Monday, December 7, 2020

Refeeding Syndrome: Opportunity for Dietitians

Dietitians’ participation on the healthcare team is enhanced if we can accurately describe the problem(s) we are addressing.  Refeeding syndrome may present an opportunity for dietitians.

Refeeding syndrome is a documented problem encountered during certain situations when a severely malnourished person starts receiving significant energy from oral, enteral or parenteral nutrition support. 

It was first named when parenteral nutrition was emerging as a nutrition intervention and malnourished patients received excessive calories, mostly from dextrose.1   There continues to be lack of clear and consistent definition of refeeding syndrome, however key risk factors are known and include those who are malnourished, have a very low BMI or who have received negligible nutrient intake over the last 5 days. 2

The rapid start of metabolism of carbohydrate increases the need for intracellular thiamin and electrolytes (e.g. phosphate, magnesium and potassium).  When these nutrients rapidly enter the cells, the result is a decrease in serum levels.  In addition, alterations in insulin levels can lead to significant sodium and fluid retention. These metabolic disruptions or are known as 'refeeding syndrome".

But is there one "best" way to create a PES statement that leads to appropriate intervention?

If you look at the guidelines for refeeding malnourished patients you will find that recommendations include screening, assessment/monitoring and evaluation of the following types of data:

-NICE guidelines identify that SNAQ may be used as a screening tool to identify those at risk for refeeding syndrome3

-Nutrition Assessment/Monitoring and Evaluation parameters used prior to initiating feeding and monitoring after initiation of feeding

Aspen Guidelines include criteria for identifying moderate or significant risk for refeeding syndrome using a combination of BMI, amount and rate of weight loss, caloric intake,  potassium, phosphorus, or magnesium serum concentrations (hypokalemia, hypophosphatemia, or hypomagnesemia), loss of subcutaneous fat, loss of muscle mass, and presence of higher risk co-morbidities.2

-Nutrition interventions include supplementation of thiamin and electrolytes (phosphate, potassium and magnesium if levels are low) prior to the start of nutrition therapy followed by a gradual increase in  energy intake to meet energy requirements by Day 2 to 4 as long as electrolyte levels are stable.

What are the appropriate PES statements?7

If you are using criteria to identify individuals "at risk" for refeeding syndrome prior to initiating feeding, then a dietitian may consider using these two PES statements:

·        Starvation related malnutrition, severe, related to prolonged nutrition inadequacies as evidenced by unintentional weight loss  (adults- of  >20% in 1 year; >10% in 6 months; >7.5% in 3 months; or >5% in 1 month), severe loss of subcutaneous fat stores, and severe muscle loss4

·        Predicted Inadequate Nutrient Intake (thiamine, phosphorus, potassium and magnesium) related to increased nutrient need during initiation of refeeding after severe malnutrition as evidenced by diagnosis of severe malnutrition, pre-feeding laboratory values for phosphorus, potassium and magnesium (as applicable) and plan to initiate refeeding to estimated requirements by Day 2.5

However if it is now Day 2 and there are documented electrolyte imbalances, then the dietitian may consider the following that reflect the actual presence of refeeding syndrome:

·        Starvation related malnutrition (severe), related to prolonged nutrition inadequacies as evidenced by unintentional weight loss  (adults- of  >20% in 1 year; >10% in 6 months; >7.5% in 3 months; or >5% in 1 month), severe loss of subcutaneous fat stores, and severe muscle loss4

·        Imbalance of nutrients related to increased need for electrolytes and thiamine during refeeding as evidenced by (hypokalemia (data), hypophosphatemia(data), and/or hypomagnesemia (data) with TPN currently contributing 75% of estimated energy needs.  6

It is important to remember there may be alterations in electrolytes from other causes, so the dietitians' clinical judgement is necessary to determine whether the evidence is present that reflects a true refeeding syndrome versus an "Altered nutrition related laboratory values.” 8

There may be situations where an "Altered nutrition-related laboratory value" may be identified first and as the clinical picture becomes more clear, this may be elevated to “imbalance of nutrients” that reflects refeeding syndrome.  6-8

BOTTOM LINE:

Since refeeding syndrome is associated with SEVERE malnutrition, the clinical picture being represented will usually include the severe malnutrition nutrition diagnoses in addition to an "imbalance of nutrients" if refeeding syndrome has occurred, or "predicted inadequate intake" where it is determined that patient is at risk for developing refeeding syndrome.

Acknowledgements:  A special thank you to Ainsley Malone, MS, RDN, LD, CNSC, FAND, FASPEN and Sandra Capra, BSc(Hons), DipNutr&Diet, MSocSc, PhD,  for providing input to concepts included in this blog. 

References:

 

1.      Weinsier RL, Krumdieck CL.  Death resulting from overzealous total parenteral nutrition:  the refeeding syndrome revisited.  Am J Clin Nutr. 1980; 34: 393-399  https://doi.org/10.1016/j.jpeds.2020.01.042

2.      da Silva, JWV et al.  ASPEN Consensus Recommendations for Refeeding Syndrome.  Nutrition in Clinical Practice.  35(2); 2020 178–195 DOI: 10.1002/ncp.10474

3.      Nutrition support in adults:  Evidence update August 2013.  National Institute for Health and Care Excellence (NICE).  Available at:  https://www.nice.org.uk/guidance/cg32/evidence/evidence-update-pdf-194887261.  Accessed December 4, 2020.

4.      Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.  Starvation Related Malnutrition (undernutrition) (NC-4.1.1). Reference Sheet.  Available at: https://www.ncpro.org/pubs/encpt-en/codeNC-4-1-1  Accessed November 22, 2020.

5.      Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.  Predicted Inadequate Nutrient Intake (Specify) (NI-5.11.1). Reference Sheet.  Available at https://www.ncpro.org/pubs/encpt-en/codeNI-5-11-1  Accessed November 22, 2020

6.      Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.  Imbalance of Nutrients (NI-5.4). Reference Sheet.  Available at https://www.ncpro.org/pubs/encpt-en/codeNI-5-4 Accessed November 22, 2020

7.      Matthews,KL, Palmer, MA, Capra SM.  The accuracy and consistency of nutrition care process terminology use in cases of refeeding syndrome.  Nutrition and Dietetics 2018: 75 p 331-336.  DOI: 10.1111/1747-0080.12389

8.      Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.  Altered Nutrition Related Laboratory Values (Nc-2-2). Reference Sheet.  Available at https://www.ncpro.org/pubs/encpt-en/codeNC-2-2, Accessed November 22, 2020


Saturday, November 21, 2020

Evolving PES Statements for Basic Elimination Diet Protocol


Lets consider a situation where you receive a consultation for a client that has been experiencing GI symptoms when on a normal diet.  The physician is concerned that it may be a food intolerance, allergy, or other inflammation-related health condition.  

The Basic Elimination Diet Protocol is one method of  determining which foods are leading to the GI discomfort.  There are the two phases...the elimination phase and the re-introduction phase.  

I received a question from dietitians in Sweden about what the PES statements might be for these two different phases.

PHASE ONE:  

For the first stage where most products are eliminated to eliminate the adverse GI signs and symptoms, the PES statement might be as follows:

Intake of protein inconsistent with needs 

    related to allergy or malabsorption syndrome from unknown protein substance 

as evidenced by medical diagnosis of potential food allergy/malabsorption and symptoms of diarrhea, nausea, vomiting when consuming normal diet.  

PHASE TWO:  

However after the foods have been eliminated from the diet, signs and symptoms of GI distress are no longer present.  You are now entering the testing in the re-introduction phase.  The PES statement might be:

Altered GI Function 

related to allergy or malabsorption syndrome from unknown protein substance

as evidenced by medical diagnosis of potential food allergy/malabsorption and symptoms of diarrhea, nasuea, vomiting when consuming normal diet.  

In this case we assumed that the substance was a protein, however it could be a carbohydrate, such as in the FODMAP Diet (e.g. short chain carbohydrates).  In some circles a variation of this is called the Autoimmune Protocol Diet. 

In this discussion we also assumed that the signs and symptoms would be GI disturbances.  However, in some cases, the Basic Elimination Diet may also be used to test whether there are food allergies or intolerances related to atopic dermatitis or eczema signs and symptoms.  This science in this area is less clear, however some believe that there may be some intrinsic skin defect (in this case in the GI tract) that allows allergens to enter the skin and results in an allergic/autoimmune response.  One way to verify that there might be a connection between food consumption and skin disruptions for an individual patient is using the Basic Elimination Diet Protocol/Autoimmune Protocol.  

While the current reference sheet included in eNCPT for Altered GI Function only includes GI symptoms, it does include reference to abnormal antibodies as one of the signs and symptoms.  It also includes Celiac Disease as one of the medical conditions that might be documentation of altered GI function.  

Whether this term, Altered GI Function, can also be used to describe altered GI functions that are thought to be associated with symptoms for dermatitis could be submitted to the Academy for consideration of whether this is an appropriate use of the term.  If so, the question might also ask whether the reference sheet should be expanded to clearly indicate the appropriateness of this use of the term in this type of situation.


Bottom Line

Your intervention for both PES statements is addressing the etiology BY affecting the signs and symptoms (usually GI discomfort).  

In the first phase you are actively removing the stimulus for the signs and symptoms.  In the second phase are are attempting to identify the unknown substance that is causing the symptoms by noting if the signs and symptoms re-appear when the food is re-introduced.  


References:

Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.  Intake of Types of Proteins Inconsistent with Needs (Specify) (NI-5.6.3), Reference Sheet.  Available at: https://www.ncpro.org/pubs/encpt-en/codeNI-5-6-3.  Accessed November 19, 2020

Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.  Intake of Types of Carbohydrates Inconsistent with Needs (Specify) (NI-5.8.3), Reference Sheet.  Available at:  https://www.ncpro.org/pubs/encpt-en/codeNI-5-8-3.  Accessed November 19, 2020
 
Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.  Altered Gastrointestinal (GI) Function (NC-1.4), Reference Sheet.  Available at:  https://www.ncpro.org/pubs/encpt-en/codeNC-1-4.  Accessed November 19, 2020.


Monday, November 16, 2020

Using your "Crystal Ball!! What about "predicted" nutrition diagnoses?

 What about "predicted" nutrition diagnoses?

One of the general principles for constructing PES statements is that you use actual data that reflect the current situation.  However there are some circumstances where the situation is emerging or is likely to occur.  You are identifying a future nutrition problem and want to be proactive and intervene early.

Let's consider the use of a "predicted" nutrition diagnosis.  Re-consider your options in the previous post about the patient who has been placed on a ventilator, is unable to eat, and you believed should have enteral tube feeding.  

In the previous example we assumed that it was Day 4 and there had already been documented inadequate oral intake and/or inadequate energy intake signs and symptoms from the patient.  

BUT what if it were Day 1 or 2?  Assume the patient had been admitted in the afternoon, placed on a ventilator and it is now the morning of Day 2 of the hospitalization.  In your estimation it appears that the need for ventilator support is likely to continue for a significant amount of time.  

Then you may want to consider using a predicted nutrition diagnosis and you can use recommendations or citations from other research that supports your PES statement in lieu of actual patient signs and symptoms.

In this case a PES statement might look like:

Predicted inadequate energy intake related to inability to maintain volitional intake while on ventilator as evidenced by nutrition guidelines recommending early enteral nutrition for ventilator patients, current diet order as NPO, and ongoing ventilator therapy.

In this case there is limited data available for this specific patient to document actual inadequate energy intake as they have been in the hospital less than 24 hours, however you have a strong case for suggesting that this situation is likely to occur in the future AND you want to be proactive.

BOTTOM LINE:  If you do not have actual signs and symptoms of a nutrition diagnosis that you believe is likely to emerge you can consider a "Predicted nutrition diagnosis.  The following nutritional diagnostic terms are available:

Energy Balance (1)

Predicted inadequate energy intake (NI-1.4)

Predicted excessive energy intake (NI-1.5)

Multinutrient (5.11)

Predicted inadequate nutrient intake (specify)_______(NI-5.11.1)

Predicted excessive nutrient intake (specify)________(NI-5.11.2)


References

Predicted Inadequate Energy Intake (NI-1.4).  Reference Sheet.  Electronic Nutrition Care Process Terminology (eNCPT).  Available at: https://www.ncpro.org/pubs/encpt-en/codeNI-1-4.   Accessed Nov 16 2020.

Predicted Excessive Energy Intake (NI-1.5)   Reference Sheet.  Electronic Nutrition Care Process Terminology (eNCPT).  Available at: https://www.ncpro.org/pubs/encpt-en/codeNI-1-5.   Accessed Nov 16 2020.

Predicted Inadequate Nutrient Intake (NI-5.11.1)   Reference Sheet.  Electronic Nutrition Care Process Terminology (eNCPT).  Available at: https://www.ncpro.org/pubs/encpt-en/codeNI-5-11-1.   Accessed Nov 16 2020.

Predicted Excessive Nutrient Intake (NI-5-11.2)   Reference Sheet.  Electronic Nutrition Care Process Terminology (eNCPT).  Available at: https://www.ncpro.org/pubs/encpt-en/codeNI-5-11-2.   Accessed Nov 16 2020.

Saturday, November 14, 2020

Inadequate Oral Intake vs more specific nutritional diagnoses


Deciding on which nutrition diagnosis will best describe the problem/issue that you are addressing is one aspect of the critical thinking and clinical judgement used by dietitians.  

The whole purpose of identifying the most accurate nutrition diagnosis is to BEST describe your assessment of the client condition that needs nutritional care.  The nutrition diagnosis and etiology chosen will lead to the most appropriate nutrition intervention and the signs and symptoms listed usually lead to appropriate monitoring and evaluation indicators.  

Our documentation in the nutrition progress is a key way to communicate with the rest of the healthcare team.  Your choice of nutrition diagnosis should allow them to understand your logic and ensure that all the healthcare team interventions are consistent and working together.  

Lets consider the initial evaluation of a patient on a ventilator where the diet order has been NPO for 4 days and patient is unable to eat due to being on a ventilator.

Following are the types of questions that you may want to ask yourself as you make the decision about a more general nutrition diagnosis (e.g. Inadequate oral intake) versus a more specific nutrition diagnosis (Inadequate energy intake).  

The table below also includes some thoughts on what the implications of a general versus more specific nutrition diagnosis might be:

Question to ask your self

Some implications of general nutrition diagnoses (e.g. Inadequate Oral Intake)

Some implications of a more specific nutritional diagnosis (e.g. Inadequate Energy Intake)

Will it make a difference in the nutrition intervention that I choose? 

Inadequate oral intake might suggest that the intervention focus is on getting oral food and beverage intake.

Inadequate energy would indicate an intervention focus on high energy foods and or beverages.

Will it make a difference in the Monitoring and Evaluation (M&E)   indicators that I choose?

M&E Indicators would most likely focus on estimates of % food on trays, or number of servings of food groups (e.g. those used in My Plate, diabetic exchanges, or renal exchanges).

M&E Indicators will likely be energy targets, e.g. 85% of estimated energy requirements.

Am I concerned about lack of intake - all nutrients, or am I really only focused on a specific nutrient or only focused only on energy?

Inadequate oral intake indicates that ALL nutrients plus energy are inadequate.  Your intervention focus will likely be on increasing all nutrients.

Inadequate energy intake could represent an intake that is adequate in some nutrients, but not adequate in energy.  Your intervention focus will be first and foremost on providing energy.

Do I have the data necessary or is it worth the extra effort to calculate the additional data?

 

If you are in a nursing home, and the resident is no longer eating (meals or snacks) as per the nursing staff.  They may report…"she is leaving almost everything on the tray".   You may not have a good estimate of the actual intake, and you do not need to calculate the specific energy requirements to know that she is not consuming enough food and beverages.  

There is no additional benefit to converting this to a more specific nutrient(s) or energy nutritional diagnosis.  

The intervention will be the same, provide frequent small quantities of foods/beverages with high nutrient/energy density according to preferences 

You are not likely to need the estimated energy or nutrient needs to guide your intervention.

If you are in acute care setting and the intervention that you are considering is going to be based on a specific energy level or specific protein level, then you may decide that it IS worth taking the extra time and energy to estimate the energy and protein requirements.  

You will most likely need this information to guide enteral feeding or very specific nutrition intervention. 

The intervention is very specifically designed to meet specified targets.  

If it is enteral or parenteral the rate and type of formula is based on estimated requirement.


Should I start with Inadequate Oral Intake and change to more specific as I gain more information and get a clearer picture of the patient/client's condition or as the situation becomes more critical?

 

In some cases, the inadequate oral intake may be a preliminary nutrition diagnosis while you gather more specific information.  This may be especially appropriate if the duration of being on the ventilator is uncertain (only 1 more day vs at least another week). 

If the patient remains on the ventilator and you are ready to change to a more specific nutrition diagnosis (e.g. Inadequate Energy Intake which you will intervene via enteral nutrition)  you can indicate that Inadequate Oral Intake is no longer relevant and replace it with Inadequate Energy Intake.

In some cases it may be more appropriate to go directly to a specific nutrition diagnosis.  

Especially if you have the necessary data and you are ready for a specific nutrition intervention targeted to the nutrient or energy used as the signs and symptoms in the more specific nutrition diagnosis.

Is there something unique to the issue that deals with ORAL intake?  Do you want to focus on the oral aspect of inadequate intake?

 

In some circumstances, the focus may be on ORAL intake.   

For example in a residential care setting, the goal may be to enhance the resident's independence and ability to self feed.  

The intervention may be to enter the resident into restorative dining.  In this case the Oral intake really is the focus of the intervention and appropriate to be used as the nutrition diagnosis

However in some situations the problem is that adequate ORAL intake is likely impossible (e.g. patient is on ventilator).  

In this case, this PES statement could incorporate the inability of maintaining volitional oral intake as an etiology and statement may signal that oral intake is the issue and alternative means of providing nutrition is needed (e.g.enteral tube feeding).  

In this case, your etiology would likely be tied to justifying why oral intake is not possible.  

For example with a patient on a ventilator, the etiology could be inability to maintain volitional oral intake while on ventilator.  

Does a more general nutrition diagnoses accurately describe the level of concern to the rest of the healthcare team. Does the situation require a more compelling nutrition diagnosis?

Inadequate oral intake related to inability to maintain volitional oral intake while on ventilator AEB no nutritional intake for 4 days- Diet order of NPO vs recommendations for early enteral nutrition in ventilator patients.



This PES statement would be most appropriate as a preliminary nutrition diagnosis where the duration of the ventilator has not been determined and there is a possibility that the ventilator will be discontinued soon.
.  
This PES statement would be most appropriate as a preliminary nutrition diagnosis where the duration of the ventilator has not been determined and there is a possibility that the ventilator will be discontinued soon.
.  

 

Inadequate energy related to inability to maintain volitional oral intake while on ventilator as evidenced by 0 energy intake for the past 4 days (Diet order NPO) compared to recommendations for early enteral nutrition with estimated requirements of 2000 kcal per day with cumulative energy deficit of 8,000 kcal 

You could also keep it simpler as follows:
 
Inadequate energy related to inability to maintain volitional oral intake while on ventilator AEB no significant energy intake vs recommendations for early enteral nutrition in ventilator patients.  


These types of PES Statements would be most appropriate if it is highly likely that the need for the ventilator will continue.  It is more straightforward since you are addressing the inability to maintain volitional intake through recommending enteral feeding.   In subsequent nutritional diagnoses you can continue to use energy and "resolve" this problem, but would use enteral nutrition diagnoses if you needed to adjust the formula.   

 BOTTOM LINE:  Neither is technically "WRONG", but depending on your situation one may fit better than the other.  Your decision should be based on what best describes your clinical judgement of the situation and what you want to convey to the rest of the healthcare team.  

Usually simpler is better, as long as it accurately describes the situation.

References:

Inadequate Oral Intake NI-2.1.  Reference Sheet.  Electronic Nutrition Care Process Terminology (eNCPT).  Available at:  https://www.ncpro.org/pubs/encpt-en/codeNI-2-1.   Accessed Nov 14 2020.

Inadequate Energy Intake NI-1.2.  Reference Sheet.  Electronic Nutrition Care Process Terminology (eNCPT).  Available at:  https://www.ncpro.org/pubs/encpt-en/codeNI-1-2.   Accessed Nov 14 2020.

Myers EF, Orrevall Y.  Using the Nutrition Care Process:  Critical Thinking Vignettes From Eight Clinical Cases.  St Louis, Mo.  EF Myers Consulting.  2018

Monday, February 11, 2019

What's in a name...Words matter!

A rose by any other name
would smell as sweet - Shakespeare
Shakespeare's saying  is interpreted to mean that the "names" we give to things does not affect what the things actually are...however the word used to represent a concept can be critical to universal understanding.

One of the goals during the development of the standardized language for dietetics was to use plain english language terms for easy understandability.  But the term selected also had to be precise enough to clearly identify a singular unique problem that a dietitian could address.

When selecting words to become terms, the emphasis was on clarity and accuracy--generally assuming that the purpose of the communication was from healthcare professional to healthcare professional.  The emphasis was not on political correctness or acceptability of using the terms from the clients' perspective.  The terms were not developed with the intention that the dietitian would actually use the words in conversations with clients.

Over the years there have been concerns about the actual words selected.  The first concerns came from the hospital legal experts who were concerned about legal liability if the dietitian identified "inadequate" intake.  They were worried that the word "inadequate" could be construed to be assigning "blame" for the inadequacy to the healthcare organization and therefore generate potential for liability/lawsuits.  The Academy sought legal advice.  The lawyer reviewed terms used by other healthcare professionals and concluded that our term was similar to other terms in use and that it should not generate liability any different than other currently used terms when used appropriately. 

However to ease the concern, the concept of a synonym was introduced.--another word or term that could be used that would mean essentially the same thing.  The alternate term selected for inadequate was "Suboptimal" intake.  Likewise for terms with "deficit" such as "Food and Nutrition Knowledge Deficit," the approved wording could be "Limited food and nutrition knowledge".  These term seemed "softer" and were chosen as the official synonym that retained the same definition and reference sheet as the original term.

The reference sheets for these terms includes a note at the bottom indicating what would be considered alternate working.  See example below:
     *If a synonym for the term "inadequate" is helpful or needed, an approved alternate is the word "suboptimal" (1))

Another concept was discussed at that time was whether local healthcare organizations who had electronic health record could develop local synonyms or alternate wording/abbreviations to appear in the text of the chart.  While this concept was discussed, the decision was made to have synonyms considered at the Academy level and if approved they would be included in subsequent revisions  to maintain consistency in use of the terms by all users.  Any user can submit a request to have a synonym considered using the process identified on the Academy website.(2)

Within the first ~5 years of development of the language, some healthcare organizations were moving toward "shared" medical records where the clients had increasing access to all information in the E H R.  At that time, there was one other term that was identified that might negatively impact client-dietitian rapport if the patient were to read it in their medical record -- "Unsupported beliefs/attitudes about food or nutrition-related topics".  In this case, a cautionary note was included in the eNCPT manual to alert dietitians that while these terms might be completely accurate, they might be inflammatory to clients and to use with caution.  See example below:
"USE WITH CAUTION TO BE SENSITIVE TO CLIENT CONCERNS"  (3)
While this term was not very "patient/client friendly",  the committee could not find suitable alternate terms to convey the same concept.

Many other terms that may be accurate, could also be perceived negatively by patients if they disagree with the healthcare professional's assessment.  For example those who are consuming large quantities of alcohol may object to having "excessive alcohol intake", "Not ready for diet/lifestyle change", "inability to manage self care", or a number of other terms that describe problems that need to be addressed by dietitians.  As more organizations view the E H R as a shared document used by the healthcare community AND the client, these issues will likely become more important.

Finding the balance between terms used by healthcare professionals and client friendly words is likely to be a larger issue in healthcare--not just confined to dietetics terminology.

In the meantime, if users of the eNCPT believe that a synonym needs to be developed for a current term, they can submit suggested terms for consideration by the Academy to begin the formal dialogue. (2)

REFERENCES

(1)   Step 2.  Nutrition Diagnosis, eNCPT Manual. Available at https://www.ncpro.org/pubs/2018-idnt-en/page-044.  Accessed Feb 1, 2019.
(2)  eNCPT Reference Manual - Submission for Changes.  Available at:  https://www.ncpro.org//404.cfm?404;http://ncpt.webauthor.com:80/terminology-submission-process.  Accessed Feb 1 2019.
(3)  Unsupported beliefs/attitudes about food or nutrition-related topics Reference Sheet.   eNCPT Manual. Available at https://www.ncpro.org/pubs/2018-idnt-en/codeNB-1-2.  Accessed Feb 1, 2019.

Thursday, December 27, 2018

eNCPT vs ICHI - Nutrition Intervention Terms




       
          In late 2018, the World Health Organization has released the Beta version of the classification system for health interventions called the International Classification of Health Interventions. (1)  As "Beta" indicates this is not a final version, but is being released for testing and comment.  

          While many countries and professions have developed their own list of  procedures to describe interventions, this classification is hoped to be a unifying structure.  It will be interesting to see how the eNCPT can be mapped to the ICHI in the future.  

         This classification system is intended to reflect the interventions delivered across all sectors of the health system: medical, surgical, primary care, community health, rehabilitation, allied health, mental health, nursing, assistance with functioning, traditional medicine and public health interventions.  The terms are now available in an on-line searchable database and have ~8000 intervention terms.  

          The health interventions are grouped into four sections depending on the target of the intervention:
  • Interventions on Body Systems and Functions
  • Interventions on Activities and Participation Domains
  • Interventions on the Environment
  • Interventions on Health-related Behaviours
          Each intervention in ICHI is described in terms of the target (the entity on which the action is carried out), the action (the deed done by an actor to the target), and means (the processes and methods by which the action is carried out).   

Below are a few of the comparisons from the ICHI and the eNCPT

eNCPT Definition of Nutrition Intervention
ICHI Definition of Health Intervention
an act performed for, with or on behalf of a person or a population whose purpose is to assess, improve, maintain, promote or modify health, functioning or health conditions. 
a purposely planned action(s) designed with the intent of changing a nutrition-related behavior, risk factor, environmental condition, or aspect of health status to resolve or improve the identified nutrition diagnosis(es) or nutrition problem(s).

This Classification is comparable to the Nutrition Intervention terms included in the eNCPT. See below for a few examples.

eNCPT
Similar ICHI Term
Nutrition Education (E)
Nutrition Education Content (1)
 (3 more specific terms)
Education to influence eating behaviours
Nutrition Education Application (2)
(3 more specific terms)
Training to influence eating behaviours
NUTRITION COUNSELING (C)
(5 more specific theoretical basis/approach and 11 more specific strategies)
Advising about eating behaviours
Or
Counselling about eating behaviours
NUTRITION BASED POPULATION ACTION (P)
Population strategies (2)
      Environmental change
      (3 more specific terms)
Environment modification to influence eating behaviours


(1)  International Classification of Health Interventions (ICHI), World Health Organization, Beta version.  Available at:  https://www.who.int/classifications/ichi/en/.  Accessed December 23, 2018

Sunday, December 23, 2018

To Use or Not to Use The Medical Diagnosis in a PES statement??  
That is the question!!

When developing the dietetics standardized language, now called the eNCPT, there was considerable debate about the connections between the medical diagnosis and nutrition diagnoses. 


We concluded that a medical diagnoses alone was insufficient to describe the problems that dietitians address..

But ...

Can a medical diagnosis be used in the PES as an etiology (or underlying cause) of the nutrition diagnosis?
   (Actively discouraged)

Can a medical diagnoses be used in the PES a sign and symptom for a nutrition diagnoses?
   (Can be used WITH other data)

Medical Diagnoses as Etiology
Relying on a medical diagnosis as the etiology is not particularly useful.  Using the medical diagnoses as the etiology is problematic since dietitians are not expected to directly "intervene" to resolve a medical diagnoses.  Using a medical diagnoses also can limit the dietitian's thinking about what etiologies exist for a nutrition diagnoses that dietitians can impact.

Examples have been created to demonstrate this difficulty and show alternative ways to construct the PES statement..

For Example the two following PES statements for a person with COPD are accurate, but one is not helpful in directing the nutrition intervention

  • Inadequate energy intake related to COPD as evidenced by energy intake ~800 kal less than estimated energy needs.

While this may be accurate, the dietitian is not usually able to intervene directly on the shortness of breath caused by COPD. 

So the dietitian is encouraged to identify a more nutrition related etiology which may focus on the specific activities that are caused by the COPD.  For example:

  • Inadequate energy intake related to inability to eat large quantities of food OR inability to cook and serve food as evidenced by reports of SOB and fatigue prior to finishing meal and limitations on ADL of cooking and serving food.

Both of these etiologies are certainly a results of shortness of breath caused by COPD, but they are etiologies that a dietitian can reasonably create nutrition interventions to address.

So the recommendation given has been given.....whenever possible find an etiology that is not a medical diagnosis that the dietitian can independently address.

Medical Diagnoses as Signs and Symptoms

So if we are not recommending using a medical diagnoses as an etiology, why is it included in the Nutrition Diagnoses Reference Sheet?

Data from the medical history, including medical diagnoses, are shown as signs and symptoms in the Nutrition Diagnosis reference sheets.  Signs and Symptoms are nutrition assessment data that are clustered together to identify whether a specific nutrition diagnoses exists.  You can use a medical diagnosis as "proof" or "evidence" that a specific nutrition diagnosis is present, along with other specific data. 

For example including the medical diagnosis of diabete mellitus along with Hemoglobin A1C value and carbohydrate intake will fully describe how the dietitian identified and verified that excessive carbohydrate intake was a nutrition diagnosis.   The medical diagnosis usually would not be sufficient by itself to support a nutrition diagnosis.

Bottom line:  Use of medical diagnoses as an etiology is discouraged since it is not usually helpful in guiding the selection of a nutrition intervention.  However a medical diagnosis may be PART of the cluster of data used to determine whether a nutrition diagnosis exists and may be used as a sign to support selection of a Nutrition Diagnoses.