Nutrition Tools, Standards and Guidelines Nutrient Recommendations

Lesson 04

Introduction:
The Department of Nutrition for Health and Development, in collaboration with FAO,
continually reviews new research and information from around the world on human nutrient
requirements and recommended nutrient intakes. This is a vast and never-ending task, given the
large number of essential human nutrients.

Many countries rely on WHO and FAO to establish and disseminate this information,
which they adopt as part of their national dietary allowances. Others use it as a base for their
standards. The establishment of human nutrient requirements is the common foundation for all
countries to develop food-based dietary guidelines for their populations.

Establishing requirements means that the public health and clinical significance of intake
levels – both normal, deficiency and excess – and associated disease patterns for each nutrient,
need to be continuously thoroughly reviewed for all age groups. Accordingly, every ten to fifteen
years, enough research is complete and new evidence accumulated to warrant WHO and FAO
undertaking a revision of at least the major nutrient requirements and recommended intakes.

Thus, this will be warrants to pattern, revise and adopt by the other nation for their
populations to achieve a recommended dietary intake and good health for all.

Objectives:
At the end of the lesson, the student can:
1.Determine the standards and guidelines on nutrients recommendations.
2.Discuss the tools in nutrition.
3.Recognize food and nutrition labelling.
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Topic Outline:
Nutrition Tools, Standards and Guidelines Nutrient Recommendations:
A. Dietary Reference Intake (DRIs)
1.Estimated Average Requirements (EAR).
2.Recommended Dietary Allowance (RDA-RENI Revised).
3.Adequate Intake (Al).
4.Tolerable Upper Intake Levels (UL).
B.Dietary Guidelines and Food Guides
1.USDA Food Guide (My Pyramid)
2.Tools in the Study of Nutrition
3. Food and Nutrition Labelling
 Try this! Look around you.
Directions: Cut out 10 Food Labels with Nutrition Facts.
1.Look for 10 Food labels with nutrition fact.
2.Cut out the nutrition labels and nutrition facts then glue/paste in an Answer key sheet provided.
3. Discuss as one or as a whole of your output.
a.What can you say or explain briefly about your output according to the Nutrition Tools,
Standards and Guidelines Nutrient Recommendations of the whole 10 cuts out nutrient label
products?.
b.Does the Nutrition label and nutrition facts are sufficient in their recommended nutrients labels
in the products. If Yes pls specify. If No why?.
3.Conclusion.
Answer Key Sheet
Name:___________________________________ Score:________
Course/Year:_______________________________ Date:_________
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Think ahead!
Directions: Search for the following tools of Nutrition. Draw and illustrate in a clear and clean
long bondpaper of the following:
1.Filipino Food Guide:
1.a.Food Pyramid for Adult.
1.b.Activity Guide(Physical activities).
1.c.Plate Model (Pinggang Pinoy).
1.d.Nutritional Guidelines for Filipinos (10 Kumainments-Sigla at Lakas ng Buhay).
2.Your Guide to Good Nutrition.
3. The United States Department of Agriculture (USDA) of Food Pyramid (My pyramid).
2.Make a Reflection paper about the following topics by consolidating as one thought.(50
words).
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Read & Ponder!

A. Dietary Reference Intake (DRIs):
1.Dietary Reference Intakes (DRIs) is a generic term for a set of nutrient reference values that
includes the Recommended Dietary Allowance (RDA), Adequate Intake (AI), Tolerable Upper
Intake Level (UL), and Estimated Average Requirement (EAR).
2.DRI is the general term for a set of reference values used to plan and assess nutrient intakes of
healthy people. These values, which vary by age and sex, include:
3.Recommended Dietary Allowance (RDA) (RENI-Revised): average daily level of intake
sufficient to meet the nutrient requirements of nearly all (97%-98%) healthy people.
4.Adequate Intake (AI): established when evidence is insufficient to develop an RDA and is set at
a level assumed to ensure nutritional adequacy.
5.Tolerable Upper Intake Level (UL): maximum daily intake unlikely to cause adverse health
effects. (see appendices)
B.Dietary Guidelines and Food Guides.
1.The United States Department of Agriculture (USDA) food pyramid, called MyPyramid to
distinguish it from earlier versions, contains recommendations on diet and exercise based on the
Dietary Guidelines for Americans 2005.

My Pyramid is intended to help Americans become more aware of what they eat and what their
nutrient requirements are. It is designed to help people learn how to eat a healthy diet, live an
active lifestyle, and maintain or gradually move in the direction of a healthy weight that will reduce
the risk of weight-related diseases. It is the most recent in a series of publications designed to
provide Americans with broad dietary recommendations that will promote health.

2.Basic Tools in the Study of Nutrition:

Your Guide To Good Nutrition ( YGGN) — the guide that classifies food according to body
building, energy- giving, and regulating functions. It is a daily food guide w/c suggests the use of
recommended amount and the number of servings in each group to provide the variety of
nutrients needed by the body.
Classification:
1. Body- Building Foods— foods rich in protein and minerals
- also supplies B vitamins and Iron
2. Energy — Giving Foods — foods rich in carbohydrates and fats
3. Regulating Foods — foods rich in vitamins, minerals, and cellulose.
2. Food Composition Table (FCT) — a table of food values computed at 100 grams edible portion.
A handbook that provides a rich source of information on the composition of foods commonly
consumed in the country.
Edible Portion (EP) — is the part of the food that is customarily eaten by the consumer
depending on his cultural/ food habits; Edible Portion is expressed as percent.
The percent edible portion is the proportion of edible matter in the food as collected or
purchased, expressed on the basis of weight.
3. Recommended Energy and Nutrition Intakes (RENI) — the revised edition of the dietary
standard (Recommended Dietary Allowance or RDA) to "emphasize that the standards are in
terms of nutrients, and not foods or diets.
RENI's are defined as levels of intakes of energy and nutrients which, on the basis of current
scientific knowledge, are considered adequate for the maintenance of health and well- being of
nearly all healthy persons in the population.
RENI's are equal to the average physiologic requirement (AR), corrected for incomplete
utilization or dietary nutrient bioavailability, plus two standard deviations (sd), or twice an
assumed coefficient variation (CV) to cover the needs of almost all individuals in the population.
Uses and Applications:
1. Goal for energy and nutrient intakes of groups and nutrient intakes of individuals.
The goal should be based on the individual's body weight since the recommended energy
intake is for a specified reference weight.
2. Reference standard for the assessment of the habitual energy and nutrient intakes
of the population or sub-groups. When used for this purpose, the percentage of individuals
with habitual intakes below the RNI (recommended nutrient intake) should be estimated.
As this percentages increase, so does the likelihood that the group is inadequately provided
for.
3. Reference standard for assessment of the adequacy of food supplies.
4. Tool for nutrition education and adequacy.
5. Basis for public health and food nutrition policies.
 e.g. on food fortification, food importation, food and nutrition labeling supplementation
program. (Refer to Appendix — A - RENI TABLE)
4. Food Exchange List (FEL) — a grouping of common food that has practically the same
amount of proteins, carbohydrates, fats and calories.
 One food item can be exchanged with another provided that the specified serving
portion is followed.
Exchange refers to food in any one group that can be substituted or exchange.
 Serving portion indicates the amount of food that can be normally consumed by
one person at one time in one meal.
5. Food Pyramid Guide
 A simple and easy to follow daily eating guide. Food Pyramid Guide a new plan for
ensuring dietary adequacy that offers five (5) categories of foods to choose from. A simple
and easy-to-follow daily eating guide.
6. Nutritional Guidelines for Filipinos
 Primary recommendations to promote good health through proper nutrition. They
seek to foster an adequate and balanced diet as well as desirable food and nutrition
practices and healthy habits suitable for general populations.
 Serve as a handy reference for counseling and education services.
Guidelines:
1. Eat a variety of foods everyday.
2. Breast-feed infants from birth to 4-6 months, and then give appropriate foods
while continuing breast feeding.
3. Maintain children's normal growth through proper diet and monitor their growth
regularly.
4. Consume fish. Lean meat, poultry, and dried beans.
5. Eat more fruits, vegetables, and root crops.
6. Eat foods prepared with edible/cooking oil daily.
7. Consume milk, milk products, or other calcium-rich foods such as small fish and
dark green leafy vegetables everyday.
8. Use iodized salt, but avoid excessive intake of salty foods.
9. Eat clean and safe foods.
10.Exercise regularly, do not smoke, and avoid drinking alcoholic beverages.
10 Nutritional Guidelines for Filipinos: (Revised)
1. Eat a variety of foods every day to get the nutrients needed by the body.
2. Breastfeed infants exclusively from birth up to 6 months then give appropriate
complementary foods while continuing breastfeeding for 2 years and beyond for
optimum growth and development.
3. Eat more vegetables and fruits every day to get the essential vitamins,
minerals, and fiber for regulation of body processes.
4. Consume fish, lean meat, poultry, egg, dried beans, or nuts daily for
growth and report of body tissues,
5. Consume milk, milk products, and other calcium-rich foods - such as
small fish and shellfish - every day for healthy bones and teeth.
6. Consume safe foods and water to prevent diarrhea and other food and
water-borne diseases.
 7. Use iodized salt to prevent Iodine Deficiency Disorders,
8. Limit intake of salty, fried, fatty, and sugar-rich foods to prevent
cardiovascular diseases.
9. Attain normal body weight through proper diet and moderate physical activity
to maintain good health and help prevent obesity,
10. Be physically active, make healthy food choices, manage stress, avoid
alcoholic beverages, and do not smoke to help prevent lifestyle-related non-
communicable diseases.

7. The Use of Computers

 Computers are considered as one of the important tools in nutrition education,
dietary analysis, diagnosis procedure and as therapeutic aids.
8. Nutrient Density
 Nutrient Density is a relative measure of nutrient in a food in proportion to its caloric
content.
 A food is considered nutritious when it contains more nutrients other than calories or
considered to have a high nutrient density
INQ or Index Nutrient Quantity = % RDA of Nutrient
%
Energy Requirement
 Food is considered nutritious if INQ of 1 or more for at least 4 nutrients for at
least 2 nutrients.
9. Labeling
 Nutritional labeling has been made mandatory for all processed foods. The ruling
requires that the label have the following format.
 Calories
 Protein
 Carbohydrates
 Fat
 Vitamin C
 Vitamin A
 Thiamine
 Riboflavin
 Niacin
 Calcium
 Iron
 Vitamin B16
 Vitamin B12
 Sodium
 The listing of other nutrients are optional

3.Food and Nutrition Labelling: How to read Food labels:

Consumers gather information about foods they purchase from a wide variety sources.
Family knowledge, education, the media and advertising all convey messages about food
characteristics; the information on those labels about the nutritional content and health benefits of
food is particularly important.
 When such information is labelled on a food product it is referred to as a "nutrition label",
"nutrition claim" or "health claim".
Nutrition claims- refer to statements describing the presence, absence, or level of a nutrient.
Heath claims-refer to statements connecting a food, food components or a nutrient to a state of
desired health.
Nutrition facts- a statement or information of food labels indicating the nutrient(s) and the
quantity of the said nutrient found or added in the processed foods or food products.
Nutrition Labelling- a system of describing processed foods or food products on the basis of their
selected nutrient content. Printed in food labels as "Nutrition Facts."
Legal Basis:
The Bureau of Food and Drugs (BFAD) under the Department of Health (DOH) is the
government's major implementor of food labelling regulations as stated in:
 RA 3750-Food, Drugs and Cosmetics Act (amended by EO 175 in1987)
 RA 7394-The Consumer Act of the Philippines;
 BFAD Administrative Order No. 88-B s. 1984-Rules and Regulations Governing
the labelling of Prepackaged food Products.
 RA 8976-Philippine Food Fortification Act of 2000.

Philippine Food Labelling:

Per DOH administrative Order No. 88-B s. 1984 the basic requirements of labelling are the
following:
1. Brandname/Tradename
2. Product Name — the product name should state the true nature of the food
3. Net WeightNolume- the unit should be metric (kg, mg, ml).
4. Ingredients- all ingredients should be declared in decreasing order of proportion
5. Manufacturer/distributor- shall be declared with complete address; street address may be
omitted only if listed phone directory in the preceding year
6. Lot Identification Code/Manufacturing date or Expiry date.
Mislabeling as defined in the Consumer Act of the Philippines. Article 85 of Republic Act No.
7394 states: "A food shall also be deemed mislabelled if it's labelling or advertising is false or
misleading in any way." For example, the use of medical symbol or logos, such as the caduceus,
misleads the consumer by giving an impression that the product is a special dietary food for a
medical purpose and that it contains much needed nutrients to attain the expected effects, such as
convalescence requirement.
Fortified Foods:
RA 8976 — Philippine food fortification act of 2000, covers all imported or locally processed
foods productions for sale or distribution in the Philippines for voluntary food fortification under
the DOH Sangkap Pinoy Seal program, or mandatory food fortification of staple foods. The added
nutrients for fortification shall be in the form of nature identical nutrients.
DOH Administrative Order No. 4-A s. 1995 serve to regulate the use of nutritional claims or
micronutrients-fortified products and to assure that the claims are true and conform with the
standards. The fortification level shall be appropriately presented on the label indicating the
following information:
 Number of servings per container/package
 Serving size by weight or volume (by weight for solid food and volume for liquid food)
 Calories (kcal) per serving
 Nutrients added and their corresponding expressed as %RENI per serving.
For general requirements on nutritional claims that are below the fortification requirements,
the Codex Guidelines on Nutritional Labelling is adapted instead. In the absence of local
regulations, the regulations, the US FDA is adapted, particularly the New Labelling and Education
Act (NLEA) of 1990, or regulations of any other internally recognized Health Agency.
Examples of NLEA Nutrients Content Descriptors used are:
 Free: no amount of or "physiologically inconsequential"
 Fat-free: less than 0.5g/serving

Reading Food Labels:

Food labels are the primary means of communication between the producer or the manufacturer
and the purchases or consumer. Nutrition labelling is a description intended to inform the consumer
of nutritional properties. It consists of two components: nutrient declaration and supplementary
nutrition information:
 Nutrient declaration — standardized statement or listing of the nutrient content of food.
 Nutrition claim — representation which states or implies that a food has some particular
nutritional properties.

The "Nutritional Facts" food labels are intended to give you information about the specific
packaged food. Measurements of fat, cholesterol, sodium, potassium, carbohydrate, proteins,
vitamins and minerals are calculated for a typical portion. This information is intended to make it
easier for you to purchase foods that will fit in your meal plan.
Serving Size- is based on the amount of food people typically eat at a given meal. This may
not be the serving amount you normally eat. It is important to pay attention to the serving size,
including the number of servings in the package and compare it how much you actually eat. Do
not confuse portion size with serving size. The size of the serving on the food package influences
all nutrients amount listed on the top part of the label. For example if the package has 4 servings
and you eat the entire package, you quadruple the calories, fat, etc. that you have eaten.
Calories and Calories from Fat: The number of calories and grams of nutrients are
provided for the stated serving size. This is the part of the food label where you find the amount
of fat per serving.
Nutrients: This section lists the daily amount of each nutrient in the food package. These
daily values are the reference numbers that are set by the government and are based on current
nutrition recommendations.
• Some labels list daily values for both 2,000 and 2,500 calorie diets.
 See if you can do this!

Directions: Identify and write the correct answer on the questions below.
_______________________1. This is intended to give information about the specific food
packaged.
_______________________2. A plan that ensure adequate dietary adequacy that is easy to follow.
_______________________3. Is designed to help people eat healthy and live active lifestyle that
reduce weight-related diseases.
_______________________4.It was revised and emphasize that the standards are in terms of
nutrients, and not foods or diets.
_______________________5.It suggests a daily recommended food guide to use an amount and
the number of servings in each group to provide the variety of nutrients needed by the body.
_______________________6. A general term for a set of reference values used to plan and assess
nutrient intakes of healthy people.
_______________________7. A handbook of a table of food values computed at 100 grams
edible portion.
_______________________8. A grouping of common food that has practically the same amount
of proteins, carbohydrates, fats and calories.
_______________________9. The Consumer Act of the Philippines.
_______________________10. A Food, Drugs and Cosmetics Act of the Philippines.

Godspeed…

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 Nutrition Care Process (ADIME Process)
Lesson 05
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Introduction:

The Nutrition Care Process is a systematic method to providing high-quality nutrition

care. It was published as part of the Nutrition Care Model. The process provides a framework for
the RDN/RND to customize care, taking into account the client's needs and values and using the
best evidence available to make decisions. Other disciplines in healthcare, including nurses,
physical therapists and occupational therapists have adopted care processes specific to their
discipline.

Nutrition Care process involved the ADIME Process Model, such as Assessment,
Diagnosis, Intervention, and Monitoring/Evaluation, is a process used to ensure high quality
nutrition care to patients and clients from nutrition professionals, such as Registered Dietitians
(RD) or Registered Dietitian Nutritionist (RDN). ADIME is used as a means of charting patient
progress and to encourage a universal language amongst nutrition professionals.
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Objectives:

At the end of the lesson, the student can:

1.Discuss the Nutrition Care Process.
2.Recognize the importance of NCP-ADIME Process of ADA Method.
3.Analyze and apply Assessment in Nutrition Care Process-ADIME Process.
4.Design and Plan Anthropometric Measurement of an individual on NCP.
5.Adopt Checklist for Documentation of Nutrition care process.
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Topic Outline:
A.Nutrition Care Process.
B.Nutrition Care Process (ADIME Process- ADA Model).
C.Nutrition Evaluation Approaches.
D.Nutrition Diagnostic Terminology.
E.Checklist for Documentation of Nutrition Care.
F.Nutritional Assessment Form.
 Try this!
Directions: Answer all the necessary information needed in the column below. Use your own
profile such as your health, medication used/taken, personal, and diet history.
Type of History & Information: Remarks:
Significant Information
Health History:
a.Current health problem(s)
b.Past health problems
c.Family health history
d.Previous surgeries
Medication History:
a.Prescription Medications
b.Over-the-counter
medications
c.Herbal & Dietary
supplements
Personal History:
a.Age
b.Gender
c.Height
d.Weight
e.Cultural/ethnic identity
f.Occupation
g.Role in family
h.Educational, Motivational,
& Economic state
Diet History:
a.Food intake
b.Eating habits and patterns
c.Lifestyle patterns
2.What can you say or Discuss about your historical and nutrition assessment results. (Reaction
paper).

Answer Key Sheet

Name:___________________________________ Score:________
Course/Year:_______________________________ Date:_________
 Think ahead!
Directions: Research on the process of the Nutrition Care using ADIME-ADA Model.
1.Draw in a clean and clear long bond paper the NCP ADIME-ADA Model.

2.Discuss briefly the concept.

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 Read & Ponder!

Nutrition care process:

The nutritional care process is defined as the process of planning and meeting the
nutritional needs of a client.

Expected Outcomes of Nutritional Care:

• Improved nutrition status • Prevention/delay of complications
• Improved food and nutrient intake • Positive behavior change
• Improved knowledge • Risk factor reduction
• Ability to identify and access available resources • Improved self -management
• Improved laboratory values, weight, blood pressure • Improved quality of life
• Reduced clinic consultations and hospital admissions
“Historical Information and Nutrition Assessment”:
Type of History & Significant Information What It Identifies

Health History
• Current health problem(s)
Health factors that affect nutrient or nutrition
• Past health problems
education needs or place the client at risk for
• Family health history
poor nutrition status.
• Previous surgeries
• Potential health (problems)

Medication History
• Prescription Medications Medications, alternative therapies, and
• Over-the-counter medications illegal drug use that can affect nutrient
• Herbal & Dietary supplements needs or alter nutrition status.
• Illegal drugs

Personal History
• Age
• Gender
Factors that affect nutrient needs, influence
• Cultural/ethnic identity
food choices, or limit diet therapy options.
• Occupation
• Role in family
• Educational, Motivational, & Economic state

Diet History
Nutrient intake and imbalances, reasons for
• Food intake
potential nutrition problems & dietary
• Eating habits and patterns
• Lifestyle patterns factors important to shaping a nutrition care
plan.

The Nutrition Care Process: ADIME (ADA Model).

The ADIME process consists of four steps:
1.Nutritional Assessment — needs critical thinking skills to do proper assessment
2. Nutrition Diagnosis — different from medical diagnosis; clustered into 3 domains
 nutrition diagnosis domains (intake, clinical & behavioral, environmental)
there are 62 nutrition diagnoses/problems clustered into the 3 domains but within each
domain are classes and in some
classes, subclasses
problems should be classified then the diagnosis components PES (problem, etiology,
signs & symptoms)
➢writing nutrition diagnostic statements and examples
- will use the ADA Standardized Language for the NCP
3. Nutrition Intervention — objectives are patient centered, achievable, stated in
behavioral terms, quantifiable terms that patient and counselor establish together.
 Four main classes are identified (Foods and/or Nutrition Provision, Nutrition
Education, Nutrition Counseling & Coordination of Care).
4. Nutrition Monitoring and Evaluation — steps include monitoring progress,
measuring outcomes and evaluating outcomes.

Nutrition Care Process: ADIME (ADA Model)

STEP 1. NUTRITION ASSESSMENT:
"Nutrition Assessment" is the first step of the Nutrition Care Process. Its purpose is to
obtain adequate information in order to identify nutrition-related problems. It is initiated by
referral and/or screening of individuals or groups for nutritional risk factors.
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.
The specific types of data gathered in the assessment will vary depending on the;
a) practice settings, b) individual/groups' present health status, c) how data are related to
outcomes to be measured, d) recommended practices such as ADA's Evidence Based
Guides for Practice and e) whether it is an initial assessment or a reassessment.
Nutrition assessment requires making comparisons between the information obtained and reliable
standards (ideal goals).
Nutrition assessment is an on-going, dynamic process that involves not only initial data collection,
but also continual reassessment and analysis of patient/client/group needs. Assessment provides
the foundation for the nutrition diagnosis at the next step of the Nutrition Care Process.
Data Sources/Tools for Assessment:
  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 Assessment Components:
 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 of Assessment:
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 of
the 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 for Continuation of Care:
If upon the completion of an initial or reassessment it is determined that the problem cannot be modified
by further nutrition care, discharge or discontinuation from this episode of nutrition care may be
appropriate.

STEP 2. NUTRITION DIAGNOSIS:

"Nutrition Diagnosis" is the second step of the Nutrition Care Process and 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.
At the end of the assessment step, data are clustered, analyzed, and synthesized. This will reveal
a nutrition diagnostic category from which to formulate a specific nutrition diagnostic statement. Nutrition
diagnosis should not be confused with medical diagnosis, which can be defined as a disease or pathology
of specific organs or body systems that can be treated or prevented.
 A nutrition diagnosis changes as the patient/client/group's response changes.
 A medical diagnosis does not change as long as the disease or condition exists.
 A patient/client/group may have the medical diagnosis of "Type 2 diabetes mellitus"; however,
after performing a nutrition assessment, dietetics professionals may diagnose, for example,
"undesirable overweight status" or "excessive carbohydrate intake."
 Analyzing assessment data and naming the nutrition diagnosis(es) provide a link to setting realistic
and measurable expected outcomes, selecting appropriate interventions, and tracking progress in
attaining those expected outcomes.
Data Sources/Tools for Monitoring and Evaluation:
■ 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 Outcomes Collected:The outcome(s) to be measured should be directly related to the

nutrition diagnosis and the goals established 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 or delay nursing
home admission).
Data Sources/Tools for Diagnosis:
■ 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
standardized language for nutrition diagnoses and intervention. (June 2003).

Nutrition Diagnosis Components (3 distinct 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 environmental
problems.
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, or environmental 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 of
events 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 also
be justified.
The ranking of nutrition diagnoses permits dietetics professionals to arrange the problems in
order of 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 during
the assessment phase, provide evidence that a nutrition-related problem exists and that the
problem identified belongs in the selected diagnostic category. They also quantify the problem
and 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 Diagnostic Statement (PES):
Whenever possible, a nutrition diagnostic statement is written in a PES format that states the
Problem (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 concise
2.Specific: patient/client/group-centered
3.Related to one client problem
4.Accurate: relate to one etiology
5.Based on reliable and accurate assessment data
Examples 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 recommended
amount by 500 kcal and 12-pound weight gain during the past 18 months (signs),
Inappropriate infant feeding practice RT lack of knowledge AEB infant receiving bedtime juice
in a bottle,
Unintended weight loss RT inadequate provision of energy by enteral products AEB 6-pound
weight 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 of Diagnosis:
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 nutrition diagnosis is the impression of dietetics professionals at a given point in time.
Therefore, as more assessment data become available, the documentation of the diagnosis may
need to be revised and updated.
Inclusion of the following information would further describe quality documentation of this step:
 Date and time; and
 Written statement of nutrition diagnosis.
Determination for Continuation of Care:
Since the diagnosis step primarily involves naming and describing the problem, the determination
for continuation of care seldom occurs at this step. Determination of the continuation of care is
more appropriately made at an earlier or later point in the Nutrition Care Process.
Nutrition diagnosis is the critical link in the nutrition care process between assessment
and intervention. Interventions can then be clearly targeted to address either the etiology or signs
and symptoms of the specific nutrition diagnosis/problem identified. Using a standardized
terminology for identifying the nutrition diagnosis/problem will make one aspect of the critical
thinking that dietetics professionals do visible to other professionals as well as provide a clear
method of communicating among dietetics professionals. Implementation of a standard language
throughout the profession, with tools to assist practitioners, will make this bold initiative a
success. Ongoing input is critical as the standardized language is created to ensure a proper
foundation for its future implementation.

STEP 3.NUTRITION INTERVENTION:

Basic Definition &Purpose:
Is the third step of the Nutrition Care Process. An intervention is a specific set of activities
and associated materials used to address the problem.
Nutrition interventions are purposefully 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.
This step involves a) selecting, b) planning, and c) implementing appropriate actions to meet
patient/client/groups' nutrition needs.
The selection of nutrition interventions is driven by 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
coordinating the nutrition care that others provide. All interventions must be based on scientific
principles and rationale and, when available, grounded in a high level of quality research
(evidence-based interventions).
Dietetics professionals work collaboratively with the patient/client/group, family, or
caregiver to create a realistic plan that has a good probability of positively influencing the
diagnosis/problem.
This client-driven process is a key element in the success of this step, distinguishing it
from previous planning steps that may or may not have involved the patient/client/group to
this degree of participation.
Data Sources/Tools for■ Evidence-based nutrition guides for practice and protocols
Interventions ■ 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 InterventionThis step includes two distinct interrelated processes:
Components 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 of importance.
 Consult ADA's MNT Evidence-Based Guides for Practice and other

practice guides. These resources can assist dietetics professionals

in identifying science-based ideal goals and selecting appropriate
interventions for MNT. They list appropriate value(s) for control or
improvement of the disease or conditions as defined and supported
in the literature.
 Determine patient-focused expected outcomes for each nutrition

diagnosis. The expected outcomes 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 increasing fiber. Expected
outcomes should be written in observable and measurable terms that
are clear and concise. They should be patient/client/group-centered
 and need to be tailored to what is reasonable to the patient's
circumstances and appropriate expectations for treatments and
outcomes.
 Confer with patient/client/group, other caregivers or policies and

program standards throughout planning step.

 Define intervention plan (for example write a nutrition

prescription, provide an education plan or community program,

create policies that influence nutrition programs and standards).
 Select specific intervention strategies that are focused on the

etiology of the problem and that are known 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 on
analysis of the assessment data and nutrition diagnosis. The
following types of critical thinking skills are especially needed in the
intervention step:
1. 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: Documentation is an on-going process that supports all of the steps in the
Nutrition Care Process.
Nutrition Interventions Quality documentation of nutrition interventions should be relevant,
accurate, and timely. It should
also support further intervention or discharge from care. Changes in
patient/client/group's level of understanding and food-related behaviors
must be documented along with changes in clinical or functional
outcomes to assure appropriate care/case management in the future.
Inclusion of the following information would further describe quality
documentation of this step:
 Date and time;
Determination for Continuation of Care:
 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 needed changes, the
dietetics professional may include discharging the client from this episode of
care as part of the planned intervention.

STEP 4. NUTRITION MONITORING AND EVALUATION:

Monitoring specifically 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, and outcomes, whereas;
Evaluation is the systematic comparison of current findings with previous status, intervention
goals, or a reference standard. Monitoring and evaluation use selected outcome indicators
(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
outcomes to 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
being made 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 appropriate outcome indicators (markers) relevant to the nutrition diagnosis
and intervention strategies. Data from this step are used to create an outcomes management
system. Refer to Outcomes Management System in text.
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 and outcomes. 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 in nutritional status. Alterations
in outcome indicators:
such as hemoglobin Al C or weight are examples that trigger reactivation of the
nutrition care process.
Data Sources/Tools for Monitoring and Evaluation:
■ 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 Outcomes Collected:The outcome(s) to be measured should be directly related to the

nutrition diagnosis and the goals established 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 or delay nursing
home admission).

Nutrition Monitoring and Evaluation Components:

 1. Monitor progress:
This step includes three distinct and interrelated processes:
■ 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 pafient/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 of Monitoring and Evaluation:
Documentation is an on-going process that supports all of the steps in the Nutrition
Care Process and is an integral part of monitoring and evaluation activities. Quality
documentation of the monitoring and evaluation step should be relevant, accurate, and
timely. It includes a statement of where the patient is now in terms of expected outcomes.
Standardized documentation enables pooling of data for outcomes measurement and quality
improvement purposes. Quality documentation 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
"mer or "not met" goal evaluation tool);
 Factors facilitating or hampering progress;

 Other positive or negative outcomes; and

 Future plans for nutrition care, monitoring, and follow

up or discharge.
Determination for Continuation of Care:
Based on the findings, the dietetics professional makes a decision to
actively continue care or discharge the patient/client/group from nutrition care (when
necessary and appropriate nutrition care is completed or no further change is expected at this
time). If nutrition care is to be continued, the nutrition care process cycles back as necessary
to assessment, diagnosis, and/or intervention for additional assessment, refinement of the
diagnosis and adjustment and/or reinforcement of the plan. If care does not continue, the
patient may still be monitored for a change in status and reentry to nutrition care at a later date.

The NCP is designed to improve the consistency and quality of

individualized patient/client care and the predictability of patient/client outcomes. It aims to
standardize the process for providing care.
The nutrition diagnosis is the new component of the NCP. The use of standardized nutrition
diagnosis language will consistently describe nutrition problems so they are clear within all
and outside the ND profession and will enhance communication and documentation of
nutrition care. Thus, naming the nutrition diagnosis(es), identifying the etiology, and signs &
symptoms to establish priority in planning the nutrition intervention is very important. Ideally,
a nutrition diagnosis (e.g., excessive CHO intake) will be resolved with nutrition intervention.
Medical diagnosis is a disease or pathology of specific organs or body systems (e.g., Diabetes
mellitus) and does not change as long as the condition exists.

Sample Nutrition Diagnostic Statement:

Metabolic Syndrome:
 PES: Inappropriate intake of types of CHO r/t knowledge deficit as evidenced by triglycerides of 300 mg/dL
 and HDL of 25 mgldL.
 Assessment Data: Food intake records; refined CHO and soft drink intake; dietary fiber. Physical activity
history.
 Intervention: Education about desirable CHO and fiber and benefits of regular exercise.
 Monitoring & Evaluation: Labs in 3-6 mos; reports of physical activity; dietary records.

Sample Nutrition Diagnostic Statement:

Diarrhea:
 PES: Altered GI fxn rit excessive intake of poorly absorbed CHOs AEB frequent intake of apple juice
and sorbitol-containing dietetic products with cramping and loose stools.
 Assessment Data: Food diary, bowel patterns.
 Intervention: Educate about impact of poorly absorbed CHO on bowel function.

 Monitoring & Evaluation: Reports of less abdominal cramping and loose stools.

Sample Nutrition Diagnostic Statement

Constipation:
 PES: Altered GI fxn r/t very low fluid intake and use of
constipating medications AEB pt complaints of hard, dry, infrequent stools.
 Assessment Data (sources of info): Fluid intake records (I & 0),
medication hx and recent changes, stool patterns and frequency.
 Intervention: Counseling about fluid sources & ways to incorporate more fluids into meals &
nourishments, discussion of fluid tracking with staff/family as well as pt, discuss need for stool softener
with M.D. or nursing staff.
 Monitoring & Evaluation: Fluid intake records, stool patterns and frequency records, review of
medication changes or addition of stool softener.
Sample Nutrition Diagnostic Statement
Type 2 Diabetes Mellitus:
 PES: Self-monitoring knowledge deficit r/t lack of under-standing how to record F&B intake AEB
incomplete food records at last two clinic visits and lab of HBA1c=8.5 mg/dL.
 Assessment Data (sources of info): Blood glucose sell-monitoring records, food diary worksheets
and meal records, blood glucose levels (fasting, 2-hr pp and /or HbAlc levels).
 Intervention: Teaching pt & family members about use of simple blood glucose self-monitoring records
(recording of timing, amount, blood glucose levels) and meal records.
 Monitoring & Evaluation: HbAlc levels (goal <7 mg/dL); other glucose labs, food diary and
records; discussion about complications of using the records.

Nutrition Evaluation Approaches:

Assessment by Anthropometry:
Nutritional anthropometry is the me asurement of variations in body size, physical
dimensions, and gross composition of the human body at different age levels and degrees
of nutrition. Anthropometric data are most useful when they reflect accurate
measurements and are recorded over a period of time.
Well-recognized and valuable measurement parameters are height, weight, and body
circumferences. Measurements are compared to population standards specific for gender
to evaluate how the body composition compares to norms.
Sample Nutrition Diagnostic Statement:
Infertility:
 PES: Imbalance of nutrients r/t low micronutrient intake (Vit A & C, Mg, & K) AEB consistent omission of
fruits and vegetables in dietary intake records and poor nutritional lab values.
 Assessment Data: Dietary recall, nutrient analysis for vitamins & minerals, laboratory analyses.

 Intervention: Counseling & education about a healthy diet for promoting optimal reproductive health.
 Monitoring & Evaluation: Dietary intake records, increased intake of F&V, improved nutritional lab
rpts.
Weight:
Body weight is a sensitive marker of current nutritional status. In children, it is a
good indicator of satisfactory diet andrecent food intake. Weight provides a crude
evaluation of overall fat and muscle stores. Actual weight reflects a meas urement
obtained at the time of examination. Note that actual weight may be influenced by
changes in the person's fluid status.
Obtaining Correct Weight Measurement:
 Use a beam balance (adult or pediatric scale) or a metabolic scale (for bedridden
person); spring-operated scales such as bathroom scale are less reliable.
 Weighing should not be done after a full meal or with full bladder. Weight should
be taken at the same time of the day preferably before breakfast. Minimum clothing
is ideal with no footwear and heavy accessories.
 Allow the subject to stand still in the middle of the scale without touching any
else. For uncooperative children, the mother should carry the child and they are
weighed together; then the mother's weight (alone) is taken. Subtract the mother's
weight from the initial weight (mother and child weight) to determine the child's
weight.
 Weight is read to the nearest 10 grams for infants or 100 grams for children and
older.
Classifying Weight Status using Reference Standards:
Weight status of children can he classified by using reference tables. In the past,
weight status is compared to growth standards developed by the Food and Nutrition
Research Institute of the Department of Science and Technology and the Philippine
Pediatric Society (F NRI-PPS, 1992). Recently, the use of the International Reference
Standards (IRS) Growth Tables and Charts (FNRI, 2003) is recommended (Table 2.1 to
2.6). Weight-for-age compares the child to reference data for weight attained at any
given age.
Prior to comparison, the correct age in months (nearest age) o f c h i l d r e n and
adolescents must be determined using this method:

Year - Month Day Sample Data

Date of weighing 2005 06 15 (June 15, 2005)
(Less) Birth date 2001 02 10 (February 10,
4 4 05 2001)

Convert age in months by multiplying by 12.

Add the age in months to the product. Disregard the number of days.
Answer:
Nearest age in months = 52
months (4 years x 12 mo/yr = 48 ± 4 mon)
Classifying Weight Status Based on Percentage Standard Weight;
An alternative way of determining the level of weight status is through
calculating the percentage, standard weight by comparing expected weight and the
actual body weight.

% standard weight = ABW X 100

DBW

Expected weight is the same as the standard weight or d e s i r a b l e b o d y w e i g h t .

Methods of computing the desirable body weight are discussed in detail in Chapter 6.
Table 2.7 is a point of reference in identifying the presence of malnutrition in children.
For teens and adults, use Table 2.8 as guidelines in categorizing we ight status of
individual.

Classifying Weight Status Based on Body Mass Index:

The body mass index, also called the Quetelet index, is fradilionally used to
estimate degree of obesity (that is, the amount of total body fat) of i ndi vi dual s .
Toda y, dat a on body mass index can be very useful in deter mining how much risk
people have of developing certain health problems because of t hei r wei ght . Thus , i t
provi des an important indication of a person's overall health

BMI = W
B M I i s c o m p u t e d u s i n g t h e equation given H2
in
the inbox and interpreted using standard weight
w h e r e : W = weight in kilos
status categories.
H = height in meter
Sample Calculation using Body Mass Index
Subject — Gerardo, 5 feet and 9 inches tall (68 inches), weighing 145 pounds
1.Convert weight into kilos by dividing his weight in pounds by 2.2 pounds per kilo:
145 pounds/2.2 pounds per kilo = 65.91 kilos
2. Convert height into meters by multiplying his height in 'inches by 0.0254 meter
per inch:
68 inches X 0.0254 meter/inch = 1.73 meters

3. Find the square of his height:

1.73 meters X 1.73 meters = 2.99 m2
4 Apply the BMi equation. Divide his weight in kg by his height in m2: 65.91
kg/2.99 m2 = 22.04 kg/ m2 (normal BMI).
Interpreting Computed BMI values:
The BMI ranges are based on the relationship between body weight and disease and death.
Overweight and obese persons are at increased risk for health conditions, including Type 2
diabetes, heart disease, hypertension, dyslipidemia (for instance, high levels of triglycerides or
high levels of LDL-cholesterol), stroke, gallbladder disease, osteoarthritis, sleep apnea and
respiratory problems, and some cancers (endometrial, breast, colon). A very low BM! (below 18.5)
is likewise associated with treater risk of health problems and death. Filipinos and other Asians
may follow the Asia Pacific Guidelines. According to the WHO expert consultation (Lancet,
2004). Asians general!), have a higher percentage of body fat than white people of the same age,
sex and BMI. in addition, the proportion of Asian people with risk factors for type 2 diabetes and
cardiovascular disease is substantial even below the existing WHO BMI cut-off points of 25
kg/m2.

Height:
Height suggests linear dimension comprising of legs, pelvis, spine, and skull. It is used as
an indication of past or chronic nutritional status (stunting, i.e., if the child's height or length falls
below the reference values, the child is stunted).

Obtaining Correct Height Measurement

 Use infantometer (for children below 1 year), a stadiometer or non-stretchable tape
measure (for older children and adults).
 For infants: Knees are extended by a firm pressure applied and bare feet are flexed at the
right angles to the lower legs. Head is positioned firmly against the fixed headboard or in
line with "0" point of measuring device.
 In children/adults: Subject should wear no shoes and properly positioned ; feet parallel,
heels, buttocks, shoulder blades and back of the head touching the scale, and head is held
 comfortably erect). The client's line of sight should be horizontal. Arms are hanging at
the sides.
 CI Use a thin and stiff headpiece; gently lower the headpiece crushing the hair and
making contact with the top of the head. Headpiece is at a right angle to the wall.

To interpret, it is recommended to use the IRS (FNRI, 2003) to categorize height status of
children, which appear in Table 2.16 to 2.21. Height of elderly and person who is bedfast or
chair bound, or with spinal curvature may be measured using a knee-height caliper.

Knee Height
Knee height is used to estimate stature of patients whose standing height cannot be taken
accurately. It is indicated in an elderly, person with large fat deposit at the back, person unable to
stand alone, or individuals who have curvature of the spine.

Obtaining Correct Knee-height Measurement

 Use a broad-blade caliper to get knee-height measurement. the subject lies on the back
with the knee bent to a 90-degree angle.
 Press the sliding blade of the caliper against the thigh about 2 inches behind the kneecap
and hold the caliper shaft in line with the shaft of the tibia. Two readings should agree
within 0.5 cm.
 Formula for estimating full height using knee height measurement data.
Men: Height (cm) = 64.19 — (0.04 x age in years) + (2.02 x knee height in cm) Women:
Height (cm) = 84.88 — (0.24 x age in years) + (1.83 x knee height in cm)

Waist-to-hip Ratio
Waist-to-hip ratio (WHR) is a valuable indicator of body fat distribution and adiposity. It
allows differentiating between the / profile of adipose tissue in overweight patients of the "apple"
type, the "pear" shape, and the intermediate type. It is also a valuable guide in evaluating health
risk (heart disease, diabetes, etc.). Alternatively, it is called abdominal/gluteal ratio or abdominal
girth measurement.

Obtaining Correct Measurement

Use non-stretchable tape measure (in centimeter). Subject should stand erectly,
abdominal muscles relaxed, arms at the sides, and feet together. The measurer faces the subject
and places the tape measure. Measure waist at the most narrow area below the rib case above the
umbilicus. Measure hip circumference at the widest point around the hips or buttocks with the
subject standing. Read measurement to the nearest 0,1.

Formula for Assessing Body Fat Distribution by WHR

 The ratio of waist and hip circumference is calculated using this formula:
WHR = Waist circumference (cm)
Hip circumference (cm)
 A ratio of 1.0 or greater in men or 0.8 or greater in women is indicative of
android obesity ("apple" shape) and an increased risk for obesity -related
diseases. This also appears to be true i n children.
 Gynoid, "pear-shaped" people, store more fat in the buttocks, thighs, and hips.
Android, "apple-shaped" people, carry their extra fat around the .
abdomen/upper body. Calculating the ratio of waist to hip is very useful in
determining the metabolic and vascular risk of individuals.
 The waist-to-hip ratio may partially explain the difference in high blood pressure
between men and women. Men are more likely to be "apples" and women to be
"pears," Men have higher rates of hypertension and more comp lications.
Waist Circumference:
Waist circumference serves as a marker of abdominal fatness. Waist
circumference alone has been considered a valid indicator for both men and women.

Interpretation of Waist Circumference Data:

Women with a waist circumferen ce greater than 35 inches and men with
waist circumference greater than 40 inches have high risk of central obesity-related
health problems.
Body Frame Size:
Determination of body frame allows the weight to be adjusted for height to
refl ect a more suit able desirable wei ght range. Bod y build (muscularity, bone
thickness, and body proportions) affect body weight. Body frame size may be
obtained through one of the methods described here.

Method 1: Based on the Ratio of Height to Wrist Circumference (Grant, 1985)

Obtaining Measurements
 To obtain wrist circumference, the subject's right hand is extended.
 Measure wrist circumference at the joint just distal to the styloid process (bony
protrusion).
 Calculate the ratio of height to wrist circumference with this equation:

Method 2 - Body frame according to wrist size

To determine frame size, wrap the fingers of one hand around the opposite wrist:
• If the thumb and middle finger overlap by 1 cm, the frame size is small.
 • If the thumb and middle finger touch, the body frame is medium.
• If the thumb and middle finger cannot reach by 1 cm, body frame is large.

Mid-Upper Arm Circumference (MUAE)

MUAC is used to evaluate fat stores. MUAC measures the size of the arm and all of its
components: muscle mass, subcutaneous fat, and bone. It provides an estimate of the arm soft
tissue or "wasting."
Technique in Measurement:
• Use either non-stretchable tape, an insertion tape, or Shakir tape (3-Colored).
• Have the subject sit with the left arm (if right-handed and vice-versa) hanging freely at
the side.
• Mark the midpoint between the acromion and olecranon.
• Place the tape gently but firmly around the mid-upper arm.
• Measure three times; readings are taken to the nearest centimeters. Average the results of
three (3) measurements.

Interpretation of MUAC Measurements:

For children, use reference table such as the FNRI-PPS Anthropometric Tables and
Charts for Filipino Children (1992) or refer to User's Manual, IRS by the FNRI (2003). Table
2.23 is an alternative reference.

Assessment by Clinical Method:

Clinical assessment of nutritional status deals basically with the examination of changes
that can be seen or felt in superficial tissues such as the skin, hair, and eyes. This method is
usually coupled with medical history taking to identify nutrition-related deficiencies or risks.
Table 2.25 provides a quick reference for recognizing nutrient deficiencies or excess.

Syndromes of Malnutrition:
Malnutrition may result from protein-energy-malnutrition (PEM), micronutrient
deficiency disorders, or chronic diet-related diseases. Protein-energy malnutrition is the most
common form of malnutrition in the world today. It often strikes early in childhood; many adults
are also affected. In children, PEM is characterized by low birth weight (2.5 kg or less), poor
growth (too short, too thin) and high levels of mortality, especially between 12 to 24 months. A
deficiency, of protein and food energy, PEM takes in three different forms, with some cases
exhibiting a combination of two. Table 2.26 illustrates the distinctive features of the three.
A lack of essential vitamins and minerals lead to micronutrient deficiency diseases. On
the other hand, diets high in calories and animal fat but low in fiber, combined with unhealthy
habits and lifestyle, can contribute to a wide range of chronic diseases.
Physical Signs of Dehydration:
Dehydration is the loss of water from the body that occurs when water output exceeds
water input. The symptoms progress rapidly from thirst, to weakness, to exhaustion and delirium
and end in death if not corrected. Other signs are:
• sunken eyes
• hollow cheekbones
• dry mucous membranes
• loss of skin turgor (elasticity)
• weak cry
• depression of the anterior fontanel
• deep, gasping respirations
• weak, rapid pulse
• thirst
• reduced urinary output
• weight loss

Biochemical Assessment of Nutritional Status:

Knowledge of the body's blood chemistry allows a person to begin a health program long
before these concerns reach the clinical or disease state. In medical nutrition therapy,
biochemical evaluation provides information on protein balance, vitamin and mineral status,
fluid status, body composition, organ function, and metabolic status. It also helps determine if
diet intervention is appropriate or if a person is complying with a special diet.
• A variety of tissue samples can be used such as the serum, plasma, urine, feces,
saliva, and other tissues taken through biopsy.
• Results of tests are generally compared to reference values that may be specific
for age and gender.
• Routine and nutrition-related biochemical tests are given in the following
presentation. Reference standards may vary and no single lab test is diagnostic
because many factors influence test results.
•1-he low blood concentration of a nutrient may reflect a primary deficiency of
that nutrient, but may also be secondary to the lack of one or several other
nutrients or to a factor unrelated to nutrition (disease conditions, physiologic state,
or treatment and medications).
• The succeeding data in Tables 2.28 to 2.30 illustrate the various parameters
valuable in assessing nutritional risks and diet-related problems.

Assessment by Dietary Methods:

Dietary evaluation provides a means of generating information on individual's food
habits, food, likes and dislikes, usual food pattern, and type of meals normally eaten over a
relatively long period of time. These data may reflect risk for nutritional deficiency or excess.
Knowledge of dietary intakes is crucial for planning programs for education and intervention.
Diet history, food recall, food frequency checklist, and food diary are some of the examples.
• Diet history — a comprehensive record of eating-related behaviors and food intake.
• 24-hour recall — a record of foods consumed by person in the last 24 hours (see inbox). o
Food frequency — a record of how often the different foods are eaten. The types (and
sometimes the amount) of foods a person routinely consumed in a week or a month can
also be included.
• Calorie court — a determination of a client's food intake. from a direct observation of
how much the person eats.
• Foad record/Food diary — a record of food intake; the client takes down all the foods
eaten over a period of time and this may include records of behaviors and symptoms,
physical activity, and medications.
• MEDFICTS questionnaire — is a rapid dietary fat screening instrument designed for
assessing the major contribution of total dietary fat, including meat, eggs, dairy, fried
foods, fat in baked goods, convenience foods, fat added at the table, and snacks (Peal, et
al., 2007). MEDFICTS has been used to evaluate self-reported dietary change in response
to nutrition education programs (e.g., NCEP Step 1 and Step 2 diets) with coronary heart
rehabilitation patients. It can also be used as an initial dietary fat screener for dietary
assessment, patient education, and behavior modification. This tool produces a score that
corresponds to percent energy from total dietary fat consumption.

Note: See Appendices for formula, computations and Forms.

___________________________________________________________________________

See if you can do this!

Nutrition Care Process.

Direction: Interview at least 1 (One) Client either from your family, friends, love ones, etc.,
with specific illness or disease/s and fill up the Nutrition Assessment Forms for NPC.
1.Apply Nutrition Care Process following the checklist and Nutritional Assessment Forms
*See appendices for the Forms. If no input/data; indicate “NONE/N/A”.
2.Conclusion and Recommendation.
*You may use the previous or past data in terms of Laboratory results.
 Answer Key Sheet
Name:______________________________________ Score:________
Course/Year:_______________________________ Date:_________

Godspeed…
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