2020lembar Referensi Asesmen

cFood/Nutrition-Related History Domain
– Food and Nutrient Intake
Energy Intake (FH-1.1)

Definition
Amount of energy intake from all sources including food, beverages, breastmilk/formula, supplements, and
via enteral and parenteral routes
Note: Whenever possible, nutrient intake data should be considered in combination with clinical,
biochemical, anthropometric information, medical diagnosis, clinical status, and/or other
factors to provide a valid assessment of nutritional status based on a totality of the evidence.
(Institute of Medicine. Dietary Reference Intakes: Applications in Dietary Assessment.Washington,
DC: National Academies Press; 2000.)
Nutrition Assessment and Monitoring and Evaluation
Indicators
Estimated energy intake
Total energy estimated intake in 24 hours (calories, kcal or kJ/day) - defined as the approximate
intake in one day of all energy
Energy estimated intake per kg in 24 hours (calories, kcal, or kJ/kg/day)—defined as the
approximate intake per kg of body weight in one day of all energy
Energy estimated intake from oral nutrition in 24 hours (calories, kcal, or kJ/day)—defined as the
estimated intake of energy in one day derived from oral intake
Energy estimated intake from enteral nutrition in 24 hours (calories, kcal, or kJ/day)—defined as
the estimated intake of energy in one day derived from enteral nutrition infusion
Energy estimated intake from parenteral nutrition in 24 hours (calories, kcal, or kJ/day)—defined as
the estimated intake of energy in one day derived from parenteral nutrition infusion
Energy estimated intake from intravenous fluids in 24 hours (calories, kcal, or kJ/day)—defined as
the estimated intake of energy in one day derived from intravenous fluid (IV) infusion
Measured energy intake
Total energy measured intake in 24 hours (calories, kcal, or kJ/day)—defined as the known quantity
of intake in one day of all energy
Energy measured intake per kg in 24 hours (calories, kcal, or kJ/kg/day)—defined as the known
quantity of intake per kg of body weight in one day of all energy
Energy measured intake from oral nutrition in 24 hours (calories, kcal, or kJ/day)—defined as the
known quantity of energy in one day derived from oral intake
Energy measured intake from enteral nutrition in 24 hours (calories, kcal, or kJ/day)—defined as
the known quanitity of energy in one day derived from enteral nutrition infusion
Energy measured intake from parenteral nutrition in 24 hours (calories, kcal, or kJ/day)—defined as
the known quantity of energy in one day derived from parenteral nutrition infusion
Energy measured intake from intravenous fluids in 24 hours (calories, kcal, or kJ/day)—defined as
the known quantity of energy in one day derived from intravenous fluid (IV) infusion
Note: Weight and weight change can be found on the Body Composition/Growth/Weight History
reference sheet.
Examples of the measurement methods or data sources for these outcome indicators: Food intake
records, 24-hour recalls, 3 to 5 day food diary, food frequency questionnaire, caretaker intake records,
menu analysis, intake and output records
Typically used with the following domains of nutrition interventions: Food and/or nutrient delivery,
nutrition education, nutrition counseling, coordination of nutrition care by nutrition professional
Typically used to determine and to monitor and evaluate change in the following nutrition
diagnoses: Inadequate energy intake, excessive energy intake, malnutrition (undernutrition), inadequate
protein energy intake, underweight, unintended weight loss, overweight/obesity, unintended weight gain,
swallowing difficulty, breastfeeding difficulty, altered GI function, limited adherence to nutrition related
recommendations
Judgment must be used to select indicators and determine the appropriate measurement techniques and
reference standards for a given client population and setting. Once identified, these indicators,
measurement techniques, and reference standards should be identified in policies and procedures or other
documents for use in client records, quality or performance improvement, or in formal research projects.
Client Example(s)
Example of one of the Nutrition Care Indicators (includes sample initial and reassessment of
documentation for one of the indicators)
Indicator(s) Selected
Total energy estimated intake in 24 hours (kcal/day)
Criteria for Evaluation
Comparison to Reference Standard, Recommendation, or Goal:
1. Reference Standard: Food diary indicates that client consumes approximately 2600 calories/kcal
(11,000 kJ) per day. 145% of estimated energy needs per day.
2. Recommendation: Client’s recommended calorie intake level is 1,800-2,000 calories/kcal (7,500-
8,400 kJ) per day.
3. Goal: Client's goal calorie intake level is 1,800 calories/kcal (7,500 kJ) per day.
Sample Nutrition Assessment and Monitoring and Evaluation Documentation
Based on client food diary, client's total energy estimated intake in 24 hours
averages approximately 2,600 calories/kcal (11,000 kJ) per day, 145% of
Initial encounter recommended level of 1,800 calories/ kcal (7,500 kJ) per day. Client's goal is 1,800
calories/kcal (7,500 kJ) per day. Will evaluate calorie intake at next encounter in
two weeks.
Significant progress toward meeting goal. Based on client's food diary,
Reassessment after patient/client consuming approximately 2,100 calories/kcal (9,000 kJ) per day,
nutrition intervention 117% of goal level of 1,800 calories/ kcal (7,500 kJ) per day. Will evaluate energy
intake at next encounter in two weeks.

References
The following are some suggested references for indicators, measurement techniques, and reference
standards for the outcome; other references may be appropriate.
1. Academy of Nutrition and Dietetics. Evidence Analysis Library: Measuring resting metabolic rate
(RMR) in the healthy and non-critically ill guideline. https://www.andeal.org/topic.cfm?
menu=5299&cat=5217. Accessed February 4, 2019.
2. Academy of Nutrition and Dietetics. Nutrition Care Manual.
https://www.nutritioncaremanual.org/index.cfm. Accessed February 4, 2019.
3. Government of Canada. Dietary Reference Intakes. https://www.canada.ca/en/health-
canada/services/food-nutrition/healthy-eating/dietary-reference-intakes.html. Accessed February
4, 2019.
4. Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty
Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2002.
5. Israel Dietary Reference Intakes.
https://www.health.gov.il/Subjects/FoodAndNutrition/Nutrition/Documents/70420914_2.pdf.
Accessed February 20, 2019.
6. Mountjoy M, Sundgot-Borgen J, Burke L, et al. International Olympic Committee (IOC)
Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update. Int J Sport
Nutr Exerc Metab. 2018;28(4):316-331.
7. The National Health and Medical Research Council. Nutrient Reference Values for Australia and
New Zealand. https://www.health.govt.nz/publication/nutrient-reference-values-australia-and-
new-zealand. Accessed February 4, 2019.
8. Nordic Council of Ministers. Nordic Nutrition Recommendations 2012: Integrating nutrition and
physical activity. 2012; https://www.norden.org/en/publication/nordic-nutrition-recommendations-
2012-0. Accessed February 20, 2019.
9. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015-2020
Dietary Guidelines for Americans. https://health.gov/dietaryguidelines/2015/. Accessed February
4, 2019.
Food/Nutrition-Related History Domain – Food and Beverage Intake

Fluid Intake (FH-1.2.1)

Definition
Amount of fluid consumed orally from all sources including food, beverages, breastmilk, infant formula,
supplements, and via enteral and parenteral routes
biochemical, anthropometric information, medical diagnosis, clinical status, and/or other factors to
provide a valid assessment of nutritional status based on a totality of the evidence. (Institute of
Medicine. Dietary Reference Intakes: Applications in Dietary Assessment.Washington, DC:
National Academies Press; 2000.)
Indicators
Estimated fluid intake
Total fluid estimated intake in 24 hours (mL/day)—defined as the approximate intake in one day of
fluid from all sources
Fluid estimated intake from oral nutrition in 24 hours (mL/day)—defined as the approximate
intake in one day of fluid from oral intake
Water estimated oral intake in 24 hours (mL/day)—defined as the approximate intake
in one day of water
Sugar sweetened beverage estimated oral intake in 24 hours (mL/day)—defined as
the approximate intake in one day of sugar sweetened beverages
Beverage with high intensity sweetener estimated oral intake in 24 hours (mL/day)—
defined as the approximate intake in one day of high intensity, nonnutritive and
nutritive, sweetened beverages that contain nutritive and nonnutritive sugar
substitutes
100 percent fruit juice estimated oral intake in 24 hours (mL/day)—defined as the
approximate intake in one day of 100% fruit juice
Liquid dairy product estimated oral intake in 24 hours (mL/day)—defined as the
approximate intake in one day of dairy beverages
Caffeinated beverage estimated oral intake in 24 hours (mL/day)—defined as the
approximate intake in one day of caffeinated beverages
Nutritionally complete liquid supplement estimated oral intake in 24 hours (mL/day)
—defined as the approximate intake in one day of liquid oral enteral nutrition
supplements
Liquid meal replacement estimated oral intake in 24 hours (mL/day)—defined as the
approximate intake in one day of liquid meal replacement
Fluid estimated intake per kg in 24 hours (mL/kg/day)--defined as the approximate intake per kg of
body weight in one day of fluid from all sources
Fluid estimated intake from food in 24 hours (mL/day)—defined as the approximate intake in one
day of fluid from food intake
Free water estimated intake in 24 hours (mL/day)—defined as the approximate intake in one
day of free water from all sources
Free water estimated intake from breastmilk in 24 hours (mL/day)—defined as the
approximate intake in one day of free water derived from breastmilk
Free water estimated intake from infant formula in 24 hours (mL/day)—defined as the
approximate intake in one day of free water derived from infant formula
Free water estimated intake from enteral nutrition in 24 hours (mL/day)—defined as the
approximate intake of free water per day derived from enteral nutrition infusion
Free water estimated intake from parenteral nutrition in 24 hours (mL/day)—defined as the
approximate intake of free water per day derived from parenteral nutrition infusion
Free water estimated intake from intravenous fluids in 24 hours (mL/day)—defined as the
approximate intake of free water per day derived from intravenous fluid (IV) infusion
Measured fluid intake
Total fluid measured intake in 24 hours (mL/day)—defined as the known quantity of intake in one
day of fluid from all sources
Fluid measured intake from oral nutrition in 24 hours (mL/day)—defined as the known
quantity of intake in one day of fluid from oral intake
Water measured oral intake in 24 hours (mL/day)—defined as the known quantity of intake
in one day of water
Sugar sweetened beverage measured oral intake in 24 hours (mL/day)—defined as the
known quantity of intake in one day of sugar sweetened beverages
Beverage with high intensity sweetener measured oral intake in 24 hours (mL/day)—defined
as the known quantity of intake in one day of high intensity sweetened beverages that
contain nutritive and nonnutritive sugar substitutes
100 percent fruit juice measured oral intake in 24 hours (mL/day)—defined as the known
quantity of intake in one day of 100% fruit juice
Liquid dairy product measured oral intake in 24 hours (mL/day)—defined as the known
quantity of intake in one day of dairy beverages
Caffeinated beverage measured oral intake in 24 hours (mL/day)—defined as the known
quantity of intake in one day of caffeinated beverages
Nutritionally complete liquid supplement measured oral intake in 24 hours (mL/day)—
defined as the known quantity of intake in one day of nutrition supplements
Liquid meal replacement measured oral intake in 24 hours (mL/day)—defined as the known
quantity of intake in one day of a liquid that can replace a meal
Fluid measured intake from food in 24 hours (mL/day)—defined as the known quantity of intake in
one day of fluid from food intake
Fluid measured intake per kg in 24 hours (mL/kg/day)--defined as the known quantity of intake per
kg of body weight in one day of fluid from all sources
Free water measured intake in 24 hours—defined as the known quantity of intake from all sources
Free water measured intake from breastmilk in 24 hours (mL/day)—defined as the known
quantity of intake in one day of free water derived from breastmilk
Free water measured intake from infant formula in 24 hours (mL/day)—defined as the
known quantity of intake in one day of free water derived from infant formula
Free water measured intake from enteral nutrition in 24 hours (mL/day)—defined as the
known quantity of intake of free water per day derived from enteral nutrition infusion
Free water measured intake from parenteral nutrition in 24 hours (mL/day)—defined as the
known quantity of intake of free water per day derived from parenteral nutrition infusion
Free water measured intake from intravenous fluids in 24 hours (mL/day)—defined as the
known quantity of intake of free water per day derived from intravenous fluid (IV) infusion
Note: Alcohol intake is recorded on the Alcohol intake reference sheet. Total volumes of breastmilk
and infant formula can be found on the Breastmilk/Infant formula intake reference sheet. Total
volume of enteral nutrition can be found on the Enteral nutrition intake reference sheet. Total
volume of parenteral nutrition can be found on the Parenteral nutrition intake reference sheet.
Biochemical measures of hydration status can be found on the Electrolyte and Renal
Profile and Urine Profile reference sheets
Examples of the measurement methods or data sources for these outcome indicators: Food and fluid
intake records, 24-hour recalls, food frequency questionnaire, intake and output data, observation, weight
measurement records
nutrition education, nutrition counseling, coordination of nutrition care by nutrition professional,
population based nutrition action
Typically used to determine and monitor and evaluate change in the following nutrition diagnoses:
Excessive or inadequate oral intake, food medication interaction, underweight, overweight/obesity,
unintended weight loss, unintended weight gain, disordered eating pattern, undesirable food choices,
limited adherence to nutrition related recommendations, inability to manage self care, swallowing
difficulty, breastfeeding difficulty, altered GI function
Client Example
Example of one (or more) of the Nutrition Care Indicators (includes sample initial and reassessment
Fluid estimated intake from oral nutrition in 24 hours (mL/day)
1. Reference Standard: Reference intake standards

2. Recommendation: Client's fluid estimated intake from oral nutrition in 24 hours is 1,000 mL (33
oz). Recommendated intake is 2,600 mL per 24 hours.
3. Goal: Client currently drinks 1,000 mL (33 oz) of oral fluids per day and has a personal goal of
consuming 1,920 mL(64 oz) of fluid per day.
Based on client's food diary, Fluid estimated intake from oral nutrition in 24
Initial nutrition
hours is approximately 1,000 mL(33 oz). Goal is to consume approximately
assessment
1,920 mL (64 oz) of fluid per day. Will monitor fluid intake at next encounter.
Significant progress toward goal fluid intake. Based on fluid intake records,
Reassessment after
patient/client increased consumption of fluids from 1,000 mL (33 oz) to 1,920
nutrition intervention
mL per day, exceeding goal and meeting recommended intake.
References
1. Canadian Nutrient File. https://food-nutrition.canada.ca/cnf-fce/index-eng.jsp. Accessed February

22, 2019.
4, 2019.
3. Institute of Medicine. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and
Sulfate. Washington, DC: National Academies Press; 2004.
6. New Zealand Food Composition Data. https://www.foodcomposition.co.nz/foodfiles/concise-
tables/. Accessed February 4, 2019.
8. US Department of Agriculture. Food and Nutrition Research Center. What’s in the Foods You Eat
Search Tool. https://www.ars.usda.gov/northeast-area/beltsville-md-bhnrc/beltsville-human-
nutrition-research-center/food-surveys-research-group/docs/whats-in-the-foods-you-eat-emsearch-
toolem. Accessed February 4, 2019.
Food Intake (FH-1.2.2)
Definition
Amount, type, and pattern of food consumed and quality of diet
Medicine. Dietary Reference Intakes: Applications in Dietary Assessment. Washington, DC:
Indicators
Amount of food
Estimated amount of food
 Grains servings estimated in 24 hours (number/day)

 Fruits servings estimated in 24 hours (number/day)
 Vegetable servings estimated in 24 hours (number/day)
 Milk products servings estimated in 24 hours (number/day)
 Protein food servings estimated in 24 hours (number/day) (eg, meat, poultry, fish, eggs, beans, nut
products)
 Fat servings estimated in 24 hours (number/day)
 Empty energy servings estimated in 24 hours (number/day)
 Estimated percent of meals eaten in 24 hours (percent/day)—defined as the approximate
proportion of all meals in one day that is consumed
Measured amount of food
 Grains servings measured in 24 hours (number/day)

 Fruits servings measured in 24 hours (number/day)
 Vegetable servings measured in 24 hours (number/day)
 Milk products servings measured in 24 hours (number/day)
 Protein food servings measured in 24 hours (number/day) (eg. meat, poultry, fish, eggs, beans, nut
products)
 Fat servings measured in 24 hours (number/day)
 Empty energy servings measured in 24 hours (number/day)
 Measured percent of meals eaten in 24 hours (percent/day)—defined as the known proportion of
all meals in one day that is consumed
Types of food
 Fortified food intake (present/absent)—defined as oral intake of foods with extra nutrients added
(eg, calcium-fortified orange juice)
 Enriched food intake (present/absent)—defined as oral intake of foods that contain the nutrients
that were added back after being lost during processing
 Special dietary food intake (present/absent)—defined as oral intake of foods that have been
modified for a nutrition purpose, eg, lactose free, gluten free, sugar free, low fat, nut free
 Medical food intake (present/absent)—defined as oral intake of foods for a special medical
purpose to manage a nutrition related disease
 Processed food intake (present/absent)—defined as oral intake of commercial convenience foods
 Quick service food intake (present/absent)—defined as oral intake of fast foods
 Self prepared food intake (present/absent)—defined as oral intake of foods prepared by the client
or supportive individuals
 Prepared food intake (present/absent)—defined as oral intake of food that is ready to eat, at or
from a restaurant, market, food station, but excludes quick service food
Meal/snack* pattern
Estimated meal and snack pattern
 Number of meals estimated in 24 hours (number/day)

 Number of snacks estimated in 24 hours (number/day)
Measured meal and snack pattern
 Number of meals measured in 24 hours (number/day)

 Number of snacks measured in 24 hours (number/day)
Diet (food and beverages) Quality Index
 Healthy eating index (HEI) 2015 score—defined as an assessment of how well reported food
intake aligns with the 2015-2020 Dietary Guidelines for Americans
Food variety (present/absent)—defined as consumption of a wide assortment of foods from different food
groups on a regular basis
Note: Liquid meal replacements/supplements are found on the Fluid Intake reference sheet.
* Snack is defined as food served between regular meals.
records, 24-hour recalls, food frequency questionnaire, menu analysis, dietary and physical activity
assessment tool (eg, MyPlate), diet quality index (eg, Healthy Eating Index) or other reference intake
standard tool
Typically used with the following domains of nutrition interventions:Food and/or nutrient delivery,
nutrition education, nutrition counseling, coordination of nutrition care by nutrition professional,
population based nutrition action
Typically used to determine and monitor and evaluate change in the following nutrition
diagnoses: Excessive or inadequate oral intake, food medication interaction, underweight,
overweight/obesity, disordered eating pattern, unintended weight gain, unintended weight loss, undesirable
food choices, limited adherence to nutrition related recommendations, inability to manage self care, limited
access to food, intake of unsafe food, inadequate or excessive energy, macronutrient or micronutrient
intake
Client Example
Example(s) of one (or more) of the Nutrition Care Indicators (includes sample initial and reassessment
Vegetable servings estimated in 24 hours and Fruit servings estimated in 24 hours
1. Reference Standard: Not applicable

2. Recommendation: Client's intake reflects an average of 1 to 2 servings vegetable servings in 24
hours and 1 fruit servings estimated in 24 hours, which is below the Dietary Approaches to Stop
Hypertension (DASH) Eating Plan recommendation of 9 servings of fruits and vegetables per
day.
3. Goal: Client’s goal is to increase fruit and vegetable intake to 5 servings per day.
Based on client’s recalls, client’s intake reflects an average of 1-2 vegetable servings
estimated in 24 hours and 1 fruit serving estimated in 24 hours, which is below client
Initial encounter
goal of 5 servings of fruits and vegetables per day. Will monitor fruit and vegetable
intake at next encounter.
Reassessment after
nutrition Met goal of increasing fruit and vegetable intake to 5 servings per day.
intervention
References
1. Academy of Nutrition and Dietetics. Evidence Analysis Library: Gestational Diabetes Evidence-
Based Nutrition Guideline. https://www.andeal.org/topic.cfm?menu=5288&cat=5537. Accessed
February 4, 2019.
3. European Commission. Food for special medical purposes.
https://ec.europa.eu/food/safety/labelling_nutrition/special_groups_food/medical_en. Accessed
February 4, 2019.
4. Food Standards Australia and New Zealand. Food for special medical purposes.
http://www.foodstandards.gov.au/consumer/nutrition/foodspecial/Pages/default.aspx. Accessed
February 4, 2019.
4, 2019.
6. Krebs-Smith SM, Pannucci TE, Subar AF, et al. Update of the Healthy Eating Index: HEI-2015. J
Acad Nutr Diet. 2018;118(9):1591-1602.
8. National Health and Medical Research Council. Australian Dietary Guidelines Summary. 2013;
https://www.eatforhealth.gov.au/sites/default/files/content/The
%20Guidelines/n55a_australian_dietary_guidelines_summary_131014_1.pdf. Accessed February
4, 2019.
9. Ogata BN, Hayes D. Position of the Academy of Nutrition and Dietetics: nutrition guidance for
healthy children ages 2 to 11 years. J Acad Nutr Diet. 2014;114(8):1257-1276.
10. US Food and Drug Administration. Medical Foods Guidance Documents & Regulatory
Information.
https://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/Medi
calFoods/default.htm. Accessed February 4, 2019.
11. USDA Center for Nutrition Policy and Promotion. MyPlate. https://www.choosemyplate.gov/.
Accessed February 4, 2019

Breastmilk*/Infant Formula Intake (FH-1.2.3)

Definition
Amount of breastmilk, and/or the amount of infant formula consumed orally
Indicators
Breastmilk intake
 Breastmilk feeding attempts in 24 hours (number/day)

 Adequacy of breastmilk intake (inadequate, adequate, excessive)
 Donor breastmilk intake (yes/no)—defined as human milk expressed from a woman’s breast to
feed an infant that is not the donor’s infant
 Mother’s expressed breastmilk intake (yes/no)—defined as human milk expelled from the
mother’s breast to feed her own infant
 Estimated breastmilk intake
o Breastmilk intake estimated volume in 24 hours (mL/day)—defined as the approximate
intake in one day of breastmilk
o Breastmilk intake estimated volume per kg in 24 hours (mL/kg/day)—defined as the
approximate intake per kg of body weight in one day of breastmilk
 Measured breastmilk intake
o Breastmilk intake measured volume in 24 hours (mL/day)—defined as the known
quantity of intake in one day of breastmilk
o Breastmilk intake measured volume per kg in 24 hours (mL/kg/day)—defined as the
known quantity of intake per kg of body weight in one day of breastmilk
Infant formula intake (oz or mL/day)
 Infant formula feedings in 24 hours (number/day)

 Adequacy of infant formula intake (inadequate, adequate, excessive)
 Infant formula intake composition (eg, cow’s milk, soy-based)—defined as the formula
characteristics and components
 Infant formula intake concentration (calories/oz, kcal/mL)—defined at the energy density of the
infant formula
 Estimated infant formula intake
o Infant formula intake estimated volume in 24 hour (mL/day)—defined as the approximate
intake in one day of infant formula
o Infant formula intake estimated volume per kg in 24 hours (mL/kg/day)—defined as the
approximate intake per kg of body weight in one day of infant formula
 Measured infant formula intake
o Infant formula intake measured volume in 24 hour (mL/day)—defined as the known
quantity of intake in one day of infant formula
o Infant formula intake measured volume per kg in 24 hours (mL/kg/day)—defined as the
known quantity of intake per kg of body weight in one day of infant formula
Note: Breastfeeding ability and capacity can be found on the Breastfeeding

Assessment reference sheet.
Weight change can be found on the Body Composition/Growth/Weight History reference

sheet.
Number of wet diapers per day can be found on the Urine Profile reference sheet.
Number/consistency of bowel movements can be found on the Nutrition-Focused Physical

Exam reference sheet.
If provided via tube use the Enteral and Parenteral Nutrition Intake reference sheet.

Examples of the measurement methods or data sources for these outcome indicators: Intake records,
24-hour recalls, usual intake recalls, observation of feeding (bottle or breast), pre and post breastfeeding
infant weights.
diagnoses: Underweight, overweight, unintended weight gain, unintended weight loss, growth rate less
than expected, limited adherence to nutrition-related recommendations, inadequate or excessive energy
intake, inadequate or excessive oral or fluid intake
*If a synonym for the term “breastmilk” is helpful or needed, an approved alternate is “human milk.”
Client Example
Example of one of the Nutrition Care Indicators (includes sample initial and reassessment documentation
for one of the indicators)
Indicator Selected
Infant formula intake volume estimated in 24 hours (mL/day)
1. Reference Standard:Client's infant formula volume estimated in 24 hours averages 410 mL (100
mL/kg body). This is below the reference standard of 150 mL/kg/day to support adequate growth.
2. Recommendation: Not applicable
3. Goal: Client currently consumes approximately 100 mL/kg/kg body weight infant formula per
day. Client's goal is to increase intake to 150 mL/kg per day.
Based on mother’s recalls, infant formula intake volume estimated in 24 hours is

Initial nutrition
410 mL (100 mL/kg/day), 33% below the reference standard of 150 mL/kg per
assessment
day. Will monitor formula intake at next encounter.
Significant progress toward goal of consuming 150 mL/kg per day. Based on
Reassessment after
mother’s records, infant formula intake volume estimated in 24 hours has
increased to approximately 575 mL (140 mL/kg/day) over the past 7 days.
References
1. Academy of Nutrition and Dietetics. Pediatric Nutrition Care Manual.

https://www.nutritioncaremanual.org/. Accessed February 19, 2019.
2. Lessen R, Kavanagh K. Position of the Academy of Nutrition and Dietetics: Promoting and
supporting breastfeeding. J Acad Nutr Diet. 2015;115(3):444-449.
3. Martins-Celini FP, Gonçalves-Ferri WA, Aragon DC, et al. Association between type of feeding
at discharge from the hospital and nutritional status of very low birth weight preterm
infants. Brazilian journal of medical and biological research = Revista brasileira de pesquisas
medicas e biologicas. 2018;51(3):1-6.
4. Newkirk M, Shakeel F, Parimi P, et al. Comparison of calorie and protein intake of very low birth
weight infants receiving mother's own milk or donor milk when the nutrient composition of
human milk Is measured with a breast milk analyzer. Nutr Clin Pract. 2018;33(5):679-686.
5. Quigley M, McGuire W. Formula versus donor breast milk for feeding preterm or low birth
weight infants. The Cochrane database of systematic reviews. 2014(4):Cd002971.
6. Swerts M, Westhof E, Bogaerts A, Lemiengre J. Supporting breast-feeding women from the
perspective of the midwife: A systematic review of the literature. Midwifery. 2016;37:32-40.
7. Van Ginkel CD, van der Meulen GN, Bak E, et al. Retrospective observational cohort study
regarding the effect of breastfeeding on challenge-proven food allergy. Eur J Clin Nutr.
2018;72(4):557-563.
Food/Nutrition-Related History Domain – Enteral/Parenteral Nutrition

Enteral Nutrition Intake (FH-1.3.1)

Definition
Amount or type of enteral nutrition provided via a tube.
Indicators
Enteral nutrition formula/solution (specify)
 Enteral nutrition formula composition (formula)
 Enteral nutrition formula concentration (calories/kcal/kJ in each mL)
 Enteral nutrition formula estimated volume in 24 hours (mL/day)
 Enteral nutrition formula measured volume in 24 hours (mL/day)
 Enteral tube feeding flush estimated volume in 24 hours (mL/day)
 Enteral tube feeding flush measured volume in 24 hours (mL/day)
Note: Enteral nutrition tolerance can be found on the Physical Exam reference sheet and/or the
pertinent biochemical/sign or symptom reference sheet.
Examples of the measurement methods or data sources for these outcome indicators: Client
report/recalls, patient/client record, home evaluation, intake and output record
nutrition education, coordination of nutrition care by nutrition professional
Inadequate or excessive intake of enteral nutrition, inadequate fluid intake, food medication interaction,
unintended weight loss or gain
Client Example
Indicator Selected
Enteral nutrition formula volume in 24 hours (mL/day)
Comparison to Goal or Reference Standard:
1. Reference-Standard: Not applicable

2. Recommendation: Client’s enteral nutrition formula volume in 24 hours meets the nutrition
prescription of 80 mL/hour in 24 hours.
3. Goal: Not applicable
Enteral nutrition formula volume in 24 hours meets 60% of recommended

Initial nutrition assessment volume for 24 hours. Increase enteral nutrition rate tored 80 mL/hour. Monitor
enteral nutrition rate advancement.
Enteral nutrition formula volume in 24 hours meeting 85% estimated need.
Reassessment after
Progress toward nutrition prescription of 1 calorie or kcal per mL at 80 mL per
hour in 24 hours.
References
standards; other references may be appropriate.
1. Charney P, Malone A. ADA Pocket Guide to Nutrition Assessment. 3rd ed. Chicago, IL: American
Dietetic Association; 2015.
2. Academy of Nutrition and Dietetics. Nutrition Care Manual. www.nutritioncaremanual.org.
Accessed December 17, 2017.
3. Centers for Medicare and Medicaid Services. National coverage determination (NCD) for enteral
and parenteral nutrition therapy. http://www.cms.hhs.gov/mcd/viewncd.asp?
ncd_id=180.2&ncd_version=1&basket=ncd
%3A180%2E2%3A1%3AEnteral+and+Parenteral+Nutritional+Therapy. Accessed May 3, 2018.
4. Compher C, Frankenfield D, Keim N, Roth-Yousey L. Best practice methods to apply to
measurement of resting metabolic rate in adults: A systematic review. J Am Diet Assoc.
2006;106:881-903.
5. Kovacevich DS, Frederick A, Kelly D, Nishikawa R, Young L. American Society for Parenteral
and Enteral Nutrition Board of Directors, Standards for Specialized Nutrition Support Task Force.
Standards for specialized nutrition support: home care patients. Nutr Clin Pract. 2005;20:579-
590.
6. Steiger E, HPEN Working Group. Consensus statements regarding optimal management of home
parenteral nutrition (HPN) access. J Parenter Enteral Nutr. 2006;30(1 Suppl):S94-S95.
Food/Nutrition-Related History Domain – Enteral/Parenteral Nutrition

Parenteral Nutrition Intake (FH-1.3.2)

Definition
Amount or type of parenteral nutrition and/or fluids provided intravenously.
(Institute of Medicine. Dietary Reference Intakes: Applications in Dietary Assessment. Washington,
Indicators
Parenteral nutrition formula/solution (specify)
 Composition (formula or description)

 Concentration (eg, percent, grams of solute per mL)
 Rate (eg, mL/hour)
 Schedule (eg, hours, timing, taper schedule)
Intravenous fluids, eg, type; amount mL/day, mL/hr, mL with medications

Note: Parenteral nutrition tolerance can be accomplished with the Physical Exam Reference sheet
and/or the pertinent biochemical/sign or symptom reference sheet.
report/recalls, client record, home evaluation, intake and output record
Inadequate or excessive intake of parenteral nutrition, inadequate fluid intake, food–medication interaction,
unintended weight loss or gain
1. Goal (tailored to patient/client’s needs)
OR
2. Reference Standard
Client Example
Example(s) of one or two of the Nutrition Care Indicators (includes sample initial and reassessment
Rate/schedule (mL/hour × number of hours)
1. Goal: Patient/client’s parenteral nutrition formula is at a rate of 50 mL per hour × 24 hours of

standard solution compared to the nutrition prescription of 80 mL/hour × 24 hours to meet
estimated nutrition requirements.
OR
2. Reference Standard: There is no reference standard for this outcome as the provision of EN/PN is
individualized.
Sample Nutrition Assessment Documentation
Parenteral nutrition formula rate of 25 mL per hour × 24 hours of standard

Initial nutrition assessment solution compared to the nutrition prescription of 80 mL/hour to meet
with client estimated nutrition requirements. Monitor nutrition initiation and rate
advancement.
Reassessment after nutrition Parenteral nutrition formula at 70 mL per hour × 24 hours. Significant
intervention progress toward nutrition prescription of 80 mL per hour × 24 hours.
References
1. Charney P, Malone A. ADA Pocket Guide to Nutrition Assessment. 2nd ed. Chicago, IL: American
Accessed June 17, 2015.
3. Cavicchi M, Philippe Beau P, Crenn P, Degott C, Messing B. Prevalence of liver disease and
contributing factors in patients receiving home parenteral nutrition for permanent intestinal
failure. Intern Med. 2000;132:525-532.
4. Centers for Medicare and Medicaid Services. National coverage determination (NCD) for enteral
and parenteral nutrition therapy. http://www.cms.hhs.gov/mcd/viewncd.asp?
ncd_id=180.2&ncd_version=1&basket=ncd
%3A180%2E2%3A1%3AEnteral+and+Parenteral+Nutritional+Therapy. Accessed June 17, 2015.
measurement of resting metabolic rate in adults: a systematic review. J Am Diet Assoc.
2006;106:881-903.
6. American Society for Parenteral and Enteral Nutrition Board of Directors and the Clinical
Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and
pediatric patients: administration of specialized nutrition support—issues unique to pediatrics. J
Parenter Enteral Nutr. 2002;26(Suppl):S97-S110.
pediatric patients: specific guidelines for disease—adults. J Parenter Enteral
Nutr. 2002;26(Suppl):S61-S96.
pediatric patients: specific guidelines for disease—pediatrics. J Parenter Enteral
Nutr. 2002;26(Suppl):S111-S138.
pediatric patients: Life cycle and metabolic conditions. J Parenter Enteral
Nutr. 2002;26(Suppl):S45-S60.
10. Kovacevich DS, Frederick A, Kelly D, Nishikawa R, Young L. American Society for Parenteral
and Enteral Nutrition Board of Directors, Standards for Specialized Nutrition Support Task Force.
Standards for specialized nutrition support: home care patients. Nutr Clin Pract. 2005;20:579-
590.
http://peds.nutritioncaremanual.org. Accessed June 17, 2015.
Food/Nutrition-Related History – Bioactive Substances
Alcohol Intake (FH-1.4.1)

Definition
Amount and pattern of alcohol (ethanol) consumption
Indicators
Alcohol intake in one week (g/week)—defined as the approximate intake over seven days of all
sources of alcohol
Alcohol intake in 24 hours (g/day)—defined as the approximate intake in one day of all sources of
alcohol
Beer intake in 24 hours (mL/day)—defined as the approximate intake in one day of beer
Distilled alcohol intake in 24 hours (mL/day)—defined as the approximate intake in one day
of distilled alcohol
Wine intake in 24 hours (mL/day)—defined as the approximate intake in one day of wine
Hard cider intake in 24 hours (mL/day)—defined as the approximate intake in one day of
cider that contains alcohol
Days per week alcoholic drinks consumed (number)—defined as usual or average number of days
per week when alcohol containing drinks are consumed
Alcohol intake pattern on drinking days (number)—defined as the typical number of standard
alcohol containing drinks on a drinking day
Note: One alcohol containing drink is defined differently in countries around the world, with
countries using grams, ounces, milliliters, and units. Where applicable in this reference sheet, one
standard alcohol containing drink equals 10 g of pure alcohol (ethanol). Professionals need to
refer to guidelines in their respective countries to determine the alcohol content of one standard
alcohol containing drink.
report/recalls, self-monitoring log
Typically used with the following domains of nutrition interventions: Nutrition education, nutrition
counseling, coordination of nutrition care by a nutrition professional, population based nutrition action
diagnoses: Excessive intake of alcohol, excessive or inadequate intake of energy, altered nutrition-related
laboratory values, impaired nutrient utilization, overweight/obesity
Client Example
Alcohol intake pattern on drinking days (number)
1. Reference Standard: Refer to country standards, if present, for alcohol reference standards.

2. Recommendation: Client’s intake of three to four standard alcohol drinks on drinking days is
significantly above the recommendation of one standard alcohol drink per day for adult females.
3. Goal: Client established a goal to reduce standard alcohol drink intake to one standard alcohol
drink per day.
Based on recalls, client’s Alcohol intake pattern on drinking days is three to four
standard alcohol drinks, which is above the recommended amount for adult females.
Initial encounter
Client established goal to reduce intake to one standard alcohol drink on drinking
days. Will monitor change in alcohol intake at next encounter
Reassessment after
Progress toward goal. Alcohol intake pattern on drinking days, based on multiple 7-
nutrition
day records, is approximately two standard alcohol drinks on drinking days.
intervention
References
1. National Institutes of Health. National Institute on Alcoholism and Alcohol Abuse. National
Council on Alcohol Abuse and Alcoholism Recommended Sets of Alcohol Consumption
Questions. https://www.niaaa.nih.gov/research/guidelines-and-resources/recommended-alcohol-
questions. Accessed February 26, 2019.
2. National Institutes of Health. National Institute on Alcoholism and Alcohol Abuse. What is a
standard drink? https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/what-
standard-drink. Accessed February 27, 2019.
3. Sobell LC, Sobell MB. Alcohol consumption measures.
https://pubs.niaaa.nih.gov/publications/AssessingAlcohol/sobell.pdf. Accessed February 27,
2019.
4, 2019.
5. World Health Organization. Management of substance abuse.
https://www.who.int/substance_abuse/publications/alcohol/en/. Accessed February 27, 2019.

Bioactive Substance Intake (FH-1.4.2)
Definition
Amount and type of bioactive substances consumed
Note: Bioactive substances are not part of the Dietary Reference Intakes, and therefore there are
no established minimum requirements or Tolerable Upper Intake Levels. However, RDNs can
assess whether estimated intakes are adequate or excessive using the client goal or nutrition
prescription for comparison.
Working definition of bioactive substances—physiologically active components of foods that may
have an effect on health. There is no scientific consensus about a definition for bioactive
substances/components.
Indicators
Estimated bioactive substance intake

Plant stanol ester estimated intake in 24 hours (g/day)—defined as the approximate intake in one
day of plant stanol esters
Plant sterol ester estimated intake in 24 hours (g/day)—defined as the approximate intake in one
day of plant sterol esters
Soy protein estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of
soy protein
Psyllium estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of
psyllium
Beta glucan estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of
beta glucan
Measured bioactive substance intake
Plant stanol ester measured intake in 24 hours (g/day)—defined as the known quantity of intake in
one day of plant stanol esters
Plant sterol ester measured intake in 24 hours (g/day)—defined as the known quantity of intake in
one day of plant sterol esters
Soy protein measured intake in 24 hours (g/day)—defined as the known quantity of intake in one
day of soy
protein
Psyllium measured intake in 24 hours (g/day)—defined as the known quantity of intake in one day
of psyllium
Beta glucan measured intake in 24 hours (g/day)—defined as the known quantity of intake in one
day of beta glucan
Food additives intake (those thought to have an effect on a client’s health); specify
High intensity sweetener additive intake
Excessive high intensity sweetener additive intake (present/absent)—defined as intake above
the recommended acceptable daily intake (ADI) of high intensity sweeteners the contain
nutritive and nonnutritive sugar substitutes
report/recalls, self monitoring log
counseling, population based nutrition action
diagnoses: Inadequate or excessive intake of bioactive substances, food medication interaction
Client Example
Indicator Selected
Plant sterol ester estimated intake in 24 hours (g/day)
1. Reference Standard:Not applicable

2. Recommendation: Client does not consume plant sterol esters compared to the recommended
intake of 2 to 3 grams per day.
3. Goal: Client established a goal to consume approximately 2 g of plant sterol esters per day 5 of 7
days per week.
Based on recalls, client consuming 0 gramsof plant sterol ester per day. Goal
Initial assessment intake of 2 g per day 5 out of 7 days per week established. Will monitor change
in plant sterol ester intake at next encounter.
Good progress toward the goal of 2 g per day 5 out of 7 days per week of plant
Reassessment after
sterol ester. Based on diet records, plant sterol ester estimated intake in 24 hours
is approximately 2 g per day 2 to 3 days per week.
References
1. Academy of Nutrition and Dietetics. Evidence Analysis Library: Disorders of Lipid Metabolism.
https://www.andeal.org/topic.cfm?menu=5300. Accessed February 4, 2019.
2. Academy of Nutrition and Dietetics. Evidence Analysis Library-GDM: Non-nutritive sweeteners.
2008; https://www.andeal.org/topic.cfm?cat=3037&highlight=nonnutritive
%20sweetener&evidence_summary_id=250587&home=1%2E. Accessed February 4, 2019.
3. Academy of Nutrition and Dietetics. Evidence Analysis Library. Gestational Diabetes Mellitus
Conclusion Statements: Carbohydrate (2001). https://www.andeal.org/topic.cfm?
highlight=nonnutritive%20sweetener&home=1&evidence_summary_id=250309&cat=3820.
4. Academy of Nutrition and Dietetics. Evidence Analysis Library-Nutritive and Non-Nutritive
Sweeteners. 2010-2011; https://www.andeal.org/topic.cfm?menu=5307. Accessed February 4,
2019.
5. Briggs Early K, Stanley K. Position of the Academy of Nutrition and Dietetics: The Role of
Medical Nutrition Therapy and Registered Dietitian Nutritionists in the Prevention and Treatment
of Prediabetes and Type 2 Diabetes. J Acad Nutr Diet. 2018;118(2):343-353.
6. Crowe KM, Francis C. Position of the Academy of Nutrition and Dietetics: Functional foods. J
Acad Nutr Diet. 2013;113(8):1096-1103.
7. European Commission. Food improvement agents: Additives.
https://ec.europa.eu/food/safety/food_improvement_agents/additives_en. Accessed February 4,
2019.
8. US Food and Drug Administration. Overview of Food Ingredients, Additives and Colors.
https://www.fda.gov/Food/IngredientsPackagingLabeling/FoodAdditivesIngredients/ucm094211.h
tm. Accessed February 4, 2019.

Caffeine Intake (FH-1.4.3)

Definition
Amount of caffeine intake from all sources including food, beverages, supplements, medications, and via
enteral and parenteral routes
Indicators
Total caffeine estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day
of caffeine
Total caffeine measured intake in 24 hours (mg/day)—defined as the known quantity of intake in
one day of caffeine
report/recalls, self monitoring log
counseling
diagnoses: Food and nutrition-related knowledge deficit
Client Example
Indicator Selected
Total caffeine estimated intake in 24 hours (mg/day)
1. Reference Standard：Client’s intake is approximately 600 mg of caffeine per day, which is above
the reference standard of 400 mg caffeine/day.
3. Goal: Client’s total caffeine estimated intake in 24 hours is above the goal the client established of
less than 400 mg caffeine/day.
Initial nutrition assessment Based on recalls, client total caffeine estimated intake in 24 hours is 600 mg
with client of caffeine/day, which is above the reference standard of 400 mg/day. Will
monitor change in caffeine intake at next encounter.
Reassessment after nutrition No progress toward the client’s goal of 400 mg of caffeine/day. Based on
intervention diet records, client still consuming 600 mg of caffeine/day.
References
1. McCusker RR, Goldberger BA, Cone EJ. Caffeine content of specialty coffees. J Anal Toxicol.
2003;27(7):520-522.
2. McCusker RR, Goldberger BA, Cone EJ. Caffeine content of energy drinks, carbonated sodas, and
other beverages. J Anal Toxicol. 2006;30(2):112-114.
3. Institute of Medicine. Caffeine in food and dietary supplements: Examining safety: Workshop
summary. Washington, DC: National Academies Press. 2014.
4. Nawrot P, Jordan S, Eastwood J, Rotstein J, Hugenholtz A, Feeley M. Effects of caffeine on
human health. Food Addit Contam. 2003;20(1): 1-30.
5. Winkelmayer WC, Stampfer MJ, Willett WC, Curhan, GC. Habitual caffeine intake and the risk
of hypertension in women. JAMA.2005;294(18):2330-2335.
Food/Nutrition-Related History – Macronutrient Intake

Fat Intake (FH-1.5.1)

Definition
Fat consumption from all sources including food, beverages, supplements, and via enteral and parenteral
routes
(Institute of Medicine. Dietary Reference Intakes: Applications in Dietary
Assessment. Washington, DC: National Academies Press; 2000.)
Indicators
Estimated fat intake
Total fat estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of all
types of fat
Saturated fat estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of
a fat that has no double bonds between carbon molecules
Trans fatty acid estimated intake in 24 hours (g/day)—defined as the approximate intake in one day
of an unsaturated fatty acid that is hydrogenated with the trans arrangement of the hydrogen atoms
adjacent to its double bonds
Polyunsaturated fat estimated intake in 24 hours (g/day)—defined as the approximate intake in one
day of a fatty acid that contains more than one double bond
 Linoleic acid (LA) estimated intake in 24 hours (g/day)—defined as the approximate intake
in one day of a polyunsaturated, omega 6 and essential fatty acid with an 18 carbon chain
length and two cis double bonds (18:2)
Monounsaturated fat estimated intake in 24 hours (g/day)—defined as the approximate intake in

one day of a fatty acid with one unsaturated (double) carbon bond
Omega 3 fatty acid estimated intake in 24 hours (mg/day)—defined as the approximate intake in
one day of a polyunsaturated fatty acid with a double bond at the third carbon atom from the methyl
end of the carbon chain
 Alpha linolenic acid estimated intake in 24 hours (mg/day)--defined as the approximate intake in
one day of a polyunsaturated and essential omega 3 fatty acid with an 18-carbon chain and three cis
double bonds (18:3)
 Eicosapentaenoic acid (EPA) estimated intake in 24 hours (mg/day)—defined as the approximate
intake in one day of a polyunsaturated, omega 3 fatty acid with a 20-carbon chain and five cis
double bonds
 Docosahexaenoic acid estimated intake in 24 hours (mg/day)—defined as the approximate intake
in one day of a polyunsaturated, omega 3 fatty acid with a 22-carbon chain and six cis double bonds
Essential fatty acid estimated intake in 24 hours (mg/day)—defined as the approximate intake in
one day of a fatty acid (Linoleic acid [18:2] and Alphalinolenic acid [18:3]) that must be provided
in the diet or enteral or parenteral nutrition because the human body cannot synthesize it
Medium chain triglyceride estimated intake in 24 hours (g/day—defined as the approximate intake
in one day of a triglyceride molecule with fatty acids having a carbon chain length of 6-12
Fat estimated intake in one meal (g/meal)—defined as the approximate intake in one meal of all
types of fat
Percent saturated fat estimated intake in 24 hours (percent/day)—defined as the approximate energy
intake in one day from fat that has no double bonds between carbon molecules as a portion of total
energy intake
Fat estimated intake from oral nutrition in 24 hours (g/day)—defined as the estimated intake of fat
in grams in one day derived from oral intake
Fat estimated intake from enteral nutrition in 24 hours (g/day)—defined as the estimated intake of
fat in grams in one day derived from enteral nutrition infusion
Fat estimated intake from parenteral nutrition in 24 hours (g/day)—defined as the estimated intake
of fat in grams in one day derived from parenteral nutrition infusion
Fat estimated intake from intravenous fluids in 24 hours (g/day)—defined as the estimated intake of
fat in grams in one day derived from intravenous fluid (IV) infusion
Fat additive estimated intake in 24 hours (mL/day)—defined as the approximate intake in one day
of fat additive
Percent fat estimated intake in 24 hours (percent/day)—defined as the approximate energy intake in
one day from fat intake
Measured fat intake

Total fat measured intake in 24 hours (g/day)—defined as the known quantity of intake in one day
of all types of fat
Saturated fat measured intake in 24 hours (g/day)—defined as the known quantity of intake in one
day of a fat that has no double bonds between carbon molecules
Trans fatty acid measured intake in 24 hours (g/day)—defined as the known quantity of intake in
one day of an unsaturated fatty acid that is hydrogenated with the trans arrangement of the
hydrogen atoms adjacent to its double bonds
Polyunsaturated fat measured intake in 24 hours (g/day)—defined as the known quantity of intake
in one day of a fatty acid that contains more than one double bond
 Linoleic acid (LA) measured intake in 24 hours (g/day)—defined as the known quantity of
intake in one day of a polyunsaturated, omega 6 and essential fatty acid with an 18 carbon
chain length and two cis double bonds (18:2)
Monounsaturated fat measured intake in 24 hours (g/day)—defined as the known quantity of intake
in one day of a fatty acid with one unsaturated (double) carbon bond
Omega 3 fatty acid measured intake in 24 hours (mg/day)—defined as the known quantity of intake
in one day of a polyunsaturated fatty acid with a double bond at the third carbon atom from the
methyl end of the carbon chain
 Alpha linolenic acid measured intake in 24 hours (mg/day)--defined as the known quantity of
intake in one day of a polyunsaturated and essential omega 3 fatty acid with an 18-carbon chain and
three cis double bonds (18:3)
 Eicosapentaenoic acid (EPA) measured intake in 24 hours (mg/day)—defined as the known
quantity of intake in one day of a polyunsaturated, omega 3 fatty acid with a 20-carbon chain and
five cis double bonds
 Docosahexaenoic acid (DHA) measured intake in 24 hours (mg/day)—defined as the known
quantity of intake in one day of a polyunsaturated, omega 3 fatty acid with a 22-carbon chain and
six cis double bonds
Essential fatty acid measured intake in 24 hours (mg/day)—defined as the known quantity of intake
in one day of a fatty acid (Linoleic acid [18:2] and Alphalinolenic acid [18:3]) that must be
provided in the diet or enteral or parenteral nutrition because the human body cannot synthesize it
Medium chain triglyceride measured intake in 24 hours (g/day)—defined as the known quantity of
intake in one day of a triglyceride molecule with fatty acids having a carbon chain length of 6-12
Fat measured intake in one meal (g/meal)—defined as the known quantity of intake in one meal of
all types of fat
Percent saturated fat measured intake in 24 hours (percent/day)—defined as the known quantity of
intake in one day of fat that has no double bonds between carbon molecules as a portion of total
energy intake
Fat measured intake from oral nutrition in 24 hours (g/day)—defined as the known quantity of
intake of fat in grams in one day derived from oral intake
Fat measured intake from enteral nutrition in 24 hours (g/day)—defined as the known quantity of
intake of fat in grams in one day derived from enteral nutrition infusion
Fat measured intake from parenteral nutrition in 24 hours (g/day)—defined as the known quantity
of intake of fat in grams in one day derived from parenteral nutrition infusion
Fat measured intake from intravenous fluids in 24 hours (g/day)—defined as the known quantity of
intake of fat in grams in one day derived from intravenous fluid (IV) infusion
Fat additive measured intake in 24 hours (mL/day)—defined as the known quantity of intake in one
day of fat additive
Percent fat measured intake in 24 hours (percent/day)—defined as the known quantity of energy
intake in one day from fat intake

Note: Plant sterol and stanol esters can be found on the Bioactive Substance Intake Reference
sheet.
records, 24-hour recalls, food frequency questionnaires, qualitative intake assessment, menu analysis, fat
and cholesterol targeted questionnaires and monitoring devices
nutrition education, nutrition counseling
diagnoses: Typically used to determine and to monitor and evaluate change in the following nutrition
diagnoses: Inadequate and excessive fat intake, intake of types of fats inconsistent with needs,
overweight/obesity, altered nutrition-related lab values, altered food and nutrition-related knowledge
deficit
Client Example
Example(s) of one of the Nutrition Care Indicators (includes sample initial and reassessment
Indicator Selected
Total fat estimated intake in 24 hours (g/day)

3. Goal: Client's total fat estimated intake in 24 hours is 120 g. Client's goal is to decrease total fat
estimated intake in 24 hours to less than 80 g.
Based on food diary, client’s total fat estimated intake in 24 hours is 120 g. Client’s
Initial encounter goal is to decrease total fat estimated intake in 24 hours to less than 80 g. Will
monitor fat intake at next appointment.
Significant progress toward the goal intake of less than 80 g of total fat estimated
Reassessment after intake in 24 hours. Based on food diary client’s total fat estimated intake in 24
nutrition intervention hours decreased from 120g to 85 g of fat in one day. Will continue to monitor
progress at next encounter in 6 weeks.
References

2. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to
reduce cardiovascular risk: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S76-99.
4, 2019.
Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press;
2002.
4, 2019.

Cholesterol Intake (FH-1.5.2)

Definition
Dietary cholesterol consumption from all sources including food, beverages, supplements, and via enteral
and parenteral routes
provide a valid assessment of nutritional status based on a totality of the evidence. (Institute of Medicine.
Dietary Reference Intakes: Applications in Dietary Assessment. Washington, DC: National Academies
Press; 2000.)
Indicators
Cholesterol estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day of
cholesterol
Cholesterol measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one
day of cholesterol
Note: Plant sterol and stanol esters can be found on the Bioactive Substance Intake Reference
sheet.
records, 24-hour recalls, food frequency questionnaires, qualitative intake assessment, menu analysis, fat
and cholesterol targeted questionnaires and monitoring devices
diagnoses: Excessive fat intake, excessive cholesterol intake, overweight/obesity, altered nutrition related
lab values, altered food and nutrition-related knowledge deficit
Client Example
Indicator Selected
Cholesterol estimated intake in 24 hours (mg/day)
2. Recommendation:Not applicable
3. Goal: Client cholesterol estimated intake is 24 hours is 350 mg/day. Client’s goal is to decrease
intake to within Healthy US-Style Eating Pattern (100-300 mg/day).
Based on food diary, client’s cholesterol estimated intake in 24 hours is 350

Initial nutrition
mg/day. Client’s goal is to reduce cholesterol estimated intake in 24 hours to 100-
assessment
300 mg/day. Will monitor cholesterol intake at next appointment.
Progress toward the goal of 100-300 mg/day of cholesterol. Based on food diary,
Reassessment after
client’s cholesterol estimated intake in 24 hours decreased from 350 mg/day to
250 mg/day. Will continue to monitor progress at next encounter in 6 weeks.
References
1. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy,
Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids. Washington, DC:
National Academies Press; 2002.
2. US Department of Health and Human Services and US Department of Agriculture. 2015-2020
12, 2018.
4. Academy of Nutrition and Dietetics. Evidence Analysis Library: Disorders of Lipid Metabolism.
5. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood
cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American
College of Cardiology/American Heart Association. J Am Coll Cardiol. 2014;63(25 Pt B):2889-
2934.
6. Van Horn L, McCoin M, Kris-Etherton PM, et al. The evidence for dietary prevention and
treatment of cardiovascular disease. J Am Diet Assoc. 2008;108(2):287-331.

Protein Intake (FH-1.5.3)

Definition
Protein intake from all sources including food, beverages, supplements, and via enteral and parenteral
routes.
biochemical, anthropometric information, medical diagnosis, clinical status, and/or other factors
to provide a valid assessment of nutritional status based on a totality of the evidence. (Institute of
Indicators
Estimated protein intake
Total protein estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of
all protein
High biological value protein estimated intake in 24 hours (g/day)—defined as the approximate
intake in one day from proteins which contain a ratio of essential amino acids that are needed for
humans
Casein estimated intake in 24 hours (g/day)—defined as the approximate intake in one day from the
phosphoprotein component in milk and milk products that can also be an ingredient in food
Whey estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of the
complete protein component in milk and milk products that can also be an ingredient in food
Gluten estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of the
protein found primarily in cereal grains and contains gliadin and a glutenin
Protein estimated intake per kg in 24 hours (g/kg/day)—defined as the approximate intake per kg of
body weight in one day of all protein
Natural protein estimated intake in 24 hours (specify, g/day)—defined as the approximate intake of
the portion of total protein that comes from food sources
Protein estimated intake in one meal (g/meal)—defined as the approximate intake in one meal of all
types of protein
Percent protein estimated intake in 24 hours (percent/day)—defined as the approximate intake in
one day from protein intake
Protein estimated intake from oral nutrition in 24 hours (specify, g/day)—defined as the
approximate intake of protein in grams per day derived from oral intake
Protein estimated intake from enteral nutrition in 24 hours (specify, g/day)—defined as the
approximate intake of protein in grams per day derived from intact or semi-elemental protein
enteral nutrition infusion
Protein additive estimated intake in 24 hours (g/day and mL/day)—defined as the approximate
intake in one day of protein additive
Measured protein intake
Total protein measured intake in 24 hours (g/day)—defined as the known quantity of intake in one
day of all protein
High biological value protein measured intake in 24 hours (g/day)—defined as the known quantity
of intake in one day from proteins which contain a ratio of essential amino acids that are needed for
humans
Casein measured intake in 24 hours (g/day)—defined as the known quantity of intake in one day
from the phosphoprotein component in milk and milk products that can also be an ingredient in
food
Whey measured intake in 24 hours (g/day)—defined as the known quantity of intake in one day of
the complete protein component in milk and milk products that can also be an ingredient in food
Gluten measured intake in 24 hours (g/day)—defined as the known quantity of intake in one day of
the protein found primarily in cereal grains and contains gliadin and a glutenin
Protein measured intake in 24 hours (g/kg/day)—defined as the known quantity of intake per kg of
body weight in one day of all protein
Natural protein measured intake in 24 hours (specify, g/day)—defined as the known quantity of
intake of the portion of total protein that comes from food sources
Protein measured intake in one meal (g/meal)—defined as the known quantity of intake in one meal
of all types of protein
Percent protein measured intake in 24 hours (percent/day)—defined as the known quantity of intake
in one day from protein intake
Protein measured intake from oral nutrition in 24 hours (specify, g/day)—defined as the known
quantity of intake of protein in grams per day derived from oral intake
Protein measured intake from enteral nutrition in 24 hours (specify, g/day)—defined as the known
quantity of intake of protein in grams per day derived from intact or semi-elemental protein enteral
nutrition infusion
Protein additive measured intake in 24 hours (g/day and mL/day)—defined as the known quantity
of intake in one day of protein additive
Note: Soy protein can be found on the Bioactive Substance Intake reference sheet. Amino acid
intake from elemental enteral nutrition, parenteral nutrition, or intravenous (IV) fluids can be
documented using terms on the Amino Acid Intake (FH-1.5.4) reference sheet.

records, 24-hour recalls, food frequency questionnaires, qualitative protein intake collection tools, nutrition
fact labels, other product information, nutrient composition tables
diagnoses: Inadequate and excessive protein intake, intake of types of proteins or amino acids inconsistent
with needs, malnutrition, inadequate protein-energy intake, altered GI function, limited adherence to
nutrition-related recommendations
Client Example
Indicator Selected
Total protein estimated intake in 24 hours (g/day)
1. Reference Standard: Client’s total protein estimated intake in 24 hours of 25 g/ day is less than the
Dietary Reference Intake of 53 g/day (0.8 g/kg body weight).
2. Recommendation: 55-65 g/day (1 to 1.2 g/kg body weight).
3. Goal: Client’s goal is to increase enteral nutrition feeding to provide at least 45 g/day protein.
Enteral feeding currently providing 25 g/day of protein, below the

recommended level of 55 to 65 g/day (1 to 1.2 g/kg BW). Client established a
Initial encounter goal to increase enteral nutrition feeding to provide total protein estimated
intake in 24 hours of at least 45 g/day. Will continue to monitor protein intake
daily.
Some progress toward goal intake of 45g protein/day. Current total protein
Reassessment after nutrition
estimated intake in 24 hours is 30 g protein/day. Will continue to monitor
intervention
protein intake daily.
References

4, 2019.
2002.
6. Mehta NM, Skillman HE, Irving SY, et al. Guidelines for the provision and assessment of
nutrition support therapy in the pediatric critically ill patient: Society of Critical Care Medicine
and American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr.
2017;41(5):706-742.
8. KDOQI Clinical Practice Guideline for Diabetes and CKD: 2012 Update. Am J Kidney Dis.
2012;60(5):850-886.
10. Singh RH, Rohr F, Frazier D, et al. Recommendations for the nutrition management of
phenylalanine hydroxylase deficiency. Genet Med. 2014;16(2):121-131.

Amino Acid Intake (FH-1.5.4)

Definition
Amino acid intake from all sources including food, beverages, supplements, and via enteral and parenteral
routes
Indicators
Estimated amino acid intake

Total amino acid estimated intake in 24 hours (mg/day)—defined as the approximate intake in one
day of total amino acids
Essential amino acid estimated intake in 24 hours (mg/day)—defined as the approximate intake in
one day of amino acids that cannot be synthesized by humans and must be provided by the diet or
by enteral or parenteral nutrition
Histidine estimated intake in 24 hours (mg/day)—defined as the approximate intake in one
day of an essential amino acid with the formula C6H9N3O2
Methionine estimated intake in 24 hours (mg/day)—defined as the approximate intake in one
day of an essential amino acid with the formula C5H11NO2S
Isoleucine estimated intake in 24 hours (mg/day)—defined as the approximate intake in one
day of an essential amino acid and branched-chain amino acid with the formula C 6H13NO2
Leucine estimated intake in 24 hours (mg/day)—defined as the approximate intake in one
day of an essential amino acid and branched-chain amino acid with the formula C 6H13NO2
Lysine estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day
of an essential amino acid with the formula C5H11NO2
Threonine estimated intake in 24 hours (mg/day)—defined as the approximate intake in one
day of an essential amino acid with the formula C4H9NO3
Tryptophan estimated intake in 24 hours (mg/day)—defined as the approximate intake in
one day of an essential amino acid with the formula C11H12N2O2
Phenylalanine estimated intake in 24 hours (mg/day)—defined as the approximate intake in
one day of an essential amino acid with the formula C9H11NO2
Valine estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day
of an essential amino acid and branched-chain amino acid with the formula C 5H11NO2
Nonessential amino acid estimated intake in 24 hours (mg/day)—defined as the approximate intake
in one day of amino acids that can be synthesized by humans
Arginine estimated intake in 24 hours (mg/day)—defined as the approximate intake in one
day of a nonessential amino acid with the formula C6H14N4O2
Glutamine estimated intake in 24 hours (mg/day)—defined as the approximate intake in one
day of a nonessential amino acid with the formula C5H10N2O3
Homocysteine estimated intake in 24 hours (mg/day)—defined as the approximate intake in
one day of a nonessential amino acid with the formula C4H9NO2S
Tyramine estimated intake in 24 hours (mg/day)—defined as the approximate intake in one
day of a nonessential amino acid with the formula C8H11NO

Measured amino acid intake
Total amino acid measured intake in 24 hours (mg/day)—defined as the known quantity of intake in
one day of total amino acids
Essential amino acid measured intake in 24 hours (mg/day)—defined as the known quantity of
intake in one day of amino acids that cannot be synthesized by humans and must be provided by the
diet or by enteral or parenteral nutrition
Histidine measured intake in 24 hours (mg/day)—defined as the known quantity of intake in
one day of an essential amino acid with the formula C6H9N3O2
Methionine measured intake in 24 hours (mg/day)—defined as the known quantity of intake
in one day of an essential amino acid with the formula C5H11NO2S
Isoleucine measured intake in 24 hours (mg/day)—defined as the known quantity of intake
in one day of an essential amino acid and branched-chain amino acid with the formula
C6H13NO2
Leucine measured intake in 24 hours (mg/day)—defined as the known quantity of intake in
one day of an essential amino acid and branched-chain amino acid with the formula
C6H13NO2
Lysine measured intake in 24 hours (mg/day)—defined as the known quantity of intake in
one day of an essential amino acid with the formula C5H11NO2
Threonine measured intake in 24 hours (mg/day)—defined as the known quantity of intake
in one day of an essential amino acid with the formula C4H9NO3
Tryptophan measured intake in 24 hours (mg/day)—defined as the known quantity of intake
in one day of an essential amino acid with the formula C11H12N2O2
Phenylalanine measured intake in 24 hours (mg/day)—defined as the known quantity of
intake in one day of an essential amino acid with the formula C9H11NO2
Valine measured intake in 24 hours (mg/day)—defined as the approximate intake in one day
of an essential amino acid and branched-chain amino acid with the formula C 5H11NO2
Nonessential amino acid measured intake in 24 hours (mg/day)—defined as the known quantity of
intake in one day of amino acids that can be synthesized by humans
Arginine measured intake in 24 hours (mg/day)—defined as the known quantity of intake in
one day of a nonessential amino acid with the formula C6H14N4O2
Glutamine measured intake in 24 hours (mg/day)—defined as the known quantity of intake
in one day of a nonessential amino acid with the formula C5H10N2O3
Homocysteine measured intake in 24 hours (mg/day)—defined as the known quantity of
intake in one day of a nonessential amino acid with the formula C4H9NO2S
Tyramine measured intake in 24 hours (mg/day)—defined as the known quantity of intake in
one day of a nonessential amino acid with the formula C8H11NO
Amino acids from enteral nutrition (specify g/day)—defined as the estimated intake of amino acids in
grams in one day derived from elemental enteral nutrition infusion
Amino acids from parenteral nutrition (specify g/day)—defined as the estimated intake of amino acids in
grams in one day derived from parenteral nutrition infusion
Amino acids from intravenous fluids (specify g/day)—defined as the estimated intake of amino acids in
grams in one day derived from intravenous (IV) infusion
records, 24-hour recalls, food frequency questionnaires, qualitative amino acid intake collection tools,
nutrition fact labels, other product information, nutrient composition tables
diagnoses: Intake of types of amino acids inconsistent with needs, malnutrition, inadequate protein-energy
intake, altered GI function, limited adherence to nutrition-related recommendations
Client Example
Histidine estimated intake in 24 hours (mg/kg/day)
1. Reference Standard：Client’s current intake of histidine per day is 520 mg/day (8 mg/kg/day)
below the EAR level of 11 mg/kg/day of histidine.
3. Goal：Client established a goal of histidine estimated intake in 24 hours of at least 715 mg/day
(11 mg/kg/day).
Histidine estimated intake in 24 hours averages 520 mg/day(8 mg/kg/day)

Initial nutrition assessment which is below the EAR of 715 mg/day (11 mg/kg/day) for a person 19 years
of age or older. Will continue to monitor histidine intake daily.
Histidine estimated intake in 24 hours averages 675 mg/day. Significant
progress toward goal intake of 715 mg/day (11 mg/kg/day) for a person 19
intervention
years of age or older.
References
1. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy,
Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids. Washington, DC:
2. Young VR, Borgouha S. Adult human amino acid requirements. Curr Opin Clin Metab Care.
1999;2:39-45.
canada/services/food-nutrition/healthy-eating/dietary-reference-intakes.html. Accessed December
18, 2017.
new-zealand. Accessed December 17, 2017.
7. Nordic Council of Ministers. Nordic Nutrition Recommendations 2012: integrating nutrition and
physical activity. http://www.norden.org/en/theme/former-themes/themes-2016/nordic-nutrition-
recommendation/nordic-nutrition-recommendations-2012. Updated 2012. Accessed December 17,
2017.

Carbohydrate Intake (FH-1.5.5)

Definition
Carbohydrate consumption from all sources including food, beverages, supplements, and via enteral and
parenteral routes, including relative measures of the quantity and/or type of carbohydrate consumed.
Indicators

Estimated carbohydrate intake
Total carbohydrate estimated intake in 24 hours (g/day)—defined as the approximate intake in one
day of total carbohydrate
Complex carbohydrate estimated intake in 24 hours (g/day)– defined as the approximate intake in
one day of a polysaccharide that is comprised of three or more sugars; also called starch
Simple carbohydrate estimated intake in 24 hours (g/day)—defined as the approximate intake in
one day of mono- and disaccharides
Galactose estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of a
monosaccharide which is a common component of lactose
Lactose estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of a
disaccharide sugar of galactose and glucose; present in milk
Fructose estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of a
monosaccharide sugar found in fruit and honey
Carbohydrate estimated intake per kg in 24 hours (g/kg/day)—defined as the approximate intake
per kg of body weight in one day of all carbohydrate
Carbohydrate estimated intake in one meal (g/meal)—defined as the approximate intake in one
meal of all types of carbohydrate
Percent carbohydrate estimated intake in 24 hours (percent/day)—defined as the approximate
energy intake in one day from carbohydrate intake
Carbohydrate estimated intake from oral nutrition in 24 hours (g/day)—defined as the estimated
intake of carbohydrate in grams in one day derived from oral intake
Carbohydrate estimated intake from enteral nutrition in 24 hours (g/day)—defined as the estimated
intake of carbohydrate in grams in one day derived from enteral nutrition infusion
Carbohydrate estimated intake from parenteral nutrition in 24 hours (g/day)—defined as the
estimated intake of carbohydrate in grams in one day derived from parenteral nutrition infusion
Carbohydrate estimated intake from intravenous fluids in 24 hours (g/day)—defined as the
estimated intake of carbohydrate in grams in one day derived from intravenous (IV) infusion
Carbohydrate additive estimated intake in 24 hours (g/day)—defined as the approximate intake in
one day of carbohydrate additive
Estimated daily glycemic index value (number)—defined as the estimated measure in one day
reflecting the consumption of all carbohydrate
Estimated daily glycemic load (number)—defined as the estimated measure in one day reflecting
the quantity and type of all carbohydrate consumed
Insulin to carbohydrate ratio (ratio)—defined as the estimated number of grams of carbohydrate
covered by one unit of rapid-acting (or short-acting) insulin
Measured carbohydrate intake
Total carbohydrate measured intake in 24 hours (g/day)—defined as the known quantity of intake in
one day of total carbohydrate
Complex carbohydrate measured intake in 24 hours (g/day)– defined as the known quantity of
intake in one day of a polysaccharide that is comprised of three or more sugars; also called starch
Simple carbohydrate measured intake in 24 hours (g/day)—defined as the known quantity of intake
in one day of mono- and disaccharides
Galactose measured intake in 24 hours (g/day)—defined as the known quantity of intake in one day
of a monosaccharide which is a common component of lactose
Lactose measured intake in 24 hours (g/day)—defined as the known quantity of intake in one day of
a disaccharide sugar of galactose and glucose; present in milk
Fructose measured intake in 24 hours (g/day)—defined as the known quantity of intake in one day
of a monosaccharide sugar found in fruit and honey
Carbohydrate measured intake per kg in 24 hours (g/kg/day)—defined as the known quantity of
intake per kg of body weight in one day of all carbohydrate
Carbohydrate measured intake in one meal (g/meal)—defined as the known quantity of intake in
one meal of all types of carbohydrate
Percent carbohydrate measured intake in 24 hours (percent/day)—defined as the known quantity of
energy intake in one day from carbohydrate intake
Carbohydrate measured intake from oral nutrition in 24 hours (g/day)—defined as the known
quantity of intake of carbohydrate in grams in one day derived from oral intake
Carbohydrate measured intake from enteral nutrition (g/day)—defined as the known quantity of
intake of carbohydrate in grams in one day derived from enteral nutrition infusion
Carbohydrate measured intake from parenteral nutrition (g/day)—defined as the known quantity of
intake of carbohydrate in grams in one day derived from parenteral nutrition infusion
Carbohydrate measured intake from intravenous fluids (g/day)—defined as the known quantity of
intake of carbohydrate in grams in one day derived from intravenous (IV) infusion
Carbohydrate additive measured intake in 24 hours (g/day)—defined as the known quantity of
intake in one day of carbohydrate additive
Note: Fiber intake can be found on the Fiber Intake reference sheet.
Psyllium and beta glucan can be found on the Bioactive Substance Intake reference sheet.
records, 24-hour or typical day’s recalls, food frequency questionnaires, qualitative intake assessment,
menu analysis, carbohydrate counting tools, intake/output sheets (for tube feeding or parenteral nutrition)
diagnoses: Inadequate and excessive carbohydrate intake, intake of types of carbohydrate inconsistent
with needs, inconsistent carbohydrate intake, altered nutrition related laboratory values, food medication
interaction
Client Example
Indicator Selected
Total carbohydrate estimated intake in 24 hours (g/day)
Comparison to Reference Standard, Recommendation, or Goal}:

2. Recommendation: Client’s total carbohydrate estimated intake in 24 hours averages 295 g/day.
3. Goal: Client’s goal intake is 225 g/day.
Based on 3-day diet records, client’s total carbohydrate estimated intake in 24

Initial encounter
hours averages 295 g/day, above the client’s goal of 225 g/day.
Good progress made toward goal. Client’s total carbohydrate estimated intake
in 24 hours averages 245 g/day. Will monitor carbohydrate intake at next
intervention
encounter.
References
1. Academy of Nutrition and Dietetics. Evidence Analysis Library: Diabetes type 1 and 2.
2. Academy of Nutrition and Dietetics. Evidence Analysis Library: Diabetes prevention.
4. American Diabetes Association. Standards of Medical Care in Diabetes.
http://care.diabetesjournals.org/content/42/Supplement_1. Accessed February 4, 2019.
5. Flood A, Subar AF, Hull SG, Zimmerman TP, Jenkins DJ, Schatzkin A. Methodology for adding
glycemic load values to the National Cancer Institute Diet History Questionnaire database. J Am
Diet Assoc. 2006;106(3):393-402.
2002.
7. Lin CS, Kimokoti RW, Brown LS, Kaye EA, Nunn ME, Millen BE. Methodology for adding
glycemic index to the National Health and Nutrition Examination Survey nutrient database. J
Acad Nutr Diet. 2012;112(11):1843-1851.
4, 2019. Academy of Nutrition and Dietetics. Diabetes Prevention. Evidence Analysis Library:
9. Lin C, Kimokoti RW, Brown LS, Kaye EA, Nunn ME, Millen BE. Methodology for adding
glycemic index to the National Health and Nutrition Examination Survey nutrient database. J
Acad Nutr Diet. 2012;112(11):1843-1851.

Fiber Intake (FH-1.5.6)

Definition
Amount and/or type of plant source matter consumed that is not completely digested but may be at least
partially fermented in the distal bowel and is derived from all sources, including food, beverages,
supplements, and via enteral routes
Indicators
Estimated fiber intake
Total fiber estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of
total fiber
Soluble fiber estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of
soluble fiber
Insoluble fiber estimated intake in 24 hours (g/day)—defined as the approximate intake in one day
of insoluble fiber
Fiber estimated intake from oral intake in 24 hours (g/day)—defined as the approximate intake of
fiber in grams in one day derived from oral intake
Fiber estimated intake from enteral nutrition in 24 hours (g/day)—defined as the approximate
intake of fiber in grams in one day derived from enteral nutrition infusion
Fiber additive estimated intake in 24 hours (g or mL/day)—defined as the approximate intake in
one day of fiber additive

Measured fiber intake
Total fiber measured intake in 24 hours (g/day)—defined as the known quantity of intake in one
day of total fiber
Soluble fiber measured intake in 24 hours (g/day)—defined as the known quantity of intake in one
day of soluble fiber
Insoluble fiber measured intake in 24 hours (g/day)—defined as the known quantity of intake in one
day of insoluble fiber
Fiber measured intake from oral nutrition in 24 hours (g/day)—defined as the known quantity of
intake of fiber in grams in one day derived from oral intake
Fiber measured intake from enteral nutrition (g/day)—defined as the known quantity of intake of
fiber in grams in one day derived from enteral nutrition infusion
Fiber additive measured intake in 24 hours (g or mL/day)—defined as the known quantity of intake
in one day of fiber additive
Note: Psyllium and beta glucan can be found on the Bioactive Substance Intake reference sheet
records, 24-hour recalls, food frequency questionnaires, qualitative intake assessment, menu analysis, fiber
counting tools, nutrition fact labels, other product information, nutrient composition tables
diagnoses: Inadequate and excessive fiber intake, altered GI function, disordered eating pattern,
inadequate bioactive substance intake
Client Example
Indicator Selected
Total fiber estimated intake in 24 hours (g/day)
1. Reference Standard: Client’s total fiber estimated intake in 24 hours averages15 g/day, which is
below the Dietary Reference Intake of 25 g/day for a 40-year-old woman.
3. Goal: Client’s goal is to increase fiber intake to approximately 25 g/day.
Based on food diary, client’s total fiber estimated intake in 24 hours averages
Initial encounter
15 g/day. Will monitor fiber intake at next encounter in three weeks.
Goal achieved. Client’s total fiber estimated intake in 24 hours averages 27
Reassessment after
g/day, which meets the goal intake of 25 g/day. Will continue to monitor to
ensure that success is sustained.
References

2. Dahl WJ, Stewart ML. Position of the Academy of Nutrition and Dietetics: health implications of
dietary fiber. J Acad Nutr Diet. 2015;115(11):1861-1870.
Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2002.
18, 2017.
6. Research Council. Nutrient Reference Values for Australia and New Zealand.
https://www.health.govt.nz/publication/nutrient-reference-values-australia-and-new-zealand.
Food/Nutrition-Related History – Micronutrient Intake

Vitamin Intake (FH-1.6.1)

Definition
Vitamin intake from all sources including food, beverages, supplements, and via enteral and parenteral
routes
Indicators
Estimated vitamin intake

Vitamin A estimated intake in 24 hours (µg/day)—defined as the approximate intake in one day of
vitamin A
Vitamin C estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day of
vitamin C
Vitamin D estimated intake in 24 hours (µg/day)—defined as the approximate intake in one day of
vitamin D;
Vitamin E estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day of
vitamin E;
Vitamin K estimated intake in 24 hours (µg/day)—defined as the approximate intake in one day of
vitamin K;
Thiamin estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day of
thiamin
Riboflavin estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day of
riboflavin
Niacin estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day of
niacin
Folate estimated intake in 24 hours (µg/day)—defined as the approximate intake in one day of
folate
Vitamin B6 estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day
of vitamin B6
Vitamin B12 estimated intake in 24 hours (µg/day)—defined as the approximate intake in one day
of vitamin B12
Pantothenic acid estimated intake in 24 hours (mg/day)—defined as the approximate intake in one
day of pantothenic acid
Biotin estimated intake in 24 hours (µg/day)—defined as the approximate intake in one day of
biotin
Multivitamin estimated intake in 24 hours (yes/no)—defined as the approximate intake in one day
of a multivitamin

Measured vitamin intake
Vitamin A measured intake in 24 hours (µg/day)—defined as the known quantity of intake in one
day of vitamin A
Vitamin C measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one
day of vitamin C
Vitamin D measured intake in 24 hours (µg/day)—defined as the known quantity of intake in one
day of vitamin D;
Vitamin E measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one
day of vitamin E;
Vitamin K measured intake in 24 hours (µg/day)—defined as the known quantity of intake in one
day of vitamin K;
Thiamin measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one day
of thiamin
Riboflavin measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one
day of riboflavin
Niacin measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one day
of niacin
Folate measured intake in 24 hours (µg/day)—defined as the known quantity of intake in one day of
folate
Vitamin B6 measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one
day of vitamin B6
Vitamin B12 measured intake in 24 hours (µg/day)—defined as the known quantity of intake in one
day of vitamin B12
Pantothenic acid measured intake in 24 hours (mg/day)—defined as the known quantity of intake
in one day of pantothenic acid
Biotin measured intake in 24 hours (µg/day)—defined as the known quantity of intake in one day of
biotin
Multivitamin measured intake in 24 hours (yes/no)—defined as the known quantity of intake in one
day of a multivitamin
Note: Laboratory measures associated with body vitamin status can be found on the Vitamin
Profile reference sheet.
Examples of the measurement methods or data sources for these outcome indicators: Client report or
recalls, food frequency, qualitative intake assessment, home evaluation, supplement use questionnaire
diagnoses: Excessive or inadequate intake of vitamins, parenteral, or enteral nutrition
Client Example
Example of one or two of the Nutrition Care Indicators (includes sample initial and reassessment
Vitamin D estimated intake in 24 hours (µg/day)
1. Reference Standard: Client’s Vitamin D estimated intake in 24 hours is 4 µg/day (160 IU), which
is below the estimated average requirement (EAR) of 10 µg (400 IU) and the RDA of 15 µg (600
IU) for a 15-year-old male.
3. Goal: Client established a goal to resume vitamin D supplement 4 out of 7 days per week.
Initial nutrition Based on recalls, client with cystic fibrosis has Vitamin D estimated intake in 24
assessment hours of 4 µg/day, which is below the Estimated Average Requirement of 10 µg (400
IU) and the RDA of 15 ug (600 IU) per day for Vitamin D for a 15-year old male.
Client has also discontinued fat-soluble vitamin supplement, but has established a goal
to take supplement 4 out of 7 days per week. Will monitor Vitamin D intake at next
encounter and intake of fat-soluble vitamin supplement and request 25 Hydroxy,
vitamin D level (Vitamin Profile reference sheet).
25 Hydroxy, vitamin D level below expected range (from Vitamin Profile). Progress
toward the EAR of 10 µg (400 IU) and RDA of 15 ug (600 IU). Based on diet record,
Reassessment after client’s Vitamin D estimated intake in 24 hours from food sources is 5-7 µg/day (200-
nutrition 280 IU), and client is taking fat-soluble vitamin supplement 5 days per week on
intervention average. Despite progress, because client has cystic fibrosis, client will need to
continue fat-soluble vitamin supplementation in addition to food sources. Repeat lab
in 3 months.
References

17, 2017.
new-zealand. Accessed December 17, 2017.
recommendation/nordic-nutrition-recommendations-2012. Updated 2012. Accessed December 17,
2017.
6. Institute of Medicine. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin
D, and Fluoride. Washington, DC: National Academies Press; 1997.
7. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC:
8. Institute of Medicine. Dietary Reference Intakes: Thiamin, Riboflavin, Niacin, Vitamin B6,
Folate, Vitamin B12, Pantothenic acid, Biotin,and Choline. Washington, DC: National Academies
Press; 1998.
9. Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron,
Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc.
Washington, DC: National Academies Press; 2001.
10. Institute of Medicine. Dietary Reference Intakes: Vitamin C, Vitamin E, Selenium, and
Carotenoids. Washington, DC: National Academies Press; 2000.
11. Marra MV, Boyer AP. Position of the American Dietetic Association; Nutrient supplementation. J
Am Diet Assoc. 2009; 109(12):2073-2085.
Food/Nutrition-Related History – Micronutrient Intake

Mineral/Element Intake (FH-1.6.2)

Definition
Mineral/element intake from all sources including food, beverages, supplements, and via enteral and
parenteral routes
(Institute of Medicine. Dietary Reference Intakes: Applications in Dietary Assessment.Washington,
Indicators
Estimated mineral intake

Calcium estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day of
calcium
Chloride estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day of
calcium
Iron estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day of iron
Magnesium estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day
of magnesium
Potassium estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of
potassium
Phosphorus estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day of
phosphorus
Sodium estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of
sodium
Zinc estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day of zinc
Sulfate estimated intake in 24 hours (g/day)—defined as the approximate intake in one day of
sulfate
Fluoride estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day of
fluoride
Copper estimated intake in 24 hours (µg/day)—defined as the approximate intake in one day of
copper
Iodine estimated intake in 24 hours (µg/day)—defined as the approximate intake in one day of
iodine
Selenium estimated intake in 24 hours (µg/day)—defined as the approximate intake in one day of
selenium
Manganese estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day of
manganese
Chromium estimated intake in 24 hours (µg/day)—defined as the approximate intake in one day of
chromium
Molybdenum estimated intake in 24 hours (µg/day)—defined as the approximate intake in one day
of molybdenum
Boron estimated intake in 24 hours (mg/day)—defined as the approximate intake in one day of
boron
Cobalt estimated intake in 24 hours (µg/day)—defined as the approximate intake in one day of
cobalt
Multimineral estimated intake in 24 hours (yes/no)—defined as the approximate intake in one day
of a multimineral
Multitrace element estimated intake in 24 hours (yes/no)—defined as the approximate intake in one
day of a multitrace element
Measured mineral intake
Calcium measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one day
of calcium
Chloride measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one
day of calcium
Iron measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one day of
iron
Magnesium measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one
day of magnesium
Potassium measured intake in 24 hours (g/day)—defined as the known quantity of intake in one day
of potassium
Phosphorus measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one
day of phosphorus
Sodium measured intake in 24 hours (g/day)—defined as the known quantity of intake in one day of
sodium
Zinc measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one day of
zinc
Sulfate measured intake in 24 hours (g/day)—defined as the known quantity of intake in one day of
sulfate
Fluoride measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one day
of fluoride
Copper measured intake in 24 hours (µg/day)—defined as the known quantity of intake in one day
of copper
Iodine measured intake in 24 hours (µg/day)—defined as the known quantity of intake in one day of
iodine
Selenium measured intake in 24 hours (µg/day)—defined as the known quantity of intake in one
day of selenium
Manganese measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one
day of manganese
Chromium measured intake in 24 hours (µg/day)—defined as the known quantity of intake in one
day of chromium
Molybdenum measured intake in 24 hours (µg/day)—defined as the known quantity of intake in
one day of molybdenum
Boron measured intake in 24 hours (mg/day)—defined as the known quantity of intake in one day
of boron
Cobalt measured intake in 24 hours (µg/day)—defined as the known quantity of intake in one day
of cobalt
Multimineral measured intake in 24 hours (yes/no)—defined as the known quantity of intake in one
day of a multimineral
Multitrace element measured intake in 24 hours (yes/no)—defined as the known quantity of intake
in one day of a multitrace element
Examples of the measurement methods or data sources for these outcome indicators: Client report or
recalls, food frequency, qualitative intake assessment, home evaluation, home care or pharmacy report,
supplement use questionnaire
diagnoses: Excessive or inadequate intake of minerals, food medication interaction, altered nutrition
related laboratory values, impaired nutrient utilization, undesirable food choices, limited adherence to
nutrition related recommendations
Client Example
Indicator Selected
Calcium estimated intake in 24 hours (mg/day)
1. Reference Standard: The client’s calcium estimated intake in 24 hours averages 500 mg/day,
which is 50% of the recommended dietary allowance for women 31 to 50 years of age.
2. Recommendation:Not applicable
3. Goal: Client’s goal is to increase calcium intake via food to 1,000 mg/day.
Based on recalls, client’s calcium estimated intake in 24 hours is 500

Initial nutrition assessment mg/day, which is below the RDA for women 31 to 50 years of age. Client’s
with client goal is to increase intake of calcium to 1,000 mg/day via calcium-rich foods.
Will monitor calcium intake at next encounter.
Reassessment after nutrition Significant progress toward RDA. Based on diet record, client’s calcium
intervention estimated intake in 24 hours is 750 mg/day, 75% of the RDA.
References
1. Academy of Nutrition and Dietetics. Nutrition Care

Manual.https://www.nutritioncaremanual.org/index.cfm. Accessed Accessed February 27, 2020.
https://www.nutritioncaremanual.org/. Accessed February 26, 2020
canada/services/food-nutrition/healthy-eating/dietary-reference-intakes.html. Accessed March 2,
2020.
Accessed March 2, 2020.
new-zealand. Accessed March 2, 2020.
recommendation/nordic-nutrition-recommendations-2012. Published 2012. Accessed March 2,
2020.
Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, Zinc.
10. Institute of Medicine. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and
Sulfate, Washington DC: National Academies Press; 2004.
12. Marra MV, Boyar AP. Position of the American Dietetic Association; Nutrient supplementation. J
Am Diet Assoc. 2009; 109(12):2073-2085.
13. National Academies of Science Engineering Medicine. Dietary Reference Intakes for Sodium and
Potassium. Washington, DC: National Academies Press; 2019
13, 2020.
Food/Nutrition-Related History –Food and Nutrient Administration

Diet Order (FH-2.1.1)

Definition
A general or modified diet prescribed and documented in a client medical record by a credentialed provider
as part of a medical treatment plan
Nutrition Assessment
Indicators
General healthful diet order
Modified diet order (eg, type, amount of energy and/or nutrients/day, distribution, texture)
Enteral nutrition order (eg, formula, rate/schedule, access)
Parenteral nutrition order (eg, solution, access, rate)
Examples of the measurement methods or data sources for these outcome indicators: Medical record,
referring health care provider or agency, client history
diagnoses: Inadequate or excessive energy, macronutrient or micronutrient intake, inadequate or excessive
oral intake, swallowing difficulty
Client Example
Example of one (or more) of the Nutrition Care Indicators (includes sample initial assessment
Modified diet order
comparison-to-reference-standard-rec-goal:
1. Reference Standard: No validated standard exists.

2. Recommendation: Customized to client.
3. Goal: Not applicable.
Initial encounter Client prescribed a 2,400 calorie or kcal (11,000 kJ) diet.

References
1. Academy of Nutrition and Dietetics. CMS rules on therapeutic diet orders.

https://www.eatrightpro.org/advocacy/licensure/therapeutic-diet-orders. Accessed February 20,
2019.
4. Andersen D, Baird S, Bates T, et al. Academy of Nutrition and Dietetics: Revised 2017 Scope of
Practice for the Nutrition and Dietetics Technician, Registered. J Acad Nutr Diet.118(2):327-342.
5. Andersen D, Baird S, Bates T, et al. Academy of Nutrition and Dietetics: Revised 2017 Scope of
Practice for the Registered Dietitian Nutritionist. J Acad Nutr Diet.118(1):141-165.
Food/Nutrition-Related History – Food and Nutrient Administration

Diet Experience (FH-2.1.2)

Definition
Previous nutrition/diet orders, diet education/counseling, and diet characteristics that influence
patient/client’s dietary intake
Indicators
Previously prescribed diets
 Previous modified diet (specify, e.g., type, amount of energy and/or nutrients/day, distribution,
texture)
 Enteral nutrition order (specify)
 Parenteral nutrition order (specify)
Previous diet/nutrition education/counseling (specify, e.g., type, year)

Self-selected diets followed (specify, e.g., commercial diets, diet books, culturally directed)
Dieting attempts
 Number of past diet attempts (number)

 Results (specify, e.g., successful/unsuccessful, pounds or kg lost)
 Successful strategies (specify, e.g., no snacking, self-monitoring)
Food allergies
 Previous modified diet (specify, e.g., type and/or foods/food group) followed as a result of
diagnosed or reported food allergy
Food intolerance
 Previous modified diet (specify, e.g., type and/or foods/food group) followed as a result of
diagnosed or reported food intolerance
Examples of the measurement methods or data sources for these outcome indicators: Patient/client
report, medical record, patient/client history, food and nutrition delivery coordination of care
counseling
diagnoses: Disordered eating pattern, not ready for diet/lifestyle change, excessive oral intake, food- and
nutrition-related knowledge deficit, unsupported beliefs/attitudes about food- or nutrition-related topics,
undesirable food choices, swallowing difficulty, intake of unsafe food
Evaluation

OR
Client Example
Example(s) of one or two of the Nutrition Care Indicators (includes sample initial assessment
Previous diet/nutrition education/counseling
1. Goal: Not generally used

OR
2. Reference Standard: No validated standard exists
Initial nutrition assessment

Patient/client completed a 6-week diabetic education class two years ago.
with client
References
1. Hager M. Hospital therapeutic diet orders and the Centers for Medicare & Medicaid Services:
steering through regulations to provide quality nutrition care and avoid survey citations. J Am Diet
Assoc. 2006; 106 (2):198-204.
4. Hager M. Therapeutic diet order writing: current issues and considerations. Topic Clin Nutr.
2007;22:28-36.


Eating Environment (FH-2.1.3)

Definition
The aggregate of surrounding things, conditions, or influences that affect food intake
Nutrition-Assessment-and-Monitoring-and-Evaluation
Indicators
Location (specify, e.g., home, school, day care, restaurant, nursing home, senior center)
Atmosphere
 Acceptable noise level (yes/no)

 Appropriate lighting (yes/no)
 Appropriate room temperature (yes/no)
 Appropriate table height (yes/no)
 Appropriate table service (e.g., plates, napkins)/meal service (type of service, e.g., table service,
buffet)/set-up (make food accessible for consumption) (yes/no)
 Eats at designated eating location (does not wander) (yes/no)
 Eats without distractions (e.g., watching TV/reading) (yes/no)
 No unpleasant odors (yes/no)
Caregiver/companion
 Allowed to select foods (often, sometimes, never)

 Caregiver influences/controls what client eats (e.g., encourages, forces) (yes/no)
 Caregiver models expected eating behavior (yes/no)
 Caretaker presence (present/not present)
 Favorite food is offered or withheld to influence behavior (reward/punishment) (yes/no)
 Has companionship while eating (another or others present) (yes/no)
 Meal/snacks offered at consistent times (“grazing” discouraged) (yes/no)
Appropriate breastfeeding accommodations/facility (yes/no)

Eats alone (specify reason, frequency)
report, medical record, referring health care provider or agency, observation
diagnoses: Inadequate oral intake, self-feeding difficulty, poor nutrition quality of life, limited access to
food
Evaluation

OR
Client Example
Eats at designated eating location
1. Goal: Two-year-old child with inadequate intake of calories/kcal/kJ and/or nutrients. Goal is to
improve intake through modifications in feeding environment and meal pattern.
OR
Caregiver completed 3-day food record indicating multiple (10) feeding opportunities
Initial nutrition throughout the day. Child consumes mostly juice, dry cereal, and chips. Prefers foods
assessment with that can be consumed from bottle or finger foods. Child does not sit at the table to eat,
client but wanders the house and is allowed to request and receive snacks ad lib. Energy and
nutrient intake is less than 75% of standard. Referral to behavioral specialist offered.
Caregiver completed follow-up 3-day food record indicating reduced number of
Reassessment after feeding opportunities throughout the day (6 to 7). States child resisted at first, but now
nutrition eats at table at regular meal/snack times. Caregiver is continuing to work with
intervention behavioral specialist for both mealtime and other behavior issues. Energy and nutrient
intake have improved to 85 to 90% of standard.
References
1. Spruijt-Metz D, Lindquist CH, Birch LL, Fisher JO, Goran MI. Relation between mothers’ child-
feeding practices and children’s adiposity. Am J Clin Nutr. 2002;75:581-586.
2. Boutelle KN, Birnbaum AS, Lytle LA, Murray DM, Story M. Associations between perceived
family meal environment and parent intake of fruit, vegetables and fat. J Nutr Educ Behav.
2003;35:24-29.
3. Birch LL, Fisher JO. Development of eating behaviors among children and
adolescents. Pediatrics. 1998;101:539-549.
4. O’Dea JA. Why do kids eat healthful food? Perceived benefits of and barriers to healthful eating
and physical activity among children and adolescents. J Am Diet Assoc. 2003;103(4):497-501.
5. Birch LL, Fisher JO. Mothers’ child-feeding practices influence daughters’ eating and
weight. Am J Clin Nutr. 2000; 71:1054-1061.
6. Birch LL. Development of food preferences. Annu Rev Nutr. 1999;19:41-62.
7. Campbell K, Crawford, D. Family food environments as determinants of preschool-aged
children’s eating behaviours: implications for obesity prevention policy. Aust J Nutr Diet.
2005;58:19-25.
8. Hurtsi UK. Factors influencing children’s food choice. Ann Med. 1999;31(Suppl 1):26-32.
9. Birch LL, Fisher JO, Davison KK. Learning to overeat: maternal use of restrictive feeding
practices promotes girls’ eating in the absence of hunger. 2003. Am J Clin Nutr. 78:215-220.
10. Wansink B, Cheney MM. Super bowls: serving bowl size and food consumption. JAMA.
2005;293:1727-1728.
11. Wansink B. Environmental factors that increase the food intake and consumption volume of
unknowing consumers. Annu Rev Nutr. 2004;24:455-479.
12. Rozin P, Kabnick K, Pete E, Fischler C, Shields C. The ecology of eating: smaller portion sizes in
France than in the United States help explain the French paradox. Psychol Sci. 2003;14:450-
454.
13. Rozin P. The meaning of food in our lives: a cross-cultural perspective on eating and well-
being. J Nutr Educ Behav. 2005;37(suppl): 107-112.
14. Birch LL, Davison KK. Family environmental factors influencing the developing behavioral
controls of food intake and childhood over weight. Pediatr Clin North Am. 2001;48(4):893-907.
15. Hetherington MM. Cues to overeat: psychological factors influencing overconsumption. Proc
Nutr Soc. 2007;66(1):113-23.

Enteral and Parenteral Nutrition Administration (FH-2.1.4)

Definition
Delivery of enteral and/or parenteral nutrition.
Indicators
Enteral access, specify, e.g., nasoentric, oroenteric, percutaneous, or surgical access with gastric,
duodenal or jejunal placement
Parenteral access, specify, e.g., peripheral, central, and/or type of catheter
Body position, enteral nutrition (EN), specify, e.g., degree angle
report/recalls, patient/client record, patient/client nutrition-focused physical exam, provider referral
diagnoses: Inadequate or excessive enteral or parenteral nutrition infusion, inadequate fluid intake,
predicted food–medication interaction
Evaluation

OR
Client Example
Enteral access (nasocentric)
1. Goal: Patient/client’s enteral nutrition is delivered via nasoenteric feeding tube which will remain
patent so patient/client can receive feeding to meet estimated nutrition requirements.
OR
2. Reference Standard: There is no reference standard for this outcome.
Patient/client’s enteral nutrition is delivered via nasoenteric feeding tube

Initial nutrition assessment which will remain patent so patient/client can receive feeding to meet
with client estimated nutrition requirements. Monitor enteral nutrition feeding access
for patency.
Reassessment after nutrition Enteral nutrition via nasoenteric feeding tube is blocked requiring
intervention replacement of feeding tube.
References
1. Academy of Nutrition and Dietetics. Critical illness evidence-based nutrition guideline, 2012.
http://andevidencelibrary.com/topic.cfm?cat=4800.. Accessed June 17, 2015.
pediatric patients: administration of specialized nutrition support—issues unique to pediatrics. J
Parenter Enteral Nutr. 2002;26(Suppl):S97-S110.
pediatric patients: access for administration of nutrition support. J Parenter Enteral
Nutr. 2002;26(1 Suppl):33SA-41SA.
4. Kovacevich DS, Frederick A, Kelly D, Nishikawa R, Young L, American Society for Parenteral
and Enteral Nutrition Board of Directors Standards for Specialized Nutrition Support Task Force.
Standards for specialized nutrition support: home care patients. Nutr Clin Pract. 2005;20:579-590.
6. McMahon MM, Nystrom E, Braunschweig C, Miles J, Compher C, American Society for
Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. clinical guidelines:
nutrition support of adult patients with hyperglycemia. J Parenter Enteral Nutr. 2013;37:23-36.
7. Arsenault D, Brenn M, Kim S, Gura K, Compher C, Simpser E, American Society for Parenteral
and Enteral Nutrition Board of Directors, Puder M. A.S.P.E.N. clinical guidelines: hyperglycemia
and hypoglycemia in the neonate receiving parenteral nutrition. J Parenter Enteral Nutr.
2012;36:81-95.

Fasting (FH-2.1.5)
Definition
Absence of nutrient administration from all sources.
Indicators
Fasting pattern in one calendar day, reported--defined as the timing within one calendar day when
the patient/client does not take in or infuse nutrients (e.g., overnight fast, fast between meals)
Fasting pattern in one calendar week, reported --defined as the timing within one calendar week
when the patient/client does not take in or infuse nutrients (e.g., Friday evening)
Fasting pattern in one calendar month, reported--defined as the timing within one calendar month
when the patient/client does not take in or infuse nutrients (e.g., every Sabbath)
Fasting pattern in one calendar year, reported --defined as the timing within one calendar year when
the patient/client does not take in or infuse nutrients (e.g., Lent, Passover, Ramadan, occasional
fasting)
Fasting tolerance, reported—defined as the length of time a patient/client can endure a lack of
nutrient intake or nutrient infusion without physiological consequence (specify in hours)
report, medical record, patient/client history, food and nutrition delivery coordination of care
counseling
diagnoses: Inadequate oral intake, inadequate carbohydrate intake, food- and nutrition-related knowledge
deficit, unsupported beliefs/attitudes about food- or nutrition-related topics
Evaluation

OR
Client Example
Fasting tolerance, reported
1. Goal：Limit or avoid fasting longer than five hours because longer periods result in physiological
consequence
OR
2. Reference Standard：No validated standard exists
The patient/client's (with an inborn error of metabolism) reported fasting

Initial nutrition assessment tolerance is approximately five hours at which time, the patient/client must
with client take in nutrients to avoid hypoglycemia. Goal established to fast no longer
than four hours, seven of seven nights per week.
Reassessment after nutrition Meeting goal. Patient/client limiting fasts to no longer than four hours on
intervention seven of seven nights per week.
References
1. Genetic Metabolic Dietitians International. Nutrition guidelines.

http://www.gmdi.org/Resources/Clinical-Practice-Tools/Nutrition-Guidelines. Accessed June 16,
2015.
Food/Nutrition-Related History – Medication and Complementary/Alternative Medicine Use

Medications (FH-3.1)
Definition
Prescription and over-the-counter (OTC) medications that may impact nutritional status
Indicators
Prescription medication use
 Current prescriptions with nutrient/food–medication interactions, specify

 Insulin or insulin secretagogues, specify
o Insulin sensitivity factor (mg/dL)—defined as the estimated reduction in
blood glucose in mg/dL per unit of rapid-acting (or short-acting) insulin, al
referred to as the correction insulin
 Medication, alter blood pressure, specify
 Medication, alter breastmilk production, specify
 Medication, lipid lowering, specify
 Medications, alter glucose levels, specify
 Other, specify
Over-the-counter (OTC) medications use
 Current OTC products with nutrient/food-medication implications, specify

 Medication, alter blood pressure, specify
 Medication, alter breastmilk production, specify
 Medication, lipid lowering, specify
 Medications, alter glucose levels, specify
 Other, specify
Misuse of medications (e.g., accidental overdose, illegal drugs, laxatives, diuretics, drug use
during pregnancy), specify

Note: Vitamin and mineral supplements can be found on the vitamin and mineral intake reference sheets.
Alcohol is found on the Alcohol Intake reference sheet
report, medical record, referring health care provider or agency
diagnoses: Food–medication interaction, increased energy expenditure, malnutrition (undernutrition),
inadequate or excessive energy, oral, fluid, carbohydrate, protein, fat, vitamin and mineral intake,
unintended weight gain or loss, overweight/obesity, underweight, disordered eating pattern
Evaluation

OR
Client Example
Prescription medication with nutrient/food–medication interactions—Prednisone
1. Goal：Patient/client with prescription for 50 mg/d prednisone and concerned about concurrent
weight gain caused by increased appetite and fluid retention. Goal is to minimize weight gain and
maintain good nutritional status during prednisone therapy.
OR
2. Reference Standard：Not applicable
Patient/client’s prescription medication is 50 mg/d prednisone for rheumatoid

arthritis. Current weight 182 lb (83 kg). Long-term therapy may result in a need
Initial nutrition
for protein, calcium, potassium, phosphorus, folate and vitamin A, C, and D
assessment with client
supplementation. Patient/client currently taking a vitamin/mineral supplement
and concerned about weight gain caused by increased appetite and fluid retention.
Patient/client’s prescription medication prednisone dose reduced to 25 mg/d.
Reassessment after
Currently taking a one-a-day multivitamin/multimineral and snacking on raw
vegetables between meals. Weight stable.
References
2. Position of the American Dietetic Association: Integration of medical nutrition therapy and
pharmacotherapy. J Am Diet Assoc. 2010;110:950-956.
3. Pronksy ZM. Food–Medication Interactions. 16th ed. Birchrunville, PA: Food–Medication
Interactions; 2010.
5. American Diabetes Association. Standards of Medical Care in Diabetes (Position Statement)–
2015. Diabetes Care. 2015;38:S1-S94.
Food/Nutrition-Related History – Medication and Complementary/Alternative Medicine Use

Complementary/Alternative Medicine (FH-3.2)

Definition
Complementary and alternative medicine products, including herbal preparations that may impact
nutritional status
Indicators
Nutrition-related complementary/alternative medicine use (e.g., gingko, St. John’s Wart, elderberry,
garlic, ephedra, probiotics)
Note: Vitamin and mineral supplements can be found on the vitamin and mineral intake reference
sheets. Alcohol is found on the Alcohol Intake reference sheet
report, medical record, referring health care provider or agency
diagnoses: Food–medication interaction, increased energy expenditure, malnutrition (undernutrition),
unintended weight gain or loss, overweight/obesity, intake of unsafe foods, disordered eating pattern
Evaluation

OR
Client Example
Complementary/alternative medicine use—ephedra
1. Goal：Patient/client taking ephedra with the hope that it will promote weight loss. Goal is to have
patient/client eliminate ephedra for safety reasons and engage in nutrition counseling for weight
management
OR
2. Reference Standard：Not applicable
Initial nutrition assessment Patient/client complementary/alternative medicine use of ephedra is for

with client weight loss. Patient/client reports being unaware of safety concerns.
Reassessment after nutrition Patient/client complementary/alternative medicine use of ephedra has stopped
intervention and success with weight loss as a result of nutrition counseling.
References
2. Pronksy ZM. Food–Medication Interactions. 16th ed. Birchrunville, PA: Food–Medication
Interactions; 2010.
4. Pediatric Weight Management Evidence Based Nutrition Practice Guideline, Adjunct Therapies.
Academy of Nutrition and Dietetics Evidence Analysis Library.
http://www.andevidencelibrary.com/topic.cfm?cat=2724. Accessed June 17, 2015.
5. National Institutes of Health and the National Center for Complementary and Alternative
Medicine. http://nccam.nih.gov/. Accessed June 17, 2015.
Food/Nutrition-Related History – Knowledge/Beliefs/Attitudes

Food and Nutrition Knowledge (FH-4.1)

Definition
Level of understanding about food, nutrition, and health or nutrition related information and guidelines
relevant to client needs
Indicators
Nutrition knowledge of community (no knowledge, minimal knowledge, basic knowledge, intermediate
knowledge, advanced knowledge)—defined as the assessed level of knowledge of a community,
subpopulation, or population
Nutrition knowledge of supportive individuals (eg, family, caregivers) (no knowledge, minimal
knowledge, basic knowledge, intermediate knowledge, advanced knowledge)—defined as the assessed
level of knowledge of those who give or support care
Nutrition knowledge of individual client (no knowledge, minimal knowledge, basic knowledge,
intermediate knowledge, advanced knowledge)—defined as the assessed level of knowledge of an
individual client
Examples of the measurement methods or data sources for these indicators: Pre- and/or posttests
administered orally, on paper, or by computer, scenario discussions, client restates key information, review
of food records, practical demonstration/test, survey, nutrition quotient, nutrition questionnaire, nutrition
assessment inventory
counseling, population based nutrition action
diagnoses: Food and nutrition related knowledge deficit, limited adherence to nutrition related
recommendations, undesirable food choices, breastfeeding difficulty, overweight/obesity, intake domain
nutrition diagnoses.
Client Example
Nutrition knowledge of individual client

1. Recommendation: Not applicable.
2. Goal: Client established a goal to learn how to accuratel read a food label and identify the total
number of grams of carbohydrate per serving of food.

References
standards for the outcome; other references may be appropriate .
1. Academy of Nutrition and Dietetics. Evidence Analysis Library: Effectiveness of Nutrition

Intervention Methods. https://www.andeal.org/topic.cfm?
cat=4756&evidence_summary_id=251212&highlight=breastfeeding&home=1. Updated 2010.
2. Snetselaar LG. Nutrition Counseling Skills for Medical Nutrition Therapy. 2nd ed. Gaithersburg,
MD: Aspen Press; 2007.
3. Kessler H, Wunderlich SM. Relationship between use of food labels and nutrition knowledge of
people with diabetes. Diabetes Educ. 1999;25(4):549-559
4. Chapman-Novakofski K, Karduck J. Improvement in knowledge, social cognitive theory
variables, and movement through stages of change after a community-based diabetes education
program. J Am Diet Assoc. 2005;105(10):1613-1616.

Food and Nutrition Skill (FH-4.2)
Definition
Level of food, nutrition, and health or nutrition-related skills relevant to client needs
Indicators
Nutrition skill of community (no skill, minimal skill, basic skill, intermediate skill, advanced skill)—
defined as the assessed level of skill of a community, subpopulation, or population
Nutrition skill of supportive individuals (eg, family, caregivers) (no skill, minimal skill, basic skill,
intermediate skill, advanced skill)—defined as the assessed level of skill of family and those who give or
support care
Nutrition skill of individual client (no skill, minimal skill, basic skill, intermediate skill, advanced skill)—
defined as the assessed level of skill of an individual client

Examples of the measurement methods or data sources for these outcome indicators: Pre- and/or
post-tests administered orally, on paper, or by computer, scenario discussions, client restates key
information, review of food records, practical demonstration, survey, nutrition questionnaire, nutrition
assessment inventory
Typically used to determine and monitor and evaluate change in the following domains of nutrition
interventions: : Nutrition education, nutrition counseling, population based nutrition action
diagnoses: : Food and nutrition related knowledge deficit, limited adherence to nutrition related
recommendations, self-feeding difficulty, breastfeeding difficulty, intake domain nutrition diagnoses.
Client Example
Nutrition skill of individual client
1. Reference Standard: Not applicable.

3. Goal: Individual client established a goal to learn to guide baby's lips and mouth for a successful
latch.
Individual client with newborn infant and no nutrition skill related to

Intitial nutrition assessmentbreastfeeding. Individual client established a goal to guide baby's lips and
mouth for a sucessful latch.
individual client with basic skill guiding baby's lips and mouth for
successful latch. Able to demonstrate successful latch 3 out of 5 times. Will
intervention
continue to monitor at next encounter.
References
1. 1. Academy of Nutrition and Dietetics. Evidence Analysis Library: Effectiveness of Nutrition

Intervention Methods. https://www.andeal.org/topic.cfm?
cat=4756&evidence_summary_id=251212&highlight=breastfeeding&home=1. Updated 2010.
2. 2. Academy of Nutrition and Dietetics. Nutrition Care Manual.
3. 3. Academy of Nutrition and Dietetics. Pediatric Nutrition Care Manual.

Beliefs and Attitudes (FH-4.3)

Definition
Acceptance of the truth about (belief) or way of thinking or feeling about (attitude) food- or nutrition-
related phenomenon or behavior, which influences food or nutrition-related behavior
Indicators
Nutrition priority of individual client (present/absent)—defined as the individual client’s beliefs and
attitudes about food and nutrition that are believed to be of prime concern
Nutrition priority of client’s supportive individuals (present/absent)—defined as the client’s
supportive individuals (eg, family, caregiver) beliefs and attitudes about food and nutrition that are
believed to be of prime concern
Nutrition priority of client’s supportive structures (present/absent)—defined as the client’s
supportive structures’ (eg, social service agencies and faith-based organizations) beliefs and
attitudes about food and nutrition that are believed to be of prime concern
Nutrition priority of client’s stakeholders (present/absent)—defined as the client’s stakeholders’
(eg, constituencies with impact on client nutrition) beliefs and attitudes about food and nutrition
that are believed to be of prime concern
Conflict with individual client’s value system (present/absent)—defined as the individual client’s
beliefs and attitudes that are incongruent with the client’s values
Conflict with client’s supportive individuals’ value system (present/absent)—defined as the client’s
beliefs and attitudes that are incongruent with the values of the client’s supportive individuals (eg,
family and caregivers)
Conflict with client supportive structures’ value system (present/absent)—defined as the client’s
beliefs and attitudes that are incongruent with the values of the client’s supportive structures (eg,
social service agencies and faith based organizations)
Conflict with stakeholders’ value system (present/absent)—defined as the client’s beliefs and
attitudes that are incongruent with the values of stakeholders (eg, constituencies with impact on
client nutrition)
Behavioral beliefs—defined as factors (motivation, control, norms, readiness) that influence the
client’s food- and nutrition-related behaviors
 Perceived susceptibility to nutrition related health problems score ( self-rated, 1=very low to 10 =
very high perceived susceptibility)—defined as a client’s belief that they have a health condition or
are at high-risk for developing a health condition
 Perceived severity of risk to health score (self-rated, 1=very low to 7= very high perceived
severity of risk )—defined as a client’s belief about the severity of their risk of a health condition
 Perceived benefit of nutrition related change score (self-rated, 1=very low to 7=very high
perceived benefit)—defined as the acceptance that the rewards are worth the sacrifice and effort
 Likelihood of performing nutrition related behavior score (self- rated, 1 = unlikely to perform
behavior to 7 = very likely to perform behavior)—defined as the probability of the client
performing the behavior(s)
 Perceived control over nutrition related behavior score (self-rated, 1=very low to 7=very high
perceived control)—defined as the client’s belief in their power to change nutrition related
behavior(s)
 Nutrition self efficacy score (self-rated, 1=very low confidence to 7 = very high confidence in
ability)—defined as the client’s confidence in their ability to change nutrition related behavior(s)
 Perceived barrier to nutrition related behavior score (self-rated, 1=very low to 7=very high
perceived barriers)—defined as the client’s belief about barriers to adopting nutrition related
behaviors
Readiness to change nutrition related behavior stage
 Precontemplation stage for readiness to change (present/absent)

 Contemplation stage for readiness to change (present/absent)
 Preparation stage for readiness to change (present/absent)
 Action stage for readiness to change (present/absent)
 Maintenance stage for readiness to change (present/absent)
 Relapse stage for readiness to change (present/absent)
Readiness to change nutrition related behavior score (self-rated on scale of 1 to 10; 1 = not ready to
10 = fully ready to change)—defined as a client assessment of their preparedness to change
nutrition related behaviors
Negative emotions about food and nutrition (present/absent)—defined as negative feelings about
food and/or nutrition
Positive emotions about food and nutrition (present/absent)—defined as positive feelings about
food and/or nutrition
Unrealistic nutrition related goals (present/absent)—defined as client food and/or nutrition
expectations that are may not be achievable
Unscientific nutrition beliefs/attitudes (present/absent)—defined as client acceptance of the truth
about food and/or nutrition that is incongruent with scientific evidence
Body image disturbance (present/absent)—defined as client’s distressing or impairing
preoccupation with defects in their body that are not apparent to others
Preoccupation with food (present absent)—defined as thoughts about food that dominate the
client’s thinking
Preoccupation with weight (present/absent)—defined as thoughts about body weight that dominate
the client’s thinking
Preoccupation with body shape (present/absent)—defined as thoughts about body shape that
dominate the client’s thinking
Negative nutrition self talk (present/absent)—defined as negative thoughts about oneself related to
food and nutrition
Positive nutrition self talk (present/absent)—defined as positive thoughts about oneself related to
food and nutrition
Preference for food (yes/no)—defined as a liking of specific food stuffs consumed
Preferences for beverages (yes/no)—defined as a liking of specific liquids consumed
Examples of the measurement methods or data sources for these outcome indicators: Client self-
report, client assessment questionnaire or interview, medical record, referring health care provider or
agency, survey data
Typically used to monitor and evaluate change in the following domains of nutrition
interventions: Food and/or nutrient delivery, nutrition education, nutrition counseling, population based
nutrition action
Unsupported beliefs/attitudes about food- or nutrition-related topics; not ready for diet/lifestyle change;
inability to manage self-care; self-monitoring deficit, excessive or inadequate oral, energy, macronutrient,
micronutrient or bioactive substance intake; imbalance of nutrients; intake of types of fats inconsistent
with needs; intake of types of proteins inconsistent with needs; intake of types of carbohydrate inconsistent
with needs; inadequate/excessive fiber intake; undesirable food choices; underweight; overweight/obesity;
disordered eating pattern; physical inactivity; excess physical activity; limited access to food or water
Client Example
Readiness to change nutrition related behavior stage

3. Goal: Client is currently in the precontemplation stage of change. Client goal is to move to the
preparation stage of change within 3 months
Assessment results indicate client is currently in the precontemplation stage of

Initial nutrition
change related to need for nutrition changes. Will initiate motivational
assessment
interviewing and reassess in two weeks.
Significant progress toward goal. Reassessment indicates that client has moved
Reassessment after
from the precontemplation stage to the contemplation stage related to need for
nutrition changes. Will reassess in two weeks.
References
1. Academy of Nutrition and Dietetics. Evidence Analysis Library. Academy of Nutrition and
Dietetics. https://www.andeal.org/?auth=1. Accessed February 13, 2020.
2. Bandura A. Human agency in social cognitive theory. Am Psychol. 1989;44(9):1175-1184.
3. Case Western Reserve University. Readiness Ruler.
https://www.centerforebp.case.edu/resources/tools/readiness-ruler. Accessed February 28, 2020.
4. de Jersey SJ, Mallan KM, Callaway LK, Daniels LA, Nicholson JM. Prospective relationships
between health cognitions and excess gestational weight gain in a cohort of healthy and overweight
pregnant women. J Acad Nutr Diet. 2017;117(8):1198-1209.
5. Evers C, De Ridder DT, Adriaanse MA. Assessing yourself as an emotional eater: mission
impossible? Health Psychol. 2009;28:717-725.
6. Harrison A, Sullivan S, Tchanturia K, Treasure J. Emotional functioning in eating disorders:
attentional bias, emotion recognition and emotion regulation. Psychol Med. 2010;1:1-11.
7. Health Belief Model. https://www.sciencedirect.com/topics/medicine-and-dentistry/health-
belief-model. Accessed February 28, 2020.
8. Keith JF, Stastny S, Brunt A, Agnew W. Barriers and Strategies for Healthy Food Choices
among American Indian Tribal College Students: A Qualitative Analysis. J Acad Nutr Diet.
2018;118(6):1017-1026.
9. McDermott MS, Oliver M, Simnadis T, et al. The Theory of Planned Behaviour and dietary
patterns: A systematic review and meta-analysis. Prev Med. 2015;81:150-156.
10. McQueen A, Vernon SW, Rothman AJ, Norman GJ, Myers RE, Tilley BC. Examining the role
of perceived susceptibility on colorectal cancer screening intention and behavior. Ann Behav Med.
2010;40(2):205-217.
11. National Institutes of Health Division of Cancer Control & Population Sciences. Perceived
severity. https://cancercontrol.cancer.gov/brp/research/constructs/perceived_severity.html.
12. Nolan LJ, Halperin LB, Geliebter A. Emotional appetite questionnaire: construct validity and
relationship with BMI. Appetite 2010;54: 314-319.
13. Ohri-Vachaspati P, Dachenhaus E, Gruner J, Mollner K, Hekler EB, Todd M. Fresh Fruit and
Vegetable Program and Requests for Fruits and Vegetables Outside School Settings. J Acad Nutr
Diet. 2018;118(8):1408-1416.
14. Otten JJ, Hirsch T, Lim C. Factors Influencing the Food Purchases of Early Care and
Education Providers. J Acad Nutr Diet. 2017;117(5):725-734.
15. Prochaska JO, DiClemente CC. Transtheoretical therapy: Toward a more integrative model of
change. Psychotherapy: Theory, Research & Practice. 1982;19(3):276-288.
16. Raynor HA, Champagne CM. Position of the Academy of Nutrition and Dietetics:
Interventions for the Treatment of Overweight and Obesity in Adults. J Acad Nutr Diet.
2016;116(1):129-147.
17. Thompson JK, Stice E. Thin-ideal internalization: Mounting evidence for a new risk factor for
body-image disturbance and eating pathology. Curr Dir Psychol Sci. 2001;10(5):181-183.
18. Tylka TL, Kroon Van Diest AM. The Intuitive Eating Scale-2: item refinement and
psychometric evaluation with college women and men. J Couns Psychol. 2013;60(1):137-153.
19. Van Strien T, Frijters JE, Bergers GP, Defares PB. The Dutch Eating Behavior Questionnaire
(DEBQ) for assessment of restrained, emotional, and external eating behavior. Int J Eat Disord.
1986;5(2):295-315.
20. van Strien T, Oosterveld P. The children's DEBQ for assessment of restrained, emotional, and
external eating in 7- to 12-year-old children. Int J Eat Disord. 2008;41(1):72-81.
Food/Nutrition-Related History – Behavior

Adherence (FH-5.1)
Definition
Level of congruence with nutrition-related recommendations or behavioral changes agreed upon by client
to achieve nutrition-related goals

Indicators
Self reported nutrition adherence score (self rated on scale of 1 to 10; 1 = not adherent to 10 =
completely adherent)—defined as a client assessment of their congruence to agreed upon nutrition
related goals
Nutrition encounter ratio (ratio) —defined as the ratio of actual nutrition encounters to the total
planned nutrition encounters
Ability to recall nutrition goals (very able to recall goals, somewhat able to recall goals, unable to
recall goals)—defined as the degree to which a client can describe previously agreed upon nutrition
objectives
Nutrition self monitoring at agreed upon rate (self rated on scale of 1 to 10; 1 = not adherent to 10 =
completely adherent)—defined as a client assessment of their congruence to agreed upon nutrition
related self monitoring
Nutrition self management as agreed upon (self rated on scale of 1 to 10; 1 = not adherent to 10 =
completely adherent) —defined as a client assessment of their congruence with agreed upon
nutrition related self management
Note: Use in conjunction with appropriate Food and Nutrition Intake, Anthropometric Data, and
Biochemical Data reference sheets.
May be useful in relapse prevention treatment (analyze and control factors that caused the lapse).
Examples of the measurement methods or data sources for these outcome indicators: Nutrition
encounter attendance, self-monitoring records (eg, food record to evaluate fat, sodium, calories/kcal/kJ,
diet quality, binge-eating), client self-report, adherence tools or questionnaires, provider assessment, self
efficacy assessment, readiness to change assessment
nutrition education, nutrition counseling, population based nutrition action
diagnoses: Limited adherence to nutrition-related recommendations, self monitoring deficity, not ready for
diet/lifestyle change
Client Example
Self reported nutrition adherence score (self rated on scale of 1 to 10)
Comparison to Reference Standard, Recommendations, or Goal

2. Recommendations: Not applicable
3. Goal: Client rates self 4/10 (1 = not adherent to 10 = completely adherent) on ability to adhere to
meal plan.
Client rates self 4/10 on ability to adhere to meal plan developed in collaboration
with dietitian. Discussions with client regarding barrier(s) to achieving goals and
Initial encounter
strategies to improve adherence. Goal set to adhere to meal plan 5 days per week.
Client will evaluate progress toward goal at the next encounter and rate adherence.
Some progress toward goal. Client rated self 6/10 on ability to adhere to meal plan 5
Reassessment after days per week. Is doing well on weekdays, but verbalizes need to improve on
nutrition intervention weekends. Discussed strategies to improve adherence to meal plan on the weekends.
Client will monitor progress and adherence at next encounter.
References
1. Asaad G, Sadegian M, Lau R, et al. The Reliability and Validity of the Perceived Dietary
Adherence Questionnaire for People with Type 2 Diabetes. Nutrients. 2015;7(7):5484-5496.
2. Bosworth H, Weinberger M, Oddone EZ. Patient Treatment Adherence: Concepts, Interventions,
and Measurement. Mahwah, NJ: Psychology Press; 2005.
3. Crowley MJ, Grubber JM, Olsen MK, Bosworth HB. Factors associated with non-adherence to
three hypertension self-management behaviors: preliminary data for a new instrument. J Gen
Intern Med. 2013;28(1):99-106.
4. DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW. Patient adherence and medical treatment
outcomes: a meta-analysis. Med Care. 2002;40(9):794-811.
5. Haynes RB. Improving patient adherence: State of the art, with a special focus on medication
taking for cardiovascular disorders. In: Burke LE, Ockene IS, eds. Compliance in Healthcare and
Research. Armonk, NY: Futura Publishing Company; 2001.
6. Jones CD, Holmes GM, DeWalt DA, et al. Self-reported recall and daily diary-recorded measures
of weight monitoring adherence: associations with heart failure-related hospitalization. BMC
Cardiovasc Disord. 2014;14(1):12.
7. Khalil AA, Darawad MW. Objectively measured and self-reported nonadherence among
Jordanian patients receiving hemodialysis. Hemodialysis international International Symposium
on Home Hemodialysis. 2014;18(1):95-103.
8. Lambert K, Mullan J, Mansfield K. An integrative review of the methodology and findings
regarding dietary adherence in end stage kidney disease. BMC Nephrol. 2017;18(1):318.
9. Milas NC, Nowalk MP, Akpele L, et al. Factors associated with adherence to the dietary protein
intervention in the Modification of Diet in Renal Disease Study. J Am Diet Assoc.
1995;95(11):1295-1300.
10. Raj GD, Hashemi Z, Soria Contreras DC, et al. Adherence to diabetes dietary guidelines assessed
using a validated questionnaire predicts glucose control in adults with type 2 diabetes. Canadian
journal of diabetes. 2018;42(1):78-87.
11. Rushe H, McGee HM. Assessing adherence to dietary recommendations for hemodialysis
patients: the Renal Adherence Attitudes Questionnaire (RAAQ) and the Renal Adherence
Behaviour Questionnaire (RABQ). J Psychosom Res. 1998;45(2):149-157.
12. Sharma S, Murphy SP, Wilkens LR, et al. Adherence to the food guide pyramid recommendations
among Japanese Americans, Native Hawaiians, and whites: results from the multiethnic cohort
study. J Am Diet Assoc. 2003;103(9):1195-1198.
13. Song EK, Moser DK, Kang SM, Lennie TA. Self-reported adherence to a low-sodium diet and
health outcomes in patients with heart failure. J Cardiovasc Nurs. 2016;31(6):529-534.
14. Thomson JL, Landry AS, Zoellner JM, et al. Participant adherence indicators predict changes in
blood pressure, anthropometric measures, and self-reported physical activity in a lifestyle
intervention: HUB city steps. Health education & behavior : the official publication of the Society
for Public Health Education. 2015;42(1):84-91.
15. Tinker LF, Perri MG, Patterson RE, et al. The effects of physical and emotional status on
adherence to a low-fat dietary pattern in the Women's Health Initiative. J Am Diet Assoc.
2002;102(6):789-800, 888.
16. Villa L, Sun D, Denhaerynck K, et al. Predicting blood pressure outcomes using single-item
physician-administered measures: a retrospective pooled analysis of observational studies in
Belgium. Br J Gen Pract. 2015;65(630):e9-e15.
17. Warren-Findlow J, Basalik DW, Dulin M, Tapp H, Kuhn L. Preliminary validation of the
Hypertension Self-Care Activity Level Effects (H-SCALE) and clinical blood pressure among
patients with hypertension. J Clin Hypertens (Greenwich). 2013;15(9):637-643.
18. Williamson DA, Anton SD, Han H, et al. Adherence is a multi-dimensional construct in the
POUNDS LOST trial. J Behav Med. 2010;33(1):35-46.

Avoidance Behavior (FH-5.2)

Definition
Keeping away from something or someone to postpone an outcome or perceived consequence
Indicators
Avoidance
 Specific foods (specify, e.g., grapefruit, seeds)

 Food groups (specify, e.g., milk/milk products)
 Fluids (specify)
 Textures (specify)
 Social situations (specify)
 Other (specify)
 Restrictive eating (yes/no)
Cause of avoidance behavior (e.g., personal choice, prescribed dietary restriction, GI distress,
suspected allergy, eating disorder, cancer treatment side effects, medications, mental illness,
Parkinson’s disease)
Examples of the measurement methods or data sources for these outcome indicators: Self-monitoring
records, patient/client interview
Typically used with the following domains of nutrition interventions: Nutrition counseling
diagnoses: Disordered eating pattern, overweight/obesity, underweight, altered GI function
Evaluation

OR
Client Example
Avoidance of social situations
1. Goal：Patient/client avoiding social situations in an effort to avoid overeating. Goal is to learn

strategies to control eating in social situations.
OR
2. Reference Standard：No validated standard exists

個 Patient/client avoids social situations because she is afraid she will overeat.
Reviewed client’s food diary and client brainstormed strategies which may help
Initial nutrition
her control eating in social situations. Patient/client will preplan food intake on
days she has social engagements, will have a piece of fruit before going to help
curb her appetite and will maintain a food diary.
Patient/client made some progress toward goal. Attended 2 of 4 social
Reassessment after engagements where food was served, and successfully controlled food intake both
nutrition intervention times. Patient/client will continue to use strategies. Will reevaluate avoidance
behavior at next encounter.

References
1. Susan H. Barriers to effective nutritional care for older adults. Nurs Stand [serial online].
2006;21:50-54.
2. Susan H. Nutrition matters for older adults. J Commun Nurs [serial online]. 2006;20:24,26,28-30.
3. Zutavern A, Brockow I, Schaaf B, Bolte G, von Berg A, Diez U, Borte M, Herbarth O, Wichmann
HE, Heinrich J, LISA Study Group. Timing of solid food introduction in relation to atopic
dermatitis and atopic sensitization: Results from a prospective birth cohort
study. Pediatrics [serial online]. 2006;117:401-411.
4. Ogden J, Karim L, Choudry A, Brown K. Understanding successful behaviour change: the role of
intentions, attitudes to the target and motivations and the example of diet. Health Educ Res[serial
online]. 2007;22:397-405.
5. Watson L, Leslie W, Hankey C. Under-nutrition in old age: diagnosis and management. Rev Clin
Gerontol [serial online]. 2006;16:23-34.
6. Brisbois TD, Hutton JL, Baracos VE, Wismer WV. Taste and smell abnormalities as an
independent cause of failure of food intake in patients with advanced cancer-an argument for the
application of sensory science. J Palliativ Care [serial online]. 2006;22:111-114.
7. Cassens D, Johnson E, Keelan S. Enhancing taste, texture, appearance, and presentation of pureed
food improved resident quality of life and weight status. Nutr Rev [serial online]. 1996;54:S51.
8. Reed PS, Zimmerman S, Sloane PD, Williams CS, Boustani M. Characteristics associated with
low food and fluid intake in long-term care residents with dementia. Gerontologist. [serial online].
2005;45:74-80.
9. Joo SH, Wood RA. The impact of childhood food allergy on quality of life. Pediatrics: Synopsis
Book: Best Articles Relevant to Pediatric Allergy [serial online]. 2003;112:459.
10. Fält B, Granérus A, Unosson M. Avoidance of solid food in weight losing older patients with
Parkinson’s disease. J Clin Nurs. 2006;15(11):1404-1412.
11. Nowak-Wegrzyn A, Sampson HA. Adverse reactions to foods. Med Clin N Am. January
2006;90(1):97-127.
12. Meyer C, Serpell L, Waller G, Murphy F, Treasure J, Leung N. Cognitive avoidance in the
strategic processing of ego threats among eating-disordered patients. Int J Eat Disord. July
2005;38(1):30-36.
13. Talley NJ. Irritable bowel syndrome. Gastroenterol Clin N Am. 2005;34(2):xi-xii,173-354.
14. Sverker A, Hensing G, Hallert C. Controlled by food—lived experiences of coeliac disease. J
Hum Nutr Diet. 2005;18(3):171-180.
15. Smith CM, Kagan SH. Prevention of systemic mycoses by reducing exposure to fungal pathogens
in hospitalized and ambulatory neutropenic patients. Oncol Nurs Forum. 2005;32(3):565-579.
16. Millson DS, Tepper SJ. Migraine treatment. Headache. J Head Face Pain. 2004;44(10):1059-61.
17. Brown AC, Hairfield M, Richards DG, McMillin DL, Mein EA, Nelson CD. Medical nutrition
therapy as a potential complementary treatment for psoriasis—five case reports. Alt Med Rev.
2004; 9(3):297-307.
18. Biddle J, Anderson J. Report on a 12-month trial of food exclusion methods in a primary care
setting. J Nutr Environ Med. 2002;12(1):11 17.

Bingeing and Purging Behavior (FH-5.3)
Definition
Eating a larger amount of food than normal for the individual during a short period of time (within any
two-hour period) accompanied by a lack of control over eating during the binge episode (i.e., the feeling
that one cannot stop eating). This may be followed by compensatory behavior to make up for the excessive
eating, referred to as purging.
Indicators
Binge eating behavior (present/absent)
 Number of binge episodes (e.g., number/day, number/week, number/month)
Purging behavior (present/absent)
 Self-induced vomiting (number/day, number/week, number/month)

 Fasting (yes/no)
 Other (specify)
Note: Misuse of laxatives, diuretics or other drugs is found on the Medication and
Complementary/Alternative Medicine reference sheets. Amount and type of physical activity is
found on the Physical Activity reference sheet.
interview, medical record, referring health care provider or agency, self-monitoring records
diagnoses: Excessive oral intake, disordered eating pattern, overweight/obesity
Evaluation

OR
Client Example
Number of binge episodes
1. Goal：Patient/client reports 3 binge eating episodes per week. Goal is to reduce binge eating to
one episode per week.
OR
2. Reference Standard：No validated standard exists.
Initial encounter with

Patient/client reports 3 binge-eating episodes this week.
patient/client
Reassessment after nutrition Some progress toward goal. Patient/client reported 2 binge eating episodes
intervention this week. Will continue to monitor at next encounter.
References
1. Fairburn CG, Wilson GT. Binge Eating:Nature, Assessment and Treatment. New York: Guilford
Press; 1993.
2. Snetselaar LG. Nutrition Counseling Skills for Medical Nutrition Therapy. 2nd ed. Gaithersburg,
MD: Aspen Press; 2007.
3. Kellogg M. Counseling Tips for Nutrition Therapists: Practice Workbook. Philadelphia, PA: Kg
Press; 2006.
4. Wonderlich SA, de Zwaan M, Mitchell JE, Peterson C, Crow S. Psychological and dietary
treatments of binge eating disorder: conceptual implications. Int J Eat Disord. 2003;34 Suppl:S58-
S73.
5. Telch CF, Agras WS, Linehan MM. Dialectical behavior therapy for binge eating disorder. J
Consult Clin Psychol. 2001;69(6):1061-1065.
6. Safer DL, Lively TJ, Telch CF, Agras WS. Predictors of relapse following successful dialectical
behavior therapy for binge eating disorder. Int J Eat Disord. 2002;32(2):155-163.
7. Devlin MJ, Goldfein JA, Petkova E, Liu L, Walsh BT. Cognitive behavioral therapy and
fluoxetine for binge eating disorder: two-year follow-up. Obesity. 2007;15(7):1702-1709.
8. Peterson CB, Mitchell JE, Engbloom S, Nugent S, Mussell MP, Miller JP. Group cognitive-
behavioral treatment of binge eating disorder: a comparison of therapist-led versus self-help
formats. Int J Eat Disord. 1998;24(2):125-136.
9. Gorin AA, Le Grange D, Stone AA. Effectiveness of spouse involvement in cognitive behavioral
therapy for binge eating disorder. Int J Eat Disord. 2003;33(4):421-433.
10. Ljotsson B, Lundin C, Mitsell K, Carlbring P, Ramklint M, Ghaderi A. Remote treatment of
bulimia nervosa and binge eating disorder: a randomized trial of Internet-assisted cognitive
behavioural therapy. Behav Res Ther. 2007;45(4):649-661. Epub 2006.
11. Celio AA, Wilfley DE, Crow SJ, Mitchell J, Walsh BT. A comparison of the binge eating scale,
questionnaire of eating and weight patterns-revised, and eating disorder examination with
instructions with the eating disorder examination in the assessment of binge eating disorder and its
symptoms. Int J Eat Disord. 2004;36:434-444.
12. Position of the American Dietetic Association. Nutrition intervention in the treatment of eating
disorders. J Am Diet Assoc. 2011;111:1236-1241.
13. Practice Paper of the Academy of Nutrition and Dietetics: Nutrition intervention in the treatment
of eating disorders. http://www.eatrightpro.org/resource/practice/position-and-practice-
papers/practice-papers/practice-paper-nutrition-intervention-in-the-treatment-of-eating-disorders.

Mealtime Behavior (FH-5.4)

Definition
Manner of acting, participating, or behaving at mealtime which influences patient/client’s food and
beverage intake
Indicators
Meal duration (minutes)

Percent of meal time spent eating (percent) Patient/client/caregiver fatigue during feeding process,
resulting in inadequate intake (yes/no)
Preference to drink rather than eat (yes/no)
Willingness to try new foods (yes/no)
Refusal to eat/chew (specify, e.g., meal, food type)
Limited number of accepted foods (specify)
Spitting food out (specify, e.g., food
type, frequency) Rigid sensory preferences (flavor, temperature, texture)
Rumination (yes/no)
Examples of the measurement methods or data sources for these outcome indicators: Observation,
medical record, referring health care provider or agency, caregiver observation, patient/client interview
coordination of nutrition care by nutrition professional
diagnoses: Self-feeding difficulty, inadequate and excessive oral intake
Evaluation

OR
Client Example
Percent of meal spent eating (percentage)
1. Goal:Four-year-old patient/client with inadequate food/beverage intake. Lunch meal observation

revealed less than 10% of mealtime was spent eating. Goal is to reduce environmental distractions
and increase percent of meal spent eating to 55%.
OR
Initial nutrition Lunch meal observation revealed that patient/client is highly distracted and
assessment with client spends less than 10% of the mealtime eating.
Reassessment after Significant progress toward goal. Environmental distractions were minimized and
nutrition intervention caregiver eats meals with patient/client. Observation reveals that approximately
40% of mealtime is spent eating. Will monitor at next encounter.
References
1. Powers SW, Patton SR, Byars KC, Mitchell MJ, Jelalian E, Mulvihill MM, Hovell MF, Stark LJ.
Caloric intake and eating behavior in infants and toddlers with cystic fibrosis. Diabetes Care.
2002;109(5):e75.
2. Wardle J, Guthrie CA, Sanderson S, Rapoport L. Development of the Children’s Eating Behaviour
Questionnaire. J Child Psychol Psychiat. 2001;42(7):963-970.
3. Chial HJ, Camilleri M, Williams DE, Litzinger K, Perrault J. Rumination Syndrome in children
and adolescents: diagnosis, treatment and prognosis. Pediatrics. 2003;111:158-162.
4. Fung EB, Samson-Fang L, Stallings VA, Conaway M, Liptak G, Henderson RC, Worley G,
O’Donnell M, Calvert B, Rosenbaum P, Chumlea W, Stevenson RD. Feeding dysfunction is
associated with poor growth and health status in children with cerebral palsy. J Am Diet Assoc.
2002;102:361-368,373.
5. Lucas B, Pechstein S, Ogata B. Nutrition concerns of children with autism spectrum
disorders. Nutr Focus. 2002;17:1-8.
6. Adams RA, Gordon C, Spangler AA. Maternal stress in caring for children with feeding
disabilities: implications for health care providers. J Am Diet Assoc. 1999;99:962-966.
7. Ramsay M, Gisel EG, Boutry M. Non-organic failure to thrive: growth failure secondary to
feeding-skills disorder. Develop Med Child Neurol. 1993;35:285-297.

Social Network (FH-5.5)

Definition
Ability to build and utilize a network of family, friends, colleagues, health professionals, and community
resources for encouragement, emotional support, and to enhance one’s environment to support behavior
change
Indicators
Ability to build and utilize social networks (e.g., may include perceived social support, social
integration, and assertiveness)
Examples of the measurement methods or data sources for these outcome indicators: Self-monitoring
records, client/patient self-report, goal-tracking tools
diagnoses: Intake domain nutrition diagnoses, underweight, overweight/obesity, disordered eating pattern,
undesirable food choices, inability to manage self-care, breastfeeding difficulty, not ready for diet/lifestyle
change, limited adherence to nutrition-related recommendations
Evaluation
OR
Client Example
Ability to build and utilize social support (e.g., may include perceived social support, social integration,
and assertiveness)
1. Goal：Overweight patient/client’s wife adds fat to all foods prepared at home. Goal is to reduce
the amount of fat in meals prepared at home by asking wife to not dress the salad or add fat
seasoning to vegetables before serving.
OR
Patient/client states that he rarely verbalizes his nutrition-related desires/needs in

Initial nutrition
family or social situations and rates his ability to elicit social support a 3 on a scale
of 1 to 10. Will evaluate at the next encounter.
Some progress toward goal. Patient/client rated himself a 5, on a scale of 1to10, on
Reassessment after his ability to elicit social support. Has begun to verbalize his needs and plans to
nutrition intervention research restaurants that meet his needs that others will enjoy. Will monitor at next
encounter in two weeks.
References
1. Barrera M, Toobert D, Angell K, Glasgow R, Mackinnon D. Social support and social-ecological

resources as mediators of lifestyle intervention effects for type 2 diabetes. J Health Psychol.
2006;11:483-495.
2. Sherbourne CD, Stewart AI. The MOS Social Support Survey. Social Sci Med. 1991;32:706-714.
3. Barrera M Jr, Glasgow RE, McKay HG, Boles SM, Feil E. Do internet-based support
interventions change perceptions of social support?: an experimental trial of approaches for
supporting diabetes self-management. Am J Comm Psychol. 2002; 30:637-654.
4. LaGreca AM, Bearman KJ. The diabetes social support questionnaire-family version: evaluating
adolescents’ diabetes-specific support from family members. J Pediatr Psychol. 2002;27:665-676.
5. Glasgow RE, Strycker LA, Toobert DJ, Eakin E. A social-ecologic approach to assessing support
for disease self-management: the Chronic Illness Resources Survey. J Behav Med. 2000;23:559-
583.
Food/Nutrition-Related History – Factors Affecting Access to Food and/or Food and Nutrition Related
Supplies

Food/Nutrition Program Participation (FH-6.1)

Definition
Patient/client eligibility for and participation in food assistance programs
Indicators
Eligibility for government programs (specify, e.g., qualification for federal programs [e.g., WIC,
Supplemental Nutrition Assistance Program [refer to state for title of program], school
breakfast/lunch program, food distribution program on U.S. Indian Reservations; state assistance
programs, such as emergency food assistance programs])
Participation in government programs (specify patient/client or family/caregiver influence)
Eligibility for community programs (specify, e.g., qualification for community programs such as
food pantries, meal sites, and meal delivery programs)
Participation in community programs (specify patient/client or family/caregiver influence)
report of eligibility/participation, referral information, home evaluation
counseling, coordination of nutrition care by nutrition professional
diagnoses: Limited access to food, inadequate or excessive energy intake
Evaluation

OR
Client Example
Participation in government programs
1. Goal：Patient/client is not participating in federal school lunch program as parent has not
completed required forms.
OR
The patient/client not participating in federal school lunch program as the

required forms are not complete. Will follow-up with family/guardian and
with client
monitor change in school lunch program participation at next appointment.
Reassessment after nutrition Progress toward goal as patient/client’s family/guardian has completed
intervention school lunch program forms.
References
1. Department of Health and Human Services (HHS) Poverty Guidelines, 2014.

http://aspe.hhs.gov/poverty/14poverty.cfm. Accessed June 17, 2015.
2. US Department of Agriculture and Health and Human Services. Dietary Guidelines for
Americans, 2010. http://www.cnpp.usda.gov/dietaryguidelines.htm. Accessed June 17, 2015.
3. Holben DH. Incorporation of food security learning activities into dietetics curricula. Top Clin
Nutr. 2005;20:339-350.
4. Holben DH, Myles W. Food insecurity in the United States: how it affects our patients. Am Fam
Physician. 2004;69;1058-1063.
5. Position of the American Dietetic Association on Food Insecurity in the United States. J Am Diet
Assoc. 2010;110:1368-1377.
6. US Department of Agriculture, Economic Research Service. Food security in the United States.
http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us.aspx /. Accessed
June 17, 2015.
Supplies
Safe Food/Meal Availability (FH-6.2)

Definition
Availability of enough healthful, safe food
Indicators
Availability of shopping facilities (specify, e.g., access to facilities with a wide variety of healthful
food choices)
Procurement of safe food (specify, e.g., financial resources for obtaining food, community gardens,
growing own food, hunting and fishing)
Appropriate meal preparation facilities (specify, e.g., access to cooking apparatus and supplies used
in
preparation, sanitary conditions and supplies for meal preparation, appropriate temperatures of
hot/cold food)
Availability of safe food storage (specify, e.g., refrigerator/freezer, dry storage, designated
containers)
Appropriate storage techniques (specify, e.g., appropriate refrigeration/freezer temperatures,
canning/
preservation, length of storage, sanitary conditions)
Identification of safe food (specify, e.g., identification of spoilage, expiration dates, identification of
foods containing poisons such as specific berries, mushrooms, etc.)

report overall food availability/food consumed during the week, referral information, home evaluation
diagnoses: Limited access to food, intake of unsafe food, inadequate or excessive energy intake
Evaluation

OR
Client Example
Availability of meal preparation facilities
1. Goal：Patient/client has no access to meal preparation facilities when extensive access to meal
preparation facilities is the goal.
OR
The patient/client has no access to meal preparation facilities. Will monitor

Initial nutrition
change in access at next appointment after coordination of nutrition care with
social work.
Reassessment after Substantial progress toward goal as patient/client has consistent access to meal
nutrition intervention preparation facility with repair of stove.
References
standard; other references may be appropriate.
1. US Department of Agriculture, Economic Research Service. Food security in the United States.
http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us.aspx /. Accessed
May 13, 2014.
http://aspe.hhs.gov/poverty/14poverty.cfm. Accessed May 13, 2014.
Americans, 2010. http://www.cnpp.usda.gov/dietaryguidelines.htm. Accessed May 13, 2014.
4. Granger LE, Holben DH. Self-identified food security knowledge and practices of family
physicians in Ohio. Top Clin Nutr. 2004;19:280-285.
5. Holben DH. Incorporation of food security learning activities into dietetics curricula. Top Clin
Nutr. 2005;20:339-350.
Physician. 2004;69;1058-1063.
7. Partnership for Food Safety Education. http://www.fightbac.org. Accessed May 13, 2014.
Assoc. 2010;110:1368-1377.
9. Position of the Academy of Nutrition and Dietetics: Nutrition security in developing nations:
Sustainable food, water, and health. J Acad Nutr Diet. 2013;113:581-595.
10. Tscholl E, Holben DH. Knowledge and practices of Ohio nurse practitioners and its relationship to
food access of patients. J Am Acad Nusr Pract. 2006;18:335-342.
11. US Environmental Protection Agency. Ground Water and Drinking Water Frequently Asked
Questions. http://water.epa.gov/drink/ Accessed May 13, 2014.. AccessedMay 13, 2014.
Supplies

Safe Water Availability (FH-6.3)

Definition
Availability of potable water
Indicators
Availability of potable water (specify, e.g., functioning well, access to treated public water supply)
Appropriate water decontamination (specify, e.g., awareness of and adherence with public health
warnings, use of strategies such as boiling, chemical, filtration treatment)
Examples of the measurement methods or data sources for these outcome indicators: Client report of
water availability and/or decontamination strategies, referral information, home evaluation
diagnoses: Inadequate fluid intake, intake of unsafe food
Client Example
Appropriate water decontamination

3. Goal: Client reports limited awareness and adherence to water decontamination recommendations.
The client has limited awareness and adherence to water decontamination

recommendations (e.g., community has a boil water alert for water used for
Initial nutrition assessment drinking and cooking). Education provided. Client establishes goal of
adherence to the decontamination guidelines for duration of alert. Will
monitor change in adherence.
Reassessment after nutrition Substantial progress toward goal as client is adhering to
intervention water decontamination guidelines.
References
1. Holben DH. Position of the American Dietetic Association: food insecurity in the United States. J
Am Diet Assoc. 2010;110(9):1368-1377.
2. Nordin SM, Boyle M, Kemmer TM. Position of the academy of nutrition and dietetics: nutrition
security in developing nations: sustainable food, water, and health. J Acad Nutr Diet.
2013;113(4):581-595.
3. US Environmental Protection Agency. Ground water and drinking water.
https://www.epa.gov/ground-water-and-drinking-water. Accessed February 12, 2018.
Supplies

Food/Nutrition Related Supplies Availability (FH-6.4)

Definition
Access to necessary food/nutrition-related supplies
Indicators
Access to food/nutrition-related supplies (specify, e.g., glucose monitor, monitoring strips, lancets,
pedometer, PN/EN supplies, thickeners, blood pressure-related devices)
Access to assistive eating devices (equipment or utensils), specify, e.g., modified utensils, plates,
bowls, gavage feeding supplies)
Access to assistive food preparation devices (specify, e.g., modified utensils for food preparation,
electric can openers, rocking knives, one-handed devices)
report, referral information, home evaluation
diagnoses: Inability to manage self-care, inadequate oral intake, self-feeding difficulty, limited adherence
to nutrition-related recommendations
Evaluation

OR
Client Example
Access to food/nutrition-related supplies
1. Goal：Patient/client has limited access to a sufficient quantity of glucose monitoring strips when
extensive access is the goal.
OR
The patient/client has limited access to a sufficient quantity of glucose

monitoring strips. Will monitor change in access to glucose monitoring
with client
strips at next appointment.
Reassessment after nutrition Some progress toward goal as patient/client has moderate access to a
intervention sufficient supply of glucose monitoring strips.
References

http://aspe.hhs.gov/poverty/14poverty.cfm. Accessed June 17, 2015.
Physician. 2004; 69; 1058-1063.
Assoc. 2010; 110: 1368-1377.
4. Position of the Academy of Nutrition and Dietetics: Nutrition security in developing nations:
Sustainable food, water, and health. J Acad Nutr Diet. 2013; 113: 581-595.
Food/Nutrition-Related History – Physical Activity and Function

Breastfeeding Assessment (FH-7.1)

Definition
Evaluation of breastfeeding ability and capacity to support the nutritional and other needs of the infant and
mother
Indicators
Initiation of breastfeeding
 Start breastfeeding (date)—defined as the day breastfeeding was initiated

 Stop breastfeeding (date)—defined as the day breastfeeding ceased
Breastfeeding approach
 Exclusive breastfeeding (yes/no)—defined as nourishment, all nutrients and fluid, provided
via breastfeeding for the first 6 months of life; permits oral vitamin and mineral
supplements and medicines
 Predominant breastfeeding (yes/no)—defined as nourishment primarily from breastmilk,
including expressed mother’s or donor breastmilk; permits infant formula and other liquids,
oral vitamin and mineral supplements and medicines
 Partial breastfeeding (yes/no)—defined as nourishment partially from breastmilk, including
expressed mother’s or donor breastmilk, with nourishment from infant formula and other
sources
Breastfeeding Difficulties
 Infant able to latch on to breast for feeding (yes/no)

 Infant unable to latch on to breast for feeding (yes/no)
 Difficulty latching on to breast for feeding (yes/no)
 Abscess of breast associated with lactation (yes/no)
 Cracked nipple associated with lactation (yes/no)
 Infection of nipple associated with lactation (yes/no)
 Non purulent mastitis associated with lactation (yes/no)
 Retracted nipple associated with lactation (yes/no)
 Inversion of nipple associated with lactation (yes/no)
 Breast engorgement associated with lactation (yes/no)
 Previous breast surgery associated with lactation (yes/no)
 Breast abnormality associated with lactation (yes/no)
 Inadequate flow of breastmilk (yes/no)
Finding related to infant’s ability to suck
 Infant able to suck (yes/no)

 Infant unable to suck (yes/no)
 Difficulty sucking (yes/no)
Note: Infant/child growth can be found on the Body Composition/Growth/Weight History reference

sheet.
Breastfeeding self-efficacy and intention to breastfeed can be found on the Beliefs and
Attitudes reference sheet.
*If a synonym for the term “breastmilk” is helpful or needed, an approved alternate is “human
milk.”
Examples of the measurement methods or data sources for these outcome indicators: Client report,
practitioner observation of breastfeeding, self-monitoring records, infant weight trends
counseling, coordination of nutrition care by nutrition professional, population based nutrition action
diagnoses: Breastfeeding difficulty, predicted breastfeeding difficulty, food and nutrition related
knowledge deficit, unsupported beliefs/attitudes about food or nutrition related topics, unintended weight
loss, inadequate fluid intake
Client Example
Exclusive breastfeeding (yes/no)
1. Reference Standard: Not applicable.

3. Goal: Client fears breastfeeding will be difficult upon return to work. Client goal is exclusive
breastfeeding until returning to work when client will add supplemental infant formula to
breastfeeding.
Postpartum client states goal of exclusive breastfeeding and then a

combination of formula and breastfeeding upon return to work. Will provide
Initial encounter nutrition education, promotion of exclusive breastfeeding and discussing
with employer accommodation for pumping breastmilk at work, and refer to
lactation support group.
Reassessment after nutrition Client reports exclusive breastfeeding for three months. Promotion of
intervention exclusive breastfeeding and nutrition education. Continue to monitor.
*If a synonym for the term “breastmilk” is helpful or needed, an approved alternate is “human milk.”
References
1. Alianmoghaddam N, Phibbs S, Benn C. Reasons for stopping exclusive breastfeeding between

three and six months: A qualitative study. J Pediatr Nurs. 2018;39:37-43.
2. Altuntas N, Turkyilmaz C, Yildiz H, et al. Validity and reliability of the infant breastfeeding
assessment tool, the mother baby assessment tool, and the LATCH scoring system. Breastfeed
Med. 2014;9(4):191-195.
3. Arslanoglu S, Corpeleijn W, Moro G, et al. Donor human milk for preterm infants: current
evidence and research directions. J Pediatr Gastroenterol Nutr. 2013;57(4):535-542.
4. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-841.
5. Carolina Global Breastfeeding Institute. https://sph.unc.edu/cgbi/publications/. Accessed February
18, 2019.
6. Ferreira H, Oliveira MF, Bernardo EBR, Almeida PC, Aquino PS, Pinheiro AKB. Factors
associated with adherence to the exclusive breastfeeding. Ciencia & saude coletiva.
2018;23(3):683-690.
7. Fewtrell M, Bronsky J, Campoy C, et al. Complementary feeding: A position paper by the
European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)
Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2017;64(1):119-132.
8. Kent JC, Hepworth AR, Sherriff JL, Cox DB, Mitoulas LR, Hartmann PE. Longitudinal changes
in breastfeeding patterns from 1 to 6 months of lactation. Breastfeed Med. 2013;8(4):401-407.
9. Kent JC, Mitoulas LR, Cregan MD, Ramsay DT, Doherty DA, Hartmann PE. Volume and
frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics.
2006;117(3):e387-395.
10. Labbok MH, Starling A. Definitions of breastfeeding: call for the development and use of
consistent definitions in research and peer-reviewed literature. Breastfeed Med. 2012;7(6):397-
402.
11. Lessen R, Kavanagh K. Position of the Academy of Nutrition and Dietetics: Promoting and
supporting breastfeeding. J Acad Nutr Diet. 2015;115(3):444-449.
12. World Health Organization. Indicators for assessing infant and young child feeding practices. Part
I: definition. https://www.who.int/maternal_child_adolescent/documents/9789241596664/en/.

Nutrition Related Activities of Daily Living and Instrumental

Activities of Daily Living (FH-7.2)
Definition
Level of cognitive and physical ability to perform nutrition-related activities of daily living and
instrumental activities of daily living by older and/or disabled persons
NNutrition Assessment and Monitoring and Evaluation
Indicators
Physical ability to complete tasks for meal preparation (plan meals, shop for meals, finances, meal
preparation) (yes/no)
Physical ability to self-feed (yes/no)
Ability to position self in relation to plate (within 12 to 18 inches (30-45 cm) from mouth to plate)
(yes/no)
Receives assistance with intake (yes/no)
Ability to use adaptive eating devices (those that have been deemed necessary and that improve
self-feeding skills) (yes/no)
Cognitive ability to complete tasks for meal preparation (planning meals, shopping for meals,
finances, meal preparation) (yes/no)
Remembers to eat (yes/no)
Recalls eating (yes/no)
Mini Mental State Examination Score (score)
Nutrition-related activities of daily living (ADL) score (score)
Nutrition-related instrumental activities of daily living (IADL) score (score)
Note:Sufficient intake of food can be found on the Food Intake reference sheet.
Sufficient intake of fluid can be found on the Fluid/Beverage Intake reference sheet.
Food security and ability to maintain sanitation can be found on the Safe Food/Meal Availability
reference sheet.
Ability to maintain weight can be found on the Body Composition/Growth/Weight History reference
sheet.
Examples of the measurement methods or data sources for these outcome indicators: Self-report,
caregiver report, home visit, targeted questionnaires and monitoring devices, ADL and/or IADL
measurement tool, congregate meal site attendance records
Typically used with the following domains of nutrition interventions: Coordination of nutrition care by
nutrition professional
diagnoses: Inability to manage self-care, impaired ability to prepare foods/meals
Evaluation

OR
Client Example
Nutrition-related instrumental activities of daily living (IADL) score
1. Goal：Patient/client with decreased food intake due to an inability to drive, no close relatives
living in the vicinity, and difficulty in performing meal preparation tasks due to weakness
OR
Patient/client with inadequate food intake due to inability to drive, no close relative
living in vicinity, subsequent weight loss and difficulties in performing ADLs and
Initial encounter with IADLs due to weakness. Patient/client is to use new strategies and community
patient/client resources to facilitate attendance at senior center congregate meals 5 times per
week, use of community-provided transportation offered to grocery store 1 x per
week, and attendance in strength training at senior center.
Significant progress in nutrition-related activities of daily living. Patient/client able
Reassessment after to attend senior center for meals and strength training 3 times this week. Goal is 5
nutrition intervention times. Will continue to assess at next encounter. Patient/client going to grocery
store 1 x per week.
References
1. Kretser A, Voss T, Kerr W, Cavadini C, Friedmann J. Effects of two models of nutritional

intervention on homebound older adults at nutritional risk. J Am Diet Assoc. 2003;103:329-336.
2. Sorbye LW, Schroll M, Finne Soveri H, Jonsson PV, Topinkova E, Ljunggren G, Bernabei R.
Unintended weight loss in the elderly living at home: the Aged in Home Care Project (AdHOC). J
Nutr Health Aging. 2008;12:10-16.
3. Folstein M, Folstein SE, McHugh PR. Mini-mental state: a practical method for grading the
cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-198.
4. Russell C. Dining Skills: Practical Interventions for Caregivers of Older Adults with Eating
Problems. Chicago, IL: Consultant Dietitians in Health Care Facilities, A Dietetic Practice Group
of the American Dietetic Association; 2001.

Physical Activity (FH-7.3)
Definition
Level of physical activity and/or amount of exercise performed
Indicators
Physical activity history (e.g., activities, preferences, attitudes)
Consistency (yes/no)
Frequency (number times/week)
Duration (number minutes/session, number of total minutes/day)
Intensity (e.g., talk test, Borg Rating of Perceived Exertion, % of predetermined max heart rate)
Type of physical activity (e.g., cardiovascular, muscular strength/endurance, flexibility; lifestyle,
programmed)
Strength (e.g., handgrip strength or other muscle strength measure)
Handgrip strength (Normal, Measurably Reduced) defined as a proxy measure of upper
extremity muscle function
TV/screen time (minutes/day)
Other sedentary activity time (e.g., commuting; sitting at desk, in meetings, at sporting or arts
events) (minutes/day)
Involuntary physical movement (present/absent)
Non exercise activity thermogensis (NEAT) (present/absent, level)
Examples of the measurement methods or data sources for these outcome indicators: History
interview/questionnaire, physical activity log, step counter, accelerometer, attendance at strength training,
balance training (for older adults), and/or aerobic classes, caretaker records, medical record, dynamometer
counseling
diagnoses: Physical inactivity, excessive exercise, underweight, overweight/obesity, unintended weight
loss or weight gain
Evaluation

OR
Client Example
Consistency and duration
1. Goal：Patient/client typically walks approximately 10 minutes, twice per week. Patient/client goal
is to walk approximately 15 minutes, 5 days per week.
OR
2. Reference Standard：Patient/client’s typical 10-minute walk, twice a week is well below the
recommended at least 30 minutes of moderate-intensity physical activity (in bouts 10 minutes or
longer), 5 days per week or at least 20 minutes of vigorous intensity physical activity (in bouts 10
minutes or longer), 3 days per week (ACSM/AHA Physical Activity Guidelines for Public Health
for adults and seniors)
Based on exercise log, patient/client doing moderate-intensity physical activities

Initial encounter with 30 minutes/day, 2 days/week. Goal is to do at least 30 minutes/day (in bouts 10
patient/client minutes or longer), moderate-intensity activities, 5 or more days/wk. Will
monitor physical activity level at next appointment.
Significant progress toward goal of exercising at 30 minutes/day, moderate-
Reassessment after
intensity activities, 5 or more days/wk. Patient/client reports doing moderate-
intensity activities 30 minutes per day, 4 days/week.
References
1. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, Macera CA, Heath GW,
Thompson PD, Bauman A. Physical activity and public health: updated recommendation for
adults from the American College of Sports Medicine and the American Heart Association. Med
Sci Sports Exer. 2007;39:8:1423-1434.
2. Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, Macera CA, Castaneda-
Sceppa C. Physical activity and public health in older adults: recommendation from the American
College of Sports Medicine and the American Heart Association. Med Sci Sports
Exer. 2007;39:8:1435-1445.
3. American College of Sports Medicine Position Stands. http://www.acsm.org/access-public-
information/position-stands. Accessed June 17, 2015.
4. Department of Health and Human Services, Centers for Disease Control and Prevention. Growing
Stronger–Strength Training for Older Adults.
http://www.cdc.gov/physicalactivity/growingstronger/index.html. Accessed June 17, 2015.
5. American College of Sports Medicine. Exercise and the older adult.
https://www.acsm.org/docs/current-comments/exerciseandtheolderadult.pdf. Accessed June 17,
2015.
6. Exercise Guidelines During Pregnancy. American Pregnancy Association.
http://www.americanpregnancy.org/pregnancyhealth/exerciseguidelines.html. Accessed June 17,
2015.
7. Fabricatore AN. Behavior therapy and cognitive-behavioral therapy of obesity: is there a
difference? J Am Diet Assoc. 2007:107:92-99.
8. American Society of Hand Therapists. Clinical Assessment Recommendations, 3rd Edition. 2013.
9. Aging In Motion Coalition Announces Establishment of ICD-10-CM Code for Sarcopenia by the
Centers for Disease Control and Prevention [press release]. Washington, DC: Aging in Motion
Coalition; 2016. http://aginginmotion.org/news/2388-2/. Accessed February 15, 2017.
10. Becker PJ, Nieman Carney L, Corkins MR, Monczka J, Smith E, Smith SE, Spear BA, White JV.
Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral
and Enteral Nutrition: Indicators recommended for identification and documentation of pediatric
malnutrition (undernutrition). J Acad Nutr Diet. 2014;114:1988-2000.
11. Bohannon, R. W., Bear-Lehman, J., Desrosiers, J., Massy-Westropp, N., & Mathiowetz, V.
(2007). Average grip strength: a meta-analysis of data obtained with a Jamar dynamometer from
individuals 75 years or more of age. Journal of Geriatric Physical Therapy (2001), 30(1), 28–30.
Retrieved from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?
dbfrom=pubmed&id=19839178&retmode=ref&cmd=prlinks
%5Cnpapers2://publication/uuid/1BFC0354-A179-431C-B0AF-46CE8F748F75. Accessed
February 15, 2017.

Factors Affecting Access to Physical Activity (FH-7.4)

Definition
Factors influencing access to physical activity opportunities and physical activity participation
Indicators
Neighborhood safety (the client’s perception of crime and traffic, presence of gangs, witness to
physical attacks, presence of community members walking or playing outside and feeling it is safe
to walk outside. Client rate on a scale of 1 to 10, 1=Unsafe, 10=Safe)
Walkability of neighborhood (the client’s perception on his/her ability to walk in a neighborhood
related to street connectivity, road type, dwelling density, and land use attributes (i.e., residential,
commercial, institutional or industrial land use). Client rate on a scale of 1 to 10, 1=Not walkable,
10=Very walkable)
Proximity to parks/green space (the client’s perception of the distance from the client's
home/workplace to the nearest park/green space. Client rate on a scale of 1 to 10, 1=Large distance
to nearest park/green space, 10=Small distance to nearest park/green space)
Access to physical activity facilities/programs (the client’s perception of the availability of physical
activity facilities/programs in the client’s environment. Client rate on a scale of 1 to 10, 1=No
availability of facilities/programs, 10=Excellent availability of facilities/programs)
Note: Physical disability, mobility and socioeconomic factors affecting physical activity can be
documented in the in Personal data (CH-1.1) and Social history (CH-3.1).
perception, neighborhood crime statistics, neighborhood traffic statistics, geographic information systems
data to map a neighborhood, availability of retail establishments within walking distance
counseling and coordination of care
diagnoses: overweight/obesity, physical inactivity, not ready for diet/lifestyle change
Client Example
Neighborhood safety
Comparison to Goal or Reference Standard, Recommendation, or Goal:
1. Reference Standard:Not applicable.

3. Goal: Client rated neighborhood as unsafe when increased physical activity is client’s goal.
Client perceives that the neighborhood is unsafe (rating of a 2) for an

individual to engage in outdoor exercise alone because of environmental
Initial encounter
factors (e.g. crime, traffic, gang presence, witness to physical attack) and has
limited ability to adhere to goal of increasing physical activity.
Client has joined a neighborhood outdoor exercise group and now rates
neighborhood safety as a 7 and has increasing adherence with regular
intervention
physical activity.
References
1. Academy of Nutrition and Dietetics. Evidence Analysis Library. Childhood obesity and the built
environment. https://www.andeal.org/topic.cfm?
cat=4558&evidence_summary_id=251313&highlight=environment&home=1. Accessed February
12, 2018.
Food/Nutrition-Related History – Nutrition Related Patient/Client Centered Measures

Nutrition Quality of Life (FH-8.1)

Definition
Extent to which the Nutrition Care Process impacts a patient/client’s physical, mental, and social well-
being related to food and nutrition
Indicators
Nutrition quality of life responses
Examples of the measurement methods or data sources for these outcome indicators: Nutrition
Quality of Life measurement tool, other quality of life tools
supplements, nutrition education, nutrition counseling, coordination of nutrition care by nutrition
professional
diagnoses:Poor nutrition quality of life, inadequate or excessive energy or macronutrient intake,
underweight, unintended weight loss, overweight/obesity, unintended weight gain, disordered eating
pattern, inability to manage self-care, swallowing difficulty, chewing difficulty, self-feeding difficulty,
altered GI function, limited access to food.
Evaluation

OR
Client Example
Nutrition quality of life score
1. Goal：Patient/client with chronic renal disease currently reports poor nutrition quality of life,
especially decreased walking ability (physical) and limited food choices on renal diet (food
impact). The goal of medical nutrition therapy is to educate and coach patient and his family on
options and strategies to significantly enhance his nutrition quality of life.
2. OR
Patient/client with chronic renal disease reports poor nutrition quality of life,
particularly in physical and food impact aspects. Patient/client to receive
Initial encounter with
intensive medical nutrition therapy with a goal to improve client’s overall
patient/clientx
nutrition quality of life over a 6-month period. Will monitor nutrition quality of
life in 6 months.
Some progress toward goal. Patient/client’s nutrition quality of life is increased,
Reassessment after
but further improvement is desired in the physical dimension. Will continue
medical nutrition therapy and reassess in 3 months.
References
1. Barr JT, Schumacher GE. The need for a nutrition-related quality-of-life measure. J Am Diet
Assoc. 2003;103:177–180.
2. Barr JT, Schumacher GE. Using focus groups to determine what constitutes quality of life in
clients receiving medical nutrition therapy: first steps in the development of a nutrition quality-of-
life survey. J Am Diet Assoc. 2003;103:844-851.
3. Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36), I: conceptual
framework and item selection. Med Care. 1992;30:473-483.
4. Moorehead M, Ardelt-Gattinger E, Lechner H, Oria H. The validation of the Moorehead-Ardelt
Quality of Life Questionnaire II. Obes Surg. 2003;13:684-692.
5. Groll D, Vanner S, Depew W, DaCosta L, Simon J, Groll A, Roblin N, Paterson W. The IBS-36: a
new quality of life measure for irritable bowel syndrome. Am J Gastroenterol. 2002;97:962-971.
6. Diabetes Control and Complications Trial Research Group. Reliability and validity of a diabetes
quality of life measure for the Diabetes Control and Complications Trial (DCCT). Diabetes Care.
1988;11:725-732.
7. Position of the American Dietetic Association. Individualized nutrition approaches for older adults
in health care communities. J Am Diet Assoc. 2010;110:1554-1563.
* This nutrition indicator is included to encourage further research.
Anthropometric Measures Domain - Anthropometric Data

Body Composition/Growth/Weight History (AD-1.1)

Definition
Measures of the body, including fat, muscle, and bone components and growth
Indicators
Height
Defined as measures of a body’s length, typically from head to foot.
 Measured height (in/cm). Defined as measured standing height.

 Measured length (in/cm). Defined as measured recumbent length
 Birth length (in/cm). Defined as measured recumbent length at birth.
 Pre-amputation measured height (in/cm). Defined as body height prior to removal of a limb
or part of a limb.
 Pre-amputation estimated height (in/cm). Defined as estimated body height prior to removal
of a limb or part of a limb.
 Estimated height (in/cm). Defined as estimated body height.
 Stated height (in/cm). Defined as stated body height.
 Measured peak adult height (in/cm). Defined as tallest measured height recorded in
adulthood.
 Stated peak adult height (in/cm). Defined as stated body height at age 25.
 Knee height (in/cm). The measured distance from the posterior surface of the thigh, just
proximal to the patella, to the sole of the foot when the knee is bent at a 90 degree angle
(adapted from the Journal of the American Dietetic Association. Chumlea, et.al.
1994;94:1385-1391.).
 Tibia length (cm). Defined as the measured distance from the superomedial edge of the tibia
to the inferior edge of the medial malleolus (Stevenson RD. Arch Pediatr Adolesc Med.
1995;149:658-62.).
 Arm span (in/cm). Defined as the measured distance of outstretched arms between the tip of
the middle finger to the tip of the other middle finger with arms parallel to the ground
(adapted Nutrition Care Manual 2016).
 Arm demispan (cm). Defined as the measured distance from the midline at the sternal notch
to the web between the middle and ring fingers along outstretched arm (Mini Nutrition
Assessment).
 Arm halfspan (cm). Defined as the measured distance from the midline at the sternal notch to
the tip of the middle finger (Mini Nutrition Assessment).
 Height measurement device. Defined as the tool used to measure height or length.
Weight
Defined as measures of a body’s mass, heaviness or lightness of a body.
 Measured weight (lb, oz, kg, g). Defined as measured body weight.
 Stated weight (lb, oz, kg, g). Defined as reported body weight.
 Stated peak weight (lb, kg). Defined as reported maximum body weight.
 Measured peak weight (lb, kg). Defined as the measured maximum body weight.
 Usual stated body weight (UBW) (lb, oz, kg, g). Defined as the reported body weight that is
typical for the individual.
 UBW percentage (%). Defined as the calculation using actual body weight divided by usual
weight and then multiplied by 100.
 Birth weight (lb, oz, kg, g). Defined as the measured body weight at birth.
 Stated pre-pregnancy weight (lb, oz, kg, g). Defined as the reported weight prior to
pregnancy.
 Dosing weight (lb, oz, kg, g). Defined as the calculated body weight that may be used to
determine the appropriate dose for medications, enteral nutrition, parenteral nutrition, and
IVs.
 Estimated dry weight (lb, oz, kg, g). Defined as the estimated body weight without excess
fluid volume (euvolemic).
 Pre-amputation measured weight (lb, oz, kg, g). Defined as the measured body weight prior
to removal of a limb or part of a limb.
 Pre-amputation estimated weight (lb, oz, kg, g). Defined as the estimated body weight prior
to removal of a limb or part of a limb.
 Post-amputation measured weight (lb, oz, kg, g). Defined as the measured body weight after
removal of a limb or part of a limb.
 Post-amputation estimated weight (lb, oz, kg, g). Defined as the estimated body weight after
removal of a limb or part of a limb.
 Pre-dialysis weight (lb, oz, kg, g). Defined as measured body weight prior to dialysis.
 Post-dialysis weight (lb, oz, kg, g). Defined as measured body weight after dialysis.
Frame
Defined as estimate of a body frame based upon height and wrist measure.
 Frame size (small/medium/large). Defined as calculation using measured wrist circumference

and measured height to estimate frame size.
 Wrist circumference (in/cm). Defined as the measured circumference of the wrist.
Weight change
Defined as measures of the difference in body weight typically over time.
 Weight gain (lb, kg, oz, g). Defined as the measured increase in body weight over a specified
period of time.
 Weight loss (lb, kg, oz, g). Defined as the measured decrease in body weight over a specified
period of time.
 Weight change percentage (%). Defined as the weight change value divided by the original
weight and multiplied by 100.
 Measured interdialytic weight gain (lb, oz, kg, g). Defined as the measured increase in body
weight between dialysis treatments.
 Measured interdialytic weight loss (lb, oz, kg, g). Defined as the measured decrease in body
weight between dialysis treatments.
 Weight change intent (intentional/unintentional). Defined as the purpose of weight gain or
weight loss.
 Measured gestational weight gain (lb, oz, kg, g). Defined as measured weight increase during
pregnancy.
 Measured gestational weight loss (lb, oz, kg, g) Defined as measured weight decrease during
pregnancy.
Body mass
Defined as measures of a body’s weight relative to height.
 Body mass index (BMI) (kg/m2). Defined as weight in kilograms divided by the square
height in meters.
 BMI prime ratio (ratio). Defined as the ratio of actual BMI to the upper limit BMI of 25.
Growth pattern indices

Defined as measures used to monitor growth.
 BMI-for-age percentile (percentile). Defined as weight in kilograms divided by the square of

height in meters at the child’s age.
 BMI-for-age z score. Defined as the standard deviation score for BMI at the child’s age.
 Head circumference (in/cm). Defined as the largest occipital-frontal circumference.
 Birth head circumference (in/cm). Defined as the largest occipital-frontal circumference at
birth.
 Head circumference-for-age percentile (percentile). Defined as attained head circumference
at the child’s age.
 Head circumference-for-age z score. (z score). Defined as the standard deviation score for
attained head circumference at the child’s age.
 Length-for-age percentile (percentile). Defined as attained growth in recumbent length at the
child’s age.
 Length-for-age z score (z score). Defined as the standard deviation score for attained length at
the child’s age.
 Stature-for-age percentile (percentile). Defined as attained growth in standing height at the
child’s age.
 Stature-for-age z score (z score). Defined as the standard deviation score for attained height at
the child’s age
 Weight-for-length percentile (percentile). Defined as body weight in proportion to attained
growth in recumbent length.
 Weight-for-length z score (z score). Defined as the standard deviation score for body weight
in proportion to attained growth in recumbent length.
 Weight-for-age percentile (percentile). Defined as body weight relative to the child’s age.
 Weight-for-age z score (z score). Defined as the standard deviation score for attained body
weight at the child’s age.
 Weight-for-stature percentile (percentile). Defined as body weight in proportion to attained
growth in standing height.
 Weight-for-stature z score (z score). Defined as the standard deviation score for body weight
in proportion to attained growth in height.
 Mid parental height comparator (in/cm). Defined as the parental heights used to predict a
child’s expected adult height centile)
Body compartment estimates

Defined as measures of fat, muscle, and bone components of a body.
 Body fat percentage (%). Defined as the portion of the body attributed to body fat and
excludes muscle, fluids, bone, or organs.
 Body fat percentage technique. Defined as the tool used to estimate body fat.
 Body surface area (m2). Defined as the measured surface area of a human body.
 Calculated body surface area (m2). Defined at the calculated surface area of a human body.
 Bone age (years). Defined as the degree of maturation of a child’s skeleton.
 Bone mineral density t score (t score). Defined as the measure of minerals in bone compared
with a healthy young adult of the same sex.
 Bone mineral density z score (z score). Defined as the measure of minerals in bone compared
with a person of the same age, sex, weight, and ethnic or racial origin.
 Bone mineral density technique. Defined as the test to measure bone mineral density.
 Mid arm muscle circumference (in/cm). Defined as the measure of the muscle area of the
upper arm.
 Mid arm muscle circumference percentile (percentile). Defined as the rank of the muscle area
of the upper arm.
 Triceps skin fold thickness (in/cm). Defined as measure of the fold of skin taken over the
tricep muscle.
 Triceps skin fold percentile (percentile). Defined as the percentile rank of the skin fold
thickness over the tricep muscle.
 Triceps skin fold z score (z score). Defined as the standard deviation score for the skin fold
thickness over the tricep muscle.
 Waist circumference (in/ cm). Defined as the circumference around the waist measured at the
umbilicus.
 Waist circumference narrowest point (in/ cm). Defined as the circumference around the waist
measured at the narrowest point.
 Waist circumference iliac crest (in/ cm). Defined as the circumference around the waist
measured at the midpoint between the lower margin of the least palpable rib and the top of
the iliac crest.
 Hip circumference (in/cm). Defined as the circumference of the hips measure at the widest
portion of the buttocks.
 Waist to hip ratio (ratio). Defined as the calculated waist circumference measurement divided
by the hip measurement.
 Mid upper arm circumference (in/cm). Defined as the circumference of the upper right arm
measured between the tip of the shoulder and the tip of the elbow.
 Mid upper arm circumference, left arm (in/cm). Defined as the circumference of the upper
left arm measured between the tip of the shoulder and the tip of the elbow.
 Mid upper arm circumference z score (z score). Defined as the standard deviation score for
mid upper arm circumference.
Examples of the measurement methods or data sources for these outcome indicators:Referring health
care provider or agency, direct measurement, patient/client report, medical record
Typically used with the following domains of nutrition interventions: Food and nutrient delivery,
diagnoses: Excessive or inadequate intake of energy, fat, protein, carbohydrate, alcohol, and/or mineral
intake; underweight, overweight, physical inactivity, excessive exercise
Client Example
Weight change/day
BMI percentile/age
1. Goal: The infant is only gaining, on average, 10 grams per day compared with a goal weight gain
of 20 to 30 grams per day.
OR
2. Reference Standard: Child’s (> age 3 years) BMI percentile/age per growth curves has crossed 2
percentile channels from 50% to 10% in last 6 months.
Child’s BMI percentile/age per growth curves has crossed 2 percentile

channels from 50% to 10% in last 6 months. Will monitor BMI
with client
percentile/age at next encounter.
Reassessment after nutrition Child’s BMI percentile/age per growth curves is unchanged from baseline
intervention\ measure.

References
1. McDowell MA, Fryar CD, Hirsch R, Ogden CL. Anthropometric Reference Data for Children and
Adults: US Population, 2007-2010. Hyattsville, MD: National Center for Health Statistics. 2012.
http://www.cdc.gov/nchs/data/series/sr_11/sr11_252.pdf. Accessed June 16, 2015.
2. Centers for Disease Control, National Center for Health Statistics. CDC Growth Charts: United
States. http://www.cdc.gov/growthcharts. Accessed June 16, 2015.
3. ACSM’s Guidelines for Exercise Testing and Prescription. 6th ed. Indianapolis, IN: American
College of Sports Medicine; 2000.
4. Charney P, Malone A. ADA Pocket Guide to Nutrition Assessment. 2nd ed. Chicago, IL:
American Dietetic Association; 2009.
5. Academy of Nutrition and Dietetics. Adult Weight Management Evidence-Based Nutrition
Practice Guideline, 2014. https://www.andeal.org/topic.cfm?menu=5276&cat=4688. Accessed
June 16, 2015.
6. Barlow SE and the Expert Committee. Expert committee recommendations regarding the
prevention, assessment, and treatment of child and adolescent overweight and obesity: summary
report. Pediatrics. 2007;120:S164-S192.
7. Callaway CW et al. Circumferences. In: Lohman TG et al. Anthropometric Standardization
Reference Manual. Champaign, IL: Human Kinetics; 1988:39-54.
8. Frankel HM. Body mass index graphic for children. Pediatrics. 2004; 113:425-426.
9. Going S. Optimizing techniques for determining body composition. Gatorade Sports Science
Institute, Sports Science Exchange. 2006; 19:1-6.
pediatric patients: Normal requirements—adults. J Parenter Enteral Nutr. 2002; 26(Suppl):S22-
S24.
pediatric patients: Normal requirements—pediatrics. J Parenter Enteral Nutr. 2002;
26(Suppl):S25-S32.
12. Heyward V, Wagner D, eds. Applied Body Composition and Assessment. 2nd ed. Champaign, IL:
Human Kinetics; 2004.
13. The Johns Hopkins Hospital. The Harriet Lane Handbook: A Manual for Pediatric House Officers.
17th ed. St. Louis, MO: Mosby; 2005.
14. Kleinman RE, ed. Pediatric Nutrition Handbook. 6th ed. Chicago, IL: American Academy of
Pediatrics; 2009.
15. Leonberg BL. Academy of Nutrition and Dietetics Pocket Guide to Pediatric Nutrition
Assessment. 2nd Ed. Chicago, IL: Academy of Nutrition and Dietetics; 2013.
16. Modlesky CM. Assessment of body size and composition. In: Dunford M. Sports Nutrition: A
Practice Manual for Professionals. 4th ed. Chicago, IL: American Dietetic Association; 2006.
19. NIDDK Weight control information network. http://win.niddk.nih.gov/. Accessed June 16, 2015.
20. NHLBI Guidelines on Overweight and Obesity, Electronic Textbook:
http://www.nhlbi.nih.gov/health-pro/guidelines/current/obesity-
guidelines/e_textbook/ratnl/20.htm. Accessed June 16, 2015.
21. Centers for Disease Control, National Center for Health Statistics. CDC Growth Charts: United
States. http://www.cdc.gov/growthcharts. Accessed June 16, 2015.
23. World Health Organization, Child Growth Standards. http://www.cdc.gov/growthcharts. Accessed
June 16, 2015.
24. Bouillanne O, Morineau G, Dupont C, Coulombel I, Vincent JP, Nicolis I, Benazeth S, Cynober
L, Aussel C. Geriatric Nutritional RiskvIndex: a new index for evaluating at-risk elderly medical
patients. Am J Clin Nutr. 2005;82:777-783.
25. Cogil B. Anthropometric Indicators Measurement Guide. Washington, DC: Food and Nutrition
Technical Assistance Project, Academy of Educational Development; 2003.
26. Samson-Fang LJ, Stevenson RD. Identification of malnutrition in children with cerebral palsy:
poor performance of weight-for-height centiles. Developmental Medicine & Child Neurology.
2000;42:162-168.
27. Zemel BS, Riley EM, Stallings VA. Evaluation of methodology for nutritional assessment in
children: anthropometry, body composition, and energy expenditure. Ann Rev Nutr. 1997;17:211-
235.
28. Mitchell CO, Lipschitz DA. Arm length measurement as an alternative to height in the nutrition
assessment of the elderly.JPEN J Parenter Enteral Nutr. 1982;6:226-229.
29. Cronk CE, Stallings VA, Spender Q, Ross JL, Widdoes HD. Measurement of short-term growth
with a new knee height-measuring device. Am J Hum Biol. 1989;31(2):206-14.
Biochemical Data, Medical Tests and Procedures– Biochemical and Medical Tests

Acid Base Balance (BD-1.1)

Definition
Balance between acids and bases in the body fluids. The pH (hydrogen ion concentration) of the arterial
blood provides an index for the total body acid-base balance.
Indicators
pH (number)
Arterial bicarbonate, HCO3 (mmol/L)
Partial pressure of carbon dioxide in arterial blood, PaCO2 (mmHg)
Partial pressure of oxygen in arterial blood, PaO2 (mmHg)
Venous pH (number)
Venous bicarbonate, CO2 (mmol/L)
Note: Sodium and chloride can be found on the Electrolyte and Renal Profile reference sheet
Examples of the measurement methods or data sources for these outcome indicators: Biochemical
measurement, laboratory report
diagnoses: Altered nutrition-related laboratory values

Client Example
pH, serum (number)
1. Goal: Not generally used.

OR
2. Reference Standard: The patient/client pH is 7.48 which is above (above, below, or within
expected range) the reference standard (7.35 to 7.45).
Initial nutrition assessment Patient/client’s pH is 7.48, which is above expected range. Will monitor
with client change in pH at next arterial blood gas.
Reassessment after nutrition Significant progress toward reference standard. Patient/client’s pH is 7.40,
intervention within expected range.
References
1. Charney P, Malone A. ADA Pocket Guide to Nutrition Assessment. 2nd ed. Chicago, IL:
American Dietetic Association; 2009.
Biochemical Data, Medical Tests and Procedures – biochemical-and-medical-tests

Electrolyte and Renal Profile (BD-1.2)

Definition
Laboratory measures associated with electrolyte balance and kidney function
Indicators
BUN (mg/dL or mmol/L)
Magnesium (mEq/L or mmol/L)
Creatinine (mg/dL or µmol/L)
Calcium, serum (mg/dL or mmol/L)
BUN: creatinine/ratio (ratio number)
Calcium, ionized (mg/dL or mmol/L)
Glomerular filtration rate (mL/min/1.73 m2)
Phosphorus (mg/dL or mmol/L)
Sodium (mEq/L or mmol/L)
Serum osmolality (mOsm/kg or mmol/kg)
Chloride (mEq/L or mmol/L)
Parathyroid hormone (pg/mL or ng/L)
Potassium (mEq/L or mmol/L)
Note: Bicarbonate can be found on the Acid Base Balance reference sheet.
Serum albumin can be found on the Protein Profile reference sheet for adjustment of serum
calcium.
diagnoses: Excessive or inadequate intake of protein or minerals
Client Example
Potassium (mEq/L)
1. Goal: A goal of serum K+ 3.5 to 5.5 mEq/L in patient/client on medications that block the renin-
angiotensin system.
OR
2. Reference Standard: The patient/client’s potassium is 2.9 mEq/L, which is below (above, below,
within expected range) the expected range (3.5 to 5.0 mEq/L).
Initial nutrition assessment Patient/client’s serum potassium is 2.9 mEq/L, which is below the expected
with client range. Will monitor change in potassium at next encounter.
Reassessment after nutrition Regression from reference standard. Patient/client’s potassium is 2.7 mEq/L,
intervention below the expected range.
References
3. National Kidney Foundation K/DOQI. Clinical practice guidelines for nutrition in chronic renal
failure. Am J Kidney Dis. 2000;35(6):S1-S104.
4. National Kidney Foundation K/DOQI Workgroup. National Kidney Foundation K/DOQI
Guidelines on bone metabolism and disease in chronic kidney disease. Am J Kidney Dis.
2003;42(4 Suppl 3):S1-S201.
5. National Kidney Foundation K/DOQI. Clinical practice guidelines on hypertension and
antihypertensive agents in chronic kidney disease. Am J Kidney Dis. 2004;43(5 Suppl 1)S1-S290).

Essential Fatty Acid Profile (BD-1.3)

Definition
Laboratory measures of essential fatty acids
Indicators
Triene:Tetraene ratio (ratio number)
measurement, laboratory report/record
diagnoses: Inadequate intake of fat, parenteral nutrition; parenteral nutrition composition inconsistent with
needs; parenteral nutrition administration inconsistent with needs; altered nutrition-related laboratory
values; impaired nutrient utilization
Evaluation

OR
Client Example
Triene:Tetraene ratio (ratio number)
1. Goal: Not generally used.

OR
2. Reference Standard: The patient/client Triene:Tetraene ratio is 0.45, which is (above, below, or
within expected range) above expected range (> 0.2-0.4 essential fatty acid deficiency).
Patient/client’s Triene:Tetraene ratio is 0.45, above the expected range

(essential fatty acid deficiency). Will monitor change in Triene:Tetraene
with client
ratio at next encounter.
Reassessment after nutrition Significant progress toward the expect range. Patient/client’s
intervention Triene:Tetraene ratio is 0.1.
References
2. Hise ME, Brown JC. Lipids. In: Gottschlich MM, ed. The ASPEN Nutrition Support Core
Curriculum: A Case-Based Approach—The Adult Patient. Silver Spring, MD:ASPEN;2007:48-
70.

Gastrointestinal Profile (BD-1.4)

Definition
Laboratory measures and medical tests associated with function of the gastrointestinal tract and related
organs
Indicators
Alkaline phosphatase (U/L)

Alanine aminotransferase, ALT
(U/L) Fructose hydrogen breath test(ppm above
Aspartate aminotransferase, AST baseline/by report)
(U/L) Glucose hydrogen breath test (ppm above
Gamma glutamyl transferase, GGT baseline/by report)
(U/L) Urea hydrogen breath test (ppm above baseline/by
Gastric residual volume (mL) report)
Bilirubin, total (mg/dL or µmol/L) Intestinal biopsy (by report)
Ammonia, serum (µg/dL or Stool culture (by report)

µmol/L) Gastric emptying time (minutes)
Toxicology report, including Small bowel transit time (minutes, hours)
alcohol (by report)
Abdominal X-ray (by report)
Prothrombin time, PT (seconds)
Abdominal CT (by report)
Partial thromboplastin time, PTT
(seconds) Abdominal ultrasound (by report)
INR (ratio) Endoscopic ultrasound [EUS] (by report)
Amylase (U/L) Pelvic CT scan (by report)
Lipase (U/L) Modified barium swallow (by report)
Fecal fat, 24 hour (g/24 hours) Barium swallow (by report)
Fecal fat, 72 hour (g/24 hours)x Esophagogastroduodenoscopy (EGD) (by

report)
Fecal fat, qualitative (by report)
ERCP [endoscopic retrograde
Fecal calprotectin (µg/g cholangiopancreatography] (by report)
stool
Capsule endoscopy (by report)
Fecal lactoferrin (ordinal)
Esophageal manometry (by report)
Pancreatic elastase (µg/g
stool) Esophageal pH test (pH)
5'-nucleotidase (U/L) Gastroesophageal reflux monitoring (by

report)
D-xylose (mg/dL)
Gastrointestinal sphincter monitoring (by
Lactulose hydrogen breath report)
test (ppm above baseline/by
report) Urate (mg/dL or µmol/L)
Lactose hydrogen breath test (ppm

above baseline/by report)
diagnoses: Altered nutrition-related laboratory values, excess intake of protein or fat
Evaluation

OR
Client Example
documentation for one of the indicators
Ammonia, serum (µg/dL)
1. {GLT:goal)?The patient/client’s serum ammonia is 105 µg/dL, which is above the goal (< 75
µg/dL) for this patient/client with end-stage liver disease.
OR
2. Reference Standard: The patient/client serum ammonia is 85 µg/dL which is above (above, below,
or percent of) the expected range (11-35 µg/dL).
Initial nutrition assessment Patient/client’s serum ammonia is 85 µg/dL, above the expected range. Will
with client monitor change in serum ammonia at next encounter.
Reassessment after nutrition Significant progress toward expected range. Patient/client’s serum ammonia
intervention 45 µg/dL.
References

Accessed May 9, 2014.

Glucose/Endocrine Profile (BD-1.5)
Definition
Laboratory measures associated with glycemic control and endocrine findings
Indicators
Glucose, fasting (mg/dL, mmol/L)
Glucose, casual* (mg/dL, mmol/L)
HgbA1c (%, mmol/mol)
Preprandial capillary plasma glucose (mg/dL, mmol/L)
Peak postprandial capillary plasma glucose (mg/dL, mmol/L)
Glucose tolerance test (mg/dL, mmol/L)
Cortisol level (µg/dL, mmol/L)
IGF-binding protein (ng/mL, mg/L)
Thyroid stimulating hormone (µmol/mL, mIU/L)
Thyroxine test or T4 (?g/dL, pmol/L)
Triiodothyronine or T3 (ng/dL, pmol/L)
Adrenocorticotropic hormone (pg/mL, pmol/L)
Follicle-stimulating hormone (mU/mL, IU/L)
Growth hormone (ng/mL, µg/L)
Luteinizing hormone (mU/mL, IU/L)
Typically used with the following domains of nutrition interventions: Biochemical measurement,
laboratory report
diagnoses: Excessive or inadequate intake of carbohydrate, energy; less than optimal intake of types of
carbohydrate; or inconsistent carbohydrate intake
Evaluation
Criteria for Evaluation/b>

OR
Client Example
HgbA1c (%, mmol/mol)
1. Goal: The patient/client’s HgbA1c is 7.8% (60 mmol/mol), which is above the expected limit, but
is an acceptable goal in a pediatric patient.
OR
2. Reference Standard:The patient/client’s HgbA1c is 11% (97 mmol/mol), which is above (above,
below, expected limit or range) the expected limit (< 6%, 42 mmol/mol).
Sample Nutrition Assessment Patient/client’s HgbA1c is 9% (75 mmol/mol), which is above the expected
Documentation limit. Will monitor change in HgbA1c at next encounter.
Reassessment after nutrition Regression from the expected limit. Patient/client’s HgbA1c is 10% (86
intervention mmol/mol).
* If a synonym for the term “Glucose, casual” is helpful or needed, an approved alternative is “Glucose,
random.”
References
1. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care;

2012;35:S11-S63.
2. Academy of Nutrition and Dietetics. Critical illness evidence-based nutrition guideline.
http://andevidencelibrary.com/topic.cfm?cat=4800. Accessed May 13, 2014.. Accessed
June 16, 2015.
3. International Diabetes Center. Global guideline for type 2 diabetes. 2012.
http://www.idf.org/global-guideline-type-2-diabetes-2012. Accessed May 13, 2014..
4. Joslin Diabetes Center. Clinical Guidelines. https://www.joslin.org/info/joslin-clinical-
guidelines.html. Accessed June 16, 2015.
Inflammatory Profile (BD-1.6)

Definition
Laboratory measures of inflammatory proteins
Indicators
C-reactive protein, highly sensitive or hs-CRP (mg/L) [cardiovascular disease]
Examples of the measurement methods or data sources for these outcome indicators:Direct
measurement, medical record
Typically used with the following domains of nutrition interventions: Food and/or nutrient delivery
Typically used with the following domains of nutrition interventions: Increased nutrient need; less than
optimal intake of types of fats inconsistent with needs; excessive physical activity
Evaluation
OR
Client Example
C-reactive protein (mg/L)
Comparison to Goal or Reference Standard?
1. Goal?Not generally used.

OR
2. Reference Standard?A patient/client has a C-reactive protein level of 4.0 mg/L, which is above
(above, below, within expected range) the expected range of 1.0 to 3.0 mg/L.
Nutrition assessment with ?Patient/client’s C-reactive protein level is 4.0 mg/L, which is above (above,
patient/client below, within expected range) the expected range of 1.0 to 3.0 mg/L.
References:
1. NHLBI Workshop Report. C-Reactive Protein: Basic and Clinical Research Needs.
http://www.nhlbi.nih.gov/research/reports/2006-crp. Accessed June 16, 2015.
2. Position of the Academy of Nutrition and Dietetics: Dietary fatty acids for healthy adults. J Acad
Nutr Diet. 2014;114:136-153.
Lipid Profile (BD-1.7)

Definition
Laboratory measures associated with lipid disorders
Indicators
Cholesterol, serum (mg/dL or mmol/L)
Cholesterol, HDL (mg/dL or mmol/L)
Cholesterol, LDL (mg/dL or mmol/L)
Cholesterol, non-HDL (mg/dL or mmol/L)
Total cholesterol:HDL cholesterol (ratio)
LDL:HDL (ratio)
Triglycerides, serum (mg/ dL or mmol/L)
measurement, laboratory report, patient/client report
counseling
diagnoses: Excessive or inadequate intake of fat, energy
Evaluation
Comparison to Goal or Reference Standard

OR
Client Example
LDL cholesterol (mg/dL)
1. Goal The patient/client’s LDL cholesterol is 200 mg/dL, compared to a goal of < 100 mg/dL.
(Note: While reference standards are generally used for laboratory measures, a goal might be used
in a special situation such as this example. The patient/client has a familial hypercholesterolemia
where a normal reference standard may not be realistic.)
OR
2. Reference Standard?The patient/client’s LDL cholesterol is 159 mg/dL, which is above the
expected limit of the NHLBI recommendation of < 100 mg/dL.

The patient/client LDL cholesterol is 159 mg/dL compared to the reference

standard (e.g., National Heart, Lung and Blood Institute) recommended level
with client
of < 100 mg/dL. Will monitor LDL cholesterol at next encounter.
Reassessment after nutrition Some progress toward goal/reference standard as patient/client’s LDL
intervention cholesterol is 145 mg/dL.
References
1. Grundy S, Cleeman JI, Bairey Merz CN, Brewer HB, Clark LT, Hunninghake DB, Pasternak RC,
Smith SC, Stone NJ, for the Coordinating Committee of the National Cholesterol Education
Program, Endorsed by the National Heart, Lung, and Blood Institute, American College
of Cardiology Foundation, and American Heart Association. Implications of recent clinical trials
for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation.
2004;110:227-239.
2. Ingelsson E, Schaefer EJ, Contois JH, McNamara JR, Sullivan L, Keyes MJ, Pencina MJ,
Schoonmaker C, Wilson PW, D’Agostino RB, Vasan RS. Clinical utility of different lipid
measures for prediction of coronary heart disease in men and women. JAMA. 2007; 298(7): 776-
785.
3. Nam BH, Kannel WB, D’Agostino RB. Search for an optimal atherogenic lipid risk profile: from
the Framingham Study. Am J Cardiol. February 1, 2006;97(3):372-5.
4. National Institutes of Health, National Heart, Lung, and Blood Institute (NHLBI). Third Report of
the Expert Panel on Detection, Evaluation, and Treatment of High Cholesterol in Adults, May
2001. http://www.nhlbi.nih.gov/health-pro/guidelines/current/cholesterol-guidelines/final-report.
5. National Kidney Foundation, K/DOQI Guidelines.
https://www.kidney.org/professionals/guidelines/guidelines_commentaries. Accessed June 16,
2015
6. Onder G, Landi F, Volpato S, Fellin R, Carbonin P, Gambassi G, Bernabei R. Serum cholesterol
levels and in-hospital mortality in the elderly. Am J Med. 2003;115:265-271.
7. Position of the American Dietetic Association. Nutrition Intervention and Human
Immunodeficiency Virus Infection. J Am Diet Assoc. 2010;110:1105-1119.
8. Ridker PM, Rifai N, Cook NR, Bradwin G, Buring JE. Non-HDL cholesterol, apolipoproteins A-I
and B100, standard lipid measures, lipid ratios, and CRP as risk factors for cardiovascular disease
in women. JAMA. 2005;294(3):326-333.
9. Wang TD, Chen WJ, Chien KL, Seh-Yi Su SS, Hsu HC, Chen MF, Liau CS, Lee YT. Efficacy of
cholesterol levels and ratios in predicting future coronary heart disease in a Chinese
population. Am J Cardiol. 2001;88(7):737-743.
10. Position of the Academy of Nutrition and Dietetics: Dietary fatty acids for healthy adults. J Acad
Nutr Diet. 2014;114:136-153.
Metabolic Rate Profile (BD-1.8)

Definition
Measures associated with or having implications for assessing metabolic rate
Indicators
Resting metabolic rate, measured (calories, kcal or kJ/day)
Respiratory quotient, measured (RQ = CO2 produced/O2 consumed)
Note: Use of RQ is considered valid if respiratory factors (hyper- or hypoventilation), equipment
failure, measurement protocol violations, or operator errors have not occurred.
Examples of the measurement methods or data sources for these outcome indicators: Direct
measurement (indirect calorimetry), medical record
Typically used with the following domains of nutrition interventions: Food and/or nutrient delivery
diagnoses: Excessive or inadequate intake of parenteral/enteral nutrition; enteral/parenteral nutrition
composition or administration inconsistent with needs; excessive energy intake; excessive mineral intake;
disordered eating pattern; excessive exercise, increased energy expenditure, increased nutrient needs
(energy), inadequate protein-energy intake.
Client Example
Example of one (or more) of the Nutrition Care Indicators (includes sample initial and reassessment
Respiratory quotient
comparison-to-reference-standard-rec-or-goal-19
1. Reference Standard: A client on parenteral nutrition support with an RQ of 1.04, which is above
(above, below, within expected range) the expected range (0.7 to 1.0) with no apparent errors in
the measurement
Client’s RQ is 1.04, with energy intake from parenteral nutrition 400 kcal (1700
kJ) higher than measured metabolic rate. No apparent respiratory factors (hyper-
Initial encounter
or hypoventilation), equipment failure, measurement protocol violations, or
operator errors. Will adjust content of parenteral nutrition and re-measure RQ.
RQ has dropped to 0.92 with no apparent measurement error. Metabolic rate and
Reassessment after
calorie/ kcal/kJ intake are matched. Parenteral nutrition has been appropriately
adjusted to equal client’s energy requirement.
References
1. Academy of Nutrition and Dietetics. Evidence Analysis Library. Adult weight management
guideline (2014). https://www.andeal.org/topic.cfm?menu=5276. Accessed February 20, 2019.
measurement of resting metabolic rate in adults: a systematic review. J Am Diet
Assoc.2006;106(6):881-903.
3. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the provision and assessment of
nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine
(SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J
Parenter Enteral Nutr. 2016;40(2):159-211.
4. Mehta NM, Skillman HE, Irving SY, et al. Guidelines for the provision and assessment of
nutrition support therapy in the pediatric critically ill patient: Society of Critical Care Medicine
and American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral
Nutr. 2017;41(5):706-742.
5. McClave SA, Lowen CC, Kleber MJ, McConnell JW, Jung LY, Goldsmith LJ. Clinical use of the
respiratory quotient obtained from indirect calorimetry. JPEN J Parenter Enteral
Nutr.2003;27(1):21-26.
Mineral Profile (BD-1.9)

Definition
Laboratory measures associated with body mineral status
Indicators
Copper, serum or plasma (µg/dL or µmol/L)
Iodine, urinary excretion (µg/24hr)
Zinc, serum or plasma (µg/dL or µmol/L)
Boron, serum or plasma (µg/L)
Chromium, serum (ng/mL or nmol/L), urinary (µg/L)
Fluoride, plasma (µmol/L)
Manganese, urinary excretion (µg/L or nmol/L), blood (µg/L or nmol/L), plasma (µg/L or nmol/L
Molybdenum, serum (ng/mL)
Selenium, serum (µmol/L), urinary excretion (µg/L or µg/day)
Note: Other measures of body mineral status, such as urinary manganese excretion, are provided
to offer complete information in the reference sheet. These are rarely used in practice, but may be
warranted in limited circumstances.
Serum calcium, magnesium, phosphorus, and potassium can be found on the Electrolyte and Renal
Serum iron, serum ferritin, and transferrin saturation can be found on the Nutritional Anemia
Thyroid stimulating hormone ( ↑ TSH as an indicator of excess iodine supplementation) can be
found on the Glucose/ Endocrine Profile reference sheet.
measurement, laboratory record
diagnoses: Excessive or inadequate intake of minerals, parenteral nutrition
Evaluation

OR
Client Example
Zinc, plasma (µg/dL
1. Goal:There is no goal generally associated with mineral status.

OR
2. Reference Standard: The patient/client’s plasma zinc is 40 µg/dL, which is below (above, below,
within expected range) the expected range (66 to 110 µg/dL) for adults.
Initial nutrition assessment Patient/client’s plasma zinc is 40 µg/dL, which is below the expected range
with client for adults. Will monitor change in plasma zinc at next encounter.
Goal/reference standard achieved as patient/client’s plasma zinc is 90 µg/dL.
intervention
References

Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, Zinc.
4. Institute of Medicine. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and
Sulfate. Washington DC: National Academies Press; 2004.
Nutritional Anemia Profile (BD-1.10)

Definition
Laboratory measures associated with nutritional anemias
Indicators
Hemoglobin (g/dL g/L or mmol/L) Serum folate (ng/mL or nmol/L)

Hematocrit (% or proportion of one (1)) Serum homocysteine (µmol/L)
Mean corpuscular volume, MCV (fL) Serum ferritin (ng/mL or pmol/L
RBC folate (ng/mL or nmol/L) Serum iron (µg/dL or µmol/L)
Red cell distribution width, RDW (%) Total iron-binding capacity (µg/dL or
Serum B12 (pg/mL or pmol/L) µmol/L)
Methylmalonic acid, serum (nmol/L) Transferrin saturation (%)
measurement, patient/client laboratory record; national/state/local nutrition monitoring and surveillance
data
diagnoses: Excessive or inadequate intake of vitamins or minerals (e.g., iron, B12, folate); altered
nutrition-related laboratory values; impaired nutrient utilization
Evaluation

OR
Client Example
Hemoglobin (gm/dL)
Serum ferritin (ng/mL)
1. {GLT:goal: The patient/client’s hemoglobin and hematocrit are below the expected limits for
adult males, but are within the goal range for a patient/client receiving hemodialysis.
OR
2. Reference Standard: The patient/client’s serum ferritin is 8 ng/mL, which is below (above, below,
or within expected range) the expected range for adult females.
Initial nutrition assessment Patient/client’s serum ferritin is 8 ng/mL, which is below the expected range
with client for adult females. Will monitor change in serum ferritin at next encounter.
Patient/client’s serum ferritin is 10.9 ng/mL, within the expected range.
intervention
References
2. Centers for Disease Control and Prevention. Recommendations to prevent and control iron
deficiency anemia in the United States. MMWR. 2002;51:897-899.
3. Johns Hopkins Hospital. The Harriet Lane Handbook: A Manual for Pediatric House
Officers. 17th ed. St. Louis, MO: Mosby; 2005.
4. National Kidney Foundation, Dialysis Outcomes Quality Initiative. Anemia in chronic kidney
disease. http://www.kidney.org/professionals/KDOQI/guidelines_commentaries.cfm. Accessed
June 16, 2015.
Protein Profile (BD-1.11)

Definition
Laboratory measures associated with hepatic and circulating proteins and protein metabolism
Albumin (g/dL or g/L)
Prealbumin (mg/dL or mg/L)
Transferrin (mg/dL or g/L)
Phenylalanine, plasma (mg/dL or µmol/L)
Tyrosine, plasma (mg/dL or µmol/L)
Amino acid panel (by report)
Phenylalanine, dried blood spot (ordinal)
Tyrosine, dried blood spot (ordinal)
Phenylalanine: tyrosine (ratio)
Hydroxyproline (mg/dL or µmol/L)
Threonine (mg/dL or µmol/L)
Serine (mg/dL or µmol/L)
Asparagine (mg/dL or µmol/L)
Glutamate (mg/dL or µmol/L)
Glutamine (mg/dL or µmol/L)
Proline (mg/dL or µmol/L)
Glycine (mg/dL or µmol/L)
Alanine (mg/dL or µmol/L)
Citrulline (mg/dL or µmol/L)
Valine (mg/dL or µmol/L)
Cysteine (mg/dL or µmol/L)
Methionine (mg/dL or µmol/L)
Isoleucine (mg/dL or µmol/L)
Leucine (mg/dL or µmol/L)
Ornithine (mg/dL or µmol/L)
Lysine (mg/dL or µmol/L)
Histidine (mg/dL or µmol/L)
Arginine (mg/dL or µmol/L)
Lysine:arginine (ratio)
Tryptophan, plasma or serum
Plasma organic acid panel (by report)
Organic acids/creatinine (mmol/mol creatinine)
3-hydroxybutyrate (mg/dL or µmol/L)
3-hydroxyisovalerate (mg/dL or µmol/L)
Acetoacetate (mg/dL or µmol/L)
Ethylmalonate (mg/dL or µmol/L)
Succinate (mg/dL or µmol/L)
Fumarate (mg/dL or µmol/L)
Glutarate (ng/dL or nmol/L)
3-methylglutarate (mg/dL or µmol/L)
Adipate (mg/dL or µmol/L)
2-hydroxyglutarate (mg/dL or µmol/L)
3-hydroxypheylacetate (mg/dL or µmol/L)
2-ketoglutarate (mg/dL or µmol/L)
Citrate (mg/dL or µmol/L)
Propionate (mg/dL or µmol/L)
Methylcitrate (mg/dL or µmol/L)
3-hydroxy propionate (mg/dL or µmol/L)
ß-hydroxy butyrate (mg/dL or µmol/L)-
Creatine kinase (U/L)
Troponin I. cardiac (ng/mL)
Troponin T.cardiac (ng/mL)
B-type natriuretic peptide (pg/mL)
Succinylacetone (mg/dL or µmol/L)
Total serum immunoglobulin A (IgA)(mg/dL or µmol/L)
Tissue transglutaminase antibodies (IgA) (U/mL)
Tissue transglutaminase antibodies (IgG) (U/mL)
Deamidated gliadin peptide antibodies (IgG) (U/mL)
Endomysial antibodies (ordinal)
Carbohydrate-deficient transferrin (mg/dL or %)
Note: Methylmalonic acid can be found on the Nutritional Anemia Profile reference sheet. Also, In
the past, hepatic transport protein measures (e.g. albumin and prealbumin) were used as indicators
of malnutrition. See the Evidence Analysis Library questions on this topic
at:https://www.andevidencelibrary.com/topic.cfm?cat=4302
diagnoses: Increased nutrient needs, malnutrition, inadequate enteral/parenteral nutrition infusion
Evaluation

OR
Client Example
Prealbumin (mg/dL)
1. Goal:Not generally used.

OR
2. Reference Standard: The patient/client’s prealbumin is 7 mg/dL, which is below (above, below,
or within the expected range) the expected range (16 to 40 mg/dL) for adults.
Initial nutrition assessment Patient/client’s prealbumin is 7.0 mg/dL, below the expected range (16 to 40
with client mg/dL) for adults. Will monitor change in prealbumin at next encounter.
Reassessment after nutrition Significant progress toward expected range as patient/client’s serum
intervention prealbumin is 13.0 mg/dL.
References
3. Academy of Nutrition and Dietetics. Celiac Disease Evidenced-based Nutrition Practice
Guideline. http://andevidencelibrary.com/topic.cfm?cat=1403. Accessed June 16, 2015.
4. Fuhrman MP, Charney P, Mueller CM. Hepatic proteins and nutrition assessment. J Am Diet
Assoc. 2004;104:1258-1264.
5. Garcia-Cazorla A, Pyruvate carboxylase deficiency: metabolic characteristics and new
neurological aspects, Ann Neurol. 2006;59:121-127.
6. Kerr DS The pyruvate dehydrogenase complex and tricarboxylic acid cycle in Fernandes J,
Saudubray JM, Tada K (eds): Inborn metabolic diseases, diagnosis and treatment; 2nd edition;
Berlin, Springer Verlag 1996; :109-119.
7. National Kidney Foundation, Clinical Practice Guidelines for Nutrition in Chronic Renal Failure,
2000. https://www.kidney.org/professionals/guidelines/guidelines_commentaries. Accessed June
16, 2015.
8. Tanaka KR, Pyruvate kinase and other enzymopathies of the erythrocyte, The metabolic and
molecular bases of inherited disease, 7th Ed; Editors: C.R.Scriver, A.L.Beaudet, W.S.Sly, D.Valle;
McGraw-Hill Inc. 1995;2:3485-3511.
Urine Profile (BD-1.12)

Definition
Physical and/or chemical properties of urine
Indicators
Urine color (by visualization)
Urine osmolality (mOsm/kg H2O)
Urine specific gravity (number)
Urine volume (mL/24 hours; however, in certain populations, eg, infants, this indicator may be
reported in number of wet diapers/day)
Urine calcium, 24 hour (mg/24 hours or mmol/24hours)
Urine d-xylose (mg/dL or mmol/L)
Urine glucose (ordinal)
Urine ketones (ordinal)
Urine sodium (mg/dL or mmol/L)
Urine microalbumin (mg/dL or mmol/L)
Urine protein, random (mg/dL or mmol/L)
Urine protein, 24-hour (mg/24 hours or mmol/24 hours)
Urine uric acid, random (mg/dL or µmol/L)
Urine uric acid, 24 hour (mg/24 hours or mmol/24 hours)
Urine organic acid panel (by report)
Urine glutarate (ordinal)
Urine methylmalonate (µg/dL)
Urine acylglycines/creatinine (mg/g creatinine or mmol/mol creatinine)
Urine argininosuccinate (mmol/L)
Urine succinylacetone/creatinine (µmol/mmol creatinine)
Urine orotate (µmol/L)
Urine orotate/creatinine (µmol/mmol creatinine)
Urine 2-hydroxyisovalerate (ordinal)
Urine 2-oxoisovalerate (ordinal)
Urine galactitol (ordinal)
Urine reducing substances (ordinal)
Urine porphyrins (ordinal)
Urine creatinine, 24 hour (mg/24hours or mmol/24hours)
Urine citrate, 24 hour (mg/24 hours or mmol/24 hours)
Urine phosphorus, 24 hour (mg/24 hours or mmol/24 hours)
Urine pH, random (number)
Urine pH, 24 hour (number)
Urine sodium, 24 hour (mEq/24 hours or mmol/24 hours)
Urine urea nitrogen, 24 hour (mg/24 hours or mmol/24 hours)
Urine oxalate, 24 hour (mg/24 hours or mmol/24 hours)
Urine chloride, 24 hour (mEq/24 hours or mmol/24 hours)
Urine ammonium, 24 hour (mg/24 hours or mmol/24 hours)
Urine magnesium, 24 hour (mg/24 hours or mmol/24 hours)
Urine potassium, 24 hour (mEq/24 hours or mmol/24 hours)
Urine sulfate, 24 hour (mg/24 hours or mmol/24 hours)
Urine cystine, 24 hour (mg/24 hours or µmol/24 hours)
Calcium oxalate supersaturation in 24 hour urine (number)
Calcium phosphate supersaturation in 24 hour urine (number)
Brushite supersaturation in 24 hour urine (number)
Uric acid supersaturation in 24 hour urine (number)
Examples of the measurement methods or data sources for these outcome indicators: Observation,
biochemical measurement, laboratory report, client report
diagnoses: Inadequate or excessive fluid intake; inadequate or excessive enteral/parenteral nutrition
infusion; inadequate or excessive mineral intake; inadequate or excessive bioactive substance intake
Client Example
Urine specific gravity (number)
comparison-to-reference-standard-rec-or-goal-19:
1. Reference Standard: The client’s urine specific gravity is 1.050, which is above (above, below,
within expected range) the expected range (1.003 to 1.030).
Client’s urine specific gravity is 1.050, which is above the expected range.
Initial encounter
Will monitor change in urine specific gravity at next encounter.
Reassessment after nutrition Significant progress toward goal, client’s urine specific gravity is 1.035,
intervention which is within the expected range.
References

2. Charney P, Malone A. Academy of Nutrition and Dietetics Pocket Guide to Nutrition Assessment.
3rd ed. Chicago, IL: Academy of Nutrition and Dietetics; 2015.
Vitamin Profile (BD-1.13)

Definition
Laboratory measures associated with body vitamin status
Indicators
Vitamin A, serum or plasma retinol (µg/dL or µmol/L)
Vitamin C, plasma or serum (mg/dL or µmol/L)
Vitamin D, 25-hydroxy (ng/mL or nmol/L)
Vitamin E, plasma alpha-tocopherol (mg/dL or µmol/L)
Thiamin, activity coefficient for erythrocyte transketolase activity (µg/mL/hr)
Riboflavin, activity coefficient for erythrocyte glutathione reductase activity (IU/g hemoglobin)
Niacin, urinary N’methyl-nicotinamide concentration (µmol/day)
Vitamin B6, plasma or serum pyridoxal 5’phosphate concentration (ng/mL or nmol/L)
Pantothenic acid, urinary pantothenate excretion (mg/day), plasma (ng/mL or nmol/L)
Biotin, urinary 3-hydroxyisovaleric acid excretion (mmol/mmol creatinine)
Biotin, lymphocyte propionyl-CoA carboxylase in pregnancy [pmol/(min × mg)], serum (ng/mL or
nmol/L)
Biotinidase (U/L)
Protein induced by vitamin K absence or antagonist II (PIVKA-II) ng/mL or nmol/L)

Note: Other measures of body vitamin status, such as urinary pantothenate excretion, are provided
to offer complete information in the reference sheet. These are rarely used in practice, but may be
warranted in limited circumstances.
Measures for folate and Vitamin B12 can be found on the Nutritional Anemia Profile reference
sheet.
Measures related to Vitamin K (PT, PTT, INR) can be found on the GI Profile reference sheet.
A test for Choline is not available. According to the DRIs, it should be evaluated in light of serum
alanine amino transferase (ALT) levels which can be found on the GI Profile (BD-1.4).
measurement, patient/client record
typically-used-with: Food and/or nutrient delivery, coordination of nutrition care by nutrition
professional
diagnoses: Excessive or inadequate intake of vitamins
Evaluation

OR
Client Example
Indicator(s) Selected:
Vitamin A, serum retinol (µg/dL)
1. Goal: Not generally used for this indicator.

OR
2. Reference Standard: The patient/client’s serum retinol is 95 µg/dL which is above (above, below,
within expected range) the expected range (10 to 60 µg/dL).
Patient/client’s serum retinol is 95 µg/dL, which is above the expected

range. Will monitor change in serum retinol at next encounter, along with
with client
vitamin A and beta-carotene intake.
Reassessment after nutrition Significant progress toward expected range. Patient/client’s retinol is 70
intervention µg/dL.

References

2. Grooper SS, Smith JL, Groff JL. Advanced Nutrition and Human Metabolism. Belmost, CA:
Thomson Wadsorth, 2005.
3. American Society for Parenteral and Enteral Nutrtion Board of Directors and the Clinical
pediatric patients: normal requirements—adults. J Parenter Enteral Nutr. 2002;26(Suppl):S22-
S24.
pediatric patients: normal requirements—pediatrics. J Parenter Enteral
Nutr. 2002;26(Suppl):S25-S32.
5. McMahon RJ. Biotin in metabolism and molecular biology. Annu Rev Nutr. 2002;22:221-239.
6. Monsen ER. Dietary Reference Intakes for the antioxidant nutrients: Vitamin C, vitamin E,
selenium, and carotenoids. J Am Diet Assoc. 2000;100:637-640.
9. Institute of Medicine. Dietary Reference Intakes: Thiamin, Riboflavin, Niacin, Vitamin B6,
Folate, Vitamin B12, Pantothenic acid, Biotin, and Choline. Washington, DC: National
Academies Press;1998.
Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc.
11. Institute of Medicine. Dietary Reference Intakes: Vitamin C, Vitamin E, Selenium, and
Carbohydrate Metabolism Profile (BD-1.14)

Definition
Laboratory measures associated with carbohydrate metabolism
Indicators
Galactose 1 phosphate in red blood cells (mg/dL or µmol/L)
Galactose 1 phosphate uridyl transferase (U/g Hgb)
Fructose (mg/dL or µmol/L)
Lactate (mg/dL or µmol/L)
Pyruvate (mg/dL or µmol/L)
Lactate/pyruvate (ratio)
Note: Other measures of metabolic conditions, such as, Pyruvate are listed on the Protein profile
(BD-1.11) reference sheet.
Nutrition education, nutrition counseling
diagnoses:Intake of types of carbohydrate inconsistent with needs, Inadequate energy intake
Evaluation

OR
Client Example
Galactose 1 phosphate in red blood cells (mg/dL or µmol/L)
1. Goal: The patient/client’s galactose-1-phosphate in RBCs is 165 mg/dL, which is above the goal
for patients with galactosemia on diet (> 125 mg/dL ). (Note: While reference standards are
generally used for laboratory measures, a goal might be used in a special situation such as this
example where a population reference standard may not be realistic.)
OR
2. Reference Standard: The patient/client’s galactose-1-phosphate in RBCs is 165 mg/dL, which is
above the upper limit for patients with galactosemia on diet (>125 mg/dL).
The patient/client’s galactose-1-phosphate in RBCs is 165 mg/dL, which is

above the goal for patients with galactosemia on diet (> 125 mg/dL). Will
with client
monitor at next encounter.
Reassessment after nutrition Significant progress toward expected range. Patient/client’s galactose-1-
intervention phosphate in RBCs is 135 mg/dL
References
1. Bosch AM, Classical galactosaemia revisited J Inher Met Dis. 2006;29:516-525.

2. Glycogen storage diseases: The metabolic and molecular bases of inherited disease, 7/e; Editors:
C.R.Scriver, A.L.Beaudet, W.S.Sly, D.Valle; McGraw-Hill Inc. 1995;1:935-965.
3. Walter JH, Recommendations for the management of galactosemia Arch Dis Child. 1999;80:93-
96.
Fatty Acid Profile (BD-1.15)

Definition
Laboratory measures associated with fatty acid metabolism
Indicators
Acylcarnitine panel (µmol/L)
Acylcarnitine, plasma (µmol/L)
Free carnitine, plasma (µmol/L)
Total carnitine, plasma (µmol/L)
Free carnitine: total carnitine (ratio)
Fatty acid panel mitochondrial C8-C18, serum or plasma (µmol/L)
Fatty acid panel essential C12-C22, serum or plasma (µmol/L)
Fatty acid panel peroxisomal C22-C26, serum or plasma (µmol/L)
MCAD enzyme assay in fibroblasts or other tissues (confirmatory)
Fatty acid ß-oxidation in fibroblasts (confirmatory)
Nutrition education, nutrition counseling
diagnoses: Intake of types of fat inconsistent with needs, Inadequate energy intake
Evaluation

OR
Client Example
Fatty acid panel mitochondrial C8-C18 (specifically Octanoylcarnitine [C8] and Octanoylcarnitine
[C8]:Decanoylcarnitine [C10] ratio)
1. Goal: The patient/client’s Octanoylcarnitine is 0.8 µmol/L, which is above the goal of 0.3 µmol/L
and a ratio of Octanoylcarnitine:Decanoylcarnitine is 10, which is above the goal of 5 for this
patient/client with MCAD. (Note: While reference standards are generally used for laboratory
measures, a goal might be used in a special situation such as this example where a population
reference standard may not be realistic.)
OR
2. Reference Standard: The patient/client’s Octanoylcarnitine is 0.8 µmol/L, which is above the
expected upper limit (>0.3µmol/L) and ratio of Octanoylcarnitine:Decanoylcarnitine is 10, which
is above the upper limit (>5).
The patient/client’s Octanoylcarnitine is 0.8 µmol/L, which is above the

Initial nutrition assessment reference standard upper limit (>0.3µmol/L) and ratio of Octanoylcarnitine:
with client Decanoylcarnitine is 10, which is above the upper limit (>5). Will monitor at
next encounter.
Significant progress toward expected range. Patient/client’s
Octanoylcarnitine concentration is 0.4, ratio of Octanoylcarnitine:
intervention
Decanoylcarnitine is 7.
References
1. Abdenur JE. MCAD deficiency. Acylcarnitines (AC) by tandem mass spectrometry (MS-MS) are
useful to monitor dietary treatment. Adv Exp Med Biol 1999;466:353-363.
2. Iafolla, AK. Medium chain acyl-coenzyme A dehydrogenase deficiency: Clinical course in 120
affected children J Pediatr 1994;124:409-415.
3. MorrisAM, Spiekerkoetter U. .Disorders of Mitochondrial Fatty Acid Oxidation and Related
Metabolic Pathways". In Saudubray JM; van den Berghe G, Walter JH.. Inborn
MetabolicDiseases: Diagnosis and Treatment (5th ed.). 2012. New York: Springer. pp. 201–216.
4. Rinaldo P, O'Shea JJ, Coates PM, Hale DE, Stanley CA, Tanaka K. Medium-Chain Acyl-CoA
Dehydrogenase Deficiency". New Eng J Med. 1988; 319: 1308–1313.
5. Walter JH. Tolerance to fast: Rational and practical evaluation in children with
hypoketonaemia. J Inherit Metab Dis. 2009; 32: 214–217.
Nutrition-Focused Physical Findings Domain – Nutrition Focused Physical Findings

Nutrition-Focused Physical Findings (PD)

Definition
Nutrition-related physical signs or symptoms associated with pathophysiological states derived from a
nutrition-focused physical exam, interview, and/or the health record.

Indicators (Note: Presence or absence unless otherwise specified)

Overall findings
 Asthenia (weakness)
 Buffalo hump
 Cachexia
 Cushingoid appearance
 Ectomorph
 Endomorph
 Lethargic
 Mesomorph
 Neglect of personal hygiene
 Obese
 Short stature for age
 Tall stature
Adipose
 Atrophy of orbital fat

 Excess subcutaneous fat
 Loss of subcutaneous fat
 Central adiposity
 Loss of subcutaneous triceps fat
 Loss of subcutaneous biceps fat
 Loss of subcutaneous fat overlying the ribs
Bones
 Bow legs
 Frontal bossing
 Harrison’s sulcus
 Rachitic rosary
 Rickets
 Scoliosis
 Acromion abnormal prominence
 Bone widening at ends
 Clavicle abnormal prominence
 Rib abnormal prominence
 Scapula abnormal prominence
 Spine abnormal prominence
 Iliac crest abnormal prominence
 Patella abnormal prominence
Cardiovascular-pulmonary system
 Absent breath sounds

 Bradycardia
 Bradypnea (slow respiration)
 Decreased breath sounds
 Dyspnea ( shortness of breath)
 Increased breath sounds
 Normal breath sounds
 Tachypnea
 Tachycardia
 Respiratory crackles (rales)
Digestive system
 Abdominal bloating
 Abdominal cramping
 Abdominal distension
 Abdominal pain
 Absence of bowel sounds
 Anorexia (loss of appetite)
 Ascites
 Bulky stool
 Constipation
 Decrease in appetite
 Diarrhea
 Early satiety
 Epigastric pain
 Excessive appetite
 Excessive belching
 Excessive flatus
 Fatty stool
 Heartburn
 Hyperactive bowel sounds
 Hypoactive bowel sounds
 Increased appetite
 Liquid stool
 Loose stool
 Nausea
 Normal bowel sounds
 Retching
 Vomiting
 Gastrointestinal drainage volume
 Gastric drainage volume
 Bile duct drainage volume
 Pancreatic drainage volume
 Chylous drainage volume
 Wound drainage volume
 Intestinal fistula drainage volume
Edema
 +1 pitting edema
 Anasarca
 Ankle edema
 Edema of calf
 Edema of eyelid
 Edema of foot
 Edema of the hand
 Edema of the scrotum
 Edema of thigh
 Edema of the vulva
 Mucosal edema
 Sacral edema
Extremities
 Amputated foot
 Amputated hand
 Amputated leg
 Athetoid movement
 Decreased range of ankle movement
 Decreased range of cervical spine movement
 Decreased range of elbow movement
 Decreased range of finger movement
 Decreased range of foot movement
 Decreased range of hip movement
 Decreased range of knee movement
 Decreased range of lumbar spine movement
 Decreased range of shoulder movement
 Decreased range of subtalar movement
 Decreased range of thumb movement
 Decreased range of toe movement
 Decreased range of thoracic spine movement
 Decreased range of wrist movement
 Hypertonia
 Hypotonia
 Joint arthralgia (joint pain)
 Lower limb spasticity
 Peripheral cyanosis
 Spasticity
 Tetany
 Upper limb spasticity
Eyes
 Abnormal vision
 Angular blepharitis
 Bitot’s spots
 Circles under eyes
 Corneal arcus
 Conjunctival discoloration
 Conjunctival hemorrhage
 Conjunctival keratinization
 Excessive tear production
 Keratomalacia
 Jaundiced sclera
 Night blindness
 Ophthalmoplegia
 Sunken eyes
 Xerophthalmia
 Xanthelasma
 Pale conjunctiva
Genitourinary
 Amenorrhea
 Anuria
 Delay in sexual development and/or puberty
 Menorrhagia
 Oliguria
 Polyuria
Hair
 Abnormal keratinization of hair follicle

 Alopecia
 Brittle hair
 Corkscrew hairs
 Dry hair
 Fine hair
 Follicular hyperkeratosis
 Hair changes due to malnutrition
 Hair lacks luster
 Hypertrichosis
 Increased loss of hair
 Nutritional hair color change
 White hair
 Easily pluckable hair
 Lanugo hair formation
Head
 Altered olfactory sense

 Anosmia (loss of sense of smell)
 Bulging fontanelle
 Epistaxis
 Headache
 Hyposmia (decreased sense of smell)
 Macrocephaly
 Microcephaly
 Nasal mucosa dry
 Sunken fontanelle
Hand and nails
 Beau's lines
 Clubbing of nail
 Flaking of nails
 Koilonychia (spoon shaped nails)
 Leukonychia
 Longitudinal grooving of nails
 Muehrcke’s lines
 Nail changes
 Palmar erythema
 Ridged nails
 Splits in nails
 Thin nails
 Trachyonychia (brittle nails)
 Splinter hemorrhages under nail
 White flecks in nails
 Blue nail bed
 Pale nail bed
 Russell’s sign
Mouth
 Ageusia (loss of taste)

 Angular stomatitis
 Aphthous ulcer of mouth
 Aptyalism (xerostomia)
 Blue lips
 Blue line on gingiva
 Candidiasis of the mouth
 Cheilosis (dry lips)
 Cheilitis
 Cleft palate
 Cracked lips
 Drooling
 Dry mucous membranes
 Dysgeusia
 Excessive salivation
 Excessive thirst
 Gingival hypertrophy
 Gingivitis
 Halitosis (breath smells unpleasant)
 Hemorrhagic gingivitis (bleeding gums)
 Hypogeusia
 Ketotic breath
 Micrognathia
 Swollen gums
 Oral candidiasis
 Oral lesion
 Parotid swelling
 Poor oral hygiene
 Retains food in mouth
 Stomatitis
 Uremic breath
 Pale gums
Muscles
 Muscle atrophy
 Muscle contracture
 Muscle cramp
 Muscle pain
 Muscle weakness
 Quadricep muscle atrophy
 Deltoid muscle atrophy
 Gastrocnemius (calf) muscle atrophy
 Gluteal muscle atrophy
 Interosseous hand muscle atrophy
 Latissimus dorsi muscle atrophy
 Pectoral muscle atrophy
 Temporalis muscle atrophy
 Trapezius muscle atrophy
Neck
 Goiter (thyroid enlargement)
Nerves, cognition, and feeling
 Abnormal gait
 Absent reflex
 Asterixis
 Ataxia
 Clouded consciousness (confusion)
 Cranial nerve finding
 Decreased vibratory sense
 Delirious
 Dementia
 Depressed mood
 Disoriented
 Dizziness
 Feels cold
 Flat affect
 Hyperreflexia (exaggeration of deep reflexes)
 Hyporeflexia (diminished reflexes)
 Inappropriate affect
 Many seizures a day
 Numbness of foot
 Numbness of hand
 Peripheral nerve disease
 Tremor of outstretched hand
 Tingling of foot
 Tingling of hand
Skin
 Acanthosis nigricans
 Calcinosis
 Carotenemia
 Cutaneous xanthoma
 Decreased skin turgor
 Dermatitis
 Diaper rash
 Dry skin
 Ecchymosis
 Erythema
 Eczema
 Flushing
 Hirsutism
 Hyperpigmentation of skin
 Impaired skin integrity
 Jaundice
 Keratinization of skin
 Pale complexion
 Peeling skin
 Petechiae
 Impaired wound healing
 Pressure injury of ankles
 Pressure injury of back
 Pressure injury of breast
 Pressure injury of buttock
 Pressure injury of dorsum of foot
 Pressure injury of elbow
 Pressure injury of head
 Pressure injury of heel
 Pressure injury of hip
 Pressure injury of knee
 Pressure injury of natal cleft
 Pressure injury of shoulder
 Pressure injury stage 1
 Pruritus of the skin
 Psoriasis
 Scaly skin
 Seborrheic dermatitis
 Skin rash
 Stasis ulcer
 Yellow skin
 Perifollicular hemorrhages
 Pressure injury of the coccyx
 Pressure injury of the sacrum
 Vesiculobullous rash
Teeth
 Baby bottle tooth decay

 Broken denture
 Broken teeth
 Dental caries
 Dental fluorosis
 Dental plaque
 Denture loose
 Denture lost
 Denture present
 Edentulous
 Erosion of teeth
 Impaired dentition
 Ill fitting denture
 Mottling of enamel
 Partially edentulous mandible
 Partially edentulous maxilla
 Rampant dental caries
Throat and swallowing
 Choking during swallowing

 Cough
 Dysphagia
 Esophageal lesion
 Food sticks on swallowing
 Gagging
 Hoarse voice
 Hypoactive gag reflex
 Odynophagia (painful swallowing)
 Swallow impairment
 Suck, swallow, breath incoordination (infants)
 Wet voice
Tongue
 Atrophy of tongue papillae

 Beefy red tongue
 Difficulty moving tongue
 Dry tongue
 Glossitis
 Glossodynia (painful tongue)
 Hypertrophy of tongue papillae
 Lesion of the tongue
 Macroglossia
 Strawberry tongue
 Short frenulum of tongue
 Split frenulum of tongue
 Blue tongue
 Cracked tongue
 Magenta tongue
 Pale tongue
Vital signs
 Blood pressure, systolic

 Blood pressure, diastolic
 Blood pressure, systolic, reported
 Blood pressure, diastolic, reported
 Heart rate
 Jugular venous pressure
 Mean arterial pressure
 Pulse rate
 Respiratory rate
 Temperature
Examples of the measurement methods or data sources for these outcome indicators: Direct
observation, client report, health record survey data
Typically used with the following domains of nutrition interventions: Food and nutrient delivery,
nutrition education, nutrition counseling, coordination of care, population based nutrition action
diagnoses: Excessive or inadequate intake of vitamins/minerals, fluid, parenteral/enteral nutrition;
overweight/obesity, underweight, unintended weight loss, malnutrition (undernutrition).
Client Example
Muscle atrophy
Loss of subcutaneous fat
1. Reference Standard: The client’s muscle atrophy and subcutaneous fat loss are mild undernutrition
in the context of acute illness or injury, which is consistent with the nutrition diagnosis of non-
severe (moderate) malnutrition. Normal reference standard is no muscle atrophy and fat pads
slightly bulged.
Client’s muscle atrophy and subcutaneous fat loss is mild, which is abnormal for
a well-nourished individual and consistent with non severe (moderate)
Initial encounter
malnutrition. Will monitor for adequate protein-calorie intake and changes in
muscle and subcutaneous fat status at next encounter.
Progress toward maintaining or gaining of muscle mass and (as appropriate)
Reassessment after
subcutaneous fat. Client’s muscle and subcutaneous fat status is improved upon
reassessment by nutrition focused physical exam.
References
1. Al-Dabagh A, Milliron BJ, Strowd L, Feldman SR. A disease of the present: Scurvy in "well-
nourished" patients. J Am Acad Dermatol. 2013;69(5):e246-7.
2. Baker JP, Detsky AS,Wesson DE, et al. Nutritional assessment: a comparison of clinical
judgement and objective measurements. N Engl J Med 1982; 306: 969–72.
3. Baker JP, Detsky AS, Whitwell J, Langer B, Jeejeebhoy KN. A comparison of the predictive value
of nutritional assessment techniques. Hum Nutr Clin Nutr 1982; 36: 233–41.
4. Brescoll J, Daveluy S. A review of vitamin B12 in dermatology. Am J Clin Dermatol.
2015;16(1):27-33.
5. Cashman MW, Sloan SB. Nutrition and nail disease. Clin Dermatol. 2010;28(4):420-425.
6. Charney P, Malone A. Academy of Nutrition and Dietetics Pocket Guide to Nutrition Assessment.
3rd ed. Chicago, IL: Academy of Nutrition and Dietetics; 2015.
7. Daniells S, Hardy G. Hair loss in long-term or home parenteral nutrition: Are micronutrient
deficiencies to blame? Curr Opin Clin Nutr Metab Care. 2010;13(6):690-697.
8. Demir N, Dogan M, Koc A, et al. Dermatological findings of vitamin B12 deficiency and
resolving time of these symptoms. Cutan Ocul Toxicol. 2014;33(1):70-73.
9. Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional
status? J Parent Ent Nutr. 1987; 11: 8-13.
10. Etani Y, Nishimoto Y, Kawamoto K, et al. Selenium deficiency in children and adolescents
nourished by parenteral nutrition and/or selenium-deficient enteral formula. J Trace Elem Med
Biol. 2014;28(4):409-413.
11. Finner AM. Nutrition and hair: Deficiencies and supplements. Dermatol Clin. 2013;31(1):167-
172.
12. Fossitt DD, Kowalski TJ. Classic skin findings of scurvy. Mayo Clin Proc. 2014;89(7):e61.
13. Fuhrman MP, Parker M. Micronutrient Assessment. Support Line: February, 2004;26(1):17-24.
14. Goldberg L, Lenzy Y. Nutrition and Hair. Clinics in Dermatology. 2010;28:412-419.
15. Jimenez M, Giovannucci E, Krall Kaye E, Joshipura KJ, Dietrich T. Predicted vitamin D status
and incidence of tooth loss and periodontitis. Public Health Nutr. 2014;17(4):844-852.
16. Lai KL, Ng JY, Srinivasan S. Xerophthalmia and keratomalacia secondary to diet-induced vitamin
A deficiency in scottish adults. Can J Ophthalmol. 2014;49(1):109-112.
17. Lakdawala N, Babalola O,3rd, Fedeles F, et al. The role of nutrition in dermatologic diseases:
Facts and controversies. Clin Dermatol. 2013;31(6):677-700.
18. Langan RC, Zawistoski KJ. Update on vitamin B12 deficiency. Am Fam Physician.
2011;83(12):1425-1430.
19. Litchford MD. Nutrition Focused Physical Assessment: Making Clinical Connections. 2012.
20. Nagraj SK, Naresh S, Srinivas K, et al. Interventions for the management of taste disturbances.
Cochrane Database Syst Rev. 2014;11:CD010470.
21. Pailhous S, Lamoureux S, Caietta E, et al. Scurvy, an old disease still in the news: Two case
reports. Arch Pediatr. 2015;22(1):63-65.
22. Piland C, Adams K, eds. Pocket Resource for Nutrition Assessment. Dietetics in Health Care
Communities. Chicago, IL:2009.
23. Pogatshnik C, Hamilton C. Nutrition-focused Physical Examination: Skin, Nails, Hair, Eyes, and
Oral Cavity. Support Line, 2011;33(2):7-15.
24. Radler DR, Lister T. Nutrient deficiencies associated with nutrition-focused physical findings of
the oral cavity. Nutr Clin Pract. 2013;28(6):710-721.
25. Ruktanonchai D, Lowe M, Norton SA, et al. Zinc deficiency-associated dermatitis in infants
during a nationwide shortage of injectable zinc - washington, DC, and houston, texas, 2012-2013.
MMWR Morb Mortal Wkly Rep. 2014;63(2):35-37.
26. Schroth RJ, Levi JA, Sellers EA, Friel J, Kliewer E, Moffatt ME. Vitamin D status of children
with severe early childhood caries: A case-control study. BMC Pediatr. 2013;13:174-2431-13-
174.
27. Sheth T, Detsky A. The relation of conjunctival pallor to the presence of anemia. J Gen Intern
Med. Feb 1997;12:2102-106.
28. Stieber MR. Scope of Practice and Legal Issues in Nutrition-focused Physical Examination.
Support Line, 2011;33(2):2-6.
Client History Domain– Personal History

Personal Data (CH-1.1)

Definition
General client information such as age, gender, sex, race, ethnicity, occupation, tobacco use, and physical
disability
Nutrition Assessment:
Indicators
Language***
Age***
 English***
 Age in days (neonates)***  Spanish***
 Age in months (up to 36  Other (specify)***
months)***
 Age in years*** Literacy factors***
 Other (e.g., age
adjusted)***  Language barrier***
 Low literacy***
Gender***
(as the behavioral, cultural, or psychological
Education***
traits typically associated with one sex)
 Years of education (Year of education)***
 Female***
 Male***
Role in family***
Sex***
(as female or male based upon reproductive  Specify***(client's reported role, e.g., mother,
organs and structures) cousin, in the description of his/her family)
 Female*** Tobacco use***

 Male***
 Yes***
Race *** o Average number cigarettes
(A group of people connected by common smoked per day
descent or origin) (number/day)***
o Total number of other tobacco
products used/day
 American Indian or Alaska
(number/day)***
Native***
o Number years tobacco
 Asian***
products used on a regular
 Black or African
basis (years)***
American***
 No***
 Native Hawaiian or Other
Pacific Islander***
 White*** Physical disability***
 Other***
 Eyesight impaired***
Ethnicity***  Hearing impaired***
(pertaining to or having common racial,  Other (specify)***
cultural, religious, or linguistic
characteristics) Mobility***
 Hispanic or Latino***  House bound***

 Not Hispanic or Latino***  Bed or chair bound***
 Other***  Tremors (Parkinson’s)***
 Other (specify)***
***Denotes indicator is used for nutrition assessment only. Other indicators are used for both nutrition
assessment and nutrition monitoring and evaluation.
medical record, referring health care provider or agency, surveys, administrative data sets
diagnoses: N/A
Client Example
Example(s) of one or more of the Nutrition Care Indicators (includes sample initial assessment
Age, sex and education level

o Goal: Not applicable
Initial nutrition assessment Client is a 40-year-old male with new onset type 2 diabetes, 7th grade
with client education level
References
1. Charney P, Malone A. Academy of Nutrition and Dietetics Pocket Guide to Nutrition Assessment,
3rd Ed. 3rd ed. Chicago: Academy of Nutrition and Dietetics; 2015.
Assessment. 2nd ed. Chicago: Academy of Nutrition and Dietetics; 2013.
3. National Institutes of Health. NIH Policy on Reporting Race and Ethnicity Data: Subjects in
Clinical Research. 2001; http://grants.nih.gov/grants/guide/notice-files/not-od-01-053.html.
4. Johnson-Askew WL, Gordon L, Sockalingam S. Practice paper of the American Dietetic
Association: addressing racial and ethnic health disparities. J Am Diet Assoc. 2011;111(3):446-
456.
Client History Domain–Patient/Client/Family Medical/Health History

Patient/Client or Family Nutrition-Oriented Medical/Health History

(CH-2.1)
Definition
Patient/client or family member disease states, conditions, and illnesses that may impact nutritional status
Indicators
Patient/client chief nutrition complaint Hematology/oncology***

(specify)***
 Anemia (specify)***
Cardiovascular***
 Cancer (specify)***
 Cardiovascular disease***
 Congestive heart failure***
Immune***
 Hyperlipidemia***
 Hypertension***
 Stroke***  AIDS/HIV***
 Other***  Food allergies***
 Sepsis/severe infection***
Endocrine/metabolism***
Integumentary***
 Cystic fibrosis***
 Diabetes mellitus***
 Diabetes, gestational***  Burns***
 Inborn errors***  Other (specify)***
 Malnutrition/failure to thrive***
 Metabolic syndrome*** Musculoskeletal***
 Obesity***
 Overweight (specify duration)***  Multiple trauma/fractures***
 Other (specify)***  Osteoporosis***
Excretory***
Neurological***
 Dehydration***
 Renal failure, acute***  Developmental delay***
 Renal failure, chronic***  Other (specify) ***
Psychological***
Gastrointestinal***
 Alcoholism***
 Crohn’s disease***  Cognitive impairment***
 Diverticulitis/osis***  Dementia/Alzheimer’s***
 Dyspepsia***  Depression***
 Inflammatory bowel disease***  Eating disorder (specify)***
 Lactase deficiency***  Psychosis***
 Liver disease***  Other (specify)***
 Pancreatic disease (specify)***
 Other (specify)*** Respiratory***
Gynecological***  Chronic obstructive pulmonary

disease***
 Amenorrhea***  Other (specify)***
 Lactating***
 Mastitis*** Other***
 Perimenopausal/postmenopausal***
 Pregnant***
o Gestational age
(weeks)***
o Single fetuses***
o Multiple fetus
(specify)***
Examples of the measurement methods or data sources for these outcome indicators: Medical record,
referring health care provider or agency
counseling
diagnoses: All
Evaluation

OR
patient-exampes
Cardiovascular disease (CVD)
1. Goal: Not typically used

OR
2. Reference Standard: No reference standard exists.
Patient/client with history of CVD. Recommend the Therapeutic Lifestyle

Changes (TLC) diet in accordance with the reference standard (e.g., NHLBI
with client
Adult Treatment Panel III guidelines)
References
2. American Heart Association Nutrition Committee: Lichtenstein A, Appel L, Brands M, Carnethon
M, Daniels S, Franch HA, Franklin B, Kris-Etherton P, Harris WS, Howard B, Karanja N, Lefevre
M, Rudel L, Sacks F, Van Horn L, Winston M, Wylie-Rosett J. Diet and
lifestyle recommendations revision 2006: a scientific statement from the American Heart
Association Nutrition Committee. Circulation. 2006;114:82-96.
3. Bantle JP, Wylie-Rosett J, Albright AL, Apovian CM, Clark NG, Franz MJ, Hoogwerf BJ,
Lichtenstein AH, Mayer-Davis E, Mooradian AD, Wheeler ML. Nutrition recommendations and
interventions for diabetes—2006: a position statement of the American Diabetes
Association. Diabetes Care. 2006;29:2140-2157.
Americans, 2010. http://www.cnpp.usda.gov/dietaryguidelines.htm. Accessed June 16, 2015.
5. US Department of Health and Human Services. National Institutes of Health. National Heart,
Lung and Blood Institute. Third Report of the Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Bethesda, MD:
National Institutes of Health; 2001.
7. Murray KO, Holli BB, Calabrese RJ. Communication & Education Skills for Dietetics
Professionals. 4th Ed. Philadelphia: Lippincott Williams & Wilkins, 2003.
Client History Domain – Patient/Client/Family Medical/Health History

Treatments/Therapy (CH-2.2)
Definition
Documented medical or surgical treatments that may impact nutritional status of the client
Indicators
Medical treatment/therapy***
 Chemotherapy***
 Dialysis***
 Mechanical ventilation/oxygen therapy***
 Ostomy (specify)***
 Radiation therapy***
 Other (specify, e.g., speech, Occupational Therapy, Physical Therapy)***
Surgical treatment***
 Coronary artery bypass graft (CABG)***

 Gastric bypass (specify type)***
 Intestinal resection***
 Joint/orthopedic surgery/replacement***
 Limb amputation***
 Organ transplant (specify)***
 Total gastrectomy***
Palliative/end-of-life care (care of client with terminal or life-threatening conditions)***
interview, medical record, referring health care provider or agency
diagnoses: Impaired nutrient utilization, increased nutrient needs, altered gastrointestinal function,
biting/chewing (masticatory) difficulty, unintended weight loss.
Client Example
Example(s) of one of the Nutrition Care Indicators (includes sample initial assessment documentation for
one of the indicators)
Radiation therapy

3. Goal: Client receiving radiation therapy for lung cancer, experiencing decreased appetite and pain
with eating. Goal is to optimize nutrition during radiation therapy.
Initial nutrition assessment Client receiving radiation therapy for lung cancer, experiencing decreased
with client appetite due to fatigue and pain with eating.
References
3. Academy of Nutrition and Dietetics. Evidence Analysis Library. https://www.andeal.org/?auth=1.
Client History Domain– Social History

Social History (CH-3.1)

Definition
Client socioeconomic status, housing situation, medical support, and involvement in social groups
Indicators
Socioeconomic factors*** Occupation***
 Economic constraints  Stay-at-home mother***

 Student***
(major/minor)***  Retired***
 Access to medical care  Specify***
(full/limited/none)***
 Diverts food money to other Religion***
needs***
 Other (specify)***  Catholic***
 Jewish***
Living/housing situation***  Protestant***
 Lives alone*** Specify***

 Lives with family
member/caregiver***  Islam***
 Homeless***  Specify***
Domestic issues*** History of recent crisis***
 Specify***  Job loss***

 Family member death***
Social and medical support***  Trauma, surgery***
 Family members***
 Caregivers*** Daily stress level (high, moderate, low bodily
 Community group/senior or mental tension)***
center/church***
 Support group attendance (e.g.,
weight control, substance abuse,
etc.)***
Geographic location of home***
 Urban***
 Rural***
 Limited exposure to sunlight (vitamin
D)***

medical record, referring health care provider or agency
diagnoses: All
Client Example
Living/housing situation and Geographic location of home
1. reference-standards: Not applicable

2. Recommedation: Not applicable
Initial nutrition assessment Client is house bound, lives in a rural area, and receives one meal/day from
with client home delivery program.
References
Assessment. 2nd ed. Chicago: Academy of Nutrition and Dietetics; 2013.

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cFood/Nutrition-Related History Domain

– Food and Nutrient Intake

Energy Intake (FH-1.1)

Sample Nutrition Assessment and Monitoring and Evaluation Documentation

Food/Nutrition-Related History Domain – Food and Beverage Intake

Fluid Intake (FH-1.2.1)

1. Reference Standard: Reference intake standards

Sample Nutrition Assessment and Monitoring and Evaluation Documentation

1. Canadian Nutrient File. https://food-nutrition.canada.ca/cnf-fce/index-eng.jsp. Accessed February

Food/Nutrition-Related History Domain – Food and Beverage Intake

 Grains servings estimated in 24 hours (number/day)

Measured amount of food

 Grains servings measured in 24 hours (number/day)

 Number of meals estimated in 24 hours (number/day)

Measured meal and snack pattern

 Number of meals measured in 24 hours (number/day)

Diet (food and beverages) Quality Index

1. Reference Standard: Not applicable

Sample Nutrition Assessment and Monitoring and Evaluation Documentation

Food/Nutrition-Related History Domain – Food and Beverage Intake

Breastmilk*/Infant Formula Intake (FH-1.2.3)

 Breastmilk feeding attempts in 24 hours (number/day)

 Infant formula feedings in 24 hours (number/day)

Note: Breastfeeding ability and capacity can be found on the Breastfeeding

Weight change can be found on the Body Composition/Growth/Weight History reference

Number/consistency of bowel movements can be found on the Nutrition-Focused Physical

If provided via tube use the Enteral and Parenteral Nutrition Intake reference sheet.

Sample Nutrition Assessment and Monitoring and Evaluation Documentation

Based on mother’s recalls, infant formula intake volume estimated in 24 hours is

1. Academy of Nutrition and Dietetics. Pediatric Nutrition Care Manual.

Food/Nutrition-Related History Domain – Enteral/Parenteral Nutrition

Enteral Nutrition Intake (FH-1.3.1)

1. Reference-Standard: Not applicable

Sample Nutrition Assessment and Monitoring and Evaluation Documentation

Enteral nutrition formula volume in 24 hours meets 60% of recommended

Food/Nutrition-Related History Domain – Enteral/Parenteral Nutrition

Parenteral Nutrition Intake (FH-1.3.2)

 Composition (formula or description)

Intravenous fluids, eg, type; amount mL/day, mL/hr, mL with medications

1. Goal: Patient/client’s parenteral nutrition formula is at a rate of 50 mL per hour × 24 hours of

Sample Nutrition Assessment Documentation

Parenteral nutrition formula rate of 25 mL per hour × 24 hours of standard

Food/Nutrition-Related History – Bioactive Substances

Alcohol Intake (FH-1.4.1)

1. Reference Standard: Refer to country standards, if present, for alcohol reference standards.

Sample Nutrition Assessment and Monitoring and Evaluation Documentation

Food/Nutrition-Related History – Bioactive Substances

Estimated bioactive substance intake

1. Reference Standard:Not applicable

Sample Nutrition Assessment and Monitoring and Evaluation Documentation

Food/Nutrition-Related History – Bioactive Substances

Caffeine Intake (FH-1.4.3)

Sample Nutrition Assessment and Monitoring and Evaluation Documentation

Food/Nutrition-Related History – Macronutrient Intake

Fat Intake (FH-1.5.1)

Monounsaturated fat estimated intake in 24 hours (g/day)—defined as the approximate intake in

Measured fat intake

1. Reference Standard: Not applicable

Sample Nutrition Assessment and Monitoring and Evaluation Documentation

1. Academy of Nutrition and Dietetics. Nutrition Care Manual.

Food/Nutrition-Related History – Macronutrient Intake

Cholesterol Intake (FH-1.5.2)