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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
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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
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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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