Etiologies--Are we missing the point? Just Ask Why 5 times???

Using the etiology (root cause) to guide the nutrition intervention is often not fully explored in  nutrition care
process discussions...other that to mention that you should ask "why?" five times to get to the root cause (or lowest level that the dietitian can impact).  More focus has been placed on correctly naming the problem as the Nutrition Diagnoses.

This example that shows the impact of varying etiologies on the choice of nutrition interventions.

Assume the Nutrition Assessment clearly indicates that there is a problem with Excessive Energy Intake (NC 3.3.1).  The person has consistently gained weight for past 2 years, the dietary history shows that the person has routinely consumed MORE than his estimated needs, and the weight status meets the criteria for being overweight.  There is no medical reason to avoid addressing his weight gain/status at this time.

Excessive Energy Intake (NC3.3.1) was selected as the problem/diagnosis.  But let's look at the difference in intervention based on varying etiologies. (See Etiology Matrix in ENCPT website)  In the ENCPT there are 28 different types of etiologies related to knowledge, beliefs and attitudes alone!!.

If the etiology for Excessive Energy Intake is identified as

• "Food and nutrition knowledge deficit" concerning identifying foods/beverages that are highest in energy or being able to identify intake that would be within optimal energy levels (plus BMI or weight data).  
• Then a logical intervention might be providing tailored Nutrition Education - Content-Recommended Modifications to help increase knowledge and understanding.  

However if the etiology is identified as

• "Lack of confidence in ability to make change" 
• Then an intervention providing knowledge/information would not likely change confidence.   However,the intervention most likely to be successful would be a Nutrition counselling approach, perhaps using an Motivational Interviewing strategy based on Stages of change to facilitate the person being able to clearly identify other situations when he/she has been successful, what the barriers are to making these changes, and exploring problem solving for the patient to discuss ways he/she can overcome the barriers and thus be more confident that they can be successful.  

OR

• "Cultural or religious practices that affect ability to" make changes
• Perhaps a Nutrition Counselling approach based on Cognitive-behavioral theory is appropriate, but not focused on changing the religious or cultural beliefs, but Problem solving to identify ways to accommodate the changes within the existing belief structure.  

OR

• "Denial of need to change"  
• Again a nutrition intervention with Nutrition counselling is appropriate, however the focus would likely be on using the Health Belief Model and perhaps Motivational interviewing to facilitate a discussion where the individual came to the realization that there were consequences likely associated with continuing in present course/not making changes that are outweighed by the benefits of making the effort to make changes.

OR

• "Food and nutrition related knowledge deficit concerning" how to prepare appropriate foods based upon nutrition prescription
• Here a nutrition education intervention would be appropriate, however it would not be the "content" of the diet it would likely need to focus on Nutrition Education-Application, Skill Development, and might involve Collaboration and Referral of Nutrition Care to community agencies/programs to find a suitable cooking course that would meet their needs.

It isn't until a person has started working with the NCP and terminology that you truly come to realize that while naming the problem is important, it is even MORE important to properly understand the etiology, the underlying cause.  Only by understanding the WHY the nutrition problem exists can the dietitian design the optimal nutrition intervention to correct the problem.  The same holds true for other types of etiologies (Access, Behavior, Physical Function, Physiologic-Metabolic, Psychological, Social-Personal, and Treatment).  

Citations:

Etiology Matrix in ENCPT, available at https://ncpt.webauthor.com (Available by subscription)

For student assignments that specifically guide students in making the connection between the etiology and the intervention see the Nutrition Care Process and Terminology:  A Practical Approach.