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Nutrition Diagnosis: A Critical Step in the Nutrition Care Process
Nutrition Diagnosis: A Critical Step in the Nutrition Care Process
ISBN: 0-88091-358-4
Copyright 2006, American Dietetic Association. All rights reserved. No part of this
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Nutrition Diagnosis: A Critical Step in the Nutrition Care Process
Table of Contents
Section I: The Nutrition Care Process
Nutrition Care Process and Model Article ....................................................................1
Section II: Development of Standardized Language
American Dietetic Association’s Standardized Language Model: Current Status.....13
Section III: Introduction to Nutrition Diagnosis
Introduction to Nutrition Diagnoses/Problems ...........................................................17
Section IV: Nutrition Diagnosis Reference Sheets
Single Page List of Nutrition Diagnostic Terminology................................................22
Section V: Nutrition Diagnosis Terms and Definitions
Nutrition Terms and Definitions ..................................................................................23
Section VI: Appendix
Procedure for NutritionControlled Vocabulary/Terminology Maintenance/Review 154
Acknowledgements Task Force Members..................................................................................................160
Consultants ................................................................................................................161
Research Reviewers ...................................................................................................162
Additional Reference on Implementation of Nutrition Care Process ....................................165
Feedback Form ......................................................................................................................171
Camera Ready Pocket Guide .................................................................................................173
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Nutrition Care Process and Model: ADA adopts roadmap to quality care and outcomes managementKAREN LACEY, MS, RD; ELLEN PRITCHETT, RD
The establishment and implementation of a standardizedNutrition Care Process (NCP) and Model were identified aspriority actions for the profession for meeting goals of the
ADA Strategic Plan to “Increase demand and utilization of ser-vices provided by members” and “Empower members to com-pete successfully in a rapidly changing environment” (1). Pro-viding high-quality nutrition care means doing the right thing atthe right time, in the right way, for the right person, and achiev-ing the best possible results. Quality improvement literatureshows that, when a standardized process is implemented, lessvariation and more predictability in terms of outcomes occur(2). When providers of care, no matter their location, use aprocess consistently, comparable outcomes data can be gener-ated to demonstrate value. A standardized Nutrition Care Pro-cess effectively promotes the dietetics professional as theunique provider of nutrition care when it is consistently used asa systematic method to think critically and make decisions toprovide safe and effective nutrition care (3).
This article describes the four steps of ADA’s Nutrition CareProcess and the overarching framework of the Nutrition CareModel that illustrates the context within which the NutritionCare Process occurs. In addition, this article provides the ratio-nale for a standardized process by which nutrition care is pro-vided, distinguishes between the Nutrition Care Process andMedical Nutrition Therapy (MNT), and discusses future impli-cations for the profession.
BACKGROUNDPrior to the adoption of this standardized Nutrition Care Pro-cess, a variety of nutrition care processes were utilized by prac-titioners and taught by dietetics educators. Other allied health
professionals, including nursing, physical therapy, and occupa-tional therapy, utilize defined care processes specific to theirprofession (4-6). When asked whether ADA should develop astandardized Nutrition Care Process, dietetics professionalswere overwhelmingly in favor and strongly supportive of havinga standardized Nutrition Care Process for use by registereddietitians (RD) and dietetics technicians, registered (DTR).
The Quality Management Committee of the House of Dele-gates (HOD) appointed a Nutrition Care Model Workgroup inMay 2002 to develop a nutrition care process and model. Thefirst draft was presented to the HOD for member input andreview in September 2002. Further discussion occurred duringthe October 2002 HOD meeting, in Philadelphia. Revisionswere made accordingly, and the HOD unanimously adopted thefinal version of the Nutrition Care Process and Model on March31, 2003 “for implementation and dissemination to the dieteticsprofession and the Association for the enhancement of thepractice of dietetics.”
SETTING THE STAGE
Definition of Quality/Rationale for a StandardizedProcessThe National Academy of Science’s (NAS) Institute of Medi-cine (IOM) has defined quality as “The degree to which healthservices for individuals and populations increase the likelihoodof desired health outcomes and are consistent with currentprofessional knowledge” (7,8). The quality performance of pro-viders can be assessed by measuring the following: (a) theirpatients’ outcomes (end-results) or (b) the degree to whichproviders adhere to an accepted care process (7,8). The Com-mittee on Quality of Health Care in America further states thatit is not acceptable to have a wide quality chasm, or a gap,between actual and best possible performance (9). In an effortto ensure that dietetics professionals can meet both require-ments for quality performance noted above, the American Di-etetic Association (ADA) supports a standardized NutritionCare Process for the profession.
Standardized Process versus Standardized CareADA’s Nutrition Care Process is a standardized process fordietetics professionals and not a means to provide standardizedcare. A standardized process refers to a consistent structureand framework used to provide nutrition care, whereas stan-
K. Lacey is lecturer and Director of Dietetic Programs
at the University of Wisconsin-Green Bay, Green Bay. She
is also the Chair of the Quality Management Committee.
E. Pritchett is Director, Quality and Outcomes at ADA
headquarters in Chicago, IL.
If you have questions regarding the Nutrition Care Pro-
cess and Model, please contact Ellen Pritchett, RD, CPHQ,
Director of Quality and Outcomes at ADA,
Copyright © 2003 by the American Dietetic Association.
0002-8223/03/10308-0014$35.00/0
doi: 10.1053/jada.2003.50564
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dardized care infers that all patients/clients receive the samecare. This process supports and promotes individualized care,not standardized care. As represented in the model (Figure 1),the relationship between the patient/client/group and dieteticsprofessional is at the core of the nutrition care process. There-fore, nutrition care provided by qualified dietetics profession-als should always reflect both the state of the science and thestate of the art of dietetics practice to meet the individualizedneeds of each patient/client/group (10).
Using the NCPEven though ADA’s Nutrition Care Process will primarily beused to provide nutrition care to individuals in health care set-tings (inpatient, ambulatory, and extended care), the processalso has applicability in a wide variety of community settings. Itwill be used by dietetics professionals to provide nutrition careto both individuals and groups in community-based agenciesand programs for the purpose of health promotion and diseaseprevention (11,12).
Key TermsTo lay the groundwork and facilitate a clear definition of ADA’sNutrition Care Process, key terms were developed. These def-initions provide a frame of reference for the specific compo-nents and their functions.
(a) Process is a series of connected steps or actions to
achieve an outcome and/or any activity or set of activities thattransforms inputs to outputs.
(b) Process Approach is the systematic identification andmanagement of activities and the interactions between activi-ties. A process approach emphasizes the importance of thefollowing:■ understanding and meeting requirements;■ determining if the process adds value;■ determining process performance and effectiveness; and■ using objective measurement for continual improvement ofthe process (13).
(c) Critical Thinking integrates facts, informed opinions, ac-tive listening and observations. It is also a reasoning process inwhich ideas are produced and evaluated. The Commission onAccreditation of Dietetics Education (CADE) defines criticalthinking as “transcending the boundaries of formal educationto explore a problem and form a hypothesis and a defensibleconclusion” (14). The use of critical thinking provides a uniquestrength that dietetics professionals bring to the Nutrition CareProcess. Further characteristics of critical thinking include theability to do the following:■ conceptualize;■ think rationally;■ think creatively;■ be inquiring; and■ think autonomously.
FIG 1. ADA Nutrition Care Process and Model.
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(d) Decision Making is a critical process for choosing the bestaction to meet a desired goal.
(e) Problem Solving is the process of the following:■ problem identification;■ solution formation;■ implementation; and■ evaluation of the results.
(f) Collaboration is a process by which several individuals orgroups with shared concerns are united to address an identifiedproblem or need, leading to the accomplishment of what eachcould not do separately (15).
DEFINITION OF ADA’S NCPUsing the terms and concepts described above, ADA’s Nutri-tion Care Process is defined as “a systematic problem-solvingmethod that dietetics professionals use to critically think andmake decisions to address nutrition related problems and pro-vide safe and effective quality nutrition care.”
The Nutrition Care Process consists of four distinct, but in-terrelated and connected steps: (a) Nutrition Assessment, (b)Nutrition Diagnosis, (c) Nutrition Intervention, and d) Nutri-tion Monitoring and Evaluation. These four steps were finalizedbased on extensive review and evaluation of previous worksdescribing nutrition care (16-24). Even though each stepbuilds on the previous one, the process is not linear. Criticalthinking and problem solving will frequently require that die-tetics professionals revisit previous steps to reassess, add, orrevise nutrition diagnoses; modify intervention strategies;and/or evaluate additional outcomes. Figure 2 describes eachof these four steps in a similar format consisting of the follow-ing:■ definition and purpose;■ key components or substeps with examples as appropriate;■ critical thinking characteristics;■ documentation elements; and■ considerations for continuation, discontinuation, or dis-charge of care.
Providing nutrition care using ADA’s Nutrition Care Processbegins when a patient/client/group has been identified at nutri-tion risk and needs further assistance to achieve or maintainnutrition and health goals. It is also important to recognize thatpatients/clients who enter the health care system are morelikely to have nutrition problems and therefore benefit fromreceiving nutrition care in this manner. The Nutrition CareProcess cycles through the steps of assessment, diagnosis, in-tervention, and monitoring and evaluation. Nutrition care caninvolve one or more cycles and ends, ideally, when nutritiongoals have been achieved. However, the patient/client/groupmay choose to end care earlier based on personal or externalfactors. Using professional judgment, the dietetics professionalmay discharge the patient/client/group when it is determinedthat no further progress is likely.
PURPOSE OF NCPADA’s Nutrition Care Process, as described in Figure 2, givesdietetics professionals a consistent and systematic structureand method by which to think critically and make decisions. Italso assists dietetics professionals to scientifically and holisti-cally manage nutrition care, thus helping patients better meettheir health and nutrition goals. As dietetics professionals con-sistently use the Nutrition Care Process, one should expect ahigher probability of producing good outcomes. The NutritionCare Process then begins to establish a link between quality
and professional autonomy. Professional autonomy resultsfrom being recognized for what we do well, not just for who weare. When quality can be demonstrated, as defined previouslyby the IOM (7,8), then dietetics professionals will stand out asthe preferred providers of nutrition services. The NutritionCare Process, when used consistently, also challenges dieteticsprofessionals to move beyond experience-based practice toreach a higher level of evidence-based practice (9,10).
The Nutrition Care Process does not restrict practice butacknowledges the common dimensions of practice by the fol-lowing:■ defining a common language that allows nutrition practice tobe more measurable;■ creating a format that enables the process to generate quan-titative and qualitative data that can then be analyzed and in-terpreted; and■ serving as the structure to validate nutrition care and show-ing how the nutrition care that was provided does what it in-tends to do.
DISTINCTION BETWEEN MNT AND THE NCPMedical Nutrition Therapy (MNT) was first defined by ADA inthe mid-1990s to promote the benefits of managing or treatinga disease with nutrition. Its components included an assess-ment of nutritional status of patients and the provision of eitherdiet modification, counseling, or specialized nutrition thera-pies. MNT soon became a widely used term to describe a widevariety of nutrition care services provided by dietetics profes-sionals. Since MNT was first introduced, dietetics professionalshave gained much credibility among legislators and otherhealth care providers. More recently, MNT has been redefinedas part of the 2001 Medicare MNT benefit legislation to be“nutritional diagnostic, therapy, and counseling services for thepurpose of disease management, which are furnished by a reg-istered dietitian or nutrition professional” (25).
The intent of the NCP is to describe accurately the spectrumof nutrition care that can be provided by dietetics profession-als. Dietetics professionals are uniquely qualified by virtue ofacademic and supervised practice training and appropriatecertification and/or licensure to provide a comprehensive arrayof professional services relating to the prevention or treatmentof nutrition-related illness (14,26). MNT is but one specifictype of nutrition care. The NCP articulates the consistent andspecific steps a dietetics professional would use when deliver-ing MNT, but it will also be used to guide nutrition educationand other preventative nutrition care services. One of the keydistinguishing characteristics between MNT and the other nu-trition services using the NCP is that MNT always involves anin-depth, comprehensive assessment and individualized care.For example, one individual could receive MNT for diabetesand also nutrition education services or participate in a com-munity-based weight loss program (27). Each service woulduse the Nutrition Care Process, but the process would be im-plemented differently; the components of each step of the pro-cess would be tailored to the type of service.
By articulating the steps of the Nutrition Care Process, thecommonalities (the consistent, standardized, four-step pro-cess) of nutrition care are emphasized even though the processis implemented differently for different nutrition services. Witha standardized Nutrition Care Process in place, MNT should notbe used to describe all of the nutrition services that dieteticsprofessionals provide. As noted above, MNT is the only appli-cation of the Nutrition Care Process (28-31). This change in
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STEP 1. NUTRITION ASSESSMENT
Basic Definition &Purpose
“Nutrition Assessment” is the first step of the Nutrition Care Process. Its purpose is to obtainadequate information in order to identify nutrition-related problems. It is initiated by referral and/orscreening of individuals or groups for nutritional risk factors. Nutrition assessment is a systematicprocess of obtaining, verifying, and interpreting data in order to make decisions about the nature andcause of nutrition-related problems. The specific types of data gathered in the assessment will varydepending on a) practice settings, b) individual/groups’ present health status, c) how data are relatedto outcomes to be measured, d) recommended practices such as ADA’s Evidence Based Guides forPractice and e) whether it is an initial assessment or a reassessment. Nutrition assessment requiresmaking comparisons between the information obtained and reliable standards (ideal goals). Nutritionassessment is an on-going, dynamic process that involves not only initial data collection, but alsocontinual reassessment and analysis of patient/client/group needs. Assessment provides thefoundation for the nutrition diagnosis at the next step of the Nutrition Care Process.
Data Sources/Tools forAssessment
� Referral information and/or interdisciplinary records� Patient/client interview (across the lifespan)� Community-based surveys and focus groups� Statistical reports; administrative data� Epidemiological studies
Types of Data Collected � Nutritional Adequacy (dietary history/detailed nutrient intake)� Health Status (anthropometric and biochemical measurements, physical & clinical conditions,
physiological and disease status)� Functional and Behavioral Status (social and cognitive function, psychological and emotional
factors, quality-of-life measures, change readiness)
Nutrition AssessmentComponents
� Review dietary intake for factors that affect health conditions and nutrition risk� Evaluate health and disease condition for nutrition-related consequences� Evaluate psychosocial, functional, and behavioral factors related to food access, selection,
preparation, physical activity, and understanding of health condition� Evaluate patient/client/group’s knowledge, readiness to learn, and potential for changing behaviors� Identify standards by which data will be compared� Identify possible problem areas for making nutrition diagnoses
Critical Thinking The following types of critical thinking skills are especially needed in the assessment step:� Observing for nonverbal and verbal cues that can guide and prompt effective interviewing
methods;� Determining appropriate data to collect;� Selecting assessment tools and procedures (matching the assessment method to the situation);� Applying assessment tools in valid and reliable ways;� Distinguishing relevant from irrelevant data;� Distinguishing important from unimportant data;� Validating the data;� Organizing & categorizing the data in a meaningful framework that relates to nutrition problems;
and� Determining when a problem requires consultation with or referral to another provider.
Documentation ofAssessment
Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.Quality documentation of the assessment step should be relevant, accurate, and timely. Inclusion ofthe following information would further describe quality assessment documentation:� Date and time of assessment;� Pertinent data collected and comparison with standards;� Patient/client/groups’ perceptions, values, and motivation related to presenting problems;� Changes in patient/client/group’s level of understanding, food-related behaviors, and other clinical
outcomes for appropriate follow-up; and� Reason for discharge/discontinuation if appropriate.
Determination forContinuation of Care
If upon the completion of an initial or reassessment it is determined that the problem cannot bemodified by further nutrition care, discharge or discontinuation from this episode of nutrition caremay be appropriate.
FIG 2. ADA Nutrition Care Process.
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STEP 2. NUTRITION DIAGNOSIS
Basic Definition &Purpose
“Nutrition Diagnosis” is the second step of the Nutrition Care Process, and is the identification andlabeling that describes an actual occurrence, risk of, or potential for developing a nutritional problemthat dietetics professionals are responsible for treating independently. At the end of the assessmentstep, data are clustered, analyzed, and synthesized. This will reveal a nutrition diagnostic categoryfrom which to formulate a specific nutrition diagnostic statement. Nutrition diagnosis should not beconfused with medical diagnosis, which can be defined as a disease or pathology of specific organsor body systems that can be treated or prevented. A nutrition diagnosis changes as thepatient/client/group’s response changes. A medical diagnosis does not change as long as thedisease or condition exists. A patient/client/group may have the medical diagnosis of “Type 2diabetes mellitus”; however, after performing a nutrition assessment, dietetics professionals maydiagnose, for example, “undesirable overweight status” or “excessive carbohydrate intake.”Analyzing assessment data and naming the nutrition diagnosis(es) provide a link to setting realisticand measurable expected outcomes, selecting appropriate interventions, and tracking progress inattaining those expected outcomes.
Data Sources/Tools forDiagnosis
� Organized and clustered assessment data� List(s) of nutrition diagnostic categories and nutrition diagnostic labels� Currently the profession does not have a standardized list of nutrition diagnoses. However ADA
has appointed a Standardized Language Work Group to begin development of standardizedlanguage for nutrition diagnoses and intervention. (June 2003)
Nutrition DiagnosisComponents (3distinct parts)
1. Problem (Diagnostic Label)The nutrition diagnostic statement describes alterations in the patient/client/group’s nutritional status.
A diagnostic label (qualifier) is an adjective that describes/qualifies the human response such as:� Altered, impaired, ineffective, increased/decreased, risk of, acute or chronic.2. Etiology (Cause/Contributing Risk Factors)The related factors (etiologies) are those factors contributing to the existence of, or maintenance of
pathophysiological, psychosocial, situational, developmental, cultural, and/or environmentalproblems.
� Linked to the problem diagnostic label by words “related to” (RT)� It is important not only to state the problem, but to also identify the cause of the problem.▫ This helps determine whether or not nutritional intervention will improve the condition or correct
the problem.▫ It will also identify who is responsible for addressing the problem. Nutrition problems are either
caused directly by inadequate intake (primary) or as a result of other medical, genetic, orenvironmental factors (secondary).
▫ It is also possible that a nutrition problem can be the cause of another problem. For example,excessive caloric intake may result in unintended weight gain. Understanding the cascade ofevents helps to determine how to prioritize the interventions.
▫ It is desirable to target interventions at correcting the cause of the problem whenever possible;however, in some cases treating the signs and symptoms (consequences) of the problem may alsobe justified.
� The ranking of nutrition diagnoses permits dietetics professionals to arrange the problems in orderof their importance and urgency for the patient/client/group.
3. Signs/Symptoms (Defining Characteristics)The defining characteristics are a cluster of subjective and objective signs and symptoms
established for each nutrition diagnostic category. The defining characteristics, gathered duringthe assessment phase, provide evidence that a nutrition related problem exists and that theproblem identified belongs in the selected diagnostic category. They also quantify the problemand describe its severity:
� Linked to etiology by words “as evidenced by” (AEB);� The symptoms (subjective data) are changes that the patient/client/group feels and expresses
verbally to dietetics professionals; and� The signs (objective data) are observable changes in the patient/client/group’s health status.
Nutrition DiagnosticStatement (PES)
Whenever possible, a nutrition diagnostic statement is written in a PES format that states theProblem (P), the Etiology (E), and the Signs & Symptoms (S). However, if the problem is either a risk(potential) or wellness problem, the nutrition diagnostic statement may have only two elements,Problem (P), and the Etiology (E), since Signs & Symptoms (S) will not yet be exhibited in the patient.A well-written Nutrition Diagnostic Statement should be:1. Clear and concise2. Specific: patient/client/group-centered3. Related to one client problem4. Accurate: relate to one etiology5. Based on reliable and accurate assessment dataExamples of Nutrition Diagnosis Statements (PES or PE)� Excessive caloric intake (problem) “related to” frequent consumption of large portions of high fat
meals (etiology) “as evidenced by” average daily intake of calories exceeding recommendedamount by 500 kcal and 12-pound weight gain during the past 18 months (signs)
FIG 2 cont’d.
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� Inappropriate infant feeding practice RT lack of knowledge AEB infant receiving bedtime juice in abottle
� Unintended weight loss RT inadequate provision of energy by enteral products AEB 6-poundweight loss over past month
� Risk of weight gain RT a recent decrease in daily physical activity following sports injury
Critical Thinking The following types of critical thinking skills are especially needed in the diagnosis step:� Finding patterns and relationships among the data and possible causes;� Making inferences (“if this continues to occur, then this is likely to happen”);� Stating the problem clearly and singularly;� Suspending judgment (be objective and factual);� Making interdisciplinary connections;� Ruling in/ruling out specific diagnoses; and� Prioritizing the relative importance of problems for patient/client/group safety.
Documentation ofDiagnosis
Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.Quality documentation of the diagnosis step should be relevant, accurate, and timely. A nutritiondiagnosis is the impression of dietetics professionals at a given point in time. Therefore, as moreassessment data become available, the documentation of the diagnosis may need to be revised andupdated.Inclusion of the following information would further describe quality documentation of this step:� Date and time; and� Written statement of nutrition diagnosis.
Determination forContinuation of Care
Since the diagnosis step primarily involves naming and describing the problem, the determination forcontinuation of care seldom occurs at this step. Determination of the continuation of care is moreappropriately made at an earlier or later point in the Nutrition Care Process.
STEP 3. NUTRITION INTERVENTION
Basic Definition &Purpose
“Nutrition Intervention” is the third step of the Nutrition Care Process. An intervention is a specificset of activities and associated materials used to address the problem. Nutrition interventions arepurposefully planned actions designed with the intent of changing a nutrition-related behavior, riskfactor, environmental condition, or aspect of health status for an individual, target group, or thecommunity at large. This step involves a) selecting, b) planning, and c) implementing appropriateactions to meet patient/client/groups’ nutrition needs. The selection of nutrition interventions is drivenby the nutrition diagnosis and provides the basis upon which outcomes are measured and evaluated.Dietetics professionals may actually do the interventions, or may include delegating or coordinatingthe nutrition care that others provide. All interventions must be based on scientific principles andrationale and, when available, grounded in a high level of quality research (evidence-basedinterventions).Dietetics professionals work collaboratively with the patient/client/group, family, or caregiver tocreate a realistic plan that has a good probability of positively influencing the diagnosis/problem. Thisclient-driven process is a key element in the success of this step, distinguishing it from previousplanning steps that may or may not have involved the patient/client/group to this degree ofparticipation.
Data Sources/Tools forInterventions
� Evidence-based nutrition guides for practice and protocols� Current research literature� Current consensus guidelines and recommendations from other professional organizations� Results of outcome management studies or Continuous Quality Index projects.� Current patient education materials at appropriate reading level and language� Behavior change theories (self-management training, motivational interviewing, behavior
modification, modeling)
Nutrition InterventionComponents
This step includes two distinct interrelated processes:1. Plan the nutrition intervention (formulate & determine a plan of action)� Prioritize the nutrition diagnoses based on severity of problem; safety; patient/client/group’s need;
likelihood that nutrition intervention will impact problem and patient/client/groups’ perception ofimportance.
� Consult ADA’s MNT Evidence-Based Guides for Practice and other practice guides. Theseresources can assist dietetics professionals in identifying science-based ideal goals and selectingappropriate interventions for MNT. They list appropriate value(s) for control or improvement of thedisease or conditions as defined and supported in the literature.
� Determine patient-focused expected outcomes for each nutrition diagnosis. The expectedoutcomes are the desired change(s) to be achieved over time as a result of nutrition intervention.They are based on nutrition diagnosis; for example, increasing or decreasing laboratory values,decreasing blood pressure, decreasing weight, increasing use of stanols/sterols, or increasingfiber. Expected outcomes should be written in observable and measurable terms that are clearand concise. They should be patient/client/group-centered and need to be tailored to what isreasonable to the patient’s circumstances and appropriate expectations for treatments andoutcomes.
FIG 2 cont’d.
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� Confer with patient/client/group, other caregivers or policies and program standards throughoutplanning step.
� Define intervention plan (for example write a nutrition prescription, provide an education plan orcommunity program, create policies that influence nutrition programs and standards).
� Select specific intervention strategies that are focused on the etiology of the problem and that areknown to be effective based on best current knowledge and evidence.
� Define time and frequency of care including intensity, duration, and follow-up.� Identify resources and/or referrals needed.2. Implement the nutrition intervention (care is delivered and actions are carried out)� Implementation is the action phase of the nutrition care process. During implementation, dietetics
professionals:▫ Communicate the plan of nutrition care;▫ Carry out the plan of nutrition care; and▫ Continue data collection and modify the plan of care as needed.� Other characteristics that define quality implementation include:▫ Individualize the interventions to the setting and client;▫ Collaborate with other colleagues and health care professionals;▫ Follow up and verify that implementation is occurring and needs are being met; and▫ Revise strategies as changes in condition/response occurs.
Critical Thinking Critical thinking is required to determine which intervention strategies are implemented based onanalysis of the assessment data and nutrition diagnosis. The following types of critical thinking skillsare especially needed in the intervention step:� Setting goals and prioritizing;� Transferring knowledge from one situation to another;� Defining the nutrition prescription or basic plan;� Making interdisciplinary connections;� Initiating behavioral and other interventions;� Matching intervention strategies with client needs, diagnoses, and values;� Choosing from among alternatives to determine a course of action; and� Specifying the time and frequency of care.
Documentation ofNutrition Interventions
Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.Quality documentation of nutrition interventions should be relevant, accurate, and timely. It shouldalso support further intervention or discharge from care. Changes in patient/client/group’s level ofunderstanding and food-related behaviors must be documented along with changes in clinical orfunctional outcomes to assure appropriate care/case management in the future. Inclusion of thefollowing information would further describe quality documentation of this step:� Date and time;� Specific treatment goals and expected outcomes;� Recommended interventions, individualized for patient;� Any adjustments of plan and justifications;� Patient receptivity;� Referrals made and resources used;� Any other information relevant to providing care and monitoring progress over time;� Plans for follow-up and frequency of care; and� Rationale for discharge if appropriate.
Determination forContinuation of Care
If the patient/client/group has met intervention goals or is not at this time able/ready to make neededchanges, the dietetics professional may include discharging the client from this episode of care aspart of the planned intervention.
STEP 4. NUTRITION MONITORING AND EVALUATION
Basic Definition &Purpose
“Nutrition Monitoring and Evaluation” is the fourth step of the Nutrition Care Process. Monitoringspecifically refers to the review and measurement of the patient/client/group’s status at a scheduled(preplanned) follow-up point with regard to the nutrition diagnosis, intervention plans/goals, andoutcomes, whereas Evaluation is the systematic comparison of current findings with previous status,intervention goals, or a reference standard. Monitoring and evaluation use selected outcomeindicators (markers) that are relevant to the patient/client/group’s defined needs, nutrition diagnosis,nutrition goals, and disease state. Recommended times for follow-up, along with relevant outcomesto be monitored, can be found in ADA’s Evidence Based Guides for Practice and other evidence-based sources.The purpose of monitoring and evaluation is to determine the degree to which progress is beingmade and goals or desired outcomes of nutrition care are being met. It is more than just “watching”what is happening, it requires an active commitment to measuring and recording the appropriateoutcome indicators (markers) relevant to the nutrition diagnosis and intervention strategies. Data fromthis step are used to create an outcomes management system. Refer to Outcomes ManagementSystem in text.
FIG 2 cont’d.
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Progress should be monitored, measured, and evaluated on a planned schedule until discharge.Short inpatient stays and lack of return for ambulatory visits do not preclude monitoring, measuring,and evaluation. Innovative methods can be used to contact patients/clients to monitor progress andoutcomes. Patient confidential self-report via mailings and telephone follow-up are some possibilities.Patients being followed in disease management programs can also be monitored for changes innutritional status. Alterations in outcome indicators such as hemoglobin A1C or weight are examplesthat trigger reactivation of the nutrition care process.
Data Sources/Tools forMonitoring andEvaluation
� Patient/client/group records� Anthropometric measurements, laboratory tests, questionnaires, surveys� Patient/client/group (or guardian) interviews/surveys, pretests, and posttests� Mail or telephone follow-up� ADA’s Evidence Based Guides for Practice and other evidence-based sources� Data collection forms, spreadsheets, and computer programs
Types of OutcomesCollected
The outcome(s) to be measured should be directly related to the nutrition diagnosis and the goalsestablished in the intervention plan. Examples include, but are not limited to:� Direct nutrition outcomes (knowledge gained, behavior change, food or nutrient intake changes,
improved nutritional status);� Clinical and health status outcomes (laboratory values, weight, blood pressure, risk factor profile
changes, signs and symptoms, clinical status, infections, complications);� Patient/client-centered outcomes (quality of life, satisfaction, self-efficacy, self-management,
functional ability); and� Health care utilization and cost outcomes (medication changes, special procedures,
planned/unplanned clinic visits, preventable hospitalizations, length of hospitalization, prevent ordelay nursing home admission).
Nutrition Monitoringand EvaluationComponents
This step includes three distinct and interrelated processes:1. Monitor progress� Check patient/client/group understanding and compliance with plan;� Determine if the intervention is being implemented as prescribed;� Provide evidence that the plan/intervention strategy is or is not changing patient/client/group
behavior or status;� Identify other positive or negative outcomes;� Gather information indicating reasons for lack of progress; and� Support conclusions with evidence.2. Measure outcomes� Select outcome indicators that are relevant to the nutrition diagnosis or signs or symptoms,
nutrition goals, medical diagnosis, and outcomes and quality management goals.� Use standardized indicators to:▫ Increase the validity and reliability of measurements of change; and▫ Facilitate electronic charting, coding, and outcomes measurement.3. Evaluate outcomes� Compare current findings with previous status, intervention goals, and/or reference standards.
Critical Thinking The following types of critical thinking skills are especially needed in the monitoring and evaluation step:� Selecting appropriate indicators/measures;� Using appropriate reference standard for comparison;� Defining where patient/client/group is now in terms of expected outcomes;� Explaining variance from expected outcomes;� Determining factors that help or hinder progress; and� Deciding between discharge or continuation of nutrition care.
Documentation ofMonitoring andEvaluation
Documentation is an on-going process that supports all of the steps in the Nutrition Care Processand is an integral part of monitoring and evaluation activities. Quality documentation of themonitoring and evaluation step should be relevant, accurate, and timely. It includes a statement ofwhere the patient is now in terms of expected outcomes. Standardized documentation enablespooling of data for outcomes measurement and quality improvement purposes. Qualitydocumentation should also include:� Date and time;� Specific indicators measured and results;� Progress toward goals (incremental small change can be significant therefore use of a Likert type
scale may be more descriptive than a “met” or “not met” goal evaluation tool);� Factors facilitating or hampering progress;� Other positive or negative outcomes; and� Future plans for nutrition care, monitoring, and follow up or discharge.
Determination forContinuation of Care
Based on the findings, the dietetics professional makes a decision to actively continue care ordischarge the patient/client/group from nutrition care (when necessary and appropriate nutrition care iscompleted or no further change is expected at this time). If nutrition care is to be continued, the nutritioncare process cycles back as necessary to assessment, diagnosis, and/or intervention for additionalassessment, refinement of the diagnosis and adjustment and/or reinforcement of the plan. If care does notcontinue, the patient may still be monitored for a change in status and reentry to nutrition care at a later date.
FIG 2 cont’d.
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describing what dietetics professionals do is truly a paradigmshift. This new paradigm is more complete, takes in more pos-sibilities, and explains observations better. Finally, it allowsdietetics professionals to act in ways that are more likely toachieve the results that are desired and expected.
NUTRITION CARE MODELThe Nutrition Care Model is a visual representation that re-flects key concepts of each step of the Nutrition Care Processand illustrates the greater context within which the NutritionCare Process is conducted. The model also identifies other fac-tors that influence and impact on the quality of nutrition careprovided. Refer to Figure 1 for an illustration of the model asdescribed below:■ Central Core: Relationship between patient/client/group anddietetics professional;■ Nutrition Care Process: Four steps of the nutrition care pro-cess (Figure 2);■ Outer rings:■ Middle ring: Strengths and abilities that dietetics profession-als bring to the process (dietetics knowledge, skills, and com-petencies; critical thinking, collaboration, and communication;evidence-based practice, and Code of Ethics) (32);■ Outer ring: Environmental factors that influence the process(practice settings, health care systems, social systems, andeconomics);■ Supporting Systems:■ Screening and Referral System as access to Nutrition Care;and■ Outcomes Management System as a means to provide contin-uous quality improvement to the process.
The model is intended to depict the relationship with whichall of these components overlap, interact, and move in a dy-namic manner to provide the best quality nutrition care possi-ble.
Central to providing nutrition care is the relationship be-tween the patient/client/group and the dietetics professional.The patient/client/groups’ previous educational experiencesand readiness to change influence this relationship. The edu-cation and training that dietetics professionals receive havevery strong components devoted to interpersonal knowledgeand skill building such as listening, empathy, coaching, andpositive reinforcing.
The middle ring identifies abilities of dietetics professionalsthat are especially applicable to the Nutrition Care Process.These include the unique dietetics knowledge, skill, and com-petencies that dietetics professionals bring to the process, inaddition to a well-developed capability for critical thinking, col-laboration, and communication. Also in this ring is evidence-based practice that emphasizes that nutrition care must incor-porate currently available scientific evidence, linking what isdone (content) and how it is done (process of care). The Codeof Ethics defines the ethical principles by which dietetics pro-fessionals should practice (33). Dietetics knowledge and evi-dence-based practice establish the Nutrition Care Process asunique to dietetics professionals; no other health care profes-sional is qualified to provide nutrition care in this manner. How-ever, the Nutrition Care Process is highly dependent on collab-oration and integration within the health care team. As statedabove, communication and participation within the health careteam are critical for identification of individuals who are appro-priate for nutrition care.
The outer ring identifies some of the environmental factors
such as practice settings, health care systems, social systems,and economics. These factors impact the ability of the patient/client/group to receive and benefit from the interventions ofnutrition care. It is essential that dietetics professionals assessthese factors and be able to evaluate the degree to which theymay be either a positive or negative influence on the outcomesof care.
Screening and Referral SystemBecause screening may or may not be accomplished by dietet-ics professionals, nutrition screening is a supportive systemand not a step within the Nutrition Care Process. Screening isextremely important; it is an identification step that is outsidethe actual “care” and provides access to the Nutrition CareProcess.
The Nutrition Care Process depends on an effective screen-ing and/or referral process that identifies clients who wouldbenefit from nutrition care or MNT. Screening is defined by theUS Preventive Services Task Force as “those preventive ser-vices in which a test or standardized examination procedure isused to identify patients requiring special intervention” (34).The major requirements for a screening test to be consideredeffective are the following:■ Accuracy as defined by the following three components:� Specificity: Can it identify patients with a condition?� Sensitivity: Can it identify those who do not have the condi-tion?� Positive and negative predictive; and■ Effectiveness as related to likelihood of positive health out-comes if intervention is provided.
Screening parameters need to be tailored to the populationand to the nutrition care services to be provided. For example,the screening parameters identified for a large tertiary acutecare institution specializing in oncology would be vastly differ-ent than the screening parameters defined for an ambulatoryobstetrics clinic. Depending on the setting and institutionalpolicies, the dietetics professional may or may not be directlyinvolved in the screening process. Regardless of whether die-tetics professionals are actively involved in conducting thescreening process, they are accountable for providing inputinto the development of appropriate screening parameters toensure that the screening process asks the right questions.They should also evaluate how effective the screening processis in terms of correctly identifying clients who require nutritioncare.
In addition to correctly identifying clients who would benefitfrom nutrition care, a referral process may be necessary toensure that the client has an identifiable method of being linkedto dietetics professionals who will ultimately provide the nutri-tion care or medical nutrition therapy. While the nutritionscreening and referral is not part of the Nutrition Care Process,it is a critical antecedent step in the overall system (35).
Outcomes Management SystemAn outcomes management system evaluates the effectivenessand efficiency of the entire process (assessment, diagnosis,interventions, cost, and others), whereas the fourth step of theprocess “nutrition monitoring and evaluations” refers to theevaluation of the patient/client/group’s progress in achievingoutcomes.
Because outcomes management is a system’s commitment toeffective and efficient care, it is depicted outside of the NCP.Outcomes management links care processes and resource uti-
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lization with outcomes. Through outcomes management, rele-vant data are collected and analyzed in a timely manner so thatperformance can be adjusted and improved. Findings are com-pared with such things as past levels of performance; organiza-tional, regional, or national norms; and standards or bench-marks of optimal performance. Generally, this information isreported to providers, administrators, and payors/funders andmay be part of administrative databases or required reportingsystems.
It requires an infrastructure in which outcomes for the pop-ulation served are routinely assessed, summarized, and re-ported. Health care organizations use complex informationmanagement systems to manage resources and track perfor-mance. Selected information documented throughout the nu-trition care process is entered into these central informationmanagement systems and structured databases. Examples ofcentralized data systems in which nutrition care data should beincluded are the following:■ basic encounter documentation for billing and cost account-ing;■ tracking of standard indicators for quality assurance and ac-creditation;■ pooling data from a large series of patients/clients/groups todetermine outcomes; and■ specially designed studies that link process and outcomes todetermine effectiveness and cost effectiveness of diagnosticand intervention approaches.
The major goal of outcomes management is to utilize col-lected data to improve the quality of care rendered in the fu-ture. Monitoring and evaluation data from individuals arepooled/aggregated for the purposes of professional account-ability, outcomes management, and systems/processes im-provement. Results from a large series of patients/clients canbe used to determine the effectiveness of intervention strate-gies and the impact of nutrition care in improving the overallhealth of individuals and groups. The effects of well-monitoredquality improvement initiatives should be reflected in measur-able improvements in outcomes.
Outcomes management comprehensively evaluates the twoparts of IOM’s definition of quality: outcomes and process. Mea-suring the relationship between the process and the outcome isessential for quality improvement. To ensure that the quality ofpatient care is not compromised, the focus of quality improve-ment efforts should always be directed at the outcome of care(36-43).
FUTURE IMPLICATIONS
Impact on Coverage for ServicesQuality-related issues are gaining in importance worldwide.Even though our knowledge base is increasing, the scientificevidence for most clinical practices in all of medicine is modest.So much of what is done in health care does not maximizequality or minimize cost (44). A standardized Nutrition CareProcess is a necessary foundation tool for gathering valid andreliable data on how quality nutrition care provided by qualifieddietetics professionals improves the overall quality of healthcare provided. Implementing ADA’s Nutrition Care Processprovides a framework for demonstrating that nutrition careimproves outcomes by the following: (a) enhancing the healthof individuals, groups, institutions, or health systems; (b) po-tentially reducing health care costs by decreasing the need formedications, clinic and hospital visits, and preventing or delay-
ing nursing home admissions; and (c) serving as the basis forresearch, documenting the impact of nutrition care providedby dietetics professionals (45-47).
Developing Scopes and Practice StandardsThe work group reviewed the questions raised by delegatesregarding the role of the RD and DTR in the Nutrition CareProcess. As a result of careful consideration of this importantissue, it was concluded that describing the various types oftasks and responsibilities appropriate to each of these creden-tialed dietetics professionals was yet another professional issuebeyond the intent and purpose of developing a standardizedNutrition Care Process.
A scope of practice of a profession is the range of servicesthat the profession is authorized to provide. Scopes of practice,depending on the particular setting in which they are used, canhave different applications. They can serve as a legal documentfor state certification/licensure laws or they might be incorpo-rated into institutional policy and procedure guidelines or jobdescriptions. Professional scopes of practice should be basedon the education, training, skills, and competencies of eachprofession (48).
As previously noted, a dietetics professional is a person who,by virtue of academic and clinical training and appropriate cer-tification and/or licensure, is uniquely qualified to provide acomprehensive array of professional services relating to pre-vention and treatment of nutrition-related conditions. A Scopeof Practice articulates the roles of the RD, DTR, and advanced-practice RD. Issues to be addressed for the future include thefollowing: (a) the need for a common scope with specializedguidelines and (b) recognition of the rich diversity of practicevs exclusive domains of practice regulation.
Professional standards are “authoritative statements thatdescribe performance common to the profession.” As such,standards should encompass the following:■ articulate the expectations the public can have of a dieteticsprofessional in any practice setting, domain, and/or role;■ expect and achieve levels of practice against which actualperformance can be measured; and■ serve as a legal reference to describe “reasonable and pru-dent” dietetics practice.
The Nutrition Care Process effectively reflects the dieteticsprofessional as the unique provider of nutrition care when it isconsistently used as a systematic method to think critically andmake decisions to provide safe and effective care. ADA’s Nutri-tion Care Process will serve as a guide to develop scopes ofpractice and standards of practice (49,50). Therefore, the workgroup recommended that further work be done to use the Nu-trition Care Process to describe roles and functions that can beincluded in scopes of practice. In May 2003, the Board of Di-rectors of ADA established a Practice Definitions Task Forcethat will identify and differentiate the terms within the profes-sion that need clarification for members, affiliates, and DPGsrelated to licensure, certification, practice acts, and advancedpractice. This task force is also charged to clarify the scope ofpractice services, clinical privileges, and accountabilities pro-vided by RDs/DTRs based on education, training, and experi-ence.
Education of Dietetics StudentsIt will be important to review the current CADE EducationalStandards to ensure that the language and level of expectedcompetencies are consistent with the entry-level practice of
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the Nutrition Care Process. Further work by the Commissionon Dietetic Registration (CDR) may need to be done to makerevisions on the RD and DTR exams to evaluate entry-levelcompetencies needed to practice nutrition care in this way.Revision of texts and other educational materials will also needto incorporate the key principles and steps of this new process(51).
Education and Credentialing of MembersEven though dietetics professionals currently provide nutritioncare, this standardized Nutrition Care Process includes somenew principles, concepts, and guidelines in each of its steps.This is especially true of steps 2 and 4 (Nutrition Diagnosis andNutrition Monitoring and Evaluation). Therefore, the implica-tions for education of dietetics professionals and their practiceare great. Because a large number of dietetics professionals stillare employed in health care systems, a comprehensive educa-tional plan will be essential. A model to be considered whenplanning education is the one used to educate dietetics profes-sionals on the Professional Development Portfolio (PDP) Pro-cess (52). Materials that could be used to provide memberswith the necessary knowledge and skills in this process couldinclude but not be limited to the following:■ articles in the Journal of the American Dietetic Associa-
tion;■ continuing professional education lectures and presentationsat affiliate and national meetings;■ self-study materials; case studies, CD-ROM workbooks, andothers;■ hands-on workshops and training programs;■ Web-based materials; and■ inclusion in the learning needs assessment and codes of theProfessional Development Portfolio.
Through the development of this educational strategic plan,the benefits to dietetics professionals and other stakeholderswill need to be a central theme to promote the change in prac-tice that comes with using this process to provide nutritioncare.
Evidence-Based PracticeThe pressure to do more with less is dramatically affecting all ofhealth care, including dietetics professionals. This pressure isforcing the health care industry to restructure to be more effi-cient and cost-effective in delivering care. It will require the useof evidenced-based practice to determine what practices arecritical to support outcomes (53,54). The Nutrition Care Pro-cess will be invaluable as research is completed to evaluate theservices provided by dietetics professionals (55). The NutritionCare Process will provide the structure for developing themethodology and data collection in individual settings, and thepractice-based research networks ADA is in the process of ini-tiating.
Standardized LanguageAs noted in Step 2 (Nutrition Diagnosis), having a standardtaxonomy for nutrition diagnosis would be beneficial. Work inthe area of articulating the types of interventions used by die-tetics professionals has already begun by the Definitions WorkGroup under the direction of ADA’s Research Committee. Fur-ther work to define terms that are part of the Nutrition CareProcess will need to continue. Even though the work groupprovided a list of terms relating to the definition and key con-cepts of the process, there are opportunities to articulate fur-
ther terms that are consistently used in this process. The Boardof Directors of ADA in May 2003 approved continuation andexpansion of a task force to address a comprehensive systemthat includes a process for developing and validating standard-ized language for nutrition diagnosis, intervention, and out-comes.
SUMMARYJust as maps are reissued when new roads are built and riverschange course, this Nutrition Care Process and Model reflectsrecent changes in the nutrition and health care environment. Itprovides dietetics professionals with the updated “road map” tofollow the best path for high-quality patient/client/group-cen-tered nutrition care.
References1. American Dietetic Association Strategic Plan. Available at: http://eatright.org(member only section). Accessed June 2, 2003.2. Wheeler D. Understanding Variation: The Key to Managing Chaos. 2nd ed.Knoxville, TN: SPC Press; 2000.3. Shojania KG, Duncan BW, McDonald KM, Wachter RM. Making HealthCare Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43 (Prepared by the University of California atSan Francisco-Stanford Evidence-based Practice Center under Contract No.290-97-0013). Rockville, MD: Agency for Healthcare Research and Quality;2001. Report No.: AHRQ Publication No. 01-E058.4. Potter, Patricia A, Perry, Anne G. Basic Nursing Theory and Practice. 4thed. St Louis: C.V. Mosby; 1998.5. American Physical Therapy Association. Guide to Physical Therapist Prac-tice. 2nd ed. Alexandria, VA; 2001.6. The Guide to Occupational Therapy Practice. Am J Occup Ther. 1999;53:3.Available at http://nweb.pct.edu/homepage/student/NUNJOL02/ot%20process.ppt. Accessed May 30, 2003.7. Kohn KN, ed. Medicare: A strategy for Quality Assurance, Volume I. Com-mittee to Design a Strategy for Quality Review and Assurance in Medicare.Washington, DC: Institute of Medicine. National Academy Press; 1990.8. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a SaferHealth System. Washington, DC: Committee on Quality of Health Care inAmerica, Institute of Medicine. National Academy Press; 2000.9. Institute of Medicine. Crossing the Quality Chasm: A New Health System forthe 21st Century. Committee on Quality in Health Care in America. RonaBriere, ed. Washington, DC: National Academy Press; 2001.10. Splett P. Developing and Validating Evidence-Based Guides for Practice:A Tool Kit for Dietetics Professionals. American Dietetic Association; 1999.11. Endres JB. Community Nutrition. Challenges and Opportunities. UpperSaddle River, NJ: Prentice-Hall, Inc; 1999.12. Splett P. Planning, Implementation and Evaluation of Nutrition Programs.In: Sharbaugh CO, ed. Call to Action: Better Nutrition for Mothers, Children,and Families. Washington, DC: National Center for Education in Maternal andChild Health (NCEMCH); 1990.13. Batalden PB, Stoltz PA. A framework for the continual improvement ofhealth care: Building and applying professional and improvement knowledgeto test changes in daily work. Jt Comm J Qual Improv. 1993;19:424-452.14. CADE Accreditation Handbook. Available at: http://www.eatright.com/cade/standards.html. Accessed March 20, 2003.15. Alfaro-LeFevre R. Nursing process overview. Applying Nursing Process.Promoting Collaborative Care. 5th ed. Lippincott; 2002.16. Grant A, DeHoog S. Nutrition Assessment Support and Management.Northgate Station, WA; 1999.17. Sandrick, K. Is nutritional diagnosis a critical step in the nutrition careprocess? J Am Diet Assoc. 2002;102:427-431.18. King LS. What is a diagnosis? JAMA. 1967;202:154.19. Doenges ME. Application of Nursing Process and Nursing Diagnosis: AnInteractive Text for Diagnostic Reasoning, 3rd ed. Philadelphia, PA: FA DavisCo; 2000.20. Gallagher-Alred C, Voss AC, Gussler JD. Nutrition intervention and patientoutcomes: a self-study manual. Columbus, OH: Ross Products Division,Abbott Laboratories; 1995.21. Splett P, Myers EF. A proposed model for effective nutrition care. J AmDiet Assoc. 2001;101:357-363.22. Lacey K, Cross N. A problem-based nutrition care model that is diagnosticdriven and allows for monitoring and managing outcomes. J Am Diet Assoc.2002;102:578-589.23. Brylinsky C. The Nutrition Care Process. In: Mahan K, Escott-Stump S,
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eds. Krause’s Food, Nutrition and Diet Therapy, 10th ed. Philadelphia, PA:W.B. Saunders Company; 2000:431-451.24. Hammond MI, Guthrie HA. Nutrition clinic: An integrated component of anundergraduate curriculum. J Am Diet Assoc. 1985;85:594.25. Final MNT Regulations. CMS-1169-FC. Federal Register, November 1,2001. Department of Health and Human Services. 42 CFR Parts: 405, 410,411, 414, and 415. Available at: http://cms.hhs.gov/physicians/pfs/cms1169fc.asp. Accessed June 27, 2003.26. Commission on Dietetic Registration CDR Certifications and State Licen-sure. Available at: http://www.cdrnet.org/certifications/index.htm. AccessedMay 30, 2003.27. Medicare Coverage Policy Decision: Duration and Frequency of the Med-ical Nutrition Therapy (MNT) Benefit (No. CAG-00097N). Available at: http://cms.hhs.gov/ncdr/memo.asp?id�53. Accessed June 2, 2003.28. American Dietetic Association Medical Nutrition Therapy Evidence-BasedGuides For Practice. Hyperlipidemia Medical Nutrition Therapy Protocol. CD-ROM; 2001.29. American Dietetic Association. Medical Nutrition Therapy Evidence-Based Guides for Practice. Nutrition Practice Guidelines for Type 1 and 2Diabetes Mellitus CD-ROM; 2001.30. American Dietetic Association. Medical Nutrition Therapy Evidence-Based Guides for Practice. Nutrition Practice Guidelines for Gestational Dia-betes Mellitus. CD-ROM; 2001.31. American Dietetic Association Medical Nutrition Therapy Evidence-BasedGuides For Practice. Chronic Kidney Disease (non-dialysis) Medical NutritionTherapy Protocol. CD-ROM; 2002.32. Gates G. Ethics opinion: Dietetics professionals are ethically obligated tomaintain personal competence in practice. J Am Diet Assoc. May 2003;103:633-635.33. Code of Ethics for the Profession of Dietetics. J Am Diet Assoc. 1999;99:109-113.34. US Preventive Services Task Force. Guide to Clinical Preventive Services,2nd ed. Washington, DC: US Department of Health and Human Services,Office of Disease Prevention and Health Promotion; 1996.35. Identifying patients at risk: ADA’s definitions for nutrition screening andnutrition assessment. J Am Diet Assoc. 1994;94:838-839.36. Donabedian A. Explorations in Quality Assessment and Monitoring. Vol-ume I: The Definition of Quality and Approaches to Its Assessment. Ann Arbor,MI: Health Administration Press; 1980.37. Carey RG, Lloyd RC. Measuring Quality Improvement in Health Care: AGuide to Statistical Process Control Applications. New York, Quality Re-sources; 1995.38. Eck LH, Slawson DL, Williams R, Smith K, Harmon-Clayton K, Oliver D. Amodel for making outcomes research standard practice in clinical dietetics.J Am Diet Assoc. 1998;98:451-457.39. Ireton-Jones CS, Gottschlich MM, Bell SJ. Practice-Oriented NutritionResearch: An Outcomes Measurement Approach. Gaithersburg, MD: AspenPublishers, Inc.; 1998.40. Kaye GL. Outcomes Management: Linking Research to Practice. Colum-bus, OH: Ross Products Division, Abbott Laboratories; 1996.41. Splett P. Cost Outcomes of Nutrition Intervention, a Three Part Mono-graph. Evansville, IN: Mead Johnson & Company; 1996.
42. Plsekk P. 1994. Tutorial: Planning for data collection part I: Asking theright question. Qual Manage Health Care. 2:76-81.43. American Dietetic Association. Israel D, Moore S, eds. Beyond NutritionCounseling: Achieving Positive Outcomes Through Nutrition Therapy. 1996.44. Stoline AM, Weiner JP. The New Medical Marketplace: A Physician’sGuide to the Health Care System in the 1990s. Baltimore: Johns HopkinsPress; 1993.45. Mathematica Policy Research, Inc. Best Practices in Coordinated CareMarch 22, 2000. Available at: http://www.mathematica-mpr.com/PDFs/bestpractices.pdf. Accessed February 22, 2003.46. Bisognano MA. New skills needed in medical leadership: The key toachieving business results. Qual Prog. 2000;33:32-41.47. Smith R. Expanding medical nutrition therapy: An argument for evidence-based practices. J Am Diet Assoc. 2003;103:313-314.48. National Council of State Boards of Nursing Model Nursing Practice Act.Available at: http://www.ncsbn.org/public/regulation/nursing_practice_model_practice_act.htm. Accessed June 27, 2003.49. Professional policies of the American College of Medical Quality (ACMQ).Available at: http://www.acmq.org/profess/list.htm. Accessed June 27, 2003.50. American Dietetic Association. Standards of professional practice. J AmDiet Assoc. 1998;98:83-85.51. O’Neil EH and the Pew Health Professions Commission. RecreatingHealth Professional Practice for a New Century. The Fourth Report of the PewHealth Professions Commission. Pew Health Professions Commission; De-cember 1998.52. Weddle DO. The professional development portfolio process: Settinggoals for credentialing. J Am Diet Assoc. 2002;102:1439-1444.53. Sackett DL, Rosenberg WMC, Gray J, Haynes RB, Richardson WS.Evidence based medicine: What it is and what it isn’t. Br Med J. 1996;312:71-72.54. Myers EF, Pritchett E, Johnson EQ. Evidence-based practice guides vs.protocols: What’s the difference? J Am Diet Assoc. 2001;101:1085-1090.55. Manore MM, Myers EF. Research and the dietetics profession: Making abigger impact. J Am Diet Assoc. 2003;103:108-112.
The Quality Management Committee Work Group devel-
oped the Nutrition Care Process and Model with input
from the House of Delegates dialog (October 2002 HOD
meeting, in Philadelphia, PA). The work group members
are the following: Karen Lacey, MS, RD, Chair; Elvira
Johnson, MS, RD; Kessey Kieselhorst, MPA, RD; Mary Jane
Oakland, PhD, RD, FADA; Carlene Russell, RD, FADA; Pa-
tricia Splett, PhD, RD, FADA; Suzanne Bertocchi, DTR,
and Tamara Otterstein, DTR; Ellen Pritchett, RD; Esther
Myers, PhD, RD, FADA; Harold Holler, RD, and Karri
Looby, MS, RD. The work group would like to extend a
special thank you to Marion Hammond, MS, and Naoimi
Trossler, PhD, RD, for their assistance in development of
the Nutrition Care Process and Model.
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Edition: 2006 12
American Dietetic Association’s Standardized Nutrition Language:
Current Status
Introduction
Evidence-based dietetic practice relies on
concise, consistent, and standardized terminology to
create and retrieve digital sources of evidence.1 This
is essential for documenting nutrition diagnoses,
interventions and outcomes in electronic health
records. A task force of the American Dietetic
Association (ADA) has begun to refine and
disseminate standardized nutrition language. The
language is built on the Nutrition Care Process and
Model that maps quality nutrition care and outcomes,
and recognizes several existing terminologies used by
other health professions. This paper will describe the
logic model for the development of the standardized
nutrition language, the Nutrition Care Process it is
built upon, and its current status.
The project goal is to support nutrition practice,
education, research, and policy with data. It is
assumed that practicing dietitians, educators, and
researchers will use the standardized nutrition
language to document care, aggregate data, and study
the evidence. Standardized terminology will provide
the foundation for developing a national dietitian
care database.
The Nutrition Care Process
The ADA Nutrition Care Model workgroup
published the Nutrition Care Process (NCP) and
Model in August 2003.2 It provides a definition of
the NCP and describes its steps and framework. The
NCP is “a systematic problem-solving method that
dietetics professionals use to critically think and
make decisions to address nutrition related problems
and provide safe and effective quality nutrition
care.”2, p1063 The four steps of the NCP, similar to
those of other clinical professions, are: (a) Nutrition
Assessment, (b) Nutrition Diagnosis, (c) Nutrition
Intervention, and (d) Nutrition Monitoring and
Evaluation. Allowing for the reality of an iterative
and comprehensive clinical process, the NCP is not
linear and it includes, but is not limited to, Medical
Nutrition Therapy. Medical Nutrition Therapy is
“nutritional diagnostic, therapy, and counseling
services for the purpose of disease management,
which are furnished by a registered dietitian or
nutrition professional.”3 The context of the NCP and
surrounding influences are captured in the Model
framework.
Standardized terms are being developed for each
step of the NCP. Nutrition Assessment is “a
systematic process of obtaining, verifying, and
interpreting data in order to make decisions about the
nature and cause of nutrition-related problems.”2 The
Nutrition Assessment includes signs and symptoms.
Nutrition Diagnosis is “the identification and labeling
that describes an actual occurrence, risk of, or
potential for developing a nutritional problem that
dietetics professionals are responsible for treating
independently.”2
Nutrition Interventions are “purposely planned
actions designed with the intent of changing a
nutrition-related behavior, risk factor, environmental
condition, or aspect of health status for an individual,
target group, or the community at large.”2,
Interventions are directed to influence the etiology or
effects of a diagnosis. Nutrition Monitoring is “the
review and measurement of the patient/client/group’s
status at a scheduled (preplanned) follow-up point
with regard to the nutrition diagnosis, intervention
plans/goals, and outcomes.” Evaluation is “the
systematic comparison of current findings with
previous status, intervention goals, or a reference
standard.”2 Evaluation may measure changes in signs
and symptoms. The NCP steps guide the delivery of
nutrition health services, education, and research and
define categories for documentation of nutrition care.
Development: Comparison with Nursing
In comparison with the development of various
nursing terminologies, the ADA nutrition language
development has been much more rapid and
centralized, due perhaps to comparatively smaller
numbers of nutrition professionals and growing
sophistication in information technology. Nursing
terminology work began in the 1970s, including the
North American Nursing Diagnosis Association
(NANDA)4 terminology, the Clinical Care
Classification (CCC),5 and others. NANDA is
specific to nursing diagnoses, while the CCC
addresses diagnoses, interventions, and outcomes.
The Nursing Minimum Data Set,6 which includes
patient information, nursing diagnoses, nursing
interventions, nursing outcomes, intensity level of
nursing care, and a unique provider number, is an
overarching framework for the various discrete
nursing terminologies, similar to the NCP.
Edition: 2006
Portions of this document have been submitted for publication elsewhere
13
Why Does Dietetics Practice Need a Standardized
Language?
There is currently no agreed upon mechanism by
which dietetics professionals can communicate with
each other or other health care professionals. Because
of this lack of agreement, there is no easy way to
classify, measure, and report on the outcomes of
nutrition interventions in various patient populations.
The Nutrition Care Process includes nutrition
diagnosis and nutrition intervention as unique steps
that provide registered dietitians a mechanism to
consistently document and communicate the work of
dietetics. There is currently no agreed upon
terminology used in dietetics practice which makes it
impossible to gather and aggregate data needed for
research, education, and reimbursement justification
via outcomes analysis.
Logic Model
A Logic Model is a simplified picture that
describes the logical relationships among the
resources invested, the activities that take place, and
the benefits to be realized from the project and the
environment in which the system/project occurs.
With the help of an informatics consultant, the
Standardized Language Task Force adopted a Project
Logic Model that identifies the expected outcomes
and impact of the Standardized Language of
Dietetics. The goal of the dietetics terminology was
seen to be "To provide data to foster nutrition
practice, education, research, and policy.”
Three time frames for evaluating the impact of
the standardized language were agreed upon. The
most immediate impacts were thought to include
recommendations for coordination with existing
terminologies, review of the structure of the dietetics
terminology, to "cross-walk" the new terminology
with existing terminologies to see if overlap exists, to
review existing intervention terms, and to identify
relevant policy issues regarding standardized
nutrition language. Intermediate impacts were
thought to include selection of a structure for the
nutrition diagnostic labels, cross-walk of the
intervention terms, to plan for generation of nutrition
outcomes measures, create strategies for ongoing
maintenance and updates of the language, to design
and implement pilot testing of the standardized
language, and to draft legislative and policy agendas.
The ultimate impact was agreed to include delivery
of quality, cost-effective nutrition care, national
growth of nutrition care, inclusion of the standardized
language in dietetics education and research,
development of a national data warehouse for
nutrition research, and support of policies designed to
foster nutrition practice, education, and research.
Several assumptions were necessary in
development of this logic model. The Task Force was
in agreement that nutrition is an essential component
of high quality health care. There was heightened
awareness of the need for data to document the
processes and outcomes of nutrition care in a variety
of settings. It was also assumed that educators,
practicing dietitians, and researchers would accept
and implement the standardized language and would
be willing to share data using the terminology for
targeted studies and ultimately a national database.
Nutrition Diagnostic Labels
To date, over 60 Nutrition Diagnostic Labels
have been defined by ADA work with focus groups,
domain experts, and membership committees.
Standardized Language Task Force members judged
the match between nutrition diagnoses terms and
similar terms listed in the National Library of
Medicine’s Unified Medical Language System
(UMLS);7 many terms have synonyms. One of the
robust terminologies in the UMLS is SNOMED-CT.8
Staff from SNOMED-CT were contacted to discuss
the process of submitting nutrition terms.
The Nutrition Diagnostic Labels include 3
domains: Clinical, Behavioral-Environmental, and
Intake. The domains, sub-classes, and specific
diagnoses are defined in the most recent version, a
summary of which follows.
DOMAIN: INTAKE
Defined as “actual problems related to intake of
energy, nutrients, fluids, bioactive substances through
oral diet or nutrition support (enteral or parenteral
nutrition)”
Class: Caloric Energy Balance
Defined as “actual or estimated changes in energy
(kcal)”
Class: Oral or Nutrition Support Intake
Defined as “actual or estimated food and beverage
intake from oral diet or nutrition support compared
with patient goal”
Class: Fluid Intake BalanceDefined as “actual or estimated fluid intake compared
with patient goal”
Class: Bioactive Substances Balance Defined as “actual or observed intake of bioactive
substances, including single or multiple functional
food components, ingredients, dietary supplements,
alcohol”
Class: Nutrient Balance
Defined as “actual or estimated intake of specific
nutrient groups or single nutrients as compared with
desired levels”
Sub-Class: Fat and Cholesterol Balance
Sub-Class: Protein Balance
Edition: 2006
Portions of this document have been submitted for publication elsewhere
14
Sub-Class: Carbohydrate and Fiber Balance
Sub-Class: Vitamin BalanceSub-Class: Mineral Balance
DOMAIN: CLINICAL
Defined as “nutritional findings/problems identified
that relate to medical or physical conditions”
Class: Functional Balance
Defined as “change in physical or mechanical
functioning that interferes with or prevents desired
nutritional consequences”
Class: Biochemical BalanceDefined as “change in capacity to metabolize
nutrients as a result of medications, surgery, or as
indicated by altered lab values”
Class: Weight Balance
Defined as “chronic weight or changed weight status
when compared with usual or desired body weight”
DOMAIN: BEHAVIORAL-
ENVIRONMENTAL
Defined as “nutritional findings/problems identified
that relate to knowledge, attitudes/beliefs, physical
environment, or access to food and food safety”
Class: Knowledge and Beliefs
Defined as “actual knowledge and beliefs as reported,
observed, or documented”
Class: Physical Activity Balance and Function
Defined as “actual physical activity, self-care, and
quality of life problems as reported, observed or
documented”
Class: Food Safety and AccessDefined as “actual problems with food access or food
safety”
© ADA
Problem-Etiology-Signs/Symptoms Statements
A Nutrition Diagnosis is best written as a PES
statement pertaining to one patient/client or group,
specific to one problem (P) and one etiology (E), and
based on assessment of signs and symptoms (S).2
Implementation of PES statements in clinical practice
is being tested in two pilot studies by ADA members.
Examples of PES statements are
(a) “Overweight/obesity (problem) related to
continued intake of high fat foods (etiology) resulting
in ~300 extra kcal/day as evidenced by a BMI of 30
(sign/symptom), and (b) Impaired ability to prepare
foods/meals (problem) related to fatigue (etiology) as
evidenced by patient/client only consuming one meal
per day.” Interventions are often guided by the
etiology of each problem. Signs and symptoms may
provide measures to evaluate outcomes and the
effectiveness of care. It is possible that the
standardized terms for assessments will be
considered relevant outcome measures.
Nutrition Interventions
Following principles for standardized
terminologies,9 the ADA has begun to identify and
define Nutrition Intervention terms. A Task Force
meeting in February 2005 identified categories of
interventions including: Treatments/Procedures,
Education, Counseling, and Referral/Coordination.
These categories are similar to those in nursing
terminologies but differing by not including
monitoring/assessment as an intervention, which is a
separate step in the Nutrition Care Process.
Synonyms to the intervention terms will be searched
in the UMLS and domain experts will judge the
extent of the matches. The Nutrition Intervention
Labels will be submitted SNOMED-CT or other
existing coding system that will be included in the
UMLS.
Future Work
Definition of Nutrition Assessment terms and
their relationship with Outcome terms is planned. In
addition, activities to communicate the standardized
language to educators, administrators, clinicians, and
researchers are planned. The ADA believes that
consistent standardized terminology will improve
patient care by enhancing the education, practice, and
research of nutrition professionals. The use of
standardized nutrition language by nutrition
professionals in the United States is in synch with
similar international efforts.
References
1. Bakken S. An informatics infrastructure is
essential for evidence-based practice. J Am MedInform Assoc. 2001;8:199-201.
2. Lacey K, Pritchett E. Nutrition care process and
model: ADA adopts road map to quality care and
outcomes management. J Am Diet Assoc.
2003;103:1061-72.
3. Final Medical Nutrition Therapy regulations.
CMS-1169-FC. Federal Register, Nov.1, 2001.
DHHS 42 CFR Parts: 405, 410, 411, 414, and 415.
Available
at:http://cms.hhs.gov/physicians/pfs/cms1169fc.asp?
Accessed: March 7, 2005.
4. North American Nursing Diagnosis Association.
Available at: http://www.nanda.org. Accessed Mar.
7, 2005.
5. Saba V. Clinical Care Classification System.
Available at http://www.sabacare.com. Accessed
March 7, 2005.
6. Werley H, Lang NM. Identification of the Nursing
Minimum Data Set. New York:NY: Springer; 1988.
Edition: 2006
Portions of this document have been submitted for publication elsewhere
15
7. National Library of Medicine. Unified Medical
Language System. 2005. Available at: http://
www.nlm.nih.gov/research/umls/umlsmain.html.
Accessed March 7, 2005.
8. College of American Pathologists. SNOMED
International Clinical Terms. Available at
http://www.snomed.org/. Accessed March 7, 2005.
9. Cimino JJ. Desiderata for controlled medical
vocabularies in the twenty-first century. Meth InformMed; 1998;37:394-403.
Edition: 2006
Portions of this document have been submitted for publication elsewhere
16
Introduction to Nutrition Diagnoses/Problems:
The New Component of the Nutrition Care Process
Introduction
The ADA has embarked on an extensive project to identify and define nutrition
diagnoses/problems for the profession of dietetics. This standardized language of nutrition
diagnoses/problems is an integral component in the Nutrition Care Process, a process designed to
improve the consistency and quality of individualized patient/client care and the predictability of
the patient/client outcomes. In fact, several other allied professional, including nursing, physical
therapy, and occupational therapy, utilize defined care processes (1).
Not only will creating this standard language help dietetic professionals better document their
nutrition care, it will serve to help achieve Association strategic goals of promoting demand for
dietetic professionals and help them be more competitive in the market place. It will also provide
a minimum data set and common data elements for future research that includes services of
dietetic professionals.
ADA’s Standardized Language Task Force developed a conceptual framework for the
standardized nutrition language and identified the nutrition diagnoses/problems. The framework
outlines the domains within which the diagnoses/problems would fall and the flow of the
nutrition care process in relation to the continuum of health, disease and disability. Sixty-two
diagnoses/problems have been identified. A worksheet has been developed for each
diagnosis/problem and expert has been incorporated.
The methodology for developing sets of terms such as these includes systematically collecting
data from multiple sources simultaneously. We collected data from a selected group of dietitians
prior to starting the project (from recognized ADA leaders and award winners), from the 12
member task force during the development, from several small group discussions (community,
ambulatory, acute care, and long term care), and from expert researcher reviewers.
The methodology for continued development and refinement of these terms has been identified.
As with the ongoing updating of the American Medical Association Current Procedural
Terminology (CPT) codes, these will also be published on an annual basis. The process to
submit your suggested changes is included in this packet. In addition, the terms have been
included in one ongoing research project in an ambulatory setting. A second descriptive research
study identifying the use of the terms will be planned and conducted through the Dietetics
Practice Based Research Network in 2005-2006. As each of the research studies is completed,
their findings will be incorporated into future versions of these terms. Future iterations and
changes to the diagnoses/problems and the worksheets are expected as this standard language
evolves. Once the initial research is completed we will formally submit these terms to become
part of nationally recognized health care databases. We have already begun the dialogue with
these groups to let them know the direction that we are headed and to keep them appraised of our
progress.
Edition: 2006 17
Nutrition Care Process and Nutrition Diagnosis
ADA’s new nutrition care process for the profession has four steps—nutrition assessment,
nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation (1).
Textbooks often describe nutrition assessment in detail and then move directly into intervention
or therapy. Nutrition diagnosis is a critical step between assessment and intervention. The
nutrition diagnosis is the identification and labeling of the specific nutrition problem that
dietetics professionals are responsible for treating independently.
Naming the nutrition diagnosis provides a way to document the link between nutrition
assessment and nutrition intervention and set realistic and measurable expected outcomes for
each patient/client. Identifying the diagnosis also assists practitioners in establishing priorities
when planning an individual patient/client’s nutrition care.
Nutrition diagnosis differs from medical diagnosis. Medical diagnosis is a disease or pathology
of specific organs or body systems (e.g., diabetes) and does not change as long as the condition
exists. A nutrition diagnosis may be temporary, altering as the patient/client’s response changes
(e.g., excessive carbohydrate intake).
Categorization of the Nutrition Diagnoses
The sixty-two nutrition diagnoses/problems have been given labels that are clustered into three
domains: intake, clinical, and behavioral-environmental. Each domain represents unique
characteristics that contribute to nutritional health. Within each domain are classes and, in some
cases, sub-classes of diagnoses. A definition of each follows:
The Intake domain lists actual problems related to intake of energy, nutrients, fluids,
bioactive substances through oral diet, or nutrition support (enteral or parenteral nutrition.)
Class: Caloric Energy Balance (1)—Actual or estimated changes in energy (kcal).
Class: Oral or Nutrition Support Intake (2)—Actual or estimated food and beverage intake from oral diet
or nutrition support compared with patient/client’s goal.
Class: Fluid Intake Balance (3)—Actual or estimated fluid intake compared with patient/client’s goal.
Class: Bioactive Substances Balance (4)—Actual or observed intake of bioactive substances, including
single or multiple functional food components, ingredients, dietary supplements, and alcohol.
Class: Nutrient Balance (5)—Actual or estimated intake of specific nutrient groups or single nutrients as
compared with desired levels.
Sub-Class: Fat and Cholesterol Balance (51)
Sub-Class: Protein Balance (52)
Sub-Class: Carbohydrate and Fiber Balance (53)
Sub-Class: Vitamin Balance (54)
Sub-Class: Mineral Balance (55)
The Clinical domain is nutritional findings/problems identified that relate to medical or
physical conditions.
Class: Functional Balance (1)—Change in physical or mechanical function that interferes with or prevents
desired nutritional consequences.
Edition: 2006 18
Class: Biochemical Balance (2)—Change in the capacity to metabolize nutrients as a result of medications,
surgery, or as indicated by altered lab values.
Class: Weight Balance (3)—Chronic weight or changed weight status when compared with usual or desired
body weight.
The Behavioral-Environmental domain includes nutritional findings/problems identified
that relate to knowledge, attitudes/beliefs, physical environment, access to food, and food
safety.
Class: Knowledge and Beliefs (1)—Actual knowledge and beliefs as reported, observed, or documented.
Class: Physical Activity Balance and Function (2)—Actual physical activity, self-care, and quality of life
problems as reported, observed, or documented.
Class: Food Safety and Access (3)—Actual problems with food access or food safety.
Examples of nutrition diagnoses and their definitions include:
INTAKE DOMAIN Caloric Energy Balance
Inadequate energy intake NI-1.4 Energy intake that is less than energy expenditure or recommended
levels. Exception: when the goal is for the client to lose weight or
during end of life care.
CLINICAL DOMAIN Functional Balance
Swallowing difficulty NC-1.1 Impaired movement of food and liquid from the mouth to the stomach.
BEHAVIORAL-ENVIRONMENTAL DOMAIN Knowledge and Beliefs
Not ready for diet/lifestyle change NB-
1.3
Lack of perceived value of nutrition-related care benefits compared to
consequences or effort required to making the change; inconsistencies
with other value structure/purpose; antecedent to behavior change.
Nutrition Diagnosis Statements (or PES)
Whenever possible, a nutrition diagnosis statement is written in the PES format that states the
problem (P), the etiology (E), and the signs/symptoms (S).
Examples Swallowing difficulty (problem) related to stroke (etiology) as evidenced by coughing
following drinking of thin liquids (sign/symptoms).
Inadequate energy intake (problem) related to lack of financial resources to purchase sufficient
food (etiology) as evidenced by weight loss of 6 pounds in the last 2 months (signs/symptoms).
Nutrition Diagnosis Worksheet
A worksheet has been developed for each diagnosis. It contains four distinct components:
nutrition diagnosis label, definition of nutrition diagnosis label, etiology, and signs/symptoms.
These worksheets will assist practitioners with consistently and correctly utilizing the nutrition
diagnoses. Below is a description of the four components of the worksheet.
The Problem or Nutrition Diagnosis Label describes alterations in the patient/client’s nutrition status that
dietetics professionals are responsible for treating independently. Nutrition diagnosis differs from medical
diagnosis in that a nutrition diagnosis changes as the patient/client response changes. The medical diagnosis
Edition: 2006 19
does not change as long as the disease or condition exists. A nutrition diagnosis allows the dietetics professional
to identify realistic and measurable outcomes, formulate interventions, and monitor and evaluate change.
The Definition of Nutrition Diagnosis Label briefly describes the Nutrition Diagnosis Label to differentiate a
discrete problem area.
The Etiology (Cause/Contributing Risk Factors) are those factors contributing to the existence of, or
maintenance of pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental
problems. It is linked to the diagnosis label by the words “related to.”
The Signs/Symptoms (Defining Characteristics) consist of subjective and/or objective data used to determine
whether the patient/client has the nutrition diagnosis specified. These are the signs and symptoms gathered
through nutrition assessment. It is linked to the etiology by the words “as evidenced by.”
Organization of Data in Signs/Symptoms (Defining Characteristics)Dietetics professionals use clinical judgment to determine the nutrition diagnosis based on data
collected from the first step of the nutrition care process: nutrition assessment. Therefore, the
items listed in the signs/symptoms (defining characteristics) are organized according to nutrition
assessment category.
Nutrition assessment is the systematic process for obtaining, verifying, and interpreting data
needed to make decisions about the nature and cause of the nutrition-related problem. The
process of nutrition assessment consists of collecting biochemical data, anthropometric
measurements, physical examination findings, food/nutrition history, and client history. On the
nutrition diagnosis worksheet, the signs/symptoms are classified by nutrition assessment
categories.
Biochemical Data include laboratory data, for example, electrolytes, glucose, hemoglobin A1C, thyroid, and lipid
panel.
Anthropometric Measurements include, for instance, height, weight, body mass index (BMI), growth rate, and
rate of weight change.
Nutrition-Focused Physical Examination includes oral health, general physical appearance, muscle and
subcutaneous fat wasting, and affect.
Food and Nutrition History consists of four areas: Food consumption, nutrition and health awareness and
management, physical activity and exercise, and food availability.
Food consumption may include factors such as, food and nutrient intake, meal and snack patterns,
environmental cues to eating, and current diets and/or food modifications.
Nutrition and health awareness and management includes, for example, knowledge and beliefs about
nutrition recommendations, self-monitoring/management practices, and past nutrition counseling and
education.
Physical activity and exercise consists of activity patterns, amount of sedentary time (e.g., TV, phone,
computer), and exercise intensity, frequency, and duration.
Food availability encompasses factors such as, food planning, purchasing, preparation abilities and
limitations, food safety practices, food/nutrition program utilization, and food insecurity.
Edition: 2006 20
Client History consists of four areas: Medication and supplement history, social history, medical/health history,
and personal history.
Medication and supplement history includes, for instance, prescription and over the counter drugs,
herbal and dietary supplements, and illegal drugs.
Social history may include such items as socioeconomic status, social and medical support, cultural and
religious beliefs, housing situation, and social isolation/connection.
Medical/health history includes chief nutrition complaint, present/past illness, disease or complication
risk, family medical history, mental/emotional health, and cognitive abilities.
Personal history consists of factors including age, occupation, role in family, and education level.
Summary
Nutrition diagnosis is the critical link in the nutrition care process between assessment and
intervention. Interventions can then be clearly targeted to address either the etiology or signs and
symptoms of the specific nutrition diagnosis/problem identified. Using a standardized
terminology for identifying the nutrition diagnosis/problem will make one aspect of the critical
thinking that dietetics professionals do visible to other professionals as well as provide a clear
method of communicating among dietetics professionals. Implementation of a standard language
throughout the profession, with tools to assist practitioners, will make this bold initiative a
success. Ongoing input is critical as the standardized language is created to ensure a proper
foundation for its future implementation.
Reference
1. Lacey K, Pritchett E. Nutrition care process and model: ADA adopts road map to quality care
and outcomes management. J Am Diet Assoc. 2003;103:1061-1072.
Edition: 2006 21
Edition: 2006 22
INTAKE NI Defined as “actual problems related to intake of energy, nutrients, fluids, bioactive substances through oral diet or nutrition support”
Caloric Energy Balance (1) Defined as “actual or estimated changes in energy (kcal)”
Hypermetabolism NI-1.1 (Increased energy needs)
Increased energy expenditure NI-1.2 Hypometabolism NI-1.3
(Decreased energy needs) Inadequate energy intake NI-1.4 Excessive energy intake NI-1.5
Oral or Nutrition Support Intake (2) Defined as “actual or estimated food and beverage intake from oral diet or nutrition support compared with patient goal”
Inadequate oral food/ NI-2.1 beverage intake
Excessive oral food/ NI-2.2 beverage intake
Inadequate intake from NI-2.3 enteral/parenteral nutrition infusion
Excessive intake from NI-2.4 enteral/parenteral nutrition
Inappropriate infusion of NI-2.5 enteral/parenteral nutrition (use with caution)
Fluid Intake (3) Defined as “actual or estimated fluid intake compared with patient goal”
Inadequate fluid intake NI-3.1 Excessive fluid intake NI-3.2
Bioactive Substance Intake (4) Defined as “actual or observed intake of bioactive substances, including single or multiple functional food components, ingredients, dietary supplements, alcohol”
Inadequate bioactive NI-4.1 substance intake
Excessive bioactive NI-4.2 substance intake
Excessive alcohol intake NI-4.3
Nutrient Intake (5) Defined as “actual or estimated intake of specific nutrient groups or single nutrients as compared with desired levels”
Increased nutrient needs NI-5.1 (specify) ____________________________
Evident protein-energy NI-5.2 malnutrition
Inadequate protein- NI-5.3 energy intake
Decreased nutrient needs NI-5.4 (specify) ____________________________
Imbalance of nutrients NI-5.5
Fat and Cholesterol (51) Inadequate fat intake NI-51.1 Excessive fat intake NI-51.2 Inappropriate intake NI-51.3
of food fats (specify) ______________________ Protein (52)
Inadequate protein intake NI-52.1 Excessive protein intake NI-52.2 Inappropriate intake NI-52.3
of amino acids (specify)_______________________ Carbohydrate and Fiber (53)
Inadequate carbohydrate NI-53.1 intake
Excessive carbohydrate NI-53.2 intake
Inappropriate intake of NI-53.3 types of carbohydrate (specify)_______________________
Inconsistent NI-53.4 carbohydrate intake
Inadequate fiber intake NI-53.5 Excessive fiber intake NI-53.6
Vitamin (54) Inadequate vitamin NI-54.1
intake (specify)Excessive vitamin NI-54.2
intake (specify)A CThiamin DRiboflavin ENiacin KFolate Other _______
Mineral (55) Inadequate mineral intake NI-55.1
(specify) Calcium IronPotassium Zinc Other _______________
Excessive mineral intake NI-55.2 (specify)
Calcium IronPotassium Zinc Other _______________
CLINICAL NC Defined as “nutritional findings/problems identified as related to medical or physical conditions”
Functional (1) Defined as “change in physical or mechanical functioning that interferes with or prevents desired nutritional consequences”
Swallowing difficulty NC-1.1 Chewing (masticatory) difficulty NC-1.2 Breastfeeding difficulty NC-1.3 Altered GI function NC-1.4
Biochemical (2) Defined as “change in capacity to metabolize nutrients as a result of medications, surgery, or as indicated by altered lab values”
Impaired nutrient utilization NC-2.1 Altered nutrition-related NC-2.2
laboratory values (specify) _____________ Food-medication interaction NC-2.3
Weight (3) Defined as “chronic weight or changed weight status when compared with usual or desired body weight”
Underweight NC-3.1 Involuntary weight loss NC-3.2 Overweight/obesity NC-3.3 Involuntary weight gain NC-3.4
BEHAVIORAL- ENVIRONMENTAL NB Defined as “nutritional findings/problems identified as related to knowledge, attitudes/beliefs, physical environment, or food supply and safety”
Knowledge and Beliefs (1) Defined as “actual knowledge and beliefs as reported or documented”
Food, nutrition, and NB-1.1 nutrition-related knowledge deficit
Harmful beliefs/attitudes NB-1.2 about food or nutrition- related topics (use with caution)
Not ready for diet/ NB-1.3 lifestyle change
Self-monitoring deficit NB-1.4 Disordered eating pattern NB-1.5 Limited adherence to nutrition- NB-1.6
related recommendations Undesirable food choices NB-1.7
Physical Activity and Function (2) Defined as “actual physical activity, self-care, and quality of life problems as reported, observed, or documented”
Physical inactivity NB-2.1 Excessive exercise NB-2.2 Inability or lack of desire NB-2.3
to manage self-care Impaired ability to NB-2.4
prepare foods/meals Poor nutrition quality of life NB-2.5 Self-feeding difficulty NB-2.6
Food Safety and Access (3) Defined as “actual problems with food access or food safety”
Intake of unsafe food NB-3.1 Limited access to food NB-3.2
NUTRITION DIAGNOSTIC TERMINOLOGY
#1 Problem ____________________________________________________________________________________________________________
Etiology ____________________________________________________________________________________________________________
Signs/Symptoms _____________________________________________________________________________________________________
#2 Problem ____________________________________________________________________________________________________________
Etiology ____________________________________________________________________________________________________________
Signs/Symptoms _____________________________________________________________________________________________________
#3 Problem ____________________________________________________________________________________________________________
Etiology ____________________________________________________________________________________________________________
Signs/Symptoms ___________________________________________________________________________________________
Date Identified Date Resolved
NU
TR
ITIO
N D
IAG
NO
SIS
TE
RM
S A
ND
DE
FIN
ITIO
NS
Nu
trit
ion
Dia
gn
os
tic
Te
rm
Te
rmN
um
be
rD
efi
nit
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gn
os
tic
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rmR
efe
ren
ce
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ee
tP
ag
eN
um
be
rs
DO
MA
IN:
IN
TA
KE
Defi
ned
as “
actu
al p
rob
lem
s r
ela
ted
to
in
take o
f en
erg
y, n
utr
ien
ts, fl
uid
s, b
ioacti
ve
su
bsta
nces t
hro
ug
h o
ral d
iet
or
nu
trit
ion
su
pp
ort
(en
tera
l o
r p
are
nte
ral n
utr
itio
n)”
NI
Cla
ss:
Calo
ric E
nerg
y B
ala
nce (
1)
Defi
ne
d a
s “
actu
al o
r esti
mate
d c
han
ges in
e
ne
rgy
(k
ca
l)”
Hyperm
eta
bolis
m (
Incre
ased e
nerg
y n
eeds)
NI-
1.1
Resting m
eta
bolic
rate
(R
MR
) above p
redic
ted r
equirem
ents
due
to s
tress, tr
aum
a, in
jury
, sepsis
, or
dis
ease. N
ote
: R
MR
is the
su
m o
f m
eta
bo
lic p
roce
sses o
f a
ctive
ce
ll m
ass r
ela
ted
to
th
e
ma
inte
nan
ce
of n
orm
al bo
dy fu
nctio
ns a
nd
re
gu
lato
ry b
ala
nce
during r
est.
32
-33
Incre
ased e
nerg
y e
xpenditure
NI-
1.2
Resting m
eta
bolic
rate
(R
MR
) above p
redic
ted
requirem
ents
due
to b
ody c
om
positio
n, m
edic
ations, endocrine, neuro
logic
, or
genetic c
hanges. N
ote
: R
MR
is the s
um
of m
eta
bolic
pro
cesses
of active c
ell
mass r
ela
ted
to the m
ain
tenance o
f norm
al body
functions a
nd r
egula
tory
bala
nce d
uring r
est.
34
Hypom
eta
bolis
m (
Decre
ased e
nerg
y n
eeds)
NI-
1.3
Resting m
eta
bolic
rate
(R
MR
) be
low
pre
dic
ted r
equ
irem
ents
due
to b
ody c
om
positio
n, m
edic
ations, endocrine, neuro
logic
, or
ge
ne
tic c
ha
ng
es
35
-36
Inadequate
energ
y inta
ke
NI-
1.4
Energ
y inta
ke
that is
less than e
nerg
y e
xpenditure
, esta
blis
hed
refe
rence s
tandard
s, or
recom
mendations b
ased u
pon
physio
logic
al needs. E
xception: w
hen the g
oal is
weig
ht lo
ss o
r
37
-38
Ed
itio
n:
20
06
23
NU
TR
ITIO
N D
IAG
NO
SIS
TE
RM
S A
ND
DE
FIN
ITIO
NS
during e
nd o
f lif
e c
are
.
Excessiv
e e
nerg
y inta
ke
NI-
1.5
Calo
ric inta
ke that exceeds e
nerg
y e
xpenditure
, esta
blis
hed
refe
rence s
tandard
s, or
recom
mendations b
ased u
pon
physio
logic
al needs. E
xception: w
hen w
eig
ht gain
is d
esired.
39
-40
Cla
ss:
Ora
l o
r N
utr
itio
n S
up
po
rt In
take (
2)
Defi
ned
as “actu
al o
r esti
mate
d f
oo
d a
nd
b
evera
ge in
take f
rom
ora
l d
iet
or
nu
trit
ion
su
pp
ort
co
mp
are
d w
ith
pa
tie
nt
go
al”
Inadequate
ora
l fo
od/b
evera
ge inta
ke
NI-
2.1
Ora
l fo
od/b
evera
ge inta
ke that is
less than e
sta
blis
hed r
efe
rence
sta
ndard
s o
r re
com
mendations b
ased u
pon p
hysio
logic
al needs.
Exception: w
hen r
ecom
mendation is
weig
ht lo
ss o
r during e
nd o
f lif
e c
are
.
41
-42
Excessiv
e o
ral fo
od/b
evera
ge inta
ke
NI-
2.2
Ora
l fo
od/b
evera
ge inta
ke that exceeds
energ
y e
xpenditure
,esta
blis
hed r
efe
rence
sta
ndard
s, or
recom
mendations b
ased
upon p
hysio
logic
al needs. E
xception: w
hen w
eig
ht gain
is
de
sire
d.
43
-44
Inadequate
inta
ke fro
m e
nte
ral/pare
nte
ral
nutr
itio
n infu
sio
nN
I-2
.3E
nte
ral o
r pa
ren
tera
l in
fusio
n th
at p
rovid
es fe
we
r ca
lorie
s o
rn
utr
ien
ts c
om
pa
red
to
esta
blis
he
d r
efe
ren
ce
sta
nda
rds o
r re
co
mm
en
da
tio
ns b
ase
d u
po
n p
hysio
log
ica
l ne
eds. E
xce
ptio
n:
when r
ecom
mendation is for
weig
ht lo
ss o
r during e
nd o
f lif
e
ca
re.
45
-46
Excessiv
e inta
ke fro
m e
nte
ral/pare
nte
ral
nutr
itio
nN
I-2.4
Ente
ral or
pa
rente
ral in
fusio
n that pro
vid
es m
ore
calo
ries o
r n
utr
ien
ts c
om
pa
red
to
esta
blis
he
d r
efe
ren
ce
sta
nda
rds o
r re
co
mm
en
da
tio
ns b
ase
d u
po
n p
hysio
log
ica
l ne
eds
47
-48
Inappro
priate
infu
sio
n o
f ente
ral/pare
nte
ral
nutr
itio
n
US
E W
ITH
CA
UT
ION
ON
LY
AF
TE
R
DIS
CU
SS
ION
WIT
H O
TH
ER
ME
MB
ER
S O
F
TH
E H
EA
LT
H C
AR
E T
EA
M
NI-
2.5
En
tera
l o
r pa
ren
tera
l in
fusio
nth
at p
rovid
es e
ith
er
few
er
or
mo
recalo
ries a
nd/o
r nutr
ients
or
is o
f th
e w
rong c
om
positio
n o
r ty
pe, is
not w
arr
ante
d b
ecause the p
atient is
able
to tole
rate
an
ente
ral
inta
ke, or
is u
nsafe
be
cause o
f th
e p
ote
ntial fo
r sepsis
or
oth
er
co
mp
lica
tion
s
49
-50
Ed
itio
n:
20
06
24
NU
TR
ITIO
N D
IAG
NO
SIS
TE
RM
S A
ND
DE
FIN
ITIO
NS
Cla
ss:
Flu
id In
take (
3)
Defi
ne
d a
s “
actu
al o
r esti
mate
d f
luid
in
take
co
mp
are
dw
ith
pa
tie
nt
go
al”
Ina
de
qu
ate
flu
id in
take
NI-
3.1
Lo
we
r in
take
of flu
id c
on
tain
ing
fo
ods o
r su
bsta
nces c
om
pare
d to
e
sta
blis
he
d r
efe
rence
sta
nd
ard
s o
r re
com
me
nda
tio
ns b
ase
d
up
on
ph
ysio
log
ica
l n
ee
ds
51
-52
Excessiv
e flu
id inta
ke
NI-
3.2
Hig
her
inta
ke o
f fluid
com
pare
d to e
sta
blis
hed r
efe
rence
sta
nda
rds o
r re
co
mm
en
da
tio
ns b
ased
up
on
ph
ysio
log
ica
l ne
eds
53
-54
Cla
ss:
Bio
ac
tiv
e S
ub
sta
nc
es
(4
)
De
fin
ed
as
“a
ctu
al o
r o
bs
erv
ed
in
take
of
bio
acti
ve s
ub
sta
nces, in
clu
din
g s
ing
le o
r m
ult
iple
fu
nc
tio
nal fo
od
co
mp
on
en
ts,
ing
red
ien
ts, d
ieta
ry s
up
ple
men
ts, alc
oh
ol”
Inadequate
bio
active s
ubsta
nce inta
ke
NI-
4.1
Low
er
inta
ke
of bio
active s
ubsta
nces
conta
inin
g foods o
r substa
nces c
om
pare
d to e
sta
blis
hed r
efe
rence
sta
ndard
s o
r re
com
mendations b
ased u
pon p
hysio
logic
al needs
55
-56
Excessiv
e b
ioactive s
ubsta
nce inta
ke
NI-
4.2
Hig
her
inta
ke o
f bio
active s
ubsta
nces o
ther
than tra
ditio
nal
nutr
ients
, such a
s functional fo
ods, bio
active food c
om
ponents
,d
ieta
ry s
up
ple
me
nts
, fo
od
co
ncen
tra
tes c
om
pa
red
to
esta
blis
he
dre
fere
nce s
tandard
s o
r re
com
mendations b
ased u
pon
ph
ysio
log
ica
l n
ee
ds
57
-58
Excessiv
e a
lcohol in
take
NI-
4.3
Inta
ke a
bove the s
uggeste
d lim
its for
alc
ohol
59-6
0
Cla
ss:
Nu
trie
nt
(5)
Defi
ne
d a
s “
actu
al o
r esti
mate
d in
take o
f sp
ecif
ic n
utr
ien
t g
rou
ps o
r sin
gle
nu
trie
nts
as c
om
pare
d w
ith
desir
ed
levels
”
Incre
ased n
utr
ient needs
(specify)
NI-
5.1
Incre
ased
need for
a s
pecific
nutr
ient com
pare
d to e
sta
blis
hed
refe
rence s
tandard
s o
r re
com
mendations based u
pon
61
-62
Ed
itio
n:
20
06
25
NU
TR
ITIO
N D
IAG
NO
SIS
TE
RM
S A
ND
DE
FIN
ITIO
NS
ph
ysio
log
ica
l n
ee
ds
Evid
ent pro
tein
-energ
y m
aln
utr
itio
nN
I-5.2
Inadequate
inta
ke o
f pro
tein
and/o
r en
erg
y63-6
4
Inadequate
pro
tein
-energ
y inta
ke
NI-
5.3
Inadequate
inta
ke o
f pro
tein
and/o
r energ
y c
om
pare
d to
esta
blis
hed r
efe
rence
sta
ndard
s o
r re
com
mendations based
upon p
hysio
logic
al needs
of short
or
recent dura
tion
65
-66
Decre
ase
d n
utr
ien
t n
eed
s(s
pe
cify)
NI-
5.4
Decre
ase
dne
ed
fo
r a
sp
ecific
nu
trie
nt co
mp
are
d to
esta
blis
hed
refe
rence s
tandard
s o
r re
com
mendations based u
pon
ph
ysio
log
ica
l n
ee
ds
67
-68
Imbala
nce o
f nutr
ients
NI-
5.5
An u
ndesirable
com
bin
ation o
f in
geste
d n
utr
ients
, such that th
e
am
ount of one n
utr
ient in
geste
d inte
rfere
s w
ith o
r alters
a
bso
rption
and
/or
utiliz
ation
of a
no
the
r n
utr
ien
t
69
-70
Su
b-C
lass:
Fat
an
d C
ho
leste
rol (5
1)
Inadequate
fat in
take
NI-
51.1
Low
er
fat in
take c
om
pare
d to e
sta
blis
hed
refe
rence s
tandard
s o
r re
com
mendations b
ased u
pon p
hysio
logic
al needs. E
xception:
when r
ecom
mendation is for
weig
ht lo
ss o
r during e
nd o
f lif
e
ca
re.
71
Excessiv
e fat in
take
NI-
51.2
Hig
her
fat in
take
co
mpare
d to e
sta
blis
hed r
efe
rence
sta
ndard
s o
rre
co
mm
en
da
tio
ns b
ase
d u
po
n p
hysio
log
ica
l ne
eds
72
-73
Inappro
priate
inta
ke o
f fo
od fats
(specify)
NI-
51.3
Inta
ke
of w
rong type o
r qualit
y o
f fo
od fats
com
pare
d to
esta
blis
hed r
efe
rence
sta
ndard
s o
r re
com
mendations based
upon p
hysio
logic
al needs
74
-75
Su
b-C
lass:
Pro
tein
(52)
Ina
de
qu
ate
pro
tein
in
take
NI-
52
.1L
ow
er
inta
ke
of
pro
tein
co
nta
inin
g fo
ods
or
sub
sta
nces c
om
pare
dto
esta
blis
hed
re
fere
nce
sta
nd
ard
s o
r re
co
mm
en
da
tion
s b
ased
upon p
hysio
logic
al needs
76
Excessiv
e p
rote
in inta
ke
NI-
52.2
Inta
ke a
bove the r
ecom
mended level and/o
r ty
pe o
f pro
tein
co
mpa
red
to
esta
blis
he
d r
efe
ren
ce
sta
nd
ard
s o
r7
7-7
8
Ed
itio
n:
20
06
26
NU
TR
ITIO
N D
IAG
NO
SIS
TE
RM
S A
ND
DE
FIN
ITIO
NS
reco
mm
en
da
tio
ns b
ase
d u
po
n p
hysio
log
ica
l ne
eds
Ina
pp
ropria
te in
take
of a
min
o a
cid
s (
specify)
NI-
52
.3In
take
th
at is
mo
re o
r le
ss th
an
recom
men
de
d le
ve
l and
/or
typ
e
of a
min
o a
cid
s c
om
pare
d to
esta
blis
he
d r
efe
ren
ce
sta
nd
ard
s o
rre
co
mm
en
da
tio
ns b
ase
d u
po
n p
hysio
log
ica
l ne
eds
78
-80
Su
b-C
lass:
Carb
oh
yd
rate
an
d
Fib
er
(53)
Inadequate
carb
ohydra
te inta
ke
NI-
53.1
Low
er
inta
ke
of carb
ohydra
te-c
onta
inin
g foods o
r substa
nces
co
mpa
red
to
esta
blis
he
d r
efe
ren
ce
sta
nd
ard
s o
rre
co
mm
en
da
tio
ns b
ase
d u
po
n p
hysio
log
ica
l ne
eds
81
Excessiv
e c
arb
ohydra
te inta
ke
NI-
53.2
Inta
ke a
bove the r
ecom
mended level and type o
f carb
ohydra
teco
mpa
red
to
esta
blis
he
d r
efe
ren
ce
sta
nd
ard
s o
rre
co
mm
en
da
tio
ns b
ase
d u
po
n p
hysio
log
ica
l ne
eds
82
-83
Inappro
priate
inta
ke o
f ty
pes o
f carb
ohydra
te(s
pe
cify)
NI-
53.3
Inta
ke o
r th
e type o
r am
ount of carb
ohydra
te that is
above o
r b
elo
w th
e e
sta
blis
he
d r
efe
ren
ce
sta
nd
ard
s o
r re
co
mm
en
da
tion
sb
ase
d u
po
n p
hysio
log
ica
l ne
eds
84
-85
Inconsis
tent carb
ohydra
te inta
ke
NI-
53.4
Inconsis
tent tim
ing o
f carb
ohydra
te inta
ke thro
ughoutth
e d
ay,
day to d
ay, or
a p
attern
of carb
ohydra
te inta
ke that is
not
co
nsis
ten
t w
ith
re
co
mm
en
de
d p
att
ern
base
d u
po
n p
hysio
log
ica
ln
ee
ds
86
-87
Inadequate
fib
er
inta
ke
NI-
53.5
Low
er
inta
ke
of fiber-
conta
inin
g foods o
r substa
nces c
om
pare
d to
esta
blis
hed r
efe
rence
sta
ndard
s o
r re
com
mendations b
ased
upon p
hysio
logic
al needs
88
-89
Exce
ssiv
e fib
er
inta
ke
NI-
53
.6H
ighe
r in
take o
f fib
er-
co
nta
inin
g fo
ods o
r su
bsta
nces c
om
pare
dto
recom
mendations b
ased u
pon p
atient/clie
nt conditio
n9
0-9
1
Su
b-C
lass:
Vit
am
in (
54)
Inadequate
vitam
in inta
ke (
specify)
NI-
54.1
Low
er
inta
ke
of vitam
in-c
onta
inin
g foods o
r substa
nces
co
mpa
red
to
esta
blis
he
d r
efe
ren
ce
sta
nd
ard
s o
rre
co
mm
en
da
tio
ns b
ase
d u
po
n p
hysio
log
ica
l ne
eds
92
-94
Ed
itio
n:
20
06
27
NU
TR
ITIO
N D
IAG
NO
SIS
TE
RM
S A
ND
DE
FIN
ITIO
NS
Excessiv
e v
itam
in inta
ke (
specify)
NI-
54.2
Hig
her
inta
ke o
f vitam
in c
onta
inin
g foods o
r substa
nces
co
mpa
red
to
esta
blis
he
d r
efe
ren
ce
sta
nd
ard
s o
rre
co
mm
en
da
tio
ns b
ase
d u
po
n p
hysio
log
ica
l ne
eds
95
-96
Su
b-C
las
s:
Min
era
l (5
5)
Ina
de
qu
ate
min
era
l in
take
(sp
ecify)
NI-
55
.1L
ow
er
inta
ke
of m
ine
ral con
tain
ing
fo
ods o
r su
bsta
nce
sco
mpa
red
to
esta
blis
he
d r
efe
ren
ce
sta
nd
ard
s o
rre
co
mm
en
da
tio
ns b
ase
d u
po
n p
hysio
log
ica
l ne
eds
97
-98
Excessiv
e m
inera
l in
take
(specify)
NI-
55.2
Hig
her
inta
ke o
f m
inera
l fr
om
foods, supple
ments
, m
edic
ations o
rw
ate
r,com
pare
d to e
sta
blis
hed r
efe
rence s
tandard
s o
rre
co
mm
en
da
tio
ns b
ase
d u
po
n p
hysio
log
ica
l ne
eds
99
-10
0
DO
MA
IN:
CL
INIC
AL
Defi
ned
as “
nu
trit
ion
al fi
nd
ing
s/p
rob
lem
sid
en
tifi
ed
that
rela
te t
o m
ed
ical o
r p
hys
ical
co
nd
itio
ns
”
NC
Cla
ss:
Fu
ncti
on
al (1
)
Defi
ne
d a
s “
ch
an
ge in
ph
ysic
al o
r m
ech
an
ical fu
ncti
on
ing
th
at
inte
rfere
s w
ith
o
r p
reven
tsd
esir
ed
nu
trit
ion
al
co
nseq
uen
ces”
Sw
allo
win
g d
ifficulty
NC
-1.1
Impaired m
ovem
ent of fo
od a
nd liq
uid
fro
m the m
outh
to the
sto
mach
10
1
Chew
ing (
masticato
ry)
difficulty
NC
-1.2
Impaired a
bili
ty to m
anip
ula
te o
r m
asticate
food for
sw
allo
win
g102-1
04
Bre
astfeedin
g d
ifficulty
NC
-1.3
Inabili
ty to s
usta
in n
utr
itio
n thro
ugh b
reastfeedin
g105-1
06
Altere
d G
I fu
nction
NC
-1.4
Changes in a
bili
ty to d
igest or
absorb
nutr
ients
107-1
08
Cla
ss:
Bio
ch
em
ical (2
)
Defi
ned
as “
ch
an
ge in
cap
acit
y t
om
eta
bo
lize
nu
trie
nts
as
a r
es
ult
of
Ed
itio
n:
20
06
28
NU
TR
ITIO
N D
IAG
NO
SIS
TE
RM
S A
ND
DE
FIN
ITIO
NS
med
icati
on
s, su
rgery
, o
r as in
dic
ate
d b
y
alt
ere
d lab
va
lues” Im
paired n
utr
ient utiliz
ation
NC
-2.1
Changes in a
bili
ty to a
bsorb
or
me
taboliz
e n
utr
ients
and b
ioactive
su
bsta
nces
10
9-1
10
Altere
d n
utr
itio
n-r
ela
ted labora
tory
valu
es
NC
-2.2
Changes in a
bili
ty to e
limin
ate
by-p
roducts
of dig
estive a
nd
me
tab
olic
pro
cesse
s1
11
-11
2
Fo
od-m
ed
ica
tio
n in
tera
ction
NC
-2.3
Un
de
sira
ble
/ha
rmfu
l in
tera
ctio
n(s
) b
etw
ee
n fo
od
an
do
ve
r th
e
counte
r (O
TC
) m
edic
ations, pre
scribed
medic
ations, herb
als
,bota
nic
als
, and/o
r die
tary
supple
ments
that dim
inis
hes,
enhances, or
alters
effect of nutr
ients
and/o
r m
edic
ations
11
3-1
14
Cla
ss:
We
igh
t (3
)
Defi
ned
as “
ch
ron
ic w
eig
ht
or
ch
an
ged
weig
ht
sta
tus w
hen
co
mp
are
d w
ith
us
ual o
r d
esir
ed
bo
dy w
eig
ht”
Underw
eig
ht
NC
-3.1
Low
body w
eig
ht com
pare
d to e
sta
blis
hed r
efe
rence s
tandard
s o
r re
com
mendations
11
5-1
16
Involu
nta
ry w
eig
ht lo
ss
NC
-3.2
Decre
ase in b
ody w
eig
ht th
at is
not pla
nned o
r desired
117-1
18
Overw
eig
ht/obesity
NC
-3.3
Incre
ased a
dip
osity c
om
pare
d to e
sta
blis
hed r
efe
rence s
tandard
so
r re
co
mm
end
atio
ns
11
9-1
20
Involu
nta
ry w
eig
ht gain
NC
-3.4
Weig
ht gain
above that w
hic
h is d
esired
or
expecte
d121-1
22
DO
MA
IN:
BE
HA
VIO
RA
L-
EN
VIR
ON
ME
NT
AL
Defi
ned
as “
nu
trit
ion
al fi
nd
ing
s/p
rob
lem
sid
en
tifi
ed
that
rela
te t
o k
no
wle
dg
e,
att
itu
des/b
eliefs
, p
hysic
al en
vir
on
men
t, o
r a
cc
es
s t
o f
oo
d a
nd
fo
od
sa
fety
”
NB
Cla
ss:
Kn
ow
led
ge a
nd
Beliefs
(1)
Ed
itio
n:
20
06
29
NU
TR
ITIO
N D
IAG
NO
SIS
TE
RM
S A
ND
DE
FIN
ITIO
NS
Defi
ned
as “
actu
al kn
ow
led
ge a
nd
be
liefs
as r
ep
ort
ed
,o
bserv
ed
, o
r d
ocu
men
ted
”
Food a
nd n
utr
itio
n-r
ela
ted k
now
ledge d
eficit
NB
-1.1
Incom
ple
te o
r in
accura
te k
now
ledge a
bout fo
od, nutr
itio
n o
r nutr
itio
n-r
ela
ted info
rmation a
nd g
uid
elin
es, e.g
., n
utr
ient
requirem
ents
, consequences o
f fo
od b
ehavio
rs, lif
e s
tage
requirem
ents
, nutr
itio
n r
ecom
mendations, dis
eases a
nd
co
nd
itio
ns, p
hysio
log
ica
l fu
nction
, o
r p
rod
ucts
12
3-1
24
Harm
ful belie
fs/a
ttitudes a
bout fo
od o
r nutr
itio
n-r
ela
ted topic
s
US
E W
ITH
CA
UT
ION
TO
BE
SE
NS
ITIV
E T
O
PA
TIE
NT
CO
NC
ER
NS
NB
-1.2
Belie
fs/a
ttitudes a
nd p
ractices a
bout fo
od, nutr
itio
n, and n
utr
itio
n-
rela
ted
to
pic
s th
at a
re in
com
pa
tib
le w
ith
so
un
d n
utr
itio
nprincip
les, nutr
itio
n c
are
, or
dis
ease/c
onditio
n
12
5-1
26
No
t re
ad
y fo
r d
iet/
life
sty
le c
ha
nge
NB
-1.3
La
ck o
f p
erc
eiv
ed
va
lue
of n
utr
itio
n-r
ela
ted
care
ben
efits
com
pare
d to c
onsequences o
r effort
required to m
akin
g the
change; in
consis
tencie
s w
ith o
ther
valu
e s
tructu
re/p
urp
ose;
ante
cedent to
behavio
r change
12
7-1
28
Self m
onitoring d
eficit
NB
-1.4
Lack o
f data
record
ing to tra
ck p
ers
onalpro
gre
ss
129-1
30
Dis
ord
ere
d e
ating p
attern
NB
-1.5
Belie
fs, attitudes, th
oughts
and b
ehavio
rs r
ela
ted to food, eating,
and w
eig
ht m
anagem
ent, inclu
din
gcla
ssic
eating d
isord
ers
as
well
as less s
evere
, sim
ilar
conditio
ns that negatively
im
pact
he
alth
13
1-1
33
Lim
ited a
dhere
nce to n
utr
itio
n-r
ela
ted
recom
mendations
NB
-1.6
La
ck o
f n
utr
itio
n-r
ela
ted
cha
ng
es a
s p
er
inte
rve
ntio
n a
gre
ed
up
on
by c
lient or
popula
tion
13
4-1
35
Un
de
sira
ble
fo
od
ch
oic
es
NB
-1.7
Fo
od
and
/or
be
ve
rag
e c
ho
ices th
at a
re in
con
sis
ten
t w
ith
US
R
ecom
mended D
ieta
ry Inta
ke, U
S D
ieta
ry G
uid
elin
es, or
with the
My P
yra
mid
or
with targ
ets
defined
in the n
utr
itio
n p
rescription o
r n
utr
itio
n c
are
pro
cess
13
6-1
37
Cla
ss:
Ph
ysic
al A
cti
vit
y a
nd
Fu
ncti
on
(2)
Defi
ned
as “
actu
al p
hysic
al acti
vit
y, self
-care
, an
d q
uality
of
life
pro
ble
ms a
s
Ed
itio
n:
20
06
30
NU
TR
ITIO
N D
IAG
NO
SIS
TE
RM
S A
ND
DE
FIN
ITIO
NS
rep
ort
ed
, o
bserv
ed
, o
r d
ocu
men
ted
”
Physic
al in
activity
NB
-2.1
Low
level of activity/s
edenta
ry b
ehavio
r to
the e
xte
nt th
at it
red
uces e
ne
rgy e
xp
en
ditu
re a
nd
im
pacts
he
alth
1
38=
139
Excessiv
e e
xerc
ise
NB
-2.2
An a
mount of exerc
ise that exceeds that w
hic
h is n
ecessary
to
impro
ve h
ealth a
nd/o
r ath
letic p
erf
orm
ance
14
0-1
41
Inabili
ty o
f la
ck o
f desire to m
anage s
elf c
are
NB
-2.3
Lack o
f capacity o
r unw
illin
gness to im
ple
ment m
eth
ods to
support
healthfu
l fo
od a
nd n
utr
itio
n-r
ela
ted b
ehavio
r1
42
-14
3
Impaired a
bili
ty to p
repare
foods/m
eals
NB
-2.4
Cognitiv
eor
physic
al im
pairm
ent th
at pre
vents
pre
para
tion o
f fo
ods/m
eals
14
4-1
45
Poor
nutr
itio
n q
ualit
y o
f lif
eN
B-2
.5D
imin
ished N
utr
itio
n Q
ualit
y o
f Life (
NQ
OL)
score
s r
ela
ted to food
imp
act,
se
lf-im
ag
e, p
sycho
log
ica
l fa
cto
rssocia
l/in
terp
ers
on
al
facto
rs, physic
al (f
acto
rs),
or
self-e
ffic
acy
14
6-1
47
Self feedin
g d
ifficulty
NB
-2.6
Impaired a
ctions to p
lace food in m
outh
148-1
49
Cla
ss:
Fo
od
Safe
ty a
nd
Access (
3)
Defi
ned
as “
actu
al p
rob
lem
s w
ith
fo
od
ac
ces
s o
r fo
od
sa
fety
”
Inta
ke o
f unsafe
food
NB
-3.1
Inta
ke o
f fo
od a
nd/o
r fluid
s inte
ntionally
or
unin
tentionally
co
nta
min
ate
d w
ith
to
xin
s, p
ois
on
ous p
rod
ucts
, in
fectiou
s a
ge
nts
,m
icro
bia
l ag
en
ts, a
dd
itiv
es, a
llerg
en
s, a
nd
/or
ag
en
ts o
fb
iote
rro
rism
15
0-1
51
Lim
ited a
ccess to food
NB
-3.2
Dim
inis
hed a
bili
ty to a
cquire food fro
m s
ourc
es (
e.g
., s
hoppin
g,
gard
enin
g, m
eal deliv
ery
), d
ue to fin
ancia
l constr
ain
ts, physic
al
impairm
ent, c
are
giv
er
support
, or
unsafe
liv
ing c
onditio
ns (
e.g
. crim
e h
inders
tra
vel to
gro
cery
sto
re).
Lim
itin
g food inta
ke
because o
f concern
s a
bout w
eig
ht or
agin
g.
15
2-1
53
Ed
itio
n:
20
06
31
INTA
KE
DO
MA
IN C
aloric
Ener
gy
Bal
ance
HY
PE
RM
ET
AB
OL
ISM
(NI-
1.1
)
Edit
ion:
20
06
32
De
fin
itio
n
Res
tin
g m
etaboli
c ra
te (
RM
R)
above
pre
dic
ted r
equir
emen
ts d
ue
to s
tres
s, t
raum
a, i
nju
ry,
sepsi
s, o
r dis
ease
. N
ote
: R
MR
is
the
sum
of
met
aboli
c pro
cess
es o
f
acti
ve
cell
mas
s re
late
d t
o t
he
mai
nte
nan
ce o
f n
orm
al b
od
y f
un
ctio
ns
and r
egula
tory
bal
ance
duri
ng r
est.
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•C
atab
oli
c il
lnes
s
•In
fect
ion
•S
epsi
s
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•In
suli
n r
esis
tan
ce (
dif
ficu
lt t
o c
on
trol
blo
od g
luco
se)
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
inati
on F
indin
gs
•F
ever
•In
crea
sed h
eart
rat
e
•In
crea
sed r
espir
atory
rat
e
•M
easu
red R
MR
> e
stim
ated
or
expec
ted R
MR
Food/N
utr
itio
n H
isto
ry
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t of,
e.g
., A
IDS
/HIV
, burn
s, c
hro
nic
obst
ruct
ive
pulm
on
ary d
isea
se,
hip
/lon
g b
on
e fr
act
ure
, in
fect
ion,
surg
ery,
tra
um
a, h
yper
thyr
oid
ism
(pre
- or
untr
eate
d),
som
e ca
nce
rs (
spec
ify)
•M
edic
atio
ns
asso
ciate
d w
ith
RM
R
INTA
KE
DO
MA
IN C
aloric
Ener
gy
Bal
ance
HY
PE
RM
ET
AB
OL
ISM
(NI-
1.1
)
Edit
ion:
20
06
33
Refe
ren
ces:
1.
Bit
z C
, T
ou
bro
S,
Lar
sen
TM
, H
ard
er H
, R
enn
ie K
L, Je
bb
SA
, A
stru
p A
. In
crea
sed
24
hou
r en
erg
y e
xp
end
itu
re i
n T
yp
e 2
dia
bet
es m
elli
tus.
Dia
bet
es C
are
. 2
00
4;2
7:2
41
6-2
24
1.
2.
Dic
ker
son
RN
, R
oth
-You
sey
L.
Med
icat
ion
eff
ects
on
met
aboli
c ra
te;
a sy
stem
atic
rev
iew
(P
art
2).
J A
m D
iet
Ass
oc.
2
00
5;1
05
:10
02
-10
09
.
3.
Dic
ker
son
RN
, R
oth
-You
sey
L.
Med
icat
ion
eff
ects
on
met
aboli
c ra
te:
a sy
stem
atic
rev
iew
(P
art
1).
J A
m D
iet
Ass
oc.
2
00
5;1
05
:83
5-8
41
.
4.
Fra
nk
enfi
eld D
, R
oth
-You
sey L
, C
om
pher
C.
Com
par
iso
n o
f pre
dic
tive
equ
atio
ns
to m
easu
red r
esti
ng m
etaboli
c ra
te i
n h
ealt
hy n
onob
ese
and o
bes
e in
div
iduals
: a
syst
emat
ic r
evie
w.J
Am
Die
t
Ass
oc.
20
05
;10
5:7
75
-78
9.
INTA
KE
DO
MA
IN C
aloric
Ener
gy
Bal
ance
INC
RE
AS
ED
EN
ER
GY
EX
PE
ND
ITU
RE
(NI-
1.2
)
Edit
ion:
20
06
34
De
fin
itio
n
Res
tin
g m
etab
oli
c ra
te (
RM
R)
above
pre
dic
ted r
equir
emen
ts d
ue
to b
od
y c
om
posi
tion
, m
edic
atio
n,
endocr
ine,
neu
rolo
gic
, or
gen
etic
chan
ge(
s).
Note
: R
MR
is
the
sum
of
met
aboli
c pro
cess
es o
f ac
tive
cell
mas
s re
late
d t
o t
he
mai
nte
nan
ce o
f n
orm
al b
od
y f
un
ctio
ns
and r
egula
tory
bal
ance
duri
ng r
est.
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•A
naboli
sm o
r gro
wth
•V
olu
nta
ry o
r in
volu
nta
ry p
hys
ical
act
ivit
y/m
ovem
ent
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
•U
nin
ten
tional
wei
ght
loss
of
10%
in 6
month
s, 5
% i
n 1
mon
th
•E
vid
ence
of
nee
d f
or
acc
eler
ated
or
catc
h u
p g
row
th o
r w
eight
gai
n i
n c
hil
dre
n;
abse
nce
of
norm
al
gro
wth
•In
crea
sed p
roport
ional
lean
bod
y m
ass
Phys
ical
Exam
inati
on F
indin
gs
•M
easu
red R
MR
> e
stim
ated
or
expec
ted R
MR
Food/N
utr
itio
n H
isto
ry•
Incr
ease
d p
hys
ical
act
ivit
y,
e.g., e
ndura
nce
ath
lete
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., P
arkin
son
’s d
isea
se,
cere
bra
l pal
sy,
Alz
hei
mer
’s d
isea
se,
oth
er
dem
enti
a
Refe
ren
ce:
1.
Fra
nk
enfi
eld D
, R
oth
-You
sey L
, C
om
pher
C.
Com
par
iso
n o
f pre
dic
tive
equ
atio
ns
to m
easu
red r
esti
ng m
etaboli
c ra
te i
n h
ealt
hy n
onob
ese
and o
bes
e in
div
iduals
: a
syst
emat
ic r
evie
w.J
Am
Die
t
Ass
oc.
20
05
;10
5:7
75
-78
9.
INTA
KE
DO
MA
IN C
aloric
Ener
gy
Bal
ance
HY
PO
ME
TA
BO
LIS
M(N
I-1
.3)
Edit
ion:
20
06
35
De
fin
itio
n
Res
tin
g m
etab
oli
c ra
te (
RM
R)
bel
ow
pre
dic
ted r
equir
emen
ts d
ue
to b
od
y c
om
posi
tion
, m
edic
atio
ns,
en
docr
ine,
neu
rolo
gic
, or
gen
etic
chan
ges
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•L
oss
of
lean
bod
y m
ass
, w
eight
loss
•M
edic
atio
ns,
e.g
., m
idaz
ola
m,
pro
pra
nal
ol,
gli
piz
ide
•E
ndocr
ine
chan
ges
, e.
g., h
ypoth
yroid
ism
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•In
crea
sed T
SH
, dec
reas
ed T
4, T
3 (
hyp
oth
yroid
ism
)
Anth
ropom
etri
c D
ata
•D
ecre
ased
wei
gh
t or
mid
-arm
mu
scle
cir
cum
fere
nce
•W
eigh
t gai
n
(e.g
., h
ypoth
yroid
ism
)
•G
row
th s
tun
tin
g o
r fa
ilure
, bas
ed o
n N
atio
nal
Cen
ter
for
Hea
lth S
tati
stic
s (N
CH
S)
gro
wth
sta
ndar
ds
Phys
ical
Exam
Fin
din
gs
•D
ecre
ased
or
norm
al a
dip
ose
an
d s
om
atic
pro
tein
sto
res
•M
easu
red R
MR
< e
stim
ated
or
expec
ted R
MR
Food/N
utr
itio
n H
isto
ry
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., h
ypoth
yroid
ism
, an
orex
ia n
ervosa
, m
aln
utr
itio
n,
fail
ure
to t
hri
ve,
Pra
der
-Wil
li s
yndro
me,
hyp
oto
nic
con
dit
ion
s
•B
rad
ycar
dia
, h
ypote
nsi
on,
dec
reas
ed b
ow
l m
oti
lity
, sl
ow
bre
ath
ing r
ate,
low
bod
y t
emper
ature
(in
sig
nif
ican
t w
eight
loss
)
•C
old
into
lera
nce
, h
air
loss
, dec
rease
d e
ndura
nce
, dif
ficu
lty c
on
cen
trat
ing,
dec
rease
d l
ibid
o,
feel
ings
of
anxie
ty/d
epre
ssio
n
INTA
KE
DO
MA
IN C
aloric
Ener
gy
Bal
ance
HY
PO
ME
TA
BO
LIS
M(N
I-1
.3)
Edit
ion:
20
06
36
Refe
ren
ces:
1.
Bro
zek
J.
Sta
rvat
ion a
nd n
utr
itio
nal
reh
abil
itat
ion;
a quan
tita
tiv
e ca
se s
tud
y.
J A
m D
iet
Ass
oc.
19
52
;28
:91
7-9
26
.
2.
Coll
ins
S.
Usi
ng m
iddle
up
per
arm
cir
cum
fere
nce
to a
ssess
sev
ere
adult
mal
nutr
itio
n d
uri
ng f
am
ine.
JAM
A.
19
96
;27
6:3
91
-39
5.
3.
Det
zer
MJ,
Lei
tenb
erg
H,
Po
ehlm
an E
T, R
ose
n J
C,
Sil
ber
g N
T,
Var
a L
S.
Res
tin
g m
etab
oli
c ra
te i
n w
om
en w
ith
bu
lim
ia n
erv
osa
: a c
ross
sec
tio
nal
and
tre
atm
ent
stu
dy.
Am
J C
lin
Nu
tr.
19
94
;60
:327
-33
2.
4.
Dic
ker
son
RN
, R
oth
-You
sey
L.
Med
icat
ion
eff
ects
on
met
aboli
c ra
te:
a sy
stem
atic
rev
iew
(P
art
2).
J A
m D
iet
Ass
oc.
2
00
5;1
05
:10
02
-10
09
.
5.
Dic
ker
son
RN
, R
oth
-You
sey
L.
Med
icat
ion
eff
ects
on
met
aboli
c ra
te:
a sy
stem
atic
rev
iew
(P
art
1).
J A
m D
iet
Ass
oc.
2
00
5;1
05
:83
5-8
41
.
6.
Fra
nk
enfi
eld D
, R
oth
-You
sey L
, C
om
pher
C.
Com
par
iso
n o
f pre
dic
tive
equ
atio
ns
to m
easu
red r
esti
ng m
etaboli
c ra
te i
n h
ealt
hy n
onob
ese
and o
bes
e in
div
iduals
: a
syst
emat
ic r
evie
w.J
Am
Die
t
Ass
oc.
20
05
;10
5:7
75
-78
9.
7.
Ker
ruis
h K
P, O
’Co
nn
er J
O,
Hu
mp
hri
es I
RJ,
Koh
n M
R,
Cla
rke
SD
, B
rio
dy
JN
, T
ho
mso
n E
J, W
rig
ht
KA
, G
ask
in K
J, B
aur
LA
. B
ody
co
mpo
siti
on
in
ado
lesc
ents
wit
h a
no
rexia
ner
vo
sa.
Am
J C
lin
Nu
tr. 2
00
2;7
5:3
1-3
7.
8.
Mo
llin
ger
LA
, S
pu
rr G
B,
el G
hat
il A
Z, B
arb
ori
ak J
S, R
oon
ey C
B, D
avid
off
DD
. D
aily
en
erg
y e
xpen
dit
ure
and
basi
l m
etab
oli
c ra
tes
of
pat
ien
ts w
ith
spin
al c
ord
in
jury
.A
rch
Ph
ys M
ed R
eha
bil
.
19
85
;66
:420
-42
6.
9.
Obar
zanek
E,
Les
em
MD
, Ji
mer
son D
C. R
esti
ng m
etab
oli
c ra
te o
f anore
xia
ner
vo
sa p
atie
nts
duri
ng w
eig
ht
gai
n.
Am
J C
lin
Nu
tr.
19
94
;60
:66
6-6
75
.
10
. P
avlo
vic
M,
Zav
alic
M,
Co
rov
ic N
, S
tili
no
vic
L,
Mal
inar
M. L
oss
of
bo
dy
mass
in
ex
pri
son
ers
of
war
.E
ur
J C
lin
Nu
tr. 1
99
3;4
7:8
08
-81
4.
INTA
KE
DO
MA
IN C
aloric
Ener
gy
Bal
ance
INA
DE
QU
AT
E E
NE
RG
Y I
NT
AK
E(N
I-1
.4)
Edit
ion:
20
06
37
De
fin
itio
n
En
ergy in
take
that
is
less
th
an e
ner
gy e
xpen
dit
ure
, es
tabli
shed
ref
eren
ce s
tan
dar
ds,
or
reco
mm
endat
ions
bas
ed u
pon p
hysi
olo
gic
al n
eeds.
E
xce
pti
on:
wh
en t
he
goal
is
wei
gh
t lo
ss o
r duri
ng e
nd o
f li
fe c
are.
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
ath
olo
gic
or
ph
ysio
logic
cau
ses
that
res
ult
in i
ncr
ease
d e
ner
gy r
equir
emen
ts o
r dec
reas
ed a
bil
ity t
o c
on
sum
e su
ffic
ien
t en
ergy,
e.g., i
ncr
ease
d n
utr
ien
t
nee
ds
due
to p
rolo
nged
cat
aboli
c il
lnes
s
•L
ack o
f ac
cess
to f
ood o
r ar
tifi
cial
nutr
itio
n,
e.g., e
con
om
ic c
on
stra
ints
, cu
ltura
l or
reli
gio
us
pra
ctic
es r
estr
icti
ng f
ood g
iven
to e
lder
ly a
nd/o
r ch
ildre
n
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r dis
ord
ered
eat
ing
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
• C
hol
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
inati
on F
indin
gs
•W
eig
ht
loss
•P
oor
den
titi
on
INTA
KE
DO
MA
IN C
aloric
Ener
gy
Bal
ance
INA
DE
QU
AT
E E
NE
RG
Y I
NT
AK
E(N
I-1
.4)
Edit
ion:
20
06
38
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•In
suff
icie
nt
ener
gy inta
ke
from
die
t co
mpar
ed t
o n
eeds
bas
ed o
n e
stim
ated
or
mea
sure
d r
esti
ng m
etab
oli
c ra
te
•R
estr
icti
on o
r om
issi
on o
f en
ergy d
ense
foods
from
die
t
•F
ood a
void
an
ce a
nd/o
r la
ck o
f in
tere
st i
n f
ood
•In
abil
ity to i
ndep
enden
tly c
on
sum
e fo
ods/
fluid
s (d
imin
ished
join
t m
obil
ity o
f w
rist
, h
and,
or
dig
its)
•P
aren
tera
l or
ente
ral
nutr
itio
n i
nsu
ffic
ien
t to
mee
t n
eeds
bas
ed o
n e
stim
ated
or
mea
sure
d r
esti
ng m
etab
oli
c ra
te
Cli
ent
His
tory
•E
xce
ssiv
e co
nsu
mp
tion
of
alco
hol
or
oth
er d
rugs
that
red
uce
hunger
Refe
ren
ce:
1.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r E
ner
gy,
Ca
rbo
hyd
rate
, F
iber
, F
at,
Fa
tty
Aci
ds,
Ch
ole
ster
ol,
Pro
tein
, a
nd
Am
ino
Aci
ds.
Was
hin
gto
n, D
C:
Nat
ion
al A
cad
em
y P
ress
; 2
00
2.
INTA
KE
DO
MA
IN C
aloric
Ener
gy
Bal
ance
EX
CE
SS
IVE
EN
ER
GY
IN
TA
KE
(NI-
1.5
)
Edit
ion:
20
06
39
De
fin
itio
n
Calo
ric
inta
ke
that
exce
eds
ener
gy e
xpen
dit
ure
, es
tabli
shed
ref
eren
ce s
tandar
ds,
or
reco
mm
endat
ion
s bas
ed u
pon p
hys
iolo
gic
al n
eeds.
Ex
cepti
on:
wh
en w
eight
gai
n i
s des
ired
.
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•H
arm
ful
bel
iefs
/att
itudes
about
food,
nutr
itio
n,
and n
utr
itio
n-r
elat
ed t
opic
s
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•L
ack o
f ac
cess
to h
ealt
hfu
l fo
od c
hoic
es,
e.g., f
ood p
rovid
ed b
y c
areg
iver
•L
ack o
f val
ue
for
beh
avio
r ch
ange,
com
pet
ing v
alues
•M
enta
l il
lnes
s, d
epre
ssio
n
•M
edic
atio
ns
that
incr
ease
appet
ite,
e.g
., s
tero
ids
•O
ver
feed
ing o
f par
ente
ral/
ente
ral
nutr
itio
n (
TP
N/E
N)
•U
nw
illi
ng o
r un
inte
rest
ed i
n r
educi
ng e
ner
gy inta
ke
•F
ailu
re t
o a
dju
st f
or
life
styl
e ch
anges
an
d d
ecre
ased
met
aboli
sm,
e.g., a
gin
g
•R
esolu
tion o
f pri
or
hyp
erm
etaboli
sm w
ith
out
reduct
ion i
n i
nta
ke
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
INTA
KE
DO
MA
IN C
aloric
Ener
gy
Bal
ance
EX
CE
SS
IVE
EN
ER
GY
IN
TA
KE
(NI-
1.5
)
Edit
ion:
20
06
40
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•O
ver
feed
ing o
f T
PN
/EN
(usu
ally
see
n e
arly
aft
er i
nit
iati
on o
f fe
edin
g):
•H
yper
gly
cem
ia
•H
yp
okal
emia
< 3
.5 m
Eq/L
•H
yp
oph
osp
hate
mia
<1.0
mE
q/L
•A
bnorm
al l
iver
fun
ctio
n t
ests
Anth
ropom
etri
c M
easu
rem
ents
•B
od
y f
at p
erce
nta
ge
> 2
5%
for
men
an
d >
32%
for
wom
en
•B
MI
> 2
5
•W
eigh
t gai
n
Phys
ical
Exam
Fin
din
gs
•In
crea
sed b
od
y a
dip
osi
ty
•O
ver
feed
ing T
PN
/EN
:
•In
crea
sed r
espir
atio
ns
Food/N
utr
itio
n H
isto
ry•
Obse
rvat
ion
s or
report
s of
inta
ke
of
calo
rica
lly d
ense
foods/
bev
erages
or
larg
e port
ion
s of
foods/
bev
erag
es
•O
bse
rvat
ion
s, r
eport
s, o
r ca
lcula
tion o
f T
PN
/EN
above
esti
mat
ed o
r m
easu
red (
e.g., i
nd
irec
t ca
lori
met
ry)
calo
ric
expen
dit
ure
•M
etab
oli
c ca
rt/i
ndir
ect
calo
rim
etry
mea
sure
men
t, e
.g., r
espir
atory
quoti
ent >
1.0
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t of,
e.g
., o
bes
ity,
over
wei
gh
t, m
etaboli
c sy
ndro
me,
dep
ress
ion,
or
anx
iety
dis
ord
er
Refe
ren
ces:
1.
McC
lav
e S
A,
Lo
wen
CC
, K
leb
er M
J, M
cCo
nn
ell
JW, Ju
ng
LY
, G
old
smit
h L
J. C
lin
ical
use
of
the
resp
irat
ory
qu
oti
ent
ob
tain
ed f
rom
in
dir
ect
calo
rim
etry
.J
Pa
ren
ter
En
tera
l N
utr
. 2
00
3;2
7:2
1-2
6.
2.
McC
lav
e S
A,
Lo
wen
CC
, K
leb
er M
J, N
ich
ols
on
JF
, Ji
mm
erso
n S
C,
McC
on
nel
l JW
, Ju
ng
LY
. A
re p
atie
nts
fed
ap
pro
pri
atel
y a
ccord
ing
to
th
eir
calo
ric
requ
irem
ents
?J
Pa
ren
ter
En
tera
l N
utr
.
19
98
;22
:375
-38
1.
3.
Over
wei
ght
and O
besi
ty:
Hea
lth C
on
sequence
s. w
ww
.surg
eon
gen
eral
.gov/t
opic
s/ob
esit
y/c
allt
oac
tio
n/f
act_
con
sequen
ces.
htm
. A
ccess
ed A
ugu
st 2
8, 20
04
.
INTA
KE
DO
MA
IN O
ral o
r N
utr
itio
n S
upport
Inta
ke
INA
DE
QU
AT
E O
RA
L F
OO
D/B
EV
ER
AG
E I
NT
AK
E(N
I-2
.1)
Edit
ion:
20
06
41
De
fin
itio
n
Ora
l fo
od/b
ever
age
inta
ke
that
is
less
than
est
abli
shed
ref
eren
ce s
tandar
ds
or
reco
mm
endat
ion
s bas
ed u
pon p
hysi
olo
gic
al n
eeds.
E
xce
pti
on
: w
hen
th
e goal
is
wei
ght
loss
or
duri
ng e
nd o
f li
fe c
are.
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses,
e.g
., i
ncr
ease
d n
utr
ien
t n
eeds
due
to p
rolo
nged
cat
aboli
c il
lnes
s
•L
ack o
f ac
cess
to f
ood,
e.g
., e
con
om
ic c
on
stra
ints
, cu
ltura
l or
reli
gio
us
pra
ctic
es, re
stri
ctin
g f
ood g
iven
to e
lder
ly a
nd/o
r ch
ildre
n
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledge
defi
cit
con
cern
ing s
uff
icie
nt
ora
l fo
od/b
ever
age
inta
ke
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r dis
ord
ered
eat
ing
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
inati
on F
indin
gs
•D
ry s
kin
, dry
mu
cous
mem
bra
nes
, poor
skin
turg
or
•W
eigh
t lo
ss, in
suff
icie
nt
gro
wth
vel
oci
ty
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•In
suff
icie
nt
inta
ke
of
ener
gy o
r hig
h-q
ual
ity p
rote
in f
rom
die
t w
hen
com
par
ed t
o r
equir
emen
ts
•E
conom
ic c
on
stra
ints
that
lim
it f
ood a
vai
labil
ity
INTA
KE
DO
MA
IN O
ral o
r N
utr
itio
n S
upport
Inta
ke
INA
DE
QU
AT
E O
RA
L F
OO
D/B
EV
ER
AG
E I
NT
AK
E(N
I-2
.1)
Edit
ion:
20
06
42
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t of
cata
boli
c il
lnes
s su
ch a
s A
IDS
, tu
ber
culo
sis,
an
orex
ia n
ervosa
,
sepsi
s, o
r in
fect
ion f
rom
rec
ent
surg
ery)
, dep
ress
ion
, ac
ute
or
chro
nic
pai
n
•P
rote
in a
nd/o
r nutr
ient
mal
abso
rpti
on
•E
xce
ssiv
e co
nsu
mp
tion
of
alco
hol
or
oth
er d
rugs
that
red
uce
hunger
•M
edic
atio
ns
that
cau
se a
nore
xia
Refe
ren
ces:
1.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r E
ner
gy,
Ca
rbo
hyd
rate
, F
iber
, F
at,
Fa
tty
Aci
ds,
Ch
ole
ster
ol,
Pro
tein
, a
nd
Am
ino
Aci
ds.
Was
hin
gto
n, D
C:
Nat
ion
al A
cad
em
y P
ress
; 2
00
2.
2.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
Inta
kes
for
Wa
ter,
Po
tass
ium
, S
od
ium
, C
hlo
rid
e, a
nd
Su
lfa
te. W
ash
ingto
n,
DC
: N
ati
onal
Aca
dem
y P
ress
; 20
02
.
INTA
KE
DO
MA
IN O
ral o
r N
utr
itio
n S
upport
Inta
ke
EX
CE
SS
IVE
OR
AL
FO
OD
/BE
VE
RA
GE
IN
TA
KE
(NI-
2.2
)
Edit
ion:
20
06
43
De
fin
itio
n
Ora
l fo
od/b
ever
age
inta
ke
that
exce
eds
ener
gy e
xpen
dit
ure
, es
tabli
shed
ref
eren
ce s
tandar
ds,
or
reco
mm
endat
ion
s bas
ed u
pon p
hys
iolo
gic
al n
eeds.
E
xce
pti
on
:
wh
en w
eigh
t gai
n i
s des
ired
.
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•H
arm
ful
bel
iefs
/att
itudes
about
food,
nutr
itio
n,
and n
utr
itio
n-r
elat
ed t
opic
s
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•L
ack o
f ac
cess
to h
ealt
hfu
l fo
od c
hoic
es,
e.g., f
ood p
rovid
ed b
y c
areg
iver
•L
ack o
f val
ue
for
beh
avio
r ch
ange,
com
pet
ing v
alues
•In
abil
ity to l
imit
or
refu
se o
ffer
ed f
oods
•L
ack o
f fo
od p
lann
ing,
purc
has
ing, an
d p
repar
ati
on s
kil
ls
•L
oss
of
appet
ite
awar
enes
s
•M
edic
atio
ns
that
incr
ease
appet
ite,
e.g
., s
tero
ids,
anti
dep
ress
ants
•U
nw
illi
ng o
r unin
tere
sted
in r
educi
ng i
nta
ke
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•V
aria
ble
hig
h b
lood g
luco
se l
evel
s
•A
bn
orm
al H
gb A
1C
Anth
ropom
etri
c M
easu
rem
ents
•W
eig
ht
gai
n n
ot
attr
ibute
d t
o f
luid
ret
enti
on o
r n
orm
al g
row
th
Phys
ical
Exam
Fin
din
gs
•E
vid
ence
of
acanth
osi
s n
igri
cans
INTA
KE
DO
MA
IN O
ral o
r N
utr
itio
n S
upport
Inta
ke
EX
CE
SS
IVE
OR
AL
FO
OD
/BE
VE
RA
GE
IN
TA
KE
(NI-
2.2
)
Edit
ion:
20
06
44
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•In
take
of
calo
rica
lly d
ense
foods/
bev
erag
es (
juic
e, s
oda,
or
alco
hol)
at
mea
ls a
nd
/or
snac
ks
•In
take
of
larg
e port
ion
s of
foods/
bever
ages
, fo
od g
roups,
or
spec
ific
food i
tem
s
•In
take
that
exce
eds
esti
mat
ed o
r m
easu
red e
ner
gy n
eeds
•H
igh
ly v
aria
ble
dai
ly c
alori
c in
take
•B
inge
eati
ng p
atte
rns
•F
requen
t, e
xce
ssiv
e in
take
of
fast
food o
r re
stau
rant
food
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., o
bes
ity,
over
wei
ght,
or
met
aboli
c sy
ndro
me,
dep
ress
ion
, an
xie
ty
dis
ord
er
•R
esti
ng m
etaboli
c ra
te m
easu
rem
ent
refl
ecti
ng e
xce
ss i
nta
ke,
e.g
., r
espir
atory
quoti
ent
> 1
.0
Refe
ren
ces:
1.
Over
wei
ght
and O
besi
ty:
Hea
lth C
on
sequence
s. w
ww
.surg
eon
gen
eral
.gov/t
opic
s/ob
esit
y/c
allt
oac
tio
n/f
act_
con
sequen
ces.
htm
. A
ccess
ed A
ugu
st 2
8, 20
04
.
2.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Wei
ght
man
agem
ent.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
14
5-1
15
5.
3.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Tota
l die
t appro
ach
to c
om
munic
atin
g f
ood a
nd n
utr
itio
n i
nfo
rmat
ion.J
Am
Die
t A
sso
c. 2
00
2;1
02
:10
0-1
08
.
4.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
The
role
of
die
teti
cs p
rofe
ssio
nal
s in
hea
lth p
rom
oti
on a
nd d
isea
se p
reventi
on.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
68
0-1
68
7.
INTA
KE
DO
MA
IN O
ral o
r N
utr
itio
n S
upport
Inta
ke
INA
DE
QU
AT
E IN
TA
KE
FR
OM
EN
TE
RA
L/P
AR
EN
TE
RA
L (
EN
/TP
N)
NU
TR
ITIO
N IN
FU
SIO
N(N
I-2
.3)
Edit
ion:
20
06
45
De
fin
itio
n
En
tera
l or
par
ente
ral
infu
sion t
hat
pro
vid
es f
ew
er c
alori
es o
r n
utr
ien
ts c
om
par
ed t
o e
stab
lish
ed r
efer
ence
sta
ndar
ds
or
reco
mm
endat
ion
s bas
ed u
pon p
hysi
olo
gic
al
nee
ds.
E
xce
pti
on
: w
hen
th
e goal
is
wei
gh
t lo
ss o
r duri
ng e
nd o
f li
fe c
are.
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•A
lter
ed a
bso
rpti
on o
r m
etaboli
sm o
f n
utr
ients
, e.
g., m
edic
atio
ns
•F
ood a
nd n
utr
itio
n-r
elat
ed k
now
ledge
def
icit
(pati
ent/
clie
nt,
car
egiv
er,
suppli
er),
e.g
., i
nco
rrec
t fo
rmu
la/f
orm
ula
tion
giv
en s
uch
as
wro
ng e
nte
ral
feed
ing,
or
mis
sin
g c
om
ponen
t of
TP
N
•L
ack o
f, c
om
pro
mis
ed,
or
inco
rrec
t ac
cess
for
del
iver
ing E
N/T
PN
•In
crea
sed b
iolo
gic
al d
eman
d o
f n
utr
ien
ts,
e.g., a
ccel
erat
ed g
row
th,
woun
d h
eali
ng,
chro
nic
in
fect
ion
, m
ult
iple
fra
cture
s
•In
tole
ran
ce o
f E
N/T
PN
•In
fusi
on v
olu
me
not
reac
hed
or
sched
ule
for
infu
sion i
nte
rrupte
d
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•C
hole
ster
ol
< 1
60 m
g/d
L (
4.1
6 m
mol/
L)
•V
itam
in/m
iner
al ab
norm
ali
ties
•C
alci
um
< 9
.2 m
g/d
L (
2.3
mm
ol/
L)
•V
itam
in K
--P
rolo
nged
pro
thro
mbin
tim
e (P
T),
par
tial
thro
mbopla
stin
tim
e (P
TT
)
•C
opper
< 7
0 µ
g/d
L (
11 µ
mol/
L)
•Z
inc
< 7
8 µ
g/d
L (
12 µ
mol/
L)
•Ir
on <
50 µ
g/d
L (
9 n
mol/
L);
iro
n b
ind
ing c
apac
ity <
250 µ
g/d
L (
44.8
µm
ol/
L)
INTA
KE
DO
MA
IN O
ral o
r N
utr
itio
n S
upport
Inta
ke
INA
DE
QU
AT
E IN
TA
KE
FR
OM
EN
TE
RA
L/P
AR
EN
TE
RA
L (
EN
/TP
N)
NU
TR
ITIO
N IN
FU
SIO
N(N
I-2
.3)
Edit
ion:
20
06
46
Anth
ropom
etri
c M
easu
rem
ents
•G
row
th f
ailu
re, bas
ed o
n N
atio
nal
Cen
ter
for
Hea
lth S
tati
stic
s (N
CH
S)
gro
wth
sta
ndar
ds
and f
etal
gro
wth
fai
lure
•In
suff
icie
nt
mat
ern
al w
eight
gai
n
•L
ack o
f pla
nn
ed w
eight
gai
n
•U
nin
ten
tional
wei
ght
loss
of
5%
in 1
month
or
10%
in 6
month
s (n
ot
attr
ibute
d t
o f
luid
) in
adult
s
•A
ny w
eigh
t lo
ss i
n i
nfa
nts
an
d c
hil
dre
n
•U
nder
wei
ght
(BM
I <
18.5
)
Phys
ical
Exam
Fin
din
gs
•C
linic
al e
vid
ence
of
vit
amin
/min
eral
def
icie
ncy
(e.
g.,
hair
loss
, ble
edin
g g
um
s, p
ale
nail
bed
s, n
euro
logic
chan
ges
)
•E
vid
ence
of
deh
ydra
tion,
e.g., d
ry m
uco
us
mem
bra
nes
, poor
skin
turg
or
•L
oss
of
skin
inte
gri
ty o
r del
aye
d w
oun
d h
eali
ng
•L
oss
of
mu
scle
mass
an
d/o
r su
bcu
tan
eous
fat
•N
ause
a, v
om
itin
g,
dia
rrh
ea
Food/N
utr
itio
n H
isto
ryO
bse
rvat
ion o
r re
port
s of:
•In
adeq
uat
e E
N/T
PN
volu
me
com
pare
d t
o e
stim
ated
or
mea
sure
d (
indir
ect
calo
rim
etry
) r
equir
emen
ts
•M
etab
oli
c ca
rt/i
ndir
ect
calo
rim
etry
mea
sure
men
t, e
.g., r
espir
atory
quoti
ent <
0.7
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t of,
e.g
., i
nte
stin
al r
esec
tion,
Cro
hn
’s d
isea
se,
HIV
/AID
S, burn
s,dec
ubit
us
ulc
ers,
pre
-ter
m b
irth
, m
aln
utr
itio
n
•F
eedin
g t
ube
or
ven
ous
acce
ss i
n w
rong p
osi
tion o
r re
moved
•A
lter
ed c
apac
ity f
or
des
ired
lev
els
of
ph
ysic
al a
ctiv
ity o
r ex
erci
se, ea
sy f
atig
ue
wit
h i
ncr
ease
d a
ctiv
ity
Refe
ren
ces:
1.
McC
lav
e S
A,
Spai
n D
A,
Sk
oln
ick
JL
, L
ow
en C
C,
Kie
ber
MJ,
Wic
ker
ham
PS
, V
og
t JR
, L
oo
ney
SW
. A
chie
vem
ent
of
stea
dy
sta
te o
pti
miz
es r
esu
lts
wh
en p
erfo
rmin
g i
nd
irec
t ca
lori
met
ry.
J
Pa
ren
ter
En
tera
l N
utr
. 2
00
3;2
7:1
6-2
0.
2.
McC
lav
e S
A,
Lo
wen
CC
, K
leb
er M
J, M
cCo
nn
ell
JW, Ju
ng
LY
, G
old
smit
h L
J. C
lin
ical
use
of
the
resp
irat
ory
qu
oti
ent
ob
tain
ed f
rom
in
dir
ect
calo
rim
etry
.J
Pa
ren
ter
En
tera
l N
utr
. 2
00
3;2
7:2
1-2
6.
3.
McC
lav
e S
A,
Sn
ider
HL
. C
lin
ical
use
of
gas
tric
res
idu
al v
olu
mes
as
a m
onit
or
for
pat
ients
on
en
tera
l tu
be
feed
ing
.J
Pa
ren
ter
En
tera
l N
utr
. 2
00
2;2
6(S
up
pl)
:S4
3-4
8;
dis
cuss
ion
S4
9-S
50
.
4.
McC
lav
e S
A,
DeM
eo M
T,
DeL
egg
e M
H,
DiS
ario
JA
, H
eyla
nd
DK
, M
alo
ney
JP
, M
ethen
y N
A,
Mo
ore
FA
, S
cola
pio
JS
, S
pai
n D
A,
Zal
og
a G
P. N
ort
h A
mer
ican
Su
mm
it o
n A
spir
atio
n i
n t
he
Cri
tica
lly
Ill
Pat
ien
t: c
on
sen
sus
stat
emen
t.J
Pa
ren
ter
En
tera
l N
utr
. 2
00
2;2
6(S
up
pl)
:S8
0-S
85
.
5.
McC
lav
e S
A, M
cCla
in C
J, S
nid
er H
L.
Sh
ou
ld i
nd
irec
t ca
lori
met
ry b
e u
sed
as
par
t o
f nu
trit
ional
ass
essm
ent?
J C
lin
Ga
stro
ente
rol.
20
01
;33
:14
-19
.
6.
McC
lav
e S
A,
Sex
ton
LK
, S
pai
n D
A,
Adam
s JL
, O
wen
s N
A,
Su
llin
s M
B,
Bla
nd
ford
BS
, S
nid
er H
L. E
nte
ral
tub
e fe
edin
g i
n t
he
inte
nsi
ve
care
un
it:
fact
ors
im
ped
ing
ad
equ
ate
del
iver
y.C
rit
Ca
re
Med
. 1
99
9;2
7:1
25
2-1
25
6.
7.
McC
lav
e S
A,
Lo
wen
CC
, K
leb
er M
J, N
ich
ols
on
JF
, Ji
mm
erso
n S
C,
McC
on
nel
l JW
, Ju
ng
LY
. A
re p
atie
nts
fed
ap
pro
pri
atel
y a
ccord
ing
to
th
eir
calo
ric
requ
irem
ents
?J
Pa
ren
ter
En
tera
l N
utr
.
19
98
;22
:375
-38
1.
8.
Spai
n D
A,
McC
lav
e S
A,
Sex
ton
LK
, A
dam
s JL
, B
lan
ford
BS
, S
ull
ins
ME
, O
wen
s N
A,
Sn
ider
HL
. In
fusi
on
pro
toco
l im
pro
ves
del
iver
y o
f en
tera
l tu
be
feed
ing
in
th
e cr
itic
al c
are
un
it.
J P
are
nte
r
En
tera
l N
utr
. 1
99
9;2
3:2
88
-29
2.
INTA
KE
DO
MA
IN O
ral o
r N
utr
itio
n S
upport
Inta
ke
EX
CE
SS
IVE
IN
TA
KE
FR
OM
EN
TE
RA
L/P
AR
EN
TE
RA
L N
UT
RIT
ION
(NI-
2.4
)
Edit
ion:
20
06
47
De
fin
itio
n
En
tera
l or
par
ente
ral
infu
sion t
hat
pro
vid
es m
ore
cal
ori
es o
r n
utr
ien
ts c
om
par
ed t
o e
stabli
shed
ref
eren
ce s
tandar
ds
or
reco
mm
endat
ion
s bas
ed u
pon p
hysi
olo
gic
al
nee
ds.
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses,
e.g
., d
ecre
ased
nee
ds
rela
ted t
o l
ow
act
ivit
y lev
els
wit
h c
riti
cal
illn
ess
or
org
an f
ailu
re
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
on t
he
par
t of
the
care
giv
er, pat
ien
t/cl
ien
t or
clin
icia
n
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•E
levat
ed B
UN
:cre
atin
ine
rati
o (
pro
tein
)
•H
yper
gly
cem
ia (
carb
oh
ydra
te)
•H
yper
capnia
•E
levat
ed l
iver
en
zym
es
Anth
ropom
etri
c M
easu
rem
ents
•W
eigh
t gai
n i
n e
xce
ss o
f le
an t
issu
e ac
cret
ion
Phys
ical
Exam
inati
on F
indin
gs
•E
dem
a w
ith e
xce
ss f
luid
ad
min
istr
atio
n
Food/N
utr
itio
n H
isto
ryR
eport
or
obse
rvat
ion o
f:
•D
ocu
men
ted i
nta
ke
from
en
tera
l or
par
ente
ral
nutr
ients
that
is
con
sist
entl
y a
bove
reco
mm
end
ed i
nta
ke
for
carb
oh
ydra
te,
pro
tein
, an
d f
at (
e.g., 3
6 k
cal/
kg f
or
wel
l, a
ctiv
e ad
ult
s, 2
5 k
cal/
kg o
r as
mea
sure
d b
y ind
irec
t ca
lori
met
ry f
or
crit
ical
ly
ill
adult
s, 0
.8 g
/kg p
rote
in f
or
wel
l ad
ult
s, 1
.5 g
/kg p
rote
in f
or
crit
icall
y ill
adu
lts,
4 m
g/k
g/m
inute
of
dex
trose
for
crit
ical
ly ill
adult
s, 1
.2 g
/kg l
ipid
for
adult
s, o
r 3 g
/kg f
or
chil
dre
n)*
* W
hen
en
teri
ng w
eight
(i.e
., g
ram
) in
form
atio
n i
nto
th
e m
edic
al r
ecord
, use
in
stit
uti
on o
r Jo
int
Com
mis
sion A
ccre
dit
atio
n o
f H
ealt
hca
re O
rgan
izat
ion
s’
appro
ved
ab
bre
via
tion l
ist.
INTA
KE
DO
MA
IN O
ral o
r N
utr
itio
n S
upport
Inta
ke
EX
CE
SS
IVE
IN
TA
KE
FR
OM
EN
TE
RA
L/P
AR
EN
TE
RA
L N
UT
RIT
ION
(NI-
2.4
)
Edit
ion:
20
06
48
Cli
ent
His
tory
•U
se o
f dru
gs
that
red
uce
req
uir
emen
ts o
r im
pai
r m
etaboli
sm o
f en
ergy,
pro
tein
, fa
t or
fluid
.
•U
nre
alis
tic
expec
tati
ons
of
wei
ght
gai
n o
r id
eal
wei
gh
t
•R
ecei
vin
g s
ignif
ican
t ca
lori
e in
take
from
lip
id o
r dex
trose
infu
sions,
or
per
iton
eal
dia
lysi
s or
in a
ssoci
ati
on w
ith o
ther
med
ical
tre
atm
ents
Refe
ren
ces:
1.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r E
ner
gy,
Ca
rbo
hyd
rate
, F
iber
, F
at,
Fa
tty
Aci
ds,
Ch
ole
ster
ol,
Pro
tein
, a
nd
Am
ino
Aci
ds.
Was
hin
gto
n, D
C:
Nat
ion
al A
cad
em
y P
ress
, 2
00
2.
2.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
Inta
kes
for
Wa
ter,
Po
tass
ium
, S
od
ium
, C
hlo
rid
e, a
nd
Su
lfa
te.
Wash
ingto
n,
DC
: N
ati
onal
Aca
dem
y P
ress
, 20
04
.
3.
Aar
sland A
, C
hin
kes
D,
Wolf
e R
R. H
epat
ic a
nd w
hole
-body f
at
synth
esis
in h
um
ans
duri
ng c
arboh
ydra
te o
ver
feedin
g.
Am
J C
lin
Nu
tr. 1
99
7;6
5:1
77
4-1
78
2.
4.
McC
lav
e S
A,
Lo
wen
CC
, K
leb
er M
J, N
ich
ols
on
JF
, Ji
mm
erso
n J
C,
McC
on
nel
l JW
, Ju
ng
LY
. A
re p
atie
nts
fed
ap
pro
pri
atel
y a
ccord
ing
to
th
eir
calo
ric
requ
irem
ents
?J
Pa
ren
ter
En
tera
l N
utr
.
19
98
;22
:375
-38
1.
5.
McC
lav
e S
A,
Lo
wen
CC
, K
leb
er M
J, M
cCo
nn
ell
JW, Ju
ng
LY
, G
old
smit
h L
J. C
lin
ical
use
of
the
resp
irat
ory
qu
oti
ent
ob
tain
ed f
rom
in
dir
ect
calo
rim
etry
.J
Pa
ren
ter
En
tera
l N
utr
. 2
00
3;2
7:2
1-2
6.
6.
Wolf
e R
R,
O'D
on
nel
l T
F, Jr
., S
ton
e M
D,
Ric
hm
and
DA
, B
urk
e JF
. In
ves
tig
atio
n o
f fa
cto
rs d
eter
min
ing
th
e o
pti
mal
glu
cose
in
fusi
on
rat
e in
to
tal
par
ente
ral
nu
trit
ion
.M
eta
bo
lism
: C
lin
ica
l &
Exp
erim
enta
l. 1
98
0;2
9:8
92
-90
0.
INTA
KE
DO
MA
IN O
ral o
r N
utr
itio
n S
upport
Inta
ke
INA
PP
RO
PR
IAT
E IN
FU
SIO
N O
F E
NT
ER
AL
OR
PA
RE
NT
ER
AL
NU
TR
ITIO
N(N
I-2
.5)
Edit
ion:
20
06
49
Use
wit
h c
au
tion
on
ly a
fter
dis
cu
ssio
n w
ith
oth
er h
ealt
h t
eam
mem
ber
s
De
fin
itio
n
En
tera
l or
par
ente
ral
infu
sion t
hat
pro
vid
es e
ith
er f
ewer
or
more
cal
ori
es a
nd/o
r n
utr
ien
ts o
r is
of
the
wro
ng c
om
posi
tion o
r ty
pe,
is
not
war
rante
d b
ecau
se t
he
pat
ient/
clie
nt
is a
ble
to t
ole
rate
an e
nte
ral
inta
ke,
or
is u
nsa
fe b
ecau
se o
f th
e pote
nti
al f
or
sepsi
s or
oth
er c
om
pli
cati
on
s
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses,
e.g
., i
mpro
vem
ent
in p
atie
nt/
clie
nt
stat
us,
all
ow
ing r
eturn
to t
ota
l or
par
tial
ora
l die
t; c
han
ges
in t
he
cours
e of
dis
ease
res
ult
ing i
n
chan
ges
in n
utr
ient
requir
emen
ts
•P
roduct
or
kn
ow
ledge
def
icit
on t
he
par
t of
the
care
giv
er o
r cl
inic
ian
•E
nd o
f li
fe c
are
if p
atie
nt/
clie
nt
or
fam
ily d
o n
ot
des
ire
nutr
itio
n s
upport
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•A
bn
orm
al l
iver
fun
ctio
n t
ests
in p
ati
ent/
clie
nt
on l
on
g t
erm
(m
ore
than
3-6
wee
ks)
fee
din
g
•A
bn
orm
al l
evel
s of
mar
ker
s sp
ecif
ic f
or
var
ious
nutr
ients
, e.
g., h
yper
ph
osp
hat
emia
in p
atie
nt/
clie
nt
rece
ivin
g f
eedin
gs
wit
h a
hig
h p
hosp
horu
s co
nte
nt,
hyp
okal
emia
in p
atie
nt/
clie
nt
rece
ivin
g f
eedin
gs
wit
h l
ow
pota
ssiu
m c
onte
nt
Anth
ropom
etri
c M
easu
rem
ents
•W
eigh
t gai
n i
n e
xce
ss o
f le
an t
issu
e ac
cret
ion
•W
eig
ht
loss
Phys
ical
Exam
inati
on F
indin
gs
•E
dem
a w
ith e
xce
ss f
luid
ad
min
istr
atio
n
•C
om
pli
cati
on
s su
ch a
s fa
tty liv
er i
n t
he
abse
nce
of
oth
er c
ause
s
•L
oss
of
subcu
tan
eous
fat
and m
usc
le s
tore
s
INTA
KE
DO
MA
IN O
ral o
r N
utr
itio
n S
upport
Inta
ke
INA
PP
RO
PR
IAT
E IN
FU
SIO
N O
F E
NT
ER
AL
OR
PA
RE
NT
ER
AL
NU
TR
ITIO
N(N
I-2
.5)
Edit
ion:
20
06
50
Food/N
utr
itio
n H
isto
ryR
eport
or
obse
rvat
ion o
f:
•D
ocu
men
ted i
nta
ke
from
en
tera
l or
par
ente
ral
nutr
ients
that
is
con
sist
entl
y a
bove
or
bel
ow
rec
om
men
ded
inta
ke
for
carb
oh
ydra
te, pro
tein
, an
d/o
r fa
t —
esp
ecia
lly r
elat
ed t
o p
atie
nt/
clie
nt’
s ab
ilit
y to c
on
sum
e an
ora
l die
t th
at m
eets
nee
ds
at t
his
poin
t in
tim
e
•D
ocu
men
ted i
nta
ke
of
oth
er n
utr
ients
th
at i
s co
nsi
sten
tly a
bove
or
bel
ow
th
at r
ecom
men
ded
•N
ause
a, v
om
itin
g,
dia
rrh
ea, hig
h g
astr
ic r
esid
ual
volu
me
Cli
ent
His
tory
•H
isto
ry o
f en
tera
l or
par
ente
ral n
utr
itio
n i
nto
lera
nce
Refe
ren
ces:
1.
Aar
sland A
, C
hin
kes
D,
Wolf
e R
R. H
epat
ic a
nd w
hole
-body f
at
synth
esis
in h
um
ans
duri
ng c
arboh
ydra
te o
ver
feedin
g.
Am
J C
lin
Nu
tr. 1
99
7;6
5:1
77
4-1
78
2.
2.
McC
lav
e S
A,
Lo
wen
CC
, K
leb
er M
J, N
ich
ols
on
JF
, Ji
mm
erso
n S
C,
McC
on
nel
l JW
, Ju
ng
LY
. A
re p
atie
nts
fed
ap
pro
pri
atel
y a
ccord
ing
to
th
eir
calo
ric
requ
irem
ents
?J
Pa
ren
ter
En
tera
l N
utr
.
19
98
;22
:375
-38
1.
3.
McC
lav
e S
A,
Lo
wen
CC
, K
leb
er M
J, M
cCo
nn
ell
JW, Ju
ng
LY
, G
old
smit
h L
J. C
lin
ical
use
of
the
resp
irat
ory
qu
oti
ent
ob
tain
ed f
rom
in
dir
ect
calo
rim
etry
.J
Pa
ren
ter
En
tera
l N
utr
. 2
00
3;2
7:2
1-2
6.
4.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r E
ner
gy,
Ca
rbo
hyd
rate
, F
iber
, F
at,
Fa
tty
Aci
ds,
Ch
ole
ster
ol,
Pro
tein
, a
nd
Am
ino
Aci
ds.
Was
hin
gto
n, D
C:
Nat
ion
al A
cad
em
y P
ress
; 2
00
2.
5.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
Inta
kes
for
Wa
ter,
Po
tass
ium
, S
od
ium
, C
hlo
rid
e, a
nd
Su
lfa
te,
Wash
ingto
n,
DC
: N
ati
onal
Aca
dem
y P
ress
; 20
04
.
6.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
Inta
kes
for
Ca
lciu
m,
Ph
osp
ho
rus,
Ma
gn
esiu
m, V
ita
min
D, a
nd
Flu
ori
de. W
ash
ing
ton
, D
C:
Nat
ional
Aca
dem
y P
ress
; 1
99
7.
7.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r V
ita
min
C,
Vit
am
in E
, S
elen
ium
, a
nd
Ca
rote
no
ids.
Was
hin
gto
n,
DC
: N
atio
nal
Aca
dem
y P
ress
; 2
00
0.
8.
Wolf
e R
R,
O'D
on
nel
l T
F, Jr
., S
ton
e M
D,
Ric
hm
and
DA
, B
urk
e JF
. In
ves
tig
atio
n o
f fa
cto
rs d
eter
min
ing
th
e o
pti
mal
glu
cose
in
fusi
on
rat
e in
to
tal
par
ente
ral
nu
trit
ion
.M
eta
bo
lism
. 1
98
0;2
9:8
92
-
90
0.
INTA
KE
DO
MA
IN F
luid
Inta
ke
INA
DE
QU
AT
E F
LU
ID I
NT
AK
E(N
I-3
.1)
Edit
ion:
20
06
51
De
fin
itio
n
Low
er i
nta
ke
of
fluid
-con
tain
ing f
oods
or
subst
ance
s co
mp
ared
to e
stab
lish
ed r
efer
ence
sta
ndar
ds
or
reco
mm
endat
ion
s bas
ed u
pon p
hys
iolo
gic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses,
e.g
., i
ncr
ease
d f
luid
nee
ds
due
to c
lim
ate/
tem
per
ature
ch
ange;
incr
ease
d e
xer
cise
or
con
dit
ion
s le
adin
g t
o i
ncr
ease
d f
luid
loss
es;
fever
causi
ng i
ncr
ease
d i
nse
nsi
ble
loss
es,
dec
reas
ed t
hir
st s
ensa
tion,
use
of
dru
gs
that
red
uce
thir
st
•L
ack o
f ac
cess
to f
luid
, e.
g., e
con
om
ic c
on
stra
ints
, cu
ltura
l or
reli
gio
us
pra
ctic
es,
inab
ilit
y to a
cces
s fl
uid
in
dep
enden
tly (
such
as
elder
ly o
r ch
ildre
n)
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r dis
ord
ered
eat
ing;
dem
enti
a re
sult
ing i
n d
ecre
ase
d r
ecognit
ion o
f th
irst
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•P
lasm
a or
ser
um
osm
ola
lity
gre
ater
than
290 m
Osm
/kg
• B
UN
, N
a
Anth
ropom
etri
c M
easu
rem
ents
•A
cute
wei
gh
t lo
ss
Phys
ical
Exam
inati
on F
indin
gs
•D
ry s
kin
and m
uco
us
mem
bra
nes
, poor
skin
turg
or
•U
rin
e outp
ut
<30 m
L/h
r
Food/N
utr
itio
n H
isto
ryR
eport
or
obse
rvat
ion o
f:
•In
suff
icie
nt
inta
ke
of
flu
id w
hen
com
par
ed t
o r
equir
emen
ts
•T
hir
st
•D
iffi
cult
y s
wal
low
ing
INTA
KE
DO
MA
IN F
luid
Inta
ke
INA
DE
QU
AT
E F
LU
ID I
NT
AK
E(N
I-3
.1)
Edit
ion:
20
06
52
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t, e
.g., A
lzh
eim
er’s
dis
ease
or
oth
er d
emen
tia
resu
ltin
g i
n d
ecre
ase
d
reco
gn
itio
n o
f th
irst
, dia
rrh
ea
•U
se o
f dru
gs
that
red
uce
th
irst
Refe
ren
ces:
1.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
Inta
kes
for
Wa
ter,
Po
tass
ium
, S
od
ium
, C
hlo
rid
e, a
nd
Su
lfa
te,
Wash
ingto
n,
DC
: N
ati
onal
Aca
dem
y P
ress
; 20
04
.
2.
Gra
nd
jean
AC
, C
amp
bel
l, S
M. H
ydra
tio
n:
Flu
ids
for
Lif
e. M
on
og
rap
h S
erie
s. W
ash
ingto
n,D
.C:
Inte
rnat
ional
Lif
e S
cien
ces
Inst
itu
te N
ort
h A
mer
ica, 2
00
4.
3.
Gra
nd
jean
AC
, R
eim
ers
KJ,
Bu
yck
x M
E.
Hy
dra
tion
: I
ssu
es f
or
the
21
st C
entu
ry.
Nu
tr R
ev. 2
00
3;6
1:2
61
-27
1.
INTA
KE
DO
MA
IN F
luid
Inta
ke
EX
CE
SS
IVE
FL
UID
IN
TA
KE
(NI-
3.2
)
Edit
ion:
20
06
53
De
fin
itio
n
Hig
her
inta
ke
of
fluid
com
par
ed t
o e
stab
lish
ed r
efer
ence
sta
ndar
ds
or r
ecom
men
dat
ion
s bas
ed u
pon p
hys
iolo
gic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses,
e.g
., d
ecre
ased
flu
id l
oss
es d
ue
to k
idn
ey,
liver
or
card
iac
fail
ure
; dim
inis
hed
wat
er a
nd s
odiu
m l
oss
es d
ue
to c
han
ges
in e
xer
cise
or
clim
ate,
syn
dro
me
of
inap
pro
pri
ate
anti
diu
reti
c h
orm
on
e (S
IAD
H)
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r dis
ord
ered
eat
ing
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•L
ow
ered
pla
sma
osm
ola
rity
(270-2
80 m
Osm
/kg),
on
ly i
f posi
tive
fluid
bal
ance
is
in e
xce
ss o
f posi
tive
salt
bal
ance
•D
ecre
ased
ser
um
sodiu
m i
n S
IAD
H
Anth
ropom
etri
c M
easu
rem
ents
•W
eigh
t gai
n
Phys
ical
Exam
inati
on F
indin
gs
•E
dem
a in
the
skin
of
the
legs,
sac
ral
area
, or
dif
fuse
ly;
wee
pin
g o
f fl
uid
s fr
om
low
er l
egs
•A
scit
es
•P
ulm
onar
y e
dem
a as
evid
ence
d b
y s
hort
nes
s of
bre
ath;
ort
hopn
ea;
crac
kle
s or
rale
s
Food/N
utr
itio
n H
isto
ryR
eport
or
obse
rvat
ion o
f:
•F
luid
inta
ke
in e
xce
ss o
f re
com
men
ded
inta
ke
•E
xce
ssiv
e sa
lt i
nta
ke
•In
abil
ity t
o t
ole
rate
soli
d f
oods
nec
essi
tati
ng a
liq
uid
die
t
INTA
KE
DO
MA
IN F
luid
Inta
ke
EX
CE
SS
IVE
FL
UID
IN
TA
KE
(NI-
3.2
)
Edit
ion:
20
06
54
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t, e
.g., e
nd s
tage
renal
dis
ease
, n
ephro
tic
syn
dro
me,
hea
rt f
ailu
re, or
liver
dis
ease
•N
ause
a, v
om
itin
g, an
ore
xia
, h
eadac
he,
mu
scle
spas
ms,
con
vuls
ion
s, c
om
a re
late
d t
o S
IAD
H
•S
hort
nes
s of
bre
ath o
r dys
pn
ea w
ith e
xer
tion o
r at
res
t
•P
rovid
ing m
edic
atio
ns
in l
arge
amoun
ts o
f fl
uid
•U
se o
f dru
gs
that
im
pai
r fl
uid
excr
etio
n
Refe
ren
ces:
1.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
Inta
kes
for
Wa
ter,
Po
tass
ium
, S
od
ium
, C
hlo
rid
e, a
nd
Su
lfa
te,
Wash
ingto
n,
DC
: N
ati
onal
Aca
dem
y P
ress
; 20
04
.
2.
Sch
rier
R.W
. ed
.R
ena
l a
nd
Ele
ctro
lyte
Dis
ord
ers.
6thed
.P
hil
adel
phia
, P
a: L
ipp
inco
tt W
illi
am
s a
nd
Wil
lkin
s; 2
00
2.
3.
SIA
DH
. A
vai
lable
at
: htt
p:/
/ww
.nlm
.nih
.go
v/m
edli
neplu
s/en
cy/a
rtic
le/0
00
394.
INTA
KE
DO
MA
IN B
ioac
tive
Subst
ance
s
INA
DE
QU
AT
E B
IOA
CT
IVE
SU
BS
TA
NC
E I
NT
AK
E(N
I-4
.1)
Edit
ion:
20
06
55
De
fin
itio
n
Low
er i
nta
ke
of
bio
acti
ve
subst
ance
s co
nta
inin
g f
oods
or
subst
ance
s co
mp
ared
to e
stab
lish
ed r
efer
ence
sta
ndar
ds
or r
ecom
men
dat
ion
s bas
ed u
pon p
hys
iolo
gic
al
nee
ds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•L
imit
ed a
cces
s to
food-c
on
tain
ing s
ubst
ance
•A
lter
ed G
I fu
nct
ion,
e.g., p
ain o
r dis
com
fort
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
Food/N
utr
itio
n H
isto
ryO
bse
rvat
ion
s or
report
s of:
•L
ow
in
take
of
pla
nt
foods
con
tain
ing:
•S
olu
ble
fib
er,
e.g., p
syll
ium
( t
ota
l an
d L
DL
ch
ole
ster
ol)
•S
oy p
rote
in (
tota
l an
d L
DL
chole
ster
ol)
•-g
luca
n,
e.g., w
hole
oat
pro
duct
s (
tota
l an
d L
DL
ch
ole
ster
ol)
•P
lan
t st
erol
and s
tan
ol
este
rs, e.
g., f
ort
ifie
d m
argar
ines
( t
ota
l an
d L
DL
ch
ole
ster
ol)
•L
ack o
f av
aila
ble
foods/
pro
duct
s w
ith b
ioac
tive
subst
an
ce i
n m
arket
s
INTA
KE
DO
MA
IN B
ioac
tive
Subst
ance
s
INA
DE
QU
AT
E B
IOA
CT
IVE
SU
BS
TA
NC
E I
NT
AK
E(N
I-4
.1)
Edit
ion:
20
06
56
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., c
ardio
vas
cula
r dis
ease
, el
evat
ed c
hole
ster
ol
•D
isco
mfo
rt o
r pai
n a
ssoci
ate
d w
ith i
nta
ke
of
foods
rich
in b
ioac
tive
subst
an
ces,
e.g
., s
olu
ble
fib
er,
-glu
can,
soy p
rote
in
Refe
ren
ce:
1.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
Fun
ctio
nal
foods.
J A
m D
iet
Ass
oc.
20
04
;10
4:8
14
-82
6.
INTA
KE
DO
MA
IN B
ioac
tive
Subst
ance
s
EX
CE
SS
IVE
BIO
AC
TIV
E S
UB
ST
AN
CE
IN
TA
KE
(NI-
4.2
)
Edit
ion:
20
06
57
De
fin
itio
n
Hig
her
inta
ke
of
bio
acti
ve
subst
an
ces
oth
er t
han
tra
dit
ion
al n
utr
ien
ts,
such
as
fun
ctio
nal
foods,
bio
acti
ve
food c
om
ponen
ts,
die
tary
supple
men
ts,
or
food
con
centr
ates
com
par
ed t
o e
stabli
shed
ref
eren
ce s
tandar
ds
or r
ecom
men
dat
ion
s bas
ed u
pon p
hysi
olo
gic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•C
on
tam
inat
ion, m
isnam
e, m
isla
bel
, m
isuse
, re
cen
t bra
nd c
han
ge,
rec
ent
dose
in
crea
se, re
cen
t fo
rmu
lati
on c
han
ge
of
subst
ance
con
sum
ed
•F
requen
t in
take
of
food c
on
tain
ing b
ioac
tive
subst
an
ce
•A
lter
ed G
I fu
nct
ion,
e.g., p
ain o
r dis
com
fort
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•L
ab v
alues
in
dic
atin
g e
xce
ssiv
e in
take
of
the
spec
ific
subst
ance
, su
ch a
s ra
pid
dro
p i
n c
hole
ster
ol
from
in
take
of
stan
ol
or
ster
ol
este
rs i
n c
om
bin
atio
n w
ith a
sta
tin d
rug
•In
crea
sed h
epat
ic e
nzy
me
refl
ecti
ng h
epat
oce
llula
r dam
age
Anth
ropom
etri
c M
easu
rem
ents
•W
eigh
t lo
ss a
s a
resu
lt o
f m
ala
bso
rpti
on o
r m
aldig
esti
on
Phys
ical
Exam
Fin
din
gs
•C
onst
ipat
ion o
r dia
rrh
ea r
elat
ed t
o e
xce
ssiv
e in
take
•N
euro
logic
chan
ges
, e.
g., a
nx
iety
, m
enta
l st
atus
chan
ges
•C
ardio
vas
cula
r ch
anges
, e.
g., h
eart
rat
e, E
KG
, blo
od p
ress
ure
INTA
KE
DO
MA
IN B
ioac
tive
Subst
ance
s
EX
CE
SS
IVE
BIO
AC
TIV
E S
UB
ST
AN
CE
IN
TA
KE
(NI-
4.2
)
Edit
ion:
20
06
58
Food/N
utr
itio
n H
isto
ryO
bse
rvat
ion
s or
report
s of:
•H
igh i
nta
ke
of
pla
nt
foods
con
tain
ing:
•S
oy p
rote
in (
tota
l an
d L
DL
chole
ster
ol)
•-g
luca
n,
e.g., w
hole
oat
pro
duct
s (
tota
l an
d L
DL
ch
ole
ster
ol)
•P
lan
t st
erol
and s
tan
ol
este
rs, e.
g., f
ort
ifie
d m
argar
ines
( t
ota
l an
d L
DL
ch
ole
ster
ol)
or
oth
er f
oods
bas
ed u
pon d
ieta
ry
subst
an
ce,
con
centr
ate,
met
aboli
te,
con
stit
uen
t, e
xtr
act
or c
om
bin
ati
on
•S
ubst
ance
s w
hic
h i
nte
rfer
e w
ith d
iges
tion
or
abso
rpti
on o
f fo
odst
uff
s
•R
ead
y a
cces
s to
avai
lable
foods/
pro
duct
s w
ith b
ioac
tive
subst
ance
, e.
g., a
s fr
om
die
tary
supple
men
t ven
dor
s
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., c
ardio
vas
cula
r dis
ease
, el
evat
ed c
hole
ster
ol,
hyp
erte
nsi
on
•D
isco
mfo
rt o
r pai
n a
ssoci
ate
d w
ith i
nta
ke
of
foods
rich
in b
ioac
tive
subst
an
ces,
e.g
., s
olu
ble
fib
er,
-glu
can,
soy p
rote
in
•A
ttem
pts
to u
se s
upple
men
ts o
r bio
acti
ve
subst
an
ces
for
wei
ght
loss
, tr
eat
con
stip
atio
n, pre
ven
t or
cure
chro
nic
or
acute
dis
ease
Refe
ren
ces:
1.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry S
up
ple
men
ts:
A f
ram
ew
ork
fo
r ev
alu
ati
ng
sa
fety
.W
ashin
gto
n,
DC
: N
atio
nal
Aca
dem
y P
ress
; 2
00
4.
2.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
Fun
ctio
nal
foods.
J A
m D
iet
Ass
oc.
20
04
;10
4:8
14
-82
6.
INTA
KE
DO
MA
IN B
ioac
tive
Subst
ance
s
EX
CE
SS
IVE
AL
CO
HO
L I
NT
AK
E(N
I-4
.3)
Edit
ion:
20
06
59
De
fin
itio
n
Inta
ke
above
the
sugges
ted l
imit
s fo
r al
coh
ol
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms.
•H
arm
ful
bel
iefs
/att
itudes
about
food,
nutr
itio
n,
and n
utr
itio
n-r
elat
ed t
opic
s
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•L
ack o
f val
ue
for
beh
avio
r ch
ange,
com
pet
ing v
alues
•A
lcoh
ol
addic
tion
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•E
levat
ed a
spar
tate
am
inotr
ansf
eras
e (A
ST
), g
amm
a-glu
tam
yl t
ran
sfer
ase
(GG
T),
car
boh
ydra
te-d
efic
ien
t tr
ansf
erri
n, m
ean
corp
usc
ula
r volu
me,
blo
od a
lcoh
ol
level
s
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•In
take
of
> 2
dri
nks/
day
(m
en)
(1 d
rin
k =
5 o
z. w
ine,
12 o
z bee
r, 1
oz.
dis
till
ed a
lcoh
ol)
•In
take
of
> 1
dri
nk/d
ay (
wom
en)
(1 d
rin
k =
5 o
z. w
ine,
12 o
z bee
r, 1
oz.
dis
till
ed a
lcoh
ol)
•B
inge
dri
nkin
g
•C
on
sum
pti
on o
f an
y a
lcoh
ol
wh
en c
on
trai
ndic
ated
INTA
KE
DO
MA
IN B
ioac
tive
Subst
ance
s
EX
CE
SS
IVE
AL
CO
HO
L I
NT
AK
E(N
I-4
.3)
Edit
ion:
20
06
60
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., s
ever
e h
yper
trig
lyce
ridem
ia,
elev
ated
blo
od p
ress
ure
,
dep
ress
ion
, li
ver
dis
ease
, pan
crea
titi
s
•N
ew m
edic
al d
iagnosi
s or
chan
ge
in e
xis
ting d
iagn
osi
s or
con
dit
ion
•H
isto
ry o
f ex
cess
ive
alco
hol
inta
ke
•G
ivin
g b
irth
to a
n i
nfa
nt
wit
h f
etal
alc
oh
ol
syn
dro
me
•D
rinkin
g d
uri
ng p
regnan
cy d
espit
e kn
ow
ledge
of
risk
•U
nex
pla
ined
fal
ls
Refe
ren
ce:
1.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
The
role
of
die
teti
cs p
rofe
ssio
nal
s in
hea
lth p
rom
oti
on a
nd d
isea
se p
reventi
on.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
68
0-1
68
7.
INTA
KE D
OM
AIN
N
utr
ient
INC
RE
AS
ED
NU
TR
IEN
T N
EE
DS
(S
PE
CIF
Y)
(NI-
5.1
)
Edit
ion:
20
06
61
De
fin
itio
n
Incr
ease
d n
eed f
or
a sp
ecif
ic n
utr
ient
com
par
ed t
o e
stabli
shed
ref
eren
ce s
tan
dar
ds
or
reco
mm
endat
ion
s bas
ed u
pon p
hysi
olo
gic
al
nee
ds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•A
lter
ed a
bso
rpti
on o
r m
etab
oli
sm o
f n
utr
ient,
e.g
., f
rom
med
icat
ion
s
•C
om
pro
mis
e of
org
ans
rela
ted t
o G
I fu
nct
ion,
e.g., p
ancr
eas,
liv
er
•D
ecre
ased
fun
ctio
nal
len
gth
of
inte
stin
e, e
.g., s
hort
bow
el s
yndro
me
•D
ecre
ased
or
com
pro
mis
ed f
un
ctio
n o
f in
test
ine,
e.g
., c
elia
c dis
ease
, C
rohn
’s d
isea
se
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•In
crea
sed d
eman
d o
f n
utr
ien
t, e
.g., a
ccel
erat
ed g
row
th,
woun
d h
eali
ng,
chro
nic
in
fect
ion
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•D
ecre
ased
ch
ole
ster
ol
< 1
60 m
g/d
L, al
bum
in, pre
album
in,
C-r
eact
ive
pro
tein
, in
dic
atin
g i
ncr
ease
d s
tres
s an
d i
ncr
ease
d
met
aboli
c n
eeds
•E
lect
roly
te/m
iner
al (
e.g., p
ota
ssiu
m, m
agnes
ium
, ph
osp
horu
s) a
bn
orm
alit
ies
•U
rinar
y o
r fe
cal
loss
es o
f sp
ecif
ic o
r re
late
d n
utr
ien
t (e
.g., f
ecal
fat
, d-x
ylo
se t
est)
•V
itam
in a
nd
/or
min
eral
def
icie
ncy
Anth
ropom
etri
c M
easu
rem
ents
•G
row
th f
ailu
re, bas
ed o
n N
atio
nal
Cen
ter
for
Hea
lth S
tati
stic
s (N
CH
S)
gro
wth
sta
ndar
ds
and f
etal
gro
wth
fai
lure
•U
nin
ten
tional
wei
ght
loss
of
5%
in 1
month
or
10%
in 6
month
s
•U
nder
wei
ght
(BM
I <
18.5
)
INTA
KE D
OM
AIN
N
utr
ient
INC
RE
AS
ED
NU
TR
IEN
T N
EE
DS
(S
PE
CIF
Y)
(NI-
5.1
)
Edit
ion:
20
06
62
Phys
ical
Exam
inati
on F
indin
gs
•C
linic
al e
vid
ence
of
vit
amin
/min
eral
def
icie
ncy
(e.
g.,
hai
r lo
ss,
ble
edin
g g
um
s, p
ale
nai
l bed
s)
•L
oss
of
skin
inte
gri
ty o
r del
aye
d w
oun
d h
eali
ng
•L
oss
of
musc
le m
ass
, su
bcu
tan
eous
fat
Food/N
utr
itio
n H
isto
ryO
bse
rvat
ion o
r re
port
s of:
•In
adeq
uat
e in
take
of
foods/
supp
lem
ent
con
tain
ing n
eeded
nutr
ien
t as
com
par
ed t
o e
stim
ated
req
uir
emen
ts
•In
tak
e of
foods
that
do n
ot
con
tain
suff
icie
nt
quan
titi
es o
f av
aila
ble
nutr
ient
(e.g
., o
ver
pro
cess
ed,
over
cooked
, or
store
d
impro
per
ly)
•F
ood a
nd n
utr
itio
n-r
elat
ed k
now
ledge
def
icit
(e.
g., l
ack
of
info
rmati
on,
inco
rrec
t in
form
atio
n o
r n
onco
mp
lian
ce w
ith
inta
ke
of
nee
ded
nutr
ient)
Cli
ent
His
tory
•F
ever
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t, e
.g., i
nte
stin
al r
esec
tion,
Cro
hn
’s d
isea
se,
HIV
/AID
S, burn
s, p
ress
ure
ulc
ers,
pre
-ter
m b
irth
, m
aln
utr
itio
n
•M
edic
atio
ns
affe
ctin
g a
bso
rpti
on o
r m
etab
oli
sm o
f n
eeded
nutr
ien
t
Refe
ren
ces:
1.
Bey
er
P. G
ast
roin
test
inal
dis
ord
ers:
Role
s of
nutr
itio
n a
nd t
he
die
teti
cs
pra
ctit
ioner
.J
Am
Die
t A
sso
c. 1
99
8;9
8:2
72
-27
7.
2.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n a
nd D
ieti
tian
s of
Can
ada:
Nu
trit
ion i
nte
rven
tion i
n t
he
care
of
per
sons
wit
h h
um
an i
mm
un
odef
icie
ncy v
iru
s in
fect
ion.J
Am
Die
t A
sso
c.
20
04
;10
4:1
42
5-1
44
1.
INTA
KE D
OM
AIN
N
utr
ient
EV
IDE
NT
PR
OT
EIN
-EN
ER
GY
MA
LN
UT
RIT
ION
(NI-
5.2
)
Edit
ion:
20
06
63
De
fin
itio
n
Inadeq
uat
e in
take
of
pro
tein
an
d/o
r en
ergy o
ver
pro
lon
ged
per
iods
of
tim
e re
sult
ing i
n l
oss
of
fat
store
s an
d/o
r m
usc
le w
asti
ng
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses,
e.g
., a
lter
ed n
utr
ien
t n
eeds
due
to p
rolo
nged
cat
aboli
c il
lnes
s, m
alabso
rpti
on
•L
ack o
f ac
cess
to f
ood,
e.g
., e
con
om
ic c
on
stra
ints
, cu
ltura
l or
reli
gio
us
pra
ctic
es, re
stri
ctin
g f
ood g
iven
to e
lder
ly a
nd/o
r ch
ildre
n
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledge
defi
cit,
e.g
., a
void
ance
of
hig
h q
ual
ity p
rote
in f
oods
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r ea
ting d
isord
ers
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•N
orm
al s
erum
alb
um
in l
evel
(un
com
pli
cate
d m
aln
utr
itio
n)
•A
lbum
in <
3.4
mg/d
L (
dis
ease
/tra
um
a-r
elat
ed m
alnutr
itio
n)
Anth
ropom
etri
c M
easu
rem
ents
•B
MI
< 1
8.5
in
dic
ates
under
wei
gh
t
•F
ailu
re t
o t
hri
ve,
e.g
. fa
ilure
to a
ttai
n d
esir
able
gro
wth
rat
es
•In
adeq
uat
e m
ater
nal
wei
gh
t gai
n
•W
eigh
t lo
ss o
f >
10%
in 6
mon
ths
or
5%
in 1
mon
th
•U
nder
wei
ght
wit
h m
usc
le w
asti
ng
•N
orm
al o
r sl
ightl
y u
nder
wei
ght,
stu
nte
d g
row
th i
n c
hil
dre
n
INTA
KE D
OM
AIN
N
utr
ient
EV
IDE
NT
PR
OT
EIN
-EN
ER
GY
MA
LN
UT
RIT
ION
(NI-
5.2
)
Edit
ion:
20
06
64
Phys
ical
Exam
Fin
din
gs
•U
nco
mpli
cate
d m
aln
utr
itio
n:
Thin
, w
aste
d a
ppea
ran
ce;
sever
e m
usc
le w
asti
ng;
min
imal
bod
y f
at;
spar
se, th
in,
dry
, ea
sily
plu
ckable
hai
r; d
ry,
thin
skin
; obvio
us
bon
y p
rom
inen
ces,
occ
ipit
al w
asti
ng;
low
ered
bod
y t
emper
ature
, blo
od p
ress
ure
,
hea
rt r
ate
; ch
anges
in h
air
or n
ails
con
sist
ent
wit
h i
nsu
ffic
ien
t pro
tein
inta
ke
•D
isea
se/t
raum
a-r
elat
ed m
aln
utr
itio
n:
Th
in t
o n
orm
al a
ppea
ran
ce,
wit
h p
erip
her
al
edem
a, a
scit
es o
r an
asar
ca;
som
e m
usc
le
was
tin
g w
ith r
eten
tion o
f so
me
bod
y f
at;
enla
rged
fat
ty l
iver
; dys
pig
men
tati
on o
f h
air
(fla
g s
ign)
and s
kin
•D
elayed
woun
d h
eali
ng
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•In
suff
icie
nt
ener
gy i
nta
ke
from
die
t co
mpar
ed t
o e
stim
ated
or
mea
sure
d R
MR
•In
suff
icie
nt
inta
ke
of
hig
h-q
ual
ity p
rote
in w
hen
com
par
ed t
o r
equir
emen
ts
•F
ood a
void
an
ce a
nd/o
r la
ck o
f in
tere
st i
n f
ood
Cli
ent
His
tory
•C
hro
nic
or
acute
dis
ease
or
trau
ma,
geo
gra
phic
loca
tion a
nd s
oci
oec
on
om
ic s
tatu
s as
soci
ate
d w
ith a
lter
ed n
utr
ien
t in
take
of
ind
igen
ou
s ph
enom
enon
•S
ever
e pro
tein
and/o
r n
utr
ien
t m
alabso
rpti
on (
e.g. ex
ten
sive
bow
el r
esec
tion
)
•E
xce
ssiv
e co
nsu
mp
tion
of
alco
hol
or
oth
er d
rugs
that
red
uce
hunger
Refe
ren
ces:
1.
Wel
lco
me
Tru
st W
ork
ing
Par
ty.
Cla
ssif
icat
ion
of
infa
nti
le m
alnu
trit
ion.
La
nce
t.1
97
0;2
:30
2-3
03
.
2.
Ser
es D
S,
Res
urr
ecti
on
, L
B.
Kw
ash
iork
or:
Dy
smet
abo
lism
ver
sus
mal
nu
trit
ion
.N
utr
Cli
n P
ract
.2
00
3;1
8:2
97
-30
1.
3.
Jell
iffe
DB
, Je
llif
fe E
F. C
ausa
tio
n o
f k
was
hio
rko
r: T
ow
ard
a m
ult
ifac
tora
l co
nse
nsu
s.P
edia
tric
s1
99
2:9
0:1
10
-11
3.
4.
Cen
ters
for
Dis
ease
Contr
ol
and P
rev
enti
on W
eb s
ite.
Avai
lab
le a
t: h
ttp:/
/ww
w.c
dc.
gov/n
ccdp
hp/d
npa/b
mi/
bm
i-adult
.htm
. A
cces
sed O
cto
ber
5, 20
04
.
5.
Fu
hrm
an M
P,
Char
ney
P,
Mu
elle
r C
M. H
epat
ic p
rote
ins
and
nu
trit
ion
ass
essm
ent.
J A
m D
iet
Ass
oc.
20
04
;10
4:1
25
8-1
26
4.
6.
U.S
. D
epart
ment
of
Hea
lth a
nd H
um
an S
ervic
es.
Th
e In
tern
ati
on
al
Cla
ssif
ica
tio
n o
f D
isea
ses,
9th R
evis
ion
, 4
th e
d. W
ash
ing
ton
DC
: U
SD
HS
S P
ubli
cati
on
No. (P
HS
) 9
1-1
26
0; 1
99
1.
INTA
KE D
OM
AIN
N
utr
ient
INA
DE
QU
AT
E P
RO
TE
IN-E
NE
RG
Y IN
TA
KE
(N
I-5
.3)
Edit
ion:
20
06
65
De
fin
itio
n
Inadeq
uat
e in
take
of
pro
tein
an
d/o
r en
ergy c
om
par
ed t
o e
stab
lish
ed r
efer
ence
sta
ndar
ds
or
reco
mm
endat
ions
bas
ed u
pon
physi
olo
gic
al n
eeds
of
short
or
rece
nt
dura
tion
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms.
•S
hort
-ter
m p
hys
iolo
gic
cau
ses,
e.g
., i
ncr
ease
d n
utr
ien
t n
eeds
due
to c
atab
oli
c il
lnes
s, m
alab
sorp
tion
•R
ecen
t la
ck o
f ac
cess
to f
ood,
e.g
., e
con
om
ic c
on
stra
ints
, cu
ltura
l or
rel
igio
us
pra
ctic
es, re
stri
ctin
g f
ood g
iven
or
food s
elec
ted
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledge
def
icit
, e.
g., a
void
ance
of
all
fats
for
new
die
ting p
atte
rn
•R
ecen
t onse
t of
psy
cholo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r ea
tin
g d
isord
ers
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•N
orm
al a
lbum
in (
in t
he
sett
ing o
f n
orm
al l
iver
fun
ctio
n d
espit
e dec
rease
pro
tein
-en
ergy in
take)
Anth
ropom
etri
c M
easu
rem
ents
•In
adeq
uat
e m
ater
nal
wei
gh
t gai
n (
mil
d b
ut
not
sever
e)
•W
eigh
t lo
ss o
f 5-7
% o
ver
past
3 m
on
ths
in a
dult
s, a
ny w
eight
loss
in c
hil
dre
n
•N
orm
al o
r sl
ightl
y u
nder
wei
ght
•G
row
th f
ailu
re i
n c
hil
dre
n
Phys
ical
Exam
Fin
din
gs
•S
low
woun
d h
eali
ng i
n p
ress
ure
ulc
er o
r su
rgic
al p
atie
nt/
clie
nt
INTA
KE D
OM
AIN
N
utr
ient
INA
DE
QU
AT
E P
RO
TE
IN-E
NE
RG
Y IN
TA
KE
(N
I-5
.3)
Edit
ion:
20
06
66
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•In
suff
icie
nt
ener
gy in
take
from
die
t co
mp
ared
to e
stim
ated
or
mea
sure
d r
esti
ng m
etab
oli
c ra
te (
RM
R)
or
reco
mm
ended
level
s
•R
estr
icti
on o
r om
issi
on o
f fo
od g
roups
such
as
dai
ry o
r m
eat
gro
up f
oods
(pro
tein
); b
read
or
mil
k g
roup f
oods
(en
ergy)
•R
ecen
t fo
od a
void
ance
and/o
r la
ck o
f in
tere
st i
n f
ood
•L
ack o
f ab
ilit
y t
o p
repar
e m
eals
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t of
mil
d p
rote
in-e
ner
gy m
aln
utr
itio
n,
rece
nt
illn
ess,
e.g
. pulm
onar
y o
r
card
iac
fail
ure
, fl
u,
infe
ctio
n,
surg
ery
•N
utr
ien
t m
alab
sorp
tion (
e.g. bar
iatr
ic s
urg
ery,
dia
rrh
ea,
stea
torr
hea
)
•E
xce
ssiv
e co
nsu
mp
tion
of
alco
hol
or
oth
er d
rugs
that
red
uce
hunger
•P
atie
nt/
clie
nt
report
s of
hun
ger
in t
he
face
of
inadeq
uat
e ac
cess
to f
ood s
upply
•P
atie
nt/
clie
nt
report
s la
ck o
f ab
ilit
y t
o p
repar
e m
eals
•P
atie
nt/
clie
nt re
port
s la
ck o
f fu
nds
for
purc
has
e of
appro
pri
ate
foods
Refe
ren
ces:
1.
Cen
ters
for
Dis
ease
Contr
ol
and P
rev
enti
on W
eb s
ite.
Avai
lab
le a
t: h
ttp:/
/ww
w.c
dc.
gov/n
ccdp
hp/d
npa/b
mi/
bm
i-adult
.htm
. A
cces
sed O
cto
ber
5, 20
04
.
2.
Fu
hrm
an M
P,
Char
ney
P,
Mu
elle
r C
M. H
epat
ic p
rote
ins
and
nu
trit
ion
ass
essm
ent.
J A
m D
iet
Ass
oc.
20
04
;10
4:1
25
8-1
26
4.
3.
U.S
. D
epart
ment
of
Hea
lth a
nd H
um
an S
ervic
es.
Th
e In
tern
ati
on
al
Cla
ssif
ica
tio
n o
f D
isea
ses,
9th R
evis
ion
, 4
th e
d. W
ash
ing
ton
DC
: U
SD
HS
S P
ubli
cati
on
No. (P
HS
) 9
1-1
26
0; 1
99
1.
INTA
KE D
OM
AIN
N
utr
ient
DE
CR
EA
SE
D N
UT
RIE
NT
NE
ED
S(S
PE
CIF
Y)
(NI-
5.4
)
Edit
ion:
20
06
67
De
fin
itio
n
Dec
reas
ed n
eed f
or
a sp
ecif
ic n
utr
ient
com
par
ed t
o e
stab
lish
ed r
efer
ence
sta
ndar
ds
or
reco
mm
endat
ion
s bas
ed u
pon p
hysi
olo
gic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•R
enal
dysf
un
ctio
n
•L
iver
dysf
un
ctio
n
•A
lter
ed c
hole
ster
ol
met
aboli
sm/r
egula
tion
•H
eart
fai
lure
•F
ood i
nto
lera
nce
s, e
.g., i
rrit
able
bow
el s
yndro
me
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•C
hole
ster
ol
> 2
00 m
g/d
L (
5.2
mm
ol/
L),
LD
L c
hole
ster
ol
> 1
00 m
g/d
L (
2.5
9 m
mol/
L),
HD
L c
hole
ster
ol
< 4
0 m
g/d
L
(1.0
36 m
mol/
L),
tri
gly
ceri
des
> 1
50 m
g/d
L (
1.6
95 m
mol/
L)
•P
hosp
hor
us
> 5
.5 m
g/d
L (
1.7
8 m
mol/
L)
•G
lom
erula
r fi
ltra
tion
rat
e (G
FR
) <
90 m
L/m
in/1
.73 m
2
•E
levat
ed B
UN
, C
r, p
ota
ssiu
m
•L
iver
fun
ctio
n t
ests
in
dic
atin
g s
ever
e li
ver
dis
ease
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
•E
dem
a/fl
uid
ret
enti
on
•In
terd
ialy
tic
wei
ght
gai
n g
reat
er t
han
expec
ted
INTA
KE D
OM
AIN
N
utr
ient
DE
CR
EA
SE
D N
UT
RIE
NT
NE
ED
S(S
PE
CIF
Y)
(NI-
5.4
)
Edit
ion:
20
06
68
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•In
tak
e hig
her
than
rec
om
men
ded
for
fat,
phosp
horu
s, s
odiu
m,
pro
tein
, fi
ber
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t th
at r
equir
e a
spec
ific
typ
e an
d/o
r am
ount
of
nutr
ient,
e.g
.,
card
iovas
cula
r dis
ease
(fa
t),
earl
y r
enal
dis
ease
(pro
tein
, ph
osp
horu
s),
ES
RD
(phosp
horu
s, s
odiu
m, pota
ssiu
m, fl
uid
),
advan
ced l
iver
dis
ease
(pro
tein
), h
eart
fai
lure
(so
diu
m, fl
uid
), i
rrit
able
bow
el d
isea
se/C
rohn’s
dis
ease
fla
re u
p (
fiber
)
•D
iagn
osi
s of
hyp
erte
nsi
on
, co
nfu
sion r
elat
ed t
o l
iver
dis
ease
Refe
ren
ces:
1.
Apar
icio
M, C
hau
vea
u P
, C
om
be
C.
Low
pro
tein
die
ts a
nd o
utc
om
es o
f re
nal
pat
ients
.J
Nep
hro
l. 2
00
1;1
4:4
33
-43
9.
2.
Bet
o J
A, B
ansa
l V
K.
Med
ical
nutr
itio
n t
her
apy i
n c
hro
nic
kid
ney
fai
lure
: In
tegra
ting c
linic
al p
ract
ice
guid
elin
es.
J A
m D
iet
Ass
oc.
20
04
;10
4:4
04
-40
9.
3.
Cu
pis
ti A
, M
ore
lli
E,
D’A
less
and
ro C
, L
up
etti
S, B
arso
tti
G.
Ph
osp
hat
e co
ntr
ol
in c
hro
nic
ure
mia
: do
n’t
fo
rget
die
t.J
Nep
hro
l. 2
00
3;1
6:2
9-3
3.
4.
Duro
se C
L, H
old
swort
h M
, W
atso
n V
, P
rzygro
dzk
a F
. K
no
wle
dge
of
die
tary
res
tric
tio
ns
and t
he
med
ical
con
sequ
ence
s of
noncom
pli
ance
by p
atie
nts
on h
emo
dia
lysi
s ar
e not
pre
dic
tive
of
die
tary
com
pli
ance
.J
Am
Die
t A
sso
c. 2
00
4;1
04
:35
-41
.
5.
Flo
ch M
H, N
aray
an R
. D
iet
in t
he
irri
tab
le b
ow
el s
yn
dro
me.
Cli
n G
ast
roen
tero
l. 2
00
2;3
5:S
45
-S5
2.
6.
Kat
o J
, K
ob
un
e M
, N
akam
ura
T,
Ku
rojw
a G
, T
akad
a K
, T
akim
oto
R, S
ato
Y, F
uji
kaw
a K
, T
akahas
hi
M, T
akayam
a T
, Ik
eda
T, N
iits
u Y
. N
orm
aliz
atio
n o
f el
evat
ed h
epat
ic 8
-hy
dro
xy
-2’-
deo
xyguano
sine
level
s in
chro
nic
hep
atit
is C
pat
ients
by p
hle
boto
my a
nd l
ow
iro
n d
iet.
Ca
nce
r R
es. 2
00
1;6
1:8
69
7-8
70
2.
7.
Lee
SH
, M
ola
ssio
tis
A.
Die
tary
an
d f
luid
co
mp
lian
ce i
n C
hin
ese
hem
od
ialy
sis
pat
ien
ts.In
t J
Nu
rs S
tud
. 2
00
2;3
9:6
95
-70
4.
8.
Po
du
val
RD
, W
olg
emu
th C
, F
erre
ll J
, H
am
mes
MS
. H
yp
erp
ho
sph
atem
ia i
n d
ialy
sis
pat
ients
: is
th
ere
a ro
le f
or
focu
sed
cou
nse
lin
g?
J R
en N
utr
. 2
00
3;1
3:2
19
-22
3.
9.
Tan
don N
, T
hak
ur
V, G
upta
n R
K, S
arin
SK
. B
enef
icia
l in
flu
ence
of
an i
ndig
enous
low
-iro
n d
iet
on s
erum
indic
ators
of
iro
n s
tatu
s in
pat
ients
wit
h c
hro
nic
liv
er d
isea
se.
Br
J N
utr
. 2
00
0;8
3:2
35
-
23
9.
10
. Z
rin
yi
M,
Juhasz
M,
Bal
la J
, K
ato
na
E,
Ben
T,
Kak
uk
G,
Pal
l D
. D
ieta
ry s
elf-
effi
cacy
: d
eter
min
ant
of
com
pli
ance
beh
avio
urs
an
d b
ioch
emic
al o
utc
om
es
in h
aem
od
ialy
sis
pat
ien
ts.
Nep
hro
l D
ial
Tra
nsp
lan
t. 2
00
3;1
9:1
86
9-1
87
3.
INTA
KE D
OM
AIN
N
utr
ient
IMB
AL
AN
CE
OF
NU
TR
IEN
TS
(N
I-5
.5)
Edit
ion:
20
06
69
De
fin
itio
n
An u
ndes
irable
com
bin
atio
n o
f in
ges
ted n
utr
ients
, su
ch t
hat
th
e am
oun
t of
on
e nutr
ient
inges
ted i
nte
rfer
es w
ith o
r al
ters
abso
rpti
on a
nd/o
r uti
liza
tion o
f an
oth
er
nutr
ien
t
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•C
onsu
mpti
on o
f hig
h d
ose
nutr
ien
t su
pple
men
ts
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•H
arm
ful
bel
iefs
/att
itudes
about
food,
nutr
itio
n,
and n
utr
itio
n-r
elat
ed i
nfo
rmat
ion
•F
ood f
add
ism
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c D
ata
Phys
ical
Exam
Fin
din
gs
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•H
igh i
nta
ke
of
iron
supple
men
ts (
zin
c ab
sorp
tion
)
•H
igh i
nta
ke
of
zin
c su
pple
men
ts (
copper
sta
tus)
•H
igh i
nta
ke
of
man
gan
ese
( i
ron s
tatu
s)
Cli
ent
His
tory
•D
iarr
hea
or
con
stip
atio
n (
iron
supple
men
ts)
•E
pig
astr
ic p
ain,
nau
sea,
vom
itin
g,
dia
rrh
ea (
zin
c su
pple
men
ts)
•C
on
trib
ute
s to
th
e dev
elopm
ent
of
anem
ia (
man
gan
ese
supp
lem
ents
)
INTA
KE D
OM
AIN
N
utr
ient
IMB
AL
AN
CE
OF
NU
TR
IEN
TS
(N
I-5
.5)
Edit
ion:
20
06
70
Refe
ren
ces:
1.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r V
ita
min
A,
Vit
am
in K
, A
rsen
ic, B
oro
n, C
hro
miu
m, C
op
per
, Io
din
e, I
ron
, M
an
ga
nes
e, M
oly
bd
enu
m, N
icke
l,
Sil
ico
n,
Va
na
diu
m, Z
inc.
Was
hin
gto
n,
DC
: N
ati
on
al A
cad
emy
Pre
ss;
20
01
.
2.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
Inta
kes
for
Ca
lciu
m,
Ph
osp
ho
rus,
Ma
gn
esiu
m, V
ita
min
D, a
nd
Flu
ori
de. W
ash
ing
ton
, D
C:
Nat
ional
Aca
dem
y P
ress
; 1
99
7.
INTA
KE
DO
MA
IN F
at an
d C
hole
ste
rol
INA
DE
QU
AT
E F
AT
IN
TA
KE
(N
I-5
1.1
)
Edit
ion:
20
06
71
De
fin
itio
n
Low
er f
at i
nta
ke
com
par
ed t
o e
stab
lish
ed r
efer
ence
sta
ndar
ds
or
reco
mm
endat
ion
s bas
ed u
pon p
hysi
olo
gic
al n
eeds.
Ex
cepti
on:
wh
en t
he
goal
is
wei
ght
loss
or
duri
ng e
nd o
f li
fe c
are.
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•In
appro
pri
ate
food c
hoic
es,
e.g., e
conom
ic c
on
stra
ints
, cu
ltura
l or
reli
gio
us
pra
ctic
es, re
stri
ctin
g f
ood g
iven
to e
lder
ly a
nd/o
r ch
ildre
n,
spec
ific
food c
hoic
es
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledge
def
icit
, e.
g,. p
rolo
nged
adh
eren
ce t
o a
ver
y low
fat
die
t
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r dis
ord
ered
eat
ing
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•T
rien
e:te
trae
ne
rati
o >
0.2
Anth
ropom
etri
c M
easu
rem
ents
•W
eig
ht
loss
if
insu
ffic
ien
t ca
lori
es c
on
sum
ed
Phys
ical
Exam
inati
on F
indin
gs
•R
ough
, sc
aly s
kin
that
bec
om
es d
erm
ati
tis
wit
h e
ssen
tial
fat
ty a
cid d
efic
ien
cy
Food/N
utr
itio
n H
isto
ryR
eport
or
obse
rvat
ion o
f
•In
take
of
esse
nti
al f
atty
aci
d c
on
tain
ing f
oods
con
sist
entl
y p
rovid
ing l
ess
than
10%
of
calo
ries
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t, e
.g., p
rolo
nged
cat
aboli
c il
lnes
s (e
.g., A
IDS
, tu
ber
culo
sis,
anore
xia
ner
vosa
, se
psi
s or
sever
e in
fect
ion f
rom
rec
ent
surg
ery)
•S
ever
e fa
t m
alab
sorp
tion
wit
h b
ow
el r
esec
tion
, pan
crea
tic
insu
ffic
iency,
or
hep
atic
dis
ease
acc
om
pan
ied b
y
stea
torr
hea
Refe
ren
ces:
1.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r E
ner
gy,
Ca
rbo
hyd
rate
, F
iber
, F
at,
Fa
tty
Aci
ds,
Ch
ole
ster
ol,
Pro
tein
, a
nd
Am
ino
Aci
ds.
Was
hin
gto
n, D
C:
Nat
ion
al A
cad
em
y P
ress
; 2
00
2.
INTA
KE
DO
MA
IN F
at an
d C
hole
ste
rol
EX
CE
SS
IVE
FA
T IN
TA
KE
(N
I-5
1.2
)
Edit
ion:
20
06
72
De
fin
itio
n
Hig
her
fat
inta
ke
com
par
ed t
o e
stabli
shed
ref
eren
ce s
tan
dar
ds
or
reco
mm
endat
ions
bas
ed u
pon p
hysi
olo
gic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•H
arm
ful
bel
iefs
/att
itudes
about
food,
nutr
itio
n,
and n
utr
itio
n-r
elat
ed t
opic
s
•L
ack o
f ac
cess
to h
ealt
hfu
l fo
od c
hoic
es,
e.g., f
ood p
rovid
ed b
y c
areg
iver
•C
han
ges
in t
ast
e an
d a
ppet
ite
or
pre
fere
nce
•L
ack o
f val
ue
for
beh
avio
r ch
ange;
com
pet
ing v
alues
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•C
hole
ster
ol
>200 m
g/d
L (
5.2
mm
ol/
L),
LD
L c
hole
ster
ol
> 1
00 m
g/d
L (
2.5
9 m
mol/
L),
HD
L c
hole
ster
ol
< 4
0 m
g/d
L (
1.0
36
mm
ol/
L),
tri
gly
ceri
des
> 1
50 m
g/d
L (
1.6
95 m
mol/
L)
•E
levat
ed s
erum
am
ylase
and/o
r li
pase
•E
levat
ed l
iver
fun
ctio
n t
ests
an
d/o
r to
tal
bil
irubin
•T
rien
e:te
trae
ne
rati
o >
0.4
•F
ecal
fat
> 7
g/
24 h
ours
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
•E
vid
ence
of
xanth
om
as
•E
vid
ence
of
skin
les
ion
s
INTA
KE
DO
MA
IN F
at an
d C
hole
ste
rol
EX
CE
SS
IVE
FA
T IN
TA
KE
(N
I-5
1.2
)
Edit
ion:
20
06
73
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•F
requen
t or
lar
ge
port
ion
s of
hig
h-f
at f
oods
•F
requen
t fo
od p
repar
atio
n w
ith a
dded
fat
•F
requen
t co
nsu
mpti
on o
f h
igh-r
isk l
ipid
s (i
.e., s
atura
ted f
at,
trans
fat,
ch
ole
ster
ol)
•R
eport
of
foods
con
tain
ing f
at a
bove
die
t pre
scri
pti
on
•In
adeq
uat
e in
take
of
esse
nti
al l
ipid
s
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t, e
.g., h
yper
lipid
emia
, cy
stic
fib
rosi
s,
angin
a, a
rther
osc
lero
sis,
pan
crea
tic,
liv
er,
and b
ilia
ry d
isea
ses;
post
-tra
nsp
lanta
tion
•M
edic
atio
n,
e.g
., p
ancr
eati
c en
zym
es,
chole
ster
ol,
or
oth
er l
ipid
-low
erin
g m
edic
atio
ns
•D
iarr
hea
, cr
ampin
g,
stea
torr
hea
, ep
igas
tric
pai
n
•F
amil
y h
isto
ry o
f h
yper
lipid
emia
, at
her
osc
lero
sis,
or
pan
crea
titi
s.
Refe
ren
ces:
1.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r E
ner
gy,
Ca
rbo
hyd
rate
, F
iber
, F
at,
Fa
tty
Aci
ds,
Ch
ole
ster
ol,
Pro
tein
, a
nd
Am
ino
Aci
ds.
Was
hin
gto
n, D
C:
Nat
ion
al A
cad
em
y P
ress
; 2
00
2.
2.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Wei
ght
man
agem
ent.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
14
5-1
15
5.
3.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Tota
l die
t appro
ach
to c
om
munic
atin
g f
ood a
nd n
utr
itio
n i
nfo
rmat
ion.J
Am
Die
t A
sso
c. 2
00
2;1
02
:10
0-1
08
.
4.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
The
role
of
die
teti
cs p
rofe
ssio
nal
s in
hea
lth p
rom
oti
on a
nd d
isea
se p
reventi
on.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
68
0-1
68
7.
INTA
KE
DO
MA
IN F
at an
d C
hole
ste
rol
INA
PP
RO
PR
IAT
E IN
TA
KE
OF
FO
OD
FA
TS
(N
I-5
1.3
)
Edit
ion:
20
06
74
De
fin
itio
n
Inta
ke
of
wro
ng t
ype
or
qual
ity o
f fo
od f
ats
com
par
ed t
o e
stab
lish
ed r
efer
ence
sta
ndar
ds
or
reco
mm
endat
ion
s bas
ed u
pon p
hys
iolo
gic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•H
arm
ful
bel
iefs
/att
itudes
about
food,
nutr
itio
n,
and n
utr
itio
n-r
elat
ed t
opic
s
•L
ack o
f ac
cess
to h
ealt
hfu
l fo
od c
hoic
es,
e.g., f
ood p
rovid
ed b
y c
areg
iver
, ped
iatr
ics,
hom
eles
s
•C
han
ges
in t
ast
e an
d a
ppet
ite
or
pre
fere
nce
•L
ack o
f val
ue
for
beh
avio
r ch
ange;
com
pet
ing v
alues
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•C
hole
ster
ol
>200 m
g/d
L (
5.2
mm
ol/
L),
LD
L c
hole
ster
ol
> 1
00 m
g/d
L (
2.5
9 m
mol/
L),
HD
L c
hole
ster
ol
< 4
0 m
g/d
L (
1.0
36
mm
ol/
L),
tri
gly
ceri
des
> 1
50 m
g/d
L (
1.6
95 m
mol/
L)
•E
levat
ed s
erum
am
ylase
and/o
r li
pase
•E
levat
ed l
iver
fun
ctio
n t
ests
, to
tal
bil
irubin
, an
d C
-rea
ctiv
e pro
tein
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
•E
vid
ence
of
xanth
om
as
•E
vid
ence
of
skin
les
ion
s
INTA
KE
DO
MA
IN F
at an
d C
hole
ste
rol
INA
PP
RO
PR
IAT
E IN
TA
KE
OF
FO
OD
FA
TS
(N
I-5
1.3
)
Edit
ion:
20
06
75
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•F
requen
t fo
od p
repar
atio
n w
ith a
dded
fat
that
is n
ot
of
des
ired
typ
e fo
r co
ndit
ion
•F
requen
t co
nsu
mp
tion o
f fa
ts t
hat
are
undes
irable
for
con
dit
ion (
i.e.
, sa
tura
ted f
at,
trans
fat,
ch
ole
ster
ol,
om
ega-
6 f
atty
acid
s)
•In
adeq
uat
e in
take
of
monoun
satu
rate
d, poly
un
satu
rate
d, or
om
ega-
3 f
atty
aci
ds
Cli
ent
His
tory
•C
ondit
ion
s as
soci
ate
d w
ith a
dia
gnosi
s or
trea
tmen
t of
dia
bet
es,
card
iac
dis
ease
s, o
bes
ity,
liv
er o
r bil
iary
dis
ord
ers
•D
iarr
hea
, cr
ampin
g,
stea
torr
hea
, ep
igas
tric
pai
n
•F
amil
y h
isto
ry o
f dia
bet
es-r
elat
ed h
eart
dis
ease
, h
yper
lipid
emia
, at
her
osc
lero
sis,
or
pan
crea
titi
s
•C
lien
t des
ires
to i
mple
men
t a
Med
iter
ran
ean-t
ype
die
t
Refe
ren
ces:
1.
de
Lo
rger
il M
, S
alen
P,
Mar
tin
JL
, M
onja
ud
I,
Del
aye
J, M
amel
le N
. M
edit
erra
nea
n d
iet,
tra
dit
ion
al r
isk
fac
tors
, an
d t
he
rate
of
card
iov
ascu
lar
com
pli
cati
on
s aft
er m
yoca
rdia
l in
farc
tio
n.
Fin
al
report
of
the
Ly
on D
iet
Hea
rt S
tudy.C
ircu
lati
on
.1
99
9;9
9:7
79
-78
5.
2.
Fra
nz
MJ,
Ban
tle
JP, B
eeb
e C
A,
Bru
nze
ll J
D,
Chia
sso
n J
-L,
Gar
g A
, H
olz
mei
ster
LA
, H
oo
gw
erf
B,
May
er-D
avis
E,
Mo
ora
dia
n A
D,
Pu
rnel
l JQ
, W
hee
ler
M: T
ech
nic
al r
evie
w. E
vid
ence
-base
d
nutr
itio
n p
rinci
ple
s an
d r
ecom
men
dat
ions
for
the
trea
tmen
t an
d p
reven
tion o
f dia
bet
es a
nd r
elat
ed c
om
pli
cati
ons.
Dia
bet
es C
are
.2
00
2;2
02
:14
8-1
98
.
3.
Kno
op
s K
TB
, d
e G
rott
LC
PG
M,
Kro
mhou
t D
, P
erri
n A
-E,
Var
ela
MV
, M
enott
i A
, van
Sta
ver
en W
A.
Med
iter
ran
ean
die
t, l
ifes
tyle
fact
ors
, an
d 1
0-y
ear
mort
alit
y i
n e
lder
ly E
uro
pea
n m
en a
nd
wom
en.
JAM
A.
20
04
;29
2:1
43
3-1
43
9,
4.
Kri
s-E
ther
ton
PM
, H
arri
s W
S,
Ap
pel
LJ,
for
the
Nu
trit
ion
Co
mm
itte
e. A
HA
sci
enti
fic
stat
emen
t. F
ish
co
nsu
mp
tio
n,
fish
oil
, o
meg
a-3
fat
ty a
cid
s, a
nd
car
dio
vasc
ula
r dis
ease
.C
ircu
lati
on
.
20
02
;10
6:2
74
7-2
75
7.
5.
Pan
agio
tak
os
DB
, P
itsa
vo
s C
, P
oly
chro
nopoulo
s E
, C
hry
soho
ou C
, Z
am
pel
as A
, T
rich
opoulo
u A
. C
an a
Medit
erra
nea
n d
iet
moder
ate
the
dev
elopm
ent
and c
linic
al p
rogre
ssio
n o
f co
ronar
y h
eart
dis
ease
? A
syst
em
atic
rev
iew
.M
ed S
ci M
on
it.2
00
4;1
0:R
A1
93
-RA
19
8.
6.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Wei
ght
man
agem
ent.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
14
5-1
15
5.
7.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Tota
l die
t appro
ach
to c
om
munic
atin
g f
ood a
nd n
utr
itio
n i
nfo
rmat
ion.J
Am
Die
t A
sso
c. 2
00
2;1
02
:10
0-1
08
.
8.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
The
role
of
die
teti
cs p
rofe
ssio
nal
s in
hea
lth p
rom
oti
on a
nd d
isea
se p
reventi
on.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
68
0-1
68
7.
9.
Zhao
G,
Eth
erto
n T
D,
Mar
tin
KR
, W
est
SG
, G
ille
s P
J, K
ris-
Eth
erto
n P
M. D
ieta
ry a
lph
a-li
no
lenic
aci
d r
edu
ces
infl
amm
ato
ry a
nd
lip
id c
ard
iovasc
ula
r ri
sk f
act
ors
in
hy
per
cho
lest
ero
lem
ic m
en a
nd
wom
en.
J N
utr
. 2
00
4;1
34
:29
91
-29
97
.
INTA
KE
DO
MA
IN P
rote
in
INA
DE
QU
AT
E P
RO
TE
IN IN
TA
KE
(NI-
52
.1)
Edit
ion:
20
06
76
De
fin
itio
n
Low
er i
nta
ke
of
pro
tein
-conta
inin
g f
oods
or
subst
ance
s co
mp
ared
to e
stabli
shed
ref
eren
ce s
tan
dar
ds
or
reco
mm
endat
ion
s bas
ed u
pon p
hysi
olo
gic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses,
e.g
., i
ncr
ease
d n
utr
ien
t n
eeds
due
to p
rolo
nged
cat
aboli
c il
lnes
s, m
alab
sorp
tion,
age
or c
on
dit
ion
•L
ack o
f ac
cess
to f
ood,
e.g
., e
con
om
ic c
on
stra
ints
, cu
ltura
l or
reli
gio
us
pra
ctic
es, re
stri
ctin
g f
ood g
iven
to e
lder
ly a
nd/o
r ch
ildre
n
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r dis
ord
ered
eat
ing
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
inati
on F
indin
gs
Die
t H
isto
ryR
eport
or
obse
rvat
ion o
f
•In
suff
icie
nt
inta
ke
of
pro
tein
to m
eet
requir
emen
ts
•C
ult
ura
l or
reli
gio
us
pra
ctic
es t
hat
lim
it p
rote
in i
nta
ke
•E
conom
ic c
on
stra
ints
that
lim
it f
ood a
vai
labil
ity
•P
rolo
nged
adh
eren
ce to a
ver
y lo
w-p
rote
in w
eig
ht
loss
die
t
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciat
ed w
ith a
dia
gn
osi
s or
trea
tmen
t, e
.g., s
ever
e pro
tein
mal
abso
rpti
on s
uch
as
bow
el r
esec
tion
Refe
ren
ce:
1.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r E
ner
gy,
Ca
rbo
hyd
rate
, F
iber
, F
at,
Fa
tty
Aci
ds,
Ch
ole
ster
ol,
Pro
tein
, a
nd
Am
ino
Aci
ds.
Was
hin
gto
n, D
C:
Nat
ion
al A
cad
em
y P
ress
; 2
00
2.
INTA
KE
DO
MA
IN P
rote
in
EX
CE
SS
IVE
PR
OT
EIN
IN
TA
KE
(NI-
52
.2)
Edit
ion:
20
06
77
De
fin
itio
n
Inta
ke
above
the
reco
mm
ended
lev
el o
f pro
tein
com
par
ed t
o e
stab
lish
ed r
efer
ence
sta
ndar
ds
or r
ecom
men
dat
ions
bas
ed u
pon p
hysi
olo
gic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•L
iver
dysf
un
ctio
n
•R
enal
dysf
un
ctio
n
•H
arm
ful
bel
iefs
/att
itu
des
about
food,
nutr
itio
n a
nd n
utr
itio
n-r
elate
d t
opic
s
•L
ack o
f ac
cess
to s
pec
iali
zed p
rote
in p
roduct
s
•M
etab
oli
c ab
norm
alit
y
•F
ood f
add
ism
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•A
lter
ed l
abora
tory
val
ues
e.g
. B
UN
, g
lom
erula
r fi
ltra
tion r
ate
(alt
ered
ren
al s
tatu
s)
Anth
ropom
etri
c M
easu
rem
ents
•G
row
th s
tun
tin
g o
r fa
ilure
bas
ed o
n N
atio
nal
Cen
ter
for
Hea
lth S
stat
isti
cs g
row
th c
har
ts (
met
aboli
c dis
ord
ers)
Phys
ical
Exam
Fin
din
gs
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•H
igh
er t
han
rec
om
men
ded
tota
l pro
tein
inta
ke,
e.g
., e
arly
ren
al
dis
ease
, ad
van
ced l
iver
dis
ease
wit
h c
on
fusi
on
•In
appro
pri
ate
supple
men
tati
on
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t, e
.g., e
arly
ren
al d
isea
se o
r ad
van
ced l
iver
dis
ease
wit
h c
on
fusi
on
INTA
KE
DO
MA
IN P
rote
in
EX
CE
SS
IVE
PR
OT
EIN
IN
TA
KE
(NI-
52
.2)
Edit
ion:
20
06
78
Refe
ren
ces:
1.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Foo
d a
nd n
utr
itio
n m
isin
form
atio
n.J
Am
Die
t A
sso
c. 2
00
2;1
02
:260
-26
6.
2.
Bet
o J
A, B
ansa
l V
K.
Med
ical
nutr
itio
n t
her
apy i
n c
hro
nic
kid
ney
fai
lure
: In
tegra
ting c
linic
al p
ract
ice
guid
elin
es.
J A
m D
iet
Ass
oc.
20
04
;10
4:4
04
-40
9.
3.
Bra
ndle
E, S
ieb
erth
HG
, H
autm
ann R
E.
Eff
ect
of
chro
nic
die
tary
pro
tein
inta
ke
on t
he
renal
fu
nct
ion i
n h
ealt
hy s
ubje
cts.
Eu
r J
Cli
n N
utr
. 1
99
6;5
0:7
34
-74
0.
4.
Fra
sset
to L
A,
Todd K
M,
Morr
is R
C J
r, S
ebast
ian A
. E
stim
atio
n o
f net
endo
gen
ous
no
nca
rbonic
acid
pro
duct
ion i
n h
um
ans
from
die
t, p
ota
ssiu
m a
nd p
rote
in c
onte
nts
.A
m J
Cli
n N
utr
. 1
99
8;6
8:5
76
-
58
3.
5.
Fri
edm
an N
, ed
.A
bso
rpti
on
an
d U
tili
zati
on
of
Am
ino
Aci
ds,
Vo
l. I
. B
oca
Rat
on,
Fla
. C
RC
Pre
ss; 1
98
9:2
29
-24
2.
6.
Hoo
gev
een
EK
, K
ost
ense
PJ,
Jag
er A
, H
ein
e R
J, J
ako
bs
C,
Bo
ute
r L
M,
Do
nk
er A
J, S
teh
ow
er C
D.
Ser
um
ho
mo
cyst
ein
e le
vel
an
d p
rote
in i
nta
ke
are
rela
ted
to
ris
k o
f m
icro
alb
um
inu
ria:
th
e H
oorn
stu
dy.
Kid
ney
Int.
19
98
;54
:20
3-2
09
.
7.
Ru
dm
an
D, D
iFu
lco
TJ,
Gal
amb
os
JT,
Sm
ith
RB
3rd
, S
alam
AA
, W
arre
n W
D. M
axim
um
rat
e o
f ex
cret
ion
an
d s
yn
thes
is o
f u
rea
in n
orm
al a
nd
cir
rho
tic
sub
ject
s.J
Cli
n I
nves
t. 1
97
3;5
2:2
24
1-2
24
9.
INTA
KE
DO
MA
IN P
rote
in
INA
PP
RO
PR
IAT
E I
NT
AK
E O
F A
MIN
O A
CID
S (
SP
EC
IFY
)(N
I-5
2.3
)
Edit
ion:
20
06
79
De
fin
itio
n
Inta
ke
that
is
more
or
less
th
an r
ecom
men
ded
lev
el a
nd/o
r ty
pe
of
amin
o a
cids
com
par
ed t
o e
stab
lish
ed r
efer
ence
sta
ndar
ds
or
reco
mm
endat
ions
bas
ed u
pon
ph
ysio
logic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•L
iver
dysf
un
ctio
n
•R
enal
dysf
un
ctio
n
•H
arm
ful
bel
iefs
/att
itudes
about
food,
nutr
itio
n-
and n
utr
itio
n-r
elat
ed t
opic
s
•M
isuse
d s
pec
iali
zed p
rote
in p
roduct
s
•M
etab
oli
c ab
norm
alit
y
•F
ood f
add
ism
•In
born
err
ors
of
met
aboli
sm
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•A
lter
ed l
abora
tory
val
ues
, e.
g.,
BU
N,
glo
mer
ula
r fi
ltra
tion r
ate
(alt
ered
ren
al s
tatu
s);
incr
ease
d u
rinar
y 3
-met
hyl
-
his
tidin
e
•E
levat
ed s
pec
ific
am
ino a
cid
s (i
nborn
err
ors
of
met
aboli
sm)
•U
rem
ia, az
ote
mia
(re
nal
pat
ients
)
•E
levat
ed h
om
ocy
stei
ne
or
amm
on
ia
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
•P
hys
ical
or
neu
rolo
gic
al c
han
ges
(in
born
err
ors
of
met
aboli
sm)
INTA
KE
DO
MA
IN P
rote
in
INA
PP
RO
PR
IAT
E I
NT
AK
E O
F A
MIN
O A
CID
S (
SP
EC
IFY
)(N
I-5
2.3
)
Edit
ion:
20
06
80
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•H
igh
er t
han
rec
om
men
ded
am
ino a
cid i
nta
ke,
e.g
., e
arly
ren
al d
isea
se,
advan
ced l
iver
dis
ease
, in
born
err
or
of
met
aboli
sm
•H
igh
er t
han
rec
om
men
ded
type
of
amin
o a
cids
for
pre
scri
bed
EN
or
TP
N t
her
apy
•In
appro
pri
ate
supple
men
tati
on, as
for
ath
lete
s
•H
igh
er t
han
rec
om
men
ded
type
of
pro
tein
, e.
g., e
xce
ss p
hen
yla
lan
ine
inta
ke
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t of
illn
ess
that
requir
es E
N o
r T
PN
th
erapy
•H
isto
ry o
f use
of
amin
o a
cids
or
pro
tein
pow
der
s fo
r at
hle
tic
enh
ance
men
t
•H
isto
ry o
f in
born
err
or
of
met
aboli
sm
Refe
ren
ces:
1.
Bet
o J
A, B
ansa
l V
K.
Med
ical
nutr
itio
n t
her
apy i
n c
hro
nic
kid
ney
fai
lure
: In
tegra
ting c
linic
al p
ract
ice
guid
elin
es.
J A
m D
iet
Ass
oc.
20
04
;10
4:4
04
-40
9.
2.
Bra
ndle
E, S
ieb
erth
HG
, H
autm
ann R
E.
Eff
ect
of
chro
nic
die
tary
pro
tein
inta
ke
on t
he
renal
fu
nct
ion i
n h
ealt
hy s
ubje
cts.
Eu
r J
Cli
n N
utr
. 1
99
6;5
0:7
34
-74
0.
3.
Cohn R
M,
Roth
KS
. H
yper
am
monia
, bane
of
the
bra
in.
Cli
n P
edia
tr. 2
00
4;4
3:6
83
-68
9.
4.
Fra
sset
to L
A,
Todd K
M,
Morr
is R
C J
r, S
ebast
ian A
. E
stim
atio
n o
f net
endo
gen
ous
no
nca
rbonic
acid
pro
duct
ion i
n h
um
ans
from
die
t, p
ota
ssiu
m a
nd p
rote
in c
onte
nts
.A
m J
Cli
n N
utr
. 1
99
8;6
8:5
76
-
58
3.
5.
Fri
edm
an N
, ed
.A
bso
rpti
on
an
d U
tili
zati
on
of
Am
ino
Aci
ds,
Vo
l. I
. B
oca
Rat
on,
Fla
:CR
C P
ress
; 1
98
9:2
29
-24
2.
6.
Hoo
gev
een
EK
, K
ost
ense
PJ,
Jag
er A
, H
ein
e R
J, J
ako
bs
C,
Bo
ute
r L
M,
Do
nk
er A
J, S
teh
ow
er C
D.
Ser
um
ho
mo
cyst
ein
e le
vel
an
d p
rote
in i
nta
ke
are
rela
ted
to
ris
k o
f m
icro
alb
um
inu
ria:
th
e H
oorn
stu
dy.
Kid
ney
Int.
19
98
;54
:20
3-2
09
.
7.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Foo
d a
nd n
utr
itio
n m
isin
form
atio
n.J
Am
Die
t A
sso
c. 2
00
2;1
02
:260
-26
6.
8.
Ru
dm
an
D, D
iFu
lco
TJ,
Gal
amb
os
JT,
Sm
ith
RB
3rd
, S
alam
AA
, W
arre
n W
D. M
axim
um
rat
e o
f ex
cret
ion
an
d s
yn
thes
is o
f u
rea
in n
orm
al a
nd
cir
rho
tic
sub
ject
s. J
Cli
n I
nve
st. 1
97
3;5
2:2
24
1-2
24
9.
INTA
KE
DO
MA
IN C
arbohyd
rate
and F
iber
Inta
ke
INA
DE
QU
AT
E C
AR
BO
HY
DR
AT
E IN
TA
KE
(N
I-5
3.1
)
Edit
ion:
20
06
81
De
fin
itio
n
Low
er i
nta
ke
of
carb
oh
ydra
te-c
onta
inin
g f
oods
or
subst
ance
s co
mp
ared
to e
stabli
shed
ref
eren
ce s
tan
dar
ds
or
reco
mm
endat
ions
bas
ed u
pon p
hysi
olo
gic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses,
e.g
., i
ncr
ease
d e
ner
gy n
eeds
due
to i
ncr
ease
d a
ctiv
ity lev
el o
r m
etab
oli
c ch
ange,
mal
abso
rpti
on
•L
ack o
f ac
cess
to f
ood,
e.g
., e
con
om
ic c
on
stra
ints
, cu
ltura
l or
reli
gio
us
pra
ctic
es, re
stri
ctin
g f
ood g
iven
to e
lder
ly a
nd/o
r ch
ildre
n
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r dis
ord
ered
eat
ing
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
inati
on F
indin
gs
•K
etone
smel
l on b
reat
h
Die
t H
isto
ryR
eport
or
obse
rvat
ion o
f:
•C
arboh
ydra
te i
nta
ke
bel
ow
rec
om
men
ded
am
oun
ts
•In
abil
ity t
o i
ndep
enden
tly c
on
sum
e fo
ods/
fluid
s, e
.g., d
imin
ish
ed m
obil
ity in h
and, w
rist
, or
dig
its
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., p
ancr
eati
c in
suff
icie
ncy
, h
epat
ic d
isea
se,
celi
ac d
isea
se,
seiz
ure
dis
ord
er,
carb
oh
ydra
te m
alabso
rpti
on,
or l
ow
-car
boh
ydra
te d
iets
Refe
ren
ce:
1.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r E
ner
gy,
Ca
rbo
hyd
rate
, F
iber
, F
at,
Fa
tty
Aci
ds,
Ch
ole
ster
ol,
Pro
tein
, a
nd
Am
ino
Aci
ds.
Was
hin
gto
n, D
C:
Nat
ion
al A
cad
em
y P
ress
; 2
00
2.
INTA
KE
DO
MA
IN C
arbohyd
rate
and F
iber
Inta
ke
EX
CE
SS
IVE
CA
RB
OH
YD
RA
TE
IN
TA
KE
(N
I-5
3.2
)
Edit
ion:
20
06
82
De
fin
itio
n
Inta
ke
above
the
reco
mm
ended
lev
el a
nd t
ype
of
carb
oh
ydra
te c
om
par
ed t
o e
stab
lish
ed r
efer
ence
sta
ndar
ds
or
reco
mm
endat
ion
s bas
ed u
pon p
hys
iolo
gic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses
requir
ing m
odif
ied c
arboh
ydra
te i
nta
ke,
e.g
., d
iabet
es m
elli
tus,
lact
ase
def
icie
ncy
, su
cras
e-is
om
alta
se d
efic
ien
cy,
aldola
se-B
def
icie
ncy
•C
ult
ura
l or
reli
gio
us
pra
ctic
es t
hat
in
terf
ere
wit
h t
he
abil
ity to r
educe
car
boh
ydra
te i
nta
ke
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledge
defi
cit,
e.g
., i
nab
ilit
y to a
cces
s su
ffic
ien
t in
form
atio
n c
on
cern
ing a
ppro
pri
ate
carb
ohydra
te i
nta
ke
•F
ood a
nd n
utr
itio
n c
om
pli
ance
lim
itat
ion
s, e
.g., l
ack o
f w
illi
ngn
ess
or
fail
ure
to m
odif
y c
arboh
ydra
te i
nta
ke
in r
espon
se to r
ecom
men
dat
ion
s fr
om
a
die
titi
an o
r ph
ysic
ian
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r dis
ord
ered
eat
ing
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•H
yper
gly
cem
ia (
fast
ing b
lood s
ugar
> 1
26 m
g/d
L)
•H
emoglo
bin
A1C
> 6
%
•A
bn
orm
al
ora
l glu
cose
tole
ran
ce t
est
(2-h
our
post
load
glu
cose
> 2
00 m
g/d
L)
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
inati
on F
indin
gs
•D
enta
l ca
ries
•D
iarr
hea
in r
espon
se t
o c
arboh
ydra
te f
eedin
g
INTA
KE
DO
MA
IN C
arbohyd
rate
and F
iber
Inta
ke
EX
CE
SS
IVE
CA
RB
OH
YD
RA
TE
IN
TA
KE
(N
I-5
3.2
)
Edit
ion:
20
06
83
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•C
ult
ura
l or
reli
gio
us
pra
ctic
es t
hat
do n
ot
support
modif
icat
ion o
f die
tary
car
boh
ydra
te i
nta
ke
•E
conom
ic c
on
stra
ints
that
lim
it a
vai
labil
ity o
f ap
pro
pri
ate
foods
•C
arboh
ydra
te i
nta
ke
that
is
con
sist
entl
y a
bove
reco
mm
end
ed a
mounts
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., d
iabet
es m
elli
tus,
inborn
err
ors
of
carb
oh
ydra
te m
etaboli
sm,
lact
ase
def
icie
ncy
, se
ver
e in
fect
ion
, se
psi
s, o
r obes
ity
•C
hro
nic
use
of
med
icat
ion
s th
at c
ause
hyp
ergly
cem
ia,
e.g., s
tero
ids
•P
ancr
eati
c in
suff
icie
ncy
res
ult
ing i
n r
educe
d i
nsu
lin p
roduct
ion
Refe
ren
ces:
1.
Bo
wm
an B
A,
Ru
ssel
l R
M.
Pre
sen
t K
no
wle
dg
e in
Nu
trit
ion
.8
th e
d. W
ash
ing
ton
, D
C: IL
SI
Pre
ss;
20
01
.
2.
Cle
men
t S
, B
rait
hw
aite
SS
, M
agee
MF
, A
hm
an
n A
, S
mit
h E
P, S
chafe
r R
G, H
irsc
h I
B,
Am
eric
an D
iab
etes
Ass
oci
atio
n D
iab
etes
in
Ho
spit
als
Wri
tin
g C
om
mit
tee.
Man
agem
ent
of
dia
bet
es i
n
hosp
itals
.D
iab
etes
Ca
re. 2
00
4;2
7:5
53
-59
2.
3.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r E
ner
gy,
Ca
rbo
hyd
rate
, F
iber
, F
at,
Fa
tty
Aci
ds,
Ch
ole
ster
ol,
Pro
tein
, a
nd
Am
ino
Aci
ds.
Was
hin
gto
n, D
C:
Nat
ion
al A
cad
em
y P
ress
; 2
00
2.
4.
The
Exp
ert
Co
mm
itte
e on t
he
Dia
gn
osi
s and C
lass
ific
atio
n o
f D
iab
etes
Mel
litu
s. D
iagno
sis
and c
lass
ific
atio
n o
f dia
bet
es m
elli
tus.
Dia
bet
es C
are
. 2
00
4;2
7:S
5-S
10
.
INTA
KE
DO
MA
IN C
arbohyd
rate
and F
iber
Inta
ke
INA
PP
RO
PR
IAT
E I
NT
AK
E O
F T
YP
ES
OF
CA
RB
OH
YD
RA
TE
S (
SP
EC
IFY
) (N
I-5
3.3
)
Edit
ion:
20
06
84
De
fin
itio
n
Inta
ke
or t
he
type
or
amount
of
carb
oh
ydra
te t
hat
is
above
or
bel
ow
th
e es
tabli
shed
ref
eren
ce s
tandar
ds
or
reco
mm
endat
ion
s bas
ed u
pon p
hysi
olo
gic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses
requir
ing c
aref
ul
use
of
modif
ied c
arboh
ydra
te,
e.g., d
iabet
es m
elli
tus,
met
aboli
c sy
ndro
me,
hyp
ogly
cem
ia,
celi
ac d
isea
se, al
lerg
ies,
obes
ity
•C
ult
ura
l or
reli
gio
us
pra
ctic
es t
hat
in
terf
ere
wit
h t
he
abil
ity to r
egula
te t
yp
es o
f ca
rboh
ydra
te c
on
sum
ed
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledge
defi
cit,
e.g
., i
nab
ilit
y to a
cces
s su
ffic
ien
t in
form
atio
n c
on
cern
ing m
ore
ap
pro
pri
ate
carb
oh
ydra
te t
ypes
an
d/o
r
amoun
ts
•F
ood a
nd n
utr
itio
n c
om
pli
ance
lim
itat
ion
s, e
.g., l
ack o
f w
illi
ngn
ess
or
fail
ure
to m
odif
y c
arboh
ydra
te i
nta
ke
in r
espon
se to r
ecom
men
dat
ion
s fr
om
a
die
titi
an, ph
ysic
ian
, or
care
giv
er
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r dis
ord
ered
eat
ing
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•H
yp
ogly
cem
ia o
r h
yper
gly
cem
ia d
ocu
men
ted o
n r
egula
r bas
is w
hen
com
par
ed w
ith g
oal
of
mai
nta
inin
g g
luco
se
level
s at
or
bel
ow
140 m
g/d
L t
hro
ughout
the
day
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
inati
on F
indin
gs
INTA
KE
DO
MA
IN C
arbohyd
rate
and F
iber
Inta
ke
INA
PP
RO
PR
IAT
E I
NT
AK
E O
F T
YP
ES
OF
CA
RB
OH
YD
RA
TE
S (
SP
EC
IFY
) (N
I-5
3.3
)
Edit
ion:
20
06
85
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•D
iarr
hea
in r
espon
se t
o h
igh r
efin
ed c
arboh
ydra
te i
nta
ke
•E
conom
ic c
on
stra
ints
that
lim
it a
vai
labil
ity o
f ap
pro
pri
ate
foods
•C
arboh
ydra
te i
nta
ke
that
is
dif
fere
nt
from
rec
om
men
ded
types
•A
ller
gic
rea
ctio
ns
to c
erta
in c
arboh
ydra
te f
oods
or
food g
roups
•L
imit
ed k
now
ledge
of
carb
oh
ydra
te c
om
posi
tion o
f fo
ods
or
of
carb
oh
ydra
te m
etaboli
sm
Cli
ent
His
tory
•C
ondit
ion
s as
soci
ate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., d
iabet
es m
elli
tus,
obes
ity,
met
aboli
c sy
ndro
me,
hyp
ogly
cem
ia
•C
hro
nic
use
of
med
icati
on
s th
at c
ause
alt
ered
glu
cose
level
s, e
.g., s
tero
ids,
anti
dep
ress
ants
, an
tip
sych
oti
cs
Refe
ren
ces:
1.
Bo
wm
an B
A,
Ru
ssel
l R
M.
Pre
sen
t K
no
wle
dg
e in
Nu
trit
ion
. 8
th e
d. W
ash
ing
ton
, D
C: IL
SI
Pre
ss,
20
01
.
2.
Cle
men
t S
, B
rait
hw
aite
SS
, M
agee
MF
, A
hm
an
n A
, S
mit
h E
P, S
chafe
r R
G, H
irsc
h I
B,
Am
eric
an D
iab
etes
Ass
oci
atio
n D
iab
etes
in
Ho
spit
als
Wri
tin
g C
om
mit
tee.
Man
agem
ent
of
dia
bet
es i
n
hosp
itals
.D
iab
etes
Ca
re. 2
00
4;2
7:5
53
-59
2.
3.
Fra
nz
MJ,
Ban
tle
JP, B
eeb
e C
A,
Bru
nze
ll J
D,
Chia
sso
n J
-L,
Gar
g A
, H
olz
mei
ster
LA
, H
oo
gw
erf
B,
May
er-D
avis
E,
Mo
ora
dia
n A
D,
Pu
rnel
l JQ
, W
hee
ler
M: T
ech
nic
al r
evie
w. E
vid
ence
-base
d
nutr
itio
n p
rinci
ple
s an
d r
ecom
men
dat
ions
for
the
trea
tmen
t an
d p
reven
tion o
f dia
bet
es a
nd r
elat
ed c
om
pli
cati
ons.
Dia
bet
es C
are
20
02
;20
2:1
48
-19
8.
4.
Sh
eard
NF
, C
lark
NG
, B
ran
d-M
ille
r JC
, F
ran
z M
J, P
i-S
un
yer
FX
, M
ayer
-Dav
is E
, K
ulk
arn
i K
, G
eil
P.
A s
tate
men
t b
y t
he
Am
eric
an D
iab
etes
Ass
oci
atio
n. D
ieta
ry c
arbo
hy
dra
te (
amou
nt
and
ty
pe)
in t
he
pre
ven
tio
n a
nd m
anag
em
ent
of
dia
bet
es.D
iab
etes
Ca
r.e
20
04
;27
:22
66
-22
71
.
5.
Gro
ss L
S,
Li
L, F
ord
ES
, L
iu S
. In
crea
sed
con
sum
pti
on
of
refi
ned
car
boh
yd
rate
s and
epid
emic
or
typ
e 2
dia
bet
es i
n t
he
Un
ited
Sta
tes:
an
eco
log
ic a
sses
smen
t.A
m J
Cli
n N
utr
20
04
;79
:77
4-7
79
.
6.
Fre
nch S
, L
in B
-H,
Guth
erie
JF
. N
atio
nal
tre
nds
in s
oft
dri
nk c
on
sum
pti
on a
mon
g c
hil
dre
n a
nd a
dole
scen
ts a
ge
6 t
o17 y
ears
: p
revale
nce,
am
ounts
, an
d s
ourc
es,
19
77
/19
78 t
o 1
994
/19
98.J
Am
Die
t
Ass
oc
20
03
.10
3L
13
26
-13
31
,
7.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r E
ner
gy,
Ca
rbo
hyd
rate
, F
iber
, F
at,
Fa
tty
Aci
ds,
Ch
ole
ster
ol,
Pro
tein
, a
nd
Am
ino
Aci
ds.
Was
hin
gto
n, D
C:
Nat
ion
al A
cad
em
y P
ress
; 2
00
2.
8.
Tef
f K
L,
Ell
iott
SS
, T
sch
öp
M,
Kie
ffer
TJ,
Rad
er D
, H
eim
an M
, T
ow
nse
nd
RR
, K
eim
NL
, D
’Ale
ssio
D,
Hav
el P
J. D
ieta
ry f
ruct
ose
red
uce
s ci
rcu
lati
ng
in
suli
n a
nd
lep
tin,
atte
nu
ates
po
stp
ran
dia
l
sup
pre
ssio
n o
f ghre
lin
, an
d i
ncr
ease
s tr
igly
ceri
des
in w
om
en.J
Cli
n E
nd
ocr
ino
l M
eta
.b2
00
4;8
9:2
96
3-2
97
2.
9.
The
Exp
ert
Co
mm
itte
e on t
he
Dia
gn
osi
s and C
lass
ific
atio
n o
f D
iab
etes
Mel
litu
s. D
iagno
sis
and c
lass
ific
atio
n o
f dia
bet
es m
elli
tus.
Dia
bet
es C
are
. 2
00
4;2
7:p
S5
-pS
10
.
INTA
KE
DO
MA
IN C
arbohyd
rate
and F
iber
Inta
ke
INC
ON
SIS
TE
NT
CA
RB
OH
YD
RA
TE
IN
TA
KE
(N
I-5
3.4
)
Edit
ion:
20
06
86
De
fin
itio
n
Inco
nsi
sten
t ti
min
g o
f ca
rboh
ydra
te i
nta
ke
thro
ughout
the
day
, day-
to-d
ay,
or
a pat
tern
of
carb
oh
ydra
te i
nta
ke
that
is
not
con
sist
ent
wit
h r
ecom
men
ded
pat
tern
bas
ed u
pon p
hys
iolo
gic
or
med
icat
ion n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses
requir
ing c
aref
ul
tim
ing a
nd c
on
sist
ency
in t
he
amount
of
carb
oh
ydra
te, e.
g., d
iabet
es m
elli
tus,
hyp
ogly
cem
ia
•C
ult
ura
l, r
elig
ious
pra
ctic
es,
or
life
styl
e fa
ctors
th
at i
nte
rfer
e w
ith t
he
abil
ity to r
egula
te t
imin
g o
f ca
rboh
ydra
te c
on
sum
pti
on
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledge
defi
cit,
e.g
., i
nab
ilit
y to a
cces
s su
ffic
ien
t in
form
atio
n c
on
cern
ing m
ore
ap
pro
pri
ate
tim
ing o
f ca
rboh
ydra
te i
nta
ke
•F
ood a
nd n
utr
itio
n c
om
pli
ance
lim
itat
ion
s, e
.g., l
ack o
f w
illi
ngn
ess
or
fail
ure
to m
odif
y c
arboh
ydra
te t
imin
g i
n r
espon
se to r
ecom
men
dat
ion
s fr
om
a
die
titi
an,
ph
ysic
ian
, or
care
giv
er
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r dis
ord
ered
eat
ing
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nu
trit
ion
Assessm
en
t C
ate
go
ry
Po
ten
tial In
dic
ato
rs o
f th
is N
utr
itio
n D
iag
no
sis
(o
ne o
r m
ore
mu
st
be p
resen
t)
Bio
chem
ical
Data
•H
yp
ogly
cem
ia o
r hyper
gly
cem
ia d
ocu
men
ted o
n r
egula
r bas
is a
ssoci
ate
d w
ith i
nco
nsi
sten
t ca
rboh
ydra
te i
nta
ke
•W
ide
var
iati
on
s in
blo
od g
luco
se l
evel
s
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
inati
on F
indin
gs
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•E
conom
ic c
on
stra
ints
that
lim
it a
vai
labil
ity o
f ap
pro
pri
ate
foods
•C
arboh
ydra
te i
nta
ke
that
is
dif
fere
nt
from
rec
om
men
ded
types
or
inges
ted o
n a
n i
rreg
ula
r bas
is
INTA
KE
DO
MA
IN C
arbohyd
rate
and F
iber
Inta
ke
INC
ON
SIS
TE
NT
CA
RB
OH
YD
RA
TE
IN
TA
KE
(N
I-5
3.4
)
Edit
ion:
20
06
87
Cli
ent
His
tory
•C
ondit
ion
s as
soci
ate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., d
iabet
es m
elli
tus,
obes
ity,
met
aboli
c sy
ndro
me,
hyp
ogly
cem
ia
•U
se o
f in
suli
n o
r in
suli
n s
ecre
tagogues
•C
hro
nic
use
of
med
icati
on
s th
at c
ause
alt
ered
glu
cose
level
s, e
.g., s
tero
ids,
anti
dep
ress
ants
, an
tip
sych
oti
cs
Refe
ren
ces:
1.
Bo
wm
an B
A,
Ru
ssel
l R
M.
Pre
sen
t K
no
wle
dg
e in
Nu
trit
ion
.8
th e
d. W
ash
ing
ton, D
C: IL
SI
Pre
ss;2
00
1.
2.
Cle
men
t S
, B
rait
hw
aite
SS
, M
agee
MF
, A
hm
an
n A
, S
mit
h E
P, S
chafe
r R
G, H
irsc
h I
B,
Am
eric
an D
iab
etes
Ass
oci
atio
n D
iab
etes
in
Ho
spit
als
Wri
tin
g C
om
mit
tee.
Man
agem
ent
of
dia
bet
es i
n
hosp
itals
.D
iab
etes
Ca
re. 2
00
4;2
7:5
53
-59
2.
3.
Cry
er P
E,
Dav
is S
N,
Sham
oon H
. T
echnic
al r
evie
w.
Hypogly
cem
ia i
n d
iabete
s.D
iab
etes
Ca
re.2
00
3;2
6:1
90
2-1
91
2.
4.
Fra
nz
MJ,
Ban
tle
JP, B
eeb
e C
A,
Bru
nze
ll J
D,
Chia
sso
n J
-L,
Gar
g A
, H
olz
mei
ster
LA
, H
oo
gw
erf
B,
May
er-D
avis
E,
Mo
ora
dia
n A
D,
Pu
rnel
l JQ
, W
hee
ler
M.
Tec
hn
ical
rev
iew
. E
vid
ence
-base
d
nutr
itio
n p
rinci
ple
s an
d r
ecom
men
dat
ions
for
the
trea
tmen
t an
d p
reven
tion o
f dia
bet
es a
nd r
elat
ed c
om
pli
cati
ons.
Dia
bet
es C
are
.2
00
2;2
02
:14
8-1
98
.
5.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r E
ner
gy,
Ca
rbo
hyd
rate
, F
iber
, F
at,
Fa
tty
Aci
ds,
Ch
ole
ster
ol,
Pro
tein
, a
nd
Am
ino
Aci
ds.
Was
hin
gto
n, D
C:
Nat
ion
al A
cad
em
y P
ress
; 2
00
2.
6.
Rab
asa-L
hore
t R
, G
aron J
, L
angel
ier
H,
Pois
son D
, C
hia
sson J
-L:
The
effe
cts
of
mea
l ca
rboh
ydra
te c
onte
nt
on i
nsu
lin r
equir
emen
ts i
n t
yp
e 1 p
atie
nts
wit
h d
iabet
es t
reat
ed i
nte
nsi
vel
y w
ith t
he
bas
al b
olu
s (u
ltra
lente
-reg
ula
r) i
nsu
lin r
egim
en.D
iab
etes
Ca
re1
99
9;2
2:6
67-6
73
.
7.
Sav
oca
MR
, M
ille
r C
K,
Lu
dw
ig D
A.
Foo
d h
abit
s ar
e re
late
d t
o g
lyce
mic
co
ntr
ol
am
on
g p
eop
le w
ith
ty
pe
2 d
iab
etes
mel
litu
s.J
Am
Die
t A
sso
c.2
00
4;1
04
:56
0-5
66
.
8.
The
Exp
ert
Co
mm
itte
e on t
he
Dia
gn
osi
s and C
lass
ific
atio
n o
f D
iab
etes
Mel
litu
s. D
iagno
sis
and c
lass
ific
atio
n o
f dia
bet
es m
elli
tus.
Dia
bet
es C
are
. 2
00
4;2
7:S
5-S
10
.
9.
Wole
ver
TM
S, H
am
ad S
, C
hia
sson
J-L
, Jo
sse
RG
, L
eite
r L
A,
Ro
dg
er N
W,
Ro
ss S
A,
Ryan
EA
. D
ay
-to
-day
con
sist
ency
in
am
ou
nt
and
sou
rce
of
carb
oh
ydra
te i
nta
ke
ass
oci
ated
wit
h i
mpro
ved
glu
cose
contr
ol
in t
yp
e 1 d
iabet
es.
J A
m C
oll
Nu
tr.1
99
9;1
8:2
42
-24
7.
INTA
KE
DO
MA
IN C
arbohyd
rate
and F
iber
Inta
ke
INA
DE
QU
AT
E F
IBE
R I
NT
AK
E (
NI-
53
.5)
Edit
ion:
20
06
88
De
fin
itio
n
Low
er i
nta
ke
of
fiber
-con
tain
ing f
oods
or
subst
ance
s co
mp
ared
to e
stabli
shed
ref
eren
ce s
tand
ards
or
reco
mm
endat
ion
s bas
ed u
pon p
hys
iolo
gic
al
nee
ds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•L
ack o
f ac
ces
s to
fib
er-c
onta
inin
g f
oods
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r dis
ord
ered
eat
ing
•P
rolo
nged
adh
eren
ce to a
low
-fib
er o
r lo
w-r
esid
ue
die
t
•D
iffi
cult
y c
hew
ing o
r sw
allo
win
g h
igh-f
iber
foods
•E
conom
ic c
on
stra
ints
that
lim
it a
vai
labil
ity o
f ap
pro
pri
ate
foods
•In
abil
ity o
r un
wil
lingn
ess
to p
urc
hase
or
con
sum
e fi
ber
-con
tain
ing f
oods
•In
appro
pri
ate
food p
repar
atio
n p
ract
ices
, e.
g., r
elia
nce
on o
ver
pro
cess
ed,
over
cooked
foods
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
inati
on F
indin
gs
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•In
suff
icie
nt
inta
ke
of
fib
er w
hen
com
par
ed t
o r
ecom
men
ded
am
oun
ts (
38 g
/day
for
men
an
d 2
5 g
/day
for
wom
en;
21
g/d
for
wom
en >
50 y
ears
an
d 3
1 g
/d f
or
men
>5
0 y
ears
)
INTA
KE
DO
MA
IN C
arbohyd
rate
and F
iber
Inta
ke
INA
DE
QU
AT
E F
IBE
R I
NT
AK
E (
NI-
53
.5)
Edit
ion:
20
06
89
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., u
lcer
dis
ease
, in
flam
mat
ory
bow
el d
isea
se,
or
shor
t bow
el
syn
dro
me
trea
ted w
ith a
low
-fib
er d
iet
•L
ow
sto
ol
volu
me
Refe
ren
ces:
1.
DiP
alm
a JA
. C
urr
ent
trea
tmen
t opti
on
s fo
r ch
ronic
const
ipat
ion.
Rev
Ga
stro
ente
rol
Dis
ord
. 2
00
4;2
:S3
4-S
42
.
2.
Hig
gin
s P
D, Jo
hanso
n J
F.
Epid
emio
logy o
f co
nst
ipat
ion i
n N
ort
h A
mer
ica:
a s
yst
emat
ic r
evie
w.
Am
J G
ast
roen
tero
l. 2
00
4;9
9:7
50
-75
9.
3.
Lem
bo
A,
Cam
ilie
ri M
. C
hro
nic
co
nst
ipat
ion
.N
ew
En
gl
J M
ed. 2
00
3;3
49
:36
0-3
68
.
4.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r E
ner
gy,
Ca
rbo
hyd
rate
, F
iber
, F
at,
Fa
tty
Aci
ds,
Ch
ole
ster
ol,
Pro
tein
, a
nd
Am
ino
Aci
ds.
Wash
ingto
n, D
C:
Nat
ion
al A
cad
em
y P
ress
; 2
00
2.
5.
Tal
ley N
J. D
efin
itio
n,
epid
em
iolo
gy,
and i
mpact
of
chro
nic
co
nst
ipat
ion.
Rev
Ga
stro
ente
rol
Dis
ord
. 2
00
4;2
:S3
-S1
0.
INTA
KE
DO
MA
IN C
arbohyd
rate
and F
iber
Inta
ke
EX
CE
SS
IVE
FIB
ER
IN
TA
KE
(N
I-5
3.6
)
Edit
ion:
20
06
90
De
fin
itio
n
Hig
her
inta
ke
of
fiber
-con
tain
ing f
oods
or
subst
ance
s co
mp
ared
to r
ecom
men
dat
ion
s bas
ed u
pon p
atie
nt/
clie
nt
con
dit
ion
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledge
defi
cit
about
des
irable
quan
titi
es o
f fi
ber
for
indiv
idual
con
dit
ion
•H
arm
ful
bel
iefs
or
atti
tudes
about
food o
r n
utr
itio
n-r
elat
ed t
opic
s, e
.g., o
bse
ssio
n w
ith b
ow
el f
requen
cy a
nd h
abit
s
•L
ack o
f kn
ow
ledg
e ab
out
appro
pri
ate
fiber
inta
ke
for
con
dit
ion
•P
oor
den
titi
on,
GI
stri
cture
or
dys
moti
lity
•F
ood p
repar
atio
n o
r ea
ting p
atte
rns
that
in
volv
e only
hig
h-f
iber
foods
to t
he
excl
usi
on o
f oth
er n
utr
ien
t-den
se f
oods
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
inati
on F
indin
gs
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•F
iber
inta
ke
hig
her
than
tole
rate
d o
r gen
eral
ly r
ecom
men
ded
for
curr
ent
med
ical
con
dit
ion
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t, e
.g., u
lcer
dis
ease
, ir
rita
ble
bow
el s
yndro
me,
in
flam
mato
ry b
ow
el
dis
ease
, sh
ort
bow
el s
yndro
me,
div
erti
culi
tis,
obst
ruct
ive
con
stip
atio
n, pro
lapsi
ng h
emorr
hoid
s, g
astr
oin
test
inal
stri
cture
, ea
ting d
isord
ers,
or
men
tal
illn
ess
wit
h o
bse
ssiv
e-co
mpuls
ive
ten
den
cies
•N
ause
a, v
om
itin
g,
exce
ssiv
e fl
atu
len
ce,
dia
rrh
ea,
abdom
inal cr
ampin
g, h
igh s
tool
volu
me
or
freq
uen
cy that
cause
s
dis
com
fort
to t
he
indiv
idual
, obst
ruct
ion
, ph
yto
bez
oar
INTA
KE
DO
MA
IN C
arbohyd
rate
and F
iber
Inta
ke
EX
CE
SS
IVE
FIB
ER
IN
TA
KE
(N
I-5
3.6
)
Edit
ion:
20
06
91
Refe
ren
ces:
1.
DiP
alm
a JA
. C
urr
ent
trea
tmen
t opti
on
s fo
r ch
ronic
const
ipat
ion.
Rev
Ga
stro
ente
rol
Dis
ord
. 2
00
4;2
:S3
4-S
42
.
2.
Hig
gin
s P
D, Jo
hanso
n J
F.
Epid
emio
logy o
f co
nst
ipat
ion i
n N
ort
h A
mer
ica:
a s
yst
emat
ic r
evie
w.
Am
J G
ast
roen
tero
l. 2
00
4;9
9:7
50
-75
9.
3.
Lem
bo
A,
Cam
ilie
ri M
. C
hro
nic
co
nst
ipat
ion
.N
ew
En
gl
J M
ed. 2
00
3;3
49
:36
0-3
68
.
4.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r E
ner
gy,
Ca
rbo
hyd
rate
, F
iber
, F
at,
Fa
tty
Aci
ds,
Ch
ole
ster
ol,
Pro
tein
, a
nd
Am
ino
Aci
ds.
Was
hin
gto
n, D
C:
Nat
ion
al A
cad
em
y P
ress
; 2
00
2.
5.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Hea
lth i
mpli
cati
on
s of
die
tary
fib
er.
J A
m D
iet
Ass
oc.
20
02
;10
2:9
93
-10
00
.
6.
Tal
ley N
J. D
efin
itio
n,
epid
em
iolo
gy,
and i
mpact
of
chro
nic
co
nst
ipat
ion.
Rev
Ga
stro
ente
rol
Dis
ord
. 2
00
4;2
:S3
-S1
0.
7.
van
den B
erg H
, van d
er G
aag
M, H
endri
ks
H. In
flu
ence
of
life
style
on v
itam
in b
ioav
ail
abil
ity.In
t J
Vit
am
Nu
tr R
es. 2
00
2;7
2:5
3-5
5.
8.
Wal
d A
. Ir
rita
ble
bow
el s
yndro
me.
Cu
rr T
rea
t O
pti
on
s G
ast
roen
tero
l. 1
99
9;2
:13
-19
.
INTA
KE
DO
MA
IN V
itam
in In
take
INA
DE
QU
AT
E V
ITA
MIN
IN
TA
KE
(SP
EC
IFY
)(N
I-5
4.1
)
Edit
ion:
20
06
92
De
fin
itio
n
Low
er i
nta
ke
of
vit
am
in-c
onta
inin
g f
oods
or
subst
ance
s co
mp
ared
to e
stabli
shed
ref
eren
ce s
tan
dar
ds
or
reco
mm
endat
ion
s bas
ed u
pon p
hysi
olo
gic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses,
e.g
., i
ncr
ease
d n
utr
ien
t n
eeds
due
to p
rolo
nged
cat
aboli
c il
lnes
s, d
isea
se s
tate
, m
alab
sorp
tion,
or
med
icat
ion
s
•L
ack o
f ac
cess
to f
ood,
e.g
., e
con
om
ic c
on
stra
ints
, cu
ltura
l or
reli
gio
us
pra
ctic
es, re
stri
ctin
g f
ood g
iven
to e
lder
ly a
nd/o
r ch
ildre
n
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
con
cern
ing f
ood s
ourc
es o
f vit
am
ins
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r ea
ting d
isord
ers
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
INTA
KE
DO
MA
IN V
itam
in In
take
INA
DE
QU
AT
E V
ITA
MIN
IN
TA
KE
(SP
EC
IFY
)(N
I-5
4.1
)
Edit
ion:
20
06
93
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)*
Bio
chem
ical
Data
•V
itam
in A
: se
rum
ret
inol:
<
10
g/d
L (
0.3
5
mol/
L)
•V
itam
in C
: p
lasm
a co
nce
ntr
atio
ns
< 0
.2 m
g/d
L (
11.4
m
ol/
L)
•V
itam
in D
: io
niz
ed c
alci
um
< 3
.9 m
g/d
L (
0.9
8 m
mol/
L)
wit
h e
levat
ed p
arat
hyr
oid
horm
on
e, n
orm
al s
erum
cal
cium
, an
d
seru
m p
hosp
hor
us
< 2
.6 m
g/d
L (
0.8
4 m
mol/
L)
•V
itam
in E
: pla
sma
alpha-
toco
pher
ol
< 1
8
mol/
g (
41.8
m
ol/
L)
•V
itam
in K
: el
evat
ed p
roth
rom
bin
tim
e; a
lter
ed I
NR
(w
ith
out
anti
-coag
ula
tion t
her
apy)
•T
hia
min
: er
yth
rocy
te t
ran
sket
ola
se a
ctiv
ity >
1.2
0 µ
g/m
L/h
•R
ibo
flavin
– e
ryth
rocy
te g
luta
thio
ne
reduct
ase
> 1
.2 I
U/g
m h
emoglo
bin
•N
iaci
n:
N’m
ethyl-
nic
oti
nam
ide
excr
etio
n <
5.8
µm
ol/
day
•V
itam
in B
6:
pla
sma
pry
rdoxal
5’p
hosp
hat
e <
5 n
g/m
L (
20 n
mol/
L)
•V
itam
in B
12:
seru
m c
on
centr
atio
n <
24.4
ng/d
L (
180 p
mol/
L);
ele
vat
ed h
om
ocy
stei
ne
•F
oli
c ac
id:
seru
m c
on
centr
atio
n <
0.3
g/d
L (
7 n
mol/
L);
red
cel
l fo
late
< 3
15 n
mol/
L
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
•V
itam
in A
: nig
ht
bli
ndn
ess,
Bit
ot’
s sp
ots
, xer
opth
alm
ia,
foll
icula
r h
yper
ker
atosi
s
•V
itam
in C
: fo
llic
ula
r h
yper
ker
atosi
s, p
etic
hia
e, e
cch
ymosi
s, c
oil
ed h
airs
, in
flam
ed a
nd b
leed
ing g
um
s, p
erif
oli
cula
r
hem
orr
hag
es,
join
t ef
fusi
ons,
art
hra
lgia
, an
d i
mpai
red w
oun
d h
eali
ng
•V
itam
in D
: w
iden
ing a
t en
ds
of
lon
g b
on
es, ra
chit
ic r
osa
ry i
n c
hil
dre
n,
rick
ets,
ost
eom
ala
cia
•R
ibofl
avin
: so
re t
hro
at, h
yper
emia
, ed
ema
of
phar
yngea
l an
d o
ral
mu
cous
mem
bra
nes
, ch
eilo
sis,
angula
r st
om
ati
tis,
glo
ssit
is, se
borr
hei
c der
mat
itis
, an
d n
orm
och
rom
ic, n
orm
ocy
tic
anem
ia w
ith p
ure
ery
thro
cyte
cyto
pla
sia
of
the
bon
e
mar
row
•N
iaci
n:
sym
met
rica
l, p
igm
ente
d r
ash o
n a
reas
expose
d t
o s
unli
ght,
bri
gh
t re
d t
on
gue,
pel
lagra
•V
itam
in B
6:
seborr
hei
c der
mat
itis
, st
om
atit
is,
chei
losi
s, g
loss
itis
, co
nfu
sion
, dep
ress
ion
•V
itam
in B
12:
tingli
ng a
nd n
um
bn
ess
in e
xtr
emit
ies,
dim
inis
hed
vib
rato
ry a
nd p
osi
tion s
ense
, m
oto
r dis
turb
ance
s in
cludin
g
gait
dis
turb
ance
s
* T
o c
onver
t co
nv
enti
onal
unit
s to
le S
yste
me
Inte
rna
tio
na
le d
'Un
ites
(S
I),
Jays
Cli
nic
al
Ser
vic
es,
Cli
nic
al L
ab
ora
tory
So
ftw
are
and
Co
nsu
ltin
g w
eb
sit
e u
sed
. W
eb
sit
e a
ddre
ss:
htt
p:/
/dw
jay.t
ripod.c
om
/conv
ersi
on
.htm
l .
Acc
esse
d A
ugust
12,
200
5.
See
Young D
S (
Refe
rence
#5
) fo
r pri
nte
d f
act
or
conv
ersi
on
s.
INTA
KE
DO
MA
IN V
itam
in In
take
INA
DE
QU
AT
E V
ITA
MIN
IN
TA
KE
(SP
EC
IFY
)(N
I-5
4.1
)
Edit
ion:
20
06
94
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•D
ieta
ry h
isto
ry r
efle
cts
inadeq
uat
e in
take
of
foods
con
tain
ing s
pec
ific
vit
amin
s as
com
par
ed t
o r
equir
emen
ts o
r
reco
mm
ended
lev
el
•D
ieta
ry h
isto
ry r
efle
cts
exce
ssiv
e co
nsu
mp
tion o
f fo
ods
that do n
ot
conta
in a
vai
lable
vit
amin
s, e
.g., o
ver
pro
cess
ed,
over
cooked
, or
impro
per
ly s
tore
d f
oods
Cli
ent
His
tory
•P
rolo
nged
use
of
subst
ance
s know
n t
o i
ncr
ease
vit
amin
req
uir
emen
ts o
r re
duce
vit
am
in a
bso
rpti
on
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t, e
.g., m
alab
sorp
tion a
s a
resu
lt o
f ce
liac
dis
ease
, sh
ort
bow
el s
yndro
me,
or
infl
amm
atory
bow
el
•C
erta
in e
nvir
onm
enta
l co
ndit
ion
s, e
.g., i
nfa
nts
excl
usi
vel
y f
ed b
reas
t m
ilk w
ith l
imit
ed e
xposu
re t
o s
un
light
(vit
amin
D)
Refe
ren
ces:
1.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r V
ita
min
A,
Vit
am
in K
, A
rsen
ic, B
oro
n, C
hro
miu
m, C
op
per
, Io
din
e, I
ron
, M
an
ga
nes
e, M
oly
bd
enu
m, N
icke
l,
Sil
ico
n,
Va
na
diu
m, a
nd
Zin
c. W
ashin
gto
n, D
C:
Nat
ional
Aca
dem
y P
ress
; 2
00
0.
2.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r T
hia
min
e, R
ibo
fla
vin
, N
iaci
n,
Vit
am
in B
6,
Fo
late
, V
ita
min
B1
2,
Pa
nto
then
ic A
cid
, B
ioti
n, a
nd
Ch
oli
ne
Was
hin
gto
n,
DC
: N
atio
nal
Aca
dem
y P
ress
; 2
00
0.
3.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r V
ita
min
C,
Vit
am
in E
, S
elen
ium
, a
nd
Ca
rote
no
ids.
Was
hin
gto
n,
DC
: N
atio
nal
Aca
dem
y P
ress
; 2
00
0.
4.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
Inta
kes
for
Ca
lciu
m,
Ph
osp
ho
rus,
Ma
gn
esiu
m, V
ita
min
D, a
nd
Flu
ori
de. W
ash
ing
ton
, D
C:
Nat
ional
Aca
dem
y P
ress
; 1
99
7.
5.
Youn
g D
S. Im
ple
men
tati
on o
f S
I unit
s fo
r cl
inic
al l
abora
tory
dat
a,
style
sp
ecif
icat
ion
s and c
onver
sio
n t
able
s.A
nn
In
tern
Med
. 1
98
7;1
06
:11
4-2
9. R
epri
nte
d,J
Nu
tr. 1
99
0;1
20
:20
-35
.
INTA
KE
DO
MA
IN V
itam
in In
take
EX
CE
SS
IVE
VIT
AM
IN I
NT
AK
E(S
PE
CIF
Y)
(NI-
54
.2)
Edit
ion:
20
06
95
De
fin
itio
n
Hig
her
inta
ke
of
vit
am
in-c
onta
inin
g f
oods
or
subst
ance
s co
mp
ared
to e
stabli
shed
ref
eren
ce s
tan
dar
ds
or
reco
mm
endat
ion
s bas
ed u
pon p
hysi
olo
gic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses,
e.g
., d
ecre
ased
nutr
ien
t n
eeds
due
to p
rolo
nged
im
mobil
ity o
r ch
ronic
ren
al d
isea
se
•A
cces
s to
foods
and s
upple
men
ts i
n e
xce
ss o
f n
eeds,
e.g
., c
ult
ura
l or
rel
igio
us
pra
ctic
es,
inap
pro
pri
ate
food a
nd s
upple
men
ts g
iven
to p
regnan
t w
om
en,
elder
ly o
r ch
ildre
n
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledge
defi
cit
con
cern
ing f
ood a
nd s
upple
men
tal
sourc
es o
f vit
am
ins
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r ea
ting d
isord
ers
•A
ccid
enta
l over
dose
fro
m o
ral
and s
upple
men
tal
form
s, e
nte
ral
or
par
ente
ral
sourc
es
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)*
Bio
chem
ical
Data
•V
itam
in D
: io
niz
ed c
alci
um
> 5
.4 m
g/d
L (
1.3
5 m
mol/
L)
wit
h e
levat
ed p
arat
hyr
oid
horm
on
e, n
orm
al s
erum
cal
cium
, an
d
seru
m p
hosp
hor
us
> 2
.6 m
g/d
L (
0.8
4 m
mol/
L)
•V
itam
in K
: sl
ow
ed p
roth
rom
bin
tim
e or
alt
ered
IN
R
•N
iaci
n:
N-m
ethyl
nic
oti
nam
ide
excr
etio
n >
5.8
µm
ol/
day
•V
itam
in B
6:
pla
sma
pyr
idoxal
5’p
hosp
hat
e >
5 ng/m
L (
20 n
mol/
L)
•V
itam
in A
: se
rum
ret
inol
con
cen
trat
ion >
60 µ
g/d
L (
2.0
9µ
mol/
L)
Anth
ropom
etri
c M
easu
rem
ents
* T
o c
onver
t co
nv
enti
onal
unit
s to
le S
yste
me
Inte
rna
tio
na
le d
'Un
ites
(S
I),
Jays
Cli
nic
al
Ser
vic
es,
Cli
nic
al L
ab
ora
tory
So
ftw
are
and
Co
nsu
ltin
g w
eb
sit
e u
sed
. W
eb
sit
e a
ddre
ss:
htt
p:/
/dw
jay.t
ripod.c
om
/conv
ersi
on
.htm
l .
Acc
esse
d A
ugust
12,
200
5.
See
Young D
S (
Refe
rence
#8
) fo
r pri
nte
d f
act
or
conv
ersi
on
s.
INTA
KE
DO
MA
IN V
itam
in In
take
EX
CE
SS
IVE
VIT
AM
IN I
NT
AK
E(S
PE
CIF
Y)
(NI-
54
.2)
Edit
ion:
20
06
96
Phys
ical
Exam
Fin
din
gs
•V
itam
in A
: ch
anges
in t
he
skin
an
d m
uco
us
mem
bra
nes
; dry
lip
s (c
hei
liti
s),
earl
y-d
ryn
ess
of
the
nas
al m
uco
sa a
nd e
yes;
late
r-dry
nes
s, e
ryth
ema,
sca
ling a
nd p
eeli
ng o
f th
e sk
in,
hai
r lo
ss,
and n
ail
frag
ilit
y. H
eadac
he,
nau
sea,
and v
om
itin
g.
Infa
nts
may
hav
e bulg
ing f
on
tan
elle
; ch
ildre
n m
ay d
evel
op b
one
alte
rati
ons.
•V
itam
in D
: el
evat
ed s
erum
cal
cium
(h
yper
calc
emia
) an
d p
hosp
horu
s (h
yper
ph
osp
hat
emia
) le
vel
s;
calc
ific
atio
n o
f so
ft
tiss
ues
(ca
lcin
osi
s),
incl
udin
g t
he
kid
ney
, lu
ngs,
hea
rt, an
d e
ven
th
e ty
mp
anic
mem
bra
ne
of
the
ear,
whic
h c
an r
esult
in
dea
fnes
s. H
eadach
e an
d n
ause
a. I
nfa
nts
giv
en e
xce
ssiv
e am
ounts
of
vit
amin
D m
ay h
ave
gast
roin
test
inal
upse
t, b
on
e
fragil
ity,
an
d r
etar
ded
gro
wth
.
•V
itam
in K
: h
emoly
tic
anem
ia i
n a
dult
s or
sever
jau
ndic
e in
in
fan
ts h
ave
bee
n n
ote
d o
n r
are
occ
asio
ns
•N
iaci
n:
his
tam
ine
rele
ase
wh
ich c
ause
s fl
ush
ing, ag
gra
vat
ion o
f as
thm
a or
liver
dis
ease
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•H
isto
ry o
r m
easu
red i
nta
ke
refl
ects
exce
ssiv
e in
take
of
foods
and s
upple
men
ts c
onta
inin
g v
itam
ins
as c
om
par
ed t
o
esti
mat
ed r
equir
emen
ts, in
cludin
g f
ort
ifie
d c
erea
ls,
mea
l re
pla
cem
ents
, vit
amin
-min
eral
supple
men
ts,
oth
er d
ieta
ry
supple
men
ts (
e.g
., f
ish l
iver
oil
s or
capsu
les)
, tu
be
feed
ing,
and/o
r par
ente
ral
solu
tions
•In
tak
e >
Tole
rable
Upper
Lim
its
(UL
) fo
r vit
amin
A (
as r
etin
ol
este
r, n
ot
as
-car
ote
ne)
is
600 µ
g/d
for
infa
nts
and
toddle
rs;
900 µ
g/d
for
chil
dre
n 4
-8 y
rs, 1,7
00 µ
g/d
for
chil
dre
n 9
-13 y
rs, 2,8
00 µ
g/d
for
chil
dre
n 1
4-1
8 y
rs, an
d 3
,000 µ
g/d
for
adult
s
•In
take
gre
ater
than
UL
for
vit
amin
D is
25 µ
g/d
ay f
or
infa
nts
and 5
0 µ
g/d
ay f
or
chil
dre
n a
nd a
dult
s
•N
iaci
n:
clin
ical
, h
igh-d
ose
nia
cinam
ide
(NA
) use
of
1 t
o 2
g,
thre
e ti
mes
per
day
can
hav
e si
de
effe
cts
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t, e
.g., c
hro
nic
liv
er o
r kid
ney
dis
ease
s, h
eart
fai
lure
, ca
nce
r
Refe
ren
ces:
1.
All
en L
H, H
ask
ell
M. E
stim
atin
g t
he
po
tenti
al f
or
vit
am
in A
to
xic
ity
in
wo
men
an
d y
ou
ng
ch
ild
ren.
J N
utr
. 2
00
2;1
32
:S2
90
7-S
29
19
.
2.
Cro
qu
et V
, P
ilet
te C
, L
espin
e A
, V
uil
lem
in E
, R
ou
ssel
et M
C, O
ber
ti F
, S
ain
t A
nd
re J
P,
Per
iqu
et B
, F
ran
cois
S, If
rah
N,
Cal
es P
. H
epat
ic h
yp
er-v
itam
ino
sis
A:
imp
ort
ance
of
reti
ny
l es
ter
lev
el
det
erm
inati
on.
Eu
r J
Ga
stro
ente
rol
Hep
ato
l. 2
00
0;1
2:3
61
-36
4.
3.
Kra
sin
ski
SD
, R
uss
ell
RM
, O
trad
ov
ec C
L,
Sado
wsk
i JA
, H
artz
S
C, Ja
cob
RA
, M
cGand
y R
B.
Rel
atio
nsh
ip o
f vit
amin
A a
nd
vit
amin
E i
nta
ke
to f
ast
ing
pla
sma
reti
no
l, r
etin
ol-
bin
din
g p
rote
in,
reti
nyl
este
rs,
caro
ten
e, a
lpha-t
oco
ph
erol,
an
d c
hole
ster
ol
am
ong e
lderl
y p
eople
and y
oung a
dult
s: i
ncr
ease
d p
lasm
a re
tin
yl
este
rs a
mong v
itam
in A
-sup
ple
men
t u
sers
.A
m J
Cli
n N
utr
. 1
98
9;4
9:1
12
-
12
0.
4.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r V
ita
min
A,
Vit
am
in K
, A
rsen
ic, B
oro
n, C
hro
miu
m, C
op
per
, Io
din
e, I
ron
, M
an
ga
nes
e, M
oly
bd
enu
m, N
icke
l,
Sil
ico
n,
Va
na
diu
m, a
nd
Zin
c. W
ashin
gto
n, D
C:
Nat
ional
Aca
dem
y P
ress
; 2
00
0.
5.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r T
hia
min
e, R
ibo
fla
vin
, N
iaci
n,
Vit
am
in B
6,
Fo
late
, V
ita
min
B1
2,
Pa
nto
then
ic A
cid
, B
ioti
n, a
nd
Ch
oli
ne
Was
hin
gto
n,
DC
: N
atio
nal
Aca
dem
y P
ress
; 2
00
0.
6.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r V
ita
min
C,
Vit
am
in E
, S
elen
ium
, a
nd
Ca
rote
no
ids.
Was
hin
gto
n, D
C:
Nat
ional
Aca
dem
y P
ress
;200
0.
7.
Ru
ssel
l R
M. N
ew v
iew
s o
n R
DA
s fo
r old
er a
du
lts.
J A
m D
iet
Ass
oc.
19
97
;97
:51
5-5
18
.
8.
Youn
g D
S. Im
ple
men
tati
on o
f S
I unit
s fo
r cl
inic
al l
abora
tory
dat
a,
style
sp
ecif
icat
ion
s and c
onver
sio
n t
able
s.A
nn
In
tern
Med
. 1
98
7;1
06
:11
4-2
9. R
epri
nte
d,J
Nu
tr. 1
99
0;1
20
:20
-35
..
INTA
KE
DO
MA
IN M
iner
al I
nta
ke
INA
DE
QU
AT
E M
INE
RA
L I
NT
AK
E(S
PE
CIF
Y)
(NI-
55
.1)
Edit
ion:
20
06
97
De
fin
itio
n
Low
er i
nta
ke
of
min
eral
-conta
inin
g f
oods
or
subst
ance
s co
mp
ared
to e
stabli
shed
ref
eren
ce s
tan
dar
ds
or
reco
mm
endat
ion
s bas
ed u
pon p
hysi
olo
gic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses,
e.g
., i
ncr
ease
d n
utr
ient
nee
ds
due
to p
rolo
nged
cat
aboli
c il
lnes
s, m
alab
sorp
tion, h
yper
excr
etio
n, n
utr
ien
t/dru
g a
nd n
utr
ient/
nutr
ien
t
inte
ract
ion
, gro
wth
an
d m
atura
tion
•L
ack o
f ac
cess
to f
ood,
e.g
., e
con
om
ic c
on
stra
ints
, cu
ltura
l or
reli
gio
us
pra
ctic
es, re
stri
ctin
g f
ood g
iven
to e
lder
ly a
nd/o
r ch
ildre
n
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledge
defi
cit
con
cern
ing f
ood s
ourc
es o
f m
iner
als
; m
isdia
gn
osi
s of
lact
ose
in
tole
ran
ce/l
acta
se d
efic
ien
cy;
per
cepti
on o
f
con
flic
tin
g n
utr
itio
n m
essa
ges
fro
m h
ealt
h p
rofe
ssio
nals
, in
appro
pri
ate
reli
ance
on s
upple
men
ts
•P
sych
olo
gic
al c
ause
s, e
.g., d
epre
ssio
n o
r ea
ting d
isord
ers
•E
nvir
onm
enta
l ca
use
s, e
.g., i
nad
equat
ely tes
ted n
utr
ien
t bio
avai
labil
ity o
f fo
rtif
ied f
oods,
bev
erag
es a
nd s
upple
men
ts,
inap
pro
pri
ate
mar
ket
ing o
f fo
rtif
ied
foods/
bev
erag
es/s
upp
lem
ents
as
a su
bst
itute
for
nat
ura
l fo
od s
ourc
e of
nutr
ien
t(s)
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)*
Bio
chem
ical
Data
•C
alci
um
: bon
e m
iner
al c
on
ten
t (B
MC
) bel
ow
th
e yo
un
g a
dult
mea
n.
Hyp
oca
lciu
ria,
ser
um
25(O
H)D
< 3
2 n
g/m
L
•P
hosp
hor
us
< 2
.6 m
g/d
L (
0.8
4 m
mol/
L)
•M
agnes
ium
< 1
.8 m
g/d
L (
0.7
mm
ol/
L)
•Ir
on:
hem
oglo
bin
< 1
30 g
/L (
mal
es);
< 1
20 g
/L
(fe
male
s)
•Io
din
e: u
rinar
y e
xcr
etio
n <
100 µ
g /
L (
788 n
mol/
L)
•C
opper
: s
erum
copper
< 6
4 µ
g /
dL
(10 µ
mol/
L)
Anth
ropom
etri
c M
easu
rem
ents
•H
eight
loss
* T
o c
onver
t co
nv
enti
onal
unit
s to
le S
yste
me
Inte
rna
tio
na
le d
'Un
ites
(S
I),
Jays
Cli
nic
al
Ser
vic
es,
Cli
nic
al L
ab
ora
tory
So
ftw
are
and
Co
nsu
ltin
g w
eb
sit
e u
sed
. W
eb
sit
e a
ddre
ss:
htt
p:/
/dw
jay.t
ripod.c
om
/conv
ersi
on
.htm
l .
Acc
esse
d A
ugust
12,
200
5.
See
Young D
S (
Refe
rence
#5
) fo
r pri
nte
d f
act
or
conv
ersi
on
s.
INTA
KE
DO
MA
IN M
iner
al I
nta
ke
INA
DE
QU
AT
E M
INE
RA
L I
NT
AK
E(S
PE
CIF
Y)
(NI-
55
.1)
Edit
ion:
20
06
98
Phys
ical
Exam
Fin
din
gs
•C
alc
ium
: dim
inis
hed
bon
e m
iner
al d
ensi
ty,
hyper
ten
sion
, poly
cyst
ic o
var
y s
yndro
me,
pre
men
stru
al s
yndro
me,
kid
ney
stones
, co
lon p
oly
ps,
obes
ity
Food/N
utr
itio
n H
isto
ryO
bse
rvat
ions/
report
s of
insu
ffic
ien
t m
iner
al
inta
ke
from
die
t co
mp
ared
to r
ecom
men
ded
in
take:
•F
ood a
void
ance
and/o
r el
imin
atio
n o
f w
hole
food g
roup(s
) fr
om
die
t
•L
ack o
f in
tere
st i
n f
ood
•In
appro
pri
ate
food c
hoic
es a
nd/o
r ch
ronic
die
tin
g b
ehav
ior
•E
xce
ssiv
e N
a in
take,
inad
equat
e vit
amin
D i
nta
ke/
exposu
re
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t of,
e.g
., m
alabso
rpti
on a
s a
resu
lt o
f ce
liac
dis
ease
, sh
ort
bow
el
syn
dro
me,
or
infl
amm
atory
bow
el d
isea
se
•O
ther
sig
nif
ican
t m
edic
al d
iagn
ose
s an
d t
her
apie
s
•E
stro
gen
sta
tus
•G
eogra
ph
ic l
atit
ude
and h
isto
ry o
f U
VB
exposu
re/u
se o
f su
nsc
reen
•C
han
ge
in l
ivin
g e
nvir
onm
ent/
indep
enden
ce
•U
se o
f popula
r pre
ss/i
nte
rnet
as
sourc
e of
med
ical
an
d/o
r n
utr
itio
n i
nfo
rmat
ion
Refe
ren
ces:
1.
App
el L
J, M
oore
TJ,
Ob
arza
nek
E,
Vo
llm
er W
M,
Sv
etk
ey L
P,
Sac
ks
FM
, B
ray
GA
, V
og
t T
M, C
utl
er J
A,
Win
dhau
ser
MM
, L
in P
-H,
Kar
anja
N.
A c
lin
ical
tri
al o
f th
e ef
fect
s o
f d
ieta
ry p
atte
rns
on
blo
od p
ress
ure
.N
En
gl
J M
ed. 1
99
7;3
36
:11
17
-11
24
.
2.
Hea
ney R
P.
Role
of
die
tary
sodiu
m i
n o
steoporo
sis.
Am
J C
lin
Nu
tr (
in p
ress
) 2
00
5.
3.
Hea
ney R
P.
Nu
trie
nts
, in
tera
ctio
ns,
and f
ood
s. T
he
import
ance
of
sourc
e. I
n:
Burc
khar
dt
P,
Daw
son-H
ughes
B, H
eaney R
P,
eds.
Nu
trit
ion
al
Asp
ects
of
Ost
eop
oro
sis.
2nd e
d. S
an
Die
go
, C
alif
:
Els
evie
r. 2
00
4:6
1-7
6.
4.
Hea
ney,
RP
. N
utr
ients
, in
tera
ctio
ns,
an
d f
oods.
Ser
um
25
-hy
dro
xy
-vit
am
in D
an
d t
he
hea
lth o
f th
e ca
lciu
m e
conom
y.
In B
urc
khar
dt
P,
Daw
son-H
ughes
B, H
eaney
RP
, ed
s.N
utr
itio
na
l A
spec
ts o
f
Ost
eop
oro
sis.
2nd e
d.
San
Die
go
, C
alif
: E
lsev
ier.
20
04
:22
7-2
44
.
5.
Hea
ney
RP
, R
affe
rty
K,
Bie
rman
J. N
ot
all
calc
ium
-fort
ifie
d b
ever
ages
are
equ
al.N
utr
To
da
y. 2
00
5;4
0:3
9-4
1.
6.
Hea
ney R
P,
Do
wel
l M
S, H
ale
CA
, B
endic
h A
. C
alci
um
abso
rpti
on v
arie
s w
ithin
the
refe
ren
ce r
ange
for
seru
m 2
5-h
ydro
xyvit
amin
D.J
Am
Co
ll N
utr
. 2
00
3;2
2:1
42
-14
6.
7.
Hea
ney
RP
, D
ow
ell
MS
, R
affe
rty
K, B
ierm
an J
. B
ioav
aila
bil
ity
of
the
calc
ium
in
fort
ifie
d s
oy
im
itat
ion
mil
k,
wit
h s
om
e o
bse
rvat
ion
s o
n m
eth
od.
Am
J C
lin
Nu
tr.
20
00
;71
:11
66
-11
69
.
8.
Holi
ck M
F.
Fu
nct
ions
of
vit
am
in D
: im
port
ance
for
pre
venti
on o
f co
mm
on c
ancer
s, t
yp
e I
dia
bet
es a
nd h
eart
dis
ease
. In
: B
urc
khar
dt
P, D
aw
son-H
ug
hes
B, H
eaney
RP
, ed
s.N
utr
itio
na
l A
spec
ts o
f
Ost
eop
oro
sis.
2nd e
d.
San
Die
go
, C
alif
: E
lsev
ier;
20
04
:18
1-2
01
.
9.
Mas
sey
LK
, W
hit
ing
SJ.
Die
tary
sal
t, u
rin
ary
cal
ciu
m, an
d b
on
e lo
ss.J
Bo
ne
Min
er R
es.
19
96
;1
1:7
31
-73
6.
10
. S
uar
az F
L,
Savai
ano
D,
Arb
isi
P,
Lev
itt
MD
. T
ole
rance
to
th
e dail
y i
ng
esti
on
of
two
cu
ps
of
mil
k b
y i
nd
ivid
ual
s cl
aim
ing
lac
tose
into
lera
nce
.A
m J
Cli
n N
utr
. 1
99
7;6
5:1
50
2-1
50
6.
11
. T
hys-
Jaco
bs
S,
Do
novan D
, P
apad
op
oulo
s A
, S
arre
l P
. B
ilez
ikia
n J
P.
Vit
am
in D
an
d c
alci
um
dysr
egula
tion i
n t
he
poly
cyst
ic o
var
ian s
yndro
me.
Ste
roid
s. 1
99
9;6
4:4
30
-43
5.
12
. T
hys-
Jacob
s S
, S
tark
ey P
, B
ernst
ein D
, T
ian J
. C
alci
um
car
bonat
e and t
he
pre
men
stru
al s
yn
dro
me:
Eff
ects
on p
rem
enst
rual
and m
enst
rual
sym
pto
mat
olo
gy.
Am
J O
bst
et G
yn
eco
l.1
99
8;1
79
:44
4-
45
2.
13
. Y
oun
g D
S. Im
ple
men
tati
on o
f S
I unit
s fo
r cl
inic
al l
abora
tory
dat
a,
style
sp
ecif
icat
ion
s and c
onver
sion t
able
s.A
nn
In
tern
Med
. 1
98
7;1
06
:11
4-2
9. R
epri
nte
d,J
Nu
tr. 1
99
0;1
20
:20
-35
.
14
. Z
emel
MB
, T
ho
mp
son
W,
Mil
stea
d A
, M
orr
is K
, C
amp
bel
l P
. C
alci
um
an
d d
airy
acc
eler
atio
n o
f w
eig
ht
and
fat
lo
ss d
uri
ng
en
erg
y r
estr
icti
on
in
ob
ese
adu
lts.
Ob
esit
y R
es. 2
00
4;1
2:5
82
-59
0.
INTA
KE
DO
MA
IN M
iner
al I
nta
ke
EX
CE
SS
IVE
MIN
ER
AL
IN
TA
KE
(S
PE
CIF
Y)
(NI-
55
.2)
Edit
ion:
20
06
99
De
fin
itio
n
Hig
her
inta
ke
of
min
eral
fro
m f
oods,
supple
men
ts, m
edic
atio
ns
or
wat
er,
com
par
ed t
o e
stab
lish
ed r
efer
ence
sta
ndar
ds
or
reco
mm
endat
ion
s bas
ed u
pon
ph
ysio
logic
al n
eeds
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•H
arm
ful
bel
iefs
/att
itudes
about
food,
nutr
itio
n,
and n
utr
itio
n-r
elat
ed t
opic
s
•F
ood f
add
ism
•A
ccid
enta
l over
-supp
lem
enta
tion
•O
ver
con
sum
pti
on o
f a
lim
ited
var
iety
of
foods
•L
ack o
f kn
ow
ledg
e ab
out
man
agem
ent
of
dia
gn
ose
d g
enet
ic d
isord
er t
hat
alt
ers
min
eral
hom
eost
asi
s su
ch a
s h
emoch
rom
oto
sis
(iro
n),
Wil
son
’s D
isea
se
(copper
)
•L
ack o
f kn
ow
ledg
e ab
out
man
agem
ent
of
dia
gn
ose
d d
isea
se s
tate
th
at r
equir
es m
iner
al r
estr
icti
on s
uch
as
chole
stati
c li
ver
dis
ease
(co
pper
an
d m
angan
ese)
and r
enal
insu
ffic
ien
cy (
ph
osp
horu
s, m
agn
esiu
m,
pota
ssiu
m)
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
INTA
KE
DO
MA
IN M
iner
al I
nta
ke
EX
CE
SS
IVE
MIN
ER
AL
IN
TA
KE
(S
PE
CIF
Y)
(NI-
55
.2)
Edit
ion:
20
06
10
0
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Chan
ges
in a
ppro
pri
ate
labora
tory
val
ues
, su
ch a
s:
• T
SH
(io
din
e su
pple
men
tati
on)
• H
DL
(zi
nc
supple
men
tati
on)
• s
erum
fer
riti
n a
nd t
ran
sfer
rin s
atura
tion (
iron o
ver
load
)
•H
yper
ph
osp
hat
emia
•H
yper
magnes
emia
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
•H
air
and n
ail
chan
ges
(se
leniu
m)
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•H
igh i
nta
ke
of
foods
or
supple
men
ts c
on
tain
ing m
iner
als
com
par
ed t
o D
RIs
•D
ecre
ased
app
etit
e (z
inc
supple
men
tati
on)
Cli
ent
His
tory
•G
I dis
turb
ance
s (i
ron,
magn
esiu
m,
copper
, z
inc,
sel
eniu
m)
•C
opper
-def
icie
ncy
an
emia
(zi
nc)
•L
iver
dam
age
(copper
, ir
on),
enam
el o
r sk
elet
al f
luoro
sis
(flu
ori
de)
Refe
ren
ces:
1.
Bo
wm
an B
A,
Ru
ssel
l R
M,
eds.
Pre
sen
t K
no
wle
dg
e in
Nu
trit
ion
.8
th e
d. W
ash
ing
ton,
DC
: IL
SI
Pre
ss;
20
01
.
2.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
In
take
s fo
r V
ita
min
A,
Vit
am
in K
, A
rsen
ic, B
oro
n, C
hro
miu
m, C
op
per
, Io
din
e, I
ron
, M
an
ga
nes
e, M
oly
bd
enu
m, N
icke
l,
Sil
ico
n,
Va
na
diu
m, Z
inc.
Was
hin
gto
n,
DC
: N
ati
on
al A
cad
emy
Pre
ss;
20
01
.
3.
Nat
ional
Aca
dem
y o
f S
cien
ces,
Inst
itute
of
Med
icin
e.D
ieta
ry R
efer
ence
Inta
kes
for
Ca
lciu
m,
Ph
osp
ho
rus,
Ma
gn
esiu
m, V
ita
min
D, a
nd
Flu
ori
de. W
ash
ing
ton
, D
C:
Nat
ional
Aca
dem
y P
ress
; 1
99
7.
4.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Foo
d a
nd n
utr
itio
n m
isin
form
atio
n.J
Am
Die
t A
sso
c. 2
00
2;1
02
:260
-26
6.
CLIN
CA
L D
OM
AIN
F
unct
ional
SW
AL
LO
WIN
G D
IFF
ICU
LT
Y (
NC
-1.1
)
Edit
ion:
20
06
10
1
De
fin
itio
n
Impai
red m
ovem
ent
of
food a
nd l
iquid
fro
m t
he
mouth
to t
he
stom
ach
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•M
ech
anic
al c
ause
s, e
.g., i
nfl
amm
atio
n,
surg
ery,
str
ictu
re,
or o
ral,
ph
aryn
gea
l an
d e
sophagea
l tu
mors
•M
oto
r ca
use
s, e
.g., n
euro
logic
al o
r m
usc
ula
r dis
ord
ers,
such
as,
cer
ebra
l pal
sy,
stro
ke,
mult
iple
scl
erosi
s, s
cler
oder
ma,
pre
mat
uri
ty
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
•E
vid
ence
of
deh
ydra
tion,
e.g., d
ry m
uco
us
mem
bra
nes
, poor
skin
turg
or
Food/N
utr
itio
n H
isto
ryO
bse
rvat
ion
s or
report
s of:
•C
ough
ing,
chokin
g,
pro
lon
ged
ch
ewin
g, pouch
ing o
f fo
od,
regurg
itati
on,
faci
al e
xpre
ssio
n c
han
ges
duri
ng e
atin
g,
pro
lon
ged
feed
ing t
ime,
dro
oli
ng, n
ois
y w
et u
pper
air
way
soun
ds,
fee
lin
g o
f “f
ood g
etti
ng s
tuck
,” p
ain w
hil
e sw
allo
win
g
•D
ecre
ased
food i
nta
ke
•A
void
ance
of
foods
•M
ealt
ime
resi
stan
ce
Cli
ent
His
tory
•C
ondit
ion
s as
soci
ate
d w
ith a
dia
gnosi
s or
trea
tmen
t of
dys
ph
agia
, ac
hal
asia
•R
adio
logic
al f
ind
ing
s, e
.g., a
bn
orm
al s
wal
low
ing s
tudie
s
•R
epea
ted u
pper
res
pir
atory
in
fect
ion
s an
d o
r pn
eum
on
ia
Refe
ren
ce:
1.
Bra
un
wal
d E
, F
auci
AS
, K
asp
er D
L,
Hau
ser
SL
, L
on
go
DL
, Ja
mes
on
JL
, ed
s.H
arr
iso
n’s
Pri
nci
ple
s o
f In
tern
al M
edic
ine.1
5th e
d. N
ew Y
ork
, N
Y:
McG
raw
-Hil
l,.2
00
1.
CLIN
CA
L D
OM
AIN
F
unct
ional
CH
EW
ING
(M
AS
TIC
AT
OR
Y)
DIF
FIC
UL
TY
(N
C-1
.2)
Edit
ion:
20
06
10
2
De
fin
itio
n
Impai
red a
bil
ity to b
ite
or
chew
food i
n p
repar
atio
n f
or
swal
low
ing
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•C
ran
iofa
cial
mal
form
atio
ns
•O
ral
surg
ery
•N
euro
mu
scula
r dysf
un
ctio
n
•P
arti
al o
r co
mple
te e
den
tuli
sm
•S
oft
tis
sue
dis
ease
(pri
mar
y o
r ora
l m
anif
esta
tion
s of
a sy
stem
ic d
isea
se)
•X
erost
om
ia
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
•M
issi
ng t
eeth
•A
lter
atio
ns
in c
rania
l n
erves
V,
VII
, IX
, X
, X
II
•D
ry o
r cr
acked
lip
s, t
ongue
•O
ral
lesi
ons
•Im
pai
red t
on
gue
movem
ent
•Il
l-fi
ttin
g d
entu
res
or b
roken
den
ture
s
CLIN
CA
L D
OM
AIN
F
unct
ional
CH
EW
ING
(M
AS
TIC
AT
OR
Y)
DIF
FIC
UL
TY
(N
C-1
.2)
Edit
ion:
20
06
10
3
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•D
ecre
ased
in
take
of
food
•A
lter
atio
ns
in f
ood i
nta
ke
from
usu
al
•D
ecre
ased
inta
ke
or
avoid
ance
of
food d
iffi
cult
to f
orm
into
a b
olu
s, e
.g., n
uts
, w
hole
pie
ces
of
mea
t, p
oult
ry,
fish
, f
ruit
s,veg
etable
s
•A
void
ance
of
foods
of
age-
appro
pri
ate
textu
re
•S
pit
tin
g f
ood o
ut
or
pro
lon
ged
fee
din
g t
ime
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t, e
.g., a
lcoh
oli
sm;
Alz
hei
mer
’s; h
ead, n
eck o
r phar
yngea
l ca
nce
r;,
cere
bra
l pal
sy;
cleft
lip
/pal
ate;
ora
l so
ft t
issu
e in
fect
ion
s (e
.g., c
andid
iasi
s, l
eukopla
kia
); l
ack o
f dev
elopm
enta
l re
adin
ess;
ora
l m
anif
esta
tion
s of
syst
emic
dis
ease
(e.
g., r
heu
mat
oid
art
hri
tis,
lup
us,
Cro
hn
’s d
isea
se,
pen
phig
us
vulg
aris
, H
IV,
dia
bet
es)
•R
ecen
t m
ajo
r ora
l su
rger
y
•W
ired
jaw
•C
hem
oth
erap
y w
ith o
ral
side
effe
cts
•R
adia
tion t
her
apy to o
ral
cavit
y
Refe
ren
ces:
1.
Bai
ley
R,
Led
ikw
e JH
, S
mic
ikla
s-W
rig
ht H
, M
itch
ell
DC
, Je
nse
n G
L.
Per
sist
ent
ora
l h
ealt
h p
rob
lem
s as
soci
ated
wit
h c
om
orb
idit
y a
nd
im
pai
red
die
t qu
alit
y i
n o
lder
ad
ult
s. J
Am
Die
t A
sso
c.
20
04
;10
4:1
27
3-1
27
6.
2.
Mar
tin
WE
. O
ral
hea
lth
in
th
e el
der
ly.
In
: C
her
no
ff R
, ed
..G
eria
tric
Nu
trit
ion
. 2
nd e
d.
Gai
ther
sbu
rg,
Mar
yl:
Asp
en P
ub
lish
ers;
19
99
:10
7-1
69
.
3.
Dorm
enval
V, M
ojo
n P
, B
ud
tz-J
org
ense
n E
. A
sso
ciat
ion
bet
wee
n s
elf-
ass
esse
d m
asti
cato
ry a
bil
ity,
nu
trit
ional
sta
tus
and
sal
ivar
y f
low
rat
e in
ho
spit
aliz
ed e
lder
ly.
Ora
l D
is. 1
99
9;5
:32
-38
.
4.
Hil
debra
nd G
H, D
om
ingu
ez B
L,
Sch
ork
MA
, L
oesc
he
WJ.
Fu
nct
ional
unit
s, c
hew
ing,
swal
low
ing a
nd f
oo
d a
void
ance
am
ong t
he
eld
erly
.J
Pro
sth
et D
en
t. 1
99
7;7
7:5
85
-59
5.
5.
Hir
ano
H,
Ish
iyam
a N
, W
atanab
e I,
Nasu
I.
Mas
tica
tory
abil
ity
in
rel
atio
n t
o o
ral
stat
us
and
gen
eral
hea
lth
in
ag
ing.J
Nu
tr H
ealt
h A
gin
g.
19
99
;3:4
8-5
2.
6.
Hu
hm
ann M
, T
oug
er-D
eck
er R
, B
yham
-Gra
y L
, O
’Sull
ivan
-Mai
llet
J,
Von H
agen S
. C
om
par
ison o
f dysp
hagia
scr
eenin
g b
y a
reg
iste
red d
ieti
tian
in a
cute
str
ok
e pat
ients
to s
pee
ch l
anguag
e
pat
holo
gis
t’s
eval
uati
on
.T
op
Cli
n N
utr
. 2
00
4;1
9:2
39
-24
9.
7.
Kad
em
ani
D, G
lick
M.
Ora
l ulc
erat
ions
in i
ndiv
iduals
infe
cted w
ith h
um
an i
mm
un
odef
icie
ncy v
iru
s: c
linic
al p
rese
nta
tions,
dia
gno
sis,
man
agem
ent
and r
elevan
ce
to d
isea
se p
rogre
ssio
n.
Qu
inte
ssen
ce I
nt.
. 1
99
8;2
9:1
10
3-1
10
8.
8.
Kel
ler
HH
, O
stb
ye
T, B
rig
ht-
See
E. P
redic
tors
of
die
tary
in
tak
e in
Onta
rio
sen
iors
.C
an
J P
ub
lic
Hea
lth
. 1
99
7;8
8:3
03
-30
9.
9.
Kra
ll E
, H
ayes
C, G
arci
a R
. H
ow
den
titi
on
sta
tus
and
mast
icat
ory
fu
nct
ion
aff
ect
nu
trie
nt
inta
ke.
J A
m D
ent
Ass
oc.
19
98
;12
9:1
26
1-1
26
9.
10
. Jo
ship
ura
K, W
ille
tt W
C, D
ougla
ss C
W.
The
impac
t of
eden
tulo
usn
ess
on f
ood a
nd n
utr
ient
inta
ke. J
Am
Den
t A
sso
c. 1
99
6;1
27
:45
9-4
67
.
11
. M
ack
le T
, T
ou
ger
-Dec
ker
R, O
’Su
lliv
an M
aill
et J
, H
oll
and
B. R
egis
tere
d D
ieti
tian
s’ u
se o
f p
hy
sica
l as
sess
men
t p
aram
eter
s in
pra
ctic
e.J
Am
Die
t A
sso
c. 2
00
4;1
03
:16
32
-16
38
.
12
. M
oble
y C
, S
aunder
s M
. O
ral
hea
lth s
cree
nin
g g
uid
elin
es
for
no
nden
tal
hea
lthca
re p
rovid
ers.
J A
m D
iet
Ass
oc.
19
97
;97
:S1
23
-12
6.
13
. M
ors
e, D
. O
ral and
phar
yn
gea
l ca
nce
r. I
n:
To
ug
er-D
eck
er R
, S
iro
is D
, M
ob
ley
C.,
ed
s.N
utr
itio
n a
nd
Ora
l M
edic
ine.
Toto
wa
NJ:
Hu
mana
Pre
ss. 2
00
5.
14
. M
oy
nih
an P
, B
utl
er T
, T
ho
maso
n J
, Je
pso
n N
. N
utr
ien
t in
tak
e in
par
tial
ly d
enta
te p
atie
nts
: th
e ef
fect
of
pro
sth
etic
reh
abil
itat
ion.
J D
ent.
20
00
;28
:55
7-5
63
.
15
. P
osi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
Ora
l hea
lth a
nd n
utr
itio
n.J
Am
Die
t A
sso
c. 2
00
3;1
03
:61
5-6
25
.
16
. S
ayhou
n N
R,
Lin
CL
, K
rall
E.
Nu
trit
ion
al s
tatu
s o
f th
e o
lder
adu
lt i
s ass
oci
ate
d w
ith
den
titi
on
sta
tus.
J A
m D
iet
Ass
oc.
20
03
;10
3:6
1-6
6.
18
. S
hei
ham
A,
Ste
ele
JG. T
he
impact
of
ora
l h
ealt
h o
n s
tate
d a
bil
ity
to
eat
cer
tain
fo
od
s; f
ind
ing
fro
m t
he
nat
ional
die
t an
d n
utr
itio
n s
urv
ey o
f old
er p
eop
le i
n G
reat
Bri
tain
.G
ero
do
nto
logy.
19
99
;16
:11
-20
.
19
. S
hip
J, D
uff
y V
, Jo
nes
J,
Lang
mo
re S
. G
eria
tric
ora
l h
ealt
h a
nd
its
im
pac
t o
n e
atin
g.J
Am
Ger
iatr
So
c. 1
99
6;4
4:4
56
-46
4.
CLIN
CA
L D
OM
AIN
F
unct
ional
CH
EW
ING
(M
AS
TIC
AT
OR
Y)
DIF
FIC
UL
TY
(N
C-1
.2)
Edit
ion:
20
06
10
4
20
. T
ouger
-Dec
ker
R.
Cli
nic
al a
nd l
abora
tory
ass
ess
men
t of
nutr
itio
n s
tatu
s.D
ent
Cli
n N
ort
h A
m..
20
03
;47
:25
9-2
78
.
21
. T
ou
ger
-Dec
ker
R,
Sir
ois
D,
Mo
ble
y C
, ed
s.N
utr
itio
n a
nd
Ora
l M
edic
ine.
Toto
wa
NJ:
Hu
mana
Pre
ss.
20
05
22
. W
alls
AW
, S
teel
e JG
, S
hei
ham
A,
Mar
cen
es W
, M
oy
nih
an P
J. O
ral
hea
lth
and
nu
trit
ion
in
old
er p
eop
le.J
Pu
bli
c H
ealt
h D
ent.
20
00
;60
:30
4-3
07
.
CLIN
CA
L D
OM
AIN
F
unct
ional
BR
EA
ST
FE
ED
ING
DIF
FIC
UL
TY
(N
C-1
.3)
Edit
ion:
20
06
10
5
De
fin
itio
n
Inabil
ity to s
ust
ain
in
fan
t n
utr
itio
n t
hro
ugh b
reas
tfee
din
g
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
Infa
nt: •
Dif
ficu
lty latc
hin
g o
n,
e.g., t
ight
fren
ulu
m
•P
oor
suck
ing a
bil
ity
•O
ral
pai
n
•M
aln
utr
itio
n/m
alab
sorp
tion
•L
eth
argy,
slee
pin
ess
•Ir
rita
bil
ity
•S
wal
low
ing d
iffi
cult
y
Moth
er:
•P
ain
ful
brea
sts,
nip
ple
s
•B
reas
t or
nip
ple
abn
orm
alit
y
•M
asti
tis
•P
erce
pti
on o
f in
adeq
uate
mil
k s
upply
•L
ack o
f so
cial
, cu
ltura
l, o
r en
vir
onm
enta
l su
ppor
t
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•L
abora
tory
evid
ence
of
deh
ydra
tion i
n i
nfa
nt
Anth
ropom
etri
c M
easu
rem
ents
•A
ny w
eigh
t lo
ss o
r poor
wei
ght
gai
n i
n i
nfa
nt
Phys
ical
Exam
Fin
din
gs
•F
ren
ulu
m a
bnorm
alit
y (
infa
nt)
CLIN
CA
L D
OM
AIN
F
unct
ional
BR
EA
ST
FE
ED
ING
DIF
FIC
UL
TY
(N
C-1
.3)
Edit
ion:
20
06
10
6
Food/N
utr
itio
n H
isto
ryO
bse
rvat
ion
s or
report
s of
(in
fan
t):
•C
ough
ing
•C
ryin
g, la
tchin
g o
n a
nd o
ff,
pound
ing o
n b
reas
ts
•D
ecre
ased
fee
din
g f
requen
cy/d
ura
tion,
earl
y c
essa
tion o
f fe
edin
g, an
d/o
r fe
edin
g r
esis
tan
ce
•In
fant
leth
argy
•H
un
ger
, la
ck o
f sa
tiet
y a
fter
fee
din
g
•F
ewer
than
six
wet
dia
per
s in
24 h
ours
•In
fant
vom
itin
g o
r dia
rrh
ea
Obse
rvat
ions
or
report
s of
(moth
er):
•S
mall
am
oun
t of
mil
k w
hen
pum
pin
g
•L
ack o
f co
nfi
den
ce i
n a
bil
ity to b
reas
tfee
d
•D
oes
n’t
hea
r in
fan
t sw
allo
win
g
•C
on
cern
s re
gar
din
g m
oth
er’s
ch
oic
e to
bre
ast
feed
/lac
k o
f su
pp
ort
•In
suff
icie
nt
kn
ow
ledge
of
bre
astf
eedin
g o
r in
fant
hung
er/s
atie
ty s
ign
als
•L
ack o
f fa
cili
ties
or
acco
mm
odat
ion
s at
pla
ce o
f em
plo
ym
ent
or
in c
om
mun
ity f
or
bre
astf
eedin
g
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t (i
nfa
nt)
, e.
g.,
cle
ft l
ip/p
alat
e, t
hru
sh, pre
mat
ure
bir
th, m
alabso
rpti
on
, in
fect
ion
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t (m
oth
er),
e.g
., m
ast
itis
, ca
ndid
iasi
s, e
ngorg
emen
t, h
isto
ry o
f bre
ast
surg
ery
Refe
ren
ces:
1.
Bar
ron
SP
, L
ane
HW
, H
ann
an T
E,
Str
uem
ple
r B
, W
illi
ams
JC.
Fac
tors
in
flu
enci
ng
du
rati
on
of
bre
ast
fee
din
g a
mo
ng
lo
w-i
nco
me
wo
men
.J
Am
Die
t A
sso
c. 1
98
8;8
8:1
55
7-1
56
1.
2.
Bry
ant
C, C
ore
il J
, D
’An
gel
o S
L,
Bai
ley D
FC
, L
azar
ov M
A.
A s
trat
egy f
or
pro
moti
ng b
reast
feed
ing a
mong e
con
om
ical
ly d
isad
van
tag
ed w
om
en a
nd a
dole
scents
.N
AA
CO
G’s
Cli
n I
ssu
Per
ina
t
Wo
men
s H
ealt
h N
urs
. 1
99
2;3
:72
3-7
30
.
3.
Ben
tley
ME
, C
aulf
ield
LE
, G
ross
SM
, B
ron
ner
Y,
Jen
sen
J, K
essl
er L
A,
Pai
ge
DM
. S
ou
rces
of
infl
uen
ce o
n in
ten
tio
n t
o b
reas
tfee
d a
mon
g A
fric
an-A
mer
ican
wo
men
at
entr
y t
o W
IC.J
Hu
m L
act
.
19
99
;15
:27
-34
.
4.
More
land J
C,
Llo
yd L
, B
rau
n S
B, H
ein
s JN
. A
new
tea
chin
g m
odel
to p
rolo
ng b
reast
feedin
g a
mong L
atin
os.
J H
um
La
ct. 2
00
0;1
6:3
37
-34
1.
5.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Bre
akin
g t
he
bar
rier
s to
bre
ast
feed
ing.
J A
m D
iet
Ass
oc.
20
01
;10
1:1
21
3-1
22
0.
6.
Woold
rig
e M
S,
Fis
cher
C. C
oli
c,
"ov
erfe
edin
g"
and s
ym
pto
ms
of
lacto
se m
ala
bso
rpti
on i
n t
he
bre
ast
-fed
bab
y.
La
nce
t. 1
98
8;2
:38
2-3
84
.
CLIN
CA
L D
OM
AIN
F
unct
ional
AL
TE
RE
D G
AS
TR
OIN
TE
ST
INA
L (
GI)
FU
NC
TIO
N (
NC
-1.4
)
Edit
ion:
20
06
10
7
De
fin
itio
n
Chan
ges
in a
bil
ity t
o d
iges
t or
abso
rb n
utr
ients
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•A
lter
atio
ns
in G
I an
atom
ical
str
uct
ure
, e.
g., g
astr
ic b
ypas
s, R
oux e
n Y
•C
han
ges
in t
he
GI
trac
t m
oti
lity
, e.
g., g
astr
opar
esis
•C
om
pro
mis
ed G
I tr
act
funct
ion
, e.
g., c
elia
c dis
ease
, C
rohn
’s d
isea
se,
infe
ctio
n, ra
dia
tion t
her
apy
•C
om
pro
mis
ed f
unct
ion o
f re
late
d G
I org
ans,
e.g
., p
ancr
eas,
liv
er
•D
ecre
ased
fun
ctio
nal
len
gth
of
the
GI
trac
t, e
.g., s
hort
bow
el s
yndro
me
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•A
bn
orm
al d
iges
tive
enzy
me
and f
ecal
fat
stu
die
s
•A
bn
orm
al h
ydro
gen
bre
ath t
est,
d-x
ylo
se t
est,
sto
ol
cult
ure
, an
d g
astr
ic e
mpty
ing a
nd/o
r sm
all
bow
el t
ran
sit
tim
e
Anth
ropom
etri
c M
easu
rem
ents
•W
asti
ng d
ue
to m
aln
utr
itio
n i
n s
ever
e ca
ses
Phys
ical
Exam
Fin
din
gs
•D
ecre
ased
musc
le m
ass
•A
bd
om
inal
dis
ten
sion
•In
crea
sed (
or
som
etim
es d
ecre
ased
) bow
el s
oun
ds
CLIN
CA
L D
OM
AIN
F
unct
ional
AL
TE
RE
D G
AS
TR
OIN
TE
ST
INA
L (
GI)
FU
NC
TIO
N (
NC
-1.4
)
Edit
ion:
20
06
10
8
Food/N
utr
itio
n H
isto
ryO
bse
rvat
ion
s or
report
s of:
•A
void
ance
or
lim
itat
ion o
f to
tal
inta
ke
or
inta
ke
of
spec
ific
foods/
food g
roups
due
to G
I sy
mpto
ms,
e.g
., b
loat
ing,
cram
pin
g,
pai
n,
dia
rrh
ea,
stea
torr
hea
(gre
asy,
float
ing,
foul-
smel
ling s
tools
) es
pec
iall
y f
oll
ow
ing i
ng
esti
on o
f fo
od
•F
ood a
nd n
utr
itio
n-r
elat
ed k
now
ledge
def
icit
, e.
g., l
ack o
f in
form
atio
n, in
corr
ect
info
rmat
ion o
r n
onco
mp
lian
ce w
ith
modif
ied d
iet
or m
edic
atio
n s
ched
ule
Cli
ent
His
tory
•A
nore
xia
, nause
a, v
om
itin
g,
dia
rrh
ea,
stea
torr
hea
, co
nst
ipati
on
, ab
dom
inal
pai
n
•E
ndosc
opic
or
colo
nosc
opic
exam
inat
ion r
esult
s, b
iopsy
res
ult
s
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., m
alab
sorp
tion,
mal
dig
esti
on,
stea
torr
hea
, co
nst
ipat
ion,
div
erti
culi
tis,
Cro
hn’s
dis
ease
, in
flam
mat
ory
bow
el d
isea
se, cy
stic
fib
rosi
s, c
elia
c dis
ease
, ir
rita
ble
bow
el s
yndro
me,
infe
ctio
n
•S
urg
ical
pro
cedure
s, e
.g., e
sophagec
tom
y, d
ilata
tion,
gas
trec
tom
y, v
agoto
my,
gast
ric
byp
ass
, bow
el r
esec
tion
s
Refe
ren
ce:
1.
Bra
un
wal
d E
, F
auci
AS
, K
asp
er D
L,
Hau
ser
SL
, L
on
go
DL
, Ja
mes
on
JL
, ed
s.H
arr
iso
n’s
Pri
nci
ple
s o
f In
tern
al M
edic
ine.1
5th e
d. N
ew Y
ork
, N
Y:
McG
raw
-Hil
l;2
00
1.
CLIN
CA
L D
OM
AIN
B
ioch
emic
al
IMP
AIR
ED
NU
TR
IEN
T U
TIL
IZA
TIO
N (
NC
-2.1
)
Edit
ion:
20
06
10
9
De
fin
itio
n
Chan
ges
in a
bil
ity to a
bso
rb o
r m
etab
oli
ze n
utr
ien
ts a
nd b
ioac
tive
subst
ance
s
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•A
lter
atio
ns
in g
ast
roin
test
inal
anat
om
ical
str
uct
ure
•C
om
pro
mis
ed f
unct
ion o
f th
e G
I tr
act
•C
om
pro
mis
ed f
unct
ion o
f re
late
d G
I org
ans,
e.g
., p
ancr
eas,
liv
er
•D
ecre
ased
fun
ctio
nal
len
gth
of
the
GI
trac
t
•M
etab
oli
c dis
ord
ers
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•A
bn
orm
al d
iges
tive
enzy
me
and f
ecal
fat
stu
die
s
•A
bnorm
al h
ydro
gen
bre
ath t
est,
d-x
ylose
tes
t
•A
bnorm
al t
ests
for
inborn
err
ors
of
met
aboli
sm
Anth
ropom
etri
c M
easu
rem
ents
•W
eigh
t lo
ss o
f 5%
in 1
mon
th,
10%
in 6
month
s
•G
row
th s
tun
ting o
r fa
ilure
Phys
ical
Exam
Fin
din
gs
•A
bd
om
inal
dis
ten
sion
•In
crea
sed o
r dec
rease
d b
ow
el s
oun
ds
•E
vid
ence
of
vit
amin
or
min
eral
def
icie
ncy
, e.
g.,
glo
ssit
is,
chei
losi
s, m
outh
les
ions
CLIN
CA
L D
OM
AIN
B
ioch
emic
al
IMP
AIR
ED
NU
TR
IEN
T U
TIL
IZA
TIO
N (
NC
-2.1
)
Edit
ion:
20
06
11
0
Food/N
utr
itio
n H
isto
ryO
bse
rvat
ion
s or
report
s of:
•A
void
ance
or
lim
itat
ion o
f to
tal
inta
ke
or
inta
ke
of
spec
ific
foods/
food g
roups
due
to G
I sy
mpto
ms,
e.g
., b
loat
ing,
cram
pin
g,
pai
n,
dia
rrh
ea,
stea
torr
hea
(gre
asy,
float
ing,
foul-
smel
ling s
tools
) es
pec
iall
y f
oll
ow
ing i
ng
esti
on o
f fo
od
Cli
ent
His
tory
•D
iarr
hea
, st
eato
rrh
ea,
abdom
inal
pai
n
•E
ndosc
opic
or
colo
nosc
opic
exam
inat
ion r
esult
s, b
iopsy
res
ult
s
•C
ondit
ion
s as
soci
ate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., m
alab
sorp
tion,
mal
dig
esti
on,
cyst
ic f
ibro
sis,
cel
iac
dis
ease
,
Cro
hn
’s d
isea
se,
infe
ctio
n,
radia
tion t
her
apy,
inborn
err
ors
of
met
aboli
sm
•S
urg
ical
pro
cedure
s, e
.g., g
astr
ic b
ypas
s, b
ow
el r
esec
tion
Refe
ren
ces:
1.
Bey
er
P. G
ast
roin
test
inal
dis
ord
ers:
Role
s of
nutr
itio
n a
nd t
he
die
teti
cs
pra
ctit
ioner
.J
Am
Die
t A
sso
c. 1
99
8;9
8:2
72
-27
7.
2.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Hea
lth i
mpli
cati
on
s of
die
tary
fib
er.
J A
m D
iet
Ass
oc.
20
02
;10
2:9
93
-10
00
.
CLIN
CA
L D
OM
AIN
B
ioch
emic
al
AL
TE
RE
D N
UT
RIT
ION
-RE
LA
TE
D L
AB
OR
AT
OR
Y V
AL
UE
S (
SP
EC
IFY
) (N
C-2
.2)
Edit
ion:
20
06
11
1
De
fin
itio
n
Chan
ges
due
to b
od
y c
om
posi
tion, m
edic
atio
ns,
bod
y s
yst
em o
r gen
etic
s, o
r ch
anges
in a
bil
ity t
o e
lim
inat
e bypro
duct
s of
dig
esti
ve
and m
etab
oli
c pro
cess
es
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•K
idn
ey,
liver
, ca
rdia
c, e
ndocr
ine,
neu
rolo
gic
, an
d/o
r pulm
onar
y d
ysfu
nct
ion
•O
ther
org
an d
ysf
un
ctio
n t
hat
lea
ds
to b
ioch
emic
al c
han
ges
:
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Fin
din
gs
such
as:
•In
crea
sed A
ST
, A
LT
, T
. bil
i, s
erum
am
mon
ia (
liver
dis
ord
ers)
•A
bn
orm
al B
UN
, C
r, K
, ph
osp
horu
s, g
lom
erula
r fi
ltra
tion r
ate
(G
FR
) (k
idn
ey d
isord
ers)
•A
lter
ed p
O2 a
nd p
CO
2 (
pulm
onar
y d
isord
ers)
•A
bnorm
al s
erum
lip
ids
•A
bn
orm
al p
lasm
a glu
cose
lev
els
•O
ther
fin
din
gs
of
acute
or
chro
nic
dis
order
s th
at a
re a
bn
orm
al a
nd o
f nutr
itio
nal
ori
gin
or
con
sequen
ce
Anth
ropom
etri
c M
easu
rem
ents
•R
apid
wei
ght
chan
ges
•O
ther
anth
ropom
etri
c m
easu
res
that
are
alt
ered
Phys
ical
Exam
Fin
din
gs
•Ja
un
dic
e, e
dem
a, a
scit
es,
itch
ing (
liver
dis
ord
ers)
•E
dem
a, s
hor
tnes
s of
bre
ath
(ca
rdia
c dis
order
s)
•B
lue
nai
l bed
s, c
lubbin
g (
pulm
onar
y d
isord
ers)
CLIN
CA
L D
OM
AIN
B
ioch
emic
al
AL
TE
RE
D N
UT
RIT
ION
-RE
LA
TE
D L
AB
OR
AT
OR
Y V
AL
UE
S (
SP
EC
IFY
) (N
C-2
.2)
Edit
ion:
20
06
11
2
Food/N
utr
itio
n H
isto
ryO
bse
rvat
ion
s or
report
s of:
•A
nore
xia
, nause
a, v
om
itin
g
•In
abil
ity to c
on
sum
e fu
ll m
eals
due
to s
hort
nes
s of
bre
ath o
r ab
dom
inal
dis
tenti
on
•In
take
of
foods
hig
h i
n o
r over
all
exce
ss i
nta
ke
of
pro
tein
, pota
ssiu
m,
ph
osp
horu
s, s
odiu
m,
fluid
•In
adeq
uat
e in
take
of
mic
ron
utr
ients
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledge
defi
cit,
e.g
., l
ack o
f in
form
atio
n, in
corr
ect
info
rmat
ion o
r n
onco
mp
lian
ce w
ith
modif
ied d
iet
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t of,
e.g
., r
enal
or
liver
dis
ease
, al
coh
oli
sm, ca
rdio
-pulm
onar
y d
isord
ers
Refe
ren
ces:
1.
Bet
o J
A, B
ansa
l V
K.
Med
ical
nutr
itio
n t
her
apy i
n c
hro
nic
kid
ney
fai
lure
: in
tegra
ting c
linic
al p
ract
ice
guid
elin
es.
J A
m D
iet
Ass
oc.
20
04
;10
4:4
04
-40
9.
2.
Dav
ern
II
TJ,
Sch
arsc
hm
idt
BF
. B
ioch
emic
al l
iver
tes
ts.
In
Fel
dm
an
M, S
char
sch
mid
t B
F, S
leis
eng
er M
H,
eds.
Sle
isen
ger
an
d F
ord
tra
n’s
Ga
sro
inte
stin
al a
nd
Liv
er D
isea
se,
ed 6
, vo
l 2
.
Phil
adel
ph
ia,
Pa:
WB
Sau
nd
ers,
19
98
:11
12
-11
22
.
3.
Du
rose
CL
, H
old
swort
h M
, W
atso
n V
, P
rzygro
dzk
a F
. K
now
ledge
of
die
tary
res
tric
tion
s and t
he
med
ical
con
sequ
ence
s of
noncom
pli
ance
by p
atie
nts
on h
emo
dia
lysi
s ar
e not
pre
dic
tive
of
die
tary
com
pli
ance
.J
Am
Die
t A
sso
c. 2
00
4;1
04
:35
-41
.
4.
Kasi
ske
BL
, L
akat
ua
JD,
Ma
JZ, L
ou
is T
A.
A m
eta-
anal
ysi
s o
f th
e ef
fect
s o
f die
tary
pro
tein
res
tric
tio
n o
n th
e ra
te o
f d
ecli
ne
in r
enal
fu
nct
ion
.A
m J
Kid
ney
Dis
. 1
99
8;3
1;9
54
-96
1.
5.
Knig
ht
EL
, S
tam
pfe
r M
J, H
ank
inso
n S
E,
Spie
gel
man
D,
Cu
rhan
GC
. T
he
imp
act
of
pro
tein
in
tak
e o
n r
enal
fu
nct
ion
dec
lin
e in
wo
men
wit
h n
orm
al r
enal
fu
nct
ion
or
mil
d r
enal
in
suff
icie
ncy
.A
nn
Inte
rn M
ed. 2
00
3;1
38
:46
0-4
67
.
6.
Nak
ao T
, M
atsu
moto
, O
kad
a T
, K
anaz
aw
a Y
, Y
osh
ino M
, N
agaoka
Y, T
akeg
uchi
F.
Nu
trit
ional
manag
em
ent
of
dia
lysi
s pat
ients
: bal
anci
ng a
mong n
utr
ient
inta
ke,
dia
lysi
s do
se, and n
utr
itio
nal
stat
us.
Am
J K
idn
ey D
is. 2
00
3;4
1:S
13
3-S
13
6.
7.
Nat
ional
Kid
ney
Foun
dat
ion.
Par
t 5.
Eval
uat
ion o
f la
bora
tory
mea
sure
men
ts f
or
clin
ical
ass
essm
ent
of
kid
ney
dis
ease
.A
m J
Kid
ney
Dis
. 2
00
2;3
9:S
76
-S9
2.
8.
Nat
ion
al K
idn
ey F
ou
ndat
ion
. G
uid
elin
e 9
. A
sso
ciat
ion
of
lev
el o
f G
FR
wit
h n
utr
itio
nal
sta
tus.
Am
J K
idn
ey D
is.
20
02
;39
:S1
28
-S1
42
.
CLIN
CA
L D
OM
AIN
B
ioch
emic
al
FO
OD
-ME
DIC
AT
ION
IN
TE
RA
CT
ION
(N
C-2
.3)
Edit
ion:
20
06
11
3
De
fin
itio
n
Un
des
irable
/har
mfu
l in
tera
ctio
n(s
) bet
wee
n f
ood a
nd o
ver
-the-
coun
ter
(OT
C)
med
icat
ion
s, p
resc
ribed
med
icat
ion
s, h
erbal
s, b
ota
nic
als,
an
d/o
r die
tary
supple
men
ts t
hat
dim
inis
hes
, en
han
ces,
or
alte
rs e
ffec
t of
nutr
ients
an
d/o
r m
edic
atio
ns
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•C
om
bin
ed i
nges
tion o
r ad
min
istr
atio
n o
f m
edic
ati
on a
nd f
ood t
hat
res
ult
s in
un
des
irab
le/h
arm
ful
inte
ract
ion(s
)
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•A
lter
atio
ns
of
bio
chem
ical
tes
ts b
ased
upon m
edic
atio
n e
ffec
t an
d p
atie
nt/
clie
nt
con
dit
ion
Anth
ropom
etri
c M
easu
rem
ents
•A
lter
atio
ns
of
anth
ropom
etri
c m
easu
rem
ents
bas
ed u
pon m
edic
ati
on e
ffec
t an
d p
atie
nt/
clie
nt
con
dit
ion
s, e
.g., w
eight
gai
n
and c
ort
icost
eroid
s
Phys
ical
Exam
Fin
din
gs
Food/N
utr
itio
n H
isto
ryO
bse
rvat
ion
s or
report
s of:
•In
take
that
is
pro
ble
mati
c or
inco
nsi
sten
t w
ith O
TC
, pre
scri
bed
dru
gs,
her
bal
s, b
ota
nic
als,
or
die
tary
supple
men
ts s
uch
as:
•fi
sh o
ils
and p
rolo
nged
ble
edin
g
•co
um
adin
, vit
amin
K-r
ich f
ood
s
•hig
h-f
at d
iet
wh
ile
on c
hole
ster
ol-
low
erin
g m
edic
atio
ns
•ir
on s
upple
men
ts,
con
stip
atio
n a
nd l
ow
-fib
er d
iet
•In
take
that
does
not
suppor
t re
pla
cem
ent
or
mit
igat
ion o
f O
TC
, pre
scri
bed
dru
gs,
her
bal
s, b
ota
nic
als,
or
die
tary
supple
men
ts
affe
cts
such
as
pota
ssiu
m-w
asti
ng d
iure
tics
•C
han
ges
in a
pp
etit
e or
tast
e
CLIN
CA
L D
OM
AIN
B
ioch
emic
al
FO
OD
-ME
DIC
AT
ION
IN
TE
RA
CT
ION
(N
C-2
.3)
Edit
ion:
20
06
11
4
Cli
ent
His
tory
•M
ult
iple
dru
gs
(OT
C,
pre
scri
bed
dru
gs,
her
bal
s, b
ota
nic
als,
or
die
tary
supple
men
ts)
that
are
kn
ow
n t
o h
ave
food m
edic
atio
n
inte
ract
ion
s
•M
edic
atio
ns
that
req
uir
e nutr
ient
supple
men
tati
on t
hat
can
not
be
acco
mpli
shed
via
food i
nta
ke
such
as
isonia
zid a
nd
Vit
amin
B6
Refe
ren
ce:
1.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
Inte
gra
tion o
f nutr
itio
n a
nd p
har
maco
ther
apy.J
Am
Die
t A
sso
c. 2
00
3;1
03
:13
63
-13
70
.
CLIN
CA
L D
OM
AIN
W
eig
ht
UN
DE
RW
EIG
HT
(N
C-3
.1)
Edit
ion:
20
06
11
5
De
fin
itio
n
Low
bod
y w
eig
ht
com
par
ed t
o e
stabli
shed
ref
eren
ce s
tan
dar
ds
or
reco
mm
endat
ion
s
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•D
isord
ered
eat
ing p
atte
rn
•E
xce
ssiv
e ph
ysic
al a
ctiv
ity
•H
arm
ful
bel
iefs
/att
itudes
about
food,
nutr
itio
n,
and n
utr
itio
n-r
elat
ed t
opic
s
•In
adeq
uat
e en
ergy i
nta
ke
•In
crea
sed e
ner
gy n
eeds
•L
imit
ed a
cces
s to
food
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
•W
eigh
t fo
r ag
e le
ss t
han
5th
per
centi
le f
or
infa
nts
youn
ger
than
12 m
onth
s
•D
ecre
ased
skin
fold
th
icknes
s an
d m
id-a
rm m
usc
le c
ircu
mfe
ren
ce (
MA
MC
)
•B
MI
< 1
8.5
(m
ost
adult
s)
•B
MI
for
old
er a
dult
s (o
ver
65 y
ears
) <
23
•B
MI
< 5
th p
erce
nti
le (
chil
dre
n,
2-1
9 y
ears
)
Phys
ical
Exam
Fin
din
gs
•D
ecre
ased
som
ati
c pro
tein
sto
res,
musc
le w
asti
ng (
glu
teal
and t
empora
l)
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•In
adeq
uat
e in
take
of
food c
om
par
ed t
o e
stim
ated
or
mea
sure
d n
eeds
CLIN
CA
L D
OM
AIN
W
eig
ht
UN
DE
RW
EIG
HT
(N
C-3
.1)
Edit
ion:
20
06
11
6
•L
imit
ed s
upply
of
food i
n h
om
e
•D
ieti
ng,
food f
addis
m
•H
un
ger
•R
efusa
l to
eat
•P
hys
ical
act
ivit
y g
reat
er t
han
rec
om
men
ded
am
ount
Cli
ent
His
tory
•M
aln
utr
itio
n,
vit
amin
/min
eral
def
icie
ncy
•Il
lnes
s or
ph
ysic
al d
isab
ilit
y
•M
enta
l il
lnes
s, d
emen
tia,
con
fusi
on
•M
easu
red r
esti
ng m
etab
oli
c ra
te (
RM
R)
hig
her
th
an e
xpec
ted a
nd/o
r es
tim
ated
RM
R
•M
edic
atio
ns
that
aff
ect
appet
ite,
e.g
., s
tim
ula
nts
for
atte
nti
on d
efic
it h
yper
acti
vit
y d
isord
er
•A
thle
te, dan
cer,
or
gym
nas
t
Refe
ren
ces:
1.
Ass
ess
men
t of
nutr
itio
nal
sta
tus.
In:
Kle
inm
an R
, ed
.P
edia
tric
Nu
trit
ion
Ha
nd
bo
ok,
5th e
d. C
hic
ago
, Il
l: A
mer
ican
Aca
dem
y o
f P
ed
iatr
ics,
20
04
:40
7-4
23
.
2.
Bec
k A
M, O
vese
n L
W.
At
whic
h b
ody m
ass
ind
ex a
nd d
egre
e of
wei
ght
loss
sh
ould
ho
spit
aliz
ed e
lder
ly p
atie
nts
be
consi
der
ed a
t nutr
itio
nal
ris
k?
Cli
n N
utr
. 1
99
8;1
7:1
95
-19
8.
3.
Bla
um
CS
, F
ries
BE
, F
iata
ron
e M
A.
Fac
oto
rs a
sso
ciat
ed w
ith
lo
w b
od
y m
ass
ind
ex a
nd
wei
gh
t lo
ss i
n n
urs
ing
ho
me
resi
den
ts.J
Ger
on
tolo
gy:
Med
Sci
. 1
99
5;5
0A
:M1
62
-M1
68
.
4.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
Dom
esti
c fo
od a
nd n
utr
itio
n s
ecuri
ty.J
Am
Die
t A
sso
c. 2
00
2;1
02
:18
40
-18
47
.
5.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
Ad
dre
ssin
g w
orl
d h
ung
er,
maln
utr
itio
n,
and f
ood i
nse
curi
ty.J
Am
Die
t A
sso
c. 2
00
3;1
03
:10
46
-10
57
.
6.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Nu
trit
ion i
nte
rven
tio
n i
n t
he
trea
tment
of
anore
xia
ner
vosa
, buli
mia
ner
vo
sa, and e
atin
g d
isord
er n
ot
oth
erw
ise
spec
ifie
d (
ED
NO
S).
J A
m D
iet
Ass
oc.
20
01
;10
1:8
10
-81
9.
7.
Sch
nei
der
SM
, A
l-Ja
ou
ni
R,
Piv
ot
X, B
rau
lio
VB
, R
ampal
P, H
ebu
ern
e X
. L
ack
of
adapta
tio
n t
o s
ever
e m
aln
utr
itio
n i
n e
lder
ly p
atie
nts
.C
lin
Nu
tr.
20
02
;21
(6):
49
9-5
04
.
8.
Spea
r B
A.
Adole
scen
t gro
wth
and d
evel
op
men
t.J
Am
Die
t A
sso
c. 2
00
2 (
sup
pl)
;10
2:S
23
- S
29
.
CLIN
CA
L D
OM
AIN
W
eig
ht
INV
OL
UN
TA
RY
WE
IGH
T L
OS
S (
NC
-3.2
)
Edit
ion:
20
06
11
7
De
fin
itio
n
Dec
rease
in b
ody w
eigh
t th
at i
s n
ot
pla
nn
ed o
r des
ired
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•P
hys
iolo
gic
cau
ses,
e.g
., i
ncr
ease
d n
utr
ien
t n
eeds
due
to p
rolo
nged
cat
aboli
c il
lnes
s
•L
ack o
f ac
cess
to f
ood,
e.g
., e
con
om
ic c
on
stra
ints
, cu
ltura
l or
reli
gio
us
pra
ctic
es, re
stri
ctin
g f
ood g
iven
to e
lder
ly a
nd/o
r ch
ildre
n
•P
rolo
ng
ed h
osp
ital
izat
ion
•P
sych
olo
gic
al i
ssues
•L
ack o
f se
lf-f
eedin
g a
bil
ity
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
•W
eigh
t lo
ss o
f 5%
wit
hin
1 m
onth
, 7.5
% i
n 3
mon
ths
and 1
0%
in 6
mon
ths
Phys
ical
Exam
inati
on F
indin
gs
•F
ever
•In
crea
sed h
eart
rat
e
•In
crea
sed r
espir
atory
rat
e
•L
oss
of
subcu
tan
eous
fat
and m
usc
le s
tore
s
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•N
orm
al o
r usu
al i
nta
ke
in f
ace
of
illn
ess
•P
oor
inta
ke,
ch
ange
in e
atin
g h
abit
s, s
kip
ped
mea
ls
•C
han
ge
in w
ay c
loth
es f
it,
e.g
., b
ecom
ing l
oose
r
CLIN
CA
L D
OM
AIN
W
eig
ht
INV
OL
UN
TA
RY
WE
IGH
T L
OS
S (
NC
-3.2
)
Edit
ion:
20
06
11
8
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., A
IDS
/HIV
, burn
s, c
hro
nic
obst
ruct
ive
pulm
on
ary d
isea
se,
hip
/long b
on
e fr
actu
re, in
fect
ion,
surg
ery,
tra
um
a, h
yper
thyr
oid
ism
(pre
-or
untr
eate
d),
som
e ty
pes
of
can
cer
or
met
ast
atic
dis
ease
(sp
ecif
y)
•M
edic
atio
ns
asso
ciate
d w
ith w
eigh
t lo
ss,
such
as
cert
ain a
nti
dep
ress
ants
or
can
cer
chem
oth
erap
y
Refe
ren
ces:
1.
Coll
ins
N.
Pro
tein
-ener
gy m
alnutr
itio
n a
nd i
nv
olu
nta
ry w
eig
ht
loss
: N
utr
itio
nal
and p
har
mac
olo
gic
str
ateg
ies
to e
nhance
woun
d h
eali
ng.
Exp
ert
Op
inio
n P
ha
rma
coth
er. 2
00
3;7
:11
21
-11
40
.
2.
Sple
tt P
L,
Ro
th-Y
ou
sey
LL
, V
og
elza
ng
JL
. M
edic
al n
utr
itio
n t
her
apy
fo
r th
e pre
ven
tio
n a
nd
tre
atm
ent
of
un
inte
nti
on
al w
eig
ht
loss
in
res
iden
tial
hea
lth
care
faci
liti
es.
J A
m D
iet
Ass
oc.
20
03
;
10
3:3
52
-36
2.
3.
Wal
lace
JL
, S
chw
artz
RS
, L
aCro
ix A
Z,
Uh
lman
n R
F,
Pea
rlm
an R
A. In
volu
nta
ry w
eig
ht
loss
in
old
er p
atie
nts
: in
cid
ence
an
d c
linic
al s
ign
ific
ance
.J
Am
Ger
iatr
So
c. 1
99
5;4
3:3
29
-33
7.
CLIN
CA
L D
OM
AIN
W
eig
ht
OV
ER
WE
IGH
T/O
BE
SIT
Y (
NC
-3.3
)
Edit
ion:
20
06
11
9
De
fin
itio
n
Incr
ease
d a
dip
osi
ty c
om
par
ed t
o e
stab
lish
ed r
efer
ence
sta
ndar
ds
or
reco
mm
endat
ion
s
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•D
ecre
ased
en
ergy n
eeds
•D
isord
ered
eat
ing p
atte
rn
•E
xce
ss e
ner
gy inta
ke
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•N
ot
read
y f
or
die
t/li
fest
yle
chan
ge
•P
hysi
cal
inac
tivit
y
•In
crea
sed p
sych
olo
gic
al/l
ife
stre
ss
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
•B
MI
above
norm
ativ
e st
andar
d f
or
age
and g
ender
•W
aist
cir
cum
fere
nce
above
norm
ativ
e st
andar
d f
or
age
and g
ender
•In
crea
sed s
kin
fold
thic
knes
s
•W
eigh
t fo
r h
eight
above
norm
ativ
e st
andar
d f
or
age
and g
ender
Phys
ical
Exam
Fin
din
gs
•In
crea
sed b
od
y a
dip
osi
ty
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•O
ver
con
sum
pti
on o
f hig
h-f
at a
nd/o
r ca
lori
call
y-d
ense
food o
r bev
erag
e
CLIN
CA
L D
OM
AIN
W
eig
ht
OV
ER
WE
IGH
T/O
BE
SIT
Y (
NC
-3.3
)
Edit
ion:
20
06
12
0
•L
arge
port
ions
of
food (
port
ion s
ize
gre
ater
than
tw
ice
than
rec
om
men
ded
)
•E
xce
ssiv
e en
ergy inta
ke
•In
freq
uen
t, l
ow
-dura
tion a
nd
/or
low
-in
ten
sity
ph
ysic
al a
ctiv
ity
•L
arge
amoun
ts o
f se
den
tary
act
ivit
ies,
e.g
., T
V w
atch
ing
, re
adin
g,
com
pute
r use
in b
oth
lei
sure
and w
ork
/sch
ool
•U
nce
rtai
nty
reg
ardin
g n
utr
itio
n-r
elat
ed r
ecom
men
dat
ion
s
•In
abil
ity to a
pp
ly n
utr
itio
n-r
elat
ed r
ecom
men
dat
ion
s
•In
abil
ity to m
ain
tain
wei
gh
t or
regai
n o
f w
eight
•U
nw
illi
ngnes
s or
dis
inte
rest
in a
pply
ing n
utr
itio
n-r
elat
ed r
ecom
men
dat
ion
s
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t of,
e.g
., h
ypoth
yroid
ism
, m
etaboli
c sy
ndro
me,
eat
ing d
isord
er n
ot
oth
erw
ise
spec
ifie
d,
dep
ress
ion
•P
hysi
cal
dis
abil
ity o
r li
mit
atio
n
•H
isto
ry o
f ph
ysic
al,
sexual
, or
emoti
on
al a
buse
•M
easu
red r
esti
ng m
etab
oli
c ra
te (
RM
R)
low
er t
han
expec
ted a
nd/o
r es
tim
ated
RM
R
•M
edic
atio
ns
that
im
pac
t R
MR
, e.
g., m
idaz
ola
m, pro
pra
nal
ol,
gli
piz
ide
Refe
ren
ces:
1.
Cra
wfo
rd S
. P
rom
oti
ng d
ieta
ry c
han
ge.
Ca
n J
Ca
rdio
l. 1
99
5;1
1(s
up
pl
A):
14
A-1
5A
.
2.
Dic
ker
son
RN
, R
oth
-You
sey
L.
Med
icat
ion
eff
ects
on
met
aboli
c ra
te:
a sy
stem
atic
rev
iew
(P
art
2).
J A
m D
iet
Ass
oc.
2
00
5;1
05
:10
02
-10
09
.
3.
Dic
ker
son
RN
, R
oth
-You
sey
L.
Med
icat
ion
eff
ects
on
met
aboli
c ra
te:
a sy
stem
atic
rev
iew
(P
art
1).
J A
m D
iet
Ass
oc.
2
00
5;1
05
:83
5-8
41
.
4.
Ku
man
yik
a S
K,
Van
Horn
L, B
ow
en D
, P
erri
MG
, R
oll
s B
J, C
zajk
ow
ski
SM
, S
chro
n E
. M
ainte
nan
ce o
f die
tary
beh
avio
r ch
ang
e.H
ealt
h P
sych
ol.
20
00
;19
(1 s
up
pl)
:S4
2-S
56
.
5.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Wei
ght
man
agem
ent.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
14
5-1
15
5.
6.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Tota
l die
t appro
ach
to c
om
munic
atin
g f
ood a
nd n
utr
itio
n i
nfo
rmat
ion.J
Am
Die
t A
sso
c 2
00
2;1
02
:10
0-1
08
.
7.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
The
role
of
die
teti
cs p
rofe
ssio
nal
s in
hea
lth p
rom
oti
on a
nd d
isea
se p
reventi
on.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
68
0-1
68
7.
8.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Nu
trit
ion i
nte
rven
tio
n i
n t
he
trea
tment
of
anore
xia
ner
vosa
, buli
mia
ner
vo
sa, and e
atin
g d
isord
er n
ot
oth
erw
ise
spec
ifie
d (
ED
NO
S).
J A
m D
iet
Ass
oc.
20
01
;10
1:8
10
-81
9.
9.
Shep
her
d R
. R
esis
tan
ce t
o c
han
ges
in d
iet.
Pro
c N
utr
So
c. 2
00
2;6
1:2
67
-27
2.
10
. U
.S.
Pre
ven
tive
Ser
vic
es T
ask F
orc
e. B
ehavio
ral
cou
nse
ling i
n p
rim
ary c
are
to p
rom
ote
a h
ealt
hy d
iet.
Am
J P
rev
Med
. 2
00
3;2
4:9
3-1
00
.
CLIN
CA
L D
OM
AIN
W
eig
ht
INV
OL
UN
TA
RY
WE
IGH
T G
AIN
(N
C-3
.4)
Edit
ion:
20
06
12
1
De
fin
itio
n
Wei
gh
t gai
n a
bove
that
whic
h i
s des
ired
or
pla
nn
ed
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•Il
lnes
s ca
usi
ng u
nex
pec
ted w
eight
gai
n b
ecau
se o
f h
ead t
raum
a, i
mm
obil
ity,
par
alysi
s or
rela
ted c
on
dit
ion
•C
hro
nic
use
of
med
icat
ion
s kn
ow
n t
o c
ause
wei
ght
gai
n,
such
as
use
of
cert
ain
anti
dep
ress
ants
, an
tipsy
choti
cs,
cort
icost
eroid
s, c
erta
in H
IV m
edic
atio
ns
•C
ondit
ion l
eadin
g t
o e
xce
ssiv
e fl
uid
wei
ght
gai
ns
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•D
ecre
ase
in s
erum
alb
um
in, h
ypon
atre
mia
, el
evat
ed f
asti
ng s
eru
m l
ipid
lev
els,
ele
vat
ed f
asti
ng g
luco
se l
evel
s, f
luct
uat
ing
horm
on
e le
vel
s
Anth
ropom
etri
c M
easu
rem
ents
•W
eig
ht his
tory
– n
oti
ng a
ny in
crea
se i
n w
eight
gre
ater
than
pla
nn
ed o
r des
ired
, su
ch a
s 10%
in 6
month
s
•N
oti
ceab
le c
han
ge
in b
od
y f
at d
istr
ibuti
on
Phys
ical
Exam
inati
on F
indin
gs
•F
at a
ccum
ula
tion
—ex
cess
ive
subcu
tan
eous
fat
store
s
•L
ipod
yst
roph
y a
ssoci
ate
d w
ith H
IV m
edic
atio
ns—
incr
ease
in d
ors
oce
rvia
l fa
t, b
reas
t en
larg
emen
t, i
ncr
ease
d a
bdom
inal
gir
th
•E
dem
a
•S
hort
nes
s of
bre
ath
•S
ensi
tivit
y to c
old
, co
nst
ipat
ion, an
d h
air
loss
CLIN
CA
L D
OM
AIN
W
eig
ht
INV
OL
UN
TA
RY
WE
IGH
T G
AIN
(N
C-3
.4)
Edit
ion:
20
06
12
2
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•In
take
con
sist
ent
wit
h e
stim
ated
or
mea
sure
d e
ner
gy n
eeds
•C
han
ges
in r
ecen
t fo
od i
nta
ke
level
•U
se o
f al
coh
ol,
nar
coti
cs
•E
xtr
eme
hung
er w
ith o
r w
ith
out
pal
pit
atio
ns,
tre
mor,
and s
wea
tin
g
•P
hys
ical
inac
tivit
y o
r ch
ange
in p
hys
ical
act
ivit
y lev
el
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t of
asth
ma,
psy
chia
tric
ill
nes
ses,
rh
eum
atic
con
dit
ions,
HIV
/AID
S,
Cush
ing’s
syn
dro
me,
obes
ity,
Pra
der
-Wil
li s
yndro
me
•F
luid
adm
inis
trat
ion a
bove
requir
emen
ts
•C
han
ge
in s
leep
hab
its,
in
som
nia
•M
usc
le w
eakn
ess
•F
atig
ue
•M
edic
atio
ns
asso
ciate
d w
ith i
ncr
ease
d a
ppet
ite
Refe
ren
ces:
1.
Lic
hte
nst
ein
K,
Del
aney
K, W
ard
D,
Pal
ella
F.
Cli
nic
al f
act
ors
ass
oci
ated
wit
h i
nci
den
ce a
nd
pre
val
ence
of
fat
atro
ph
y a
nd
acc
um
ula
tio
n (
abst
ract
P6
4).
An
tivi
r T
her
. 2
00
0;
5:6
1-6
2
2.
Hea
th K
V, H
ogg R
S,
Chan K
J, H
arri
s M
, M
onte
ssori
V, O
’Shau
ghnes
sy M
V,
Mo
nta
ner
JS
. L
ipo
dyst
rophy-a
sso
ciat
ed m
orp
holo
gic
al,
chole
ster
ol
and t
rigly
ceri
de
abnorm
ali
ties
in a
po
pula
tion-
bas
ed H
IV/A
IDS
tre
atm
ent
dat
abase
.A
IDS
. 2
00
1;1
5:2
31
-23
9.
3.
Saf
ri S
, G
run
feld
C.
Fat
dis
trib
uti
on
an
d m
etab
oli
c ch
an
ges
in
pat
ien
ts w
ith
HIV
in
fect
ion
.A
IDS
. 1
99
9;1
3:2
49
3-2
50
5.
4.
Sat
tler
F.
Body h
abit
us
changes
rela
ted t
o l
ipod
yst
roph
y.
Cli
n I
nfe
ct D
is. 2
00
3;3
6:S
84
-S9
0.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
FO
OD
- A
ND
NU
TR
ITIO
N-R
EL
AT
ED
KN
OW
LE
DG
E D
EF
ICIT
(N
B-1
.1)
Edit
ion:
20
06
12
3
De
fin
itio
n
Inco
mp
lete
or
inac
cura
te k
now
ledg
e ab
out
food,
nutr
itio
n, or
nutr
itio
n-r
elat
ed i
nfo
rmat
ion a
nd g
uid
elin
es, e.
g., n
utr
ien
t re
quir
emen
ts,
con
sequen
ces
of
food
beh
avio
rs, li
fe s
tage
requir
emen
ts, n
utr
itio
n r
ecom
men
dat
ions,
dis
ease
s an
d c
on
dit
ions,
physi
olo
gic
al
fun
ctio
n, or
pro
duct
s
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•H
arm
ful
bel
iefs
/att
itudes
about
food,
nutr
itio
n,
and n
utr
itio
n-r
elat
ed t
opic
s
•L
ack o
f pri
or
exposu
re t
o i
nfo
rmat
ion
•L
anguag
e or
cult
ura
l bar
rier
im
pac
ting a
bil
ity t
o l
earn
info
rmat
ion
•L
earn
ing d
isabil
ity,
neu
rolo
gic
al o
r se
nso
ry i
mpai
rmen
t
•P
rior
exposu
re t
o i
nco
mp
atib
le i
nfo
rmat
ion
•P
rior
exposu
re t
o i
nco
rrec
t in
form
atio
n
•U
nw
illi
ng t
o l
earn
or
unin
tere
sted
in l
earn
ing i
nfo
rmat
ion
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
FO
OD
- A
ND
NU
TR
ITIO
N-R
EL
AT
ED
KN
OW
LE
DG
E D
EF
ICIT
(N
B-1
.1)
Edit
ion:
20
06
12
4
Food/N
utr
itio
n H
isto
ryO
bse
rvat
ion
s or
report
s of:
•V
erbal
izes
inac
cura
te o
r in
com
ple
te i
nfo
rmat
ion
•P
rovid
es i
nac
cura
te o
r in
com
ple
te w
ritt
en r
espon
se t
o q
ues
tionn
aire
/wri
tten
tool,
or
is u
nable
to r
ead w
ritt
en t
ool
•D
emon
stra
tes
inab
ilit
y t
o a
pply
food-
and n
utr
itio
n-r
elat
ed i
nfo
rmat
ion
, e.
g., s
elec
t fo
od b
ased
on n
utr
itio
n t
her
apy o
r
pre
par
e in
fant
feed
ing a
s in
stru
cted
•R
elate
s co
nce
rns
about
pre
vio
us
atte
mpts
to l
earn
in
form
atio
n
•V
erbal
izes
un
wil
lingnes
s to
lea
rn o
r dis
inte
rest
in l
earn
ing i
nfo
rmat
ion
Cli
ent
His
tory
•C
lien
t or
care
giv
er h
as
no p
rior
know
ledg
e of
nee
d f
or
food a
nd n
utr
itio
n-r
elat
ed r
ecom
men
dat
ions
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t of,
e.g
., m
enta
l il
lnes
s
•N
ew m
edic
al d
iagnosi
s or
chan
ge
in e
xis
ting d
iagn
osi
s or
con
dit
ion
Refe
ren
ces:
1.
Cra
wfo
rd S
. P
rom
oti
ng d
ieta
ry c
han
ge.
Ca
n J
Ca
rdio
l. 1
99
5;1
1(s
up
pl
A):
14
A-1
5A
.
2.
Ku
man
yik
a S
K,
Van
Horn
L, B
ow
en D
, P
erri
MG
, R
oll
s B
J, C
zajk
ow
ski
SM
, S
chro
n E
. M
ainte
nan
ce o
f die
tary
beh
avio
r ch
ang
e.H
ealt
h P
sych
ol.
20
00
;19
(1 s
up
pl)
:S4
2-S
56
.
3.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Wei
ght
man
agem
ent.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
14
5-1
15
5.
4.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Tota
l die
t appro
ach
to c
om
munic
atin
g f
ood a
nd n
utr
itio
n i
nfo
rmat
ion.J
Am
Die
t A
sso
c. 2
00
2;1
02
:10
0-1
08
.
5.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
The
role
of
die
teti
cs p
rofe
ssio
nal
s in
hea
lth p
rom
oti
on a
nd d
isea
se p
reventi
on.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
68
0-1
68
7.
6.
Shep
her
d R
. R
esis
tan
ce t
o c
han
ges
in d
iet.
Pro
c N
utr
So
c. 2
00
2;6
1:2
67
-27
2.
7.
U.S
. P
reven
tive
Ser
vic
es T
ask F
orc
e. B
ehavio
ral
cou
nse
ling i
n p
rim
ary c
are
to p
rom
ote
a h
ealt
hy d
iet.
Am
J P
rev
Med
. 2
00
3;2
4:9
3-1
00
.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
HA
RM
FU
L B
EL
IEF
S/A
TT
ITU
DE
S O
R P
RA
CT
ICE
S A
BO
UT
FO
OD
, N
UT
RIT
ION
,A
ND
NU
TR
ITIO
N-R
EL
AT
ED
TO
PIC
S (
NB
-1.2
)
Edit
ion:
20
06
12
5
Use
wit
h c
au
tion
: B
e se
nsi
tive
to p
ati
en
t co
nce
rns.
De
fin
itio
n
Bel
iefs
/att
itudes
or
pra
ctic
es a
bout
food,
nutr
itio
n,
and n
utr
itio
n-r
elat
ed t
opic
s th
at a
re i
nco
mpat
ible
wit
h s
oun
d n
utr
itio
n p
rin
ciple
s, n
utr
itio
n c
are
or
dis
ease
/condit
ion (
excl
udin
g d
isord
ered
eat
ing p
atte
rns
and e
atin
g d
isord
ers)
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•D
isbel
ief
in s
cien
ce-b
ased
food a
nd n
utr
itio
n i
nfo
rmat
ion
•E
xposu
re t
o i
nco
rrec
t fo
od a
nd n
utr
itio
n i
nfo
rmat
ion
•E
ati
ng b
ehav
ior
serv
es a
purp
ose
oth
er t
han
nouri
shm
ent
(e.g
. P
ica)
•D
esir
e fo
r a
cure
for
a ch
ronic
dis
ease
thro
ugh t
he
use
of
alte
rnati
ve
ther
apy
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•F
ood f
etis
h, P
ica
•F
ood f
add
ism
•In
tak
e th
at r
efle
cts
an i
mbal
ance
of
nutr
ients
/food g
roups
•A
void
ance
of
foods/
food g
roups
(e.g
., s
ugar
, w
hea
t, c
ooked
foods)
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
HA
RM
FU
L B
EL
IEF
S/A
TT
ITU
DE
S O
R P
RA
CT
ICE
S A
BO
UT
FO
OD
, N
UT
RIT
ION
,A
ND
NU
TR
ITIO
N-R
EL
AT
ED
TO
PIC
S (
NB
-1.2
)
Edit
ion:
20
06
12
6
Cli
ent
His
tory
•C
ondit
ion
s as
soci
ate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., o
bes
ity,
dia
bet
es,
cance
r, c
ardio
vas
cula
r dis
ease
, m
enta
l il
lnes
s
Refe
ren
ces:
1.
Chap
man G
E, B
eagan
B.
Wom
en's
per
spec
tiv
es o
n n
utr
itio
n,
hea
lth,
and b
reast
can
cer
.J
Nu
tr E
du
c B
eha
v. 2
00
3;3
5:1
35
-14
1.
2.
Gonza
lez
VM
, V
itouse
k K
M.
Fea
red f
ood i
n d
ieti
ng a
nd n
on-d
ieti
ng y
ou
ng w
om
en:
a pre
lim
inar
y v
alid
atio
n o
f th
e F
ood P
ho
bia
Surv
ey.
Ap
peti
te. 2
00
4;4
3:1
55
-17
3.
3.
Jow
ett
SL
, S
eal
CJ,
Ph
illi
ps
E,
Gre
go
ry W
, B
arto
n J
R,
Wel
fare
MR
. D
ieta
ry b
elie
fs o
f p
eop
le w
ith
ulc
erat
ive
coli
tis
and
th
eir
effe
ct o
n r
elap
se a
nd
nu
trie
nt
inta
ke.
Cli
n N
utr
. 2
00
4;2
3:1
61
-17
0.
4.
Mad
den
H,
Cham
ber
lain
K.
Nu
trit
ional
hea
lth m
ess
ages
in w
om
en's
mag
azi
nes
: a
confl
icte
d s
pace
for
wo
men
rea
der
s.J
Hea
lth
Psy
cho
log
y. 2
00
4;9
:58
3-5
97
.
5.
Pet
ers
CL
, S
hel
ton J
, S
har
ma
P.
An i
nv
esti
gati
on o
f fa
ctors
that
infl
uen
ce t
he
con
sum
pti
on o
f die
tary
su
pple
men
ts.
Hea
lth
Ma
rk P
sych
ol.
20
03
;21
:11
3-1
35
.
6.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Foo
d a
nd n
utr
itio
n m
isin
form
atio
n.J
Am
Die
t A
sso
c. 2
00
2;1
02
:260
-26
6.
7.
Pov
ey R
, W
elle
ns
B, C
onn
er M
. A
ttit
ud
es t
ow
ards
foll
ow
ing m
eat,
veget
aria
n a
nd v
egan d
iets
: an
exam
inat
ion o
f th
e ro
le o
f am
biv
alen
ce.
Ap
pet
ite.
20
01
;37
:15
-26
.
8.
Putt
erm
an E
, L
inden
W.
Ap
pea
rance
ver
sus
hea
lth:
does
the
reas
on f
or
die
ting a
ffec
t die
ting b
ehav
ior?
J B
eha
v M
ed. 2
00
4;2
7:1
85
-20
4.
9.
Sal
min
en E
, H
eik
kil
a S
, P
ou
ssa
T,
Lag
stro
m H
, S
aari
o R
, S
alm
inen
S.
Fem
ale
pat
ien
ts t
end
to
alt
er t
hei
r die
t fo
llo
win
g t
he
dia
gno
sis
of
rheu
mat
oid
art
hri
tis
and
bre
ast
cance
r.P
rev
Med
.
20
02
;34
:529
-53
5.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
NO
T R
EA
DY
FO
R D
IET
/LIF
ES
TY
LE
CH
AN
GE
(N
B-1
.3)
Edit
ion:
20
06
12
7
De
fin
itio
n
Lac
k o
f per
ceiv
ed v
alue
of
nutr
itio
n-r
elat
ed b
ehav
ior
chan
ge
com
par
ed t
o c
ost
s (c
on
sequen
ces
or
effo
rt r
equir
ed t
o m
ake
chan
ges
); c
onfl
ict
wit
h p
erso
nal
val
ue
syst
em;
ante
ceden
t to
beh
avio
r ch
ang
e
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•H
arm
ful
bel
iefs
/att
itudes
about
food,
nutr
itio
n,
and n
utr
itio
n-r
elat
ed t
opic
s
•C
ogn
itiv
e def
icit
s or
inab
ilit
y to f
ocu
s on d
ieta
ry c
han
ges
•L
ack o
f so
cial
support
for
imple
men
ting c
han
ges
•D
enia
l of
nee
d t
o c
han
ge
•P
erce
pti
on t
hat
tim
e, i
nte
rper
sonal,
or
finan
cial
con
stra
ints
pre
ven
t ch
anges
•U
nw
illi
ng o
r unin
tere
sted
in l
earn
ing i
nfo
rmat
ion
•L
ack o
f se
lf-e
ffic
acy f
or
mak
ing c
han
ge
or
dem
ora
liza
tion f
rom
pre
vio
us
fail
ure
s at
chan
ge
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
•N
egat
ive
bod
y l
anguag
e, e
.g., f
row
nin
g, la
ck o
f ey
e co
nta
ct, def
ensi
ve
post
ure
, la
ck o
f fo
cus,
fid
get
ing (
Note
: bod
y
lan
guag
e var
ies
by c
ult
ure
.)
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
NO
T R
EA
DY
FO
R D
IET
/LIF
ES
TY
LE
CH
AN
GE
(N
B-1
.3)
Edit
ion:
20
06
12
8
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•D
enia
l of
nee
d f
or
food-
and n
utr
itio
n-r
elat
ed c
han
ges
•In
abil
ity to u
nder
stan
d r
equir
ed c
han
ges
•F
ailu
re t
o k
eep a
ppoin
tmen
ts/s
ched
ule
foll
ow
-up a
ppoin
tmen
ts o
r en
gag
e in
coun
seli
ng
•P
revio
us
fail
ure
s to
eff
ecti
vel
y c
han
ge
targ
et b
ehav
ior
•D
efen
siven
ess,
host
ilit
y,
or
resi
stan
ce t
o c
han
ge
•L
ack o
f ef
fica
cy t
o m
ake
chan
ge
or
to o
ver
com
e bar
rier
s to
chan
ge
Cli
ent
His
tory
•N
ew m
edic
al d
iagnosi
s, c
han
ge
in e
xis
tin
g d
iagn
osi
s or
con
dit
ion
, or
chro
nic
non
-com
pli
ance
Refe
ren
ces:
1.
Cra
wfo
rd S
. P
rom
oti
ng d
ieta
ry c
han
ge.
Ca
n J
Ca
rdio
l. 1
99
5;1
1:1
4A
-15
A.
2.
Gre
ene
GW
, R
oss
i S
R,
Ro
ssi
JS, V
elic
er W
F, F
ava
JS, P
roch
ask
a JO
. D
ieta
ry a
ppli
cati
on
s o
f th
e S
tag
es o
f C
han
ge
Mo
del
.J
Am
Die
t A
sso
c.
19
99
;99
:67
3-6
78
.
3.
Ku
man
yik
a S
K,
Van
Horn
L, B
ow
en D
, P
erri
MG
, R
oll
s B
J, C
zajk
ow
ski
SM
, S
chro
n E
. M
ainte
nan
ce o
f die
tary
beh
avio
r ch
ang
e.H
ealt
h P
sych
ol.
20
00
;19
:S4
2-S
56
.
4.
Pro
chask
a JO
, V
elic
er W
F.
The
Tra
nst
heore
tica
l M
od
el o
f behav
ior
change.
Am
J H
ealt
h P
rom
oti
on
. 1
99
7;1
2:3
8–
48
.
5.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Tota
l die
t appro
ach
to c
om
munic
atin
g f
ood a
nd n
utr
itio
n i
nfo
rmat
ion.J
Am
Die
t A
sso
c. 2
00
2;1
02
:10
0-1
08
.
6.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
The
role
of
die
teti
cs p
rofe
ssio
nal
s in
hea
lth p
rom
oti
on a
nd d
isea
se p
reventi
on.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
68
0-1
68
7.
7.
Res
nic
ow
K,
Jack
son
A,
Wan
g T
, D
e A
, M
cCar
ty F
, D
ud
ley
W,
Bar
on
ow
ski
T.
A m
oti
vat
ional
in
terv
iew
ing
inte
rven
tio
n t
o in
crea
se f
ruit
an
d v
eget
able
inta
ke
thro
ugh
bla
ck c
hu
rch
es:
Res
ult
s o
f
the
Eat
for
Lif
e tr
ial.
Am
J P
ub
lic
Hea
lth
. 2
00
1;9
1:1
68
6-1
69
3.
8.
Shep
her
d R
. R
esis
tan
ce t
o c
han
ges
in d
iet.
Pro
c N
utr
So
c. 2
00
2;6
1:2
67
-27
2.
9.
U.S
. P
reven
tive
Ser
vic
es T
ask F
orc
e. B
ehavio
ral
cou
nse
ling i
n p
rim
ary c
are
to p
rom
ote
a h
ealt
hy d
iet.
Am
J P
rev
Med
. 2
00
3;2
4:9
3-1
00
.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
SE
LF
-MO
NIT
OR
ING
DE
FIC
IT (
NB
-1.4
)
Edit
ion:
20
06
12
9
De
fin
itio
n
Lac
k o
f data
rec
ord
ing t
o t
rack
per
son
al p
rogre
ss
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•L
ack o
f so
cial
support
for
imple
men
ting c
han
ges
•L
ack o
f val
ue
for
beh
avio
r ch
ange
or
com
pet
ing v
alues
•P
erce
pti
on t
hat
lack
of
reso
urc
es,
e.g., t
ime,
fin
anci
al,
or
soci
al
support
pre
ven
t se
lf-m
onit
ori
ng
•C
ult
ura
l bar
rier
im
pact
ing a
bil
ity t
o t
rack
per
sonal
pro
gre
ss
•L
earn
ing d
isab
ilit
y,
neu
rolo
gic
al,
or s
enso
ry im
pai
rmen
t
•P
rior
exposu
re t
o i
nco
mp
atib
le i
nfo
rmat
ion
•N
ot
read
y f
or
die
t/li
fest
yle
chan
ge
•U
nw
illi
ng o
r unin
tere
sted
in t
rack
ing p
rogre
ss
•L
ack o
f fo
cus
and a
tten
tion t
o d
etai
l, d
iffi
cult
y w
ith t
ime
man
agem
ent
and/o
r org
aniz
atio
n
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•R
ecord
ed d
ata
inco
nsi
sten
t w
ith b
ioch
emic
al d
ata,
e.g
., d
ieta
ry in
take
is n
ot
con
sist
ent
wit
h b
ioch
emic
al d
ata
Anth
ropom
etri
c M
easu
rem
ents
•R
ecord
ed d
ata
inco
nsi
sten
t w
ith w
eig
ht
stat
us
or
gro
wth
pat
tern
data
, e.
g., d
ieta
ry in
take
is n
ot
con
sist
ent
wit
h w
eigh
t
statu
s or
gro
wth
pat
tern
Phys
ical
Exam
Fin
din
gs
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
SE
LF
-MO
NIT
OR
ING
DE
FIC
IT (
NB
-1.4
)
Edit
ion:
20
06
13
0
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•In
com
ple
te s
elf-
monit
ori
ng r
ecord
s, e
.g., g
luco
se,
food,
fluid
inta
ke,
wei
ght,
ph
ysic
al a
ctiv
ity,
ost
om
y o
utp
ut
reco
rds
•E
mbar
rass
men
t or
an
ger
reg
ardin
g n
eed f
or
self
-monit
ori
ng
•U
nce
rtai
nty
of
how
to c
om
ple
te m
on
itori
ng r
ecord
s
•U
nce
rtai
nty
reg
ardin
g c
han
ges
th
at c
ould
/sh
ould
be
made
in r
espon
se t
o d
ata
in s
elf
mon
itori
ng r
ecord
s
•N
o s
elf
manag
emen
t eq
uip
men
t, e
.g. n
o b
lood g
luco
se m
on
itor,
ped
om
eter
Cli
ent
His
tory
•D
iagn
ose
s re
quir
ing s
elf-
monit
ori
ng,
e.g., d
iabet
es m
elli
tus,
obes
ity,
new
ost
om
y
•N
ew m
edic
al d
iagnosi
s or
chan
ge
in e
xis
ting d
iagn
osi
s or
con
dit
ion
Refe
ren
ces:
1.
Am
eric
an D
iabet
es A
ssoci
atio
n.
Tes
ts o
f gly
cem
ia i
n d
iabet
es.
Dia
bet
es C
are
. 2
00
4;2
7:S
91
-S9
3.
2.
Bak
er R
C,
Kir
sch
enbau
m D
S. W
eig
ht
contr
ol
duri
ng t
he
holi
days:
hig
hly
co
nsi
sten
t se
lf-m
onit
ori
ng a
s a
pote
nti
ally
use
ful
copin
g
mech
anis
m.
Hea
lth
Psy
cho
l. 1
99
8;1
7:3
67
-37
0.
3.
Ber
ko
wit
z R
I, W
adden
TA
, T
ersh
akovec
AM
. B
ehavio
r th
erap
y a
nd s
ibutr
am
ine
for
trea
tment
of
adole
scen
t ob
esit
y.JA
MA
. 2
00
3;2
89
:18
05
-18
12
.
4.
Cra
wfo
rd S
. P
rom
oti
ng d
ieta
ry c
han
ge.
Ca
n J
Ca
rdio
l. 1
99
5;1
1(s
up
pl
A):
14
A-1
5A
.
5.
Jeff
ery
R,
Dre
wn
ow
ski
A, E
pst
ein
L,
Stu
nk
ard
A, W
ilso
n G
, W
ing
R.
Lo
ng
-ter
m m
ain
ten
ance
of
wei
gh
t lo
ss:
curr
ent
stat
us.
Hea
lth
Psy
cho
l. 2
00
0;1
9:5
-16
.
6.
Ku
man
yik
a S
K,
Van
Horn
L, B
ow
en D
, P
erri
MG
, R
oll
s B
J, C
zajk
ow
ski
SM
, S
chro
n E
. M
ainte
nan
ce o
f die
tary
beh
avio
r ch
ang
e.H
ealt
h P
sych
ol.
20
00
;19
(1 s
up
pl)
:S4
2-S
56
.
7.
Lic
htm
an S
W,
Pis
ask
a K
, B
erm
an E
R, P
esto
ne
M, D
ow
lin
g H
, O
ffen
bach
er E
, W
eise
l H
, H
eshk
a S
, M
atth
ews
DE
, H
eym
sfie
ld S
B.
Dis
crep
ancy
bet
wee
n s
elf-
rep
ort
ed a
nd
act
ual
cal
ori
c in
tak
e an
d
exer
cise
in o
bes
e s
ubje
cts
.N
En
gl
J M
ed . 1
99
2;3
27
:18
93
-18
98
.
8.
Wad
den
, T
A. C
har
acte
rist
ics
of
succ
essf
ul
wei
ght
loss
mai
nta
iner
s. I
n:
All
iso
n D
B, P
i-S
un
yer
FX
, ed
s.O
bes
ity
trea
tmen
t: e
sta
bli
shin
g g
oa
ls, im
pro
vin
g o
utc
om
es, a
nd
rev
iew
ing
th
e re
sea
rch
ag
end
a.
New
York
, N
Y:
Ple
nu
m P
ress
;199
5:1
03
-11
1.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
DIS
OR
DE
RE
D E
AT
ING
PA
TT
ER
N (
NB
-1.5
)
Edit
ion:
20
06
13
1
De
fin
itio
n
Bel
iefs
, at
titu
des
, th
oughts
an
d b
ehav
iors
rel
ated
to f
ood,
eati
ng, an
d w
eight
man
agem
ent,
in
cludin
g c
lass
ic e
atin
g d
isord
ers
as w
ell
as l
ess
sever
e, s
imil
ar
con
dit
ion
s th
at n
egat
ivel
y im
pac
t h
ealt
h
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•O
bse
ssiv
e des
ire
to b
e th
in r
elat
ed t
o f
amil
ial,
soci
etal,
bio
logic
al/g
enet
ic,
and/o
r gen
etic
fac
tors
•W
eig
ht re
gula
tion
/pre
occ
upati
on s
ignif
ican
tly in
fluen
ces
self
est
eem
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•E
levat
ed c
hole
ster
ol,
abn
orm
al l
ipid
pro
file
s, h
ypogly
cem
ia, h
ypokal
emia
[an
orex
ia n
ervosa
(A
N)]
•H
ypokale
mia
an
d h
ypoch
lore
mic
alk
alosi
s [b
uli
mia
ner
vosa
(B
N)]
•H
yp
ote
nsi
on,
brad
ycar
dia
, lo
w b
ody t
emp
erat
ure
, h
yponatr
emia
, an
emia
, h
ypoth
yroid
, le
uco
pen
ia,
elev
ated
BU
N (
AN
)
•U
rin
e posi
tive
for
ket
on
es (
AN
)
Anth
ropom
etri
c M
easu
rem
ents
•B
MI
< 1
7.5
, ar
rest
ed g
row
th a
nd d
evel
opm
ent,
fai
lure
to g
ain w
eigh
t duri
ng p
erio
d o
f ex
pec
ted g
row
th, w
eigh
t le
ss t
han
85%
of
expec
ted w
eigh
t (A
N)
•B
MI
> 2
9 [
eati
ng d
isord
er n
ot
oth
erw
ise
spec
ifie
d (
ED
NO
S)]
•S
ign
ific
ant
wei
gh
t fl
uct
uat
ion (
BN
)
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
DIS
OR
DE
RE
D E
AT
ING
PA
TT
ER
N (
NB
-1.5
)
Edit
ion:
20
06
13
2
Phys
ical
Exam
Fin
din
gs
•S
ever
ely d
eple
ted a
dip
ose
an
d s
om
atic
pro
tein
sto
res
(AN
)
•L
anugo h
air
form
atio
n o
n f
ace
and t
run
k,
brit
tle
list
less
hai
r, c
yan
osi
s of
han
ds
and f
eet,
an
d d
ry s
kin
(A
N)
•N
orm
al o
r ex
cess
adip
ose
and n
orm
al s
om
atic
pro
tein
sto
res
(BN
, E
DN
OS
)
•D
amag
ed t
ooth
en
amel
(B
N)
•E
nla
rged
par
oti
d g
lan
ds
(BN
)
•P
erip
her
al e
dem
a (B
N)
•S
kel
etal
musc
le l
oss
(A
N)
•C
ardia
c ar
rhyt
hm
ias
(AN
, B
N)
•Ir
rita
bil
ity,
dep
ress
ion (
AN
, B
N)
•In
abil
ity t
o c
once
ntr
ate
(AN
)
•P
osi
tive
Ru
ssel
l’s
Sig
n (
BN
) ca
llous
on b
ack o
f h
and f
rom
sel
f in
duce
d v
om
itin
g
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•A
void
ance
of
food o
r ca
lori
e-co
nta
inin
g b
ever
ages
(A
N,
BN
)
•F
ear
of
foods
or
dysf
un
ctio
nal
th
oughts
reg
ardin
g f
ood o
r fo
od e
xper
ien
ces
(AN
, B
N)
•D
enia
l of
hung
er (
AN
)
•F
ood p
reocc
upati
on (
AN
, B
N)
•K
now
ledgea
ble
about
curr
ent
die
t fa
d (
AN
, B
N, E
DN
OS
)
•F
asti
ng (
AN
, B
N)
•In
tak
e of
larg
er q
uan
tity
of
food i
n a
def
ined
tim
e per
iod,
a se
nse
of
lack
of
con
trol
over
eat
ing d
uri
ng t
he
epis
ode
(BN
,E
DN
OS
)
•E
xce
ssiv
e ph
ysic
al a
ctiv
ity (
AN
, B
N,
ED
NO
S)
•E
ati
ng m
uch
more
rap
idly
th
an n
orm
al,
eati
ng u
nti
l fe
elin
g u
nco
mfo
rtably
full
; co
nsu
min
g l
arge
amoun
ts o
f fo
od w
hen
not
feel
ing p
hys
ical
ly h
un
gry
; ea
ting a
lon
e bec
ause
of
bei
ng e
mbar
rass
ed b
y h
ow
much
on
e is
eat
ing;
feel
ing d
isgu
sted
wit
hon
esel
f, d
epre
ssed
, or
ver
y g
uil
ty a
fter
over
eati
ng (
ED
NO
S)
•E
ats
in p
rivat
e (A
N,
BN
)
•Ir
rati
onal
th
oughts
about
food’s
aff
ect
on t
he
bod
y (
AN
, B
N,
ED
NO
S)
•P
atte
rn o
f ch
ron
ic d
ieti
ng
•W
eigh
t pre
occ
upati
on
•E
xce
ssiv
e re
lian
ce o
n n
utr
itio
n T
erm
ing a
nd p
reocc
upati
on w
ith n
utr
ien
t co
nte
nt
of
foods
•In
flex
ibil
ity w
ith f
ood s
elec
tion
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
DIS
OR
DE
RE
D E
AT
ING
PA
TT
ER
N (
NB
-1.5
)
Edit
ion:
20
06
13
3
Cli
ent
His
tory
•B
radyca
rdia
(h
eart
rat
e <
60 b
eats
/min
), h
ypote
nsi
on (
syst
oli
c <
90 m
m H
g),
and o
rth
ost
ati
c h
ypote
nsi
on (
AN
)
•S
elf-
induce
d v
om
itin
g,
dia
rrh
ea,
blo
atin
g,
con
stip
atio
n a
nd f
latu
len
ce (
BN
)
•R
eport
of
alw
ays
feel
ing c
old
(A
N)
•M
isuse
of
laxati
ves
, en
emas
, diu
reti
cs,
stim
ula
nts
an
d/o
r m
etab
oli
c en
han
cers
(A
N,
BN
)
•M
usc
le w
eakn
ess,
fat
igu
e, c
ardia
c ar
rhyt
hm
ias,
deh
ydra
tion
, an
d e
lect
roly
te i
mbal
ance
(A
N, B
N)
•D
iagnosi
s, e
.g., a
nor
exia
ner
vosa
, buli
mia
ner
vosa
, bin
ge
eati
ng,
eati
ng d
isord
er n
ot
oth
erw
ise
spec
ifie
d,
amen
orrh
ea
•H
isto
ry o
f m
ood a
nd a
nxie
ty d
isord
ers
(e.g
., d
epre
ssio
n, obse
ssiv
e co
mpu
lsiv
e dis
ord
er),
per
sonali
ty d
isord
ers,
subst
ance
abuse
dis
ord
ers
•F
amil
y h
isto
ry o
f E
D,
dep
ress
ion,
OC
D,
anxie
ty d
isord
ers
(AN
, B
N)
•A
void
ance
of
soci
al
even
ts w
her
e fo
od i
s se
rved
Refe
ren
ces:
1.
Ander
son G
H,
Ken
ned
y S
H,
eds.
Th
e B
iolo
gy
of
Fea
st a
nd
Fa
min
e. N
ew Y
ork
: A
cad
emic
Pre
ss;
19
92
.
2.
Am
eric
an P
sych
iatr
ic A
sso
ciat
ion
.D
iag
no
stic
an
d S
tati
stic
al
Ma
nu
al
for
Men
tal D
iso
rder
s (F
ou
rth
Ed
itio
n,
Tex
t R
evis
ion
). W
ash
ingto
n, D
C:
AP
A P
ress
; 2
00
0.
3.
Am
eric
an P
sych
iatr
ic A
sso
ciat
ion.
Pra
ctic
e guid
elin
es
for
the
trea
tmen
t of
pati
ents
wit
h e
atin
g d
isord
ers.
Am
J P
sych
iatr
y. 2
00
0;1
57
(su
pp
l):1
-39
.
4.
Cook
e R
A,
Cham
ber
s JB
. A
nore
xia
ner
vo
sa a
nd t
he
hea
rt.
Br
J H
osp
Med
. 1
99
5;5
4:3
13
-31
7.
5.
Fis
her
M.
Med
ical
co
mpli
cati
on
s of
anore
xia
an
d b
uli
mia
ner
vosa
.A
do
l M
ed
. 1
99
2;3
:48
1-5
02
.
6.
Gra
len S
J, L
evin
MP
, S
mola
k L
et al
. D
ieti
ng a
nd d
isord
ered
eat
ing d
uri
ng e
arly
an
d m
iddle
adole
scents
: D
o t
he
infl
uen
ces
rem
ain t
he
sam
e?In
t J
Ea
t D
iso
rd. 1
99
0;9
:50
1-5
12
.
7.
Har
ris
JP,
Kri
epe
RE
, R
oss
bac
k C
N. Q
T p
rolo
ngat
ion b
y i
sopro
tere
nol
in a
nore
xia
ner
vosa
.J
Ad
ol
Hea
lth
. 1
99
3;1
4:3
90
-39
3.
8.
Kapla
n A
S, G
arf
unk
el P
E,
eds.
Med
ica
l Is
sues
an
d t
he
Ea
tin
g D
iso
rder
s: T
he
Inte
rfa
ce. N
ew Y
ork
,NY
: B
run
ner
/Man
zel
Pu
bli
sher
s; 1
99
3.
9.
Key
s A
, B
roze
k J
, H
ensc
hel
A, M
ick
elso
n O
, T
aylo
r H
L.T
he
Bio
log
y o
f H
um
an
Sta
rva
tio
n, 2
nd
vo
l. M
inn
eap
oli
s, M
inn
: U
niv
ersi
ty o
f M
inn
esota
Pre
ss; 1
95
0.
10
. K
irkle
y B
G. B
uli
mia
: cl
inic
al
char
act
eris
tics
, dev
elop
men
t, a
nd e
tio
log
y.J
Am
Die
t A
sso
c. 1
98
6;8
6:4
68
-47
5.
11
. K
reip
e R
E,
Up
hoff
M.
Tre
atm
ent
and o
utc
om
e of
adole
scen
ts w
ith a
nore
xia
ner
vo
sa.
Ad
ole
sc M
ed.1
99
2;1
6:5
19
-54
0.
12
. K
reip
e R
E, B
irndorf
DO
. E
atin
g d
isord
ers
in a
dole
scen
ts a
nd y
ou
ng a
dult
s.M
ed C
lin
N A
m. 2
00
0;8
4(4
):1
02
7-1
04
9.
13
. M
ord
asi
ni
R,
Klo
se G
, G
rete
r H
. S
econdar
y t
yp
e II
hyp
erli
popro
tein
emia
in p
atie
nts
wit
h a
nore
xia
ner
vosa
.M
eta
bo
lism
. 1
97
8;2
7:7
1-7
9.
14
. P
osi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Nu
trit
ion i
nte
rven
tio
n i
n t
he
trea
tment
of
anore
xia
ner
vo
sa,
buli
mia
ner
vo
sa, and e
atin
g d
isord
er n
ot
oth
erw
ise
spec
ifie
d (
ED
NO
S).
J A
m D
iet
Ass
oc.
20
01
;10
1:8
10
-81
9.
16
. R
ock
C,
Yager
J. N
utr
itio
n a
nd e
atin
g d
isord
ers:
a p
rim
er f
or
clin
icia
ns.
Int
J E
at
Dis
ord
. 1
98
7;6
:26
7-2
80
.
17
. R
ock
CL
. N
utr
itio
nal
an
d m
edic
al a
sses
sment
and m
anag
emen
t of
eati
ng d
isord
ers.
Nu
tr C
lin
Ca
re. 1
99
9;2
:33
2-3
43
.
18
. S
cheb
end
ach
J,
Rei
cher
t-A
nd
erso
n P
. N
utr
itio
n i
n E
atin
g D
iso
rder
s. I
n:
Mahan
K,
Esc
ott
-Stu
mp
S,
eds.
Kra
us’
s N
utr
itio
n a
nd
Die
t T
her
ap
y. N
ew Y
ork
, N
Y:
McG
raw
- H
ill;
20
00
.
19
. S
ilb
er T
. A
nore
xia
ner
vosa
: M
orb
idit
y a
nd m
ort
alit
y.
Peia
tr A
nn
. 1
98
4;1
3:8
51
-85
9.
20
. S
wen
ne
I. H
eart
ris
k a
ssoci
ate
d w
ith w
eig
ht
loss
in a
nore
xia
ner
vo
sa a
nd e
atin
g d
isord
ers:
ele
ctro
card
iogra
phic
changes
duri
ng t
he
earl
y p
hase
of
refe
edin
g.A
cta
Pa
edia
tr.
20
00
;89
:44
7-4
52
.
21
. T
urn
er J
M, B
uls
ara
MK
, M
cDer
mo
tt B
M, B
yrn
e G
C, P
rin
ce R
L, F
orb
es
DA
. P
redic
tors
of
low
bo
ne d
en
sity
in
you
ng
ad
ole
scent
fem
ale
s w
ith
anore
xia
nerv
osa
and
oth
er d
ieti
ng
dis
ord
ers.
Int
J
Ea
t D
iso
rd.
20
01
;30
:24
5-2
51
.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
LIM
ITE
D A
DH
ER
EN
CE
TO
NU
TR
ITIO
N-R
EL
AT
ED
RE
CO
MM
EN
DA
TIO
NS
(N
B-1
.6)
Edit
ion:
20
06
13
4
De
fin
itio
n
Lac
k o
f n
utr
itio
n-r
elat
ed c
han
ges
as
per
inte
rven
tion a
gre
ed u
pon b
y c
lien
t or
popula
tion
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•L
ack o
f so
cial
support
for
imple
men
ting c
han
ges
•L
ack o
f val
ue
for
beh
avio
r ch
ange
or
com
pet
ing v
alues
•P
erce
pti
on t
hat
tim
e or
fin
anci
al c
on
stra
ints
pre
ven
t ch
anges
•P
revio
us
lack
of
succ
ess
in m
akin
g h
ealt
h-r
elat
ed c
han
ges
•P
oor
un
der
stan
din
g o
f h
ow
an
d w
hy to m
ake
chan
ges
•U
nw
illi
ng t
o a
pply
or
unin
tere
sted
in a
pply
ing i
nfo
rmat
ion
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•E
xpec
ted l
abora
tory
outc
om
es a
re n
ot
achie
ved
Anth
ropom
etri
c M
easu
rem
ents
•E
xpec
ted a
nth
ropom
etri
c outc
om
es a
re n
ot
ach
ieved
Phys
ical
Exam
Fin
din
gs
•N
egat
ive
bod
y l
anguag
e, e
.g., f
row
nin
g, la
ck o
f ey
e co
nta
ct, fi
dg
etin
g (
Note
: bod
y lan
guag
e var
ies
by c
ult
ure
)
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
LIM
ITE
D A
DH
ER
EN
CE
TO
NU
TR
ITIO
N-R
EL
AT
ED
RE
CO
MM
EN
DA
TIO
NS
(N
B-1
.6)
Edit
ion:
20
06
13
5
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•E
xpec
ted f
ood/n
utr
itio
n-r
elat
ed o
utc
om
es a
re n
ot
ach
ieved
•In
abil
ity to r
ecal
l ag
reed
upon c
han
ges
•F
ailu
re t
o c
om
ple
te a
ny a
gre
ed u
pon h
om
ework
•L
ack o
f co
mpli
ance
or
inco
nsi
sten
t co
mp
lian
ce w
ith p
lan
•F
ailu
re t
o k
eep a
ppoin
tmen
ts o
r sc
hed
ule
foll
ow
-up a
ppoin
tmen
ts
•L
ack o
f ap
pre
ciat
ion o
f th
e im
port
ance
of
makin
g r
ecom
men
ded
nutr
itio
n-r
elat
ed c
han
ges
•U
nce
rtai
nty
as
to h
ow
to c
on
sist
entl
y a
pp
ly f
ood/n
utr
itio
n i
nfo
rmat
ion
Cli
ent
His
tory
Refe
ren
ces:
1.
Cra
wfo
rd S
. P
rom
oti
ng d
ieta
ry c
han
ge.
Ca
n J
Ca
rdio
l. 1
99
5;1
1(s
up
pl
A):
14
A-1
5A
.
2.
Ku
man
yik
a S
K,
Van
Horn
L, B
ow
en D
, P
erri
MG
, R
oll
s B
J, C
zajk
ow
ski
SM
, S
chro
n E
. M
ainte
nan
ce o
f die
tary
beh
avio
r ch
ang
e.H
ealt
h P
sych
ol.
20
00
;19
(1 s
up
pl)
:S4
2-S
56
.
3.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Tota
l die
t appro
ach
to c
om
munic
atin
g f
ood a
nd n
utr
itio
n i
nfo
rmat
ion.J
Am
Die
t A
sso
c. 2
00
2;1
02
:10
0-1
08
.
4.
Shep
her
d R
. R
esis
tan
ce t
o c
han
ges
in d
iet.
Pro
c N
utr
So
c. 2
00
2;6
1:2
67
-27
2.
5.
U.S
. P
reven
tive
Ser
vic
es T
ask F
orc
e. B
ehavio
ral
cou
nse
ling i
n p
rim
ary c
are
to p
rom
ote
a h
ealt
hy d
iet.
Am
J P
rev
Med
. 2
00
3;2
4:9
3-1
00
.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
UN
DE
SIR
AB
LE
FO
OD
CH
OIC
ES
(N
B-1
.7)
Edit
ion:
20
06
13
6
De
fin
itio
n
Food a
nd/o
r bev
erage
choic
es t
hat
are
in
con
sist
ent
wit
h U
S R
ecom
men
ded
Die
tary
In
take,
US
Die
tary
Guid
elin
es,
or
wit
h t
he
My P
yra
mid
or
wit
h t
arget
s
def
ined
in t
he
nutr
itio
n p
resc
ripti
on o
r nutr
itio
n c
are
pro
cess
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•L
ack o
f pri
or
exposu
re t
o o
r m
isun
der
stan
din
g o
f in
form
atio
n
•L
anguag
e, r
elig
ious,
or
cult
ura
l bar
rier
s af
fect
ing a
bil
ity t
o a
pply
in
form
atio
n
•L
earn
ing d
isabil
itie
s, n
euro
logic
al o
r se
nso
ry im
pai
rmen
t
•H
igh l
evel
of
fati
gu
e or
oth
er s
ide
effe
ct o
f th
erap
y
•In
adeq
uat
e ac
cess
to r
ecom
men
ded
foods
•P
erce
pti
on t
hat
fin
anci
al c
on
stra
ints
pre
ven
t se
lect
ion o
f fo
od c
hoic
es c
on
sist
ent
wit
h r
ecom
men
dat
ions
•F
ood a
ller
gie
s an
d a
ver
sion
s im
ped
ing f
ood c
hoic
es c
on
sist
ent
wit
h g
uid
elin
es
•L
acks
moti
vat
ion a
nd/o
r re
adin
ess
to a
pply
or
support
syst
ems
chan
ge
•U
nw
illi
ng o
r unin
tere
sted
in l
earn
ing i
nfo
rmat
ion
•P
sych
olo
gic
al
lim
itat
ion
s
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•E
levat
ed l
ipid
pan
el
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
•F
ind
ings
con
sist
ent
wit
h v
itam
in/m
iner
al
def
icie
ncy
or
exce
ss
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
K
now
ledge
and B
elie
fs
UN
DE
SIR
AB
LE
FO
OD
CH
OIC
ES
(N
B-1
.7)
Edit
ion:
20
06
13
7
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•In
tak
e in
consi
sten
t w
ith U
S D
ieta
ry G
uid
elin
es o
r M
y P
yram
id (
e.g., o
mis
sion o
f en
tire
nutr
ien
t gro
ups,
dis
pro
port
ionat
e
inta
ke
such
as
juic
e fo
r youn
g c
hil
dre
n])
•In
acc
ura
te o
r in
com
ple
te u
nder
stan
din
g o
f th
e guid
elin
es
•In
abil
ity t
o a
pply
guid
elin
e in
form
atio
n
•In
abil
ity (
e.g
. ac
cess
) or
un
wil
lin
gn
ess
to s
elec
t, o
r dis
inte
rest
in s
elec
tin
g f
ood c
on
sist
ent
wit
h t
he
guid
elin
es
Cli
ent
His
tory
•C
ondit
ion
s as
soci
ate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., m
enta
l il
lnes
s
Refe
ren
ces:
1.
Bir
ch L
L,
Fis
her
JA
. A
ppet
ite
and e
ati
ng b
ehav
ior
in c
hil
dre
n.
Ped
iatr
Cli
n N
ort
h A
m.1
99
5:4
2;9
31
-95
3.
2.
Bu
tte
N, C
obb
K,
Dw
yer
J, G
ran
ey L
, H
eird
W,
Ric
har
d K
. T
he
star
t h
ealt
hy
fee
din
g g
uid
elin
es f
or
infa
nts
an
d t
od
dle
rs.
J A
m D
iet
Ass
oc.
20
04
;10
4:4
42
-45
4.
3.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Wei
ght
man
agem
ent.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
14
5-1
15
5.
4.
Dole
cek
TA
, S
tam
lee
J, C
aggiu
la A
W,
Til
lots
on
JL
, B
uzz
ard
IM
. M
eth
od
s o
f die
tary
an
d n
utr
itio
nal
ass
essm
ent
and
in
terv
enti
on
an
d o
ther
met
ho
ds
in t
he
mu
ltip
le r
isk
fac
tor
inte
rven
tio
n t
rial
.A
m
J C
lin
Nu
tr.
19
97
;65
(su
ppl)
:19
6S
-21
0S
.
5.
Epst
ein L
H, G
ord
y C
C, R
aynor
HA
, B
eddom
e M
, K
ilanow
ski
CK
, P
alu
ch R
. In
crea
sin
g f
ruit
an
d v
eget
able
inta
ke
and d
ecr
easi
ng f
at a
nd s
ugar
inta
ke
in f
am
ilie
s at
ris
k f
or
chil
dh
ood o
bes
ity.
Ob
esit
y R
es.2
00
1;9
:17
1-1
78
.
6.
Fre
eland
-Gra
ves
J, N
itzk
e S
. T
ota
l die
t appro
ach
to c
om
mu
nic
atin
g f
ood a
nd n
utr
itio
n i
nfo
rmat
ion.J
Am
Die
t A
sso
c. 2
00
2;1
02
:10
0-1
08
.
7.
Fre
nch
SA
. P
rici
ng e
ffec
ts o
n f
oo
d c
hoic
es.
J N
utr
. 2
00
3;1
33
(su
pp
l):8
41
S-8
43
S.
8.
Gle
ns
K,
Basi
l M
, M
aria
chi
E,
Go
ldb
erg J
, S
ny
der
D. W
hy A
mer
ican
s ea
t w
hat
they
do:
tast
e, n
utr
itio
n,
cost
, co
nv
enie
nce
and w
eig
ht
contr
ol
concer
ns
as
infl
uen
ces
on f
ood c
onsu
mpti
on.
J A
m
Die
t A
sso
c. 1
99
8;9
8:1
11
8-1
12
6.
9.
Ham
pl
JS,
An
der
son J
V, M
ull
is R
. T
he
role
of
die
teti
cs p
rofe
ssio
nal
s in
hea
lth p
rom
oti
on a
nd d
isea
se p
reven
tion.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
68
0-1
68
7.
10
. L
in S
H, G
uth
rie
J, F
raza
o E
. A
mer
ican
chil
dre
n’s
’ die
ts a
re n
ot
mak
ing
th
e gra
de.
Fo
od
Rev
. 2
00
1;2
4:8
-17
.
11
. S
atte
r E
. F
eedin
g d
yn
amic
s: h
elp
ing
chil
dre
n t
o e
at w
ell.
J P
edia
tr H
ealt
hca
re. 1
99
5;9
:17
8-1
84
.
12
. S
tory
M, H
olt
K,
So
fka
D,
eds.
Bri
gh
t F
utu
res
in P
ract
ice:
Nu
trit
ion
, 2
nd e
d. A
rlin
gto
n,
Va:
Nat
ion
al C
ente
r fo
r E
du
cati
on
in
Mat
ernal C
hil
d H
ealt
h;
20
02
.
13
. P
elto
GH
, L
evit
t E
, T
hai
ru L
. Im
pro
vin
g f
eedin
g p
ract
ices,
curr
ent
pat
tern
s, c
om
mo
n c
onst
rain
ts a
nd t
he
desi
gn o
f in
terv
enti
ons.
Fo
od
Nu
tr B
ull
. 2
00
3;2
4:4
5-8
2.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
P
hys
ical A
ctivity
and F
unct
ion
PH
YS
ICA
L IN
AC
TIV
ITY
(NB
-2.1
)
Edit
ion:
20
06
13
8
De
fin
itio
n
Low
level
of
acti
vit
y/se
den
tary
beh
avio
r to
th
e ex
ten
t th
at i
t re
duce
s en
ergy e
xpen
dit
ure
an
d i
mpac
ts h
ealt
h
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•F
inan
cial
con
stra
ints
that
may
pre
ven
t su
ffic
ien
t le
vel
of
acti
vit
y
•H
arm
ful
bel
iefs
/att
itudes
about
ph
ysic
al a
ctiv
ity
•In
jury
or
life
styl
e ch
ange
that
red
uce
s ph
ysic
al a
ctiv
ity o
r act
ivit
ies
of
dai
ly l
ivin
g
•L
ack o
f pri
or
educa
tion a
bout
nee
d f
or
ph
ysic
al a
ctiv
ity o
r how
to i
nco
rpora
te e
xer
cise
, e.
g., p
hys
ical
dis
abil
ity,
arth
riti
s
•L
ack o
f ro
le m
odel
s, e
.g., f
or
chil
dre
n
•L
ack o
f so
cial
support
an
d/o
r en
vir
onm
enta
l sp
ace
or
equip
men
t
•L
ack o
f sa
fe e
nvir
onm
ent
for
physi
cal
acti
vit
y
•L
ack o
f val
ue
or
com
pet
ing v
alues
for
beh
avio
r ch
ange
•T
ime
con
stra
ints
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
P
hys
ical A
ctivity
and F
unct
ion
PH
YS
ICA
L IN
AC
TIV
ITY
(NB
-2.1
)
Edit
ion:
20
06
13
9
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•In
freq
uen
t, l
ow
-dura
tion a
nd
/or
low
-in
ten
sity
ph
ysic
al a
ctiv
ity
•L
arge
amoun
ts o
f se
den
tary
act
ivit
ies,
e.g
., T
V w
atch
ing
, re
adin
g,
com
pute
r use
in b
oth
lei
sure
and w
ork
/sch
ool
•B
arri
ers
to p
hys
ical
act
ivit
y, e
.g., t
ime
con
stra
ints
, av
aila
bil
ity o
f a
safe
envir
onm
ent
for
exer
cise
Cli
ent
His
tory
•L
ow
car
dio
-res
pir
ato
ry f
itn
ess
and
/or
low
musc
le s
tren
gth
•M
edic
al d
iagn
ose
s th
at m
ay b
e as
soci
ate
d w
ith o
r re
sult
in d
ecre
ased
act
ivit
y, e
.g.,
art
hri
tis,
chro
nic
fat
igu
e sy
ndro
me,
morb
id o
bes
ity,
kn
ee s
urg
ery
•M
edic
atio
ns
that
cau
se s
om
nole
nce
an
d d
ecre
ased
cognit
ion
•P
sych
olo
gic
al d
iagn
osi
s, e
.g., d
epre
ssio
n,
anxie
ty d
isord
ers
Refe
ren
ces:
1.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Wei
ght
man
agem
ent.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
14
5-1
15
5.
2.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Tota
l die
t appro
ach
to c
om
munic
atin
g f
ood a
nd n
utr
itio
n i
nfo
rmat
ion.J
Am
Die
t A
sso
c. 2
00
2;1
02
:10
0-1
08
.
3.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
The
role
of
die
teti
cs p
rofe
ssio
nal
s in
hea
lth p
rom
oti
on a
nd d
isea
se p
reventi
on.
J A
m D
iet
Ass
oc.
20
02
;10
2:1
68
0-1
68
7.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
P
hys
ical A
ctivity
and F
unct
ion
EX
CE
SS
IVE
EX
ER
CIS
E(N
B-2
.2)
Edit
ion:
20
06
14
0
De
fin
itio
n
An a
mount
of
exer
cise
th
at e
xce
eds
that
whic
h i
s n
eces
sary
to i
mpro
ve
hea
lth a
nd/o
r at
hle
tic
per
form
ance
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•D
isord
ered
eat
ing
•Ir
rati
onal
bel
iefs
/att
itudes
about
food,
nutr
itio
n, an
d f
itn
ess
•“A
ddic
tive”
beh
avio
rs/p
erso
nal
ity
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•E
levat
ed l
iver
en
zym
es,
e.g., L
DH
, S
GO
T
•A
lter
ed m
icro
nutr
ient
stat
us,
e.g
., d
ecre
ase
d s
erum
fer
riti
n, zi
nc,
and I
GF
-bin
din
g p
rote
in
•In
crea
sed h
emat
ocr
it
•S
upp
ress
ed i
mm
un
e fu
nct
ion
•P
oss
ibly
ele
vat
ed c
ort
isol
level
s
Anth
ropom
etri
c M
easu
rem
ents
•W
eig
ht
loss
, ar
rest
ed g
row
th a
nd d
evel
opm
ent,
fai
lure
to g
ain w
eigh
t duri
ng p
erio
d o
f ex
pec
ted g
row
th (
rela
ted u
sual
ly to
dis
ord
ered
eat
ing)
Phys
ical
Exam
Fin
din
gs
•D
eple
ted a
dip
ose
and s
om
ati
c pro
tein
sto
res
(rel
ated
usu
all
y to d
isord
ered
eat
ing)
•F
requen
t an
d/o
r pro
lon
ged
in
juri
es a
nd/o
r il
lnes
ses
•C
hro
nic
fat
igue
•C
hro
nic
mu
scle
sore
nes
s
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
P
hys
ical A
ctivity
and F
unct
ion
EX
CE
SS
IVE
EX
ER
CIS
E(N
B-2
.2)
Edit
ion:
20
06
14
1
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•C
on
tinued
/rep
eate
d h
igh l
evel
s of
exer
cise
exce
edin
g l
evel
s n
eces
sary
to i
mpro
ve
hea
lth a
nd/o
r at
hle
tic
per
form
ance
•E
xer
cise
dai
ly w
ith
out
rest
/reh
abil
itat
ion d
ays
•E
xer
cise
whil
e in
jure
d/s
ick
•F
ors
akin
g f
amil
y, j
ob,
soci
al r
espon
sibil
itie
s to
exer
cise
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gn
osi
s or
trea
tmen
t of,
e.g
., a
nore
xia
ner
vosa
, buli
mia
ner
vosa
, bin
ge
eati
ng,
eati
ng d
isord
er
not
oth
erw
ise
spec
ifie
d,
amen
orr
hea
•E
vid
ence
of
add
icti
ve,
obse
ssiv
e, o
r co
mpu
lsiv
e te
nden
cies
Refe
ren
ces:
1.
Ais
sa-B
enhad
dad
A, B
ou
ix D
, K
hal
ed S
, M
ical
lef
JP, M
erci
er J
, B
rin
ger
J,
Bru
n J
F.
Ear
ly h
emorh
eolo
gic
asp
ects
of
ov
ertr
ain
ing
in
eli
te a
thle
tes.
Cli
n H
emo
rheo
l M
icro
circ
. 1
99
9;2
0:1
17
-12
5.
2.
Am
eric
an P
sych
iatr
ic A
sso
ciat
ion
.D
iag
no
stic
an
d S
tati
stic
al
Ma
nu
al
of
Men
tal
Dis
ord
ers.
4th e
d.
Was
hin
gto
n, D
C:
Am
eric
an P
sych
iatr
ic A
sso
ciat
ion
; 2
00
0.
3.
Dav
is C
, B
rew
er H
, R
atu
sny D
. B
ehavio
ral
freq
uency
an
d p
sych
olo
gic
al c
om
mit
men
t: n
ece
ssar
y c
once
pts
in t
he
stud
y o
f ex
cess
ive
exer
cisi
ng
.J
Beh
av
Med
. 1
99
3;1
6:6
11
-62
8
4.
Dav
is C
, C
lari
dg
e G
. T
he
eati
ng d
isord
er a
s addic
tion:
a psy
chobio
logic
al p
ersp
ecti
ve.
Ad
dic
t B
eha
v. 1
99
8;2
3:4
63
-47
5.
5.
Davis
C,
Kenned
y S
H, R
avel
ski
E, D
ionn
e M
. T
he
role
of
phy
sica
l act
ivit
y i
n t
he
dev
elopm
ent
and m
ainte
nance
of
eati
ng d
isord
ers.
Psy
cho
l M
ed. 1
99
4;2
4:9
57
-96
7.
6.
Kle
in D
A, B
ennet
t A
S,
Sch
eben
dach
J,
Fo
ltin
RW
, D
evli
n M
J, W
alsh
BT
. E
xer
cise
“ad
dic
tio
n”
in a
no
rex
ia n
erv
osa
: m
od
el d
evel
op
men
t and
pil
ot
dat
a.C
NS
Sp
ect
r. 2
00
4;9
:53
1-5
37
.
7.
Lak
ier-
Sm
ith L
. O
ver
trai
nin
g,
exce
ssiv
e ex
erci
se,
and a
lter
ed i
mm
unit
y:
this
a h
elper
-1 v
s help
er-2
lym
phocy
te r
espo
nse
?S
po
rts
Med
. 2
00
3;3
3:3
47
-36
4.
8.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Nu
trit
ion i
nte
rven
tio
n i
n t
he
trea
tment
of
anore
xia
ner
vosa
, buli
mia
ner
vo
sa, and e
atin
g d
isord
er n
ot
oth
erw
ise
spec
ifie
d (
ED
NO
S).
J A
m D
iet
Ass
oc.
20
01
;10
1:8
10
-81
9.
9.
Shep
har
d R
J, S
hek
PN
. A
cute
and c
hro
nic
over
-exer
tion:
do d
epre
ssed
im
mune
resp
onse
s pro
vid
e use
ful
mar
ker
s?In
t J
Sp
ort
s M
ed. 1
99
8;1
9:1
59
-17
1.
10
. S
mit
h L
L. T
issu
e tr
aum
a: t
he
un
der
lyin
g c
ause
of
over
train
ing s
yndro
me?
J S
tren
gth
Co
nd
Res
. 2
00
4;1
8:1
85
-19
3.
11
. U
rhau
sen A
, K
inder
mann W
. D
iagno
sis
of
ov
ertr
ainin
g:
what
tools
do w
e have.
Sp
ort
s M
ed. 2
00
2;3
2:9
5-1
02
.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
P
hys
ical A
ctivity
and F
unct
ion
INA
BIL
ITY
OR
LA
CK
OF
DE
SIR
E T
O M
AN
AG
E S
EL
F-C
AR
E(N
B-2
.3)
Edit
ion:
20
06
14
2
De
fin
itio
n
Lac
k o
f ca
paci
ty o
r unw
illi
ngnes
s to
im
ple
men
t m
eth
ods
to s
upp
ort
hea
lthfu
l fo
od-
and n
utr
itio
n-r
elat
ed b
ehav
ior
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•F
ood-
and n
utr
itio
n-r
elat
ed k
now
ledg
e defi
cit
•L
ack o
f ca
reta
ker
or
soci
al s
upport
for
imple
men
ting c
han
ges
•L
ack o
f devel
opm
enta
l re
adin
ess
to p
erfo
rm s
elf
man
agem
ent
task
s, e
.g.
ped
iatr
ics
•L
ack o
f val
ue
or
com
pet
ing v
alues
for
beh
avio
r ch
ange
•P
erce
pti
on t
hat
lack
of
reso
urc
es (
tim
e, f
inan
cial
, su
pport
per
sons)
pre
ven
t se
lf c
are
•C
ult
ura
l bel
iefs
an
d p
ract
ices
•L
earn
ing d
isabil
ity,
neu
rolo
gic
al o
r se
nso
ry i
mpai
rmen
t
•P
rior
exposu
re t
o i
nco
mp
atib
le i
nfo
rmat
ion
•N
ot
read
y f
or
die
t/li
fest
yle
chan
ge
•U
nw
illi
ng o
r un
inte
rest
ed i
n l
earn
ing/a
pply
ing i
nfo
rmat
ion
•N
o s
elf-
man
agem
ent
tools
or
dec
isio
n g
uid
es
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
P
hys
ical A
ctivity
and F
unct
ion
INA
BIL
ITY
OR
LA
CK
OF
DE
SIR
E T
O M
AN
AG
E S
EL
F-C
AR
E(N
B-2
.3)
Edit
ion:
20
06
14
3
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•In
abil
ity t
o i
nte
rpre
t dat
a or
sel
f-m
anag
emen
t to
ols
•E
mbar
rass
men
t or
an
ger
reg
ardin
g n
eed f
or
self
-monit
ori
ng
•U
nce
rtai
nty
reg
ardin
g c
han
ges
th
at c
ould
/sh
ould
be
made
in r
espon
se t
o d
ata
in s
elf-
monit
ori
ng r
ecord
s
Cli
ent
His
tory
•D
iagn
ose
s th
at a
re a
ssoci
ated
wit
h s
elf
man
agem
ent,
e.g
., d
iabet
es m
elli
tus,
obes
ity,
car
dio
vas
cula
r dis
ease
, re
nal
or
liver
dis
ease
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., c
ognit
ive
or
emoti
onal
im
pai
rmen
t
•N
ew m
edic
al d
iagnosi
s or
chan
ge
in e
xis
ting d
iagn
osi
s or
con
dit
ion
Refe
ren
ces:
1.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Pro
vid
ing n
utr
itio
n s
ervic
es f
or
infa
nts
, ch
ildre
n, and a
dult
s w
ith d
evel
op
men
tal
dis
abil
itie
s an
d s
pec
ial
hea
lth c
are
nee
ds.
J A
m D
iet
Ass
oc.
20
04
;10
4:9
7-1
07
.
2.
Cra
wfo
rd S
. P
rom
oti
ng d
ieta
ry c
han
ge.
Ca
n J
Ca
rdio
l. 1
99
5;1
1(s
up
pl
A):
14
A-1
5A
.
3.
Fal
k L
W, B
iso
gn
i C
A,
So
bal
J. D
iet
chang
e pro
cess
es o
f par
tici
pants
in
an
in
ten
siv
e h
eart
pro
gra
m.J
Nu
tr E
du
c. 2
00
0;3
2:2
40
-25
0.
4.
Gla
sgo
w R
E, H
am
pso
n S
E,
Str
yck
er L
A, R
uggie
ro L
. P
erso
nal
-mo
del
bel
iefs
and s
oci
al-e
nvir
onm
enta
l bar
rier
s re
late
d t
o d
iabet
es s
elf-
manag
em
ent.
Dia
bet
es C
are
. 1
99
7;2
0:5
56
-56
1.
5.
Keen
an D
P,
AbuS
abha
R,
Sig
man
-Gra
nt
M,
Ach
terb
erg C
, R
uff
ing J
. F
act
ors
per
ceiv
ed t
o i
nfl
uen
ce d
ieta
ry f
at r
educt
ion b
ehavio
rs.J
Nu
tr E
du
c.1
99
9;3
1:1
34
-14
4.
6.
Ku
man
yik
a S
K,
Van
Horn
L, B
ow
en D
, P
erri
MG
, R
oll
s B
J, C
zajk
ow
ski
SM
, S
chro
n E
. M
ainte
nan
ce o
f die
tary
beh
avio
r ch
ang
e.H
ealt
h P
sych
ol.
20
00
;19
(1 s
up
pl)
:S4
2-S
56
.
7.
Sporn
y, L
A, C
onte
nto
IR
. S
tages
of
change
in d
ieta
ry f
at r
educti
on:
So
cial
psy
cholo
gic
al c
orr
elate
s.J
Nu
tr E
du
c. 1
99
5;2
7:1
91
.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
P
hys
ical A
ctivity
and F
unct
ion
IMP
AIR
ED
AB
ILIT
Y T
O P
RE
PA
RE
FO
OD
S/M
EA
LS
(NB
-2.4
)
Edit
ion:
20
06
14
4
De
fin
itio
n
Cogn
itiv
e or
ph
ysic
al i
mpai
rmen
t th
at p
reven
ts p
repar
atio
n o
f fo
ods/
mea
ls
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•L
earn
ing d
isabil
ity,
neu
rolo
gic
al o
r se
nso
ry i
mpai
rmen
t
•L
oss
of
men
tal
or
cogn
itiv
e ab
ilit
y,
e.g., d
emen
tia
•P
hysi
cal
dis
abil
ity
•H
igh l
evel
of
fati
gu
e or
oth
er s
ide
effe
ct o
f th
erap
y
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
Food/N
utr
itio
n H
isto
ryO
bse
rvat
ion
s or
report
s of:
•D
ecre
ased
over
all
inta
ke
•E
xce
ssiv
e co
nsu
mpti
on o
f co
nven
ien
ce f
oods,
pre
-pre
par
ed m
eals
, an
d f
oods
pre
par
ed a
way f
rom
hom
e re
sult
ing i
n a
n
inab
ilit
y to a
dh
ere
to n
utr
itio
n p
resc
ripti
on
•U
nce
rtai
nty
reg
ardin
g a
ppro
pri
ate
foods
to p
repar
e bas
ed u
pon n
utr
itio
n p
resc
ripti
on
•In
abil
ity t
o p
urc
has
e an
d t
ran
sport
foods
to o
ne’
s h
om
e
Cli
ent
His
tory
•C
ondit
ion
s as
soci
ate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., c
ognit
ive
impai
rmen
t, c
ereb
ral
pal
sy,
par
aple
gia
, si
gh
t
impai
rmen
t, r
igoro
us
ther
apy r
egim
en,
rece
nt
surg
ery
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
P
hys
ical A
ctivity
and F
unct
ion
IMP
AIR
ED
AB
ILIT
Y T
O P
RE
PA
RE
FO
OD
S/M
EA
LS
(NB
-2.4
)
Edit
ion:
20
06
14
5
Refe
ren
ces:
1.
Andre
n E
, G
rim
by G
. A
ctiv
ity l
imit
atio
ns
in p
erso
nal
, do
mes
tic
and v
oca
tio
nal
task
s: a
stu
dy o
f adult
s w
ith i
nborn
an
d e
arly
acq
uir
ed m
obil
ity d
isord
ers.
Dis
ab
il R
eha
bil
. 2
00
4;2
6:2
62
-27
1.
2.
Andre
n E
, G
rim
by G
. D
epen
den
ce
in d
aily
act
ivit
ies
and l
ife
sati
sfac
tion i
n a
dult
subje
cts
wit
h c
ereb
ral
pal
sy o
r sp
ina
bif
ida:
a f
oll
ow
-up s
tud
y.
Dis
ab
il R
eha
bil
. 2
00
4;2
6:5
28
-53
6.
3.
Fort
in S
, G
od
bo
ut
L, B
rau
n C
M.
Co
gnit
ive
stru
ctu
re o
f ex
ecu
tiv
e d
efic
its
in f
ronta
lly
les
ioned
hea
d t
rau
ma
pat
ients
per
form
ing
act
ivit
ies
of
dai
ly l
ivin
g.
Co
rtex
. 2
00
3;3
9:2
73
-29
1.
4.
Godb
out
L, D
ouce
t C
, F
iola
M.
The
scri
pti
ng o
f ac
tivit
ies
of
dai
ly l
ivin
g i
n n
orm
al a
gin
g:
anti
cipat
ion a
nd s
hif
ting d
efi
cits
wit
h p
rese
rvat
ion o
f se
qu
enci
ng.
Bra
in C
og
n. 2
00
0;4
3:2
20
-22
4.
5.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Pro
vid
ing n
utr
itio
n s
ervic
es f
or
infa
nts
, ch
ildre
n, and a
dult
s w
ith d
evel
op
men
tal
dis
abil
itie
s an
d s
pec
ial
hea
lth c
are
nee
ds.
J A
m D
iet
Ass
oc.
20
04
;10
4:9
7-1
07
.
6.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
Dom
esti
c fo
od a
nd n
utr
itio
n s
ecuri
ty.J
Am
Die
t A
sso
c. 2
00
2;1
02
:18
40
-18
47
.
7.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
Ad
dre
ssin
g w
orl
d h
ung
er,
maln
utr
itio
n,
and f
ood i
nse
curi
ty. J
Am
Die
t A
sso
c.2
00
3;1
03
:10
46
-10
57
.
8.
San
dst
rom
K,
Ali
nder
J, O
ber
g B
. D
escr
ipti
ons
of
fun
ctio
nin
g a
nd h
ealt
h a
nd r
elat
ion
s to
a g
ross
moto
r cl
ass
ific
atio
n i
n a
dult
s w
ith c
ereb
ral
pal
sy.
Dis
ab
il R
eha
bil
. 2
00
4;2
6:1
02
3-1
03
1.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
P
hys
ical A
ctivity
and F
unct
ion
PO
OR
NU
TR
ITIO
N Q
UA
LIT
Y O
F L
IFE
(N
QO
L)
(NB
-2.5
)
Edit
ion:
20
06
14
6
De
fin
itio
n
Dim
inis
hed
NQ
OL
sco
res
rela
ted t
o f
ood i
mpac
t, s
elf
imag
e, p
sych
olo
gic
al f
acto
rs, so
cial
/inte
rper
sonal
fac
tors
, ph
ysic
al f
acto
rs, or
self
-eff
icac
y
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms.
•F
ood-
and n
utr
itio
n k
now
ledge-
rela
ted d
efic
it
•N
ot
read
y f
or
die
t/li
fest
yle
chan
ge
•N
egat
ive
impac
t of
curr
ent
or
pre
vio
us
med
ical
nutr
itio
n t
her
apy (
MN
T)
•F
ood o
r ac
tivit
y b
ehav
ior-
rela
ted d
iffi
cult
y
•P
oor
self
-eff
icac
y
•A
lter
ed b
od
y im
age
•F
ood i
nse
curi
ty
•L
ack o
f so
cial
support
for
imple
men
ting c
han
ges
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
P
hys
ical A
ctivity
and F
unct
ion
PO
OR
NU
TR
ITIO
N Q
UA
LIT
Y O
F L
IFE
(N
QO
L)
(NB
-2.5
)
Edit
ion:
20
06
14
7
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•U
nfa
vora
ble
NQ
OL
rati
ng
•F
rust
rati
on o
r dis
sati
sfac
tion w
ith M
NT
rec
om
men
dat
ion
s
•In
acc
ura
te o
r in
com
ple
te i
nfo
rmat
ion r
elat
ed t
o M
NT
rec
om
men
dat
ions
•In
abil
ity to c
han
ge
food-
or
acti
vit
y-re
late
d b
ehavio
r
•C
once
rns
about
pre
vio
us
atte
mp
ts t
o l
earn
in
form
atio
n
•U
nw
illi
ngnes
s or
dis
inte
rest
in l
earn
ing i
nfo
rmat
ion
Cli
ent
His
tory
•N
ew m
edic
al d
iagnosi
s or
chan
ge
in e
xis
ting d
iagn
osi
s or
con
dit
ion
•R
ecen
t oth
er l
ifes
tyle
or
life
ch
anges
, e.
g., q
uit
sm
okin
g, in
itia
ted e
xer
cise
, w
ork
ch
ange,
hom
e re
loca
tion
Refe
ren
ces:
1.
Bar
r JT
, S
chum
ach
er G
E.
The
need
for
a nutr
itio
n-r
elat
ed q
ual
ity-o
f-li
fe m
easu
re.J
Am
Die
t A
sso
c. 2
00
3;1
03
:17
7-1
80
.
2.
Barr
JT
, S
chu
mach
er G
E.
Usi
ng
fo
cus
gro
up
s to
dete
rmin
e w
hat
con
stit
ute
s qu
ali
ty o
f li
fe i
n c
lients
receiv
ing
medic
al
nu
trit
ion
th
erap
y:
Fir
st s
tep
s in
th
e d
evel
op
ment
of
a n
utr
itio
n q
uali
ty-o
f-li
fe
surv
ey.
J A
m D
iet
Ass
oc.
20
03
;10
3:8
44
-85
1.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
P
hys
ical A
ctivity
and F
unct
ion
SE
LF
-FE
ED
ING
DIF
FIC
UL
TY
(NB
-2.6
)
Edit
ion:
20
06
14
8
De
fin
itio
n
Impai
red a
ctio
ns
to p
lace
food o
r bev
erag
es i
n m
outh
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•In
abil
ity to g
rasp
cups
and u
ten
sils
for
self
-fee
din
g
•In
abil
ity to s
upport
an
d/o
r co
ntr
ol
hea
d a
nd n
eck
•L
ack o
f co
ord
inat
ion o
f han
d t
o m
outh
•L
imit
ed p
hys
ical
str
ength
or
range
of
moti
on
•In
abil
ity to b
end e
lbow
or
wri
st
•In
abil
ity to s
it w
ith h
ips
squar
e an
d b
ack s
trai
ght
•L
imit
ed a
cces
s to
food
s co
nduci
ve
for
self
-fee
din
g
•L
imit
ed v
isio
n
•R
elu
ctan
ce o
r av
oid
ance
of
self
fee
din
g
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
Fin
din
gs
•D
ry m
uco
us
mem
bra
nes
, h
oar
se o
r w
et v
oic
e, t
on
gue
extr
usi
on
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
P
hys
ical A
ctivity
and F
unct
ion
SE
LF
-FE
ED
ING
DIF
FIC
UL
TY
(NB
-2.6
)
Edit
ion:
20
06
14
9
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•B
ein
g p
rovid
ed w
ith f
oods
that
may n
ot
be
con
duci
ve
to s
elf-
feed
ing,
e.g., p
eas,
bro
th-t
ype
soups
•P
oor
lip c
losu
re, dro
oli
ng
•D
roppin
g o
f cu
ps,
ute
nsi
ls
•E
moti
onal
dis
tres
s, a
nx
iety
, or
frust
rati
on s
urr
oundin
g m
ealt
imes
•F
ailu
re t
o r
ecogn
ize
foods
•F
org
ets
to e
at
•In
appro
pri
ate
use
of
food
•R
efusa
l to
eat
or
chew
•D
roppin
g o
f fo
od f
rom
ute
nsi
l (s
pla
shin
g a
nd s
pil
ling o
f fo
od)
on r
epea
ted a
ttem
pts
to f
eed
•U
ten
sil
bit
ing
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciat
ed w
ith a
dia
gn
osi
s or
trea
tmen
t of,
e.g
., n
euro
logic
al
dis
ord
ers,
Par
kin
son
’s d
isea
se, A
lzh
eim
er’s
dis
ease
, T
ardiv
e d
yskin
esia
, m
ult
iple
scl
erosi
s, s
troke,
par
alysi
s, d
evel
opm
enta
l del
ay
•P
hys
ical
lim
itat
ions,
e.g
., f
ract
ure
d a
rms,
tra
ctio
n, co
ntr
actu
res
•S
urg
ery r
equir
ing r
ecum
ben
t posi
tion
•D
emen
tia/o
rgan
ic b
rain
syn
dro
me
•D
ysp
hag
ia
•W
eig
ht
loss
•S
hort
nes
s of
bre
ath
•T
rem
ors
Refe
ren
ces:
1.
Co
nsu
ltan
t D
ieti
tian
s in
Hea
lth
care
Fac
ilit
ies.
Din
ing
Ski
lls
Su
pp
lem
ent:
Pra
ctic
al
Inte
rven
tio
ns
for
Ca
reg
iver
s o
f E
ati
ng
Dis
ab
led
Old
er A
du
lts.
Pen
saco
la,
Fla
: A
mer
ican
Die
teti
c A
sso
ciat
ion
;
19
92
.
2.
Morl
ey J
E.
Anore
xia
of
agin
g:
physi
olo
gic
al a
nd p
atholo
gic
.A
m J
Cli
n N
utr
. 1
99
7;6
6:7
60
-77
3.
3.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
ssoci
atio
n:
Pro
vid
ing n
utr
itio
n s
ervic
es f
or
infa
nts
, ch
ildre
n, and a
dult
s w
ith d
evel
op
men
tal
dis
abil
itie
s an
d s
pec
ial
hea
lth c
are
nee
ds.
J A
m D
iet
Ass
oc.
20
04
;10
4:9
7-1
07
.
4.
San
dm
an P
, N
orb
erg A
, A
dolf
sso
n R
, E
rikss
on S
, N
yst
rom
L.
Pre
val
ence
an
d c
har
act
eris
tics
of
per
son
s w
ith d
epen
den
cy o
n f
eedin
g a
t in
stit
uti
on
s.S
can
d J
Ca
rin
g S
ci. 1
99
0;4
:12
1-1
27
.
5.
Sie
bens
H,
Tru
pe
E,
Sie
ben
s A
, C
ooke
F,
An
shen S
, H
anau
er R
, O
ster
G.
Corr
elat
es a
nd c
onse
qu
ence
s of
feedin
g d
epen
den
cy.
J A
m G
eria
tr S
oc.
19
86
;34
:19
2-1
98
.
6.
Vel
las
B,
Fit
ten
LJ,
ed
s.R
esea
rch
an
d P
ract
ice
in A
lzh
eim
er’s
Dis
ease
. N
ew Y
ork
, N
Y:
Sp
rin
ger
Pu
bli
shin
g C
om
pan
y;
19
98
.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
F
ood S
afety
and A
cces
s
INT
AK
E O
F U
NS
AF
E F
OO
D(N
B-3
.1)
Edit
ion:
20
06
15
0
De
fin
itio
n
Inta
ke
of
food a
nd/o
r fl
uid
s in
tenti
onal
ly o
r unin
tenti
on
ally
con
tam
inat
ed w
ith t
oxin
s, p
ois
on
ous
pro
duct
s, i
nfe
ctio
us
agen
ts, m
icro
bia
l ag
ents
, ad
dit
ives
,
alle
rgen
s, a
nd/o
r ag
ents
of
bio
terr
ori
sm
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•L
ack o
f kn
ow
ledg
e ab
out
pote
nti
ally
un
safe
food
•L
ack o
f kn
ow
ledg
e ab
out
pro
per
food/f
eedin
g,
stor
age
and p
repar
atio
n,
e.g., i
nfa
nt
and e
nte
ral
form
ula
, or
bre
ast
mil
k
•E
xp
osu
re t
o c
on
tam
inate
d w
ater
or
food,
e.g., c
om
munit
y o
utb
reak
of
illn
ess
docu
men
ted b
y s
urv
eill
ance
and/o
r re
spon
se a
gen
cy
•M
enta
l il
lnes
s, c
on
fusi
on o
r al
tere
d a
war
enes
s
•In
adeq
uat
e fo
od s
tora
ge
equip
men
t/fa
cili
ties
, e.
g., r
efri
ger
ator
•In
adeq
uat
e sa
fe f
ood s
upply
, e.
g., i
nad
equat
e ac
cess
to m
arket
s w
ith s
afe,
un
conta
min
ate
d f
ood
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•P
osi
tive
stool
cult
ure
for
infe
ctio
us
cause
s, s
uch
as
list
eria
, sa
lmon
ella
, h
epat
itis
A,
E.
coli
,cy
closp
ora
•T
oxic
olo
gy r
eport
s fo
r dru
gs,
med
icin
als,
pois
ons
in b
lood o
r fo
od s
ample
s
Anth
ropom
etri
c M
easu
rem
ents
Phys
ical
Exam
inati
on F
indin
gs
•E
vid
ence
of
deh
ydra
tion,
e.g., d
ry m
uco
us
mem
bra
nes
, dam
aged
tis
sues
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
F
ood S
afety
and A
cces
s
INT
AK
E O
F U
NS
AF
E F
OO
D(N
B-3
.1)
Edit
ion:
20
06
15
1
Food/N
utr
itio
n H
isto
ryO
bse
rvat
ions/
report
s of
inta
ke
of
pote
nti
al
unsa
fe f
oods
(e.g
., p
regn
ant
and l
acta
tin
g w
om
en):
•M
ercu
ry c
on
tent
of
fish
an
d i
n n
on-f
ood i
tem
s
•R
aw e
ggs,
unpast
euri
zed
mil
k p
roduct
s, s
oft
ch
eese
s, u
nder
cooked
mea
ts (
infa
nts
, ch
ildre
n,
imm
un
oco
mpro
mis
ed
per
son
s, p
regnan
t an
d l
act
atin
g w
om
en, an
d e
lder
ly)
•W
ild p
lants
, ber
ries
, an
d m
ush
room
s
Obse
rvat
ions/
report
s of
unsa
fe f
ood/f
eedin
g o
r st
ora
ge
and p
repar
ati
on p
ract
ices
(en
tera
l an
d i
nfa
nt
form
ula
, or
bre
ast
mil
k)
Cli
ent
His
tory
•C
ond
itio
ns
asso
ciate
d w
ith a
dia
gnosi
s or
trea
tmen
t of,
e.g
., f
ood b
orn
e il
lnes
s, s
uch
as,
bac
teri
al,
vir
al,
and p
aras
itic
infe
ctio
n, m
enta
l il
lnes
s, d
emen
tia
•P
ois
on
ing b
y d
rugs,
med
icin
als
, or
bio
logic
al s
ubst
ance
s
•P
ois
onin
g f
rom
pois
onous
food s
tuff
s or
pois
onous
pla
nts
•D
iarr
hea
, cr
am
pin
g,
blo
atin
g, fe
ver
, n
ause
a, v
om
itin
g,
vis
ion p
roble
ms,
chil
ls,
diz
zines
s, h
eadac
he
•C
ardia
c, n
euro
logic
, re
spir
atory
ch
anges
Refe
ren
ces:
1.
Cen
ters
for
Dis
ease
Contr
ol
and P
rev
enti
on.
Dia
gnosi
s an
d M
anag
em
ent
of
Foo
dborn
e Il
lness
: A
Pri
mer
for
Phy
sici
ans.
A
vai
lab
le a
t:
ww
w.c
dc.
gov/m
mw
r/pre
vie
w/m
mw
rhtm
l/rr
53
04
a1.h
tm.
Acc
esse
d J
uly
2, 2
00
4.
2.
Fo
od
Saf
ety
and
In
spec
tio
n S
ervic
e. T
he
Fig
ht
BA
C S
urv
ey T
oo
l an
d D
ata
Entr
y T
oo
l.
Avai
lable
at:
ww
w.f
sis.
usd
a.g
ov
/OA
/fse
s/b
ac_
dat
atool.
htm
. A
cces
sed
Ju
ly 2
, 2
00
4.
3.
Ger
ald
BL
, P
erk
in J
E. F
oo
d a
nd
wat
er s
afe
ty.J
Am
Die
t A
sso
c. 2
00
3;1
03
:120
3-1
21
8.
4.
Par
tner
ship
for
Foo
d S
afe
ty E
duca
tio
n.
Fou
r st
eps.
A
vail
able
at:
htt
p:/
/ww
w.f
ightb
ac.
org
/fours
tep
s.cf
m?se
cti
on=
4.
Acc
esse
d J
uly
2,
20
04
.
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
F
ood S
afety
and A
cces
s
LIM
ITE
D A
CC
ES
S T
O F
OO
D(N
B-3
.2)
Edit
ion:
20
06
15
2
De
fin
itio
n
Dim
inis
hed
abil
ity to a
cquir
e fo
od f
rom
sourc
es (
e.g., s
hoppin
g,
gar
den
ing,
mea
l del
iver
y),
due
to f
inan
cial
con
stra
ints
, ph
ysic
al i
mpai
rmen
t, c
areg
iver
support
,
or
un
safe
liv
ing c
on
dit
ion
s (e
.g. cr
ime
hin
der
s tr
avel
to g
roce
ry s
tore
). L
imit
atio
n t
o f
ood b
ecau
se o
f co
nce
rns
about
wei
ght
or
agin
g.
Eti
olo
gy
(Cause
/Contr
ibuti
ng R
isk
Fact
ors
)
Fac
tors
gat
her
ed d
uri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
th
at c
on
trib
ute
to t
he
exis
tence
or
the
mai
nte
nan
ce o
f path
oph
ysio
logic
al,
psy
choso
cial,
sit
uat
ional,
dev
elopm
enta
l, c
ult
ura
l, a
nd/o
r en
vir
onm
enta
l pro
ble
ms:
•C
areg
iver
in
ten
tional
ly o
r unin
tenti
onall
y n
ot
pro
vid
ing a
cces
s to
food,
e.g
., u
nm
et n
eeds
for
food o
r ea
ting a
ssis
tan
ce, ab
use
/neg
lect
•C
om
munit
y a
nd g
eogra
phic
al c
on
stra
ints
for
shoppin
g a
nd t
ran
sport
atio
n
•L
ack o
f fi
nan
cial
reso
urc
es o
r la
ck o
f ac
cess
to f
inan
cial
res
ourc
es t
o p
urc
hase
suff
icie
nt
food
•L
imit
ed o
r ab
sen
t co
mm
un
ity s
upple
men
tal
food p
rogra
ms,
e.g
., f
ood p
antr
y,
shel
ter
•F
ailu
re t
o p
arti
cipat
e in
food p
rogra
ms
such
as
WIC
, N
atio
nal
Sch
ool
Lunch
Pro
gra
m,
food s
tam
ps
•P
hys
ical
or
psy
cholo
gic
al l
imit
atio
ns
that
dim
inis
h a
bil
ity t
o s
hop,
e.g
., w
alkin
g,
sigh
t, m
enta
l/em
oti
onal
hea
lth
Sig
ns
/Sy
mp
tom
s(D
efin
ing C
hara
cteri
stic
s)
A t
ypic
al
clust
er o
f su
bje
ctiv
e an
d o
bje
ctiv
e si
gn
s an
d s
ympto
ms
gath
ered
duri
ng t
he
nutr
itio
n a
sses
smen
t pro
cess
that
pro
vid
e ev
iden
ce t
hat
a pro
ble
m e
xis
ts;
quan
tify
th
e pro
ble
m a
nd d
escr
ibe
its
sever
ity.
Nutritio
n A
sses
smen
t Cate
gory
Pote
ntial I
ndic
ato
rs o
f th
is N
utritio
n D
iagnosis
(one o
r m
ore
must
be p
rese
nt)
Bio
chem
ical
Data
•In
dic
ator
s of
macr
on
utr
ien
t or
vit
amin
/min
eral
sta
tus
Anth
ropom
etri
c M
easu
rem
ents
•G
row
th f
ailu
re, bas
ed o
n N
atio
nal
Cen
ter
for
Hea
lth S
tati
stic
s (N
CH
S)
gro
wth
sta
ndar
ds
•U
nder
wei
ght
(BM
I <
18.5
)
Phys
ical
Exam
Fin
din
gs
•F
ind
ings
con
sist
ent
wit
h v
itam
in o
r m
iner
al
def
icie
ncy
BE
HA
VIO
RA
L-E
NV
IRO
NM
EN
TA
L D
OM
AIN
F
ood S
afety
and A
cces
s
LIM
ITE
D A
CC
ES
S T
O F
OO
D(N
B-3
.2)
Edit
ion:
20
06
15
3
Food/N
utr
itio
n H
isto
ryR
eport
s or
obse
rvat
ion
s of:
•F
ood f
add
ism
•B
elie
f th
at
agin
g c
an b
e sl
ow
ed b
y d
ieta
ry lim
itat
ion
s an
d e
xtr
eme
exer
cise
•H
un
ger
•In
adeq
uat
e in
take
of
food a
nd
/or
spec
ific
nutr
ien
ts
•L
imit
ed s
upply
of
food i
n h
om
e
•L
imit
ed v
arie
ty o
f fo
ods
Cli
ent
His
tory
•M
aln
utr
itio
n,
vit
amin
or
min
eral
def
icie
ncy
•Il
lnes
s or
ph
ysic
al d
isab
ilit
y
•C
ondit
ion
s as
soci
ate
d w
ith a
dia
gnosi
s or
trea
tmen
t, e
.g., m
enta
l il
lnes
s, d
emen
tia
•L
ack o
f su
itab
le s
upport
sys
tem
s
Refe
ren
ces:
1.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
Dom
esti
c fo
od a
nd n
utr
itio
n s
ecuri
ty.J
Am
Die
t A
sso
c. 2
00
2;1
02
:18
40
-18
47
.
2.
Posi
tion o
f th
e A
mer
ican
Die
teti
c A
sso
ciat
ion:
Addre
ssin
g w
orl
d h
ung
er,
maln
utr
itio
n,
and f
ood i
nse
curi
ty.J
Am
Die
t A
sso
c. 2
00
3;1
03
:10
46
-10
57.
SUBJECT: NUTRITION CONTROLLED VOCABULARY/TERMINOLOGY
MAINTENANCE/REVIEW
SUBJECT: NUTRITION CONTROLLED
VOCABULARY/TERMINOLOGY
MAINTENANCE/REVIEW
AMERICAN DIETETIC
ASSOCIATION120 South Riverside Plaza Suite 2000
CHICAGO, ILLINOIS 60606-6995
Effective Date: April 2005
Revision Date: June 2006
Review Date:
PURPOSE:
This policy establishes the has established the process followed by the Nutrition Care
Process/Standardized Language (NCP/SL) Committee to maintain a current Nutrition Care
Process and list of nutrition controlled vocabulary terminology that document the Nutrition Care
Process.
STRUCTURE:
The NCP/SL Committee is a joint House of Delegates and Board of Directors Committee and
provides semi-annual reports to both bodies.
PROCEDURES:
The NCP/SL Committee accepts proposals for modification or additions to the Nutrition
Diagnostic Terminology as follows:
1. Any individual ADA member or Dietetic Practice Group can submit proposals for
modification or additions by completing the attached two documents:
a. Proposed Nutrition Diagnostic Terminology Modification/Addition letter
b. Reference worksheet for proposed modification/addition
2. The NCP/SL will review the submissions at their routine face-to-face meetings or
teleconferences to establish the following:
a. Is the term already represented by an existing term?
i. If so the new term can be added as a synonym for the existing term or
replace the existing term.
ii. If not, then the term can be considered for addition to the list of terms as
long as it meets the need for describing elements of dietetic practice in the
context of the nutrition care process.
b. Does the term overlap with an existing term, but add new elements?
i. If yes, then the existing term can be modified to include the new elements
or the proposed term can be clarified to be distinctly different from the
existing term through a dialogue with the proposal submitter.
ii. If no, then consider adding new term.
c. Is the term distinct and separate from all existing terms?
i. If yes, then ensure that the term is in the context of dietetic practice within
the Nutrition Care Process and consider adding to list of terms.
ii. If no, then work with proposal submitter to discuss how to integrate into
existing terms or create a separate term.
3. The NCP/SL Committee will prepare a summary of comments and one representative of
the NCP/SL will confer with the proposal submitter after the initial discussion to answer
Edition: 2006 154
SUBJECT: NUTRITION CONTROLLED VOCABULARY/TERMINOLOGY
MAINTENANCE/REVIEW
questions and discuss the initial input from the NCP/SL Committee. If the proposal
submitter is not satisfied with the direction proposed by the NCP/SL Committee, then
they will be invited to submit additional documentation and have time on the next
teleconference/meeting agenda to personally present their concerns.
4. Changes or modifications accepted by the NCP/SL Committeewill be integrated into the
list that is re-published on an annual basis.
STAFFING:
Governance and Scientific Affairs and Research provide staff support to NCP/SL Committee and
for Research Committee functions.
Attachments
1. Letter template for proposing a New Term for Nutrition Diagnostic Terminology
2. Letter template for proposing Modifications to Nutrition Diagnostic Terminology
3. Template for Reference Sheet to support additions/modifications to Nutrition
Diagnostic Terminology
4. Completed Reference Sheet Example (Case with PES statement not included)
Edition: 2006 155
SUBJECT: NUTRITION CONTROLLED VOCABULARY/TERMINOLOGY
MAINTENANCE/REVIEW
Attachment 1: Letter Template for Proposing a New Term for Nutrition Diagnostic
Terminology
Date: _____________
To: NCP/SL Committee
Scientific Affairs and Research
American Dietetic Association
120 South Riverside Plaza, Suite 2000
Chicago, IL 60606-6995
[email protected]; [email protected]
Subject: Proposed Addition to Nutrition Diagnostic Terminology
(I/We) would like to propose a new term, _____________________(Proposed term to add to
the Nutrition Diagnostic Terminology list). The reason I/we believe that this term should be
added is as follows (insert concise rationale for change and may include brief example of
when the situation arose that the current term was inadequately defined):
1. (Insert first statement of rationale.)
2. (Insert second statement of rationale, if applicable.)
3. (Insert example of situation where this modification was needed.)
Other terms that are similar and explanations of why they do not exactly match our new
proposed term are as follows:
1. (Insert number and name.) – (Insert 2-3 sentences to illustrate why the existing term
does not meet your need.)
2. (Insert number and name.) – (Insert 2-3 sentences to illustrate why the existing term
does not meet your need.)
3. (Add as many as applicable.)
Attached is the a reference sheet that includes the label, description, proposed domain and
category, examples of etiologies and signs and symptoms and a case that illustrates when this
term would be used and the corresponding PES statement that would be used in medical
record documentation.
The point of contact for this proposal is ___________________________________ (insert
name), who can be reached at ______(best contact telephone number) and _______(e-mail
address).
Thank you for considering our request.
Signature block
(Organizational unit if applicable)
Attachments: (1) Completed Reference Sheet Template (Case and PES statement example not
included)
Edition: 2006 156
SUBJECT: NUTRITION CONTROLLED VOCABULARY/TERMINOLOGY
MAINTENANCE/REVIEW
Attachment 2: Letter Template for Proposing Modifications to Nutrition Diagnostic
Terminology
Date: ____________________
To: NCP/SL Committee
Scientific Affairs and Research
American Dietetic Association
120 South Riverside Plaza, Suite 2000
Chicago, IL 60606-6995
[email protected]; [email protected]
Subject: Proposed Modification to Existing Nutrition Diagnostic Terminology
(I/We) would like to propose a modification or the term, _____________________(insert
Number and Name from current Nutrition Diagnostic Terminology list). The reason I/we
believe that this term should be modified is as follows (insert concise rationale for change
and may include brief example of when the situation arose that the current term was
inadequately defined):
1. (Insert first statement of rationale.)
2. (Insert second statement of rationale, if applicable.)
3. (Insert example of situation where this modification was needed.)
Attached is the revised reference sheet which shows the changes highlighted or bolded for
your consideration.
The point of contact for this proposal is ___________________________________ (insert
name), who can be reached at ______(best contact telephone number) and _______(e-mail
address).
Thank you for considering our request.
Signature block
(Organizational unit if applicable)
Attachments: (1) Completed Reference Sheet Template
Edition: 2006 157
SUBJECT: NUTRITION CONTROLLED VOCABULARY/TERMINOLOGY
MAINTENANCE/REVIEW
Attachment 3: Template for Reference Sheet for New Term or Proposing Modifications
Select DOMAIN: CLINICAL/FUNCTIONAL or BEHAVIORAL/ENVIRONMENTAL
Select Category, e.g., Functional Balance
Nutrition Diagnostic Label (Leave number blank, if new term.)
Insert a 1-4 word label.
Definition of Nutrition Diagnostic Label Insert 1 sentence or bullet that describes the intent of the new or modified label.
Etiology (Cause/Contributing Risk Factors)
Factors gathered during the nutrition assessment process that contribute to the existence of or the maintenance of
pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems:
Insert common etiologies for Nutrition Diagnostic Label
Signs/Symptoms (Defining Characteristics) A typical cluster of subjective and objective signs and symptoms
gathered during the nutrition assessment process that provide evidence that a problem exists; quantify the problem
and describe its severity.
Nutrition AssessmentCategory
Potential Indicators of this Nutrition Diagnosis (one or more must be present)
Biochemical Data (Insert as appropriate.)
Anthropometric Measurements (Insert as appropriate.)
Physical Exam Findings (Insert as appropriate.)
Food/Nutrition History (Insert as appropriate.)
Client History (Insert as appropriate.)
Edition: 2006 158
SUBJECT: NUTRITION CONTROLLED VOCABULARY/TERMINOLOGY
MAINTENANCE/REVIEW
Attachment 4: Template for Completed Reference Sheet
DOMAIN: CLINICAL/FUNCTIONAL
Category: Functional Balance
Nutrition Diagnostic Label (NC-1.1.)
Swallowing difficulty.
Definition of Nutrition Diagnostic Label Impaired movement of food and liquid from the mouth to the stomach.
Etiology (Cause/Contributing Risk Factors)
Factors gathered during the nutrition assessment process that contribute to the existence of or the maintenance of
pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems:
Mechanical causes such as inflammation; surgery; stricture; or oral, pharyngeal and esophageal
tumors
Motor causes, e.g., neurological or muscular disorders such as cerebral palsy, stroke, multiple
sclerosis, scleroderma, or prematurity
Signs/Symptoms (Defining Characteristics) A typical cluster of subjective and objective signs and symptoms
gathered during the nutrition assessment process that provide evidence that a problem exists; quantify the problem
and describe its severity.
Nutrition AssessmentCategory
Potential Indicators of this Nutrition Diagnosis (one or more must be present)
Biochemical Data
Anthropometric Measurements
Physical Exam Findings Evidence of dehydration, e.g., dry mucous membranes, poor skin
turgor
Food/Nutrition History Observations or reports of:
Coughing, choking, prolonged chewing, pouching of food,
regurgitation, facial expression changes during eating, prolonged
feeding time, drooling, noisy wet upper airway sounds, feeling of
“food getting stuck,” pain while swallowing
Decreased food intake
Avoidance of foods
Mealtime resistance
Client History Conditions associated with a diagnosis or treatment of dysphagia,
achalasia
Radiological findings, e.g., abnormal swallowing studies
Repeated upper respiratory infections and/or pneumonia
Edition: 2006 159
2003-2005 Standardized Language Task Force and Terminology Expert Reviewers
Edition: 2006 160
Standardized Language Task Force
Chair
Sylvia Escott-Stump, MA, RD, LDN
Dietetic Programs Director
East Carolina University
155 Rivers Building, Dept. NUHM
Greenville, NC 27858
Task Force Member 2003-2005
Peter Beyer, MS, RD, LD
Associate Professor
University of Kansas Medical Center
7315 Rosewood Drive
Prairie Village, KS 66208-2458
Task Force Member 2003-2005
Christina Biesemeier MS, RD, LDN, FADA
313 Logans Circle
Franklin TN 37067-1363
Task Force Member 2003-2005
Pam Charney, MS, RD, CNSD
2460 64th Ave SE
Mercer Island, WA 98040
Task Force Member 2003-2005
Marion Franz, MS, RD, CDE
6635 Limerick Dr.
Minneapolis, MN 55439-1260
Task Force Member 2003-2005
Karen Lacey, MS, RD, CD
500 Saint Mary’s Blvd
Green Bay, WI 54301-2610
Task Force Member 2003-2005
Kathleen Niedert, MBA, RD, LD, FADA
PO Box 843
110 Ardis Street
Hudson, IA 50643-0843
Task Force Member 2003-2005
Mary Jane Oakland, PhD, RD, LD, FADA
1612 Truman Drive
Ames, IA 50010-4344
Task Force Member 2003-2005
Patricia Splett, PhD, MPH, RD
Splett & Associates
3219 Midland Avenue
St. Paul, MN 55110
Task Force Member 2003-2005
Frances Tyus, MS, RD, LD
19412 Mayfair Ln
Cleveland, OH 44128-2727
Task Force Member 2003-2005
Naomi Trostler, PhD, RD
Institute of Biochemistry, Food Science, and
Nutrition
Faculty of Agriculture, Food and Environmental
Quality Sciences
The Hebrew University of Jerusalem
PO Box 12
Rehovot 76100, Israel
Task Force Member 2004-2005
Robin Leonhardt, RD
1905 North 24th Street
Sheboygan, WI 53081-2124
Attended Face to Face Meeting in Summer
2003
Staff Liaisons
Esther Myers, PhD, RD, FADA
Director of Scientific Affairs and Research
ADA Headquarters
120 South Riverside Plaza, Suite 2000
Chicago, IL 60606-6995
Work (312) 899-4860
Fax (312) 899-4757
E-mail: [email protected]
Ellen Pritchett, RD, CPHQ
Director, Quality and Outcomes
ADA Headquarters
120 South Riverside Plaza, Suite 2000
Chicago, IL 60606-6995
Work (312) 899-4823
Fax (312) 899-4757
E-mail: [email protected]
Staff Liaison 2003-2005
Lt Col Vivian Hutson, MA, MHA, RD, LD,
Fellow,
American College of Healthcare Executives
Staff Liaison 2003-2004
2003-2005 Standardized Language Task Force and Terminology Expert Reviewers
Consultants
Donna G. Pertel, MEd, RD
5 Bonny Lane
Clinton, CT 06413
Patricia Splett, PhD, MPH, RD
Splett & Associates
3219 Midland Avenue
St. Paul, MN 55110
Melinda L. Jenkins, Ph.D., FNP
Assistant Professor of Clinical Nursing
Columbia University School of Nursing
630 W. 168 St., mail code 6
New York, NY 10032
Annalynn Skipper, MS, RD, FADA
P.O. Box 45
Oak Park, IL 60303
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2003-2005 Standardized Language Task Force and Terminology Expert Reviewers
(Cornell)
Increased energy expenditure (when
part of hypermetabolism)
NI-1.2 Jonathan Waitman, MD for Louis Arrone, MD
(Cornell)
Hypometabolism NI-1.3 Edith Lerner, PhD (Case Western Reserve University)
Inadequate energy intake NI-1.4 Joel Mason, MD (Tufts)
Excessive energy intake NI-1.5 Jim Hill, MD (University of Colorado)
INTAKE DOMAIN – Oral or Nutrition Support Intake
Inadequate oral food/beverage intake NI-2.1 Anne Voss, PhD, RD (Ross Labs)
Excessive oral food/beverage intake NI-2.2 Jessica Krenkel, MS, RD (University of Nevada)
Inadequate intake from
enteral/parenteral nutrition
NI-2.3 Kenneth Kudsk, MD (University of Wisconsin)
Excessive intake from
enteral/parenteral nutrition
NI-2.4 Annalynn Skipper, MS, RD (University of Nebraska
Lincoln)
Inappropriate infusion of
enteral/parenteral nutrition
NI-2.5 Annalynn Skipper, MS, RD (University of Nebraska-
Lincoln)
INTAKE DOMAIN – Fluid Intake Balance
Inadequate fluid intake NI-3.1 Ann Grandjean, EdD, RD (International Center for
Sports Nutrition)
Excessive fluid intake NI-3.2 Joel Kopple, MD (UCLA)
INTAKE DOMAIN – Bioactive Substances Intake Balance
Inadequate bioactive substance intake NI-4.1 Johanna Lappe, PhD, RN (Creighton)
Excess bioactive substance NI-4.2 Elizabeth Jeffery, PhD (Univ. of IL, Champaign)
Excessive alcohol intake NI-4.3 Janice Harris, PhD, RD (University of Kansas)
INTAKE DOMAIN – Nutrient Intake Balance
Increased nutrient needs (specify) NI-5.1 Carol Braunschweig, PhD, RD (University of Illinois,
Chicago)
Evident protein-energy malnutrition NI-5.2 Charlette R. Gallagher Allred, PhD, RD (Retired-Ross
Labs)
Inadequate protein energy intake NI-5.3 Trisha Fuhrman, MS, RD, FADA, CNSD (Coram, Inc.)
Decreased nutrient needs (specify) NI-5.4 Jeannmarie Beiseigel, PhD, RD (USDA)
Imbalance of nutrients NI-5.5 Molly Kretsch, PhD, RD (USDA)
INTAKE DOMAIN – Nutrient Balance – Fat and Cholesterol Balance
Inadequate fat intake NI-51.1 Alice Lichtenstein, DSc (Tufts)
Excessive fat intake NI-51.2 Wendy Mueller Cunnigham, PhD, RD (Cal State)
Inappropriate intake of food fats NI-51.3 Nancy Lewis, PhD, RD (University of Nebraska-
Lincoln)
INTAKE DOMAIN – Nutrient Balance – Protein Balance
Inadequate protein intake NI-52.1 Don Layman, PhD (University of Illinois-Champaign)
Excessive or unbalanced protein intake NI-52.2 Linda A. Vaughan, PhD, RD (Arizona State)
Inappropriate intake of amino acids NI-52.3 Allison Yates, PhD, RD (Industry, formerly Director of
the IOM Food and Nutrition Board)
INTAKE DOMAIN – Nutrient Balance – Carbohydrate Balance
Inadequate carbohydrate intake NI-53.1 Robert Wolfe, PhD (University of Texas Medical
Branch)
Excessive carbohydrate intake NI-53.2 Anne Daly, MS, RD
Inappropriate intake of types of
carbohydrate
NI-53.3 Lyn Wheeler, MS, RD, CD, FADA, CDE (Indiana
University School of Medicine)
Inconsistent intake of carbohydrate NI-53.4 Maggie Powers, MS, RD, CDE (International Diabetes
Center)
Inadequate fiber intake NI-53.5 Joanne Slavin, PhD, RD (University of Minnesota)
Excess fiber intake NI-53.6 Judith Marlett, PhD, RD (University of Wisconsin)
INTAKE DOMAIN – Nutrient Balance – Vitamin Balance
Inadequate vitamin intake (specify) NI-54.1 Laurie A. Kruzich, MS, RD (Iowa State)
Kristina Penniston, PhD, RD (University of Wisconsin)
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2003-2005 Standardized Language Task Force and Terminology Expert Reviewers
Expert Reviewers
Nutrition Diagnosis Labels
Nutrition Diagnostic Label Dx Label # Reviewers
CLINICAL DOMAIN – Functional Balance
Swallowing difficulty NC-1.1 Moshe Shike, MD (Memorial Sloan Kettering)
Chewing (masticatory) difficulty NC-1.2 Helen Smiciklas-Wright, PhD, RD (Penn State)
Riva Touger-Decker, PhD, RD (UMDNJ)
Breastfeeding difficulty NC-1.3 Maureen A. Murtaugh, PhD, RD (University of Utah)
Altered GI function NC-1.4 Larry Cheskin, MD (Johns Hopkins)
CLINICAL DOMAIN – Biochemical Balance
Impaired nutrient utilization NC-2.1 Laura Matarese, MS, RD, CNSD (Cleveland Clinic)
Altered nutrition-related laboratory
values
NC-2.2 Denise Baird Schwartz, MS, RD, CNSD (Clinical
practice)
Food-medication interaction NC-2.3 Andrea Hutchins, PhD, RD (Arizona State University
East, Mesa, AZ)
CLINICAL DOMAIN – Weight Balance
Underweight NC-3.1 Bonnie Spear, PhD, RD (University of Alabama,
Birmingham)
Involuntary weight loss NC-3.2 Jody Vogelzang, MS, RD, LD, CD, FADA (Texas
Women’s University)
Overweight/obesity NC-3.3 Rebecca Mullis, PhD, RD (Georgia)
Involuntary weight gain NC-3.4 Celia Hayes, MS, RD (HRSA)
BEHAVIORAL-ENVIRONMENTAL DOMAIN – Knowledge and Beliefs
Food- and nutrition-related knowledge
deficit
NB-1.1 Penny Kris-Etherton, PhD, RD (Penn State)
Harmful beliefs/attitudes about food,
nutrition, and nutrition-related topics
NB-1.2 Keith-Thomas Ayoob, PhD, RD (Albert Einstein)
Not ready for diet/lifestyle change NB-1.3 Geoffrey Greene, PhD, RD (University of Rhode
Island)
Self-monitoring deficit NB-1.4 Linda Delahanty, MS, RD (Harvard)
Disordered eating pattern NB-1.5 Eileen Stellefson Myers, PhD, RD (Private practice)
Leah Graves, MS, RD (Saint Francis Hospital, Tulsa,
OK)
Limited adherence to nutrition-related
recommendations
NB-1.6 Ellen Parham, PhD, RD (Northern IL)
Undesirable food choices NB-1.7 Kathy Cobb, MS, RD (Centers for Disease Control)
BEHAVIORAL-ENVIRONMENTAL DOMAIN – Physical Activity Balance and Function
Physical inactivity NB-2.1 Melinda Manore, PhD, RD (Oregon State)
Excessive exercise NB-2.2 Katherine Beals, PhD, RD (Industry, formerly Ball
State)
Inability to manage self-care NB-2.3 Emily Gier, MS, RD (Cornell)
Impaired ability to prepare foods/meals NB-2.4 Marla Reicks, PhD, RD (U of MN)
Poor nutrition quality of life NB-2.5 Elvira Johnson, MS, RD (Private practice)
Self-feeding difficulty NB-2.6 Mary Cluskey, PhD, RD (Oregon State)
BEHAVIORAL-ENVIRONMENTAL DOMAIN – Food Safety and Access
Intake of unsafe food NB-3.1 Johanna Dwyer, DSc, RD (Tufts)
Limited access to food NB-3.2 Sondra King, PhD, RD (Northern Illinois University)
INTAKE DOMAIN – Caloric Energy Balance
Hypermetabolism NI-1.1 Jonathan Waitman, MD for Louis Arrone, MD
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2003-2005 Standardized Language Task Force and Terminology Expert Reviewers
Excess vitamin intake (specify) NI-54.2 Kristina Penniston, PhD, RD (University of Wisconsin)
INTAKE DOMAIN – Nutrient Balance – Mineral Balance
Inadequate mineral intake (specify) NI-55.1 Bob Heaney, MD (Creighton)
Excessive mineral intake (specify) NI-55.2 Joan Fischer, PhD, RD (University of Georgia)
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from the associationOF PROFESSIONAL INTEREST
Implementing Nutrition Diagnosis, Step Two in theNutrition Care Process and Model: Challenges and
Lessons Learned in Two Health Care FacilitiesJennifer Mathieu; Mandy Foust, RD; Patricia Ouellette, RD
In adherence to the American Die-tetic Association’s (ADA) StrategicPlan goal of establishing and im-
plementing a standardized NutritionCare Process (NCP) in the hopes of“increasing demand and utilization ofservices provided by members” (1), di-etetics professionals in two healthcare facilities established an NCP pi-lot program in 2005, in collaborationwith ADA. The pilot sites were theVirginia Hospital Center in Arlingtonand the Veterans Affairs MedicalCenter in San Diego, CA.
This article gives a background onthe NCP and model, the standardizedlanguage used in the nutrition diag-nosis step, medical record documen-tation, and an explanation of how thetwo sites came to participate in thepilot program. It also provides a time-line for each site’s implementation ofthe NCP, including challenges facedand lessons learned. Similarities anddifferences in approaches will also bediscussed. Managers from both facili-ties will offer advice to facilities whoare contemplating implementation ofthe NCP and nutrition diagnoses inthe future.
BACKGROUNDADA developed a four-step NCP andModel that appeared in the August2003 issue of the Journal. The NCP
consists of four “distinct but interre-lated and connected steps”—Nutri-tion Assessment, Nutrition Diagno-sis, Nutrition Intervention, andNutrition Monitoring and Evaluation(2). The NCP and Model were devel-oped by the Quality ManagementCommittee Work Group with inputfrom the House of Delegates.
This new model calls for dieteticsprofessionals to incorporate a newstep—making a nutrition diagnosis—which involves working with definedterminology. It also asks dieteticsprofessionals to chart their diagnosisin the form of a statement that estab-lishes the patient’s problem (diagnos-tic label), etiology (cause/contributingrisk factors), and signs and symptoms(defining characteristics). This isknown as a PESS statement, andmakes up the heart of the NCP’s sec-ond step—nutrition diagnosis.
“The second step is the cultureshift,” says Susan Ramsey, MS, RD,CDE, LDN, senior manager of medi-cal nutrition services for Sodexho whoalso serves on ADA’s Research Com-mittee. “The second step forces us tomake a one-line statement. It bringsthe whole assessment into one clearvision.”
According to the article by Laceyand Pritchett, using the new modelprovides many benefits. The modeldefines a common language that al-lows nutrition practice to be moremeasurable, creates a format that en-ables the process to generate quanti-tative and qualitative data that canthen be analyzed and interpreted,serves as the structure to validate nu-trition care, and shows how the carethat was provided does what it in-tends to do (2). It also gives the pro-fession a greater sense of autonomy,says Ramsey. “It’s given us responsi-
bility for our work instead of lookingfor permission from others.”
The nutrition diagnostic labels andreference sheets were developed bythe Standardized Language TaskForce, chaired by Sylvia Escott-Stump, MA, RD, LDN. It is from thislist that dietetics professionals utiliz-ing the NCP list the P (problem) partof their PESS statement. According toEscott-Stump, this StandardizedLanguage will help bring dieteticsprofessionals a new focus and theability to target their interventionsinto more effective results that willmatch the patient nutrition diagnosis(problem).
It is Escott-Stump’s belief that doc-umenting nutrition diagnoses, inter-ventions, and outcomes will allow fordietetics professionals to better trackdiagnoses over several clients, allow-ing the profession to be more likely totrack the types of nutrition diagnosesthat clients have, and be able to statethat the profession affects certaintypes of acute and chronic diseasesmore than others.
“For example, now we believe thatour impact on cardiovascular, endo-crine, and renal diseases is strong,but we may find that our profession-als impact gastrointestinal disordersthe most,” says Escott-Stump. “Byhaving standardized language, wewill be able to validate or correct oursuspicions.”
This pilot implementation of thenutrition care model also tested a newmethod of charting that differs fromthe traditional Subjective ObjectiveAssessment Plan format (SOAP). Thenew ADI template stands for Assess-ment, Diagnosis, and Intervention(including Monitoring and Evalua-tion).
According to Dr Esther Myers,
J. Mathieu is xxx, Houston, TX.M. Foust is xxx. P. Ouellette isxxx.
Address correspondence to: Jen-nifer Mathieu, 5639 Berry CreekDr, Houston, TX 77017. E-mail:[email protected]/05/xx0x-0000$30.00/0doi: 10.1016/j.jada.2005.07.015
© 2005 by the American Dietetic Association Journal of the AMERICAN DIETETIC ASSOCIATION 1Edition: 2006 165
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PhD, RD, FADA, ADA’s Research andScientific Affairs director, ADA plansto expand these two pilot teststhrough the Peer Network for Nutri-tion Diagnosis in the next 2 years.This group of dietetics professionalswill receive additional training andnetworking opportunities to assistthem as they implement this newmodel within their facility and thenshare their knowledge with other di-etetics professionals in their geo-graphical region.
Their experience will be used to de-termine what additional implementa-tion tools are needed. In addition, aformal research project will be con-ducted through the Dietetics PracticeBased Research Network in early2006.
IMPLEMENTATION OF THE PROGRAMVirginia Hospital CenterMandy Foust, RD and Clinical Nutri-tion Manager of the Virginia HospitalCenter, is contracted through So-dexho to oversee patient services atthe 400-bed facility. In December2004, Foust, who had learned aboutPESS statements while in school, de-cided to have her college dietetic in-tern Anne Avery research currentchanges and updates in charting fordietetics professionals.
Avery spoke with Dr Myers and dis-cussed the possibility of the VirginiaHospital Center serving as a pilot sitefor the new model. Foust was excitedabout the idea for several reasons. “Tome, the nutrition care model is a clin-ically based, concise way of chartingthat sets goals and is more standard-ized with other disciplines,” she says.Until the implementation of the pilotproject, the RDs on staff at the Vir-ginia Hospital Center used the SOAPformat of charting.
A conference call took place be-tween Foust, Dr Myers, Avery, andAvery’s internship director at Vir-ginia Tech. Foust selected one of herfive inpatient registered dietitians(RDs) to serve as the first RD to usethe new method. It was decided Averywould present an in-service on thenutrition care model to the dieteticsprofessionals on staff. This in-serviceprovided the RDs with introductoryinformation, the four steps of theNCP, PESS statements, diagnosticlabeling, and why the changes wouldbe beneficial.
Foust says there were concernsfrom her staff about the new method.These included that the new ADIcharting format would not allow themto be thorough enough and that itseemed “too cookie cutter.” Staff alsoexpressed concern that it would bedifficult to sum up two or more seri-ous problems in one PESS statement.They also worried that physicianswould be wary of the term “nutritiondiagnosis.”
Over several days in mid-Decem-ber, Foust arranged meetings withseveral hospital administrators, in-cluding the vice president of the hos-pital, the chief nursing officer, themedical staff president, and the chiefof the nutrition committee to get theirfeedback on the pilot project. She alsokept her supervisor at Sodexhoabreast of the situation. “Because Iam a contractor, I want to make sureI’m covering my bases,” says Foust.She says the Virginia Hospital Centeris “very interdisciplinary” and thatshe wanted there to be an awarenessof the upcoming changes.
Administrators initially had ques-tions about how the new methodwould benefit patients, but Foust saysafter she met with them and pre-sented them with information on thenutrition care model, they were recep-tive to the changes. The physicianwho served as chief of the hospital’snutrition committee had concernsabout the idea of a nutrition diagno-sis. Foust says she reassured himthat the new method did not ask RDsto make a medical diagnosis or inter-fere with a physician’s orders.
After the nutrition committee ap-proved the project in early January2005, Foust was asked to inform sev-eral other hospital staff membersabout the new format, including thechief of surgery and the chief of sur-gical education. Because the first RDto participate in the pilot projectworked in the intensive care unit(ICU), Foust was also asked to notifythe medical director of the ICU, twoICU nurse educators, and the ICUpatient care director via formal let-ters. Responses to these letters en-couraged Foust to seek approval forthe project from the hospital’s pa-tient-monitoring committee.
During the end of January whilewaiting for a response from the pa-tient-monitoring committee, Foustmet for about an hour each week with
the RD who would be the first to usethe new method. The RD used actualpatients from her daily census to be-gin practicing PESS statements andADI charting. Foust shared the re-sults with Dr Myers and the Stan-dardized Language Task Force often.Through early to mid-February theRD submitted her notes in both theSOAP format and the new format as away of practicing the new method.
At the end of January, the patient-monitoring committee gave theproject its approval. Before imple-mentation officially occurred, Foustrequested permission and modifiedthe Hakel-Smith Coding Instrumentas an auditing tool to evaluate thecharts. She also developed a question-naire for allied health professionals togive feedback on the new system ofcharting.
On February 16, 2005, the ICU RD,Korinne Umbaugh, officially begansubmitting all of her notes using theADI template. Foust audited two tothree charts each day. In late Febru-ary, a second RD began using the newmethod of charting. On March 28, athird RD began the process. By themiddle of April, all five RDs were us-ing the ADI template, with the fifthRD beginning the process on the sec-ond week of the month.
Throughout the entire transitionFoust met formally and informallywith staff RDs both individually andin groups. Foust says at least 20 min-utes of each weekly hour-long staffmeeting continues to be spent dis-cussing the new method of chartingand reviewing PESS statements. Atthis time Foust is editing about 10%of the charts.
Unfortunately, Foust did not re-ceive as many completed question-naires as she hoped for from alliedhealth professionals. However, herinitial chart audits showed that bythe end of April the staff had becomemuch more comfortable with the pro-cess. Audits revealed notes thatsteadily became more direct and con-cise, as well as more outcome-ori-ented. Extraneous information wasnot included as often.
Veterans Affairs Medical Center, SanDiegoPatricia Ouellette, RD, is the deputydirector of nutrition and food servicesfor the Veterans Affairs Medical Cen-
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ter in San Diego, CA. The MedicalCenter is a 238-bed facility. There arethree RDs who focus on the inpatientareas of the facility.
In January 2004, the facility’s di-rector of nutrition and food service,Ginger Hughes, MS, RD, distributedthe August 2003 article by KarenLacey, MS, RD and Ellen Pritchett,RD, about the NCP that appeared inthe Journal. The staff was advised toread the article and become familiarwith it. In the fall of 2004, internshipprogram director Tere Bush-Zurn andoutpatient dietitian Teresa Hillearyreceived a scholarship to attend theNutrition Diagnosis Roundtable forEducators workshop at the ADA’s2004 Food and Nutrition Conferenceand Exhibition. Bush-Zurn and Hill-eary relayed what they learned withthe rest of their staff when they re-turned to California.
In November 2004, a staff meetingis held to discuss questions and con-cerns surrounding the NCP andPESS statements. The staff agreed tostart using the PESS statements assoon as possible. After a December2004 workshop presented by a visit-ing Lacey, the staff agreed that theywanted to work toward transitioningto the nutrition care model and wouldserve as a pilot site.
“It evolved after a year of looking atthe process and after a lot of discus-sions with the staff,” says Ouellette.“We are a teaching institution and wewanted to challenge ourselves interms of our practice. We also have adietetic internship program and feelresponsible for providing the internswith the most progressive concepts inour field of practice.”
As with the Virginia Hospital Cen-ter RDs, the RDs at the VA had beenusing the SOAP format for manyyears and they had similar concernsover whether the new method wouldbe deemed thorough enough. Theywere also concerned that one PESSstatement would not be enough if thepatient had several complicated prob-lems.
Based on staff consensus, in Febru-ary 2005 the staff started devotingtime at the weekly staff meeting todiscussing issues related to the newmethod. The staff practiced writingPESS statements and shared the re-sults with each other during thistime. They also discussed questions
and concerns related to the newmethod.
At the same time, several staffmembers, including the staff’s perfor-mance improvement/information tech-nology dietitian, worked separately todevelop a point-and-click computerversion of the inpatient initial nutri-tion assessment ADI template thatcould be used by the inpatient RDs onstaff when writing their notes.
During the last week in March, theinpatient RDs spent 1 week writingtheir notes using both the old SOAPmethod and the new template. OnApril 4, the staff officially imple-mented the new version of chartingfor the inpatient initial nutrition as-sessments and stopped using theSOAP method completely. For thefirst month after the official imple-mentation, Ouellette checked everyinpatient initial nutrition assessmentchart note and provided weekly feed-back to the staff.
In May, the auditing componentswere incorporated into the NFS Peri-odic Performance Review plan imple-mented as part of the Joint Commis-sion on Accreditation of HealthcareOrganizations’ continuous readinessphilosophy. Although not required,they believed this was a good way tocontinue to audit and document theprocess.
Ouellette continued to meet withRDs individually as problems andquestions developed about thechange. Her initial audits revealedthat the majority of the staff uses thesame five to six diagnostic labels. Shealso assessed that after 2 weeks ofusing the new ADI template exclu-sively, PESS statements markedlyimproved and chart notes becamemore focused and concise. After 3weeks the amount of time spent onthe notes shortened, suggesting thatthe staff was becoming more comfort-able with the process.
In regard to diagnostic labels, Ouel-lette’s staff began the practice of uti-lizing two diagnostic labels and com-bining them into one PESS statementif the two conditions were closely re-lated (eg, difficulty swallowing andchewing difficulty).
The monitoring component of theprocess still needs to be observedcarefully, as many of Ouellette’s staffmembers are not yet in the habit ofstating which specific laboratory testsneed to be performed.
SIMILARITIES AND DIFFERENCESThe biggest difference between thetwo sites was the time spent seekingapproval for the project before pro-ceeding. As a contractor, Foust be-lieved she needed to secure approvalfrom several different administratorsbefore beginning implementation.Ouellette’s approval process occurredmuch more informally. Ouellette saysthis is because the VA allows flexibil-ity in how Nutrition and Food Ser-vices’ processes are carried out.
Another difference centered on theway staff RDs began participating inthe implementation. Ouellette’s staffdiscussed the process for about a yearbefore they all began the new methodof charting at the same time. Ouel-lette and her staff wanted to workwith only one inpatient charting tem-plate at a time, and this allowed themto do so. Also, Ouellette believed thatif the SOAP method template wasavailable, RDs might be tempted to goback to the old format that they feltmost comfortable using.
After the staff in-service, Fouststarted one of her RDs on the newmethod and others followed over a pe-riod of months. As the implementa-tion was occurring, the staff had sev-eral meetings to discuss the newchanges. Foust believed this gradualmethod of implementation allowedtime for RDs who were having troublewith the new method to learn fromRDs who were actively working withit.
The similarities between both sitesincluded the increased amount of ad-ministrative time spent on the change(especially at the manager level) aswell as the decision to focus thechange to inpatient areas only. Foustand Ouellette both said this decisionwas made because inpatient casestend to be more complex, and if thesecases could be dealt with successfullyit would be even easier to make thetransition with outpatient cases. Thesites shared another similarity inthat the types of concerns held by thestaffs were nearly identical, as werethe challenges they faced and the les-sons they learned.
CHALLENGES AND LESSONS LEARNEDAccording to Foust and Ouellette, thebiggest challenge for both sites wasassisting their RDs in completelychanging the way they think about
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their chart notes. “It’s a brand newlanguage,” says Foust. “My RDs arealready seeing 14, 16 patients a day,and it’s a long process when you’restarting something new.”
Both managers say their RDs had ahard time excluding extraneous lan-guage. In the SOAP format, for exam-ple, RDs were used to including infor-mation about everything fromdecades-old surgeries, the patient’sgeneral mood, and other aspects ofthe patient’s condition that are notrelevant to a nutrition diagnosis.With the nutrition care model, thecharting must be much more exact.“This new method requires us to focuson establishing a nutrition label andforces us to restrict our charting towhat is relevant to that nutritionaldiagnosis,” says Ouellette.
Also challenging for the RDs wasthe creation of the PESS statements.“They initially roadblock with thePESS,” says Foust. “It is a completelydifferent way of formatting yourthoughts. It’s moving from a very con-versational way of charting to a moreclinical-sounding, concise note. Thisresults in a struggle when first chart-ing.”
Staff members at both sites hadconcerns over what to do when thereseemed to be two separate but equallyimportant problems. After discus-sions with Dr Myers, it was decidedthat, on occasion, two PESS state-ments can be used.
Ouellette adds that another chal-lenge comes from the fact that thenutrition care model means a differ-ent way of approaching formattingthe chart note. “The chart note reallyhas to be decided after determiningthe PESS statement,” says Ouellette.“The statement can only be deter-mined after a thorough nutritionalassessment. The chart review and pa-tient consultation method are thesame, but the structuring of the chartnote is quite different. We no longerdo this in a linear fashion. We startfrom the middle with the PESS state-ment and complete both ends—as-sessment and goals—from there.”
RDs also struggled with how towrite PESS statements for patientsthat simply had no nutrition risk.Foust says she urged her staff to rec-ognize that if they were experts inmaking a nutrition diagnosis, theycould say that at certain times thereis no nutrition diagnosis. Ouellette
adds that it might be a good idea tocreate a category of “potential” diag-nostic labels that could be used forpatients who are basically stable withtube feedings or dialysis, but who stillneed to be monitored.
While the PESS statement provedto be the most difficult hurdle, RDsalso had to learn to be more specificwhen it came time to express howthey would monitor and evaluatetheir patients. It wasn’t enough towrite “monitor labs,” says Foust. “Youneed to give specific labs and thenfollow with an explanation and ex-pected outcomes.”
For managers, keeping morale ofstaff up was a challenge. This wasespecially true for RDs who spoke offeeling stifled by the new method andwho constantly feared they weremaking a mistake. Managers learnedthey needed to spend extra time en-couraging their RDs and remindingthem that they were working on acutting-edge project.
“All of my RDs are competent andbrilliant,” says Foust. “Changing theway they chart and implementingnew techniques can cause doubt. Thiscan potentially alter their clinical selfconfidence, and you want to maintaina positive outlook to avoid this.”
Both Foust and Ouellette say it wasbeneficial to work in groups on PESSstatements and learn from eachother, being sure to highlight well-written charts as well as the ones thatthat needed attention. Foust andOuellette also learned that not everyRD would learn at the same pace.While RDs who had been in the pro-fession for a shorter amount of timewere often able to grasp the conceptfaster, Ouellette adds that, in gen-eral, the RDs who had the easiesttime were the ones with personalitytypes that adjusted well to change,regardless of experience level.
ADVICE TO SITES READY FORIMPLEMENTATIONBoth Foust and Ouellette offer simi-lar advice to sites seeking to imple-ment the NCP and model. Both sug-gest an in-service for the staff and thedistribution of materials well aheadof implementation. Ouellette alsosuggests providing training from aknowledgeable source, as was thecase with Karen Lacey speaking to
her staff using ADA slides describingthe NCP.
Both managers suggest settingaside a generous portion of the weeklystaff meeting time to discuss themodel, review PESS statements, an-swer questions, and motivate thestaff with positive feedback.
While Foust and Ouellette had dif-ferent experiences in terms of seekingapproval from the administration toimplement the program, both suggestallowing time to meet with the neces-sary people in the facility, as the ap-proval needed will differ from facilityto facility.
Most of all, Ouellette and Foustsuggest that future managers andstaffs remind themselves that transi-tioning to the nutrition care model isa beneficial but time-consuming pro-cess that requires patience. Both saythey have seen marked improve-ments among their staff over time,and many of the initial challengeshave been overcome with patienceand practice.
“You’re changing the way you’rethinking, you’re changing the wayyou’re charting, it’s a huge change,”says Ouellette. “There are no short-cuts you can take. But my staff isexcited about being on the forefront.It’s certainly a worthwhile thing.”
Adds Foust, “This continues to bean excellent groundbreaking experi-ence.”
The authors would like to acknowl-edge the contributions of the follow-ing people in the preparation of thisarticle: Susan Ramsey, MS, RD, CDE,LDN, senior manager of medical nu-trition services for Sodexho who alsoserves on ADA’s Research Commit-tee; Sylvia Escott-Stump MA, RD,LDN, Standardized Language TaskForce Chair; and Esther Myers, PhD,RD, FADA, ADA’s Research and Sci-entific Affairs director.
References1. American Dietetic Association
Strategic Plan. Available at:http://www.eatright.org (mem-ber-only section). Accessed April17, 2005.
2. Lacey K, Pritchett E. NutritionCare Process and Model: ADAadopts road map to quality careand outcomes management. J AmDiet Assoc. 2003;103:1061-1072.
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TIMELINES OF IMPLEMENTATIONVirginia Hospital CenterDecember 2004● Idea of participating in pilot project presented to facil-
ity.● Staff in-service held to educate staff about the NCP,
ADI charting, and PESS statements.● Meetings between clinical nutrition manager and hos-
pital administrators to discuss the NCP and seek ap-proval for participation in the pilot project.
January 2005● Hospital nutrition committee approves the pilot
project.● Other hospital administrators, including those on the
unit where the first RD to participate in the projectworks, are informed of the pilot project.
● The hospital’s patient-monitoring committee approvesthe pilot project.
● Throughout the month of January, the first RD to takepart in the project meets regularly with clinical nutri-tion manager to practice ADI charting and PESS state-ments.
● Clinical nutrition manager obtains permission andmodifies the Hakel-Smith Coding Instrument as a wayof auditing charts.
February 2005● From early to mid-February, the first RD to participate
in the project charts using both the ADI and SOAPformats before formally transitioning to the ADImethod alone on February 16.
● In late February, a second RD begins to exclusively usethe ADI method of charting.
March 2005● By the end of March, a third RD has transitioned to the
ADI method of charting.● Throughout the entire process, the clinical nutrition
manager meets formally and informally with RDs bothindividually and in groups to discuss concerns andmonitor progress.
● Throughout the process, at least 20 minutes of eachweekly staff meeting are devoted to reviewing the ADImethod of charting, PESS statements, questions, andconcerns.
April 2005● By the start of April, a fourth RD is exclusively using
the ADI method of charting, with the fifth and final RDmaking the transition by mid-April.
● The clinical nutrition manager audits 10% of charts.
Veterans Affairs Medical Center, San Diego
January 2004● Director of nutrition and food services distributes jour-
nal articles about the NCP to staff.
October 2004● Two staff members attend the Nutrition Diagnosis
Roundtable for Educators workshop at ADA’s Foodand Nutrition Conference and Exhibition and sharewhat they learn with the rest of the staff upon theirreturn.
November 2004● A staff meeting is held to discuss questions and con-
cerns surrounding the NCP and PESS statements.
December 2004● ADA’s Karen Lacey, Chair of ADA’s Quality Manage-
ment Working Group on the NCP, provides the staffwith a workshop on the NCP.
February 2005● The staff begins to devote time during each weekly
staff meeting to practice using the new method and toshare PESS statements.
● Several staff members, including the staff’s perfor-mance improvement/information technology dietitian,develop a point-and-click computer version of the ADItemplate for the staff to use.
March 2005● Toward the end of March, the staff spends 1 week
using both the SOAP format and the new ADI tem-plate to chart notes.
April 2005● On April 4, the staff officially implements the new
method of charting exclusively.● The deputy director of nutrition and food service
checks each inpatient initial nutrition assessmentchart note and provides feedback to individuals.
May 2005● Ongoing auditing was accomplished by incorporating
the auditing elements into the periodic performancereview plan implemented to ensure continuous readi-ness for the Joint Commission on Accreditation ofHealthcare Organization’s review.
OF PROFESSIONAL INTEREST
Month 2005 ● Journal of the AMERICAN DIETETIC ASSOCIATION 5Edition: 2006 169
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NUTRITION CARE PROCESS AND MODEL WORK GROUP
Karen Lacey, MS, RD, ChairElvira Johnson, MS, RDKessey Kieselhorst, MPA, RDMary Jane Oakland, PhD, RD, FADACarlene Russell, RD, FADAPatricia Splett, PhD, RD, FADAStaff Liaisons:Harold Holler, RDEsther Myers, PhD, RD, FADAEllen Pritchett, RDKarri Looby, MS, RD
The work group would like to extend a special thankyou to Marion Hammond, MS, and Naomi Trostler, PhD,RD, for their assistance in development of the NCP andModel.
STANDARDIZED LANGUAGE TASK FORCE
Sylvia Escott-Stump, MA, RD, LDN, ChairPeter Beyer, MS, RD, LDChristina Biesemeier MS, RD, LDN, FADAPam Charney, MS, RD, CNSDMarion Franz, MS, RD, CDEKaren Lacey, MS, RD, CDCarrie LePeyre, RD, LDNKathleen Niedert, MBA, RD, LD, FADAMary Jane Oakland, PhD, RD, LD, FADAPatricia Splett, PhD, MPH, RDFrances Tyus, MS, RD, LD
The task force would like to extend a special thank youto Naomi Trostler, PhD, RD, FADA.
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6 Month 2005 Volume xx Number xEdition: 2006 170
FEEDBACK FORM
We welcome feedback on revisions to this reference for Nutrition Diagnosing. After
evaluating each section, please indicate whether you would recommend that the section should
be included in the next edition. Following this, please identify other questions that you would
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The Nutrition Care Process: Nutrition Care Process and Model Article
Development of Standardized Language: American Dietetic
Association’s Standardized Language Model/Current Status
Introduction to Nutrition Diagnoses/Problems
Nutrition Diagnosis Reference Sheets: Single page list of Nutrition
Diagnostic Terminology
Nutrition Diagnosis Terms and Definitions: Table of Contents for next
document
Nutrition Diagnosis Reference Sheets (128 pages)
Procedure for Nutrition Controlled Vocabulary/Terminology
Maintenance/Review
Camera Ready Pocket Guide
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