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.

The Story of Kalix

This post is by Claire Nichols, Co-founder of Kalix and Accredited Practising Dietitian.
Hi everyone. I am very excited to be sitting here writing our first ever blog post. Well, I actually have to admit, coming up with a topic for the blog was a bit daunting. I mean there are lots of things to write about really, our new features, for example, but what I really wanted to do was to start with something a bit different compared to our newsletter. I so thought I would try to answer some of the big questions; who are we, what are we doing, how we got here and the meaning of life (well maybe not that one). So here goes…

Two years ago I would have never guessed, I would be a co-founder of a software company. My knowledge of IT was little to none. Sure, I could turn on a computer, make a Word document, google a topic, but I didn’t know where, to begin with making a blog, let alone a website. Then came a problem, followed by an idea and then an opportunity.

The problem arose just after starting my previous job as Early Intervention Service Dietitian in North West Tasmania. The position was funded with a special government grant, so there was a lot of pressure to measure and evaluate the effectiveness of my professional practice. Evaluating the effectiveness of dietetic practice, is easy enough, isn’t it? When you see a patient, you measure their weight and the next time you see them, you measure it again. If they’ve lost weight you’ve done a good job if they haven’t, you then haven’t…Hopefully, you are all screaming NO right now.

For the non-Dietitians reading this;

1) Dietitians do not only see patients for weight control.

2) Weight loss is hard! Improving overall diet quality, and improved patient health is what we want to achieve as healthcare professionals, right? But how does one measure healthy lifestyle?more active and establishing a healthy lifestyle are all positive achievements. They all result in improved health, irrespective of the amount of weight loss.

 The idea So I went about investigating how to measure and evaluate professional practice. I came across International Dietetics and Nutrition Terminology (IDNT) and the Nutrition Care Process (NCP). Well, actually I was using IDNT at the time and I had been since 2009 but only to write PES statements. There is a lot more to IDNT than PES statements.

For non-Dietitians NCP is a problem-solving method that Dietitians use to “think critically and make decisions that address practice-related problems”. IDNT is a “standardized set of terms used to describe the results of each step of the NCP model.” PES is a statement about the Nutrition Diagnosis or nutrition issue. Clear? If not that’s ok, I will talk about it more in future posts.

Why I like IDNT

  • There are lots of terms, getting to close to 1000 now I think (yes I actually like that).
  • They cover all the stages of the Nutrition Care Process (Assessment, Diagnosis, Intervention and Monitoring/Evaluation) i.e. initial and review assessments.
  • They include most factors in dietetics e.g. Food variety is a term, as well as Meal or snack pattern, Nutrition quality of life responses, Frequency, Consistency, Duration, and Intensity of physical activity and of course, good old Food intake, to name a few.

ideaSo my light bulb moment….because IDNT is standardized and covers all the data a dietitian would collect during initial and review assessments if I was to write all my patient documentation using IDNT then I could use a software system to track changes in the variables associated with IDNT terms. Tracking the changes in these variables would be an easy, sensitive and efficient way of evaluating professional practice. I could even use IDNT to evaluate the effectiveness of particular interventions by correlating Intervention terms with changes in the variables associated with Assessment and Monitoring/Evaluation terms.

By using IDNT I could evaluate my professional practice without having to spend extra time measuring, recording and analyzing data. The statistical analysis would be built into patient documentation and patient documentation is something I had to do anyway!

The problem was finding a software system that uses IDNT in this way. I needed a software system that supports quick electronic documentation using IDNT terms, tracks of changes in patient data over time and correlate changes in variables.

There must be something like that out there, right? No, not really. Why? My best guess is because 1) software developers are really really expensive to hire, and 2) actual building software with this functionality would take a long time.

 The opportunity- I was very lucky to have my own software developer on hand, Felix Jorkowski. So we embarked on this little project together and it has grown and grown.

So I might be the most unlikely co-founder of a software company but win or lose I am glad I took the risk to try something new. I will finish this blog with a quote which I think sums things up really well.

“You can’t make footprints in the sands of time by sitting on your butt. And who wants to leave buttprints in the sands of time?” Bob Moawad


Nutrition Care Process and Model Part I. The 2008 Update. J Am Diet Assoc. 2008; 108:1113-1117.

Nutrition Care Process Part II: Using the International Dietetics and Nutrition Terminology to Document the Nutrition Care Process J Am Diet Assoc. 2008; 108:1287-1293.