Academy of Nutrition and Dietetics: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Intellectual and Developmental Disabilities

Abstract

The Behavioral Health Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics (Academy), under the guidance of the Academy Quality Management Committee and its Scope of Practice Sub-committee, has developed Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians (RDs) in Intellectual and Developmental Disabilities (IDD). These documents build on the Academy's Revised 2008 SOP for RDs in Nutrition Care and SOPP for RDs.1American Dietetic Association Quality Management CommitteeAmerican Dietetic Association Revised 2008 Standards of Practice for Registered Dietitians in Nutrition Care; Standards of Professional Performance for Registered Dietitians; Standards of Practice for Dietetic Technicians, Registered, in Nutrition Care; and Standards of Professional Performance for Dietetic Technicians, Registered.J Am Diet Assoc. 2008; 108: 1538-1542e9Abstract Full Text Full Text PDF Google Scholar The Academy's Code of Ethics2American 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. 2009; 109: 1461-1467Abstract Full Text Full Text PDF PubMed Google Scholar and the 2008 SOP in Nutrition Care and SOPP for RDs1American Dietetic Association Quality Management CommitteeAmerican Dietetic Association Revised 2008 Standards of Practice for Registered Dietitians in Nutrition Care; Standards of Professional Performance for Registered Dietitians; Standards of Practice for Dietetic Technicians, Registered, in Nutrition Care; and Standards of Professional Performance for Dietetic Technicians, Registered.J Am Diet Assoc. 2008; 108: 1538-1542e9Abstract Full Text Full Text PDF Google Scholar are tools within the Scope of Dietetics Practice Framework3O'Sullivan-Maillet J. Skates J. Pritchett E. Scope of dietetics practice framework.J Am Diet Assoc. 2005; 105: 634-640Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar that guide the practice and performance of RDs in all settings. The concept of scope of practice is fluid,4Visocan B. Swift J. Understanding and using the scope of dietetics practice framework: A step-wise approach.J Am Diet Assoc. 2006; 106: 459-463Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar changing in response to the expansion of knowledge, the health care environment, and technology. An RD's statutory scope of practice is defined by state legislation (ie, licensure, certification, or title protection laws) and differs from state to state. An RD may determine his or her own individual scope of practice using the Scope of Dietetics Practice Framework,3O'Sullivan-Maillet J. Skates J. Pritchett E. Scope of dietetics practice framework.J Am Diet Assoc. 2005; 105: 634-640Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar which takes into account federal regulations; state laws; institutional policies and procedures; and individual competence, accountability, and responsibility for his or her own actions. The Revised 2008 SOP and SOPP1American Dietetic Association Quality Management CommitteeAmerican Dietetic Association Revised 2008 Standards of Practice for Registered Dietitians in Nutrition Care; Standards of Professional Performance for Registered Dietitians; Standards of Practice for Dietetic Technicians, Registered, in Nutrition Care; and Standards of Professional Performance for Dietetic Technicians, Registered.J Am Diet Assoc. 2008; 108: 1538-1542e9Abstract Full Text Full Text PDF Google Scholar reflect the minimum competent level of dietetics practice and professional performance for RDs. These standards serve as blueprints for the development of focus area SOP and SOPP for RDs in competent, proficient, and expert levels of practice. The SOP in nutrition care address the four steps of the Nutrition Care Process and activities related to patient/client care.5Lacey K. Pritchett E. Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management.J Am Diet Assoc. 2003; 103: 1061-1072Abstract Full Text Full Text PDF PubMed Scopus (288) Google Scholar They are designed to promote the provision of safe, effective, and efficient food and nutrition services, facilitate evidence-based practice, and serve as a professional evaluation resource. The SOPP are authoritative statements that describe a competent level of behavior in the professional role. Categorized behaviors that correlate with professional performance are divided into six separate standards. Approved April 2012 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy) House of Delegates and the Executive Committee of the Behavioral Health Nutrition Dietetic Practice Group of the Academy. Scheduled review date: April 2017.Questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitians in Intellectual and Developmental Disabilities (IDD) may be addressed to Academy quality management staff: Karen Hui, RD, LDN, manager, Quality Management or Sharon McCauley, MS, MBA, RD, LDN, FADA, director, Quality Management at . These focus area standards for RDs in IDD are a guide for self-evaluation and expanding practice, a means of identifying areas for professional development, and a tool for demonstrating competence in delivering IDD nutrition services. They are used by RDs to assess their current level of practice and to determine the education and training required to maintain currency in their focus area and advancement to a higher level of practice. In addition, the standards may be used to assist RDs in transitioning their knowledge and skills to a new focus area of practice. Like the 2008 “core” SOP in Nutrition Care and SOPP, the indicators (ie, measurable action statements that illustrate how each standard can be applied in practice) (see Figure 1, Figure 2, Figure 3 available online at www.andjrnl.org) for the SOP and SOPP for RDs in IDD were developed with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDs in IDD were reviewed and approved by the Executive Committee of the Behavioral Health Nutrition Dietetic Practice Group, the Academy Quality Management Committee, and its Scope of Practice Subcommittee. In dietetics, a competent practitioner is an RD who is starting practice after having obtained RD registration by the Commission on Dietetic Registration or an experienced RD who has recently assumed responsibility to provide nutrition care in a new focus area. A focus area is defined as an area of dietetics practice that requires focused knowledge, skills, and experience. A competent practitioner who has obtained RD status and is starting in professional employment acquires on-the-job skills and engages in tailored continuing education to enhance knowledge and skills. RDs expand their breadth of competence and advance their careers through education and training, knowledge and skill development, professional experience, and interactions with others. The practice of a competent RD can include responsibilities across several areas of practice including, but not limited to, more than one of the following: community, clinical, consultation and business, research, education, and food and nutrition management. A proficient practitioner is an RD who is generally 3 or more years beyond entry into the profession, who has obtained operational job performance skills, and is successful in his or her chosen focus area of practice. The proficient practitioner demonstrates additional knowledge, skills, and experience in a focus area of dietetics practice. An RD can acquire specialist credentials, if available, to demonstrate proficiency in a focus area of practice. An expert practitioner is an RD who is recognized within the profession and has mastered the highest degree of skill in or knowledge of a certain focus or generalized area of nutrition and dietetics through additional knowledge, experience, and/or training. An expert practitioner exhibits a set of characteristics that includes leadership and vision and demonstrates effectiveness in planning, achieving, evaluating, and communicating targeted outcomes. An expert practitioner may have an expanded or specialist role, or both, and may possess an advanced credential, if available, in a focus area of practice. Generally, the practice is more complex, and the practitioner has a high degree of professional autonomy and responsibility.6Scope of Practice definition of terms Academy of Nutrition and Dietetics website.http://www.eatright.org/scopeGoogle Scholar These Standards, along with the Code of Ethics,2American 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. 2009; 109: 1461-1467Abstract Full Text Full Text PDF PubMed Google Scholar answer the questions: Why is an RD uniquely qualified to provide IDD nutrition services? What knowledge, skills, and competencies does an RD need to demonstrate for the provision of safe, effective, and quality IDD care at the competent, proficient, and expert levels? Nutrition services for individuals or people with IDD must balance nutrition needs with the individual's desires, abilities, and supports (necessary services and adaptations) to achieve quality of life. Knowledge and understanding of the unique aspects of providing services to individuals with IDD are essential for the RD to effectively deliver nutrition care. Developmental disabilities (DD) are defined as severe chronic disabilities that can be cognitive or physical or both. DD is a broad term that includes intellectual disability (ID) as well as other disabilities that originate before age 22 years.7American Association on Intellectual and Developmental DisabilitiesDefinition of intellectual disabilities.http://aaidd.org/content_100.cfm?navID=21Google Scholar ID is diagnosed before age 18 years and is synonymous with the previously used term mental retardation in kind, level, type, and duration of the disability. ID is characterized by significant limitations both in intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills.7American Association on Intellectual and Developmental DisabilitiesDefinition of intellectual disabilities.http://aaidd.org/content_100.cfm?navID=21Google Scholar Developmental disabilities are likely to be lifelong and can substantially inhibit a person's capacity to do at least three of the following7American Association on Intellectual and Developmental DisabilitiesDefinition of intellectual disabilities.http://aaidd.org/content_100.cfm?navID=21Google Scholar:•self-care activities (ie, dress, bathe, eat, and other activities of daily living);•speak and be understood;•learn;•ambulate;•make decisions;•live on their own; and•earn and manage an income.DDs can be the result of identified etiologies, such as chromosomal abnormalities, congenital anomalies, inherited metabolic disorders, specific syndromes, neurodevelopment or neuromuscular dysfunction, or may not be associated with any diagnosed condition. Although there are hundreds of specific diagnoses that involve IDD, the most well-known diagnoses that manifest as IDD include Down syndrome, fragile X, autism spectrum disorder, cerebral palsy, and intellectual disability, unspecified.8The Arc, For People with Intellectual and Developmental DisabilitiesStill in the shadows with their future uncertain: A report on family and individual needs for disability supports (FINDS), 2011.www.thearc.org/document.doc?id=3140Google Scholar The estimated total number of people with ID or DD in the United States from 1994 to 1995 was 4,132,878 (a prevalence of 15.8 people per 1000).9Prevalence of Mental Retardation and/or Developmental Disabilities: Analysis of the 1994/1995 NHIS-D Institute of Community Integration, University of Minnesota, Minneapolis.MR/DD Data Brief. 2000; 1 (Accessed March 16, 2012): 1-11http://rtc.umn.edu/docs/dddb2-1.pdfGoogle Scholar DDs were reported in 1 in 6 children in the United States from 2006 to 2008.10Boyle C.A. Boulet S. Schieve L.A. et al.Trends in the prevalence of developmental disabilities in US children, 1997-2008.Pediatrics. 2011; 127: 1034-1042Crossref PubMed Scopus (1142) Google Scholar About 13.4 million (4.8%) of the noninstitutionalized child and youth population 5 years and older were estimated to have cognitive difficulty in 2008.11Brault M.W. Review of changes to the measurement of disability in the 2008 American Community Survey US Census Bureau, September 22, 2009.http://www.census.gov/hhes/www/disability/2008ACS_disability.pdfGoogle Scholar Estimates for adults age 60 years and older with IDD range between 600,000 and 1.6 million. This rapidly growing population is expected to be several million by 2030.11Brault M.W. Review of changes to the measurement of disability in the 2008 American Community Survey US Census Bureau, September 22, 2009.http://www.census.gov/hhes/www/disability/2008ACS_disability.pdfGoogle Scholar Improved care from birth through adulthood has resulted in longer lives for premature babies and a better quality of life and greater longevity in people with IDD. With increasing longevity, the variety of conditions and functional impairments places people with IDD at greater risk for developing chronic diseases.12Rosenzweig L.Y. Serving the aging developmentally disabled population.Top Clin Nutr. 2008; 23: 98-102Crossref Scopus (2) Google Scholar Compared to the population without disabilities, individuals with IDD are at greater risk for health problems resulting in higher morbidity and earlier mortality.13Reichard A. Stolzle H. Fox M.H. Health disparities among adults with physical disabilities or cognitive limitations compared to individuals with no disabilities in the United States.Disabil Health J. 2011; 4: 59-67Crossref PubMed Scopus (205) Google Scholar, 14Schieve L.A. Gonzalez V. Boulet S.L. et al.Concurrent medical conditions and health care use and needs among children with learning and behavioral developmental disabilities, National Health Interview Survey, 2006-2010 National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, United States.Res Dev Disabil. 2012; 33: 467-476Crossref PubMed Scopus (175) Google Scholar Such risks can be magnified when a comorbid mental health issue emerges; individuals with coexisting IDD and psychiatric disorders have been identified as a group with particularly complex service needs.15Antochi R. Stavrakaki C. Emery P.C. Psychopharmacological treatments in persons with dual diagnosis of psychiatric disorders and developmental disabilities.Postgrad Med J. 2003; 79: 139-146Crossref PubMed Scopus (30) Google Scholar There is a strong need for RD involvement to address and manage the multiple special nutritional needs of children and adults with IDD.16Buie T. Campbell D.B. Fuchs 3rd, G.J. et al.Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals with ASDs: A consensus report.Pediatrics. 2010; 125: S1-S18Crossref PubMed Scopus (498) Google Scholar, 17American Dietetic AssociationPosition of the American Dietetic Association: Providing nutrition services for people with developmental disabilities and special health care needs.J Am Diet Assoc. 2010; 110: 296-307Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Health and nutrition issues, often unmet in children with IDD, may include metabolic problems, feeding difficulties, food allergies, and growth and/or developmental problems.18Oeseburg B. Dijkstra G.J. Groothoff J.W. Reijneveld S.A. Jansen D.E. Prevalence of chronic health conditions in children with intellectual disability: A systematic literature review.Intellect Dev Disabil. 2011; 49: 59-85Crossref PubMed Scopus (124) Google Scholar Early intervention is critical in improving treatment outcomes, preventing secondary disability,19American Academy of PediatricsRole of the Medical Home in Family-Centered Early Intervention Services.Pediatrics. 2007; 120: 1153-1158Crossref PubMed Scopus (52) Google Scholar and influencing future nutritional health needs. Nutrition problems in the adult are often related to secondary conditions, such as overweight/obesity, gastrointestinal dysfunction, cardiovascular disease (including risk factors), diabetes, osteoporosis, cancer, anemia and food allergies.20Seekins T. Trace M. Bainbridge D. et al.Promoting health and preventing secondary conditions among adults with developmental disabilities.in: Field M.J. Jette A.M. Martin L. Workshop on Disability in America: A New Look. National Academies Press, Washington, DC2006: 251-264Google Scholar Unlike “typical” aging, some individuals with a disability begin to show higher rates of medical and functional problems at age 50 or younger, including dementia and Alzheimer's disease. Research documents nutritional deficits, inadequate diets, and poor nutritional status among adults with IDD living in the community.21Bertoli S. Nutritional status and dietary patterns in disabled people.Nutr Metab Cardiovasc Dis. 2006; 16: 100-112Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 22Humphries K. Traci M.A. Seekins T. Nutrition education and support program for community-dwelling adults with intellectual disabilities.Intellect Dev Disabil. 2008; 46: 335-345Crossref PubMed Scopus (26) Google Scholar Twenty percent (20%) of children ages 10 through 17 years with IDD are obese vs 15% of children without disabilities.23Child and Adolescent Health Measurement InitiativeNational Survey of Children's Health, 2007 Data Resource Center on Child and Adolescent Health website.http://www.nschdata.orgGoogle Scholar Obesity rates for adults with disabilities are 58% higher than for adults without disabilities.24Behavioral Risk Factor Surveillance System Survey data.http://www.cdc.gov/brfss/Google Scholar Factors contributing to a higher incidence of overweight and obesity include consuming fewer healthy food choices, medications that contribute to weight gain, physical limitations, lack of social and financial support, poor eating habits, lack of exercise, and depression.25American Association on Health and DisabilityObesity and disability.http://www.aahd.us/wp-content/uploads/2012/03/Obesity2011.pdfDate: April 2011Google Scholar Gastroesophageal reflux disease is believed to occur in almost 50% of individuals with IDD due to premature birth, comorbid complex physical disabilities, and advancing age.26Medina W.C. Nonverbal individuals with intellectual/developmental disabilities experiencing GERD: From infants to older adults.Int J Nursing Intell Dev Disab. 2005; 2: 2-10Google Scholar A range of physical and behavioral difficulties often require that the individual receive mealtime assistance, adaptation, and intervention to ensure safety and adequate nutrition.27Ball S.L. Panter S.G. Redley M. Proctor C.A. Byrne K. Clare I.C.H. The extent and nature of need for mealtime support among adults with intellectual disabilities.J Intell Disab Res. 2011; 56: 382-401Crossref PubMed Scopus (34) Google Scholar Problems with oral-motor control and swallowing lead to discomfort, poor nutritional status, dehydration, aspiration, asphyxiation, and can be life threatening.28Sullivan P.B. Lamber B. Rose M. Ford-Adams M. Johnson A. Griffiths P. Prevalence and severity of feeding and nutritional problems in children with neurological impairment: Oxford Feeding Study.Dev Med Child Neurol. 2000; 42: 674-680Crossref PubMed Scopus (345) Google Scholar Consulting with a speech-language pathologist or occupational therapist is key to addressing many of these concerns in the individual with IDD. Individuals with IDD require varying levels of individualized services and supports determined through person-centered planning, which values the specific needs and desires of the individual. The individual is empowered to achieve personal and/or health-related goals based on strengths and capacity, not disability.7American Association on Intellectual and Developmental DisabilitiesDefinition of intellectual disabilities.http://aaidd.org/content_100.cfm?navID=21Google Scholar, 29Lipscomb R. Person-first practice: Treating patients with disabilities.J Am Diet Assoc. 2010; 110: S8-S12Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The network of people supporting an individual with IDD may be referred to as the circle of support, planning team, support network, or care team. A nutrition plan for a person with IDD often requires adaptation of the typical treatment approach to meet the person's unique needs. An RD with experience in the care of the IDD population is uniquely qualified to provide medical nutrition therapy across the full continuum of care, consistent with the person's medical and behavioral condition(s), prognosis, functional abilities, intellectual and cognitive skills, living environment, self-determination, and choices. Provision of nutrition services (eg, consultation, assessment, intervention planning, staff and care provider training, implementation, and monitoring) may occur in the person's home, supported living environment, group home, or intermediate care facility, as well as school, job, and day programs. RDs may also provide nutrition care to children and adults with IDD in acute care settings, outpatient clinics, long-term care settings, skilled nursing, and school settings. Regardless of the setting, it is beneficial when nutrition services are provided within a person-centered medical home model.30American Academy of Family PhysiciansDefinition of patient-centered medical home.http://www.aafp.org/online/en/home/policy/policies/p/patientcenteredmedhome.htmlGoogle Scholar According to the Family and Individual Needs for Disability Supports survey of 2011, the vast majority of people with IDD (98%) report living in the community, with 78% living with family members, 9% in group homes of six or fewer people and 7% in their own homes or apartments.8The Arc, For People with Intellectual and Developmental DisabilitiesStill in the shadows with their future uncertain: A report on family and individual needs for disability supports (FINDS), 2011.www.thearc.org/document.doc?id=3140Google Scholar RDs are accountable and responsible for overall provision of nutrition services provided in IDD. In institutional, acute care, and long-term care facilities, dietetic technicians, registered (DTRs) and other support staff may assist in the provision of nutrition care of the individual with IDD. As part of RD/DTR teams, DTRs work under an RD's supervision when providing person-centered nutrition care. A comprehensive evaluation is needed when assessing nutritional status in the child or adult with IDD. The assessment should include the impact of disability on nutritional status, current supports, social skills, mealtime supports and dining skills, mobility, sensory processing needs, social and communication skills, level of independence, and cognitive level.31American Dietetic AssociationBehavioral Health Nutrition Dietetic Practice GroupThe Adult with Intellectual and Developmental Disabilities: A Resource Tool for Nutritional Professionals. Academy of Nutrition and Dietetics, Chicago, IL2008Google Scholar, 32Ekvall S. Ekvall V. Pediatric Nutrition in Chronic Diseases and Developmental Disorders: Prevention, Assessment, and Treatment.2nd ed. Oxford University Press, New York, NY2005Google Scholar Another key component is assessing the level of support and assistance the person needs to carry out the nutrition plan. Assessment often requires multiple measures or parameters in addition to using clinical judgment. Anthropometrics in the IDD population can be difficult to obtain because of structural anomalies (eg, kyphosis, scoliosis), as well as neuromuscular, sensory, and compliance issues.31American Dietetic AssociationBehavioral Health Nutrition Dietetic Practice GroupThe Adult with Intellectual and Developmental Disabilities: A Resource Tool for Nutritional Professionals. Academy of Nutrition and Dietetics, Chicago, IL2008Google Scholar To calculate desired body weight, it may be necessary to use multiple methods and compare results. Methods include World Health Organization or Centers for Disease Control and Prevention growth charts.33Centers for Disease Control and Prevention website Growth charts.http://www.cdc.gov/growthcharts/Google Scholar Specialty growth curves, while available, are not recommended as a clinical tool.34Bull M.J. Academy of Pediatrics, Committee on GeneticsClinical report: Health supervision for children with Down syndrome.Pediatrics. 2011; 128 (Accessed March 16, 2012): 393-406http://pediatrics.aappublications.org/content/128/2/393.fullCrossref PubMed Scopus (667) Google Scholar Conventional methods to estimate energy requirements are not always accurate in IDD.31American Dietetic AssociationBehavioral Health Nutrition Dietetic Practice GroupThe Adult with Intellectual and Developmental Disabilities: A Resource Tool for Nutritional Professionals. Academy of Nutrition and Dietetics, Chicago, IL2008Google Scholar, 35Dickerson R.N. Brown R.O. Hanna D.L. Williams J.E. Energy requirements of non-ambulatory, tube-fed adult patients with cerebral palsy and chronic hypothermia.Nutrition. 2003; 19: 741-746Crossref PubMed Scopus (11) Google Scholar Degree of spasticity, severity of the disorder, muscle atrophy, stunted growth, extent of mobility or ambulation, and low muscle tone are factors affecting energy needs. More than one method of determining energy needs may be required, along with assessing weight history/trends, monitoring weights, reviewing laboratory data and food intake records, observing meal times, and obtaining information from the individual and care providers. Multiple medications and long-term use of certain medications or treatments and their potential side effects (eg, antiepileptic, psychotropic medications36Muench J. Hamer A.M. Adverse effects of antipsychotic medications.Am Fam Physician. 2010; 81: 617-622PubMed Google Scholar) are often factors impacting nutrition status and gastrointestinal function. It is common for individuals with IDD to take numerous prescription and nonprescription medications and to use complementary and alternative therapies.37Kiefer D. Pitluk J. Klunk K. An overview of CAM: Components and clinical uses.Nutr Clin Pract. 2009; 24: 549-559Crossref PubMed Scopus (11) Google Scholar The RD needs to review all medications and potential food−medication interactions, as well as any alternative or nontraditional therapies (eg, fish oil, gluten-free, casein-free diet38Marcason W. What is the current status of research concerning use of a gluten-free, casein-free diet for children diagnosed with autism?.J Am Diet Assoc. 2009; 109: 572Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar) and assist in assessing effective use, risk vs benefit, and any associated safety issues. RDs frequently provide services to individuals with IDD who receive or are in need of enteral nutrition support. The RD describes the potential nutritional benefits, risks, and alternatives of enteral nutrition/tube placement for the individual. The RD contributes to decisions regarding formula selection, formula administration (ie, frequency, volume, rate), and proper positioning during and after formula administration. The RD consults with the circle of support when foods are consumed orally in addition to formula by tube, such as the use of intermittent meals that may be incorporated into the individual's daily routine. RDs in this focus area identify creative approaches to nutrition interventions and determine appropriate nutrition education materials and age-appropriate tools. They discern the level of understanding and support needed by the person, family, and care providers. When developing the nutrition intervention, the RD considers how the person communicates, such as vocalizations, body movements, sign language, and use of augmentative and alternative communication devices.39National Joint Committee for the Communication Needs of Persons with Severe DisabilitiesGuidelines for meeting the communication needs of persons with severe disabilities [Guidelines].http://www.asha.org/docs/html/GL1992-00201.htmlGoogle Scholar The use of person-first language is essential, focusing on the person rather than the disability.29Lipscomb R. Person-first practice: Treating patients with disabilities.J Am Diet Assoc. 2010; 110: S8-S12Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Education and adequate training are essential in all steps of implementing the nutrition care plan, not just for the person with IDD, but also for the family, care providers, educators, and other health care professionals. Living environments requiring care provider(s) support can be complicated by high staff turnover and the care provider's lack of food-preparation skills and nutrition knowledge.22Humphries K. Traci M.A. Seekins T. Nutrition education and support program for community-dwelling adults with intellectual disabilities.Intellect Dev Disabil. 2008; 46: 335-345Crossref PubMed Scopus (26) Google Scholar In addition, a care provider's personal choices and habits may influence the individual's behavior, creating barriers to successful intervention and outcomes. Developing rapport and respectful working relationships with individuals and their circle of support is crucial for desirable outcomes. Behavioral responses or actions, both positive and negative, in individuals with IDD communicate wants, needs, or emotions. Determining what the person is trying to c