Nutrition Care Process Terminology Research Articles

Evaluation of the nutrition care process documentation in the patients' records using the Diet-NCP-Audit: experience in a medium-sized multi-site Swiss hospital.

The nutrition care process (NCP) is a four-step systematic approach to guide dietitians in providing high-quality nutrition care. It fosters critical thinking and enhances the consistency of dietitians' documentation. Following international recommendations, University Training Hospital of Fribourg (HFR) implemented it in 2013. This study aimed to evaluate the quality of NCP documentation in electronic patient records (EPRs) and to determine the nutrition problems dietitians most often identified while documenting their actions. The audit was performed on 92 EPRs using the Diet-NCP-Audit, which was translated into French for this study. The documentation quality was assessed as high in 62% of the EPRs, and nutrition diagnoses were mostly documented. In half of the EPRs, nutrition assessment (step 1 of the NCP) was inconsistent with nutrition diagnosis (step 2). Dietitians often used the same nutrition problems: out of the 73 nutrition problems defined in NCP terminology, only 4 (5%) represented 58% of the 189 problems identified in the EPR audit. EPRs were mostly assessed as high quality. However, the entire process requires improved consistency. The poorly documented link between the NCP steps and the restricted choices of nutrition problems dietitians identified should be addressed because they could reveal that dietitians have not fully adopted critical thinking, which the NCP stresses.

Implementation of the Nutrition Care Process and the Nutrition Care Process Terminology among German- and French-Speaking Dietitians in Switzerland: A Secondary Analysis of the Swiss International Nutrition Care Process and Terminology Implementation Survey Data.

Successful implementation of the Nutrition Care Process (NCP) and the Nutrition Care Process Terminology (NCPT) depends on many factors, one of which is the spoken language of the users. Exploring implementation barriers and enablers in a multilingual country such as Switzerland, with a specific focus on dietitians speaking German and French, may provide valuable insights for successful implementation in other multilingual countries. The aim of this study was to compare the enablers and barriers encountered by Swiss German- and French-speaking dietitians in the implementation of NCP and NCPT in their daily work. The multinational observational INIS study was conducted between February-April 2017 using an online survey. Swiss data from the study were analyzed in a secondary analysis in August2021. In Switzerland, 237 registered dietitians participated in the INIS study. In this secondary analysis, a total of 228 (German-speaking n= 144, French-speaking n= 84) questionnaires were included. Nine participants were excluded because either they had incomplete surveys or had not completed dietetics training. Primary variables were barriers and enablers to the use of NCP and NCPT in their daily work. Furthermore, characteristics, familiarity with NCP and NCPT, and the extent of implementation of standardized nutrition diagnoses according to NCPT were analyzed. Descriptive statistics, including summary statistics with percentages, were used. Differences between the two groups were analyzed using the Fisher exact test. The most common barrier was lack of time; no significant differences were found between the two groups regarding implementation barriers. Some statistically significant differences were found in the frequency of mentioning enablers, such as "recommendation by the association to use NCP and NCPT" (German-speaking 89%, French-speaking 77%; P < 0.05), "requirement by the workplace" (German-speaking 75%, French-speaking 53%; P < 0.01), "allocated time to practice" (German-speaking 63%, French-speaking 43%; P < 0.05), and "electronic healthcare records" (German-speaking 81%, French-speaking 44%; P < 0.001). Some differences in enablers were found between German- and French-speaking dietitians, although the two groups were similar for all barriers and many enablers. In multilingual countries such as Switzerland, implementation strategies may need to be adapted to the language and the dietitians' specific experiences of using NCP and NCPT to ensure optimal use throughout the country.

Taking a Deeper Dive Into Malnutrition and Revision Arthroplasty: When Do Nutritionists Get Involved?

BackgroundPerioperative malnutrition is associated with increased complications and mortality following revision total joint arthroplasty (rTJA). Nutritional consultations are useful in characterizing patient nutritional status but are inconsistently utilized post rTJA. We sought: 1) to describe the prevalence of nutritional consultations post rTJA, 2) to determine if septic rTJA patients needed consultations more often, and 3) if a diagnosis of ‘malnutrition’ from the nutritionist conferred increased readmission rates. MethodsA retrospective study of 2,697 rTJAs performed in a single institution over a 4-year period was performed. Patient demographics, reasons for rTJA, occurrences of nutritional consultation (indicated if body mass index < 20, malnutrition screening tool score ≥ 2, or poor oral intake postoperatively), specific nutritional diagnosis (according to 2020 Electronic Nutrition Care Process Terminology and 90-day readmission rates were recorded and analyzed). Rates of consultations and adjusted logistic regressions were calculated. ResultsThere were 501 patients (18.6%) who required nutritional consultations, with 55 (11.0%) of these patients receiving a ‘malnutrition’ diagnosis. Septic rTJA patients required significantly more nutritional consultations (P < .01) and were significantly more likely to have ‘malnutrition’ (P = .49). A diagnosis of malnutrition was associated with the highest odds of all-cause readmission (odds ratio (OR) = 3.89, P = .01), which was even higher than undergoing a septic rTJA. ConclusionNutritional consultations occur frequently following rTJA. Patients who receive a diagnosis of ‘malnutrition’ through consultation are at significantly higher risk for readmission and require close follow-up. Future efforts are needed to further characterize these patients in order to identify as well as optimize them preoperatively.

Individual and contextual factors in the Swedish Nutrition Care Process Terminology implementation.

Standardised terminologies and classification systems play an increasingly important role in the continuous work towards high quality patient care. Currently, a standardised terminology for nutrition care, the Nutrition Care Process (NCP) Terminology (NCPT), is being implemented across the world, with terms for four steps: Nutrition Assessment (NA), Nutrition Diagnosis (ND), Nutrition Intervention (NI) and Nutrition Monitoring and Evaluation (NME). To explore associations between individual and contextual factors and implementation of a standardised NCPT among Swedish dietitians. A survey was completed by 226 dietitians, focussing on: (a) NCPT implementation level; (b) individual factors; and (c) contextual factors. Associations between these factors were explored through a two-block logistic regression analysis. Contextual factors such as intention from management to implement the NCPT (OR (odds ratio) ND 15.0, 95% Confidence Interval (CI) 3.9-57.4, NME 3.7, 95% CI 1.1-13.0) and electronic health record (EHR) headings from the NCPT (OR NI 3.6, 95% CI 1.4-10.7, NME 3.8, 95% CI 1.1-11.5) were associated with higher implementation. A positive attitude towards the NCPT (model 1 OR ND 3.8, 95% CI 1.5-9.8, model 2 OR ND 5.0, 95% CI 1.4-17.8) was also associated with higher implementation, while other individual factors showed less association. Contextual factors such as intention from management, EHR structure, and pre-defined terms and headings are key to implementation of a standardised terminology for nutrition and dietetic care. Clinical leadership and technological solutions should be considered key areas in future NCPT implementation strategies.

A quasi-experimental study provides evidence that registered dietitian nutritionist care is aligned with the Academy of Nutrition and Dietetics evidence-based nutrition practice guidelines for type 1 and 2 diabetes.

BackgroundOne previous study examined implementation of evidence-based nutrition practice guidelines (EBNPG).ObjectivesTo describe alignment of registered dietitian nutritionists' (RDNs) documented nutrition care with the Academy of Nutrition and Dietetics' EBNPG for Type 1 and Type 2 diabetes and examine impact of a midpoint training on care alignment with the guideline.MethodsIn this 2-year, quasi-experimental study, 19 RDNs providing outpatient medical nutrition therapy to adults with diabetes (n = 562) documented 787 initial and follow-up encounters. At study midpoint, RDNs received a guideline content training. A validated, automated tool was used to match standardized nutrition care process terminology (NCPT) in the documentation to NCPT expected to represent guideline implementation. A congruence score ranging from 0 (recommendation not identified) to 4 (recommendation fully implemented) was generated based on matching. Multilevel linear regression was used to examine pre-to-post training changes in congruence scores.ResultsMost patients (~75%) had only one documented RDN encounter. At least one guideline recommendation was fully implemented in 67% of encounters. The recommendations “individualize macronutrient composition” and “education on glucose monitoring” (partially or fully implemented in 85 and 79% of encounters, respectively) were most frequently implemented. The mean encounter congruence scores were not different from pre-to-post guideline training (n = 19 RDNs, 519 encounters pre-training; n = 14 RDNs, 204 encounters post-training; β = −0.06, SE = 0.04; 95% CI: −0.14, 0.03).ConclusionsMost RDN encounters had documented evidence that at least one recommendation from the EBNPG was implemented. The most frequently implemented recommendations were related to improving glycemic control. A midpoint guideline training had no impact on alignment of care with the guideline.

An Examination of the Sex-Specific Nature of Nutrition Assessment within the Nutrition Care Process: Considerations for Nutrition and Dietetics Practitioners Working with Transgender and Gender Diverse Clients

Continuing Professional Education (CPE) InformationThe Continuing Professional Education (CPE) quiz for this article is available for free to Academy members through the MyCDRGo app (available for iOS and Android devices) and through www.jandonline.org (click on “CPE” in the menu and then “Academy Journal CPE Articles”). Log in with your Academy of Nutrition and Dietetics or Commission on Dietetic Registration username and password, click “Journal Article Quiz” on the next page, then click the “Additional Journal CPE quizzes” button to view a list of available quizzes. Non-members may take CPE quizzes by sending a request to [email protected] . There is a $45 fee per quiz (includes quiz and copy of article) for non-members. CPE quizzes are valid for 3 years after the issue date in which the articles are published.The Nutrition Care Process (NCP) is the standardized process for nutrition and dietetics practitioners to deliver care.1Swan W. Vivant A. Hakel-Smith N. et al.Nutrition Care Process and Model update: toward realizing people-centered care and outcomes management.J Acad Nutr Diet. 2017; 117: 2003-2014Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar,2Swan W. Pertel D.G. Hotson B. et al.Nutrition Care Process (NCP) update part 2: developing and using the NCP terminology to demonstrate efficacy of nutrition care and related outcomes.J Acad Nutr Diet. 2019; 119: 840-855Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Nutrition assessment is the first step of the NCP and is utilized to gather and synthesize client data that will ultimately inform a nutrition diagnosis. This step is considered an ongoing process of initial data collection, reassessment, and analysis against reference standards. The eight domains of nutrition assessment are: food/nutrition-related history; anthropometric measure; biochemical data, medical tests, and procedures; nutrition-focused physical findings; client history; assessment, monitoring, and evaluation tools; etiology category; and progress evaluation.3Academy of Nutrition and DieteticsNutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.http://www.ncpro.orgDate accessed: July 21, 2021Google Scholar The Continuing Professional Education (CPE) quiz for this article is available for free to Academy members through the MyCDRGo app (available for iOS and Android devices) and through www.jandonline.org (click on “CPE” in the menu and then “Academy Journal CPE Articles”). Log in with your Academy of Nutrition and Dietetics or Commission on Dietetic Registration username and password, click “Journal Article Quiz” on the next page, then click the “Additional Journal CPE quizzes” button to view a list of available quizzes. Non-members may take CPE quizzes by sending a request to [email protected] . There is a $45 fee per quiz (includes quiz and copy of article) for non-members. CPE quizzes are valid for 3 years after the issue date in which the articles are published. Certain aspects of nutrition assessment are sex-specific, meaning they require nutrition and dietetics practitioners to select a male or female sex. This presents a unique question for nutrition and dietetics practitioners working with transgender and gender diverse (TGGD) clients. For the purposes of this article, we are using the term transgender to describe a person whose gender identity differs from the sex that was assigned at birth, and term gender diverse to describe a broader range of gender identities that may be more complex or fluid. As detailed in the client history domain of the electronic Nutrition Care Process Terminology, the term sex refers to a person’s sex assigned at birth based on the assessment of external genitalia, reproductive organs, chromosomes, and gonads, whereas the terms gender or gender identity refer to a person’s internal sense of self and how they fit into the world with respect to gender.3Academy of Nutrition and DieteticsNutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.http://www.ncpro.orgDate accessed: July 21, 2021Google Scholar,4UCSF Transgender Care, Department of Family and Community Medicine, University of California San FranciscoGuidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. 2016.https://transcare.ucsf.edu/guidelinesDate accessed: July 21, 2021Google Scholar It is noteworthy that these terms may evolve over time and be interpreted differently based on cultural context and local realities.5Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 20212;13(4):165-232.Google Scholar Given that nutrition assessment is the seminal step in the delivery of nutrition care, the purpose of this article is to evaluate the sex-specific nature of nutrition assessment within the NCP. Our objectives are to identify the aspects of nutrition assessment that rely on biological sex, suggest approaches for nutrition and dietetics practitioners when working with TGGD clients, and illustrate the possible approaches with three sample cases. In the United States, an estimated 0.6% of adults and 0.7% of youth aged 13 to 17 years identify as TGGD.6Flores A.R. Herman J.L. Gates G.J. et al.How many adults identify as transgender in the United States?.https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/Date accessed: March 7, 2022Google Scholar,7Herman J.L. Flores A.R. Brown T.N.T. et al.Age of individuals who identify as transgender in the United States. The Williams Institute, UCLA School of Law, 2017https://williamsinstitute.law.ucla.edu/wp-content/uploads/Age-Trans-Individuals-Jan-2017.pdfDate accessed: March 7, 2022Google Scholar Although societal understanding and acceptance is growing, marked health disparities persist among the TGGD population second to gender-based stigma and discrimination. TGGD adults in the United States are more than twice as likely to live in poverty and three times more likely to experience unemployment than the general population. Within the health care system, one-third of TGGD adults had at least one recent negative experience related to their gender identity such as verbal harassment or being refused treatment. Nearly one-quarter of TGGD adults avoided seeking needed health care due to fear of mistreatment. Due to the compounding effects of other forms of discrimination, transgender adults of color reported even higher rates of poverty, unemployment, and resulting health disparities.8James S.E. Herman J.L. Rankin S. et al.The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, 2016Google Scholar Nutrition-related health disparities include elevated rates of disordered eating and body dysmorphia, food insecurity, and overweight and obesity compared with cisgender populations.9Arikawa A.Y. Ross J. Wright L. et al.Results of an online survey about food insecurity and eating disorder behaviors administered to a volunteer sample of self-described LGBTQ+ young adults aged 18 to 35 years.J Acad Nutr Diet. 2021; 121: 1231-1241Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 10Becerra-Culqui T.A. Liu Y. Nash R. et al.Mental health of transgender and gender nonconforming youth compared with their peers.Pediatrics. 2018; 141e20173845Crossref PubMed Scopus (130) Google Scholar, 11Coelho J.S. Suen J. Clark B.A. et al.Eating disorder diagnoses and symptom presentation in transgender youth: a scoping review.Curr Psychiatry Rep. 2019; 21: 107Crossref PubMed Scopus (36) Google Scholar, 12Kirby S.R. Linde J.A. Understanding the nutritional needs of transgender and gender-nonconforming students at a large public midwestern university.Transgend Health. 2020; 5: 33-41Crossref PubMed Scopus (6) Google Scholar, 13Linsenmeyer W.R. Katz I.M. Reed J.L. et al.Disordered eating, food insecurity, and weight status among transgender and gender nonbinary youth and young adults: a cross-sectional study using a nutrition screening protocol.LGBT Health. 2021; 8: 359-366Crossref PubMed Scopus (2) Google Scholar, 14Russomanno J. Patterson J.G. Jabson J.M. Food insecurity among transgender and gender nonconforming individuals in the southeast United States: a qualitative study.Transgend Health. 2019; 4: 89-99Crossref PubMed Scopus (18) Google Scholar Disordered eating may be exacerbated among TGGD youth due to the use of food as a coping mechanism for gender-related stigma or distress.11Coelho J.S. Suen J. Clark B.A. et al.Eating disorder diagnoses and symptom presentation in transgender youth: a scoping review.Curr Psychiatry Rep. 2019; 21: 107Crossref PubMed Scopus (36) Google Scholar,13Linsenmeyer W.R. Katz I.M. Reed J.L. et al.Disordered eating, food insecurity, and weight status among transgender and gender nonbinary youth and young adults: a cross-sectional study using a nutrition screening protocol.LGBT Health. 2021; 8: 359-366Crossref PubMed Scopus (2) Google Scholar Beyond the intersection with poverty and homelessness, food insecurity may be elevated among TGGD youth and adults due to fear of discrimination at faith-based food pantries, the need to provide identification that may include a photograph or gender marker inconsistent with gender identity, the competing financial burden of food and medical care, and familial rejection.9Arikawa A.Y. Ross J. Wright L. et al.Results of an online survey about food insecurity and eating disorder behaviors administered to a volunteer sample of self-described LGBTQ+ young adults aged 18 to 35 years.J Acad Nutr Diet. 2021; 121: 1231-1241Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,12Kirby S.R. Linde J.A. Understanding the nutritional needs of transgender and gender-nonconforming students at a large public midwestern university.Transgend Health. 2020; 5: 33-41Crossref PubMed Scopus (6) Google Scholar, 13Linsenmeyer W.R. Katz I.M. Reed J.L. et al.Disordered eating, food insecurity, and weight status among transgender and gender nonbinary youth and young adults: a cross-sectional study using a nutrition screening protocol.LGBT Health. 2021; 8: 359-366Crossref PubMed Scopus (2) Google Scholar, 14Russomanno J. Patterson J.G. Jabson J.M. Food insecurity among transgender and gender nonconforming individuals in the southeast United States: a qualitative study.Transgend Health. 2019; 4: 89-99Crossref PubMed Scopus (18) Google Scholar TGGD individuals may transition in different ways to align with their gender identity, such as socially, legally, or medically, although the types of therapeutic options, timing, and duration are variable and individualized.5Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 20212;13(4):165-232.Google Scholar Medical interventions are medically necessary for many transgender individuals to alleviate the psychological distress caused by gender dysphoria.5Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 20212;13(4):165-232.Google Scholar,8James S.E. Herman J.L. Rankin S. et al.The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, 2016Google Scholar Among adolescents, medical interventions may include pubertal hormone suppression to allow more time for gender identity exploration and to prevent development of secondary sexual characteristics that do not align with gender identity, followed by masculinizing or feminizing hormone therapy (HT).4UCSF Transgender Care, Department of Family and Community Medicine, University of California San FranciscoGuidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. 2016.https://transcare.ucsf.edu/guidelinesDate accessed: July 21, 2021Google Scholar,5Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 20212;13(4):165-232.Google Scholar Among adults, medical interventions may include HT and/or gender-affirming surgeries.4UCSF Transgender Care, Department of Family and Community Medicine, University of California San FranciscoGuidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. 2016.https://transcare.ucsf.edu/guidelinesDate accessed: July 21, 2021Google Scholar,5Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 20212;13(4):165-232.Google Scholar Clinical practice guidelines and standards of care published by national and international health organizations are used to guide the medical care of TGGD clients (see Table 1).Table 1Clinical practice guidelines and standards of care for transgender populationsStandards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People by the World Professional Association for Transgender Health: https://www.wpath.org/Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People by the University of California, San Francisco: https://transcare.ucsf.edu/guidelinesClinical Practice Guidelines for the Treatment of Gender Dysphoric/Gender-Incongruent Persons by the Endocrine Society: https://academic.oup.com/jcem/article/102/11/3869/4157558 Open table in a new tab Understanding aspects of a client’s medical transition is particularly relevant to nutrition and dietetics practitioners given the nutrition-related implications that may result.15Fergusson P. Greenspan N. Maitland L. et al.Towards providing culturally aware nutritional care for transgender people: key issues and considerations.Can J Diet Pract Res. 2018; 79: 74 e9Crossref Scopus (11) Google Scholar Masculinizing and feminizing HT may result in changes to anthropometric measures (ie, body weight and waist circumference), laboratory values (ie, lipid panel and complete blood count), and diagnostic tests (ie, bone mineral density).15Fergusson P. Greenspan N. Maitland L. et al.Towards providing culturally aware nutritional care for transgender people: key issues and considerations.Can J Diet Pract Res. 2018; 79: 74 e9Crossref Scopus (11) Google Scholar, 16Fernandez J.D. Tannock L.R. Metabolic effects of hormone therapy in transgender patients.Endocr Pract. 2016; 22: 383-388Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 17Fighera T.M. Ziegelmann P.K. da Silva T.R. et al.Bone mass effects of cross-sex hormone therapy in transgender people: updated systematic review and meta-analysis.J Endocrine Society. 2019; 3: 943-964Crossref PubMed Scopus (19) Google Scholar, 18Rahman R. Linsenmeyer W.R. Caring for transgender patients and clients: nutrition-related clinical and psychosocial considerations.J Acad Nutr Diet. 2019; 119: 727 e32Abstract Full Text Full Text PDF Scopus (13) Google Scholar Not only are these measures expected to change with HT, but many of the reference standards rely on sex-specific values. For example, body fat is expected to decrease or increase with masculinizing and feminizing HT, respectively, which is further complicated by the sex-specific reference values for body fat percentage.5Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 20212;13(4):165-232.Google Scholar,19American College of Sports MedicineGuidelines for Exercise Testing and Prescription.11th ed. Wolters Kluwer, 2021Google Scholar This presents a unique question for nutrition and dietetics practitioners regarding how to best interpret a client’s data. Currently no clinical practice standards exist to guide the nutrition care of TGGD clients, although we can apply clinical reasoning and draw from advancements in the broader medical community.20Rozga M. Linsenmeyer W. Cantwell Wood J. et al.Hormone therapy, health outcomes and the role of nutrition in transgender individuals: a scoping review.Clin Nutr ESPEN. 2020; 40: 42-56Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Various aspects of nutrition assessment require nutrition and dietetics professionals to choose between male or female biological sex. Table 2 details the sex-specific data collected within each nutrition assessment domain. These attributes may influence interpretation of the client’s data and the remaining steps of the NCP, including the nutrition diagnosis, intervention, and monitoring and evaluation. For example, the decision to interpret a TGGD adolescent’s body mass index (BMI)-for-age percentile on the growth chart for a boy or girl may influence the nutrition diagnosis for weight status as underweight, healthy weight, overweight, or obese.Table 2Sex-specific data points of nutrition assessment within the Nutrition Care Process.Nutrition assessment domainCommon data points with sex-specific reference rangesCommentsFood/nutrition-related historyEnergy needsSome predictive energy equations use sex/gender as a variable; that is, Harris-Benedict, Mifflin-St JeorDietary Reference Intake valuesThe Estimated Energy Requirements, Recommended Dietary Allowances, and Adequate Intakes for water, energy, and the energy nutrients, plus the Recommended Dietary Allowances and Adequate Intakes for vitamins and mineralsAnthropometric measuresBody fat percentageWaist circumferenceWaist-to-hip ratioBody mass index-for-age percentilesBiochemical data, medical tests, and proceduresHigh-density lipoprotein cholesterolWhen used as the clinical cutoff for clinical identification of metabolic syndromeCholesterol to high-density lipoprotein ratioHemoglobinFor patients receiving masculinizing hormone therapy: the University of California San Francisco guidelines recommend using the male reference value for the upper limit of normal and the male value for the lower limit of normal if amenorrheic.4UCSF Transgender Care, Department of Family and Community Medicine, University of California San FranciscoGuidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. 2016.https://transcare.ucsf.edu/guidelinesDate accessed: July 21, 2021Google ScholarFor patients on feminizing hormone therapy: The University of California San Francisco guidelines recommend using the female reference value for the lower limit of normal and the male reference value for the upper limit of normal4UCSF Transgender Care, Department of Family and Community Medicine, University of California San FranciscoGuidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. 2016.https://transcare.ucsf.edu/guidelinesDate accessed: July 21, 2021Google ScholarHematocritRed blood cell countFerritinCreatinineFor clients on both feminizing and masculinizing hormone therapy: The University of California San Francisco guidelines recommend using the male reference value for the upper limit of normal4UCSF Transgender Care, Department of Family and Community Medicine, University of California San FranciscoGuidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. 2016.https://transcare.ucsf.edu/guidelinesDate accessed: July 21, 2021Google ScholarAlkaline phosphataseBone mineral densityNutrition-focused physical findingsNoneAlthough there are no sex-specific reference values related to the nutrition-focused physical exam, changes in muscle and fat mass are expected with a medical transitionClient historyNoneThe 2-step method of sex and gender identity data is ideal to separately query sex assigned at birth and gender identityaTate CC, Ledbetter JN, Youssef CP. A two-question method for assessing gender categories in the social and medical sciences. J Sex Res. 2013;50(8):767-776.Assessment, monitoring and evaluation toolsNoneThis domain refers to an array of tools that may be used to assess for and/or monitor health and disease status, some of which may be sex-specific (ie, minimum dietary diversity for women indicator score)Etiology categoryNoneProgress evaluationNonea Tate CC, Ledbetter JN, Youssef CP. A two-question method for assessing gender categories in the social and medical sciences. J Sex Res. 2013;50(8):767-776. Open table in a new tab As depicted in Table 2, the sex-specific attributes of nutrition assessment are clustered in the first three domains. Within food/nutrition-related history, estimation of energy needs may require use of predictive energy equations where sex is a variable, such as the Harris-Benedict or Mifflin-St Jeor equations.21Harris J.A. Benedict F.G. A biometric study of basal metabolism in man.Proc Natl Acad Sci U S A. 1918; 4: 370-373Crossref PubMed Google Scholar,22Mifflin M.D. Jeor S.T. Hill L.A. et al.A new predictive equation for resting energy expenditure in healthy individuals.Am J Clin Nutr. 1990; 51: 241-247Crossref PubMed Scopus (1526) Google Scholar When evaluating adequacy of water, energy, the energy-yielding nutrients, and vitamins and minerals, certain Dietary Reference Intakes (DRI) provide sex-specific references such as the Estimated Energy Requirement, Recommended Dietary Allowances (RDA), and Adequate Intakes.23Institute of Medicine, Food and Nutrition BoardDietary Reference Intakes: The Essential Guide to Nutrient Requirements. The National Academies Press, 2006Google Scholar The DRI values for some nutrients do not vary between the male and female values, whereas others reflect a dramatic difference. For example, the RDA for vitamin D is 600 IU/day for both women and men aged 19 to 70 years, whereas the RDA for iron assumes the presence of menstruation and more than doubles for women compared with men aged 19 to 50 years (18 mg/day and 8 mg/day, respectively).23Institute of Medicine, Food and Nutrition BoardDietary Reference Intakes: The Essential Guide to Nutrient Requirements. The National Academies Press, 2006Google Scholar Within the anthropometric measures domain, body fat percentage, waist circumference, and wait-to-hip ratio rely on sex-specific reference ranges.24National Institutes of Health, National Heart, Lung and Blood Institute, North American Association for the Study of ObesityThe Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. National Academies Press, 2000Google Scholar, 25National Institutes of Health, US Department of Health and Human Services, National Heart, Lunch, and Blood InstituteManaging Overweight and Obesity and Adults: Systematic Evidence Review from the Obesity Expert Panel. National Academies Press, 2013Google Scholar, 26World Health OrganizationWaist Circumference and Waist-Hip Ratio: Report of a WHO Expert Consultation. World Health Organization, 2011Google Scholar For children aged 2 to 20 years, interpretation of BMI-for-age percentiles rely on a separate growth chart for girls vs boys.27Centers for Disease Control and Prevention, National Center for Health StatisticsCDC growth charts: United States.https://www.cdc.gov/growthcharts/Date accessed: September 28, 2021Google Scholar Lastly, within the domain of biochemical data, medical tests, and procedures, interpretation of multiple laboratory values relies on sex-specific ranges, including those within a lipid panel (high-density lipoprotein cholesterol level and cholesterol to high-density lipoprotein cholesterol ratio), complete blood count (hemoglobin, hematocrit, red blood cell count, and ferritin levels), kidney function (creatinine excretion), and liver function (alkaline phosphatase level). Interpretation of bone mineral density testing relies on z and T scores relative to the average values for a person of the same age and sex.28Noland D. Litchford M. Principles of nutritional laboratory testing.in: Raymond J.L. Kelly M. Krause and Mahan’s Food & the Nutrition Care Process. 15th edition. Elsevier, 2021: 981-1001Google Scholar, 29Harris E.K. Boyd J.C. On dividing reference data into subgroups to produce separate reference ranges.Clin Chem. 1990; 36: 265-270Crossref PubMed Scopus (262) Google Scholar, 30Harris E.K. Boyd J.C. Statistical Bases of Reference Values in Laboratory Medicine. Marcel Dekker, 1995Crossref Google Scholar, 31How to Define and Determine Reference Intervals in the Clinical Laboratory: Approved Guideline. National Committee for Clinical Laboratory Standards, 2001Google Scholar The following approaches are based on clinical reasoning and drawn from the broader medical community. Given the emerging nature of transgender health research, these approaches are not finite and are likely to evolve with the growing body of science. For adolescents on pubertal suppression therapy and adolescents/adults who have not medically transitioned with HT or surgical interventions, nutrition and dietetics practitioners can utilize the reference values consistent with the client’s sex assigned at birth. Given that the predictive energy questions,21Harris J.A. Benedict F.G. A biometric study of basal metabolism in man.Proc Natl Acad Sci U S A. 1918; 4: 370-373Crossref PubMed Google Scholar,22Mifflin M.D. Jeor S.T. Hill L.A. et al.A new predictive equation for resting energy expenditure in healthy individuals.Am J Clin Nutr. 1990; 51: 241-247Crossref PubMed Scopus (1526) Google Scholar DRI values,23Institute of Medicine, Food and Nutrition BoardDietary Reference Intakes: The Essential Guide to Nutrient Requirements. The National Academies Press, 2006Google Scholar anthropometric measures,25National Institutes of Health, US Department of Health and Human Services, National Heart, Lunch, and Blood InstituteManaging Overweight and Obesity and Adults: Systematic Evidence Review from the Obesity Expert Panel. National Academies Press, 2013Google Scholar, 26World Health OrganizationWaist Circumference and Waist-Hip Ratio: Report of a WHO Expert Consultation. World Health Organization, 2011Google Scholar, 27Centers for Disease Control and Prevention, National Center for Health StatisticsCDC growth charts: United States.https://www.cdc.gov/growthcharts/Date accessed: September 28, 2021Google Scholar and reference ranges for certain biochemical data points28Noland D. Litchford M. Principles of nutritional laboratory testing.in: Raymond J.L. Kelly M. Krause and Mahan’s Food & the Nutrition Care Process. 15th edition. Elsevier, 2021: 981-1001Google Scholar, 29Harris E.K. Boyd J.C. On dividing reference data into subgroups to produce separate reference ranges.Clin Chem. 1990; 36: 265-270Crossref PubMed Scopus (262) Google Scholar, 30Harris E.K. Boyd J.C. Statistical Bases of Reference Values in Laboratory Medicine. Marcel Dekker, 1995Crossref Google Scholar, 31How to Define and Determine Reference Intervals in the Clinical Laboratory: Approved Guideline. National Committee for Clinical Laboratory Standards, 2001Google Scholar are based on clinically reported sex-specific differences, utilizing a client’s sex assigned at birth will provide the most accurate assessment for those who have not medically transitioned. This approach has been utilized in clinical practice by health care teams caring for TGGD clients.13Linsenmeyer W.R. Katz I.M. Reed J.L. et al.Disordered eating, food insecurity, and weight status among transgender and gender nonbinary youth and young adults: a cross-sectional study using a nutrition screening protocol.LGBT Health. 2021; 8: 359-366Crossref PubMed Scopus (2) Google Scholar,32Linsenmeyer W. Rahman R. Transgender and gender nonconforming youth: considerations for registered dietitian nutritionists.Weight Management Matters. 2021; 19: 8-14Google Scholar An estimated 62% of TGGD adults in the United States have medically transitioned with HT and an additional 23% plan to do so in the future. A smaller proportion have had gender-affirming surgeries (4% to 43% depending on surgery type), with orchiectomy as the most common transfeminine surgery and chest surgery as the most common transmasculine surgery.33Grant J.M. Mottet L.A. Tanis J. et al.Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011Google Scholar Therefore, nutrition and dietetics practitioners should not assume that a TGGD client has medically transitioned based on their gender identity or expression, and should gather this information as part of their past medical history through chart review and/or the client interview. Physical changes typically begin and peak within a certain window of time after initiating HT, although the timing and scale of changes will vary among individuals. The World Professional Association for Transgender Health guidelines specify the expected time of onset and maximum effect with masculinizing HT (ie, increased muscle mass/strength, body fat redistribution, and cessation of menses) and feminizing HT (ie, body fat redistribution, decreased muscle mass/strength, and softening of skin/decreased oiliness).5Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 20212;13(4):165-232.Google Scholar For example, clients on masculinizing HT may experience increased muscle mass/strength starting at 6 to 12 months with an expected maximum effect at 2 to 5 years, whereas those on feminizing HT may experience decreased muscle mass/strength starting at 3 to 6 months with an expected maximum effect at 1 to 2 years.5Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 20212;13(4):165-232.Google Scholar Nutrition and dietetics professionals can use these guidelines to inform their decision to use the male or female reference values, especially for those that are directly related to anticipated physical changes with HT such as body fat percentage, waist circumference, waist-to-hip ratio, and the interpretation of laboratory values related to iron status. Lastly, the need to individualize nutrition assessment is especially relevant given that some clients may seek moderate changes with HT or a combination of masculine and feminine secondary sex characteristics.4UCSF Transgender Care, Department of Family and Community Medicine, University of California San FranciscoGuidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. 2016.https://transcare.ucsf.edu/guidelinesDate accessed: July 21, 2021Google Scholar For certain parameters of nutrition assessment, it may be reasonable to express data as a range using both the female and male reference values, especially where ranges are routinely used in clinical practice such as estimating energy or protein needs.23Institute of Medicine, Food and Nutrition BoardDietary Reference Intakes: The Essential Guide to Nutrient Requirements. The National Academies Press, 2006Google Scholar,34Linsenmeyer W. Drallmeier T. Thomure M. Towards gender-affirming nutrition assessment: a case series of adult transgender men with distinct nutrition considerations.Nutr J. 2020; 19: 1-8PubMed Google Scholar This may also be appropriate for patients on HT for a relatively short period (ie, <6 months) or who are on low-to-moderate HT regimens and therefore intentionally within the midrange between the male and female norms.4UCSF Transgender Care, Department of Family and Community Medicine, University of California San FranciscoGuidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. 2016.https://transcare.ucsf.edu/guidelinesDate accessed: July 21, 2021Google Scholar Nutrition and dietetics practitioners have reported this approach using case studies and clinical case series of TGGD adults, and in their interpretation of BMI percentile charts for TGGD youth.32Linsenmeyer W. Rahman R. Transgender and gender nonconforming youth: considerations for registered dietitian nutritionists.Weight Management Matters. 2021; 19: 8-14Google Scholar,33Grant J.M. Mottet L.A. Tanis J. et al.Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011Google Scholar,35Linsenmeyer W.R. Rahman R. Diet and nutritional considerations for a FTM transgender male: a case report.J Am Coll Health. 2018; 66: 533-536Crossref PubMed Scopus (3) Google Scholar,36Kidd K.M. Sequeira G.M. Dhar C.P. et al.Gendered body mass index percentile charts and transgender youth: making the case to change charts.Transgend Health. 2019; 4: 297-299Crossref PubMed Scopus (5) Google Scholar, The following cases were developed by the authors and based on real TGGD patients seen through our clinical practices. The authors are cisgender registered dietitian nutritionists and physicians who specialize in clinical practice and research with the TGGD community. The case studies were reviewed by a trans man who is active in the lesbian, gay, bisexual, and transgender community to ensure the language presented is culturally appropriate (see the Acknowledgements). LB is a 17-year old, non-Hispanic White individual who was referred to a registered dietitian nutritionist for disordered eating. LB was assigned male at birth, identifies as nonbinary, and uses they/their pronouns. They wear both masculine and feminine clothing and are not interested in pursuing medical interventions such as HT or surgery. LB is 5-ft, 6-in tall and weighs 120 lb. Which growth chart would be most accurate to assess LB’s weight status? Given that LB has not medically transitioned, using the growth chart consistent with their sex assigned at birth (male) would provide the most accurate interpretation of their weight status. LB’s BMI is 20 based on their height and weight. Using the BMI-for-age growth chart for boys ages 2 to 20 years, LB is in the 30th percentile for BMI-for-age. Although using sex assigned at birth to assess weight status, nutrition and dietetics practitioners can honor LB’s nonbinary gender identity in a several of ways, such as using their correct name and pronouns, ensuring their medical records accurately represent their gender identity, and using gender-neutral language to describe the body if that is LB’s preference.18Rahman R. Linsenmeyer W.R. Caring for transgender patients and clients: nutrition-related clinical and psychosocial considerations.J Acad Nutr Diet. 2019; 119: 727 e32Abstract Full Text Full Text PDF Scopus (13) Google Scholar,32Linsenmeyer W. Rahman R. Transgender and gender nonconforming youth: considerations for registered dietitian nutritionists.Weight Management Matters. 2021; 19: 8-14Google Scholar The CDC growth charts are inherently limited for TGGD patients who are medically transitioning due to the binary options of boy or girl charts.27Centers for Disease Control and Prevention, National Center for Health StatisticsCDC growth charts: United States.https://www.cdc.gov/growthcharts/Date accessed: September 28, 2021Google Scholar Current standards of care do not address which growth chart to utilize.4UCSF Transgender Care, Department of Family and Community Medicine, University of California San FranciscoGuidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. 2016.https://transcare.ucsf.edu/guidelinesDate accessed: July 21, 2021Google Scholar,5Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 20212;13(4):165-232.Google Scholar Existing research has reported the strategy of assessing growth using both the boy and girl charts for TGGD patients who are medically transitioning and has underpinned the need for further research in this area.13Linsenmeyer W.R. Katz I.M. Reed J.L. et al.Disordered eating, food insecurity, and weight status among transgender and gender nonbinary youth and young adults: a cross-sectional study using a nutrition screening protocol.LGBT Health. 2021; 8: 359-366Crossref PubMed Scopus (2) Google Scholar,32Linsenmeyer W. Rahman R. Transgender and gender nonconforming youth: considerations for registered dietitian nutritionists.Weight Management Matters. 2021; 19: 8-14Google Scholar,36Kidd K.M. Sequeira G.M. Dhar C.P. et al.Gendered body mass index percentile charts and transgender youth: making the case to change charts.Transgend Health. 2019; 4: 297-299Crossref PubMed Scopus (5) Google Scholar JY is a 50-year old, African American trans man who was referred to nutrition services for nutrition assessment and suspected iron deficiency. JY was assigned female at birth, identifies as a trans man, and uses he/his or they/their pronouns. JY’s past medical history indicates he medically transitioned in his mid-20s, has been on masculinizing HT consistently for the past 25 years, and is amenorrheic. JY is training for a marathon and runs at a moderate pace approximately 10 to 15 hours per week. Their labs are provided below. Given JY’s past medical history and the University of California San Francisco guidelines (see Table 2), which reference values would be most appropriate to assess hemoglobin and hematocrit?Hemoglobin = 12 g/dLHematocrit = 37%Red blood cells = 5.0 mLPlatelet count = 250,000White blood cells = 6,000 cells/mL Given that JY medically transitioned more than 2 decades ago and is amenorrheic, it would be appropriate to use the male reference ranges for hemoglobin (13.5 to 16.5 g/dL) and hematocrit (41% to 50%). This is consistent with the University of California San Francisco guidelines for interpretation of hemoglobin and hematocrit values based on HT and amenorrheic status.4UCSF Transgender Care, Department of Family and Community Medicine, University of California San FranciscoGuidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. 2016.https://transcare.ucsf.edu/guidelinesDate accessed: July 21, 2021Google Scholar MR is a 30-year old, Hispanic trans woman seeking nutrition counseling for metabolic syndrome and weight management. MR was assigned male at birth, identifies as a trans woman, and uses she/her pronouns. She started feminizing HT 1 month ago. MR is 5-ft, 8-in tall and weighs 180 lb; she would prefer a smaller physique and expressed that she would like to lose about 30 lb. She does Pilates or yoga once a week and walks her dog for 30 minutes daily. Using the Estimated Energy Requirement equation, what are MR’s energy needs to maintain her current weight? What energy requirement would support MR’s weight loss goal? Given that MR has just started HT and energy needs are often described in a range, it would be appropriate to express her energy needs in a range using the female and male values. To maintain her current weight, she would need 2,570 to 2,850 kcal/day. To support her weight loss goal with a 500-kcal/day deficit, she would need 2,070 to 2,350 kcal/day. Multiple attributes of nutrition assessment rely on sex-specific reference values. This poses a unique question for nutrition and dietetics practitioners working with TGGD clients regarding when to use the male or female reference values. Although existing clinical care guidelines provide some guidance on the interpretation of lab values with sex-specific ranges, nutrition and dietetics practitioners must apply clinical reasoning to determine the most appropriate strategies based on the client’s stage of medical transition and the nature of the reference value. Ongoing research is needed to inform the optimal approach to deliver gender-affirming nutrition care for TGGD clients.

Evaluating the Implementation of Evidence-based Kidney Nutrition Practice Guidelines: The AUGmeNt Study Protocol

Evidence-based nutrition practice guidelines (EBNPGs) inform registered dietitian nutritionist (RDN) care for patients with chronic kidney disease grade 5 treated by dialysis; however, there has been little evaluation of best practices for implementing EBNPGs. In this effectiveness-implementation hybrid study with a quasi-experimental design, United States RDNs in hemodialysis clinics will document initial and follow-up nutrition care for patients with chronic kidney disease grade 5 treated by dialysis using the Academy of Nutrition and Dietetics Health Informatics Infrastructure before and after being randomly assigned to a training model: (1) EBNPG knowledge training or (2) EBNPG knowledge training plus an implementation toolkit. The aims of the study include examining congruence of RDN documentation of nutrition care with the EBNPG; describing common RDN-reported EBNPG acceptability, adoption, and adaptation issues; and determining the feasibility of estimating the impact of RDN care on nutrition-related patient outcomes. The AUGmeNt study can inform effective development and implementation of future EBNPGs. Keywords: Chronic kidney diseases; medical nutrition therapy; implementation science; clinical practice guideline; nutrition care process terminology; dietitian.

Using a web-based platform to apply the Nutrition Care Process and capture nutrition outcomes and patient satisfaction in a student-led dietetic outpatient clinic: a pilot study

Evaluation of health care services utilising student providers is essential in determining effectiveness, quality of care, and student performance. We investigated the effectiveness of a student-led dietetic clinic in patient satisfaction and nutrition outcomes. A mixed-methods observational cohort pilot study utilising surveys and focus groups was conducted in outpatient student-led dietetic clinics at a university used for student education. Nutrition care and outcomes were documented using the Nutrition Care Process Terminology (NCPT) in a web-based platform. The patient satisfaction survey (n=88) of patients attending student-led dietetic clinics revealed an overall ranking of 4.0 (mean score 4.33 ± 0.34) out of 5, ranging between “very satisfied” and “satisfied.” Survey and focus group data showed that the highest satisfaction rates were for students’ interpersonal skills (4.80 ± 0.43). Fourteen patients attended &gt;2 consultations. 23.5% of the patients resolved their nutrition diagnoses, and an average weight loss of 2.2 kg per patient was achieved (n = 8). Positive patient satisfaction ratings, combined with improved nutrition outcomes, support the value of student-led clinics as an education and health care delivery modality. These findings are worthy of exploring further on a large scale.

Selection of Terms from the Nutrition Care Process Terminology of Brazilian Renal Dietitians

Selection of Terms from the Nutrition Care Process Terminology of Brazilian Renal Dietitians

Academy of Nutrition and Dietetics Nutrition Research Network: Validation of a Novel Nutrition Informatics Tool to Assess Agreement Between Documented Nutrition Care and Evidence-Based Recommendations

More evidence regarding registered dietitian nutritionist implementation of evidence-based nutrition practice guidelines (EBNPGs) is needed. We assessed the utility of an automated informatics tool to evaluate congruence of documented nutrition care with 13 individual recommendations in the diabetes mellitus (DM) EBNPG and with the guideline overall. A concurrent validation study was conducted using Nutrition Care Process Terminology documentation entered in the Academy of Nutrition and Dietetics Health Informatics Infrastructure by registered dietitian nutritionists caring for patients with DM. A 15% subset (n = 115) of the 790 patient encounters recorded were selected randomly, and the documented care was evaluated using the automated DM Expected Care Plan (ECP) Analyzer and expert audit. Recommendation-level congruence, as determined by each method, was compared using Cohen’s κ analysis, and the accuracy, sensitivity, and specificity of the DM ECP Analyzer for assessing overall guideline-level congruence was calculated with expert audits as the “gold standard.” For recommendation-level congruence, the DM ECP Analyzer identified more instances of recommendation implementation in the patient encounters, and classified more encounters as including partial or full recommendation implementation for 10 of the 13 recommendations, compared with the expert audit. There was slight to fair agreement between the DM ECP and the expert audit for most individual recommendations, with a mean ± standard deviation level of agreement of κ = .17 ± .19 across all eligible recommendations. At the guideline level, the DM Analyzer had high accuracy (98.3%) and sensitivity (99.1%) and low specificity (0%; no true negatives detected). The DM ECP Analyzer is acceptable for conducting automated audits of nutrition documentation to assess congruence of documented care with recommendations for evidence-based care. Future changes to the EBNPG, Nutrition Care Process Terminology, Academy of Nutrition and Dietetics Health Informatics Infrastructure, and the DM ECP Analyzer could potentially improve recommendation-level performance. The DM ECP Analyzer can be modified for other EBNPGs to facilitate automated assessment of guideline implementation.

Etiology Intervention Link Predicts Resolution of Nutrition Diagnosis: A Nutrition Care Process Outcomes Study from a Veterans’ Health Care Facility

In this article, we evaluate relationships between Nutrition Care Process (NCP) chain links and improvement or resolution of the nutrition diagnosis. We conducted a retrospective record review for 12 months in a single Veterans Health Administration health care system using the Veterans Health Administration–specific monitoring and evaluation terms, NCP terminology, and its etiology categories to evaluate outcomes. Logistic regression analysis revealed that the strongest predictor for diagnosis improvement was the etiology–intervention link. The odds of improving the nutrition diagnosis were 51.43 times higher when the etiology–intervention link was present. The odds of improving the nutrition diagnosis were 19.74 times higher when the evidence–diagnosis link was present and 9.46 times higher when the intervention–goal link was present. For every added nutrition visit by the registered dietitian nutritionist, the odds of improving the nutrition diagnosis increased by 32.5%. For every increased point on the NCP audit score, the odds of resolving or improving the nutrition diagnosis increased by 37.7%. When applying the NCP, the presence of the etiology–intervention link significantly improves the odds of resolving the nutrition diagnosis in a Veterans Health Administration population. For the first time, we show evidence that the NCP works as designed. Also, we demonstrate that the quality of NCP documentation impacts resolution of the diagnosis, and we describe the methodology for how to evaluate NCP outcomes. Registered dietitian nutritionists are encouraged to critically evaluate links of the NCP chain, assess NCP documentation for quality, and pursue follow-up visits to improve resolution of nutrition problems.

Simulation in Learning and Using the Nutrition Care Process/Terminology: Experiences and Perceptions of Dietitians in Canada.

Purpose: To investigate experiences with, and perceptions of, simulation in learning and using the Nutrition Care Process/Terminology (NCP/T) of dietitians in Canada. Methods: In February-March 2017, a convenience sample of 382 dietitians in Canada (71.8% in clinical practice) completed an online survey regarding the type(s), setting(s), and perceptions of the simulations in which they engaged in learning and using the NCP/T. Results: A majority (76.7%) of respondents had engaged in NCP/T-related simulation, most commonly case studies (85.3%) and role-play (42.0%), as part of workplace/volunteer training (51.4%) and undergraduate internship/stage/practicum (34.2%). Nearly half (49.5%) of respondents learned all 4 NCP components via simulation, with Nutrition Diagnosis being the most common individual component (57%). Over three-quarters of respondents agreed/strongly agreed that simulation helped them better understand/use the NCP/T and that NCP/T-related knowledge/skills gained through simulation are transferable to the clinical setting/dietetic practice. Conclusions: Dietitians in Canada perceive simulation to have helped them learn and use the NCP/T. Resources should be directed at further developing simulation for teaching the NCP/T in dietetics education and training. Research investigating characteristics, barriers, and facilitators of effective NCP/T-simulation, using objective (vs. perceived) learning outcome measures is needed.

Content Validation of Defining Characteristics of Nineteen Prevalent Nutrition Diagnoses in Adult Hospitalized Patients

Abstract Objectives To validate the content of 19 prevalent nutrition diagnoses (NDs), 17 from the Nutrition Care Process Terminology (NCPT) and two other NDs, identified by Clinical Registered Dietitian Nutritionists (CRDN) in an acute-care hospital and identify critical defining characteristics (signs and/or symptoms). Methods Using a descriptive research design with survey methodology, a ND Validation Instrument was completed by seven CRDNs with knowledge of NDs. Each ND included a label, a definition, and a mean number of 14 defining characteristics (range 1–33). CRDNs were asked to read labels, definitions and think about adult hospitalized patients and use a 4-point Likert scale (very, quite, very little, and not at all characteristic) to rate the 264 defining characteristics. Diagnostic content validity (DCV) scores using weighted means were calculated. Critical defining characteristics were identified with a DCV score of ≥0.80. Results The CRDNs had 13.29 ± 5.09 years of clinical experience and 12.57 ± 5.26 years using NDs at the study site. Seventy-one % of the CRDNs held a graduate degree. The DCV scores of 264 critical characteristics ranged from 0.32 to 1.00. Twenty-four % (n = 64) of the characteristics were validated with a mean of 3.36 critical characteristics per diagnosis (range: 1–10). Eighty-nine % (n = 57) of the critical characteristics were in three of the five NCPT assessment categories: (Food/Nutrition-Related History; Anthropometric measurements and Nutrition-focused physical findings. Conclusions Content validation of 19 NDs resulted in the identification of 24% (N = 64) of characteristics as valid with 89% (N = 57) clustered in three of the five NCPT assessment categories. The low content validity of 76% (N = 200) of the characteristics suggests that the criteria are not representative or consistent with the definitions of the NDs. Identification of a minimum number of critical characteristics and assessment categories for each diagnosis will make it easier for CRDNs to learn the signs/symptoms and to recognize them when present in patients, to make an accurate diagnosis. Further validation studies with larger samples and various patient populations, nationally and internationally, are needed to refine critical characteristics and assessment categories. Funding Sources None.

Status of nutrition care process implementation in hospitals in Jeddah, Saudi Arabia

The Nutrition Care Process (NCP) and Nutrition Care Process Terminology (NCPT) are currently implemented by dietetics practitioners worldwide, with various advantages, including ensuring consistency and clarity of dietetics-related healthcare records and the possibility to collect and analyse patient outcomes; however, how Saudi dietitians experience the implementation process is poorly understood. The aim of this study was to explore the experiences of Saudi dietitians of NCP implementation in hospitals in Jeddah. In this quantitative, cross-sectional study, 56 dietitians were recruited from six principal hospitals in Jeddah. A questionnaire was used to collect data on the characteristics of the dietitians and hospital-related clinical nutrition care performance, the perception and opinions of dietitians towards the NCP, and the status of NCP implementation. Almost all dietitians (98%) were aware of the NCP; however, only 27% had received NCP training. Most dietitians (73%) reported that their department currently follows the NCP, while only 26% reported using the standardized NCP, including International Classification of Functioning, Disability & Health - Dietetics (ICF-D)-WHO and International Dietetic & Nutrition Terminology (IDNT) - USA, with 63% following the hospital's own NCP. Reported reasons for hospitals not following the NCP included insufficient dietitians, lack of experience, or conflict with the hospital's nutrition care system. A majority of dietitians reported no perceived barriers to applying the NCP; however, 23% reported NCP documentation as a challenge. The majority of dietitians are aware of the NCP and feel confident to practice; however, the NCP model is not currently implemented in Jeddah hospitals as standard. On-going education, a training program, and an implementation plan should be prioritised.

Naming Nutrition Injustice: How Might Dietitians Articulate a Socially Just Dietetic Practice?

This paper invites readers to consider how the ideals, concepts, and language of nutrition justice may be incorporated into the everyday practice of clinical dietitians whose work is often carried out within large, conservative, primary care institutions. How might clinical dietitians address the nutritional injustices that bring people to their practice, when practitioners are constrained by the limits of current diagnostic language, as well as the exigencies of their workplaces. In the first part of this paper, I draw on Cadieux and Slocum’s work on food justice to develop a conceptual framework for nutrition justice. I assert that a justice-oriented understanding of nutrition redresses inequities built in to the biomedicalization of nutrition and health, and seeks to trouble by whom and how these are defined. In the second part of this paper, I draw on the conceptual framework of nutrition justice to develop a politicized language framework that articulates nutrition problems as the outcome of nutritional injustices rather than individuals’ deficits of knowledge, willingness to change, or available resources. This language framework serves as a counterpoint to the current and widely accepted clinical language tool, the Nutrition Care Process Terminology, that exemplifies biomedicalized understandings of nutrition and health. Together, I propose that the conceptual and language frameworks I develop in this paper work together to foster what Croom and Kortegast (2018) call “critical professional praxis” within dietetics.

Client History as Standard Domain in Nutrition Assessment Protocols: Content Analysis of Clinical Nutrition Textbooks (P13-014-19)

ObjectivesThe purpose of this work was to conduct content analysis of college-level clinical nutrition textbooks, specifically text coverage of client history, one of five standard domains in nutrition assessment protocols. MethodsTen clinical nutrition textbooks were identified in Books-in-Print electronic database (Bowker LLC) using nutrition (title keyword) and medical nutrition therapy (subject keyword) with refinements, e.g., range: 01–01-2013 to 06–01-2018, and exclusion criteria, e.g., study guides. The evidence base for client history was determined from the Academy of Nutrition and Dietetics’ (AND) International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process, 4th ed. (2013), subsequently published as AND’s Nutrition Care Process Terminology (e-NCPT), which organizes client history into three categories: personal history; patient/client/family medical/health history; and social history. ResultsOnly seven of the ten clinical nutrition textbooks had chapters/sections devoted to nutrition assessment; these seven textbooks mentioned all three categories of client history delineated in the AND evidence base albeit at significantly varying depth of coverage. Only two of the textbooks, however, acknowledged client history as one of five domains of nutrition assessment whereas others infused aspects of client history into the chapters/sections thus fracturing the presentation of client history material. Only four textbooks mentioned using physical examination data provided by the physician or nurse as a resource in determining client history. And only one textbook included “client history” in the index of the textbook. ConclusionsContent analysis of clinical nutrition textbooks revealed fractured coverage of client history which detracts from developing clinical skills for implementing this domain of nutrition assessment protocols. Furthermore, the prevailing reference standard perhaps short changes clinical nutrition practice by not aligning client history with the standard format associated with medical history plus physical examination. These systematic limitations in current textbook coverage may inhibit optimal evidence-based education and subsequent clinical nutrition practice. Funding SourcesNone.

Use of the Nutrition Care Process and Nutrition Care Process Terminology in an International Cohort Reported by an Online Survey Tool

BackgroundDietitians in countries across the world have been implementing the Nutrition Care Process (NCP) and Terminology (NCPT) during the past decade. The implementation process has been evaluated in specific countries and in smaller international studies; however, no large international study comparing implementation between countries has been completed. ObjectiveThe aim of this study was to describe and compare the level of NCP/NCPT implementation across 10 countries. MethodsA previously tested web-based survey was completed in 2017 by 6,719 dietitians across 10 countries. Participants were recruited through e-mail lists, e-newsletters, and social media groups for dietitians. Nondietitians were excluded through screening questions and targeted dissemination channels. Main outcome measures and statistical analysisThe main outcome of interest was the level of implementation of each of the four NCP steps. Differences in implementation between the NCP (process) and NCPT (terminology) were also measured. Differences between groups were assessed using Kruskal-Wallis test and Mann-Whitney U test. Multiple linear regression was used to assess relationships between the main outcomes and respondent demographic information. ResultsAustralia, New Zealand, and the United States had higher implementation rates compared with other countries surveyed. Awareness of the NCP was high in most countries (>90%) but lower in Greece (50%). All countries had a higher implementation level of the NCP (process) compared with the NCPT (terminology). Dietitians working with inpatients reported the highest implementation levels while those working in public health reported the lowest. ConclusionsDietitians in countries with more experience in NCP/NCPT implementation and a clear implementation strategy had higher levels of implementation. To achieve a successful NCP/NCPT implementation among dietitians, there is a need to promote the value of a standardized dietetic language together with the more easily implemented process. There is also a need to promote NCP/NCPT for all areas of practice, and develop strategic plans for implementation of the NCP and NCPT.

The International Nutrition Care Process and Terminology Implementation Survey: Towards a Global Evaluation Tool to Assess Individual Practitioner Implementation in Multiple Countries and Languages

BackgroundThe Nutrition Care Process (NCP) and NCP Terminology (NCPT) is a systematic framework for critical thinking, decision making, and communication for dietetics practitioners worldwide, aiming to improve quality and patient safety in nutrition care. Although dietetics practitioners in several countries have implemented the NCP/NCPT during recent years, to date there is no globally validated instrument for the evaluation of NCP/NCPT implementation that is available in different languages and applicable across cultures and countries. ObjectiveThe aim of this study was to develop and test a survey instrument in several languages to capture information at different stages of NCP/NCPT implementation across countries and cultures. SettingIn this collaboration between dietetics practitioners and researchers from 10 countries, an International NCP/NCPT Implementation Survey tool was developed and tested in a multistep process, building on the experiences from previous surveys. The tool was translated from English into six other languages. It includes four modules and describes demographic information, NCP/NCPT implementation, and related attitudes and knowledge. MethodsThe survey was reviewed by 42 experts across 10 countries to assess content validity and clarity. After this, 30 dietetics practitioners participated in cognitive interviews while completing the survey. A pilot study was performed with 210 participants, of whom 40 completed the survey twice within a 2- to 3-week interval. ResultsScale content validity index average was 0.98 and question clarity index was 0.8 to 1.0. Cognitive interviews and comments from experts led to further clarifications of the survey. The repeated pilot test resulted in Krippendorff’s α=.75. Subsequently, refinements of the survey were made based on comments submitted by the pilot survey participants. ConclusionsThe International NCP/NCPT Implementation Survey tool demonstrated excellent content validity and high test–retest reliability in seven different languages and across an international context. This tool will be valuable in future research and evaluation of implementation strategies.

Are Dietitians Documenting Malnutrition Based on Subjective Global Assessment Category?

Purpose: This study reports on dietitian use of the Nutrition Care Process Terminology (NCPT) diagnosis of malnutrition based on Subjective Global Assessment (SGA). Methods: Nutrition assessment reports for adults in medical, surgical, and cardiac units in 13 Canadian hospitals were retrospectively examined for a 6-week period in 2014. Reports with a SGA and NCPT diagnosis were included regardless of why the patient was seen by the dietitian. Results: Of the 932 nutrition assessment reports, 857 (92%) included an SGA. Based on SGA, the prevalence of mild to moderate malnutrition (SGA B) and severe malnutrition (SGA C) was 53.4% (n = 458) and 10.0% (n = 86), respectively. When categorized as severely malnourished, the most common NCPT diagnoses were "malnutrition" (n = 55, 72.4%), "inadequate oral intake" (n = 11, 14.5%), and "inadequate protein-energy intake" (n = 10,13.1%). Among those with SGA B and C, the assignment of the NCPT malnutrition diagnosis was 19.8% (n = 95). Conclusions: Dietitians play a key role in the prevention, identification, and treatment of malnutrition in the hospitalized patient and are well positioned to take a leadership role in improving its documentation. Ongoing audits, staff support, and training regarding NCPT use may improve the application of the malnutrition diagnosis. Future research examining dietitian barriers to using the malnutrition diagnosis would be valuable.

Adopting Nutrition Care Process Terminology at the National Level: The Norwegian Experience in Evaluating Compatibility with International Statistical Classification of Diseases and Related Health Problems, 10th Revision, and the Existing Norwegian Coding System

Continuing Professional Education (CPE) Information The Continuing Professional Education (CPE) quiz for this article is available for free to Academy members through the MyCDRGo app (available for iOS and Android devices) and through www.jandonline.org (click on “CPE” in the menu and then “Academy Journal CPE Articles”). Log in with your Academy of Nutrition and Dietetics or Commission on Dietetic Registration username and password, click “Journal Article Quiz” on the next page, then click the “Additional Journal CPE quizzes” button to view a list of available quizzes. Non-members may take CPE quizzes by sending a request to [email protected] There is a fee of $45 per quiz (includes quiz and copy of article) for non-member Journal CPE. CPE quizzes are valid for 1 year after the issue date in which the articles are published. Advances in information technology have accelerated the use of electronic health records and activities in terminology mapping. Dietitians need to be knowledgeable about the capabilities of different terminologies to effectively capture nutrition care data. If nutrition care is not reflected in the health care system, our professional contributions will not be visible. Data documenting nutrition care needs to be visible at the patient care level, in health care records, as well as in the statistics used by decision makers at health care institutions on national and international levels. It will be increasingly important for dietitians to participate in international collaborations among health care professionals pursuing common goals. The Continuing Professional Education (CPE) quiz for this article is available for free to Academy members through the MyCDRGo app (available for iOS and Android devices) and through www.jandonline.org (click on “CPE” in the menu and then “Academy Journal CPE Articles”). Log in with your Academy of Nutrition and Dietetics or Commission on Dietetic Registration username and password, click “Journal Article Quiz” on the next page, then click the “Additional Journal CPE quizzes” button to view a list of available quizzes. Non-members may take CPE quizzes by sending a request to [email protected] There is a fee of $45 per quiz (includes quiz and copy of article) for non-member Journal CPE. CPE quizzes are valid for 1 year after the issue date in which the articles are published.