

in 1

month

or

10%

in 6

month

s (n

ot

attr

ibute

d t

o f

luid

) in

adult

s

•A

ny w

eigh

t lo

ss i

n i

nfa

nts

an

d c

hil

dre

n

•U

nder

wei

ght

(BM

I <

18.5

)

Phys

ical

Exam

Fin

din

gs

•C

linic

al e

vid

ence

of

vit

amin

/min

eral

def

icie

ncy

(e.

g.,

hair

loss

, ble

edin

g g

um

s, p

ale

nail

bed

s, n

euro

logic

chan

ges

)

•E

vid

ence

of

deh

ydra

tion,

e.g., d

ry m

uco

us

mem

bra

nes

, poor

skin

turg

or

•L

oss

of

skin

inte

gri

ty o

r del

aye

d w

oun

d h

eali

ng

•L

oss

of

mu

scle

mass

an

d/o

r su

bcu

tan

eous

fat

•N

ause

a, v

om

itin

g,

dia

rrh

ea

Food/N

utr

itio

n H

isto

ryO

bse

rvat

ion o

r re

port

s of:

•In

adeq

uat

e E

N/T

PN

volu

me

com

pare

d t

o e

stim

ated

or

mea

sure

d (

indir

ect

calo

rim

etry

) r

equir

emen

ts

•M

etab

oli

c ca

rt/i

ndir

ect

calo

rim

etry

mea

sure

men

t, e

.g., r

espir

atory

quoti

ent <

0.7

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t of,

e.g

., i

nte

stin

al r

esec

tion,

Cro

hn

’s d

isea

se,

HIV

/AID

S, burn

s,dec

ubit

us

ulc

ers,

pre

-ter

m b

irth

, m

aln

utr

itio

n

•F

eedin

g t

ube

or

ven

ous

acce

ss i

n w

rong p

osi

tion o

r re

moved

•A

lter

ed c

apac

ity f

or

des

ired

lev

els

of

ph

ysic

al a

ctiv

ity o

r ex

erci

se, ea

sy f

atig

ue

wit

h i

ncr

ease

d a

ctiv

ity

Refe

ren

ces:

1.

McC

lav

e S

A,

Spai

n D

A,

Sk

oln

ick

JL

, L

ow

en C

C,

Kie

ber

MJ,

Wic

ker

ham

PS

, V

og

t JR

, L

oo

ney

SW

. A

chie

vem

ent

of

stea

dy

sta

te o

pti

miz

es r

esu

lts

wh

en p

erfo

rmin

g i

nd

irec

t ca

lori

met

ry.

J

Pa

ren

ter

En

tera

l N

utr

. 2

00

3;2

7:1

6-2

0.

2.

McC

lav

e S

A,

Lo

wen

CC

, K

leb

er M

J, M

cCo

nn

ell

JW, Ju

ng

LY

, G

old

smit

h L

J. C

lin

ical

use

of

the

resp

irat

ory

qu

oti

ent

ob

tain

ed f

rom

in

dir

ect

calo

rim

etry

.J

Pa

ren

ter

En

tera

l N

utr

. 2

00

3;2

7:2

1-2

6.

3.

McC

lav

e S

A,

Sn

ider

HL

. C

lin

ical

use

of

gas

tric

res

idu

al v

olu

mes

as

a m

onit

or

for

pat

ients

on

en

tera

l tu

be

feed

ing

.J

Pa

ren

ter

En

tera

l N

utr

. 2

00

2;2

6(S

up

pl)

:S4

3-4

8;

dis

cuss

ion

S4

9-S

50

.

4.

McC

lav

e S

A,

DeM

eo M

T,

DeL

egg

e M

H,

DiS

ario

JA

, H

eyla

nd

DK

, M

alo

ney

JP

, M

ethen

y N

A,

Mo

ore

FA

, S

cola

pio

JS

, S

pai

n D

A,

Zal

og

a G

P. N

ort

h A

mer

ican

Su

mm

it o

n A

spir

atio

n i

n t

he

Cri

tica

lly

Ill

Pat

ien

t: c

on

sen

sus

stat

emen

t.J

Pa

ren

ter

En

tera

l N

utr

. 2

00

2;2

6(S

up

pl)

:S8

0-S

85

.

5.

McC

lav

e S

A, M

cCla

in C

J, S

nid

er H

L.

Sh

ou

ld i

nd

irec

t ca

lori

met

ry b

e u

sed

as

par

t o

f nu

trit

ional

ass

essm

ent?

J C

lin

Ga

stro

ente

rol.

20

01

;33

:14

-19

.

6.

McC

lav

e S

A,

Sex

ton

LK

, S

pai

n D

A,

Adam

s JL

, O

wen

s N

A,

Su

llin

s M

B,

Bla

nd

ford

BS

, S

nid

er H

L. E

nte

ral

tub

e fe

edin

g i

n t

he

inte

nsi

ve

care

un

it:

fact

ors

im

ped

ing

ad

equ

ate

del

iver

y.C

rit

Ca

re

Med

. 1

99

9;2

7:1

25

2-1

25

6.

7.

McC

lav

e S

A,

Lo

wen

CC

, K

leb

er M

J, N

ich

ols

on

JF

, Ji

mm

erso

n S

C,

McC

on

nel

l JW

, Ju

ng

LY

. A

re p

atie

nts

fed

ap

pro

pri

atel

y a

ccord

ing

to

th

eir

calo

ric

requ

irem

ents

?J

Pa

ren

ter

En

tera

l N

utr

.

19

98

;22

:375

-38

1.

8.

Spai

n D

A,

McC

lav

e S

A,

Sex

ton

LK

, A

dam

s JL

, B

lan

ford

BS

, S

ull

ins

ME

, O

wen

s N

A,

Sn

ider

HL

. In

fusi

on

pro

toco

l im

pro

ves

del

iver

y o

f en

tera

l tu

be

feed

ing

in

th

e cr

itic

al c

are

un

it.

J P

are

nte

r

En

tera

l N

utr

. 1

99

9;2

3:2

88

-29

2.

INTA

KE

DO

MA

IN O

ral o

r N

utr

itio

n S

upport

Inta

ke

EX

CE

SS

IVE

IN

TA

KE

FR

OM

EN

TE

RA

L/P

AR

EN

TE

RA

L N

UT

RIT

ION

(NI-

2.4

)

Edit

ion:

20

06

47

De

fin

itio

n

En

tera

l or

par

ente

ral

infu

sion t

hat

pro

vid

es m

ore

cal

ori

es o

r n

utr

ien

ts c

om

par

ed t

o e

stabli

shed

ref

eren

ce s

tandar

ds

or

reco

mm

endat

ion

s bas

ed u

pon p

hysi

olo

gic

al

nee

ds.

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses,

e.g

., d

ecre

ased

nee

ds

rela

ted t

o l

ow

act

ivit

y lev

els

wit

h c

riti

cal

illn

ess

or

org

an f

ailu

re

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

on t

he

par

t of

the

care

giv

er, pat

ien

t/cl

ien

t or

clin

icia

n

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•E

levat

ed B

UN

:cre

atin

ine

rati

o (

pro

tein

)

•H

yper

gly

cem

ia (

carb

oh

ydra

te)

•H

yper

capnia

•E

levat

ed l

iver

en

zym

es

Anth

ropom

etri

c M

easu

rem

ents

•W

eigh

t gai

n i

n e

xce

ss o

f le

an t

issu

e ac

cret

ion

Phys

ical

Exam

inati

on F

indin

gs

•E

dem

a w

ith e

xce

ss f

luid

ad

min

istr

atio

n

Food/N

utr

itio

n H

isto

ryR

eport

or

obse

rvat

ion o

f:

•D

ocu

men

ted i

nta

ke

from

en

tera

l or

par

ente

ral

nutr

ients

that

is

con

sist

entl

y a

bove

reco

mm

end

ed i

nta

ke

for

carb

oh

ydra

te,

pro

tein

, an

d f

at (

e.g., 3

6 k

cal/

kg f

or

wel

l, a

ctiv

e ad

ult

s, 2

5 k

cal/

kg o

r as

mea

sure

d b

y ind

irec

t ca

lori

met

ry f

or

crit

ical

ly

ill

adult

s, 0

.8 g

/kg p

rote

in f

or

wel

l ad

ult

s, 1

.5 g

/kg p

rote

in f

or

crit

icall

y ill

adu

lts,

4 m

g/k

g/m

inute

of

dex

trose

for

crit

ical

ly ill

adult

s, 1

.2 g

/kg l

ipid

for

adult

s, o

r 3 g

/kg f

or

chil

dre

n)*

* W

hen

en

teri

ng w

eight

(i.e

., g

ram

) in

form

atio

n i

nto

th

e m

edic

al r

ecord

, use

in

stit

uti

on o

r Jo

int

Com

mis

sion A

ccre

dit

atio

n o

f H

ealt

hca

re O

rgan

izat

ion

s’

appro

ved

ab

bre

via

tion l

ist.

INTA

KE

DO

MA

IN O

ral o

r N

utr

itio

n S

upport

Inta

ke

EX

CE

SS

IVE

IN

TA

KE

FR

OM

EN

TE

RA

L/P

AR

EN

TE

RA

L N

UT

RIT

ION

(NI-

2.4

)

Edit

ion:

20

06

48

Cli

ent

His

tory

•U

se o

f dru

gs

that

red

uce

req

uir

emen

ts o

r im

pai

r m

etaboli

sm o

f en

ergy,

pro

tein

, fa

t or

fluid

.

•U

nre

alis

tic

expec

tati

ons

of

wei

ght

gai

n o

r id

eal

wei

gh

t

•R

ecei

vin

g s

ignif

ican

t ca

lori

e in

take

from

lip

id o

r dex

trose

infu

sions,

or

per

iton

eal

dia

lysi

s or

in a

ssoci

ati

on w

ith o

ther

med

ical

tre

atm

ents

Refe

ren

ces:

1.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r E

ner

gy,

Ca

rbo

hyd

rate

, F

iber

, F

at,

Fa

tty

Aci

ds,

Ch

ole

ster

ol,

Pro

tein

, a

nd

Am

ino

Aci

ds.

Was

hin

gto

n, D

C:

Nat

ion

al A

cad

em

y P

ress

, 2

00

2.

2.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

Inta

kes

for

Wa

ter,

Po

tass

ium

, S

od

ium

, C

hlo

rid

e, a

nd

Su

lfa

te.

Wash

ingto

n,

DC

: N

ati

onal

Aca

dem

y P

ress

, 20

04

.

3.

Aar

sland A

, C

hin

kes

D,

Wolf

e R

R. H

epat

ic a

nd w

hole

-body f

at

synth

esis

in h

um

ans

duri

ng c

arboh

ydra

te o

ver

feedin

g.

Am

J C

lin

Nu

tr. 1

99

7;6

5:1

77

4-1

78

2.

4.

McC

lav

e S

A,

Lo

wen

CC

, K

leb

er M

J, N

ich

ols

on

JF

, Ji

mm

erso

n J

C,

McC

on

nel

l JW

, Ju

ng

LY

. A

re p

atie

nts

fed

ap

pro

pri

atel

y a

ccord

ing

to

th

eir

calo

ric

requ

irem

ents

?J

Pa

ren

ter

En

tera

l N

utr

.

19

98

;22

:375

-38

1.

5.

McC

lav

e S

A,

Lo

wen

CC

, K

leb

er M

J, M

cCo

nn

ell

JW, Ju

ng

LY

, G

old

smit

h L

J. C

lin

ical

use

of

the

resp

irat

ory

qu

oti

ent

ob

tain

ed f

rom

in

dir

ect

calo

rim

etry

.J

Pa

ren

ter

En

tera

l N

utr

. 2

00

3;2

7:2

1-2

6.

6.

Wolf

e R

R,

O'D

on

nel

l T

F, Jr

., S

ton

e M

D,

Ric

hm

and

DA

, B

urk

e JF

. In

ves

tig

atio

n o

f fa

cto

rs d

eter

min

ing

th

e o

pti

mal

glu

cose

in

fusi

on

rat

e in

to

tal

par

ente

ral

nu

trit

ion

.M

eta

bo

lism

: C

lin

ica

l &

Exp

erim

enta

l. 1

98

0;2

9:8

92

-90

0.

INTA

KE

DO

MA

IN O

ral o

r N

utr

itio

n S

upport

Inta

ke

INA

PP

RO

PR

IAT

E IN

FU

SIO

N O

F E

NT

ER

AL

OR

PA

RE

NT

ER

AL

NU

TR

ITIO

N(N

I-2

.5)

Edit

ion:

20

06

49

Use

wit

h c

au

tion

on

ly a

fter

dis

cu

ssio

n w

ith

oth

er h

ealt

h t

eam

mem

ber

s

De

fin

itio

n

En

tera

l or

par

ente

ral

infu

sion t

hat

pro

vid

es e

ith

er f

ewer

or

more

cal

ori

es a

nd/o

r n

utr

ien

ts o

r is

of

the

wro

ng c

om

posi

tion o

r ty

pe,

is

not

war

rante

d b

ecau

se t

he

pat

ient/

clie

nt

is a

ble

to t

ole

rate

an e

nte

ral

inta

ke,

or

is u

nsa

fe b

ecau

se o

f th

e pote

nti

al f

or

sepsi

s or

oth

er c

om

pli

cati

on

s

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses,

e.g

., i

mpro

vem

ent

in p

atie

nt/

clie

nt

stat

us,

all

ow

ing r

eturn

to t

ota

l or

par

tial

ora

l die

t; c

han

ges

in t

he

cours

e of

dis

ease

res

ult

ing i

n

chan

ges

in n

utr

ient

requir

emen

ts

•P

roduct

or

kn

ow

ledge

def

icit

on t

he

par

t of

the

care

giv

er o

r cl

inic

ian

•E

nd o

f li

fe c

are

if p

atie

nt/

clie

nt

or

fam

ily d

o n

ot

des

ire

nutr

itio

n s

upport

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•A

bn

orm

al l

iver

fun

ctio

n t

ests

in p

ati

ent/

clie

nt

on l

on

g t

erm

(m

ore

than

3-6

wee

ks)

fee

din

g

•A

bn

orm

al l

evel

s of

mar

ker

s sp

ecif

ic f

or

var

ious

nutr

ients

, e.

g., h

yper

ph

osp

hat

emia

in p

atie

nt/

clie

nt

rece

ivin

g f

eedin

gs

wit

h a

hig

h p

hosp

horu

s co

nte

nt,

hyp

okal

emia

in p

atie

nt/

clie

nt

rece

ivin

g f

eedin

gs

wit

h l

ow

pota

ssiu

m c

onte

nt

Anth

ropom

etri

c M

easu

rem

ents

•W

eigh

t gai

n i

n e

xce

ss o

f le

an t

issu

e ac

cret

ion

•W

eig

ht

loss

Phys

ical

Exam

inati

on F

indin

gs

•E

dem

a w

ith e

xce

ss f

luid

ad

min

istr

atio

n

•C

om

pli

cati

on

s su

ch a

s fa

tty liv

er i

n t

he

abse

nce

of

oth

er c

ause

s

•L

oss

of

subcu

tan

eous

fat

and m

usc

le s

tore

s

INTA

KE

DO

MA

IN O

ral o

r N

utr

itio

n S

upport

Inta

ke

INA

PP

RO

PR

IAT

E IN

FU

SIO

N O

F E

NT

ER

AL

OR

PA

RE

NT

ER

AL

NU

TR

ITIO

N(N

I-2

.5)

Edit

ion:

20

06

50

Food/N

utr

itio

n H

isto

ryR

eport

or

obse

rvat

ion o

f:

•D

ocu

men

ted i

nta

ke

from

en

tera

l or

par

ente

ral

nutr

ients

that

is

con

sist

entl

y a

bove

or

bel

ow

rec

om

men

ded

inta

ke

for

carb

oh

ydra

te, pro

tein

, an

d/o

r fa

t —

esp

ecia

lly r

elat

ed t

o p

atie

nt/

clie

nt’

s ab

ilit

y to c

on

sum

e an

ora

l die

t th

at m

eets

nee

ds

at t

his

poin

t in

tim

e

•D

ocu

men

ted i

nta

ke

of

oth

er n

utr

ients

th

at i

s co

nsi

sten

tly a

bove

or

bel

ow

th

at r

ecom

men

ded

•N

ause

a, v

om

itin

g,

dia

rrh

ea, hig

h g

astr

ic r

esid

ual

volu

me

Cli

ent

His

tory

•H

isto

ry o

f en

tera

l or

par

ente

ral n

utr

itio

n i

nto

lera

nce

Refe

ren

ces:

1.

Aar

sland A

, C

hin

kes

D,

Wolf

e R

R. H

epat

ic a

nd w

hole

-body f

at

synth

esis

in h

um

ans

duri

ng c

arboh

ydra

te o

ver

feedin

g.

Am

J C

lin

Nu

tr. 1

99

7;6

5:1

77

4-1

78

2.

2.

McC

lav

e S

A,

Lo

wen

CC

, K

leb

er M

J, N

ich

ols

on

JF

, Ji

mm

erso

n S

C,

McC

on

nel

l JW

, Ju

ng

LY

. A

re p

atie

nts

fed

ap

pro

pri

atel

y a

ccord

ing

to

th

eir

calo

ric

requ

irem

ents

?J

Pa

ren

ter

En

tera

l N

utr

.

19

98

;22

:375

-38

1.

3.

McC

lav

e S

A,

Lo

wen

CC

, K

leb

er M

J, M

cCo

nn

ell

JW, Ju

ng

LY

, G

old

smit

h L

J. C

lin

ical

use

of

the

resp

irat

ory

qu

oti

ent

ob

tain

ed f

rom

in

dir

ect

calo

rim

etry

.J

Pa

ren

ter

En

tera

l N

utr

. 2

00

3;2

7:2

1-2

6.

4.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r E

ner

gy,

Ca

rbo

hyd

rate

, F

iber

, F

at,

Fa

tty

Aci

ds,

Ch

ole

ster

ol,

Pro

tein

, a

nd

Am

ino

Aci

ds.

Was

hin

gto

n, D

C:

Nat

ion

al A

cad

em

y P

ress

; 2

00

2.

5.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

Inta

kes

for

Wa

ter,

Po

tass

ium

, S

od

ium

, C

hlo

rid

e, a

nd

Su

lfa

te,

Wash

ingto

n,

DC

: N

ati

onal

Aca

dem

y P

ress

; 20

04

.

6.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

Inta

kes

for

Ca

lciu

m,

Ph

osp

ho

rus,

Ma

gn

esiu

m, V

ita

min

D, a

nd

Flu

ori

de. W

ash

ing

ton

, D

C:

Nat

ional

Aca

dem

y P

ress

; 1

99

7.

7.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r V

ita

min

C,

Vit

am

in E

, S

elen

ium

, a

nd

Ca

rote

no

ids.

Was

hin

gto

n,

DC

: N

atio

nal

Aca

dem

y P

ress

; 2

00

0.

8.

Wolf

e R

R,

O'D

on

nel

l T

F, Jr

., S

ton

e M

D,

Ric

hm

and

DA

, B

urk

e JF

. In

ves

tig

atio

n o

f fa

cto

rs d

eter

min

ing

th

e o

pti

mal

glu

cose

in

fusi

on

rat

e in

to

tal

par

ente

ral

nu

trit

ion

.M

eta

bo

lism

. 1

98

0;2

9:8

92

-

90

0.

INTA

KE

DO

MA

IN F

luid

Inta

ke

INA

DE

QU

AT

E F

LU

ID I

NT

AK

E(N

I-3

.1)

Edit

ion:

20

06

51

De

fin

itio

n

Low

er i

nta

ke

of

fluid

-con

tain

ing f

oods

or

subst

ance

s co

mp

ared

to e

stab

lish

ed r

efer

ence

sta

ndar

ds

or

reco

mm

endat

ion

s bas

ed u

pon p

hys

iolo

gic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses,

e.g

., i

ncr

ease

d f

luid

nee

ds

due

to c

lim

ate/

tem

per

ature

ch

ange;

incr

ease

d e

xer

cise

or

con

dit

ion

s le

adin

g t

o i

ncr

ease

d f

luid

loss

es;

fever

causi

ng i

ncr

ease

d i

nse

nsi

ble

loss

es,

dec

reas

ed t

hir

st s

ensa

tion,

use

of

dru

gs

that

red

uce

thir

st

•L

ack o

f ac

cess

to f

luid

, e.

g., e

con

om

ic c

on

stra

ints

, cu

ltura

l or

reli

gio

us

pra

ctic

es,

inab

ilit

y to a

cces

s fl

uid

in

dep

enden

tly (

such

as

elder

ly o

r ch

ildre

n)

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r dis

ord

ered

eat

ing;

dem

enti

a re

sult

ing i

n d

ecre

ase

d r

ecognit

ion o

f th

irst

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•P

lasm

a or

ser

um

osm

ola

lity

gre

ater

than

290 m

Osm

/kg

• B

UN

, N

a

Anth

ropom

etri

c M

easu

rem

ents

•A

cute

wei

gh

t lo

ss

Phys

ical

Exam

inati

on F

indin

gs

•D

ry s

kin

and m

uco

us

mem

bra

nes

, poor

skin

turg

or

•U

rin

e outp

ut

<30 m

L/h

r

Food/N

utr

itio

n H

isto

ryR

eport

or

obse

rvat

ion o

f:

•In

suff

icie

nt

inta

ke

of

flu

id w

hen

com

par

ed t

o r

equir

emen

ts

•T

hir

st

•D

iffi

cult

y s

wal

low

ing

INTA

KE

DO

MA

IN F

luid

Inta

ke

INA

DE

QU

AT

E F

LU

ID I

NT

AK

E(N

I-3

.1)

Edit

ion:

20

06

52

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t, e

.g., A

lzh

eim

er’s

dis

ease

or

oth

er d

emen

tia

resu

ltin

g i

n d

ecre

ase

d

reco

gn

itio

n o

f th

irst

, dia

rrh

ea

•U

se o

f dru

gs

that

red

uce

th

irst

Refe

ren

ces:

1.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

Inta

kes

for

Wa

ter,

Po

tass

ium

, S

od

ium

, C

hlo

rid

e, a

nd

Su

lfa

te,

Wash

ingto

n,

DC

: N

ati

onal

Aca

dem

y P

ress

; 20

04

.

2.

Gra

nd

jean

AC

, C

amp

bel

l, S

M. H

ydra

tio

n:

Flu

ids

for

Lif

e. M

on

og

rap

h S

erie

s. W

ash

ingto

n,D

.C:

Inte

rnat

ional

Lif

e S

cien

ces

Inst

itu

te N

ort

h A

mer

ica, 2

00

4.

3.

Gra

nd

jean

AC

, R

eim

ers

KJ,

Bu

yck

x M

E.

Hy

dra

tion

: I

ssu

es f

or

the

21

st C

entu

ry.

Nu

tr R

ev. 2

00

3;6

1:2

61

-27

1.

INTA

KE

DO

MA

IN F

luid

Inta

ke

EX

CE

SS

IVE

FL

UID

IN

TA

KE

(NI-

3.2

)

Edit

ion:

20

06

53

De

fin

itio

n

Hig

her

inta

ke

of

fluid

com

par

ed t

o e

stab

lish

ed r

efer

ence

sta

ndar

ds

or r

ecom

men

dat

ion

s bas

ed u

pon p

hys

iolo

gic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses,

e.g

., d

ecre

ased

flu

id l

oss

es d

ue

to k

idn

ey,

liver

or

card

iac

fail

ure

; dim

inis

hed

wat

er a

nd s

odiu

m l

oss

es d

ue

to c

han

ges

in e

xer

cise

or

clim

ate,

syn

dro

me

of

inap

pro

pri

ate

anti

diu

reti

c h

orm

on

e (S

IAD

H)

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r dis

ord

ered

eat

ing

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•L

ow

ered

pla

sma

osm

ola

rity

(270-2

80 m

Osm

/kg),

on

ly i

f posi

tive

fluid

bal

ance

is

in e

xce

ss o

f posi

tive

salt

bal

ance

•D

ecre

ased

ser

um

sodiu

m i

n S

IAD

H

Anth

ropom

etri

c M

easu

rem

ents

•W

eigh

t gai

n

Phys

ical

Exam

inati

on F

indin

gs

•E

dem

a in

the

skin

of

the

legs,

sac

ral

area

, or

dif

fuse

ly;

wee

pin

g o

f fl

uid

s fr

om

low

er l

egs

•A

scit

es

•P

ulm

onar

y e

dem

a as

evid

ence

d b

y s

hort

nes

s of

bre

ath;

ort

hopn

ea;

crac

kle

s or

rale

s

Food/N

utr

itio

n H

isto

ryR

eport

or

obse

rvat

ion o

f:

•F

luid

inta

ke

in e

xce

ss o

f re

com

men

ded

inta

ke

•E

xce

ssiv

e sa

lt i

nta

ke

•In

abil

ity t

o t

ole

rate

soli

d f

oods

nec

essi

tati

ng a

liq

uid

die

t

INTA

KE

DO

MA

IN F

luid

Inta

ke

EX

CE

SS

IVE

FL

UID

IN

TA

KE

(NI-

3.2

)

Edit

ion:

20

06

54

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t, e

.g., e

nd s

tage

renal

dis

ease

, n

ephro

tic

syn

dro

me,

hea

rt f

ailu

re, or

liver

dis

ease

•N

ause

a, v

om

itin

g, an

ore

xia

, h

eadac

he,

mu

scle

spas

ms,

con

vuls

ion

s, c

om

a re

late

d t

o S

IAD

H

•S

hort

nes

s of

bre

ath o

r dys

pn

ea w

ith e

xer

tion o

r at

res

t

•P

rovid

ing m

edic

atio

ns

in l

arge

amoun

ts o

f fl

uid

•U

se o

f dru

gs

that

im

pai

r fl

uid

excr

etio

n

Refe

ren

ces:

1.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

Inta

kes

for

Wa

ter,

Po

tass

ium

, S

od

ium

, C

hlo

rid

e, a

nd

Su

lfa

te,

Wash

ingto

n,

DC

: N

ati

onal

Aca

dem

y P

ress

; 20

04

.

2.

Sch

rier

R.W

. ed

.R

ena

l a

nd

Ele

ctro

lyte

Dis

ord

ers.

6thed

.P

hil

adel

phia

, P

a: L

ipp

inco

tt W

illi

am

s a

nd

Wil

lkin

s; 2

00

2.

3.

SIA

DH

. A

vai

lable

at

: htt

p:/

/ww

.nlm

.nih

.go

v/m

edli

neplu

s/en

cy/a

rtic

le/0

00

394.

INTA

KE

DO

MA

IN B

ioac

tive

Subst

ance

s

INA

DE

QU

AT

E B

IOA

CT

IVE

SU

BS

TA

NC

E I

NT

AK

E(N

I-4

.1)

Edit

ion:

20

06

55

De

fin

itio

n

Low

er i

nta

ke

of

bio

acti

ve

subst

ance

s co

nta

inin

g f

oods

or

subst

ance

s co

mp

ared

to e

stab

lish

ed r

efer

ence

sta

ndar

ds

or r

ecom

men

dat

ion

s bas

ed u

pon p

hys

iolo

gic

al

nee

ds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•L

imit

ed a

cces

s to

food-c

on

tain

ing s

ubst

ance

•A

lter

ed G

I fu

nct

ion,

e.g., p

ain o

r dis

com

fort

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

Food/N

utr

itio

n H

isto

ryO

bse

rvat

ion

s or

report

s of:

•L

ow

in

take

of

pla

nt

foods

con

tain

ing:

•S

olu

ble

fib

er,

e.g., p

syll

ium

( t

ota

l an

d L

DL

ch

ole

ster

ol)

•S

oy p

rote

in (

tota

l an

d L

DL

chole

ster

ol)

•-g

luca

n,

e.g., w

hole

oat

pro

duct

s (

tota

l an

d L

DL

ch

ole

ster

ol)

•P

lan

t st

erol

and s

tan

ol

este

rs, e.

g., f

ort

ifie

d m

argar

ines

( t

ota

l an

d L

DL

ch

ole

ster

ol)

•L

ack o

f av

aila

ble

foods/

pro

duct

s w

ith b

ioac

tive

subst

an

ce i

n m

arket

s

INTA

KE

DO

MA

IN B

ioac

tive

Subst

ance

s

INA

DE

QU

AT

E B

IOA

CT

IVE

SU

BS

TA

NC

E I

NT

AK

E(N

I-4

.1)

Edit

ion:

20

06

56

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., c

ardio

vas

cula

r dis

ease

, el

evat

ed c

hole

ster

ol

•D

isco

mfo

rt o

r pai

n a

ssoci

ate

d w

ith i

nta

ke

of

foods

rich

in b

ioac

tive

subst

an

ces,

e.g

., s

olu

ble

fib

er,

-glu

can,

soy p

rote

in

Refe

ren

ce:

1.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

Fun

ctio

nal

foods.

J A

m D

iet

Ass

oc.

20

04

;10

4:8

14

-82

6.

INTA

KE

DO

MA

IN B

ioac

tive

Subst

ance

s

EX

CE

SS

IVE

BIO

AC

TIV

E S

UB

ST

AN

CE

IN

TA

KE

(NI-

4.2

)

Edit

ion:

20

06

57

De

fin

itio

n

Hig

her

inta

ke

of

bio

acti

ve

subst

an

ces

oth

er t

han

tra

dit

ion

al n

utr

ien

ts,

such

as

fun

ctio

nal

foods,

bio

acti

ve

food c

om

ponen

ts,

die

tary

supple

men

ts,

or

food

con

centr

ates

com

par

ed t

o e

stabli

shed

ref

eren

ce s

tandar

ds

or r

ecom

men

dat

ion

s bas

ed u

pon p

hysi

olo

gic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•C

on

tam

inat

ion, m

isnam

e, m

isla

bel

, m

isuse

, re

cen

t bra

nd c

han

ge,

rec

ent

dose

in

crea

se, re

cen

t fo

rmu

lati

on c

han

ge

of

subst

ance

con

sum

ed

•F

requen

t in

take

of

food c

on

tain

ing b

ioac

tive

subst

an

ce

•A

lter

ed G

I fu

nct

ion,

e.g., p

ain o

r dis

com

fort

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•L

ab v

alues

in

dic

atin

g e

xce

ssiv

e in

take

of

the

spec

ific

subst

ance

, su

ch a

s ra

pid

dro

p i

n c

hole

ster

ol

from

in

take

of

stan

ol

or

ster

ol

este

rs i

n c

om

bin

atio

n w

ith a

sta

tin d

rug

•In

crea

sed h

epat

ic e

nzy

me

refl

ecti

ng h

epat

oce

llula

r dam

age

Anth

ropom

etri

c M

easu

rem

ents

•W

eigh

t lo

ss a

s a

resu

lt o

f m

ala

bso

rpti

on o

r m

aldig

esti

on

Phys

ical

Exam

Fin

din

gs

•C

onst

ipat

ion o

r dia

rrh

ea r

elat

ed t

o e

xce

ssiv

e in

take

•N

euro

logic

chan

ges

, e.

g., a

nx

iety

, m

enta

l st

atus

chan

ges

•C

ardio

vas

cula

r ch

anges

, e.

g., h

eart

rat

e, E

KG

, blo

od p

ress

ure

INTA

KE

DO

MA

IN B

ioac

tive

Subst

ance

s

EX

CE

SS

IVE

BIO

AC

TIV

E S

UB

ST

AN

CE

IN

TA

KE

(NI-

4.2

)

Edit

ion:

20

06

58

Food/N

utr

itio

n H

isto

ryO

bse

rvat

ion

s or

report

s of:

•H

igh i

nta

ke

of

pla

nt

foods

con

tain

ing:

•S

oy p

rote

in (

tota

l an

d L

DL

chole

ster

ol)

•-g

luca

n,

e.g., w

hole

oat

pro

duct

s (

tota

l an

d L

DL

ch

ole

ster

ol)

•P

lan

t st

erol

and s

tan

ol

este

rs, e.

g., f

ort

ifie

d m

argar

ines

( t

ota

l an

d L

DL

ch

ole

ster

ol)

or

oth

er f

oods

bas

ed u

pon d

ieta

ry

subst

an

ce,

con

centr

ate,

met

aboli

te,

con

stit

uen

t, e

xtr

act

or c

om

bin

ati

on

•S

ubst

ance

s w

hic

h i

nte

rfer

e w

ith d

iges

tion

or

abso

rpti

on o

f fo

odst

uff

s

•R

ead

y a

cces

s to

avai

lable

foods/

pro

duct

s w

ith b

ioac

tive

subst

ance

, e.

g., a

s fr

om

die

tary

supple

men

t ven

dor

s

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., c

ardio

vas

cula

r dis

ease

, el

evat

ed c

hole

ster

ol,

hyp

erte

nsi

on

•D

isco

mfo

rt o

r pai

n a

ssoci

ate

d w

ith i

nta

ke

of

foods

rich

in b

ioac

tive

subst

an

ces,

e.g

., s

olu

ble

fib

er,

-glu

can,

soy p

rote

in

•A

ttem

pts

to u

se s

upple

men

ts o

r bio

acti

ve

subst

an

ces

for

wei

ght

loss

, tr

eat

con

stip

atio

n, pre

ven

t or

cure

chro

nic

or

acute

dis

ease

Refe

ren

ces:

1.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry S

up

ple

men

ts:

A f

ram

ew

ork

fo

r ev

alu

ati

ng

sa

fety

.W

ashin

gto

n,

DC

: N

atio

nal

Aca

dem

y P

ress

; 2

00

4.

2.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

Fun

ctio

nal

foods.

J A

m D

iet

Ass

oc.

20

04

;10

4:8

14

-82

6.

INTA

KE

DO

MA

IN B

ioac

tive

Subst

ance

s

EX

CE

SS

IVE

AL

CO

HO

L I

NT

AK

E(N

I-4

.3)

Edit

ion:

20

06

59

De

fin

itio

n

Inta

ke

above

the

sugges

ted l

imit

s fo

r al

coh

ol

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms.

•H

arm

ful

bel

iefs

/att

itudes

about

food,

nutr

itio

n,

and n

utr

itio

n-r

elat

ed t

opic

s

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•L

ack o

f val

ue

for

beh

avio

r ch

ange,

com

pet

ing v

alues

•A

lcoh

ol

addic

tion

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•E

levat

ed a

spar

tate

am

inotr

ansf

eras

e (A

ST

), g

amm

a-glu

tam

yl t

ran

sfer

ase

(GG

T),

car

boh

ydra

te-d

efic

ien

t tr

ansf

erri

n, m

ean

corp

usc

ula

r volu

me,

blo

od a

lcoh

ol

level

s

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•In

take

of

> 2

dri

nks/

day

(m

en)

(1 d

rin

k =

5 o

z. w

ine,

12 o

z bee

r, 1

oz.

dis

till

ed a

lcoh

ol)

•In

take

of

> 1

dri

nk/d

ay (

wom

en)

(1 d

rin

k =

5 o

z. w

ine,

12 o

z bee

r, 1

oz.

dis

till

ed a

lcoh

ol)

•B

inge

dri

nkin

g

•C

on

sum

pti

on o

f an

y a

lcoh

ol

wh

en c

on

trai

ndic

ated

INTA

KE

DO

MA

IN B

ioac

tive

Subst

ance

s

EX

CE

SS

IVE

AL

CO

HO

L I

NT

AK

E(N

I-4

.3)

Edit

ion:

20

06

60

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., s

ever

e h

yper

trig

lyce

ridem

ia,

elev

ated

blo

od p

ress

ure

,

dep

ress

ion

, li

ver

dis

ease

, pan

crea

titi

s

•N

ew m

edic

al d

iagnosi

s or

chan

ge

in e

xis

ting d

iagn

osi

s or

con

dit

ion

•H

isto

ry o

f ex

cess

ive

alco

hol

inta

ke

•G

ivin

g b

irth

to a

n i

nfa

nt

wit

h f

etal

alc

oh

ol

syn

dro

me

•D

rinkin

g d

uri

ng p

regnan

cy d

espit

e kn

ow

ledge

of

risk

•U

nex

pla

ined

fal

ls

Refe

ren

ce:

1.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

The

role

of

die

teti

cs p

rofe

ssio

nal

s in

hea

lth p

rom

oti

on a

nd d

isea

se p

reventi

on.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

68

0-1

68

7.

INTA

KE D

OM

AIN

N

utr

ient

INC

RE

AS

ED

NU

TR

IEN

T N

EE

DS

(S

PE

CIF

Y)

(NI-

5.1

)

Edit

ion:

20

06

61

De

fin

itio

n

Incr

ease

d n

eed f

or

a sp

ecif

ic n

utr

ient

com

par

ed t

o e

stabli

shed

ref

eren

ce s

tan

dar

ds

or

reco

mm

endat

ion

s bas

ed u

pon p

hysi

olo

gic

al

nee

ds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•A

lter

ed a

bso

rpti

on o

r m

etab

oli

sm o

f n

utr

ient,

e.g

., f

rom

med

icat

ion

s

•C

om

pro

mis

e of

org

ans

rela

ted t

o G

I fu

nct

ion,

e.g., p

ancr

eas,

liv

er

•D

ecre

ased

fun

ctio

nal

len

gth

of

inte

stin

e, e

.g., s

hort

bow

el s

yndro

me

•D

ecre

ased

or

com

pro

mis

ed f

un

ctio

n o

f in

test

ine,

e.g

., c

elia

c dis

ease

, C

rohn

’s d

isea

se

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•In

crea

sed d

eman

d o

f n

utr

ien

t, e

.g., a

ccel

erat

ed g

row

th,

woun

d h

eali

ng,

chro

nic

in

fect

ion

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•D

ecre

ased

ch

ole

ster

ol

< 1

60 m

g/d

L, al

bum

in, pre

album

in,

C-r

eact

ive

pro

tein

, in

dic

atin

g i

ncr

ease

d s

tres

s an

d i

ncr

ease

d

met

aboli

c n

eeds

•E

lect

roly

te/m

iner

al (

e.g., p

ota

ssiu

m, m

agnes

ium

, ph

osp

horu

s) a

bn

orm

alit

ies

•U

rinar

y o

r fe

cal

loss

es o

f sp

ecif

ic o

r re

late

d n

utr

ien

t (e

.g., f

ecal

fat

, d-x

ylo

se t

est)

•V

itam

in a

nd

/or

min

eral

def

icie

ncy

Anth

ropom

etri

c M

easu

rem

ents

•G

row

th f

ailu

re, bas

ed o

n N

atio

nal

Cen

ter

for

Hea

lth S

tati

stic

s (N

CH

S)

gro

wth

sta

ndar

ds

and f

etal

gro

wth

fai

lure

•U

nin

ten

tional

wei

ght

loss

of

5%

in 1

month

or

10%

in 6

month

s

•U

nder

wei

ght

(BM

I <

18.5

)

INTA

KE D

OM

AIN

N

utr

ient

INC

RE

AS

ED

NU

TR

IEN

T N

EE

DS

(S

PE

CIF

Y)

(NI-

5.1

)

Edit

ion:

20

06

62

Phys

ical

Exam

inati

on F

indin

gs

•C

linic

al e

vid

ence

of

vit

amin

/min

eral

def

icie

ncy

(e.

g.,

hai

r lo

ss,

ble

edin

g g

um

s, p

ale

nai

l bed

s)

•L

oss

of

skin

inte

gri

ty o

r del

aye

d w

oun

d h

eali

ng

•L

oss

of

musc

le m

ass

, su

bcu

tan

eous

fat

Food/N

utr

itio

n H

isto

ryO

bse

rvat

ion o

r re

port

s of:

•In

adeq

uat

e in

take

of

foods/

supp

lem

ent

con

tain

ing n

eeded

nutr

ien

t as

com

par

ed t

o e

stim

ated

req

uir

emen

ts

•In

tak

e of

foods

that

do n

ot

con

tain

suff

icie

nt

quan

titi

es o

f av

aila

ble

nutr

ient

(e.g

., o

ver

pro

cess

ed,

over

cooked

, or

store

d

impro

per

ly)

•F

ood a

nd n

utr

itio

n-r

elat

ed k

now

ledge

def

icit

(e.

g., l

ack

of

info

rmati

on,

inco

rrec

t in

form

atio

n o

r n

onco

mp

lian

ce w

ith

inta

ke

of

nee

ded

nutr

ient)

Cli

ent

His

tory

•F

ever

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t, e

.g., i

nte

stin

al r

esec

tion,

Cro

hn

’s d

isea

se,

HIV

/AID

S, burn

s, p

ress

ure

ulc

ers,

pre

-ter

m b

irth

, m

aln

utr

itio

n

•M

edic

atio

ns

affe

ctin

g a

bso

rpti

on o

r m

etab

oli

sm o

f n

eeded

nutr

ien

t

Refe

ren

ces:

1.

Bey

er

P. G

ast

roin

test

inal

dis

ord

ers:

Role

s of

nutr

itio

n a

nd t

he

die

teti

cs

pra

ctit

ioner

.J

Am

Die

t A

sso

c. 1

99

8;9

8:2

72

-27

7.

2.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n a

nd D

ieti

tian

s of

Can

ada:

Nu

trit

ion i

nte

rven

tion i

n t

he

care

of

per

sons

wit

h h

um

an i

mm

un

odef

icie

ncy v

iru

s in

fect

ion.J

Am

Die

t A

sso

c.

20

04

;10

4:1

42

5-1

44

1.

INTA

KE D

OM

AIN

N

utr

ient

EV

IDE

NT

PR

OT

EIN

-EN

ER

GY

MA

LN

UT

RIT

ION

(NI-

5.2

)

Edit

ion:

20

06

63

De

fin

itio

n

Inadeq

uat

e in

take

of

pro

tein

an

d/o

r en

ergy o

ver

pro

lon

ged

per

iods

of

tim

e re

sult

ing i

n l

oss

of

fat

store

s an

d/o

r m

usc

le w

asti

ng

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses,

e.g

., a

lter

ed n

utr

ien

t n

eeds

due

to p

rolo

nged

cat

aboli

c il

lnes

s, m

alabso

rpti

on

•L

ack o

f ac

cess

to f

ood,

e.g

., e

con

om

ic c

on

stra

ints

, cu

ltura

l or

reli

gio

us

pra

ctic

es, re

stri

ctin

g f

ood g

iven

to e

lder

ly a

nd/o

r ch

ildre

n

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledge

defi

cit,

e.g

., a

void

ance

of

hig

h q

ual

ity p

rote

in f

oods

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r ea

ting d

isord

ers

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•N

orm

al s

erum

alb

um

in l

evel

(un

com

pli

cate

d m

aln

utr

itio

n)

•A

lbum

in <

3.4

mg/d

L (

dis

ease

/tra

um

a-r

elat

ed m

alnutr

itio

n)

Anth

ropom

etri

c M

easu

rem

ents

•B

MI

< 1

8.5

in

dic

ates

under

wei

gh

t

•F

ailu

re t

o t

hri

ve,

e.g

. fa

ilure

to a

ttai

n d

esir

able

gro

wth

rat

es

•In

adeq

uat

e m

ater

nal

wei

gh

t gai

n

•W

eigh

t lo

ss o

f >

10%

in 6

mon

ths

or

5%

in 1

mon

th

•U

nder

wei

ght

wit

h m

usc

le w

asti

ng

•N

orm

al o

r sl

ightl

y u

nder

wei

ght,

stu

nte

d g

row

th i

n c

hil

dre

n

INTA

KE D

OM

AIN

N

utr

ient

EV

IDE

NT

PR

OT

EIN

-EN

ER

GY

MA

LN

UT

RIT

ION

(NI-

5.2

)

Edit

ion:

20

06

64

Phys

ical

Exam

Fin

din

gs

•U

nco

mpli

cate

d m

aln

utr

itio

n:

Thin

, w

aste

d a

ppea

ran

ce;

sever

e m

usc

le w

asti

ng;

min

imal

bod

y f

at;

spar

se, th

in,

dry

, ea

sily

plu

ckable

hai

r; d

ry,

thin

skin

; obvio

us

bon

y p

rom

inen

ces,

occ

ipit

al w

asti

ng;

low

ered

bod

y t

emper

ature

, blo

od p

ress

ure

,

hea

rt r

ate

; ch

anges

in h

air

or n

ails

con

sist

ent

wit

h i

nsu

ffic

ien

t pro

tein

inta

ke

•D

isea

se/t

raum

a-r

elat

ed m

aln

utr

itio

n:

Th

in t

o n

orm

al a

ppea

ran

ce,

wit

h p

erip

her

al

edem

a, a

scit

es o

r an

asar

ca;

som

e m

usc

le

was

tin

g w

ith r

eten

tion o

f so

me

bod

y f

at;

enla

rged

fat

ty l

iver

; dys

pig

men

tati

on o

f h

air

(fla

g s

ign)

and s

kin

•D

elayed

woun

d h

eali

ng

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•In

suff

icie

nt

ener

gy i

nta

ke

from

die

t co

mpar

ed t

o e

stim

ated

or

mea

sure

d R

MR

•In

suff

icie

nt

inta

ke

of

hig

h-q

ual

ity p

rote

in w

hen

com

par

ed t

o r

equir

emen

ts

•F

ood a

void

an

ce a

nd/o

r la

ck o

f in

tere

st i

n f

ood

Cli

ent

His

tory

•C

hro

nic

or

acute

dis

ease

or

trau

ma,

geo

gra

phic

loca

tion a

nd s

oci

oec

on

om

ic s

tatu

s as

soci

ate

d w

ith a

lter

ed n

utr

ien

t in

take

of

ind

igen

ou

s ph

enom

enon

•S

ever

e pro

tein

and/o

r n

utr

ien

t m

alabso

rpti

on (

e.g. ex

ten

sive

bow

el r

esec

tion

)

•E

xce

ssiv

e co

nsu

mp

tion

of

alco

hol

or

oth

er d

rugs

that

red

uce

hunger

Refe

ren

ces:

1.

Wel

lco

me

Tru

st W

ork

ing

Par

ty.

Cla

ssif

icat

ion

of

infa

nti

le m

alnu

trit

ion.

La

nce

t.1

97

0;2

:30

2-3

03

.

2.

Ser

es D

S,

Res

urr

ecti

on

, L

B.

Kw

ash

iork

or:

Dy

smet

abo

lism

ver

sus

mal

nu

trit

ion

.N

utr

Cli

n P

ract

.2

00

3;1

8:2

97

-30

1.

3.

Jell

iffe

DB

, Je

llif

fe E

F. C

ausa

tio

n o

f k

was

hio

rko

r: T

ow

ard

a m

ult

ifac

tora

l co

nse

nsu

s.P

edia

tric

s1

99

2:9

0:1

10

-11

3.

4.

Cen

ters

for

Dis

ease

Contr

ol

and P

rev

enti

on W

eb s

ite.

Avai

lab

le a

t: h

ttp:/

/ww

w.c

dc.

gov/n

ccdp

hp/d

npa/b

mi/

bm

i-adult

.htm

. A

cces

sed O

cto

ber

5, 20

04

.

5.

Fu

hrm

an M

P,

Char

ney

P,

Mu

elle

r C

M. H

epat

ic p

rote

ins

and

nu

trit

ion

ass

essm

ent.

J A

m D

iet

Ass

oc.

20

04

;10

4:1

25

8-1

26

4.

6.

U.S

. D

epart

ment

of

Hea

lth a

nd H

um

an S

ervic

es.

Th

e In

tern

ati

on

al

Cla

ssif

ica

tio

n o

f D

isea

ses,

9th R

evis

ion

, 4

th e

d. W

ash

ing

ton

DC

: U

SD

HS

S P

ubli

cati

on

No. (P

HS

) 9

1-1

26

0; 1

99

1.

INTA

KE D

OM

AIN

N

utr

ient

INA

DE

QU

AT

E P

RO

TE

IN-E

NE

RG

Y IN

TA

KE

(N

I-5

.3)

Edit

ion:

20

06

65

De

fin

itio

n

Inadeq

uat

e in

take

of

pro

tein

an

d/o

r en

ergy c

om

par

ed t

o e

stab

lish

ed r

efer

ence

sta

ndar

ds

or

reco

mm

endat

ions

bas

ed u

pon

physi

olo

gic

al n

eeds

of

short

or

rece

nt

dura

tion

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms.

•S

hort

-ter

m p

hys

iolo

gic

cau

ses,

e.g

., i

ncr

ease

d n

utr

ien

t n

eeds

due

to c

atab

oli

c il

lnes

s, m

alab

sorp

tion

•R

ecen

t la

ck o

f ac

cess

to f

ood,

e.g

., e

con

om

ic c

on

stra

ints

, cu

ltura

l or

rel

igio

us

pra

ctic

es, re

stri

ctin

g f

ood g

iven

or

food s

elec

ted

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledge

def

icit

, e.

g., a

void

ance

of

all

fats

for

new

die

ting p

atte

rn

•R

ecen

t onse

t of

psy

cholo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r ea

tin

g d

isord

ers

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•N

orm

al a

lbum

in (

in t

he

sett

ing o

f n

orm

al l

iver

fun

ctio

n d

espit

e dec

rease

pro

tein

-en

ergy in

take)

Anth

ropom

etri

c M

easu

rem

ents

•In

adeq

uat

e m

ater

nal

wei

gh

t gai

n (

mil

d b

ut

not

sever

e)

•W

eigh

t lo

ss o

f 5-7

% o

ver

past

3 m

on

ths

in a

dult

s, a

ny w

eight

loss

in c

hil

dre

n

•N

orm

al o

r sl

ightl

y u

nder

wei

ght

•G

row

th f

ailu

re i

n c

hil

dre

n

Phys

ical

Exam

Fin

din

gs

•S

low

woun

d h

eali

ng i

n p

ress

ure

ulc

er o

r su

rgic

al p

atie

nt/

clie

nt

INTA

KE D

OM

AIN

N

utr

ient

INA

DE

QU

AT

E P

RO

TE

IN-E

NE

RG

Y IN

TA

KE

(N

I-5

.3)

Edit

ion:

20

06

66

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•In

suff

icie

nt

ener

gy in

take

from

die

t co

mp

ared

to e

stim

ated

or

mea

sure

d r

esti

ng m

etab

oli

c ra

te (

RM

R)

or

reco

mm

ended

level

s

•R

estr

icti

on o

r om

issi

on o

f fo

od g

roups

such

as

dai

ry o

r m

eat

gro

up f

oods

(pro

tein

); b

read

or

mil

k g

roup f

oods

(en

ergy)

•R

ecen

t fo

od a

void

ance

and/o

r la

ck o

f in

tere

st i

n f

ood

•L

ack o

f ab

ilit

y t

o p

repar

e m

eals

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t of

mil

d p

rote

in-e

ner

gy m

aln

utr

itio

n,

rece

nt

illn

ess,

e.g

. pulm

onar

y o

r

card

iac

fail

ure

, fl

u,

infe

ctio

n,

surg

ery

•N

utr

ien

t m

alab

sorp

tion (

e.g. bar

iatr

ic s

urg

ery,

dia

rrh

ea,

stea

torr

hea

)

•E

xce

ssiv

e co

nsu

mp

tion

of

alco

hol

or

oth

er d

rugs

that

red

uce

hunger

•P

atie

nt/

clie

nt

report

s of

hun

ger

in t

he

face

of

inadeq

uat

e ac

cess

to f

ood s

upply

•P

atie

nt/

clie

nt

report

s la

ck o

f ab

ilit

y t

o p

repar

e m

eals

•P

atie

nt/

clie

nt re

port

s la

ck o

f fu

nds

for

purc

has

e of

appro

pri

ate

foods

Refe

ren

ces:

1.

Cen

ters

for

Dis

ease

Contr

ol

and P

rev

enti

on W

eb s

ite.

Avai

lab

le a

t: h

ttp:/

/ww

w.c

dc.

gov/n

ccdp

hp/d

npa/b

mi/

bm

i-adult

.htm

. A

cces

sed O

cto

ber

5, 20

04

.

2.

Fu

hrm

an M

P,

Char

ney

P,

Mu

elle

r C

M. H

epat

ic p

rote

ins

and

nu

trit

ion

ass

essm

ent.

J A

m D

iet

Ass

oc.

20

04

;10

4:1

25

8-1

26

4.

3.

U.S

. D

epart

ment

of

Hea

lth a

nd H

um

an S

ervic

es.

Th

e In

tern

ati

on

al

Cla

ssif

ica

tio

n o

f D

isea

ses,

9th R

evis

ion

, 4

th e

d. W

ash

ing

ton

DC

: U

SD

HS

S P

ubli

cati

on

No. (P

HS

) 9

1-1

26

0; 1

99

1.

INTA

KE D

OM

AIN

N

utr

ient

DE

CR

EA

SE

D N

UT

RIE

NT

NE

ED

S(S

PE

CIF

Y)

(NI-

5.4

)

Edit

ion:

20

06

67

De

fin

itio

n

Dec

reas

ed n

eed f

or

a sp

ecif

ic n

utr

ient

com

par

ed t

o e

stab

lish

ed r

efer

ence

sta

ndar

ds

or

reco

mm

endat

ion

s bas

ed u

pon p

hysi

olo

gic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•R

enal

dysf

un

ctio

n

•L

iver

dysf

un

ctio

n

•A

lter

ed c

hole

ster

ol

met

aboli

sm/r

egula

tion

•H

eart

fai

lure

•F

ood i

nto

lera

nce

s, e

.g., i

rrit

able

bow

el s

yndro

me

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•C

hole

ster

ol

> 2

00 m

g/d

L (

5.2

mm

ol/

L),

LD

L c

hole

ster

ol

> 1

00 m

g/d

L (

2.5

9 m

mol/

L),

HD

L c

hole

ster

ol

< 4

0 m

g/d

L

(1.0

36 m

mol/

L),

tri

gly

ceri

des

> 1

50 m

g/d

L (

1.6

95 m

mol/

L)

•P

hosp

hor

us

> 5

.5 m

g/d

L (

1.7

8 m

mol/

L)

•G

lom

erula

r fi

ltra

tion

rat

e (G

FR

) <

90 m

L/m

in/1

.73 m

2

•E

levat

ed B

UN

, C

r, p

ota

ssiu

m

•L

iver

fun

ctio

n t

ests

in

dic

atin

g s

ever

e li

ver

dis

ease

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

•E

dem

a/fl

uid

ret

enti

on

•In

terd

ialy

tic

wei

ght

gai

n g

reat

er t

han

expec

ted

INTA

KE D

OM

AIN

N

utr

ient

DE

CR

EA

SE

D N

UT

RIE

NT

NE

ED

S(S

PE

CIF

Y)

(NI-

5.4

)

Edit

ion:

20

06

68

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•In

tak

e hig

her

than

rec

om

men

ded

for

fat,

phosp

horu

s, s

odiu

m,

pro

tein

, fi

ber

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t th

at r

equir

e a

spec

ific

typ

e an

d/o

r am

ount

of

nutr

ient,

e.g

.,

card

iovas

cula

r dis

ease

(fa

t),

earl

y r

enal

dis

ease

(pro

tein

, ph

osp

horu

s),

ES

RD

(phosp

horu

s, s

odiu

m, pota

ssiu

m, fl

uid

),

advan

ced l

iver

dis

ease

(pro

tein

), h

eart

fai

lure

(so

diu

m, fl

uid

), i

rrit

able

bow

el d

isea

se/C

rohn’s

dis

ease

fla

re u

p (

fiber

)

•D

iagn

osi

s of

hyp

erte

nsi

on

, co

nfu

sion r

elat

ed t

o l

iver

dis

ease

Refe

ren

ces:

1.

Apar

icio

M, C

hau

vea

u P

, C

om

be

C.

Low

pro

tein

die

ts a

nd o

utc

om

es o

f re

nal

pat

ients

.J

Nep

hro

l. 2

00

1;1

4:4

33

-43

9.

2.

Bet

o J

A, B

ansa

l V

K.

Med

ical

nutr

itio

n t

her

apy i

n c

hro

nic

kid

ney

fai

lure

: In

tegra

ting c

linic

al p

ract

ice

guid

elin

es.

J A

m D

iet

Ass

oc.

20

04

;10

4:4

04

-40

9.

3.

Cu

pis

ti A

, M

ore

lli

E,

D’A

less

and

ro C

, L

up

etti

S, B

arso

tti

G.

Ph

osp

hat

e co

ntr

ol

in c

hro

nic

ure

mia

: do

n’t

fo

rget

die

t.J

Nep

hro

l. 2

00

3;1

6:2

9-3

3.

4.

Duro

se C

L, H

old

swort

h M

, W

atso

n V

, P

rzygro

dzk

a F

. K

no

wle

dge

of

die

tary

res

tric

tio

ns

and t

he

med

ical

con

sequ

ence

s of

noncom

pli

ance

by p

atie

nts

on h

emo

dia

lysi

s ar

e not

pre

dic

tive

of

die

tary

com

pli

ance

.J

Am

Die

t A

sso

c. 2

00

4;1

04

:35

-41

.

5.

Flo

ch M

H, N

aray

an R

. D

iet

in t

he

irri

tab

le b

ow

el s

yn

dro

me.

Cli

n G

ast

roen

tero

l. 2

00

2;3

5:S

45

-S5

2.

6.

Kat

o J

, K

ob

un

e M

, N

akam

ura

T,

Ku

rojw

a G

, T

akad

a K

, T

akim

oto

R, S

ato

Y, F

uji

kaw

a K

, T

akahas

hi

M, T

akayam

a T

, Ik

eda

T, N

iits

u Y

. N

orm

aliz

atio

n o

f el

evat

ed h

epat

ic 8

-hy

dro

xy

-2’-

deo

xyguano

sine

level

s in

chro

nic

hep

atit

is C

pat

ients

by p

hle

boto

my a

nd l

ow

iro

n d

iet.

Ca

nce

r R

es. 2

00

1;6

1:8

69

7-8

70

2.

7.

Lee

SH

, M

ola

ssio

tis

A.

Die

tary

an

d f

luid

co

mp

lian

ce i

n C

hin

ese

hem

od

ialy

sis

pat

ien

ts.In

t J

Nu

rs S

tud

. 2

00

2;3

9:6

95

-70

4.

8.

Po

du

val

RD

, W

olg

emu

th C

, F

erre

ll J

, H

am

mes

MS

. H

yp

erp

ho

sph

atem

ia i

n d

ialy

sis

pat

ients

: is

th

ere

a ro

le f

or

focu

sed

cou

nse

lin

g?

J R

en N

utr

. 2

00

3;1

3:2

19

-22

3.

9.

Tan

don N

, T

hak

ur

V, G

upta

n R

K, S

arin

SK

. B

enef

icia

l in

flu

ence

of

an i

ndig

enous

low

-iro

n d

iet

on s

erum

indic

ators

of

iro

n s

tatu

s in

pat

ients

wit

h c

hro

nic

liv

er d

isea

se.

Br

J N

utr

. 2

00

0;8

3:2

35

-

23

9.

10

. Z

rin

yi

M,

Juhasz

M,

Bal

la J

, K

ato

na

E,

Ben

T,

Kak

uk

G,

Pal

l D

. D

ieta

ry s

elf-

effi

cacy

: d

eter

min

ant

of

com

pli

ance

beh

avio

urs

an

d b

ioch

emic

al o

utc

om

es

in h

aem

od

ialy

sis

pat

ien

ts.

Nep

hro

l D

ial

Tra

nsp

lan

t. 2

00

3;1

9:1

86

9-1

87

3.

INTA

KE D

OM

AIN

N

utr

ient

IMB

AL

AN

CE

OF

NU

TR

IEN

TS

(N

I-5

.5)

Edit

ion:

20

06

69

De

fin

itio

n

An u

ndes

irable

com

bin

atio

n o

f in

ges

ted n

utr

ients

, su

ch t

hat

th

e am

oun

t of

on

e nutr

ient

inges

ted i

nte

rfer

es w

ith o

r al

ters

abso

rpti

on a

nd/o

r uti

liza

tion o

f an

oth

er

nutr

ien

t

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•C

onsu

mpti

on o

f hig

h d

ose

nutr

ien

t su

pple

men

ts

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•H

arm

ful

bel

iefs

/att

itudes

about

food,

nutr

itio

n,

and n

utr

itio

n-r

elat

ed i

nfo

rmat

ion

•F

ood f

add

ism

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c D

ata

Phys

ical

Exam

Fin

din

gs

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•H

igh i

nta

ke

of

iron

supple

men

ts (

zin

c ab

sorp

tion

)

•H

igh i

nta

ke

of

zin

c su

pple

men

ts (

copper

sta

tus)

•H

igh i

nta

ke

of

man

gan

ese

( i

ron s

tatu

s)

Cli

ent

His

tory

•D

iarr

hea

or

con

stip

atio

n (

iron

supple

men

ts)

•E

pig

astr

ic p

ain,

nau

sea,

vom

itin

g,

dia

rrh

ea (

zin

c su

pple

men

ts)

•C

on

trib

ute

s to

th

e dev

elopm

ent

of

anem

ia (

man

gan

ese

supp

lem

ents

)

INTA

KE D

OM

AIN

N

utr

ient

IMB

AL

AN

CE

OF

NU

TR

IEN

TS

(N

I-5

.5)

Edit

ion:

20

06

70

Refe

ren

ces:

1.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r V

ita

min

A,

Vit

am

in K

, A

rsen

ic, B

oro

n, C

hro

miu

m, C

op

per

, Io

din

e, I

ron

, M

an

ga

nes

e, M

oly

bd

enu

m, N

icke

l,

Sil

ico

n,

Va

na

diu

m, Z

inc.

Was

hin

gto

n,

DC

: N

ati

on

al A

cad

emy

Pre

ss;

20

01

.

2.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

Inta

kes

for

Ca

lciu

m,

Ph

osp

ho

rus,

Ma

gn

esiu

m, V

ita

min

D, a

nd

Flu

ori

de. W

ash

ing

ton

, D

C:

Nat

ional

Aca

dem

y P

ress

; 1

99

7.

INTA

KE

DO

MA

IN F

at an

d C

hole

ste

rol

INA

DE

QU

AT

E F

AT

IN

TA

KE

(N

I-5

1.1

)

Edit

ion:

20

06

71

De

fin

itio

n

Low

er f

at i

nta

ke

com

par

ed t

o e

stab

lish

ed r

efer

ence

sta

ndar

ds

or

reco

mm

endat

ion

s bas

ed u

pon p

hysi

olo

gic

al n

eeds.

Ex

cepti

on:

wh

en t

he

goal

is

wei

ght

loss

or

duri

ng e

nd o

f li

fe c

are.

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•In

appro

pri

ate

food c

hoic

es,

e.g., e

conom

ic c

on

stra

ints

, cu

ltura

l or

reli

gio

us

pra

ctic

es, re

stri

ctin

g f

ood g

iven

to e

lder

ly a

nd/o

r ch

ildre

n,

spec

ific

food c

hoic

es

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledge

def

icit

, e.

g,. p

rolo

nged

adh

eren

ce t

o a

ver

y low

fat

die

t

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r dis

ord

ered

eat

ing

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•T

rien

e:te

trae

ne

rati

o >

0.2

Anth

ropom

etri

c M

easu

rem

ents

•W

eig

ht

loss

if

insu

ffic

ien

t ca

lori

es c

on

sum

ed

Phys

ical

Exam

inati

on F

indin

gs

•R

ough

, sc

aly s

kin

that

bec

om

es d

erm

ati

tis

wit

h e

ssen

tial

fat

ty a

cid d

efic

ien

cy

Food/N

utr

itio

n H

isto

ryR

eport

or

obse

rvat

ion o

f

•In

take

of

esse

nti

al f

atty

aci

d c

on

tain

ing f

oods

con

sist

entl

y p

rovid

ing l

ess

than

10%

of

calo

ries

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t, e

.g., p

rolo

nged

cat

aboli

c il

lnes

s (e

.g., A

IDS

, tu

ber

culo

sis,

anore

xia

ner

vosa

, se

psi

s or

sever

e in

fect

ion f

rom

rec

ent

surg

ery)

•S

ever

e fa

t m

alab

sorp

tion

wit

h b

ow

el r

esec

tion

, pan

crea

tic

insu

ffic

iency,

or

hep

atic

dis

ease

acc

om

pan

ied b

y

stea

torr

hea

Refe

ren

ces:

1.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r E

ner

gy,

Ca

rbo

hyd

rate

, F

iber

, F

at,

Fa

tty

Aci

ds,

Ch

ole

ster

ol,

Pro

tein

, a

nd

Am

ino

Aci

ds.

Was

hin

gto

n, D

C:

Nat

ion

al A

cad

em

y P

ress

; 2

00

2.

INTA

KE

DO

MA

IN F

at an

d C

hole

ste

rol

EX

CE

SS

IVE

FA

T IN

TA

KE

(N

I-5

1.2

)

Edit

ion:

20

06

72

De

fin

itio

n

Hig

her

fat

inta

ke

com

par

ed t

o e

stabli

shed

ref

eren

ce s

tan

dar

ds

or

reco

mm

endat

ions

bas

ed u

pon p

hysi

olo

gic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•H

arm

ful

bel

iefs

/att

itudes

about

food,

nutr

itio

n,

and n

utr

itio

n-r

elat

ed t

opic

s

•L

ack o

f ac

cess

to h

ealt

hfu

l fo

od c

hoic

es,

e.g., f

ood p

rovid

ed b

y c

areg

iver

•C

han

ges

in t

ast

e an

d a

ppet

ite

or

pre

fere

nce

•L

ack o

f val

ue

for

beh

avio

r ch

ange;

com

pet

ing v

alues

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•C

hole

ster

ol

>200 m

g/d

L (

5.2

mm

ol/

L),

LD

L c

hole

ster

ol

> 1

00 m

g/d

L (

2.5

9 m

mol/

L),

HD

L c

hole

ster

ol

< 4

0 m

g/d

L (

1.0

36

mm

ol/

L),

tri

gly

ceri

des

> 1

50 m

g/d

L (

1.6

95 m

mol/

L)

•E

levat

ed s

erum

am

ylase

and/o

r li

pase

•E

levat

ed l

iver

fun

ctio

n t

ests

an

d/o

r to

tal

bil

irubin

•T

rien

e:te

trae

ne

rati

o >

0.4

•F

ecal

fat

> 7

g/

24 h

ours

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

•E

vid

ence

of

xanth

om

as

•E

vid

ence

of

skin

les

ion

s

INTA

KE

DO

MA

IN F

at an

d C

hole

ste

rol

EX

CE

SS

IVE

FA

T IN

TA

KE

(N

I-5

1.2

)

Edit

ion:

20

06

73

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•F

requen

t or

lar

ge

port

ion

s of

hig

h-f

at f

oods

•F

requen

t fo

od p

repar

atio

n w

ith a

dded

fat

•F

requen

t co

nsu

mpti

on o

f h

igh-r

isk l

ipid

s (i

.e., s

atura

ted f

at,

trans

fat,

ch

ole

ster

ol)

•R

eport

of

foods

con

tain

ing f

at a

bove

die

t pre

scri

pti

on

•In

adeq

uat

e in

take

of

esse

nti

al l

ipid

s

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t, e

.g., h

yper

lipid

emia

, cy

stic

fib

rosi

s,

angin

a, a

rther

osc

lero

sis,

pan

crea

tic,

liv

er,

and b

ilia

ry d

isea

ses;

post

-tra

nsp

lanta

tion

•M

edic

atio

n,

e.g

., p

ancr

eati

c en

zym

es,

chole

ster

ol,

or

oth

er l

ipid

-low

erin

g m

edic

atio

ns

•D

iarr

hea

, cr

ampin

g,

stea

torr

hea

, ep

igas

tric

pai

n

•F

amil

y h

isto

ry o

f h

yper

lipid

emia

, at

her

osc

lero

sis,

or

pan

crea

titi

s.

Refe

ren

ces:

1.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r E

ner

gy,

Ca

rbo

hyd

rate

, F

iber

, F

at,

Fa

tty

Aci

ds,

Ch

ole

ster

ol,

Pro

tein

, a

nd

Am

ino

Aci

ds.

Was

hin

gto

n, D

C:

Nat

ion

al A

cad

em

y P

ress

; 2

00

2.

2.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Wei

ght

man

agem

ent.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

14

5-1

15

5.

3.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Tota

l die

t appro

ach

to c

om

munic

atin

g f

ood a

nd n

utr

itio

n i

nfo

rmat

ion.J

Am

Die

t A

sso

c. 2

00

2;1

02

:10

0-1

08

.

4.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

The

role

of

die

teti

cs p

rofe

ssio

nal

s in

hea

lth p

rom

oti

on a

nd d

isea

se p

reventi

on.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

68

0-1

68

7.

INTA

KE

DO

MA

IN F

at an

d C

hole

ste

rol

INA

PP

RO

PR

IAT

E IN

TA

KE

OF

FO

OD

FA

TS

(N

I-5

1.3

)

Edit

ion:

20

06

74

De

fin

itio

n

Inta

ke

of

wro

ng t

ype

or

qual

ity o

f fo

od f

ats

com

par

ed t

o e

stab

lish

ed r

efer

ence

sta

ndar

ds

or

reco

mm

endat

ion

s bas

ed u

pon p

hys

iolo

gic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•H

arm

ful

bel

iefs

/att

itudes

about

food,

nutr

itio

n,

and n

utr

itio

n-r

elat

ed t

opic

s

•L

ack o

f ac

cess

to h

ealt

hfu

l fo

od c

hoic

es,

e.g., f

ood p

rovid

ed b

y c

areg

iver

, ped

iatr

ics,

hom

eles

s

•C

han

ges

in t

ast

e an

d a

ppet

ite

or

pre

fere

nce

•L

ack o

f val

ue

for

beh

avio

r ch

ange;

com

pet

ing v

alues

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•C

hole

ster

ol

>200 m

g/d

L (

5.2

mm

ol/

L),

LD

L c

hole

ster

ol

> 1

00 m

g/d

L (

2.5

9 m

mol/

L),

HD

L c

hole

ster

ol

< 4

0 m

g/d

L (

1.0

36

mm

ol/

L),

tri

gly

ceri

des

> 1

50 m

g/d

L (

1.6

95 m

mol/

L)

•E

levat

ed s

erum

am

ylase

and/o

r li

pase

•E

levat

ed l

iver

fun

ctio

n t

ests

, to

tal

bil

irubin

, an

d C

-rea

ctiv

e pro

tein

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

•E

vid

ence

of

xanth

om

as

•E

vid

ence

of

skin

les

ion

s

INTA

KE

DO

MA

IN F

at an

d C

hole

ste

rol

INA

PP

RO

PR

IAT

E IN

TA

KE

OF

FO

OD

FA

TS

(N

I-5

1.3

)

Edit

ion:

20

06

75

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•F

requen

t fo

od p

repar

atio

n w

ith a

dded

fat

that

is n

ot

of

des

ired

typ

e fo

r co

ndit

ion

•F

requen

t co

nsu

mp

tion o

f fa

ts t

hat

are

undes

irable

for

con

dit

ion (

i.e.

, sa

tura

ted f

at,

trans

fat,

ch

ole

ster

ol,

om

ega-

6 f

atty

acid

s)

•In

adeq

uat

e in

take

of

monoun

satu

rate

d, poly

un

satu

rate

d, or

om

ega-

3 f

atty

aci

ds

Cli

ent

His

tory

•C

ondit

ion

s as

soci

ate

d w

ith a

dia

gnosi

s or

trea

tmen

t of

dia

bet

es,

card

iac

dis

ease

s, o

bes

ity,

liv

er o

r bil

iary

dis

ord

ers

•D

iarr

hea

, cr

ampin

g,

stea

torr

hea

, ep

igas

tric

pai

n

•F

amil

y h

isto

ry o

f dia

bet

es-r

elat

ed h

eart

dis

ease

, h

yper

lipid

emia

, at

her

osc

lero

sis,

or

pan

crea

titi

s

•C

lien

t des

ires

to i

mple

men

t a

Med

iter

ran

ean-t

ype

die

t

Refe

ren

ces:

1.

de

Lo

rger

il M

, S

alen

P,

Mar

tin

JL

, M

onja

ud

I,

Del

aye

J, M

amel

le N

. M

edit

erra

nea

n d

iet,

tra

dit

ion

al r

isk

fac

tors

, an

d t

he

rate

of

card

iov

ascu

lar

com

pli

cati

on

s aft

er m

yoca

rdia

l in

farc

tio

n.

Fin

al

report

of

the

Ly

on D

iet

Hea

rt S

tudy.C

ircu

lati

on

.1

99

9;9

9:7

79

-78

5.

2.

Fra

nz

MJ,

Ban

tle

JP, B

eeb

e C

A,

Bru

nze

ll J

D,

Chia

sso

n J

-L,

Gar

g A

, H

olz

mei

ster

LA

, H

oo

gw

erf

B,

May

er-D

avis

E,

Mo

ora

dia

n A

D,

Pu

rnel

l JQ

, W

hee

ler

M: T

ech

nic

al r

evie

w. E

vid

ence

-base

d

nutr

itio

n p

rinci

ple

s an

d r

ecom

men

dat

ions

for

the

trea

tmen

t an

d p

reven

tion o

f dia

bet

es a

nd r

elat

ed c

om

pli

cati

ons.

Dia

bet

es C

are

.2

00

2;2

02

:14

8-1

98

.

3.

Kno

op

s K

TB

, d

e G

rott

LC

PG

M,

Kro

mhou

t D

, P

erri

n A

-E,

Var

ela

MV

, M

enott

i A

, van

Sta

ver

en W

A.

Med

iter

ran

ean

die

t, l

ifes

tyle

fact

ors

, an

d 1

0-y

ear

mort

alit

y i

n e

lder

ly E

uro

pea

n m

en a

nd

wom

en.

JAM

A.

20

04

;29

2:1

43

3-1

43

9,

4.

Kri

s-E

ther

ton

PM

, H

arri

s W

S,

Ap

pel

LJ,

for

the

Nu

trit

ion

Co

mm

itte

e. A

HA

sci

enti

fic

stat

emen

t. F

ish

co

nsu

mp

tio

n,

fish

oil

, o

meg

a-3

fat

ty a

cid

s, a

nd

car

dio

vasc

ula

r dis

ease

.C

ircu

lati

on

.

20

02

;10

6:2

74

7-2

75

7.

5.

Pan

agio

tak

os

DB

, P

itsa

vo

s C

, P

oly

chro

nopoulo

s E

, C

hry

soho

ou C

, Z

am

pel

as A

, T

rich

opoulo

u A

. C

an a

Medit

erra

nea

n d

iet

moder

ate

the

dev

elopm

ent

and c

linic

al p

rogre

ssio

n o

f co

ronar

y h

eart

dis

ease

? A

syst

em

atic

rev

iew

.M

ed S

ci M

on

it.2

00

4;1

0:R

A1

93

-RA

19

8.

6.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Wei

ght

man

agem

ent.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

14

5-1

15

5.

7.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Tota

l die

t appro

ach

to c

om

munic

atin

g f

ood a

nd n

utr

itio

n i

nfo

rmat

ion.J

Am

Die

t A

sso

c. 2

00

2;1

02

:10

0-1

08

.

8.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

The

role

of

die

teti

cs p

rofe

ssio

nal

s in

hea

lth p

rom

oti

on a

nd d

isea

se p

reventi

on.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

68

0-1

68

7.

9.

Zhao

G,

Eth

erto

n T

D,

Mar

tin

KR

, W

est

SG

, G

ille

s P

J, K

ris-

Eth

erto

n P

M. D

ieta

ry a

lph

a-li

no

lenic

aci

d r

edu

ces

infl

amm

ato

ry a

nd

lip

id c

ard

iovasc

ula

r ri

sk f

act

ors

in

hy

per

cho

lest

ero

lem

ic m

en a

nd

wom

en.

J N

utr

. 2

00

4;1

34

:29

91

-29

97

.

INTA

KE

DO

MA

IN P

rote

in

INA

DE

QU

AT

E P

RO

TE

IN IN

TA

KE

(NI-

52

.1)

Edit

ion:

20

06

76

De

fin

itio

n

Low

er i

nta

ke

of

pro

tein

-conta

inin

g f

oods

or

subst

ance

s co

mp

ared

to e

stabli

shed

ref

eren

ce s

tan

dar

ds

or

reco

mm

endat

ion

s bas

ed u

pon p

hysi

olo

gic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses,

e.g

., i

ncr

ease

d n

utr

ien

t n

eeds

due

to p

rolo

nged

cat

aboli

c il

lnes

s, m

alab

sorp

tion,

age

or c

on

dit

ion

•L

ack o

f ac

cess

to f

ood,

e.g

., e

con

om

ic c

on

stra

ints

, cu

ltura

l or

reli

gio

us

pra

ctic

es, re

stri

ctin

g f

ood g

iven

to e

lder

ly a

nd/o

r ch

ildre

n

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r dis

ord

ered

eat

ing

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

inati

on F

indin

gs

Die

t H

isto

ryR

eport

or

obse

rvat

ion o

f

•In

suff

icie

nt

inta

ke

of

pro

tein

to m

eet

requir

emen

ts

•C

ult

ura

l or

reli

gio

us

pra

ctic

es t

hat

lim

it p

rote

in i

nta

ke

•E

conom

ic c

on

stra

ints

that

lim

it f

ood a

vai

labil

ity

•P

rolo

nged

adh

eren

ce to a

ver

y lo

w-p

rote

in w

eig

ht

loss

die

t

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciat

ed w

ith a

dia

gn

osi

s or

trea

tmen

t, e

.g., s

ever

e pro

tein

mal

abso

rpti

on s

uch

as

bow

el r

esec

tion

Refe

ren

ce:

1.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r E

ner

gy,

Ca

rbo

hyd

rate

, F

iber

, F

at,

Fa

tty

Aci

ds,

Ch

ole

ster

ol,

Pro

tein

, a

nd

Am

ino

Aci

ds.

Was

hin

gto

n, D

C:

Nat

ion

al A

cad

em

y P

ress

; 2

00

2.

INTA

KE

DO

MA

IN P

rote

in

EX

CE

SS

IVE

PR

OT

EIN

IN

TA

KE

(NI-

52

.2)

Edit

ion:

20

06

77

De

fin

itio

n

Inta

ke

above

the

reco

mm

ended

lev

el o

f pro

tein

com

par

ed t

o e

stab

lish

ed r

efer

ence

sta

ndar

ds

or r

ecom

men

dat

ions

bas

ed u

pon p

hysi

olo

gic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•L

iver

dysf

un

ctio

n

•R

enal

dysf

un

ctio

n

•H

arm

ful

bel

iefs

/att

itu

des

about

food,

nutr

itio

n a

nd n

utr

itio

n-r

elate

d t

opic

s

•L

ack o

f ac

cess

to s

pec

iali

zed p

rote

in p

roduct

s

•M

etab

oli

c ab

norm

alit

y

•F

ood f

add

ism

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•A

lter

ed l

abora

tory

val

ues

e.g

. B

UN

, g

lom

erula

r fi

ltra

tion r

ate

(alt

ered

ren

al s

tatu

s)

Anth

ropom

etri

c M

easu

rem

ents

•G

row

th s

tun

tin

g o

r fa

ilure

bas

ed o

n N

atio

nal

Cen

ter

for

Hea

lth S

stat

isti

cs g

row

th c

har

ts (

met

aboli

c dis

ord

ers)

Phys

ical

Exam

Fin

din

gs

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•H

igh

er t

han

rec

om

men

ded

tota

l pro

tein

inta

ke,

e.g

., e

arly

ren

al

dis

ease

, ad

van

ced l

iver

dis

ease

wit

h c

on

fusi

on

•In

appro

pri

ate

supple

men

tati

on

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t, e

.g., e

arly

ren

al d

isea

se o

r ad

van

ced l

iver

dis

ease

wit

h c

on

fusi

on

INTA

KE

DO

MA

IN P

rote

in

EX

CE

SS

IVE

PR

OT

EIN

IN

TA

KE

(NI-

52

.2)

Edit

ion:

20

06

78

Refe

ren

ces:

1.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Foo

d a

nd n

utr

itio

n m

isin

form

atio

n.J

Am

Die

t A

sso

c. 2

00

2;1

02

:260

-26

6.

2.

Bet

o J

A, B

ansa

l V

K.

Med

ical

nutr

itio

n t

her

apy i

n c

hro

nic

kid

ney

fai

lure

: In

tegra

ting c

linic

al p

ract

ice

guid

elin

es.

J A

m D

iet

Ass

oc.

20

04

;10

4:4

04

-40

9.

3.

Bra

ndle

E, S

ieb

erth

HG

, H

autm

ann R

E.

Eff

ect

of

chro

nic

die

tary

pro

tein

inta

ke

on t

he

renal

fu

nct

ion i

n h

ealt

hy s

ubje

cts.

Eu

r J

Cli

n N

utr

. 1

99

6;5

0:7

34

-74

0.

4.

Fra

sset

to L

A,

Todd K

M,

Morr

is R

C J

r, S

ebast

ian A

. E

stim

atio

n o

f net

endo

gen

ous

no

nca

rbonic

acid

pro

duct

ion i

n h

um

ans

from

die

t, p

ota

ssiu

m a

nd p

rote

in c

onte

nts

.A

m J

Cli

n N

utr

. 1

99

8;6

8:5

76

-

58

3.

5.

Fri

edm

an N

, ed

.A

bso

rpti

on

an

d U

tili

zati

on

of

Am

ino

Aci

ds,

Vo

l. I

. B

oca

Rat

on,

Fla

. C

RC

Pre

ss; 1

98

9:2

29

-24

2.

6.

Hoo

gev

een

EK

, K

ost

ense

PJ,

Jag

er A

, H

ein

e R

J, J

ako

bs

C,

Bo

ute

r L

M,

Do

nk

er A

J, S

teh

ow

er C

D.

Ser

um

ho

mo

cyst

ein

e le

vel

an

d p

rote

in i

nta

ke

are

rela

ted

to

ris

k o

f m

icro

alb

um

inu

ria:

th

e H

oorn

stu

dy.

Kid

ney

Int.

19

98

;54

:20

3-2

09

.

7.

Ru

dm

an

D, D

iFu

lco

TJ,

Gal

amb

os

JT,

Sm

ith

RB

3rd

, S

alam

AA

, W

arre

n W

D. M

axim

um

rat

e o

f ex

cret

ion

an

d s

yn

thes

is o

f u

rea

in n

orm

al a

nd

cir

rho

tic

sub

ject

s.J

Cli

n I

nves

t. 1

97

3;5

2:2

24

1-2

24

9.

INTA

KE

DO

MA

IN P

rote

in

INA

PP

RO

PR

IAT

E I

NT

AK

E O

F A

MIN

O A

CID

S (

SP

EC

IFY

)(N

I-5

2.3

)

Edit

ion:

20

06

79

De

fin

itio

n

Inta

ke

that

is

more

or

less

th

an r

ecom

men

ded

lev

el a

nd/o

r ty

pe

of

amin

o a

cids

com

par

ed t

o e

stab

lish

ed r

efer

ence

sta

ndar

ds

or

reco

mm

endat

ions

bas

ed u

pon

ph

ysio

logic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•L

iver

dysf

un

ctio

n

•R

enal

dysf

un

ctio

n

•H

arm

ful

bel

iefs

/att

itudes

about

food,

nutr

itio

n-

and n

utr

itio

n-r

elat

ed t

opic

s

•M

isuse

d s

pec

iali

zed p

rote

in p

roduct

s

•M

etab

oli

c ab

norm

alit

y

•F

ood f

add

ism

•In

born

err

ors

of

met

aboli

sm

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•A

lter

ed l

abora

tory

val

ues

, e.

g.,

BU

N,

glo

mer

ula

r fi

ltra

tion r

ate

(alt

ered

ren

al s

tatu

s);

incr

ease

d u

rinar

y 3

-met

hyl

-

his

tidin

e

•E

levat

ed s

pec

ific

am

ino a

cid

s (i

nborn

err

ors

of

met

aboli

sm)

•U

rem

ia, az

ote

mia

(re

nal

pat

ients

)

•E

levat

ed h

om

ocy

stei

ne

or

amm

on

ia

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

•P

hys

ical

or

neu

rolo

gic

al c

han

ges

(in

born

err

ors

of

met

aboli

sm)

INTA

KE

DO

MA

IN P

rote

in

INA

PP

RO

PR

IAT

E I

NT

AK

E O

F A

MIN

O A

CID

S (

SP

EC

IFY

)(N

I-5

2.3

)

Edit

ion:

20

06

80

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•H

igh

er t

han

rec

om

men

ded

am

ino a

cid i

nta

ke,

e.g

., e

arly

ren

al d

isea

se,

advan

ced l

iver

dis

ease

, in

born

err

or

of

met

aboli

sm

•H

igh

er t

han

rec

om

men

ded

type

of

amin

o a

cids

for

pre

scri

bed

EN

or

TP

N t

her

apy

•In

appro

pri

ate

supple

men

tati

on, as

for

ath

lete

s

•H

igh

er t

han

rec

om

men

ded

type

of

pro

tein

, e.

g., e

xce

ss p

hen

yla

lan

ine

inta

ke

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t of

illn

ess

that

requir

es E

N o

r T

PN

th

erapy

•H

isto

ry o

f use

of

amin

o a

cids

or

pro

tein

pow

der

s fo

r at

hle

tic

enh

ance

men

t

•H

isto

ry o

f in

born

err

or

of

met

aboli

sm

Refe

ren

ces:

1.

Bet

o J

A, B

ansa

l V

K.

Med

ical

nutr

itio

n t

her

apy i

n c

hro

nic

kid

ney

fai

lure

: In

tegra

ting c

linic

al p

ract

ice

guid

elin

es.

J A

m D

iet

Ass

oc.

20

04

;10

4:4

04

-40

9.

2.

Bra

ndle

E, S

ieb

erth

HG

, H

autm

ann R

E.

Eff

ect

of

chro

nic

die

tary

pro

tein

inta

ke

on t

he

renal

fu

nct

ion i

n h

ealt

hy s

ubje

cts.

Eu

r J

Cli

n N

utr

. 1

99

6;5

0:7

34

-74

0.

3.

Cohn R

M,

Roth

KS

. H

yper

am

monia

, bane

of

the

bra

in.

Cli

n P

edia

tr. 2

00

4;4

3:6

83

-68

9.

4.

Fra

sset

to L

A,

Todd K

M,

Morr

is R

C J

r, S

ebast

ian A

. E

stim

atio

n o

f net

endo

gen

ous

no

nca

rbonic

acid

pro

duct

ion i

n h

um

ans

from

die

t, p

ota

ssiu

m a

nd p

rote

in c

onte

nts

.A

m J

Cli

n N

utr

. 1

99

8;6

8:5

76

-

58

3.

5.

Fri

edm

an N

, ed

.A

bso

rpti

on

an

d U

tili

zati

on

of

Am

ino

Aci

ds,

Vo

l. I

. B

oca

Rat

on,

Fla

:CR

C P

ress

; 1

98

9:2

29

-24

2.

6.

Hoo

gev

een

EK

, K

ost

ense

PJ,

Jag

er A

, H

ein

e R

J, J

ako

bs

C,

Bo

ute

r L

M,

Do

nk

er A

J, S

teh

ow

er C

D.

Ser

um

ho

mo

cyst

ein

e le

vel

an

d p

rote

in i

nta

ke

are

rela

ted

to

ris

k o

f m

icro

alb

um

inu

ria:

th

e H

oorn

stu

dy.

Kid

ney

Int.

19

98

;54

:20

3-2

09

.

7.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Foo

d a

nd n

utr

itio

n m

isin

form

atio

n.J

Am

Die

t A

sso

c. 2

00

2;1

02

:260

-26

6.

8.

Ru

dm

an

D, D

iFu

lco

TJ,

Gal

amb

os

JT,

Sm

ith

RB

3rd

, S

alam

AA

, W

arre

n W

D. M

axim

um

rat

e o

f ex

cret

ion

an

d s

yn

thes

is o

f u

rea

in n

orm

al a

nd

cir

rho

tic

sub

ject

s. J

Cli

n I

nve

st. 1

97

3;5

2:2

24

1-2

24

9.

INTA

KE

DO

MA

IN C

arbohyd

rate

and F

iber

Inta

ke

INA

DE

QU

AT

E C

AR

BO

HY

DR

AT

E IN

TA

KE

(N

I-5

3.1

)

Edit

ion:

20

06

81

De

fin

itio

n

Low

er i

nta

ke

of

carb

oh

ydra

te-c

onta

inin

g f

oods

or

subst

ance

s co

mp

ared

to e

stabli

shed

ref

eren

ce s

tan

dar

ds

or

reco

mm

endat

ions

bas

ed u

pon p

hysi

olo

gic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses,

e.g

., i

ncr

ease

d e

ner

gy n

eeds

due

to i

ncr

ease

d a

ctiv

ity lev

el o

r m

etab

oli

c ch

ange,

mal

abso

rpti

on

•L

ack o

f ac

cess

to f

ood,

e.g

., e

con

om

ic c

on

stra

ints

, cu

ltura

l or

reli

gio

us

pra

ctic

es, re

stri

ctin

g f

ood g

iven

to e

lder

ly a

nd/o

r ch

ildre

n

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r dis

ord

ered

eat

ing

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

inati

on F

indin

gs

•K

etone

smel

l on b

reat

h

Die

t H

isto

ryR

eport

or

obse

rvat

ion o

f:

•C

arboh

ydra

te i

nta

ke

bel

ow

rec

om

men

ded

am

oun

ts

•In

abil

ity t

o i

ndep

enden

tly c

on

sum

e fo

ods/

fluid

s, e

.g., d

imin

ish

ed m

obil

ity in h

and, w

rist

, or

dig

its

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., p

ancr

eati

c in

suff

icie

ncy

, h

epat

ic d

isea

se,

celi

ac d

isea

se,

seiz

ure

dis

ord

er,

carb

oh

ydra

te m

alabso

rpti

on,

or l

ow

-car

boh

ydra

te d

iets

Refe

ren

ce:

1.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r E

ner

gy,

Ca

rbo

hyd

rate

, F

iber

, F

at,

Fa

tty

Aci

ds,

Ch

ole

ster

ol,

Pro

tein

, a

nd

Am

ino

Aci

ds.

Was

hin

gto

n, D

C:

Nat

ion

al A

cad

em

y P

ress

; 2

00

2.

INTA

KE

DO

MA

IN C

arbohyd

rate

and F

iber

Inta

ke

EX

CE

SS

IVE

CA

RB

OH

YD

RA

TE

IN

TA

KE

(N

I-5

3.2

)

Edit

ion:

20

06

82

De

fin

itio

n

Inta

ke

above

the

reco

mm

ended

lev

el a

nd t

ype

of

carb

oh

ydra

te c

om

par

ed t

o e

stab

lish

ed r

efer

ence

sta

ndar

ds

or

reco

mm

endat

ion

s bas

ed u

pon p

hys

iolo

gic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses

requir

ing m

odif

ied c

arboh

ydra

te i

nta

ke,

e.g

., d

iabet

es m

elli

tus,

lact

ase

def

icie

ncy

, su

cras

e-is

om

alta

se d

efic

ien

cy,

aldola

se-B

def

icie

ncy

•C

ult

ura

l or

reli

gio

us

pra

ctic

es t

hat

in

terf

ere

wit

h t

he

abil

ity to r

educe

car

boh

ydra

te i

nta

ke

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledge

defi

cit,

e.g

., i

nab

ilit

y to a

cces

s su

ffic

ien

t in

form

atio

n c

on

cern

ing a

ppro

pri

ate

carb

ohydra

te i

nta

ke

•F

ood a

nd n

utr

itio

n c

om

pli

ance

lim

itat

ion

s, e

.g., l

ack o

f w

illi

ngn

ess

or

fail

ure

to m

odif

y c

arboh

ydra

te i

nta

ke

in r

espon

se to r

ecom

men

dat

ion

s fr

om

a

die

titi

an o

r ph

ysic

ian

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r dis

ord

ered

eat

ing

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•H

yper

gly

cem

ia (

fast

ing b

lood s

ugar

> 1

26 m

g/d

L)

•H

emoglo

bin

A1C

> 6

%

•A

bn

orm

al

ora

l glu

cose

tole

ran

ce t

est

(2-h

our

post

load

glu

cose

> 2

00 m

g/d

L)

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

inati

on F

indin

gs

•D

enta

l ca

ries

•D

iarr

hea

in r

espon

se t

o c

arboh

ydra

te f

eedin

g

INTA

KE

DO

MA

IN C

arbohyd

rate

and F

iber

Inta

ke

EX

CE

SS

IVE

CA

RB

OH

YD

RA

TE

IN

TA

KE

(N

I-5

3.2

)

Edit

ion:

20

06

83

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•C

ult

ura

l or

reli

gio

us

pra

ctic

es t

hat

do n

ot

support

modif

icat

ion o

f die

tary

car

boh

ydra

te i

nta

ke

•E

conom

ic c

on

stra

ints

that

lim

it a

vai

labil

ity o

f ap

pro

pri

ate

foods

•C

arboh

ydra

te i

nta

ke

that

is

con

sist

entl

y a

bove

reco

mm

end

ed a

mounts

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., d

iabet

es m

elli

tus,

inborn

err

ors

of

carb

oh

ydra

te m

etaboli

sm,

lact

ase

def

icie

ncy

, se

ver

e in

fect

ion

, se

psi

s, o

r obes

ity

•C

hro

nic

use

of

med

icat

ion

s th

at c

ause

hyp

ergly

cem

ia,

e.g., s

tero

ids

•P

ancr

eati

c in

suff

icie

ncy

res

ult

ing i

n r

educe

d i

nsu

lin p

roduct

ion

Refe

ren

ces:

1.

Bo

wm

an B

A,

Ru

ssel

l R

M.

Pre

sen

t K

no

wle

dg

e in

Nu

trit

ion

.8

th e

d. W

ash

ing

ton

, D

C: IL

SI

Pre

ss;

20

01

.

2.

Cle

men

t S

, B

rait

hw

aite

SS

, M

agee

MF

, A

hm

an

n A

, S

mit

h E

P, S

chafe

r R

G, H

irsc

h I

B,

Am

eric

an D

iab

etes

Ass

oci

atio

n D

iab

etes

in

Ho

spit

als

Wri

tin

g C

om

mit

tee.

Man

agem

ent

of

dia

bet

es i

n

hosp

itals

.D

iab

etes

Ca

re. 2

00

4;2

7:5

53

-59

2.

3.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r E

ner

gy,

Ca

rbo

hyd

rate

, F

iber

, F

at,

Fa

tty

Aci

ds,

Ch

ole

ster

ol,

Pro

tein

, a

nd

Am

ino

Aci

ds.

Was

hin

gto

n, D

C:

Nat

ion

al A

cad

em

y P

ress

; 2

00

2.

4.

The

Exp

ert

Co

mm

itte

e on t

he

Dia

gn

osi

s and C

lass

ific

atio

n o

f D

iab

etes

Mel

litu

s. D

iagno

sis

and c

lass

ific

atio

n o

f dia

bet

es m

elli

tus.

Dia

bet

es C

are

. 2

00

4;2

7:S

5-S

10

.

INTA

KE

DO

MA

IN C

arbohyd

rate

and F

iber

Inta

ke

INA

PP

RO

PR

IAT

E I

NT

AK

E O

F T

YP

ES

OF

CA

RB

OH

YD

RA

TE

S (

SP

EC

IFY

) (N

I-5

3.3

)

Edit

ion:

20

06

84

De

fin

itio

n

Inta

ke

or t

he

type

or

amount

of

carb

oh

ydra

te t

hat

is

above

or

bel

ow

th

e es

tabli

shed

ref

eren

ce s

tandar

ds

or

reco

mm

endat

ion

s bas

ed u

pon p

hysi

olo

gic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses

requir

ing c

aref

ul

use

of

modif

ied c

arboh

ydra

te,

e.g., d

iabet

es m

elli

tus,

met

aboli

c sy

ndro

me,

hyp

ogly

cem

ia,

celi

ac d

isea

se, al

lerg

ies,

obes

ity

•C

ult

ura

l or

reli

gio

us

pra

ctic

es t

hat

in

terf

ere

wit

h t

he

abil

ity to r

egula

te t

yp

es o

f ca

rboh

ydra

te c

on

sum

ed

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledge

defi

cit,

e.g

., i

nab

ilit

y to a

cces

s su

ffic

ien

t in

form

atio

n c

on

cern

ing m

ore

ap

pro

pri

ate

carb

oh

ydra

te t

ypes

an

d/o

r

amoun

ts

•F

ood a

nd n

utr

itio

n c

om

pli

ance

lim

itat

ion

s, e

.g., l

ack o

f w

illi

ngn

ess

or

fail

ure

to m

odif

y c

arboh

ydra

te i

nta

ke

in r

espon

se to r

ecom

men

dat

ion

s fr

om

a

die

titi

an, ph

ysic

ian

, or

care

giv

er

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r dis

ord

ered

eat

ing

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•H

yp

ogly

cem

ia o

r h

yper

gly

cem

ia d

ocu

men

ted o

n r

egula

r bas

is w

hen

com

par

ed w

ith g

oal

of

mai

nta

inin

g g

luco

se

level

s at

or

bel

ow

140 m

g/d

L t

hro

ughout

the

day

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

inati

on F

indin

gs

INTA

KE

DO

MA

IN C

arbohyd

rate

and F

iber

Inta

ke

INA

PP

RO

PR

IAT

E I

NT

AK

E O

F T

YP

ES

OF

CA

RB

OH

YD

RA

TE

S (

SP

EC

IFY

) (N

I-5

3.3

)

Edit

ion:

20

06

85

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•D

iarr

hea

in r

espon

se t

o h

igh r

efin

ed c

arboh

ydra

te i

nta

ke

•E

conom

ic c

on

stra

ints

that

lim

it a

vai

labil

ity o

f ap

pro

pri

ate

foods

•C

arboh

ydra

te i

nta

ke

that

is

dif

fere

nt

from

rec

om

men

ded

types

•A

ller

gic

rea

ctio

ns

to c

erta

in c

arboh

ydra

te f

oods

or

food g

roups

•L

imit

ed k

now

ledge

of

carb

oh

ydra

te c

om

posi

tion o

f fo

ods

or

of

carb

oh

ydra

te m

etaboli

sm

Cli

ent

His

tory

•C

ondit

ion

s as

soci

ate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., d

iabet

es m

elli

tus,

obes

ity,

met

aboli

c sy

ndro

me,

hyp

ogly

cem

ia

•C

hro

nic

use

of

med

icati

on

s th

at c

ause

alt

ered

glu

cose

level

s, e

.g., s

tero

ids,

anti

dep

ress

ants

, an

tip

sych

oti

cs

Refe

ren

ces:

1.

Bo

wm

an B

A,

Ru

ssel

l R

M.

Pre

sen

t K

no

wle

dg

e in

Nu

trit

ion

. 8

th e

d. W

ash

ing

ton

, D

C: IL

SI

Pre

ss,

20

01

.

2.

Cle

men

t S

, B

rait

hw

aite

SS

, M

agee

MF

, A

hm

an

n A

, S

mit

h E

P, S

chafe

r R

G, H

irsc

h I

B,

Am

eric

an D

iab

etes

Ass

oci

atio

n D

iab

etes

in

Ho

spit

als

Wri

tin

g C

om

mit

tee.

Man

agem

ent

of

dia

bet

es i

n

hosp

itals

.D

iab

etes

Ca

re. 2

00

4;2

7:5

53

-59

2.

3.

Fra

nz

MJ,

Ban

tle

JP, B

eeb

e C

A,

Bru

nze

ll J

D,

Chia

sso

n J

-L,

Gar

g A

, H

olz

mei

ster

LA

, H

oo

gw

erf

B,

May

er-D

avis

E,

Mo

ora

dia

n A

D,

Pu

rnel

l JQ

, W

hee

ler

M: T

ech

nic

al r

evie

w. E

vid

ence

-base

d

nutr

itio

n p

rinci

ple

s an

d r

ecom

men

dat

ions

for

the

trea

tmen

t an

d p

reven

tion o

f dia

bet

es a

nd r

elat

ed c

om

pli

cati

ons.

Dia

bet

es C

are

20

02

;20

2:1

48

-19

8.

4.

Sh

eard

NF

, C

lark

NG

, B

ran

d-M

ille

r JC

, F

ran

z M

J, P

i-S

un

yer

FX

, M

ayer

-Dav

is E

, K

ulk

arn

i K

, G

eil

P.

A s

tate

men

t b

y t

he

Am

eric

an D

iab

etes

Ass

oci

atio

n. D

ieta

ry c

arbo

hy

dra

te (

amou

nt

and

ty

pe)

in t

he

pre

ven

tio

n a

nd m

anag

em

ent

of

dia

bet

es.D

iab

etes

Ca

r.e

20

04

;27

:22

66

-22

71

.

5.

Gro

ss L

S,

Li

L, F

ord

ES

, L

iu S

. In

crea

sed

con

sum

pti

on

of

refi

ned

car

boh

yd

rate

s and

epid

emic

or

typ

e 2

dia

bet

es i

n t

he

Un

ited

Sta

tes:

an

eco

log

ic a

sses

smen

t.A

m J

Cli

n N

utr

20

04

;79

:77

4-7

79

.

6.

Fre

nch S

, L

in B

-H,

Guth

erie

JF

. N

atio

nal

tre

nds

in s

oft

dri

nk c

on

sum

pti

on a

mon

g c

hil

dre

n a

nd a

dole

scen

ts a

ge

6 t

o17 y

ears

: p

revale

nce,

am

ounts

, an

d s

ourc

es,

19

77

/19

78 t

o 1

994

/19

98.J

Am

Die

t

Ass

oc

20

03

.10

3L

13

26

-13

31

,

7.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r E

ner

gy,

Ca

rbo

hyd

rate

, F

iber

, F

at,

Fa

tty

Aci

ds,

Ch

ole

ster

ol,

Pro

tein

, a

nd

Am

ino

Aci

ds.

Was

hin

gto

n, D

C:

Nat

ion

al A

cad

em

y P

ress

; 2

00

2.

8.

Tef

f K

L,

Ell

iott

SS

, T

sch

öp

M,

Kie

ffer

TJ,

Rad

er D

, H

eim

an M

, T

ow

nse

nd

RR

, K

eim

NL

, D

’Ale

ssio

D,

Hav

el P

J. D

ieta

ry f

ruct

ose

red

uce

s ci

rcu

lati

ng

in

suli

n a

nd

lep

tin,

atte

nu

ates

po

stp

ran

dia

l

sup

pre

ssio

n o

f ghre

lin

, an

d i

ncr

ease

s tr

igly

ceri

des

in w

om

en.J

Cli

n E

nd

ocr

ino

l M

eta

.b2

00

4;8

9:2

96

3-2

97

2.

9.

The

Exp

ert

Co

mm

itte

e on t

he

Dia

gn

osi

s and C

lass

ific

atio

n o

f D

iab

etes

Mel

litu

s. D

iagno

sis

and c

lass

ific

atio

n o

f dia

bet

es m

elli

tus.

Dia

bet

es C

are

. 2

00

4;2

7:p

S5

-pS

10

.

INTA

KE

DO

MA

IN C

arbohyd

rate

and F

iber

Inta

ke

INC

ON

SIS

TE

NT

CA

RB

OH

YD

RA

TE

IN

TA

KE

(N

I-5

3.4

)

Edit

ion:

20

06

86

De

fin

itio

n

Inco

nsi

sten

t ti

min

g o

f ca

rboh

ydra

te i

nta

ke

thro

ughout

the

day

, day-

to-d

ay,

or

a pat

tern

of

carb

oh

ydra

te i

nta

ke

that

is

not

con

sist

ent

wit

h r

ecom

men

ded

pat

tern

bas

ed u

pon p

hys

iolo

gic

or

med

icat

ion n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses

requir

ing c

aref

ul

tim

ing a

nd c

on

sist

ency

in t

he

amount

of

carb

oh

ydra

te, e.

g., d

iabet

es m

elli

tus,

hyp

ogly

cem

ia

•C

ult

ura

l, r

elig

ious

pra

ctic

es,

or

life

styl

e fa

ctors

th

at i

nte

rfer

e w

ith t

he

abil

ity to r

egula

te t

imin

g o

f ca

rboh

ydra

te c

on

sum

pti

on

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledge

defi

cit,

e.g

., i

nab

ilit

y to a

cces

s su

ffic

ien

t in

form

atio

n c

on

cern

ing m

ore

ap

pro

pri

ate

tim

ing o

f ca

rboh

ydra

te i

nta

ke

•F

ood a

nd n

utr

itio

n c

om

pli

ance

lim

itat

ion

s, e

.g., l

ack o

f w

illi

ngn

ess

or

fail

ure

to m

odif

y c

arboh

ydra

te t

imin

g i

n r

espon

se to r

ecom

men

dat

ion

s fr

om

a

die

titi

an,

ph

ysic

ian

, or

care

giv

er

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r dis

ord

ered

eat

ing

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nu

trit

ion

Assessm

en

t C

ate

go

ry

Po

ten

tial In

dic

ato

rs o

f th

is N

utr

itio

n D

iag

no

sis

(o

ne o

r m

ore

mu

st

be p

resen

t)

Bio

chem

ical

Data

•H

yp

ogly

cem

ia o

r hyper

gly

cem

ia d

ocu

men

ted o

n r

egula

r bas

is a

ssoci

ate

d w

ith i

nco

nsi

sten

t ca

rboh

ydra

te i

nta

ke

•W

ide

var

iati

on

s in

blo

od g

luco

se l

evel

s

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

inati

on F

indin

gs

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•E

conom

ic c

on

stra

ints

that

lim

it a

vai

labil

ity o

f ap

pro

pri

ate

foods

•C

arboh

ydra

te i

nta

ke

that

is

dif

fere

nt

from

rec

om

men

ded

types

or

inges

ted o

n a

n i

rreg

ula

r bas

is

INTA

KE

DO

MA

IN C

arbohyd

rate

and F

iber

Inta

ke

INC

ON

SIS

TE

NT

CA

RB

OH

YD

RA

TE

IN

TA

KE

(N

I-5

3.4

)

Edit

ion:

20

06

87

Cli

ent

His

tory

•C

ondit

ion

s as

soci

ate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., d

iabet

es m

elli

tus,

obes

ity,

met

aboli

c sy

ndro

me,

hyp

ogly

cem

ia

•U

se o

f in

suli

n o

r in

suli

n s

ecre

tagogues

•C

hro

nic

use

of

med

icati

on

s th

at c

ause

alt

ered

glu

cose

level

s, e

.g., s

tero

ids,

anti

dep

ress

ants

, an

tip

sych

oti

cs

Refe

ren

ces:

1.

Bo

wm

an B

A,

Ru

ssel

l R

M.

Pre

sen

t K

no

wle

dg

e in

Nu

trit

ion

.8

th e

d. W

ash

ing

ton, D

C: IL

SI

Pre

ss;2

00

1.

2.

Cle

men

t S

, B

rait

hw

aite

SS

, M

agee

MF

, A

hm

an

n A

, S

mit

h E

P, S

chafe

r R

G, H

irsc

h I

B,

Am

eric

an D

iab

etes

Ass

oci

atio

n D

iab

etes

in

Ho

spit

als

Wri

tin

g C

om

mit

tee.

Man

agem

ent

of

dia

bet

es i

n

hosp

itals

.D

iab

etes

Ca

re. 2

00

4;2

7:5

53

-59

2.

3.

Cry

er P

E,

Dav

is S

N,

Sham

oon H

. T

echnic

al r

evie

w.

Hypogly

cem

ia i

n d

iabete

s.D

iab

etes

Ca

re.2

00

3;2

6:1

90

2-1

91

2.

4.

Fra

nz

MJ,

Ban

tle

JP, B

eeb

e C

A,

Bru

nze

ll J

D,

Chia

sso

n J

-L,

Gar

g A

, H

olz

mei

ster

LA

, H

oo

gw

erf

B,

May

er-D

avis

E,

Mo

ora

dia

n A

D,

Pu

rnel

l JQ

, W

hee

ler

M.

Tec

hn

ical

rev

iew

. E

vid

ence

-base

d

nutr

itio

n p

rinci

ple

s an

d r

ecom

men

dat

ions

for

the

trea

tmen

t an

d p

reven

tion o

f dia

bet

es a

nd r

elat

ed c

om

pli

cati

ons.

Dia

bet

es C

are

.2

00

2;2

02

:14

8-1

98

.

5.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r E

ner

gy,

Ca

rbo

hyd

rate

, F

iber

, F

at,

Fa

tty

Aci

ds,

Ch

ole

ster

ol,

Pro

tein

, a

nd

Am

ino

Aci

ds.

Was

hin

gto

n, D

C:

Nat

ion

al A

cad

em

y P

ress

; 2

00

2.

6.

Rab

asa-L

hore

t R

, G

aron J

, L

angel

ier

H,

Pois

son D

, C

hia

sson J

-L:

The

effe

cts

of

mea

l ca

rboh

ydra

te c

onte

nt

on i

nsu

lin r

equir

emen

ts i

n t

yp

e 1 p

atie

nts

wit

h d

iabet

es t

reat

ed i

nte

nsi

vel

y w

ith t

he

bas

al b

olu

s (u

ltra

lente

-reg

ula

r) i

nsu

lin r

egim

en.D

iab

etes

Ca

re1

99

9;2

2:6

67-6

73

.

7.

Sav

oca

MR

, M

ille

r C

K,

Lu

dw

ig D

A.

Foo

d h

abit

s ar

e re

late

d t

o g

lyce

mic

co

ntr

ol

am

on

g p

eop

le w

ith

ty

pe

2 d

iab

etes

mel

litu

s.J

Am

Die

t A

sso

c.2

00

4;1

04

:56

0-5

66

.

8.

The

Exp

ert

Co

mm

itte

e on t

he

Dia

gn

osi

s and C

lass

ific

atio

n o

f D

iab

etes

Mel

litu

s. D

iagno

sis

and c

lass

ific

atio

n o

f dia

bet

es m

elli

tus.

Dia

bet

es C

are

. 2

00

4;2

7:S

5-S

10

.

9.

Wole

ver

TM

S, H

am

ad S

, C

hia

sson

J-L

, Jo

sse

RG

, L

eite

r L

A,

Ro

dg

er N

W,

Ro

ss S

A,

Ryan

EA

. D

ay

-to

-day

con

sist

ency

in

am

ou

nt

and

sou

rce

of

carb

oh

ydra

te i

nta

ke

ass

oci

ated

wit

h i

mpro

ved

glu

cose

contr

ol

in t

yp

e 1 d

iabet

es.

J A

m C

oll

Nu

tr.1

99

9;1

8:2

42

-24

7.

INTA

KE

DO

MA

IN C

arbohyd

rate

and F

iber

Inta

ke

INA

DE

QU

AT

E F

IBE

R I

NT

AK

E (

NI-

53

.5)

Edit

ion:

20

06

88

De

fin

itio

n

Low

er i

nta

ke

of

fiber

-con

tain

ing f

oods

or

subst

ance

s co

mp

ared

to e

stabli

shed

ref

eren

ce s

tand

ards

or

reco

mm

endat

ion

s bas

ed u

pon p

hys

iolo

gic

al

nee

ds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•L

ack o

f ac

ces

s to

fib

er-c

onta

inin

g f

oods

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r dis

ord

ered

eat

ing

•P

rolo

nged

adh

eren

ce to a

low

-fib

er o

r lo

w-r

esid

ue

die

t

•D

iffi

cult

y c

hew

ing o

r sw

allo

win

g h

igh-f

iber

foods

•E

conom

ic c

on

stra

ints

that

lim

it a

vai

labil

ity o

f ap

pro

pri

ate

foods

•In

abil

ity o

r un

wil

lingn

ess

to p

urc

hase

or

con

sum

e fi

ber

-con

tain

ing f

oods

•In

appro

pri

ate

food p

repar

atio

n p

ract

ices

, e.

g., r

elia

nce

on o

ver

pro

cess

ed,

over

cooked

foods

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

inati

on F

indin

gs

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•In

suff

icie

nt

inta

ke

of

fib

er w

hen

com

par

ed t

o r

ecom

men

ded

am

oun

ts (

38 g

/day

for

men

an

d 2

5 g

/day

for

wom

en;

21

g/d

for

wom

en >

50 y

ears

an

d 3

1 g

/d f

or

men

>5

0 y

ears

)

INTA

KE

DO

MA

IN C

arbohyd

rate

and F

iber

Inta

ke

INA

DE

QU

AT

E F

IBE

R I

NT

AK

E (

NI-

53

.5)

Edit

ion:

20

06

89

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., u

lcer

dis

ease

, in

flam

mat

ory

bow

el d

isea

se,

or

shor

t bow

el

syn

dro

me

trea

ted w

ith a

low

-fib

er d

iet

•L

ow

sto

ol

volu

me

Refe

ren

ces:

1.

DiP

alm

a JA

. C

urr

ent

trea

tmen

t opti

on

s fo

r ch

ronic

const

ipat

ion.

Rev

Ga

stro

ente

rol

Dis

ord

. 2

00

4;2

:S3

4-S

42

.

2.

Hig

gin

s P

D, Jo

hanso

n J

F.

Epid

emio

logy o

f co

nst

ipat

ion i

n N

ort

h A

mer

ica:

a s

yst

emat

ic r

evie

w.

Am

J G

ast

roen

tero

l. 2

00

4;9

9:7

50

-75

9.

3.

Lem

bo

A,

Cam

ilie

ri M

. C

hro

nic

co

nst

ipat

ion

.N

ew

En

gl

J M

ed. 2

00

3;3

49

:36

0-3

68

.

4.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r E

ner

gy,

Ca

rbo

hyd

rate

, F

iber

, F

at,

Fa

tty

Aci

ds,

Ch

ole

ster

ol,

Pro

tein

, a

nd

Am

ino

Aci

ds.

Wash

ingto

n, D

C:

Nat

ion

al A

cad

em

y P

ress

; 2

00

2.

5.

Tal

ley N

J. D

efin

itio

n,

epid

em

iolo

gy,

and i

mpact

of

chro

nic

co

nst

ipat

ion.

Rev

Ga

stro

ente

rol

Dis

ord

. 2

00

4;2

:S3

-S1

0.

INTA

KE

DO

MA

IN C

arbohyd

rate

and F

iber

Inta

ke

EX

CE

SS

IVE

FIB

ER

IN

TA

KE

(N

I-5

3.6

)

Edit

ion:

20

06

90

De

fin

itio

n

Hig

her

inta

ke

of

fiber

-con

tain

ing f

oods

or

subst

ance

s co

mp

ared

to r

ecom

men

dat

ion

s bas

ed u

pon p

atie

nt/

clie

nt

con

dit

ion

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledge

defi

cit

about

des

irable

quan

titi

es o

f fi

ber

for

indiv

idual

con

dit

ion

•H

arm

ful

bel

iefs

or

atti

tudes

about

food o

r n

utr

itio

n-r

elat

ed t

opic

s, e

.g., o

bse

ssio

n w

ith b

ow

el f

requen

cy a

nd h

abit

s

•L

ack o

f kn

ow

ledg

e ab

out

appro

pri

ate

fiber

inta

ke

for

con

dit

ion

•P

oor

den

titi

on,

GI

stri

cture

or

dys

moti

lity

•F

ood p

repar

atio

n o

r ea

ting p

atte

rns

that

in

volv

e only

hig

h-f

iber

foods

to t

he

excl

usi

on o

f oth

er n

utr

ien

t-den

se f

oods

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

inati

on F

indin

gs

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•F

iber

inta

ke

hig

her

than

tole

rate

d o

r gen

eral

ly r

ecom

men

ded

for

curr

ent

med

ical

con

dit

ion

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t, e

.g., u

lcer

dis

ease

, ir

rita

ble

bow

el s

yndro

me,

in

flam

mato

ry b

ow

el

dis

ease

, sh

ort

bow

el s

yndro

me,

div

erti

culi

tis,

obst

ruct

ive

con

stip

atio

n, pro

lapsi

ng h

emorr

hoid

s, g

astr

oin

test

inal

stri

cture

, ea

ting d

isord

ers,

or

men

tal

illn

ess

wit

h o

bse

ssiv

e-co

mpuls

ive

ten

den

cies

•N

ause

a, v

om

itin

g,

exce

ssiv

e fl

atu

len

ce,

dia

rrh

ea,

abdom

inal cr

ampin

g, h

igh s

tool

volu

me

or

freq

uen

cy that

cause

s

dis

com

fort

to t

he

indiv

idual

, obst

ruct

ion

, ph

yto

bez

oar

INTA

KE

DO

MA

IN C

arbohyd

rate

and F

iber

Inta

ke

EX

CE

SS

IVE

FIB

ER

IN

TA

KE

(N

I-5

3.6

)

Edit

ion:

20

06

91

Refe

ren

ces:

1.

DiP

alm

a JA

. C

urr

ent

trea

tmen

t opti

on

s fo

r ch

ronic

const

ipat

ion.

Rev

Ga

stro

ente

rol

Dis

ord

. 2

00

4;2

:S3

4-S

42

.

2.

Hig

gin

s P

D, Jo

hanso

n J

F.

Epid

emio

logy o

f co

nst

ipat

ion i

n N

ort

h A

mer

ica:

a s

yst

emat

ic r

evie

w.

Am

J G

ast

roen

tero

l. 2

00

4;9

9:7

50

-75

9.

3.

Lem

bo

A,

Cam

ilie

ri M

. C

hro

nic

co

nst

ipat

ion

.N

ew

En

gl

J M

ed. 2

00

3;3

49

:36

0-3

68

.

4.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r E

ner

gy,

Ca

rbo

hyd

rate

, F

iber

, F

at,

Fa

tty

Aci

ds,

Ch

ole

ster

ol,

Pro

tein

, a

nd

Am

ino

Aci

ds.

Was

hin

gto

n, D

C:

Nat

ion

al A

cad

em

y P

ress

; 2

00

2.

5.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Hea

lth i

mpli

cati

on

s of

die

tary

fib

er.

J A

m D

iet

Ass

oc.

20

02

;10

2:9

93

-10

00

.

6.

Tal

ley N

J. D

efin

itio

n,

epid

em

iolo

gy,

and i

mpact

of

chro

nic

co

nst

ipat

ion.

Rev

Ga

stro

ente

rol

Dis

ord

. 2

00

4;2

:S3

-S1

0.

7.

van

den B

erg H

, van d

er G

aag

M, H

endri

ks

H. In

flu

ence

of

life

style

on v

itam

in b

ioav

ail

abil

ity.In

t J

Vit

am

Nu

tr R

es. 2

00

2;7

2:5

3-5

5.

8.

Wal

d A

. Ir

rita

ble

bow

el s

yndro

me.

Cu

rr T

rea

t O

pti

on

s G

ast

roen

tero

l. 1

99

9;2

:13

-19

.

INTA

KE

DO

MA

IN V

itam

in In

take

INA

DE

QU

AT

E V

ITA

MIN

IN

TA

KE

(SP

EC

IFY

)(N

I-5

4.1

)

Edit

ion:

20

06

92

De

fin

itio

n

Low

er i

nta

ke

of

vit

am

in-c

onta

inin

g f

oods

or

subst

ance

s co

mp

ared

to e

stabli

shed

ref

eren

ce s

tan

dar

ds

or

reco

mm

endat

ion

s bas

ed u

pon p

hysi

olo

gic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses,

e.g

., i

ncr

ease

d n

utr

ien

t n

eeds

due

to p

rolo

nged

cat

aboli

c il

lnes

s, d

isea

se s

tate

, m

alab

sorp

tion,

or

med

icat

ion

s

•L

ack o

f ac

cess

to f

ood,

e.g

., e

con

om

ic c

on

stra

ints

, cu

ltura

l or

reli

gio

us

pra

ctic

es, re

stri

ctin

g f

ood g

iven

to e

lder

ly a

nd/o

r ch

ildre

n

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

con

cern

ing f

ood s

ourc

es o

f vit

am

ins

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r ea

ting d

isord

ers

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

INTA

KE

DO

MA

IN V

itam

in In

take

INA

DE

QU

AT

E V

ITA

MIN

IN

TA

KE

(SP

EC

IFY

)(N

I-5

4.1

)

Edit

ion:

20

06

93

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)*

Bio

chem

ical

Data

•V

itam

in A

: se

rum

ret

inol:

<

10

g/d

L (

0.3

5

mol/

L)

•V

itam

in C

: p

lasm

a co

nce

ntr

atio

ns

< 0

.2 m

g/d

L (

11.4

m

ol/

L)

•V

itam

in D

: io

niz

ed c

alci

um

< 3

.9 m

g/d

L (

0.9

8 m

mol/

L)

wit

h e

levat

ed p

arat

hyr

oid

horm

on

e, n

orm

al s

erum

cal

cium

, an

d

seru

m p

hosp

hor

us

< 2

.6 m

g/d

L (

0.8

4 m

mol/

L)

•V

itam

in E

: pla

sma

alpha-

toco

pher

ol

< 1

8

mol/

g (

41.8

m

ol/

L)

•V

itam

in K

: el

evat

ed p

roth

rom

bin

tim

e; a

lter

ed I

NR

(w

ith

out

anti

-coag

ula

tion t

her

apy)

•T

hia

min

: er

yth

rocy

te t

ran

sket

ola

se a

ctiv

ity >

1.2

0 µ

g/m

L/h

•R

ibo

flavin

– e

ryth

rocy

te g

luta

thio

ne

reduct

ase

> 1

.2 I

U/g

m h

emoglo

bin

•N

iaci

n:

N’m

ethyl-

nic

oti

nam

ide

excr

etio

n <

5.8

µm

ol/

day

•V

itam

in B

6:

pla

sma

pry

rdoxal

5’p

hosp

hat

e <

5 n

g/m

L (

20 n

mol/

L)

•V

itam

in B

12:

seru

m c

on

centr

atio

n <

24.4

ng/d

L (

180 p

mol/

L);

ele

vat

ed h

om

ocy

stei

ne

•F

oli

c ac

id:

seru

m c

on

centr

atio

n <

0.3

g/d

L (

7 n

mol/

L);

red

cel

l fo

late

< 3

15 n

mol/

L

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

•V

itam

in A

: nig

ht

bli

ndn

ess,

Bit

ot’

s sp

ots

, xer

opth

alm

ia,

foll

icula

r h

yper

ker

atosi

s

•V

itam

in C

: fo

llic

ula

r h

yper

ker

atosi

s, p

etic

hia

e, e

cch

ymosi

s, c

oil

ed h

airs

, in

flam

ed a

nd b

leed

ing g

um

s, p

erif

oli

cula

r

hem

orr

hag

es,

join

t ef

fusi

ons,

art

hra

lgia

, an

d i

mpai

red w

oun

d h

eali

ng

•V

itam

in D

: w

iden

ing a

t en

ds

of

lon

g b

on

es, ra

chit

ic r

osa

ry i

n c

hil

dre

n,

rick

ets,

ost

eom

ala

cia

•R

ibofl

avin

: so

re t

hro

at, h

yper

emia

, ed

ema

of

phar

yngea

l an

d o

ral

mu

cous

mem

bra

nes

, ch

eilo

sis,

angula

r st

om

ati

tis,

glo

ssit

is, se

borr

hei

c der

mat

itis

, an

d n

orm

och

rom

ic, n

orm

ocy

tic

anem

ia w

ith p

ure

ery

thro

cyte

cyto

pla

sia

of

the

bon

e

mar

row

•N

iaci

n:

sym

met

rica

l, p

igm

ente

d r

ash o

n a

reas

expose

d t

o s

unli

ght,

bri

gh

t re

d t

on

gue,

pel

lagra

•V

itam

in B

6:

seborr

hei

c der

mat

itis

, st

om

atit

is,

chei

losi

s, g

loss

itis

, co

nfu

sion

, dep

ress

ion

•V

itam

in B

12:

tingli

ng a

nd n

um

bn

ess

in e

xtr

emit

ies,

dim

inis

hed

vib

rato

ry a

nd p

osi

tion s

ense

, m

oto

r dis

turb

ance

s in

cludin

g

gait

dis

turb

ance

s

* T

o c

onver

t co

nv

enti

onal

unit

s to

le S

yste

me

Inte

rna

tio

na

le d

'Un

ites

(S

I),

Jays

Cli

nic

al

Ser

vic

es,

Cli

nic

al L

ab

ora

tory

So

ftw

are

and

Co

nsu

ltin

g w

eb

sit

e u

sed

. W

eb

sit

e a

ddre

ss:

htt

p:/

/dw

jay.t

ripod.c

om

/conv

ersi

on

.htm

l .

Acc

esse

d A

ugust

12,

200

5.

See

Young D

S (

Refe

rence

#5

) fo

r pri

nte

d f

act

or

conv

ersi

on

s.

INTA

KE

DO

MA

IN V

itam

in In

take

INA

DE

QU

AT

E V

ITA

MIN

IN

TA

KE

(SP

EC

IFY

)(N

I-5

4.1

)

Edit

ion:

20

06

94

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•D

ieta

ry h

isto

ry r

efle

cts

inadeq

uat

e in

take

of

foods

con

tain

ing s

pec

ific

vit

amin

s as

com

par

ed t

o r

equir

emen

ts o

r

reco

mm

ended

lev

el

•D

ieta

ry h

isto

ry r

efle

cts

exce

ssiv

e co

nsu

mp

tion o

f fo

ods

that do n

ot

conta

in a

vai

lable

vit

amin

s, e

.g., o

ver

pro

cess

ed,

over

cooked

, or

impro

per

ly s

tore

d f

oods

Cli

ent

His

tory

•P

rolo

nged

use

of

subst

ance

s know

n t

o i

ncr

ease

vit

amin

req

uir

emen

ts o

r re

duce

vit

am

in a

bso

rpti

on

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t, e

.g., m

alab

sorp

tion a

s a

resu

lt o

f ce

liac

dis

ease

, sh

ort

bow

el s

yndro

me,

or

infl

amm

atory

bow

el

•C

erta

in e

nvir

onm

enta

l co

ndit

ion

s, e

.g., i

nfa

nts

excl

usi

vel

y f

ed b

reas

t m

ilk w

ith l

imit

ed e

xposu

re t

o s

un

light

(vit

amin

D)

Refe

ren

ces:

1.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r V

ita

min

A,

Vit

am

in K

, A

rsen

ic, B

oro

n, C

hro

miu

m, C

op

per

, Io

din

e, I

ron

, M

an

ga

nes

e, M

oly

bd

enu

m, N

icke

l,

Sil

ico

n,

Va

na

diu

m, a

nd

Zin

c. W

ashin

gto

n, D

C:

Nat

ional

Aca

dem

y P

ress

; 2

00

0.

2.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r T

hia

min

e, R

ibo

fla

vin

, N

iaci

n,

Vit

am

in B

6,

Fo

late

, V

ita

min

B1

2,

Pa

nto

then

ic A

cid

, B

ioti

n, a

nd

Ch

oli

ne

Was

hin

gto

n,

DC

: N

atio

nal

Aca

dem

y P

ress

; 2

00

0.

3.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r V

ita

min

C,

Vit

am

in E

, S

elen

ium

, a

nd

Ca

rote

no

ids.

Was

hin

gto

n,

DC

: N

atio

nal

Aca

dem

y P

ress

; 2

00

0.

4.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

Inta

kes

for

Ca

lciu

m,

Ph

osp

ho

rus,

Ma

gn

esiu

m, V

ita

min

D, a

nd

Flu

ori

de. W

ash

ing

ton

, D

C:

Nat

ional

Aca

dem

y P

ress

; 1

99

7.

5.

Youn

g D

S. Im

ple

men

tati

on o

f S

I unit

s fo

r cl

inic

al l

abora

tory

dat

a,

style

sp

ecif

icat

ion

s and c

onver

sio

n t

able

s.A

nn

In

tern

Med

. 1

98

7;1

06

:11

4-2

9. R

epri

nte

d,J

Nu

tr. 1

99

0;1

20

:20

-35

.

INTA

KE

DO

MA

IN V

itam

in In

take

EX

CE

SS

IVE

VIT

AM

IN I

NT

AK

E(S

PE

CIF

Y)

(NI-

54

.2)

Edit

ion:

20

06

95

De

fin

itio

n

Hig

her

inta

ke

of

vit

am

in-c

onta

inin

g f

oods

or

subst

ance

s co

mp

ared

to e

stabli

shed

ref

eren

ce s

tan

dar

ds

or

reco

mm

endat

ion

s bas

ed u

pon p

hysi

olo

gic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses,

e.g

., d

ecre

ased

nutr

ien

t n

eeds

due

to p

rolo

nged

im

mobil

ity o

r ch

ronic

ren

al d

isea

se

•A

cces

s to

foods

and s

upple

men

ts i

n e

xce

ss o

f n

eeds,

e.g

., c

ult

ura

l or

rel

igio

us

pra

ctic

es,

inap

pro

pri

ate

food a

nd s

upple

men

ts g

iven

to p

regnan

t w

om

en,

elder

ly o

r ch

ildre

n

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledge

defi

cit

con

cern

ing f

ood a

nd s

upple

men

tal

sourc

es o

f vit

am

ins

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r ea

ting d

isord

ers

•A

ccid

enta

l over

dose

fro

m o

ral

and s

upple

men

tal

form

s, e

nte

ral

or

par

ente

ral

sourc

es

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)*

Bio

chem

ical

Data

•V

itam

in D

: io

niz

ed c

alci

um

> 5

.4 m

g/d

L (

1.3

5 m

mol/

L)

wit

h e

levat

ed p

arat

hyr

oid

horm

on

e, n

orm

al s

erum

cal

cium

, an

d

seru

m p

hosp

hor

us

> 2

.6 m

g/d

L (

0.8

4 m

mol/

L)

•V

itam

in K

: sl

ow

ed p

roth

rom

bin

tim

e or

alt

ered

IN

R

•N

iaci

n:

N-m

ethyl

nic

oti

nam

ide

excr

etio

n >

5.8

µm

ol/

day

•V

itam

in B

6:

pla

sma

pyr

idoxal

5’p

hosp

hat

e >

5 ng/m

L (

20 n

mol/

L)

•V

itam

in A

: se

rum

ret

inol

con

cen

trat

ion >

60 µ

g/d

L (

2.0

9µ

mol/

L)

Anth

ropom

etri

c M

easu

rem

ents

* T

o c

onver

t co

nv

enti

onal

unit

s to

le S

yste

me

Inte

rna

tio

na

le d

'Un

ites

(S

I),

Jays

Cli

nic

al

Ser

vic

es,

Cli

nic

al L

ab

ora

tory

So

ftw

are

and

Co

nsu

ltin

g w

eb

sit

e u

sed

. W

eb

sit

e a

ddre

ss:

htt

p:/

/dw

jay.t

ripod.c

om

/conv

ersi

on

.htm

l .

Acc

esse

d A

ugust

12,

200

5.

See

Young D

S (

Refe

rence

#8

) fo

r pri

nte

d f

act

or

conv

ersi

on

s.

INTA

KE

DO

MA

IN V

itam

in In

take

EX

CE

SS

IVE

VIT

AM

IN I

NT

AK

E(S

PE

CIF

Y)

(NI-

54

.2)

Edit

ion:

20

06

96

Phys

ical

Exam

Fin

din

gs

•V

itam

in A

: ch

anges

in t

he

skin

an

d m

uco

us

mem

bra

nes

; dry

lip

s (c

hei

liti

s),

earl

y-d

ryn

ess

of

the

nas

al m

uco

sa a

nd e

yes;

late

r-dry

nes

s, e

ryth

ema,

sca

ling a

nd p

eeli

ng o

f th

e sk

in,

hai

r lo

ss,

and n

ail

frag

ilit

y. H

eadac

he,

nau

sea,

and v

om

itin

g.

Infa

nts

may

hav

e bulg

ing f

on

tan

elle

; ch

ildre

n m

ay d

evel

op b

one

alte

rati

ons.

•V

itam

in D

: el

evat

ed s

erum

cal

cium

(h

yper

calc

emia

) an

d p

hosp

horu

s (h

yper

ph

osp

hat

emia

) le

vel

s;

calc

ific

atio

n o

f so

ft

tiss

ues

(ca

lcin

osi

s),

incl

udin

g t

he

kid

ney

, lu

ngs,

hea

rt, an

d e

ven

th

e ty

mp

anic

mem

bra

ne

of

the

ear,

whic

h c

an r

esult

in

dea

fnes

s. H

eadach

e an

d n

ause

a. I

nfa

nts

giv

en e

xce

ssiv

e am

ounts

of

vit

amin

D m

ay h

ave

gast

roin

test

inal

upse

t, b

on

e

fragil

ity,

an

d r

etar

ded

gro

wth

.

•V

itam

in K

: h

emoly

tic

anem

ia i

n a

dult

s or

sever

jau

ndic

e in

in

fan

ts h

ave

bee

n n

ote

d o

n r

are

occ

asio

ns

•N

iaci

n:

his

tam

ine

rele

ase

wh

ich c

ause

s fl

ush

ing, ag

gra

vat

ion o

f as

thm

a or

liver

dis

ease

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•H

isto

ry o

r m

easu

red i

nta

ke

refl

ects

exce

ssiv

e in

take

of

foods

and s

upple

men

ts c

onta

inin

g v

itam

ins

as c

om

par

ed t

o

esti

mat

ed r

equir

emen

ts, in

cludin

g f

ort

ifie

d c

erea

ls,

mea

l re

pla

cem

ents

, vit

amin

-min

eral

supple

men

ts,

oth

er d

ieta

ry

supple

men

ts (

e.g

., f

ish l

iver

oil

s or

capsu

les)

, tu

be

feed

ing,

and/o

r par

ente

ral

solu

tions

•In

tak

e >

Tole

rable

Upper

Lim

its

(UL

) fo

r vit

amin

A (

as r

etin

ol

este

r, n

ot

as

-car

ote

ne)

is

600 µ

g/d

for

infa

nts

and

toddle

rs;

900 µ

g/d

for

chil

dre

n 4

-8 y

rs, 1,7

00 µ

g/d

for

chil

dre

n 9

-13 y

rs, 2,8

00 µ

g/d

for

chil

dre

n 1

4-1

8 y

rs, an

d 3

,000 µ

g/d

for

adult

s

•In

take

gre

ater

than

UL

for

vit

amin

D is

25 µ

g/d

ay f

or

infa

nts

and 5

0 µ

g/d

ay f

or

chil

dre

n a

nd a

dult

s

•N

iaci

n:

clin

ical

, h

igh-d

ose

nia

cinam

ide

(NA

) use

of

1 t

o 2

g,

thre

e ti

mes

per

day

can

hav

e si

de

effe

cts

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t, e

.g., c

hro

nic

liv

er o

r kid

ney

dis

ease

s, h

eart

fai

lure

, ca

nce

r

Refe

ren

ces:

1.

All

en L

H, H

ask

ell

M. E

stim

atin

g t

he

po

tenti

al f

or

vit

am

in A

to

xic

ity

in

wo

men

an

d y

ou

ng

ch

ild

ren.

J N

utr

. 2

00

2;1

32

:S2

90

7-S

29

19

.

2.

Cro

qu

et V

, P

ilet

te C

, L

espin

e A

, V

uil

lem

in E

, R

ou

ssel

et M

C, O

ber

ti F

, S

ain

t A

nd

re J

P,

Per

iqu

et B

, F

ran

cois

S, If

rah

N,

Cal

es P

. H

epat

ic h

yp

er-v

itam

ino

sis

A:

imp

ort

ance

of

reti

ny

l es

ter

lev

el

det

erm

inati

on.

Eu

r J

Ga

stro

ente

rol

Hep

ato

l. 2

00

0;1

2:3

61

-36

4.

3.

Kra

sin

ski

SD

, R

uss

ell

RM

, O

trad

ov

ec C

L,

Sado

wsk

i JA

, H

artz

S

C, Ja

cob

RA

, M

cGand

y R

B.

Rel

atio

nsh

ip o

f vit

amin

A a

nd

vit

amin

E i

nta

ke

to f

ast

ing

pla

sma

reti

no

l, r

etin

ol-

bin

din

g p

rote

in,

reti

nyl

este

rs,

caro

ten

e, a

lpha-t

oco

ph

erol,

an

d c

hole

ster

ol

am

ong e

lderl

y p

eople

and y

oung a

dult

s: i

ncr

ease

d p

lasm

a re

tin

yl

este

rs a

mong v

itam

in A

-sup

ple

men

t u

sers

.A

m J

Cli

n N

utr

. 1

98

9;4

9:1

12

-

12

0.

4.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r V

ita

min

A,

Vit

am

in K

, A

rsen

ic, B

oro

n, C

hro

miu

m, C

op

per

, Io

din

e, I

ron

, M

an

ga

nes

e, M

oly

bd

enu

m, N

icke

l,

Sil

ico

n,

Va

na

diu

m, a

nd

Zin

c. W

ashin

gto

n, D

C:

Nat

ional

Aca

dem

y P

ress

; 2

00

0.

5.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r T

hia

min

e, R

ibo

fla

vin

, N

iaci

n,

Vit

am

in B

6,

Fo

late

, V

ita

min

B1

2,

Pa

nto

then

ic A

cid

, B

ioti

n, a

nd

Ch

oli

ne

Was

hin

gto

n,

DC

: N

atio

nal

Aca

dem

y P

ress

; 2

00

0.

6.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r V

ita

min

C,

Vit

am

in E

, S

elen

ium

, a

nd

Ca

rote

no

ids.

Was

hin

gto

n, D

C:

Nat

ional

Aca

dem

y P

ress

;200

0.

7.

Ru

ssel

l R

M. N

ew v

iew

s o

n R

DA

s fo

r old

er a

du

lts.

J A

m D

iet

Ass

oc.

19

97

;97

:51

5-5

18

.

8.

Youn

g D

S. Im

ple

men

tati

on o

f S

I unit

s fo

r cl

inic

al l

abora

tory

dat

a,

style

sp

ecif

icat

ion

s and c

onver

sio

n t

able

s.A

nn

In

tern

Med

. 1

98

7;1

06

:11

4-2

9. R

epri

nte

d,J

Nu

tr. 1

99

0;1

20

:20

-35

..

INTA

KE

DO

MA

IN M

iner

al I

nta

ke

INA

DE

QU

AT

E M

INE

RA

L I

NT

AK

E(S

PE

CIF

Y)

(NI-

55

.1)

Edit

ion:

20

06

97

De

fin

itio

n

Low

er i

nta

ke

of

min

eral

-conta

inin

g f

oods

or

subst

ance

s co

mp

ared

to e

stabli

shed

ref

eren

ce s

tan

dar

ds

or

reco

mm

endat

ion

s bas

ed u

pon p

hysi

olo

gic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses,

e.g

., i

ncr

ease

d n

utr

ient

nee

ds

due

to p

rolo

nged

cat

aboli

c il

lnes

s, m

alab

sorp

tion, h

yper

excr

etio

n, n

utr

ien

t/dru

g a

nd n

utr

ient/

nutr

ien

t

inte

ract

ion

, gro

wth

an

d m

atura

tion

•L

ack o

f ac

cess

to f

ood,

e.g

., e

con

om

ic c

on

stra

ints

, cu

ltura

l or

reli

gio

us

pra

ctic

es, re

stri

ctin

g f

ood g

iven

to e

lder

ly a

nd/o

r ch

ildre

n

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledge

defi

cit

con

cern

ing f

ood s

ourc

es o

f m

iner

als

; m

isdia

gn

osi

s of

lact

ose

in

tole

ran

ce/l

acta

se d

efic

ien

cy;

per

cepti

on o

f

con

flic

tin

g n

utr

itio

n m

essa

ges

fro

m h

ealt

h p

rofe

ssio

nals

, in

appro

pri

ate

reli

ance

on s

upple

men

ts

•P

sych

olo

gic

al c

ause

s, e

.g., d

epre

ssio

n o

r ea

ting d

isord

ers

•E

nvir

onm

enta

l ca

use

s, e

.g., i

nad

equat

ely tes

ted n

utr

ien

t bio

avai

labil

ity o

f fo

rtif

ied f

oods,

bev

erag

es a

nd s

upple

men

ts,

inap

pro

pri

ate

mar

ket

ing o

f fo

rtif

ied

foods/

bev

erag

es/s

upp

lem

ents

as

a su

bst

itute

for

nat

ura

l fo

od s

ourc

e of

nutr

ien

t(s)

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)*

Bio

chem

ical

Data

•C

alci

um

: bon

e m

iner

al c

on

ten

t (B

MC

) bel

ow

th

e yo

un

g a

dult

mea

n.

Hyp

oca

lciu

ria,

ser

um

25(O

H)D

< 3

2 n

g/m

L

•P

hosp

hor

us

< 2

.6 m

g/d

L (

0.8

4 m

mol/

L)

•M

agnes

ium

< 1

.8 m

g/d

L (

0.7

mm

ol/

L)

•Ir

on:

hem

oglo

bin

< 1

30 g

/L (

mal

es);

< 1

20 g

/L

(fe

male

s)

•Io

din

e: u

rinar

y e

xcr

etio

n <

100 µ

g /

L (

788 n

mol/

L)

•C

opper

: s

erum

copper

< 6

4 µ

g /

dL

(10 µ

mol/

L)

Anth

ropom

etri

c M

easu

rem

ents

•H

eight

loss

* T

o c

onver

t co

nv

enti

onal

unit

s to

le S

yste

me

Inte

rna

tio

na

le d

'Un

ites

(S

I),

Jays

Cli

nic

al

Ser

vic

es,

Cli

nic

al L

ab

ora

tory

So

ftw

are

and

Co

nsu

ltin

g w

eb

sit

e u

sed

. W

eb

sit

e a

ddre

ss:

htt

p:/

/dw

jay.t

ripod.c

om

/conv

ersi

on

.htm

l .

Acc

esse

d A

ugust

12,

200

5.

See

Young D

S (

Refe

rence

#5

) fo

r pri

nte

d f

act

or

conv

ersi

on

s.

INTA

KE

DO

MA

IN M

iner

al I

nta

ke

INA

DE

QU

AT

E M

INE

RA

L I

NT

AK

E(S

PE

CIF

Y)

(NI-

55

.1)

Edit

ion:

20

06

98

Phys

ical

Exam

Fin

din

gs

•C

alc

ium

: dim

inis

hed

bon

e m

iner

al d

ensi

ty,

hyper

ten

sion

, poly

cyst

ic o

var

y s

yndro

me,

pre

men

stru

al s

yndro

me,

kid

ney

stones

, co

lon p

oly

ps,

obes

ity

Food/N

utr

itio

n H

isto

ryO

bse

rvat

ions/

report

s of

insu

ffic

ien

t m

iner

al

inta

ke

from

die

t co

mp

ared

to r

ecom

men

ded

in

take:

•F

ood a

void

ance

and/o

r el

imin

atio

n o

f w

hole

food g

roup(s

) fr

om

die

t

•L

ack o

f in

tere

st i

n f

ood

•In

appro

pri

ate

food c

hoic

es a

nd/o

r ch

ronic

die

tin

g b

ehav

ior

•E

xce

ssiv

e N

a in

take,

inad

equat

e vit

amin

D i

nta

ke/

exposu

re

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t of,

e.g

., m

alabso

rpti

on a

s a

resu

lt o

f ce

liac

dis

ease

, sh

ort

bow

el

syn

dro

me,

or

infl

amm

atory

bow

el d

isea

se

•O

ther

sig

nif

ican

t m

edic

al d

iagn

ose

s an

d t

her

apie

s

•E

stro

gen

sta

tus

•G

eogra

ph

ic l

atit

ude

and h

isto

ry o

f U

VB

exposu

re/u

se o

f su

nsc

reen

•C

han

ge

in l

ivin

g e

nvir

onm

ent/

indep

enden

ce

•U

se o

f popula

r pre

ss/i

nte

rnet

as

sourc

e of

med

ical

an

d/o

r n

utr

itio

n i

nfo

rmat

ion

Refe

ren

ces:

1.

App

el L

J, M

oore

TJ,

Ob

arza

nek

E,

Vo

llm

er W

M,

Sv

etk

ey L

P,

Sac

ks

FM

, B

ray

GA

, V

og

t T

M, C

utl

er J

A,

Win

dhau

ser

MM

, L

in P

-H,

Kar

anja

N.

A c

lin

ical

tri

al o

f th

e ef

fect

s o

f d

ieta

ry p

atte

rns

on

blo

od p

ress

ure

.N

En

gl

J M

ed. 1

99

7;3

36

:11

17

-11

24

.

2.

Hea

ney R

P.

Role

of

die

tary

sodiu

m i

n o

steoporo

sis.

Am

J C

lin

Nu

tr (

in p

ress

) 2

00

5.

3.

Hea

ney R

P.

Nu

trie

nts

, in

tera

ctio

ns,

and f

ood

s. T

he

import

ance

of

sourc

e. I

n:

Burc

khar

dt

P,

Daw

son-H

ughes

B, H

eaney R

P,

eds.

Nu

trit

ion

al

Asp

ects

of

Ost

eop

oro

sis.

2nd e

d. S

an

Die

go

, C

alif

:

Els

evie

r. 2

00

4:6

1-7

6.

4.

Hea

ney,

RP

. N

utr

ients

, in

tera

ctio

ns,

an

d f

oods.

Ser

um

25

-hy

dro

xy

-vit

am

in D

an

d t

he

hea

lth o

f th

e ca

lciu

m e

conom

y.

In B

urc

khar

dt

P,

Daw

son-H

ughes

B, H

eaney

RP

, ed

s.N

utr

itio

na

l A

spec

ts o

f

Ost

eop

oro

sis.

2nd e

d.

San

Die

go

, C

alif

: E

lsev

ier.

20

04

:22

7-2

44

.

5.

Hea

ney

RP

, R

affe

rty

K,

Bie

rman

J. N

ot

all

calc

ium

-fort

ifie

d b

ever

ages

are

equ

al.N

utr

To

da

y. 2

00

5;4

0:3

9-4

1.

6.

Hea

ney R

P,

Do

wel

l M

S, H

ale

CA

, B

endic

h A

. C

alci

um

abso

rpti

on v

arie

s w

ithin

the

refe

ren

ce r

ange

for

seru

m 2

5-h

ydro

xyvit

amin

D.J

Am

Co

ll N

utr

. 2

00

3;2

2:1

42

-14

6.

7.

Hea

ney

RP

, D

ow

ell

MS

, R

affe

rty

K, B

ierm

an J

. B

ioav

aila

bil

ity

of

the

calc

ium

in

fort

ifie

d s

oy

im

itat

ion

mil

k,

wit

h s

om

e o

bse

rvat

ion

s o

n m

eth

od.

Am

J C

lin

Nu

tr.

20

00

;71

:11

66

-11

69

.

8.

Holi

ck M

F.

Fu

nct

ions

of

vit

am

in D

: im

port

ance

for

pre

venti

on o

f co

mm

on c

ancer

s, t

yp

e I

dia

bet

es a

nd h

eart

dis

ease

. In

: B

urc

khar

dt

P, D

aw

son-H

ug

hes

B, H

eaney

RP

, ed

s.N

utr

itio

na

l A

spec

ts o

f

Ost

eop

oro

sis.

2nd e

d.

San

Die

go

, C

alif

: E

lsev

ier;

20

04

:18

1-2

01

.

9.

Mas

sey

LK

, W

hit

ing

SJ.

Die

tary

sal

t, u

rin

ary

cal

ciu

m, an

d b

on

e lo

ss.J

Bo

ne

Min

er R

es.

19

96

;1

1:7

31

-73

6.

10

. S

uar

az F

L,

Savai

ano

D,

Arb

isi

P,

Lev

itt

MD

. T

ole

rance

to

th

e dail

y i

ng

esti

on

of

two

cu

ps

of

mil

k b

y i

nd

ivid

ual

s cl

aim

ing

lac

tose

into

lera

nce

.A

m J

Cli

n N

utr

. 1

99

7;6

5:1

50

2-1

50

6.

11

. T

hys-

Jaco

bs

S,

Do

novan D

, P

apad

op

oulo

s A

, S

arre

l P

. B

ilez

ikia

n J

P.

Vit

am

in D

an

d c

alci

um

dysr

egula

tion i

n t

he

poly

cyst

ic o

var

ian s

yndro

me.

Ste

roid

s. 1

99

9;6

4:4

30

-43

5.

12

. T

hys-

Jacob

s S

, S

tark

ey P

, B

ernst

ein D

, T

ian J

. C

alci

um

car

bonat

e and t

he

pre

men

stru

al s

yn

dro

me:

Eff

ects

on p

rem

enst

rual

and m

enst

rual

sym

pto

mat

olo

gy.

Am

J O

bst

et G

yn

eco

l.1

99

8;1

79

:44

4-

45

2.

13

. Y

oun

g D

S. Im

ple

men

tati

on o

f S

I unit

s fo

r cl

inic

al l

abora

tory

dat

a,

style

sp

ecif

icat

ion

s and c

onver

sion t

able

s.A

nn

In

tern

Med

. 1

98

7;1

06

:11

4-2

9. R

epri

nte

d,J

Nu

tr. 1

99

0;1

20

:20

-35

.

14

. Z

emel

MB

, T

ho

mp

son

W,

Mil

stea

d A

, M

orr

is K

, C

amp

bel

l P

. C

alci

um

an

d d

airy

acc

eler

atio

n o

f w

eig

ht

and

fat

lo

ss d

uri

ng

en

erg

y r

estr

icti

on

in

ob

ese

adu

lts.

Ob

esit

y R

es. 2

00

4;1

2:5

82

-59

0.

INTA

KE

DO

MA

IN M

iner

al I

nta

ke

EX

CE

SS

IVE

MIN

ER

AL

IN

TA

KE

(S

PE

CIF

Y)

(NI-

55

.2)

Edit

ion:

20

06

99

De

fin

itio

n

Hig

her

inta

ke

of

min

eral

fro

m f

oods,

supple

men

ts, m

edic

atio

ns

or

wat

er,

com

par

ed t

o e

stab

lish

ed r

efer

ence

sta

ndar

ds

or

reco

mm

endat

ion

s bas

ed u

pon

ph

ysio

logic

al n

eeds

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•H

arm

ful

bel

iefs

/att

itudes

about

food,

nutr

itio

n,

and n

utr

itio

n-r

elat

ed t

opic

s

•F

ood f

add

ism

•A

ccid

enta

l over

-supp

lem

enta

tion

•O

ver

con

sum

pti

on o

f a

lim

ited

var

iety

of

foods

•L

ack o

f kn

ow

ledg

e ab

out

man

agem

ent

of

dia

gn

ose

d g

enet

ic d

isord

er t

hat

alt

ers

min

eral

hom

eost

asi

s su

ch a

s h

emoch

rom

oto

sis

(iro

n),

Wil

son

’s D

isea

se

(copper

)

•L

ack o

f kn

ow

ledg

e ab

out

man

agem

ent

of

dia

gn

ose

d d

isea

se s

tate

th

at r

equir

es m

iner

al r

estr

icti

on s

uch

as

chole

stati

c li

ver

dis

ease

(co

pper

an

d m

angan

ese)

and r

enal

insu

ffic

ien

cy (

ph

osp

horu

s, m

agn

esiu

m,

pota

ssiu

m)

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

INTA

KE

DO

MA

IN M

iner

al I

nta

ke

EX

CE

SS

IVE

MIN

ER

AL

IN

TA

KE

(S

PE

CIF

Y)

(NI-

55

.2)

Edit

ion:

20

06

10

0

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Chan

ges

in a

ppro

pri

ate

labora

tory

val

ues

, su

ch a

s:

• T

SH

(io

din

e su

pple

men

tati

on)

• H

DL

(zi

nc

supple

men

tati

on)

• s

erum

fer

riti

n a

nd t

ran

sfer

rin s

atura

tion (

iron o

ver

load

)

•H

yper

ph

osp

hat

emia

•H

yper

magnes

emia

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

•H

air

and n

ail

chan

ges

(se

leniu

m)

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•H

igh i

nta

ke

of

foods

or

supple

men

ts c

on

tain

ing m

iner

als

com

par

ed t

o D

RIs

•D

ecre

ased

app

etit

e (z

inc

supple

men

tati

on)

Cli

ent

His

tory

•G

I dis

turb

ance

s (i

ron,

magn

esiu

m,

copper

, z

inc,

sel

eniu

m)

•C

opper

-def

icie

ncy

an

emia

(zi

nc)

•L

iver

dam

age

(copper

, ir

on),

enam

el o

r sk

elet

al f

luoro

sis

(flu

ori

de)

Refe

ren

ces:

1.

Bo

wm

an B

A,

Ru

ssel

l R

M,

eds.

Pre

sen

t K

no

wle

dg

e in

Nu

trit

ion

.8

th e

d. W

ash

ing

ton,

DC

: IL

SI

Pre

ss;

20

01

.

2.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

In

take

s fo

r V

ita

min

A,

Vit

am

in K

, A

rsen

ic, B

oro

n, C

hro

miu

m, C

op

per

, Io

din

e, I

ron

, M

an

ga

nes

e, M

oly

bd

enu

m, N

icke

l,

Sil

ico

n,

Va

na

diu

m, Z

inc.

Was

hin

gto

n,

DC

: N

ati

on

al A

cad

emy

Pre

ss;

20

01

.

3.

Nat

ional

Aca

dem

y o

f S

cien

ces,

Inst

itute

of

Med

icin

e.D

ieta

ry R

efer

ence

Inta

kes

for

Ca

lciu

m,

Ph

osp

ho

rus,

Ma

gn

esiu

m, V

ita

min

D, a

nd

Flu

ori

de. W

ash

ing

ton

, D

C:

Nat

ional

Aca

dem

y P

ress

; 1

99

7.

4.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Foo

d a

nd n

utr

itio

n m

isin

form

atio

n.J

Am

Die

t A

sso

c. 2

00

2;1

02

:260

-26

6.

CLIN

CA

L D

OM

AIN

F

unct

ional

SW

AL

LO

WIN

G D

IFF

ICU

LT

Y (

NC

-1.1

)

Edit

ion:

20

06

10

1

De

fin

itio

n

Impai

red m

ovem

ent

of

food a

nd l

iquid

fro

m t

he

mouth

to t

he

stom

ach

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•M

ech

anic

al c

ause

s, e

.g., i

nfl

amm

atio

n,

surg

ery,

str

ictu

re,

or o

ral,

ph

aryn

gea

l an

d e

sophagea

l tu

mors

•M

oto

r ca

use

s, e

.g., n

euro

logic

al o

r m

usc

ula

r dis

ord

ers,

such

as,

cer

ebra

l pal

sy,

stro

ke,

mult

iple

scl

erosi

s, s

cler

oder

ma,

pre

mat

uri

ty

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

•E

vid

ence

of

deh

ydra

tion,

e.g., d

ry m

uco

us

mem

bra

nes

, poor

skin

turg

or

Food/N

utr

itio

n H

isto

ryO

bse

rvat

ion

s or

report

s of:

•C

ough

ing,

chokin

g,

pro

lon

ged

ch

ewin

g, pouch

ing o

f fo

od,

regurg

itati

on,

faci

al e

xpre

ssio

n c

han

ges

duri

ng e

atin

g,

pro

lon

ged

feed

ing t

ime,

dro

oli

ng, n

ois

y w

et u

pper

air

way

soun

ds,

fee

lin

g o

f “f

ood g

etti

ng s

tuck

,” p

ain w

hil

e sw

allo

win

g

•D

ecre

ased

food i

nta

ke

•A

void

ance

of

foods

•M

ealt

ime

resi

stan

ce

Cli

ent

His

tory

•C

ondit

ion

s as

soci

ate

d w

ith a

dia

gnosi

s or

trea

tmen

t of

dys

ph

agia

, ac

hal

asia

•R

adio

logic

al f

ind

ing

s, e

.g., a

bn

orm

al s

wal

low

ing s

tudie

s

•R

epea

ted u

pper

res

pir

atory

in

fect

ion

s an

d o

r pn

eum

on

ia

Refe

ren

ce:

1.

Bra

un

wal

d E

, F

auci

AS

, K

asp

er D

L,

Hau

ser

SL

, L

on

go

DL

, Ja

mes

on

JL

, ed

s.H

arr

iso

n’s

Pri

nci

ple

s o

f In

tern

al M

edic

ine.1

5th e

d. N

ew Y

ork

, N

Y:

McG

raw

-Hil

l,.2

00

1.

CLIN

CA

L D

OM

AIN

F

unct

ional

CH

EW

ING

(M

AS

TIC

AT

OR

Y)

DIF

FIC

UL

TY

(N

C-1

.2)

Edit

ion:

20

06

10

2

De

fin

itio

n

Impai

red a

bil

ity to b

ite

or

chew

food i

n p

repar

atio

n f

or

swal

low

ing

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•C

ran

iofa

cial

mal

form

atio

ns

•O

ral

surg

ery

•N

euro

mu

scula

r dysf

un

ctio

n

•P

arti

al o

r co

mple

te e

den

tuli

sm

•S

oft

tis

sue

dis

ease

(pri

mar

y o

r ora

l m

anif

esta

tion

s of

a sy

stem

ic d

isea

se)

•X

erost

om

ia

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

•M

issi

ng t

eeth

•A

lter

atio

ns

in c

rania

l n

erves

V,

VII

, IX

, X

, X

II

•D

ry o

r cr

acked

lip

s, t

ongue

•O

ral

lesi

ons

•Im

pai

red t

on

gue

movem

ent

•Il

l-fi

ttin

g d

entu

res

or b

roken

den

ture

s

CLIN

CA

L D

OM

AIN

F

unct

ional

CH

EW

ING

(M

AS

TIC

AT

OR

Y)

DIF

FIC

UL

TY

(N

C-1

.2)

Edit

ion:

20

06

10

3

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•D

ecre

ased

in

take

of

food

•A

lter

atio

ns

in f

ood i

nta

ke

from

usu

al

•D

ecre

ased

inta

ke

or

avoid

ance

of

food d

iffi

cult

to f

orm

into

a b

olu

s, e

.g., n

uts

, w

hole

pie

ces

of

mea

t, p

oult

ry,

fish

, f

ruit

s,veg

etable

s

•A

void

ance

of

foods

of

age-

appro

pri

ate

textu

re

•S

pit

tin

g f

ood o

ut

or

pro

lon

ged

fee

din

g t

ime

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t, e

.g., a

lcoh

oli

sm;

Alz

hei

mer

’s; h

ead, n

eck o

r phar

yngea

l ca

nce

r;,

cere

bra

l pal

sy;

cleft

lip

/pal

ate;

ora

l so

ft t

issu

e in

fect

ion

s (e

.g., c

andid

iasi

s, l

eukopla

kia

); l

ack o

f dev

elopm

enta

l re

adin

ess;

ora

l m

anif

esta

tion

s of

syst

emic

dis

ease

(e.

g., r

heu

mat

oid

art

hri

tis,

lup

us,

Cro

hn

’s d

isea

se,

pen

phig

us

vulg

aris

, H

IV,

dia

bet

es)

•R

ecen

t m

ajo

r ora

l su

rger

y

•W

ired

jaw

•C

hem

oth

erap

y w

ith o

ral

side

effe

cts

•R

adia

tion t

her

apy to o

ral

cavit

y

Refe

ren

ces:

1.

Bai

ley

R,

Led

ikw

e JH

, S

mic

ikla

s-W

rig

ht H

, M

itch

ell

DC

, Je

nse

n G

L.

Per

sist

ent

ora

l h

ealt

h p

rob

lem

s as

soci

ated

wit

h c

om

orb

idit

y a

nd

im

pai

red

die

t qu

alit

y i

n o

lder

ad

ult

s. J

Am

Die

t A

sso

c.

20

04

;10

4:1

27

3-1

27

6.

2.

Mar

tin

WE

. O

ral

hea

lth

in

th

e el

der

ly.

In

: C

her

no

ff R

, ed

..G

eria

tric

Nu

trit

ion

. 2

nd e

d.

Gai

ther

sbu

rg,

Mar

yl:

Asp

en P

ub

lish

ers;

19

99

:10

7-1

69

.

3.

Dorm

enval

V, M

ojo

n P

, B

ud

tz-J

org

ense

n E

. A

sso

ciat

ion

bet

wee

n s

elf-

ass

esse

d m

asti

cato

ry a

bil

ity,

nu

trit

ional

sta

tus

and

sal

ivar

y f

low

rat

e in

ho

spit

aliz

ed e

lder

ly.

Ora

l D

is. 1

99

9;5

:32

-38

.

4.

Hil

debra

nd G

H, D

om

ingu

ez B

L,

Sch

ork

MA

, L

oesc

he

WJ.

Fu

nct

ional

unit

s, c

hew

ing,

swal

low

ing a

nd f

oo

d a

void

ance

am

ong t

he

eld

erly

.J

Pro

sth

et D

en

t. 1

99

7;7

7:5

85

-59

5.

5.

Hir

ano

H,

Ish

iyam

a N

, W

atanab

e I,

Nasu

I.

Mas

tica

tory

abil

ity

in

rel

atio

n t

o o

ral

stat

us

and

gen

eral

hea

lth

in

ag

ing.J

Nu

tr H

ealt

h A

gin

g.

19

99

;3:4

8-5

2.

6.

Hu

hm

ann M

, T

oug

er-D

eck

er R

, B

yham

-Gra

y L

, O

’Sull

ivan

-Mai

llet

J,

Von H

agen S

. C

om

par

ison o

f dysp

hagia

scr

eenin

g b

y a

reg

iste

red d

ieti

tian

in a

cute

str

ok

e pat

ients

to s

pee

ch l

anguag

e

pat

holo

gis

t’s

eval

uati

on

.T

op

Cli

n N

utr

. 2

00

4;1

9:2

39

-24

9.

7.

Kad

em

ani

D, G

lick

M.

Ora

l ulc

erat

ions

in i

ndiv

iduals

infe

cted w

ith h

um

an i

mm

un

odef

icie

ncy v

iru

s: c

linic

al p

rese

nta

tions,

dia

gno

sis,

man

agem

ent

and r

elevan

ce

to d

isea

se p

rogre

ssio

n.

Qu

inte

ssen

ce I

nt.

. 1

99

8;2

9:1

10

3-1

10

8.

8.

Kel

ler

HH

, O

stb

ye

T, B

rig

ht-

See

E. P

redic

tors

of

die

tary

in

tak

e in

Onta

rio

sen

iors

.C

an

J P

ub

lic

Hea

lth

. 1

99

7;8

8:3

03

-30

9.

9.

Kra

ll E

, H

ayes

C, G

arci

a R

. H

ow

den

titi

on

sta

tus

and

mast

icat

ory

fu

nct

ion

aff

ect

nu

trie

nt

inta

ke.

J A

m D

ent

Ass

oc.

19

98

;12

9:1

26

1-1

26

9.

10

. Jo

ship

ura

K, W

ille

tt W

C, D

ougla

ss C

W.

The

impac

t of

eden

tulo

usn

ess

on f

ood a

nd n

utr

ient

inta

ke. J

Am

Den

t A

sso

c. 1

99

6;1

27

:45

9-4

67

.

11

. M

ack

le T

, T

ou

ger

-Dec

ker

R, O

’Su

lliv

an M

aill

et J

, H

oll

and

B. R

egis

tere

d D

ieti

tian

s’ u

se o

f p

hy

sica

l as

sess

men

t p

aram

eter

s in

pra

ctic

e.J

Am

Die

t A

sso

c. 2

00

4;1

03

:16

32

-16

38

.

12

. M

oble

y C

, S

aunder

s M

. O

ral

hea

lth s

cree

nin

g g

uid

elin

es

for

no

nden

tal

hea

lthca

re p

rovid

ers.

J A

m D

iet

Ass

oc.

19

97

;97

:S1

23

-12

6.

13

. M

ors

e, D

. O

ral and

phar

yn

gea

l ca

nce

r. I

n:

To

ug

er-D

eck

er R

, S

iro

is D

, M

ob

ley

C.,

ed

s.N

utr

itio

n a

nd

Ora

l M

edic

ine.

Toto

wa

NJ:

Hu

mana

Pre

ss. 2

00

5.

14

. M

oy

nih

an P

, B

utl

er T

, T

ho

maso

n J

, Je

pso

n N

. N

utr

ien

t in

tak

e in

par

tial

ly d

enta

te p

atie

nts

: th

e ef

fect

of

pro

sth

etic

reh

abil

itat

ion.

J D

ent.

20

00

;28

:55

7-5

63

.

15

. P

osi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

Ora

l hea

lth a

nd n

utr

itio

n.J

Am

Die

t A

sso

c. 2

00

3;1

03

:61

5-6

25

.

16

. S

ayhou

n N

R,

Lin

CL

, K

rall

E.

Nu

trit

ion

al s

tatu

s o

f th

e o

lder

adu

lt i

s ass

oci

ate

d w

ith

den

titi

on

sta

tus.

J A

m D

iet

Ass

oc.

20

03

;10

3:6

1-6

6.

18

. S

hei

ham

A,

Ste

ele

JG. T

he

impact

of

ora

l h

ealt

h o

n s

tate

d a

bil

ity

to

eat

cer

tain

fo

od

s; f

ind

ing

fro

m t

he

nat

ional

die

t an

d n

utr

itio

n s

urv

ey o

f old

er p

eop

le i

n G

reat

Bri

tain

.G

ero

do

nto

logy.

19

99

;16

:11

-20

.

19

. S

hip

J, D

uff

y V

, Jo

nes

J,

Lang

mo

re S

. G

eria

tric

ora

l h

ealt

h a

nd

its

im

pac

t o

n e

atin

g.J

Am

Ger

iatr

So

c. 1

99

6;4

4:4

56

-46

4.

CLIN

CA

L D

OM

AIN

F

unct

ional

CH

EW

ING

(M

AS

TIC

AT

OR

Y)

DIF

FIC

UL

TY

(N

C-1

.2)

Edit

ion:

20

06

10

4

20

. T

ouger

-Dec

ker

R.

Cli

nic

al a

nd l

abora

tory

ass

ess

men

t of

nutr

itio

n s

tatu

s.D

ent

Cli

n N

ort

h A

m..

20

03

;47

:25

9-2

78

.

21

. T

ou

ger

-Dec

ker

R,

Sir

ois

D,

Mo

ble

y C

, ed

s.N

utr

itio

n a

nd

Ora

l M

edic

ine.

Toto

wa

NJ:

Hu

mana

Pre

ss.

20

05

22

. W

alls

AW

, S

teel

e JG

, S

hei

ham

A,

Mar

cen

es W

, M

oy

nih

an P

J. O

ral

hea

lth

and

nu

trit

ion

in

old

er p

eop

le.J

Pu

bli

c H

ealt

h D

ent.

20

00

;60

:30

4-3

07

.

CLIN

CA

L D

OM

AIN

F

unct

ional

BR

EA

ST

FE

ED

ING

DIF

FIC

UL

TY

(N

C-1

.3)

Edit

ion:

20

06

10

5

De

fin

itio

n

Inabil

ity to s

ust

ain

in

fan

t n

utr

itio

n t

hro

ugh b

reas

tfee

din

g

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

Infa

nt: •

Dif

ficu

lty latc

hin

g o

n,

e.g., t

ight

fren

ulu

m

•P

oor

suck

ing a

bil

ity

•O

ral

pai

n

•M

aln

utr

itio

n/m

alab

sorp

tion

•L

eth

argy,

slee

pin

ess

•Ir

rita

bil

ity

•S

wal

low

ing d

iffi

cult

y

Moth

er:

•P

ain

ful

brea

sts,

nip

ple

s

•B

reas

t or

nip

ple

abn

orm

alit

y

•M

asti

tis

•P

erce

pti

on o

f in

adeq

uate

mil

k s

upply

•L

ack o

f so

cial

, cu

ltura

l, o

r en

vir

onm

enta

l su

ppor

t

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•L

abora

tory

evid

ence

of

deh

ydra

tion i

n i

nfa

nt

Anth

ropom

etri

c M

easu

rem

ents

•A

ny w

eigh

t lo

ss o

r poor

wei

ght

gai

n i

n i

nfa

nt

Phys

ical

Exam

Fin

din

gs

•F

ren

ulu

m a

bnorm

alit

y (

infa

nt)

CLIN

CA

L D

OM

AIN

F

unct

ional

BR

EA

ST

FE

ED

ING

DIF

FIC

UL

TY

(N

C-1

.3)

Edit

ion:

20

06

10

6

Food/N

utr

itio

n H

isto

ryO

bse

rvat

ion

s or

report

s of

(in

fan

t):

•C

ough

ing

•C

ryin

g, la

tchin

g o

n a

nd o

ff,

pound

ing o

n b

reas

ts

•D

ecre

ased

fee

din

g f

requen

cy/d

ura

tion,

earl

y c

essa

tion o

f fe

edin

g, an

d/o

r fe

edin

g r

esis

tan

ce

•In

fant

leth

argy

•H

un

ger

, la

ck o

f sa

tiet

y a

fter

fee

din

g

•F

ewer

than

six

wet

dia

per

s in

24 h

ours

•In

fant

vom

itin

g o

r dia

rrh

ea

Obse

rvat

ions

or

report

s of

(moth

er):

•S

mall

am

oun

t of

mil

k w

hen

pum

pin

g

•L

ack o

f co

nfi

den

ce i

n a

bil

ity to b

reas

tfee

d

•D

oes

n’t

hea

r in

fan

t sw

allo

win

g

•C

on

cern

s re

gar

din

g m

oth

er’s

ch

oic

e to

bre

ast

feed

/lac

k o

f su

pp

ort

•In

suff

icie

nt

kn

ow

ledge

of

bre

astf

eedin

g o

r in

fant

hung

er/s

atie

ty s

ign

als

•L

ack o

f fa

cili

ties

or

acco

mm

odat

ion

s at

pla

ce o

f em

plo

ym

ent

or

in c

om

mun

ity f

or

bre

astf

eedin

g

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t (i

nfa

nt)

, e.

g.,

cle

ft l

ip/p

alat

e, t

hru

sh, pre

mat

ure

bir

th, m

alabso

rpti

on

, in

fect

ion

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t (m

oth

er),

e.g

., m

ast

itis

, ca

ndid

iasi

s, e

ngorg

emen

t, h

isto

ry o

f bre

ast

surg

ery

Refe

ren

ces:

1.

Bar

ron

SP

, L

ane

HW

, H

ann

an T

E,

Str

uem

ple

r B

, W

illi

ams

JC.

Fac

tors

in

flu

enci

ng

du

rati

on

of

bre

ast

fee

din

g a

mo

ng

lo

w-i

nco

me

wo

men

.J

Am

Die

t A

sso

c. 1

98

8;8

8:1

55

7-1

56

1.

2.

Bry

ant

C, C

ore

il J

, D

’An

gel

o S

L,

Bai

ley D

FC

, L

azar

ov M

A.

A s

trat

egy f

or

pro

moti

ng b

reast

feed

ing a

mong e

con

om

ical

ly d

isad

van

tag

ed w

om

en a

nd a

dole

scents

.N

AA

CO

G’s

Cli

n I

ssu

Per

ina

t

Wo

men

s H

ealt

h N

urs

. 1

99

2;3

:72

3-7

30

.

3.

Ben

tley

ME

, C

aulf

ield

LE

, G

ross

SM

, B

ron

ner

Y,

Jen

sen

J, K

essl

er L

A,

Pai

ge

DM

. S

ou

rces

of

infl

uen

ce o

n in

ten

tio

n t

o b

reas

tfee

d a

mon

g A

fric

an-A

mer

ican

wo

men

at

entr

y t

o W

IC.J

Hu

m L

act

.

19

99

;15

:27

-34

.

4.

More

land J

C,

Llo

yd L

, B

rau

n S

B, H

ein

s JN

. A

new

tea

chin

g m

odel

to p

rolo

ng b

reast

feedin

g a

mong L

atin

os.

J H

um

La

ct. 2

00

0;1

6:3

37

-34

1.

5.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Bre

akin

g t

he

bar

rier

s to

bre

ast

feed

ing.

J A

m D

iet

Ass

oc.

20

01

;10

1:1

21

3-1

22

0.

6.

Woold

rig

e M

S,

Fis

cher

C. C

oli

c,

"ov

erfe

edin

g"

and s

ym

pto

ms

of

lacto

se m

ala

bso

rpti

on i

n t

he

bre

ast

-fed

bab

y.

La

nce

t. 1

98

8;2

:38

2-3

84

.

CLIN

CA

L D

OM

AIN

F

unct

ional

AL

TE

RE

D G

AS

TR

OIN

TE

ST

INA

L (

GI)

FU

NC

TIO

N (

NC

-1.4

)

Edit

ion:

20

06

10

7

De

fin

itio

n

Chan

ges

in a

bil

ity t

o d

iges

t or

abso

rb n

utr

ients

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•A

lter

atio

ns

in G

I an

atom

ical

str

uct

ure

, e.

g., g

astr

ic b

ypas

s, R

oux e

n Y

•C

han

ges

in t

he

GI

trac

t m

oti

lity

, e.

g., g

astr

opar

esis

•C

om

pro

mis

ed G

I tr

act

funct

ion

, e.

g., c

elia

c dis

ease

, C

rohn

’s d

isea

se,

infe

ctio

n, ra

dia

tion t

her

apy

•C

om

pro

mis

ed f

unct

ion o

f re

late

d G

I org

ans,

e.g

., p

ancr

eas,

liv

er

•D

ecre

ased

fun

ctio

nal

len

gth

of

the

GI

trac

t, e

.g., s

hort

bow

el s

yndro

me

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•A

bn

orm

al d

iges

tive

enzy

me

and f

ecal

fat

stu

die

s

•A

bn

orm

al h

ydro

gen

bre

ath t

est,

d-x

ylo

se t

est,

sto

ol

cult

ure

, an

d g

astr

ic e

mpty

ing a

nd/o

r sm

all

bow

el t

ran

sit

tim

e

Anth

ropom

etri

c M

easu

rem

ents

•W

asti

ng d

ue

to m

aln

utr

itio

n i

n s

ever

e ca

ses

Phys

ical

Exam

Fin

din

gs

•D

ecre

ased

musc

le m

ass

•A

bd

om

inal

dis

ten

sion

•In

crea

sed (

or

som

etim

es d

ecre

ased

) bow

el s

oun

ds

CLIN

CA

L D

OM

AIN

F

unct

ional

AL

TE

RE

D G

AS

TR

OIN

TE

ST

INA

L (

GI)

FU

NC

TIO

N (

NC

-1.4

)

Edit

ion:

20

06

10

8

Food/N

utr

itio

n H

isto

ryO

bse

rvat

ion

s or

report

s of:

•A

void

ance

or

lim

itat

ion o

f to

tal

inta

ke

or

inta

ke

of

spec

ific

foods/

food g

roups

due

to G

I sy

mpto

ms,

e.g

., b

loat

ing,

cram

pin

g,

pai

n,

dia

rrh

ea,

stea

torr

hea

(gre

asy,

float

ing,

foul-

smel

ling s

tools

) es

pec

iall

y f

oll

ow

ing i

ng

esti

on o

f fo

od

•F

ood a

nd n

utr

itio

n-r

elat

ed k

now

ledge

def

icit

, e.

g., l

ack o

f in

form

atio

n, in

corr

ect

info

rmat

ion o

r n

onco

mp

lian

ce w

ith

modif

ied d

iet

or m

edic

atio

n s

ched

ule

Cli

ent

His

tory

•A

nore

xia

, nause

a, v

om

itin

g,

dia

rrh

ea,

stea

torr

hea

, co

nst

ipati

on

, ab

dom

inal

pai

n

•E

ndosc

opic

or

colo

nosc

opic

exam

inat

ion r

esult

s, b

iopsy

res

ult

s

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., m

alab

sorp

tion,

mal

dig

esti

on,

stea

torr

hea

, co

nst

ipat

ion,

div

erti

culi

tis,

Cro

hn’s

dis

ease

, in

flam

mat

ory

bow

el d

isea

se, cy

stic

fib

rosi

s, c

elia

c dis

ease

, ir

rita

ble

bow

el s

yndro

me,

infe

ctio

n

•S

urg

ical

pro

cedure

s, e

.g., e

sophagec

tom

y, d

ilata

tion,

gas

trec

tom

y, v

agoto

my,

gast

ric

byp

ass

, bow

el r

esec

tion

s

Refe

ren

ce:

1.

Bra

un

wal

d E

, F

auci

AS

, K

asp

er D

L,

Hau

ser

SL

, L

on

go

DL

, Ja

mes

on

JL

, ed

s.H

arr

iso

n’s

Pri

nci

ple

s o

f In

tern

al M

edic

ine.1

5th e

d. N

ew Y

ork

, N

Y:

McG

raw

-Hil

l;2

00

1.

CLIN

CA

L D

OM

AIN

B

ioch

emic

al

IMP

AIR

ED

NU

TR

IEN

T U

TIL

IZA

TIO

N (

NC

-2.1

)

Edit

ion:

20

06

10

9

De

fin

itio

n

Chan

ges

in a

bil

ity to a

bso

rb o

r m

etab

oli

ze n

utr

ien

ts a

nd b

ioac

tive

subst

ance

s

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•A

lter

atio

ns

in g

ast

roin

test

inal

anat

om

ical

str

uct

ure

•C

om

pro

mis

ed f

unct

ion o

f th

e G

I tr

act

•C

om

pro

mis

ed f

unct

ion o

f re

late

d G

I org

ans,

e.g

., p

ancr

eas,

liv

er

•D

ecre

ased

fun

ctio

nal

len

gth

of

the

GI

trac

t

•M

etab

oli

c dis

ord

ers

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•A

bn

orm

al d

iges

tive

enzy

me

and f

ecal

fat

stu

die

s

•A

bnorm

al h

ydro

gen

bre

ath t

est,

d-x

ylose

tes

t

•A

bnorm

al t

ests

for

inborn

err

ors

of

met

aboli

sm

Anth

ropom

etri

c M

easu

rem

ents

•W

eigh

t lo

ss o

f 5%

in 1

mon

th,

10%

in 6

month

s

•G

row

th s

tun

ting o

r fa

ilure

Phys

ical

Exam

Fin

din

gs

•A

bd

om

inal

dis

ten

sion

•In

crea

sed o

r dec

rease

d b

ow

el s

oun

ds

•E

vid

ence

of

vit

amin

or

min

eral

def

icie

ncy

, e.

g.,

glo

ssit

is,

chei

losi

s, m

outh

les

ions

CLIN

CA

L D

OM

AIN

B

ioch

emic

al

IMP

AIR

ED

NU

TR

IEN

T U

TIL

IZA

TIO

N (

NC

-2.1

)

Edit

ion:

20

06

11

0

Food/N

utr

itio

n H

isto

ryO

bse

rvat

ion

s or

report

s of:

•A

void

ance

or

lim

itat

ion o

f to

tal

inta

ke

or

inta

ke

of

spec

ific

foods/

food g

roups

due

to G

I sy

mpto

ms,

e.g

., b

loat

ing,

cram

pin

g,

pai

n,

dia

rrh

ea,

stea

torr

hea

(gre

asy,

float

ing,

foul-

smel

ling s

tools

) es

pec

iall

y f

oll

ow

ing i

ng

esti

on o

f fo

od

Cli

ent

His

tory

•D

iarr

hea

, st

eato

rrh

ea,

abdom

inal

pai

n

•E

ndosc

opic

or

colo

nosc

opic

exam

inat

ion r

esult

s, b

iopsy

res

ult

s

•C

ondit

ion

s as

soci

ate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., m

alab

sorp

tion,

mal

dig

esti

on,

cyst

ic f

ibro

sis,

cel

iac

dis

ease

,

Cro

hn

’s d

isea

se,

infe

ctio

n,

radia

tion t

her

apy,

inborn

err

ors

of

met

aboli

sm

•S

urg

ical

pro

cedure

s, e

.g., g

astr

ic b

ypas

s, b

ow

el r

esec

tion

Refe

ren

ces:

1.

Bey

er

P. G

ast

roin

test

inal

dis

ord

ers:

Role

s of

nutr

itio

n a

nd t

he

die

teti

cs

pra

ctit

ioner

.J

Am

Die

t A

sso

c. 1

99

8;9

8:2

72

-27

7.

2.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Hea

lth i

mpli

cati

on

s of

die

tary

fib

er.

J A

m D

iet

Ass

oc.

20

02

;10

2:9

93

-10

00

.

CLIN

CA

L D

OM

AIN

B

ioch

emic

al

AL

TE

RE

D N

UT

RIT

ION

-RE

LA

TE

D L

AB

OR

AT

OR

Y V

AL

UE

S (

SP

EC

IFY

) (N

C-2

.2)

Edit

ion:

20

06

11

1

De

fin

itio

n

Chan

ges

due

to b

od

y c

om

posi

tion, m

edic

atio

ns,

bod

y s

yst

em o

r gen

etic

s, o

r ch

anges

in a

bil

ity t

o e

lim

inat

e bypro

duct

s of

dig

esti

ve

and m

etab

oli

c pro

cess

es

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•K

idn

ey,

liver

, ca

rdia

c, e

ndocr

ine,

neu

rolo

gic

, an

d/o

r pulm

onar

y d

ysfu

nct

ion

•O

ther

org

an d

ysf

un

ctio

n t

hat

lea

ds

to b

ioch

emic

al c

han

ges

:

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Fin

din

gs

such

as:

•In

crea

sed A

ST

, A

LT

, T

. bil

i, s

erum

am

mon

ia (

liver

dis

ord

ers)

•A

bn

orm

al B

UN

, C

r, K

, ph

osp

horu

s, g

lom

erula

r fi

ltra

tion r

ate

(G

FR

) (k

idn

ey d

isord

ers)

•A

lter

ed p

O2 a

nd p

CO

2 (

pulm

onar

y d

isord

ers)

•A

bnorm

al s

erum

lip

ids

•A

bn

orm

al p

lasm

a glu

cose

lev

els

•O

ther

fin

din

gs

of

acute

or

chro

nic

dis

order

s th

at a

re a

bn

orm

al a

nd o

f nutr

itio

nal

ori

gin

or

con

sequen

ce

Anth

ropom

etri

c M

easu

rem

ents

•R

apid

wei

ght

chan

ges

•O

ther

anth

ropom

etri

c m

easu

res

that

are

alt

ered

Phys

ical

Exam

Fin

din

gs

•Ja

un

dic

e, e

dem

a, a

scit

es,

itch

ing (

liver

dis

ord

ers)

•E

dem

a, s

hor

tnes

s of

bre

ath

(ca

rdia

c dis

order

s)

•B

lue

nai

l bed

s, c

lubbin

g (

pulm

onar

y d

isord

ers)

CLIN

CA

L D

OM

AIN

B

ioch

emic

al

AL

TE

RE

D N

UT

RIT

ION

-RE

LA

TE

D L

AB

OR

AT

OR

Y V

AL

UE

S (

SP

EC

IFY

) (N

C-2

.2)

Edit

ion:

20

06

11

2

Food/N

utr

itio

n H

isto

ryO

bse

rvat

ion

s or

report

s of:

•A

nore

xia

, nause

a, v

om

itin

g

•In

abil

ity to c

on

sum

e fu

ll m

eals

due

to s

hort

nes

s of

bre

ath o

r ab

dom

inal

dis

tenti

on

•In

take

of

foods

hig

h i

n o

r over

all

exce

ss i

nta

ke

of

pro

tein

, pota

ssiu

m,

ph

osp

horu

s, s

odiu

m,

fluid

•In

adeq

uat

e in

take

of

mic

ron

utr

ients

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledge

defi

cit,

e.g

., l

ack o

f in

form

atio

n, in

corr

ect

info

rmat

ion o

r n

onco

mp

lian

ce w

ith

modif

ied d

iet

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t of,

e.g

., r

enal

or

liver

dis

ease

, al

coh

oli

sm, ca

rdio

-pulm

onar

y d

isord

ers

Refe

ren

ces:

1.

Bet

o J

A, B

ansa

l V

K.

Med

ical

nutr

itio

n t

her

apy i

n c

hro

nic

kid

ney

fai

lure

: in

tegra

ting c

linic

al p

ract

ice

guid

elin

es.

J A

m D

iet

Ass

oc.

20

04

;10

4:4

04

-40

9.

2.

Dav

ern

II

TJ,

Sch

arsc

hm

idt

BF

. B

ioch

emic

al l

iver

tes

ts.

In

Fel

dm

an

M, S

char

sch

mid

t B

F, S

leis

eng

er M

H,

eds.

Sle

isen

ger

an

d F

ord

tra

n’s

Ga

sro

inte

stin

al a

nd

Liv

er D

isea

se,

ed 6

, vo

l 2

.

Phil

adel

ph

ia,

Pa:

WB

Sau

nd

ers,

19

98

:11

12

-11

22

.

3.

Du

rose

CL

, H

old

swort

h M

, W

atso

n V

, P

rzygro

dzk

a F

. K

now

ledge

of

die

tary

res

tric

tion

s and t

he

med

ical

con

sequ

ence

s of

noncom

pli

ance

by p

atie

nts

on h

emo

dia

lysi

s ar

e not

pre

dic

tive

of

die

tary

com

pli

ance

.J

Am

Die

t A

sso

c. 2

00

4;1

04

:35

-41

.

4.

Kasi

ske

BL

, L

akat

ua

JD,

Ma

JZ, L

ou

is T

A.

A m

eta-

anal

ysi

s o

f th

e ef

fect

s o

f die

tary

pro

tein

res

tric

tio

n o

n th

e ra

te o

f d

ecli

ne

in r

enal

fu

nct

ion

.A

m J

Kid

ney

Dis

. 1

99

8;3

1;9

54

-96

1.

5.

Knig

ht

EL

, S

tam

pfe

r M

J, H

ank

inso

n S

E,

Spie

gel

man

D,

Cu

rhan

GC

. T

he

imp

act

of

pro

tein

in

tak

e o

n r

enal

fu

nct

ion

dec

lin

e in

wo

men

wit

h n

orm

al r

enal

fu

nct

ion

or

mil

d r

enal

in

suff

icie

ncy

.A

nn

Inte

rn M

ed. 2

00

3;1

38

:46

0-4

67

.

6.

Nak

ao T

, M

atsu

moto

, O

kad

a T

, K

anaz

aw

a Y

, Y

osh

ino M

, N

agaoka

Y, T

akeg

uchi

F.

Nu

trit

ional

manag

em

ent

of

dia

lysi

s pat

ients

: bal

anci

ng a

mong n

utr

ient

inta

ke,

dia

lysi

s do

se, and n

utr

itio

nal

stat

us.

Am

J K

idn

ey D

is. 2

00

3;4

1:S

13

3-S

13

6.

7.

Nat

ional

Kid

ney

Foun

dat

ion.

Par

t 5.

Eval

uat

ion o

f la

bora

tory

mea

sure

men

ts f

or

clin

ical

ass

essm

ent

of

kid

ney

dis

ease

.A

m J

Kid

ney

Dis

. 2

00

2;3

9:S

76

-S9

2.

8.

Nat

ion

al K

idn

ey F

ou

ndat

ion

. G

uid

elin

e 9

. A

sso

ciat

ion

of

lev

el o

f G

FR

wit

h n

utr

itio

nal

sta

tus.

Am

J K

idn

ey D

is.

20

02

;39

:S1

28

-S1

42

.

CLIN

CA

L D

OM

AIN

B

ioch

emic

al

FO

OD

-ME

DIC

AT

ION

IN

TE

RA

CT

ION

(N

C-2

.3)

Edit

ion:

20

06

11

3

De

fin

itio

n

Un

des

irable

/har

mfu

l in

tera

ctio

n(s

) bet

wee

n f

ood a

nd o

ver

-the-

coun

ter

(OT

C)

med

icat

ion

s, p

resc

ribed

med

icat

ion

s, h

erbal

s, b

ota

nic

als,

an

d/o

r die

tary

supple

men

ts t

hat

dim

inis

hes

, en

han

ces,

or

alte

rs e

ffec

t of

nutr

ients

an

d/o

r m

edic

atio

ns

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•C

om

bin

ed i

nges

tion o

r ad

min

istr

atio

n o

f m

edic

ati

on a

nd f

ood t

hat

res

ult

s in

un

des

irab

le/h

arm

ful

inte

ract

ion(s

)

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•A

lter

atio

ns

of

bio

chem

ical

tes

ts b

ased

upon m

edic

atio

n e

ffec

t an

d p

atie

nt/

clie

nt

con

dit

ion

Anth

ropom

etri

c M

easu

rem

ents

•A

lter

atio

ns

of

anth

ropom

etri

c m

easu

rem

ents

bas

ed u

pon m

edic

ati

on e

ffec

t an

d p

atie

nt/

clie

nt

con

dit

ion

s, e

.g., w

eight

gai

n

and c

ort

icost

eroid

s

Phys

ical

Exam

Fin

din

gs

Food/N

utr

itio

n H

isto

ryO

bse

rvat

ion

s or

report

s of:

•In

take

that

is

pro

ble

mati

c or

inco

nsi

sten

t w

ith O

TC

, pre

scri

bed

dru

gs,

her

bal

s, b

ota

nic

als,

or

die

tary

supple

men

ts s

uch

as:

•fi

sh o

ils

and p

rolo

nged

ble

edin

g

•co

um

adin

, vit

amin

K-r

ich f

ood

s

•hig

h-f

at d

iet

wh

ile

on c

hole

ster

ol-

low

erin

g m

edic

atio

ns

•ir

on s

upple

men

ts,

con

stip

atio

n a

nd l

ow

-fib

er d

iet

•In

take

that

does

not

suppor

t re

pla

cem

ent

or

mit

igat

ion o

f O

TC

, pre

scri

bed

dru

gs,

her

bal

s, b

ota

nic

als,

or

die

tary

supple

men

ts

affe

cts

such

as

pota

ssiu

m-w

asti

ng d

iure

tics

•C

han

ges

in a

pp

etit

e or

tast

e

CLIN

CA

L D

OM

AIN

B

ioch

emic

al

FO

OD

-ME

DIC

AT

ION

IN

TE

RA

CT

ION

(N

C-2

.3)

Edit

ion:

20

06

11

4

Cli

ent

His

tory

•M

ult

iple

dru

gs

(OT

C,

pre

scri

bed

dru

gs,

her

bal

s, b

ota

nic

als,

or

die

tary

supple

men

ts)

that

are

kn

ow

n t

o h

ave

food m

edic

atio

n

inte

ract

ion

s

•M

edic

atio

ns

that

req

uir

e nutr

ient

supple

men

tati

on t

hat

can

not

be

acco

mpli

shed

via

food i

nta

ke

such

as

isonia

zid a

nd

Vit

amin

B6

Refe

ren

ce:

1.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

Inte

gra

tion o

f nutr

itio

n a

nd p

har

maco

ther

apy.J

Am

Die

t A

sso

c. 2

00

3;1

03

:13

63

-13

70

.

CLIN

CA

L D

OM

AIN

W

eig

ht

UN

DE

RW

EIG

HT

(N

C-3

.1)

Edit

ion:

20

06

11

5

De

fin

itio

n

Low

bod

y w

eig

ht

com

par

ed t

o e

stabli

shed

ref

eren

ce s

tan

dar

ds

or

reco

mm

endat

ion

s

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•D

isord

ered

eat

ing p

atte

rn

•E

xce

ssiv

e ph

ysic

al a

ctiv

ity

•H

arm

ful

bel

iefs

/att

itudes

about

food,

nutr

itio

n,

and n

utr

itio

n-r

elat

ed t

opic

s

•In

adeq

uat

e en

ergy i

nta

ke

•In

crea

sed e

ner

gy n

eeds

•L

imit

ed a

cces

s to

food

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

•W

eigh

t fo

r ag

e le

ss t

han

5th

per

centi

le f

or

infa

nts

youn

ger

than

12 m

onth

s

•D

ecre

ased

skin

fold

th

icknes

s an

d m

id-a

rm m

usc

le c

ircu

mfe

ren

ce (

MA

MC

)

•B

MI

< 1

8.5

(m

ost

adult

s)

•B

MI

for

old

er a

dult

s (o

ver

65 y

ears

) <

23

•B

MI

< 5

th p

erce

nti

le (

chil

dre

n,

2-1

9 y

ears

)

Phys

ical

Exam

Fin

din

gs

•D

ecre

ased

som

ati

c pro

tein

sto

res,

musc

le w

asti

ng (

glu

teal

and t

empora

l)

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•In

adeq

uat

e in

take

of

food c

om

par

ed t

o e

stim

ated

or

mea

sure

d n

eeds

CLIN

CA

L D

OM

AIN

W

eig

ht

UN

DE

RW

EIG

HT

(N

C-3

.1)

Edit

ion:

20

06

11

6

•L

imit

ed s

upply

of

food i

n h

om

e

•D

ieti

ng,

food f

addis

m

•H

un

ger

•R

efusa

l to

eat

•P

hys

ical

act

ivit

y g

reat

er t

han

rec

om

men

ded

am

ount

Cli

ent

His

tory

•M

aln

utr

itio

n,

vit

amin

/min

eral

def

icie

ncy

•Il

lnes

s or

ph

ysic

al d

isab

ilit

y

•M

enta

l il

lnes

s, d

emen

tia,

con

fusi

on

•M

easu

red r

esti

ng m

etab

oli

c ra

te (

RM

R)

hig

her

th

an e

xpec

ted a

nd/o

r es

tim

ated

RM

R

•M

edic

atio

ns

that

aff

ect

appet

ite,

e.g

., s

tim

ula

nts

for

atte

nti

on d

efic

it h

yper

acti

vit

y d

isord

er

•A

thle

te, dan

cer,

or

gym

nas

t

Refe

ren

ces:

1.

Ass

ess

men

t of

nutr

itio

nal

sta

tus.

In:

Kle

inm

an R

, ed

.P

edia

tric

Nu

trit

ion

Ha

nd

bo

ok,

5th e

d. C

hic

ago

, Il

l: A

mer

ican

Aca

dem

y o

f P

ed

iatr

ics,

20

04

:40

7-4

23

.

2.

Bec

k A

M, O

vese

n L

W.

At

whic

h b

ody m

ass

ind

ex a

nd d

egre

e of

wei

ght

loss

sh

ould

ho

spit

aliz

ed e

lder

ly p

atie

nts

be

consi

der

ed a

t nutr

itio

nal

ris

k?

Cli

n N

utr

. 1

99

8;1

7:1

95

-19

8.

3.

Bla

um

CS

, F

ries

BE

, F

iata

ron

e M

A.

Fac

oto

rs a

sso

ciat

ed w

ith

lo

w b

od

y m

ass

ind

ex a

nd

wei

gh

t lo

ss i

n n

urs

ing

ho

me

resi

den

ts.J

Ger

on

tolo

gy:

Med

Sci

. 1

99

5;5

0A

:M1

62

-M1

68

.

4.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

Dom

esti

c fo

od a

nd n

utr

itio

n s

ecuri

ty.J

Am

Die

t A

sso

c. 2

00

2;1

02

:18

40

-18

47

.

5.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

Ad

dre

ssin

g w

orl

d h

ung

er,

maln

utr

itio

n,

and f

ood i

nse

curi

ty.J

Am

Die

t A

sso

c. 2

00

3;1

03

:10

46

-10

57

.

6.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Nu

trit

ion i

nte

rven

tio

n i

n t

he

trea

tment

of

anore

xia

ner

vosa

, buli

mia

ner

vo

sa, and e

atin

g d

isord

er n

ot

oth

erw

ise

spec

ifie

d (

ED

NO

S).

J A

m D

iet

Ass

oc.

20

01

;10

1:8

10

-81

9.

7.

Sch

nei

der

SM

, A

l-Ja

ou

ni

R,

Piv

ot

X, B

rau

lio

VB

, R

ampal

P, H

ebu

ern

e X

. L

ack

of

adapta

tio

n t

o s

ever

e m

aln

utr

itio

n i

n e

lder

ly p

atie

nts

.C

lin

Nu

tr.

20

02

;21

(6):

49

9-5

04

.

8.

Spea

r B

A.

Adole

scen

t gro

wth

and d

evel

op

men

t.J

Am

Die

t A

sso

c. 2

00

2 (

sup

pl)

;10

2:S

23

- S

29

.

CLIN

CA

L D

OM

AIN

W

eig

ht

INV

OL

UN

TA

RY

WE

IGH

T L

OS

S (

NC

-3.2

)

Edit

ion:

20

06

11

7

De

fin

itio

n

Dec

rease

in b

ody w

eigh

t th

at i

s n

ot

pla

nn

ed o

r des

ired

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•P

hys

iolo

gic

cau

ses,

e.g

., i

ncr

ease

d n

utr

ien

t n

eeds

due

to p

rolo

nged

cat

aboli

c il

lnes

s

•L

ack o

f ac

cess

to f

ood,

e.g

., e

con

om

ic c

on

stra

ints

, cu

ltura

l or

reli

gio

us

pra

ctic

es, re

stri

ctin

g f

ood g

iven

to e

lder

ly a

nd/o

r ch

ildre

n

•P

rolo

ng

ed h

osp

ital

izat

ion

•P

sych

olo

gic

al i

ssues

•L

ack o

f se

lf-f

eedin

g a

bil

ity

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

•W

eigh

t lo

ss o

f 5%

wit

hin

1 m

onth

, 7.5

% i

n 3

mon

ths

and 1

0%

in 6

mon

ths

Phys

ical

Exam

inati

on F

indin

gs

•F

ever

•In

crea

sed h

eart

rat

e

•In

crea

sed r

espir

atory

rat

e

•L

oss

of

subcu

tan

eous

fat

and m

usc

le s

tore

s

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•N

orm

al o

r usu

al i

nta

ke

in f

ace

of

illn

ess

•P

oor

inta

ke,

ch

ange

in e

atin

g h

abit

s, s

kip

ped

mea

ls

•C

han

ge

in w

ay c

loth

es f

it,

e.g

., b

ecom

ing l

oose

r

CLIN

CA

L D

OM

AIN

W

eig

ht

INV

OL

UN

TA

RY

WE

IGH

T L

OS

S (

NC

-3.2

)

Edit

ion:

20

06

11

8

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., A

IDS

/HIV

, burn

s, c

hro

nic

obst

ruct

ive

pulm

on

ary d

isea

se,

hip

/long b

on

e fr

actu

re, in

fect

ion,

surg

ery,

tra

um

a, h

yper

thyr

oid

ism

(pre

-or

untr

eate

d),

som

e ty

pes

of

can

cer

or

met

ast

atic

dis

ease

(sp

ecif

y)

•M

edic

atio

ns

asso

ciate

d w

ith w

eigh

t lo

ss,

such

as

cert

ain a

nti

dep

ress

ants

or

can

cer

chem

oth

erap

y

Refe

ren

ces:

1.

Coll

ins

N.

Pro

tein

-ener

gy m

alnutr

itio

n a

nd i

nv

olu

nta

ry w

eig

ht

loss

: N

utr

itio

nal

and p

har

mac

olo

gic

str

ateg

ies

to e

nhance

woun

d h

eali

ng.

Exp

ert

Op

inio

n P

ha

rma

coth

er. 2

00

3;7

:11

21

-11

40

.

2.

Sple

tt P

L,

Ro

th-Y

ou

sey

LL

, V

og

elza

ng

JL

. M

edic

al n

utr

itio

n t

her

apy

fo

r th

e pre

ven

tio

n a

nd

tre

atm

ent

of

un

inte

nti

on

al w

eig

ht

loss

in

res

iden

tial

hea

lth

care

faci

liti

es.

J A

m D

iet

Ass

oc.

20

03

;

10

3:3

52

-36

2.

3.

Wal

lace

JL

, S

chw

artz

RS

, L

aCro

ix A

Z,

Uh

lman

n R

F,

Pea

rlm

an R

A. In

volu

nta

ry w

eig

ht

loss

in

old

er p

atie

nts

: in

cid

ence

an

d c

linic

al s

ign

ific

ance

.J

Am

Ger

iatr

So

c. 1

99

5;4

3:3

29

-33

7.

CLIN

CA

L D

OM

AIN

W

eig

ht

OV

ER

WE

IGH

T/O

BE

SIT

Y (

NC

-3.3

)

Edit

ion:

20

06

11

9

De

fin

itio

n

Incr

ease

d a

dip

osi

ty c

om

par

ed t

o e

stab

lish

ed r

efer

ence

sta

ndar

ds

or

reco

mm

endat

ion

s

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•D

ecre

ased

en

ergy n

eeds

•D

isord

ered

eat

ing p

atte

rn

•E

xce

ss e

ner

gy inta

ke

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•N

ot

read

y f

or

die

t/li

fest

yle

chan

ge

•P

hysi

cal

inac

tivit

y

•In

crea

sed p

sych

olo

gic

al/l

ife

stre

ss

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

•B

MI

above

norm

ativ

e st

andar

d f

or

age

and g

ender

•W

aist

cir

cum

fere

nce

above

norm

ativ

e st

andar

d f

or

age

and g

ender

•In

crea

sed s

kin

fold

thic

knes

s

•W

eigh

t fo

r h

eight

above

norm

ativ

e st

andar

d f

or

age

and g

ender

Phys

ical

Exam

Fin

din

gs

•In

crea

sed b

od

y a

dip

osi

ty

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•O

ver

con

sum

pti

on o

f hig

h-f

at a

nd/o

r ca

lori

call

y-d

ense

food o

r bev

erag

e

CLIN

CA

L D

OM

AIN

W

eig

ht

OV

ER

WE

IGH

T/O

BE

SIT

Y (

NC

-3.3

)

Edit

ion:

20

06

12

0

•L

arge

port

ions

of

food (

port

ion s

ize

gre

ater

than

tw

ice

than

rec

om

men

ded

)

•E

xce

ssiv

e en

ergy inta

ke

•In

freq

uen

t, l

ow

-dura

tion a

nd

/or

low

-in

ten

sity

ph

ysic

al a

ctiv

ity

•L

arge

amoun

ts o

f se

den

tary

act

ivit

ies,

e.g

., T

V w

atch

ing

, re

adin

g,

com

pute

r use

in b

oth

lei

sure

and w

ork

/sch

ool

•U

nce

rtai

nty

reg

ardin

g n

utr

itio

n-r

elat

ed r

ecom

men

dat

ion

s

•In

abil

ity to a

pp

ly n

utr

itio

n-r

elat

ed r

ecom

men

dat

ion

s

•In

abil

ity to m

ain

tain

wei

gh

t or

regai

n o

f w

eight

•U

nw

illi

ngnes

s or

dis

inte

rest

in a

pply

ing n

utr

itio

n-r

elat

ed r

ecom

men

dat

ion

s

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t of,

e.g

., h

ypoth

yroid

ism

, m

etaboli

c sy

ndro

me,

eat

ing d

isord

er n

ot

oth

erw

ise

spec

ifie

d,

dep

ress

ion

•P

hysi

cal

dis

abil

ity o

r li

mit

atio

n

•H

isto

ry o

f ph

ysic

al,

sexual

, or

emoti

on

al a

buse

•M

easu

red r

esti

ng m

etab

oli

c ra

te (

RM

R)

low

er t

han

expec

ted a

nd/o

r es

tim

ated

RM

R

•M

edic

atio

ns

that

im

pac

t R

MR

, e.

g., m

idaz

ola

m, pro

pra

nal

ol,

gli

piz

ide

Refe

ren

ces:

1.

Cra

wfo

rd S

. P

rom

oti

ng d

ieta

ry c

han

ge.

Ca

n J

Ca

rdio

l. 1

99

5;1

1(s

up

pl

A):

14

A-1

5A

.

2.

Dic

ker

son

RN

, R

oth

-You

sey

L.

Med

icat

ion

eff

ects

on

met

aboli

c ra

te:

a sy

stem

atic

rev

iew

(P

art

2).

J A

m D

iet

Ass

oc.

2

00

5;1

05

:10

02

-10

09

.

3.

Dic

ker

son

RN

, R

oth

-You

sey

L.

Med

icat

ion

eff

ects

on

met

aboli

c ra

te:

a sy

stem

atic

rev

iew

(P

art

1).

J A

m D

iet

Ass

oc.

2

00

5;1

05

:83

5-8

41

.

4.

Ku

man

yik

a S

K,

Van

Horn

L, B

ow

en D

, P

erri

MG

, R

oll

s B

J, C

zajk

ow

ski

SM

, S

chro

n E

. M

ainte

nan

ce o

f die

tary

beh

avio

r ch

ang

e.H

ealt

h P

sych

ol.

20

00

;19

(1 s

up

pl)

:S4

2-S

56

.

5.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Wei

ght

man

agem

ent.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

14

5-1

15

5.

6.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Tota

l die

t appro

ach

to c

om

munic

atin

g f

ood a

nd n

utr

itio

n i

nfo

rmat

ion.J

Am

Die

t A

sso

c 2

00

2;1

02

:10

0-1

08

.

7.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

The

role

of

die

teti

cs p

rofe

ssio

nal

s in

hea

lth p

rom

oti

on a

nd d

isea

se p

reventi

on.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

68

0-1

68

7.

8.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Nu

trit

ion i

nte

rven

tio

n i

n t

he

trea

tment

of

anore

xia

ner

vosa

, buli

mia

ner

vo

sa, and e

atin

g d

isord

er n

ot

oth

erw

ise

spec

ifie

d (

ED

NO

S).

J A

m D

iet

Ass

oc.

20

01

;10

1:8

10

-81

9.

9.

Shep

her

d R

. R

esis

tan

ce t

o c

han

ges

in d

iet.

Pro

c N

utr

So

c. 2

00

2;6

1:2

67

-27

2.

10

. U

.S.

Pre

ven

tive

Ser

vic

es T

ask F

orc

e. B

ehavio

ral

cou

nse

ling i

n p

rim

ary c

are

to p

rom

ote

a h

ealt

hy d

iet.

Am

J P

rev

Med

. 2

00

3;2

4:9

3-1

00

.

CLIN

CA

L D

OM

AIN

W

eig

ht

INV

OL

UN

TA

RY

WE

IGH

T G

AIN

(N

C-3

.4)

Edit

ion:

20

06

12

1

De

fin

itio

n

Wei

gh

t gai

n a

bove

that

whic

h i

s des

ired

or

pla

nn

ed

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•Il

lnes

s ca

usi

ng u

nex

pec

ted w

eight

gai

n b

ecau

se o

f h

ead t

raum

a, i

mm

obil

ity,

par

alysi

s or

rela

ted c

on

dit

ion

•C

hro

nic

use

of

med

icat

ion

s kn

ow

n t

o c

ause

wei

ght

gai

n,

such

as

use

of

cert

ain

anti

dep

ress

ants

, an

tipsy

choti

cs,

cort

icost

eroid

s, c

erta

in H

IV m

edic

atio

ns

•C

ondit

ion l

eadin

g t

o e

xce

ssiv

e fl

uid

wei

ght

gai

ns

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•D

ecre

ase

in s

erum

alb

um

in, h

ypon

atre

mia

, el

evat

ed f

asti

ng s

eru

m l

ipid

lev

els,

ele

vat

ed f

asti

ng g

luco

se l

evel

s, f

luct

uat

ing

horm

on

e le

vel

s

Anth

ropom

etri

c M

easu

rem

ents

•W

eig

ht his

tory

– n

oti

ng a

ny in

crea

se i

n w

eight

gre

ater

than

pla

nn

ed o

r des

ired

, su

ch a

s 10%

in 6

month

s

•N

oti

ceab

le c

han

ge

in b

od

y f

at d

istr

ibuti

on

Phys

ical

Exam

inati

on F

indin

gs

•F

at a

ccum

ula

tion

—ex

cess

ive

subcu

tan

eous

fat

store

s

•L

ipod

yst

roph

y a

ssoci

ate

d w

ith H

IV m

edic

atio

ns—

incr

ease

in d

ors

oce

rvia

l fa

t, b

reas

t en

larg

emen

t, i

ncr

ease

d a

bdom

inal

gir

th

•E

dem

a

•S

hort

nes

s of

bre

ath

•S

ensi

tivit

y to c

old

, co

nst

ipat

ion, an

d h

air

loss

CLIN

CA

L D

OM

AIN

W

eig

ht

INV

OL

UN

TA

RY

WE

IGH

T G

AIN

(N

C-3

.4)

Edit

ion:

20

06

12

2

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•In

take

con

sist

ent

wit

h e

stim

ated

or

mea

sure

d e

ner

gy n

eeds

•C

han

ges

in r

ecen

t fo

od i

nta

ke

level

•U

se o

f al

coh

ol,

nar

coti

cs

•E

xtr

eme

hung

er w

ith o

r w

ith

out

pal

pit

atio

ns,

tre

mor,

and s

wea

tin

g

•P

hys

ical

inac

tivit

y o

r ch

ange

in p

hys

ical

act

ivit

y lev

el

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t of

asth

ma,

psy

chia

tric

ill

nes

ses,

rh

eum

atic

con

dit

ions,

HIV

/AID

S,

Cush

ing’s

syn

dro

me,

obes

ity,

Pra

der

-Wil

li s

yndro

me

•F

luid

adm

inis

trat

ion a

bove

requir

emen

ts

•C

han

ge

in s

leep

hab

its,

in

som

nia

•M

usc

le w

eakn

ess

•F

atig

ue

•M

edic

atio

ns

asso

ciate

d w

ith i

ncr

ease

d a

ppet

ite

Refe

ren

ces:

1.

Lic

hte

nst

ein

K,

Del

aney

K, W

ard

D,

Pal

ella

F.

Cli

nic

al f

act

ors

ass

oci

ated

wit

h i

nci

den

ce a

nd

pre

val

ence

of

fat

atro

ph

y a

nd

acc

um

ula

tio

n (

abst

ract

P6

4).

An

tivi

r T

her

. 2

00

0;

5:6

1-6

2

2.

Hea

th K

V, H

ogg R

S,

Chan K

J, H

arri

s M

, M

onte

ssori

V, O

’Shau

ghnes

sy M

V,

Mo

nta

ner

JS

. L

ipo

dyst

rophy-a

sso

ciat

ed m

orp

holo

gic

al,

chole

ster

ol

and t

rigly

ceri

de

abnorm

ali

ties

in a

po

pula

tion-

bas

ed H

IV/A

IDS

tre

atm

ent

dat

abase

.A

IDS

. 2

00

1;1

5:2

31

-23

9.

3.

Saf

ri S

, G

run

feld

C.

Fat

dis

trib

uti

on

an

d m

etab

oli

c ch

an

ges

in

pat

ien

ts w

ith

HIV

in

fect

ion

.A

IDS

. 1

99

9;1

3:2

49

3-2

50

5.

4.

Sat

tler

F.

Body h

abit

us

changes

rela

ted t

o l

ipod

yst

roph

y.

Cli

n I

nfe

ct D

is. 2

00

3;3

6:S

84

-S9

0.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

FO

OD

- A

ND

NU

TR

ITIO

N-R

EL

AT

ED

KN

OW

LE

DG

E D

EF

ICIT

(N

B-1

.1)

Edit

ion:

20

06

12

3

De

fin

itio

n

Inco

mp

lete

or

inac

cura

te k

now

ledg

e ab

out

food,

nutr

itio

n, or

nutr

itio

n-r

elat

ed i

nfo

rmat

ion a

nd g

uid

elin

es, e.

g., n

utr

ien

t re

quir

emen

ts,

con

sequen

ces

of

food

beh

avio

rs, li

fe s

tage

requir

emen

ts, n

utr

itio

n r

ecom

men

dat

ions,

dis

ease

s an

d c

on

dit

ions,

physi

olo

gic

al

fun

ctio

n, or

pro

duct

s

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•H

arm

ful

bel

iefs

/att

itudes

about

food,

nutr

itio

n,

and n

utr

itio

n-r

elat

ed t

opic

s

•L

ack o

f pri

or

exposu

re t

o i

nfo

rmat

ion

•L

anguag

e or

cult

ura

l bar

rier

im

pac

ting a

bil

ity t

o l

earn

info

rmat

ion

•L

earn

ing d

isabil

ity,

neu

rolo

gic

al o

r se

nso

ry i

mpai

rmen

t

•P

rior

exposu

re t

o i

nco

mp

atib

le i

nfo

rmat

ion

•P

rior

exposu

re t

o i

nco

rrec

t in

form

atio

n

•U

nw

illi

ng t

o l

earn

or

unin

tere

sted

in l

earn

ing i

nfo

rmat

ion

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

FO

OD

- A

ND

NU

TR

ITIO

N-R

EL

AT

ED

KN

OW

LE

DG

E D

EF

ICIT

(N

B-1

.1)

Edit

ion:

20

06

12

4

Food/N

utr

itio

n H

isto

ryO

bse

rvat

ion

s or

report

s of:

•V

erbal

izes

inac

cura

te o

r in

com

ple

te i

nfo

rmat

ion

•P

rovid

es i

nac

cura

te o

r in

com

ple

te w

ritt

en r

espon

se t

o q

ues

tionn

aire

/wri

tten

tool,

or

is u

nable

to r

ead w

ritt

en t

ool

•D

emon

stra

tes

inab

ilit

y t

o a

pply

food-

and n

utr

itio

n-r

elat

ed i

nfo

rmat

ion

, e.

g., s

elec

t fo

od b

ased

on n

utr

itio

n t

her

apy o

r

pre

par

e in

fant

feed

ing a

s in

stru

cted

•R

elate

s co

nce

rns

about

pre

vio

us

atte

mpts

to l

earn

in

form

atio

n

•V

erbal

izes

un

wil

lingnes

s to

lea

rn o

r dis

inte

rest

in l

earn

ing i

nfo

rmat

ion

Cli

ent

His

tory

•C

lien

t or

care

giv

er h

as

no p

rior

know

ledg

e of

nee

d f

or

food a

nd n

utr

itio

n-r

elat

ed r

ecom

men

dat

ions

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t of,

e.g

., m

enta

l il

lnes

s

•N

ew m

edic

al d

iagnosi

s or

chan

ge

in e

xis

ting d

iagn

osi

s or

con

dit

ion

Refe

ren

ces:

1.

Cra

wfo

rd S

. P

rom

oti

ng d

ieta

ry c

han

ge.

Ca

n J

Ca

rdio

l. 1

99

5;1

1(s

up

pl

A):

14

A-1

5A

.

2.

Ku

man

yik

a S

K,

Van

Horn

L, B

ow

en D

, P

erri

MG

, R

oll

s B

J, C

zajk

ow

ski

SM

, S

chro

n E

. M

ainte

nan

ce o

f die

tary

beh

avio

r ch

ang

e.H

ealt

h P

sych

ol.

20

00

;19

(1 s

up

pl)

:S4

2-S

56

.

3.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Wei

ght

man

agem

ent.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

14

5-1

15

5.

4.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Tota

l die

t appro

ach

to c

om

munic

atin

g f

ood a

nd n

utr

itio

n i

nfo

rmat

ion.J

Am

Die

t A

sso

c. 2

00

2;1

02

:10

0-1

08

.

5.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

The

role

of

die

teti

cs p

rofe

ssio

nal

s in

hea

lth p

rom

oti

on a

nd d

isea

se p

reventi

on.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

68

0-1

68

7.

6.

Shep

her

d R

. R

esis

tan

ce t

o c

han

ges

in d

iet.

Pro

c N

utr

So

c. 2

00

2;6

1:2

67

-27

2.

7.

U.S

. P

reven

tive

Ser

vic

es T

ask F

orc

e. B

ehavio

ral

cou

nse

ling i

n p

rim

ary c

are

to p

rom

ote

a h

ealt

hy d

iet.

Am

J P

rev

Med

. 2

00

3;2

4:9

3-1

00

.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

HA

RM

FU

L B

EL

IEF

S/A

TT

ITU

DE

S O

R P

RA

CT

ICE

S A

BO

UT

FO

OD

, N

UT

RIT

ION

,A

ND

NU

TR

ITIO

N-R

EL

AT

ED

TO

PIC

S (

NB

-1.2

)

Edit

ion:

20

06

12

5

Use

wit

h c

au

tion

: B

e se

nsi

tive

to p

ati

en

t co

nce

rns.

De

fin

itio

n

Bel

iefs

/att

itudes

or

pra

ctic

es a

bout

food,

nutr

itio

n,

and n

utr

itio

n-r

elat

ed t

opic

s th

at a

re i

nco

mpat

ible

wit

h s

oun

d n

utr

itio

n p

rin

ciple

s, n

utr

itio

n c

are

or

dis

ease

/condit

ion (

excl

udin

g d

isord

ered

eat

ing p

atte

rns

and e

atin

g d

isord

ers)

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•D

isbel

ief

in s

cien

ce-b

ased

food a

nd n

utr

itio

n i

nfo

rmat

ion

•E

xposu

re t

o i

nco

rrec

t fo

od a

nd n

utr

itio

n i

nfo

rmat

ion

•E

ati

ng b

ehav

ior

serv

es a

purp

ose

oth

er t

han

nouri

shm

ent

(e.g

. P

ica)

•D

esir

e fo

r a

cure

for

a ch

ronic

dis

ease

thro

ugh t

he

use

of

alte

rnati

ve

ther

apy

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•F

ood f

etis

h, P

ica

•F

ood f

add

ism

•In

tak

e th

at r

efle

cts

an i

mbal

ance

of

nutr

ients

/food g

roups

•A

void

ance

of

foods/

food g

roups

(e.g

., s

ugar

, w

hea

t, c

ooked

foods)

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

HA

RM

FU

L B

EL

IEF

S/A

TT

ITU

DE

S O

R P

RA

CT

ICE

S A

BO

UT

FO

OD

, N

UT

RIT

ION

,A

ND

NU

TR

ITIO

N-R

EL

AT

ED

TO

PIC

S (

NB

-1.2

)

Edit

ion:

20

06

12

6

Cli

ent

His

tory

•C

ondit

ion

s as

soci

ate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., o

bes

ity,

dia

bet

es,

cance

r, c

ardio

vas

cula

r dis

ease

, m

enta

l il

lnes

s

Refe

ren

ces:

1.

Chap

man G

E, B

eagan

B.

Wom

en's

per

spec

tiv

es o

n n

utr

itio

n,

hea

lth,

and b

reast

can

cer

.J

Nu

tr E

du

c B

eha

v. 2

00

3;3

5:1

35

-14

1.

2.

Gonza

lez

VM

, V

itouse

k K

M.

Fea

red f

ood i

n d

ieti

ng a

nd n

on-d

ieti

ng y

ou

ng w

om

en:

a pre

lim

inar

y v

alid

atio

n o

f th

e F

ood P

ho

bia

Surv

ey.

Ap

peti

te. 2

00

4;4

3:1

55

-17

3.

3.

Jow

ett

SL

, S

eal

CJ,

Ph

illi

ps

E,

Gre

go

ry W

, B

arto

n J

R,

Wel

fare

MR

. D

ieta

ry b

elie

fs o

f p

eop

le w

ith

ulc

erat

ive

coli

tis

and

th

eir

effe

ct o

n r

elap

se a

nd

nu

trie

nt

inta

ke.

Cli

n N

utr

. 2

00

4;2

3:1

61

-17

0.

4.

Mad

den

H,

Cham

ber

lain

K.

Nu

trit

ional

hea

lth m

ess

ages

in w

om

en's

mag

azi

nes

: a

confl

icte

d s

pace

for

wo

men

rea

der

s.J

Hea

lth

Psy

cho

log

y. 2

00

4;9

:58

3-5

97

.

5.

Pet

ers

CL

, S

hel

ton J

, S

har

ma

P.

An i

nv

esti

gati

on o

f fa

ctors

that

infl

uen

ce t

he

con

sum

pti

on o

f die

tary

su

pple

men

ts.

Hea

lth

Ma

rk P

sych

ol.

20

03

;21

:11

3-1

35

.

6.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Foo

d a

nd n

utr

itio

n m

isin

form

atio

n.J

Am

Die

t A

sso

c. 2

00

2;1

02

:260

-26

6.

7.

Pov

ey R

, W

elle

ns

B, C

onn

er M

. A

ttit

ud

es t

ow

ards

foll

ow

ing m

eat,

veget

aria

n a

nd v

egan d

iets

: an

exam

inat

ion o

f th

e ro

le o

f am

biv

alen

ce.

Ap

pet

ite.

20

01

;37

:15

-26

.

8.

Putt

erm

an E

, L

inden

W.

Ap

pea

rance

ver

sus

hea

lth:

does

the

reas

on f

or

die

ting a

ffec

t die

ting b

ehav

ior?

J B

eha

v M

ed. 2

00

4;2

7:1

85

-20

4.

9.

Sal

min

en E

, H

eik

kil

a S

, P

ou

ssa

T,

Lag

stro

m H

, S

aari

o R

, S

alm

inen

S.

Fem

ale

pat

ien

ts t

end

to

alt

er t

hei

r die

t fo

llo

win

g t

he

dia

gno

sis

of

rheu

mat

oid

art

hri

tis

and

bre

ast

cance

r.P

rev

Med

.

20

02

;34

:529

-53

5.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

NO

T R

EA

DY

FO

R D

IET

/LIF

ES

TY

LE

CH

AN

GE

(N

B-1

.3)

Edit

ion:

20

06

12

7

De

fin

itio

n

Lac

k o

f per

ceiv

ed v

alue

of

nutr

itio

n-r

elat

ed b

ehav

ior

chan

ge

com

par

ed t

o c

ost

s (c

on

sequen

ces

or

effo

rt r

equir

ed t

o m

ake

chan

ges

); c

onfl

ict

wit

h p

erso

nal

val

ue

syst

em;

ante

ceden

t to

beh

avio

r ch

ang

e

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•H

arm

ful

bel

iefs

/att

itudes

about

food,

nutr

itio

n,

and n

utr

itio

n-r

elat

ed t

opic

s

•C

ogn

itiv

e def

icit

s or

inab

ilit

y to f

ocu

s on d

ieta

ry c

han

ges

•L

ack o

f so

cial

support

for

imple

men

ting c

han

ges

•D

enia

l of

nee

d t

o c

han

ge

•P

erce

pti

on t

hat

tim

e, i

nte

rper

sonal,

or

finan

cial

con

stra

ints

pre

ven

t ch

anges

•U

nw

illi

ng o

r unin

tere

sted

in l

earn

ing i

nfo

rmat

ion

•L

ack o

f se

lf-e

ffic

acy f

or

mak

ing c

han

ge

or

dem

ora

liza

tion f

rom

pre

vio

us

fail

ure

s at

chan

ge

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

•N

egat

ive

bod

y l

anguag

e, e

.g., f

row

nin

g, la

ck o

f ey

e co

nta

ct, def

ensi

ve

post

ure

, la

ck o

f fo

cus,

fid

get

ing (

Note

: bod

y

lan

guag

e var

ies

by c

ult

ure

.)

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

NO

T R

EA

DY

FO

R D

IET

/LIF

ES

TY

LE

CH

AN

GE

(N

B-1

.3)

Edit

ion:

20

06

12

8

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•D

enia

l of

nee

d f

or

food-

and n

utr

itio

n-r

elat

ed c

han

ges

•In

abil

ity to u

nder

stan

d r

equir

ed c

han

ges

•F

ailu

re t

o k

eep a

ppoin

tmen

ts/s

ched

ule

foll

ow

-up a

ppoin

tmen

ts o

r en

gag

e in

coun

seli

ng

•P

revio

us

fail

ure

s to

eff

ecti

vel

y c

han

ge

targ

et b

ehav

ior

•D

efen

siven

ess,

host

ilit

y,

or

resi

stan

ce t

o c

han

ge

•L

ack o

f ef

fica

cy t

o m

ake

chan

ge

or

to o

ver

com

e bar

rier

s to

chan

ge

Cli

ent

His

tory

•N

ew m

edic

al d

iagnosi

s, c

han

ge

in e

xis

tin

g d

iagn

osi

s or

con

dit

ion

, or

chro

nic

non

-com

pli

ance

Refe

ren

ces:

1.

Cra

wfo

rd S

. P

rom

oti

ng d

ieta

ry c

han

ge.

Ca

n J

Ca

rdio

l. 1

99

5;1

1:1

4A

-15

A.

2.

Gre

ene

GW

, R

oss

i S

R,

Ro

ssi

JS, V

elic

er W

F, F

ava

JS, P

roch

ask

a JO

. D

ieta

ry a

ppli

cati

on

s o

f th

e S

tag

es o

f C

han

ge

Mo

del

.J

Am

Die

t A

sso

c.

19

99

;99

:67

3-6

78

.

3.

Ku

man

yik

a S

K,

Van

Horn

L, B

ow

en D

, P

erri

MG

, R

oll

s B

J, C

zajk

ow

ski

SM

, S

chro

n E

. M

ainte

nan

ce o

f die

tary

beh

avio

r ch

ang

e.H

ealt

h P

sych

ol.

20

00

;19

:S4

2-S

56

.

4.

Pro

chask

a JO

, V

elic

er W

F.

The

Tra

nst

heore

tica

l M

od

el o

f behav

ior

change.

Am

J H

ealt

h P

rom

oti

on

. 1

99

7;1

2:3

8–

48

.

5.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Tota

l die

t appro

ach

to c

om

munic

atin

g f

ood a

nd n

utr

itio

n i

nfo

rmat

ion.J

Am

Die

t A

sso

c. 2

00

2;1

02

:10

0-1

08

.

6.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

The

role

of

die

teti

cs p

rofe

ssio

nal

s in

hea

lth p

rom

oti

on a

nd d

isea

se p

reventi

on.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

68

0-1

68

7.

7.

Res

nic

ow

K,

Jack

son

A,

Wan

g T

, D

e A

, M

cCar

ty F

, D

ud

ley

W,

Bar

on

ow

ski

T.

A m

oti

vat

ional

in

terv

iew

ing

inte

rven

tio

n t

o in

crea

se f

ruit

an

d v

eget

able

inta

ke

thro

ugh

bla

ck c

hu

rch

es:

Res

ult

s o

f

the

Eat

for

Lif

e tr

ial.

Am

J P

ub

lic

Hea

lth

. 2

00

1;9

1:1

68

6-1

69

3.

8.

Shep

her

d R

. R

esis

tan

ce t

o c

han

ges

in d

iet.

Pro

c N

utr

So

c. 2

00

2;6

1:2

67

-27

2.

9.

U.S

. P

reven

tive

Ser

vic

es T

ask F

orc

e. B

ehavio

ral

cou

nse

ling i

n p

rim

ary c

are

to p

rom

ote

a h

ealt

hy d

iet.

Am

J P

rev

Med

. 2

00

3;2

4:9

3-1

00

.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

SE

LF

-MO

NIT

OR

ING

DE

FIC

IT (

NB

-1.4

)

Edit

ion:

20

06

12

9

De

fin

itio

n

Lac

k o

f data

rec

ord

ing t

o t

rack

per

son

al p

rogre

ss

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•L

ack o

f so

cial

support

for

imple

men

ting c

han

ges

•L

ack o

f val

ue

for

beh

avio

r ch

ange

or

com

pet

ing v

alues

•P

erce

pti

on t

hat

lack

of

reso

urc

es,

e.g., t

ime,

fin

anci

al,

or

soci

al

support

pre

ven

t se

lf-m

onit

ori

ng

•C

ult

ura

l bar

rier

im

pact

ing a

bil

ity t

o t

rack

per

sonal

pro

gre

ss

•L

earn

ing d

isab

ilit

y,

neu

rolo

gic

al,

or s

enso

ry im

pai

rmen

t

•P

rior

exposu

re t

o i

nco

mp

atib

le i

nfo

rmat

ion

•N

ot

read

y f

or

die

t/li

fest

yle

chan

ge

•U

nw

illi

ng o

r unin

tere

sted

in t

rack

ing p

rogre

ss

•L

ack o

f fo

cus

and a

tten

tion t

o d

etai

l, d

iffi

cult

y w

ith t

ime

man

agem

ent

and/o

r org

aniz

atio

n

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•R

ecord

ed d

ata

inco

nsi

sten

t w

ith b

ioch

emic

al d

ata,

e.g

., d

ieta

ry in

take

is n

ot

con

sist

ent

wit

h b

ioch

emic

al d

ata

Anth

ropom

etri

c M

easu

rem

ents

•R

ecord

ed d

ata

inco

nsi

sten

t w

ith w

eig

ht

stat

us

or

gro

wth

pat

tern

data

, e.

g., d

ieta

ry in

take

is n

ot

con

sist

ent

wit

h w

eigh

t

statu

s or

gro

wth

pat

tern

Phys

ical

Exam

Fin

din

gs

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

SE

LF

-MO

NIT

OR

ING

DE

FIC

IT (

NB

-1.4

)

Edit

ion:

20

06

13

0

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•In

com

ple

te s

elf-

monit

ori

ng r

ecord

s, e

.g., g

luco

se,

food,

fluid

inta

ke,

wei

ght,

ph

ysic

al a

ctiv

ity,

ost

om

y o

utp

ut

reco

rds

•E

mbar

rass

men

t or

an

ger

reg

ardin

g n

eed f

or

self

-monit

ori

ng

•U

nce

rtai

nty

of

how

to c

om

ple

te m

on

itori

ng r

ecord

s

•U

nce

rtai

nty

reg

ardin

g c

han

ges

th

at c

ould

/sh

ould

be

made

in r

espon

se t

o d

ata

in s

elf

mon

itori

ng r

ecord

s

•N

o s

elf

manag

emen

t eq

uip

men

t, e

.g. n

o b

lood g

luco

se m

on

itor,

ped

om

eter

Cli

ent

His

tory

•D

iagn

ose

s re

quir

ing s

elf-

monit

ori

ng,

e.g., d

iabet

es m

elli

tus,

obes

ity,

new

ost

om

y

•N

ew m

edic

al d

iagnosi

s or

chan

ge

in e

xis

ting d

iagn

osi

s or

con

dit

ion

Refe

ren

ces:

1.

Am

eric

an D

iabet

es A

ssoci

atio

n.

Tes

ts o

f gly

cem

ia i

n d

iabet

es.

Dia

bet

es C

are

. 2

00

4;2

7:S

91

-S9

3.

2.

Bak

er R

C,

Kir

sch

enbau

m D

S. W

eig

ht

contr

ol

duri

ng t

he

holi

days:

hig

hly

co

nsi

sten

t se

lf-m

onit

ori

ng a

s a

pote

nti

ally

use

ful

copin

g

mech

anis

m.

Hea

lth

Psy

cho

l. 1

99

8;1

7:3

67

-37

0.

3.

Ber

ko

wit

z R

I, W

adden

TA

, T

ersh

akovec

AM

. B

ehavio

r th

erap

y a

nd s

ibutr

am

ine

for

trea

tment

of

adole

scen

t ob

esit

y.JA

MA

. 2

00

3;2

89

:18

05

-18

12

.

4.

Cra

wfo

rd S

. P

rom

oti

ng d

ieta

ry c

han

ge.

Ca

n J

Ca

rdio

l. 1

99

5;1

1(s

up

pl

A):

14

A-1

5A

.

5.

Jeff

ery

R,

Dre

wn

ow

ski

A, E

pst

ein

L,

Stu

nk

ard

A, W

ilso

n G

, W

ing

R.

Lo

ng

-ter

m m

ain

ten

ance

of

wei

gh

t lo

ss:

curr

ent

stat

us.

Hea

lth

Psy

cho

l. 2

00

0;1

9:5

-16

.

6.

Ku

man

yik

a S

K,

Van

Horn

L, B

ow

en D

, P

erri

MG

, R

oll

s B

J, C

zajk

ow

ski

SM

, S

chro

n E

. M

ainte

nan

ce o

f die

tary

beh

avio

r ch

ang

e.H

ealt

h P

sych

ol.

20

00

;19

(1 s

up

pl)

:S4

2-S

56

.

7.

Lic

htm

an S

W,

Pis

ask

a K

, B

erm

an E

R, P

esto

ne

M, D

ow

lin

g H

, O

ffen

bach

er E

, W

eise

l H

, H

eshk

a S

, M

atth

ews

DE

, H

eym

sfie

ld S

B.

Dis

crep

ancy

bet

wee

n s

elf-

rep

ort

ed a

nd

act

ual

cal

ori

c in

tak

e an

d

exer

cise

in o

bes

e s

ubje

cts

.N

En

gl

J M

ed . 1

99

2;3

27

:18

93

-18

98

.

8.

Wad

den

, T

A. C

har

acte

rist

ics

of

succ

essf

ul

wei

ght

loss

mai

nta

iner

s. I

n:

All

iso

n D

B, P

i-S

un

yer

FX

, ed

s.O

bes

ity

trea

tmen

t: e

sta

bli

shin

g g

oa

ls, im

pro

vin

g o

utc

om

es, a

nd

rev

iew

ing

th

e re

sea

rch

ag

end

a.

New

York

, N

Y:

Ple

nu

m P

ress

;199

5:1

03

-11

1.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

DIS

OR

DE

RE

D E

AT

ING

PA

TT

ER

N (

NB

-1.5

)

Edit

ion:

20

06

13

1

De

fin

itio

n

Bel

iefs

, at

titu

des

, th

oughts

an

d b

ehav

iors

rel

ated

to f

ood,

eati

ng, an

d w

eight

man

agem

ent,

in

cludin

g c

lass

ic e

atin

g d

isord

ers

as w

ell

as l

ess

sever

e, s

imil

ar

con

dit

ion

s th

at n

egat

ivel

y im

pac

t h

ealt

h

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•O

bse

ssiv

e des

ire

to b

e th

in r

elat

ed t

o f

amil

ial,

soci

etal,

bio

logic

al/g

enet

ic,

and/o

r gen

etic

fac

tors

•W

eig

ht re

gula

tion

/pre

occ

upati

on s

ignif

ican

tly in

fluen

ces

self

est

eem

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•E

levat

ed c

hole

ster

ol,

abn

orm

al l

ipid

pro

file

s, h

ypogly

cem

ia, h

ypokal

emia

[an

orex

ia n

ervosa

(A

N)]

•H

ypokale

mia

an

d h

ypoch

lore

mic

alk

alosi

s [b

uli

mia

ner

vosa

(B

N)]

•H

yp

ote

nsi

on,

brad

ycar

dia

, lo

w b

ody t

emp

erat

ure

, h

yponatr

emia

, an

emia

, h

ypoth

yroid

, le

uco

pen

ia,

elev

ated

BU

N (

AN

)

•U

rin

e posi

tive

for

ket

on

es (

AN

)

Anth

ropom

etri

c M

easu

rem

ents

•B

MI

< 1

7.5

, ar

rest

ed g

row

th a

nd d

evel

opm

ent,

fai

lure

to g

ain w

eigh

t duri

ng p

erio

d o

f ex

pec

ted g

row

th, w

eigh

t le

ss t

han

85%

of

expec

ted w

eigh

t (A

N)

•B

MI

> 2

9 [

eati

ng d

isord

er n

ot

oth

erw

ise

spec

ifie

d (

ED

NO

S)]

•S

ign

ific

ant

wei

gh

t fl

uct

uat

ion (

BN

)

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

DIS

OR

DE

RE

D E

AT

ING

PA

TT

ER

N (

NB

-1.5

)

Edit

ion:

20

06

13

2

Phys

ical

Exam

Fin

din

gs

•S

ever

ely d

eple

ted a

dip

ose

an

d s

om

atic

pro

tein

sto

res

(AN

)

•L

anugo h

air

form

atio

n o

n f

ace

and t

run

k,

brit

tle

list

less

hai

r, c

yan

osi

s of

han

ds

and f

eet,

an

d d

ry s

kin

(A

N)

•N

orm

al o

r ex

cess

adip

ose

and n

orm

al s

om

atic

pro

tein

sto

res

(BN

, E

DN

OS

)

•D

amag

ed t

ooth

en

amel

(B

N)

•E

nla

rged

par

oti

d g

lan

ds

(BN

)

•P

erip

her

al e

dem

a (B

N)

•S

kel

etal

musc

le l

oss

(A

N)

•C

ardia

c ar

rhyt

hm

ias

(AN

, B

N)

•Ir

rita

bil

ity,

dep

ress

ion (

AN

, B

N)

•In

abil

ity t

o c

once

ntr

ate

(AN

)

•P

osi

tive

Ru

ssel

l’s

Sig

n (

BN

) ca

llous

on b

ack o

f h

and f

rom

sel

f in

duce

d v

om

itin

g

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•A

void

ance

of

food o

r ca

lori

e-co

nta

inin

g b

ever

ages

(A

N,

BN

)

•F

ear

of

foods

or

dysf

un

ctio

nal

th

oughts

reg

ardin

g f

ood o

r fo

od e

xper

ien

ces

(AN

, B

N)

•D

enia

l of

hung

er (

AN

)

•F

ood p

reocc

upati

on (

AN

, B

N)

•K

now

ledgea

ble

about

curr

ent

die

t fa

d (

AN

, B

N, E

DN

OS

)

•F

asti

ng (

AN

, B

N)

•In

tak

e of

larg

er q

uan

tity

of

food i

n a

def

ined

tim

e per

iod,

a se

nse

of

lack

of

con

trol

over

eat

ing d

uri

ng t

he

epis

ode

(BN

,E

DN

OS

)

•E

xce

ssiv

e ph

ysic

al a

ctiv

ity (

AN

, B

N,

ED

NO

S)

•E

ati

ng m

uch

more

rap

idly

th

an n

orm

al,

eati

ng u

nti

l fe

elin

g u

nco

mfo

rtably

full

; co

nsu

min

g l

arge

amoun

ts o

f fo

od w

hen

not

feel

ing p

hys

ical

ly h

un

gry

; ea

ting a

lon

e bec

ause

of

bei

ng e

mbar

rass

ed b

y h

ow

much

on

e is

eat

ing;

feel

ing d

isgu

sted

wit

hon

esel

f, d

epre

ssed

, or

ver

y g

uil

ty a

fter

over

eati

ng (

ED

NO

S)

•E

ats

in p

rivat

e (A

N,

BN

)

•Ir

rati

onal

th

oughts

about

food’s

aff

ect

on t

he

bod

y (

AN

, B

N,

ED

NO

S)

•P

atte

rn o

f ch

ron

ic d

ieti

ng

•W

eigh

t pre

occ

upati

on

•E

xce

ssiv

e re

lian

ce o

n n

utr

itio

n T

erm

ing a

nd p

reocc

upati

on w

ith n

utr

ien

t co

nte

nt

of

foods

•In

flex

ibil

ity w

ith f

ood s

elec

tion

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

DIS

OR

DE

RE

D E

AT

ING

PA

TT

ER

N (

NB

-1.5

)

Edit

ion:

20

06

13

3

Cli

ent

His

tory

•B

radyca

rdia

(h

eart

rat

e <

60 b

eats

/min

), h

ypote

nsi

on (

syst

oli

c <

90 m

m H

g),

and o

rth

ost

ati

c h

ypote

nsi

on (

AN

)

•S

elf-

induce

d v

om

itin

g,

dia

rrh

ea,

blo

atin

g,

con

stip

atio

n a

nd f

latu

len

ce (

BN

)

•R

eport

of

alw

ays

feel

ing c

old

(A

N)

•M

isuse

of

laxati

ves

, en

emas

, diu

reti

cs,

stim

ula

nts

an

d/o

r m

etab

oli

c en

han

cers

(A

N,

BN

)

•M

usc

le w

eakn

ess,

fat

igu

e, c

ardia

c ar

rhyt

hm

ias,

deh

ydra

tion

, an

d e

lect

roly

te i

mbal

ance

(A

N, B

N)

•D

iagnosi

s, e

.g., a

nor

exia

ner

vosa

, buli

mia

ner

vosa

, bin

ge

eati

ng,

eati

ng d

isord

er n

ot

oth

erw

ise

spec

ifie

d,

amen

orrh

ea

•H

isto

ry o

f m

ood a

nd a

nxie

ty d

isord

ers

(e.g

., d

epre

ssio

n, obse

ssiv

e co

mpu

lsiv

e dis

ord

er),

per

sonali

ty d

isord

ers,

subst

ance

abuse

dis

ord

ers

•F

amil

y h

isto

ry o

f E

D,

dep

ress

ion,

OC

D,

anxie

ty d

isord

ers

(AN

, B

N)

•A

void

ance

of

soci

al

even

ts w

her

e fo

od i

s se

rved

Refe

ren

ces:

1.

Ander

son G

H,

Ken

ned

y S

H,

eds.

Th

e B

iolo

gy

of

Fea

st a

nd

Fa

min

e. N

ew Y

ork

: A

cad

emic

Pre

ss;

19

92

.

2.

Am

eric

an P

sych

iatr

ic A

sso

ciat

ion

.D

iag

no

stic

an

d S

tati

stic

al

Ma

nu

al

for

Men

tal D

iso

rder

s (F

ou

rth

Ed

itio

n,

Tex

t R

evis

ion

). W

ash

ingto

n, D

C:

AP

A P

ress

; 2

00

0.

3.

Am

eric

an P

sych

iatr

ic A

sso

ciat

ion.

Pra

ctic

e guid

elin

es

for

the

trea

tmen

t of

pati

ents

wit

h e

atin

g d

isord

ers.

Am

J P

sych

iatr

y. 2

00

0;1

57

(su

pp

l):1

-39

.

4.

Cook

e R

A,

Cham

ber

s JB

. A

nore

xia

ner

vo

sa a

nd t

he

hea

rt.

Br

J H

osp

Med

. 1

99

5;5

4:3

13

-31

7.

5.

Fis

her

M.

Med

ical

co

mpli

cati

on

s of

anore

xia

an

d b

uli

mia

ner

vosa

.A

do

l M

ed

. 1

99

2;3

:48

1-5

02

.

6.

Gra

len S

J, L

evin

MP

, S

mola

k L

et al

. D

ieti

ng a

nd d

isord

ered

eat

ing d

uri

ng e

arly

an

d m

iddle

adole

scents

: D

o t

he

infl

uen

ces

rem

ain t

he

sam

e?In

t J

Ea

t D

iso

rd. 1

99

0;9

:50

1-5

12

.

7.

Har

ris

JP,

Kri

epe

RE

, R

oss

bac

k C

N. Q

T p

rolo

ngat

ion b

y i

sopro

tere

nol

in a

nore

xia

ner

vosa

.J

Ad

ol

Hea

lth

. 1

99

3;1

4:3

90

-39

3.

8.

Kapla

n A

S, G

arf

unk

el P

E,

eds.

Med

ica

l Is

sues

an

d t

he

Ea

tin

g D

iso

rder

s: T

he

Inte

rfa

ce. N

ew Y

ork

,NY

: B

run

ner

/Man

zel

Pu

bli

sher

s; 1

99

3.

9.

Key

s A

, B

roze

k J

, H

ensc

hel

A, M

ick

elso

n O

, T

aylo

r H

L.T

he

Bio

log

y o

f H

um

an

Sta

rva

tio

n, 2

nd

vo

l. M

inn

eap

oli

s, M

inn

: U

niv

ersi

ty o

f M

inn

esota

Pre

ss; 1

95

0.

10

. K

irkle

y B

G. B

uli

mia

: cl

inic

al

char

act

eris

tics

, dev

elop

men

t, a

nd e

tio

log

y.J

Am

Die

t A

sso

c. 1

98

6;8

6:4

68

-47

5.

11

. K

reip

e R

E,

Up

hoff

M.

Tre

atm

ent

and o

utc

om

e of

adole

scen

ts w

ith a

nore

xia

ner

vo

sa.

Ad

ole

sc M

ed.1

99

2;1

6:5

19

-54

0.

12

. K

reip

e R

E, B

irndorf

DO

. E

atin

g d

isord

ers

in a

dole

scen

ts a

nd y

ou

ng a

dult

s.M

ed C

lin

N A

m. 2

00

0;8

4(4

):1

02

7-1

04

9.

13

. M

ord

asi

ni

R,

Klo

se G

, G

rete

r H

. S

econdar

y t

yp

e II

hyp

erli

popro

tein

emia

in p

atie

nts

wit

h a

nore

xia

ner

vosa

.M

eta

bo

lism

. 1

97

8;2

7:7

1-7

9.

14

. P

osi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Nu

trit

ion i

nte

rven

tio

n i

n t

he

trea

tment

of

anore

xia

ner

vo

sa,

buli

mia

ner

vo

sa, and e

atin

g d

isord

er n

ot

oth

erw

ise

spec

ifie

d (

ED

NO

S).

J A

m D

iet

Ass

oc.

20

01

;10

1:8

10

-81

9.

16

. R

ock

C,

Yager

J. N

utr

itio

n a

nd e

atin

g d

isord

ers:

a p

rim

er f

or

clin

icia

ns.

Int

J E

at

Dis

ord

. 1

98

7;6

:26

7-2

80

.

17

. R

ock

CL

. N

utr

itio

nal

an

d m

edic

al a

sses

sment

and m

anag

emen

t of

eati

ng d

isord

ers.

Nu

tr C

lin

Ca

re. 1

99

9;2

:33

2-3

43

.

18

. S

cheb

end

ach

J,

Rei

cher

t-A

nd

erso

n P

. N

utr

itio

n i

n E

atin

g D

iso

rder

s. I

n:

Mahan

K,

Esc

ott

-Stu

mp

S,

eds.

Kra

us’

s N

utr

itio

n a

nd

Die

t T

her

ap

y. N

ew Y

ork

, N

Y:

McG

raw

- H

ill;

20

00

.

19

. S

ilb

er T

. A

nore

xia

ner

vosa

: M

orb

idit

y a

nd m

ort

alit

y.

Peia

tr A

nn

. 1

98

4;1

3:8

51

-85

9.

20

. S

wen

ne

I. H

eart

ris

k a

ssoci

ate

d w

ith w

eig

ht

loss

in a

nore

xia

ner

vo

sa a

nd e

atin

g d

isord

ers:

ele

ctro

card

iogra

phic

changes

duri

ng t

he

earl

y p

hase

of

refe

edin

g.A

cta

Pa

edia

tr.

20

00

;89

:44

7-4

52

.

21

. T

urn

er J

M, B

uls

ara

MK

, M

cDer

mo

tt B

M, B

yrn

e G

C, P

rin

ce R

L, F

orb

es

DA

. P

redic

tors

of

low

bo

ne d

en

sity

in

you

ng

ad

ole

scent

fem

ale

s w

ith

anore

xia

nerv

osa

and

oth

er d

ieti

ng

dis

ord

ers.

Int

J

Ea

t D

iso

rd.

20

01

;30

:24

5-2

51

.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

LIM

ITE

D A

DH

ER

EN

CE

TO

NU

TR

ITIO

N-R

EL

AT

ED

RE

CO

MM

EN

DA

TIO

NS

(N

B-1

.6)

Edit

ion:

20

06

13

4

De

fin

itio

n

Lac

k o

f n

utr

itio

n-r

elat

ed c

han

ges

as

per

inte

rven

tion a

gre

ed u

pon b

y c

lien

t or

popula

tion

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•L

ack o

f so

cial

support

for

imple

men

ting c

han

ges

•L

ack o

f val

ue

for

beh

avio

r ch

ange

or

com

pet

ing v

alues

•P

erce

pti

on t

hat

tim

e or

fin

anci

al c

on

stra

ints

pre

ven

t ch

anges

•P

revio

us

lack

of

succ

ess

in m

akin

g h

ealt

h-r

elat

ed c

han

ges

•P

oor

un

der

stan

din

g o

f h

ow

an

d w

hy to m

ake

chan

ges

•U

nw

illi

ng t

o a

pply

or

unin

tere

sted

in a

pply

ing i

nfo

rmat

ion

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•E

xpec

ted l

abora

tory

outc

om

es a

re n

ot

achie

ved

Anth

ropom

etri

c M

easu

rem

ents

•E

xpec

ted a

nth

ropom

etri

c outc

om

es a

re n

ot

ach

ieved

Phys

ical

Exam

Fin

din

gs

•N

egat

ive

bod

y l

anguag

e, e

.g., f

row

nin

g, la

ck o

f ey

e co

nta

ct, fi

dg

etin

g (

Note

: bod

y lan

guag

e var

ies

by c

ult

ure

)

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

LIM

ITE

D A

DH

ER

EN

CE

TO

NU

TR

ITIO

N-R

EL

AT

ED

RE

CO

MM

EN

DA

TIO

NS

(N

B-1

.6)

Edit

ion:

20

06

13

5

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•E

xpec

ted f

ood/n

utr

itio

n-r

elat

ed o

utc

om

es a

re n

ot

ach

ieved

•In

abil

ity to r

ecal

l ag

reed

upon c

han

ges

•F

ailu

re t

o c

om

ple

te a

ny a

gre

ed u

pon h

om

ework

•L

ack o

f co

mpli

ance

or

inco

nsi

sten

t co

mp

lian

ce w

ith p

lan

•F

ailu

re t

o k

eep a

ppoin

tmen

ts o

r sc

hed

ule

foll

ow

-up a

ppoin

tmen

ts

•L

ack o

f ap

pre

ciat

ion o

f th

e im

port

ance

of

makin

g r

ecom

men

ded

nutr

itio

n-r

elat

ed c

han

ges

•U

nce

rtai

nty

as

to h

ow

to c

on

sist

entl

y a

pp

ly f

ood/n

utr

itio

n i

nfo

rmat

ion

Cli

ent

His

tory

Refe

ren

ces:

1.

Cra

wfo

rd S

. P

rom

oti

ng d

ieta

ry c

han

ge.

Ca

n J

Ca

rdio

l. 1

99

5;1

1(s

up

pl

A):

14

A-1

5A

.

2.

Ku

man

yik

a S

K,

Van

Horn

L, B

ow

en D

, P

erri

MG

, R

oll

s B

J, C

zajk

ow

ski

SM

, S

chro

n E

. M

ainte

nan

ce o

f die

tary

beh

avio

r ch

ang

e.H

ealt

h P

sych

ol.

20

00

;19

(1 s

up

pl)

:S4

2-S

56

.

3.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Tota

l die

t appro

ach

to c

om

munic

atin

g f

ood a

nd n

utr

itio

n i

nfo

rmat

ion.J

Am

Die

t A

sso

c. 2

00

2;1

02

:10

0-1

08

.

4.

Shep

her

d R

. R

esis

tan

ce t

o c

han

ges

in d

iet.

Pro

c N

utr

So

c. 2

00

2;6

1:2

67

-27

2.

5.

U.S

. P

reven

tive

Ser

vic

es T

ask F

orc

e. B

ehavio

ral

cou

nse

ling i

n p

rim

ary c

are

to p

rom

ote

a h

ealt

hy d

iet.

Am

J P

rev

Med

. 2

00

3;2

4:9

3-1

00

.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

UN

DE

SIR

AB

LE

FO

OD

CH

OIC

ES

(N

B-1

.7)

Edit

ion:

20

06

13

6

De

fin

itio

n

Food a

nd/o

r bev

erage

choic

es t

hat

are

in

con

sist

ent

wit

h U

S R

ecom

men

ded

Die

tary

In

take,

US

Die

tary

Guid

elin

es,

or

wit

h t

he

My P

yra

mid

or

wit

h t

arget

s

def

ined

in t

he

nutr

itio

n p

resc

ripti

on o

r nutr

itio

n c

are

pro

cess

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•L

ack o

f pri

or

exposu

re t

o o

r m

isun

der

stan

din

g o

f in

form

atio

n

•L

anguag

e, r

elig

ious,

or

cult

ura

l bar

rier

s af

fect

ing a

bil

ity t

o a

pply

in

form

atio

n

•L

earn

ing d

isabil

itie

s, n

euro

logic

al o

r se

nso

ry im

pai

rmen

t

•H

igh l

evel

of

fati

gu

e or

oth

er s

ide

effe

ct o

f th

erap

y

•In

adeq

uat

e ac

cess

to r

ecom

men

ded

foods

•P

erce

pti

on t

hat

fin

anci

al c

on

stra

ints

pre

ven

t se

lect

ion o

f fo

od c

hoic

es c

on

sist

ent

wit

h r

ecom

men

dat

ions

•F

ood a

ller

gie

s an

d a

ver

sion

s im

ped

ing f

ood c

hoic

es c

on

sist

ent

wit

h g

uid

elin

es

•L

acks

moti

vat

ion a

nd/o

r re

adin

ess

to a

pply

or

support

syst

ems

chan

ge

•U

nw

illi

ng o

r unin

tere

sted

in l

earn

ing i

nfo

rmat

ion

•P

sych

olo

gic

al

lim

itat

ion

s

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•E

levat

ed l

ipid

pan

el

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

•F

ind

ings

con

sist

ent

wit

h v

itam

in/m

iner

al

def

icie

ncy

or

exce

ss

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

K

now

ledge

and B

elie

fs

UN

DE

SIR

AB

LE

FO

OD

CH

OIC

ES

(N

B-1

.7)

Edit

ion:

20

06

13

7

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•In

tak

e in

consi

sten

t w

ith U

S D

ieta

ry G

uid

elin

es o

r M

y P

yram

id (

e.g., o

mis

sion o

f en

tire

nutr

ien

t gro

ups,

dis

pro

port

ionat

e

inta

ke

such

as

juic

e fo

r youn

g c

hil

dre

n])

•In

acc

ura

te o

r in

com

ple

te u

nder

stan

din

g o

f th

e guid

elin

es

•In

abil

ity t

o a

pply

guid

elin

e in

form

atio

n

•In

abil

ity (

e.g

. ac

cess

) or

un

wil

lin

gn

ess

to s

elec

t, o

r dis

inte

rest

in s

elec

tin

g f

ood c

on

sist

ent

wit

h t

he

guid

elin

es

Cli

ent

His

tory

•C

ondit

ion

s as

soci

ate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., m

enta

l il

lnes

s

Refe

ren

ces:

1.

Bir

ch L

L,

Fis

her

JA

. A

ppet

ite

and e

ati

ng b

ehav

ior

in c

hil

dre

n.

Ped

iatr

Cli

n N

ort

h A

m.1

99

5:4

2;9

31

-95

3.

2.

Bu

tte

N, C

obb

K,

Dw

yer

J, G

ran

ey L

, H

eird

W,

Ric

har

d K

. T

he

star

t h

ealt

hy

fee

din

g g

uid

elin

es f

or

infa

nts

an

d t

od

dle

rs.

J A

m D

iet

Ass

oc.

20

04

;10

4:4

42

-45

4.

3.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Wei

ght

man

agem

ent.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

14

5-1

15

5.

4.

Dole

cek

TA

, S

tam

lee

J, C

aggiu

la A

W,

Til

lots

on

JL

, B

uzz

ard

IM

. M

eth

od

s o

f die

tary

an

d n

utr

itio

nal

ass

essm

ent

and

in

terv

enti

on

an

d o

ther

met

ho

ds

in t

he

mu

ltip

le r

isk

fac

tor

inte

rven

tio

n t

rial

.A

m

J C

lin

Nu

tr.

19

97

;65

(su

ppl)

:19

6S

-21

0S

.

5.

Epst

ein L

H, G

ord

y C

C, R

aynor

HA

, B

eddom

e M

, K

ilanow

ski

CK

, P

alu

ch R

. In

crea

sin

g f

ruit

an

d v

eget

able

inta

ke

and d

ecr

easi

ng f

at a

nd s

ugar

inta

ke

in f

am

ilie

s at

ris

k f

or

chil

dh

ood o

bes

ity.

Ob

esit

y R

es.2

00

1;9

:17

1-1

78

.

6.

Fre

eland

-Gra

ves

J, N

itzk

e S

. T

ota

l die

t appro

ach

to c

om

mu

nic

atin

g f

ood a

nd n

utr

itio

n i

nfo

rmat

ion.J

Am

Die

t A

sso

c. 2

00

2;1

02

:10

0-1

08

.

7.

Fre

nch

SA

. P

rici

ng e

ffec

ts o

n f

oo

d c

hoic

es.

J N

utr

. 2

00

3;1

33

(su

pp

l):8

41

S-8

43

S.

8.

Gle

ns

K,

Basi

l M

, M

aria

chi

E,

Go

ldb

erg J

, S

ny

der

D. W

hy A

mer

ican

s ea

t w

hat

they

do:

tast

e, n

utr

itio

n,

cost

, co

nv

enie

nce

and w

eig

ht

contr

ol

concer

ns

as

infl

uen

ces

on f

ood c

onsu

mpti

on.

J A

m

Die

t A

sso

c. 1

99

8;9

8:1

11

8-1

12

6.

9.

Ham

pl

JS,

An

der

son J

V, M

ull

is R

. T

he

role

of

die

teti

cs p

rofe

ssio

nal

s in

hea

lth p

rom

oti

on a

nd d

isea

se p

reven

tion.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

68

0-1

68

7.

10

. L

in S

H, G

uth

rie

J, F

raza

o E

. A

mer

ican

chil

dre

n’s

’ die

ts a

re n

ot

mak

ing

th

e gra

de.

Fo

od

Rev

. 2

00

1;2

4:8

-17

.

11

. S

atte

r E

. F

eedin

g d

yn

amic

s: h

elp

ing

chil

dre

n t

o e

at w

ell.

J P

edia

tr H

ealt

hca

re. 1

99

5;9

:17

8-1

84

.

12

. S

tory

M, H

olt

K,

So

fka

D,

eds.

Bri

gh

t F

utu

res

in P

ract

ice:

Nu

trit

ion

, 2

nd e

d. A

rlin

gto

n,

Va:

Nat

ion

al C

ente

r fo

r E

du

cati

on

in

Mat

ernal C

hil

d H

ealt

h;

20

02

.

13

. P

elto

GH

, L

evit

t E

, T

hai

ru L

. Im

pro

vin

g f

eedin

g p

ract

ices,

curr

ent

pat

tern

s, c

om

mo

n c

onst

rain

ts a

nd t

he

desi

gn o

f in

terv

enti

ons.

Fo

od

Nu

tr B

ull

. 2

00

3;2

4:4

5-8

2.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

P

hys

ical A

ctivity

and F

unct

ion

PH

YS

ICA

L IN

AC

TIV

ITY

(NB

-2.1

)

Edit

ion:

20

06

13

8

De

fin

itio

n

Low

level

of

acti

vit

y/se

den

tary

beh

avio

r to

th

e ex

ten

t th

at i

t re

duce

s en

ergy e

xpen

dit

ure

an

d i

mpac

ts h

ealt

h

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•F

inan

cial

con

stra

ints

that

may

pre

ven

t su

ffic

ien

t le

vel

of

acti

vit

y

•H

arm

ful

bel

iefs

/att

itudes

about

ph

ysic

al a

ctiv

ity

•In

jury

or

life

styl

e ch

ange

that

red

uce

s ph

ysic

al a

ctiv

ity o

r act

ivit

ies

of

dai

ly l

ivin

g

•L

ack o

f pri

or

educa

tion a

bout

nee

d f

or

ph

ysic

al a

ctiv

ity o

r how

to i

nco

rpora

te e

xer

cise

, e.

g., p

hys

ical

dis

abil

ity,

arth

riti

s

•L

ack o

f ro

le m

odel

s, e

.g., f

or

chil

dre

n

•L

ack o

f so

cial

support

an

d/o

r en

vir

onm

enta

l sp

ace

or

equip

men

t

•L

ack o

f sa

fe e

nvir

onm

ent

for

physi

cal

acti

vit

y

•L

ack o

f val

ue

or

com

pet

ing v

alues

for

beh

avio

r ch

ange

•T

ime

con

stra

ints

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

P

hys

ical A

ctivity

and F

unct

ion

PH

YS

ICA

L IN

AC

TIV

ITY

(NB

-2.1

)

Edit

ion:

20

06

13

9

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•In

freq

uen

t, l

ow

-dura

tion a

nd

/or

low

-in

ten

sity

ph

ysic

al a

ctiv

ity

•L

arge

amoun

ts o

f se

den

tary

act

ivit

ies,

e.g

., T

V w

atch

ing

, re

adin

g,

com

pute

r use

in b

oth

lei

sure

and w

ork

/sch

ool

•B

arri

ers

to p

hys

ical

act

ivit

y, e

.g., t

ime

con

stra

ints

, av

aila

bil

ity o

f a

safe

envir

onm

ent

for

exer

cise

Cli

ent

His

tory

•L

ow

car

dio

-res

pir

ato

ry f

itn

ess

and

/or

low

musc

le s

tren

gth

•M

edic

al d

iagn

ose

s th

at m

ay b

e as

soci

ate

d w

ith o

r re

sult

in d

ecre

ased

act

ivit

y, e

.g.,

art

hri

tis,

chro

nic

fat

igu

e sy

ndro

me,

morb

id o

bes

ity,

kn

ee s

urg

ery

•M

edic

atio

ns

that

cau

se s

om

nole

nce

an

d d

ecre

ased

cognit

ion

•P

sych

olo

gic

al d

iagn

osi

s, e

.g., d

epre

ssio

n,

anxie

ty d

isord

ers

Refe

ren

ces:

1.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Wei

ght

man

agem

ent.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

14

5-1

15

5.

2.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Tota

l die

t appro

ach

to c

om

munic

atin

g f

ood a

nd n

utr

itio

n i

nfo

rmat

ion.J

Am

Die

t A

sso

c. 2

00

2;1

02

:10

0-1

08

.

3.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

The

role

of

die

teti

cs p

rofe

ssio

nal

s in

hea

lth p

rom

oti

on a

nd d

isea

se p

reventi

on.

J A

m D

iet

Ass

oc.

20

02

;10

2:1

68

0-1

68

7.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

P

hys

ical A

ctivity

and F

unct

ion

EX

CE

SS

IVE

EX

ER

CIS

E(N

B-2

.2)

Edit

ion:

20

06

14

0

De

fin

itio

n

An a

mount

of

exer

cise

th

at e

xce

eds

that

whic

h i

s n

eces

sary

to i

mpro

ve

hea

lth a

nd/o

r at

hle

tic

per

form

ance

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•D

isord

ered

eat

ing

•Ir

rati

onal

bel

iefs

/att

itudes

about

food,

nutr

itio

n, an

d f

itn

ess

•“A

ddic

tive”

beh

avio

rs/p

erso

nal

ity

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•E

levat

ed l

iver

en

zym

es,

e.g., L

DH

, S

GO

T

•A

lter

ed m

icro

nutr

ient

stat

us,

e.g

., d

ecre

ase

d s

erum

fer

riti

n, zi

nc,

and I

GF

-bin

din

g p

rote

in

•In

crea

sed h

emat

ocr

it

•S

upp

ress

ed i

mm

un

e fu

nct

ion

•P

oss

ibly

ele

vat

ed c

ort

isol

level

s

Anth

ropom

etri

c M

easu

rem

ents

•W

eig

ht

loss

, ar

rest

ed g

row

th a

nd d

evel

opm

ent,

fai

lure

to g

ain w

eigh

t duri

ng p

erio

d o

f ex

pec

ted g

row

th (

rela

ted u

sual

ly to

dis

ord

ered

eat

ing)

Phys

ical

Exam

Fin

din

gs

•D

eple

ted a

dip

ose

and s

om

ati

c pro

tein

sto

res

(rel

ated

usu

all

y to d

isord

ered

eat

ing)

•F

requen

t an

d/o

r pro

lon

ged

in

juri

es a

nd/o

r il

lnes

ses

•C

hro

nic

fat

igue

•C

hro

nic

mu

scle

sore

nes

s

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

P

hys

ical A

ctivity

and F

unct

ion

EX

CE

SS

IVE

EX

ER

CIS

E(N

B-2

.2)

Edit

ion:

20

06

14

1

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•C

on

tinued

/rep

eate

d h

igh l

evel

s of

exer

cise

exce

edin

g l

evel

s n

eces

sary

to i

mpro

ve

hea

lth a

nd/o

r at

hle

tic

per

form

ance

•E

xer

cise

dai

ly w

ith

out

rest

/reh

abil

itat

ion d

ays

•E

xer

cise

whil

e in

jure

d/s

ick

•F

ors

akin

g f

amil

y, j

ob,

soci

al r

espon

sibil

itie

s to

exer

cise

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gn

osi

s or

trea

tmen

t of,

e.g

., a

nore

xia

ner

vosa

, buli

mia

ner

vosa

, bin

ge

eati

ng,

eati

ng d

isord

er

not

oth

erw

ise

spec

ifie

d,

amen

orr

hea

•E

vid

ence

of

add

icti

ve,

obse

ssiv

e, o

r co

mpu

lsiv

e te

nden

cies

Refe

ren

ces:

1.

Ais

sa-B

enhad

dad

A, B

ou

ix D

, K

hal

ed S

, M

ical

lef

JP, M

erci

er J

, B

rin

ger

J,

Bru

n J

F.

Ear

ly h

emorh

eolo

gic

asp

ects

of

ov

ertr

ain

ing

in

eli

te a

thle

tes.

Cli

n H

emo

rheo

l M

icro

circ

. 1

99

9;2

0:1

17

-12

5.

2.

Am

eric

an P

sych

iatr

ic A

sso

ciat

ion

.D

iag

no

stic

an

d S

tati

stic

al

Ma

nu

al

of

Men

tal

Dis

ord

ers.

4th e

d.

Was

hin

gto

n, D

C:

Am

eric

an P

sych

iatr

ic A

sso

ciat

ion

; 2

00

0.

3.

Dav

is C

, B

rew

er H

, R

atu

sny D

. B

ehavio

ral

freq

uency

an

d p

sych

olo

gic

al c

om

mit

men

t: n

ece

ssar

y c

once

pts

in t

he

stud

y o

f ex

cess

ive

exer

cisi

ng

.J

Beh

av

Med

. 1

99

3;1

6:6

11

-62

8

4.

Dav

is C

, C

lari

dg

e G

. T

he

eati

ng d

isord

er a

s addic

tion:

a psy

chobio

logic

al p

ersp

ecti

ve.

Ad

dic

t B

eha

v. 1

99

8;2

3:4

63

-47

5.

5.

Davis

C,

Kenned

y S

H, R

avel

ski

E, D

ionn

e M

. T

he

role

of

phy

sica

l act

ivit

y i

n t

he

dev

elopm

ent

and m

ainte

nance

of

eati

ng d

isord

ers.

Psy

cho

l M

ed. 1

99

4;2

4:9

57

-96

7.

6.

Kle

in D

A, B

ennet

t A

S,

Sch

eben

dach

J,

Fo

ltin

RW

, D

evli

n M

J, W

alsh

BT

. E

xer

cise

“ad

dic

tio

n”

in a

no

rex

ia n

erv

osa

: m

od

el d

evel

op

men

t and

pil

ot

dat

a.C

NS

Sp

ect

r. 2

00

4;9

:53

1-5

37

.

7.

Lak

ier-

Sm

ith L

. O

ver

trai

nin

g,

exce

ssiv

e ex

erci

se,

and a

lter

ed i

mm

unit

y:

this

a h

elper

-1 v

s help

er-2

lym

phocy

te r

espo

nse

?S

po

rts

Med

. 2

00

3;3

3:3

47

-36

4.

8.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Nu

trit

ion i

nte

rven

tio

n i

n t

he

trea

tment

of

anore

xia

ner

vosa

, buli

mia

ner

vo

sa, and e

atin

g d

isord

er n

ot

oth

erw

ise

spec

ifie

d (

ED

NO

S).

J A

m D

iet

Ass

oc.

20

01

;10

1:8

10

-81

9.

9.

Shep

har

d R

J, S

hek

PN

. A

cute

and c

hro

nic

over

-exer

tion:

do d

epre

ssed

im

mune

resp

onse

s pro

vid

e use

ful

mar

ker

s?In

t J

Sp

ort

s M

ed. 1

99

8;1

9:1

59

-17

1.

10

. S

mit

h L

L. T

issu

e tr

aum

a: t

he

un

der

lyin

g c

ause

of

over

train

ing s

yndro

me?

J S

tren

gth

Co

nd

Res

. 2

00

4;1

8:1

85

-19

3.

11

. U

rhau

sen A

, K

inder

mann W

. D

iagno

sis

of

ov

ertr

ainin

g:

what

tools

do w

e have.

Sp

ort

s M

ed. 2

00

2;3

2:9

5-1

02

.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

P

hys

ical A

ctivity

and F

unct

ion

INA

BIL

ITY

OR

LA

CK

OF

DE

SIR

E T

O M

AN

AG

E S

EL

F-C

AR

E(N

B-2

.3)

Edit

ion:

20

06

14

2

De

fin

itio

n

Lac

k o

f ca

paci

ty o

r unw

illi

ngnes

s to

im

ple

men

t m

eth

ods

to s

upp

ort

hea

lthfu

l fo

od-

and n

utr

itio

n-r

elat

ed b

ehav

ior

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•F

ood-

and n

utr

itio

n-r

elat

ed k

now

ledg

e defi

cit

•L

ack o

f ca

reta

ker

or

soci

al s

upport

for

imple

men

ting c

han

ges

•L

ack o

f devel

opm

enta

l re

adin

ess

to p

erfo

rm s

elf

man

agem

ent

task

s, e

.g.

ped

iatr

ics

•L

ack o

f val

ue

or

com

pet

ing v

alues

for

beh

avio

r ch

ange

•P

erce

pti

on t

hat

lack

of

reso

urc

es (

tim

e, f

inan

cial

, su

pport

per

sons)

pre

ven

t se

lf c

are

•C

ult

ura

l bel

iefs

an

d p

ract

ices

•L

earn

ing d

isabil

ity,

neu

rolo

gic

al o

r se

nso

ry i

mpai

rmen

t

•P

rior

exposu

re t

o i

nco

mp

atib

le i

nfo

rmat

ion

•N

ot

read

y f

or

die

t/li

fest

yle

chan

ge

•U

nw

illi

ng o

r un

inte

rest

ed i

n l

earn

ing/a

pply

ing i

nfo

rmat

ion

•N

o s

elf-

man

agem

ent

tools

or

dec

isio

n g

uid

es

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

P

hys

ical A

ctivity

and F

unct

ion

INA

BIL

ITY

OR

LA

CK

OF

DE

SIR

E T

O M

AN

AG

E S

EL

F-C

AR

E(N

B-2

.3)

Edit

ion:

20

06

14

3

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•In

abil

ity t

o i

nte

rpre

t dat

a or

sel

f-m

anag

emen

t to

ols

•E

mbar

rass

men

t or

an

ger

reg

ardin

g n

eed f

or

self

-monit

ori

ng

•U

nce

rtai

nty

reg

ardin

g c

han

ges

th

at c

ould

/sh

ould

be

made

in r

espon

se t

o d

ata

in s

elf-

monit

ori

ng r

ecord

s

Cli

ent

His

tory

•D

iagn

ose

s th

at a

re a

ssoci

ated

wit

h s

elf

man

agem

ent,

e.g

., d

iabet

es m

elli

tus,

obes

ity,

car

dio

vas

cula

r dis

ease

, re

nal

or

liver

dis

ease

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., c

ognit

ive

or

emoti

onal

im

pai

rmen

t

•N

ew m

edic

al d

iagnosi

s or

chan

ge

in e

xis

ting d

iagn

osi

s or

con

dit

ion

Refe

ren

ces:

1.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Pro

vid

ing n

utr

itio

n s

ervic

es f

or

infa

nts

, ch

ildre

n, and a

dult

s w

ith d

evel

op

men

tal

dis

abil

itie

s an

d s

pec

ial

hea

lth c

are

nee

ds.

J A

m D

iet

Ass

oc.

20

04

;10

4:9

7-1

07

.

2.

Cra

wfo

rd S

. P

rom

oti

ng d

ieta

ry c

han

ge.

Ca

n J

Ca

rdio

l. 1

99

5;1

1(s

up

pl

A):

14

A-1

5A

.

3.

Fal

k L

W, B

iso

gn

i C

A,

So

bal

J. D

iet

chang

e pro

cess

es o

f par

tici

pants

in

an

in

ten

siv

e h

eart

pro

gra

m.J

Nu

tr E

du

c. 2

00

0;3

2:2

40

-25

0.

4.

Gla

sgo

w R

E, H

am

pso

n S

E,

Str

yck

er L

A, R

uggie

ro L

. P

erso

nal

-mo

del

bel

iefs

and s

oci

al-e

nvir

onm

enta

l bar

rier

s re

late

d t

o d

iabet

es s

elf-

manag

em

ent.

Dia

bet

es C

are

. 1

99

7;2

0:5

56

-56

1.

5.

Keen

an D

P,

AbuS

abha

R,

Sig

man

-Gra

nt

M,

Ach

terb

erg C

, R

uff

ing J

. F

act

ors

per

ceiv

ed t

o i

nfl

uen

ce d

ieta

ry f

at r

educt

ion b

ehavio

rs.J

Nu

tr E

du

c.1

99

9;3

1:1

34

-14

4.

6.

Ku

man

yik

a S

K,

Van

Horn

L, B

ow

en D

, P

erri

MG

, R

oll

s B

J, C

zajk

ow

ski

SM

, S

chro

n E

. M

ainte

nan

ce o

f die

tary

beh

avio

r ch

ang

e.H

ealt

h P

sych

ol.

20

00

;19

(1 s

up

pl)

:S4

2-S

56

.

7.

Sporn

y, L

A, C

onte

nto

IR

. S

tages

of

change

in d

ieta

ry f

at r

educti

on:

So

cial

psy

cholo

gic

al c

orr

elate

s.J

Nu

tr E

du

c. 1

99

5;2

7:1

91

.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

P

hys

ical A

ctivity

and F

unct

ion

IMP

AIR

ED

AB

ILIT

Y T

O P

RE

PA

RE

FO

OD

S/M

EA

LS

(NB

-2.4

)

Edit

ion:

20

06

14

4

De

fin

itio

n

Cogn

itiv

e or

ph

ysic

al i

mpai

rmen

t th

at p

reven

ts p

repar

atio

n o

f fo

ods/

mea

ls

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•L

earn

ing d

isabil

ity,

neu

rolo

gic

al o

r se

nso

ry i

mpai

rmen

t

•L

oss

of

men

tal

or

cogn

itiv

e ab

ilit

y,

e.g., d

emen

tia

•P

hysi

cal

dis

abil

ity

•H

igh l

evel

of

fati

gu

e or

oth

er s

ide

effe

ct o

f th

erap

y

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

Food/N

utr

itio

n H

isto

ryO

bse

rvat

ion

s or

report

s of:

•D

ecre

ased

over

all

inta

ke

•E

xce

ssiv

e co

nsu

mpti

on o

f co

nven

ien

ce f

oods,

pre

-pre

par

ed m

eals

, an

d f

oods

pre

par

ed a

way f

rom

hom

e re

sult

ing i

n a

n

inab

ilit

y to a

dh

ere

to n

utr

itio

n p

resc

ripti

on

•U

nce

rtai

nty

reg

ardin

g a

ppro

pri

ate

foods

to p

repar

e bas

ed u

pon n

utr

itio

n p

resc

ripti

on

•In

abil

ity t

o p

urc

has

e an

d t

ran

sport

foods

to o

ne’

s h

om

e

Cli

ent

His

tory

•C

ondit

ion

s as

soci

ate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., c

ognit

ive

impai

rmen

t, c

ereb

ral

pal

sy,

par

aple

gia

, si

gh

t

impai

rmen

t, r

igoro

us

ther

apy r

egim

en,

rece

nt

surg

ery

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

P

hys

ical A

ctivity

and F

unct

ion

IMP

AIR

ED

AB

ILIT

Y T

O P

RE

PA

RE

FO

OD

S/M

EA

LS

(NB

-2.4

)

Edit

ion:

20

06

14

5

Refe

ren

ces:

1.

Andre

n E

, G

rim

by G

. A

ctiv

ity l

imit

atio

ns

in p

erso

nal

, do

mes

tic

and v

oca

tio

nal

task

s: a

stu

dy o

f adult

s w

ith i

nborn

an

d e

arly

acq

uir

ed m

obil

ity d

isord

ers.

Dis

ab

il R

eha

bil

. 2

00

4;2

6:2

62

-27

1.

2.

Andre

n E

, G

rim

by G

. D

epen

den

ce

in d

aily

act

ivit

ies

and l

ife

sati

sfac

tion i

n a

dult

subje

cts

wit

h c

ereb

ral

pal

sy o

r sp

ina

bif

ida:

a f

oll

ow

-up s

tud

y.

Dis

ab

il R

eha

bil

. 2

00

4;2

6:5

28

-53

6.

3.

Fort

in S

, G

od

bo

ut

L, B

rau

n C

M.

Co

gnit

ive

stru

ctu

re o

f ex

ecu

tiv

e d

efic

its

in f

ronta

lly

les

ioned

hea

d t

rau

ma

pat

ients

per

form

ing

act

ivit

ies

of

dai

ly l

ivin

g.

Co

rtex

. 2

00

3;3

9:2

73

-29

1.

4.

Godb

out

L, D

ouce

t C

, F

iola

M.

The

scri

pti

ng o

f ac

tivit

ies

of

dai

ly l

ivin

g i

n n

orm

al a

gin

g:

anti

cipat

ion a

nd s

hif

ting d

efi

cits

wit

h p

rese

rvat

ion o

f se

qu

enci

ng.

Bra

in C

og

n. 2

00

0;4

3:2

20

-22

4.

5.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Pro

vid

ing n

utr

itio

n s

ervic

es f

or

infa

nts

, ch

ildre

n, and a

dult

s w

ith d

evel

op

men

tal

dis

abil

itie

s an

d s

pec

ial

hea

lth c

are

nee

ds.

J A

m D

iet

Ass

oc.

20

04

;10

4:9

7-1

07

.

6.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

Dom

esti

c fo

od a

nd n

utr

itio

n s

ecuri

ty.J

Am

Die

t A

sso

c. 2

00

2;1

02

:18

40

-18

47

.

7.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

Ad

dre

ssin

g w

orl

d h

ung

er,

maln

utr

itio

n,

and f

ood i

nse

curi

ty. J

Am

Die

t A

sso

c.2

00

3;1

03

:10

46

-10

57

.

8.

San

dst

rom

K,

Ali

nder

J, O

ber

g B

. D

escr

ipti

ons

of

fun

ctio

nin

g a

nd h

ealt

h a

nd r

elat

ion

s to

a g

ross

moto

r cl

ass

ific

atio

n i

n a

dult

s w

ith c

ereb

ral

pal

sy.

Dis

ab

il R

eha

bil

. 2

00

4;2

6:1

02

3-1

03

1.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

P

hys

ical A

ctivity

and F

unct

ion

PO

OR

NU

TR

ITIO

N Q

UA

LIT

Y O

F L

IFE

(N

QO

L)

(NB

-2.5

)

Edit

ion:

20

06

14

6

De

fin

itio

n

Dim

inis

hed

NQ

OL

sco

res

rela

ted t

o f

ood i

mpac

t, s

elf

imag

e, p

sych

olo

gic

al f

acto

rs, so

cial

/inte

rper

sonal

fac

tors

, ph

ysic

al f

acto

rs, or

self

-eff

icac

y

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms.

•F

ood-

and n

utr

itio

n k

now

ledge-

rela

ted d

efic

it

•N

ot

read

y f

or

die

t/li

fest

yle

chan

ge

•N

egat

ive

impac

t of

curr

ent

or

pre

vio

us

med

ical

nutr

itio

n t

her

apy (

MN

T)

•F

ood o

r ac

tivit

y b

ehav

ior-

rela

ted d

iffi

cult

y

•P

oor

self

-eff

icac

y

•A

lter

ed b

od

y im

age

•F

ood i

nse

curi

ty

•L

ack o

f so

cial

support

for

imple

men

ting c

han

ges

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

P

hys

ical A

ctivity

and F

unct

ion

PO

OR

NU

TR

ITIO

N Q

UA

LIT

Y O

F L

IFE

(N

QO

L)

(NB

-2.5

)

Edit

ion:

20

06

14

7

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•U

nfa

vora

ble

NQ

OL

rati

ng

•F

rust

rati

on o

r dis

sati

sfac

tion w

ith M

NT

rec

om

men

dat

ion

s

•In

acc

ura

te o

r in

com

ple

te i

nfo

rmat

ion r

elat

ed t

o M

NT

rec

om

men

dat

ions

•In

abil

ity to c

han

ge

food-

or

acti

vit

y-re

late

d b

ehavio

r

•C

once

rns

about

pre

vio

us

atte

mp

ts t

o l

earn

in

form

atio

n

•U

nw

illi

ngnes

s or

dis

inte

rest

in l

earn

ing i

nfo

rmat

ion

Cli

ent

His

tory

•N

ew m

edic

al d

iagnosi

s or

chan

ge

in e

xis

ting d

iagn

osi

s or

con

dit

ion

•R

ecen

t oth

er l

ifes

tyle

or

life

ch

anges

, e.

g., q

uit

sm

okin

g, in

itia

ted e

xer

cise

, w

ork

ch

ange,

hom

e re

loca

tion

Refe

ren

ces:

1.

Bar

r JT

, S

chum

ach

er G

E.

The

need

for

a nutr

itio

n-r

elat

ed q

ual

ity-o

f-li

fe m

easu

re.J

Am

Die

t A

sso

c. 2

00

3;1

03

:17

7-1

80

.

2.

Barr

JT

, S

chu

mach

er G

E.

Usi

ng

fo

cus

gro

up

s to

dete

rmin

e w

hat

con

stit

ute

s qu

ali

ty o

f li

fe i

n c

lients

receiv

ing

medic

al

nu

trit

ion

th

erap

y:

Fir

st s

tep

s in

th

e d

evel

op

ment

of

a n

utr

itio

n q

uali

ty-o

f-li

fe

surv

ey.

J A

m D

iet

Ass

oc.

20

03

;10

3:8

44

-85

1.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

P

hys

ical A

ctivity

and F

unct

ion

SE

LF

-FE

ED

ING

DIF

FIC

UL

TY

(NB

-2.6

)

Edit

ion:

20

06

14

8

De

fin

itio

n

Impai

red a

ctio

ns

to p

lace

food o

r bev

erag

es i

n m

outh

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•In

abil

ity to g

rasp

cups

and u

ten

sils

for

self

-fee

din

g

•In

abil

ity to s

upport

an

d/o

r co

ntr

ol

hea

d a

nd n

eck

•L

ack o

f co

ord

inat

ion o

f han

d t

o m

outh

•L

imit

ed p

hys

ical

str

ength

or

range

of

moti

on

•In

abil

ity to b

end e

lbow

or

wri

st

•In

abil

ity to s

it w

ith h

ips

squar

e an

d b

ack s

trai

ght

•L

imit

ed a

cces

s to

food

s co

nduci

ve

for

self

-fee

din

g

•L

imit

ed v

isio

n

•R

elu

ctan

ce o

r av

oid

ance

of

self

fee

din

g

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

Fin

din

gs

•D

ry m

uco

us

mem

bra

nes

, h

oar

se o

r w

et v

oic

e, t

on

gue

extr

usi

on

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

P

hys

ical A

ctivity

and F

unct

ion

SE

LF

-FE

ED

ING

DIF

FIC

UL

TY

(NB

-2.6

)

Edit

ion:

20

06

14

9

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•B

ein

g p

rovid

ed w

ith f

oods

that

may n

ot

be

con

duci

ve

to s

elf-

feed

ing,

e.g., p

eas,

bro

th-t

ype

soups

•P

oor

lip c

losu

re, dro

oli

ng

•D

roppin

g o

f cu

ps,

ute

nsi

ls

•E

moti

onal

dis

tres

s, a

nx

iety

, or

frust

rati

on s

urr

oundin

g m

ealt

imes

•F

ailu

re t

o r

ecogn

ize

foods

•F

org

ets

to e

at

•In

appro

pri

ate

use

of

food

•R

efusa

l to

eat

or

chew

•D

roppin

g o

f fo

od f

rom

ute

nsi

l (s

pla

shin

g a

nd s

pil

ling o

f fo

od)

on r

epea

ted a

ttem

pts

to f

eed

•U

ten

sil

bit

ing

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciat

ed w

ith a

dia

gn

osi

s or

trea

tmen

t of,

e.g

., n

euro

logic

al

dis

ord

ers,

Par

kin

son

’s d

isea

se, A

lzh

eim

er’s

dis

ease

, T

ardiv

e d

yskin

esia

, m

ult

iple

scl

erosi

s, s

troke,

par

alysi

s, d

evel

opm

enta

l del

ay

•P

hys

ical

lim

itat

ions,

e.g

., f

ract

ure

d a

rms,

tra

ctio

n, co

ntr

actu

res

•S

urg

ery r

equir

ing r

ecum

ben

t posi

tion

•D

emen

tia/o

rgan

ic b

rain

syn

dro

me

•D

ysp

hag

ia

•W

eig

ht

loss

•S

hort

nes

s of

bre

ath

•T

rem

ors

Refe

ren

ces:

1.

Co

nsu

ltan

t D

ieti

tian

s in

Hea

lth

care

Fac

ilit

ies.

Din

ing

Ski

lls

Su

pp

lem

ent:

Pra

ctic

al

Inte

rven

tio

ns

for

Ca

reg

iver

s o

f E

ati

ng

Dis

ab

led

Old

er A

du

lts.

Pen

saco

la,

Fla

: A

mer

ican

Die

teti

c A

sso

ciat

ion

;

19

92

.

2.

Morl

ey J

E.

Anore

xia

of

agin

g:

physi

olo

gic

al a

nd p

atholo

gic

.A

m J

Cli

n N

utr

. 1

99

7;6

6:7

60

-77

3.

3.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

ssoci

atio

n:

Pro

vid

ing n

utr

itio

n s

ervic

es f

or

infa

nts

, ch

ildre

n, and a

dult

s w

ith d

evel

op

men

tal

dis

abil

itie

s an

d s

pec

ial

hea

lth c

are

nee

ds.

J A

m D

iet

Ass

oc.

20

04

;10

4:9

7-1

07

.

4.

San

dm

an P

, N

orb

erg A

, A

dolf

sso

n R

, E

rikss

on S

, N

yst

rom

L.

Pre

val

ence

an

d c

har

act

eris

tics

of

per

son

s w

ith d

epen

den

cy o

n f

eedin

g a

t in

stit

uti

on

s.S

can

d J

Ca

rin

g S

ci. 1

99

0;4

:12

1-1

27

.

5.

Sie

bens

H,

Tru

pe

E,

Sie

ben

s A

, C

ooke

F,

An

shen S

, H

anau

er R

, O

ster

G.

Corr

elat

es a

nd c

onse

qu

ence

s of

feedin

g d

epen

den

cy.

J A

m G

eria

tr S

oc.

19

86

;34

:19

2-1

98

.

6.

Vel

las

B,

Fit

ten

LJ,

ed

s.R

esea

rch

an

d P

ract

ice

in A

lzh

eim

er’s

Dis

ease

. N

ew Y

ork

, N

Y:

Sp

rin

ger

Pu

bli

shin

g C

om

pan

y;

19

98

.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

F

ood S

afety

and A

cces

s

INT

AK

E O

F U

NS

AF

E F

OO

D(N

B-3

.1)

Edit

ion:

20

06

15

0

De

fin

itio

n

Inta

ke

of

food a

nd/o

r fl

uid

s in

tenti

onal

ly o

r unin

tenti

on

ally

con

tam

inat

ed w

ith t

oxin

s, p

ois

on

ous

pro

duct

s, i

nfe

ctio

us

agen

ts, m

icro

bia

l ag

ents

, ad

dit

ives

,

alle

rgen

s, a

nd/o

r ag

ents

of

bio

terr

ori

sm

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•L

ack o

f kn

ow

ledg

e ab

out

pote

nti

ally

un

safe

food

•L

ack o

f kn

ow

ledg

e ab

out

pro

per

food/f

eedin

g,

stor

age

and p

repar

atio

n,

e.g., i

nfa

nt

and e

nte

ral

form

ula

, or

bre

ast

mil

k

•E

xp

osu

re t

o c

on

tam

inate

d w

ater

or

food,

e.g., c

om

munit

y o

utb

reak

of

illn

ess

docu

men

ted b

y s

urv

eill

ance

and/o

r re

spon

se a

gen

cy

•M

enta

l il

lnes

s, c

on

fusi

on o

r al

tere

d a

war

enes

s

•In

adeq

uat

e fo

od s

tora

ge

equip

men

t/fa

cili

ties

, e.

g., r

efri

ger

ator

•In

adeq

uat

e sa

fe f

ood s

upply

, e.

g., i

nad

equat

e ac

cess

to m

arket

s w

ith s

afe,

un

conta

min

ate

d f

ood

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•P

osi

tive

stool

cult

ure

for

infe

ctio

us

cause

s, s

uch

as

list

eria

, sa

lmon

ella

, h

epat

itis

A,

E.

coli

,cy

closp

ora

•T

oxic

olo

gy r

eport

s fo

r dru

gs,

med

icin

als,

pois

ons

in b

lood o

r fo

od s

ample

s

Anth

ropom

etri

c M

easu

rem

ents

Phys

ical

Exam

inati

on F

indin

gs

•E

vid

ence

of

deh

ydra

tion,

e.g., d

ry m

uco

us

mem

bra

nes

, dam

aged

tis

sues

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

F

ood S

afety

and A

cces

s

INT

AK

E O

F U

NS

AF

E F

OO

D(N

B-3

.1)

Edit

ion:

20

06

15

1

Food/N

utr

itio

n H

isto

ryO

bse

rvat

ions/

report

s of

inta

ke

of

pote

nti

al

unsa

fe f

oods

(e.g

., p

regn

ant

and l

acta

tin

g w

om

en):

•M

ercu

ry c

on

tent

of

fish

an

d i

n n

on-f

ood i

tem

s

•R

aw e

ggs,

unpast

euri

zed

mil

k p

roduct

s, s

oft

ch

eese

s, u

nder

cooked

mea

ts (

infa

nts

, ch

ildre

n,

imm

un

oco

mpro

mis

ed

per

son

s, p

regnan

t an

d l

act

atin

g w

om

en, an

d e

lder

ly)

•W

ild p

lants

, ber

ries

, an

d m

ush

room

s

Obse

rvat

ions/

report

s of

unsa

fe f

ood/f

eedin

g o

r st

ora

ge

and p

repar

ati

on p

ract

ices

(en

tera

l an

d i

nfa

nt

form

ula

, or

bre

ast

mil

k)

Cli

ent

His

tory

•C

ond

itio

ns

asso

ciate

d w

ith a

dia

gnosi

s or

trea

tmen

t of,

e.g

., f

ood b

orn

e il

lnes

s, s

uch

as,

bac

teri

al,

vir

al,

and p

aras

itic

infe

ctio

n, m

enta

l il

lnes

s, d

emen

tia

•P

ois

on

ing b

y d

rugs,

med

icin

als

, or

bio

logic

al s

ubst

ance

s

•P

ois

onin

g f

rom

pois

onous

food s

tuff

s or

pois

onous

pla

nts

•D

iarr

hea

, cr

am

pin

g,

blo

atin

g, fe

ver

, n

ause

a, v

om

itin

g,

vis

ion p

roble

ms,

chil

ls,

diz

zines

s, h

eadac

he

•C

ardia

c, n

euro

logic

, re

spir

atory

ch

anges

Refe

ren

ces:

1.

Cen

ters

for

Dis

ease

Contr

ol

and P

rev

enti

on.

Dia

gnosi

s an

d M

anag

em

ent

of

Foo

dborn

e Il

lness

: A

Pri

mer

for

Phy

sici

ans.

A

vai

lab

le a

t:

ww

w.c

dc.

gov/m

mw

r/pre

vie

w/m

mw

rhtm

l/rr

53

04

a1.h

tm.

Acc

esse

d J

uly

2, 2

00

4.

2.

Fo

od

Saf

ety

and

In

spec

tio

n S

ervic

e. T

he

Fig

ht

BA

C S

urv

ey T

oo

l an

d D

ata

Entr

y T

oo

l.

Avai

lable

at:

ww

w.f

sis.

usd

a.g

ov

/OA

/fse

s/b

ac_

dat

atool.

htm

. A

cces

sed

Ju

ly 2

, 2

00

4.

3.

Ger

ald

BL

, P

erk

in J

E. F

oo

d a

nd

wat

er s

afe

ty.J

Am

Die

t A

sso

c. 2

00

3;1

03

:120

3-1

21

8.

4.

Par

tner

ship

for

Foo

d S

afe

ty E

duca

tio

n.

Fou

r st

eps.

A

vail

able

at:

htt

p:/

/ww

w.f

ightb

ac.

org

/fours

tep

s.cf

m?se

cti

on=

4.

Acc

esse

d J

uly

2,

20

04

.

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

F

ood S

afety

and A

cces

s

LIM

ITE

D A

CC

ES

S T

O F

OO

D(N

B-3

.2)

Edit

ion:

20

06

15

2

De

fin

itio

n

Dim

inis

hed

abil

ity to a

cquir

e fo

od f

rom

sourc

es (

e.g., s

hoppin

g,

gar

den

ing,

mea

l del

iver

y),

due

to f

inan

cial

con

stra

ints

, ph

ysic

al i

mpai

rmen

t, c

areg

iver

support

,

or

un

safe

liv

ing c

on

dit

ion

s (e

.g. cr

ime

hin

der

s tr

avel

to g

roce

ry s

tore

). L

imit

atio

n t

o f

ood b

ecau

se o

f co

nce

rns

about

wei

ght

or

agin

g.

Eti

olo

gy

(Cause

/Contr

ibuti

ng R

isk

Fact

ors

)

Fac

tors

gat

her

ed d

uri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

th

at c

on

trib

ute

to t

he

exis

tence

or

the

mai

nte

nan

ce o

f path

oph

ysio

logic

al,

psy

choso

cial,

sit

uat

ional,

dev

elopm

enta

l, c

ult

ura

l, a

nd/o

r en

vir

onm

enta

l pro

ble

ms:

•C

areg

iver

in

ten

tional

ly o

r unin

tenti

onall

y n

ot

pro

vid

ing a

cces

s to

food,

e.g

., u

nm

et n

eeds

for

food o

r ea

ting a

ssis

tan

ce, ab

use

/neg

lect

•C

om

munit

y a

nd g

eogra

phic

al c

on

stra

ints

for

shoppin

g a

nd t

ran

sport

atio

n

•L

ack o

f fi

nan

cial

reso

urc

es o

r la

ck o

f ac

cess

to f

inan

cial

res

ourc

es t

o p

urc

hase

suff

icie

nt

food

•L

imit

ed o

r ab

sen

t co

mm

un

ity s

upple

men

tal

food p

rogra

ms,

e.g

., f

ood p

antr

y,

shel

ter

•F

ailu

re t

o p

arti

cipat

e in

food p

rogra

ms

such

as

WIC

, N

atio

nal

Sch

ool

Lunch

Pro

gra

m,

food s

tam

ps

•P

hys

ical

or

psy

cholo

gic

al l

imit

atio

ns

that

dim

inis

h a

bil

ity t

o s

hop,

e.g

., w

alkin

g,

sigh

t, m

enta

l/em

oti

onal

hea

lth

Sig

ns

/Sy

mp

tom

s(D

efin

ing C

hara

cteri

stic

s)

A t

ypic

al

clust

er o

f su

bje

ctiv

e an

d o

bje

ctiv

e si

gn

s an

d s

ympto

ms

gath

ered

duri

ng t

he

nutr

itio

n a

sses

smen

t pro

cess

that

pro

vid

e ev

iden

ce t

hat

a pro

ble

m e

xis

ts;

quan

tify

th

e pro

ble

m a

nd d

escr

ibe

its

sever

ity.

Nutritio

n A

sses

smen

t Cate

gory

Pote

ntial I

ndic

ato

rs o

f th

is N

utritio

n D

iagnosis

(one o

r m

ore

must

be p

rese

nt)

Bio

chem

ical

Data

•In

dic

ator

s of

macr

on

utr

ien

t or

vit

amin

/min

eral

sta

tus

Anth

ropom

etri

c M

easu

rem

ents

•G

row

th f

ailu

re, bas

ed o

n N

atio

nal

Cen

ter

for

Hea

lth S

tati

stic

s (N

CH

S)

gro

wth

sta

ndar

ds

•U

nder

wei

ght

(BM

I <

18.5

)

Phys

ical

Exam

Fin

din

gs

•F

ind

ings

con

sist

ent

wit

h v

itam

in o

r m

iner

al

def

icie

ncy

BE

HA

VIO

RA

L-E

NV

IRO

NM

EN

TA

L D

OM

AIN

F

ood S

afety

and A

cces

s

LIM

ITE

D A

CC

ES

S T

O F

OO

D(N

B-3

.2)

Edit

ion:

20

06

15

3

Food/N

utr

itio

n H

isto

ryR

eport

s or

obse

rvat

ion

s of:

•F

ood f

add

ism

•B

elie

f th

at

agin

g c

an b

e sl

ow

ed b

y d

ieta

ry lim

itat

ion

s an

d e

xtr

eme

exer

cise

•H

un

ger

•In

adeq

uat

e in

take

of

food a

nd

/or

spec

ific

nutr

ien

ts

•L

imit

ed s

upply

of

food i

n h

om

e

•L

imit

ed v

arie

ty o

f fo

ods

Cli

ent

His

tory

•M

aln

utr

itio

n,

vit

amin

or

min

eral

def

icie

ncy

•Il

lnes

s or

ph

ysic

al d

isab

ilit

y

•C

ondit

ion

s as

soci

ate

d w

ith a

dia

gnosi

s or

trea

tmen

t, e

.g., m

enta

l il

lnes

s, d

emen

tia

•L

ack o

f su

itab

le s

upport

sys

tem

s

Refe

ren

ces:

1.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

Dom

esti

c fo

od a

nd n

utr

itio

n s

ecuri

ty.J

Am

Die

t A

sso

c. 2

00

2;1

02

:18

40

-18

47

.

2.

Posi

tion o

f th

e A

mer

ican

Die

teti

c A

sso

ciat

ion:

Addre

ssin

g w

orl

d h

ung

er,

maln

utr

itio

n,

and f

ood i

nse

curi

ty.J

Am

Die

t A

sso

c. 2

00

3;1

03

:10

46

-10

57.

SUBJECT: NUTRITION CONTROLLED VOCABULARY/TERMINOLOGY

MAINTENANCE/REVIEW

SUBJECT: NUTRITION CONTROLLED

VOCABULARY/TERMINOLOGY

MAINTENANCE/REVIEW

AMERICAN DIETETIC

ASSOCIATION120 South Riverside Plaza Suite 2000

CHICAGO, ILLINOIS 60606-6995

Effective Date: April 2005

Revision Date: June 2006

Review Date:

PURPOSE:

This policy establishes the has established the process followed by the Nutrition Care

Process/Standardized Language (NCP/SL) Committee to maintain a current Nutrition Care

Process and list of nutrition controlled vocabulary terminology that document the Nutrition Care

Process.

STRUCTURE:

The NCP/SL Committee is a joint House of Delegates and Board of Directors Committee and

provides semi-annual reports to both bodies.

PROCEDURES:

The NCP/SL Committee accepts proposals for modification or additions to the Nutrition

Diagnostic Terminology as follows:

1. Any individual ADA member or Dietetic Practice Group can submit proposals for

modification or additions by completing the attached two documents:

a. Proposed Nutrition Diagnostic Terminology Modification/Addition letter

b. Reference worksheet for proposed modification/addition

2. The NCP/SL will review the submissions at their routine face-to-face meetings or

teleconferences to establish the following:

a. Is the term already represented by an existing term?

i. If so the new term can be added as a synonym for the existing term or

replace the existing term.

ii. If not, then the term can be considered for addition to the list of terms as

long as it meets the need for describing elements of dietetic practice in the

context of the nutrition care process.

b. Does the term overlap with an existing term, but add new elements?

i. If yes, then the existing term can be modified to include the new elements

or the proposed term can be clarified to be distinctly different from the

existing term through a dialogue with the proposal submitter.

ii. If no, then consider adding new term.

c. Is the term distinct and separate from all existing terms?

i. If yes, then ensure that the term is in the context of dietetic practice within

the Nutrition Care Process and consider adding to list of terms.

ii. If no, then work with proposal submitter to discuss how to integrate into

existing terms or create a separate term.

3. The NCP/SL Committee will prepare a summary of comments and one representative of

the NCP/SL will confer with the proposal submitter after the initial discussion to answer

Edition: 2006 154


MAINTENANCE/REVIEW

questions and discuss the initial input from the NCP/SL Committee. If the proposal

submitter is not satisfied with the direction proposed by the NCP/SL Committee, then

they will be invited to submit additional documentation and have time on the next

teleconference/meeting agenda to personally present their concerns.

4. Changes or modifications accepted by the NCP/SL Committeewill be integrated into the

list that is re-published on an annual basis.

STAFFING:

Governance and Scientific Affairs and Research provide staff support to NCP/SL Committee and

for Research Committee functions.

Attachments

1. Letter template for proposing a New Term for Nutrition Diagnostic Terminology

2. Letter template for proposing Modifications to Nutrition Diagnostic Terminology

3. Template for Reference Sheet to support additions/modifications to Nutrition

Diagnostic Terminology

4. Completed Reference Sheet Example (Case with PES statement not included)

Edition: 2006 155


MAINTENANCE/REVIEW

Attachment 1: Letter Template for Proposing a New Term for Nutrition Diagnostic

Terminology

Date: _____________

To: NCP/SL Committee

Scientific Affairs and Research

American Dietetic Association

120 South Riverside Plaza, Suite 2000

Chicago, IL 60606-6995

[email protected]; [email protected]

Subject: Proposed Addition to Nutrition Diagnostic Terminology

(I/We) would like to propose a new term, _____________________(Proposed term to add to

the Nutrition Diagnostic Terminology list). The reason I/we believe that this term should be

added is as follows (insert concise rationale for change and may include brief example of

when the situation arose that the current term was inadequately defined):

1. (Insert first statement of rationale.)

2. (Insert second statement of rationale, if applicable.)

3. (Insert example of situation where this modification was needed.)

Other terms that are similar and explanations of why they do not exactly match our new

proposed term are as follows:

1. (Insert number and name.) – (Insert 2-3 sentences to illustrate why the existing term

does not meet your need.)

2. (Insert number and name.) – (Insert 2-3 sentences to illustrate why the existing term

does not meet your need.)

3. (Add as many as applicable.)

Attached is the a reference sheet that includes the label, description, proposed domain and

category, examples of etiologies and signs and symptoms and a case that illustrates when this

term would be used and the corresponding PES statement that would be used in medical

record documentation.

The point of contact for this proposal is ___________________________________ (insert

name), who can be reached at ______(best contact telephone number) and _______(e-mail

address).

Thank you for considering our request.

Signature block

(Organizational unit if applicable)

Attachments: (1) Completed Reference Sheet Template (Case and PES statement example not

included)

Edition: 2006 156


MAINTENANCE/REVIEW

Attachment 2: Letter Template for Proposing Modifications to Nutrition Diagnostic

Terminology

Date: ____________________

To: NCP/SL Committee


American Dietetic Association



[email protected]; [email protected]

Subject: Proposed Modification to Existing Nutrition Diagnostic Terminology

(I/We) would like to propose a modification or the term, _____________________(insert

Number and Name from current Nutrition Diagnostic Terminology list). The reason I/we

believe that this term should be modified is as follows (insert concise rationale for change

and may include brief example of when the situation arose that the current term was

inadequately defined):

1. (Insert first statement of rationale.)

2. (Insert second statement of rationale, if applicable.)

3. (Insert example of situation where this modification was needed.)

Attached is the revised reference sheet which shows the changes highlighted or bolded for

your consideration.

The point of contact for this proposal is ___________________________________ (insert

name), who can be reached at ______(best contact telephone number) and _______(e-mail

address).

Thank you for considering our request.

Signature block

(Organizational unit if applicable)

Attachments: (1) Completed Reference Sheet Template

Edition: 2006 157


MAINTENANCE/REVIEW

Attachment 3: Template for Reference Sheet for New Term or Proposing Modifications

Select DOMAIN: CLINICAL/FUNCTIONAL or BEHAVIORAL/ENVIRONMENTAL

Select Category, e.g., Functional Balance

Nutrition Diagnostic Label (Leave number blank, if new term.)

Insert a 1-4 word label.

Definition of Nutrition Diagnostic Label Insert 1 sentence or bullet that describes the intent of the new or modified label.

Etiology (Cause/Contributing Risk Factors)

Factors gathered during the nutrition assessment process that contribute to the existence of or the maintenance of

pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems:

Insert common etiologies for Nutrition Diagnostic Label

Signs/Symptoms (Defining Characteristics) A typical cluster of subjective and objective signs and symptoms

gathered during the nutrition assessment process that provide evidence that a problem exists; quantify the problem

and describe its severity.

Nutrition AssessmentCategory

Potential Indicators of this Nutrition Diagnosis (one or more must be present)

Biochemical Data (Insert as appropriate.)

Anthropometric Measurements (Insert as appropriate.)

Physical Exam Findings (Insert as appropriate.)

Food/Nutrition History (Insert as appropriate.)

Client History (Insert as appropriate.)

Edition: 2006 158


MAINTENANCE/REVIEW

Attachment 4: Template for Completed Reference Sheet

DOMAIN: CLINICAL/FUNCTIONAL

Category: Functional Balance

Nutrition Diagnostic Label (NC-1.1.)

Swallowing difficulty.

Definition of Nutrition Diagnostic Label Impaired movement of food and liquid from the mouth to the stomach.

Etiology (Cause/Contributing Risk Factors)

Factors gathered during the nutrition assessment process that contribute to the existence of or the maintenance of

pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems:

Mechanical causes such as inflammation; surgery; stricture; or oral, pharyngeal and esophageal

tumors

Motor causes, e.g., neurological or muscular disorders such as cerebral palsy, stroke, multiple

sclerosis, scleroderma, or prematurity

Signs/Symptoms (Defining Characteristics) A typical cluster of subjective and objective signs and symptoms

gathered during the nutrition assessment process that provide evidence that a problem exists; quantify the problem

and describe its severity.

Nutrition AssessmentCategory

Potential Indicators of this Nutrition Diagnosis (one or more must be present)

Biochemical Data

Anthropometric Measurements

Physical Exam Findings Evidence of dehydration, e.g., dry mucous membranes, poor skin

turgor

Food/Nutrition History Observations or reports of:

Coughing, choking, prolonged chewing, pouching of food,

regurgitation, facial expression changes during eating, prolonged

feeding time, drooling, noisy wet upper airway sounds, feeling of

“food getting stuck,” pain while swallowing

Decreased food intake

Avoidance of foods

Mealtime resistance

Client History Conditions associated with a diagnosis or treatment of dysphagia,

achalasia

Radiological findings, e.g., abnormal swallowing studies

Repeated upper respiratory infections and/or pneumonia

Edition: 2006 159

2003-2005 Standardized Language Task Force and Terminology Expert Reviewers

Edition: 2006 160

Standardized Language Task Force

Chair

Sylvia Escott-Stump, MA, RD, LDN

Dietetic Programs Director

East Carolina University

155 Rivers Building, Dept. NUHM

Greenville, NC 27858

Task Force Member 2003-2005

Peter Beyer, MS, RD, LD

Associate Professor

University of Kansas Medical Center

7315 Rosewood Drive

Prairie Village, KS 66208-2458


Christina Biesemeier MS, RD, LDN, FADA

313 Logans Circle

Franklin TN 37067-1363


Pam Charney, MS, RD, CNSD

2460 64th Ave SE

Mercer Island, WA 98040


Marion Franz, MS, RD, CDE

6635 Limerick Dr.

Minneapolis, MN 55439-1260


Karen Lacey, MS, RD, CD

500 Saint Mary’s Blvd

Green Bay, WI 54301-2610


Kathleen Niedert, MBA, RD, LD, FADA

PO Box 843

110 Ardis Street

Hudson, IA 50643-0843


Mary Jane Oakland, PhD, RD, LD, FADA

1612 Truman Drive

Ames, IA 50010-4344


Patricia Splett, PhD, MPH, RD

Splett & Associates

3219 Midland Avenue

St. Paul, MN 55110


Frances Tyus, MS, RD, LD

19412 Mayfair Ln

Cleveland, OH 44128-2727


Naomi Trostler, PhD, RD

Institute of Biochemistry, Food Science, and

Nutrition

Faculty of Agriculture, Food and Environmental

Quality Sciences

The Hebrew University of Jerusalem

PO Box 12

Rehovot 76100, Israel


Robin Leonhardt, RD

1905 North 24th Street

Sheboygan, WI 53081-2124

Attended Face to Face Meeting in Summer

2003

Staff Liaisons

Esther Myers, PhD, RD, FADA

Director of Scientific Affairs and Research

ADA Headquarters



Work (312) 899-4860

Fax (312) 899-4757

E-mail: [email protected]

Ellen Pritchett, RD, CPHQ

Director, Quality and Outcomes

ADA Headquarters



Work (312) 899-4823

Fax (312) 899-4757

E-mail: [email protected]

Staff Liaison 2003-2005

Lt Col Vivian Hutson, MA, MHA, RD, LD,

Fellow,

American College of Healthcare Executives

Staff Liaison 2003-2004


Consultants

Donna G. Pertel, MEd, RD

5 Bonny Lane

Clinton, CT 06413

Patricia Splett, PhD, MPH, RD

Splett & Associates

3219 Midland Avenue

St. Paul, MN 55110

Melinda L. Jenkins, Ph.D., FNP

Assistant Professor of Clinical Nursing

Columbia University School of Nursing

630 W. 168 St., mail code 6

New York, NY 10032

Annalynn Skipper, MS, RD, FADA

P.O. Box 45

Oak Park, IL 60303

Edition: 2006 161


(Cornell)

Increased energy expenditure (when

part of hypermetabolism)

NI-1.2 Jonathan Waitman, MD for Louis Arrone, MD

(Cornell)

Hypometabolism NI-1.3 Edith Lerner, PhD (Case Western Reserve University)

Inadequate energy intake NI-1.4 Joel Mason, MD (Tufts)

Excessive energy intake NI-1.5 Jim Hill, MD (University of Colorado)

INTAKE DOMAIN – Oral or Nutrition Support Intake

Inadequate oral food/beverage intake NI-2.1 Anne Voss, PhD, RD (Ross Labs)

Excessive oral food/beverage intake NI-2.2 Jessica Krenkel, MS, RD (University of Nevada)

Inadequate intake from

enteral/parenteral nutrition

NI-2.3 Kenneth Kudsk, MD (University of Wisconsin)

Excessive intake from


NI-2.4 Annalynn Skipper, MS, RD (University of Nebraska

Lincoln)

Inappropriate infusion of


NI-2.5 Annalynn Skipper, MS, RD (University of Nebraska-

Lincoln)

INTAKE DOMAIN – Fluid Intake Balance

Inadequate fluid intake NI-3.1 Ann Grandjean, EdD, RD (International Center for

Sports Nutrition)

Excessive fluid intake NI-3.2 Joel Kopple, MD (UCLA)

INTAKE DOMAIN – Bioactive Substances Intake Balance

Inadequate bioactive substance intake NI-4.1 Johanna Lappe, PhD, RN (Creighton)

Excess bioactive substance NI-4.2 Elizabeth Jeffery, PhD (Univ. of IL, Champaign)

Excessive alcohol intake NI-4.3 Janice Harris, PhD, RD (University of Kansas)

INTAKE DOMAIN – Nutrient Intake Balance

Increased nutrient needs (specify) NI-5.1 Carol Braunschweig, PhD, RD (University of Illinois,

Chicago)

Evident protein-energy malnutrition NI-5.2 Charlette R. Gallagher Allred, PhD, RD (Retired-Ross

Labs)

Inadequate protein energy intake NI-5.3 Trisha Fuhrman, MS, RD, FADA, CNSD (Coram, Inc.)

Decreased nutrient needs (specify) NI-5.4 Jeannmarie Beiseigel, PhD, RD (USDA)

Imbalance of nutrients NI-5.5 Molly Kretsch, PhD, RD (USDA)

INTAKE DOMAIN – Nutrient Balance – Fat and Cholesterol Balance

Inadequate fat intake NI-51.1 Alice Lichtenstein, DSc (Tufts)

Excessive fat intake NI-51.2 Wendy Mueller Cunnigham, PhD, RD (Cal State)

Inappropriate intake of food fats NI-51.3 Nancy Lewis, PhD, RD (University of Nebraska-

Lincoln)

INTAKE DOMAIN – Nutrient Balance – Protein Balance

Inadequate protein intake NI-52.1 Don Layman, PhD (University of Illinois-Champaign)

Excessive or unbalanced protein intake NI-52.2 Linda A. Vaughan, PhD, RD (Arizona State)

Inappropriate intake of amino acids NI-52.3 Allison Yates, PhD, RD (Industry, formerly Director of

the IOM Food and Nutrition Board)

INTAKE DOMAIN – Nutrient Balance – Carbohydrate Balance

Inadequate carbohydrate intake NI-53.1 Robert Wolfe, PhD (University of Texas Medical

Branch)

Excessive carbohydrate intake NI-53.2 Anne Daly, MS, RD

Inappropriate intake of types of

carbohydrate

NI-53.3 Lyn Wheeler, MS, RD, CD, FADA, CDE (Indiana

University School of Medicine)

Inconsistent intake of carbohydrate NI-53.4 Maggie Powers, MS, RD, CDE (International Diabetes

Center)

Inadequate fiber intake NI-53.5 Joanne Slavin, PhD, RD (University of Minnesota)

Excess fiber intake NI-53.6 Judith Marlett, PhD, RD (University of Wisconsin)

INTAKE DOMAIN – Nutrient Balance – Vitamin Balance

Inadequate vitamin intake (specify) NI-54.1 Laurie A. Kruzich, MS, RD (Iowa State)

Kristina Penniston, PhD, RD (University of Wisconsin)

Edition: 2006 163


Expert Reviewers

Nutrition Diagnosis Labels

Nutrition Diagnostic Label Dx Label # Reviewers

CLINICAL DOMAIN – Functional Balance

Swallowing difficulty NC-1.1 Moshe Shike, MD (Memorial Sloan Kettering)

Chewing (masticatory) difficulty NC-1.2 Helen Smiciklas-Wright, PhD, RD (Penn State)

Riva Touger-Decker, PhD, RD (UMDNJ)

Breastfeeding difficulty NC-1.3 Maureen A. Murtaugh, PhD, RD (University of Utah)

Altered GI function NC-1.4 Larry Cheskin, MD (Johns Hopkins)

CLINICAL DOMAIN – Biochemical Balance

Impaired nutrient utilization NC-2.1 Laura Matarese, MS, RD, CNSD (Cleveland Clinic)

Altered nutrition-related laboratory

values

NC-2.2 Denise Baird Schwartz, MS, RD, CNSD (Clinical

practice)

Food-medication interaction NC-2.3 Andrea Hutchins, PhD, RD (Arizona State University

East, Mesa, AZ)

CLINICAL DOMAIN – Weight Balance

Underweight NC-3.1 Bonnie Spear, PhD, RD (University of Alabama,

Birmingham)

Involuntary weight loss NC-3.2 Jody Vogelzang, MS, RD, LD, CD, FADA (Texas

Women’s University)

Overweight/obesity NC-3.3 Rebecca Mullis, PhD, RD (Georgia)

Involuntary weight gain NC-3.4 Celia Hayes, MS, RD (HRSA)

BEHAVIORAL-ENVIRONMENTAL DOMAIN – Knowledge and Beliefs

Food- and nutrition-related knowledge

deficit

NB-1.1 Penny Kris-Etherton, PhD, RD (Penn State)

Harmful beliefs/attitudes about food,

nutrition, and nutrition-related topics

NB-1.2 Keith-Thomas Ayoob, PhD, RD (Albert Einstein)

Not ready for diet/lifestyle change NB-1.3 Geoffrey Greene, PhD, RD (University of Rhode

Island)

Self-monitoring deficit NB-1.4 Linda Delahanty, MS, RD (Harvard)

Disordered eating pattern NB-1.5 Eileen Stellefson Myers, PhD, RD (Private practice)

Leah Graves, MS, RD (Saint Francis Hospital, Tulsa,

OK)

Limited adherence to nutrition-related

recommendations

NB-1.6 Ellen Parham, PhD, RD (Northern IL)

Undesirable food choices NB-1.7 Kathy Cobb, MS, RD (Centers for Disease Control)

BEHAVIORAL-ENVIRONMENTAL DOMAIN – Physical Activity Balance and Function

Physical inactivity NB-2.1 Melinda Manore, PhD, RD (Oregon State)

Excessive exercise NB-2.2 Katherine Beals, PhD, RD (Industry, formerly Ball

State)

Inability to manage self-care NB-2.3 Emily Gier, MS, RD (Cornell)

Impaired ability to prepare foods/meals NB-2.4 Marla Reicks, PhD, RD (U of MN)

Poor nutrition quality of life NB-2.5 Elvira Johnson, MS, RD (Private practice)

Self-feeding difficulty NB-2.6 Mary Cluskey, PhD, RD (Oregon State)

BEHAVIORAL-ENVIRONMENTAL DOMAIN – Food Safety and Access

Intake of unsafe food NB-3.1 Johanna Dwyer, DSc, RD (Tufts)

Limited access to food NB-3.2 Sondra King, PhD, RD (Northern Illinois University)

INTAKE DOMAIN – Caloric Energy Balance

Hypermetabolism NI-1.1 Jonathan Waitman, MD for Louis Arrone, MD

Edition: 2006 162


Excess vitamin intake (specify) NI-54.2 Kristina Penniston, PhD, RD (University of Wisconsin)

INTAKE DOMAIN – Nutrient Balance – Mineral Balance

Inadequate mineral intake (specify) NI-55.1 Bob Heaney, MD (Creighton)

Excessive mineral intake (specify) NI-55.2 Joan Fischer, PhD, RD (University of Georgia)

Edition: 2006 164

60616263646566676869707172737475767778798081828384858687888990919293949596979899

100101102103104105106107108109110111

from the associationOF PROFESSIONAL INTEREST

Implementing Nutrition Diagnosis, Step Two in theNutrition Care Process and Model: Challenges and

Lessons Learned in Two Health Care FacilitiesJennifer Mathieu; Mandy Foust, RD; Patricia Ouellette, RD

In adherence to the American Die-tetic Association’s (ADA) StrategicPlan goal of establishing and im-

plementing a standardized NutritionCare Process (NCP) in the hopes of“increasing demand and utilization ofservices provided by members” (1), di-etetics professionals in two healthcare facilities established an NCP pi-lot program in 2005, in collaborationwith ADA. The pilot sites were theVirginia Hospital Center in Arlingtonand the Veterans Affairs MedicalCenter in San Diego, CA.

This article gives a background onthe NCP and model, the standardizedlanguage used in the nutrition diag-nosis step, medical record documen-tation, and an explanation of how thetwo sites came to participate in thepilot program. It also provides a time-line for each site’s implementation ofthe NCP, including challenges facedand lessons learned. Similarities anddifferences in approaches will also bediscussed. Managers from both facili-ties will offer advice to facilities whoare contemplating implementation ofthe NCP and nutrition diagnoses inthe future.

BACKGROUNDADA developed a four-step NCP andModel that appeared in the August2003 issue of the Journal. The NCP

consists of four “distinct but interre-lated and connected steps”—Nutri-tion Assessment, Nutrition Diagno-sis, Nutrition Intervention, andNutrition Monitoring and Evaluation(2). The NCP and Model were devel-oped by the Quality ManagementCommittee Work Group with inputfrom the House of Delegates.

This new model calls for dieteticsprofessionals to incorporate a newstep—making a nutrition diagnosis—which involves working with definedterminology. It also asks dieteticsprofessionals to chart their diagnosisin the form of a statement that estab-lishes the patient’s problem (diagnos-tic label), etiology (cause/contributingrisk factors), and signs and symptoms(defining characteristics). This isknown as a PESS statement, andmakes up the heart of the NCP’s sec-ond step—nutrition diagnosis.

“The second step is the cultureshift,” says Susan Ramsey, MS, RD,CDE, LDN, senior manager of medi-cal nutrition services for Sodexho whoalso serves on ADA’s Research Com-mittee. “The second step forces us tomake a one-line statement. It bringsthe whole assessment into one clearvision.”

According to the article by Laceyand Pritchett, using the new modelprovides many benefits. The modeldefines a common language that al-lows nutrition practice to be moremeasurable, creates a format that en-ables the process to generate quanti-tative and qualitative data that canthen be analyzed and interpreted,serves as the structure to validate nu-trition care, and shows how the carethat was provided does what it in-tends to do (2). It also gives the pro-fession a greater sense of autonomy,says Ramsey. “It’s given us responsi-

bility for our work instead of lookingfor permission from others.”

The nutrition diagnostic labels andreference sheets were developed bythe Standardized Language TaskForce, chaired by Sylvia Escott-Stump, MA, RD, LDN. It is from thislist that dietetics professionals utiliz-ing the NCP list the P (problem) partof their PESS statement. According toEscott-Stump, this StandardizedLanguage will help bring dieteticsprofessionals a new focus and theability to target their interventionsinto more effective results that willmatch the patient nutrition diagnosis(problem).

It is Escott-Stump’s belief that doc-umenting nutrition diagnoses, inter-ventions, and outcomes will allow fordietetics professionals to better trackdiagnoses over several clients, allow-ing the profession to be more likely totrack the types of nutrition diagnosesthat clients have, and be able to statethat the profession affects certaintypes of acute and chronic diseasesmore than others.

“For example, now we believe thatour impact on cardiovascular, endo-crine, and renal diseases is strong,but we may find that our profession-als impact gastrointestinal disordersthe most,” says Escott-Stump. “Byhaving standardized language, wewill be able to validate or correct oursuspicions.”

This pilot implementation of thenutrition care model also tested a newmethod of charting that differs fromthe traditional Subjective ObjectiveAssessment Plan format (SOAP). Thenew ADI template stands for Assess-ment, Diagnosis, and Intervention(including Monitoring and Evalua-tion).

According to Dr Esther Myers,

J. Mathieu is xxx, Houston, TX.M. Foust is xxx. P. Ouellette isxxx.

Address correspondence to: Jen-nifer Mathieu, 5639 Berry CreekDr, Houston, TX 77017. E-mail:[email protected]/05/xx0x-0000$30.00/0doi: 10.1016/j.jada.2005.07.015

© 2005 by the American Dietetic Association Journal of the AMERICAN DIETETIC ASSOCIATION 1Edition: 2006 165

12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152

PhD, RD, FADA, ADA’s Research andScientific Affairs director, ADA plansto expand these two pilot teststhrough the Peer Network for Nutri-tion Diagnosis in the next 2 years.This group of dietetics professionalswill receive additional training andnetworking opportunities to assistthem as they implement this newmodel within their facility and thenshare their knowledge with other di-etetics professionals in their geo-graphical region.

Their experience will be used to de-termine what additional implementa-tion tools are needed. In addition, aformal research project will be con-ducted through the Dietetics PracticeBased Research Network in early2006.

IMPLEMENTATION OF THE PROGRAMVirginia Hospital CenterMandy Foust, RD and Clinical Nutri-tion Manager of the Virginia HospitalCenter, is contracted through So-dexho to oversee patient services atthe 400-bed facility. In December2004, Foust, who had learned aboutPESS statements while in school, de-cided to have her college dietetic in-tern Anne Avery research currentchanges and updates in charting fordietetics professionals.

Avery spoke with Dr Myers and dis-cussed the possibility of the VirginiaHospital Center serving as a pilot sitefor the new model. Foust was excitedabout the idea for several reasons. “Tome, the nutrition care model is a clin-ically based, concise way of chartingthat sets goals and is more standard-ized with other disciplines,” she says.Until the implementation of the pilotproject, the RDs on staff at the Vir-ginia Hospital Center used the SOAPformat of charting.

A conference call took place be-tween Foust, Dr Myers, Avery, andAvery’s internship director at Vir-ginia Tech. Foust selected one of herfive inpatient registered dietitians(RDs) to serve as the first RD to usethe new method. It was decided Averywould present an in-service on thenutrition care model to the dieteticsprofessionals on staff. This in-serviceprovided the RDs with introductoryinformation, the four steps of theNCP, PESS statements, diagnosticlabeling, and why the changes wouldbe beneficial.

Foust says there were concernsfrom her staff about the new method.These included that the new ADIcharting format would not allow themto be thorough enough and that itseemed “too cookie cutter.” Staff alsoexpressed concern that it would bedifficult to sum up two or more seri-ous problems in one PESS statement.They also worried that physicianswould be wary of the term “nutritiondiagnosis.”

Over several days in mid-Decem-ber, Foust arranged meetings withseveral hospital administrators, in-cluding the vice president of the hos-pital, the chief nursing officer, themedical staff president, and the chiefof the nutrition committee to get theirfeedback on the pilot project. She alsokept her supervisor at Sodexhoabreast of the situation. “Because Iam a contractor, I want to make sureI’m covering my bases,” says Foust.She says the Virginia Hospital Centeris “very interdisciplinary” and thatshe wanted there to be an awarenessof the upcoming changes.

Administrators initially had ques-tions about how the new methodwould benefit patients, but Foust saysafter she met with them and pre-sented them with information on thenutrition care model, they were recep-tive to the changes. The physicianwho served as chief of the hospital’snutrition committee had concernsabout the idea of a nutrition diagno-sis. Foust says she reassured himthat the new method did not ask RDsto make a medical diagnosis or inter-fere with a physician’s orders.

After the nutrition committee ap-proved the project in early January2005, Foust was asked to inform sev-eral other hospital staff membersabout the new format, including thechief of surgery and the chief of sur-gical education. Because the first RDto participate in the pilot projectworked in the intensive care unit(ICU), Foust was also asked to notifythe medical director of the ICU, twoICU nurse educators, and the ICUpatient care director via formal let-ters. Responses to these letters en-couraged Foust to seek approval forthe project from the hospital’s pa-tient-monitoring committee.

During the end of January whilewaiting for a response from the pa-tient-monitoring committee, Foustmet for about an hour each week with

the RD who would be the first to usethe new method. The RD used actualpatients from her daily census to be-gin practicing PESS statements andADI charting. Foust shared the re-sults with Dr Myers and the Stan-dardized Language Task Force often.Through early to mid-February theRD submitted her notes in both theSOAP format and the new format as away of practicing the new method.

At the end of January, the patient-monitoring committee gave theproject its approval. Before imple-mentation officially occurred, Foustrequested permission and modifiedthe Hakel-Smith Coding Instrumentas an auditing tool to evaluate thecharts. She also developed a question-naire for allied health professionals togive feedback on the new system ofcharting.

On February 16, 2005, the ICU RD,Korinne Umbaugh, officially begansubmitting all of her notes using theADI template. Foust audited two tothree charts each day. In late Febru-ary, a second RD began using the newmethod of charting. On March 28, athird RD began the process. By themiddle of April, all five RDs were us-ing the ADI template, with the fifthRD beginning the process on the sec-ond week of the month.

Throughout the entire transitionFoust met formally and informallywith staff RDs both individually andin groups. Foust says at least 20 min-utes of each weekly hour-long staffmeeting continues to be spent dis-cussing the new method of chartingand reviewing PESS statements. Atthis time Foust is editing about 10%of the charts.

Unfortunately, Foust did not re-ceive as many completed question-naires as she hoped for from alliedhealth professionals. However, herinitial chart audits showed that bythe end of April the staff had becomemuch more comfortable with the pro-cess. Audits revealed notes thatsteadily became more direct and con-cise, as well as more outcome-ori-ented. Extraneous information wasnot included as often.

Veterans Affairs Medical Center, SanDiegoPatricia Ouellette, RD, is the deputydirector of nutrition and food servicesfor the Veterans Affairs Medical Cen-


2 Month 2005 Volume xx Number xEdition: 2006 166

60616263646566676869707172737475767778798081828384858687888990919293949596979899

100101102103104105106107108109110111

ter in San Diego, CA. The MedicalCenter is a 238-bed facility. There arethree RDs who focus on the inpatientareas of the facility.

In January 2004, the facility’s di-rector of nutrition and food service,Ginger Hughes, MS, RD, distributedthe August 2003 article by KarenLacey, MS, RD and Ellen Pritchett,RD, about the NCP that appeared inthe Journal. The staff was advised toread the article and become familiarwith it. In the fall of 2004, internshipprogram director Tere Bush-Zurn andoutpatient dietitian Teresa Hillearyreceived a scholarship to attend theNutrition Diagnosis Roundtable forEducators workshop at the ADA’s2004 Food and Nutrition Conferenceand Exhibition. Bush-Zurn and Hill-eary relayed what they learned withthe rest of their staff when they re-turned to California.

In November 2004, a staff meetingis held to discuss questions and con-cerns surrounding the NCP andPESS statements. The staff agreed tostart using the PESS statements assoon as possible. After a December2004 workshop presented by a visit-ing Lacey, the staff agreed that theywanted to work toward transitioningto the nutrition care model and wouldserve as a pilot site.

“It evolved after a year of looking atthe process and after a lot of discus-sions with the staff,” says Ouellette.“We are a teaching institution and wewanted to challenge ourselves interms of our practice. We also have adietetic internship program and feelresponsible for providing the internswith the most progressive concepts inour field of practice.”

As with the Virginia Hospital Cen-ter RDs, the RDs at the VA had beenusing the SOAP format for manyyears and they had similar concernsover whether the new method wouldbe deemed thorough enough. Theywere also concerned that one PESSstatement would not be enough if thepatient had several complicated prob-lems.

Based on staff consensus, in Febru-ary 2005 the staff started devotingtime at the weekly staff meeting todiscussing issues related to the newmethod. The staff practiced writingPESS statements and shared the re-sults with each other during thistime. They also discussed questions

and concerns related to the newmethod.

At the same time, several staffmembers, including the staff’s perfor-mance improvement/information tech-nology dietitian, worked separately todevelop a point-and-click computerversion of the inpatient initial nutri-tion assessment ADI template thatcould be used by the inpatient RDs onstaff when writing their notes.

During the last week in March, theinpatient RDs spent 1 week writingtheir notes using both the old SOAPmethod and the new template. OnApril 4, the staff officially imple-mented the new version of chartingfor the inpatient initial nutrition as-sessments and stopped using theSOAP method completely. For thefirst month after the official imple-mentation, Ouellette checked everyinpatient initial nutrition assessmentchart note and provided weekly feed-back to the staff.

In May, the auditing componentswere incorporated into the NFS Peri-odic Performance Review plan imple-mented as part of the Joint Commis-sion on Accreditation of HealthcareOrganizations’ continuous readinessphilosophy. Although not required,they believed this was a good way tocontinue to audit and document theprocess.

Ouellette continued to meet withRDs individually as problems andquestions developed about thechange. Her initial audits revealedthat the majority of the staff uses thesame five to six diagnostic labels. Shealso assessed that after 2 weeks ofusing the new ADI template exclu-sively, PESS statements markedlyimproved and chart notes becamemore focused and concise. After 3weeks the amount of time spent onthe notes shortened, suggesting thatthe staff was becoming more comfort-able with the process.

In regard to diagnostic labels, Ouel-lette’s staff began the practice of uti-lizing two diagnostic labels and com-bining them into one PESS statementif the two conditions were closely re-lated (eg, difficulty swallowing andchewing difficulty).

The monitoring component of theprocess still needs to be observedcarefully, as many of Ouellette’s staffmembers are not yet in the habit ofstating which specific laboratory testsneed to be performed.

SIMILARITIES AND DIFFERENCESThe biggest difference between thetwo sites was the time spent seekingapproval for the project before pro-ceeding. As a contractor, Foust be-lieved she needed to secure approvalfrom several different administratorsbefore beginning implementation.Ouellette’s approval process occurredmuch more informally. Ouellette saysthis is because the VA allows flexibil-ity in how Nutrition and Food Ser-vices’ processes are carried out.

Another difference centered on theway staff RDs began participating inthe implementation. Ouellette’s staffdiscussed the process for about a yearbefore they all began the new methodof charting at the same time. Ouel-lette and her staff wanted to workwith only one inpatient charting tem-plate at a time, and this allowed themto do so. Also, Ouellette believed thatif the SOAP method template wasavailable, RDs might be tempted to goback to the old format that they feltmost comfortable using.

After the staff in-service, Fouststarted one of her RDs on the newmethod and others followed over a pe-riod of months. As the implementa-tion was occurring, the staff had sev-eral meetings to discuss the newchanges. Foust believed this gradualmethod of implementation allowedtime for RDs who were having troublewith the new method to learn fromRDs who were actively working withit.

The similarities between both sitesincluded the increased amount of ad-ministrative time spent on the change(especially at the manager level) aswell as the decision to focus thechange to inpatient areas only. Foustand Ouellette both said this decisionwas made because inpatient casestend to be more complex, and if thesecases could be dealt with successfullyit would be even easier to make thetransition with outpatient cases. Thesites shared another similarity inthat the types of concerns held by thestaffs were nearly identical, as werethe challenges they faced and the les-sons they learned.

CHALLENGES AND LESSONS LEARNEDAccording to Foust and Ouellette, thebiggest challenge for both sites wasassisting their RDs in completelychanging the way they think about


Month 2005 ● Journal of the AMERICAN DIETETIC ASSOCIATION 3Edition: 2006 167

12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152

their chart notes. “It’s a brand newlanguage,” says Foust. “My RDs arealready seeing 14, 16 patients a day,and it’s a long process when you’restarting something new.”

Both managers say their RDs had ahard time excluding extraneous lan-guage. In the SOAP format, for exam-ple, RDs were used to including infor-mation about everything fromdecades-old surgeries, the patient’sgeneral mood, and other aspects ofthe patient’s condition that are notrelevant to a nutrition diagnosis.With the nutrition care model, thecharting must be much more exact.“This new method requires us to focuson establishing a nutrition label andforces us to restrict our charting towhat is relevant to that nutritionaldiagnosis,” says Ouellette.

Also challenging for the RDs wasthe creation of the PESS statements.“They initially roadblock with thePESS,” says Foust. “It is a completelydifferent way of formatting yourthoughts. It’s moving from a very con-versational way of charting to a moreclinical-sounding, concise note. Thisresults in a struggle when first chart-ing.”

Staff members at both sites hadconcerns over what to do when thereseemed to be two separate but equallyimportant problems. After discus-sions with Dr Myers, it was decidedthat, on occasion, two PESS state-ments can be used.

Ouellette adds that another chal-lenge comes from the fact that thenutrition care model means a differ-ent way of approaching formattingthe chart note. “The chart note reallyhas to be decided after determiningthe PESS statement,” says Ouellette.“The statement can only be deter-mined after a thorough nutritionalassessment. The chart review and pa-tient consultation method are thesame, but the structuring of the chartnote is quite different. We no longerdo this in a linear fashion. We startfrom the middle with the PESS state-ment and complete both ends—as-sessment and goals—from there.”

RDs also struggled with how towrite PESS statements for patientsthat simply had no nutrition risk.Foust says she urged her staff to rec-ognize that if they were experts inmaking a nutrition diagnosis, theycould say that at certain times thereis no nutrition diagnosis. Ouellette

adds that it might be a good idea tocreate a category of “potential” diag-nostic labels that could be used forpatients who are basically stable withtube feedings or dialysis, but who stillneed to be monitored.

While the PESS statement provedto be the most difficult hurdle, RDsalso had to learn to be more specificwhen it came time to express howthey would monitor and evaluatetheir patients. It wasn’t enough towrite “monitor labs,” says Foust. “Youneed to give specific labs and thenfollow with an explanation and ex-pected outcomes.”

For managers, keeping morale ofstaff up was a challenge. This wasespecially true for RDs who spoke offeeling stifled by the new method andwho constantly feared they weremaking a mistake. Managers learnedthey needed to spend extra time en-couraging their RDs and remindingthem that they were working on acutting-edge project.

“All of my RDs are competent andbrilliant,” says Foust. “Changing theway they chart and implementingnew techniques can cause doubt. Thiscan potentially alter their clinical selfconfidence, and you want to maintaina positive outlook to avoid this.”

Both Foust and Ouellette say it wasbeneficial to work in groups on PESSstatements and learn from eachother, being sure to highlight well-written charts as well as the ones thatthat needed attention. Foust andOuellette also learned that not everyRD would learn at the same pace.While RDs who had been in the pro-fession for a shorter amount of timewere often able to grasp the conceptfaster, Ouellette adds that, in gen-eral, the RDs who had the easiesttime were the ones with personalitytypes that adjusted well to change,regardless of experience level.

ADVICE TO SITES READY FORIMPLEMENTATIONBoth Foust and Ouellette offer simi-lar advice to sites seeking to imple-ment the NCP and model. Both sug-gest an in-service for the staff and thedistribution of materials well aheadof implementation. Ouellette alsosuggests providing training from aknowledgeable source, as was thecase with Karen Lacey speaking to

her staff using ADA slides describingthe NCP.

Both managers suggest settingaside a generous portion of the weeklystaff meeting time to discuss themodel, review PESS statements, an-swer questions, and motivate thestaff with positive feedback.

While Foust and Ouellette had dif-ferent experiences in terms of seekingapproval from the administration toimplement the program, both suggestallowing time to meet with the neces-sary people in the facility, as the ap-proval needed will differ from facilityto facility.

Most of all, Ouellette and Foustsuggest that future managers andstaffs remind themselves that transi-tioning to the nutrition care model isa beneficial but time-consuming pro-cess that requires patience. Both saythey have seen marked improve-ments among their staff over time,and many of the initial challengeshave been overcome with patienceand practice.

“You’re changing the way you’rethinking, you’re changing the wayyou’re charting, it’s a huge change,”says Ouellette. “There are no short-cuts you can take. But my staff isexcited about being on the forefront.It’s certainly a worthwhile thing.”

Adds Foust, “This continues to bean excellent groundbreaking experi-ence.”

The authors would like to acknowl-edge the contributions of the follow-ing people in the preparation of thisarticle: Susan Ramsey, MS, RD, CDE,LDN, senior manager of medical nu-trition services for Sodexho who alsoserves on ADA’s Research Commit-tee; Sylvia Escott-Stump MA, RD,LDN, Standardized Language TaskForce Chair; and Esther Myers, PhD,RD, FADA, ADA’s Research and Sci-entific Affairs director.

References1. American Dietetic Association

Strategic Plan. Available at:http://www.eatright.org (mem-ber-only section). Accessed April17, 2005.

2. Lacey K, Pritchett E. NutritionCare Process and Model: ADAadopts road map to quality careand outcomes management. J AmDiet Assoc. 2003;103:1061-1072.



60616263646566676869707172737475767778798081828384858687888990919293949596979899

100101102103104105106107108109110111

TIMELINES OF IMPLEMENTATIONVirginia Hospital CenterDecember 2004● Idea of participating in pilot project presented to facil-

ity.● Staff in-service held to educate staff about the NCP,

ADI charting, and PESS statements.● Meetings between clinical nutrition manager and hos-

pital administrators to discuss the NCP and seek ap-proval for participation in the pilot project.

January 2005● Hospital nutrition committee approves the pilot

project.● Other hospital administrators, including those on the

unit where the first RD to participate in the projectworks, are informed of the pilot project.

● The hospital’s patient-monitoring committee approvesthe pilot project.

● Throughout the month of January, the first RD to takepart in the project meets regularly with clinical nutri-tion manager to practice ADI charting and PESS state-ments.

● Clinical nutrition manager obtains permission andmodifies the Hakel-Smith Coding Instrument as a wayof auditing charts.

February 2005● From early to mid-February, the first RD to participate

in the project charts using both the ADI and SOAPformats before formally transitioning to the ADImethod alone on February 16.

● In late February, a second RD begins to exclusively usethe ADI method of charting.

March 2005● By the end of March, a third RD has transitioned to the

ADI method of charting.● Throughout the entire process, the clinical nutrition

manager meets formally and informally with RDs bothindividually and in groups to discuss concerns andmonitor progress.

● Throughout the process, at least 20 minutes of eachweekly staff meeting are devoted to reviewing the ADImethod of charting, PESS statements, questions, andconcerns.

April 2005● By the start of April, a fourth RD is exclusively using

the ADI method of charting, with the fifth and final RDmaking the transition by mid-April.

● The clinical nutrition manager audits 10% of charts.

Veterans Affairs Medical Center, San Diego

January 2004● Director of nutrition and food services distributes jour-

nal articles about the NCP to staff.

October 2004● Two staff members attend the Nutrition Diagnosis

Roundtable for Educators workshop at ADA’s Foodand Nutrition Conference and Exhibition and sharewhat they learn with the rest of the staff upon theirreturn.

November 2004● A staff meeting is held to discuss questions and con-

cerns surrounding the NCP and PESS statements.

December 2004● ADA’s Karen Lacey, Chair of ADA’s Quality Manage-

ment Working Group on the NCP, provides the staffwith a workshop on the NCP.

February 2005● The staff begins to devote time during each weekly

staff meeting to practice using the new method and toshare PESS statements.

● Several staff members, including the staff’s perfor-mance improvement/information technology dietitian,develop a point-and-click computer version of the ADItemplate for the staff to use.

March 2005● Toward the end of March, the staff spends 1 week

using both the SOAP format and the new ADI tem-plate to chart notes.

April 2005● On April 4, the staff officially implements the new

method of charting exclusively.● The deputy director of nutrition and food service

checks each inpatient initial nutrition assessmentchart note and provides feedback to individuals.

May 2005● Ongoing auditing was accomplished by incorporating

the auditing elements into the periodic performancereview plan implemented to ensure continuous readi-ness for the Joint Commission on Accreditation ofHealthcare Organization’s review.


Month 2005 ● Journal of the AMERICAN DIETETIC ASSOCIATION 5Edition: 2006 169

12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152

NUTRITION CARE PROCESS AND MODEL WORK GROUP

Karen Lacey, MS, RD, ChairElvira Johnson, MS, RDKessey Kieselhorst, MPA, RDMary Jane Oakland, PhD, RD, FADACarlene Russell, RD, FADAPatricia Splett, PhD, RD, FADAStaff Liaisons:Harold Holler, RDEsther Myers, PhD, RD, FADAEllen Pritchett, RDKarri Looby, MS, RD

The work group would like to extend a special thankyou to Marion Hammond, MS, and Naomi Trostler, PhD,RD, for their assistance in development of the NCP andModel.

STANDARDIZED LANGUAGE TASK FORCE

Sylvia Escott-Stump, MA, RD, LDN, ChairPeter Beyer, MS, RD, LDChristina Biesemeier MS, RD, LDN, FADAPam Charney, MS, RD, CNSDMarion Franz, MS, RD, CDEKaren Lacey, MS, RD, CDCarrie LePeyre, RD, LDNKathleen Niedert, MBA, RD, LD, FADAMary Jane Oakland, PhD, RD, LD, FADAPatricia Splett, PhD, MPH, RDFrances Tyus, MS, RD, LD

The task force would like to extend a special thank youto Naomi Trostler, PhD, RD, FADA.



FEEDBACK FORM

We welcome feedback on revisions to this reference for Nutrition Diagnosing. After

evaluating each section, please indicate whether you would recommend that the section should

be included in the next edition. Following this, please identify other questions that you would

like answered in the next version. Finally, any additional materials you would find helpful is

appreciated. Thank you for your time.

Should the following items should be included in the nex

version:

Please

Check ( )

YES NO

The Nutrition Care Process: Nutrition Care Process and Model Article

Development of Standardized Language: American Dietetic

Association’s Standardized Language Model/Current Status

Introduction to Nutrition Diagnoses/Problems

Nutrition Diagnosis Reference Sheets: Single page list of Nutrition

Diagnostic Terminology

Nutrition Diagnosis Terms and Definitions: Table of Contents for next

document

Nutrition Diagnosis Reference Sheets (128 pages)

Procedure for Nutrition Controlled Vocabulary/Terminology

Maintenance/Review

Camera Ready Pocket Guide

What questions would you like answered in the 2007 version?

What additional materials would be helpful in the 2007 version?

Please remove this form from packet and mail to:


Nutrition Care Process /Standardized Language Committee

American dietetic Association



You can also email this information to: [email protected]

Edition: 2006 171

Edition: 2006 172

Documents

Nutrition Diagnosis - CGMH Diagnosis from... · Nutrition Diagnosis: ... Using the NCP Even though ADA’s ... (14,26). MNT is but one speciﬁc type of nutrition care. The NCP articulates