Potential Implementation of Nutrition-Focused Physical Examination (Nfpe) in Indonesia

PERCEPTION STUDY OF DIETITIANS, NUTRITION STUDENTS, AND EDUCATORS: POTENTIAL IMPLEMENTATION OF NUTRITION-FOCUSED PHYSICAL EXAMINATION (NFPE) IN INDONESIA

A thesis submitted to the Kent State University College of Education, Health, and Human Services in partial fulfillment of the requirements for the degree of Master of Science

Yosephin A. Pranoto

May 2019

Thesis written by

Yosephin A. Pranoto

M.S., Kent State University, 2019

Approved by

______, Director, Master’s Thesis Committee Karen Lowry Gordon

______, Member, Master’s Thesis Committee Natalie Caine-Bish

______, Member, Master’s Thesis Committee Tanya R. Falcone

Accepted by

______, Director, School of Health Sciences Ellen Glickman

______, Dean, College of Education, Health and James Hannon Human Services

iii

PRANOTO, YOSEPHIN A., RD, May 2019 Nutrition

PERCEPTION STUDY OF DIETITIANS, NUTRITION STUDENTS, AND EDUCATORS: POTENTIAL IMPLEMENTATION OF NUTRITION- FOCUSED PHYSICAL EXAMINATION (NFPE) IN INDONESIA (93 pp.)

Director of Thesis: Karen Lowry Gordon, PhD, RD, LD

Objective- To determine the perception of potential implementation of NFPE in

Indonesia on dietitians, nutrition students, and educator.

Sample- A convenience sample of dietitians, nutrition students, and educators in

Indonesia.

Instrument- An electronic questionnaire with 31 questions including demographic data, five points Likert scale perception responses, and one open-ended question were used for this study.

Statistical analysis- Demographic data was summarized and presented in table of distribution frequencies, perception data from all three groups of participant were summed and then averaged. To test the hypothesis, simple ANOVA was used with significance level of P ≤ 0.05.

Outcomes- The average perception score for dietitians, students, and educators was

4.14, 4.13, and 4.24 respectively (i.e. A score of five being the most positive). The scores fell between the statement of “agree” and “strongly agree”. Dietitians, nutrition students, and educators in Indonesia have a statistically similar perception score regarding the potential implementation of NFPE (p=0.118). The top five potential barriers listed from participant’s answers are: inter-professional collaboration in clinical settings, lack of prior education and training about NFPE, limited availability

of tools and resources to perform physical examination on patients, patients trust towards dietitian, and the high workload of a dietitian.

Conclusion- There were no statistically significant difference between dietitians, nutrition students, and educator on their perception of potential implementation of

NFPE in Indonesia. While initiating the NFPE education and training in both clinical settings and academic fields, several potential barriers also need to be addressed.

ACKNOWLEDGEMENTS

For there is nothing that I achieved until this day will ever be possible without the blessing of God Almighty and the support from:

Dr. Gordon, Natalie, and Tany. Thank you for saying yes since day one on my idea and for believing in this passion and dreams of mine: to bring something home, something for my country, Indonesia.

My dearest parents, Lorensius Hardi Pranoto and BR. Diah Utari. I know it is not easy to let this culprit flew across the universe by herself, but it is always your prayer that keeps me safe and fueled with courage to do this adventure. My sister Maria Anindita Pranoto, my little brother Emanuel Hardanto Pranoto, and my brother-from-another-parents Bonaventura A. A. Tresadi. Thank you all for filling my part of duties in our family while I am away. You guys with all of our furry-gang made it possible for me to achieve this milestone.

My best friend and forever the better part of me: Lady Anjani. Thank you for always believing in me and stand by my side for the ups and downs.

Leonardus Aviandika H. Pramana. Thanks to you I got to see myself in a different way that I may never think of. It warms my heart every time I realize I will never have to go on this adventure alone anymore 

My partners in crime and the best sisters: Fabiola Lopez and Tam Nguyen. Thank you for this togetherness and all the moments we have shared! What a blessing to have you two since day one here in the U.S.!

The Kent family (that made my transition went smoother than I can ever imagine): Jillian Machamer; Walter and Gen Davis; The Frank’s and Grammy + Papa; my favorite girls Lavisha Singh and Wafa Al Awaisi; my Indonesian folks Mbak Noor, Mbak Susi and Family, Mbak Alice, and the whole Permias Kent gang! Thank you and thank God I have you all here at Kent!

My Fulbright family. Thank you for all the adventures we got to spend together. Especially for my favorite Mendocina, Marisol Masso! It has been the best experience in my life to be part of you all. I will always treasure each one of you in my heart.

My forever inspiration, my one and only grandma: Eyang Uti. My big family and their constant prayers and support for me. The Martini’s and The Pranoto’s. I am so sorry I missed a lot of big moments these past two years, but I know we are always close by heart.

***

Last but not least, for each and every one of you that I cannot mention by names. Thanks for your friendship, prayers, and support, it’s truly saved me from all the obstacles that I had to conquer. You know who you are. Thank you!

TABLE OF CONTENTS

Page ACKNOWLEDGEMENTS ………………...……………………………….……… iv

LIST OF TABLES ……………………...………………………….………………. vii

CHAPTER I. INTRODUCTION ………………………………………………….………....… 1 Overview of Literature ……………...……….…………..………………….…… 1 Statement of The Problem ……………...…………………..……………….…… 3 Purpose Statement ………...………...…………………..…….…………….…… 4 Null Hypotheses ……………...……………..……………………...……….…… 5 Operational Definitions …...…...... …………..……………………..……….…… 5

II. LITERATURE REVIEW …....…………………..………………...……….…… 6 Malnutrition …...…………………………..……………………...………....…… 6 Prevalence of Malnutrition ...….…………..……………………...……….…… 6 Risk and Consequences of Untreated Malnutrition …………...... ……….…… 7 Malnutrition Criteria …...………………………………………...……….…… 9 Nutritional Screening and Assessment Tools …..…………………..…………… 10 Available Tools to Assess Malnutrition …....….………………..……….…… 11 Dietary Assessment …....…………………..….………………...……….…… 12 Laboratory Values …...……………………..…………………...……….…… 13 Body composition …...…………………..……………………...……….…… 15 Malnutrition Screening/Assessment Tools In the Developing Countries .…… 17 Nutrition-Focused Physical Examination (NFPE) ………...……………….…… 18 NFPE Strength and Benefit ..…………...……………………………...……… 19 Procedure of NFPE ..…………………...……………………………...……… 19 Guidelines for NFPE ..…………………...…………….……………...……… 21 Nutrition Field in Indonesia ..……………………..……………………...……… 22 The Field of Study/Education System ………………..….…………...……… 23 Accreditation and Licensing of Dietitians ………………..…………...……… 24 Clinical Application/Scope of Pratice of Nutrition in the United States ..….…… 26 The Implementation of NFPE ..………………...………………………...……… 27 In The United States (U.S.) ..…………………..……………………...……… 28 Perception of Dietitians ..……………………………………………...……… 29 Perception of Other Health Providers ..…..…………………………...……… 29 Potential Implementation in Indonesia ..……………………………...……… 30 Rates of Deficiencies/Toxicities ..…………...………………………...……… 31 Barriers of NFPE Implementation ..…………………………………...……… 32

III. METHODS ..………………...……………………..…………………...……… 34 Overview ..……………………………..…………..…………………...……… 34 Sample ..………………………………..…………..…………………...……… 34 Survey Development ..…………………………………..……………...……… 35 Procedures ..………………………………………..…………………...……… 36 Data Analysis ..……………………...……………..…………………...……… 37

IV. JOURNAL ARTICLE..…………………………………..………………...…… 38

Introduction ..………………….…………………..…………………...……… 38 Methodology..……………………………………..…………………...……… 42 Research Sample ………………………………..…………………...……… 42 Instrument of Measurement ……………………..………...………....……… 42 Procedures ………..……………………………..…………………...……… 43 Data Analysis …….……………………………..…………………...……… 44 Results ..…………………….……………………..…………………...……… 45 Demographics ………………………………..…………………...……… 45 Perception ……….…………………………..…………………...……… 46 Potential Barriers …………...………………..…………………...……… 46 Discussion ..……………………...………………..…………………...……… 52 Limitations ..………………………………..……..…………………...……… 56 Applications ..……………………………………..…………………...……… 57 Conclusion ..………………………………..……..…………………...……… 58

APPENDICES ..…………………………………..……….………………...……… 60 APPENDIX A. PERCEPTION OF DIETITIANS, NUTRITION STUDENTS, AND EDUCATORS TOWARDS NFPE QUESTIONNAIRE ………………...……… 61 APPENDIX B. TRANSLATED VERSION OF QUESTIONNAIRE (BAHASA ...INDONESIA) ………………………………………………....…..…………...…. 69 APPENDIX C. E-MAIL COVER LETTER OF QUESTIONNAIRE …...….…… 78 APPENDIX D. E-MAIL REMINDER …………………..…….………....………. 80

REFERENCES …...…...………………………………..……………...……...……. 82

LIST OF TABLES

Table Page

1. Academy/A.S.P.E.N. malnutrition characteristics …………………………...… 22

2. The Demographic Data of Study Participants Surveyed on Perception Study of

Nutrition-Focused Physical Examination Implementation in Indonesia …...... 47

3. The Average Perception Score of Nutrition-Focused Physical Examination

(NFPE) Among Dietitians, Students, and Educators in Indonesia …………..… 48

4. The Differences in Average Perception Score of Nutrition-Focused Physical

Examination (NFPE) Among Dietitians, Students, and Educators in Indonesia..52

5. Potential Barriers of NFPE Implementation in Indonesia based on Participants

Answer on the Open-Ended Question ……….………………………...………. 53

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CHAPTER I

INTRODUCTION

Overview of Literature

The prevalence of malnutrition in a hospital setting worldwide is between 30-

55% (Barker, Gout & Crowe, 2011). Both in developed and developing countries, the prevalence of malnutrition is high. Therefore this issue remains as a health problem that needs to be addressed. In the United States (U.S.), a developed country, the malnutrition prevalence is between 33-53% (Corkins, Guentes, DiMaria-Ghalili,

Jensen, Malone & Miller, 2013). In a developing country like Indonesia, the malnutrition rate is even higher at 45-75% (Subagio, Puruhita & Kern, 2016).

Malnutrition will result in a decrease of the immune system, slower wound healing and muscle wasting (Barker, Gout & Crowe, 2011). Furthermore, malnutrition in hospitalized patients has been associated with a longer hospital stays, which leads to a higher medical cost when compared with well-nourished patients (Curtis, Bernier,

Jeejeebhoy, Allard, Duerksen, Gramlich & Keller, 2017). It is vital to identify and document malnutrition as part of nutrition practice in a clinical setting in order to prevent further decline of a patient’s nutritional status (Modarski & Hand, 2018).

Nutrition-focused physical examination (NFPE) is a thorough assessment method performed by Registered Dietitian (RDs) to investigate the physical sign of malnutrition on patients. This method involves fundamental techniques of a physical exam such as inspection, palpation, auscultation, and percussion (Desjardins, Brody &

Touger-Deker, 2018). Since 2003, components of NFPE started to be incorporated in

2 the nutrition care process and in 2012, it was officially included in the standard of practice for RDs in the U.S. (Touger-Decker, 2006). Performing this physical examination in a clinical setting is an important part of assessment of nutritional status while providing convenient data to inform prognosis, further monitoring and intervention aspects of nutrition-related disease progression (Madden & Smith, 2016).

The implementation of NFPE by dietitians in the U.S. is based on the pocket guide published by the Academy of Nutrition and Dietetics. The malnutrition characteristics are defined as three main parts. The first one is a general aspect observed with an interview with the patient on energy intake and patient’s interpretation of losing weight. The next aspect includes muscle mass, body fat, and fluid accumulation status that can be obtained by performing palpation on the patient.

The third aspect is the grip strength of patient. Two characteristics from the aspects mentioned above are the minimum recommendation for diagnosis of malnutrition.

There are two classes of malnutrition defined by NFPE, non-severe/moderate and severe malnutrition (Modarski, 2017).

A developing country like Indonesia which is still facing a high rate of malnutrition might benefit from adopting NFPE. Indonesia has different conditions than a developed country like the U.S. that need to be addressed such as the socioeconomic aspects, the development of the nutrition field is standard of practice and education system. With high influence of Muslim majority in the society (87% of the population), people might not be comfortable with physical examination in general. However, malnutrition is a significant problem and, in 2007, one in three adults in Indonesia was potentially suffering from a nutritional problem (Hanandita &

Tampubolon, 2015). Furthermore, the hospitalized patients that were found to be malnourished in Indonesia directly increased the risk of morbidity and mortality 3

(Subagio, Puruhita & Kern, 2016). A study published in 2004 reported that 75% of hospitalized patients in Indonesia experienced a further decline in their nutritional status (Kusumayanti, Hadi & Susetyowati, 2004).

Professionals in the nutrition field in Indonesia should be part of the organization of Dietitian/Nutritionist in Indonesia, called PERSAGI (Persatuan Ahli

Gizi Indonesia) that maintain the importance of nutrition promotion as an aspect to gain a state of well-being for the society ("Sejarah | Persagi," n.d.). The organization that monitors and guarantee the quality of health providers in Indonesia is called

Majelis Tenaga Kesehatan Indonesia (MTKI). One of its other roles is to give registration letter/certificate for all health professionals including dietitians/nutritionists in Indonesia, especially those who works in a clinical settings and provide nutrition care for patients (Majelis Tenaga Kesehatan Indonesia (MTKI), n.d.). One way to introduce and start the implementation of NFPE in Indonesia is to incorporate all aspects of nutrition field practitioners (dietitians) and academics

(students and educator of nutrition program).

Statement of The Problem

Nutritional assessment and screening tools availability has been proven to be an important resource in dietetic practice to help them prevent and treat malnutrition

(Eglseer, et. al. , 2017). In the U. S., NFPE was developed and used by dietitians on hospitalized patients and several studies showed evidence that NFPE has many strengths and benefits when implemented and optimized by proper prior training

(Madden & Smith, 2016; Modarski, Hand, Wolff & Steiber, 2017; Desjardins, Brody,

& Touger-Decker, 2018). In a developing country like Indonesia, research and 4 development of reliable and high-quality nutritional assessment procedures are still needed to diagnose malnutrition. With a strategic approach and training for dietitians in Indonesia, NFPE may be beneficial to the nutrition field in Indonesia in general and specifically in clinical settings. However, due to the different conditions between the developed country such as the U.S. and a developing country like Indonesia, there may be barriers to the acceptance of NFPE.

There are no recent studies that can be found regarding the implementation of

NFPE in developing countries including Indonesia. The field of nutrition itself in

Indonesia was established in 2003 for an undergraduate degree (Pramono 2013).

More professionals and development in this field are still needed. Learning from previous study conducted in the U. S., several barriers exist with the use of NFPE and include the perceptions on physical assessment as the scope of practice, lack of knowledge and training, time/duration concern, and poor confidence (Modarski,

Indonesia can be formulated.

Purpose Statement

The purpose of the study is to determine the perception of dietitians, nutrition students and educators on potential implementation of NFPE in Indonesia.

Null Hypothesis

There is no difference in perception towards NFPE between students, educators and professionals in nutrition fields in Indonesia.

Operational Definitions

● Perception: someone’s understanding and representation towards specific

information or condition that are provided for them, in this study, perception

score will be measured by a five-points Likert scale in a self-administered

questionnaire

● Nutrition Student: undergraduate student in nutrition program in Indonesia

● Nutrition Educator: lecturer or teaching staff in nutrition program in Indonesia

● Dietitian: dietitian and nutritionist that provides nutrition care for patients in a

clinical setting (hospital, health clinic, private practice, and community health

center) in Indonesia

CHAPTER II

LITERATURE REVIEW

Malnutrition

Malnutrition by definition can be a state of nutrition imbalance, and can include either over or under nourished condition of someone. Usually, the over nourished case is more common in a developed country and under nourished prevalences are higher in a developing country. For malnutrition case in a hospital setting, both developed and developing countries will have a concerning rate of malnutrition cases (Barker, Gout & Crowe, 2011). This undernutrition condition is when the state of human body has undergone a lack of adequate calories, protein, or other nutrients needed to maintain and repair healthy tissues in the body (White,

Guenter, Jensen, Malone & Schofield 2012). There are several causes for malnutrition, including the deficiency of overall dietary intake, higher requirements of calories associated with diseases, complications or combinations of these factors.

Specifically, in hospital settings, the diagnosis of malnutrition usually results from a combination of malnutrition and cachexia (Barker, Gout & Crowe, 2011).

Prevalence of Malnutrition

The prevalence of malnutrition in a hospital setting worldwide is between 30-

55% (Barker, Gout & Crowe, 2011). In the US (United States) as a developed country, malnutrition prevalence in hospital setting is reported around 33-53%

(Corkins, Guenter, DiMaria-Ghalili, Jensen, Malone & Miller, 2013). However,

7 malnutrition is a significant problem in developing countries too. In 2007, one in three adults in Indonesia was potentially suffering from a nutritional problem

(Hanandita & Tampubolon, 2015). Around 45%-70% of hospitalized patients were found to be malnourished in Indonesia and this directly increased the risk of morbidity and mortality rate (Subagio, Puruhita & Kern, 2016). A study published in

2004 reported that 75% of hospitalized patients in Indonesia experienced a further decline in their nutritional status (Kusumayanti, Hadi & Susetyowati, 2004).

Risk and Consequences of Untreated Malnutrition

Malnutrition affects negatively in every aspect of life. In children, the physiological function in the body altered and resulted in the deteriorating of energy mobilization and nutrient reserves; these alterations limit the capability of body to respond to stresses such as infection. A specialized treatment and intervention are required since this issue associated with high rates of mortality and morbidity in children (Collins, Dent, Binns, Bahwere, Sadler & Hallam, 2006). During pregnancy, malnutrition or protein-calorie malnutrition can leads to lower placental weight. This placental weight decrease then also resulted in the high prevalence of low-birth- weight babies (Lechtig, Yarbrough, Delgado, Martorell, Klein & Béhar, 1975).

Moreover, on elderly population, the consequences of malnutrition result in several dysfunction of the body that directly affected daily activities, associated with the increase of complication rates, morbidity, and mortality compared with individuals with no risk/condition of malnutrition. The untreated malnutrition also account for more hospital length of stay and readmissions (Lahmann, Tannen, & Suhr, 2016).

It is common in the US for hospitalized patients (adults population) to be malnourished, and it is closely related with negative outcomes including higher 8 infection rates (Corkins, Guenter, DiMaria-Ghalili, Jensen, Malone & Miller, 2013).

Malnutrition in the human body will also result in a decrease of the immune system, slower wound healing and muscle wasting (Barker, Gout & Crowe, 2011). It is vital to identify and document malnutrition as part of nutrition practice in a clinical setting in order to prevent further decline of a patient’s nutritional status (Modarski & Hand,

2018). Moreover, malnutrition in hospitalized patients has also shown to be associated with a longer hospital stays, which leads to a higher medical costs when compared with well-nourished patients (Curtis, Bernier, Jeejeebhoy, Allard,

Duerksen, Gramlich & Keller, 2017). A significantly longer length of stay (LOS), about six days and higher costs of more than $17,000 (P < .0001) are found in patients with malnutrition diagnosis (Corkins, Guenter, DiMaria-Ghalili, Jensen, Malone &

Miller, 2013). Malnutrition can go underdiagnosed and untreated in many hospitalized patients (Tappenden, Quatrara, Parkhurst, Malone, Fanjiang & Ziegler,

2013).

Unrecognized malnutrition conditions not only increases the risk of further complications for patients but can also result in inevitably higher reimbursements to the hospital. All the issues stated previously if combined, it indirectly increases the hospital costs to treat patients. Studies in Australia, German, and The U.S. showed a similar conclusion regarding the undiagnosed and undocumented diagnosis/cases of malnutrition on a patient. This issue resulted in the increase of financial loss and decrease of the reimbursement for these hospitals (Barker, Gout & Crowe, 2011). In numbers, the under-diagnosed malnutrition patients increased the cost of more than

USD 1,600 per patient per hospital stay (Chima, Barco, Dewitt, Maeda, Teran &

Mullen, 1997). The number of researchers who have examined the relationship between malnutrition and its effect on both patients and treatment costs provide 9 evidence that malnutrition screening, assessment to develop appropriate diagnosis and later to provide appropriate treatment for patients is beneficial for both individuals and hospitals (Barker, Gout & Crowe, 2011). This documentation of malnutrition diagnosis and treatment of patients through appropriate screening and assessment steps is crucial for every stakeholder, from the patients and families, health care providers, hospital administrators to the third-party payers (Field & Hand, 2015).

Malnutrition Criteria

The European Society for Clinical Nutrition and Metabolism (ESPEN) criterion of malnutrition in adults in clinical settings is one of the following criteria:

● BMI 18.5 kg/m2

● Weight loss >10% (indefinite of time)

● Five percent weight loss (in three months) and BMI <20 kg/m2 for patients

<70 years

● <22 kg/m2 for patients 70 year

● Low FFMI of <15 and <17 kg/m2 in females and males respectively

(Cederholm, Bosaeus, Barazzoni, Bauer, Van Gossum, Klek, et al, , 2015)

A validation study towards this new ESPEN guideline reported that this new criteria guidelines can be used to detect undernutrition in a clinical setting and it is independently associated with the patient length of stay

(Guerra, Fonseca, Sousa, Jesus, Pichel & Amaral, 2017). A study conducted based on new ESPEN criterion mentioned above by Poulia et al. (2017), reported in their study of the two most used screening tools comparison, the Malnutrition Universal

Screening Tool (MUST) and NRS-2002. The study showed that MUST was better at 10 corresponding with ESPEN criteria to be used as a malnutrition screening tools in a clinical setting.

The American Society for Enteral and Parenteral Nutrition (ASPEN) criterion of malnutrition (undernutrition) for adults stated that the identification of two or more of the following six characteristics is recommended as the criteria of diagnosis:

● Insufficient energy intake

● Weight loss

● Loss of muscle mass

● Loss of subcutaneous fat

● Localized or generalized fluid accumulation

● Diminished functional status as measured by the hand-grip strength

(White, Guenter, Jensen, Malone & Schofield 2012)

Nutritional Screening and Assessment Tools

The Journal of The Academy of Nutrition and Dietetics (2015) released an article to determine the difference between nutritional screening and assessment in clinical practice. Basically, screening is to decide the risk of malnutrition while the assessment is about deciding the real presence of malnutrition (Field & Hand,

2015). A reliable tool to screen malnutrition and assess nutritional status is still needed, as stated by Van Bokhorst-de van der Schueren et al., (2014). They analyzed 20 different tools from 26 studies on long-term care facilities worldwide and all of these tools have their limitations, whether its inconsistency or the lack of power on capturing nutritional status. A predictive validity for malnutrition-related outcomes could not be found on any of the tools. Another systematic review reported 11 and emphasized a condition in European countries whereas not one single tool is proficient to provide adequate nutrition screening and assessment data likewise predicting outcomes (Van Bokhorst–de van der Schueren, Guaitoli, Jansma, & De

Vet, 2014).

Available Tools to Assess Malnutrition

A nutritional assessment tool that is widely used in the hospital setting is SGA

(Subjective Global Assessment). This assessment method determines nutritional status from physical examination findings and review of history (Detsky,

McLaughlin, Baker, Johnston, Whittaker, Mendelson, Jeejeebhoy, 1987). Based on a systematic review article, this tool is valid to define the nutritional diagnosis of hospitalized patients (clinical and surgical). It also has a potential superiority in the early detection of malnutrition (Da Silva Fink, Daniel de Mello, & Daniel de Mello,

2015). Based on SGA, in 1999, one screening tool was developed in order to provide a simple, reliable and valid source to detect the risk of adult malnutrition in hospital settings. The tool called as Malnutrition Screening Tool (MST) that consisted of two items related with patient’s appetite and recent unintentional weight loss (Ferguson,

Capra, Bauer, Banks, 1999).

Comprehensive Geriatric Assessment (CGA) is a method developed for geriatric patients that have been proven to have a positive postoperative impact for elderly that undergo an elective surgery. This assessment method evaluates and optimizes physical, psychological, functional and social issues to enhance long-term outcomes for patients. Implementation of investigations, treatment, rehabilitation and follow up will usually follow the interdisciplinary assessment by health providers

(Partridge, Harari, Martin, & Dhesi, 2013). 12

Dietary Assessment

The use of the FFQ as a reliable tool to assess nutrition supported by several studies, one of the studies conducted in Europe in 2017 showed a moderate relative validity for protein and several food groups such as fruits, egg, meat, sausage, nuts, salty snacks, and beverages (Steinemann, Grize, Ziesemer, Kauf, Probst-Hensch,

Brombach, 2017). In the same study, FFQ is shown to be a decent tool to perform a large epidemiological study (Steinemann, Grize, Ziesemer, Kauf, Probst-Hensch,

Brombach, 2017). Some limitations of FFQ are the wide variations of listed food items within the same groups. the tendency for over-reporting of a specific group can be a result of multiple items in one food group. On the contrary, single item food groups may lead to an under-reporting fallout (Steinemann, Grize, Ziesemer, Kauf,

Probst-Hensch, Brombach, 2017). FFQ in one study is report was indicated as a no better tool to show the distribution of dietary habit on individuals than another assessment method like 24 hour recalls due to the tendency of estimating frequency inaccurately (Bingham, Gill, Welch, Day, Cassidy, Khaw, Sneyd et al, 1994).

In 2007, Tucker reported the use of twenty-four-hour (24-h) dietary recall in a population study to assess dietary intake of individual and population. On this method of assessment, each person is asked by an interviewer to recall foods they consumed from the last 24-h. In most large studies in the U.S., a multiple pass system has been used. This system is an approach where participants are asked to provide names of food they have consumed the whole day. After that, they are asked to provide further detail such as: type of food, preparation method, and portion. Next thing that is asked to participant are snacks and beverages they might consume in between meals and probed with a commonly forgotten food list. The best way to collect 24-h recall data is to collect multiple days from each participant. 13

Another assessment method to estimate recent diet of someone or some group is dietary record. On this method of assessment, the participant records all the foods and beverages consumed on a list/form provided for a specific period of time. The form provided to participant should be made with effective format to provide an adequate space to record all the data. Dietary record can also be used to analyze the risk of intake inadequacy. In special occasion such as children dietary assessment, the dietary record can be filled by someone else (i.e. parent or guardian). Ideally, all the food is recorded at the time of each meal/snack time (Ortega, Perez-Rodrigo, &

Lopez-Sobaler, 2015)

According to a review on common dietary assessment methods and their feasibility in epidemiology studies, Shim, Oh, and Kim (2014) concluded that

“Dietary intake is difficult to measure, and any single method cannot assess dietary exposure perfectly”. Therefore, the use of dietary assessment methods (FFQ, 24 h recall, and dietary record) should be selected cautiously with consideration of each study objective, some of the strength of those three methods are explained below:

● 24-hour dietary recall: standardized, reduced time and cost, improve

feasibility

● Dietary record: standardized, real-time, reduce time and cost, improve

feasibility

● FFQ: complex information can be collected with high accuracy

Laboratory Values

One of the patient’s laboratory value that has been a common biomarker of nutritional status for decades is Albumin (Forse & Shizgal, 1980). Several formulas were developed by incorporating albumin value to define the nutritional status of 14 patient, including Nutrition Risk Index (NRI), Geriatric Nutrition Risk Index (GNRI), and CONUT. The NRI is calculated with simple equation incorporating serum albumin and body weight loss. There are three categories of malnutrition with the calculation of NRI score and status of not malnourished when score is >100. The three categories are mild malnourishment (97.5-100), and moderate malnourishment (83.5-<97.5), and severe malnourishment (<83.5) (Thieme, Cutchma, Chieferdecker, & Campos, 2013).

Geriatric Nutritional Risk Index (GNRI) is another tool to determine the nutritional status of the elderly patient, one of the high-risk group of population for malnutrition.

This method is measured with serum albumin and weight loss data. Those two components are strong independent risk factors for mortality in this age group

(Bouillanne, Morineau, Dupont, Coulombel, Vincent, Nicolis, Aussel, 2005). In Japan, a new assessment method called the controlling nutritional status (CONUT) score is developed to measure the prognosis of heart failure (HF) patients based on their laboratory values. CONUT score calculated from serum albumin, total cholesterol level, and total lymphocyte count which allows data of the nutritional status being evaluated from protein reserves, calorie depletion, and immune parameters. A one point increase score of CONUT was discovered to be an independent predictor of mortality and this method was found to be helpful to predict HF patient’s prognosis in a hospital setting (Nishi, Seo, Hamada-Harimura, Sato, Sai, Yamamoto, Ishizu et al,

2017). Other than albumin, C-reactive protein (CRP) may also predict malnutrition in patients with end-stage renal disease (Honda et al., 2006). A study in 2004 stated that serum ferritin concentrations were found to be higher in malnourished patients as assessed by the SGA and other similar nutritional scoring tools. Serum ferritin is a frequently used marker of iron status in dialysis patients (Kalantar-Zadeh, Rodriguez

& Humphreys, 2004). However, the current consensus regarding laboratory markers to 15 determine nutritional status is that they are not reliable by themselves and therefore should be as a complement to a thorough physical examination (Bharadwaj et al., 2016).

Body Composition

Other methods of assessing nutritional status are body composition measurement. The triceps skinfold thickness (TSF) is one of the physical assessment method to obtain body fat data from patient that has been used for a long time. The proper steps to obtain the measurement is to make sure that both observer and subject are always standing. Subjects should provide a bare upper arm area for the procedure by rolling up their sleeve and stand with the left arm hanging openly. To identify the spot of measurement, which is a posterolateral border of the left acromion, observer should palpate and later put the end of a measuring-tape against this border and run down the tape to the upper border of the olecranon. After the distance between the two points is read, the position mid-way marked with ink and then a skinfold is pulled out in the vertical plane. While holding the calipers horizontally, observer apply the center of the jaws exactly in the ink mark. The jaws then released to grip the skinfold, the forefingers released and the dial is read when the needle has stopped running. Through this number obtained then the body fat percentage can be determine (Ruiz, Colley, &

Hamilton, 1971). While the measurement made by the first step of the TSF can also be used as another nutritional status measurement called as the Mid-Arm Muscle

Circumference (MACM). There is one study supported the efficacy of the MACM measurement, with higher MACM, patient seems to have a better health status and survival (Noori et al., 2010).

According to Prado and Heymsfield (2014), assessing body composition is a valuable method that can provide vital data to support treatment decisions, prognosis 16 and quality of life in clinical and also non-clinical settings. An increased comprehension of tissue volume and mass, the quality, patterns, and functions of these parts of the human body leads to a better understanding upon its reflection on nutritional status and health risk impact. Several methods that are commonly used in clinical practice are:

Computed Tomography (CT) and Magnetic Resonance Imaging (MRI).

Two imaging methods that are considered to be the gold standard reference to

assess body composition at a tissue level. The difference between these two

methods is in how images are obtained, MRI does not use the ionizing

radiation and relies on the proton density of tissues instead. This is also why

MRI is considered to be less harmful than CT and therefore allowed whole-

body and repeated calculation to be performed.

Dual-energy X-ray Absorptiometry (DXA). This method was initially

initiated to assess the density of bone mineral and since then became the gold

standard. However, technology and software advancements have made the

DXA be able to provide an estimation of another component like fat mass

(FM) and fat-free mass (FFM). This method is also faster, more accessible

and affordable than CT and MRI.

Ultrasound Scanning (USS). The fundamental of this imaging method is the

waves of sound reflecting back from the tissue in the track of the beam. The

level of this reflection of sound depends on the acoustic impedance between

tissue bonds. Although further studies still needed to validate the use of USS

to provide body composition data in the nutrition field, its reliability to

provide information on adipose and muscle thicknesses, visceral and

subcutaneous adipose tissue differentiation has proven to be good. Another 17

strength of USS is the portability, non-invasive and fast. It is also cheaper

than other imaging techniques and the recorded data can be stored

electronically.

Bioelectrical Impedance Analysis (BIA). The basic work of BIA involves

the painless low amplitude current moving through the body and obtaining the

measurement of resistance and reactance. BIA assumes that this resistance

data is conversely proportional to Total Body Water (TBW) and electrolytes

distribution. Because of the lack of relevant clinical studies investigating the

reliability and sensitivity of BIA, the use of this method has been frequently

criticized regardless of its practicality and low cost.

(Smith & Madden, 2016)

Malnutrition Screening/Assessment Tools in the Developing Countries

One of the measurement that can be used as the criteria for malnutrition is mid upper arm circumference (MUAC). A cutoff of 23.5 cm was developed and has been used on pregnant women in several countries to predict acute malnutrition (Food and

Nutrition Technical Assistance (FANTA), n.d.). Since 1996, the measurement of

MUAC also has been used in developing countries as a screening method for underweight and to identify the preferential loss of peripheral tissue stores of fat and protein. Malnutrition grade criteria according to this measurements, for examples are:

MUAC < 200 mm for men and < 190 mm for women for grade four malnutrition,

MUAC < 170 and < 160 mm for men and women respectively for grade four. These criteria can be used for rapid screening on population/group (Ferro-Luzzi & James,

1996). 18

A validity study conducted in Vietnam shows that NRS-2002 (Nutrition Risk

Screening) is the best choice to use in Asian developing countries based on specificity and sensitivity (assessed with SGA (Subjective Global Assessment) to fulfill some criteria, such as Body Mass Index (BMI), weight loss, decreased intake, severity of disease, mobility, psychological stress, and neuropsychological problems (Tran,

Banks, Hannan-Jones, Do, & Gallegos, 2018). SGA also used in one study conducted in Indonesia along with other tools such as Body Mass Index (BMI) and dietary assessment methods just as 24-hour recall and FFQ (Kurniasari, Surono & Pangastuti,

2015). In 2017, a study conducted in Indonesia to assess the health status of older adults utilized several nutritional assessments and screening tools for their subjects such as Mini Nutritional Assessment (MNA), Malnutrition Universal Screening Tool

(MUST), MST, Short Nutritional Assessment Questionnaire (SNAQ), and GNRI.

This study also utilizes 24-hour recall and Semi-Quantitative FFQ to obtain nutrient intake data (Arjuna, Soenen, Hasnawati, Lange, Chapman & Luscombe-Marsh,

2017).

Nutrition-Focused Physical Examination (NFPE)

The establishment of NFPE in the United States started since the new malnutrition criteria by ASPEN included a proper assessment of body fat and muscle mass as identifying data to diagnose malnutrition. A step in Nutrition Care Process

(NCP) called nutrition-focused physical assessment (NFPA) is the origin of NFPE that is no longer used since the establishment of NFPE. This step has been proven as an efficient, cost-effective and easily learnable skill to inspect muscle and fat stores and patient. Not only that, but NFPA (now NFPE) can also detect edema and 19 deficiencies of macronutrients. To be able to perform this assessment, dietitians need to receive extensive training and thus they may gain more benefit for patients care

(Fischer, JeVenn and Hipskind, 2015).

NFPE Strength and Benefit

The importance of physical examination to determine body composition and morphological aspect on assessing nutritional status also shown by a review article in

2016. Madden and Smith said that this method will be able to provide prognostically data that later can be used as an opportunity to monitor the nutrition-related effects in disease progression. Moreover, looking at the importance of this procedure, an accurately followed standardized protocols can manage challenges associated with anthropometric assessment. In 2017, the Academy of Nutrition and Dietetics or “the

Academy” stated that, “after the training (of NFPE), reimbursement for malnutrition as a major comorbidity or complication was 292.3% higher than the baseline year, while it was 171.6% of the baseline year for malnutrition as a comorbidity or complication. Together this represents an increase of $57.2 million in reimbursement for the health system during the 1-year period” (Mordarski, Hand, Wolff, & Steiber,

2017).

Procedures of NFPE

To perform NFPE on someone according to the pocket guide, there are some areas that are used as the parameters to assess nutritional status. On the head area, examination is performed in the orbital region that surrounds the eye and the temple region. Next, on the upper body part examination is performed in the muscle part of clavicle bone region, acromion bone region, scapular bone region, upper arm region 20

(triceps/biceps), and thoracic and lumbar region. The next examination area are muscles on the limbs such as dorsal hand, patellar region, anterior thigh region and posterior calf region. The figure below shows the anatomical area of physical examination on NFPE.

(Figure 1. Anterior and Posterior Muscles for Inspection and Palpation Procedures in NFPE. Source: Cleveland Clinic Center for Medical Art and Photography as reprinted by Fischer, JeVenn, and Hipskind (2015))

More detection of nutrition-related signs can also be assessed by performing

NFPE on someone by examining parts of the body and looking for signs of nutrition- related condition. From the hair, signs that can be examined are alopecia (thin, sparse, and patchy), depigmentation, dryness, corkscrew hair, flag sign, and lanugo.

Inside the eyes, examination performed to find any signs of xanthelasma (small, yellowish lumps around eyes), inflammation of eyelids, pale conjunctiva, keratomalacia, and Bitot’s spot. Other facial area in general can show signs like pallorness, hyperpigmentation, enlarged parotid gland, paleness or burning on lips.

From the mouth, signs that can be examined are soreness, stomatitis, cheilitis, swollen or raw-beefy red tounge, paleness of the tounge, glossitis, gingivitis, spongy gums, dental caries, abnormal eruption on teeth, and mottling. From the neck area, enlarged 21 thyroid and goiter may also be found through examination. Beau’s lines, Muehrcke’s lines, spoon-shaped and easily split are the signs that can be examined from nails.

Finally, from the overall appearance of the skin examination can be performed to find signs of slow wound healing, psoriasis, eczema, goose flesh, oiliness, waxy, petechiae, purpura, xerosis, and perifollicular hemmorrhage (Modarski, 2017).

Guidelines for NFPE

The implementation of NFPE by dietitians in the United States (the U.S.) is based on the pocket guide published by the Academy. The Academy is the world’s largest organization of food and nutrition professionals. As shown as Table 1, malnutrition characteristics are defined as three main parts. The first one is a general aspect observed with interview like energy intake and patient’s interpretation of losing weight. The next aspect are examinations on muscle mass (temples, clavicle, shoulders, interosseous muscles, scapula, thigh, and calf), body fat (subcutaneous fat in orbital, triceps, and the ribs), and fluid accumulation (extremities, vulvar/scrotal edema or ascites) status that can be obtained by performing palpation on patient. And the third aspect is the grip strength of patient that measured with standardized device.

Two characteristics from the aspects mentioned before are the minimum recommendation for diagnosis of malnutrition. There are three groups of malnutrition defined by NFPE according to their contexts: acute illness/injury, chronic illness, and social/environmental circumstances. In between those three groups, there are two sub-classes of malnutrition: non-severe/moderate and severe malnutrition (Modarski,

2017).

Table 1. Academy/A.S.P.E.N. malnutrition characteristics Clinical Malnutrition in the Malnutrition in the Malnutrition in the Characteris context of acute illness or context of chronic illness context of social or tic injury environmental circumstances Non-severe Severe Non-severe Severe Non-severe Severe (moderate) malnutrition (moderate) malnutrition (moderate) malnutrition malnutrition malnutrition malnutrition Energy <75% of ≤50% of <75% of ≤75% of <75% of ≤50% of intake estimated estimated estimated estimated estimated estimated energy energy energy energy energy energy requiremen requiremen requiremen requiremen requiremen requiremen t for >7 t for ≥5 t for ≥ 1 t for ≥ 1 t for ≥ 3 t for ≥ 1 days days month month month month Interpretati o 1-2 % in o >1-2 % o 5% in a o >5% in o 5% in a o >5% in on of a week in a month a month month a month weight loss o 5% in a week o 7.5% in o >7.5% o 7.5% in o >7.5% month o >5% in 3 in 3 3 in 3 o 7.5% in a month months months months months 3 o >7.5% o 10% in o >10% in o 10% in o >10% in months in 3 6 6 6 6 months months months months months o 20% in o >20% in o 20% in o >20% in a year a year a year a year Physical findings Body fat Mild Severe Mild Severe Mild Severe Muscle Mild Severe Mild Severe Mild Severe mass Fluid Mild Severe Mild Severe Mild Severe accumulati on Reduced N/A Measurably N/A Measurably N/A Measurably grip reduced reduced reduced strength

(White, Guenter, Jensen, Malone & Schofield 2012)

Nutrition Field in Indonesia

The nutrition field in Indonesia started when a research on this area was

conducted around the 19th century, such as the study on cassava and sweet potato by P.

J. Maier and P. H. F. Fromberg. Another important finding is the anti-beriberi

component in rice by Eijkman and the establishment of the health laboratory on the 23 colonization era by The Dutch at that time. Continuous research was done focusing more on Indonesia food composition list (Daftar Komposisi Bahan Makanan)

(Pramono, 2013). In a developing country like Indonesia, the number of malnutrition still high and concerning (Hanandita & Tampubolon, 2015). Malnutrition status of a hospitalized patient has always shown to be associated with a worse outcome such as a longer hospital stays, which also leads to a higher cost when compared with well- nourished patients (Curtis et al, 2017).

The Field of Study/Education System

At the beginning of the independence era, health and nutrition status of

Indonesia was one of the lowest in the world as a result of a high number of child mortality, childbirth mortality for women. The founding father of nutrition in

Indonesia, Poorwo Soedarmo was assigned to lead the health and nutrition promotion program by the health ministry, and until then the field of nutrition in Indonesia was started to develop including formal education to provide professionals of health and nutrition in the country. Poorwo Soedarmo introduced the first concept of complete and balanced nutrition on a daily meal with “4 Sehat 5 Sempurna” (healthy four and perfect five) in 1952 and three years after that the nutrition science was officially included in medical faculty curriculum (Pramono, 2013).

Nutritionist education institution was established in 1956 on the vocational level

(one, two, three years vocational degree) and in 1966 was named as Nutrition

Academy (Akademi Gizi). Bachelor degree in nutrition was established around the year of 2003, pioneered by several universities such as Universitas Diponegoro

Semarang, Universitas Gadjah Mada Yogyakarta, Universitas Indonesia Esa Unggul

Jakarta, and Universitas Brawijaya Malang (Pramono, 2013). According to the 24

Indonesian nutrition higher education institution association (AIPGI), currently, there are 69 universities active with a total of 13 public universities (Asosiasi Institusi

Pendidikan Tinggi Gizi Indonesia (AIPGI), n.d.).

Role, Accreditation, and Licensing of Dietitians in Indonesia

According to the ministry of health republic of Indonesia/Peraturan Menteri

Kesehatan (PERMENKES), dietitian/nutritionist is someone who graduated from nutrition major as required by the constitution of the ministry of education. In general, the roles of dietitian/nutritionist are: providing education and counseling care of nutrition and dietetics, performing nutrition care process for patient/client on clinical settings, facilitating an education/training/development of nutrition care, and managing the food institution/production for certain group/population in big scale.

Based on their level of education, dietitians/nutritionists are qualified as four different categories. First, is they who graduated from three years advocacy program (Diploma tiga/D3) is called as intermediate level of dietitian or technician, after they passed the competency exam they received a title of technical registered dietisien (TRD). Next, is they who graduated from four years advocacy program (Diploma empat/D4) is called as the bachelor of applied nutrition science. The third one is they who graduated from the bachelor level/undergraduate (S1) degree and they are called as bachelor of nutrition. Both of those who graduated from D4 and S1 level, after they passed the competency exam will received a title of Registered Nutritionist. The fourth and the last one is they who pursued a dietetic internship and passed the competency exam are called as registered dietitian (RD). The difference between an

RD and TRD is on practical application/scope of practice. TRD scope of practice is limited to provide nutrition care on healthy population and special group like pregnant women, breastfeed mother, infants, children, adults and elderly. TRD competencies 25 are not including the nutrition care for patients with complications and they have to work under the supervision of an RD (Kementerian Kesehatan Republik Indonesia

(Ministry of Health Republic of Indonesia), 2013).

Professionals in the Nutrition field as a loyal citizen of Republik Indonesia that reposed by Pancasila and Undang-undang Dasar 1945 aware and fully responsible towards their obligations for the country. The organization of Nutritionist in Indonesia, called PERSAGI (Persatuan Ahli Gizi Indonesia) also believe that nutrition promotion is one important aspect to gain a state of well-being for the society. This organization was established on January 13th, 1957 as a non-political union for professionals in the field of health and nutrition to work together at the noble goal mentioned before ("Sejarah | Persagi," n.d.).

According to the regulation from the ministry of health republic of Indonesia

(PERMENKES), to practice and provide nutrition care to their client, dietitians must obtain a certificate of competence, SIPTGz/Surat Izin Praktik Tenaga Gizi,

SIKTGz/Surat Izin Kerja Tenaga Gizi and STRTGz/Surat Tanda Registrasi Tenaga

Gizi or a registration letter of work/ppractice for dietitian issued by Majelis Tenaga

Kesehatan Indonesia (MTKI). The MTKI is an organization that monitors and guarantee the quality of health providers in Indonesia. One of its other roles is to give registration letter/certificate for all health professionals in Indonesia that are called as

Surat Tanda Registrasi (STR) (Majelis Tenaga Kesehatan Indonesia (MTKI), n.d.).

This license and registration need to be renewed every five years. All nutrition professionals that pursue their career around the field of nutrition must obtain

STRTGz/Surat Tanda Registrasi Tenaga Gizi (registration letter) no matter where they work (private practice or in health institution). With the SIPTGz/Surat Izin

Praktik Tenaga Gizi (dietitians practice license) dietitian can open their private 26 practice/work independently or work in a healthcare institution. For those who obtain

SIKTGz/Surat Izin Kerja Tenaga Gizi (nutritionist/dietitian working permit) can work in several nutrition care settings such as health clinic, hospital, and community health center but they cannot work privately/independently (Kementerian Kesehatan

Republik Indonesia (Ministry of Health Republic of Indonesia), 2013).

Clinical Application/Scope of Practice of Nutrition in The United States

There are two types of credentialed nutrition and dietetics practitioners in the US according to the Academy, registered dietitian nutritionists (RDNs) and nutrition and dietetic technicians, registered (NDTRs). The scope of practice for RDN is based on food, nutrition, and dietetics practice, in addition to related services developed, directed, and provided by the RDN in order to protect the society in general; promotes health and well-being of individuals such as patients/clients; and provide standardized services, programs, and commodities. There are few practice components for RDNs and NDTRs, including resources, foundational, management and advancement, credentials, and education that are guided and monitored by the

Academy. The difference between RDN and NDTR is that to obtain RDN credentials, someone needs to pursue the education and other requirements enacted by

ACEND (accrediting agency for dietetics education programs) and CDR

(credentialing agency of the Academy). Once registered, RDNs are required to maintain their registration every five years by documenting their professional development portfolio to the CDR including 75 hours of sustaining education. RDNs practice within the scope of applicable laws, including: federal, state, and institution regulations and policies. In clinical settings, an RDN uses the NCP (nutrition care 27 process) to individualize their care and service for clients/patients. There are some specialty areas that offered by the CDR, such as gerontological, oncology, obesity and weight management, pediatric, renal and sports nutrition/dietetics ("Academy of

Nutrition and Dietetics: Scope of Practice for the Registered Dietitian," 2018).

Another thing that distinguished RDN and NDTR are their responsibilities, in a clinical settings NDTRs may be supervised by RDNs. RDNs are responsible on providing a Medical Nutrition Therapy (MNT). MNT is a certain application of the

Nutrition Care Process (NCP) in clinical settings that is focused on the disease management. MNT requires in-depth individualized nutrition assessment and a duration and frequency of care. The RDN is responsible for managing the overall nutrition care for patients/clients and therefore also in charge on assigning duties to others including NDTR ("Academy of Nutrition and Dietetics: Revised 2017

Standards of Practice in Nutrition Care and Standards of Professional Performance for

Dietetic Technicians, Registered," 2018).

The Implementation of NFPE

In order to practice the nutritional screening and assessment optimally regarding the attempt to prevent hospital malnutrition and its related outcomes, only validated tools should be used by dietitians. Improving the resource utilization can be done by helping dietitians and nutritionist to feel more comfortable on completing this step of screening and assessment along with their collaborative works with other health professionals such as a medical doctor (MD), registered nurse (RN) and pharmacist. Perceptions of this health providers also contribute an important effect on the clinical field and can determine the successful implementation of comprehensive 28 nutrition care for patients (Field & Hand, 2015). There is a possibility that other health providers (MD, RN or pharmacist) lack of knowledge in RDs scope of practice can stand as a barrier in clinical practice of nutrition (Modarski, Hand, Wolff &

Steiber, 2017).

To become competent in performing NFPE is required for all dietitians at every level of practice of clinical nutrition according to Touger-Decker (2006). The implementation of NFPE by Registered Dietitian (RD) can be promoted by a more intensive training while the factors that were reported as limitations are workload, time availability and lack of education and training (Stankorb, Rigassio-Radler, Khan,

& Touger-Decker, 2010). RD that received an additional NFPE training performed significantly more NFPE elements compared with those without this additional training (Desjardins, Brody, & Touger-Decker, 2018).

In The United States

The implementation of NFPE is still in an ongoing process, it is best accomplished in a collaborative way of approach in a healthcare institution. Healthcare professional’s collaboration is needed to get a successful achievement of evaluating, diagnosing, documenting and receiving aspect (Malone and Hamilton, 2013). With the training/workshop of NFPE given to RDs, a survey study reported that participants gain the following things, such as: increase of knowledge, more comfort on performance, repayment of malnutrition diagnosis

(Modarski, Hand, Wolff & Steiber, 2017).

Perception of Dietitians

RDs barriers to performing NFPE in their daily practice including the perception about NFPE that is not part of their scope of practice and the discomfort feeling to touch patients. Other reasons are the inadequate training and/or education, a concern of time and lack of confidence (Modarski et al, 2017). A qualitative study on

RDs perception conducted internationally and gave several points of conclusion including how regulation was a concern for practitioners and can actually become a solution to face discerned negativity by dietitians and RDs should be able to apply existing skills as part of their nutrition care (Abraham, Frewer, and Stewart-Knox,

2017).

Perception of Other Health Providers

To improve knowledge, attitude, and skills of health professionals an educational intervention (training) is proven to be a promising way (Beach et al,

2005). Perception can be assessed with a qualitative study followed with the transcription process to yield patterns of answers from subjects as performed by

Whitaker et al (2016) on their study towards nutrition counseling for patient and provider. A survey study in Canada conducted with a validated questionnaire to assess differences in health professionals perception and also to analyze the influencing factors of practicing family-centered care method in clinical settings. On this study, the authors concluded that one of the main barriers to implement this method is the lack of interdisciplinary collaboration (Bruce, B., Letourneau, N.,

Ritchie, J., Larocque, S., Dennis, C., & Elliott, M. R., 2002).

A study about physicians perception in Canada showed a similar result to

European physicians perceptions regarding nutrition care in clinical settings. This 30 survey study was conducted based on a developed questionnaire that focused on nutrition support guidelines for hospitalized patients. It has been exhibited that physicians feel a gap between recent nutrition care and what is considered as an optimal nutritional care. These physicians believe in the relevance and importance of nutrition care of patients in hospital settings, therefore they are also open to educational opportunities for collaborative works to provide nutritional care for patients (Duerksen, Keller, Vesnaver, Allard, Bernier, Gramlich, Jeejeebhoy et al,

2014).

In the USA, Canada, and Australia since more than a decade ago nurses already incorporated their nursing practice with physical assessment in the hospital as a component of health assessment. From an international literature, the researcher concluded that any change to the nurse’s role in health assessment, to involve physical assessment skills, depend upon strategies that involve the regulatory, educational and practice elemental of nursing. All of these components will promote health outcomes for a population that seeks health care (Lesa & Dixon, 2007).

Pharmacist perception towards physical assessment as part of their role in a hospital setting shows a promising improvement. They see the importance of their health care team to define the role pharmacist-performed physical assessment, eliminate misconceptions and cultivate collaboration (Chua, Ladha, Pammett, &

Turgeon, 2017).

Potential Implementation in Indonesia

In a hospital or clinical settings, malnutrition in adult patients continues to be unrecognized and therefore untreated. Therefore the development of nutrition screening and assessment tools to provide comprehensive data to be able to give early 31 nutrition intervention in patients is very important with the goal to reduce complication related with malnutrition, longer length of hospital stay, readmission rates, mortality and cost of care. (Tappenden, Quatrara, Parkhurst, Malone, Fanjiang

& Ziegler, 2013). There is no study performed in Indonesia regarding the application of NFPE yet.

Rates of Deficiencies/Toxicities

A systematic review reported their analysis on micronutrient intakes among community-dwelling older adults in developed Western countries. This article conclusion stated that there are six micronutrients that were considered as public health concerns, they are vitamin D, thiamin, riboflavin, Ca, Mg and Se (Ter Borg,

Verlaan, Hemsworth, Mijnarends, Schols, Luiking, De Groot, 2015). More complex condition is still happening in developing countries such as the deficiency of vitamin

A that remains to be a major public health problem. Consumption of rice in Asia provides up to 80% of daily energy intake on the community, therefore, some studies were conducted to analyze vitamin A deficiency by collecting dietary data of fortified and non-fortified rice consumption in developing countries. Data sets obtained from

Philipines and Indonesia, national surveys show that rice consumption was low however there has been speculation that underreporting might have happened as marked by the low report of energy intake of 1519 and 1147 kcal/d among women in

Philippines and Indonesia respectively (De Moura, Moursi, Angel, Angeles-Agdeppa,

Atmarita, Gironella, Muslimatun et al,, 2016).

A great concern for women in productive age in Indonesia is iron deficiency.

In underweight young women, the prevalence of iron deficiency is even greater than normal or overweight ones (Sumarmi, Puspitasari, Handajani, & Wirjatmadi, 32

2016). Another deficiency occurred in a high-risk population that can be found worldwide is the deficiency of vitamin D or as measured as 25(OH)D. A study suggested that elderly and newborns are appeared to be at a generally higher risk of lower 225(OH)D values. From stratified analyses, observation of age-related difference was prone in the Asia/Pacific and Middle East/Africa regions (Hilger,

Friedel, Herr, Rausch, Roos, Wahl, Hoffmann et al,, 2013).

Barriers of NFPE Implementation

Some internal (comes from the dietitian) barriers affected the implementation of NFPE in the United States reported in 2017 are lack of training and education, concern about duration required, poor confidence, uncomfortable feeling on performing physical examination and confusion on the scope of practice (Modarski,

Hand, Wolff & Steiber, 2017). A systematic review reported from 38 studies regarding the barriers and facilitators of shared decision making in clinical practice based on health professionals perception. In this article, three categories of barriers obtained from the studies are knowledge, attitude, and behavior while the most frequently reported facilitators were motivation and perception. Gaps of knowledge should be the focus of future work to achieve better collaboration in clinical practice

(Légaré, Ratté, Gravel, & Graham, 2008). Field and Hand (2015) also stated that other health professional’s perceptions towards RDs scope of practice can create potential barriers including their confusion of nutritional screening and assessment definitions that leads to the lack of acceptance and understanding of this process. The implementation of NFPE is still in an ongoing process, it is best accomplished in a collaborative way of approach in the healthcare institution. Healthcare professional’s 33 collaboration is needed to get a successful achievement of evaluating, diagnosing, documenting and receiving aspect (Malone & Hamilton, 2013).

CHAPTER III

METHODS

Overview

The purpose of the study was to determine the perception of potential implementation of Nutrition-Focused Physical Examination (NFPE) in Indonesia between dietitians, nutrition students and educators and analyze the difference between those groups. This was a mixed method research with cross-sectional design (survey). The independent variable for this study was the background of subjects (i.e. student, educator and dietitian) and the perception was the dependent variable. An approval for this study from the Institutional Review Board (IRB) had been obtained (IRB number: 19-049).

Sample

The sampling method that was used for the study was a convenience sampling and a snowball sampling. The inclusion criteria for the participant in general included: subject must be ≥18 years old in age and they must be a citizen of

35 like hospital, community clinic and private practice in Indonesia, participant must have a main role on their daily basis to provide nutritional care for patients.

Survey Development

An online questionnaire using Qualtrics had three main parts: demographic data, a five-point Likert scale was used to measure perception, and the last part was an open-ended question to cover the topic of potential barriers of NFPE implementation in Indonesia (Appendix A). All parts of the questionnaire were translated in Bahasa

Indonesia (the national language of Indonesia) for the convenience of study participants

(Appendix B). The first part of the questionnaire is a set of questions to obtain demographic data of the participant. There were five demographic questions about participant’s sex, age, affiliation, institution location and for students and educators, the institution status (public or private university), and also one additional data of prior education for participating dietitians. The second part of the survey was the five-point

Likert scale to assess participant’s perception regarding the implementation of NFPE in Indonesia. There were 23 questions on this part, with four general questions about nutrition care and its relation with physical assessment by dietitians, three questions regarding their comfort on performing procedures on patients, two questions of inter- professionals collaboration, three questions about nutrition-related physical sign or change on human body, one question regarding the amount of time given to perform physical examination and the last eight questions asked about their comfort of actually performing the procedures of NFPE on patient. There were also two additional questions for dietitians about the current condition of their institution and workload on the clinical setting. The last part of the questionnaire was one open-ended question to 36 cover the potential barrier of NFPE implementation in Indonesia based on participant’s opinion. The validation that was performed on the questionnaire was a face validity or a review of the questionnaire by experts on the nutrition field (Registered Dietitians at

Kent State University).

Procedures

The procedures for this study was started with the development of questionnaires and validation process. Next, a request of IRB (Institutional Review

Board) approval was submitted before the data collection was started. After the approval from IRB was obtained, data collection was done by publishing online questionnaire to targeted population by email and cross-platform messaging service.

Researcher obtained participants email from PERSAGI (“Persatuan Ahli Gizi

Indonesia” or the organization of Dietitian and Nutritionist in Indonesia) and AIPGI

(“Asosiasi Institusi Pendidikan Tinggi Gizi Indonesia” or Indonesian nutrition higher education institution association). An email with cover letter to explain the purpose of this research and to provide contact person for the participant if they had questions or any concern (Appendix C) was send to participants. An email reminder was followed every two weeks (Appendix D). Other than this publication through email, participants were recruited with snowball sampling method where an anonymous link for the online survey was passed around from one group to another through cross- platform messaging service to maximise the recruitment process based on participant’s prefered method of communication. The anonymous link to access the survey could only be filled by participant once to avoid duplication of data from the same subject. Participation in this study was anonymous and voluntary with no 37 compensation given and this term was stated on electronic consent on the beginning of the questionnaire. By clicking the electronic consent, participant agrees on terms given and they were at least 18 years of age. After four weeks of data collection process, all data were returned via Qualtrics and analyzed statistically with SPSS statistics software.

Data Analysis

All of the collected data via Qualtrics were analyzed with several methods.

For demographic data, summarization of the mean and standard deviation were provided in simple tabulation. For the five-point Likert scale on each group, every response was scored as following: “strongly disagree” is valued as one, “disagree” is two, “neutral/not sure” is three, “agree” is four, and “strongly agree” is five. From all

23 questions, the minimum possible score is 23 and the maximum possible score is

115. Participants that completed less than 90% of the questionnaire were excluded from statistical analysis. Participant scores were averaged on each group to obtain the final score. Finally, to test the hypothesis, simple ANOVA was performed with the

Statistical Package for Social Science (SPSS) version 24. All results were considered significant at P ≤ 0.05.

CHAPTER IV

JOURNAL ARTICLE

Introduction

Malnutrition in hospitalized patients worldwide remains a global health problem with the prevalence between 30-55% (Barker, Gout & Crowe, 2011). Both in developed and developing countries, the prevalence of malnutrition demonstrates a high rate. In the United States (U.S.), a developed country, the malnutrition prevalence is between 33-53% (Corkins, Guentes, DiMaria-Ghalili, Jensen, Malone &

Miller, 2013). In a developing country like Indonesia, the malnutrition rate is even higher at 45-75% (Subagio, Puruhita & Kern, 2016). Malnutrition will result in a decrease of the immune system, slower wound healing and muscle wasting (Barker,

Gout & Crowe, 2011). Furthermore, malnutrition in hospitalized patients has been associated with longer hospital stays, which leads to a higher healthcare cost when compared with well-nourished patients (Curtis, Bernier, Jeejeebhoy, Allard,

Duerksen, Gramlich & Keller, 2017). It is vital to identify and document malnutrition as part of nutrition practice in a clinical setting in order to prevent further decline of a patient’s nutritional status (Modarski & Hand, 2018).

Since 2003, Nutrition-focused physical examination (NFPE) components started to be incorporated in the nutrition care process and in 2012, it was officially included in the standard of practice for Registered Dietitian (RDs) in the U.S.

(Touger-Decker, 2006). NFPE is a thorough assessment method performed by RDs to

investigate the physical sign of malnutrition in patients. This method involves fundamental techniques of a physical exam such as inspection, palpation, auscultation, and percussion (Desjardins, Brody & Touger-Deker, 2018). Performing this physical examination in a clinical setting is an important part of assessment of nutritional status while providing convenient data to inform prognosis, further monitoring and intervention aspects of nutrition-related disease progression (Madden

& Smith, 2016).

The implementation of NFPE by dietitians in the U.S. is based on the pocket guide published by the Academy of Nutrition and Dietetics (Modarski, 2017). The malnutrition characteristics are defined as three main parts. The first one is a general aspect observed with an interview with the patient on energy intake and patient’s interpretation of losing weight. The next aspect includes muscle mass, body fat, and fluid accumulation status that can be obtained by performing palpation on patient.

And the third aspect is the grip strength of patient. Two characteristics from the aspects mentioned above are the minimum recommendation for diagnosis of malnutrition. There are two classes of malnutrition defined by NFPE, non- severe/moderate and severe malnutrition (Modarski, 2017).

A developing country like Indonesia that is still facing a high rate malnutrition might benefit from adopting NFPE. Indonesia has different conditions that a developed country like the U.S. that need to be addressed such as the socioeconomic aspects, the development of nutrition field standard of practice and education system.

With high influence of Muslim majority in the society (87% of the population), people might not be comfortable about physical examination in general. However, malnutrition is a significant problem and, in 2007, one in three adults in Indonesia

was potentially suffering from a nutritional problem (Hanandita & Tampubolon,

2015). Furthermore, the hospitalized patients that were found to be malnourished in

Indonesia directly increased the risk of morbidity and mortality (Subagio, Puruhita &

Kern, 2016). A study published in 2004, reported that 75% of hospitalized patients in

Indonesia experienced a further decline in their nutritional status (Kusumayanti, Hadi

& Susetyowati, 2004).

Professionals in the nutrition field in Indonesia should be part of the organization of Dietitian/Nutritionist in Indonesia, called PERSAGI (Persatuan Ahli

Gizi Indonesia) that maintain the importance of nutrition promotion as an aspect to gain a state of well-being for the society ("Sejarah | Persagi," n.d.). The organization that monitors and guarantees the quality of health providers in Indonesia is called

Majelis Tenaga Kesehatan Indonesia (MTKI). One of its other roles is to give registration letter/certificate for all health professionals including dietitians/nutritionists in Indonesia, especially those who work in clinical settings and provide nutrition care for patients (Majelis Tenaga Kesehatan Indonesia (MTKI), n.d.). One way to introduce and start the implementation of NFPE in Indonesia is to incorporate all aspects of nutrition field practitioners (dietitians) and academics

(students and educator of nutrition program).

Nutritional assessment and screening tools availability has been proven to be an important resource in dietetic practice to help them prevent and treat malnutrition

(Madden & Smith, 2016; Modarski, Hand, Wolff & Steiber, 2017; Desjardins, Brody,

& Touger-Decker, 2018). In a developing country like Indonesia, research and development of reliable and high-quality nutritional assessment procedures are still needed to diagnose malnutrition. With a strategic approach and training for dietitians in Indonesia, NFPE may be beneficial to the nutrition field in Indonesia in general and more specifically in clinical settings. However, due to the different conditions found between a developed country such as the U.S. and a developing country like

Indonesia, there may be barriers to the acceptance of NFPE such as the culture or socioeconomic condition.

There are no recent studies that can be found regarding the implementation of

NFPE in developing countries including Indonesia. The field of nutrition itself in

Indonesia was established in 2003 for an undergraduate degree (Pramono 2013).

More professionals and development in this field are still needed. Learning from a previous study conducted in the U. S., several barriers exist with the use of NFPE and including the perceptions on physical assessment as the scope of practice, lack of knowledge and training, time/duration concern, and poor confidence (Modarski,

Hand, Wolff & Steiber, 2017). Before NFPE can be introduced in Indonesia, evaluation of students, educators and professionals in the nutrition field on NFPE should be determined, therefore, the strategy to initiate the implementation of NFPE in Indonesia can be formulated. The primary purpose of the study was to determine the perception of dietitians, nutrition students and educators on potential implementation of NFPE in Indonesia.

Methodology

This study was a quantitative research with cross-sectional design (survey). The independent variable for this study was the background of subjects (i.e. student, educator, and dietitian) and perception was the dependent variable. An approval for the proposal of this study from the Institutional Review Board (IRB) was obtained

(IRB number: 19-049).

Research Sample

The sampling method that was used for the study was convenience sampling and complemented by snowball sampling. The inclusion criteria for the participant in general included: subject must be ≥18 years old in age and they must be a citizen of

Indonesia. For participating students, they must be currently enrolled in a nutrition program for an undergraduate degree in a university in Indonesia. For participating educator, they must be currently employed and teach in a nutrition program in a university in Indonesia. For participating dietitian or nutritionist in clinical settings like hospital, community clinic and private practice in Indonesia, participant must have a main role on their daily basis to provide nutritional care for patients.

Instrument of Measure

An online questionnaire using The Qualtrics XM (version 3) had three main parts: demographic questions, perception questions, and an open-ended question on the potential barriers of NFPE implementation in Indonesia. All parts of the questionnaire were translated in Bahasa Indonesia (the national language of Indonesia) for the convenience of study participants. The first part of the questionnaire was a set of questions to obtain demographic data of the participant. There were six demographic

questions about participant’s sex, age, affiliation, institution location and for students and educators, the institution status (public or private university), and also one additional question on prior education for participating dietitians. The second part of the survey was the five-point Likert scale to assess participant’s perception regarding the implementation of NFPE in Indonesia. There were 23 questions in this section, with five general questions about nutrition care and its relation with physical assessment by dietitians, four questions regarding their comfort on performing procedures on patients, two questions on inter-professionals collaboration, three questions about nutrition-related physical sign or change on human body, one question regarding the amount of time given to perform physical examination, and eight questions asked about their comfort of actually performing the procedures of NFPE on patient. The last two questions asked about comfort on performing NFPE based on patient’s gender. There were also two additional questions for dietitians about the current condition of their institution and workload in the clinical setting. The last part of the questionnaire was one open-ended question to cover the potential barrier of NFPE implementation in Indonesia. The validation that was performed on the questionnaire was a face validity or a review of the questionnaire by experts on the nutrition field

(Registered Dietitians at Kent State University).

Procedures

The procedures for this study was started with the development of questionnaires and validation process. A request of IRB (Institutional Review Board) approval was submitted before the data collection was started. After the approval from IRB was obtained, data collection was completed by publishing an online questionnaire using the Qualtrics XM (version 3) to the targeted population by email

and cross-platform messaging service. The data collection process from the online survey was started on February 4, 2019 and closed on March 4, 2019. The researcher obtained participants’ email from PERSAGI (“Persatuan Ahli Gizi Indonesia” or the organization of Dietitian and Nutritionist in Indonesia) and AIPGI (“Asosiasi Institusi

Pendidikan Tinggi Gizi Indonesia” or Indonesian nutrition higher education institution association). An email with cover letter to explain the purpose of this research and to provide contact person for the participant if they had questions or any concern (Appendix C) was sent to participants. An email reminder was followed every two weeks (Appendix D) for. Participants were also recruited with a snowball sampling method where an anonymous link for the online survey was passed around from one group to another through a cross-platform messaging service to maximize the recruitment process based on the participant’s prefered method of communication.

The anonymous link to access the survey could only be used by the participant once to avoid duplication of data from the same subject. Participation in this study was anonymous and voluntary with no compensation given and this term was stated on electronic consent on the beginning of the questionnaire. By clicking the electronic consent, the participant agreed on terms given and agreed they were at least 18 years of age. After four weeks of the data collection process, all data were returned via

Qualtrics and analyzed statistically with SPSS statistics software (version 24).

Data Analysis

All of the collected data via Qualtrics XM (version 3) were analyzed with several methods. For demographic data, summarization of the mean and standard deviation were provided in simple tabulation. For the five-point Likert scale on each group, every response was scored as following: “strongly disagree” was valued as

one, “disagree” was two, “neutral/not sure” was three, “agree” was four, and “strongly agree” was given a score of five. From all 23 perception questions, the minimum possible score was 23 and the maximum possible score was 115. Participants that completed less than 90% of the questionnaire were excluded from statistical analysis.

Participant scores were averaged for each group (i.e. Student, educator, and dietitians) to obtain the final score. Finally, to test the hypothesis, a simple ANOVA was performed with SPSS (version 24). All results were considered significant at P ≤

0.05.

Results

In exactly one month period of data collection process, total participants obtained for the study were 520 responses. Out of this number, 370 participants agreed to participate in the study. Fifty three participants were excluded from the analysis because they did not fall within the inclusion criteria. From the remaining

317 valid responses, fourty four participants answered less than 90% of the perception score part (Likert scale) and therefore also were excluded from the data analysis, leaving the total number of subjects used in the investigation to 273 participants.

Demographics The overall demographic of the study participants can be seen in Table 2. The majority of the participant were female (91%) and the largest group were nutrition students (42.3%) followed by dietitian (33.7%) and educator (24%) respectively.

Participant’s age ranged from 18 to 53 years old with the average of 25.08 ± 5.62

years old. The main location of participants’ institution located in the most populated area in Indonesia, the Java Island (298 participants). Most participating students and educators were from a public university (68%) and only 63 participants (32%) were from private university. For participating dietitians, more than half of them had a bachelor degree as their prior education (50.9%) followed by an advocacy degree

(42.1%).

Perception

The perception score was assessed by a five-point Likert scale and is highlighted in Table 3. In the section of general nutrition care as a nutrition professional, the perception score of all three groups were above four or in other words dietitians, students, and educator in Indonesia were all between “agree” and

“strongly agree” towards the statements regarding nutrition care practice. Moreover, on the statement about their willingness to update the knowledge and skills to provide the best nutrition care for patients all three groups show a high average score that potentially provide a great opportunity in the future work.

Simple ANOVA analysis (Table 4) showed no significant difference between three groups of participants. With the average perception score of 4.16 out of maximum five means that dietitians, students and educator in nutrition field in

Indonesia have a positive perception at the potential implementation of NFPE.

Potential Barrier

From the open-ended question on the end of questionnaire, 218 (79.9%) participants answered this question and the result of this qualitative data demonstrated

Table 2 The Demographic Data of Participants Surveyed on Perception Study of Nutrition-Focused Physical Examination (NFPE) Implementation in Indonesia N= 370

Demographic n %

Sex (n=370) Female 337 91 Male 33 9 Affiliations (n=317) Dietitian 107 33.7 Student 134 42.3 Educator 76 24 Location of Institution (n=364) Java Island 298 81.9 Sumatera & Kalimantan Island 42 11.5 Other Islands 24 6.6 Type of Institution/University (n= 197)* Public 134 68 Private 63 32 Prior Education (n=114)** Advocacy degree 48 42.1 Bachelor degree 58 50.9 Dietetic Internship 5 4.4 Master’s degree 3 2.6

Note: data obtained from all responses on the beginning of survey (before exclusion of <90% completion on perception questions part) *for students and educators only **for dietitians only

Table 3 The Average Perception Score of Nutrition-Focused Physical Examination (NFPE) Among Dietitians, Students, and Educators in Indonesia N= 273 Mean ± SD Statements Dietitians Students Educators (n=98) (n=114) (n=61) General nutrition care I believe that the nutrition care should 4.61 ± 0.53 4.71 ± 0.46 4.70 ± 0.49 be based on the best interest for patient I believe that as a nutrition 4.86 ± 0.61 4.89 ± 0.31 4.87 ± 0.46 professionals, I need to update my knowledge and skills to provide the best nutrition care for patient I am willing to do an extra 4.90 ± 0.30 4.69 ± 0.46 4.89 ± 0.32 training/workshop to learn a new method in clinical nutrition field I believe that physical assessment is 4.38 ± 0.67 4.36 ± 0.58 4.44 ± 0.37 part of dietitian/nutrition scope of practice in clinical setting Comfort and confidence on performing procedures I believe that I can introduce and 4.23 ± 0.70 4.21 ± 0.62 4.20 ± 0.65 explain the procedure that I am going to do to patient clearly I believe that I can assure my patient 4.45 ± 0.63 4.48 ± 0.67 4.51 ± 0.59 that it is very important for me to obtain data as complete as possible to provide the best nutrition care for them I will be comfortable performing 4.43 ± 0.79 4.39 ± 0.76 4.66 ± 0.51 physical examination on patient if I received prior training and education about it

I believe that other health 4.62 ± 0.60 4.55 ± 0.61 4.64 ± 0.63 professionals (i.e. medical doctor/registered nurse/pharmacist) positive perception and knowledge about my scope of role will give me more confidence to perform a physical examination on patient Nutrition-related physical sign/change I believe that physical sign of 4.57 ± 0.64 4.45 ± 0.70 4.70 ± 0.46 nutrition-related medical disease progress is important to be documented I believe that physical sign of 4.56 ± 0.61 4.42 ± 0.68 4.67 ± 0.54 malnutrition or intoxication from any nutrient is important to be documented I believe that a change in physical 4.50 ± 0.50 4.37 ± 0.57 4.52 ± 0.54 condition have a strong relation with nutritional status of patient Time given to perform physical examination on patients I am more comfortable if I have 4.39 ± 0.62 4.19 ± 0.68 4.36 ± 0.77 enough time to perform a physical examination on every patient during my working hour

Table 3 (continued) The Average Perception Score of Nutrition-Focused Physical Examination (NFPE) Among Dietitians, Students, and Educators in Indonesia N= 273 Mean ± SD Statements Dietitians Students Educators (n=98) (n=114) (n=61) Comfort on performing NFPE procedures I will feel comfortable to touch 3.37 ± 0.79 3.59 ± 0.81 3.87 ±0.81 (palpate) the orbital area of my patient to examine the status of fat loss I will feel comfortable to touch 4.06 ± 0.69 4.12 ± 0.60 4.10 ± 0.75 (palpate) the upper arm region (triceps/biceps) of my patient to examine the status of fat loss I will feel comfortable to touch 3.59 ± 0.85 3.51 ± 0.79 3.69 ± 0.90 (palpate) the thoracic and lumbar region (ribs, lower back, midaxillary line) of my patient to examine the status of fat loss I will feel comfortable to touch 3.43 ± 0.84 3.70 ± 0.82 3.90 ± 0.72 (palpate) the temple region of my patient to examine the status of muscle loss I will feel comfortable to touch 3.52 ± 0.80 3.64 ± 0.80 3.82 ± 0.78 (palpate) the clavicle bone region (pectoralis major, deltoid, trapezius muscles) of my patient to examine the status of muscle loss I will feel comfortable to touch 3.67 ± 0.73 3.73 ± 0.70 3.92 ± 0.80 (palpate) the scapular bone region (trapezius, suprasppinus, infraspinus muscles) of my patient to examine the status of muscle loss I will feel comfortable to touch 3.85 ± 0.75 3.85 ± 0.77 3.90 ± 0.85 (palpate) the dorsal hand (interosseous muscles) of my patient to examine the status of muscle loss I will feel comfortable to perform 4.10 ± 0.68 3.98 ± 0.68 4.07 ± 0.81 pressure on the extremities area of my patient to examine the status of edema

several potential barrier that might need to be addressed in the future on the

initiating program of NFPE in Indonesia. The barriers mentioned by the participants

can be seen in Table 5 with the top five barriers from the list, including: poor inter-

professional collaboration between health professionals in clinical settings, lack of

education and training on NFPE, availability of tools and resources needed to perform

physical assessment on patients, patients trust towards dietitians, and the workload of

dietitians.

Table 4 The Differences in Average Perception Score of Nutrition-Focused Physical Examination (NFPE) Among Dietitians, Students, and Educators in Indonesia Group Mean Std. Deviation n p Dietitian 4.14 0.35 98 Student 4.13 0.32 114 0.118* Educator 4.24 0.36 61 Total 4.16 0.34 273 *F(2, 270) = 2.158 Statistical significance was set at p ≤ 0.05

Discussion

The primary purpose of this study was to determine the difference between dietitian, student, and educator’s perception on potential implementation of NFPE in

Indonesia. Determination of these three groups perception can be used as a foundation to form an effective strategy for the initiation of NFPE implementation in

Indonesia. From the statistical analysis, it was shown that there were no significant differences on the perceptions between dietitians, students, and educators regarding the idea of starting to implement NFPE in Indonesia. Therefore, the starting point of the initiation of NFPE can potentially begin both in the clinical and academic settings.

The specific statements on the questionnaire regarding the participant’s perception towards their willingness to update the knowledge and skills through extra training and workshop to learn new methods in clinical nutrition field to be able to provide the best nutrition care for their client/patient received high average perception scores in all three groups. This data highlights a great opportunity for NFPE implementation in

Indonesia through educational platforms such as training, workshop, or even incorporating it as a part of the course in university/education institution.

Table 5

Potential Barriers of Nutrition-Focused Physical Examination (NFPE) Implementation in Indonesia based on Participants Answer on the Open-Ended Question of Questionnaire (N=218)

Barrier Factor* n

Interprofessional collaboration 83

Education and training 66

Availability of tools and resources 53

Patients trust towards dietitian 53

Workload 48

Role understanding 33

Muslim norm 18

Self confidence 13

Others 10

*Note: participant can answer more than one responses

The accessible training on NFPE will help dietitians/future dietitians to perform this assessment and then bring direct benefit on the care of their patient (Fischer, JeVenn and Hipskind, 2015).

There were two aspects of NFPE that were relatively well perceived by the participants of this study. The first one was the required examination of doing a palpation on upper arm region (triceps/biceps), and the other one was the examination

of edema status on patient’s extremities (with the exception on students group with average score of 3.98 ± 0.68). Other than those two procedures, the remaining NFPE that a dietitian have to perform on patient received lower average perception scores on the range of three point zero and three point five, or they are in between “neutral/not sure” and “agree” statement. This slightly different perceptions on performing physical examination on some areas of patient’s body may be due to the fact that

NFPE is something unfamiliar for them and this is also a new set of skills that they have to learn.

From the open-ended question at the end of questionnaire regarding participant’s opinion on potential barriers to implement NFPE in Indonesia, several aspects were mentioned, including (the top five): inter-professional collaboration in clinical settings, lack of prior education and training about NFPE, limited availability of tools and resources to perform physical examination on patients, patients trust towards dietitian, and the high workload of a dietitian. This findings are similar with a study conducted by Modarski et al in 2017 that reported some internal (comes from the dietitian) barriers affected the implementation of NFPE in the United States.

Some of the barriers are: lack of training and education, concern about duration required, poor confidence, uncomfortable feeling on performing physical examination and confusion on the scope of practice. There are several possibilities that cause those barriers that will be discussed further.

The number one potential barriers is the issue on inter-professional collaboration in clinical settings. If there is a positive collaboration of work between health providers in the clinical settings, this will also positively impact their confidence and comfort on performing nutrition care to their client/patient.

Meanwhile, in the U.S., Field and Hand (2015) also stated that other health professional’s perceptions towards RDs scope of practice can create potential barriers that leads to the lack of acceptance and understanding of this process. These particular findings are similar with the findings of Malone and Hamilton in 2013, they stated that healthcare professional’s collaboration is needed to get a successful achievement of evaluating, diagnosing, documenting and receiving aspect. This specific issue should be continuously advocated on every level (academic, clinical practice, etc.) to create a better collaboration between health providers in the future for the best interest of patients.

The third potential barrier is pointing at the limitation/poor availability of tools and resources to perform physical examination on patients. The data obtained from participating dietitians response on the last two questions also reflecting the real condition on the clinical nutrition field. Most of the dietitian stated that they workplace and workload (that is listed on number five on potential barrier list) do not positively support them to be able to provide the best nutrition care (especially physical examination) to their patients. The most possible thing to do to work on this issue is to continuously promoting the importance of dietitian’s role in the clinical setting and advocating the associated institutions to develop a better workplace with supporting resources for dietitian to provide the best nutritional care for the patients.

Even though the Muslim norm in the society was not in the top five potential barriers (it was listed number seven), this potential barriers may be affecting the practice of dietitians in clinical settings. All three groups’ average score is lower than three for “I will feel less comfortable to perform physical examination (direct skin to skin contact) to patient with the opposite sex as me” statements. On the contrary,

when it comes to performing physical examination on the same sex patient, all three groups’ average score was higher. In dietitian’s daily practice, similar problem also found in the U.S., reported by Modarski et al (2017), this study stated that the discomfort feeling to touch patients is one of the barriers to perform NFPE. The discomfort of performing physical examination for dietitians was occurred everywhere, in the U.S. and also in this study (Indonesia). In conclusion, the main barrier for NFPE implementation might be caused by the general feeling of unfamiliarity of this new regimen of examination that nutrition professionals and academia have to deal with, this can easily become the cause of discomfort feeling and less self-confidence. This new area then also resulted in less positive attitude and perception to physically assess patient directly (skin to skin). Therefore, the next step of future work should be focused on how to effectively educate and train dietitian and educator (that will educate nutrition student) to be able to finally initiated the implementation of NFPE in Indonesia.

Limitations

The main limitations that applied to this study is the time constraint. The time available for researcher to investigate this study problem and measure consistency of the collected data over time is limited by the due date of this thesis. With more time availability, more participants potentially would be recruited, especially participants that live in small islands area of Indonesia, therefore, a bigger sample size and broader geographical coverage could have been obtained. Another limitation that was faced by the researcher was the lack of prior research/studies on the targeted topic,

especially in the scope of developing country like Indonesia. This issue resulted in a least optimal formation of the basis of the literature review to have a better understanding of the problem this study was investigating.

Applications

Prior studies regarding the implementation of NFPE in Indonesia and other developing countries are currently not available even though NFPE may be beneficial to the nutrition field in Indonesia. This is what made it impossible to compare this study with others, not even with prior studies conducted in the U.S. since both countries have a different characteristics (i.e. socioeconomic status, cultural condition, etc.). This study results are the beginning of a long process to support the work of implementing a new method in the clinical nutrition field in Indonesia. Learning from previous studies conducted in the U. S., several barriers exist with the use of NFPE and include the perceptions on physical assessment as the scope of practice, lack of knowledge and training, time/duration concern, and poor confidence (Modarski,

Hand, Wolff & Steiber, 2017). A strategic approach and training for dietitians in

Indonesia can be determined through this evaluation made by dietitians as a nutrition professional, nutrition student and educator in academia that will provide future professionals in the nutrition field. Based on the result of this study, the nutrition society in Indonesia has a positive perception towards the potential implementation of

NFPE and this also point out at the great potential to initiate this new method through education and training. Finally, there is an agreement from several studies that support the general effort on increasing dietitian’s comfort on performing NFPE in the

U.S. that can also be implemented in Indonesia. Previous studies supported the fact that the increase of knowledge, attitude, skills, better comfort on performance, and repayment of malnutrition diagnosis can be obtained through training and education

(Beach et al, 2005; Modarski, Hand, Wolff & Steiber, 2017). Moreover, gaps of knowledge should also be the focus of future work to achieve better collaboration in clinical practice between health professionals (Légaré, Ratté, Gravel, & Graham,

2008). In conclusion, as the pioneer study of the complicated movement process ahead to implement NFPE in the developing countries, especially in Indonesia, the results can be passed down for future studies and investigation around this topic. The initiation of NFPE implementation in Indonesia can be started with a seminar to publish the results of this study and complemented with a training/workshop. Experts from the U.S. can also be invited to Indonesia to deliver a speech/lecture of NFPE and also to facilitate the training/workshop.

Conclusion

There are no statistically significant difference between dietitians, nutrition students, and educator on their perception of potential implementation of NFPE in

Indonesia. Dietitians, students, and educator in nutrition field in Indonesia have a positive perception at the potential implementation of NFPE. While initiating the

NFPE education and training in both clinical settings and academic fields, several potential barriers also need to be addressed, such as: inter-professional collaboration in clinical settings, lack of prior education and training about NFPE, limited

availability of tools and resources to perform physical examination on patients, patients trust towards dietitian, and the high workload of a dietitian.

APPENDICES

APPENDIX A

PERCEPTION OF DIETITIANS, NUTRITION STUDENTS, AND EDUCATORS TOWARDS NFPE QUESTIONNAIRE

PERCEPTION STUDY OF DIETITIANS, NUTRITION STUDENTS, AND EDUCATOR: POTENTIAL IMPLEMENTATION OF NUTRITION-FOCUSED PHYSICAL EXAMINATION (NFPE) IN INDONESIA

Yosephin Pranoto, RD/ Master Candidate (M. S.) in Nutrition, Kent State University

Welcome to the research study!

We are interested in understanding the perception of dietitians and nutrition students in Indonesia towards Nutrition-Focused Physical Examination (NFPE). You will be presented with information relevant to NFPE and asked to answer some questions about it. Please be assured that your responses will be kept completely anonymous.

The study should take you around 15 minutes to complete. Your participation in this research is voluntary. You have the right to withdraw at any point during the study, for any reason, and without any prejudice. If you would like to contact the Principal

Investigator in the study to discuss this research, please e-mail

Yosephin Anandati Pranoto at [email protected].

By clicking on the options below, you acknowledge that your participation in the study is voluntary, you are 18 years of age, and that you are aware that you may choose to terminate your participation in the study at any time and for any reason.

I AGREE

Brief introduction of NFPE Nutrition-focused physical examination (NFPE) is a thorough assessment method to investigate the physical sign of malnutrition on patient performed by Registered Dietitian (RDs). Since 2003, in the United States components of NFPE started to merge in the nutrition care process, but not until 2012 it was officially included in the standard of practice for RDs. This method involves fundamental techniques of a physical exam such as inspection or using the senses of sight, smell and hearing, but mostly visually examine the general appearance of the patient (appearance, behavior, skin color, and movement), palpation or using the sense of touch that requires a hands-on examination of patient’s body (directly on the skin), auscultation is using the sense of hearing or listening with the stetoscope to examine bowel sound and movement, and the last one is percussion that is tapping with index finger on the other hand (the sense of touch) around the abdominal quadrants of patient. The physical examination is performed directly on the patient’s skin and cannot be performed over the clothes. An RD needs to physically touch patients to examine the storage of fat or muscle and accumulation of fluid on several areas of the body such as the extremities, orbital, triceps, ribs, temporalis muscle, clavicles, shoulders, interosseous muscles, scapula, thigh and calf. Performing this physical examination in a clinical setting will allow RDs to assess nutritional status while providing convenient data to inform prognosis and further monitoring and intervention aspects of nutrition-related disease progression. To further analyze and determine the potential application of NFPE in Indonesia this study will be conducted with a survey to collect data of dietitians and nutrition student’s perception towards NFPE. References: - Desjardins, S., Brody, R., & Touger-Decker, R. (2018). Nutrition-Focused Physical Examination Practices of Registered Dietitian Nutritionists Who Have Completed an In-Person NFPE Course. Topics in Clinical Nutrition, 33(2), 95-105. doi:10.1097/tin.0000000000000132 - Mordarski, B. A., Hand, R. K., Wolff, J., & Steiber, A. L. (2017). Increased Knowledge, Self-Reported Comfort, and Malnutrition Diagnosis and Reimbursement as a Result of the Nutrition-Focused Physical Exam Hands-On Training Workshop. Journal of the Academy of Nutrition and Dietetics, 117(11), 1822-1828. doi:10.1016/j.jand.2017.06.362 - Mordarski, B. A., & Hand, R. K. (2018). Patterns in Adult Malnutrition Assessment and Diagnosis by Registered Dietitian Nutritionists: 2014-2017. Journal of the Academy of Nutrition and Dietetics. doi:10.1016/j.jand.2018.07.010 - Mordarski, B. E. (2017). Nutrition Focused Physical Exam pocket guide. S.l.: American Dieteetic Assn. - Touger-Decker, R. (2006). Physical Assessment Skills for Dietetics Practice. Topics in Clinical Nutrition, 21(3), 190-198. doi:10.1097/00008486-200607000-00006

-Questionnaire starts-

Demographic Data

1. Sex :

● Female

● Male

2. Age : (in year)

3. Affiliation :

● Dietitian/Nutritionist

● Student

● Educator

4. Institution : (status & location of inst.)

5. Prior education (for Dietitian/Nutritionist only), please check all that apply:

● Advocacy (D3)

● Bachelor degree (D4/S1)

● Master’s degree (S2)

● Dietetic internship (DI)

● Others: …………………………..

Perception towards NFPE (five points Likert scale)

“There is no right or wrong answer. Every response will be greatly appreciated for the success of the study result! ” Instruction for dietitians: Please respond to each statement provided below with your most honest response with the best of your knowledge.

Instruction for students: Please respond honestly with a concept of “IF you are working in a clinical setting in the future and provide nutrition care for patient in daily basis”.

Instruction for educator: Please respond honestly with a concept of “IF you are working in a clinical setting and provide nutrition care for patient in daily basis”.

NO Strongly Agree Neutral Disagree Strongly Statements agree or not disagree sure 6. I believe that the nutrition care should be based on the best interest for patient 7. I believe that as a nutrition professionals, I need to update my knowledge and skills to provide the best nutrition care for patient 8. I am willing to do an extra training/workshop to learn a new method in clinical nutrition field 9. I believe that physical assessment is part of dietitian/nutrition scope of practice in clinical setting 10. I believe that I can introduce and explain the procedure that I am going to do to patient clearly 11. I believe that I can assure my patient that it is very important for me to obtain data as complete as possible to provide the best nutrition care for them 12. I will be comfortable performing physical examination on patient if I received prior training and education about it 13. I will be comfortable to perform physical examination on patient when other health professionals (i.e. medical

doctor/registered nurse/pharmacist) are being supportive about it 14. I believe that other health professionals (i.e. medical doctor/registered nurse/pharmacist) positive perception and knowledge about my scope of role will give me more confidence to perform a physical examination on patient 15. I believe that physical sign of nutrition- related medical disease progress is important to be documented 16. I believe that physical sign of malnutrition or intoxication from any nutrient is important to be documented 17. I believe that a change in physical condition have a strong relation with nutritional status of patient 18. I am more comfortable if I have enough time to perform a physical examination on every patient during my working hour 19. I will feel comfortable to touch (palpate) the orbital area of my patient to examine the status of fat loss 20. I will feel comfortable to touch (palpate) the upper arm region (triceps/biceps) of my patient to examine the status of fat loss 21. I will feel comfortable to touch (palpate) the thoracic and lumbar region (ribs, lower back, midaxillary line) of my patient to examine the status of fat loss 22. I will feel comfortable to touch (palpate) the temple region of my patient to examine the status of muscle loss 23. I will feel comfortable to touch (palpate) the clavicle bone region (pectoralis major, deltoid, trapezius muscles) of my patient to examine the status of muscle loss 24. I will feel comfortable to touch (palpate) the scapular bone region (trapezius, suprasppinus, infraspinus muscles) of my patient to examine the status of muscle loss 25. I will feel comfortable to touch (palpate) the dorsal hand (interosseous muscles) of my patient to examine the status of muscle loss

26. I will feel comfortable to perform pressure on the extremities area of my patient to examine the status of edema 27. I will feel more comfortable to perform physical examination (direct skin to skin contact) to patient with the same sex as me 28. I will feel less comfortable to perform physical examination (direct skin to skin contact) to patient with the opposite sex as me 29. I have the time to perform physical examination on my patient* 30. I am working on a facility that support me to perform physical examination on my patient (available equipment/facility, quite room, privacy for my patient, etc.)* *this question only asked to clinical dietitians/nutritionists

31. On the space provided below, please tell us about the potential barrier to

implement NFPE in Indonesia that might occur in a clinical practice in your

opinion:

-End of questionnaire. “THANK YOU FOR YOUR PARTICIPATION! ”-

APPENDIX B

TRANSLATED VERSION OF QUESTIONNAIRE (IN BAHASA INDONESIA)

TRANSLATED VERSION OF BAHASA INDONESIA

PERSEPSI TERHADAP IMPLEMENTASI NUTRITION-FOCUSED PHYSICAL EXAMINATION (NFPE) DI INDONESIA

Yosephin Anandati Pranoto, RD/ Kandidat Master of Science (M. S.) in Nutrition, Kent State University

Selamat datang di penelitian kami!

Kami ingin meneliti persepsi dietisien/ahli gizi dan mahasiswa gizi di Indonesia terhadap Nutrition-Focused Physical Examination (NFPE) atau “Pemeriksaan Fisik Terfokus Gizi”. Anda akan diberikan informasi dasar terkait metode NFPE ini dan diminta untuk menjawab pertanyaan-pertanyaan terkait persepsi Anda terhadapnya. Kami menjamin bahwa seluruh jawaban dan identitas Anda akan dijaga kerahasiaannya (anonim).

Pengerjaan survey ini akan memakan waktu sekitar 15 menit. Partisipasi Anda dalam penelitian ini sepenuhnya adalah suka rela. Anda memiliki hak penuh untuk mengundurkan diri dari penelitian ini sewaktu-waktu tanpa resiko maupun sanksi dalam bentuk apa pun.

Jika Anda ingin bertanya maupun membutuhkan informasi lebih lanjut mengenai penelitian ini, Anda dapat menghubungi peneliti utama melalui e-mail: [email protected].

Dengan meng-klik tombol di bawah ini, Anda menyatakan bahwa Anda: berusia paling tidak 18 tahun, mengerti bahwa partisipasi Anda dalam studi ini adalah suka rela, dan Anda dapat mengundurkan diri kapan pun tanpa terkena sanksi/resiko apa pun.

SETUJU

Penjelasan singkat tentang NFPE Nutrition-focused physical examination (NFPE) adalah metode pemeriksaan menyeluruh untuk menemukan tanda-tanda fisik malnutrisi pada pasien yang dilakukan oleh dietisien/ahli gizi. Sejak tahun 2003 di Amerika Serikat, komponen dari nfpe mulai disertakan dalam proses asuhan gizi pasien dan pada tahun 2012 secara resmi metode ini menjadi standar praktek untuk dietisien/ahli gizi di lingkup klinis. Metode ini melibatkan teknik dasar pemeriksaan fisik seperti inspeksi atau pemeriksaan secara visual terhadap kondisi pasien secara umum, palpasi atau pemeriksaan dengan tangan terhadap bagian-bagian tubuh pasien (kontak langsung dengan kulit pasien), auskultasi atau mendengarkan bising usus melalui stetoskop, dan yang terakhir adalah perkusi yang dilakukan dengan mengetukkan jari telunjuk ke tangan yang diletakkan di sekitar area abdomen pasien (kuadran). Pemeriksaan fisik ini dilakukan dengan sentuhan langsung ke kulit passion dan tidak dapat dilakukan dengan dibatasi baju/kain. Seorang ahli gizi harus menyentuh pasien secara langsung untuk dapat menilai simpanan lemak atau otot dan akumulasi cairan/edema pada beberapa area tubuh pasien, seperti ekstremitas, orbital, trisep, tulang iga, otot temporal, klavikula, pundak, otot interosseous, skapula, paha, dan betis. Melakukan pemeriksaan fisik di lingkup klinis akan menghasilkan data obyektif yang dapat digunakan dietisien/ahli gizi untuk menilai status gizi pasien dan menentukan prognosis dan monitoring lanjutan dan intervensi gizi yang berkaitan dengan perkembangan penyakit terkait gizi pada pasien. Untuk menilai dan menentukan potensi implementasi NFPE di Indonesia, maka penelitian ini dilakukan dengan survey guna memperoleh data persepsi dietitisien/ahli gizi dan mahasiswa gizi terkait NFPE. References:

- Desjardins, S., Brody, R., & Touger-Decker, R. (2018). Nutrition-Focused Physical Examination Practices of Registered Dietitian Nutritionists Who Have Completed an In- Person NFPE Course. Topics in Clinical Nutrition, 33(2), 95-105. doi:10.1097/tin.0000000000000132 - Mordarski, B. A., Hand, R. K., Wolff, J., & Steiber, A. L. (2017). Increased Knowledge, Self- Reported Comfort, and Malnutrition Diagnosis and Reimbursement as a Result of the Nutrition-Focused Physical Exam Hands-On Training Workshop. Journal of the Academy of Nutrition and Dietetics, 117(11), 1822-1828. doi:10.1016/j.jand.2017.06.362 - Mordarski, B. A., & Hand, R. K. (2018). Patterns in Adult Malnutrition Assessment and Diagnosis by Registered Dietitian Nutritionists: 2014-2017. Journal of the Academy of Nutrition and Dietetics. doi:10.1016/j.jand.2018.07.010 - Mordarski, B. E. (2017). Nutrition Focused Physical Exam pocket guide. S.l.: American Dieteetic Assn. - Touger-Decker, R. (2006). Physical Assessment Skills for Dietetics Practice. Topics in Clinical Nutrition, 21(3), 190-198. doi:10.1097/00008486-200607000-00006

-KUESIONER DIMULAI-

DATA DEMOGRAFIS

1. Jenis Kelamin :

● Wanita

● Pria

2. Umur : (dalam tahun)

3. Posisi/status :

● Dietisien/ahli gizi

● Mahasiswa

● Dosen/tenaga pendidik

4. Institusi : (nama & lokasi)

6. Pendidikan sebelum bekerja (untuk ahli gizi), centang semua yang sesuai:

 Advocacy (D3)

● Bachelor degree (D4/S1)

● Master’s degree (S2)

● Dietetic internship (DI)

● Others: …………………………..

Persepsi terhadap NFPE

“Tidak ada jawaban benar atau salah, setiap respon akan sangat berarti untuk kesuksesan penelitian ini! ”

Instruksi untuk dietisien/ahli gizi: Silahkan menjawab setiap pernyataan di bawah ini dengan jujur dan sesuai dengan pemahaman anda masing-masing.

Instruksi untuk mahasiswa: Silahkan menjawab dengan konsep “SEANDAINYA anda bekerja di lingkup klinis di masa depan dan memberikan asuhan gizi pada pasien setiap harinya”.

Instruksi untuk dosen atau tenaga pengajar: Silahkan menjawab dengan konsep “SEANDAINYA anda bekerja di lingkup dan memberikan asuhan gizi pada pasien setiap harinya”.

NO Sangat Setuju Netral/tid Tidak Sangat Pernyataan setuju ak yakin setuju tidak setuju 6. Saya yakin bahwa asuhan gizi harus mengutamakan kepentingan pasien 7. Saya percaya bahwa sebagai professional di bidang gizi, saya membutuhkan pembaharuan/update pengetahuan dan skill secara berkala untuk memberikan asuhan gizi yang terbaik untuk pasien saya 8. Saya bersedia untuk melakukan/mengambil pelatihan dan seminar tambahan untuk belajar metode baru di bidang gizi klinik 9. Saya yakin pemeriksaan fisik pada pasien merupakan bagian dari lingkup praktek seorang dietisien/ahli gizi di bidang klinik 10. Saya yakin bahwa saya bisa menjelaskan prosedur pemeriksaan terkait gizi pada pasien dengan jelas 11. Saya yakin bahwa saya dapat meyakinkan pasien saya bahwa pengumpulan data selengkap mungkin penting untuk memberikan asuhan gizi yang terbaik (optimal) untuk mereka

12. Saya akan merasa nyaman melakukan pemeriksaan fisik pada pasien jika saya mendapatkan pelatihan dan pendidikan sebelumnya 13. Saya akan merasa nyaman untuk melakukan pemeriksaan fisik pada pasien jika tenaga kesehatan lain bersikap suportif (seperti dokter, perawat, apoteker) 14. Saya percaya bahwa persepsi positif dan pengakuan akan ruang lingkup kerja saya dari tenaga kesehatan lain (dokter, perawat, apoteker, dll) akan membuat saya merasa lebih percaya diri untuk melakukan pemeriksaan fisik pada pasiens 15. Saya yakin bahwa tanda-tanda fisik dari penyakit/kondisi medis terkait gizi pada pasien sangat penting untuk didokumentasikan 16. Saya yakin bahwa tanda-tanda fisik dari malnutrisi atau intoksifikasi zat-zat gizi pada pasien sangat penting untuk didokumentasikan 17. Saya percaya bahwa perubahan- perubahan kondisi fisik memiliki hubungan yang erat dengan status gizi pasien 18. Saya akan merasa lebih nyaman jika saya memiliki waktu yang cukup untuk melakukan pemeriksaan fisik terhadap pasien di jam kerja saya 19. Saya merasa nyaman untuk menyentuh (palpasi) area orbital/sekitar bola mata untuk memeriksa status simpanan lemak pada pasien 20. Saya merasa nyaman untuk menyentuh (palpasi) area lengan atas/trisep dan bisep untuk memeriksa status simpanan lemak pada pasien 21. Saya merasa nyaman untuk menyentuh (palpasi) area dada dan punggung (tulang iga, punggung bawah) untuk memeriksa status simpanan lemak pada pasien 22. Saya merasa nyaman untuk menyentuh (palpasi) area pelipis/temple region untuk memeriksa status simpanan otot pada pasien

23. Saya merasa nyaman untuk menyentuh (palpasi) tulang klavikula dan pundak (pectoralis major, deltoid, trapezius muscles) untuk memeriksa simpanan otot pada pasien 24. Saya merasa nyaman untuk menyentuh (palpasi) area seputar tulang skapula (trapezius, suprasppinus, infraspinus muscles) untuk memeriksa simpanan otot pada pasien 25. Saya akan merasa nyaman untuk menyentuh (palpasi) bagian punggung tangan/dorsal (interosseous muscles) untuk memeriksa simpanan otot pada pasien 26. Saya merasa nyaman untuk menekan area ekstrimitas pasien untuk memeriksa adanya akumulasi cairan/edema 27. Saya akan merasa lebih nyaman untuk melakukan pemeriksaan fisik terhadap pasien yang berjenis kelamin sama dengan saya 28. Saya akan merasa kurang nyaman untuk melakukan pemeriksaan fisik terhadap pasien yang berbeda jenis kelamin dengan saya 29. Berdasarkan jam kerja saya saat ini/pada umumnya, saya memiliki cukup waktu untuk melakukan pemeriksaan fisik pada pasien saya* 30. Saya bekerja di institusi yang mendukung saya untuk dapat melakukan pemeriksaan fisik pada pasien saya (ketersediaan alat pemeriksaan, lingkungan yang tenang dan privasi pasien terjaga, dll.)* *Pertanyaan khusus untuk partisipan berprofesi ahli gizi klinis

31. Tolong tuliskan di bawah ini, potensi hambatan-hambatan (internal

maupun eksternal) yang mungkin dihadapi oleh ahli gizi di Rumah

Sakit/lingkup klinis untuk dapat mengimplementasikan NFPE menurut

pendapat Anda:

-Akhir dari Kuesioner. “TERIMA KASIH ATAS PARTISIPASI ANDA! ”-

APPENDIX C

E-MAIL COVER LETTER OF QUESTIONNAIRE

Dear Survey Participant,

My name is Yosephin Pranoto and I am a graduate student and Master of Science in Nutrition candidate with Kent State University College of Education, Health, and Human Services (EHHS). I am conducting a survey to obtain data for my thesis research on the potential implementation of Nutrition-Focused Physical Examination (NFPE) in Indonesia.

Therefore, I would like to ask your help to participate in my study by completing the electronic survey questionnaire as a student or professional in the nutrition field in Indonesia. Your input and opinion will be kept confidential. Should you have any concerns or questions, please feel free to contact me or my advisor on the provided information on the bottom of this email.

We will send you a reminder via email in two weeks after you received this email. Your participation is voluntary and you may withdraw from the study at any time without any penalty or consequences. This study has been approved by the Institutional Review Board (IRB) at Kent State University. Link for starting the survey: https://kent.qualtrics.com/jfe/form/SV_9oeHOfO5xqeTQ9v Thank you for your interest and participation in this study and we value and appreciate your responses.

Sincerely, Yosephin A. Pranoto, RD ( [email protected] ) Principal Investigator Nutrition and Dietetics Master of Science Candidate School of Health Sciences Kent State University

Karen Lowry Gordon, PhD, RD, LD ( [email protected] ) Associate Professor and Thesis Advisor School of Health Sciences Kent State University

APPENDIX D

E-MAIL REMINDER

Dear Survey Participant,

Thank you for your interest and participation on this study! We are interested in understanding the perception of dietitians and nutrition students in Indonesia towards Nutrition-Focused Physical Examination (NFPE).

This is a friendly reminder to complete the online survey that we sent two weeks ago. For your convenience, we have provided the link here (it will bring you directly to the survey) on this email. Should you have any concerns or questions, please feel free to contact me or my advisor on the provided information on the bottom of this email.

This link will be available for the next two weeks before the completion of the data collection process. After that, you will not be able to access the survey anymore.

Again, your responses are greatly valued and appreciated!

Thank you 

Sincerely,

Yosephin A. Pranoto, RD ( [email protected] ) Principal Investigator Nutrition and Dietetics Master of Science Candidate School of Health Sciences Kent State University

Karen Lowry Gordon, PhD, RD, LD ( [email protected] ) Associate Professor and Thesis Advisor School of Health Sciences Kent State University

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