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Nutrition resources made for RDs, by an RD

CHF Case Study Part 1 – The MNT

Better understand how to mange real-life patients as a registered dietitian in clinical nutrition with this straightforward CHF case study.

CHF Case Study - The MNT

This is part one of a simple and very short CHF case study review. 

It’s very close to a real life patient who doesn’t have a lot of complexities with their current conditions. But as with all your patients, it does require you to consider multiple angles before finally deciding on an acute nutritional issue — and then writing the nutrition assessment.

In this post, we’ll look at the patient and talk through the medical nutrition therapy you have available.

In the next post we’ll review how to write the note and PES statement using this case study as the example.

Need to know what the abbreviations mean? Pick up this free download for quick reference as you walk through this case study .

Let’s get our CHF case study started with a look at our patient.

CHF Case Study Introduction: Meet your patient

Your patient is a 47 yo man admitted last night to the CCU (cardiac care unit) with CHF exacerbation and SOB. You’ve gotten a referral to see him for weight management and dietary support. 

*This is not a lot of information. But when you’re assigned a new referral, this is usually the only the information you’ll get. As you start learning more about them, take note of when a piece of information is missing. Then, as you continue the assessment make sure you find the answer to that question.

Gathering more information: What’s in the chart

After reviewing the EMR, you note that your patient has a PMH of HTN and DM.

Labs pulled on his admission show an A1C: 7.3%, Glu: 102, with all other pertinent labs WNL. His height is noted to be 5’10” with a wt on admit of 343 lb.

There’s both a cardiology and endocrinology referral pending. At this time, you’re the first provider to start charting on this patient.

*Reviewing the chart before you see your patient is essential. It gives you a good sense of who they are, what their most acute issues possibly are, and where you’re likely going to focus your nutritional assessment. Here is where you’ll begin to see the bigger picture beyond their admitting diagnosis, and start to identify some of the more chronic or ongoing issues your patient is having.

What else you notice: A previous admission

In the EMR, you realize the chart goes back almost 8 month.

This is because your patient was admitted 7 months ago for SOB and +3 pitting B/L LE edema with a then weight of 278 lb. This was when he was also diagnosed with CHF, which means it’s a pretty new condition for your patient. And when you take a look at his old labs, you notice that at that time his A1C was 5.6%.

Since then your patient has had meds in place that include a diuretic, metformin, two blood pressure meds, and a 81 mg aspirin.

The RD note from his last admission states this patient had steady weight gain of 53 lbs during the 3 months leading up to that hospitalization.  They had discussed lifestyle changes to address edema and weight gain, heart health , and how to better manage his fairly well controlled diabetes .

The assessment summary also notes your patient was not ready to make any nutritional changes and the reporting RD was concerned he might be non-compliant with his meds.

The PES statement used was: 

Excessive nutrient intake (energy, sodium) related to CHF with SOB as evidenced by B/L LE +3 pitting edema, 53 lb / 23.6% wt gain x 3 months and pt with fast food intake 4-5 x/week.

*If your patient has had a past admission, review it! You’ll not only get a look at what’s happening with your patient right now as your read the EMR, but the past assessment will give you a clear idea what was happening with them before you came on the case. Use this information to get a better idea of where they previously struggled, and what kind of conversation you might want to have with them down the line.

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First, identify the most acute nutritional issue., what is an acute issue.

The most acute issue is the one thing that needs to be managed right now , in order to make sure your patient improves quickly and gets discharged fast. 

This can get confusing. How do you know what IS most important in the first place?

Think of it like this:

ACUTE is something extreme, serious, immediate CHRONIC is persistent, long-term, possibly incurable

These can be a medical problem (like acute kidney failure), something long term (like chronic kidney disease), or it can be something else entirely (dehydration that leads to altered renal labs). 

A dietitian working in an acute care setting (usually a hospital) is going to focus on those issues that have the ability to be resolved to the point where your patient is able to be discharged.

For those RDs working in long-term care with patients who primarily have chronic conditions, you’re going to be looking for the most acute item that you can help to normalize into a chronic condition.

Make sense? Sort of…? How about this:

The most acute nutritional issue is a significant problem your patient is having which has both direct implications on their nutritional well-being and most importantly, what you as a dietitian can impact through your scope of practice.  

Knowing what you know about this patient, the most acute nutritional issue might take on a couple of forms.

And in this case, depending on how you’re planning to manage your patient,  you might consider it to be: 

• CHF exacerbation
• The significant changes in weight

All of these are acceptable places to start both your evaluation and your interventions. As long as you ALWAYS do one thing: justify your recommendation .

If you can justify your reasoning and validate every argument you choose to make, you can choose any problem you consider to be most acute and run with it.

*None of these are wrong answers, and the all have the potential to be considered the most acute nutritional issue. More important than which is the best answer to choose is how you can justify the issue you consider the most significant. Here are some examples:

• CHF with a likely high sodium intake and possibly non-compliance with prescribed meds
• The significant changes in weight, likely related to ongoing edema 2/2 CHF and possibly also related to intake and previously reported h/o fast food
• DM with elevated A1C and glu labs possible 2/2 poor knowledge/understanding of how to manage blood sugar

Next, what will you do about the most acute issue.

This is where your interventions — or how you plant to solve that acute problem — come in. 

The interventions you choose should be completely aligned with the most significant nutritional issue you choose to focus on.

Examples of interventions you’ll be working on include things like:

• The diet order you assign
• Any supplements you consider relevant
• The nutrition education you provide
• Next steps or recommendations for your patient when discharged
• Any follow up support you’ll do or referrals you’ll make while your patient remains admitted

Each of these will ultimately become part of the way you both justify your recommendations and how you formulate your PES statement .

And just like choosing the most acute nutritional issue, the only requirement is that you’re able to say exactly why you’re doing what you’re doing.

For example:

If the most acute nutritional issue is CHF, then your intervention will revolve around managing things like sodium intake, managing fluid and improving edema.

If you decide the most acute nutritional issue is the significant weight changes your patient has gone through, you’ll focus the interventions on an improved weight status. Maybe that’s simply weight stability. Maybe it’s improved intake or better food choices.

If you believe that diabetes is the most acute nutritional issue, you must illustrate the significance in your patient’s change in A1C and identify interventions that will support improved glucose control. 

*The most acute nutritional issue is also what you’ll be writing your PES statement about. So as long as you can give concrete reasons for every problem you choose to focus on, you’ll have a strong ability to justify every decision you make for your patient.

Finally, is there any information you’re missing?

We’ve talked about everything you can find on paper.

But as you’re reviewing the information available in the chart, look for gaps.

Gaps in what you know and gaps in what you can explain about your patient or their medical history.

Most of the time, there’s a good chance you’re missing some information.

Information that will stop you from making really strong justifications for your recommendations.

Maybe you didn’t see something in the chart, that’s possible. But a lot of times the information you’re missing has nothing to do with you or a mistake you made. 

A lot of times, it’s simply about what isn’t available in the chart. Or even more likely, what your patient hasn’t told anyone yet.

How to know what you’re missing

Make a list of things that would make justifying your recommendations stronger or something that might make identifying the most acute nutritional issue easier to do.

Think about things like:

• Usual body weight over the last 6 months to a year
• What a typical day of eating looks like (including what they drink, eat between meals, or portion sizes they might not share)
• Any other medications, herbs, or other supplements they take (especially the ones they don’t think “count”), and any meds they’ve opted out of taking
• Knowledge of what they should be doing (or anything they think they’re doing correctly)
• Any lab work that might be relevant or missing 

Many times you’ll find this kind of information in one place: hearing it directly from your patient.

What we haven’t covered is the conversation you’re going to have when you visit your patient and do their in-person evaluation. 

Part of this will be the NFPE (nutrition focused physical exam).

But an arguably bigger part of visiting your patient is what you’ll learn by asking him some specific questions to help you fill in some of the gaps you’ve probably noticed as you’ve looked at his chart.

Things like:

• What his current diet is like?
• Does his take his medications regularly?
• What kind of things does he want to know or feel he needs help with

These are the kinds of things you as the dietitian will ask, which very likely, no one else will ask.

But the answers you get will also help you structure and focus your assessment interventions and possibly even the PES statement.

Ready to talk about how to do some charting on this patient?

This is the first part of a two part CHF case study. Check out part 2 of this series where we’ll be looking at how to pull all of this information we’ve collected into a nutrition assessment note and get you thinking about some possible PES statements.

Looking for more support?

• Clinical Evaluation Power Pack : A complete downloadable set of tips, tricks and templates to help you write perfect assessments every time
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• Case Study Library : Full access to all past case study replays and each monthly live case study review sessions

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Dietetic and Nutrition Case Studies

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Dietetic and Nutrition Case Studies This book is dedicated to Pat Judd (1947–2015), inspirational dietitian and educator. Dietetic and Nutrition Case Studies EDITED BY Judy Lawrence Registered Dietitian, the Research Officer for the BDA, and Visiting Researcher, Nutrition and Dietetics, King’s College London, England Pauline Douglas Registered Dietitian, a Senior Lecturer and Clinical Dietetic Facilitator, Northern Ireland Centre for Food and Health (NICHE), Ulster University, Northern Ireland Joan Gandy Registered Dietitian, a Freelance Dietitian and Visiting Researcher in Nutrition and Dietetics, University of Hertfordshire, England This edition first published 2016 © 2016 by John Wiley & Sons, Ltd Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging-in-Publication Data Names: Lawrence, Judy, 1960- , editor. | Gandy, Joan, editor. | Douglas, Pauline, 1961- , editor. Title: Dietetic and nutrition case studies / edited by Judy Lawrence, Joan Gandy, Pauline Douglas. Description: Chichester, West Sussex ; Hoboken, NJ : John Wiley & Sons, 2016. | Complemented by: Manual of dietetic practice / edited by Joan Gandy in conjunction with the British Dietetic Association. Fifth edition. 2014. | Includes bibliographical references and index. Identifiers: LCCN 2015040817 (print) | LCCN 2015042999 (ebook) | ISBN 9781118897102 (pbk.) | ISBN 9781118898239 (pdf) | ISBN 9781118898246 (epub) Subjects: | MESH: Dietetics. | Nutritional Physiological Phenomena. | Diet Therapy. | Problem-Based Learning. Classification: LCC RM216 (print) | LCC RM216 (ebook) | NLM WB 400 | DDC 615.8/54 – dc23 LC record available at http://lccn.loc.gov/2015040817 A catalogue record for this book is available from the British Library. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Set in 9/12pt, MeridienLTStd by SPi Global, Chennai, India. 1 2016 Contents List of contributors, ix Preface, xvii Online resources, xix PART I 1 Model and process for nutrition and dietetic practice, 3 2 Nutrition care process terminology (NCPT), 8 3 Record keeping, 12 4 Assessment, 16 PART II Case studies 1 Veganism, 25 2 Older person – ethical dilemma, 28 3 Older person, 31 4 Learning disabilities: Prader–Willi syndrome, 34 5 Freelance practice, 39 6 Public health – weight management, 41 7 Public health – learning disabilities, 48 8 Public health – calorie labelling on menus, 52 9 Genetics and hyperlipidaemia, 55 10 Intestinal failure, 59 11 Irritable bowel syndrome, 62 12 Liver disease, 66 13 Renal disease, 69 14 Renal – black and ethnic minority, 72 15 Motor neurone disease/amyotrophic lateral sclerosis, 75 16 Chronic fatigue syndrome/myalgic encephalopathy, 78 v vi Contents 17 Refsum’s disease, 81 18 Adult phenylketonuria, 83 19 Osteoporosis, 86 20 Eating disorder associated with obesity, 90 21 Forensic mental health, 92 22 Food allergy, 97 23 HIV/AIDS, 102 24 Type 1 diabetes mellitus, 106 25 Type 2 diabetes mellitus – Kosher diet, 111 26 Type 2 diabetes mellitus – private patient, 114 27 Gestational diabetes mellitus, 117 28 Polycystic ovary syndrome, 121 29 Obesity – specialist management, 125 30 Obesity – Prader–Willi syndrome, 131 31 Bariatric surgery, 136 32 Stroke and dysphagia, 140 33 Hypertension, 143 34 Coronary heart disease, 146 35 Haematological cancer, 150 36 Head and neck cancer, 153 37 Critical care, 157 38 Traumatic brain injury, 160 39 Spinal cord injury, 164 40 Burns, 167 41 Telehealth and cystic fibrosis, 170 Case studies’ answers 1 Veganism, 173 2 Older person-ethical dilemma, 177 3 Older person, 180 4 Learning disabilities: Prader–Willi syndrome, 183 5 Freelance practice, 186 6 Public health – weight management, 189 7 Public health – learning disabilities, 193 Contents vii 8 Public health – calorie labelling on menus, 197 9 Genetics and hyperlipidaemia, 199 10 Intestinal failure, 205 11 Irritable bowel syndrome, 207 12 Liver disease, 210 13 Renal disease, 216 14 Renal – black and ethnic minority, 221 15 Motor neurone disease/amyotrophic lateral sclerosis, 224 16 Chronic fatigue syndrome/myalgic encephalopathy, 227 17 Refsum’s disease, 230 18 Adult phenylketonuria, 233 19 Osteoporosis, 236 20 Eating disorder associated with obesity, 238 21 Forensic mental health, 242 22 Food allergy, 245 23 HIV/AIDS, 248 24 Type 1 diabetes mellitus, 251 25 Type 2 diabetes mellitus – Kosher diet, 254 26 Type 2 diabetes mellitus – private patient, 257 27 Gestational diabetes mellitus, 261 28 Polycystic ovary syndrome, 266 29 Obesity – specialist management, 269 30 Obesity – Prader–Willi syndrome, 272 31 Bariatric surgery, 276 32 Stroke and dysphagia, 283 33 Hypertension, 285 34 Coronary heart disease, 287 35 Haematological cancer, 290 36 Head and neck cancer, 296 37 Critical care, 302 38 Traumatic brain injury, 307 39 Spinal cord injury, 312 40 Burns, 315 41 Telehealth and cystic fibrosis, 317 viii Contents Appendices A1 Dietary reference values, 323 A2 Weights and measures, 328 A3 Dietary data, 335 A4 Body mass index, 342 A5 Anthropometric and functional data, 346 A6 Predicting energy requirements, 352 A7 Clinical chemistry, 353 Index, 361 List of contributors Ellie Allen Clinical Lead Dietitian, University College London Hospitals NHS Foundation Trust, London, United Kingdom Barbara Martini Arora Freelance Registered Dietitian, Bromley, United Kingdom Eleanor Baldwin Advanced Dietitian – Adult Refsums Disease and Bariatrics, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom Julie Beckerson Haemato-Oncology Specialist, Imperial College Healthcare NHS Trust, London, United Kingdom Kathleen Beggs Clinical Tutor, The University of British Columbia, Vancouver, BC, Canada Helen Bennewith Professional Lead for Addiction and Mental Health Dietetics, NHS Greater Glasgow and Clyde, Glasgow, Scotland, United Kingdom Sarah Bowyer PhD Research Student in Rural Health, University of the Highlands and Islands, Inver- ness, Scotland, United Kingdom Rachael Brandreth Children’s Weight Management Dietitian, Royal Cornwall Hospital Trust, Cornwall, United Kingdom Elaine Cawadias Clinical Instructor, Faculty of Land and Food Systems, The University of British Columbia, Vancouver, BC, Canada ix x List of contributors Alison Culkin Research Dietitian, London North West Healthcare NHS Trust, London, United Kingdom Rachael Donnelly Acting Clinical Lead Dietitian, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom Pauline Douglas Senior Lecturer and Clinical Dietetic Facilitator, Northern Ireland Centre for Food and Health (NICHE), University of Ulster, Londonderry, Northern Ireland, United Kingdom Hilary Du Cane Freelance Dietitian and Marketeer, United Kingdom Alastair Duncan Lead Dietitian, NIHR Clinical Doctoral Research Fellow, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom Mary Flynn Chief Specialist Public Health Nutrition, Food Safety Authority of Ireland, Dublin, Ireland; Visiting Professor, University of Ulster, Coleraine, Northern Ireland, United Kingdom Caroline Foster Specialist Dietitian, Leeds and York Partnership NHS Foundation Trust, Leeds, United Kingdom Lisa Gaff Specialist Dietitian, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom Joan Gandy Freelance Dietitian and Visiting Researcher, Nutrition and Dietetics, University of Hertfordshire, Hatfield, United Kingdom Elaine Gardner Freelance Dietitian, London, United Kingdom Susie Hamlin Senior Specialist Dietitian Liver Transplantation, Hepatology and Critical Care, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom List of contributors xi Nicola Henderson AHP Team Lead, NHS Forth Valley, Larbert, United Kingdom Sandra Hood Diabetes Dietitian, The Diabetes Centre, Dorset County Hospital NHS Foundation Trust, Dorchester, Dorset, United Kingdom Nicola Howle Mental Health Dietitian, South Staffordshire and Shropshire Healthcare NHS Foun- dation Trust, Lichfield, United Kingdom Bushra Jafri Human Nutrition and Dietetics, London Metropolitan University, London, United Kingdom Yvonne Jeanes Senior Lecturer in Clinical Nutrition, University of Roehampton, London, United Kingdom Sema Jethwa Senior Diabetes Specialist Dietitian, University College London Hospital NHS Trust, London, United Kingdom; Freelance Dietitian, Hertfordshire, United Kingdom Susanna Johnson Community Paediatric Dietitian, Wembley Centre for Health and Care, Central London Community Healthcare NHS Trust, London, United Kingdom Natasha Jones Advanced Specialist Haematology/TYA dietitian, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom Ruth Kander Senior Dietitian and Consultant Dietitian, Imperial College Healthcare NHS Trust, London, United Kingdom and Consultant East Kent Dietitian. Joanna Lamming Specialist Weight Management Dietitian, East, Kent, United Kingdom Anne Laverty Specialist Dietitian, Learning Disabilities, Northern Health and Social Care Trust, Coleraine, Northern Ireland, United Kingdom xii List of contributors Judy Lawrence Research Officer BDA and Visiting Researcher, King’s College London, London, United Kingdom Julie Leaper Senior Specialist Dietitian (Liver/ICU) St James’s Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom Sian Lewis Macmillan Clinical Lead Dietitian, Chair of BDA Specialist Oncology Group, Velindre Cancer Centre, Wales, United Kingdom Sherly X. Li PhD Candidate, MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom Seema Lodhia HCA Healthcare, London, United Kingdom Julie Lovegrove Head of the Hugh Sinclair Unit of Human Nutrition, University of Reading, Reading, United Kingdom Marjorie Macleod Specialist Dietitian, Learning Disabilities Service, NHS Lothian, Edinburgh, Scotland, United Kingdom Paul McArdle Lead Clinical Dietitian and Deputy Head of Dietetics, NIHR Clinical Doctoral Research Fellow and Freelance Dietitian, Birmingham Community Healthcare NHS Trust, Birmingham, United Kingdom Angela McComb Health and Social Wellbeing Improvement Manager, Northern Health and Social Care Trust, Londonderry, Northern Ireland, United Kingdom Caoimhe McDonald Research Dietitian, Mercers Institute for Research on Ageing, St. James Hospital, Dublin, Ireland Jennifer McIntosh Clinical Lead Dietitian, Leeds and York Partnership NHS Foundation Trust, Leeds, United Kingdom List of contributors xiii Yvonne McKenzie Specialist in Gastrointestinal Nutrition, Clinical Lead in IBS for the Gastroenterology Specialist Group of the British Dietetic Association, Birmingham, United Kingdom Kirsty-Anna McLaughlin Community Nutrition Support Dietitian, Wiltshire Primary Care Trust, Wiltshire, United Kingdom Kassandra Montanheiro Macmillan Senior Specialist Dietitian, University College London Hospitals NHS Foundation Trust, London, United Kingdom Eileen Murray Specialist Mental Health Dietitian, NHS Greater Glasgow and Clyde Directorate of Forensic Mental Health and Learning Disabilities, Glasgow, Scotland, United Kingdom Mary O’Kane Consultant Dietitian (Adult Obesity), Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom Sian O’Shea Head of Nutrition and Dietetics for Learning Disabilities, Aberkenfig Health Board, Bridgend, United Kingdom Sue Perry Deputy Head of Dietetics, Hull Royal Infirmary, Hull and East Yorkshire Hospitals NHS Trust, Hull, United Kingdom Gail Pinnock Specialist Bariatric Surgery Dietitian, Homerton University Hospital NHS Foundation Trust, London, United Kingdom Vicki Pout Deputy Acute Dietetic Manager, Queen Elizabeth the Queen Mother Hospital, Kent Community Health NHS Foundation Trust, Margate, Kent, United Kingdom Louise Robertson Specialist Dietian, Inherited Metabolic Diseases, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom Juneeshree S. Sangani Freelance Dietitian, United Kingdom xiv List of contributors Nicola Scott Senior Specialist Haematology Dietitian, St James’s University Hospital, Leeds Teach- ing Hospital NHS Trust, Leeds, United Kingdom Ella Segaran Specialist Dietitian for Critical Care, Chair of Dietitians in Critical Care Specialist Group of the BDA, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom Reena Shaunak Diabetes Specialist Dietitian, West Middlesex University Hospital NHS Trust, Isleworth, United Kingdom Bushra Siddiqui Renal Dietitian, Queen Elizabeth Hospital Birmingham, University Hospitals Birm- ingham NHS Foundation Trust, Birmingham, United Kingdom Isabel Skypala Consultant Allergy Dietitian and Clinical Lead for Food Allergy, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom Alison Smith Prescribing Support Dietitian, Aylesbury Vale Clinical Commissioning Group and Chiltern Clinical Commissioning Group, Aylesbury, United Kingdom Chris Smith Specialist Paediatric Dietitian, Royal Alexandra Hospital, Brighton, United Kingdom Clare Stradling NIHR Doctoral Research Fellow, Birmingham Heartlands Hospital, University of Birmingham, Birmingham, United Kingdom Carolyn Taylor Specialist Dietitian, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom Lucy Turnbull Clinical Lead for Chronic Disease and Weight Management Services, Central London Community Healthcare, London, United Kingdom Evelyn Volders Senior Lecturer Nutrition and Dietetics, Monash University, Melbourne, Victoria, Australia List of contributors xv Kirsten Whitehead Assistant Professor, Division of Nutritional Sciences, University of Nottingham, Nottingham, United Kingdom Kate Williams Head of Nutrition and Dietetics, South London and Maudsley NHS Foundation Trust, London, United Kingdom E. Mark Windle Specialist Dietitian, Burns and Intensive Care, Mid Yorkshire Hospitals NHS Trust, Wakefield, United Kingdom Preface Problem-based learning (PBL) is increasingly becoming the preferred method of teaching in health care. There is currently a dearth of appropriately written case studies. This book takes a PBL approach to dietetics and nutrition and aims to address this gap. It has been written to complement the Manual of Dietetic Practice (MDP) (5th edition), and the case studies are cross-referenced accordingly. Uniquely, the case studies are written and peer reviewed by registered dietitians, drawing on their own experiences and specialist knowledge. This book has been written and edited with many readers in mind. Lecturers and staff in universities with courses in dietetics and nutrition will undoubtedly find it relevant although it will be useful to many other health care students and professionals. The case studies are also aimed at qualified dietitians and nutritionists as a tool to enhance their continuing professional development. Readers will be able to work through the case studies individually and in groups in different settings including dietetic departments. It will also help dietetic students and dietitians to identify further areas of practice that may be of interest to them. Each case study follows the Process for Nutrition and Dietetic Practice (PNDP) that was published by the British Dietetic Association (BDA) in 2012. While throughout the world there are slight variations in nutrition and dietetic models and processes, the case studies can be successfully used alongside these. In addition, the Nutrition Care Process Terminology (NCPT), formally known as International Dietetics and Nutrition Terminology (IDNT), is used throughout the case studies – a feature prac- titioners worldwide will find useful. Each case study starts with a scenario, which will enable the reader to identify the need for a nutritional intervention. This is followed by the assessment step of the PNDP and is standardised by the use the ABCDE format in most cases. Questions are posed about the assessment, the intervention and evaluation and monitoring steps. Some case studies also include further questions to stretch more newly qualified and more experienced practitioners. The PNDP is central to all areas of practice although it may be easier to identify each step in clinical areas than in other areas such as public health. This book includes real life case studies in public health, an increasingly impor- tant area of practice, and although they may be more detailed by carefully working through the case study and answers, it is possible to identify each and every step of PNDP. Questions on ethical issues are included in some case studies; however, ethics should always be of prime importance to any health care professional and is central to practice. xvii xviii Preface The book is split into two parts; firstly to reinforce keys areas of practice pertinent to this book it starts with the following introductory chapters: • Model and process for dietetic practice • Nutrition care process terminology • Documentation and record keeping • Assessment – including the ABCDE assessment process This is followed by the case studies and separate answers. To avoid duplication the references for both the case studies and the answers are given at the end of each case study regardless of where they are cited. For completeness and to aid readers, many appendices from the Manual of Dietetic Practice are reproduced in the book. They include dietary reference values, weight and measures, dietary data, anthropometric data, energy prediction equations and so on and clinical chemistry. Many of the case studies also have a link to a relevant PEN, Practice Based Evidence in Nutrition (PEN), practice question or resource. Dietitians in Australia, Canada, the United Kingdom and Ireland will be familiar with this global resource for nutrition practice. We hope that readers enjoy using this book as much as we have enjoyed compiling it. Finally, we would like to thank the contributors and reviewers who have been invaluable when compiling this book. Judy Lawrence Pauline Douglas Joan Gandy Online resources Additional resources, which may be of interest to readers of this book, can be found on the companion website for the Manual of Dietetic Practice, 5th Edition, edited by Joan Gandy. http://www.manualofdieteticpractice.com/ The website includes • Case study summaries (PDF) • An alphabetical list of web resources • Appendices from the book (PDF) • Reference lists with CrossRef links • Tables from the Manual of Dietetic Practice (PDF) • Figures from the Manual of Dietetic Practice (PPT) • Updates xix PART I CHAPTER 1 Model and process for nutrition and dietetic practice Judy Lawrence The nutrition care process and model was first conceived by the Academy of Nutrition and Dietetics (Lacey & Pritchett, 2003). Since then it has evolved and been adapted and is now used by dietitians and nutritionists worldwide. The case studies in this book are written with the nutrition and dietetic care process in mind. The process can be used in any setting including clinical dietetics and public health. Although case studies in this book are based around the British Dietetic Association’s (BDA) (2012) model and process (Figure 1.1) used by dietitians in the United Kingdom, they can be used alongside other versions of the process and model as well. The model starts with the identification of nutritional need, followed by six stages, namely, assess- ment, identification of the nutrition and dietetic diagnosis, planning the nutrition and dietetic intervention, implementing the intervention, monitoring and reviewing the intervention and finally evaluating the intervention. The case studies use the ABCDE approach (Gandy, 2014), were A is for anthropome- try, B stands for biochemical and haematological markers, C for clinical, D for dietary and E is used to include economic, environmental and social issues that may be rele- vant. Information collected during the assessment is used to make the nutrition and dietetic diagnosis. More details of the assessment can be found in Chapter 4. Identifying the nutrition and dietetic diagnosis The nutrition and dietetic diagnosis is the nutritional problem that is assessed using the dietitian’s clinical reasoning skills and resolved or improved by dietetic interven- tion. The nutrition and dietetic diagnosis is a key part of the care process, and once the correct diagnosis has been made the intervention and the most appropriate outcomes to monitor will fall into place. The nutrition and dietetic diagnosis is written as a struc- tured sentence known as the PASS statement, where P is the problem, A the aetiology and SS the signs and symptoms. The PASS statement should describe the ‘Problem’ related to ‘Aetiology’ as characterised by ‘Signs/Symptoms’, for example; inadequate energy intake (problem) related to an overly restrictive gluten free diet (aetiology) as characterised by weight loss of 4 kg and anxiety regarding appropriate food choices Dietetic and Nutrition Case Studies, First Edition. Edited by Judy Lawrence, Pauline Douglas, and Joan Gandy. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd. Companion Website: http://www.manualofdieteticpractice.com/ 3 4 Dietetic and Nutrition Case Studies Identification of nutritional need Evaluation 6 1 Assessment Monitor Service user’s values and Identification and review 5 service user/dietitian 2 of nutrition relationship and dietetic diagnosis 43 Implement Plan nutrition and nutrition and dietetic dietetic intervention intervention Figure 1.1 Nutrition and dietetic process (BDA (2012), p. 7. Reproduced with permission of British Dietetis Association). (signs and symptoms). A well-written PASS statement is one where the dietitian or nutritionist can improve or resolve the problem, the intervention addresses the aeti- ology and the signs and symptoms can be monitored and improved. The nutrition and dietetic diagnosis can be broken down into the three steps; problem, aetiology and signs and symptoms. Problem This is the nutritional (dietetic) problem not the medical problem; it is the problem that can be addressed by dietetic intervention. In these case studies, the problems are expressed using the diagnosis terms as approved by the BDA. More details about the terminology can be found in Chapter 2 on international language and terminology. The problem is the change in the nutrition state that is described by adjectives such as decreased/increased, excessive/inadequate, restricted and imbalanced. In the United Kingdom, nutrition and dietetic diagnosis terms fall into one of the following seven categories: • Energy balance; • Oral or nutritional support; • Nutrient intake; Model and process for nutrition and dietetic practice 5 • Function, for example, swallowing; • Biochemical; • Weight; and • Behavioural/environmental. There may be more than one problem, so a number of nutritional and dietetic diagnoses may be possible but these can often be consolidated into one diagnosis or one diagnosis may be prioritised, using clinical judgement and the client’s wishes. Some nutrition and dietetic diagnosis may be more appropriate than others; practice and experience will hone this skill. Aetiology The aetiology is the cause of the nutritional problem. Causes may be related to behavioural issues such as food choices, environmental issues such as food avail- ability, knowledge such as not knowing which foods are gluten free, physical such as inability to chew food, or cultural such as beliefs about foods. There may be more than one cause for the problem that a client has but the dietitian should be able to identify the basis of the problem using the information gained during the assessment process. For example, a client may have an incomplete knowledge of their gluten-free diet and this may be caused by: • Missing a dietetic appointment; • Not appreciating that all gluten-containing foods need to avoided; • A misconception that the diet was not important; and • A lack of awareness of the gluten content of many manufactured foods. It is also important that the aetiology identified in the PASS statement is one that the dietitian can influence because the aetiology forms the basis of the intervention. It may be difficult to identify the cause of the problem and in such circumstances the pragmatic approach may be to identify the contributing factors. Once identified, the aetiology may be linked to the problem using the phrase ‘related to’. Signs and symptoms Signs are the objective evidence that the problem exists; they may be from anthropometric measurements, biochemical or haematological results. Symptoms are subjective: they may be things that the patient/client has talked about such as tiredness, clothes being too tight or loose, difficulty swallowing and lack of understanding. Signs and symptoms gathered during the assessment process can be used to quantify the problem and indicate its severity. Signs and symptoms may be linked to the aetiology using the phrase ‘characterised by’. It is not necessary to have both signs and symptoms in the diagnostic statement; one or the other is adequate. Alternative diagnoses may be made when answering the questions in the case studies. It does not necessarily mean that your statement is incorrect; it may be a reasonable alternative or less of a priority. Check that your PASS statement describes a problem that can be altered by dietetic intervention and that the evidence collected during the assessment process suggests that it is important. The signs and symptoms should ideally be ones that can be measures to help advance the progress in alleviating the problem. 6 Dietetic and Nutrition Case Studies Nutrition intervention The nutrition intervention is the action taken by the dietitian to address the diagnosis. Ideally, the intervention should be aimed at the cause of the problem, the aetiology, but if this is not possible then the intervention should address the signs and symptoms of the problem. In some cases, the intervention may be to maintain a current situa- tion, for example, adult PKU. The intervention may involve the dietitian in delegating or co-ordinating the nutrition care done by others. The intervention has two stages: planning and implementation. For each PASS statement it is necessary to establish a goal based on the signs and symptoms (planning) and an appropriate interven- tion based on the aetiology (implementation). The intervention should of course be evidence based. Interventions may involve recommending, implementing, ordering, teaching or referring to other professionals. Planning Planning the intervention may involve collecting more information from the patient or from other sources. Planning should involve the patient/client/carer or group in agreeing and prioritising the necessary steps, to ensure that the care is patient centred. Implementation Implementing the intervention is the phase of the nutrition and dietetic care process, which involves taking action. The intervention may involve the dietitian in training someone else to take action, or in supporting the patient/client to make behavioural changes. The dietitian may facilitate change through others, for example a dietetic assistant, nurse, care assistant, carer or teacher. The implementation may be some- thing that is done to an unconscious patient such as the delivery of a prescribed total parenteral nutrition feeding regimen. Alternatively, the intervention may involve a community or group, for example a school meals project or lipid lowering group. Monitoring and review Monitoring focuses on changes in the signs and symptoms that were identified in the initial assessment to see if progress is being achieved and goals are met. The goals should be SMART: S – specific M – measurable A – achievable R – realistic T – timely SMART goals should make the monitoring process easier. Monitoring should be ongoing or carried out at planned intervals so that the results of the monitoring pro- cess can be used to review the intervention and modify it, if necessary. This may Model and process for nutrition and dietetic practice 7 involve a new assessment and a new nutrition and dietetic diagnosis, which will in turn lead to new goals and additional monitoring. Some of the case studies in this book involve more than one nutrition and dietetic diagnosis. Evaluation Evaluation takes place at the end of the process. It involves collecting data about the current situation and comparing it with data from the assessment, with a reference standard such as BMI indicators of obesity or HbA1c measures of diabetes, or with goals that were established early in the planning process. The effectiveness of the evaluation can be judged by changes in the signs and symptoms identified in the nutrition and dietetic diagnosis. The nutrition and dietetic care process may be an ongoing process where an indi- vidual patient is seen many times over a number of years for a chronic condition such as diabetes or it may be a short episode of care. References BDA (2012) Process and model for nutrition and dietetic practice. URL https://www.bda.uk.com/ professional/practice/process [accessed on 27 May 2015]. Gandy, J. (2014) Assessment of nutritional status. In: Gandy, J. (ed), Manual of Dietetic Practice, 5th edn. Wiley Blackwell, Oxford. Lacey, K. & Pritchett, E. (2003) Nutrition care process and model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc, 103 (8), 1061–1072. Resource Qureshi, N. et al. (2014) Professional practice. In: Gandy, J. (ed), Manual of Dietetic Practice, 5th edn. Wiley Blackwell, Oxford. CHAPTER 2 Nutrition care process terminology (NCPT) Pauline Douglas The challenges for the nutrition and dietetic practitioner are to prevent and reduce the burden of nutrition related health problems for individuals or groups of people. Dietitians and nutritionists must advance practice from experience based to evidence based and demonstrate quality practice and optimise nutritional outcomes. To do this they must have a common language that they can benchmark their practice with other dietitians. They must demonstrate practice through the acquisition and use of complex systems of communication. This allows them to convey meaningful infor- mation to others. In addition: • It provides supporting documentation for the reimbursement of dietetic services provided. • It engages dietitians from academia through to practice to provide a profession fit for purpose and competent to practice. With an increasing mobility of heath care professionals around the world the lan- guage needs to be standardised to convey meaningful information in a uniform way. This allows for the comparison of like messages in a logical process to facilitate the pro- duction of evidence-based practice. Also service users are travelling within countries and across borders for treatment and expect a consistent quality of care. Using standard terminology: • Promotes consistency and continuity of care; • Structures communication • Within and across professions; • Within and across nations; • Allows evaluation of the quality of care; • Facilitates research and building of a professional knowledge base (e.g. Practice-Based Evidence in Nutrition developed by Dietitians of Canada. There is now a PEN global dietetic partnership of associations of Australia, Canada, Ireland, New Zealand, South Africa and the UK, Evidence Analysis Library of Academy of Nutrition and Dietetics); • Facilitates professional development; and • Improves professional image, credibility, accountability of dietitians. Dietetic and Nutrition Case Studies, First Edition. Edited by Judy Lawrence, Pauline Douglas, and Joan Gandy. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd. Companion Website: http://www.manualofdieteticpractice.com/ 8 Nutrition care process terminology (NCPT) 9 Why is standardised language important? It provides a common means of communication for healthcare professionals. Other healthcare professions, for example, nurses, physiotherapists, occupational therapists and so on have shown the benefits of having a standardised language. Making nurs- ing practice count (Beyea, 1999) ensures that when a nurse talks about a stage three pressure area, another nurse fully understands what the first nurse is describing. An example from dietetics is that there are differing definitions and understanding of what is meant by nutritional support. In some countries this relates to enteral and parenteral nutrition and in others this also includes food fortification and oral nutri- tional supplementation. A standardised language is complementary to a nutrition and dietetic process. It ensures that there is comparability in the terms used to describe diagnoses, interven- tions and outcomes of nutritional care. It is important to stress that this still ensures the dietitian provides individualised nutritional care for the patient or the population ensuring the patient/service user is at the centre of all care by taking into account their needs, values and culture. Dietitians do not work alone. They are integral members of the inter-professional health team. As such communication of their work needs to be accessible to other healthcare professionals, commissioners of service or those reimbursing them for their services. The World Health Organization uses the International Classification of Diseases (ICD) as the standard diagnostic tool for epidemiology, health manage- ment and clinical purposes. It is used to monitor the incidence and prevalence disease for general health and populations. Similarly the International Classification of Func- tioning, Disability and Health (ICF) is the WHO framework for measuring health and disability at both individual and population levels. In 2003 the Academy of Nutrition and Dietetics (AND) published the concepts of a nutrition care process and model. Other professional bodies have now modi- fied this to best meet the needs of their members and their healthcare provision, for example, BDA (2012). In 2008, AND defined the language to complement the pro- cess. This was called International Dietetic and Nutrition Terminology (IDNT) now known as the Nutrition Care Process Terminology (NCPT). In Europe, the Dutch Dietetic Association were also developing another dietetic language. This was mod- elled on the International Classification of Function (ICF) and is now recognised as the ICF – Dietetique. Now as the work of the National Dietetic Associations from across the world is being published, working groups are being established to facilitate international collaboration to further develop dietetic practice in this area. The International Health Terminology Standards Development Organization (IHTSDO) is a not for profit organisation based in Europe. This organisation owns and administers the rights to health terminologies and related standards includ- ing Systematised Nomenclature of Medicine – Clinical Terms (SNOMED – CT). SNOMED – CT is a comprehensive medical terminology incorporating several termi- nologies from various healthcare disciplines. While being of international scope it can be adapted to each countries requirements. This international dietetic working group has been working closely to incorporate NCPT as an integral element of SNOMED. 10 Dietetic and Nutrition Case Studies The WHO and IHTSDO have agreed to try to harmonise WHO classifications and SNOMED – CT terminologies to develop common terms used by both organisations. This has the potential to support further integration of different dietetic languages and thus enhance dietetic practice. In Europe a key priority is ‘to support Member States in developing common identification and authentication measures to facilitate transferability of data across border healthcare’ (Euro- pean Parliament and Council, 2011). As a result NCPT developments have facilitated eNCPT being available in several languages, for example, English, French, Italian, Spanish and Swedish again supporting international standards for dietetic practice and facilitating working across borders. Nutrition care process terminology The NCPT is used alongside the Nutrition and Dietetic Care Process. In the diagnosis the PASS statement (problem, aetiology, signs and symptoms) the problem is the change in nutrition state that is described by adjectives such as decreased/increased, excessive/inadequate, restricted and imbalanced. In addition nutrition and dietetic diagnosis terms fall into one of seven categories: • Energy balance; • Oral or nutritional support; • Nutrient intake; • Function, for example, swallowing; • Biochemical; • Weight; and • Behavioural/environmental. The descriptors used in the different countries can challenge the dietitian to define the problem in a way that their service users may find acceptable. The interested professional bodies are collaborating on this to gain appropriate, relevant country specific additions and alternatives. Dietetic professional bodies need to continue to work collaboratively to ensure deititians have a standardised language. It is important that the dietetic profession continue to engage with and use the NCPT. It should become an integral element of academic training, further developed within practice placement settings and then fully embraced by dietitians throughout their professional practice. Acknowledgements The Professional Practice Committee of the European Federation of Associations of Dietitians especially Constantina Papoutsakis, Ylva Orrevall, Lene Thorensen, Naomi Trostler, Remijnse Wineke and Claudia Bolleurs for their insight and knowledge. Nutrition care process terminology (NCPT) 11 References BDA (2012) Model and Process for Dietetic Practice. BDA, Birmingham. Beyea, S.C. (1999) Standardised language – making nursing practice count. AORN Journal, 70, 831–832, 834, 837–838. European Parliament and Council. (2011) Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011, on the application of patients’ rights in cross-border healthcare, Article 14, Official Journal of the European Union, L 88, 45. Resources AND Evidence Analysis Library. www.andeal.org. BDA Diagnosis Terms. www.bda.uk.com/professional/practice/terminology. Practice Based Evidence in Nutrition (PEN). www.pennutrition.com/index.aspx. CHAPTER 3 Record keeping Judy Lawrence In the UK the Health and Care Professions Council (HCPC) (2013) requires that dietitians ‘make reasoned decisions’ and ‘record the decisions and reasoning appropriately’ as part of their Standards of Proficiency. There is also a specific record keeping standard of proficiency; standard 10 which is ‘be able to maintain records appropriately’, this is expanded in points 10.1 and 10.2 which outline the need for records to be in line with relevant protocols, guidelines and legal requirements. This chapter discusses these guidelines and legal requirements. Dietitians from outside the UK should check with their own regulatory body and employer to ensure that their record keeping meets the required standard. Legislation In the UK there are a number of pieces of legislation that relate to records and record keeping. The Data Protection Act 1998 The Act relates to the protection of personal data (e.g. medical notes) about a liv- ing individual, such as data held by a public authority (e.g. NHS). This includes patient record cards kept by a dietitian, medical records to which a dietitian may contribute and electronic records. Data is said to be identifiable even if the informa- tion is recorded against a number that can then be matched to a person by accessing a different piece of information. The Act also regulates the processing of personal data. The term processing includes the storage, use, disclosure and the destruction of the data. The Act has six principles, they are that data should be processed fairly and lawfully, that data collected for a specific purpose or purposes should not be further processed for any purpose that is incompatible with the original purpose, that data collection should not be excessive in relation to the purpose, data should be accurate and where necessary up to date, data should not be kept for longer than is necessary and finally data should be processed in accordance with the rights of the individual. These principles may be subject to interpretation by an employer, and there will be Dietetic and Nutrition Case Studies, First Edition. Edited by Judy Lawrence, Pauline Douglas, and Joan Gandy. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd. Companion Website: http://www.manualofdieteticpractice.com/ 12 Record keeping 13 local policies relating to them, for example a patient has the right to request access to information about themselves. A patient can ask to see what you have written during a consultation and comment on what has been written. If a patient or carer writes requesting to see the notes it is necessary to conform to local policy require- ments first, for example, an employer may require certain information as proof of identity from the patient or carer. All records are owned by the employing authority and requests for medical notes or electronic records should be dealt with by the clin- ical governance team. With regard to information being accurate, an opinion about a patient’s nutritional condition that you believe to be accurate but that the individ- ual disagrees with or believes to be inaccurate may be expressed. For example an anorexic patient may regard the statement that they are underweight as inaccurate. It is still legally possible to make this statement in their notes although a record that the patient disagrees with the assessment should be noted. The assessment should be backed by recording a weight and relevant BMI range. Freedom of Information Act 2000 The Freedom of Information Act covers information held by public bodies in England, Wales and Northern Ireland, information in Scotland is covered by Scotland’s 2002 Freedom of Information Act. The Freedom of Information Act is about removing unnecessary secrecy; it allows members of the public to request information from public authorities. The NHS and state schools are public authorities, but not all chari- ties that receive public money would necessarily be covered by the Act. The Act does not cover patient’s access to health records; this process is covered by the Data Protec- tion Act as discussed above. A dietitian employed by the NHS and working in private practice would only have to disclose information about their NHS work under the Act. The Act only covers information that is recorded, it is not necessary to write informa- tion down specifically to disclose it if it is not already recorded. Minutes of meetings and continuing professional development (CPD) portfolios are regarded as records. Private information on a work computer such as a private email does not have to be disclosed, but it would be necessary to disclose work related emails if requested. Organisations should have policies or guidelines in place to help employees comply with the Act. The Act does not interfere with copyright laws or intellectual property rights. Therefore someone can request copies of diet sheets that but they cannot use this information to produce copies if the work is subject to copyright. If a patient makes a request for information it is necessary to respond within 20 working days so it is important to contact the appropriate person in the organisation as soon as possible so that the request can be dealt with promptly. If a patient ver- bally asks for information they should be helped to put the request in writing and sent by post, email, a request on the organisation’s Facebook page or Twitter feed, to the appropriate person. Any information that can be shared easily such as clinic times or numbers of people working in a department should not be subject to formal procedures. The Data Protection Act may prohibit the release of data that has been requested; the clinical governance team or appropriate person, should be consulted for advice. Clinical records should only be released by a person specified to do so within the organisation. 14 Dietetic and Nutrition Case Studies Access to Health Records Act 1990 This Act gives people the right to request access to the health records of a deceased person. Guidelines There are a number of guidelines available. The NHS has an information gover- nance toolkit (https://www.igt.hscic.gov.uk/) that aims to help individuals and organisations to handle information properly. Each NHS organisation should have an individual appointed as a Caldicott Guardian, it is their responsibility to ensure that the organisation respects patient confidentiality and service user information. The BDA (2008) has guidance on record keeping although it is important to recognise that the nutrition and dietetic care process should guide the content of record keeping, for example, assessment, diagnosis, intervention and so on. The Royal College of Physicians (2013) has also produced record keeping standards covering electronic health records that have been endorsed by the BDA. The case studies in this book have questions about recording information and these guidelines may be helpful, but individual employer’s guidelines should be followed first. The introduction of electronic records should improve accuracy in health care records by improving legibility and access. The use of common language and SNOMED terms should also improve communication and understanding between the various health professionals using the health record. For more information about the nutrition and dietetic terms in SNOMED, see Chapter 2. Good record keeping should include the following points: • Records should be made at the time of the event or as near as possible to that time. • Records should be complete, accurate and fit for purpose. • A complete record should include details of an assessment, what care has been provided or is planned, and any action that has been taken or shared with other health professionals. • Handwriting on paper records should be legible and in black ink. • Records should be dated and signed with a name and designation. • Records should be clear, terms such as ‘ate well’ should be avoided. • Records should be relevant and opinions justified if possible. • Records should be in electronic format wherever possible. • Always log off an unattended computer. Social media Records can be in a variety of formats that includes social media, telephone messages and videos. The BDA (2013) and the Dietitians Association of Australia (2011) both have useful publications to help get the most out of social media whilst avoiding some of the pitfalls. In essence it is essential to think before posting and don’t make comments that would not be said a in person in a professional meeting. Don’t reveal Record keeping 15 information that could identify a patient or client either directly or indirectly and don’t repeat anything that is confidential. References BDA. (2008) Guidance for dietitians for records and record keeping. www.bda.uk.com/publications/ professional/record_keeping [accessed on 22 September 2015]. BDA. (2013) Professional guidance document. Making sense of social media. www.bda.uk.com/ professional/practice/professionalism/social_media [accessed on 22 September 2015]. Dietitians Association of Australia. (2011) Dialling into the digital age. Guidance on social media for DAA members. http://www.pennutrition.com/KnowledgePathway.aspx?kpid=3728& trid=22864&trcatid=33 [accessed on 8 October 2015]. Health and Care Professions Council (HCPC). (2013) Standards of proficiency. www.hpc- uk.org/assets/documents/1000050CStandards_of_Proficiency_Dietitians.pdf [accessed on 22 September 2015]. Royal College of Physicians. (2013) Standards for the clinical structure and content of patient records. https://www.rcplondon.ac.uk/resources/standards-clinical-structure-and-content-patient- records [accessed on 22 September 2015]. Resources Health and Social Care Information Centre Guide to confidentiality in health and social care. (2013) Treating confidential information with respect. http://www.hscic.gov.uk/media/12822/ Guide-to-confidentiality-in-health-and-social-care/pdf/HSCIC-guide-to-confidentiality.pdf [accessed on 22 September 2015]. Information Commission Office. The guide to data protection. https://ico.org.uk/for-organisations/ guide-to-data-protection/ [accessed on 22 September 2015]. Information Commission Office. The guide to freedom of information. https://ico.org.uk/media/ for-organisations/documents/1642/guide_to_freedom_of_information.pdf [accessed on 22 September 2015]. NHS England. (2014) Documents and record management policy. http://www.england.nhs.uk/wp- content/uploads/2014/02/rec-man-pol.pdf [accessed on 22 September 2015]. Qureshi, N. et al. (2014) Professional practice. In: Gandy, J. (ed), Manual of Dietetic Practice, 5th edn. Wiley Blackwell, Oxford. CHAPTER 4 Assessment Joan Gandy Assessment is fundamental to dietetic and nutrition practice and an essential step in the nutrition and dietetic process (see Chapter 1). The BDA (2012) defined assess- ment as ‘ … a systematic process of collecting and interpreting information in order to make decisions about the nature and cause of nutrition related health issues that affect an individual, a group or a population’. It forms the basis of the nutrition and dietetic diagnosis and intervention and is key in establishing outcome measures in order to evaluate and monitor the intervention. The ABCDE format, as described by Gandy (2014) has been developed to structure and standardise dietetic and nutrition assessment. This format is used throughout this book and often summarised in a table. Table 4.1 gives details of the five domains used in this format. The information collected during assessment and the tools used to collect this information will vary depending on the setting, for example, individual, group, com- munity, and population. Domains Anthropometry, body composition and function Anthropometry is often used in nutrition and dietetic assessments with height and weight being used most frequently. Since the introduction of easily available equipment body composition and functional assessments, for example, bioelectri- cal impedance analysis (BIA) and dynamometry, are increasingly being used by dietitians and nutritionists in a variety of settings. Anthropometry Anthropometry is defined as the external measurement of the human body. It is affected by nutritional and health status and other factors including ethnicity, age and gender. Anthropometric measurements are often used in prediction equations, for example, body mass index (BMI), or compared with standards. It is essential that stan- dards that are appropriate to the age, ethnic or gender group be used. All equipment must be serviced regularly, for example, weighing scales, or replaced as appropriate Dietetic and Nutrition Case Studies, First Edition. Edited by Judy Lawrence, Pauline Douglas, and Joan Gandy. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd. Companion Website: http://www.manualofdieteticpractice.com/ 16 Assessment 17 Table 4.1 Nutritional assessment domains. Domain Example procedure for individuals Anthropometry, body composition and Weight, height, body mass index, skinfold thickness, functional waist circumference Bioelectrical impedance analysis Biochemical and haematological Grip strength dynamometry Physical activity questionnaires Clinical Diet Vitamin status tests Environmental, behavioural and social Lipid status Iron status – haemoglobin, ferritin and so on Physical appearance, blood pressure, medication, indirect calorimetry 24 h recall, food frequency questionnaire (FFQ) Shopping habits, housing, cooking facilities, education Source: Gandy (2014), Table 2.2.1, p. 48. Reproduced with permission from Wiley Blackwell. for example tape measures will stretch over time. Anthropometry requires training and experience to produce reliable and reproducible results. It is essential to establish what, if any, standards are used within the local context, for example, NHS guidance. Body weight Weighing scales must be maintained and calibrated regularly and should be Class III or above. Body weight is affected by many factors including fluid retention (oedema, ascites), dehydration, accuracy of the scales, amputations, splints, casts and replace- ment joints. A weight adjustment table for amputations is shown in Appendix A5. If weight cannot be obtained self reported weight, estimated weight made by carers, relatives, dietitians or other health care professionals may be used. Specialist weigh- ing equipment, for example, weighing beds and chairs are available in some clinical settings, for example, spinal cord injury, obesity clinics. Height Height is usually measured using a stadiometer. When height cannot be measured, for example, bed bound patients, or is unreliable, for example, scoliosis it can be estimated using alternative methods such as ulna length, knee height or demispan (Appendix A5). Body mass index BMI is a weight for height indicator that may be used to classify overweight and obesity and is calculated as weight (kg)/height (m2). A ready reckoner and the WHO classifications of BMI for overweight and obesity are shown in Appendix A4. BMI does not give an indication of adipose distribution and therefore is being superseded as the preferred measure of non-communicable disease risk by waist circumference. It is affected by ethnicity, setting, age and body composition. If height is not available 18 Dietetic and Nutrition Case Studies in the elderly (over 64 years) demiquet or mindex can be used for men and women respectively (Appendix A4). Waist circumference Waist circumference assesses visceral adiposity and is therefore increasing used to assess obesity related morbidity risk. NICE (2006) recommend the use of both BMI and waist circumference to assess health risks. Appendix A5 shows the WHO waist circumference classifications for health risks (WHO, 2008). It is measured at the halfway point between the lowest rib and the iliac crest in the midaxillary line. Mid upper arm circumference When neither weight nor height can be measured, the BMI can be estimated using the mid upper arm circumference (MUAC), or mid arm circumference (MAC). Appendix A5 shows reference data derived from an American population; UK data is not available. Skinfold thickness Calipers are used to take skinfold measurements at specific sites to estimate per- centage body fat by substitution into prediction formulae, for example, Durnin & Womersley (1974). Triceps skinfold thickness (TSF) is used in bed bound patients to estimate endogenous fat stores (see Appendix A5). It can be combined with MUAC to evaluate body composition and is especially useful in patients with peripheral oedema or ascites Mid arm muscle circumference (MAMC) Mid arm muscle circumference (MAMC) is derived from TSF and MUAC as an indica- tor of muscle mass and therefore protein stores. The formulae used to derive MAMC and standards are shown in Appendix A5. Body composition Dietitians frequently use skinfold thicknesses to evaluate body composition however increasing other techniques such as BIA are being used. Functional assessment An example of this is hand grip strength (HGS) dynamometry (Appendix A5). Impaired HGS is associated with poor postoperative recovery (Griffiths & Clark, 1984) and related to loss of independence in the elderly. Increasingly dietitians assess physical activity levels; questionnaires are frequently used although other tools, for example, accelerometers are available. Biochemical and haematological markers Biochemical and haematological parameters are an important part of assessment and as outcome measures used in evaluation of the intervention. These markers are essen- tial when monitoring many clinical conditions, e.g. diabetes mellitus, renal disease and in assessing the status of some nutrients, for example, iron status in anaemia. Assessment 19 Appendix A7 gives examples of reference ranges for some parameters; it is essential to recognise that normal ranges and standards will vary between laboratories and that reference ranges from the local setting must be used. Clinical The clinical assessment will include physical appearance, medical history, test results and current medication; both prescribed and obtained without prescription. These details can usually be collated from the nursing or medical notes or family or carers. When collating information on medication it is important to consider drug nutrient interactions. The medical history and test results are vital elements of the assessment giving essential information for developing the intervention. Physical observations are vital indicators of nutritional status and should not be overlooked. For example loose clothing may indicate weight loss, breathlessness may indicate anaemia or other clinical conditions. Dietary assessment Establishing the extent to which nutritional needs are being met is core to the nutri- tion and dietetic assessment. It is usually important to assess current food and bever- age intake, changes (duration and severity) in appetite and factors that affect intake. In clinical situations may also be important to consider recent changes in meal pat- terns, food choice and consistency. The choice of dietary assessment method will depend on many factors including setting, population, age, literacy, assessor training and experience, cost, nutrients to be assessed, etc (Welch, 2014). An understanding of the limitations and applications of each method is essential in clinical and other settings to ensure the most appropri- ate method. Assessment can be either respective or current. Table 4.2 describes the characteristics of the most frequently used dietary assessment methods. It is impor- tant to quantify foods and drinks consumed either by weighing or estimations. Pho- tographs, models and standard size serving vessels may be used to aid quantification. Dietary data can be used qualitatively, for example, to assess food preferences or meal patterns however in clinical practice it is most frequently used quantitatively. The energy and nutrient content of the diet are calculated using food composition data. A software programme is most frequently used to facilitate these calculations. However an understanding of the limitations of food composition data is essential (Landais & Holdsworth, 2014). The results of any dietary assessment need to be interpreted in the context of the individual or population’s requirements. This is usually done by comparison with dietary reference values such as those published by the Department of Health (1991) and SACN (2011) or dietary recommendations (SACN, 2008) or the Institute of Medicine. However it is important to consider the limitations of any dietary reference value (Gandy, 2014). Environmental, behavioural and social assessment These factors can have a significant impact on nutritional status. Relevant factors include psychological status, for example, depression, ability to buy, prepare and cook 20 Dietetic and Nutrition Case Studies Table 4.2 Characteristics of dietary assessment methods. Method Advantages Limitations Retrospective methods Not reliant on long-term Single 24 HR can be used for group 24 h recall (24 HR) (single or memory; interview length assessments but not for estimating multiple days) 20–45 min intake of individuals Diet history Respondent literacy not required Report of past intake is influenced by Food frequency questionnaire current diet; trained interviewers (FFQ) (if portion estimates Useful for large sample sizes; required included termed semi relatively straightforward to quantitative FFQ) complete Need to be developed for specific population group to ensure important Short frequency questionnaires Targeted to specific food types, food items are covered and requires administration simpler and updating to accommodate changes to easier than long questionnaires supply of foods; responses governed by cognitive, numeric, and literacy abilities of respondents also by length and complexity of the food list Not easy to develop for clinical practice since specific computer programs need to be developed Need to be developed for specific population group to ensure questions are relevant Current methods No requirement for memory Literate, cooperative respondents Weighed food record (weighed retrieval as it records current required as burden is high; possible inventory technique) intake; food intake weighed so that respondents change usual eating estimates of quantity patterns to simplify the record; high Food record with estimated consumed not required data entry costs weights No requirement for memory retrieval as it records current Literate, cooperative respondents Duplicate analysis intake required as burden is high; possible that respondents change usual eating Records using electronic Greater accuracy patterns to simplify the record equipment, for example, mobile phones, digital cameras Visual records of foods. Avoids Very labour intensive; requires need for paper records. Data laboratory to do food composition can be sent to investigators analysis electronically Currently involves labour intensive programmes to convert to usable data, that is, quantities and types of foods, although systems are in development to deal with this; limited use in older people who experience difficulties with using newer technology Source: Gandy (2014), Table 2.3.1, p. 62. Reproduced with permission from Wiley Blackwell. Assessment 21 food and social factors religious and cultural beliefs, income, education and addiction, for example, alcoholism. References BDA (2012). Process and model for nutrition and dietetic practice. www.bda.uk.com/professional/ practice/process [accessed on 27 May 2015]. Department of Health (DH) (1991) Dietary reference values for food energy and nutrients for the United Kingdom. Report of the Panel on dietary reference values of the Committee on Medical Aspects of Food Policy. Report on Health and Social Subjects 41. HMSO, London. Durnin, J.V.G.A. & Womersley, J. (1974) Body fat assessed from total body density and its esti- mation from skinfold thickness: measurements on 481 men and women aged from 16 to 72 years. British Journal of Nutrition, 32, 77–97. Gandy, J. (2014) Assessment of nutritional status. In: Gandy, J. (ed), Manual of Dietetic Practice, 5th edn. Wiley Blackwell, Oxford. Griffith, C.D.M. & Clark, R.G. (1984) A comparison of the ’Sheffield’ prognostic index with forearm muscle dynamometry in patients from Sheffield undergoing major abdominal and urological surgery. Clinical Nutrition, 3, 147–151. Landais, E. & Holdsworth, M. (2014) Food composition tables and databases. In: Gandy, J. (ed), Manual of Dietetic Practice, 5th edn. Wiley Blackwell, Oxford. National Institute for Health and Clinical Excellence (NICE) (2006) Obesity Guidance on the Pre- vention, Identification, Assessment and Management of Overweight and Obesity in Adults and Children. Clinical Guideline 43. NICE, London. Scientific Advisory Committee on Nutrition (2008) Dietary Reference Values for Energy TSO London. www.sacn.gov.uk [accessed on 25 September 2015]. Scientific Advisory Committee on Nutrition (2011) The nutritional wellbeing of the British popula- tion TSO London. www.sacn.gov.uk [accessed on 25 September 2015]. Welch, A. (2014) Dietary assessment. In: Gandy, J. (ed), Manual of Dietetic Practice, 5th edn. Wiley Blackwell, Oxford. World Health Organization (2008) Waist circumference and waist–hip ratio. Report of a WHO expert consultation. www.who.int [last accessed 16 February 2013]. Resources Gandy, J. (2014) Assessment of nutritional status. In: Gandy, J. (ed), Manual of Dietetic Practice, 5th edn. Wiley Blackwell, Oxford. Gandy, J. (2014) Dietary reference values. In: Gandy, J. (ed), Manual of Dietetic Practice, 5th edn. Wiley Blackwell, Oxford. Gibson, R.S. (2005) Principles of Nutritional Assessment, 2nd edn. Oxford University Press, Oxford. Landais, E. & Holdsworth, M. (2014) Food composition tables and databases. In: Gandy, J. (ed), Manual of Dietetic Practice, 5th edn. Wiley Blackwell, Oxford. PEN: Practice Based Evidence in Nutrition-Nutrition assessment. http://www.pennutrition.com/ KnowledgePathway.aspx?kpid=16177&trid=16444&trcatid=42 [accessed on 25 September 2015]. UK Food Databanks. http://www.ifr.ac.uk/fooddatabanks/nutrients.htm [accessed on 25 September 2015]. Welch, A. (2014) Dietary assessment. In: Gandy, J. (ed), Manual of Dietetic Practice, 5th edn. Wiley Blackwell, Oxford. PART II CASE STUDY 1 Veganism Sandra Hood Wendy is 32 years old, a single mother with a 6-year-old daughter. She has a law degree and works part time in a legal practice. Wendy has recently changed from a vegetarian diet, which she followed for the previous 10 years, to a vegan diet. Wendy is very active, walking her daughter to and from school daily, which is 3 miles away, making a total of 12 miles a day. She also attends ballet classes once a week. At her own request, she has been referred by her GP, following a recent diagnosis of rheuma- toid arthritis (RA). Assessment Weight 43 kg Domain Height 1.49 m Anthropometry, body None composition and functional Biochemical and No medical history of note documented haematological markers Breakfast Clinical Banana (100 g) or avocado (145 g) Diet Lunch Salad sandwich (140 g) followed by dried fruit Environmental, behavioural (60 g) and sunflower seeds (15 g) and social Dinner (main meal) Wholemeal rice (180 g) or other grain with salad (250 g) or stir fried vegetables (180 g) Snacks – fresh fruit Drinks – water Prior to changing to a vegan diet, was very reliant on cheese Very active Dietetic and Nutrition Case Studies, First Edition. Edited by Judy Lawrence, Pauline Douglas, and Joan Gandy. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd. Companion Website: http://www.manualofdieteticpractice.com/ 25 26 Dietetic and Nutrition Case Studies She suffered from anorexia when she was 16 years old but is in remission and managing well although she remains anxious about her weight. Questions 1. What is the definition of a vegan diet? 2. What other information do you need? 3. What is the nutrition and dietetic diagnosis? Write it as a PASS statement. 4. Which nutrients in particular should be considered when assessing a vegan diet? 5. What is Wendy’s body mass index (BMI), and is this cause for concern? 6. Wendy has been self-referred via her GP. Do you need to inform the GP of your discussions with Wendy? Further questions 7. Fish oil supplements rich in n − 3 PUFAs have been found to ameliorate pain and symptoms of RA (Goldberg & Katz, 2007). Are there any plant-based alternatives? 8. Wendy is considering a further pregnancy. What would be your concerns? 9. What are the ethical implications of accepting a referral from Wendy when your clinical service is overstretched? References Appleby, P., Roddam, A., Allen, N. et al. (2007) Comparative fracture risk in vegetarians and non-vegetarians in EPIC Oxford. European Journal of Clinical Nutrition, 61 (12), 1400–1406. Carter, J.P., Furman, T. & Hutcheson, H.R. (1987) Preeclampsia and reproductive performance in a community of vegans. Southern Medical Journal, 80 (6), 692–697. Craig, W.J. & Mangels, A.R. (2009) Position of the American Dietetic Association: vegetarian diets. Journal of the American Dietetic Association, 109 (7), 1266–1282. Crowe, F.L., Steur, M., Allen, N.E. et al. (2011) Plasma concentrations of 25-hydroxy vitamin D in meat eaters, fish eaters, vegetarians and vegans: results from the EPIC Oxford study. Public Health and Nutrition, 14 (2), 340–346. Davis, B.C. & Kris-Etherton, P.M. (2003) Achieving optimal essential fatty acid status in veg- etarians: current knowledge and practical implications. American Journal of Clinical Nutrition, 78 (Suppl. 3), 640S–646S. De Bortoli, M.C. & Cozzolino, S.M. (2009) Zinc and selenium nutritional status in vegetarians. Biological Trace Element Research, 127 (3), 228–233. Erdeve, O., Arsan, S., Atasay, B. et al. (2009) A breast-fed newborn with megaloblastic anaemia- treated with vitamin B12 supplementation of the mother. Journal of Pediatric Hematology and Oncology, 31 (10), 763–765. Gibson, R.S. (1994) Content and bioavailability of trace elements in vegetarian diets. American Journal of Clinical Nutrition, 59 (Suppl. 5), 1223S–1232S. Goldberg, R.J. & Katz, J. (2007) A meta-analysis of the analgesic effects of omega-3 polyunsat- urated fatty acid supplementation for inflammatory joint pain. Pain, 129, 210–223. Institute of Medicine, Food and Nutrition Board (2001) Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. National Academy Press, Washington, DC. Veganism 27 Kniskern, M.A. & Johnston, C.S. (2011) Protein dietary reference intakes may be inadequate for vegetarians if low amounts of animal protein are consumed. Nutrition, 27 (6), 727–730. Kornsteiner, M., Singer, I. & Elmadfa, I. (2008) Very low n − 3 long chain polyunsaturated fatty acid status in Austrian vegetarians and vegans. Annals of Nutrition and Metabolism, 52 (1), 37–47. Leung, A.M., Lamar, A., He, X. et al. (2011) Iodine status and thyroid function of Boston-area vegetarians and vegans. Journal of Clinical Endocrinology and Metabolism, 96 (8), E1303–E1307. Mangels, R., Messina, V. & Messina, M. (2010) The Dietitian’s Guide to Vegetarian Diets, 3rd edn. Jones and Bartlett, Sudbury, MA, pp. 530–535. Mariani, A., Chalies, S., Jeziorski, E. et al. (2009) Consequences of exclusive breast feeding in vegan mother newborn – case report. Archives of Pediatrics, 16 (11), 1461–1463. Mathey, C., Di Marco, N., Poujol, A. et al. (2007) Failure to thrive and psychomotor regression revealing vitamin B12 deficiency in 3 infants. Archives of Pediatrics, 14 (5), 467–471. Outilia, T.A., Karkkainen, M.U., Seppanen, R.H. et al. (2000) Dietary intake of vita- min D in premenopausal healthy vegans was insufficient to maintain concentrations of 25-hydroxyvitamin D and intact parathyroid hormone within normal ranges during the win- ter in Finland. Journal of the American Dietetic Association, 100 (4), 434–441. Roed, C., Skovby, F. & Lund, A.M. (2009) Severe vitamin B12 deficiency in infants breastfed by vegans. Ugeskr Laeger, 171 (43), 3099–3101. Rosell, M.S., Lloyd-Wright, Z., Appleby, P.N. et al. (2005) Long chain n − 3 polyunsaturated fatty acids in plasma in British meat-eating, vegetarian and vegan men. American Journal of Clinical Nutrition, 82 (2), 327–334. Sanders, T.A. (2009) DHA status of vegetarians. Prostaglandins, Leukotrienes and Essential Fatty Acids, 81 (2–3), 137–141. Simpoulous, A.P. (2009) Omega-6/omega-3 essential fatty acids: biological effects. In: A.P. Sim- poulous & N.G. Bazan (eds) Omega-3 fatty acids the brain and retina. World Review of Nutrition and Dietetics, 99, 1–16. Smolka, V., Bekarek, V., Hlidova, E. et al. (2001) Metabolic complications and neurologic mani- festations of vitamin B12 deficiency in children of vegetarian mothers. Journal of Czech Physi- cians, 140 (23), 732–735. Weiss, R., Fogelman, Y. & Bennett, M. (2004) Severe vitamin B12 deficiency in an infant asso- ciated with a maternal deficiency and a strict vegetarian diet. Journal of Pediatric Hematolgy and Oncology, 26 (4), 270–271. Welch, A.A., Shakya-Shrestha, S., Lentjes, M.A. et al. (2010) Dietary intake and status of n − 3 polyunsaturated fatty acids in a population of fish-eating and non-fish-eating meat-eaters, vegetarians and vegans and the product-precursor ratio [corrected] of alpha-linolenic acid to long-chain polyunsaturated fatty acids: results from the EPIC-Norfolk cohort. American Journal of Clinical Nutrition, 92 (5), 1040–1051. Resources Gardener, E. (2014) Vegetarianism and vegan diets. In: J. Gandy (ed), Manual of Dietetic Practice, 5th edn. Wiley Blackwell, Oxford. PEN: Practice Based Evidence in Nutrition. Do individuals with rheumatoid arthritis who follow a vegan diet have improvement in their arthritic symptoms compared to individuals with rheumatoid arthritis who follow a non-vegetarian diet?. http://www.pennutrition.com/KnowledgePathway .aspx?kpid=978&pqcatid=146&pqid=7876. CASE STUDY 2 Older person – ethical dilemma Nicola Howle∗ Rose is currently an inpatient at the mental health hospital; she is 93 years old. Her only family is her sister, who she lived with prior to admission. She often appears confused and has limited engagement in conversations. Rose is bedbound and hoisted for all transfers. She has been in hospital for 4 months; she was originally admitted to the acute hospital following a fall at home and was treated in the elderly assessment ward for a urinary tract infection. She was then discharged to a community hospital for assessment of her care needs and rehabilitation. During this time she refused to eat and drink, and underwent a period of naso-gastric (NG) feeding. She pulled the NG tube out twice and continued to refuse to eat and drink. The ward doctors felt she was depressed, so Rose was admitted to an older peoples assessment ward at the mental health hospital. At this time she was referred to the dietetic service for urgent provision of an NG feeding regimen to help build her up prior to commencing electroconvulsive therapy (ECT). On attending the ward, the doctor and nursing staff are very concerned about Rose. She has been assessed by a second opinion doctor who states that Rose is unlikely to survive ECT. The ward staff are unconvinced that she is depressed as Rose has lim- ited communication and they are unable to complete the assessments for depression. The ward staff and doctor feel that she is at the end of her life and should be kept comfortable. However, the consultant has asked for NG feeding for 2 weeks and to go ahead with ECT later that week. IV fluids have been prescribed as her oral intake is very poor. ∗On behalf of the BDA Older People Specialist Group. Dietetic and Nutrition Case Studies, First Edition. Edited by Judy Lawrence, Pauline Douglas, and Joan Gandy. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd. Companion Website: http://www.manualofdieteticpractice.com/ 28

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Climbing Nutrition

Case study #1: simon (20-year-old athletic male).

by Brian Rigby, MS, CISSN

March 31, 2016 10 Replies

Case Studies

Since I started this blog almost a year ago, I’ve written many articles on good practices in sports nutrition, eating for climbing performance, and also on popular myths that ought to be debunked. I hope that through these articles you have been able to make healthy changes to your diet, and as a result have seen your climbing improve.

This is all good, but there’s still something missing—sometimes it’s hard to bridge the gap between theory and practice. For this reason, I’m debuting a new type of feature I’ll be running every now and again on Climbing Nutrition: Case Studies . Basically, I’m going to show you some of the process I would go through were I to see a particular individual as a client.

Though each case study is by nature individual (and therefore not necessarily cut to fit your own physiology), the basic work remains similar—so you should be able to go through the process yourself to come up with your own results.

Alright, let’s begin:

Client Information

Name: Simon Age: 20 Sex: Male Height: 5′ 10″ (178 cm) Weight: 145 lbs (66 kg)

Client’s Reason for Inquiry

I climb 3-4 days each week and ski (teaching and touring) another 2. For a long time, I’ve tried to keep my weight low in order to have the best strength-to-weight ratio, but whenever I make gains on the strength side from my training it doesn’t seem to transfer to my climbing. I’ve been stuck at v5-v6 for about a year now.

Simon’s weight and height gives him a BMI (body mass index) of 20.8, well within the healthy range of 18.5 to 24.9. A flaw in the design of the BMI, however, is that it cannot accurately measure fat mass vs. lean mass. Athletes tend to have greater amounts of lean mass (and less fat) than the average individual whom the BMI was designed for, and so in reality Simon is likely even leaner than the BMI indicates (in extreme cases, large athletes can appear to be “overweight” according to their BMI due to muscle mass). Without a body fat reading we cannot know for certain, but it’s probable that Simon has no more than 10-12 lbs of (perfectly healthy) fat he could lose before dropping into an unhealthy range. Thus, as far as strength-to-weight ratio is concerned, losing weight is not likely to yield a major benefit, especially for the amount of work it would require to lose fat below this already low level.

In our correspondence, Simon says he eats around 2,400 calories each day. Since Simon exercises 5-6 days each week, it’s unlikely this is enough calories to support his strength goals. Instead, this amount of energy is likely to be on the lower end of weight maintenance—a sort of metabolic limbo where the body attempts to preserve muscle tissue but doesn’t have enough energy to support muscle growth. Chances are good that Simon could eat significantly more calories each day and still maintain weight, or gain only minimal weight through muscle gain. He will also have more energy to train harder (or longer at a higher intensity), which will have even more significant effects on his strength.

Client Caloric Goal

Using the Harris-Benedict Energy Equation , we can calculate that Simon has a basal metabolic rate (BMR) of roughly 1,675 kcal/day.

Harris-Benedict Energy Equation

• Imperial: (4.55 * weight in lbs) + (15.88 * height in inches) – (5 * age in years) = BMR
• Men: Add 5 calories to the calculated BMR
• Women: Subtract 161 calories from the calculated BMR

A BMR only covers the essential functions necessary for sustaining life at its most basic level, though; unless Simon is literally lying in bed all day—eating nothing, drinking nothing, doing nothing—we need to multiply it by the appropriate modifier. There are two ways of doing this: the simple, averaged approach; or the more complex, individualized approach. Since Simon has given me a breakdown of his weekly activities, I will ultimately use the individualized approach. First, however, I’ll show you the generalized approach in case you choose to use this method instead.

Harris-Benedict Activity Modifiers

• Sedentary:  BMR * 1.2
• Light (1-3 days/week):  BMR * 1.375
• Moderate (3-5 days/week):  BMR * 1.55
• Vigorous (6-7 days/week):  BMR * 1.725
• Extreme (6-7 days/week, multiple workouts per day):  BMR * 1.9

Since Simon exercises an average of 5-6 days per week (3-4 days climbing, 2 days skiing), he falls into the “Moderate” to “Vigorous” category of physical activity level. “Moderate” has a modifier of 1.55, while “Vigorous” has a modifier of 1.725. Thus, for a more moderate week, Simon will need roughly 2,600 kcal per day (1,675 kcal/day * 1.55), while a more vigorous week calls for roughly 2,900 kcal per day (1,675 kcal/day * 1.725).

Based on this information, Simon’s daily intake appears to be 200-500 calories shy of the recommended amount for maintainance—and low enough to have a noticeable negative impact on his climbing and training. By increasing calories to the recommended amount, he would have more energy, gain strength easier (and transfer that strength to climbing), and still maintain weight.

Really, though, it’s better to individualize your plan whenever you can. The problem with modifiers is that they’re very broad, subject to interpretation, and error-prone. For example, it would appear based on the above list that exercising for one hour three days a week and exercising for two hours five days a week are equivalent, when it’s instantly apparent that they’re not—but two people might still calculate their metabolic rates as equivalent based on the above modifiers, despite having wildly different lifestyles! Furthermore, there’s no concern with intensity. An hour of walking is equivalent to an hour of race-pace running, even though there is a huge difference in the calories burned by each activity. An individual approach overcomes these limitations.

To individualize your plan, you just need to know approximately how many calories your chosen exercises burn, and approximately how long you engage in them each day. There is still room for error (overestimation of intensity or time, for example), but these errors will likely be much smaller in magnitude—only a 25-100 calorie difference across a day, rather than a 200+ calories difference.

The first step in an individualized plan is to calculate your  sedentary metabolic rate —your BMR multiplied by the sedentary modifier of 1.2. This sedentary rate accounts for all the little things we do everyday that are  not included in your BMR, such as eating, sitting upright, walking around, standing, etc. Simon’s sedentary rate is roughly 2,000 calories per day (1,675 * 1.2 = 2,010).

Next, we determine the average caloric cost of the activities Simon engages in. The easiest way to go about this is to just use an online calculator such as this on e and plug in your weight and the activity you’re interested in.

For Simon (weight 145 lbs), ski touring will burn between 400 (for an easy pace on gentle terrain) to 525 (for vigorous effort) per hour, with higher rates possible for certain conditions. Teaching skiing is a little harder to quantify because it’s variable, but light downhill skiing burns roughly 264 calories per hour (this would only include the time actually  skiing , not chairlifts, etc.) and it’ll likely be at least that.

According to the exercise calculator, climbing burns about 660 calories per hour, but we can be more specific here based on intensity. Based on this research , climbing burns roughly 17 kcal/minute for easy routes, 19 kcal/minute for moderate routes, and 22 kcal/minute for difficult routes (for an experienced climber). For a new climber, a difficult route—“difficult” is relative to skill, by the way, not absolute based on grades—burns 23 kcal/minute. Bouldering is of higher intensity, so it’s possible that it burns even more calories, but given the lack of data we’ll just assume it burns 22 kcal/minute. This is “on the wall” time only, which varies from person to person, but is likely to average 10-20 minutes per hour for bouldering. That means that each hour of bouldering will burn an average of 220-440 kcal.

Now, all we have to do is multiply each activity’s caloric cost by the time spent doing it and add that to Simon’s daily total. If we assume he climbs two hours per day with an average amount of “on the wall” time, he would burn 660 calories doing so. That means he should consume about 2,660 calories on a day he climbs (2,000 from his sedentary metabolic rate and 660 from his activities) to maintain weight. Or, on a day of ski touring that lasts six hours, he should consume 4,400 calories to maintain weight.

Macronutrient Breakdown

The final step is to determine the macronutrient breakdown of any given day. This is perhaps a little more complicated just because protein needs remain static  (roughly 100-160 grams per day) while carbohydrate and fat needs will vary based on total daily activity. Normally when I work with clients, I provide a “base goal” for each macronutrient (in addition to calories) and then a “per hour of exercise” goal as well (with variations according to intensity), but here I’m going to show a slightly easier variation.

First, based on Simon’s BMR of 2,000 calories per day, protein should account for roughly 24% of the calories in his diet (120 grams of protein at 4 calories per gram equals 480 calories, divided into 2,000 calories equals 24%—the 120 grams is the important part). Since this is a sedentary day, we’ll leave carbohydrates towards the lower end at 50%, which leaves fat at 26%. Even though 50% isn’t ideal for aerobic activities such as ski touring , the actual percentage will wind up being significantly  higher on ski touring days because protein doesn’t increase. If this isn’t clear right now, don’t worry, you’ll see the math in just a bit.

Simon’s Macronutrients on a Sedentary Day

• Protein:  120 g (480 kcal; 24%)
• Carbs:  250 g (1,000 kcal; 50%)
• Fat:  58 g (520 kcal; 26%)

To determine what his needs will be on non-sedentary days, we’ll figure out the ratio of carbohydrate-to-fat calories. In Simon’s case, it’s roughly 2-to-1 (50% carbs to 26% fat, or 50:26 –> 1.92:1), and he should try to keep this ratio approximately the same on active days as well. That means getting two calories of carbohydrate-based energy for every single calorie of fat-based energy.

For those interested in the gram-to-gram breakdown, carbohydrates weigh in at 4 calories per gram and fat weighs in at 9 calories per gram, which makes the gram of carbohydrate to gram of fat ratio about 4.5:1 (1/2 gram of carbohydrates for every 1/9 gram of fat). This isn’t necessary to figure out the rest of Simon’s macronutrient schedule, though, so don’t worry too much about it.

On days when Simon climbs, he should consume an estimated 2,660 calories (or more or less depending on the total amount of climbing). When the 480 calories from protein are subtracted, we are left with 2,180 calories—66.6% of which should come from carbohydrates, and 33.3% of which should come from fat (that 2-to-1 ratio). That comes out to roughly 1,440 carbohydrate calories (55% of his total caloric intake) and 720 fat calories (27% of his total caloric intake), which is about 360 grams of carbs and 80 grams of fat. So Simon’s climbing day macronutrients look more like this:

Simon’s Macronutrients on a Climbing Day

• Protein:  120g (480 kcal; 18%)
• Carbs:  360 g (1,440 kcal; 55%)
• Fat:  80 g (720 kcal; 27%)

Already you can see that carbohydrates are playing a much more significant role!

Now let’s do the same operation for the ski touring day. Removing the 480 calories of protein from the assumed 4,400 he will burn throughout the day, we are left with 3,920 total calories. At a 2:1 carb/fat ratio, about 2,600 of those calories should come from carbs while 1,300 should come from fat—this is equivalent to 650 grams of carbs and 144 grams of fat. Now, carbohydrates make up about 59% of his diet, fat is about 30%, and protein is only 11%!

Simon’s Macronutrients on a Ski Touring Day

• Protein: 120 g (480 kcal; 18%)
• Carbs: 650 g (2,600 kcal; 59%)
• Fat: 144 g (1,300 kcal; 30%)

The greater Simon’s caloric need, the greater role carbohydrates will play in his day, according to our specified ratio. Moving from a sedentary day to a moderately active climbing day to a significantly active ski touring day, Simon’s carbohydrate goal moves from 50% to 55% to almost 60% while fat only moves from 26% to 30% (and protein dwindles in relative “importance”).

For most people, starting with a similar caloric ratio (roughly 1:2:1 protein/carbs/fat) as the one demonstrated here is probably adequate, especially if you do a combination of anaerobic (bouldering, single-pitch sport climbing, campus training, fingerboarding, etc.) and aerobic (low-intensity multi-pitch climbing, hiking, cycling, etc.) activities. If you’re much more on the anaerobic side of spectrum, you can safely alter the carb-to-fat ratio to be 1.5:1 (45% carbohydrates, 30% fat on a sedentary day) without affecting performance. If you engage in a lot of aerobic activity, you may wish to increase it to 2.75:1 (55% carbohydrates, 20% fat on a sedentary day) or even 4:1 (60% carbohydrates, 15% fat on a sedentary day).

Test in the Real World

Determining theoritical ratios is only the first step for any nutrition plan. After we have a target to aim for, we need to gauge it against real world results, which means implementing the plan and monitoring Simon’s weight. If Simon continues to maintain weight with the increased caloric load, then we know we’ve hit about the right area, and we might even increase calories slightly until we find the point at which he starts to gain weight (so we can be certain he is doing the most for muscle recovery and strength gain). If Simon gains weight, then we’ll back calories off slowly until he starts to maintain again. He shouldn’t lose weight since we’re increasing calories.

Aside from monitoring progress in a concrete way such as through weight maintenance (or body fat readings, if he had a way to do it), Simon should also subjectively feel stronger and more able to translate his training strength gains to his climbing. He should have more energy, recover faster, and stay strong longer. If all of this is true, and his weight is stable, then we would consider Simon’s plan to be successful and he would follow it until his goals changed. If there are problems that persist longer than a week or two (the amount of time it can sometimes take to “break in” a diet), then we’ll make some changes depending on the specifics of the problems.

Wrapping Up

Simon is a great example of an average, active male climber. His focus on staying lean no matter the cost was inhibiting his strength gains on the wall and providing no discernible benefit since he was already quite lean. By increasing his daily calories to a more appropriate level, he should be able to continue to maintain weight while improving his ability to gain strength. If followed accurately for an extended period of time, he may even gain small amounts of muscle and lose equal amounts of fat (AKA “body recomposition”), thereby dramatically improving his strength-to-weight ratio.

If Simon does not resemble you or your goals, don’t fret! This is just our first case study, and I’ll more than likely cover someone with a similar goal or physique to your own in the future. In the meantime, you should hopefully be able to apply the lessons learned from this first case study to yourself (provided your goal is weight maintenance) and get positive results.

If you have questions about this case study, please ask them in the comments below so I can answer publicly on this page and clarify the confusion for everyone! If you think you’d be a great example for a case study, fill out the form on this page and  please be patient. I will do my best to answer your needs via email (at the least), or possibly use you as another example in the months to come.

Until next time!

10 comments

Very interesting from a theoretical point of view. But it seems almost impossible to implement in the real world. How does numbers and ratios translate to real food. It must take a lot of planning just to figure out what to actually eat. Also, how can you time your food intake on a normal workday that leaves little or no room for frequent food breaks and prepping.

Also, I have been a hardgainer my whole life and I can testify to eating enough calories is no way as easy as stated in post. Seems like you need to eat tons of food in very frequent intervals. Again the macro breakdown leads to a more practical issue: How does numbers translate to real food?

There are logistical issues, to be sure—issues that are probably better tackled in a separate post—but let me try to provide a little hope here. Let’s assume Simon will have the chance to eat 5 meals/snacks on a given climbing day. With his base carb requirement of 250 grams, that means he should eat approximately 50 grams of carbohydrate per meal, or just over a single cup of most cooked starchy carbs. A cup is not a lot, so this shouldn’t be infeasible. The remaining 110 grams of carbs that he needs from climbing can come from preloading before exercise (slow-digesting carbs to buoy blood glucose during his climb), intraexercise replenishment (such as a sports drink, or fruit), or afterwards in the form of extra food (over the next few hours, about an extra 2.5 cups of starchy carbs). In this case, I’m only focusing on carbohydrates because they are the most challenging to get enough of for most people, at least without resorting to highly concentrated forms like refined sugars.

A ski touring day would be more challenging, but since he will presumably be exercising with little break we can rely more on the above-mentioned concentrated sources, which will also be easier to digest during exercise. Dried fruit, sports drink mixed into his water, and granola bars all make it easier to get the necessary number of calories.

In all cases, it does take planning, but the end result is worth it, I think. Energy will be higher, recovery faster, and training gains will be increased. This isn’t to say everyone must plan like this, but rather than there’s value in doing it if you care to, just as there’s value in putting together a training schedule and sticking with it despite the logistical and motivational problems associated with putting together a weeks-long exercise schedule in advance. But, as I said, I think another post will ultimately do your question/comment more justice, so I’ll try to get one out soon!

you have a great blog here! would you like to make some invite posts on my blog?

Thanks! Send me an email here if you’re interested in guest posts .

Thank you for this post. It is very helpful. Because I don’t want to pay the $39.95 to read the article at https://link.springer.com/article/10.1007%2Fs00421-007-0501-0 , could you help me in determining the number of calories burned per minute for a 115# female for easy, moderate, and difficult bouldering ? I assume the numbers in the case study, 17 kcal/minute for easy routes, 19 kcal/minute for moderate routes, and 22 kcal/minute for difficult routes, are specific to Simon’s weight.

The numbers provided were based on the averages in the article itself, which were themselves based on an average weight of 64 kg (141 lb). It’s an imperfect approximation, but we just really don’t have any good data on the caloric cost of climbing so it’s the best I could offer! Based on weight, we could estimate up or down by the same factor as the weight change and get in the same ballpark, so a heavier 160 lb climber might burn 19 kcal/min while a lighter 120 lb climber might burn 15 kcal/min. But, these are only estimates because it’s tough to know precisely how the caloric costs associated with climbing relate to weight compared to how they do for running or other more well-studied sports. Sorry I couldn’t give a more precise answer!

I have a question with regard to carbohydrates. Do they include fibre or not? I used the formula kcal from all carbohydrates equals 4*gramms of carbohydrates + 2*gramms of fibre. And then I took the ratio 2:1 for all carbohydrates to fat. Is that correct in your opinion? The fibre should somehow be included since it contributes to the calorie intake.

Thank you very much and best regards, Chris

Fiber doesn’t have a significant effect on our caloric intake since it’s indigestible. Some fibers are fermentable by our gut bacteria and those bacteria will release short-chain fatty acids as a by product that will be absorbed and used by the cells lining our intestine and thereby technically add to our caloric intake, but overall the net calories from fiber will be negligible.

Since Simon is active on most days of the week, there are days when he is not. Compute for his TER on his sedentary days.??

Since Simon is active on most days of the week, there are days when he is not. Compute for his TER on his sedentary days.

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Creative Steps to Write a Nutrition Case Study

Table of Contents

Nutrition plays a vital role in improving a patient’s health. However, each patient has unique nutritional needs requiring a personalized healthcare approach. That’s where nutrition case studies come in. These case studies comprehensively assess a patient’s nutritional status and help develop an individualized nutrition plan. They also help to monitor and evaluate the patient’s progress toward their health goals over time. In this article, we will provide a step-by-step guide on  how to write a nutrition case study . This post will help you understand the importance of nutrition case studies, whether you are a healthcare professional or a student.

What Is a Nutrition Case Study?

A nutrition case study comprehensively reports an individual’s nutritional status, dietary habits, and health outcomes . Healthcare professionals typically use these case studies to evaluate and treat patients. This is with various nutritional concerns, such as obesity, malnutrition, or chronic diseases. If you are a nutrition student or practitioner, learning how to write a nutrition case study is an essential skill to have. 

Importance of Nutrition Case Study

Nutrition case studies are a crucial tool for healthcare professionals in nutrition and dietetics. Here are some of the reasons why nutrition case studies are essential:

Provides a Comprehensive Assessment of a Patient’s Nutritional Status

 Nutrition case studies involve a detailed analysis of a patient’s dietary intake, medical history, and lifestyle factors that may impact their nutritional status. This information is used to develop a personalized nutrition plan tailored to the patient’s needs.

Develops an Individualized Nutrition Plan

A nutrition case study’s personalized approach to healthcare leads to an individualized nutrition plan. This approach can lead to better patient outcomes, improved health outcomes, and a higher quality of life for the patient.

Monitors and Evaluates Progress Over Time

Nutrition case studies track a patient’s food intake, weight, body composition, and other health outcomes over time. This enables healthcare professionals to monitor and evaluate the patient’s progress toward their health goals and adjust the nutrition plan as needed.

Provides Education About Healthy Eating Habits and Lifestyle Changes

Nutrition case studies can help educate patients about healthy eating habits and lifestyle changes. By providing a detailed assessment of a patient’s nutritional status, healthcare professionals can help patients make sustainable changes to their diet and lifestyle.

Supports Evidence-Based Practice

Nutrition case studies are based on evidence-based practice, meaning the nutrition plan is grounded in scientific research and clinical expertise. This approach ensures that the patient receives the best care based on the latest research and clinical knowledge.

Steps on How to Write a Nutrition Case Study

Selecting the patient.

The first step in writing a nutrition case study is selecting the patient. Typically, the patient has sought out nutritional counseling or treatment for a specific reason. These reasons include weight management, a chronic disease, or a food allergy. The patient should be willing to participate in the case study and provide detailed information about their diet, health history, and lifestyle habits. When selecting a patient, obtaining their written consent to participate in the case study is essential. This should include an explanation of the purpose of the case study and how their information will be used. It should also add any potential risks or benefits of participating. The patient should know that they can stop participating in the research at any moment if they don’t want to.

Gathering Information

The next step in writing a nutrition case study is gathering information about the patient. This includes a comprehensive assessment of their dietary habits, health status, medical history, and lifestyle factors that may impact their nutrition. To gather this information, you may need to conduct a nutrition assessment, which typically includes the following components:

Anthropometric Measurements

This involves measuring the patient’s height, weight, body mass index (BMI), and other body composition measures.

Dietary Intake Assessment

This involves collecting information about the patient’s dietary habits, including food preferences, allergies, and cultural or religious dietary restrictions.

Biochemical Assessment

This involves analyzing the patient’s blood, urine, or other biological samples to assess their nutritional status.

Medical History

This involves collecting information about the patient’s past and current medical conditions, medications, and surgeries.

Lifestyle Assessment

This involves collecting information about the patient’s physical activity, stress, and other lifestyle factors that may impact their nutrition status. Gathering as much information as possible is essential to create a comprehensive nutrition case study. This information will help you develop an individualized nutrition plan addressing the patient’s needs and concerns.

Developing a Nutrition Plan

Once you have gathered all the necessary information, the next step is to develop a nutrition plan for the patient. The nutrition plan should be based on the patient’s dietary needs, health goals, and lifestyle factors. It should also consider any medical conditions or medications that may impact the patient’s nutritional status. The nutrition plan should include the following components:

Macronutrient and Micronutrient Recommendations

This involves recommending specific amounts of carbohydrates, protein, fat, and other essential nutrients the patient should consume daily.

Food Group Recommendations

This involves recommending specific food groups for the patient, such as fruits, vegetables, whole grains, and lean proteins.

Meal and Snack Recommendations

This involves recommending specific meals and snacks for the patient to meet their nutritional needs throughout the day.

Nutritional Supplements

This involves recommending specific nutritional supplements, such as vitamins, minerals, or protein powders, that may help patients meet their nutritional needs.

Behavioral Recommendations

This involves recommending specific behavioral changes that may impact the patient’s nutrition status, such as increasing physical activity or reducing stress. The nutrition plan should be individualized to the patient’s needs and preferences. It should also be realistic and achievable, considering any barriers the patient may face in following the plan.

Implementing the Nutrition Plan

Once the nutrition plan has been developed, the next step is implementing it with the patient. This may involve educating the patient about healthy eating habits and strategies for making dietary changes. The patient should also be encouraged to track their food intake and monitor their progress toward their health goals. Working collaboratively with the patient throughout the implementation process is essential, as ongoing support and guidance are needed. This may involve regular follow-up appointments or communication via phone or email. The patient should be encouraged to ask questions and share any concerns or challenges they may be experiencing.

Monitoring and Evaluating Progress

The final step in writing a nutrition case study is monitoring and evaluating the patient’s progress. This involves tracking the patient’s food intake, weight, body composition, and other health outcomes. The patient’s progress should be regularly assessed, and adjustments made to the nutrition plan as needed. Objective measures such as laboratory values or body composition assessments are essential to evaluate the patient’s progress. This can help ensure that the nutrition plan is effective and that the patient is progressing toward their health goals.

How to Write a Nutrition Case Study

Once the nutrition plan has been implemented and the patient’s progress has been evaluated, it is time to write the case study. The case study should be organized in a logical and easy-to-read format, and should include the following sections:

Introduction

This should provide an overview of the patient’s case and outline the purpose of the case study.

Patient History

You should provide a comprehensive overview of the patient’s medical history, dietary habits, and lifestyle factors that may impact their nutritional status.

Nutrition Assessment

This should provide a detailed assessment of the patient’s nutritional status, including anthropometric measurements, dietary intake, biochemical markers, and medical history.

Nutrition Plan

This should provide a comprehensive overview of the patient’s individualized nutrition plan. They include macronutrient and micronutrient recommendations, food group recommendations, meal and snack recommendations, nutritional supplement recommendations, and behavioral recommendations.

Implementation and Follow-Up

This should provide an overview of the patient’s progress in implementing the nutrition plan, including any challenges or barriers encountered. It should also outline the follow-up appointments or communication that took place between the patient and healthcare provider.

This should provide an overview of the patient’s progress towards their health goals, including any changes in weight, body composition, or laboratory values.

This should provide an interpretation of the patient’s results, including any limitations or strengths of the case study. It should also provide a summary of the key takeaways and implications for future practice.

Writing a nutrition case study may not be the most exciting task in the world, but it is a crucial one. By following these steps and using a bit of wit and creativity, healthcare professionals can effectively communicate their patient’s nutritional needs . This shows progress toward their health goals. Who knows, maybe writing a nutrition case study will be more fun than you thought!

Abir Ghenaiet

Abir is a data analyst and researcher. Among her interests are artificial intelligence, machine learning, and natural language processing. As a humanitarian and educator, she actively supports women in tech and promotes diversity.

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Chapter 1: An Overview of Nutrition Case study

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Case Analysis 2023-Autumn All Nutrition

• Health Science

• Open access
• Published: 06 June 2024

Knowledge mobilization between the food industry and public health nutrition scientists: findings from a case study

• Marie Le Bouthillier 1 , 2 ,
• Sophie Veilleux 1 , 3 , 4 ,
• Jeanne Loignon 1 , 4 ,
• Mylène Turcotte 1 ,
• Laurélie Trudel 4 &
• Véronique Provencher 1 , 2 , 4  

BMC Nutrition volume  10 , Article number:  81 ( 2024 ) Cite this article

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Improving the nutritional quality of the food supply increases access to nutritious foods, which improves dietary habits and population health. Yet, knowledge mobilization initiatives between public health nutrition researchers and food industries are often not adequately considered and understood. This study explored what elements related to this specific context need to be recognized so that researchers can better mobilize nutrition science knowledge with the food industry to promote the nutritional improvement of food products.

A case study qualitative approach was selected to answer the research question, using semi-structured interviews as the data collection technique. Québec baking industry actors were shown a mock-up of an online mobilization platform sharing the results of the Food Quality Observatory that describes the nutritional quality of breads offered in Québec, Canada. They were asked to think aloud as they explored the web platform and were interviewed. Two coders analyzed the data using an inductive approach and thematic content analysis, starting with individual open coding, and then put forward their analyses and drafted the final themes.

The final data consisted of 10 semi-structured interviews conducted between October 2019 and August 2020. Four main themes were identified: the industry’s context, the knowledge mobilization initiative, the product-related matters stemming from the information shared and the motivation within the industry. Within each theme, sub-themes were highlighted and related to the industries’ motivation to improve their products’ nutritional quality. This study also specified key considerations for changes to the sodium and fiber content in bread.

Other steps beyond using simple language and a website format could be taken to better mobilize scientific knowledge with food industries, such as providing more consumer information, using an integrated knowledge mobilization approach that includes a consideration of ethics, working with communication professionals, collaborating with food science experts, and providing resources to act on shared information. Legislation such as the front-of-pack regulations could accelerate the pace of collaboration between researchers and industry. Overall, establishing a prior relationship with industries could help gain a better understanding of the themes highlighted in this study. Future research could build on this case study to provide more insights and solidify these findings.

Classification codes

Public Health, Public Private, Policy Making, Research Institutions, Use of Knowledge.

Peer Review reports

Introduction

Improving the nutritional quality of the food supply, meaning improving the nutrient profile of food products, can enhance public health through better access to nutritious foods for consumers [ 1 ]. Public health researchers are involved in these improvements via the emerging role of universities to contribute to society, through activities that apply their knowledge toward innovation in businesses or organizations [ 2 ]. However, a gap remains between public health nutrition researchers’ knowledge of the potential areas of nutritional improvement in foods, and their application by food businesses. Frequent assessment of the nutritional quality of the food supply can attest to this, as there is a disparity between what is currently offered and what scientists have determined to be a nutritious food supply [ 3 , 4 ]. Although public health researchers are not the only scientists who could share their knowledge for the benefit of the nutritional quality of foods, to our knowledge they have not yet been directly studied in the literature, despite their primary role in generating studies on public health in relation to food reformulation [ 1 , 5 ].

To address this disparity, public health nutrition researchers should engage in more collaborative activities with food industries, such as knowledge mobilization (KM) initiatives. KM is a broad term that includes many activities such as sharing, synthesizing, exchanging, and co-producing knowledge between producers and users [ 6 ]. In a scientific context, the goal is for research and evidence to inform decisions and an understanding of public policy, professional practice, and other applications to transform research into action [ 7 ]. An example of a positive KM outcome between food industries and nutrition researchers is that scientific knowledge in the field of nutrition leads to healthier products being produced by the food industry [ 8 ].

The present study investigated the case of a KM initiative between public health researchers in nutrition and the baking industry after the provision of scientific information; however, the findings can help inform situations with other types of food businesses or other public health organizations and at different stages of KM. The aim of this study is to explore elements related to a KM initiative between public health researchers and the food industry, including the industry’s context prior to KM, the KM initiative itself including the knowledge shared, the product-related issues involved in improving the nutritional value of products, and the industry’s motivation. Highlighting key elements to guide knowledge mobilization approaches will help researchers and research organizations better use their findings for the benefit of public health. Food businesses could also benefit from this research, as healthy and improved products are increasingly in demand among consumers [ 9 ]. It can also potentially improve policy and legislation by highlighting sensitive issues for industries regarding the nutritional improvement of food products.

Literature review

Generally speaking, the best practices to specifically engage in KM involves an initial attempt to understand the needs of information users [ 6 ]. Moreover, regardless of the type of industry, there are several barriers to mobilizing knowledge generated by scientists, including the knowledge user’s capacity to absorb scientific knowledge, the ambiguity of information, differing goals, and trust issues between organizations [ 10 , 11 , 12 ]. Whether these aspects of KM apply to the specific context of food industries and public health researchers is unclear due to food sector characteristics.

KM initiatives in food industries may have additional or different specifications than those made with other types of businesses, as this sector has certain particularities. Food innovations include technological, social, and cultural dimensions, and the food industry is a low-tech sector that is primarily motivated by improving its products in response to consumer demands [ 13 , 14 , 15 , 16 ]. In addition, companies produce products with short shelf lives; therefore, selling these foods quickly is paramount [ 17 ]. Finally, the food industry is highly dependent on ingredient suppliers [ 18 , 19 ].

In terms of the type of knowledge shared in KM, most studies to date on food industry innovation processes involve knowledge coming from either food science or food engineering, but not from nutrition sciences [ 20 , 21 ]. Food products have seen major improvements in packaging or in the biotechnologies used to produce them, while incremental improvements in the nutrient profile of staple foods have yet to be realized [ 3 , 4 , 21 ]. As such, it has been shown that dietitians and other nutrition professionals can improve their knowledge translation skills [ 22 ]. One study conducted in the context of a collaboration between five nutrition researchers and five food companies revealed positive attitudes toward collaboration, but special attention must be paid to common goals, trust, prejudice, and collaboration agreements [ 23 ]. Outside this study, little is known about the key elements of a KM initiative to consider, such as the context, barriers, and attitudes to be aware of when sharing nutrition science with the food industry, rather than knowledge about innovative technologies or ingredients.

Ethical issues are often a concern for nutrition researchers in collaborating with the food industry, especially regarding scientific independence and rigor [ 24 , 25 , 26 ]. Many guidelines are available to address these concerns and to guide actions and partnerships with the food sector. For example, the American Society for Nutrition suggests a set of twelve principles to ensure integrity in the pursuit of research with food business research [ 27 ]. Overall, it is recommended to work toward better collaboration between public health organizations and industries to create a healthy and sustainable food system and to address and overcome those ethical concerns, rather than not collaborate [ 8 , 28 , 29 ]. As such, much research has focused on how industries can influence public health and nutrition policy [ 30 ], but little research has been conducted on how scientists can positively influence industries in return, by mobilizing their knowledge effectively with positive public health outcomes.

Materials and methods

A qualitative approach was selected for this study, given the exploratory objective of investigating key elements that public health nutrition researchers should consider to better mobilize their knowledge with the food industry and encourage nutritional improvement of food products [ 31 , 32 , 33 ]. The grounded theory approach guided the philosophical research perspective, while the COREQ guidelines helped with the reporting of the study [ 34 , 35 ]. This study was defined as a case study, given the limitations of what has been studied and that this study represents a preliminary analysis of this delimited context, which is intended to foster new hypotheses and research questions [ 36 ]. The data collection technique selected was individual semi-structured interviews along with the think-aloud method, which allows for rich insights and the possibility of follow-up questions by interviewers [ 37 , 38 ]. The Comité d’éthique de la recherche avec les êtres humains de l’Université Laval (#2019 –225 A-1/11-05-2020) approved this study. All methods were carried out in accordance with the applicable guidelines and regulations. Informed consent was obtained from the study participants.

The case study was a KM approach between the Québec baking industry, represented by the Conseil de la Boulangerie du Québec (CBQ), and nutrition researchers from the Food Quality Observatory (Observatory). The CBQ is a non-profit organization that includes business members from the baking and pastry sector of the Québec food-processing industry. Their mission is to support the industry’s development and represent it at various levels of government. The Observatory’s mission is to monitor the food supply to improve food quality and accessibility [ 39 ]. Among its activities, which are funded by the government of Québec, the Observatory conducts studies on the nutritional quality of the different food categories most consumed by Quebecers ( https://offrealimentaire.ca/en ).

In 2019, the Observatory team presented the results of a study on the nutritional quality of sliced bread at a general meeting attended by a member of the Conseil de la Transformation Alimentaire du Québec (CTAQ), of which the CBQ is a subcommittee. The members then asked the researchers to present the results to the CBQ members directly. This request was made because these results could benefit this sector, as a potential front-of-pack (FOP) regulation for high-sodium products could be implemented by Health Canada (Gouvernement du Canada, 2018, Gouvernement du Canada, 2022). This would impact sliced bread packages since 27% of products studied were above the 15% daily value for sodium, meaning that they would have to potentially bear an FOP indication [ 3 ]. Thus, the Observatory team verbally presented the study results to some CBQ members, who suggested that the information could be simplified. The researchers decided to create the current research project, where workers from CBQ member industries would be interviewed by the research team, to better address and understand this issue.

Before recruiting these participants, the results of the Observatory’s study were presented on an online platform. The platform was created by the research team, with the aim of simplifying the data presented and inviting participants to become involved in improving the nutritional quality of the products offered by the food business for which they work. The platform was written in French, as all participants spoke French as their first language, as did the research team. The platform consisted of four stages: “1. Tell us more about you;” “2. About us;” “3. Our results;” and “4. Resources.” First, information about the participants was obtained, after which information about the researcher who conducted the study was presented. Next, text and figures directly from the study, as well as a model of the potential impact of sodium reduction or fiber increase in a fictitious product on the public’s consumption, were presented [ 40 ]. This model was a fictional estimate of how a change in the nutrient content and thus FOP information of a bread product, adjusted for sales and consumption, would be reflected in changes in sodium and fiber intake. A figure illustrating their product’s ranking in terms of fiber and sodium content compared to competitors’ products was also presented. The platform ended with potential concrete solutions to implement nutrient changes (e.g., alternative ingredients) and an awareness that businesses could have a significant impact on public health, even by implementing minor changes. A certificate of participation was granted upon completion via the platform.

In addition, a semi-structured interview guide was developed (Appendix A) based on the four stages of the platform [ 41 ]. Fifteen questions were available in any of the four stages of the platform, in addition to eight specific questions for Stage 1, three questions for Stage 2, 19 questions for Stage 3, and nine questions for Stage 4. Before the first interview, a pilot test conducted with two professionals working with food companies in an innovation support service affiliated with the research center confirmed that the online platform and interview guide were easy to understand.

To obtain an optimal diversity of participating businesses, the sampling process was conducted in two phases with two sets of criteria for recruitment. For both recruitment waves, the CTAQ supported discussions between the research team and CBQ businesses with the CTAQ proposing that CBQ members participate in the research project. A document explaining the mandate, deliverables, and criteria was presented. The names of interested members were supplied by the CTAQ to the research team, who then contacted the members by telephone to introduce the project and assess their eligibility. If CBQ members were willing to participate, they were sent a consent form, and a date was set for the interview with the research team. All interviews were set to last 90 min in total. Overall, 10 participants were recruited and included in the final analysis, representing nine food businesses, and all participants agreed to participate. With this final sample size, saturation of the major themes was achieved when analyzing the data, so no additional recruitment took place [ 42 ].

The first set of participants ( n  = 6) was recruited via convenience sampling [ 43 ] through contact with the CTAQ in October and November 2019. To be eligible for this study, all participants were required to be working at a food business that either produced bread or provided ingredients for bread products sold in Canada. To help meet this criterion, the participants had to be members of the CBQ. Within the companies, individuals needed to work in one of the following sectors, which were considered complementary and relevant to food product improvement: management, R&D, marketing/sales, operations, production, or product evaluation. The individual interviews were face-to-face and took place in the participant’s office during their business hours, in Québec, Canada.

Following this first sample and analysis of the data collected, a second set of participants ( n  = 4) was recruited using theoretical sampling [ 43 ] through the extended network of the CTAQ in July 2020. The aim of this second set of participants was to add greater sample diversity regarding participants’ roles in businesses and business size, as the businesses recruited thus far did not vary sufficiently in terms of these two criteria. Participants were classified as either belonging to either a large business (500 employees or more) or a small-to-medium enterprise (SME) (between 10 and 499 employees) [ 44 ], to guide the recruitment of this second set of participants. The second set of interviews was conducted during office hours, but through video conference due to COVID-19 restrictions.

During the interviews conducted by researchers M.L.B. (registered dietitian and graduate student), J.L. (registered dietitian research professional) and M.T. (registered dietitian research professional), the participants were asked to think aloud as they experienced the online platform [ 38 ]. This method provided insights into how they processed the information (content and format) and their reasoning while exploring the platform. In addition to probing participants about what they were saying aloud, the interviewer selected questions to generate discussions about the platform in general, nutrition improvement, and technical aspects of the website based on the interview guide, following the best practices for semi-structured interviews [ 41 ]. Although the questions may have varied from participant to participant, all themes relevant to the analysis were discussed.

Audio recordings of the interviews were transcribed verbatim by a contracted research assistant with guidelines based on the method put forward by Bazeley [ 45 ], and participants were assigned numbers to protect their confidentiality. All transcripts were checked by interviewers for completeness and accuracy prior to data analysis but were not sent to participants for validation. For the analysis, researchers were first guided by a general inductive approach [ 46 ]. This allowed the participants to have a strong voice in articulating the results of this study, as this method allows new ideas to emerge from a specific context, as opposed to affirming existing concepts in the literature. Throughout the data analysis, researchers were careful to maintain their reflexivity through reflective writing, the use of a journal to capture thoughts during coding for each coder, and collaboration within the research team to discuss key findings, as they were close to the team that had conducted the original study presented on the platform, and had to minimize the impact of their biases, personal experience, and prior knowledge of the situation [ 47 , 48 ].

The researchers used thematic content analysis to code the data, in which themes were coded as a unit of analysis after which their frequency was considered [ 49 , 50 ], as described in other qualitative studies [ 12 , 51 , 52 ]. All interviews were first open-coded by two researchers using NVivo10 (QSR International). They individually coded each verbatim transcript, merged their analyses and discussed discrepancies to reach agreement for each code in each interview. They subsequently developed second-order themes as first-order themes became saturated, and additional interviews were coded. Only themes reported by seven or more participants are presented in the results section to focus on the most salient themes and impart sufficient depth and detail to convey the richness and complexity of our data, while avoiding “thin” codes [ 53 ]. Participants were treated as an homogenous group, as their characteristics were useful for recruitment and diversifying the sample in terms of roles in the organization and business size for the theoretical sampling but were not used to create sub-groups. Attempts to group respondents into smaller groups created clusters that were too small or had no relevant differences. Finally, through discussion within the research team, a structure emerged from the themes as a conceptual model. Participants did not provide feedback on the findings.

Table  1 first describes each participant’s key characteristics. Results are then presented according to the final themes in the resulting conceptual model, namely, the industry’s context, the KM initiative for product improvement, the product-related matters stemming from shared knowledge, and the sense of motivation. Tables  2 , 3 and 4 , and 5 present more details on each of these themes, descriptions and sample quotes. Finally, the resulting conceptual model is presented in Fig.  1 . All the original quotes are in French and were translated into English by the researchers.

Participant characteristics

Of the ten participants who were interviewed, five were from ingredient supplier businesses and the other five were from producer/supplier businesses. Seven participants worked in marketing/sales, two in R&D, and one in management. Of the nine different food businesses represented (two participants were from the same business), four were SMEs and five were large businesses. In terms of organizational hierarchy, seven participants worked in the management of a sector or in general management, two were heads of a sector, and one was an employee. Seven had between five and twenty years of experience in their sector, while the other three had fewer than five years of experience. (Table  1 ).

Industry context

All participants discussed the context of their organization during the interviews (Table  2 ). For all participants, the importance of customers was central to their decision-making process, even for business-to-business (BtoB) businesses, which have other businesses as customers, or business-to-consumer (BtoC) businesses, which have consumers as customers. Influence of other actors was also considered and discussed as being entirely part of a business’ current context. Notably, Participant #1 mentioned Health Canada as an actor that could influence their context, and that communication was sometimes difficult. They also spoke at length about their reality, including their experiences, competitors, values, and practices. Interestingly, the role of the baker in the development of recipes and its influence on the nutritional quality of products emerged as salient in the business discourse.

The KM initiative for product improvement

Participants characterized many sub-themes regarding the knowledge mobilization web platform initiative and how the information had been communicated (Table  3 ). Most participants would have preferred a more collaborative approach, using a more interactive platform to generate the scientific results presented. For example, Participant 2 felt that he had to accept not only the results, but also the approach. Moreover, the only two nutrients addressed were sodium and fiber, and he questioned the prerequisites of the observational study. Participants commented that the online platform was too long. Regarding the shared information, adapting the message to their reality was also important to keep them interested in the study. For example, it was relevant to have information about the Québec market, as most product data are usually from the US market. In addition, participants emphasized having the information properly explained, such as knowing the nutritional standards and the recommendations on which they are based. Finally, the need for synthetization and clearer objectives was important, such as determining what exact quantity of sodium per slice is considered healthy.

Product-related matters stemming from shared knowledge

Many product-related questions emerged from the knowledge shared on the platform, indicating the implications of the shared information for their products (Table  4 ). First, participants explained that a modification to a nutrient, either fiber or sodium, would modify the shelf life of bread products, as well as its taste and texture. In addition, participants mentioned that there were many labelling and regulatory implications to consider before making any changes; in particular, the effect that a warning symbol (FOP) would have on their package, and how relevant it would be to recognize it. It is also important to consider the vocation of a product. For example, if a product is created to be tasty rather than healthy, changing its purpose to be more nutritious may impact its taste. Finally, three types of needs were mentioned to be able to modify the nutritional quality of their products: financial resources, material resources, and more information, particularly regarding alternative ingredients.

Sense of motivation

Throughout the text, excerpts about the participants’ motivation to improve the nutritional quality of their products were coded bimodally, with first-order themes detailing what motivated them (Table  5 ).

All participants were motivated to improve the nutritional quality of their products. For example, participants felt that it was right that actions were being taken to improve the food supply quality. Two clear motivations stood out: participants felt motivated when they could see an impact on public health and when a change might bring them new clients (data not shown).

Simultaneously, some participants felt less motivated about improving the nutritional quality of their products. There were no specific, clear-cut reasons for being less motivated that surfaced in the analysis; however, many individual reasons were given by the participants. For example, a sense that it might not be the role of their business to improve public health, but that their priority is to make bread to be eaten.

Resulting conceptual model

The resulting conceptual model, presented in Fig.  1 , summarizes the four final themes presented and identified as salient in the participants’ discourse during the interviews: the context of the industry’s KM initiative for product improvement, product-related matters stemming from shared knowledge, and sense of motivation. The themes are presented with associations to show how they were conceptualized relative to each other. First, the industry context was pervasive in the participants’ discourse. As a result, this theme is conceptualized in the background and encompasses other themes. The KM initiative itself (i.e., the online platform) was another major theme characterized by participants, as well as considerations of product-related matters stemming from shared knowledge. The first concept relates to how the information was communicated, and the second relates to the implications of that information for the participants. Notably, the arrow is unidirectional from the KM initiative for product improvement to product-related matters stemming from shared knowledge. This is because, without the presence of the KM platform and the information shared, product issues would not have emerged in the conversation. Both themes reported the usefulness of the platform and the information shared. These three themes were related to how participants expressed their sense of motivation for the KM initiative throughout the interviews, as they mentioned that they were either more motivated or less motivated to improve the nutritional quality of their products.

Schematization of the four final salient themes emerging from the analysis

This study provided a portrayal of themes for researchers to consider to better mobilize public health nutrition knowledge with food industries to improve the nutritional quality of products. We presented four salient themes resulting in a conceptual model from the food industry representatives’ discourse: how their industry’s context, the KM initiative itself, and product-related matters stemming from the shared information contributed to their motivation to improve the nutritional quality of their products. For each theme, we presented the theme, description and sample quotes. Our study provides insights into a KM initiative between public health nutrition researchers and the food industry, which has not been done before. It also allows for the comparison of previous general insights from other contexts with this specific one, such as the importance of universities’ knowledge mobilization capabilities and their dynamics in the innovation ecosystem to promote social change [ 54 ], or the importance of high consumer demand for product innovation for the success of industry-university collaboration [ 55 ]. Furthermore, our study highlights key considerations for when the scientific knowledge shared with food industries is nutrition sciences rather than food sciences, or food engineering knowledge. Regarding the case studied, we also specified key considerations before suggesting any changes in sodium and fiber in bread, as well as technical features to consider when developing an online KM platform for the food industry.

The theme industry context, a topic discussed in other work related to the use of knowledge assets in organizations and in open innovation [ 56 , 57 ], showed that customers appeared central to the industry’s discourse in improving the nutritional quality of their products, as they are mentioned both in context and as a source of motivation. This also resonates with other studies in which consumer acceptance is paramount before any food reformulation is considered [ 14 , 58 , 59 , 60 ]. Indeed, sodium reduction, an improvement suggested in the current KM approach, is known to be accepted by consumers [ 61 ]. This is consistent with our theme of “product vocation”, which implies that products on the shelf will not change if there are still profitable consumers for them. Thus, as a more healthy and socially conscious generation of consumers enters the market [ 62 ], the industry might develop healthier products to meet consumer demands if they see the opportunity for more revenue. Industries could gain a competitive advantage in collaborating with public health researchers, as innovative and healthy product ideas can potentially increase sales [ 63 ]. In our data, being unable to sell an improved product is one aspect of not being motivated to improve the nutritional quality of their product. The opposite is also true, where it is a motivator if it can increase sales. Thus, researchers who wish to engage in KM initiatives should be aware of the importance of the consumer to industries and can present consumer data and potential profit-generating opportunities to get their attention and motivate them to improve the nutritional quality of their products.

Regarding the KM initiative itself, the participants in our study mentioned that they would have preferred a more collaborative approach. Our mobilization could be described as end-of-grant knowledge transfer (KT), where we involved knowledge users only when the results were generated, versus an integrated KT, where the knowledge users are involved early in the research design [ 64 ]. An integrated KT approach usually fosters research that is more relevant to the knowledge users because they are involved in every step of the research project. This finding is consistent with common guidelines for effective knowledge mobilization, which recommend meeting with knowledge users, especially at the beginning of a project [ 65 ]. Nevertheless, regarding food systems in particular, the frequent association of the food industry with researchers has led to fierce criticism of their proximity and influence, as well as the potential to distort scientific results [ 25 , 30 ]. Good ethical practices should always be implemented to ensure that such collaborations are conducted with high scientific rigor. Cullerton and colleagues found a high level of agreement on the principles relating to standards of research governance, transparency, and publication in the literature on partnerships between public health researchers and food industries [ 66 ]. However, there was less agreement on the appropriateness of industry collaboration [ 66 ]. As such, Hawkes and Buse suggest involving food industries only after public health objectives have been set [ 24 ]. Researchers must be aware that integrating food industries prior to the generation of results can be beneficial to KM itself. However, it must be conducted with due regard to the independence and integrity of the results and be carefully executed.

As for the technical aspects of the KM approach, such as the length of the platform and the need for resources and clearer messaging, synthesized information and adapted messages could easily be improved, according to the participants. For example, working with a marketing/communication agency or science education organization could improve the communication aspect of KM. Researchers could also use the help of the technology transfer office or other similar intermediaries, where they may find useful allies in creating better industry-targeted communication [ 67 , 68 ]. Researchers should collaborate with other professionals and seek help to develop a well-executed KM initiative online or in person and avoid developing it independently.

In terms of product issues arising from the information shared on the platform, many points were raised from a food science perspective specifically related to shelf life, taste, and texture. Working with food technologists or chefs (e.g., directly with bakers) could help anticipate obstacles that public health researchers might face in suggesting a product improvement that may not be technically feasible. Providing potential solutions could enhance motivation and improve absorptive capacities for new knowledge among industries [ 10 , 13 , 69 , 70 ]. Another solution may be to provide companies with resources where they can obtain ideas on how to implement a suggested improvement. The need for resources, whether financial, physical, or informational, was also echoed in previous work on university-industry collaboration, where factors conducive to successful collaboration include the availability of resources to pursue a collaboration [ 71 ]. Researchers need to focus on product-related issues and a lack of resources, either by providing additional food science knowledge or sources of help and resources, to improve the likelihood that nutritional knowledge will be used.

Regarding motivation, legislation was mentioned both as a part of their motivation and as a product-related matter. The upcoming front-of-pack (FOP) regulation in Canada, which was launched in June 2022, will identify products that are high in total sugar, saturated fat, and sodium [ 72 ], which may be a concern for industries. Our data show that this could entice industries to change their products (i.e., reformation) since they want to avoid this warning on their packaging. Other studies have found results consistent with this effect, where food patterns are improved after the implementation of FOP labelling [ 73 , 74 ]. This study also highlights key elements for improving public policy, providing insight into sensitive industry issues regarding nutritional improvements. Any regulations regarding FOP labelling could accelerate the pace of collaboration between nutrition researchers and the food industry because of the need for compliance or the fear of losing consumers, who may negatively view products with such labelling.

Finally, our resulting conceptual framework shares similarities with Bacon et al.’s model of conditions for knowledge transfer [ 75 , 76 ]. The model suggests that a combination of relationship, organizational, and knowledge characteristics contributes to successful knowledge transfer among members of an open innovation ecosystem. In this model, the “learning intent” of organizations [ 77 ], i.e., the willingness to learn new knowledge, is crucial for successful knowledge transfer. This theme is similar to our “sense of motivation” theme, as both themes delineate the motivation to be proactive with the shared information. Bacon et al. also emphasized that “tie strength” can play an important role in successful knowledge transfer, suggesting that actions be taken to strengthen exchanges among organizations. Many studies have highlighted that trust and communication are important to efficiently implement evidence [ 10 , 11 , 78 ]. Building a long-term relationship with food industries could be beneficial in improving the success of KM, as it may help produce a more adapted message and reduce ambiguity [ 10 ]. Inter-organizational trust is one of the strongest mechanisms for lowering barriers to university-industry collaborations [ 79 ]. As Levin has indicated, simply sharing evidence and asking individuals to change is insufficient [ 78 ]. According to our study, we believe that the themes that have emerged could have been better addressed prior to the KM initiative if the research team had built an earlier relationship with the food industries that were considering knowledge mobilization. In particular, we could have understood their realities and the influence of other actors, two themes that have revealed themselves to be significant in their context, along with the other themes. In fact, as general advice, we believe that building a long-term relationship with industries can help any KM initiative by providing insights to address the themes found in this study, as well as to build trust.

The limitations of our study include the limited salience of themes regarding motivators or de-motivators (under the theme of “sense of motivation”), as the probing questions asked during the interviews were not focused on producing sufficient data regarding these sub-themes. Rather, the data found were scattered in the interviews. However, future research could place greater focus on these motivators/limitations with specific questions. Our data can only address the relationship between all themes and the industry’s sense of motivation, and not the specification of that sense with various subthemes. In addition, we presented this concept as opposites, meaning either being motivated or not. Future work could refine this conceptualization as two side of a spectrum under the same theme. Other limitations include the small number of respondents and the lack of characterization of participants’ discourses. It would be interesting to know whether the discourse of SMEs or large companies differ, as they exist in different contexts and these differences might appear, for example, in the necessary resources. Unfortunately, our analysis was not sensitive to this filter, given the small number of participants when grouping by characteristics. Finally, the translation of our participant’s quote from French (the language in which the study was conducted) to English for the purpose of this paper may have influenced the accuracy of the reporting of some of our participant’s discourse. The verification of the quotes by a trained translator might have helped to enhance accuracy. Further research is needed on this topic, since other types of food products and a post COVID-19 context might lead to additional or different insights, as participants’ characteristics and contexts may vary.

Recommendations for public health researchers and practitioners to better mobilize nutrition science for nutrient improvement with the food industry include providing them with more information about consumer interest in targeted nutrients, using an integrated approach to knowledge mobilization that considers ethics and integrity, working with communication professionals to better disseminate scientific information, working with food science experts to address potential technical barriers to proposed nutrient reformulation, and providing resources, such as financial or material, to act on shared information and support food reformulation. Legislation such as the FOP could accelerate the pace of collaboration between researchers and industry. As this is a case study that raises new questions and hypotheses, future research could further elaborate on these findings with additional in-depth interviews and focus groups with similar participants to solidify the findings and deepen the analysis of the themes highlighted. Overall, it appears of relevance for researchers to build collaborative and transparent relationships with food industry to further address the recommendations resulting from this study and be proactive in their solutions to mobilize the scientific knowledge they generate and contribute to population health.

Data availability

To protect participant’s confidentiality, interview respondents were assured raw data would remain confidential and would not be shared.

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Acknowledgements

An earlier version of this paper was presented to the 2022 Canadian Nutrition Society Annual Conference. The authors thank the participants and the Conseil De la Boulangerie du Québec (CBQ) for their involvement.

The Food Quality Observatory is funded as part of the Politique gouvernementale de prévention en santé of the Gouvernement du Québec. The project received financial support from the ministère de la Santé et des Services sociaux du Québec (MSSS), the ministère de l’Agriculture, des Pêcheries et de l’Alimentation du Québec (MAPAQ), Québec en forme, the ministère de l’Économie et de l’Innovation, the Canada Foundation for Innovation and the Institut sur la nutrition et les aliments fonctionnels at Université Laval.

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Centre NUTRISS—Nutrition, Santé et Société, Institut sur la Nutrition et les Aliments Fonctionnels (INAF), Université Laval, 2440, Hochelaga Boulevard, Pavillon des services, office 2729-L Qc, Quebec, QC, G1V 0A6, Canada

Marie Le Bouthillier, Sophie Veilleux, Jeanne Loignon, Mylène Turcotte & Véronique Provencher

École de Nutrition, Université Laval, 2440, Hochelaga Boulevard, Pavillon des services, office 2729-L Qc, Quebec, QC, G1V 0A6, Canada

Marie Le Bouthillier & Véronique Provencher

Faculté des sciences de l’administration, Université Laval, Quebec, QC, G1V 0A6, Canada

Sophie Veilleux

Institut sur la Nutrition et les Aliments Fonctionnels (INAF), Université Laval, 2440, Hochelaga Boulevard, Pavillon des services, office 2729-L Qc, Quebec, QC, G1V 0A6, Canada

Sophie Veilleux, Jeanne Loignon, Laurélie Trudel & Véronique Provencher

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Marie Le Bouthillier: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Visualization; Writing – Original Draft; Writing – Review & editing. Sophie Veilleux: Conceptualization; Supervision, Writing – review & editing. Jeanne Loignon: Data Curation; Formal analysis; Investigation; Methodology; Writing – Review & editing. Mylène Turcotte: Conceptualization; Data Curation; Investigation; Methodology; Writing – Review & editing. Laurélie Trudel: Conceptualization; Funding acquisition; Project administration. Véronique Provencher: Conceptualization; Funding acquisition; Project administration; Resources; Supervision, Writing – Review & editing. All authors read and approved the final manuscript.

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Correspondence to Véronique Provencher .

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Ethical approval was obtained for this study by the Comité d’éthique de la recherche avec les êtres humains de l’Université Laval (#2019 –225 A-1/11-05-2020). All methods were carried out in accordance with the applicable guidelines and regulations. Informed consent was obtained from the study participants.

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Le Bouthillier, M., Veilleux, S., Loignon, J. et al. Knowledge mobilization between the food industry and public health nutrition scientists: findings from a case study. BMC Nutr 10 , 81 (2024). https://doi.org/10.1186/s40795-024-00889-z

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Received : 30 August 2023

Accepted : 28 May 2024

Published : 06 June 2024

DOI : https://doi.org/10.1186/s40795-024-00889-z

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