NUTRITION CARE PROCESS

LECTURE / SECOND SEMESTER / MIDTERM TOPIC WEEK 7

NUTRITION ASSESSMENT

● Undernutrition
NUTRITIONAL ASSESSMENT
○ A deficiency state due to lack of calories and/or one
or more of the essential nutrients
● An evaluation of nutritional status of individual or population ● Overnutrition
through measurements of food and nutrient and evaluation of ○ Refers to an excess of one or more nutrients, but
nutrition-related health indicators usually due to an excess of energy
● The measurement of indicators of dietary status and
nutrition-related health status to identify the possible METHODS IN NUTRITIONAL ASSESSMENT
occurrence, nature, and extent of impaired nutritional status,
which can range from deficiency to toxicity
● A comprehensive approach, completed by a registered 1. Direct Method
dietitian, to defining nutritional status that uses medical, ● Based on the recognition of physical signs or
nutrition, and medication histories; physical examination, examination of changes in body components
anthropometric measurements; and laboratory data believed to be related to inadequate nutrition
○ Anthropometric methods
OBJECTIVES OF NUTRITIONAL ASSESSMENT
○ Biochemical/Laboratory methods
○ Clinical methods
General: ○ Biophysical
● To discover facts to guide action programs intended to ○ Dietary methods
improve nutrition and health 2. Indirect Method
● Based on examination of factors or proxy
Specific: measurements suggestive of nutritional deficiencies.
1. To identify specific nutritional problems of groups/persons at Individuals need not be examined directly
nutritional risk ○ Ecological factors
2. To assess the relationship between nutrition and health
ANTHROPOMETRIC METHOD
3. To determine the type of intervention to alter nutritional status
4. To map out the magnitude and geographical distribution of
malnutrition ● Measurements of variations of physical dimensions and the
5. To discover and analyze ecological factors responsible for gross composition of human body at different age levels and
malnutrition degrees of nutrition
6. To monitor the effects of nutrition intervention ● They involve the measurement of the physical dimensions and
gross composition of the body
PURPOSE OF NUTRITIONAL ASSESSMENT
● These measurements vary with age (sometimes with sex and
race) and degree of nutrition
● Strategic planning ● Useful in circumstances where chronic imbalances of protein
● Basis for program evaluation and energy have occurred
● Policy formulation ● Can detect moderate and severe degrees of malnutrition in
some cases, but they cannot be used identify specific nutrient
deficiency states
NUTRITIONAL STATUS
2 TYPES OF ANTHROPOMETRIC MEASUREMENT
1. Measurements that assess body size & growth indices
NUTRITION STATUS OR NUTRITURE ● Body weight
● Recumbent length and stature/height
● State of the body resulting from the consumption and ● Head circumference
utilization of nutrients ● Growth indices: weight-for-height, height-for-age,
● Condition of the body resulting from the ingestion, digestion, head circumference for age
absorption, transport and utilization of nutrients made ● Body mass index (BMI)
available to the body. It depends also on the body;s ability to 2. Measurements that determine body composition
digest and utilize the nutrients ● Measurements of body fat/assessment of body fat
from skin folds
Good or optimal nutrition ○ biceps skinfold; triceps skinfold;
● the body has adequate supply of essential nutrients that are subscapular skinfold; suprailiac skinfold
efficiently utilized such that growth and good health are ○ waist-to-hip ratio (WHR) and waist
maintained at the highest possible level circumference
Malnutrition ● Measurements of fat-free mass
● a pathological state due to relative or an absolute deficiency or ○ mid-upper arm circumference, mid-upper
excess of essential nutrients at the cellular level for a long arm muscle circumference (MUAMC),
period of time. The condition manifests itself by physical, mid-upper-arm muscle area (AMA)
physiological and biochemical abnormalities
USES
Forms of Malnutrition 1. Detect protein-energy malnutrition in all age groups
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 2. Evaluate the progress of growth of infants, children,
adolescents, and pregnant women
3. Monitor changes in growth and/or body composition over time
ADVANTAGES
1. Simple, safe and non-invasive techniques are involved
2. Inexpensive equipment is required
3. Relatively easy to carry out
4. Retrospective information is generated on past long-term
nutritional history, which cannot be obtained with equal
confidence using other techniques
5. Mild to moderate under nutrition, as well as sever states of
under or over nutrition, can be identified
6. Changes in nutritional status over time and from one
generation to the next, a phenomenon known as the secular
trend, can be evaluated
7. Screening tests that identify individuals at high risk to under or
over nutrition can be devised
ANTHROPOMETRIC ASSESSMENT
Commonly used anthropometric measurement
● Weight
● Length
● Circumference
● Assessment of Body Fat
● Assessment of Fat-Free Mass
Weight
● The most commonly used indicator of nutritional status and
fluid balance
● An assessment of body mass
● Very popular among health workers and parents because of its
usefulness as a source of health education
● Gives a sensitive indication of current nutritional status (acute
malnutrition)
Significance
● Weight loss may represent the presence of disease or
nutritional impairment
● Weight gain may indicate development of obesity or edema
Equipment
● Types of Scales Available
○ Beam balance or clinical scale
■ The most accurate weighing instrument
○ Spring balance
■ Measurements are less accurate since
the spring can become easily stretched
and thus become inaccurate from
frequent use or with the expansion of the
spring that occurs in unduly hot weather
○ Espada or butcher steelyard
■ Used in the Philippines. A simple and
inexpensive weighing apparatus. It is
compact or can easily be transported, but
it has to be suspended from the branch of
a tree or rood but within eye level reading.
Measuring Technique
● Preferably, a beam balance scale should be used; but if there
is no alternative, the butcher’s steelyard can be used. The
bathroom scale should not be used if the two scales are
available.
○ Weighing Infants
■ Cover the pan of pediatric scale with a
blanket or a towel
■ Balance the scale to zero
■ Place the infant in the middle of the pan
scale so the weight is well distributed
equally over the pan
■ Once the infant lying quietly, record the
weight to the nearest 10 g.
○ Weighing children and adults
■ Calibrate instruments with known weights
to determine accuracy of weighing scale
■ Scale must be placed on hard flat surface
■ Balance the scale to zero
■ Weigh the subjects barefoot and wearing
light clothing
■ Subject should stand unassisted in the
center of the platform without touching
anything
■ Subject should stand straight but relaxed
with hands at the sides and with the body
weight equally distributed on both fee
■ Read measurement at eye level and
record
■ Weight should be read to the nearest 100
g (0.1 kg)
■ Return scale to zero after measurements
Height
● It assess linear dimension which is composed of the legs,
pelvis, spine, and the skull
● Being a dimensional measurement it is less sensitive that
weight
● It assess linear growth
● Recumbent length is measured for infants, children less that 2
years old and children 24-36 months old who cannot stand
erectly without assistance
● For older children and adults, standing height (stature) is
measured
● Used as an index of chronic nutritional status of children and
adults
● It indicates “stunting” of a child full growth potential
○ Stunting
■ Slowing of skeletal growth; the end result
of a reduced rate of linear growth
● Length: length board of infantometer
● Height: several instruments can be used to measure stature
○ Stadiometer
○ Microtoise
○ Length Board
○ Tape or measuring stick affixed to a true vertical
surface
Measuring Techniques
● Length
○ The child shoes or socks should be removed
○ The child should lie in supine position (lying on
his/her back), with head towards to headboard and
the body parallel to the backboard
○ The child shoulder and buttocks should touch the
surface of the backboard
○ Two examiners are required to correctly position and
child; the first holds the child’s head so that it is
contact with the headboard while the second
examiner holds the child’s knee to keep them
straight and moves the footboard to rest firmly
against the heels
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 ○ Record measurements to the nearest 0.1 cm or
millimeter
● Height 5. Determine body mass index (BMI)
○ The subject should stand on the platform without a. Body Mass Index (BMI) is a measurement
shoes on of body fatness or adiposity. It is also
○ The subject should stand tall, feet flat, heels almost called the Quetelet Index
together looking straight ahead, shoulders replaced
with arms at the sides, legs straight and knees
together with shoulder blades, buttocks, and heels
touching the measurement surface
○ Make sure that the subject’s knees are not flexed
and the heels are not lifted from the floor BMI IN ADULTS
○ Lower the moveable headboard or horizontal are ● Limitation
gently until it firmly touched the crown of the head ○ BMI does not distinguish between weight associated
○ Take the measurement with the examiner eyes level with muscle or weight body fat
with the headboard to avoid parallax errors ■ Two people with similar BMI may have
○ Read it to the nearest millimeter significant differences in their fat mass
and fat-free mass
Commonly used indices from measurement of weight and height ○ BMI does not give an indication about the
● Weight for age distribution of body fat
○ The most commonly used method of interpreting ■ Waist circumference and/or skinfolds can
weight data because it is easy to compute and be measured to get this information
understandable to all; it refers to the weight of a
certain individual at a certain age. It is an index of BMI WHO CLASSIFICATION
under nutrition and widely used to assess
protein-energy malnutrition and overnutrition when
the measurement of length is difficult
● Height for age
○ Height is expressed as a function of the height of a
reference population of the same age. It is an index
of past or chronic nutritional status
● Weight for height
○ A sensitive index of current nutritional status. It is
age-independent for the first 10 years of life. It is a
measure of wasting IOTF - ASIA PACIFIC GUIDELINES

Commonly used indices from measurement of weight and height

● Weight for adults can be interpreted using any of the following
methods:
1. Compare the actual weight to desirable body weight
(DBW tables. Use midpoint if a range of values is
give
2. Compute DBW based in height
a. For the two methods, a %DBW higher
than 120 indicates obesity, %DBW less
than 90 indicates undernutrition
3. Compare present wight with % standard weight, Cut-off points in classifying adults and lactating women based on
a. %standard weight = ABW x 100 BMI (FNRI)
DBW

4. Determine recent weight change

a. Recent weight change relates %UBW to
BMI-FOR-AGE AS INDICATOR OF CHILD OVERWEIGHT/OBESITY
the weight change
● WHO recommends the use of internationally derive,
i. 5% weight loss in less than a
age-specific BMI values for children that are equivalent to BMI
month or 10% weight loss in
adult definitions for overweight (>25) and obesity (>30)
less than 6 months identifies an
individual with nutritional risk
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EPIDEMIOLOGICAL CRITERIA FOR ASSESSING SEVERITY OF Clinical threshold indicating obesity:
UNDERNUTRITION IN POPULATION OF UNDER-FIVE CHILDREN ● >102 cm for males (=40 inches)
● >88 cm for females (=35 inches)

WAIST AND HIP RATIO

CIRCUMFERENCE MEASUREMENTS
1. Head circumference
● An important procedure to detect abnormalities of
head and brain growth particularly in first year of life
2. Chest/Head circumference ratio
● Detects protein-energy malnutrition in young
children. A C/H ratio of less than one (<1) for
children aged 6 months to 5 years is indicative of fat
and muscle wasting on the chest as well as failure
Recommended WHR:
to develop
● A valuable indicator of body fat distribution and adiposity. It
allows differentiating between the profile or adipose tissue in
overweight patients of the apple type, the pear shape and the
intermediate type. It is also a valuable guide in evaluating
health risk (heart disease, diabetes, etc.)
● Gynoid “pear-shaped” people store more fat in the buttocks,
thighs, and hips. Android “apple-shaped” people carry their
extra fat around abdomen/upper body.
● Male <1
● Female <.85

ASSESSMENT OF BODY FAT

● Body fat can be assessed through skinfold measurement

Methods of measuring subcutaneous fat

1. Physical and chemical analysis
2. Ultrasonics
3. Densitometry
4. Gaseous uptake of fat-soluble gases
5. Radiological anthropometry

ASSESSMENT OF FAT-FREE MASS

3. Mid-Upper Arm circumference
● Can be used for rapid diagnosis of protein-energy
malnutrition in children 1-4 years of age. It is used to
evaluate fat stores. MUAC measures the size of the
arm and all of its components: muscle mass,
subcutaneous fat, and bone. It provides an estimate
of arm soft tissue or wasting
Techniques in measurements
BIOCHEMICAL/LABORATORY METHODS
1. Use either non-stretchable tape, an insertion tape or shakir
tape
2. Have subject sit with the left arm (if right-handed and
vise-versa) hanging freely at the side
3. Mark the midpoint between the acromion and olecranon
4. Place the tape gently but firmly around the mid-upper arm
5. Measure three times; readings are taken to the nearest
centimeters. Average the results of 3 measurements
INTERPRETATION OF MUAC MEASUREMENT
LAB TEST FOR ASSESSING VITAMIN AND MINERAL STATUS
● The fat-free mass is a mixture of protein, minerals, and water.
The muscle serves as the major protein source. Assessment
of muscle mass provides an index of protein reserves of the
body
● Muscle mass can be determined by measuring arm muscle
area
● Arm muscle area cannot be measured directly but it can be
derived mathematically using MUAC and triceps skinfold
measurement
● Several stages in the development of nutritional deficiencies
can be identified by laboratory
● In under-or over nutrition, the tissue stores of
nutrients/gradually change which are detected in the levels of
nutrients or in the levels of their metabolic products in certain
fluids and tissues, and/or in the activity of some
nutrient-dependent enzymes

WAIST CIRCUMFERENCE
● It measures of obesity
● It reflects intra-abdominal fat mass

Recommended Waist Circumference

● <102 cm fat males
● <88 cm for females
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COMMON LABORATORY EXAMINATION

CLINICAL METHOD

● They use medical history and physical examination to detect

sign (observation made by a qualified examiner) and
symptoms (manifestations reported by the patient) associated
with malnutrition
● Signs and symptoms are often non-specific and only develop
during the advance stages of nutritional depletion

PHYSICAL SIGNS OF NUTRITIONAL STATUS

DIETARY METHODS

• They identify the first stage of any nutritional deficiency

• In this stage, the dietary intake of one or more nutrients is
inadequate, either due to primary deficiency or secondary
deficiency. Secondary deficiency results even if dietary intakes may
be adequate but conditioning factors (i.e. intake of certain drugs,
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 certain disease states interfere with the ingestion, absorption,
transport, utilization or excretion of nutrients
ASSESSMENT BY DIETARY METHODS
1. Diet History
● A comprehensive record of eating-related behavior
and food intake
2. 24-hour food recall
● A record of foods consumed by person in the last 24
hours
3. Food frequency
● A record of how often the different foods are eaten.
The types (and sometimes the amount) of foods a
person routinely consumed in a week or month can
also be included
4. Calorie Count
● A determination of a client's food intake from a direct
observation of how much the person eats
5. Food record/ Food diary
● A record of food intake; the client takes down all the
foods eaten over a period of time and this may
include records of behavior and symptoms, physical
activity and medication
ECOLOGICAL
● Aside from these assessment methods, some ecological factors
known to influence nutrition status of individuals or populations are
often collected. These include:
○ Household composition, education, literacy, ethnicity, religion,
income, employment, material resources, water supply and
household sanitation, access to health and agricultural
services, land ownership
○ Additional data on food prices, adequacy of food preparation
equipment, percentage of household income spent on certain
foods
○ Data on health and vital statistics
○ Non-nutritional variables strongly related to malnutrition: birth
order over severe breakdown of marriage, death of either
parents, and episodes of infectious diseases in early life
NUTRITIONAL CARE PROCESS: NUTRITION ASSESSMENT
Nutrition Assessment
● Once nutrition screening has identified a patient to be at
nutritional risk, a nutritional assessment should be done to
determine the severity and causes of the patient nutritional
impairment, to evaluate whether the nutritional impairment is a
factor contributing to the worsening of the patient’s medical
condition, and to monitor the patient’s response to nutrition
support
Nutrition Assessment Data comes from two sources:
1. Health Record System:
● Laboratory data
● Medical diagnosis
● Epidemiological studies
● Administrative reports
2. Created during assessment, to be added to medical
record
● Nutritional intake
● Current anthropometric measures
● Additional client history gathered in interview
NUTRITION ASSESSMENT
Once nutrition screening has identified a patient to be at
nutritional risk, a nutritional assessment should be done to determine the
severity and causes of the patient nutritional impairment, to evaluate
whether the nutritional impairment is a factor contributing to the
worsening of the patient’s medical condition, and to monitor the patient’s
response to nutrition support.
Nutrition Assessment Data comes from two sources:
1. Health Record System
● Laboratory data
● Medical diagnosis
● Epidemiological studies
● Administrative reports
2. Created during assessment, to be added to medical
record
● Nutritional intake
● Current anthropometric measures
● Additional client history gathered in interview
➔ It is the first step in the Nutrition Care Process (NCP)
➔ It involves the collection, review clustering and interpretation of
factors affecting a patient’s nutritional and health status
Nutrition Assessment Domains:
1. Food/Nutrition Related History (FH)
2. Anthropometric Measurements (AD)
3. Biochemical Data, Medical Tests and Procedures (BD)
4. Nutrition-Focused Physical Findings (PD)
5. Client History (CH)
6. Comparative Standards (CS)
FOOD/NUTRITION-RELATED HISTORY
● Includes data related to food and nutrient intake and
physical activity.
Consists of four areas:
1. Food Intake
● Include factors such as composition and adequacy
of food and nutrient intake, meal and snack
patterns, environmental cues to eating, food and
nutrient tolerance, and current diets and/or food
modifications.
2. Nutrition and Health awareness and management
● Include, for example, knowledge and beliefs about
nutrition recommendations, self-monitoring/
management practices, and past nutrition
counseling and education.
3. Physical activity and Exercise
● Consists of functional status, activity
patterns,amount of sedentary time (e.g., TV, phone,
computer), and exercise intensity, frequency, and
duration.
4. Food Availability
● Encompassess factors such as food planning,
purchasing, preparation, abilities and limitations,
food safety practices, food/nutrition program
utilization, and food insecurity,
Domain: Food/Nutrition- Related History
Classes:
1. Food and nutrient intake
● Include factors such as composition and adequacy
of food and nutrient intake, and meal and snack
patterns.
2. Food and Nutrient Administration
● Include current and previous diets and/or food
modifications, eating environment, and enteral and
parenteral nutrition administration.
3. Medication and Complementary/Alternative Medicine Use
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 ● Includes prescription and over the counter medications, Classes:
including herbal preparations and complementary medicine ● Nutrition-Focused Physical Findings
products used. ○ Overall findings
4. Knowledge, Beliefs, Attitudes ○ Adipose
● Includes understanding of nutrition-related concepts ○ Bones
and conviction of the truth and feelings/emotions ○ Cardiovascular-pulmonary system
toward some nutrition-related statement or ○ Digestive system
phenomenon along with readiness to change
CLIENT HISTORY
nutrition-related behavior.
5. Behavioral factors affecting achievement of nutrition
related goals Domain: Client History
● Include patient/client activities and actions which ● Involves information on personal, individual and family medical
influence achievement of nutrition-related goals and health history, living/housing situation and social support
6. Factors affecting access to food and
food/nutrition-related supplies Classes:
● Includes factors that affect intake and availability of ● Personal history
a sufficient quantity of safe, healthful food and water ● Patient/client/family medical/ health history
as well as food/nutrition-related supplies ● Social History
7. Physical activity and function
● Includes physical activity, cognitive and physical COMPARATIVE STANDARDS
ability to engage in specific tasks, e.g.,
breastfeeding and self-feeding Domains: Client History
8. Nutrition-related patient/client-centered measures ● Includes reference standards or individual goals against which
● Consists of the patient/client's perception of his or the dietitian compares the nutrition assessment data
her nutrition intervention and its impact on life.
Classes:
● In order to determine if an individual or group’s diet is ● Energy needs
adequate, information regarding intake must be gathered ● Macronutrient needs
and evaluated. ● Fluid needs
● Micronutrient needs
Methods to acquire information: ● Weight and Growth recommendation
● 24 hour food recall
● Food frequency questionnaire There are a few issues and limitations when using reference or
● Food record comparative standards during assessment:
● Accurate measurements for dietary intake in often difficult due
ANTHROPOMETRIC MEASUREMENTS
to the subjective nature of the assessment tools
● The reference or comparative standards are population based
Domain: Anthropometric Measurements and do not represent any one individual.
● Involves the use of body measurements including growth, ● It is important to understand the population for whom the
weight, height, body mass and frame size to assess nutritional standard is developed, e.g., the DRIs are developed for
status healthy individuals
● The individual or population your assessing may or may not be
Classes: healthy
● Height
● Weight
● Frame SAMPLE CASE STUDY
● Weight change
● Body mass Description of patient:
● Growth pattern indices ● 67 year old Hispanic male
BIOCHEMICAL DATA, MEDICAL TESTS AND PROCEDURES ● Medical diagnosis of heart failure (diagnosed 2 months prior)
● Retired engineer
● Lives alone in apartment
Domain: Biochemical Data, Medical Tests, and Procedures ● Height 5’6 : Weight: 135 lbs.
● Includes tests and procedures used to make diagnosis ● Weight loss of 20 lbs. From dyspnea
● Inability to consume large meals
Classes: ● Unable to shop or cook
● Acid-base intake ● 24 hour recall indicates be uses many frozen and processed
● Electrolyte and renal profile foods; intake between 1000-1200 kcal/day
● Essential fatty acid profile
● Gastrointestinal profile
● Glucose/endocrine profile SAMPLE NUTRITION ASSESSMENT
● Inflammatory profile

NUTRITION-FOCUSED PHYSICAL FINDINGS (FD) Domain: Food/Nutrition Related History

Class: Food and Nutrient Intake
● Total energy intake: 1000 -1200 kcal/day
Domain: Nutrition-Focused Physical Findings ● Unable to consume large meals
● Includes findings obtained by evaluation body systems in a ● Convenience frozen meals
Nutrition-Focused physical exam. Sources of data include
physical examination, medical records and direct observations Class: Behavior
● Do not like eating alone
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Class: Physical Activity and Function
● Inability to shop for food and cook

Domain: Anthropometric Measurement

Class: Body composition/growth/weight history
Height: 5’6
Weight: 135 lbs.
Weight change: decrease of 20 lbs. over 2 months

Domain: Biochemical Data, Medical Test and Procedure

● No information

Domain: Nutrition-Focused Physical Findings (PD)

● No information

Domain: Client History

Class: Personal History
● Age: 67 years old
● Gender: Male
● Ethnicity: Hispanic
● Language: Spanish/English

Class: Patient/Client/Family Medical/Health History

● Patient has medical diagnosis of heart failure in last 2 months,
dyspnea

Class: Social History

● Patient living in apartment 4 blocks from medical center
● Retired engineer

Domain: Comparative Standards

Class: Energy Needs
● 1850 kcal/day to maintain weight

Class: Micronutrient needs

● Sodium less than 2000 mg/day

Class: Weight and Growth Recommendation:

DBW: 136 lbs. Or 62 kg
Body Mass Index: 21.78 (Normal)
Recommended BMI between 19-24.9

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NUTRITION CARE PROCESS
LECTURE / SECOND SEMESTER / MIDTERM TOPIC WEEK

NUTRITION DIAGNOSIS

NUTRITION DIAGNOSIS PES Statement Format

P Problem The Nutrition Diagnosis the nutrition

● The second step in the NCP
problems
● Identification and labeling that describes and actual
occurrence, risk of, or potential for developing a nutritional
E Etiology related to…
problem that dietetic professionals are responsible for treating
The cause of cause of the nutrition
independently
diagnosis
● Nutrition Diagnosis identifies that nutrition-related problem that
dietetic intervention can improve or resolve such as “excess
S Signs and as evidence by:
potassium” in the diet of someone requiring dialysis, or
Symptoms The evidence that the nutrition diagnosis
“inconsistent carbohydrate intake” in some diagnosed with
and etiology exist
diabetes
● Nutrition diagnosis is different from a medical diagnosis. A
medical diagnosis describes disease condition or pathology
such as “cardiovascular disease” or “diabetes” PES STATEMENT CHARACTERISTICS

Medical Diagnosis Nutritional Diagnosis ● Based in reliable and accurate nutrition assessment data
● Accurately elated to an etiology
Definition: Describes a disease, Definition: Identifies the nutrition ● simple , clear, concise
condition or pathology such as related problem that dietetic ● Specific to the patient/client/group
cardiovascular disease or intervention can improve or ● Related to a single patient/client nutrition-related problem
diabetes resolve, such as “excess
potassium” in the diet of P - PROBLEM
someone requiring dialysis or
“inconsistent carbohydrate
intake” in someone diagnosed The Nutrition Diagnosis identifies the specific nutrition problem
with diabetes. that the dietitian is responsible for treating and works towards resolving.
There are 3 classifications of the nutrition diagnosis: intake, clinical, and
Example: Diabetes Example: Excessive behavioral.
carbohydrate intake related to
visits to DanMig’s Creamery as Nutrition Diagnosis Domain
evidenced by diet hx and high 1. Intake
blood glucose ● There related to nutrition and intake related
problems
Nutrition Assessment: 2. Clinical
High blood pressure lots of process foods and salt ● These diagnoses include medical or physical
conditions that have a nutritional impact.
Nutrition Diagnosis: 3. Behavioral-Environment
Hypertension? ● This category covers the nutritional problems
Excessive intake of sodium? associated with nutrition knowledge and belief
(including attitude), physical activity and function
(e.g. ability to self care) and food access and safety.
4. Other
PES STATEMENT
● Where there is no nutritional diagnosis

● Nutrition Diagnosis is summarized into a structured sentence.
It is called either the Nutrition Diagnosis statement or the
Problem/Etiology/Signs and Symptoms (PES Statement).
● Three Elements of PES Statement
○ Problem
■ The nutrition issue
○ Etiology
■ Defined as the “the cause, set of cause,
or manner of causation of a disease or
condition
○ Signs and Symptoms
■ Provide evidence for the nutrition
diagnosis
INTAKE
● Includes problems related to nutrition intake through diet and
nutrition support intake diagnoses cover that include a
patient’s energy balance and intake of fluid, nutrients, and
bioactive substances.
Classes:
● Energy balance
○ Actual or estimated changes in energy
● Oral or Nutrition Support Intake
○ Actual or estimated food and beverage intake from
oral diet or nutrition support compared with
patient/client goal
● Fluid Intake

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 ○ Actual or estimated fluid intake compared with ● Not ready for diet/lifestyle change - lack of perceived value of
patient/client’s goal nutrition-related behavior change compared to cost
● Bioactive Substances Intake (consequences or effort required to make changes)
○ Actual or observed intake of bioactive substances,
OTHER
including single or multiple functional food
components, ingredients, dietary supplements, and
alcohol. ● Has only one term. It is used when the dietitian concludes,
● Nutrient Intake after the Nutrition Assessment, that there is no Nutrition
○ Actual or estimated intake of specific nutrient groups Diagnosis to resolve
or single nutrients as compared with desired levels.
Classes:
EXAMPLE: ● No nutrition diagnosis at this time
Domain: Intake
Class: Energy Intake
● Inadequate Energy - Energy intake is less than energy E - ETIOLOGY
expenditure or recommended physiological needs.

CLINICAL ● The etiology describes the cause of the nutrition diagnosis in

the PES statement. The Nutrition Intervention should be aimed
at resolving the Etiology (underlying cause of the nutrition
● Includes findings/problems related to medical and physical problem). The etiology statement is free text. Etiologies are
condition. The clinical category covers functional changes or grouped in categories according to cause of the diagnosis
impairments, biochemical changes and weight ● There is no incorrect etiology statement, but it should include
these general points:
Classes: ○ The etiology is the “root cause” of the Nutrition
● Functional Diagnosis.
○ Changes in physical or mechanical functioning that ○ The Nutrition Intervention, should aim to resolve or
interferes with or prevents desired nutritional at least attempt to improve the Etiology
consequences ○ The Etiology is supported by the nutrition
● Biochemical assessment data.
○ Changes in the capacity to metabolize nutrients as a
result of medications, surgery, or as indicated by LIST OF CATEGORIES OF ETIOLOGY
altered lab values ● Access
● Weight ○ Limited or no access to services due to isolated
○ Chronic weight or changed weight status when location
compared with usual or desired body weight ● Behavior
○ Disordered eating, excessive exercise or refusing
EXAMPLE: food, so as to prevent patient from achieving
Domain: Clinical nutrition goals
Class: Functional ● Belief / Attitudes
● Swallowing difficulty - impaired movement of food and liquid ○ About change, such as “time constraints prevent me
from the mouth to the stomach from changing my diet”
BEHAVIORAL-ENVIRONMENTAL ● Cultural
○ Social or religious customs: that the practice of
fasting for religious occasions alters usual eating
● Includes problems of access to food and water, the patient’s patterns
level of physical activity and function; and access to ● Environmental / Physical
nutrition-related supplies ○ Inability to self-feed
● Knowledge
Classes: ○ Level of food nutrition-related knowledge
● Knowledge and Beliefs ● Psychological
○ Actual knowledge and beliefs are reported, ○ Depression, mental illness or dysfunctional thoughts
observed, or documented relating to food
■ Food - and nutrition - related knowledge ● Physiological
deficit ○ Metabolic changes related to malabsorption
■ Not ready for diet/lifestyle change ● Social / Personal
■ Undesirable food choices ○ Limited family or social support, financial challenges
● Physical Activity and Function ● Treatment
○ Actual physical activity, self-care and quality of life ○ Reduced appetite related to medications or medical
problems as reported observed or documented / surgical treatment
■ Physical inactivity
■ Excessive physical activity
S - SIGNS AND SYMPTOMS
● Food Safety and Access
○ Actual problems with food access or food safety
■ Intake of unsafe food ● Signs are objective data obtained through direct physical
■ Limited access to food examination, observation, lab values and test results.
● Symptoms are subjective data reported by client’s or their
EXAMPLE: family’s rather than actual results.
Domain: Behavioral - Environmental ● Like Etiology, Signs and Symptoms in the PES Statement are
Class: Knowledge and Beliefs free text. It is an important skill for a dietitian to identify the

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 Signs and Symptoms that demonstrate a Nutrition Diagnosis ○ The impact of the nutrition problem of the patient’s
exists. The signs and symptoms statement should support the medical condition or health status
Nutrition Diagnosis. It should be specific, so it can be ○ The patient’s personal needs and their
monitored and measured, to be able to evaluate changes. understanding of the importance of the diagnosis
○ The information provided in the medical referral
EXAMPLE OF NUTRITION DIAGNOSIS STATEMENT ○ The patient’s preferences
○ The likelihood that the associated Nutrition
Intervention will make a significant improvement
Diagnosis or Problem Etiology Signs and Symptoms
● As a general rule apply the Intake related Nutrition
Diagnoses first because these are specific to the dietitian's
Excessive related to Frequent As Increasing role. Clinical Nutrition and Behavioral - Environmental
fat intake consumpti evidence serum Diagnoses follow. Behavioral - Environmental related
on of by cholesterol nutrition diagnoses are best applied as the Etiology.
fast-food level
meals
EVALUATION THE PES STATEMENT
Disordered related to Harmful As Use of
eating belief evidence laxatives
● P (selecting the Problem)
pattern about food by after meals
○ Can the nutrition professional resolve or improve the
and
nutrition diagnosis for the patient/client
nutrition
● E (selecting the Etiology)
○ Evaluate whether the etiology is the specific “root
Altered GI related to Undesirabl As Inadequate
cause” that can be addressed with a nutrition
function e food evidence fiber and
intervention. If addressing the etiology cannot
choices by fluid intake
resolve the problem, can the RND intervention at
and
least lessen the signs and symptoms?
excessive
● S (selecting the Signs and Symptoms to address)
intake of
○ Will measuring the signs and symptoms indicate if
refined
the problem is resolved or improved?
carbohydra
○ Are the signs and symptoms specific enough that
tes
the RND can monitor (measure / evaluate changes)
and document resolution or improvement of nutrition
diagnosis
NUTRITION DIAGNOSTIC TERMINOLOGY
EXAMPLE OF EVALUATION
● PES Statement: Excessive Fat Intake related to limited access
to healthful options - frequent consumption of high fat,
fast-food meals as evidenced by serum cholesterol level of
230 mg/dL and patient report of 10 meals per week of
hamburgers and fries.
● Evaluation:
1. Can the RND resolve the problem?
2. Does the etiology make sense? Does it match the
assessment data?
3. Is there a reasonable intervention
4. Can you monitor this patient on the basis of the
stated signs and symptoms?

SAMPLE CASE STUDY

Mrs. Dela Cruz has type 2 diabetes and has been referred for
ongoing nutritional care by her primary care physician. The last blood
test showed a hemoglobin A1c level of 9.3% (78.1 mmol/mol)

You conduct a Nutrition Assessment. The patient is 65 years

PRIORITIZING NUTRITION DIAGNOSIS
● Dietitians will often identify more Nutrition Diagnoses that can
be addressed in one consultation. By ranking these diagnoses
in order of urgency, the practitioner can target those that are
most important. It order to determine which diagnoses should
take priority, the dietitian will assess:
old and lives by herself. The diabetes diagnosis was made two years
ago. She takes metformin twice daily. Height is 5 ft 3 in (160 cm) and
weighs 139 lbs (63 kg). BMI is 24.6 kg/m. Her weight has been stable for
several years. She does not eat breakfast, and has a light lunch
consisting of two jelly sandwiches (four slices white bread and 4 tbsp
jelly) and a glass or regular soda. The evening meal is 6 pcs salami with
6 tbs mixed vegetables and three cups of cooked rice and a canned
pineapple juice. Her only income is the old-age pension and money is
tight. She does not snack, and drinks only water and unsweetened black
coffee or iced tea.
NUTRITION ASSESSMENT

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NUTRITION DIAGNOSIS