UNIT II

NUTRITION COUNSELING

• Nutrition Care Process - Goal setting

• Design – Plan of action
• Dietary and physical assessment
• Documentation - SOAP, IAO
• Evaluation and follow up
• Components of counseling protocol & proforma

Geetha Santhosh Ph.D, R.D

PG Food Science & Nutrition, Dept of Nutrition & Dietetics,
Mount Carmel College, Autonomous
 NUTRITION COUNSELING - RECAP
2

• Nutrition counselling is an ongoing process in which a health

professional, usually a registered dietitian, works with an individual to
assess his or her usual dietary intake and identify areas where
change is needed.
• Process of guiding a client towards healthy nutrition lifestyle by
meeting normal nutritional needs & solving problems that are
difficult to change
Curry KR, Jaffe A Nutrition Counselling & Communication Skills. Philadelphia : Saunders, 1998
NUTRITION CARE PROCESS
Nutrition care process and model: an academic and practice
odyssey.
•Marian I Hammond, E F Myers, Naomi Trostler
•Published 2014
•Medicine
•Journal of the Academy of Nutrition and Dietetics

I N 2003, THE ACADEMY OF Nutrition and Dietetics, formerly the American Dietetic Association, adopted a Nutrition Care Process and
Model (NCPM) that identifies the unique contribution of dietetics practitioners to health care outcomes and establishes a glo bal standard for
provision of nutrition care by dietetics practitioners (Figure 1). This pivotal landmark enjoys a long odyssey. It honors the pre-1970s
researchers, educators, and practitioners who built firm foundations for future change. One of the early visions of an NCPM diagram emerged
when Marian I. Hammond, MS, RD, a nutrition program faculty member in what is now the Department of Nutritional Sciences at The
Pennsylvania State University (PSU), created a series of visual diagrams called the Hammond models. This series consisted of the 1970 original
integrative Hammond model and the 1977, 1984, and 1986 iterations (Figures 2 through 5). At that time, dietetics educators faced teaching
emerging nutritional counseling principles without a framework to organize the changing content of dietetics practice. Independently, the
Kellogg Continuing Professional Education Development Project Team embarked on a 5-year project (1980 to 1985) to develop new
approaches to continuing education (CE) programming for selected professions, including clinical dietetics. As part of its work, the Kellogg
Continuing Professional Education Development Project Team reviewed the Hammond model and endorsed the 1986 iteration to repr esent its
research results and to disseminate them through the Academy/Kellogg Continuing Professional Education Development Project Te am
collaboration. Developmental work with the Hammond models ended in 1986 when Hammond left the teaching field and stored relevant
documents. A succeeding PSU faculty member used the 1986 iteration in a nutrition counseling course.* In 1998, the Academy appointed a
Health Services Research Task Force charged with documenting the value of dietetics services’ contribution to health care outcomes to
further justify reimbursement for dietetics services/ medical nutrition therapy. One of the main challenges facing the task force was how to
identify the unique contribution of dietetics to overall health care outcomes (ie, What specific activities were consistently accomplished only by
dietitians? What changes in health care outcomes could be reasonably attributed to those activities?). This article reviews t he steady evolution
of the Hammond models and their impact on the current NCPM, compares key concepts of the Hammond models and NCPM iterations,
describes their uses and benefits, and includes references used in their development. It provides an important historical perspective about the
evolution of the NCPM and, consequently, presents information that will be helpful for developing future models/strategies to achieve best
practices in nutrition care. LESS
View On PubMed
[Link]

[Link]
NUTRITION CARE PROCESS DIETETIC PRACTICE
Explore the Behavior Journey

Figure 2. 1970 Original Hammond Model. This is a scan of the original hand-drawn pencil
sketch. Readers can note the erasures in the patientedietitian core. Hammond
Figure 3. 1977 Hammond Model.
Figure 4. 1984 Hammond Model.
Figure 1. 2003 Academy Nutrition Care Process and Model. Reprinted from Lacey and Pritchett.
Figure 8. 2008 Academy Nutrition Care Process and Model. Reprinted from International Dietetics and Nutrition
Terminology Reference Manual: Standardized Language for the Nutrition Care Process.
[Link]
THE HELPING HAND
 ADA NUTRITION CARE PROCESS AND MODEL
Screening & Referral
System
➢ Identify risk factors
➢ Use appropriate tools
and methods
➢ Involve
interdisciplinary
collaboration
Nutrition Diagnosis
➢ Identify and label problem
Nutrition Assessment ➢ Determine cause/contributing risk
➢ Obtain/collect timely and factors
appropriate data ➢ Cluster signs and symptoms/
➢ Analyze/interpret with defining characteristics
evidence- based standards
➢Document
➢ Document

Relationship
Between
Patient/Client/Group Nutrition Intervention
& Dietetics ➢ Plan nutrition intervention
Professional • Formulate goals and
determine a plan of action
➢Implement the nutrition intervention
Nutrition Monitoring and • Care is delivered and actions
-
Evaluation are carried out
➢ Monitor progress ➢ Document
➢ Measure outcome indicators
➢ Evaluate outcomes
➢ Document

Outcomes
Management System
➢ Monitor the success of the Nutrition Care
Process implementation
➢ Evaluate the impact with aggregate data
➢ Identify and analyze causes of less than
optimal performance and outcomes
➢ Refine the use of the Nutrition Care
Process
 OUTER RING & CENTRAL CORE OF
NUTRITION CARE MODEL
Practice Settings
• Strengths brought to process Health care systems
by dietetics professional Social System
Factors of external environment
• dietetics knowledge Economics

• skills of critical thinking,

collaboration, communication Code of ethics
Skills & Competencies
• evidence-based practice Dietetics knowledge
Critical thinking
• Factors of external environment Collaboration
Communication
• health care system, practice Evidence based practice
setting
• social support, economics,
Relationship between the
education level Client & the Dietetics
Professional(s)
Collaborative
Client-focused
Individualized
 IMPORTANT FOR NCP
• Important to Gear Up for Assessment & Diagnosis
• Introduce terminology & methods
• Purpose of assessment = identify problems (diagnosis)
• Introduce Evidence Based Nutrition Practice Guidelines (EBNPG)
• Education & Counseling
• Awareness & implementation of nutrition counseling approaches & strategies
(terminology)
• Connect to types of nutrition diagnosis being addressed
• Refer to EBNPG
• Community Nutrition
• Population settings, sectors & approaches (terminology)
• MNT (I & II)
• Putting it all together
• Includes all NCP activities – Screening , Four Steps, Outcome Management
• Research Methodologies
• Framework for outcomes
 ADA’S NUTRITION CARE
PROCESS STEPS

• Nutrition Assessment
• Nutrition Diagnosis
• Nutrition Intervention
• Nutrition Monitoring and Evaluation

For more information, access the ADA member page in the Quality
Management section. [Link]
 NUTRITION ASSESSMENT COMPONENTS

• Gather data, considering

• Dietary intake
• Nutrition related consequences of health and disease condition
• Psycho-social, functional, and behavioral factors
• Knowledge, readiness, and potential for change

• Compare to relevant standards

• Identify possible problem areas
EXAMPLE OF NUTRITION ASSESSMENT
CONTENT

Type of assessment
Nutrition Content component
assessment Nutritional adequacy
what data Fat and cholesterol intake
are most Trans fatty acid intake
What type
effective for Health status
of Lipid profile
identifying
clients’ assessment BMI
nutrition data? Waist circumference
related What are the reliable
problem standards (ideal goals)?
of interest • how well, how much,
how long
DIETARY & PHYSICAL ASSESSMENT
PURPOSE OF DIETARY ASSESSMENT

To assess the diet of the client

For planning an effective diet
Research purpose to assess the effect of menu plan

Gives a clue on
Adequacy : Provides inputs on adequacy of diet compared to RDA , modified RDA
Balanced Diet : As per principles of diet, diet as per food groups
Variety : Selection of food based on availability
Nutrient Density: Based on condition, the nutrient
Choice of Dietary Assessment Tool Depends on
Purpose for which it is needed
Availability, Validity, Reliability
Level of information
Availability of time
Availability of resources
Trained manpower
Equipment

Methods of Dietary Assessment

Food Balance Sheet Method
Inventory method
Expenditure pattern method
Weighment Method

Diet history
24 hour dietary recall method
Food Frequency Questionnaire
Recording method
24 Hour Dietary Recall
• Quick , easy, less time
• Reliability, validity to be checked
• Easy to administer, requires skill
• Quick easy, short term memory reliance – not sure of true representation of
person’s usual intake
• Varies with physiological status, clinical status / history, economic status
• Check family members intake and no. of members in family with age
• Cooked quantity with standardized measures for better reliability
• More objective than diet history
• Does not require literacy

Caution
• One recall is seldom representative of the usual intake
• Memory driven
• Trained observer
• Deliberate misreporting
• Omission of dressings, sauces & beverages – leads to low estimate of energy intake
• Data entry can be labor intensive
• Trained interviewer
• High level of subject motivation

Activity :
24 hour recall , Food item, preparation, method, qty., time
Accurate information is important
Face to face interview, telephonic

•Quantification of amount of food

•Standardized Measures
•Cups, Glasses, Teaspoon, Table spoon
•Weighment method
•Photographs
•Number associated with shapes
•Models as indicators
•Approximate measures tricky but estimate can be made
•Use an automated system for data collection where provision is done for
describing food at appropriate level of detail
•Food records can be used with instructions & follow up
Be careful of not drawing conclusions without detailed interview process
Explore open questions – high level of specificity be sensitive to cultural difference
Food intake is recorded by subject or observer, check for plate wastage
Conversation rather than questioning
Reducing error in data collection
Considerable training & practice of interviewer
Ask about previous day to jog the subject’s memory
Avoid asking questions in a manner that would influence subject’s responses
Neutral attitude, non judgmental
Careful reviewing by qualified nutritionist
Skilled interviewer
Relaxed & unhurried atmosphere

Rapport the key for positive outcome

• Food Frequency
• Captures across the week / month
• Memory driven
• Fills the gaps of 24 hour dietary recall
• Best usability 24 hour recall & Food Frequency
DIET ASSESSMENT TOOLS – PROS & CONS
METHOD STRENGTHS LIMITATIONS
Client Assessment Key to strengths & barriers May be invasive
Questionnaire Not culturally sensitive
Preliminary assessment
form with medical, past,
drug, psycho social
Food diary / Log Independent of memory Requires literacy
Accurate intake data Motivated client
period of 3 – 7 days Information about food data Time consuming
Can influence food intake

24 hour Recall Quick, easy, not a burden on Memory dependent

client Under / over reporting
Judging portion size
essential
Food Frequency Overall picture No meal pattern data
Not affected by season
 NUTRITIONAL ASSESSMENT

• Assessing nutritional status of patients is • Dieting history

important for several reasons. A thorough
nutritional assessment will identify individuals at • Difficulty chewing or swallowing
risk for malnutrition and provide baseline
• Vomiting
information for nutritional assessments in the
future. • Mobility problems
• Some patients that will require a thorough
• Diarrhea
nutritional assessment include those patients with:
• Recent unintentional weight loss • Inability to feed self

• Chemotherapy or radiation • Recent surgery or major illness or injury

• Recent weight gain • Substance abuse
• Food allergies or intolerance • Chronic conditions
• Decreased appetite
• Potential for social isolation
• Multiple medications
• Low income
• Alterations in sense of taste
Nutrition Focused Physical Exam (NFPE)
Getting started
Prepare for patient interaction
Standard & universal precautions
General observation of patients
First impression & physical characteristics to note during interview
• What is the apparent state of health
• What is the level of consciousness
• Does the patient show signs of physical distress
• How is the patient dressed
• Do you see any signs of nutrient deficiencies
• Is there any voluntary movement or signs of paralysis
• Body positioning
• Body language
• Ability to communicate

A PICTURE IS WORTH A 1000 WORDS

Look at the patient & concentrate on the areas that reflect what the patient expressed in
the nutrition history.
Focus on high turn over rate areas
Area Appearance Deficiency

HAIR Sparse, dry, dull , easily plucked Protein , Zinc, EFA

SKIN Scaly, cracked rash, lesions B Vitamins , Vitamin A

LIPS Cracks at the sides, swollen Vitamin B2, B3 , B6

EYES Cornea , conjunctiva Iron, B Complex, Vitamin

A
TONGUE Glossitis, magneta colour Vitamin B 12, B2
 NUTRITION DIAGNOSIS
Purpose
• Identify and label the nutrition problem
• Nutrition diagnosis
NOT medical diagnosis
• EXPLICIT statement of nutrition diagnosis

Note: Documentation is an on-going process that supports

all the steps in the Nutrition Care Process

How do we get from Assessment to Intervention?

Nutrition Diagnosis
Important for Quality Nutrition Care
 THREE COMPONENTS MAKE UP THE PES STATEMENT :
The Problem (P)– the Nutrition Diagnosis
The Etiology (E)– the cause/s of the nutrition problem (Nutrition Diagnosis)
The Signs and Symptoms (S)– the evidence that the nutrition problem (Nutrition
Diagnosis) exists.

The PES statement is a structured sentence, hence has a specific format to follow.
Here’s a sample of how to structure your statement:
NUTRITION DIAGNOSIS TERM
(the nutrition Problem)
related to
THE ETIOLOGY
(the cause/s of the problem or Nutrition Diagnosis)
as evidenced by
THE SIGNS AND SYMPTOMS
(the evidence that the nutrition problem or Nutrition Diagnosis exists).
THE PROBLEM (P) – THE NUTRITION DIAGNOSIS
Identifies the specific nutrition problem that the dietitian is responsible for treating
and works towards resolving. The nutrition diagnosis uses specific terminology from
the eNCP.
3 classifications of the nutrition diagnosis: Intake, clinical, and behavioral
• Intake: nutrition and intake related problems
•Clinical: medical or physical conditions that have a nutritional impact.
•Behavioral: covers the nutritional problems associated with nutrition knowledge
and belief (including attitude), physical activity and function (e.g. ability to self care)
and food access and safety).
The nutrition diagnosis should be specific to the role [Link] Nutrition
Diagnosis is something that as a dietitian one can resolve (ideally) or improve.
THE ETIOLOGY (E) – THE CAUSE/S OF THE NUTRITION
PROBLEM/NUTRITION DIAGNOSIS
‘E’ in the PES Statement stands for Etiology.
The definition of etiology is “the cause, set of causes, or manner of causation of a disease
or condition.” (Oxford Dictionary).
The etiology describes the cause of the nutrition diagnosis in the PES statement.
The Nutrition Intervention should be aimed at resolving the Etiology (underlying cause of
the nutrition problem).
Etiologies are grouped in categories according to cause of the diagnosis.
No incorrect etiology statement, but it should include these general points:
[Link] Etiology is the “root cause” of the Nutrition Diagnosis.
[Link] Nutrition Intervention, should aim to resolve or at least attempt to improve the
Etiology.
[Link] Etiology is supported by the nutrition assessment data.
SIGNS AND SYMPTOMS (S) – EVIDENCE THAT THE NUTRITION
DIAGNOSIS EXISTS
•Signs are objective data obtained through direct physical examination, observation, lab
values and test results.
•Symptoms are subjective data reported by the client’s or their family’s rather than
actual results.
Like Etiology, Signs and Symptoms in the PES Statement are free text.
An important skill for a dietitian to identify the Signs and Symptoms that demonstrate
that a Nutrition Diagnosis exists.
The signs and symptoms statement should support the Nutrition Diagnosis.
It should be specific, so it can be monitored and measured, to be able to evaluate
changes.
P - Fluctuating blood
Monitor initial to date with
sugars
possible reasons
related to

E - excessive
Analyse the diet - recall
carbohydrate intake
as evidenced by
Regular meal timings,
S -inconsistent timing of
identify the reasons,
meals and increased
facilitate
snacking
 NUTRITION INTERVENTION

Purpose
• Plan and implement purposeful actions to address the identified
nutrition problem
• bring about change
• set goals and expected outcomes
• client-driven
• based on scientific principles and best available evidence

Note: Documentation is an on-going process that supports

all the steps in the Nutrition Care Process
Identify nutrition goals by listening to the client’s ideas
• Define desired nutrition behaviors ( what to do)
• Determine conditions / circumstances (where and when to do it)
• Establish the extent or level (how much / how often to do it)

Identify nutrition sub goals

• A sub goal for a long term goal of eliminating snacks would be

to eliminate morning snacks & determine a workable suitable
behavior

Establish client commitment , which includes identifying obstacles

that might prevent goal attainment & listing resources needed for
goal achievement
Questions to ask

Why is the client here?

Is the problem the client describes all or any part of the problem

He just isn’t motivated to follow this diet

Real problem – emotional stress treated before nutrition counseling can take place.
Can go simultaneously

Ready to change clients , questions

• What are the problematic nutrition behaviors and related concerns
• Can I describe the conditions contributing to nutrition adherence
• Am I aware of the present severity and intensity of the nutrition
problem
 Lack sufficient Diagnose problem
Solve a problem of
information to follow involving lack of
lack of planning
desired regimen commitment

Standard measures IT MIGHT REFLECT

understanding Going to party but BADLY
forbidden to eat Choose words
1 cup
Call host to check carefully
1 exchange what is being made Give right guidance
Provide sufficient Drops in adherence facilitate the change
information to follow is very common
eating pattern
Person with diabetes
“I just want to be free from dietary worries for a while. Life is
so complicated. I want to forget my diet and splurge” Work menus in advance
Elicit help from family in
meal preparation
Counselor response specified nights
Fine don’t worry about it for a week Rely on exchange lists for
meals
What can we do to streamline your dietary Build in time to relax
efforts ? before each meal
Let us begin by identifying when diet is most frequently a Work more on positive
problem self thoughts

Identification Client suggestions &

Client records in a diary thoughts related to eating counselor experiences
before & after meals allows for joint solution
to the problem of lack of
I ate that chocolate cake even though I knew it would be commitment
too high in calories after that huge dinner
Negative patterns consistently at dinner times, bring in
strategies to make meal more positive experience
 NUTRITION MONITORING &
EVALUATION
Purpose
• Determine the progress that is being made toward the client’s
goals or desired outcomes

Monitoring: review and measurement of status at scheduled times

• Evaluation: systematic comparison with previous status,
intervention goals, reference standard

Note: Documentation is an on-going process that

supports all the steps in the Nutrition Care Process
 Reassessment of progress for both clients & counselors
Reuse questioning format , focusing on the desired objective & whether it was met
Counsellor monitors the client for a time in the client's environment

Counsellor
Important to reflect counselling process
What changes could have been made
Approaches used
Improve efficacy /quality

Counseling Spectrum

IDEAL

Totally Nutrition
Totally Client
Counselor
Centered
Centered
NCP – PUTTING IT ALL TOGETHER
• Setting specific, achievable, measurable positive goals
• Design action plan
• Dietary assessment
• History - health , drug, psycho social, diet
• Physical examination
• Anthropometry
• Biochemical analysis
• Evaluate dietary status with standardized commonly used
assessment tools
• Assess total energy expenditure
• Utilize format – SOAP, IAO
DEVELOPING NCP
Step 1 – Food Intake Data Collection
• Be careful not to advice, preach or condemn
• Portion size

STEP 2 - Data Analysis

• Food group evaluations
• Food component analysis

STEP 3 – Interpretation Of Analysis

• Comparison to RDA , Food Guide Pyramid
• Energy determinations
• Harris Benedict not valid – over estimation
• Anthropometry
• Height , weight comparison to std. values , BMI
• Waist , hip based on situation
• Life style determination

Step 4 – Documentation / Charting

• Reflect
• Evaluate
• Document - clear ,well written
• Plan
• Opt for a user friendly format / pro forma
DOCUMENTATION
 SOAP FORMAT
• Subjective
• Physical activity, appetite changes, socio eco. status

• Objective
• Factual [Link]. lab, anthropometry, diagnosis

• Assessment
• Interpretation of client based on the above
• Summarize, reflect & study the impact
• Provide possible approaches & intervention

• Plan
• Therapeutic plans
• Educational plans to address nutrition related issues
 IAO FORMAT

• Issue
• Log all nutrition related client concerns – realistically addressed

• Assessment
• Identify specific interventions related to issue

• Outcomes
• Identify expected outcomes

• Follow up – sometimes added to indicate the progress of the anticipated

outcomes, labelled as ongoing, achieved or unrealistic
Differ for Follow – up Consultations
Nutrition Reassessment
Reassessment starts with M & E indicators
Determine whether intervention is being successful
Determine other changes that need to be assessed

Nutrition Diagnosis
Determine status of previous nutrition diagnosis
Keep or add new nutrition diagnosis to guide care
If problems resolved, then discharge patients

Nutrition Intervention
Adjust nutrition prescription if needed
Provide intervention to sustain positive changes and achieve new changes

Nutrition Monitoring & Evaluation

Determine if changes are needed to indicators to reflect new intervention or
criteria adjusted for maintenance
EFFECTIVE NUTRITION
COUNSELORS
• Honest & genuine – give effective feed back

• Flexible - willingness to work at client’s pace

• Optimistic & hopeful – reassurance of life style changes

• Respect, value, care & trust others

• Accurately understand what people feel from their frame of reference (

empathy)

• Recognize individual personality & appreciate

THE KEY TO EFFECTIVE
COUNSELING
• Establish trust & rapport

• Identify barriers, Determine priorities

• Assess current eating behaviour,

motivation, ready to change

• Determine family role or other

support

• Tailor intervention approach, Ensure

monitoring & follow up
NUTRITION COUNSELING
TEAM APPROACH

• Not just different disciplines coming together

• Blending and complementing
• Blurring professional boundaries
• Interdependent
Together
Everyone
Achieves Doctor
NURSES
More
Nutritionists