USING THE NUTRITION CARE PROCESS FOR INTEGRATIVE AND

USING THE NUTRITION CARE PROCESS FOR INTEGRATIVE AND FUNCTIONAL NUTRITION KELLY MORROW, MS, RDN CYNTHIA BARTOK, PHD, RDN MAY 10, 2018 © 2018 Morrow and Bartok

TODAY’S PRESENTERS Cynthia Bartok, MS, RDN Associate Professor Kelly Morrow, MS, RDN, CD, FAND DIFM-Immediate Past Chair Associate Professor Department of Nutrition and Exercise Science Bastyr University, Kenmore, WA 2

OBJECTIVES By the end of today’ presentation the attendee will be able to: • Summarize the consistencies between the Nutrition Care Process (NCP) model and Integrative and Functional Nutrition (IFN) care • When needed, creatively use the NCP model and terminology to provide IFN care • Develop PES statements and interventions using NCP terms that address IFN perspectives on health, disease, and delivery of care 3

OUTLINE 1. The NCP model as a foundation for IFN care 2. Commonalities between the IFN radial and NCP Assessment Terminology 3. Case Study: • Creative application of the NCP Diagnosis Terminology when providing IFN care • NCP Intervention Terminology that aligns with IFN principles of care • NCP Monitoring and Evaluation strategies that allow for deeper exploration of underlying causes of disease 4. Future directions for NCP terminology 4

The NCP model as a foundation for IFN care 5

PRINCIPLES OF THE NUTRITION CARE PROCESS (NCP) • The Nutrition Care Process (NCP) is a patientcentered, standardized process for providing care that increases the likelihood of positive outcomes 1 • Standardized approach results in consistent, high quality nutrition care • Process identifies and addresses the root cause of nutritional problems • Focus is on delivery of evidence-based nutrition interventions 1 Academy of Nutrition and Dietetics. Nutrition care process and nutrition monitoring and evaluation. In: Nutrition Terminology Reference Manual (e. NCPT): Dietetics Language for Nutrition Care [Internet]. Chicago: Academy of Nutrition and Dietetics; 2017 [cited 2018 April 29]. Available from: https: //www. ncpro. org/pubs/idnt-en. 2 6

INTEGRATIVE AND FUNCTIONAL NUTRITION (IFN) CARE 1 Integrative approach: • Person-centered, prevention- and wellness-oriented • Identifies and addresses the root cause of disease • Integrates conventional and functional medicine interventions Functional Nutrition approach: • Each client is an individual with a: • Unique genetic makeup • Unique biochemistry and metabolic pattern • Unique environment and lifestyle • Unique “story” of antecedents, triggering events, and mediators/perpetuators of health problems • Interactions among the individual’s unique biology, environmental exposures (positive and negative), and lifestyle are important to prevent, explain, and treat disease 1 Ford D, Raj S. Batheja RK, et al. American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Integrative and Functional Medicine JADA 111: 902– 913, 2011. 7

NCP STEP 1: NUTRITION ASSESSMENT • Nutrition Assessment is a systematic process of obtaining, verifying, and interpreting data needed to identify nutrition-related problems, their causes, and significance 1. • IFN Approach 2: • Integrative and Functional Medicine Matrix • Functional Medical Nutrition Therapy Radial • Nutrition: foods, bioactives, dietary supplements, toxin exposures • Biochemistry: metabolome, genetics • Anthropometry: body composition • Nutrition focused physical exam and Medical Symptom Questionnaire 1 Academy of Nutrition and Dietetics. Nutrition care process and nutrition monitoring and evaluation. In: Nutrition Terminology Reference Manual (e. NCPT): Dietetics Language for Nutrition Care [Internet]. Chicago: Academy of Nutrition and Dietetics; 2017 [cited 2018 April 29]. Available from: https: //www. ncpro. org/pubs/idnt-en/page-001. 2 Ford D, Raj S. Batheja RK, et al. American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Integrative and Functional Medicine JADA 111: 902– 913, 2011. 8

NCP STEP 2: NUTRITION DIAGNOSIS • Nutrition Diagnosis is a specific nutrition problem that can be resolved or improved through treatment/nutrition intervention by a nutrition and dietetics practitioner 1. • IFN Approach 2: • Evidence-based and practice-based aspects to prioritization of diagnoses • Incorporates IFMNT data into PES statement • Identifies root of nutritional problem Example: Excessive vitamin intake (Vitamin A, NI-5. 9. 2. 1) related to food- and nutrition-related knowledge deficit concerning vitamin supplements for preconception as evidenced by elevated serum retinol concentration and reported intake of 5, 000 ug retinol/day (166% of UL) via supplements. 1 Academy of Nutrition and Dietetics. Nutrition care process and nutrition monitoring and evaluation. In: Nutrition Terminology Reference Manual (e. NCPT): Dietetics Language for Nutrition Care [Internet]. Chicago: Academy of Nutrition and Dietetics; 2017 [cited 2018 April 29]. Available from: https: //www. ncpro. org/pubs/idnt-en/category-2. 2 Ford D, Raj S. Batheja RK, et al. American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Integrative and Functional Medicine JADA 111: 902– 913, 2011. 9

NCP STEP 3: NUTRITION INTERVENTION • Nutrition Intervention is a purposefully planned actions intended to positively change a nutritionrelated behavior, environmental condition, or aspect of health status for the patient/client, community, or population 1. • IFN Approach 2: • Evidence-based and practice-based intervention strategies • Addresses root of nutritional problem, core imbalances • Goal is client wellness • Incorporation/referral to complementary care 1 Academy of Nutrition and Dietetics. Nutrition care process and nutrition monitoring and evaluation. In: Nutrition Terminology Reference Manual (e. NCPT): Dietetics Language for Nutrition Care [Internet]. Chicago: Academy of Nutrition and Dietetics; 2017 [cited 2018 April 29]. Available from: https: //www. ncpro. org/pubs/idnt-en/category-2. 2 Ford D, Raj S. Batheja RK, et al. American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Integrative and Functional Medicine JADA 111: 902– 913, 2011. 10

NCP STEP 4: NUTRITION MONITORING & EVALUATION • Nutrition Monitoring & Evaluation includes: • data collection (reassessment) • data review (monitoring) • data analysis (evaluation) to determine whether the client is meeting the nutrition intervention goals or desired outcomes 1. • IFN Approach 2: • Broad reassessment and review of IFN data • Consideration of core imbalances at the root of persistent problems • Consideration of the individual response to the intervention provided 1 Academy of Nutrition and Dietetics. Nutrition care process and nutrition monitoring and evaluation. In: Nutrition Terminology Reference Manual (e. NCPT): Dietetics Language for Nutrition Care [Internet]. Chicago: Academy of Nutrition and Dietetics; 2017 [cited 2018 April 29]. Available from: https: //www. ncpro. org/pubs/idnt-en/category-2. 2 Ford D, Raj S. Batheja RK, et al. American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Integrative and Functional Medicine JADA 111: 902– 913, 2011. 11

Commonalities between the IFN radial and NCP Assessment Terminology 12

IFMNT RADIAL • Web-like connections between core areas of imbalance • Incorporates aspects of the patients: • lifestyle (client history) • signs and symptoms (nutrition physical) • biomarkers (lab assessment), • metabolic pathways and networks (nutrition focused physical, nutrition and lab assessment) 13

IFN NUTRITION ASSESSMENT TERMINOLOGY • Nutrition assessment categories include IFN core areas of imbalance • Cellular Integrity • Nutrition focused physical exam and biochemical assessment, nutrition intake including quality and quantity of fats, multiple micronutrients such as vitamin A, folate, choline… • Digestion • Nutrition focused physical exam, bioactive substance intake (prebiotics / probiotics), fiber, physical activity, hydration, client history (stress) • Energy Metabolism • Lab assessment, nutrition focused physical, mitochondrial support nutrients, anthropometric assessment

IFN NUTRITION ASSESSMENT TERMINOLOGY • Nutrition assessment categories include IFN core areas of imbalance • Inflammation / Oxidative Stress • Lab assessment, nutrition physical • Neuro/Endocrine Imbalance • Lab assessment, environmental exposures • Nutritional Status • Complementary and alternative medicine, macronutrient quantity and quality, bioactive substance intake, knowledge and beliefs, physical activity

CASE STUDY EXAMPLE MIGRAINES 16

MEET JOSEPH • 39 yo White male with 20 year history of chronic migraines (1 -2 x/week – daily) and ADHD Client History: • Migraines may be mild enough to “live with” but occasionally result in missed work • Self-management: Coke (caffeine, sugar), pizza, burgers (salt); avoid alcohol (trigger) • Medical management: Imitrex (Migraine), Xanax (Sleep), Propenolol (HTN medication used for migraines), Adderall (ADHD); chiropractic care/manipulations • Social: High responsibility managerial role at Amazon; married with 3 children under age of 4; relocated to Seattle 1 yr ago from East Coast • Environment: new house (carpet, paint); allergies to dust, trees, smoke 17

MEET JOSEPH Food and Nutrition-Related History: • Assessment: On average consumes 3 meals and 1 snack per/d. Skips lunch occasionally due to time constraints or appetite suppression(Adderall). Current diet includes many high glycemic and convenience foods. Compared to Basytr Healthy plate: 1 serving of fruit and 1 serving of vegetables/d (L), 1 -2 servings of whole grains and starches (L), 2 -3 serving protein (adequate), 0 servings of healthy fat and digestives/fermented foods (L). Diet contains multiple high histamine and tyramine foods. • Typical Day: • B (630 a-7 a): cereal - raisin bran or puffed rice with 2% milk and occasional fruit such as strawberries, raspberries, or blueberries, orange juice and coffee w/ cream • L (130 p): take out from food trucks - chicken and cheddar quesadilla, pizza 1 -2 x/wk, or deli meat sandwich • D (6 p-7 p): typically homemade - protein (chicken or beef), starch or grain (pasta, rice or potatoes), and salad (often spinach salad with parmesan cheese, tomatoes, vinaigrette dressing. Likes olives and pickles too) • Snack (8 p): ice cream or something else sweet like Oreos • Beverage and ETOH intake: 48 oz water/d; 1 -2 Cokes/d; 20 oz coffee/d (more than 20 oz triggers migraine); ETOH 1 -2 x/mos in social settings 18

MEET JOSEPH Anthropometric Measures: • Height (in/cm): 71 in/180. 3 cm • Weight (lb/kg): 205 lb/ 93. 2 kg • BMI: 28. 6 (“normal”) • Weight hx: 3% increase in previous 12 months Biochemical Data, Medical Tests and Procedures: • Blood glucose: 93 mg/d. L (high end of normal) • Hemoglobin A 1 C: 5. 4% (high end of normal) • Cholesterol: 201 mg/d. L (elevated) • Triglycerides: 145 mg/d. L (high end of normal) 19

MEET JOSEPH Nutrition Focused Physical Exam Findings • GI Function: in past dairy caused diarrhea; stools are loose after breakfast daily • Sleep hx: 6 hr/night often interrupted; takes Xanax if wakes in middle of night • Energy: 4/10 • Stress: moderate r/t migraines and busy schedule • Blood pressure: 118/76 mm Hg (normal) • Physical exam: fidgeting/leg bouncing; appears well-nourished with good skin color; slight central adiposity 20

IFN-BASED NUTRITION ASSESSMENT • Core Areas of Imbalance: • Signs & Symptoms/Nutrition Physical: • Cellular Integrity: nerve function • Nervous system instability, chronic migraines • Environmental Exposures: home (? ), allergens • Skeletal - symptoms improved with chiropractic care • Inflammation/Oxidative Stress: potential for neurogenic inflammation • Central adiposity, weight gain • Nutritional Status: predicted low EFA, Mg, • Biomarkers: Vitamin B 6, folate, water; high glycemic diet; highly processed food sources; low whole-foods; • Concerning FBG, A 1 C, cholesterol; trend towards low protective bioactive compounds; high intake metabolic syndrome (? ) of tyramine and histamine foods; food sensitivities/allergens/intolerances (? ) • Metabolic Pathways/Networks: • Lifestyle: • Poor sleep; high stress; sedentary; low PA; highdemand family and work life • Predicted low intake of micronutrients and EFA to support nervous system function • DNI, including nutrient depletions • Learned patterns of migraine management using low quality foods 21

IFN-BASED STRATEGY • IFN Assessment reveals a interconnected map of potential contributors to migraines • Evaluate what is within our scope of practice vs. referrals/inter-professional integration • RDN Scope: Evidence-based and practice-based consideration of dietary factors that increase migraines • Patient-centered approach • Generalized to personalized education on potential contributors to migraines • Patient input into sequence of interventions based on what is realistic, preferable, high impact 22

IFN-BASED NUTRITION DIAGNOSIS/INTERVENTION • Priority #1: Low nutrient/high glycemic diet that may contribute to poor nervous system function and poor blood glucose control • Diagnosis: Undesirable food choices (NB-1. 7) related to knowledge deficit regarding dietary and lifestyle factors that influence migraines as evidenced by low intake of whole foods including anti-inflammatory vegetables, whole grains, legumes, nuts and seeds vs Bastyr Healthy Plate standards. • Intervention: Foods-based nutrition education to gradually improve diet quality; focus on easy to prepare meal and snack ideas that are nutrient dense and low in glycemic load; emphasis on magnesium, B-vitamin, and EFA-rich food choices; immediate support through a MVM; monitor whether migraine severity and frequency decrease. 23

IFN-BASED NUTRITION DIAGNOSIS/INTERVENTION • Priority #2: High intake of tyramine and histamine foods which may exacerbate migraines • Diagnosis: Excessive bioactive substance intake (NI-4. 2) related to preference for convenience foods and as evidenced by typical intake of high tyramine and histamine foods like cheese, vinegar based dressing, deli meats, and cola. • Intervention: Nutrition education on the potential relationship between tyramine, histamine, and migraines; nutrition education on food and beverage choices that are lower in tyramine and histamine; monitor whether migraine severity and frequency decrease. 24

IFN-BASED MONITORING AND EVALUATION Based on a broader set of assessment data and interventions, the IFN care provider 1 can: • Consider the individual response to the intervention provided • Evaluate progress towards a reduction in disease or towards enhanced wellness • Evaluate progress (or lack of progress) through assessment of key IFN data and Core Imbalances (i. e. go back to original assessment “roadmap”; assess new data): • • • Lifestyle – e. g. stress, limited time for self-care, activity level Signs and Symptoms - Medical symptom questionnaire (MSQ) results Biomarkers and Metabolic Pathways/Networks - e. g. functional lab assessment Allergens/Intolerances Environmental exposures and elimination – e. g. functional lab assessment Genetics – e. g. MTHFR • Determine whether referrals to other providers is indicated and/or has been helpful to client 1 Ford D, Raj S. Batheja RK, et al. American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Integrative and Functional Medicine JADA 111: 902– 913, 2011. 25

Conclusions an future directions for NCP terminology 26

KEY POINTS • Many NCP Assessment, Diagnosis, and Intervention terms fit well within a context of IFN care • Sometimes, IFN care can require creative use of NCP Diagnoses • Cases with stress, fatigue, environmental exposures: No diagnoses specifically capture these problems; often include these as etiologies of identified nutrition problems • “Catch-all” Diagnoses include Undesirable Food Choices (NB-1. 7) and Food- and Nutrition-related Knowledge Deficit (NB-1. 1) • No foods-based diagnoses in the Intake Domain (stated preference of NCP) • Requirement to name one nutrient problem per PES, while IFN care involves interconnected, multinutrient problems • Opportunities to request changes to the NCP: • https: //www. ncpro. org//404. cfm? 404; http: //ncpt. webauthor. com: 80/terminology-submission-process

QUESTIONS? Cynthia Bartok, MS, RDN Associate Professor Kelly Morrow, MS, RDN, CD, FAND DIFM-Immediate Past Chair Associate Professor Department of Nutrition and Exercise Science Bastyr University, Kenmore, WA © 2018 Morrow and Bartok 28

REFERENCES • Kohn, JB. Is There a Diet for Histamine Intolerance? Journal of the Academy of Nutrition and Dietetics; 114(11): 1860 • Borkum JM. Migraine Triggers and Oxidative Stress: A Narrative Review and Synthesis. Headache. 2016 Jan; 56(1): 12 -35 • Sun-Edelstein C, Mauskop A. Role of magnesium in the pathogenesis and treatment of migraine. Expert Rev Neurother. 2009 Mar; 9(3): 369 -79. doi: 10. 1586/14737175. 9. 3. 369. • Ramsden et al. Targeted alteration of dietary n-3 and n-6 fatty acids for the treatment of chronic headaches: A randomized trial. Pain. 2013; 154(11): 2 -22 • Izquierdo-Casas J et al. Low serum diamine oxidase (DAO) activity levels in patients with migraine. J Physiol Biochem. 2018 Feb; 74(1): 93 -99 • Tox Town: Environmental Health Concerns and Toxic Chemicals Where you Live, Work and Play. https: //toxtown. nlm. nih. gov/ 29

https: //my. clevelandclinic. org/ccf/. . . /Medical%20 Symptoms%20 Questionnaire. pdf 30

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