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A nutrition assessment is the first and most important step in diabetes medical nutrition therapy. A comprehensive nutrition assessment is crucial in identifying a client's diabetes management goals and determining an appropriate nutrition intervention.

Diabetes medical nutrition therapy (MNT) is defined as a four-step model that includes assessment of an individual’s metabolic and lifestyle parameters, identification of nutrition goals, intervention designed to achieve these goals, and evaluation of clinical outcomes.¹

Nutrition practice guidelines for insulin-dependent diabetes mellitus (IDDM) (see article by Splett and Leontos on p. 128) and non-insulin-dependent diabetes mellitus (NIDDM)² have been developed to increase the quality and consistency of diabetes MNT. Diabetes educators can use these guidelines to anticipate and simplify the decision-making process and foster improved metabolic control. The practice guidelines provide a framework that can assist diabetes educators in the nutrition assessment, goal setting, intervention, and evaluation of outcomes of diabetes MNT for people with IDDM and NIDDM.

Nutrition Assessment: A Definition
Although assessment is the initial step of the four-step model, beginning the relationship or establishing rapport with a client is an important preliminary step. Usually, this begins during the assessment phase and continues throughout the educational process, to develop a genuine and trusting relationship between diabetes educator and client.

Nutrition assessment is the most crucial step in diabetes MNT. The assessment forms the basis for developing the intervention plan and identifying potential changes to a client’s lifestyle and health habits that will improve health. The main purpose of an assessment is to gather information needed to assist in the development of individual nutrition goals and subsequently establish an appropriate nutrition intervention.

Preliminary Data
Before diabetes educators can conduct a comprehensive nutrition assessment, they must collect preliminary data, either from a hospital or clinic medical record or from a referring physician. The data needed for review includes health service utilization, type of diabetes, current treatment regimen, laboratory values, current medications, risk assessment for complications, previous diabetes education, current nutrition therapy, guidelines for exercise, the physician’s diabetes management goals, and the client’s self-management needs.

In some clinical circumstances, information about previous diabetes education and current nutrition therapy, guidelines for exercise, physician’s goals for the client, and the client’s self-management needs is not available in the medical record and may not be included in a referring letter from the physician. This information would then become part of the data gathered in the nutrition assessment.

Components of a Nutrition Assessment
The major components of a nutrition assessment are collection of clinical data, nutrition history, weight history, physical activity history, monitoring, psychosocial and economic issues (including stress and social support), knowledge, skill level, readiness to change, and barriers to learning.2 Table 1 contains the nutrition assessment components and specific data to be considered at the initial assessment visit.

Dietitians must obtain and use information from all these components to develop achievable goals and workable interventions appropriate to each client. Assessment is ongoing, and is continuously modified and updated throughout the diabetes MNT process.

Dietitians cannot cover all of these assessment components in-depth in the initial session with their clients. The amount of time it takes to do an assessment varies widely and depends on the dietitian, the client, and other factors, such as the client’s ability to provide information, as well as the complexity of information needed.

Table 1. Initial Nutrition Assessment
Component	Assessments
Clinical Data	Obtain height, weight, BMI, waist/hip ratio. Determine reasonable body wt. Estimate daily energy needs.
Nutrition History	Assess current nutrition therapy (if not available from preliminary data). Evaluate who does food prep/shopping. Determine frequency/choices when eating out. Assess alcohol intake. Determine use of vitamin/minerals/nutrition supplements. Assess for eating disorders. Complete nutrition history (using one or a combination of the following methods: 24-hr recall, usual food intake, food frequency, food records). Evaluate energy intake and macronutrient composition (type and amount).
Weight History	Obtain weight history, recent weight changes, and weight goals.
Physical Activity History	Determine activity types and frequency. Estimate energy expenditure. Determine limitations that hinder exercise. Assess willingness and ability to become more physically active.
Monitoring	Assess knowledge of target blood glucose ranges. Assess blood glucose method/frequency of testing. Assess other types of record keeping being con ducted (food, physical activity, etc.). Assess client benefits from monitoring.
Psychosocial/Economic	Assess living situation, finances, educational background, employment. Assess ethnic or religious beliefs. Assess level of family and social support. Assess level of stress.
Knowledge and skills level	Assess survival or continuing education knowledge level.
Expectations and readiness to change
This table is adapted from reference 2. J Am Diet Assoc 95:999-1006, 1995.

Resources
Many different tools and resources are available to assist in the gathering and development of a comprehensive nutrition assessment. In 1993, a steering committee of the American Diabetes Association and The American Dietetic Association set out to identify nutrition-related diabetes resources in need of updating, as well as new products for development.

One of the resources developed by a work group of this steering committee was Facilitating Lifestyle Change: A Resource Manual. The manual consists of a series of resource forms developed to assist in promoting lifestyle change. The lifestyle change process identifies four steps that correspond to the four-step model of diabetes MNT—assessment, goal setting, intervention, and evaluation. One of the resources in this manual, the Lifestyle Questionnaire, was designed primarily as an assessment tool. The questionnaire contains seven sections, which coincide with the nutrition assessment components listed in Table 1. These sections are described below.

1. Do You Want To Change Your Lifestyle?
This section helps ensure that a client’s expectations are compatible with the anticipated clinical outcomes that have been established. It also helps focus attention on areas of information that the client is most receptive to learning, as well as assisting in establishing a priority list for learning needs (Figure 1).

2. Nutrition History
This section helps assess:
• past nutrition interventions
• previous meal planning methods used and self-assessment of comprehension and compliance
• household/family situation
• eating away from home issues (provides additional insight on social, financial, and lifestyle considerations)
• alcohol intake (provides additional insight about habitual use and contribution toward excess calories, elevated triglyceride levels, and glycemic control)
• intake of nutrition supplements (potential for drug/nutrient interaction; often not reported to a physician in an assessment of medications)
• compulsive eating issues

3. Food Record Form
This form can be used to collect and assess nutrition history information, most often gathered as a usual food intake or 24-hour food recall. This allows the educator to see common trends in food intake. It would not take into account day-to-day variability, so having a client self-monitor using this form for several days or using an additional nutrition history assessment tool, such as a food frequency questionnaire, would be necessary to make a more accurate evaluation.

If the form is used as a food record, it is important to instruct clients in properly recording their food intake, such as determining portion size, describing food preparation, and listing all food ingredients (e.g., fat used to season vegetables or specific components of a mixed dish, salad, or sandwich).

4. Weight History
This form is designed for use with clients for whom weight loss is the primary desired clinical outcome. However, the words "weight change" were chosen instead of "weight loss" to make this form more appropriate as a tool for assessing anyone’s weight. The specific components of the weight history form include:
• usual weight, weight history, and healthy weight goal
• readiness-to-change assessment
• expectations regarding weight change

5. Physical Activity History
This form assesses current activity level, readiness to become more physically active, and types of physical activities of interest.

6. Stress History
This section assesses a client’s current level of stress, the ways a client reacts to stress, and the client’s need for education and counseling in stress management.

7. Record-Keeping History
This section assesses previous experience with self-monitoring (e.g., food records, exercise records, or blood glucose monitoring). This information may help in assessing a client’s interest level and the level of complexity for participation in self-monitoring.
Other components to consider in completing an initial nutrition assessment (Table 1) include clinical data, knowledge and skill level, and readiness to change.

Clinical data. The information needed to gather clinical data such as body mass index (BMI), reasonable body weight, and daily energy needs is well known to most diabetes educators and is readily available in many resources. A list of these resources is included in the Suggested Reading section of this article.

Knowledge and skill level. Many dietitians/diabetes educators have developed their own checklists or surveys to assess a client’s knowledge of nutrition. Table 2 provides an example of a knowledge checklist specific to diabetes MNT. Another method to assess knowledge is to compare client information collected from nutrition questionnaires and a verbal nutrition history with established goals or standards for education.³

Table 2. Nutrition Knowledge Checklist

The following checklist was developed to reflect the 1994 American Diabetes Association Nutrition Recommendations. This can be used as a tool for the Dietitian/Diabetes Educator to access current understanding of the nutrition related aspects of diabetes management. This worksheet can be filled out lby the professional as part of a detialed assessment. The date can be added by the topics noted under "Needs Info" when instructed.

Knows	N/A	Needs Info	Nutrition Knowledge
			A simple definition of carbohydrate (sugar and starch)
			That foods containing carbohydrates do not have to be restricted.
			Food sources of starch (breeat, pasta, cereals)
			Food sources of sugars (hard candy, carbonated beverages, jelly, syrups)
			How to incorporate simple sugars into the meal plan
			That fiber may have beneficial effects on blood lipid levels
			Food sources of fiber
			Food sources of protein (meat, poultry, fish, eggs, dairy, legumes)
			Types of fat (monounsaturated, polyunsaturated, saturated)
			Food sources of the three types of fat (olive oil, corn oil, butter)
			The effects of each type of fat on blood lipids
			Caloric contribution of fat as compared to carbohydrate and protein
			Goals for balanced nutrition
			The relationship of weight loss, exercise, diet, and medication to blood glucose management
			The benefits of exercise (for blood glucose, lipids, and weight)
			The desired range for fasting blood glucose
			The desired range for glycosylated hemoglobin
			Goal or target range for blood glucose levels
			Weight goal
			Lipid goals (Including total cholesterol, HDL, LDL, and triglycerides)

Readiness to change. The transtheoretical model for behavioral change developed by Prochaska and associates provides a framework for assessing readiness to change using a five-stage model.4 These stages include: 1) Precontemplation = no intention to change in the foreseeable future; 2) Contemplation = aware that a problem exists, thinking about making a change; 3) Preparation = decision making; 4) Action = making changes; 5) Maintenance = working to prevent relapse.

These stages of change have been applied to a variety of health behavior interventions, including fat reduction, exercise, smoking cessation, alcohol treatment, self-monitoring of blood glucose, and weight control.⁵ In the Lifestyle Questionnaire, readiness-to-change questions are included in both the Weight History and Physical Activity History sections. The questions and responses are worded as follows:

Are you interested in working to change your weight?
— Yes, right now.
— No, I can’t right now.

— No, but I will think it over.
— No, not now.
— No, I’m not interested.

Are you interested in becoming more physically active?
— Yes, right now.
— No, I can’t right now.
— No, but I will think it over.
— No, not now.
— No, I’m not interested.

Movement through these five stages often involves a move in either direction. Focusing intervention on the appropriate stage can facilitate tailoring intervention to the client’s needs, thus improving the likelihood of success. Assessment of readiness to change can guide diabetes educators in negotiating with clients to establish behavior change goals.

Collecting Assessment Data
The two most common barriers to obtaining assessment data in clinical practice are time limitations and clients’ reluctance to provide information. Some solutions that may help maximize time include:
• Use data previously collected by other staff.
• Focus on assessment information that is the most pertinent to the client.
• Prioritize information by obtaining the most crucial information first.
• Provide clients with forms or questionnaires to be completed before their visits (i.e., at the initial visit to complete for a subsequent visit, in the mail before the next scheduled visit, or in the clinic or office waiting room before their visit).

Some ways to help maximize the information clients provide include:
• Take time to develop rapport and establish trust with clients.
• Ask questions and respond to answers in a nonjudgmental way. There are no wrong or bad answers.
• Respect clients’ emotional state, which may require waiting to obtain comprehensive assessment data.

Summary
Nutrition assessment serves an educational purpose for diabetes educators and clients because it can improve a client’s awareness of health status, treatment options, and lifestyle factors that affect health. Nutrition assessment also provides diabetes educators with an opportunity to set the tone of their relationships with clients. Ideally, diabetes educators and clients should develop a working partnership.

Diabetes educators should ask not only for information, but also for a client’s reactions, feelings, and thoughts about the information being discussed. This starts a natural progression into the next step of the four-step model of diabetes MNT—goal setting.

For additional information on nutrition assessment, diabetes educators can refer to Diabetes Medical Nutrition Therapy: A Professional Guide, which will be published later this year by the American Diabetes Association and The American Dietetic Association.

Suggested Reading
Powers M, Ed.: Handbook of Diabetes Medical Nutrition Therapy 2nd Edition . Rockville, MD: Aspen Publishers, 1996.

Green Pastors J, Holler HJ (Eds): Diabetes Medical Nutrition Therapy: A Guide for Professionals Alexandria Va: American Diabetes Association and The American Dietetic Association, 1996. In preparation

Peragallo-Dittko V (Ed.): A Core Curriculum for Diabetes Educators 2nd Edition. Chicago: American Association of Diabetes Educators; 1993.

References
¹Fels Tinker L, Heins JM, Holler HJ: Commentary and translation: 1994 nutrition recommendations for diabetes. J Am Diet Assoc 94:838-39, 1994.

²Monk A, Barry B, McClain K, Weaver T, Cooper N, Franz MJ: Practice guidelines for medical nutrition therapy provided by dietitians for persons with noninsulin-dependent diabetes mellitus. J Am Diet Assoc 95:999-1006, 1995.

³Brink S, Siminerio L, Eds.: Diabetes Education Goals. Alexandria, VA: American Diabetes Association, 1995.

⁴Prochaska JO, DiClemente CC, Norcross JC: In search of how people change: applications to addictive behaviors. Am Psychol 47:1102-14, 1992.

⁵Prochaska JO, Ruggiero L, Eds.: From Research to Practice: Readiness for change. Diabetes Spectrum 6:22-60, 1993.

Facilitating Lifestyle Change: A Resource Manual costs $19.95 for ADA members and $22.95 for non-members, plus shipping and handling. To order, call 1-800-ADA-ORDER.

Joyce Green Pastors, MS, RD, CDE, is a diabetes nutrition specialist and research assistant professor at the University of Virginia Diabetes Out-reach Program, in Charlottesville.