Nutrition and Dietetic Practice

Model and Process for Nutrition and Dietetic Practice

• The primary aim of dietetic practice is to improve the nutritional health of individuals, groups, communities, or populations.
• Optimizing nutritional health can improve symptoms treatable with dietetic intervention.
• The British Dietetic Association's (BDA) Model and Process for Nutrition and Dietetic Practice was established in 2012.
• Dietitians adhere to an ethical code of conduct and professional practice in their interventions.
• Client-centered care improves outcomes and satisfaction, according to Robinson et al. in 2008.
• The Institute of Medicine defines client-centered care as respecting and responding to individual patient preferences, needs, and values in clinical decisions (2001).
• Dietitians empower clients by providing information and skills for informed decisions.
• Recognizing that clients have differing needs requires advanced communication skills to avoid a one-size-fits-all approach.
• Clients should actively participate in decisions about their dietetic care.
• The BDA's Model and Process has 6 steps (as of 2021), placing decision-making skills and the service user’s needs at the centre of the intervention.
• This process facilitates implementing a standard quality of care.

The 6 Steps of the Model and Process

• Any dietetic process begins with screening.
• Screening identifies individuals who would benefit from dietetic consultation or those at risk of health conditions.
• Positive screening results warrant further testing.
• World Diabetes Day campaigns in Valletta involve medical students screening for high blood glucose.
• Hospital admissions often include screenings for malnutrition.
• Screening for nutritional issues is not always done routinely by dietitians due to feasibility; nurses often perform this task.
• Individuals identified at nutritional risk should be referred to a dietitian for assessment.
• Nutritional assessment is required to identify and diagnose nutritional problems.
• A single consultation requires knowledge of biology, food, medicine, communication, empathy, and respect.

Step 1: Assessment

• Assessment is a systematic process of collecting, analyzing, and interpreting information to make decisions about nutrition-related health issues.
• The aims of an assessment include identifying nutrition-related problems.
• Assessment informs the development and monitoring of interventions.
• These assessments are initiated by identification of need through screening, referral, or self-referral.
• Assessment includes anthropometry, biochemistry, clinical judgement, dietary, environmental/behavioral, and functional evaluations.
• Information from medical records and interviews with clients/relatives are data sources.
• Anthropometric data includes height, weight, body fat percentage, waist circumference, and grip strength.
• Biochemistry involves laboratory data, including blood tests.
• Clinical assessment includes health, medication, family medical history, clinical examination, and surgical procedures.
• Dietary assessments can be completed using 24-hour recall and food frequency questionnaires (FFQ).
• Environmental and social aspects involve gathering information on socioeconomic data, education level, and accessibility/availability of food/fluid.

Step 2: Dietetic Diagnosis

• Dietetic diagnosis involves identifying nutritional problems that affect physical, mental, and/or social well-being.
• It labels specific nutrition problems that dietetics practitioners independently treat.
• Diagnosis is a critical step in the Nutrition and Dietetics Practice (NDP).
• Dietitians use critical reasoning skills to evaluate assessment information when making a diagnosis.
• They prioritize nutritional issues and determine if addressing them will improve the service user's health and outcomes.
• Benefits include identifying specific nutritional issues the dietitian can influence.
• Benefits include sharing nutritional priorities with other professionals.
• Benefits include identifying assessment indicators for monitoring and evaluation.
• Benefits include demonstrating thoroughness in assessment through communicating with other professionals.

Diagnostic Statements

• The diagnostic statement needs to include the problem (dietetic diagnosis).
• It needs to include the cause (aetiology).
• It needs to include why the dietitian considers it a problem (signs and symptoms).
• Dietetic diagnosis goes further than only identifying a medical condition.
• Emphasis should be placed on the dietetic aspect, such as inadequate knowledge of appropriate food intake to control diabetes or inadequate oral intake.
• The diagnosis should focus on nutrition problems that prompted the dietitian's involvement.
• Aetiology is linked to the diagnosis, such as identifying what is causing malnutrition.
• The aetiology must be something that can be resolved or lessened through intervention.
• Aetiology of malnutrition may be decreased food intake.
• The final step is identifying related symptoms, which must be linked to the diagnosis.
• Malnutrition due to lack of food intake, evidenced by involuntary weight loss of 5 kg in the previous month, is given as an example.
• The symptoms need to be specific and measurable.
• The aim of any dietetic intervention is to improve the symptoms identified.
• These symptoms will be used in the monitoring phase.
• Any dietetic diagnosis should be clear, concise, and meaningful to other healthcare professionals.
• Its aetiology should be treatable through dietetic intervention, and its signs and symptoms need to be listed.

Record Keeping

• Accurate record keeping is important.
• All records should be accurate, systematic, and legible.
• Record keeping is part of the standards of proficiency for dietitians.
• It serves as the basis of good communication between professionals.
• It provides a permanent record of the dietetic intervention.
• Records are also used for auditing purposes.

Step 3: Strategy

• Every planned intervention needs to be evidence-based and effective, achieving predicted outcomes while effectively using available resources.
• The dietetic intervention must focus on the nutrition diagnosis.
• For example, if the nutrition diagnosis identified lack of knowledge on a gluten-free diet, the aim is to increase that knowledge.
• The dietitian needs the ability to identify the intervention outcome with goal setting.
• They need to set the timescale to achieve the goals.
• Strategies need to be identified, such as leaflets or motivational interviewing.
• Monitoring is for determining the extent of goals being achieved.
• Outcome measurement should use SMART principles (systematic, measurable, achievable, realistic, timely).
• Interventions must be client-centered.
• The dietitian should have the appropriate skills, knowledge, and competency to reach the targets set.
• Collaboration with others should be implemented as needed.
• Good communication skills are required.
• Evidence-based practice is essential.
• If malnutrition is the diagnosis as a result of a decreased oral intake, the plan can include meals and snacks, supplements, feeding assistance and environment modifications, and medication management.
• If a client is discharged from the care institution, the dietetic plan should be given to the new entity.

Step 4: Implementation

• Step 4 involves implementing the stepwise plan agreed upon with the client.
• If the plan involves a bedtime snack to avoid hypoglycemic episodes, the dietitian needs to communicate with the carers to ensure the delivery and consumption of the snack.
• The length, frequency, and duration of intervention need to be defined.

Step 5: Monitoring and Review

• Monitoring is essential to ensure the intervention is effective and achieves SMART outcomes.
• Monitoring is needed to readjust outcomes and the planned intervention.
• The plan needs to be checked for barriers and facilitators to progress.
• The frequency of review depends on the nutrition intervention and outcomes being achieved.

Step 6: Evaluation

• Evaluation is important for auditing purposes.
• The evaluation is needed for professional growth and reflective practice.
• The evaluation involves determining whether the intervention plan has been achieved.
• The evaluation is to identify what could have been done differently.
• It also includes audits on service for quality of care.