IDNT and the Nutrition Care Process: PART 3-PES Statements

Welcome to Part 3 of my journey through the of IDNT and the Nutrition Care Process. I hope you enjoyed Part 1 Nutrition Assessment and Part 2 Nutrition Diagnosis.

The Nutrition Care Process is the systematic approach to providing high-quality nutrition care developed the Academy of Nutrition & Dietetics. Kalix’s electronic documentation feature was built on the back of the nutrition care process. Electronic documentation systems like Kalix make charting a lot quicker. They can even limit the need to learn and memorize standardized terminology.


So it is time to delve deeper into the PES Statement.

What is a PES Statement?

When discussing any topic, I like to start with a definition. Definitions help to check that we’re all on the same page before progressing further. So here goes… A PES statement (or Nutrition Diagnosis Statement) is a structured sentence that describes the specific nutrition problem that you (the dietitian) is responsible for treating and working toward resolving, the cause/s of the problem and the evidence that this problem exists.

Hence 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:

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).

Excessive intake

An Example

Excessive energy intake, related to limited access to healthful food choices (healthful food choices not provided as an option by carer), as evidenced by estimated intake of energy (9 500kJ/day) is in excess of estimated energy needs (7 500kJ/day) and BMI equals 45kg/m2.

Lets look at its parts:

The Problem (P)  (Nutrition Diagnosis): is excessive energy intake (NI-1.3). This is the specific nutrition problem that the Nutrition Intervention aims to treat and resolve.

related to

The Etiology (E) (the cause/s of the nutrition problem/Nutrition Diagnosis): is that the client has limited access to healthful food choices. The carer provides the client’s meals.  Healthful (e.g., adequate amounts of fresh fruit and vegetables) food choices are not provided as an option by the carer. 

as evidenced by

The Signs and Symptoms (S) (the evidence that the nutrition problem (or Nutrition Diagnosis) exists:  the client’s estimated intake of energy (9 500kJ/day) is in excess of his estimated energy needs (7 500kJ/day). The client’s BMI equals 45kg/m2 (obesity class III).

Now lets discuss each component of the PES statement.

The Problem (P)– the Nutrition Diagnosis

I discussed the Nutrition Diagnosis in my previous post, it’s worth a read for a quick refresher. Let’s start with a definition again:

The Nutrition Diagnosis, identifies the specific nutrition problem that the dietitian is responsible for treating and works towards resolving. 

The Nutrition Diagnosis comes from specific terminology found in eNCPT (previously the IDNT Reference Manual) .

The Nutrition Diagnosis terms are classified into three categories:

Intake: these diagnosis relate to intake and nutrition related problems (oral, enteral and parenteral nutrition). Intake diagnosis cover the areas including energy balance, fluid intake, bioactive substances and nutrient intake.

Examples: excessive energy intake, less than optimal intake of types of carbohydrate, inadequate calcium intake. 

Clinical: these diagnosis include medical or physical conditions that have a nutritional impact. The clinical category covers the areas of functional changes or impairments, biochemical changes (altered ability to metabolize nutrients) and weight. 

Examples: altered GI function, impaired nutrient utilization, overweight/obesity.  

Behavioral-Environmental: this category 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).

Examples:  undesirable food choices,  physical inactivity and limited access to food or water.

As a general rule (as with most rules there are exceptions) choose from Intake related Nutrition Diagnosis first, Clinical related Nutrition Diagnosis second and Behavioral-Environmental last.

Diagnosis should be specific to the role of dietitians. Behavioral-Environmental related Nutrition Diagnosis often fit better as the etiology (E) (the cause of the nutrition problem), and not the Nutrition Diagnosis itself. Remember the aim of your Nutrition Intervention is to resolve (ideally) the Nutrition Diagnosis.

Make sure you check that your Nutrition Diagnosis is something that you as a dietitian can resolve (ideally) or improve. Some of the Behavioral-Environmental related Nutrition Diagnosis can be a bit tricky for a dietitian to solve.

How to choose the correct Nutrition Diagnosis

There are no right or wrong diagnosis choice (truly). Some choices may be better than others. Things to consider include:

  1. Is it a nutrition based diagnosis, not a medical diagnosis (e.g., increased nutrient needs v.s. altered GI function)?
  2. Is it the nutrition problem what your intervention aims to solve? Even though the client may have a particular nutrition problem e.g., inadequate fiber, if your intervention is not focused on increasing fiber intake i.e., your nutrition goals are around reducing saturated fat intake, leave that diagnosis for another time.  
  3. Can Nutrition Diagnosis be resolved (ideally) or improved?
  4. Is the Nutrition Diagnosis specific to the role of the dietitian (i.e., something you as a dietitian is responsible for resolving)? For example Altered nutrition related laboratory values vs. Excessive carbohydrate intake.
  5. Does your Nutrition Assessment data support the Nutrition Diagnosis?

Nutrition care Process

The Etiology (E) -the cause/s of the nutrition problem/Nutrition Diagnosis

The ‘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).

Hence the Etiology in a PES Statement describes the cause of the nutrition problem (Nutrition Diagnosis). The Nutrition Intervention should be aimed at resolving the underlying cause of the nutrition problem (the Etiology).

The etiology in a PES Statement is free text. The eNCP includes some examples of etiologies for Nutrition Diagnosis terminology as well as the online Etiology Matrix These resources are very useful, however, they are examples only. It’s an important skill for a dietitian to is able to identify the root cause of a client’s nutrition problem.   

Etiology are also grouped into categories based on the type of cause or contributing risk. Below is the list of categories with an example etiology for each. I have not listed the related Nutrition Diagnosis, why not try to list them yourself?

  • Access: e.g. community and geographical constraints (client lives in rural area with limited access to public transport).
  • Behavior e.g. unwilling or disinterested in tracking progress.
  • Beliefs–Attitudes Etiologies e.g. perception that time and financial constraints prevent dietary changes. 
  • Cultural: e.g. the practice of Ramadan prevents the intake of regular meals.
  • Knowledge: e.g. food- and nutrition-related knowledge deficit concerning appropriate fluid intake.
  • Physical: e.g. lack of self-feeding ability
  • Physiologic–Metabolic: e.g. altering fatty acid needs due to  chyle fluid leak.
  • Psychological: e.g. binge eating behaviors associated with a diagnosed anxiety disorder.
  • Social–Personal: e.g. lack of social and family support for implementing dietary modifications.
  • Treatment:  e.g. reduced appetite associated with the use of  Ritalin.

How to choose the correct Etiology

Again there is no incorrect choice when deciding between Nutrition Diagnosis Etiology. Remember: use your critical thinking skills to identify the root cause.

  1. The Etiology is the “root cause” of the nutrition problem (Nutrition Diagnosis).
  2. The Nutrition Intervention, should aim to resolve the Etiology (ideally).
  3. The Etiology is supported by the nutrition assessment data.**

Identifying the root cause

A colleague of mine suggests a very good trick for finding the root cause for a particular Nutrition Diagnosis.  When looking for an etiology, ask WHY 5 times (or until you come to the last etiology, that you as a dietitian can address).

For example:

Excessive oral intake

Why?  Excessive intake of high calorie-density foods and beverages.

Why? Excessive take away food intake.

Why? Client purchases most of his meals from fast food restaurants with limited healthful choices.

Why? The client does not prepare meals at home.

Why?  The client lacks the food preparation skills to prepare healthful food at home –root cause.

Signs and Symptoms (S) -evidence that the nutrition problem (Nutrition Diagnosis) exists

Yes we start again with more definitions. Consistency is king! Signs and Symptoms detail the evidence or defining characteristics that prove that the nutrition problem (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. 

Signs and Symptoms are also used during the last stage of the Nutrition Care Process- Monitoring and Evaluation, to determine the amount of progress made toward resolving the Nutrition Diagnosis (more on this in future blogs).

The Signs and Symptoms data is obtained during the first stage in the Nutrition Care Process, Nutrition Assessment.  Like Etiology, Signs and Symptoms in the PES Statement are free text. The eNCP includes some examples of Sign and Symptoms for Nutrition Diagnosis terminology. They are examples only. It is an important skill for a dietitian to is able to identify the evidence (or Signs and Symptoms) that demonstrate that a Nutrition Diagnosis exists.  

How to choose the correct Signs and Symptoms

  1. Do the Signs and Symptoms support and provide evidence that the Nutrition Diagnosis (nutrition problem) exists?
  2. Are the Signs and Symptoms supported by the Nutrition Assessment data?**
  3. Are the Signs and Symptoms specific enough that they can be monitored to measure/evaluate changes from one visit to another?
  4. Can measuring the Signs and Symptoms tell you that the problem is resolved or improved?

**Think back to the Nutrition Care Indicators mentioned in the previous blogs (assessment data that is used to identify a client’s Nutrition Diagnosis and its etiology and signs/symptoms.) 

So that’s about it for now. I will go before this post turns into an essay. I hope you find it useful. Next time: Nutrition Intervention!! (One day!)

IDNT and The Nutrition Care Process: Part 2 Nutrition Diagnosis

Welcome to Part 2 of my journey through the of IDNT and the Nutrition Care Process. I hope you enjoyed part 1 Nutrition Assessment, click here to read.

The Nutrition Care Process is the systematic approach to providing high-quality nutrition care developed the Academy of Nutrition & Dietetics. Kalix’s electronic documentation feature was built on the back of the nutrition care process. Electronic documentation systems like Kalix make charting a lot quicker. They can even limit the need to learn and memorize standardized terminology.

It’s time for the next step in the Nutrition Care Process (NCP), and this is the step that receives the most attention-Nutrition Diagnosis. The attention hogging Nutrition Diagnosis identifies the specific nutrition problem that we (the Dietitian) are responsible for treating and (ideally) resolving. We resolve this nutrition problem through our nutrition intervention.

So, I might have been a bit harsh towards poor Nutrition Diagnosis. Calling him an attention hog is bit unfair, it’s not his fault after all.

The fact is, most of the training on the Nutrition Care Process that I’ve attended (both in Australia and the US) focuses primarily on the Nutrition Diagnosis.

Sure, there are arguably good reasons for this;

The ability to create a Nutrition Diagnosis requires a shift in thinking.

The idea of using and identifying a Nutrition Diagnosis over a medical one may appear to be new, I argue it is something we, Dietitians have always done.

In our work as Dietitians, the focus of our thinking (as well as our documentation) is often on our client’s (or patient’s) medical diagnosis e.g. type II diabetes, stage 3 renal disease, and hypertension.

The Nutrition Care Process encourages us to move our thinking towards our area of specialty-Nutrition. Hence, the focus of the Nutrition Care Process is the nutrition problem (i.e., the Nutrition Diagnosis) that the Dietitian is responsible for treating independently. It is still important to consider the client’s medical diagnosis (obviously), but focus your thinking (and documentation) around the nutrition problem.

As Dietitians, it is not our job to diagnose medical conditions. Sure, through our nutritional interventions we help to treat/management them, but Dietitians do not diagnose medical conditions.

An example

Type II diabetes

A client with type II diabetes is referred to see you, a Dietitian for advice on modifying his diet. His referring practitioner wants him to achieve improved blood glucose control.

You know as a Dietitian, many things may be affecting this client’s blood glucose control, not just his diet. But you take a diet history, and you can see that there is definitely room for improvement. As you assess this client’s diet history, you see that he eats a very large, carbohydrate-heavy evening meal, he skips breakfast and lunch just consists of a white bread sandwich with jam. 

What will your nutrition intervention focus on (write it down)?

Yes your right! Your interventions for this client are focused on establishing a consistent carbohydrate intake throughout the day, limiting heavy carbohydrate meals and choosing mostly low GI foods. 

Now what is the Nutrition Diagnosis?

Considering, the Nutrition Diagnosis is the specific nutrition problem that you (the Dietitian) is responsible for treating and (ideally) resolving, what is the Nutrition Diagnosis for the above case?

Think: the nutrition problem (Nutrition Diagnosis) is what our interventions aim to solve.

Suggested Nutrition Diagnosis

Inconsistent carbohydrate intake -a diagnosis for an intervention that is aimed at establishing consistent carbohydrate intake.
Excessive carbohydrate intake– a diagnosis for an intervention that is aimed at limiting heavy carbohydrate meals.
Less than optimal intake of types of carbohydrate-a diagnosis for an intervention that is targetted at choosing mostly low GI foods.

The Nutrition  Diagnosis is not

  • Type II Diabetes –this is the medical diagnosis, not the nutrition problem.
  • Altered nutrition-related laboratory values– you can select this diagnosis, but remember, many factors may be affecting this client’s blood glucose control, not just his diet. Diet/intake related Nutrition Diagnosis are always preferable.

Even though the referring practitioner wants the client to improve his blood glucose control, the goal of your intervention is to achieve dietary modifications.

The IDNT manual (2013) explains;

“the [dietitian] identifies and labels a specific nutrition diagnosis (problem) that… he or she is responsible for treating independently (e.g., excessive carbohydrate intake). With nutrition intervention, the nutrition diagnosis ideally resolves.

In contrast, a medical diagnosis describes a disease or pathology of organs or body systems (e.g., diabetes)… [dietitians] do not identify medical diagnoses; they diagnose phenomena in the nutrition domain.”

This is the shift in thinking.

Some argue that the ability for Dietitians to identify a Nutrition Diagnosis (instead of a medical one) is new. As I said earlier, I believe it is something we Dietitians have always done.

The format that the Nutrition Diagnosis is written is in, is a bit different.  But as Dietitians we have always been being able to identify the particular nutrition issue/s our clients have. These nutrition issues are the focus of our interventions.

How would a Dietitian know that a particular client needs to limit their heavy carbohydrate meals if they were not aware that the Nutrition Diagnosis (problem) is Excessive Carbohydrate Intake?

PEZ Statements

Ok not the right PES, but just as tasty. 

The PES Statement

So onto the PES Statement (this will be discussed in detail next blog):
The Nutrition Diagnosis is summarized into a structured sentence called the nutrition diagnosis statement or PES statement. The PES statement links the Nutrition Assessment to the Nutrition Intervention to set realistic and measurable goals/outcomes from the nutrition care.

The PES statement:
(P) the nutritional problem (the selected Nutrition Diagnosis), related to (E) etiology, as evidenced by (S) signs and symptoms.

So why I call the Nutrition Diagnosis, an attention hog that it is often people’s primary focus when learning the Nutrition Care Process. However, the Nutrition Diagnosis should not be considered in isolation. Think of it concurrently with the other stages of the Nutrition Care Process (Assessment, Intervention and Monitoring/Evaluation).

Nutrition Assessment
As I discussed in the last blog, during the Nutrition Assessment, the Dietitian gains a lot of information specifically relating to the Nutrition Diagnosis.

Remember that I mentioned Nutrition Care Indicators last blog (assessment data that are used to identify a client’s Nutrition Diagnosis and its etiology and signs/symptoms.) This where you get the info needed to form your PES statement.

Nutrition Intervention
As discussed in this article, the Nutrition Intervention should be aimed at resolving the Nutrition Diagnosis; hence the two are directly linked (more on this next blog).

Monitoring and Evaluation
During this stage Dietitians monitor the client’s progress towards resolving the Nutrition Diagnosis. The factors that are monitored to measure the client’s the progress are also the Nutrition Care Indicators-  the E and S from the PES statement (more on this in future blogs.)


  1.  Nutrition Diagnosis,  is not a medical diagnosis.
  2. Nutrition Diagnosis, describes the nutrition problem that the intervention aims to solve.
  3. Diet and intake related Nutrition Diagnosis are preferable over medical or behavioral based ones.
  4. Do not think of the Nutrition Diagnosis in isolation. Think of it concurrently with the other stages of the Nutrition Care Process (Assessment, Intervention and Monitoring/Evaluation).

Next blog I will explore the PES Statement in more detail.



IDNT and the Nutrition Care Process: Part 1- Nutrition Assessment

Nutrition Assessment

This post is Part 1 of IDNT and the Nutrition Care Process.

It’s an adventure through the world of IDNT (International Dietetic and Nutrition Terminology) and the Nutrition Care Process.  I said it is an adventure right? So I hope to make it a fun experience for all. My aim to explain to you (in my own way) what the Nutrition Care Process is all about.  I also plan to convert all you nonbelievers to the ways of IDNT. Tough task I have set myself…but I will give it my best.

If there is questions or topics around IDNT and the Nutrition Care Process you want me to cover, please let me know.

So here goes.

I hope you find it useful.

What is NCP and IDNT?

In a nutshell, the Nutrition Care Process (NCP) is a model for providing high-quality nutrition care and International Dietetics and Nutrition Terminology (IDNT) is the standardized language used to describe the NCP.

I have written about the benefits of NCP and IDNT a few times before, so I will not repeat myself here, but I will mention one of the uses for IDNT. IDNT is used for the documentation of clients’ (or patients’) nutrition care, i.e. medical note documentation.  And this is how we use IDNT in Kalix. The standardized documentation format for NCP is ADIME (A-Assessment, D-Diagnosis, I- Intervention, ME-Monitoring, and Evaluation). And again this is the format we use in Kalix. In saying that, you can use IDNT to write notes in whatever format you like including SOAP, ABCD, etc.

Nutrition care Process

Nutrition Assessment

The first stage in the Nutrition Care Process is the Nutrition Assessment, and hence, this is the first section in ADIME. Assessment contains the data you collect about a client/patient during the consultation, from medical records, food records, weight records, client observations, from discussions with other healthcare providers, carers or family members, etc.

There is one crucial point I would like everyone to understand about Nutrition Assessment in NCP. But, before I explain it, I would like to ask, a fundamental question:

Why do Dietitians conduct nutritional assessments with clients?

Sure, there is not one answer to this, but many. Some of the reasons include:

• To confirm clients’ medical history
• Collect anthropometric measurements
• Gather information about their diet and food intake
• Learn clients’ personal preferences to assist with providing tailored advice

The list can go on… but now I ask you, why do Dietitians collect this information and what do we do with it?

Dietitians conduct nutritional assessments to obtain client data, which we verify (check that it is accurate) and interpret (compare it to relevant reference standards). We determine whether the dietary modifications are required or not, i.e., that a nutrition-related problem exists (this problem is the Nutrition Diagnosis). Dietitians then examine this client data to identify the cause/s of the nutrition-related problem (its etiology) and its significance (the effect the nutrition-related problem has on client’s health and wellbeing). All of this information then used to determine how to go about resolving (this is the Nutrition Intervention) the nutrition-related problem.

Makes sense…so what is my important point?

Nutrition Assessment, should not be just list of assessment information, it should contain only relevant information that is used to demonstrate;
• Whether a nutrition-related problem exists
• The cause/s of the nutrition-related problem
• It’s significance (the effect the nutrition-related problem has on client’s health and wellbeing).

As Dietitians, our time as is too precious to be wasted writing irrelevant information in the Nutrition Assessment. So I recommend to you to only enter relevant information in the Nutrition Assessment section.

Now we have that clear, it will talk a bit about what makes up the Nutrition Assessment section.

In the ADIME the Nutrition Assessment is ordered a little bit different compared to other note writing formats, with Food/Nutrition-Related History listed first.

Food/Nutrition-Related History

This section includes all information about your client’s oral intake, as well as nutritional support plus enteral and parental nutrition. Basically, any diet-related information i.e., the client’s diet history (and your analysis of it), complementary/alternative medicine use, knowledge/beliefs about food and eating, access to adequate healthful food and nutrition quality of life. Physical activity history also lives here.

Ok, a common comment I hear about this section, is why isn’t Anthropometric first?

In ADIME, we list the most important stuff first. We know medical staff do not always read every part of a Dietitian’s notes, they may read the first part then skim the rest. Food/Nutrition-Related History is the most important part of a Dietitian’s documentation, right? A Dietitian’s ability accurate gather nutrition and diet-related information and interpret it, is what makes us unique as a profession. Other professionals measure weight and other anthropometric measurements (even doctors do it sometimes), all health professionals collect medical histories, most check the biochemical/lab data, but only dietitians assess dietary and nutrition-related history. That’s why is section is first.

Anthropometric Measurements

We all know what goes here, height, weight, body mass index (BMI), growth pattern indices/percentile, and weight history, etc.

Something I would like to talk about (and it’s something that I have touched on previously) is Nutrition Care Indicators. Nutrition Care Indicators are client data gathered during the nutrition assessment that is used to identify a client’s Nutrition Diagnosis and its etiology and signs/symptoms. i.e., they are indicators that nutrition care is required. Any Nutrition Assessment data can be a Nutrition Care Indicator, including anthropometric measurements e.g. the client’s BMI. If a client’s BMI is in the obese category, for example, this is an indicator that nutrition care is warranted for weight management. In this case, the client’s BMI will be used as a sign and symptom for the Nutrition Diagnosis of Excessive Energy Intake (the reason for why it is a sign and symptom and not the Nutrition Diagnosis will be explained in the next blog).

 Biochemical Data (Blood Tests), Medical Tests and Procedures

Includes laboratory data, (e.g., electrolytes, blood glucose levels, and lipid panel) and tests (e.g., gastric emptying time, resting metabolic rate).

The critical thing to remember here, is the Nutrition Care Process supports evidenced-based practice, it is not enough to say client A has an HbA1c of 10%, you need to show what this means (interpret it). It does not have to be a long description…all you have to do is compare your client results against some relevant standard. It can be a reference standards, i.e., the Diabetes Society recommended HbA1c target or the client’s goal, e.g., reduce HbA1c by 1%.

Client A’s HbA1c is 11% [The client’s result and the Nutrition Care Indicator], which is above [the comparison- it does not need to be long] the recommended range of < 7% [the reference range].

Nutrition-Focused Physical Findings

These are findings obtained from the evaluation of “body systems” including overall appearance, cardiovascular, digestive system, skin and vital signs. The results should be nutrition-related physical characteristics, such as nausea, loss of subcutaneous fat and temporal wasting, and they should be associated with pathophysiological states e.g. cancer cachexia, malnutrition. So again, I emphasise only including relevant information. Nutrition-focused physical findings can be derived from a nutrition-focused physical exam, medical records, direct observation, client reports, etc.

 Client History

This section includes current and past information related to personal, medical, family, and social history. Personal History includes general client information such as age, gender, race/ethnicity, language, education, and role in family. Medical history can be a history of the client or the family history. Medical history should only contain conditions that may have a nutritional impact, so no irrelevant information. Social History includes items such as socioeconomic status, living situation, medical care and involvement in social groups.

Client information is often used as part of the etiology for a Nutrition Diagnosis e.g., economic constraints, cultural practices and depression (etiology), can be the cause of Inadequate Energy Intake (Nutrition Diagnosis).

So that is all for Nutrition Assessment, next blog I will talk about Nutrition Diagnosis and PES Statements. Below are some final tips.

P.S. I would love to hear what you think about this blog, please share your thoughts below.


1. Decide on what data is appropriate to collect (consider the client, your setting, the referral reason, etc.)
2. Collect data using applicable validated assessment tools
3. Distinguishing relevant between relevant and irrelevant data (only include relevant data)
4. Validate your data by comparing it against relevant standards or client goals.