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                     with written permission of Umschau Zeitschriftenverlag GmbH, Wiesbaden.                                                          Science & Research | Original Contribution
                                                                                                                    Peer-reviewed | Manuscript received: 16.11.2017 | Revision accepted: 06.07.2018
                     Nutrition diagnosis according to the German- 
                     Nutrition Care Process (G-NCP) model 
                     Challenges for implementation – a case study
                     Ute Hager, Nicole Blechmann, Janina Kuhn, Stefanie Neugebauer,  
                     Karen Amerschläger, Kathrin Kohlenberg-Müller
                     Introduction
                                                                                                        Abstract
                     The “Framework Agreement on Qual-                                                   Nutrition diagnosis is the second step in the G-NCP model and it is based on the 
                     ity Assurance in Nutrition Counsel-                                                 information collected in the assessment. It is carried out systematically in the 
                     ling and Nutrition Education” (Rah-                                                 form of PESR statements that state the nutrition problem (P), etiology (E), signs 
                     menvereinbarung zur Qualitätssiche-                                                 and symptoms (S) and resources (R). The aim of this study was to investigate 
                     rung in der Ernährungsberatung und                                                  and discuss the practical implementation of the guidelines for diagnosis on the 
                     Ernährungsbildung) of the German                                                    basis of a case study. Some challenges arose in formulating the PESR statements: 
                     Nutrition Society (DGE) states in par-                                              Several aspects of the process of assigning nutrition assessment data using the 
                     ticular that in nutrition counselling                                               G-NCP system require a rethink. 
                     scientific standards, counselling meth-
                     odology standards, and process-ori-                                                 Nutrition diagnosis forms the interface between nutrition assessment and inter-
                     ented standards must be observed,                                                   vention, and this requires an awareness of how each of the process steps are 
                     and that the counselling process must                                               woven together. It was found that when implementing process-driven actions 
                     be documented and evaluated [1].                                                    according to the G-NCP model, there is some variance in terms of the interpre-
                     This is where the models for nutrition                                              tation of the guidelines of the Manual of the German Association of Dietitians 
                     counselling come in [2, 3].                                                         (VDD), and that there is a need for specific training for the users.
                     For Germany, the German-Nutrition                                                   Keywords: Nutrition diagnosis, PESR statements, German-Nutrition Care Process 
                     Care Process (G-NCP) (• Figure 1) was                                               (G-NCP), quality assurance in nutrition counselling, behavioral/environmental
                     developed to provide quality assurance 
                     and greater transparency in the nutri-
                     tion counselling and therapy process.                                          The G-NCP follows the four-step NCP 
                     The manual [4] published by the Ger-                                           from the US [5], but it has five process 
                     man Association of Dietitians (VDD)  steps instead of four because the Ger-
                     provides a “guideline for the profes-                                          man-Nutrition Care Process describes 
                     sional conduct of dietitians”. This laid                                       the planning and implementation of 
                     a foundation for establishing stand-                                           the intervention as two separate pro-
                     ard elements of quality assurance in  cess steps [4]. There have already been 
                                                               1
                     nutrition counselling  – the G-NCP –                                           some  relevant  publications:  a  case 
                     with the five following process steps:                                         study from the context of oncology 
                     • nutrition assessment                                                         practice [6], and possible nutrition di-                                           Citation: 
                     • nutrition diagnosis                                                          agnoses for patients with bronchial                                                Hager U, Blechmann N, Kuhn 
                     • planning and                                                                 carcinoma, type 2 diabetes mellitus [7],                                           J, Neugebauer S, Amerschläger 
                     • implementation of an intervention                                            Crohn’s disease [8] and insulinoma [9].                                            K, Kohlenberg-Müller K (2018) 
                     • monitoring and evaluation                                                                                                                                       Nutrition diagnosis according to 
                                                                                                                                                                                       the G-NCP model. Challenges for 
                                                                                                    Nutrition diagnosis                                                                implementation – a case study. 
                                                                                                                                                                                       Ernahrungs Umschau 65(11): 
                     1  For the sake of better readability, this arti-                              Nutrition diagnosis according to                                                   187–195
                       cle is limited to the term “nutrition counsel-                               G-NCP is done by formulating PESR                                                  This article is available online: 
                       ling”. Process-driven action and G-NCP are of                                statements consisting  of four com-
                       course relevant to both nutrition counselling                                                                                                                   DOI: 10.4455/eu.2018.042
                       and nutrition therapy.                                                       ponents (• Overview 1). 
                                                                                                           Ernaehrungs Umschau international | 11/2018    
                                                                                                                                                                                           187
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                                           Science & Research | Original Contribution                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    with written permission of Umschau Zeitschriftenverlag GmbH, Wiesbaden.
                          The German-Nutrition Care Prozess-Modell (G-NCP-Modell)
                                                                                                                                                                                         
                          Outcomes Management System                                                                                                                                                                                                                       Screening/Referral                                                                                                           side effects of treatment, or medi-                                                                                                                                                                                            Resources (R)
                                                                                                                                                     
                                                                                                                                                                              e                                                                                                                                                                                                                         cal status.
                                                                                                                                                  Clinical R asoning                                                                                                                                                                                                                          -  Psychological causes are also  The G-NCP goes further than other 
                                                                                                   
                                                                                                                                                                                                                                                                          In                                                                                                                            rele vant, for example in the areas                                                                                                                                                                                            models [2, 3] in terms of diagnosis 
                                                                                                                                       luation                                            a Nutrit                                                                            tra-
                                                                      s                                                        va                                                              sses                    ion                                                             a                                                                                                                of motivation and behavior.                                                                                                                                                                                                    – it also records resources. Resources 
                                                               line                                                         E                                                                                sme                                                                         nd
                                                            de                                                                                                                                                            nt                                                                  In                                                                                              -  The nutrition problem may also be                                                                                                                                                                                                     are defined as “characteristics, forces, 
                                                        Gui                                   n I      o       p    m I                                                                                                                                                                          ter-                   So
                                 y                   nal                                    et     N f      el                                                                                                                                                                                       pro                  cia                                                                           attributable to various values held                                                                                                                                                                                            possibilities and abilities of the user 
                                m                    o                                     r       u      m                                    Relation between                                                                                                                                        fe                  l 
                                                     i
                                o                    s                                     v                                                                                                                                                                                                           s                    S
                                noc                  sef                                   en      tri    en                                  Dietitian and User                                                                                ion    sis                                            nois                 tsy                                                                          by the client. In addition to indi-                                                                                                                                                                                            or their environment [...] which can 
                                  E                   orP d                                  tio tiontati                                                                                                                                trit      no                                               C la                  me                                                                            vidual attitudes to nutrition-re-                                                                                                                                                                                              influence the management of their 
                                                           n a                                    n                 on                                                                                                           Nu iag                                                        allo
                                                               sci  h                                                                                                                                                                   D                                                r o b                                                                                                          lated issues, political or religious                                                                                                                                                                                           nutrition problem” [4]. The manual 
                                                                     t E                                                                           Planning of                                                                                                                    o it  a
                                                                                                                                                   I     Nutrition                                                                                                              n                                                                                                                       principles may also play an im-                                                                                                                                                                                                for the G-NCP suggests a distinction 
                                                              S                                                             Mon                      ntervention                                                        nt
                                                                 etti                                                                     itoring and Re-Assessme                                                                                                                   m                                                                                                                   portant role.                                                                                                                                                                                                                  be made between beneficial and in-
                                                                            ng                                            Evi                                                                                              ce                                       Syste
                                                                                                                                   dence Based Dietetics Practi                                                                                           lth                                                                                                                                 -  The client may also have knowledge                                                                                                                                                                                                    hibitory resources [4].
                                                                                                                                                                                                                                            Hea                                     
                                                                                                                                                                                                                                                                                                                 © German Dietetic Association (VDD e.V.)
                                                                                                                                                                                                                                                                                                                                                                                                       gaps or difficulty assessing issues 
                                                                                                                                                                                                                                                                                                                             Reprinting with permission only
                                                                                                                                                                                                                                                                                                                                                                                                       regarding nutrition and health.                                                                                                                                                                                                 In order to make a nutrition diagno-
                                                                 Fig. 1:  The German-Nutrition Care Process-Modell                                                                                                                                                                                                                                                                            -  Furthermore, the client's social si-                                                                                                                                                                                                  sis, the individual data collected in 
                                                                                                     (G-NCP Modell)                                                                                                                                                                                                                                                                                     tuation is an important factor. In                                                                                                                                                                                             the nutrition assessment are struc-
                                                                                                                                                     In the G-NCP model, additional in-                                                                                                                                                                                                                 addition to their individual person-                                                                                                                                                                                           tured, grouped and considered in the 
                                                                                                                                                     formation about resources (R) is                                                                                                                                                                                                                   ality and their social environment,                                                                                                                                                                                            context of the rest of the data. The 
                                                                                                                                                     collected [4], and this information                                                                                                                                                                                                                the question of secure access to  PESR statements that are formulated 
                                                                                                                                                     is not part of nutrition diagnosis in                                                                                                                                                                                                              food may also be taken into con-                                                                                                                                                                                               on the basis of this data are prior-
                                                                                                                                                     the NCP model [2, 5], nor is it part                                                                                                                                                                                                               sideration, among other things [4].                                                                                                                                                                                            itized for the subsequent planning 
                                                                                                                                                     of the “British Model and Process for                                                                                                                                                                                                    Overall, etiology (E) should be ac-                                                                                                                                                                                                      and implementation of the inter-
                                                                                                                                                     Nutrition and Dietetic Practice” [3].                                                                                                                                                                                                    corded special importance because  vention. Based on this, the nutrition 
                                                                                                                                                                                                                                                                                                                                                                                              the nutritional intervention that  counsellor must continuously make 
                                                                                                                                                     Formulating PESR statements ac-                                                                                                                                                                                                          comes later in the process will be  assessments and decisions. The VDD 
                                                                                                                                                     cording to the G-NCP model is a  geared towards tackling the etiology                                                                                                                                                                                                                                                                                                                                                                                                             manual states that decisions should 
                                                                                                                                                     systematic procedure for making a  – and therefore the client’s living en-                                                                                                                                                                                                                                                                                                                                                                                                        not simply be made, but should also 
                                                                                                                                                     nutrition diagnosis based on the data                                                                                                                                                                                                    vironment.                                                                                                                                                                                                                               be reflected upon and justified (clini-
                                                                                                                                                     collected in the nutrition assessment.                                                                                                                                                                                                                                                                                                                                                                                                                                            cal reasoning) [4, 10]. 
                                                                                                                                                                                                                                                                                                                                                                                              Signs and symptoms (S)
                                                                                                                                                     The nutrition problem (P)                                                                                                                                                                                                                Signs and symptoms allow conclu-
                                                                                                                                                     The nutrition problem “is the core  sions to be drawn about the nutri-                                                                                                                                                                                                                                                                                                                                                                                                            Study question
                                                                                                                                                     statement of the nutrition diagno-                                                                                                                                                                                                       tion problem. Here, objective data                                                                                                                                                                                                       The G-NCP is based on a theoretical 
                                                                                                                                                     sis and describes the exact changes  is contrasted with the client’s sub-                                                                                                                                                                                                                                                                                                                                                                                                         model that is intended to be imple-
                                                                                                                                                     in the nutritional status or the nu-                                                                                                                                                                                                     jective assessments of their state of                                                                                                                                                                                                    mented in practice and used widely. 
                                                                                                                                                     tritional situation of the user” [4].  health: In addition to quantifiable                                                                                                                                                                                                                                                                                                                                                                                                        It has been designed as a “field-of-
                                                                                                                                                     Each nutrition problem is addressed                                                                                                                                                                                                      values such as BMI or laboratory  action-specific process model” [8] 
                                                                                                                                                     by a separate PESR statement [8].                                                                                                                                                                                                        para meters, qualitative data (such                                                                                                                                                                                                      for professional conduct in nutrition 
                                                                                                                                                                                                                                                                                                                                                                                              as data from a subjective assessment                                                                                                                                                                                                     counselling, which means that its 
                                                                                                                                                     The etiology (E)                                                                                                                                                                                                                         of quality of life and wellbeing) can                                                                                                                                                                                                    applicability in nutrition counselling 
                                                                                                                                                                                                                                                                                                                                                                                              also be considered a sign of a nutri-                                                                                                                                                                                                    is of crucial importance. 
                                                                                                                                                     The etiology is defined as: “those                                                                                                                                                                                                       tion-related problem [4]. It should be 
                                                                                                                                                     factors contributing to the existence                                                                                                                                                                                                    noted that many different items of 
                                                                                                                                                     of, or maintenance of pathophysio-                                                                                                                                                                                                       objective and subjective data are col-                                                                                                                                                                                                                Overview 1:  The four compo-
                                                                                                                                                     logical,  psychosocial,  situational,                                                                                                                                                                                                    lected in a nutrition assessment, but                                                                                                                                                                                                                                                                                             nents of the PESR 
                                                                                                                                                     developmental, cultural, and/or be-                                                                                                                                                                                                      the distinction between “subjective                                                                                                                                                                                                                                                                                               statement [4]
                                                                                                                                                     havioral/environmental problems”  and objective signs and symptoms” is 
                                                                                                                                                     [3]. It is crucial that behavioral/en-                                                                                                                                                                                                   limited to information that provides                                                                                                                                                                                                                  P =  Problem (nutrition problem)
                                                                                                                                                     vironmental factors are integrated  evidence of the presence of the specific                                                                                                                                                                                                                                                                                                                                                                                                                   E =  Etiology 
                                                                                                                                                     into the formulation of PESR state-                                                                                                                                                                                                      nutrition problem (P) [8]. According 
                                                                                                                                                     ments if they influence nutrition:                                                                                                                                                                                                       to the manual [4], food consumption                                                                                                                                                                                                                   S =  Signs/symptoms
                                                                                                                                                     -  Etiology may include medical  must also be categorized under signs                                                                                                                                                                                                                                                                                                                                                                                                                          R = Resources [4] 
                                                                                                                                                               factors, such as physical resilience,                                                                                                                                                                                          and symptoms (S). 
                                                                                                                                                                                                                                                                                                                                                              
                                                                                                                                                                                                                                                                                                                               188 Ernaehrungs Umschau international | 11/2018
                                                                                                                 Copyright!
                                                                                                                 Reproduction and dissemination – also partial – applicable to all media only 
                                                                                                                 with written permission of Umschau Zeitschriftenverlag GmbH, Wiesbaden.
             In order to test its applicability, the           nutritional knowledge, nutritional be-           nutrition assessment was system-
             G-NCP was examined in the context  havior, physical activity, quality of life,                     atically analyzed with regard to the 
             of a case study [11], and the appli-              willingness to change, and motivation            subsequent PESR components:
             cation of the model was subjected to              in a targeted manner. For the record-            -  The energy and nutrient intakes 
             critical reflection. The focus of this            ing of the clinical status, anthropomet-           calculated on the basis of the 7-day 
             publication is on the case study-based            ric data, the client’s body composition            food diary were checked for devi-
             examination of nutrition diagnosis  (seca mBCA) and their resting energy                             ations from the DACH reference 
             as part of the G-NCP. This process  expenditure (REE) (COSMED Quark                                  values. These deviations were then 
             step was selected because a paradigm              RMR) were measured, and metabolic                  assessed to check if they constitute 
             shift can be observed here: Unlike                parameters in the blood were also de-              a nutrition problem (P) for the cli-
             medical diagnosis, nutrition diagno-              termined.                                          ent (either an existing problem or a 
             sis focuses on the client’s nutrition                                                                problem that may be “expected in 
             in the context of factors that may  Nutrition diagnosis: Formu-                                      the foreseeable future” [8]). 
             be influencing nutritional behavior.              lation of the PESR statements                    -  The information from the nutri-
             What is special about nutrition diag-                                                                tion assessment sheet was checked 
             nosis according to the G-NCP model  For the nutrition diagnosis, several                             for possible signs and symptoms 
             is that the client’s living environment           PESR statements (which were based                  (S) which could provide evidence of 
             and resources are directly linked to  on the manual [4]) were formulated                             nutrition problems (P). 
             their nutritional behavior, and this              using the data from the nutrition as-            -  The content of the nutrition as-
             is taken into account when planning               sessment. The PESR statements were                 sessment was reflected upon with 
             the subsequent intervention [4].                  developed using a multi-step process:              regard to which information pro-
                                                                                                                  vided by the client may allow con-
                                                               1. Data review and creation of                     clusions to be drawn about behav-
             Methodology                                       hypotheses and PESR statements                     ioral/environmental etiologies (E).
                                                               In an initial step of action all avail-          -  The content of the nutrition assess-
             Case study and nutrition                          able documents from the nutrition                  ment was checked for resources (R) 
             assessment                                        assessment were reviewed to look                   which would either benefit (beneficial: 
             In a case study, a nutrition consul-              for connections between the data –                 R+) or impede (inhibitory: R-) subse-
             tation was designed according to the  e.g. between BMI and energy intake.                            quent behavioral change in the client. 
             G-NCP model [4] for a breast cancer  Next, the investigation focused on                            As part of the transition from nu-
             patient of 58 years of age – 4.5 years            data that was outside the normal  trition diagnosis to planning of the 
             after completion of her treatment  range – e.g. a BMI ≥ 25 kg/m². In  intervention, the nutrition consult-
             (breast cancer survivor, Phase 2 [12]),           line with the manual’s recommen-                 ant carried out an additional deci-
             and was implemented by a nutrition  dation, the approach that was taken                            sion-making process to determine 
             counsellor qualified nutrition scientist          was to make hypotheses about all  which PESR statements were to be 
                                    2
             (“Oecotrophologe”)  with a VDD cer-               relevant data and translate them  prioritized, and thus taken forward 
             tificate for nutrition counselling) using         into PESR statements.                            into the intervention and evaluation.
             all five process steps. Information from 
             the nutrition assessment about key  2. Discussion of hypotheses and  
             categories such as client history, diet           statements                                       Results: Formulation of the 
             history,  behavioral/environmental                In a second step, the decisions made             PESR statements and chal-
             factors, and clinical status were docu-           were discussed and reflected upon  lenges in the implemen-
             mented in a nutrition assessment sheet.           within the project group together  tation of the guidelines of 
             For  the  client  history,  sociodemo-            with the nutrition consultant in  the G-NCP model
             graphic data and the medical history  order to ensure that well-founded 
             were recorded. For the diet history, a            decisions were reached [4, 10]. The              Two PESR statements were prior-
             7-day food diary was evaluated with               discussion focused on the four key  itized for the client in this case study 
             the aid of software (Prodi 6.5 expert),           decisions are shown in • Overview 2.             (• Table 1).
             plus the client was asked to provide 
             information about their experience of             3. Reformulation of the PESR  
             diets and their eating behavior over life-        statements                                       2  In Germany there are study programmes in 
             time, and their resting energy expend-            In a third step of action, the PESR                the field of „Oecotrophologie“ which differs 
             iture (REE) was determined by calcula-            statements were reformulated on                    from both dietetics and nutrition science. 
             tion. For the behavioral/environmental            the basis of the results of the reflec-            „Oecotrophologie“ uses an interdisciplinary 
                                                                                                                  approach to nutrition and food- as well as 
             category, the client was asked about              tions. In this step the data from the              household-related issues. 
                                                                   Ernaehrungs Umschau international | 11/2018    
                                                                                                                    189
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                                                                                                                                  Reproduction and dissemination – also partial – applicable to all media only 
         Science & Research | Original Contribution                                                                               with written permission of Umschau Zeitschriftenverlag GmbH, Wiesbaden.
                                                    PESR statement 1                                                    PESR statement 2
                                 P = Problem        energy intake too high: 2302 kcal/day                               fat intake too high: 87 g/day 
                                 (nutritional       (115% of the D-A-CH reference value)                                (134% of the D-A-CH reference value)
                                 problem)                                                                               cholesterol intake: 430 mg/day 
                                                                                                                        (143% of the D-A-CH reference value)
                                 E = Etiology       value held: large portion sizes as a sign of appreciation           value held: caring for the family synonymous 
                                                    social situation: frequent role as a host for 5 or more guests,     with hearty cooking
                                                    with a focus on meals taken together                                knowledge deficit/difficulty assessing nutritio-
                                                                                                                        nal issues: client does not consider her own diet 
                                                                                                                        to be “high in fat” 
                                                                                                                        social situation: parents and relatives often con-
                                                                                                                        sume meat and meat products → early and lasting 
                                                                                                                        taste preferences for meat and meat products
                                 S = Signs/         overweight: BMI 26.5 kg/m²,                                         increased LDL cholesterol level in the plasma: 
                                 Symptoms           current body weight: 72.5 kg                                        172 mg/dL 
                                                    fat mass FM: 31.5 kg, 43 % of the body weight                       increased total cholesterol level in the plasma: 
                                                    resting energy expenditure (REE): 1338 kcal/24h                     247 mg/dL
                                                    7-day food diary:                                                   7-day food diary: 
                                                    frequent consumption of energy-dense foods [per week]:              frequent consumption of foods high in fat and 
                                                    1392 mL of fruit juices, 700 mL of other drinks containing          cholesterol [per week]: 
                                                    sugar, 860 g of cake/baked goods, 159 g of fats/oils, 860 g  159 g of fats/oils, 860 g of meat, 270 g of meat 
                                                    of meat, 270 g of meat products                                     products
                                                    physical activities: walking, cycling for 0–4 hrs/week; 
                                                    irregularly
                                                    the comparison of physical activities with the 7-day food 
                                                    diary reveals a positive energy balance
                                 R = Resources      R+:  • pleasure in exercise                                         R+: •   positive experiences with dietary changes
                                                        • highly motivated to change diet and lifestyle                       •  highly motivated to change diet and 
                                                                                                                               lifestyle
                                                    R-:  • sporting activity depends on season                          R-: •    taking care of the family as the role of the 
                                                        •  consumption of energy-dense food and drinks as a                   woman 
                                                          reward after sporting activities                                    •  social occasions with high meat consump-
                                                                                                                              tion, lack of awareness of the high fat 
                                                                                                                              content of foods consumed
                                    Tab. 1: PESR statements on the client’s energy and fat intake based on the manual [4] 
                                In order to create the PESR state-               products according to the food diary             Distinguishing between inhibitory 
                                ments, a four-step procedure was  as the “etiology” (“E”) of an elevated                          resources (R-) and etiology (E)
                                developed.  In  this  procedure,  the            fat intake as a nutrition problem (P).           In this case study, it became clear 
                                available data from the nutrition  However, after reflection within the                           that the consumption of meat and 
                                assessment must be analyzed with  project group conspicuous intake  meat products was not purely a 
                                a view to categorization in the cat-             levels (i. e. of meat) were catego-              taste preference, but that the cli-
                                egories P, E, S, and R from the very             rized as “signs and symptoms” (S)   ent was also socialized (E) in such 
                                beginning. This approach is intended             (• Table 1). A rethink was required  a way that her perception was that 
                                to ensure that the PESR system is  in order to categorize this informa-                           a “good” wife and mother “is pro-
                                given greater weight. The following              tion about food not as a problem (P)             viding for her family well” when 
                                challenges arose in the four stages:             or an etiology (E), but as signs and             providing hearty cooking (R-). 
                                                                                 symptoms (S).                                    While processing the case study, the 
                                1. Categorization of nutrition                                                                    question arose of how far this sense 
                                assessment data                                  Allocation of taste preferences to               of responsibility on the part of the 
                                                                                 PESR statements                                  client represented an inhibitory re-
                                Allocation of foods to PESR statements           The client reported in the nutrition  source (R-) or a component of the 
                                The PESR statements formulated  assessment that meat and meat prod-                               etiology (E) in the sense of the values 
                                in the initial step of action (before  ucts “just taste good”. When prepar-                       held by the client (• Table 1).
                                reflecting the statements with the               ing the PESR statements, it was not 
                                project  group)  highlighted  exces-             clear where and how these taste pref-
                                sive consumption of meat and meat  erences should be categorized.
                                                                             
                                                                   190 Ernaehrungs Umschau international | 11/2018
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...Copyright reproduction and dissemination also partial applicable to all media only with written permission of umschau zeitschriftenverlag gmbh wiesbaden science research original contribution peer reviewed manuscript received revision accepted nutrition diagnosis according the german care process g ncp model challenges for implementation a case study ute hager nicole blechmann janina kuhn stefanie neugebauer karen amerschlager kathrin kohlenberg muller introduction abstract framework agreement on qual is second step in it based ity assurance counsel information collected assessment carried out systematically ling education rah form pesr statements that state problem p etiology e signs menvereinbarung zur qualitatssiche symptoms s resources r aim this was investigate rung der ernahrungsberatung und discuss practical guidelines ernahrungsbildung basis some arose formulating society dge states par several aspects assigning data using ticular counselling system require rethink scientific s...

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