Victorian ADIME/IDNT Working Party Version 3: May 2014 Facilitator Notes Prior to presenting to your group, print out the final slide in A4 size and use this for your participants worksheet. It is recommended not to print out the presentation for use during the presentation The presentation will provide 1 refresher example for your participants and then proceed with case example. The presentation is designed so that your participants complete the diagnosis section first followed with a discussion about the most appropriate diagnosis to use. The completion of the PES statement should only be completed after this discussion. Victorian ADIME/IDNT Working Party Version 3: May 2014

Food Intolerance (FODMaPs) Presented by Victorian ADIME/IDNT Working Party Version 3: May 2014

Refresher Example of PES Statement Excessive energy intake (NI-1.5) related to frequent consumption of large portions of high-fat meals as evidenced by average daily energy intake exceeding recommended amount by 2000kj & 6kg gain during the past 18 months Victorian ADIME/IDNT Working Party Version 3: May 2014

Food Intolerance (FODMaPs) Nutrition Assessment (A) 36 year old male referred for diet advice to assist with management of irritable bowel syndrome (IBS) Medical/Clinical: Normal gastroscopy and colonoscopy whilst consuming gluten Reported symptoms include abdominal pain, bloating, flatulence and frequent loose bowel motions ( ~ 6 per day) Has not previously undergone any nutrition elimination diet or food challenges Patient unable to identify trigger foods, states reacts to everything Positive hydrogen breath tests for fructose, lactose and sorbitol Anthropometry: Ht: 175cm Wt: 75kgs BMI: 24.5kg/m2 Weight has been stable for years Biochemistry: Nil significant Victorian ADIME/IDNT Working Party Version 3: May 2014

Food Intolerance (FODMaPs) Social: Lives with wife. No children. Works full time as a barrister Frequency of bowel motions is affecting his work Runs for ~30 minutes 3-4 times per week. Diet: Consumes wheat based breakfast cereals, bread and pasta, onion in pasta sauces/casseroles and stock, 600ml fruit juice per day and chews sugar free gum. Eats pears and apples regularly. Uses full cream dairy in latte, no yoghurt. Irregular meal pattern – often misses lunch 1-2 x coffees per day ETOH – 1 x glass of wine with the evening meal Victorian ADIME/IDNT Working Party Version 3: May 2014

Victorian ADIME/IDNT Working Party Version 3: May 2014 Using the nutrition diagnosis reference sheet Identify possible nutrition diagnoses that could fit this case study 1. ____________________________________________________________ 2. ____________________________________________________________ 3. ____________________________________________________________ 4. ____________________________________________________________ 5. ____________________________________________________________ Learners should find at least 9. Victorian ADIME/IDNT Working Party Version 3: May 2014

All Possible Diagnoses Excessive bioactive substance intake (specify) (NI 4.2) Less than optimal intake of types of carbohydrate (specify) (NI – 5.8.3) ie: fructose, lactose, sorbitol Less than optimal intake of types of proteins or amino acids (specify) (NI 5.7.3) Food and Nutrition knowledge deficit (NB – 1.1) Inconsistent Carbohydrate Intake (NI-5.8.4) Altered Gastrointestinal (GI) function (NC-1.4) Inadequate Carbohydrate Intake (NI-5.8.1) Undesirable food choices (NB-1.7) Victorian ADIME/IDNT Working Party Version 3: May 2014

Victorian ADIME/IDNT Working Party Version 3: May 2014 Key Diagnoses Most appropriate diagnoses for this case study: Less than optimal intake of types of carbohydrate (specify) (NI – 5.8.3) ie: fructose, lactose, sorbitol Food and Nutrition knowledge deficit (NB – 1.1) Altered Gastrointestinal (GI) function (NC-1.4) Victorian ADIME/IDNT Working Party Version 3: May 2014

Other diagnosis’s and reason/s why you might not use them: Excessive bioactive substance intake (NI-4.2) - FODMaPs are not bioactive substances Less than optimal intake of types of proteins or amino acids (specify) (NI-5.7.3) – FODMaPs are not protein or amino acids Inconsistent Carbohydrate Intake (NI-5.8.4) – has to do with blood glucose levels Inadequate Carbohydrate Intake (NI-5.8.1) – lower intake of carbohydrate compared to reference standards Undesirable food choices (NB-1.7) – has to do with inconsistency in regards to dietary reference intake standards Victorian ADIME/IDNT Working Party Version 3: May 2014

Based on the above case study write 2 to 3 possible PES statements ___________________ as related to E:______________________________ _________________as evidenced by S/S:_____________________________ ______________________________ Victorian ADIME/IDNT Working Party Version 3: May 2014

Evaluating your PES Statement When developing your PES statements, think about the following: { } can the dietitian resolve the nutrition diagnosis? { } if tossing up between 2 diagnoses, attempt to select the INTAKE domain first { } is the aetiology the “root cause” (ask “but why”) { } will measuring the ‘signs and symptoms’ tell you if the problem is resolved? { } are the signs and symptoms specific enough that you can measure them?   Victorian ADIME/IDNT Working Party Version 3: May 2014

Victorian ADIME/IDNT Working Party Version 3: May 2014 PES statement 1 Less than optimal intake of types of carbohydrate (NI – 5.8.3) ie: fructose, lactose and sorbitol related to new diagnosis of fructose, lactose and sorbitol malabsorption based on hydrogen breath tests as evidenced by GIT symptoms - abdominal pain, bloating, flatulence and frequent loose bowel motions ( ~ 6 per day) and positive intake of fructose, lactose and sorbitol containing foods Victorian ADIME/IDNT Working Party Version 3: May 2014

Victorian ADIME/IDNT Working Party Version 3: May 2014 PES statement 2 Food and Nutrition knowledge deficit (NB – 1.1) related to no previous education or understanding of the details of sugar malabsorption required for a low FODMaP diet as evidenced by patient unable to identify foods high in fructose, lactose and sorbitol and such foods being present in diet history. Victorian ADIME/IDNT Working Party Version 3: May 2014

Victorian ADIME/IDNT Working Party Version 3: May 2014 PES statement 3 Altered Gastrointestinal (GI) function (NC-1.4) related to malabsorption of fructose, lactose and sorbitol as evidenced by positive hydrogen breath tests indicating fructose, lactose and sorbitol malabsorption, GIT symptoms - abdominal pain, bloating, flatulence and frequent loose bowel motions ( ~ 6 per day) and positive intake of fructose, lactose and sorbitol containing foods Victorian ADIME/IDNT Working Party Version 3: May 2014

If NO Hydrogen breath tests? Unable to make a diagnosis on the initial consultation. In this case it would be a ‘suspected diagnosis’ which can be confirmed on review consultations. Victorian ADIME/IDNT Working Party Version 3: May 2014

Victorian ADIME/IDNT Working Party Version 3: May 2014 References PES FAQ and Terminology IDNT Edition 3, v4, Nutrition and Dietetics Department, Princess Alexandra Hospital, Queensland Victorian ADIME/IDNT Working Party Version 3: May 2014

Case Study Newly Diagnosed fructose, lactose and sorbitol malabsorption referred for diet advice to assist with management of irritable bowel syndrome (IBS) Medical/Clinical: Normal colonoscopy and gastroscopy whilst consuming gluten Positive hydrogen breath tests for fructose, lactose & sorbitol Reported symptoms include abdominal pain, bloating, flatulence & frequent loose bowel motions (~6 per day) Anthropometry: Ht: 175cm Wt: 75kgs BMI: 24.5kg/m2 Weight has been stable for years Biochemistry: Nil significant Exercise: Runs for ~30 minutes 3-4 times per week Social: Lives with wife. No children. Works as a barrister Frequency of bowel motions is affecting his work Diet: Consumes wheat based breakfast cereals, bread and pasta, onion in pasta sauces/casseroles and stock, 600ml fruit juice per day and chews sugar free gum. Eats pears and apples regularly. Uses full cream dairy in latte, no yoghurt. Irregular meal pattern – often misses lunch 1-2 x coffees per day ETOH – 1 x glass of wine with the evening meal Using the nutrition diagnosis reference sheet, identify possible nutrition diagnoses that could fit this case study 1. _______________________________________________ 5. ____________________________________________________ 2. _______________________________________________ 6. ____________________________________________________ 3. _______________________________________________ 7. ____________________________________________________ 4. _______________________________________________ 8. ____________________________________________________ Based on the above case study write three possible PES statements PES Statement 1: P:__________________________________________________________________________________________as related to E:________________________________________________________________________________________as evidenced by S/S:___________________________________________________________________________________________________ PES Statement 2: PES Statement 3: A4 working sheet, write in font 12, when printing print to A4 size