nutrition diagnosis: a critical step in the nutrition care

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Nutrition Diagnosis: A Critical Step in the Nutrition Care Process

Table of Contents

Section I: The Nutrition Care Process Nutrition Care Process and Model Article ....................................................................1

Section II: Development of Standardized Language ADA’s Standardized Language Model and Current Status ..........................................13

Section III: Introduction to Nutrition Diagnosis Introduction to Nutrition Diagnosis.............................................................................18

Section IV: Nutrition Diagnosis Terms and Definitions Nutrition Terms and Definitions ..................................................................................22

Section V: Nutrition Diagnosis Reference Sheets Single Page List of Terminology..................................................................................32

Section VI: Appendix Procedure for Nutrition Diagnostic Controlled Vocabulary/Terminology

Maintenance/Review ..................................................................................................154

Acknowledgements Task Force Members..................................................................................................160 Consultants ................................................................................................................161 Research Reviewers ...................................................................................................162

Feedback Form ......................................................................................................................165Camera Ready Pocket Guide .................................................................................................167

Please check the ADA Web site for additional materials

http://www.eatright.org/Member/index_10708.cfm?CFID=11486918&CFTOKEN=27367992http://www.eatright.org/Member/83_12962.cfm

Nutrition Care Process and Model: ADA adopts roadmap to quality care and outcomes managementKAREN LACEY, MS, RD; ELLEN PRITCHETT, RD

The establishment and implementation of a standardizedNutrition Care Process (NCP) and Model were identified aspriority actions for the profession for meeting goals of the

ADA Strategic Plan to “Increase demand and utilization of ser-vices provided by members” and “Empower members to com-pete successfully in a rapidly changing environment” (1). Pro-viding high-quality nutrition care means doing the right thing atthe right time, in the right way, for the right person, and achiev-ing the best possible results. Quality improvement literatureshows that, when a standardized process is implemented, lessvariation and more predictability in terms of outcomes occur(2). When providers of care, no matter their location, use aprocess consistently, comparable outcomes data can be gener-ated to demonstrate value. A standardized Nutrition Care Pro-cess effectively promotes the dietetics professional as theunique provider of nutrition care when it is consistently used asa systematic method to think critically and make decisions toprovide safe and effective nutrition care (3).

This article describes the four steps of ADA’s Nutrition CareProcess and the overarching framework of the Nutrition CareModel that illustrates the context within which the NutritionCare Process occurs. In addition, this article provides the ratio-nale for a standardized process by which nutrition care is pro-vided, distinguishes between the Nutrition Care Process andMedical Nutrition Therapy (MNT), and discusses future impli-cations for the profession.

BACKGROUNDPrior to the adoption of this standardized Nutrition Care Pro-cess, a variety of nutrition care processes were utilized by prac-titioners and taught by dietetics educators. Other allied health

professionals, including nursing, physical therapy, and occupa-tional therapy, utilize defined care processes specific to theirprofession (4-6). When asked whether ADA should develop astandardized Nutrition Care Process, dietetics professionalswere overwhelmingly in favor and strongly supportive of havinga standardized Nutrition Care Process for use by registereddietitians (RD) and dietetics technicians, registered (DTR).

The Quality Management Committee of the House of Dele-gates (HOD) appointed a Nutrition Care Model Workgroup inMay 2002 to develop a nutrition care process and model. Thefirst draft was presented to the HOD for member input andreview in September 2002. Further discussion occurred duringthe October 2002 HOD meeting, in Philadelphia. Revisionswere made accordingly, and the HOD unanimously adopted thefinal version of the Nutrition Care Process and Model on March31, 2003 “for implementation and dissemination to the dieteticsprofession and the Association for the enhancement of thepractice of dietetics.”

SETTING THE STAGE

Definition of Quality/Rationale for a StandardizedProcessThe National Academy of Science’s (NAS) Institute of Medi-cine (IOM) has defined quality as “The degree to which healthservices for individuals and populations increase the likelihoodof desired health outcomes and are consistent with currentprofessional knowledge” (7,8). The quality performance of pro-viders can be assessed by measuring the following: (a) theirpatients’ outcomes (end-results) or (b) the degree to whichproviders adhere to an accepted care process (7,8). The Com-mittee on Quality of Health Care in America further states thatit is not acceptable to have a wide quality chasm, or a gap,between actual and best possible performance (9). In an effortto ensure that dietetics professionals can meet both require-ments for quality performance noted above, the American Di-etetic Association (ADA) supports a standardized NutritionCare Process for the profession.

Standardized Process versus Standardized CareADA’s Nutrition Care Process is a standardized process fordietetics professionals and not a means to provide standardizedcare. A standardized process refers to a consistent structureand framework used to provide nutrition care, whereas stan-

K. Lacey is lecturer and Director of Dietetic Programs

at the University of Wisconsin-Green Bay, Green Bay. She

is also the Chair of the Quality Management Committee.

E. Pritchett is Director, Quality and Outcomes at ADA

headquarters in Chicago, IL.

If you have questions regarding the Nutrition Care Pro-

cess and Model, please contact Ellen Pritchett, RD, CPHQ,

Director of Quality and Outcomes at ADA,

[email protected]

Copyright © 2003 by the American Dietetic Association.

0002-8223/03/10308-0014$35.00/0

doi: 10.1053/jada.2003.50564

OF PROFESSIONAL INTEREST

Journal of THE AMERICAN DIETETIC ASSOCIATION / 1061Edition: 2006 1

dardized care infers that all patients/clients receive the samecare. This process supports and promotes individualized care,not standardized care. As represented in the model (Figure 1),the relationship between the patient/client/group and dieteticsprofessional is at the core of the nutrition care process. There-fore, nutrition care provided by qualified dietetics profession-als should always reflect both the state of the science and thestate of the art of dietetics practice to meet the individualizedneeds of each patient/client/group (10).

Using the NCPEven though ADA’s Nutrition Care Process will primarily beused to provide nutrition care to individuals in health care set-tings (inpatient, ambulatory, and extended care), the processalso has applicability in a wide variety of community settings. Itwill be used by dietetics professionals to provide nutrition careto both individuals and groups in community-based agenciesand programs for the purpose of health promotion and diseaseprevention (11,12).

Key TermsTo lay the groundwork and facilitate a clear definition of ADA’sNutrition Care Process, key terms were developed. These def-initions provide a frame of reference for the specific compo-nents and their functions.

(a) Process is a series of connected steps or actions to

achieve an outcome and/or any activity or set of activities thattransforms inputs to outputs.

(b) Process Approach is the systematic identification andmanagement of activities and the interactions between activi-ties. A process approach emphasizes the importance of thefollowing:■ understanding and meeting requirements;■ determining if the process adds value;■ determining process performance and effectiveness; and■ using objective measurement for continual improvement ofthe process (13).

(c) Critical Thinking integrates facts, informed opinions, ac-tive listening and observations. It is also a reasoning process inwhich ideas are produced and evaluated. The Commission onAccreditation of Dietetics Education (CADE) defines criticalthinking as “transcending the boundaries of formal educationto explore a problem and form a hypothesis and a defensibleconclusion” (14). The use of critical thinking provides a uniquestrength that dietetics professionals bring to the Nutrition CareProcess. Further characteristics of critical thinking include theability to do the following:■ conceptualize;■ think rationally;■ think creatively;■ be inquiring; and■ think autonomously.

FIG 1. ADA Nutrition Care Process and Model.


1062 / August 2003 Volume 103 Number 8Edition: 2006 2

(d) Decision Making is a critical process for choosing the bestaction to meet a desired goal.

(e) Problem Solving is the process of the following:■ problem identification;■ solution formation;■ implementation; and■ evaluation of the results.

(f) Collaboration is a process by which several individuals orgroups with shared concerns are united to address an identifiedproblem or need, leading to the accomplishment of what eachcould not do separately (15).

DEFINITION OF ADA’S NCPUsing the terms and concepts described above, ADA’s Nutri-tion Care Process is defined as “a systematic problem-solvingmethod that dietetics professionals use to critically think andmake decisions to address nutrition related problems and pro-vide safe and effective quality nutrition care.”

The Nutrition Care Process consists of four distinct, but in-terrelated and connected steps: (a) Nutrition Assessment, (b)Nutrition Diagnosis, (c) Nutrition Intervention, and d) Nutri-tion Monitoring and Evaluation. These four steps were finalizedbased on extensive review and evaluation of previous worksdescribing nutrition care (16-24). Even though each stepbuilds on the previous one, the process is not linear. Criticalthinking and problem solving will frequently require that die-tetics professionals revisit previous steps to reassess, add, orrevise nutrition diagnoses; modify intervention strategies;and/or evaluate additional outcomes. Figure 2 describes eachof these four steps in a similar format consisting of the follow-ing:■ definition and purpose;■ key components or substeps with examples as appropriate;■ critical thinking characteristics;■ documentation elements; and■ considerations for continuation, discontinuation, or dis-charge of care.

Providing nutrition care using ADA’s Nutrition Care Processbegins when a patient/client/group has been identified at nutri-tion risk and needs further assistance to achieve or maintainnutrition and health goals. It is also important to recognize thatpatients/clients who enter the health care system are morelikely to have nutrition problems and therefore benefit fromreceiving nutrition care in this manner. The Nutrition CareProcess cycles through the steps of assessment, diagnosis, in-tervention, and monitoring and evaluation. Nutrition care caninvolve one or more cycles and ends, ideally, when nutritiongoals have been achieved. However, the patient/client/groupmay choose to end care earlier based on personal or externalfactors. Using professional judgment, the dietetics professionalmay discharge the patient/client/group when it is determinedthat no further progress is likely.

PURPOSE OF NCPADA’s Nutrition Care Process, as described in Figure 2, givesdietetics professionals a consistent and systematic structureand method by which to think critically and make decisions. Italso assists dietetics professionals to scientifically and holisti-cally manage nutrition care, thus helping patients better meettheir health and nutrition goals. As dietetics professionals con-sistently use the Nutrition Care Process, one should expect ahigher probability of producing good outcomes. The NutritionCare Process then begins to establish a link between quality

and professional autonomy. Professional autonomy resultsfrom being recognized for what we do well, not just for who weare. When quality can be demonstrated, as defined previouslyby the IOM (7,8), then dietetics professionals will stand out asthe preferred providers of nutrition services. The NutritionCare Process, when used consistently, also challenges dieteticsprofessionals to move beyond experience-based practice toreach a higher level of evidence-based practice (9,10).

The Nutrition Care Process does not restrict practice butacknowledges the common dimensions of practice by the fol-lowing:■ defining a common language that allows nutrition practice tobe more measurable;■ creating a format that enables the process to generate quan-titative and qualitative data that can then be analyzed and in-terpreted; and■ serving as the structure to validate nutrition care and show-ing how the nutrition care that was provided does what it in-tends to do.

DISTINCTION BETWEEN MNT AND THE NCPMedical Nutrition Therapy (MNT) was first defined by ADA inthe mid-1990s to promote the benefits of managing or treatinga disease with nutrition. Its components included an assess-ment of nutritional status of patients and the provision of eitherdiet modification, counseling, or specialized nutrition thera-pies. MNT soon became a widely used term to describe a widevariety of nutrition care services provided by dietetics profes-sionals. Since MNT was first introduced, dietetics professionalshave gained much credibility among legislators and otherhealth care providers. More recently, MNT has been redefinedas part of the 2001 Medicare MNT benefit legislation to be“nutritional diagnostic, therapy, and counseling services for thepurpose of disease management, which are furnished by a reg-istered dietitian or nutrition professional” (25).

The intent of the NCP is to describe accurately the spectrumof nutrition care that can be provided by dietetics profession-als. Dietetics professionals are uniquely qualified by virtue ofacademic and supervised practice training and appropriatecertification and/or licensure to provide a comprehensive arrayof professional services relating to the prevention or treatmentof nutrition-related illness (14,26). MNT is but one specifictype of nutrition care. The NCP articulates the consistent andspecific steps a dietetics professional would use when deliver-ing MNT, but it will also be used to guide nutrition educationand other preventative nutrition care services. One of the keydistinguishing characteristics between MNT and the other nu-trition services using the NCP is that MNT always involves anin-depth, comprehensive assessment and individualized care.For example, one individual could receive MNT for diabetesand also nutrition education services or participate in a com-munity-based weight loss program (27). Each service woulduse the Nutrition Care Process, but the process would be im-plemented differently; the components of each step of the pro-cess would be tailored to the type of service.

By articulating the steps of the Nutrition Care Process, thecommonalities (the consistent, standardized, four-step pro-cess) of nutrition care are emphasized even though the processis implemented differently for different nutrition services. Witha standardized Nutrition Care Process in place, MNT should notbe used to describe all of the nutrition services that dieteticsprofessionals provide. As noted above, MNT is the only appli-cation of the Nutrition Care Process (28-31). This change in



STEP 1. NUTRITION ASSESSMENT

Basic Definition &Purpose

“Nutrition Assessment” is the first step of the Nutrition Care Process. Its purpose is to obtainadequate information in order to identify nutrition-related problems. It is initiated by referral and/orscreening of individuals or groups for nutritional risk factors. Nutrition assessment is a systematicprocess of obtaining, verifying, and interpreting data in order to make decisions about the nature andcause of nutrition-related problems. The specific types of data gathered in the assessment will varydepending on a) practice settings, b) individual/groups’ present health status, c) how data are relatedto outcomes to be measured, d) recommended practices such as ADA’s Evidence Based Guides forPractice and e) whether it is an initial assessment or a reassessment. Nutrition assessment requiresmaking comparisons between the information obtained and reliable standards (ideal goals). Nutritionassessment is an on-going, dynamic process that involves not only initial data collection, but alsocontinual reassessment and analysis of patient/client/group needs. Assessment provides thefoundation for the nutrition diagnosis at the next step of the Nutrition Care Process.

Data Sources/Tools forAssessment

� Referral information and/or interdisciplinary records� Patient/client interview (across the lifespan)� Community-based surveys and focus groups� Statistical reports; administrative data� Epidemiological studies

Types of Data Collected � Nutritional Adequacy (dietary history/detailed nutrient intake)� Health Status (anthropometric and biochemical measurements, physical & clinical conditions,

physiological and disease status)� Functional and Behavioral Status (social and cognitive function, psychological and emotional

factors, quality-of-life measures, change readiness)

Nutrition AssessmentComponents

� Review dietary intake for factors that affect health conditions and nutrition risk� Evaluate health and disease condition for nutrition-related consequences� Evaluate psychosocial, functional, and behavioral factors related to food access, selection,

preparation, physical activity, and understanding of health condition� Evaluate patient/client/group’s knowledge, readiness to learn, and potential for changing behaviors� Identify standards by which data will be compared� Identify possible problem areas for making nutrition diagnoses

Critical Thinking The following types of critical thinking skills are especially needed in the assessment step:� Observing for nonverbal and verbal cues that can guide and prompt effective interviewing

methods;� Determining appropriate data to collect;� Selecting assessment tools and procedures (matching the assessment method to the situation);� Applying assessment tools in valid and reliable ways;� Distinguishing relevant from irrelevant data;� Distinguishing important from unimportant data;� Validating the data;� Organizing & categorizing the data in a meaningful framework that relates to nutrition problems;

and� Determining when a problem requires consultation with or referral to another provider.

Documentation ofAssessment

Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.Quality documentation of the assessment step should be relevant, accurate, and timely. Inclusion ofthe following information would further describe quality assessment documentation:� Date and time of assessment;� Pertinent data collected and comparison with standards;� Patient/client/groups’ perceptions, values, and motivation related to presenting problems;� Changes in patient/client/group’s level of understanding, food-related behaviors, and other clinical

outcomes for appropriate follow-up; and� Reason for discharge/discontinuation if appropriate.

Determination forContinuation of Care

If upon the completion of an initial or reassessment it is determined that the problem cannot bemodified by further nutrition care, discharge or discontinuation from this episode of nutrition caremay be appropriate.

FIG 2. ADA Nutrition Care Process.



STEP 2. NUTRITION DIAGNOSISBasic Definition &

Purpose“Nutrition Diagnosis” is the second step of the Nutrition Care Process, and is the identification andlabeling that describes an actual occurrence, risk of, or potential for developing a nutritional problemthat dietetics professionals are responsible for treating independently. At the end of the assessmentstep, data are clustered, analyzed, and synthesized. This will reveal a nutrition diagnostic categoryfrom which to formulate a specific nutrition diagnostic statement. Nutrition diagnosis should not beconfused with medical diagnosis, which can be defined as a disease or pathology of specific organsor body systems that can be treated or prevented. A nutrition diagnosis changes as thepatient/client/group’s response changes. A medical diagnosis does not change as long as thedisease or condition exists. A patient/client/group may have the medical diagnosis of “Type 2diabetes mellitus”; however, after performing a nutrition assessment, dietetics professionals maydiagnose, for example, “undesirable overweight status” or “excessive carbohydrate intake.”Analyzing assessment data and naming the nutrition diagnosis(es) provide a link to setting realisticand measurable expected outcomes, selecting appropriate interventions, and tracking progress inattaining those expected outcomes.

Data Sources/Tools forDiagnosis

� Organized and clustered assessment data� List(s) of nutrition diagnostic categories and nutrition diagnostic labels� Currently the profession does not have a standardized list of nutrition diagnoses. However ADA

has appointed a Standardized Language Work Group to begin development of standardizedlanguage for nutrition diagnoses and intervention. (June 2003)

Nutrition DiagnosisComponents (3distinct parts)

1. Problem (Diagnostic Label)The nutrition diagnostic statement describes alterations in the patient/client/group’s nutritional status.

A diagnostic label (qualifier) is an adjective that describes/qualifies the human response such as:� Altered, impaired, ineffective, increased/decreased, risk of, acute or chronic.2. Etiology (Cause/Contributing Risk Factors)The related factors (etiologies) are those factors contributing to the existence of, or maintenance of

pathophysiological, psychosocial, situational, developmental, cultural, and/or environmentalproblems.

� Linked to the problem diagnostic label by words “related to” (RT)� It is important not only to state the problem, but to also identify the cause of the problem.▫ This helps determine whether or not nutritional intervention will improve the condition or correct

the problem.▫ It will also identify who is responsible for addressing the problem. Nutrition problems are either

caused directly by inadequate intake (primary) or as a result of other medical, genetic, orenvironmental factors (secondary).

▫ It is also possible that a nutrition problem can be the cause of another problem. For example,excessive caloric intake may result in unintended weight gain. Understanding the cascade ofevents helps to determine how to prioritize the interventions.

▫ It is desirable to target interventions at correcting the cause of the problem whenever possible;however, in some cases treating the signs and symptoms (consequences) of the problem may alsobe justified.

� The ranking of nutrition diagnoses permits dietetics professionals to arrange the problems in orderof their importance and urgency for the patient/client/group.

3. Signs/Symptoms (Defining Characteristics)The defining characteristics are a cluster of subjective and objective signs and symptoms

established for each nutrition diagnostic category. The defining characteristics, gathered duringthe assessment phase, provide evidence that a nutrition related problem exists and that theproblem identified belongs in the selected diagnostic category. They also quantify the problemand describe its severity:

� Linked to etiology by words “as evidenced by” (AEB);� The symptoms (subjective data) are changes that the patient/client/group feels and expresses

verbally to dietetics professionals; and� The signs (objective data) are observable changes in the patient/client/group’s health status.

Nutrition DiagnosticStatement (PES)

Whenever possible, a nutrition diagnostic statement is written in a PES format that states theProblem (P), the Etiology (E), and the Signs & Symptoms (S). However, if the problem is either a risk(potential) or wellness problem, the nutrition diagnostic statement may have only two elements,Problem (P), and the Etiology (E), since Signs & Symptoms (S) will not yet be exhibited in the patient.A well-written Nutrition Diagnostic Statement should be:1. Clear and concise2. Specific: patient/client/group-centered3. Related to one client problem4. Accurate: relate to one etiology5. Based on reliable and accurate assessment dataExamples of Nutrition Diagnosis Statements (PES or PE)� Excessive caloric intake (problem) “related to” frequent consumption of large portions of high fat

meals (etiology) “as evidenced by” average daily intake of calories exceeding recommendedamount by 500 kcal and 12-pound weight gain during the past 18 months (signs)

FIG 2 cont’d.



� Inappropriate infant feeding practice RT lack of knowledge AEB infant receiving bedtime juice in abottle

� Unintended weight loss RT inadequate provision of energy by enteral products AEB 6-poundweight loss over past month

� Risk of weight gain RT a recent decrease in daily physical activity following sports injury

Critical Thinking The following types of critical thinking skills are especially needed in the diagnosis step:� Finding patterns and relationships among the data and possible causes;� Making inferences (“if this continues to occur, then this is likely to happen”);� Stating the problem clearly and singularly;� Suspending judgment (be objective and factual);� Making interdisciplinary connections;� Ruling in/ruling out specific diagnoses; and� Prioritizing the relative importance of problems for patient/client/group safety.

Documentation ofDiagnosis

Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.Quality documentation of the diagnosis step should be relevant, accurate, and timely. A nutritiondiagnosis is the impression of dietetics professionals at a given point in time. Therefore, as moreassessment data become available, the documentation of the diagnosis may need to be revised andupdated.Inclusion of the following information would further describe quality documentation of this step:� Date and time; and� Written statement of nutrition diagnosis.


Since the diagnosis step primarily involves naming and describing the problem, the determination forcontinuation of care seldom occurs at this step. Determination of the continuation of care is moreappropriately made at an earlier or later point in the Nutrition Care Process.

STEP 3. NUTRITION INTERVENTION


“Nutrition Intervention” is the third step of the Nutrition Care Process. An intervention is a specificset of activities and associated materials used to address the problem. Nutrition interventions arepurposefully planned actions designed with the intent of changing a nutrition-related behavior, riskfactor, environmental condition, or aspect of health status for an individual, target group, or thecommunity at large. This step involves a) selecting, b) planning, and c) implementing appropriateactions to meet patient/client/groups’ nutrition needs. The selection of nutrition interventions is drivenby the nutrition diagnosis and provides the basis upon which outcomes are measured and evaluated.Dietetics professionals may actually do the interventions, or may include delegating or coordinatingthe nutrition care that others provide. All interventions must be based on scientific principles andrationale and, when available, grounded in a high level of quality research (evidence-basedinterventions).Dietetics professionals work collaboratively with the patient/client/group, family, or caregiver tocreate a realistic plan that has a good probability of positively influencing the diagnosis/problem. Thisclient-driven process is a key element in the success of this step, distinguishing it from previousplanning steps that may or may not have involved the patient/client/group to this degree ofparticipation.

Data Sources/Tools forInterventions

� Evidence-based nutrition guides for practice and protocols� Current research literature� Current consensus guidelines and recommendations from other professional organizations� Results of outcome management studies or Continuous Quality Index projects.� Current patient education materials at appropriate reading level and language� Behavior change theories (self-management training, motivational interviewing, behavior

modification, modeling)

Nutrition InterventionComponents

This step includes two distinct interrelated processes:1. Plan the nutrition intervention (formulate & determine a plan of action)� Prioritize the nutrition diagnoses based on severity of problem; safety; patient/client/group’s need;

likelihood that nutrition intervention will impact problem and patient/client/groups’ perception ofimportance.

� Consult ADA’s MNT Evidence-Based Guides for Practice and other practice guides. Theseresources can assist dietetics professionals in identifying science-based ideal goals and selectingappropriate interventions for MNT. They list appropriate value(s) for control or improvement of thedisease or conditions as defined and supported in the literature.

� Determine patient-focused expected outcomes for each nutrition diagnosis. The expectedoutcomes are the desired change(s) to be achieved over time as a result of nutrition intervention.They are based on nutrition diagnosis; for example, increasing or decreasing laboratory values,decreasing blood pressure, decreasing weight, increasing use of stanols/sterols, or increasingfiber. Expected outcomes should be written in observable and measurable terms that are clearand concise. They should be patient/client/group-centered and need to be tailored to what isreasonable to the patient’s circumstances and appropriate expectations for treatments andoutcomes.

FIG 2 cont’d.



� Confer with patient/client/group, other caregivers or policies and program standards throughoutplanning step.

� Define intervention plan (for example write a nutrition prescription, provide an education plan orcommunity program, create policies that influence nutrition programs and standards).

� Select specific intervention strategies that are focused on the etiology of the problem and that areknown to be effective based on best current knowledge and evidence.

� Define time and frequency of care including intensity, duration, and follow-up.� Identify resources and/or referrals needed.2. Implement the nutrition intervention (care is delivered and actions are carried out)� Implementation is the action phase of the nutrition care process. During implementation, dietetics

professionals:▫ Communicate the plan of nutrition care;▫ Carry out the plan of nutrition care; and▫ Continue data collection and modify the plan of care as needed.� Other characteristics that define quality implementation include:▫ Individualize the interventions to the setting and client;▫ Collaborate with other colleagues and health care professionals;▫ Follow up and verify that implementation is occurring and needs are being met; and▫ Revise strategies as changes in condition/response occurs.

Critical Thinking Critical thinking is required to determine which intervention strategies are implemented based onanalysis of the assessment data and nutrition diagnosis. The following types of critical thinking skillsare especially needed in the intervention step:� Setting goals and prioritizing;� Transferring knowledge from one situation to another;� Defining the nutrition prescription or basic plan;� Making interdisciplinary connections;� Initiating behavioral and other interventions;� Matching intervention strategies with client needs, diagnoses, and values;� Choosing from among alternatives to determine a course of action; and� Specifying the time and frequency of care.

Documentation ofNutrition Interventions

Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.Quality documentation of nutrition interventions should be relevant, accurate, and timely. It shouldalso support further intervention or discharge from care. Changes in patient/client/group’s level ofunderstanding and food-related behaviors must be documented along with changes in clinical orfunctional outcomes to assure appropriate care/case management in the future. Inclusion of thefollowing information would further describe quality documentation of this step:� Date and time;� Specific treatment goals and expected outcomes;� Recommended interventions, individualized for patient;� Any adjustments of plan and justifications;� Patient receptivity;� Referrals made and resources used;� Any other information relevant to providing care and monitoring progress over time;� Plans for follow-up and frequency of care; and� Rationale for discharge if appropriate.


If the patient/client/group has met intervention goals or is not at this time able/ready to make neededchanges, the dietetics professional may include discharging the client from this episode of care aspart of the planned intervention.

STEP 4. NUTRITION MONITORING AND EVALUATION


“Nutrition Monitoring and Evaluation” is the fourth step of the Nutrition Care Process. Monitoringspecifically refers to the review and measurement of the patient/client/group’s status at a scheduled(preplanned) follow-up point with regard to the nutrition diagnosis, intervention plans/goals, andoutcomes, whereas Evaluation is the systematic comparison of current findings with previous status,intervention goals, or a reference standard. Monitoring and evaluation use selected outcomeindicators (markers) that are relevant to the patient/client/group’s defined needs, nutrition diagnosis,nutrition goals, and disease state. Recommended times for follow-up, along with relevant outcomesto be monitored, can be found in ADA’s Evidence Based Guides for Practice and other evidence-based sources.The purpose of monitoring and evaluation is to determine the degree to which progress is beingmade and goals or desired outcomes of nutrition care are being met. It is more than just “watching”what is happening, it requires an active commitment to measuring and recording the appropriateoutcome indicators (markers) relevant to the nutrition diagnosis and intervention strategies. Data fromthis step are used to create an outcomes management system. Refer to Outcomes ManagementSystem in text.

FIG 2 cont’d.



Progress should be monitored, measured, and evaluated on a planned schedule until discharge.Short inpatient stays and lack of return for ambulatory visits do not preclude monitoring, measuring,and evaluation. Innovative methods can be used to contact patients/clients to monitor progress andoutcomes. Patient confidential self-report via mailings and telephone follow-up are some possibilities.Patients being followed in disease management programs can also be monitored for changes innutritional status. Alterations in outcome indicators such as hemoglobin A1C or weight are examplesthat trigger reactivation of the nutrition care process.

Data Sources/Tools forMonitoring andEvaluation

� Patient/client/group records� Anthropometric measurements, laboratory tests, questionnaires, surveys� Patient/client/group (or guardian) interviews/surveys, pretests, and posttests� Mail or telephone follow-up� ADA’s Evidence Based Guides for Practice and other evidence-based sources� Data collection forms, spreadsheets, and computer programs

Types of OutcomesCollected

The outcome(s) to be measured should be directly related to the nutrition diagnosis and the goalsestablished in the intervention plan. Examples include, but are not limited to:� Direct nutrition outcomes (knowledge gained, behavior change, food or nutrient intake changes,

improved nutritional status);� Clinical and health status outcomes (laboratory values, weight, blood pressure, risk factor profile

changes, signs and symptoms, clinical status, infections, complications);� Patient/client-centered outcomes (quality of life, satisfaction, self-efficacy, self-management,

functional ability); and� Health care utilization and cost outcomes (medication changes, special procedures,

planned/unplanned clinic visits, preventable hospitalizations, length of hospitalization, prevent ordelay nursing home admission).

Nutrition Monitoringand EvaluationComponents

This step includes three distinct and interrelated processes:1. Monitor progress� Check patient/client/group understanding and compliance with plan;� Determine if the intervention is being implemented as prescribed;� Provide evidence that the plan/intervention strategy is or is not changing patient/client/group

behavior or status;� Identify other positive or negative outcomes;� Gather information indicating reasons for lack of progress; and� Support conclusions with evidence.2. Measure outcomes� Select outcome indicators that are relevant to the nutrition diagnosis or signs or symptoms,

nutrition goals, medical diagnosis, and outcomes and quality management goals.� Use standardized indicators to:▫ Increase the validity and reliability of measurements of change; and▫ Facilitate electronic charting, coding, and outcomes measurement.3. Evaluate outcomes� Compare current findings with previous status, intervention goals, and/or reference standards.

Critical Thinking The following types of critical thinking skills are especially needed in the monitoring and evaluation step:� Selecting appropriate indicators/measures;� Using appropriate reference standard for comparison;� Defining where patient/client/group is now in terms of expected outcomes;� Explaining variance from expected outcomes;� Determining factors that help or hinder progress; and� Deciding between discharge or continuation of nutrition care.

Documentation ofMonitoring andEvaluation

Documentation is an on-going process that supports all of the steps in the Nutrition Care Processand is an integral part of monitoring and evaluation activities. Quality documentation of themonitoring and evaluation step should be relevant, accurate, and timely. It includes a statement ofwhere the patient is now in terms of expected outcomes. Standardized documentation enablespooling of data for outcomes measurement and quality improvement purposes. Qualitydocumentation should also include:� Date and time;� Specific indicators measured and results;� Progress toward goals (incremental small change can be significant therefore use of a Likert type

scale may be more descriptive than a “met” or “not met” goal evaluation tool);� Factors facilitating or hampering progress;� Other positive or negative outcomes; and� Future plans for nutrition care, monitoring, and follow up or discharge.


Based on the findings, the dietetics professional makes a decision to actively continue care ordischarge the patient/client/group from nutrition care (when necessary and appropriate nutrition care iscompleted or no further change is expected at this time). If nutrition care is to be continued, the nutritioncare process cycles back as necessary to assessment, diagnosis, and/or intervention for additionalassessment, refinement of the diagnosis and adjustment and/or reinforcement of the plan. If care does notcontinue, the patient may still be monitored for a change in status and reentry to nutrition care at a later date.

FIG 2 cont’d.



describing what dietetics professionals do is truly a paradigmshift. This new paradigm is more complete, takes in more pos-sibilities, and explains observations better. Finally, it allowsdietetics professionals to act in ways that are more likely toachieve the results that are desired and expected.

NUTRITION CARE MODELThe Nutrition Care Model is a visual representation that re-flects key concepts of each step of the Nutrition Care Processand illustrates the greater context within which the NutritionCare Process is conducted. The model also identifies other fac-tors that influence and impact on the quality of nutrition careprovided. Refer to Figure 1 for an illustration of the model asdescribed below:■ Central Core: Relationship between patient/client/group anddietetics professional;■ Nutrition Care Process: Four steps of the nutrition care pro-cess (Figure 2);■ Outer rings:■ Middle ring: Strengths and abilities that dietetics profession-als bring to the process (dietetics knowledge, skills, and com-petencies; critical thinking, collaboration, and communication;evidence-based practice, and Code of Ethics) (32);■ Outer ring: Environmental factors that influence the process(practice settings, health care systems, social systems, andeconomics);■ Supporting Systems:■ Screening and Referral System as access to Nutrition Care;and■ Outcomes Management System as a means to provide contin-uous quality improvement to the process.

The model is intended to depict the relationship with whichall of these components overlap, interact, and move in a dy-namic manner to provide the best quality nutrition care possi-ble.

Central to providing nutrition care is the relationship be-tween the patient/client/group and the dietetics professional.The patient/client/groups’ previous educational experiencesand readiness to change influence this relationship. The edu-cation and training that dietetics professionals receive havevery strong components devoted to interpersonal knowledgeand skill building such as listening, empathy, coaching, andpositive reinforcing.

The middle ring identifies abilities of dietetics professionalsthat are especially applicable to the Nutrition Care Process.These include the unique dietetics knowledge, skill, and com-petencies that dietetics professionals bring to the process, inaddition to a well-developed capability for critical thinking, col-laboration, and communication. Also in this ring is evidence-based practice that emphasizes that nutrition care must incor-porate currently available scientific evidence, linking what isdone (content) and how it is done (process of care). The Codeof Ethics defines the ethical principles by which dietetics pro-fessionals should practice (33). Dietetics knowledge and evi-dence-based practice establish the Nutrition Care Process asunique to dietetics professionals; no other health care profes-sional is qualified to provide nutrition care in this manner. How-ever, the Nutrition Care Process is highly dependent on collab-oration and integration within the health care team. As statedabove, communication and participation within the health careteam are critical for identification of individuals who are appro-priate for nutrition care.

The outer ring identifies some of the environmental factors

such as practice settings, health care systems, social systems,and economics. These factors impact the ability of the patient/client/group to receive and benefit from the interventions ofnutrition care. It is essential that dietetics professionals assessthese factors and be able to evaluate the degree to which theymay be either a positive or negative influence on the outcomesof care.

Screening and Referral SystemBecause screening may or may not be accomplished by dietet-ics professionals, nutrition screening is a supportive systemand not a step within the Nutrition Care Process. Screening isextremely important; it is an identification step that is outsidethe actual “care” and provides access to the Nutrition CareProcess.

The Nutrition Care Process depends on an effective screen-ing and/or referral process that identifies clients who wouldbenefit from nutrition care or MNT. Screening is defined by theUS Preventive Services Task Force as “those preventive ser-vices in which a test or standardized examination procedure isused to identify patients requiring special intervention” (34).The major requirements for a screening test to be consideredeffective are the following:■ Accuracy as defined by the following three components:� Specificity: Can it identify patients with a condition?� Sensitivity: Can it identify those who do not have the condi-tion?� Positive and negative predictive; and■ Effectiveness as related to likelihood of positive health out-comes if intervention is provided.

Screening parameters need to be tailored to the populationand to the nutrition care services to be provided. For example,the screening parameters identified for a large tertiary acutecare institution specializing in oncology would be vastly differ-ent than the screening parameters defined for an ambulatoryobstetrics clinic. Depending on the setting and institutionalpolicies, the dietetics professional may or may not be directlyinvolved in the screening process. Regardless of whether die-tetics professionals are actively involved in conducting thescreening process, they are accountable for providing inputinto the development of appropriate screening parameters toensure that the screening process asks the right questions.They should also evaluate how effective the screening processis in terms of correctly identifying clients who require nutritioncare.

In addition to correctly identifying clients who would benefitfrom nutrition care, a referral process may be necessary toensure that the client has an identifiable method of being linkedto dietetics professionals who will ultimately provide the nutri-tion care or medical nutrition therapy. While the nutritionscreening and referral is not part of the Nutrition Care Process,it is a critical antecedent step in the overall system (35).

Outcomes Management SystemAn outcomes management system evaluates the effectivenessand efficiency of the entire process (assessment, diagnosis,interventions, cost, and others), whereas the fourth step of theprocess “nutrition monitoring and evaluations” refers to theevaluation of the patient/client/group’s progress in achievingoutcomes.

Because outcomes management is a system’s commitment toeffective and efficient care, it is depicted outside of the NCP.Outcomes management links care processes and resource uti-



lization with outcomes. Through outcomes management, rele-vant data are collected and analyzed in a timely manner so thatperformance can be adjusted and improved. Findings are com-pared with such things as past levels of performance; organiza-tional, regional, or national norms; and standards or bench-marks of optimal performance. Generally, this information isreported to providers, administrators, and payors/funders andmay be part of administrative databases or required reportingsystems.

It requires an infrastructure in which outcomes for the pop-ulation served are routinely assessed, summarized, and re-ported. Health care organizations use complex informationmanagement systems to manage resources and track perfor-mance. Selected information documented throughout the nu-trition care process is entered into these central informationmanagement systems and structured databases. Examples ofcentralized data systems in which nutrition care data should beincluded are the following:■ basic encounter documentation for billing and cost account-ing;■ tracking of standard indicators for quality assurance and ac-creditation;■ pooling data from a large series of patients/clients/groups todetermine outcomes; and■ specially designed studies that link process and outcomes todetermine effectiveness and cost effectiveness of diagnosticand intervention approaches.

The major goal of outcomes management is to utilize col-lected data to improve the quality of care rendered in the fu-ture. Monitoring and evaluation data from individuals arepooled/aggregated for the purposes of professional account-ability, outcomes management, and systems/processes im-provement. Results from a large series of patients/clients canbe used to determine the effectiveness of intervention strate-gies and the impact of nutrition care in improving the overallhealth of individuals and groups. The effects of well-monitoredquality improvement initiatives should be reflected in measur-able improvements in outcomes.

Outcomes management comprehensively evaluates the twoparts of IOM’s definition of quality: outcomes and process. Mea-suring the relationship between the process and the outcome isessential for quality improvement. To ensure that the quality ofpatient care is not compromised, the focus of quality improve-ment efforts should always be directed at the outcome of care(36-43).

FUTURE IMPLICATIONS

Impact on Coverage for ServicesQuality-related issues are gaining in importance worldwide.Even though our knowledge base is increasing, the scientificevidence for most clinical practices in all of medicine is modest.So much of what is done in health care does not maximizequality or minimize cost (44). A standardized Nutrition CareProcess is a necessary foundation tool for gathering valid andreliable data on how quality nutrition care provided by qualifieddietetics professionals improves the overall quality of healthcare provided. Implementing ADA’s Nutrition Care Processprovides a framework for demonstrating that nutrition careimproves outcomes by the following: (a) enhancing the healthof individuals, groups, institutions, or health systems; (b) po-tentially reducing health care costs by decreasing the need formedications, clinic and hospital visits, and preventing or delay-

ing nursing home admissions; and (c) serving as the basis forresearch, documenting the impact of nutrition care providedby dietetics professionals (45-47).

Developing Scopes and Practice StandardsThe work group reviewed the questions raised by delegatesregarding the role of the RD and DTR in the Nutrition CareProcess. As a result of careful consideration of this importantissue, it was concluded that describing the various types oftasks and responsibilities appropriate to each of these creden-tialed dietetics professionals was yet another professional issuebeyond the intent and purpose of developing a standardizedNutrition Care Process.

A scope of practice of a profession is the range of servicesthat the profession is authorized to provide. Scopes of practice,depending on the particular setting in which they are used, canhave different applications. They can serve as a legal documentfor state certification/licensure laws or they might be incorpo-rated into institutional policy and procedure guidelines or jobdescriptions. Professional scopes of practice should be basedon the education, training, skills, and competencies of eachprofession (48).

As previously noted, a dietetics professional is a person who,by virtue of academic and clinical training and appropriate cer-tification and/or licensure, is uniquely qualified to provide acomprehensive array of professional services relating to pre-vention and treatment of nutrition-related conditions. A Scopeof Practice articulates the roles of the RD, DTR, and advanced-practice RD. Issues to be addressed for the future include thefollowing: (a) the need for a common scope with specializedguidelines and (b) recognition of the rich diversity of practicevs exclusive domains of practice regulation.

Professional standards are “authoritative statements thatdescribe performance common to the profession.” As such,standards should encompass the following:■ articulate the expectations the public can have of a dieteticsprofessional in any practice setting, domain, and/or role;■ expect and achieve levels of practice against which actualperformance can be measured; and■ serve as a legal reference to describe “reasonable and pru-dent” dietetics practice.

The Nutrition Care Process effectively reflects the dieteticsprofessional as the unique provider of nutrition care when it isconsistently used as a systematic method to think critically andmake decisions to provide safe and effective care. ADA’s Nutri-tion Care Process will serve as a guide to develop scopes ofpractice and standards of practice (49,50). Therefore, the workgroup recommended that further work be done to use the Nu-trition Care Process to describe roles and functions that can beincluded in scopes of practice. In May 2003, the Board of Di-rectors of ADA established a Practice Definitions Task Forcethat will identify and differentiate the terms within the profes-sion that need clarification for members, affiliates, and DPGsrelated to licensure, certification, practice acts, and advancedpractice. This task force is also charged to clarify the scope ofpractice services, clinical privileges, and accountabilities pro-vided by RDs/DTRs based on education, training, and experi-ence.

Education of Dietetics StudentsIt will be important to review the current CADE EducationalStandards to ensure that the language and level of expectedcompetencies are consistent with the entry-level practice of



the Nutrition Care Process. Further work by the Commissionon Dietetic Registration (CDR) may need to be done to makerevisions on the RD and DTR exams to evaluate entry-levelcompetencies needed to practice nutrition care in this way.Revision of texts and other educational materials will also needto incorporate the key principles and steps of this new process(51).

Education and Credentialing of MembersEven though dietetics professionals currently provide nutritioncare, this standardized Nutrition Care Process includes somenew principles, concepts, and guidelines in each of its steps.This is especially true of steps 2 and 4 (Nutrition Diagnosis andNutrition Monitoring and Evaluation). Therefore, the implica-tions for education of dietetics professionals and their practiceare great. Because a large number of dietetics professionals stillare employed in health care systems, a comprehensive educa-tional plan will be essential. A model to be considered whenplanning education is the one used to educate dietetics profes-sionals on the Professional Development Portfolio (PDP) Pro-cess (52). Materials that could be used to provide memberswith the necessary knowledge and skills in this process couldinclude but not be limited to the following:■ articles in the Journal of the American Dietetic Associa-tion;■ continuing professional education lectures and presentationsat affiliate and national meetings;■ self-study materials; case studies, CD-ROM workbooks, andothers;■ hands-on workshops and training programs;■ Web-based materials; and■ inclusion in the learning needs assessment and codes of theProfessional Development Portfolio.

Through the development of this educational strategic plan,the benefits to dietetics professionals and other stakeholderswill need to be a central theme to promote the change in prac-tice that comes with using this process to provide nutritioncare.

Evidence-Based PracticeThe pressure to do more with less is dramatically affecting all ofhealth care, including dietetics professionals. This pressure isforcing the health care industry to restructure to be more effi-cient and cost-effective in delivering care. It will require the useof evidenced-based practice to determine what practices arecritical to support outcomes (53,54). The Nutrition Care Pro-cess will be invaluable as research is completed to evaluate theservices provided by dietetics professionals (55). The NutritionCare Process will provide the structure for developing themethodology and data collection in individual settings, and thepractice-based research networks ADA is in the process of ini-tiating.

Standardized LanguageAs noted in Step 2 (Nutrition Diagnosis), having a standardtaxonomy for nutrition diagnosis would be beneficial. Work inthe area of articulating the types of interventions used by die-tetics professionals has already begun by the Definitions WorkGroup under the direction of ADA’s Research Committee. Fur-ther work to define terms that are part of the Nutrition CareProcess will need to continue. Even though the work groupprovided a list of terms relating to the definition and key con-cepts of the process, there are opportunities to articulate fur-

ther terms that are consistently used in this process. The Boardof Directors of ADA in May 2003 approved continuation andexpansion of a task force to address a comprehensive systemthat includes a process for developing and validating standard-ized language for nutrition diagnosis, intervention, and out-comes.

SUMMARYJust as maps are reissued when new roads are built and riverschange course, this Nutrition Care Process and Model reflectsrecent changes in the nutrition and health care environment. Itprovides dietetics professionals with the updated “road map” tofollow the best path for high-quality patient/client/group-cen-tered nutrition care.

References1. American Dietetic Association Strategic Plan. Available at: http://eatright.org(member only section). Accessed June 2, 2003.2. Wheeler D. Understanding Variation: The Key to Managing Chaos. 2nd ed.Knoxville, TN: SPC Press; 2000.3. Shojania KG, Duncan BW, McDonald KM, Wachter RM. Making HealthCare Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43 (Prepared by the University of California atSan Francisco-Stanford Evidence-based Practice Center under Contract No.290-97-0013). Rockville, MD: Agency for Healthcare Research and Quality;2001. Report No.: AHRQ Publication No. 01-E058.4. Potter, Patricia A, Perry, Anne G. Basic Nursing Theory and Practice. 4thed. St Louis: C.V. Mosby; 1998.5. American Physical Therapy Association. Guide to Physical Therapist Prac-tice. 2nd ed. Alexandria, VA; 2001.6. The Guide to Occupational Therapy Practice. Am J Occup Ther. 1999;53:3.Available at http://nweb.pct.edu/homepage/student/NUNJOL02/ot%20process.ppt. Accessed May 30, 2003.7. Kohn KN, ed. Medicare: A strategy for Quality Assurance, Volume I. Com-mittee to Design a Strategy for Quality Review and Assurance in Medicare.Washington, DC: Institute of Medicine. National Academy Press; 1990.8. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a SaferHealth System. Washington, DC: Committee on Quality of Health Care inAmerica, Institute of Medicine. National Academy Press; 2000.9. Institute of Medicine. Crossing the Quality Chasm: A New Health System forthe 21st Century. Committee on Quality in Health Care in America. RonaBriere, ed. Washington, DC: National Academy Press; 2001.10. Splett P. Developing and Validating Evidence-Based Guides for Practice:A Tool Kit for Dietetics Professionals. American Dietetic Association; 1999.11. Endres JB. Community Nutrition. Challenges and Opportunities. UpperSaddle River, NJ: Prentice-Hall, Inc; 1999.12. Splett P. Planning, Implementation and Evaluation of Nutrition Programs.In: Sharbaugh CO, ed. Call to Action: Better Nutrition for Mothers, Children,and Families. Washington, DC: National Center for Education in Maternal andChild Health (NCEMCH); 1990.13. Batalden PB, Stoltz PA. A framework for the continual improvement ofhealth care: Building and applying professional and improvement knowledgeto test changes in daily work. Jt Comm J Qual Improv. 1993;19:424-452.14. CADE Accreditation Handbook. Available at: http://www.eatright.com/cade/standards.html. Accessed March 20, 2003.15. Alfaro-LeFevre R. Nursing process overview. Applying Nursing Process.Promoting Collaborative Care. 5th ed. Lippincott; 2002.16. Grant A, DeHoog S. Nutrition Assessment Support and Management.Northgate Station, WA; 1999.17. Sandrick, K. Is nutritional diagnosis a critical step in the nutrition careprocess? J Am Diet Assoc. 2002;102:427-431.18. King LS. What is a diagnosis? JAMA. 1967;202:154.19. Doenges ME. Application of Nursing Process and Nursing Diagnosis: AnInteractive Text for Diagnostic Reasoning, 3rd ed. Philadelphia, PA: FA DavisCo; 2000.20. Gallagher-Alred C, Voss AC, Gussler JD. Nutrition intervention and patientoutcomes: a self-study manual. Columbus, OH: Ross Products Division,Abbott Laboratories; 1995.21. Splett P, Myers EF. A proposed model for effective nutrition care. J AmDiet Assoc. 2001;101:357-363.22. Lacey K, Cross N. A problem-based nutrition care model that is diagnosticdriven and allows for monitoring and managing outcomes. J Am Diet Assoc.2002;102:578-589.23. Brylinsky C. The Nutrition Care Process. In: Mahan K, Escott-Stump S,



eds. Krause’s Food, Nutrition and Diet Therapy, 10th ed. Philadelphia, PA:W.B. Saunders Company; 2000:431-451.24. Hammond MI, Guthrie HA. Nutrition clinic: An integrated component of anundergraduate curriculum. J Am Diet Assoc. 1985;85:594.25. Final MNT Regulations. CMS-1169-FC. Federal Register, November 1,2001. Department of Health and Human Services. 42 CFR Parts: 405, 410,411, 414, and 415. Available at: http://cms.hhs.gov/physicians/pfs/cms1169fc.asp. Accessed June 27, 2003.26. Commission on Dietetic Registration CDR Certifications and State Licen-sure. Available at: http://www.cdrnet.org/certifications/index.htm. AccessedMay 30, 2003.27. Medicare Coverage Policy Decision: Duration and Frequency of the Med-ical Nutrition Therapy (MNT) Benefit (No. CAG-00097N). Available at: http://cms.hhs.gov/ncdr/memo.asp?id�53. Accessed June 2, 2003.28. American Dietetic Association Medical Nutrition Therapy Evidence-BasedGuides For Practice. Hyperlipidemia Medical Nutrition Therapy Protocol. CD-ROM; 2001.29. American Dietetic Association. Medical Nutrition Therapy Evidence-Based Guides for Practice. Nutrition Practice Guidelines for Type 1 and 2Diabetes Mellitus CD-ROM; 2001.30. American Dietetic Association. Medical Nutrition Therapy Evidence-Based Guides for Practice. Nutrition Practice Guidelines for Gestational Dia-betes Mellitus. CD-ROM; 2001.31. American Dietetic Association Medical Nutrition Therapy Evidence-BasedGuides For Practice. Chronic Kidney Disease (non-dialysis) Medical NutritionTherapy Protocol. CD-ROM; 2002.32. Gates G. Ethics opinion: Dietetics professionals are ethically obligated tomaintain personal competence in practice. J Am Diet Assoc. May 2003;103:633-635.33. Code of Ethics for the Profession of Dietetics. J Am Diet Assoc. 1999;99:109-113.34. US Preventive Services Task Force. Guide to Clinical Preventive Services,2nd ed. Washington, DC: US Department of Health and Human Services,Office of Disease Prevention and Health Promotion; 1996.35. Identifying patients at risk: ADA’s definitions for nutrition screening andnutrition assessment. J Am Diet Assoc. 1994;94:838-839.36. Donabedian A. Explorations in Quality Assessment and Monitoring. Vol-ume I: The Definition of Quality and Approaches to Its Assessment. Ann Arbor,MI: Health Administration Press; 1980.37. Carey RG, Lloyd RC. Measuring Quality Improvement in Health Care: AGuide to Statistical Process Control Applications. New York, Quality Re-sources; 1995.38. Eck LH, Slawson DL, Williams R, Smith K, Harmon-Clayton K, Oliver D. Amodel for making outcomes research standard practice in clinical dietetics.J Am Diet Assoc. 1998;98:451-457.39. Ireton-Jones CS, Gottschlich MM, Bell SJ. Practice-Oriented NutritionResearch: An Outcomes Measurement Approach. Gaithersburg, MD: AspenPublishers, Inc.; 1998.40. Kaye GL. Outcomes Management: Linking Research to Practice. Colum-bus, OH: Ross Products Division, Abbott Laboratories; 1996.41. Splett P. Cost Outcomes of Nutrition Intervention, a Three Part Mono-graph. Evansville, IN: Mead Johnson & Company; 1996.

42. Plsekk P. 1994. Tutorial: Planning for data collection part I: Asking theright question. Qual Manage Health Care. 2:76-81.43. American Dietetic Association. Israel D, Moore S, eds. Beyond NutritionCounseling: Achieving Positive Outcomes Through Nutrition Therapy. 1996.44. Stoline AM, Weiner JP. The New Medical Marketplace: A Physician’sGuide to the Health Care System in the 1990s. Baltimore: Johns HopkinsPress; 1993.45. Mathematica Policy Research, Inc. Best Practices in Coordinated CareMarch 22, 2000. Available at: http://www.mathematica-mpr.com/PDFs/bestpractices.pdf. Accessed February 22, 2003.46. Bisognano MA. New skills needed in medical leadership: The key toachieving business results. Qual Prog. 2000;33:32-41.47. Smith R. Expanding medical nutrition therapy: An argument for evidence-based practices. J Am Diet Assoc. 2003;103:313-314.48. National Council of State Boards of Nursing Model Nursing Practice Act.Available at: http://www.ncsbn.org/public/regulation/nursing_practice_model_practice_act.htm. Accessed June 27, 2003.49. Professional policies of the American College of Medical Quality (ACMQ).Available at: http://www.acmq.org/profess/list.htm. Accessed June 27, 2003.50. American Dietetic Association. Standards of professional practice. J AmDiet Assoc. 1998;98:83-85.51. O’Neil EH and the Pew Health Professions Commission. RecreatingHealth Professional Practice for a New Century. The Fourth Report of the PewHealth Professions Commission. Pew Health Professions Commission; De-cember 1998.52. Weddle DO. The professional development portfolio process: Settinggoals for credentialing. J Am Diet Assoc. 2002;102:1439-1444.53. Sackett DL, Rosenberg WMC, Gray J, Haynes RB, Richardson WS.Evidence based medicine: What it is and what it isn’t. Br Med J. 1996;312:71-72.54. Myers EF, Pritchett E, Johnson EQ. Evidence-based practice guides vs.protocols: What’s the difference? J Am Diet Assoc. 2001;101:1085-1090.55. Manore MM, Myers EF. Research and the dietetics profession: Making abigger impact. J Am Diet Assoc. 2003;103:108-112.

The Quality Management Committee Work Group devel-oped the Nutrition Care Process and Model with inputfrom the House of Delegates dialog (October 2002 HODmeeting, in Philadelphia, PA). The work group membersare the following: Karen Lacey, MS, RD, Chair; ElviraJohnson, MS, RD; Kessey Kieselhorst, MPA, RD; Mary JaneOakland, PhD, RD, FADA; Carlene Russell, RD, FADA; Pa-tricia Splett, PhD, RD, FADA; Suzanne Bertocchi, DTR,and Tamara Otterstein, DTR; Ellen Pritchett, RD; EstherMyers, PhD, RD, FADA; Harold Holler, RD, and KarriLooby, MS, RD. The work group would like to extend aspecial thank you to Marion Hammond, MS, and NaoimiTrossler, PhD, RD, for their assistance in development ofthe Nutrition Care Process and Model.



American Dietetic Association’s Standardized Nutrition Language: Current Status

Introduction Evidence-based dietetic practice relies on

concise, consistent, and standardized terminology to create and retrieve digital sources of evidence.1 This is essential for documenting nutrition diagnoses, interventions and outcomes in electronic health records. A task force of the American Dietetic Association (ADA) has begun to refine and disseminate standardized nutrition language. The language is built on the Nutrition Care Process and Model that maps quality nutrition care and outcomes, and recognizes several existing terminologies used by other health professions. This paper will describe the logic model for the development of the standardized nutrition language, the Nutrition Care Process it is built upon, and its current status.

The project goal is to support nutrition practice, education, research, and policy with data. It is assumed that practicing Dietitians, educators, and researchers will use the standardized nutrition language to document care, aggregate data, and study the evidence. Standardized terminology will provide the foundation for developing a national dietitian care database.

The Nutrition Care ProcessThe ADA Nutrition Care Model workgroup

published the Nutrition Care Process (NCP) and Model in August 2003.2 It provides a definition of the NCP, describes its steps and framework. The NCP is “a systematic problem-solving method that dietetics professionals use to critically think and make decisions to address nutrition related problems and provide safe and effective quality nutrition care.”2, p1063 The four steps of the NCP, similar to those of other clinical professions, are: a) Nutrition Assessment, b) Nutrition Diagnosis, c) Nutrition Intervention, and d) Nutrition Monitoring and Evaluation. Allowing for the reality of an iterative and comprehensive clinical process, the NCP is not linear and it includes, but is not limited to, Medical Nutrition Therapy. Medical Nutrition Therapy is “nutritional diagnostic, therapy, and counseling services for the purpose of disease management, which are furnished by a registered dietitian or nutrition professional.”3 The context of the NCP and surrounding influences are captured in the Model framework.

Standardized terms are being developed for each step of the NCP. Nutrition Assessment is “a systematic process of obtaining, verifying, and interpreting data in order to make decisions about the nature and cause of nutrition-related problems.”2, p1064

The Nutrition Assessment includes signs and symptoms. Nutrition Diagnosis is “the identification and labeling that describes an actual occurrence, risk of, or potential for developing a nutritional problem that dietetics professionals are responsible for treating independently.” 2, p.1065

Nutrition Interventions are “purposely planned actions designed with the intent of changing a nutrition-related behavior, risk factor, environmental condition, or aspect of health status for an individual, target group, or the community at large.”2, p.1066

Interventions are directed to influence the etiology or effects of a diagnosis. Nutrition Monitoring is “the review and measurement of the patient/client/group’s status at a scheduled (preplanned) follow-up point with regard to the nutrition diagnosis, intervention plans/goals, and outcomes.” Evaluation is “the systematic comparison of current findings with previous status, intervention goals, or a reference standard.”2, p.1067 Evaluation may measure changes in signs and symptoms. The NCP steps guide the delivery of nutrition health services, education, and research and define categories for documentation of nutrition care.

Development: Comparison with Nursing In comparison with the development of

various nursing terminologies, the ADA nutrition language development has been much more rapid and centralized, due perhaps to comparatively smaller numbers of nutrition professionals and growing sophistication in information technology. Nursing terminologies work began in the 1970s, including the North American Nursing Diagnosis (NANDA)4 terminology, the Clinical Care Classification (CCC),5 and others. NANDA is specific to nursing diagnosis, while the CCC addresses diagnoses, interventions, and outcomes. The Nursing Minimum Data Set6 which includes patient information, nursing diagnoses, nursing interventions, nursing outcomes, intensity level of nursing care, and a unique provider number is an over-arching framework for the various discrete nursing terminologies, similar to the NCP.

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Why Does Dietetics Practice Need a Standardized Language?

There is currently no agreed upon mechanism by which dietetics professionals can communicate with each other or other healthcare professionals. Because of this lack of agreement, there is no easy way to classify, measure, and report on the outcomes of nutrition interventions in various patient populations. The Nutrition Care Process includes nutrition diagnosis and nutrition intervention as unique steps that provide Registered Dietitians a mechanism to consistently document and communicate the work of dietetics[13]. There is currently no agreed upon terminology used in dietetics practice making it impossible to gather and aggregate data needed for research, education, and reimbursement justification via outcomes analysis.

Logic Model

A Logic Model is a simplified picture that describes the logical relationships among the resources invested, the activities that take place, and the benefits to be realized from the project and the environment in which the system/project occurs. With the help of an informatics consultant, the Standardized Language Task Force adopted a Project Logic Model that identifies the expected outcomes and impact of the Standardized Language of Dietetics. The goal of the dietetics terminology was seen to be "To provide data to foster nutrition practice, education, research, and policy". Three time frames for evaluating the impact of the standardized language were agreed upon. The most immediate impacts were thought to include recommendations for coordination with existing terminologies, review of the structure of the dietetics terminology, to "cross-walk" the new terminology with existing terminologies to see if overlap exists, to review existing intervention terms, and to identify relevant policy issues regarding standardized nutrition language. Intermediate impacts were thought to include selection of a structure for the nutrition diagnostic labels, cross-walk of the intervention terms, to plan for generation of nutrition outcomes measures, create strategies for ongoing maintenance and updates of the language, to design and implement pilot testing of the standardized language, and to draft legislative and policy agendas. The ultimate impact was agreed to include delivery of quality, cost-effective nutrition care, national growth of nutrition care, inclusion of the standardized language in dietetics education and research, development of a national data warehouse for nutrition research, and support of policies designed to foster nutrition practice, education, and research.

Several assumptions were necessary in development of this logic model. The Task Force was in agreement that nutrition is an essential component of high quality health care. There was heightened awareness of the need for data to document the processes and outcomes of nutrition care in a variety of settings. It was also assumed that educators, practicing dietitians, and researchers would accept and implement the standardized language and would be willing to share data using the terminology for targeted studies and ultimately a national database.

Nutrition Diagnostic Labels To date, over 60 Nutrition Diagnostic Labels

have been defined by ADA work with focus groups, domain experts, and membership committees. Standardized Language Task Force members judged the match between nutrition diagnoses terms and similar terms listed in the National Library of Medicine’s Unified Medical Language System (UMLS); many terms have synonyms. One of the robust terminologies in the UMLS is SNOMED-CT. Staff from SNOMED-CT were contacted to discuss the process of submitting nutrition terms.

The Nutrition Diagnostic Labels include 3 domains: Clinical, Behavioral-Environmental, and Intake. The domains, sub-classes, and specific diagnoses are defined in the most recent version, a summary of which follows.11

DOMAIN: INTAKE Defined as “actual problems related to intake of energy, nutrients, fluids, bioactive substances through oral diet or nutrition support (enteral or parenteral nutrition)” Class: Caloric Energy Balance Defined as “actual or estimated changes in energy (kcal)”Class: Oral or Nutrition Support Intake Defined as “actual or estimated food and beverage intake from oral diet or nutrition support compared with patient goal” Class: Fluid Intake Balance Defined as “actual or estimated fluid intake compared with patient goal” Class: Bioactive Substances Balance Defined as “actual or observed intake of bioactive substances, including single or multiple functional food components, ingredients, dietary supplements, alcohol”Class: Nutrient Balance Defined as “actual or estimated intake of specific nutrient groups or single nutrients as compared with desired levels” Sub-Class: Fat and Cholesterol Balance

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Sub-Class: Protein Balance) Sub-Class: Carbohydrate and Fiber Balance Sub-Class: Vitamin Balance

Sub-Class: Mineral BalanceDOMAIN: CLINICAL

Defined as “nutritional findings/problems identified that relate to medical or physical conditions” Class: Functional Balance Defined as “change in physical or mechanical functioning that interferes with or prevents desired nutritional consequences” Class: Biochemical Balance Defined as “change in capacity to metabolize nutrients as a result of medications, surgery, or as indicated by altered lab values” Class: Weight Balance Defined as “chronic weight or changed weight status when compared with usual or desired body weight”

DOMAIN: BEHAVIORAL-ENVIRONMENTAL

Defined as “nutritional findings/problems identified that relate to knowledge, attitudes/beliefs, physical environment, or access to food and food safety” Class: Knowledge and Beliefs Defined as “actual knowledge and beliefs as reported, observed, or documented” Class: Physical Activity Balance and Function Defined as “actual physical activity, self-care, and quality of life problems as reported, observed or documented” Class: Food Safety and Access Defined as “actual problems with food access or food safety” © ADA

Problem-Etiology-Signs/Symptoms Statements A Nutrition Diagnosis is best written as a PES

statement pertaining to one patient/client or group, specific to one problem (P) and one etiology (E), and based on assessment of signs and symptoms (S).2

Implementation of PES statements in clinical practice is being tested in two pilot studies by ADA members. Examples of PES statements are a)”Overweight/obesity (problem) related to continued intake of high fat foods (etiology) resulting in ~300 extra kcal/day as evidenced by a BMI of 30(sign/symptom), and b) Impaired ability to prepare foods/meals (problem) related to fatigue (etiology) as evidenced by patient/client only consuming one meal per day.”11 Interventions are often guided by the etiology of each problem. Signs and symptoms may provide measures to evaluate outcomes and the effectiveness of care. It is possible that the standardized terms for assessments will be considered relevant outcome measures.

Nutrition Interventions Following principles for standardized

terminologies,12 the ADA has begun to identify and define Nutrition Intervention terms. A Task Force meeting in February 2005 identified categories of interventions including: Treatments/Procedures, Education, Counseling, and Referral/ Coordination. These categories are similar to those in nursing terminologies but differing by not including monitoring/assessment as an intervention, which is a separate step in the Nutrition Care Process. Synonyms to the intervention terms will be searched in the UMLS and domain experts will judge the extent of the matches. The Nutrition Intervention Labels will be submitted SNOMED-CT or other existing coding system that will be included in the UMLS.

Future Work Definition of Nutrition Assessment terms and

their relationship with Outcome terms is planned. In addition, activities to communicate the standardized language to educators, administrators, clinicians, and researchers are planned. The ADA believes that consistent standardized terminology will improve patient care by enhancing the education, practice, and research of nutrition professionals. The use of standardized nutrition language by nutrition professionals in the U.S. is in synch with similar international efforts.

References 1. Bakken S. An informatics infrastructure is essential for evidence-based practice. JAMIA2001;8:199-201. 2. Lacey K, Pritchett E. Nutrition care process and model: ADA adopts road map to quality care and outcomes management. JADA. 2003 Aug; 103 (8):1061-72. 3. Final Medical Nutrition Therapy regulations. CMS-1169-FC. Federal Register, Nov.1, 2001. DHHS 42 CFR Parts: 405, 410, 411, 414, and 415. Retrieved Mar. 7, 2005 from http://cms.hhs.gov/physicians/pfs/cms1169fc.asp.4. North American Nursing Diagnosis Association. Retrieved Mar. 7, 2005 from http://www.nanda.org/5. Saba V (2005). Clinical Care Classification System. Retrieved Mar. 7, 2005 from http://www.sabacare.com6. Werley H, Lang NM. Identification of the nursing minimum data set. New York: Springer, 1988. 7. Alternative Billing Codes. Retrieved Mar. 7, 2005 from http://www.alternativelink.com/ali/home/

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8. National Library of Medicine (2005). Unified Medical Language System. Retrieved Mar. 7, 2005 from http://www.nlm.nih.gov/research/umls/umlsmain.html9. College of American Pathologists. SNOMED CT. Skokie, IL: author, 2005. Retrieved Mar. 7, 2005 from http://www.snomed.org/10. Logical Observation Identifiers Names and Codes. Retrieved Mar. 7, 2005 from http://www.loinc.org/11. Escott-Stump S, Hutson V, Lacey K, Myers E, Oakland MJ, Splett P. Nutrition Diagnosis: What’s In It For My Practice? JADA in press 2005. 12. Cimino JJ. Desiderata for Controlled Medical Vocabularies in the Twenty-First Century. Methods of Information in Medicine; 1998;37:394-403

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Introduction to nutrition diagnoses/problems: The new component of the nutrition care process

Introduction

The ADA has embarked on an extensive project to identify and define nutrition diagnoses/problems for the profession of dietetics. This standardized language of nutrition diagnoses/problems is an integral component in the Nutrition Care Process, a process designed to improve the consistency and quality of individualized patient/client care and the predictability of the patient/client outcomes. In fact, several other allied professional, including nursing, physical therapy, and occupational therapy, utilize defined care processes (1).

Not only will creating this standard language help dietetic professionals better document their nutrition care, it will serve to help achieve Association strategic goals of promoting demand for dietetic professionals and help them be more competitive in the market place. It will also provide a minimum data set and common data elements for future research that includes services of dietetic professionals.

ADA’s Standardized Language Task Force developed a conceptual framework for the standardized nutrition language and identified the nutrition diagnoses/problems. The framework outlines the domains within which the diagnoses/problems would fall and the flow of the nutrition care process in relation to the continuum of health, disease and disability. Sixty-twodiagnoses/problems have been identified. A worksheet has been developed for each diagnosis/problem and expert has been incorporated.

The methodology for developing sets of terms such as these includes systematically collecting data from multiple sources simultaneously. We collected data from a selected group of dietitians prior to starting the project (from ADA recognized leaders and award winners), from the 12 member task force during the development, from several small group discussions (community, ambulatory, acute care, and long term care) and from expert researcher reviewers.

The methodology for continued development and refinement of these terms has been identified. As with the ongoing updating of the American Medical Association CPT codes, these will also be published on an annual basis. The process to submit your suggested changes is included in this packet. In addition, the terms have been included in one ongoing research project in an ambulatory setting. A second descriptive research study identifying the use of the terms will be planned and conducted through the Dietetics Practice Based Research Network in 2005-2006. As each of the research studies are completed their findings will be incorporated into future versions of these terms. Future iterations and changes to the diagnoses/problems and the worksheets are expected as this standard language evolves. Once the initial research is completed we will formally submit these terms to become part of nationally recognized health care databases. We have already begun the dialogue with these groups to let them know the direction that we are headed and to keep them appraised of our progress.

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Nutrition Care Process and Nutrition DiagnosisADA’s new nutrition care process for the profession has four steps—nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation (1). Textbooks often describe nutrition assessment in detail and then move directly into intervention or therapy. Nutrition diagnosis is a critical step between assessment and intervention. The nutrition diagnosis is the identification and labeling of the specific nutrition problem that dietetics professionals are responsible for treating independently. Naming the nutrition diagnosis provides a way to document the link and set realistic and measurable expected outcomes (1).

The diagnosis provides a way to document the link between nutrition assessment and nutrition intervention and set realistic and measurable expected outcomes for each patient/client. Identifying the diagnosis also assists practitioners in establishing priorities when planning an individual patient/client’s nutrition care.

Nutrition diagnosis differs from medical diagnosis. Medical diagnosis is a disease or pathology of specific organs or body systems (e.g., diabetes) and does not change as long as the condition exists. A nutrition diagnosis may be temporary, altering as the patient/client’s response changes (e.g., excessive carbohydrate intake).

Categorization of the Nutrition DiagnosesThe sixty-two nutrition diagnoses/problems have been given labels that are clustered into three domains: clinical, behavioral-environmental, and intake. Each domain represents unique characteristics that contribute to nutritional health. Within each domain are classes and, in some cases, sub-classes of diagnoses. A definition of each follows:

The Intake domain lists actual problems related to intake of energy, nutrients, fluids, bioactive substances through oral diet, or nutrition support (enteral or parenteral nutrition.)

Class: Caloric Energy Balance (1)—Actual or estimated changes in energy (kcal). Class: Oral or Nutrition Support Intake (2)—Actual or estimated food and beverage intake from oral diet or nutrition support compared with patient/client’s goal. Class: Fluid Intake Balance (3)—Actual or estimated fluid intake compared with patient/client’s goal. Class: Bioactive Substances Balance (4)—Actual or observed intake of bioactive substances, including single or multiple functional food components, ingredients, dietary supplements, and alcohol.

Class: Nutrient Balance (5)—Actual or estimated intake of specific nutrient groups or single nutrients as compared with desired levels. Sub-Class: Fat and Cholesterol Balance (51) Sub-Class: Protein Balance (52) Sub-Class: Carbohydrate and Fiber Balance (53) Sub-Class: Vitamin Balance (54) Sub-Class: Mineral Balance (55) The Clinical domain is nutritional findings/problems identified that relate to medical or physical conditions.

Class: Functional Balance (1)—Change in physical or mechanical function that interferes with or prevents desired nutritional consequences.

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Class: Biochemical Balance (2)—Change in the capacity to metabolize nutrients as a result of medications, surgery, or as indicated by altered lab values.

Class: Weight Balance (3)—Chronic weight or changed weight status when compared with usual or desired body weight.

The Behavioral-Environmental domain includes nutritional findings/problems identified that relate to knowledge, attitudes/beliefs, physical environment, access to food, and food safety.

Class: Knowledge and Beliefs (1)—Actual knowledge and beliefs as reported, observed, or documented. Class: Physical Activity Balance and Function (2)—Actual physical activity, self-care, and quality of life problems as reported, observed or documented.

Class: Food Safety and Access (3)—Actual problems with food access or food safety.

Examples of nutrition diagnoses and their definitions include:

INTAKE DOMAIN Caloric Energy Balance

Inadequate energy intake NI-1.4 Energy intake that is less than energy expenditure or recommended levels. Exception: when the goal is for the client to lose weight or during end of life care.

CLINICAL DOMAIN Functional Balance

Swallowing difficulty NC-1.1 Impaired movement of food and liquid from the mouth to the stomach.

BEHAVIORAL-ENVIONEMENTAL DOMAIN Knowledge and Beliefs

Not ready for diet/lifestyle change NB-1.3

Lack of perceived value of nutrition-related care benefits compared to consequences or effort required to making the change; inconsistencies with other value structure/purpose; antecedent to behavior change.

Nutrition Diagnosis Statements (or PES)Whenever possible, a nutrition diagnosis statement is written in the PES format that states the problem (P), the etiology (E), and the signs/symptoms (S).

Examples Swallowing difficulty (problem) related to stroke (etiology) as evidenced by coughing

following drinking of thin liquids (sign/symptoms).

Inadequate energy intake (problem) related to lack of financial resources to purchase sufficient food (etiology) as evidenced by weight loss of 6 pounds in the last 2 months (signs/symptoms).

Nutrition Diagnosis Worksheet A worksheet has been developed for each diagnosis. It contains four distinct components: nutrition diagnosis label, definition of nutrition diagnosis label, etiology, and signs/symptoms. These worksheets will assist practitioners with consistently and correctly utilizing the nutrition diagnoses. Below is a description of the four components of the worksheet.

The Problem or Nutrition Diagnosis Label describes alterations in the patient/client’s nutrition status that dietetics professionals are responsible for treating independently. Nutrition diagnosis differs from medical

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diagnosis in that a nutrition diagnosis changes as the patient/client response changes. The medical diagnosis does not change as long as the disease or condition exists. A nutrition diagnosis allows the dietetics professional to identify realistic and measurable outcomes, formulate interventions, and monitor and evaluate change.

The Definition of Nutrition Diagnosis Label briefly describes the Nutrition Diagnosis Label to differentiate a discrete problem area.

The Etiology (Cause/Contributing Risk Factors) are those factors contributing to the existence of, or maintenance of pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems. It is linked to the diagnosis label by the words “related to.”

The Signs/Symptoms (Defining Characteristics) consist of subjective and/or objective data used to determine whether the patient/client has the nutrition diagnosis specified. These are the signs and symptoms gathered through nutrition assessment. It is linked to the etiology by the words “as evidenced by.”

Organization of Data in Signs/Symptoms (Defining Characteristics) Dietetics professionals use clinical judgment to determine the nutrition diagnosis based on data collected from the first step of the nutrition care process: nutrition assessment. Therefore, the items listed in the signs/symptoms (defining characteristics) are organized according to nutrition assessment category.

Nutrition assessment is the systematic process for obtaining, verifying, and interpreting data needed to make decisions about the nature and cause of the nutrition-related problem. The process of nutrition assessment consists of collecting biochemical data, anthropometric measurements, physical examination findings, food/nutrition history, and client history. On the nutrition diagnosis worksheet, the signs/symptoms are classified by nutrition assessment categories.

Biochemical Data include laboratory data, for example, electrolytes, glucose, Hemoglobin A1C, thyroid, and lipid panel.

Anthropometric Measurements include, for instance, height, weight, body mass index (BMI), growth rate, and rate of weight change.

Nutrition-Focused Physical Examination includes oral health, general physical appearance, muscle and subcutaneous fat wasting, and affect.

Food and Nutrition History consists of four areas: Food consumption, nutrition and health awareness and management, physical activity and exercise, and food availability.

Food consumption may include factors such as, food and nutrient intake, meal and snack patterns, environmental cues to eating, and current diets and/or food modifications.

Nutrition and health awareness and management includes, for example, knowledge and beliefs about nutrition recommendations, self-monitoring/management practices, and past nutrition counseling and education.

Physical activity and exercise consists of activity patterns, amount of sedentary time (e.g., TV, phone, computer), and exercise intensity, frequency, and duration.

Food availability encompasses factors such as, food planning, purchasing, preparation abilities and limitations, food safety practices, food/nutrition program utilization, and food insecurity.

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Client History consists of four areas: Medication and supplement history, social history, medical/health history, and personal history.

Medication and supplement history includes, for instance, prescription and over the counter drugs, herbal and dietary supplements, and illegal drugs.

Social history may include items, such as, socioeconomic status, social and medical support, cultural and religious beliefs, housing situation, and social isolation/connection.

Medical/health history includes chief nutrition complaint, present/past illness, disease or complication risk, family medical history, mental/emotional health, and cognitive abilities.

Personal history consists of factors including age, occupation, role in family, and education level.

SummaryNutrition diagnosis is the critical link in the nutrition care process between assessment and intervention. Interventions can then be clearly targeted to address either the etiology or signs and symptoms of the specific nutrition diagnosis/problem identified. Using a standardized terminology for identifying the nutrition diagnosis/problem will make one aspect of the critical thinking that dietetics professionals do visible to other professionals as well as provide a clear method of communicating among dietetics professionals. Implementation of a standard language throughout the profession, with tools to assist practitioners, will make this bold initiative a success. Ongoing input is critical as the standardized language is created to ensure a proper foundation for its future implementation.

Reference1. Lacey K, Pritchett E. Nutrition care process and model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc. 2003;103:1061-1072.

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NUTRITION DIAGNOSTIC TERMINOLOGY

INTAKE NI Defined as “actual problems related to intake of energy, nutrients, fluids, bioactive substances through oral diet or nutrition support”

Caloric Energy Balance (1) Defined as “actual or estimated changes in energy (kcal)”

Hypermetabolism NI-1.1 (Increased energy needs)

Increased energy expenditure NI-1.2 Hypometabolism NI-1.3

(Decreased energy needs) Inadequate energy intake NI-1.4 Excessive energy intake NI-1.5

Oral or Nutrition Support Intake (2) Defined as “actual or estimated food and beverage intake from oral diet or nutrition support compared with patient goal”

Inadequate oral food/ NI-2.1 beverage intake

Excessive oral food/ NI-2.2 beverage intake

Inadequate intake from NI-2.3 enteral/parenteral nutrition infusion

Excessive intake from NI-2.4 enteral/parenteral nutrition

Inappropriate infusion of NI-2.5 enteral/parenteral nutrition (use with caution)

Fluid Intake (3) Defined as “actual or estimated fluid intake compared against patient goal”

Inadequate fluid intake NI-3.1Excessive fluid intake NI-3.2

Bioactive Substances (4) Defined as “actual or observed intake of bioactive substances, including single or multiple functional food components, ingredients, dietary supplements, alcohol”

Inadequate bioactive NI-4.1 substance intake

Excessive bioactive NI-4.2 substance intake

Excessive alcohol intake NI-4.3

Nutrient (5) Defined as “actual or estimated intake of specific nutrient groups or single nutrients as compared with desired levels”

Increased nutrient needs NI-5.1 (specify) ___________________________

Evident protein- energy NI-5.2 malnutrition

Inadequate protein- NI-5.3 energy intake

Decreased nutrient needs NI-5.4 (specify) ___________________________

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Imbalance of nutrients NI-5.5

Fat and Cholesterol (51) Inadequate fat intake NI-51.1 Excessive fat intake NI-51.2 Inappropriate intake NI-51.3

of food fats (specify) ______________________ Protein (52)

Inadequate protein intake NI-52.1 Excessive protein intake NI-52.2 Inappropriate intake NI-52.3

of amino acids (specify) ______________________ Carbohydrate and Fiber Intake (53)

Inadequate carbohydrate NI-53.1 intake

Excessive carbohydrate NI-53.2 intake

Inappropriate intake of NI-53.3 types of carbohydrate (specify) ______________________

Inconsistent NI-53.4 carbohydrate intake

Inadequate fiber intake NI-53.5 Excessive fiber intake NI-53.6

Vitamin Intake (54) Inadequate vitamin NI-54.1

intake (specify) _________________ Excessive vitamin NI-54.2

intake (specify) _________________ A CThiamin DRiboflavin ENiacin KFolate Other _______

Mineral Intake (55) Inadequate mineral intake NI-55.1

(specify) Calcium IronPotassium Zinc Other __________

Excessive mineral intake NI-55.2 (specify)

Calcium IronPotassium Zinc Other __________

CLINICAL NC Defined as “nutritional findings/problems identified as related to medical or physical conditions”

Functional (1) Defined as “change in physical or mechanical functioning that interferes with or prevents desired nutritional consequences”

Swallowing difficulty NC-1.1 Chewing (masticatory) difficulty NC-1.2 Breastfeeding difficulty NC-1.3 Altered GI function NC-1.4

Biochemical (2) Defined as “change in capacity to metabolize nutrients as a result of medications, surgery, or as indicated by altered lab values”

Impaired nutrient utilization NC-2.1 Altered nutrition-related NC-2.2

laboratory values Food medication interaction NC-2.3

Weight (3) Defined as “chronic weight or changed weight status when compared with usual or desired body weight”

Underweight NC-3.1 Involuntary weight loss NC-3.2 Overweight/obesity NC-3.3 Involuntary weight gain NC-3.4

BEHAVIORAL- ENVIRONMENTAL NB Defined as “nutritional findings/problems identified as related to knowledge, attitudes/beliefs, physical environment, or food supply and safety”

Knowledge and Beliefs (1) Defined as “actual knowledge and beliefs as observed or documented”

Food and nutrition-related NB-1.1 knowledge deficit

Harmful beliefs/attitudes NB-1.2 about food or nutrition- related topics (use with caution)

Not ready for diet/ NB-1.3 lifestyle change

Self monitoring deficit NB-1.4 Disordered eating pattern NB-1.5 Limited adherence to nutrition- NB-1.6

related recommendations Undesirable food choices NB-1.7

Physical Activity and Function (2) Defined as “actual physical activity, self-care, and quality of life problems as reported, observed or documented”

Physical inactivity NB-2.1 Excessive exercise NB-2.2 Inability or lack of desire NB-2.3

to manage self care Impaired ability to NB-2.4

prepare foods/meals Poor nutrition quality of life NB-2.5 Self-feeding difficulty NB-2.6

Food Safety and Access (3) Defined as “actual problems with food access or food safety”

Intake of unsafe food NB-3.1Limited access to food NB-3.2

#1 Problem ____________________________________________________________________________________________________________ Etiology ____________________________________________________________________________________________________________ Signs/Symptoms _____________________________________________________________________________________________________#2 Problem ____________________________________________________________________________________________________________ Etiology ____________________________________________________________________________________________________________ Signs/Symptoms _____________________________________________________________________________________________________#3 Problem ____________________________________________________________________________________________________________ Etiology ____________________________________________________________________________________________________________ Signs/Symptoms ___________________________________________________________________________________________

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rate

an

ente

ral

inta

ke, o

r is

uns

afe

beca

use

of th

e po

tent

ial f

or s

epsi

s or

oth

er

com

plic

atio

ns

18-1

9

Edi

tion:

200

6 24

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

Cla

ss:

Flu

id In

take

(3)

D

efin

ed a

s “a

ctu

al o

r es

tim

ated

flu

id in

take

co

mp

ared

wit

h p

atie

nt

go

al”

Inad

equa

te fl

uid

inta

keN

I-3.

1Lo

wer

inta

ke o

f flu

id c

onta

inin

g fo

ods

or s

ubst

ance

s co

mpa

red

to

esta

blis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

up

on p

hysi

olog

ical

nee

ds

20-2

1

Exc

essi

ve fl

uid

inta

keN

I-3.

2H

ighe

r in

take

of f

luid

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

22

-23

Cla

ss:

Bio

acti

ve S

ub

stan

ces

(4)

Def

ined

as

“act

ual

or

ob

serv

ed in

take

of

bio

acti

ve s

ub

stan

ces,

incl

ud

ing

sin

gle

or

mu

ltip

le f

un

ctio

nal

fo

od

co

mp

on

ents

, in

gre

die

nts

, die

tary

su

pp

lem

ents

, alc

oh

ol”

Inad

equa

te b

ioac

tive

subs

tanc

e in

take

NI-

4.1

Low

er in

take

of b

ioac

tive

subs

tanc

es c

onta

inin

g fo

ods

or

subs

tanc

es c

ompa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

re

com

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

24-2

5

Exc

essi

ve b

ioac

tive

subs

tanc

e in

take

NI-

4.2

Hig

her

inta

ke o

f bio

activ

e su

bsta

nces

oth

er th

an tr

aditi

onal

nu

trie

nts,

suc

h as

func

tiona

l foo

ds, b

ioac

tive

food

com

pone

nts,

di

etar

y su

pple

men

ts, f

ood

conc

entr

ates

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

26-2

7

Exc

essi

ve a

lcoh

ol in

take

NI-

4.3

Inta

ke a

bove

the

sugg

este

d lim

its fo

r al

coho

l 28

-29

Cla

ss:

Nu

trie

nt

(5)

D

efin

ed a

s “a

ctu

al o

r es

tim

ated

inta

ke o

f sp

ecif

ic n

utr

ien

t g

rou

ps

or

sin

gle

nu

trie

nts

as

co

mp

ared

wit

h d

esir

ed le

vels

”

Incr

ease

d nu

trie

nt (

spec

ify)

need

sN

I-5.

1 In

crea

sed

need

for

a sp

ecifi

c nu

trie

nt c

ompa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed u

pon

30-3

1

Edi

tion:

200

6 25

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

phys

iolo

gica

l nee

ds

Evi

dent

pro

tein

-ene

rgy

mal

nutr

ition

NI-

5.2

Inad

equa

te in

take

of p

rote

in a

nd/o

r en

ergy

32

-33

Inad

equa

te p

rote

in-e

nerg

y in

take

NI-

5.3

Inad

equa

te in

take

of p

rote

in a

nd/o

r en

ergy

com

pare

d to

es

tabl

ishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed

upon

phy

siol

ogic

al n

eeds

of s

hort

or

rece

nt d

urat

ion

34-3

5

Dec

reas

ed n

utrie

nt (

spec

ify)

need

sN

I-5.

4 D

ecre

ased

nee

d fo

r a

spec

ific

nutr

ient

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

36-3

7

Imba

lanc

e of

nut

rient

sN

I-5.

5 A

n un

desi

rabl

e co

mbi

natio

n of

inge

sted

nut

rient

s, s

uch

that

the

amou

nt o

f one

nut

rient

inge

sted

inte

rfer

es w

ith o

r al

ters

ab

sorp

tion

and/

or u

tiliz

atio

n of

ano

ther

nut

rient

38-3

9

S

ub

-Cla

ss:

Fat

an

d C

ho

lest

ero

l (5

1)

Inad

equa

te fa

t int

ake

NI-

51.1

Low

er fa

t int

ake

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or

reco

mm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds. E

xcep

tion:

w

hen

reco

mm

enda

tion

is fo

r w

eigh

t los

s or

dur

ing

end

of li

fe

care

.

40

Exc

essi

ve fa

t int

ake

NI-

51.2

Hig

her

fat i

ntak

e co

mpa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

re

com

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

41

-42

Inap

prop

riate

inta

ke o

f foo

d fa

ts (

spec

ify)

NI-

51.3

In

take

of w

rong

type

or

qual

ity o

f foo

d fa

ts c

ompa

red

to

esta

blis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

up

on p

hysi

olog

ical

nee

ds

43-4

4

S

ub

-Cla

ss:

Pro

tein

(52

)

Inad

equa

te p

rote

in in

take

NI-

52.1

Low

er in

take

of p

rote

in c

onta

inin

g fo

ods

or s

ubst

ance

s co

mpa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed

upon

phy

siol

ogic

al n

eeds

45

Exc

essi

ve p

rote

in in

take

NI-

52.2

Inta

ke a

bove

the

reco

mm

ende

d le

vel a

nd/o

r ty

pe o

f pro

tein

co

mpa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

46

-47

Edi

tion:

200

6 26

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

reco

mm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

Inap

prop

riate

inta

ke o

f am

ino

acid

s (s

peci

fy)

NI-

52.3

Inta

ke th

at is

mor

e or

less

than

rec

omm

ende

d le

vel a

nd/o

r ty

pe

of a

min

o ac

ids

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or

reco

mm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

48-4

9

S

ub

-Cla

ss:

Car

bo

hyd

rate

an

d

Fib

er (

53)

Inad

equa

te c

arbo

hydr

ate

inta

keN

I-53

.1Lo

wer

inta

ke o

f car

bohy

drat

e co

ntai

ning

food

s or

sub

stan

ces

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or

reco

mm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

50

Exc

essi

ve c

arbo

hydr

ate

inta

keN

I-53

.2In

take

abo

ve th

e re

com

men

ded

leve

l and

type

of c

arbo

hydr

ate

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or

reco

mm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

51-5

2

Inap

prop

riate

inta

ke o

f typ

es o

f car

bohy

drat

e (s

peci

fy)

NI-

53.3

Inta

ke o

r th

e ty

pe o

r am

ount

of c

arbo

hydr

ate

that

is a

bove

or

belo

w th

e es

tabl

ishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

ba

sed

upon

phy

siol

ogic

al n

eeds

53-5

4

Inco

nsis

tent

car

bohy

drat

e in

take

NI-

53.4

Inco

nsis

tent

tim

ing

of c

arbo

hydr

ate

inta

ke th

roug

hout

the

day,

da

y to

day

, or

a pa

ttern

of c

arbo

hydr

ate

inta

ke th

at is

not

co

nsis

tent

with

rec

omm

ende

d pa

ttern

bas

ed u

pon

phys

iolo

gica

l ne

eds

55-5

6

Inad

equa

te fi

ber

inta

keN

I-53

.5Lo

wer

inta

ke o

f fib

er c

onta

inin

g fo

ods

or s

ubst

ance

s co

mpa

red

to

esta

blis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

up

on p

hysi

olog

ical

nee

ds

57-5

8

Exc

essi

ve fi

ber

inta

keN

I-53

.6H

ighe

r in

take

of f

iber

con

tain

ing

food

s or

sub

stan

ces

com

pare

d to

rec

omm

enda

tions

bas

ed u

pon

patie

nt/c

lient

con

ditio

n

59-6

0

S

ub

-Cla

ss:

Vit

amin

(54

)

Inad

equa

te v

itam

in in

take

(sp

ecify

)N

I-54

.1

Low

er in

take

of v

itam

in c

onta

inin

g fo

ods

or s

ubst

ance

s co

mpa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed

upon

phy

siol

ogic

al n

eeds

61-6

3

Edi

tion:

200

6 27

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

Exc

essi

ve v

itam

in in

take

(sp

ecify

)N

I-54

.2

Hig

her

inta

ke o

f vita

min

con

tain

ing

food

s or

sub

stan

ces

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or

reco

mm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

64-6

5

S

ub

-Cla

ss:

Min

eral

(55

)

Inad

equa

te m

iner

al in

take

(sp

ecify

)N

I-55

.1

Low

er in

take

of m

iner

al c

onta

inin

g fo

ods

or s

ubst

ance

s co

mpa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

re

com

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

66-6

7

Exc

essi

ve m

iner

al in

take

NI-

55.2

Hig

her

inta

ke o

f min

eral

from

food

s, s

uppl

emen

ts, m

edic

atio

ns o

r w

ater

, com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or

reco

mm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

68-6

9

DO

MA

IN:

CL

INIC

AL

Defi

ned

as “

nu

trit

ion

al fi

nd

ing

s/p

rob

lem

s

iden

tifi

ed

th

at

rela

te t

o m

ed

ical o

r p

hys

ical

co

nd

itio

ns

”

NC

Cla

ss:

Fu

nct

ion

al (

1)

Def

ined

as

“ch

ang

e in

ph

ysic

al o

r m

ech

anic

al f

un

ctio

nin

g t

hat

inte

rfer

es w

ith

o

r p

reve

nts

des

ired

nu

trit

ion

al

con

seq

uen

ces”

Sw

allo

win

g di

fficu

ltyN

C-1

.1

Impa

ired

mov

emen

t of f

ood

and

liqui

d fr

om th

e m

outh

to th

e st

omac

h 70

Che

win

g (m

astic

ator

y) d

iffic

ulty

NC

-1.2

Im

paire

d ab

ility

to m

anip

ulat

e or

mas

ticat

e fo

od fo

r sw

allo

win

g 71

-73

Bre

astfe

edin

g di

fficu

ltyN

C-1

.3

Inab

ility

to s

usta

in n

utrit

ion

thro

ugh

brea

stfe

edin

g 74

-75

Alte

red

GI f

unct

ion

NC

-1.4

Cha

nges

in a

bilit

y to

dig

est o

r ab

sorb

nut

rient

s 76

-77

Cla

ss:

Bio

chem

ical

(2)

D

efin

ed a

s “c

han

ge

in c

apac

ity

to

met

abo

lize

nu

trie

nts

as

a re

sult

of

Edi

tion:

200

6 28

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

med

icat

ion

s, s

urg

ery,

or

as in

dic

ated

by

alte

red

lab

val

ues

” Impa

ired

nutr

ient

util

izat

ion

NC

-2.1

C

hang

es in

abi

lity

to a

bsor

b or

met

abol

ize

nutr

ient

s an

d bi

oact

ive

subs

tanc

es

78-7

9

Alte

red

nutr

ition

-rel

ated

labo

rato

ry v

alue

s N

C-2

.2C

hang

es in

abi

lity

to e

limin

ate

by-p

rodu

cts

of d

iges

tive

and

met

abol

ic p

roce

sses

80

-81

Foo

d m

edic

atio

n in

tera

ctio

nN

C-2

.3

Und

esira

ble/

harm

ful i

nter

actio

n(s)

bet

wee

n fo

od a

nd o

ver

the

coun

ter

(OT

C)

med

icat

ions

, pre

scrib

ed m

edic

atio

ns, h

erba

ls,

bota

nica

ls, a

nd/o

r di

etar

y su

pple

men

ts th

at d

imin

ishe

s,

enha

nces

, or

alte

rs e

ffect

of n

utrie

nts

and/

or m

edic

atio

ns

82-8

3

Cla

ss:

Wei

gh

t (3

) D

efin

ed a

s “c

hro

nic

wei

gh

t o

r ch

ang

ed

wei

gh

t st

atu

s w

hen

co

mp

ared

wit

h u

sual

or

des

ired

bo

dy

wei

gh

t”

Und

erw

eigh

tN

C-3

.1

Low

bod

y w

eigh

t com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or

reco

mm

enda

tions

84

-85

Invo

lunt

ary

wei

ght l

oss

NC

-3.2

Dec

reas

e in

bod

y w

eigh

t tha

t is

not p

lann

ed o

r de

sire

d 86

-87

Ove

rwei

ght/o

besi

tyN

C-3

.3

Incr

ease

d ad

ipos

ity c

ompa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

88

-89

Invo

lunt

ary

wei

ght g

ain

NC

-3.4

W

eigh

t gai

n ab

ove

that

whi

ch is

des

ired

or e

xpec

ted

90-9

1

DO

MA

IN:

BE

HA

VIO

RA

L-

EN

VIR

ON

ME

NT

AL

Defi

ned

as “

nu

trit

ion

al fi

nd

ing

s/p

rob

lem

s

iden

tifi

ed

th

at

rela

te t

o k

no

wle

dg

e,

att

itu

des/b

eliefs

, p

hys

ical en

vir

on

men

t, o

r

access t

o f

oo

d a

nd

fo

od

safe

ty”

NB

Cla

ss:

Kn

ow

led

ge

and

Bel

iefs

(1)

Edi

tion:

200

6 29

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

Def

ined

as

“act

ual

kn

ow

led

ge

and

bel

iefs

as

rep

ort

ed, o

bse

rved

, or

do

cum

ente

d”

Foo

d an

d nu

triti

on-r

elat

ed k

now

ledg

e de

ficit

NB

-1.1

In

com

plet

e or

inac

cura

te k

now

ledg

e ab

out f

ood,

nut

ritio

n or

nu

triti

on-r

elat

ed in

form

atio

n an

d gu

idel

ines

e.g

. nut

rient

re

quire

men

ts, c

onse

quen

ces

of fo

od b

ehav

iors

, life

sta

ge

requ

irem

ents

, nut

ritio

n re

com

men

datio

ns, d

isea

ses

and

cond

ition

s, p

hysi

olog

ical

func

tion,

or

prod

ucts

92-9

3

Har

mfu

l bel

iefs

/atti

tude

s ab

out f

ood

or

nutr

ition

-rel

ated

topi

csU

SE

WIT

H C

AU

TIO

N T

O B

E S

EN

SIT

IVE

TO

P

AT

IEN

T C

ON

CE

RN

S

NB

-1.2

Bel

iefs

/atti

tude

s an

d pr

actic

es a

bout

food

, nut

ritio

n, a

nd n

utrit

ion-

rela

ted

topi

cs th

at a

re in

com

patib

le w

ith s

ound

nut

ritio

n pr

inci

ples

, nut

ritio

n ca

re o

r di

seas

e/co

nditi

on

94-9

5

Not

rea

dy fo

r di

et/li

fest

yle

chan

geN

B-1

.3

Lack

of p

erce

ived

val

ue o

f nut

ritio

n-re

late

d ca

re b

enef

its

com

pare

d to

con

sequ

ence

s or

effo

rt r

equi

red

to m

akin

g th

e ch

ange

; inc

onsi

sten

cies

with

oth

er v

alue

str

uctu

re/p

urpo

se;

ante

cede

nt to

beh

avio

r ch

ange

96-9

7

Sel

f mon

itorin

g de

ficit

NB

-1.4

Lack

of d

ata

reco

rdin

g to

trac

k pe

rson

al p

rogr

ess

98-9

9

Dis

orde

red

eatin

g pa

ttern

NB

-1.5

Bel

iefs

, atti

tude

s, th

ough

ts a

nd b

ehav

iors

rel

ated

to fo

od, e

atin

g,

and

wei

ght m

anag

emen

t, in

clud

ing

clas

sic

eatin

g di

sord

ers

as

wel

l as

less

sev

ere,

sim

ilar

cond

ition

s th

at n

egat

ivel

y im

pact

he

alth

100-

102

Lim

ited

adhe

renc

e to

nut

ritio

n-re

late

d re

com

men

datio

nsN

B-1

.6La

ck o

f nut

ritio

n-re

late

d ch

ange

s as

per

inte

rven

tion

agre

ed u

pon

by c

lient

or

popu

latio

n 10

3-10

4

Und

esira

ble

food

cho

ices

NB

-1.7

F

ood

and/

or b

ever

age

choi

ces

that

are

inco

nsis

tent

with

US

R

ecom

men

ded

Die

tary

Inta

ke, U

S D

ieta

ry G

uide

lines

, or

with

the

Foo

d G

uide

Pyr

amid

or

with

targ

ets

defin

ed in

the

nutr

ition

pr

escr

iptio

n or

nut

ritio

n ca

re p

roce

ss

105-

106

Cla

ss:

Ph

ysic

al A

ctiv

ity

and

Fu

nct

ion

(2)

D

efin

ed a

s “a

ctu

al p

hys

ical

act

ivit

y, s

elf-

care

, an

d q

ual

ity

of

life

pro

ble

ms

as

Edi

tion:

200

6 30

NU

TR

ITIO

N D

IAG

NO

SIS

TE

RM

S A

ND

DE

FIN

ITIO

NS

rep

ort

ed, o

bse

rved

or

do

cum

ente

d”

Phy

sica

l ina

ctiv

ityN

B-2

.1Lo

w le

vel o

f act

ivity

/sed

enta

ry b

ehav

ior

to th

e ex

tent

that

it

redu

ces

ener

gy e

xpen

ditu

re a

nd im

pact

s he

alth

10

7-10

8

Exc

essi

ve e

xerc

ise

NB

-2.2

An

amou

nt o

f exe

rcis

e th

at e

xcee

ds th

at w

hich

is n

eces

sary

to

impr

ove

heal

th a

nd/o

r at

hlet

ic p

erfo

rman

ce

109-

110

Inab

ility

of l

ack

of d

esire

to m

anag

e se

lf ca

re

NB

-2.3

Lack

of c

apac

ity o

r un

will

ingn

ess

to im

plem

ent m

etho

ds to

su

ppor

t hea

lthfu

l foo

d an

d nu

triti

on-r

elat

ed b

ehav

ior

111-

112

Impa

ired

abili

ty to

pre

pare

food

s/m

eals

NB

-2.4

Cog

nitiv

e or

phy

sica

l im

pairm

ent t

hat p

reve

nts

prep

arat

ion

of

food

s/m

eals

11

3-11

4

Poo

r nu

triti

on q

ualit

y of

life

NB

-2.5

D

imin

ishe

d N

QO

L sc

ores

rel

ated

to fo

od im

pact

, sel

f-im

age,

ps

ycho

logi

cal f

acto

rs s

ocia

l/int

erpe

rson

al, p

hysi

cal,

or s

elf-

effic

acy

115-

116

Sel

f fee

ding

diff

icul

tyN

B-2

.6

Impa

ired

actio

ns to

pla

ce fo

od in

mou

th

117-

118

Cla

ss:

Fo

od

Saf

ety

and

Acc

ess

(3)

Def

ined

as

“act

ual

pro

ble

ms

wit

h f

oo

d

acce

ss o

r fo

od

saf

ety”

Inta

ke o

f uns

afe

food

NB

-3.1

Inta

ke o

f foo

d an

d/or

flui

ds in

tent

iona

lly o

r un

inte

ntio

nally

co

ntam

inat

ed w

ith to

xins

, poi

sono

us p

rodu

cts,

infe

ctio

us a

gent

s,

mic

robi

al a

gent

s, a

dditi

ves,

alle

rgen

s, a

nd/o

r ag

ents

of

biot

erro

rism

119-

120

Lim

ited

acce

ss to

food

NB

-3.2

Dim

inis

hed

abili

ty to

acq

uire

food

from

sou

rces

(e.

g. s

hopp

ing,

ga

rden

ing,

mea

l del

iver

y), d

ue to

fina

ncia

l con

stra

ints

, phy

sica

l im

pairm

ent,

care

give

r su

ppor

t, or

uns

afe

livin

g co

nditi

ons

(e.g

. cr

ime

hind

ers

trav

el to

gro

cery

sto

re).

Lim

itatio

n to

food

bec

ause

of

con

cern

s ab

out w

eigh

t or

agin

g.

121-

122

Edi

tion:

200

6 31

INTA

KE D

OMAI

N C

aloric

Ene

rgy B

alanc

e

HY

PE

RM

ET

AB

OL

ISM

(NI-

1.1)

De

fin

itio

n

Res

ting

met

abol

ic r

ate

(RM

R)

abov

e pr

edic

ted

requ

irem

ents

due

to s

tres

s, tr

aum

a, in

jury

, sep

sis,

or

dise

ase.

Not

e: R

MR

is th

e su

m o

f m

etab

olic

pro

cess

es o

f ac

tive

cell

mas

s re

late

d to

the

mai

nten

ance

of

norm

al b

ody

func

tions

and

reg

ulat

ory

bala

nce

duri

ng r

est.

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems:

Cat

abol

ic il

lnes

s

Infe

ctio

n

Seps

is

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a In

sulin

res

ista

nce

(dif

ficu

lt to

con

trol

blo

od g

luco

se)

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

min

atio

n F

indi

ngs

Feve

r

Incr

ease

d he

art r

ate

Incr

ease

d re

spir

ator

y ra

te

Mea

sure

d R

MR

> e

stim

ated

or

expe

cted

RM

R

Foo

d/N

utri

tion

His

tory

C

lient

His

tory

C

ondi

tions

ass

ocia

ted

with

a d

iagn

osis

or

trea

tmen

t of,

e.g

., A

IDS/

HIV

, bur

ns, c

hron

ic o

bstr

uctiv

e pu

lmon

ary

dise

ase,

hi

p/lo

ng b

one

frac

ture

, inf

ectio

n, s

urge

ry, t

raum

a, h

yper

thyr

oidi

sm (

pre-

or u

ntre

ated

), s

ome

canc

ers

(spe

cify

)

Med

icat

ions

ass

ocia

ted

with

R

MR

Edi

tion:

200

6 32

INTA

KE D

OMAI

N C

aloric

Ene

rgy B

alanc

e

HY

PE

RM

ET

AB

OL

ISM

(NI-

1.1)

Refe

ren

ces:

1.

Bitz

C, T

oubr

o S,

Lar

sen

TM

, Har

der

H, R

enni

e K

L, J

ebb

SA, A

stru

p A

. Inc

reas

ed 2

4 ho

ur e

nerg

y ex

pend

iture

in T

ype

2 di

abet

es m

ellit

us. D

iabe

tes

Car

e. 2

004;

27:2

416-

21.

2.

Dic

kers

on R

N, R

oth-

You

sey

L. M

edic

atio

n ef

fect

s on

met

abol

ic r

ate:

A s

yste

mat

ic r

evie

w. U

npub

lishe

d da

ta.

3.

Fran

kenf

ield

D, R

oth-

You

sey

L, C

omph

er C

. Com

pari

son

of p

redi

ctiv

e eq

uatio

ns to

mea

sure

d re

stin

g m

etab

olic

rat

e in

hea

lthy

nono

bese

and

obe

se in

divi

dual

s, a

sys

tem

atic

rev

iew

. In

pres

s

Edi

tion:

200

6 33

INTA

KE D

OMAI

N C

aloric

Ene

rgy B

alanc

e

INC

RE

AS

ED

EN

ER

GY

EX

PE

ND

ITU

RE

(N

I-1.

2)

De

fin

itio

n

Res

ting

met

abol

ic r

ate

(RM

R)

abov

e pr

edic

ted

requ

irem

ents

due

to b

ody

com

posi

tion,

med

icat

ions

, end

ocri

ne, n

euro

logi

c, o

r ge

netic

cha

nges

. Not

e: R

MR

is th

e su

m o

f m

etab

olic

pro

cess

es o

f ac

tive

cell

mas

s re

late

d to

the

mai

nten

ance

of

norm

al b

ody

func

tions

and

reg

ulat

ory

bala

nce

duri

ng r

est.

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems:

Ana

bolis

m o

r gr

owth

Vol

unta

ry o

r in

volu

ntar

y ph

ysic

al a

ctiv

ity/m

ovem

ent

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Uni

nten

tiona

l wei

ght l

oss

of 1

0% in

6 m

onth

s, 5

% in

1 m

onth

Evi

denc

e of

nee

d fo

r ac

cele

rate

d or

cat

ch u

p gr

owth

or

wei

ght g

ain

in c

hild

ren;

abs

ence

of

norm

al g

row

th

Incr

ease

d pr

opor

tiona

l lea

n bo

dy m

ass

Phy

sica

l Exa

min

atio

n F

indi

ngs

Mea

sure

d R

MR

> e

stim

ated

or

expe

cted

RM

R

Foo

d/N

utri

tion

His

tory

In

crea

sed

phys

ical

act

ivity

, e.g

., en

dura

nce

athl

ete

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

Park

inso

n’s

dise

ase,

cer

ebra

l pal

sy, A

lzhe

imer

’s d

isea

se, o

ther

de

men

tia

Refe

ren

ces:

1.

Fran

kenf

ield

D, R

oth-

You

sey

L, C

omph

er C

. Com

pari

son

of p

redi

ctiv

e eq

uatio

ns to

mea

sure

d re

stin

g m

etab

olic

rat

e in

hea

lthy

nono

bese

and

obe

se in

divi

dual

s, a

sys

tem

atic

rev

iew

. In

pres

s.

Edi

tion:

200

6 34

INTA

KE D

OMAI

N C

aloric

Ene

rgy B

alanc

e

HY

PO

ME

TA

BO

LIS

M(N

I-1.

3)

De

fin

itio

n

Res

ting

met

abol

ic r

ate

(RM

R)

belo

w p

redi

cted

req

uire

men

ts d

ue to

bod

y co

mpo

sitio

n, m

edic

atio

ns, e

ndoc

rine

, neu

rolo

gic,

or

gene

tic c

hang

es

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems:

Los

s of

lean

bod

y m

ass,

wei

ght l

oss

Med

icat

ions

, e.g

., m

idaz

olam

, pro

pran

alol

, glip

izid

e

End

ocri

ne c

hang

es, e

.g.,

hypo

thyr

oidi

sm

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a In

crea

sed

TSH

, dec

reas

ed T

4, T

3 (h

ypot

hyro

idis

m)

Ant

hrop

omet

ric

Dat

a D

ecre

ased

wei

ght o

r m

id-a

rm m

uscl

e ci

rcum

fere

nce

Wei

ght g

ain

(e.

g., h

ypot

hyro

idis

m)

Gro

wth

stu

ntin

g or

fai

lure

, bas

ed o

n N

atio

nal C

ente

r fo

r H

ealth

Sta

tistic

s (N

CH

S) g

row

th s

tand

ards

Phy

sica

l Exa

m F

indi

ngs

Dec

reas

ed o

r no

rmal

adi

pose

and

som

atic

pro

tein

sto

res

Mea

sure

d R

MR

< e

stim

ated

or

expe

cted

RM

R

Foo

d/N

utri

tion

His

tory

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

hypo

thyr

oidi

sm, a

nore

xia

nerv

osa,

mal

nutr

ition

, fai

lure

to

thri

ve, P

rade

r-W

illi s

yndr

ome,

hyp

oton

ic c

ondi

tions

Bra

dyca

rdia

, hyp

oten

sion

, de

crea

sed

bow

l mot

ility

, slo

w b

reat

hing

rat

e, lo

w b

ody

tem

pera

ture

(in

sig

nifi

cant

wei

ght l

oss)

Col

d in

tole

ranc

e, h

air

loss

, dec

reas

ed e

ndur

ance

, dif

ficu

lty c

once

ntra

ting,

dec

reas

ed li

bido

, fee

lings

of

anxi

ety/

depr

essi

on

Edi

tion:

200

6 35

INTA

KE D

OMAI

N C

aloric

Ene

rgy B

alanc

e

HY

PO

ME

TA

BO

LIS

M(N

I-1.

3)

Refe

ren

ces:

1.

Bro

zek

J. S

tarv

atio

n an

d nu

triti

onal

reh

abili

tatio

n; a

qua

ntita

tive

case

stu

dy. J

Am

Die

t Ass

oc. 1

952;

28:9

17-9

26.

2.

Col

lins

S. U

sing

mid

dle

uppe

r ar

m c

ircu

mfe

renc

e to

ass

ess

seve

re a

dult

mal

nutr

ition

dur

ing

fam

ine.

JA

MA

. 199

6;27

6:39

1-39

5.

3.

Det

zer

MJ,

Lei

tenb

erg

H, P

oehl

man

ET

, Ros

en J

C, S

ilber

g N

T, V

ara

LS.

Res

ting

met

abol

ic r

ate

in w

omen

with

bul

imia

ner

vosa

: a c

ross

sec

tiona

l and

trea

tmen

t stu

dy. A

m J

Clin

Nut

r.19

94;6

0:32

7-33

2.4.

D

icke

rson

RN

, Rot

h-Y

ouse

y L

. Med

icat

ion

effe

cts

on m

etab

olic

rat

e: A

sys

tem

atic

rev

iew

. Unp

ublis

hed

data

. 5.

Fr

anke

nfie

ld D

, Rot

h-Y

ouse

y L

, Com

pher

C. C

ompa

riso

n of

pre

dict

ive

equa

tions

to m

easu

red

rest

ing

met

abol

ic r

ate

in h

ealth

y no

nobe

se a

nd o

bese

indi

vidu

als,

a s

yste

mat

ic r

evie

w. I

n pr

ess.

6.

Ker

ruis

h K

P, O

’Con

ner

JO, H

umph

ries

IR

J, K

ohn

MR

, Cla

rke

SD, B

riod

y JN

, Tho

mso

n E

J, W

righ

t KA

, Gas

kin

KJ,

Bau

r L

A. B

ody

com

posi

tion

in a

dole

scen

ts w

ith a

nore

xia

nerv

osa.

Am

J C

lin

Nut

r. 2

002;

75:3

1-37

. 7.

M

ollin

ger

LA

, Spu

rr G

B, e

l Gha

til A

Z, B

arbo

riak

JS,

Roo

ney

CB

, Dav

idof

f D

D. D

aily

ene

rgy

expe

nditu

re a

nd b

asil

met

abol

ic r

ates

of

patie

nts

with

spi

nal c

ord

inju

ry. A

rch

Phy

s M

ed R

ehab

il.19

85;6

6:42

0-42

6.

8.

Oba

rzan

ek E

, Les

em M

D, J

imer

son

DC

. Res

ting

met

abol

ic r

ate

of a

nore

xia

nerv

osa

patie

nts

duri

ng w

eigh

t gai

n. A

m J

Clin

Nut

r. 1

994;

60:6

66-6

75.

9.

Pavl

ovic

M, Z

aval

ic M

, Cor

ovic

N, S

tilin

ovic

L, M

alin

ar M

. Los

s of

bod

y m

ass

in e

x pr

ison

ers

of w

ar. E

ur J

Cli

n N

utr.

199

3;47

:808

-814

.

Edi

tion:

200

6 36

INTA

KE D

OMAI

N C

aloric

Ene

rgy B

alanc

e

INA

DE

QU

AT

E E

NE

RG

Y I

NT

AK

E (

NI-

1.4)

De

fin

itio

n

Ene

rgy

inta

ke th

at is

less

than

ene

rgy

expe

nditu

re, e

stab

lishe

d re

fere

nce

stan

dard

s, o

r re

com

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

Exc

eptio

n: w

hen

the

goal

is w

eigh

t los

s or

dur

ing

end

of li

fe c

are.

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems:

Path

olog

ic o

r ph

ysio

logi

c ca

uses

whi

ch r

esul

t in

incr

ease

d en

ergy

req

uire

men

ts o

r de

crea

sed

abili

ty to

con

sum

e st

uffi

ness

ene

rgy,

e.g

., in

crea

sed

nutr

ient

ne

eds

due

to p

rolo

nged

cat

abol

ic il

lnes

s

Lac

k of

acc

ess

to f

ood

or a

rtif

icia

l nut

ritio

n, e

.g. e

cono

mic

con

stra

ints

, cul

tura

l or

relig

ious

pra

ctic

es r

estr

ictin

g fo

od g

iven

to e

lder

ly a

nd/o

r ch

ildre

n

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or d

isor

dere

d ea

ting

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a C

hol

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

min

atio

n F

indi

ngs

Wei

ght l

oss

Poor

den

titio

n

Edi

tion:

200

6 37

INTA

KE D

OMAI

N C

aloric

Ene

rgy B

alanc

e

INA

DE

QU

AT

E E

NE

RG

Y I

NT

AK

E (

NI-

1.4)

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Insu

ffic

ient

ene

rgy

inta

ke f

rom

die

t com

pare

d to

nee

ds b

ased

on

estim

ated

or

mea

sure

d re

stin

g m

etab

olic

rat

e

Res

tric

tion

or o

mis

sion

of

ener

gy d

ense

foo

ds f

rom

die

t

Food

avo

idan

ce a

nd/o

r la

ck o

f in

tere

st in

foo

d

Inab

ility

to in

depe

nden

tly c

onsu

me

food

s/fl

uids

(di

min

ishe

d jo

int m

obili

ty o

f w

rist

, ha

nd, o

r di

gits

)

Pare

nter

al o

r en

tera

l nut

ritio

n in

suff

icie

nt to

mee

t nee

ds b

ased

on

estim

ated

or

mea

sure

d re

stin

g m

etab

olic

rat

e

Clie

nt H

isto

ry

Exc

essi

ve c

onsu

mpt

ion

of a

lcoh

ol o

r ot

her

drug

s th

at r

educ

e hu

nger

Refe

ren

ces:

1 N

atio

nal A

cade

my

of S

cien

ces,

Ins

titut

e of

Med

icin

e. D

ieta

ry R

efer

ence

Int

akes

for

Ene

rgy,

Car

bohy

drat

e, F

iber

, Fat

, Fat

ty A

cids

, Cho

lest

erol

, Pro

tein

, and

Am

ino

Aci

ds. W

ashi

ngto

n, D

C:

Nat

iona

l Aca

dem

y Pr

ess;

200

2.

Edi

tion:

200

6 38

INTA

KE D

OMAI

N C

aloric

Ene

rgy B

alanc

e

EX

CE

SS

IVE

EN

ER

GY

IN

TA

KE

(N

I-1.

5)

De

fin

itio

n

Cal

oric

inta

ke th

at e

xcee

ds e

nerg

y ex

pend

iture

, est

ablis

hed

refe

renc

e st

anda

rds,

or

reco

mm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds. E

xcep

tion:

whe

n w

eigh

t ga

in is

des

ired

.

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems:

Har

mfu

l bel

iefs

/atti

tude

s ab

out f

ood,

nut

ritio

n, a

nd n

utri

tion-

rela

ted

topi

cs

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Lac

k of

acc

ess

to h

ealth

ful f

ood

choi

ces,

e.g

., fo

od p

rovi

ded

by c

areg

iver

, ped

iatr

ics,

hom

eles

s

Lac

k of

val

ue f

or b

ehav

ior

chan

ge, c

ompe

ting

valu

es

Men

tal i

llnes

s, d

epre

ssio

n

Med

icat

ions

that

incr

ease

app

etite

, e.g

. ste

roid

s

Ove

rfee

ding

of

pare

nter

al/e

nter

al n

utri

tion

(TPN

/EN

)

Unw

illin

g or

uni

nter

este

d in

red

ucin

g en

ergy

inta

ke

Failu

re to

adj

ust f

or li

fest

yle

chan

ges

and

decr

ease

d m

etab

olis

m (

e.g.

agi

ng)

Res

olut

ion

of p

rior

hyp

erm

etab

olis

m w

ithou

t red

uctio

n in

inta

ke

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Edi

tion:

200

6 39

INTA

KE D

OMAI

N C

aloric

Ene

rgy B

alanc

e

EX

CE

SS

IVE

EN

ER

GY

IN

TA

KE

(N

I-1.

5)Nu

tritio

n As

sess

men

t Cat

egor

y Po

tent

ial In

dica

tors

of t

his N

utrit

ion

Diag

nosis

(one

or m

ore m

ust b

e pre

sent

) B

ioch

emic

al D

ata

Ove

rfee

ding

of

TPN

/EN

(us

ually

see

n ea

rly

afte

r in

itiat

ion

of f

eedi

ng):

Hyp

ergl

ycem

ia

Hyp

okal

emia

< 3

.5 m

Eq/

l

Hyp

opho

spha

tem

ia <

1.0

mE

q/l

Abn

orm

al li

ver

func

tion

test

s

Ant

hrop

omet

ric

Mea

sure

men

ts

Bod

y fa

t per

cent

age

>25%

for

men

and

> 3

2% f

or w

omen

BM

I >

25

Wei

ght g

ain

Phy

sica

l Exa

m F

indi

ngs

Incr

ease

d bo

dy a

dipo

sity

Ove

rfee

ding

TPN

/EN

:

Incr

ease

d re

spir

atio

ns

Foo

d/N

utri

tion

His

tory

O

bser

vatio

ns o

r re

port

s of

inta

ke o

f hi

gh c

alor

ic d

ensi

ty o

r la

rge

port

ions

of

food

s/be

vera

ges

Obs

erva

tions

, rep

orts

or

calc

ulat

ion

of T

PN/E

N a

bove

est

imat

ed o

r m

easu

red

(e.g

., in

dire

ct c

alor

imet

ry)

calo

ric

expe

nditu

re

Met

abol

ic c

art/i

ndir

ect c

alor

imet

ry m

easu

rem

ent,

e.g.

, res

pira

tory

quo

tient

>1.

0

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

obes

ity, o

verw

eigh

t, m

etab

olic

syn

drom

e, d

epre

ssio

n, o

r an

xiet

y di

sord

er

Refe

ren

ces:

1.

McC

lave

SA

, Low

en C

C, K

lebe

r M

J, M

cCon

nell

JW, J

ung

LY

, Gol

dsm

ith L

J. C

linic

al u

se o

f th

e re

spir

ator

y qu

otie

nt o

btai

ned

from

indi

rect

cal

orim

etry

. J P

aren

ter

Ent

eral

Nut

r. 2

003;

27:2

1-26

. 2.

M

cCla

ve S

A, L

owen

CC

, Kle

ber

MJ,

Nic

hols

on J

F, J

imm

erso

n SC

, McC

onne

ll JW

, Jun

g L

Y. A

re p

atie

nts

fed

appr

opri

atel

y ac

cord

ing

to th

eir

calo

ric

requ

irem

ents

? J

Par

ente

r E

nter

al N

utr.

1998

;22:

375-

381.

3.

O

verw

eigh

t and

Obe

sity

: Hea

lth C

onse

quen

ces.

ww

w.s

urge

onge

nera

l.gov

/topi

cs/o

besi

ty/c

allto

actio

n/fa

ct_c

onse

quen

ces.

htm

. Acc

esse

d A

ugus

t 28,

200

4.

Edi

tion:

200

6 40

INTA

KE D

OMAI

N O

ral o

r Nut

ritio

n Su

ppor

t Int

ake

INA

DE

QU

AT

E O

RA

L F

OO

D/B

EV

ER

AG

E I

NT

AK

E (

NI-

2.1)

De

fin

itio

n

Ora

l foo

d/be

vera

ge in

take

that

is le

ss th

an e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds. E

xcep

tion:

whe

n th

e go

al is

w

eigh

t los

s or

dur

ing

end

of li

fe c

are.

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems:

Phys

iolo

gic

caus

es, e

.g. i

ncre

ased

nut

rien

t nee

ds d

ue to

pro

long

ed c

atab

olic

illn

ess

Lac

k of

acc

ess

to f

ood,

e.g

. eco

nom

ic c

onst

rain

ts, c

ultu

ral o

r re

ligio

us p

ract

ices

, res

tric

ting

food

giv

en to

eld

erly

and

/or

child

ren

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit c

once

rnin

g su

ffic

ient

ora

l foo

d/be

vera

ge in

take

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or d

isor

dere

d ea

ting

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

min

atio

n F

indi

ngs

Dry

ski

n, m

ucou

s m

embr

anes

, poo

r sk

in tu

rgor

Wei

ght l

oss,

insu

ffic

ient

gro

wth

vel

ocity

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Insu

ffic

ient

inta

ke o

f en

ergy

or

high

qua

lity

prot

ein

from

die

t whe

n co

mpa

red

to r

equi

rem

ents

Eco

nom

ic c

onst

rain

ts th

at li

mit

food

ava

ilabi

lity

Edi

tion:

200

6 41

INTA

KE D

OMAI

N O

ral o

r Nut

ritio

n Su

ppor

t Int

ake

INA

DE

QU

AT

E O

RA

L F

OO

D/B

EV

ER

AG

E I

NT

AK

E (

NI-

2.1)

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f c

atab

olic

illn

ess

such

as

AID

S, tu

berc

ulos

is, a

nore

xia

nerv

osa,

se

psis

or

infe

ctio

n fr

om r

ecen

t sur

gery

), d

epre

ssio

n, a

cute

or

chro

nic

pain

Prot

ein

and/

or n

utri

ent m

alab

sorp

tion

Exc

essi

ve c

onsu

mpt

ion

of a

lcoh

ol o

r ot

her

drug

s th

at r

educ

e hu

nger

Med

icat

ions

that

cau

se a

nore

xia

Refe

ren

ces:

1.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r E

nerg

y, C

arbo

hydr

ate,

Fib

er, F

at, F

atty

Aci

ds, C

hole

ster

ol, P

rote

in, a

nd A

min

o A

cids

. Was

hing

ton,

DC

: N

atio

nal A

cade

my

Pres

s; 2

002.

2.

N

atio

nal A

cade

my

of S

cien

ces,

Ins

titut

e of

Med

icin

e. D

ieta

ry R

efer

ence

Int

akes

for

Wat

er, P

otas

sium

, Sod

ium

, Chl

orid

e, a

nd S

ulfa

te. W

ashi

ngto

n, D

C: N

atio

nal A

cade

my

Pres

s; 2

002.

Edi

tion:

200

6 42

INTA

KE D

OMAI

N O

ral o

r Nut

ritio

n Su

ppor

t Int

ake

EX

CE

SS

IVE

OR

AL

FO

OD

/BE

VE

RA

GE

IN

TA

KE

(N

I-2.

2)

De

fin

itio

n

Ora

l foo

d/be

vera

ge in

take

that

exc

eeds

ene

rgy

expe

nditu

re, e

stab

lishe

d re

fere

nce

stan

dard

s, o

r re

com

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

. E

xcep

tion:

w

hen

wei

ght g

ain

is d

esir

ed.

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems:

Har

mfu

l bel

iefs

/atti

tude

s ab

out f

ood,

nut

ritio

n, a

nd n

utri

tion-

rela

ted

topi

cs

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Lac

k of

acc

ess

to h

ealth

ful f

ood

choi

ces,

e.g

., fo

od p

rovi

ded

by c

areg

iver

, ped

iatr

ics,

hom

eles

s

Lac

k of

val

ue f

or b

ehav

ior

chan

ge, c

ompe

ting

valu

es

Inab

ility

to li

mit

or r

efus

e of

fere

d fo

ods

Lac

k of

foo

d pl

anni

ng, p

urch

asin

g, a

nd p

repa

ratio

n sk

ills

Los

s of

app

etite

aw

aren

ess

Med

icat

ions

that

incr

ease

app

etite

, e.g

. ste

roid

s, a

ntid

epre

ssan

ts

Unw

illin

g or

uni

nter

este

d in

red

ucin

g in

take

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a V

aria

ble

high

blo

od g

luco

se le

vels

Abn

orm

al H

gb A

1C

Ant

hrop

omet

ric

Mea

sure

men

ts

Wei

ght g

ain

not a

ttrib

uted

to f

luid

ret

entio

n or

nor

mal

gro

wth

Phy

sica

l Exa

m F

indi

ngs

Evi

denc

e of

aca

ntho

sis

nigr

ican

s

Edi

tion:

200

6 43

INTA

KE D

OMAI

N O

ral o

r Nut

ritio

n Su

ppor

t Int

ake

EX

CE

SS

IVE

OR

AL

FO

OD

/BE

VE

RA

GE

IN

TA

KE

(N

I-2.

2)F

ood/

Nut

ritio

n H

isto

ry

Rep

orts

or

obse

rvat

ions

of:

Inta

ke o

f hi

gh c

alor

ic d

ensi

ty f

oods

/bev

erag

es (

juic

e, s

oda,

or

alco

hol)

at m

eals

and

/or

snac

ks

Inta

ke o

f la

rge

port

ions

of

food

s/be

vera

ges,

foo

d gr

oups

, or

spec

ific

foo

d ite

ms

Inta

ke th

at e

xcee

ds e

stim

ated

or

mea

sure

d en

ergy

nee

ds

Hig

hly

vari

able

dai

ly c

alor

ic in

take

Bin

ge e

atin

g pa

ttern

s

Freq

uent

, exc

essi

ve f

ast f

ood

or r

esta

uran

t int

ake

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

obes

ity, o

verw

eigh

t, or

met

abol

ic s

yndr

ome,

dep

ress

ion,

an

xiet

y di

sord

er

Res

ting

met

abol

ic r

ate

mea

sure

men

t ref

lect

ing

exce

ss in

take

, e.g

., re

spir

ator

y qu

otie

nt >

1.0

Refe

ren

ces:

1.

Ove

rwei

ght a

nd O

besi

ty: H

ealth

Con

sequ

ence

s. w

ww

.sur

geon

gene

ral.g

ov/to

pics

/obe

sity

/cal

ltoac

tion/

fact

_con

sequ

ence

s.ht

m. A

cces

sed

Aug

ust 2

8, 2

004.

Posi

tion

of th

e A

mer

ican

Die

tetic

A

ssoc

iatio

n: W

eigh

t man

agem

ent.

J A

m D

iet A

ssoc

. 200

2;10

2:11

45-1

155.

2.

Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: T

otal

die

t app

roac

h to

com

mun

icat

ing

food

and

nut

ritio

n in

form

atio

n. J

Am

Die

t Ass

oc 2

002;

102:

100-

108.

3.

Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: T

he r

ole

of d

iete

tics

prof

essi

onal

s in

hea

lth p

rom

otio

n an

d di

seas

e pr

even

tion.

J A

m D

iet A

ssoc

. 200

2;10

2:16

80-1

687.

Edi

tion:

200

6 44

INTA

KE D

OMAI

N O

ral o

r Nut

ritio

n Su

ppor

t Int

ake

INA

DE

QU

AT

E I

NT

AK

E F

RO

M E

NT

ER

AL

/PA

RE

NT

ER

AL

(E

N/T

PN

) N

UT

RIT

ION

IN

FU

SIO

N (

NI-

2.3)

De

fin

itio

n

Ent

eral

or

pare

nter

al in

fusi

on th

at p

rovi

des

few

er c

alor

ies

or n

utri

ents

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal

need

s. E

xcep

tion:

whe

n th

e go

al is

wei

ght l

oss

or d

urin

g en

d of

life

car

e.

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Alte

red

abso

rptio

n or

met

abol

ism

of

nutr

ient

s, e

.g.,

med

icat

ions

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit (

patie

nt/c

lient

, car

egiv

er, s

uppl

ier)

-- in

corr

ect f

orm

ula/

form

ulat

ion

give

n, e

.g.,

wro

ng e

nter

al f

eedi

ng, m

issi

ng

com

pone

nt o

f T

PN

Lac

k of

, com

prom

ised

, or

inco

rrec

t acc

ess

for

deliv

erin

g E

N/T

PN

Incr

ease

d bi

olog

ical

dem

and

of n

utri

ents

, e.g

., ac

cele

rate

d gr

owth

, wou

nd h

ealin

g, c

hron

ic in

fect

ion,

mul

tiple

fra

ctur

es

Into

lera

nce

of E

N/T

PN

Infu

sion

vol

ume

not r

each

ed o

r sc

hedu

le f

or in

fusi

on in

terr

upte

d

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a C

hole

ster

ol <

160

mg/

dL

Vita

min

/min

eral

abn

orm

aliti

es

Cal

cium

< 9

.2 m

g/dL

Vita

min

K--

Prol

onge

d pr

othr

ombi

n tim

e (P

T),

par

tial t

hrom

bopl

astin

tim

e (P

TT

)

Cop

per

< 70

µg/

dL

Zin

c <

12 µ

mol

/L

Iron

< 5

0 µ

g/dL

; iro

n bi

ndin

g ca

paci

ty <

250

µg/

dL

Edi

tion:

200

6 45

INTA

KE D

OMAI

N O

ral o

r Nut

ritio

n Su

ppor

t Int

ake

INA

DE

QU

AT

E I

NT

AK

E F

RO

M E

NT

ER

AL

/PA

RE

NT

ER

AL

(E

N/T

PN

) N

UT

RIT

ION

IN

FU

SIO

N (

NI-

2.3)

Ant

hrop

omet

ric

Mea

sure

men

ts

Gro

wth

fai

lure

, bas

ed o

n N

atio

nal C

ente

r fo

r H

ealth

Sta

tistic

s (N

CH

S) g

row

th s

tand

ards

and

fet

al g

row

th f

ailu

re

Insu

ffic

ient

mat

erna

l wei

ght g

ain

Lac

k of

pla

nned

wei

ght g

ain

Uni

nten

tiona

l wei

ght l

oss

of 5

% in

1 m

onth

or

10%

in 6

mon

ths

(not

attr

ibut

ed to

flu

id)

in a

dults

A

ny w

eigh

t los

s in

infa

nts

and

child

ren

Und

erw

eigh

t (B

MI

<18

.5)

Phy

sica

l Exa

m F

indi

ngs

Clin

ical

evi

denc

e of

vita

min

/min

eral

def

icie

ncy

(e.g

., ha

ir lo

ss, b

leed

ing

gum

s, p

ale

nail

beds

, neu

rolo

gic

chan

ges)

E

vide

nce

of d

ehyd

ratio

n, e

.g.,

dry

muc

ous

mem

bran

es, p

oor

skin

turg

or

Los

s of

ski

n in

tegr

ity o

r de

laye

d w

ound

hea

ling

Los

s of

mus

cle

mas

s an

d/or

sub

cuta

neou

s fa

t N

ause

a, v

omiti

ng, d

iarr

hea

Foo

d/N

utri

tion

His

tory

O

bser

vatio

n or

rep

orts

of:

In

adeq

uate

EN

/TPN

vol

ume

com

pare

d to

est

imat

ed o

r m

easu

red

(ind

irec

t cal

orim

etry

) r

equi

rem

ents

M

etab

olic

car

t/ind

irec

t cal

orim

etry

mea

sure

men

t, e.

g., r

espi

rato

ry q

uotie

nt <

0.7

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

inte

stin

al r

esec

tion,

Cro

hn’s

dis

ease

, HIV

/AID

S, b

urns

, de

cubi

tus

ulce

rs, p

re-t

erm

bir

th, m

alnu

triti

on

Feed

ing

tube

or

veno

us a

cces

s in

wro

ng p

ositi

on o

r re

mov

ed

Alte

red

capa

city

for

des

ired

leve

ls o

f ph

ysic

al a

ctiv

ity o

r ex

erci

se, e

asy

fatig

ue w

ith in

crea

sed

activ

ity

Refe

ren

ces:

1.

McC

lave

SA

, Spa

in D

A, S

koln

ick

JL, L

owen

CC

, Kie

ber

MJ,

Wic

kerh

am P

S, V

ogt J

R, L

oone

y SW

. Ach

ieve

men

t of

stea

dy s

tate

opt

imiz

es r

esul

ts w

hen

perf

orm

ing

indi

rect

cal

orim

etry

. JP

aren

ter

Ent

eral

Nut

r. 2

003;

27:1

6-20

. 2.

M

cCla

ve S

A, L

owen

CC

, Kle

ber

MJ,

McC

onne

ll JW

, Jun

g L

Y, G

olds

mith

LJ.

Clin

ical

use

of

the

resp

irat

ory

quot

ient

obt

aine

d fr

om in

dire

ct c

alor

imet

ry. J

Par

ente

r E

nter

al N

utr.

200

3;27

:21-

26.

3.

McC

lave

SA

, Sni

der

HL

. Clin

ical

use

of

gast

ric

resi

dual

vol

umes

as

a m

onito

r fo

r pa

tient

s on

ent

eral

tube

fee

ding

. J P

aren

ter

Ent

eral

Nut

r. 2

002;

26(S

uppl

):S4

3-48

; dis

cuss

ion

S49-

S50.

4.

M

cCla

ve S

A, D

eMeo

MT

, DeL

egge

MH

, DiS

ario

JA

, Hey

land

DK

, Mal

oney

JP,

Met

heny

NA

, Moo

re F

A, S

cola

pio

JS, S

pain

DA

, Zal

oga

GP

. Nor

th A

mer

ican

Sum

mit

on A

spir

atio

n in

the

Cri

tical

ly I

ll Pa

tient

: con

sens

us s

tate

men

t. J

Par

ente

r E

nter

al N

utr.

200

2;26

(Sup

pl):

S80-

S85.

5.

M

cCla

ve S

A, M

cCla

in C

J, S

nide

r H

L. S

houl

d in

dire

ct c

alor

imet

ry b

e us

ed a

s pa

rt o

f nu

triti

onal

ass

essm

ent?

J C

lin G

astr

oent

erol

. 200

1;33

:14-

19.

6.

M

cCla

ve S

A, S

exto

n L

K, S

pain

DA

, Ada

ms

JL, O

wen

s N

A, S

ullin

s M

B, B

land

ford

BS,

Sni

der

HL

. Ent

eral

tube

fee

ding

in th

e in

tens

ive

care

uni

t: fa

ctor

s im

pedi

ng a

dequ

ate

deliv

ery.

Cri

t Car

e M

ed. 1

999;

27:1

252-

1256

. 7.

M

cCla

ve S

A, L

owen

CC

, Kle

ber

MJ,

Nic

hols

on J

F, J

imm

erso

n SC

, McC

onne

ll JW

, Jun

g L

Y. A

re p

atie

nts

fed

appr

opri

atel

y ac

cord

ing

to th

eir

calo

ric

requ

irem

ents

? J

Par

ente

r E

nter

al N

utr.

1998

;22:

375-

381.

8.

Sp

ain

DA

, McC

lave

SA

, Sex

ton

LK

, Ada

ms

JL, B

lanf

ord

BS,

Sul

lins

ME

, Ow

ens

NA

, Sni

der

HL

. Inf

usio

n pr

otoc

ol im

prov

es d

eliv

ery

of e

nter

al tu

be f

eedi

ng in

the

crit

ical

car

e un

it. J

Par

ente

r E

nter

al N

utr.

199

9;23

:288

-292

.

Edi

tion:

200

6 46

INTA

KE D

OMAI

N O

ral o

r Nut

ritio

n Su

ppor

t Int

ake

EX

CE

SS

IVE

IN

TA

KE

FR

OM

EN

TE

RA

L O

R P

AR

EN

TE

RA

L N

UT

RIT

ION

(N

I-2.

4)

De

fin

itio

n

Ent

eral

or

pare

nter

al in

fusi

on th

at p

rovi

des

mor

e ca

lori

es o

r nu

trie

nts

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal

need

s.

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Phys

iolo

gic

caus

es, e

.g. d

ecre

ased

nee

ds r

elat

ed to

low

act

ivity

leve

ls w

ith c

ritic

al il

lnes

s or

org

an f

ailu

re

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit o

n th

e pa

rt o

f th

e ca

regi

ver,

pat

ient

/clie

nt o

r cl

inic

ian

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a E

leva

ted

BU

N:c

reat

inin

e ra

tio (

prot

ein)

Hyp

ergl

ycem

ia (

carb

ohyd

rate

)

Hyp

erca

pnia

Ele

vate

d liv

er e

nzym

es

Ant

hrop

omet

ric

Mea

sure

men

ts

Wei

ght g

ain

in e

xces

s of

lean

tiss

ue a

ccre

tion

Phy

sica

l Exa

min

atio

n F

indi

ngs

Ede

ma

with

exc

ess

flui

d ad

min

istr

atio

n

Foo

d/N

utri

tion

His

tory

R

epor

t or

obse

rvat

ion

of

Doc

umen

ted

inta

ke f

rom

ent

eral

or

pare

nter

al n

utri

ents

that

is c

onsi

sten

tly a

bove

rec

omm

ende

d in

take

for

car

bohy

drat

e,

prot

ein,

and

fat

(e.

g.36

Kca

l/kg

for

wel

l, ac

tive

adul

ts, 2

5 K

cal/k

g or

as

mea

sure

d by

indi

rect

cal

orim

etry

for

cri

tical

ly

ill a

dults

, 0.8

g/k

g pr

otei

n fo

r w

ell a

dults

, 1.5

g/k

g pr

otei

n fo

r cr

itica

lly il

l adu

lts, 4

mg/

kg/m

inut

e of

dex

tros

e fo

r cr

itica

lly il

l adu

lts, 1

.2 g

/kg

lipid

for

adu

lts, o

r 3

gm/k

g fo

r ch

ildre

n)

Edi

tion:

200

6 47

INTA

KE D

OMAI

N O

ral o

r Nut

ritio

n Su

ppor

t Int

ake

EX

CE

SS

IVE

IN

TA

KE

FR

OM

EN

TE

RA

L O

R P

AR

EN

TE

RA

L N

UT

RIT

ION

(N

I-2.

4)C

lient

His

tory

U

se o

f dr

ugs

that

red

uce

requ

irem

ents

or

impa

ir m

etab

olis

m o

f en

ergy

, pro

tein

, fat

or

flui

d.

Unr

ealis

tic e

xpec

tatio

ns o

f w

eigh

t gai

n or

idea

l wei

ght

Rec

eivi

ng s

igni

fica

nt c

alor

ie in

take

fro

m li

pid

or d

extr

ose

infu

sion

s, o

r pe

rito

neal

dia

lysi

s or

in a

ssoc

iatio

n w

ith o

ther

m

edic

al tr

eatm

ents

Refe

ren

ces:

1.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r E

nerg

y, C

arbo

hydr

ate,

Fib

er, F

at, F

atty

Aci

ds, C

hole

ster

ol, P

rote

in, a

nd A

min

o A

cids

. Was

hing

ton,

DC

: N

atio

nal A

cade

my

Pres

s, 2

002.

2.

N

atio

nal A

cade

my

of S

cien

ces,

Ins

titut

e of

Med

icin

e. D

ieta

ry R

efer

ence

Int

akes

for

Wat

er, P

otas

sium

, Sod

ium

, Chl

orid

e, a

nd S

ulfa

te. W

ashi

ngto

n, D

C: N

atio

nal A

cade

my

Pres

s, 2

004.

3.

A

arsl

and

A, C

hink

es D

, Wol

fe R

R. H

epat

ic a

nd w

hole

-bod

y fa

t syn

thes

is in

hum

ans

duri

ng c

arbo

hydr

ate

over

feed

ing.

Am

J C

lin N

utr.

199

7;65

:177

4-17

82.

4.

McC

lave

SA

, Low

en C

C, K

lebe

r M

J, e

t al.

Are

pat

ient

s fe

d ap

prop

riat

ely

acco

rdin

g to

thei

r ca

lori

c re

quir

emen

ts?

J P

aren

Ent

er N

utr.

199

8;22

:375

-381

. 5.

M

cCla

ve S

A, L

owen

CC

, Kle

ber

MJ,

McC

onne

ll JW

, Jun

g L

Y, G

olds

mith

LJ.

Clin

ical

use

of

the

resp

irat

ory

quot

ient

obt

aine

d fr

om in

dire

ct c

alor

imet

ry. J

Par

en E

nter

Nut

r. 2

003;

27:2

1-26

. 6.

W

olfe

RR

, O'D

onne

ll T

F, J

r., S

tone

MD

, Ric

hman

d D

A, B

urke

JF.

Inv

estig

atio

n of

fac

tors

det

erm

inin

g th

e op

timal

glu

cose

infu

sion

rat

e in

tota

l par

ente

ral n

utri

tion.

Met

abol

ism

: C

linic

al &

E

xper

imen

tal.

1980

;29:

892-

900.

Edi

tion:

200

6 48

INTA

KE D

OMAI

N O

ral o

r Nut

ritio

n Su

ppor

t Int

ake

INA

PP

RO

PR

IAT

E I

NF

US

ION

OF

EN

TE

RA

L O

R P

AR

EN

TE

RA

L N

UT

RIT

ION

(N

I-2.

5)U

se w

ith

cau

tion

–on

ly a

fter

dis

cuss

ion

wit

h o

ther

hea

lth

tea

m m

ember

s

De

fin

itio

n

Ent

eral

or

pare

nter

al in

fusi

on th

at p

rovi

des

eith

er f

ewer

or

mor

e ca

lori

es a

nd/o

r nu

trie

nts

or is

of

the

wro

ng c

ompo

sitio

n or

type

, is

not w

arra

nted

bec

ause

the

patie

nt/c

lient

is a

ble

to to

lera

te a

n en

tera

l int

ake,

or

is u

nsaf

e be

caus

e of

the

pote

ntia

l for

sep

sis

or o

ther

com

plic

atio

ns

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems:

Phys

iolo

gic

caus

es, e

.g. i

mpr

ovem

ent i

n pa

tient

/clie

nt s

tatu

s, a

llow

ing

retu

rn to

tota

l or

part

ial o

ral d

iet;

chan

ges

in th

e co

urse

of

dise

ase

resu

lting

in

chan

ges

in n

utri

ent r

equi

rem

ents

Prod

uct o

r kn

owle

dge

defi

cit o

n th

e pa

rt o

f th

e ca

regi

ver

or c

linic

ian

End

of

life

care

if p

atie

nt/c

lient

or

fam

ily d

o no

t des

ire

nutr

ition

sup

port

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a A

bnor

mal

live

r fu

nctio

n te

sts

in p

atie

nt/c

lient

on

long

term

(m

ore

than

3-6

wee

ks)

feed

ing

Abn

orm

al le

vels

of

mar

kers

spe

cifi

c fo

r va

riou

s nu

trie

nts,

e.g

., hy

per

phos

phat

emia

in p

atie

nt/c

lient

rec

eivi

ng f

eedi

ngs

with

a h

igh

phos

phor

us c

onte

nt, h

ypok

alem

ia in

pat

ient

/clie

nt r

ecei

ving

fee

ding

s w

ith lo

w p

otas

sium

con

tent

Ant

hrop

omet

ric

Mea

sure

men

ts

Wei

ght g

ain

in e

xces

s of

lean

tiss

ue a

ccre

tion

Wei

ght l

oss

Phy

sica

l Exa

min

atio

n F

indi

ngs

Ede

ma

with

exc

ess

flui

d ad

min

istr

atio

n

Com

plic

atio

ns s

uch

as: f

atty

live

r in

the

abse

nce

of o

ther

cau

ses

Los

s of

sub

cuta

neou

s fa

t and

mus

cle

stor

es

Edi

tion:

200

6 49

INTA

KE D

OMAI

N O

ral o

r Nut

ritio

n Su

ppor

t Int

ake

INA

PP

RO

PR

IAT

E I

NF

US

ION

OF

EN

TE

RA

L O

R P

AR

EN

TE

RA

L N

UT

RIT

ION

(N

I-2.

5)F

ood/

Nut

ritio

n H

isto

ry

Rep

ort o

r ob

serv

atio

n of

Doc

umen

ted

inta

ke f

rom

ent

eral

or

pare

nter

al n

utri

ents

that

is c

onsi

sten

tly a

bove

or

belo

w r

ecom

men

ded

inta

ke f

or

carb

ohyd

rate

, pro

tein

, and

/or

fat–

esp

ecia

lly r

elat

ed to

pat

ient

/clie

nt’s

abi

lity

to c

onsu

me

an o

ral d

iet t

hat m

eets

nee

ds a

t th

is p

oint

in ti

me

Doc

umen

ted

inta

ke o

f ot

her

nutr

ient

s th

at is

con

sist

ently

abo

ve o

r be

low

that

rec

omm

ende

d

Nau

sea,

vom

iting

, dia

rrhe

a, h

igh

gast

ric

resi

dual

vol

ume

Clie

nt H

isto

ry

His

tory

of

ente

ral o

r pa

rent

eral

nut

ritio

n in

tole

ranc

e

Refe

ren

ces:

1.

Aar

slan

d A

, Chi

nkes

D, W

olfe

RR

. Hep

atic

and

who

le-b

ody

fat s

ynth

esis

in h

uman

s du

ring

car

bohy

drat

e ov

erfe

edin

g. A

m J

Clin

Nut

r. 1

997;

65:1

774-

1782

. 2.

M

cCla

ve S

A, L

owen

CC

, Kle

ber

MJ,

Nic

hols

on J

F, J

imm

erso

n SC

, McC

onne

ll JW

, Jun

g L

Y. A

re p

atie

nts

fed

appr

opri

atel

y ac

cord

ing

to th

eir

calo

ric

requ

irem

ents

? J

Par

ente

r E

nter

al N

utr.

1998

;22:

375-

381.

3.

M

cCla

ve S

A, L

owen

CC

, Kle

ber

MJ,

McC

onne

ll JW

, Jun

g L

Y, G

olds

mith

LJ.

Clin

ical

use

of

the

resp

irat

ory

quot

ient

obt

aine

d fr

om in

dire

ct c

alor

imet

ry. J

Par

ente

r E

nter

al N

utr.

200

3;27

:21-

26.

4.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r E

nerg

y, C

arbo

hydr

ate,

Fib

er, F

at, F

atty

Aci

ds, C

hole

ster

ol, P

rote

in, a

nd A

min

o A

cids

. Was

hing

ton,

DC

: N

atio

nal A

cade

my

Pres

s; 2

002.

5.

N

atio

nal A

cade

my

of S

cien

ces,

Ins

titut

e of

Med

icin

e. D

ieta

ry R

efer

ence

Int

akes

for

Wat

er, P

otas

sium

, Sod

ium

, Chl

orid

e, a

nd S

ulfa

te, W

ashi

ngto

n D

C. N

atio

nal A

cade

my

Pres

s, 2

004.

6.

N

atio

nal A

cade

my

of S

cien

ces,

Ins

titut

e of

Med

icin

e. D

ieta

ry R

efer

ence

Int

akes

for

Cal

cium

, Pho

spho

rus,

Mag

nesi

um, V

itam

in D

, and

Flu

orid

e. W

ashi

ngto

n, D

.C. N

atio

nal A

cade

my

Pres

s: 1

997.

7.

N

atio

nal A

cade

my

of S

cien

ces,

Ins

titut

e of

Med

icin

e. D

ieta

ry R

efer

ence

Int

akes

for

Vita

min

C, V

itam

in E

, Sel

eniu

m, a

nd C

arot

enoi

ds. W

ashi

ngto

n, D

.C. N

atio

nal A

cade

my

Pres

s: 2

000.

8.

W

olfe

RR

, O'D

onne

ll T

F, J

r., S

tone

MD

, Ric

hman

d D

A, B

urke

JF.

Inv

estig

atio

n of

fac

tors

det

erm

inin

g th

e op

timal

glu

cose

infu

sion

rat

e in

tota

l par

ente

ral n

utri

tion.

Met

abol

ism

: C

linic

al &

E

xper

imen

tal.

1980

;29:

892-

900.

Edi

tion:

200

6 50

INTA

KE D

OMAI

N F

luid

Inta

ke

INA

DE

QU

AT

E F

LU

ID I

NT

AK

E (

NI-

3.1)

De

fin

itio

n

Low

er in

take

of

flui

d co

ntai

ning

foo

ds o

r su

bsta

nces

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Phys

iolo

gic

caus

es, e

.g. i

ncre

ased

flu

id n

eeds

due

to c

limat

e/te

mpe

ratu

re c

hang

e; in

crea

sed

exer

cise

or

cond

ition

s le

adin

g to

incr

ease

d fl

uid

loss

es; f

ever

ca

usin

g in

crea

sed

inse

nsib

le lo

sses

, dec

reas

ed th

irst

sen

satio

n, u

se o

f dr

ugs

that

red

uce

thir

st

Lac

k of

acc

ess

to f

luid

, e.g

., ec

onom

ic c

onst

rain

ts, c

ultu

ral o

r re

ligio

us p

ract

ices

, una

ble

to a

cces

s fl

uid

inde

pend

ently

, suc

h as

, eld

erly

or

child

ren

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or d

isor

dere

d ea

ting;

dem

entia

res

ultin

g in

dec

reas

ed r

ecog

nitio

n of

thir

st

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a Pl

asm

a or

ser

um o

smol

ality

gre

ater

than

290

mO

sm/k

g

BU

N,

Na

Ant

hrop

omet

ric

Mea

sure

men

ts

Acu

te w

eigh

t los

s

Phy

sica

l Exa

min

atio

n F

indi

ngs

Dry

ski

n an

d m

ucou

s m

embr

anes

, poo

r sk

in tu

rgor

Uri

ne o

utpu

t <30

mL

/hr

Foo

d/N

utri

tion

His

tory

R

epor

t or

obse

rvat

ion

of

Insu

ffic

ient

inta

ke o

f fl

uid

whe

n co

mpa

red

to r

equi

rem

ents

Thi

rst

Dif

ficu

lty s

wal

low

ing

Edi

tion:

200

6 51

INTA

KE D

OMAI

N F

luid

Inta

ke

INA

DE

QU

AT

E F

LU

ID I

NT

AK

E (

NI-

3.1)

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

Alz

heim

er’s

dis

ease

or

othe

r de

men

tia r

esul

ting

in

decr

ease

d re

cogn

ition

of

thir

st, d

iarr

hea

Use

of

drug

s th

at r

educ

e th

irst

Refe

ren

ces:

1.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r W

ater

, Pot

assi

um, S

odiu

m, C

hlor

ide,

and

Sul

fate

, Was

hing

ton,

DC

: Nat

iona

l Aca

dem

y Pr

ess;

200

4.

2.

Gra

ndje

an A

C, C

ampb

ell,

SM. H

ydra

tion:

Flu

ids

for

Life

. M

onog

raph

Ser

ies.

Was

hing

ton

D.C

. Int

erna

tiona

l Lif

e Sc

ienc

es I

nstit

ute

Nor

th A

mer

ica,

200

4.

3.

Gra

ndje

an A

C, R

eim

ers

KJ,

Buy

ckx

ME

: H

ydra

tion:

Iss

ues

for

the

21st

Cen

tury

. N

utri

tion

Rev

iew

s 20

03;6

1:26

1-27

1.

Edi

tion:

200

6 52

INTA

KE D

OMAI

N F

luid

Inta

ke

EX

CE

SS

IVE

FL

UID

IN

TA

KE

(N

I-3.

2)

De

fin

itio

n

Hig

her

inta

ke o

f fl

uid

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Phys

iolo

gic

caus

es, e

.g. d

ecre

ased

flu

id lo

sses

due

to k

idne

y, li

ver

or c

ardi

ac f

ailu

re; d

imin

ishe

d w

ater

and

sod

ium

loss

es d

ue to

cha

nges

in e

xerc

ise

or

clim

ate,

Syn

drom

e of

inap

prop

riat

e di

uret

ic h

orm

one

(SIA

DH

)

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or d

isor

dere

d ea

ting

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a L

ower

ed p

lasm

a os

mol

arity

(27

0-28

0 m

Osm

/kg)

, onl

y if

pos

itive

flu

id b

alan

ce is

in e

xces

s of

pos

itive

sal

t bal

ance

Dec

reas

ed s

erum

sod

ium

in S

IAD

H

Ant

hrop

omet

ric

Mea

sure

men

ts

Wei

ght g

ain

Phy

sica

l Exa

min

atio

n F

indi

ngs

Ede

ma

in th

e sk

in o

f th

e le

gs, s

acra

l are

a, o

r di

ffus

ely;

wee

ping

of

flui

ds f

rom

low

er le

gs

Asc

ites

Pulm

onar

y ed

ema

as e

vide

nced

by

shor

tnes

s of

bre

ath;

ort

hopn

ea; c

rack

les

or r

ales

Foo

d/N

utri

tion

His

tory

R

epor

t or

obse

rvat

ion

of

Flui

d in

take

in e

xces

s of

rec

omm

ende

d in

take

Exc

essi

ve s

alt i

ntak

e

Inab

ility

to to

lera

te s

olid

foo

ds n

eces

sita

ting

a liq

uid

diet

Edi

tion:

200

6 53

INTA

KE D

OMAI

N F

luid

Inta

ke

EX

CE

SS

IVE

FL

UID

IN

TA

KE

(N

I-3.

2)C

lient

His

tory

C

ondi

tions

ass

ocia

ted

with

a d

iagn

osis

or

trea

tmen

t of,

e.g

., en

d st

age

rena

l dis

ease

, nep

hrot

ic s

yndr

ome,

hea

rt f

ailu

re,

or li

ver

dise

ase

Nau

sea,

vom

iting

, ano

rexi

a, h

eada

che,

mus

cle

spas

ms,

con

vuls

ions

, com

a (S

IAD

H)

Shor

tnes

s of

bre

ath

or d

yspn

ea w

ith e

xert

ion

or a

t res

t

Prov

idin

g m

edic

atio

ns in

larg

e am

ount

s of

flu

id

Use

of

drug

s th

at im

pair

flu

id e

xcre

tion

Refe

ren

ces:

1.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r W

ater

, Pot

assi

um, S

odiu

m, C

hlor

ide,

and

Sul

fate

, Was

hing

ton

DC

. Nat

iona

l Aca

dem

y Pr

ess,

200

4.

2.

Schi

rer,

R.W

. ed.

Ren

al a

nd E

lect

roly

te D

isor

ders

. Phi

lade

lphi

a. L

ipin

cott

Will

iam

s an

d W

illki

ns, 2

003.

3.

SI

AD

H: h

ttp://

ww

w.n

lmni

h.go

v/m

edlin

eplu

s/en

cy/a

rtic

le/0

0039

4.ht

m.

Edi

tion:

200

6 54

INTA

KE D

OMAI

N B

ioac

tive S

ubst

ance

s

INA

DE

QU

AT

E B

IOA

CT

IVE

SU

BS

TA

NC

E I

NT

AK

E (

NI-

4.1)

De

fin

itio

n

Low

er in

take

of

bioa

ctiv

e su

bsta

nces

con

tain

ing

food

s or

sub

stan

ces

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal

need

s

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Lim

ited

acce

ss to

foo

d co

ntai

ning

sub

stan

ce

Alte

red

GI

func

tion,

e.g

., pa

in o

r di

scom

fort

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Foo

d/N

utri

tion

His

tory

O

bser

vatio

ns o

r re

port

s of

:

Low

inta

ke o

f pl

ant f

oods

con

tain

ing:

Solu

ble

fibe

r, e

.g.,

psyl

lium

( to

tal a

nd L

DL

cho

lest

erol

)

Soy

prot

ein

( to

tal a

nd L

DL

cho

lest

erol

)

-glu

can,

e.g

., w

hole

oat

pro

duct

s (

tota

l and

LD

L c

hole

ster

ol)

Low

inta

ke o

f pl

ant f

oods

con

tain

ing:

Pla

nt s

tero

l and

sta

nol e

ster

s, e

.g.,

fort

ifie

d m

arga

rine

s (

tota

l and

LD

L c

hole

ster

ol)

Lac

k of

ava

ilabl

e fo

ods/

prod

ucts

with

bio

activ

e su

bsta

nce

in m

arke

ts

Edi

tion:

200

6 55

INTA

KE D

OMAI

N B

ioac

tive S

ubst

ance

s

INA

DE

QU

AT

E B

IOA

CT

IVE

SU

BS

TA

NC

E I

NT

AK

E (

NI-

4.1)

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

card

iova

scul

ar d

isea

se, e

leva

ted

chol

este

rol

Dis

com

fort

or

pain

ass

ocia

ted

with

inta

ke o

f fo

ods

rich

in b

ioac

tive

subs

tanc

es, e

.g.,

solu

ble

fibe

r,

-glu

can,

soy

pro

tein

Refe

ren

ces:

1.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Fun

ctio

nal f

oods

. J A

m D

iet A

ssoc

. 200

4;10

4:81

4-82

6.

Edi

tion:

200

6 56

INTA

KE D

OMAI

N B

ioac

tive S

ubst

ance

s

EX

CE

SS

IVE

BIO

AC

TIV

E S

UB

ST

AN

CE

IN

TA

KE

(N

I-4.

2)

De

fin

itio

n

Hig

her

inta

ke o

f bi

oact

ive

subs

tanc

es o

ther

than

trad

ition

al n

utri

ents

, suc

h as

fun

ctio

nal f

oods

, bio

activ

e fo

od c

ompo

nent

s, d

ieta

ry s

uppl

emen

ts, f

ood

conc

entr

ates

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Con

tam

inat

ion,

mis

Ter

min

g, m

isus

e, r

ecen

t bra

nd c

hang

e, r

ecen

t dos

e in

crea

se, r

ecen

t for

mul

atio

n ch

ange

of

subs

tanc

e co

nsum

ed

Freq

uent

inta

ke o

f fo

od c

onta

inin

g bi

oact

ive

subs

tanc

e

Alte

red

GI

func

tion,

e.g

., pa

in o

r di

scom

fort

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a L

ab v

alue

s in

dica

ting

exce

ssiv

e in

take

of

the

spec

ific

sub

stan

ce, s

uch

as r

apid

dro

p in

cho

lest

erol

fro

m in

take

of

stan

ol o

r st

erol

est

ers

and

a st

atin

dru

g an

d re

late

d di

etar

y ch

ange

s or

med

icat

ions

Incr

ease

d he

patic

enz

yme

refl

ectin

g he

pato

cellu

lar

dam

age

Ant

hrop

omet

ric

Mea

sure

men

ts

Wei

ght l

oss

as a

res

ult o

f m

alab

sorp

tion

or m

aldi

gest

ion

Phy

sica

l Exa

m F

indi

ngs

Con

stip

atio

n or

dia

rrhe

a re

late

d to

exc

essi

ve in

take

Neu

rolo

gic

chan

ges,

e.g

., an

xiet

y, m

enta

l sta

tus

chan

ges

Car

diov

ascu

lar

chan

ges,

e.g

., he

art r

ate,

EK

G c

hang

es, b

lood

pre

ssur

e

Edi

tion:

200

6 57

INTA

KE D

OMAI

N B

ioac

tive S

ubst

ance

s

EX

CE

SS

IVE

BIO

AC

TIV

E S

UB

ST

AN

CE

IN

TA

KE

(N

I-4.

2)F

ood/

Nut

ritio

n H

isto

ry

Obs

erva

tions

or

repo

rts

of:

Hig

h in

take

of

plan

t foo

ds c

onta

inin

g:

Soy

prot

ein

( to

tal a

nd L

DL

cho

lest

erol

)

-glu

can,

e.g

., w

hole

oat

pro

duct

s (

tota

l and

LD

L c

hole

ster

ol)

Hig

h in

take

of

food

s co

ntai

ning

: Pla

nt s

tero

l and

sta

nol e

ster

s, e

.g.,

fort

ifie

d m

arga

rine

s (

tota

l and

LD

L c

hole

ster

ol)

or

othe

r fo

ods

base

d up

on f

ood

Ter

m

Subs

tanc

es w

hich

inte

rfer

e w

ith d

iges

tion

or a

bsor

ptio

n of

foo

dstu

ffs

Rea

dy a

cces

s to

ava

ilabl

e fo

ods/

prod

ucts

with

bio

activ

e su

bsta

nce,

e.g

., as

fro

m d

ieta

ry s

uppl

emen

t ven

dors

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

card

iova

scul

ar d

isea

se, e

leva

ted

chol

este

rol,

hype

rten

sion

,

Dis

com

fort

or

pain

ass

ocia

ted

with

inta

ke o

f fo

ods

rich

in b

ioac

tive

subs

tanc

es, e

.g.,

solu

ble

fibe

r,

-glu

can,

soy

pro

tein

Atte

mpt

s to

use

sup

plem

ents

or

bioa

ctiv

e su

bsta

nces

for

wei

ght l

oss,

trea

t con

stip

atio

n, p

reve

nt o

r cu

re c

hron

ic o

r ac

ute

dise

ase

Refe

ren

ces:

1.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Sup

plem

ents

: A

fram

ewor

k fo

r ev

alua

ting

safe

ty. W

ashi

ngto

n, D

C: N

atio

nal A

cade

my

Pres

s; 2

004.

2.

Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: F

unct

iona

l foo

ds. J

Am

Die

t Ass

oc. 2

004;

104:

814-

826.

Edi

tion:

200

6 58

INTA

KE D

OMAI

N B

ioac

tive S

ubst

ance

s

EX

CE

SS

IVE

AL

CO

HO

L I

NT

AK

E (

NI-

4.3)

De

fin

itio

n

Inta

ke a

bove

the

sugg

este

d lim

its f

or a

lcoh

ol

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Har

mfu

l bel

iefs

/atti

tude

s ab

out f

ood,

nut

ritio

n, a

nd n

utri

tion-

rela

ted

topi

cs

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Lac

k of

val

ue f

or b

ehav

ior

chan

ge, c

ompe

ting

valu

es

Alc

ohol

add

ictio

n

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a E

leva

ted

aspa

rtat

e am

inot

rans

fera

se (

AST

), g

amm

a-gl

utam

yl tr

ansf

eras

e (G

GT

), c

arbo

hydr

ate-

defi

cien

t tra

nsfe

rrin

, mea

n co

rpus

cula

r vo

lum

e, b

lood

alc

ohol

leve

ls

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Inta

ke o

f >

2 dr

inks

*/da

y (m

en)

Inta

ke o

f >

1 dr

ink*

/day

(w

omen

)

Bin

ge d

rink

ing

Con

sum

ptio

n of

any

alc

ohol

whe

n co

ntra

indi

cate

d

*1 d

rink

= 5

oz.

win

e, 1

2 oz

bee

r, 1

oz.

dis

tille

d al

coho

l

Edi

tion:

200

6 59

INTA

KE D

OMAI

N B

ioac

tive S

ubst

ance

s

EX

CE

SS

IVE

AL

CO

HO

L I

NT

AK

E (

NI-

4.3)

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

seve

re h

yper

trig

lyce

ride

mia

, ele

vate

d bl

ood

pres

sure

, de

pres

sion

, liv

er d

isea

se, p

ancr

eatit

is

New

med

ical

dia

gnos

is o

r ch

ange

in e

xist

ing

diag

nosi

s or

con

ditio

n

His

tory

of

exce

ssiv

e al

coho

l int

ake

Giv

ing

birt

h to

an

infa

nt w

ith f

etal

alc

ohol

syn

drom

e

Dri

nkin

g du

ring

pre

gnan

cy d

espi

te k

now

ledg

e of

ris

k

Une

xpla

ined

fal

ls

Refe

ren

ces:

1.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

The

rol

e of

die

tetic

s pr

ofes

sion

als

in h

ealth

pro

mot

ion

and

dise

ase

prev

entio

n. J

Am

Die

t Ass

oc. 2

002;

102:

1680

-168

7.

Edi

tion:

200

6 60

INTA

KE D

OMAI

N N

utrie

nt

INC

RE

AS

ED

NU

TR

IEN

T (

SP

EC

IFY

) N

EE

DS

(N

I-5.

1)

De

fin

itio

n

Incr

ease

d ne

ed f

or a

spe

cifi

c nu

trie

nt c

ompa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Alte

red

abso

rptio

n or

met

abol

ism

of

nutr

ient

, e.g

., fr

om m

edic

atio

ns

Com

prom

ise

of o

rgan

s re

late

d to

GI

func

tion,

e.g

. pan

crea

s, li

ver

Dec

reas

ed f

unct

iona

l len

gth

of in

test

ine,

e.g

., sh

ort b

owel

syn

drom

e

Dec

reas

ed o

r co

mpr

omis

ed f

unct

ion

of in

test

ine,

e.g

., C

elia

c di

seas

e, C

rohn

’s d

isea

se

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Incr

ease

d de

man

d of

nut

rien

t, e.

g., a

ccel

erat

ed g

row

th, w

ound

hea

ling,

chr

onic

infe

ctio

n

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a D

ecre

ased

cho

lest

erol

< 1

60 m

g/dL

, alb

umin

, pre

albu

min

, C r

eact

ive

prot

ein,

indi

catin

g in

crea

sed

stre

ss a

nd in

crea

sed

met

abol

ic n

eeds

Ele

ctro

lyte

/min

eral

(e.

g., p

otas

sium

, mag

nesi

um, p

hosp

horu

s) a

bnor

mal

ities

Uri

nary

or

feca

l los

ses

of s

peci

fic

or r

elat

ed n

utri

ent (

e.g.

, fec

al f

at, d

-xyl

ose

test

)

Vita

min

and

/or

min

eral

def

icie

ncy

Ant

hrop

omet

ric

Mea

sure

men

ts

Gro

wth

fai

lure

, bas

ed o

n N

atio

nal C

ente

r fo

r H

ealth

Sta

tistic

s (N

CH

S) g

row

th s

tand

ards

and

fet

al g

row

th f

ailu

re

Uni

nten

tiona

l wei

ght l

oss

of 5

% in

1 m

onth

or

10%

in 6

mon

ths

Und

erw

eigh

t (B

MI

<18

.5)

Edi

tion:

200

6 61

INTA

KE D

OMAI

N N

utrie

nt

INC

RE

AS

ED

NU

TR

IEN

T (

SP

EC

IFY

) N

EE

DS

(N

I-5.

1)P

hysi

cal E

xam

inat

ion

Fin

ding

s C

linic

al e

vide

nce

of v

itam

in/m

iner

al d

efic

ienc

y (e

.g.,

hair

loss

, ble

edin

g gu

ms,

pal

e na

il be

ds)

Los

s of

ski

n in

tegr

ity o

r de

laye

d w

ound

hea

ling

Los

s of

mus

cle

mas

s, s

ubcu

tane

ous

fat

Foo

d/N

utri

tion

His

tory

O

bser

vatio

n or

rep

orts

of:

Inad

equa

te in

take

of

food

s/su

pple

men

t con

tain

ing

need

ed n

utri

ent a

s co

mpa

red

to e

stim

ated

req

uire

men

ts

Inta

ke o

f fo

ods

that

do

not c

onta

in s

uffi

cien

t qua

ntiti

es o

f av

aila

ble

nutr

ient

(e.

g. o

ver

proc

esse

d, o

verc

ooke

d, o

r st

ored

im

prop

erly

)

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit (

e.g.

, lac

k of

info

rmat

ion,

inco

rrec

t inf

orm

atio

n or

non

-com

plia

nce

with

in

take

of

need

ed n

utri

ent)

Clie

nt H

isto

ry

Feve

r

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

inte

stin

al r

esec

tion,

Cro

hn’s

dis

ease

, HIV

/AID

S, b

urns

, pr

essu

re u

lcer

s, p

re-t

erm

bir

th, m

alnu

triti

on

Med

icat

ions

aff

ectin

g ab

sorp

tion

or m

etab

olis

m o

f ne

eded

nut

rien

t

Refe

ren

ces:

1.

Bey

er P

. Gas

troi

ntes

tinal

dis

orde

rs: R

oles

of

nutr

ition

and

the

diet

etic

s pr

actit

ione

r. J

Am

Die

t Ass

oc. 1

998;

98:2

72-2

77.

2.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion

and

Die

titia

ns o

f C

anad

a: N

utri

tion

inte

rven

tion

in th

e ca

re o

f pe

rson

s w

ith h

uman

imm

unod

efic

ienc

y vi

rus

infe

ctio

n. J

Am

Die

t Ass

oc.

2004

;104

:142

5-14

41.

Edi

tion:

200

6 62

INTA

KE D

OMAI

N N

utrie

nt

EV

IDE

NT

PR

OT

EIN

EN

ER

GY

MA

LN

UT

RIT

ION

(N

I-5.

2)

De

fin

itio

n

Inad

equa

te in

take

of

prot

ein

and/

or e

nerg

y ov

er p

rolo

nged

per

iods

of

time

resu

lting

in lo

ss o

f fa

t sto

res

and/

or m

uscl

e w

astin

g

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Phys

iolo

gic

caus

es, e

.g. a

ltere

d nu

trie

nt n

eeds

due

to p

rolo

nged

cat

abol

ic il

lnes

s, m

alab

sorp

tion

Lac

k of

acc

ess

to f

ood,

e.g

., ec

onom

ic c

onst

rain

ts, c

ultu

ral o

r re

ligio

us p

ract

ices

, res

tric

ting

food

giv

en to

eld

erly

and

/or

child

ren

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit,

e.g.

, avo

idan

ce o

f hi

gh q

ualit

y pr

otei

n fo

ods

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or e

atin

g di

sord

ers

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a N

orm

al s

erum

alb

umin

leve

l (un

com

plic

ated

mal

nutr

ition

)

Alb

umin

< 3

.4 m

g/dL

(di

seas

e/tr

aum

a re

late

d m

alnu

triti

on)

Ant

hrop

omet

ric

Mea

sure

men

ts

BM

I <

18.5

indi

cate

s un

derw

eigh

t

Failu

re to

thri

ve, e

.g. f

ailu

re to

atta

in d

esir

able

gro

wth

rat

es

Inad

equa

te m

ater

nal w

eigh

t gai

n

Wei

ght l

oss

of >

10%

in 6

mon

ths

Und

erw

eigh

t with

mus

cle

was

ting

Nor

mal

or

slig

htly

und

erw

eigh

t, st

unte

d gr

owth

in c

hild

ren

Edi

tion:

200

6 63

INTA

KE D

OMAI

N N

utrie

nt

EV

IDE

NT

PR

OT

EIN

EN

ER

GY

MA

LN

UT

RIT

ION

(N

I-5.

2)P

hysi

cal E

xam

Fin

ding

s U

ncom

plic

ated

mal

nutr

ition

: T

hin,

was

ted

appe

aran

ce; s

ever

e m

uscl

e w

astin

g; m

inim

al b

ody

fat;

spar

se, t

hin,

dry

, eas

ily

pluc

kabl

e ha

ir; d

ry, t

hin

skin

; obv

ious

bon

y pr

omin

ence

s, o

ccip

ital w

astin

g; lo

wer

ed b

ody

tem

pera

ture

, blo

od p

ress

ure,

he

art r

ate,

cha

nges

in h

air

or n

ails

con

sist

ent w

ith in

suff

icie

nt p

rote

in in

take

Dis

ease

/trau

ma

rela

ted

mal

nutr

ition

: T

hin

to n

orm

al a

ppea

ranc

e, w

ith p

erip

hera

l ede

ma,

asc

ites

or a

nasa

rca;

low

er

extr

emiti

es; s

ome

mus

cle

was

ting

with

ret

entio

n of

som

e bo

dy f

at; e

nlar

ged

fatty

live

r; d

yspi

gmen

tatio

n of

hai

r (f

lag

sign

) an

d sk

in

Del

ayed

wou

nd h

ealin

g

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f

Insu

ffic

ient

ene

rgy

inta

ke f

rom

die

t com

pare

d to

est

imat

ed o

r m

easu

red

RM

R

Insu

ffic

ient

inta

ke o

f hi

gh q

ualit

y pr

otei

n w

hen

com

pare

d to

req

uire

men

ts

Food

avo

idan

ce a

nd/o

r la

ck o

f in

tere

st in

foo

d

Clie

nt H

isto

ry

Chr

onic

or

acut

e di

seas

e or

trau

ma,

geo

grap

hic

loca

tion

and

soci

o-ec

onom

ic s

tatu

s as

soci

ated

with

alte

red

nutr

ient

inta

ke

of in

dige

nous

phe

nom

enon

Seve

re p

rote

in a

nd/o

r nu

trie

nt m

alab

sorp

tion

(e.g

. ext

ensi

ve b

owel

res

ectio

n)

Exc

essi

ve c

onsu

mpt

ion

of a

lcoh

ol o

r ot

her

drug

s th

at r

educ

e hu

nger

Refe

ren

ces:

1.

Wel

lcom

e T

rust

Wor

king

Par

ty. C

lass

ific

atio

n of

infa

ntile

mal

nutr

ition

. Lan

cet 1

970;

2:30

2-30

3.

2.

Sere

s D

S, R

esur

rect

ion,

LB

. Kw

ashi

orko

r: D

ysm

etab

olis

m v

ersu

s m

alnu

triti

on. N

utr

Clin

Pra

c 20

03;1

8:29

7-30

1.

3.

Jelli

ffe

DB

, Jel

liffe

EF.

Cau

satio

n of

kw

ashi

orko

r: T

owar

d a

mul

tifac

tora

l con

sens

us. P

edia

tric

s 19

92:9

0:11

0-11

3.4.

C

ente

rs f

or D

isea

se C

ontr

ol a

nd P

reve

ntio

n w

ebsi

te: h

ttp://

ww

w.c

dc.g

ov/n

ccdp

hp/d

npa/

bmi/b

mi-

adul

t.htm

. A

cces

sed

Oct

ober

5, 2

004.

5.

Fu

hrm

an M

P, C

harn

ey P

, Mue

ller

CM

. Hep

atic

pro

tein

s an

d nu

triti

on a

sses

smen

t. J

Am

Die

t Ass

oc. 2

004;

104:

1258

-126

4.

6.

U.S

. Dep

artm

ent o

f H

ealth

and

Hum

an S

ervi

ces.

The

Int

erna

tiona

l Cla

ssifi

catio

n of

Dis

ease

s, 9

th R

evis

ion,

4th E

d. W

ashi

ngto

n C

D: P

ublic

atio

n N

o. (

PHS)

91-

1260

, 199

1.

Edi

tion:

200

6 64

INTA

KE D

OMAI

N N

utrie

nt

INA

DE

QU

AT

E P

RO

TE

IN E

NE

RG

Y I

NT

AK

E (

NI-

5.3)

De

fin

itio

n

Inad

equa

te in

take

of

prot

ein

and/

or e

nerg

y co

mpa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds o

f sh

ort o

r re

cent

du

ratio

n

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Shor

t-te

rm p

hysi

olog

ic c

ause

s, e

.g. i

ncre

ased

nut

rien

t nee

ds d

ue to

cat

abol

ic il

lnes

s, m

alab

sorp

tion

Rec

ent l

ack

of a

cces

s to

foo

d, e

.g.,

econ

omic

con

stra

ints

, cul

tura

l or

relig

ious

pra

ctic

es, r

estr

ictin

g fo

od g

iven

or

food

sel

ecte

d

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit,

e.g.

, avo

idan

ce o

f al

l fat

s fo

r ne

w d

ietin

g pa

ttern

Rec

ent o

nset

of

psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or e

atin

g di

sord

ers

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a N

orm

al a

lbum

in (

in th

e se

tting

of

norm

al li

ver

func

tion

desp

ite d

ecre

ase

prot

ein-

ener

gy in

take

)

Ant

hrop

omet

ric

Mea

sure

men

ts

Inad

equa

te m

ater

nal w

eigh

t gai

n (m

ild b

ut n

ot s

ever

e)

Wei

ght l

oss

of 5

-7%

ove

r pa

st 3

mon

ths

in a

dults

, any

wei

ght l

oss

in c

hild

ren

Nor

mal

or

slig

htly

und

erw

eigh

t

Gro

wth

fai

lure

in c

hild

ren

Phy

sica

l Exa

m F

indi

ngs

Slow

wou

nd h

ealin

g in

pre

ssur

e ul

cer

or s

urgi

cal p

atie

nt/c

lient

Edi

tion:

200

6 65

INTA

KE D

OMAI

N N

utrie

nt

INA

DE

QU

AT

E P

RO

TE

IN E

NE

RG

Y I

NT

AK

E (

NI-

5.3)

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f

Insu

ffic

ient

ene

rgy

inta

ke f

rom

die

t com

pare

d to

est

imat

ed o

r m

easu

red

RM

R o

r re

com

men

ded

leve

ls

Res

tric

tion

or o

mis

sion

of

food

gro

ups

such

as

dair

y or

mea

t gro

up f

oods

(pr

otei

n); b

read

or

milk

gro

up f

oods

(en

ergy

)

Rec

ent f

ood

avoi

danc

e an

d/or

lack

of

inte

rest

in f

ood

Lac

k of

abi

lity

to p

repa

re m

eals

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f m

ild p

rote

in-e

nerg

y m

alnu

triti

on, r

ecen

t illn

ess,

e.g

. pul

mon

ary

or

card

iac

failu

re, f

lu, i

nfec

tion,

sur

gery

Nut

rien

t mal

abso

rptio

n (e

.g. b

aria

tric

sur

gery

, dia

rrhe

a, s

teat

orrh

ea)

Exc

essi

ve c

onsu

mpt

ion

of a

lcoh

ol o

r ot

her

drug

s th

at r

educ

e hu

nger

Patie

nt/c

lient

rep

orts

of

hung

er in

the

face

of

inad

equa

te a

cces

s to

foo

d su

pply

Patie

nt/c

lient

rep

orts

lack

of

abili

ty to

pre

pare

mea

ls

Patie

nt/c

lient

rep

orts

lack

of

fund

s fo

r pu

rcha

se o

f ap

prop

riat

e fo

ods

Refe

ren

ces:

1.

Cen

ters

for

Dis

ease

Con

trol

and

Pre

vent

ion

web

site

: http

://w

ww

.cdc

.gov

/ncc

dphp

/dnp

a/bm

i/bm

i-ad

ult.h

tm.

Acc

esse

d O

ctob

er 5

, 200

4.

2.

Fuhr

man

MP,

Cha

rney

P, M

uelle

r C

M. H

epat

ic p

rote

ins

and

nutr

ition

ass

essm

ent.

J A

m D

iet A

ssoc

. 200

4;10

4:12

58-1

264.

3.

U

.S. D

epar

tmen

t of

Hea

lth a

nd H

uman

Ser

vice

s. T

he I

nter

natio

nal C

lass

ifica

tion

of D

isea

ses,

9th R

evis

ion,

4th E

d. W

ashi

ngto

n C

D: P

ublic

atio

n N

o. (

PHS)

91-

1260

, 199

1.

Edi

tion:

200

6 66

INTA

KE D

OMAI

N N

utrie

nt

DE

CR

EA

SE

D N

UT

RIE

NT

(S

PE

CIF

Y)

NE

ED

S (

NI-

5.4)

De

fin

itio

n

Dec

reas

ed n

eed

for

a sp

ecif

ic n

utri

ent c

ompa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Ren

al d

ysfu

nctio

n

Liv

er d

ysfu

nctio

n

Alte

red

chol

este

rol m

etab

olis

m/r

egul

atio

n

Hea

rt f

ailu

re

Food

into

lera

nces

, e.g

., ir

rita

ble

bow

el s

yndr

ome

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a C

hole

ster

ol >

200

mg/

dL, L

DL

cho

lest

erol

> 1

00 m

g/dL

, HD

L c

hole

ster

ol <

40

mg/

dL, t

rigl

ycer

ides

> 1

50 m

g/dL

Phos

phor

us >

5.5

mg/

dL

Glo

mer

ular

filt

ratio

n ra

te (

GFR

) <

90 m

L/m

in/1

.73

m2

Ele

vate

d B

UN

, Cr,

pot

assi

um

Liv

er f

unct

ion

test

s in

dica

ting

seve

re li

ver

dise

ase

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Ede

ma/

flui

d re

tent

ion

Inte

rdia

lytic

wei

ght g

ain

grea

ter

than

exp

ecte

d

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Inta

ke h

ighe

r th

an r

ecom

men

ded

for

fat,

phos

phor

us, s

odiu

m, p

rote

in, f

iber

Edi

tion:

200

6 67

INTA

KE D

OMAI

N N

utrie

nt

DE

CR

EA

SE

D N

UT

RIE

NT

(S

PE

CIF

Y)

NE

ED

S (

NI-

5.4)

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent t

hat r

equi

re a

spe

cifi

c ty

pe a

nd/o

r am

ount

of

nutr

ient

, e.g

., ca

rdio

vasc

ular

dis

ease

(fa

t), e

arly

ren

al d

isea

se (

prot

ein,

pho

s), E

SRD

(ph

os, s

odiu

m, p

otas

sium

, flu

id),

adv

ance

d liv

er

dise

ase

(pro

tein

), h

eart

fai

lure

(so

dium

, flu

id),

irri

tabl

e bo

wel

dis

ease

/Cro

hn’s

fla

re u

p (f

iber

)

Dia

gnos

is o

f hy

pert

ensi

on, c

onfu

sion

rel

ated

to li

ver

dise

ase

Refe

ren

ces:

1.

Apa

rici

o M

, Cha

uvea

u P,

Com

be C

. L

ow p

rote

in d

iets

and

out

com

es o

f re

nal p

atie

nts.

J N

ephr

ol. 2

001;

14:4

33-9

. 2.

B

eto

JA, B

ansa

l VK

. Med

ical

nut

ritio

n th

erap

y in

chr

onic

kid

ney

failu

re: I

nteg

ratin

g cl

inic

al p

ract

ice

guid

elin

es. J

Am

Die

t Ass

oc. 2

004;

104:

404-

409.

3.

C

upis

ti A

, Mor

elli

E, D

’Ale

ssan

dro

C, L

upet

ti S,

Bar

sott

i G. P

hosp

hate

con

trol

in c

hron

ic u

rem

ia: d

on’t

for

get d

iet.

J N

ephr

ol.

2003

;16:

29-3

3.

4.

Dur

ose

CL

, Hol

dsw

orth

M, W

atso

n V

, Prz

ygro

dzka

F. K

now

ledg

e of

die

tary

res

tric

tions

and

the

med

ical

con

sequ

ence

s of

non

com

plia

nce

by p

atie

nts

on h

emod

ialy

sis

are

not p

redi

ctiv

e of

die

tary

co

mpl

ianc

e. J

Am

Die

t Ass

oc. 2

004;

104:

35-4

1.

5.

Floc

h M

H, N

aray

an R

. D

iet i

n th

e ir

rita

ble

bow

el s

yndr

ome.

Clin

Gas

troe

nter

ol.

2002

;35:

pS45

-pS5

2.

6.

Kat

o J,

Kob

une

M, N

akam

ura

T, K

uroj

wa

G, T

akad

a K

, Tak

imot

o R

, Sat

o Y

, Fuj

ikaw

a K

, Tak

ahas

hi M

, Tak

ayam

a T

, Ike

da T

, Niit

su Y

. Nor

mal

izat

ion

of e

leva

ted

hepa

tic 8

-hyd

roxy

-2’-

deox

ygua

nosi

ne le

vels

in c

hron

ic h

epat

itis

C p

atie

nts

by p

hleb

otom

y an

d lo

w ir

on d

iet.

Can

cer

Res

. 200

1;61

:869

7-87

02.

7.

Lee

Sh,

Mol

assi

otis

A.

Die

tary

and

flu

id c

ompl

ianc

e in

Chi

nese

hem

odia

lysi

s pa

tient

s. I

nt J

Nur

s St

ud.

2002

;39:

695-

704.

8.

Po

duva

l RD

, Wol

gem

uth

C, F

erre

ll J,

Ham

mes

MS.

Hyp

erph

osph

atem

ia in

dia

lysi

s pa

tient

s: is

the

re a

rol

e fo

r fo

cuse

d co

unse

ling?

J R

en N

utr.

200

3;13

:219

-223

. 9.

T

ando

n N

, Tha

kur

V, G

upta

n R

K, S

arin

SK

. Ben

efic

ial i

nflu

ence

of

an in

dige

nous

low

-iro

n di

et o

n se

rum

indi

cato

rs o

f ir

on s

tatu

s in

pat

ient

s w

ith c

hron

ic li

ver

dise

ase.

Br

J N

utr.

200

0;83

:235

-23

9.

10.

Zri

nyi M

, Juh

asz

M, B

alla

J, K

aton

a E

, Ben

T, K

akuk

G, P

all D

. Die

tary

sel

f-ef

fica

cy: d

eter

min

ant o

f co

mpl

ianc

e be

havi

ours

and

bio

chem

ical

out

com

es in

hae

mod

ialy

sis

patie

nts.

Nep

hrol

Dia

l Tr

ansp

lant

. 200

3;19

:186

9-73

.

Edi

tion:

200

6 68

INTA

KE D

OMAI

N N

utrie

nt

IMB

AL

AN

CE

OF

NU

TR

IEN

TS

(N

I-5.

5)

De

fin

itio

n

An

unde

sira

ble

com

bina

tion

of in

gest

ed n

utri

ents

, suc

h th

at th

e am

ount

of

one

nutr

ient

inge

sted

inte

rfer

es w

ith o

r al

ters

abs

orpt

ion

and/

or u

tiliz

atio

n of

ano

ther

nu

trie

nt

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Con

sum

ptio

n of

hig

h do

se n

utri

ent s

uppl

emen

ts

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Har

mfu

l bel

iefs

/atti

tude

s ab

out f

ood,

nut

ritio

n an

d nu

triti

on-r

elat

ed in

form

atio

n

Food

fad

dism

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Dat

a

Phy

sica

l Exa

m F

indi

ngs

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Hig

h in

take

of

iron

sup

plem

ents

( z

inc

abso

rptio

n)

Hig

h in

take

of

zinc

sup

plem

ents

( c

oppe

r st

atus

)

Hig

h in

take

of

man

gane

se (

iron

sta

tus)

Clie

nt H

isto

ry

Dia

rrhe

a or

con

stip

atio

n (i

ron

supp

lem

ents

)

Epi

gast

ric

pain

, nau

sea,

vom

iting

, , d

iarr

hea

(zin

c su

pple

men

ts)

Con

trib

utes

to th

e de

velo

pmen

t of

anem

ia (

man

gane

se s

uppl

emen

ts)

Edi

tion:

200

6 69

INTA

KE D

OMAI

N N

utrie

nt

IMB

AL

AN

CE

OF

NU

TR

IEN

TS

(N

I-5.

5)R

efe

ren

ces:

1.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r V

itam

in A

, Vita

min

K, A

rsen

ic, B

oron

, Chr

omiu

m, C

oppe

r, I

odin

e, I

ron,

Man

gane

se, M

olyb

denu

m, N

icke

l,Si

licon

, Van

adiu

m, Z

inc.

Was

hing

ton,

DC

: Nat

iona

l Aca

dem

y Pr

ess;

200

1.

2.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r C

alci

um, P

hosp

horu

s, M

agne

sium

, Vita

min

D, a

nd F

luor

ide.

Was

hing

ton,

DC

: Nat

iona

l Aca

dem

y Pr

ess;

199

7.

Edi

tion:

200

6 70

INTA

KE D

OMAI

N F

at an

d Ch

oles

tero

l

INA

DE

QU

AT

E F

AT

IN

TA

KE

(N

I-51

.1)

De

fin

itio

n

Low

er f

at in

take

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

. Exc

eptio

n: w

hen

the

goal

is w

eigh

t los

s or

du

ring

end

of

life

care

.

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Inap

prop

riat

e fo

od c

hoic

es, e

.g.,

econ

omic

con

stra

ints

, cul

tura

l or

relig

ious

pra

ctic

es, r

estr

ictin

g fo

od g

iven

to e

lder

ly a

nd/o

r ch

ildre

n, s

peci

fic

food

cho

ices

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit,

e.g.

pro

long

ed a

dher

ence

to a

ver

y lo

w f

at d

iet

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or d

isor

dere

d ea

ting

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a T

rien

e: te

trae

ne r

atio

>0.

2

Ant

hrop

omet

ric

Mea

sure

men

ts

Wei

ght l

oss

if in

suff

icie

nt c

alor

ies

cons

umed

Phy

sica

l Exa

min

atio

n F

indi

ngs

Rou

gh, s

caly

ski

n th

at b

ecom

es d

erm

atiti

s w

ith e

ssen

tial f

atty

aci

d de

fici

ency

Foo

d/N

utri

tion

His

tory

R

epor

t or

obse

rvat

ion

of

Inta

ke o

f es

sent

ial f

atty

aci

d co

ntai

ning

foo

ds c

onsi

sten

tly p

rovi

ding

less

than

10%

of

calo

ries

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

prol

onge

d ca

tabo

lic il

lnes

s (e

.g. A

IDS,

tube

rcul

osis

, an

orex

ia n

ervo

sa, s

epsi

s or

sev

ere

infe

ctio

n fr

om r

ecen

t sur

gery

)

Seve

re f

at m

alab

sorp

tion

with

bow

el r

esec

tion,

pan

crea

tic in

suff

icie

ncy,

or

hepa

tic d

isea

se a

ccom

pani

ed b

y st

eato

rrhe

a

Refe

ren

ces:

1.

Die

tary

Ref

eren

ce I

ntak

es fo

r E

nerg

y, C

arbo

hydr

ate,

Fib

er, F

at, F

atty

Aci

ds, C

hole

ster

ol, P

rote

in, a

nd A

min

o A

cids

. Ins

titut

e of

Med

icin

e of

the

Nat

iona

l Aca

dem

ies.

Nat

iona

l Aca

dem

y Pr

ess,

W

ashi

ngto

n, D

.C. 2

002.

Edi

tion:

200

6 71

INTA

KE D

OMAI

N F

at an

d Ch

oles

tero

l

EX

CE

SS

IVE

FA

T I

NT

AK

E (

NI-

51.2

)

De

fin

itio

n

Hig

her

fat i

ntak

e co

mpa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Har

mfu

l bel

iefs

/atti

tude

s ab

out f

ood,

nut

ritio

n, a

nd n

utri

tion-

rela

ted

topi

cs

Lac

k of

acc

ess

to h

ealth

ful f

ood

choi

ces,

e.g

., fo

od p

rovi

ded

by c

areg

iver

, ped

iatr

ics,

hom

eles

s

Cha

nges

in ta

ste

and

appe

tite

or p

refe

renc

e

Lac

k of

val

ue f

or b

ehav

ior

chan

ge, c

ompe

ting

valu

es

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a C

hole

ster

ol >

200

mg/

dL, L

DL

cho

lest

erol

> 1

00 m

g/dL

, HD

L c

hole

ster

ol <

40

mg/

dL, t

rigl

ycer

ides

> 1

50 m

g/dL

Ele

vate

d se

rum

am

ylas

e an

d/or

lipa

se

Ele

vate

d L

FTs,

T. B

ili

Tri

ene-

tetr

aene

rat

io >

0.4

Feca

l fat

> 7

gms/

24

hour

s

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Evi

denc

e of

xan

thom

as

Evi

denc

e of

ski

n le

sion

s

Edi

tion:

200

6 72

INTA

KE D

OMAI

N F

at an

d Ch

oles

tero

l

EX

CE

SS

IVE

FA

T I

NT

AK

E (

NI-

51.2

)F

ood/

Nut

ritio

n H

isto

ry

Rep

orts

or

obse

rvat

ions

of:

Freq

uent

or

larg

e po

rtio

ns o

f hi

gh f

at f

oods

Freq

uent

foo

d pr

epar

atio

n w

ith a

dded

fat

Freq

uent

con

sum

ptio

n of

hig

h ri

sk li

pids

(i.e

. sat

urat

ed f

at, t

rans

fat

, cho

lest

erol

)

Rep

ort o

f fo

ods

cont

aini

ng f

at a

bove

die

t pre

scri

ptio

n

Inad

equa

te in

take

of

esse

ntia

l lip

ids

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

hype

rlip

idem

ia, c

ystic

fib

rosi

s, a

ngin

a, a

rthe

rosc

lero

sis,

pa

ncre

atic

, liv

er, a

nd b

iliar

y di

seas

es, p

ost-

tran

spla

ntat

ion

Med

icat

ion,

e.g

., pa

ncre

atic

enz

ymes

, cho

lest

erol

or

othe

r lip

id lo

wer

ing

med

icat

ions

Dia

rrhe

a, c

ram

ping

, ste

ator

rhea

, epi

gast

ric

pain

Fam

ily h

isto

ry o

f hy

perl

ipid

emia

, ath

eros

cler

osis

or

panc

reat

itis.

Refe

ren

ces:

1.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r E

nerg

y, C

arbo

hydr

ate,

Fib

er, F

at, F

atty

Aci

ds, C

hole

ster

ol, P

rote

in, a

nd A

min

o A

cids

. Was

hing

ton,

DC

: N

atio

nal A

cade

my

Pres

s; 2

002.

2.

Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: W

eigh

t man

agem

ent.

J A

m D

iet A

ssoc

. 200

2;10

2:11

45-1

155.

3.

Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: T

otal

die

t app

roac

h to

com

mun

icat

ing

food

and

nut

ritio

n in

form

atio

n. J

Am

Die

t Ass

oc. 2

002;

102:

100-

108.

4.

Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: T

he r

ole

of d

iete

tics

prof

essi

onal

s in

hea

lth p

rom

otio

n an

d di

seas

e pr

even

tion.

J A

m D

iet A

ssoc

. 200

2;10

2:16

80-1

687.

Edi

tion:

200

6 73

INTA

KE D

OMAI

N F

at an

d Ch

oles

tero

l INA

PP

RO

PR

IAT

E I

NT

AK

E O

F F

OO

D F

AT

S (

NI-

51.3

)

De

fin

itio

n

Inta

ke o

f w

rong

type

or

qual

ity o

f fo

od f

ats

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Har

mfu

l bel

iefs

/atti

tude

s ab

out f

ood,

nut

ritio

n, a

nd n

utri

tion-

rela

ted

topi

cs

Lac

k of

acc

ess

to h

ealth

ful f

ood

choi

ces,

e.g

., fo

od p

rovi

ded

by c

areg

iver

, ped

iatr

ics,

hom

eles

s

Cha

nges

in ta

ste

and

appe

tite

or p

refe

renc

e

Lac

k of

val

ue f

or b

ehav

ior

chan

ge, c

ompe

ting

valu

es

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a C

hole

ster

ol >

200

mg/

dL, L

DL

cho

lest

erol

> 1

00 m

g/dL

, HD

L c

hole

ster

ol <

40

mg/

dL, t

rigl

ycer

ides

> 1

50 m

g/dL

Ele

vate

d se

rum

am

ylas

e an

d/or

lipa

se

Ele

vate

d L

FTs,

T. B

ili,

c-re

activ

e pr

otei

n

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Evi

denc

e of

xan

thom

as

Evi

denc

e of

ski

n le

sion

s

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Freq

uent

foo

d pr

epar

atio

n w

ith a

dded

fat

that

is n

ot o

f de

sire

d ty

pe f

or c

ondi

tion

Freq

uent

con

sum

ptio

n of

fat

s th

at a

re u

ndes

irab

le f

or c

ondi

tion

(i.e

. sat

urat

ed f

at, t

rans

fat

, cho

lest

erol

, om

ega-

6 fa

tty a

cids

)

Inad

equa

te in

take

of

mon

ouns

atur

ated

, pol

yuns

atur

ated

, or

omeg

a-3

fatty

aci

ds

Edi

tion:

200

6 74

INTA

KE D

OMAI

N F

at an

d Ch

oles

tero

l INA

PP

RO

PR

IAT

E I

NT

AK

E O

F F

OO

D F

AT

S (

NI-

51.3

)C

lient

His

tory

C

ondi

tions

ass

ocia

ted

with

a d

iagn

osis

or

trea

tmen

t of

diab

etes

, car

diac

dis

ease

s, o

besi

ty, l

iver

or

bilia

ry d

isor

ders

Dia

rrhe

a, c

ram

ping

, ste

ator

rhea

, epi

gast

ric

pain

Fam

ily h

isto

ry o

f di

abet

es-r

elat

ed h

eart

dis

ease

, hyp

erlip

idem

ia, a

ther

oscl

eros

is o

r pa

ncre

atiti

s.

Clie

nt d

esir

es to

impl

emen

t a M

edite

rran

ean-

type

die

t

Refe

ren

ces:

1.

de L

orge

ril M

, Sal

en P

, Mar

tin J

-L, M

onja

ud I

, Del

aye

J, M

amel

le N

: Med

iterr

anea

n di

et, t

radi

tiona

l ris

k fa

ctor

s, a

nd th

e ra

te o

f ca

rdio

vasc

ular

com

plic

atio

ns a

fter

myo

card

ial i

nfar

ctio

n. F

inal

re

port

of

the

Lyo

n D

iet H

eart

Stu

dy. C

ircu

lati

on. 1

999;

99:

779-

785.

2.

Fr

anz

MJ,

Ban

tle J

P, B

eebe

CA

, Bru

nzel

l JD

, Chi

asso

n J-

L, G

arg

A, H

olzm

eist

er L

A, H

oogw

erf

B, M

ayer

-Dav

is E

, Moo

radi

an A

D, P

urne

ll JQ

, Whe

eler

M: T

echn

ical

rev

iew

. Evi

denc

e-ba

sed

nutr

ition

pri

ncip

les

and

reco

mm

enda

tions

for

the

trea

tmen

t and

pre

vent

ion

of d

iabe

tes

and

rela

ted

com

plic

atio

ns. D

iabe

tes

Car

e. 2

002;

202:

148-

198.

3.

K

noop

s K

TB

, de

Gro

tt L

CPG

M, K

rom

hout

D, P

erri

n A

-E, V

arel

a )

M-V

, Men

otti

A, v

an S

tave

ren

WA

: Med

iter

rane

an d

iet,

lifes

tyle

fac

tors

, and

10-

year

mor

talit

y in

eld

erly

Eur

opea

n m

en a

nd

wom

en. J

AM

A. 2

004;

292:

1433

-143

9,

4.

Kri

s-E

ther

ton

PM, H

arri

s W

S, A

ppel

LJ,

for

the

Nut

riti

on C

omm

ittee

: AH

A s

cien

tific

sta

tem

ent.

Fish

con

sum

ptio

n, f

ish

oil,

omeg

a-3

fatty

aci

ds, a

nd c

ardi

ovas

cula

r di

seas

e. C

ircu

lati

on.

2002

;106

:274

7-27

57.

5.

Pana

giot

akos

DB

, Pits

avos

C, P

olyc

hron

opou

los

E, C

hrys

ohoo

u C

, Zam

pela

s A

, Tri

chop

oulo

u A

. Can

a M

edite

rran

ean

diet

mod

erat

e th

e de

velo

pmen

t and

clin

ical

pro

gres

sion

of

coro

nary

hea

rt

dise

ase?

A s

yste

mat

ic r

evie

w. M

ed S

ci M

onit.

200

4;10

:RA

193-

RA

198.

6.

Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: W

eigh

t man

agem

ent.

J A

m D

iet A

ssoc

. 200

2;10

2:11

45-1

155.

7.

Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: T

otal

die

t app

roac

h to

com

mun

icat

ing

food

and

nut

ritio

n in

form

atio

n. J

Am

Die

t Ass

oc. 2

002;

102:

100-

108.

8.

Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: T

he r

ole

of d

iete

tics

prof

essi

onal

s in

hea

lth p

rom

otio

n an

d di

seas

e pr

even

tion.

J A

m D

iet A

ssoc

. 200

2;10

2:16

80-1

687.

9.

Z

hao

G, E

ther

ton

TD

, Mar

tin K

R, W

est S

G, G

illes

PJ,

Kri

s-E

ther

ton

PM. D

ieta

ry a

lpha

-lin

olen

ic a

cid

redu

ces

infl

amm

ator

y an

d lip

id c

ardi

ovas

cula

r ri

sk f

acto

rs in

hyp

erch

oles

tero

lem

ic m

en a

nd

wom

en. J

Nut

r. 2

004;

134:

2991

-299

7.

Edi

tion:

200

6 75

INTA

KE D

OMAI

N P

rote

in

INA

DE

QU

AT

E P

RO

TE

IN I

NT

AK

E (

NI-

52.1

)

De

fin

itio

n

Low

er in

take

of

prot

ein

cont

aini

ng f

oods

or

subs

tanc

es c

ompa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Phys

iolo

gic

caus

es, e

.g. i

ncre

ased

nut

rien

t nee

ds d

ue to

pro

long

ed c

atab

olic

illn

ess,

mal

abso

rptio

n, a

ge o

r co

nditi

on

Lac

k of

acc

ess

to f

ood,

e.g

., ec

onom

ic c

onst

rain

ts, c

ultu

ral o

r re

ligio

us p

ract

ices

, res

tric

ting

food

giv

en to

eld

erly

and

/or

child

ren

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or d

isor

dere

d ea

ting

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

min

atio

n F

indi

ngs

Die

t His

tory

R

epor

t or

obse

rvat

ion

of

Insu

ffic

ient

inta

ke o

f pr

otei

n to

mee

t req

uire

men

ts

Cul

tura

l or

relig

ious

pra

ctic

es th

at li

mit

prot

ein

inta

ke

Eco

nom

ic c

onst

rain

ts th

at li

mit

food

ava

ilabi

lity

Prol

onge

d ad

here

nce

to a

ver

y lo

w p

rote

in w

eigh

t los

s di

et

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

seve

re p

rote

in m

alab

sorp

tion

such

as

bow

el r

esec

tion

Refe

ren

ces:

1.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r E

nerg

y, C

arbo

hydr

ate,

Fib

er, F

at, F

atty

Aci

ds, C

hole

ster

ol, P

rote

in, a

nd A

min

o A

cids

. Was

hing

ton

DC

: N

atio

nal A

cade

my

Pres

s; 2

002.

Edi

tion:

200

6 76

INTA

KE D

OMAI

N P

rote

in

EX

CE

SS

IVE

PR

OT

EIN

IN

TA

KE

(N

I-52

.2)

De

fin

itio

n

Inta

ke a

bove

the

reco

mm

ende

d le

vel o

f pr

otei

n co

mpa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Liv

er d

ysfu

nctio

n

Ren

al d

ysfu

nctio

n

Har

mfu

l bel

iefs

/atti

tude

s ab

out f

ood,

nut

ritio

n an

d nu

triti

on-r

elat

ed to

pics

Lac

k of

acc

ess

to s

peci

aliz

ed p

rote

in p

rodu

cts

Met

abol

ic a

bnor

mal

ity

Food

fad

dism

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a A

ltere

d la

bora

tory

val

ues

e.g.

B

UN

, g

lom

erul

ar f

iltra

tion

rate

(al

tere

d re

nal s

tatu

s)

Ant

hrop

omet

ric

Mea

sure

men

ts

Gro

wth

stu

ntin

g or

fai

lure

bas

ed o

n N

CH

S gr

owth

cha

rts

(met

abol

ic d

isor

ders

)

Phy

sica

l Exa

m F

indi

ngs

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Hig

her

than

rec

omm

ende

d to

tal p

rote

in in

take

, e.g

., ea

rly

rena

l dis

ease

, adv

ance

d liv

er d

isea

se w

ith c

onfu

sion

Inap

prop

riat

e su

pple

men

tatio

n

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

earl

y re

nal d

isea

se o

r ad

vanc

ed li

ver

dise

ase

with

con

fusi

on

Edi

tion:

200

6 77

INTA

KE D

OMAI

N P

rote

in

EX

CE

SS

IVE

PR

OT

EIN

IN

TA

KE

(N

I-52

.2)

Refe

ren

ces:

1.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Foo

d an

d nu

triti

on m

isin

form

atio

n. J

Am

Die

t Ass

oc. 2

002;

102:

260-

266.

2.

B

eto

JA, B

ansa

l VK

. Med

ical

nut

ritio

n th

erap

y in

chr

onic

kid

ney

failu

re: I

nteg

ratin

g cl

inic

al p

ract

ice

guid

elin

es. J

Am

Die

t Ass

oc. 2

004;

104:

404-

409.

3.

B

rand

le E

, Sie

bert

h H

G, H

autm

ann

RE

. Eff

ect o

f ch

roni

c di

etar

y pr

otei

n in

take

on

the

rena

l fun

ctio

n in

hea

lthy

subj

ects

. Eur

J C

lin

Nut

r. 1

996;

50:7

34-7

40.

4.

Fras

setto

LA

, Tod

d K

M, M

orri

s R

C J

r, S

ebas

tian

A. E

stim

atio

n of

net

end

ogen

ous

nonc

arbo

nic

acid

pro

duct

ion

in h

uman

s fr

om d

iet,

pota

ssiu

m a

nd p

rote

in c

onte

nts.

Am

J C

lin N

utr.

199

8;68

:576

-58

3.

5.

Frie

dman

N, e

d. A

bsor

ptio

n an

d U

tiliz

atio

n of

Am

ino

Aci

ds, V

ol. I

. Boc

a R

aton

, FL

: CR

C P

ress

, 198

9, p

p229

-242

. 6,

H

ooge

veen

EK

, Kos

tens

e PJ

, Jag

er A

, Hei

ne R

J, J

akob

s C

, Bou

ter

LM

, Don

ker

AJ,

Ste

how

er C

D. S

erum

hom

ocys

tein

e le

vel a

nd p

rote

in in

take

are

rel

ated

to r

isk

of m

icro

albu

min

uria

: the

Hoo

rn

stud

y. K

idne

y In

t. 19

98;5

4:20

3-20

9.

7.

R

udm

an D

, DiF

ulco

TJ,

Gal

ambo

s JT

, Sm

ith R

B 3

rd, S

alam

AA

, War

ren

WD

. Max

imum

rat

e of

exc

retio

n an

d sy

nthe

sis

of u

rea

in n

orm

al a

nd c

irrh

otic

sub

ject

s. J

Cli

n In

vest

. 197

3.;5

2:22

41-

2249

.

Edi

tion:

200

6 78

INTA

KE D

OMAI

N P

rote

in

INA

PP

RO

PR

IAT

E I

NT

AK

E O

F A

MIN

O A

CID

S (

SP

EC

IFY

) (N

I-52

.3)

De

fin

itio

n

Inta

ke th

at is

mor

e or

less

than

rec

omm

ende

d le

vel a

nd/o

r ty

pe o

f am

ino

acid

s co

mpa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Liv

er d

ysfu

nctio

n

Ren

al d

ysfu

nctio

n

Har

mfu

l bel

iefs

/atti

tude

s ab

out f

ood,

nut

ritio

n an

d nu

triti

on-r

elat

ed to

pics

Mis

used

spe

cial

ized

pro

tein

pro

duct

s

Met

abol

ic a

bnor

mal

ity

Food

fad

dism

Inbo

rn e

rror

s of

met

abol

ism

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a A

ltere

d la

bora

tory

val

ues

e.g.

B

UN

, g

lom

erul

ar f

iltra

tion

rate

(al

tere

d re

nal s

tatu

s); i

ncre

ased

uri

nary

3-m

ethy

l-hi

stid

ine

Ele

vate

d sp

ecif

ic a

min

o ac

ids

(inb

orn

erro

rs o

f m

etab

olis

m)

Ure

mia

, azo

tem

ia (

rena

l pat

ient

s)

Ele

vate

d ho

moc

yste

ine

or a

mm

onia

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Phys

ical

or

neur

olog

ical

cha

nges

(in

born

err

ors

of m

etab

olis

m)

Edi

tion:

200

6 79

INTA

KE D

OMAI

N P

rote

in

INA

PP

RO

PR

IAT

E I

NT

AK

E O

F A

MIN

O A

CID

S (

SP

EC

IFY

) (N

I-52

.3)

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Hig

her

than

rec

omm

ende

d am

ino

acid

inta

ke, e

.g.,

earl

y re

nal d

isea

se, a

dvan

ced

liver

dis

ease

, inb

orn

erro

r of

met

abol

ism

Hig

her

than

rec

omm

ende

d ty

pe o

f am

ino

acid

s fo

r pr

escr

ibed

PE

N th

erap

y

Inap

prop

riat

e su

pple

men

tatio

n, a

s fo

r at

hlet

es

Hig

her

than

rec

omm

ende

d ty

pe o

f pr

otei

n, e

.g.,

exce

ss p

heny

lala

nine

inta

ke

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f ill

ness

that

req

uire

s PE

N th

erap

y

His

tory

of

use

of a

min

o ac

ids

or p

rote

in p

owde

rs f

or a

thle

tic e

nhan

cem

ent

His

tory

of

inbo

rn e

rror

of

met

abol

ism

Refe

ren

ces:

1.

Bet

o JA

, Ban

sal V

K. M

edic

al n

utri

tion

ther

apy

in c

hron

ic k

idne

y fa

ilure

: Int

egra

ting

clin

ical

pra

ctic

e gu

idel

ines

. J A

m D

iet A

ssoc

. 200

4;10

4:40

4-40

9.

2.

Bra

ndle

E, S

iebe

rth

HG

, Hau

tman

n R

E. E

ffec

t of

chro

nic

diet

ary

prot

ein

inta

ke o

n th

e re

nal f

unct

ion

in h

ealth

y su

bjec

ts. E

ur J

Cli

n N

utr.

199

6;50

:734

-740

. 3.

C

ohn

RM

, Rot

h K

S. H

yper

amm

onia

, ban

e of

the

brai

n. C

lin P

edia

tr. 2

004;

43:6

83.

4.

Fras

setto

LA

, Tod

d K

M, M

orri

s R

C J

r, S

ebas

tian

A. E

stim

atio

n of

net

end

ogen

ous

nonc

arbo

nic

acid

pro

duct

ion

in h

uman

s fr

om d

iet,

pota

ssiu

m a

nd p

rote

in c

onte

nts.

Am

J C

lin N

utr.

199

8;68

:576

-58

3.

5.

Frie

dman

N, e

d. A

bsor

ptio

n an

d U

tiliz

atio

n of

Am

ino

Aci

ds, V

ol. I

. Boc

a R

aton

, FL

: CR

C P

ress

, 198

9, p

p229

-242

. 6.

H

ooge

veen

EK

, Kos

tens

e PJ

, Jag

er A

, Hei

ne R

J, J

akob

s C

, Bou

ter

LM

, Don

ker

AJ,

Ste

how

er C

D. S

erum

hom

ocys

tein

e le

vel a

nd p

rote

in in

take

are

rel

ated

to r

isk

of m

icro

albu

min

uria

: the

Hoo

rn

stud

y. K

idne

y In

t. 19

98;5

4:20

3-20

9.

7.

Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: F

ood

and

nutr

ition

mis

info

rmat

ion.

J A

m D

iet A

ssoc

. 200

2;10

2:26

0-26

6.

8.

Rud

man

D, D

iFul

co T

J, G

alam

bos

JT, S

mith

RB

3rd

, Sal

am A

A, W

arre

n W

D. M

axim

um r

ate

of e

xcre

tion

and

synt

hesi

s of

ure

a in

nor

mal

and

cir

rhot

ic s

ubje

cts.

J C

lin I

nves

t. 19

73.;5

2:22

41-2

249.

Edi

tion:

200

6 80

INTA

KE D

OMAI

N C

arbo

hydr

ate a

nd F

iber

Inta

ke

INA

DE

QU

AT

E C

AR

BO

HY

DR

AT

E I

NT

AK

E (

NI-

53.1

)

De

fin

itio

n

Low

er in

take

of

carb

ohyd

rate

con

tain

ing

food

s or

sub

stan

ces

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Phys

iolo

gic

caus

es, e

.g. i

ncre

ased

ene

rgy

need

s du

e to

incr

ease

d ac

tivity

leve

l or

met

abol

ic c

hang

e, m

alab

sorp

tion

Lac

k of

acc

ess

to f

ood,

e.g

., ec

onom

ic c

onst

rain

ts, c

ultu

ral o

r re

ligio

us p

ract

ices

, res

tric

ting

food

giv

en to

eld

erly

and

/or

child

ren

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or d

isor

dere

d ea

ting

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

min

atio

n F

indi

ngs

Ket

one

smel

l on

brea

th

Die

t His

tory

R

epor

t or

obse

rvat

ion

of

Car

bohy

drat

e in

take

bel

ow r

ecom

men

ded

amou

nts

Inab

ility

to in

depe

nden

tly c

onsu

me

food

s/fl

uids

, e.g

., di

min

ishe

d m

obili

ty in

han

d, w

rist

, or

digi

ts

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

panc

reat

ic in

suff

icie

ncy,

hep

atic

dis

ease

, cel

iac

dise

ase,

se

izur

e di

sord

er, c

arbo

hydr

ate

mal

abso

rptio

n, o

r lo

w c

arbo

hydr

ate

diet

s

Refe

ren

ces:

1.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r E

nerg

y, C

arbo

hydr

ate,

Fib

er, F

at, F

atty

Aci

ds, C

hole

ster

ol, P

rote

in, a

nd A

min

o A

cids

. Was

hing

ton

DC

: N

atio

nal A

cade

my

Pres

s; 2

002.

Edi

tion:

200

6 81

INTA

KE D

OMAI

N C

arbo

hydr

ate a

nd F

iber

Inta

ke

EX

CE

SS

IVE

CA

RB

OH

YD

RA

TE

IN

TA

KE

(N

I-53

.2)

De

fin

itio

n

Inta

ke a

bove

the

reco

mm

ende

d le

vel a

nd ty

pe o

f ca

rboh

ydra

te c

ompa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Phys

iolo

gic

caus

es r

equi

ring

mod

ifie

d ca

rboh

ydra

te in

take

, e.g

., di

abet

es m

ellit

us, l

acta

se d

efic

ienc

y, s

ucra

se-i

som

alta

se d

efic

ienc

y, a

ldol

ase-

B d

efic

ienc

y

Cul

tura

l or

relig

ious

pra

ctic

es th

at in

terf

ere

with

the

abili

ty to

red

uce

carb

ohyd

rate

inta

ke

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit,

e.g.

, ina

bilit

y to

acc

ess

suff

icie

nt in

form

atio

n co

ncer

ning

app

ropr

iate

car

bohy

drat

e in

take

Food

and

nut

ritio

n co

mpl

ianc

e lim

itatio

ns, e

.g.,

lack

of

will

ingn

ess

or f

ailu

re to

mod

ify

carb

ohyd

rate

inta

ke in

res

pons

e to

rec

omm

enda

tions

fro

m a

di

etiti

an o

r ph

ysic

ian

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or d

isor

dere

d ea

ting

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a H

yper

glyc

emia

(fa

stin

g bl

ood

suga

r >1

26m

g/dL

)

Hem

oglo

bin

A1C

>6%

Abn

orm

al o

ral g

luco

se to

lera

nce

test

(2

hour

pos

t loa

d gl

ucos

e >

200

mg/

dL)

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

min

atio

n F

indi

ngs

Den

tal c

arie

s

Dia

rrhe

a in

res

pons

e to

car

bohy

drat

e fe

edin

g

Edi

tion:

200

6 82

INTA

KE D

OMAI

N C

arbo

hydr

ate a

nd F

iber

Inta

ke

EX

CE

SS

IVE

CA

RB

OH

YD

RA

TE

IN

TA

KE

(N

I-53

.2)

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Cul

tura

l or

relig

ious

pra

ctic

es th

at d

o no

t sup

port

mod

ific

atio

n of

die

tary

car

bohy

drat

e in

take

Eco

nom

ic c

onst

rain

ts th

at li

mit

avai

labi

lity

of a

ppro

pria

te f

oods

Car

bohy

drat

e in

take

that

is c

onsi

sten

tly a

bove

rec

omm

ende

d am

ount

s

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

diab

etes

mel

litus

, inb

orn

erro

rs o

f ca

rboh

ydra

te

met

abol

ism

, lac

tase

def

icie

ncy,

sev

ere

infe

ctio

n, s

epsi

s, o

r ob

esity

Chr

onic

use

of

med

icat

ions

that

cau

se h

yper

glyc

emia

, e.g

. ste

roid

s

Panc

reat

ic in

suff

icie

ncy

resu

lting

in r

educ

ed in

sulin

pro

duct

ion

Refe

ren

ces:

1.

Bow

man

BA

, Rus

sell

RM

. Pre

sent

Kno

wle

dge

in N

utri

tion.

8th E

d. W

ashi

ngto

n, D

C: I

LSI

Pre

ss, 2

001.

2.

C

lem

ent S

, Bra

ithw

aite

SS,

McG

ee M

F, A

hman

n A

, et a

l. M

anag

emen

t of

diab

etes

in h

ospi

tals

. Dia

bete

s C

are.

200

4;27

:553

-592

. 3.

N

atio

nal A

cade

my

of S

cien

ces,

Ins

titut

e of

Med

icin

e. D

ieta

ry R

efer

ence

Int

akes

for

Ene

rgy,

Car

bohy

drat

e, F

iber

, Fat

, Fat

ty A

cids

, Cho

lest

erol

, Pro

tein

, and

Am

ino

Aci

ds. W

ashi

ngto

n, D

C:

Nat

iona

l Aca

dem

y Pr

ess;

200

2.

4.

The

Exp

ert C

omm

ittee

on

the

Dia

gnos

is a

nd C

lass

ific

atio

n of

Dia

bete

s M

ellit

us. D

iagn

osis

and

cla

ssif

icat

ion

of d

iabe

tes

mel

litu

s.D

iabe

tes

Car

e. 2

004;

27:p

S5-p

S10.

Edi

tion:

200

6 83

INTA

KE D

OMAI

N C

arbo

hydr

ate a

nd F

iber

Inta

ke

INA

PP

RO

PR

IAT

E I

NT

AK

E O

F T

YP

ES

OF

CA

RB

OH

YD

RA

TE

S (

SP

EC

IFY

) (N

I-53

.3)

De

fin

itio

n

Inta

ke o

r th

e ty

pe o

r am

ount

of

carb

ohyd

rate

that

is a

bove

or

belo

w th

e es

tabl

ishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Phys

iolo

gic

caus

es r

equi

ring

car

eful

use

of

mod

ifie

d ca

rboh

ydra

te, e

.g.,

diab

etes

mel

litus

, met

abol

ic s

yndr

ome,

hyp

ogly

cem

ia, c

elia

c di

seas

e, a

llerg

ies,

ob

esity

Cul

tura

l or

relig

ious

pra

ctic

es th

at in

terf

ere

with

the

abili

ty to

reg

ulat

e ty

pes

of c

arbo

hydr

ate

cons

umed

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit,

e.g.

, ina

bilit

y to

acc

ess

suff

icie

nt in

form

atio

n co

ncer

ning

mor

e ap

prop

riat

e ca

rboh

ydra

te ty

pes

and/

or

amou

nts

Food

and

nut

ritio

n co

mpl

ianc

e lim

itatio

ns, e

.g.,

lack

of

will

ingn

ess

or f

ailu

re to

mod

ify

carb

ohyd

rate

inta

ke in

res

pons

e to

rec

omm

enda

tions

fro

m a

di

etiti

an, p

hysi

cian

, or

care

give

r

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or d

isor

dere

d ea

ting

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a H

ypog

lyce

mia

or

hype

rgly

cem

ia d

ocum

ente

d on

reg

ular

bas

is w

hen

com

pare

d w

ith g

oal o

f m

aint

aini

ng g

luco

se

leve

ls a

t or

belo

w 1

40 m

g/dl

thro

ugho

ut th

e da

y

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

min

atio

n F

indi

ngs

Edi

tion:

200

6 84

INTA

KE D

OMAI

N C

arbo

hydr

ate a

nd F

iber

Inta

ke

INA

PP

RO

PR

IAT

E I

NT

AK

E O

F T

YP

ES

OF

CA

RB

OH

YD

RA

TE

S (

SP

EC

IFY

) (N

I-53

.3)

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Dia

rrhe

a in

res

pons

e to

hig

h re

fine

d ca

rboh

ydra

te in

take

Eco

nom

ic c

onst

rain

ts th

at li

mit

avai

labi

lity

of a

ppro

pria

te f

oods

Car

bohy

drat

e in

take

that

is d

iffe

rent

fro

m r

ecom

men

ded

type

s

Alle

rgic

rea

ctio

ns to

cer

tain

car

bohy

drat

e fo

ods

or f

ood

grou

ps

Lim

ited

know

ledg

e of

car

bohy

drat

e co

mpo

sitio

n of

foo

ds o

r of

car

bohy

drat

e m

etab

olis

m

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

diab

etes

mel

litus

, obe

sity

, met

abol

ic s

yndr

ome,

hy

pogl

ycem

ia

Chr

onic

use

of

med

icat

ions

that

cau

se a

ltere

d gl

ucos

e le

vels

, e.g

. ste

roid

s, a

ntid

epre

ssan

ts, a

ntip

sych

otic

s

Refe

ren

ces:

1.

Bow

man

BA

, Rus

sell

RM

. Pre

sent

Kno

wle

dge

in N

utri

tion.

8th E

d. W

ashi

ngto

n, D

C: I

LSI

Pre

ss, 2

001.

2.

C

lem

ent S

, Bra

ithw

aite

SS,

McG

ee M

F, A

hman

n A

, et a

l. M

anag

emen

t of

diab

etes

in h

ospi

tals

. Dia

bete

s C

are.

200

4;27

:553

-592

. 3.

Fr

anz

MJ,

Ban

tle J

P, B

eebe

CA

, Bru

nzel

l JD

, Chi

asso

n J-

L, G

arg

A, H

olzm

eist

er L

A, H

oogw

erf

B, M

ayer

-Dav

is E

, Moo

radi

an A

D, P

urne

ll JQ

, Whe

eler

M: T

echn

ical

rev

iew

. Evi

denc

e-ba

sed

nutr

ition

pri

ncip

les

and

reco

mm

enda

tions

for

the

trea

tmen

t and

pre

vent

ion

of d

iabe

tes

and

rela

ted

com

plic

atio

ns. D

iabe

tes

Car

e 20

02;2

02:1

48-1

98.

4.

Sh

eard

NF,

Cla

rk N

G, B

rand

-Mill

er J

C, F

ranz

MJ,

Pi-

Sun

yer

FX, M

ayer

-Dav

is E

, Kul

karn

i K, G

eil P

: A s

tate

men

t by

the

Am

eric

an D

iabe

tes

Ass

ocia

tion.

Die

tary

car

bohy

drat

e (a

mou

nt a

nd ty

pe)

in th

e pr

even

tion

and

man

agem

ent o

f di

abet

es. D

iabe

tes

Car

e 20

04;2

7:22

66-2

271.

5.

G

ross

LS,

Li L

, For

d E

S, L

iu S

: Inc

reas

ed c

onsu

mpt

ion

of r

efin

ed c

arbo

hydr

ates

and

epi

dem

ic o

r ty

pe 2

dia

bete

s in

the

Uni

ted

Stat

es: a

n ec

olog

ic a

sses

smen

t. A

m J

Cli

n N

utr

2004

;79:

774-

779.

6.

Fr

ench

S, L

in B

-H, G

uthe

rie

JF: N

atio

nal t

rend

s in

sof

t dri

nk c

onsu

mpt

ion

amon

g ch

ildre

n an

d ad

oles

cent

s ag

e 6

to17

yea

rs: p

reva

lenc

e, a

mou

nts,

and

sou

rces

, 197

7/19

78 to

199

4/19

98. J

Am

Die

t A

ssoc

2003

;103

L13

26-1

331,

7.

N

atio

nal A

cade

my

of S

cien

ces,

Ins

titut

e of

Med

icin

e. D

ieta

ry R

efer

ence

Int

akes

for

Ene

rgy,

Car

bohy

drat

e, F

iber

, Fat

, Fat

ty A

cids

, Cho

lest

erol

, Pro

tein

, and

Am

ino

Aci

ds. W

ashi

ngto

n, D

C:

Nat

iona

l Aca

dem

y Pr

ess;

200

2.

8.

Tef

f K

L, E

lliot

t SS

, Tsc

höp

M, K

ieff

er T

J, R

ader

D, H

eim

an M

, Tow

nsen

d R

R, K

eim

NL

, D’A

less

io D

, Hav

el P

J: D

ieta

ry f

ruct

ose

redu

ces

circ

ulat

ing

insu

lin a

nd le

ptin

, atte

nuat

es p

ostp

rand

ial

supp

ress

ion

of g

hrel

in, a

nd in

crea

ses

trig

lyce

ride

s in

wom

en. J

Cli

n E

ndoc

rino

l Met

ab 2

004;

89:2

963-

2972

.9.

T

he E

xper

t Com

mitt

ee o

n th

e D

iagn

osis

and

Cla

ssif

icat

ion

of D

iabe

tes

Mel

litus

. Dia

gnos

is a

nd c

lass

ific

atio

n of

dia

bete

s m

elli

tus.

Dia

bete

s C

are.

200

4;27

:pS5

-pS1

0.

Edi

tion:

200

6 85

INTA

KE D

OMAI

N C

arbo

hydr

ate a

nd F

iber

Inta

ke

INC

ON

SIS

TE

NT

CA

RB

OH

YD

RA

TE

IN

TA

KE

(N

I-53

.4)

De

fin

itio

n

Inco

nsis

tent

tim

ing

of c

arbo

hydr

ate

inta

ke th

roug

hout

the

day,

day

to d

ay, o

r a

patte

rn o

f ca

rboh

ydra

te in

take

that

is n

ot c

onsi

sten

t with

rec

omm

ende

d pa

ttern

ba

sed

upon

phy

siol

ogic

or

med

icat

ion

need

s

Eti

olog

y(C

ause

/Con

trib

utin

g R

isk

Fac

tors

)Fa

ctor

s ga

ther

ed d

urin

g th

e nu

triti

on a

sses

smen

t pro

cess

that

con

trib

ute

to th

e ex

iste

nce

or th

e m

aint

enan

ce o

f pa

thop

hysi

olog

ical

, psy

chos

ocia

l, si

tuat

iona

l, de

velo

pmen

tal,

cultu

ral,

and/

or e

nvir

onm

enta

l pro

blem

s.

Phys

iolo

gic

caus

es r

equi

ring

car

eful

tim

ing

and

cons

iste

ncy

in th

e am

ount

of

carb

ohyd

rate

, e.g

., di

abet

es m

ellit

us, h

ypog

lyce

mia

Cul

tura

l, re

ligio

us p

ract

ices

, or

lifes

tyle

fac

tors

that

inte

rfer

e w

ith th

e ab

ility

to r

egul

ate

timin

g of

car

bohy

drat

e co

nsum

ptio

n

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit,

e.g.

, ina

bilit

y to

acc

ess

suff

icie

nt in

form

atio

n co

ncer

ning

mor

e ap

prop

riat

e tim

ing

of c

arbo

hydr

ate

inta

ke

Food

and

nut

ritio

n co

mpl

ianc

e lim

itatio

ns, e

.g.,

lack

of

will

ingn

ess

or f

ailu

re to

mod

ify

carb

ohyd

rate

tim

ing

in r

espo

nse

to r

ecom

men

datio

ns f

rom

a

diet

itian

, ph

ysic

ian,

or

care

give

r

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or d

isor

dere

d ea

ting

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nu

trit

ion

Assessm

en

t C

ate

go

ry

Po

ten

tial In

dic

ato

rs o

f th

is N

utr

itio

n D

iag

no

sis

(o

ne

or

mo

re m

ust

be p

resen

t)

Bio

chem

ical

Dat

a H

ypog

lyce

mia

or

hype

rgly

cem

ia d

ocum

ente

d on

reg

ular

bas

is a

ssoc

iate

d w

ith in

cons

iste

nt c

arbo

hydr

ate

inta

ke

Wid

e va

riat

ions

in b

lood

glu

cose

leve

ls

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

min

atio

n F

indi

ngs

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Eco

nom

ic c

onst

rain

ts th

at li

mit

avai

labi

lity

of a

ppro

pria

te f

oods

Car

bohy

drat

e in

take

that

is d

iffe

rent

fro

m r

ecom

men

ded

type

s or

inge

sted

on

an ir

regu

lar

basi

s

Edi

tion:

200

6 86

INTA

KE D

OMAI

N C

arbo

hydr

ate a

nd F

iber

Inta

ke

INC

ON

SIS

TE

NT

CA

RB

OH

YD

RA

TE

IN

TA

KE

(N

I-53

.4)

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

diab

etes

mel

litus

, obe

sity

, met

abol

ic s

yndr

ome,

hy

pogl

ycem

ia

Use

of

insu

lin o

r in

sulin

sec

reta

gogu

es

Chr

onic

use

of

med

icat

ions

that

cau

se a

ltere

d gl

ucos

e le

vels

, e.g

. ste

roid

s, a

ntid

epre

ssan

ts, a

ntip

sych

otic

s

Refe

ren

ces:

1.

Bow

man

BA

, Rus

sell

RM

. Pre

sent

Kno

wle

dge

in N

utri

tion.

8th E

d. W

ashi

ngto

n, D

C: I

LSI

Pre

ss, 2

001.

2.

C

lem

ent S

, Bra

ithw

aite

SS,

McG

ee M

F, A

hman

n A

, et a

l. M

anag

emen

t of

diab

etes

in h

ospi

tals

. Dia

bete

s C

are.

200

4;27

:553

-592

. 3.

C

ryer

PE

, Dav

is S

N, S

ham

oon

H: T

echn

ical

rev

iew

. Hyp

ogly

cem

ia in

dia

bete

s. D

iabe

tes

Car

e 20

03;2

6L19

02-1

912.

4.

Fr

anz

MJ,

Ban

tle J

P, B

eebe

CA

, Bru

nzel

l JD

, Chi

asso

n J-

L, G

arg

A, H

olzm

eist

er L

A, H

oogw

erf

B, M

ayer

-Dav

is E

, Moo

radi

an A

D, P

urne

ll JQ

, Whe

eler

M: T

echn

ical

rev

iew

. Evi

denc

e-ba

sed

nutr

ition

pri

ncip

les

and

reco

mm

enda

tions

for

the

trea

tmen

t and

pre

vent

ion

of d

iabe

tes

and

rela

ted

com

plic

atio

ns. D

iabe

tes

Car

e 20

02;2

02:1

48-1

98.

5.

N

atio

nal A

cade

my

of S

cien

ces,

Ins

titut

e of

Med

icin

e. D

ieta

ry R

efer

ence

Int

akes

for

Ene

rgy,

Car

bohy

drat

e, F

iber

, Fat

, Fat

ty A

cids

, Cho

lest

erol

, Pro

tein

, and

Am

ino

Aci

ds. W

ashi

ngto

n, D

C:

Nat

iona

l Aca

dem

y Pr

ess;

200

2.

6.

Rab

asa-

Lho

ret R

, Gar

on J

, Lan

gelie

r H

, Poi

sson

D, C

hias

son

J-L

: The

eff

ects

of

mea

l car

bohy

drat

e co

nten

t on

insu

lin r

equi

rem

ents

in ty

pe 1

pat

ient

s w

ith d

iabe

tes

trea

ted

inte

nsiv

ely

wit

h th

e ba

sal b

olus

(ul

tral

ente

-reg

ular

) in

sulin

reg

imen

. Dia

bete

s C

are

1999

;22:

667-

673.

7.

Sa

voca

MR

, Mill

er C

K, L

udw

ig D

A: F

ood

habi

ts a

re r

elat

ed to

gly

cem

ic c

ontr

ol a

mon

g pe

ople

with

type

2 d

iabe

tes

mel

litus

. J A

m D

iet A

ssoc

200

4;10

4:56

0-56

6.

8.

The

Exp

ert C

omm

ittee

on

the

Dia

gnos

is a

nd C

lass

ific

atio

n of

Dia

bete

s M

ellit

us. D

iagn

osis

and

cla

ssif

icat

ion

of d

iabe

tes

mel

litu

s.D

iabe

tes

Car

e. 2

004;

27:p

S5-p

S10.

9.

W

olev

er T

MS,

Ham

ad S

, Chi

asso

n J-

L, J

osse

RG

, Lei

ter

LA

, Rod

ger

NW

, Ros

s SA

, Rya

n E

A: D

ay-t

o-da

y co

nsis

tenc

y in

am

ount

and

sou

rce

of c

arbo

hydr

ate

inta

ke a

ssoc

iate

d w

ith im

prov

ed

gluc

ose

cont

rol i

n ty

pe 1

dia

bete

s. J

Am

Col

l Nut

r 19

99; 1

8:24

2-24

7.

Edi

tion:

200

6 87

INTA

KE D

OMAI

N C

arbo

hydr

ate a

nd F

iber

Inta

ke IN

AD

EQ

UA

TE

FIB

ER

IN

TA

KE

(N

I-53

.5)

De

fin

itio

n

Low

er in

take

of

fibe

r co

ntai

ning

foo

ds o

r su

bsta

nces

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Lac

k of

acc

ess

to f

iber

con

tain

ing

food

s

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or d

isor

dere

d ea

ting

Prol

onge

d ad

here

nce

to a

low

fib

er o

r lo

w r

esid

ue d

iet

Dif

ficu

lty c

hew

ing

or s

wal

low

ing

high

fib

er f

oods

Eco

nom

ic c

onst

rain

ts th

at li

mit

avai

labi

lity

of a

ppro

pria

te f

oods

Inab

ility

or

unw

illin

gnes

s to

pur

chas

e or

con

sum

e fi

ber

cont

aini

ng f

oods

Inap

prop

riat

e fo

od p

repa

ratio

n pr

actic

es, e

.g.,

relia

nce

on o

ver

proc

esse

d, o

verc

ooke

d fo

ods

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

min

atio

n F

indi

ngs

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Insu

ffic

ient

inta

ke o

f fi

ber

whe

n co

mpa

red

to r

ecom

men

ded

amou

nts

(38

g/da

y fo

r m

en a

nd 2

5 g/

day

for

wom

en)

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

ulce

r di

seas

e, in

flam

mat

ory

bow

el d

isea

se, o

r sh

ort b

owel

sy

ndro

me

trea

ted

with

a lo

w f

iber

die

t

Low

sto

ol v

olum

e

Edi

tion:

200

6 88

INTA

KE D

OMAI

N C

arbo

hydr

ate a

nd F

iber

Inta

ke IN

AD

EQ

UA

TE

FIB

ER

IN

TA

KE

(N

I-53

.5)

Refe

ren

ces:

1.

DiP

alm

a JA

. Cur

rent

trea

tmen

t opt

ions

for

chr

onic

con

stip

atio

n. R

ev G

astr

oent

erol

Dis

ord

2004

;2:S

34-S

42.

2.

Hig

gins

PD

, Joh

anso

n JF

. Epi

dem

iolo

gy o

f co

nstip

atio

n in

Nor

th A

mer

ica:

a s

yste

mat

ic r

evie

w. A

m J

Gas

troe

nter

ol 2

004;

99:7

50-7

59.

3.

Lem

bo A

, Cam

ilier

i M. C

hron

ic c

onst

ipat

ion.

New

Eng

J M

ed 2

003;

349:

360-

368.

4.

N

atio

nal A

cade

my

of S

cien

ces,

Ins

titut

e of

Med

icin

e. D

ieta

ry R

efer

ence

Int

akes

for

Ene

rgy,

Car

bohy

drat

e, F

iber

, Fat

, Fat

ty A

cids

, Cho

lest

erol

, Pro

tein

, and

Am

ino

Aci

ds. W

ashi

ngto

n, D

C:

Nat

iona

l Aca

dem

y Pr

ess;

200

2.

5.

Tal

ley

NJ.

Def

initi

on, e

pide

mio

logy

, and

impa

ct o

f ch

roni

c co

nstip

atio

n. R

ev G

astr

oent

erol

Dis

ord

2004

;2:S

3-S1

0.

Edi

tion:

200

6 89

INTA

KE D

OMAI

N C

arbo

hydr

ate a

nd F

iber

Inta

ke

EX

CE

SS

IVE

FIB

ER

IN

TA

KE

(N

I-53

.6)

De

fin

itio

n

Hig

her

inta

ke o

f fi

ber

cont

aini

ng f

oods

or

subs

tanc

es c

ompa

red

to r

ecom

men

datio

ns b

ased

upo

n pa

tient

/clie

nt c

ondi

tion

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit a

bout

des

irab

le q

uant

ities

of

fibe

r fo

r in

divi

dual

con

ditio

n

Har

mfu

l bel

iefs

or

attit

udes

abo

ut f

ood

or n

utri

tion-

rela

ted

topi

cs, e

.g.,

obse

ssio

n w

ith b

owel

fre

quen

cy a

nd h

abits

Lac

k of

kno

wle

dge

abou

t app

ropr

iate

fib

er in

take

for

con

ditio

n

Poor

den

titio

n, G

I st

rict

ure

or d

ysm

otili

ty

Food

pre

para

tion

or e

atin

g pa

ttern

s th

at in

volv

e on

ly h

igh

fibe

r fo

ods

to th

e ex

clus

ion

of o

ther

nut

rien

t-de

nse

food

s

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

min

atio

n F

indi

ngs

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Fibe

r in

take

hig

her

than

tole

rate

d or

gen

eral

ly r

ecom

men

ded

for

curr

ent m

edic

al c

ondi

tion

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

ulce

r di

seas

e, ir

rita

ble

bow

el s

yndr

ome,

infl

amm

ator

y bo

wel

dis

ease

, sho

rt b

owel

syn

drom

e, d

iver

ticul

itis,

obs

truc

tive

cons

tipat

ion,

pro

laps

ing

hem

orrh

oids

, gas

troi

ntes

tinal

st

rict

ure,

eat

ing

diso

rder

s, o

r m

enta

l illn

ess

with

obs

essi

ve-c

ompu

lsiv

e te

nden

cies

Nau

sea,

vom

iting

, exc

essi

ve f

latu

lenc

e, d

iarr

hea,

abd

omin

al c

ram

ping

, hig

h st

ool v

olum

e or

fre

quen

cy th

at c

ause

s di

scom

fort

to th

e in

divi

dual

, obs

truc

tion,

phy

tobe

zoar

Edi

tion:

200

6 90

INTA

KE D

OMAI

N C

arbo

hydr

ate a

nd F

iber

Inta

ke

EX

CE

SS

IVE

FIB

ER

IN

TA

KE

(N

I-53

.6)

Refe

ren

ces:

1.

DiP

alm

a JA

. Cur

rent

trea

tmen

t opt

ions

for

chr

onic

con

stip

atio

n. R

ev G

astr

oent

erol

Dis

ord

2004

;2:p

S34-

pS42

. 2.

H

iggi

ns P

D, J

ohan

son

JF. E

pide

mio

logy

of

cons

tipat

ion

in N

orth

Am

eric

a: a

sys

tem

atic

rev

iew

. Am

J G

astr

oent

erol

200

4;99

:750

-759

. 3.

L

embo

A, C

amili

eri M

. Chr

onic

con

stip

atio

n. N

ew E

ng J

Med

. 200

3;34

9:36

0-36

8.

4.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es f

or E

nerg

y, C

arbo

hydr

ate,

Fib

er, F

at, F

atty

Aci

ds, C

hole

ster

ol, P

rote

in, a

nd A

min

o A

cids

. Was

hing

ton,

DC

: N

atio

nal A

cade

my

Pres

s; 2

002.

5.

Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: H

ealth

impl

icat

ions

of

diet

ary

fibe

r. J

Am

Die

t Ass

oc. 2

002;

102:

993-

1000

. 6.

T

alle

y N

J. D

efin

ition

, epi

dem

iolo

gy, a

nd im

pact

of

chro

nic

cons

tipat

ion.

Rev

Gas

troe

nter

ol D

isor

d. 2

004;

2:pS

3-pS

10.

7.

van

den

Ber

g H

, van

der

Gaa

g M

, Hen

drik

s H

. Inf

luen

ce o

f lif

esty

le o

n vi

tam

in b

ioav

aila

bilit

y. I

nt J

Vita

m N

utr

Res

. 200

2;72

:53-

5.

8.

Wal

d A

. Irr

itabl

e bo

wel

syn

drom

e. C

urr

Trea

t Opt

ions

Gas

troe

nter

ol. 1

999;

2:13

-19.

Edi

tion:

200

6 91

INTA

KE D

OMAI

N V

itam

in In

take

INA

DE

QU

AT

E V

ITA

MIN

IN

TA

KE

(SP

EC

IFY

)(N

I-54

.1)

De

fin

itio

n

Low

er in

take

of

vita

min

con

tain

ing

food

s or

sub

stan

ces

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Phys

iolo

gic

caus

es, e

.g. i

ncre

ased

nut

rien

t nee

ds d

ue to

pro

long

ed c

atab

olic

illn

ess,

dis

ease

sta

te, m

alab

sorp

tion,

or

med

icat

ions

Lac

k of

acc

ess

to f

ood,

e.g

., ec

onom

ic c

onst

rain

ts, c

ultu

ral o

r re

ligio

us p

ract

ices

, res

tric

ting

food

giv

en to

eld

erly

and

/or

child

ren

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit c

once

rnin

g fo

od s

ourc

es o

f vi

tam

ins

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or e

atin

g di

sord

ers

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Edi

tion:

200

6 92

INTA

KE D

OMAI

N V

itam

in In

take

INA

DE

QU

AT

E V

ITA

MIN

IN

TA

KE

(SP

EC

IFY

)(N

I-54

.1)

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a V

itam

in A

-ser

um r

etin

ol <

0.3

5 m

mol

/L

Vita

min

C –

pla

sma

conc

entr

atio

ns <

.2 m

g/dL

Vita

min

D-

ioni

zed

calc

ium

< .9

8 m

mol

/L w

ith e

leva

ted

para

thyr

oid

horm

one,

nor

mal

ser

um c

alci

um, a

nd s

erum

ph

osph

orus

< 2

.6 m

g/dL

Vita

min

E-

plas

ma

alph

a-to

coph

erol

<18

mol

/g

Vita

min

K –

ele

vate

d pr

othr

ombi

n tim

e; a

ltere

d IN

R (

with

out a

nti-

coag

ulat

ion

ther

apy)

Thi

amin

– e

ryth

rocy

te tr

ansk

etol

ase

activ

ity >

1.2

0 m

cg/m

l/h

Rib

ofla

vin

– er

ythr

ocyt

e gl

utat

hion

e re

duct

ase

> 1

.2 I

U/m

g he

mog

lobi

n

Nia

cin

– N

’met

hyl-

nico

tinam

ide

excr

etio

n <5

.8 µ

mol

/day

Vita

min

B6

– pl

asm

a pr

yrdo

xal 5

’pho

spha

te <

20 n

ml/L

Vita

min

B12

– s

erum

con

cent

ratio

n <1

80 p

mol

/L; e

leva

ted

hom

ocys

tein

e

Folic

aci

d—se

rum

con

cent

ratio

n <7

nm

ol/L

; red

cel

l fol

ate

< 31

5 nm

ol/L

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Vita

min

A –

nig

ht b

lindn

ess,

Bito

t’s

spot

s, x

erop

thal

mia

, fol

licul

ar h

yper

kera

tosi

s

Vita

min

C –

fol

licul

ar h

yper

kera

tosi

s, p

etic

hiae

, ecc

hym

osis

, coi

led

hair

s, in

flam

ed a

nd b

leed

ing

gum

s, p

erif

olic

ular

he

mor

rhag

es, j

oint

eff

usio

ns, a

rthr

algi

a, a

nd im

pair

ed w

ound

hea

ling

Vita

min

D –

wid

enin

g at

end

s of

long

bon

es, r

achi

tic r

osar

y in

chi

ldre

n, r

icke

ts, o

steo

mal

acia

Rib

ofla

vin

– so

re th

roat

, hyp

erem

ia, e

dem

a of

pha

ryng

eal a

nd o

ral m

ucou

s m

embr

anes

, che

ilosi

s, a

ngul

ar s

tom

atiti

s,

glos

sitis

, seb

orrh

eic

derm

atiti

s, a

nd n

orm

oshr

omic

, nor

moc

ytin

ane

mia

with

pur

e er

ythr

ocyt

e cy

topl

asia

of

the

bone

m

arro

w

Nia

cin

– sy

mm

etri

cal,

pigm

ente

d ra

sh o

n ar

eas

expo

sed

to s

unlig

ht, b

righ

t red

tong

ue, p

ella

gra

Vita

min

B6

– se

borr

heic

der

mat

itis,

sto

mat

itis,

che

ilosi

s, g

loss

itis,

con

fusi

on, d

epre

ssio

n

Vita

min

B12

– ti

nglin

g an

d nu

mbn

ess

in e

xtre

miti

es, d

imin

ishe

d vi

brat

ory

and

posi

tion

sens

e, m

otor

dis

turb

ance

s in

clud

ing

gait

dist

urba

nces

Edi

tion:

200

6 93

INTA

KE D

OMAI

N V

itam

in In

take

INA

DE

QU

AT

E V

ITA

MIN

IN

TA

KE

(SP

EC

IFY

)(N

I-54

.1)

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Die

tary

his

tory

ref

lect

s in

adeq

uate

inta

ke o

f fo

ods

cont

aini

ng s

peci

fic

vita

min

s as

com

pare

d to

req

uire

men

ts o

r re

com

men

ded

leve

l

Die

tary

his

tory

ref

lect

s ex

cess

ive

cons

umpt

ion

of f

oods

that

do

not c

onta

in a

vaila

ble

vita

min

s, e

.g. o

ver

proc

esse

d, o

ver

cook

ed, o

r im

prop

erly

sto

red

food

s

Clie

nt H

isto

ry

Prol

onge

d us

e of

sub

stan

ces

know

n to

incr

ease

vita

min

req

uire

men

ts o

r re

duce

vita

min

abs

orpt

ion

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

mal

abso

rptio

n as

a r

esul

t of

celia

c di

seas

e, s

hort

bow

el

synd

rom

e, o

r in

flam

mat

ory

bow

el

Cer

tain

env

iron

men

tal c

ondi

tions

, e.g

. inf

ants

exc

lusi

vely

fed

bre

ast m

ilk w

ith li

mite

d ex

posu

re to

sun

light

(V

itam

in D

)

Refe

ren

ces:

1.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r V

itam

in A

, Vita

min

K, A

rsen

ic, B

oron

, Chr

omiu

m, C

oppe

r, I

odin

e, I

ron,

Man

gane

se, M

olyb

denu

m, N

icke

l,Si

lico

n, V

anad

ium

, and

Zin

c. W

ashi

ngto

n, D

.C. N

atio

nal A

cade

my

Pres

s: 2

000.

2.

N

atio

nal A

cade

my

of S

cien

ces,

Ins

titut

e of

Med

icin

e. D

ieta

ry R

efer

ence

Int

akes

for

Thia

min

e, R

ibof

lavi

n, N

iaci

n, V

itam

in B

6, F

olat

e, V

itam

in B

12, P

anto

then

ic A

cid,

Bio

tin,

and

Cho

line

Was

hing

ton,

D.C

. Nat

iona

l Aca

dem

y Pr

ess:

200

0.

3.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r V

itam

in C

, Vita

min

E, S

elen

ium

, and

Car

oten

oids

. Was

hing

ton,

D.C

. Nat

iona

l Aca

dem

y Pr

ess:

200

0.

4.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r C

alci

um, P

hosp

horu

s, M

agne

sium

, Vita

min

D, a

nd F

luor

ide.

Was

hing

ton,

D.C

. Nat

iona

l Aca

dem

y Pr

ess:

19

97.

Edi

tion:

200

6 94

INTA

KE D

OMAI

N V

itam

in In

take

EX

CE

SS

IVE

VIT

AM

IN I

NT

AK

E(S

PE

CIF

Y)

(NI-

54.2

)

De

fin

itio

n

Hig

her

inta

ke o

f vi

tam

in c

onta

inin

g fo

ods

or s

ubst

ance

s co

mpa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

bas

ed u

pon

phys

iolo

gica

l nee

ds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Phys

iolo

gic

caus

es, e

.g. d

ecre

ased

nut

rien

t nee

ds d

ue to

pro

long

ed im

mob

ility

or

chro

nic

rena

l dis

ease

Acc

ess

to f

oods

and

sup

plem

ents

in e

xces

s of

nee

ds, e

.g.,

cultu

ral o

r re

ligio

us p

ract

ices

, ina

ppro

pria

te f

ood

and

supp

lem

ents

giv

en to

pre

gnan

t wom

en,

elde

rly

or c

hild

ren

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit c

once

rnin

g fo

od a

nd s

uppl

emen

tal s

ourc

es o

f vi

tam

ins

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or e

atin

g di

sord

ers

Acc

iden

tal o

verd

ose

from

ora

l and

sup

plem

enta

l for

ms,

ent

eral

or

pare

nter

al s

ourc

es

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a V

itam

in D

- io

nize

d ca

lciu

m >

.98

with

ele

vate

d pa

rath

yroi

d ho

rmon

e, n

orm

al s

erum

cal

cium

, and

ser

um p

hosp

horu

s >

2.6

Vita

min

K –

slo

wed

pro

thro

mbi

n tim

e or

alte

red

INR

Nia

cin

– N

’met

hyl-

nico

tinam

ide

excr

etio

n >5

.8 µ

mol

/day

Vita

min

B6

– pl

asm

a pr

yrdo

xal 5

’pho

spha

te >

20 n

oml/L

Vita

min

A –

ser

um r

etin

ol c

once

ntra

tion

> 60

µg/

dL

Ant

hrop

omet

ric

Mea

sure

men

ts

Edi

tion:

200

6 95

INTA

KE D

OMAI

N V

itam

in In

take

EX

CE

SS

IVE

VIT

AM

IN I

NT

AK

E(S

PE

CIF

Y)

(NI-

54.2

)P

hysi

cal E

xam

Fin

ding

s V

itam

in A

– c

hang

es in

the

skin

and

muc

ous

mem

bran

es; d

ry li

ps (

chei

litis

), e

arly

-dry

ness

of

the

nasa

l muc

osa

and

eyes

; la

ter-

dryn

ess,

ery

them

a, s

calin

g an

d pe

elin

g of

the

skin

, hai

r lo

ss, a

nd n

ail f

ragi

lity.

Hea

dach

e, n

ause

a, a

nd v

omiti

ng.

Infa

nts

may

hav

e bu

lgin

g fo

ntan

elle

; chi

ldre

n m

ay d

evel

op b

one

alte

ratio

ns.

Vita

min

D –

ele

vate

d se

rum

cal

cium

(hy

perc

alce

mia

) an

d ph

osph

orus

(hy

perp

hosp

hate

mia

) le

vels

; ca

lcif

icat

ion

of s

oft

tissu

es (

calc

inos

is),

incl

udin

g th

e ki

dney

, lun

gs, h

eart

, and

eve

n th

e ty

mpa

nic

mem

bran

e of

the

ear,

whi

ch c

an r

esul

t in

deaf

ness

. Hea

dach

e an

d na

usea

. Inf

ants

giv

en e

xces

sive

am

ount

s of

vita

min

D m

ay h

ave

gast

roin

test

inal

ups

et, b

one

frag

ility

, and

ret

arde

d gr

owth

.

Vita

min

K –

hem

olyt

ic a

nem

ia in

adu

lts o

r se

ver

jaun

dice

in in

fant

s ha

ve b

een

note

d on

rar

e oc

casi

ons

Nia

cin

– hi

stam

ine

rele

ase

whi

ch c

ause

s fl

ushi

ng, a

ggra

vatio

n of

ast

hma

or li

ver

dise

ase

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f

His

tory

or

mea

sure

d in

take

ref

lect

s ex

cess

ive

inta

ke o

f fo

ods

and

supp

lem

ents

con

tain

ing

vita

min

s as

com

pare

d to

es

timat

ed r

equi

rem

ents

, inc

ludi

ng f

ortif

ied

cere

als,

mea

l rep

lace

men

ts, v

itam

in-m

iner

al s

uppl

emen

ts, o

ther

die

tary

su

pple

men

ts (

e.g.

, fis

h liv

er o

ils o

r ca

psul

es),

tube

fee

ding

, and

/or

pare

nter

al s

olut

ions

Inta

ke g

reat

er th

an U

L f

or v

itam

in A

(as

ret

inol

est

er, n

ot a

s -c

arot

ene)

is 6

00 µ

g/d

for

infa

nts

and

todd

lers

; 900

µg/

d fo

r ch

ildre

n 4-

8 yr

s, 1

700

µg/

d fo

r ch

ildre

n 9-

13 y

rs, 2

800

for

child

ren

14-1

8 yr

s, a

nd 3

000

µg/

d fo

r ad

ults

Inta

ke g

reat

er th

an U

L f

or v

itam

in D

is 2

5 µ

g/da

y fo

r in

fant

s an

d 50

µg/

day

for

child

ren

and

adul

ts

Nia

cin:

hig

h do

ses

of 1

to 2

g o

f N

A th

ree

times

per

day

can

hav

e si

de e

ffec

ts o

f cl

inic

al u

ses

of h

igh

dose

s of

1 to

2 g

of

NA

thre

e tim

es p

er d

ay

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

chro

nic

liver

or

kidn

ey d

isea

ses,

hea

rt f

ailu

re, c

ance

r

Refe

ren

ces:

1.

Alle

n L

H, H

aske

ll M

. Est

imat

ing

the

pote

ntia

l for

vita

min

A to

xici

ty in

wom

en a

nd y

oung

chi

ldre

n. J

Nut

r. 2

002;

132:

pS29

07-p

S291

9.

2.

Cro

quet

V, P

ilette

C, L

espi

ne A

, Vui

llem

in E

, Rou

ssel

et M

C, O

bert

i F, S

aint

And

re J

P, P

eriq

uet B

, Fra

ncoi

s S,

Ifr

ah N

, Cal

es P

. Hep

atic

hyp

er-v

itam

inos

is A

: im

port

ance

of

retin

yl e

ster

leve

l de

term

inat

ion.

Eur

J G

astr

oent

erol

Hep

atol

. 200

0;12

:361

-364

. 3.

K

rasi

nski

SD

, Rus

sell

RM

, Otr

adov

ec C

L, S

adow

ski J

A, H

artz

SC

, Jac

ob R

A, M

cGan

dy R

B. R

elat

ions

hip

of v

itam

in A

and

vita

min

E in

take

to f

astin

g pl

asm

a re

tinol

, ret

inol

-bin

ding

pro

tein

, re

tinyl

est

ers,

car

oten

e, a

lpha

-toc

ophe

rol,

and

chol

este

rol a

mon

g el

derl

y pe

ople

and

you

ng a

dults

: inc

reas

ed p

lasm

a re

tinyl

est

ers

amon

g vi

tam

in A

-sup

plem

ent u

sers

. Am

J C

lin N

utr.

198

9;49

:112

-12

0.

4.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r V

itam

in A

, Vita

min

K, A

rsen

ic, B

oron

, Chr

omiu

m, C

oppe

r, I

odin

e, I

ron,

Man

gane

se, M

olyb

denu

m, N

icke

l,Si

lico

n, V

anad

ium

, and

Zin

c. W

ashi

ngto

n, D

.C. N

atio

nal A

cade

my

Pres

s:20

00.

5.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r Th

iam

ine,

Rib

ofla

vin,

Nia

cin,

Vita

min

B6,

Fol

ate,

Vita

min

B12

, Pan

toth

enic

Aci

d, B

ioti

n, a

nd C

holin

eW

ashi

ngto

n, D

.C. N

atio

nal A

cade

my

Pres

s:20

00.

6.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r V

itam

in C

, Vita

min

E, S

elen

ium

, and

Car

oten

oids

. Was

hing

ton,

D.C

. Nat

iona

l Aca

dem

y Pr

ess:

2000

. 7.

R

usse

ll R

M. N

ew v

iew

s on

RD

As

for

olde

r ad

ults

. J A

m D

iet A

ssoc

. 199

7;97

:515

-518

.

Edi

tion:

200

6 96

INTA

KE D

OMAI

N M

iner

al In

take

INA

DE

QU

AT

E M

INE

RA

L I

NT

AK

E (

NI-

55.1

)D

efi

nit

ion

Low

er in

take

of

min

eral

con

tain

ing

food

s or

sub

stan

ces

com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Phys

iolo

gic

caus

es, e

.g. i

ncre

ased

nut

rien

t nee

ds d

ue to

pro

long

ed c

atab

olic

illn

ess,

mal

abso

rptio

n, h

yper

excr

etio

n, n

utri

ent/d

rug

and

nutr

ient

/nut

rien

t in

tera

ctio

n, g

row

th a

nd m

atur

atio

n

Lac

k of

acc

ess

to f

ood,

e.g

. eco

nom

ic c

onst

rain

ts, c

ultu

ral o

r re

ligio

us p

ract

ices

, res

tric

ting

food

giv

en to

eld

erly

and

/or

child

ren

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit c

once

rnin

g fo

od s

ourc

es o

f m

iner

als;

mis

-dia

gnos

is o

f la

ctos

e in

tole

ranc

e/la

ctas

e de

fici

ency

; per

cept

ion

of

conf

lictin

g nu

triti

on m

essa

ges

from

hea

lth p

rofe

ssio

nals

, ina

ppro

pria

te r

elia

nce

on s

uppl

emen

ts

Psyc

holo

gica

l cau

ses,

e.g

. dep

ress

ion

or e

atin

g di

sord

ers

Env

iron

men

tal c

ause

s, e

.g. i

nade

quat

ely

test

ed n

utri

ent b

ioav

aila

bilit

y of

for

tifie

d fo

ods,

bev

erag

es a

nd s

uppl

emen

ts, i

napp

ropr

iate

mar

ketin

g of

for

tifie

d fo

ods/

beve

rage

s/su

pple

men

ts a

s a

subs

titut

e fo

r na

tura

l foo

d so

urce

of

nutr

ient

(s)

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a C

alci

um –

bon

e m

iner

al c

onte

nt (

BM

C)

belo

w th

e yo

ung

adul

t mea

n. H

ypoc

alci

uria

, ser

um 2

5(O

H)D

< 3

2 ng

/mL

Phos

phor

us <

2.6

mg/

dL

Mag

nesi

um <

1.8

mg/

dL

Iron

– h

emog

lobi

n <1

30g/

L (

mal

es; <

120g

/L (

fem

ales

), e

tc.

Iodi

ne –

uri

nary

exc

retio

n <1

00µ

g/L

Cop

per

– se

rum

cop

per

<10µ

mol

/L, e

tc

Ant

hrop

omet

ric

Mea

sure

men

ts

Hei

ght l

oss

Phy

sica

l Exa

m F

indi

ngs

Cal

cium

– d

imin

ishe

d B

MD

, hyp

erte

nsio

n, P

CO

S, P

MS,

kid

ney

ston

es, c

olon

pol

yps,

obe

sity

Edi

tion:

200

6 97

INTA

KE D

OMAI

N M

iner

al In

take

INA

DE

QU

AT

E M

INE

RA

L I

NT

AK

E (

NI-

55.1

)F

ood/

Nut

ritio

n H

isto

ry

Obs

erva

tions

/rep

orts

of

insu

ffic

ient

min

eral

inta

ke f

rom

die

t com

pare

d to

rec

omm

ende

d in

take

Food

avo

idan

ce a

nd/o

r el

imin

atio

n of

who

le f

ood

grou

p(s)

fro

m d

iet

Lac

k of

inte

rest

in f

ood

Inap

prop

riat

e fo

od c

hoic

es a

nd/o

r ch

roni

c di

etin

g be

havi

or

Exc

essi

ve N

a in

take

, ina

dequ

ate

Vita

min

D in

take

/exp

osur

e

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

mal

abso

rptio

n as

a r

esul

t of

celia

c di

seas

e, s

hort

bow

el

synd

rom

e, o

r in

flam

mat

ory

bow

el d

isea

se

Oth

er s

igni

fica

nt m

edic

al d

iagn

oses

and

ther

apie

s

Est

roge

n st

atus

Geo

grap

hic

latit

ude

and

hist

ory

of U

VB

exp

osur

e/us

e of

sun

scre

en

Cha

nge

in li

ving

env

iron

men

t/ind

epen

denc

e

Use

of

popu

lar

pres

s/in

tern

et a

s so

urce

of

med

ical

and

/or

nutr

ition

info

rmat

ion

Refe

ren

ces:

1.

App

el L

J, M

oore

TJ,

Oba

rzan

ek E

, Vol

lmer

WM

, Sve

tkey

LP,

Sac

ks F

M, B

ray

GA

, Vog

t TM

, Cut

ler

JA, W

indh

ause

r M

M, L

in P

-H, K

aran

ja N

. A

clin

ical

tria

l of

the

effe

cts

of d

ieta

ry p

atte

rns

on

bloo

d pr

essu

re.

N E

ng J

Med

. 199

7;33

6:11

17-1

124.

2.

H

eane

y R

P. R

ole

of d

ieta

ry s

odiu

m in

ost

eopo

rosi

s. A

m J

Clin

Nut

r (i

n pr

ess)

200

5.

3.

Hea

ney,

RP.

Nut

rien

ts, i

nter

actio

ns, a

nd f

oods

. The

Im

port

ance

of

Sour

ce, I

n B

urck

hard

t P, D

awso

n-H

ughe

s B

, Hea

ney

RP,

Eds

. Nut

riti

onal

Asp

ects

of O

steo

poro

sis

2nd E

d. S

an D

iego

, CA

: E

lsev

ier,

200

4:61

-76.

4.

H

eane

y, R

P. N

utri

ents

, int

erac

tions

, and

foo

ds. S

erum

25-

hydr

oxy-

vita

min

D a

nd th

e he

alth

of

the

calc

ium

eco

nom

y, I

n B

urck

hard

t P, D

awso

n-H

ughe

s B

, Hea

ney

RP,

Eds

. Nut

ritio

nal A

spec

ts o

f O

steo

poro

sis

2nd E

d. S

an D

iego

, CA

: Els

evie

r, 2

004:

227-

244.

5.

H

eane

y R

P, R

affe

rty

K, B

ierm

an J

. Not

all

calc

ium

-for

tifi

ed b

ever

ages

are

equ

al. N

utr

Toda

y (i

n pr

ess)

. 200

4.

6.

Hea

ney

RP,

Dow

ell M

S, H

ale

CA

, Ben

dich

A. C

alci

um a

bsor

ptio

n va

ries

with

in th

e re

fere

nce

rang

e fo

r se

rum

25-

hydr

oxyv

itam

in D

.J A

m C

oll N

utr.

200

3;22

:142

-146

. 7.

H

eane

y R

P, D

owel

l MS,

Raf

fert

y K

, Bie

rman

J. B

ioav

aila

bilit

y of

the

calc

ium

in f

ortif

ied

soy

imita

tion

mil

k, w

ith s

ome

obse

rvat

ions

on

met

hod.

Am

J C

lin N

utr.

200

0;71

:116

6-11

69.

8.

H

olic

k M

F. F

unct

ions

of

vita

min

D: i

mpo

rtan

ce f

or p

reve

ntio

n of

com

mon

can

cers

, Typ

e I

diab

etes

and

hea

rt D

isea

se. p

p. 1

81-2

01. I

n: N

utri

tiona

l Asp

ects

of O

steo

poro

sis,

2nd

Edi

tion.

Bur

ckha

rdt

P, D

awso

n-H

ughe

s B

, Hea

ney

RP,

eds

. Els

evie

r In

c., S

an D

iego

, CA

, 200

4 9.

M

asse

y L

K, W

hitin

g SJ

. Die

tary

sal

t, ur

inar

y ca

lciu

m, a

nd b

one

loss

. J B

one

Min

er R

es. 1

1:73

1-73

6, 1

996.

10

. Su

araz

FL

, Sav

aian

o D

, Arb

isi P

, Lev

itt M

D. T

oler

ance

to th

e da

ily in

gest

ion

of tw

o cu

ps o

f m

ilk b

y in

divi

dual

s cl

aim

ing

lact

ose

into

lera

nce.

Am

J C

lin N

utr.

199

7;65

:150

2-15

06.

11.

Thy

s- J

acob

s S,

Don

ovan

D, P

apad

opou

los

A, S

arre

l P. B

ilezi

kian

JP.

Vita

min

D a

nd c

alci

um d

ysre

gula

tion

in th

e po

lycy

stic

ova

rian

syn

drom

e. S

tero

ids.

64:

430-

435,

199

9.

12.

Thy

s-Ja

cobs

S, S

tark

ey P

, Ber

nste

in D

, Tia

n J.

Cal

cium

car

bona

te a

nd th

e pr

emen

stru

al s

yndr

ome:

Eff

ects

on

prem

enst

rual

and

men

stru

al s

ympt

omat

olog

y. A

m J

Obs

tet G

ynec

ol. 1

998;

179:

444-

452.

13

. Z

emel

MB

, Tho

mps

on W

, Mils

tead

A, M

orri

s K

, Cam

pbel

l P. C

alci

um a

nd d

airy

acc

eler

atio

n of

wei

ght a

nd f

at lo

ss d

urin

g en

ergy

res

tric

tion

in o

bese

adu

lts. O

besi

ty R

es. 1

2:58

2-59

0, 2

004.

Edi

tion:

200

6 98

INTA

KE D

OMAI

N M

iner

al In

take

EX

CE

SS

IVE

MIN

ER

AL

IN

TA

KE

(N

I-55

.2)

De

fin

itio

n

Hig

her

inta

ke o

f m

iner

al f

rom

foo

ds, s

uppl

emen

ts, m

edic

atio

ns o

r w

ater

, com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns b

ased

upo

n ph

ysio

logi

cal n

eeds

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Har

mfu

l bel

iefs

/atti

tude

s ab

out f

ood,

nut

ritio

n, a

nd n

utri

tion-

rela

ted

topi

cs

Food

fad

dism

Acc

iden

tal o

ver-

supp

lem

enta

tion

Ove

rcon

sum

ptio

n of

a li

mite

d va

riet

y of

foo

ds

Lac

k of

kno

wle

dge

abou

t man

agem

ent o

f di

agno

sed

gene

tic d

isor

der

alte

ring

min

eral

hom

eost

asis

[he

moc

hrom

otos

is (

iron

), W

ilson

’s D

isea

se (

copp

er)]

Lac

k of

kno

wle

dge

abou

t man

agem

ent o

f di

agno

sed

dise

ase

stat

e re

quir

ing

min

eral

res

tric

tion

[cho

lest

atic

live

r di

seas

e (c

oppe

r an

d m

anga

nese

), r

enal

in

suff

icie

ncy

(pho

spho

rus,

mag

nesi

um, p

otas

sium

)]

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a C

hang

es in

app

ropr

iate

labo

rato

ry v

alue

s, s

uch

as:

TSH

(io

dine

sup

plem

enta

tion)

HD

L (

zinc

sup

plem

enta

tion)

ser

um f

erri

tin a

nd tr

ansf

erri

n sa

tura

tion

(iro

n ov

erlo

ad)

Hyp

erph

osph

atem

ia

Hyp

erm

agne

sem

ia

Edi

tion:

200

6

99

INTA

KE D

OMAI

N M

iner

al In

take

EX

CE

SS

IVE

MIN

ER

AL

IN

TA

KE

(N

I-55

.2)

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Hai

r an

d na

il ch

ange

s (s

elen

ium

)

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Hig

h in

take

of

food

s or

sup

plem

ents

con

tain

ing

min

eral

com

pare

d to

DR

Is

Dec

reas

ed a

ppet

ite (

zinc

sup

plem

enta

tion)

Clie

nt H

isto

ry

GI

dist

urba

nces

(ir

on, m

agne

sium

, cop

per,

zin

c, s

elen

ium

)

Cop

per

defi

cien

cy a

nem

ia (

zinc

)

Liv

er d

amag

e (c

oppe

r, ir

on),

ena

mel

or

skel

etal

flu

oros

is (

fluo

ride

)

Refe

ren

ces:

1.

Bow

man

BA

, Rus

sell

RM

, eds

. Pre

sent

Kno

wle

dge

in N

utri

tion.

8th E

d. W

ashi

ngto

n, D

C: I

LSI

Pre

ss; 2

001.

2.

N

atio

nal A

cade

my

of S

cien

ces,

Ins

titut

e of

Med

icin

e. D

ieta

ry R

efer

ence

Int

akes

for

Vita

min

A, V

itam

in K

, Ars

enic

, Bor

on, C

hrom

ium

, Cop

per,

Iod

ine,

Iro

n, M

anga

nese

, Mol

ybde

num

, Nic

kel,

Silic

on, V

anad

ium

, Zin

c. W

ashi

ngto

n, D

C: N

atio

nal A

cade

my

Pres

s; 2

001.

3.

Nat

iona

l Aca

dem

y of

Sci

ence

s, I

nstit

ute

of M

edic

ine.

Die

tary

Ref

eren

ce I

ntak

es fo

r C

alci

um, P

hosp

horu

s, M

agne

sium

, Vita

min

D, a

nd F

luor

ide.

Was

hing

ton,

DC

: Nat

iona

l Aca

dem

y Pr

ess;

199

7.

4.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Foo

d an

d nu

triti

on m

isin

form

atio

n. J

Am

Die

t Ass

oc. 2

002;

102:

260-

266.

Edi

tion:

200

6

100

CLIN

CAL

DOMA

IN

Func

tiona

l

SW

AL

LO

WIN

G D

IFF

ICU

LT

Y (

NC

-1.1

)

De

fin

itio

n

Impa

ired

mov

emen

t of

food

and

liqu

id f

rom

the

mou

th to

the

stom

ach

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Mec

hani

cal c

ause

s, e

.g.,

infl

amm

atio

n, s

urge

ry, s

tric

ture

, or

oral

, pha

ryng

eal a

nd e

soph

agea

l tum

ors

Mot

or c

ause

s, e

.g.,

neur

olog

ical

or

mus

cula

r di

sord

ers,

suc

h as

, cer

ebra

l pal

sy, s

trok

e, m

ultip

le s

cler

osis

, scl

erod

erm

a, p

rem

atur

ity

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Evi

denc

e of

deh

ydra

tion,

e.g

., dr

y m

ucou

s m

embr

anes

, poo

r sk

in tu

rgor

Foo

d/N

utri

tion

His

tory

O

bser

vatio

ns o

r re

port

s of

: C

ough

ing,

cho

king

, pro

long

ed c

hew

ing,

pou

chin

g of

foo

d, r

egur

gita

tion,

fac

ial e

xpre

ssio

n ch

ange

s du

ring

eat

ing,

pro

long

ed

feed

ing

time,

dro

olin

g, n

oisy

wet

upp

er a

irw

ay s

ound

s, f

eelin

g of

“fo

od g

ettin

g st

uck,

” pa

in w

hile

sw

allo

win

g D

ecre

ased

foo

d in

take

A

void

ance

of

food

s M

ealti

me

resi

stan

ce

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f dy

spha

gia,

ach

alas

ia

Rad

iolo

gica

l fin

ding

s, e

.g.,

abno

rmal

sw

allo

win

g st

udie

s

Rep

eate

d up

per

resp

irat

ory

infe

ctio

ns a

nd o

r pn

eum

onia

Refe

ren

ces:

1.

Bra

unw

ald

E, F

auci

AS,

Kas

per

DL

, Hau

ser

SL, L

ongo

DL

, Jam

eson

JL

, ed.

Har

riso

n’s

Pri

ncip

les

of I

nter

nal M

edic

ine.

15th

Edi

tion.

New

Yor

k, N

Y: M

cGra

w-H

ill,.2

001.

Edi

tion:

200

6

101

CLIN

CAL

DOMA

IN

Func

tiona

l

CH

EW

ING

(M

AS

TIC

AT

OR

Y)

DIF

FIC

UL

TY

(N

C-1

.2)

De

fin

itio

n

Impa

ired

abi

lity

to b

ite o

r ch

ew f

ood

in p

repa

ratio

n fo

r sw

allo

win

g

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Cra

niof

acia

l mal

form

atio

ns

Ora

l sur

gery

Neu

rom

uscu

lar

dysf

unct

ion

Part

ial o

r co

mpl

ete

eden

tulis

m

Soft

tiss

ue d

isea

se (

prim

ary

or o

ral m

anif

esta

tions

of

a sy

stem

ic d

isea

se)

Xer

osto

mia

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Mis

sing

teet

h

Alte

ratio

ns in

cra

nial

ner

ves

V, V

II, I

X, X

, XII

Dry

or

crac

ked

lips,

tong

ue

Ora

l les

ions

Impa

ired

tong

ue m

ovem

ent

Ill-

fitti

ng d

entu

res

or b

roke

n de

ntur

es

Edi

tion:

200

6

102

CLIN

CAL

DOMA

IN

Func

tiona

l

CH

EW

ING

(M

AS

TIC

AT

OR

Y)

DIF

FIC

UL

TY

(N

C-1

.2)

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Dec

reas

ed in

take

of

food

A

ltera

tions

in f

ood

inta

ke f

rom

usu

al

Dec

reas

ed in

take

or

avoi

danc

e of

foo

d di

ffic

ult t

o fo

rm in

to a

bol

us, e

.g.,

nuts

, w

hole

pie

ces

of m

eat,

poul

try,

fis

h, f

ruits

, ve

geta

bles

A

void

ance

of

food

s of

age

-app

ropr

iate

text

ure

Spitt

ing

food

out

or

prol

onge

d fe

edin

g tim

e

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

alco

holis

m, A

lzhe

imer

’s, h

ead,

nec

k or

pha

ryng

eal c

ance

r,

cere

bral

pal

sy, c

left

lip/

pala

te, o

ral s

oft t

issu

e in

fect

ions

(e.

g., c

andi

dias

is, l

euko

plak

ia),

lack

of

deve

lopm

enta

l rea

dine

ss,

oral

man

ifes

tatio

ns o

f sy

stem

ic d

isea

se (

e.g.

, rhe

umat

oid

arth

ritis

, lup

us, C

rohn

’s d

isea

se, p

enph

igus

vul

gari

s, H

IV,

diab

etes

)R

ecen

t maj

or o

ral s

urge

ry

Wir

ed ja

w

Che

mot

hera

py w

ith o

ral s

ide

effe

cts

Rad

iatio

n th

erap

y to

ora

l cav

ity

Refe

ren

ces:

1.

Bai

ley

R, L

edik

we

JH, S

mic

ikla

s-W

righ

t H, M

itch

ell D

C, J

ense

n G

L. P

ersi

sten

t ora

l hea

lth p

robl

ems

asso

ciat

ed w

ith c

omor

bidi

ty a

nd im

pair

ed d

iet q

ualit

y in

old

er a

dults

. J A

m D

iet A

ssoc

.20

04;1

04:1

273-

1276

. 2.

C

hern

off

R, e

d. O

ral h

ealth

in th

e el

derl

y. G

eria

tric

Nut

ritio

n. G

aith

ersb

urg,

MD

: Asp

en P

ublis

hers

, 199

9.

3.

Dor

men

val V

, Moj

on P

, Bud

tz-J

orge

nsen

E. A

ssoc

iatio

n be

twee

n se

lf-a

sses

sed

mas

ticat

ory

abili

ty, n

utri

tiona

l sta

tus

and

saliv

ary

flow

rat

e in

hos

pita

lized

eld

erly

. Ora

l Dis

ease

s. 1

999;

5:32

-38.

4.

H

ildeb

rand

GH

, Dom

ingu

ez B

L, S

chor

k M

A, L

oesc

he W

J. F

unct

iona

l uni

ts, c

hew

ing,

sw

allo

win

g an

d fo

od a

void

ance

am

ong

the

elde

rly.

J P

rost

het D

ent.

1997

;77:

585-

595.

5.

H

iran

o H

, Ish

iyam

a N

, Wat

anab

e I,

Nas

u I.

Mas

ticat

ory

abili

ty in

rel

atio

n to

ora

l sta

tus

and

gene

ral h

ealth

in a

ging

. J N

utr

Hea

lth A

ging

. 199

9;3:

48-5

2.

6.

Huh

man

n M

, Tou

ger-

Dec

ker

R, B

yham

-Gra

y L

, O’S

ulli

van-

Mai

llet J

, Von

Hag

en S

. Com

pari

son

of d

ysph

agia

scr

eeni

ng b

y a

regi

ster

ed d

ietit

ian

in a

cute

str

oke

patie

nts

to s

peec

h la

ngua

ge

path

olog

ist’

s ev

alua

tion.

Top

Cli

n N

utr.

200

4;19

:239

-249

. 7.

K

adem

ani D

, Glic

k M

. Ora

l ulc

erat

ions

in in

divi

dual

s in

fect

ed w

ith h

uman

imm

unod

efic

ienc

y vi

rus:

clin

ical

pre

sent

atio

ns, d

iagn

osis

, man

agem

ent a

nd r

elev

ance

to d

isea

se p

rogr

essi

on.

Qui

ntes

senc

e In

tern

atio

nal.

1998

;29:

1103

-110

8.

8.

Kel

ler

HH

, Ost

bye

T, B

righ

t-Se

e E

. Pre

dict

ors

of d

ieta

ry in

take

in O

ntar

io s

enio

rs. C

an J

Pub

lic

Hea

lth.

199

7;88

:303

-309

. 9.

K

rall

E, H

ayes

C, G

arci

a R

. How

den

titio

n st

atus

and

mas

ticat

ory

func

tion

affe

ct n

utri

ent i

ntak

e. J

Am

Den

t Ass

oc. 1

998;

129:

1261

-126

9.

10.

Josh

ipur

a K

, Will

ett W

C, D

ougl

ass

CW

. The

impa

ct o

f ed

entu

lous

ness

on

food

and

nut

rien

t int

ake.

J A

m D

ent A

ssoc

. 199

6;12

7:45

9-46

7.

11.

Mac

kle

T, T

ouge

r-D

ecke

r R

, O’S

ulliv

an M

aille

t J, H

olla

nd, B

. R

egis

tere

d D

ietit

ians

’ us

e of

phy

sica

l ass

essm

ent p

aram

eter

s in

pra

ctic

e. J

Am

Die

t Ass

oc. 2

004;

103:

1632

-163

8.

12.

Mob

ley

C, S

aund

ers

M. O

ral h

ealth

scr

eeni

ng g

uide

lines

for

non

dent

al h

ealth

care

pro

vide

rs. J

Am

er D

iet A

ssoc

. 199

7;97

:pS1

23-1

26.

13.

Mor

se, D

. Ora

l and

pha

ryng

eal c

ance

r. I

n: R

Tou

ger-

Dec

ker

et a

l eds

. Nut

riti

on a

nd O

ral M

edic

ine.

Tot

owa

NJ:

Hum

ana

Pres

s, I

nc 2

005,

pag

es 2

05.2

22.

14.

Moy

niha

n P,

But

ler

T, T

hom

ason

J, J

epso

n N

. Nut

rien

t int

ake

in p

artia

lly d

enta

te p

atie

nts:

the

effe

ct o

f pr

osth

etic

reh

abili

tatio

n.J

Den

t. 20

00;2

8:55

7-56

3.

15.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Ora

l hea

lth a

nd n

utri

tion.

J A

m D

iet A

ssoc

. 200

3;10

3:61

5-62

5.

16.

Sayh

oun

NR

Lin

CL

, Kra

ll E

. Nut

riti

onal

sta

tus

of th

e ol

der

adul

t is

asso

ciat

ed w

ith d

entit

ion

stat

us. J

Am

Die

t Ass

oc. 2

003;

103:

61-6

6.

18.

Shei

ham

A, S

teel

e JG

. The

impa

ct o

f or

al h

ealth

on

stat

ed a

bilit

y to

eat

cer

tain

foo

ds; f

indi

ng f

rom

the

natio

nal d

iet a

nd n

utri

tion

surv

ey o

f ol

der

peop

le in

Gre

at B

rita

in. G

erod

onto

logy

.19

99;1

6:11

-20.

19

. Sh

ip J

, Duf

fy V

, Jon

es J

, Lan

gmor

e S.

Ger

iatr

ic o

ral h

ealth

and

its

impa

ct o

n ea

ting.

J A

m G

eria

tr S

oc. 1

996;

44:4

56-4

64.

Edi

tion:

200

6

103

CLIN

CAL

DOMA

IN

Func

tiona

l

CH

EW

ING

(M

AS

TIC

AT

OR

Y)

DIF

FIC

UL

TY

(N

C-1

.2)

20.

Tou

ger-

Dec

ker

R. C

linic

al a

nd la

bora

tory

ass

essm

ent o

f nu

triti

on s

tatu

s. D

ent C

lin N

orth

Am

eric

a. 2

003;

47:2

59-2

78.

21.

Tou

ger-

Dec

ker

R, S

iroi

s D

, Mob

ley

C (

eds)

. Nut

riti

on a

nd O

ral M

edic

ine.

Hum

ana

Pres

s, S

epte

mbe

r 20

04.

22.

Wal

ls A

W, S

teel

e JG

, She

iham

A, M

arce

nes

W, M

oyni

han

PJ. O

ral h

ealth

and

nut

ritio

n in

old

er p

eopl

e. J

Pub

lic H

ealth

Den

t. 20

00;6

0:30

4-30

7.

Edi

tion:

200

6

104

CLIN

CAL

DOMA

IN

Func

tiona

l

BR

EA

ST

FE

ED

ING

DIF

FIC

UL

TY

(N

C-1

.3)

De

fin

itio

n

Inab

ility

to s

usta

in in

fant

nut

ritio

n th

roug

h br

east

feed

ing

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Infa

nt: D

iffi

culty

latc

hing

on,

e.g

., tig

ht f

renu

lum

Poor

suc

king

abi

lity

Ora

l pai

n

Mal

nutr

ition

/mal

abso

rptio

n

Let

harg

y, s

leep

ines

s

Irri

tabi

lity

Swal

low

ing

diff

icul

ty

Moth

er: Pa

infu

l bre

asts

, nip

ples

Bre

ast o

r ni

pple

abn

orm

ality

Mas

titis

Perc

eptio

n of

inad

equa

te m

ilk s

uppl

y

Lac

k of

soc

ial,

cultu

ral,

or e

nvir

onm

enta

l sup

port

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a L

abor

ator

y ev

iden

ce o

f de

hydr

atio

n in

infa

nt

Ant

hrop

omet

ric

Mea

sure

men

ts

Any

wei

ght l

oss

or p

oor

wei

ght g

ain

in in

fant

Phy

sica

l Exa

m F

indi

ngs

Fren

ulum

abn

orm

ality

(in

fant

)

Edi

tion:

200

6

105

CLIN

CAL

DOMA

IN

Func

tiona

l

BR

EA

ST

FE

ED

ING

DIF

FIC

UL

TY

(N

C-1

.3)

Foo

d/N

utri

tion

His

tory

O

bser

vatio

ns o

r re

port

s of

(in

fant

):

Cou

ghin

g

Cry

ing,

latc

hing

on

and

off,

pou

ndin

g on

bre

asts

Dec

reas

ed f

eedi

ng f

requ

ency

/dur

atio

n, e

arly

ces

satio

n of

fee

ding

, and

/or

feed

ing

resi

stan

ce

Infa

nt le

thar

gy

Hun

ger,

lack

of

satie

ty a

fter

fee

ding

Few

er th

an s

ix w

et d

iape

rs in

24

hour

s

Infa

nt v

omiti

ng o

r di

arrh

ea

Obs

erva

tions

or

repo

rts

of (

mot

her)

:

Smal

l am

ount

of

milk

whe

n pu

mpi

ng

Lac

k of

con

fide

nce

in a

bilit

y to

bre

astf

eed

Doe

sn’t

hea

r in

fant

sw

allo

win

g

Con

cern

s re

gard

ing

mot

her’

s ch

oice

to b

reas

tfee

d/la

ck o

f su

ppor

t

Insu

ffic

ient

kno

wle

dge

of b

reas

tfee

ding

or

infa

nt h

unge

r/sa

tiety

sig

nals

Lac

k of

fac

ilitie

s or

acc

omm

odat

ions

at p

lace

of

empl

oym

ent o

r in

com

mun

ity f

or b

reas

tfee

ding

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f (i

nfan

t), e

.g.,

clef

t lip

/pal

ate,

thru

sh, p

rem

atur

e bi

rth,

mal

abso

rptio

n, in

fect

ion

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f (m

othe

r), e

.g.,

mas

titis

, can

didi

asis

, eng

orge

men

t, hi

stor

y of

bre

ast s

urge

ry

Refe

ren

ces:

1.

Bar

ron

SP, L

ane

HW

, Han

nan

TE

, Str

uem

pler

B, W

illia

ms

JC. F

acto

rs in

flue

ncin

g du

ratio

n of

bre

ast f

eedi

ng a

mon

g lo

w-i

ncom

e w

omen

. J A

m D

iet A

ssoc

. 198

8;88

:155

7-15

61.

2.

Bry

ant C

, Cor

eil J

, D’A

ngel

o SL

, Bai

ley

DFC

, Laz

arov

MA

. A s

trat

egy

for

prom

otin

g br

east

feed

ing

amon

g ec

onom

ical

ly d

isad

vant

aged

wom

en a

nd a

dole

scen

ts. N

AA

CO

G’s

Cli

n Is

su P

erin

atW

omen

’s H

ealth

Nur

s. 1

992;

3:72

3-73

0.

3.

Ben

tley

ME

, Cau

lfie

ld L

E, G

ross

SM

, Bro

nner

Y, J

ense

n J,

Kes

sler

LA

, Pai

ge D

M. S

ourc

es o

f in

flue

nce

on in

tent

ion

to b

reas

tfee

d am

ong

Afr

ican

-Am

eric

an w

omen

at e

ntry

to W

IC. J

Hum

Lac

t.19

99;1

5:27

-34.

4.

M

orel

and

JC, L

loyd

L, B

raun

SB

, Hei

ns J

N. A

new

teac

hing

mod

el to

pro

long

bre

astf

eedi

ng a

mon

g L

atin

os. J

Hum

Lac

t. 20

00;1

6:33

7-34

1.

5.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Bre

akin

g th

e ba

rrie

rs to

bre

astf

eedi

ng. J

Am

Die

t Ass

oc. 2

001;

101:

1213

-122

0.

6.

Woo

ldri

ge M

S, F

isch

er C

. Col

ic, "

over

feed

ing"

and

sym

ptom

s of

lact

ose

mal

abso

rptio

n in

the

brea

st-f

ed b

aby.

Lan

cet.

1988

;2:3

82-3

84.

Edi

tion:

200

6

106

CLIN

CAL

DOMA

IN

Func

tiona

l

AL

TE

RE

D G

AS

TR

OIN

TE

ST

INA

L (

GI)

FU

NC

TIO

N (

NC

-1.4

)

De

fin

itio

n

Cha

nges

in a

bilit

y to

dig

est o

r ab

sorb

nut

rien

ts

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Alte

ratio

ns in

GI

anat

omic

al s

truc

ture

, e.g

., ga

stri

c by

pass

, Rou

x E

n Y

Cha

nges

in th

e G

I tr

act m

otili

ty, e

.g.,

gast

ropa

resi

s

Com

prom

ised

GI

trac

t fun

ctio

n, e

.g.,

Cel

iac

dise

ase,

Cro

hn’s

dis

ease

, inf

ectio

n, r

adia

tion

ther

apy

Com

prom

ised

fun

ctio

n of

rel

ated

GI

orga

ns, e

.g. p

ancr

eas,

live

r

Dec

reas

ed f

unct

iona

l len

gth

of th

e G

I tr

act,

e.g.

, sho

rt b

owel

syn

drom

e

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a A

bnor

mal

dig

estiv

e en

zym

e an

d fe

cal f

at s

tudi

es

Abn

orm

al h

ydro

gen

brea

th te

st, d

-xyl

ose

test

, sto

ol c

ultu

re, a

nd g

astr

ic e

mpt

ying

and

/or

smal

l bow

el tr

ansi

t tim

e

Ant

hrop

omet

ric

Mea

sure

men

ts

Was

ting

due

to m

alnu

triti

on in

sev

ere

case

s

Phy

sica

l Exa

m F

indi

ngs

Dec

reas

ed m

uscl

e m

ass

Abd

omin

al d

iste

nsio

n

Incr

ease

d (o

r so

met

imes

dec

reas

ed)

bow

el s

ound

s

Edi

tion:

200

6

107

CLIN

CAL

DOMA

IN

Func

tiona

l

AL

TE

RE

D G

AS

TR

OIN

TE

ST

INA

L (

GI)

FU

NC

TIO

N (

NC

-1.4

)F

ood/

Nut

ritio

n H

isto

ry

Obs

erva

tions

or

repo

rts

of:

Avo

idan

ce o

r lim

itatio

n of

tota

l int

ake

or in

take

of

spec

ific

foo

ds/f

ood

grou

ps d

ue to

GI

sym

ptom

s, e

.g.,

bloa

ting,

cra

mpi

ng,

pain

, dia

rrhe

a, s

teat

orrh

ea (

grea

sy, f

loat

ing,

fou

l-sm

ellin

g st

ools

) es

peci

ally

fol

low

ing

inge

stio

n of

foo

d

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit,

e.g.

, lac

k of

info

rmat

ion,

inco

rrec

t inf

orm

atio

n or

non

-com

plia

nce

with

m

odif

ied

diet

or

med

icat

ion

sche

dule

Clie

nt H

isto

ry

Ano

rexi

a, n

ause

a, v

omiti

ng, d

iarr

hea,

ste

ator

rhea

, con

stip

atio

n, a

bdom

inal

pai

n

End

osco

pic

or c

olon

osco

pic

exam

inat

ion

resu

lts, b

iops

y re

sults

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

mal

abso

rptio

n, m

aldi

gest

ion,

ste

ator

rhea

, con

stip

atio

n,

dive

rtic

uliti

s, C

rohn

’s d

isea

se, i

nfla

mm

ator

y bo

wel

dis

ease

, cys

tic f

ibro

sis,

cel

iac

dise

ase,

irri

tabl

e bo

wel

syn

drom

e,

infe

ctio

n

Surg

ical

pro

cedu

res,

e.g

., es

opha

gect

omy,

dila

tatio

n, g

astr

ecto

my,

vag

otom

y, g

astr

ic b

ypas

s, b

owel

res

ectio

ns

Refe

ren

ces:

1.

Bra

unw

ald

E, F

auci

AS,

Kas

per

DL

, Hau

ser

SL, L

ongo

DL

, Jam

eson

JL

, ed.

Har

riso

n’s

Pri

ncip

les

of I

nter

nal M

edic

ine.

15th

Edi

tion.

New

Yor

k, N

Y: M

cGra

w-H

ill,.2

001.

Edi

tion:

200

6

108

CLIN

CAL

DOMA

IN

Bioc

hem

ical

IMP

AIR

ED

NU

TR

IEN

T U

TIL

IZA

TIO

N (

NC

-2.1

)

De

fin

itio

n

Cha

nges

in a

bilit

y to

abs

orb

or m

etab

oliz

e nu

trie

nts

and

bioa

ctiv

e su

bsta

nces

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Alte

ratio

ns in

gas

troi

ntes

tinal

ana

tom

ical

str

uctu

re

Com

prom

ised

fun

ctio

n of

the

GI

trac

t

Com

prom

ised

fun

ctio

n of

rel

ated

GI

orga

ns, e

.g. p

ancr

eas,

live

r

Dec

reas

ed f

unct

iona

l len

gth

of th

e G

I tr

act

Met

abol

ic d

isor

ders

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a A

bnor

mal

dig

estiv

e en

zym

e an

d fe

cal f

at s

tudi

es

Abn

orm

al h

ydro

gen

brea

th te

st, d

-xyl

ose

test

Abn

orm

al te

sts

for

inbo

rn e

rror

s of

met

abol

ism

Ant

hrop

omet

ric

Mea

sure

men

ts

Wei

ght l

oss

of 5

% in

one

mon

th, 1

0% in

six

mon

ths

Gro

wth

stu

ntin

g or

fai

lure

Phy

sica

l Exa

m F

indi

ngs

Abd

omin

al d

iste

nsio

n

Incr

ease

d or

dec

reas

ed b

owel

sou

nds

Evi

denc

e of

vita

min

, min

eral

def

icie

ncy,

e.g

., gl

ossi

tis, c

heilo

sis,

mou

th le

sion

s

Edi

tion:

200

6 10

9

CLIN

CAL

DOMA

IN

Bioc

hem

ical

IMP

AIR

ED

NU

TR

IEN

T U

TIL

IZA

TIO

N (

NC

-2.1

)F

ood/

Nut

ritio

n H

isto

ry

Obs

erva

tions

or

repo

rts

of:

Avo

idan

ce o

r lim

itatio

n of

tota

l int

ake

or in

take

of

spec

ific

foo

ds/f

ood

grou

ps d

ue to

GI

sym

ptom

s, e

.g.,

bloa

ting,

cra

mpi

ng,

pain

, dia

rrhe

a, s

teat

orrh

ea (

grea

sy, f

loat

ing,

fou

l-sm

ellin

g st

ools

) es

peci

ally

fol

low

ing

inge

stio

n of

foo

d

Clie

nt H

isto

ry

Dia

rrhe

a, s

teat

orrh

ea, a

bdom

inal

pai

n

End

osco

pic

or c

olon

osco

pic

exam

inat

ion

resu

lts, b

iops

y re

sults

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

mal

abso

rptio

n, m

aldi

gest

ion,

cys

tic f

ibro

sis,

cel

iac

dise

ase,

C

rohn

’s d

isea

se, i

nfec

tion,

rad

iatio

n th

erap

y, in

born

err

ors

of m

etab

olis

m

Surg

ical

pro

cedu

res,

e.g

., ga

stri

c by

pass

, bow

el r

esec

tion

Refe

ren

ces:

1.

Bey

er P

. Gas

troi

ntes

tinal

dis

orde

rs: R

oles

of

nutr

ition

and

the

diet

etic

s pr

actit

ione

r. J

Am

Die

t Ass

oc. 1

998;

98:2

72-2

77.

2.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Hea

lth im

plic

atio

ns o

f di

etar

y fi

ber.

J A

m D

iet A

ssoc

. 200

2;10

2:99

3-10

00.

Edi

tion:

200

6 11

0

CLIN

CAL

DOMA

IN

Bioc

hem

ical

AL

TE

RE

D N

UT

RIT

ION

-RE

LA

TE

D L

AB

OR

AT

OR

Y V

AL

UE

S (

SP

EC

IFY

) (N

C-2

.2)

De

fin

itio

n

Cha

nges

due

to b

ody

com

posi

tion,

med

icat

ions

, bod

y sy

stem

cha

nges

or

gene

tics

or c

hang

es in

abi

lity

to e

limin

ate

by-p

rodu

cts

of d

iges

tive

and

met

abol

ic

proc

esse

s

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Kid

ney,

live

r, c

ardi

ac, e

ndoc

rine

, neu

rolo

gic

and/

or p

ulm

onar

y dy

sfun

ctio

n

Oth

er o

rgan

dys

func

tion

that

lead

s to

bio

chem

ical

cha

nges

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a Fi

ndin

gs s

uch

as:

Incr

ease

d A

ST, A

LT

, T. b

ili, s

erum

am

mon

ia (

liver

dis

orde

rs)

Abn

orm

al B

UN

, Cr,

K, p

hosp

horu

s, g

lom

erul

ar f

iltra

tion

rate

(G

FR)

(kid

ney

diso

rder

s)

Alte

red

pO2

and

pCO

2 (p

ulm

onar

y di

sord

ers)

Abn

orm

al s

erum

lipi

ds

Abn

orm

al p

lasm

a gl

ucos

e le

vels

Oth

er f

indi

ngs

of a

cute

or

chro

nic

diso

rder

s th

at a

re a

bnor

mal

and

of

nutr

ition

al o

rigi

n or

con

sequ

ence

Ant

hrop

omet

ric

Mea

sure

men

ts

Rap

id w

eigh

t cha

nges

Oth

er a

nthr

opom

etri

c m

easu

res

that

are

alte

red

Phy

sica

l Exa

m F

indi

ngs

Jaun

dice

, ede

ma,

asc

ites,

itch

ing

(liv

er d

isor

ders

)

Ede

ma,

sho

rtne

ss o

f br

eath

(ca

rdia

c di

sord

ers)

Blu

e na

il be

ds, c

lubb

ing

(pul

mon

ary

diso

rder

s)

Edi

tion:

200

6 11

1

CLIN

CAL

DOMA

IN

Bioc

hem

ical

AL

TE

RE

D N

UT

RIT

ION

-RE

LA

TE

D L

AB

OR

AT

OR

Y V

AL

UE

S (

SP

EC

IFY

) (N

C-2

.2)

Foo

d/N

utri

tion

His

tory

O

bser

vatio

ns o

r re

port

s of

:

Ano

rexi

a, n

ause

a, v

omiti

ng

Inab

ility

to c

onsu

me

full

mea

ls d

ue to

sho

rtne

ss o

f br

eath

or

abdo

min

al d

iste

ntio

n

Inta

ke o

f fo

ods

high

in o

r ov

eral

l exc

ess

inta

ke o

f pr

otei

n, p

otas

sium

, pho

spho

rus,

sod

ium

, flu

id

Inad

equa

te in

take

of

mic

ronu

trie

nts

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit,

e.g.

, lac

k of

info

rmat

ion,

inco

rrec

t inf

orm

atio

n or

non

-com

plia

nce

with

m

odif

ied

diet

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

rena

l or

liver

dis

ease

, alc

ohol

ism

, car

dio-

pulm

onar

y di

sord

ers

Refe

ren

ces:

1.

Bet

o JA

, Ban

sal V

K.

Med

ical

nut

ritio

n th

erap

y in

chr

onic

kid

ney

failu

re: i

nteg

ratin

g cl

inic

al p

ract

ice

guid

elin

es. J

Am

Die

t Ass

oc. 2

004;

104:

404-

409.

2.

D

aver

n II

TJ,

Sch

arsc

hmid

t BF:

Bio

chem

ical

live

r te

sts.

In

Feld

man

M, S

char

schm

idt B

F, S

leis

enge

r M

H (

eds)

: Sle

isen

ger

and

For

dtra

n’s

Gas

roin

test

inal

and

Liv

er D

isea

se, e

d 6,

vol

2,

Phila

delp

hia,

PA

: WB

Sau

nder

s, 1

998,

pp

1112

-112

2.

3.

Dur

ose

CL

, Hol

dsw

orth

M, W

atso

n V

, Prz

ygro

dzka

F.

Kno

wle

dge

of d

ieta

ry r

estr

ictio

ns a

nd th

e m

edic

al c

onse

quen

ces

of n

onco

mpl

ianc

e by

pat

ient

s on

hem

odia

lysi

s ar

e no

t pre

dict

ive

of d

ieta

ry

com

plia

nce.

J A

m D

iet A

ssoc

. 200

4;10

4:35

-41.

4.

K

assi

ske

BL

, Lak

atua

JD

, Ma

JZ, L

ouis

TA

. A m

eta-

anal

ysis

of

the

effe

cts

of d

ieta

ry p

rote

in r

estr

icti

on o

n th

e ra

te o

f de

clin

e in

ren

al f

unct

ion.

Am

J K

idne

y D

is. 1

998;

31;9

54-9

61.

5.

Kni

ght E

L, S

tam

pfer

MJ,

Han

kins

on S

E, S

pieg

elm

an D

, Cur

han

GC

. The

impa

ct o

f pr

otei

n in

take

on

rena

l fun

ctio

n de

clin

e in

wom

en w

ith n

orm

al r

enal

fun

ctio

n or

mil

d re

nal i

nsuf

fici

ency

. Ann

In

tern

Med

. 200

3;13

8:46

0-46

7.

6.

Nak

ao T

, Mat

sum

oto,

Oka

da T

, Kan

azaw

a Y

, Yos

hino

M, N

agao

ka Y

, Tak

eguc

hi F

. Nut

ritio

nal m

anag

emen

t of

dial

ysis

pat

ient

s: b

alan

cing

am

ong

nutr

ient

inta

ke, d

ialy

sis

dose

, and

nut

ritio

nal

stat

us.

Am

J K

idne

y D

is. 2

003;

41:p

S133

-pS1

36.

7.

Nat

iona

l Kid

ney

Foun

datio

n, I

nc.

Part

5. E

valu

atio

n of

labo

rato

ry m

easu

rem

ents

for

clin

ical

ass

essm

ent o

f ki

dney

dis

ease

. A

m J

Kid

ney

Dis

. 20

02;3

9:pS

76-p

S92.

8.

N

atio

nal K

idne

y Fo

unda

tion,

Inc

. G

uide

line

9. A

ssoc

iatio

n of

leve

l of

GFR

with

nut

ritio

nal s

tatu

s. A

m J

Kid

ney

Dis

. 20

02;3

9:pS

128-

pS14

2.

Edi

tion:

200

6 11

2

CLIN

CAL

DOMA

IN

Bioc

hem

ical

FO

OD

ME

DIC

AT

ION

IN

TE

RA

CT

ION

(N

C-2

.3)

De

fin

itio

n

Und

esir

able

/har

mfu

l int

erac

tion(

s) b

etw

een

food

and

ove

r th

e co

unte

r (O

TC

) m

edic

atio

ns, p

resc

ribe

d m

edic

atio

ns, h

erba

ls, b

otan

ical

s, a

nd/o

r di

etar

y su

pple

men

ts th

at d

imin

ishe

s, e

nhan

ces,

or

alte

rs e

ffec

t of

nutr

ient

s an

d/or

med

icat

ions

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Com

bine

d in

gest

ion

or a

dmin

istr

atio

n of

med

icat

ion

and

food

that

res

ults

in u

ndes

irab

le/h

arm

ful i

nter

actio

n

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a A

ltera

tions

of

bioc

hem

ical

test

s ba

sed

upon

med

icat

ion

affe

ct a

nd p

atie

nt/c

lient

con

ditio

n

Ant

hrop

omet

ric

Mea

sure

men

ts

Alte

ratio

ns o

f an

thro

pom

etri

c m

easu

rem

ents

bas

ed u

pon

med

icat

ion

affe

ct a

nd p

atie

nt/c

lient

con

ditio

ns

e.g.

, wei

ght g

ain

and

cort

icos

tero

ids

Phy

sica

l Exa

m F

indi

ngs

Edi

tion:

200

6 11

3

CLIN

CAL

DOMA

IN

Bioc

hem

ical

FO

OD

ME

DIC

AT

ION

IN

TE

RA

CT

ION

(N

C-2

.3)

Foo

d/N

utri

tion

His

tory

O

bser

vatio

ns o

r re

port

s of

:

Inta

ke th

at is

pro

blem

atic

or

inco

nsis

tent

with

OT

C, p

resc

ribe

d dr

ugs,

her

bals

, bot

anic

als,

and

die

tary

sup

plem

ents

e.g.

, fis

h oi

ls a

nd p

rolo

nged

ble

edin

g

e.g.

, cou

mad

in, V

itam

in K

ric

h fo

ods

e.g.

, hig

h fa

t die

t whi

le o

n ch

oles

tero

l low

erin

g m

edic

atio

ns

e.g.

, iro

n su

pple

men

ts, c

onst

ipat

ion

and

low

fib

er d

iet

Inta

ke th

at d

oes

not s

uppo

rt r

epla

cem

ent o

r m

itiga

tion

of O

TC

, pre

scri

bed

drug

s, h

erba

ls, b

otan

ical

s, a

nd d

ieta

ry

supp

lem

ents

aff

ects

e.g.

, pot

assi

um w

astin

g di

uret

ics

Cha

nges

in a

ppet

ite o

r ta

ste

Clie

nt H

isto

ry

Mul

tiple

dru

gs (

OT

C, p

resc

ribe

d dr

ugs,

her

bals

, bot

anic

als,

and

die

tary

sup

plem

ents

) th

at a

re k

now

n to

hav

e fo

od

med

icat

ion

inte

ract

ions

Med

icat

ions

that

req

uire

nut

rien

t sup

plem

enta

tion

that

can

not

be

acco

mpl

ishe

d vi

a fo

od in

take

e.g.

, iso

niaz

id a

nd V

itam

in B

6

Re

fere

nc

e:

1.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Int

egra

tion

of n

utri

tion

and

phar

mac

othe

rapy

. J A

m D

iet A

ssoc

. 200

3;10

3:13

63-1

370.

Edi

tion:

200

6 11

4

CLIN

CAL

DOMA

IN

Weig

ht

UN

DE

RW

EIG

HT

(N

C-3

.1)

De

fin

itio

n

Low

bod

y w

eigh

t com

pare

d to

est

ablis

hed

refe

renc

e st

anda

rds

or r

ecom

men

datio

ns

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Dis

orde

red

eatin

g pa

ttern

Exc

essi

ve p

hysi

cal a

ctiv

ity

Har

mfu

l bel

iefs

/atti

tude

s ab

out f

ood,

nut

ritio

n, a

nd n

utri

tion-

rela

ted

topi

cs

Inad

equa

te e

nerg

y in

take

Incr

ease

d en

ergy

nee

ds

Lim

ited

acce

ss to

foo

d

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Wei

ght f

or a

ge le

ss th

an 5

th P

erce

ntile

for

Inf

ants

less

than

12

mon

ths

Dec

reas

ed s

kin

fold

thic

knes

s an

d M

AM

C

BM

I <

18.5

(m

ost a

dults

)

BM

I fo

r ol

der

adul

ts (

over

65

year

s) <

23

BM

I <

5th

per

cent

ile (

child

ren,

2-1

9 ye

ars)

Phy

sica

l Exa

m F

indi

ngs

Dec

reas

ed s

omat

ic p

rote

in s

tore

s, m

uscl

e w

astin

g (g

lute

al a

nd te

mpo

ral)

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Inad

equa

te in

take

of

food

com

pare

d to

est

imat

ed o

r m

easu

red

need

s

Edi

tion:

200

6 11

5

CLIN

CAL

DOMA

IN

Weig

ht

UN

DE

RW

EIG

HT

(N

C-3

.1)

Lim

ited

supp

ly o

f fo

od in

hom

e

Die

ting,

foo

d fa

ddis

m

Hun

ger

Ref

usal

to e

at

Phys

ical

act

ivity

gre

ater

than

rec

omm

ende

d am

ount

Clie

nt H

isto

ry

Mal

nutr

ition

, vita

min

/min

eral

def

icie

ncy

Illn

ess

or p

hysi

cal d

isab

ility

Men

tal i

llnes

s, d

emen

tia, c

onfu

sion

Mea

sure

d re

stin

g m

etab

olic

rat

e (R

MR

) m

easu

rem

ent h

ighe

r th

an e

xpec

ted

and/

or e

stim

ated

RM

R

Med

icat

ions

that

aff

ect a

ppet

ite, e

.g. s

timul

ants

for

AD

HD

Ath

lete

, dan

cer,

gym

nast

Refe

ren

ces:

1.

Ass

essm

ent o

f nu

triti

onal

sta

tus.

In:

Kle

inm

an R

(ed

.). P

edia

tric

Nut

riti

on H

andb

ook,

5th e

d. A

mer

ican

Aca

dem

y of

Ped

iatr

ics,

200

4:40

7-42

3 2.

B

eck

AM

, Ove

sen

LW

. At w

hich

bod

y m

ass

inde

x an

d de

gree

of

wei

ght l

oss

shou

ld h

ospi

taliz

ed e

lder

ly p

atie

nts

be c

onsi

dere

d at

nut

ritio

nal r

isk?

Clin

Nut

r. 1

998;

17(5

):19

5-19

8

3.

Bla

um C

S, F

ries

BE

, Fia

taro

ne M

A. F

acot

ors

asso

ciat

ed w

ith lo

w b

ody

mas

s in

dex

and

wei

ght l

oss

in n

ursi

ng h

ome

resi

dent

s. J

Ger

onto

logy

: M

ed S

ci. 1

995;

50A

(3):

m16

2-M

168

4.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Dom

estic

foo

d an

d nu

triti

on s

ecur

ity. J

Am

Die

t Ass

oc. 2

002;

102:

1840

-184

7.

5.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Add

ress

ing

wor

ld h

unge

r, m

alnu

triti

on, a

nd f

ood

inse

curi

ty. J

Am

Die

t Ass

oc. 2

003;

103:

1046

-105

7.

6.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Nut

ritio

n in

terv

entio

n in

the

trea

tmen

t of

anor

exia

ner

vosa

, bul

imia

ner

vosa

, and

eat

ing

diso

rder

not

oth

erw

ise

spec

ifie

d (E

DN

OS

). J

Am

Die

t Ass

oc.

2001

;101

:810

-819

. 7.

Sc

hnei

der

SM, A

l-Ja

ouni

R, P

ivot

X, B

raul

io V

B, R

ampa

l P, H

ebue

rne

X. L

ack

of a

dapt

atio

n to

sev

ere

mal

nutr

ition

in e

lder

ly p

atie

nts.

Clin

Nut

r. 2

002;

21(6

):49

9-50

4 8.

Sp

ear

BA

. Ado

lesc

ent g

row

th a

nd d

evel

opm

ent.

J A

m D

iet A

ssoc

. 200

2 (s

uppl

);10

2:pS

23-

pS29

.

Edi

tion:

200

6 11

6

CLIN

CAL

DOMA

IN

Weig

ht

INV

OL

UN

TA

RY

WE

IGH

T L

OS

S (

NC

-3.2

)

De

fin

itio

n

Dec

reas

e in

bod

y w

eigh

t tha

t is

not p

lann

ed o

r de

sire

d

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Phys

iolo

gic

caus

es, e

.g. i

ncre

ased

nut

rien

t nee

ds d

ue to

pro

long

ed c

atab

olic

illn

ess

Lac

k of

acc

ess

to f

ood,

e.g

. eco

nom

ic c

onst

rain

ts, c

ultu

ral o

r re

ligio

us p

ract

ices

, res

tric

ting

food

giv

en to

eld

erly

and

/or

child

ren

Prol

onge

d ho

spita

lizat

ion

Psyc

holo

gica

l iss

ues

Lac

k of

sel

f fe

edin

g ab

ility

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Wei

ght l

oss

of 5

% w

ithin

30

days

, .7.

5% in

90

days

and

10%

in 1

80 d

ays

Phy

sica

l Exa

min

atio

n F

indi

ngs

Feve

r

Incr

ease

d he

art r

ate

Incr

ease

d re

spir

ator

y ra

te

Los

s of

sub

cuta

neou

s fa

t and

mus

cle

stor

es

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Nor

mal

or

usua

l int

ake

in f

ace

of il

lnes

s

Poor

inta

ke, c

hang

e in

eat

ing

habi

ts, s

kipp

ed m

eals

Cha

nge

in w

ay c

loth

es f

it

Edi

tion:

200

6 11

7

CLIN

CAL

DOMA

IN

Weig

ht

INV

OL

UN

TA

RY

WE

IGH

T L

OS

S (

NC

-3.2

)C

lient

His

tory

C

ondi

tions

ass

ocia

ted

with

a d

iagn

osis

or

trea

tmen

t of,

e.g

., A

IDS/

HIV

, bur

ns, c

hron

ic o

bstr

uctiv

e pu

lmon

ary

dise

ase,

hi

p/lo

ng b

one

frac

ture

, inf

ectio

n, s

urge

ry, t

raum

a, h

yper

thyr

oidi

sm (

pre-

or u

ntre

ated

), s

ome

type

s of

can

cer

or m

etas

tatic

di

seas

e (s

peci

fy)

Med

icat

ions

ass

ocia

ted

with

wei

ght l

oss,

suc

h as

cer

tain

ant

idep

ress

ants

or

canc

er c

hem

othe

rapy

Refe

ren

ces:

1.

Col

lins

N. P

rote

in-e

nerg

y m

alnu

triti

on a

nd in

volu

ntar

y w

eigh

t los

s: N

utri

tion

al a

nd p

harm

acol

ogic

str

ateg

ies

to e

nhan

ce w

ound

hea

ling.

Exp

ert O

pini

on P

harm

acot

her.

200

3;7:

1121

-114

0.

2.

Sple

tt PL

, Rot

h-Y

ouse

y L

L, V

ogel

zang

JL

. Med

ical

nut

ritio

n th

erap

y fo

r th

e pr

even

tion

and

trea

tmen

t of

unin

tent

iona

l wei

ght l

oss

in r

esid

entia

l hea

lthc

are

faci

litie

s. J

Am

Die

t Ass

oc. 2

003;

10

3:35

2-36

2.3.

W

alla

ce J

L, S

chw

artz

RS,

LaC

roix

AZ

, Uhl

man

n R

F, P

earl

man

RA

. Inv

olun

tary

wei

ght l

oss

in o

lder

pat

ient

s: in

cide

nce

and

clin

ical

sig

nifi

canc

e. J

Am

Ger

iatr

Soc

. 199

5;43

:329

-337

.

Edi

tion:

200

6 11

8

CLIN

CAL

DOMA

IN

Weig

ht

OV

ER

WE

IGH

T/O

BE

SIT

Y (

NC

-3.3

)

De

fin

itio

n

Incr

ease

d ad

ipos

ity c

ompa

red

to e

stab

lishe

d re

fere

nce

stan

dard

s or

rec

omm

enda

tions

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Dec

reas

ed e

nerg

y ne

eds

Dis

orde

red

eatin

g pa

ttern

Exc

ess

ener

gy in

take

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Not

rea

dy f

or d

iet/l

ifes

tyle

cha

nge

Phys

ical

inac

tivity

Incr

ease

d ps

ycho

logi

cal/l

ife

stre

ss

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

BM

I ab

ove

norm

ativ

e st

anda

rd f

or a

ge a

nd g

ende

r

Wai

st c

ircu

mfe

renc

e ab

ove

norm

ativ

e st

anda

rd f

or a

ge a

nd g

ende

r

Incr

ease

d sk

in f

old

thic

knes

s

Wei

ght f

or h

eigh

t abo

ve n

orm

ativ

e st

anda

rd f

or a

ge a

nd g

ende

r

Phy

sica

l Exa

m F

indi

ngs

Incr

ease

d bo

dy a

dipo

sity

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Ove

r co

nsum

ptio

n of

hig

h fa

t and

/or

calo

ric

dens

ity f

ood

or b

ever

age

Edi

tion:

200

6 11

9

CLIN

CAL

DOMA

IN

Weig

ht

OV

ER

WE

IGH

T/O

BE

SIT

Y (

NC

-3.3

)L

arge

por

tions

of

food

(po

rtio

n si

ze g

reat

er th

an tw

ice

than

rec

omm

ende

d)

Exc

essi

ve e

nerg

y in

take

Infr

eque

nt, l

ow d

urat

ion

and/

or lo

w in

tens

ity p

hysi

cal a

ctiv

ity

Lar

ge a

mou

nts

of s

eden

tary

act

iviti

es e

.g. T

V w

atch

ing,

rea

ding

, com

pute

r us

e in

bot

h le

isur

e an

d w

ork/

scho

ol

Unc

erta

inty

reg

ardi

ng n

utri

tion-

rela

ted

reco

mm

enda

tions

Inab

ility

to a

pply

nut

ritio

n-re

late

d re

com

men

datio

ns

Inab

ility

to m

aint

ain

wei

ght o

r re

gain

of

wei

ght

Unw

illin

gnes

s or

dis

inte

rest

in a

pply

ing

nutr

ition

-rel

ated

rec

omm

enda

tions

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

hypo

thyr

oidi

sm, m

etab

olic

syn

drom

e, e

atin

g di

sord

er n

ot

othe

rwis

e sp

ecif

ied,

dep

ress

ion

Phys

ical

dis

abili

ty o

r lim

itatio

n

His

tory

of

phys

ical

, sex

ual,

or e

mot

iona

l abu

se

Mea

sure

d re

stin

g m

etab

olic

rat

e (R

MR

) m

easu

rem

ent l

ower

than

exp

ecte

d an

d/or

est

imat

ed R

MR

Med

icat

ions

that

impa

ct R

MR

, e.g

., m

idaz

olam

, pro

pran

alol

, glip

izid

e

Refe

ren

ces:

1.

Cra

wfo

rd S

. Pr

omot

ing

diet

ary

chan

ge.

Can

J C

ardi

ol. 1

995;

11(s

uppl

A):

14A

-15A

. 2.

D

icke

rson

RN

, Rot

h-Y

ouse

y L

. Med

icat

ion

effe

cts

on m

etab

olic

rat

e: A

sys

tem

atic

rev

iew

. Unp

ublis

hed

data

.3.

K

uman

yika

SK

, Van

Hor

n L

, Bow

en D

, Per

ri M

G, R

olls

BJ,

Cza

jkow

ski S

M, S

chro

n E

. M

aint

enan

ce o

f di

etar

y be

havi

or c

hang

e. H

ealth

Psy

chol

. 200

0;19

(1 s

uppl

):S4

2-S5

6.

4.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Wei

ght m

anag

emen

t. J

Am

Die

t Ass

oc. 2

002;

102:

1145

-115

5.

5.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Tot

al d

iet a

ppro

ach

to c

omm

unic

atin

g fo

od a

nd n

utri

tion

info

rmat

ion.

J A

m D

iet A

ssoc

200

2;10

2:10

0-10

8.

6.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

The

rol

e of

die

tetic

s pr

ofes

sion

als

in h

ealth

pro

mot

ion

and

dise

ase

prev

entio

n. J

Am

Die

t Ass

oc. 2

002;

102:

1680

-168

7.

7.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Nut

ritio

n in

terv

entio

n in

the

trea

tmen

t of

anor

exia

ner

vosa

, bul

imia

ner

vosa

, and

eat

ing

diso

rder

not

oth

erw

ise

spec

ifie

d (E

DN

OS

). J

Am

Die

t Ass

oc.

2001

;101

:810

-819

. 8.

Sh

ephe

rd R

. R

esis

tanc

e to

cha

nges

in d

iet.

Pro

c N

utr

Soc.

200

2;61

:267

-272

. 9.

U

.S. P

reve

ntiv

e Se

rvic

es T

ask

Forc

e. B

ehav

iora

l cou

nsel

ing

in p

rim

ary

care

to p

rom

ote

a he

alth

y di

et. A

m J

Pre

v M

ed. 2

003;

24:9

3-10

0.

Edi

tion:

200

6 12

0

CLIN

CAL

DOMA

IN

Weig

ht

INV

OL

UN

TA

RY

WE

IGH

T G

AIN

(N

C-3

.4)

De

fin

itio

n

Wei

ght g

ain

abov

e th

at w

hich

is d

esir

ed o

r pl

anne

d

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Illn

ess

caus

ing

unex

pect

ed w

eigh

t gai

n be

caus

e of

hea

d tr

aum

a, im

mob

ility

, par

alys

is o

r re

late

d co

nditi

on

Chr

onic

use

of

med

icat

ions

kno

wn

to c

ause

wei

ght g

ain,

suc

h as

use

of

cert

ain

antid

epre

ssan

ts, a

ntip

sych

otic

s, c

ortic

oste

roid

s, c

erta

in H

IV m

edic

atio

ns

Con

ditio

n le

adin

g to

exc

essi

ve f

luid

wei

ght g

ains

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a D

ecre

ase

in s

erum

alb

umin

, hyp

onat

rem

ia, e

leva

ted

fast

ing

seru

m li

pid

leve

ls, e

leva

ted

fast

ing

gluc

ose

leve

ls, f

luct

uatin

g ho

rmon

e le

vels

Ant

hrop

omet

ric

Mea

sure

men

ts

Wei

ght h

isto

ry –

not

ing

any

incr

ease

in w

eigh

t gre

ater

than

pla

nned

or

desi

red,

suc

h as

10%

in 6

mon

ths

Not

icea

ble

chan

ge in

bod

y fa

t dis

trib

utio

n

Phy

sica

l Exa

min

atio

n F

indi

ngs

Fat a

ccum

ulat

ion

- ex

cess

ive

subc

utan

eous

fat

sto

res

Lip

odys

trop

hy a

ssoc

iate

d w

ith H

IV d

iagn

osis

- in

crea

se in

dor

soce

rvia

l fat

, bre

ast e

nlar

gem

ent,

incr

ease

d ab

dom

inal

gir

th

Ede

ma

Shor

tnes

s of

bre

ath

Sens

itivi

ty to

col

d, c

onst

ipat

ion,

and

hai

r lo

ss

Edi

tion:

200

6 12

1

CLIN

CAL

DOMA

IN

Weig

ht

INV

OL

UN

TA

RY

WE

IGH

T G

AIN

(N

C-3

.4)

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Inta

ke c

onsi

sten

t with

est

imat

ed o

r m

easu

red

ener

gy n

eeds

Cha

nges

in r

ecen

t foo

d in

take

leve

l

Use

of

alco

hol,

narc

otic

s

Ext

rem

e hu

nger

with

or

with

out p

alpi

tatio

ns, t

rem

or, a

nd s

wea

ting

Phys

ical

inac

tivity

or

chan

ge in

phy

sica

l act

ivity

leve

l

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f as

thm

a, p

sych

iatr

ic il

lnes

ses,

rhe

umat

ic c

ondi

tions

, HIV

/AID

S,

Cus

hing

’s s

yndr

ome,

obe

sity

, Pra

der-

Will

i syn

drom

e

Flui

d ad

min

istr

atio

n ab

ove

requ

irem

ents

Cha

nge

in s

leep

hab

its, i

nsom

nia

Mus

cle

wea

knes

s

Fatig

ue

Med

icat

ions

ass

ocia

ted

with

incr

ease

d ap

petit

e

Refe

ren

ces:

1.

Lic

hten

stei

n K

, Del

aney

K, W

ard

D, P

alel

la F

. C

linic

al F

acto

rs a

ssoc

iate

d w

ith in

cide

nce

and

prev

alen

ce o

f fa

t atr

ophy

and

acc

umul

atio

n (a

bstr

act P

64).

Ant

ivir

The

r. 2

000;

5:6

1-62

2.

H

eath

KV

, Hog

g R

S, C

han

KJ,

Har

ris

M M

onte

ssor

i V, O

’Sha

ughn

essy

MV

, Mon

tane

r JS

. L

ipod

ystr

ophy

-ass

ocia

ted

mor

phol

ogic

al, c

hole

ster

ol a

nd tr

igly

ceri

de a

bnor

mal

ities

in a

pop

ulat

ion-

base

d H

IV/A

IDS

trea

tmen

t dat

abas

e. A

IDS.

200

1;15

:231

-239

. 3.

Sa

fri S

, Gru

nfel

d C

. Fat

dis

trib

utio

n an

d m

etab

olic

cha

nges

in p

atie

nts

with

HIV

infe

ctio

n. A

IDS.

199

9;13

:249

3-25

05.

4.

Sattl

er F

. B

ody

habi

tus

chan

ges

rela

ted

to li

pody

stro

phy.

Clin

Inf

ect D

is.

2003

;36:

pS84

-pS9

0.

Edi

tion:

200

6 12

2

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

FO

OD

AN

D N

UT

RIT

ION

-RE

LA

TE

D K

NO

WL

ED

GE

DE

FIC

IT (

NB

-1.1

)

De

fin

itio

n

Inco

mpl

ete

or in

accu

rate

kno

wle

dge

abou

t foo

d, n

utri

tion

or n

utri

tion-

rela

ted

info

rmat

ion

and

guid

elin

es e

.g. n

utri

ent r

equi

rem

ents

, con

sequ

ence

s of

foo

d be

havi

ors,

life

sta

ge r

equi

rem

ents

, nut

ritio

n re

com

men

datio

ns, d

isea

ses

and

cond

ition

s, p

hysi

olog

ical

fun

ctio

n, o

r pr

oduc

ts

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Har

mfu

l bel

iefs

/atti

tude

s ab

out f

ood,

nut

ritio

n, a

nd n

utri

tion-

rela

ted

topi

cs

Lac

k of

pri

or e

xpos

ure

to in

form

atio

n

Lan

guag

e or

cul

tura

l bar

rier

impa

ctin

g ab

ility

to le

arn

info

rmat

ion

Lea

rnin

g di

sabi

lity,

neu

rolo

gica

l or

sens

ory

impa

irm

ent

Prio

r ex

posu

re to

inco

mpa

tible

info

rmat

ion

Prio

r ex

posu

re to

inco

rrec

t inf

orm

atio

n

Unw

illin

g or

uni

nter

este

d in

lear

ning

info

rmat

ion

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Edi

tion:

200

6 12

3

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

FO

OD

AN

D N

UT

RIT

ION

-RE

LA

TE

D K

NO

WL

ED

GE

DE

FIC

IT (

NB

-1.1

)F

ood/

Nut

ritio

n H

isto

ry

Obs

erva

tions

or

repo

rts

of:

Ver

baliz

es in

accu

rate

or

inco

mpl

ete

info

rmat

ion

Prov

ides

inac

cura

te o

r in

com

plet

e w

ritte

n re

spon

se to

que

stio

nnai

re/w

ritte

n to

ol o

r is

una

ble

to r

ead

wri

tten

tool

Dem

onst

rate

s in

abili

ty to

app

ly f

ood

and

nutr

ition

-rel

ated

info

rmat

ion,

e.g

. sel

ect f

ood

base

d on

nut

ritio

n th

erap

y or

pre

pare

in

fant

fee

ding

as

inst

ruct

ed

Rel

ates

con

cern

s ab

out p

revi

ous

atte

mpt

s to

lear

n in

form

atio

n

Ver

baliz

es u

nwill

ingn

ess

or d

isin

tere

st in

lear

ning

info

rmat

ion

Clie

nt H

isto

ry

Clie

nt o

r ca

regi

ver

has

no p

rior

kno

wle

dge

of n

eed

for

food

and

nut

ritio

n-re

late

d re

com

men

datio

ns

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

men

tal i

llnes

s

New

med

ical

dia

gnos

is o

r ch

ange

in e

xist

ing

diag

nosi

s or

con

ditio

n

Refe

ren

ces:

1.

Cra

wfo

rd S

. Pr

omot

ing

diet

ary

chan

ge.

Can

J C

ardi

ol. 1

995;

11(s

uppl

A):

14A

-15A

. 2.

K

uman

yika

SK

, Van

Hor

n L

, Bow

en D

, Per

ri M

G, R

olls

BJ,

Cza

jkow

ski S

M, S

chro

n E

. M

aint

enan

ce o

f di

etar

y be

havi

or c

hang

e. H

ealth

Psy

chol

. 200

0;19

(1 s

uppl

):S4

2-S5

6.

3.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Wei

ght m

anag

emen

t. J

Am

Die

t Ass

oc. 2

002;

102:

1145

-115

5.

4.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Tot

al d

iet a

ppro

ach

to c

omm

unic

atin

g fo

od a

nd n

utri

tion

info

rmat

ion.

J A

m D

iet A

ssoc

200

2;10

2:10

0-10

8.

5.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

The

rol

e of

die

tetic

s pr

ofes

sion

als

in h

ealth

pro

mot

ion

and

dise

ase

prev

entio

n. J

Am

Die

t Ass

oc. 2

002;

102:

1680

-168

7.

6.

Shep

herd

R.

Res

ista

nce

to c

hang

es in

die

t. P

roc

Nut

r So

c. 2

002;

61:2

67-2

72.

7.

U.S

. Pre

vent

ive

Serv

ices

Tas

k Fo

rce.

Beh

avio

ral c

ouns

elin

g in

pri

mar

y ca

re to

pro

mot

e a

heal

thy

diet

. Am

J P

rev

Med

. 200

3;24

:93-

100.

Edi

tion:

200

6 12

4

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

HA

RM

FU

L B

EL

IEF

S/A

TT

ITU

DE

S O

R P

RA

CT

ICE

S A

BO

UT

FO

OD

, N

UT

RIT

ION

,

AN

D N

UT

RIT

ION

-RE

LA

TE

D T

OP

ICS

(N

B-1

.2)

Use

wit

h c

au

tion

: B

e se

nsi

tive

to p

ati

ent

con

cern

s

De

fin

itio

n

Bel

iefs

/atti

tude

s or

pra

ctic

es a

bout

foo

d, n

utri

tion,

and

nut

ritio

n-re

late

d to

pics

that

are

inco

mpa

tible

with

sou

nd n

utri

tion

prin

cipl

es, n

utri

tion

care

or

dise

ase/

cond

ition

(ex

clud

ing

diso

rder

ed e

atin

g pa

ttern

s an

d ea

ting

diso

rder

s)

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Dis

belie

f in

sci

ence

-bas

ed f

ood

and

nutr

ition

info

rmat

ion

Exp

osur

e to

inco

rrec

t foo

d an

d nu

triti

on in

form

atio

n

Eat

ing

beha

vior

ser

ves

a pu

rpos

e ot

her

than

nou

rish

men

t (e.

g. P

ICA

)

Des

ire

for

a cu

re f

or a

chr

onic

dis

ease

thro

ugh

the

use

of a

ltern

ativ

e th

erap

y

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Food

fet

ish,

PIC

A

Food

fad

dism

Inta

ke th

at r

efle

cts

an im

bala

nce

of n

utri

ents

/foo

d gr

oups

Avo

idan

ce o

f fo

ods/

food

gro

ups

(e.g

., su

gar,

whe

at, c

ooke

d fo

ods)

Edi

tion:

200

6 12

5

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

HA

RM

FU

L B

EL

IEF

S/A

TT

ITU

DE

S O

R P

RA

CT

ICE

S A

BO

UT

FO

OD

, N

UT

RIT

ION

,

AN

D N

UT

RIT

ION

-RE

LA

TE

D T

OP

ICS

(N

B-1

.2)

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

obes

ity, d

iabe

tes,

can

cer,

car

diov

ascu

lar

dise

ase,

men

tal i

llnes

s

Refe

ren

ces:

1.

Cha

pman

GE

, Bea

gan

B.

Wom

en's

per

spec

tives

on

nutr

ition

, hea

lth, a

nd b

reas

t can

cer.

J N

utr

Edu

c B

ehav

. 200

3;35

:135

-141

. 2.

G

onza

lez

VM

, Vito

usek

KM

. Fe

ared

foo

d in

die

ting

and

non-

diet

ing

youn

g w

omen

: a p

relim

inar

y va

lidat

ion

of th

e Fo

od P

hobi

a Su

rvey

. App

etite

. 200

4;43

:155

-173

. 3.

Jo

wet

t SL

, Sea

l CJ,

Phi

llips

E, G

rego

ry W

, Bar

ton

JR, W

elfa

re M

R. D

ieta

ry b

elie

fs o

f pe

ople

with

ulc

erat

ive

colit

is a

nd th

eir

effe

ct o

n re

laps

e an

d nu

trie

nt in

take

. C

lin

Nut

r. 2

004;

23:1

61-1

70.

4.

Mad

den

H, C

ham

berl

ain

K.

Nut

ritio

nal h

ealth

mes

sage

s in

wom

en's

mag

azin

es: a

con

flic

ted

spac

e fo

r w

omen

rea

ders

. J H

ealth

Psy

chol

ogy.

200

4;9:

583-

597.

5.

Pe

ters

CL

, She

lton

J, S

harm

a P.

An

inve

stig

atio

n of

fac

tors

that

infl

uenc

e th

e co

nsum

ptio

n of

die

tary

sup

plem

ents

. Hea

lth M

ark

Qua

rter

ly. 2

003;

21:1

13-1

35.

6.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Foo

d an

d nu

triti

on m

isin

form

atio

n. J

Am

Die

t Ass

oc. 2

002;

102:

260-

266.

7.

Po

vey

R, W

elle

ns B

, Con

ner

M. A

ttitu

des

tow

ards

fol

low

ing

mea

t, ve

geta

rian

and

veg

an d

iets

: an

exam

inat

ion

of th

e ro

le o

f am

biva

lenc

e. A

ppet

ite.

2001

;37:

15-2

6.

8.

Putte

rman

E, L

inde

n W

. App

eara

nce

vers

us h

ealth

: doe

s th

e re

ason

for

die

ting

affe

ct d

ietin

g be

havi

or?

J B

ehav

Med

. 200

4;27

:185

-204

. 9.

Sa

lmin

en E

, Hei

kkila

S, P

ouss

a T

, Lag

stro

m H

, Saa

rio

R, S

alm

inen

S. F

emal

e pa

tient

s te

nd to

alte

r th

eir

diet

fol

low

ing

the

diag

nosi

s of

rhe

umat

oid

arth

ritis

and

bre

ast c

ance

r. P

rev

Med

.20

02;3

4:52

9-53

5.

Edi

tion:

200

6 12

6

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

NO

T R

EA

DY

FO

R D

IET

/LIF

ES

TY

LE

CH

AN

GE

(N

B-1

.3)

De

fin

itio

n

Lac

k of

per

ceiv

ed v

alue

of

nutr

ition

-rel

ated

beh

avio

r ch

ange

com

pare

d to

cos

ts (

cons

eque

nces

or

effo

rt r

equi

red

to m

ake

chan

ges)

; con

flic

t w

ith p

erso

nal

valu

e sy

stem

; ant

eced

ent t

o be

havi

or c

hang

e

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Har

mfu

l bel

iefs

/atti

tude

s ab

out f

ood,

nut

ritio

n, a

nd n

utri

tion-

rela

ted

topi

cs

Cog

nitiv

e de

fici

ts o

r in

abili

ty to

foc

us o

n di

etar

y ch

ange

s

Lac

k of

soc

ial s

uppo

rt f

or im

plem

entin

g ch

ange

s

Den

ial o

f ne

ed to

cha

nge

Perc

eptio

n th

at ti

me,

inte

rper

sona

l or

fina

ncia

l con

stra

ints

pre

vent

cha

nges

Unw

illin

g or

uni

nter

este

d in

lear

ning

info

rmat

ion

Lac

k of

sel

f-ef

fica

cy f

or m

akin

g ch

ange

or

dem

oral

izat

ion

from

pre

viou

s fa

ilure

s at

cha

nge

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Neg

ativ

e bo

dy la

ngua

ge, e

.g. f

row

ning

, lac

k of

eye

con

tact

, def

ensi

ve p

ostu

re, l

ack

of f

ocus

, fid

getin

g (N

ote.

Bod

y la

ngua

ge v

arie

s by

cul

ture

.)

Edi

tion:

200

6 12

7

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

NO

T R

EA

DY

FO

R D

IET

/LIF

ES

TY

LE

CH

AN

GE

(N

B-1

.3)

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Den

ial o

f ne

ed f

or f

ood

and

nutr

ition

-rel

ated

cha

nges

Inab

ility

to u

nder

stan

d re

quir

ed c

hang

es

Failu

re to

kee

p ap

poin

tmen

ts/s

ched

ule

follo

w-u

p ap

poin

tmen

ts o

r en

gage

in c

ouns

elin

g

Prev

ious

fai

lure

s to

eff

ectiv

ely

chan

ge ta

rget

beh

avio

r

Def

ensi

vene

ss, h

ostil

ity o

r re

sist

ance

to c

hang

e

Lac

k of

eff

icac

y to

mak

e ch

ange

or

to o

verc

ome

barr

iers

to c

hang

e

Clie

nt H

isto

ry

New

med

ical

dia

gnos

is, c

hang

e in

exi

stin

g di

agno

sis

or c

ondi

tion,

or

chro

nic

non-

com

plia

nce

Refe

ren

ces:

1.

Cra

wfo

rd S

. Pr

omot

ing

diet

ary

chan

ge.

Can

J C

ardi

ol. 1

995;

11:1

4A-1

5A.

2.

Gre

ene,

GW

, Ros

si, S

R, R

ossi

, JS,

Vel

icer

, WF,

Fav

a, J

S, P

roch

aska

, JO

. D

ieta

ry a

pplic

atio

ns o

f th

e St

ages

of

Cha

nge

Mod

el.

J A

m D

iet A

ssoc

. 19

99; 9

9:67

3-67

8.

3.

Kum

anyi

ka S

K, V

an H

orn

L, B

owen

D, P

erri

MG

, Rol

ls B

J, C

zajk

owsk

i SM

, Sch

ron

E.

Mai

nten

ance

of

diet

ary

beha

vior

cha

nge.

Hea

lth P

sych

ol. 2

000;

19:p

S42-

pS56

. 4.

Pr

ocha

ska

JO, V

elic

er W

F.

The

Tra

nsth

eore

tical

Mod

el o

f be

havi

or c

hang

e. A

m J

Hea

lth

Pro

mot

ion.

199

7;12

: 38–

48.

5.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Tot

al d

iet a

ppro

ach

to c

omm

unic

atin

g fo

od a

nd n

utri

tion

info

rmat

ion.

J A

m D

iet A

ssoc

200

2;10

2:10

0-10

8.

6.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

The

rol

e of

die

tetic

s pr

ofes

sion

als

in h

ealth

pro

mot

ion

and

dise

ase

prev

entio

n. J

Am

Die

t Ass

oc. 2

002;

102:

1680

-168

7.

7.

Res

nico

w K

, Jac

kson

A, W

ang

T, D

e A

, McC

arty

F, D

udle

y W

, B

aron

owsk

i T. A

mot

ivat

iona

l int

ervi

ewin

g in

terv

entio

n to

incr

ease

fru

it an

d ve

geta

ble

inta

ke th

roug

h bl

ack

chur

ches

: Res

ults

of

the

Eat

for

Lif

e tr

ial.

Am

J P

ublic

Hea

lth.

2001

; 91:

1686

-169

3.

8.

Shep

herd

R.

Res

ista

nce

to c

hang

es in

die

t. P

roc

Nut

r So

c. 2

002;

61:2

67-2

72.

9.

U.S

. Pre

vent

ive

Serv

ices

Tas

k Fo

rce.

Beh

avio

ral c

ouns

elin

g in

pri

mar

y ca

re to

pro

mot

e a

heal

thy

diet

. Am

J P

rev

Med

. 200

3;24

:93-

100.

Edi

tion:

200

6 12

8

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

SE

LF

-MO

NIT

OR

ING

DE

FIC

IT (

NB

-1.4

)

De

fin

itio

n

Lac

k of

dat

a re

cord

ing

to tr

ack

pers

onal

pro

gres

s

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Lac

k of

soc

ial s

uppo

rt f

or im

plem

entin

g ch

ange

s

Lac

k of

val

ue f

or b

ehav

ior

chan

ge o

r co

mpe

ting

valu

es

Perc

eptio

n th

at la

ck o

f re

sour

ces,

e.g

., tim

e, f

inan

cial

, or

soci

al s

uppo

rt p

reve

nt s

elf-

mon

itori

ng

Cul

tura

l bar

rier

impa

ctin

g ab

ility

to tr

ack

pers

onal

pro

gres

s

Lea

rnin

g di

sabi

lity,

neu

rolo

gica

l, or

sen

sory

impa

irm

ent

Prio

r ex

posu

re to

inco

mpa

tible

info

rmat

ion

Not

rea

dy f

or d

iet/l

ifes

tyle

cha

nge

Unw

illin

g or

uni

nter

este

d in

trac

king

pro

gres

s

Lac

k of

foc

us a

nd a

ttent

ion

to d

etai

l, di

ffic

ulty

with

tim

e m

anag

emen

t and

/or

orga

niza

tion

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a R

ecor

ded

data

inco

nsis

tent

with

bio

chem

ical

dat

a, e

.g.,

diet

ary

inta

ke is

not

con

sist

ent w

ith b

ioch

emic

al d

ata

Ant

hrop

omet

ric

Mea

sure

men

ts

Rec

orde

d da

ta in

cons

iste

nt w

ith w

eigh

t sta

tus

or g

row

th p

atte

rn d

ata,

e.g

., di

etar

y in

take

is n

ot c

onsi

sten

t with

wei

ght

stat

us o

r gr

owth

pat

tern

Phy

sica

l Exa

m F

indi

ngs

Edi

tion:

200

6 12

9

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

SE

LF

-MO

NIT

OR

ING

DE

FIC

IT (

NB

-1.4

)F

ood/

Nut

ritio

n H

isto

ry

Rep

orts

or

obse

rvat

ions

of:

Inco

mpl

ete

self

-mon

itori

ng r

ecor

ds, e

.g.,

gluc

ose,

foo

d, f

luid

inta

ke, w

eigh

t, ph

ysic

al a

ctiv

ity, o

stom

y ou

tput

rec

ords

Em

barr

assm

ent o

r an

ger

rega

rdin

g ne

ed f

or s

elf-

mon

itori

ng

Unc

erta

inty

of

how

to c

ompl

ete

mon

itori

ng r

ecor

ds

Unc

erta

inty

reg

ardi

ng c

hang

es th

at c

ould

/sho

uld

be m

ade

in r

espo

nse

to d

ata

in s

elf

mon

itori

ng r

ecor

ds

No

self

man

agem

ent e

quip

men

t, e.

g. n

o bl

ood

gluc

ose

mon

itor,

ped

omet

er

Clie

nt H

isto

ry

Dia

gnos

es a

ssoc

iate

d w

ith s

elf-

mon

itori

ng, e

.g.,

diab

etes

mel

litus

, obe

sity

, new

ost

omy

New

med

ical

dia

gnos

is o

r ch

ange

in e

xist

ing

diag

nosi

s or

con

ditio

n

Refe

ren

ces:

1.

Am

eric

an D

iabe

tes

Ass

ocia

tion.

Tes

ts o

f gl

ycem

ia in

dia

bete

s. D

iabe

tes

Car

e. 2

004;

27:p

S91-

pS93

. 2.

B

aker

RC

, Kir

sche

nbau

m D

S. W

eigh

t con

trol

dur

ing

the

holid

ays:

hig

hly

cons

iste

nt s

elf-

mon

itori

ng a

s a

pote

ntia

lly u

sefu

l cop

ing

mec

hani

sm. H

ealt

h P

sych

ol. 1

998;

17:3

67-3

70.

3.

Ber

kow

itz R

I, W

adde

n T

A, T

ersh

akov

ec A

M. B

ehav

ior

ther

apy

and

sibu

tram

ine

for

trea

tmen

t of

adol

esce

nt o

besi

ty. J

AM

A. 2

003;

289:

1805

-181

2.

4.

Cra

wfo

rd S

. Pr

omot

ing

diet

ary

chan

ge.

Can

J C

ardi

ol. 1

995;

11(s

uppl

A):

14A

-15A

. 5.

Je

ffer

y R

, Dre

wno

wsk

i A, E

pste

in L

, Stu

nkar

d A

, Wils

on G

, Win

g R

: Lon

g-te

rm m

aint

enan

ce o

f w

eigh

t los

s: c

urre

nt s

tatu

s. H

ealth

Psy

chol

ogy.

200

0;19

:5-1

6.

6.

Kum

anyi

ka S

K, V

an H

orn

L, B

owen

D, P

erri

MG

, Rol

ls B

J, C

zajk

owsk

i SM

, Sch

ron

E.

Mai

nten

ance

of

diet

ary

beha

vior

cha

nge.

Hea

lth P

sych

ol. 2

000;

19(1

sup

pl):

S42-

S56.

7.

L

icht

man

SW

, Pis

arka

K, B

erm

an E

R e

t al:

Dis

crep

ancy

bet

wee

n se

lf-r

epor

ted

and

actu

al c

alor

ic in

take

and

exe

rcis

e in

obe

se s

ubje

cts.

N E

ngl J

Med

. 19

92;3

27:1

893-

1898

. 8.

W

adde

n, T

A. C

hara

cter

istic

s of

suc

cess

ful w

eigh

t los

s m

aint

aine

rs. I

n: A

lliso

n D

B, P

i-Su

nyer

FX

, edi

tors

. Obe

sity

trea

tmen

t: e

stab

lishi

ng g

oals

, im

prov

ing

outc

omes

, and

rev

iew

ing

the

rese

arch

ag

enda

. New

Yor

k: P

lenu

m P

ress

; 199

5. p

. 103

-111

.

Edi

tion:

200

6 13

0

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

DIS

OR

DE

R E

AT

ING

PA

TT

ER

N (

NB

-1.5

)

De

fin

itio

n

Bel

iefs

, atti

tude

s, th

ough

ts a

nd b

ehav

iors

rel

ated

to f

ood,

eat

ing,

and

wei

ght m

anag

emen

t, in

clud

ing

clas

sic

eatin

g di

sord

ers

as w

ell a

s le

ss s

ever

e, s

imila

r co

nditi

ons

that

neg

ativ

ely

impa

ct h

ealth

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Fam

ilial

, soc

ieta

l, bi

olog

ical

/gen

etic

, and

/or

envi

ronm

enta

l rel

ated

obs

essi

ve d

esir

e to

be

thin

Wei

ght r

egul

atio

n/pr

eocc

upat

ion

sign

ific

antly

infl

uenc

es s

elf

este

em

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a E

leva

ted

chol

este

rol,

abno

rmal

lipi

d pr

ofile

s, h

ypog

lyce

mia

, hyp

okal

emia

[an

orex

ia n

ervo

sa (

AN

)]

Hyp

okal

emia

and

hyp

ochl

orem

ic a

lkal

osis

[bu

limia

ner

vosa

(B

N)]

H

ypot

ensi

on, b

rady

card

ia, l

ow b

ody

tem

pera

ture

, hyp

onat

rem

ia, a

nem

ia, h

ypot

hyro

id, l

euco

peni

a, e

leva

ted

BU

N (

AN

) U

rine

pos

itive

for

ket

ones

(A

N)

Ant

hrop

omet

ric

Mea

sure

men

ts

BM

I <

17.

5, a

rres

ted

grow

th a

nd d

evel

opm

ent,

failu

re to

gai

n w

eigh

t dur

ing

peri

od o

f ex

pect

ed g

row

th, w

eigh

t les

s th

an

85%

of

expe

cted

(A

N)

BM

I >

29 [

eatin

g di

sord

er n

ot o

ther

wis

e sp

ecif

ied

(ED

NO

S)]

Sign

ific

ant w

eigh

t flu

ctua

tion

(BN

)

Edi

tion:

200

6 13

1

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

DIS

OR

DE

R E

AT

ING

PA

TT

ER

N (

NB

-1.5

)P

hysi

cal E

xam

Fin

ding

s Se

vere

ly d

eple

ted

adip

ose

and

som

atic

pro

tein

sto

res

(AN

) L

anug

o ha

ir f

orm

atio

n on

fac

e an

d tr

unk,

bri

ttle

listle

ss h

air,

cya

nosi

s of

han

ds a

nd f

eet,

and

dry

skin

(A

N)

N

orm

al o

r ex

cess

adi

pose

and

nor

mal

som

atic

pro

tein

sto

res

(BN

, ED

NO

S)

Dam

aged

toot

h en

amel

(B

N)

Enl

arge

d pa

rotid

gla

nds

(BN

) Pe

riph

eral

ede

ma

(BN

) Sk

elet

al m

uscl

e lo

ss (

AN

) C

ardi

ac a

rrhy

thm

ias

(AN

, BN

) Ir

rita

bilit

y, d

epre

ssio

n (A

N, B

N)

Inab

ility

to c

once

ntra

te (

AN

) Po

sitiv

e R

usse

ll’s

Sign

(B

N)

callo

us o

n ba

ck o

f ha

nd f

rom

sel

f in

duce

d vo

miti

ng

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Avo

idan

ce o

f fo

od o

r ca

lori

e co

ntai

ning

bev

erag

es (

AN

, BN

) Fe

ar o

f fo

ods

or d

ysfu

nctio

nal t

houg

hts

rega

rdin

g fo

od o

r fo

od e

xper

ienc

es (

AN

, BN

)

Den

ial o

f hu

nger

(A

N)

Food

pre

occu

patio

n (A

N, B

N)

Kno

wle

dgea

ble

abou

t cur

rent

die

t fad

(A

N, B

N, E

DN

OS)

Fa

stin

g (A

N, B

N)

Inta

ke o

f la

rger

qua

ntity

of

food

in a

def

ined

tim

e pe

riod

, a s

ense

of

lack

of

cont

rol o

ver

eatin

g du

ring

the

epis

ode

(BN

, E

DN

OS)

E

xces

sive

phy

sica

l act

ivity

(A

N, B

N, E

DN

OS)

E

atin

g m

uch

mor

e ra

pidl

y th

an n

orm

al, u

ntil

feel

ing

unco

mfo

rtab

ly f

ull,

cons

umin

g la

rge

amou

nts

of f

ood

whe

n no

t fee

ling

phys

ical

ly h

ungr

y; e

atin

g al

one

beca

use

of b

eing

em

barr

asse

d by

how

muc

h on

e is

eat

ing;

fee

ling

disg

uste

d w

ith o

nese

lf,

depr

esse

d, o

r ve

ry g

uilty

aft

er o

vere

atin

g (E

DN

OS)

E

ats

in p

riva

te (

AN

, BN

) Ir

ratio

nal t

houg

hts

abou

t foo

d’s

affe

ct o

n th

e bo

dy (

AN

, BN

, ED

NO

S)

Patte

rn o

f ch

roni

c di

etin

g W

eigh

t pre

occu

patio

n

Exc

essi

ve r

elia

nce

on n

utri

tion

Ter

min

g an

d pr

eocc

upat

ion

with

nut

rien

t con

tent

of

food

s In

flex

ibili

ty w

ith f

ood

sele

ctio

n

Edi

tion:

200

6 13

2

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

DIS

OR

DE

R E

AT

ING

PA

TT

ER

N (

NB

-1.5

)C

lient

His

tory

B

rady

card

ia (

Hea

rt R

ate

<60

beat

s/m

in),

hyp

oten

sion

(sy

stol

ic <

90 m

m H

G),

and

ort

host

atic

hyp

oten

sion

(A

N)

Self

-ind

uced

vom

iting

, dia

rrhe

a, b

loat

ing,

con

stip

atio

n an

d fl

atul

ence

(B

N),

alw

ays

cold

(A

N)

Mis

use

of la

xativ

es, e

nem

as, d

iure

tics,

stim

ulan

ts a

nd o

r m

etab

olic

enh

ance

rs (

AN

,BN

)

Mus

cle

wea

knes

s, f

atig

ue, c

ardi

ac a

rrhy

thm

ias,

deh

ydra

tion

and

elec

trol

yte

imba

lanc

e (A

N, B

N)

D

iagn

osis

e.g

. ano

rexi

a ne

rvos

a, b

ulim

ia n

ervo

sa, b

inge

eat

ing,

eat

ing

diso

rder

not

oth

erw

ise

spec

ifie

d, a

men

orrh

ea,

His

tory

of

moo

d an

d an

xiet

y di

sord

ers

(e.g

., de

pres

sion

, obs

essi

ve c

ompu

lsiv

e di

sord

er),

per

sona

lity

diso

rder

s, s

ubst

ance

ab

use

diso

rder

s Fa

mily

his

tory

of

ED

, dep

ress

ion,

OC

D, a

nxie

ty d

isor

ders

(A

N, B

N)

Avo

idan

ce o

f so

cial

eve

nts

whe

re f

ood

is s

erve

d

Refe

ren

ces:

1.

And

erso

n G

H, K

enne

dy S

H, e

ds. T

he B

iolo

gy o

f Fea

st a

nd F

amin

e. N

ew Y

ork:

Aca

dem

ic P

ress

, 199

2.

2.

Am

eric

an P

sych

iatr

ic A

ssoc

iatio

n. D

iagn

ostic

and

sta

tistic

al m

anua

l for

men

tal d

isor

ders

(fo

urth

edi

tion,

text

rev

isio

n). A

PA P

ress

: Was

hing

ton

DC

; 200

0.

3.

Am

eric

an P

sych

iatr

ic A

ssoc

iatio

n. P

ract

ice

guid

elin

es f

or th

e tr

eatm

ent o

f pa

tient

s w

ith e

atin

g di

sord

ers.

Am

J P

sych

. 200

0;15

7 (s

uppl

):1-

39.

4.

Coo

ke R

A, C

ham

bers

JB

. Ano

rexi

a ne

rvos

a an

d th

e he

art.

Br

J H

osp

Med

. 199

5;54

:313

-317

. 5.

Fi

sher

M. M

edic

al c

ompl

icat

ions

of

anor

exia

and

bul

imia

ner

vosa

. Ado

l Med

Sta

t of t

he A

rt R

evie

ws.

199

2;3:

481-

502.

6.

G

rale

n SJ

, Lev

in M

P, S

mol

ak L

et a

l. D

ietin

g an

d di

sord

ered

eat

ing

duri

ng e

arly

and

mid

dle

adol

esce

nts:

Do

the

infl

uenc

es r

emai

n th

e sa

me?

Int

J E

atin

g D

isor

der.

199

0;9:

501-

512.

7.

H

arri

s JP

, Kri

epe

RE

, Ros

sbac

k C

N. Q

T p

rolo

ngat

ion

by is

opro

tere

nol i

n an

orex

ia n

ervo

sa. J

Ado

l Hea

lth. 1

993;

14:3

90-3

93.

8.

Kap

lan

AS,

Gar

funk

el P

E, e

ds. M

edic

al I

ssue

s an

d th

e E

atin

g D

isor

ders

: Th

e In

terf

ace.

New

Yor

k: B

runn

er/M

anze

l Pub

lishe

rs, 1

993.

9.

K

eys

A, B

roze

k J,

Hen

sche

l A, M

icke

lson

O, T

aylo

r H

L. T

he B

iolo

gy o

f Hum

an S

tarv

atio

n, 2

nd v

ol. M

inne

apol

is, M

N: U

nive

rsity

of

Min

neso

ta P

ress

, 195

0.

10.

Kir

kley

BG

. Bul

imia

: clin

ical

cha

ract

eris

tics,

dev

elop

men

t, an

d et

iolo

gy. J

Am

Die

t Ass

oc. 1

986;

86:4

68-4

75.

11.

Kre

ipe

RE

, Uph

off

M. T

reat

men

t and

out

com

e of

ado

lesc

ents

with

ano

rexi

a ne

rvos

a. A

dole

sc M

ed.1

992;

16:5

19-5

40.

12.

Kre

ipe

RE

, Bir

ndor

f D

O. E

atin

g di

sord

ers

in a

dole

scen

ts a

nd y

oung

adu

lts. M

edic

al C

linic

s of

Nor

th A

mer

ica.

200

0;84

(4):

1027

-104

9.

13.

Mor

dasi

ni R

, Klo

se G

, Gre

ter

H. S

econ

dary

type

II

hype

rlip

opro

tein

emia

in p

atie

nts

with

ano

rexi

a ne

rvos

a. M

etab

olis

m. 1

978;

27:7

1-79

. 14

. Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: N

utri

tion

inte

rven

tion

in th

e tr

eatm

ent o

f an

orex

ia n

ervo

sa, b

ulim

ia n

ervo

sa, a

nd e

atin

g di

sord

er n

ot o

ther

wis

e sp

ecif

ied

(ED

NO

S).

J A

m D

iet A

ssoc

.20

01;1

01:8

10-8

19.

15.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Nut

ritio

n in

terv

entio

n in

the

trea

tmen

t of

anor

exia

ner

vosa

, bul

imia

ner

vosa

, and

eat

ing

diso

rder

not

oth

erw

ise

spec

ifie

d (E

DN

OS

). J

Am

Die

t Ass

oc.

2001

;101

:810

-819

. 16

. R

ock

C, Y

ager

J. N

utri

tion

and

eatin

g di

sord

ers:

a p

rim

er f

or c

linic

ians

. Int

J E

atin

g D

is. 1

987;

6:26

7-28

0.

17.

Roc

k, C

L. N

utri

tiona

l and

med

ical

ass

essm

ent a

nd m

anag

emen

t of

eatin

g di

sord

ers.

Nut

r C

lin C

are.

199

9;2:

332-

343.

18

. Sc

hebe

ndac

h J,

Rei

cher

t-A

nder

son

P. N

utri

tion

in E

atin

g D

isor

ders

. In:

Kra

us’s

Nut

riti

on a

nd D

iet T

hera

py. M

ahan

K, E

scot

t-St

ump

S (e

ds).

McG

raw

- H

ill: N

ew Y

ork,

NY

; 200

0.

19.

Silb

er T

. Ano

rexi

a ne

rvos

a: M

orbi

dity

and

mor

talit

y. P

ed A

nn. 1

984;

13:

851-

859.

20

. Sw

enne

I. H

eart

ris

k as

soci

ated

with

wei

ght l

oss

in a

nore

xia

nerv

osa

and

eatin

g di

sord

ers:

ele

ctro

card

iogr

aphi

c ch

ange

s du

ring

the

earl

y ph

ase

of r

efee

ding

. Act

a P

aedi

atr.

200

0;89

:447

-452

. 21

. T

urne

r JM

, Bul

sara

MK

, McD

erm

ott B

M, B

yrne

GC

, Pri

nce

RL

, For

bes

DA

. Pr

edic

tors

of

low

bon

e de

nsity

in y

oung

ado

lesc

ent f

emal

es w

ith a

nore

xia

nerv

osa

and

othe

r di

etin

g di

sord

ers.

Int

J

Eat

ing

Dis

orde

rs.

2001

;30:

245-

251.

Edi

tion:

200

6 13

3

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

LIM

ITE

D A

DH

ER

EN

CE

TO

NU

TR

ITIO

N-R

EL

AT

ED

RE

CO

MM

EN

DA

TIO

NS

(N

B-1

.6)

De

fin

itio

n

Lac

k of

nut

ritio

n-re

late

d ch

ange

s as

per

inte

rven

tion

agre

ed u

pon

by c

lient

or

popu

latio

n

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Lac

k of

soc

ial s

uppo

rt f

or im

plem

entin

g ch

ange

s

Lac

k of

val

ue f

or b

ehav

ior

chan

ge o

r co

mpe

ting

valu

es

Perc

eptio

n th

at ti

me

or f

inan

cial

con

stra

ints

pre

vent

cha

nges

Prev

ious

lack

of

succ

ess

in m

akin

g he

alth

-rel

ated

cha

nges

Poor

und

erst

andi

ng o

f ho

w a

nd w

hy to

mak

e th

e ch

ange

Unw

illin

g or

uni

nter

este

d in

app

lyin

g in

form

atio

n

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a E

xpec

ted

labo

rato

ry o

utco

mes

are

not

ach

ieve

d

Ant

hrop

omet

ric

Mea

sure

men

ts

Exp

ecte

d an

thro

pom

etri

c ou

tcom

es a

re n

ot a

chie

ved

Phy

sica

l Exa

m F

indi

ngs

Neg

ativ

e bo

dy la

ngua

ge, e

.g. f

row

ning

, lac

k of

eye

con

tact

, fid

getin

g

Edi

tion:

200

6 13

4

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

LIM

ITE

D A

DH

ER

EN

CE

TO

NU

TR

ITIO

N-R

EL

AT

ED

RE

CO

MM

EN

DA

TIO

NS

(N

B-1

.6)

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Exp

ecte

d fo

od/n

utri

tion-

rela

ted

outc

omes

are

not

ach

ieve

d In

abili

ty to

rec

all a

gree

d up

on c

hang

es

Failu

re to

com

plet

e an

y ag

reed

upo

n ho

mew

ork

Lac

k of

com

plia

nce

or in

cons

iste

nt c

ompl

ianc

e w

ith p

lan

Fa

ilure

to k

eep

appo

intm

ents

or

sche

dule

fol

low

-up

appo

intm

ents

L

ack

of a

ppre

ciat

ion

of th

e im

port

ance

of

mak

ing

reco

mm

ende

d nu

triti

on-r

elat

ed c

hang

es

Unc

erta

inty

as

to h

ow to

con

sist

ently

app

ly f

ood/

nutr

ition

info

rmat

ion

Clie

nt H

isto

ry

Refe

ren

ces:

1.

Cra

wfo

rd S

. Pr

omot

ing

diet

ary

chan

ge.

Can

J C

ardi

ol. 1

995;

11(s

uppl

A):

14A

-15A

. 2.

K

uman

yika

SK

, Van

Hor

n L

, Bow

en D

, Per

ri M

G, R

olls

BJ,

Cza

jkow

ski S

M, S

chro

n E

. M

aint

enan

ce o

f di

etar

y be

havi

or c

hang

e. H

ealth

Psy

chol

. 200

0;19

(1 s

uppl

):S4

2-S5

6.

3.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Tot

al d

iet a

ppro

ach

to c

omm

unic

atin

g fo

od a

nd n

utri

tion

info

rmat

ion.

J A

m D

iet A

ssoc

200

2;10

2:10

0-10

8.

4.

Shep

herd

R.

Res

ista

nce

to c

hang

es in

die

t. P

roc

Nut

r So

c. 2

002;

61:2

67-2

72.

5.

U.S

. Pre

vent

ive

Serv

ices

Tas

k Fo

rce.

Beh

avio

ral c

ouns

elin

g in

pri

mar

y ca

re to

pro

mot

e a

heal

thy

diet

. Am

J P

rev

Med

. 200

3;24

:93-

100.

Edi

tion:

200

6 13

5

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

UN

DE

SIR

AB

LE

FO

OD

CH

OIC

ES

(N

B-1

.7)

De

fin

itio

n

Food

and

/or

beve

rage

cho

ices

that

are

inco

nsis

tent

with

US

Rec

omm

ende

d D

ieta

ry I

ntak

e, U

S D

ieta

ry G

uide

lines

, or

with

the

Food

Gui

de P

yram

id o

r w

ith

targ

ets

defi

ned

in th

e nu

triti

on p

resc

ript

ion

or n

utri

tion

care

pro

cess

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Lac

k of

pri

or e

xpos

ure

to o

r m

isun

ders

tand

ing

of in

form

atio

n

Lan

guag

e, r

elig

ious

, or

cultu

ral b

arri

er im

pact

ing

abili

ty to

app

ly in

form

atio

n

Lea

rnin

g di

sabi

litie

s, n

euro

logi

cal o

r se

nsor

y im

pair

men

t

Hig

h le

vel o

f fa

tigue

or

othe

r si

de e

ffec

t of

ther

apy

Inad

equa

te a

cces

s to

rec

omm

ende

d fo

ods

Perc

eptio

n th

at f

inan

cial

con

stra

ints

pre

vent

sel

ectio

n of

foo

d ch

oice

s co

nsis

tent

with

rec

omm

enda

tions

Food

alle

rgie

s an

d av

ersi

ons

impe

ding

foo

d ch

oice

s co

nsis

tent

with

gui

delin

es

Lac

ks m

otiv

atio

n an

d or

rea

dine

ss to

app

ly o

r su

ppor

t sys

tem

s ch

ange

Unw

illin

g or

uni

nter

este

d in

lear

ning

info

rmat

ion

Psyc

holo

gica

l lim

itatio

ns

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a E

leva

ted

lipid

pan

el

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Find

ings

con

sist

ent w

ith v

itam

in/m

iner

al d

efic

ienc

y or

exc

ess

Edi

tion:

200

6 13

6

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Kno

wled

ge an

d Be

liefs

UN

DE

SIR

AB

LE

FO

OD

CH

OIC

ES

(N

B-1

.7)

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Inta

ke in

cons

iste

nt w

ith U

S D

ieta

ry G

uide

lines

or

Food

Gui

de P

yram

id (

e.g.

, om

issi

on o

f en

tire

nutr

ient

gro

ups,

di

spro

port

iona

te in

take

[e.

g., j

uice

for

you

ng c

hild

ren]

)

Inac

cura

te o

r in

com

plet

e un

ders

tand

ing

of th

e gu

idel

ines

Inab

ility

to a

pply

gui

delin

e in

form

atio

n

Inab

ility

to (

e.g.

acc

ess)

, unw

illin

gnes

s, o

r di

sint

eres

t in

sele

ctin

g fo

od c

onsi

sten

t with

the

guid

elin

es

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

men

tal i

llnes

s

Refe

ren

ces:

1.

Bir

ch L

L, F

ishe

r JA

. App

etite

and

eat

ing

beha

vior

in c

hild

ren.

Ped

iatr

Cli

n N

orth

Am

.199

5:42

(4)9

31-9

53.

2.

But

te N

, Cob

b K

, Dw

yer

J, G

rane

y L

, Hei

rd W

, Ric

hard

K. T

he s

tart

hea

lthy

feed

ing

guid

elin

es f

or in

fant

s an

d to

ddle

rs. J

Am

Die

t Ass

oc.2

004:

104:

3:44

2-45

4.

3.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Wei

ght m

anag

emen

t. J

Am

Die

t Ass

oc. 2

002;

102:

1145

-115

5.

4.

Dol

ecek

TA

, Sta

mle

e J,

Cag

giul

a A

W, T

illot

son

JL, B

uzza

rd I

M. M

etho

ds o

f di

etar

y an

d nu

triti

onal

ass

essm

ent a

nd in

terv

entio

n an

d ot

her

met

hods

in th

e m

ultip

le r

isk

fact

or in

terv

entio

n tr

ial.

Am

J C

lin N

utr.

199

7;65

(sup

pl):

196S

-210

S.

5.

Eps

tein

LH

, Gor

dy C

C, R

ayno

r H

A, B

eddo

me

M, K

ilano

wsk

i CK

, Pal

uch

R. I

ncre

asin

g fr

uit a

nd v

eget

able

inta

ke a

nd d

ecre

asin

g fa

t and

sug

ar in

take

in f

amili

es a

t ris

k fo

r ch

ildho

od o

besi

ty.

Obe

sity

Res

.200

1:9:

171-

178.

6.

Fr

eela

nd-G

rave

s J,

Nitz

ke S

. Tot

al d

iet a

ppro

ach

to c

omm

unic

atin

g fo

od a

nd n

utri

tion

info

rmat

ion.

J A

m D

iet A

ssoc

200

2;10

2:10

0-10

8.

7.

Fren

ch S

A. P

rici

ng e

ffec

ts o

n fo

od c

hoic

es. J

Nut

r. 2

003;

133:

841S

-843

S.

8.

Gle

ns K

, Bas

il M

, Mar

iach

i E, G

oldb

erg

J, S

nyde

r D

. Why

Am

eric

ans

eat w

hat t

hey

do: t

aste

, nut

ritio

n, c

ost,

conv

enie

nce

and

wei

ght c

ontr

ol c

once

rns

as in

flue

nces

on

food

con

sum

ptio

n. J

Am

D

iet A

ssoc

. 199

8;98

:111

8-11

26.

9.

Ham

pl J

S, A

nder

son

JV, M

ullis

R. T

he r

ole

of d

iete

tics

prof

essi

onal

s in

hea

lth p

rom

otio

n an

d di

seas

e pr

even

tion.

J A

m D

iet A

ssoc

. 200

2;10

2:16

80-1

687.

10

. L

in S

H, G

uthr

ie J

, Fra

zao

E. A

mer

ican

chi

ldre

n’s’

die

ts a

re n

ot m

akin

g th

e gr

ade.

Foo

d R

evie

w. 2

001;

24(2

): 8

-17.

11

. Sa

tter

E. F

eedi

ng d

ynam

ics:

hel

ping

chi

ldre

n to

eat

wel

l. J

Ped

iatr

Hea

lthca

re. 1

995;

9:17

8-18

4.

12.

Stor

y M

, Hol

t K, S

ofka

D, e

ds. 2

002.

Bri

ght f

utur

es in

pra

ctic

e: N

utri

tion,

2nd

. Ed.

Arl

ingt

on, V

A N

atio

nal C

ente

r fo

r E

duca

tion

in M

ater

nal C

hild

Hea

lth.

13.

Pelto

GH

, Lev

itt E

, Tha

iru

L. I

mpr

ovin

g fe

edin

g pr

actic

es, c

urre

nt p

atte

rns,

com

mon

con

stra

ints

and

the

desi

gn o

f in

terv

enti

ons.

Foo

d N

utr

Bul

l. 20

03;2

4:45

-82.

Edi

tion:

200

6 13

7

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Phy

sical

Activ

ity an

d Fu

nctio

n

PH

YS

ICA

L I

NA

CT

IVIT

Y (

NB

-2.1

)

De

fin

itio

n

Low

leve

l of

activ

ity/s

eden

tary

beh

avio

r to

the

exte

nt th

at it

red

uces

ene

rgy

expe

nditu

re a

nd im

pact

s he

alth

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Fina

ncia

l con

stra

ints

that

may

pre

vent

suf

fici

ent l

evel

of

activ

ity

Har

mfu

l bel

iefs

/atti

tude

s ab

out p

hysi

cal a

ctiv

ity

Inju

ry o

r lif

esty

le c

hang

e th

at r

educ

es p

hysi

cal a

ctiv

ity o

r ac

tiviti

es o

f da

ily li

ving

Lac

k of

pri

or e

xpos

ure

for

need

for

phy

sica

l act

ivity

or

how

to in

corp

orat

e ex

erci

se, e

.g.,

phys

ical

dis

abili

ty, a

rthr

itis

Lac

k of

rol

e m

odel

s, e

.g.,

for

child

ren

Lac

k of

soc

ial s

uppo

rt a

nd/o

r en

viro

nmen

tal s

pace

or

equi

pmen

t

Lac

k of

saf

e en

viro

nmen

t for

phy

sica

l act

ivity

Lac

k of

val

ue f

or b

ehav

ior

chan

ge o

r co

mpe

ting

valu

es

Tim

e co

nstr

aint

s

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Edi

tion:

200

6 13

8

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Phy

sical

Activ

ity an

d Fu

nctio

n

PH

YS

ICA

L I

NA

CT

IVIT

Y (

NB

-2.1

)F

ood/

Nut

ritio

n H

isto

ry

Rep

orts

or

obse

rvat

ions

of:

Infr

eque

nt, l

ow d

urat

ion

and/

or lo

w in

tens

ity p

hysi

cal a

ctiv

ity

Lar

ge a

mou

nts

of s

eden

tary

act

iviti

es e

.g. T

V w

atch

ing,

rea

ding

, com

pute

r us

e in

bot

h le

isur

e an

d w

ork/

scho

ol

Bar

rier

s to

phy

sica

l act

ivity

, e.g

., tim

e co

nstr

aint

s, a

vaila

bilit

y of

a s

afe

envi

ronm

ent f

or e

xerc

ise

Clie

nt H

isto

ry

Low

car

dio-

resp

irat

ory

fitn

ess

and/

or

low

mus

cle

stre

ngth

Med

ical

dia

gnos

es th

at m

ay b

e as

soci

ated

with

or

resu

lt in

dec

reas

ed a

ctiv

ity, e

.g.,

arth

ritis

, chr

onic

fat

igue

syn

drom

e,

mor

bid

obes

ity, k

nee

surg

ery

Med

icat

ions

that

cau

se s

omno

lenc

e an

d de

crea

sed

cogn

ition

Psyc

holo

gica

l dia

gnos

is, e

.g.,

depr

essi

on, a

nxie

ty d

isor

ders

Refe

ren

ces:

1.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Wei

ght m

anag

emen

t. J

Am

Die

t Ass

oc. 2

002;

102:

1145

-115

5.

2.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Tot

al d

iet a

ppro

ach

to c

omm

unic

atin

g fo

od a

nd n

utri

tion

info

rmat

ion.

J A

m D

iet A

ssoc

200

2;10

2:10

0-10

8.

3.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

The

rol

e of

die

tetic

s pr

ofes

sion

als

in h

ealth

pro

mot

ion

and

dise

ase

prev

entio

n. J

Am

Die

t Ass

oc. 2

002;

102:

1680

-168

7.

Edi

tion:

200

6 13

9

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Phy

sical

Activ

ity an

d Fu

nctio

n

EX

CE

SS

IVE

EX

ER

CIS

E (

NB

-2.2

)

De

fin

itio

n

An

amou

nt o

f ex

erci

se th

at e

xcee

ds th

at w

hich

is n

eces

sary

to im

prov

e he

alth

and

/or

athl

etic

per

form

ance

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Dis

orde

red

eatin

g

Irra

tiona

l bel

iefs

/atti

tude

s ab

out f

ood,

nut

ritio

n, a

nd f

itnes

s

“Add

ictiv

e” b

ehav

iors

/per

sona

lity

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a E

leva

ted

liver

enz

ymes

, e.g

., L

DH

, SG

OT

Alte

red

mic

ronu

trie

nt s

tatu

s, e

.g.,

decr

ease

d se

rum

fer

ritin

, zin

c, a

nd I

GF-

bind

ing

prot

ein

Incr

ease

d he

mat

ocri

t

Supp

ress

ed im

mun

e fu

nctio

n

Poss

ibly

ele

vate

d co

rtis

ol le

vels

Ant

hrop

omet

ric

Mea

sure

men

ts

Wei

ght l

oss,

arr

este

d gr

owth

and

dev

elop

men

t, fa

ilure

to g

ain

wei

ght d

urin

g pe

riod

of

expe

cted

gro

wth

(re

late

d us

ually

to

diso

rder

ed e

atin

g)

Phy

sica

l Exa

m F

indi

ngs

Dep

lete

d ad

ipos

e an

d so

mat

ic p

rote

in s

tore

s (r

elat

ed u

sual

ly to

dis

orde

red

eatin

g)

Freq

uent

and

/or

prol

onge

d in

juri

es a

nd/o

r ill

ness

es

Chr

onic

fat

igue

Chr

onic

mus

cle

sore

ness

Edi

tion:

200

6 14

0

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Phy

sical

Activ

ity an

d Fu

nctio

n

EX

CE

SS

IVE

EX

ER

CIS

E (

NB

-2.2

)F

ood/

Nut

ritio

n H

isto

ry

Rep

orts

or

obse

rvat

ions

of:

Con

tinue

d/re

peat

ed h

igh

leve

ls o

f ex

erci

se e

xcee

ding

leve

ls n

eces

sary

to im

prov

e he

alth

and

/or

athl

etic

per

form

ance

Exe

rcis

e da

ily w

ithou

t res

t/reh

abili

tatio

n da

ys

Exe

rcis

e w

hile

inju

red/

sick

Fors

akin

g fa

mily

, job

, soc

ial r

espo

nsib

ilitie

s to

exe

rcis

e

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

anor

exia

ner

vosa

, bul

imia

ner

vosa

, bin

ge e

atin

g, e

atin

g di

sord

er

not o

ther

wis

e sp

ecif

ied,

am

enor

rhea

Evi

denc

e of

add

ictiv

e, o

bses

sive

, or

com

puls

ive

tend

enci

es

Re

fere

nc

e:

1.

Ais

sa-B

enha

ddad

A, B

ouix

D, K

hale

d S,

Mic

alle

f JP

, Mer

cier

J, B

ring

er J

, Bru

n JF

. Ear

ly h

emor

heol

ogic

asp

ects

of

over

trai

ning

in e

lite

athl

etes

. Cli

n H

emor

heol

Mic

roci

rc. 1

999;

20:1

17-1

25.

2.

Am

eric

an P

sych

iatr

ic A

ssoc

iatio

n. D

iagn

osti

c an

d St

atis

tica

l Man

ual o

f Men

tal D

isor

ders

. 4th

Ed.

Was

hing

ton,

DC

. Am

eric

an P

sych

iatr

ic A

ssoc

iatio

n.

3.

Dav

is C

, Bre

wer

H, R

atus

ny D

. Beh

avio

ral f

requ

ency

and

psy

chol

ogic

al c

omm

itm

ent:

nece

ssar

y co

ncep

ts in

the

stud

y of

exc

essi

ve e

xerc

isin

g. J

Beh

av M

ed. 1

993;

16:6

11-6

28

4.

Dav

is C

, Cla

ridg

e G

. The

eat

ing

diso

rder

as

addi

ctio

n: a

psy

chob

iolo

gica

l per

spec

tive.

Add

ict B

ehav

. 199

8;23

:463

-475

. 5.

D

avis

C, K

enne

dy S

H, R

avel

ski E

, Dio

nne

M. T

he r

ole

of p

hysi

cal a

ctiv

ity in

the

deve

lopm

ent a

nd m

aint

enan

ce o

f ea

ting

diso

rder

s. P

sych

ol M

ed. 1

994;

24:9

57-9

67.

6.

Kle

in D

A, B

enne

tt A

S, S

cheb

enda

ch J

, Fol

tin R

W, D

evlin

MJ,

Wal

sh B

T. E

xerc

ise

“add

ictio

n” in

ano

rexi

a ne

rvos

a: m

odel

dev

elop

men

t and

pilo

t dat

a. C

NS

Spec

tr. 2

004;

9:53

1-53

7.

7.

Lak

ier-

Sm

ith L

. Ove

rtra

inin

g, e

xces

sive

exe

rcis

e, a

nd a

ltere

d im

mun

ity: t

his

a he

lper

-1 v

s he

lper

-2 ly

mph

ocyt

e re

spon

se?

Spor

ts M

ed. 2

003;

33:3

47-3

64.

8.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Nut

ritio

n in

terv

entio

n in

the

trea

tmen

t of

anor

exia

ner

vosa

, bul

imia

ner

vosa

, and

eat

ing

diso

rder

not

oth

erw

ise

spec

ifie

d (E

DN

OS

). J

Am

Die

t Ass

oc.

2001

;101

:810

-819

. 9.

Sh

epha

rd R

J, S

hek

PN. A

cute

and

chr

onic

ove

r-ex

ertio

n: d

o de

pres

sed

imm

une

resp

onse

s pr

ovid

e us

eful

mar

kers

? In

t J S

port

s M

ed. 1

998;

19:1

59-1

71.

10.

Smith

LL

. Tis

sue

trau

ma:

the

unde

rlyi

ng c

ause

of

over

trai

ning

syn

drom

e? J

Str

engt

h C

ond

Res

. 200

4;18

:185

-93.

11

. U

rhau

sen

A, K

inde

rman

n W

. Dia

gnos

is o

f ov

ertr

aini

ng: w

hat t

ools

do

we

have

. Spo

rts

Med

. 200

2;32

:95-

102.

Edi

tion:

200

6 14

1

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Phy

sical

Activ

ity an

d Fu

nctio

n

INA

BIL

ITY

OR

LA

CK

OF

DE

SIR

E T

O M

AN

AG

E S

EL

F C

AR

E (

NB

-2.3

)

De

fin

itio

n

Lac

k of

cap

acity

or

unw

illin

gnes

s to

impl

emen

t met

hods

to s

uppo

rt h

ealth

ful f

ood

and

nutr

ition

-rel

ated

beh

avio

r

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Food

and

nut

ritio

n-re

late

d kn

owle

dge

defi

cit

Lac

k of

car

etak

er o

r so

cial

sup

port

for

impl

emen

ting

chan

ges

Lac

k of

dev

elop

men

tal r

eadi

ness

to p

erfo

rm s

elf

man

agem

ent t

asks

, e.g

. ped

iatr

ics

Lac

k of

val

ue f

or b

ehav

ior

chan

ge o

r co

mpe

ting

valu

es

Perc

eptio

n th

at la

ck o

f re

sour

ces

(tim

e, f

inan

cial

, sup

port

per

sons

) pr

even

t sel

f ca

re

Cul

tura

l bel

iefs

and

pra

ctic

es

Lea

rnin

g di

sabi

lity,

neu

rolo

gica

l or

sens

ory

impa

irm

ent

Prio

r ex

posu

re to

inco

mpa

tible

info

rmat

ion

Not

rea

dy f

or d

iet/l

ifes

tyle

cha

nge

Unw

illin

g or

uni

nter

este

d in

lear

ning

/app

lyin

g in

form

atio

n

No

self

man

agem

ent t

ools

or

deci

sion

gui

des

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Edi

tion:

200

6 14

2

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Phy

sical

Activ

ity an

d Fu

nctio

n

INA

BIL

ITY

OR

LA

CK

OF

DE

SIR

E T

O M

AN

AG

E S

EL

F C

AR

E (

NB

-2.3

)F

ood/

Nut

ritio

n H

isto

ry

Rep

orts

or

obse

rvat

ions

of:

Inab

ility

to in

terp

ret d

ata

or s

elf

man

agem

ent t

ools

Em

barr

assm

ent o

r an

ger

rega

rdin

g ne

ed f

or s

elf-

mon

itori

ng

Unc

erta

inty

reg

ardi

ng c

hang

es c

ould

/sho

uld

be m

ade

in r

espo

nse

to d

ata

in s

elf

mon

itori

ng r

ecor

ds

Clie

nt H

isto

ry

Dia

gnos

es th

at a

re a

ssoc

iate

d w

ith s

elf

man

agem

ent,

e.g.

, dia

bete

s m

ellit

us, o

besi

ty, c

ardi

ovas

cula

r di

seas

e, r

enal

or

liver

di

seas

e

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

cogn

itive

or

emot

iona

l im

pair

men

t

New

med

ical

dia

gnos

is o

r ch

ange

in e

xist

ing

diag

nosi

s or

con

ditio

n

Refe

ren

ces:

1.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Pro

vidi

ng n

utri

tion

serv

ices

for

infa

nts,

chi

ldre

n, a

nd a

dults

with

dev

elop

men

tal d

isab

ilitie

s an

d sp

ecia

l hea

lth c

are

need

s. J

Am

Die

t Ass

oc.

2004

;104

:97-

107.

2.

C

raw

ford

S.

Prom

otin

g di

etar

y ch

ange

. C

an J

Car

diol

. 199

5;11

(sup

pl A

):14

A-1

5A.

3.

Falk

LW

, Bis

ogni

CA

, Sob

al J

. Die

t cha

nge

proc

esse

s of

par

ticip

ants

in a

n in

tens

ive

hear

t pro

gram

.J N

utr

Edu

. 200

0;32

:240

-250

. 4.

G

lasg

ow R

E, H

amps

on S

E, S

tryc

ker

LA

, Rug

gier

o L

. Per

sona

l-m

odel

bel

iefs

and

soc

ial-

envi

ronm

enta

l bar

rier

s re

late

d to

dia

bete

s se

lf-m

anag

emen

t.D

iabe

tes

Car

e. 1

997;

20:5

56-5

61.

5.

Kee

nan

DP,

Abu

Sabh

a R

, Sig

man

-Gra

nt M

, Ach

terb

erg

C, R

uffi

ng J

. Fac

tors

per

ceiv

ed to

infl

uenc

e di

etar

y fa

t red

uctio

n be

havi

ors.

J N

utr

Edu

.199

9;31

:134

-144

. 6.

K

uman

yika

SK

, Van

Hor

n L

, Bow

en D

, Per

ri M

G, R

olls

BJ,

Cza

jkow

ski S

M, S

chro

n E

. M

aint

enan

ce o

f di

etar

y be

havi

or c

hang

e. H

ealt

h P

sych

ol. 2

000;

19(1

sup

pl):

S42-

S56.

7.

Sp

orny

, Lor

a A

,Con

tent

o, I

sobe

l R.S

tage

s of

cha

nge

in d

ieta

ry f

at r

educ

tion:

Soc

ial p

sych

olog

ical

cor

rela

tes.

J N

utr

Edu

. 199

5;27

:191

.

Edi

tion:

200

6 14

3

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Phy

sical

Activ

ity an

d Fu

nctio

n

IMP

AIR

ED

AB

ILIT

Y T

O P

RE

PA

RE

FO

OD

S/M

EA

LS

(N

B-2

.4)

De

fin

itio

n

Cog

nitiv

e or

phy

sica

l im

pair

men

t tha

t pre

vent

s pr

epar

atio

n of

foo

ds/m

eals

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Lea

rnin

g di

sabi

lity,

neu

rolo

gica

l or

sens

ory

impa

irm

ent

Los

s of

men

tal o

r co

gniti

ve a

bilit

y, e

.g.,

dem

entia

Phys

ical

dis

abili

ty

Hig

h le

vel o

f fa

tigue

or

othe

r si

de e

ffec

t of

ther

apy

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Foo

d/N

utri

tion

His

tory

O

bser

vatio

ns o

r re

port

s of

:

Dec

reas

ed o

vera

ll in

take

Exc

essi

ve c

onsu

mpt

ion

of c

onve

nien

ce f

oods

, pre

-pre

pare

d m

eals

, and

foo

ds p

repa

red

away

fro

m h

ome

resu

lting

in a

n in

abili

ty to

adh

ere

to n

utri

tion

pres

crip

tion

Unc

erta

inty

reg

ardi

ng a

ppro

pria

te f

oods

to p

repa

re b

ased

upo

n nu

triti

on p

resc

ript

ion

Inab

ility

to p

urch

ase

and

tran

spor

t foo

ds to

one

’s h

ome

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

cogn

itive

impa

irm

ent,

cere

bral

pal

sy, p

arap

legi

a, s

ight

im

pair

men

t, ri

goro

us th

erap

y re

gim

en, r

ecen

t sur

gery

Edi

tion:

200

6 14

4

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Phy

sical

Activ

ity an

d Fu

nctio

n

IMP

AIR

ED

AB

ILIT

Y T

O P

RE

PA

RE

FO

OD

S/M

EA

LS

(N

B-2

.4)

Refe

ren

ces:

1.

And

ren

E, G

rim

by G

. Act

ivity

lim

itatio

ns in

per

sona

l, do

mes

tic a

nd v

ocat

iona

l tas

ks: a

stu

dy o

f ad

ults

with

inbo

rn a

nd e

arly

acq

uire

d m

obili

ty d

isor

ders

. Dis

abil

Reh

abil.

200

4;26

:262

-271

.

2.

And

ren

E, G

rim

by G

. D

epen

denc

e in

dai

ly a

ctiv

ities

and

life

sat

isfa

ctio

n in

adu

lt su

bjec

ts w

ith c

ereb

ral p

alsy

or

spin

a bi

fida

: a f

ollo

w-u

p st

udy.

Dis

abil

Reh

abil.

200

4;26

:528

-536

. 3.

Fo

rtin

S, G

odbo

ut L

, Bra

un C

M. C

ogni

tive

stru

ctur

e of

exe

cutiv

e de

fici

ts in

fro

ntal

ly le

sion

ed h

ead

trau

ma

patie

nts

perf

orm

ing

activ

ities

of

daily

livi

ng. C

orte

x. 2

003;

39:2

73-2

91.

4.

God

bout

L, D

ouce

t C, F

iola

M. T

he s

crip

ting

of a

ctiv

ities

of

daily

livi

ng in

nor

mal

agi

ng: a

ntic

ipat

ion

and

shif

ting

defi

cits

with

pre

serv

atio

n of

seq

uenc

ing.

Bra

in C

ogn.

200

0;43

:220

-224

.

5.

Posi

tion

of th

e A

mer

ican

Die

tetic

Ass

ocia

tion:

Pro

vidi

ng n

utri

tion

serv

ices

for

infa

nts,

chi

ldre

n, a

nd a

dults

with

dev

elop

men

tal d

isab

ilitie

s an

d sp

ecia

l hea

lth c

are

need

s. J

Am

Die

t Ass

oc.

2004

;104

:97-

107.

6.

Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: D

omes

tic f

ood

and

nutr

ition

sec

urity

. J A

m D

iet A

ssoc

. 200

2;10

2:18

40-1

847.

7.

Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: A

ddre

ssin

g w

orld

hun

ger,

mal

nutr

ition

, and

foo

d in

secu

rity

. J A

m D

iet A

ssoc

. 200

3;10

3:10

46-1

057.

8.

Sand

stro

m K

, Alin

der

J, O

berg

B.

Des

crip

tions

of

func

tioni

ng a

nd h

ealth

and

rel

atio

ns to

a g

ross

mot

or c

lass

ific

atio

n in

adu

lts w

ith c

ereb

ral p

alsy

. Dis

abil

Reh

abil.

200

4;26

:102

3-10

31.

Edi

tion:

200

6 14

5

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Phy

sical

Activ

ity an

d Fu

nctio

n

PO

OR

NU

TR

ITIO

N Q

UA

LIT

Y O

F L

IFE

(N

QO

L)

(NB

-2.5

)

De

fin

itio

n

Dim

inis

hed

NQ

OL

sco

res

rela

ted

to f

ood

impa

ct, s

elf

imag

e, p

sych

olog

ical

fac

tors

soc

ial/i

nter

pers

onal

, phy

sica

l, or

sel

f ef

fica

cy

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Food

and

nut

ritio

n kn

owle

dge-

rela

ted

defi

cit

Not

rea

dy f

or d

iet/l

ifes

tyle

cha

nge

Neg

ativ

e im

pact

of

curr

ent o

r pr

evio

us m

edic

al n

utri

tion

ther

apy

(MN

T)

Food

or

activ

ity b

ehav

ior

-rel

ated

dif

ficu

lty

Poor

sel

f-ef

fica

cy

Alte

red

body

imag

e

Food

inse

curi

ty

Lac

k of

soc

ial s

uppo

rt f

or im

plem

entin

g ch

ange

s

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Edi

tion:

200

6 14

6

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Phy

sical

Activ

ity an

d Fu

nctio

n

PO

OR

NU

TR

ITIO

N Q

UA

LIT

Y O

F L

IFE

(N

QO

L)

(NB

-2.5

)F

ood/

Nut

ritio

n H

isto

ry

Rep

orts

or

obse

rvat

ions

of:

Unf

avor

able

NQ

OL

rat

ing

Frus

trat

ion

or d

issa

tisfa

ctio

n w

ith M

NT

rec

omm

enda

tions

Inac

cura

te o

r in

com

plet

e in

form

atio

n re

late

d to

MN

T r

ecom

men

datio

ns

Inab

ility

to c

hang

e fo

od o

r ac

tivity

rel

ated

beh

avio

r

Con

cern

s ab

out p

revi

ous

atte

mpt

s to

lear

n in

form

atio

n

Unw

illin

gnes

s or

dis

inte

rest

in le

arni

ng in

form

atio

n

Clie

nt H

isto

ry

New

med

ical

dia

gnos

is o

r ch

ange

in e

xist

ing

diag

nosi

s or

con

ditio

n

Rec

ent o

ther

life

styl

e or

life

cha

nges

, e.g

., qu

it sm

okin

g, in

itiat

ed e

xerc

ise,

wor

k ch

ange

, hom

e re

loca

tion

Refe

ren

ces:

1.

Bar

r JT

, Sch

umac

her

GE

. The

nee

d fo

r a

nutr

ition

-rel

ated

qua

lity-

of-l

ife

mea

sure

. J A

m D

iet A

ssoc

. 200

3;10

3:17

7-18

0.

2.

Bar

r JT

, Sch

umac

her

GE

. Usi

ng f

ocus

gro

ups

to d

eter

min

e w

hat c

onst

itute

s qu

ality

of

life

in c

lient

s re

ceiv

ing

med

ical

nut

ritio

n th

erap

y: F

irst

ste

ps in

the

deve

lopm

ent o

f a

nutr

ition

qua

lity-

of-l

ife

surv

ey. J

Am

Die

t Ass

oc. 2

003;

103:

844-

851.

Edi

tion:

200

6 14

7

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Phy

sical

Activ

ity an

d Fu

nctio

n

SE

LF

-FE

ED

ING

DIF

FIC

UL

TY

(N

B-2

.6)

De

fin

itio

n

Impa

ired

act

ions

to p

lace

foo

d or

bev

erag

es in

mou

th

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Inab

ility

to g

rasp

cup

s an

d ut

ensi

ls f

or s

elf-

feed

ing

Inab

ility

to s

uppo

rt a

nd/o

r co

ntro

l hea

d an

d ne

ck

Lac

k of

coo

rdin

atio

n of

han

d to

mou

th

Lim

ited

phys

ical

str

engt

h or

ran

ge o

f m

otio

n

Inab

ility

to b

end

elbo

w o

r w

rist

Inab

ility

to s

it w

ith h

ips

squa

re a

nd b

ack

stra

ight

Lim

ited

acce

ss to

foo

ds c

ondu

cive

for

sel

f-fe

edin

g

Lim

ited

visi

on

Rel

ucta

nce

or a

void

ance

of

self

fee

ding

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

m F

indi

ngs

Dry

muc

ous

mem

bran

es, h

oars

e or

wet

voi

ce, t

ongu

e ex

trus

ion

Edi

tion:

200

6 14

8

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Phy

sical

Activ

ity an

d Fu

nctio

n

SE

LF

-FE

ED

ING

DIF

FIC

UL

TY

(N

B-2

.6)

Foo

d/N

utri

tion

His

tory

R

epor

ts o

r ob

serv

atio

ns o

f:

Bei

ng p

rovi

ded

with

foo

ds th

at m

ay n

ot b

e co

nduc

ive

to s

elf-

feed

ing,

e.g

., pe

as, b

roth

-typ

e so

ups

Poor

lip

clos

ure,

dro

olin

g

Dro

ppin

g of

cup

s, u

tens

ils

Em

otio

nal d

istr

ess,

anx

iety

, or

frus

trat

ion

surr

ound

ing

mea

ltim

es

Failu

re to

rec

ogni

ze f

oods

Forg

ets

to e

at

Inap

prop

riat

e us

e of

foo

d

Ref

usal

to e

at o

r ch

ew

Dro

ppin

g of

foo

d fr

om u

tens

il (s

plas

hing

and

spi

lling

of

food

) on

rep

eate

d at

tem

pts

to f

eed

Ute

nsil

bitin

g

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

neur

olog

ical

dis

orde

rs, P

arki

nson

’s, A

lzhe

imer

’s, T

ardi

ve

dysk

ines

ia, m

ultip

le s

cler

osis

, str

oke,

par

alys

is, d

evel

opm

enta

l del

ay

Phys

ical

lim

itatio

ns, e

.g.,

frac

ture

d ar

ms,

trac

tion,

con

trac

ture

s

Surg

ery

requ

irin

g re

cum

bent

pos

ition

Dem

entia

/org

anic

bra

in s

yndr

ome

Dys

phag

ia

Wei

ght l

oss

Shor

tnes

s of

bre

ath

Tre

mor

s

Refe

ren

ces:

1.

Con

sulta

nt D

ietit

ians

in H

ealth

care

Fac

ilitie

s. D

inin

g Sk

ills

Supp

lem

ent:

Pra

ctic

al I

nter

vent

ions

for

Car

egiv

ers

of E

atin

g D

isab

led

Old

er A

dults

. Pen

saco

la, F

L: A

mer

ican

Die

tetic

Ass

ocia

tion,

19

92.

2.

Mor

ley

JE. A

nore

xia

of a

ging

: phy

siol

ogic

al a

nd p

atho

logi

c. A

m J

Clin

Nut

r. 1

997;

66:

760-

773.

3.

Po

sitio

n of

the

Am

eric

an D

iete

tic A

ssoc

iatio

n: P

rovi

ding

nut

ritio

n se

rvic

es f

or in

fant

s, c

hild

ren,

and

adu

lts w

ith d

evel

opm

enta

l dis

abili

ties

and

spec

ial h

ealth

car

e ne

eds.

J A

m D

iet A

ssoc

.20

04;1

04:9

7-10

7.

4.

Sand

man

P, N

orbe

rg A

, Ado

lfss

on R

, Eri

ksso

n S,

Nys

trom

L. P

reva

lenc

e an

d ch

arac

teri

stic

s of

per

sons

with

dep

ende

ncy

on f

eedi

ng a

t ins

titut

ions

. Sca

nd J

Car

ing

Sci.

1990

;4:1

21-1

27.

5.

Sieb

ens

H, T

rupe

E, S

iebe

ns A

, Coo

ke F

, Ans

hen

S, H

anau

er R

, Ost

er G

. Cor

rela

tes

and

cons

eque

nces

of

feed

ing

depe

nden

cy.

J A

m G

eria

tr S

oc. 1

986;

34:1

92-1

98.

6.

Vel

las

B, F

itten

LJ

eds.

Res

earc

h an

d P

ract

ice

in A

lzhe

imer

’s D

isea

se. N

ew Y

ork,

NY

: Spr

inge

r Pu

blis

hing

Com

pany

, 199

8.

Edi

tion:

200

6 14

9

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Foo

d Sa

fety

and

Acce

ss

INT

AK

E O

F U

NS

AF

E F

OO

D (

NB

-3.1

)

De

fin

itio

n

Inta

ke o

f fo

od a

nd/o

r fl

uids

inte

ntio

nally

or

unin

tent

iona

lly c

onta

min

ated

with

toxi

ns, p

oiso

nous

pro

duct

s, in

fect

ious

age

nts,

mic

robi

al a

gent

s, a

dditi

ves,

al

lerg

ens,

and

/or

agen

ts o

f bi

oter

rori

sm

Eti

olo

gy (

Cau

se/C

ontr

ibut

ing

Ris

k F

acto

rs)

Fact

ors

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at c

ontr

ibut

e to

the

exis

tenc

e or

the

mai

nten

ance

of

path

ophy

siol

ogic

al, p

sych

osoc

ial,

situ

atio

nal,

deve

lopm

enta

l, cu

ltura

l, an

d/or

env

iron

men

tal p

robl

ems.

Lac

k of

kno

wle

dge

abou

t pot

entia

lly u

nsaf

e fo

od

Lac

k of

kno

wle

dge

abou

t pro

per

food

/fee

ding

, (in

fant

and

ent

eral

for

mul

a, b

reas

t milk

) st

orag

e an

d pr

epar

atio

n

Exp

osur

e to

con

tam

inat

ed w

ater

or

food

, e.g

., co

mm

unity

out

brea

k of

illn

ess

docu

men

ted

by s

urve

illan

ce a

nd/o

r re

spon

se a

genc

y

Men

tal i

llnes

s, c

onfu

sion

or

alte

red

awar

enes

s

Inad

equa

te f

ood

stor

age

equi

pmen

t/fac

ilitie

s, e

.g.,

refr

iger

ator

Inad

equa

te s

afe

food

sup

ply,

e.g

., in

adeq

uate

mar

kets

with

saf

e, u

ncon

tam

inat

ed f

ood

Sig

ns

/Sym

pto

ms

(D

efin

ing

Cha

ract

eris

tics)

A ty

pica

l clu

ster

of

subj

ectiv

e an

d ob

ject

ive

sign

s an

d sy

mpt

oms

gath

ered

dur

ing

the

nutr

ition

ass

essm

ent p

roce

ss th

at p

rovi

de e

vide

nce

that

a p

robl

em e

xist

s;

quan

tify

the

prob

lem

and

des

crib

e its

sev

erity

.

Nutri

tion

Asse

ssm

ent C

ateg

ory

Pote

ntial

Indi

cato

rs o

f thi

s Nut

ritio

n Di

agno

sis (o

ne o

r mor

e mus

t be p

rese

nt)

Bio

chem

ical

Dat

a Po

sitiv

e st

ool c

ultu

re f

or in

fect

ious

cau

ses,

suc

h as

list

eria

, sal

mon

ella

, hep

atiti

s A

, E. c

oli,

cycl

ospo

ra

Tox

icol

ogy

repo

rts

for

drug

s, m

edic

inal

s, p

oiso

ns in

blo

od o

r fo

od s

ampl

es

Ant

hrop

omet

ric

Mea

sure

men

ts

Phy

sica

l Exa

min

atio

n F

indi

ngs

Evi

denc

e of

deh

ydra

tion,

e.g

., dr

y m

ucou

s m

embr

anes

, dam

aged

tiss

ues

Edi

tion:

200

6 15

0

BEHA

VIOR

AL-E

NVIR

ONME

NTAL

DOM

AIN

Foo

d Sa

fety

and

Acce

ss

INT

AK

E O

F U

NS

AF

E F

OO

D (

NB

-3.1

)F

ood/

Nut

ritio

n H

isto

ry

Obs

erva

tions

/rep

orts

of

inta

ke o

f po

tent

ial u

nsaf

e fo

ods

e.g.

, mer

cury

con

tent

of

fish

, non

-foo

d ite

ms

(pre

gnan

t and

lact

atin

g w

omen

)

e.g.

, raw

egg

s, u

npas

teur

ized

milk

pro

duct

s, s

oft c

hees

es, u

nder

cook

ed m

eats

(in

fant

s, c

hild

ren,

imm

unoc

ompr

omis

ed

pers

ons,

pre

gnan

t and

lact

atin

g w

omen

, and

eld

erly

)

e.g.

, wild

pla

nts,

ber

ries

, mus

hroo

ms

Obs

erva

tions

/ rep

orts

of

unsa

fe f

ood/

feed

ing

(ent

eral

and

infa

nt f

orm

ula,

bre

ast m

ilk)

stor

age

and

prep

arat

ion

prac

tices

Clie

nt H

isto

ry

Con

ditio

ns a

ssoc

iate

d w

ith a

dia

gnos

is o

r tr

eatm

ent o

f, e

.g.,

food

bor

ne il

lnes

s, s

uch

as, b

acte

rial

, vir

al, a

nd p

aras

itic

infe

ctio

n, m

enta

l illn

ess,

dem

entia

Pois

onin

g by

dru

gs, m

edic

inal

s, a

nd b

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SUBJECT: NUTRITION CONTROLLED VOCABULARY/TERMINOLOGY MAINTENANCE/REVIEW

AMERICAN DIETETIC ASSOCIATION 120 South Riverside Plaza Suite 2000 CHICAGO, ILLINOIS 60606-6995

Effective Date: April 2005 Revision Date: June 2006

Review Date: PURPOSE:This policy establishes the has established the process followed by the Nutrition Care Process/Standardized Language (NCP/SL) Committee to maintain a current Nutrition Care Process and list of nutrition controlled vocabulary terminology that document the Nutrition Care Process.

STRUCTURE:The NCP/SL Committee is a joint House of Delegates and Board of Directors Committee and provides semi-annual reports to both bodies.

PROCEDURES:The NCP/SL Committee accept proposals for modification or additions to the Nutrition Diagnostic Terminology as follows:

1. Any individual ADA member or Dietetic Practice Group can submit proposals for modification or additions by completing the attached two documents:

a. Proposed Nutrition Diagnostic Terminology Modification/Addition letter b. Reference worksheet for proposed modification/addition

2. The NCP/SL will review the submissions at their routine face-to-face meetings or teleconferences to establish the following:

a. Is the term already represented by an existing term? i. If so the new term can be added as a synonym for the existing term or

replace the existing term. ii. If not, then the term can be considered for addition to the list of terms as

long as it meets the need for describing elements of dietetic practice in the context of the nutrition care process.

b. Does the term overlap with an existing term, but add new elements? i. If yes, then the existing term can be modified to include the new elements

or the proposed term can be clarified to be distinctly different from the existing term through a dialogue with the proposal submitter.

ii. If no, then consider adding new term c. Is the term distinct and separate from all existing terms?

i. If yes, then ensure that the term is in the context of dietetic practice within the Nutrition Care Process and consider adding to list of terms.

ii. If no, then work with proposal submitter to discuss how to integrate into existing terms or create a separate term.

3. The NCP/SL will prepare a summary of comments and one representative of the NCPSL will confer with the proposal submitter after the initial discussion to answer questions and discuss the initial input from the NCP/SL Committee. If the proposal submitter is not satisfied with the direction proposed by the NCP/SL, then they will be invited to submit additional documentation and have time on the next teleconference/meeting agenda to personally present their concerns.

Edition: 2006 154

Edition: 2006 155

4. Changes or modifications accepted by the NCP/SL will be integrated into the list that is re-published on an annual basis.

STAFFING: Governance and Scientific Affairs and Research provide staff support for Research Committee functions.

Attachments 1. Template for Letter for submitting Proposal for Modifications to Nutrition Diagnostic

Terminology 2. Template for Letter for submitting Propposal for New Term for Nutrition Diagnostic

Terminology 3. Template for Reference Sheet to support modification/additions to Nutrition Diagnostic

Terminology 4. Sample Reference Sheet 5. Sample Case with PES statement

Edition: 2006 156

Attachment 1 to Nutrition Controlled Vocabulary/Terminology Maintenance Policy-Template for letter for proposing new term

Date

To: NCP/SL Committee Scientific Affairs and Research 120 South Riverside Plaza, Suite 2000 Chicago, IL 60606-6995 [email protected] and [email protected]

Subject: Proposed Addition to Nutrition Diagnostic Terminology

(1/We) would like to propose a new term, ____,_________________(Proposed term to add to the Nutrition Diagnostic Terminology list). The reason !/we believe that this term should be added is as follows: (insert concise rationale for change, may include brief example of when the situation arose that the current term was inadequately defined)

1. (insert first statement of rationale) 2. (Insert second statement of rationale, if applicable) 3. (Insert example of situation where this modification was needed)

Other terms which are similar with explanations of why they do not exactly match our new proposed term are as follows:

1. (Insert Number and Name) – (Insert 2-3 sentences to illustrate why the existing term does not meet your need)

2. (Insert Number and Name) – (Insert 2-3 sentences to illustrate why the existing term does not meet your need)

3. (Add as many as applicable)

Attached is the a reference sheet that includes the label, description, proposed domain and category, examples of etiologies and signs and symptoms and a case that illustrates when this term would be used and the corresponding PES statement that would be used in medical record documentation.

The point of contact for this proposal is ___________________________________ (insert name) who can be reached at ______( best contact telephone number0 and _______(e-mail address).

Thank you for considering our request

Signature block (Organizational unit if applicable)

Attachments 1. Reference Sheet 2. Case with PES statement

Edition: 2006 157

Attachment 2 to Nutrition Controlled Vocabulary/Terminology Maintenance Policy-Template for letter proposing modification of term

Date

To: NCP/SL Committee Scientific Affairs and Research 120 South Riverside Plaza, Suite 2000 Chicago, IL 60606-6995 [email protected] and [email protected]

Subject: Proposed Modification to existing term in Nutrition Diagnostic Terminology

(1/We) would like to propose a modification or the term, ____,, _________________(Number and Name from current Nutrition Diagnostic Terminology list). The reason !/we believe that this term should be modified is as follows: (insert concise rationale for change, may include brief example of when the situation arose that the current term was inadequately defined)

4. (insert first statement of rationale) 5. (Insert second statement of rationale, if applicable) 6. (Insert example of situation where this modification was needed)

Attached is the revised reference sheet that shows the changes highlighted or bolded for your consideration.

The point of contact for this proposal is ___________________________________ (insert name) who can be reached at ______( best contact telephone number0 and _______(e-mail address).

Thank you for considering our request

Signature block (Organizational unit if applicable)

Attachment Modified Reference Sheet for Term

Edition: 2006 158

Attachment 3 to Nutrition Controlled Vocabulary/Terminology Maintenance Policy -Template for Reference Sheet(Select CLINICAL/ FUNCTIONAL or BEHAVIORAL/ENVIRONMENTAL) DOMAIN (Select Category e.g. Functional Balance)

Nutrition Diagnostic Label (Leave number blank) (Insert 1-4 word label)

Definition of Nutrition Diagnostic Label (Insert 1 sentence or bullet that describe the intent of the label)

Etiology (Cause/Contributing Risk Factors) Factors gathered during the nutrition assessment process that contribute to the existence of or the maintenance of pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems.

(Insert common etiologies for Nutrition Diagnostic Label)

Signs/Symptoms (Defining Characteristics) A typical cluster of subjective and objective signs and symptoms gathered during the nutrition assessment process that provide evidence that a problem exists; quantify the problem and describe its severity.

Nutrition Assessment Category Potential Indicators of this Nutrition Diagnosis (one or more must be present)

Biochemical Data (Insert as appropriate) Anthropometric Measurements (Insert as appropriate) Physical Exam Findings (Insert as appropriate) Food/Nutrition History (Insert as appropriate) Client History (Insert as appropriate) .

Edition: 2006 159

Attachment 3 to Nutrition Controlled Vocabulary/Terminology Maintenance Policy -Completed Reference SheetCLINICAL DOMAIN Functional Balance

Nutrition Diagnostic Label NC-1.1 Swallowing difficulty

Definition of Nutrition Diagnostic Label Impaired movement of food and liquid from the mouth to the stomach

Etiology (Cause/Contributing Risk Factors) Factors gathered during the nutrition assessment process that contribute to the existence of or the maintenance of pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems.

Mechanical causes, e.g., inflammation, surgery, stricture, or oral, pharyngeal and esophageal tumors

Motor causes, e.g., neurological or muscular disorders, such as, cerebral palsy, stroke, multiple sclerosis, scleroderma, prematurity

Signs/Symptoms (Defining Characteristics) A typical cluster of subjective and objective signs and symptoms gathered during the nutrition assessment process that provide evidence that a problem exists; quantify the problem and describe its severity.

Nutrition Assessment Category Potential Indicators of this Nutrition Diagnosis (one or more must be present)

Biochemical Data Anthropometric Measurements Physical Exam Findings Evidence of dehydration, e.g., dry mucous membranes, poor

skin turgor Food/Nutrition History Observations or reports of :

Coughing, choking, prolonged chewing, pouching of food, regurgitation, facial expression changes during eating, prolonged feeding time, drooling, noisy wet upper airway sounds, feeling of “food getting stuck,” pain while swallowing

Decreased food intake Avoidance of foods Mealtime resistance

Client History Conditions associated with a diagnosis or treatment of dysphagia, achalasia

Radiological findings, e.g., abnormal swallowing studies Repeated upper respiratory infections and or pneumonia

.

2003 - 2005 Standardized Language Task Force and Terminology Expert Reviewers

Edition: 2006 160

Standardized Language Task Force

Chair Sylvia Escott-Stump, MA, RD, LDN Dietetic Programs Director East Carolina University 155 Rivers Building, Dept. NUHM Greenville, NC 27858 Task Force Member 2003-2005

Peter Beyer, MS, RD, LD Associate Professor University of Kansas Medical Center 7315 Rosewood Drive Prairie Village, KS 66208-2458Task Force Member 2003-2005

Christina Biesemeier MS, RD, LDN, FADA 313 Logans Circle Franklin TN 37067-1363 Task Force Member 2003-2005

Pam Charney, MS, RD, CNSD 10772 Country Walk Court Dayton, OH 45458-4752Task Force Member 2003-2005

Marion Franz, MS, RD, CDE 6635 Limerick Dr. Minneapolis, MN 55439-1260 Task Force Member 2003-2005

Karen Lacey, MS, RD, CD 500 Saint Mary’s Blvd Green Bay, WI 54301-2610 Task Force Member 2003-2005

Kathleen Niedert, MBA, RD, LD, FADA PO Box 843 110 Ardis Street Hudson, IA 50643-0843 Task Force Member 2003-2005

Mary Jane Oakland, PhD, RD, LD, FADA 1612 Truman Drive Ames, IA 50010-4344 Task Force Member 2003-2005

Patricia Splett, PhD, MPH, RD Splett & Associates 3219 Midland Avenue St. Paul, MN 55110 Task Force Member 2003-2005

Frances Tyus, MS, RD, LD 19412 Mayfair Ln Cleveland, OH 44128-2727 Task Force Member 2003-2005

Naomi Trostler, PhD, RD Institute of Biochemistry, Food Science, and Nutrition Faculty of Agriculture, Food and Environmental Quality Sciences The Hebrew University of Jerusalem PO Box 12 Rehovot 76100, IsraelTask Force Member 2004-2005

Robin Leonhardt, RD 1905 North 24th Street Sheboygan, WI 53081-2124 Attended Face to Face Meeting in Summer

2003

Staff LiaisonsEsther Myers, PhD, RD, FADA Director of Scientific Affairs and Research ADA Headquarters 120 South Riverside Plaza Suite 2000 Chicago, IL 60619 Work (312) 899-4860 Fax (312) 899-4757 E-mail: [email protected]

Ellen Pritchett, RD, CPHQ Director, Quality and Outcomes ADA Headquarters 120 South Riverside Plaza Suite 2000 Chicago, IL 60619 Work (312) 899-4823 Fax (312) 899-4757 E-mail: [email protected] Liaison 2003-2005

Lt Col Vivian Hutson, MA,MHA,RD,LD, FACHEStaff Liaison 2003-2004


Edition: 2006 161

Consultants

Donna G. Pertel, MEd, RD 5 Bonny Lane Clinton, CT 06413

Patricia Splett, PhD, MPH, RD Splett & Associates 3219 Midland Avenue St. Paul, MN 55110

Melinda L. Jenkins, Ph.D., FNP Assistant Professor of Clinical Nursing Columbia University School of Nursing 630 W. 168 St., mail code 6 New York, NY 10032

Annalynn Skipper, MS, RD, FADA P.O. Box 45 Oak Park, IL 60303


Expert Reviewers Nutrition Diagnosis Labels

Nutrition Diagnostic Label Dx Label # Reviewers

CLINICAL DOMAIN – Functional Balance Swallowing difficulty NC-1.1 Moshe Shike, MD (Memorial Sloan Kettering) Chewing (masticatory) difficulty NC-1.2 Helen Smiciklas-Wright, PhD, RD (Penn State)

Riva Touger-Decker, PhD, RD (UMDNJ) Breastfeeding difficulty NC-1.3 Maureen A. Murtaugh, PhD, RD (University of Utah) Altered GI function NC-1.4 Larry Cheskin, MD (Johns Hopkins) CLINICAL DOMAIN – Biochemical Balance Impaired nutrient utilization NC-2.1 Laura Matarese, MS, RD, CNSD (Cleveland Clinic) Altered nutrition-related laboratory values

NC-2.2 Denise Baird Schwartz, MS, RD, CNSD (Clinical practice)

Food medication interaction NC-2.3 Andrea Hutchins, PhD, RD (Arizona State University East, Mesa, AZ)

CLINICAL DOMAIN – Weight Balance Underweight NC-3.1 Bonnie Spear, PhD, RD (University of Alabama,

Birmingham Involuntary weight loss NC-3.2 Jody Vogelzang, MS, RD, LD, CD, FADA (Texas

Women’s University) Overweight/obesity NC-3.3 Rebecca Mullis, PhD, RD (Georgia) Involuntary weight gain NC-3.4 Celia Hayes, MS, RD (HRSA)

BEHAVIORAL-ENVIRONMENTAL DOMAIN – Knowledge and Beliefs Food and nutrition-related knowledge deficit

NB-1.1 Penny Kris-Etherton, PhD, RD (Penn State)

Harmful beliefs/attitudes about food, nutrition, and nutrition-related topics

NB-1.2 Keith-Thomas Ayoob, PhD, RD (Albert Einstein)

Not ready for diet/lifestyle change NB-1.3 Geoffrey Greene, PhD, RD (University of Rhode Island)

Self monitoring deficit NB-1.4 Linda Delahanty, MS, RD (Harvard) Disordered eating pattern NB-1.5 Eileen Stellefson Myers, PhD, RD (Private practice)

Leah Graves, MS, RD (Saint Francis Hospital, Tulsa, OK)

Limited adherence to nutrition-related recommendations

NB-1.6 Ellen Parham, PhD, RD (Northern IL)

Undesirable food choices NB-1.7 Kathy Cobb, MS, RD (Centers for Disease Control) BEHAVIORAL-ENVIRONMENTAL DOMAIN – Physical Activity Balance and Function Physical inactivity NB-2.1 Melinda Manore, PhD, RD (Oregon State) Excessive exercise NB-2.2 Katherine Beals, PhD, RD (Industry, formerly Ball

State)Inability to manage self care NB-2.3 Emily Gier, MS, RD (Cornell) Impaired ability to prepare foods/meals NB-2.4 Marla Reicks, PhD, RD (U of MN) Poor nutrition quality of life NB-2.5 Elvira Johnson, MS, RD (Private practice) Self feeding difficulty NB-2.6 Mary Cluskey, PhD, RD (Oregon State) BEHAVIORAL-ENVIRONMENTAL DOMAIN – Food Safety and Access Intake of unsafe food NB-3.1 Johanna Dwyer, DSc, RD (Tufts) Limited access to food NB-3.2 Sondra King, PhD, RD (Northern Illinois University)

INTAKE DOMAIN – Caloric Energy Balance Hypermetabolism NI-1.1 Jonathan Waitman, MD for Louis Arrone, MD

Edition: 2006 162


(Cornell) Increased energy expenditure (when part of hypermetabolism)

NI-1.2 Jonathan Waitman, MD for Louis Arrone, MD (Cornell)

Hypometabolism NI-1.3 Edith Lerner, PhD (Case Western Reserve University) Inadequate energy intake NI-1.4 Joel Mason, MD (Tufts) Excessive energy intake NI-1.5 Jim Hill, MD (University of Colorado) INTAKE DOMAIN – Oral or Nutrition Support Intake Inadequate oral food/beverage intake NI-2.1 Anne Voss, PhD, RD (Ross Labs) Excessive oral food/beverage intake NI-2.2 Jessica Krenkel, MS, RD (University of Nevada) Inadequate intake from enteral/parenteral nutrition

NI-2.3 Kenneth Kudsk, MD (University of Wisconsin)

Excessive intake from enteral/parenteral nutrition

NI-2.4 Annalynn Skipper, MS, RD (University of Nebraska Lincoln)

Inappropriate infusion of enteral/parenteral nutrition

NI-2.5 Annalynn Skipper, MS, RD (University of Nebraska-Lincoln)

INTAKE DOMAIN – Fluid Intake Balance Inadequate fluid intake NI-3.1 Ann Grandjean, EdD, RD (International Center for

Sports Nutrition) Excessive fluid intake NI-3.2 Joel Kopple, MD (UCLA) INTAKE DOMAIN – Bioactive Substances Balance Inadequate bioactive substance intake NI-4.1 Johanna Lappe, PhD, RN (Creighton) Excess bioactive substance NI-4.2 Elizabeth Jeffery, PhD (Univ. of IL, Champaign) Excessive alcohol intake NI-4.3 Janice Harris, PhD, RD (University of Kansas) INTAKE DOMAIN – Nutrient Balance Increased nutrient (specify) needs NI-5.1 Carol Braunschweig, PhD, RD (University of Illinois,

Chicago)Evident protein-energy malnutrition NI-5.2 Charlette R. Gallagher Allred, PhD, RD (Retired-Ross

Labs) Inadequate protein energy intake NI-5.3 Trisha Fuhrman, MS, RD (Caremark) Decreased nutrient (specify) needs NI-5.4 Jeannmarie Beiseigel, PhD, RD (USDA) Imbalance of nutrients NI-5.5 Molly Kretsch, PhD, RD (USDA) INTAKE DOMAIN – Nutrient Balance – Fat and Cholesterol BalanceInadequate fat intake NI-51.1 Alice Lichtenstein, DSc (Tufts) Excessive fat intake NI-51.2 Wendy Mueller Cunnigham, PhD, RD (Cal State) Inappropriate intake of food fats NI-51.3 Nancy Lewis, PhD, RD (University of Nebraska-

Lincoln) INTAKE DOMAIN – Nutrient Balance – Protein BalanceInadequate protein intake NI-52.1 Don Layman, PhD (University of Illinois-Champaign) Excessive or unbalanced protein intake NI-52.2 Linda A. Vaughan, PhD, RD (Arizona State) Inappropriate intake of amino acids NI-52.3 Allison Yates, PhD, RD (Industry, formerly Director of

the IOM Food and Nutrition Board) INTAKE DOMAIN – Nutrient Balance – Carbohydrate BalanceInadequate carbohydrate intake NI-53.1 Robert Wolfe, PhD (University of Texas Medical

Branch) Excessive carbohydrate intake NI-53.2 Anne Daly, MS, RD Inappropriate intake of types of carbohydrate

NI-53.3 Lyn Wheeler, MS, RD, CD, FADA, CDE (Indiana University School of Medicine)

Inconsistent intake of carbohydrate NI-53.4 Maggie Powers, MS, RD, CDE (International Diabetes Center)

Inadequate fiber intake NI-53.5 Joanne Slavin, PhD, RD (University of Minnesota) Excess fiber intake NI-53.6 Judith Marlett, PhD, RD (University of Wisconsin) INTAKE DOMAIN – Nutrient Balance – Vitamin BalanceInadequate vitamin intake (specify) NI-54.1 Laurie A. Kruzich, MS, RD (Iowa State)

Kristina Penniston, PhD, RD (University of Wisconsin)

Edition: 2006 163


Excess vitamin intake NI-54.2 Kristina Penniston, PhD, RD (University of Wisconsin) INTAKE DOMAIN – Nutrient Balance – Mineral BalanceInadequate mineral intake (specify) NI-55.1 Bob Heaney, MD (Creighton) Excessive mineral intake NI-55.2 Joan Fischer, PhD, RD (University of Georgia)

Edition: 2006 164


Edition: 2006 165

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Introduction to Nutrition Diagnosis Terminology Nutrition Care Process and Model Article ADA’s Standardized Language Model and Current Status Procedure for submitting proposed changes Single Page list of Terminology Eight pages of Terms and Definitions (Table of Contents to next document) Reference Sheets (128 pages)

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Scientific Affairs and Research Standardized Language/Nutrition Care Process Committee 120 South Riverside Plaza Suite 2000 Chicago, IL 60606-6995

Edition: 2006 165

Edition: 2006 166

INTAKE NIDefi ned as “actual problems related to intake of energy, nutrients, fl uids, bioactive substances through oral diet or nutrition support”Caloric Energy Balance (1)Defi ned as “actual or estimated changes in energy (kcal)”

� Hypermetabolism (Increased energy needs) NI-1.1� Increased energy expenditure NI-1.2� Hypometabolism (Decreased energy needs) NI-1.3� Inadequate energy intake NI-1.4� Excessive energy intake NI-1.5

Oral or Nutrition Support Intake (2)Defi ned as “actual or estimated food and beverage intake from oral diet or nutrition support” compared with patient goal”

� Inadequate oral food/beverage intake NI-2.1� Excessive oral food/beverage intake NI-2.2� Inadequate intake from NI-2.3

enteral/parenteral nutrition infusion� Excessive intake from NI-2.4

enteral/parenteral nutrition� Inappropriate infusion of NI-2.5

enteral/parenteral nutrition (use with caution)Fluid Intake (3)Defi ned as “actual or estimated fl uid intake compared against patient goal”

� Inadequate fl uid intake NI-3.1� Excessive fl uid intake NI-3.2

Bioactive Substances (4)Defi ned as “actual or observed intake of bioactive substances, including single or multiple functional food components, ingredients, dietary supplements, alcohol”

� Inadequate bioactive substance intake NI-4.1� Excessive bioactivesubstance intake NI-4.2� Excessive alcohol intake NI-4.3

Nutrient (5)Defi ned as “actual or estimated intake of specifi c nutrient groups or single nutrients as compared with desired levels”

� Increased nutrient needs NI-5.1 (specify) _______________________________________

� Evident protein- energy malnutrition NI-5.2� Inadequate protein-energy intake NI-5.3� Decreased nutrient needs NI-5.4

(specify) _______________________________________� Imbalance of nutrients NI-5.5Fat and Cholesterol (51)� Inadequate fat intake NI-51.1� Excessive fat intake NI-51.2� Inappropriate intake of food fats NI-51.3

(specify) _______________________________________ Protein (52)

� Inadequate protein intake NI-52.1� Excessive protein intake NI-52.2� Inappropriate intake of amino acids NI-52.3

(specify) _______________________________________ Carbohydrate and Fiber Intake (53)

� Inadequate carbohydrate intake NI-53.1 � Excessive carbohydrate intake NI-53.2� Inappropriate intake of types of carbohydrate NI-53.3

(specify) _______________________________________� Inconsistent carbohydrate intake NI-53.4� Inadequate fi ber intake NI-53.5� Excessive fi ber intake NI-53.6

Vitamin Intake (54)� Inadequate vitamin intake (specify) NI-54.1� Excessive vitamin intake (specify) NI-54.2

� A � C� Thiamin � D� Ribofl avin � E� Niacin � K� Folate � Other ________________

Mineral Intake (55)� Inadequate mineral intake (specify) NI-55.1

� Calcium � Iron� Potassium � Zinc� Other ___________________________________

� Excessive mineral intake (specify) NI-55.2 � Calcium � Iron� Potassium � Zinc� Other ___________________________________

CLINICAL NCDefi ned as “nutritional fi ndings/problems identifi ed as related to medical or physical conditions”Functional (1)Defi ned as “change in physical or mechanical functioning that interferes with or prevents desired nutritional consequences”

� Swallowing diffi culty NC-1.1� Chewing (masticatory) diffi culty NC-1.2� Breastfeeding diffi culty NC-1.3� Altered GI function NC-1.4

Biochemical (2)Defi ned as “change in capacity to metabolize nutrients as a result of medications, surgery, or as indicated by altered lab values”

� Impaired nutrient utilization NC-2.1� Altered nutrition-related laboratory values NC-2.2� Food medication interaction NC-2.3

Weight (3) Defi ned as “chronic weight or changed weight status when compared with usual or desired body weight”

� Underweight NC-3.1� Involuntary weight loss NC-3.2� Overweight/obesity NC-3.3� Involuntary weight gain NC-3.4

BEHAVIORAL-ENVIRONMENTAL NBDefi ned as “nutritional fi ndings/problems identifi ed as related to knowledge, attitudes/beliefs, physical environment, or food supply and safety”Knowledge and Beliefs (1)Defi ned as “actual knowledge and beliefs as observed or documented”

� Food and nutrition-related knowledge defi cit NB-1.1� Harmful beliefs/attitudes about food or NB-1.2

nutrition-related topics (use with caution)� Not ready for diet/lifestyle change NB-1.3� Self monitoring defi cit NB-1.4� Disordered eating pattern NB-1.5� Limited adherence to nutrition- NB-1.6

related recommendations� Undesirable food choices NB-1.7

Physical Activity and Function (2)Defi ned as “actual physical activity, self-care, and quality of life problems as reported, observed or documented”

� Physical inactivity NB-2.1� Excessive exercise NB-2.2� Inability or lack of desire to manage self care NB-2.3� Impaired ability to prepare foods/meals NB-2.4� Poor nutrition quality of life NB-2.5� Self-feeding diffi culty NB-2.6

Food Safety and Access (3)Defi ned as “actual problems with food access or food safety”

� Intake of unsafe food NB-3.1� Limited access to food NB-3.2

Edition: 2006

NUTRITION DIAGNOSTIC TERMINOLOGY NUTRITION DIAGNOSTIC TERMINOLOGYNUTRITION DIAGNOSTIC TERMINOLOGYNUTRITION DIAGNOSTIC TERMINOLOGY

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nutrition diagnosis: a critical step in the nutrition care

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