Dietetic and Nutrition E-Book

Judy Lawrence

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 556

Veröffentlichungsjahr: 2016

Beschreibung

The ideal companion resource to ‘Manual of Dietetic Practice’, this book takes a problem-based learning approach to dietetics and nutrition with cases written and peer reviewed by registered dietitians, drawing on their own experiences and specialist knowledge

• Each case study follows the Process for Nutrition and Dietetic Practice published by the British Dietetic Association in 2012
• Includes case studies in public health, an increasingly important area of practice

Leseprobe

Table of Contents

Cover

Dedication

Title Page

Copyright

List of contributors

Preface

Online resources

Part I

Chapter 1: Model and process for nutrition and dietetic practice

Identifying the nutrition and dietetic diagnosis

Nutrition intervention

Monitoring and review

Evaluation

References

Resource

Chapter 2: Nutrition care process terminology (NCPT)

Why is standardised language important?

Nutrition care process terminology

Acknowledgements

References

Resources

Chapter 3: Record keeping

Legislation

Guidelines

Social media

References

Resources

Chapter 4: Assessment

Domains

References

Resources

Part II

Case Study 1: Veganism

References

Resources

Case Study 2: Older person – ethical dilemma

References

Resources

Case Study 3: Older person

Resources

Case Study 4: Learning disabilities: Prader–Willi syndrome

Patient history and care plan

References

Resources

Case Study 5: Freelance practice

References

Resources

Case Study 6: Public health – weight management

Scoping exercise for the Well North programme

Acknowledgements

References

Resource

Case Study 7: Public health – learning disabilities

The pilot phase

Results of the pilot study

References

Resources

Case Study 8: Public health – calorie labelling on menus

Resources

Case Study 9: Genetics and hyperlipidaemia

References

Resources

Case Study 10: Intestinal failure

Reference

Resources

Case Study 11: Irritable bowel syndrome

References

Resources

Case Study 12: Liver disease

References

Resource

Case Study 13: Renal disease

References

Resource

Case Study 14: Renal – black and ethnic minority

Reference

Resources

Case Study 15: Motor neurone disease/amyotrophic lateral sclerosis

References

Resource

Case Study 16: Chronic fatigue syndrome/myalgic encephalopathy

References

Resource

Case Study 17: Refsum's disease

Reference

Resource

Case Study 18: Adult phenylketonuria

References

Resource

Case Study 19: Osteoporosis

References

Resources

Case Study 20: Eating disorder associated with obesity

References

Resources

Case Study 21: Forensic mental health

References

Case Study 22: Food allergy

Resources

Case Study 23: HIV/AIDS

References

Resources

Case Study 24: Type 1 diabetes mellitus

References

Resources

Case Study 25: Type 2 diabetes mellitus – Kosher diet

References

Resources

Case Study 26: Type 2 diabetes mellitus – private patient

Resources

Case Study 27: Gestational diabetes mellitus

Acknowledgement

References

Resources

Case Study 28: Polycystic ovary syndrome

Acknowledgement

References

Resources

Case Study 29: Obesity – specialist management

Intervention

Evaluation

References

Resources

Case Study 30: Obesity – Prader–Willi syndrome

Acknowledgements

References

Resources

Case Study 31: Bariatric surgery

References

Resources

Case Study 32: Stroke and dysphagia

References

Resources

Case Study 33: Hypertension

Resources

Case Study 34: Coronary heart disease

References

Resources

Case Study 35: Haematological cancer

References

Resources

Case Study 36: Head and neck cancer

References

Resources

Case Study 37: Critical care

References

Resource

Case Study 38: Traumatic brain injury

References

Resource

Case Study 39: Spinal cord injury

References

Resource

Case Study 40: Burns

Reference

Resources

Case Study 41: Telehealth and cystic fibrosis

References

Resources

Case Study 1: Veganism

Answers

Answers to further questions

Case Study 2: Older person-ethical dilemma

Answers

Case Study 3: Older person

Answers

Case Study 4: Learning disabilities

Answers

Answer to further question

Case Study 5: Freelance practice

Answers

Case Study 6: Public health – weight management

Answers

Answers to further questions

Case Study 7: Public health – learning disabilities

Answers

Answers to further questions

Case Study 8: Public health – calorie labelling on menus

Answers

Case Study 9: Genetics and hyperlipidaemia

Answers

Answers to further questions

Case Study 10: Intestinal failure

Answers

Answers to further questions

Case Study 11: Irritable bowel syndrome

Answers

Answers to further questions

Case Study 12: Liver disease

Answers

Answers to further questions

Case Study 13: Renal disease

Answers

Answers to further questions

Case Study 14: Renal – black and ethnic minority

Answers

Case Study 15: Motor neurone disease/amyotrophic lateral sclerosis

Answers

Answers to further questions

Case Study 16: Chronic fatigue syndrome/myalgic encephalopathy

Answers

Answers to further questions

Case Study 17: Refsum's disease

Answers

Answers to further questions

Case Study 18: Adult phenylketonuria

Answers

Answers to further questions

Case Study 19: Osteoporosis

Answers

Case Study 20: Eating disorder associated with obesity

Answers

Answers to further questions

Case Study 21: Forensic mental health

Answers

Answers to further questions

Case Study 22: Food allergy

Answers

Answers to further questions

Case Study 23: HIV/AIDS

Answers

Answers to further questions

Case Study 24: Type 1 diabetes mellitus

Answers

Answers to further questions

Case Study 25: Type 2 diabetes mellitus – Kosher diet

Answers

Case Study 26: Type 2 diabetes mellitus – private patient

Answers

Case Study 27: Gestational diabetes mellitus

Answers

Answers to further questions

Case Study 28: Polycystic ovary syndrome

Answers

Answers to further questions

Case Study 29: Obesity – specialist management

Answers

Case Study 30: Obesity – Prader–Willi syndrome

Answers

Answer to further question

Case Study 31: Bariatric surgery

Answers

Answers to further questions

Case Study 32: Stroke and dysphagia

Answers

Answers to further questions

Case Study 33: Hypertension

Answers

Case Study 34: Coronary heart disease

Answers

Answers for further questions

Case Study 35: Haematological cancer

Answers

Answers to further questions

Case Study 36: Head and neck cancer

Answers

Answers to further questions

Case Study 37: Critical care

Answers

Answers to further questions

Case Study 38: Traumatic brain injury

Answers

Case Study 39: Spinal cord injury

Answers

Answers to further questions

Case Study 40: Burns

Answers

Case Study 41: Telehealth and cystic fibrosis

Answers

Answers to further questions

Appendices

APPENDIX A1: Dietary reference values

Energy

References

APPENDIX A2: Weights and measures

Height/length

Weight

Volume

Reference

APPENDIX A3: Dietary data

Conversion factors

Food exchange lists

E number classification system

Reference

APPENDIX A4: Body mass index

Reference

APPENDIX A5: Anthropometric and functional data

Demiquet and mindex

Upper arm anthropometry

Estimating height from ulna length

References

APPENDIX A6: Predicting energy requirements

References

APPENDIX A7: Clinical chemistry

Conversion calculations

Osmolarity and osmolality

References

Index

End User License Agreement

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Guide

Cover

Table of Contents

Preface

Part I

Chapter 1: Model and process for nutrition and dietetic practice

List of Illustrations

Chapter 1: Model and process for nutrition and dietetic practice

Figure 1.1 Nutrition and dietetic process (BDA (2012), p. 7. Reproduced with permission of British Dietetis Association).

APPENDIX A5: Anthropometric and functional data

Figure 5.1 How to measure ulna length.

APPENDIX A7: Clinical chemistry

Figure 7.1 Normal distribution curve.

Figure 7.2 Theoretical distribution of values for in health and disease.

List of Tables

Case Study 6: Public health – weight management

Table 6.1 Timescale of key activities planned, implemented and evaluated

This book is dedicated to Pat Judd (1947–2015), inspirational dietitian and educator.

Dietetic and Nutrition Case Studies

Edited By

Judy Lawrence

Registered Dietitian, the Research Officer for the BDA, and Visiting Researcher,Nutrition and Dietetics, King's College London, England

Pauline Douglas

Registered Dietitian, a Senior Lecturer and Clinical Dietetic Facilitator, Northern Ireland Centre for Food and Health (NICHE), Ulster University, Northern Ireland

Joan Gandy

Registered Dietitian, a Freelance Dietitian and Visiting Researcher in Nutrition and Dietetics, University of Hertfordshire, England

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Library of Congress Cataloging-in-Publication Data

Names: Lawrence, Judy, 1960- , editor. | Gandy, Joan, editor. | Douglas, Pauline, 1961- , editor.

Title: Dietetic and nutrition case studies / edited by Judy Lawrence, Joan

Gandy, Pauline Douglas.

Description: Chichester, West Sussex ; Hoboken, NJ : John Wiley & Sons, 2016.

| Complemented by: Manual of dietetic practice / edited by Joan Gandy in conjunction with the British Dietetic Association. Fifth edition. 2014. |

Includes bibliographical references and index.

Identifiers: LCCN 2015040817 (print) | LCCN 2015042999 (ebook) | ISBN 9781118897102 (pbk.) | ISBN 9781118898239 (pdf) | ISBN 9781118898246 (epub)

Subjects: | MESH: Dietetics. | Nutritional Physiological Phenomena. | Diet

Therapy. | Problem-Based Learning.

Classification: LCC RM216 (print) | LCC RM216 (ebook) | NLM WB 400 | DDC

615.8/54–dc23

LC record available at http://lccn.loc.gov/2015040817

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

List of contributors

Ellie Allen

Clinical Lead Dietitian, University College London Hospitals NHS Foundation Trust, London, United Kingdom

Barbara Martini Arora

Freelance Registered Dietitian, Bromley, United Kingdom

Eleanor Baldwin

Advanced Dietitian – Adult Refsums Disease and Bariatrics, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom

Julie Beckerson

Haemato-Oncology Specialist, Imperial College Healthcare NHS Trust, London, United Kingdom

Kathleen Beggs

Clinical Tutor, The University of British Columbia, Vancouver, BC, Canada

Helen Bennewith

Professional Lead for Addiction and Mental Health Dietetics, NHS Greater Glasgow and Clyde, Glasgow, Scotland, United Kingdom

Sarah Bowyer

PhD Research Student in Rural Health, University of the Highlands and Islands, Inverness, Scotland, United Kingdom

Rachael Brandreth

Children's Weight Management Dietitian, Royal Cornwall Hospital Trust, Cornwall, United Kingdom

Elaine Cawadias

Registered Dietitian, The Ottawa Hospital Rehabilitation Centre, ALS Clinic, Ottawa, ON Canada

Alison Culkin

Research Dietitian, London North West Healthcare NHS Trust, London, United Kingdom

Rachael Donnelly

Acting Clinical Lead Dietitian, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom

Pauline Douglas

Senior Lecturer and Clinical Dietetic Facilitator, Northern Ireland Centre for Food and Health (NICHE), University of Ulster, Londonderry, Northern Ireland, United Kingdom

Hilary Du Cane

Freelance Dietitian and Marketeer, United Kingdom

Alastair Duncan

Lead Dietitian, NIHR Clinical Doctoral Research Fellow, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom

Mary Flynn

Chief Specialist Public Health Nutrition, Food Safety Authority of Ireland, Dublin, Ireland; Visiting Professor, University of Ulster, Coleraine, Northern Ireland, United Kingdom

Caroline Foster

Specialist Dietitian, Leeds and York Partnership NHS Foundation Trust, Leeds, United Kingdom

Lisa Gaff

Specialist Dietitian, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom

Joan Gandy

Freelance Dietitian and Visiting Researcher, Nutrition and Dietetics, University of Hertfordshire, Hatfield, United Kingdom

Elaine Gardner

Freelance Dietitian, London, United Kingdom

Susie Hamlin

Senior Specialist Dietitian Liver Transplantation, Hepatology and Critical Care, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom

Nicola Henderson

AHP Team Lead, NHS Forth Valley, Larbert, United Kingdom

Sandra Hood

Diabetes Dietitian, The Diabetes Centre, Dorset County Hospital NHS Foundation Trust, Dorchester, Dorset, United Kingdom

Nicola Howle

Mental Health Dietitian, South Staffordshire and Shropshire Healthcare NHS Foundation Trust, Lichfield, United Kingdom

Bushra Jafri

Human Nutrition and Dietetics, London Metropolitan University, London, United Kingdom

Yvonne Jeanes

Senior Lecturer in Clinical Nutrition, University of Roehampton, London, United Kingdom

Sema Jethwa

Senior Diabetes Specialist Dietitian, University College London Hospital NHS Trust, London, United Kingdom; Freelance Dietitian, Hertfordshire, United Kingdom

Susanna Johnson

Community Paediatric Dietitian, Wembley Centre for Health and Care, Central London Community Healthcare NHS Trust, London, United Kingdom

Natasha Jones

Advanced Specialist Haematology/TYA dietitian, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom

Ruth Kander

Senior Dietitian and Consultant Dietitian, Imperial College Healthcare NHS Trust, London, United Kingdom and Consultant East Kent Dietitian.

Joanna Lamming

Specialist Weight Management Dietitian, East, Kent, United Kingdom

Anne Laverty

Specialist Dietitian, Learning Disabilities, Northern Health and Social Care Trust, Coleraine, Northern Ireland, United Kingdom

Judy Lawrence

Research Officer BDA and Visiting Researcher, King's College London, London, United Kingdom

Julie Leaper

Senior Specialist Dietitian (Liver/ICU) St James's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom

Sian Lewis

Macmillan Clinical Lead Dietitian, Chair of BDA Specialist Oncology Group, Velindre Cancer Centre, Wales, United Kingdom

Sherly X. Li

PhD Candidate, MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom

Seema Lodhia

HCA Healthcare, London, United Kingdom

Julie Lovegrove

Head of the Hugh Sinclair Unit of Human Nutrition, University of Reading, Reading, United Kingdom

Marjorie Macleod

Specialist Dietitian, Learning Disabilities Service, NHS Lothian, Edinburgh, Scotland, United Kingdom

Paul McArdle

Lead Clinical Dietitian and Deputy Head of Dietetics, NIHR Clinical Doctoral Research Fellow and Freelance Dietitian, Birmingham Community Healthcare NHS Trust, Birmingham, United Kingdom

Angela McComb

Health and Social Wellbeing Improvement Manager, Northern Health and Social Care Trust, Londonderry, Northern Ireland, United Kingdom

Caoimhe McDonald

Research Dietitian, Mercers Institute for Research on Ageing, St. James Hospital, Dublin, Ireland

Jennifer McIntosh

Clinical Lead Dietitian, Leeds and York Partnership NHS Foundation Trust, Leeds, United Kingdom

Yvonne McKenzie

Specialist in Gastrointestinal Nutrition, Clinical Lead in IBS for the Gastroenterology Specialist Group of the British Dietetic Association, Birmingham, United Kingdom

Kirsty-Anna McLaughlin

Community Nutrition Support Dietitian, Wiltshire Primary Care Trust, Wiltshire, United Kingdom

Kassandra Montanheiro

Macmillan Senior Specialist Dietitian, University College London Hospitals NHS Foundation Trust, London, United Kingdom

Eileen Murray

Specialist Mental Health Dietitian, NHS Greater Glasgow and Clyde Directorate of Forensic Mental Health and Learning Disabilities, Glasgow, Scotland, United Kingdom

Mary O'Kane

Consultant Dietitian (Adult Obesity), Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom

Sian O'Shea

Head of Nutrition and Dietetics for Learning Disabilities, Aberkenfig Health Board, Bridgend, United Kingdom

Sue Perry

Deputy Head of Dietetics, Hull Royal Infirmary, Hull and East Yorkshire Hospitals NHS Trust, Hull, United Kingdom

Gail Pinnock

Specialist Bariatric Surgery Dietitian, Homerton University Hospital NHS Foundation Trust, London, United Kingdom

Vicki Pout

Deputy Acute Dietetic Manager, Queen Elizabeth the Queen Mother Hospital, Kent Community Health NHS Foundation Trust, Margate, Kent, United Kingdom

Louise Robertson

Specialist Dietian, Inherited Metabolic Diseases, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom

Juneeshree S. Sangani

Freelance Dietitian, United Kingdom

Nicola Scott

Senior Specialist Haematology Dietitian, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom

Ella Segaran

Specialist Dietitian for Critical Care, Chair of Dietitians in Critical Care Specialist Group of the BDA, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom

Reena Shaunak

Diabetes Specialist Dietitian, West Middlesex University Hospital NHS Trust, Isleworth, United Kingdom

Bushra Siddiqui

Renal Dietitian, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom

Isabel Skypala

Consultant Allergy Dietitian and Clinical Lead for Food Allergy, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom

Alison Smith

Prescribing Support Dietitian, Aylesbury Vale Clinical Commissioning Group and Chiltern Clinical Commissioning Group, Aylesbury, United Kingdom

Chris Smith

Specialist Paediatric Dietitian, Royal Alexandra Hospital, Brighton, United Kingdom

Clare Stradling

NIHR Doctoral Research Fellow, Birmingham Heartlands Hospital, University of Birmingham, Birmingham, United Kingdom

Carolyn Taylor

Specialist Dietitian, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom

Lucy Turnbull

Clinical Lead for Chronic Disease and Weight Management Services, Central London Community Healthcare, London, United Kingdom

Evelyn Volders

Senior Lecturer Nutrition and Dietetics, Monash University, Melbourne, Victoria, Australia

Kirsten Whitehead

Assistant Professor, Division of Nutritional Sciences, University of Nottingham, Nottingham, United Kingdom

Kate Williams

Head of Nutrition and Dietetics, South London and Maudsley NHS Foundation Trust, London, United Kingdom

E. Mark Windle

Specialist Dietitian, Burns and Intensive Care, Mid Yorkshire Hospitals NHS Trust, Wakefield, United Kingdom

Preface

Problem-based learning (PBL) is increasingly becoming the preferred method of teaching in health care. There is currently a dearth of appropriately written case studies. This book takes a PBL approach to dietetics and nutrition and aims to address this gap. It has been written to complement the Manual of Dietetic Practice (MDP) (5th edition), and the case studies are cross-referenced accordingly. Uniquely, the case studies are written and peer reviewed by registered dietitians, drawing on their own experiences and specialist knowledge. This book has been written and edited with many readers in mind. Lecturers and staff in universities with courses in dietetics and nutrition will undoubtedly find it relevant although it will be useful to many other health care students and professionals. The case studies are also aimed at qualified dietitians and nutritionists as a tool to enhance their continuing professional development. Readers will be able to work through the case studies individually and in groups in different settings including dietetic departments. It will also help dietetic students and dietitians to identify further areas of practice that may be of interest to them.

Each case study follows the Process for Nutrition and Dietetic Practice (PNDP) that was published by the British Dietetic Association (BDA) in 2012. While throughout the world there are slight variations in nutrition and dietetic models and processes, the case studies can be successfully used alongside these. In addition, the Nutrition Care Process Terminology (NCPT), formally known as International Dietetics and Nutrition Terminology (IDNT), is used throughout the case studies – a feature practitioners worldwide will find useful.

Each case study starts with a scenario, which will enable the reader to identify the need for a nutritional intervention. This is followed by the assessment step of the PNDP and is standardised by the use the ABCDE format in most cases. Questions are posed about the assessment, the intervention and evaluation and monitoring steps. Some case studies also include further questions to stretch more newly qualified and more experienced practitioners. The PNDP is central to all areas of practice although it may be easier to identify each step in clinical areas than in other areas such as public health. This book includes real life case studies in public health, an increasingly important area of practice, and although they may be more detailed by carefully working through the case study and answers, it is possible to identify each and every step of PNDP. Questions on ethical issues are included in some case studies; however, ethics should always be of prime importance to any health care professional and is central to practice.

The book is split into two parts; firstly to reinforce keys areas of practice pertinent to this book it starts with the following introductory chapters:

Model and process for dietetic practice

Nutrition care process terminology

Documentation and record keeping

Assessment – including the ABCDE assessment process

This is followed by the case studies and separate answers. To avoid duplication the references for both the case studies and the answers are given at the end of each case study regardless of where they are cited. For completeness and to aid readers, many appendices from the Manual of Dietetic Practice are reproduced in the book. They include dietary reference values, weight and measures, dietary data, anthropometric data, energy prediction equations and so on and clinical chemistry.

Many of the case studies also have a link to a relevant PEN, Practice Based Evidence in Nutrition (PEN), practice question or resource. Dietitians in Australia, Canada, the United Kingdom and Ireland will be familiar with this global resource for nutrition practice.

We hope that readers enjoy using this book as much as we have enjoyed compiling it. Finally, we would like to thank the contributors and reviewers who have been invaluable when compiling this book.

Judy LawrencePauline DouglasJoan Gandy

Online resources

Additional resources, which may be of interest to readers of this book, can be found on the companion website for the Manual of Dietetic Practice, 5th Edition, edited by Joan Gandy.

http://www.manualofdieteticpractice.com/

The website includes

Case study summaries (PDF)

An alphabetical list of web resources

Appendices from the book (PDF)

Reference lists with CrossRef links

Tables from the

Manual of Dietetic Practice

(PDF)

Figures from the

Manual of Dietetic Practice

(PPT)

Updates

Part I

Chapter 1Model and process for nutrition and dietetic practice

Judy Lawrence

The nutrition care process and model was first conceived by the Academy of Nutrition and Dietetics (Lacey & Pritchett, 2003). Since then it has evolved and been adapted and is now used by dietitians and nutritionists worldwide. The case studies in this book are written with the nutrition and dietetic care process in mind. The process can be used in any setting including clinical dietetics and public health. Although case studies in this book are based around the British Dietetic Association's (BDA) (2012) model and process (Figure 1.1) used by dietitians in the United Kingdom, they can be used alongside other versions of the process and model as well. The model starts with the identification of nutritional need, followed by six stages, namely, assessment, identification of the nutrition and dietetic diagnosis, planning the nutrition and dietetic intervention, implementing the intervention, monitoring and reviewing the intervention and finally evaluating the intervention.

Figure 1.1 Nutrition and dietetic process (BDA (2012), p. 7. Reproduced with permission of British Dietetis Association).

The case studies use the ABCDE approach (Gandy, 2014), were A is for anthropometry, B stands for biochemical and haematological markers, C for clinical, D for dietary and E is used to include economic, environmental and social issues that may be relevant. Information collected during the assessment is used to make the nutrition and dietetic diagnosis. More details of the assessment can be found in Chapter 4.

Identifying the nutrition and dietetic diagnosis

The nutrition and dietetic diagnosis is the nutritional problem that is assessed using the dietitian's clinical reasoning skills and resolved or improved by dietetic intervention. The nutrition and dietetic diagnosis is a key part of the care process, and once the correct diagnosis has been made the intervention and the most appropriate outcomes to monitor will fall into place. The nutrition and dietetic diagnosis is written as a structured sentence known as the PASS statement, where P is the problem, A the aetiology and SS the signs and symptoms. The PASS statement should describe the ‘Problem’ related to ‘Aetiology’ as characterised by ‘Signs/Symptoms’, for example; inadequate energy intake (problem) related to an overly restrictive gluten free diet (aetiology) as characterised by weight loss of 4 kg and anxiety regarding appropriate food choices (signs and symptoms). A well-written PASS statement is one where the dietitian or nutritionist can improve or resolve the problem, the intervention addresses the aetiology and the signs and symptoms can be monitored and improved. The nutrition and dietetic diagnosis can be broken down into the three steps; problem, aetiology and signs and symptoms.

Problem

This is the nutritional (dietetic) problem not the medical problem; it is the problem that can be addressed by dietetic intervention. In these case studies, the problems are expressed using the diagnosis terms as approved by the BDA. More details about the terminology can be found in Chapter 2 on international language and terminology. The problem is the change in the nutrition state that is described by adjectives such as decreased/increased, excessive/inadequate, restricted and imbalanced. In the United Kingdom, nutrition and dietetic diagnosis terms fall into one of the following seven categories:

Energy balance;

Oral or nutritional support;

Nutrient intake;

Function, for example, swallowing;

Biochemical;

Weight; and

Behavioural/environmental.

There may be more than one problem, so a number of nutritional and dietetic diagnoses may be possible but these can often be consolidated into one diagnosis or one diagnosis may be prioritised, using clinical judgement and the client's wishes. Some nutrition and dietetic diagnosis may be more appropriate than others; practice and experience will hone this skill.

Aetiology

The aetiology is the cause of the nutritional problem. Causes may be related to behavioural issues such as food choices, environmental issues such as food availability, knowledge such as not knowing which foods are gluten free, physical such as inability to chew food, or cultural such as beliefs about foods. There may be more than one cause for the problem that a client has but the dietitian should be able to identify the basis of the problem using the information gained during the assessment process. For example, a client may have an incomplete knowledge of their gluten-free diet and this may be caused by:

Missing a dietetic appointment;

Not appreciating that all gluten-containing foods need to avoided;

A misconception that the diet was not important; and

A lack of awareness of the gluten content of many manufactured foods.

It is also important that the aetiology identified in the PASS statement is one that the dietitian can influence because the aetiology forms the basis of the intervention. It may be difficult to identify the cause of the problem and in such circumstances the pragmatic approach may be to identify the contributing factors. Once identified, the aetiology may be linked to the problem using the phrase ‘related to’.

Signs and symptoms

Signs are the objective evidence that the problem exists; they may be from anthropometric measurements, biochemical or haematological results. Symptoms are subjective: they may be things that the patient/client has talked about such as tiredness, clothes being too tight or loose, difficulty swallowing and lack of understanding. Signs and symptoms gathered during the assessment process can be used to quantify the problem and indicate its severity. Signs and symptoms may be linked to the aetiology using the phrase ‘characterised by’. It is not necessary to have both signs and symptoms in the diagnostic statement; one or the other is adequate.

Alternative diagnoses may be made when answering the questions in the case studies. It does not necessarily mean that your statement is incorrect; it may be a reasonable alternative or less of a priority. Check that your PASS statement describes a problem that can be altered by dietetic intervention and that the evidence collected during the assessment process suggests that it is important. The signs and symptoms should ideally be ones that can be measures to help advance the progress in alleviating the problem.

Nutrition intervention

The nutrition intervention is the action taken by the dietitian to address the diagnosis. Ideally, the intervention should be aimed at the cause of the problem, the aetiology, but if this is not possible then the intervention should address the signs and symptoms of the problem. In some cases, the intervention may be to maintain a current situation, for example, adult PKU. The intervention may involve the dietitian in delegating or co-ordinating the nutrition care done by others. The intervention has two stages: planning and implementation. For each PASS statement it is necessary to establish a goal based on the signs and symptoms (planning) and an appropriate intervention based on the aetiology (implementation). The intervention should of course be evidence based. Interventions may involve recommending, implementing, ordering, teaching or referring to other professionals.

Planning

Planning the intervention may involve collecting more information from the patient or from other sources. Planning should involve the patient/client/carer or group in agreeing and prioritising the necessary steps, to ensure that the care is patient centred.

Implementation

Implementing the intervention is the phase of the nutrition and dietetic care process, which involves taking action. The intervention may involve the dietitian in training someone else to take action, or in supporting the patient/client to make behavioural changes. The dietitian may facilitate change through others, for example a dietetic assistant, nurse, care assistant, carer or teacher. The implementation may be something that is done to an unconscious patient such as the delivery of a prescribed total parenteral nutrition feeding regimen. Alternatively, the intervention may involve a community or group, for example a school meals project or lipid lowering group.

Monitoring and review

Monitoring focuses on changes in the signs and symptoms that were identified in the initial assessment to see if progress is being achieved and goals are met. The goals should be SMART:

S – specific

M – measurable

A – achievable

R – realistic

T – timely

SMART goals should make the monitoring process easier. Monitoring should be ongoing or carried out at planned intervals so that the results of the monitoring process can be used to review the intervention and modify it, if necessary. This may involve a new assessment and a new nutrition and dietetic diagnosis, which will in turn lead to new goals and additional monitoring. Some of the case studies in this book involve more than one nutrition and dietetic diagnosis.

Evaluation

Evaluation takes place at the end of the process. It involves collecting data about the current situation and comparing it with data from the assessment, with a reference standard such as BMI indicators of obesity or HbA1c measures of diabetes, or with goals that were established early in the planning process. The effectiveness of the evaluation can be judged by changes in the signs and symptoms identified in the nutrition and dietetic diagnosis.

The nutrition and dietetic care process may be an ongoing process where an individual patient is seen many times over a number of years for a chronic condition such as diabetes or it may be a short episode of care.

References

BDA (2012) Process and model for nutrition and dietetic practice. URL

https://www.bda.uk.com/professional/practice/process

[accessed on 27 May 2015].

Gandy, J. (2014) Assessment of nutritional status. In: Gandy, J. (ed),

Manual of Dietetic Practice

, 5th edn. Wiley Blackwell, Oxford.

Lacey, K. & Pritchett, E. (2003) Nutrition care process and model: ADA adopts road map to quality care and outcomes management.

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Chapter 2Nutrition care process terminology (NCPT)

Pauline Douglas

The challenges for the nutrition and dietetic practitioner are to prevent and reduce the burden of nutrition related health problems for individuals or groups of people. Dietitians and nutritionists must advance practice from experience based to evidence based and demonstrate quality practice and optimise nutritional outcomes. To do this they must have a common language that they can benchmark their practice with other dietitians. They must demonstrate practice through the acquisition and use of complex systems of communication. This allows them to convey meaningful information to others. In addition:

It provides supporting documentation for the reimbursement of dietetic services provided.

It engages dietitians from academia through to practice to provide a profession fit for purpose and competent to practice.

With an increasing mobility of heath care professionals around the world the language needs to be standardised to convey meaningful information in a uniform way. This allows for the comparison of like messages in a logical process to facilitate the production of evidence-based practice. Also service users are travelling within countries and across borders for treatment and expect a consistent quality of care.

Using standard terminology:

Promotes consistency and continuity of care;

Structures communication

Within and across professions;

Within and across nations;

Allows evaluation of the quality of care;

Facilitates research and building of a professional knowledge base (e.g. Practice-Based Evidence in Nutrition developed by Dietitians of Canada. There is now a PEN global dietetic partnership of associations of Australia, Canada, Ireland, New Zealand, South Africa and the UK, Evidence Analysis Library of Academy of Nutrition and Dietetics);

Facilitates professional development; and

Improves professional image, credibility, accountability of dietitians.

Why is standardised language important?

It provides a common means of communication for healthcare professionals. Other healthcare professions, for example, nurses, physiotherapists, occupational therapists and so on have shown the benefits of having a standardised language. Making nursing practice count (Beyea, 1999) ensures that when a nurse talks about a stage three pressure area, another nurse fully understands what the first nurse is describing. An example from dietetics is that there are differing definitions and understanding of what is meant by nutritional support. In some countries this relates to enteral and parenteral nutrition and in others this also includes food fortification and oral nutritional supplementation.

A standardised language is complementary to a nutrition and dietetic process. It ensures that there is comparability in the terms used to describe diagnoses, interventions and outcomes of nutritional care. It is important to stress that this still ensures the dietitian provides individualised nutritional care for the patient or the population ensuring the patient/service user is at the centre of all care by taking into account their needs, values and culture.

Dietitians do not work alone. They are integral members of the inter-professional health team. As such communication of their work needs to be accessible to other healthcare professionals, commissioners of service or those reimbursing them for their services. The World Health Organization uses the International Classification of Diseases (ICD) as the standard diagnostic tool for epidemiology, health management and clinical purposes. It is used to monitor the incidence and prevalence disease for general health and populations. Similarly the International Classification of Functioning, Disability and Health (ICF) is the WHO framework for measuring health and disability at both individual and population levels.

In 2003 the Academy of Nutrition and Dietetics (AND) published the concepts of a nutrition care process and model. Other professional bodies have now modified this to best meet the needs of their members and their healthcare provision, for example, BDA (2012). In 2008, AND defined the language to complement the process. This was called International Dietetic and Nutrition Terminology (IDNT) now known as the Nutrition Care Process Terminology (NCPT). In Europe, the Dutch Dietetic Association were also developing another dietetic language. This was modelled on the International Classification of Function (ICF) and is now recognised as the ICF – Dietetique. Now as the work of the National Dietetic Associations from across the world is being published, working groups are being established to facilitate international collaboration to further develop dietetic practice in this area.

The International Health Terminology Standards Development Organization (IHTSDO) is a not for profit organisation based in Europe. This organisation owns and administers the rights to health terminologies and related standards including Systematised Nomenclature of Medicine – Clinical Terms (SNOMED – CT). SNOMED – CT is a comprehensive medical terminology incorporating several terminologies from various healthcare disciplines. While being of international scope it can be adapted to each countries requirements. This international dietetic working group has been working closely to incorporate NCPT as an integral element of SNOMED. The WHO and IHTSDO have agreed to try to harmonise WHO classifications and SNOMED – CT terminologies to develop common terms used by both organisations. This has the potential to support further integration of different dietetic languages and thus enhance dietetic practice.

In Europe a key priority is ‘to support Member States in developing common identification and authentication measures to facilitate transferability of data across border healthcare’ (European Parliament and Council, 2011). As a result NCPT developments have facilitated eNCPT being available in several languages, for example, English, French, Italian, Spanish and Swedish again supporting international standards for dietetic practice and facilitating working across borders.

Nutrition care process terminology

The NCPT is used alongside the Nutrition and Dietetic Care Process. In the diagnosis the PASS statement (problem, aetiology, signs and symptoms) the problem is the change in nutrition state that is described by adjectives such as decreased/increased, excessive/inadequate, restricted and imbalanced. In addition nutrition and dietetic diagnosis terms fall into one of seven categories:

Energy balance;

Oral or nutritional support;

Nutrient intake;

Function, for example, swallowing;

Biochemical;

Weight; and

Behavioural/environmental.

The descriptors used in the different countries can challenge the dietitian to define the problem in a way that their service users may find acceptable. The interested professional bodies are collaborating on this to gain appropriate, relevant country specific additions and alternatives. Dietetic professional bodies need to continue to work collaboratively to ensure deititians have a standardised language.

It is important that the dietetic profession continue to engage with and use the NCPT. It should become an integral element of academic training, further developed within practice placement settings and then fully embraced by dietitians throughout their professional practice.

Acknowledgements

The Professional Practice Committee of the European Federation of Associations of Dietitians especially Constantina Papoutsakis, Ylva Orrevall, Lene Thorensen, Naomi Trostler, Remijnse Wineke and Claudia Bolleurs for their insight and knowledge.

References

BDA (2012)

Model and Process for Dietetic Practice

. BDA, Birmingham.

Beyea, S.C. (1999) Standardised language – making nursing practice count.

AORN Journal

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70

, 831–832, 834, 837–838.

European Parliament and Council. (2011) Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011, on the application of patients' rights in cross-border healthcare, Article 14,

Official Journal of the European Union

,

L 88

, 45.

Resources

AND Evidence Analysis Library.

www.andeal.org

.

BDA Diagnosis Terms.

www.bda.uk.com/professional/practice/terminology

.

Practice Based Evidence in Nutrition (PEN).

www.pennutrition.com/index.aspx

.

Chapter 3Record keeping

Judy Lawrence

In the UK the Health and Care Professions Council (HCPC) (2013) requires that dietitians ‘make reasoned decisions’ and ‘record the decisions and reasoning appropriately’ as part of their Standards of Proficiency. There is also a specific record keeping standard of proficiency; standard 10 which is ‘be able to maintain records appropriately’, this is expanded in points 10.1 and 10.2 which outline the need for records to be in line with relevant protocols, guidelines and legal requirements. This chapter discusses these guidelines and legal requirements. Dietitians from outside the UK should check with their own regulatory body and employer to ensure that their record keeping meets the required standard.

Legislation

In the UK there are a number of pieces of legislation that relate to records and record keeping.

The Data Protection Act 1998

The Act relates to the protection of personal data (e.g. medical notes) about a living individual, such as data held by a public authority (e.g. NHS). This includes patient record cards kept by a dietitian, medical records to which a dietitian may contribute and electronic records. Data is said to be identifiable even if the information is recorded against a number that can then be matched to a person by accessing a different piece of information. The Act also regulates the processing of personal data. The term processing includes the storage, use, disclosure and the destruction of the data. The Act has six principles, they are that data should be processed fairly and lawfully, that data collected for a specific purpose or purposes should not be further processed for any purpose that is incompatible with the original purpose, that data collection should not be excessive in relation to the purpose, data should be accurate and where necessary up to date, data should not be kept for longer than is necessary and finally data should be processed in accordance with the rights of the individual. These principles may be subject to interpretation by an employer, and there will be local policies relating to them, for example a patient has the right to request access to information about themselves. A patient can ask to see what you have written during a consultation and comment on what has been written. If a patient or carer writes requesting to see the notes it is necessary to conform to local policy requirements first, for example, an employer may require certain information as proof of identity from the patient or carer. All records are owned by the employing authority and requests for medical notes or electronic records should be dealt with by the clinical governance team. With regard to information being accurate, an opinion about a patient's nutritional condition that you believe to be accurate but that the individual disagrees with or believes to be inaccurate may be expressed. For example an anorexic patient may regard the statement that they are underweight as inaccurate. It is still legally possible to make this statement in their notes although a record that the patient disagrees with the assessment should be noted. The assessment should be backed by recording a weight and relevant BMI range.

Freedom of Information Act 2000

The Freedom of Information Act covers information held by public bodies in England, Wales and Northern Ireland, information in Scotland is covered by Scotland's 2002 Freedom of Information Act. The Freedom of Information Act is about removing unnecessary secrecy; it allows members of the public to request information from public authorities. The NHS and state schools are public authorities, but not all charities that receive public money would necessarily be covered by the Act. The Act does not cover patient's access to health records; this process is covered by the Data Protection Act as discussed above. A dietitian employed by the NHS and working in private practice would only have to disclose information about their NHS work under the Act. The Act only covers information that is recorded, it is not necessary to write information down specifically to disclose it if it is not already recorded. Minutes of meetings and continuing professional development (CPD) portfolios are regarded as records. Private information on a work computer such as a private email does not have to be disclosed, but it would be necessary to disclose work related emails if requested. Organisations should have policies or guidelines in place to help employees comply with the Act. The Act does not interfere with copyright laws or intellectual property rights. Therefore someone can request copies of diet sheets that but they cannot use this information to produce copies if the work is subject to copyright.

If a patient makes a request for information it is necessary to respond within 20 working days so it is important to contact the appropriate person in the organisation as soon as possible so that the request can be dealt with promptly. If a patient verbally asks for information they should be helped to put the request in writing and sent by post, email, a request on the organisation's Facebook page or Twitter feed, to the appropriate person. Any information that can be shared easily such as clinic times or numbers of people working in a department should not be subject to formal procedures. The Data Protection Act may prohibit the release of data that has been requested; the clinical governance team or appropriate person, should be consulted for advice. Clinical records should only be released by a person specified to do so within the organisation.

Access to Health Records Act 1990

This Act gives people the right to request access to the health records of a deceased person.

Guidelines

There are a number of guidelines available. The NHS has an information governance toolkit (https://www.igt.hscic.gov.uk/) that aims to help individuals and organisations to handle information properly. Each NHS organisation should have an individual appointed as a Caldicott Guardian, it is their responsibility to ensure that the organisation respects patient confidentiality and service user information.

The BDA (2008) has guidance on record keeping although it is important to recognise that the nutrition and dietetic care process should guide the content of record keeping, for example, assessment, diagnosis, intervention and so on. The Royal College of Physicians (2013) has also produced record keeping standards covering electronic health records that have been endorsed by the BDA. The case studies in this book have questions about recording information and these guidelines may be helpful, but individual employer's guidelines should be followed first.

The introduction of electronic records should improve accuracy in health care records by improving legibility and access. The use of common language and SNOMED terms should also improve communication and understanding between the various health professionals using the health record. For more information about the nutrition and dietetic terms in SNOMED, see Chapter 2.

Good record keeping should include the following points:

Records should be made at the time of the event or as near as possible to that time.

Records should be complete, accurate and fit for purpose.

A complete record should include details of an assessment, what care has been provided or is planned, and any action that has been taken or shared with other health professionals.

Handwriting on paper records should be legible and in black ink.

Records should be dated and signed with a name and designation.

Records should be clear, terms such as ‘ate well’ should be avoided.

Records should be relevant and opinions justified if possible.

Records should be in electronic format wherever possible.

Always log off an unattended computer.

Social media

Records can be in a variety of formats that includes social media, telephone messages and videos. The BDA (2013) and the Dietitians Association of Australia (2011) both have useful publications to help get the most out of social media whilst avoiding some of the pitfalls. In essence it is essential to think before posting and don't make comments that would not be said a in person in a professional meeting. Don't reveal information that could identify a patient or client either directly or indirectly and don't repeat anything that is confidential.

References

BDA. (2008) Guidance for dietitians for records and record keeping.

www.bda.uk.com/publications/professional/record_keeping

[accessed on 22 September 2015].

BDA. (2013) Professional guidance document. Making sense of social media.

www.bda.uk.com/professional/practice/professionalism/social_media

[accessed on 22 September 2015].

Dietitians Association of Australia. (2011) Dialling into the digital age. Guidance on social media for DAA members.

http://www.pennutrition.com/KnowledgePathway.aspx?kpid=3728&trid=22864&trcatid=33

[accessed on 8 October 2015].

Health and Care Professions Council (HCPC). (2013) Standards of proficiency.

www.hpc-uk.org/assets/documents/1000050CStandards_of_Proficiency_Dietitians.pdf

[accessed on 22 September 2015].

Royal College of Physicians. (2013) Standards for the clinical structure and content of patient records.

https://www.rcplondon.ac.uk/resources/standards-clinical-structure-and-content-patient-records

[accessed on 22 September 2015].

Resources

Health and Social Care Information Centre Guide to confidentiality in health and social care. (2013) Treating confidential information with respect.

http://www.hscic.gov.uk/media/12822/Guide-to-confidentiality-in-health-and-social-care/pdf/HSCIC-guide-to-confidentiality.pdf

[accessed on 22 September 2015].

Information Commission Office. The guide to data protection.

https://ico.org.uk/for-organisations/guide-to-data-protection/

[accessed on 22 September 2015].

Information Commission Office. The guide to freedom of information.

https://ico.org.uk/media/for-organisations/documents/1642/guide_to_freedom_of_information.pdf

[accessed on 22 September 2015].

NHS England. (2014) Documents and record management policy.

http://www.england.nhs.uk/wp-content/uploads/2014/02/rec-man-pol.pdf

[accessed on 22 September 2015].

Qureshi, N.

et al

. (2014) Professional practice. In: Gandy, J. (ed),

Manual of Dietetic Practice

, 5th edn. Wiley Blackwell, Oxford.

Chapter 4Assessment

Joan Gandy

Assessment is fundamental to dietetic and nutrition practice and an essential step in the nutrition and dietetic process (see Chapter 1). The BDA (2012) defined assessment as ‘…a systematic process of collecting and interpreting information in order to make decisions about the nature and cause of nutrition related health issues that affect an individual, a group or a population’. It forms the basis of the nutrition and dietetic diagnosis and intervention and is key in establishing outcome measures in order to evaluate and monitor the intervention.

The ABCDE format, as described by Gandy (2014) has been developed to structure and standardise dietetic and nutrition assessment. This format is used throughout this book and often summarised in a table. Table 4.1 gives details of the five domains used in this format.

Table 4.1 Nutritional assessment domains

Domain

Example procedure for individuals

Anthropometry, body composition and functional

Weight, height, body mass index, skinfold thickness, waist circumferenceBioelectrical impedance analysisGrip strength dynamometryPhysical activity questionnaires

Biochemical and haematological

Vitamin status testsLipid statusIron status – haemoglobin, ferritin and so on

Clinical

Physical appearance, blood pressure, medication, indirect calorimetry

Diet

24 h recall, food frequency questionnaire (FFQ)

Environmental, behavioural and social

Shopping habits, housing, cooking facilities, education

Source: Gandy (2014), Table 2.2.1, p. 48. Reproduced with permission from Wiley Blackwell.

The information collected during assessment and the tools used to collect this information will vary depending on the setting, for example, individual, group, community, and population.

Domains

Anthropometry, body composition and function

Anthropometry is often used in nutrition and dietetic assessments with height and weight being used most frequently. Since the introduction of easily available equipment body composition and functional assessments, for example, bioelectrical impedance analysis (BIA) and dynamometry, are increasingly being used by dietitians and nutritionists in a variety of settings.

Anthropometry

Anthropometry is defined as the external measurement of the human body. It is affected by nutritional and health status and other factors including ethnicity, age and gender. Anthropometric measurements are often used in prediction equations, for example, body mass index (BMI), or compared with standards. It is essential that standards that are appropriate to the age, ethnic or gender group be used. All equipment must be serviced regularly, for example, weighing scales, or replaced as appropriate for example tape measures will stretch over time. Anthropometry requires training and experience to produce reliable and reproducible results. It is essential to establish what, if any, standards are used within the local context, for example, NHS guidance.

Body weight

Weighing scales must be maintained and calibrated regularly and should be Class III or above. Body weight is affected by many factors including fluid retention (oedema, ascites), dehydration, accuracy of the scales, amputations, splints, casts and replacement joints. A weight adjustment table for amputations is shown in Appendix A5. If weight cannot be obtained self reported weight, estimated weight made by carers, relatives, dietitians or other health care professionals may be used. Specialist weighing equipment, for example, weighing beds and chairs are available in some clinical settings, for example, spinal cord injury, obesity clinics.

Height

Height is usually measured using a stadiometer. When height cannot be measured, for example, bed bound patients, or is unreliable, for example, scoliosis it can be estimated using alternative methods such as ulna length, knee height or demispan (Appendix A5).

Body mass index

BMI is a weight for height indicator that may be used to classify overweight and obesity and is calculated as weight (kg)/height (m2). A ready reckoner and the WHO classifications of BMI for overweight and obesity are shown in Appendix A4. BMI does not give an indication of adipose distribution and therefore is being superseded as the preferred measure of non-communicable disease risk by waist circumference. It is affected by ethnicity, setting, age and body composition. If height is not available in the elderly (over 64 years) demiquet or mindex can be used for men and women respectively (Appendix A4).

Waist circumference

Waist circumference assesses visceral adiposity and is therefore increasing used to assess obesity related morbidity risk. NICE (2006) recommend the use of both BMI and waist circumference to assess health risks. Appendix A5 shows the WHO waist circumference classifications for health risks (WHO, 2008). It is measured at the halfway point between the lowest rib and the iliac crest in the midaxillary line.

Mid upper arm circumference

When neither weight nor height can be measured, the BMI can be estimated using the mid upper arm circumference (MUAC), or mid arm circumference (MAC). Appendix A5 shows reference data derived from an American population; UK data is not available.

Skinfold thickness

Calipers are used to take skinfold measurements at specific sites to estimate percentage body fat by substitution into prediction formulae, for example, Durnin & Womersley (1974). Triceps skinfold thickness (TSF) is used in bed bound patients to estimate endogenous fat stores (see Appendix A5). It can be combined with MUAC to evaluate body composition and is especially useful in patients with peripheral oedema or ascites

Mid arm muscle circumference (MAMC)

Mid arm muscle circumference (MAMC) is derived from TSF and MUAC as an indicator of muscle mass and therefore protein stores. The formulae used to derive MAMC and standards are shown in Appendix A5.

Body composition

Dietitians frequently use skinfold thicknesses to evaluate body composition however increasing other techniques such as BIA are being used.

Functional assessment

An example of this is hand grip strength (HGS) dynamometry (Appendix A5). Impaired HGS is associated with poor postoperative recovery (Griffiths & Clark, 1984) and related to loss of independence in the elderly. Increasingly dietitians assess physical activity levels; questionnaires are frequently used although other tools, for example, accelerometers are available.

Biochemical and haematological markers

Biochemical and haematological parameters are an important part of assessment and as outcome measures used in evaluation of the intervention. These markers are essential when monitoring many clinical conditions, e.g. diabetes mellitus, renal disease and in assessing the status of some nutrients, for example, iron status in anaemia. Appendix A7 gives examples of reference ranges for some parameters; it is essential to recognise that normal ranges and standards will vary between laboratories and that reference ranges from the local setting must be used.

Clinical

The clinical assessment will include physical appearance, medical history, test results and current medication; both prescribed and obtained without prescription. These details can usually be collated from the nursing or medical notes or family or carers. When collating information on medication it is important to consider drug nutrient interactions. The medical history and test results are vital elements of the assessment giving essential information for developing the intervention. Physical observations are vital indicators of nutritional status and should not be overlooked. For example loose clothing may indicate weight loss, breathlessness may indicate anaemia or other clinical conditions.

Dietary assessment

Establishing the extent to which nutritional needs are being met is core to the nutrition and dietetic assessment. It is usually important to assess current food and beverage intake, changes (duration and severity) in appetite and factors that affect intake. In clinical situations may also be important to consider recent changes in meal patterns, food choice and consistency.

The choice of dietary assessment method will depend on many factors including setting, population, age, literacy, assessor training and experience, cost, nutrients to be assessed, etc (Welch, 2014). An understanding of the limitations and applications of each method is essential in clinical and other settings to ensure the most appropriate method. Assessment can be either respective or current. Table 4.2 describes the characteristics of the most frequently used dietary assessment methods. It is important to quantify foods and drinks consumed either by weighing or estimations. Photographs, models and standard size serving vessels may be used to aid quantification. Dietary data can be used qualitatively, for example, to assess food preferences or meal patterns however in clinical practice it is most frequently used quantitatively. The energy and nutrient content of the diet are calculated using food composition data. A software programme is most frequently used to facilitate these calculations. However an understanding of the limitations of food composition data is essential (Landais & Holdsworth, 2014). The results of any dietary assessment need to be interpreted in the context of the individual or population's requirements. This is usually done by comparison with dietary reference values such as those published by the Department of Health (1991) and SACN (2011) or dietary recommendations (SACN, 2008) or the Institute of Medicine. However it is important to consider the limitations of any dietary reference value (Gandy, 2014).

Table 4.2 Characteristics of dietary assessment methods

Method

Advantages

Limitations

Retrospective methods

24 h recall (24 HR) (single or multiple days)

Not reliant on long-term memory; interview length 20–45 min