Anticipatory guidance...Identifying nutrition problems that don't yet exist??

A key concept in the Nutrition Care Process is that dietitians identify an existing nutrition problem, called a nutrition diagnosis, by clustering existing signs and symptoms from the nutrition assessment that shows that the nutrition diagnoses exists.  So doesn't that eliminate the possibility of prevention and anticipatory guidance??


Nutrition Diagnoses/Problems
In 2011 (Third Edition International Dietetics & Nutrition Terminology) the nutrition diagnostic terminology was expanded to identify four nutrition diagnoses that provide the ability to "predict" future nutrition problems, thus supporting the concept of prevention and anticipatory guidance.

• Predicted inadequate energy intake (NI-1.4)
• Predicted excessive energy intake (NI-1.5)
• Predicted inadequate nutrient intake  (NI-5.11.1)
• Predicted excessive nutrient intake  (NI-5.11.2)
• Predicted food-medication interaction (NC-2.4)
• Predicted breast-feeding difficulty (NC-1.5)

The definition of these terms indicate that they are used to reflect future problems, e.g. intake of one or more nutrients that is anticipated  (predicted based on observation, experience, or scientific reason) to fall short of or exceed estimated nutrient requirements, established reference standards, or recommendations based on physiological needs.  

Etiology
The types of etiologies that would be the "cause" of these nutrition diagnoses could be scheduled or planned medical therapy or medication that is predicted (based on research, experience or scientific reason) to either increase or decrease nutrient requirements, or change the ability to consume, absorb, or utilize nutrients.  In some cases cultural or religious practices could also be the "cause" of predicted problems.   In other cases etiology may be social issues such as housing or living conditions or potential for environmental emergency or catastrophe/disaster shown through research to be risk factors for intake problems.  

Signs and Symptoms
But what about the need to have signs and symptoms to document the presence of the nutrition diagnosis?  In the case of "predicted" nutrition diagnoses the reference sheets  indicate that you may use "estimated" needs or "estimates" of future intake.  

 The data used for these estimates may be findings of research projects as opposed to actual patient data.  History or presence of a condition for which research shows an increased prevalence of insufficient nutrient(s) intake in a similar population may be used as a sign and symptom.  For example the post surgery predicted energy needs for someone that is scheduled to undergo major surgery for cancer may be based on research findings related to the energy needed for future wound healing combined with research that documents a simultaneous decrease in intake could document a predicted gap between future intake and requirements.   This would then be used to set the stage for anticipatory guidance prior to surgery about coping with the future situation.

PES Statements might be:
Predicted excessive energy intake related to future immobilization of leg and lack of awareness of changes needed as evidenced current PAL of 1.8 expected to go to 1.2 and estimated current intake of 2800 kcal compared to reduced energy requirements of 1800 kcal during restricted mobilization scheduled for 4 weeks in December.
    ( intervention might be nutrition education on energy balance and meal planning for lower energy intake.)

Predicted suboptimal energy intake related to scheduled head and neck radiation therapy, lack of awareness of future dietary requirements, and anticipated changes in appetite as evidenced by scheduled radiation for next 3 months and usual weight loss of 5-10 KG/month for other patients receiving similar treatment (reference as appropriate).
    ( Intervention might be nutrition education on principles.) 

Predicted excessive carbohydrate intake  or Excessive carbohydrate intake related to strong family history of diabetes and lack of perceived susceptibility as evidenced by reports of all siblings and parents with Type 2 DM and current carbohydrate intake inconsistent with principles of diet for prevention of Type 2 DM.
     (Intervention might be nutrition counseling using health belief model and education on principles of prevention of DM EBNPG recommendations.)

Predicted excessive intake of nutrients in foods not tolerated related to potential diagnosis of food intolerances/allergies as evidenced by history of gastrointestinal distress and pain.
    ( Intervention might be nutrition education and use of self monitoring to test tolerance of foods.)

Full descriptions of the "predicted" nutrition diagnoses are available in the electronic NCPT.  Available at:  https://ncpt.webauthor.com/.  

Is that all there is??? Getting beyond knowledge deficit diagnoses for IBD.

What about conditions where the focus of the nutrition care is to help the patient learn to identify foods that are tolerated so future dietary intake can be planned to avoid them, but still be nutritionally adequate??

One of the conditions that would likely lead to this type of nutrition care may be Inflammatory Bowel Diseases (IBD).  In this case the focus of the dietitian's care is often to guide the patient in effectively use self-management skills.  They may need to have a systematic way to monitor their dietary intake, identify signs and symptoms as they begin to emerge and more effectively identify what dietary components are likely to be connected to the GI disturbances.  The self-management skills would also include helping the patient identify when they need to seek medical/dietetics follow-up care vs when they can/should manage the issue themselves.

Depending on the focus of the dietitian's intervention nutrition diagnoses could range from:

Concerns over Knowledge

• Food and Nutrition-Related Knowledge Deficit - most appropriate when the patient is newly diagnosed or when patient acknowledges lack of knowledge about the principles and food tolerances.  

This type of nutrition diagnosis is easiest to document, justify and support with nutrition assessment data (statement from patient about desire to know more, or documentation that patient could not accurately respond to questions) and will easily lead to an intervention of nutrition education.  The nutrition education intervention can focus on principles of planning intake during times of remission (content) as well as how to identify "flare" and how to adjust dietary intake during those periods (application).  The education can also identify the content of "when should the patient seek additional health care vs when can they manage the situation themselves" (application)

However the experienced dietitian may not be satisfied with this level of sophistication and wish to more clearly describe their nutrition care.  Other types of nutrition diagnoses can be added that are likely appropriate to more fully describe the range of nutrition problems (diagnoses) that are being addressed and a more full range of interventions used by the dietitian.  Following are the types of issues that are likely to be encountered:

Concerns over intake issues:
These issues could be ones that already exist or predicted for the future.  Often there are intake issues likely to be of concern, for example energy, fat soluble vitamins, B12, soluble vs insoluble fiber, and Calcium.  

These could be identified either as existing problems (intake that is already compromised) or those that are likely to be compromised in the future with repeated flares or by elimination of foods that have been identified as not being well tolerated.

• Predicted suboptimal* energy intake - if they are concerned about a future problem that could result from a combination of reduced intake due to trying to avoid food caused GI disturbances combined with decreased absorption which could be supported by research/experience with other patients with similar IBD diagnoses and symptoms.
• Predicted suboptimal* nutrient intake - if the concern is about a specific nutrient or nutrients that are likely to be unavailable due to malabsorption, perhaps fat soluble vitamins which could be supported by research/experience with other patients experiencing compromised intake or absorption.
• Predicted excessive intake may be used if the concern if over nutrients in foods not tolerated related to potential diagnosis of food intolerances/allergies which could be supported with nutrition assessment data about their history of gastrointestinal distress and pain.

Concerns over other behavioral/environmental issues
In most cases the individuals with IBD also are coping with behavioral and attitudinal issues.  For example they may not be keeping adequate food journals to identify which food items are trigger foods for flares. They may also be denying that they have a chronic condition that will need long term management on their part.  These types of nutrition diagnoses will often lead to more nutrition counseling types of intervention in addition to the knowledge needed.  Following are some of the types of other nutrition diagnoses likely to be addressed:

• Self-monitoring deficit related to need to rule in and rule out specific food as evidenced by history of GI disturbances, medical diagnosis of inflammatory bowel, and unverified or changing food tolerances
• Unsupported beliefs/attitudes about food and nutrition-related topics -  related to not ready for lifestyle change and denial of impact of diagnosis as evidenced by expression of reluctance to implement self-monitoring or other lifestyle changes necessary to manage the IBD.
• Inability to manage self-care  related to newly diagnosed IBD and lack of previous exposure to information about IBD nutrition care as evidenced by new medical diagnoses in medical record and referral for initial evaluation for nutrition therapy for IBD.  This may be an appropriate nutrition diagnoses if the dietitian is focusing on helping the patient learn the principles as well as developing the skills to apply the principles in self-management.  This would also include helping the patient identify when they need to seek medical assistance and when they can manage on their own.  
• Not Ready For Diet/Lifestyle Change related to unsupported beliefs/attitudes about whether the IBD will resolve without lifestyle changes as evidenced by patient's ability to verbalize knowledge, but providing reasons why changes in lifestyle are not necessary/possible at this time.  This would be used when the patient is experiencing a conflict between "knowing" what to do and actually planning and making the lifestyle changes necessary to manage their condition

Concerns over GI tract functioning

In some cases the dietitian may want to focus on the GI malfunctioning.  However this may or may not be useful to effectively direct the nutrition intervention chosen.  If this option is chosen, the dietitian may choose:

• Altered GI function related to unspecified food tolerances as evidenced by flares of GI symptoms (diarrhea, bloating) and patient verbalizing not knowing which foods precede flares.

Concerns over food/medication interactions

In many cases patients are managed by medications that also have nutritional implications for increased appetite, decreased absorption of fat soluble nutrients, or bone demineralization.  In these cases, the dietitian may also want to address either existing or predicted food/medication interactions.  

• Food-Medication Interaction or Predicted food-medication interactions would be appropriate diagnoses to use in these situations  

Specific nutrition diagnoses reference sheets are available to help the dietitian decide which best describes their thinking about the types of nutrition issues they have chosen to address.

BOTTOM LINE:  Dietitians have many choices of nutrition diagnoses that can be used to  fully describe the focus and nature of the nutrition care provided.  Some are based on existing situations and some based on predicting future situations that are likely to emerge.

Academy of Nutrition and Dietetics, E Nutrition Care Process and Terminology (ENCPT) available at:   https://ncpt.webauthor.com/pubs/idnt-en/file.cfm?item_type=xm_file&id=88978.  Accessed December 26, 2015

*If a synonym for the term “inadequate” is helpful or needed, an approved alternate is the word “suboptimal.”