The purpose of nutrition problem identification is to identify specific nutrition-related problems that will be the focus of nutrition intervention at the current point in time. Based on findings from the nutrition assessment, the dietitian prioritizes current problems that compromise achieving and maintaining plasma BCAA levels in the desired range and meeting nutritional needs necessary to support normal growth and development and overall health and quality of life.

Table 6 identifies common nutrition diagnoses associated with MSUD, written in the PES (problem, etiology, signs and symptoms) format developed by the Academy of Nutrition and Dietetics Nutrition Care Process.

TABLE 6 - Nutrition Problem Identification for MSUD based on the International Dietetics and Nutrition Terminology Reference Manual, 3rd Edition

Nutrition Diagnosis (Problem)	Related to (Etiology)	As Evidenced By (Signs and Symptoms)
Based on assessment findings, specify the current nutrition-related problem(s) to be addressed through nutrition management.	Identify the most pertinent underlying cause(s) or contributing risk factors for the specific problem. The etiology is commonly the target of nutrition intervention.	List subjective and objective data that characterize the specific problem and are also used to monitor nutrition intervention and outcomes.
Examples of specific nutrition problems:	Examples of underlying causes of the problem:	Examples of data used to determine and monitor the problem:
Intake Domain Excessive protein intake Insufficient protein intake Intake of types of protein or amino acids inconsistent with needs (specify) Predicted excessive energy intake Predicted suboptimal energy intake Excessive fat intake Inadequate fat intake Excessive enteral nutrition infusion Inadequate enteral nutrition infusion Enteral nutrition composition inconsistent with needs Clinical Domain Impaired nutrient utilization Altered nutrition-related lab values Food-medication interaction (specify) Growth rate below expected Underweight Overweight/obesity Behavioral-Environmental Domain Food and nutrition-related knowledge deficit Limited adherence to nutrition-related recommendations Limited access to food	Consumption Factors Lack of medical food consumption Suboptimal medical food consumption Excessive intake of (specify food or beverage) Provider Factors Nutrition prescription no longer meets protein needs Nutrition prescription no longer meets energy needs Underlying Disease Factors New diagnosis of MSUD LEU, VAL, and ILE restriction necessary for MSUD treatment Acute illness or infection Poor appetite due to (specify) Patient/Caretaker Knowledge and Behavior Factors Food choices suboptimal Lack of knowledge Limited adherence to dietary therapy recommendations Presentation to clinic for initial nutrition education Off diet Access Factors Lack of financial resources for medical food and low-protein foods Lack of medical insurance Inadequate third-party or denial of coverage for medical foods or low protein foods Lack of access to resources or care	From Biochemical Tests Laboratory value compared to norm or goal (specify) (e.g. plasma LEU of 300 µmol/L) Abnormal plasma amino acids (specify) Presence of ketones in urine Positive DNPH test From Anthropometrics Growth pattern, weight, weight-for-height or BMI compared to standards (specify) Weight gain/loss (specify weight change) over the past (specify time frame) From Clinical/Medical Exam or History New diagnosis of MSUD EFA deficiency (physical sign or lab value) From Diet History Estimated or calculated intake from diet record or dietary recall, compared to recommendation or individual's nutrition prescription (specify) From Patient Report Verbalized lack of skill or understanding to implement nutrition recommendations Lack of appreciation for the importance of making nutrition-related changes Lack of social or familial support

Table content is based on Nutrition Care Process (NCP) terminology developed by the Academy of Nutrition and Dietetics. NCP uses the following structure for documenting nutrition problems: nutrition diagnosis (Problem), related to (Etiology), and as evidenced by (Signs and Symptoms). Examples listed identify concerns particular to MSUD and are grouped in domains of: Intake, Clinical, and Behavioral-Environmental. Problems identified may relate to any Etiology and be evidenced by any Signs and Symptoms within a domain.