Cascade of Nutrition Outcomes - One Thing Leads To Another!!

The critical thinking involved in Monitoring and Evaluation, the last step in the Nutrition Care
Process, is the identification of indicators and criteria that will provide evidence that the nutrition intervention of the dietitian is effective.

Outcomes can be thought of as occurring in a cascade, each level of outcome leading to outcomes in the next layer, until you reach the ultimate outcome desired.  This may be visualized as shown using the domains of terminology.

For example, let's take a case of a person with Diabetes Mellitus who received both nutrition education related to how to choose foods according to plan and counselling to ensure readiness to change.
Then one short term  indicator of success for this nutrition intervention may be a change in knowledge about optimal food choices and change in readiness to change that could be measured at the end of the nutrition consultation and again at the beginning of the next appointment.  This change in knowledge and beliefs and attitudes would be expected to lead to a change in behavior around food choices, perhaps in adherence with meal planning/food choice guidance and types of food/meals consumed.  That change would then lead to a change in food or nutrient intake, perhaps change in total carbohydrate intake or total energy intake.  This change over time would likely lead to changes in self monitored blood glucose levels and eventually to change in HBA1C.  These changes could then lead to changes in quality of life measures, perhaps health related quality of life scores or disease specific quality of life scores.

Dietitians often look at the biochemical measures or anthropometric measures and overlook the more immediate short term measures that are related to their intervention  or overlook the more global quality of life measures.

If we miss the opportunity to document  immediate short term measures that are specific to our intervention (changes in knowledge, behavior, and dietary intake), we don't really know if the changes in laboratory values are related to our intervention or whether they are coming from other interventions such as medication changes.

While dietitians do not claim full responsibility for changes in biochemical or anthropometric measures, without the immediate short term measures we lack any evidence that we even contributed to the outcomes!!

Bottom line:  Using the cascade of outcomes diagram helps dietitian think of a range of outcomes that demonstrate effectiveness of nutrition interventions and create a logical argument that nutrition interventions are related to positive health outcomes.

Want to practice NCPT, but not impact patient care??? Case simulations may be part of the answer

As more people both in the US and internationally are exploring and implementing both the Nutrition Care Process and using standardized terminology (eNCPT), more demonstration cases are being developed for use.

Is there a way to develop some common guidelines that can assist those developing cases to make their cases as effective as possible?  And assist educators in selecting the right resource for their needs?

After having the recent experience of  developing the five in-depth cases using two "standardized patients" for our new text, Nutrition Care Process and Terminology:  A Practical Approach, here are some starting thoughts.  Some of these are pretty basic, but it is amazing how they stand the test of time.

• Cases developed to demonstrate the use of the Nutrition Care Process and the Nutrition Care Process Terminology need to reflect the most current terminology.  
• Much to our chagrin, the minute we released our text in early October 2015, there was an update to the ENCPT.  This caused several months of intense review to update the terms used in our cases and activities and publication of an update to address new terms.

• A clear articulation of the exact skills to be learned in a case is essential.  Attention is needed to reflect  all aspects of the interaction between the patient and dietitian to maximize the learning from a case study/simulation.  To help educators select resources, attention to clear learning objectives are essential.  

• Different types of cases needed for different skills
• Starting with a written story that provides all the key elements of the patient's life is entirely appropriate for an objective that deals only with how the dietitian uses data/information to evaluate the situation.  But this would not be sufficient to address the skills needed to review a medical record to extract data nor the interviewing skills necessary to elicit the information from the patients or the communication skills needed to verbally summarize nutrition care.   
• We decided to supplement the written story with a Virtual Learning Environment with video clips and the opportunity for student so submit videos where they "asked" the patent questions, or recorded their opening comments or summary to the patient, or discussed patient progress with the physician.  These types of additional components take a written case a step closer to "real life".  Karen Lacey's forward summarized her opinion on this aspect.  

• The eNCPT Student Companion Guide created by the Academy also includes a basic patient scenario and may be appropriate for the very first introduction to the process and terminology. However the first printing of the Instructor Solution Manual had some information that needed to be more clearly presented (e.g. regarding what was being shown as "prescription"  and "intervention" in the answer keys in the solution manual were co-mingled creating confusion about what the Nutrition Prescription was, what the Nutrition Intervention was, and how to appropriately use the terminology.  The examples provided were not consistent with the descriptions on the eNCPT.)  This guide also includes sample exam questions that can be used to test content knowledge.  It provided a framework for identifying ALL potential nutrition diagnoses based on existence of nutrition assessment signs and symptoms that may be useful as a starting point for less advanced students.  

• There are other aspects of nutrition care that can also be incorporated into different types of simulation.  For example, a simulation that allows the practitioner to explore whether they should be performing a specific task is also needed.  Especially for students who are still learning what is within and what is outside their scope of care.  The "cases" provided by the Academy address some common situations e.g. writing PN and EN orders, ordering laboratory tests, making physical activity recommendations, screening for swallowing difficulties.  These are available to members and for sale to non members addresses this need.   The cases developed by Quality Management from the Academy include the eNCPT as a resource for the cases. 

• Cases are also available that demonstrate various ethical situations, e.g. social media and applying the code of ethics to decisions.  Whenever appropriate these cases should also integrate the framework of the nutrition care process and terminology.  

• Technology continues to evolve at a dizzying pace.  Harnessing the latest to effectively provide learning experiences will be key.  
• The use of Second Life Avatars to allow the students to more fully "experience" doing a Subjective Global Assessment is certainly a unique way used by Dr Alison Steiber.  
• Work completed by Dr Pattie Landers to develop case studies that include the experience of using electronic medical records also provides a different type of simulation experience.   While we know that each electronic medical records is quite unique, being able to see and experience the potential features is essential to ensuring a smooth transition from paper cases/medical records into the world of electronic documentation.

While we know that experiential learning is essential, it will be a challenge to keep these simulations current and to curate the resources available to continually select the most appropriate for the stated objective for the cases.  Just as the case study developers are challenged, so are the educators challenged to continually review and select the materials that most closely meets their classroom/educational program needs.

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.”

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. 

— Anonymous

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.

References:

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. (Dictionary.com)
• The identification of the nature of an illness or other problem by examination of the symptoms: (Oxford Dictionary)

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:

Class/Category	Each allows the dietitian to identify both the estimated need as well as method to measure of estimate the need/requirement
Energy Needs	Kcal 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	Fluid Method of estimating
Micronutrient Needs	Vitamins (A, C, D, E, K, Thiamin, Riboflavin, Niacin, Folate, B6, B12, Pantothenic acid, Biotin) Minerals (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

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

Journal of Academy of Nutrition and Dietetics