Manual of  Dietetic Practice

Manual of Dietetic PracticeSixth Edition

Edited by Joan Gandy

In conjunction with

The British Dietetic Association

This edition first published 2019 © 2019 The British Dietetic Association © The British Dietetic Association

Edition HistoryBlackwell Science Ltd (1e, 198; 2e, 1994; 3e, 2001); Blackwell Publishing Ltd (4e 2007); The British Dietetic Association. Published by John Wiley & Sons, (5e 2014)

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Library of Congress Cataloging‐in‐Publication Data

Names: Gandy, Joan, editor. | British Dietetic Association, issuing body.Title: Manual of dietetic practice / edited by Joan Gandy in conjunction with the British Dietetic Association.Description: Sixth edition. | Hoboken, NJ : John Wiley & Sons, Inc. : The British Dietetic Association, 2019. | Includes bibliographical references and index. | Identifiers: LCCN 2018039798 (print) | LCCN 2018041076 (ebook) | ISBN 9781119235903 (Adobe PDF) | ISBN 9781119235910 (ePub) | ISBN 9781119235927 (hardcover)Subjects: | MESH: Diet Therapy | Dietetics | Nutritional Physiological PhenomenaClassification: LCC RM216 (ebook) | LCC RM216 (print) | NLM WB 400 | DDC 615.8/54–dc23LC record available at https://lccn.loc.gov/2018039798

Cover design by Wiley

Set in 9.5/11.5 pt ITC Garamond by SPi Global, Pondicherry, India

10 9 8 7 6 5 4 3 2 1

This book is dedicated to Edith Elliot (BDA member number 001) for her outstanding and continuing contribution to dietetics.

This edition is also dedicated to Briony Thomas (Editor of the first three editions and Co-editor of the fourth edition of the Manual of Dietetic Practice) 1950–2019.

Contents

Contributors xi

Foreword xvi

Preface xvii

About the companion website xviii

Part 1 General topics 1

Section 1 Dietetic practice 3

1.1 Professional practice 5

1.2 Dietary modification 18

1.3 Changing health behaviour 23

Section 2 nutritional status 37

2.1 Dietary reference values and food‐based dietary guidelines 39

2.2 Assessment of nutritional status 46

2.3 Dietary assessment 63

2.4 Food composition tables and databases 70

Section 3 nutrition in specific groups 77

3.1 Women’s health 79

3.1.1 Polycystic ovary syndrome 79

3.1.2 Premenstrual syndrome 82

3.1.3 Menopause 85

3.2 Preconception and pregnancy 88

3.3 Older adults 96

3.4 People in low‐income groups 108

3.5 Working with minority ethnic groups 116

3.6 Vegetarianism and vegan diets 129

3.7 People with learning disabilities 140

3.8 Paediatric clinical dietetics and childhood nutrition 158

3.8.1 Introduction 158

3.8.2 Growth, nutritional assessment and  nutritional requirements 159

3.8.3 Growth faltering 169

3.8.4 Nutritional care of the preterm infant 176

3.8.5 Community paediatric dietetics 179

3.8.6 Autism 180

3.8.7 Special needs 181

3.8.8 Paediatric general medicine 183

3.8.9 Paediatric oral nutritional support 184

viii Contents

3.8.10 Paediatric enteral tube nutrition 185

3.8.11 Paediatric parenteral nutrition 189

3.8.12 Paediatric gastroenterology 192

3.8.13 Cystic fibrosis 194

3.8.14 Paediatric liver disease 196

3.8.15 Paediatric nephrology 197

3.8.16 Neurology and the ketogenic diet 199

3.8.17 Inherited metabolic disorders 200

3.8.18 Paediatric food hypersensitivity 202

3.8.19 Paediatric human immunodeficiency virus 205

3.8.20 Paediatric diabetes 206

3.8.21 Cardiology 208

3.8.22 Paediatric cancers 210

3.8.23 Nutrition support in the critically ill child 212

3.8.24 Paediatric haematopoietic stem cell and bone marrow transplantation 215

3.8.25 Neurosurgery 216

3.8.26 Burns 219

3.8.27 General surgery 221

Section 4 Specific areas of dietetic practice 223

4.1 Freelance dietetics 225

4.2 Public health nutrition 233

4.3 Sports nutrition 252

4.4 Food service 260

4.4.1 Food service in hospitals and institutions 260

4.4.2 Prisons 270

4.4.3 Armed Forces 272

4.5 Food law and labelling 274

Section 5 other topics related to practice 287

5.1 Genetics and nutritional genomics 289

5.2 Functional foods 298

5.3 Medicines management 303

5.4 Alternative and complementary therapies 311

Part 2 Clinical dietetic practice 319

Section 6 nutrition support 321

6.1 Nutritional requirements in clinical practice 323

6.2 Malnutrition 332

6.3 Oral nutritional support 343

6.4 Enteral nutrition 351

6.5 Parenteral nutrition 364

6.6 Fluids and electrolytes 371

ixContents

Section 7 clinical dietetic practice 379

7.1 Respiratory disease 381

7.2 Dental disorders 391

7.3 Dysphagia 397

7.4 Gastrointestinal disorders 406

7.4.1 Disorders of the upper aerodigestive tract 406

7.4.2 Orofacial granulomatosis 407

7.4.3 Disorders of the stomach and duodenum 411

7.4.4 Gastroparesis 415

7.4.5 Disorders of the pancreas 421

7.4.6 Malabsorption 426

7.4.7 Coeliac disease 432

7.4.8 Inflammatory bowel disease 446

7.4.9 Intestinal failure and intestinal resection 454

7.4.10 Irritable bowel syndrome 464

7.4.11 Other disorders of the colon and rectum 470

7.4.12 Liver and biliary disease 478

7.4.13 Cystic fibrosis 505

7.5 Renal disorders 518

7.5.1 Chronic kidney disease and acute kidney injury 518

7.5.2 Kidney stones 545

7.6 Neurological disease 554

7.6.1 Parkinson’s disease 554

7.6.2 Motor neurone disease 561

7.6.3 Rare neurological conditions 569

7.6.4 Multiple sclerosis 577

7.6.5 Chronic fatigue syndrome/myalgic encephalomyelitis 581

7.6.6 Neurorehabilitation 587

7.7 Refsum’s disease 595

7.8 Inherited metabolic disorders in adults 600

7.9 Musculoskeletal disorders 612

7.9.1 Osteoporosis 612

7.9.2 Arthritis 622

7.9.3 Gout 629

7.10 Mental health 633

7.10.1 Nutrition and mental health 633

7.10.2 Eating disorders 644

7.10.3 Dementias 656

7.11 Immunology and immune disease 663

7.11.1 Nutrition and immunity 663

7.11.2 Food hypersensitivity 668

7.11.3 Human immunodeficiency virus (HIV) 700

7.12 Diabetes mellitus 715

7.13 Obesity 731

7.13.1 General aspects and prevention of obesity 731

7.13.2 The management of obesity and overweight in adults 739

x Contents

7.13.3 Bariatric surgery 751

7.13.4 Childhood obesity 755

7.14 Cardiovascular disease 761

7.14.1 General aspects of cardiovascular disease 761

7.14.2 Coronary heart disease 770

7.14.3 Dyslipidaemia 783

7.14.4 Hypertension 794

7.14.5 Stroke 803

7.15 Cancer 811

7.15.1 General aspects of cancer 811

7.15.2 Head and neck cancer 822

7.15.3 Cancer of the gastrointestinal tract 834

7.15.4 Breast cancer 842

7.15.5 Lung cancer 846

7.15.6 Gynaecological cancers 849

7.15.7 Prostate cancer 853

7.15.8 Haematological cancers and high‐dose therapy 857

7.15.9 Cancer cachexia 864

7.16 Palliative and end‐of‐life care 869

7.17 Trauma and critical care 875

7.17.1 Critical care 875

7.17.2 Traumatic brain injury 888

7.17.3 Spinal cord injury 898

7.17.4 Burn injury 905

7.17.5 Surgery 912

7.17.6 Wound healing, tissue viability and pressure sores 921

aPPendiCesAppendix A1 Dietary reference values 927

Appendix A2 Dietary data 931

Appendix A3 Anthropometric and function data 934

Appendix A4 Predicting energy requirements 938

Appendix A5 Clinical chemistry 939

Appendix A6 Nutritional supplements and enteral feeds 941

Appendix A7 Nutrition screening tools 955

Index 961

Contributors

Editor and Contributor

Joan Gandy Dietetics Department, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, HertfordshireAddress for correspondence: c/o The British Die-tetic Association, 5th Floor, Charles House, 148/9 Great Charles Street Queensway, Birmingham B3 3HT, UK

Contributors

Sarah Adam Metabolic Dietitian, Royal Hospital for Children, Queen Elizabeth Hospital, Glasgow

Phil Addicott Mental Health Dietitian, Cardiff and Vale University Health Board, Cardiff, Wales

Lindsey Allan Macmillan Oncology Dietitian, Royal Surrey County Hospital, Guildford

Ursula Arens Freelance Nutrition Writer, LondonSarah Armer Specialist Dietitian  –  Home Enteral

Feeding, Community Nutrition and Dietetic Service, South West Yorkshire NHS Foundation Trust, Barnsley, South Yorkshire

Lisa Baker Catering Dietitian, Medirest (Compass Group), London

Melanie Baker Clinical Lead, Nutrition Support Team (Leicester Intestinal Failure Team), Department of Nutrition and Dietetics, University Hospitals of Leices-ter NHS Trust, Leicester

Eleanor Baldwin Specialist Dietitian – Adult Refsum’s Disease, Nutrition and Dietetic Department, Chelsea and Westminster Hospital NHS Foundation Trust, London

Rachael Barlow Clinical Academic, Cardiff and Vale University Health Board and Cardiff University, Fac-ulty Member for Enhanced Recovery after Surgery (ERAS) Society, UK

Tahira Bashir Freelance Specialist Dietitian, Unique Inspiration Ltd, Birmingham

Julie Beckerson Specialist Haemato‐Oncology Dieti-tian, Hammersmith Hospital, Imperial College Health-care NHS Trust, London

Jason Beyers Lead Paediatric Dietitian, Department of Nutrition & Dietetics, Bristol Royal Hospital for Children, Bristol

Ruth Birt Regulatory Affairs Consultant, Regulatory Solutions Ltd, Glasgow

Jamie Blackshaw Team Leader: Obesity and Healthy Weight, Public Health England, London

Caroline Bovey Advanced Public Health Dietitian, Department of Nutrition and Dietetics, Aneurin Bevan University Health Board, Caerleon, Cardiff

Lauren Bowen Head of Patient Catering, ISS Facility Services Healthcare, London

Rachel Bracegirdle Oncology Dietitian, Guy’s and St Thomas’ NHS Foundation Trust, London

Emily Bridge Clinical Lead Burn Dietitian, Nottingham University Hospitals NHS Trust, Nottingham

Claire Bullock Paediatric Dietitian, Department of Nutri-tion and Dietetics, Derriford Hospital, Plymouth, Devon

Gaynor Bussell Freelance Dietitian Specialising in Women’s Health, Cardigan, Ceredigion, Wales

Sarah J. Cameron Specialist Dietitian in Neuroreha-bilitation, Wolfson Neurorehabilitation Centre, Queen Mary Hospital, Roehampton

Helen Campbell Dietitian, Nutrition and Dietetics Department, The Alfred Hospital, Melbourne, Victoria, Australia

Rachel Carruthers Metabolic Dietitian, Charles Dent Metabolic Unit, University College London Hospitals, London

Elaine Cawadias Dietitian, Ottawa, Ontario, CanadaAbbie Cawood Visiting Research Fellow, Faculty of

Medicine, University of Southampton, SouthamptonHeidi Chan Senior Medical Affairs Advisor for Inher-

ited Metabolic Diseases, LondonSaira Chowdhury Senior Specialist Upper GI Oncol-

ogy Dietitian, Department of Nutrition and Dietetics, Guy’s and St Thomas’ NHS Foundation Trust, London

Angela Cleaver Senior Gastroenterology Dietitian, University Hospital Llandough, Cardiff

Barbara Cochrane Paediatric Metabolic Dietitian, Queen Elizabeth University Hospital, Glasgow

Peter Collins Senior Lecturer/Course Coordina-tor, Nutrition and Dietetics, School of Exercise and Nutrition Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia

Lisa Cooke Head of Paediatric Dietetics, Nutrition and SALT, Bristol Royal Hospital for Children, Bristol

June Copeman Principal Lecturer, Nutrition and Die-tetics, Leeds Beckett University, Leeds, West Yorkshire

Kathy Cowbrough Nutrition and Dietetic Consultant, Retford, Nottinghamshire

Emma Craig Clinical Lead Dietitian, Dietetics Department, The Royal Hospital for Neuro‐disability, West Hill, London

Julie Crocker Lead Cystic Fibrosis Dietitian, Royal Hospital for Children, Glasgow

xii Contributors

Helen Croker Senior Research Associate and Unit Manager of the Obesity Policy Research Unit, Faculty of Population Health Sciences, Great Ormond Street Institute of Child Health, Great Ormond Street Hospital NHS Foundation Trust, London

Alison Culkin Lead Intestinal Failure Dietitian, St Mark’s Hospital, Harrow, London

Janeane Dart Senior Lecturer, Department of Nutri-tion and Dietetics and Food, Monash University, Mel-bourne, Australia

Vicky Davies Professional Lead for Nutrition and Die-tetics, Therapy Services, The Walton Centre, Liverpool

Adri De Sousa Respiratory Specialist Dietitian, Die-tetic Department, Royal Papworth Hospital NHS Trust, Cambridge

Mhairi Donald Macmillan Consultant Dietitian, Sussex Cancer Centre, Royal Sussex County Hospital, Brigh-ton, Sussex

Sarah Donald Metabolic Dietitian, Cambridge Univer-sity Hospitals NHS Foundation Trust, Addenbrookes Hospital, Cambridge

Pauline Douglas Senior Lecturer, Ulster University, Coleraine, Northern Ireland

Jennie Dunwoody Senior Dietitian, Dietetics Department, The Royal Hospital for Neuro‐disability, West Hill, London

Pamela Dyson Research Dietitian, University of Oxford, Oxford Centre for Diabetes, Endocrinology & Metabo-lism (OCDEM), Churchill Hospital, Oxford

Shelley Easter Specialist Paediatric Dietitian, Bristol Royal Hospital for Children, Bristol

Lucy Eldridge Dietetic Team Leader, Department of Nutrition and Dietetics, The Royal Marsden NHS Foundation Trust, London

Charlotte Ellerton Specialist Metabolic Dietitian, National Hospital for Neurology & Neurosurgery, London

Kiri Elliott Policy Officer – Education and Professional Development, British Dietetic Association, Birmingham

Clare Ewan Paediatric Dietitian, Musgrove Park Hospital, Taunton

Lydia Fletcher Senior Dietitian, Dietetics Department, The Royal Hospital for Neuro‐disability, West Hill, London

Suzanne Ford Specialist Metabolic Dietitian, North Bristol NHS Trust, Bristol

Lynette Forsythe Specialist Paediatric Dietitian  – Intestinal Failure and Neonates, Royal Manchester Children’s Hospital, Central Manchester Hospitals NHS Foundation Trust, Manchester

Joan Gandy Dietetics Department, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire

Elaine Gardner Freelance Dietitian, Module Organiser for Nutrition and Infection, The London School of Hygiene & Tropical Medicine, London

Emma Gaskin Specialist Senior Dietitian, Therapies; Nutrition and Dietetics, Medway NHS Foundation Trust, Medway Maritime Hospital, Gillingham

Gillian Gatiss Specialist Hepatology and Research Dieti-tian, Department of Nutrition and Dietetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge

Samantha K. Gill Research Associate, King’s College London, London

Jenny Gillespie Practitioner, Paediatric Overweight Service Tayside, Perth Royal Infirmary, Perth, Scotland

Eva Glass Macmillan Head and Neck Dietitian, ABMU Local Health Board, Swansea

Jane Green Specialist Community Dietitian, Dodding-ton Hospital, Doddington, Cambridge & Peterborough NHS Foundation Trust, Cambridgeshire

Karen Green Senior Specialist Dietitian (Neurosci-ences), Department of Nutrition & Dietetics, The National Hospital for Neurology & Neurosurgery, London

Poonam Gulia Specialist Dietitian  –  Gastroenterology, GutCare Clinic at Dr Ashok’s Ayurveda Medical Group, Birmingham

Vanessa Halliday Senior Lecturer, Public Health Section, School of Health and Related Research (ScHARR), Uni-versity of Sheffield, Sheffield

Catherine R. Hankey Senior Lecturer in Human Nutri-tion, University of Glasgow, Glasgow Royal Infirmary, Glasgow

Lynn Harbottle Freelance Consultant in Nutrition, Die-tetics and Well‐being, Bournemouth, Dorset

Kathryn Hart Lecturer in Nutrition and Dietetics, Department of Nutritional Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey

Michelle Harvie Lead Research Dietitian, Prevent Breast Cancer Research Unit, University Hospital South Man-chester, Manchester

Jennette Higgs Director, Food to Fit Ltd, International Nutrition and Dietetics Consultants, Towcester, Northamptonshire

Julie Hinchliffe Cardiovascular Rehabilitation Special-ist Dietitian, Salford Royal NHS Foundation Trust, Salford

Linda Hindle Deputy Chief Allied Health Professions Officer, National Engagement Lead for Police, Fire and Ambulance Services, Public Health England, London

Richard Hoffman Senior Lecturer (Retired), School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire

Michelle Holdsworth Professor of Public Health, School of Health and Related Research (ScHARR)  –  Public Health Section, University of Sheffield, Sheffield

Sandra Hood Diabetes Specialist Dietitian and Community Lead, Dorset County Hospital NHS Foundation Trust, Dorchester, Dorset

Sarah Howe Specialist Dietitian in Inherited Metabolic Disorders, Department of Nutrition and Dietetics, University Hospitals Birmingham NHS Foundation Trust, Birmingham

Rosanna Hudson Policy Officer  –  Education, British Dietetic Association, Birmingham

Joana Jardim Regional Healthcare Dietitian, ISS Facil-ity Services Healthcare, Kettering

Yvonne Jeanes Principal Lecturer, Clinical Nutrition, Department of Life Sciences, University of Roehamp-ton, London

xiiiContributors

Judith John Consultant Dietitian in Public Health, Public Health Wales, Cardiff, Wales

Katie Johnson Clinical Team Manager, Community Neurological Rehabilitation Service, St Mary’s Hospital, Leeds Community Healthcare NHS Trust, Leeds

Katie Keetarut Highly Specialist Dietitian (Inflammatory Bowel Disease), University College London Hospital, London

Sue Kellie Deputy Chief Executive, British Dietetic Association, Birmingham

Katie Kennedy Company Dietitian, Dr Schär, WarringtonNatasha Kershaw Burns Dietitian, St Andrew’s Burn

Centre, ChelmsfordKaren Klassen Post‐doctoral Research Fellow,

Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Australia

Annemarie Knight Programme Lead, Dietetics, King’s College, London

Edwige Landais Researcher in Nutrition, Institut de Recher-che pour le Développement (IRD), UMR 204 ‘Nutrition et Alimentation des Populations aux Suds’, France

Martin Lau Services Development Manager and Dieti-tian, Arthritis Action, London

Anne Laverty Community Dietitian (Learning Disability) (retired), Northern Health and Social Care Trust, Northern Ireland

Judy Lawrence Research Officer, British Dietetic Association, Birmingham

Sherly X. Li Research Dietitian, MRC Epidemiology Unit, University of Cambridge, Cambridge

Rebecca Lindstrom Sowman Specialist Gastroenterol-ogy & Lower GI Surgery Dietitian, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London

Miranda Lomer Senior Consultant Dietitian in Gastro-enterology, Guy’s and St Thomas’ NHS Foundation Trust, London

Jacqueline Lowdon Clinical Specialist Paediatric Die-titian, Leeds Children’s Hospital, The Leeds Teaching Hospitals NHS Trust, Belmont Grove, Leeds

Marjory Macleod Dietitian FBDA (retired), Learning Disabilities Service, NHS Lothian, Edinburgh, Scotland

Angela Madden Lead for Nutrition and Dietetics, School of Life and Medical Sciences, University of Hertford-shire, Hatfield, Hertfordshire

Bruno Mafrici Lead Renal Dietitian/Team Leader, Die-tetics, Nottingham University Hospitals NHS Trust, Nottingham

Linda Main Freelance Dietitian, Drummond Consul-tants Ltd & Dietitian at HEART UK – The Cholesterol Charity

Kwunita Man Lead Dietitian for Neurology, Nutrition and Dietetics Service, Hertfordshire Community NHS Trust, Hertfordshire

Sara Mancell Lead Children’s Dietitian, Nutrition & Dietetics Department, King’s College Hospital NHS Foundation Trust, London

Tanita Manton Senior Dietitian, The Royal Hospital for Neuro‐disability, West Hill, London

Luise V. Marino Clinical Academic Paediatric Dietitian, Paediatric Intensive Care, HEE/NIHR ICA Clinical Lectureship, Department of Dietetics/SLT, University Hospital Southampton NHS Foundation Trust, Southampton

Alison McGlone Clinical Specialist Lead Dietitian, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast

Jennifer McIntosh Allied Health Professional Lead/Specialist Dietitian, Specialist Services and Learning Disability Care Group, Leeds and York Partnership NHS Foundation Trust, York, North Yorkshire

Yvonne McKenzie Specialist Dietitian in Gastrointes-tinal Nutrition and IBS, Clinical Lead in IBS for the Gastroenterology Specialist Group of the British Die-tetic Association, Oxford

Annette McLean Dietetic Lead for Mental Health, and Deputy Head of Nutrition and Dietetics, Llandough Hospital, Cardiff and Vale University Health Board, Cardiff, Wales

Helen McNair Older‐Adults Dietitian, Community Nutrition and Dietetic Service (Barnsley), South West Yorkshire Partnership NHS Foundation Trust, Barns-ley, South Yorkshire

Lauren McVeigh Specialist Paediatric Dietitian, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol

Christina Merryfield Lead Dietitian, Bupa Cromwell Hospital, London

Rosan Meyer Honorary Senior Lecturer, Department of Paediatrics, Imperial College, London

Emma Mills Mansfield, NottinghamshireHayley Moroney Specialist Dietitian, The National

Hospital for Neurology and Neurosurgery, LondonAlison Morton Consultant Dietitian (retired) (Adult

Cystic Fibrosis), Formerly at Leeds Teaching Hospitals NHS Trust, Leeds

Charlene Mulhern Childhood Obesity Workforce Deliv-ery Manager, Health Intelligence Division, Public Health England, London

Camille Newby Regional Specialist Paediatric Die-titian in Inherited Metabolic Disease, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol

Heather Norris Neonatal Dietitian, St Michael’s Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol

Mary O’Kane Consultant Dietitian (Adult Obesity), Leeds Teaching Hospitals NHS Trust, Leeds

Siân O’Shea Freelance Dietitian, CardiffFionna Page Independent Nutrition Consultant

and Registered Dietitian, First Page Nutrition Ltd, Wiltshire

Katherine Paterson Clinical Lead Specialist Cardiology and Obesity Dietitian, Department of Nutrition and Dietetics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich

Dympna Pearson Freelance Dietitian & Behaviour Change Trainer, Leicester, Leicestershire

xiv Contributors

Sue Perry Deputy Head of Dietetics, Hull and East Yorkshire Hospitals NHS Trust, Hull, East Yorkshire

Mary Phillips Advanced Specialist Dietitian (Hepato‐pancreato‐biliary Surgery), Royal Surrey County Hospital, Guildford

Ursula Philpot Level Lead and Senior Lecturer, Nutri-tion and Dietetics, School of Clinical and Applied Sci-ences, Leeds Beckett University, Leeds, West Yorkshire

Gail Pinnock Specialist Bariatric Surgery Dietitian, Stone Allerton, Somerset

Vicki Pout Deputy Acute Dietetic Manager, Clinical Nutrition and Dietetics, Queen Elizabeth The Queen Mother Hospital, Kent Community Health NHS Foundation Trust, Margate, Kent

Charlotte Proctor Advanced Specialist Critical Care Dietitian, Northwick Park Hospital and St Mark’s Hospital, Harrow, Middlesex

Najia Qureshi Head of Education and Professional Development, British Dietetic Association, Birmingham

Jean Redmond Scientific Director, Real‐World & Ana-lytics Solutions, IQVIA, London

Gail Rees Associate Professor in Human Nutrition, School of Biomedical and Healthcare Sciences, Plym-outh University, Plymouth

Claudia Rueb Specialist Dietitian, Upper GI Surgery & Cancer, St Mary’s Hospital, Imperial College Health-care NHS Trust, London

Alan Rio The Royal Marsden Hospital, Fulham Road, London

Sarah Ripley Country Manager (UK), Cambrooke Ther-apeutics, Manchester

Louise Robertson Specialist Dietitian in Inherited Meta-bolic Disorders, Department of Nutrition and Dietetics, University Hospitals Birmingham NHS Foundation Trust, Birmingham

Martina Rooney Doctoral Researcher, Nutrition Inno-vation Centre for Food and Health (NICHE), Ulster University, Coleraine, Northern Ireland

Laura Rowe Nutrition & Dietetics Professional Lead/Spe-cialist Diabetes Dietitian, Airedale General Hospital, Steeton, West Yorkshire

Lisa Ryan Head of Department of Natural Sciences, School of Science and Computing, Galway‐Mayo Insti-tute of Technology, Galway, Ireland

Gurpreet Sagoo Specialist Paediatric Dietitian, Great Ormond Street Hospital, Great Ormond Street Hospital for Children NHS Foundation Trust, London

Inez Schoenmakers Senior Lecturer, Department of Medicine, Norwich Medical School, Faculty of Medi-cine and Health Sciences, University of East Anglia, Norwich, Norfolk

Laura Sealy Specialist Paediatric Dietitian (Oncol-ogy, Haematology and BMT), Nutrition & Dietetics Department, Bristol Royal Hospital for Children, Bristol

Clare Shaw Consultant Dietitian, Department of Nutri-tion and Dietetics, The Royal Marsden NHS Foundation Trust, London and Sutton

Katherine Singleton Paediatric and Metabolic Dieti-tian, Department of Nutrition and Dietetics, University Hospital of Wales, Cardiff

Isabel Skypala Consultant Allergy Dietitian, Clinical Lead for Food Allergy, Department of Allergy & Clinical Immunology, Royal Brompton & Harefield NHS Foundation Trust, South Kensington, London

Lynsey Spillman Specialist Hepatology and Research Dietitian, Department of Nutrition and Dietetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge

Laura Stewart Weight Management and Diabetes Ser-vice Lead, Perth Royal Infirmary, NHS Tayside, Perth

Rebecca Stratton Visiting Research Fellow, Faculty of Medicine, University of Southampton, Univer-sity Hospital Southampton NHS Foundation Trust, Southampton

Louise Sutton Head of Sport and Exercise Nutrition, Carnegie School of Sport, Leeds Beckett University, Leeds

Bella Talwar Clinical Lead Dietitian, Nutrition & Die-tetics, Head and Neck Centre, University College Lon-don Hospitals NHS Foundation Trust, London

Ella Terblanche Advanced Dietitian for Critical Care, Imperial College Healthcare NHS Trust, London

Laura Thomas Gastroenterology Dietitian, Department of Nutrition and Dietetics, University Hospital Lland-ough, Penarth, Wales

Karen Thomsett Dietitian, Dent Community Health NHS Trust, Whitstable and Tankerton Community Hospital, Whitstable, Kent

Sarah Trace Specialist Paediatric Dietitian (Nephrol-ogy), Paediatric Dietetic Department, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol

Helen Truby Professor of Nutrition and Dietetics, Direc-tor of Dietetics, Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Australia

Anthony Twist Specialist Dietitian, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, Shropshire

Sarah Wallis Senior Dietitian, Frimley Park Hospital, Frimley Health NHS Foundation Trust, Portsmouth Road, Frimley

Mary Ward Professor of Nutrition and Dietetics, Nutri-tion Innovation Centre for Food and Health (NICHE), School of Biomedical Sciences, Ulster University, Northern Ireland

C. Elizabeth Weekes Senior Consultant Dietitian, Department of Nutrition and Dietetics, Guy’s & St Thomas’ NHS Foundation Trust, London

Ailsa Welch Professor of Nutritional Epidemiology, Department of Population Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, Norfolk

Kevin Whelan Professor of Dietetics, Head of Department of Nutritional Sciences, King’s College, London

Rhys White Principal Oncology Dietitian, Department of Nutrition and Dietetics, Guy’s and St Thomas’ NHS Foundation Trust, London

Kirsten Whitehead Lecturer in Dietetics University of Nottingham, School of Biosciences, Division of Nutri-tional Sciences, Sutton Bonington Campus, University of Nottingham, Loughborough, Leicestershire

xvContributors

Harriet Williams Area Head of Dietetics, Department of Nutrition and Dietetics, Betsi Cadwaladr University Health Board, Ysbyty Gwynedd, Bangor

Kate Williams Lead Dietitian, Adult Eating Disorders Service, South London and Maudsley NHS Foundation Trust, London

Lisa Williams All Wales Nutrition Training Facilitator, Cardiff and Vale University Health Board, Cardiff, Wales

Nicola Williams Team Lead Dietitian, Royal Manchester Children’s Hospital, Central Manchester Foundation Trust, Manchester

Samford Wong Lead Dietitian for Spinal Injuries and Research, National Spinal Injuries Centre, Stoke Man-deville Hospital, Aylesbury

Paula Wood Principal Scientist, Research Dietitian, Personal and Human Performance Team, Defence Science and Technology Laboratory, Porton Down, Salisbury, Wiltshire

Philippa Wright Lead for Paediatric Rehabilitation and Therapies, The Royal Brompton & Harefield Foundation Trust, South Kensington, London

The BDA Specialist Groups

•Critical Care•Diabetes•Food Allergy•Food Services•Freelance Dietitians•Gastroenterology•HIV Care

•Mental Health•Neurosciences•Obesity•Older People•Oncology•Paediatric•Parenteral & Enteral Nutrition•Public Health•Renal Nutrition•Sports Nutrition

Sub‐Groups

•Autism (sub‐group of Paediatric)•Haematology (sub‐group of Oncology)•Paediatric Oncology (sub‐group of Paediatric)•Prescribing Support Dietitians (sub‐group of Older

People)•Trauma (sub group of Critical Care)

Other contributors

•Paul Appleby•Kerrie Boyd•Neasa Forde•Heather Russell•Alison Smith• Jill Stewart•Malgorzata Szychta•Emma Tovey•Tazmin Wisudha‐Edwards•Sue Wolfe

Dietitians are highly trained professionals who work in a wide variety of settings. While most dietitians work in clinical areas and public health, they also have key roles in an increasing range of areas, including research, teaching, journalism and the media, sport, industry and public relations. Their education and training are based on a core curriculum which uses many resources, includ-ing the British Dietetic Association’s (BDA) Manual of Dietetic Practice (MDP).

The MDP is the core text, and as such it essential that it be revised periodically. This, the sixth edition, has been completely revised by experienced practitioners from all related fields of practice. Some chapters have been completely rewritten, including ‘Assessment of nutritional status’, ‘People in low‐income groups’ and ‘Public health nutrition’. Embracing the need to work

in an increasingly diverse environment, a new chapter, ‘Working with minority ethnic groups’, replaces ‘Dietary patterns of black and minority ethnic groups’.

Dietitians from all areas of practice and all levels of experience, from students to professors, have con-tributed in varying degrees to this publication. In addition, many of the authors have also contributed the BDA’s series of specialist texts, thereby ensur-ing that MDP dovetails into more advanced texts and practice. As such, the MDP is an essential text for all students and qualified dietitians, and other health professionals.

Richard BalfeThe Lord Balfe of Dulwich, Honorary President of

the British Dietetic Association

Foreword

Preface

This is the sixth edition of the Manual of Dietetic Practice, and it is part of a range of resources available to dieti-tians, dietetic students and others. The range includes an increasing number of specialist dietetic texts, and this edition of the manual is written, as far as possible, to complement these texts. Some specialisms are too small to warrant a separate text, and are therefore included in the Manual of Dietetic Practice, e.g. inherited metabolic disorders in adults. This edition of the manual is aimed mainly at non‐specialist dietitians and dietetic students, and is intended for use as a standard textbook in dietetic departments. Since the publication of the fifth edition of the manual, a book of case studies in dietetics and nutri-tion has also been published.

Dietetics is a dynamic profession, which means that knowledge and practice change rapidly, and dietitians are working in more diverse areas. All the chapters have been updated and revised, and some have been com-pletely rewritten. The shift towards prevention and pri-mary care is reflected in the rewritten chapter Public health nutrition. As the demographics of the population change, dietitians need to be able to work with more diverse groups. This is reflected in the revised chapter Working with minority ethnic groups. It is important that dietitians are up to date with changes in social systems, and the chapter People in low income groups has there-fore been rewritten to reflect this.

In keeping with the previous edition, dietitians from across the width of the profession, from students to pro-fessors, have contributed to this edition. The systemic approach of the manual has been maintained to be in line with the specialisms of the BDA specialist groups and other dietetics groups and networks.

The Manual of Dietetic Practice is constructed to be cohesive, and, as such, there is considerable cross‐

referencing between chapters. It is divided into two parts, encompassing seven sections with appendices, as follows:

Part 1 General topicsSection 1 – Dietetic practiceSection 2 – Nutritional statusSection 3 – Nutrition in specific groupsSection 4 – Specific areas of dietetic practiceSection 5 – Other topics related to practice

Part 2 Clinical dietetic practiceSection 6 – Nutrition supportSection 7 – Clinical dietetic practice

The area of paediatric dietetics is always challenging, as well as interesting, and Chapter 3.8 provides an appro-priate level of knowledge for non‐paediatric dietitians who work with children in general settings. It is hoped that dietitians will find this useful, and that it will pro-vide student dietitians with an introduction to another exciting and satisfying area of practice.

There is a dedicated Manual of Dietetic Practice website (www.manualofdieteticpractice.com/default.asp) that has additional resources, including figures and tables that can be downloaded.

Although editing the manual has been a challenge, the level of support has been overwhelming and inspir-ing. I am indebted to the many people who have written or revised the book’s chapters, the many reviewers and other contributors. Finally, I would like to thank Mirjana Misina, project manager, who has worked alongside me throughout and made the process so much easier than the last time!

Joan Gandy

About the companion website

This book is accompanied by a companion website:

www.manualofdieteticpractice.com

The website includes:

•Figures and tables in PowerPoint•Web resources•Appendices•References from the book

General topicsPart 1

Dietetic practice

Section 1

Manual of Dietetic Practice, Sixth Edition. Edited by Joan Gandy. © 2019 The British Dietetic Association. Published 2019 by John Wiley & Sons Ltd. Companion website: www.manualofdieteticpractice.com

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Dietetics is a well‐respected and established profession, albeit a relatively new one. The first UK dietitian, Ruth Pybus, a nursing sister, was appointed in 1924 at the Royal Infirmary in Edinburgh. She initially sought to demonstrate that a dietetic outpatient clinic could sig­nificantly reduce the number of admissions and there­fore benefit the hospital. She was successful and, after a 6‐month trial, her appointment as a dietitian was con­firmed. The development of other dietetic departments quickly followed, especially in London, and the first non‐nursing dietitians were appointed in 1928. From these early days, dietetics has been a science‐based profession and, in the 1980s, became the first of the allied health professions (AHPs) to become a graduate profession.

The British Dietetic Association (BDA) was founded in 1936 as the professional association for registered die­titians in Great Britain and Northern Ireland. The BDA promotes the vital work of its members in order to raise the profile of the profession. It represents the best inter­ests of dietitians collectively when working with national organisations, stakeholders and key partners, and aims to influence government policy. This in turn drives demand for evidence‐based nutrition and dietetics.

Dietetics is both an art and a science that requires the application of safe and evidence‐based practice, reflective practice and systematic clinical reasoning. A dietitian needs to combine these skills with knowledge and experience, together with intuition, insight and understanding of the

individual (or specific) circumstance, in order to maintain and improve practice. Following several public enquiries at the end of the last century, it was recognised that there needed to be greater priority given to nonclinical aspects of care, such as skills in communicating with colleagues and service users, management, development of team­work, shared learning across professional boundaries, auditing, reflective practice and leadership. Subsequent legislative changes were implemented with the establish­ment of the Health and Care Professions Council (HCPC).

Dietetics as a profession

A degree of responsibility and expectation are part of being a professional. A member of any profession, including dietetics, must, within their practice, agree to be governed by a code of ethics, uphold high standards of performance and competence, behave with integrity and morality, and be selfless in the promotion of the public good (Cruess et  al., 2004). Furthermore, these commitments form the basis of an understanding that results in professions, and their members, being account­able to service users and to society.

Professional regulation

To use the title of dietitian, and to practise as one, it is mandatory to have completed an approved programme of education and be registered with the HCPC. The HCPC

Najia Qureshi, Judy Lawrence, Rosanna Hudson, Samantha K. Gill, Kiri Elliott, Sue Kellie and Joan Gandy

Key points

■ UK dietitians must be graduates of an approved education programme and registered with the Health and Care Professions Council.

■ The British Dietetic Association is a professional association that aims to inform, protect, represent and support its members.

■ Dietitians are autonomous practitioners who work within an ethical framework of conduct.

■ The nutrition and dietetic process is central to dietetic practice.

■ Dietetics is an evidence‐based profession with research and outcome evaluation at its core.

■ Dietitians engage in continuing professional development throughout their careers to ensure that their practice is robust, effective and innovative.

Professional practice

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was set up in 2001 to protect the health and well‐being of people using the services of the health professionals registered with them. It aims to:

•Maintain and publish a public register of properly qualified members of the professions.

•Approve and uphold high standards of education and training and continuing good practice.

• Investigate complaints and take appropriate action.•Work in partnership with the public and other groups,

including professional bodies.

To remain on the HCPC register, dietitians must con­tinue to meet the standards that are set for the profes­sion. The professional standards are:

•Good character of health professionals.•Health.•Proficiency (dietetics).•Conduct performance and ethics.•Continuing professional development (CPD).•Education and training.

The HCPC uses these standards to determine if a reg­istrant is fit to practise. If the HCPC finds that there are concerns about a dietitian’s ability to practise safely and effectively, and therefore fitness to practise is impaired, it has the legal right to take action. This may mean that such registrants are not allowed to practise, or that they are limited in what they are allowed to do. The HCPC can legally take appropriate action to enforce this (HCPC, 2010).

The British Dietetic Association as a professional body

The distinction between a regulatory body (HCPC) and a professional body (BDA) is often misunderstood. It is important that dietitians be fully aware of the differ­ences from the beginning of professional training. Much like the HCPC, the BDA is committed to protecting the public and service users. However, the two organisa­tions achieve this in very different ways (Table  1.1.1). The HCPC has the ultimate authority to prevent dieti­tians from practising if, following investigation, they are deemed to be unsafe or untrustworthy. However, the BDA provides guidance, advice, learning and network­ing opportunities, and professional indemnity insurance cover, all with the aim of supporting the development of safe and effective practitioners. This ultimately helps protect the public and service users. The BDA also pro­vides a trade union function and supports members throughout their working life on issues such as pay and conditions, equal opportunities, maternity rights, and health and safety.

Autonomy

Autonomy can be defined as the right of self‐governance. As independent practitioners who practice autono­mously, dietitians are accountable for their decision‐ making, given that they have a moral and legal obligation

for the provision of safe and competent service delivery (BDA, 2017). This means they are answerable for their actions and omissions, regardless of advice or direc­tions from another health professional. Dietitians have a duty of care for their service users and clients, who are entitled to receive safe and competent care or service. The HCPC states that, as autonomous and accountable professionals, dietitians ‘… need to make informed and reasonable decisions about their practice. This might include getting advice and support from education pro-viders, employers, professional bodies, colleagues and other people to make sure that you protect the wellbeing of service users at all times’ (HCPC, 2016).

It is important that dietitians be aware of the bound­aries of their autonomy, which will never be limitless but confined to their scope of practice. As with all health professionals, dietitians must never practise in isola­tion. Up‐to‐date knowledge skills and experience are the cornerstones of safe and effective practice, and as such dietitians should always have access to a support network of learning, development and peer review. In the National Health Service (NHS) setting, the system for learning and development is usually already established via internal processes, e.g. supervision, appraisal, local training programmes, library services and journal clubs. Outside of the NHS, these processes are not automat­ically in place, and it is essential that healthcare pro­fessionals actively establish a network of support and learning to match their scope of practice, e.g. freelance practice (see Chapter 4.1, Freelance dietetics).

Scope of practice

Identifying individual scope of practice is not easy as the boundaries will be different for each practitioner and

Table 1.1.1 Remits of  the  Health and  Care Professions Council (regulatory body) and  the  British Dietetic Association (professional body)

Health and Care Professions Council

British Dietetic Association

Protect the public and service users

Protect the public and service users

Set professional standards of practice

Membership support

Approve education programmes that train and educate graduates to meet these standards

Advance the science and practice of dietetics

Register graduates of these programmes

Promote education and training in the science and practice of dietetics

Ensure registrants meet professional standards

Regulate the relationships between dietitians and their employers through the trade union

Sanction registrants who do not meet these standards

Provide professional indemnity insurance

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will evolve over time (BDA, 2009). The description of a dietitian’s scope of practice is often broad and may describe some or all of the factors shown in Table 1.1.2.

A much more specific scope of practice is described in relation to specific service users. When presented with a service user, the dietitian should undertake a personal risk assessment as part of the overall assessment, asking key questions before proceeding. These questions include:

• Is the service user safe?•Am I safe?•Can I justify the decision I have made during the

assessment (e.g. has the research, evidence, standards and guidance been considered)?

•Can I identify the most appropriate approach for the service user group?

•Do I have the correct balance of skills, knowledge and experience to be competent in my chosen approach?

•Do I need to seek advice from a peer/team lead/professional body?

Extended scope of practice

The extended roles that a dietitian will undertake are those outside their core and specialist roles. They are usually (but not exclusively) roles traditionally carried out by other health professionals of at least specialist or advanced level, either as a core duty or role extension. Additional skills and knowledge are acquired through formal training. The extended role practitioner must advance dietetic practice and contribute to improving outcomes. Examples of extended roles include:

•Replacing gastrostomy tubes in the community.• Inserting peripheral midlines for intravenous feeding.•Supplementary prescribing of medicines.

Activities such taking blood pressure or a finger‐prick test of blood to test for blood glucose are not included in the extended roles of a dietitian. Whatever role a

dietitian commits to, extended or otherwise, they must constantly be aware of their individual scope of practice, and practice within this. Extended roles and pushing the boundaries of nutrition and dietetic practice are not new. It is actively encouraged by the BDA, and is part of what continues to make dietetics the relevant, dynamic and resourceful profession it is.

Ethics and conduct

Conduct is the manner in which a person behaves, espe­cially in a particular place or situation, while ethics are moral principles that govern an individual’s or a group’s behaviour. However, it is essential to put these definitions into context for them to have any meaning. In professional practice, professional ethical conduct is of paramount importance. Outside of their professional role, dietitians have the right to behave how they choose, within the limits of the law, and this will be limited only by personal ethical boundaries. In professional practice, it is the professional codes of conduct that provide the framework for how, and the benchmark by which, ethical conduct will be mea­sured. A major function of a code of conduct is to enable professionals to make informed choices when faced with an ethical dilemma. For the dietetic workforce, the key guidance is laid out in the HCPC’s Standards of conduct, performance and ethics (2016) and Guidance on conduct and ethics for students (2009).

The BDA’s Code of Professional Conduct (2017) builds on the generic standards of the HCPC with more dietetic‐specific guidance. They apply to the whole dietetic work­force from unregulated students and support workers to qualified dietitians. This code is necessarily broad and cannot provide definitive answers to every situation that members may encounter over the course of their careers. They have been written in such a way as to pro­vide members with the freedom to advance, develop and innovate practice in their chosen area of nutrition and dietetics, centred on the needs and expectations of their service users.

Purpose of dietetics

The primary purpose of the practice of dietetics is to optimise the nutritional health of the service users, be they an individual, group or community, or population. By optimising the nutritional health of the service users, the dietitian expects to positively influence health out­comes. In dietetics, it is common for the dietitian to seek to influence or change other aspects of care or treatment, e.g. medication or the psychological well‐being of the ser­vice user. However, the primary purpose of the dietitian is to identify and take action to improve the nutritional status of the service user and to improve those symptoms that are amenable to dietetic intervention.

Any single consultation or professional activity is incredibly complex and involves a number of different and varied strands of knowledge – from biological and social sciences to food and medicine, alongside commu­nication and clinical decision‐making skills and attributes

Table 1.1.2 Factors that define dietetic scope of practice

Factor Example

Occupational role Clinician, researcher, educator, writer, consultant

Sector Private practice, industry, higher education, commercial

Environment Acute, community, GP practice, industry, media

Client group Children, elderly, people with learning difficulties, public, supermarket

Speciality Diabetes, public health, obesity, product development

Approaches Behavioural therapy, group education, anthropometry, cook‐and‐eat session

Types of cases for referral elsewhere

Other dietitians or other healthcare professionals, social services

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such as empathy and respect. These are applied within professional and legal frameworks and boundaries and within organisational and social norms and standards. Most of this thought process is invisible to other pro­fessionals (and often to the user) as it takes place rap­idly in the dietitian’s mind. The integration of all these components in a systematic way is what differentiates between dietitians and other professionals who pro­vide some nutrition services. Service users, health pro­fessionals, healthcare organisations and governments demand high‐quality healthcare. Quality in healthcare can be measured in domains such as patient experience, effectiveness and safety.

Process for nutrition and dietetic practice

The BDA’s Process for Nutrition and Dietetic Practice (PNDP) (the Process) (2016) demonstrates how dieti­tians integrate professional knowledge and skills into evidence‐based decision‐making, and hence the Pro­cess could be described as the cornerstone of practice. The Process describes the fundamentals of the dietetic intervention and is a tool in facilitating the profession to provide a consistent quality of care. It is applicable to all areas of practice including clinical, public health and health promotion, and whether working with indi­viduals, groups or communities.

The Process is shown in Figure  1.1.1, and it clearly shows the central role of the service user in dietetic practice. Service users bring their culture, beliefs and attitudes to the intervention, and these values guide

shared decision‐making. Within statutory regulated health services, this focus on the service user is described as patient‐centred care. There are many and varied defi­nitions for patient‐centred care, but that of the Institute of Medicine (2001) ‘Providing care that is respectful of, and responsive to, individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions’ encompasses all the concepts.

While providing a concept for a systemic method for practice, the Process does not undermine the professional autonomy of the dietitian, who is required to make decisions at every step. The Process clearly identifies the steps within a dietetic intervention and the skills, resources and knowledge used by the dietitian, but does not replace the dietitian’s decision‐making. The BDA nutrition and dietetic process consists of five steps (Table 1.1.3):

•Assessment.•Nutrition and dietetic diagnosis.•Formulation and planning of the intervention.• Implementation of the intervention.•Monitoring and evaluation.

Dietetic diagnosis

As previously stated, dietitians are autonomous pro­fessionals, and therefore responsible for their actions. One of the ways in which a dietitian demonstrates this autonomy is the identification of a nutritional and die­tetic diagnosis. The diagnosis step may be considered the most important step in the Process, but it is often the

3Plan nutritionand dieteticintervention

4Implementnutrition anddieteticintervention

3

1 Assessment

5Monitor andreview

6Evaluation

Identi�cation of nutritionalneed

Service users’ values andservice user/dietitiarelationship

n 2 Identi�cation of nutritionand dieteticdiagnosis

Figure 1.1.1 Nutrition and Dietetic Process (source: The British Dietetic Association 2016. Reproduced with permission from The British Dietetic Association)

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step that is missed. In making a diagnosis, the dietitian uses critical reasoning skills to evaluate the assessment information and to make judgements as to the risks to the service user(s) of taking action, or not. The dietitian will prioritise the nutritional issues identified and make a judgement as to whether taking action on these issues will make a difference to the health and outcomes for the service user (individual, group or population).

In developing the diagnosis, the dietitian identifies the relevant aspects of the assessment, and clearly states the nutritional problems that he or she and the service user have prioritised, the nutritional issues the dietitian can influence and the impact the nutritional and dietetic

intervention will have on the service user’s health (physical, mental or social well‐being). The benefits from making a nutritional and dietetic diagnosis include:

•Sharing with the others involved with the service user the nutritional issue(s) that the dietitian and service user have prioritised.

• Identifying the specific nutritional issue(s) that the dietitian can influence.

• Identifying the indicators in the assessment process that will form the basis of monitoring and evaluation.

•Demonstrating the thoroughness of the assessment pro­cess and clearly communicating this to other professionals.

Table 1.1.3 Definitions of the steps in the Model and Process for Nutrition and Dietetic Practice (BDA, 2016)

Step Definition

Assessment A systematic process of collecting and interpreting information to make decisions about the nature and cause of nutrition‐related health issues in an individual, a group or a population

Its purpose is to obtain adequate and relevant information to identify nutrition‐related problems and to inform the development and monitoring of the intervention

It is initiated by the identification of need, e.g. screening, referral by a health professional, self‐referral, high‐level public health data, epidemiological data or other similar process

Identification of nutritional and dietetic diagnosis

Identification of nutritional problems that impact on the physical, mental and/or social well‐being where the dietitian is responsible for action

IndividualIt requires therapeutic or educational action as determined by the dietitian and service user

Based on scientific evaluation of physical and psychological signs, symptoms, dietary and medical history, procedures and test results, and the priorities of the service user

GroupsIn a therapeutic group, there will be a diagnosis for the individuals in the group (as individuals). In a public health group, the diagnosis step will be the same as for the population

PopulationsWithin a public health needs assessment framework, the nutritional diagnosis is defined as assessing a nutritional health priority for action. It involves choosing (for action) the nutritional health conditions and determinant factors with the most significant size, impact and severity

At all levels, it includes the identification and categorisation of the occurrence, risk or potential for the development of a nutritional problem that the dietitian will be responsible for treating independently or of leading the strategy to manage

Plan intervention A set of activities and associated resources that are used to address the identified nutritional and dietetic diagnosis, designed with the intent of changing nutrition‐related behaviours, risk factors, environmental factors or aspects of physical or psychological health or nutritional status of the individual, group or population. All interventions are planned with the communities, service users and carers who are the recipients of the intervention. This client‐centred approach is a key element in developing a realistic plan that has a high probability of positively influencing the outcome. This will usually involve describing:

• Overall measurable and specific outcomes• Intermediate goals that will achieve the outcomes, determined by the diagnosis statement and

assessment information• Plan designed to meet the goals and outcomes – interventions, provision of food, provision

of nutritional support, education package, counselling, coordination of care, social marketing campaigns, food availability, food shopping and cooking skills

• Roles and responsibilities of individuals, professionals and organisations in delivering the plan

Implementation The action phase of the nutrition and dietetic process. Dietitians may carry out the intervention, or delegate to or coordinate with another health or social care professional; patient, client or carer; voluntary organisation or member of the nutrition and dietetic team

Monitoring The review and measurement of the client, group or population’s nutritional status at planned intervals with regard to the nutritional diagnosis, intervention plan, goals and outcomes. It includes monitoring the implementation processes of the plan

Evaluation The systematic comparison of current findings against previous status, intervention goals and outcomes or a reference standard, and usually takes place at the end of the process

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The diagnostic statement should clearly record for all service providers the problem, its cause (aetiology) and why the dietitian considers that it is a problem (symp­toms). This statement also forms the basis of the monitor­ing and evaluation step as dietitians will also have identi­fied the most important indicators from their description of the symptoms.

Recording and information management

Another fundamental aspect of professionalism is the accurate recording of the nutrition and dietetic process. The HCPC (2013) standards of proficiency require dieti­tians to be able to maintain records appropriately. The information in records, including dietetic records, is used for many different purposes. Most importantly, it provides a permanent account of the dietetic process, especially the intervention, and a means of communication between all professionals and others involved, including the ser­vice user. Information contained within records is also used for several other purposes, including demonstrating the overall effectiveness of the dietetic service and, possi­bly, organisation, quality monitoring and service improve­ment, research and public health purposes. While the increasing use of electronic health records requires more systematic record keeping, there is evidence that using a systematic format in any record, paper or electronic, improves the quality of care and service user outcomes (Mann & Williams, 2003). It is therefore important that the information in professional records be recorded accurately, systematically and consistently.

Quality improvement

Quality (Donabedian, 1980) has many dimensions. In the health service, patients, the public and carers expect safe, effective and consistent high‐quality care and treatment. For the individual dietitian, this is a requirement of reg­istration with the HCPC. Quality improvement involves a series of activities undertaken to reduce the gap between current practice and desired practice.

As a result of the need to account for its management and clinical efficiency, effectiveness and value for money, the NHS developed the concept of clinical gov­ernance. Clinical governance is defined as ‘the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which clinical excellence will flour-ish’ (Scally & Donaldson, 1998, p. 61). The principles of clinical governance are embedded within the organisa­tion and encompass:

•Clinical audit.•Evidence‐based practice.• Information governance (including record keeping).•Patient and public involvement.•Patient safety.•Revalidation and performance.•Risk management and medicolegal issues.

The term clinical effectiveness was developed as a response to demands to provide evidence of effective­ness. Health professionals have developed measures to report on the quality of clinical services and assess the effectiveness of medical interventions. These include:

•Clinical or medical audit.•Outcome measures.•Evidence‐based practice.•Guidelines.

Clinical audit is carried out locally and nationally, and provides a method for systematically evaluating, reflecting upon and reviewing practices against evidence‐based standards.

Dietetic outcome measurement

The provision of safe, effective and good‐quality care, or intervention, is fundamental to dietetic practice and is a HCPC registration requirement. A dietitian needs to know that an intervention is evidence based and effective, i.e. that it achieves the predicted outcome and makes effective use of the available resources. To demonstrate this, dietitians need to be able to systematically and consistently identify and predict what the desired outcomes of their interventions will be, the timescale involved and to what extent this has been achieved from the viewpoint of both the dietitian and the recipient. Measuring outcomes and sharing this information demonstrate the value of a dietetic service to commissioners and to the wider health community. Systematic collection and analysis of outcome data can facilitate decision‐making and enhance the quality of healthcare.

Measurement of outcomes can take place at the individual, service, multidisciplinary team, organisation­al or national level. Measuring healthcare outcomes is a developing field, and no single methodology is universally applicable to all situations or able to capture all dimen­sions of care. Outcome measurement should use SMAART principles (systematic, measurable, appropriate, accept­able, realistic and timely). There are several approaches to measurement, and an increasing number of validated tools are available. Measures may be patient reported  –  such as patient reported outcome measures (PROMs) (see Chapter 2.2, Assessment of nutritional status) or patient re­ported experience measures (PREMS). Putting the patient at the centre of care is a central feature of health policy across the UK, so measuring the patient experience has to be a key component of outcome measurement. Ther­apy outcome measures are those where the professional measures a change in a specified domain. The use and development of validated outcome measures in dietetics is an emerging methodology, and one that is underpinned by application of the Process to enable a consistent approach to the provision of dietetic care.

Digitalisation

Information technologies are revolutionising healthcare delivery. Traditionally, face‐to‐face or telephone consulta­tions were the mainstay of dietetic contacts but now video consultations are becoming more common, providing