What is a Nutrition Diagnosis?
A nutrition diagnosis is a nutrition problem that the Registered Dietitian Nutritionist (RDN) identifies and is responsible for treating. A nutrition diagnosis is part of the Nutrition Care Process (NCP), which is a standardized approach to providing nutrition care. Nutrition diagnoses are written as PES statements using nutrition diagnostic terminology.
Nutrition Diagnoses within the Nutrition Care Process
The NCP has four steps, which include:
- Nutrition assessment
- Diagnosis
- Intervention
- Monitoring/evaluation
After a nutrition assessment or reassessment is completed, the RDN can identify and label one or more nutrition problems that they are responsible for treating. This is the nutrition diagnosis. These nutrition-related problems can then be resolved or improved through the third step of the Nutrition Care Process which is the intervention.
Differences Between a Nutrition Diagnosis and Medical Diagnosis
Dietitians cannot diagnose patients with medical conditions, as this is outside our scope of practice. Nutrition diagnoses and medical diagnoses are quite different.
A nutrition diagnosis is created by a dietitian to describe a nutrition-related issue. It can generally be resolved, or at least improved, through a nutrition intervention provided by the nutrition professional.
A medical diagnosis is generally made by a physician to describe the pathology of a medical condition or disease.
Let’s use the disease state of diabetes as an example. Diabetes is the medical diagnosis provided by the physician. The RDN may identify several nutrition diagnoses such as excessive oral intake, food and nutrition related knowledge deficit, or inconsistent carbohydrate intake.
Standardized Language Using Nutrition Diagnostic Terminology
ICD-10 is the current standardized language used for medical diagnoses. A physician may write “diabetes” in a medical chart, but a corresponding ICD-10 code, such as E11.9, will also generally be documented somewhere in the patient’s chart.
These codes have a corresponding medical diagnosis that uses standardized language. For example, the ICD-10 code E11.9 is described as type 2 diabetes mellitus without complications.
Using this standardized language makes sure that there is a universal way of communicating, so things like billing and collecting data is much easier and streamlined.
Similarly, dietitians also have a standardized language for nutrition diagnoses, called nutrition diagnostic terminology. While the alpha or numeric codes associated with the terminology aren’t documented in the patient’s chart, a specific and concise language is used.
Four Domains of Nutrition Diagnostic Terminology
There is a large number of potential nutrition diagnoses, and they are classified into four different domains:
- Intake
- Clinical nutrition
- Behavioral-environmental
- Nutrition situation
Intake Domain
This set of nutrition diagnoses are related to the intake of energy, nutrients or fluids through either the oral diet, enteral nutrition or parenteral nutrition. These are based on either estimated or actual intake compared to goal levels.
The intake domain is further broken down into subdomains, or classes. Examples of these include energy balance, oral or nutrition support intake, protein intake and mineral intake.
Clinical Nutrition Domain
The clinical nutrition diagnoses are related to medical or physical conditions. Some of the subclasses of this domain include functional, biochemical, weight and malnutrition.
Behavioral-Environmental Domain
The Behavioral-Environmental domain includes nutritional problems related to knowledge, attitudes, beliefs, access to food and the patient’s physical environment. The subclasses of the behavioral-environmental domain include knowledge and beliefs, physical activity and function, and finally food safety and access.
Nutrition Situation Domain
The nutrition situation domain includes just one nutrition diagnosis, which is “no nutrition diagnosis at this time.” This is to be used when there is no nutrition problem identified.
The Academy of Nutrition and Dietetics (AND) does specify that this diagnosis should not be used if additional information is still pending for the nutrition assessment.
Example Nutrition Diagnoses
While there is a very long list of potential nutrition diagnoses, here are some examples for the different domains:
Intake domain examples:
- Excessive energy intake
- Inadequate enteral nutrition infusion
- Inadequate fluid intake
- Excessive alcohol intake
- Increased nutrient needs
- Inadequate fiber intake
- Inadequate intake of calcium
- Excessive intake of sodium
Clinical domain examples:
- Swallowing difficulty
- Underweight
- Obesity Class III
- Unintended weight gain
- Growth rate below expected
- Severe acute disease or injury related malnutrition
- Mild non illness related pediatric malnutrition
Behavioral-environmental domain examples:
- Food and nutrition related knowledge deficit
- Self monitoring deficit
- Limited ability to prepare food for eating
- Food insecurity
- Limited access to nutrition related supplies
Nutrition situation diagnosis:
- No nutrition diagnosis at this time
How to Obtain the Nutrition Diagnostic Terminology
In order to obtain the complete list of nutrition diagnosis terminology, it must be purchased. Originally, this list was available in printed form, called the International Dietetics & Nutrition Terminology (IDNT) Reference Manual. Several editions of this manual were printed before it went exclusively online.
Now, a subscription to the Electronic Nutrition Care Process Terminology (eNCPT) website must be purchased. The current annual price for an individual AND member is $50 and $100 for non-members. There are also student, organization, educator and developer subscriptions with various pricing available.
Communicating the Nutrition Diagnosis with a PES Statement
After one or more nutrition diagnoses are identified, the work is not done! Now the diagnosis needs to be communicated alongside the etiology and supporting signs and symptoms. This is done by creating what is known as a PES statement, also known as a nutrition diagnosis statement.
How to Write a PES Statement
PES statements are written in the following format:
[Problem/nutrition diagnosis] related to [Etiology], as evidenced by [Signs/symptoms].
Let’s break this down by each section:
Problem/Nutrition Diagnosis
The P in PES is the nutrition diagnosis chosen from the nutrition diagnostic terminology list. For example, excessive sodium intake.
Etiology
The etiology is the “root cause” or contributing risk factors for the nutrition problem. The etiology could be related to a wide variety of factors including the patient’s cultural values, beliefs, medical condition, physical or cognitive function, medical or surgical treatment, or social history.
A potential etiology for excessive sodium intake could be reliance on convenience and fast foods.
Signs/Symptoms
The last step of writing the PES statement is the signs/symptoms. These are the defining characteristics collected in the assessment step used to determine the nutrition diagnosis.
The signs and symptoms could be from a variety of sources, such as the medical record, your interview of the patient, or from a Nutrition Focused Physical Exam.
You may list several signs and symptoms. They should be specific enough to monitor in the last step of the Nutrition Care Process, which is monitoring/evaluation.
Here’s an example of a complete PES statement, including signs/symptoms:
Excessive sodium intake related to reliance on convenience and fast foods as evidenced by an average intake of 4343 mg sodium daily, ankle edema and elevated blood pressure readings.
Tips for Writing PES Statements
- Use information gathered in the assessment to determine the nutrition problem
- Use critical thinking to make inferences
- The nutrition diagnosis can ideally be resolved, or at least improved, through a nutrition intervention provided by the dietitian
- Choose nutrition diagnoses from the intake domain over other domains, as these are the most likely to be resolved by the dietitian through a nutrition intervention
- PES statements should be clear and concise
- Keep PES statements to three or less for a patient
- Feel free to not write complete and proper sentences by leaving out words such as “and” and “the”
Summary
A nutrition diagnosis is a formal, standardized way for an RDN to communicate the nutrition problem identified. This is done by writing a PES statement. The nutrition diagnosis is then addressed by the nutrition intervention and then monitored and evaluated as appropriate.
Note that the 2023 edition of the Nutrition Care Process Terminology (eNCP) is used, which is the most current version at the time of this article being published.
Resources:
Electronic Nutrition Care Process Terminology (eNCPT)
The Nutrition Care Process and Model – FAQs
RDN’s Complete Guide to Credentialing and Billing: The Private Payer Market