Nutrition Interventions and the Nutrition Prescription

The Nutrition Intervention, sometimes called the “nutrition prescription,” is the third and perhaps the most crucial step in the Nutrition Care Process (NCP). The intervention is where the RDN aims to make a clinical impact in the patient’s health status and outcome.

This blog will cover:

• The Definition of a Nutrition Intervention

• What the Dietitian Needs to Know About the Nutrition Intervention

• The Intervention Domains, Classes, and Subclasses

• Nutrition Intervention Examples

As a review, these are the 4 Steps of the Nutrition Care Process:

(click on any of the links below to learn more!)

Nutrition Assessment

A Guide to the Nutrition-Focused Physical Exam

Nutrition Diagnosis and PES Statements

NUTRITION INTERVENTION

Nutrition Monitoring/Evaluation

What Is The Nutrition Intervention?

The nutrition intervention is the third step in the Nutrition Care Process and it involves both planning and implementing an intervention to improve the patient’s nutritional health outcome, specifically targeted at the nutrition diagnosis.

According to the Academy of Nutrition and Dietetics (2014): ”The purpose of a nutrition intervention is to resolve or improve the nutrition diagnosis or nutrition problem by provision of advice, education, or delivery of the food component of a specific diet or meal plan tailored to the patient/client’s* needs.”

What The Dietitian Needs To Know

• Interventions should be specific - stating what, where, when, and how.

• The goal of the intervention should be “fixing" the nutrition diagnosis, addressing the root cause (or etiology) of the nutrition diagnosis, AND reducing the signs/symptoms. These should already be identified listed in the PES statement, which you wrote in step 2 of the Nutrition Care Process: Nutrition Diagnosis.

• The intervention is selected from Nutrition Care Process Terminology (NCPT), which is broken down into Domains, Classes, and Subclasses. Using this official NCPT terminology, you will write the “nutrition prescription” in your patient assessment/record. (Don’t worry - I have included several examples below!)

• The intervention should specify the amount/duration/frequency of care. For example, if the intervention is nutrition education in the outpatient setting, you might specific once per week for 8 weeks. If the intervention is a protein supplement for wound healing, you might specify once per day for 30 days.

• Nutrition intervention strategies should be matched with the patient’s needs, and it should be appropriate for the clinical setting.

• When you have selected the intervention, be sure to discuss it with the patient and explain the reasoning. For example, if you are prescribing a supplement, you want to let the patient know why and have their agreement to take it. You will also inform the appropriate members of the patient’s care team.

Nutrition Intervention Domains and Classes

There are 4 domains to the nutrition intervention. Having said that, the first, “Food and/or Nutrient Delivery” is the most commonly used and often the most appropriate, especially in the clinical setting. *Note that you may use more than one intervention if you believe that is the best course of action!

1. Food and/or Nutrient Delivery

This is the most commonly used domain for nutrition interventions, and it entails an individual approach for providing food or nutrients to the patient.

There are 6 classes in this domain:

• Meals and Snacks

• Enteral and Parenteral Nutrition

• Nutrition Supplements

• Feeding Assistance

• Manage Feeding Environment

• Nutrition-Related Medication Management

*This domain is most often used in the clinical setting, such as in hospitals and rehabilitation centers.

2. Nutrition Education

This is the process of instructing the patient with skills/knowledge to help them voluntarily improve their food, activity, and lifestyle choices and behaviors.

There are 2 classes in this domain:

• Nutrition Education - Content

• Nutrition Education - Application

*This domain is often used in the outpatient setting, where you have more time and multiple sessions to education and train your patient. You may also do nutrition education before a patient is discharged from the hospital. For example, you may educate a diabetes patient or a heart attack patient on dietary patterns to follow before they go home.

3. Nutrition Counseling

This domain involves a collaborative nutrition counselor-patient relationship where priorities, goals, and action plans for diet and lifestyle change are put in place. The emphasis is on goal setting and behavior modification. Note how this differentiates from simply educating the patient. Both counseling and education are often necessary for nutrition-related behavior change.

There are 2 classes:

• Theoretical basis/approach

• Strategies

*Like Nutrition Education, Nutrition Counseling is often used in the outpatient setting as well community settings, where you have more time and multiple follow up appointments with your patient.

4. Coordination of Nutrition Care

When additional expertise is required as part of the patient’s care team in order to address the nutrition diagnosis, an intervention from this domain may be used. Sometimes, such as in the case of a suspected eating disorder, help from other healthcare professionals or institutions may be needed.

There are 2 classes:

• Collaboration and referral of nutrition care

• Discharge and transfer of nutrition care to a new setting or provider

Examples of Nutrition Interventions

Since “Food and/or Nutrient Delivery” is the most commonly used domain, let’s look at some examples of interventions for each of the classes within it!

(1) Meals and Snacks

Examples:

• Modify composition of meals/snacks: Texture-modified diet: Pureed diet (ND-1.2.1.3)

• Modify composition of meals/snacks: Energy-modified diet: Decreased energy diet (ND-1.2.2.2)

• Modify composition of meals/snacks: Fat-modified diet: decreased fat diet (ND-1.2.5.2)

• Fluid modified diet: Fluid-restricted diet (ND-1.2.8.2)

(2) Enteral and Parenteral Nutrition

Examples:

• Enteral nutrition: Modify volume of enteral nutrition (ND-2.1.4)

• Enteral nutrition: Modify route of enteral nutrition (ND-2.1.6)

• Parenteral nutrition/IV fluids: Modify schedule of parenteral nutrition (ND-2.2.5)

(3) Nutrition Supplement Therapy

Examples:

• Vitamin supplement therapy: B12 (ND-3.2.3)

• Mineral supplement therapy: Zinc (ND-3.2.4)

• Medical food supplement therapy: Commercial beverage (ND-3.1.1)

(4) Feeding Assistance

• Adaptive eating device (ND-4.1)

• Menu selection assistance (ND-4.5)

• Meal set up (ND-4.3)

(5) Manage Feeding Environment

• Table height (ND-5.4)

• Meal location (ND-5.8)

(6) Nutrition-Related Medication Management

• Over the counter (OTC) medication (ND-6.2)

Putting It All Together: The Nutrition Prescription!

⭐️At this point, you have conducted a thorough Nutrition Assessment, you have determined a Nutrition Diagnosis and PES (Problem, Etiology, Signs/symptoms) Statement, and you have selected the best Intervention(s) to solve the nutrition-related diagnosis for your patient. In the clinical notes for your patient, you will now tie it all together by writing a Nutrition Prescription.

⭐️The Nutrition Prescription is the product of the hard work you already did in selecting the appropriate Nutrition Diagnosis, PES Statement, and Intervention(s) for your patient. Your nutrition prescription is 1-2 sentences that provide a context in which the intervention will now be implemented.

⭐️Nutrition Prescription refers to the patient/client’s individual recommended dietary intake of energy and/or selected foods or nutrients based on current reference standard and dietary guidelines and the patient/client’s health and nutrition diagnosis. (Academy of Nutrition and Dietetics, 2015).

⭐️When writing your Nutrition Prescription, you will take into consideration the nutrition diagnosis, the estimated energy and nutrition needs you calculated, the overall assessment, and the intervention. It is essentially exactly what it sounds like: a prescription for nutritional wellness based on everything you have learned about the patient. It incorporates the official intervention terminology and puts it into a nice packaged statement.

Take a look at these sample Nutrition Prescriptions based on some of the PES Statement examples we provided in the Nutrition Diagnosis blog:

⭐️Example 1: Cancer Treatment

PES Statement:

Predicted suboptimal energy intake RT increased nutrient needs from chemotherapy treatment, AEB current caloric intake at 60% of estimated needs with treatment.

Nutrition Prescription:

• Medical food supplement therapy: Commercial beverage (ND-3.1.1): Ensure Vanilla per patient preference, 8 oz TID (3x per day) between meals to provide an additional 750 kcal, 27 g protein per day.

*Note: We cannot cure cancer nor can we remove the chemotherapy treatment (the etiology), but notice what we can do: We can increase the caloric intake to meet the patient’s estimated energy requirements (EER) by adding supplemental nutrition. When doing so, first discuss the intervention with your patient/patient’s family members to let them know why you are adding it and to ask which flavors they might prefer. There are puddings, ice creams, and shakes in various flavors and textures, so part of your intervention is to determine which supplement meets the patient’s needs and preferences. This example does not show you the exact calorie needs determined in the assessment, but we can assume that 750 kcal makes up the missing 40% of caloric needs as statement in the PES statement (putting total EER at 1875 kcal/d). Hence, you are addressing the nutrition problem (P) by targeting correction of the signs/symptoms (S).

⭐️Example 2: Anorexia Nervosa

PES Statement:

Inadequate energy intake RT disordered eating pattern and history of anorexia nervosa AEB BMI of 16.8 and reported caloric intake at only 52% of estimated energy needs.

Nutrition Prescription:

• Medical food supplement therapy: Commercial beverage (ND-3.1.1): Ensure Plus TID between meals to provide an additional 1050 kcal, 39 g protein per day.

• Collaboration and Referral of Nutrition Care: Collaboration with other providers (RC-1.4): meet with patient’s psychiatrist and mental health counselor to discuss plan of care.

Note: Every case will be different, but this example is from a patient seen in the inpatient setting with anorexia nervosa, who is being assessed and stabilized before a further treatment decision is made. Collaboration with the physician and mental health care providers is essential in the treatment of eating disorders. In this case, the patient has agreed to try medical food supplements to meet her caloric needs (in hospital settings, tube feeding may be required in the stabilization phase of treating Anorexia Nervosa, but this patient has agreed to oral supplementation). Patient preferences in choice of supplement are important, as stated in the prior example, and even more so when there is an ED diagnosis. Nutrition counseling and education are part of the ED recovery, often within an eating disorder facility in both inpatient and outpatient settings. Here, the prescription addresses the problem of inadequate intake by increasing intake and collaborating with the patient’s mental health team.

⭐️Example 3: Type II Diabetes

PES Statement:

Excessive carbohydrate intake RT limited diet compliance and diagnosis of Type 2 Diabetes, AEB reported intake of 80% calories from carbohydrates, HbA1C 8.2%, and blood sugar 240.

Nutrition Prescription:

• Energy-modified diet: Decreased carbohydrate diet (ND-1.2.4.3). Carbohydrates to be decreased to 50% of total daily caloric intake, distributed with no more than 40-60 g CHO per meal and 15-30 g for snacks.

• Nutrition Education: Recommended Modifications (E-1.5): consult with RD before discharge to discuss carbohydrate intake reduction, carbohydrate counting, and blood sugar monitoring education.

⭐️WHAT SHOULD I DO NEXT???⭐️

After the Nutrition Intervention comes Nutrition Monitoring and Evaluation!

Head on over to the Nutrition Monitoring and Evaluation Blog to wrap up your review of the Nutrition Care Process!

⭐️In the Brilliant Dietitians blog, you can learn how to use the Nutrition Care Process and write Nutrition Prescriptions for specific medical conditions, along with the appropriate Medical Nutrition Therapy.⭐️

Check out the blog archives for disease-specific treatment protocols!

3 Steps to become an Expert in Medical Nutrition Therapy TODAY!

1. Sign up for FREE to receive MNT Cheat Sheets for Dietitians, and be in-the-know about new podcast episodes, blogs, and other top-notch resources for dietitians and dietetic students! (bottom of this page!)

2. Read the Brilliant Dietitian Blog to learn more about Medical Nutrition Therapy!

3. Head over to the Medical Nutrition Therapy Podcast and subscribe!

Hey You, awesome RD or RD-to-be! Do you still have questions about the Nutrition Care Process and Nutrition Interventions? You can email me directly at brilliantdietitians@gmail.com with your questions and requests and I will get back to you ASAP!

“Have a fantastic day and get out there and BE A BRILLIANT DIETITIAN!"

😀 Bethany, MS, RDN

Your Brilliant Dietitian Coach

Blog Sources:

https://www.ncpro.org/encpt-tutorials