Toward Harmonization of the Nutrition Care Process Terminology and the International Classification of Functioning, Disability and Health−Dietetics: Results of a Mapping Exercise and Implications for Nutrition and Dietetics Practice and Research

Open AccessPublished:February 06, 2017DOI:https://doi.org/10.1016/j.jand.2016.12.002
      The Continuing Professional Education (CPE) quiz for this article is available for free to Academy members through the MyCDRGo app (available for iOS and Android devices) and through www.jandonline.org (click on “CPE” in the menu and then “Academy Journal CPE Articles”). Log in with your Academy of Nutrition and Dietetics or Commission on Dietetic Registration username and password, click “Journal Article Quiz” on the next page, then click the “Additional Journal CPE quizzes” button to view a list of available quizzes. Non-members may take CPE quizzes by sending a request to [email protected] There is a fee of $45 per quiz (includes quiz and copy of article) for non-member Journal CPE. CPE quizzes are valid for 1 year after the issue date in which the articles are published.
      Quality, continuity, and safety are essential aspects of all health care interventions and are equally important in e-health care
      The term e-health care refers to health care practice supported by electronic processes and communication such as electronic health records, which enables the communication of patient data between different health care professionals and Telemedicine (physical and psychological diagnosis and treatments at a distance).
      The term e-health care refers to health care practice supported by electronic processes and communication such as electronic health records, which enables the communication of patient data between different health care professionals and Telemedicine (physical and psychological diagnosis and treatments at a distance).
      . In addition, e-health is increasingly used in various settings and new models of care in European countries. The e-Health Governance Initiative founded by the European Union has worked to establish a common structure for e-health within Europe to facilitate quality health care within countries and across borders.

      eHealth Network. Guidelines on Minimum/Non-Exhaustive Patient Summary Dataset for Electronic Exchange in Accordance with the Cross-Border Directive 2011/24/EU. Published November 19, 2013. http://ec.europa.eu/health/ehealth/key_documents/index_en.htm. Accessed June 12, 2016.

      Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients’ rights in cross-border healthcare.
      The Guidelines on Minimum/Non-Exhaustive Patient Summary Dataset for Electronic Exchange in Accordance with the Cross-Border Directive 2011/24/EU

      eHealth Network. Guidelines on Minimum/Non-Exhaustive Patient Summary Dataset for Electronic Exchange in Accordance with the Cross-Border Directive 2011/24/EU. Published November 19, 2013. http://ec.europa.eu/health/ehealth/key_documents/index_en.htm. Accessed June 12, 2016.

      indicate that member states wishing to engage in cross-border communication may perform mapping, transcoding, and translation activities to support such activity. A major theme of this initiative is the semantic and technical interoperability of data,
      Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients’ rights in cross-border healthcare.
      which is a high-priority target in nutrition and dietetics care as well.

      Yuill KA. Report on Knowledge and Perceived Use of a Nutrition Care Process & Standardised Language by Dietitians in Europe. European Federation of the Association of Dietitians (EFAD); 2012.

      To achieve interoperability of data, a standardized nutrition and dietetics terminology is essential and should be mandatory for documentation in electronic health records systems.
      • Hoggle L.B.
      • Michael M.A.
      • Houston S.M.
      • Ayres E.J.
      Electronic health record: Where does nutrition fit in?.
      Currently, two different nutrition and dietetics terminologies are used in Europe, namely the Nutrition Care Process Terminology (NCPT),

      Academy of Nutrition and Dietetics. Nutrition terminology reference manual (eNCPT): Dietetics language for nutrition care. https://ncpt.webauthor.com/. Accessed May 9, 2016.

      developed by the Academy of Nutrition and Dietetics, and the Classifications and Coding Lists for Dietetics (CCD), developed by the Dutch Association of Dietitians, in collaboration with the Dutch Institute of Allied Health Care. The International Classification of Functioning, Disability and Health−Dietetics (ICF-Dietetics)
      Dutch Dietetic Association
      Dutch ICF-Dietetiek, Revised Version October 2012; Derived Dietetic Classification on Dutch Translation of the WHO International Classification of Functioning, Disability and Health.
      is the most important classification of the CCD.
      The NCPT is based on the Nutrition Care Process and Model
      • Splett P.
      • Myers E.F.
      A proposed model for effective nutrition care.
      • Lacey K.
      • Pritchett E.
      Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management.
      Writing Group of the Nutrition Care Process/Standardized Language Committee
      Nutrition care process and model part I: The 2008 update.
      • Hammond M.I.
      • Myers E.F.
      • Trostler N.
      Nutrition Care Process and Model: An academic and practice odyssey.
      and is designed to improve the consistency and quality of individualized or group care of individuals with any kind of nutrition-related problems and diagnoses. The NCPT defines standard terms for each step of the Nutrition Care Process and includes a reference manual providing definitions and important usage advice for each term.

      Academy of Nutrition and Dietetics. Nutrition terminology reference manual (eNCPT): Dietetics language for nutrition care. https://ncpt.webauthor.com/. Accessed May 9, 2016.

      The development and continuous dissemination of a standardized language covering the Nutrition Care Process began in 2003.
      Writing Group of the Nutrition Care Process/Standardized Language Committee
      Nutrition care process part II: Using the International Dietetics and Nutrition Terminology to document the nutrition care process.
      The fourth edition of this terminology was published in 2013.
      Academy of Nutrition and Dietetics
      International Dietetics and Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process.
      Finally, the NCPT, the former International Dietetics and Nutrition Terminology, was published as an electronic version (eNCPT).

      Academy of Nutrition and Dietetics. Nutrition terminology reference manual (eNCPT): Dietetics language for nutrition care. https://ncpt.webauthor.com/. Accessed May 9, 2016.

      During the development of NCPT, the Academy of Nutrition and Dietetics began including the terminology in the Systematized Nomenclature of Medicine International and in Logical Observation Identifiers Names and Codes, and the International Classification of Diseases.

      Academy of Nutrition and Dietetics. Nutrition terminology reference manual (eNCPT): Dietetics language for nutrition care. https://ncpt.webauthor.com/. Accessed May 9, 2016.

      Meanwhile, countries in Europe and worldwide, such as Sweden, Denmark, Norway, Switzerland, and Canada, have started to translate and implement the NCPT.

      Academy of Nutrition and Dietetics. Nutrition terminology reference manual (eNCPT): Dietetics language for nutrition care. https://ncpt.webauthor.com/. Accessed May 9, 2016.

      An advantage of the NCPT for the practicing registered dietitian nutritionist (RDN) is that it is a sophisticated and specific nutrition and dietetics terminology covering the whole Nutrition Care Process.
      The CCD is a standardized nutrition and dietetics terminology consisting of different classifications and code lists, such as a classification to describe a person’s functioning (ICF-Dietetics), a classification of procedures of RDNs, a classification of assistive products for RDNs, a classification of medical terms for RDNs, and several code lists. The CCD has been developed to document the Dietetic Care Process,
      • Runia S.
      • Visser W.
      • Tiebie J.
      • Heerkens Y.
      Methodisch Handelen. Informatorium voor Voeding en Diëtetiek.
      • Visser W.
      • Runia S.
      • Tiebie J.
      • Heerkens Y.
      Eenduidig Taalgebruik bij het Diagnostisch en Therapeutisch Handelen van de Diëtist. Informatorium voor Voeding en Diëtetiek.
      which consists of referral and nutrition/dietetics screening, nutrition/dietetics assessment, dietetics diagnoses, treatment plan and intervention, evaluation and closing. In 1999, the first draft of the CCD
      • Beens M.
      • Heerkens Y.
      Classificaties en Codelijsten voor de Diëtetiek.
      was developed, followed by a first version of the CCD
      • Lie E.
      • Heerkens Y.F.
      Classificaties en Codelijsten voor de Diëtetiek.
      in 2003. In 2012, a revision was published.
      The ICF-Dietetics, as the main classification of the CCD, is based on the International Classification of Functioning, Disability and Health (ICF) and the biopsychosocial Model of the World Health Organization (WHO).

      World Health Organization. International Classification of Functioning, Disability and Health: Children & Youth Version; ICF-CY. Geneva, Switzerland: World Health Organization; 2007. http://apps.who.int/iris/bitstream/10665/43737/1/9789241547321_eng.pdf. Accessed June 15, 2016.

      World Health Organization
      International Classification of Functioning, Disability and Health: ICF.
      The ICF-Dietetics can be seen as a derivative of the ICF and contains most of the original ICF categories specified by the ICF code, title, description and inclusions and exclusions, and of added specific nutrition/dietetics categories. The advantage of the ICF is the applicability by different health professionals. In addition, the ICF helps to achieve a common understanding of assessment, intervention targets, and evaluation.
      • Rauch A.
      • Cieza A.
      • Stucki G.
      How to apply the International Classification of Functioning, Disability and Health (ICF) for rehabilitation management in clinical practice.
      The joint use of the ICF and the International Classification of Diseases,

      World Health Organization. ICD-10: International Statistical Classification of Diseases and Related Health Problems, 10th Revision. http://www.who.int/classifications/icd/icdonlineversions/en/. Published 2016. Accessed June 12, 2016.

      in order to complement medical diagnosis with information on functioning and health-related information, is recommended by WHO and is true for the ICF-Dietetics as well.
      The ICF-Dietetics is currently used by dietitians in the Netherlands and Belgium. It has been accepted by the Dutch WHO Collaborating Centre for the Family of International Classifications solely. Due to its multidisciplinary applicability of the ICF, Austria and other European Countries (eg, Germany) are considering implementing the ICF-Dietetics.
      The aims of this article were to describe and discuss how interoperability and harmonization could influence nutrition/dietetics practice and research on the one hand, and, on the other hand, provide information on a unidirectional mapping exercise from the NCPT to the ICF-Dietetics.

      Practice Implications

      The use of a standardized terminology will enhance communication, transparency, and measurability of the care process and its evaluation in terms of reimbursement and payment systems.
      • Hakel-Smith N.
      • Lewis N.M.
      A standardized nutrition care process and language are essential components of a conceptual model to guide and document nutrition care and patient outcomes.
      Moreover, a standardized terminology enables the comparison and interpretation of health care results or different studies across countries and would allow the creation of a new body of knowledge on effectiveness and efficiency of nutrition and dietetic care.
      Writing Group of the Nutrition Care Process/Standardized Language Committee
      Nutrition care process part II: Using the International Dietetics and Nutrition Terminology to document the nutrition care process.
      • Hakel-Smith N.
      • Lewis N.M.
      A standardized nutrition care process and language are essential components of a conceptual model to guide and document nutrition care and patient outcomes.
      • Hakel-Smith N.
      • Lewis N.M.
      • Eskridge K.M.
      Orientation to nutrition care process standards improves nutrition care documentation by nutrition practitioners.
      Thus, a consequent use of a standardized terminology within countries is an important step in quality nutrition/dietetics care. Inadequate or inconsistent documentation of the nutrition/dietetics care process with ambiguous terminology or different meanings of terms will have a negative impact on quality.
      • Hakel-Smith N.
      • Lewis N.M.
      A standardized nutrition care process and language are essential components of a conceptual model to guide and document nutrition care and patient outcomes.
      • Hakel-Smith N.
      • Lewis N.M.
      • Eskridge K.M.
      Orientation to nutrition care process standards improves nutrition care documentation by nutrition practitioners.
      Furthermore, documented care data are comparable only if the terms used to describe the care process have the same definitions and understanding among RDNs. This makes data pooling meaningful at both national and international levels. These are prerequisites for making quality health care available to every person in future. Therefore, interoperability and harmonization of the nutrition and dietetics terminologies are needed.

      What Is Interoperability?

      The European Committee for Standardization defines interoperability as a process in which “an application can accept data from another and perform a specified task in an appropriate and satisfactory manner (as judged by the user of the receiving system) without the need for extra operator intervention.”

      Joint Initiative for Global Standards Harmonization Health Informatics Document Registry and Glossary Standards Knowledge Management Tool. http://www.skmtglossary.org/default.aspx. Accessed July 2016.

      Furthermore, semantic interoperability “means that data shared by systems are understood by these at the level of fully defined domain concepts.” This includes that the meaning of exchanged information is unambiguously interpretable.

      Joint Initiative for Global Standards Harmonization Health Informatics Document Registry and Glossary Standards Knowledge Management Tool. http://www.skmtglossary.org/default.aspx. Accessed July 2016.

      Prerequisites for semantic interoperability and data sharing are a standardized terminology and a corresponding classification. For example, in a cross-border setting, it is agreed that it is necessary to have structured and coded data for identified fields.

      eHealth Network. Guidelines on Minimum/Non-Exhaustive Patient Summary Dataset for Electronic Exchange in Accordance with the Cross-Border Directive 2011/24/EU. Published November 19, 2013. http://ec.europa.eu/health/ehealth/key_documents/index_en.htm. Accessed June 12, 2016.

      What Is Harmonization?

      In the context of this article, two definitions of harmonization were considered that have been proposed by the International Organization for Standardization: concept harmonization and term harmonization.
      Concept harmonization means “the reduction or elimination of minor differences between two or more closely related concepts, without transferring a concept system to another language.”
      ISO TC 37/SC 1
      ISO 860:2007 Terminology Work—Harmonization of Concepts and Terms.
      It involves the comparison and matching of concepts and concept systems in one or more languages or subject fields by describing similarities and differences. Term harmonization, on the other hand, “refers to the designation of a single concept (in different languages) by terms that reflect similar characteristics or similar forms.” Term harmonization is possible if the concepts that the terms represent are almost the same or very similar.
      ISO TC 37/SC 1
      ISO 860:2007 Terminology Work—Harmonization of Concepts and Terms.

      Why Are Interoperability and Harmonization Important to the Profession of RDNs?

      Electronic data storage and processing and exchange of data within a country as well as across country borders are increasingly important topics in health care. These issues are primarily driven by high quality, continuity, and quantity aspects—for example, big data initiatives.

      eHealth Network. Guidelines on Minimum/Non-Exhaustive Patient Summary Dataset for Electronic Exchange in Accordance with the Cross-Border Directive 2011/24/EU. Published November 19, 2013. http://ec.europa.eu/health/ehealth/key_documents/index_en.htm. Accessed June 12, 2016.

      Currently, health insurance and population-based data sets are increasingly used to enhance clinical practice and research in order to answer advanced clinical questions that can only be analyzed based on large data sets. RDNs should keep on track with this health information technology developments and changes.
      RDNs apply the Nutrition/Dietetic Care Process in their clinical practice. This process was designed to improve consistency and quality of nutrition/dietetics care, as well as to assess outcomes.
      • Lacey K.
      • Pritchett E.
      Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management.
      Academy of Nutrition and Dietetics
      International Dietetics and Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process.
      Semantic interoperability of data is necessary to link the Nutrition/Dietetic Care Process to a valid outcome management system. To achieve semantic interoperability, a standardized nutrition and dietetics terminology as well as a coding system for documentation are needed.
      Outcomes research and cross-border care are reasons why harmonization of nutrition/dietetics care data across countries and different languages will become more important in the future. Harmonization improves effective and efficient nutrition/dietetics care and development of informed evidence by means of benchmark and good practice models. In accordance with the two definitions given here, the following two different aspects of this harmonization have to be considered: Firstly, harmonization is necessary in the cross-cultural adoption process when translating a standardized nutrition and dietetics terminology from the source into a target language. Ensuring equivalence involves maintaining the same meaning of the word or concept between the source and target languages. Equivalence is achieved through interpretation, which goes beyond word-for-word translation in order to explain the meaning of concepts using understandable terms and the grammatical rules of the target language.
      • Kim T.Y.
      • Coenen A.
      Toward harmonising WHO international classifications: A nursing perspective.
      Secondly, because there are currently two different standardized nutrition and dietetics terminologies used, for interoperability and joint use, concept harmonization between these two terminologies is indispensable.
      Inter-terminology mapping or linking is a common method to compare terminologies.
      • Kim T.Y.
      • Coenen A.
      Toward harmonising WHO international classifications: A nursing perspective.
      • Kim T.Y.
      • Hardiker N.
      • Coenen A.
      Inter-terminology mapping of nursing problems.
      • Wieteck P.
      Furthering the development of standardized nursing terminology through an ENP®-ICNP® cross-mapping.
      This method describes not only whether there are comparable concepts, it also defines the gap, a potential different understanding of concepts and terms, and visualizes which terms and concepts are needed to be harmonized. Thus, mapping can be seen as a first step in a harmonization process.
      ISO TC 37/SC 1
      ISO 860:2007 Terminology Work—Harmonization of Concepts and Terms.

      Mapping of the NCPT to the ICF-Dietetics

      The mapping exercise was carried out using the online version, eNCPT 2015,

      Academy of Nutrition and Dietetics. Nutrition terminology reference manual (eNCPT): Dietetics language for nutrition care. https://ncpt.webauthor.com/. Accessed May 9, 2016.

      and the ICF-Dietetics (Dutch Dietetic Association and Dutch Institute of Allied Health Care, ICF-Dietetics Draft-α version, unpublished data, 2012), as it was the only available English version. However, this version was presented to all members of the European Federation of the Associations of Dietitians and also to a workgroup of the International Confederation of Dietetic Associations.
      The specific objectives were to explore how many and which terms of the NCPT are covered by the ICF-Dietetics, distinguished between the original ICF categories and the added specific dietetics categories, furthermore, to highlight similarities and differences.
      In total, the NCPT contains 1,276 NCPT terms, namely of 816 “nutrition assessment, monitoring and evaluation” terms (including 52 “comparative standards”), 160 “diagnosis” terms, and 300 “intervention” terms. Because ICF is not designed to classify interventions and comparative standards, 764 “assessment, monitoring and evaluation” (without “comparative standards”) and 160 “diagnoses” terms were selected for the mapping process (n=924).
      The NCPT is organized in a hierarchical structure with domains, classes, sub-classes, and, in parts, sub-sub-classes. The smallest unit of the NCPT is the term with an alpha-numeric code that consists of the prefix of the domain and the number of the hierarchical structure. For example, the diagnosis domain “Intake (NI)” is further classified with the class, for example, “Nutrient (5),” further with the sub-class “Fat and Cholesterol (5.6)” and finally the term “Inadequate Fat Intake (NI-5.6.1).”
      The ICF (as main part of the ICF-Dietetics) was used for the mapping as standard. The ICF is a core classification of WHO, is used worldwide, and has been used in numerous studies as standard for mapping exercises.
      • Stamm T.A.
      • Cieza A.
      • Machold K.P.
      • Smolen J.S.
      • Stucki G.
      Content comparison of occupation-based instruments in adult rheumatology and musculoskeletal rehabilitation based on the International Classification of Functioning, Disability and Health.
      • Stamm T.A.
      • Mattsson M.
      • Mihai C.
      • et al.
      Concepts of functioning and health important to people with systemic sclerosis: A qualitative study in four European countries.
      • Coenen M.
      • Kus S.
      • Rudolf K.-D.
      • et al.
      Do patient-reported outcome measures capture functioning aspects and environmental factors important to individuals with injuries or disorders of the hand?.
      • Stucki A.
      • Borchers M.
      • Stucki G.
      • Cieza A.
      • Amann E.
      • Ruof J.
      Content comparison of health status measures for obesity based on the international classification of functioning, disability and health.
      The ICF is structured hierarchically with a numeric code that begins with the chapter number (one digit) followed by the second level (three digits), and the third and fourth levels (one digit each). The ICF has two parts. Part one covers functioning and disability and includes two components “Body Functions (b)”/“Body Structures (s),” and “Activities/Participation (d).” Part two covers contextual factors that include the components “Environmental Factors (e)” and “Personal Factors (pf).”
      World Health Organization
      International Classification of Functioning, Disability and Health: ICF.
      Although Personal Factors has not yet been classified in the ICF.
      The ICF-Dietetics enlarges the ICF by adding codes and categories addressing nutrition and dietetics−related issues. More precisely, the ICF-Dietetics includes 900 specific nutrition/dietetics categories in addition to approximately 1,000 of the original ICF categories. These enhance the granularity in this field. An example of the hierarchical structure of the ICF-Dietetics and its underlying model is shown in Figure 1 (available at www.jandonline.org). In contrast to the ICF, the ICF-Dietetics proposes categories addressing biochemical data, differentiates between “Activities (a)” and “Participation (p),” and provides a first draft of codes covering “Personal Factors (pf).”

      Method of the Mapping Exercise

      The mapping exercise was based on well-established ICF-Linking Rules.
      • Cieza A.
      • Fayed N.
      • Bickenbach J.
      • Prodinger B.
      Refinements of the ICF Linking Rules to strengthen their potential for establishing comparability of health information.
      • Cieza A.
      • Geyh S.
      • Chatterji S.
      • Kostanjsek N.
      • Üstün B.
      • Stucki G.
      ICF linking rules: An update based on lessons learned.
      The first author (G.G.), a clinical and research dietitian trained in ICF linking, performed the entire mapping process of 924 NCPT terms. Each term/concept was linked to the most precise ICF-Dietetics category. A specific dietetic category was assigned in case a more precise dietetics category, compared to the original ICF categories, was available. If NCPT terms comprised more than one concept, every single concept was linked to the ICF-Dietetics, meaning that one NCPT term could be linked to more than one ICF-Dietetics category. For quality assurance, 15% of the NCPT terms were randomly selected and linked by a second researcher (M.C., psychologist) experienced in linking health-related data to the ICF. Percentage agreement with 95% CI and Cohen’s κ
      • Cohen J.
      A coefficient of agreement for nominal scales.
      between the two linkers was calculated to verify the quality of the mapping. In addition, four members of the Dutch CCD committee (C.B., W.K.V., S.R., and Y.F.H.) involved in the development of the ICF-Dietetics, reviewed about 15% of the mapping results, which were chosen because of mapping difficulties and disagreements between the two raters (G.G. and M.C.). If unclear meanings regarding the NCPT terms were brought up, requests for clarification were mailed to Naomi Trostler, PhD, RD, FAND, one of the developers of the NCPT. Based on this additional information, a final consensus for the mapping results was reached by the two researchers (G.G. and M.C.). Figure 2 illustrates the process of mapping exercise.
      Figure thumbnail gr2
      Figure 2Process of Nutrition Care Practice Terminology (NCPT)/International Classification of Functioning, Disability and Health (ICF)−Dietetics mapping exercise.
      According the ICF-Linking Rules,
      • Cieza A.
      • Geyh S.
      • Chatterji S.
      • Kostanjsek N.
      • Üstün B.
      • Stucki G.
      ICF linking rules: An update based on lessons learned.
      concepts that could not be linked to an ICF category and that were clearly not personal factors were assigned “not covered (nc).” If the information about the NCPT term was not sufficient to make a decision about the most precise ICF-Dietetics category, the concept was assigned “not definable (nd).” If the NCPT term referred to a medical diagnosis or a health condition according to the International Statistical Classification of Diseases and Related Health Problems, 10th revision,

      World Health Organization. ICD-10: International Statistical Classification of Diseases and Related Health Problems, 10th Revision. http://www.who.int/classifications/icd/icdonlineversions/en/. Published 2016. Accessed June 12, 2016.

      it was assigned “health condition (nc-hc).” In addition to the ICF-Linking Rules, the closeness of the match with respect to comparable concepts was described by using “same,” “similar,” “broader,” and “narrower,” which is adapted from Zielstorff and colleagues.
      • Zielstorff R.D.
      • Tronni C.
      • Basque J.
      • Griffin L.R.
      • Welebob E.M.
      Mapping nursing diagnosis nomenclatures for coordinated care.
      Table 1 shows definitions and examples of these closeness-of-match categories. Figure 3 depicts the entire mapping decision process.
      Table 1Nutrition Care Practice Terminology (NCPT)/International Classification of Functioning, Disability and Health (ICF)−Dietetics mapping: Definition and example of closeness-of-matched categories (granularity)
      Closeness of matched categoriesDefinition
      Adapted from Zielstorff and colleagues.36
      Example NCPTICF-Dietetics−linked categories
      SameThe term in the NCPT is nearly identical in wording and concept to the ICF termPD-1.1.5.13

      Epigastric pain
      b28012 Pain in stomach or abdominal
      ICF-Dietetics original ICF category,


      b280120 Pain in stomach
      Added, more-precise dietetics category: The ICF-Dietetics consists of original ICF categories and additional specific dietetics categories. The table depicts the original ICF categories and the added specific dietetics categories in case a more-precise added dietetics category was available.
      SimilarThe term is comparable: or “alike in substance”FH-1.2.2.3

      Meals/snack pattern
      d5701 Managing diet and fitness
      ICF-Dietetics original ICF category,


      a570100 Selecting and consuming meals
      Added, more-precise dietetics category: The ICF-Dietetics consists of original ICF categories and additional specific dietetics categories. The table depicts the original ICF categories and the added specific dietetics categories in case a more-precise added dietetics category was available.
      BroaderThe term is larger in scope, or less specific, or can be considered to encompass the term in the ICFPD-1.1.20.3

      Difficulty moving tongue
      b5103 Manipulation of food in the mouth
      Added, more-precise dietetics category: The ICF-Dietetics consists of original ICF categories and additional specific dietetics categories. The table depicts the original ICF categories and the added specific dietetics categories in case a more-precise added dietetics category was available.
      NarrowerThe term is smaller in scope, or more specific, or can be considered to be encompassed by the ICF termBD-1.4.29

      Gastric emptying time
      b5150 Transport of food through stomach and intestines
      Added, more-precise dietetics category: The ICF-Dietetics consists of original ICF categories and additional specific dietetics categories. The table depicts the original ICF categories and the added specific dietetics categories in case a more-precise added dietetics category was available.


      b51500 Transport of food through stomach
      Added, more-precise dietetics category: The ICF-Dietetics consists of original ICF categories and additional specific dietetics categories. The table depicts the original ICF categories and the added specific dietetics categories in case a more-precise added dietetics category was available.
      a Adapted from Zielstorff and colleagues.
      • Zielstorff R.D.
      • Tronni C.
      • Basque J.
      • Griffin L.R.
      • Welebob E.M.
      Mapping nursing diagnosis nomenclatures for coordinated care.
      b ICF-Dietetics original ICF category,
      c Added, more-precise dietetics category: The ICF-Dietetics consists of original ICF categories and additional specific dietetics categories. The table depicts the original ICF categories and the added specific dietetics categories in case a more-precise added dietetics category was available.
      Figure thumbnail gr3
      Figure 3Nutrition Care Practice Terminology (NCPT)/International Classification of Functioning, Disability and Health (ICF)−Dietetics mapping: decision process (adapted from Cieza and colleagues
      • Cieza A.
      • Fayed N.
      • Bickenbach J.
      • Prodinger B.
      Refinements of the ICF Linking Rules to strengthen their potential for establishing comparability of health information.
      ) complemented with closeness-of-match categories (adapted from Zielstorff and colleagues
      • Zielstorff R.D.
      • Tronni C.
      • Basque J.
      • Griffin L.R.
      • Welebob E.M.
      Mapping nursing diagnosis nomenclatures for coordinated care.
      ).

      What Are the Major Findings?

      A total of 960 NCPT concepts were linked. Of these concepts 830 (86.5%) matched with a corresponding ICF-Dietetics category, namely, 259 NCPT concepts (31.2%) with an original ICF category and 571 NCPT concepts (68.8%) with a more precise dietetics category. Figure 4 illustrates the frequencies of matched NCPT concepts regarding NCPT domains and the corresponding ICF components.
      Figure thumbnail gr4
      Figure 4Nutrition Care Practice Terminology (NCPT)/International Classification of Functioning, Disability and Health (ICF)−Dietetics mapping results: Frequencies of 830 mapped concepts regarding NCPT domains and ICF components. The ovals represent NCPT domains and rectangles represent ICF components. Dark black arrows show to which ICF component the NCPT concepts of each domain were mainly linked. The additional dotted arrows indicate frequencies <20%.
      The mapping exercise demonstrate similarities and differences, in terms of 310 “same” concepts (37.3%) and 55 (6.6%) concepts of “similar” granularity, whereas 433 (52.2%) of the NCPT terms were more specific (“narrower”) and 32 (3.9%) less specific (“broader”) than the ICF-Dietetics categories. One hundred thirty NCPT terms (13.5%) could not be linked to a specific ICF-Dietetics category. Of these terms, 103 (79.2%) were assigned to “health condition,” 25 (19.2%) to “not definable,” and two (1.5%) to “not covered” (NO-1.1: No Nutrition Diagnosis at This Time and FH-2.1.3.5: Eats Alone).
      The actual mapping results of Nutrition Diagnostic Terminology have been provided as Table 2 (available at www.jandonline.org).

      Accuracy of Mapping Process

      The two researchers agreed on 83.3% (95% CI 76.3 to 89.7) of the linked concepts at component level. The calculated κ coefficients ranged between 0.76 at the component and 0.61 at the fourth level of the ICF-Dietetics classification. These results can, therefore, be regarded as substantial agreement.
      • Landis J.R.
      • Koch G.G.
      The measurement of observer agreement for categorial data.

      What Were the Challenges and Limitations of the Mapping Process?

      Although the mapping process is explained in the literature and could, thus, be well planned and structured, we still faced some challenges. The ICF-Dietetics describes the actual situation of individuals at one point in time, not the future or past, and no causal relationships between domains of functioning. Thus, we linked, for example, NI-1.4: Predicted Inadequate Energy Intake to the ICF-Dietetics category a570103: Managing Intake of Energy, and PD-1.1.10.8: Hair Changes Due to Malnutrition to b850: Functions of Hair. In practical use of the ICF-Dietetics, notes should be added to document the time point(s) of the assessment or causal relationships.
      Furthermore, the ICF-Dietetics is about functioning and contextual factors of the individual. Assistive products, like tests or questionnaires for nutrition diagnostics, are described in the Classification Assistive Products for Dietetics, and interventions are described in the Classification Interventions for Dietetics.
      • Lie E.
      • Heerkens Y.F.
      Classificaties en Codelijsten voor de Diëtetiek.
      The NCPT, however, also includes tests and medical interventions. For our mapping exercise, we applied the following questions when linking these tests or interventions: What is the aim of this intervention? What is assessed/tested with this test? This was done in agreement with the published ICF-Linking Rules.
      • Cieza A.
      • Fayed N.
      • Bickenbach J.
      • Prodinger B.
      Refinements of the ICF Linking Rules to strengthen their potential for establishing comparability of health information.
      In addition, there were NCPT terms that can be linked to different ICF-Dietetics categories, for example, NI-4.3: Excessive Alcohol Intake was linked to a57022: Avoiding Risks of Drug or Alcohol Addiction and to the ICF-Dietetics component Personal Factors, having in mind personal habits with regard to the use of alcohol. In these cases, we documented both possible linking opportunities.
      Limitations of this study were that we have mapped NCPT terms to the ICF-Dietetics and not the other way around, and not to other classifications of the CCD. This means that this study does not give detailed insight in terms of the ICF-Dietetics, which are not covered in the NCPT, and not which terms of the NCPT are covered by other classifications of the CCD. However, our study provides the first content comparison of the NCPT and the ICF-Dietetics. It is a first step to harmonize the currently used nutrition and dietetics terminologies.

      What Can We Learn from This Study?

      The mapping of the NCPT to the ICF-Dietetics shows that although both terminologies have different purposes and are based on different models, the great majority of the NCPT terms (86.5%) could be linked to corresponding ICF-Dietetics categories. That indicates that two standardized terminologies that illustrate the same process came largely to similar results.
      The original ICF categories of the ICF-Dietetics cover the NCPT terms in a very nonspecific manner, while the more-specific added dietetic categories provide more specialization in the area of nutrition and nutrition-related aspects; for example, managing nutrition and diet and digestive functions. It is important to emphasize that the ICF has been established as a common language for describing health and health-related states in order to improve communication between different users.
      World Health Organization
      International Classification of Functioning, Disability and Health: ICF.
      It is a framework and reference system that describes functioning and contextual factors of people with all kinds of health conditions or health-related problems. Therefore, the ICF-Dietetics does not cover the whole nutrition/dietetics care process, as the NCPT does.
      However, the NCPT has a mainly biomedical approach; about two-thirds of the NCPT terms were linked to the ICF-Dietetics components “Body Functions,” “Body Structures,” and “Health Conditions.” ICF-Dietetics provide a framework and classification based on the biopsychosocial perspective, covering additional “Activities and Participation” and “Environmental Factors” categories.
      In addition, the mapping exercise indicates that NCPT terms were likely to be more granular than categories from the ICF-Dietetics (eg, FH.1.5.3.5: Gluten Intake was linked to the ICF-Dietetics proposed category a5701021: Managing Intake of Protein and FH-1.5.1.2: Saturated Fat Intake to a5701020: Managing Intake of Fat). The NCPT terms describe precisely the whole care process. This is an advantage for the practicing RDN compared to the sole use of the ICF-Dietetics. However, the ICF-Dietetics in the Netherlands is used in combination with other classifications, such as the Classifications of Assistive Products.
      • Lie E.
      • Heerkens Y.F.
      Classificaties en Codelijsten voor de Diëtetiek.
      This makes it possible to define the specific type of protein and fat.
      Finally, the NCPT provides specific, validated, nutrition diagnosis terminology.
      • Ritter-Gooder P.
      • Lewis N.M.
      Content validity of nutrition diagnostic term involuntary weight loss.
      • Ritter-Gooder P.K.
      • Lewis N.M.
      • Eskridge K.M.
      Content validation of a standardized language diagnosis by certified specialists in gerontological nutrition.
      Nutrition diagnosis is defined by the Academy of Nutrition and Dietetics as “existing nutrition problems that the food and nutrition professional is responsible for treating.”
      Writing Group of the Nutrition Care Process/Standardized Language Committee
      Nutrition care process and model part I: The 2008 update.
      In the Netherlands, the diagnosis of the dietitian is formulated as the “professional specific judgment about the health profile of the client.”
      • Runia S.
      • Visser W.
      • Tiebie J.
      • Heerkens Y.
      Methodisch Handelen. Informatorium voor Voeding en Diëtetiek.
      • Visser W.
      • Runia S.
      • Tiebie J.
      • Heerkens Y.
      Eenduidig Taalgebruik bij het Diagnostisch en Therapeutisch Handelen van de Diëtist. Informatorium voor Voeding en Diëtetiek.
      • Runia S.
      • Tiebie J.
      • Visser W.
      Dietische diagnose onmisbaar bij effectieve behandeling: volg de logica: Probleem-doel-advies.
      The ICF-Dietetics can be employed to describe and code (problems in) functioning and the negative and positive influence of contextual factors (environmental and personal) using qualifiers. Qualifiers are additional digits that can be used to indicate the severity of problems, in terms of impairments in body functions or structures, limitations in activities, and restrictions in participation.
      World Health Organization
      International Classification of Functioning, Disability and Health: ICF.
      • Runia S.
      • Tiebie J.
      • Visser W.
      Dietische diagnose onmisbaar bij effectieve behandeling: volg de logica: Probleem-doel-advies.
      Despite these differences, nearly all NCPT diagnosis terms were linked to ICF-Dietetics categories, just in their neutral form. In this study, no use was made of the possibility to add qualifiers. For example, NB-2.4: Impaired Ability to Prepare Foods/Meals was mapped to the ICF category a630: Preparing Meals. Further information and the actual mapping results of these diagnosis terms are provided in Table 2 (available at www.jandonline.org).

      Acknowledgements

      The authors thank both developers of the NCPT, Naomi Trostler, PhD, RD, FAND, and Esther Myers, PhD, RDN, FAND, for their contributions to this study.

      Supplementary Materials

      Figure thumbnail gr1
      Figure 1Nutrition Care Practice Terminology (NCPT)

      Academy of Nutrition and Dietetics. Nutrition terminology reference manual (eNCPT): Dietetics language for nutrition care. https://ncpt.webauthor.com/. Accessed May 9, 2016.

      /International Classification of Functioning, Disability and Health (ICF)−Dietetics (Dutch Dietetic Association and Dutch Institute of Allied Health Care, ICF-Dietetics Draft-α version, unpublished data, 2012) mapping. The ICF-Dietetics is based on the Biopsychosocial Model of Functioning and Disability and on the hierarchical structure of the ICF.
      World Health Organization
      International Classification of Functioning, Disability and Health: ICF.
      The figure depicts the interactions between components of the ICF (Body Functions/Body Structures, Activities, Participation, Environmental Factors, Personal Factors) and an example of the hierarchical structure of original ICF categories and added more precise dietetics categories (highlighted in red). The ICF describes human functioning from different perspectives (Body Functions/Body Structures and Activities/Participation) that is influenced on the one hand by health conditions (classified with the International Statistical Classification of Diseases and Related Health Problems, 10th revision

      World Health Organization. ICD-10: International Statistical Classification of Diseases and Related Health Problems, 10th Revision. http://www.who.int/classifications/icd/icdonlineversions/en/. Published 2016. Accessed June 12, 2016.

      ) and, on the other hand, by contextual factors (Environmental and Personal factors). Each ICF component is organized in a hierarchical structure. The ICF-Dietetics enlarges the original ICF by adding categories and codes (highlighted in red) addressing nutrition and dietetics−related issues to enhance the granularity in this field. Throughout the whole ICF-Dietetics, the hierarchical structure of the ICF is maintained and further lower (more detailed) levels are added.
      Adapted and reprinted from: International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; page 18, Copyright 2001.
      World Health Organization
      International Classification of Functioning, Disability and Health: ICF.
      Table 2Nutrition Care Practice Terminology (NCPT)

      Academy of Nutrition and Dietetics. Nutrition terminology reference manual (eNCPT): Dietetics language for nutrition care. https://ncpt.webauthor.com/. Accessed May 9, 2016.

      /International Classification of Functioning, Disability and Health (ICF)−Dietetics (Dutch Dietetic Association and Dutch Institute of Allied Health Care, ICF-Dietetics Draft-α version, unpublished data, 2012) mapping result of 160 Nutrition Care Practice Terminology nutrition diagnostic terms
      The mapping exercise was based on well-established Linking Rules.33 The ICF-Dietetics consists of original ICF categories and additional specific dietetic categories (added ICF-Dietetics). Each NCPT term were linked to the most precise ICF-Dietetics category. An added ICF-Dietetics category was assigned in case a more precise specific dietetic category compared to the original ICF was available. If an NCPT term comprised more than one concept, every single concept was linked to the ICF-Dietetics, meaning that one NCPT term could be linked to more than one ICF-Dietetics category.
      NCPT termDomain/classNCPT term no.ICF type of categoryICF-Dietetics categoryICF-Dietetics codeCloseness category
      In addition to the ICF-Linking Rules, 33 the closeness of the match in respect of comparable concepts was described by using “same,” “similar,” “broader” and “narrower,” adopted from Zielstorff and colleagues36: Same: The term in the NCPT is nearly identical in wording and underlying concept to the ICF term. Similar: The term is comparable: or “alike in substance.” Broader: The term is larger in scope, or less specific, or can be considered to encompass the term in the ICF. Narrower: The term is smaller in scope, or more specific, or can be considered to be encompassed by the ICF term.
      Not-matched category
      According the ICF-Linking Rules, concepts that could not be linked to an ICF-Dietetics category and that were clearly not personal factors were assigned “not covered (nc).” If the information of the NCPT term was not sufficient to make a decision about the most precise ICF-Dietetics component, the concept was assigned “not definable (nd).” If the NCPT term referred to a medical diagnosis or a health condition according to the ICD-10, it was assigned “health condition (nc-hc).”
      Nutrition diagnostic terminology
      IntakeNI
       Energy balance1
      Increased energy expenditureNI-1.1Added ICF-DieteticsIncreased need for energyb5404.x2Same
      Inadequate energy intakeNI-1.2Added ICF-DieteticsManaging intake of energy according to RGV
      RGV=Dutch Dietary Guidelines: Making sure that nutritional intake is optimum for the person, which usually means that the nutrition complies with the RGV or Dietary Reference Values established by age category.
      a570103Same
      Excessive energy intakeNI-1.3Added ICF-DieteticsManaging intake of energy according to RGVa570103Same
      Predicted inadequate energy intakeNI-1.4Added ICF-DieteticsManaging intake of energy according to RGVa570103Same
      Predicted excessive energy intakeNI-1.5Added ICF-DieteticsManaging intake of energy according to RGVa570103Same
       Oral or nutrition support intake2
      Inadequate oral intakeNI-2.1Added ICF-DieteticsManaging nutrition according to RGVa57010Narrower
      Excessive oral intakeNI-2.2Added ICF-DieteticsManaging nutrition according to RGVa57010Narrower
      Inadequate enteral nutrition infusionNI-2.3Added ICF-DieteticsManaging use of diet products, diet preparations and nutritional supplementsa570111Narrower
      Excessive enteral nutrition infusionNI-2.4Added ICF-DieteticsManaging use of diet products, diet preparations and nutritional supplementsa570111Narrower
      Enteral nutrition composition inconsistent with needsNI-2.5Added ICF-DieteticsManaging use of diet products, diet preparations and nutritional supplementsa570111Narrower
      Enteral nutrition administration inconsistent with needsNI-2.6Added ICF-DieteticsManaging use of diet products, diet preparations and nutritional supplementsa570111Narrower
      Inadequate parenteral nutrition infusionNI-2.7Added ICF-DieteticsManaging use of diet products, diet preparations and nutritional supplementsa570111Narrower
      Excessive parenteral nutrition infusionNI-2.8Added ICF-DieteticsManaging use of diet products, diet preparations and nutritional supplementsa570111Narrower
      Parenteral nutrition composition inconsistent with needsNI-2.9Added ICF-DieteticsManaging use of diet products, diet preparations and nutritional supplementsa570111Narrower
      Parenteral nutrition administration inconsistent with needsNI-2.10Added ICF-DieteticsManaging use of diet products, diet preparations and nutritional supplementsa570111Narrower
      Limited food acceptanceNI-2.11Added ICF-DieteticsMotivation to eatb13010Narrower
       Fluid intake3
      Inadequate fluid intakeNI-3.1Added ICF-DieteticsManaging intake of fluids according to RGVa5701023Same
      Excessive fluid intakeNI-3.2Added ICF-DieteticsManaging intake of fluids according to RGVa5701023Same
       Bioactive substances4
      Inadequate bioactive substance intakeNI-4.1Added ICF-DieteticsManaging intake of nutrients according to RGV other specified
      In contrast to the previous versions of the ICF-Linking Rules,34 it is recommend now to use “other specified” categories (ending with the digit “8”). Experience has shown that not using “8”-categories leads to lost information. Therefore, the authors of the ICF-Linking Rules33 suggest now, if a concept is linked to an “8”-category, the additional information not specified within the ICF should be documented along with the ICF category. Furthermore, it must be mentioned that the ICF-Dietetics is used in combination with other classifications, such as the Classifications of Assistive Products.6 This makes it possible to define the specific type of protein (such as gluten or amino acids) and fat (such as saturated fat).
      : bioactive substance
      a5701028Same
      Inadequate plant stanol ester intakeNI-4.1.1Added ICF-DieteticsManaging intake of nutrients according to RGV other specified: plant stanol estera5701028Same
      Inadequate plant sterol ester intakeNI-4.1.2Added ICF-DieteticsManaging intake of nutrients according to RGV other specified: plant sterol estera5701028Same
      Inadequate soy protein intakeNI-4.1.3Added ICF-DieteticsManaging intake of nutrients according to RGV other specified: soy proteina5701028Same
      Inadequate psyllium intakeNI-4.1.4Added ICF-DieteticsManaging intake of nutrients according to RGV, other specified: Inadequate psylliuma5701028Same
      Inadequate β-glucan intakeNI-4.1.5Added ICF-DieteticsManaging intake of nutrients according to RGV, other specified: β-glucana5701028Same
      Excessive bioactive substance intakeNI-4.2Added ICF-DieteticsManaging intake of nutrients according to RGV, other specified: bioactive substancea5701028Same
      Excessive plant stanol ester intakeNI-4.2.1Added ICF-DieteticsManaging intake of nutrients according to RGV, other specified: plant stanol estera5701028Same
      Excessive plant sterol ester intakeNI-4.2.2Added ICF-DieteticsManaging intake of nutrients according to RGV, other specified: plant sterol estera5701028Same
      Excessive soy protein intakeNI-4.2.3Added ICF-DieteticsManaging intake of nutrients according to RGV, other specified soy proteina5701028Same
      Excessive psyllium intakeNI-4.2.4Added ICF-DieteticsManaging intake of nutrients according to RGV, other specified: psylliuma5701028Same
      Excessive β-glucan intakeNI-4.2.5Added ICF-DieteticsManaging intake of nutrients according to RGV, other specified: β-glucana5701028Same
      Excessive food additive intakeNI-4.2.6Added ICF-DieteticsManaging intake of nutrients according to RGV, other specified: food additivea5701028Same
      Excessive caffeine intakeNI-4.2.7Added ICF-DieteticsManaging intake of nutrients according to RGV, other specified: caffeinea5701028Same
      Excessive alcohol intakeNI-4.3Added ICF-DieteticsExcessive use of alcohol at this momentpf615.x2Same
      Added ICF-DieteticsAvoiding risks of drug or alcohol addictiona57022Same
       Nutrient5
      Increased nutrient needsNI-5.1Added ICF-DieteticsNeed for nutrientsb5405Same
      Inadequate protein-energy intakeNI-5.2Added ICF-DieteticsManaging intake of protein according to RGVb5405Similar
      Decreased nutrient needsNI-5.3Added ICF-DieteticsNeed for nutrientsb5405Same
      Imbalance of nutrientsNI-5.4Added ICF-DieteticsManaging intake of nutrients according to RGVa570102Same
       Fat and cholesterol5.5
      Inadequate fat intakeNI-5.5.1Added ICF-DieteticsManaging intake of fat according to RGVa5701020Same
      Excessive fat intakeNI-5.5.2Added ICF-DieteticsManaging intake of fat according to RGVa5701020Same
      Intake of types of fats inconsistent with needsNI-5.5.3Added ICF-DieteticsManaging intake of fat according to RGVa5701020Narrower
       Protein5.6
      Inadequate protein intakeNI-5.6.1Added ICF-DieteticsManaging intake of protein according to RGVa5701021Same
      Excessive protein intakeNI-5.6.2Added ICF-DieteticsManaging intake of protein according to RGVa5701021Same
      Intake of types of proteins inconsistent with needsNI-5.6.3Added ICF-DieteticsManaging intake of protein according to RGVa5701021Narrower
       Amino acid5.7
      Intake of types of amino acids inconsistent with needsNI-5.7.1Added ICF-DieteticsManaging intake of protein according to RGVa5701021Narrower
       Carbohydrate and fiber5.8
      Inadequate carbohydrate intakeNI-5.8.1Added ICF-DieteticsManaging intake of carbohydrates according to RGVa5701022Same
      Excessive carbohydrate intakeNI-5.8.2Added ICF-DieteticsManaging intake of carbohydrates according to RGVa5701022Same
      Intake of types of carbohydrate inconsistent with needsNI-5.8.3Added ICF-DieteticsManaging intake of carbohydrates according to RGVa5701022Narrower
      Inconsistent carbohydrate intakeNI-5.8.4Added ICF-DieteticsManaging intake of carbohydrates according to RGVa5701022Narrower
      Inadequate fiber intakeNI-5.8.5Added ICF-DieteticsManaging intake of carbohydrates according to RGVa5701022Narrower
      Excessive fiber intakeNI-5.8.6Added ICF-DieteticsManaging intake of carbohydrates according to RGVa5701022Narrower
       Vitamin5.9
      Inadequate vitamin intakeNI-5.9.1Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Same
      ANI-5.9.1.1Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      CNI-5.9.1.2Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      DNI-5.9.1.3Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      ENI-5.9.1.4Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      KNI-5.9.1.5Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      ThiaminNI-5.9.1.6Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      RiboflavinNI-5.9.1.7Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      NiacinNI-5.9.1.8Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      FolateNI-5.9.1.9Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      B-6NI-5.9.1.10Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      B-12NI-5.9.1.11Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      Pantothenic acidNI-5.9.1.12Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      BiotinNI-5.9.1.13Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      Excessive vitamin intakeNI-5.9.2Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Same
      ANI-5.9.2.1Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      CNI-5.9.2.2Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      DNI-5.9.2.3Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      ENI-5.9.2.4Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      KNI-5.9.2.5Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      ThiaminNI-5.9.2.6Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      RiboflavinNI-5.9.2.7Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      NiacinNI-5.9.2.8Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      FolateNI-5.9.2.9Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      B-6NI-5.9.2.10Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      B-12NI-5.9.2.11Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      Pantothenic acidNI-5.9.2.12Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
      BiotinNI-5.9.2.13Added ICF-DieteticsManaging intake of vitamins according to RGVa5701024Narrower
       Mineral5.10
      Inadequate mineral intakeNI-5.10.1Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Same
      CalciumNI-5.10.1.1Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      ChlorideNI-5.10.1.2Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      IronNI-5.10.1.3Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      MagnesiumNI-5.10.1.4Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      PotassiumNI-5.10.1.5Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      PhosphorusNI-5.10.1.6Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      SodiumNI-5.10.1.7Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      ZincNI-5.10.1.8Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      SulfateNI-5.10.1.9Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      FluorideNI-5.10.1.10Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      CopperNI-5.10.1.11Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      IodineNI-5.10.1.12Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      SeleniumNI-5.10.1.13Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      ManganeseNI-5.10.1.14Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      ChromiumNI-5.10.1.15Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      MolybdenumNI-5.10.1.16Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      BoronNI-5.10.1.17Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      CobaltNI-5.10.1.18Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      Excessive mineral intakeNI-5.10.2Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Same
      CalciumNI-5.10.2.1Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      ChlorideNI-5.10.2.2Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      IronNI-5.10.2.3Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      MagnesiumNI-5.10.2.4Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      PotassiumNI-5.10.2.5Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      PhosphorusNI-5.10.2.6Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      SodiumNI-5.10.2.7Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      ZincNI-5.10.2.8Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      SulfateNI-5.10.2.9Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      FluorideNI-5.10.2.10Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      CopperNI-5.10.2.11Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      IodineNI-5.10.2.12Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      SeleniumNI-5.10.2.13Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      ManganeseNI-5.10.2.14Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      ChromiumNI-5.10.2.15Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      MolybdenumNI-5.10.2.16Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      BoronNI-5.10.2.17Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
      CobaltNI-5.10.2.18Added ICF-DieteticsManaging intake of minerals according to RGVa5701025Narrower
       Multinutrient5.11
      Predicted inadequate nutrient intakeNI-5.11.1Added ICF-DieteticsManaging intake of nutrients according to RGVa570102Same
      Predicted excessive nutrient intakeNI-5.11.2Added ICF-DieteticsManaging intake of nutrients according to RGVa570102Same
      ClinicalNC
       Functional1
      Swallowing difficultyNC-1.1Original ICFSwallowingb5105Same
      Biting/chewing (masticatory) difficultyNC-1.2Original ICFBitingb5101Same
      Original ICFChewingb5102Same
      Breastfeeding difficultyNC-1.3Original ICFCarrying out breastfeedinga5601Same
      Altered gastrointestinal functionNC-1.4Original ICFGastric functionsb5332Broader
      Original ICFIntestinal functionb5335Broader
      Predicted breastfeeding difficultyNC-1.5Original ICFCarrying out breastfeedinga5601Same
       Biochemical2
      Impaired nutrient utilizationNC-2.1Original ICFAssimilation functionsb520Similar
      Altered nutrition-related laboratory valuesNC-2.2nd
      Food–medication interactionNC-2.3nd
      Predicted food–medication interactionNC-2.4nd
       Weight3
      UnderweightNC-3.1Added ICF-DieteticsBody weight too lows7052.x1Same
      Unintended weight lossNC-3.2Added ICF-DieteticsUndesired weight lossb 5310.x2Same
      Overweight/obesityNC-3.3Added ICF-DieteticsBody weight too highs7052.x2Same
      Overweight, adult or pediatricNC-3.3.1Added ICF-DieteticsOverweight/BMI
      BMI=body mass index; calculated as kg/m2.
      25.0-29.9
      s7052.x21Broader
      Obese, pediatricNC-3.3.2Added ICF-DieteticsBody weight too highs7052.x2Narrower
      Obese, class INC-3.3.3Added ICF-DieteticsObesity I/BMI 30.0-34.9s 7052.x22Same
      Obese, class IINC-3.3.4Added ICF-DieteticsObesity II/BMI 35.0-39.9s 7052.x23Same
      Obese, class IIINC-3.3.5Added ICF-DieteticsObesity III/BMI>40.0s 7052.x24Same
      Unintended weight gainNC-3.4Added ICF-DieteticsUndesired weight gainb5311.x2Same
      Growth rate below expectedNC-3.5Original ICFGrowth maintenance functionsb560Same
      Excessive growth rateNC-3.6Original ICFGrowth maintenance functionsb560Same
       Malnutrition disorders4
      MalnutritionNC-4.1Added ICF-DieteticsNutritional statusb532Narrower
      Starvation related malnutritionNC-4.1.1Added ICF-DieteticsNutritional statusb532Narrower
      Chronic disease− or condition-related malnutritionNC-4.1.2Added ICF-DieteticsNutritional statusb532Narrower
      Acute disease- or injury-related malnutritionNC-4.1.3Added ICF-DieteticsNutritional statusb532Narrower
      Behavioral−environmentalNB
       Knowledge and beliefs1
      Food- and nutrition-related knowledge deficitNB-1.1Added ICF-DieteticsKnowledge about nutrition

      Inclusion of myths about nutrition, relation to nutrition and disease
      pf4652Same
      Unsupported beliefs/attitudes about food- or nutrition-related topics (use with caution)NB-1.2Added ICF-DieteticsAttitude on nutritional behaviorpf4550Broader
      Not ready for diet/lifestyle changeNB-1.3Added ICF-DieteticsMotivation to adjust dietb13011Same
      Self-monitoring deficitNB-1.4Original ICFHigher-level cognitive functionsb164Narrower
      Disordered eating patternNB-1.5Added ICF-DieteticsManaging nutrition according to RGVa57010Similar
      Limited adherence to nutrition-related recommendationsNB-1.6Added ICF-DieteticsKeep to therapypf450Same
      Undesirable food choicesNB-1.7Added ICF-DieteticsManaging proper choice of food productsa5701012Similar
       Physical activity and function2
      Physical inactivityNB-2.1Added ICF-DieteticsManaging adequate physical activitya57013Same
      Excessive physical activityNB-2.2Added ICF-DieteticsManaging adequate physical activitya57013Same
      Inability to manage self-careNB-2.3Original ICFSelf-carea5Same
      Impaired ability to prepare foods/mealsNB-2.4Original ICFPreparing mealsa630Same
      Poor nutrition quality of lifeNB-2.5Added ICF-DieteticsQuality of lifepf480Narrower
      Self-feeding difficultyNB-2.6Original ICFEatinga550Same
       Food safety and access3
      Intake of unsafe foodNB-3.1Added ICF-DieteticsIdentification of rotten, contaminated, or in any other way dangerous fooda6304Same
      Limited access to foodNB-3.2Original ICFFoode1101Same
      Limited access to nutrition-related suppliesNB-3.3Original ICFFoode1102Same
      Limited access to potable waterNB-3.4Added ICF-DieteticsDrinking watere112Same
       OtherNO
      Other1
      No nutrition diagnosis at this timeNO-1.1nc
      a The mapping exercise was based on well-established Linking Rules.
      • Cieza A.
      • Fayed N.
      • Bickenbach J.
      • Prodinger B.
      Refinements of the ICF Linking Rules to strengthen their potential for establishing comparability of health information.
      The ICF-Dietetics consists of original ICF categories and additional specific dietetic categories (added ICF-Dietetics). Each NCPT term were linked to the most precise ICF-Dietetics category. An added ICF-Dietetics category was assigned in case a more precise specific dietetic category compared to the original ICF was available. If an NCPT term comprised more than one concept, every single concept was linked to the ICF-Dietetics, meaning that one NCPT term could be linked to more than one ICF-Dietetics category.
      b In addition to the ICF-Linking Rules,
      • Cieza A.
      • Fayed N.
      • Bickenbach J.
      • Prodinger B.
      Refinements of the ICF Linking Rules to strengthen their potential for establishing comparability of health information.
      the closeness of the match in respect of comparable concepts was described by using “same,” “similar,” “broader” and “narrower,” adopted from Zielstorff and colleagues
      • Zielstorff R.D.
      • Tronni C.
      • Basque J.
      • Griffin L.R.
      • Welebob E.M.
      Mapping nursing diagnosis nomenclatures for coordinated care.
      : Same: The term in the NCPT is nearly identical in wording and underlying concept to the ICF term. Similar: The term is comparable: or “alike in substance.” Broader: The term is larger in scope, or less specific, or can be considered to encompass the term in the ICF. Narrower: The term is smaller in scope, or more specific, or can be considered to be encompassed by the ICF term.
      c According the ICF-Linking Rules, concepts that could not be linked to an ICF-Dietetics category and that were clearly not personal factors were assigned “not covered (nc).” If the information of the NCPT term was not sufficient to make a decision about the most precise ICF-Dietetics component, the concept was assigned “not definable (nd).” If the NCPT term referred to a medical diagnosis or a health condition according to the ICD-10, it was assigned “health condition (nc-hc).”
      d RGV=Dutch Dietary Guidelines: Making sure that nutritional intake is optimum for the person, which usually means that the nutrition complies with the RGV or Dietary Reference Values established by age category.
      e In contrast to the previous versions of the ICF-Linking Rules,
      • Cieza A.
      • Geyh S.
      • Chatterji S.
      • Kostanjsek N.
      • Üstün B.
      • Stucki G.
      ICF linking rules: An update based on lessons learned.
      it is recommend now to use “other specified” categories (ending with the digit “8”). Experience has shown that not using “8”-categories leads to lost information. Therefore, the authors of the ICF-Linking Rules
      • Cieza A.
      • Fayed N.
      • Bickenbach J.
      • Prodinger B.
      Refinements of the ICF Linking Rules to strengthen their potential for establishing comparability of health information.
      suggest now, if a concept is linked to an “8”-category, the additional information not specified within the ICF should be documented along with the ICF category. Furthermore, it must be mentioned that the ICF-Dietetics is used in combination with other classifications, such as the Classifications of Assistive Products. This makes it possible to define the specific type of protein (such as gluten or amino acids) and fat (such as saturated fat).
      f BMI=body mass index; calculated as kg/m2.

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