WEBVTT 1 00:00:00.769 --> 00:00:03.630 Welcome to the summary of the DNCP 2 00:00:03.640 --> 00:00:07.110 two discussion on identifying nutrition problems. 3 00:00:07.119 --> 00:00:09.800 For two specific issues encountered 4 00:00:10.170 --> 00:00:13.220 when treating clients with inflammatory bowel disease 5 00:00:13.229 --> 00:00:15.880 by the dietician from Sweden Sarah Anderson 6 00:00:17.010 --> 00:00:19.180 to set the context for the discussion. 7 00:00:19.190 --> 00:00:21.680 Here is a quick overview of the medical condition, 8 00:00:21.969 --> 00:00:25.379 inflammatory bowel disease is an abnormal activation of 9 00:00:25.389 --> 00:00:29.790 the mucosal immune response and secondary systematic responses. 10 00:00:30.059 --> 00:00:33.770 The usual medical goals are to induce and maintain remission 11 00:00:33.950 --> 00:00:35.959 and to improve nutritional status. 12 00:00:36.529 --> 00:00:39.599 The medical treatment usually consists of medications, 13 00:00:39.700 --> 00:00:42.930 usually corticosteroids, anti inflammatory agents, 14 00:00:43.119 --> 00:00:47.060 immunosuppressants, antibiotics and anti cytic kinds. 15 00:00:47.549 --> 00:00:50.279 If there is surgical treatment, it will be bowel resection. 16 00:00:50.619 --> 00:00:53.959 This information was taken from Kraus chapter 28. 17 00:00:54.860 --> 00:00:56.529 The medical nutrition therapy for I 18 00:00:56.880 --> 00:01:00.750 disease usually focuses on oral and antril intake, 19 00:01:00.759 --> 00:01:03.869 parental intake and severe disease or blockage, 20 00:01:05.339 --> 00:01:07.910 identifying the foods that are well tolerated 21 00:01:08.040 --> 00:01:10.220 testing for food intolerances, 22 00:01:10.440 --> 00:01:14.870 modifying fiber based on the symptoms and supplements to account for any 23 00:01:15.040 --> 00:01:16.379 uh inadequacies. 24 00:01:16.389 --> 00:01:22.589 Usually considering folate B six B 12 vitamin D iron and omega three fatty acids 25 00:01:22.819 --> 00:01:25.089 and may consider pre or probiotics. 26 00:01:25.889 --> 00:01:28.319 And again, this information came from Kraus. 27 00:01:30.040 --> 00:01:30.980 In this case, 28 00:01:30.989 --> 00:01:34.889 the specific information we're being asked to consider is two types 29 00:01:34.900 --> 00:01:38.750 of issues that are encountered in Sweden with clients with IBD. 30 00:01:39.230 --> 00:01:43.059 The first situation is where an IBD patient has a 31 00:01:43.069 --> 00:01:46.790 severe flare up and comes in with either frequent diarrhea, 32 00:01:46.800 --> 00:01:48.250 abdominal pain or nausea 33 00:01:48.639 --> 00:01:52.290 and has both reduced oral intake related to fear of more 34 00:01:52.300 --> 00:01:56.220 G I symptoms and increased losses through the frequent diarrhea. 35 00:01:56.519 --> 00:02:01.529 The dietary intake is very limited to small servings of food per day. 36 00:02:02.480 --> 00:02:06.099 The second situation is where a consultation request is 37 00:02:06.110 --> 00:02:09.089 sent to the dietician that asks for an assessment 38 00:02:09.210 --> 00:02:11.839 and to initiate or start a bowel relief 39 00:02:11.850 --> 00:02:14.889 intervention where the patient will only drink nutrition, 40 00:02:14.899 --> 00:02:18.350 nutrient supplements, similar to exclusive antral nutrition, 41 00:02:18.360 --> 00:02:22.389 but only for a few days more commonly, 1 to 5 days. 42 00:02:22.759 --> 00:02:25.509 And then note that bowel relief is an intervention. 43 00:02:25.520 --> 00:02:28.130 But we're trying to figure out what would be the pe s 44 00:02:28.139 --> 00:02:32.850 statement identifying the problem that the bowel relief is intended to solve. 45 00:02:33.710 --> 00:02:36.800 Additional information was provided during the sessions 46 00:02:36.929 --> 00:02:40.860 uh by the dietician from Sweden indicating that in some cases, 47 00:02:40.869 --> 00:02:45.300 the the patient will have both situations occurring simultaneously. 48 00:02:45.539 --> 00:02:49.350 Other times the patients will only have one of these situations. 49 00:02:49.800 --> 00:02:52.279 And then in addition, in some cases, 50 00:02:52.289 --> 00:02:57.380 but not all malnutrition and weight loss will also exist as separate diagnoses. 51 00:02:58.029 --> 00:02:59.619 As we approach this question, 52 00:02:59.630 --> 00:03:03.320 we asked the groups to consider writing a pe 53 00:03:03.330 --> 00:03:06.820 s statement separately for each of the two situations. 54 00:03:06.830 --> 00:03:09.179 And then think about whether or not there could be 55 00:03:09.190 --> 00:03:12.699 a single pe s statement that might address both situations. 56 00:03:13.580 --> 00:03:18.649 Each of the groups identified challenges when they created their pe S statements, 57 00:03:18.720 --> 00:03:21.789 either with selecting the nutrition, diagnostic term, 58 00:03:21.800 --> 00:03:25.990 selecting the ideology or selecting the signs and symptoms. 59 00:03:26.389 --> 00:03:28.470 As the pe F statements are shown, 60 00:03:28.479 --> 00:03:32.880 the highlighted words show where these challenges occurred that we discussed. 61 00:03:33.279 --> 00:03:35.910 The description of the discussion will occur later 62 00:03:38.690 --> 00:03:44.820 for the first situation where a patient comes with an IBD flare up and has been 63 00:03:44.830 --> 00:03:47.800 reluctant to eat and has been um consuming 64 00:03:47.809 --> 00:03:50.360 a very limited quantity and limited variety. 65 00:03:50.610 --> 00:03:53.399 We could use inadequate oral intake as shown below 66 00:03:53.539 --> 00:03:58.699 inadequate oral intake related to fear of increasing G I symptoms during 67 00:03:58.710 --> 00:04:02.509 an X number of months flare up as evidenced by energy intake 68 00:04:02.520 --> 00:04:06.570 of X kilocalories less than requirements and weight loss in the past 69 00:04:06.580 --> 00:04:09.279 of X number of pounds in the past X number of months, 70 00:04:09.919 --> 00:04:12.509 it could also be worded slightly differently. 71 00:04:12.690 --> 00:04:16.690 Inadequate oral intake related to eating less to avoid diarrhea 72 00:04:16.700 --> 00:04:19.428 and abdominal pain during an X month flare up. 73 00:04:19.440 --> 00:04:24.010 As evidenced by energy intake of X number of kilocalories less than requirements 74 00:04:24.170 --> 00:04:28.029 for the past three months, as well as X number, pounds of weight loss. 75 00:04:29.790 --> 00:04:32.589 We also looked at trying to select terms for the knowledge, 76 00:04:32.600 --> 00:04:34.160 beliefs and attitudes domain. 77 00:04:34.809 --> 00:04:38.769 We tried inadequate oral intake related to unsupported beli 78 00:04:38.959 --> 00:04:41.859 which is fear of eating to avoid G I symptoms 79 00:04:41.910 --> 00:04:45.630 as evidenced by consuming only 500 kilocalories per day. 80 00:04:45.640 --> 00:04:48.839 Versus an X number of kilocalorie per day, estimated needs 81 00:04:49.190 --> 00:04:53.059 or this could be stated as a percent of estimated requirements for either 82 00:04:53.220 --> 00:04:55.100 uh energy or nutrients 83 00:04:55.600 --> 00:05:00.279 and patient reporting, only two small servings of food per day to avoid diarrhea. 84 00:05:01.609 --> 00:05:05.799 We tried using the unsupported beliefs as a diagnostic term and it would look 85 00:05:05.809 --> 00:05:09.239 like this unsupported beliefs related to restricting 86 00:05:09.250 --> 00:05:11.839 oral intake to avoid G I symptoms 87 00:05:11.980 --> 00:05:14.440 as evidenced by food group restriction, 88 00:05:14.450 --> 00:05:17.269 not supported by evidence and patient reporting, 89 00:05:17.279 --> 00:05:21.820 avoidance of all foods except crackers, for example, to avoid diarrhea, 90 00:05:22.589 --> 00:05:24.529 we all felt that this one sounded too 91 00:05:24.540 --> 00:05:27.079 harsh and judgmental and probably would not be one 92 00:05:27.250 --> 00:05:28.260 that we would use. 93 00:05:30.670 --> 00:05:31.089 Now, 94 00:05:31.100 --> 00:05:34.089 let's move to that second situation where a consultation 95 00:05:34.100 --> 00:05:37.500 request was sent to the dietician asking for an assessment 96 00:05:37.649 --> 00:05:40.140 and to start a ball relief intervention. 97 00:05:40.779 --> 00:05:43.329 So here might be a potential pe S statement 98 00:05:43.529 --> 00:05:46.279 altered G I function related to 99 00:05:46.290 --> 00:05:50.230 unknown triggers associated with exacerbation of IBD 100 00:05:50.390 --> 00:05:54.109 as evidenced by diarrhea, X, number of times per day, nausea, 101 00:05:54.119 --> 00:05:55.519 X number of times per day, 102 00:05:55.529 --> 00:06:00.359 patient reporting avoidance of all foods except small quantities of XX 103 00:06:00.589 --> 00:06:04.809 and the need for temporary bowel relief. As per physician consult, 104 00:06:06.279 --> 00:06:12.019 here are two additional examples, altered G I function related to IBD, 105 00:06:12.029 --> 00:06:17.429 severe flare up as evidenced by frequent diarrhea and need for bowel relief. 106 00:06:17.440 --> 00:06:22.230 As per physician consult to avoid potential food triggers causing flare ups 107 00:06:22.640 --> 00:06:25.869 or slightly rewarded to not have a medical diagnosis. 108 00:06:25.880 --> 00:06:32.170 You could state it as altered G I function related to severe inflammation in bowel 109 00:06:32.179 --> 00:06:36.809 as evidenced by eczema of diarrhea per day and the need for bowel relief. 110 00:06:36.820 --> 00:06:38.640 As per physician consult, 111 00:06:38.880 --> 00:06:43.000 this group also felt they would like to incorporate this information into 112 00:06:43.010 --> 00:06:47.890 a malnutrition or chronic disease related if that particular condition existed. 113 00:06:47.899 --> 00:06:50.350 And that could work in that pe s statement. 114 00:06:51.929 --> 00:06:55.140 The groups discuss the following considerations in selecting 115 00:06:55.149 --> 00:06:57.450 the ideology for the pe s statement, 116 00:06:57.809 --> 00:07:02.119 choosing ideology is normally one that we think the dietician can resolve. 117 00:07:02.130 --> 00:07:05.700 And we usually recommend not using a medical diagnosis. 118 00:07:06.040 --> 00:07:09.950 However, this may be a situation where using the medical diagnosis, 119 00:07:09.959 --> 00:07:16.070 IBD may be more clear and we can only lessen the signs and symptoms of the flare up, 120 00:07:16.079 --> 00:07:19.079 not resolve the original medical diagnosis. 121 00:07:19.630 --> 00:07:23.260 The process of exploring to see if there are any other ideologies using 122 00:07:23.269 --> 00:07:27.059 the ideology matrix and the reference sheet is helpful especially for students. 123 00:07:27.559 --> 00:07:30.899 We understand that it's also challenging to make the pe F statement 124 00:07:30.910 --> 00:07:36.260 concise and clear with fewer words and still adequately describe the situation. 125 00:07:38.279 --> 00:07:39.470 During our discussion, 126 00:07:39.480 --> 00:07:42.450 we actually went to the ENCPT and used the 127 00:07:42.459 --> 00:07:47.570 ideology matrix to systematically go through the categories of ideology 128 00:07:47.750 --> 00:07:53.989 to confirm that we believe that use the use of IBD in the ideology might be warranted. 129 00:07:54.290 --> 00:08:00.730 We did not identify any other ideology that fully described it as clearly as IBD, 130 00:08:00.739 --> 00:08:02.700 the medical diagnosis of IBD. 131 00:08:02.750 --> 00:08:05.359 Since inflammation is very broad and we 132 00:08:05.369 --> 00:08:07.839 thought that this might be considered a nonpreferred 133 00:08:07.850 --> 00:08:10.859 situation where the medical diagnosis might be the 134 00:08:10.869 --> 00:08:13.750 most concise way to describe the ideology. 135 00:08:13.980 --> 00:08:16.519 And if you use the IBD flare up, 136 00:08:16.529 --> 00:08:20.290 then the flare up is what the dietician is attempting to resolve. 137 00:08:20.299 --> 00:08:21.640 Not the IBD. 138 00:08:25.459 --> 00:08:30.500 Other considerations discussed by the group were in selecting signs and symptoms. 139 00:08:30.619 --> 00:08:32.789 And the question was specifically, 140 00:08:32.799 --> 00:08:35.349 is it appropriate to refer to information 141 00:08:35.359 --> 00:08:38.840 from the physician's consultation as a sign. 142 00:08:38.859 --> 00:08:42.109 For example, the consultation request for bowel relief, 143 00:08:43.119 --> 00:08:44.090 just a refresher. 144 00:08:44.099 --> 00:08:46.140 A symptom is a subjective feeling or 145 00:08:46.150 --> 00:08:49.020 concern perceived by the person experiencing them. 146 00:08:49.440 --> 00:08:51.650 A sign is something that's observed and 147 00:08:51.659 --> 00:08:54.419 measured by another usually health care provider 148 00:08:54.570 --> 00:08:57.929 that is a physical manifestation of a disease. 149 00:08:58.650 --> 00:08:59.390 For example, 150 00:08:59.400 --> 00:09:04.570 it's referred to as a physical response linked medical fact or characteristic. 151 00:09:04.900 --> 00:09:08.309 Both signs and symptoms are used to make a diagnosis 152 00:09:08.859 --> 00:09:10.340 for medical diagnosis. 153 00:09:10.349 --> 00:09:12.469 The signs are often laboratory results, 154 00:09:12.479 --> 00:09:16.109 tests procedure results or measurements by other instruments 155 00:09:16.460 --> 00:09:19.590 for nutritional diagnosis. We use the same data 156 00:09:19.760 --> 00:09:25.309 but we also use data from other health care providers such as a medical diagnosis 157 00:09:25.409 --> 00:09:29.409 to infer the presence of a physical manifestation of a disease. 158 00:09:29.869 --> 00:09:34.320 If you look in our reference sheets, we include a category called client history. 159 00:09:34.409 --> 00:09:38.280 And this includes information that we did not directly observe, 160 00:09:38.289 --> 00:09:40.960 but it informs us about the presence of 161 00:09:40.969 --> 00:09:43.619 a physical manifestations of a disease condition. 162 00:09:46.109 --> 00:09:50.859 When we look at resources specific to the nutrition care process, for example, 163 00:09:50.869 --> 00:09:52.159 the ENCPT 164 00:09:52.359 --> 00:09:58.070 and we find that signs and symptoms are defined as defining characteristics 165 00:09:58.080 --> 00:10:02.929 that consist of subjective and or objective data from the nutrition assessment, 166 00:10:02.940 --> 00:10:05.630 monitoring and evaluation terminology. 167 00:10:06.059 --> 00:10:07.869 When we look at that terminology, 168 00:10:07.880 --> 00:10:11.380 we see that there's a category of data called client history. 169 00:10:11.919 --> 00:10:16.549 And in that section, there is a term called treatments and therapy, 170 00:10:16.820 --> 00:10:20.200 which is defined as documented medical or surgical treatments. 171 00:10:20.210 --> 00:10:23.479 They may impact the nutritional status of a client. 172 00:10:23.690 --> 00:10:28.239 In this case, the bowel rest would be a documented medical treatment 173 00:10:28.570 --> 00:10:31.830 that is being impacting the nutritional status of the client. 174 00:10:32.450 --> 00:10:35.640 The encpt goes further to explain that the signs 175 00:10:35.650 --> 00:10:38.919 and symptoms are gathering during the nutritional assessment. 176 00:10:39.419 --> 00:10:42.479 And then it says that you're going to describe the signs 177 00:10:42.489 --> 00:10:46.260 and symptoms using the five categories of nutrition assessment data, 178 00:10:46.270 --> 00:10:48.200 which includes client history. 179 00:10:48.510 --> 00:10:52.080 And it says that within the category, those are the indicators 180 00:10:52.219 --> 00:10:55.280 that are associated with specific nutrition diagnosis 181 00:10:55.289 --> 00:10:57.239 and they're listed on the reference sheet. 182 00:10:57.830 --> 00:10:59.400 When we look at reference sheets, 183 00:10:59.409 --> 00:11:02.219 we see that they have a category of data as 184 00:11:02.229 --> 00:11:05.669 a sign and symptom that includes the client history. 185 00:11:05.890 --> 00:11:09.890 So we use information from the medical record that 186 00:11:10.460 --> 00:11:14.520 states the current medical diagnosis and we use that to infer 187 00:11:14.530 --> 00:11:18.099 the physical signs and symptoms that are would have been present 188 00:11:18.270 --> 00:11:22.739 that represent the disease that is being identified as the medical diagnosis. 189 00:11:24.340 --> 00:11:29.010 When we attempted to write a single pe s statement to reflect both situations. 190 00:11:29.020 --> 00:11:30.679 We were not very successful. 191 00:11:30.900 --> 00:11:33.880 Our attempt resulted in this um example, 192 00:11:34.000 --> 00:11:37.049 malnutrition, acute disease or injury related. 193 00:11:37.059 --> 00:11:39.719 We would have to determine whether it was chronic or acute 194 00:11:40.049 --> 00:11:45.710 related to alterations in G I tract and avoidance of intake for fear of eating, 195 00:11:45.719 --> 00:11:47.919 causing G I symptoms and mal 196 00:11:48.070 --> 00:11:51.130 absorption due to severe inflammation in the bowel, 197 00:11:51.400 --> 00:11:56.130 as evidenced by less than 50% of the intake for X time period 198 00:11:56.239 --> 00:11:58.659 and diarrhea x times per week. 199 00:11:58.700 --> 00:12:01.710 Uh data for other malnutrition indicators will be included, 200 00:12:01.719 --> 00:12:05.070 patient reports of avoiding food intake to stop G 201 00:12:05.080 --> 00:12:07.710 I symptoms and need for temporary bowel relief. 202 00:12:07.719 --> 00:12:09.539 As per physician consult 203 00:12:10.159 --> 00:12:13.049 our conclusion, we didn't really think this was a very good option. 204 00:12:13.059 --> 00:12:16.789 That would really describe both situations in a single pe s statement. 205 00:12:18.409 --> 00:12:22.380 And specifically, when we were talking about selecting a nutrition diagnosis, 206 00:12:22.390 --> 00:12:26.799 there were challenges between choosing acute versus chronic malnutrition. 207 00:12:27.150 --> 00:12:29.510 For one, the information we provided, 208 00:12:29.520 --> 00:12:33.090 we didn't know how long the person had had IBD or if the 209 00:12:33.099 --> 00:12:36.900 flare ups are a routine issue in this client's management of IBD, 210 00:12:37.530 --> 00:12:41.760 having a severe initial flare up might be considered an acute event. 211 00:12:42.299 --> 00:12:44.659 When we look at the malnutrition reference sheets 212 00:12:44.669 --> 00:12:46.859 and look specifically to see if they can help 213 00:12:46.869 --> 00:12:49.049 us determine which would be the most like most 214 00:12:49.059 --> 00:12:51.809 appropriate to use on the acute reference sheet. 215 00:12:51.820 --> 00:12:54.729 It doesn't mention any presence of chronic disease 216 00:12:55.590 --> 00:12:59.090 and we determined it might be only appropriate if this was an initial 217 00:12:59.099 --> 00:13:03.510 occurrence of a flare up and the IBD had not been previously diagnosed. 218 00:13:03.630 --> 00:13:06.140 You could specify either moderate or severe 219 00:13:06.520 --> 00:13:10.650 when we look at the chronic malnutrition reference sheet. 220 00:13:10.710 --> 00:13:14.619 We see that there are specific examples included in the reference sheet 221 00:13:14.739 --> 00:13:16.010 and it as quote 222 00:13:16.210 --> 00:13:21.010 genetic or acquired conditions, cerebral palsy cystic fibrosis, 223 00:13:21.020 --> 00:13:24.210 seizure disorders, metabolic and IBD. 224 00:13:24.669 --> 00:13:26.969 And we can specify moderate or severe. 225 00:13:27.440 --> 00:13:32.890 So in the end, we're thinking that if IBD has already been officially diagnosed, 226 00:13:32.900 --> 00:13:35.250 it would most likely be chronic. 227 00:13:35.260 --> 00:13:37.809 Even if it was a severe acute episode, 228 00:13:37.820 --> 00:13:41.659 it would still be probably chronic malnutrition, chronic disease malnutrition. 229 00:13:42.059 --> 00:13:47.289 However, if IBD had not been yet diagnosed and there was a flare up, 230 00:13:47.299 --> 00:13:50.270 then that might be considered an acute malnutrition. 231 00:13:52.960 --> 00:13:54.690 Here are some examples that were 232 00:13:54.700 --> 00:13:57.809 created using how they were previously documenting 233 00:13:58.030 --> 00:13:59.640 the pe S statements. 234 00:13:59.919 --> 00:14:03.270 The first one would describe a situation where the patient had 235 00:14:03.280 --> 00:14:07.000 already started the bowel relief prior to becoming to the dietician 236 00:14:07.289 --> 00:14:08.950 limited food acceptance 237 00:14:09.219 --> 00:14:12.729 related to ongoing intestinal inflammation with increased 238 00:14:12.739 --> 00:14:15.570 losses and diarrhea and prescribed ball relief. 239 00:14:15.940 --> 00:14:20.989 As evidenced by intake of dietary supplements, eight, only eight pieces per day 240 00:14:21.099 --> 00:14:22.869 and diarrhea eight times per day. 241 00:14:23.929 --> 00:14:26.020 Another pe s statement might have reflected 242 00:14:26.030 --> 00:14:28.539 the situation before they started the bo relief 243 00:14:29.159 --> 00:14:31.770 limited food acceptance because of fear of 244 00:14:31.780 --> 00:14:35.380 increased symptoms during ongoing intestinal inflammation, 245 00:14:35.950 --> 00:14:40.169 as evidenced by weight loss of X pounds per week 246 00:14:40.179 --> 00:14:42.929 and eating only two portions of food per day. 247 00:14:43.940 --> 00:14:46.599 And the third one, limited food acceptance, 248 00:14:46.609 --> 00:14:50.570 fear of mal absorption during ongoing intestinal inflammation, 249 00:14:50.599 --> 00:14:52.549 as evidenced by weight loss of 250 00:14:52.729 --> 00:14:54.479 pounds per day per week, 251 00:14:54.599 --> 00:14:58.169 increased losses after every meal and patient reports, 252 00:14:58.179 --> 00:15:00.190 avoiding food to reduce symptoms. 253 00:15:02.770 --> 00:15:04.780 As you have heard from the case, 254 00:15:04.789 --> 00:15:07.830 there's probably not any one perfect answer to either 255 00:15:07.840 --> 00:15:11.039 one of these scenarios because there are many if 256 00:15:11.280 --> 00:15:14.880 thens in this particular question or this particular case, 257 00:15:14.890 --> 00:15:18.840 if malnutrition diagnose coexists, then you can do this. 258 00:15:18.909 --> 00:15:22.280 If we use the information from the consultation request, 259 00:15:22.349 --> 00:15:24.260 then we could state it like this. 260 00:15:24.489 --> 00:15:30.179 If we're long term IBD versus a acute flare up without an IB diagnosis, 261 00:15:30.190 --> 00:15:33.289 then this type of pe S statement might be appropriate. 262 00:15:33.460 --> 00:15:35.340 So there is no single right answer. 263 00:15:35.349 --> 00:15:37.890 But you've heard lots of discussion about how to determine 264 00:15:37.900 --> 00:15:41.859 which will best describe the situation for your individual patient. 265 00:15:43.219 --> 00:15:47.549 So in closing, I'd like to say a special thank you to the invited discussions 266 00:15:47.710 --> 00:15:49.659 and especially to Sarah Anderson, 267 00:15:49.669 --> 00:15:52.330 the dietician from Sweden who provided the 268 00:15:52.340 --> 00:15:55.039 questions for us and the background information. 269 00:15:55.229 --> 00:15:57.729 Um and Sharon Hunter who coordinated and 270 00:15:57.739 --> 00:15:59.929 the others who reviewed and provided input. 271 00:16:00.750 --> 00:16:06.309 Save the date for our next do NCPT, August 3rd and consider nominating a topic, 272 00:16:06.320 --> 00:16:10.679 use the link that's provided on this page uh to submit your questions. 273 00:16:10.880 --> 00:16:12.820 And then one final disclaimer 274 00:16:13.020 --> 00:16:16.659 the information presented here is from this NCP user group, 275 00:16:16.669 --> 00:16:19.570 which is an independently supported and operated group 276 00:16:19.724 --> 00:16:22.294 that is not officially sanctioned by nor do 277 00:16:22.304 --> 00:16:24.815 the views expressed represent the Academy of Nutrition 278 00:16:25.434 --> 00:16:26.335 and dietetics. 279 00:16:26.645 --> 00:16:29.445 The responses provided reflect the collective thinking 280 00:16:29.455 --> 00:16:32.104 of the dieticians who participated in discussions. 281 00:16:32.414 --> 00:16:35.645 Questions that require Academy of Nutrition and dietetics responses will 282 00:16:35.655 --> 00:16:38.664 be forwarded to the Academy by the user group manager. 283 00:16:38.775 --> 00:16:39.594 Thank you. 284 00:16:39.705 --> 00:16:40.515 Have a good day.