Monday, March 23, 2015

Should standardized language be used to write a nutrition diagnosis?

For most diagnoses all that is needed is an ounce of knowledge, an ounce of intelligence, and a pound of thoroughness. 
Arabic Proverb. In Lancet (1951). In John Murtagh, General Practice (1998), 125. 

One question that was raised during the MEDNA pilot survey last year was "Should standardized language be used to write a nutrition diagnosis?"

You really can't make a nutrition diagnosis UNLESS you have a standardized language.  In order to make a diagnosis of any kind, you must first have a list of diagnosis with descriptions that can be used to select/assign a nutrition diagnosis.  

To explain this thinking, here is a bit of background on the definition and description of "diagnosis".    

In  the Journal of the American Medical Association, in 1967 LS King, MD, discussed three critical components that needed to be present for the diagnosis process:  
     1-A preexisting series of categories or classes to provide the framework for the diagnosis
     2-A particular entity/situation that is being evaluated (patient's situation)
     3-The deliberate judgement that the entity being evaluated belongs to THIS particular category (versus other categories)

In this article King referenced an older reference, The Principles of Sciences:  A Treatise in Logic and Scientific Method  by Jevons, WS that was originally published in the 1830's and again in 1913.  It described diagnosis as follows:   

 " Diagnosis consists in comparing the qualities of a certain object with the definition of a series of classes;  the absence in the object of any one quality stated in the definition excludes it from the class thus defined;  whereas, if we fine every point of a definition exactly fulfilled in the specimen, we may at once assign to the class in question."  

Webster dictionary states that the first known use of the word diagnosis was in 1655 and it's language origin is from the Greek words,  diagignōskein meaning to distinguish and gignōskein meaning to know (Miriam Webster Dictionary)

So Bottom line:  You need to have a list of categories of nutrition diagnoses and corresponding descriptions that will allow the dietitian to accurately determine whether the patient's signs and symptoms match a preexisting definition of a particular nutrition diagnosis.


King, LS.  What is a Diagnosis?  Journal of American Medical Association.  1967;202(8):154-157.

Jevons, W S. The Principles of Sciences:  A Treatise in Logic and Scientific Method. Second ed.  London, Macmillan and Company, Ltd., 1913.

Current definitions of "Diagnosis" in dictionaries follow:

  • The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data.(The Free Dictionary)
  • The process of determining by examination the nature and circumstances of a diseased condition. (
  • The identification of the nature of an illness or other problem by examination of the symptoms(Oxford Dictionary)

Tuesday, March 17, 2015

Comparative Standards...why are they part of nutrition assessment?

The Nutrition Assessment Terminology includes a domain called Comparative Standards as an additional resource.  To understand why they are included we can go back to the description of nutrition assessment itself.
The Nutrition Assessment Component Summary identifies the following three activities in Nutrition Assessment:

  • Reviewing data collected for the purpose of identifying factors that influence nutritional status or health status
  • Clustering the data collected to identify a nutrition diagnosis (using the signs and symptoms on the nutrition diagnosis reference sheets as a guide)
  • Identifying which standard will be used to compare the data against to determine if it is "unusual", for example either higher than expected or lower than expected.

One type of critical thinking that takes place during the Nutrition Assessment step is to identify what standards should be used to compare the data against, e.g. what is the appropriate comparative standard. How much energy is too much?  to little?  How much Vitamin B6 is too much or too little for this patient?

To assist the dietitian in explaining the care that is being provided we have Comparative Standards.  The E-NCPT includes a sixth domain as an addendum to the Nutrition Assessment terminology that is to be used to document how the dietitian "evaluated" the data collected from the patient or medical record during the nutrition assessment data collection.  These terms allow the dietitian to enter data into fields in the following categories:

Each allows the dietitian to identify both the estimated need as well as method to measure of estimate the need/requirement
Energy Needs
Specify formula and activity/injury factors used
Macronutrient Needs
Daily intake in grams of fat, protein, carbohydrate (type and total quantity), or fiber
Method of estimating (for example if national reference standards are used such as Dietary Reference Intakes or disease related standards)
Fluid Needs
Method of estimating
Micronutrient Needs
(A, C, D, E, K, Thiamin, Riboflavin, Niacin, Folate, B6, B12, Pantothenic acid, Biotin)
(Calcium, Chloride, Chromium, Cobalt, Copper, Fluoride, iodine, Iron, Magnesium, Manganese, Molybdenum, Phosphorus, Potassium, Selenium, Sodium Sulfate, Zinc)
Method of estimating needs
Weight and Growth Recommendations
Ideal body weight parameters, BMI, or growth patterns for children (weight for age, length of age, head circumference or weight for stature, or BMI for age)

In addition the Comparative Standards includes additional reference material that addresses concerns that dietitians may have when using national reference standards that were developed for groups of "healthy" people and then applying these standards to individuals who may not be "healthy".

 While the E-NCPT includes the Dietary Reference Intakes (DRI) used in the United States and Canada, it also addresses using other country's national reference standard when they are available.

If you have access/subscription to the E-NCPT the following pages address the information summarized in this blog.

Nutrition Assessment Component Summary in ENCPT

Nutrition Assessment - Identify relevant data by comparing to standards in ENCPT

Guidance for interpreting national reference standards - both US and Internationally in ENCPT

Wednesday, March 4, 2015

Roadmap for Implementing NCP

"Good ideas are not adopted automatically. They must be driven into practice with courageous impatience. Once implemented they can be easily overturned or subverted through apathy or lack of follow-up, so a continuous effort is required.“
-- Admiral Hyman Rickover (1900-1986)
The Academy of Nutrition and Dietetics Nutrition Care Process and Standardized Language Committee reviewed change management literature from 2003 to 2008.  One reference used was the book Leading Change.  John Kotter of Harvard Business School published steps in implementing organizational change that have been used to guide teams of dietitians as they implemented the Nutrition Care Process and standardized language.  Kotter's eight stage process can easily apply to teams of dietitians implementing the nutrition care process in medical organizations.

Kotter's Eight Stage Process used to lead successful change is:

1-Establishing a Sense of Urgency
Examine the circumstances leading to the decisions to implement, identify and discuss crises, potential problems or major opportunities

2-Creating the Guiding Coalition
Put together a group with enough power to lead the change and get the group to work together as a team

3-Developing and Vision and Strategy
Create a vision to help direct the change effort and developing strategies for achieving that vision

4-Communicating the Change Vision
Use every way possible to communicate the new vision and strategies and have the leadership demonstrate the behavior expected of others in the organization,  

5-Empowering Employees for Broad-Based Actions
Eliminate obstacles, change structure or systems that undermine the vision and encourage risk taking, nontraditional ideas, activities and actions.  

6-Generating Short-Term Wins
Plan for visible improvements in performance, create those wins and visibly recognize and reward people who make the wins possible.

7-Consolidating Gains and Producing More Change
Use newly developed successful processes/products to change all systems, structures, and policies to be consistent with new vision.  Develop the capacity of people who CAN implement the vision and re-imagine the process with new projects, themes, and change agents.
8-Anchoring New Approaches in the Culture
Create better performance through focused, leadership, management; articulate the connections between the new behaviors and organizational successes, ensure leadership development and succession.

Read more examples of implementation through published journal articles.  For example, the Journal of the Academy of Nutrition and Dietetics has special feature called "collections".  One of the collections that have been gathered is a group of articles published on the Nutrition Care Process and standardized language.  If you log on to the Journal page, the "collections" tab is the second tab on the navigation bar.  You will find several articles that summarize various methods use to implement the NCP and standardized language.  

Kotter, J.P.  Leading Change, Harvard School Press 1996