American Dietetic Association’s Standardized Nutrition Language: Current Status

Introduction
Evidence-based dietetic practice relies on concise, consistent, and standardized
terminology to create and retrieve digital sources of evidence. This is essential for
documenting nutrition diagnoses, interventions and outcomes in electronic health records.
A task force of the American Dietetic Association (ADA) has begun to refine and
disseminate standardized nutrition language. The language is built on the Nutrition Care
Process and Model that maps quality nutrition care and outcomes, and recognizes several
existing terminologies used by other health professions. This paper will describe the logic
model for the development of the standardized nutrition language, the Nutrition Care
Process it is built upon, and its current status.

The project goal is to support nutrition practice, education, research, and policy with data.
It is assumed that practicing dietitians, educators, and researchers will use the
standardized nutrition language to document care, aggregate data, and study the
evidence. Standardized terminology will provide the foundation for developing a national
dietitian care database.

The Nutrition Care Process

The ADA Nutrition Care Model workgroup published the Nutrition Care Process (NCP) and
Model in August 2003.2 It provides a definition of the NCP and describes its steps and
framework. The NCP is “a systematic problem-solving method that dietetics professionals
use to critically think and make decisions to address nutrition related problems and provide
safe and effective quality nutrition care.”. The four steps of the NCP, similar to those of
other clinical professions, are: (a) Nutrition Assessment, (b) Nutrition Diagnosis, (c)
Nutrition Intervention, and (d) Nutrition Monitoring and Evaluation. Allowing for the reality
of an iterative and comprehensive clinical process, the NCP is not linear and it includes,
but is not limited to, Medical Nutrition Therapy. Medical Nutrition Therapy is “nutritional
diagnostic, therapy, and counseling services for the purpose of disease management,
which are furnished by a registered dietitian or nutrition professional.”3 The context of the
NCP and surrounding influences are captured in the Model framework.

Standardized terms are being developed for each step of the NCP. 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 Nutrition
Assessment includes signs and symptoms.
Nutrition Diagnosis 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.”

Nutrition Interventions are “purposely 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.”

Interventions are directed to influence the etiology or effects of a diagnosis. Nutrition

Monitoring is “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.” Evaluation is “the systematic comparison of current findings
with previous status, intervention goals, or a reference standard.” Evaluation may measure
changes in signs and symptoms. The NCP steps guide the delivery of nutrition health
services, education, and research and define categories for documentation of nutrition
care.

Development: Comparison with Nursing

In comparison with the development of various nursing terminologies, the ADA nutrition
language development has been much more rapid and centralized, due perhaps to
comparatively smaller numbers of nutrition professionals and growing sophistication in
information technology. Nursing terminology work began in the 1970s, including the North
American Nursing Diagnosis Association (NANDA)4 terminology, the Clinical Care
Classification (CCC),5 and others. NANDA is specific to nursing diagnoses, while the CCC
addresses diagnoses, interventions, and outcomes.

The Nursing Minimum Data Set, which includes patient information, nursing diagnoses,
nursing interventions, nursing outcomes, intensity level of nursing care, and a unique
provider number, is an overarching framework for the various discrete nursing
terminologies, similar to the NCP.

Why Does Dietetics Practice Need a Standardized Language?

There is currently no agreed upon mechanism by which dietetics professionals can
communicate with each other or other health care professionals. Because of this lack of
agreement, there is no easy way to classify, measure, and report on the outcomes of
nutrition interventions in various patient populations.

The Nutrition Care Process includes nutrition diagnosis and nutrition intervention as
unique steps that provide registered dietitians a mechanism to consistently document and
communicate the work of dietetics. There is currently no agreed upon terminology used in
dietetics practice which makes it impossible to gather and aggregate data needed for
research, education, and reimbursement justification via outcomes analysis.

Logic Model
A Logic Model is a simplified picture that describes the logical relationships among the
resources invested, the activities that take place, and the benefits to be realized from the
project and the environment in which the system/project occurs.

With the help of an informatics consultant, the Standardized Language Task Force
adopted a Project Logic Model that identifies the expected outcomes and impact of the
Standardized Language of Dietetics. The goal of the dietetics terminology was seen to be
"To provide data to foster nutrition practice, education, research, and policy.”

Three time frames for evaluating the impact of the standardized language were agreed
upon. The most immediate impacts were thought to include recommendations for
coordination with existing terminologies, review of the structure of the dietetics
terminology, to "cross-walk" the new terminology with existing terminologies to see if
overlap exists, to review existing intervention terms, and to identify relevant policy issues
regarding standardized nutrition language. Intermediate impacts were thought to include
selection of a structure for the nutrition diagnostic labels, cross-walk of the intervention
terms, to plan for generation of nutrition outcomes measures, create strategies for ongoing
maintenance and updates of the language, to design and implement pilot testing of the
standardized language, and to draft legislative and policy agendas.
The ultimate impact was agreed to include delivery of quality, cost-effective nutrition care,
national growth of nutrition care, inclusion of the standardized language in dietetics
education and research, development of a national data warehouse for nutrition research,
and support of policies designed to foster nutrition practice, education, and research.

Several assumptions were necessary in development of this logic model. The Task Force
was in agreement that nutrition is an essential component of high quality health care.
There was heightened awareness of the need for data to document the processes and
outcomes of nutrition care in a variety of settings. It was also assumed that educators,
practicing dietitians, and researchers would accept and implement the standardized
language and would be willing to share data using the terminology for targeted studies and
ultimately a national database.

Nutrition Diagnostic Labels

To date, over 60 Nutrition Diagnostic Labels have been defined by ADA work with focus
groups, domain experts, and membership committees.

Standardized Language Task Force members judged the match between nutrition
diagnoses terms and similar terms listed in the National Library of Medicine’s Unified
Medical Language System (UMLS); many terms have synonyms. One of the robust
terminologies in the UMLS is SNOMED-CT. Staff from SNOMED-CT were contacted to
discuss the process of submitting nutrition terms.

The Nutrition Diagnostic Labels include 3 domains: Clinical, Behavioral-Environmental,

and Intake. The domains, sub-classes, and specific diagnoses are defined in the most
recent version, a summary of which follows.

DOMAIN: INTAKE

Defined as “actual problems related to intake of energy, nutrients, fluids, bioactive

substances through oral diet or nutrition support (enteral or parenteral nutrition)”
Class: Caloric Energy Balance

Defined as “actual or estimated changes in energy (kcal)”

Class: Oral or Nutrition Support Intake

Defined as “actual or estimated food and beverage intake from oral diet or nutrition support
compared with patient goal”
Class: Fluid Intake Balance

Defined as “actual or estimated fluid intake compared with patient goal”

Class: Bioactive Substances Balance

Defined as “actual or observed intake of bioactive substances, including single or multiple

functional food components, ingredients, dietary supplements, alcohol”
Class: Nutrient Balance

Defined as “actual or estimated intake of specific nutrient groups or single nutrients as

compared with desired levels”
Sub-Class: Fat and Cholesterol Balance
Sub-Class: Protein Balance
Sub-Class: Carbohydrate and Fiber Balance
Sub-Class: Vitamin Balance
Sub-Class: Mineral Balance

DOMAIN: CLINICAL

Defined as “nutritional findings/problems identified that relate to medical or physical

conditions”
Class: Functional Balance

Defined as “change in physical or mechanical functioning that interferes with or prevents

desired nutritional consequences”
Class: Biochemical Balance

Defined as “change in capacity to metabolize nutrients as a result of medications, surgery,

or as indicated by altered lab values”
Class: Weight Balance

Defined as “chronic weight or changed weight status when compared with usual or desired
body weight”

DOMAIN: BEHAVIORALENVIRONMENTAL

Defined as “nutritional findings/problems identified that relate to knowledge,

attitudes/beliefs, physical environment, or access to food and food safety”
Class: Knowledge and Beliefs

Defined as “actual knowledge and beliefs as reported, observed, or documented”

Class: Physical Activity Balance and Function

Defined as “actual physical activity, self-care, and quality of life problems as reported,
observed or documented”
Class: Food Safety and Access

Defined as “actual problems with food access or food safety” © ADA

Problem-Etiology-Signs/Symptoms Statements
A Nutrition Diagnosis is best written as a PES statement pertaining to one patient/client or
group, specific to one problem (P) and one etiology (E), and based on assessment of
signs and symptoms (S). Implementation of PES statements in clinical practice is being
tested in two pilot studies by ADA members. Examples of PES statements are (a)
“Overweight/obesity (problem) related to continued intake of high fat foods (etiology)
resulting in ~300 extra kcal/day as evidenced by a BMI of 30 (sign/symptom), and (b)
Impaired ability to prepare foods/meals (problem) related to fatigue (etiology) as evidenced
by patient/client only consuming one meal per day.” Interventions are often guided by the
etiology of each problem. Signs and symptoms may provide measures to evaluate
outcomes and the effectiveness of care. It is possible that the standardized terms for
assessments will be considered relevant outcome measures.

Nutrition Interventions
Following principles for standardized terminologies,9 the ADA has begun to identify and
define Nutrition Intervention terms. A Task Force meeting in February 2005 identified
categories of interventions including: Treatments/Procedures, Education, Counseling, and
Referral/Coordination.

These categories are similar to those in nursing terminologies but differing by not including
monitoring/assessment as an intervention, which is a separate step in the Nutrition Care
Process. Synonyms to the intervention terms will be searched in the UMLS and domain
experts will judge the extent of the matches. The Nutrition Intervention Labels will be
submitted SNOMED-CT or other existing coding system that will be included in the UMLS.

Future Work
Definition of Nutrition Assessment terms and their relationship with Outcome terms is
planned. In addition, activities to communicate the standardized language to educators,
administrators, clinicians, and researchers are planned. The ADA believes that consistent
standardized terminology will improve patient care by enhancing the education, practice,
and research of nutrition professionals. The use of standardized nutrition language by
nutrition professionals in the United States is in synch with similar international efforts.

Introduction to Nutrition Diagnoses/Problems: The New Component of the Nutrition

Care Process Introduction

The ADA has embarked on an extensive project to identify and define nutrition
diagnoses/problems for the profession of dietetics. This standardized language of nutrition
diagnoses/problems is an integral component in the Nutrition Care Process, a process
designed to improve the consistency and quality of individualized patient/client care and
the predictability of the patient/client outcomes. In fact, several other allied professional,
including nursing, physical therapy, and occupational therapy, utilize defined care
processes (1).

Not only will creating this standard language help dietetic professionals better document
their nutrition care, it will serve to help achieve Association strategic goals of promoting
demand for dietetic professionals and help them be more competitive in the market place.
It will also provide a minimum data set and common data elements for future research that
includes services of dietetic professionals.

ADA’s Standardized Language Task Force developed a conceptual framework for the
standardized nutrition language and identified the nutrition diagnoses/problems. The
framework outlines the domains within which the diagnoses/problems would fall and the
flow of the nutrition care process in relation to the continuum of health, disease and
disability. Sixty-two diagnoses/problems have been identified. A worksheet has been
developed for each diagnosis/problem and expert has been incorporated.

The methodology for developing sets of terms such as these includes systematically
collecting data from multiple sources simultaneously. We collected data from a selected
group of dietitians prior to starting the project (from recognized ADA leaders and award
winners), from the 12 member task force during the development, from several small
group discussions (community, ambulatory, acute care, and long term care), and from
expert researcher reviewers.
The methodology for continued development and refinement of these terms has been
identified.

As with the ongoing updating of the American Medical Association Current Procedural
Terminology (CPT) codes, these will also be published on an annual basis. The process to
submit your suggested changes is included in this packet. In addition, the terms have been
included in one ongoing research project in an ambulatory setting. A second descriptive
research study identifying the use of the terms will be planned and conducted through the
Dietetics Practice Based Research Network in 2005-2006. As each of the research studies
is completed, their findings will be incorporated into future versions of these terms. Future
iterations and changes to the diagnoses/problems and the worksheets are expected as
this standard language evolves. Once the initial research is completed we will formally
submit these terms to become part of nationally recognized health care databases. We
have already begun the dialogue with these groups to let them know the direction that we
are headed and to keep them appraised of our progress.

Nutrition Care Process and Nutrition Diagnosis

ADA’s new nutrition care process for the profession has four steps—nutrition assessment,
nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation (1).
Textbooks often describe nutrition assessment in detail and then move directly into
intervention or therapy. Nutrition diagnosis is a critical step between assessment and
intervention. The nutrition diagnosis is the identification and labeling of the specific
nutrition problem that dietetics professionals are responsible for treating independently.
Naming the nutrition diagnosis provides a way to document the link between nutrition
assessment and nutrition intervention and set realistic and measurable expected
outcomes for each patient/client. Identifying the diagnosis also assists practitioners in
establishing priorities when planning an individual patient/client’s nutrition care.
Nutrition diagnosis differs from medical diagnosis. Medical diagnosis is a disease or
pathology of specific organs or body systems (e.g., diabetes) and does not change as long
as the condition exists. A nutrition diagnosis may be temporary, altering as the
patient/client’s response changes (e.g., excessive carbohydrate intake).

Categorization of the Nutrition Diagnoses

The sixty-two nutrition diagnoses/problems have been given labels that are clustered into
three domains: intake, clinical, and behavioral-environmental. Each domain represents
unique characteristics that contribute to nutritional health. Within each domain are classes
and, in some cases, sub-classes of diagnoses. A definition of each follows:
The Intake domain lists actual problems related to intake of energy, nutrients, fluids,
bioactive substances through oral diet, or nutrition support (enteral or parenteral nutrition.)

Class: Caloric Energy Balance (1)—Actual or estimated changes in energy (kcal).

Class: Oral or Nutrition Support Intake (2)—Actual or estimated food and beverage intake from oral
diet or nutrition support compared with patient/client’s goal.
Class: Fluid Intake Balance (3)—Actual or estimated fluid intake compared with patient/client’s goal.
Class: Bioactive Substances Balance (4)—Actual or observed intake of bioactive substances,
including single or multiple functional food components, ingredients, dietary supplements, and
alcohol.
Class: Nutrient Balance (5)—Actual or estimated intake of specific nutrient groups or single
nutrients as compared with desired levels.
Sub-Class: Fat and Cholesterol Balance (51)
Sub-Class: Protein Balance (52)
Sub-Class: Carbohydrate and Fiber Balance (53)
Sub-Class: Vitamin Balance (54)
Sub-Class: Mineral Balance (55)

The Clinical domain is nutritional findings/problems identified that relate to medical

or physical conditions.

Class: Functional Balance (1)—Change in physical or mechanical function that interferes with or
prevents desired nutritional consequences.
Class: Biochemical Balance (2)—Change in the capacity to metabolize nutrients as a result of
medications, surgery, or as indicated by altered lab values.
Class: Weight Balance (3)—Chronic weight or changed weight status when compared with usual or
desired body weight.

The Behavioral-Environmental domain includes nutritional findings/problems identified

that relate to knowledge, attitudes/beliefs, physical environment, access to food, and food
safety.

Class: Knowledge and Beliefs (1)—Actual knowledge and beliefs as reported, observed, or
documented.
Class: Physical Activity Balance and Function (2)—Actual physical activity, self-care, and quality of
life problems as reported, observed, or documented.
Class: Food Safety and Access (3)—Actual problems with food access or food safety.

Examples of nutrition diagnoses and their definitions include:

INTAKE DOMAIN
� Caloric Energy Balance
Inadequate energy intake NI-1.4 Energy intake that is less than energy expenditure or
recommended levels. Exception: when the goal is for the client to lose weight or during end of life
care.
CLINICAL DOMAIN
� Functional Balance Swallowing difficulty NC-1.1 Impaired movement of food and liquid from the
mouth to the stomach.
BEHAVIORAL-ENVIRONMENTAL DOMAIN
� Knowledge and Beliefs
Not ready for diet/lifestyle change NB-1.3
Lack of perceived value of nutrition-related care benefits compared to consequences or effort
required to making the change; inconsistencies with other value structure/purpose; antecedent to
behavior change.

Nutrition Diagnosis Statements (or PES)

Whenever possible, a nutrition diagnosis statement is written in the PES format that states
the problem (P), the etiology (E), and the signs/symptoms (S).
Examples
� Swallowing difficulty (problem) related to stroke (etiology) as evidenced by coughing
following drinking of thin liquids (sign/symptoms).
� Inadequate energy intake (problem) related to lack of financial resources to purchase
sufficient food (etiology) as evidenced by weight loss of 6 pounds in the last 2 months
(signs/symptoms).

Nutrition Diagnosis Worksheet

A worksheet has been developed for each diagnosis. It contains four distinct components:
nutrition diagnosis label, definition of nutrition diagnosis label, etiology, and
signs/symptoms.
These worksheets will assist practitioners with consistently and correctly utilizing the
nutrition diagnoses. Below is a description of the four components of the worksheet.

The Problem or Nutrition Diagnosis Label describes alterations in the patient/client’s nutrition
status that dietetics professionals are responsible for treating independently. Nutrition diagnosis
differs from medical diagnosis in that a nutrition diagnosis changes as the patient/client response
changes. The medical diagnosis does not change as long as the disease or condition exists. A
nutrition diagnosis allows the dietetics professional to identify realistic and measurable outcomes,
formulate interventions, and monitor and evaluate change.
The Definition of Nutrition Diagnosis Label briefly describes the Nutrition Diagnosis Label to
differentiate a discrete problem area.
The Etiology (Cause/Contributing Risk Factors) are those factors contributing to the existence
of, or maintenance of pathophysiological, psychosocial, situational, developmental, cultural, and/or
environmental problems. It is linked to the diagnosis label by the words “related to.”
The Signs/Symptoms (Defining Characteristics) consist of subjective and/or objective data used
to determine whether the patient/client has the nutrition diagnosis specified. These are the signs
and symptoms gathered through nutrition assessment. It is linked to the etiology by the words “as
evidenced by.”

Organization of Data in Signs/Symptoms (Defining Characteristics) Dietetics professionals

use clinical judgment to determine the nutrition diagnosis based on data collected from the
first step of the nutrition care process: nutrition assessment. Therefore, the items listed in
the signs/symptoms (defining characteristics) are organized according to nutrition
assessment category.

Nutrition assessment is the systematic process for obtaining, verifying, and interpreting
data needed to make decisions about the nature and cause of the nutrition-related
problem. The process of nutrition assessment consists of collecting biochemical data,
anthropometric measurements, physical examination findings, food/nutrition history, and
client history. On the nutrition diagnosis worksheet, the signs/symptoms are classified by
nutrition assessment categories.

Biochemical Data include laboratory data, for example, electrolytes, glucose, hemoglobin A1C,
thyroid, and lipid panel.
Anthropometric Measurements include, for instance, height, weight, body mass index (BMI),
growth rate, and rate of weight change.
Nutrition-Focused Physical Examination includes oral health, general physical appearance,
muscle and subcutaneous fat wasting, and affect.
Food and Nutrition History consists of four areas: Food consumption, nutrition and health
awareness and management, physical activity and exercise, and food availability.
Food consumption may include factors such as, food and nutrient intake, meal and snack patterns,
environmental cues to eating, and current diets and/or food modifications.
Nutrition and health awareness and management includes, for example, knowledge and beliefs
about nutrition recommendations, self-monitoring/management practices, and past nutrition
counseling and education.
Physical activity and exercise consists of activity patterns, amount of sedentary time (e.g., TV,
phone, computer), and exercise intensity, frequency, and duration.
Food availability encompasses factors such as, food planning, purchasing, preparation abilities and
limitations, food safety practices, food/nutrition program utilization, and food insecurity.
Client History consists of four areas: Medication and supplement history, social history,
medical/health history, and personal history.
Medication and supplement history includes, for instance, prescription and over the
counter drugs, herbal and dietary supplements, and illegal drugs.
Social history may include such items as socioeconomic status, social and medical
support, cultural and religious beliefs, housing situation, and social isolation/connection.
Medical/health history includes chief nutrition complaint, present/past illness, disease or
complication risk, family medical history, mental/emotional health, and cognitive abilities.
Personal history consists of factors including age, occupation, role in family, and education
level.

Summary
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.