November 2009 Issue

It’s About Time — Adapt to New Nutrition Assessment Tools to Optimize Care
By Dina Aronson, MS, RD
Today’s Dietitian
Vol. 11 No. 11 P. 10

Whether you’re an RD in clinical practice, private practice, or another area, no doubt you’ve heard about or been exposed to new ways to assess your patients’ and clients’ nutritional status. Reflecting on my own texts and notes from my internship days, it has become abundantly clear that it’s time to recycle those materials and get up to speed with what forward-thinking facilities and individuals are doing to better assess and manage their patients and clients.

Paper charting, SOAP notes, and calculating calorie needs by hand have been replaced by electronic medical records (EMRs), the Nutrition Care Process, and handheld nutrition calculators or applications, respectively. For many, these transitions have not been smooth. Learning new technology can be difficult, and it is especially challenging for entire departments to change the way they convey information to staff. Peggy Turner, MS, RD/LD, an assistant professor and the dietetic internship director for Oklahoma University, explains, “Developing more assessment tools is important, but we also need more education on how to fully use/implement those tools, such as what is a database, what are data points, what data to collect and why?”

Nutrition assessment methodology itself is constantly changing. A search of the scientific literature yields more than 1,000 articles over the past five years detailing the validation of new tools, new assessment and screening methods, and dietitians’ acceptance of new technologies for assessing patients, measuring data, and predicting outcomes. The good news is that these specialized tools improve care by helping better identify at-risk patients and populations and painting a clearer picture of patients’ nutritional status. The not-so-good news is that quality care may become compromised when healthcare professionals use different screening and assessment methods. Continuity of care, clear documentation, and effective communication may be challenging with so many ways to do the same job.

Are RDs Ready?
Given these challenges, some may question whether advances in nutrition assessment have saved time and increased productivity. “In the beginning, new technology presents new challenges, which renders our productivity unchanged. In the long run, I think productivity increases significantly,” says Turner. She explains that finding information faster—using the Internet or a handheld device, for example—makes a big difference in productivity. “I can also find information in an EMR much faster because I don’t have to wait to find the hard copy that the doctor has,” she notes.

Liz Friedrich, MPH, RD, CSG, LDN, a nutrition and health promotion consultant in Salisbury, N.C., who works in long-term care, agrees: “I have three facilities that are going totally electronic with their records, and I can tell it will increase my productivity tremendously. I can type much faster than I can write. And rather than sit at a nurse’s desk and rifle through charts, weight books, and meal intake records, everything will be in front of me on the laptop.”

Friedrich has also used electronic assessment tools in facilities that still use a paper system. Many RDs concur with her finding that these tools “increase productivity by allowing me to do calculations in seconds rather than minutes.”

Still, according to Turner and Friedrich, many RDs who are uncomfortable with technology may not find it as time-saving as they do. They say that to reap its benefits, RDs must invest the time up front to learn how to use it. Technology will be the most useful in facilities where such education is mandatory. Similarly, if new technology implementation is required in dietetic training programs and offered as part of continuing education, the workforce will become more tech-savvy every year.  

A 2005 study published as a poster in the Journal of the American Dietetic Association measured anxiety levels in students using a handheld calculator as a method of conducting nutrition assessments. The students reported feeling most worried that they could destroy patient information by hitting the wrong key or that they would make mistakes that could not be corrected. On the other hand, the students were confident that, with practice, they could master the skills needed to work with such software and, with patience and motivation, anyone could learn to use the technology. It would be interesting to repeat this study with today’s dietetic students, who use higher levels of technology in all aspects of their work and who understand that backups, logged history, and modern programs work to minimize or correct input errors.

Regardless of where each of us stands in our comfort level and use of nutrition assessment technology, it’s here to stay. According to Annie Sasseville, RD, an expert blogger and nutrition consultant in Denver, “If you are not computer oriented or struggle to understand computer language, I can see how these advances would slow you down. But now that I have learned how to use it, I feel that I would be lost without this technology. And since I know this is the direction the world is going, we have to adapt, keep up, and be as efficient as possible.”

Emerging Nutrition Assessment Tools
Nutrition assessment tools are typically developed for specific purposes, such as for research studies, acute or long-term care, or the generally healthy population. Among these main areas, one size does not fit all. For example, a food-frequency questionnaire designed to assess calcium intake in postmenopausal Caucasian women will differ from one created to measure monounsaturated fat intake among African American youths. Like finding the right tools for a household project, it’s important to develop or discover the right tools for effective nutrition assessment for a specific individual or population. The more specialized our projects become, the more dependent we become on computer technology for areas in research and data management.

RDs aren’t the only ones using this technology to improve nutrition assessment and outcomes. Our clients are also using computers to track their intake and other data so that we can use the information in increasingly meaningful ways. For example, Viocare, a Princeton, N.J.-based wellness company specializing in corporate wellness tools, nutrition research, and behavior change, has developed several innovative nutrition assessment tools. One of its products, VioScreen, is a Web-based food-frequency questionnaire that is capturing the attention of many who are interested in merging Web technology with wellness.

Unlike the handwritten method, this tool prompts users by asking questions based on previously entered information. For example, rather than providing a static line item for how much butter a user consumes per week, it will first “learn” that he or she consumes three bagels per week. Based on that input, the program will then inquire about typical bagel accompaniments, such as butter and cream cheese. The program takes less time than the paper version and is more interactive and engaging, resulting in more accurate data. It also prompts users for more complete data when they leave a question unanswered. The application provides comprehensive reports designed not only to provide an objective listing of food intake but also to help identify specific dietary patterns that have implications for lifestyle change. In addition, it provides optional behavioral feedback based on user input. Such a tool has vast applications in all sorts of wellness contexts.

Does this mean that these “smart” computer technologies are an alternative to or substitute for the RD? “Not at all,” says Rick Weiss, president of Viocare. “Our technology is not trying to replace the RD/counselor but rather providing a way for them to be more efficient and effective.”

Weiss explains that the RD still analyzes the data and works with clients to help them get results. “Our goal is to optimize wellness by combining a personalized lifestyle counseling protocol with scientifically proven dietary and physical activity analysis technologies,” he says.

The food-frequency questionnaire isn’t the only nutrition assessment tool well suited for Web use. The National Cancer Institute’s ASA24 is a Web-based, automated, and self-administered 24-hour dietary recall. This tool makes it feasible to administer multiple days of recalls in large-scale epidemiologic studies, surveillance studies, behavioral trials, or clinical research. The ultimate goal was to create software for an engaging and easy-to-use instrument and to make this software available to investigators on a Web site so that they could easily use the system at minimal or no cost.

ASA24 features graphic enhancements, an animated character to guide participants, and audio language and cues to enhance use in low-literacy populations. In addition, the software includes pictures of foods in multiple portion sizes to help respondents estimate portion size. It can quickly compute nutrient and food group estimates for each recall day. Possible advantages of this technique over interviewer-administered 24-hour recall include a higher level of accuracy (people are less likely to underreport to a machine than to a person), increased accessibility, and ease of enhancement to strengthen validity and reliability.

Exciting Prospects
Whatever your area of expertise, cutting-edge technologies are evolving to help nutrition professionals better manage, track, assess, and ultimately help patients and clients. It’s an exciting time to learn how high-tech assessment tools and methods are creating unique opportunities to develop novel skill sets and embrace new challenges.

— Dina Aronson, MS, RD, owns Welltech Solutions, a nutrition and technology consulting company.

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