The following table illustrates Nutrition Assessment data important to celiac disease.
Explanatory additions to the NCP Mind Map are in blue font.
NCP terms and codes are in black font. Codes are provided for the domains and the primary and secondary headings beneath each domain.
Select the Nutrition Assessment domain below to go directly to that section.
- Food/Nutrition-Related History (FH)
- Anthropometric Measurements (AD)
- Biochemical Data, Medical Tests and Procedure (BD)
- Nutrition-Focused Physical Findings (PD)
- Client History (CH)
- Assessment, Monitoring and Evaluation Tools (AT)
- Etiology Category (EY)
- Comparative standards (CS)
- Progress Evaluation (EV)
| FOOD/NUTRITION-RELATED HISTORY (FH) |
|
FOOD AND NUTRIENT INTAKE (FH-1)
|
| ANTHROPOMETRIC MEASUREMENTS (AD) |
| Body composition/growth/weight history (AD-1.1) · Height · Weight - Measured weight (lb, oz, kg, g) - Stated weight (lb, oz, kg, g) - Stated peak weight (lb, kg) - Measured peak weight (lb, kg) - Usual stated body weight (UBW) (lb, oz, kg, g) - UBW percentage (%) - You may consider age of onset at this point(3) · Frame - Frame size (small/medium/large) · Weight change, consider malabsorption and weight loss as signs and symptoms of Celiac disease - Weight gain (lb, oz, kg, g) - Weight loss (lb, oz, kg, g) - Weight change intent (intentional/unintentional) - Specify time frame - Lowest weight/time - Highest weight/time - Patterns of weight loss and gain · Body mass - Body mass index (BMI) (kg/m2) - Body mass index prime ratio (actual BMI to the upper limit BMI of 25) · Body compartment estimates - Body fat percentage (%) - Waist circumference (in or cm) - Waist to hip ratio (ratio) · Note growth failure in infants |
| BIOCHEMICAL DATA, MEDICAL TESTS AND PROCEDURES (BD) |
|
Acid-base balance (BD-1.1) |
| PHYSICAL EXAM FINDINGS (PD) |
| Nutrition focused physical findings (PD-1.1) · Overall findings - Weight loss/change in how clothes fit (specify) · Adipose finding - Loss of subcutaneous fat · Dental enamel cracks · Digestive system - Bowel function, including flatus (specify type, frequency, volume) - Dyspepsia - Anorexia - Decrease in appetite - Diarrhea - Early satiety - Epigastric pain - Excessive belching - Excessive flatus - Fatty stool (steatorrhoea) - Heartburn—gastroesophageal reflux disease - Loose stool - Nausea - Recurrent apthous ulcers - Urgency - Vomiting · Hair finding - Alopecia · Head finding - Headache · Hand and nails finding - Nail changes - Splits in nails · Nerves, cognition, and feelings - Depressed mood - Flat effect · Skin finding - Dermatitis herpetiformis - Easy bruising |
| CLIENT HISTORY (CH) |
| PERSONAL HISTORY (CH-1) Personal data (CH-1.1) · Age · Gender, personal identification · Sex, biological · Race, if relevant to care · Ethnicity · Language · Literacy factors · Education · Role in family · Tobacco (and drug) use · Physical disability · Mobility CLIENT AND/OR FAMILY HEALTH HISTORY (CH-2) Patient/client OR family nutrition-oriented medical/health history (CH-2.1) Specify issue(s) and whether it is patient/client history (P) or family history (F) · Patient/client chief nutrition complaint (specify) P or F, celiac disease · Patients or family with celiac disease are at increased risk of: · Endocrine/metabolism (specify) P or F - Insulin dependent diabetes (Type 1), especially in children - Anemia, especially iron deficiency · Gastrointestinal (specify) P or F - Liver disorders (Autoimmune hepatitis and primary biliary cirrhosis) · Integumentary (specify) P or F - Dermatitis herpetiformis · Musculoskeletal (specify) P or F - Osteopenic bone disease · Neurological (specify) P or F - Disorders, including ataxia, seizures, myasthenia gravis · Psychological (specify) P or F - Depression · Respiratory (specify) P or F - Other (specify), sleep apnea Treatments/therapy (CH-2.2) · Medical treatment/therapy (specify) · Surgical treatment (specify) - Surgical history SOCIAL CONTEXT (CH-3) Social history (CH-3.1) · Socioeconomic factors (specify) - Economic constraints (major/minor), food budget limits - Access to medical care (full, limited, none) · Living/housing situation (specify) - Other household members eating the same food - The person who does the shopping and cooking · Domestic issues (specify) · Social and medical support (specify) - Family members, roles - Support from friends - Physician/nurse involvement · Geographic location of home (specify) - Travel time to consultations · Occupation (specify) - Impact on physical activity · Religion (specify) - Impact on intake, such as Ramadan · History of recent crisis (specify) - Likelihood of emotional eating · Daily stress level (specify) (high, moderate, low bodily or mental tension) |
| ASSESSMENT, MONITORING AND EVALUATION TOOLS (AT) |
| NUTRITION ASSESSMENT, MONITORING AND EVALUATION TOOL RATINGS (AT-1) Subjective global assessment (SGA) rating (AT-1.1) The scored patient generated subjective global assessment (PG-SGA) rating (AT-1.3) · pt-global.org The scored patient generated subjective global assessment (PG-SGA) score (AT-1.4) Mini nutritional assessment long form (MNA-LF) rating (AT-1.5) |
| ETIOLOGY CATEGORY (EY) |
|
NUTRITION DIAGNOSIS ETIOLOGY CATEGORY IDENTIFICATION (EY-1) Beliefs attitudes etiology (EY-1.1) Cultural etiology (EY-1.2) Knowledge etiology (EY-1.3) Physical function etiology (EY-1.4) Physiologic metabolic etiology (EY-1.5) Psychological etiology (EY-1.6) Social personal etiology (EY-1.7) Treatment etiology (EY-1.8) Access etiology (EY-1.9) Behavior etiology (EY-1.10) |
| COMPARATIVE STANDARD (CS) |
| Sample related to celiac disease |
| ENERGY NEEDS (CS-1) Estimated energy needs (CS-1.1) · Total energy estimated needs in 24 hours · Method for estimating total energy needs - Simple ratio method - Measured resting metabolic rate (RMR) or Mifflin-St Jeor equation(4) - Physical activity factor (PAF) MACRONUTRIENT NEEDS (CS-2) Estimated fat needs (CS-2.1) · Total fat estimated needs in 24 hours · Method for estimating total fat needs · Proportion of energy needs from fat in 24 hours Estimated protein needs (CS-2.2) · Total protein estimated needs in 24 hours · Total protein estimated needs per kg body weight - 0.75 g of protein per kg of adjusted ideal body weight(5) · Method for estimating total protein needs - Nutrient Reference Values, Australia · Proportion of energy needs from protein in 24 hours Estimated carbohydrate needs (CS-2.3) · Total carbohydrate estimated needs in 24 hours · Method for estimating total carbohydrate needs · Proportion of energy needs from carbohydrate in 24 hours Estimated fiber needs (CS-2.4) · Total fiber estimated needs in 24 hours · Method for estimating total fiber needs · Type of fiber needed FLUID NEEDS (CS-3) Estimated fluid needs (CS-3.1) · Total fluid estimated needs · Method for estimating needs MICRONUTRIENT NEEDS (CS-4) Estimated vitamin needs (CS-4.1) Estimated mineral needs (CS-4.2) WEIGHT AND GROWTH RECOMMENDATION (CS-5) Recommended body weight/body mass index/growth (CS-5.1) · Ideal/reference body weight (IBW) · Recommended body mass index (BMI) - See BMI classification in the Perspective |
| PROGRESS EVALUATION (EV) |
|
INTERVENTION GOAL STATUS (EV-1) New goal identified (EV-1.1) Goal achieved (EV-1.2) Goal discontinued (EV-1.3) Goal not achieved (EV-1.4) Some progress toward goal (EV-1.5) Some digression away from goal (EV-1.6)
New nutrition diagnosis (EV-2.1) Active nutrition diagnosis (EV-2.2) Resolved nutrition diagnosis (EV-2.3) Discontinued nutrition diagnosis (EV-2.4) |
References
1. Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. 2023. Accessed 2 May 2024. Available from: https://www.ncpro.org/.
2. Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. NCP Step 1: Nutrition Assessment. 2020; Accessed 07 June 2021. Available from: https://www.ncpro.org/pubs/2020-encpt-en/page-015.
3. Donini LM, Savina C, Gennaro E, De Felice MR, Rosano A, Pandolfo MM, Del Balzo V, Cannella C, Ritz P, Chumlea WC. A systematic review of the literature concerning the relationship between obesity and mortality in the elderly. J Nutr Health Aging. 2012; 16: 89-98.
4. Mifflin MD, St-Jeor S, Hill LA, et al. A new predictive equation for resting energy expenditure in healthy individuals. Am J Clin Nutr. 1990; 51: 241-247.
5. National Health and Medical Research Council, Nutrient Reference Values, Protein. Accessed 30 May 2018, Available from: https://www.nrv.gov.au/nutrients/protein