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FIFTH EDITION

Nutrition AND

Dietetics
Practice and Future Trends

Esther A. Winterfeldt, PhD

Professor Emeritus, Department of Nutritional Sciences
College of Human Environmental Sciences
Oklahoma State University
Stillwater, Oklahoma

Margaret L. Bogle, PhD

Retired
Active Member of the Academy of Nutrition and Dietetics
Dallas, Texas

Lea L. Ebro, PhD

Professor Emeritus, Department of Nutritional Sciences
College of Human Environmental Sciences
Oklahoma State University
Stillwater, Oklahoma
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Library of Congress Cataloging-in-Publication Data
Names: Winterfeldt, Esther A., author. | Bogle, Margaret L., author. | Ebro,
  Lea L., author.
Title: Nutrition and dietetics : practice and future trends / Esther A.
  Winterfeldt, PhD, Professor Emeritus, Department of Nutritional Sciences,
  College of Human Environmental Sciences, Oklahoma State University,
  Stillwater, Oklahoma, Margaret L. Bogle, PhD, RD, LD, Lower Mississippi
  Delta Nutrition Intervention Research Initiative, Agriculture Research
  Service, United States Department of Agriculture, Little Rock, Arkansas,
  Lea L. Ebro, PhD, Professor Emeritus, Department of Nutritional Sciences,
  College of Human Environmental Sciences, Oklahoma State University,
  Stillwater, Oklahoma.
Other titles: Dietetics (Winterfeldt)
Description: Fifth edition. | Burlington, MA : Jones & Bartlett Learning,
  [2018] | Revision of: Dietetics / Esther A. Winterfeldt, Margaret L.
  Bogle, Lea L. Ebro. 3rd ed. c2011. | Includes bibliographical references
  and index.
Identifiers: LCCN 2016049226 | ISBN 9781284107975 (alk. paper)
Subjects: LCSH: Dietetics—Vocational guidance.
Classification: LCC RM217 .W56 2018 | DDC 613.2023—dc23 LC record available at https://lccn.loc.gov/2016049226
6048
Printed in the United States of America
21 20 19 18 17 10 9 8 7 6 5 4 3 2 1
 Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Chapter 1 Introduction to the Profession of Nutrition
  and Dietetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The Early Practice of Dietetics . . . . . . . . . . . . . . . . . 3
Founding of the Academy of Nutrition
  and Dietetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Influential Leaders . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Dietetics as a Profession . . . . . . . . . . . . . . . . . . . . . . 8
Growth of the Profession . . . . . . . . . . . . . . . . . . . . . 9
Reaching out to the Public . . . . . . . . . . . . . . . . . . . . 15
Historical Events in the Academy of Nutrition
  and Dietetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Chapter 2 The Academy of Nutrition and Dietetics . . . . . . . . 21
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
The Strategic Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Membership Categories. . . . . . . . . . . . . . . . . . . . . . . 24
Membership Benefits . . . . . . . . . . . . . . . . . . . . . . . . 25
Governance of the Academy of Nutrition
  and Dietetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Position Papers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Dietitian Salaries. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

iii

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iv    C ontents vk.com/lingualib

Affiliated Units of the Academy of Nutrition

  and Dietetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Chapter 3 Educational Preparation in Dietetics . . . . . . . . . . . 37
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Undergraduate Education. . . . . . . . . . . . . . . . . . . . . 38
Dietetics Education Programs. . . . . . . . . . . . . . . . . . 39
Education Program Standards. . . . . . . . . . . . . . . . . . 40
Supervised Practice in Dietetics. . . . . . . . . . . . . . . . . 41
Advanced-Level Education . . . . . . . . . . . . . . . . . . . . 43
Distance Education. . . . . . . . . . . . . . . . . . . . . . . . . . 46
Future Education Preparation. . . . . . . . . . . . . . . . . . 47
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Chapter 4 Credentialing of Nutrition and
  Dietetic Practitioners. . . . . . . . . . . . . . . . . . . . . . 51
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Development of Credentialing . . . . . . . . . . . . . . . . . 54
Commission on Dietetic Registration. . . . . . . . . . . . 55
Registered Dietitian Nutritionist. . . . . . . . . . . . . . . . 56
Dietetic Technician, Registered or Nutrition and
  Dietetics Technician, Registered. . . . . . . . . . . . . . 56
New Dietetic Technician Registration Eligibility
 Pathway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Specialist Certification . . . . . . . . . . . . . . . . . . . . . . . 60
Interdisciplinary Specialist Certification
  in Obesity and Weight Management. . . . . . . . . . . 61
Advanced Practice Certification in Clinical
 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Certificates of Training. . . . . . . . . . . . . . . . . . . . . . . 63
Recertification of the RD/RDN and DTR/NDTR. . . . 64
Recertification of Specialists and Advanced Practice
  in Clinical Nutrition. . . . . . . . . . . . . . . . . . . . . . . 65
Appropriate Use of Credentials. . . . . . . . . . . . . . . . . 65
 C o n t e n t s      v

Legal Regulation Statutes for Dietitians

  Nutritionists and Dietetic Technicians. . . . . . . . . 66
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Chapter 5 The Nutrition and Dietetics Professional. . . . . . . . 73
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Scope of Practice and Performance Standards. . . . . . 74
Ethical Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Diversity and Culturally Competent Practice . . . . . . 80
Lifelong Professional Development. . . . . . . . . . . . . . 80
The Legal Basis of Practice . . . . . . . . . . . . . . . . . . . . 84
Evidence-Based Practice . . . . . . . . . . . . . . . . . . . . . . 85
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Chapter 6 The Dietitian in Clinical Practice. . . . . . . . . . . . . . 91
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Employment Settings of Dietitians and Dietetic
 Technicians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Practice Audit Activities . . . . . . . . . . . . . . . . . . . . . . 95
Organization of Clinical Nutrition Services. . . . . . . . 95
Responsibilities in Clinical Dietetics. . . . . . . . . . . . . 96
The Clinical Nutrition Service Team . . . . . . . . . . . . 100
Clinical Dietetics Outlook . . . . . . . . . . . . . . . . . . . . 102
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Chapter 7 Management in Food and Nutrition Systems. . . . . 107
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Activities of Entry-Level Dietitians and
  Dietetic Technicians. . . . . . . . . . . . . . . . . . . . . . . 109
Areas of Employment. . . . . . . . . . . . . . . . . . . . . . . . 110
Characteristics of Successful Food and
  Nutrition Managers . . . . . . . . . . . . . . . . . . . . . . . 114
Expanded Opportunities. . . . . . . . . . . . . . . . . . . . . . 117
Expansion of Roles. . . . . . . . . . . . . . . . . . . . . . . . . . 117
vi    C ontents

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Chapter 8 The Public Health/Community
  Nutrition Dietitian . . . . . . . . . . . . . . . . . . . . . . . 121
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Public Health/Community Practice . . . . . . . . . . . . . 123
Public Health Nutrition. . . . . . . . . . . . . . . . . . . . . . 124
Community Nutrition . . . . . . . . . . . . . . . . . . . . . . . 125
Career Outlook. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Chapter 9 Dietitians in the Government and
  Military Services . . . . . . . . . . . . . . . . . . . . . . . . . 129
Part I. The Government. . . . . . . . . . . . . . . . . . . . . . 130
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Government Programs in Food and Nutrition . . . . . 131
Role of the Academy of Nutrition and Dietetics
  in Policy Formation . . . . . . . . . . . . . . . . . . . . . . . 135
Policy Issues in Dietetics. . . . . . . . . . . . . . . . . . . . . . 136
Part II. The Military Services . . . . . . . . . . . . . . . . . . 137
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Chapter 10 The Consultant in Health Care, Business,
  and Private Practice. . . . . . . . . . . . . . . . . . . . . . . 141
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Becoming a Consultant. . . . . . . . . . . . . . . . . . . . . . . 143
The Consultant in Health Care and
  Extended Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
The Consultant in Business Practice. . . . . . . . . . . . . 148
The Consultnt in Private Practice. . . . . . . . . . . . . . . 150
Ethical and Legal Bases of Practice . . . . . . . . . . . . . . 154
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
 C o n t e n t s      vii

Chapter 11 Career Choices in Business, Communications,

  and Health and Wellness. . . . . . . . . . . . . . . . . . . 157
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
The Dietitian in Business and Communications. . . . 158
The Dietitian in Health and Wellness Programs. . . . 161
Practice Groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Chapter 12 The Dietitian as Manager and Leader. . . . . . . . . . . 173
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Management Functions. . . . . . . . . . . . . . . . . . . . . . . 177
Skills and Abilities of Managers. . . . . . . . . . . . . . . . . 178
Management in Practice. . . . . . . . . . . . . . . . . . . . . . 186
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Chapter 13 The Dietitian as Educator. . . . . . . . . . . . . . . . . . . . 191
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Educational Activities of Dietitians. . . . . . . . . . . . . . 193
Learning to Teach. . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Career Opportunities in Education. . . . . . . . . . . . . . 195
Educator Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Types of Learning. . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Adults as Learners. . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Teaching Groups and Teams . . . . . . . . . . . . . . . . . . 208
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Chapter 14 The Dietitian as Researcher. . . . . . . . . . . . . . . . . . . 213
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Importance of Research in Dietetics . . . . . . . . . . . . . 215
The Research Philosophy of the Academy. . . . . . . . . 215
The Academy’s Research Priorities . . . . . . . . . . . . . . 216
Research Applications. . . . . . . . . . . . . . . . . . . . . . . . 219
viii    C ontents

Involvement in Research. . . . . . . . . . . . . . . . . . . . . . 220

Career Opportunities in Research. . . . . . . . . . . . . . . 220
Information Sources. . . . . . . . . . . . . . . . . . . . . . . . . 224
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Chapter 15 The Future in Dietetics and Nutrition . . . . . . . . . . 227
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Degree Options. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Communications and Technology . . . . . . . . . . . . . . 234
Food and the Food Supply. . . . . . . . . . . . . . . . . . . . 235
Management and Leadership. . . . . . . . . . . . . . . . . . . 237
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Appendix A Code of Ethics for the Profession of Dietetics
  and Process for Consideration of Ethics
  Issues (2009) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Preamble. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Application. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
Fundamental Principles. . . . . . . . . . . . . . . . . . . . . . . 244
Appendix B Dietetics Career Development Guide. . . . . . . . . . . 247

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
 Preface
As in previous editions, Nutrition and Dietetics: Practice and Future
Trends, Fifth Edition presents an overall look at the dietetic profession—
what dietitians do, where they practice, and the education and experiences
needed to become a credentialed, fully prepared dietitian, nutritionist,
and dietetic technician. For this edition, we have updated all the chapters,
added a chapter on the government and military, and looked extensively
at all references.
Our profession is focused on helping patients, clients, and the public
to maintain healthy lifestyles that help prevent the onset of chronic dis-
ease and enhance the quality of life throughout the life cycle. Through
educational programs, research, and many forms of communication, reli-
able and relevant information is provided for the public, consumers, and
clients.
Dietitian nutritionists, through their unique knowledge of both the
science and art of nutrition, are leaders in the promotion of nutritional
health today. Because of this blend of scientific knowledge and the social
and cultural factors that influence what people eat, dietitian nutritionists
are able to use their skills to help individuals in illness and disease preven-
tion as well as those who are healthy and active. Dietitian nutritionists
also interact with professionals in other disciplines and are able to blend
their assorted expertise for the benefit of clients. Their participation in
basic research and integration of new scientific concepts into all areas of
practice adds an invaluable dimension to the dietetic profession.
This text is geared toward students beginning in dietetics, those who
may be undecided about a career choice, and those who are nearing com-
pletion of their education and training and exploring career opportuni-
ties. Job opportunities for the non-RD are also included throughout the
text. In addition, dietitians and nutritionists considering a career change

ix
x    P reface

will find information about many career options, including some new
emerging opportunities. Some may become entrepreneurs and join the
business world, some may partner with other professionals in health care
institutions to provide their expertise for clients, and some may become
consultants and others may become educators and researchers. The oppor-
tunities for food and nutrition professionals are greater today than at any
time in the past, and we encourage students to fully explore the many
career possibilities.
Readers will find updated information regarding education, credential-
ing, salary data, and position descriptions. The reader will note that refer-
ences are inclusive through mid-2016. The Academy will be publishing
practice audit results later in 2016 and some position papers are currently
under revision with an expected 2016 publication date.
We thank the Academy of Nutrition and Dietetics headquarters staff
for timely information. We also acknowledge and thank other profession-
als who contributed to this text by sharing their knowledge and expertise
in this and previous editions.
We encourage faculties and students to make full use of information
sources provided as well as others which will lend further details in topic
areas. We hope readers will be stimulated to participate in and enjoy the
privileges of helping others through the practice of nutrition and dietetics.

New to This Edition

Each chapter has been reviewed and revised for the Fifth Edition. Notable
changes include the following:
• Chapter 9, “Dietitians in the Government and Military Services,” is
new to this edition and discusses the roles of dietitians within gov-
ernment and military organizations as well as public policy.
• Chapter 15, “The Future in Dietetics and Nutrition,” has been com-
pletely rewritten to discuss future opportunities due to changes in
the field as well as future educational needs as indicated both by the
Academy of Nutrition and Dietetics and employers of dietitians.
• Chapter 8, “The Public Health/Community Health Nutrition
Dietitian,” has been extensively revised to streamline the discussion
of community and public health in relation to each other.
• Chapter 5, “The Nutrition and Dietetics Professional,” discusses
diversity in greater detail.
 P reface      xi

• Charts and tables throughout the text have been updated to reflect
the latest salary and Academy membership data for dietitians.

Instructor Resources
Qualified instructors can receive access to the full suite of Instructor
Resources for the Fifth Edition, including the following:
• Test Bank
• Slides in PowerPoint format
• Lecture Outlines
Esther A. Winterfeldt, PhD
Margaret L. Bogle, PhD
Lea L. Ebro, PhD
 Reviewers
Susan E. Adams, MS, RD, LDN, FAND
Assistant Professor
La Salle University
Philadelphia, PA

Melissa Anderson, PhD, RD, LDN

Director, School of Human Ecology
Tennessee Tech University
Cookeville, TN

Cynthia Blanton, PhD, RD

Associate Professor
Idaho State University
Pocatello, ID

Detri Brech, PhD, RD, LD, CDE

Professor
Ouachita Baptist University
Arkadelphia, AR

Judi Brooks, PhD, RD

Professor
Eastern Michigan University
Ypsilanti, MI

Eileen Chopnick, MBA, RDN, LDN

Adjunct Faculty
La Salle University
Philadelphia, PA
xiii
xiv    R eviewers

Barbara Lloyd, MA, RD

Assistant Professor
Southwest Tennessee Community College
Memphis, TN

Diane Longstreet, PhD, MPH, RD, LDN

Instructor
Keiser University
Lakeland, FL

Jaimette McCulley, MS, RD, LD

Assistant Professor
Fontbonne University
St. Louis, MO

Katie Miner, PhD, RDN, LD

Senior Instructor
University of Idaho
Moscow, ID

Deborah Myers, EdD, RD

Professor
Bluffton University
Bluffton, OH

Patricia H. Terry, PhD, RD, LD

Professor and Dietetics Program Director
Samford University
Birmingham, AL

Peggy Turner, MS, RD/LD, FAND

Assistant Professor
The University of Oklahoma Health Sciences Center
Oklahoma City, OK

Kit Werner, PhD, RD, CD, CDE

Clinical Assistant Professor and Nutritional Science Clinical Director
University of Wisconsin—Milwaukee
Milwaukee, WI
 1

CHAPTER
Introduction to the
Profession of Nutrition
and Dietetics
“An honorable past lies behind, a developing present
is with us, and a promising future lies before us.”1

OUTLINE
• Learning Objectives
• Introduction
• The Early Practice of Dietetics
• Cooking Schools
• Hospital Dietetics
• Clinics
• The Military
• Founding of the Academy of Nutrition and Dietetics
• Influential Leaders
• Recognized Leaders Today
• Dietetics as a Profession
• Growth of the Profession
• Membership
• Registration and Licensure
• The Academy of Nutrition and Dietetics Foundation
• Dietetic Technicians and Managers
• Legislative Activity
• Areas of Practice

1
2    I ntroduction to the P rofession of N utrition and D ietetics

• Dietetic Practice Groups

• Long-Range Planning
• Professional Partnerships
• Reaching Out to the Public
• Historical Events in the Academy of Nutrition and Dietetics
• Summary
• Definitions
• References

LEARNING OBJECTIVES
The student will be able to:
1. Describe early practices in dietetics.
2. Become familiar with the founding of the Academy of Nutrition
and Dietetics.
3. Discuss how the profession has grown since inception.
4. Become familiar with names of early leaders in the profession
and their contributions.
5. Name and describe the primary practice areas in dietetics.

IN T RO D UC TI O N
“What is a dietitian?” “What does a dietitian do?”
Recognition of the dietitian as a food and nutrition expert became offi-
cial in 1917. This, however, was not the actual beginning of the practice
of dietetics. The use of diet in the treatment of disease was already an
ancient practice even though it was based more on trial and error than on
scientific knowledge. Besides physicians, others including home econo-
mists, nurses, and cooks were practicing and teaching about good dietary
practices, and researchers were uncovering the secrets of nutrients in foods
and their health-promoting effect.2
Dietetics has been practiced as long as people have been eating. The term
derives from dieto, meaning diet or food. According to earliest historical
 The Early Practice of D i e t e t i c s      3

evidence, our ancestors were forced to concentrate on simply finding food

with little concern about the variety or composition of that food. Today,
however, food is plentiful. At least in the developed countries of the world,
being able to choose and eat too much from that abundant food supply has
become a major problem, resulting in adverse health for many.
Recommendations about eating and food choices have come from bib-
lical admonitions as well as from early physicians and scientists. Physicians
in Europe and China, including Hippocrates, formed theories about the
relationship between food and the state of a person’s health.3 Many of the
early physicians and scientists emphasized adding or eliminating certain
foods from the diet according to disease symptoms, although there was no
knowledge at that time about nutrients. Until the discovery of the major
nutrients in food during the 19th and 20th centuries, a scientific basis for
many of the eating recommendations was tenuous at best.
During the 18th century, research by chemists and physicians began to
yield information concerning digestion, respiration, and other metabolic
functions. The studies were forerunners of later discoveries that identi-
fied the elusive substances in foods that were responsible for many of
the effects described much earlier in the etiology of disease. Fats, carbo-
hydrates, and amines were known by the mid-1800s, but vitamins and
minerals were not discovered until the early 1900s.4
One of the most fascinating accounts of the relationship between
specific foods and illness is found in Lind’s Treatise of Scurvy written in
1753.5 When it was discovered that lemons and limes or their juice would
prevent the dreaded scurvy among sailors at sea for long periods of time, it
was a lifesaving piece of knowledge. Vitamin C from citrus fruits was later
termed the antiscorbutic vitamin. Other breakthroughs came when vitamin
A was found to be a factor in the prevention of skin lesions and blindness
in both animals and people, and when niacin, one of the B-vitamin group,
was found to prevent pellagra in humans and black tongue in dogs.6 There
are equally vivid accounts of discoveries of other nutrients.7

T H E EARLY P R A C TI C E O F DI ET ET I C S
Cooking Schools
Early cooking schools in the United States, following their emergence in
Europe in the early 1800s, led the way toward good dietary practices.8 One of
the first was the New York Cooking Academy founded in 1876, soon followed
4    I ntroduction to the P rofession of N utrition and D ietetics

by schools in Boston and Philadelphia.9 The schools not only offered cooking
instruction but conducted laboratories in chemistry and special classes for the
sick.10 The schools trained many of the men and women who were in charge
of food service in hospitals and the Red Cross during World War I.

Hospital Dietetics
Early practitioners in dietetics were in hospitals feeding the sick. Because
little was known about people’s nutritional needs in either health or ill-
ness, food selection was not a major concern. Menus were monotonous
and usually featured only a few foods. One account of menus in a New
York hospital indicated that mush, molasses, and beer were served for
breakfast and supper several days a week. Fruits and vegetables did not
appear on menus until later, and then usually only as a garnish.11
Florence Nightingale is credited not only with improving nursing of
the sick during the Crimean War in the mid-1800s but also with improv-
ing the food supply and sanitary conditions in hospitals.12

Clinics
The Frances Stern Clinic in Boston was one of the leading food clinics
established in the late 1800s to provide diets for the sick poor. This clinic
continues as a leading treatment center and serves as a model for similar
clinics throughout the United States.

The Military
Dietitians played important roles during the Civil War and World Wars I
and II. During World War I, many served in military hospitals both over-
seas and in the United States. In World War II during the 1940s, hun-
dreds of dietitians volunteered for active service. Dietitians also worked
closely with the Office of the Surgeon General and the Red Cross to help
train more individuals in nutrition. Military service and training pro-
grams are important professional opportunities for dietitians today.13

FOUND I NG O F TH E A C A D E M Y OF
NUT RIT I O N A N D D I E TE TI C S
The history of the profession of dietetics in the United Stated is also
the history of the American Dietetic Association (ADA; now called the
Academy of Nutrition and Dietetics) because the two grew together in
 Founding of the Academy of Nutrition and D i e t e t i c s      5

increasingly important ways. The profession flourished because the asso-

ciation took early steps to oversee both the education and practice of its
members. In turn, dietitians supported the association and its activities.
Before the founding of the ADA, persons who worked in food and
nutrition programs could join the American Home Economics Associa-
tion and thus were able to associate and communicate with others of like
interests. Dietitians were few in number, and, although they had some-
what similar backgrounds, there was no way to identify persons who were
professionally qualified. In 1917, a group of about 100 dietitians met in
Cleveland, Ohio, for the purpose of “providing an opportunity for the
dietitians of the country to come together and meet with the scientific
research workers and to see that the feeding of as many people as possible
be placed in the hands of women trained to feed them in the best man-
ner known.”14 Because this was wartime, the government had extensive
food conservation programs and used home economists, dietitians, and
volunteers to conduct the programs. At the first meeting of the associa-
tion, officers were elected and a constitution and bylaws were drawn up
overnight. Dues were $1 per year, and there were 39 charter members.
Lulu Grace Graves was the first president, and Lenna Frances Cooper was
the first vice president.
World War I was, in great part, the impetus that brought early dieti-
tians together to discuss the feeding needs. However, it was also recog-
nized that the services of dietitians in hospitals were rapidly assuming
greater importance, both in food service and in treating illness with diet.
Researchers were making great strides in nutrition science, and, as more
became known about nutrients, maintaining good nutrition and treating
certain illnesses with diet became more precise.
Four areas of practice in dietetics were first identified: dietotherapy,
teaching, social welfare, and administration.15 The vision of the early lead-
ers is evident in that the same four areas of practice exist today, although
terminology as well as practice in each area have undergone many changes.
The first area, dietotherapy, or the treatment of disease by diet, was later
termed diet therapy, then clinical dietetics, and now is known as medi-
cal nutrition therapy or clinical nutrition. Dietitians instructed dietetics
students, nurses, physicians, and patients. Later called the education sec-
tion, this group established education standards and specified the experi-
ences needed in an internship to become professionally competent. The
social welfare area of practice was later named community nutrition. The
6    I ntroduction to the P rofession of N utrition and D ietetics

administration practice became known as institution administration and

later food systems management or management in food and nutrition.
The association continued to grow and by 1927 had 1200 members.
The office headquarters were located in Chicago, and the association was
legally incorporated in the state of Illinois. The first edition of the Journal
of the American Dietetic Association was published in 1925, with four issues
per year. Early issues of the journal featured subjects similar to those pub-
lished today, such as hospital food service, personnel issues, and special
diets, especially the diabetic diet.

IN F LUENT I A L L E A D E R S
Sarah Tyson Rorer has been credited as the first American dietitian. She was
an instructor in one of the early cooking schools and educated both dieti-
tians and physicians in hospital dietetics. Ellen H. Richards was the founder
and leader of the home economics movement and so is claimed as one of
the early leaders in dietetics. Lulu Graves served as the first president of the
ADA and established a training course for hospital dietitians at Cornell Uni-
versity. Lenna Frances Cooper was an early ADA president and director of
the School of Home Economics at Battle Creek Health Care Institution in
Michigan. Later, she was appointed to the staff of the U.S. surgeon general
in Washington, DC. She is commemorated through a lecture presented each
year at the annual meeting of the ADA by a current leader in the profession.16
Ruth Wheeler prepared the first outline of a training course for student
dietitians that established education requirements for dietetics practice.
Mary E. Barber, another ADA president, was the director of home eco-
nomics at Battle Creek and was appointed as a food consultant in 1941
to assist with the problems of feeding l.5 million soldiers in World War
II. She also edited the first official history of the ADA. Mary Swartz Rose
was a leader in nutrition research and nutrition education for the public
and established the Department of Nutrition at Columbia University.
The Mary Swartz Rose fellowship for graduate study is awarded yearly in
honor of this outstanding scientist and scholar.17
Mary P. Huddleston was the editor of the ADA journal from 1927 to
1946. An annual award is presented in her name to the author of the best
article published in the previous year’s journal. Anna Boller Beach was
the first executive secretary of the ADA in 1923, served as president, and
was the historian of the association for many years. Lydia J. Roberts was
 You get the link on our page
vk.com/lingualib I n f l u e n t i a l L e a d e r s      7

a leading nutritionist at the University of Chicago and the University of

Puerto Rico. She initiated nutrition education programs to improve the
nutritional status of children in Puerto Rico and was recognized widely
for this accomplishment. Mary deGarmo Bryan inspected hospital train-
ing courses for dietitians in the 1930s and also developed a training course
for directors of school lunch programs.
Scores of other influential leaders led the way in dietetics. Additional
information can be found in Carry the Flame: The History of the American
Dietetic Association18 and in several issues of the Academy journal. This
brief listing highlights those leaders who played key roles in founding the
association and thus were pioneers in the profession of dietetics.
Many influential leaders have stepped forth over the years to assume
leadership positions that moved the Association forward. The historical
series of articles beginning in 2012 (shown later in this chapter) point to
many persons and events important in the growing profession. A 2013
President’s page made reference to several leaders in specific areas of
practice.19

Recognized Leaders Today

Each year, the Academy selects leaders who have made significant contri-
butions to the profession and are singled out for recognition at the annual
meeting. The highest honor awarded is the Marjorie Hulsizer Copher
Award for which one recipient is named each year. The award is given
in recognition of Copher who had a distinguished career in WWI, hav-
ing been decorated by both England and France for improving food ser-
vice delivery in field hospitals before serving as chief dietitian at Barnes
Hospital in St. Louis. The awardee is a leader who has shown extensive,
active participation and service to the profession of dietetics nutrition.
The complete listing of persons receiving the honor can be accessed on
the Academy website.
The Medallion Awards are presented each year to several (5 to 10)
Academy members who have demonstrated outstanding service to the
profession in various ways. Dietitian nutritionists who have been mem-
bers of the Academy for at least 10 years are eligible to be nominated. All
past recipients are also listed on the Academy website.
Another honor awarded each year is for a member selected to present
the Lenna Frances Cooper Memorial Lecture. The person receiving the
award presents a lecture on a topic of his/her choice at the annual meeting,
8    I ntroduction to the P rofession of N utrition and D ietetics

which is published later in the journal. Persons selected are accomplished

speakers as well as having made unique contributions to the profession.
In 2015, the Academy established a new designation: Fellow of the
Academy of Nutrition and Dietetics (FAND). This honor recognizes
Academy leadership, volunteer, and presentation experience on behalf of
the Association. Recipients add the designation “FAND” to their title.
Several other honors and awards are given annually in recognition of
outstanding service at the state or national level and for leadership in spe-
cific areas of practice. The Academy also recognizes one or more persons
in allied professions by bestowing honorary membership. The Honors
Committee of the Board of Directors establishes criteria for the awards
and makes selections among those nominated for national awards.

D IE T ET ICS A S A P R O F E S S I ON
A profession is defined as an area of practice with the following character-
istics: specialized knowledge, continuing education, a code of ethics, and
a commitment to service for others. Plato first described a profession as
“the occupation … to which one devotes himself, a calling in which one
professes to have acquired some special knowledge used by way of instruc-
tion, guidance, or advice to others, or of servicing them in some art.”20
Dietetics, like other professions that fit Plato’s description, is organized
around these principles in the following ways:
Specialized knowledge. Standards for education for dietetics were estab-
lished as early as 1919. At least 2 years of college was first recommended,
which later became a 4-year requirement or a 2-year course for institutional
managers. Courses for the bachelor’s degree were specified, and, later, hos-
pital training of 6 months was added to the educational requirement. Sub-
sequent education plans were introduced that continued to specify needed
courses. In 1987, standards of education were established, by which dietet-
ics education focused more on the outcomes of the educational process.
The ADA set up a review process that periodically updated educational
requirements as the profession grew and matured. Dietitians and employers
alike recognize the specialized knowledge required to practice in dietetics.
Continuing education. When dietetics was registered as an accredited
profession in the 1960s, a requirement of 75 hours of continuing educa-
tion each 5 years was initiated. A wide number of educational events were
recognized as meeting this requirement and were given credit accordingly.
 Growth of the P r o f e s s i o n      9

Continuing professional education is a well-established function of the

Academy through the center for professional education, which offers con-
ferences, annual meeting events, and other opportunities.
A code of ethics. A code of ethics for its members was developed in
1942.21 The code was updated and expanded over the years, moving from
the Code of Professional Conduct to the 2009 Code of Ethics for the Profes-
sion of Dietetics and Process for Consideration of Ethics Issues. Published
jointly by the Academy and the Commission on Dietetic Registration, it
provides guidance to dietetic practitioners in their professional practice
and conduct.22
Service to others. The seal of the Academy carries the motto, “Quam
Plurimis Prodesse,” which means, “benefit as many as possible.” Dieti-
tians recognize a professional commitment to help the public attain opti-
mal health and quality of life through the practice of good nutritional
habits. The organization reflects this imperative in all areas of practice.
As of January 1, 2012, the name of the association was changed to the
Academy of Nutrition and Dietetics.

G RO W T H O F TH E P R O F E SSI ON
Membership
In 1917, the requirements for membership were lenient to bring in as
many practitioners as possible. Gradually, however, active membership
became based on specified education and practical experience. Several
categories of membership have been added over the years, and at present,
the categories are active, honorary, international, retired, student, and
associate members.
Membership in the Academy has risen steadily over the years. The
membership grew by about 1000 to 1500 each decade until a growth
spurt in the late 1960s, with the addition of about 15,000 members
between 1968 and 1978. In 2015, the membership stood over 75,000 of
which about 5 percent were men.
Registration and Licensure
In 1969, the association established the system of national professional certifi-
cation under which the dietitian was designated as a registered dietitian (RD).
The title carried legal status and denoted the professional who met the educa-
tion and experience requirements to practice, in addition to participating in
10    I ntroduction to the P rofession of N utrition and D ietetics

continuing education, thereby maintaining currency of practice. A national

testing program was also developed to establish eligibility. Employers soon
became familiar with the RD credential and began specifying it as a condition
of employment. Today, 75 percent of all dietitians are registered.
Licensure of dietitians occurs in states in which state governments have
passed legislation recognizing the profession and awarded state-level legal
standing. Forty-seven states have enacted licensure laws for dietitians.

The Academy of Nutrition and Dietetics Foundation

The arm of the association with a tax status identifying it as an educational
and scientific nonprofit organization, the Foundation solicits and accepts
monies donated for scholarships, research, and other designated projects.
Several major studies have been funded by the foundation, and programs
and lectureships at the annual meeting have been made possible through
gifts and donations.

Dietetic Technicians and Managers

Managers. The Hospital, Institution, and Educational Food Service Society
(HIEFSS) was formed in 1960 as an organization for food service supervi-
sors. It was an independent society but closely tied to the ADA through
membership standards as well as financial support. The name was later
changed to the Association for Managers of Food Operations (AMFO),
and the title for members became food manager. The current name of this
association is the Association of Nutrition and Foodservice Professionals
(ANFP). Persons completing a voluntary certificate program have the title,
certified dietary manager (CDA). Membership stands at over 14,000.
Dietetic technicians. Dietetic technician programs require specific edu-
cation and training, usually 2 years in a community college program of
study. As with the RD, the technician member can also become registered
by meeting the specific standards and passing an examination. He or she
earns the title dietetic technician, registered (DTR).
Several milestones in the history of the DTRs follow:23
• 1986. The American Dietetic Association grandfathered 3618
dietetic technicians into membership.
• 1987. The first administration of the registration exam for dietetic
technicians in nutrition care services and food service systems man-
agement was conducted.
 Growth of the P r o f e s s i o n      11

• 1987. The passing standard for the registration examination for

dietetic technicians was established.
• 1988. Continuing education requirements for DTRs were enacted.
• 1990. First DTR elected to the Commission on Dietetic Registration.
• 1990. Administration of the first registration examination based on
the 1990 role delineation study took place, and new passing stan-
dards were developed.
• 1996. New test specifications for the DTR examination were
implemented.
• 2007. New test specifications for DTR registration examination
were implemented.
• 2009. Pathway III process was implemented to allow didactic pro-
gram in dietetics graduates to sit for the DTR examination.
• 2015. Membership stood at 75,000.

Legislative Activity
Involvement in legislative activity began when dietitians promoted a bill to
grant military rank to dietitians serving in World War I. In the 1940s and
1950s, legislative activity centered around setting standards for employ-
ment in the Veterans Administration, passage of the national School
Lunch Act, and, in 1946, support of the Maternal and Child Health
bill. Signaling even more extensive efforts, the association changed its tax
status in the 1960s to permit active lobbying and made its voice heard
by establishing an office in Washington, DC, and taking positions on
national issues. A political action committee (PAC) was formed in 1980,
through which Academy members donate funds and recognize legislators
who promote legislation on behalf of food and nutrition issues. Each year,
the Academy identifies key legislative issues for particular attention and
activity by the Washington office and members. The current legislative
priorities for the Academy are discussed later in this chapter.

Areas of Practice
The practice of dietetics was first structured around four areas in which
dietitians were employed. Little was documented about the number of
dietitians working in each area until periodic membership surveys were
initiated in the early 1980s. As shown in Table 1-1, clinical dietetics is
the area in which the highest number of dietitians work. Fifty-six percent
12    I ntroduction to the P rofession of N utrition and D ietetics

Table 1-1.  Primary Area of Practice by Dietitians (Percent)

Practice Area 2007a 2009b 2011c 2013d 2015e

Clinical dietetics 55 56 56 57 57

Food and nutrition 12 12 12 12 11

management

Community nutrition 11 11 11 11 10

Consultation/business 11 8 8 8 8

Education/research 6 7 7 6 7

Other 5 6 6 6 7

Sources: a. Rogers, D. “Compensation and Benefits Survey 2007: Above Average Pay Gain
Seen for Registered Dietitians.” J Am Diet Assoc 108 (2008): 416–425.
b. American Dietetic Association. Compensation and Benefits Survey of the Dietetics Profes-
sion 2009. Accessed October 20, 2009, www.eatright.org
c. Warde, B. “Compensation and Benefits Survey 2011: Moderate Growth in Registered
Dietitian and Dietetic Technician Registered, Compensation in the Past 2 Years.” J Acad Nutr
Diet 112 (2012): 29–40.
d. Rogers, D. “Compensation and Benefits Survey 2013: Education and Job Responsibility
Key to Increased Compensation.” J Acad Nutr Diet 113 (2014):17–33.
e. Rogers, D. “Compensation and Benefits Survey 2015.” J Acad Nutr Diet 116, no. 3 (2016):
370–388.

of DTRs also work in clinical practice. Although this initially designated

hospital-related dietetics, the clinical dietetics category now includes acute
inpatient, ambulatory, and long-term care. The number of dietitians
working in food service administration has declined in recent years while
other areas of practice have remained close to the same.

Dietetic Practice Groups

Dietetic practice groups (DPGs) are formed by Academy members prac-
ticing in or having a particular interest in an identified area of practice.
DPGs provide a means of networking among group members. The groups
elect officers, collect dues, and publish a newsletter or similar communi-
cation for its members. From the original 9 groups established in 1978,
there are now 26 practice groups.24 Additional subgroups, or member
interest groups (MIGs), have also been formed.
 Growth of the P r o f e s s i o n      13

Long-Range Planning
Leaders in dietetics have consistently taken steps to position the profession
to meet both present and future needs. This has been achieved through
planning groups, task forces, committees, and outside consultants. In
1959, through a study, it was determined that active recruitment, edu-
cational opportunities, interaction with other professional groups, and
an emphasis on research were needed for continued growth and develop-
ment of the profession. These goals were expanded in the 1970s with
the appointment of a task force and a study commission on dietetics.
The study outcome was a report that examined the roles of dietitians and
their educational needs for the future. Titled, The Profession of Dietetics:
The Report of the Study Commission on Dietetics, the report influenced the
direction of the association for many years. A second in-depth study in
1984 became a major reference source for long-range planning.25,26
Many planning activities that moved the profession forward in signifi-
cant ways were initiated in the 1980s. The first of a series of long-range
planning conferences convened in 1981, with a second in 1984. Invited
leaders discussed goals and needs and made far-reaching recommenda-
tions. The future was also explored in a strategic planning conference in
1995.27 The ADA moved decisively toward public outreach and increased
involvement in the policy arena, although emphasis on association mem-
bers and their professional welfare continued.
Further landmark studies examined the education of dietitians, reg-
istration and licensure, and advanced practice. In the 1970s, a master
plan for education for practice identified trends affecting the demand for
dietitians and estimated numbers that would be needed in the future.28
Role delineation studies included dietetic technicians and described the
roles of dietitians and technicians in a variety of settings. These and other
studies in the 1990s, including one by the Task Force on Critical Issues:
Registration Eligibility and Licensure,29 continued to show opportunities
that enhanced both education and practice and led to continued advances
in the profession.
Two task forces in early 2000, the Task Force on the Future Practice and
Education and the Phase 2, Future Practice and Education Task Force,
initiated broad and comprehensive studies of practice and education.30
The board of directors undertakes long-range planning on a regu-
lar basis. Using expert consultants and the results of special studies and
14    I ntroduction to the P rofession of N utrition and D ietetics

surveys, the board examines trends impacting dietetic practice to make

long-term projections and set goals. The Strategic Plan of 2011–2012 is
the current document outlining the association’s goals.

Professional Partnerships
The Academy currently maintains liaisons with some 140 allied groups
and associations. The formation of these partnerships has advanced
mutual efforts and made many programs and activities possible. A long-
standing affiliation with the American Public Health Association and the
American Diabetes Association has resulted in the development of the
diabetic exchange lists and joint publication of the booklet, Choose Your
Foods: Exchange Lists for Diabetes. Grants from the public health associa-
tion also allowed the ADA to sponsor workshops on programmed learn-
ing. The U.S. Public Health Service sponsors a nutrition section that
administers programs critical to health care in the United States. The
American Diabetes Association exchanges speakers with the Academy at
conferences and annual meetings.
The American Hospital Association is another important organization
allied with the Academy. Hospitals employ many dietitians who contrib-
ute to patient care. Hospital-accrediting bodies (e.g., the Joint Commis-
sion) include nutrition and food services in their surveys regarding the
quality of the services.
The Food and Nutrition Science Alliance (FANSA) was formed in 1992
with the Institute of Food Technology, the American Society for Clinical
Nutrition, and the American Society of Nutritional Science. This linkage
brought together a combined membership of more than 100,000 who join
forces to speak with one voice on food and nutrition issues and to translate
scientific information into practical advice for consumers. FANSA is a
partnership of seven professional scientific societies whose members have
joined forces to speak with one voice on food and nutrition issues.31
The Academy of Nutrition and Dietetics has participated in many pro-
grams with governmental agencies, including the U.S. Department of
Agriculture (USDA), the Department of Health and Human Services
(DHHS), the National Institutes of Health, the National Research Coun-
cil, and the U.S. Congress.
The International Confederation of Dietetic Associations is composed
of 34 national dietetic associations. The American Dietetic Association
was an early member of this group. The purposes of the confederation are
 Reaching Out to the P u b l i c      15

to achieve integrated communication; promote an enhanced image for

the profession; and increase awareness of standards of education, training,
and practice in dietetics.
The American Overseas Academy is affiliated with the Academy. The
members are Academy members living overseas. The members enjoy the
same benefits and privileges as other Academy of Nutrition and Dietetics–
affiliated groups.
An International Congress of Dietetics is held in a major city every 5
years. The first congress was held in Amsterdam in 1952, with the ADA
as one of the founding groups. Organized for the purpose of sharing
information, the congress publishes an international bulletin and holds
an annual meeting. The 2012 congress was held in Sydney, Australia.

REACH I N G O U T TO TH E PUBL I C
The Academy has initiated many programs over the years directed to the
general public. Foremost among the services currently offered by the orga-
nization are the Academy website, www.eatright.org, and toll-free num-
ber, 1-800-877-1600. The website is a source of current information for
professionals as well as consumers interested in food and nutrition issues
and programs. Employers searching for a dietitian may also use the web-
site to make connections.
Begun as a Dietitian’s Week observance in three states, this focus is
now a month-long event each March with both local and national empha-
sis and known as National Nutrition Month.
A dial-a-dietitian program, funded by the Nutrition Foundation, was
started in Detroit in 1961. Many states now offer similar services designed
to provide information in a timely manner in response to questions from
the public.
A training program was initiated in 1982 to prepare selected dieti-
tians to serve as spokespersons for the profession to reach the public with
food and nutrition information through the media. More spokespersons,
including state media persons, have been added in most major media in
the United States. Referred to as the spokesperson network, the program
continues to be highly successful at reaching the public with timely and
reliable information through television and other media outlets.
Participation in national projects and campaigns is another way the
association impacts the public. Over the years, campaigns on women’s
16    I ntroduction to the P rofession of N utrition and D ietetics

health, child nutrition, osteoporosis, high blood pressure, and other issues
have been the focus of several medical and health-related groups, includ-
ing the Academy.
Childhood obesity has been a focus of the Academy and the Foun-
dation for several years in concert with other governmental and private
groups, such as The Alliance for a Healthier Generation. Academy mem-
bers also serve on the committee to develop the Dietary Guidelines for
Americans and on the Food and Nutrition Board of the National Acad-
emy of Sciences.

H IS T O RICA L E V E N TS I N THE A C A DEM Y

O F NUT RITI O N A N D D I E TE TI C S
A series of historical events in the association have been published begin-
ning in 2012. The titles are as follows:
• History and Governance32
• Networking Groups33
• The Foundation34
• Dietetic Students35
• The Military Roots36
• Corporate Relations37
• The Academy’s Past38
• Annual Meeting39
• Founding of the Academy40
• Recruitment Materials41
• Communications42
• Modern History43

SU MMARY
The history of the dietetics profession is a rich account of consistent
growth, forward-thinking leaders, and the emergence of dietitians as lead-
ers among those concerned with the health and well-being of all citizens.
As a profession, dietetics has established standards for practitioner educa-
tion, a code of ethics, registration and licensure systems, and a tradition
of partnership and collaboration with others in allied areas of professional
practice to extend outreach and service. The Academy of Nutrition and
 R e f e r e n c e s      17

Dietetics supports its members as they practice in a wide variety of careers,

and it also reaches out to the public with timely and reliable information
about food and nutrition issues.

D E F INI T I O N S

Academy of Nutrition and Dietetics. The professional organization for

dietitians. Formerly known as the American Dietetic Association.
Dietetic practice group (DPG). An organized group of Academy of
Nutrition and Dietetics members with similar interests in an area of
practice or a particular subject area.
Dietetic technician. A graduate of an approved dietetic technician
program.
Dietitian. A professional who translates the science of food and nutri-
tion to enhance the health and well-being of individuals and groups.
Nutritionist. A professional with academic credentials in nutrition; he
or she may also be an RD.
Registered dietitian (RD). A dietitian who has fulfilled the eligibility
requirements of the Commission on Dietetic Registration.

REFE REN C E S
1. Barber, M.I. History of the American Dietetic Association (1917–1959). (Philadelphia:
JB Lippincott Co., 1959), p. 3.
2. Corbett, F.R. “The Training of Dietitians for Hospitals.” J Home Ec 1 (1909): 62.
3. ADA. A New Look at the Profession of Dietetics. Report of the 1984 Study Commission
on Dietetics. (Chicago: The American Dietetic Association, 1985), p. 29.
4. Todhunter, E.N. “Development of Knowledge in Nutrition. 1. Animal
Experiments.” J Am Diet Assoc 41 (1962): 328–334.
5. Beeuwkes, A.M. “The Prevalence of Scurvy among Voyageurs to America
1493–1600.” J Am Diet Assoc 24 (1948): 300–304.
6. Goldberger, J. “Pellagra.” J Am Diet Assoc 4 (1929): 212–227.
7. McCoy, C.M. “Seven Centuries of Scientific Nutrition.” J Am Diet Assoc 15
(1939): 648–658.
8. Shircliffe, A. “American Schools of Cookery.” J Am Diet Assoc 23 (1947): 776–777.
9. See Note 3.
10. Rorer, S.T. “Early Dietetics.” J Am Diet Assoc 10 (1934): 289–295.
11. Cassell, J. Carry the Flame: The History of the American Dietetic Association.
(Chicago: The American Dietetic Association, 1990).
18    I ntroduction to the P rofession of N utrition and D ietetics

12. Cooper, L.F. “Florence Nightingale’s Contribution to Dietetics.” J Am Diet Assoc

39 (1954): 121–127.
13. Mathieu, J. “RDs in the Military.” J Am Diet Assoc 108, no. 12 (2008): 1984–1987.
14. See Note 11.
15. See Note 3.
16. See Note 11.
17. Ibid.
18. Ibid.
19. President’s Page. “Members Who Have Climbed to the Top.” J Acad Nutr Diet
114, no. 4 (2014): 517.
20. See Note 11.
21. Ibid.
22. American Dietetic Association/Commission on Dietetic Registration. “Code of
Ethics for the Profession of Dietetics and Process for Consideration of Ethics
Issues.” J Am Diet Assoc 109, no. 8 (2009): 1461–1467.
23. Babjak, P. Personal communication.
24. List of Dietetic Practice Groups (DPGs). www.eatright.org (10/11/15)
25. ADA. The Profession of Dietetics. The Report of the Study Commission on Dietetics.
(Chicago: The American Dietetic Association, 1972).
26. “A new look at the profession of dietetics. Final report of the American Dietetic
Association Foundation 1984 Study Commission on Dietetics: Summary and
recommendations.” J Am Diet Assoc 84 (1984): 1052–1063.
27. ADA. ADA Annual Report. 1994–1995. (Chicago: The American Dietetic
Association, 1995), p. 5.
28. Council on Educational Preparation. “Report of the Task Force on Competencies.”
J Am Diet Assoc 73 (1978): 281.
29. Registration Eligibility and Licensure Task Force. Report of the Critical Issues.
(Chicago: The American Dietetic Association, 1992).
30. ADA. Report of the Phase 2. Future Practice and Education Task Force. (Chicago:
American Dietetic Association, 2008).
31. Food and Nutrition Service Alliance. www.foodprocessding.com/industrylinks.
32. Stein, K. “The Academy’s Governance and Practice: Restructuring for the
Challenges of the Turn of the 21st Century.” J Acad Nutr Diet 112, no. 11 (2012):
1871–1896.
33. Stein, K. “Networking Groups: Advancing Nutrition and Practice Groups through
Practice, Culture, and Geography.” J Acad Nutr Diet 113, no. 2 (2013): 326–343.
34. Stein, K. “Advancing the Dietetics Profession through the Foundation’s
Philanthropy.” J Acad Nutr Diet 113, no. 6 (2013): 834–855.
35. Stein, K. “History Snapshot: Dietetics Student Experience in the 1940s.”
J Acad Nutr Diet 114, no. 10 (2014): 1648–1662.
36. Stein, K. “The Academy’s Military Roots Visualized.” J Acad Nutr Diet 114, no.
12 (2014): 2023–2049.
 R e f e r e n c e s      19

37. Stein, K. “Advancing Health through Sustained Collaboration: How the History
of Corporate Relations Extended the Academy’s Reach.” J Acad Nutr Diet 115,
no. 1 (2015): 131–142.
38. Stein, K. “What We Ate: Reports of the Academy’s Past.” J Acad Nutr Diet 115,
no. 2 (2015): 286–302.
39. Stein, K. “Coming Together Conference: A Philosophic Journey through
Academy Annual Meeting in the 20th Century.” J Acad Nutr Diet 115, no. 4
(2015): 635–659.
40. Stein, K. “A Few Days in Autumn: The Founding of the Academy of Nutrition
and Dietetics.” J Acad Nutr Diet 115, no. 6 (2015): 1008–1009.
41. Stein, K. “A Pictorial Job Fair: A Glimpse at the Academy’s Vintage Professional
Recruitment Materials.” J Acad Nutr Diet 115, no. 9 (2015): 1500–1513.
42. Stein, K. “Communications at the Academy: Where Strategy and Trending
Conspire to Shape History.” J Acad Nutr Diet 115, no. 7 (2015): 1148–1168.
43. Stein, K. “The Value of Belonging: The Recent History of Member Services at the
Academy.” J Acad Nutr Diet 116, no. 1 (2016): 100–162.
 2

CHAPTER
The Academy of
Nutrition and Dietetics
“Our capacity to influence the public—to change lives—is
limitless, and it is something we do year-round.”1

OUTLINE
• Learning Objectives
• Introduction
• The Strategic Plan
• Membership Categories
• Membership Benefits
• Governance of the Academy of Nutrition and Dietetics
• Board of Directors
• House of Delegates
• Accreditation Council for Education in Nutrition and
Dietetics
• Commission on Dietetic Registration
• Dietetic Practice Groups
• Position Papers
• Dietitian Salaries
• Affiliated Units of the Academy of Nutrition and Dietetics
• State and District Associations
• Academy of Nutrition and Dietetics Foundation
• Washington Office
• American Overseas Dietetic Association

21
22    T he A cademy of N utrition and D ietetics

• Summary
• Definitions
• References

LEARNING OBJECTIVES
The student will be able to:
1. Name and describe the functions of the various governing
groups in the Academy.
2. Become familiar with dietetic practice groups (DPGs) and
their purposes.
3. Know the categories of membership and their requirements.
4. Understand how goals and priorities are part of a strategic
plan for an organization.
5. Discuss member benefits.

IN T RO D UC TI O N
The Academy of Nutrition and Dietetics stands as the professional orga-
nization of about 75,000 food and nutrition experts (5 percent male and
95 percent female). In the 99 years since its founding, this organization
has been the major forum for the networking of dietitians, for research
related to food and nutrition, for managerial activities, and for political
activities necessary to govern itself and for outreach to the public.
The original constitution and bylaws of the association have been
amended frequently, but the focus of the association has remained con-
stant from the beginning: maintaining a concern for the continuing inter-
ests of dietitians and dietetic professionals in their education, practice
opportunities, and research for the future. The Academy, as the profes-
sional association for practitioners, has long-standing concerns for the
protection of the public in areas of nutritional health and disease pre-
vention and the welfare of the practitioner (or individual member). The
organization and its leaders of elected members have worked through the
years to keep these concerns in focus.
 T h e S t r a t e g i c P l a n      23

The mission statement of the Academy of Nutrition and Dietetics

is, “empowering members to be the nation’s food and nutrition
leaders.”2 The mission statement sets the agenda for the association and
its programs and is described as the association’s reason for being. The
values that guide the organizational and member behavior are customer
focus, integrity, innovation, social responsibility, and diversity.3 The values
are defined as:
Customer focus—meet the needs and exceed the expectations of all
customers.
Integrity—act ethically with accountability for lifelong learning, com-
mitment to excellence, and professionalism.
Innovation—embrace change with creativity and strategic thinking.
Social responsibility—make decisions with consideration for inclusivity
as well as environmental, economic, and social implications.
Diversity—recognize and respect differences in culture, ethnicity, age,
gender, race, creed, religion, sexual orientation, physical ability,
politics, and socioeconomic characteristics.
The vision of the Academy is to “optimize the nation’s health through
food and nutrition.”4

T H E S T RATE G I C P L A N
Through activation of the mission and vision statements along with the
identified values and goals, a strategic plan for the Academy and its mem-
bers is in effect. The goals help focus, set priorities, and assign resources.
They specify outcomes and represent what needs to be achieved. Four
major goals are identified along with 16 strategies to help define how the
goals are to be accomplished.5 The goals are:
1. The public trusts and chooses Registered Dietitian/Nutritionists
as food, nutrition and health experts.
2. Academy members optimize the health of individuals and popula-
tions served.
3. Members and prospective members view the Academy as vital to
professional success.
4. Members collaborate across disciplines with international and
nutrition communities.
24    T he A cademy of N utrition and D ietetics

In 2008, the Academy adopted a standard logo, replacing a mix of over

100 different visual brands.6 The logo bears the words, “Eat right.”

MEMB E RS HI P C ATE G O R I E S
Membership in the Academy is available in any one of the following cat-
egories: active, honorary, retired, student, international.7 Associate mem-
bership is also available to practitioners in other fields.
The largest category of membership is active, which generally includes
those who hold a baccalaureate degree and have met academic require-
ments specified by the Academy; an individual with an advanced degree
and an emphasis in a closely allied area with dietetics; or a dietetic tech-
nician, registered (DTR). In addition, any person who has completed a
term as president of the association or one who has previously paid dues
to obtain life membership may also hold active membership.
The retired member category is an option for any member who is at
least 62 years of age, either actively employed or no longer employed.
Student members are those enrolled in an accredited program, a student
in a college degree program intending to enter an accredited program, or
active members returning to school for a degree in a dietetic-related course
of study. Honorary membership is awarded to individuals who have made
contributions to the field of nutrition or dietetics and are deemed eligible
by the board of directors (BOD). International members are those per-
sons who have completed formal training outside the United States and
U.S. territories and have been verified by a country’s professional dietetics
association or regulatory body. The Associate category is open to persons
in allied fields with a minimum of a bachelor’s degree and training or cer-
tification in a specified profession. See the Academy website for a listing
of the designated professions.
The rights and privileges of each of the membership categories appear
in the bylaws of the Academy. The dues may change from year to year by
action of the house of delegates (HOD). Dues differ for each category,
with a portion of the national dues offsetting the cost of the Journal of the
Academy of Nutrition and Dietetics and a rebate returned to the state affili-
ate associations for each member of the state. In addition, the national
dietetic practice groups (DPGs) charge for membership in their groups
and provide newsletters and other educational materials for members in
the specific practice area.
Governance of the Academy of Nutrition and D i e t e t i c s      25

MEMB E RSH I P B E N E F I TS
Membership in the Academy benefits the individual and collective members
in many ways.8 These may be summarized under the following categories:
• Websites
• Publications and subscriptions
• Career resources
• Practice resources
• Social networking
• Educational opportunities
• Policy initiatives and advocacy
• Science and quality
• Networking and promotions
• Promotional resources
• Branding services
• Additional benefits
• Honors and awards
• Professional insurance
• Academy Credit Card

G O V E RNA N C E O F TH E A CA DEM Y OF
NUT RIT I O N A N D D I E TE TIC S
The organizational structure of the ADA/Academy of Nutrition and
Dietetics changed over time; however, governance has been through
members who were either elected, appointed, or volunteered from the
membership at large. Those elected each year are the officers serving on
the BOD, delegates to the HOD by states, members of the Commission
on Dietetic Registration, and members of the Accreditation Council for
Education in Nutrition and Dietetics (ACEND). Members of the founda-
tion board are appointed, and membership in DPGs is by member choice.
A chief executive officer (CEO) is employed by the board to oversee and
manage a paid staff at the headquarters in Chicago. Under the leadership
of the CEO, the staff members form partnerships with the various volun-
teer groups, forming teams to accomplish the variety of tasks necessary to
keep the organization functional and to implement the strategic plan. The
BOD and the HOD function as a voice for members.
26    T he A cademy of N utrition and D ietetics

Board of Directors
The board of directors (BOD) is composed of 19 members: president,
president-elect, past president, treasurer, treasurer-elect, past treasurer,
three directors at large, six HOD directors, two public members, the
foundation chair, and the CEO, who is nonvoting. The BOD governs the
organization through the following activities:
• Sets and monitors strategic direction
• Oversees fiscal planning
• Provides leadership for professional initiatives
• Selects, supports, and assesses the CEO and conducts an annual
performance appraisal
• Appoints persons to represent the association
• Establishes guidelines and policies for appeals, publications, awards,
and honors
• Administers and enforces the professional code of ethics
• Exercises powers and performs lawful acts under the Illinois Not-for-
Profit Corporation Act

House of Delegates
The house of delegates (HOD) is composed of 105 delegates who repre-
sent each state, almost all the DPGs, the Commission of Dietetic Regis-
tration, ACEND, dietetic technicians, and student members. The House
leadership team develops and implements program goals of the House.
Issues that are identified as important to the membership are discussed at
each Spring and Fall session of the HOD.
The House of Delegates includes 105 members as follows:
• 66 Affiliate Delegates elected by members of the 53 affiliate dietetic
associations.
• 26 Dietetic Practice Group (DPG) members elected or appointed by
each DPG
• 7 at-large Delegates as follows: 1 from ACEND, 1 from CDR,
1 student member, 1 under age 30 member, 1 from DTR, 1 retired
member, and 1 from NDEP.
• 6 HOD Directors including the Speaker, Speaker-elect, immediate
past speaker, 3 appointed
Governance of the Academy of Nutrition and D i e t e t i c s      27

The House of Delegates, as the voice of members, governs the profes-

sion and develops policy on many professional issues.
The Leadership team develops and implements programs based on the
core functions as follows:
• Member focus
• Information systems and communications
• Strategic thinking and visioning
• New products and services development
• Governance
• Professional leadership
• Setting policy for the profession
• Financial
The HOD provides a forum for membership and professional issues,
and establishes and maintains professional standards of the membership.
Core roles of the HOD include adopting and maintaining a code of ethics
in conjunction with the CDR, developing position statements and other
professional papers, establishing qualifications and dues of members, and
the formula for dues payment to affiliate organizations. The HOD also
identifies and prioritizes trends and recommends policy and strategic
direction for the Academy. The HOD has the authority to establish com-
mittees and rules and policies of organization and governance, including
its own composition and size.
Both the BOD and the HOD represent Academy members and gov-
ern the Academy. As a comparison, the BOD is likened to the executive
branch of the U.S. government and the HOD to the legislative branch.
Both groups work together closely to promote the interests of the mem-
bers and further the profession.

Accreditation Council for Education in Nutrition and Dietetics

The Accreditation Council for Education in Nutrition and Dietetics
(ACEND) establishes and enforces standards for the educational prepara-
tion of dietetics professionals and recognizes dietetics education programs
that meet the standards. The ACEND administers and has authority for
all actions that apply to accreditation of entry-level education programs
that include standard setting, fees, finances, and administration. There
are 12 members on the council. At least half of the members represent
28    T he A cademy of N utrition and D ietetics

each program type (dietetic technician, didactic, coordinated, and dietetic

internship). The council includes one representative of other constituents,
one dietetic student, and two representatives of the public.

Commission on Dietetic Registration

The mission of the Commission on Dietetic Registration (CDR) is to
protect the public through credentialing and assessment procedures that
ensure the competence of registered dietitians and dietetic technicians,
registered and specialists.
The CDR sets the standards for certification and recertification and
enforces the code of ethics of the association. The commission issues
credentials to those individuals who meet the standards. Dietitians thus
attain the registered dietitian (RD) designation, and dietetic technicians,
the DTR. Specialists receive the certified specialist title.

Dietetic Practice Groups

Dietetic practice groups (DPGs) are professional interest groups within
the Academy framework. The 28 active groups show the diversity of the
practice areas in which dietitians work (Table 2-1). Each group networks
to serve its members, charges fees to support its activities, and maintains
communication with its members by various means. The groups also
sponsor educational sessions at the annual meeting. The requirements to
join a DPG are Academy membership or registration status and payment
of dues. A member may belong to as many groups as desired.
Formation of new groups occurs after interest groups become large
enough to seek official status. A petition is submitted with no fewer than
500 signatures indicating interest, individuals willing to serve as officers,
and a budget. Aside from maintaining a minimum of 300 members,
other uniform requirements include publication of a newsletter at least
quarterly for its members, maintaining governing documents, conduct-
ing an annual meeting of its members, and maintaining a balanced bud-
get. DPGs offer networking opportunities with professionals with similar
interests and provide significant opportunities for leadership responsibili-
ties both within the DPG and the Academy.
A practice group may also develop subunits or groups of members
within the DPG based on a practice area or issue of interest to the mem-
bers of the group, thus creating an even smaller group of dietitians with
closely allied interests. Currently, 30 subspecialty areas exist within the
 You get the link on our page
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Governance of the Academy of N u t r i t i o n a n d D i e t e t i c s      29

Table 2-1.  Dietetic Practice Groups 2015–2016

2015–2016 Dietetic
Practice Groups (DPGs) Description

Behavioral Health Nutrition BHN members are the most valued source of food
(BHN) DPG and nutrition service for persons with addictions,
eating disorders, intellectual and developmental
disabilities, and mental illness.

Clinical Nutrition Managers who direct clinical nutrition programs

Management (CNM) DPG across the continuum of care.

Diabetes Care and Members involved in patient and professional education,

Education (DCE) DPG as well as research for the management of diabetes.

Dietetic Technicians in Members are advocates for dietetic technician,

Practice (DTP) DPG registered, as dietetics practitioners in providing
quality client care.

Dietitians in Health Care Practitioners typically employed under contract who

Communities (DHCC) provide nutrition consultation to acute and long-
DPG term-care facilities, home care companies, healthcare
agencies, and the foodservice industry.

Dietitians in Business and Food and nutrition practitioners who work for or consult
Communications (DBC) with corporations, businesses, and organizations, or
DPG who are self-employed or business owners.

Dietitians in Integrative Food and nutrition practitioners that promote the

and Functional Medicine integration of conventional nutrition practices with
(DIFM) DPG evidenced-based alternatives including functional and
integrative medicine and nutrition.

Dietitians in Nutrition Dietitians who integrate the science and practice of

Support (DNS) DPG enteral and parenteral nutrition to provide nutrition
support therapy to individuals (adults, pediatrics,
inpatients, outpatients, home care, transplantation,
and complex gastrointestinal disorders).

Food and Culinary Members who promote food education and culinary
Professionals (FCP) DPG skills to enhance quality of life and health of the public.

Healthy Aging (HA) DPG Practitioners who provide and manage nutrition
programs and services to older adults in a variety of
settings.

Hunger and Environmental Members who lead the future in sustainable

Nutrition (HEN) DPG and accessible food and water systems through
education, research, and action.

Management in Food and Food and nutrition care managers generally employed
Nutrition Systems (MFNS) in healthcare institution, universities, corrections, and
DPG other facilities.
(continues)
30    T he A cademy of N utrition and D ietetics

Table 2-1.  Dietetic Practice Groups 2015–2016 (Continued)

2015–2016 Dietetic
Practice Groups (DPGs) Description

Medical Nutrition Practice Practitioners who practice a wide range of medical

Group (MNPG) DPG nutrition therapy across the continuum of care in a
variety of settings.

Nutrition Education for the Practitioners involved in the design, implementation,

Public (NEP) DPG and evaluation of nutrition education programs for
target populations.

Nutrition Educators of Members involved in education and communication

Health Professionals with physicians, nurses, dentists, and other
(NEHP) DPG healthcare professionals.

Nutrition Entrepreneurs NE members shape the future of dietetics practice by

(NE) DPG pursuing innovative and creative ways of providing
nutrition products and services to consumers,
industry, media, and business.

Oncology Nutrition (ON) Members shape the future of dietetics practice by

DPG pursuing innovative and creative ways to provide
nutrition products and services to consumer,
industry, media, and business.

Pediatric Nutrition (PNPG) Practitioners who provide nutrition services for the
DPG pediatric population in a wide variety of settings.

Public Health/Community Nutrition professionals who work in partnership with

Nutrition (PHCNPG) DPG healthcare providers, community leaders, and other
key stakeholders to serve the public in a variety of
roles and settings.

Renal Dietitians (RPG) Practitioners who provide medical nutrition service

DPG to chronic kidney disease patients in dialysis facilities,
clinics, hospitals, university settings, and private practice.

Research (RDPG) DPG Members who conduct research in various areas

to promote practice standards, health policy, and
disease prevention.

School Nutrition Services School foodservice directors, nutrition educators, and

(SNS) DPG corporate dietitians working in the delivery of food
service and nutrition education to children.

Sports, Cardiovascular, Nutrition practitioners with expertise and skills in

and Wellness Nutrition promoting the role of nutrition in physical performance,
(SCAN) DPG cardiovascular health, wellness, and disordered eating.

Vegetarian Nutrition (VN) Nutrition practitioners who focus on information and

DPG resources for plant-based diets.
 D i e t i t i a n S a l a r i e s      31

Table 2-1.  Dietetic Practice Groups 2015–2016 (Continued)

2015–2016 Dietetic
Practice Groups (DPGs) Description

Weight Management Practitioners who work in the prevention and treatment

(WM) DPG of overweight and obesity throughout the life cycle.

Women’s Health (WH) Practitioners addressing women’s nutrition care issues

DPG during the reproductive period through menopause.

Printed with permission from Academy of Nutrition and Dietetics.

main DPGs. In addition, 10 Member Interest Groups (MIGs) have been

formed whereby specific population groups can share mutual interests.
(See www.eatright.org for lists of sub groups and member interest groups.)

P O S IT I O N PA P E R S
A position paper represents a consensus of viewpoints and professional
interests and is used in many ways such as in media contacts, in draft-
ing legislation and testifying before governmental groups, and for com-
munication with the public. A nutrition position paper is described as a
statement of the association’s stance on an issue that affects the nutritional
status of the public; it is derived from pertinent facts and data, and is
germane to the Academy’s mission, vision, philosophy, and values. Posi-
tion papers are periodically updated or deleted, and others added by the
HOD. Copies of current position papers are available from the Academy
headquarters office or at www.eatright.org.

D IE T I T I A N S A L A R I E S
The salary levels of dietitians and dietetic technicians have risen over
the years, with certain practice areas commanding higher salaries. These
changes reflect the increasingly important roles played by dietitians and
dietetic technicians. In 1938, it was reported that hospital dietitians, on
the average, earned an annual salary in the range of $1090 to $7000. At
that time, benefits such as room, board, and laundry were often supplied
by the employer in addition to a salary. In positions other than those
offered by hospitals, the salaries ranged from $1200 to $4000 per year.
32    T he A cademy of N utrition and D ietetics

In 1946, the average salary was reported to be $3000—not a significant

improvement.9
In 1981, the ADA initiated the first survey of members that reported
salaries along with other data regarding employment. At that time, the
average yearly salary was $16,000, although the study did not equate all
salaries with full-time practice and the actual full-time salaries were prob-
ably higher.10 The median yearly salary for dietitians in all areas of prac-
tice from 2007 to 2015 is shown in Table 2-2. In 2015, the median salary
for all dietitians was $63,700.
When comparing salaries by areas of practice in dietetics, it is apparent
that dietitians in food and nutrition management and education/research
have the highest incomes while those earning the least are in community
nutrition practice. Several factors account for differences in compensa-
tion: years in a position, education level, job responsibilities, number of
persons supervised, budget responsibility, and location.11

Table 2-2.  Median Income for Registered Dietitians by Area of

Practice
Practice Area 2007a 2009b 2011c 2013d 2015e

Clinical 51,668 55,390 56,056 58,280 60,320

Food and nutrition management 64,002 67,995 70,990 74,006 78,000

Community nutrition 48,006 52,000 51,120 54,205 56,000

Consultation/business 60,008 69,992 65,000 65,603 77,000

Education/research 66,061 65,000 64,000 65,000 80,000

All areas 53,000 56,700 57,990 60,000 63,700

Sources: a. Rogers, D. “Compensation and Benefits Survey 2007: Above-Average Pay Gain
Seen for Registered Dietitians.” J Am Diet Assoc 108 (2008): 446–425.
b. American Dietetic Association. “Compensation and Benefits Survey of the Dietetics Profes-
sion 2009,” accessed at www.eatright.org.
c. Ward, B. “Compensation and Benefits Survey 2011: Moderate Growth in Registered Dieti-
tian and Dietetic Technician, Registered, Compensation in the Past 2 Years.” J Acad Nutr Diet 1
(2012): 29–40.
d. Rogers, D. “Compensation and Benefits Survey 2013: Education and Job Responsibility
Key to Increased Compensation.” J Acad Nutr Diet 114, no. 1 (2014): 17–33
e. Rogers, D. “Compensation and Benefits Survey.” J Acad Nutr Diet 116, no. 3 (2016):
370–388.
A f f i l i a t e d U n i t s o f t h e A c a d e m y o f N u t r i t i o n a n d D i e t e t i c s     33

The median wage for the registered dietetic technician was $36,000 in
2007, $39,000 in 2009, $40,000 in 2011, $40,000 in 2013, and $43,000
in 2015.12

AFF ILIAT E D U N I TS O F THE A C A DEM Y OF

NUT RIT I O N A N D D I E TE TIC S
State and District Associations
Each of the 50 states and Puerto Rico are affiliates of the Academy and are
organized with state and district associations. Membership in the Acad-
emy determines the membership in state affiliates because states generally
charge no membership fees and instead receive rebates from the Academy
according to the number of members. A member of the Academy is auto-
matically a member of a state affiliate.
The state organizations for the most are parallel to the national orga-
nization. Each state elects its delegates to represent its members in the
HOD. The number of district organizations is determined by the states
as well as how they fit into the state organization. The district groups pro-
vide educational and informational programs for the grassroots members.
Most states have one or two meetings per year that provide continuing
education opportunities for the members. Delegates from the state take
state and/or member issues to the HOD for all members to have input
into the functioning of the Academy.

Academy of Nutrition and Dietetics Foundation

The Academy of Nutrition and Dietetics Foundation is a nonprofit arm
of the Academy that solicits and receives monies to benefit the Academy,
with a large percentage of the monies going to provide scholarships for
both undergraduate and graduate students and for member research proj-
ects. The foundation fosters alignment with corporate sponsors and con-
ducts member campaigns for fund-raising. The foundation also provides
services for the public in various ways.
More than 900 students have been awarded scholarships since 2007,
totaling nearly $1.4 million. The Evidence Analysis Library, a resource
offered through the Foundation, is a member-accessible online reference
library housing relevant nutritional research on important dietetic prac-
tice questions. The service is also available through a subscription service
to others.13
34    T he A cademy of N utrition and D ietetics

Washington Office
The Academy maintains an office in Washington, DC, to have a presence
in the capital and further the legislative efforts of the profession. This
allows the association to be in touch with legislative issues as they are
being considered and as they occur. Although these legislative and lobby-
ing efforts required a tax status change by the association when they were
first initiated, the benefits accrue to individual members directly and to
consumers and the public indirectly.
The staff of the Washington office and Academy members work with
legislators and government agencies to introduce and promote bills that
further the interests of the profession and its members. An example is
the passage of the Medical Nutrition Therapy Act, which resulted from
a sustained effort on the part of ADA staff together with legislators over
several years. Members contribute to a political action committee (PAC)
that makes awards to legislators who promote programs and activities
important to the Academy.

American Overseas Dietetic Association

Dietitians who have met all requirements for membership in the Academy
are eligible for membership in the overseas association. They may join
DPGs and enjoy all the same benefits of membership as they would in the
United States.

SU MMARY
The Academy of Nutrition and Dietetics is the professional organization
serving and promoting the interests of its members. The programs and
initiatives administered by the Academy are for the benefit of the mem-
bers and the public. The Academy is governed by elected and appointed
volunteer members of boards, commissions, and committees, all of
whom perform specific functions according to the bylaws of the Acad-
emy. Important as the functions that the Academy provides for members
are, it is recognized as the authoritative voice to the public with guid-
ance regarding food and nutrition issues. The active promotion of policy
 R e f e r e n c e s      35

that enhances the health and well-being of all individuals is accomplished

through activities by members and by the Washington legislative office.

D E F INI T I O N S

Bylaws. Authoritative rules governing an association or group.

Chief executive officer (CEO). A person employed by the association to
direct the headquarters office operations and implement the pro-
grams and fiscal affairs of the association. May also serve as an official
spokesperson for the Academy on direction of the board of directors.
Governance. Activities involved in conducting the affairs of an
organization.
Strategic plan. Plans and strategies that shape the overall activities and
functions of an organization.

REFE REN C E S
1. Escott-Stump, S.A. “President’s Page.” J Acad Nutr Diet 112, no. 3 (2012): 352.
2. www.eatright.org (10/12/15).
3. Ibid.
4. Ibid.
5. Ibid.
6. Switt, J.T. “The American Dietetic Association’s New Look.” J Am Diet Assoc 108
(2008): 932–933.
7. Bylaws of the Academy of Nutrition and Dietetics. www.eatright.org (10/15/15)
8. Weinland, J., and L. Smothers. “2015 Academy Member Benefits Update.”
J Acad Nutr Diet 115, no. 4 (2015): 505–509.
9. Cassell, J. Carry the Flame: The History of the American Dietetic Association.
(Chicago: The American Dietetic Association, 1990).
10. Baldyga, W.W. “Results from the 1981 Census of the American Dietetic
Association.” J Am Diet Assoc 83 (1983): 343–348.
11. Rogers, D. “Compensation and Benefits Survey 2015.” J Acad Nutr Diet 116,
no. 3 (2016): 370–388.
12. See Note 11.
13. Academy of Nutrition and Dietetics website. Accessed November 5, 2012,
www.eatright.org
 3

CHAPTER
Educational Preparation
In Dietetics
“As a profession, the one thing that we can predict is that the
greatest change in our practice will be the change in knowledge
and how we integrate new science into our daily practice.”1

OUTLINE
• Learning Objectives
• Introduction
• Undergraduate Education
• Dietetics Education Programs
• Didactic Program in Dietetics
• Coordinated Program in Dietetics
• Dietetic Technician Program
• Education Program Standards
• Supervised Practice in Dietetics
• Advanced-Level Education
• Types of Programs
• Benefits of Advanced Study
• The Graduate Program Experience
• Research Experience
• Further Opportunities
• Future Education Preparation
• Summary
• Definitions
• References

37
38    E ducational P reparation in D ietetics

LEARNING OBJECTIVES
The student will be able to:
1. Discuss the academic requirements for practice in dietetics
and membership in the Academy.
2. Compare the didactic program in dietetics and the coordi-
nated program in dietetics.
3. Describe the standards of education and their purpose.
4. Understand the application process for supervised practice.
5. Understand how competencies for entry-level practice are
integrated into supervised practice.
6. Know the basic requirements for advanced study and degrees.

IN T RO D UC TI O N
Education is the key to dietetic practice and to the future of the profes-
sion. As with all professionals, a specialized body of knowledge is required
of individuals who practice in any area of dietetics. Because of the impor-
tance of education in the profession, early leaders in dietetics set standards
for the education of dietitians. The standards have been revised at inter-
vals as the practice evolved and the needs of those being served changed.

UND E RG RA D U ATE E D U C AT I ON
The educational preparation of the dietitian begins in the undergraduate
degree program. Study for the baccalaureate degree is based in the bio-
logical, physiological, behavioral, and social sciences, and it includes both
theoretical and applied courses. The college or university offering a degree
program plans a curriculum that meets both the educational standards
of the Academy of Nutrition and Dietetics and the university require-
ments, including general education courses. A baccalaureate degree from
an accredited college or university, combined with a supervised experience
either integrated into the degree program or in an internship following
the degree, is required to fulfill all education requirements.
A curriculum that meets the academic standards is referred to as a
didactic program in dietetics (DPD). A program that offers the practical
 D i e t e t i c s E d u c a t i o n P r o g r a m s      39

experience component concurrently with the degree is termed a coordi-

nated program (CP). The dietetic technician (DT) program similarly fol-
lows a course of study in a 2-year college or institution that includes or is
followed by a practice component.

D IE T ET IC S E D U C ATI O N P ROGR A M S
Didactic Program in Dietetics
The didactic or classwork portion of the dietetics educational requirement
is completed during the degree program, either undergraduate or graduate.
Following the degree conferral, the student completes a supervised prac-
tice program or internship. The traditional didactic program is a 4-year
bachelor of science degree. Many of the courses required in the DPD com-
bine classroom and laboratory work, especially in food production, clinical
nutrition, and science courses such as chemistry and microbiology.
During the latter part of the program, usually the senior year, the stu-
dent applies to one or more dietetic internships through a computerized
matching program. Notification is given in April or November about a
match or acceptance to the student’s program of choice. After completion
of the supervised portion of the program, the student may take the regis-
tration examination.

Coordinated Program in Dietetics

In the coordinated program (CP) in dietetics, the didactic portion of
a program and supervised practice are completed during the course of
study toward the degree, either undergraduate or graduate. The student
graduating from this program is prepared for entry-level practice upon
completion of the degree. In most universities, students enter the CP for
their junior and senior years. The program is sometimes described as a
“two-by-two,” meaning the first 2 years are general study and may be at a
community or junior college and the last 2 include the integrated courses
leading to the degree. Some programs may be longer than the traditional
4 years, depending on the specific program requirements.
A university designates the criteria for admission to the CP. The selec-
tion criteria commonly include grade point average, writing skill, work
experience, letters of recommendation, and, sometimes, an interview. A
minimum of 1200 hours of supervised practice is required in the CP. The
40    E ducational P reparation in D ietetics You get the link on our page
vk.com/lingualib

program is intense in terms of time requirements and experiences but can

reduce the time needed to prepare for practice. On completion of the
degree, the student is eligible to take the registration examination.

Dietetic Technician Program

The dietetic technician (DT) program is similar to the CP in that both
didactic and supervised practice (minimum of 450 clock hours) are
required. The Accreditation Council for Education in Nutrition and
Dietetics (ACEND) also accredits the programs. Graduates of the pro-
gram may also become registered by taking the DTR examination. Many
of the programs are offered in 2-year colleges or technical schools.

ED UCAT IO N P R O G R A M S TA N DA R DS
ACEND sets the standards by which dietitians are educated. The stan-
dards have been issued in various forms since 1924 and have undergone
many changes in both concept and form. For instance, early emphasis
was on the specific courses a student was required to take during a degree
program. Now, the standards are based on the outcomes expected from
the education experience, and education program directors translate the
expected outcomes into courses and course content. ACEND further
specifies how a degree program is structured, including the goals and
philosophy of the program, the students, the curriculum, the program
resources, and evaluation of the program.
The standards for all degree and experience program include the
following:2
1. Program characteristics and resources
2. Mission, goals, and objectives of the program
3. Curriculum learning activities
4. Faculty and preceptors
5. Supervised practice and learning sites
6. Information for prospective students and the public
7. Policies and procedures
8. Program evaluation and improvement
The ACEND evaluates each educational program through an accredi-
tation site visit based on an extensive self-study prepared by the program
director and staff. The purpose of the site visit, conducted by registered
 Supervised Practice in D i e t e t i c s      41

dietitians designated by ACEND, is to assist the program in continued

assessment that ensures qualified, competent program graduates who pass
the registration examination and are prepared to practice. A program may
be accredited for a period of 5 to 10 years. Periodic reports are submitted
to the Academy indicating that the program continues to provide educa-
tion that meets the standards. A list of all accredited programs is available
from a college or university or from the Academy website.

S UPE RV I S E D P R A C TI C E I N DI ET ET I C S
Preprofessional or supervised practice is an essential step toward becom-
ing a registered dietitian nutritionist (RDN) or nutrition and dietetics
technician, registered (NDTR). For the DPD student, the dietetic intern-
ship follows the degree. Supervised practice takes place in the work setting
where students learn to apply their knowledge and skills under the direc-
tion of a preceptor. Successful completion of supervised practice program
establishes eligibility for an individual to take the registration examination
and apply for active membership in the Academy. Competency in dietetics
practice is the goal of supervised practice. Competency is regarded as the
ability to carry out tasks within certain expected standards or parameters.
Supervised practice programs are based on the standards of education
and the competencies for entry-level practice. All supervised programs
must offer a minimum of 1200 hours of experience for the dietitian and
450 hours for the DT. A current listing of all programs is available on the
Academy website.
Programs follow the same standards; however, there is flexibility in the
way the programs meet the standards through the kinds of experiences
offered. Although ACEND accredits the educational programs, it does
not mandate the kinds of experiences or the amount of time in each area
of practice. Each program sets the curriculum and experiences that meet
the goals of the program and the needs of the student.
Experiences are structured around three key areas of activity in dietet-
ics: clinical nutrition, food service management, and community dietet-
ics. Programs that do not offer all the experiences in one institution will
arrange with others in the community or area to provide them.
Besides the dietetic internship, the CP, and the DT practice, the Indi-
vidualized Supervised Practice Pathway (ISSP) also offers a pathway to
registration and membership.3 The ISSP, offered in 2015 in 11 programs,
42    E ducational P reparation in D ietetics

provides a way for persons not matched for an internship placement

to gain experience and for doctoral students not holding a verification
statement or having completed didactic course work. Requirements for
acceptance to the program are determined by the institution or program
offering the experience as is the choice of a preceptor for the student.
What do students need to know before applying to a supervised experience
program? Students should know that a period of supervised experience is
required to establish eligibility to become an RDN or NDTR and that
acceptance into a program is competitive. The application process should
begin early in the senior year to assemble all required materials by gradu-
ation and, if required by the program desired by the student, to visit one
or more programs. Students applying for a dietetic internship will usually
participate in the national computer matching. Information about this
process may be obtained from the program director or the Academy.
What are the characteristics of successful applicants? Generally, applicants
with a grade point average of 3.0 or above in food, nutrition, and man-
agement courses and better than average in biological and physical science
courses will be considered first. Approximately 1 year of work experience
or dietetics-related volunteer or paid experience will increase the chance
of being chosen.
What else is important to know? In addition to good grades and work
experience, applicants are encouraged to investigate programs early to
identify the specific admission criteria and to apply to one or more. Suc-
cessful applicants often apply to as many as three programs. If the program
requires or offers graduate credit during the supervised experience, the
student will need to apply to graduate school and complete the graduate
record examination (GRE). In addition, applicants are encouraged to be
flexible and be willing to relocate if necessary.
Program directors who advise students and students themselves need
to have other options in mind when an internship appointment is not
obtained. Some plan to gain more working experience and then reapply.
Another alternative is an advanced degree. Some students gain additional
training or complete course work for allied health areas such as nursing,
physician assistant, or physical therapy. Employment areas that in most
cases do not require the RD credential might also be considered. Exam-
ples are pharmaceutical companies, journalism and communications, hos-
pitality, athletic training spas and centers, tourism, retirement homes,
cooperative extension, and school food service.
 A d v a n c e d - L e v e l E d u c a t i o n      43

AD VANCE D - L E V E L E D U C AT I ON
Advanced-level education may be described as continuing education, pre-
professional education, or graduate education. More baccalaureate stu-
dents are pursuing a graduate degree; more employers are requiring an
advanced degree, training, or advanced credentials; and more disciplines
are becoming specialized, thus requiring advanced-level education. Grad-
uate education is formal study beyond a baccalaureate degree that leads
to an advanced degree, that is, the master’s or doctoral degree. Gradu-
ate study involves concentrated work in a specific academic area. Some
universities offer or require graduate study concurrently with the dietetic
internship.
Among the purposes of advanced education are opportunities for indi-
viduals to explore new ideas and gain a higher level of knowledge and
understanding required to recognize and fully discharge personal, social,
and professional responsibilities. Practical benefits also accrue, including
networking with other advanced practitioners and specialists, the possibil-
ity of career advancement and financial gain.

Types of Programs
The master of science (MS) degree usually requires 1 to 2 years of full-
time study and may be longer depending on the major area of study, the
research undertaken, and whether the student attends full or part-time.
The doctor of philosophy (PhD) or doctor of education (EdD) usually
requires a minimum of 3 years of full-time study. Original research and
a thesis or dissertation, or an equivalent academic work, will be required
depending on the field of study and the requirements of the educa-
tional institution. The doctoral degree is considered the terminal degree
although, at times, it will be followed by postdoctoral academic study.
Some allied healthcare disciplines offer a “practice doctorate” for
advanced-level degree study. This has also been proposed in dietetics by
Academy members and may be a consideration in the future as another
route to advanced work.4

Benefits of Advanced Study

The benefits of an advanced degree include the development of intel-
lectual skills such as the ability to master complex information, problem
solve, and explore new ideas. Career benefits include the development of
44    E ducational P reparation in D ietetics

advanced practice skills, the in-depth exploration of subjects in one’s area

of practice or in another area, and the acquisition of new perspectives.
Dietitians often pursue graduate study for career advancement or prepara-
tion for a career change. Dietitians who are prepared to perform in mul-
tiskilled or cross-trained positions will usually rely on graduate education
to increase their knowledge and practice skills.
The type of positions dietitians assume as they progress in their careers
are usually those with increasing responsibility and autonomy that require
management and leadership skills. Competition for jobs may also increase
the demand for advanced degrees. New and expanding career options and
the job market in general affects demand and availability and, in turn,
may influence dietitians in their education choices. Graduate education
provides an opportunity to develop expertise that allows dietitians to
assume leadership roles.
In the 2015 Compensation and Benefits survey, it was reported that over
half (52 percent) of RDNs hold an advanced degree. Among NDTRs, 57
percent hold the Associate degree and 39 percent the bachelor’s degree.5
The financial advantage of an advanced degree for RDNs is shown
in Table 3-1. The dietitian with a master’s degree receives $500 more
and the doctoral degree $30,000 more than a person with the bachelor’s

Table 3-1.  Median Yearly Income of Registered Dietitians by

Education Level
Degree Level 2011a 2013b 2015c

Bachelor degree 55,000 57,574 60,008

Master degree 60,000 61,506 65,478

Doctoral degree 75,000 75,005 92,000

ALL RDs 58,000 60,000 63,700

Sources: a. Ward, B. “Compensation and Benefits Survey 2011: Moderate Growth in Regis-
tered Dietitian and Dietetic Technician, Registered, Compensation in the past 2 years.” J Acad
Nutr Diet 112, no. 1 (2012): 29–40.
b. Rogers, D. “Compensation and Benefits Survey 2013; Education and Job Responsibility
Key to Increased Compensation.” J Acad Nutr Diet 114, no. 1 (2014): 17–33.
c. Rogers, D. “Compensation and Benefits Survey 2015.” J Acad Diet 116, no. 3 (2016):
370–388.
 A d v a n c e d - L e v e l E d u c a t i o n      45

degree. State licensure and specialty certification affect salaries and

are often equated with advanced study. Dietitians working in practice
areas that often require an advanced degree, such as food and nutri-
tion management and education and research, earn the highest sala-
ries. For NDTRs, the median yearly wage is $42,000—an increase from
$40,000 in 2013. The factors affecting salaries are about the same as
for the NRD—education, experience, responsibility, and location. The
NDTRs in food and nutrition management generally earn the highest
salaries.
Other reasons to pursue graduate study are for continuing education
credit to maintain registration status, when state licensure regulations
mandate an advanced degree and continuing education, and for gaining
research skills and understanding research reports. All dietitians apply
research in their practice and need to demonstrate the ability to interpret
current research and basic statistics.

The Graduate Program Experience

Information about graduate programs is available in the Academy Direc-
tory of Programs and from universities. Prospective students find it help-
ful to talk with faculty and to request college catalogs and departmental
information before applying. No two programs are alike and the best fit
between the student and the program will be important once the student
is admitted. Universities that give the student an active role in depart-
mental activities as well as individual time in a mentoring and supporting
atmosphere will greatly enhance the graduate experience. Departmental
research and the availability of financial aid should also be explored. Assis-
tantships give financial aid and teaching, research, and/or administrative
experiences according to assignments.

Research Experience
The selection of a research study is based on an area of interest, the need
as determined by a literature search, and the feasibility of the study (based
on cost, time involvement, and availability of equipment and/or subjects).
Ongoing departmental research by faculty can provide a way for the stu-
dent to assume a part of the research.
The process of investigating a problem, reviewing the literature, plan-
ning and implementing the study, collecting and analyzing data, and
46    E ducational P reparation in D ietetics

writing a clear and well-developed document that is accepted by a graduate

faculty committee is a significant effort. The research experience requires
initiative, critical thinking, problem solving, and ethical procedures. The
successful completion of a research study often launches a student into
publishing the results and into further research, thus making an impor-
tant contribution to scholarship.

D IS TANCE E D U C ATI O N
Distance education is the means by which many colleges and universities
now offer courses and degree programs. With the increased use of tech-
nology by both students and practitioners, such offerings are often attrac-
tive to part-time students, older returning students, and others who reside
away from a university setting. Three universities now offer the DPD by
distance. In 2015, 26 internships also offered part of the curriculum by
distance.6
An example of an established, successful distance education program
is the Great Plains Interactive Distance Education Alliance (IDEA) that
offers the master’s degree. The alliance is composed of 12 universities in
the Midwest who offer a common core of subjects with elective options
offered by the individual universities. The degree is granted by the univer-
sity in which the student is enrolled.7
“A Guide for Effective Nutrition Intervention and Education” (GENIE)
is an online resource for the assessment of the quality of a program.8 By
using a checklist of nine categories, a program director can determine how
effective a program is and make any necessary adjustments.
A large-scale online distance opportunity is available through the “Mas-
sive Open Online Courses” (MOOCS).9 Free courses are open to anyone
worldwide. Enrollments of several thousand are not unusual as evidenced
by a course offered by Cornell University on “Infant and Young Child
Feeding” with thousands enrolled. A variety of instructional methods are
used along with tests.
Continuing education opportunities for professionals are increasingly
offered by distance through webinars, teleconferences, teleseminars, and
social networking means. The annual public policy workshop is now
offered by distance. Many dietetic practice groups regularly communicate
through blogs, Facebook, Twitter, and Skype.
 F u t u r e E d u c a t i o n P r e p a r a t i o n      47

In some locations, patient health care is provided through a “telehealth”

system. Medical nutrition therapy may be a part of the practice as well as
consultation in business and private practice. Legal and ethical consid-
erations as well as professionalism are important when these means of
communication are used.10

F UT URE E D U C ATI O N P R E PA R AT I ON
The education of the dietitian focuses on the present and future roles
professionals will fulfill. The traditional roles continue to expand as envi-
ronmental, demographic business, and health trends create new oppor-
tunities for practice. ACEND, working with the Council on Future
Practice, plans toward future practice and education needs. In 2013,
they initiated an Environmental Scan that revealed emerging nontra-
ditional practice settings for nutrition and dietetics and an expanding
scope of practice in the profession. For instance, there is an increased
focus on disease prevention and integrative health care. There is also a
need for more knowledge in areas such as nutritional pharmacology,
case management, behavioral counseling, prescriptive authority, coding
and reimbursement, evidence-based practice, and informatics. There is
also a growing importance for healthcare professionals to work more
interprofessionally.
As an outcome of the environmental scan, ACEND made several
recommendations:11
1. The requirement of a minimum of the master’s degree as prepara-
tion for an entry-level, generalist, registered dietitian nutritionist.
2. The bachelor’s degree required for entry-level nutrition and dietet-
ics technician.
3. Associate degree preparation for nutrition health workers.
4. Competencies to be identified for each degree level.
5. Experiential learning integrated into each degree program.
6. Each degree level prepares students for employment.
7. Future exploration of high school and doctoral level programs.
Some of the recommendations have been approved and others are
under study for their implications for the future of education and practice.
One that has been approved is the requirement for the master’s degree for
48    E ducational P reparation in D ietetics

the entry-level RDN will be implemented as of 2024.12 Another is super-

vised practice integrated into the didactic program.
New standards for all degree and experience programs were developed
by ACEND in 2016 to be implemented upon finalization in 2017.13

SU MMARY
Dietetics education has evolved over time but has always been based on pre-
paring the student for professional practice. The Academy designates the
educational standards that are followed by all dietetics programs, thus ensur-
ing competent practitioners. With a background of academic knowledge and
practical skills, dietitians and DTs are prepared for a wide variety of careers.
Over half of practicing dietitians today hold a graduate degree. There
are benefits in doing so—research competence, continuing education for
personal and professional growth, and career enhancement. Even more
dietitians will receive advanced education as the new education require-
ments become effective. The outcome will be an informed public and a
heightened recognition of the dietitian as the expert in food and nutrition
and a member of interprofessional teams.

D E F INI T I O N S

Accreditation. The process whereby a private nongovernmental agency

or association grants public recognition to an institution or an indi-
vidual who meets necessary qualifications and periodic evaluation.
Advanced study. Study beyond the traditional baccalaureate level.
Advanced practice. Effective discharge of job requirements that demon-
strates a high level of skills, knowledge, and behaviors.
Coordinated program (CP). A degree undergraduate program that
combines didactic and experiential learning.
Preceptor. A person who guides, mentors, and evaluates a student
during supervised practice.
Specialist. One who possesses a proficient level of knowledge, skill, and
experience to qualify for a specific credential.
Supervised practice. Learning experiences associated with activities
guided by a leader or preceptor.
 R e f e r e n c e s      49

REFE REN C E S
1. Parks, S.D., M.R. Schiller, and J. Bryk. “President’s Page.” J Am Diet Assoc 12
(1994): 1159–1161.
2. 2017 Education Program Standards. Accreditation Council for Education and
Dietetics. www.eatright.org/ACEND
3. Wilson, A. New Supervised Practice Pathway Offers Additional Options to Dietet-
ics Graduate. ADA Times 9, no. 1 (2011): 18–19.
4. Skipper, A., and N.M., Lewis. “Clinical Registered Dietitians, Employers,
and Educators are Interested in Advanced Practice Education and Professional
Doctorate Degrees in Clinical Nutrition.” J Am Diet Assoc 106, no. 12 (2006):
2062–2066.
5. Rogers, D. “Compensation and Benefits Survey 2015.” J Acad Nutr Diet 116,
no. 3 (2016): 370–388.
6. www.eatright.org
7. http://www.gpidea.org/
8. www.eatright.PRO.org/GENIE.
9. Stark, C.M. “Massive Open Online Courses: How Registered Dietitians
Use MOOCS for Nutrition Education.” J Acad Nutr Diet 114, no. 8 (2014):
1147–1155.
10. Ayres, E.J. “The Impact of Social Media and Business and Ethical Practices in
Dietetics.” J Acad Nutr Diet 113, no. 11 (2013): 1539–1543.
11. Rationale for Future Education Preparation of Nutrition and Dietetics
Practitioners. www.eatright.org/ACEND. August 2015.
12. www.eatright.org/ACEND. August 2016.
13. See Note 2.
 4

CHAPTER
Credentialing of
Nutrition and Dietetic
Practitioners
“Nutrition and dietetics credentialing protects and improves
the health of the public and supports practitioner competence,
quality practice, lifelong learning and career advancement.”
Vision Statement of The Commission on Dietetic Registration1

OUTLINE
• Learning Objectives
• Introduction
• Development of Credentialing
• Commission on Dietetic Registration
• Registered Dietitian Nutritionist
• Dietetic Technician, Registered or Nutrition and Dietetics
Technician, Registered
• New Dietetic Technician Registration Elgibility Pathway
• Examination Candidate Information and Study Resources
• Specialist Certification
• Interdisciplinary Specialist Certification in Obesity and
Weight Management
• Advanced Practice Certification in Clinical Nutrition
• Certificates of Training
• Recertification of the RD/RDN and DTR/NDTR

51
52    C redentialing of N utrition and D ietetic P ractitioners

• Recertification of Specialists and Advanced Practice in

Clinical Nutrition
• Appropriate Use of Credentials
• Legal Regulation Statutes for Dietitians Nutritionists and
Dietetic Technicians
• Summary
• Definitions
• References

LEARNING OBJECTIVES
The student will be able to:
1. Understand the importance of credentialing for practice.
2. Become familiar with the Commission on Dietetic Registra-
tion and how it functions.
3. Know the academic and test requirements for becoming
credentialed.
4. Become familiar with the certification and recertification pro-
cess and the portfolio requirements.
5. Become aware of the requirements for specialization in
dietetics.
6. Know the legal requirements pertaining to certification of
dietitians and nutritionists.

IN T RO D UC TI O N
The term dietitian is one that evolved over time. Early practitioners were
called dietologists, dietists, and dietotherapists.2 Before the American
Dietetic Association (ADA) was formed, (currently the Academy of Nutri-
tion and Dietetics), a dietitian was described as “a person who special-
izes in the knowledge of food and can meet the demands of the medical
profession for diet therapy.”3 This adequately described the professional
for many decades. Today the Academy defines a dietitian: “A dietitian is a
person who is trained in the science of nutrition and dietetics.”4
 I n t r o d u c t i o n      53

The science of food and nutrition formed the basis for the organization
of a group of practicing professionals. One of the earliest concerns of this
group was the overwhelming amount of food faddism and fallacies found
among the general public and even among other professionals. It was dif-
ficult, if not impossible, for the public to determine who was a credible
source of information and to separate fact from fiction between the many
medical and health claims for specific foods and procedures.
This early concern for protection of the public by disseminating the
knowledge of dietitians has continued to the present time. Not only did
it lead to the national organization of dietitians that could promote the
professionals as having expertise in “diet-therapy, teaching, social welfare,
and administration,” but it served as the impetus to begin thinking about
credentialing of practitioners.
A concern raised at the second annual meeting of the ADA in 1918
was the “need to distinguish between dietitians with a college degree
and special training in some scientific work and the ones with lesser
training.”5
This was perhaps the first formal reference to dietetic credentialing.
The 1926 president of the association, Florence Smith, urged that the
group establish professional standards for dietitians and that state or
national registration could be the answer. In 1929, a study of national
registration was initiated, and the following definition of a dietitian
was adopted: “Any person who is qualified for membership in The
American Dietetic Association is by virtue of uniform basic training
and required experience, entitled to be designated as a dietitian.”6 In
the 1950s, the association appointed a committee to formally study
state licensure of dietitians. 7 The issue of specialties in practice also
surfaced with the suggestion that membership should be expanded to
include others who were well qualified in the many specialties embraced
within the definition of dietetics.8 Although certification of dietitians
occurred in the late 1960s, it was not until the late 1990s that educa-
tion and membership requirements were differentiated to accommo-
date practitioners with similar basic preparation but in specialized or
focused areas of practice.
The differences between a generalist and a specialist surfaced and
were thoroughly debated. A generalist was defined as a dietitian who
could perform in all areas of practice, such as a single dietitian in a small
hospital, or one who could move from one practice area to another. A
54    C redentialing of N utrition and D ietetic P ractitioners

specialist was a dietitian wanting to restrict his or her practice in one area,
such as clinical or food service. The generalist role was advanced by the
following themes:
1. All dietitians are the same.
2. Dietitians can move from one area of practice to another (food
service to public health, for example) without additional training.
3. Greater external recognition of the term dietitian was established.
By contrast, the specialized role was driven by the following themes:
1. The explosion of knowledge and technology required each dieti-
tian to know more and more about less and less.
2. There was a need to differentiate among dietitians with varying
skills and knowledge, advanced education, and experience gained
on the job.
3. Part-time employment opportunities emerged.
4. New, innovative practice areas developed, such as school food ser-
vice, nursing home consultation, enteral and parenteral nutrition
techniques, and nutrition support.

D E V E LO P M E N T O F C R E D E NT I A L I N G
In the 1960s, a committee was established to study licensure, registration,
and certification. Registration was the credentialing process chosen at that
time by the ADA House of Delegates and the ADA membership. An
amendment to the constitution was approved for the Final Revised Pro-
posal for Professional Registration in 1969.9 A committee, later to become
known as the Commission on Dietetic Registration (CDR), then began
the implementation of a certification process for members. The title for
those ADA members who chose to become certified was registered dieti-
tian (RD). A detailed account of the implementation and a review of the
first 5 years of professional registration were published in the Journal of the
American Dietetic Association in 1974.10
The professional registration system adopted by the association differed
significantly from other health professional certification systems at that
time in that candidates had to pass a national examination, and RDs had
to document evidence of continuing education in each 5-year period to
 C o m m i s s i o n O n D i e t e t i c R e g i s t r a t i o n      55

renew registration. Thus registration was designed as a voluntary process

to ensure competency of dietitians through the qualifications required to
take the registration examination, passing the examination, and formal
continuing education. All of this was evidence of the concern of the pro-
fession for the health, safety, and welfare of the public by encouraging
high standards of performance by dietetic practitioners as stated in the
amendment to the constitution.
By late 1970, 90 percent of the membership was registered, with the
majority grandfathered in during the period before establishment of the
examination. Credentialing of the dietetic technician and various dietetic
specialists followed with qualifications developed by the Commission on
Dietetic Registration.11

CO MMI S S I O N O N D I E TE TI C
REG I S T RATI O N
The mission of the Commission on Dietetic Registration (CDR), as the
credentialing agency and organization unit of the Academy of Nutri-
tion and Dietetics (AND, referred to as the Academy), is to administer
rigorous, valid, and reliable credentialing processes to protect the public
and meet the needs of CDR’s credentialed practitioners, employers, and
consumers.
Credentialed practitioners elect the Commission members for 3-year
terms. Members of the Commission elect the CDR Chair.
The Commission’s RDN, RD, NDTR, and DTR certification pro-
grams are fully accredited by the National Commission for Certifying
Agencies (NCCA), the accrediting arm of the Institute for Credential-
ing Excellence based in Washington, DC. This accreditation reflects
achievement of the highest standards of professional credentialing. As
of early 2016, CDR was maintaining a registry of more than 100,000
dietetic practitioners. CDR is the administratively autonomous creden-
tialing agency for the Academy and develops, revises, and administers
the examination for registration; sets the standards for certification
and recertification; establishes the Code of Ethics for the Profession of
Dietetics jointly with the Academy; and issues credentials to individu-
als who meet these standards for competency to practice in the dietetics
profession.12,13
56    C redentialing of N utrition and D ietetic P ractitioners

RE G IS T ERE D D I E TI TI A N N UT R I T I ON I ST
CDR establishes the requirements for eligibility to take the entry-level exami-
nation for dietitians. Requirements include academic preparation, supervised
practice, and confirmation of academic and practice requirements by online
verification. The examination is administered online and individual appli-
cants can schedule a time to take it throughout the year. The examination
is also available in other countries from organizations with which the Acad-
emy has reciprocity. Currently those are Dietitians of Canada, the Dutch
Association of Dietitians, the Philippine Professional Regulation Commis-
sion, and the Irish Nutrition and Dietetic Institute. Traditionally the aca-
demic eligibility requirements to take the registered dietitian nutritionist
(RDN/RD) examination was the completion of a baccalaureate degree from
a U.S. regionally accredited college or university or foreign equivalent.
The Council on Future Practice Visioning Report of 2012 recom-
mended changing the requirement from a baccalaureate degree to a mini-
mum of a graduate degree. The full report is now available.14 That formed
the basis for CDR to change the entry-level education requirements for
dietitians beginning January 1, 2024, from a baccalaureate degree to a
minimum of a graduate degree.
Detailed explanation of all of the current eligibility requirements may
be accessed at: http:www.cdrnet.org. They are subject to change and the
most reliable information is on the CDR website. Additional details of the
academic requirements can be accessed at: http://www.eatrightacend.org.
After passing the examination and being credentialed by CDR, reg-
istered dietitians (RD and RDN) are required to comply with CDR
recertification requirements, the “Code of Ethics for the Profession of
Dietetics,” the “Scope of Practice for the Registered Dietitian,” and the
“Revised 2012 Standards of Practice in Nutrition Care and Standards of
Professional Performance for Registered Dietitians.”15–17

D IE T ET IC T E C H N I C I A N , R EGI ST ER ED
O R NUT RI TI O N A N D D I E TE T I C S
T ECH NI CI A N , R E G I S TE R E D
CDR establishes the eligibility requirements for dietetic technicians. Cur-
rently the requirement is completion of an Associate degree granted by a
regionally accredited college or university with the Accreditation Council
 Nutrition and D i e t e t i c s T e c h n i c i a n , R e g i s t e r e d      57

for Education in Nutrition and Dietetics (ACEND) accredited Dietetic

Technician Program. http://eatrightacend.org.
The dietetic technician, registered (DTR) or nutrition and dietetics
technician, registered (NDTR) is a critical member of the dietetics team
and has become even more important as the practice of dietetics in every
area becomes more complicated and time consuming and with the increas-
ing number of opportunities for employment. Dietetic technicians are
trained in food and nutrition and are an integral part of health care, food
service, and other dietetics and healthcare teams. In small, rural hospi-
tals, the DTR/NDTR is sometimes the only trained dietetics practitioner
addressing all aspects of care available full time. In this situation, the DTR/
NDTR works under the supervision of an RD/RDN via established pro-
tocols to implement the nutrition care process based on state regulations.
The “Scope of Dietetic Practice for the Dietetic Technician, Registered”
published in 2013 addresses supervision, entry-level, and advanced prac-
tice for DTRs.18
Currently the small number of DTRs and dietetic technician educational
programs place this segment of our profession at risk for continued existence.
An increase in the number of DTRs/NDTRs is vital to sustain expansion of
practice areas for dietitians and achieve the future vision for the profession.
A functional career ladder for dietetic technicians discussed below as a
new pathway for technicians will strengthen the dietetics profession as we
seek to enhance the recognition, authority, autonomy, prestige, income,
and satisfaction of dietetics team members and their customers.
It is well known that NDTR/DTRs work in nontraditional or emerging
areas of practice with more diverse possibilities for the future. After appro-
priate years of practice, NDTR/DTRs also may work with RDN/RDs in
advanced-level practice. The use of the “Scope of Practice for the Dietetic
Technician, Registered” and the “Revised 2012 Standards of Practice in
Nutrition Care and Standards of Professional Performance for Dietetic Tech-
nicians, Registered” addresses this issue of advanced practice for DTRs.19,20
The opportunities for employment keep expanding for the DTR, espe-
cially in areas where supply of RDN/RDs cannot meet the demand. More
and more employers, especially in the healthcare arena, are requiring that
an individual be credentialed as a DTR/NDTR in order to practice in
their facilities. Some current unique opportunities are:
• Supervising food safety and sanitation in a variety of public and
private venues
58    C redentialing of N utrition and D ietetic P ractitioners

• Assisting individuals and groups in wellness and fitness centers to

know how food relates to fitness
• Managing and directing food service employees in assisted living and
retirement centers
• Assisting the RD/RDN in collecting data from patients or par-
ticipants in research studies (in hospitals, clinics, and community
research centers)
The Final Report of the Phase 2 Future Practice and Education Task Force
provides more detail of innovative educational experiences and unique
roles and employment for DTRs both now and in the future.21
In summary, the DTR/NDTR of today will extend the scope of practice
for the RD/RDN in the future and will allow the RD/RDNs to delegate
responsibilities, enabling them to practice at specialty and advanced lev-
els. However, for this to happen, the RD/RDN must understand the role
and appropriate responsibilities of the DTR/NDTR, which will increase
visibility and credibility of the dietetic professional team and benefit cli-
ents, facilities, and the profession of dietetics. Last but not least, dietetic
professionals and the Academy must promote the value of DTR/NDTR
educational programs and the dietetic technician as a creditable member
of the team for practice in tomorrow’s world.

NEW D I E T E TI C TE C H N I C I A N
RE G IS T RAT I O N E L I G I B I L I TY PAT HWAY
For the past several years, the CDR and others have noted the decline
in the number of technicians. This decline has been complicated by the
lack of educational programs for technicians in many states, resulting in
employers being unable to find appropriately trained technicians and
increasing the unavailability of technicians in the United States.
The CDR has supported the role of the technician and believes that a
new pathway will address both of these issues. This decision is consistent
with the CDR’s public protection mission in that it provides a credential
for the numerous non-credentialed Didactic Programs in Dietetics (DPD)
graduates currently employed in dietetic technician positions. Once cre-
dentialed as DTR/NDTRs, these individuals will be required to comply
with the CDR recertification requirements. The CDR also believes that
this alternative registration eligibility option will provide a dietetics career
 N e w D i e t e t i c T e c h n i c i a n P a t h w a y      59

ladder, increase the availability and visibility of DTR/NDTRs throughout

the country, and ultimately enhance the value of the DTR/NDTR cre-
dential.22 The Dietetics Career Development Guide uses the Dreyfus model
of skill acquisition to show how practitioners can attain increasing levels
of knowledge and skills throughout a career.23,24
In 2009, CDR established a New Pathway III for dietetic techni-
cians. Individuals who complete both a baccalaureate degree and a DPD
will be able to take the registration examination for dietetic technicians
without meeting additional academic or supervised practice require-
ments. This decision also provides for the numerous non-credentialed
DPD graduates currently employed in dietetic technician positions to
become credentialed. The CDR also believes that this alternative reg-
istration eligibility option will increase the availability and visibility of
DTRs throughout the country, ultimately enhancing the value of the
DTR credential.
Effective June 1, 2009, the two pathways to establish eligibility to take
the registration examinations for dietetic technicians are:
1. Pathway I. Completion of an associate’s degree granted by a U.S.
regionally accredited college or university with the Accreditation
Council for Education in Nutrition and Dietetics (ACEND)
Accredited Dietetic Technician Program.
2. Pathway III. Completion of a baccalaureate degree granted by a
U.S. regionally accredited college or university, or foreign equiva-
lent, completion of an ACEND-accredited Didactic Program
in Dietetics (DPD), and completion of an ACEND-accredited
dietetic technician supervised practice.
All dietetic technician Pathway III candidates must be submitted for
registration eligibility by their graduating institution’s current DPD
director. In addition, candidates must complete an electronic application
available on the CDR’s website at: https://www.cdrnet.org.
After passing the registration examination for dietetic technicians and
being credentialed by the CDR, DTRs/NDTRs are required to com-
ply with CDR recertification requirements, the “Code of Ethics for the
Profession of Dietetics,” “Scope of Practice for the Dietetic Technician,
Registered and the Revised 2012 Standards of Practice in Nutrition Care
and Standards of Professional Performance for Dietetic Technicians,
Registered.”25–27
60    C redentialing of N utrition and D ietetic P ractitioners

The following are additional Academy and CDR webpages of impor-

tance to individuals preparing for certification as dietetic technicians:

Examination Candidate Information and Study Resources

Computer-based testing FAQ:
https://www.cdrnet.org/vault/2459/web/files/CBTFactSheet082015
.pdf
Study Guide for the Registration Examination for Dietetic
Technicians, 6th ed. https://www.eatrightstore.org/product
/2ACAE4B2-2092-46D5-9435-0710C45CC866

SP ECIALI S T C E RTI F I C ATI O N

The concept of specialized practice in dietetics was approved by the ADA
House of Delegates in 1986. Currently, the Academy defines a special-
ist as a practitioner who demonstrates additional knowledge, skills, and
experience in a focus area of dietetics practice by the attainment of a cre-
dential.28 Three areas of practice were selected for initial certification:
pediatric nutrition, renal nutrition, and metabolic nutrition care. The
metabolic nutrition care specialist was later discontinued.
New criteria were established for the specialist, which include educa-
tion and experience requirements as well as the successful completion of
the CDR examination in the focus area. Specialists are currently creden-
tialed in the following areas:
Gerontological Nutrition
Sports Dietetics
Pediatric Nutrition
Renal Nutrition
Oncology Nutrition
As of 2016, one additional specialty certification will be available: Board
Certified Specialist in Obesity and Weight Management (Interdisciplin-
ary Certification). This is the first certificate offered as an “interdisciplin-
ary” certificate. Additional information about this specialist certification
is presented later in this chapter.
Although minimum eligibility requirements (Current RD/DRN status
with CDR, passing an examination in the focus area, maintenance of
 Certification in Obesity and W e i g h t M a n a g e m e n t      61

RD/RDN status with CDR, and documentation of practice experience)

for the specialists listed above are similar, there are some differences in
specifics. Therefore, it is necessary for candidates to access the CDR web-
site (https://www.cdrnet.org) for current information on certification and
recertification in a specific focus area.

INT E RD I S C I P L I N A RY S P E C I A L I ST
CERT IF IC ATI O N I N O B E S I T Y A N D WEI GHT
MANAG E M E N T
In 2013 the Council of Future Practice was (the Academy unit charged
with the evaluation of new specialist certification petitions) presented with
a petition from the Weight Management (WMDPG) and the Diabetes
Care and Education (DCEDPG) practice groups for the development of a
new obesity and weight management certification for Registered Dietitian
Nutritionists (RDN). In July 2013, CDR agreed to move forward on the
recommendation of the Future Council of Practice to proceed with the
new specialist certification. Later in the year representatives of the petition-
ing groups (WMDPG and DCEDPG) along with representatives from
the Obesity Society asked CDR to consider offering this certificate as an
“interdisciplinary” certification. CDR appointed a Task Force that included
representatives from the Academy Board of Directors, Council of Future
Practice, Weight Management and Diabetes Care, and Education DPGs to
consider this recommendation. After receiving comments from Academy
membership and further discussion, CDR indicated that pros and cons
received were evenly split. After much deliberation CDR agreed to move
forward with the development process. The Task Force recommended that
other allied health professionals be invited to participate in the practice
audit: nurse practitioners, physician assistants, licensed clinical psycholo-
gists, clinical exercise physiologists, and licensed clinical social workers be
included. In drafting the practice analysis survey instrument additional
practitioners involved in weight management and representatives from the
American College of Sports Medicine (ACSM), its Health Fitness Special-
ist, and Society of Behavioral Medicine (SBM), its Licensed Professional
Counselor, and Licensed Marriage and Family Therapist were included.
After the audit is complete, the professionals to be included for potential
certification will be known. CDR has projected that the first examination
for the specialist certification will be administered in the fall of 2016.
62    C redentialing of N utrition and D ietetic P ractitioners

Raynor and Champagne provide further background information of

the role of the dietitian in the weight management area.29 They discuss
the development of the position of the Academy as to interventions and
treatment of overweight and obesity in adults.
Additional information about the process, practice audit results, and
minimum eligibility, maintenance and documentation of experience
requirements for the interdisciplinary board certified specialist is available
at: https://www.cdrnet.org/weight-management. Professionals certified
will be known as Board Certified Specialist in Obesity and Weight Man-
agement (CSOWM).

ADVANCED P R A C TI C E C E RTI F I C AT I ON I N
CL INI CAL N U TR I TI O N
Practitioners continued to pursue avenues to distinguish between entry level
and advanced levels of practice.30 An additional recognition was developed
in 1993 for those practicing at advanced levels in any area of dietetics. Indi-
vidual professionals were designated as: Fellow of the American Dietetic
Association (FADA). This certification was available until 2003 for those
having an advanced degree, 8 years of practice, plus other documented pro-
fessional achievements. This FADA recognition was discontinued because
of limited participation of members of the Academy. See Chapter 2 for
details of a new fellows program (Fellow of Academy of Nutrition and
Dietetics [FAND]) under membership benefits of the Academy.
Research and discussion within the Academy continued to address the
issue of career ladders and levels of practice, including advanced prac-
tice.31,32 Future roles and definitions for RD/RDNs, DTR/Ns, specialists,
and advanced practice were further delineated in 2011 by the Council on
Future Practice.33
CDR conducted a practice audit from 2005 to 2007 to identify and
delineate advanced levels of practice (ALP) in nutrition and dietetics with
the goal of determining the need for an advanced level of practice cre-
dential.34 This study suggested that focus areas in clinical nutrition, com-
munity nutrition, management, business, and education/research were
identified as having some unique ALP characteristics and needing further
study. Other papers have shown the effort of numerous practitioners in
moving this effort forward.35–39
 Certificates of T r a i n i n g      63

The focus area of clinical nutrition was chosen as the initial area for an
audit study and to develop, if feasible, an ALP credential. This seemed
appropriate as clinical nutrition represents the largest practice group of
practitioners in the Academy. In 2013 CDR appointed the Advanced
Level Clinical Practice Audit Task Force.40
A subsequent article, “Developing an Advanced Practice Credential
for Registered Dietitian Nutritionists in Clinical Practice,” authored by
Brody et al, provides details of the proceedings necessary to design and
develop a new certification program for practitioners in advanced clinical
nutrition practice as identified by the 2013 practice audit.41
CDR has described the profile of practitioners achieving the ALP cre-
dential in clinical dietetics as “experienced registered dietitians who have
the knowledge and skills required to autonomously apply the nutrition
care process at an optimal level of accuracy and efficiency” (http://www
.cdrnet.org). The initial deadline for eligibility applications was set for
August 6, 2016. Examinations are scheduled for November 2016 with
the anticipation that a new group of registered dietitians would achieve
the credential of Advanced Practice Certification in Clinical Nutrition
(RDN-AP or RD_AP) in late 2016.

CERT IF IC ATE S O F TR A I N I N G
As the epidemic of obesity continues and the need for registered dietitians
to become more involved in the efforts to prevent and treat obesity, the
CDR offers three certificates of training in weight management. These
certificates are in Childhood and Adolescent Weight Management, Adult
Weight Management, and a Level 2 Certificate in Adult Weight Manage-
ment. The certificate programs are designed to develop practitioners of
comprehensive weight management care for adults, children, and adoles-
cents. The certificates are available only for active, student, international
and retired members of the Academy, and CDR credentialed practitio-
ners: RDN, RD, NDTR, and DTR. As of mid-2015 over 20,000 practi-
tioners have received a certificate with the majority from the adult weight
management area.
Training for the certificates includes:
• State-of-the-art information and skills shared by leading practitioners
• Hands-on experience with cases and exercises
64    C redentialing of N utrition and D ietetic P ractitioners

• Reference and other resource materials

• A range of 32 to 50 continuing professional education units (CPEUs)
depending on the individual certificates
This training and the subsequent certificates have become very useful
and popular with dietetic professionals returning to the workplace, work-
ing in private practice, and to registered dietitians in general. There is no
reissue of the certificates, but certificate holders are encouraged to partici-
pate in retraining as needed. Additional information can be found at the
CDR website: https://www.cdrnet.org/weight-management.

RE CERT IF IC ATI O N O F TH E R D/R DN A N D

D T R/ ND T R
In 2001, the CDR implemented a new process for continued certification
termed the Professional Development Portfolio (PDP).42–45 To maintain
registered status, RDN/RDs and NDTR/DTRs must participate in the
CDR’s mandatory PDP recertification system and remit the annual reg-
istration maintenance fee. Using this plan, the individual RDN/RD and
NDTR/DTR assumes the responsibility for learning, professional devel-
opment, and career direction. The PDP requires each practitioner to first
engage in self-reflection, followed by assessment and goal setting. This
process is followed by the development of a 5-year plan that reflects a criti-
cal analysis of goals and the steps to be taken to maintain professional com-
petency. The Academy’s “Revised 2012 Standards of Practice in Nutrition
Care and Standards of Professional Performance for Registered Dietitians”
and the CDR’s “Professional Development Portfolio” mutually ensure
competence of the dietetics practitioner.46,47 See https//www.cdrnet.org.
As greater numbers of registered dietitians retire, maintaining com-
petence and adhering to the Code of Ethics for the Profession of Dietet-
ics will present challenges, especially for those maintaining RDN/RD
status.48 A recent article by Dahl and Nye discusses this issue, which could
be viewed as relevant to all practitioners in detail.49
Participation in continuing professional education activities is essen-
tial for lifelong development to maintain and improve knowledge and
skills for competent dietetics practice. RDN/RDs and NDRT/DTRs
must report continuing professional education activities CPEU) using
the portfolio recertification system. The process by which the required
75  CPEUs are accumulated is also determined by the CDR, which
 A pp r o p r i a t e U s e of C r e d e n t i a l s      65

specifies the educational activities that qualify to be used as CPEUs. Begin-

ning with the 5-year recertification starting in 2012 and ending in 2017,
RDs and DTRs are required to complete 1 CPEU in ethics (Learning
Need Code 1050). The details of the continuing education requirements
including the new ethics requirement can be accessed at https://www
.cdrnet.org.
To maintain certification, an RDN/RD is required to pay yearly main-
tenance fee and engage in 75 hours of continuing education (CPEU) over
a 5-year period. A DTR/NDTR pays yearly fee and must accrue 50 hours
(CPEU) in a 5-year period. The details for dietitians and technicians
maintaining certification can be found at the CDR website (https://www
.cdrnet.org) under the Professional Development Resource Center.

RECE RT I F I C ATI O N O F S P E C I A L I ST S A N D
AD VANCE D P R A C TI C E I N C L I N I C A L
NUT RIT I O N
The specialty board certification is a practice credential (just as RDN/RD
and DTR/NDTR) that represents to the public that the certificate holder
possesses the knowledge, skills, and experience to function effectively as a
specialist in a specific focus area of practice. The nature of the knowledge and
skills to practice at a specialty level is subject to change due to technological
and scientific advances. Recertification testing helps to provide continuing
assurance that the certified specialist has indeed maintained knowledge in his
or her specialty or focus area. Details of the recertification process for each
specialist can be found at the following link: https://www.cdrnet.org.
Therefore, those who wish to recertify in the same specialty area at the
end of their 5-year certification period must meet the following criteria:
• Currently be a registered dietitian with the CDR
• Successfully complete an eligibility application
• Submit an application fee
• Successfully complete a specialty examination

APP RO PR I ATE U S E O F C R EDEN T I A L S

In 1989, the CDR issued a statement on the protection of the creden-
tials RD and DTR.50 The CDR recognized that the credentials that it
controls are most valuable to it and to the holders of those credentials
66    C redentialing of N utrition and D ietetic P ractitioners

because they are awarded only to individuals who have met the education
and experiential requirements and have passed appropriate examinations.
Practitioners may use these credentials only if they continue to meet CDR
requirements, including payment of a registration maintenance fee and
fulfillment of the continuing education hours required. The 2009 Code
of Ethics for the Profession of Dietetics has specific details about the use
of the various credentials of the Academy of Nutrition and Dietetics along
with responsibilities and consequences.51
As noted in the CDR statement, “The most common usage is after the
practitioner’s name as a professional designation, e.g., Jane Doe, RD or
John Smith, DTR.”52 Other specific details of the joint policy statement
of the CDR and the Academy’s board of directors are available online at:
https://www.cdrnet.org.

LE G AL RE G U L ATI O N S TATU T ES F OR
D IE T I T I AN S N U TR I TI O N I S TS A N D
D IE T ET IC T E C H N I C I A N S
Forty-seven states and Puerto Rico now have laws that regulate dietitians
or nutritionists through licensure, statutory certification, or registration.
Thirty-eight, or 80 percent, of these states have included the protec-
tion of a scope of practice as well as protection of the name registered
dietitian. One-half of these states protect the title of nutritionist as well;
Nebraska protects the title of medical nutrition therapist, and Maine has
licensure for dietetic technicians. State licensure and state certification
are entirely separate and distinct from registration or certification by the
CDR (https://www.cdrnet.org).
The 47 states that regulate dietitians or nutritionists do so through
licensure, statutory certification, or registration. For state regulation pur-
poses, these terms are defined as the following:53
• Licensure. Licensure is a process by which state governmental agencies
grant time-limited permission to an individual to be recognized as
and/or engaged in a given occupation after verifying that the individ-
ual has met predetermined, standardized competency qualifications.
• Statutory certification. This certification limits use of particular titles
to persons meeting predetermined requirements, while persons not
certified can still practice the occupation or profession.
 S u m m a r y      67

• Registration. It is the least restrictive form of state regulation. As with

certification, unregistered persons are permitted to practice the pro-
fession. Typically, exams are not given and enforcement of the regis-
tration requirement is minimal.
Dietetic practitioners are licensed by states to ensure that only quali-
fied, trained professionals provide nutrition services or advice to indi-
viduals requiring or seeking nutrition care or dietetics information. In
states with licensure, only state-licensed dietetics professionals can provide
nutrition counseling and other services, included in the scope of practice,
as a part of the licensure law. Non-licensed practitioners may be subject to
prosecution for practicing without a license. States with certification laws
limit the use of particular titles (e.g., dietitian or nutritionist) to persons
meeting predetermined requirements; however, persons not certified can
still practice without using the title. Consumers in these states who are
seeking nutrition therapy assistance need to be more cautious and aware
of the qualifications of the provider they choose.
As dietitian nutritionists or dietetic technicians travel from state to state
to practice dietetics, it is important to contact a state Academy of Nutri-
tion and Dietetics or a state regulatory agency to determine state licensure
law provisions prior to practicing dietetics. Contacting the state Academy
or State licensure agency will provide specific state related information
about licensure in the state. CDR maintains a current list of states with
licensure and or certification laws as well (https://www.cdrnet.org).

S UMMARY
Dietitians continue to desire recognition and differentiation among their
peers that is visible and can be communicated to consumers, clients, and
other professional practitioners. The CDR credentialing program does
this. The RDN/RD has become valued to the point that most individu-
als consider it synonymous with dietitian. The same is becoming true for
the DTR/NDTR. Many employers view both as mandatory credentials
to practice in various employment settings for dietetic professionals. Cre-
dentials also have been used in international markets and jobs to describe
individuals and job qualifications. For dietitians, dietetic technicians, and
dietetic specialists, this is a plus as the world moves toward a global prac-
tice and global economy.
68    C redentialing of N utrition and D ietetic P ractitioners

Consumers will always demand credentials of some kind. As consumers

recognize that the credentials of the Commission on Dietetic Registration
provide assurance that the practitioners are competent and can provide
services they want, the demand will continue to rise. More significantly,
these credentials will enhance the dietetics professionals’ efforts to describe
the diversity of their capabilities and to obtain a competitive advantage
in the practice of dietetics in the United States and internationally.

D E F INI T I O N S

Certification. The process by which a nongovernmental agency or

association grants recognition to an individual who has met certain
predetermined qualifications specified by that agency or association
(e.g., registration for dietitians and dietetic technicians administered
by the CDR).
Credentialing. Formal recognition of professional or technical compe-
tence as by certification or licensure.
Licensure. Process by which a government agency grants permission to an
individual to engage in a given occupation upon finding that the appli-
cant has attained the minimal degree of competency necessary to ensure
that the public health, safety, and welfare are reasonably well protected.
Practitioner. One who practices in a profession or occupation.
Registration. See Certification.
Scope of practice. Extent of or dimensions of activities performed in an
area of practice.
For additional definitions of terms commonly used by the Academy
consult the 2016 Updated Definition of Terms List.54

RE F E RENC E S
1. Commission on Dietetic Registration: Accessed April 11, 2016, https://www
.cdrnet.org
2. Cassell, J. Carry the Flame: The History of the American Dietetic Association.
(Chicago: The American Dietetic Association, 1990), p. 9.
3. See Note 2, p. 3.
4. A cademy of Dietetics and Nutrition Quality Management Committee. Definition
of Terms List. Updated January 2015. Accessed April 11, 2016, https:/www
.eatrightpro.org/_/media/eatrightpro%20files/practice/scope%20standards%20
of%20practice/definition%20of%20of20terms%20list.ashx
 R e f e r e n c e s      69

5. See Note 2, p. 22.

6. See Note 2, p. 26.
7. See Note 2, p. 71.
8. Perry, E. “Report of the Executive Board.” J Am Diet Assoc 26 (1950):
949–957.
9. ADA. Constitution of the American Dietetic Association, as Amended. (Chicago:
The American Dietetic Association, 1971).
10. Bogle, M.L. “Registration: The Sine Qua Non of a Competent Dietitian.”
J Am Diet Assoc 74 (1974): 616–620.
11. See Note 1.
12. ADA. “Bylaws of American Dietetic Association,” revised March 10, 2002.
Accessed March 1, 2004, www.eatright.org/member/governance/85_12428.cfm
13. ADA. “American Dietetic Association/Commission on Dietetic Registration Code
of Ethics for the Profession of Dietetics and Process for Consideration of Ethics
Issues.” J Am Diet Assoc 109 (2009): 1461–1467.
14. ADA. Council on Future Practice Visioning Report. (Chicago: The American Dietetic
Association, 2011).
15. See Note 13.
16. The Academy Quality Management Committee and Scope of Practice Subcom-
mittee of The Quality Management Committee. “Academy of Nutrition and
Dietetics: Scope of Practice for the Registered Dietitian.” J Acad Nutr Diet 113,
no. 6 (2013): S17–S28.
17. The Academy Quality Management Committee and Scope of Practice Subcom-
mittee of the Quality Management Committee. “Academy of Nutrition and
Dietetics: Revised 2012 Standards of Practice in Nutrition Care and Standards of
Professional Performance for Registered Dietitians.” J Acad Nutr Diet 113, no. 6
(2013): S29–S45.
18. The Academy Quality Management Committee and Scope of Practice Subcom-
mittee of the Quality Management Committee. “Academy of Nutrition and
Dietetics: Scope of Practice for the Dietitian Technician, Registered.” J Acad Nutr
Diet 113, no. 6 (2013): S46–S55.
19. See Note 18.
20. The Academy Quality Management Committee and Scope of Practice Subcom-
mittee of the Quality Management Committee. “Academy of Nutrition and
Dietetics: Revised 2012 Standards of Practice in Nutrition Care and Standards
of Professional Performance for the Dietetic Technician, Registered.” J Acad Nutr
Diet 113, no. 6 (2013): S56–S71.
21. ADA. Final Report of the Phase 2 Future Practice and Education Task Force. (Chicago:
The American Dietetic Association, 2008), pp. 2–72.
22. See Note 21.
23. Dreyfus, H.L., and S.E. Dreyfus. Mind over Machine. (New York: The Free Press,
1986).
24. Dreyfus, S.E. “The Five-Stage Model of Adult Skill Acquisition.” Bull Sci Technol
Soc 14 (2004): 177–181.
25. See Note 13.
70    C redentialing of N utrition and D ietetic P ractitioners

26. See Note 18.

27. See Note 20.
28. See Note 4.
29. Raynor, H.A., and C.M. Champagne. “Position of the Academy of Nutrition and
Dietetics Interventions for the Treatment of Overweight and Obesity in Adults.”
J Acad Nutr Diet 116, no. 1 (2016): 129–147.
30. Bogle, M.L., L. Balogun, J. Cassell, A. Catakis, H.J. Holler, and C. Flynn.
“Achieving Excellence in Dietetic Practice: Certification of Specialists and
Advanced-level Practitioners.” J Am Diet Assoc 93 (1993): 149–150.
31. Touger-Decker, R. “Advanced-level Practice Degree Options: Practice Doctorates
in Dietetics.” J Am Diet Assoc 104 (2004): 1456–1458.
32. Skipper, A., and N.M. Lewis. “Using Initiative to Achieve Autonomy: A Model
for Advanced Practice in Medical Mutrition Therapy.” J Am Diet Assoc 106 (2006):
1219–1225.
33. Academy of Nutrition and Dietetics. Visioning Report: Moving Forward—A Vision
for the Continuum of Dietetics Education, Credentialing and Practice. (Chicago, IL:
Academy of Nutrition and Dietetics, 2012). Accessed April 11, 2016, http://www
.eatrightpro.org/~/media/eatrightpro%20files/practice/future%20practice
/visioning%20report%20final.ashx
34. Commission on Dietetic Registration. “Commission on Dietetic Registration
2005–2007 Levels of Practice Study Executive Summary.” Accessed April 11,
2016, https://www.cdrnet.org/whatsnew/Executive%20Summary.htm
35. Brody, R.A., L. Byham-Gray, M.R. Passannante, R. Touger-Decker, and
J. O’Sullivan-Maillet. “Essential Practice Activities of Clinical Advanced Practice
Registered Dietitians: A Delphi Study.” J Am Diet Assoc 111 (2011): A17.
36. Brody, R.A., L. Byham-Gray, R. Touger-Decker, M.R. Passannante, and
J. O’Sullivan Malliet. “Identifying Components of Advanced-clinical Nutrition
Practice: A Delphi Study.” J Am Diet Assoc 112 (1012): 859–869.
37. Wildish, D.E., S. Evers. “A Definition, Description, and Framework for Advanced
Practice in Dietetics.” Can J Diet Pract Res 71, no. 1 (2010): ed–e11.
38. O’Sullivan Maillet, J., R.A. Brody, A Skipper, J.M. Pavlinac. “Framework for
Analyzing Supply and Demand for Specialist and Advanced Practice Registered
Dietitians.” J Acad Nutr Diet 112, 3 suppl (2012): S47–S55.
39. Brody, R.A., L. Byham-Gray, R. Touger-Decker, M.R. Passannante, P. Rothpletz-
Puglia, J. O’Sullivan Maillet. “What Clinical Activities Do Advanced Practice
Registered Dietitians Nutritionists Perform? Results of a Delphi Study.”
J Acad Nutr Diet 114, no. 5 (2014): 718–733.
40. Mueller, C., D. Rogers, R.A. Brody, C.L. Chaffee Jr, R. Tougher-Decker. “Report
from the Advanced-Level Clinical Practice Audit Task Force of the Commission
on Dietetic Registration: Results of the 2013 Advanced-Level Clinical Practice
Audit.” J Acad Nutr Diet 115, no. 4 (2015): 624–634.
41. Brody, R.A., A. Skipper, C.L. Chaffee Jr, N.H. Wooldridge, J.R. Kicklighter,
R. Tougher-Decker. “Developing an Advanced Practice Credential for Registered
Dietitian Nutritionists in Clinical Nutrition Practice.” J Acad Nutr Diet 115,
no. 4 (2015): 619–623.
 R e f e r e n c e s      71

42. Weddle, D.O., S.P. Himsburg, N. Collins, and R. Lewis. “The Professional Devel-
opment Portfolio Process: Setting Goals for Credentialing.” J Am Diet Assoc 102,
no. 10 (2002): 1439–1444.
43. See Note 4, p. 4.
44. Keirn, K.S., C.A. Johnson, and G.E. Gates. “Learning Needs and Continuing Pro-
fessional Education Activities of Professional Development Portfolio Participants.”
J Am Diet Assoc 101, no. 6 (2001): 697–702.
45. Keirn, K.S., G.E. Gates, and C.A. Johnson. “Dietetics Professionals Have a Posi-
tive Perception of Professional Development.” J Am Diet Assoc 101, no. 7 (2001):
820–824.
46. See Note 17.
47. See Note 42.
48. Gates, G. “Ethics Opinion: Dietetic Professionals Are Ethically Obligated to Main-
tain Personal Competence in Practice.” J Am Diet Assoc 103 (2003): 633–635.
49. Dahl, L., and S. Nye. “Competency for Retired Credentialed Practitioners.”
J Am Diet Assoc 112 (2012): 934–936.
50. Academy of Nutrition and Dietetics. “RD/DTR Credentialing (CDR).” Accessed
April 11, 2016, http://www.eatright.org/HealthProfessionals/content.aspx?id=64
42458781&terms=RD%2fDTR%20Credentialing#.UPsWAI5xBFA
51. See Note 13.
52. See Note 50.
53. See Note 4.
54. Ibid.
 5

CHAPTER
The Nutrition and
Dietetics Professional
“The dietetics practitioner provides professional services
with objectivity and with respect for the unique needs
and values of individuals.”1

OUTLINE
• Learning Objectives
• Introduction
• Scope of Practice and Performance Standards
• Standards of Practice and Standards of Professional
Performance
• Ethical Practice
• Diversity and Culturally Competent Practice
• Lifelong Professional Development
• Delivery of Learning
• Informatics
• Health Insurance Portability and Accountability Act
• The Legal Basis of Practice
• Evidence-Based Practice
• Summary
• Definitions
• References

73
74    T he N utrition and D ietetics P rofessional

LEARNING OBJECTIVES
The student will be able to:
1. Become familiar with Scope of Practice and its implications
for the Academy member.
2. Understand the attributes of a professional.
3. Become familiar with the essential elements of ethical prac-
tice and the Code of Ethics.
4. Gain appreciation for the importance of lifelong professional
development.
5. Know how to apply evidence-based practice.

IN T RO D UC TI O N
Professional practice can be defined in several ways—first and foremost
as practice based on specialized learning and training and adherence to a
code of ethical actions and behavior adopted by the group. Dietitians who
develop a professional portfolio are familiar with the process involved, such
as a plan for continued competence in practice with supporting goals and
measures to meet the goals. The portfolio emphasis is on continued learn-
ing and self-monitoring—both distinguishing features of a professional.
Dietetics practice is based on a fluid and flexible framework. The core
of the profession is food and nutrition services for individuals, groups, and
communities. The dietetics professional provides services through com-
munication and collaboration with others by using management tech-
niques, research, science, technology, and leadership skills.

SC O PE O F P R A C TI C E A N D P ER F OR M A N C E
STAND ARD S
In response to a need to provide guidance for members practicing in diverse
roles in dietetics, the Academy appointed a Task Force in 2004 to develop
a Scope of Practice Framework. Directions for using the framework fol-
lowed with periodic updates. The framework provided a flexible decision-
making structure by which dietitians could determine if specific activities
fell within the scope of dietetics practice. Three broad areas were defined in
the framework: foundation knowledge, evaluation, and resources.
 Scope of Practice and P e r f o r m a n c e S t a n d a r d s      75

Scope of Practice (Individual) is also referred to as Scope of Practice in

Nutrition and Dietetics and provides the flexible boundaries of the individ-
ual’s professional practice. For the Scope of Practice (Statutory) the Acad-
emy has adopted the definition of the Center for the Health Professions,
University of California, San Francisco. It can be accessed at http://future
.ucsf.edu/Content/29/2007-12 Promising Scope of Practice Models for the
Health professions.pdf. The statutory Scope of Practice refers to the prac-
titioner’s qualifications, board representation, fees, and renewal as well as
listing a range of roles, examples of specific activities and regulations within
which the nutrition and dietetics practitioners perform.2 The scope of prac-
tice for the registered dietitian nutritionist (RDN) focuses on “food and
nutrition and related service developed, directed and provided by RDNs to
protect the public, community, and populations; enhance the health and
well-being of patients/clients; and deliver quality products, programs, and
services across all focus areas.”3 The scope of practice for the dietetic techni-
cian, registered (DTR) focuses on “food and nutrition-related services pro-
vided by DTRs who work under supervision when in direct patient/client
nutrition care and who may work independently.”4 As a part of the Scope of
Practice, the Standards of Practice (SOP) and the Standards of Professional
Performance (SOPP) are used as tools by credentialed dietetics practitio-
ners. They are to be used for self-evaluation, professional development, and
advancement of practice. Some regulatory agencies may use the SOP and
SOPP to determine competency for credentialed practitioners.5

Standards of Practice and Standards of Professional Performance

The Academy published guidelines for professional practice in 1998 and
revised them in 2012 as “Scope of Practice in Nutrition and Dietetics.”6
The first standards for a specific or focus area were developed for the Reg-
istered Dietitian and Dietetic Technician in nutrition care and revised in
2012.7,8 They were general in content that outlined activities that apply in
all areas of dietetic practice. These became the blueprint for the develop-
ment of standards in many other areas of practice. The general standards
specified the following activities:
• Minimum levels of practice and performance
• Common indicators for self-evaluation
• Consistency in practice and performance
• The role of dietetics and the services that the RDN and the DTR
provide within the healthcare team
76    T he N utrition and D ietetics P rofessional

• The food and nutrition services provided in a framework that encour-

ages continuous quality improvement
• A basis for researchers to investigate relationships between dietetics
practice and outcomes
• A framework for educators to set objectives for educational programs
that reflect applicable federal laws and regulations
Professional standards are important because they promote safe, effec-
tive, and efficient food and nutrition services; they are developed from
evidence-based practice (EBP); they provide for improved health care and
food and nutrition service-related outcomes; they ensure continuous qual-
ity improvement; they promote dietetics research, innovation, and prac-
tice development, and they help the individual RDN and DTR develop
professionally.
SOP and SOPP have now been developed in many areas of dietetic prac-
tice. SOP can be defined as “the minimum expectations or skill for competent
performance”. SOPP may be defined as “guides for the activities regarded as
essential to attain professional expectations that is, the knowledge, skills,
and competencies required at various levels of care.” In simplest terms, the
SOP describes what is done—the job requirements—at defined levels of skill
and the SOPP describes the actions necessary to achieve this. The two are
complementary documents and are developed to be used together.
The following areas of practice have developed SOP and SOPP docu-
ments, which are available on the Academy website and in the Journal of
the Academy.
a. Adult Weight Management
b. Pediatrics
c. Public Health and Community Nutrition
d. Sustainable, Resilient, and healthy Food and Water Systems
e. Sports Nutrition
f. Management in Food and Nutrition Systems
g. Nephrology Nutrition
h. Nutrition Support
i. Nutrition Care for Registered Dietitians
j. Nutrition Care for Dietetic Technicians
k. Clinical Nutrition Management
l. Intellectual and Developmental Disabilities
m. Disordered Eating and Eating Disorders
 E t h i c a l P r a c t i c e      77

n. Diabetes Care
o. Integrative and Functional Medicine
p. Extended Care Settings
q. Oncology Nutrition Care
r. Education of Dietetics Practitioners
s. Diabetes
t. Behavioral Health Care
In addition to the standards for areas of practice, standards have also
been developed by the Academy for organization self-assessment and
quality improvement.9

E T H I CAL P R A C TI C E
The Code of Ethics for the Profession of Dietetics is the guiding document for
ethical practice. The Code is developed by the Academy and the Council
for Dietetic Registration as a voluntary enforceable code of behavior. The
code challenges all members to uphold ethical principles. The process of
enforcement includes a way to deal with any complaints about members
and credentialed practitioners. An ethics committee enforces the code and
educated members about the ethical principles to be followed.
Several guiding principles outline the concerns, values and ethics of the
dietetics profession as follows:10
1. The nutrition and dietetics practitioner conducts himself or her-
self with honesty, integrity, and fairness.
2. The nutrition and dietetics practitioner supports and promotes
high standards of professional practice. The practitioner accepts
the obligation to protect clients, the public, and the profession by
upholding the Code of Ethics and reporting perceived violations
of the Code through the processes provided.
3. The practitioner provides professional services with objectivity
and with respect and consideration for the unique needs and val-
ues of individuals.
4. The practitioner protects confidential information and makes full
disclosure about any limitations to guarantee full confidentiality.
5. The practitioner does not invite, accept or offer gifts, monetary
incentives, or other considerations that affect or reasonably give an
appearance of affecting his or her professional judgment.
78    T he N utrition and D ietetics P rofessional

6. The nutrition and dietetics practitioner does not invite, accept or

offer gifts, monetary incentives, or other considerations that affect
or reasonably give an appearance of affecting his or her profes-
sional judgment.
In all areas of practice, situations arise at times in which the ethical
course of action may not always be clear. Ethical conflicts of interest and
poorly conducted business practices are examples of how unethical con-
duct may impact dietetic practice.11 Other ethical considerations include
issues of confidentiality, promotion and endorsement of products, and
recognition of professional judgment.
In clinical practice, activities relating to providing dietary supplemen-
tation advice and conducting online counseling and consultation make
it important to be familiar with regulations as well as the code of ethics
in order to avoid liability risk. Other instances in which ethical conduct
must be considered are disclosure of confidential information, accept-
ing gifts, discussing patient/clients, and charting or giving information
about prices or salaries. In such cases, open discussion with a supervisor or
trusted experienced peers, checking relevant policies before acting is the
best course to follow. A personal code of conduct that espouses integrity,
fairness, and a sense of always wanting to do the right thing helps make
difficult decisions about ethical questions easier.
The increased use of electronic communications in all areas of practice
requires ethical decision-making.12 There are few guidelines for the use of
media that deal with ethical behavior and communication with the public
and it is often difficult to know what is reliable and valid information. The
Nutrition Entrepreneurship Dietetic Practice group has established a nutri-
tion blog to make it easier to find science-based information and elevate
the voice of the registered dietitian online.13 E-professionalism is a term used
to describe professional attitudes and behaviors in the use of digital media
and applies to still-evolving SOP, legality etiquette, and perception.14
Ethics in research and the use of copyrighted material from journals are
also areas in which dietitians need to be aware of regulations that apply
and use professional judgment.15
The obligation to maintain personal competence in practice is empha-
sized as an ethical obligation.16 Practitioners need to continually build
on their knowledge and skills and to continue to acquire new techniques
and evidence-based information. By continuing to stay current, improved
performance provides quality service in the work setting.
 E t h i c a l P r a c t i c e      79

The manager or leader assists in developing organization practices and

policies that promote ethical practice. Such policies set the ethical standards
for activities, such as purchasing, financial management, patient care, and
information provided to patients and clients. The manager or leader sets an
example for ethical behavior built on openness and trust and makes sure all
employees know the policies and procedures of the workplace. The manager
assists in making ethical decisions by identifying that the situation is an ethical
dilemma, determining how the issue applies to the Code of Ethics, and select-
ing alternative actions and strategies to successfully implement a decision.17
An ethical deliberation process is shown in Table 5-1.

Table 5-1.  Suggested Ethical Deliberative Process

1. Clarify the moral question—the first statement of the moral problem
2. Re-create the context.
a. Gather data.
b. Consider relevant facts.
c. Consider relevant values.
3. Name stakeholders and their relationships.
4. Identify ways of ethical thinking used by the stakeholder.
a. Rules thinking—doing what is right by following the rules
b. Role thinking—being true to self and your sense of virtue
c. Goals thinking—producing good outcomes regardless of rules
5. Determine practical limits to the situation: policies, laws, standards, and codes.
6. Balance a client’s belief and preferences with his or her best interests.
7. Respect advance directives.
8. Assume a client has decisional capacity.
9. If not, select a substitute decision maker if necessary.
10. Restate the ethical problem.
11. Search for possible options
12. Test various options. Check through each option for:
a. Rules—is it right?
b. Roles—can I feel good about this?
c. Goal—what good will it do?
13. Justify the option selected for recommendation.
a. Keep the client’s best interest at the center of options.
b. Provide a description of what will likely happen and provide a clear action.
c. Plan for each option recommended—suggestions of practical pathways.

Reprinted from Journal of the American Dietetic Association, 102, Number 5 (May 2002):
Julie O’Sullivan Maillet et al, “Position of the American Dietetic Association: Ethical and Legal Issues
in Nutrition, Hydration, and Feeding,” 716–726, Copyright 2002, with permission from Elsevier.
80    T he N utrition and D ietetics P rofessional

D IV E RS I T Y A N D C U LTU R A L LY
COMP E T EN T P R A C TI C E
A former president of the Academy described culturally competent prac-
tice as a way to overcome health disparities and improve care across all
population groups.18 Interaction with clients of diverse cultures in a sensi-
tive and effective manner is a key strategy in the promotion of food and
nutrition behavior and beliefs.
Cultural competence is often implemented through diversity initiatives.
Diversity can refer to age, physical ability, religion, socioeconomic status, sex,
and ethnicity. Professional organizations sensitive to diversity issues focus on
attracting a membership that reflects these demographics.19 The Academy
has developed a number of initiatives toward promoting diversity, includ-
ing the following official statement: “The Academy values and respects the
diverse viewpoints and individual differences of all people. The Academy’s
mission and vision are most effectively realized through the promotion of
a diverse membership that reflects cultural, ethnic, gender, race, religious,
sexual orientation, socioeconomic, geographical, political, educational, expe-
riential and philosophical characteristics of the public it serves. The Academy
actively identifies and offers opportunities to individuals with varied skills,
talents, abilities, ideas, disabilities, backgrounds, and practice expertise.”20
The Code of Ethics further delineates issues relating to ensuring equality
in practice. Reflecting the Academy’s commitment to diversity, several grants
and awards are provided by the profession. These include Diversity Mini-
Grants for students and underrepresented groups within the profession and
Diversity Promotion Grants to support minority recruitment and retention
projects. The Diversity Leaders Program supports active members from under-
represented groups within the profession and a Diversity Action Award to an
educational institution, Affiliate dietetic association, dietetic practice group, or
other recognized Academy group in recognition of past accomplishments. A
compilation of articles published in a Journal Supplement is titled: “Building
a Brighter Tomorrow: Diversity, Mentoring, and the Future of Dietetics.”21

LIF E LO NG P R O F E S S I O N A L DEVEL OPM EN T

The Center for Professional Development in the Academy office offers
and coordinates activities designed to support all food and nutrition
professionals in continual building of their knowledge and skills. The
 L i f e l o n g P r o f e s s i o n a l D e v e l o p m e n t      81

activities include multidisciplinary topics, enhanced technology skills, and

programming. Examples are the annual Food and Nutrition Conference
and Exposition (FNCE); training programs for specialty certification and
conferences and events including sessions at FNCE conducted by dietetic
practice groups. Build distance-learning opportunities are also offered
through teleseminars and webinars. In addition, group and individual
self-study is available.

Delivery of Learning
Food and nutrition professionals use a variety of methods to continually
build professional skills. The range of learning opportunities is greater
than ever considering the many advancements in technology that allow
individual study a well as group learning and interaction. For example,
teleconferencing today replaces many former face-to-face meetings, thus
saving travel and related costs. Networking through social network sites
is another way dietetic professionals connect with and learn from others
with similar interests and concerns.22
Online video and streaming video are effective ways of communicating
nutrition messages.23 Switt24 offers suggestions for creating and manag-
ing a website by offering unique, original content; registering with search
engines, and developing a newsletter.
Self-direction in learning is the ability to engage in educational activi-
ties without external reinforcement. Individuals who do so typify some or
all of the following characteristics:
• Willingness to change
• Ability to identify weaknesses or shortcomings
• Ability to capitalize on strengths
• Ability to learn from constructive criticism
• Willingness to participate in all forms of learning
• Willingness to try new techniques for learning
• Willingness to invest time and money in learning
• Willingness to find a mentor or become one
• Volunteering in organizations and groups
• Sharing learning by applying concepts with others
• Providing feedback to instructors, mentors and supervisors
• Assuming personal responsibility for learning
• Allowing the possibility of new careers and experiences
82    T he N utrition and D ietetics P rofessional

Besides maintaining and improving professional competence, there

are other reasons for participation in continuing education activities and
why there may be deterrents in doing so. Several reasons and deterrents
are shown in Table 5-2. To determine the types of learning experiences
that most benefit an individual, several questions may be posed for self-
examination of needs (Table 5-3).

Informatics
Informatics refers to the use of electronic support for using and man-
aging information. Health informatics is described by the Department
of Health and Human Services as “the intersection of information sci-
ence, computer media, and health care.” Health information tools include
electronic media, clinical guidelines, formal medical technologies, and
information and communication systems. The medical and nursing pro-
fessions have taken the lead in the use of technology, most directly in the
development of electronic health records.25
Nutrition informatics is defined as “the effective retrieval, organization,
storage, and optimum use of information, data, and knowledge of food

Table 5-2.  Factors Influencing Continuing Professional Education

Reasons for participation in continuing professional education:
• Professional development and improvement
• Professional service
• College learning and interaction
• Professional commitment and reflection
• Personal benefits and job security
Deterrents to participation in continuing professional education:
• Disengagement and apathy for learning or career
• Costs
• Family
• Failure to see the worth or benefit
• Lack of quality in offerings
• Demands of work constraints

Reprinted from Journal of the American Dietetic Association, 103, Number 3 (March
2003), Petrillo, T. “Lifelong Learning Goals: Individual Steps That Propel the Profession of
Dietetics,” 298–300, Copyright 2003, with permission from Elsevier.
 L i f e l o n g P r o f e s s i o n a l D e v e l o p m e n t      83

Table 5-3.  Questions to Determine Self-Needs

What kind of learning is needed to improve performance in your current job?
How can you change or improve your current job?
What is your capacity for learning and growth in a new job?
What transferable skills do you possess for a new career path?
What new skills are required for you to be qualified to contribute in a new job?
What are your personal interests?
What career path did you once consider?
What leisure time interests do you enjoy?
What type of a learning experience is most favorable to you and why?
What related learning opportunities lie just beyond your field of practice?
What skill sets are important to your employer?

Data from Davis, J.R. Toolbox for Reflection and Developing an Action Learning Plan: Managing
Your Own. (San Francisco: Berrett-Koehler Publisher 2000), p. 10. Petrillo, T. “Lifelong
Learning Goals: Individual Steps That Propel the Profession of Dietetics.” J Am Diet Assoc
103, no. 3 (2003): 298–300.

and nutrition-related problem solving and decision making.” Informatics is

supported by the use of information standards, information processing and
information technology.26 The term is also simply defined as “the intersec-
tion of information, nutrition, and technology.” The use of automation
is transforming dietetic practice in hospital dietary departments as well as
in business, research, and private practice. The time involved in nutrition
assessments of patients can be decreased, communications between clinical
and food service areas can be accomplished much faster. Dietitians can help
shape the trend toward automation in hospitals and food service institu-
tions. The demand for informatics is expected to continue to grow, making
this an area in which dietitians need to become proficient.27
Dietitians use websites for information that is scientifically sound and
that provides information from many sources. Foremost among these is
the Academy Evidence Analysis Library.28
A national undertaking that will connect health records to electronics
for every American is under way. The dietetics profession is a part of the
national effort, making it imperative that a concerted effort is made to
prepare practitioners for the use of nutrition information aligned with the
broad fields of medicine and health. This also presents the opportunity to
integrate food and nutrition with related activities into the system.29
84    T he N utrition and D ietetics P rofessional

Health Insurance Portability and Accountability Act

All practitioners need to be familiar with the provisions of the Health Insurance
Portability and Accountability Act (HIPPA) Act of 1996 and the additional
Privacy Rule of 2003.30 Developed by the Department of Health and Human
Services, these acts provide patients with access to their medical records and
increased control over their health information. HIPPA includes provisions
for electronic transactions and safeguards to protect the security and confiden-
tiality of health information. All health providers, including dietitians, must
be aware of the need to protect the privacy of information about patients in
the clinical setting and be familiar with the policies and procedures established
by the institution for the enforcement of the regulations.31

T H E LEG AL B A S I S O F P R A CT I C E
The practice of dietetics is directly affected by many laws and regulations
that must be followed in order to avoid legal consequences. Fortunately,
as Derelian32 points out, almost all disputes that involve a dietitian would
be of a civil nature, such as contract breaches or negligence. Busey33 indi-
cates that dietitians may increasingly become parties to lawsuits consider-
ing the number of RDNs who go into private practice and the fact that
they play important roles in the healthcare process. He gives suggestions
regarding the types of lawsuits in which a dietitian may become involved
and discusses steps in the process when lawsuits occur. He further points
out that if the terminology used in documentation of patient care is sub-
ject to more than one interpretation, this could become a legally disputed
issue. An example is the use of the word inadequate in describing patient
progress, as it could denote negligence.34
Three specific areas of practice that are of importance regarding pos-
sible legal issues are: practice beyond one’s qualifications, billing, and
proper use of healthcare resources and advertising services.35 Responsibil-
ity in practice can mean that as advanced tasks become part of the job
requirements, additional training will usually be needed. Examples are
in activities such as insulin regulation, diet ordering, and placement of a
nasal gastric tube. Similarly, if the dietitian advances in job level, further
credentials, and learning may be required.
Dietitians working in clinical practice as well as in business or pri-
vate practice need to develop and use standardized billing procedures,
including written documents that explain the billing to clients. Billing to
 E v i d e n c e - B a s e d P r a c t i c e      85

third party payers will always entail policies and procedures that must be
adhered to in order to avoid legal complications.
Registered dietitians who advertise their services must be honest in all
claims made and should list their areas of preferred or limited practice.
Claims for guaranteed results should never be made if he or she is unable
to document the results. All practices should be sound—nutritionally,
ethically, and legally.
The increased use of electronic technology such as in telehealth or telemedi-
cine in which the dietitian may be a participant is another area in which legal
questions may arise.36 Examples of such issues are licensure, facility certifica-
tion and accreditation, reimbursement and Medicare Part B issues, and profes-
sional liability insurance. All dietitians are strongly encouraged to carry personal
liability insurance for protection against malpractice or other issues described.

E V ID E NC E - B A S E D P R A C TI C E
EBP is viewed as necessary for the best outcomes in all areas of dietetic prac-
tice. Evidence-based medicine is a model of clinical decision-making that uses
a systematic process to integrate the best research-based evidence with clinical
expertise and patient values to answer questions about a patient’s plan of care.36
EBP is described as “the use of systematically reviewed scientific evidence in
making food and nutrition practice decisions by integrating the best available
evidence with professional expertise and client values to improve outcomes.”37
Dietitians need to incorporate EBP into activities as payment for services may
be dependent on outcomes. Change in practice is constant, and this approach
ensures that decisions are sound. By applying the process, dietitians are able to
successfully compete in the healthcare environment where positive outcomes,
proven efficiency, cost effectiveness, and sharing of outcomes are important.
The Academy provides a valuable resource to members through the
Evidence Analysis Library (EAL). Through use of the EAL, profession-
als can stay current on the research in any area of dietetics. A variety of
resources are offered, including evidence summaries of the major research
on any given topic, bibliographies, and conclusion statements with an
evaluation of the strength of the evidence.37
A guide for appraising resources for evidence-based information is
shown in Table 5-4. Evidence must be balanced with the client’s values
and preferences for optimal shared decision-making, and resources must
be reliable, relevant, and readable.38
86    T he N utrition and D ietetics P rofessional

Table 5-4.  Guide for Appraising Resources for Evidence-Based

Information
Method and quality of information
• How was the resource compiled?
• Were explicit criteria for seeking and appraising evidence described, and were they
adhered to?
• How is the resource maintained?
Rating scale for methods and quality of information
0. No evidence cited
1. Evidence is cited, but there is no explicit criteria for the selection or evaluation of
the content; the selection of content suggests lack of consistent evidence standards
2. Evidence is cited, and there are explicit criteria for the election or evaluation of
the content, or both the selection of content suggests lack of adherence to these
evidence standards.
3. Evident is cited, but there are not explicit criteria for the selection or evaluation of
the content the selection of content suggests adherence to some evidence standards.
4. Evidence is cited, and there are explicit criteria for the selection or evaluation of
the content, or both; the selection of content suggests some adherence to evi-
dence standards.
5. Evidence I cited, and there are explicit criteria for the selection and evaluation
of the content the selection of content suggest adherence to evidence standards
most of the time.

Clinical usefulness
• Did the resource provide clinically useful answers?
• How did you use this resource?
• Was it easy to use?
• Were the answers easily accessible and readable within a few minutes?
• Will you use this resource?
• If so, when and how?
Rating scale for clinical usefulness
0. Not useful clinically.
1. Clinically useful answers are rarely available and are not easily accessible or
readable within a few minutes.
2. Clinically useful answers are available some of the time but are not easily
accessible or readable within a few minutes.
3. Clinically useful answers are available some of the time and are easily accessible
and readable within a few minutes.
4. Clinically useful answers are available most of the time but are not easily
accessible or readable within a few minutes.
5. Clinically useful answers are available most of the time and are easily accessible
and readable within a few minutes.
 S u m m a r y      87

Table 5-4.  Guide for Appraising Resources for Evidence-Based

Information (Continued)
Details on specific resources
Evidence-based medical texts
The following points could be used as a minimal checklist:
• Does the resource provide an explicit statement about the type of evidence on
which any statements or recommendation are based? Did the authors adhere to
these criteria? For example, claims about effectiveness of an intervention might
be accompanied by a statement about either the level of evidence (which would
need to be defined somewhere in the text) or a statement about the exact type of
evidence (e.g., “There have been three randomized controlled trials.”)
• Was there an explicit and adequate search for this evidence? For example, a
search for evidence about an intervention might have started with a look for
adequate systematic reviews. If this was done, it might be followed by a search of
the Cochrane Central Register of Controlled Trials.
• Is there quantification of the results? For example, statements about diagnostic
accuracy should contain measures of accuracy such as sensitivity and specificity.
The minimum criteria for an evidence-based resource would be adherence to the
first bullet point. Better resources should also address the other two points.
Meta-resources (e.g., listings or search engines for other resources)
These resources should provide and explicit statement about the selection criteria
for inclusion in the listing. Better resource should also include a descriptive review
such as that described in the three points for evidence-based medical texts.

Reproduced from Straus, S., and R.B. Haynes. “Managing Evidence-Based Knowledge: The
Need for Reliable, Relevant, and Readable Resources.” CMAJ 180, no. 9(2009): 942–945.
Copyright © 2009. This work is protected by copyright and the making of this copy was with
the permission of Access Copyright. Any alteration of its content or further copying in any
form whatsoever is strictly prohibited unless otherwise permitted by law.and preferences for
optimal shared decision-making, and information resources must be reliable, relevant, and
readable.38

S UMMARY
The professional dietitian is one who is competent in practice and con-
tinually participates in ongoing education. Knowledge and skills go hand
in hand with personal qualities and ethical practice, understanding the
legal basis of practice and incorporating the concept of evidence-based
activities in professional practice. As the voice of authority in food and
nutrition, the dietitian is a professional in every sense of the term.
88    T he N utrition and D ietetics P rofessional

D E F INI T I O N S

Diversity. A term with multiple, subjective definitions; may refer to age,

physical ability, religion, socioeconomic status, sex, race, ethnicity,
or other factors.
Evidence-based. Action based on research data and evaluation of
outcomes.
Standard. A measure of proficiency at an established level.

RE F E RENC E S
1. Code of Ethics for the Profession of Dietetics and Process for Consideration of
Ethics Issues.
2. Definition of Terms List. Academy of Nutrition and Dietetics. Approved by House
of Delegates Leadership Team January 27, 2016.
3. Scope of Practice in Nutrition and Dietetics. “Academy Quality Management
Committee and Scope of Practice Subcommittee of the Quality Management
Committee. Academy of Nutrition and Dietetics.” J Acad Nutr Diet 113, 6 suppl
(2013): S11–S16.
4. See Note 3 with page numbers: S17–S28.
5. See Note 3 with page numbers: S46–S55.
6. Academy Scope of Practice Decision Tool: A Self-Assessment Guide. “Academy
Quality Management Committee and Scope of Practice Subcommittee.”
J Acad Nutr Diet 113, 6 suppl (2013): S10.
7. Academy of Nutrition and Dietetics: Revised 2012 Standards of Practice in
Nutrition Care and Standards of Professional Performance for Registered
Dietitians. “Academy Quality Management Committee and Scope of Practice
Subcommittee of the Quality Management Committee.” J Acad Nutr Diet 113,
z96 suppl (2013): S29–S45.
8. Academy of Nutrition and Dietetics: Revised Standards of Practice in Nutrition
Care and Standards of Professional Performance for Dietetic Technicians,
Registered. “Academy of Quality Management Committee and Scope of Practice
Subcommittee of the Quality Management Committee.” J Acad Nutr Diet 113,
6 suppl (2013): S56–S71.
9. Price, J.A., S. Kent, S.M. McCauley, J. Parekh, C.J. Klein. “Using Academy
Standards of Excellence in Nutrition and Dietetics for Organization Self-Assessment
and Quality Improvement.” J Acad Nutr Diet 114, 8 (2014): 1279–1292.
10. Code of Ethics for the Profession of Dietetics. Accessed May 15, 2016, www
.eatright.org
11. Grandgenett, R., and D. Derelian. “Ethics in Business Practice.” J Am Diet Assoc
110, 7 (2010): 1103–1104.
 R e f e r e n c e s      89

12. Castle, D., and R. DeBusk. “The Electronic Health Record: Genetic Information
and Patient Privacy.” J Am Diet Assoc 118, 8 (2008): 1372–1374.
13. Ventures. Newsletter of Nutrition Entrepreneurs DPG. “Nutrition Blog Network.”
Acad Nutr Diet XXXVII, 1 (2010): 2.
14. Aase, S. “Toward E-Professionalism: Thinking Through the Implications of
Navigating the Digital World.” J Am Diet Assoc 110, 10 (2010): 1440–1449.
15. Nicklas, J.A., W. Karmally, C.E. O’Neil. “Nutrition Professionals are Obligated
to Follow Ethical Guidelines when Conducting Industry-Funded Research.”
J Am Diet Assoc 111, 12 (2011): 1931–1932.
16. Academy of Nutrition and Dietetics. “Registered Dietitian Nutritionists
and Nutrition and Dietetics Technicians, Registered, Are Ethically Obligated to
Maintain Personal Competence in Practice.” J Acad Nutr Diet 115, 5 (2015):
811–814.
17. Fornari, A. “Approaches to Ethical Decision-Making.” J Acad Nutr Diet 115,
1 (2015): 119–121.
18. Rogriguez, J.C. “Culturally Competent Dietetics: Increasing Awareness: Improving
Care.” J Am Diet Assoc 110, 5 (2010): 57.
19. Diversity Strengthens our Academy and Profession. “President’s Page.” J Acad Nutr
Diet 115, 10 (2015): 1559.
20. Diversity. Accessed October 29, 2015, www.eatright.org/diversity
21. Bergman, E.A. “Building a Brighter Tomorrow: Diversity, Mentoring, and the
Future of Dietetics.” J Acad Nutr Diet 113, Suppl 3 (2013): S5–S47.
22. Brown, D. “Networking Moves Online.” J Am Diet Assoc 109, 2 (2010): 210–211.
23. Lane, M. “Streaming Soon to a Computer Near You: How Online Video Will
Change Media and Maybe Your Practice Forever.” ADA Times 108, 1 (2008): 20.
24. Switt, J.T. “Drawing Attention to Your Website.” J Am Diet Assoc 108, 1 (2008): 20.
25. Hoggle, L.B., M.A. Michael, S.M. Houston, E.J. Ayres. “Nutrition Informatics.”
J Am Diet Assoc 108, 1 (2008): 134–139.
26. Yadrick, M.M. “Informatics: A Word We Need to Know.” J Am Diet Assoc 108,
1 (2008): 134–139.
27. Aase, Y. “Improved Understanding the Promises and Challenges Nutrition Infor-
matics Poses for Dietetics Careers.” J Am Diet Assoc 110, 12 (2010): 1794–1795.
28. Murphy, W.J. “A New Breed of Evidence and the Tools to Generate It: Introducing
ANDHII.” J Acad Nutr Diet 115, 1 (2015): 19–26.
29. Department of Health and Human Services. “Understanding Health Information
Privacy.” Accessed February 12, 2015, www.hhs/gov/ocr/privacy/hipaa
30. Hoggle, L.B., M.A. Michael, S.M. Houston, E.J. Ayres. “Electronic Health Record:
Where Does Nutrition Fit In?” J Am Diet Assoc 106, 10 (2006): 1688–1695.
31. See Note 30.
32. Derelian, D. “Dietetics: Legalities, Ethics, and Eccentricities.” J Am Diet Assoc 100,
3 (2000): 519–523.
33. Busey, J.C. “Help! I’ve Just Been Served.” J Am Diet Assoc 109, 4 (2009): 600–605.
34. Busey, J.C. “Use of the Word Inadequate—A Legal Perspective.” J Am Diet Assoc
108, 6 (2008): 935–936.
90    T he N utrition and D ietetics P rofessional

35. Busey, J.C. “Telehealth—Opportunities and Pitfalls.” J Am Diet Assoc 109,

8 (2008): 1296–1301.
36. Shanklin, C. “Evidence-Based Practice: Practice Based on Evidence—Right?”
ADA Times 2003, 3: 1,3.
37. Academy of Nutrition and Dietetics. “Evidence-Based Practice.” Accessed
October 29, 2015, www.eatright.org
38. Straus, S., and R.B. Haynes. “Managing Evidence-Based Knowledge: The Need
for Reliable, Relevant and Readable Resources.” CMAJ 180, 9 (2009): 942–945.
 6

CHAPTER
The Dietitian
in Clinical Practice
“We need both cognitive ability and emotional intelligence to
help people understand and use the Dietary Guidelines.”1

OUTLINE
• Learning Objectives
• Introduction
• Employment Settings of Dietitians and Dietetic Technicians
• Practice Audit Activities
• Organization of Clinical Nutrition Services
• Responsibilities in Clinical Dietetics
• Nutrition Care Process and Model
• Medical Nutrition Therapy
• Standards of Practice
• The Clinical Nutrition Service Team
• Clinical Nutrition Manager or Chief Clinical Dietitian
• Clinical Dietitian
• Dietetic Technician
• Dietetic Assistant
• Clinical Dietetics Outlook
• Communicating Nutrition Messages
• Electronic Health Records
• Clinical Privileging
• Trends in Clinical Dietetics

91
92    T he D ietitian in C linical P ractice

• Summary
• Definitions
• References

LEARNING OBJECTIVES
The student will be able to:
1. Become familiar with employment settings for clinical
dietitians.
2. Name the members of the clinical team and their functions.
3. Discuss how clinical services may be organized.
4. Understand the range of responsibilities in clinical practice.
5. Gain information about the future outlook in clinical practice.

IN T RO D UC TI O N
The discipline of clinical dietetics originated in 1899 when dietitian was
defined by the American Home Economics Association as “individuals
with a knowledge of food who provide diet therapy for the medical profes-
sion.”2 Until 1917, dietitians were affiliated with this association, but after
1917 they belonged to the newly formed American Dietetic Association.3
The earliest dietitians worked primarily in hospitals or were associated
with food-assistance programs. During the 1930s and 1940s, dietitians
became involved in either food production and food service or in the plan-
ning and provision of diets for special medical needs. The title, therapeutic
dietitian, was used to describe the person who provided food for medical
reasons, such as the prevention of a nutrient deficiency or to help with the
treatment of disease.4 Examples of early diet therapy are the Sippy diet
that used milk and cream to treat ulcers and the Kempner rice diet to treat
hypertension; each was named for the physician who designed it.
As the dietitian’s role in the hospital became one of providing special-
ized care and modifying diets to treat various medical conditions, the title,
clinical dietitian, replaced the former titles.
In the early 1970s, reports of widespread malnutrition among hospital-
ized patients helped to increase the visibility of clinical dietitians.5 Clinical
 Employment Settings in D i e t e t i c s      93

dietitians began to take a more active role in screening and monitoring

patients along with the provision of nutrition support. Development of indi-
vidual nutrition care plans became important functions of clinical dietitians.
As the role of diet in the etiology of chronic diseases became better defined,
clinical dietitians began to spend a greater percentage of their time participat-
ing in the prevention of diseases, such as heart disease, cancer, and diabetes.

E MPLO YM E N T S E TTI N G S OF DI ET I T I A N S
AND D IE TE TI C TE C H N I C I A N S
In the 2015 survey of registered dietitians (RDs) and dietetic technicians,
registered (DTRs), 84 percent of those contacted reported they were
currently employed in dietetics.6 This high percentage of dietitians and
dietetic technicians who were working in the field of dietetics reflected the
diversity of job opportunities. Tables 6-1–6-3 show the primary employ-
ment areas of dietitians. Fifty-seven percent of RDs and 56 percent of
DTRs were employed in clinical areas of practice. These findings and
earlier membership surveys with similar findings indicate stability in these
employment areas and that clinical of practice are the predominate area
chosen area by entry-level professionals.

Table 6-1.  Primary Practice Area of Dietitians

RDs (%) DTRs (%)

Clinical nutrition—acute care/inpatient 32 42

Clinical nutrition—ambulatory care 17  1

Clinical nutrition—long-term care  8 13

Community nutrition 10 15

Food and nutrition management 11 17

Consultation and business  8  3

Education and research  7  1

Base: 8853 RDs and DTRs.

Reprinted from Journal of the Academy of Nutrition and Dietetics, Volume 112, Number 1
(January 2012), Ward. B. “Compensation and Benefits Survey 2011, Moderate Growth in
Registered Dietitian and Dietetic Technician, Registered, Compensation in the Past 2 years,”
29–40, Copyright 2012, with permission from Elsevier.
94    T he D ietitian in C linical P ractice

Table 6-2.  Highest Number of Positions in Clinical Practice—RDs

RDs (%)
Clinical dietitian 16
Outpatient dietitian, general  5
Outpatient dietitian, specialist—diabetes  3
Outpatient dietitian, specialist—renal  3
Clinical dietitian, long-term care  8
Women, infants, and children nutritionist  5
Director of food and nutrition services  4
Public Health Nutritionist  3

Reproduced from Ward. B. Compensation and Benefits Survey 2011, Moderate Growth in
Registered Dietitian and Dietetic Technician, Registered, Compensation in the past 2 years.
Acad Nutr Diet J 2012(112);29-40. Reprinted from Journal of the Academy of Nutrition and
Dietetics, Volume 112, Number 1 (January 2012)

The primary areas of clinical practice are as follows:

1. Acute care/inpatient
a. Hospitals
2. Ambulatory care
a. Hospital outpatient departments
b. Clinics
c. Outpatient care centers
3. Long-term care
a. Nursing homes
b. Assisted living facilities
c. Alzheimer’s disease units

Table 6-3.  Highest Number of Positions—DTRs

DTR
Dietetic technician, clinical 41
Dietetic technician, long-term care 12
WIC nutritionists  5
Director of food and nutrition service  5
Food service management  9

Reprinted from Journal of the Academy of Nutrition and Dietetics, Volume 112, Number 1
(January 2012), Ward. B. “Compensation and Benefits Survey 2011, Moderate Growth in
Registered Dietitian and Dietetic Technician, Registered, Compensation in the Past 2 years,”
29–40, Copyright 2012, with permission from Elsevier.
 Organization of C l i n i c a l N u t r i t i o n S e r v i c e s      95

P RACT IC E A U D I T A C TI V I TI ES
The Commission on Dietetic Registration conducts a practice audit every
5 years. The practice areas of RDs and DTRs are compared to show where
there is a higher level of involvement. In clinical practice, the particular
areas in which RDs indicate a higher level of involvement than DTRs
include the following:7
• Principles of education including designing courses and evaluating
education programs.
• Conducting research. Designing, developing proposals, reporting at
professional conferences, and writing for publication.
• Providing nutrition care to individuals. This comprised the largest
area of activity as would be expected and included development of
institutional standards for nutrition care, evaluating clients’ overall
health status, recommending and writing orders for tube feedings,
parenteral nutrition, medications, etc.
• Providing nutrition programs for population groups, which included
designing services to meet nutrition-related needs of groups.
The 2015 Entry-Level Dietetics Practice Audit may be accessed at:
Rogers D, Griswold K, Leibowitz PK, Sauer KL, Doughten S. Distinc-
tions in Entry-Level Registered Dietitian Nutritionist and Nutrition and
Dietetics Technicians, Registered: Further Results from the 2015 Com-
mission on Dietetic Registration Entry-Level Dietetics Practice Audit.
J Acad Nutr Diet 116 (2016) No. 10:1685–1696.

O RG ANI Z ATI O N O F C L I N I C A L N UT R I T I ON
S E RV I CES
Clinical nutrition services may be organized in several ways, depending on
the setting. In most hospitals, clinical nutrition services are managed by the
director of clinical nutrition, or the chief clinical dietitian. Typically, the
chief clinical dietitian reports to an individual whose primary responsibili-
ties are overall management of the entire food and nutrition department.
In others, clinical dietetics may be organized as a separate department that
reports to an executive or administrator with other patient care responsibili-
ties such as nursing or pharmacy. There are advantages and disadvantages to
both types of organization. Combining clinical nutrition with food services
can facilitate communication regarding patient food choices and menus. By
96    T he D ietitian in C linical P ractice You get the link on our
page
vk.com/lingualib
contrast, clinical nutrition as a separate department may increase visibility as
an important patient care service unit distinct from food service.

RESPONSIBILITIES IN CLINICAL DIETETICS

Nutrition Care Process and Model
The Quality Management Committee of the Academy of Nutrition and
Dietetics developed a nutrition care process (NCP) and model that was
adopted by the house of delegates of the American Dietetic Association
in 2003.8 The purpose of the planning model was “for implementation
and dissemination to the dietetics profession and the association for the
enhancement of the practice of dietetics.”9 The NCP is defined as sys-
tematic problem-solving methods that dietetic professionals use to criti-
cally think and make decisions to address nutrition-related problems and
to provide safe and effective quality nutrition care. Several models were
developed before adoption of the present model.
In 2008, a review and update of the process was undertaken following a
survey of ADA groups experienced in using the NCP.11 The process, now
referred to as the nutrition care process and model (NCPM), included
revisions in the original model and defined the functions under each step
as follows (Figure 6-1):
1. Nutrition assessment. In step 1, a systematic approach to collect,
record, and interpret relevant data from patients, clients, family
members, caregivers, and other individual groups is undertaken.
Examples of the type of data collected are food and nutrition-
related history, anthropometric measurements, biochemical data,
medical tests and procedures, nutrition-focused physical examina-
tion findings, and client history.
2. Nutrition diagnosis. Nutrition professionals identify and label exist-
ing nutrition problems they are responsible for treating indepen-
dently. The determination for continuation of care follows this step.
3. Nutrition intervention. Action is taken with the intent of changing
a nutrition-related behavior, risk factor, environmental condition,
or aspect of health status. This entails writing a plan of care, col-
laborating with the patient or client to identify goals of the inter-
action, and partnering with the patient and other caregivers to
carry out the plan.
 Responsibilities in C l i n i c a l D i e t e t i c s      97

Screening & Referral System The Nutrition Care Process

• Identify risk factors
• Use appropriate tools and methods
• Involve interdisciplinary collaboration
Practice Setting
s
f Ethic Diete
de o tics
Kn
Co ow
led
ge
Nutrition Assessment Nutrition Diagnosis
& Re-assessment • Identify & label problem
• Obtain/collect timely & • Determine cause/
e
ctic

appropriate data contributing risk factors

• Analyze/interpret with • Cluster signs & symptoms/

Hea
Pra

Ski
evidence-based defining characteristics

lls &

lth Ca
Evidence-based

standards • Document
• Document
Economics

Comperencies
Relationship Between

re Systems
Patient/Client/Group &
Dietetics Professional

Nutrition Monitoring Nutrition Intervention

& Evaluation • Plan nutrition intervention
• Monitor progress Formulate goals &
• Measure outcome determine a plan of action
on

indicators • Implement nutrition

C
ati

r
• Evaluate outcomes intervention

itic
c

• Document Care is delivered &

i
un

al
hi
actions are carried T
m

m nk
Co out ing
• Document

Collaboration
Social Systems

Outcomes Management System

• Monitor the success of the Nutrition Care Process implementation
• Evaluate the impact with aggregate data
• Identify and analyze causes of less than optimal performance and outcomes
• Refine the use of the Nutrition Care Process

FIGURE 6-1.  The Nutrition Care Process and Model.

Reprinted from Journal of the American Dietetic Association 108, no. 7 (July 2008), “Nutrition
Care Process and Model,”1116, 2008, with permission from Elsevier.

4. Nutrition monitoring and evaluation . In this final step, the amount

of progress is identified and whether the goals and expected out-
comes are being met is determined. Three steps are involved,
which are as follows:
a. Monitor progress.
b. Measure the outcomes.
c. Evaluate the outcomes by comparing to earlier status or refer-
ence standards.
98    T he D ietitian in C linical P ractice

A standardized set of terms has been developed to describe the results

in each step of the NCPM.12 The terms help facilitate the inclusion of
RD activities in electronic health record keeping, and also in policies,
procedures, rules, and legislation. The use of such standardized reporting
primarily assists in documenting nutrition care in the medical record in a
way that will refer to each of the four steps in the NCPM and highlight
the role of nutrition in patient care.

Medical Nutrition Therapy

Medical nutrition therapy (MNT) has been defined as “all diagnostic,
therapeutic, or counseling services provided by an RD for management
or treatment of any disease, condition, disorder, or illness.”13 A history
of the development of MNT, its importance in the national healthcare
discussion, and the challenges presented to members were discussed by
the government relations office of the ADA in 2005.14 Established by
legislation under Medicare Part B, provision was made for Medicare reim-
bursement to dietitians for care in two disease conditions—diabetes and
renal disease. The stipulation was that Medicare MNT providers must
use evidence-based protocols or guides for practice to illustrate that the
MNT offered by RDs has a positive medical impact on patients and a
positive impact on healthcare budgets. The rationale and justification for
the successful passage of legislation extending MNT to other disease treat-
ments depends, in large part, on the evidence that can be demonstrated
regarding its beneficial effects. Cost containment is a critical part of all
healthcare reform measures, and passage of any new MNT therapies will
demand good scientific evidence of both its cost-effectiveness and effi-
cacy. To this end, evidence-based outcomes research that documents the
clinical effectiveness of MNT is all important. Evidence-based practice
(EBP), it follows, improves the quality of care and helps manage costs.
By adopting EBP in providing MNT, RDs will use the best available evi-
dence to provide therapy, in addition to their own clinical expertise and
experience.
The academy assists dietitians by maintaining a library of resources,
the Evidence Analysis Library (EAL), available online at www
.adaevidencelibrary.com. The EAL gathers the best, most current, and
most relevant research on important questions in dietetic practice and is
available at no cost to all ADA members.15 The EAL offers evidence-based
 Responsibilities in C l i n i c a l D i e t e t i c s      99

nutrition practice guidelines in areas such as lipid metabolism, adult

weight management, and critical illnesses.
It can be noted that MNT describes the broad area of practice formerly
called diet therapy or therapeutic dietetics, and NCPM is the application
of nutrition therapies to disease conditions including guides for nutrition
education and preventive nutrition care services.

Standards of Practice
The Standards of Practice in nutrition care describe the minimum expecta-
tions for competent nutrition care practice. The Standards of Professional
Performance (SOPP), a companion document, describe the expectation
for competent behavior in the nondirect patient or client nutrition care
aspect of RD and DTR roles. First developed in 2005, the standards were
updated in 2008 and again in 2012.16
The standards of practice (SOP) in nutrition care specify the following:
• Address activities related to patient/client care during the NCP.
• Apply to RDs and DTRs who have direct contact with indi-
vidual patient/client care in acute and long-term care as well as in
public health, community, extended care, and ambulatory care
settings.
• Formatted according to the four steps of the NCP (i.e., nutrition
assessment, nutrition diagnosis, nutrition intervention, and nutrition
monitoring and evaluation).
• Reflect the individual levels (RD and DTR) of training, responsibility,
and accountability.
The SOPP include the following:
• Address behaviors related to the professional role that are not in the
NCP.
• Apply to RDs and DTRs in all practice settings.
• Address six domains of professional performance (i.e., provision of
services; application of research; communication and application of
knowledge; use and management of resources; quality in practice;
and competence and accountability).
• Reflect the individual levels (RD and DTR) of training, responsibility,
and accountability.
100    T he D ietitian in C linical P ractice

THE CLINICAL NUTRITION SERVICE TEAM

Clinical nutrition services may be provided by a number of team members
in healthcare facilities. Inpatient nutritional care in hospitals is usually the
responsibility of persons in several positions—clinical nutrition manag-
ers or chief clinical dietitians, clinical dietitians, dietetic technicians, and
dietetic assistants. Outpatient clinics and ambulatory care centers may use
all four positions but are more likely to employ only clinical dietitians.
Extended care facilities and physician offices may have clinical dietitians
on staff; however, more often these facilities use a consulting dietitian to
provide MNT for selected patients and clients. Consulting dietitians may
be in private practice or part of a group practice.
Clinical Nutrition Manager or Chief Clinical Dietitian
The clinical nutrition manager or chief clinical dietitian is primarily
responsible for directing the activities of clinical dietitians, dietetic tech-
nicians, and dietetic assistants. Major tasks performed include develop-
ing and managing budgets for the clinical area, hiring clinical nutrition
employees, evaluating employee job performance, providing in-service
and on-the-job training, reviewing productivity reports, writing job
descriptions, scheduling employees, developing policies and procedures,
designing performance standards, and developing and implementing
goals and objectives for the department. The clinical nutrition manager
is also responsible for communicating with the staff of other departments
and the administration. Ultimately, the clinical nutrition manager ensures
that performance is actually accomplished to achieve the goals and objec-
tives for the department. The Clinical Nutrition Management dietetic
practice group provides a newsletter and a yearly workshop on practice
updates and opportunities for networking with peers.
Clinical Dietitian
The primary responsibility of the clinical dietitian is to provide nutri-
tional care for patients. Clinical dietitians in hospitals are involved in
nutritional screening for patients to determine the presence of or risk
of developing malnutrition, to perform nutritional assessments, and to
develop nutrition care plans. Clinical nutrition services may be provided
to general patient-care units or may be based on a medical specialization
(e.g., critical care or diabetes education). Clinical dietitians are important
 T h e C l i n i c a l N u t r i t i o n S e r v i c e T e a m      101

members of the healthcare team because they consult and collaborate with
physicians, pharmacists, nurses, social workers, chaplains, and others in
providing nutritional care.
Clinical dietitians are the source of authoritative knowledge about
MNT and patient nutrition education. They routinely communicate with
other disciplines regarding developments in MNT and patient educa-
tion through in-service teams, rounds, and multidisciplinary patient care
conferences.
Successful clinical dietitians in acute healthcare facilities must also be
able to apply managerial concepts to provide effective nutritional care.
Management tasks often performed by clinical dietitians include sched-
uling of patient care services, in-service training, on-the-job training,
employee interviews and evaluations, writing, job descriptions, planning
cycle menus, and evaluating the quality of patient food.
Typical activities of a clinical dietitian include the following:17
• Use the NCP to screen, assess, diagnose, interview, and evaluate
nutritional care of patients.
• Provide instruction to patients and families on nutritional needs.
• Review medical records for information including nutrition-related
data.
• Calculate nutrient and fluid requirements.
• Evaluate nutrient intake and make adjustments accordingly.
• Adapt regular diets to meet individual needs or preferences.
• Plan oral diets with multiple nutritional requirements.
• Refer clients to community resources for ongoing service (Women,
Infants, and Children program; Mobile Meals, outpatient clinics,
and wellness centers).
• Use evidence analysis in making practical decisions about needed
care.
• Perform quality assurance and make performance improvements as
needed.
• Utilize technology as freely as possible.
• Communicate with physicians, nurses, and other staff.
• Attend medical rounds.
• Provide ongoing evaluation for employees.
• Utilize SOP and SOPP in providing care.
• Serve as preceptor for dietetic interns and other students.
102    T he D ietitian in C linical P ractice

Clinical dietitians may be members of one or more dietetic practice

groups. Besides working in general clinical practice, dietitians may be titled
gerontological nutritionists, dietitians in developmental and psychiatric dis-
orders, oncology dietitians, renal dietitians, pediatric dietitians, diabetes
care and support, dietitians in nutrition support, perinatal nutritionists, and
others. The diversity of specialty and subspecialty areas of practice reflects
the broad range of interests and opportunities open to the clinical dietitian.

Dietetic Technician
The dietetic technician in the clinical setting assists the clinical dietitian
and is a valuable member of the nutrition care team. Typically, major
functions performed include gathering data for nutritional screening
and assigning a level of risk for malnutrition according to predetermined
criteria. He or she may help with nutritional assessments by gathering
laboratory and anthropometric data, collecting and analyzing nutritional
intakes, obtaining nutritional histories, and reviewing medical histories.
Dietetic technicians may administer nourishment and dietary supple-
ments for patients and monitor and document intakes. They may provide
information to help patients select menus and give simple diet instruc-
tions. Dietetic technicians maintain a high level of knowledge of nutri-
tional care. Management responsibilities of dietetic technicians may also
include supervision of dietetic assistants and students.

Dietetic Assistant
The dietetic assistant helps the clinical dietitian and dietetic technician in
some of the routine aspects of nutritional care. He or she is often respon-
sible for processing diet orders, checking patient intakes, giving nourish-
ments, and transmitting special food requests. Dietetic assistants may also
help distribute and pick up inpatient menus and pass and collect trays.
They may be involved in evaluating food acceptance and gathering food
records to evaluate and document nutrient intakes.

CL INI CAL D I E TE TI C S O U TL OOK

Communicating Nutrition Messages
Dietitians increasingly use technology to both gain and transmit informa-
tion to clients and the public. They are well qualified to also evaluate infor-
mation from all sources including the extensive array of material offered
 C l i n i c a l D i e t e t i c s O u t l o o k      103

on the Internet.20 Through nutrition Informatics, all dietitians, whether in

early learning stages or already proficient in data management, have access to
apps and websites for assistance. Nutrition informatics is defined as the “the
effective retrieval, organization, storage and optimal use information, data
and knowledge for food, and nutrition-related problem solving and deci-
sion making.”21 The Academy Nutrition Informatics Committee defines
it simply as “the interaction of information, nutrition and technology.”22
The Informatics committee conducted a Delphi Study in 2011 that
resulted in descriptions of five levels of competency in the application of
computer skills.23 They ranged from possessing computer usage skill to
becoming an Informatics expert involved in research and work with other
health care providers to develop new methods for data and information
management.
Technology provides a way to engage patients and clients, to expand
the reach of practice and potentially lower health care costs. Through
the use of the many apps now available on the Internet, dietitians have
many resources to assist in providing information as well as help in sorting
through the best and most reliable information. The Nutrition Entrepre-
neurs DPG and the Clinical Nutrition Managers both have subgroups on
technology and informatics.24 Further, the Informatics Committee began
a series in 2015 to introduce different ways practitioners may identify as a
“Nutrition Informatics Registered Dietitian.”25
Dietitians can also take advantage of online courses by long distance
offered as “Massive Open Online Courses.” They are courses of broad
appeal developed by education and other experts that are offered free of
charge.26 They offer a variety of courses in many subject areas including
food, nutrition, health, management, and many others.

Electronic Health Records

The passage of the Health Information Technology for Economic and
Clinical Health (HITECH) act in 2009 provided for primary physicians
and small hospital to adopt electronic health records. Although NRDs
or DTRs were not specifically included in the incentives offered, a com-
mittee of the Academy is developing ways dietitians can also participate
and indeed will need to as the changeover is undertaken by hospitals. An
example is information for incorporating Nutrition Care Plan terminol-
ogy into the system. Dietitians will need to be ready to contribute to the
health record as the change from paper records is adopted by 2017.27
104    T he D ietitian in C linical P ractice

Clinical Privileging
RDs are now permitted to order patient diets independently without
requiring the supervision or approval of a physician or other practitioner.
Clinical privileging refers to a process by which a hospital, specifically
the governing body and the medical staff of the hospital, develop and
implement procedures to ensure safe and quality patient care.18,19 The
approval for this change came in 2014 when the Centers for Medicare and
Medicaid published a rule to this effect.28 The RDN must be privileged
to order diets by the hospital in which he or she is employed and comply
with any licensing regulations. As well as writing the diet order, the RDN
may order lab tests and make modifications to the diet order based on the
lab tests. This is a change the Academy has worked toward for a long time
and it positions the dietitian as the expert in the patient’s nutritional care.

Trends in Clinical Dietetics

Demographic trends have an impact on dietetic practice. For instance, the
aging population and especially the growth of the “oldest old” means that
nutrition is critical in helping keep this group healthy as long as possible.
This is also the group that is at highest risk for chronic diseases that are
treated in part with medical nutrition therapy. Increasing diversity among
groups served also has implications for dietitians in creating cultural com-
petency and raising awareness.24
The obesity/overweight epidemic today is an area in which nutrition
education for the public is more important than ever. Dietitians may find
increasing opportunities to work with food processors, grocery stores, and
advertisers to reach the public with the most effective nutrition messages.
All these areas are discussed in more detail later in this text.

SU MMARY
Clinical dietetics is the largest area of employment for dietitians, especially
at the entry level. Future roles will expand as new skills and competen-
cies through advanced training and education are attained. Employment
opportunities exist in acute care centers, in community-based programs,
in consultation and private practice, in communications, and in many
entrepreneurial undertakings.
The clinical dietitian is central in helping persons during illness through
nutrition interventions. Equally important is helping individuals prevent
 R e f e r e n c e s      105

the onset of chronic disease by the application of optimal nutrition prac-

tices throughout life. The expansion of MNT with cost-effectiveness data
and demonstration of quality practice is a continuing challenge for the
dietetics profession. Even though employment increasingly moves outside
the traditional hospital or clinic, the services provided by the clinical dieti-
tians will remain vital to the health and well-being of people experiencing
illness and who need nutritional care.

D E F INI T I O N S

Clinical dietetics. The area of practice in which persons with illness

or injury involving nutritional factors are treated using assessment,
planning, and implementing nutrition care plans.
Clinical nutrition services. Activities provided in the practice of clinical
dietetics, such as medical nutrition therapy and counseling.
Diet therapy. Treatment by diet; a term now replaced by clinical nutri-
tion therapy or medical nutrition therapy.
Extended care facility. An institution that extends health care beyond
the acute care setting when long-term term care is needed.
Medical nutrition therapy. The application of nutrition in the manage-
ment of illness or injury.
Outpatient clinic. Treatment area of a hospital or healthcare facility in
which patients are treated on an outpatient basis.

REFE REN C E S
1. Escott-Stump, S.A. “Our Nutrition Literacy Challenge: Making the 2010 Dietary
Guidelines Relevant for Consumers.” J Acad Nutr Diet 111 (2011): 979.
2. Cooper, L.F. “The Dietitian and Her Profession.” J Am Diet Assoc 14 (1938):
751–758.
3. See Note 2, p.752.
4. Huyck, L., and M.M. Rowe. Managing Clinical Nutrition Services. (Rockville,
MD: Aspen Publisher, 1990), pp. 243.
5. Butterworth, E. “The Skeleton in the Hospital Closet.” Nutrition Today 4 (1974): 4.
6. Rogers, D. “Compensation and Benefits Survey 2015.” J Acad Nutr Diet 115, 3
(2015): 370–388.
7. Ward, B.D., D. Rogers, M.M. Mueller, C.R. Touger-Decker, K.L. Sauer, and
D. Schmidt. “Distinguishing Entry-Level RD and DTR Practice: Results from the
2010 Commission on Dietetic Registration Entry-Level Dietetics Practice Audit.”
J Am Diet Assoc 111 (2011): 1749–1755.
106    T he D ietitian in C linical P ractice

8. Lacy, K., and E. Pritchett. “Nutrition Care Process and Model: ADA Adopts Road
Map to Quality Care and Outcomes Management.” J Am Diet Assoc 103 (2003):
1061–1071.
9. See Note 8.
10. Hammond, M.L. “Nutrition Care Process and Model: And Academic and Practice
Odyssey.” J Acad Nutr Diet 114, 12 (2014): 1879–1894.
11. Writing Group of the Nutrition Care Process/Standardized Language Committee.
J Am Diet Assoc 108 (2008): 1113–1117.
12. Writing Group of the Nutrition Care Process and Standardized Language Com-
mittee. “Nutrition Care Process and Model Part II: Using the International
Dietetics and Nutrition Terminology to Document the Nutrition Care Process.”
J Am Diet Assoc 108 (2008): 1287–1293.
13. Smith, R.E., S. Patrick, P. Michael, and M. Hager. “Medical Nutrition Therapy:
The Case of ADA’s Advocacy Efforts (Part 1).” J Am Diet Assoc 105 (2005):
825–834.
14. Smith, R.E., S. Patrick, P. Michael, and M. Hager. “Medical Nutrition Therapy:
The Case of ADA’s Advocacy Efforts. (Part II).” J Am Diet Assoc 105 (2005):
987–996.
15. Blumberg-Kason, S., and R. Lipscomb. “Evidence-Based Nutrition Practice
Guidelines: A Valuable Resource in the Evidence-Analysis Library.” J Am Diet
Assoc 106 (2006): 1935–1936.
16. Boucher, J., A. Evert, A. Daly, K. Kulkami, J.A. Rizzotta, K. Burton, and
B. Bradshaw. “American Dietetic Association Revised Standards and Standards
of Professional Performance for Registered Dieticians (Generalist, Specialty, and
Advanced) in Diabetes Care.”
17. Ward, B., C. Mueller, R. Touger-Decker, and K.L. Sauer. “Entry-Level Dietet-
ics Practice Today: Results from the 2010 Commission on Dietetic Registration
Entry-Level Dietetics Practice Audit.” J Am Diet Assoc 111 (2011): 914–941.
18. Hager, M.H. “Clinical Privileging for Registered Dietitians. A Regulatory Perspec-
tive.” J Am Diet Assoc 107 (2007): 558–560.
19. Hager, M.H., and S.M. McCauley. “Clinical Privileging: What It Is—and Isn’t.”
J Am Diet Assoc 109 (2009): 400–402.
20. Communicating Accurate Food and Nutrition Information. “Practice Paper by
the Academy of Nutrition and Dietetics.” J Acad Nutr Diet 112, 5 (2012): 759.
21. Ayres, E.J., J.L. Greer-Carney, P.E.F. McShane, A. Miller, and P. Turner. “Nutrition
Informatics Competencies across all Level of Practice: A National Delphi Study.”
J Acad Nutr Diet 112, 12 (2012): 2042–2053.
22. See Note 2.
23. Boyce, B. “Nutrition Apps: Opportunities to Guide Patients and Grow Your
Career.” J Acad Nutr Diet 114, 1 (2014): 13–15.
24. Accessed April 11, 2015, www.eatrightPRO.org
25. Stark, C.M. “Massive Open Online Courses: How Registered Dietitians Use
MOOCs for Nutrition Education.” J Acad Nutr Diet 114, 8 (2014): 1147–1155.
26. Accessed May 11, 2015, [email protected]
27. Accessed March 11, 2015, www.eatrightPRO.org
 7

CHAPTER
Management in Food
and Nutrition Systems
“Food management RDs need to have technical expertise,
knowledge, and interpersonal skills.”1

OUTLINE
• Learning Objectives
• Introduction
• Activities of Entry-Level Dietitians and Dietetic Technicians
• Areas of Employment
• Food and Nutrition Management in Acute Care
• Food and Nutrition Management in Long-Term Care
Facilities
• Food and Nutrition Management in Noninstitutional
Settings
• School Nutrition Programs
• Clinical Nutrition Management
• Commercial Food Service
• Additional Areas of Opportunity
• Characteristics of Successful Food and Nutrition Managers
• Expanded Opportunities
• Expansion of Roles
• Summary
• Definitions
• References

107
108    M anagement in F ood and  N utrition S ystems

LEARNING OBJECTIVES
The student will be able to:
1. Know the areas of employment in systems in food and nutri-
tion management.
2. Describe the activities and responsibilities of the management
dietitian.
3. Know the range of opportunities and advancements in food
and nutrition management.
4. Understand how the functions of management activities
differ in clinical, institutional, and commercial foodservice.
5. Become aware of the impact of technology in future
foodservice operations.

IN T RO D UC TI O N
Food and food service are prominent in the history of the profession of
dietetics. One of the main purposes of the first organized meeting of the
American Dietetic Association (ADA) was to discuss ways of meeting
food shortages during World War I. Many of the first members of the
association served overseas feeding hospitalized soldiers and people liv-
ing under wartime conditions. Cooking schools, scientists who produced
the first tables of food values, early-day soup kitchens, and school lunch
programs were among the forerunners of institutions that fed the public.2
Food service in hospitals was the primary focus of the first dietitians.
During the 1890s, food service in hospitals was managed by the chef,
the housekeeper, or the nursing department. In the early 1900s, how-
ever, many dietitians were in charge of dietary departments and had the
responsibility for all food service as well as teaching nurses and providing
diet therapy for patients with metabolic diseases. Hospital dietitians dealt
with budgets, department organization, personnel management, and qual-
ity food service. Nutrition was recognized as an aspect of medicine, and
food prescriptions were handled as apothecary compounds, thus creating a
demand for special diet kitchens. The hospital dietitian had the same status
as the superintendent of nurses and was recognized as the nutrition expert.3
Dietitians with food service management responsibilities became mem-
bers of the Food Administration section in the ADA, and their practice
A c t i v i t i e s o f E n t r y -L e v e l D i e t i t i a n s a n d D i e t e t i c T e c h n i c i a n s     109

was referred to as administrative dietetics. The terminology now used is

management in food and nutrition systems.
Management is discussed fully later in the text as a skill needed by dieti-
tians in all areas of practice.

ACT I V IT I E S O F E N TRY- L E VEL DI ET I T I A N S

AND D IE TE TI C TE C H N I C I A N S
In 2010, the Commission on Dietetic Registration conducted a practice
audit among dietitians and dietetic technicians and indicated the percent-
age of time spent in selected activities. Management activities of both
groups are shown in Table 7-1.

Table 7-1.  Management Activities of Entry-Level Dietitians and

Dietetic Technicians
Activity (Percent) RD DTRa

Managing human resources

Assign or schedule staff 15 25

Male decisions on personnel actions 10 23

Comply with labor relations 15 23

Evaluate performance of staff 22 31

Managing food and material resources

Maintain safety and sanitation of food, facilities, or equipment 27 53

Monitor stage conditions 22 39

Develop menus for clients with normal needs 33 45

Evaluate food products by taste, smell, and appearance 33 50

Calculate quantities to purchase of food other material resources 9 21

Purchase food, nutritional supplements, equipment, or supplies 14 24

Assess client satisfaction with food and/or nutrition service 40 59

Adjust daily menu, food production, or distribution based on 11 30

availability of food, labor, or equipment

Institute or maintain sustainability practices 8 18

(continues)
110    M anagement in F ood and  N utrition S ystems

Table 7-1.  Management Activities of Entry-Level Dietitians and

Dietetic Technicians (Continued)
Activity (Percent) RD DTRa

Manage facilities

Maintain facilities and equipment 11 24

Assure safety of employees, patients, clients, and customers 25 38

a. The higher percentages of involvement by dietetic technicians in many of the management

categories reflect the areas in which technicians are most often employed. This was a survey
of entry-level professionals, and it should be noted that more dietitians begin their careers in
clinical areas of practice; this was borne out in those particular areas surveyed.
Notes: RD 5 registered dietitian; DTR 5 dietetic technician, registered.
Reprinted from Journal of the American Dietetic Association 111, Number 11 (November
2011), Ward, B., D. Rogers, C. Mueller, R. Touger-Decker, KI.L. Sauer, C. Schmidt,
“Distinguishing Entry-Level RD and DTR Practice: Results from the 2010 Commission on
Dietetic Registration Entry-Level Dietetics Practice Audit, 1749–1755,” Copyright 2011,
with permission from Elsevier.

AR EAS O F E M P L O Y M E N T
In the 2015 membership survey, 11 percent of registered dietitians (RDs)
and 17 percent of dietetic technicians, registered (DTRs) indicated their
practice is in food and nutrition management. Further, 24 percent of
practitioners are executives, directors, or managers, and another 17 percent
are supervisors or coordinators.4
In the same study, it was reported that salaries for the food and nutrition
manager are the highest of those in any practice area. The salaries reflect
both geographic location and years of experience as the food and nutrition
manager is nearly always a dietitian with work experience beyond entry
level and may have an advanced degree or a business degree.
Dietitians in food and nutrition management typically affiliate with
one or more of the following five dietetic practice groups: Management in
Food and Nutrition Systems, Dietitians in Business and Communication,
School Nutrition Services, Food and Culinary Professionals, and Hunger
and Environmental Nutrition. In addition, clinical managers may belong
to the Clinical Nutrition Management group. Dietitians in food and
nutrition management may be identified through a wide range of titles,
such as coordinator, specialist, executive dietitian, director of food and
nutrition services, director of clinical nutrition, or chief administrator.
 Areas of E m p l o y m e n t      111

Practice areas are often categorized by work settings, such as food and
nutrition management in acute care, long-term care, and noninstitutional
employment areas. To encompass the broader management area, clinical
nutrition management, commercial food service, and school nutrition are
added to this list. A discussion of each follows.

Food and Nutrition Management in Acute Care

Food service in acute care is the type of service provided in hospitals or
similar healthcare institutions in which patients receive short-term medi-
cal treatment, usually 1–5 days. Several characteristics of this type of food
service are:
1. Fast turnover of patients with day-to-day fluctuations in the num-
ber of meals prepared and served.
2. Special diets requiring different types of food preparation. In some
instances, as many as 50 percent of all patients will require special
or modified diets.
3. Selective menus for patients, increasing the number of food items
prepared.
4. Multiple serving systems in an institution, such as individual tray
service, decentralized service with pantries on patient floors, and
restaurant-style service providing individualized patient service.
In some institutions, food is prepared in bulk, then preportioned and
held until the time of meal service, when it is rethermalized and served. In
others, food is prepared centrally just before meal service and either por-
tioned individually or sent in bulk to patient areas for individual service.
Production and food service systems vary, but in each system, the dietitian
has overall responsibility for food production and service or may share this
responsibility with a dietetic technician, chef, or manager. Whatever the
scope of his or her responsibility, the dietitian must be knowledgeable in
food production techniques, food purchasing, safety and sanitation, stra-
tegic planning, human relations, communication skills, managerial skills,
and financial management.

Food and Nutrition Management in Long-Term Care Facilities

The provision of food for clients in nursing homes, extended care facilities,
and correctional institutions is included in the long-term care category.
Food service in these institutions differs from that in acute care in that
112    M anagement in F ood and  N utrition S ystems

clients are long term and are usually served in group settings. Central
food production and few special diets are typical because most of the long-
term clients will be following a normal, healthy eating pattern. The food
service, especially in smaller nursing homes and extended care facilities,
may be managed by a dietetic technician or by a certified dietary manager
under the direction of a dietitian consultant. In correctional institutions,
the day-to-day management is often provided by nonprofessionals under
the direction of a dietitian consultant when one is available. All aspects
of food service management are equally as important in long-term care as
in the hospital with the added necessity of ensuring nutritional adequacy
and acceptability over longer periods of time. In almost all long-term
facilities, there are federal and state regulations relating to the provision of
food services to clients that must be followed for the institution to receive
government funding and provide quality care. The qualifications for the
food service manager are also specified in the regulations.

Food and Nutrition Management in Noninstitutional Settings

Management of food and nutrition in noninstitutional settings is typi-
cally provided in colleges and universities, employee cafeterias, and busi-
ness and commercial enterprises. The food service may be for-profit or
nonprofit, depending on the type of institution. Generally, institutions
serving the public will be for profit while schools or businesses provid-
ing employee food services are more often nonprofit. Clients choose to
patronize the food services offered and the type of food services may vary
widely. A college or university, for instance, may offer cafeteria, dining
room, restaurant, catering, and vending services. School and employee
food service is often provided by cafeteria service along with vending and
dining room service. Many businesses provide employee cafeterias or res-
taurant service. The dietitian’s responsibility is to provide food that is
safe and acceptable to the customers, meets financial expectations, and
promotes good nutrition.

School Nutrition Programs

School nutrition programs, offering either lunch or breakfast, or both, are
available in 100,000 public schools through grade 12, nonprofit private
schools, and residential child care institutions.5 Over 31 million students
from preschool through grade 12 were fed daily. An average of 11 million
children per day participated in the federal school breakfast program in
 Areas of E m p l o y m e n t      113

2009. The programs are administered and partially funded by the fed-
eral government, and they must meet specific guidelines for nutritional
quality of meals and for student eligibility. Free or reduced-price meals
are provided based on the family economic status. The emphasis is on
long-term health benefits for children through establishing good eating
habits. The following is a position statement supporting school nutrition
programs:
It is the position of the Academy, School Nutrition Association, and
Society for Nutrition Education that comprehensive, integrated nutri-
tion services in schools, kindergarten through grade 12, are an essential
component of coordinated school health programs that will improve
the nutritional status, health, and academic performance of our nation’s
children. Local school wellness policies may strengthen comprehensive
nutrition services in schools by providing opportunities for multidisci-
plinary teams to identify and address local school needs.6

Dietitians in school nutrition programs need both managerial and

nutrition education skills. That school nutrition programs provide satisfy-
ing careers to many is shown in a recent study of job satisfaction; dietitians
with management responsibilities, including those in school child nutri-
tion programs, showed the highest level of satisfaction with the nature of
the work and a higher overall level of satisfaction compared to national
indices.7
The customer is the most important consideration when offering
school food service that meets strict guidelines for safety and nutritional
quality while also controlling costs.8 Some programs use websites to pro-
mote offerings and others use newspaper advertising to publish menus
and gain public support.

Clinical Nutrition Management

As discussed earlier, the clinical nutrition manager is the professional who
directs the activities of a clinical unit in hospitals and healthcare insti-
tutions. This may include responsibility for one or more units and the
supervision of other professionals in clinical areas. The clinical manager
performs many of the same management functions as the food service
dietitian—management of human, financial, and material resources. The
clinical dietitian who progresses from an entry-level position to a manage-
ment position will normally have 5–10 years or more of experience and
may not be involved in day-to-day activities directly related to patient care.
114    M anagement in F ood and  N utrition S ystems

Commercial Food Service

Commercial food service is described as retail and hospitality food ser-
vice establishments that prepare food for immediate consumption on or
off premises. The types of establishments employing dietitians include
independent restaurants, catering services, casual and family dining res-
taurants, and fine dining restaurants. Supermarket chains, limited service
(fast-food) chains, and hotel chains also have high potential for dietetic
services. Five specific areas of need in these institutions are nutrition edu-
cation, healthful menu planning, recipe and menu analysis, marketing,
and quality assurance.
Skills in public relations, communications, marketing, purchasing, and
financial management are expected of dietitians who work in commer-
cial food services. Therefore, additional training and experience are often
needed by the dietitian to be fully qualified for these roles.

Additional Areas of Opportunity

Additional opportunities for dietitians in food service management include
positions in food corporations, such as research and development, con-
sumer affairs, communications, government liaison, emergency feeding
for displaced persons, disaster planning centers, military-based homeless
shelters and food distribution centers, worldwide religious ministries and
government food programs, adult and child care programs, and academic
units with food, nutrition, or hospitality programs. Many dietitians are
employed in contract food service companies that provide for-profit man-
agement services. Hospitals, colleges and universities, schools, employee
cafeterias in businesses, hotels and restaurants, and healthcare institutions
may contract with a company who manages food services for a negotiated
fee. The companies hire and often train their own personnel, including
dietitian managers.

CHARACT E R I S TI C S O F S U C CESSF UL F OOD

AN D NUT R I TI O N M A N A G E R S
Employment areas in food and nutrition management require registered
dietitian nutritionist (RDN) leaders who are effective in the management
of human, material, and financial resources. Food and nutrition services in
healthcare facilities are becoming more complex in meeting the demands
of the administration, patients, and clients. From a historical standpoint,
C h a r a c t e r i s t i c s o f S u c c e s s f u l F o o d a n d N u t r i t i o n M a n a g e r s     115

meal service to patients was the primary focus of foodservice departments

in healthcare especially in hospitals. Services are now expected in other
units within an institution as shown in Figure 7-1.
With this expansion of services offered, the RDN and DTR have a
wide scope of practice responsibilities in healthcare systems as well as in
business, industry, and consulting. These include planning, organizing,
staffing, budgeting, directing, and controlling.9 Managers must make
decisions in the best interests of both the department and the institution
and be able to communicate effectiveness to the organization’s leadership.
The productivity of the department is directly related to the quality of the
managerial decisions and to the outcomes of departmental efforts.
According to Puckett,9 today’s management RDN must, at a mini-
mum, possess competencies in the following areas:
• Environmental protection rules
• The political environment
• Marketing and customer satisfaction
• Continual quality improvement
• Work design and productivity
• Innovative cost-containment measures
• Food consumption patterns
• Human resource trends
• Food and water safety
• Disaster and emergency planning
• Project and process management
• Cultural diversity in the marketplace

Patient Meal Services Retail Clinical

• Room service • Cafes • Inpatient
• Guest meals • Food courts • Out-patient
• Celebration meals • Vending • Community outreach
• Post-discharge • Catering • Clinical research
meal delivery • Convenience stores
• Coffee shops

FIGURE 7-1.  Scope of Services.

Reproduced from Practice Paper of the Academy of Nutrition and Dietetics: Principles of
Productivity in Food and Nutrition Services: Applications in the 21st Century Health Care
Reform Era. J Acad Nutr Diet 2015;115(7):1141–1147.
116    M anagement in F ood and  N utrition S ystems

Competencies typical of visionary leaders who are effective in their

position and in the organization and who are successful in their practice
are shown in Table 7-2.
As in other areas of practice, the RDN in food service management
usually begins at a competent level of knowledge and skills at entry-level
following registration. The next stage is proficiency in operational skills
and the possible beginning of specialist credentials followed by the expert
who continues to build on his/her knowledge, skills, and credentials.10

Table 7-2.  Competencies Needed by Healthcare Food Service

Managers
Successful healthcare food service managers will:

• Use management techniques to cultivate relationships in and out of the institu-

tion and achieve cooperation through teamwork.
• Demonstrate effective communications to achieve understanding of personnel
and departmental policies.
• Achieve an organizational structure, mission statement, policies, and procedures
that effect necessary changes when indicated.
• Possess technological knowledge of food service, practice experience, and external
business and administrative needs.
• Use management techniques based on sound character, compassion, insight, and
personal integrity.
• Exhibit personal behaviors and attitudes consistent with professional and
institutional goals.
• Pursue professional knowledge and growth.
• performance.
Possess effective supervisory and managerial skills to derive optimal employee

• Achieve ways to enhance performance and growth of employee.

• with superiors.the policies of the institution and an ability to interface effectively
Understand

• Exhibit effective use of resource (fiscal, personnel, and material) to facilitate

planning and current operations.
• Possess analytic and decision-making techniques to achieve maximum quality for
customer and clients.
• Formulate a creative vision that integrates mutually satisfying department and
institutional goals.

Adapted from Journal of the American Dietetic Association, 95, Watabe-Dawson, M. “Visionary
Leaders Are Key to Success in Food Service,” p. 13. Copyright 1995, with permission from
Elsevier.
 Expansion of R o l e s      117

E X PAND E D O P P O RTU N I TIES

Entry-level dietitians with management responsibilities are employed pri-
marily in food service or clinical nutrition service operations. The pre-
dominant responsibilities at this level involve technical skills that ensure
that food is procured, managed, prepared, and delivered to patients and
other clients, and that appropriate nutrition services are provided. With
experience and perhaps advanced study, conceptual skills are utilized to
identify problem areas requiring attention, to select appropriate tech-
niques, analyze alternative strategies, and select solutions consistent with
organization goals.
From entry-level positions, dietitians may advance to the assistant or
associate director level of a department and eventually to director or chief
administrator. They may manage multidepartmental units or a complex
of smaller hospitals, specialty clinics, or long-term care centers. They may
become the chief operating officer of a healthcare facility.
Dietitians directing food and nutrition services must have a diversi-
fied, multipurpose, broad-based education and experiences from which to
draw for expanded roles. They must be familiar with applicable computer
software, business organization, marketing, labor relations, industrial
engineering, writing and media relations, public relations, financial man-
agement data evaluation, policy formation and problem solving, decision
making, negotiation, behavior modification techniques, and dealing with
challenges.

E X PANS I O N O F R O L E S
Expanded roles may include new and challenging positions that come
from the foundation the dietitian receives and that may not even gen-
erally be associated with dietetics. In health care, for instance, there is
heightened consumer interest in what constitutes healthy food. The food
industry wants effective marketing of its products, including information
about safety and nutrient value, and wants to develop new products. All
these areas represent opportunities in consumer education, writing, food
safety, media positions, public policy, food demonstration, and more.
Disaster planning and emergency training is a further need for the
food service manager. In events such as floods, hurricanes, earthquakes,
118    M anagement in F ood and  N utrition S ystems

and fires, the availability of food and water becomes of paramount con-
cern.11 “Nutrition security,” defined as “secure access to appropriate
diets, a sanitary environment and adequate health services and care,”
may become huge issues if they are not met.12 Fortunately there are
many evidence-based food-related resources available to RDNs and
DTRs for personal training and to share with clients and others in pub-
lic health and healthcare settings. The Food and Drug Administration,
the Centers for Disease Control and Prevention, organizations, and the
Internet all provide resource materials. The U.S. Department of Agri-
culture also maintains a hot line for food safety information.12 A tuto-
rial on disaster planning is available from the Academy.13 Many local,
state, and national groups provide credible sources of information and
training in these areas. The RDN or DTR may also consider obtaining
certificates of training offered by groups such as the Food Marketing
Institute, the National Restaurant Association, the National Registry of
Food Safety Professionals, and others. Such certifications can be further
used to meet requirements for professional development and to main-
tain state licensure credentials.14
Interesting and informative accounts of events during actual world
disasters such as the Japanese earthquake and Hurricane Sandy in
New Orleans give insight into how food and nutrition issues can be
handled.15,16
A new dimension in foodservice management is the use of automa-
tion to simplify many tasks—especially those of a repetitive or dangerous
nature. With the rapid advances in technology today, machines may take
over many foodservice tasks in the future. An example of one type of auto-
mation under development is an optical scanner that analyzes food for
nutrient content, actual ingredients, and any additives or contaminants.17
A database of standard foods and food varieties is to be developed after
which it will be possible to test whether the food contains what the label
claims and allowing reliable and immediate information to the manager.
Machines could conceivably take over tasks such as cleaning, trash
collecting, controlling temperatures, tray delivery and pickup, manag-
ing storerooms, loading and unloading dish machines, and others. The
foodservice manager needs to be cognizant of emerging technological
trends such as these in order to make decisions about their applicability
in practice.18
 R e f e r e n c e s      119

S UMMARY
The dietitian in food service management has career opportunities in
food, food production and service, management, and the higher levels of
activities associated with management and leadership. For the motivated
and skilled dietitians, higher salary levels and greater degrees of responsi-
bility and self-actualization can be realized.

D E F INI T I O N S

Food production. The process of preparing and serving food, including

purchasing, storage, and processing.
Food services. Production and service of food; also refers to the unit or
group responsible for feeding groups.
Food service systems. Activities that together form the inputs, transfor-
mation, and outputs that make up an entire food operation.
Human resources. The personnel in an organization.
Management. The administration and coordination of the activities
and functions in an organizational unit.
Quality assurance. The certification of the continual, optimal, effective,
and efficient outcomes of a service or program.
Resource allocation. The equitable distribution of financial, physical,
and human capital.

REFE REN C E S
1. Puckett, R.P., W. Barkley, G. Dixon, K. Egan, C. Koch, T. Malone, J.
Scott-Smith, B. Sheridan, et al. “The American Dietetic Association Standards
of Professional Performance for Registered Dietitians (Generalist and Advanced)
in Management of Food and Nutrition Systems.” J Am Diet Assoc 109 (2009):
540–543.
2. Cassell, J.A. Carry the Flame: The History of the American Dietetic Association.
(Chicago: American Dietetic Association, 1990).
3. Barker, A., M. Foltz, M.B.F. Arensberg, and M.R. Schiller. Leadership in Dietetics:
Achieving a Vision for the Future. (Chicago: American Dietetic Association,
1994).
4. Rogers, D. “Compensation and Benefits Survey 2015.” J Acad Nutr Diet 115, no. 3
(2015): 370–388.
120    M anagement in F ood and  N utrition S ystems

5. www.fns.usda/gov/nslp/national (3/20/16).
6. “Position of the American Dietetic Association, School Nutrition Association,
and Society for Nutrition Education: Comprehensive School Nutrition Services.”
J Acad Nutr Diet 110 (2010): 1738–1748.
7. Sauer, K., D. Canter, and C. Shanklin. “Job Satisfaction of Dietitians with
Management Responsibilities: An Exploratory Study Supporting ADA’s Research
Priorities.” J Am Diet Assoc 110 (2010): 1432–1440.
8. Boyce, B. “Satisfying Customers and Lowering Costs in Foodservice: Can Both Be
Accomplished Simultaneously?” J Acad Nutr Diet 111 (2011): 1458–1466.
9. Puckett, R.P. “Leadership Managing for Change.” In Food Service Manual for
Health Care Institutions, 3rd ed. (San Francisco: Jossey-Bass, 2004), p. 30–32.
10. Berthelsen, R.M., W.C. Barclay, P.M. Oliver, V. McLymont, R. Puckett. “Academy
of Nutrition and Dietetics: Revised 2014 Standards of Professional Performance
for Registered Nutritionist in Management of Food and Nutrition Systems.”
J Acad Nutr Diet 114, no. 7 (2014): 1104–1112.
11. “Position of the Academy of Nutrition and Dietetics: Food and Water Safety.”
J Acad Nutr Diet 114, no. 11 (2014): 1819–1828.
12. See Note 11.
13. www.eatright.org/disaster (4/3/15).
14. See Note 11.
15. Amagai, T., S. Ichimaru, M. Tai, Y. Ejira, A. Muto. “Nutrition in the Great East
Japan Earthquake Disaster.” Nutr in Clin Pract 29, no. 5 (2014): 585–594.
16. Trent L, Allen S. “Hurricane Sandy: Nutrition Support During Disasters.”
Nutr I Clin Pract 29, no. 5 (2014): 576–584.
17. Washington Post: March 30, 2016.
18. “Man and Machine Knowledge Work in the Age of the Algorithm.”
Harvard Business Review (June 2015): 57–65.
 8

CHAPTER
The Public Health/
Community Nutrition
Dietitian
“Primary prevention is the most effective and affordable course of
action for preventing and reducing the risk for chronic disease.”1

OUTLINE
• Learning Objectives
• Introduction
• Public Health/Community Practice
• Public Health Nutrition
• Community Nutrition
• Career Outlook
• Summary
• Definitions
• References

LEARNING OBJECTIVES
The student will be able to:
1. Describe Public Health Nutrition and Community Nutrition
Practice.
2. Become familiar with the activities of the community dietitian
in community settings and programs.

121
122    T he P ublic H ealth /C ommunity N utrition D ietitian

3. Understand the role of nutritionists in public health and ways

they may differ from the traditional community nutrition
setting.
4. Relate how public health programs promote the prevention
of disease.
5. Become aware of specialty areas of practice in community
nutrition.

IN T RO D UC TI O N
Public health/community nutrition is an area of nutrition and dietetics
practice that addresses the entire range of food and nutrition issues relat-
ing to individuals, families, and special groups with a common bond such
as place of work, place of residence, language, culture, and health. Com-
munity nutrition programs include those that provide increased access to
food, food and nutrition, and health care. Public health is the component
of community nutrition that is publicly funded and provided through a
state or local health agency to promote health, prevent disease, and pro-
vide primary care. The “community dietitian,” “community nutritionist,”
or “public health nutritionist” provides nutrition services to identified
groups.
Professionals in this area of practice establish links with other profes-
sionals involved in a broad range of human services, including child care
agencies, services for the elderly, churches, summer feeding programs,
educational institutions, and researchers. They focus on promoting opti-
mum health and preventing disease in the community by using a popula-
tion focus and a client or personal health service approach.
Community nutrition is influenced by the collective beliefs and prac-
tices of everyone in the community. For instance, it is estimated that
about 70 percent of all premature deaths in the United States are caused
by environmental factors and individual behaviors.2 The costs of health
care for obesity and its complications continue to rise as this controllable
condition rises among the population. Childhood obesity is a particular
risk as it often leads to adult obesity and chronic diseases later in life.
 P u b l i c H e a l t h / C o m m u n i t y P r a c t i c e      123

Dietitians need to continue to demonstrate the value they bring to help-

ing solve the economic burden of rising health costs that are estimated
to be in the billions each year. Recent estimates of the healthcare costs
related to obesity alone are over $190 billion per year, or approximately
21 percent of all healthcare expenditures, and this does not include the
cost of lost productivity, poor quality of life, or accommodations that
must be made for equipment, seating, etc.3

P UBLIC HE A LTH / C O M M UN I T Y PR A C T I C E
Dietitians in community and public health areas work in many settings
that focus on improving the health of population groups. Positions are
characterized by an emphasis on health and wellness and the applica-
tion of nutritional science. The dietitians may work in federal, state, or
local public health agencies; neighborhood community health centers;
industry; ambulatory health clinics; home health agencies and specialized
community projects; nonprofit and for-profit private and community
health agencies/institutions; private practice and hospitals; and public and
private schools.
The Public Health/Community Nutrition Dietetic Practice Group
describes the following wide variety of roles and settings in which dieti-
tians work:4
• Providing population-based services at the national, state, and local
level.
• Providing direct care in the Special Supplemental Nutrition Program
for Women, Infants, and Children (WIC), primary care clinics, and
other community-based settings.
• Serving as consultants to Head Start programs, child care centers,
schools, school-based health clinics, home health programs, nursing
homes, and other health care programs.
• Teaching in colleges, universities, and Cooperative Extension Service.
• Conducting research in academic and public health/community
settings.
• Engaging in program planning, development, implementation, and
evaluation at the federal, state, and local levels.
• Providing leadership and training in food safety, emergency pre-
paredness, food security, and sustainable food and water systems.
124    T he P ublic H ealth /C ommunity N utrition D ietitian

The position paper “The Role of Health Promotion and Chronic

Disease Prevention” also describes a range of activities dietitians perform
in these areas.5

PU BLIC H E A LTH N U TR I TI O N
Every state has a department of health within state government employ-
ing public health dietitians. Many states use dietitians in programs such a
Native American health service, Health and Human Services or welfare,
departments of education, school nutrition programs, and in Area Agen-
cies for the Aging.
The public health dietitian (or nutritionist) is usually required to have,
at a minimum, the master’s degree. He/she may not always be a registered
dietitian nutritionist (RDN).
The full range of responsibilities of the public health dietitian includes
familiarity with the field of public health. All segments of the population,
including the healthy and those who are vulnerable to or experiencing
chronic disease, are targeted. Assessment of health needs, applying pre-
ventive measures, and intervening with treatments and rehabilitation are
core functions. This broader approach is distinguished from the clini-
cal approach which more often concentrates on one-on-one assessment
and care. Health promotion and disease prevention through service and
research are requirements of all public health personnel.
The public health nutritionist establishes linkages with related com-
munity nutrition programs, nutrition education, food assistance, social
or welfare services, and care services to the elderly. The public health
approach has the following characteristics:6
• Interventions that promote health and prevent communicable
and chronic diseases by managing or controlling the community
environment.
• The promotion of a healthy lifestyle as a shared value for all people.
• Directing money and energy to the problems that affect the lives of
the largest number of people in the community.
• Targeting the underserved or unserved by virtue of income, age, eth-
nicity, heredity, or lifestyle that are vulnerable to disease, hunger, or
malnutrition.
 C o m m u n i t y N u t r i t i o n      125

• Collaboration of the public, community leaders, legislators, policy

makers, administrators, and health and human services professionals in
assessing and responding to community needs and consumer demands.
• Monitoring the nutritional health of the people in the community
to ensure that the public health system achieves its objectives and
responds to needs.

CO MMUN I TY N U TR I TI O N
About 11 percent of RDNs and 12 percent of DTRs indicate their work
area is in community nutrition. The Special Supplemental Nutrition
Program for WIC employs 6 percent of the RDNs and 9 percent of the
DTRs.7 According to a 2012 membership survey of the PHCN DPG,
some 45 percent of the respondents said community nutrition was their
primary area of practice.8
Nutrition professionals in community nutrition usually acquire a general
base of knowledge and a level of expertise in a chosen area (such as the needs
of infants and children, pregnant women, older persons, or migrant indi-
viduals). The ability to use scientific methods to study, interpret, promote,
and apply finding to community health problems through a knowledge of
research is essential to practice. The community dietitian needs to under-
stand the nutritional needs across the life cycle, use computer technology
efficiently, and be aware of multiethnic needs and a diverse population. To
be a credible nutrition resource, the RDN must understand the fundamen-
tals of nutrition, food science, and dietetics, and have an underlying knowl-
edge of human physiology, chemistry, biochemistry, epidemiology, statistics,
and behavioral sciences. The RDN must also collaborate with community
leaders and other professionals (such as social workers, public health nurses,
rehabilitation specialists, pharmacists, teachers, store owners, etc.). Changing
behavior by providing information about foods that are affordable and avail-
able in local market is a vital part of the counseling process.
Typical activities of the community nutrition RDN include the
following:
• Assessment and prioritizing nutrition problems for various age and
population groups.
• Ethical considerations in all programs and services offered.
126    T he P ublic H ealth /C ommunity N utrition D ietitian

• The integration of nutrition services into the overall agency mission,

goals, and plans.
• Multidisciplinary and interdisciplinary team membership.
• Selection and/or development of nutrition education materials or
approaches appropriate for individuals or small groups within the
target population.
• Media strategies used in print, broadcasting, and telecommunica-
tions to reach population groups.
• Training of other agency staff and providing technical assistance to
other staff.
• Serving as a resource to the public, media, business, and industry.
As noted earlier, over half the dietitians employed in community
nutrition work in the WIC program. This program provides nutrition
screening and nutrition education as well as food vouchers for low-
income pregnant, breastfeeding and nonbreastfeeding women, and their
children up to 5 years of age. The program is administered by the U.S.
Department of Agriculture, which provides funding to state agencies for
the program.
Other positions are in maternal and child nutrition, adult health, food
service management, children with special needs and programs, day care
programs for all ages, school nutrition, and programs in aging. Others
may work in corrections institutions and in home care.
Another important area of practice in the community is in coopera-
tive extension. This program is administered through land-grant colleges
and universities in each state.9 Personnel are employed at the county, dis-
trict, and state levels. The primary responsibilities in this area of practice
include planning, developing, and implementing nutrition, food, and
health-related programs for all ages—4-H groups for young people as well
as adult groups. Specialists in subject matter areas plan programs, provide
specialized information, and help direct activities of county and district
personnel.
In most states, the RDN credential may not be required for positions
in cooperative extension. It is therefore a very promising area of practice
for those who have not completed an internship or achieved the RD
status.
 S u m m a r y      127

CAREER O U TL O O K
Widespread concerns exist today within the public regarding the associa-
tion of food and nutrition with other community/public health problems.
The obesity epidemic and its complications continue to be a huge multifac-
eted problem with economic, medical, social, and psychological implica-
tions. Food availability, food safety, health disparities among ethnic groups,
nutrition information, and misinformation are all impacting public health.
The public health/community dietitian has an important role to play in
helping meet these concerns. Involvement in policy decisions, obtaining
advanced clinical skills, and advanced study in epidemiology and research
methodology along with the use of evidence-based research are examples of
ways the dietitian can help meet critical community health needs. In addi-
tion, networking and collaborating with other public health professionals
is critical to success.10,11 Dietitians who are prepared with managerial and
conceptual skills as well as informatics will be increasingly needed in long-
range program planning and policy implementation in communities.
The 2012 Member Survey by the PHCN DPG indicated a need for
additional knowledge and skills acknowledged by the members who
responded.12 The following are areas indicated by 25 percent or more of
the respondents:
• Community assessment
• Policy development
• Infant/child health
• Weight management
• Survey/surveillance and data
The list shows the forward thinking of the dietetic professionals cur-
rently working in community and public health nutrition.

S UMMARY
Public health/community nutrition encompasses a wide variety of
programs and activities that impacts every segment of the population.
Both food and feeding programs along with overall health maintenance
and measures to prevent chronic diseases are the focus of professionals that
128    T he P ublic H ealth /C ommunity N utrition D ietitian

work in these areas. State and federal programs target population groups
who are underserved or unserved and dietitian/nutritionists provide nutri-
tion surveillance, good feeding, and nutrition intake guidance, and collab-
orate with other professionals to provide service in these programs. Many
opportunities are open for nutrition professionals in these areas of practice.

D E F INI T I O N S

Community health. Health measures applied to groups of people.

Community nutrition. Nutrition issues and services provided for groups
of people.
Program planning. Needs assessment and action plans to meet needs.
Surveillance. Research-based activities to assess a program’s reach and
impact.

RE F E RENC E S
1. American Dietetic Association. “Position of the American Dietetic Association:
The Roles of Registered Dietitians and Diet Technicians in Health Promotion and
Disease Prevention.” J Acad Nutr Diet 113 (2013): 972–979.
2. Ibid.
3. Kaufman, M. Nutrition in Promoting the Public Health: Strategies, Principles, and
Practice. (Sudbury, MA: Jones and Bartlett, 2007).
4. Public Health/Community Nutrition DPG. www.eatrightpro.org (2/25/16).
5. Slawson, D.L., N. Fitzgerald, and K.T. Morgan. “Position of the Academy of
Nutrition and Dietetics: The Role of Nutrition in Health Promotion and Disease
Prevention.” J Acad Nutr Diet 113, no. 7 (2013): 972–979.
6. See Note 1.
7. Rogers, D. “Compensation and Benefits Survey 2015.” J Acad Nutr Diet 116,
no. 3 (2016): 370–388.
8. Public Health/Community Nutrition Practice Group 2012 Membership Survey
Results. www.eatrightpro.org (3/15/16).
9. Chapman-Novakofski, K., and M. Reicks. “Dietetics Practitioners in Extension:
What Is the Current Climate and Future Demand?” J Acad Nutr Diet 113, no. 10
(2013): 1875–1884.
10. Institute of Medicine. Building Health Workforce Capacity through Community-
Base Health Professional Education. Workshop Summary. (Washington, DC: The
National Academies Press, October 3, 2014).
11. See Note 10.
12. See Note 8.
 9

CHAPTER
Dietitians in the
Government and
Military Services
“If dietetics is your profession, politics is your business.”1

OUTLINE
• Learning Objectives
• Part I. The Government
• Introduction
• Government Programs in Food and Nutrition
• Role of The Academy of Nutrition and Dietetics in Policy
Formation
• Washington Office
• Public Policy Workshop
• Position and Practice Papers
• Legislative Network Coordinators
• Political Action Committee
• Policy Issues In Dietetics
• Part II. The Military Services
• Summary
• Definitions
• References

129
130    D ietitians in the G overnment and M ilitary  S ervices

LEARNING OBJECTIVES
The student will be able to:
1. Name the largest federal government agencies related to food
and nutrition.
2. Explain the differences and similarities between the Dietary
Guidelines and Healthy People 2020.
3. Discuss ways the U.S. Department of Agriculture (USDA)
provides food assistance to low-income groups.
4. Understand roles dietitians and dietetic technicians hold in
government positions.
5. Describe how the dietary reference intakes (DRIs) are used
and for what purposes.

PART I. T HE G O V E R N M E N T

IN T RO D UC TI O N
Dietitians and nutritionists are employed in government activities and
programs at the federal, state, and city or local levels. In 2015, about
6 percent of registered dietitian nutritionists (RDNs) and dietetic techni-
cians, registered (DTRs) worked in government agencies and programs.2
Even though the total number employed is small, all dietitians have vital
interests in government activities because of the impact on professional
practice in many areas of food, nutrition, and health, and many are
actively involved in public policy through state legislative initiatives and
support of national priorities.
Dietitians play a leading role in reaching the public about food, nutri-
tion, and nutrition-related issues that are initiated by government agen-
cies and/or by legislators. In doing so, the dietitian relies on his or her base
of knowledge as well as on new and continuing information coming from
research, food industry, and from the government. Congress passes legis-
lation and government agencies issue guides and regulations that add to
the bases of dietetic practice. For example, the Food and Nutrition Board
of the National Research Council develops DRIs for the public, the Food
 Government Programs in Food and N u t r i t i o n      131

and Drug Administration develops food labeling and food safety regula-
tions, and the U.S. Department of Agriculture (USDA) and the Depart-
ment of Health and Human Services (DHHS) issue food guides such as
the Dietary Guidelines and MyPlate. These regulations and guides are
important adjuncts to dietetic practice and nutrition education.

G O V E RNM E N T P R O G R A M S I N F OOD A N D
NUT RIT I O N
The USDA and DHHS are the two largest agencies of the government
with the responsibility for the adequacy and safety of the food supply
and for the health of all citizens. These objectives are realized through
nutrition research, nutrition education, and food-related programs. The
USDA has traditionally had the responsibility for food production, food
consumption, and normal nutrition while the DHHS deals with the met-
abolic effects of dietary consumption patterns, particularly in relation to
chronic disease.3 There is overlap in these functions, but the agencies col-
laborate as well as conduct their specific programs and both are concerned
with the nutritional health of all citizens.
The number of programs funded and administered by the government
is extensive, and they deal with a broad range of activities concerned with
the food supply, nutrition surveillance and monitoring, and recommen-
dations for the public based on food surveys and research. The major
programs in food and nutrition may be categorized as follows:
1. National food and nutrition surveys. The USDA has collected data
on food intakes of individuals and families for many years. The
“Continuing Survey of Food Intakes of Individuals” (CSFII) was a
nationwide dietary survey beginning in 1985. The survey became
part of the National Nutrition Monitoring System in 1990. In
addition, the Diet and Health Knowledge Survey (DHKS) began
in 1989 as a telephone survey using a personal interview question-
naire. Both these surveys were merged with the National Food and
Nutrition Survey (NFNS) in 2002.
The National Nutrition Monitoring and Related Research Act
(NNMRR) was enacted by Congress in 1990 and is now con-
ducted regularly. The law was passed to provide more organization
and unification to existing survey methods and to coordinate the
132    D ietitians in the G overnment and M ilitary  S ervices

efforts of the 22 federal agencies that implement or review nutri-

tion services and surveys.
Another national survey is conducted by the Centers for Disease
Control and Prevention (CDC) called the National Health and
Nutrition Examination Survey (NHANES). In this survey, about
6000 individuals are interviewed each year on food intakes fol-
lowed by medical histories, physical measurements, and biochemi-
cal evaluations. Reports of the findings ae released each 2 years.
2. Nutrition research. Both the USDA and DHHS conduct research
regarding nutrient content of foods, nutrient intakes, and the
role of nutrition in treatment and prevention of disease. The
National Institutes of Health (NIH), through research units
within DHHS, conducts research in the major diseases and issue
guidelines for dietary and nutritional management of many of
the conditions.
The USDA sponsors research through grants to land-grant col-
leges and universities through the Agricultural Research Service.
The department also conducts research at six centers around the
country, an associated laboratory, and a research program in the
Mississippi Delta. The research is focused on foods and the agri-
cultural system and the effects on health, quality of life, and the
promotion of a nutritious food supply.
The DHHS sponsors research through the NIH, a complex of
27 institutes and centers in Washington, DC, and on campuses
throughout the country through intramural grants and programs.
The NIH is described as the nation’s medical research agency and
represents the largest funded research source in the world. The
focus of the research is to improve health and prevent disease.
Many dietitian/nutritionists are employed in this agency.
3. Food assistance and nutrition programs. The National School Lunch
and Breakfast Program, conducted by the USDA, provides free
or reduced price meals in public, nonprofit private, and residen-
tial institutions. The national program is administered at the local
level through state education agencies. Guidelines for foods served,
based on the Dietary Guidelines, are developed by the Food and
Nutrition Service. After-school snacks and summer feeding pro-
grams are also provided. Many dietitians are employed in school
foodservice.
 Government Programs in Food and N u t r i t i o n      133

The Supplemental Nutrition Assistance Program (SNAP) is also

conducted by the USDA. Funding by monthly food vouchers is
provided to low-income households to purchase food from gro-
cery stores or other sources such as farmer markets. Nutrition edu-
cation is not a required part of this program although it is often
provided to the clients by cooperative extension agents and com-
munity dietitians and nutritionists.
A large segment of community-based dietitians and nutritionists
are employed in the Women’s, Infants and Children’s Program
(WIC). Based usually in state or county health departments, the
program provides foods as well as nutrition counseling and nutri-
tion assessment to women during pregnancy and to children up to
5 years of age.
The nutrition program for the elderly provides a nutritious meal
for older adults in congregate dining centers or through home-
delivered meals. There is no income requirement for persons in
this program and the programs are important for offering social
contact as well as food for seniors.
4. Food legislation and regulations. The Food and Drug Administra-
tion issues guides for food safety, food labeling, and food additives,
and monitors food in general. A grading system and labeling for
meats and meat products is conducted by the USDA. The CDC
monitors and collects data on food-related illnesses and issues rec-
ommendations for the public. Several other agencies such as the
Environmental Protection Agency and the Federal Trade Commis-
sion that also monitor food advertising issue regulations regarding
food and food safety. All these departments function to develop
their regulations based on legislation enacted by Congress.
5. Dietary guidelines for the public. The two large agencies—USDA
and DHHS—appoint a scientific committee each 5 years to review
the evidence and make recommendations for current Dietary
Guidelines for Americans. The guidelines focus on good eating
practices in terms of best food choices and foods and nutrient to
be avoided or reduced. The latter are primarily sodium, fat, and
sugar while those recommended are ones containing fiber, com-
plex carbohydrates, and plant-based proteins. Exercise and safe
food handling and, in 2015, an emphasis on the whole diet pat-
tern are all part of the guidance. The two agencies issue the final
134    D ietitians in the G overnment and M ilitary  S ervices

recommendations that are incorporated into the school foodser-

vice program, community nutrition programs, and many others.
“Healthy People” is published at 10-year intervals by the DHHS
focusing on total health of the U.S. population. Currently work-
ing toward the 2020 goals of the program, the targets are nutrition
and weight, heart disease and stroke, diabetes, oral health, cancer,
and healthy aging. Specific objectives are developed, which are
evaluated at the midpoint of each decade to assess progress toward
the goals.
Recommended dietary allowances (RDAs) were first developed in
1943 and were updated at approximate 10-year intervals thereaf-
ter. In 1998, the pattern changed with the issuance of a group of
guidelines known as dietary reference intakes (DRIs) that are now
the standards for nutrient intakes for individuals and groups by
age, sex, and activity. The guides are developed by the Food and
Nutrition Board of the National Research Council.
6. Nutrition education. Nutrition education for the public is extensive
and varied. The translation of dietary guidance into specific eating
patterns is the responsibility of the Center for Nutrition Policy
and Promotion in the USDA. The current pattern is the MyPlate,
a pictorial representation of the recommended eating plan. Guides
for using the plan are also issued. There have been other plans in
the past such as the Food Pyramid and Basic Four and Basic Seven.
Other information sources provided by the USDA are the
National Nutrient Databank, the National Evidence Library, and
the National Agriculture Library that supplies information world-
wide. DHHS maintains the National Medical Library with the
NIH to provide disease prevention and treatment information to
the public as well as to researchers and professionals in the medical
and allied health fields.
At the state level, dietitians in public health nutrition are employees
of state health departments and conduct nutrition and health education
programs in the community. Dietitians in the Indian Health Service
work in state programs administered by the Federal Office of Indian
Affairs. Nutrition education for individuals and families is also con-
ducted through the cooperative extension service at land-grant colleges
and universities.
 Role of the Academy of Nutrition and D i e t e t i c s      135

Agencies administering school food service programs, the food stamp

program, and the elderly nutrition programs vary from state to state. How-
ever, the programs are all similar and meet the same national standards.
The national network of federal, state, and local cooperative extension
personnel “extend” research and pertinent information from the govern-
ment and the educational institutions to the public.

RO LE O F TH E A C A D E M Y OF N UT R I T I ON
AND D IE TE TI C S I N P O L I C Y F OR M AT I ON
Washington Office
The Academy became active in governmental and legislative affairs in the
1960s and now has a very effective network in place. A Washington office
is staffed in part with persons who are registered as lobbyists on behalf of
the Association. The staff monitors legislative developments in food and
nutrition and practice-related issues and works closely with the Depart-
ment of Government and Legal Affairs in the Chicago headquarters office
to promote the association’s priorities for action. A volunteer legislative
and public policy team, appointed by the Board of Directors, works with
both offices to gain information from states and members and, in turn,
transmit information back to states and members about pending public
policy actions.

Public Policy Workshop

A workshop is conducted by the Washington and Chicago headquarters
staff each year to inform members of pending legislation, to help them
become knowledgeable about the political process and to make contacts
with legislators and other government officials. Currently, the workshop
is offered by live streaming television, affording two-way interaction with
members.

Position and Practice Papers

Another important way the Association provides policy input is through
position and practice papers developed by members and approved for
publication by the House of Delegates. The papers represent a consensus
of viewpoints and professional interests and are used in many ways such as
media contacts, in contacting legislators, and with the public. Papers are
136    D ietitians in the G overnment and M ilitary  S ervices

periodically updated or deleted if the information is out of date or no

longer relevant.
Examples of current position and practice papers that are particularly
pertinent to policy issues are the following4:
• Healthy Food Choices
• Nutrition and Disease Prevention: Intervention and Management
• Nutrition Through the Life Span
• Safeguarding the Public
• Nutrition and Women’s Health
• Promoting Ecologic Sustainability within the Food System
• Using the DRIs
Position papers issued by the Academy may be accessed at www
.eatright.org

Legislative Network Coordinators

Each state designates a legislative chair and a legislative network coordina-
tor (LNC), who coordinate legislative activities among Academy members
in the state. The LNC helps prepare other volunteers who use prepared
talking points in contacts with members. In addition, grassroot liaisons
(GRL) are designated in each state who are assigned to one or more leg-
islators to work with them directly in advocating for Academy positions.

Political Action Committee

The Academy of Nutrition and Dietetics Political Action Committee
(ANDPAC) receives voluntary contributions from members for the purpose
of promoting legislative action on issues of concern. The monies received
are used to make a yearly contribution to a Congressman or woman who
has been instrumental in forwarding Association public policy concerns.
The designee is recognized at the annual meeting of the Academy.

POLI CY I S S U E S I N D I E TE TI CS
Public policy and advocacy are core functions of the Academy and crucial
to achieving the mission, vision, goals, and strategies of the Association.
Public policy influences the public image of the Academy and its members
as well as the successful implementation of actions the Association stands
for—better health for all citizens.
 P a r t I I . T h e M i l i t a r y S e r v i c e s      137

Academy groups and members work on a broad range of issues. For

focus and guidance regarding policy issues, several priority areas are
identified:5
• Disease prevention and treatment, including cancer, cardiovascular
disease, diabetes and pre-diabetes, HIV/AIDS, obesity and weight,
access to health care.
• Lifecycle nutrition, including prenatal and maternal health, early
childhood nutrition, school-age students, and nutrition for older
adults.
• Quality health care, including healthcare equity, consumer protec-
tion and licensure, workforce demand, research and monitoring,
lowering healthcare costs, and quality measures.
• Medical nutrition therapy (MNT) has been a legislative priority in
the Academy leading to its initial passage by Congress in the 1990s.
By continuing to work closely with the Centers for Medicare and
Medicaid Services (CMS), specific issues are addressed pertaining
to the role of RDNs in the management of illness or injury. Reim-
bursement for services provided by the dietitian/nutritionist is an
objective.6

PART I I. TH E M I L I TA RY S E RVI C ES
Military service is another area of practice for dietitians in the govern-
ment. Dietitians are employed in the army, navy, and air force where they
function in very similar activities as in many other areas of dietetics. Most
work in hospitals throughout the United States and in other countries and
have positions in clinical dietetics, food service management, and com-
munity nutrition. Others are in research, in personnel recruiting, and in
health promotion.
Dietitians in the military service meet the education and experience
requirements of the Academy and are registered. They receive basic mili-
tary training, as in a field hospital, for readiness in the event of war or
military action. They are commissioned officers and can expect to prog-
ress in rank and salary as well as in positions over time.
In the army, dietetic interns and dietitians are members of the Army
Medical Specialist Corps. In the air force, they are members of the
U.S. Air Force Biomedical Science Corps. In the navy, most work in
138    D ietitians in the G overnment and M ilitary  S ervices

hospitals in the United States and elsewhere where military personnel

are stationed.
At the entry level, duties of the dietitian include providing nutrition
assessments and counseling for inpatients, consultation with child care
and schools located on military bases, and nutrition/health promotion for
the military community. Other job duties may include supervising food
production and service. The entry-level dietitian is often responsible for
personnel management of a small military staff and civilian staff depend-
ing on the position. Senior dietitians are more often involved in establish-
ing policy that affects the nutritional health of soldiers and their families.
A U.S. Military Dietetic Internship Consortium is offered in Texas,
which combines a master’s degree with the internship. Course work for
the degree is offered at Baylor University and supervised practice may be
taken at one of three locations: Fort Sam Houston, San Antonio Medi-
cal Center, Walter Reed National Military Center in Bethesda, or the
Madigan Army Medical Center at Fort Lewis, Washington. The master’s
degree is awarded by Baylor University.
Army dietitians, as commissioned officers, are paid and promoted
based on their military rank. Housing and food allowances are also pro-
vided based on geographic location. Promotions are dependent on educa-
tion (advanced degrees), military education (the Army offers officer/leader
development courses), and job performance. An advantage of the military
promotion system is that a dietitian may change job position or location
without a loss of seniority. Military dietitians can expect to relocate at
intervals, and with each move, there are opportunities for varied positions.
Continuing education to maintain RD eligibility as well as for continued
self-development is highly encouraged.
A history of military dietitians in the Association and their service was
published in the Journal of the Academy in 2014.7

SU MMARY
Dietitians are employed in the government at national, state, and local
levels. They are involved in legislation and develop position and practice
papers as well as contributing to a PAC. They participate in food and
nutrition research and provide nutrition education for the public. They
are commissioned officers in the military services providing nutritional
care and food services for military personnel and families.
 R e f e r e n c e s      139

Activities of the Academy on behalf of dietitians include promotion

of policy issues important to the profession and education of dietitians
in legislative activities. Dietitians are involved in policy making through
contacts with legislators and in support of Association activities that fur-
ther the profession of dietetics and benefit the public.

D E F INI T I O N S

Food Assistance. Food that is provided in feeding programs or by

voucher to buy food.
Political Action Committee. Group pooling of money to support political
candidates or office holders.
Public Policy. The promotion of a law, a regulation, or a recommenda-
tion targeted to the public at large.
Regulation. Written rules to activate laws passed through legislation.

REFE REN C E S
1. Washington Report. ADA Courier. 35, no. 9 (1996): 1.
2. Rogers, D. “Compensation and Benefits Survey 2015.” J Acad Nutr Diet 116,
no. 3 (2016): 370–388.
3. www.eatright.org/advocacy (11/23/15).
4. The Academy of Nutrition and Dietetics. “Position and Practice Paper Update.”
J Acad Nutr Diet 115, no. 2 (2015): 284–285.
5. Eatright.org (11/23/15).
6. Neidert, K. “Advocating at the Centers for Medicare and Medicaid Services.”
J Acad Nutr Diet 113, no. 4 (2013): 505–507.
7. Stein, K. “The Academy’s Military Roots Visualized.” J Acad Nutr Diet 114,
no. 12 (2014): 2023–2049.
 10

CHAPTER
The Consultant in
Health Care, Business,
and Private Practice
“Entrepreneurs shape the future dietetics practice by
pursuing innovative and creative ways of providing
nutrition products and services.”1

OUTLINE
• Learning Objectives
• Introduction
• Becoming a Consultant
• Contracts and Fees
• The Consultant in Health Care and Extended Care
• Regulations
• Areas of Practice
• Roles and Responsibilities
• Standards for Quality Assurance
• The Consultant in Business Practice
• Areas of Practice
• The Consultant in Private Practice
• Starting a Practice
• Areas of Practice
• Practice Roles

141
142    T he C onsultant in H ealth  C are , B usiness , and P rivate P ractice

• Ethical and Legal Bases of Practice

• Summary
• Definitions
• References

LEARNING OBJECTIVES
The student will be able to:
1. Become familiar with personal characteristics needed to
become a consultant.
2. Develop a resume if not already completed.
3. Gain knowledge about setting fees, negotiating contracts,
and obtaining liability insurance.
4. Become familiar with federal, state, and local regulations
pertaining to consulting in healthcare facilities.
5. Understand in general the responsibilities of the consultant
in health care.
6. Understand consultation in business and the variety of
options available.
7. Become familiar with the range of opportunities available in
private practice.

IN T RO D UC TI O N
As a result of the 2015 Compensation and Benefits Survey, it was reported
that 8 percent of registered dietitians (RDs) and about 2 percent of dietetic
technicians, registered (DTRs) indicated their primary practice area was
in consultation and business.2 Many dietitians have found the schedule
flexibility and compensation of self-employment attractive alternatives
to  more traditional positions. An entrepreneurial drive is often the
impetus for a professional to become a consultant and/or establish a prac-
tice. Others do so because family or other obligations lead to becoming a
consultant for a better lifestyle fit.
 Becoming a C o n s u l t a n t      143

Healthcare institutions have moved an increasing number of services

from inpatient care into outpatient clinics, other community agencies,
or home care. Governmental regulations led to the need for nutrition
consultants in extended care facilities in the 1970s. Together, these trends
have led to the need for a greater number of consultant dietitians.
Three types of consultant practice are discussed in this chapter, and while
there are similar characteristics of the successful practitioner as in many of
the job requirements, each area is unique in several ways because of the
nature of the business or practice. The practice areas are consultants in
health care and extended care, such as nursing homes and long-term care
institutions, consultants in business, and consultants in private practice.

B E CO MIN G A C O N S U LTA NT
Starting a practice as a consultant requires forethought and planning.
Two very helpful publications available to guide the dietitian in planning
are Helm’s The Entrepreneurial Dietitian and The Competitive Edge.3,4
The first step is self-assessment. Personal characteristics are important
because an entrepreneur needs to be self-directed, energetic, and action
oriented. Previous working experience in dietetics is very important for
the person considering becoming a consultant because a great deal of
independent activity and judgment is needed, and success is dependent
on having had opportunities to develop these characteristics. A number of
questions leading to an assessment of a person’s readiness for practice are
the following:5
• Are you a self-starter?
• Are you a risk taker?
• Do you have a positive, friendly interest in others?
• Are you a leader?
• Can you handle responsibility?
• Are you a good organizer?
• Are you able to handle a flexible working schedule?
• Do you make up your mind quickly?
• Can people rely on you?
• Can you handle reversals and downturns in business?
A professional making a career change to consulting may need to
update his or her resume. It is important to tailor the resume in a way that
144    T he C onsultant in H ealth  C are , B usiness , and P rivate P ractice

emphasizes experience and professional qualifications, highlighting those

skills that pertain most closely to the position being planned. The resume
should be concise, should use strong action verbs, and should be specific
about past experiences. Examples of resumes for several different career
areas are shown by Matthieu.6
Employers look for workers with skills as well as knowledge and specific
competencies. A comprehensive discussion of competency-based hiring
gives helpful guides to the job expectations and interview.7
The interview will be a next important step after the resume has been
sent and after one or more call-backs from interested clients. A pro-
fessional attitude and appearance make a good first impression. Some
advance research about the company or facility will help to formulate
additional questions and show interest. Discussion of the amount of time,
contracts, and pay should come in the later part of the interview.8
Networking with other successful dietitians through one or more prac-
tice groups is an excellent way of gaining valuable start-up information.
Mentors may be found and networks established from these contacts.
Professional liability insurance should be considered early in the planning
stage. This insurance is available through the office of the Academy of
Nutrition and Dietetics. Networking is also a way of obtaining accounts
or positions. Initiating contacts with a healthcare facility or business is
followed by a meeting with the administrator and other key personnel.
Negotiations should include a clear understanding of the amount of time
the consultant will be needed. Although regulations in a healthcare insti-
tution may require a dietetic consultant only a small number of hours per
month, there may be compelling reasons for more time to be spent in the
facility. For instance, in institutions with a large number of residents or in
institutions in which a number of residents require skilled care, additional
consultation time may well be needed.

Contracts and Fees

Major considerations for the dietitian in consultation and private practice
are setting prices and fees and obtaining reimbursement for services. These
will be spelled out in the contract, which is a legal document outlining the
obligations between the parties involved.9 Establishing and negotiating
the ground rules are important in the initial stages of the process.
Consultants can gain information about reimbursement rates by
researching pay levels in the area and region for different types of
The Consultant in Health Care and E x t e n d e d C a r e      145

consulting work and for basic salary levels. Networking with others in a
practice group is a good way of obtaining information regarding typical
fees. Dietitians who receive reimbursement from insurers or hospitals for
medical nutrition therapy (MNT) will be guided by MNT codes estab-
lishing payment for treatments authorized by Medicare.10
Expenses such as liability insurance, mileage, travel, and any educa-
tional components needed should be added to the base pay to arrive at a
fee.11 Ethical billing practices are pointed out in an article by Horowitz
and White.11

T H E CO N S U LTA N T I N H E ALT H C A R E A N D
E X T END E D C A R E
The role of the consultant in healthcare facilities and extended care
became important with the enactment of the Medicare regulations by
the Centers for Medicare and Medicaid Services or (CMS). The Omni-
bus Reconciliation Act of 1987, amended in 1990 and 1993, provided
regulations for nutritional care in long-term facilities that received
federal Medicare funds.12 These facilities (primarily nursing homes)
were required to hire a qualified dietitian; as a result, the demand for
consultant dietitians rapidly increased from a limited employment
area with a short history, few guidelines, and dietitians on their own
insofar as job requirements and benefits were concerned. Consultation
in healthcare facilities became areas in which many dietitians soon
found employment. The opportunities helped many dietitians who
had been out of the workforce to return to practice. Some of these
dietitians needed to be updated in practice knowledge and skills and
turned to continuing education opportunities to refresh themselves
on necessary information to practice. Today, many dietitians work as
consultants in nursing homes and small hospitals funded by federal
and state agencies.
Federal regulations state that the consultant’s visits should be of
“sufficient frequency to meet the food and nutrition needs of residents
in the facility.”13 In many facilities, this meant a minimum of 8 hours a
month. While the federal regulations were vague in regard to the actual
amount of time required, many states, through licensing, require a
minimum of 8 hours. A dietitian contracts with a facility for the amount
of time needed, at or above the minimum, to meet the facility’s needs.
146    T he C onsultant in H ealth  C are , B usiness , and P rivate P ractice

Some consultants contract with more than one facility and may thereby
work part time or full time as they choose. Some dietitians are employed
full time for a multifacility chain or in one large facility.

Regulations
A consultant must be familiar with state and federal regulations that
apply to long-term or extended care facilities. The health department in
each state can provide copies of both regulations. Federal regulations are
precise concerning both the physical plant and operations as well as staff-
ing. Each facility has its own procedures and set of regulations governing
operations. The consultant needs to be thoroughly familiar with these as
well as the policies and goals of the facility.
All healthcare providers in the United States need to be familiar with
the Health Insurance Portability and Accountability Act (HIPAA) of
1996, as this set of rules concerning rights of patients and clients must be
addressed and clients notified of the facility’s privacy procedures.14

Areas of Practice
Long-term facilities include nursing homes, skilled nursing facilities, sub-
acute care centers, adult day care, residential care facilities, and alcohol
and drug rehabilitation facilities. Long-term care facilities may be owned
privately, by the cities or counties, by religious organizations, or by corpo-
rations. They may be for profit or not for profit; the number of beds varies.
Consultants also may be hired to visit developmentally disabled clients
in their homes. In addition, some state health departments contract with
consultants to provide services for Women, Infants, and Children (WIC)
participants. Other consultants work in home health care, congregate
feeding sites, senior citizen centers, correctional facilities, group homes for
the developmentally disabled, hospice programs, and small rural hospi-
tals. Adult day care, group homes, and retirement communities are other
facilities offering opportunities for the consultant dietitian in health care.

Roles and Responsibilities

A consultant functions in an advisory capacity within a facility; however,
he or she has ethical and professional responsibilities for the nutritional
care of the residents. Ethical practice issues must be guided by the Acade-
my’s code of ethics. Professional responsibilities are delineated in the ADA
Standards of Practice for Professional Performance for Registered Dietitians
The Consultant in Health Care and E x t e n d e d C a r e      147

in Nutrition Care15 and the ADA Standards of Practice of Practice and

Standards of Professional Performance for Registered Dietitians (Competent,
Proficient, and Expert) in Extended Care Settings.16 By developing rapport
and using organizational skills, the consultant is able to accomplish the
needed tasks. Because he or she is usually not in the facility full time, the
day-to-day supervision of dietary services may be provided by a DTR or
a dietetic manager.
When a consultant begins employment in a facility, one of the first
activities should be to need to assess of the food and nutrition services
for the residents. This assessment will guide further planning and action.
Documentation of observations and plans for future visits are very impor-
tant, beginning with the first visit. The typical activities a consultant per-
forms during a visit to a facility include the following:
• Conferring with the dietary manager and the administrator about
day-to-day operations and any problems that need to be addressed
during the visit
• Performing nutrition assessment of new residents and conducting a
follow-up for all others
• Checking at-risk residents and making recommendations for fur-
ther nutritional care as indicated. This includes noting unexplained
changes in weight or the development of pressure ulcers, checking
those on tube feedings, and noting signs of dehydration or otherwise
poor nutritional status
• Observing the meal service and eating a meal to evaluate food quality
• Making nutrition rounds and visiting the group dining area at meal
time to observe the residents’ acceptance of the food and their food
intake
• Conducting educational in-service sessions for employees and
exchange information regarding departmental activities
• Documenting all activities with any recommendations for follow-up
The consultant may be responsible for developing policy and procedure
manuals for the quality improvement program, for safety and sanitation
procedures, and for budget management. The reference diet manual should
be reviewed and signed by the chief of the medical staff at least annually
and should be updated regularly. Consultants may also teach dietetic tech-
nician students, conduct classes for the dietary manager, and serve as a
preceptor for students in supervised experiences in long-term care.
148    T he C onsultant in H ealth  C are , B usiness , and P rivate P ractice

Standards for Quality Assurance

The dietetics in health care communities dietetic practice group developed
standards of practice in 2011 as a guide for quality assurance in practice.17
The standards specify areas of activity with examples of outcomes. They
include the provision of services, application of research, communication
and application of knowledge, utilization and management of resources,
and continued competence and professional accountability.
Through written documentation, consultant dietitians can verify actual
performance and implement action to meet the expected outcomes. The
standards also help develop a workable plan to help consultants meet the
responsibilities for which they have been contracted and to evaluate their
own knowledge, clinical experience, and management expertise.

THE CONSULTANT IN BUSINESS PRACTICE

An increasingly popular area of practice for the dietitian with an entre-
preneurial drive is in business and nontraditional career areas. Poten-
tial practice areas identified by the Nutrition Entrepreneurs practice
group include services for individuals, corporations, the media, restau-
rants, food companies, Internet and business technology, sports and
health facilities, and coaching. Other areas are in pharmaceutical sales,
medical and institutional equipment sales, catering, chefs’ schools, and
specialized clinics.
Dietitians who work as consultants in businesses of all kinds like to
take on new challenges and are often described as risk takers in new
areas of practice. They are energetic and versatile individuals with back-
grounds and experience preparing them for innovative roles—roles they
may even be required to create. Although many of the responsibilities of
a consultant may be similar to those for a full-time dietitian, one of the
main differences is often the duration of the assignment. In an estab-
lished business, the consultant may be given a short-term contract with
an identified scope of work and specific deliverables (outcomes). The
scope of services is usually an assignment to set up or improve the busi-
ness practices of the client. It also may be a specific project with a defined
beginning and end time period. Examples of activities the consultant may
perform include evaluating staffing patterns, establishing an inventory
and cost-control system, planning a new production or service system,
 The Consultant in B u s i n e s s P r a c t i c e      149

recommending equipment purchases, and establishing a computerized

control system.

Areas of Practice
Business consulting firms at times employ entry-level dietitians for con-
sulting, usually within a defined scope of responsibility. More often,
the dietitian is experienced in some area (e.g., as a clinical dietitian in
a healthcare facility or manager of a food service system). The dietitian
may have also worked as an assistant with other dietitian for a food
processor equipment manufacturer, publisher, marketing company, or
software company. When hired, he or she may first be assigned to a
team leader to work on a specific part of a major project. With experi-
ence, there may be opportunities to expand into other nontraditional
roles such as facility management, accounting, design, sales, or market-
ing. The range of responsibility is dependent on the scope of the services
performed by the company and those that the dietitians can develop for
the company.
The following guidelines can be used by those who may be consider-
ing moving into management with the goal of consultation in business,
private practice, or health care:
• Consider one’s personal qualifications for independent action
• Seek advice from a veteran manager or other mentors
• Join a practice group for networking and sharing
• Become familiar with the mission and goals of the business or health-
care organization
• Keep up-to-date with the professional literature and continuing
education opportunities
• Take advantage of the evidence-based library resources
• Consider further education if advancement and pay would benefit
• Attend professional seminars and meetings
• Be familiar with and apply all aspects of ethical practice
• Match job requirements with education and experience
• Be proficient in the use of technology
• Seek ways to constantly evaluate personal performance
Communications through use of social media is increasingly important
in consultations of all kinds, including business. Ethical considerations must
be a part of this usage as outlined in an ethics opinion by the Academy.18
150    T he C onsultant in H ealth  C are , B usiness , and P rivate P ractice

T H E CO NSU LTA N T I N P R I VAT E PR A C T I C E

Many dietitians today become entrepreneurs and enter private practice for
a variety of reasons. Some seek new and innovative opportunities out of
choice; others do so due to circumstances that make private practice an
attractive choice. Examples of the latter might be the loss of a job or the
need to work varying hours because of family responsibilities. Opportuni-
ties for women in the business world are unquestionably increasing. The
healthcare industry continues to downsize from large, centralized centers
to outpatient and community centers with fewer staff. Many dietitians seek
greater independence and new challenges and, along with a business climate
that encourages entrepreneurs, find satisfying careers in private practice.
Not all consultants start a business. Some work at home and com-
bine home and family responsibilities with part-time, contract-type work
such as writing, preparing marketing and educational materials, computer
searches, and home visits. If a decision is made to open an office, appro-
priate equipment must be obtained, and secretarial help, as well as other
assistants or an office manager, will need to be considered.

Starting a Practice
Cross19 provides a helpful checklist for starting a private practice. The first
step, she points out, is to maintain an updated file of one’s professional cre-
dentials and achievements. Regarding references, both giving and receiving
employment references may present important issues to be considered.20
Obtaining state licensure or certification and keeping professional creden-
tials up to date helps establish qualifications. Joining the state association,
dietetic practice groups, and specialty groups, if applicable, will provide
opportunities for networking. Becoming involved in local business groups
or taking business classes helps one learn the business climate.
Creating a vision and finding one’s focus, then creating the road map
or business plan, is the next step.21 The business plan should incorporate
the mission and vision statement, product or service to be provided, a
description of the target market, the competition, and financial projec-
tions. Identifying where to find professional support from an accountant,
a banker, a marketing specialist, an information technology specialist, and
perhaps a lawyer will provide valuable assistance. Banks, investment com-
panies, and community small-business start-up programs often provide
advice to assist entrepreneurs in starting a business.
 The Consultant in P r i v a t e P r a c t i c e      151

Establishing the business basics by estimating expenses, obtaining

necessary insurance, and writing policies and procedures are important
steps. A marketing program and a quality-assurance program will help
launch and maintain the business. The benefits that can be realized from
careful planning include seeing clients succeed and realizing a business
profit.
The dietitian who enters private practice needs to possess confidence,
determination, perseverance, and the motivation to remain current on
trends and changes in the profession and the business world. Remaining
up to date comes in great part through taking advantage of continuing
education opportunities. The Nutrition Entrepreneurs practice group
advises anyone going into private practice—whether to write a book, start
a business, become a speaker or coach, or use the Internet to market or
provide products and services—to find help through a mentor, and it
offers participation in a mentorship program.

Areas of Practice
The consultant in private practice usually will be located outside an orga-
nization, but also may be an intrapreneur, or one within an organization
who develops new ideas or services that are used profitably in some way.
The potential work settings are as diverse as the practitioner’s interests
and expertise as well as the market demand. This variety is illustrated in
Table 10-1.
The professional services provided are influenced by the needs of the
consumer, the demands and changing environments of health care, changes
in regulatory agencies, increased autonomy, and advances in science and
technology.22 As new ideas are disseminated and needs identified, more
roles are defined for the private practitioner. Dietitians may form alliances
and networks to provide services. By teaming with other professionals,
the ability to market services and products and share business expense is
enhanced. The opportunities presented through a wider range of contacts
also may be increased. Examples of such associations are dietitian net-
works and dietitian-independent practice associations. Dietetic practice
groups provide a means for networking among professionals.

Practice Roles
Consultants in private practice may teach clients and consumers in areas
ranging from wellness and prevention to MNT, business and industry,
152    T he C onsultant in H ealth  C are , B usiness , and P rivate P ractice

Table 10-1.  Settings for Consulting in Private Practice

Private office
Media and communications
Private home
Grocery stores
Physician’s or other allied health professional’s office
Restaurants and culinary industry
Corporate settings of work sites
Home health care
Business and industry
Health/fitness/wellness centers and spas
Food companies
Community-based programs
Hotels and resorts
Schools
Research centers
Hospitals
Medical education consulting firms
Day and group homes
Private specialty clinic (specializing in sports medicine, eating disorders, diabetes,
renal diseases, oncology, HIV/AIDS)
Senior citizen centers
Nursing homes
Governmental contracts
Rehabilitation centers
Child development centers
Assisted living facilities
Retirement centers

Adapted from Alexander-Israel, D., and C. Roman-Shriver. In Dietetics: Practice and Future
Trends, 3rd ed. E.A. Winterfeldt, M.L. Bogle, and L.L. Ebro. (Gaithersburg, MD: Aspen
Publishers, 2011), p. 137.

food service and culinary trades, and writing and media presentation. A
list of activities is shown in Table 10-2 as examples of the types of services
that consultants may perform.
Practice roles often can be expanded with more training in business,
marketing, and communications and with the development of new skills
that cross the boundaries into other health professions.23 For example,
 The Consultant in P r i v a t e P r a c t i c e      153

Table 10-2.  Roles of Consultants in Private Practice

Assessment of nutritional status
Menu evaluation and planning
Recipe evaluation and modification
One-on-one counseling
Family counseling
Group counseling
Monitoring of nutritional intervention
Dietary analysis and evaluation of products
Consultant to agencies, institutions, and programs with nutrition components, such
as extended care, school food service, hospitals, government agencies, or clinics
Consultant to professionals (health care, food service, culinary industry)
Consultant to corporations (fitness centers, wellness/health promotion programs,
benefits departments)
Writing for the lay public (books, newsletters, magazines, newspaper articles)
Professional publications
Group training, presentations, workshops
Developing nutritious/healthier menu items for restaurants
Restaurant and culinary staff training
Assistance in marketing nutrition in restaurants
Computer/software programming (quality management, nutrition education, food
service, clinical nutrition)
Developing and marketing nutrition education programs (private and public)
Supermarket tours and grocery information guides
Nutrition labeling information
Rehabilitation and sports injury consultation
Nutrition care planning
Monitoring compliance with local, state, federal regulations (long-term care facili-
ties, drug and alcohol centers, prisons)
Developing, administering, and evaluating nutrition standards
Multidisciplinary preventive and therapeutic services
Health coaching

Data from Alexander-Israel, D., and C. Roman-Shriver. In Dietetics: Practice and Future
Trends. E.A. Winterfeldt, M.L. Bogle, and L.L. Ebro. (Gaithersburg, MD: Aspen Publishers,
1998), p. 209.

dietitians can become proficient at taking blood pressure and body com-
position measurements in the home care setting; can secure American
College of Sports Medicine Exercise Test Technology certification for
performing electrocardiogram-monitored stress tests in sports medicine
154    T he C onsultant in H ealth  C are , B usiness , and P rivate P ractice

clinics, or Clinical Laboratory Certification for blood analysis; or can use

phlebotomy skills in wellness programs.
Continually emerging roles demand expansion of the dietitian’s scope
of practice and skills and capitalizing on the talents that are unique to
dietitians. Among these are the ability to apply food and nutrition knowl-
edge, use nutrition assessment tools, apply lifestyle-change education to
prevent or manage disease, and to collect data on outcomes of nutrition
intervention on quality of life and overall care costs.

ETHICAL AND LEGAL BASES OF PRACTICE

The Code of Ethics for the Profession of Dietetics is the primary document
governing ethical practice in all areas of dietetics. This document, along
with any applicable rules or statutes of practice, including licensure from
state and local authorities, should be familiar to all consultants. These
guidelines will clarify the responsibilities to the public, to clients, to the
profession, and to colleagues and other professionals. Feeney24 offers
practical tips for the dietitian applying the code to ethical practice when
questions or conflicts arise. Grandgenett25 gives specific case examples of
ethical dilemmas in business practice with discussion of ways they can be
handled.
As discussed earlier, the consultant may need to retain legal advice at
the outset in order to negotiate a contract and other job-related provi-
sions. The contract is a legal document that guides the consultant’s scope
of practice and may serve as a template for later functions. All consultants
should carry personal liability insurance to protect against the possibility
of legal action arising out of job-related activities.

SU MMARY
Traditional institutional roles for dietitians, especially in clinical dietet-
ics, are still predominant practice settings; however, many dietitians are
using their clinical background to become entrepreneurs in their own
practice. The dietitian who possesses the needed personal attributes and
the initiative and creativity needed for entrepreneurial success may find a
rewarding new career in consultation in healthcare facilities, businesses,
or private practice.
 R e f e r e n c e s      155

D E F INI T I O N S

Client. The recipient of services or products.

Consultant. A skilled and knowledgeable person qualified to give expert
professional advice.
Entrepreneur. An innovative person who initiates a new activity, career,
or business.
Intrapraneur. A person within an organization who develops new ideas
or services.
Long-term care. Assistance provided over time to people with chronic
health conditions and/or physical disabilities and those who are
unable to care for themselves.
Managed care. A system of care administered by an entity outside a
hospital or healthcare institution in which access, cost, and quality
of care are controlled by direct intervention before or during service
for purposes of creating efficiencies and/or reducing costs.
Nutrition assessment. Evaluation of an individual’s nutritional status
based on anthropometric, biochemical, clinical, and dietary
information.
Private practice. Self-employment in which a person manages his or her
own working career.
Quality improvement. The provision of service that assures the needs of
those served are met through adherence to high standards of care.

REFE REN C E S
1. Academy of Nutrition and Dietetics. Nutrition Entrepreneurs Dietetic Practice
Group. (2012).
2. Rogers, D. “Compensation and Benefits Survey 2015.” J Acad Nutr Diet 115,
no. 3 (2015): 20.
3. Helm, K.K. The Entrepreneurial Nutritionist, 4th ed. (Lake Dallas, TX: K.K. Helm
Publications, 2010).
4. Helm, K.K. The Competitive Edge. Advanced Marketing for Dietetic Professionals,
3rd ed. (Chicago: The Academy of Nutrition and Dietetics, 2009).
5. Adapted from: Cross, A.T. “Practical and Legal Considerations of Private Nutrition
Practice.” J Am Diet Assoc 95 (1995): 21–29.
6. Matthieu, J. “Revamping Your Resume for Your Specialty.” J Am Diet Assoc 110
(2010): 353–355.
156    T he C onsultant in H ealth  C are , B usiness , and P rivate P ractice

7. Peregrin, T. “Competency Based Hiring: The Key to Recruiting and Retaining

Successful Employees.” J Acad Nutr Diet 114, no. 9 (2014): 1330–1339.
8. McCafree, J. “Contract Basics: What a Dietitian Should Know.” J Acad Nutr Diet
103 (2003): 429–440.
9. Peregrin, T. “From Contracts to Clean Claim: Guidelines for Getting Paid.”
J Am Diet Assoc 110 (2010): 837–839.
10. Bender, T. “2009 Medicare MNT Payment Information.” Ventures XXV, no. 4
(2009): 10.
11. Hodorowicz, M.A., and J.V. White. “Elements of Ethical Billing for Nutritional
Professionals.” J Acad Nutr Diet 112, no. 3 (2012): 432–435.
12. Omnibus Budget Reconciliation Act 1987. Amended 1990, 1993.
13. “Skilled Nursing Facilities: Standards for Certification and Participation in
Medicare and Medicaid Programs.” Federal Register 39 (1974): 22–38.
14. Boyce, B. “HIPAA Compliance from a Private Practice Per View.” J Acad Nutr Diet
114, no. (9), 2014: 1341–1346.
15. American Dietetic Association Quality Management Committee. “American
Dietetic Association Revised 2008 Standards of Practice for Registered Dietitians
in Nutrition; Standards of Professional Practice for Registered Dietitians; Stan-
dards of Practice for Dietetic Technicians, Registered, in Nutrition Care; and Stan-
dards of Professional Performance for Dietetic Technicians, Registered.” J Am Diet
Assoc 108 (2008): 1538–1542.
16. Roberts, L., S.C. Cryst, G.E. Robinson, C.H. Robinson, C.H. Elliott,
L.C. Moore, M. Rybicki, and M.P. Carlson. “American Dietetic Association:
Standards of Practice and Standards of Professional Performance for Registered
Dietitians (Competent, Proficient, and Expert) in Extended Care Settings.”
J Am Diet Assoc 11 (2011): e617–624, e627.
17. See Note 16.
18. Ayres, E.J. “The Impact of Social Media on Business and Ethical Practices in
Dietetics.” J Acad Nutr Diet 113, no. (11): 1539–1543.
19. Cross, M. “Getting Started in Private Practice: A Checklist to Your Entrepreneurial
Path.” J Am Diet Assoc 108 (2008): 21–24.
20. Zackin, F.M. “Employment References—Giving and Receiving.” J Am Diet Assoc
108 (2008): 1053–1055.
21. See Note 8.
22. ADA. “The Role of Dietetics Professional in Health Promotion and Disease
Prevention.” J Am Diet Assoc 102 (2002): 1680–1687.
23. See Note 6.
24. Feeney, M.J. “When Ethics Collide: An independent Dietetic Consultant’s
Perspective on Balancing Professional Ethics with the Wishes of Your Client.”
J Am Diet Assoc 108 (2008): 29–31.
25. Grandgenett, R. “Ethics in Business Practice.” J Am Diet Assoc 110 (2010):
1103–1104.
 11

CHAPTER
Career Choices
in Business,
Communications, and
Health and Wellness
“The ancient Greeks attained a high level of civilization
based on good nutrition, regular physical activity,
and intellectual development.”1

OUTLINE
• Learning Objectives
• Introduction
• The Dietitian in Business and Communications
• Career Opportunities
• Mentors and Networks
• Strategic Skill Building
• The Dietitian in Health and Wellness Programs
• Sports Nutrition
• Cardiovascular Nutrition
• Wellness and Health Promotion
• Disordered Eating
• Practice Groups
• Summary
• Definitions
• References

157
158    C areer C hoices

LEARNING OBJECTIVES
The student will be able to:
1. Discuss the wide range of employment opportunities in
business.
2. Describe areas of practice in health and wellness, sports, and
specialty areas in medical nutrition.
3. Gain awareness of the communication skills needed by the
successful consultant.
4. Gain appreciation for the personal characteristics helpful in
the business world.
5. Understand the importance of networking and mentors in
making employment decisions.

IN T RO D UC TI O N
Hospitals and extended care facilities have long been the work settings
for the largest percentage of dietitians and dietetic technicians; however,
other potential career choices are emerging in other settings. This move-
ment is in part because of the creativity in education and the changing
needs for nutrition information. Consultation and private practice were
discussed in a previous chapter. In this chapter, three additional general
areas of dietetic practice potential and opportunity are presented: busi-
ness, communications, and health and wellness.

T H E D I E T I TI A N I N B U S I N E SS A N D
COMMUNI C ATI O N S
Following a career path in business and/or communications has generally
been considered a nontraditional choice for dietitians. The Academy of
Nutrition and Dietetics membership survey in 2015 indicated that about
32 percent of dietitians work in the for-profit sector, including those in
contract food management, managed care organizations, and other for-
profit organizations. Thirty nine percent worked in nonprofit organi-
zations and 20 percent for governments.2 The for-profit category also
represents a wide range of positions, including private practice, owning
 The Dietitian in Business and C o m m u n i c a t i o n s      159

a business, and working with corporations, trade associations, food and

pharmaceutical companies, and hotels and restaurants. Private practice
in clinical dietetics and nutrition is also moving to negotiated contracts
with medical specialty clinics, medical departments (i.e., pediatrics, gas-
troenterology, internal medicine, oncology, etc.) within the hospital set-
ting, especially as hospital stays become shorter and fewer professionals are
employed on staff.
Expanded opportunities in business and communications are expected
to continue and grow as employers add dietitians to their organization by
realizing their value to the business. The major reasons appear to be to
increase the company’s credibility, to promote customer health and nutri-
tion, and to increase the understanding of customer/consumer needs.
Given the current trends reported by the Food Marketing Institute, con-
sumers believe the main payoffs of good health are being more active,
relieving stress, lowering disease risk, having more energy and living
longer.3 Food producers, food retailers, and food service establishments
take note of what is important to the public and respond by providing
products that help meet nutritional and other needs. Food labeling laws,
healthy vending programs, the government farm bill, food safety regula-
tions, and other governmental initiatives are helping to position good
nutrition within closer reach of people.

Career Opportunities
There are many paths to a career in business and communications for
interested and qualified dietitians. The importance of early exposure to
the business world is increasingly recognized, as pointed out in recom-
mendations that dietetics students experience a rotation in a business
environment as part of their undergraduate study, dietetic internship, or
graduate study.4 Students and supervisors can discover opportunities by
contacting exhibitors at professional meetings, local businesses, or by con-
tacting other professionals in business and communications. A business
rotation may also offer the opportunity for exposure to marketing and
public relations activities that are essential in business.
The Dietitians in Business and Communications practice group identi-
fies its members as presidents, vice presidents, food service directors, food
stylists, researchers, consultants, sales managers, marketing managers,
in store workshop providers, restaurateurs, test kitchen managers, and
software specialists. Emerging areas involve personal/individual grocery
160    C areer C hoices

shoppers, in-home nutrition coaches, and gourmet food preparation

instruction.5
How does an individual get a start in business? Several steps are impor-
tant, including the following:
• Make a list of your talents, skills, and interests.
• Make a list of all the possible areas in which you could work, includ-
ing, but not limited to writing, speaking, publishing, research, mar-
keting, teaching, sales, media, cooking demonstrations, counseling,
coaching, managing, catering, and product development.
• Make a list of the group with whom you enjoy working and/or in
which you have had some experience.
• Read journals and newsletters: the Journal of the Academy of Nutrition
and Dietetics, Food and Nutrition magazine, dietetic practice group
newsletters, and others and make a list of dietitians doing things you
would enjoy doing and can do.
• Contact others working in your areas of interest—find a mentor.
• Network, network, network—with other dietitian nutritionists and
professionals in related areas of practice.6–8
Dietitians in business and communications cite several positive things
they like about their jobs: challenging work, learning opportunities, cre-
ativity, fast pace, flexible scheduling, visibility, and remuneration. At
the same time, some indicate there can be stress, long hours, a fast pace,
bureaucracy, a lot of information to absorb, and a critical responsibility
for targeted continuing education. The dietitian who is flexible, willing to
take risks, and is interested in the business world is most likely to succeed.

Mentors and Networks

The dietitian/nutritionists following nontraditional paths agree that
having a mentor, networking, developing a strategic skill set, and keep-
ing current with research and consumer trends are factors necessary to
build successful careers.9–11 A mentor may be a coworker, an instructor,
or another professional. A mentor in the same organization can provide
insight into policies, procedures, and the unspoken policies of a company.
Networking both inside and outside the boundaries of dietetics is a way
of finding a mentor, gathering information, and connecting with others.12
The networking offered through dietetic practice groups is invaluable
to professionals looking for opportunities for change or advancement
 The Dietitian in Health and W e l l n e s s P r o g r a m s      161

in nontraditional areas. Affiliating with other professional associations

will provide more ideas and contacts. Social media (Facebook, Twitter,
blogs, etc.) and technology are also involved in the communications skills
needed to progress. Many otherwise traditional encounters now take place
on email and social media outlets.

Strategic Skill Building

The ability to communicate effectively, along with business know-how
and public relations, or people skills, is strategic to a successful career.
Industry studies routinely point out that communicating well means the
difference between success and failure. The ability to build on earlier edu-
cation and experience leads to professional growth and enhanced job per-
formance. For example, if a job requires evaluating research and working
with research and development, a good grounding in science is important.
Clinical education and experience help a dietitian nutritionist understand
the health and nutritional implications when producing and marketing a
new food, dietary supplement, or educational materials.
Advancing into positions with increasing responsibility and managerial
skill necessitates continuing education, often in the business-related areas
of study. The growth of online and distance education helps make this
possible even for the professional working full time or in locations away
from the educational setting. Dietitians in business frequently continue
their education by acquiring an MBA or an advanced degree in manage-
ment or finance.
In today’s world it is imperative to establish a website and participate
in social media in order for dietetic professionals to enhance their business
image, complement business advertising, attract new client or customers
outside the local area, or to start a new business venture.13 They may also
find this a useful way to learn more about specific businesses and to build
and enhance networks.

T H E D I E TI TI A N I N H E A LTH A N D
W E LLNES S P R O G R A M S
Wellness, health promotion, corporate fitness, elite professional ath-
letes, and sports nutrition programs are all career opportunities that have
increased in recent years. Although sports and dietetics as professions or
areas of interest have existed for centuries, the combination of the two as
162    C areer C hoices

a career specialty is relatively recent. The growth of wellness and fitness

programs has been rapid as the relationship between nutritional status and
maintenance of health, prevention of disease, and the slowing of aging
effects becomes more evident.14
A poor diet is a known risk factor for the development of the three
chronic diseases that are the leading cause of death in adults in the United
States, that is, cancer, cardiovascular disease, and stroke.15 Additional
health problems of adults are also closely associated with diet and eating
behaviors, such as obesity, diabetes, high blood pressure, and osteoporo-
sis. The number of deaths and medical costs can be significantly altered
by changes in diet and lifestyle when it is considered that billions of dol-
lars are spent each year on schemes and unproven methods to reduce
body weight and prevent cancer, not to mention the money spent treating
adults with these diseases and their complications.
Reports from the National Health and Nutrition Examination Survey
III (NHANES) indicate an alarming increase in the prevalence and sever-
ity of obesity in young children, older children, and adolescents, as well as
adults.16 These statistics point to the need for programs in health promo-
tion, wellness, fitness, and the prevention and treatment of obesity, all of
which greatly expands career options for dietitian nutritionists.
Some dietitians have developed their own programs through practice
and research and now market or license the programs to other dietitians
and health professionals, both nationally and internationally. Others con-
tinue to work in hospitals, ambulatory care centers, clinics, senior living
centers, rehabilitation centers, and athletic clubs or gyms. Those in private
practice provide counseling and medical nutrition therapies aimed at pre-
venting and treating obesity and other disease conditions.
Even with, or perhaps because of the increasing prevalence of obesity,
many dietary fads, drugs, and questionable dieting programs have esca-
lated and now account for enormous amounts of money each year. This
phenomenon emphasizes the need and opportunities that exist for dieti-
tians and other health professionals in this area.

Sports Nutrition
Interest in sports and cardiovascular nutrition among members of the
Academy led to the formation of the Sports, Cardiovascular, and Wellness
Nutrition dietetic practice group. Disordered eating as an area of practice
was added to the group to include dietary professionals with an interest
 The Dietitian in Health and W e l l n e s s P r o g r a m s      163

in this area (such as anorexia nervosa and bulimia), as they recognized the
frequent presence of eating disorders among athletes and the critical role
that the identification and treatment of disordered eating has in maintain-
ing health and wellness.
The Academy of Nutrition and Dietetics, the Dietitians of Canada and
the American College of Sports Nutrition issued a position paper in 2009
concerning nutrition and athletic performance.17 The importance of opti-
mal nutrition and the roles and responsibilities of healthcare profession-
als was discussed in the paper. The educational needs of those aspiring to
become a sports nutritionist were detailed in an article by Clark.18 Knowl-
edge of nutrition and exercise science, physiology, business skills, and a
foundation of strong clinical experience are all important, especially because
many sports nutritionists are entrepreneurs. A list of the clinical concerns
commonly presented to a sports nutritionist is shown in Table 11-1.

Table 11-1.  Clinical Concerns Commonly Presented to a Sports

Nutritionist
Allergies Diarrhea

Alcohol addiction Gastric reflux

Amenorrhea Gout

Anemia Headaches

Anorexia Hypoglycemia

Arteriosclerosis Hyperlipidemia

Binge eating Hypertension

Body image distortion Menopause

Bulimia Obesity/overweight

Cancer (prevention, Osteoporosis

recovery form)

Chronic fatigue Pregnancy/perinatal nutrition

Constipation Stress fractures

Diabetes Surgery (special nutritional pre- and postoperative)

Data from Journal of the American Dietetic Association 100, Number 12 (December 2000),
Clark, N. “Identifying the Educational Needs of Aspiring Sports Nutritionists,” 1522–1524,
Copyright 2000.
164    C areer C hoices

Dietetic professionals with a specialty in sports nutrition can be found

in a wide variety of settings, from sports medicine, rehabilitation clinics to
professional athletic teams, high school athletics, the Olympics, and from
colleges and universities to fitness centers, private clubs, and corporate fit-
ness programs. Many incorporate sports nutrition into their more general
practice of nutrition counseling or private practice. Today, several profes-
sional sports teams include dietitians as paid consultants whose expertise
serves to enhance the player’s performance. A few professional athletes
have employed personal dietitians primarily to help them maintain appro-
priate body weight and ratio of fat to lean body mass.
Some dietitians specialize as nutrition trainers for college athletes and
teams in the sport or sports in which they have the greatest personal inter-
est, such as swimming, wrestling, baseball, or cycling.
Many dietetic professionals working in the area of sports nutrition also
work as clinical dietitians for acute care facilities, as outpatient dietitians,
or in private practice in nutrition counseling. In addition, some dietitians
are employed to supervise the food production and training tables in col-
lege athletic residence halls. Some professional athletes seek information
on diet during the off-season to maintain body weight and strength. As
part of his or her daily routine, a sports nutritionist may counsel athletes
one on one regarding their food intake and appropriate nutrients or their
use of dietary supplemental aids.19 A nutritionist may also conduct group
classes on low-fat eating at a fitness center or work with a high school
team to suggest healthful choices for eating when the team travels. Sports
nutritionists also serve as part-time staff at health clubs and are available
to answer questions members may ask on nutrition or to conduct classes
on eating for competition and good health.
An additional career for some dietitians with experience in sports nutri-
tion and fitness has emerged in writing and developing nutrition educa-
tion materials appropriate for athletes of all ages. Other dietitians enjoy
speaking and/or writing for the media and consultative arrangements with
any number of organizations. Another career option that is growing ema-
nates from the proliferation of gymnasiums and physical fitness centers
for young children and adolescents. Although these gyms and centers
were started for tumbling and gymnastic opportunities, there is a need
for expertise in nutrition in these settings, especially combined with prin-
ciples of child development. Parents and consumers are welcoming the
dietitian’s expertise related to treatment of obesity, weight maintenance,
 The Dietitian in Health and W e l l n e s s P r o g r a m s      165

and disordered eating patterns in young children and adolescents. In some

instances, entrepreneurial dietitians are developing centers and mobile
units that go to elementary schools or other sites for demonstrations
of appropriate physical activity and the benefits of good food choices
and nutrition. Last but not least are the opportunities for “coaching”/
counseling family sports enthusiasts which include marathon and other
competitive events for the entire family.
Knowledge of exercise physiology through course work in exercise sci-
ence is essential if the sports nutritionist combines nutrition and exercise
in work with clients. Many dietetic professionals work to enhance their
education and expertise by entering graduate programs in exercise physi-
ology, counseling, psychology, or business administration. In addition,
although few college or university programs in sports nutrition currently
exist, many graduate students choose to conduct research for their thesis
or dissertation on a topic directly related to sports nutrition. By acquiring
a strong foundation in foods and normal and clinical nutrition with study
in a related area, the dietetic student can better prepare him or herself for
practice in sports nutrition.
A list of roles and responsibilities for the sports dietitian is found in the
position paper: “Position of the American Dietetic Association, Dietitians
of Canada, and the American College of Sports Medicine.”20

Cardiovascular Nutrition
With the abundance of continuing research in the area of diet and heart
disease as well as the fact that heart disease remains the number one cause
of death for Americans, careers in cardiovascular nutrition offer many
options. Most acute-care facilities whose services include open-heart
surgery have cardiac rehabilitation programs in place. These typically
include inpatient and outpatient components, both of which offer nutri-
tion counseling and education as part of the program. Cardiac rehabilita-
tion programs include multidisciplinary teams who deal with all aspects
of risk factor reduction, as well as education of the patient and family.
Team members may include a medical director, cardiac rehabilitation
nurse clinicians, exercise therapist, social worker, occupational therapist,
and a dietitian/nutritionist. Education of the patient and family is often
conducted in a variety of ways, from individual instruction to group or
online classes. The dietitian may also design and conduct classes on low-
fat cooking and other food preparation techniques.
166    C areer C hoices

Dietitians who specialize in cardiovascular nutrition may be employed

by lipid research clinics. These professionals are responsible for teaching
clinic patients how to change their eating habits to lower total fat and
saturated fat or to comply with a research feeding protocol. In this setting
as at a university, they may conduct research on the latest cardiology/
nutrition methodologies. Opportunities also exist with pharmaceutical
companies as sales representatives or in the public relations departments
of large food companies that market products to patients with cardiovas-
cular disease and their families.

Wellness and Health Promotion

The opportunities for dietitians in wellness and health promotion are
numerous and diverse. Dietitians who specialize in wellness may have a pri-
vate practice or consulting business and negotiate contracts with industry,
corporations, or health clubs. Others are employed by medical centers or
corporations to manage their on-site-wellness and health promotion pro-
grams, which may include conducting classes for employees, developing
incentives to foster a greater interest in exercise and nutrition, and increas-
ing productivity by helping to reduce employee illness. Because nutrition
is part of wellness, dietitians specializing in wellness and health promotion
may also be involved inn programs on smoking cessation, meditation and
yoga, stress management, exercise, back safety, and employee relations.
Corporations and large institutions initially began providing work-
site wellness programs for their employees because research and reports
showed that these programs improved employee health, increased pro-
ductivity, and decreased absenteeism and lost work days due to illness.
As these programs developed and increased in number across the country
in businesses of all sizes, data began to accumulate on the economic ben-
efits of work-site wellness programs. With healthcare costs soaring and
major changes occurring in healthcare and insurance coverage, employers
were eager to explore wellness and health promotion programs that would
save the corporation money. The common method for defining economic
benefits is through cost-benefit ratios in which the cost is the actual dollar
cost of providing the program, and benefits are expressed in dollars saved
from reduced absenteeism, disability expenses, and medical costs.
The ability to work as a facilitator and to conduct classes in a group set-
ting is an important characteristic of the successful wellness professional.
 The Dietitian in Health and W e l l n e s s P r o g r a m s      167

Counseling skills are also necessary because dealing with high-risk persons
may be a regular aspect of the job. In addition, the dietitian must be pre-
pared to analyze and evaluate enormous amounts of information available
to employees and clients through media routes. This counseling may take
place in groups, individually, at health fairs, over the telephone, or via
computers.
Wellness and fitness programs are also emerging for increasing num-
bers in the aging and retired population as well as the younger employed
groups. Research indicates that even though aging is inevitable, biologic
aging can be delayed through appropriate nutrition and exercise.21 As the
number of senior citizens increases, this provides another career oppor-
tunity for dietitians specializing in health promotion as senior citizens
strive to maximize independence and well-being. Programs to improve
fitness and the quality of life and encourage wellness in this age group
including nutrition, exercise, and lifestyle changes are developing. As
most of these programs are built around a “social” model rather than a
“medical” model, other professionals and non-professionals are moving
to secure positions in these areas. This means that dietitian nutritionists
must be proactive in promoting the unique and appropriate expertise of
the dietetic professionals.
Several national organizations provide excellent and accurate informa-
tion for dietitians seeking up-to-date knowledge on wellness and health
promotion programs and concepts. In addition, all have information
on the Internet. The major organizations with this information are the
following:
• The Academy of Nutrition and Dietetics (www.eatright.org)
• International Food Information Council (www.ific.org)
• National Institutes of Health (www.nih.gov)
• Centers for Disease Control and Prevention (www.cdc.gov)
• American College of Sports Medicine (www.ascm.org)
• American Alliance on Health, Physical Education, Recreation, and
Dance (www.aahperd.org)
• Food and Nutrition Information Center (www.fnic.nal.usda.gov)
• National Administration on Aging (www.aoa.acl.gov)
• American Association of Retired Persons (www.aarp.org)
• Center for Nutrition Policy and Promotion (www.cnpp.usda.gov)
• American Public Health Association (www.apha.org)
168    C areer C hoices

The Internet also offers the opportunity and challenge for the indi-
vidual dietitian nutritionist to develop websites and disseminate nutrition
and fitness messages by this means.

Disordered Eating
Dietitians who specialize in disordered eating work in a variety of settings,
including residential treatment centers, hospitals (both medical and psy-
chiatric), outpatient clinics, managed care organizations, university health
centers, and private practice. The specialty of disordered or problematic
eating encompasses several areas in which nutritional, physical, and psy-
chological issues are intertwined with eating behavior, such as obesity,
chronic dieting, and binge eating disorder. Complications of these disor-
ders are potentially life threatening. Many have their origin or manifesta-
tion in childhood or adolescence. Although most of these disorders affect
adolescent females, there are reports of similar behavior in males. Effective
treatment of disordered eating requires knowledge and skill in counsel-
ing, cognitive behavioral therapy, family systems theory addiction, and
pharmacology.22
Because of the biopsychological nature of disordered eating, the role of
the dietitian on the treatment team is vital. The dietitian educates the cli-
ent about food, physical activity, and body shape and size, and guides his
or her in developing a sound eating style and physical activity pattern. Cli-
ents may share their thoughts and feeling about food, weight, and physical
activity with the dietitian. They may also share life situations and events
that are stressful for them, such as job change, marital problems, school
problem, relationships, and burnout. The dietitian helps clients identify
how stress affects their eating style and how they feel about food, their
body size and shape, and physical activity. Ongoing communication with
the treatment team therapist, psychiatrist, and physician is essential so
that the dietitian can discern which issues are nutrition-related and which
are psychological or medical. It takes years of experience for the dietitian
to most effectively complement his or her skills and expertise with other
members of the team.
Dietitians working in programs to treat disordered eating benefit from
regular supervision from a mental health professional who specializes in
problematic eating. This relationship provides a forum for discussion of
specific cases, as well as helps to clarify which issues are appropriately
addressed in nutrition therapy versus psychotherapy. Furthermore, many
 S u m m a r y      169

dietitians seek continuing education in areas such as women’s issues,

cognitive behavioral therapy, family counseling, psychotherapeutic
counseling skills, and psychopharmacology. The intention is to sharpen
counseling skills and enhance the understanding of sociological and psy-
chological aspects of disordered eating while consistently staying within
the scope of practice of the dietetic professional, adhering to the stan-
dards of practice and professional performance and the Academy’s code
of ethics.23,24

P RACT IC E G R O U P S
Dietitians in business typically join the Dietitians in Business and
Communications practice group, the Management in Food and
Nutrition Systems practice group, the Food and Culinary Profession-
als practice group, and the Nutrition Entrepreneurs practice group. By
joining one or more of the groups, members are able to benefit from
networking, mentoring, information exchange, professional enhance-
ment, and leadership opportunities. The Academy practice groups
have individual websites and offer their members continuing educa-
tion programs, periodic newsletters, forums for exploring practice
issues, and innovative products and services. In addition, the Academy
code of ethics, appropriate standards of practice, and standards of pro-
fessional performance provide guidance and information about prac-
tice content, ethics, and what is expected of dietetic professionals in
these areas of practice.25–27 Dietitians in health and wellness programs
have a number of choices among the various clinical groups, with
the Sports, Cardiovascular, and Wellness Nutrition group likely the
primary choice. Others are Behavioral Health Nutrition and Weight
Management. Standards of practice and professional performance are
available for these areas as well.28–32

S UMMARY
The dietitian in business and communications often deals with the public
in visible and varied ways. The opportunities in these areas continually
expand as consumers, employers, and government authorities become
increasingly aware of the health benefits of good food choices and seek
valid information.
170    C areer C hoices

Dietitians with expertise in worksite wellness, sports and cardiovascular

nutrition, and disordered eating are increasingly in demand in nontradi-
tional settings. They must be creative, proactive, and adept in the promo-
tion of healthy eating behaviors and the unique expertise of the dietitian
nutritionist. In addition, nutrition information and education must be
presented in a manner that is directly usable by consumers. The dieti-
tian nutritionist must be able to translate scientific information into user-
friendly terms that distinguish between fact and fiction for consumers.

D E F INI T I O N S

Anorexia nervosa. An eating disorder characterized by a preoccupation

with dieting and thinness that leads to excessive weight loss.
Bulimia nervosa. An eating disorder involving frequent episodes of
binge eating followed by purging, also leading to excessive weight loss.
Cardiovascular nutrition. Application of medical nutrition therapy
for those with heart and blood vessel conditions or to prevent the
diseases.
Disordered eating. Abnormal eating patterns.
Health promotion. Education and preventive measures directed toward
healthy populations to foster wellness and prevention of disease.
Networking. Activities directed toward making connections with others
through varied contacts.
Sports nutrition. The area of nutrition specific to the needs of those who
participate in sports activities.
Wellness. State of optimal health and the absence of disease.

RE F E RENC E S
1. Simopoulos, A. “A Declaration of Olympia on Nutrition and Fitness.” Nutr Today
3 (1996): 250–252.
2. Rogers, D. “Compensation and Benefits Survey 2015,” J Acad Nutr Diet 116,
no. 3 (2016): 370–388.
3. Food Marketing Institute. “Trends in the United States: Consumer Attitudes and
the Supermarket.” www.fmi.org
4. Kapica, C, and J.O.S. Maillet. “A Business Rotation for Dietitians—An Impera-
tive in the New Millennium.” J Am Diet Assoc 102 (2002): 1220.
 R e f e r e n c e s      171

5. Indorato, D.A. “Innovative Services by and for the Dietitian.” Today’s Dietitian 3
(2001): 16–19.
6. Eliot, K.A., and K.M. Kolasa. “The Value in Interprofessional, Collaborative-
ready nutrition, and Dietetics practitioners.” J Acad Nutr Diet 115, no. 10 (2015):
1578–1588.
7. DiMaria-Ghalili, R.A., J.M. Murtallo, B.W. Tobin, L. Hark, L. Van Horn, and
C.A. Palmer. “Challenges and Opportunities for Nutrition Education and Train-
ing in the Health Care Professions: Intraprofessional and Interprofessional Call to
Action.” Am J Clin Nutr 99, suppl 5 (2014): 1184S–1193S.
8. Institute of Medicine. Building Health Workforce Capacity through Community-
based Health Professional Education. Workshop Summary. (Washington, DC:
The National Academies Press: October 3, 2014). www.iom.edu/reports/2014/
BuildingHealthWorkforceCapaity. (4/28/2016).
9. Academy of Nutrition and Dietetics, www.eatrightpro.org/public/page
10. Lipscomb, R., and S. An. “Mentoring 101: Building a Mentoring Relationship.”
J Acad Nutr Diet 113, no. 5 (2013): S29–S31.
11. Peregrin, T. “Mentoring Can Be An Effective Professional Development Experi-
ence to Enhance or Expand Your Career.” J Acad Nutr Diet 113, no. 5 (2013):
S42–S47.
12. See Note 6.
13. Pangan, T, and C. Bedner. “Dietitian Business Websites: A survey of Their Profit-
ability and How You Can Make Yours Profitable. J Am Diet Assoc 102 (2002):
399–402.
14. Golson, S.K. “Make Time for Daily Physical Activity.” J Am Diet Assoc 109
(2009): 18.
15. National Center for Health Statistics. “Data 1997–2010.” www.cdc.gov
16. Centers for Disease Control and Prevention. “Overweight among Children and
Adolescents, 16–19 Years of Age, by Selected Characteristics. U.S. 963–65 through
2005–2006.” www.cdc.gov
17. Nutrition and Athletic Performance for Adults. “Position of the Academy of
Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports
Medicine: Nutrition and Athletic Performance.” J Am Diet Assoc 116 (2016):
509–527.
18. Clark, N. “Identifying the Educational Needs of Aspiring Sports Nutritionists.”
J Am Diet Assoc 100 (2000): 1522–1524.
19. Shattuck, D. “Sports Nutritionists Feel the Competitive Edge.” J Am Diet Assoc
101 (2001): 517–518.
20. See Note 17.
21. Etgen, T., D. Sander, U. Huntgeburth, H. Pappas, H. Fasti, and H. Bickel.
“Physical Activity and Incident Cognitive Impairment in Elderly Persons.”
Arch Intern Med 170 (2010): 186–193.
22. Nutrition Intervention in the Treatment of Eating Disorders. Position Paper.
J Am Diet Assoc 2011;111:1236–1241.
172    C areer C hoices

23. Tholking, M.M., A.C. Mellowsprings, S.G. Eberle, R.P. Lamb, E.S. Myers, C.S.
Scribner, R.F. Sloan, et al. “American Dietetic Association: Standards of Practice
and Standards of Professional Performance for Registered (Competent, Proficient,
and Expert) in Disordered Eating Disorders (DE and Ed).” J Am Diet Assoc 111
(2011): 1241–1249.
24. American Dietetic Association/Commission on Dietetic Registration. “Code of
Ethics for the Profession of Dietetics and Process for Consideration of Ethics
Issues.” J Am Diet Assoc 109 (2009): 1461–1467.
25. See Note 24.
26. Academy of Nutrition and Dietetics Quality Management Committee and Scope
of Practice Subcommittee of the Quality Management Committee. “Revised 2012
Standards of Practice in Nutrition Care and Standards of Professional Performance
for Registered Dietitians.” J Acad Nutr Diet 113, no. 6 (2013): S29–S45.
27. Academy of Nutrition and Dietetics Quality Management Committee and Scope
of Practice Subcommittee of the Quality Management Committee. “Revised 2012
Standards of Practice in Nutrition Care and Standards of Professional Performance
for Dietetic Technicians, Registered.” J Acad Nutr Diet 113 (2013): S56–S71.
28. Academy of Nutrition and Dietetics Quality Management Committee and
Scope of Practice Subcommittee of the Quality Management Committee. “Scope
of Practice for the Registered Dietitian.” J Acad Nutr Diet 113, no. 6 (2013):
S17–S28.
29. Academy of Nutrition and Dietetics Quality Management Committee and Scope
of Practice Subcommittee of the Quality Management Committee. “Scope of
Practice for the Dietetic Technician, Registered.” J Acad Nutr Diet 113, no. 6
(2013): S46–S55.
30. Steinmuller, P.L., L.J. Kruskall, C.A. Karpinski, M.M. Manore, M.A. Macedonia,
N.L. Meyer. “Academy of Nutrition and Dietetics. Revised 2014 Standards of
Practice and Standards of Professional Performance for Registered Dietitian Nutri-
tionists (Competent, Proficient, and Expert) in Sports Nutrition and Dietetics.”
J Acad Nutr Diet 114 (2014): 631–641.
31. Emerson, M.P., P. Kerr, M.D.C. Soler, T.A. Girard, R. Hofflinger, E. Pritchett,
and M. Otto. “American Dietetic Association Standards of Practice and Standards
of Professional Performance for Registered Dietitians (Generalist, Specialty, and
Advanced) in Behavioral Health Care.” J Am Diet Assoc 106 (2006): 608–613.
32. Jortberg, B., F. Myers, L. Gigliotti, B.J. Ivens, M. Lebre, S.B. March, I. Nogueira,
et al. “Academy of Nutrition and Dietetics: Standards of Practice and Standards
of Professional Performance for Registered Dietitian Nutritionists (Competent,
Proficient, and Expert) in Adult Weight Management.” J Acad Nutr Diet 115,
no. 4 (2015): 609–618.
 12

CHAPTER
The Dietitian as
Manager and Leader
“Skills such as team building, delegation, communication,
negotiation, and self-management are fundamental to high
performance. Fortunately, these can be learned and enhanced
through continuing education and training.”1

OUTLINE
• Learning Objectives
• Introduction
• Leadership
• Attaining Leadership Skills
• Leadership Development
• Leadership for Quality and Efficiency
• Management Functions
• Skills and Abilities of Managers
• Human Relations Skills
• Technical Skills
• Conceptual Skills
• Common Competencies for Healthcare Managers
• Management in Practice
• Summary
• Definitions
• References

173
174    T he D ietitian as M anager   and L eader

LEARNING OBJECTIVES
The student will be able to:
1. Become aware of the characteristics of leaders and managers.
2. Become familiar with how leadership skill is attained.
3. Understand how leadership skills contribute to quality and
efficiency in an organization.
4. Understand the interrelationship between technical, human
relations, and conceptual skills in management.
5. Explain the importance of management skill in clinical and
community practice.

IN T RO D UC TI O N
Management is often regarded as the responsibilities and challenges that
have to do with being in charge or being the boss of a department, and
therefore, the entry-level dietitian often believes that he or she does not
need to be concerned with knowing how to manage. In reality, all dietitians,
regardless of their job title or job responsibilities, perform many managerial
functions and need to develop managerial skills. The clinical dietitian, the
food service manager, the nutritionist in community nutrition programs,
the educator, the private practitioner, the dietitian in business and industry,
and healthcare administrators all perform management functions. Among
these functions are setting goals, evaluating outcomes, managing resources,
integrating and coordinating personnel activities, training personnel and
allied professionals, communicating, and promoting quality control.
Management and leadership have many overlapping characteristics and
have been described in several ways by leaders in the management field. A
simplified way to view them is to think of management as the activities that
go into making a department or an institution run—doing things—and lead-
ership as the qualities a person (a manager) needs to possess in order to make
things go right. We could say “things are managed and people are led.”2
In this chapter, we discuss leadership and management separately, but
because many functions are complementary, both need to be developed
together. A professional cannot be truly successful unless characteristics
of both leadership and management skills are evident in the workplace.
 L e a d e r s h ip      175

LE AD ERS H I P
Frank3 describes leadership as “the art of bringing together people with
diverse talents, interests, ideas, and backgrounds to voluntarily participate
in a shared approach toward common or compatible goals.” This defini-
tion makes the distinction between accomplishing tasks and inspiring
people to willingly perform those tasks. Leadership consists of the traits
that accompany good management skills, and for someone to be success-
ful, the two functions need to go together.
Leaders and thinkers, including Peter Drucker, who is recognized as an
authority on leadership, consider that three important characteristics for
successful leadership are:4
1. Thinking through the mission of the organization, defining it,
and establishing it clearly and visibly. The leader sets the goals and
priorities and maintains the standards.
2. Viewing leadership as a responsibility and not a rank or a privilege.
Effective leaders are rarely permissive, but when things go wrong,
they do not blame others. They encourage and help develop strong
associates.
3. Earning trust in order to have followers. To trust a leader, it is not
necessary to like or to agree; rather trust is the conviction that the
leader means what he or she says and has integrity.

Attaining Leadership Skills

A question often debated is whether people are born leaders or whether
they develop leadership skills and thereby become leaders. In support of
the view that leadership skills can be acquired, several actions that make
for leadership development are the following:5
• Well-defined values
• Commitment to quality
• Responsive to the consumer, client, and the public
• Stimulating a nurturing work environment
• Creativity and innovation
• Open lines of communication and shared information
• Inclusive process for decision making
• Planning and fostering meaningful change to achieve goals and
improved performance
176    T he D ietitian as M anager   and L eader

Leadership Development
The American Dietetic Association (ADA) developed the Institute for
Leadership in 2003.6 At a yearly event, members received training in lead-
ership, dialogue, and sharing perspectives through private, personalized
agendas. Interactive breakout sessions and workshops as well as structured
networking events were a part of the annual sessions. A certificate of train-
ing is offered at the conclusion of each annual forum. The institute was
discontinued in 2011. Now, however, the Academy offers an online lead-
ership certificate program, offering two levels of leadership training. The
level 2 program, introduced in 2014, offers four modules of learning.7
In reviewing traditional leadership theory, it has been suggested that
more information is needed about the way dietitians develop as leaders.8
Consistent with earlier theories about the way humans grow through
stages of mental development and become leaders in predictable ways, a
newer theory is that of constructive development, described as an alterna-
tive approach to leadership as a way of growing in stages.9 Studies of lead-
ers across industries and organizational levels show that 5 percent of all
leaders are at a stage where they are focused on self and seldom welcome
feedback; 80 percent are in a middle stage of avoiding conflict, becoming
a member of a group, having a strong belief system, and being result and
goal oriented, while 15 percent are at the highest stage during which there
is systematic problem solving, seeking feedback, realizing the complexity
of the environment, and having a deep appreciation of others. When a
survey of Academy leaders was conducted in 2006, most were shown to be
in the high part of the medium range group. It is suggested that by becom-
ing aware of their own stage, dietitians can develop further in their lead-
ership ability by seeking out a supportive environment, perhaps through
advanced study, mentors, supportive coworkers, networking, and others.
Another aspect of leadership is the need for what has become known as
emotional intelligence, along with intellectual and technical skills. The most
effective leader has a high degree of emotional intelligence. This is defined
as self-awareness, self-regulation, motivation, empathy, and social skills.
These skills can be learned through experience and internal commitment.10

Leadership for Quality and Efficiency

Leadership development programs, increasingly conducted in hospitals
and other healthcare organizations, improve both the quality and efficiency
 M a n a g e m e n t F u n c t i o n s      177

of care. Opportunities found to result from four qualitative studies of

leadership development are the following:11
• Improve the quality of the workforce
• Increase efficiency in the organization’s education and development
activities
• Reduce turnover and related expenses
• Focus organizational attention on specific priorities

MANAG E M E N T F U N C TI O N S
Management is usually defined in terms of the traditional functions
described by management experts. Although the number of functions
varies according to the way in which they are presented, the following six
are universally accepted:12
1. Planning. Planning is the activity of setting goals and objectives.
The extent of the planning, from setting broad, long-range goals
for a large organization to planning shorter term goals, will usu-
ally be determined by where persons are in the organizational
hierarchy.
2. Organizing. Organizing is the reflection of how the organization
accomplishes its goals and objectives. The tasks to be performed,
assignment of tasks, allocation of resources, and flow of authority
and communication are established.
3. Coordinating. Coordinating involves activities that lead to the
efficient use of resources to attain the goals and objectives.
4. Staffing. Staffing means determining human resource needs, then
recruiting, selecting, hiring, and training the necessary staff.
5. Directing. Directing (or leading) refers to those activities that
enable accomplishment of the organization goals, that commu-
nicate those goals, and that create an atmosphere that encourages
commitment and desired performance.
6. Controlling. Controlling occurs when performance is assessed
against standards that have been translated from the goals and
objectives and corrective measures applied as needed.
Dietitians who are experienced in management areas of practice are
aware that overarching all those activities is the need to communicate
178    T he D ietitian as M anager   and L eader

effectively—realizing that this is always a two-way process—and to

develop the ability to work in productive ways with others in the orga-
nization at all levels. Setting goals and standards, incorporating as much
technology as feasible and needed, and being financially astute are all criti-
cal to successful practice.

SK ILLS AND A B I L I TI E S O F MA N A GER S

Three fundamental sets of skills needed by managers at various levels to
function effectively are human relations skills, technical skills, and con-
ceptual skills (Figure 12-1). Earlier traditional views of management
held that top managers primarily needed human relations and conceptual
skills, while the more contemporary view is that technical skills as well are
increasingly important for the top manager, especially in small organiza-
tions and in those with flattened and decentralized organizational pat-
terns. What is immediately apparent from Figure 12-1 is that all levels of
managers and even employees need to possess equal amounts of human

Contemporary Cross Section of Management Skills

Skills Needed

Conceptual
Top Managers
Skill

Middle Managers

Human Relations
Skill
Supervisors

Technical
Employees
Skill

FIGURE 12-1.  Balancing Management and Leadership.

Reproduced from Woods RH, King JZ. Leadership and Management in the Hospitality
Industry. 3rd ed. Lansing, MI. American Hotel and Lodging Educational Institute, 2010, p. 56.
 Skills and Abilities of M a n a g e r s      179

relations skills that are predominant among the three sets of skills. The
need for technical skills increases with lesser overall managerial responsi-
bilities, while the higher conceptual skills decrease. The use of particular
skills, such as the need to hire and train new employees or to engage in
long-range strategic planning, will vary from day to day with changes in
the work environment. The specific activities practiced in these three skill
areas are discussed in the following sections.

Human Relations Skills

Interpersonal Relationships
Interpersonal skills are always rated highly when management skills are
described or studied. The ability to work with others toward common
goals is the number one factor denoting success among healthcare depart-
mental managers.13 Human factors may also influence how this is done
successfully; for instance, regulatory requirements such as the Family
Medical Leave Act (FMLA) provide job security for workers but may
also present labor coverage problems for the manager. Changing job
assignments, paying overtime, or bringing additional workers can affect
resources and make the manager’s job more difficult.
Generational diversity, or the involvement of several distinct genera-
tions in the workplace, presents another aspect of achieving successful
working relationships.14 Different generations of workers are assumed to
have different loyalties and expectations resulting in the need for open-
mindedness, effective communication, and respect for others on the part
of the manager. Dealing with language skills, literacy, and other sociocul-
tural issues can impact relationships.15

Communication
Communication at both individual and group levels ensures that informa-
tion flow reaches all those in an organization. Keeping others informed,
seeking input from others in the organization, and rewarding staff for
good work and successes lead to satisfaction and cooperation. Staff mem-
bers are excellent sources of information, ideas, and solutions, and should
always be involved when new programs or procedures are being planned.
The manager needs to receive information from as many sources as pos-
sible and no one in the organization should be overlooked for this input.
180    T he D ietitian as M anager   and L eader

The skillful communicator is often one who is also a transformational

leader. Such a manager stimulates innovative ways of thinking, can achieve
greater performance on the part of those managed and has vision that can
lead to organizational change when needed. By communicating openly
and directly with all members of a team, others are motivated to share in
commitment to the needs of the group as a whole.16

Coaching and Mentoring

Most dietitians will be, at some time in their career, in the position of
assisting and supporting a coworker or employee as they learn a new job or
develop new skills, and thus will become a coach or mentor. A mentor is
described as a person who teaches through verbal instruction, demonstra-
tion of particular activities or skills, and role modeling. Coaching is similar
in that it is used to inspire and motivate as well as teach. The successful
dietitian may function in both these roles in order to accomplish needed
tasks. Staff personnel perform at different levels and learn in different ways.
It is the enterprising coach or mentor who is able to adapt actions to moti-
vate, encourage, and support staff, thereby creating a productive and har-
monious team. Mentoring is discussed in greater detail later in this text.

Managing Conflict
Conflict occurs in any organization and wherever people work in groups.
Conflict may arise from competition for resources, overlapping respon-
sibilities, status struggles, poor communications, inadequate training, or
differences in values and beliefs. The dietitian who recognizes causes of
conflict and assists in taking steps to overcome the differences will be
looked to as a manager and leader. When dealt with quickly and construc-
tively, conflict can be a way of improving performance.17

Networking
Networking within an organization leads to both communication and coop-
eration. People form networks for sharing social and business information and
to increase professional competence. Sharing information is vital in any orga-
nization, and the manager will seek opportunities to network both within and
beyond the work unit and will encourage others to also network. Networking
with other professionals through the dietetic practice groups of the Academy
 Skills and Abilities of M a n a g e r s      181

and other groups can lead to personal growth, a greater understanding of

practice requirements, and enhanced performance in every area of practice.

Technical Skills
Technical skills are those that require a specialized knowledge of techniques,
methods, procedures, and processes that accomplish the work of an orga-
nization. Knowing how to access and use technology for communications
is a must for all professionals in the modern workplace. Online informa-
tion is rapidly becoming the means by which professionals remain current.
Conferences, workshops, meetings, and classes are offered online, by tele-
conference, or by similar means using newer technology. Not only is com-
munications technology of increasing importance, but technology related
to better and faster job performance benefits both individuals and an orga-
nization. To the extent that professionals become experts in the technology
needed for their jobs, they will also become mentors and coaches for others.
Technology is used in food production and food service and in all areas
of clinical practice. Computerized work schedules, purchasing and inven-
tory control, employee records, and production schedules are examples.
These activities point to the need for continual training for all staff and a
strong working knowledge of the use of technical equipment of all kinds.

Job Skills
The manager has knowledge of what is required of the workforce to per-
form in an organization but does not generally perform the work except
on an as-needed basis. However, this knowledge allows the manager to
supervise those with the specific skills to fulfill the job requirements. The
need to have job know-how is essential to assess performance, meet goals,
and ensure quality outputs.

Resource Management
Financial management, including cost controls and budget management,
comes to mind first when the management of resources is described as a
management function. Resources, however, can also refer to job-related
supplies and equipment, staff assistance, and even time and energy. Every
dietitian and dietetic technician carries certain responsibilities for manag-
ing resources and also may be involved in budgeting and long-range plan-
ning for the use of resources.
182    T he D ietitian as M anager   and L eader

The importance of including financial management in dietetics pro-

grams is emphasized by dietetics program directors. In one survey, educa-
tors agreed or strongly agreed with the statement, “Entry-level registered
dietitians need to be trained in financial management concepts as well as
clinical concepts in order to be competent practitioners.”18
Benchmarking is a process by which the manager can measure the effi-
ciency of work, the products produced, and the services for comparison
and improvement.19 This process is used in both healthcare and food
services. Performance measures that include financial management, cus-
tomer service, human resources, and operational activities are evaluated in
the benchmarking process. Measurements used provide information that
can be compared and used for improvement.

Training and Staff Development

The responsibility for hiring and training personnel is primarily that of
upper-level management; however, all professionals will at times help train
and develop new employees or other professionals. The team concept often
followed in healthcare institutions, food service, and hospitality requires that
all members of a team function fully and efficiently. Further, team mem-
bers must know their job-related roles as well as their expected roles as a
team member. Efficiency evolves from knowledge and practice and must be
encouraged and assisted by those already experienced within an organization.

Team Building
A team functions in ways that support individual efforts and leads to
greater productivity. Teams vary in number, may be formal or informal,
and may form in a variety of ways. For instance, a team may be formed
within a department or from several departments or disciplines to accom-
plish more than can be accomplished by individuals. Teams may also be
temporary or permanent.
The value of teams lies in sharing knowledge and working toward common
goals using the experience and expertise of several people in decision making
and problem solving. The manager encourages teams and helps make them
effective by arranging for persons to participate and providing for training of
team members as needed. Teams function best when they are empowered
with authority or legal power to reach a level of self-management.20
 Skills and Abilities of M a n a g e r s      183

Work groups of persons working together for a common purpose are

often formed. As with teams, they may be formally constituted or may
function in an informal way such as a gathering of people to solve daily
problems. The group leader has several tasks, which include understand-
ing the internal workings of the group, planning ahead and being proac-
tive, and managing interpersonal relations for group cohesion.

Quality Management
Quality is defined as meeting standards and expectations, sometimes in
terms of high quality or above a norm or average. The Quality Man-
agement Committee of the Academy provides direction for monitoring,
developing, approving, evaluating, and maintaining quality management
in dietetics. The team members of the group interact with the Scope of
Practice Framework committee, the Evidence-Based practice committee,
and the Nutrition Care Process committee. Quality assurance in practice
results through the coordinated efforts of these groups.
Dietitians in all areas of practice can monitor their own quality of work
through the Code of Ethics for the Profession of Dietetics, the standards of
professional performance, and the professional development portfolio.
The outcome is competent practice and a basis for quality improvement.
In the 2010 Commission on Dietetic Registration practice audit,21
58  percent of entry-level dietitians indicated they perform quality
assurance or performance management.
Every institution, department, business, or professional association
strives to produce quality goods, services, and people. Rather than rely-
ing on subjective methods to detect quality, most organizations establish
performance measures by which they assess and ensure continuous qual-
ity. In dietetics, performance standards are in effect and are described in
other sections of this book. Food production managers use performance
measures to ensure the quality of the food service. Patient satisfaction sur-
veys are used for ongoing assessment of the services received. Clinical out-
comes can be measured for quality through specific established indicators.
The community nutritionist measures quality by satisfactory outcomes of
persons receiving instruction and care. The educator measures outcomes
and the quality of the education by how his or her students perform.
Quality control is a part of every dietitian’s job responsibility and is a
managerial function.
184    T he D ietitian as M anager   and L eader

Conceptual Skills
The manager performs a certain number of activities based on visualiz-
ing the larger picture beyond the technical aspects of his or her position.
The ability to realistically anticipate the future, to plan and set goals, to
provide direction in an organization, and to model professional behavior
constitutes conceptual ability or skill.

Strategic Planning and Goal Setting

In general, strategic planning occurs at the upper levels of management
as it requires data gathering and analysis; development of strategies, goals,
and objectives; and implementation of action plans. However, profes-
sionals at all levels in an organization participate in data gathering and in
setting short- and long-term goals. They are a part of the planning process
to set direction and plans of action for the organization.
Some plans are general, such as the determination of values, mission,
and vision statements. Others are more detailed and may be developed at
the supervisory level. If operational plans are short range, they are usually
expected to occur within a year. Long-term plans extend beyond 1 year—
sometimes beyond 10 years. The food and nutrition professional often
contributes to both types of planning by conducting feasibility studies,
cost-effectiveness studies, and quality-control measures.

Ethical Conduct
In dietetics, the Code of Ethics for the Profession of Dietetics is the guiding
document to ethical practice. In any institution, the manager or leader
assists in developing organization practices and policies that promote ethi-
cal practice. Such practices are established in purchasing, financial man-
agement, patient care issues, and information provided by patients and
clients. The manager or leader sets the example for ethical behavior and
integrity built on openness and trust.

Managing Change
Change occurs when there is dissatisfaction with things as they are and
there is a desire to change them. Change may occur slowly or rapidly as in
the event of sudden or unplanned circumstances. The leader who welcomes
 Skills and Abilities of M a n a g e r s      185

change and uses it to motivate and improve a department will be the most
successful. When members of a unit work together to make changes, the
efforts are usually rewarded by acceptance of the new procedure by all
those affected. In contrast, if change is imposed by the leader without input
from the other members, there is often resistance and slow acceptance.
Dietitians who counsel clients to make changes do not always meet
with success. Time constraints and client expectations as well as moti-
vations that differ from those of the dietitian are factors in the change
process. Change models that take into consideration the complexities
of behavior and one’s approach to what it takes to help people change
are often helpful. One approach is the use of goal setting in a way that
the client being counseled is a part of the process and understands the
expected outcome.22
The first step in initiating change is identifying the problem. One or
more achievable goals for overcoming the problem are set next. In acting,
persons typically mobilize their personal and social resources and identify
barriers to reaching the goal. Self-monitoring and rewards provide addi-
tional motivation to attain the goal. The reward may be external, but an
effective internal reward is one such as learning that leads to sustained
performance and further goal setting.
Dietetics professionals constantly face change because of new develop-
ments in health care, organizational change, and shifts in management
with a new mission and vision goals. Even environmental and political
situations create change. When changes are viewed as opportunities, they
are more likely to lead to positive results. The creative manager or leader
helps create an atmosphere that welcomes and plans for this outcome.

Common Competencies for Healthcare Managers

The Healthcare Leadership Alliance is a consortium of six major pro-
fessional organizations.23 A study conducted by the alliance reported on
the following five competencies common among practicing healthcare
managers (Figure 12-2):
1. Communication and relationship management: The ability to com-
municate clearly and concisely with internal and external customers
and facilitate interactions with individuals and groups.
2. Leadership: The ability to inspire excellence, create and attain
shared vision, and manage change.
186    T he D ietitian as M anager   and L eader

Communication
and
Relationship
Management

Knowledge
of the
Professionalism
Healthcare
Environment

Business
Knowledge
and Skills

FIGURE 12-2.  The Healthcare Leadership Alliance Competency Model.

3. Professionalism: The ability to align personal and organizational

conduct with ethical and professional standards that include a
responsibility to the patient and community, a service orientation,
and a commitment to lifelong learning and improvement.
4. Knowledge of the healthcare environment: The demonstrated under-
standing of the healthcare system and the environment in which
healthcare managers and providers function.
5. Business skills and knowledge: The ability to apply business prin-
ciples, including systems thinking, in the healthcare environment.

MANAG E M E N T I N P R A C TI CE
Management of food and nutrition systems is a diverse, dynamic area
of practice that requires registered dietitian nutritionist (RDN) leaders
who are effective in the management of human, material, and finan-
cial resources. They also need to be visionary in navigating programs
 S u m m a r y      187

and services through ever changing times in health care and other busi-
ness. Public interest and healthier eating options are growing. This is in
response to the obesity incidence of the population and a general interest
in healthier lifestyles. Hospitals are being challenged to offer healthy food
options in employee and visitor dining rooms as well as for patients.24
Personnel issues are without doubt one of the most time-consuming
but critical parts of a manager’s job. Motivating and inspiring is a large
part of the job, which requires constant and effective communication,
feedback on performance, and a conscious focus on cultural issues. Like-
wise, reviewing and updating training methods and materials can be an
effective way of keeping personnel interested and motivated.
A focus on quality in every aspect of a food service system or clinical
unit is a must in order to ensure acceptance by patients and clients. Even
though quality is not easy to define, it is recognized—both when appar-
ent and when lacking. The astute manager continually monitors perfor-
mance of the unit by using customer surveys and informal feedback and
by soliciting employee input. He or she regularly reviews all standards of
ethical practice and ensures that they are fully understood and practiced
by all in the organization. Ethical practices at all levels in a department
create the environment in which an emphasis on quality is routine and
ongoing.
The effective manager uses all available resources for continual
improvement. Using the evidence-based library materials, networking
with others in a practice group, and mentoring students and interns help
keep the practitioner current. Further, the manager of the unit will ben-
efit by ensuring that others in the work unit have continued education
opportunities.
The management role is one that is multifaceted. It is one that requires
technical know-how but just as importantly, people skills, as has been
pointed out in the descriptions of managers’ multiple roles.

S UMMARY
Managers and leaders possess many characteristics that are similar, but
there are differences in roles and responsibilities. The skillful manager
possesses human, technical, and conceptual abilities that permit him or
her to accomplish work through coworkers and to attain goals. The leader
may perform some or all of these same functions but will also inspire,
188    T he D ietitian as M anager   and L eader

motivate, and create a sense of unity and purpose. The dietitian, regard-
less of the area of practice, must perform managerial functions such as
goal setting, communicating, team building, and managing resources.
Many critical functions in the workplace will also require the dietitian
to lead.

D E F INI T I O N S

Benchmarking. Comparing performance measures for the development

of better methods and procedures.
Coach. A person who guides, inspires, and motivates.
Leadership. The qualities that allow an individual to influence the
actions of others.
Mentor. A person who teaches and guides by instructing, demonstrat-
ing, encouraging, and role modeling.
Resource management. The handling of money, equipment and sup-
plies, or personnel essential to the administration of an organiza-
tional unit.
Strategic planning. Long-range planning that involves data gathering,
data analysis, development of goals and objectives, and action plans.

RE F E RENC E S
1. Covey, S.R. Principle-Centered Leadership. (New York: Simon and Schuster, 1990).
2. Canter, D.D., K.L. Sauer, and C.W. Shanklin. “Management Is a Multifaceted
Component Essential to the Skill Set of Successful Dietetics Practitioners.”
J Acad Nutr Diet 112, suppl. 2 (2012): S5.
3. Frank, G.C. Community Nutrition: Applying Epidemiology to Contemporary Practice.
(Sudbury, MA: Jones and Bartlett, 2008).
4. Drucker, P.F. Managing for the Future: The 1990s and Beyond. (New York: Ruman
Talley Books, Plume, 1992).
5. Cloud, H. In: M. Kaufman. Nutrition in Promoting the Public’s Health. Strategies,
Principles, and Practice. (Sudbury MA: Jones and Bartlett, 2007): 537–549.
6. Leadership Institute, 2012. www.eatright.org
7. Boyce, B. “Learning to Lead: Developing Dietetics Leaders.” J Acad Nutr Diet 114,
no. 5 (2014): 688–692.
8. Gregoire, M.B., and S.W. Arendt. “Leadership: Reflections over the Past 100 Years.”
J Am Diet Assoc 104 (2004): 395–403.
 R e f e r e n c e s      189

9. Hunter, A.M.B., N.M. Lewis, and P.K. Ritter-Gooder. “Constructive Develop-

mental Theory: An Alternative Approach to Leadership.” J Am Diet Assoc 111
(2011): 1804–1808.
10. Coleman, E. “What Makes a Leader?” Har Bus Rev (November–December 1998):
23–32.
11. McLearney, A.S. “Using Leadership Development Programs to Improve Quality
and Efficiency in Healthcare.” J Healthcare Management 53, no. 5 (2008):
319–331.
12. Gould, R.S., and D. Canter. “Management Matters.” J Am Diet Assoc 108 (2008):
1834–1836.
13. Canter, D., and M.F. Nettles. “Dietitians as Multidepartment Managers in Health
Care Settings.” J Am Diet Assoc 103 (2003): 237–240.
14. Brown, D. “Ways Dietitians of Different Generations Can Work Together.”
J Am Diet Assoc 103 (2003): 1461–1462.
15. “Practice Paper of the Academy of Nutrition and Dietetics: Principles of Produc-
tivity in Food and Nutrition Services: Applications in the 21st Century Healthcare
Reform Era.” J Acad Nutr Diet 115, no. 7 (2015): 1141–1147.
16. Curtis, E.L.K., and R. O’Connell. “Essential Leadership Skills for Motivating and
Developing Staff.” Nurs Manage 18 (2011): 32–35.
17. Bartosek, C.B. In: M. Kaufman. Nutrition in Promoting the Public Health:
Strategies, Principles, and Practice. (Sudbury, MA: Jones and Bartlett, 2007), 471.
18. McKnight, I.E.G., M.L. Dundas, and J.T. Girvan. “Dietetics Program Directors
Areas of Practice.” J Am Diet Assoc 102 (2002): 82–84.
19. Johnson, B.C., and J. Chambers. “Foodservice Benchmarking: Practices, Attitudes,
and Beliefs of Foodservice Directors.” J Am Diet Assoc 100 (2000): 175–180.
20. Weisberg, K. “Spirited Pioneer.” Foodservice Dir 5 (2007): 65–66.
21. Ward, B.D., C. Roger, R. Mueller, R. Touger-Decker, and K.L. Sauer. “Entry-
Level Dietetics Practice Today: Results from the 2010 Commission on Dietetic
Registration Entry-Level Dietetics Practice Audit.” J Am Diet Assoc 111 (2011):
914–941.
22. Cullen, K.W., T. Baranowski, and S.P. Smith. “Using Goal Setting as a Strategy for
Dietary Behavior Change.” J Am Diet Assoc 102 (2001): 562–565.
23. Steff, M.E. “Common Competencies for All Healthcare Managers: The Health-
care Leadership Alliance Model.” J Healthcare Management 53 (2008): 360–373.
24. See Note 15.
 13

CHAPTER
The Dietitian as Educator
“Continuing education within the workforce must be coupled
with lifelong learning to keep pace with advancements made
within healthcare and technology.”1

OUTLINE
• Learning Objectives
• Introduction
• Educational Activities of Dietitians
• Learning to Teach
• Career Opportunities in Education
• Elementary and Secondary Schools
• Colleges and Universities
• Medical and Dental Education
• Nursing and Allied Health Nutrition Education
• Industry-Based Education
• Work-Site Nutrition Education
• Educator Roles
• Mentor
• Coach
• Preceptor
• Counselor
• Communicator
• Types of Learning
• Service Learning
• Problem-Based Learning
• Project-Based Learning
• Adults as Learners

191
192    T he D ietitian as E ducator

• Teaching Groups and Teams

• Summary
• Definitions
• References

LEARNING OBJECTIVES
The student will be able to:
1. Discuss the steps involved in learning to teach.
2. Become familiar with career options in education.
3. Describe the mentor, coach, and preceptor role.
4. Explain how communication is a vital part of education.
5. Discuss learning styles of persons at differing age groups.
6. Give examples of a dietitian’s (in any area of practice)
educator role.

IN T RO D UC TI O N
Dietitians sometimes reveal that they chose dietetics as a career in part
because they did not view themselves as teachers. The reality, however, is that
all dietitians are educators, most frequently in locations other than the class-
room. The educational settings are as diverse as the careers in which dieti-
tians work; the learners are individuals and groups of all ages. For example,
the dietitian who works in clinical dietetics in a hospital or healthcare center
teaches patients, families, and allied health personnel. A dietitian in food
service management teaches and trains food service personnel and may teach
personnel in other departments. Dietitians in business or private practice
may teach patients, other personnel, and the public. In all areas of practice,
the dietitian may also teach dietetic interns and dietetic technician students.
The educator role is one of the most important a dietitian fulfills. Knowl-
edge of subject matter is attained by the professional through academic prepa-
ration in a degree program and practical experience in a supervised practice
program. Added to this knowledge is an understanding of how to teach effec-
tively and how people learn. Observation of other educators, continuing edu-
cation, and professional experience, as well as practice, lead to expertise as an
educator.
 Educational Activities of D i e t i t i a n s      193

Dietitians need to possess several skills related to teaching. These

include verbal and nonverbal communications, speaking to groups,
behavior modification and motivation, principles of learning, teaching
techniques, and knowledge about how to work with groups. These skills
can be learned and improved the more they are practiced.
Dietitians in education typically affiliate with one of the three follow-
ing dietetic practice groups: Nutrition Education for the Public, Nutrition
Educators of Health Professionals, or Dietetic Educators of Practitioners.

EDUCATIONAL ACTIVITIES OF DIETITIANS

The Commission on Dietetic Registration (CDR) periodically indicates
the educational activities performed by entry-level dietitians and dietetic
technicians.2 The activities are shown in Table 13-1.

Table 13-1.  % of Educational Activities Performed by Entry-Level

Dietitians and Dietetic Technicians
Activity RD Percent DTR Percent

Asses Assess learning needs of patients/clients, 90 73

employees, and students

Develop instructional materials for individuals and group 81 58

Teach classes or laboratories 48 38

Evaluate learner knowledge and performance 64 48

Supervise students or precept interns 55 32

Provide health-promotion or risk-reduction programs 21 12

to population groups

Distribute nutrition information through the media 17  6

Design individual courses or seminars for patients,  51

clients, employees, and students

Design group-related courses for educational institutions 16  0

Evaluate educational programs 23  0

Design services to meet nutrition-related needs of 19  0

population

This article was published in the Journal of the American Dietetic Association, 92(12), Roach, et al,
“Improving Dietitians’ Teaching Skills,” pp. 1749–1757, Copyright Elsevier (2001).
194    T he D ietitian as E ducator

LE ARNI NG TO TE A C H
Teaching skills are developed when the educator follows a process that
will result in an effective outcome; that is, the learner is a participant in
the process and acquires new knowledge. Depending on the type of teach-
ing session—formal as in a classroom or informal as in the workplace—
the process may involve a very structured plan that follows specific steps
or a more flexible plan with input from learners.
The steps in the process are the following:
1. The assessment of learner needs
2. The development of performance objectives
3. The instructional strategy including content and delivery method
4. Preparation of instructional materials
5. Evaluation or follow-up of the learning session
The steps may be shortened or compressed in informal teaching situa-
tions; nevertheless, thought should be given to each of the steps whether
in a one-on-one session or in group sessions. In the first step, the assess-
ment of learner needs is the basis for planning a teaching session. This
may be determined from practical experience and observation of job per-
formance, a change in organizational needs, a job change, or whether it
is new information or a reinforcement of the learner’s understanding of
information presented earlier. Having one or more objectives in mind
gives focus to the teaching session and provides a reference later as to the
effectiveness of the lesson.
The content of the lesson and the way the material is to be presented
require advance planning along with the determination of teaching aids
needed. The content and the way it is presented can vary widely, and the
instructor makes choices about both based on the size of the group, the
makeup of the group, and the needs of the group. An experienced teacher
knows the type of presentation that is most effective in certain situations
and uses this in planning the lesson.
The final step is to assess what the learner has learned and therefore the suc-
cess of the teaching session. This may occur at the time of a teaching session
or in follow-up sessions and may be by observation, questioning, or testing.
Online education is an increasingly popular method of presenting edu-
cational material, and it should be noted that the same process is followed
when designing this type of instruction.3
 C a r e e r O pp o r t u n i t i e s in E d u c a t i o n      195

Several observations that will assist the instructor in planning and con-
ducting learning sessions are the following:
1. Learners hear and process information in individual ways. Repeti-
tion and variety in presentation means better reception.
2. Introduce key points early in the session and repeat as necessary.
3. The learners’ previous knowledge influences what they learn in a
new situation.
4. Present new information in small amounts at a time. Illustrate new
concepts and facts with examples and easily understood terminol-
ogy related to the workplace or class subject.
5. Encourage active learning by participation of the learner. Encour-
age questions, give time for discussion, and give assignments for
future sessions or follow-up if applicable.

CAREER O P P O RTU N I TI E S I N EDUC AT I ON

While all dietitians do some teaching in whatever area of practice they are
employed, there is a diversity of career areas in education that dietitians
may pursue. These are discussed in the following sections.

Elementary and Secondary Schools

School-based nutrition education is incorporated into health and science
classes in primary, middle, and high schools. A dietitian who teaches at
these levels must meet state teacher training and certification require-
ments. Generally, those who teach grades K–12 have responsibilities that
extend well beyond food, nutrition, and health.
Some state departments of education have nutrition education and
training sections that often employ registered dietitians who have
advanced degrees in education. Such positions include creating curricula
to integrate nutrition with other subjects, developing teaching materials,
identifying instructional resources, and training teachers to deliver nutri-
tion education.
Job opportunities for dietitians in child nutrition programs affect dieti-
tians from the lunchroom to the classroom. School-based health centers—
rapidly growing models for the delivery of comprehensive primary health
care in elementary, middle, and high schools—afford another opportu-
nity for dietitians interested in working with children and adolescents.4
196    T he D ietitian as E ducator

There is also a need in these school-based centers for dietitians certified by

the CDR for weight management of children and adolescents.5

Colleges and Universities

There are teaching opportunities for dietitians in culinary institutes, tech-
nical schools, and 2- or 4-year colleges. Such positions are often associated
with programs for chefs, food service supervisors, dietetic technicians,
dietary managers, entry-level dietitians, and hospitality managers. The
emphasis is on teaching in the classroom, laboratory, or practice setting.
Course responsibilities may include food preparation and food science,
basic and applied nutrition, meal management, cultural food practices,
food service management and equipment, nutrition assessment and ther-
apy, nutrition counseling and education, and community nutrition.
University faculty roles are quite varied. In addition to their teaching
responsibilities, university faculty are required to conduct research and provide
service within the institution, community, or profession. They advise students
on academic choices and research, serve on committees, consult with commu-
nity groups, share their expertise with the media and the public, and provide
departmental and university leadership for nutrition-related initiatives.
Higher education can include teaching other groups of students. For
example, some institutions offer nutrition courses for nondietetics majors
to fulfill requirements for general education, teacher certification, or
health and physical education. Programs in the allied health professions
may include nutrition courses. Dietitians can teach courses in nutritional
anthropology or epidemiology, often included as part of the master’s
degree in public health programs.

Medical and Dental Education

Some graduate-trained dietitians are engaged in medical and dental
education. Such a role requires assertiveness and creativity to convince
administrators of the unique contributions that dietitians have to offer in
medical and dental education. For an emphasis on prevention and health
promotion, nutrition is a required component, and dietitians are the best
qualified persons to provide this education. An in-depth knowledge of
nutrition science and medical nutrition therapy is required. Additionally,
medical and dental nutrition educators must possess leadership ability,
self-direction, strong communication skills, conceptual thinking skills,
time management techniques, and flexibility.
 C a r e e r O pp o r t u n i t i e s in E d u c a t i o n      197

Nutrition education can occur at any level of a medical or dental cur-

riculum. It may consist of nutrition science with clinical application
during the first 2 years while basic information is the major part of the
curriculum. As students enter the clinical part of their program, sample
meals featuring special diets are often effective teaching tools. Nutrition
rounds and seminars can be incorporated when students are in residen-
cies. Practicing dietitians can be involved in problem-based learning as an
effective way to make nutrition relevant for future medical practice.

Nursing and Allied Health Nutrition Education

Nutrition services are often provided by nondietitians, depending on the
practice setting and contributions of various health professionals. For
example, nurses regularly monitor food intake, evaluate laboratory values
indicative of nutritional status, and give patients nutritional advice. Den-
tal hygienists and health educators often screen for health or nutritional
problems and provide education and intervention. All health professionals
should understand the role nutrition plays in wellness and disease preven-
tion, and they need training on appropriate interventions. Nutrition is
included in the curriculum for nurses’ training programs, and dietitians
often teach the courses.

Industry-Based Education
Companies that manufacture medical nutrition products often employ
dietitians to provide technical and clinical information to the sales force
and to other personnel, including clinicians, retail pharmacists, and edu-
cators of healthcare professionals. Dietitians may educate via telephone,
webinars, written correspondence, electronic mail, and by personal visits.
They may participate in developing video, audio, and slide programs;
technical monographs; newsletters; brochures; and professional and
patient education publications on topics of medical nutrition therapy.
Companies that manufacture institutional equipment, food products,
supplemental products such as high-protein and other preparations for
tube feedings, infant formula, and supplements for nutritional additives
may also employ dietitians to help promote and demonstrate the use of
the products.
Personal characteristics and skills necessary for success in industry-
based education include technical and professional proficiency, ability
to critically and objectively analyze issues, attention to detail, high work
198    T he D ietitian as E ducator

standards, skill in written and oral communications, adaptability, and

ability to tolerate stress. Clearly, such positions require a proficiency in
nutritional science, practitioner experience, conceptual and analytic skills,
altruistic values, and a service ethic.

Work-Site Nutrition Education

As increased attention is given to the role of nutrition in health and dis-
ease prevention, more opportunities for dietitians will open in work-site
wellness programs. These work sites may include manufacturing plants,
insurance companies, and service organizations. Some of these positions
will focus entirely on nutrition education and may include screening for
nutritional risk, program development, leading classes and demonstra-
tions, creating exhibits and displays, and evaluating the effectiveness of
nutrition education initiatives. Dietitians in these positions may provide
valuable experience for dietetic interns or other students as well.
Work-site education opportunities can also include coordinators of
training in large dietetics departments or at the regional level of contract
food and nutrition service companies. Dietitians in such roles may oversee
a dietetic internship, coordinate in-service training for food service and
other personnel, and direct training for students from affiliating programs.
Individuals with the appropriate background may be promoted to director
of training and development at the institutional or corporate level.

ED UCAT O R R O L E S
As shown in the CDR audit of dietetics practice, dietitians participate
in many activities in which they teach employees, patients, allied health
professionals, students, and consumers. A variety of approaches are used
to reach the desired audience, all of which involve communication. Verbal
interaction and nonverbal cues enter into the effectiveness of the message,
and the skilled educator takes into account the best way to communicate
with the learner. Several of the roles by which dietitians interact with
learners are discussed in the following section.

Mentor
A mentor is a person who may teach verbally, by demonstration of
particular activities or skills, role modeling, or a combination of these
approaches. The mentoring relationship is a shared experience between a
 E d u c a t o r R o l e s      199

teacher and a learner. A mentor may be one’s peer, an instructor, a trusted

advisor, or anyone more skilled—think of the teenager who helps a par-
ent or grandparent become computer literate. The mentor may also be
described as a tutor in that one-on-one teaching is the method used.6
The Nutrition Entrepreneurs practice group conducts a mentorship
program aimed toward matching volunteer mentors with other members
who need guidance to make their vision a reality.7 The mentor program
offers rewards for both mentors and those mentored.

Coach
A coach is one who inspires and motivates others. Coaching is sometimes
described as the role assumed with individuals who are already achieving
at a high level and is simply positive feedback for continued high per-
formance. The coaching role is effective when involvement and trust are
created, expectations are clarified, performance is acknowledged, actions
are challenged, and achievement is rewarded. The football coach is the
classic example of one who performs all these functions in the expectation
of having a winning team.
Coaching is similar to reflective teaching in that the teacher may dem-
onstrate a new procedure or piece of information, and the learner repeats
the procedure. The coach responds with advice, criticism, explanation,
description, or further demonstration. The learner reflects and compares
the new information to his or her previous knowledge and acts accordingly.

Preceptor
The preceptor is one who provides direction and instruction, supervised
performance, and evaluation of the learners ability in applied practice.
The dietitian who oversees a dietetic intern in supervised practice has the
title of preceptor. A preceptor must have good interpersonal and time-
management skills as well as subject-matter competence as a skilled prac-
titioner. Preceptors are essential in dietetics education and to the future of
dietetic practice. They should consult and follow the Standards of Practice
and Standards of Professional Performance for Registered Dietitians (General-
ist, Specialty, Advanced) in Education of Dietetics Practitioners developed by
the American Dietetic Association and educators to guide their practice.8
Many benefits are realized by both the preceptor and the student as well
as the department or institution providing experiences for the student.
Among the benefits for preceptors observed in one study were assisting
200    T he D ietitian as E ducator

students with application of knowledge and expertise, gaining personal

satisfaction, observing students’ growth from novice to practitioner, and
stimulating ongoing interest in the profession.9 Students gained valuable
knowledge from the example set by experienced professionals and were
guided to levels of achievement that allowed them to assume entry-level
positions well prepared. The preceptor role was investigated by Winham
et al10 regarding the attitudes and perceptions held by a large sample of
registered dietitians. While the value of the preceptor role was highly per-
ceived, several areas were identified as possible target activities that would
further enhance the experience and encourage others to assume the role.
Descriptions of the various roles as perceived by the teacher, preceptor/
teacher, preceptor/mentor, and mentor are shown in Table 13-2.

Table 13-2.  Preceptor Roles

Preceptor/ Preceptor/
teacher Preceptor mentor Mentor

View of View student View intern as View intern as a

intern as continued a prospective colleagueb
learner coworkerb

Conceptual Focus on both Focus on

focus theory and practice-based
practice learning learninga

Prior Assess intern’s Assume

knowledge prior content intern has
knowledgec necessary
content
knowledgeb

Theory/ Combine basic Demonstrate the Identify

practice subject matter incorporation unwritten
with application of theory in workplace
practicea policies and
practicesb

Learning Provide learning Suggest useful Encourage intern

experiences experiences of learning to determine
varied types experiences learning
to help intern experiences
achieve learning to achieve
objectivesa objectivesc
 E d u c a t o r R o l e s      201

Table 13-2.  Preceptor Roles (Continued)

Preceptor/ Preceptor/
teacher Preceptor mentor Mentor

Ethical Discuss potential Uses case Identify

concerns ethical issuesc studies to actual
demonstrate ethical
concernsb

Strengths- Identify intern’s Help intern

weaknesses strengths and become
weaknessesa aware of
strengths
and
weaknessesa

Progress Evaluation Provide periodic

evaluation of continued feedback during
academic internship
progress

Intern self- Identify Strongly

evaluation usefulness of encourage
self-evaluationc intern to
participate in
self-evaluationc

Role model Illustrate role View yourself as View yourself as

modeling by a professional a personal role
example role modela modela

Duration of Recognize View the

relationship relationship with relationship
intern is limiteda with the intern
as indefiniteb

Columns represent the categorical descriptions for each role. Rows represent the functions/
elements that relate to the supervised practice experience.
a. Practice preceptors indicated they “frequently” execute and do not want to change.
b. Practice preceptors executed in varying degrees from frequently or occasionally to seldom/
never, but do not want to change.
c. Practice preceptors believed they should do more often.
Data from Journal of the American Dietetic Association 102, Number 7 (July 2002),
Wilson, M.A. “Dietetic Preceptors Perceive Their Role to Include a Variety of Elements,”
969, Copyright 2002.
202    T he D ietitian as E ducator

Counselor
Counseling is a process of listening, accepting, clarifying, and helping
clients or students form conclusions and develop plans of action. The
process is guided toward helping individuals learn about their needs and
about methods of coping with them.
Motivational interviewing is defined as a way of helping others bring
about behavior change, such as curbing addictive behaviors.11 This tech-
nique was used in a study that led to increased fruit and vegetable intake
by African Americans.12 This type of counseling is also described as a
directive, client-centered style for eliciting behavior change by helping
clients explore and resolve ambivalence.
A cognitive interview technique is sometimes used to assist in under-
standing how audiences or individuals process information. Respondents
are led through a survey or message and asked to respond with their
thoughts, feelings, or ideas that come to mind. With this information,
better messages are formed and valuation tools are targeted.13
Patient-centered counseling facilitates change by assessing patients’
needs and tailoring the intervention to the patient’s stage in the pro-
cess of change, personal goals, and unique challenges. 14 Four steps
are followed: assessment, advising, assisting, and follow-up. In step 1,
the dietitian-counselor asks questions to determine present behaviors.
Open-ended questions will help gain this information. (See Table 13-3
for examples.) In step 2, advisement based on the assessment is given
toward helping the person make changes. Assisting, in step 3, involves
giving motivational statements and encouragement. Goals and specific
skills such as self-monitoring and problem solving will also be discussed.
In the final step, follow-up toward maintaining dietary change will be
presented and attainment of earlier goals discussed. Further help will
also be provided.

Communicator
Effective communication is of utmost importance in all areas of dietetics,
and almost any job description will include the need to communicate at
all levels in an organization with both groups and individuals. Profes-
sionals who develop verbal and written skills, along with listening skills,
establish strong relationships with clients, patients, and staff.
 E d u c a t o r R o l e s      203

Table 13-3.  A Model for Open-Ended Questioning

Questions for assessing stage of change and motivation
How do you feel about your current diet?
What problems have you had because of your diet?
What would you like to change about your diet now?
Why would you like to change your diet now?
What concerns do you have about changing your diet now?
What reasons might you have to want to maintain your current diet?
Questions for assessing past experiences with dietary change
What changes have you made to your diet? How long did you maintain the changes?
If so, for how long? If not, how long did you maintain the change?
How did you make changes in your diet? What helped?
What difficulties did you encounter? How did you handle them?
Questions about anticipated challenges or barriers to change
What could get in your way of attaining your goal?
What situations will make it hardest for you to achieve your goal?
What other situations might make it difficult for you to maintain your change?
Questions about strategies to cope with challenges or barriers to change
What could you do when you face this challenge?
What else could you do in the face of this challenge or barrier?
What could help you cope with this challenge? How?
What has been helpful in the past to deal with this barrier?
Who could help you cope with this challenge? How?
What has been helpful in the past to deal with this barrier?
Questions for goal setting
What are you willing to change in your diet now?
When? How often will you do this?
Where will you do it?
What will you have to do in advance to ensure that you are able to make and maintain
this change?
How confident are you of your ability to make and maintain this change?
Questions for follow-up
How did you do with your plan?
What helped you stay on target?
What difficulties did you encounter?
Questions for assessing lapse and relapse
What made it difficult for you to stay with your plan?
How did you feel after that?
What else could you have done to stay on track?
What would you like to do now?

Reprinted from Journal of the American Dietetic Association 101, no. 3 (March 2001), Rosal, M.C.,
C.B. Ebbeling, I. Lofgren, J.K. Ockene, I.S. Ockene, and J.R. Hebert. “Facilitating Dietary Change: The
Patient-Centered Counseling Model,” 333, Copyright 2001, with permission from Elsevier.
204    T he D ietitian as E ducator

There are, at a minimum, seven components of the communication

process. The components are as follows:
1. Source. The source is the starting point for information exchange.
2. Message. The message is the idea or information transmitted
verbally or nonverbally.
3. Channel. The channel is the pathway for messages between the
sender and the receiver.
4. Receiver. The receiver takes in the message, assigns meaning,
interprets, and responds to the message.
5. Feedback. Feedback refers to the response from the receiver to the
sender.
6. Environment. The environment is the context in which the message
occurs, such as physical surroundings and cultural, historic, or
attitudinal factors.
7. Noise. Noise is any aural, visual, or internal factor that can distract
from the meaning of the message.
The communication methods that ensure messages are received need
to be carefully selected. Professionals who provide nutrition information
to the public will choose methods such as television, Internet, or printed
materials. The development of dietary guidance messages through the use
of focus groups and surveys of consumers is described by Borra et al.15 In
the consumer message development model (Figure 13-1), the issues are
defined, the message developed and assessed, then fine-tuned and validated.

Develop Sharpen
Message Concepts Messages
(Step 2) (Step 4)

Define Concerns Assess Evaluate and

(Step 1) Message Concepts Validate Messages
(Step 3) (Step 5)

FIGURE 13-1.  The Consumer Message Development Model.

Modified from Journal of the American Dietetic Association 101, Number 6 (June 20010,
Borra, S., L. Kelly, M. Tuttle, and K. Neville. “Developing Actionable Dietary Guidance
Messages: Dietary Fat as a Case Study,” 679, Copyright 2001.
 E d u c a t o r R o l e s      205

Today, while the use of e-mail, voice mail, and other social media are
efficient, it should be emphasized that face-to-face communication is
still important in many situations.16 Human contact, especially in direct
contact with patients, is the most reliable way of assuring the message is
received because interaction can occur at the same time and reaction to
the message assessed.
In a study to determine the best means of communicating nutrition
education for elderly adults, several factors were found to be successful.17
They included limiting educational messages to one or two, reinforcing
and personalizing messages, providing purposeful activities and incentives,
providing access to health professionals, and using behavior change.
A model was developed showing these elements (Figure 13-2).

Regular contact Active

with health involvement in
professionals determining
goals of
intervention

Messages Focus on
that are: behavior
• limited in modification
number
• simple
Hands-on
• targeted
activity
• practical
• reinforced

Individual
within group of
adults with specific
health, socioeconomic,
or other staus

Social environment
(e.g., family,
friends)

Physical environment
(e.g., home,
neighborhood)

FIGURE 13-2.  A Framework for a Nutrition Intervention.

Modified from Journal of the American Dietetic Association 104, Number 1 (January 2004),
Sayhoun, N.R., C.A. Pratt, and A. Anderson. “Evaluation of Nutrition Education Interven-
tions for Older Adults: A Proposed Framework,” 66, Copyright 2004.
206    T he D ietitian as E ducator

T YPE S O F L E A R N I N G
Education programs are based on learning outcomes or categories of learn-
ing, described as domains of learning. One classification, often used in
education, describes five types of learning outcomes or skills as follows18:
1. Psychomotor skills. The learner acquires motor skills along with the
know-how to perform tasks.
2. Intellectual skills. Information-processing skills allow the learner to
perform a new activity.
3. Verbal processing skills. The learner is able to provide information
through stating, listing, or describing something.
4. Attitudinal skills. The learner makes choices or decisions to act in
certain ways. These may include long-term goals that determine a
person’s ability to perform psychomotor or other skills.
5. Cognitive skills. The learner has attained abstract strategies to
become self-directed through the use of intellectual skills.
Another so-called index of learning styles19 describes the following
eight types of learning:
1. Active. An active learner likes trying things out and enjoys working
in groups.
2. Reflective. A reflective learner thinks things through; he or she pre-
fers working alone or with one or two partners.
3. Sensing. A sensing learner is concrete, practical, and oriented
towards facts and procedures.
4. Intuitive. An intuitive learner is conceptual, innovative, and ori-
ented toward theories and underling meanings.
5. Visual. A visual learner prefers visual representations or presented
material.
6. Verbal. A verbal learner prefers written and spoken explanations.
7. Sequential. A sequential learner undertakes a linear thinking pro-
cess and prefers learning in incremental steps.
8. Global. A global learner undertakes a holistic thinking process and
prefers to learn in large steps.
Education through the use of methods that involve the learner in an
active, participatory way can lead to very effective outcomes. Internships
 Types of L e a r n i n g      207

are examples of service learning. Problem-based learning is the method by

which a student discovers new knowledge through individual learning in
solving a problem. Project-based learning, similar to problem-based, is the
method in which learner involvement is guided by an instructor. These
three types of learning are described in the following sections.

Service Learning
Service learning is the type of educational experience that combines
explicit academic learning with service.20 In many professions, combining
classroom study and community learning experiences is a way of enhanc-
ing and retaining learning. In dietetics, the internship is an example
because it combines practice with instruction. Another example is the
college class that places students in a community site such as a school
or elderly nutrition program for experiences that are a part of the course
requirements. Seeing and experiencing nutrition applied in specific com-
munity programs makes subject matter come alive and leads to a better
understanding of the value and need of community service.

Problem-Based Learning
A method often used in medical and business schools, problem-based learn-
ing requires students to work through problems to find answers to real-life
situations. This provides a context for students to learn critical thinking and
problem-solving skills and to acquire knowledge of the essential concepts of
a course of study.21 In this method, students are presented a problem and
organized into groups to discuss the problem. Students pose questions and
rank the learning issues generated in the session. Students and the instruc-
tor discuss the resources needed to research the learning issues. Students
then summarize their knowledge and connect the new concepts to older
ones and define new learning issues as they progress through the problem.
The benefit is that students recognize that learning is an ongoing process
with new learning issues to be explored. Case-based learning is a method
of problem-based learning designed to connect education and specialized
practice while also developing skill for entry-level practice.22
The role of the instructor is to guide, probe, and support students’
initiatives. When faculty incorporate problem-based learning into classes,
they empower students to take a responsible role in their learning. As a
result, faculty must be ready to yield some authority to their students.
208    T he D ietitian as E ducator

Project-Based Learning
Similar to problem-based learning, project-based learning is a form of
instruction that places emphasis on the students’ involvement in working
through job-related situations. It is described as a long-term, problem-
focused, meaningful unit of instruction that integrates concepts from a
number of disciplines. An example might be the design of a kitchen layout
using work flow, equipment, and production schedules. Both teacher and
student receive support in fulfilling their roles, the teacher as facilitator
and shepherd of projects, and the student by participating in a worthwhile
project. A project-based learning support system that supports learning
through a computer-mediated interface using learner-centered software
has been described.23 This type of learning is useful in simulations or
when students share a concentrated experience. New tools and structures
are often needed to support the effectiveness of this type of learning, but
it provides good results amid complex and challenging projects.

ADULT S AS L E A R N E R S
Conducting learning sessions for adults is different from teaching younger
people. Dietitians need to be aware of the differences in order to adapt their
teaching for the best learning outcomes. Adult learners, for example, have
backgrounds of experience they bring to new learning situations and they are
usually independent and self-directed. They may prefer to work alone or in
small groups. Participating in activities and solving problems are typical pref-
erences for learning styles as they may have immediate need for the informa-
tion. Adults are often motivated by factors such as the need for an educational
undertaking for economic or professional advancement reasons, a desire to
learn new material, and for personal satisfaction. Even health reasons may fac-
tor into adult choices with the research showing that mental capacity is more
readily maintained when the mind continues to be used throughout life.

T EACH I NG G R O U P S A N D TEA M S
Groups of people usually act in ways that are different than when they
are in a one-on-one learning situation. Group dynamics is a term often
applied to this behavior because it describes how members relate to each
other, how they communicate among themselves, and how they work as a
group. The teacher or leader of the group needs to understand how these
 S u m m a r y      209

dynamics can affect the learning process and the ways the educational
message needs to be delivered.
Groups function best when all members participate because informa-
tion is more likely to be shared and understood as new ideas, questions,
clarifications, etc., occur. All group members need to understand the pur-
pose and expected outcomes of the learning situation, and the leader has
the responsibility to make sure this is clear at the outset of the lesson.
When disagreements or tension arise in the group, the leader should be
prepared to change the subject or take a time-out or use some other tech-
nique to get the group back on track. Giving support, encouraging discus-
sion, and including all the group members in active participation helps
ensure the session will accomplish its goals.
While teams are focused as a work group, many of the same character-
istics as evidenced in groups will also appear. Teams may be formed in
order to accomplish more through the combined efforts and expertise of
individual members. Participation in teams, however, requires that mem-
bers understand their role and the expectations for the group.
When teams are formed, members may be uncertain of their role and
will depend on a leader to guide them into a team role. There may be con-
flict as team members clarify the team’s goals. The leader then needs to
redirect the energies of the team by encouraging open communication. As
relationships become cohesive, the team functions as a unit and develops
patterns of communication and behavior. The leader facilitates decision
making and problem solving. The team members find ways of handling
conflict, and methods that become standards for evaluating team perfor-
mance therefore develop.

S UMMARY
The role of educator is one of the most important of those performed by the
dietitian and dietetic technician. To be an effective educational leader, the
professional must have a working knowledge of the education process by
assessing learners’ basic knowledge, setting learning goals, planning learning
content and delivery methods, and evaluating the outcomes of the learning.
The dietitian may function in a number of educator roles, including that of
mentor, coach, preceptor, or counselor. The effective teacher in any of these
roles is skilled in communications and has the qualities of a leader in under-
standing individuals and groups and fostering productive learning situations.
210    T he D ietitian as E ducator

D E F INI T I O N S

Assessment. The process of evaluating actions or conditions to base

additional activity.
Cognitive skills. The application of intellectual capabilities to accomplish
objectives.
Education. The systematic instruction and training designed to impart
knowledge and develop a skill.
Instruction. The activity by which knowledge or teaching is imparted.
Psychomotor skills. The ability to perform physical tasks based on
knowing or thinking.
Training. Actions by which persons are brought to a desired standard
of efficiency or behavior by instruction and practice.

RE F E RENC E S
1. Boyce, B. “2011 Future Connections Summit on Dietetic Practice, Credentialing,
and Education: Summary of Presentations on Shaping the Future of the Dietetic
Profession.” J Am Diet Assoc 111 (2011): 1591–1599.
2. Ward, B., D. Rogers, C. Mueller, R. Touger-Decker, and K.L. Sauer. “Entry-
Level Dietetics Practice Today: Results from the 2010 Commission of Dietetic
Registration Entry-Level Dietetics Practice Audit.” J Am Diet Assoc 111 (2011):
914–941.
3. Sandon, L. “A System for Designing Effective Online Education.” J Am Diet Assoc
107 (2007): 1305–1306.
4. “Position of the American Dietetic Association, School Nutrition Association,
and Society for Nutrition Education: Comprehensive School Nutrition Services.”
J Am Diet Assoc 110 (2010): 1738–1749.
5. American Dietetic Association. “Certificate of Training in Childhood and Adoles-
cent Weight Management.” Accessed December 1, 2015, www.eatright.org
6. Managan, L. “The Many Modes of Mentoring: New Spins on the Classic Rela-
tionship.” J Acad Nutr Diet 112, no. 9 (2012): 1324–1328.
7. Bitzer, R., Nutrition Entrepreneurs Practice Group. “Mentor Program.” Ventures
XXV, no. 4 (2009): 11.
8. Anderson, J.A., K. Kennedy-Hagen, M.R. Stieber, D.S. Hollingsworth, K. Kattel-
man, C.L. Stein-Arnold, and B.M. Egan. “Dietetics Educators of Practitioners and
Dietetic Association Standards of Professional Performance for Registered Dieti-
tians (Generalist, Specialty/Advanced) in Education of Dietetics Practitioners.”
J Am Diet Assoc 109 (2009): 747–754.
 R e f e r e n c e s      211

9. Marincic, P.Z., and E.E. Francfort. “Supervised Program Preceptors’ Percep-

tions of Rewards, Benefits, Support, and Commitment to the Preceptor Role.”
J Am Diet Assoc 102 (2002): 543–545.
10. Winham, D.M., A.A. Wooden, A.M. Hutchins, L.M. Morse, C.M. Shepard,
S. Mayal-Kreiser, and J. Hempl. “Attitudes and Perception of the Dietetic
Internship Preceptor Role by Arizona Nutrition Professionals.” Topics in Clinical
Nutrition 29, no. 3 (2014): 210–226.
11. Thorpe, M. “Motivational Interviewing and Dietary Behavior Change.” J Am Diet
Assoc 103 (2003): 150–151.
12. Resicow, K., A. Jackson, T. Wang, F. McCarty, W.W. Dudley, and T. Baranowski.
“A Motivational Interviewing Intervention to Increase Fruit and Vegetable Intake
Through Black Churches; Results of the Eat for Life Trial.” Am J Public Health 91
(2001): 1686–1693.
13. Carbone, E.T., M.K. Campbell, and L. Honess-Morreal. “Use of Cognitive
Interview Techniques in the Development of Nutrition Surveys and Interactive
Messages for Low-Income Populations.” J Am Diet Assoc 102 (2002): 690–696.
14. Rosal, M.C., C.B. Ebbeling, I. Lofgren, J.K. Ockene, I.S. Ockene, and
J.R. Hebert. “Facilitating Dietary Change: The Patient-Centered Counseling
Model.” J Am Diet Assoc 101 (2001): 332–341.
15. Borra, S., L. Kelly, M. Tuttle, and K. Neville. “Developing Actionable Dietary
Guidance Messages: Dietary Fat as a Case Study.” J Am Diet Assoc 101 (2001):
678–684.
16. Hallowell, E.M. “The Human Moment at Work.” Harvard Bus Review
(January–February 1999): 1–8.
17. Sayhoun, N.R., C.A. Oratt, and A. Anderson. “Evaluation of Nutrition Education
Interventions for Older Adults: A Proposed Framework.” J Am Diet Assoc 101
(2001): 58–69.
18. Gagne, R.M. Instructional Technology: Foundations. (Hillsdale, NJ: Lawrence
Erlbaum Associates, 1987): 25.
19. Palermo, C., K.Z. Walker, T. Brown, and M. Zogi. “How Dietetics Students
Like to Learn: Implications for Curriculum Planners.” Dietitians Association of
Australia. J Compilation (2009).
20. Kim, Y., and A. Canfield. “How to Develop a Service Learning Program in
Dietetics Education.” J Am Diet Assoc 102 (2002): 174–176.
21. Dietetic Educators of Practitioners Practice Group. “Problem-Based Learning:
Preparing Students to Succeed in the 21st Century.” DEP Line 17, no. 3 (1998): 1–5.
22. Harman, T., B. Bertrand, A. Green, A. Pettus, J. Jennings, E. Wall-Bassett, and
O.T. Babatunde. “Case-Based Learning Facilitates Critical Thinking in Under-
graduate Nutrition Education: Students Describe the Big Picture.” J Acad Nutr
Diet 115, no. 3 (2015): 378–388.
23. Laffey, J., T. Tupper, D. Musser, and J. Wedman. “A Computer-Mediated Support
for Project-Based Learning.” Technology Research and Development 46, no. 1
(1998): 73–86.
 14

CHAPTER
The Dietitian as
Researcher
“Research is the foundation of our profession.”1

OUTLINE
• Learning Objectives
• Introduction
• Importance of Research in Dietetics
• The Research Philosophy of the Academy
• The Academy’s Research Priorities
• The Research Committee
• Research Dietetic Practice Group
• Research Applications
• Evidence-Based Practice
• Involvement in Research
• Career Opportunities in Research
• Food and Industry Companies
• Government
• Community and Public Health
• Human Nutrition Research Centers
• Information Sources
• Summary
• Definitions
• References

213
214    T he D ietitian as R esearcher

LEARNING OBJECTIVES
The student will be able to:
1. Gain information about research goals of the Academy.
2. Understand the importance of research in dietetics.
3. Become familiar with the ways dietitians can participate in
research in all areas of practice.
4. Know practical applications of evidence-based and outcome
research.

IN T RO D UC TI O N
Many dietitians conduct research as a part of their work. This is espe-
cially true for dietitians who specialize in nutrition support, pediat-
rics, renal dietetics, oncology, AIDS, or diabetes. These dietitians and
those in all other areas of practice use research in various ways. They
may critique and use research data for professional reference as needed.
All dietitians are encouraged to perform or collect data for outcome
research studies to demonstrate the effectiveness of medical nutrition
therapy and/or the quality and acceptance of the services performed. In
the clinical setting, dietitians may collaborate with physicians who are
conducting nutrition-related studies, and even though they may not call
themselves researchers, they are in fact participating in research and are
critical to the process.
With the increasing emphasis on research in the Academy of Nutri-
tion and Dietetics and in the profession generally, many dietitians
are incorporating research studies into their practice. In part, there is
a sense that more applied research studies are needed as more basic,
laboratory-oriented research does not always meet the needs of everyday
practice. To this end, a member network called the Dietetics Practice-
Based Research Network (DPBRN) has been formed.2 The network is
open to all who are interested in addressing questions encountered in
practice and to continually improve the delivery of food and nutrition
services.
 The Research Philosophy of the A c a d e m y      215

IMPORTANCE OF RESEARCH IN DIETETICS

“Research represents the future for dietetics; it is the foundation for our
credibility, our recognition, and our professional respect. Without research,
we cannot properly educate or advocate, nor would we have the credibil-
ity in either endeavor.”3 All professions continually reshape themselves
to meet ever-changing needs in society and research is essential for these
changes and advancements to take place. Not only do dietitians need to
engage in research to gain knowledge and define new modes of therapy and
new techniques in all areas of practice, they also need to take a scholarly
approach to everyday practice. Many practicing dietitians have an image
of research as overwhelming or irrelevant, when in fact the reality is quite
different. There are a number of exciting ways for practicing dietitians to
become involved with research, ranging from simply learning more about
dietetics-related research, to evaluating research findings to make evidence-
based decisions in work settings and participating in scientific projects.4
Employers of dietitians and those using dietetic services need to be
assured that the services they are using are supported by research. Research
is the basis for education because it drives the core knowledge and compe-
tencies and is used in setting public policy. The ability to conduct and use
research further allows professionals to be recognized by the public as a val-
ued and credible source of scientifically supported nutrition information.
The Academy has taken further steps to encourage and increase research
by creating a software platform to advance evidence-based research called
the Academy of Nutrition and Dietetics Health Informatics infrastructure
(ANDHII); the program provides for a collection of data about dietetic
practice on a national scale and makes it available for outcomes research
and quality improvement.5

T H E RE S E A R C H P H I L O S O PHY
OF THE ACADEMY
The research philosophy of the profession is the following:
The Academy of Nutrition and Dietetics believes that research is the
foundation of the profession, providing the basis for practice, educa-
tion, and policy. Dietetics is the integration and application of prin-
ciples derived from the sciences of nutrition, biochemistry, physiology,
food management, and behavioral and social sciences to achieve and
216    T he D ietitian as R esearcher

maintain people’s health; therefore dietetics research is a dynamic col-

laborative and assimilative endeavor. This research is broad in scope,
ranging from basic to applied practice research.6

The Academy uses research as the basis of decisions, policy, and com-
munication in a variety of roles. The roles include the following:
• Advocate. Federal and nongovernmental agencies, organizations, and
individuals who can support the Academy’s research agenda.
• Facilitator. Targets key research questions and facilitates a successful
process to answer the questions.
• Convener. Brings together scientists and practitioners from various
disciplines to explore new approaches in solving research questions.
• Funder. Prepares, disseminates, and funds research proposals on key
research questions important to the profession.
• Educator. Develops professional opportunities for members to
enhance their knowledge and use of research.
• Disseminator. Distributes research results to members and the public
through publications, work sites, and print and electronic media.

T H E ACAD E M Y ’ S R E S E A R C H PR I OR I T I ES
The Research Committee
The Research Committee of the Academy, reporting to the board of direc-
tors and the house of delegates (HOD), sets the research agenda for the
Academy. In this capacity, the committee develops, maintains, and evalu-
ates the research priorities.7 The Academy’s statement of purpose empha-
sizes research: “The Academy is committed to improving the nation’s
health and advancing the profession of dietetics through research, educa-
tion, and advocacy.”8 Two specific strategies to help reach these goals are
to equip members to use research in their work and provide research and
resources that can be translated into evidence-based practice.
In 2014, the research committee identified priority research areas as
the following:
• Prevention and treatment of obesity and chronic diseases.
• Nutrition and lifestyle education.
• Nutritional status and disease risk assessment.
• Translational nutrition.
 T h e A c a d e m y ’ s R e s e a r c h P r i o r i t i e s      217

• Nutrition and genetics.

• Provision of dietetic services.
• Customer satisfaction.
• Education and retention of dietetic practitioners.
• Safe, secure, and sustainable food supply.
Funding for approved projects comes from the Academy foundation
and other Academy-affiliated groups, from governmental agencies, and
from the food and nutrition industry. A tool kit that provides a lesson
tutorial, practice suggestions, and resources for conducting research is
available from the headquarters office.
Figure 14-1 illustrates the interaction between practice, education, and
policy.

Research Dietetic Practice Group

The Research Dietetic practice group has over 650 members from a vari-
ety of work settings, including clinical research centers, nonprofit groups,
governmental agencies, universities, and many practice areas. Member-
ship is open to all Academy members who conduct research or are inter-
ested in research. Members collaborate on Academy projects, such as the
Evidence Analysis Library, to bring together research from many sources,
and in the preparation of position papers.
Members of this group also form liaisons with the Research Committee
of the Association and the DPBRN. The practice group provides a mem-
ber network, conducts continuing professional education events, provides
a packet of information for new members, and produces a website and a
periodic publication. Research awards are given to recognize the research
and publications generated by members.

Dietetics Practice-Based Research Network

The Dietetics Practice-Based Research Network (DPBRN) brings prac-
titioners and researchers together to identify research that is needed in
practice settings, design significant research to obtain funding, and carry
research into real-life practice. The focus of the research conducted by
members is in studies that can be immediately incorporated into practice.
Professionals who lack the time, money, or perhaps experience to conduct
research on their own find that this group activity presents an opportunity
to benefit from research by answering questions, keeping abreast of new
information, and improving their practice.
218    T he D ietitian as R esearcher

Current practice

Questions

Is answer available?

Yes No

Change practice to Design and conduct study

incorporate answer to answer question
Yes

Reflect on results.
Will they improve patient outcomes?
Yes
No

Communicate results Retain current practice

To other To other To administrators Examine study

members of nutrition and/or insurance and determine No
healthcare professionals providers whether the
team original question
was answered

Yes

Accept results

Communicate results to
nutrition professionals

FIGURE 14-1.  Detailed Progression of How Research and Clinical Practice are
Integrated.
Reprinted from Journal if the American Dietetic Association 89, Number 4, 1998. Eck LH,
Slawson DO, Williams R, Smith K, Harmon-Clayton K, Oliver D, “A Model for Making
Outcomes Research Standard Practice in Clinical Dietetics. Copyright 1998, with permission
from Elsevier.
 R e s e a r c h A pp l i c a t i o n s      219

RES EARC H A P P L I C ATI O N S

Evidence-Based Practice
Evidence-based practice, based on evidence-based research, is the inte-
gration of the best available evidence from reviewed research with pro-
fessional expertise and client values to make food and nutrition practice
decisions.8 Every area of practice in dietetics involves making decisions
about the best procedures to follow, and given that new information con-
tinually leads to a need to make necessary changes or to update practice,
evidence analysis provides this information. The evidence analysis process
involves the following steps:
1. Formulate one or more questions to be researched.
2. Conduct a literature search for each question.
3. Critically appraise each report found in the literature as to the
quality of the research and the findings.
4. Summarize the evidence.
5. Develop conclusions and assign a grade based on the strength of
the evidence.
6. Put into practice.
The Evidence Analysis Library at the Academy headquarters is main-
tained for the benefit of members of the Academy and others needing
the information. The best and most relevant nutrition information is
reviewed and is available in this accessible, user-friendly library.9 Because
of the research data held, governmental and other groups also use the
information and the process in making policy decisions. One example
group is the Food and Drug Administration, which uses the process to
make decisions about the use of health claims on food labels.
Outcomes research is increasingly important in the linkage of practice
and research in order to make advancements in all areas of dietetics. Cur-
rently, translational research is being used in much the same way as out-
comes research, that is, to link research to practice applications in all areas.
Van Horn points out the value of clinical nutrition outcomes research and
the involvement of dietitians in a letter in the journal.10 Surveys show that
while dietitians consider research important and are interested in it, many
experience obstacles to performing outcomes research because of a lack of
knowledge about the process, along with limited time and funding.11,12
220    T he D ietitian as R esearcher

Dietetic educators and university faculty have also experienced barriers to

research activities even though research is required of most faculty.13

IN V O LV E M E N T I N R E S E A R CH
The Commission on Dietetic Registration conducts periodic audits of
practice areas of RDs and DTRs. Data was collected for entry-level prac-
titioners and is shown in Table 14-1. While the 2015 Compensation and
Benefits Survey indicated that only 6 percent of RDs and 2 percent of
DTRs are employed in education and research, the higher involvement in
specific research-related activities in the practice audit would be expected
to represent activities performed as a part of the job but not as the major
area of employment.14 The fact that dietetic technicians also participate
in some research activities very likely reflects degrees obtained beyond the
basic technician education requirements as well as job responsibilities.

CA RE E R O P P O RTU N I TI E S I N R ESEA R C H
Many university-affiliated hospitals have centers dedicated to types of clin-
ical research. Others have long-term, multidisciplinary research projects
that include a nutrition component. Some dietitians work at a general
clinical research center (GCRC), usually associated with an academic med-
ical center and federally funded. There are about 80 GCRCs funded by
the National Institutes of Health located at universities across the country.
Research dietitians may oversee the metabolic kitchens associated with
the GCRCs, analyze nutrient intakes, conduct calorimetry studies, assist
in the development of nutrition-related protocols, and participate in
rounds and seminars.
Some GCRC dietitians manage their own research programs, direct
nutrition research, and collaborate with the medical school faculty in
research. Some large national studies provide numerous opportunities for
dietitians to become involved as nutrition counselors, data managers, or
project directors.
There is a need for dietitians in clinical research. The best dietetics
practice must be based on scientific principles and sound theory. Recent
activities of the National Institutes of Health support these concepts.15 In
an attempt to advance the translation research activities into new drugs,
equipment, new therapies for diseases, and prevention, it has established
 C a r e e r O pp o r t u n i t i e s in R e s e a r c h      221

Table 14-1.  Research Activities of RDs and DTRs

Percent involved in any way

RD DTR

Evaluate and synthesize research literature 19 10

Use evidence analysis in practical decisions 76 32

Review research literature 54 21

Evaluate and synthesize research literature 19 10

Use evidence analysis in practice decisions 76 32

Review research literature 54 21

Collect data for research 24  0

Analyze data 42  0

Write grant proposals 36  0

Develop hypotheses for research studies  5  0

Design research studies  6  0

Develop research proposals  5  0

Conduct research studies  8  0

Report research at professional conferences  6  0

Write manuscripts for peer-reviewed journals  5  0

Review and use national nutrition survey data 29  0

Identify nutrition-related problems within population groups 12  0

Collect data for research 24  0

Analyze data 42  0

Write grant proposals 36  0

Develop hypotheses for research studies  5  0

Design research studies  6  0

Develop research proposals  5  0

Conduct research studies  8  0

Reprinted from Journal of the American Dietetic Association 111, no. 11 (November 2011), Ward, B.,
D. Rogers, C. Mueller, R. Touger-Decker, KI.L. Sauer, C. Schmidt, “Distinguishing Entry-Level
RD and DTR Practice: Results from the 2010 Commission on Dietetic Registration Entry-Level
Dietetics Practice Audit, 1749–1755, Copyright 2011, with permission from Elsevier.
222    T he D ietitian as R esearcher

the National Center for Advancing Translational Science (NCATS). This

center will fund projects and translational science centers all over the
nation, which will provide dietitians and nutrition scientists with oppor-
tunities to collaborate with other scientists and compete for grants in
applied research as basic science. Additional evidence is needed to support
the value of many approaches to clinical dietetics. Additional knowledge is
needed in areas of nutritional status of individuals and populations at risk
for disease, genetic components of disease related to food intake patterns,
identification of nutrient requirements associated with disease conditions,
environmental risks (including dietary risks), nutrition interventions as
therapy for disease conditions, and eating behavioral research. With the
crises in healthcare delivery, especially in adult and childhood obesity, the
outcomes of nutrition intervention are an important area of investigation.

Food and Industry Companies

Many food companies employ dietitians. Roles vary but include research
related to product or recipe development. Roles can also focus on transla-
tion of research into meaningful information for the public or develop-
ment of nutrition education for children, adults, and professionals.
Companies that manufacture infant formulas and medical nutritional
products often employ dietitians to conduct research or to monitor clinical
investigations in hospitals, nursing homes, and home care settings. Roles
might include work related to:
• Nutritional needs of infants, children, and the elderly
• Acceptability of flavors and textures of products designed for oral use
• Coordination of studies to determine the effectiveness of new
products
• Initiation of outcomes research to explore the cost-effectiveness of
medical nutrition therapy

Government
There are many opportunities for research dietitians in government-
sponsored centers and laboratories. These include positions such as:
• Nutrition scientists at the Department of Agriculture laboratories
studying nutrient requirements, vitamins and minerals, eating pat-
tern interventions, and other nutrition topics
 C a r e e r O pp o r t u n i t i e s in R e s e a r c h      223

• Researchers at the U.S. Army Natick Research, Development, and

Engineering Center in Massachusetts involved in studies related
to food behaviors and the acceptance and consumption of military
rations
• Nutrition epidemiologists at the Centers for Disease Control and
Prevention in Atlanta, Georgia, exploring patterns of nutrition-
related-diseases and nutrition surveillance throughout the country
• Life science specialists at the Congressional Research Service in the
Library of Congress, answering questions and conducting research
for members of Congress and staff on food and nutrition issues
• Nutrition researchers at the National Aeronautical and Space Admin-
istration in Houston studying nutrition needs of space explorers

Community and Public Health

Since the leading causes of death in the United States continue to be
nutrition-related chronic diseases, more efforts and opportunities are
rising in community and population-based nutrition research. As con-
sumers become more aware of disease consequences of their food choices
and eating behaviors, they demand more evidence. Many dietitians who
previously worked only in service program areas in community and pub-
lic health are seizing the opportunity for research activities that docu-
ment the value of nutrition and the dietitians’ role in interventions. Great
opportunities exist in conjunction with the obesity epidemic in getting
individuals and communities involved in the food environment and in
interventions that really change eating behaviors and adherence to dietary
recommendations.
Schools are involved in research especially suited for nutrition,
healthy behaviors, and weight maintenance by providing researchers
access to students that they can follow over time. Dietitians will be
needed in greater numbers for these research and education programs
to be successful.
Many land-grant universities are conducting nutrition research in
developing countries around the world. This research involves food and
agriculture production, economic development, and nutritional assess-
ment and intervention in various populations. As more and more global-
ization occurs, these ventures will increase, thus providing even greater
opportunities for dietitians in research.
224    T he D ietitian as R esearcher

Human Nutrition Research Centers

The Agricultural Research Service of the U.S. Department of Agriculture
funds six human nutrition research centers. These include the Children’s
Nutrition Research Center at Baylor College of Medicine in Houston,
Texas, and the Arkansas Children’s Nutrition Center at Arkansas Children’s
Hospital at the University of Arkansas for Medical Sciences. The center
in Boston, Massachusetts, specializes in nutrition research for the aging
population and is associated with Tufts University. Located on the campus
of the University of California at Davis, the Western Human Nutrition
Research Center concentrates on nutrition intervention strategies. The
center in Beltsville, Maryland, conducts basic and applied research on
nutrient composition, national dietary surveys, nutrient requirements,
function of physiochemicals, and similar studies. The sixth center, located
in Grand Forks, North Dakota, is associated with the University of North
Dakota and conducts research in mineral requirements and utilization as
well as community-based research with Native Americans. Opportunities
are available at these centers for all levels of dietetic practice (entry level,
advanced, specialists, and dietetic technicians) and include clinical trials,
basic science and applied research, and community-based research.

IN F O RMAT I O N S O U R C E S
An excellent source for information about types of research and research
methodology with an emphasis in nutrition is Research: Successful Approaches
by Monsen and Van Horn.16 The Journal of the Academy of Nutrition and
Dietetics provides valuable research articles and opportunities identifying
other dietetic researchers along with opportunities to publish. Other use-
ful sources for dietitians conducting or planning research feature qualita-
tive research,17 publishing research,18–20 and scientific integrity.21,22 The
Research Dietetics practice group offers opportunities for collaboration,
networking, and mentoring for various kinds of research.

SU MMARY
Researchers may be based in specialized clinical research centers, government
agencies, industry, universities, or the workplace. Roles vary according to
the employing institution’s mission and purpose. Key areas of investigation
relate to nutrient requirements, nutrient utilization, and outcomes of medical
 R e f e r e n c e s      225

nutrition therapy. Opportunities for participating in outcomes research in

order to enhance practice exist through collaborative research that utilizes
the expertise of dietitians in many practice settings. All dietitians can benefit
from research findings applied to practice and can utilize the Academy’s
Evidence Analysis Library for the current and best research.

D E F INI T I O N S

Evidence-based research. The compilation of research studies that,

together, allows for a decision regarding application to practice.
Outcomes research. Studies that focus on results of interventions and
application of research results.
Research. Systematic investigation leading to new knowledge or new
applications of known information. To conduct research, a question
is formulated, a literature search is conducted, experimental activi-
ties are applied, and results are recorded.

REFE REN C E S
1. Pavlinac, J.M. “President’s Page.” J Am Diet Assoc 110 (2010): 499.
2. Trostler, N., E.F. Meyer., and L.N. Snetselaar. “Description of Practice Charac-
teristics and Professional Activities of Dietetics Practice-Based Research Network
Members.” J Am Diet Assoc 108 (2008): 1060–1067.
3. Yadrick, M. “President’s Page.” J Am Diet Assoc 108 (2008): 11601.
4. See Note 1.
5. Murphy, W.J. “New Breed of Evidence and the Tools to Generate It: Introducing
ANDHII” J Acad Nutr Diet 115, no. 1 (2015): 19–22.
6. www.eatright.org (1/9/16).
7. See Note 5.
8. Vaughn, L.A., and C.J.J. Manning. “Meeting the Challenges of Dietetics Practice
with Evidence-Based Decisions.” J Am Diet Assoc 104 (2004): 282–284.
9. Academy of Dietetics and Nutrition. “Evidence-Based Library.” www.eatright.org
10. Van Horn, L. “Clinical Nutrition Research: New Approaches and New Outcomes.”
Acad Nutr Diet J (2012): 971.
11. McCaffree, J. “Overcoming Obstacles to Outcomes Research.” J Am Diet Assoc
102 (2002): 71.
12. Hayes, J.E., and C.A. Peterson. “Use of an Outcomes Research Collaborative
Training Curriculum to Enhance Entry-Level Dietitians and Established Profes-
sionals’ Self-Reported Understanding of Research.” J Am Diet Assoc 103 (2003):
77–81.
226    T he D ietitian as R esearcher

13. Whelan, K., and S. Markless. “Factors That Influence Research Involvement
among Registered Dietitians Working as University Faculty: A Qualitative
Interview Study.” J Acad Nutr Diet 102 (2012): 1021–1028.
14. Rogers, D. “Compensation and Benefits Survey 2015.” J Acad Nutr Diet 115,
no. 3 (2015): 370–388.
15. U.S. Department of Health and Human Services. “NIH Establishes National
Center for Advancing Translational Sciences.” NIH News, press release,
December 23, 2011.
16. Monsen, E.R., and L. Van Horn. Research, Successful Approaches, 3rd ed. (Chicago:
American Dietetic Association, 2007).
17. Harris, J.E., G.P.M. Gleason, C. Boushey, J.A. Beto, and B. Bruemer. “An Intro-
duction to Qualitative Research for Food and Nutrition Professionals.” J Am Diet
Assoc 109 (2009): 80–90.
18. Boushey, C., J. Harris, B. Bruemmer, S.A. Archer, and L. Van Horn. “Publishing
Nutrition Research: A Review of Study Design, Statistical Analyses, and Other
Key Elements of Manuscript Preparation. Part 1.” J Am Diet Assoc 106 (2006):
89–96.
19. Harris, J.E., C.J. Boushey, B. Bruemmer, and S.A. Archer. “Publishing Nutrition
Research: A Review of Nonparametric Methods.” J Am Diet Assoc 108 (2008):
1488–1496.
20. Boushey, C.J., J. Harris, B. Bruemmer, and S.A. Archer. “Publishing Nutrition
Research: A Review of Sampling, Sample Size, Statistical Analyses, and Other
Key Elements of Manuscript Preparation. Part 2.” J Am Diet Assoc 108 (2008):
679–688.
21. The International Life Sciences Institute North America Conflict of Interest/
Scientific Integrity Guiding Principles Working Group. “Funding Food Science
and Nutrition Research: Financial Conflicts and Scientific Integrity.” J Am Diet
Assoc 109 (2009): 929–936.
22. Nicklas, T.S., W. Karmally, and C.E. O’Neil. “Nutrition Professionals Are
Obligated to Follow Ethical Guidelines When Conducting Industry-Funded
Research.” J Am Diet Assoc 111 (2011): 1931–1932.
 15

CHAPTER
The Future in Dietetics
and Nutrition
“This is the time for the science of nutrition.
This is the moment, and we have to seize it.”
Bernadine Healy1

OUTLINE
• Learning Objectives
• Introduction
• Education
• Degree Options
• Practice
• Non-RD Practice
• Practice Needs
• Communications and Technology
• Foods and the Food Supply
• Management and Leadership
• Summary
• Definitions
• References

227
228    T he F uture in D ietetics and N utrition

LEARNING OBJECTIVES
1. Project future roles anticipated in the health care, the foods
industry, nutrition research, private practice, and community
nutrition.
2. Understand the range of future opportunities through chang-
ing technologies.
3. Discuss future educational needs as indicated by employers
of dietitians.
4. Become familiar with the role of management and leadership
in food service systems and other dietetic areas.
5. Understand the importance of informatics in dietetic practice.

IN T RO D UC TI O N
All organizations, of necessity, plan for the future in terms of goals,
timelines, personnel, economic considerations, and the business/pro-
fessional climate. The Academy of Nutrition and Dietetics (AND)
expends a great deal of time and effort in all these areas. The House
of Delegates, Accreditation Council on Education in Nutrition and
Dietetics (ACEND), the Commission on Dietetic Registration (CDR),
and the Foundation and the Board of Directors all participate in activi-
ties designed to identify and prepare for the future of the Academy and
its members.
The House of Delegates has established a mega issues process as a “stra-
tegic and futuristic projection to impact the profession 3 to 5 years into
the future.” The Council on Future Practice works with both ACEND
and CDR to anticipate and identify actions and needs for the future. In
the Council’s Visioning Report,2 education, credentialing, and practice
needs of the profession are outlined, with recommendations the Acad-
emy may take toward implementing the goals in these areas. The AND
Foundation projects needs for funding scholarships and research for the
Academy and works closely with business/industry groups for funding.
The Board of Directors periodically appoints committees to investigate
 E d u c a t i o n      229

issues and conduct long-range planning seminars and workshops for lead-
ers and members. Most recently, the AND Foundation was charged with
developing a 100th anniversary strategy to celebrate the anniversary of
the Academy. In 2014, a 100th Anniversary Steering Committee was
identified to begin the planning and implementation strategies. Three
issues were initially identified: RDNs (registered dietitian nutritionists)
as global leaders in food systems; increased global capacity of nutrition
professionals; and nutrition recognized as a central pillar of individual and
public health.3 These themes clearly represent the thinking of moving the
Academy into the next 100 years and will impact future careers, practice,
and education for dietetic practitioners.
As a part of the system-wide health field, the dietetics/nutrition profes-
sion is bound by the same practice needs identified by the Institute of
Medicine as core competencies.4 These are: patient-centered care, work in
interdisciplinary teams, provision of evidence-based practice, application
of quality improvement, and use of informatics.
In this chapter, issues important to the future of the Academy are
emphasized. The general topics are: 1. Education, 2. Practice, 3. Com-
munications and Technology, 4. Foods and the food supply, and 5. Man-
agement and productivity.

E D UCAT I O N
Change is constant in response to dietetic practice needs. Numerous com-
mittees, study groups, surveys, and reports over the years attest to the
intent to assure qualified practitioners now and in the future. Changes
in health care, in food service, in community programs, and in govern-
mental programs and policies have all impacted the profession, making it
necessary to constantly examine the educational preparation of dietitian/
nutritionists in all of these areas.
The Academy’s Environmental Scan in 2012 identified in the Vision-
ing Report, a need for more knowledge in emerging areas in nutrition
and dietetics are identified as nutritional genomics, telehealth, nutri-
tional pharmacology, case management, behavioral counseling, prescrip-
tive authority, coding and reimbursement, evidence-based practice, and
informatics. Also indicated in the Visioning Report, most health profes-
sions are now requiring the advanced degree and experience for entry-level
230    T he F uture in D ietetics and N utrition

practice. This will become a requirement in dietetics education in 2024

due to the advancement in the profession.5
There is a further need for all professionals to be educated to work more
interprofessionally (partnering with other RDNs with unique skills and
expertise), collaborate and network with other professional disciplines,
apply evidence-based research, and business skills.6
The importance of interprofessional education is evidenced when there
is coordination among all groups providing client services or health care.
The Institute of Medicine has recommended an overhaul of the health-
care system, stating that all professionals should be educated to deliver
patient-centered care as members of an interdisciplinary team.7 This is
true in most areas of future dietetic practice. For example, a rapidly grow-
ing area of senior retirement communities and independent living facilities
will provide opportunities for RDNs and dietetics technician, registered
(DTRs). The teams will be composed of RDNs, chefs, physical therapists,
fitness trainers, occupational and speech therapists, and physicians as these
communities seek to provide a complete continuum of care for the rapidly
expanding number of “baby boomers” who choose a different lifestyle.
These communities are more in tune with social models (lifestyle, health,
wellness, physical activities, etc.) than the medical/clinical models of the
past (nursing homes, etc.). Although RDNs have not moved quickly into
these areas, their skill and knowledge are much needed in an atmosphere
where the dining experience becomes the most important event of the day
for many and it will not be served in apartments or at bedsides. In addi-
tion food and nutrition information is eagerly sought by the residents,
particularly in regard to physical activity and staying active. Corporate
management firms are forming to deliver these services and dietitians of
the future must be involved.
Several universities now incorporate interprofessional experiences in
education programs and cite a number of benefits that accrue as a result.
Part-time work experiences, summer internships, travel abroad programs,
student exchange programs, and shadowing of working professionals are
examples of such experiences that give students valuable insights into the
work world and future careers.
Educators are offering more degree options and emphases at all levels
of study. As an example of what one university offers to expand student
career options, the following are available:8
 P r a c t i c e      231

Degree Options
i. Dietetics
ii. Allied Health
iii. Human Nutrition and Pre-medicine
iv. Community Nutrition with Emphases in Nutrition and Exercise;
Nutrition Education; School Nutrition and Exercise; Nutrition
Education; School Nutrition and Food Service Management;
Food, Nutrition and the Public
Emerging trends also point to the need for practitioners to continually
acquire the necessary knowledge and skills throughout their working lives
by continuing education through advanced degrees, workshops, seminars,
webinars, distance program, and others.

P RACT IC E
Societal trends, health care, public health policies, advances in communi-
cations, technology, and the biosciences all impact the practice of dietet-
ics now and into the future.9 As new and existing competitors become
more aggressive in seeking to provide food and nutrition programs and
seminars, RDNs must become more assertive with owning the food and
nutrition profession. Trends such as these point to the need to be proac-
tive in preparing for changing roles through educational and experiential
means. Health educators and pharmacists continue to provide more food/
nutrition information which is a perfect example of the need for RDNs
to take leadership in these roles and pursue partnering and collaborating
with these professionals as well as others.
RDNs must be able to recognize the need for their expertise in new
areas and willing to try new career scenarios. These may include emergency
feeding of immigrants or displaced groups; serving on health policy groups
at all levels of government; collaborating with genetic and epidemiology
researchers to ensure that the impact of food eaten and food composition
is considered; assisting in rural health centers with assessment, treatment,
and education of clients and professionals; working with foundations/agen-
cies that fund community programs; and assisting in the development of
small businesses relating to food and nutrition in rural areas. Another area
not to be overlooked is the inclusion of the RDN in research in food and
232    T he F uture in D ietetics and N utrition

related community nutrition. An emerging role for RDNs is in promoting

community organizations to involve and assist community citizens in the
planning, implementing, and evaluating programs and research planned in
their communities to achieve healthy communities.
As a result of the 2014, Centers of Medicare and Medicaid Services rul-
ing, RDNs may write diet orders for modified diets and medical nutrition
therapy including vitamin and mineral supplementation, enteral and par-
enteral nutrition, and can order nutritional laboratory tests.10 The com-
plex knowledge of pharmacology is needed to carefully select and time
medical nutrition therapy in patients also receiving medication therapy.
It has been estimated that by the year 2050, 33 percent of the U.S. pop-
ulation will have diabetes mellitus.11 Due to this predicted increase and
changing healthcare models, RDNs will be increasingly called upon to
provide services as a level 3 educator (uncertified educator of Diabetes Self-
Management Education Provider—four levels) and DTRs will serve as level 2
educators. The emergence of nontraditional settings will require nutrition
and dietetics positions to work in community health centers, faith-based
institutions, public libraries, retail pharmacy clinics, congregate housing for
the elderly, nephrology clinics, bariatric surgery practices, patient-centered
medical homes, nurse-managed health centers, community nursing centers,
telehealth, worksites, schools, and diabetes-related companies.
The U.S. Bureau of Labor Statistics has projected growth in demand
for diabetes educators due to an expansion of federally qualified health
centers and other community health centers from the Patient Protection
and Affordable Care Act. Little work has been done at present on state
licensure of diabetes educators and they are classified as “health educators”
as there is no standard job classification by the U.S. government.12

Non-RD Practice
The Academy is faced with the reality that a large number of food and
nutrition graduates do not become registered. This may be due to any of
several reasons: lack of an internship appointment, geographical location,
or for economic reasons. Colleges and universities share a responsibility
with the association to advise students about the realities of the job market
with and without the credential. Throughout several of the chapters in
this book, suggestions are given for potential practice areas not requiring
registration. The Academy has taken some steps to assist the non-RD, but
this is a situation needing further focus and attention.
 P r a c t i c e      233

In 2013, Practice Audit of the Non-RD and DTR graduate, 13

880 individuals indicated job titles currently held and activities performed.
The survey gives insight into the types of positions held in clinical nutri-
tion practice, in community nutrition, and in food and nutrition manage-
ment. Only a few indicated a practice area in education and research or
in consultation and business. As the career and client base continues to
increase, RDNs will be in greater demand and will need to collaborate and
partner with the DTRs and other noncertified food and nutrition gradu-
ates in order to meet the growing needs. For RDNs this means assuming
leadership and moving into the “expert” roles, and delegating “novice,” or
beginning tasks to DTRs and others in order to maintain their position as
the food/nutrition experts.
As the public of all ages (especially the large numbers of baby boom-
ers) plus related professionals (MD, OT, PharmD, chefs, food compa-
nies, etc.) become more aware of the importance of nutrition and foods
in health, wellness, disease prevention, activity levels, and even mental
health, professional roles begin to blur. Again this is an indication that
RDNs must be aggressive in presenting their skills and knowledge unique
to this area.

Practice Needs
The focus of practice in all areas of food and nutrition is customer/client
needs and preferences. It can be generally said that consumers are concerned
about convenience, quality, personalization, cost, and accessibility. Leader-
ship and business skills are highly valued in the profession as are innovation
and entrepreneurship. As new practice opportunities arise that lead to new
career choices, nutrition, and dietetics practitioners will need to be even
more strategic in planning their educational pathways and careers.
There is a need for intensive, behavioral dietary counseling for persons
with a range of risk factors for chronic diseases, especially cardiovascular
disease as the major cause of death in the United States that can be deliv-
ered by nutrition and dietetics practitioners. Behavioral counseling, in turn,
suggests a need for increased skill in counseling, motivational interviewing,
coordination of care, and program planning.14 Medical care is changing and
becoming more “health care” as shown by the increase in home care, patient
centered medical homes, and independent living retirement communities.
Perhaps the greatest need in terms of numbers of clients continues to
be in the areas of health and wellness. Health and wellness concerns are
234    T he F uture in D ietetics and N utrition

becoming more universal and RDNs must take the leadership role espe-
cially since the fundamentals of food and nutrition impact every aspect
of health and wellness. The general public is becoming more aware of the
relationship between nutrition and healthy lifestyles (including mental
health). The Internet provides much information that has yet to be con-
firmed and needs translation and verification by dietetic professionals.
The potential for an exciting specific area of practice is nutritional
genomics for which RDNs will be key personnel and need education
and skills not currently being attained by enough practitioners or stu-
dents to fill the need.15 Nutrigenomics provides the potential for food
and dietary intake modifications in preventing disease, individualizing
(personalized nutrition) treatment of disease, and in health and wellness.
Ongoing research in this area illustrated the need for knowledge in nutri-
tion, genomics, bioinformatics, molecular biology, and epidemiology.
Dietitians in research are and will continue to be engaged in determining
new high tech methods of dietary assessment, futuristic food prepara-
tion, and working with food scientists to understand the complexities of
food composition in nano- and micronutrient bases. This emerging area
requires a full understanding, interpretation, and communication of com-
plex genetic testing results to assess disease risk.16
In the present healthcare climate, there are increasing opportunities for
the RDN to advocate for inclusion and to demonstrate value and willing-
ness to collaborate for new partnerships. Examples are in patient-centered
medical homes and accountability care organizations.17 This new area is
structured to reward improved outcomes of programs and treatments and
since dietitians are attuned to wellness and disease prevention, they are
well placed to take advantage of these opportunities.
A career model described as a “lattice career ladder” allows persons to
define their careers in ways that are flexible and that fulfill gaps in ser-
vices.18 As priorities and circumstances change, careers may be customized
for the best and most supportive environment.

COMMUNI C ATI O N S A N D TE C HN OL OGY

Trends in communications, informatics, and technology change and
progress on a regular basis. Business, industry, and retail establishments
provide programs, products, and services for the public and it is up to the
consumer to discern among these what is reliable and in their best interests.
 Food and the F o o d S u pp l y      235

A few dietitians have been employed with food and nutrition product
companies for years. There is a need and great opportunities for dietitians
to provide leadership with corporations and businesses in ways that help
the public obtain accurate and useful nutrition information.
Communications remain the life blood of professionals, organizations,
and business entities. Traditional means of communication such as face to
face meetings and written communication are increasingly replaced by
teleconferencing, webinars, emails, and other social media means. And the
media technology itself keeps changing and evolving. As future practice
options open, there will be an even greater need to recognize the many
communication modes available to reach consumers and for dietitians
to continually update their own professional expertise. This is also true
in the area of personalized nutrition counseling and nutrition education
(especially games for children, teens, and possibly other age groups).
Telenutrition is increasingly offered today by telephone consultation
through dietitian call centers and by other website tools for dietary assess-
ment, social networking video-based application, smartphone texting,
and others. The entry-level RD will need to keep abreast of the new tech-
nologies and their professional, personal, legal, and ethical responsibilities
in providing telenutrition. These responsibilities include digital comput-
ers regulatory requirements and privacy laws among others.19
Mobile APPS are discussed by Stein20 as an advanced way for reaching
clients for remote counseling. This has the potential of reaching many
consumers and clients outside the traditional office environment. There
are legal and policy considerations, as with any technological commu-
nication means, but this is a widespread trend that health professionals
need to be knowledgeable about for application to their practice. Another
opportunity for future RDNs to be assertive is partnering with profession-
als in information technology, engineers, and those inventing games and
other hand held devices to ensure accurate food and nutrition is included
in their products.

F O O D AN D TH E F O O D S UPPLY
Food, food safety, food sustainability, food labeling, and genetically mod-
ified foods are all topics of consumer interest and concern. At the same
time, the U.S. food supply does not match up well with dietary advice and
food policy. For instance, the Healthy Eating Index-2010 pinpoints fruit,
236    T he F uture in D ietetics and N utrition

vegetables, whole grains, dairy, and sodium at less than sufficient avail-
ability.21,22 From a public health perspective, this can be problematic in
regard to access and intake of the right kind of food. Health problems, it
should be noted, also arise from poor food choices as well as from poverty,
lack of reliable information, or lack of access to grocery stores and other
sources of food.
A framework for food and water systems that ensures equitable and
optimal access now and in the future was developed by the Hunger
and Environmental Nutrition Practice Group.23 Several principles are
incorporated24:
• Nutrition and health from safe and secure food and water supplies.
• Social, cultural, and ethical capital that promotes cultural diver-
sity; empowers social responsibility and community engagement;
advances ethical, humane, and fair treatment of individuals and
animals.
• Environmental stewardship that conserves, protects, and renews nat-
ural resources.
• Economic vitality to build community wealth and viable economics.
The involvement of RDNs and DTRs in dispersing information about
food and the food supply toward improving the health of Americans will
be even more critical in the future. Consumer attitudes and beliefs about
food are often shaped by the media and through advertising. The Dietary
Guidelines for Americans and MyPlate form the foundation for good
food choices and should be strongly promoted by all healthcare groups.
Dietitians providing input into policy formation, such as the national
Farm Bill, the dietary guidelines, and other governmental policies about
food and nutrition is a way of influencing food availability and other
issues regarding food and the food supply.25 Some of the current issues
receiving attention are more emphasis on fresh, local, and organic foods
and more federal funding for fruits and vegetable production. In the lat-
est version of the Farm Bill, funds were also provided to help farmers
transition from conventional to organic farming. Still controversial are
subsidies for dairy producers and corn growers. RDNs should be involved
in public debates over any of these issues that could preclude an adequate
food supply for all Americans.
Legislation and regulations have a direct impact on dietetic practice
through actions affecting health care, food, and consumer issues. The Dietary
 Management and L e a d e r s h ip      237

Guidelines for Americans, with an emphasis on prevention of chronic

disease through food choices, continue to be controversial. Surveys have
shown that they are not universally followed and that the agricultural sys-
tem is not fully compatible with the guidelines. This presents an urgency
for dietitians to take the lead in educating other professionals, individuals,
and the public about best food practices for health and wellness and to
document their preeminence of knowledge and skills in this area. A rela-
tively untapped area of application of the Dietary Guidelines is beginning
to emerge. A recent report in Food Management magazine documents
the implementation of the Centers for Disease Control and Prevention
(CDC) “healthy workplace foodservice guidelines” as an example of con-
sumers demanding healthier food choices for an active lifestyle.26
Food safety is an ongoing concern for all dietitians given the regu-
lar media reports of outbreaks due to food handling and contamination.
Community dietitians and nutritionists have many opportunities for rais-
ing awareness of safety risks and ways to prevent illness through good
practices. Through programs such as Child School Nutrition, the Elderly
Nutrition Program, WIC, and the Supplemental Nutrition Assistance
Program (SNAP), consumers can be reached directly with food safety
information critical to health. Oversight of regulations and enforce-
ment of sanitation codes and safety measures in effect are also important
steps in safeguarding health. Most of these food safety issues provide an
opportunity for partnering of RDNs and microbiologists, chefs, sanitarian
specialists, and other professionals.

MANAG E M E N T A N D L E A DER SHI P

Although only about 12 percent of RDNs identify their area of practice
as Food and Nutrition Management, all dietitians are managers in certain
ways. An emphasis on managerial competence is needed more than ever
as opportunities for expanded interprofessional employment occur.The
food and foodservice environment will drive changes in the profession
and the role of food service and the manager will become more important
at the same time. The ability to manage budgets, personnel produc-
tion, and service is a complex and challenging undertaking. Managerial
skills acquired through both education and experience help prepare
individuals to assume positions of increasing responsibility and, in turn,
better salaries.
238    T he F uture in D ietetics and N utrition

Management skills have been identified as a weakness among entry-

level RDNs by employers.27 The Academy has identified management
competencies in food and nutrition services in health care but it has been
suggested that educational competencies need to be reexamined to pro-
mote management as an essential part of the dietetics curriculum and
professional practice. Management is a critical skill in all areas of practice.
Employers emphasize the need for RDNs who can see the big picture and
think strategically, run and justify programs, understand health care as a
business, add value, and are entrepreneurial.27
Hospitals are challenged to offer healthier food in all areas; school nutri-
tion program directors are required to respond to new regulations, public
eating places are increasingly required to make nutrition information avail-
able and some policy makers are dealing with public initiatives that pro-
mote healthier practices through taxes or other directives. The challenges
are very real and management expertise in all areas of practice is needed to
help meet the needs in food service and in programs for the public.
Productivity and accountability are integral parts of a manager’s respon-
sibility. Managers are expected to make decisions in the best interests of
the system—not just a department. Critical, forward-looking thinking is
valued and is an essential part of ensuring productivity of a unit. In this
regard, another dimension—that of “polarity thinking” is necessarily a
part of what a manager must do. Polarities are defined as interdependent
yet potentially polar opposite pairs of values.28 An example is a manager
or an institution holding to the highest quality of food service but at the
lowest cost. Another example is a school that wants to promote good
eating for students but also provides vending machines with junk food
for income. A community dietitian may be faced with advising clients to
follow the Dietary Guidelines when they lack access to good sources of
fruits and vegetables or they lack knowledge or can’t afford them. Polarity
thinking requires skill in balancing both ends of such situations within the
context of the organization. Even though they may be competing values,
they must be managed effectively, and simultaneously.
Leadership skills for the dietitian are essential in communications, in
demonstrating ability and professionalism, and in building brands and
businesses. Consultants in all areas of practice must display leadership skill
in order to be successful. Leadership involves keeping abreast of future
and emerging trends, networking and sharing knowledge, being innova-
tive and creative, and even risk-taking.
 R e f e r e n c e s      239

S UMMARY
The future offers many challenges and opportunities for dietitians. Food
and nutrition are gaining prime importance in the issues of health and
wellness at no time in the past as there been so much interest in nutrition
and food science. Dietetic professionals must “seize the moment” as sug-
gested by Healy and be ready to embrace the changes and challenges of the
future. Educational standards will change as practice requirements evolve
and educators respond to change in the best interests of their students.
The workplace increasingly offers new and innovative areas for practice
especially for the professional who is willing to take the risk for a new
and exciting career. Some things will not change. Continuing education
with increased knowledge and expertise will always be needed in keeping
with communication and technological changes. Effective managers and
leaders in food service systems and nutrition systems as well as in all other
areas of practice will continue to be valued and valuable to patients, client,
student, customers, and the public.

D E F INI T I O N S

Healthy Eating Index. A measure of diet quality that assesses conformity

to recommended dietary intake.
Food sustainability. Describes adequacy of the food supply.
Paradigm. A model or template for how things should be done.
Polarity. Pertaining to the opposite ends or sides of an object or subject.
Productivity. The output efficiency of something produced or measured.
Standards. Statements of specifications by which something may be
tested or measured.

REFE REN C E S
1. Healy, B. Why Nutrition and Genomics Are Important. “The Promise of Nutrige-
nomics.” Institute of Medicine. Nutrigenomics and Beyond: Informing the Future—
Workshop Summary. (Washington, DC: The National Academies Press, 2007).
2. Kicklighter, J.R., M.M. Cluskey, A.M. Hunter, N.K. Nyland, and B.A. Spear.
“Council on Future Practice Visioning Report and Consensus Agreement for
Moving Toward the Continuum of Dietetics Education, Credentialing, and
Practice.” J Acad Nutr Diet 113, no. 12 (2013): 1710–1731.
240    T he F uture in D ietetics and N utrition

3. Connor, S.L. “Our Academy’s First Hundred Years—and the Next.” J Acad Nutr
Diet 115, no. 2 (2015): 179.
4. Institute of Medicine. “The IOM’s Future Practice Educational Recommenda-
tions.” 2012.
5. Rationale for Future Education Preparation of Nutrition and Dietetics
Practitioners. 2015. www.eatright.org/ACEND
6. Eliot, K.A. “The Value in Interprofesssional Collaborative-Ready Nutrition and
Dietetics Practitioners.” J Acad Nutr Diet 115, no. 10 (2015): 1578–1588.
7. See Note 4.
8. Department of Nutritional Sciences. Oklahoma State University. 2015–2016.
(With permission.)
9. See Note 2.
10. Federal Register. Medicare and Medicaid Programs; regulatory provisions to promote
program efficiency, transparency and burden reduction. www.federalregister.gov.
May 12, 2014. (4/4/16).
11. Martin, A.L., and R.D. Lipman. “The Future of Diabetes Education: Expanded
Opportunities and Roles for Diabetes Educators.” Diabetes Educ 39, no. 4 (2013):
436–446.
12. See Note 11.
13. Sauer, H. “Results of the 2013 Non-RD Baccalaureate DPD Graduate Dietetics
Practice Audit.” J Acad Nutr Diet 114, no. 10 (2014): 1630–1639.
14. Smart, H. “Nutrition Students Gain Skills from Motivational Interviewing
Curriculum.” J Acad Nutr Diet 114, no. 11 (2014): 1712–1717.
15. See Note 1.
16. www.eatright.org/ACEND Standards.
17. Boyce, B. “Emerging Paradigms in Dietetics Practice and Health Care: Patient-
Centered Medical Homes and Accountable Organizations.” J Acad Nutr Diet 115,
no. 11 (2015): 1765–1770.
18. Gilbride, J.A., S.C. Parks, and R. Dowling. “The Potential of Nutrition and
Dietetics Practice.” Topics in Clinical Nutrition 28, no. 3 (2013): 220–232.
19. Benko, C., and S. Vickberg. “The Corporate Lattice: A Strategic Response to the
Changing World of Work.” Deloitte Review 8 (2011): 95–97.
20. Stein, K. “Remote Nutrition Counseling: Considerations in a New Channel for
Client Communications.” J Acad Nutr Diet 115, no. 10 (2015): 1561–1576.
21. Miller, P.E., J. Reedy, S.I. Kirkpatrick, S. Krebs-Smith. “The United States Food
Supply Is not Consistent with Dietary Guidance: Evidence from an Evaluation
Using the Healthy Eating Index-2010.” J Acad Nutr Diet 115, no. 1 (2015): 95–100.
22. Zizza, C.A. “Policies and Politics of the US Food Supply.” J Acad Nutr Diet 115,
no. 1 (2015): 27–30.
23. Tagtow, A., K. Robien, R. Bergquist, M. Bruening, L. Dierks, B.E. Hartman,
R. Robinson-O’Brien, et al. “Academy of Nutrition and Dietetics: Standards of
Professional Performance for Registered Dietitian Nutritionists (Competent,
Proficient, and Expert) in Sustainable, Resilient, and healthy Food and Water
Systems.” J Acad Nutr Diet 114, no. 3 (2014): 475–488.
 R e f e r e n c e s      241

24. See Note 23.

25. Taylor, M. “CDC Builds New Café on Healthy-Eating Guidelines.”
Food Management 10, no. 2 (2016): 19.
26. Berthelson, R.M., W.C. Barkley, P.M. Oliver, V. McLymont, R. Puckett. “Academy
of Nutrition and Dietetics: Revised 2014 Standards of Professional Performance
for Registered Dietitian Nutritionists in Management of Food and Nutrition
Systems.” J Acad Nutr Diet 114, no. 7 (2014): 1104–1112.
27. “Practice Paper of the Academy of Nutrition and Dietetics: Principles of Produc-
tivity in Food and Nutrition Services: Applications in the 21st Century Health
Care Reform Era.” J Acad Nutr Diet 115, no. 7 (2015): 1141–1147.
28. Cluskey, M., B. Gerald, and M. Gregoire. “Management in Dietetics: Are We
Prepared for the Future?” J Acad Nutr Diet 112, Suppl. 2 (2012): S34–S35.
 A

APPENDIX
Code of Ethics for the
Profession of Dietetics
and Process for
Consideration of Ethics
Issues (2009)

P REAMBL E
The American Dietetic Association (ADA) and its credentialing agency,
the Commission on Dietetic Registration (CDR), believe it is in the
best interest of the profession and the public it serves to have a Code
of Ethics in place that provides guidance to dietetic practitioners in
their professional practice and conduct. Dietetics practitioners have
voluntarily adopted this Code of Ethics to reflect the values and ethical
principles guiding the dietetics profession and to set forth commitments
and obligations of the dietetics practitioner to the public, clients, the
profession, colleagues, and other professionals. The current Code of
Ethics was approved on June 2, 2009, by the ADA Board of Directors,
House of Delegates, and the Commission on Dietetic Registration.

243
244    C ode of E thics for the P rofession of D ietetics

AP PLICAT I O N
The Code of Ethics applies to the following practitioners:
(a) In its entirety to members of ADA who are Registered Dietitians
or Dietetic Technicians.
(b) Except for sections dealing solely with the credential, to all mem-
bers of ADA who are not RDs or DTRs.
(c) Except for aspects dealing solely with membership, to all RDs and
DTRs who are not members of ADA.

FU ND AME N TA L P R I N C I P L E S

1. The dietetics practitioner conducts himself/herself with honesty,

integrity, and fairness.
2. The dietetics practitioner supports and promotes high standards of
professional practice. The dietetics practitioner accepts the obliga-
tion to protect clients, the public, and the profession by upholding
the Code of Ethics for the profession of dietetics and by reporting
perceived violations of the Code through the processes established
by ADA and its credentialing agency, CDR.
3. The dietetics practitioner considers the health, safety, and welfare
of the public at all times.
4. The dietetics practitioner complies with all laws and regulations
applicable or related to the profession or to the practitioner’s ethi-
cal obligations as described in this Code.
5. The dietetics practitioner provides professional services with
objectivity and with respect for the unique needs and values of
individuals.
6. The dietetics practitioner does not engage in false or misleading
practices or communications.
7. The dietetics practitioner withdraws from professional practice
when unable to fulfill his or her professional duties and responsi-
bilities to clients and others.
8. The dietetics practitioner recognizes and exercises professional
judgment within the limits of his or her qualifications and collabo-
rates with others, seeks counsel, or makes referrals as appropriate.
 F u n d a m e n t a l P r i n c ip l e s      245

9. The dietetics practitioner treats clients and patients with respect

and consideration.
10. The dietetics practitioner protects confidential information and
makes full disclosure about any limitations on his or her ability to
guarantee full confidentiality.
11. The dietetics practitioner, in dealing with and providing services
to clients and others, complies with the same principles set forth
above.
12. The dietetics practitioner practices dietetics based on evidence-
based principles and current information.
13. The dietetics practitioner presents reliable and substantiated infor-
mation and interprets controversial information without personal
bias, recognizing that legitimate differences of opinion exist.
14. The dietetics practitioner assumes a life-long responsibility and
accountability for personal competence in practice, consistent with
accepted professional standards, continually striving to increase
professional knowledge and skills and to apply them in practice.
15. The dietetics practitioner is alert to the occurrence of a real or
potential conflict of interest and takes appropriate action when-
ever a conflict arises.
16. The dietetics practitioner permits the use of his or her name for
the purpose of certifying that dietetics services have been rendered
only if he or she has provided or supervised the provision of those
services.
17. The dietetics practitioner accurately presents professional qualifi-
cations and credentials.
18. The dietetics practitioner does not invite, accept, or offer gifts,
monetary incentives, or other considerations that affect or rea-
sonably give an appearance of affecting his or her professional
judgment.
19. The dietetics practitioner demonstrates respect for the values,
rights, knowledge, and skills of colleagues and other professionals.
Adapted from Journal of the American Dietetic Association, 109(8)
“The  American Dietetic Association/Commission on Dietetic
Registration Code of Ethics for the Profession of Dietetics and Process for
Consideration of Ethics Issues,” pp. 1461–1467, Copyright © 2009, with
permission from Elsevier.
 B

APPENDIX
Dietetics Career
Development Guide

247
 248    D ietetics C areer D evelopment G uide

Dietetics Career Development Guide

Expert
Builds and maintains
knowledge,
skills and credentials

Advanced Practice
Continues at the highest level of knowledge,
skills & behaviors including leadership,
vision and/or advanced credential

Proficient
Operational Skills Obtained and Adeptly Practiced Long Term
May Begin to Acquire Specialist Credentials
Life-long Learning and Professional Development …

Competent
Standards
Start of Practice after Registration
of
(Generally, the First Three Years of Practice)
Standards Professional
of Practice Performance
(SOP) (SOPP)

Beginner
(Learning Phase)
CP Supervised Practice DTP
(Coordinated DI (Dietetic Technician
Program) (Dietetic Internship) Program)

Novice
CP Didactic Education DTP
(Coordinated DPD (Didactic (Dietetic Technician
Program) Program in Dietetics) Program)

RD Pathways DTR Pathway

Knowledge &
Focus Area
Skills

EDUCATION FOR ENTRY INTO CAREER

Associate, Baccalaureate or Advanced Degree
Definition of Dietetics: Dietetics is the integration, application and communication of
principles derived from food, nutrition, social, business and basic sciences, to achieve
and maintain optimal nutrition status of individuals through the development, provision
and management of effective food and nutrition services in a variety of settings.
© Academy of Nutrition and Dietetics. Reprinted by permission of Academy of Nutrition
and Dietetics.
 Glossary

Academy of Nutrition and Dietetics. The professional organization for

dietitians. Formerly known as the American Dietetic Association.
Accreditation. The process whereby a private nongovernmental agency
or association grants public recognition to an institution or an indi-
vidual who meets necessary qualifications and periodic evaluation.
Advanced practice. Effective discharge of job requirements that demon-
strates a high level of skills, knowledge, and behaviors.
Advanced study. Study beyond the traditional baccalaureate level.
Anorexia nervosa. An eating disorder characterized by a preoccupation
with dieting and thinness that leads to excessive weight loss.
Assessment. The process of evaluating actions or conditions to base
additional activity.
Benchmarking. Comparing performance measures for the development
of better methods and procedures.
Bulimia nervosa. An eating disorder involving frequent episodes of
binge eating followed by purging, also leading to excessive weight loss.
Bylaws. Authoritative rules governing an association or group.
Cardiovascular nutrition. Application of medical nutrition therapy for
those with heart and blood vessel conditions or to prevent the diseases.

249
250    G lossary

Certification. The process by which a nongovernmental agency or

association grants recognition to an individual who has met certain
predetermined qualifications specified by that agency or association
(e.g., registration for dietitians and dietetic technicians administered
by the CDR).
Chief executive officer (CEO). A person employed by the association
to direct the headquarters office operations and implement the
programs and fiscal affairs of the association. May also serve as an
official spokesperson for the Academy on direction of the board of
directors.
Client. The recipient of services or products.
Clinical dietetics. The area of practice in which persons with illness
or injury involving nutritional factors are treated using assessment,
planning, and implementing nutrition care plans.
Clinical nutrition services. Activities provided in the practice of clinical
dietetics, such as medical nutrition therapy and counseling.
Coach. A person who guides, inspires, and motivates.
Cognitive skills. The application of intellectual capabilities to accom-
plish objectives.
Community health. Health measures applied to groups of people.
Community nutrition. Nutrition issues and services provided for groups
of people.
Consultant. A skilled and knowledgeable person qualified to give expert
professional advice.
Coordinated program (CP). A degree undergraduate program that com-
bines didactic and experiential learning.
Credentialing. Formal recognition of professional or technical compe-
tence as by certification or licensure.
Diet therapy. Treatment by diet; a term now replaced by clinical nutri-
tion therapy or medical nutrition therapy .
 G lossary      251

Dietetic practice group (DPG). An organized group of Academy of

Nutrition and Dietetics members with similar interests in an area of
practice or a particular subject area.
Dietetic technician. A graduate of an approved dietetic technician
program.
Dietitian. A professional who translates the science of food and
nutrition to enhance the health and well-being of individuals and
groups.
Disordered eating. Abnormal eating patterns.
Diversity. A term with multiple, subjective definitions; may refer to age,
physical ability, religion, socioeconomic status, sex, race, ethnicity,
or other factors.
Education. The systematic instruction and training designed to impart
knowledge and develop a skill.
Entrepreneur. An innovative person who initiates a new activity, career,
or business.
Evidence-based research. The compilation of research studies that,
together, allows for a decision regarding application to practice.
Evidence-based. Action based on research data and evaluation of
outcomes.
Extended care facility. An institution that extends health care beyond
the acute care setting when long-term term care is needed.
Food Assistance. Food that is provided in feeding programs or by
voucher to buy food.
Food production. The process of preparing and serving food, including
purchasing, storage, and processing.
Food service systems. Activities that together form the inputs, transfor-
mation, and outputs that make up an entire food operation.
Food services. Production and service of food; also refers to the unit or
group responsible for feeding groups.
252    G lossary

Food sustainability. Describes adequacy of the food supply.

Governance. Activities involved in conducting the affairs of an
organization.
Health promotion. Education and preventive measures directed toward
healthy populations to foster wellness and prevention of disease.
Healthy Eating Index. A measure of diet quality that assesses conformity
to recommended dietary intake.
Human resources. The personnel in an organization.
Instruction. The activity by which knowledge or teaching is imparted.
Intrapraneur. A person within an organization who develops new ideas
or services.
Leadership. The qualities that allow an individual to influence the
actions of others.
Licensure. Process by which a government agency grants permission to an
individual to engage in a given occupation upon finding that the appli-
cant has attained the minimal degree of competency necessary to ensure
that the public health, safety, and welfare are reasonably well protected.
Long-term care. Assistance provided over time to people with chronic
health conditions and/or physical disabilities and those who are
unable to care for themselves.
Managed care. A system of care administered by an entity outside a
hospital or healthcare institution in which access, cost, and quality
of care are controlled by direct intervention before or during service
for purposes of creating efficiencies and/or reducing costs.
Management. The administration and coordination of the activities
and functions in an organizational unit.
Medical nutrition therapy. The application of nutrition in the manage-
ment of illness or injury.
Mentor. A person who teaches and guides by instructing, demonstrat-
ing, encouraging, and role modeling.
 G lossary      253

Networking. Activities directed toward making connections with others

through varied contacts.
Nutrition assessment. Evaluation of an individual’s nutritional status based
on anthropometric, biochemical, clinical, and dietary information.
Nutritionist. A professional with academic credentials in nutrition; he
or she may also be an RD.
Outcomes research. Studies that focus on results of interventions and
application of research results.
Outpatient clinic. Treatment area of a hospital or healthcare facility in
which patients are treated on an outpatient basis.
Paradigm. A model or template for how things should be done.
Polarity. Pertaining to the opposite ends or sides of an object or subject.
Political Action Committee. Group pooling of money to support politi-
cal candidates or office holders.
Practitioner. One who practices in a profession or occupation.
Preceptor. A person who guides, mentors, and evaluates a student dur-
ing supervised practice.
Private practice. Self-employment in which a person manages his or her
own working career.
Productivity. The output efficiency of something produced or measured.
Program planning. Needs assessment and action plans to meet needs.
Psychomotor skills. The ability to perform physical tasks based on know-
ing or thinking.
Public Policy. The promotion of a law, a regulation, or a recommenda-
tion targeted to the public at large.
Quality assurance. The certification of the continual, optimal, effective,
and efficient outcomes of a service or program.
Quality improvement. The provision of service that assures the needs of
those served are met through adherence to high standards of care.
254    G lossary

Registered dietitian (RD). A dietitian who has fulfilled the eligibility

requirements of the Commission on Dietetic Registration.
Registration. See Certification.
Regulation. Written rules to activate laws passed through legislation.
Research. Systematic investigation leading to new knowledge or new
applications of known information. To conduct research, a question
is formulated, a literature search is conducted, experimental activi-
ties are applied, and results are recorded.
Resource allocation. The equitable distribution of financial, physical,
and human capital.
Resource management. The handling of money, equipment and supplies,
or personnel essential to the administration of an organizational unit.
Scope of practice. Extent of or dimensions of activities performed in an
area of practice.
Specialist. One who possesses a proficient level of knowledge, skill, and
experience to qualify for a specific credential.
Sports nutrition. The area of nutrition specific to the needs of those who
participate in sports activities.
Standard. A measure of proficiency at an established level.
Standards. Statements of specifications by which something may be
tested or measured.
Strategic plan. Plans and strategies that shape the overall activities and
functions of an organization.
Strategic planning. Long-range planning that involves data gathering,
data analysis, development of goals and objectives, and action plans.
Supervised practice. Learning experiences associated with activities
guided by a leader or preceptor.
Surveillance. Research-based activities to assess a program’s reach and
impact.
Training. Actions by which persons are brought to a desired standard
of efficiency or behavior by instruction and practice.
Wellness. State of optimal health and the absence of disease.
 Index
Page numbers followed by f or t represent figures and tables.

A legislative network coordinator (LNC), 136

Academy Nutrition Informatics lobbying of, 11
Committee, 103 membership, 9, 24–25
Academy of Nutrition and Dietetics mission statement of, 23
(AND), 21–35, 163, 167, 214 partner organizations, 14–15
affiliated units of, 33–34 political action committee, 11
associate members of, 9 Political Action Committee
board of directors, 13–14, 26 (ANDPAC), 136
bylaws of, 5, 22 position and practice papers, 135–136
code of ethics. See Code of Ethics for the position papers of. See Position papers of
Profession of Dietetics academy
Commission on Dietetic Registration public policy workshop, 135
(CDR), 28 registration status through, 9–10, 54–55
constitution of, 22 Research Committee of, 216–217
contact information, 15 salary surveys, 31–33, 32t
defined, 17 strategic plan for, 23–24
dietetic practice groups, 28–31, 29–31t. values of, 23
See also Dietetic practice groups Washington office, 11, 34, 135
(DPGs) website, 15, 60
diversity initiatives of, 80 Academy of Nutrition and Dietetics
dues for membership, 5, 24 Foundation, 10, 33
Evidence Analysis Library, 219 Academy practice groups, 169
founding of, 4–6 Accreditation, defined, 48
goals and strategic plan of, 13, 23–24 Accreditation Council for Education in
governance of, 25–31 Nutrition and Dietetics (ACEND),
historical events in, 16 27–28, 40–41, 47–48, 228
historical overview, 22 Active learner, 206
house of delegates, 26–27 Active membership, in academy, 24
journal, 6 Acute care, food and nutrition management
legislative activity of, 11, 34 in, 111

255
256     I ndex

ADA. See American Dietetic Association Association for Managers of Food

(ADA) Operations (AMFO), 10
Administrative dietetics. See Management Association of Nutrition and Foodservice
Admission requirements, for coordinated Professionals (ANFP), 10
program, 39 Athletic trainers. See Sports nutrition
Adolescents. See Children Attitudinal skills, 206
Advanced-level education, 43–46. See also Audit of practice areas, clinical dietetics, 95
Continuing education
benefits of, 43–45, 44t B
defined, 43 Baccalaureate degrees, 38
graduate programs, 45 Behavioral counseling, 233
research experience, 45–46 Behavioral Health Nutrition and Weight
types of programs, 43 Management, 169
Advanced practice Benchmarking, 182
in clinical nutrition, 65 Board of directors (BOD), 13–14, 26
defined, 48 Bulimia nervosa, 163
Advanced study, defined, 48 Business skills, 186, 186f
Alliance for a Healthier Generation, 16 Bylaws
Ambulatory care centers, 100 of academy, 5, 22
American Alliance on Health, Physical defined, 35
Education, Recreation, and
Dance, 167 C
American Association of Retired Cardiovascular nutrition, 165–166
Persons, 167 Career choices. See also Employment
American College of Sports Medicine, 167 cardiac rehabilitation programs, 165–166
American College of Sports Medicine community dietitian, 127
Exercise Test Technology consultants. See Consultants
certification, 153 for dietitian in business and
American College of Sports Nutrition, 163 communications, 159–160
American Diabetes Association, 14 for dietitian in education, 195–198
American Dietetic Association (ADA), 176. of dietitians/dietetic technicians, 93–94,
See also Academy of Nutrition and 93–94t
Dietetics (AND) sports nutrition and fitness, 164–165
and dietetics profession, 8 treatment of disordered eating, 168–169
historical overview, 4–5 trends
history and growth of, 9–15, 12t education, 229–231
American Home Economics Association, 5 practice of dietetics, 231–234
American Hospital Association, 14 wellness and health promotion, 166–168
American Overseas Dietetic Association, Career development, 57. See also Advanced-
15, 34 level education; Continuing
American Public Health Association, 14, 167 education
Anorexia nervosa, 163 Center for Nutrition Policy and
Areas of practice, 11–12, 12t. See also Promotion, 167
Employment Centers for Disease Control and
Army dietitians, 137–138 Prevention, 167
Army Medical Specialist Corps, 137 Centers for Medicare and Medicaid
Assistantships, 45 Services or (CMS), 145
Associate membership, in academy, 24 Certificates of training, 63–64
 I n d e x      2 5 7

Certification, 55–67 Coaches. See also Mentors

advanced practice in clinical nutrition, educators as, 199
62–63 managers as, 180
defined, 68 Coaching and mentoring, 180
dietetic technicians, registered, 56–58 Code of Ethics for the Profession of Dietetics, 154
effect on salary, 44–45 adoption and maintenance of, 27
establishment of, 9 cultural competence and, 80
interdisciplinary specialist certification development of, 9, 55
in obesity and weight management, ethical practice, 184
61–62 professional practice, 77–79, 79t
recertification, 64–65 quality management, 183
of registered dietitian, 56 Cognitive interview technique, 202
of specialists, 60–61 Cognitive skills, 206
Certified dietary manager (CDA), 10 Colleges and universities
Chief clinical dietitian, 100 accreditation by ACEND, 40–41
Chief executive officer (CEO), 35 distance education, 46–47
Childhood obesity, 122 undergraduate degrees, 38–39
Children Commercial food service, 114. See also
community nutrition work for, 126 Management
obesity in, 16 Commission on Dietetic Registration
school nutrition programs, 112–113 (CDR), 28, 193, 228
Child School Nutrition, 237 certificates of training, 63–64
Chronic illness, 93 certification through
Client. See Patients advanced practice in clinical nutrition,
Clinical dietetics, 91–105 62–63
clinical dietitian, 100–102 DTRs, requirements for, 56–58
defined, 105 interdisciplinary specialist certification
dietetic assistant, 102 in obesity and weight management,
dietetic technician, 102 61–62
earliest use of, 2–4, 92–93 RDs, requirements for, 56
employment settings of, 93–94, 93–94t recertification, 64–65
employment survey for, 11–12, 12t specialists, requirements for, 60–61
history of, 92–93 code of ethics, 9, 55
medical nutrition therapy, 98–99 development of, 54
nutrition care process and model, Commission on Dietetic Registration
96–98, 97f practice audit, 2010, 183
organization of clinical nutrition services, Communication
95–96 communicator, role of, 202
outlook and trends for, 102–104 components of, 204
practice audit activities, 95 consumer message development model,
standards of practice, 99 204, 204f
standards of professional managers and, 179–180
performance, 99 means of communicating nutrition,
trends in, 104 205, 205f
Clinical nutrition managers, 100, 113 mobile APPS, 235
Clinical nutrition services, 105. See also relationship management and, 185
Medical nutrition therapy (MNT) telenutrition, 235
Clinical privileging, 104 trends in, 234–235
258     I ndex

Community dietitian, 122, 238 Copyrighted research, 78

career outlook, 127 Council on Future Practice, 47, 228
Community nutrition, 11–12, 12t, 122 Counseling, 202
activities of, 125–126 Counselors, dietitians as, 160, 162. See also
community dietitian and, 125 Medical nutrition therapy (MNT)
cooperative extension activities, 126 for athletes, 164
earliest use of, 5 behavioral dietary counseling for at risk
nutrition professionals in, 125 persons, 233
RDN, role of, 125 cardiac rehabilitation programs, 165
Compensation and Benefits survey, 44 educators, 202
Competencies, supervised practice, roles as perceived by the teacher,
41–42 preceptor/teacher, preceptor/
Computer matching for supervised mentor, and mentor, 200t–201t
practice, 39 for family sports enthusiasts, 165
Conflict management, 180 wellness and health promotion, 167
Conflicts of interest, 78 Credentialing of nutrition and dietetic
Consultants practitioners, 51–68
areas of practice, 146, 149, 151 appropriate use of, 65–66
in business and nontraditional career Commission on Dietetic Registration, 55
areas, 148–149 defined, 68
contracts and fees, 144–145 development of, 54–55
employment survey for, 11–12, 12t DTR credential, requirements for, 56–58
ethical and legal bases of practice, 154 overview of, 52–54
in health care and extended care, RD credential, requirements for, 56
145–148 specialist credential, requirements for,
in private practice, 150–154, 60–61
152t–153t Cultural competence, 80
quality assurance in practice, 148 Customer focus, 23
regulations for, 146
roles and responsibilities, 146–147 D
starting a practice, 143–144 Decision making
Consumer message development model, ethical practice and, 77–79, 79t
204, 204f evidence-based practice and, 85, 86–87t
Continuing education informatics, 82, 83
advanced level education, 43–46, 44t nutrition care process and model,
Center for Professional 96–98, 97f
Development, 80 Department of Health and Human Services
delivery of learning, 81–82 (DHHS), 131–132, 134
distance education, 46 Diabetes Care and Education (DCEDPG)
HIPPA Act, 84 practice group, 61
informatics, 82, 83 Diagnosis, 96, 97f
management in food and nutrition Dial-a-dietitian program, 15
systems, 110–114 Didactic program in dietetics (DPD),
“Continuing Survey of Food Intakes of 38–39, 58
Individuals” (CSFII), 131 Diet and Health Knowledge Survey
Cooking classes, 3–4 (DHKS), 131
Coordinated program in dietetics (CP), Dietary Guidelines, 236–237, 238
39–40, 48 Dietary guidelines for public, 133–134
 I n d e x      2 5 9

Dietary reference intakes (DRIs), 134 as consultants, 143–154. See also

Dietetic assistant, 102 Consultants
Dietetic practice doctorate degree, 43 defined, 17, 52, 92
Dietetic practice groups (DPGs), 12 educational activities of, 193, 193t
defined, 17 education for. See Education
descriptions and purpose of, 28–31, educator role of, 192–193, 198–205
29–31t employment settings of, 93–94, 93–94t
dues for, 24 employment survey for, 11–12, 12t
networking through, 28 ethics and, 77–78
subunits of, 28 expanded opportunities for, 117
Dietetics. See also Clinical dietetics expanded roles, 117–118
educational preparation for. in health and wellness programs, 161–169
See Education legal considerations for, 84–85
employment survey for, 11–12, 12t means of communicating nutrition,
history of, 1–17. See also History of 205, 205f
dietetics as mentor, 160
as profession, 8–9 networking, 160–161
standards of practice, 148 nontraditional choice of career for,
Dietetics Career Development Guide, 59 158–161
Dietetics Practice-Based Research Network in private practice, 159
(DPBRN), 214, 217 professional practice of. See Professional
Dietetics technician, registered practice
(DTRs), 230 salaries of, 31–33, 32t
practice of dietetics, 233 in sports nutrition, 162–165
role in dispersing information, 236 strategic skill building, 161
Dietetic technician (DT) program, 39, 40 teaching skills, 194–195
Dietetic technicians, registered (DTRs), in treatment of disordered eating,
125, 130, 142 168–169
career development for, 57 in wellness and health promotion,
credentialing of, 58–60 166–168
defined, 17 Dietitians in Business and Communications
educational requirements. See Education practice group, 169
employment settings of, 57–58, 93–94, Dietitians of Canada, 163
93–94t. See also Employment Dietotherapy, 5
employment survey for, 11–12, 12t Diet therapy, 2–4, 92, 105
legal regulation statutes for, 66–67 Disease prevention, 124–125
management activities of, 109–110, Disordered eating, 168–169
109–110t Distance education, 46–47
recertification of, 64–65 District and state associations, 33
registration eligibility pathway for, 58–60 Diversity, 23, 80, 88
responsibilities of, 102 Doctoral degree, 43
salaries of, 31–33, 32t DPD. See Didactic program in dietetics
scope of practice for, 75 (DPD)
Dietitians Dreyfus model of skill acquisition, 59
in business and communications, Drucker, Peter, 175
158–161 Dues/maintenance fees
in cardiovascular nutrition, 165–166 for academy membership, 5, 24, 27
for clinical dietetics. See Clinical dietetics for dietetic practice groups, 28
260     I ndex

E opportunities for DTRs, 57–58

Education, 37–48 public health/community dietitian, 127
advanced-level, 43–46, 44t survey for, 11–12, 12t
coordinated program in dietetics, Entrepreneur, 142, 143, 150
39–40 The Entrepreneurial Dietitian and The
degree options, 231 Competitive Edge (Helm), 143
didactic program in dietetics, 38–39, 59 Entry-level dietitians, management
dietetic technician program, 39, 40 activities of, 109–110, 109–110t
distance, 46–47 E-professionalism, 78
for DTR registration eligibility pathway, Evidence Analysis Library (EAL), 85, 98–99
58–60 Evidence-based practice (EBP), 98, 219–220
early requirements, 8–9 for decision making, 85, 86–87t
emerging areas in nutrition and dietetics, defined, 85, 88
229–230 standards of practice based on, 76
future preparation, 47–48 Extended care facility, defined, 105
graduate, 43
scholarships, 33 F
standards, 5, 27, 40–41 Family Medical Leave Act (FMLA), 179
supervised practice in dietetics, 41–42 Fellow of the Academy of Nutrition and
trends in, 13 Dietetics (FAND), 8
undergraduate, 38–39 Fellow of the American Dietetic Association
Educators, dietitians as (FADA), 62
activities of, 193, 193t Food and Culinary Professionals practice
adults as learners, 208 group, 169
career opportunities for, 195–198 Food and Drug Administration, 130–131
coaches, 199 Food and Nutrition Board of the National
communicator, 202–205, 204f–205f Research Council, 130
counselors, 202 Food and Nutrition Conference and
employment survey for, 11–12, 12t Exposition (FNCE), 81
history of, 5 Food and Nutrition Information Center, 167
mentors, 198–199 Food and nutrition management, 237–238
planning lessons, 194 Food and nutrition managers, characteristics
preceptors, 199–200, 201t–202t of, 114–116, 115f, 116t
teaching groups and teams, 208–209 Food and Nutrition Science Alliance
teaching process, 194–195 (FANSA), 14
types of learning, 206–208 Food assistance and nutrition programs,
university faculty roles, 196 132–133
Elderly Nutrition Program, 237 Food legislation and regulations, 133
Electrocardiogram-monitored stress tests in Food production, defined, 119
sports medicine, 153 Food Pyramid, 134
Electronic health records, 103 Food safety, 123, 127, 131, 133, 159, 237
Employment Food services, defined, 119
areas of practice, 11–12, 12t Food service systems, defined, 119
of dietitians/dietetic technicians, 93–94, Food supply, position papers on, 235–237
93–94t Frances Stern Clinic, 4
management in food and nutrition Fund-raising, 33
systems, 110–114, 117 Future of dietetics, planning for, 13–14
 I n d e x      2 6 1

G Healthcare Leadership Alliance, 185

General clinical research center Healthcare Leadership Alliance
(GCRC), 220 Competency Model, 186f
Generalist Health informatics, 82, 83
defined, 53 Health Information Technology for
role of, 54 Economic and Clinical Health
GENIE. See Guide for Effective Nutrition (HITECH), 103
Intervention and Education Health Insurance Portability and
(GENIE) Accountability Act (HIPPA) of
Gerontological nutrition specialists, 60 1996, 84, 146
Global learner, 206 Health promotion, 124–125
Goal setting, 184 Health records, electronic, 103
of academy, 13 Healthy Eating Index-2010, 235–236
Governance of academy History of dietetics, 1–17
Accreditation Council for Education in areas of practice, 11–12, 12t
Nutrition and Dietetics (ACEND), clinical dietetics, 92–93
27–28, 40–41 dietetic practice groups, 12
board of directors, 13–14, 26 dietetic technicians, 10–11
Commission on Dietetic Registration dietitian, early definition of, 52
(CDR), 55 early practice of, 2–4, 108–109
defined, 35 leaders in, 6–8
house of delegates, 26–27 legislative activity, 11
Government, U.S. long-range planning, 13–14
military dietetic careers, 4 managers, 10
Government programs in food and milestones in, 9–15, 12t
nutrition, 131–135 public outreach, 15–16
dietary guidelines, 133–134 World War I and, 4, 5, 11
food assistance and nutrition programs, World War II and, 4, 6
132–133 Honorary membership, in academy, 24
food legislation and regulations, 133 Hospital, Institution, and Educational
national food and nutrition surveys, Food Service Society (HIEFSS), 10
131–132 Hospital dietetics
nutrition education, 134 early use of, 4–7
nutrition research, 132 food and nutrition systems for, 111
Graduate education, 43 House of Delegates, 228
Graduate record examination (GRE), 42 House of delegates (HOD), 26–27
Great Plains Interactive Distance Education Human relations skills, manager’s
Alliance (IDEA), 46 knowledge of, 179–181
Group dynamics, 208 Human resources, defined, 119
Guide for Effective Nutrition Intervention Hunger and Environmental Nutrition
and Education (GENIE), 46 Practice Group, 236

H I
Health care, 117 Illness
electronic records, 103 chronic, 93
Healthcare costs, 123, 166 diet and, 5
for obesity, 122 Index of learning styles, 206
262     I ndex

Individualized Supervised Practice Pathway Life science specialists, 223

(ISSP), 41–42 Long-range planning of academy, 13–14
Industry-based education, 197–198 Long-term care, 143, 146–147
Informatics, 82, 83, 102–103 food and nutrition management in,
Innovation, defined, 23 111–112
Integrity, defined, 23
Intellectual skills, 206 M
Interdisciplinary specialist certification, in Management, 107–119, 177–178
obesity and weight management, change management, 184–186
61–62 clinical nutrition manager, 100
International Confederation of Dietetic coaching and mentoring, 180
Associations, 14 communication, 179
International Congress of Dietetics, 15 conflict management, 180
International Food Information Council, 167 controlling, 177
International membership, in academy, 24 coordinating, 177
Internships, 206 defined, 119
Interpersonal relationships and skills, 179 directing (or leading), 177
Intervention, 96, 97f employment settings for, 110–114, 117
Intuitive learner, 206 ethical practice and, 184
ISSP (Individualized Supervised Practice food and nutrition, 237–238
Pathway), 41–42 food and nutrition managers, 114–116,
115f, 116t
J interpersonal relationships, 179
Jobs. See Career choices; Employment networking, 180–181
Job skills, manager’s knowledge of, 181 organizing, 177
Journal of the Academy of Nutrition and planning, 177
Dietetics, 224 in practice, 186–187
Journal of the American Dietetic Association, quality management, 183
6, 24 resource, 181–182
skills and abilities of managers,
K 178–186
Knowledge of healthcare environment, common competencies for healthcare
186, 186f managers, 185–186
conceptual skills, 184–185
L contemporary cross section of, 178f
Lattice career ladder, 234 human relations skills, 179–181
Leaders, in dietetics profession, 6–8 job skills, 181
Leadership, 175–177, 185, 186f, 237–238 productivity and accountability, 238
attaining leadership skills, 175 technical skills, 181–183
characteristics for successful, 175 staffing, 177
defined, 175 strategic planning and goal
development of, 176 setting, 184
for quality and efficiency, 176–177 team building, 182
Legislative activity, 11, 34 training and staff development, 182
Legislative network coordinator (LNC), 136 Management in Food and Nutrition
Licensure of dietitians Systems practice group, 169
defined, 66, 68 Massive Open Online Courses
establishment of, 10 (MOOCS), 46, 103
requirements of, 45 Master’s degree, 43
 I n d e x      2 6 3

Medallion Awards, 7 Networking, 180–181

Medical and dental education, 196–197 advanced education and, 43
Medical Nutrition Therapy Act, 34 practice groups and, 28
Medical nutrition therapy (MNT), 137, Noncredentialed DPD graduates, 58
145, 151 Noninstitutional settings, food and
defined, 105 nutrition management in, 112
early use of, 2–4 Non-RD practice, 232–233
Medical Nutrition Therapy Act, 34 Nursing and allied health nutrition
responsibilities in clinical dietetics, education, 197
98–99 Nutrigenomics, 234
Member interest groups (MIGs), 13, 31 Nutrition
Mentors assessments, 96, 97f
educators as, 199 diagnosis, 96, 97f
managers as, 180 intervention, 96, 97f
Metabolic nutrition care specialist, 60 monitoring and evaluation, 97, 97f
MIGs (member interest groups), 13, 31 position papers on, 31
Military dietetics, 4 Nutrition and dietetics technician, registered
Military service, dietitians in, 137–138 (NDTR), 41, 42. See also Dietetic
Minerals, 3 technicians, registered (DTRs)
Monitoring progress of patients, 97, 97f recertification of, 64–65
MOOCS. See Massive Open Online salary of, 44–45
Courses (MOOCS) Nutrition assessment, 147, 154
Motivational interviewing, 202, 233 Nutrition care process and model (NCPM),
MyPlate, 134 96–98, 97f
Nutrition education for public, 134
N Nutrition Entrepreneurship Dietetic
National Administration on Aging, 167 Practice group, 78
National Agriculture Library, 134 Nutrition Entrepreneurs practice group,
National Center for Advancing Translational 148, 151, 169, 199
Science (NCATS), 222 Nutrition epidemiologists, 223
National Commission for Certifying Nutrition Foundation, 15
Agencies (NCCA), 55 Nutrition informatics, 82, 83, 102–103
National Evidence Library, 134 Nutritionist, 17
National food and nutrition surveys, ethics and, 77–78
131–132 legal regulation statutes for, 66–67
National Health and Nutrition Examination Nutrition research, 132
Survey (NHANES), 132 Nutrition researchers, 223
National Institutes of Health, 167 Nutrition security, 118
National Medical Library, 134
National Nutrient Databank, 134 O
National Nutrition Monitoring and Related Obesity
Research Act (NNMRR), 131 children and, 16
National Nutrition Month, 15 cost of health care for, 122
National School Lunch and Breakfast prevention and treatment of, 162
Program, 132 and weight management, 61–62
NCPM (nutrition care process and model), Omnibus Reconciliation Act of
96–98, 97f 1987, 145
NDTR. See Nutrition and dietetics Oncology nutrition specialists, 60
technician, registered (NDTR) Open-ended questioning model, 202, 203t
264     I ndex

Organization of clinical nutrition services, Professional development

95–96 advanced-level education, 43–46, 44t
Outcomes research, 215, 219, 222, 225 Center for Professional Development
Outpatient clinic, defined, 105 activities for, 80–81
delivery of learning, 81–82, 82–83t
P informatics, 82, 83
Patient Protection and Affordable Care Professional Development Portfolio
Act, 232 (PDP), 64
Patients, 192 Professionalism, 186, 186f, 237
assessments and counseling for Professional practice, 73–88. See also
inpatients, duties of dietitian, 138 Standards of professional
cardiac rehabilitation programs, performance (SOPP)
164–165 continuing education, 80–84,
centered care, 229–230 82–83t
centered counseling, 202 defined, 73
centered medical homes, 233–234 diversity and cultural competence, 80
clinical dietitian’s responsibilities to, ethical practice, 77–79, 79t
101–102 evidence-based practice, 85, 86–87t
diversity of, 80 legal considerations, 84–85
education, 197 performance standards, 74–77
ethical practice and, 184 scope of, 74–77
nutrition assessments, 96, 97f The Profession of Dietetics: The Report of
nutrition care process and model, the Study Commission on Dietetics
96–98, 97f (ADA), 13
rules concerning rights of, 146 Program planning, 123, 127
satisfaction, 183 Project-based learning, 208
standards of practice for interaction Psychomotor skills, 206
with, 99 Public health, 229, 236
treatment of disordered eating, 168 approach to health promotion and
Pediatric nutrition specialists, 60 disease prevention, 124–125
Polarities, defined, 238 areas of work, 123–124
Policy issues in dietetics, 136–137 community nutrition dietitians and,
Political action committee (PAC), 11 122–124
Poor diet, risk factors of, 162 defined, 122
Position papers of academy dietitians, 124–125, 134
defined, 31 education, 196
developing, 27 policies, 231
Practice of dietetics, 231–234 protection of, 53
Practitioner, defined, 68 service program areas in, 223
Preceptors, 199–200, 201t–202t Public Health/Community Nutrition
defined, 48 Dietetic Practice Group, 123
Private practice, 150–154, 152t–153t, 159 Public health dietitians, 124
Private practice consultants, 150–154, Public health nutritionist, 122, 124
152t–153t Public Health Service, U.S., 14
areas of practice, 151 Public outreach programs, 13, 15–16
Problem-based learning, 207 Public policy, in dietetics, 135–137, 215
Profession Public Policy Workshop, 135
defined, 8 Public service and military, opportunities
dietetics as, 8–9 in, 4
 I n d e x      2 6 5

Q Regulatory requirements
Quality, defined, 183 for consultants, 146
Quality assurance, 119, 148, 183 Family Medical Leave Act (FMLA), 179
Quality improvement, 76, 77, 147, 183, Health Insurance Portability and
215, 229 Accountability Act (HIPAA) of
Quality management, 183 1996, 146
Quality Management Committee, HIPPA, 84
96, 183 for professional practice, 84–85
state regulation of dietitians, 45
R telenutrition, 235
RDN. See Registered dietitian nutritionist Renal nutrition specialists, 60
(RDN) Research
Recertification earliest use, for food, 3
of RD/RDN and DTR/NDTR, ethics in, 78
64–65 Research: Successful Approaches (Monsen and
of specialists, 65 Van Horn), 224
Recommended dietary allowances Research Dietetic practice group, 217
(RDAs), 134 Researchers in dietetics, 167
Red Cross, 4 activities of RDs and DTRs, 220, 221t
Reflective learner, 206 for cardiovascular nutrition, 165–166
Registered dietitian nutritionist (RDN), 41, career opportunities for
42, 130, 186, 229 community and population-based
and clinical privileging, 104 nutrition research, 223
emerging areas in nutrition and in food and industry companies, 222
dietetics, 230 at general clinical research center
legal considerations for, 85 (GCRC), 220
management skills, 238 in government-sponsored centers and
new career scenarios, 231 laboratories, 222–223
practice of dietetics, 231–234 at human nutrition research centers, 224
recertification of, 64–65 Evidence Analysis Library, 85, 98–99
role in community nutrition, 125 evidence-based practice, 85, 86–87t
salary of, 44 evidence-based practice (EBP), 219–220
scope of practice for, 75 information sources for, 224
Registered dietitians (RDs), 142 interaction between practice, education,
certification of, 56 and policy, 218f
defined, 17 philosophy of the academy for, 215–216
employment settings of, 93–94, priority research areas, 216–217
93–94t relevance of, 215
establishment of credential, 9–10 skills attained in graduate study, 45–46
recertification of, 64–65 for sports nutrition, 165
salaries of, 33 strategic skill building, 161–162
supervising of DTRs by, 57 at U.S. Army Natick Research,
Registration and examination. See Development, and Engineering
also Commission on Dietetic Center, 223
Registration (CDR) Residency programs. See Supervised
defined, 67 practice/internships
eligibility pathway for DTRs, 58–60 Resource allocation, 119
eligibility requirements, 56 Resource management, 181–182
establishment of, 9–10 Retired membership, in academy, 24
266     I ndex

S Specialized knowledge requirement, 8.

Salaries of dietitians, 31–33, 32t See also Education
School-based nutrition education, Special Supplemental Nutrition Program
195–196 for Women, Infants, and Children
Schools. See also Colleges and universities (WIC), 123
adults, teaching, 208 Spokesperson network, 15
college and university educators, 196 Sports, Cardiovascular, and Wellness
elementary and secondary educators, Nutrition dietetic practice group,
195–196 162, 169
medical and dental education, Sports dietetics specialists, 60
196–197 Sports nutrition, 162–165
nursing and allied health nutrition clinical concerns, 163t
education, 197 Staff development, 182. See also
nutrition programs, 112–113 Continuing education
nutrition programs for, 195–196 Standards, defined, 88
Scope of practice, defined, 68 Standards, educational, 5, 27,
Scope of Practice Framework, 74–75 40–41
Self-assessment, 77 Standards of Practice (SOP),
Self-employment. See Consultants 75–77, 99
Self-monitoring, goal attainment and, Standards of professional performance
185, 202 (SOPP)
Sensing learner, 206 for clinical dietetics, 99
Sequential learner, 206 in professional practice, 75–77
Service learning, 207 State and district associations, 33
Skills and abilities State laws. See Regulatory requirements
Dreyfus model of acquiring, 59 Statutory certification, 66
of managers. See Skills and abilities of Strategic planning
managers of academy, 13, 23–24
for research, 45–46 defined, 35
Skills and abilities of managers, 178–186. of managers, 184
See also Management Strategic Plan of 2011–2012 (ADA), 14
common competencies for healthcare Student membership, in academy, 24
managers, 185–186 Study Guide for the Registration Examination
conceptual skills, 184–185 for Dietetic Technicians, 60
contemporary cross section of, 178f Supervised practice/internships
human relations skills, 179–181 application for, 39
job skills, 181 defined, 48
productivity and accountability, 238 matching system for, 39
technical skills, 181–183 requirements of, 39
Skills for learning outcomes, 206 Supplemental Nutrition Assistance
Social responsibility, 23 Program (SNAP), 133, 237
Specialists, 125–126, 237
defined, 48, 54 T
life science, 223 Task forces of ADA, 13, 74
recertification, 65 Teachers. See Educators, dietitians as
role of, 54 Team building, 182
 I n d e x      2 6 7

Technological changes V
future of dietetics and, 234–235 Values, of academy, 23
informatics, 82, 83 Verbal learner, 206
Telehealth, 47 Verbal processing skills, 206
Telenutrition, 235 Visioning Report, 229
Therapeutic dietitian, 92. See also Medical Visual learner, 206
nutrition therapy (MNT) Vitamins, 3
Training, staff development and, 182
Training certificates, 63–64 W
Trends Wages. See Salaries of dietitians
in clinical dietetics, 102–104 Websites, of academy, 60
in education, 13 Weight management, obesity and,
Trust, 175, 184 interdisciplinary specialist
certification in, 61–62
U Weight Management practice group
Undergraduate education, 38–39 (WMDPG), 61
Universities. See Colleges and universities WIC (Special Supplemental Nutrition
University faculty roles, 196 Program for Women, Infants, and
U.S. Department of Agriculture (USDA), Children), 123, 133, 237
14, 131–132 Work-site nutrition education, 198
U.S. Military Dietetic Internship Work-site wellness programs, 166
Consortium, 138