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HIV/AIDS Nutrition Intervention Mind Map

 
Once the Nutrition Assessment is concluded the dietitian specifies a Nutrition Prescription. For malnourished cancer patients the purpose of the prescription is to define the optimal energy balance and dietary intake needed in order for the patient to achieve good nutrition status. 

The Nutrition Prescription is used as a means of framing key recommendations and to communicating nutrition information to other members of the health-care team, including other dietitians the patient may see on follow-up consultations. In communicating with the patient and their family, practitioners should avoid using specialized language or technical terminology about nutrient and energy targets. 
The Nutrition Prescription needs to reflect the Comparative Standards in the NCP Step 1. Practitioners should also take account of short- and long-term goals, focused on both the patient and their family. 

Select the Nutrition Intervention domain below to go directly to that section.

 

NUTRITION INTERVENTION PLANNING
IDENTIFY NUTRITION INTERVENTION GOAL(S) (CG)

Identify goal description (CG-1.1) 
(based upon nutrition assessment/monitoring and evaluation or nutrition intervention terms) 
 

Identify goal target value (CG-1.2) 
(based upon nutrition assessment/monitoring and evaluation or nutrition intervention terms) 
 

Identify goal timeframe (CG-1.3) 
(duration) 
 

Identify goal subject (CG-1.4)  
(individual client, supportive individual, supportive structure) 
 

Identify goal setter (CG-1.5) 
(individual client, supportive individual, supportive structure, professional, mutually established between individual client and professional)
PRESCRIPTION PLANNING (NP)(1,2)
Sample related to malnutrition and oncology
Nutrition prescription (NP-1.1)  
·  Specifies a target energy level; short term for weight gain and long term for weight maintenance 
·  Identifies specific macronutrient targets 
   -  High-protein diet 
   -  Protein requirements are estimated at actual body weight × 1.2 to 1.5 g/kg/day (cancer, surgery, chemotherapy/radiation therapy)(3,4) 
·  Defines target servings per food category  
·  Includes a meal plan, if that is deemed helpful 
·  Sets a target physical activity level
AIMS OF MEDICAL NUTRITION THERAPY FOR MALNUTRITION AND ONCOLOGY
· To create an energy balance that prevents weight loss and when necessary promotes weight gain  
· To achieve or maintain healthy eating behaviours consistent with national dietary guidelines 
· To achieve or maintain improvements in outcomes unrelated to weight, including physical activity, biochemical parameters and psychosocial and emotional health  

NUTRITION INTERVENTION IMPLEMENTATION
FOOD AND/OR NUTRIENT DELIVERY (ND)(1,2)
MEALS AND SNACKS (ND-1) 
The "Meals and Snacks" Intervention is used only if the dietitian is providing or prescribing foods or supplements. This happens when the patient is in an inpatient facility that provides meals, is receiving meals at home or is receiving vitamin/mineral supplements or meal replacements.  

General/healthful diet (ND-1.1), following the national dietary guideline recommendations 

Modify composition of meals/snacks (ND-1.2) 
·  Energy modified diet, if patient is in an institutional setting or having meals delivered to home 
     - Increased energy diet 


NUTRITION SUPPLEMENT THERAPY (ND-3) 
Medical Food Supplement Therapy (ND-3.1) 
· Commercial beverage medical food supplement therapy, meal replacements, oral nutrition support 
· Commercial food medical food supplement therapy, pre-packaged, high-energy meals 

Vitamin and Mineral Supplement Therapy (ND-3.2), may need vitamin/mineral supplement
NUTRITION EDUCATION (E)(1,2)
Consider baseline knowledge, literacy level, language barriers and lifestyle factors.  

NUTRITION EDUCATION CONTENT (E-1) 
Instruction or training intended to lead to nutrition related knowledge. 

Content related nutrition education (E-1.1) 
Defined as instruction intended to lead to nutrition-related knowledge. 

·  Base Content-related nutrition education on patient's preferences, Food- and Nutrition-Related History (FH) and estimates of nutrient needs 
      - Base energy requirements on resting metabolic rate (RMR). Where possible, measure RMR using indirect calorimetry  
      - When indirect calorimetry in unavailable apply the national guidelines or appropriate energy prediction equation 
      - Estimate total energy needs by applying the appropriate physical activity factor 
· Emphasize the importance of meeting normal nutrition requirements for key minerals (calcium, iron, iodine) and vitamins (B-group, A and D) 
· Discuss protein requirements of 1.2 to 1.5g/kg/day of actual body weight (3,4) 
· Advise on how to increase energy and protein intake, discussing: 
      - A high-energy, high-protein diet 
      - Increasing intake of protein foods, dairy foods and fats and oils (as tolerated) 
      - Oral nutrition support between or with meals (5,6) 
      - Meal supplements such as high-energy bars between or with meals 
      - Fortifying normal foods 
      - Increasing nutrient-dense foods 
      - Including of high-energy glucose powders 
· Discuss strategies to meeting fluid requirements 
      - Recommend a straw for cold drinks or for beverages with objectionable taste, such as elemental formulas 
· Provide appropriate meal modifications, such as texture modification (7) 
· Discuss how to monitor the effects of certain foods such as spicy foods 
· Encourage consistent eating pattern with total caloric consumption distributed across the day as up to six meals/snacks 
· Discuss serving size, variety, frequency and availability of high-energy drinks and foods 
· Advise on changing food-related behaviors 
      - Provide information on serving size and dedicated mealtimes 
· Advise on eating environment 
      -  Focused mealtimes with support as required (5) 
      -  Adequate time for meals (30 minutes minimum) (7) 
      -  Preparation prior to meal, such as positioning, toileting, hand-washing, clearing of over-bed trolley (7) 
      -  Eating in chair for patients in bed (7) 
      -  Open packaging (7) 
      -  Eating independently 
      -  Eating slowly and chewing well 
For inpatients 
· Maintain records and assess actual food consumption versus the food offered (5) 
· Not missed meals and provide make-up meals 
· Document nutrition care plan, including serial goals for treatment and assessment 
· Familiarize medical team with nutrition care plan(5) 
· Discuss the following based on assessment results: 
      -  Peer and family support  
      -  Hobbies 
      -  Sleep-pattern goal (aim is regular seven to eight hours per day) 
· Advice on alcohol consumption within national guidelines; for example, in the United States, ≤ 2 standard drinks per day for men and ≤ 1 for women (8,9) 

In circumstances where the patient has limited time and wants to make immediate changes, the practitioner might recommend several changes with a significant impact with the view to comprehensive follow-up.  
Recommend a few minor changes that will have the greatest impact on energy balance. 

Education on nutrition's influence on health (E-1.2) 
Defined as instruction intended to lead to knowledge about the association between nutrition and health and disease status. 
 ·  Explain the diet-disease relationship 
·  Explain risks associated with malnutrition 
·  Explain the benefits of maintaining/increasing weight   

Physical activity guidance (E1.3) 
Defined as instruction intended to lead to physical activity-related knowledge and change. 
Discuss the importance of maintaining physical activity 
·  Provide information on national physical-activity guidelines with approval from family doctor and other practitioners involved 
·  Identify preferred physical activity and encourage the inclusion of physical activity on most/all days as able 
·  Identify possibilities for incidental physical activity 
·  Encourage the inclusion of physical activity on most/all days as able 
·  Consider that an accumulated physical-activity approach may be of benefit for those unable to engage in prolonged activity 


NUTRITION EDUCATION APPLICATION (E-2) 
Nutrition related laboratory result interpretation education (E-2.1) 
Defined as instruction or training leading to nutrition-related laboratory result interpretation. 

Nutrition related skill education (E-2.2) 
Defined as instruction or training leading to nutrition-related skill development.  
·  Instruction on the use of: 
   -  National guidelines/food guides/meal plans to guide food choices 
   -  Diet logs to identify areas for improvement in dietary intake 
   -  Physical activity logs to identify areas for improvement in activity level 
   -  Electronic tools, such as phone apps, to aid in decision-making 
   -  Procedures to modify recipes to increase calorie and protein intake (without increasing volume) 
   -  Food preparation methods to adjust to changes in taste and preferences of texture 
   -  Shopping, food preparation and cooking  
   -  Physical activity equipment  
   -  Identify changes in intake or weight that warrant a follow-up consultation  

Technical nutrition education (E-2.3) 
Defined as instruction or training leading to nutrition-related result interpretation or skills. 
·  Instruction on: 
   -  Heart-rate goals and physical activity  
   -  Strategies to increase intensity and duration within the patient's physical restrictions
NUTRITION COUNSELING (C)(1,2)

Using the terminology for counseling intervention, select both the Theoretical Basis/Approaches and Strategies. 
Refer to the Tool Kit for examples of counseling theories and strategies.  

NUTRITION COUNSELING THEORETICAL BASIS/APPROACH (C-1) 
No single behavioral approach is better than another in the treatment of malnutrition. Using various approaches in combination is most likely to support long-term weight gain. In any consultation, the dietitian can apply one or more of the theoretical approaches depending on their assessment of the individual's needs. (10) 

Nutrition counseling based on cognitive-behavioral theory approach (C-1.1) 
·  Facilitate using behavior modification to: 
   -  Achieve desirable food choices and physical-activity choice(10) 
   -  Identify and change antecedents to loss of appetite and less-than-optimum food choices 
   -  Develop specific goals to modify environment or cognitions supporting diet choices consistent with a high-energy and high-protein diet 
·  Provide individual or group-based psychological interventions 

Nutrition counseling based on health belief model theory (C-1.2) 
·  Strengthen understanding of susceptibility to co-morbidities associated with under-nutrition and cancer and the potential impact on quality of life 
·  Strengthen perception of the benefits of increasing energy and protein intake on present and future quality of life 
·  Enhance self-efficacy in making changes that will lead to health benefits 

Nutrition counseling based on social learning theory approach (C-1.3) 
·  Explore interaction of the personal characteristics (self-efficacy, skills, knowledge) 
·  Explore patient's interaction with their environment, their understanding of the behavior under change, their analytical ability with their diet, skill in preparing high-energy and high-protein foods and emotional support from family and friends 
·  Explore selecting, preparing and consuming high-energy, high-protein foods and beverages 
·  Identify role models who have been successful in similar situations 
·  Strengthen belief that choosing foods higher in energy will influence outcomes important to them such as ability to play with grandchildren, living to see grandchildren born, ability to travel with spouse 

Nutrition counseling based on transtheoretical model/stages of change approach (C-1.4) 
·  Determine stage of change initiating any change talk or goal setting 
 

·  Precontemplation 
   -  Encourage acceptance of lifestyle changes to lower-energy intake/increase physical activity. 
 

·  Contemplation 
   -  Promote confidence in ability to make changes



· Preparation  
   -  Reinforce any changes already made and set small-change goals such as including high-energy, high protein beverages at snack times 

· Action  
   -  Engage the patient in skill training 

· Maintenance 
   -  Identify social support and problem-solving 

Other (C-1.5) 
· Provide regular dietetic consultations (to be negotiated) 
   -  Plan should be reviewed after two weeks for suitability 
   -  Frequent reviews in the first three months following the initial consultation 


NUTRITION COUNSELING STRATEGIES (C-2) 
Nutrition counseling based on motivational interviewing strategy (C-2.1) 
· Address self-efficacy and resolve any ambivalence about ability to make and sustain changes 
· Clarify impact of malnutrition and how it may affect aspects of life that the patient values most 
· Elicit "change talk" about how to move closer to a high-energy, high-protein diet pattern and desirable levels of physical activity 
· After receiving permission, dietitian can offer guidance in identifying solutions to overcome barriers 

Nutrition counseling based on goal setting strategy (C-2.2) 
· Patient's goals for diet and behavior change need to be realistic 
· Identify how and when the changes will start 
· Patient should resist the temptation to set goals that are too large, or to set too many goals at once 

Nutrition counseling based on self monitoring strategy (C-2.3) 
· Familiarize patient with: 
   - Logs of dietary intake (complete, or specific to one food category). Help create awareness and support change 
   - Logs of environment and emotions that can identify triggers leading to positive and negative food choices 
   - Logs of physical activity used to reinforce self-efficacy and identify opportunities for increasing physical activity 

Nutrition counseling based on problem solving strategy (C-2.4) 
· Brainstorm possible approaches to making high-energy, high-protein food choices 
· Weigh pros and cons of various approaches 
· Establish how and when success will be measured 
· Adjust strategy if necessary 

Nutrition counseling based on social support strategy (C-2.5) 
· Identify patient to identify sources of support among family, friends and co-workers 
· Guide discussions to identify the type of support that will be most helpful. Some patients prefer verbal support and acknowledgment, others prefer actions such as offering energy-dense snacks but not talking about it publicly 
· Role-play ways to ask for support 

Nutrition counseling based on stress management strategy (C-2.6) 
· If stress is antecedent to loss of appetite, explore ways to relieve stress, such as meditation/progressive muscle relaxation 
· Facilitate development of time-management skills 
· Promote seven to eight hours of sleep per day 

Nutrition counseling based on stimulus control strategy (C-2.7) 
· Guide discussions to identify triggers or cues leading to appetite stimulation 
· Help patient to identify triggers, cues or situations that lead to increased physical activity 

Nutrition counseling based on cognitive restructuring strategy (C-2.8) 
· Teach patient ways to change self-talk. This might involve  focussing on successes rather than failures   

Nutrition counseling based on relapse prevention strategy (C-2.9) 
· Discuss situations in which meals may be missed and discuss strategies to avoid this occurring 
· Guide patient to identify situations where physical activity is likely to be overlooked and what can be done to ensure that physical activity occurs, for example using exercise as a social activity 

Nutrition counseling based on rewards/contingency management strategy (C-2.10) 
· Guide selection of non-food rewards such as new clothes or entertainment, to celebrate small behavior changes or small weight-gain goals 
· Establish a system to ensure that rewards are truly contingent on achieving specified goals
COORDINATION OF NUTRITION CARE BY A NUTRITION PROFESSIONAL (RC)(1,2)
COLLABORATION AND REFERRAL OF NUTRITION CARE (RC-1) 
Team meeting involving nutrition professional (RC-1.1) 
· Consider the benefits of multidisciplinary oncology-care programs 

Referral to nutrition professional to another nutrition professional with different expertise (RC-1.2)  
· A general-practice dietitian may choose to refer on to a specialist dietitian 

Collaboration by nutrition professional with other providers (RC-1.4) 
· Interdisciplinary involvement — consider referral to family doctor/psychologist/physical therapist 

Referral by nutrition professional to community agencies/programs (RC-1.6) 
· Identify local providers and clinical and community-based programs 
· Identify peer-support groups 

DISCHARGE AND TRANSFER OF NUTRITION CARE TO NEW SETTING OR PROVIDER (RC-2)  
Discharge and transfer of nutrition care to other providers (RC-2.1) 

Discharge and transfer of nutrition care to community agencies and programs (RC-2.2) 

Discharge and transfer of nutrition care from nutrition professional to another nutrition professional (RC-2.3)

 


References 
1.  Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. 2023. Accessed 4 July 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 3: Nutrition Intervention. 2023; Accessed 4 July 2024. Available from: https://www.ncpro.org/pubs/2020-encpt-en/page-055 
3.  Bauer J, Ash S, Davidson W, Hill J, Brown T, Isenring E, et al. Evidence based practice guidelines for the nutritional management of cancer cachexia. Nutr & Diet. 2006; 63: S3-S32. 
4.  Queensland Government: Nutrition Education Materials Online. Estimating energy, protein & fluid requirements for adult clinical conditions 2017; Accessed 5 July 2021. Available from: https://www.health.qld.gov.au/nutrition/resources/est_rqts.pdf 
5.  Tappenden KA, Quatrara B, Parkhurst ML et al. Critical role of nutrition in improving quality of care: 12. An interdisciplinary call to action to address adult hospital malnutrition. J Acad Nutr Diet. 2013; 113: 1219-1237. 
6.  Ross C, Caballero B, Cousins RJ et al., editors. Modern nutrition in health and disease. 11 ed. Lippincott, Williams & Wilkins: Baltimore; 2014. 
7.  New South Wales Health. Policy Directive. Nutrition care. 2011. Accessed 8 August 2017. Available from: http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2011_078.pdf 
8.  U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/ 
9.  American Heart Association. Alcohol & Heart Health. 2015; Accessed 16 August 2017. Available from: http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyEating/Alcohol-and-Heart-Health_UCM_305173_Article.jsp 
10.  National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. 2013; Accessed 14 August 2017. Available from: www.nhmrc.gov.au/guidelines-publications/n57

 

Updated July 04, 2024
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