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Table of Contents
Year : 2020  |  Volume : 6  |  Issue : 3  |  Page : 51-58

Implementation of nutrition care process in nephrology practice: A mini review

1 Ashwini Kidney and Dialysis Centre Pvt Ltd, Nagpur, Maharashtra, India
2 Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Shatabdi Super Speciality Hospital, Nashik, Maharashtra, India

Date of Submission30-Dec-2020
Date of Acceptance04-Jan-2021
Date of Web Publication13-Apr-2021

Correspondence Address:
Dr. Dhananjay S Ookalkar
Ashwini Kidney and Dialysis Centre Pvt Ltd, Nagpur, 401 B, Neeti Gaurav Complex, Ramdaspeth, Nagpur - 440 022, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrnm.jrnm_28_20

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The American academy of nutrition introduced the nutrition care process (NCP) in 2003. The introduction of nutrition care process has resulted in achievement of higher quality of care due to reduction in variance in nutrition care, better communication due to use of standardized language, help in outcome research.Although of immense benefit, its introduction and adaptation has been slow in India. Although of immense benefit, its introduction and adaptation has been slow in India. This article aims to introduce the concept of NCP and highlight the ways in which it has been implemented in other countries. It discusses the enablers and barriers to its implementation as seen in other countries and proposes a road map to its implementation in India. Going by the reviewed literature, the major steps which would facilitate the adaptation of NCP in India would be its endorsements by leading associations of nutritionists, its introduction in the syllabus of postgraduate studies of clinical nutrition in universities, the training of practicing nutritionists by regular workshops, and the introduction and integration of apps to carry out repetitive tasks in NCP implementations in patient care.

Keywords: Apps, nephrology practice, nutrition care process

How to cite this article:
Ookalkar DS, Saxena AT, Puri H, Ookalkar A, Fulzade S. Implementation of nutrition care process in nephrology practice: A mini review. J Renal Nutr Metab 2020;6:51-8

How to cite this URL:
Ookalkar DS, Saxena AT, Puri H, Ookalkar A, Fulzade S. Implementation of nutrition care process in nephrology practice: A mini review. J Renal Nutr Metab [serial online] 2020 [cited 2021 Jun 13];6:51-8. Available from: http://www.jrnm.in/text.asp?2020/6/3/51/313633

  Introduction Top

Although the nutrition care process (NCP) has been introduced more than 17 years ago by the Academy of Nutrition and has found widespread acceptance in the United States, Canada, and other developed countries, its introduction and acceptance has been awaited in India.

The health-care professions consider the implementation of health-care models, with standardized processes and terminologies, as a necessity that increases the effectiveness and efficiency of health-care systems. The dietetic discipline has developed the NCP as an organized framework to standardize the provision of high-quality nutrition care.[1] The NCP was developed by the Academy of Nutrition and Dietetics (AND) (formally the American Dietetic Association) in 2003 to ensure the reliability and quality of care for each patient/client or groups of patients/clients and the predictability of patient/client outcomes.[2]

In 2012, the Dietetic Workforce Demand Study Task Force predicted only 75% of demand for Registered Dietitians (RDs) in the US would be met in 2020 (5, N. Nyland et al.). The study also identified technology as having potential to transform how RDs deliver nutrition counseling and personalized nutrition.[3]

Quality improvement literature shows that, when a standardized process is implemented, less variation and more predictability in terms of outcomes occur.[2]

The NCP has made the practice of dietetics more focused improving the communication with other health-care team members, facilitating outcome research.

The implementation of the NCP requires a time-tested skill sets and practices to ensure adoption, sustenance, and impact. For the delivery of more consistent and effective quality nutrition care by RDs, the AND (the Academy) recommends their NCP.[1],[2],[4] The systematic method allows RDs to diagnose and develop treatment plans for nutrition-related problems.[2]

Having a standardized NCP framework facilitates outcomes for research to evaluate the impact of nutrition care on patient health outcomes. Subsequently, the efficacy of nutrition care can be demonstrated, enabling advocacy for the role of RDs in obesity and chronic disease treatment and prevention.[2],[5] Moreover, productivity and communication between RDs and other members of the health-care team have improved through diagnosis-focused documentation of the NCP.[5]

Although it is beyond the scope of this work to dwell minutely into the concepts of NCP, described elaborately elsewhere,[1],[2],[4] the main aim of this work is to highlight how the concept can be implemented in nephrology practice.

The literature was searched using Google Scholar and PubMed using the keywords NCP nephrology dietetics apps restricting the search to English language and human articles published after 2003.

  Advantages of Implementing Nutrition Care Process in Practice Top

Quality of health care requires standardization to reduce variation in care and thereby improve effectiveness and efficiency. The NCP helps in reducing the variance by having a standardized process and a standardized language (SL).

The NCP is used as a didactic education tool and to support research by providing a common language that allows dietetics practitioners to generate quantitative and qualitative data that can be measured, analyzed, and interpreted, to evaluate nutrition care practice.[6],[7]

The NCP also provides a structure for systematic evaluation of outcomes, which can be used to demonstrate the effectiveness of dietetics practice as well as in dietetics research.[3] The standardized NCP terminology (NCPT) was developed to support dietetics practitioners in clinical documentation, dietetics-related communication, outcome management, and research.[1],[5]

In light of recent research, the use of SL has been identified as a key practice tool to advance the level of practice to a higher level and support its integrity.[6]

Many dietetics practitioners from the United States, Australia, and Sweden have reported a number of significant benefits to the implementation of the NCP/NCPT; the NCP has been demonstrated to improve documentation of dietetic care and patient outcomes,[6] as recorded patient information is standardized, leading to more concise notes that improve accuracy and clarity in communication between health-care providers.[7]

Improved continuity of care for patients seen by more than one dietitian over time has been reported, because the standardized methods and language of NCP system notes are easier to interpret if the patient transfers to another dietitian or hospital.[8],[9]

  What is the Nutrition Care Process Top

The NCP model consists of four steps: nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation. Each of these steps is interconnected and consecutive. The monitoring/evaluation step determines progress in resolving the diagnosis.[3]

  Experiences in Various Countries in Implementation of Nutrition Care Process Top

A survey in Saudi Arabia regarding implementation of nutrition care process revealed that majority of the respondents had awareness of the nutrition care process during their under- or postgraduate degrees (64%). Despite the high level of awareness of the NCP, only 27% of the dietitians had received NCP training. Among those who had yet to receive NCP training (73%), the majority expressed a preference for short-term training sessions (67%).[7] Dietetic association members from Australia, New Zealand and Singapore were invited to participate in an online survey assessing NCPT implementation, knowledge, and self-rated familiarity, attitudes, benefits, concerns, barriers, and enablers.[10]

In logistic regression models, independent positive predictors of current NCPT users were knowledge (P = 0.003), confidence to implement (P = 0.036), confidence to write nutrition diagnoses (P = 0.002) and experiencing managerial support (P = 0.004). Not seeing a reason to change was a significant negative predictor of NCPT use (P = 0.003). An independent positive predictor of dietitians viewing NCPT implementation as important was feeling that it will improve patient care (P < 0.001), while negative predictors were seeing minimal benefit in changing (P < 0.001) and a preference to continue with current routine (P = 0.015). Independent positive predictors of dietitians viewing NCPT as applicable to their practice were NCPT knowledge (P = 0.009), seeing the value of NCPT (P < 0.001) and attendance at workshops or conferences (P = 0.014).[10]

  Dietitians' Opinions about the Challenges of Nutrition Care Process Implementation Top

The overwhelming majority of dietitians believed that their hospital should follow the NCP (94%), with 38% perceiving no challenges to its implementation. Fifty-three percent of respondents did perceive challenges, including assessment, diagnosis, intervention, monitoring, and evaluation (ADIME) documentation (23%), choosing reference (9%), monitoring/evaluation (9%), nutritional diagnosis (7%), and conducting the assessment (5%).[7]

  Enablers and Barriers to Implementation of Nutrition Care Process in Practice Top

Barriers to implementation of nutrition care process

In a quantitative, cross-sectional study, 56 dietitians were recruited from six principal hospitals in Jeddah. Regarding factors that may be preventing current NCP implementation in their department, 41% reported that there were not enough dietitians, 36% reported a lack of experience, and 23% stated that there was a potential conflict with the hospital's nutrition care system.[7]

Reported reasons for hospitals not following the NCP included insufficient dietitians, lack of experience, or conflict with the hospital's nutrition care system. A majority of dietitians reported no perceived barriers to applying the NCP; however, 23% reported NCP documentation as a challenge.

The insufficient NCP training opportunities reported in the Jeddah hospitals included in this study are likely to be representative of wider dietitian practice in the rest of the country and may indicate a major barrier to effective NCP implementation in Saudi Arabia. NCP hospital training and workshops could be used as a first step to raise awareness of the importance of the following international, standardized NCP practice.[6] A study by Porter et al. suggested that training must be on-going to embed the concepts into hospital dietetic practice. Thus, it is important to develop an NCP implementation package, including training, as a continuous driver for change.[7],[11],[12]

Among the challenges that were identified, the ADIME documentation was most commonly reported as the greatest, possibly due to the new feature (nutrition diagnosis, the second step) of dietitian care, which requires training and workshops to learn to write “Problem/Etiology/Signs/Symptoms” statements.

Previous studies have reported that primary barriers were as follows: participants' lack of NCP knowledge, the perception among dieticians that the NCP was not applicable in all dietetic care contexts, time limits, and no current use of the NCP in routine clinical practice,[13],[14]

According to Laur and Valaitis,[15] to make changes to nutrition care in a hospital, there needs to be a focus on improving hospital performance, strongly emphasizing the need for “good people management” and the impact that this can have on culture change. Hence, it is important to raise awareness and understanding among staff, to generate interest and an urgency to change practice. This should be supported by and driven by managers.[16]

Time limitations, lack of incorporation of the NCPT within electronic health records, and lack of suitability for all areas of practice are some previously identified barriers.[4],[6],[17]

Enablers to implementation of nutrition care process adaptation

In 2010, the Swedish Association of Clinical Dietitians (DRF), in cooperation with the Department of Clinical Nutrition and Dietetics, Karolinska University Hospital, became the first dietetic association in Europe to contract with the AND for the right to translate and publish terms and definitions from the third edition of the International Dietetics and Nutrition Terminology (IDNT) Manual.

The Swedish Association of Clinical Dietitians (DRF), therefore, supports the introduction of the NCP and NCPT in Sweden. To date, several NCP training courses have been held in Sweden.

According to Vision 2020 of the European Federation of association of dieticians released in March 2014 by 2020, dietitians in Europe will be using SL and work according to a NCP model. All higher education institutions would have included a NCP model and a SL for dietitians in their curriculum, all national dietetic associations encourage and facilitate dietitians to use a NCP in various practice settings, and dietitians would have implemented a SL in research to enable a global collaboration.

  Education Top

Educators and practice placement dietitians need to be trained and become familiar with NCEP models and standard language for dietitians and have support in teaching it to students and interns. Students need to be given the opportunity to practice and document using an NCP model and a standard language during their practice.

  The Role of Mobile Health Top

The public market for and acceptance of mobile health (mHealth) technologies, such as smartphone applications (apps), has experienced dramatic growth, with over 259,000 mHealth apps available.[10] Fifty-eight percent of US smartphone owners have downloaded a health-related app,[18] with fitness and nutrition apps most frequently downloaded.[17]

If implemented appropriately, apps could support dietetic practice by increasing accuracy, efficiency, and quality of clinical decision-making when applying the NCP,[7] as well as improving patient access to point-of-care services and patient–provider communication, to ultimately improve patient outcomes.[19] Nutrition software can help with all the repetitive tasks, yet crucial, of a nutrition appointment. Allowing the dietician to really understand the client and achieve better results with them.

Recent reports indicate the dietetic profession has adopted health apps into their practice. Eighty-three percent of US RDs were found to recommend apps.[6]

To support app use among RDs, the Academy has undertaken science-based reviews of nutrition apps, which are included in their food and nutrition magazine.[11] However, there has been no systematic process proposed of how to incorporate apps into the NCP.

  Use of Apps in Various Activities of Nutrition Care Process Top

The end goal of any nutrition software is to help dietitians and nutritionists be more organized, achieve better results with clients and be able to track their progress by decreasing daily workload and reducing time wasted on repetitive tasks.

Nutrition assessment

During patient assessment, RDs will obtain, verify, and interpret anthropometric, biochemical, medical, social, and client history, as well as dietary information.[1],[20]

RDs usually conduct a diet history to estimate nutritional adequacy and meal patterns but sometimes ask patients to keep a diet record in advance of their consultation. However, paper-based dietary records are burdensome for patients and labor intensive for RDs to analyze, thereby reducing counseling time available.[13]

Apps provide a convenient means to record data in near real time during eating occasions and have demonstrated greater acceptability than paper-based food diaries.[15],[16],[21]

Most nutrition apps convert the food intakes into nutrients and provide valid estimates of energy and nutrient intake comparable to traditional dietary assessments.[22],[23],[24] An evaluation of variance across 23 commercial weight loss apps revealed that 17 of 23 apps assessed were within 100 kcal of weighed food records.[25]

An app which has gained wide adaptation among dieticians, is the Nutrium.[26]

The Nutrium software stores clients' files food composition databases requirements, checks all the foods available and their nutritional value . The Nutrium software is compliant with all the data protection such as in an Electronic Medical Record (EMR).

Automated calculation tasks such as calculations for basal metabolic rate, daily energy expenditure, and body fat percentage can be handled by Nutrium saving precious time.

Image-based reminder system

Some commercial apps also include image logs to complement the digital dietary record and assist with prompting memory when reviewing records or by dietitians for qualitative assessment.[25],[27] Sole image-based dietary record apps show promise in lowering the burden of logging, though challenges remain for automated computer vision approaches to reliably assess the vast array of foods.[28]

Anthropometric measurements

Collection of anthropometric measurements and monitoring could also be enhanced. Apps and wireless scales provide a popular and simple method to assess, monitor, and visualize weight history.[25]

The Academy's NutriCare Tools app contains a compilation of evidence-based tools, including calculators that assess energy and fluid requirements and a range of anthropometric tools.[29] Fitness and exercise wearables, such as Fitbit or smart watches, can also support the passive assessment of physical activity, including valid estimates of step counts and energy expenditure.[30],[31]

Apps for diabetes management enable patients to log blood glucose levels, track insulin injections and oral medication, and record exercise, carbohydrate, and other dietary intakes.[32]

Some diabetes apps also allow patients to synchronize blood glucose measurements from glucometers for simplified recording and visualization of trends.[33],[34],[35] Certain diabetes apps have been approved by the US Food and Drug Administration.[32],[36]

Nutrition diagnosis

From data gathered in nutrition assessment, RDs can identify the etiology, signs, and symptoms of nutrition problems, which can then be targeted through a treatment or nutrition intervention.[1],[37] With many complex terminology references in this step, the former IDNT app, now integrated into the Kalix software, KalixInc, Victoria, Australia[38] is a useful tool for guiding RDs on the selection of relevant and appropriate nutrition diagnoses.

Nutrition diagnostic domains most likely to be established by health apps include the intake domain for energy, nutrients, and fluids; clinical domain diagnoses, such as weight loss or weight gain; and behavioral-environmental aspects, such as knowledge and beliefs and physical activity.[1]

Etiologies related to the behavior category of the Nutrition Diagnosis Etiology Matrix (e.g., disordered eating pattern, excessive or inadequate energy intake, and excessive physical activity)[1] are readily identified by health apps.

With continued recording, dietary patterns and anomalies can be detected, albeit dependent on patient input of the data. Therefore, examining patient-generated health data (PGHD) via app records may also allow RDs to uncover additional information about other etiological categories, such as beliefs attitudes, culture, or knowledge, that may be contributing to the nutrition problem.

Nutrition intervention

To address the etiology or signs and symptoms of the nutrition diagnosis, RDs plan individualized interventions and provide nutrition education and counseling.[1] Dietitian-specific tools, such as NutriGuides, an app developed by the Academy, contains an accessible compilation of the Evidence Analysis Library to help RDs determine best-practice treatment.[39]

Emerging evidence provides some support for using apps in lifestyle change[40],[41] and weight[41],[42] and chronic disease management[12],[43],[44] However, apps appear to be more effective when complemented with counseling sessions, education, or other mHealth technologies (e.g., text messaging) in multicomponent interventions rather than with standalone use.[40],[45],[46]

Nutrition education is a NCP interventionstrategy,[1] Apps to deliver information is likely to be acceptable to patients, as 63% of US smartphone users access information about health conditions via smartphones.[47] Calorie or nutrient information provided by apps is reported to be a useful resource in patient nutrition care.[8] Educational information on diabetes, including managing blood glucose and diabetes-related treatments, is also accessible in some diabetes apps.[32],[48],[49] However, there is opportunity for more personalized patient education, particularly apps centered around dietary and clinical guidelines.[25],[32],[49],[50],[51]

NutriCare Tools app provides education on reading food labels.[29] Fooducate provides interpretations of nutrients and ingredients of food labels from scanned product barcodes,[51] and ShopWell scores foods based on individual dietary preferences, with content that has been reviewed and developed by RDs.[52] FoodSwitch is a commercial-research partnership app that utilizes a traffic light system for identifying healthier packaged foods.[53] Researchers have also developed the MyNutriCart app based on the Dietary Guidelines for Americans.[54],[62]

Nutrium helps to easily create and update meal plans, nutritional recommendations, and recipes; the software can provide DRVs of macro- and micronutrients personalized to each client.

Setting goals

Generic goal setting is a common feature in apps.[25],[32],[55],[56],[57],[58],[59],[60],[61] However, personalized goal setting is often only available in premium subscription versions of commercial apps. Dietitians of Canada developed eaTracker, an app allowing users to choose from 87 “ready-made” SMART goals, covering 13 different categories, or to write their own goals.[62] With more customization features like customized goals, recipes, foods in the apps, the users had greater chances of weight loss success.[63]

Nutrium helps the dieticians to get in touch with the clients through messaging and check on the clients there by helping in “hands holding” to reach the goal.

Monitoring of nutrition-related parameters

Regular and frequent self-monitoring is a foundational component of weight loss[64] and improved glycemic control in diabetes management.[65] Adherence to self-monitoring is superior with apps compared to traditional pen- and paper-based records[21],[42],[49],[66],[67],[68] making apps a good choice for increasing patient compliance with self-monitoring and achieving positive weight and dietary outcomes.[63],[67],[68],[69],[70],[71],[72] Self-monitoring increases patient awareness of behaviors, giving them confidence to self-manage their health, for example, adjusting insulin based on self-monitored blood glucose readings.[44]

Using interactive tools with clients has improved retention rates and thus outcomes.

The literature affirms that patient self-management and behavioral regulation is more effective when self-monitoring is combined with other components of control theory, such as the provision of feedback on performance and reviewing of goals.[73] To promote patient accountability after app prescription, a review of app records of PGHD should be routine in nutrition care. In the current practice, reviewing of app data as part of every follow-up consultation is infrequent among dietitians.[8]

Apps with data sharing functionalities that innately integrate into dietitian-designed health record platforms (e.g., Healthie, Easy Diet Diary Connect, and MyPace)[74],[75],[76],[77] present opportunities to increase the convenience of accessing and reviewing app records.[78] In turn, the quality of patient–provider communication and degree of support between consultations from remote nutrition care is enhanced through the greater connectivity of apps.[32],[78] Many diabetes apps have capabilities to export data via email, unlike most weight loss apps.[25],[35],[58]

Limitation of use of apps for self-monitoring

Long-term sustained use of apps for dietary self-monitoring is challenging to maintain, and adherence to app use rapidly declines over time.[21],[71],[79],[80] Patient engagement with apps can be increased through human support and accountability.[79],[72] Retention rates for mHealth apps are higher when health-care professionals prescribe mHealth apps to patients rather than making general recommendations.[17]

Thus, RDs should define a realistic frequency and pattern of tracking tailored to patients' individual capacities for self-monitoring and lifestyles when they prescribe apps. Self-monitoring consistently over consecutive days may be unnecessary, with evidence highlighting that long-term intermittent self-monitoring over 6 months was more successful and associated with greater weight loss compared to short-term self-monitoring.[70]

Where patients are less compliant with self-monitoring, encouraging frequent logging of only specific meal occasions, such as dinner, can assist in the maintenance of weight loss.[69] Logging physical activity for sustained periods using wearables presents fewer challenges due to their passive nature and ability to sync automatically.

Stein has previously discussed a range of apps that enable remote nutrition counseling and could enhance dietetic practice models.[81]

  The Future of Apps and Wearables for Dietetic Practice Top

Incorporating apps into the NCP could permit the dietitian to devote more practice time to nutrition behavioral counseling. RDs have reported that video conference apps and smartphones are among the technologies they were currently or expecting to use for telehealth within the next 5 years.[82]

Health apps often include standardized criteria for weight, glycemic control, or recommended physical activity, calorie and nutrient intake. This facilitates comparison of clients data with standards. Alerts could be integrated into the platforms for review on a daily basis.[78]

Manual vs electronic medical record: Which is better in implementing nutrition care process

The implementation of an electronic system compared with a paper-based system in a population receiving hemodialysis resulted in significant improvements in the efficiency of nutrition care and effectiveness related to patient outcomes.[20]

  Conclusions Top

The NCP/NCPT is currently being implemented in a number of different countries globally, and to date, different editions of the NCPT have been translated into 11 languages and dialects. It is not yet introduced in India. The benefits of implanting the NCP have been demonstrated in many countries. It will be useful to get the leading nutritionists' associations to endorse the NCP, get the academia to introduce the NCP training in undergraduate and postgraduate training, and conduct regular workshops for the practicing dieticians. This is a time-consuming program, hence a vision statement and an action plan need to be developed involving the multiple stakeholders.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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Smartphone apps and the nutrition care process: Current perspectives and future considerations Author links open overlay panel Juliana ChenaLukeGemmingaRhonaHanningbMargaretAllman-Farinellia Patient Education and Counseling 2018;101:750-7.  Back to cited text no. 82


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