Dietetics practice

• The practice of dietetics aims to optimize the nutritional health of service users, whether individuals, groups, communities, or populations.
• This optimization should also improve symptoms that can be addressed through dietetic intervention.
• The BDA's Model and Process for Nutrition and Dietetic Practice was released in 2012.
• Dietitians must adhere to the Ethical Code of Conduct and the Code of Professional Practice for every intervention.
• The dietitian needs skills and competencies in dietetics, dietetic knowledge, critical thinking and the ability to collaborate with others.
• Client-centered care improves outcomes and increases satisfaction with care and has been demonstrated to do so since around 2008.
• The Institute of Medicine defines client-centered care as providing respectful and responsive care that considers individual patient preferences, needs, and values to guide all clinical decisions.
• Client-centered care also means that the dietitian empowers the client to make their own decisions through skill and information.
• Each client has needs, dietitians should use advanced communication skills to understand them and move away from a "one diet fits all' solution.
• Clients should be actively involved in deciding the direction of their dietetic care.
• The 6 steps of the Model and Process are described by the BDA in 2021.
• Decision-making skills and the service user's needs are at the center of the intervention.
• This process supports the implementation of a standard quality of care

The Dietetic Process

• Any dietetic process begins with screening.
• Screening identifies both the people who would benefit from a consultation and those at risk of a health condition.
• Positive screenings merit further tests.
• A screening campaign by the medical student association in Valletta checks for high blood glucose readings on World Diabetes Day.
• Persons are screened for malnutrition upon admission to hospital.
• Nurses often handle nutritional screening, as it is not always feasible for dietitians to do so routinely.
• People identified as at risk of a nutritional issue need to be referred to a dietitian for assessment.
• A nutritional assessment serves to identify and diagnose the nutritional problem.
• A single consultation requires knowledge of biological, food, medicine, communication, empathy and respect.

Step 1: Assessment

• Assessment is a systematic process of analyzing and collecting information to make decisions about nutrition-related health issues.
• Assessment aims to obtain information to identify nutrition-related issues and inform development/monitoring of intervention.
• Assessment is initiated by identification of need through screening, referral, or self-referral.
• Types of assessments include anthropometry, biochemistry, clinical judgement, dietary, environmental/behavioral and functional.
• Sources of information include medical records, interview with the client/relatives.
• Anthropometric data includes height, weight, body fat, waist circumference, and grip strength.
• Biochemistry involves laboratory data, including blood tests.
• Clinical assessment involves health history, medication history, clinical examination, family medical history and surgical procedures.
• Dietary assessment can be done using 24 hour recall or FFQ.
• Environmental and social aspects seek information on socioeconomic data, education level, accessibility and availability of food/fluid.

Step 2: Dietetic Diagnosis

• Dietetic diagnosis involves identifying nutritional problems impacting physical, mental, and/or social wellbeing.
• Dietetic diagnosis can be described as "the identification and labeling of specific nutrition problems that dietetics practitioners are responsible for treating".
• The diagnosis step may be considered the most important step in the Nutritional Diagnostic Processing.
• Critical reasoning skills are used to evaluate information and prioritize nutritional issues.
• Judgements should be made about whether the issues identified will make a difference to the health and outcomes for the service.
• Benefits of making a nutritional diagnosis include identifying nutritional issues the dietitian can influence.
• The process also supports identifying the indicators and sharing priorities, in addition to demonstrating thoroughness.
• A diagnostic statement should include the problem, its cause (aetiology), and why the dietitian considers it a problem (signs and symptoms).
• Dietetic diagnoses must focus on dietetic aspects like inadequate food intake knowledge, not medical conditions like type 2 diabetes.
• The diagnosis should focus on the nutrition problem which means the person needs a dietitian.
• Aetiology must be something able to be resolved or lessened in severity through the appropriate intervention.
• Aetiology can be malnutrition, in this case it can be decreased food intake.
• Symptoms should be linked to diagnosis.
• Symptoms must be measurable, for example a malnutrition diagnosis evidenced by an involuntary weight loss of 5 kg in the previous month.
• The aim of any dietetic intervention is to ameliorate the symptoms in the dietetic diagnosis.
• Symptoms will go on to be used in the monitoring phase of the dietetic process.
• A dietetic diagnosis should be clear, concise, meaningful, and have treatable aetiology with listed signs/symptoms.

Record Keeping

• Accurate record keeping is of utmost importance.
• All records should be accurate, systematic, and legible.
• Record keeping is regarded as part of the standards of proficiency of dietitians.
• Basis of record keeping is good communication, being a permanent record of the dietetic intervention for auditing purposes.

Step 3: Strategy

• All planned interventions need to be evidence-based and effective.
• This means achieving the predicted outcome and using the available resources wisely.
• The dietetic intervention must focus on the nutrition diagnosis.
• If the nutrition diagnosis identified a lack of knowledge on a gluten-free diat, the intervention should aim to increase knowledge.
• Dietitians need to identify goals, set timescales, describe intervention and the extent this has been achieved during monitoring.
• Outcome measurement should use the SMART principles: systematic, measurable, achievable, realistic, and timely.
• All planned interventions must be client-centered.
• Dietitians should have appropriate skills, knowledge, and competency how to reach the targets set by others in collaboration.
• Communication and evidence-based practice skills are a must.
• If malnutrition due to decreased oral intake is diagnosed, plans can include meals, snacks, supplements, feeding assistance and medication management.
• When clients are discharged, the dietitian should ensure the new entity is communicated to.

Step 4: Implementation

• Implement the stepwise plan agreed with the client.
• For plans including a bedtime snack to avoid night-time hypogylcaemic episodes, speak to carers.
• The length, frequency and duration of the intervention needs to be defined.

Step 5: Monitor and Review

• Monitoring is essential to check if the intervention is effective and meeting the SMART outcomes.
• Re-adjustment of the outcomes and planned intervention is needed for monitoring.
• Check for barriers in implementing the plan and facilitators to progress.
• Review frequency depends on nutrition intervention and outcomes achieved.

Step 6: Evaluation

• Evaluation is an important step in the auditing process and is needed for professional growth through reflective practice.
• Evaluation includes an assessment of whether the plan has been achieved and what could have been done differently.
• Audits on service for quality of care are also included.