Keywords

4.1 Human Nutrition and Norimasa Hosoya

At the time when we had solved the problem of food shortages and malnutrition caused by an overemphasis on staple foods, nutrition in Japan had lost direction with regard to future research, education, and practice. In other words, there were no prospects for the future. Overeating, obesity, and lifestyle-related diseases were becoming a problem due to the simplification and westernization of the diet, but these were considered to be individual lifestyle problems caused by lack of exercise and overeating, and not problems that needed to be addressed by society as a whole. By daring to call non-communicable chronic diseases “lifestyle-related diseases”, it was implied that what was wrong was “your lifestyle, not a national problem”. Although there were experts who complained about the harmful effects of obesity and lifestyle-related diseases, there were only a few who studied the subject head-on. There were also intellectuals who argued that nutrition and dietitians were unnecessary, and that qualification as a dietitian was becoming part of the tool set for brides.

It was often said in wedding speeches, “A groom who marries a dietitian will be lucky to have good food and good health.” Some of the professors who trained dietitians even said that if all housewives were qualified as dietitians, it would be possible to improve nutrition at home, thus eliminating the need for education of professionals. At the root of the low regard for the academic value of nutrition and the professional reputation of dietitians was the belief that nutrition problems were ultimately caused by poverty and food shortages, and would be solved naturally if countries became prosperous. Indeed, the world’s nutrition problems were concentrated in the developing countries of the Southern Hemisphere, where poverty was the greatest cause.

4.1.1 Diversity of Nutritional Issues

At the same time, the nutrition problem was becoming a situation that could not be solved by simple economic means alone. This is because it has become clear that, as people become more affluent, obesity due to overnutrition caused by overeating, as well as non-communicable diseases such as diabetes and cardiovascular diseases, become more frequent, which increases medical costs and affects national finances. Even in affluent Western industrialized countries, a new type of undernutrition that does not depend on food shortages is emerging among the sick, the elderly, and young women. In particular, since the 1970s, clinical malnutrition and disease-related malnutrition have become social problems in Western industrialized countries. In Japan as well, it has become apparent that some of the injured, sick, and elderly people who are admitted to hospitals and welfare facilities and who eat menus prepared by nutritionists are suffering from malnutrition. Moreover, it has become clear that if such a condition is left untreated, the effectiveness of surgery and drug therapy decreases, the level of nursing care increases, and the number of days spent in hospital increases, which ultimately increases medical and nursing care costs.

4.1.2 The Birth of Human Nutrition

Many nutrition professionals in our country were unable to find a methodology that could address the diversity and complexity of these nutritional issues. At this time, Professor Norimasa Hosoya of the University of Tokyo appeared on the scene like a savior. He was a leading researcher on the digestion and absorption of nutrients, and he argued that the issue of nutrition should be expanded from the ingestion of nutrients to the internal dynamics of the body, and that the nutrition of the human body should be comprehensively evaluated and judged using biochemical methods such as blood tests and urine tests. In other words, in order to improve human health and to prevent and treat diseases, it is necessary to clarify the internal dynamics of nutrients at the individual level, the organ and tissue level, and the cellular level, and to improve the condition of the body, which is expressed in the comprehensive concept of “Human Nutrition”. Therefore, he said that the evaluation of foods and diets should not be determined merely by the nutrient content, as in the past, but by their ability to improve nutritional status. In the case of malnutrition caused by food shortages, the risk was on the food side, and the problem could be solved by improving the food supply, food selection, and menu, etc. However, in the case of obesity, lifestyle-related diseases, and malnutrition of the injured, sick, and elderly, the risk was on the human side. Dr. Hosoya explained that we should reconsider nutrition from the human side.

4.2 Initiatives for Human Nutrition

4.2.1 Encounter with Dr. Norimasa Hosoya

I first met Dr. Norimasa Hosoya at the “Regional Workshop on Nutrition Policy and Supporting Program” held at Ewha Women’s University in Seoul in 1977 (Showa 52). two to three experts from each of a number of countries, mainly in Asia. the FDA, WHO, and UNICEF participated in the workshop, which was held for 2 weeks at the International House of the university, where attendees ate and slept. The purpose of the conference was “how to save children in Asia and Africa suffering from nutritional deficiency”, and it was the first time for me to participate in a full-scale workshop. I had to complete a grueling schedule of keynote speeches and plenary sessions in the morning, group discussions on each theme in the afternoon, and report writing from evening to midnight. Finally, exhausted by the complexity of the discussions and the stress of the English language, I ended up urinating blood. In addition to this, when I returned to my room, Dr. Hosoya came to my room every night with a glass of whiskey in his hand, and gave me a long, one-sided talk, saying, “‘Nakamura-kun , from now on, it is human nutrition.”

However, to tell the truth, I did not understand this well, because I was a novice and did not know the situation of nutrition problems and nutrition research in Japan at that time.

In the first place, nutrition is a science for human beings, and I didn’t think it was necessary to call it “human nutrition”.

However, after about 10 years, I gradually came to understand the meaning of the term “human nutrition”, which is to say that although nutrition can contribute to the maintenance and promotion of human health and to the prevention and treatment of diseases, the approach that makes this possible should be based on food and people. In other words, the conventional method of surveying diets, calculating nutrient intakes, comparing them with requirements, clarifying problems, and providing nutritional guidance is ineffective in a situation where under-eating and over-eating coexist, and where malnutrition is caused by internal factors such as disease and aging. I understood in my own way that Dr. Hosoya was arguing that we need to be closer to human beings, and that we need to construct new research, education, and practice methods for nutritional science, starting from human beings. When I told a famous scholar that it took me 10 years to understand what Dr. Hosoya was saying, he said, “That’s too soon. In general, it takes about 20 years.”

4.2.2 Overseas Training

In order to learn more about human nutrition, there was a time when I went to the United States and Australia every year from 1993 to 1996 with 20–30 volunteers led by Dr. Hosoya. We visited and trained at the Ohio State University, Stanford University, California State University Sacramento], the University of Minnesota, the Mayo Clinic, the University of Sydney, and so on. During this training, I learned that research and education in nutrition is [are] conducted in the biochemistry and public health departments of medical schools, and that dietitians work not in kitchens and offices but in hospital wards, where they are trained as medical professionals in the same way as doctors, nurses, and pharmacists. The dietitians in the wards were practicing and researching clinical nutrition in cooperation with other professions. At each training site, a mountain of materials was handed out and the study was hard, but it was fresh and shocking.

Dr. Hosoya and I shouted, “This is a black ship coming to the Japanese nutrition world.”

4.2.3 From Nutritional Requirements to Dietary Intakes Standard

I attended an impressive symposium at the International Congress of Nutrition held in Montreal in 1997. There was a bold proposal from the U.S. and Canada to revise the then existing “Nutritional Requirements” and to establish a universal “Dietary Reference Intake” . At the symposium, there was a lively discussion on the significance and methods of the proposal. Six months later, Dr. Hosoya invited Dr. Vernon Young, who was the chairman of the “Review Committee on the U.S. Dietary Reference Intakes”, to Japan, and a closed meeting was held with a small number of participants. Conventional nutrient requirements were recommended to prevent nutrient deficiencies, but the problem of over-nutrition and over-consumption of nutrients from supplements had emerged, and the necessity of establishing reference values that could be adapted to prevent both deficiencies and excesses was discussed. However, since it is difficult to determine appropriate reference values for individuals or a limited group of people, it was proposed that the reference values should be based on scientific evidence and estimated to reduce the risk of deficiency or excess. This is the origin of the current “Dietary Reference Intakes for Japanese”.

At this conference, Dr. Young made a memorable statement. “There are many eminent nutritionists in the world, each an expert in his or her own nutrient, but none have been able to answer the basic question, ‘What should we eat and how much? This is a major question for future nutritional research.”

4.3 Inauguration of the “Committee to Study the Role of Dietitians in the 21st Century”

In Japan, as in Europe and the United States, the need for research and education centered on human nutrition has gradually spread, and people who share this philosophy have emerged, giving rise to new academic societies.

In 1980 (Showa 55), “The Japanese Society for Clinical Nutrition” was founded mainly by physicians, and the following year, in 1981 (Showa 56), “The Japanese Clinical Nutrition Association” was founded based on the collaboration between physicians and dietitians who actually take charge of clinical nutrition. On the other hand, in the surgical field, studies on nutritional supplementation associated with surgical intervention began, and in 1998 (Heisei 10), the “Japanese Society for Parenteral and Enteral Nutrition (JSPEN)” (At present, Japanese Society for Clinical Nutrition And Metabolism) was established. In 1998, the “Japan Society for Metabolism and Clinical Nutrition” was established based on internal medicine.

4.3.1 The Need for Clinical Dietitians

The doctors and dietitians who had received training in Europe and the United States strongly felt the need to establish a system of clinical dietitians stationed in hospital wards as in Western countries, and took every opportunity to gather information from Europe and the United States and to hold repeated training sessions to educate and enlighten the public in Japan. At conferences, we presented invited lectures by clinical dietitians from abroad We set up the “Nutrition Therapy (NT) Study Group”, mainly in Tokyo and Osaka, and repeated study sessions at a pace of once a month. In the study group, we referred to the core curriculum of the American Society for Parenteral & Enteral Nutrition (ASPEN) for Nutrition Support Dietetics. This text was used as a reference (Photo 13). Based on this text, the first book on human nutrition written in Japanese, “Clinical Nutrition Management,” was published. (Photos 4.1 and 4.2).

Photo 4.1
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Textbook for Nutrition Support Dietetics in the USA. (Gottschlich et al. 1993)

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Photo 4.2
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Textbook for Nutrition Therapy Study Group. (Hosoya and Nakamura 1997)

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Research and training in nutrition and nutritional supplementation methods began to be carried out mainly by the Nutrition Therapy Study Group. In the course of these discussions, it was suggested that dietitians should be in charge of cooking, menu planning, and general nutritional guidance, and that the position of clinical dietitian to provide nutritional management and advice based on the assessment and evaluation of the nutritional status of patients.

From September 2 to 4, 1994 (Heisei 6), volunteers gathered at Akane-so, Ministry of Health and Welfare, under the title of “Study Group on the Clinical Dietitians System”, and held discussions for 3 days and nights (Photo 15). The members who gathered were people who had trained in the US and Australia, members of the NT Study Group, those who were actively engaged in clinical nutrition activities, and also registered dietitians in the U.S. who had studied in the U.S. and were engaged in clinical nutrition work. Dr. Hosoya and the author took the lead in preparing a preliminary draft of the “Clinical Dietitians System” and published it in “Nutrition Japan, 37(12), extra issue” (Photo 4.3).

Photo 4.3
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Akane-So meeting where the clinical dietitian system was discussed (September 1994)

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Photo 4.4
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“Nutrition Japan”, in which the clinical nutritionist system was published (vol. 37, no. 12, 1994)

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Dr. Hosoya requested the board of directors of The Japanese Society of Clinical Nutrition to establish “Clinical Dietitian” as a qualification system certified by the society. However, the discussion at the board meeting was confused, and in the end, it was adjourned because it was not possible to summarize the various opinions. This was because the board members did not understand the significance of creating the specialization of clinical dietitians and the nature of their work. The directors at that time were physicians and scholars who had academic interests in nutrition in the fields of physiology, biochemistry, cardiology, maternal and child health, pediatrics, metabolism, surgery, etc. It seems that they did not fully understand the significance of nutrition therapy and the training of professionals in clinical practice. Some people thought that it was not the job of academic societies to train professionals because nutrition research in Japan was mainly focused on agriculture and home economics. Dr. Yuichiro Goto, former president of Tokai University, who was the chairman of the study committee, Dr. Hosoya, and I were disappointed that our dream had ended in a mirage. However, now that I think about it, it is an undoubted fact that this kind of movement was the catalyst for the subsequent Law Reform 2000, and the members who participated in this movement became the leaders of human nutrition and clinical nutrition in Japan.

When discussing the clinical dietitian system, one of the topics that came up frequently was the role and duties in clinical practice. If we were to do the same thing as before, that would not be considered clinical work, and there would be no need to create a new qualification. Training that does not have specific duties and roles is at high risk of falling behind, as was the case with the “National Training Seminar on Pathological Nutrition” that we conducted previously. As a result of our discussions, we arrived at the concept of “nutritional management based on the evaluation and determination of the nutritional status of patients”. The term nutritional management has been used in hospital food service, but this was the management of nutrients contained in the menu. The new clinical nutrition management was defined as nutritional management to improve the nutritional status of human beings, and its goal was to implement nutrition therapy, nutritional supplementation, and also nutritional education in order to improve the nutritional status of the subject. This was the exact embodiment of human nutrition.

This led us to the conclusion that the first thing we needed to learn in the future was “Nutritional Assessment”, which is the evaluation and assessment of nutritional status. Around 1993 (Heisei 5), several volunteers from the Ministry of Health, Labor and Welfare, the National Institute of Nutrition, and St. Marianna University School of Medicine started a voluntary study group. The content of the study was to decipher Rosalind Gibson’s thick “Principles of Nutritional Assessment”. I remember reading the book with excitement, as it opened up a new world of nutrition that I had never encountered before. In fact, the members of this group became the key players behind the Law Reform 2000. Using Gibson’s book as a reference, I published Japan’s first review on “Nutritional Assessment” in “Nutrition and Dietary Life Information”, the journal of the Nutrition Guidance Institute of the Japan Dietetic Association. I argued that the new role and duties of dietitians were to assess and judge nutritional status comprehensively, not only from the nutrient intake from the diet, but also from the body composition, clinical examination, and self-perceived symptoms.

4.3.2 Proposal of the Committee

Against this background, in 1997 (Heisei 9), the Ministry of Health, Labour and Welfare established the “Committee to Study the Role of Dietitians in the 21st Century” (Chairperson: Norimasa Hosoya). At this time, I remember Dr. Hosoya saying happily, “The Japanese Society of Clinical Nutrition has abandoned us, but the Ministry of Health, Labour and Welfare is going to create clinical dietitians.” Representatives from a variety (Table 4.1) of fields participated in the committee, and after 1 year of extensive discussions, the following recommendations were made.

Table 4.1 List of the committee to study the role of dietitians in the twenty-first century
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“Measures against lifestyle-related diseases have become a major health issue for the nation. In order to prevent the onset and progression of lifestyle-related diseases, it is important to improve dietary habits. And nutritional guidance requires a high level of expertise and skills based on nutritional assessment and evaluation. However, current registered dietitians are mainly involved in food service management, and few are involved in nutritional management for injured and sick patients based on nutritional evaluation and assessment. In Europe and the United States, registered dietitians are positioned as specialists in nutrition for people who suffer from chronic diseases and other illnesses, from prevention to treatment, so it is necessary to comprehensively review the role of registered dietitians in Japan.”

In other words, before creating clinical dietitians, in order to rebuild the dysfunctional clinical nutrition system, registered dietitians should be educated and trained based on human nutrition, and their role should be to improve the nutritional status of humans, and their methods should include interpersonal work that introduces a management system. The study specifically concluded that it is necessary to introduce nutrition care management to improve the nutritional status of subjects with diverse and complex nutritional needs by assessing and evaluating nutritional status, planning and implementing appropriate diet, nutritional supplementation, and nutrition education, and monitoring and reassessing the results.

4.4 Innovations After the Law Reform 2000

As the study committees continued to discuss the issue, we wondered how best to frame the dietitian system, and furthermore, since the Dietitian Act was a parliamentary law, how to persuade parliamentarians to approve it as well. The Japan Dietetic Association was also involved in a number of discussions. Many parliamentarians and administrative officials helped in the revision of this law. In particular, I will never forget the presence of Takumi Nemoto, Deputy Minister of Health, Labour and Welfare (Minister of Health, Labour and Welfare from 2018). We consulted with him many times and he organized the requests from the Dietitians’ Association and the issues related to the system, which were presented as the “Nemoto Memo” on July 16, 1999. After consulting with legal experts, he said that this would be a good idea.

“Nemoto Memo”

July 16, 1999

  1. 1.

    Since the introduction of dietitians in 1962

    Licensed nutritionist, registered dietitian

  2. 2.

    The role of the dietitian and the requirements for licensure have since become social realities appropriate for licensure

    1. ①

      Individual, interpersonal and professional nutritional guidance has replaced group meal guidance

    2. ②

      The work of the dietitian will have an exclusive effect on the business

      Nutritional guidance fee by dietitian can be calculated from the medical service fee

    3. ③

      Passing the national examination is now required to become a registered dietitian

  3. 3.

    Uncertainty about the scope of work is eliminated

  4. 4.

    Growing discrepancy between directions and reality, resulting in social confusion

In other words, the amendment aimed to clarify the duties of registered dietitians, to change the system from “registration” to “license”, and to increase the effectiveness of individual and personal nutrition guidance. In order to do this, it was now essential to have education and training based on human nutrition and to pass a national examination. All of this was made possible by the “Law Reform 2000”.

On July 21, 1999 (Heisei 11), the General Conference on the Reform of the Dietetic Act was held at the Hotel Okura in Tokyo, with delegations from each prefecture. The venue was filled with about 500 participants, and almost all the Diet members came to greet the participants and expressed their support for the revision of the Dietitians Act (Photo 4.5).

Photo 4.5
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General Conference on the Reform of the Dietetic Act at Hotel Okura, Tokyo (July 21, 1999)

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On March 15, 2000 (Heisei 12), The Dietitians Act was debated in the House of Representatives‘Committee on Health and Welfare in the 147th Diet, following a report by the Committee to Study the Role of Dietitians in the twenty-first century. (Table 4.2). On April 7, the 147th ordinary session of the Diet approved a partial amendment to the Dietitians Act [effective 1 April 2002 (Heisei 14)].

Table 4.2 Proposed amendments to the Dietitians Act
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The profession of dietitian was changed from a registration system to a licensing system, the qualifications for taking the examination were reviewed, and the new definition and duties of dietitians were clarified (Table 4.3). The conventional cooking, menu planning, and general nutritional guidance are [now] performed by dietitians, while nutritional management and guidance based on the evaluation and assessment of the nutritional status of the patient are performed by registered dietitians. The work at hospitals and other facilities centered on food service management has evolved into comprehensive clinical nutrition management, including not only food service management but also nutritional supplementation using catheters. The curriculum for training dietitians was also completely revised, and emphasis was placed on medical education in physiology, biochemistry, anatomy, pathology, and clinical nutrition.

Table 4.3 Definition of a registered dietitian
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4.4.1 From the Nutrition Improvement Act to the Health Promotion Act

In 2002 (Heisei 14), the “Nutrition Improvement Act” was amended to [into] the “Health Promotion Act”. The Health Promotion Act focuses on measures to prevent lifestyle-related diseases, and nutrition issues are dealt with as part of comprehensive health promotion, including exercise, smoking cessation, and stress management. Under the Health Promotion Act, specified food service facilities must have a registered dietitian, and facilities other than specified food service facilities must also endeavor to have a registered dietitian. In these standards, the importance of assessment of nutritional status and of quality control of meals based on nutritional assessment of the subjects was described in accordance with the purpose of the revision of the Dietitian Act (Table 4.4).

Table 4.4 Nutrition management standards in the enforcement regulations of the health promotion act
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4.4.2 Changes in Dietetic Work

The role of registered dietitians in medical and welfare care has changed dramatically since the “Amendment of the Dietitians Act 2000”. Nutritional management in hospitals and welfare facilities has changed from the nutritional management of menu preparation to the nutritional management of injured and sick patients. In other words, the role of nutrition management in hospitals and welfare facilities has changed from the regulation of energy and nutrients contained in food to the management of nutrition to improve the nutritional status and health of people.

Conventionally, hospital food was categorized into special treatment food and general food. Special treatment food was prepared based on the doctor’s dietary prescription for each patient, and general food was prepared by considering hospitalized patients as a group, calculating the weighted average recommended nutritional amount based on the characteristics of the group, preparing a menu that met the amount, and providing food using a group cooking method.

In addition, even for patients who were eligible for therapeutic diets, the nutritional reference amount was intended for the treatment of diseases, and the diets were provided without sufficient consideration for the nutritional status of the patients. Therefore, patients whose nutritional needs increased due to the stress of the disease became undernourished as a result of the therapeutic diet, and their taste buds changed as a result of the symptoms of the disease or the side effects of the [drop] drugs, and patients with reduced appetites left food uneaten, further worsening their nutritional status. In other words, the food service system in hospitals and welfare facilities at that time was not designed to improve the nutritional status of the injured, disabled, or individual patients. As a result, various types of malnutrition appeared, and this led to a decline in the quality of medical care and nursing care.

In order to solve these problems, “additional nutrition care management” by dietitians was approved for the first time in 2005 (Heisei 17) in long-term care insurance. This achievement was developed into the “additional fee for nutrition management” for medical care in the 2006 (Heisei 18) revision of medical fees. Although nutritional management is necessary for all inpatients, at the time, only a few dietitians had mastered the techniques of clinical nutritional management, and therefore reimbursement was granted only when it was implemented. In 2012 (Heisei 24), the “additional fee for nutrition management” was abolished and nutrition management was included in the calculation requirements of the basic hospitalization fee.

In other words, clinical nutrition management now became mandatory for all hospitalized patients.

4.4.3 Launch of the NST

In 2010 (Heisei 22), “Nutritional support team: NST” was approved for acute stage patients with injuries and illnesses for which nutritional management is difficult for dietitians alone, through multidisciplinary cooperation. The concept of team care was not limited just to nutritional management, but also extended to the treatment of bedsores, diabetes, kidney disease and cancer. In the area of health care, guidance for high-risk individuals in terms of preventing lifestyle-related diseases, in other words, measures against metabolic syndrome, was launched in 2008 (Heisei 20) as a specific health checkup and specific health guidance, in which registered dietitians participated together with doctors and public health nurses.

In just the 10 years after the Law Reform 2000, registered dietitians were placed in all fields of health care (primary prevention), medical care (secondary prevention), and welfare (tertiary prevention) (Fig. 4.1). In a sense, a brand design for “Japan Nutrition” has been created. The Law Reform 2000, which required the development of nutrition policy based on human nutrition, was a major change in the education, work, and social evaluation of dietitians. It was also a major project that put our nutrition on a par with that of Western countries. Human nutrition has also influenced public nutrition, applied nutrition, and nutrition education since then.

Fig. 4.1
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The mission of the registered dietitian

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4.5 Nutrition Management and Nutrition Care Process

The development of human nutrition has shown that the assessment of nutrition in the clinical field is not only a matter of developing a diet for an individual disease and assisting drug or surgical therapy. It has become clear that improving the nutritional status of the injured and sick can improve the therapeutic effect of drugs and surgical treatment, reduce the exacerbation of disease and the appearance of complications, decrease days of hospitalization, and reduce the increase in medical and nursing care costs. Traditionally, nutrition management in hospitals was limited to the management of hospital food, and the aim of this management was to ensure that the nutrients contained in the food were properly controlled, and that [drop] nutrition management was part of food service management. In other words, the nutritional status of each hospitalized patient was not assessed and judged before meals were served. Nutrition management was not designed to improve the nutritional status of patients.

4.5.1 Introduction of the NCP

Starting in 1990, there was a worldwide debate on the significance and methods of nutritional status assessment, determination, nutritional supplementation, and team care, and the question of the need for clinical nutrition management was raised. However, the methods differed among medical institutions and countries, and confusion continued. Under these circumstances, standardization of nutrition management was considered. In 1998, Polly Fitz, president of the American Academy of Nutrition and Dietetics (AND), established the Task Force on Nutrition Management in Health Services Research and began a full-scale study of nutrition management in 2001. In 2003, the AND formally decided to introduce the Nutrition Care Process (NCP) based on the results of the study and published the results in its journal.

The NCP is a “quality nutrition management system” for improving human nutrition and consists of the following:

  1. 1.

    Nutrition Assessment

  2. 2.

    Nutrition Diagnosis

  3. 3.

    Nutrition intervention

  4. 4.

    Nutrition Monitoring and Evaluation

In other words, the cycle begins with the evaluation and determination of the nutritional status of the subject, the formulation and implementation of an intervention plan, the monitoring and reevaluation of the results, and the continuation of further intervention. In Japan, this method was also introduced and developed as “nutritional care management” in the revision of long-term care insurance in 2005 (Heisei 17).

4.5.2 Proposals for International Standardization

AND proposed further international standardization of the NCP in 2005, and held the International Meeting on Standardized Language for Dietetics at AND headquarters in Chicago on August 23–24 of that year (Photo 4.6). The members of the meeting consisted of representatives from the United States, Canada, Israel, Australia, the United Kingdom, and Japan, and the present author participated in the meeting. At the conference, active discussions were held on the medical system, the situation of hospital food and nutrition management, implementation methods, education and training systems, as well as the nutritional status and nutritional problems of each country. Among these topics, a lot of time was spent on the introduction of “nutritional diagnosis”.

Photo 4.6
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Member of the international meeting on standardized language for dietetics

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The reason for this was that in many countries, there is a strong perception that “diagnosis” is an act that only doctors are allowed to perform because it involves responsibility for treatment methods, and there was a opinion in countries other than the United States that we should proceed with caution. I also talked about the current situation in Japan, and promised for the time being to publish a translation of the textbook used in the U.S. instead of introducing the NCP immediately. In the end, it was agreed that a symposium on NCP would be held at the ICD in Yokohama in 2008, and that the participating countries would work to educate and promote NCP in their respective countries, with the International Federation of Dietitians at the core.

4.6 The Significance and Methods of Nutritional Diagnosis

The Nutrition Care Process (NCP) is a systems approach to providing quality nutrition care and is a standardized framework of how to manage nutrition. In implementation, it is created for each individual subject and not all patients/clients will receive the same nutrition and diet therapy. It is necessary to take into account the individual needs and characteristics of the patient/client, and to base the treatment on scientific evidence, and the key to this is the Nutrition Diagnosis.

4.6.1 Definition of a Nutritional Diagnosis

Nutrition diagnosis is the diagnosis of a subject’s nutritional status based on the nutritional assessment and the identification of specific issues that should be resolved or improved by nutritional intervention. In other words, while the nutritional assessment evaluates each of the following items: food/nutrition history, biochemical data, medical tests, procedures, physical measurements, physical signs, and treatment history, the nutritional diagnosis is a comprehensive evaluation and judgment based on the individual evaluations of the nutritional assessment. For example, just as a physician comprehensively evaluates each patient’s interview, physical signs, subjective symptoms, and clinical examination, and finally diagnoses the disease as “〇〇 disease”, nutritional diagnosis aims to express the nutritional status in a single word using standardized criteria. Just as there are international diagnostic standards for diseases, it can be said that nutritional diagnosis has created international standards for determining nutritional status. In this way, interprofessional variation in nutritional management can be minimized, and the condition of the patient can be instantly understood by hearing the diagnosis, and nutritional issues that need to be resolved can be objectively determined.

It is important to note that a nutritional diagnosis is not the same as a medical diagnosis performed by a physician. In other words, a nutritional diagnosis is a diagnosis of a condition or phenomenon that is limited to the nutritional domain, and is based on the assumption that it can be improved by nutrition therapy intervention. For example, “energy/protein deficiency” or “beriberi” is a diagnosis of disease made by a physician, but a nutritional diagnosis is a diagnosis of nutritional status. When there is an insufficient intake of energy, protein, or vitamin B1, and the nutritional status can be expected to improve by increasing the intake of the nutrient, the nutritional diagnosis is “energy/protein deficiency” or “vitamin B1 deficiency”.

AND has developed diagnostic criteria for 70 different types of nutrition problems, and the diagnostic criteria consist of the following three items:

  1. ①

    Intake: Excessive or inadequate intake of food or nutrients compared to actual or estimated requirements

  2. ②

    Clinical nutrition: nutrition problems related to pathological conditions and physical conditions

  3. ③

    Behavior and environment: knowledge, attitudes, and beliefs of the subject, the environment surrounding the body, access to food, and food safety issues.

4.7 Writing Nutritional Diagnoses and Nutritional Interventions, Development of Monitoring

4.7.1 PES and Nutritional Diagnosis

Nutrition diagnosis is described by the standardized PES method: P (Problem or Nutrition Diagnosis Label) indicates the problem or nutrition diagnosis and what the patient or client needs in order to improve,;E (Etiology) indicates the causes and triggers that worsen the nutritional status,; and S (Signs/Symptoms) are the symptoms and signs of the subject and are the data in the nutrition assessment that are essential to the nutrition diagnosis (Table 4.6). The nutritional assessment is included in the S and the nutritional diagnosis is made by comprehensively evaluating these items. The nutritional diagnosis can be described in one sentence, “Based on the evidence of [S], [E] is the cause, the nutritional diagnosis is [P]”. If expressed in this way, medical personnel can commonly understand the basis for the nutritional diagnosis and the factors that worsened the nutritional state, can recognize the contents of the most important nutritional disorder for nutritional management, and can implement high priority nutritional management.

For example, if a patient has lost weight due to a decrease in intake, a nutritional assessment will show that “the patient has a low eating rate and has lost 5 kg of weight over the past 4 weeks”. However, this does not allow us to know “what caused the decrease in intake”. In other words, an intervention plan cannot be established at this point. In the PES description, S is the nutritional assessment, E is the cause or trigger, and P is the nutritional diagnosis.

The nutritional diagnosis could be listed as “NI-2.1 Inadequate Oral Intake”. The full description by the PES would be “due to an average 30% decrease in eating rate and 5 kg weight loss over 4 weeks (S), a decrease in appetite resulting from ill-fitting dentures and constipation (E), Inadequate oral intake (P).” (Tables 4.5 and 4.6)

Table 4.5 Nutrition diagnosis items
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Table 4.6 Nutrition Diagnosis
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4.7.2 Nutritional Interventions

The next step in the process, “nutritional intervention,” is to develop a nutritional plan on how to modify and improve the diet and nutritional support to solve E. There are two types of nutritional plans: a therapeutic plan and an educational plan, and it is necessary to develop an appropriate nutritional intervention according to the condition and needs of the subject (Table 4.7). The nutrition plan consists of four components: ① food and nutrition provision, ② nutrition education, ③ nutrition counseling, and ④ coordination of nutrition care.

Table 4.7 Notes on the development of nutritional intervention plans
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4.7.3 Monitoring and Re-assessment

The final process, monitoring or reassessment, is to evaluate whether or not the Ss on which the nutrition diagnosis was based have improved. In other words, the symptoms/signs and laboratory tests used in the nutritional assessment are evaluated to determine the extent to which these have changed as a result of the nutritional intervention. In this case, it is important to quantify the subject’s improved status. If the monitored items have improved, it can be determined that the nutritional treatment has been implemented as planned, and the causes and factors that worsened the nutritional status have improved. However, if they have not improved, the reasons why they have not improved should be re-examined, and the initial process should be returned to and re-assessed. In this case, if the nutritional assessment, which was the basis for the nutritional diagnosis, is improving, but the cause is not improving, then the treatment plan in the nutritional intervention is inappropriate and a change in the plan should be considered. In this way, the nutritional status is gradually improved by rotating the management cycle, which is a method of clinical nutrition management.

4.8 Dr. Hosoya’s Last Message

In April 2016 (Heisei 28), 16 years after the Law Reform 2020, there was a workshop on the future of practical activities in clinical nutrition, organized by the Japanese Society for Clinical Nutrition. Prior to the workshop, a special lecture was given by Dr. Hosoya (Photo 4.7). He asked the participants if he could sit because of the burden on his legs due to his advanced age, and I operated the Power Point beside him. He said, “The research and practice of clinical nutrition in our country are lagging internationally, and we have not yet caught up. Those concerned must make greater efforts.” Surprisingly, in the latter half of his talk, he suddenly stood up and leaned forward, and remained standing until the end of his talk. The participants were so overwhelmed by the power of his speech that they were all speechless, and the hall was enveloped in silence for a moment, with no one asking any questions or expressing any opinions.

Photo 4.7
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The last lecture by Dr. Norimasa Hosoya

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Four months after this lecture, Dr. Hosoya suddenly passed away. Looking back, this lecture was the last message from Dr. Hosoya who kept shouting “Let’s bring nutrition back to human beings”, and if an extraordinary nutritionist named “Hosoya Norimasa” had not appeared in Japan in the latter half of the twentieth century, the Japanese nutrition world would have sunk like a leaky boat. During his lifetime, I heard criticism and complaints from him about the politics the government, academic societies, and individuals every week, and sometimes I was fed up with them.

Now that I think about it, I wonder if this is a sign that the reform was so difficult and, in fact, is still unfinished.

Unlike the time when we aimed to revise the law, today the social evaluation of nutrition is incomparably higher, and its academic reputation, the environment for research and education, as well as the role of the profession, have been improved. However, what we must not forget is that this situation was made possible by the many sleepless nights and efforts of many of our predecessors. If we do not know the history, we cannot see the problems of the present, and we cannot open the way to the future.